Pattern of bacteraemia following endoscopic elective oesophageal injection sclerotherapy and band ligation in cirrhotic patients

Gastrointestinal endoscopy is an invasive technique and it may be associated with a risk of bacteraemia, especially if endoscopy is associated with an intervention such as injection sclerotherapy or band ligation. The aim of the work is to investigate the incidence of bacteraemia following elective elastic band ligation and elective injection sclerotherapy in cirrhotic patients. Our study included 80 cirrhotic patients with grade III-IV oesophageal varices divided into three groups: 30 patients treated with elective injection sclerotherapy, 30 patients treated with elective band ligation and 20 patients underwent diagnostic upper endoscopy and served as control. All patients were subjected to full clinical evaluation, abdominal ultrasonography and lab investigations, including blood culture before and after the endoscopic procedure. No positive blood cultures were detected before the technique. Seven patients [8.75%] had positive blood culture after endoscopy; six of them [20%] were in the injection sclerotherapy group, one patient [3.33%] in the band ligation group and none in the upper endoscopy group. Positive blood culture was more frequent in child C patients [four patients] compared to child B [two patients] and child A patients [one patient] with statistically significant difference. Three types of micro-organisms were isolated: Acinetobacter, alpha haemolytic streptococci and coagulase negative staphylococci. The rate of bacteraemia is higher in the injection sclerotherapy group compared with the band ligation group, especially in child C patients

Non invasive prediction of varices in Egyptian cirrhotic patients

Cirrhotic patients frequently undergo screening endoscopy for the presence of varices. In the future, this social and medical burden will increase due to the greater number of patients with chronic liver disease and their improved survival. In this study, our aim was to develop a predictive model using independent risk factors for the presence of varices in the enrolled patients. 200 patients with liver cirrhosis with no history of variceal haemorrhage were subjected to clinical examination; laboratory investigations [CBC, Liver biochemical profile, serum urea and creatinine], modified Child-Pugh score and MELD score were calculated. Abdominal ultrasonography and Doppler study of the portal and splenic veins studying the liver size, the presence of periportal thickening, hepatic veins flow pattern, the splenic longest axis and volume, the presence of ascites and collaterals. Portal vein and splenic vein diameter, patency, cross sectional area, mean flow velocity, blood flow volume congestion index and direction of flow of portal vein were calculated. Platelets count/Splenic diameter ratio and Right liver lobe diameter/ albumin ratio were calculated for all patients. Upper endoscopy was done where oesophageal varices were graded according to modified Thakeb classification. This study revealed that 83% of patients had oesophageal varices; 52% had small sized oesophageal varices and 31% had large sized oesophageal varices. In patients with varices; 12% had biphasic and 22.9% had monophasic hepatic veins flow pattern, with p value of 0.002. Portal vein direction of flow was bidirectional in 22.9% and Hepatofugal in 9.6% with a p value of 0.004. The portal vein velocity of 9.3 +/- 2.3cm/ sec with a p value of <0.001 and the ascites was present in 77% of patients with a p value of 0.005. In patients with large sized varices; shrunken liver was present in 83.1% of patients with a p value of 0.005 and serum albumin <2.5gm/dl with a p value of 0.008. Hepatic veins flow pattern [biphasic and monophasic], portal vein direction of flow [hepatofugal and bidirectional], decreased portal vein velocity and the presence of ascites [moderate and marked] were the significant variables for prediction of presence of varices. Shrunken liver and the low serum albumin were the significant variables for prediction of large varices

Spirometric plus left ventricular and pulmonary blood flow echocardiographic findings in patients with scleroderma before and after sildenafil

Systemic sclerosis [scleroderma] is a chronic debilitating disease that is caused by the occurrence of fibrotic changes and vascular abnormalities at various levels such as: Skin, lungs, kidneys or heart. Lung involvement in scleroderma is one of the leading causes of mortality in this disease. Sildenafil inhibits phosphodiesterase type 5, an enzyme that metabolizes cyclic guanosine monophosphate, thereby enhancing the cyclic guanosine monophosphate-mediated relaxation and growth inhibition of vascular smooth-muscle cells, including those in the lung. We hypothesized that chronic oral administration of the phosphodiesterase-5 inhibitor sildenafil could improve the pulmonary haemodynamics in Systemic sclerosis [Ssc] patients. To investigate the use of sildenafil, detect the effect of sildenafil on the left ventricular function and the pulmonary blood flow echocardiographic parameters and pulmonary functions in a series of SSc patients. Twenty three systemic sclerosis cases were selected for the study. All patients were subjected to clinical evaluation, laboratory investigations, plain chest X-ray, ECG, basal pulmonary function tests and basal echocardiographic assessment. One week of therapy with oral sildenafil 75mg/day in three divided doses was given to the patients, after which they were subjected to a second assessment of respiratory function tests and echocardiography. Sildenafil therapy resulted in the following changes: Mitral E/A was significantly increased [p<0.05]. This was further supported by a significant drop of the pre-ejection period [p<0.001] after using sildenafil. There was a significant rise in acceleration time and the ratio between it and ejection time in both aortic and pulmonary Doppler. Also there was a significant decrease in pulmonary artery diameter [p<0.001], maximal pulmonary flow velocity [p<0.001], pulmonary integral area under the curve [p<0.001] and mean acceleration [p=0.007]. Some ventricular contractility indices as the posterior wall excursion [p=0.001], inter-ventricular septal excursion [p=0.043], velocity of posterior wall excursion [p<0.001], velocity of interventricular septal excursion [p<0.001] showed statistically significant increase. The left ventricular internal dimensions and volume in diastole showed a significant drop [p=0.001, p=0.002 respectively], there was a significant increase in the interventricular septum thickness in systole and diastole [p<0.05] with a borderline significant increase in posterior wall thickness in systole [p=0.05]. Spirometric studies showed a statistically significant increase in FEV[25-75] after the use of sildenafil, [p<0.05] which denotes improvement of airway obstruction. Sildenafil improved left ventricular systolic and diastolic functions and may improve pulmonary blood flow in patients with systemic sclerosis. PDE-5 inhibitors are efficacious in scleroderma-associated pulmonary hypertension

Validity of platelet count/spleen diameter ratio as a predictor of esophageal varices in patients with liver cirrhosis

Portal hypertension commonly accompanies the presence of liver cirrhosis, and the development of esophageal varices [OV] is one of the major complications of portal hypertension. To evaluate platelet count/splenic size ratio as a non-invasive parameter to predict the presence or absence of esophageal varices in patients with liver cirrhosis. Eighty-six cirrhotic patients who underwent digestive upper endoscopy, were classified into Group 1 which is formed of 60 patients who had endoscopic evidence of OV and Group 2 which is formed of 26 patients who had no endoscopic evidence of OV. All the patients underwent thorough clinical examination, laboratory and ultrasonographic evaluation. Laboratory investigations were done in the form of complete blood count including platelet count [PLT]; liver function tests [aspartate transaminase [AST], alanine aminotransferase [ALT], serum bilirubin and prothrombin time [PT]], schistosomal antibodies, hepatitis B surface antigen [HBsAg] and hepatitis C virus antibodies. Abdominal ultrasonography and upper gastrointestinal endoscopy were done for all patients. Patients with OV had lower mean platelet count and higher mean spleen diameter than patients without OV [p=0.003 and p=0.01 respectively]. The mean values of the ratio of platelet count/spleen diameter was significantly lower among OV group when compared with patients who had no endoscopic evidence of OV [p=0.002]. There was no significant difference in the platelet count/spleen diameter ratio between different grades of OV. Large OV was associated with increased portal vein diameter [p=0.05]. Lower platelet count/splenic size ratio is associated with the presence of OV yet it cannot be used as a predictor of OV and so the endoscopy remains the standard screening test for OV among patients with liver cirrhosis

Percutanous ablative therapy for HCC: a comparison of three modalities

This study was performed on 78 patients having liver cirrhosis with 91 focal hepatic lesions detected by ultrasound and proved histopathologically to be HCC [biopsy and/or fine needle aspiration cytology; FNAC]. They were 70 males and 8 females their ages ranged between 37 and 75 years old. Patients were classified into three groups, Group A was formed of 32 patients with 37 focal lesions where they received RFA. Group B encountered 25 patients with 26 focal lesions and they received PAI Group C included 21 patients with 28 focal lesions were treated by PEI. Complete ablation was assessed by re-biopsy and/or FNAC, triphasic CT and AFP serum level. As regards the outcome of therapy in group A, complete ablation was achieved in 14/18 [78%] for lesions

Plasminogen activator inhibitor-I and insulin resistance in coronary heart disease male patients with and without type 2 diabetes mellitus

Features and prognosis of coronary heart disease [CHD] differ between diabetics and nondiabetics. This work aimed to study plasminogen activator inhibitor-l [PAl-1] antigen as a fibrinolytic marker, insulin resistance and lipid profile in type 2 diabetic and nondiabetic male patients with CHD, in an attempt to find an explanation-in part-why type 2 diabetics have a less favorable prognosis than the nondiabetics as regard CHD. Sixty male patients with CHD were selected; their age range was 50-60 years. 30 patients were with type 2 diabetes mellitus [DM] [group I] and 30 patients were non-diabetics [group II]. In addition to 15 matched healthy volunteers [control group]. Compared with the controls, diabetic group showed significant higher fasting glucose and insulin levels, insulin resistance [by homeostatic model assessment HOMA], systolic and diastolic blood pressure levels, total cholesterol, triglycerides, low density lipoprotein-cholesterol [LDL-C] and PAI-1; this is in addition to significant lower level of high density lipoprotein-cholesterol [HDL-C]. On comparing the nondiabetic group with the controls, there were similar pattern of changes. On comparing the diabetic and the nondiabetic groups, there were significant increases of systolic blood pressure, total cholesterol, triglycerides;LDL-C, PAl-1, and HOMA index. Both diastolic blood pressure and HDL-C showed non-significant changes. In both the diabetic and nondiabetic groups, PAI-1 showed positive correlations with systolic and diastolic blood pressures, HOMA index, total cholesterol, triglycerides and LDL-C; while HDL-C showed negative correlation. In both the diabetic and nondiabetic groups, HOMA showed positive correlations with total cholesterol, triglycerides, LDL-C and PAI-1; while it was negatively correlated with HDL-C. It was noted that CHD male patients whether with or without type 2 DM were dyslipidemic, with high readings of blood pressure, insulin resistant and had high level of PAl-1. However, CHD patients with type 2 DM had higher degree of disturbances of these coronary risk factors than the nondiabetic patients with CHD. Insulin resistance appeared to be important in such disturbances. In addition, there were complex relationships among the few studied CHD risk factors. This was noted in both studied groups. Finally, it can be concluded from this study that the less favorable prognosis of male patients with type 2 DM and CHD appeared to be -in part-to the heavier burden of the atherothrombotic risk factors of higher blood pressure, dyslipidemia, insulin resistance and abnormal fibrinolysis than the nondiabetic patients. We recommend reduction of insulin resistance in the male diabetic and nondiabetic patients with CHD to reduce the tendency to develop thromboses, hence reducing risk of CHD events

Optimal end-tidal Sevoflurane concentration for rapid and safe insertion of laryngeal mask airway and endotracheal tube in children

Laryngeal mask airway and sevoflurane are increasingly used in anesthesia for children undergoing minor and moderate surgical procedures. We aimed to determine end tidal sevoflurane concentration that allows insertion of either LMA or ETT without adverse airway events within clinically acceptable time [5 minutes]. One hundred and sixty children [3-9 years] were randomly allocated into either LMA [70 children] or ETT group [90 children] according to method of airway securing. Patients in each group were further subdivided into subgroups [n = 10 each] according to the predetermined sevoflurane concentration that would be applied for 5 minutes, into LMA [7 subgroups] 1%, 1.5%, 2%, 2.5%, 3%, 3.5% and 4% and ETT [9 subgroups] 2%, 2.5%, 3%, 3.5%, 4%, 4.5%, 5%, 5.5% and 6%. Patient response to either LMA or ETT insertion was recorded as yes or no. Curves were constructed by plotting the value of end tidal sevoflurane concentration against percentage of non responders in each subgroup. Mean arterial pressure, heart rate, end tidal carbon dioxide and oxygen saturation were also recorded. End tidal sevoflurane concentrations that achieved LMA insertion without response in 50% and 95% of children were 2.2 [0.2]% and 3.8 [0.24]% respectively meanwhile, those for endotracheal intubation were 3.8 [0.37]% and 5.9 0.39]% respectively. Rapid [5 minutes] and safe insertion of LMA and ETT in 95% of children could be achieved at end tidal sevoflurane concentrations of 3.8 [0.24]% and 5.9 [0.39]% respectively

Structure assessment in a neonatal intensive care unit

The aim of this study was to asses the quality of the nursing care provided at the Neonatal Intensive Care Unit [NICU] at Princess Badia Teaching Hospital, Jordan, as regards the various components of structure domain within the context of quality. A checklist for structure assessment was developed including criteria classified under three main areas; namely, material resources, human resources and organizational structure. The results revealed certain deviations from the recommended compliance scores for each area. Recommendations were proposed to stress the importance of the NICU being specifically built to reflect the practice, environment and cultural needs as well as continuous education activities of NICU staff. Documented policy and procedure manuals were also recommended for assuring maintained quality care at the NICU

Quality of nursing care provided in a neonatal intensive care unit. Structure assessment

Structure is considered one of the three major approaches in the evaluation of quality; the other two being process and outcome. Appraisal of structure involves the attributes of the settings in which care is delivered that includes the material resources, the human resources and the organizational structure. The aim of the study was to assess the quality of nursing care provided at the neonatal intensive care unit [NICU] at Princess Badia Teaching Hospital, Jordan, as regards the various components of structure domain within the context of quality. A checklist for structure assessment was developed which included criteria classified under three main areas; namely, material resources, human resources and organizational structure. The results revealed certain deviations from the recommended compliance scores for each area. Recommendations were proposed to stress the importance of the NlCU being specifically built to reflect practice, environment and cultural needs as well as continuous education activities of NICU staff. Documented policy and procedure manuals were also recommended for assuring maintained quality care at the NICU

Low back pain in rheumatoid arthritis

This study was conducted on forty rheumatoid arthritis [RA] patients. They consisted of 38 females and 2 males, with a mean age of 39.55 +/- 68 years. They used to suffer from low back pain with a mean of 20.3 +/- 15.5 months duration. The mean duration of RA was 4.15 +/- 3.38 years. Five females and 15 males suffering from mechanical low back pain for a mean of 21.4 +/- 13.7 months were included in the study for comparison. Their mean age was 40.4 +/- 6.7 years. All patients were subjected to clinical and physical examination of lumbo-sacral region and imaging studies: plain X- rays both antero-posterior and lateral views as well as computed tomography [CT] of the lumbo-sacral spine. There was a significant difference in straight leg raising and femoral nerve stretch tests between the two groups. Plain X-rays showed a highly significant difference in osteophytes and a significant difference in osteoporosis, spondylolisthesis, erosion and facet joint changes. CT findings showed a highly significant difference at vacuum phenomenon in both groups and a significant difference in osteophytes, facet joint, disc changes and osteoporosis. Also, there was a highly significant correlation between duration of RA and development of osteoporosis. Type of medication and duration of RA had significant correlation with development of osteoporosis. The cause of low back pain in RA is multifactorial including facet joint synovitis, crush fracture, associated osteoporosis, spondylolisthesis and disc changes. Osteoporosis and facet joints appear more clear by using CT