Dose-dependent protective effect of baicalin against testicular torsion-detorsion in rats.

Testicular torsion/detorsion induces oxidative/nitrosative stress, inflammation and apoptosis of testicular tissues. Baicalin exerts antioxidant and anti-inflammatory properties. This study investigated the possible protective effect of baicalin against testicular torsion-detorsion injury in rats. Surgical testicular torsion was induced for 2 h, followed by detorsion which was continued for 24 h. Baicalin was administered in three different doses (25, 50 and 100 mg kg-1 , by intraperitoneal injection). Each dose was given twice, the first 30 min before and the second 12 h after testicular detorsion. Baicalin, in a dose-dependent manner, decreased the torsion/detorsion-induced elevations of testicular malondialdehyde, nitric oxide, tumour necrosis factor-α, BCL2-associated X protein (Bax), cytosolic cytochrome c and caspase-3 and caspase-9 activities. Baicalin, dose dependently, attenuated the reductions of B-cell leucemia/lymphoma 2 (Bcl-2), and glutathione peroxidase and superoxide dismutase activities in testicular tissues resulted from torsion/detorsion. In addition, baicalin ameliorated the histopathological testicular tissue damage and reduced the expression of Fas ligand in rat testes exposed to torsion/detorsion in a dose-dependent manner. It was concluded that baicalin, dose dependently, ameliorated testicular injury induced by torsion/detorsion via its antioxidant, antinitrosative, anti-inflammatory and anti-apoptotic effects.

Emergency obstetric hysterectomy in a university hospital: A 25-year review.

Over the past 25 years, 43 peripartum hysterectomies were performed at the authors' institution, an incidence of 0.64/1,000 deliveries; 31 procedures followed caesarean section and 12 were performed for haemorrhage following vaginal delivery. The common indications for hysterectomy were abnormal placentation (39.5%), uterine atony (23.3%), uterine rupture (23.3%), and haemorrhage during caesarean section (11.6%). The risk factors for hysterectomy included advancing maternal age and parity, previous caesarean section scars and abnormal placentation. Subtotal hysterectomy was performed in 72.1% cases which appeared a quicker and safer procedure than total hysterectomy in desperately ill patients. Five (11.6%) maternal deaths occurred in the series. Mortality was associated with massive haemorrhage. With rising caesarean section rates worldwide, MRI and colour Doppler sonography is useful to diagnose antepartum placenta accreta/bladder involvement in order to plan elective surgery that is associated with reduced maternal morbidity and mortality. Early decision to perform an emergency hysterectomy is essential before the patient's condition deteriorates, besides availability of an experienced obstetrician to undertake a technically demanding operation.

The association of gastroesophageal reflux with bronchial asthma. Can asthma also trigger reflux?

BACKGROUND/AIMS: The frequency of gastroesophageal reflux (GER) among asthmatic patients was found to range from 34% to 89% at different locations. The aims of this study have been to determine the frequency of GER in patients with asthma in the Saudi environment, to ascertain the main mechanism whereby GER triggers asthma, and to seek any evidence whether asthma can also trigger GER. METHODOLOGY: Fifty asthmatic patients were consecutively recruited as they reported to King Fahd Hospital of the University (KFHU), Al-Khobar, Saudi Arabia, in the period from February 2000 to February 2001; their mean age +/- SD was 38.0 +/- 9.8 years. Twenty-two subjects without asthma or GER served as controls; their mean age +/- SD was 29.4 +/- 8.6. Both groups were subjected to a questionnaire, esophageal manometry, dual probe ambulatory 24-hour pH monitoring, and pulmonary function tests. RESULTS: Among the asthmatic group 22 patients (44%) had GER. Accordingly, the asthmatic patients were divided into two groups: asthmatic with GER (n=22), and asthmatic without GER (n=28). Hoarseness of voice and nocturnal symptoms were found to be significant predictors for the presence of GER in asthmatics. Manometry revealed that asthmatic patients with GER had higher gastric pressure (11.4 +/- 4.0 mmHg vs. 8.4 +/- 2.8 mmHg; p=0.006) and lower resting pressure at the lower esophageal sphincter (LES) (21.2 +/- 8.7 mmHg vs. 28.2 +/- 9.3 mmHg; p=0.013) when compared with controls, both factors favoring the occurrence of reflux. With regard to pH data, acid reflux occurred both at the distal and proximal esophagus but the percent total acid exposure time was about 7 times longer at the distal than at the proximal esophagus (5.80 vs. 0.9). In addition, gastric pressure was positively and significantly correlated with distal esophageal acid exposure time and the DeMeester score, negatively correlated with spirometric parameters in asthmatic patients, as well as found to be a significant predictor of the severity of asthma (p=0.006). CONCLUSIONS: Forty-four percent of the sample of asthmatic patients reporting to KFHU had GER. Since distal esophageal total acid exposure time was nearly 7 times longer than at the proximal esophagus, the main mechanism for GER triggering asthma is the vagally mediated reflex initiated by acid in the distal esophagus. In addition, the positive correlation of increased gastric pressure with the distal esophageal acid exposure time and the DeMeester score, its negative correlation with spirometric parameters and being a significant predictor of asthma severity suggest that severe asthma may trigger or aggravate GER.

DOOR syndrome: deficiency of E1 component of the 2-oxoglutarate dehydrogenase complex.

Four patients from three families with the clinical features of DOOR syndrome (onycho-osteodystrophy, dystrophic thumbs, sensorineural deafness, and increased urinary levels of 2-oxoglutarate) are the subjects of this report. Our report deals with the autosomal recessive form of the disease, wherein the activity of 2-oxoglutarate decarboxylase (E1(0)) in fibroblasts and white blood cells of the patients is decreased. The activity of E1(0) in all patients' fibroblasts and white blood cells was significantly lower compared to the controls. This study demonstrates for the first time that E1(0) deficiency is an important biochemical marker for the autosomal recessive form of DOOR syndrome.

Acute renal failure in an intensive care unit.

OBJECTIVE: To determine the clincal course and outcome of acute renal failure in an intensive care unit set-up. METHODS: All patients admitted to the intensive care until who developed acute renal failure were prospectively studied over a 3-year period from 1996 to 1999, at King Fahd Hospital of the University, Al Khobar, Kingdom of Saudi Arabia. They were investigated for the causes of their acute renal failure, given appropriate treatment and their course carefully documented until discharge from the intensive care unit. RESULTS: Forty-seven patients (29 male and 18 female) were studied. The majority were Saudis (81%). The age range was 28-81 years with a mean of 53 +/- 14 years. Renal causes, 31 cases (66%), were the most frequent causes of acute renal failure. Pre-renal causes occurred in 12 cases (25.5%) and post-renal causes in 4 cases (8.5%). Three quarters of the causes were medical and one quarter surgical. Septicemia (22 cases), dehydration with hypovolemia (8 cases) and myo/hemoglobinuria (5 cases) were the leading medical causes. Fifteen patients (32%) died in the intensive care unit while 32 were discharged (68%). Multiple organ dysfunction, disseminated intravascular coagulopathy, acute respiratory distress syndrome and diabetes mellitus were the major factors that adversely affected mortality. There was a statistically significant difference in the length of intensive care unit stay of the survivors (5.7+/-2.6 days) compared to the deceased (11+/-5.8 days) (P<0.005). Renal replacement therapy was performed in 15 patients (10 continuous veno-venous hemodialysis and 5 conventional hemodialysis). Almost 3 quarters (73%) of the deceased required renal replacement therapy. CONCLUSION: The development of acute renal failure in the setting of an intensive care unit carried a poor prognosis. Renal causes are responsible for 2 in 3 cases. Septicemia, dehydration/hypovolemia, myo/hemoglobinuria are the leading medical causes while multiple organ dysfunction, disseminated intravascular coagulopathy, acute respiratory distress syndrome and diabetes mellitus increase mortality. The poor prognosis of patients developing acute renal failure in the intensive care unit can be improved if attention is paid to prevention of septicemia, dehydration, prompt and aggressive treatment of multiple organ dysfunction, disseminated intravascular coagulopathy, acute respiratory distress syndrome and diabetes mellitus.

Ischemic strokes requiring mechanical ventilation in the Intensive Care Unit.

OBJECTIVE: To describe the clinical profile and the outcome of patients with clinical diagnosis of ischemic stroke requiring mechanical ventilation at King Fahd Hospital of the University. METHODS: A descriptive study of all cases of ischemic stroke patients requiring mechanical ventilation admitted to the Intensive Care Unit at King Fahd Hospital of the University, Saudi Arabia, between August 1996 - August 1998 with their clinical pattern and outcome. RESULTS: A total of 25 stroke patients with female to male ratio of 1.7:1 and mean age of 61.2+/-2.6 years. The vascular territories were middle cerebral artery 60% of the case, 20% basilar and 20% multiple territories. Hypertension (80%), diabetes mellitus (72%), hyperlipidemia (36%), hyperglycemia (32%) and obesity (16%) were the common risk factors. Glasgow Coma Scale on admission and 24 hours later were reported. The computerized tomography of the head shows ischemic strokes in the following distribution: Middle cerebral artery 48%, basilar 20% and mixed territories 32%. Of the twenty-five patients in the Intensive Care Unit, 14 patients (56%) showed improvement, 2 patients (8%) unchanged, and 9 patients (36%) died. Age, absence of corneal reflexes, presence of multiple infarcts on computerized tomography of the head and systemic complication of heart failure, hyperosmolar and pneumonia are associated features indicating poor outcome. CONCLUSION: The risk factors, predictors and poor outcome are similar with those reported in the literature. The outcome of stroke with mechanically ventilated patients, in the opinion of the author, calls for a need of specialized stroke team and the establishment of a Neuro-Intensive Care Unit, which will help in optimizing treatment strategies and appropriately allocate resources.

Where is critical care medicine in today's undergraduate medical curriculum?

Critical Care Medicine is a well-established specialty in developed countries. Medical students have exposure to it at undergraduate level and it is an independent subspecialty at postgraduate level. However, in the Kingdom of Saudi Arabia, Critical Care Medicine is minimally taught under other subject headings in Surgery, Internal Medicine or Anesthesia. This article discusses the need for the inclusion of Critical Care Medicine in the undergraduate curriculum for better integration of basic and clinical sciences on one hand and improvement of the student's base of knowledge and quality of patient care on the other.

Cough: a practical approach for the primary care physician in saudi arabia.

Cough is one of the cardinal symptoms of respiratory tract disorders and could be a manifestation of a serious non-respiratory tract disease. Cough is generated by an integrated mechanism between the central nervous and respiratory systems. The triggering factor of the above integration is an initial irritant, which stimulates the cough reflex and, hence, the mechanism of cough will take place. Persistent cough in a non-smoking adult is considered one of the most common presentations to physicians practicing in hospital or primary care settings and can be caused by many disorders. The objective of this article is to highlight a practical approach for the primary care physicians to the initial management of cough.

Gastric involvement in Waldenstrom macroglobulinemia: CT findings.

Waldenstrom macroglobulinemia is a plasma cell dyscrasia that rarely presents with gastrointestinal involvement. We report a case of gastric involvement of Waldenstrom macroglobulinemia detected by CT.

Clinical profile of patients admitted to the coronary care unit with possible myocardial infarction without diagnostic ECG and/or enzyme changes.

Concern has been expressed about the cost-effectiveness of the Coronary Care Unit (CCU) and solution options offered on account of the large number of patients admitted to the CCU who turn out not to have acute myocardial infarction. In a prospective study over four years, we studied a group of patients admitted to the CCU with suspected myocardial infarction but who did not have diagnostic ECG and/or enzyme changes for the causes of their chest pain. We compared the clinical profile of these patients (Group A) with that of a random sample of patients with confirmed myocardial infarction (Group B). Gastrointestinal disorders, musculoskeletal chest pain, panic and anxiety disorders were the major causes of chest pain in Group A patients. A normal ECG and a normal creatine phosphokinase (CPK) within the first 24 hours, a normal initial random blood sugar, a younger age and absence of coronary risk factors effectively separated Group A patients as low risk from Group B patients as high risk for acute myocardial infarction. These simple parameters will assist physicians providing CCU care in most hospitals in early decision making and in the judicious use of the CCU.

Why do cardiology out-patient appointments fail in Saudi Arabia?

In a retrospective study, 534 appointments for a cardiology clinic were analysed to determine the frequency of no-show and to identify contributory factors. The overall rate of no-show was 30.1%, which is higher than the 18% and 20% reported from other teaching hospitals. Variables with the strongest univariate association with no-show were nationality (Saudi 35%, non-Saudi 22%; p = 0.0015), gender (males 34%, females 25%; p = 0.03), heart failure (present 44%, absent 27.9%; p = 0.005) and valvular heart disease (present 23.4%, absent 32.6%; p = 0.04). Turning to a stepwise logistic regression to predict no-show behaviour, we found that nationality, gender and heart failure were significant, while valvular heart disease was not. We conclude by recommending that physicians and mass media should share in the responsibility of stressing the importance of keeping out-patient department (OPD) appointments to all patients especially those who are more prone to no-show behaviour, namely male nationals. Telephone and mailed reminders have been used successfully to improve attendance at the OPD, and can be evaluated in our community.

Unusual presentation of cancer.

The large bowel is the most frequent primary site for metastases in inguinal hernial sacs. We report four cases, two due to carcinoid of unknown primary, and one each due to adenocarcinoma of colon, stomach and pancreas. We recommend that all hernial sacs, particularly in the elderly, be examined microscopically.

Ceftriaxone in the treatment of acute and subacute human brucellosis.

A total of 14 adults were diagnosed as having brucellosis by clinical means, serology and blood culture. The first patient to be treated failed to respond to 2 g/day intravenous ceftriaxone, therefore, subsequent patients were treated intravenously, twice daily with 2 g ceftriaxone. Immediate clinical response was seen in nine (69.2%) of the patients. Therapy was changed to tetracycline plus streptomycin in the remaining four (30.8%) patients because of lack of response after 5 days. It is concluded that ceftriaxone may be considered a second-line therapy for brucellosis in patients who cannot be given conventional therapy. Further evaluation of ceftriaxone, either alone or preferably in combination with streptomycin or rifampicin on a larger scale, is indicated.