Prevalence of coeliac disease among adult patients with autoimmune hypothyroidism in Jordan.

The prevalence of coeliac disease among patients with autoimmune hypothyroidism has not been studied before in Jordan and other Arab countries. A cross-sectional record-based review was made of all adult autoimmune hypothyroidism patients who attended a referral centre in Jordan, during an 8-month period. Coeliac disease in these patients was diagnosed by the attending physician based on positive serological tests for anti-endomysial antibodies IgA and IgG followed by duodenal biopsy to confirm the diagnosis of coeliac disease. Of 914 patients recruited, 117 (12.8%) were seropositive for coeliac disease. Of 87 seropositive patients who underwent duodenal biopsy, 39 had positive histological findings of coeliac disease (44.8%). Extrapolating from these findings the overall rate of coeliac disease among autoimmune hypothyroidism patients was estimated to be 5.7%. In multivariate logistic regression coeliac disease was significantly associated with older age (> 40 years), presence of other autoimmune diseases, vitamin B12 deficiency and anaemia.

Prevalence of coeliac disease among adult patients with autoimmune hypothyroidism in Jordan

The prevalence of coeliac disease among patients with autoimmune hypothyroidism has not been studied before in Jordan and other Arab countries. A cross-sectional record-based review was made of all adult autoimmune hypothyroidism patients who attended a referral centre in Jordan, during an 8-month period. Coeliac disease in these patients was diagnosed by the attending physician based on positive serological tests for anti-endomysial antibodies IgA and IgG followed by duodenal biopsy to confirm the diagnosis of coeliac disease. Of 914 patients recruited, 117 [12.8%] were seropositive for coeliac disease. Of 87 seropositive patients who underwent duodenal biopsy, 39 had positive histological findings of coeliac disease [44.8%]. Extrapolating from these findings the overall rate of coeliac disease among autoimmune hypothyroidism patients was estimated to be 5.7%. In multivariate logistic regression coeliac disease was significantly associated with older age [> 40 years], presence of other autoimmune diseases, vitamin B12 deficiency and anaemia

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference.

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.

Magnetic resonance cholangiopancreatography in patients with upper abdominal pain: a prospective study.

BACKGROUND/AIMS: To determine the role of magnetic resonance cholangiopancreatogram with conventional abdominal magnetic resonance examination in patients presenting clinically with upper abdominal pain and abnormal liver function tests and to compare the findings with endoscopic retrograde cholangiopancreatogram results. METHODOLOGY: Magnetic resonance cholangiopancreatogram and endoscopic retrograde cholangiopancreatogram were done in 77 patients. Conventional magnetic resonance examination of the liver and upper abdomen was done first followed by magnetic resonance cholangiopancreatogram using a half fourrier single shot turbo spin echo sequence. Conventional endoscopic retrograde cholangiopancreatogram was done by direct intraductal injection of radiographic contrast material through a duodenoscope under fluoroscopy control. RESULTS: Endoscopic retrograde cholangiopancreatogram failed in 7 patients (9%) and Magnetic resonance cholangiopancreatogram images were inadequate in 3 patients (4%). The findings of adequate magnetic resonance exams in 74 patients were: choledocholithiasis in 24 patients (32%), bile duct stricture in 19 patients (26%), normal biliary ducts in 29 patients (39%) and dilated biliary ducts with no definite cause in 2 patients (3%). The findings of successful endoscopic retrograde cholangiopancreatograms in 67 patients after exclusion of inadequate magnetic resonance cholangiopancreatograms were: choledocholithiasis in 25 patients (37%), bile duct stricture in 18 patients (27%), normal biliary ducts in 21 patients (31%) and dilated biliary ducts with no evident cause in 2 patients (3%) and hemobilia in 1 patient (2%). CONCLUSIONS: Magnetic resonance cholangiopancreatogram is a non-invasive technique, its accuracy is increased if it is combined with conventional abdominal magnetic resonance exam and it can replace the endoscopic retrograde cholangiopancreatogram.

Bleeding tendency in Wolfram syndrome: a newly identified feature with phenotype genotype correlation.

Wolfram syndrome (WS) is a recessively inherited disorder associated with recognised clinical features. Bleeding tendency was noticed in some of our patients, although this has not been reported before. We therefore studied this problem in all our WS patients and tried to postulate a possible pathogenesis. At the same time, a genetic linkage study provided evidence of locus heterogeneity of this syndrome and showed that the majority of our patients belong to the second WS locus identified in that study. Our study group consisted of 13 WS patients, belonging to WSF2 locus (group I). Controls consisted of 4 healthy siblings of WS patients (group II) and 7 diabetics who do not have WS (group III). Relevant clinical data were obtained, and a coagulation screen was carried out for all groups. All individuals in the three study groups have normal platelet count, thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (aPTT), clot retraction, Factor VIII activity (FVIIIc) and von Willebrand factor antigen (vWAg). Eleven of the WS patients have prolonged template bleeding time (BT) compared with both control groups. Patients with WS have a longer BT (mean 9.6 min, 95% CL 8.61-10.53 min) than the siblings group (mean 6.75 min, 95% CL 5.52-7.98 min) and the diabetic group (mean 5.49 min, 95% CL 4.56-6.42 min). The differences between the study group and controls are statistically significant, p = 0.02 and 0.0002, respectively. In the three groups, platelet aggregation studies were normal using adenosine diphosphate (ADP), ristocetin and epinephrine. Aggregation with collagen was either absent or impaired, with failure of secondary wave being noticed in 11 of the WS patients (85%) and normal in the control groups. The pathogenesis of this problem is not known, but could be due to an inhibitory effect of vWAgII, deficiency of thrombospondin or a defect in the platelet membrane GPIa/IIa. Bleeding diathesis is a new additional feature to the clinical spectrum of WS, which is probably a feature of the disorder WFS2 and not WFS1, as bleeding has never been reported in the latter. This provides further evidence for the phenotypic and genotypic heterogeneity of this complex disorder and may provide clues to the search for the second gene responsible for this phenotype.

Selective use of perioperative ERCP in patients undergoing laparoscopic cholecystectomy.

BACKGROUND/AIMS: Management of common bile duct stones in the era of laparoscopic surgery is still controversial. The purpose of this study is to investigate the safety, feasibility, success rate and short-term results of the selective use of endoscopic retrograde cholangiopancreatography in patients undergoing laparoscopic cholecystectomy. METHODOLOGY: A prospective study comprising 300 consecutive patients with either symptomatic or complicated gallbladder stones was performed between January 1994 and November 1996. Depending on clinical, laboratory and ultrasonographic criteria, 73 patients (24.3%) underwent endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy. The procedure was successful in 71 patients (97%) either preoperatively in 62 patients (21%) or postoperatively in 9 patients (3%). RESULTS: Endoscopic retrograde cholangiopancreatography was positive in 37 cases (52%), endoscopic sphincterotomy and stone extraction was performed in 35 cases and endoscopic sphincterotomy alone was performed in 2 cases for benign papillary stenosis. The overall predictive value for the presence of common bile duct stone was 52%, the predictive value for patients with jaundice, dilated common bile duct together with elevated liver enzymes was 73.3%. Complications of perioperative endoscopic retrograde cholangiopancreatography were encountered in 4 patients (5.5%) with no mortality. CONCLUSIONS: We conclude that the combination of perioperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy is a useful approach for the management of choledochocholelithiasis.

Nosocomial infections in the intensive care units at a university hospital in a developing country: comparison with National Nosocomial Infections Surveillance intensive care unit rates.

OBJECTIVE: As a measure of the quality of care provided to patients in the intensive care unit, comparison of nosocomial infection rates with those of the National Nosocomial Infection surveillance was completed during a 3-year observation period. DESIGN: The study design was a prospective study during 3 years between 1993 and 1995. During that period, patients at the medical/surgical and neurosurgical intensive care units and the high-risk nursery were surveyed for nosocomial infections. Device use, bloodstream infection, urinary tract infection, and ventilator-associated pneumonia nosocomial infection rates were calculated and compared with the National Nosocomial Infection Surveillance published rates for the same period. SETTING: The study setting was the medical/surgical intensive care unit, the neurosurgical intensive care unit, and the high-risk nursery at the Jordan University Hospital. RESULTS: Overall infection rates were 17.2 per 100 patients in the medical/surgical intensive care unit, 14.2 to 18.5 per 100 patients in the neurosurgical intensive care unit, and 13.4 to 73.5 per 100 patients in the high-risk nursery. When compared with the weight of the infants, these rates were 61.9 to 94 per 100 in infants weighing <1500 g, 26 to 30.8 per 100 patients in infants weighing >1500 g to 2500 g, and 11.7 to 14.4 per 100 in infants weighing >2500 g. Whereas device use was moderate, bloodstream infection and ventilator-associated pneumonia rates were >90th percentile for National Nosocomial Infection Surveillance in the high-risk nursery, and urinary tract infection was >90th percentile in the medical/surgical and neurosurgical intensive care units. Nosocomial infections at the intensive care units in developing countries need further investigation and control.

Helicobacter pylori in dyspeptic Jordanian patients.

UNLABELLED: To study the prevalence of Helicobacter pylori infection in dyspeptic Jordanian patients. PATIENTS AND METHODS: Two hundred and twenty seven consecutive dyspeptic Jordanian patients were studied with endoscopy, endoscopic biopsies, culture, and CLO urease testing for the detection of H. pylori. RESULTS: Helicobacter pylori positivity in both culture and CLO urease testing was 86%, being 78% in culture and 80% in CLO test separately. The majority of our patients were in the age range 21-60 years and H. pylori positivity was more than 90% in them. CONCLUSION: Helicobacter pylori is a common infection in dyspeptic Jordanian patients regardless of the underlying cause. Males were affected more than females.

Pattern of colonic disease in lower gastrointestinal bleeding in Jordanian patients: a prospective colonoscopic study.

PURPOSE: This study was developed to document causes of rectal bleeding of Jordanian patients and compare them with results from several parts of the world. METHODS: Diagnostic and therapeutic colonoscopy was used as a first-line investigation on 701 consecutive Jordanian patients presenting with rectal bleeding. When indicated, technetium 99m-labeled red blood counts or selective angiography were used also. RESULTS: Most common causes according to frequency were hemorrhoids, polyps, ulcerative colitis, amebic colitis, neoplasm, diverticulosis, anal fissure, Crohn's disease, and arteriovenous malformations. CONCLUSIONS: This is the first study addressing this problem from this part of the world. Findings were different from many other results published in western and eastern studies in certain disease entities.

Etiology of upper gastrointestinal bleeding in Jordanian patients: A prospective study.

Endoscopy within 24 hours from the onset of upper gastrointestinal (UGI) bleeding was carried out on 853 Jordanian patients. Lesions as a bleeding source were identified in 799 (93.7%) patients. Radioactively tagged red blood cell (RBC) scan, angiography and upper gastrointestinal follow-through radiography were complementary studies in endoscopy negative patients. Etiology remained unidentified in 16 patients. The six most common causes of UGI bleeding in this study were duodenal ulcer, gastric erosions, duodenal erosions, esophagitis, gastric ulcer and esophageal varices. Nonsteroidal anti-inflammatory drugs (NSAIDs) were a significant predisposing factor for UGI bleeding (28.6%). Mortality at the first admission was 3.4% and increased during 12 month follow-up to 6.9%. To our knowledge, this is the first study from Jordan concerning the causes of upper GI bleeding of all clinical types.

Endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of biliary and pancreatic duct disease: A prospective study on 668 Jordanian patients.

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in establishing the nature and the site of common bile and pancreatic duct disease and related complications. It was used in 668 Jordanian patients who presented with biliary or pancreatic disease and unexplained upper abdominal pain. Common bile duct (CBD) stones, postsurgical traumatic CBD strictures, papillary stenosis and malignant strictures were the most common findings in this study. The incidence of malignant strictures was less and the postsurgical CBD injuries, mainly CBD complete ligation, were more than what was reported by others. This procedure was also valuable in the investigation of unexplained upper abdominal pain and pancreatic disease.

Renal cell carcinoma presenting as Garcin's syndrome.

A 50 year old man presented with progressive unilateral cranial nerve palsies (Garcin's syndrome) for one year. Skull radiography and computed tomography (CT) showed intracranial extension of a soft tissue tumour from the right base of the skull. Necropsy revealed a papillary cell carcinoma of the right kidney and metastases in the base of the skull.

Patterns of hepatomegaly in Jordanians: a prospective study of 800 cases.

Eight hundred Jordanians with liver enlargement were studied: 369 (46%) were males and 431 (54%) females. Ages ranged between 13 and 85 years, with a mean of 47.4%: 766 cases demonstrated a single pathological process while 34 cases showed two or more processes. The most significant findings were: congestion secondary to cardiac failure in 323 cases (38.5%); inflammatory and parasitic processes in 192 cases (22.9%), including acute hepatitis (81 cases), hydatid cyst (63 cases), chronic hepatitis (27 cases), liver abscess (19 cases), brucellosis (one case) and malaria (one case); malignancy in 164 cases (19.6%); liver cirrhosis in 80 cases (9.5%); fatty metamorphosis in 47 cases (5.6%); metabolic and genetic disease in 11 cases (1.3%); miscellaneous conditions in nine cases (1.1%); and 15 apparently normal individuals (1.8%). Cardiac failure was the most frequent cause of hepatomegaly in this sample of Jordanians. Inflammatory processes were the second major cause, followed by malignancy and cirrhosis of the liver.