Case report: Insulin desensitization as the only option for managing insulin allergy in a Sudanese patient.

Introduction: Allergic reactions to insulin have become very rare with the introduction of human insulin. Anaphylaxis is a life-threatening condition that results from immediate IgE-mediated hypersensitivity. Desensitization to human insulin was reported to control immediate hypersensitivity reactions to insulin. Here, we describe the history and challenges of managing our patient and the development of an insulin desensitization protocol in a resource-limited setup. Case Summary: A 42-year-old Sudanese woman with poorly controlled type 2 diabetes on maximum antidiabetic medications required insulin therapy to achieve reasonable glycemic control. She developed progressive and severe immediate hypersensitivity reactions to insulin, including anaphylaxis. Serum sample analysis demonstrated insulin-specific IgE antibodies. The patient's poor glycemic control and the need for breast surgery indicated insulin desensitization. A 4-day desensitization protocol was delivered in an ICU bed for close observation. Following successful desensitization and 24-h observation, our patient was discharged on pre-meal human insulin, which was tolerated well to the current date. Conclusions: Although insulin allergy is rare, once encountered, it is very challenging in patients who have no other treatment options available. Different protocols for insulin desensitization are described in the literature; the agreed protocol was implemented successfully in our patient despite the limited resources.

The outcome of COVID-19 patients in the intensive care unit in Sudan: A cross-sectional study.

Background and Aim: A major outbreak of coronavirus spread all over the world and gave rise to high mortality rate and high admission rate to intensive care unit (ICU). This cohort study aims to assess the outcome of COVID-19 patients in ICU and to investigate the factors associated with mortality. Method: This is a multicentered retrospective cohort study that was conducted among confirmed cases of COVID-19 patients, who were admitted to ICU in Sudan during March 2021. The data collection was done manually from the medical records of patients. Mortality rate and association and prediction of factors associated with mortality were obtained using Statistical Package for the Social Sciences software (SPSS) version 22. Results: The mortality rate among patients in this study was 70%. Using the chi-square test we found that age, needing intubation, developing Systemic inflammatory response syndrome, neurological complications, hematological complications, and cardiac complications have a significant association with the outcome. Conclusion: Majority of COVID-19 patients who were admitted to the ICU died. 55.8% of patients developed at least one complication during their stay in ICU. The age, the need for intubation, and developing of systematic inflammatory response syndrome (SIRS) are the factors that predict the mortality.

Splenic haematoma and rupture, a rare complication of ventriculoperitoneal shunt.

Complications of ventriculoperitoneal (VP) shunts have been well described in the literature. To our knowledge, only two cases with splenic tear have been reported to date. We report here a case of splenic haematoma and rupture caused by the distal catheter looping around the spleen, requiring urgent splenectomy for spontaneous rupture and massive haemorrhage. This complication was noted six weeks following VP shunt insertion.

Use of intensive care unit priority model in directing intensive care unit admission in Sudan: A prospective cross-sectional study.

BACKGROUND: The shortage of specialized intensive care beds is one of the principal factors that limit intensive care unit (ICU) admissions. This study explores the utilization of priority criteria in directing ICU admission and predicting outcomes. METHODS: This was a prospective cross-sectional study conducted in two ICUs in Sudan from April to December 2018. Patients were assessed for ICU admission and were ranked by priority into Groups 1, 2, 3, and 4 (1 highest priority and 4 lowest priority), and these groups were compared using independent t-test, Chi-square, and ANOVA. RESULTS: A total of 180 ICU admitted patients were enrolled, 53% were male. The prioritization categories showed that 86 (47.8%), 50 (27.8%), 13 (7.2%), and 31 (17.2%) were categorized as priority 1, 2, 3, and 4, respectively. Patients in priority groups 3 and 4had significantly higher ICU mortality rates compared to those in groups 1 and 2 (P < 0.001), were likely to be older (P < 0.001), had significantly more comorbidities (P = 0.001), were more likely to be dependent (P < 0.001), and had longer ICU length of stay (P = 0.028). CONCLUSION: Patients classified as priority 3 and 4 were predominantly older and had many comorbidities. They were likely to be dependent, stay longer in ICU, and exhibit mortality.

Awareness about stroke among high and low risk individuals in Khartoum, Sudan: a cross-sectional study.

INTRODUCTION: stroke causes 10.17% of all deaths in Sudan. Levels of stroke awareness amongst patients in Sudan are unknown. The aim of this study is to assess the level of awareness of stroke risk factors, symptoms and immediate management amongst high and low risk patients. METHODS: using descriptive cross-sectional study, participants of high and low risk groups were recruited from the referral clinics of three tertiary hospitals in Khartoum. Data was collected through interviews using structured questionnaire. Knowledge score was devised to assess the awareness about stroke symptoms, risk factors, and management. RESULTS: of the 286 participants, 150 were females. The mean age was 44.66 years. About 79.4% reported that stroke is preventable. Hypertension was the most identified risk factor (71.6%) while genetics (0.2%) and alcohol (0.2%) were the least identified risk factors. Twenty-seven percent (27.6%) did not know any stroke risk factors, while 32.9% did not know any warning symptoms. Paralysis of one side of the body was the most identified warning symptom (30.7%). The mean awareness score was 21.9 ± 3.4 among the high risk group vs. 22.1 ± 3.6 among the low risk group with no statistically significant difference between the two groups (p = .717). The mean awareness score was statistically associated with the level of education (p < 0.001). CONCLUSION: the awareness level was relatively low and not statistically different between high and low risk groups. We recommend the development of an effective educational program for the whole community.

Increased Serum Levels of Asymmetric Dimethylarginine and Symmetric Dimethylarginine and Decreased Levels of Arginine in Sudanese Patients with Essential Hypertension.

INTRODUCTION: Essential hypertension (EH) is a disease caused by various environmental and genetic factors. Nitric oxide (NO) is important for the functional integrity of the endothelium. It is produced in endothelial cells by endothelial NO synthase (eNOS) that mediates the conversion of the amino acid arginine into NO and citrulline. Asymmetric dimethylarginine (ADMA) acts as an inhibitor of eNOS. In contrast, symmetric dimethylarginine (SDMA) has no direct effect on eNOS but plays an important role competing with arginine for transport across the amino acid transporter. ADMA and SDMA have been found to play a central role in the development of cardiovascular diseases. Serum ADMA levels may serve as a future diagnostic marker and a target of therapy in hypertensive patients in the Sudanese population. This study aimed to investigate the relation between serum arginine, ADMA, and SDMA levels with EH in the Sudanese population. METHODS: Patients (n = 260) with established hypertension and controls (n = 144) with normal blood pressure were included in this case-control study. Serum blood samples were analyzed for arginine, ADMA, and SDMA, using high-performance liquid chromatography-tandem mass spectrometry. Other laboratory data were measured using routine methods. Mann-Whitney's U test and χ2 tests were used for continuous and categorical data, respectively. A multivariate logistic regression analysis was conducted to investigate the independent effect of multiple variables on the development of hypertension. RESULTS: Serum arginine levels were significantly lower in the patient group than in the control group (p < 0.001). ADMA and SDMA levels were significantly higher in the patient group than the control group (p < 0.001, p = 0.001, respectively). Multivariate logistic regression analysis showed that only older age, being a male, and arginine levels are independent factors controlling the development of hypertension (p < 0.001, p < 0.001, and p = 0.046, respectively). ADMA and SDMA levels were not independent factors for the development of hypertension. CONCLUSIONS: This study demonstrated increased serum levels of ADMA and SDMA and decreased arginine levels in Sudanese patients with EH. Lowering serum ADMA levels or increasing the arginine levels might be a novel therapeutic target in these individuals.

Breaking bad news from the doctors' perspective in a paternalistic society: the case of Sudan.

Breaking bad news is a global challenge for all types of health providers. Our study assessed the attitude and practice from the doctors' perspective in a patriarchal society. A descriptive cross-sectional hospital-based study was conducted, involving doctors from both medical and surgical departments. Almost half of the respondents believed that Sudanese patients do not like to know their diagnosis, and a slightly higher proportion had no previous training on how to break bad news. Some 20% indicated that they would conceal the diagnosis from a patient if his or her relatives so requested. Less than one-quarter of respondents followed a standard protocol. Although most of the doctors subscribed to the notion that patients have the right to know everything about their illnesses, not all of them held this attitude towards their local patient population.

Association of NOS3 gene polymorphisms with essential hypertension in Sudanese patients: a case control study.

BACKGROUND: Essential hypertension (EH) is influenced by various environmental and genetic factors. Nitric oxide is important for the functional integrity of the vascular endothelium and is produced in endothelial cells by the enzyme endothelial nitric oxide synthase (eNOS). EH has a strong genetic component, and the NOS3 gene, which encodes eNOS, represents an interesting candidate for contribution to the phenotype. The most clinically relevant polymorphisms in the NOS3 gene are rs1799983 in exon 7 (encoding Glu298Asp), a variable number tandem repeat (VNTR) in intron 4, and rs2070744 (T-786C) in the promoter region. This study aims to investigate the association between these three polymorphisms in the NOS3 gene and EH in Sudanese patients. METHODS: Hypertensive patients (n = 157) > 18 years of age with established hypertension from various hospitals in Khartoum, and controls (n = 85) > 18 years of age and with blood pressure measurements <140/90, were included in this case control study. Genotypes at the NOS3 variants were determined using TaqMan and polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) analyses. Genotype and allele frequencies were compared between the two groups by χ2 analysis, and differences were expressed as odds ratios with 95% confidence intervals (CIs). P values <0.05 were considered statistically significant. RESULTS: The rs2070744 polymorphism in NOS3 was found to be associated with EH in the Sudanese population as the patients group had higher frequency of CC genotype compared with the controls (6.6% vs 6.1%, p = 0.02). Considering a dominant inheritance model, the frequency of TC + CC genotypes in patients was significantly higher than that in the control subjects (52.6% vs 34.1%, respectively; p < 0.01), with an odds ratio (95% CI) of 2.14 (1.23-3.74). In addition, the C allele was more frequent in the patients than the control group (29.6% vs 20%, p = 0.03, OR = 1.84 (1.15-2.93)). The c allele of intron 4 VNTR was reported in >1% of the Sudanese population under study. CONCLUSION: The results of this study indicated that the rs2070744 polymorphism in NOS3 may be a genetic susceptibility factor for EH in the Sudanese population. The c allele of intron 4 VNTR is not rare in the Sudanese population.

Validity and reliability of Arabic MOS social support survey.

We aimed to generate a valid reliable Arabic version of MOS social support survey (MOS-SSS). We did a cross sectional study in medical students of Faculty of Medicine in Khartoum, Sudan. We did a clustered random sampling in 500 students of which 487 were suitable for analysis. We followed the standard translation process for translating the MOS-SSS. We accomplished factor analysis to assess construct validity, and generated item-scales correlations to evaluate the convergent and discriminant validity. We extracted the Cronbach's α and Spearman Brown coefficient of spit half method to determine internal consistency. We measured stability by correlation between the scores of the MOS survey taken at two different occasions with ten days apart in 252 participants. All items correlated highly (0.788 or greater) with their hypothesized scales. All items in subscales correlated higher by two standard errors with their own scale than with any other scale. Principle component analysis with varimax rotation was conducted on the 19 items and examination of scree plot graphically suggested 4 predominant factors that account for 72 % of variance. It showed high loadings, ranging from 0.720 to 0.84 for items of emotional support, 0.699-0.845 for tangible support, 0.518-0.823 for affectionate support, and 0.740-0.816 for positive social interaction. Cronbach's alpha for overall MOS scale and subscales indicated high internal consistency. The test-retest correlation showed weak correlation between the test and retest (ranges from 0.04 to 0.104). The Arabic MOS-SSS had high validity and internal consistency.

Autonomy and confidentiality: patients' perspectives.

BACKGROUND: Little is known about patients' opinions about their rights in autonomy and confidentiality concerning their illness and this study was conducted to assess it. METHODS: This multi-centred, cross-sectional study was conducted in outpatient clinics in Khartoum, Sudan. It was delivered to 295 respondents. Data were managed using Microsoft Excel 2010 and SPSS. RESULTS: Eighty-five percent of the patients wanted to know about their conditions, of whom 17% wanted to choose their treatment and 29% believed they had the right to refuse treatment. Most of the respondents would not wish to hide information from their doctors. There was a wide variation at the rate of patients hiding information from their relatives, depending on their diagnosis (HIV 90%, malignancy 16.7% and tuberculosis 0%.) CONCLUSION: Respondents want to choose their treating doctor, know about their diseases, be consulted before a procedure. They would like to leave technical issues to their treating doctors without jeopardising their own rights.

No-reflow phenomenon following percutaneous coronary intervention for acute myocardial infarction: incidence, outcome, and effect of pharmacologic therapy.

BACKGROUND: No-reflow (NR) phenomenon is a well-known problem, often accompanying percutaneous coronary intervention for acute ST elevation myocardial infarction (STEMI). There are little data on effects of pharmacologic therapy on the resolution, outcome, and long-term natural history of NR. OBJECTIVE: Retrospectively assess incidence, management, and prognosis of NR in a tertiary referral hospital. METHODS: Study included patients with STEMI, treated with percutaneous coronary intervention (PCI). Effect of pharmacologic therapy and long-term outcome were assessed. NR was defined by thrombolysis in myocardial infarction (TIMI) < 3 or myocardial blush grade (MBG) < 3. RESULTS: Of 347 identified subjects, NR occurred in 110 (32%) by TIMI and 198 (57%) by MBG. Higher incidence was identified in men versus women (34% vs. 25% by TIMI, P = 0.08; and 60% vs. 48% by MBG, P = 0.04). Pharmacologic therapy was equally effective in restoring normal flow, increasing TIMI score from 1.62 ± 0.07 to 2.78 ± 0.06 (P < 0.0001) and MBG score from 0.43 ± 0.08 to 2.09 ± 0.11 (P < 0.0001). Twenty-three percent who did not receive pharmacologic therapy developed clinical composite of congestive heart failure, cardiogenic shock, and/or death; only 9% of patients who received pharmacologic therapy developed this composite. Patients with severe NR despite treatment had poorer prognosis. Sixty-five percent of patients who survived and had repeat angiogram about 1.5 years later had spontaneous improvement in coronary flow by MBG. CONCLUSION: NR is common in STEMI. Treatment with nicardipine, nitroprusside, and verapamil are equally effective in improving flow. If not treated, prognosis is poor.

Tako-tsubo cardiomyopathy in a patient with advanced colorectal adenocarcinoma.

Transient left ventricular dysfunction syndrome (TLVDS), or Tako-Tsubo cardiomyopathy (TC), is a clinical entity in which patients present with features of acute coronary syndrome, electrocardiogram abnormalities, and transient left ventricular (apical or mid-ventricular) dysfunction. Patients usually recover from this condition four to six weeks after the event. The etiology or triggering factors of TC remains unknown. Various triggering factors have been associated with this syndrome, with one of the most recent being malignancies. In this case report we present a postmenopausal female with underlying advanced malignancy who presented with TC. This is consistent with a recent hypothesis that in addition to currently known triggering factors, malignancies might well trigger TC in the context of a stressor or paraneoplastic phenomenon.

Atrial flutter versus atrial fibrillation in a general population: differences in comorbidities associated with their respective onset.

OBJECTIVE: Determine and compare the prevalence of known risk factors for cardiovascular disease among unselected individuals presenting with their first ever episode of atrial flutter (AFL) and atrial fibrillation (AF). STUDY DESIGN AND SETTING: We evaluated 11 pre-selected clinical variables including age, sex, smoking history and other potential cardiac risk factors. Using the resources of the Marshfield Epidemiologic Study Area, a population-based database, all newly diagnosed cases of either AFL or AF in the region during a 4-year period were identified. RESULTS: Among the 472 incident cases, 76 (16.1%) had AFL and 396 (83.9%) had AF. Compared to those with AF, subjects with AFL were more likely to have had a history of chronic obstructive pulmonary disease (25% vs. 12%, P = 0.006), heart failure (28% vs. 17%, P = 0.05), and smoking (49% vs. 37%, P = 0.06). Hypertension, on the other hand, was more common among individuals with AF (63% vs. 47%, P = 0.01). CONCLUSION: This study represents the first report to evaluate potential differences in the conditions associated with the development of AFL versus AF. Research into the mechanisms of atrial arrhythmogenesis may lead to improved preventive and therapeutic interventions.