Herpes Zoster reactivation in patients with chronic hepatitis C under treatment with directly acting antiviral agents: a case series

We report a series of cutaneous Herpes Zoster [HZ] reactivation cases in patients with hepatitis C virus [HCV] infection treated with directly acting antiviral [DAA] agents. Five cases were detected among 2133 treated patients with DAAs at one of the specialized viral hepatitis treatment centers in Egypt. A control group including 2300 age and sex matched HCV patients who were previously treated with pegylated interferon and ribavirin did not show any HZ reactivation reports while on treatment. None of cases had an evidence of immunosuppression or a risk factor for HZ reactivation. The DAAs used regimens were sofosbuvir/daclatasvir in 4 cases and sofosbuvir/simeprevir in one case. HCV clearance with antiviral therapy may bring immune changes causing reactivation of other latent viral infections like HZ. A high index of clinical suspicion may be needed to guarantee early and prompt management of such cases

Biofilm formation by e-coli causing catheter associated urinary tract infection [CAUTI] in Assiut university hospital

Urinary tract infections [UTIs] are the most common cause of nosocomial infection and up to 80% of UTIs are associated with the use of urinary catheter. Inappropriate use of this device may lead to an increase incidence of infectious complications. It has been estimated that 65 % of nosocomial infections are biofilm associated urinary tract infections, loading the health care system enormous costs. These biofilm infections are 10 to 1000 times more resistant to the effects of antimicrobial agents. In this study urine samples were collected from 150 patients with CAUTI [group 1] giving one hundred and fifty bacterial isolates and 70 non catheterized UTI patients [group 2] giving fifty bacterial isolates. Out of the two hundred isolates the most common isolated pathogens were: Escherichia coli[E.coli] [50%] in group I, [48%] in group 2, followed by Klebsiella [26.7%] in group J, [28%] in group 2, pseudomonas aeruginosa [8%] in group 1, [12%] in group 2 then Staphylococcus aureus [8.6%] in group 1, [4.%] in group 2, Proteus [4.6%] in group 1, [4%] in group 2, and lastly, Candida albicans [2%] in group 1,[4. %] in group 2. The E.coli isolates were evaluated for biofilm formation using congo red agar [CRA] and microtitre plate methods. Out of 99 E.coli isolates; 27 were non biofilm forming in group 1, 19 isolates in group 2 while 48 isolates were biofilm forming in group 7, only 5 isolates in group 2 . Using microtitre plate method; out of 48 biofilm forming isolates in group 1; 8 isolates [16.6%] were weak biofilm forming, 10 [20.8%] were moderate biofilm and 30 isolates [62.5%] were strong biofilm forming while, 3 isolates were weak biofilm forming in group2. The two methods used to detect biofilm formation [CRA test and spectrophotometer], both are valid tests. CRA is simpler but spectrophotometer differentiates between weak and strong biofilm producers

Role of EUS-FNA and percutaneous US-FNA in diagnosis of pancreatic head lesions, Egyptian experience

Pancreatic carcinoma is one of the leading cancer morbidity and mortality worldwide. Endoscopic Ultrasound [EUS] provides good direct visualization of the pancreas and EUS-FNA raises the accuracy for diagnosing pancreatic malignancies. US-FNA is another established method for diagnosing pancreatic malignancies. To determine the Role of Percutaneous US-FNA and EUS-FNA in diagnosis of pancreatic lesions. 131 patients with pancreatic masses were included in the study and sub-classified into 2 groups according to the imaging tool used, US-FNA [group I] and EUS-FNA [group II]. Using the appropriate statistical tools, sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and diagnostic accuracy were calculated for both groups. It was 88.2%, 93.9%, 96.8%, 97.5% and 90.1% respectively in group I. It was 77.8%, 100%, 100%, 75% and 86.7% respectively in group II. US-FNA/EUS-FNA are safe reliable tools for diagnosis of pancreatic lesions

Long-term effect of argon plasma coagulation [APC] in the treatment of gastric antral vascular ectasia [GAVE]

Gastric antral vascular ectasia [GAVE] is a distinct vascular abnormality, mainly involving the gastric antrum. It is a rare but well-known cause of occult gastrointestinal bleeding. Various endoscopic treatment modalities have been tried in this condition. The aim of the study is to show the long-term effect of argon plasma coagulation [APC] on GAVE. Twenty-nine patients with endoscopically proved GAVE were enrolled in the study. Clinical assessment of GAVE patients, haemoglobin [Hb] level and transfused blood units were recorded after APC using 60-80-W power setting. A second session was done 1 month after the therapeutic procedure to ensure complete ablation of all lesions. The documented Hb levels and number of blood units transfused 3 months after APC were recorded. At endoscopy, all patients had the classic type of GAVE. The mean Hb level increased from 7.5 +/- 1.7 g dl[-1] before APC to 10.2 +/- 0.8 g dl[-1] after APC [p value <0.001]. The transfusion requirements significantly decreased to 0.2 +/- 0.5 units/patient [p value <0.001]. Endoscopic APC is a safe, effective and inexpensive modality in treating GAVE and could be an alternative to the currently available endoscopic methods

Urinary excretion of glycosaminoglycans and ultrasound urinary bladder wall thickness in children with refractory primary nocturnal enuresis

This study was undertaken to determine variations in the amount of glycosaminoglycans [GAGs] excreted by patients with refractory primary nocturnal enuresis [RPNE], and assessment of associated bladder dysfunction with the use of a special ultrasound [US] protocol, as prediction of pathophysiology of refractory primary nocturnal enuresis and associated bladder dysfunction. The study included 30 children with [RPNE] with mean age 7.33 +/- 2.23 and 30 healthy age matched control children with mean age 8.9 +/- 1.68 years. All patients more than 5 years old were treated for primary nocturnal enuresis [PNE] with behavioral therapy and desmopressin for at least 6 months with no response. The studied groups were subjected to the following complete medical history, physical examination, urine analysis and their urinary GAGs excretion was assessed over 24 h using the sodium tetraboratecarbazole method. Plain KUB, and abdominal ultrasound using special protocol was designed for the evaluation of bladder parameters using bladder volume and wall thickness index [BVWI%], and expected percentage bladder volume index for kidney volume. Patients with refractory primary nocturnal enuresis had higher mean values of urinary GAGs excretion than age-matched controls. Also they had low bladder capacity and thick bladder wall more than age-matched. The mean urinary GAGs contents were 38.9, and 27.5 mg/g creatinine in patients with RPNE and controls respectively; [P<0.001]. Comparing the BVWI in normal and enuretic children in correlation with functional bladder capacities we found that patients with low capacity thick bladder wall also have high GAGs excretion. Measuring urinary GAGs excretion and Ultrasound bladder wall thickness can be used as predictive pathophysiological clues, for underlying bladder dysfunction, which has an important role in the pathophysiology of enuresis especially in refractory cases. Also they can minimizing the need for invasive urodynamic study in children with RPNE for assessing bladder wall dysfunction

Use of echocardiography and scintigraphy in assessment of coronary artery disease [comparative study]

The aim of the study was to perform a comparative study between dipyridamole Technetium Tc-99m sestamibi single photon emission computed tomographic scintigraphy [DMIBI] and dobutamine-atropine stress echocardiography [DASE] in assessment of coronary artery disease [CAD] in correlation to the coronary angiography. The study included 62 patients 43 males and 19 females [mean age: 60 +/- 11 years]. All patients underwent multistage DASE, DMIBI and coronary angiography over one month's time. These procedures were performed according to standard techniques and analysed in comparative issue for the sensitivity and their specificity in assessment of CAD. The study revealed 10 patients with three-vessel disease, 11 patients with 2 and 20 patients with single vessel disease. The other 21 patients had insignificant coronary disease for intervention. DASE and DMIBI were similarly sensitive [87% and 80% respectively] for the detection of CAD. However. DASE was more specific [91% vs. 73%, p<0.01]. Detection of Multiple wall motion abnormalities and perfusion defects were similar in both tests [72% vs. 66% respectively]. However, DASE was more specific than DMIBI [95% vs. 76% respectively p<0.01]. DASE and DMIBI were moderately concordant for the detection and extent of CAD [p<0.0001] but fairly concordant [p<0.001] in the detection of type abnormalities [normal, fixed, ischaemic or mixed]. DASE and DMIBI were comparable tests for the detection of CAD. Both were sensitive for the detection of CAD and moderately sensitive for the detection of the extent of the disease. However, DASE was more specific than DMIBI particularly in multi-vessels disease

Hemicallotasis opening wedge osteotomy for correction of proximal tibial deformities

Hemicallotasis opening wedge osteotomy [HCO] was used in this study to treat 23 patients with varus deformity of the proximal tibia. The indications for treatment were primary medial compartment osteoarthritis in 18 patients and adolescent Blount disease in 5 patients. The mean age in the osteoarthritis group was 47.8 years and 12.9 years in the Blount disease group. The total time in fixator averaged 87 days. The mean follow-up period was 22.8 months. The mean preoperative tibiofemoral angle in all patients was 8.7 degrees of varus. Mean angular correction for all patients was 11.8 degrees. The mean correction was 17.3 degrees in patients with Blount disease and 9.9 degrees in the osteoarthritis group. Optimal correction to 4 +/- 2 degrees of valgus was achieved in 18/23 patients. Three patients had under correction and two had over correction. The mean Oxford knee score among the osteoarthritis group was 33.9 points. Complications included deep venous thrombosis in one patient, delayed union in one patient, minor pin tract infection in eight patients and one patient required readjustment of the external fixator. There were no neurological or vascular complications. This work showed that HCO technique has the advantages of allowing more precise correction of the deformity with fewer complications when compared to the classic techniques

Adverse effects of neuromuscular blockers and their antagonists

Among all the drugs used for general anesthesia, neuromuscular blockers appear to play a prominent role in the incidence of severe adverse reactions. It now seems likely that most serious adverse drug reactions occurring during anesthesia are immunological in type. The frequency of life-threatening anaphylactic or anaphylactoid reactions occuring during anesthesia has been estimated to be between 1 in 1000 and 1 in 25000 anesthetic procedures, with the neuromuscular blockers being involved in 80% of cases. The mortality from such serious reactions is reported to be in the range of 3.4 to 6%. The highly immunogenic drug, suxamethonium chloride [succinylcholine], was found to be the most hazardous agent. Drug- specific immunoglobulin E antibodies to suxamethonium chloride and other neuromuscular blockers have been demonstrated. This sensitivity to neuromuscular blockers seems to be a long-lasting phenomenon. During anesthesia, the clinical features of an allergic reaction are often masked. Tachycardia and circulatory collapse may be the only signs of an allergic reaction, and they are easily misdiagnosed. Bronchospasm is reported to be present in about 40% of cases. Successful management of these patients includes stabilisation during the acute reaction and avoidance of future reactions. The latter is based on the indentification of the causative drug and potentially cross-reacting compounds. The use of suxamethonium chloride is associated with many other adverse effects, such as fasciculations, myalgia, potassium release, changes in the heart rate, increases in intragastric and intraocular pressures, and malignant hyperthermia. Because of the dangers of hyperkalemic cardiac arrest suxamethonium chloride administration in children with unrecognised muscular dystrophy, there have now been moves to limit the use of this drug in children. Although neuromuscular blockers are designed to specifically block nicotinic cholinergic receptors at the neuromuscular junction, many bind to muscarinic cholinergic receptors on ganglia and smooth muscle, and alter parasympathetically mediated heart rate and airway calibre. Most benzylisoquinolinium muscle relaxants can induce histamine release, especially when they are administered rapidly, which can lead to disturbances of cardiovascular function. In addition, nondepolarising neuromuscular blockers have been implicated in causing generalised weakness following their long term administration to patients on an intensive care unit. The problem with these adverse drug reactions is their unpredictable nature. Therefore, prompt recognition with appropriate therapy can help to improve the outcome

Clinically significant drug interactions with general anesthetics-incidence, mechanism and management

The frequency of adverse drug interactions increases disproportionately with the increase in the number of drugs given to patients. It was shown that 40% of patients given 16 drugs experienced an adverse drug interaction, compared with 5% of patients given fewer than 6 drugs. The magnitude of the drug interaction problem increases substantially in anesthetised patients because of: [i] the increased use of multiple drugs in the preoperative and intraoperative periods; and [ii] the growing population of geriatric patients who, in addition to having diminished drug metabolising capacity, are often prescribed multiple medications for concomitant medical illness. Drug interactions with volatile and intravenous anesthetics can be divided into those that are pharmacokinetic and pharmacodynamic in nature. Pharmacokinetic interactions occur when the absorption, distribution, metabolism or excretion of a drug is altered by the coadministration of a second drug. Pharmacodynamic interactions involve a change in the pharmacological effect of a drug as a result of the action of second drug at receptor sites. An interaction between drugs, if not recognised and corrected, can result in decreased drug efficacy or serious toxicity. It is essential that careful scrutiny of the patient's drug history is an integral part of the preoperative assessment. The importance of drug interactions in anesthesia has become increasingly evident for several reasons, including the increased use of multiple drugs in clinical practice and the current medicolegal climate. Anesthetised patients represent a population with a relatively high risk of drug interactions. Patients who are not receiving any drug therapy before admission are likely to receive not less than 6 to 8 drugs during anesthesia for a simple surgical procedure like laparoscopic cholecystectomy. Nevertheless, patients who present for anesthesia frequently receive a surprising number of different drugs. May et al found in the 1970s that patients received an average of 7.9 drugs during their stay in a general hospital, and Cluff et al found that patients given an antibiotic received on average 13 additional drugs. The number of drugs received by comparable patients today is unlikely to be less. Such multiple drug-taking is not confined to hospital patients. Several surveys have shown that, at any one time, 20% of elderly people in the community are taking 3 or more prescribed drugs, and this proportion rises to over 50% for patients referred to a geriatric service. In a review of adverse drug reactions on a medical ward, 22% were found to be the result of drug-drug interactions. The Boston Collaborative Surveillance Drug Program reported that 6.5% [234 of 3600] of adverse reactions were attributable of drug- durg interactions. This survey, which involved 9900 patients and 83200 drug exposures, only monitored patients on medical wards. The potential drug interactions in surgical patients have also been identified. A total of 1825 surgical patients were reviewed and at least 1 drug interaction was found in 17% of patients. The frequency of adverse drug interactions increases disproportionately with the increase in the number of drugs given to patients. It was shown that 40% of patients given 16 drugs experienced an adverse drug interaction, compared with only 5% of patients given fewer than 6 drugs. The incidence of significant drug interactions with general anesthetics is still largely unknown but is probably clinically significant. A complete drug history and clear, accurate and comprehensive drug prescribing and recording documents are essential if such interactions are to be avoided during and after anesthesia. The purpose of this review is to focus on the potentially important interactions with volatile and intravenous anesthetics. Other interactions that might occur between drugs given during anesthesia [e.g. antibiotics and neuromuscular blocking drugs] were considered outside the scope of this review

Levator muscle aponeurosis sling for severe congenital ptosis

Ten cases of severe congenital blepharoptosis were managed by using levator muscle aponeurosis as the material for frontalis sling. Eight cases were successfully corrected while two cases were under corrected. In addition to the availability of intraoperative and postoperative adjustment, this procedure gives the best postoperative lid contour in comparaison with other sling operations

Myasthenia gravis and pipecuronium

The use of pipecuronium in two patients with myasthenia gravis undergoing thymectomy is described. Neuromuscular function was monitored throughout using the train-of four [TOF] mechanical twitch response. The cumulative dose-response to pipecuronium was determined in both patients during nitrous oxide-oxygen-narcotic anaesthesia. Both patients were sensitive to pipecuronium. The ED [50] doses of pipecuronium were 11.6 and 11.1 micro g. kg [-1] and the ED [95] doses were 35 and 33.3 micro g. kg [-1] in patients # 1 and 2 respectively. Edrophonium 1 mg. kg [-1] and neostigmine 0.06 mg. kg [-1] were admistered to patients # 1 and 2 respectively for antagonism of residual neuromuscular blockade at 25 per cent spontaneous recovery of first twitch [T1] of the TOF stimulation. As with other non-depolarizing muscle relaxants pipecuronium in reduced dosage and with careful neuromuscular monitoring can be used to provide surgical relaxation safely in patients with controlled myasthenia gravis

Assessment of the fertility impact of family planning programmes in Egypt

The present study demonstrated the role of the Egyptian FPP during the period 1980 - 1988 in knowledge of FP, contraceptive use, attitude toward FP, availability, accessibility and satisfaction with methods. Four different evaluation methods have been employed for measuring the impact of FPP on fertility in Egypt: The st and ardization approach, the prevalence method, the multivariate areal analysis, and the log linear model. The st and ardization method should be applied primarily. Its effectiveness lies primarily in the capability of determining whether fertility, as measured by the CBR [or the GFR], has changed at all in the area and during the period under study, by decomposing the change in the GBR of its demographic component parts: Proportion of women of reproductive ages, age structure of women of reproductive ages, proportion of married women, and martial age specific fertility rates. The prevalence method provides direct impact measures of contraception either from program or/ and non-program use on fertility. It produces the number of births averted as well as the reduction in the natural CBR that results from the use of contraception. The multivariate areal analysis method is congruent in many ways with the problem of measuring the effect of the FPP on fertility, especially those countries which are characterized by a considerable variability within its geographical areas, such as Egypt. The last method applied is the log linear analysis. This method provides a systematic approach of analysis for discovering the kind of the relationships that may be found in contingency table

Cardio-pulmonary resuscitation: two years experience in a new teaching center

Cardiac arrest calls at a new tertiary referral hospital are reviewed over a two year period. The formation of a committee responsible for conducting and supervising the resuscitation team is outlined. There were 146 calls for 120 patients. 49 patients [40.8%] were initially resuscitated and 8 [6.66%] of these were discharged home. Age did not appear to influence the prognosis. Coronary heart disease was the commonest pathology [40%] and ventricular fibrillation and tachycardia were the leading causes of cardiac arrest