Morphométrie et variantes anatomiques des artères digestives vues au Scanner / Morphometric and anatomical variations of digestive arteries view in Computer Tomography

Les artères digestives essentiellement le tronc cœliaque et l'artère mésentérique supérieure présentent plusieurs variantes anatomiques notamment au niveau de leur origine. L'objectif de cette étude était d'illustrer l'anatomie normale ainsi que les variantes anatomiques des artères digestives vues au scanner. Nous avons réalisé une étude transversale portant sur les scanners avec coupes abdominales sans et avec injection de produit de contraste iodé au temps artériel. Le tronc cœliaque et ses branches, l'artère mésentérique supérieure et l'artère mésentérique inférieure ont été étudiés. Nous avons collecté 155 patients. Plusieurs variantes anatomiques fréquentes et multiples ont été retrouvées, dont l'absence de tronc cœliaque (3 cas), le tronc hépato-splénique (12 cas), le tronc hépato-gastrique (2 cas), le tronc gastro-splénique (5 cas) et le tronc coeliacomésentérique (1 cas). Pour l'artère hépatique, il existait les types I (121 cas), II (13 cas), IV (1 cas), V (3 cas) et IX (3 cas) selon la classification de Michels, ainsi que d'autres variantes non classifiées (14 cas). Nous avons trouvé également une artère mésentérique moyenne reliant l'artère mésentérique supérieure de l'artère mésentérique inférieure. Cela justifie l'importance et la nécessité de la réalisation du scanner avant tout acte chirurgical impliquant les artères digestives

Surgical approach to manage cerebrospinal fluid rhinorrhea through vault or through nose

Objective: Background: Surgical management of cerebrospinal fluid [CSF] rhinorrhea can be done through a transcranial approach or endoscopically using a transnasal approach. The endoscopic technology is relatively fresh in developing countries. Keeping this in mind we conducted an audit of patients undergoing endoscopic repair of CSF leaks to review their outcome in terms of recurrence and complications and compare them with the patients had transcranial repair. The objective of the study is to review the management of patients who underwent repair of CSF rhinorrhea at Lyari General Hospital, Aga Khan University Hospital and Memon Medical Institute Hospital – 10 years experience

Study design: Cross-sectional observational study

Place and duration of Study: Lyari General Hospital, Aga Khan University Hospital and Memon Medical Institute Hospital, from January 2005 to December 2014

Patients and methods: A review of patient charts having undergone surgical repair for CSF rhinorrhea in the last 10 years at our institution was conducted. Thirty eight patients meeting the inclusion criteria of having undergone a surgical procedure for the repair of CSF rhinorrhea with a minimum post operative follow up of 6 months were included in the study

Results: Skull base defects were repaired with the help of minimally invasive transnasal endoscopic approach with a success rate of 80% in comparison to transcranial repair success rate of 29%. Post-operative complications were seen in only 10% of endoscopic group and 53% of transcranial group

Conclusion: Although endoscopic management is associated with better outcomes there is room for improvement in the approach in developing countries and training programs and detailed internal audits need to be conducted to improve the situation to the level of developed countries

Insidious sensorineural hearing loss in chronic suppurative otitis media

Background: Sensorineural hearing loss may be one of the outcome of chronic suppurative otitis media

Objective: To evaluate the association of chronic suppurative otitis media with sensorineural hearing loss and also to find out whether the disease duration had any impact on hearing

Methodology: This was a cross sectional study conducted at Aga Khan University Hospital. Charts of all patients who underwent surgery for chronic suppurative otitis media from 1stJanuary 2004 to 31stDecember 2009 were reviewed. One hundred and fifty five patients out of 562 met our inclusion criteria and were included in the study. The contralateral ear was taken as control. History record and audiograms were reviewed from the patient charts for the duration of disease and evidence of SNHL at three speech frequencies [[500, 1000, and 2000 Hz]. The data was entered and analyzed by SPSS version 16

Results: Of 155 patients, 46 [29.6%] had SNHL. In a group of patients with epithelial disease[cholesteatoma] 16 out of 45 patients had SNHL whereas in the group of patients with mucosal disease [formerly known as tubotympanic type] 30 out of 110 patients had SNHL. This hearing loss found to be worsening with the duration of disease in both groups [p=0.000]

Conclusion: A significant association of SNHL was found with CSOM and disease duration. Early surgicaltreatment should be offered in order to prevent irreversible SNHL

Hirschsprung's disease; enterocolitis during the course

To determine the frequency of Hirschsprung's Disease associated enterocolitis in pre and post operative patients. Nishtar Hospital and Ibn-e-Sina Hospital, Multan from January 2008 to June 2012. A total number of 114 patients aged from less than 6 months to more than 5 years were diagnosed and treated for Hirschsprung's Disease after rectal biopsy and internal sphinterotomy. In total of 114 patients 32 [28%] developed enterocolitis before and 5 [18.5%] after definite surgery. The results of this study implicates that the early diagnosis and to make measures to decrease the post pull-through anastomostic anorectal stenosis can reduce the frequency of pre and post operative Hirschsprung's disease associated enterocolitis

Histopathological, immunohistochemical, and serological prospective study of H. pylori induced chronic gastritis

H.pylori infection is the major cause of non-autoimmune chronic gastritis. Furthermore, recent studies suggest that H.pylori could have a crucial role in the induction and/or maintenance of autoimmunity at the gastric level. Assess the role of H.pylori in the development of the histopathological features, antral G-cells changes, and induction of gastric autoimmune reaction in chronic gastritis. From each one of eighty dyspeptic patients, multiple endoscopical gastric biopsies from antral and body mucosa, and blood sample were collected. The gastric antral and body mucosa biopsies were processed separately and stained by routine [H and E stain], Giemsa stain, and modified triple Genta stains for histopathological examination according to the updated Sydney System. Further sections from antral biopsies were stained by polyclonal antigastrin antibody immunohistochemical stain for immunohistochemical examination. The blood examined serologically by indirect IF- and ELISA- tests to assess the PCA and anti-H.pylori [IgG] respectively. In antral and body mucosa, the density of H.pylori colonization had significant positive correlation with the grade of both chronic inflammation and PMN activity [P<0.05], but it had no significant correlation with the grade of glandular atrophy [P>0.05]. The mean number of antral G-cells in H.pylori positive instances had no significant difference with H.pylori negative ones [P.0.05]. The rate of anti-H.pylori [IgG] in patients with positive PCA statistically was significantly higher than those in patients with negative PCA [P<0.05]. H.pylori is the commonest cause of chronic gastritis. It plays an important role in the development of its histopathological features. It had no effect on the number of antral G-cells. It plays an important role in the development of gastric autoimmune reaction during its chronic infection that leads eventually to autoimmune chronic gastritis

Hepatitis E virus antibodies in multiply transfused patients

Hepatitis E virus [HEW infection is the leading cause of enterically transmitted hepatitis worldwide. Transmission of infection is via fecal route but the possibility of transmission by blood has been suggested, Data concerning anti-HEV prevalence among children who are exposed to risk of parenteral transmission are few and giving conflicting results. The present work studied the presence of anti-HEV antibodies [IgG and IgM], HBsAg, anti-HCV IgG, anti-HIV antibodies, serum ALT, prothrombin concentration and albumin level in 30 hemodialyzed, 20 thalassemic, 20 hemophilic patients as well as 25 matched age and sex healthy children as controls. The rate of anti-HEVIgG in hemodialyzed, thalassemic and hemophilic patients was significantly higher [43.3%, 35%, 25% respectively] than controls [8%] p>0.001, [0.003, [0.02 respectively. There was a significant positive correlation between the duration of hernodialysis and the number of patients with positive anti-HEV IgG [r = 0.87, pc0.001]. The rate of anti- HEV IgM in the patients groups was significantly higher [20%, 10%, 5% respectively] than controls [0%] p>0.004, >0.001, [0.05 respectively. There was no significant correlation between the frequency of blood transfusion and HEV reactivity in the studied patients groups. The rates of HBV and HCV infections in the different groups of patients were significantly higher [20%, 10%, 5% and 26.6%, 20%, 15% respectively] than controls [0% and 5% respectively] p<0.001, [0.007, [0.05 and <0.001, [0.03, [0.03 respectively. There was no significant correlation between HEV infection and neither HBV nor HCV infections in the studied patients groups

Conclusion: this study indicates a high prevalence of anti-HEV antibodies in multiply transfused children, carrying a possibility of parenteral transmission in endemic areas. However further larger scale technically supported studies are needed to exclude other possibilities

Neurological and psychometric evaluation of children with chronic renal failure

Various neurological and psychological disturbances in children with chronic renal failure [CRF] were reported, the quality of life and psychological adaptation of these children became of increasing interest as the prognosis of this condition improves and mortality decreases. It is recognized, however, that medical advances in nutritional support, pharmacotherapy and dialysis techniques will only finally pay off if the patient adapts to the chronic disease and if the optimal rehabilitation is achieved. The aim of the present work is to evaluate children with CRF on regular hemodialysis [HD] as regards neurological and psychological abnormalities and the correlation with the clinical, as well as, biochemical changes present in these children. The study included 25 children with CRF on regular HD as well as 25 apparently healthy children of matching age and sex as controls. All cases and control children had full clinical assessment Laboratory investigations included complete blood count, complete urine analysis, urine culture, blood urea, and serum creatinine [S.Cr] and serum electrolytes. Creatinine clearance was calculated according to Schwartz formula. Electroencephalogram [EEG] was also done. intelligences quotient [IQ] was estimated. The results showed that the incidence of convulsions and alteration of consciousness Were found significantly higher when duration of CRF is > one year or associated with hypertension, blood urea is > 25 mmol/L, and creatinine clearance is [10 ml/min/1.73 m2. Headache and irritability were significantly higher when CRF is associated with hypertension. Depression was significantly higher when duration of CRF is > one year, blood urea is > 25mmol/L. EEG abnormalities in CRF children included slow background rhythm [52%], abnormal discharge [44%] and bilateral spike and wave complex [20%]. Slow background rhythms was significantly higher when duration of CRF is > one year, blood urea is > 25 mmol/L, and creatinine clearance is

Conclusion: the risk factors for neurological complications in children with CRF are multifactorial and complex. When duration of CRF is > one year, blood urea is > 25 mmol/L, creatinine clearance is < than 10 ml/min/1.73 m2 or hypertension is developed, the frequency of encephalopathy and convulsions is higher. The presence of slow background rhythm in EEG records gives attention to duration of CRF and biochemical disturbances. Psychiatric disturbances and intellectual impairment should be considered as a part of the pediatric handling of children with CRF and need an expertise to be available in the pediatric nephrology team for dealing with both problems. IQ test is recommended to be done regularly as intellectual impairment shows significant correlation with duration of CRF

Psychomotor development of children with congenital heart disease

Children with congenital heart disease [CHD] have an increased risk for neurocognitive deficits. As the mortality of neonatal and infant surgery for CHD continues to decrease, attention is now focused on long- term sequelae, especially later cognitive and neurological function, in survivors. The aim of this work is the early assessment of the psychomotor and cognitive development in children with CHD before two years of age and to evaluate the difference between cyanotic and a cyanotic CHD regarding this development. This could help in early management to minimize neurological injury and improve the intellectual function and academic achievement for such patients in the future. Thirty-eight children with CHD [25 males and 13 females] below two years of age were studied. Twelve of them were cyanotic [31.5%] and twenty-six were a cyanotic [68.5%] CHD. Twenty children of matched age and sex were included in the study as controls. All patients were neurologically free on clinical examination. Anthropometric measurements of patients and controls were recorded including weight, recumbent length, head circumference, mid-arm circumference and the body mass index. The anthropometric percentiles were recorded as well including head circumference for age, recumbent length for age, weight for age, and weight for recumbent length percentiles. The Griffiths developmental scale were used to assess the cognitive and psychomotor developmental status of the children. They covered locomotor skills, personal social skills, hearing speech, eye-hand coordination, and cognitive performance. Total intellectual quotients [IQ %] were calculated. EEG was recorded and Echocardiography was performed for confirming the diagnosis of the CHD, measuring blood flow velocities and the pulmonary pressure. Twelve out of thirty-eight children with CHD [12/38] were diagnosed as cyanotic CHD and included TOF, D-TGA, and DORV as well as [26/38] of patients were diagnosed as a cyanotic CHD and included VSD, ASD, and pulmonary stenosis. The anthropometric measurements and percentiles were significantly lower in patients than controls with no significant differences between cyanotic and cyanotic groups. The IQ% in the studied patients ranged from 68-105% [mean 83.9 +/- 10.6] with no significant difference between cyanotic CHD [mean 82.3 +/- 15] and a cyanotic CHD group [mean 83.7 +/- 10.5] and all were considered sub average [IQ% below 90%]. Hearing speech and eye-hand coordination were the most affected parameter in the two groups of patients. There was a significant positive correlation [r= 0.439, p<0.006] between 16% and head circumference for age percentile. No relation was detected between IQ % and the other anthropometric percentiles or measurements. There was a significant negative correlation [r=-0.826, p<0.001] between IQ% and degree of pulmonary stenosis [pulmonary blood flow velocity cm/sec] in patients with valvular pulmonary stenosis and TOF, a significant positive correlation [r= 0.722, p<0.0008] between IQ % and aortic blood flow velocity [cm/sec] in patients with cyanotic CHD, a significant negative correlation [r =-0.596, p<0.0001] between IQ% and systolic pulmonary pressure in patients with cyanotic CHD. EEG changes were detected in 68% of patients. There was a significant negative correlation [r = - 0.826, p<0.001] between the severity of EEG changes and 14% in the studied patients

Conclusion: psychomotor and cognitive development is likely to be compromised in children below two years of age with CHD with no big difference between cyanotic and a cyanotic groups. Failure to thrive is obvious in these patients. The IQ % is sub average and EEG changes were detected. The hemodynamic changes secondary to the cardiac defect and the feeding problems, leading to failure to thrive, can result in impaired development and intellect This finding can help much in paying attention toward the management of such cases and for the role of early surgical interference in correction of these cardiac defects to prevent the deterioration in psychomotor and cognitive development

Cutaneous manifestations of chronic renal failure in children with emphasis on pruritus in Assiut-upper Egypt

One hundred percent of adult patients with chronic renal failure [CRF] develop cutaneous findings as a result of uremia or therapeutic intervention. The incidence of pediatric end stage renal disease [ESRD] is increasing and the life expectancy is also on rise. Despite this, only few studies have assessed cutaneous manifestations of CRF in children. Pruritus is a frequent feature found in uremic patients, and several causes have been implicated in its pathogenesis. The aim of the present work is to define the occurrence of renal failure related skin diseases in children with CRF undergoing hemodialysis with emphasis on pruritus. Also, to evaluate whether uremic pruritus is correlated to clinical data and serum levels of various endogenous substances including parathormone, vitamin A and histamine. Thirty eight children with CRF undergoing hemodialysis were included. Each patient underwent complete history taking and thorough clinical and dermatological examinations. Severity of pruritus was determined. All patients were subjected to measurement of serum calcium, phosphate, parathormone, vitamin A and histamine. In addition to serum creatinine, blood urea, albumin and hemoglobin. The result proved that the overall skin disorders were 97.6%. Xerosis was the commonest one [71.11%] followed by pruritus [52.6%], pallor [52%], sallow yellowish discoloration in 36.8%, ecchymosis [36.8%], ichthyosis [26.3%] and others. Pruritic patients were classified as mild in 45% and moderate to severe in 55% of cases. There was no relation between the presence and severity of pruritus and age, sex, duration of dialysis, xerosis and hematological and biochemical parameters except for serum histamine. However, serum levels of histamine did not correlate with severity of pruritus

Conclusion: Uremia related cutaneous manifestations were common in children undergoing hemodialysis. Serum histamine may have a potential role in the appearance of uremic pruritus in children. However, additional studies in larger scale are needed to clarify the role of histamine in the pathogenesis of pruritus

Interleukins 8 and 10, and tumor n ecrosis factor alpha and its type I soluble receptor in hemodialysis children with chronic renal failure: relationship to growth and inflammatory markers

Chronic renal failure [CRF] is envisioned as an immunodeficiency state despite the deregulated release of several cytokines and their soluble receptor. TNF-alpha, lL-8 and lL-10 were particularly implicated in priming and desensitization of human polymorphonuclear cells. We hypothesized that imbalance between the proand anti-inflammatory cytokines using inflammatory biomarker as indictors would elucidate underlying causes of such immunodeficiency in a milieu with reportedly apparent constitutively activated immune cells with possible impact on growth. Plasma from 26 chronic renal failure children on regular hemodialysis [HD] and 26 age-matched healthy control individuals were investigated by using ELISA assays for TNF-alpha, sTNF-alpha-R1, lL-8 and lL-10 that were subjected to analysis of variance and multiple regression analysis for correlation with each other and with creactive protein [CRP] and procalcitonin [measured by agglutination and RIA, respectively] as inflammatory markers, and weight-for-age, height-for-age and weight-for-height percentile as growth indices. Plasma levels of CRP, procalcitonin, TNF-alpha, sTNF-alpha-R1 and lL-10 showed significant difference comparing patients to controls, without a significant difference due to HD session per se. Similar difference was noticed for lL-8 although it was significantly increased after HD session. The molar ratio of sTNF-alpha-R1/TNF-alpha was significantly increased in patients than controls only after HD session. At the end of HD session, there was a strong positive correlation between all parameters except IL-10. The cytokines levels correlated stronger with procalcitonin than CRP. Similar correlations were observed before HD session for all parameters except for lL-8 that correlated positively only with sTNFR1 and procalcitonin. The growth indices did not show correlation with the studied biomarkers except for CRP [before and after HD session] and IL-10 [before session only] that showed positive correlation with weight-for-height percentile as a chronic malnutrition marker. Increased secretion of TNFalpha and lL-8 and decreased IL-10 indicated that Immune cells are in an activated state confirmed by the increased inflammatory biomarkers, a state possibly potentiated‘ by the increased sTNF-alpha-R1 in the light of its possible conservatory function on TNFalpha. These results show possible exhaustion of immune cells and long term desensitization in presence of marked increase in proinflammatory inducers and absence of counteracting antiinflammatory effector role in CRF pediatric patients on HD. This raises the importance of intervention approaches to correct such imbalance in favor of IL-10 for the-benefit of growth

study on breath holding spells: impact on iron therapy

To evaluate the prognosis of breath-holding spells [BHS] after iron treatment, 30 children [20 boys and 10 girls] aged between 10 months and 7 years [mean age 20.2 months] were followed prospectively for 3 months on iron therapy. It was found that spells were cyanotic in 60%, pallid in 26.7% and mixed in 13.3%. All patients were evaluated initially for hematological indices and EEG. All patients received iron therapy for 3 months [6mg/kg/day]. There was marked reduction in the frequency, duration and severity of BHS after iron therapy

Dyslipidemia, oxidative stress and cardiac dysfunction in children with chronic renal failure: effects of l-carnitine supplementation

Secondary carnitine deficiency may develop in chronic renal failure [CRF] patients undergoing long-term hemodialysis [HD], with a resulting higher incidence of cardiovascular diseases, dyslipidemia and oxidative stress. We studied the efficacy of 12 months of L-carnitine supplementation on the amelioration of dyslipidemia, oxidative stress and cardiac dysfunction in 24 CRF children undergoing long-term HD compared with 24 age- and sex-matched controls. Plasma samples were analyzed spectrophotometerically before and after dialysis sessions and after 2-month supplementation with oral L-carnitine [50 mg/kg/day] for free carnitine [FC], the lipid profile, and oxidative stress markers. Echocardiography the day following dialysis measured cardiac diameters, wall thicknesses, left ventricular mass index [MI], end diastole and systole volume indices and functions. The pre-dialysis FC concentration was substantially lower than controls and decreased significantly at the end of the dialysis session. Pre- and post-dialysis plasma levels of free fatty acids [FFAs], trigyleride [TG], total cholesterol [TC] and oxidative stress markers significantly increased while high-density lipoprotein cholesterol [HDL-C] and phospholipids significantly decreased compared to controls. Echocardiography detected a significant increase in cardiac diameters and thickness, and systolic and diastolic cardiac dysfunction. After L-carnitine supplementation, plasma levels of FC increased to normal levels. FFAs, TC and HDL-C returned to control levels while TG, phospholipids, and the oxidative stress markers decreased but remained significantly higher than controls. There was a significant decrease in cardiac diameters and an increase in left ventricular diastolic function [E/A ratio], but no correlation between FC levels and echocardiographic parameters. Pre-dialysis, post-dialysis and after treatment, plasma FC level showed a significant positive correlation with HDL-C and phospholipids and a significant negative correlation with each of oxidative stress markers, FFAs, TG and TC. On the other hand, FFAs showed a significant positive correlation with TG, TC, DC, NO and a significant negative correlation with HDL-C and phospholipids. This study demonstrates that CRF children under regular HD suffer from a decrease in the level of plasma FC, dyslipidemia, oxidative stress, and an increase in cardiac diameters and thickness with impairment of cardiac functions. Oral L-carnitine supplementation at a dose of 50 mg/kg for 2 months can increase plasma FC level, improve dyslipidemia, decrease oxidative stress with reduction of cardiac diameters and increase in diastolic function