Signature of real-time PCR in detection of Trichomonas vaginalis infection and its association with human papillomavirus genotype 16.

OBJECTIVE: Infection with Trichomonas vaginalis (TV) is the most prevalent non-viral sexually transmitted infection in the world. The objective of the study was to investigate the incidence of TV infection and its association with Human Papillomavirus (HPV) in a sample of Egyptian females. PATIENTS AND METHODS: 96 Egyptian females suspected for trichomoniasis were involved in our study. Vaginal washouts and cervical (cytobrush) samples were obtained from all patients and examined for T. vaginalis by direct wet mount, modified Diamond's culture medium, and real-time PCR. Cervical (cytobrush) samples were examined for HPV using real-time PCR. RESULTS: Out of 96 patients, 28 (29%) was positive for T. vaginalis by real-time PCR. HPV was detected in 33 patients (34.4%); 31 cases (32.3%) were infected with HPV of genotype 16, whereas only two cases (2.1%) had genotype 18 infection. A significant association was found between TV and HPV infection [Odds ratio (OR)=10.58; 95% confidence interval (CI): 3.819 - 29.29; p<0.001]. CONCLUSIONS: When it comes to diagnosing trichomoniasis in a susceptible population, real-time PCR is more reliable than traditional standard approaches. A significant association between TV and HPV infection was found. Further research into the processes by which these two organisms interact at the cellular level could be revealed.

Toward electronic health recording: evaluation of electronic patient reported outcome measures (e-PROMs) system for remote monitoring of early systemic lupus patients.

The study aimed to assess the value of evaluation of electronic patient reported outcome measures (e-PROMs) in the assessment and management of SLE disease activity flares, its association with adherence to therapy as well as organ damage. A randomized, controlled crossover study was carried out over a 24-month duration. One hundred forty-seven SLE patients meeting the revised American College of Rheumatology (ACR) criteria were enrolled. Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to assess disease activity, whereas organ damage was scored using the Systemic Lupus International Collaborating Clinics (SLICC)/ACR Damage Index. In the first 12 months, the patients were assessed every 3 months. At 12 months, the patients were randomized into a cohort of 73 patients who continued their care in the same style and 74 patients who completed an online e-PROMs questionnaire on monthly basis for another 12-month period. The data captured were then retrospectively analyzed at the end of the 24-month study period. At the end of the first year of the study, the mean SLEDAI and SDI scores were 8.72 (6.1) and 1.9 (2.2). At the end of the second year, the mean SLEDAI and SDI scores in the e-PROMs cohort were 3.1 (2.6) and 1.2 (1.3), whereas in the control group, the scores were 7.63 (6.7) and 1.8 (2.3), respectively (p < 0.01). Adjusting for possible confounding variables, the number of flares, regardless of their severity, was associated with damage accrual (OR 2.03, 95% CI 1.34 to 2.83, p < 0.001). Adherence to therapy was significantly (p < 0.1) higher in the e-PROMs group. e-PROMs was equivalent to PROMs paper format and has a potential disease-modifying effect as it facilitated close monitoring of disease activity with an option of management escalation whenever indicated.

Optimizing therapy in inflammatory arthritis: prediction of relapse after tapering or stopping treatment for rheumatoid arthritis patients achieving clinical and radiological remission.

This study aims to assess clinical, lab/immunological or imaging (joint ultrasonography) markers able to predict disease relapse in RA patients in sustained remission when tapering or stopping their treatment. One hundred fifty-seven RA patients in clinical remission (DAS-28 <2.6 for >6 months), receiving treatment with sDMARDs and bDMARD therapy, were randomly allocated into any of five groups: Group 1: continue full dose DMARDs and taper biologic therapy by 50 % (31 patients); Group 2: taper both DMARDs and biologic therapy dose by 50 % (32 patients); Group 3: taper DMARDs by 50 % and stop biologic therapy (31 patients); Group 4: stop both DMARDs and biologic therapy (31 patients); Group 5: continue medications without change (31 patients). Forty joints were assessed ultrasonographically (DAS-28 joints + ankles + metatarsophalangeal joints) and prospectively monitored for 12 months. The primary endpoint was sustained remission for 12 months. Patients were considered as having a relapse when the DAS-28 score was >3.2 and anti-rheumatic treatment was escalated. The frequency of relapse was 41.9 % in Group 1, 59.3 % in Group 2, 67.7 % in Group 3, 77.4 % in Group 4 and 6.5 % in Group 5. Relapse rates were significantly higher in patients whose ultrasound scores raised within 3 months of stopping their medications (P < 0.001 for both GS and PD scores). Cox regression identified ACPA positivity (at baseline) and progression of functional disability (at 2 months) as predictors for relapse. Tapering therapy is feasible in RA patients. Tailored dynamic approach is advised. Joint ultrasonographic assessment, ACPA positivity and worsening functional disability predicted relapse within a short term after discontinuation of the treatment. RA patients whose DAS-28 score was <2 were more likely to remain in remission.

Is it tinidazole-induced pancreatitis?

WHAT IS KNOWN AND OBJECTIVE: Metronidazole is one of the drugs with a well-recognized potential to rarely cause acute pancreatitis. The relation of other drugs of the 5-aminoimidazole group (e.g. tinidazole) to acute pancreatitis remains unknown. For the treatment of protozoal infections, tinidazole may be considered as an alternative to metronidazole in cases of intolerability or inadequate response. CASE SUMMARY: We report a case of acute pancreatitis possibly induced by tinidazole. WHAT IS NEW AND CONCLUSION: Tinidazole may probably cause acute pancreatitis similar to metronidazole. Physicians may occasionally encounter an individual with history of metronidazole-induced pancreatitis who requires antiprotozoal therapy. We believe it may be safer to choose a drug outside the 5-aminoimidazole group in this situation.

Pharmacological and clinical profile of lenvatinib (E-7080) in the treatment of advanced, radioiodine-refractory, differentiated thyroid cancer.

After the pathogenesis of thyroid carcinomas was better understood and the role of molecular alterations in RET, BRAF and RET/PTC rearrangement was revealed, several trials using multikinase inhibitors were developed during the last decade for the treatment of recurrent radioactive iodine (RAI)-refractory differentiated thyroid cancer (DTC), achieving a remarkable success. Sorafenib became the first drug approved for this indication in more than two decades after a significant improvement in the progression-free survival was demonstrated. Lenvatinib (E-7080), an orally active inhibitor of multiple receptor tyrosine kinases including vascular endothelial growth factor receptors (VEGFR) 1, 2 and 3, proto-oncogene tyrosine-protein kinase receptor Ret and mast/stem cell growth factor receptor Kit, yielded highly promising early clinical data, even when given after progression on first-line therapy. The phase III SELECT trial recently demonstrated the impressive clinical activity of the drug in RAI-refractory thyroid cancer, leading to the drug's approval by the regulatory agencies and potentially making lenvatinib the most effective drug available to date for the treatment of the disease.

Synovitis with pitting edema as the presenting manifestation of systemic lupus erythematosus.

Rheumatologists are increasingly aware of the entity synovitis with pitting edema. The remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome has been reported with an array of conditions that include polymyalgia rheumatica, rheumatoid arthritis, Sjögren's syndrome and psoriatic arthropathy. Synovitis with pitting edema is now being increasingly recognized with systemic lupus erythematosus (SLE). We report a patient who presented with edema of hands and feet and was diagnosed eventually with definite SLE. With magnetic resonance imaging, joint effusions and tenosynovitis were confirmed to be associated with the otherwise-unexplained extremity edema.

Junctional bradycardia with verapamil in renal failure--care required even with mild hyperkalaemia.

WHAT IS KNOWN AND OBJECTIVE: Treatment for hypertension with verapamil has a favourable renoprotective effect and is generally considered safe in patients with mild to moderate renal failure. In this report, we highlight the vulnerability of patients with mild to moderate renal failure to verapamil side effects especially in the presence of hyperkalaemia. CASE SUMMARY AND WHAT IS NEW: We report two cases of junctional bradycardia with slow release (SR) verapamil therapy in the presence of mild hyperkalaemia in patients with mild to moderate chronic renal failure. Verapamil and hyperkalaemia may synergistically increase the vulnerability to atrioventricular conduction delay. CONCLUSION: Renal failure patients with baseline mild hyperkalaemia are particularly liable to bradyarrhythmias with SR verapamil. In such cases, we would recommend verapamil dose reduction and avoidance of SR formulation. In cases of verapamil toxicity, actively treating any level of hyperkalaemia is recommended.

Mycophenolate mofetil as a maintenance therapy for lupus-related diffuse alveolar hemorrhage: a case report.

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of systemic lupus erythematosus (SLE). Cases complicated with DAH often have active SLE with multi-organ involvement, especially lupus nephritis. We describe a rare case of DAH as the first presenting manifestation of SLE in the absence of lupus nephritis. Remission was induced by IV methylprednisolone, IV cyclophosphamide, and plasmapheresis. Further cycles of cyclophosphamide were prevented by recurrent infections. Maintenance of remission was successfully achieved with oral mycophenolate mofetil 1 g twice daily, with a good control of SLE and without further DAH episodes.

The Arabic vowels: features and possible clinical application in communication disorders.

UNLABELLED: Most scholars, old and modern, agree that the vowel system of the Arabic language is composed of 3 vowels only, namely /i/, /ε/ and /u/. The spoken Cairo dialect suggests that there are 6 identifiable vowels, with a short and long variant for each. OBJECTIVE: The aim of this study is to test the validity of the notion that there are 6 × 2 distinct vowels, with a more central one. SUBJECTS AND METHODS: Spectral analysis was used to measure F(1) and F(2) for the vowels of 14 real words. Data was collected from 60 healthy adult informants, 30 males and 30 females. They were native Egyptians speaking the colloquial Cairene dialect. RESULTS: The values of the 6 long and short vowels plus the central one are presented. A significant difference was found between each of them. The long and short vowels differed only in the duration but did not differ in their formant values. CONCLUSION: The study illustrates the distinctive features of the vowels of the Arabic language. Each of the 7 vowels represents a distinct entity. This will have important implications in assessment and management of language, speech and voice disorders in children and adults.

Polymerase chain reaction versus conventional methods in the diagnosis of vaginal trichomoniasis.

A total of 200 females of whom 120 had manifestations of vaginal trichomoniasis and 80 asymptomatic ones were studied. In 54/120 symptomatic female (45%) and in 28/80 asymptomatic ones (35%), T. vaginalis was diagnosed by wet mount of bedside vaginal swab samples. Of 120 samples from symptomatic females, T. vaginalis was detected in 93 (77.5%) when cultured onto InPouch & 95 (79.16%) in modified thioglycolate media. Culturing 80 samples of asymptomatic females showed T. vaginalis in 35 (43.75%) onto either media. T. vaginalis genomic DNAs was amplified by PCR from 130 (65%) by using TVA5-TVA6 primer pair in 95 (79.16%) samples of 120 symptomatic females, and in 35 (43.75%) samples of 80 asymptomatic ones. Difference between groups was statistically significant. The motile trichomonads was detected by wet mount in 82/130 positive cultures giving 63.07% sensitivity & 100% positive predictive value (PPV). Flagellates were not detected by wet mount in any negative culture, giving 100% specificity & 59.32% negative predictive value (NPV). The wet mount diagnostic accuracy (DA) was 76%, without false-positive, but false negative was 48/130 (36.93%). DNA was amplified from 129/130 positive culture by TVA5-TVA6 primer pair, giving 99.23% sensitivity. No amplification was detected from one positive culture. DNA was not amplified from 69/70 negative culture using TVA5-TVA6 primer pair, giving 98.57% specificity, 99.23% PPV, 98.57% NPV and 99% DA.

Aerodynamics of the pseudo-glottis.

OBJECTIVE: The aim of this work is to study the hitherto unclear aerodynamic parameters of the pseudo-glottis following total laryngectomy. These parameters include airflow rate, sub-pseudo-glottic pressure (SubPsG), efficiency and resistance, as well as sound pressure level (SPL). PATIENTS AND METHODS: Eighteen male patients who have undergone total laryngectomy, with an age range from 54 to 72 years, were investigated in this study. All tested patients were fluent esophageal 'voice' speakers utilizing tracheo-esophageal prosthesis. The airflow rate, SubPsG and SPL were measured. RESULTS: The results showed that the mean value of the airflow rate was 53 ml/s, the SubPsG pressure was 13 cm H(2)O, while the SPL was 66 dB. The normative data obtained from the true glottis in healthy age-matched subjects are 89 ml/s, 7.9 cm H(2)O and 70 dB, respectively. Other aerodynamic indices were calculated and compared to the data obtained from the true glottis. CONCLUSION: Such a comparison of the pseudo-glottic aerodynamic data to the data of the true glottis gives an insight into the mechanism of action of the pseudo-glottis. The data obtained suggests possible clinical applications in pseudo-voice training.

Can a change in policy reduce emergency hospital admissions? Effect of admission avoidance team, guideline implementation and maximising the observation unit.

BACKGROUND: Reduction in admissions is an important aim of emergency department working policy to overcome the problems of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. A new policy was instituted in the emergency department of a hospital in Kuwait with the following components: (1) an admission avoidance team of emergency department doctors; (2) implementation of disease management guidelines; and (3) maximising the use of an emergency department observation unit. METHODS: The effects of this policy on reduction in admission rates for total medical admissions and for chest pain, bronchial asthma, heart failure, pneumonia and pyelonephritis as selected samples of common medical conditions were prospectively studied over a period of 3 years from institution of the policy and compared with the 3-year period before the policy was instituted. RESULTS: There was a significant reduction in admission rates after institution of the new policy, with a relative reduction of 35.9% for total medical admissions, 52.7% for chest pain, 49.2% for bronchial asthma, 34.7% for heart failure, 59.1% for pneumonia and 43.3% for pyelonephritis compared with the period before the policy was instituted. CONCLUSION: A multidisciplinary emergency department policy, using as much available evidence as possible, was successful in significantly reducing medical hospital admissions in spite of the rising numbers of patients visiting the emergency department and observation unit.

Differences in spatial and seasonal patterns of macrophyte assemblages between a coastal lagoon and the open sea.

Although benthic macrophytes must be considered in monitoring programs to establish the ecological status of transitional and coastal waters in the European Union, the patterns of variability in species composition of macrophyte assemblages in Mediterranean coastal lagoons has scarcely been studied. In this work the spatial (both vertical and horizontal) and seasonal dynamics of macrophyte assemblages in a coastal lagoon (Mar Menor) are compared with those of open coastal assemblages in the SW Mediterranean to analyze any biological variability in lagoon assemblages and the factors that determine such variability. Different assemblages, characterized by well defined groups of species, can be described according to their isolation from the open sea and the type of substratum; at the same time, a vertical zonation pattern, similar to that found in all marine communities but more compressed, exists. This implies that when applying the EU Water Framework Directive or assessing environmental impact, a lagoon should not be considered spatially uniform and unique unit but as a mosaic of assemblages.

Anterior hypospadias. Is repair necessary with urination in a sitting or squatting position?

OBJECTIVE: To determine the chronic complication rate of anterior hypospadias repair and to explore whether the practice of placing the neomeatus at the tip of the penis should be applicable to all cases in our community where urination is in a sitting/squatting position. METHODS: Over a 10-year period commencing 1st September 1987, 312 patients had hypospadias repair of whom 72% had anterior hypospadias. The meatus was advanced to the tip of the penis in all repairs. The location of the meatus was also determined in 281 non-complaining men with a straight penis and normal sexual and reproductive functions. Following prior information that anterior hypospadias was not associated with sexual and reproductive dysfunction, 51 patients were given a choice between repair or no repair. RESULTS: Urethrocutaneous fistula occurred in 5% of patients, urethral stricture in 3% and meatal retraction in 3%, with 92% of patients having no complications. Forty six percent of non-complaining men had the meatus in locations other than the tip of the penis. Of 51 patients with the benefit of informed consent, 73% opted for no repair. CONCLUSION: Our results of anterior hypospadias repair compare favourably with those of other centers. Placement of the meatus at the tip of the penis for anterior hypospadias should not be applicable to all patients in this community where urination is in a sitting/squatting position. Before such repairs, an informed consent is warranted by making the patients and their parents aware of the non-association of sexual and reproductive disorders with these anomalies.

Hand and distal forearm replantation--immediate and long-term follow-up.

Six cases of traumatic amputation of hand and/or forearm were treated by replantation over the last 20 years at this hospital. Reattachment was successful in all of the cases. Success was largely due to proper selection of cases, meticulous technique and availability of skilled manpower and technological help. Although survival of replanted part was achieved in all cases, functional success was not uniform as revealed by subjective and objective criteria used during evaluation and follow-up. Tamai method of scoring the functional aspect of a replanted part not only indicates the functional ability of a replanted part but also creates uniformity in data collection for easier comparison with other reported series.

Comparison of serum antibody responses to Giardia lamblia of symptomatic and asymptomatic patients.

The circulating anti-parasite antibody response against Giardia lamblia in symptomatic and asymptomatic Egyptian children with confirmed giardiasis was examined. Symptomatic patients were identified using the following criteria: presence of only G. lamblia cysts in the feces, and one or more of the following symptoms, diarrhea, abdominal pain, loss of weight, vomiting and/or nausea, and abdominal distention. The anti-parasite humoral response was measured using indirect immunofluorescence (IFA), ELISA, and immunoblotting. There was a significant difference in the anti-parasite antibody response measured by IFA of asymptomatic and symptomatic patients, in which more than 34% of the asymptomatic patients had a titer equal to or less than 1:500, and more that 29% of the symptomatic patients had a titer of 1:8,000 or higher. The circulating anti-parasite total IgM and IgA but not IgG, measured by ELISA, was significantly higher in symptomatic than in asymptomatic patients, and were related to higher cyst output observed in symptomatic individuals. Although total anti-parasite IgG response was similar in symptomatic and asymptomatic patients, the analysis of the IgG isotype responses revealed that both IgG1 and IgG3 were significantly higher in symptomatic patients. The antigen recognition by anti-parasite IgM, IgA, IgG1, and IgG3 of symptomatic and asymptomatic individuals, determined by immunoblotting, was heterogeneous and revealed only minor differences in the response of the two groups.

Cell mediated immune response in chronic liver diseases: schistosomal, viral and neoplastic.

Cell mediated immune response (CMIR) was studies in 120 patients having chronic liver diseases. Patients were divided into 6 groups, (20 each). (1) Early hepatosplenic Schistosomiasis. (EHSS), (2) Late hepatosplenic Schistosomiasis. (LHSS), (3) Hepatosplenic Schistosomiasis with hepatitis B and/or C infections, (4) Hepatitis B virus cases. (HBV), (5) Hepatitis C virus cases (HCV), (6) Hepatocellular carcinoma cases. (HCC). Twenty within normal subjects taken as controls. Laboratory investigations revealed significant esinophilia in patients of group (1), haemoglobin level was significantly reduced in patients of group (1, 2, 3, & 6), serum albumin was significantly reduced in group (2). The percentage of positivity of skin testing using purified protein derivative, ranged between 10% of patients with LHSS, HBV, HCC and HSS with HBV and/or HCV, 20% of patients with HCV and 25% of patients with EHSS. Percentage of positivity in control group was 100%. The mean diameter of delayed intradermal reaction (2.2 +/- 0.5-6.1 +/- 2.1 mms.) was significantly lower in patients than controls. The response of lymphocyte transformation test to phytohaemmagglutinin was significantly lower in patients when compared to controls. The association of HBV and/or HCV with hepatosplenomegaly was accompanied with a marked depression in cell mediated immune response. Anaemia, hypoalbuminemia and nutritional status of the patients with chronic liver diseases play a major role in the suppression of cell mediated immune response.

Aspects of assessment and management of velopharyngeal dysfunction in developing countries.

Proper assessment of patients with velopharyngeal valve incompetence is a mandatory prerequisite for optimal management. The protocol of assessment of Ain Shams University, Phoniatric Department, uses three levels of assessment of velopharyngeal valve incompetence according to the complexity of the armamentarium used. This allows application of those parts of the protocol that suit the needs of the different socioeconomic levels and geographical locations. Firstly, the elementary diagnostic procedures, which are rather simple, noninvasive, but essentially subjective. Despite the clinical feasibility of these procedures, documentation of the data is made utilizing the tools at the second level of assessment in that protocol (clinical diagnostic aids). This level comprises video-nasofiberscopy and high fidelity voice recording. An attempt to extract quasi-quantitative measures from the hitherto qualitative video-nasofiberscopy is made. The third level of assessment, namely additional instrumental measures, comprises CT scanning of the velopharyngeal port, aerodynamics, and acoustic analysis. The results of the three levels of the protocol are presented. Their significance and clinical efficacy are discussed. Some community-related problems that have faced the cleft palate team are outlined. Their sociocultural significance in a developing country is discussed.