Contributing factors of Vesico-Vaginal Fistula (VVF) among Fistula Patients in Dr.Abbo's National Fistula et Urogynecology Centre - Khartoum 2008

"Background: Vesico-vaginal Fistula (VVF) is defined as an abnormal communicating tract extending between the bladder (vesico-) and the vagina resulting in continuous involuntary discharge of urine into the vaginal vault. Vesico-vaginal fistula is still a persisting scourge in the developing countries; including Sudan in which new cases of obstetric fistula were estimated to occur every year"" #he ob$ectives of this work were to study the contributing factors of vesico-vaginal fistula in Sudanese patients"" Methods: the design was descriptive; cross-sectional; community-based study"" A total of 2 patients with vesicovaginal fistula presented to the Fistula (entre in )Khartoum Teaching hospital from July to August 2 ;; were investigated using an administrated; semi-structured questionnaire"" Results: The study revealed that 44""2of patients were 1;-24 years old; "";were teenagers when married (1; yrs old)"" While 7of the patients were illiterates; 62"";were married to illiterate husbands"" (; "";) were poor; (4 ""4) were from western regions of Sudan"" The study showed that labor was responsible for 9 ""4of VVF of whom 9""6were primiparous; 42""6delivered at home"" It was found that 4 ""4of the total deliveries were by forceps as long as 27""7were emergency caesarian sections"" (3""2) of the deliveries were attended by traditional birth attendants and ""3of cases stayed in labor for more than 24 hours; as long as 3""2were not in regular antenatal care"" Conclusion:The vesico-vaginal fistula in Sudan resulted mainly from obstructed labor"" the victim was mostly a young woman; a primigravida; who was poor; illiterate; not on regular antenatal care et being in labor more than 24 hours"" Most deliveries were carried at home; attended by traditional Birth Attendants in most cases"" the deliveries were mostly assisted by forceps; or conducted as emergency caesarian sections"" To prevent VVF; the study suggested raising awareness of women at bearing age; improve transportation; besides inclusion of the issue in the curricula of schools and universities"""

Clonal B cell populations in a minority of patients with Hashimoto's thyroiditis.

BACKGROUND: Hashimoto's thyroiditis (HT) is a risk factor for thyroid lymphoma, and clonal B cell populations in HT support this link. The literature on B cell clonality in HT is controversial. AIMS: To identify clonal B cell populations in HT and to assess their usefulness in differentiating HT from mucosa associated lymphoid tissue (MALT) lymphoma and predicting future development of lymphoma. METHODS: DNA from formalin fixed, paraffin wax embedded blocks of thyroid specimens from 10 patients with HT and two thyroid MALT lymphomas was analysed for B cell clonality by seminested polymerase chain reaction (PCR) using FRIII/LJH and FRIII/VLJH primers to amplify the IgH gene VDJ region. In one case, PCR products were sequenced. Immunohistochemistry was performed by labelled streptavidin-biotin technique using antibodies to: CD45, CD45RO, CD3, CD20, and cytokeratin. RESULTS: The histopathological and clinical findings were characteristic of HT. Clonal bands were seen in three and a polyclonal smear pattern was seen in seven cases. The clonal bands in HT were associated with a background smear, and could not be reproduced from other blocks from the same case or from deeper sections of the same block. The clonal bands in thyroid lymphomas were not associated with a background smear and were reproducible. None of the patients with clonal B cells has developed malignant lymphoma during a follow up of 10-13 years. CONCLUSIONS: B cell clonal bands in HT have different features from those in lymphoma (non-pure and non-reproducible) and do not predict future development of lymphoma.

A cardiovascular risk factor reduction clinic.

OBJECTIVE: To describe a cohort of patients referred to a cardiovascular risk factor reduction unit (CRFRU). DESIGN: Prospective cohort study. SETTING: Out-patients referred to a specialty clinic in a tertiary care hospital. PATIENTS: Seven hundred and four consecutive male and female patients with one or more cardiovascular risk factors, of whom 388 were reassessed after one year. INTERVENTIONS: Standard risk factors were measured in all participants. The probability of coronary artery disease (CAD) was assessed according to the Framingham equation and results were compared with data from the Saskatchewan Heart Health Survey for the general population of Saskatchewan. Patients received dietary and fitness advice, as well as drug therapy when indicated. For follow-up studies, the change in probability of CAD and selected variables after one year were measured. MAIN RESULTS: Patients referred to the CRFRU were at considerably higher risk for CAD than the general population. One hundred and sixty-eight of 235 men and 77 of 153 women seen in follow-up had a reduced risk score. Those who improved had a favourable change in systolic blood pressure and in their lipid profile, as well as greater weight loss. CONCLUSIONS: A CRFRU is feasible and appears to reduce risk in a considerable proportion of patients.

Disposition of lorazepam in diabetes: differences between patients treated with beef/pork and human insulins.

The pharmacokinetics of lorazepam was examined in 10 male patients with insulin-dependent diabetes mellitus before and following treatment with neomycin and cholestyramine. Neomycin and cholestyramine were given in an attempt to block the enterohepatic circulation of lorazepam and so to permit an in vivo estimate of hepatic glucuronidation. The volume of distribution and clearance of free lorazepam in diabetic patients were not significantly different from the corresponding estimates in 14 normal controls. Neomycin and cholestyramine increased the clearance of lorazepam by 63% consistent with their effect in non-diabetic controls. However, patients on beef/pork insulin exhibited a greater than normal increase on this interupting regimen (125%), and had a significantly greater neomycin/cholestyramine cycling-interrupted clearance of lorazepam than either normal controls or patients on human insulin (15.4 vs. 6.96 and 7.87 ml.min-1.kg-1). The clearance was correlated positively and significantly with HbA1c and glycated proteins (fructosamine), but only in patients on human insulin. Thus, the pharmacokinetics of lorazepam was not altered in patients with insulin-dependent diabetes mellitus. However, it is possible that there are differences in the rate and extent of hepatic glucuronidation and enterohepatic circulation of lorazepam between patients treated with beef/pork and human insulins and between diabetics treated with beef/pork insulin and non-diabetic controls.

CT assessment of silicosis in exposed workers.

For evaluation of the clinical usefulness of CT of the thorax in workers exposed to silica, 58 workers with long-term exposure to silica in the granite and foundry industries of the Eastern Townships of Quebec were examined. CT scans were compared with standard posteroanterior chest radiographs by using the International Labour Office 1980 grading system for silicosis. Six areas of the lung in each patient were assessed by both techniques for profusion (number) of opacities (small nodules), coalescence, and the presence of large opacities. CT scans and chest radiographs yielded similar average scores for detection of opacities. CT identified significantly more coalescence and large opacities in patients with simple silicosis. In patients with complicated silicosis, CT results were comparable with those of chest radiographs. CT of the thorax in workers exposed to silica does not identify more patients with minimal parenchymal disease, but it does detect earlier changes of coalescence.

Asbestos exposure dose-bronchoalveolar milieu response in asbestos workers and the sheep model: evidences of a threshold for chrysotile-induced fibrosis.

Epidemiological studies of asbestos workers have proposed a linear dose-response relationship between asbestos cumulative exposure indices and the incidence of asbestos-related lung diseases. However, for chrysotile, several studies have not observed such a linear relationship in low exposure workers. To further study the relationship of chrysotile exposure dose - lung tissue response, we designed in the sheep model one experiment of one exposure at variable intensity and one experiment with variable rates of individual exposures. In the first study, 6 groups of 6 sheep were exposed to either 0, 1, 10, 25, 50 or 100 mg chrysotile in 100 ml saline and lung lavage analyses carried out at day 0, 12, 24, 40 and 60 after. Histopathology was done at day 60. In the second experiment, 4 groups of 12 sheep were exposed to 100 ml saline every week or every two weeks, 100 mg chrysotile in 100 ml saline every week or every two weeks. In the second experiment, lung damage was assessed by changes in vital capacity (VC), lung compliance (Cst) and profusion of chest radiographic opacities (PO). On BAL in the control sheep, there were small and transient early increases in total cells/ml, macrophages/ml, neutrophils/ml, lactate dehydrogenase (LDH)/ml, alkaline phosphatase (AK)/ml, beta-glucuronidase (beta G)/ml and procollagen lll/ml. In the 1, 10, 25, and 50 mg asbestos sheep groups, there were no significant differences. However, in the 100 mg asbestos sheep, there were significant sustained increases in total cells/ml (3-6 times controls), macrophages/ml (2-6 times controls), neutrophils/ml (60-600 times controls), LDH/ml (5-10 times controls), AK/ml (1.5-2 times controls), beta G/ml (3-5 times controls), procollagen lll/ml (2 times controls) and IgG (1.5-3 times controls). These data were correlated with histopathological findings. In the sheep exposed weekly to chrysotile, significant changes in VC, Cst and PO occurred at mean cumulative exposure dose of 1.2 g whereas in the sheep exposed every 2 weeks, similar changes in VC, Cst and PO occurred at the cumulative exposure dose of 3.6 g (P less than 0.05). In conclusion, our data suggest that there is a threshold for chrysotile-induced fibrosis. This level cannot be considered adequately in term of cumulative exposure dose but must take into account intensity and rate of individual exposures.

Asbestos exposure and retention as determinants of airway disease and asbestos alveolitis.

To evaluate the relationships of asbestos exposure, retention, airway response, and the asbestos alveolitis, we exposed 2 groups of sheep every 2 wk for 3 yr to either 100 ml phosphate-buffered saline (PBS) or 100 mg UICC chrysotile fibers in 100 ml PBS. The sheep were evaluated periodically by pulmonary function tests (PFT), chest radiograph (CR), bronchoalveolar lavage (BAL), and transbronchial lung biopsy (TLB). At Month 24 of the study, all asbestos-exposed sheep had significant increases in lung resistance and upstream resistance. However, only 9 of the 16 asbestos-exposed sheep had significant changes in TLB, CR, Cst, and VC, which clearly separated them from the other 6 sheep in these parameters. The 2 groups, however, had similar air-flow limitation. At lung biopsy, all asbestos-exposed sheep had significant peribronchiolar fibrosis, with significant alveolitis only in the group of 9 sheep with radiographic and functional changes of early asbestosis. The 9 sheep also had significant changes in BAL cellularity and biochemical profile, which differentiated them from the other 6 asbestos-exposed sheep. Analysis of BAL fiber content at that point revealed that despite identical exposure, the group with interstitial lung disease had significantly more fiber retention (p less than 0.01). The data demonstrate that whereas asbestos airway disease appears to be primarily an exposure-dose-related response, the lung response appears to be more closely related to alveolar retention of the dust.

Gallium-67 uptake in the lung of asbestos exposed sheep: early association with enhanced macrophage-derived fibronectin accumulation.

To evaluate the time course and mechanisms of enhanced 67Ga lung uptake in asbestosis, we exposed two groups of sheep every 2 wk to either 100 ml saline (controls) or 100 mg UICC chrysotile fibers in 100 ml saline. The sheep were evaluated periodically by pulmonary function tests (PFT), thoracic radiograph (TR), 67Ga lung scan bronchoalveolar lavage (BAL), and transbronchial lung biopsy (TLB). By month 24 of the study, 9/15 exposed sheep had developed the initial alveolitis and had significant changes in PFT, TR, and TLB. The other six exposed sheep differed from controls only by a 75% increase in BAL fibronectin until month 30, where significant changes in albumin occurred and 67Ga scan score increased. The nine sheep with alveolitis had significant sustained increases in 67Ga scan and BAL levels from month 6, associated with a 150% increase in BAL fibronectin and other parameters of disease activity changed from month 18 to 30. We concluded that in the sheep model of asbestosis, significant changes in 67Ga scan, 67Ga BAL counts, and excessive elevation of BAL fibronectin preceded other parameters of disease activity. The data suggest that excessively activated macrophages are primarily responsible for the early 67Ga lung uptake.

[Infectious mononucleosis and splenic pseudocyst: presentation of a case]. / Mononucléose infectieuse et pseudokyste splénique: présentation d'un cas.

The authors report the clinical case of an 18-year-old patient who presented with a symptomatic mass in the left upper quadrant 6 months after having infectious mononucleosis. The preoperative investigation consisted principally of echography and computerized axial tomography of the abdomen, which demonstrated a cystic mass of the lower pole of the spleen. Splenectomy was carried out. Histologic examination showed a pseudocyst of the spleen with a fibrous capsule without an epithelial lining. The treatment and pathogenesis of pseudocysts of the spleen secondary to infectious mononucleosis are discussed.

Clinical features to stage alveolitis in asbestos workers.

To analyze the clinical features of asbestos-induced alveolitis and stage its activity, we evaluated 217 asbestos workers by the usual clinical, radiological, and functional parameters and computerized gallium 67(Ga) lung scan; we obtained bronchoalveolar lavage (BAL) in 33 and lung biopsy in 6. In addition, we scored the profusion of lung rales and correlated it with other parameters of severity of asbestosis. In the 55 workers without asbestosis and normal 67Ga scan, BAL analyses were comparable to those of controls. Of the 56 without asbestosis but increased 67Ga lung uptake, BAL analyses in 8 documented a predominantly macrophagic alveolitis (confirmed on lung biopsy in 3), with the highest levels of BAL fibronectin. In the 106 workers with asbestosis, 67Ga lung uptake was increased in 75; BAL in 17 demonstrated a macrophagic and neutrophilic alveolitis with elevated fibronectin levels. Lung biopsy in 3 of the latter workers documented peribronchiolar fibrosing alveolitis. Rale scores in all workers or in those without asbestosis did not correlate with 67Ga scores; they correlated fairly well with profusion of parenchymal opacities (Rs = 0.42) and rigidity of the lung pressure-volume curve (Rs = 0.39). Thus, 67Ga lung uptake is an early indicator of chronic macrophagic alveolitis in asbestos workers, which usually progresses to asbestosis. In the disease, profusion of lung rales constitutes a simple clinical mode of assessment of disease severity that correlates better with radiological and functional parameters than with parameters of alveolitis.

Radiographic assessment of pleuropulmonary disease in asbestos workers: posteroanterior, four view films, and computed tomograms of the thorax.

To study the clinical usefulness of computed tomography (CT) scanning of the thorax in asbestos related pleuropulmonary disease, 127 long term asbestos workers of the mines and mills in the Eastern Townships of Québec were examined. The CT scan was compared with the standard posteroanterior (PA) chest film and the four view films using the ILO grading system for profusion of disease. Six lung areas and six pleural sites were studied. On the basis of the usual diagnostic criteria, 41% of the workers had asbestosis. For profusion of parenchymal disease, there was an excellent correlation (r = 0.96, p less than 0.001) between PA and four view films and the latter did not significantly increase the total profusion score; the CT scan correlated less well with the PA film (r = 0.79, p less than 0.01) and the scatter of the data was larger. In 10 of the 53 (19%) workers with asbestosis the pulmonary lesions were not recognised by CT scan. For profusion of pleural plaques, there was an excellent correlation (p = 0.91, p less than 0.001) between PA and four view films; scores were identical in 73%, higher for PA in 7%, and higher for four view films in 19%. CT scan scores, however, were identical with PA films in 31%, higher for CT scan in 13% (owing to higher scores on lateral pleural sites), and lower for CT scan in 56% (owing to lower scores at diaphragm and costophrenic angle sites). Pleural calcifications were identified in 24 workers for a total of 40 sites; 13 as possible, 31% identified by two modes, and 27 as definite. Of the latter, 14 were seen only on CT scan. In the workers with rigid pressure volume curve of the lung and increased Gallium-67 lung uptake only, CT scan total scores were not significantly higher than in those without these markers of early interstitial lung disease (5 +/- 1 v 4 +/- 1, p less than 0.05). Thus the four view films and CT scan appear to be useful mainly in the assessment of pleural disease. The four view film identifies more sites of pleural plaques and the CT scan more pleural calcified plaques.

Pulmonary uptake of gallium-67 in asbestos-exposed humans and sheep.

To evaluate the 67Ga lung uptake as an indicator of inflammatory activity in asbestosis, we obtained 67Ga lung scans in 58 long-term asbestos workers. The 67Ga localized excessively in the lungs of 17 of the 21 workers with asbestosis. Among workers without sufficient criteria for the diagnosis of asbestosis, the 67Ga scan index was significantly increased in 43% (16 of 37). Among the 16 with positive 67Ga scan, abnormal pressure-volume curve and/or gas exchange data were found in 87%, whereas in the 21 workers with negative 67Ga scan, similar abnormalities were found in only 29%. In the sheep model of the disease, bronchoalveolar analysis after 67Ga scan demonstrated that the excessive uptake of 67Ga in asbestosis is caused by enhanced serum protein leakage and macrophage accumulation in the lung. Thus, 67Ga scanning in asbestos workers may be a useful indicator of early lung damage.

Asbestos-induced lung injury in the sheep model: the initial alveolitis.

In order to study the cellular and biochemical changes in early asbestosis, three groups of sheep were repeatedly exposed to intratracheal instillations of either saline (controls), low doses of UICC chrysotile asbestos (LD), or high doses of the fibers (HD) until an alveolitis was observed in all HD sheep during the twelfth month of exposure. All sheep were studied bimonthly by transbronchial lung biopsy (LB), bronchoalveolar lavage (BAL), pulmonary function tests (PFT), and chest roentgenograms (CXR). While LBs of the HD sheep demonstrated large accumulations of monocyte-macrophages in the alveolar and interstitial spaces, those of controls and LD sheep did not. In BAL, there was no difference in total and differential cell counts between groups, but the BAL lymphocyte proliferative capacity was clearly depressed in all asbestos-exposed sheep. In the BAL supernatant, total proteins (mainly albumin, beta + gamma globulins) and lactate dehydrogenase were significantly elevated in the HD group only. This alveolitis was associated with a fall in vital capacity, lung compliance, diffusing capacity, and arterial PO2. Abnormalities on CXR appeared 3 months later. Thus, the cellular and biochemical features of early asbestosis are clearly distinct from those reported in idiopathic pulmonary fibrosis.

Ultrasonography in the diagnosis of rectus abdominis hematoma.

Because bleeding into the rectus sheath may give a clinical picture simulating an acute abdomen, it is essential that an accurate diagnosis be made so that an unnecessary laparotomy is not performed. Plain films do not give adequate information and computerized axial tomography is not always available, but ultrasonography, which is noninvasive and is readily available, provides an accurate diagnosis as in the case reported in this paper. A 57-year-old woman had bilateral hematomas of the rectus sheath that did not occur simultaneously. She had a chronic debilitating disease as do the majority of such patients. Long-term cortisone therapy with secondary breakdown of connective tissue was probably the predisposing factor. During a blood transfusion that was needed following operation for osteomyelitis the patient had a severe reaction accompanied by sudden onset of severe abdominal pain on the left side. Ultrasonography confirmed the tentative diagnosis of rectus sheath hematoma. The patient was treated conservatively. The pain subsided within a few days leaving an ecchymosis. Two weeks later she experienced a similar pain on the right side which was also diagnosed by ultrasonography as a rectus sheath hematoma. Again, with conservative treatment the pain subsided leaving discolouration of the skin. The authors stress the value of ultrasonography in diagnosing rectus sheath hematoma and the importance of conservative management.