Perforated isolated jejunal diverticulum: a rare cause of acute abdomen

A 45-year-old female presented with pain in peri-umbilical region for past one day along with history of non-bilious vomiting and non passage of stool and flatus for past one day. On physical examination, patient was afebrile, mild dehydration was present, tachycardia of 102 beats per minute with normal blood pressure. On clinical examination, the abdomen was diffusely tender with rebound tenderness. Bowel sounds were absent. Laboratory investigations revealed leucocytosis. An erect plain chest X-ray was done, didn’t reveal any gas under the diaphragm. Contrast enhanced computed tomography abdomen was done which showed a hollow viscus perforation with intra-abdominal free air and pelvic free fluid. Patient was resuscitated with IV fluid, broad-spectrum antibiotics were started and immediately taken up for exploratory laparotomy. Three jejunal diverticula identified at mesenteric border, with pin-head perforation in one of the diverticula. Small bowel resection including the three diverticula and primary end-to-end anastomosis was performed. Post-operative period was uneventful. Patient discharged on satisfactory conditions. This case stresses the importance to consider this entity in cases of unexplained gastrointestinal symptoms because any treatment delay may lead to unsuccessful clinical outcome.

Prevalence and molecular detection of contagious bovine pleuropneumonia in large ruminants in Punjab, Pakistan

@#Contagious bovine pleuropneumonia (CBPP) is a highly contagious disease of cattle caused by Mycoplasma mycoides subsp. mycoides. It is characterized by anorexia, fever, dyspnea, polypnea, cough, and nasal discharges. Gross lesions in the lung such as marbling, sequestra, thickening of interlobular septa, and consolidation are evident. Serological tests including complement fixation test and competitive enzyme-linked immunosorbent assay and molecular tests such as polymerase chain reactions are used for diagnostic purposes. In this study, lung samples of suspected large ruminants (cattle n=560, buffalo n=293) were collected from abattoirs of three districts of Punjab namely Lahore, Kasur and Jhang. PCR was performed with specific primers, targeting the 16S ribosomal RNA gene to detect the positive cases. The results indicated that 49 samples (8.75%) of cattle were positive, with maximum prevalence was observed in Jhang with 16 positive samples (10.06%), but CBPP was not detected in any buffalo sample. High prevalence of disease was seen in cattle of more than seven years of age, in female cattle, and in cross-bred cattle. Age and gender were found significantly associated (P<0.05) with the prevalence of the disease. Gene sequencing of identified 5 isolates of Mycoplasma mycoides subsp. mycoides had more than 99% similarities with the strains isolated from China, Italy, Australia and Tanzania and were categorized into a monophyletic group but strain isolated from Portugal had more than 55% variable regions, hence clustered separately. This study confirms the presence of contagious bovine pleuropneumonia in the country which can be a threat to the livestock export market and warrants the implementation of control measures to mitigate the economic losses associated with the disease.

Synthesis and Development of BACE 1 Inhibitor for Alzheimer’s Diseases from Medicinal Plants

Medicinal plants have shown great promise in treating Alzheimer’s disease (AD), which significantly contributes to the production of pharmaceutical and cosmetic molecules with biologically efficient moieties. Plants derived bioactive compounds have been isolated from the medicinal plants and are used in brain diseases. Accountable for brain diseases. Plant extracts have undesirable effects such as acute or chronic toxicity; this could be involved in the delay or discouraging the adoption to the brain cells for proper and effective treatment. β-secretase is the primary protease in the process of producing Amyloid β (Aβ), which is an amyloid precursor protein in brain cells. This review is focused on the numerous different bioactive compounds present in medicinal plants such as Flavonoids, Phenyl propanoids, Prenylated flavones, Naphthoquinone, Resveratrol, Phlorotannins and Glycoside derivatives. Even though medicinal plants and their functional derivatives were reported to be good source of alternative medicines for long sought diseases like AD; but clinical trials on human are yet to be beyond the preliminary stages. The useful applications of these compounds, as bio-markers are also being explored, to further enrich control of Alzheimer’s.

Spatial and Temporal distribution of Aedes (Diptera: Culicidae) mosquitoes in Shah Alam

Surveys are conducted at central zone of Shah Alam in determining the distribution of dengue vector mosquito population. A minimum of 100 houses was randomly searched for breeding at every 24 localities in central zone of Shah Alam. Number of buildings at central zone of Shah Alam was obtained from the local authorities in order to calculate the sample size. The positive and wet containers in each locality were recorded and the types of container for positive containers were categorized accordingly. The numbers of larvae in each container were collected. The pupal index (PI), house index (HI), container index (CI), and the Breteau index were calculated for each locality. Plastic containers (CID 1) showed the highest number of positive, while Seksyen 1 and Seksyen 14 showed the highest percentage of BI with 70% and 80% respectively. This study would provide the information regarding Aedes mosquito infestation and , highlighted the central region as the dengue fever was fluctuating in these area. It can also help to create strategy to reduce the mosquito menace in our country with more cost-effective mosquito larval control.

Characterization and anti - microbial susceptibility of gram - negative bacteria isolated from bloodstream infections of cancer patients on chemotherapy in Pakistan.

Purpose: Bloodstream infection remains a major cause of morbidity and mortality in patients undergoing treatment for cancer. Severe infections due to Gram-negative bacilli & staphylococci are common in cancer patients. Altered gut flora because of frequent antibiotic administration and damage of epithelial surfaces contribute to the development of infection. To access the use of new potent antibiotics against bloodstream infection in cancer patients and to determine the cross resistance of Gram-negative bacterial strains. Materials and Methods: We studied the bacterial spectrum & antimicrobial susceptibility pattern of cephalosporins, fluoroquinolones, carbapenems and aminoglycosides against Gram-negative bacterial strains in cancer patients. The susceptibility was determined by broth dilution method according to National Committee for Clinical Laboratory Standards (NCCLS) now called Clinical Laboratory Standards Institute (CLSI) during study period (July 2006 to Jan 2007). Results: A total of 60 Gram-negative bacterial blood cultures were examined. Among these, Pseudomonas aeruginosa was the most common (38%). The Minimum Inhibitory Concentration at which 50% (MIC 50 ) and 90% (MIC 90 ) of Enterobacteriaceae and P. aeruginosa inhibited were found. Resistance in P.aeruginosa against cefepime, meropenem, ciprofloxacin, ceftriaxone, tobramycin, cefoperazone and imipenem was 60%, 13%, 80%, 67%, 40%, 90% and 10% respectively while for Enterobacteriaceae 80%, 20%, 88%, 72%, 20%, 90% and four per cent resistance was observed. Meropenem was found to be the most effective antimicrobial against Gram-negative bacteria. Conclusion: High resistance observed in this study warrants the needs of surveillance of resistant pattern of antimicrobial agents. Due to increased level of drug resistance, carbapenem would be a prudent choice in high- risk cases.

Central nervous system tuberculosis and adjuvant corticosteroid therapy.

Tuberculous involvement of central nervous system is one of the important health issues causing high mortality and morbidity. Uncertainty and doubt dominate all aspects of CNS tuberculosis. Diagnosis is mainly based on clinical features, cerebrospinal fluid changes, and imaging characteristics. Few studies have shown that corticosteroids improve the clinical outcome, although the precise mechanism of action remains tentative. All the cases were selected on strong clinical suspicion of CNS tuberculosis. They were graded according to tuberculous meningitis (TM) severity grades. In this connection, we studied 13 patients in one medicine unit over 12 month's period to see the effect of corticosteroid as part of the outcome. Nine patients (69.23%) were in grade II, three (23.08%) patients were in grade III, and one (7.69%) was in grade I. Seven patients (53.85%) had tuberculous meningitis and six (46.15%) had tuberculoma (CT or MRI). Out of 13 cases 3 patients (23%) died in the hospital and 10 patients (77%) improved, of whom 2 patients (20%) recovered completely and 8 patients (80%) had residual neurological deficit. Our study suggests that the early detection of CNS tuberculosis is the most important prognostic factor. Timely started anti-Koch's treatment with adjuvant corticosteroid therapy has a direct bearing on patient outcome.

Evaluation of alternative diagnostic techniques for diagnosis of cerebral malaria in a tertiary referral hospital in Bangladesh.

Five alternative techniques for diagnosis of malaria were evaluated in 124 clinically diagnosed cerebral malaria cases admitted in a tertiary hospital in Bangladesh. Clinical diagnosis of cerebral malaria was done by WHO criteria. The tests were conventional routine malaria microscopy; prolonged microscopy; dipstick antigen capture assay (Para Sight TM-F test); pigments in peripheral leucocytes and routine microscopy repeated at 12 hours interval. First four tests were done at 0 hours of hospital admission and repeat routine microscopy was added at 12 hours interval. Diagnostic capability of the test was 64%, 65%, 69%, 27% and 63% respectively. None of the tests except pigments in peripheral leucocytes was superior at initial evaluation. Only the dipstick test added 5% more diagnostic possibility compared with routine microscopy as standard. Stratification of diagnostic capability in different ways improved diagnosis 15% and 11% in smear negative cases by dipstick and prolonged microscopy respectively. It was increased by 50% (5/10 patients) with dipstick test in the smear negative patients with history of anti-malarials prior to hospital admission.

Consecutive bites on two persons by the same cobra: a case report

In tropical countries like Bangladesh, persons are bitten by snakes every day and a considerable number of patients die en route to the hospital. An event of consecutive neurotoxic bites on two men by a single snake was observed in the Snake Bite Study Clinic (SBSC) of the Chittagong Medical College Hospital (CMCH). Two brothers, working in their semi-pucca restaurant, were successively bitten by the same cobra on their lower limbs. Within an hour, they were taken to the CMCH. Few minutes after admission, both developed symptoms of neurotoxicity: ptosis, nasal voice, dysphagia, broken neck sign, etc. They received polyvalent antivenom (Haffkine Bio-Pharmaceuticals Company, India) and other auxiliary treatment immediately. Within few hours, neurotoxic features were completely absent. Later, the snake was captured in the restaurant kitchen and identified as monocellate cobra (Naja kauthia) by the SBSC. The elder brother developed significant antivenom reactions and both presented necrosis and ulceration at the bite sites. In these cases, immediate arrival to the hospital and early administration of antivenom resulted in successful recoveries.(AU)

Anti-snake venom: use and adverse reaction in a snake bite study clinic in Bangladesh

Snakebites can present local or systemic envenomation, while neurotoxicity and respiratory paralysis are the main cause of death. The mainstay of management is anti-snake venom (ASV), which is highly effective, but liable to cause severe adverse reactions including anaphylaxis. The types of adverse reaction to polyvalent anti-snake venom have not been previously studied in Bangladesh. In this prospective observational study carried out between 1999 and 2001, in the Snake Bite Study Clinic of Chittagong Medical College Hospital, 35 neurotoxic-snake-bite patients who had received polyvalent anti-snake venom were included while the ones sensitized to different antitoxins and suffering from atopy were excluded. The common neurotoxic features were ptosis (100%), external ophthalmoplegia (94.2%), dysphagia (77.1%), dysphonia (68.5%) and broken neck sign (80%). The percentage of anti-snake venom reaction cases was 88.57%; pyrogenic reaction was 80.64%; and anaphylaxis was 64.51%. The common features of anaphylaxis were urticaria (80%); vomiting and wheezing (40%); and angioedema (10%). The anti-snake venom reaction was treated mainly with adrenaline for anaphylaxis and paracetamol suppository in pyrogenic reactions. The average recovery time was 4.5 hours. Due to the danger of reactions the anti-snake venom should not be withheld from a snakebite victim when indicated and appropriate guidelines should be followed for its administration.(AU)

Monitoring efficacy of commonly used antimalarials by a 14-day in-vivo test in a new settler's camp in endemic zone at Cox's Bazar.

The study was done in a new settler's camp "Barachara" under Sadar thana of Cox's Bazar district. It has a total population of 784 of all age groups, registered in the middle of the study period. A prospective evaluation of all cases of fever were done over 12 months, to see the pattern of febrile illness among the population and to compare the therapeutic efficacy of two alternative drug regimens for uncomplicated falciparum malaria (UM). Blood for malarial parasite (MP) was done in all cases of fever and was treated in line with the new clinical case definitions and treatment guidelines for malaria in Bangladesh. Slide positive UM cases were subjected to a "14-day in-vivo test" for therapeutic efficacy testing of antimalarial agents. The two drug regimens were randomised by lottery--a) 3 days oral chloroquine plus single dose sulphadoxin/pyrimethamine (CQ + SP) and, b) 3 days oral quinine plus single dose sulphadoxin/pyrimethamine (Q3 + SP). Drug administration was supervised by the field assistant and was followed up on days 3, 7 and 14 for blood slide examinations and clinical assessment. Sensitive response was observed in 79% of the cases in the CQ + SP group and 84% in the Q3 + SP group. Early treatment failure (persistently febrile and parasitaemic on days 3 or 7) was observed in 16% in the CQ + SP group and 9% in the Q3 + SP group. Both the evaluated drug regimens had less than 20% failures and can be used as alternative first line agents and Q3 + SP regimens can also be used as the second line agents for treatment failure (to chloroquine and/or SP) UM cases in the study area.

Cerebral malaria--a study of 104 cases.

One hundred and four adult cases of cerebral malaria (73 male, 31 female) were studied between July 1995 to June 1996 in Chittagong Medical College Hospital. Diagnosis of cerebral malaria was based on unrousable coma or any neurological manifestation in a febrile patient with asexual Plasmodium falciparum in blood film. Intermittent fever (83%), vomiting (80%), headache (75%), convulsion (60%) and history of travel or residence in malaria endemic area were important features noted in patients with cerebral malaria. Most of the patients (69%) were admitted within 25 to 48 hours following unconsciousness. The factors are more common in cases with high mortality with diastolic blood pressure (DBP) below 60 mm of Hg, anaemia, persistence of Glasgow Coma Score below 5 on day 2, high parasite count at presentation, proteinuria and high level of serum urea. Out of 104 cases of cerebral malaria 66 patients (63.5%) recovered without sequelae, 34 patients (32.7%) died and 4 patients (3.8%) recovered with some residual sequelae. Establishment of intensive care unit in tertiary level hospitals is necessary to take appropriate measure for severe cerebral malaria cases for reduction of mortality.

nasocardiac reflex

Sudden bradycardia and hypotension as a result of Nasocardiac reflex was manifested in a fit young man during the surgical procedure of septoplasty. Adequate monitoring is of paramount importance in all rhinological procedures and drug of choice during such event is intravenous atropine

Malignant melanoma of the eyelid in a Pakistan woman

Malignant melanotic tumors occur infrequently in Pakistan, and an eyelid malignant melanoma is even rare. During a prospective study of the eye tumors in Sindh, we saw a 65-yea-old woman who had a malignant melanoma of the right lower eyelid, the first such published documentation from Pakistan. The tumor had metastasized to preauricular lymph nodes, the enlargement of which had been apparent to the patient for nearly six months. The management included full thickness eyelid and preauricular lymph node excision followed by local irradiation. No recurrence occurred during the first six postoperative months, after which the patient unfortunately was lost to follow-up. [Pakistan Journal of Ophthalmology 9:41-42, April, 1993.]

Higher incidence of eyelid squamous cell carcinoma in comparison to basal cell carcinoma

According to this study, the incidence of eyelid squamous cell carcinoma [45%] is nearly twice the incidence of basal cell carcinoma [25%] in the upper Sindh and the surrounding areas of Baluchistan, Pakistan. Also, squamous cell carcinoma occurred twice as frequently in the lower eyelid [six cases] than in the upper eyelid [three cases]. Both of these findings are contrary to the established views of the Western authors and publications. Nonetheless, more research is needed in all parts of the country to confirm this most interesting discovery of our study. Out of a total of 20 histopathologically studied eyelid tumors collected from the Department of Ophthalmology and the Department of Pathology, Chandka Medical College, Larkana, nine [45%] were squamous cell carcinomas, 5 [25%] basal cell carcinomas, one [5%] sebaceous adenocarcinoma, two [10%] neurofibromas, one [5%] compound nevus, and one [5%] tricho-epithelioma. One lesion [5%] was a chronic tuberculous granuloma. The racial, genetic, socioeconomic, and environmental factors may be responsible for this reverse trend in the relative incidence of squamous and basal cell carcinomas of the eyelid. All of the patients in this study were from the poor socioeconomic group

Role of the human rotavirus in childhood diarrhea

The human rotavirus [HRV] was detected by the enzyme-linked-immunosorbent assay [ELISA] in stool samples of 34[23%] of 150 infants and young children below three years of age hospitalized for the management of acute gastroenteritis at Al- Yarmouk Teaching Hospital, Baghdad, over a nine-month period [February through October, 1985]. The HRV was found to be the most important agent associated with diarrhoea in this study. Five of the rotavirus-positive patient had associated bacterial enteropathogens

Oculocardiac reflex during excision of periorbital tumor - a case report

The occurrence of oculocardiac reflex causing severe bradycardia and hypotension during the excision of a large, hemorrhagic, periorbital tumor in a 66 year old male is presented. The reflex occurred despite complete destruction of the eye by the tumor. Intravenous atropine, 0.5 mg, restored both the heart rate and blood pressure and prevented further occurrence of the reflex during the rest of the operation