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To reach such a consistent theory which contains the quantum field theory of particle physics and Einstein’s theory of gravitation as limiting cases, one may proceed in the following way: Standard quantum field theory just ignores the effects of gravity. This is justified in many cases due to the weakness of gravitational interactions at the presently accessible scales. In a first step beyond this approximation, one may consider an external gravitational field that is not influenced by the quantum fields. Here one may think of sources of gravitational fields that are not influenced by the quantum fields under consideration, as high-energy experiments in the gravitational field of the earth or quantum fields in the gravitational field of dark matter and dark energy. This approach amounts to the treatment of quantum field theory on curved spacetimes. The problem of quantization in curved spacetimes is now clearly visible. In Minkowski spacetime, there is a large group of symmetries that enforces a particular choice of vacuum by demanding the vacuum to be invariant. Such a criterion is absent for a general spacetime (M,g). We therefore do not know which state to choose as the vacuum. One might hope that the different prescriptions might be unitarily equivalent such that it doesn’t matter which state one takes to define the theory. Sadly this is not the case: The Stone-Von Neumann theorem is no longer valid for systems with an infinite amount of degrees of freedom. This means that unitarily inequivalent representations of the canonical commutation relations will arise, and it is not clear which equivalence concept representation is the physical one. In the second section of this chapter, we review the notions of Cauchy surfaces and global hyperbolicity.

Bartholinitis, or Bartholin's gland abscess, is a relatively common gynecological condition among women of reproductive age. Its annual incidence is estimated at approximately 0.5 per 1,000 women, which corresponds to a lifetime cumulative risk of about 2%. The condition primarily affects patients between 20 and 50 years old, with a peak frequency observed between 35 and 50 years.After menopause, due to the natural involution of the gland, Bartholin's cysts and abscesses become less frequent, although they can still occur. Moreover, in women over 50, the appearance of a new mass in the gland region should prompt caution, as it may, in rare cases, indicate a carcinoma of the Bartholin's gland or an adjacent vulvar cancer. Therefore, for patients over 40 presenting with a newly emerged cyst or abscess, clinical guidelines recommend performing a biopsy or excision to rule out malignancy. We present the case of a 50-year-old woman with no significant medical history, who was urgently referred to the gynecological emergency department due to confusion, unexplained fever of 40 °C, and resistant leucorrhoea following a week of corticosteroid antibiotic therapy. Clinical examination revealed a large, tender right vulvar mass, indicative of an acute Bartholin's abscess. The patient exhibited signs of septic shock and was admitted to the ICU. Following a diagnosis of sepsis, broad-spectrum antibiotic therapy was initiated, alongside fluid resuscitation and norepinephrine support. Surgical drainage of the abscess confirmed the presence of E. coli. The patient's condition improved rapidly, and she was discharged on postoperative day 8 with no complications. This case underscores that while Bartholin's abscess is typically benign, severe complications, including septic shock, can occur—especially in patients over 50. The appearance of a new Bartholin's region mass in older women should prompt consideration of malignancy, necessitating biopsy or excision. Recent studies compare various therapeutic approaches including simple incision and drainage, Word catheter placement, marsupialization, silver nitrate application, and complete gland excision. Each method has its advantages and drawbacks, with marsupialization offering lower recurrence rates and higher patient satisfaction in many instances. 

Background: Haemodialysis is the commonest method of Renal Replacement Therapy in Nigeria. Despite an advancement in the technicality and better understanding of haemodialysis, a number of complications are known to be associated with this procedure.. Objective: We aimed to highlight our experiences and share some of the uncommon complications encountered during haemodialysis and present the outcome of our patients. Subjects and methods: A retrospective review of 101 patients during the last two years was done. Data extracted include: sociodemographic characteristic, aetiology of kidney disease, type of vascular access, intradialytic complication and outcome of treatment. Results: The total number of dialysis session during the period was 823. Males constituted a higher proportion (64.4%) and were found to be older than female patients 49.8 vs 42.8 years (P=0.001). Majority (89.1%) had chronic kidney disease while chronic glomerulonephritis was the main cause of CKD as seen in about 45% of the patient. Due to the cost implication, only 2(1.98%) were able to undergo 3 sessions of dialysis per week for up to 1 month. Vascular access was femoral (66.3%), internal jugular vein (25.7%), while only 2% used Artero-venous-fistula and one patient had femoral vessel pseudoaneurysm from frequent cannulation. The commonest complication was hypotension which was present in 15.8%. Twenty-eight deaths were recorded, 44(43%) were either lost to follow up or absconded while 5% were transplanted at a referral centre. Conclusion: Challenges of renal replacement therapy is overwhelming in our country due to poor human and financial resources. Early diagnosis and adequate government support are advocated.

Anti-glomerular basement membrane (anti-GBM) disease is an uncommon autoimmune disease that classically presents as an aggressive necrotizing and crescentic glomerulonephritis (CG), with or without pulmonary hemorrhage, and typically does not relapse. The pathologic hallmark is linear staining of GBM for Immunoglobulin G (IgG) which binds to the alpha-3 chain of type IV collagen. Recent reports have noted the occurrence of anti-GBM disease with atypical clinical presentations. We describe a case of a 22-year-old female presenting an anti-GBM disease with typical histological features with a singular clinical presentation with lower limb edema, elevated serum creatinine and nephrotic range proteinuria. Renal biopsy showed signs of chronicity and direct immunofluorescence microscopy demonstrated diffuse, intense linear positivity for IgG. All serologic tests were negative, including anti-GBM antibodies. Hence, a diagnosis of atypical anti-GBM disease was made. The patient was treated initially with mycophenolate mofetil and corticosteroids. After 3 months she began to aggravate renal function so mycophenolate of mofetil was discontinued and a low dose cyclophosphamide was initiated.

Glomus tympanicum (GT) is a highly vascular, benign, and slow-growing tumor of the middle ear. It can be confused with other common ear diseases such as acute middle ear infection, otitis media with effusion, ear trauma… It is accurately diagnosed by history and endoscopy. CT scan showing: the presence of eroding jugular bulb is the most important thing to distinguish glomus tympanicum and glomus jugulare and assess the extension of the tumor to make good surgical planning. We present here the three cases in Can Tho ENT hospital: where total excisions were achieved trans-canal endoscopically without embolization. These procedures were safe, quick, and effective due to the better visualization of the surgical field with the endoscope.

Background: In sickle cell anemia (SCA), compromise of the renal vasculature due to sickled red cells has been recognized. Objectives: To assess the renal function and blood pressure pattern in children with sickle cell anaemia (SCA) presenting in a tertiary institution. Method: A cross-sectional study of patients with sickle cell anaemia (SCA) over six months involving the use of questionnaires, general physical examination, blood pressure, investigations for haemoglobin genotype, urinalysis, serum creatinine, screening for hepatitis B and HIV. Results: 51 children with SCA were seen. The prevalence of impaired renal function as defined by reduced eGFR <90mL/min/1.73m2 in this study was 27.5%, previous hospital admission and blood transfusion were associated with reduction in eGFR but blood pressure did not have significant correlation with the eGFR. The overall mean age at diagnosis of SCA was 4.09 ± 3.33 (years). Conclusion: Impaired renal function is a major comorbid condition in children with SCA. In countries/locations where there is no newborn screening for sickle cell disease, diagnosis is delayed, thus detecting impaired renal function may be delayed, therefore the need for early detection and management is imperative.Introduction

Hypertension is one of the most common chronic diseases of human, affecting more than one billion people worldwide. When it becomes chronic, hypertension leaves behind cardiac hypertrophy, heart failure, stroke, and kidney disease, resulting in substantial morbidity and mortality. Treatments that effectively reduce blood pressure can prevent these complications. Abnormalities in the production of urine by the kidneys have been implicated in increased vascular resistance, leading to high blood pressure and increased cardiac mass. By matching urinary excretion of salt and water with dietary intake, balance is usually attained, thereby maintaining a constant extracellular fluid volume and blood pressure. Based on the capacity for the kidney to excrete sodium, this blood pressure-altering mechanism should have sufficient advantage to limit intravascular volume and consequently lower blood pressure in response to a range of stimuli from elevated heart rate to increase peripheral vascular resistance. A major determinant of the level of intra- and extra- renal blood pressure is therefore sodium handling, and it is controlled by complex physiological mechanism by hormones, inflammatory mediators, and the sympathetic nervous system. Homoeostasis and favourable influence sodium balance are a basic mechanism of efficacy for diuretics and dietary sodium restriction in hypertension. Renin Angiotensin System (RAS) inhibitors, vasodilators, and β-blockers work to facilitate pressure-natriuresis. Also, WNK signaling pathways, soluble inflammatory mediators, and pathways regulating extra-renal sodium disposition may be the focus towards elimination of sodium and reducing blood pressure in hypertension.

The National Programme for Prevention and Control of Deafness (NPCD) was launched in 2006 by Government of India, but despite its phase wise implementation, the community oriented ear care has not been properly realized in view of existing IPHS Standards 2012 at PHC Level. So understanding of its real impact after implementation is desired. Therefore the Impact of Implementation status of community oriented ear care at the primary health system level on NPCD in India needs exploration.

Quadricuspid aortic valve (QAV) is rare congenital malformation of the aortic valve with estimated prevalence of 0.013% to 0.043% [1-4]. QAV is most commonly associated with aortic insufficiency (AI), which is found in almost 75% of cases [5]. QAV can also be associated with other cardiac defects such as ventricular or atrial septal defects, patent ductus arteriosus, subaortic fibromuscular stenosis, malformation of the mitral valve, and coronary anomalies [3]. Up to 40% of all patients with QAV undergo aortic valve replacement surgery most commonly due to progressive AI in 88% of case [2,3,6]. Here we report a case from our institution of a woman with QAV with severe AI and anomalous origin of the right coronary artery.

Background and Aims: the Aim of the study was to find the level of protection among the healthcare workers (nurses, doctors, housekeeping staff and general duty assistants) by doing Anti-HBsAb titer and vaccinate those who were not properly immunized against HBV infection. Materials and Methods: The study was approved by the Institutional review board of the Hospital. The study group included doctors, nurses, technical staff and lab attendants. Anti-HBs antibody titer was done on Vitros 3600 (OCD, USA). Tests were performed according to manufacturer’s instruction. Vaccine provided was Engerix B (GSK Glaxo, Belgium). Vaccination was provided to all employees had titer below 10 miu/ml. Results: 489 of 794(61.5%) HCW had no history of previous vaccination and only 293 (36.9%) subjects had complete vaccination. Only 60.8 % (482/794) of the total subjects had titer above 10 miu/ml and were protected against Hepatitis B. Around 80.6% (246/305) of those who were fully vaccinated and 40.8% (237/489) of those who were not vaccinated previously had protective anti-HBs titers(>10 miu/ml). Majority (86.8%, 271/312) who had titer below 10 miu/ml were unvaccinated. Two of eight employees who had history of needle stick injury in past were found non-immune to Hepatitis-B infection. Conclusion: Despite being involved in the procedures with high chances of infections through needle stick or other exposures, only one third of health care workers were vaccinated against hepatitis B. We recommend that all the HCWs should be vaccinated for Hepatitis B and their anti-HBs levels determined at regular intervals.