Recognizing and treating cutaneous signs of liver disease.

Cutaneous changes may be the first clue that a patient has liver disease. Recognizing these signs is crucial to diagnosing liver conditions early. Here we describe the spectrum of skin manifestations that may be found in various liver diseases.

Agrypnia excitata: current concepts and future prospects in management.

Agrypnia excitata is an extremely rare, life-threatening syndrome characterized by autonomic activation, persistent insomnia, and generalized overactivity. Agrypnia excitata describes a triad of three separate conditions: delirium tremens, Morvan's chorea, and familial fatal insomnia (FFI). Each of the aforementioned three conditions have sleep disturbances as a unifying theme and results in distinct neurophysiological findings. The following is an overview of agrypnia excitata with a particular emphasis placed upon each of the three individual conditions that constitute the syndrome with recommendations on appropriate management.

Chilaiditi syndrome complicated by cecal perforation.

Chilaiditi sign is a radiological finding which describes the interposition of a part of the bowel between the diaphragm and the liver, a finding that can be misinterpreted as pneumoperitonium. Chilaiditi syndrome refers to a clinically symptomatic patient in the presence of the classical radiographic findings. It is a very rare syndrome which usually follows a benign course. Here we report the first documented case of Chiliaditi syndrome complicated by cecal perforation.

Derm diagnoses you can't afford to miss.

Management of hereditary angioedema should include fresh frozen plasma containing C1 inhibitor (C1-INH), whenever possible; if C1-INH-containing plasma is unavailable, fresh frozen plasma can be used instead. Do not give neomycin to patients with suspected cellulitis; the drug may promote antibiotic resistance in Staphylococcus aureus, a pathogen often associated with this condition. Whenever a patient presents with erythematous skin lesions and a recent history of receiving penicillin or a cephalosporin antibiotic, a sulfa derivative, or an anticonvulsant, the suspected medication should be stopped until Stevens-Johnson syndrome is ruled out.

Ocular complications of cancer therapy: a primer for the ophthalmologist treating cancer patients.

PURPOSE OF REVIEW: Cancer patients may develop ocular complications secondary to direct or metastatic involvement with cancer, radiation exposure, or chemotherapy. As many as 1.4 million new cancer cases arise in the United States annually. RECENT FINDINGS: Chemotherapy administration remains a critical aspect of treating many cancers and offers improved prognosis and prolonged survival in many cases; however, these therapies are known to cause a wide range of toxicities. SUMMARY: Ocular side effects such as photophobia, cataracts, glaucoma, retinopathy, and other ocular toxicities have been reported following chemotherapy administration. To effectively treat cancer patients, oncologists, primary care clinicians, and ophthalmologists should be aware of the potential ophthalmic toxicities certain widely used chemotherapeutic agents and radiation therapy may pose to their patients, particularly in the setting of preexisting ocular conditions.

The Stanford V regimen is effective in patients with good risk Hodgkin lymphoma but radiotherapy is a necessary component.

One-hundred and thirteen patients between the ages of 15 and 88 years with biopsy proven, untreated Hodgkin lymphoma were treated by physicians in the Nebraska Lymphoma Study Group using the Stanford V regimen (bleomycin, doxorubicin, etoposide, mechlorethamine, prednisone, vinblastine and vincristine) between January 1997 and January 2006. With a median follow-up of all surviving patients of 63 months, the 5-year overall survival (OS) was 84% and the 5-year progression-free survival (PFS) was 74%. Age >60 years, other than nodular sclerosing histological subtype, Ann Arbor Stage III/IV, and the presence of B-symptoms significantly predicted treatment outcome. Patients with 0-2 of these factors had a 5-year PFS and OS of 80% and 89% vs. 20% and 40% for patients with 3 or 4 factors. Patients who received radiotherapy had a superior 5-year PFS (86% vs. 42%) and OS (96% vs. 53%). Patients with 0-2 adverse risk factors who received radiotherapy had an excellent treatment outcome with 5-year PFS of 88% and a 5-year OS of 97%. The Stanford V chemotherapy regimen has an excellent treatment outcome for good prognosis patients with Hodgkin lymphoma. The results are compromised when radiotherapy is not utilized.

A case of aortic dissection in a cocaine abuser: a case report and review of literature.

BACKGROUND: Prompt diagnosis and management of aortic dissection are key to reduce patient morbidity and mortality; hence the need to a have a high index of suspicion for this condition. We believe it's important to report this case because it underscores the relationship between cocaine abuse and aortic dissection. In addition it strongly emphasizes basic principles in medicine: patients should not be profiled, and chronic complaints may need reassessment. CASE PRESENTATION: We are presenting a case of Stanford type A aortic dissection in a 46 year old patient with history of cocaine abuse. The aortic dissection presented as worsening of chronic upper abdominal pains he has had for years. He presented to us hours after using crack cocaine. CONCLUSION: Aortic dissection associated with cocaine abuse develops at a younger age. Therefore it's crucial to have high index of suspicion for aortic dissection in this subset of patients. Furthermore as this case illustrates, serious diseases can masquerade in old complaints. Patients should never be profiled, and chronic complaints should always be revisited.

Primary squamous cell carcinoma of the lung with bony metastasis in a 13-year-old boy: case report and review of literature.

Primary bronchogenic carcinoma of the lung is extremely rare in children, particularly the squamous cell type. Only 6 cases have been reported in the literature. We are reporting a case of metastatic squamous cell carcinoma in a 13-year-old boy who presented with left shoulder pain secondary to bone metastasis. Given the lack of specific symptoms associated with such malignancies, many children are at risk of delayed diagnosis and, as a result, associated metastases. Diagnostic evaluation hinges on biopsy of suspected lesion and histopathologic evaluation. Treatment regimens are rather ill defined, though the mainstay is surgical resection of the lesion along with chemotherapy and palliative radiotherapy for bone metastasis.

Monitoring of physiological parameters from multiple patients using wireless sensor network.

This paper presents a wireless sensor network system that has the capability to monitor physiological parameters from multiple patient bodies. The system uses the Medical Implant Communication Service band between the sensor nodes and a remote central control unit (CCU) that behaves as a base station. The CCU communicates with another network standard (the internet or a mobile network) for a long distance data transfer. The proposed system offers mobility to patients and flexibility to medical staff to obtain patient's physiological data on demand basis via Internet. A prototype sensor network including hardware, firmware and software designs has been implemented and tested. The developed system has been optimized for power consumption by having the nodes sleep when there is no communication via a bidirectional communication.

Rhabdomyolysis induced by simvastatin-fluconazole combination.

Rhabdomyolysis is a potential adverse consequence of statin therapy. Here, we report a patient with prostate cancer being treated with simvastatin who developed rhabdomyolysis after coadministration with fluconazole. The rhabdomyolysis promptly resolved after discontinuation of fluconazole, suggesting the possible role of drug interaction in the development of rhabdomyolysis with coadministration of the two medications. Both simvastatin and fluconazole were promptly discontinued, and the patient was admitted to the intensive care unit, where vigorous hydration along with urine alkalinization led to resolution of rhabdomyolysis. Since statins are commonly prescribed treatments for individuals with hyperlipidemia, caution is advised in coadministration with azoles such as fluconazole. Although supportive treatment remains the mainstay of therapy for patients with rhabdomyolysis, fatal consequences can arise from hyperkalemia, cardiac arrhythmia, renal failure and disseminated intravascular coagulation.

A rare case of hemochromatosis and Wilson's disease coexisting in the same patient.

Wilson's disease and hereditary hemochromatosis are two inherited diseases with life-threatening complications. Early recognition and prompt treatment may be instrumental in reducing such complications associated with these disorders. Although both Wilson's disease and hereditary hemochromatosis are genetic in nature, the two conditions have distinct, unrelated genetic etiologies. Two distinct, separate mutations are required for simultaneous existence of the two diseases. As such, the likelihood of the two conditions coexisting is exceedingly rare. Here we report a case of a 23-year-old male with hereditary hemochromatosis with coexistent Wilson's disease. Only two reported cases exist in which this dual diagnosis was present simultaneously. In our patient, laboratory evaluation demonstrated elevated ferritin, transferrin saturation >90%, and subsequent liver biopsy demonstrated diffuse fibrotic changes. Confirmatory genetic analysis revealed the patient to be a compound heterozygous for C282Y and H63D gene mutations. Given the patient's young age and the improbability of hemochromatosis-induced hepatic damage at that age, an alternative diagnosis was sought. Further analysis revealed reduced serum ceruloplasmin along with elevated urinary copper excretion. Subsequent ophthalmologic exam revealed bilateral Kaiser Fleischer rings. In conclusion, Wilson's disease and genetic hemochromatosis both involve inherent flaws in the transportation of heavy metals and their accumulation in hepatocytes. Although both diseases arise from distinctly different genetic mutations, the coincidence of the two disorders can, in rare cases, occur.

Transient midventricular ballooning: a case report and review of the literature.

BACKGROUND: We describe a case of transient left midventricular ballooning in 68-year-old male patient presented with picture of acute coronary syndrome. CASE PRESENTATION: The left ventriculogram showed mid ventricular akinesis and dilatation along with hypercontractile apex and basal segments. Follow up echocardiogram after one month showed resolution of wall motions abnormalities and normalization of the left ventricular function. CONCLUSION: This is considered as a new variant of previously reported transient left ventricular apical ballooning; the only difference in our case is the location of wall motions abnormalities.

Performance evaluation of a Wireless Body Area sensor network for remote patient monitoring.

In recent years, interests in the application of Wireless Body Area Network (WBAN) have grown considerably. A WBAN can be used to develop a patient monitoring system which offers flexibility and mobility to patients. Use of a WBAN will also allow the flexibility of setting up a remote monitoring system via either the internet or an intranet. For such medical systems it is very important that a WBAN can collect and transmit data reliably, and in a timely manner to the monitoring entity. In this paper we examine the performance of an IEEE802.15.4/Zigbee MAC based WBAN operating in different patient monitoring environment. We study the performance of a remote patient monitoring system using an OPNET based simulation model.

A wireless medical monitoring over a heterogeneous sensor network.

This paper presents a heterogeneous sensor network system that has the capability to monitor physiological parameters from multiple patient bodies by means of different communication standards. The system uses the recently opened medical band called MICS (Medical Implant Communication Service) between the sensor nodes and a remote central control unit (CCU) that behaves as a base station. The CCU communicates with another network standard (the internet or a mobile network) for a long distance data transfer. The proposed system offers mobility to patients and flexibility to medical staff to obtain patient's physiological data on demand basis via Internet. A prototype sensor network including hardware, firmware and software designs has been implemented and tested by incorporating temperature and pulse rate sensors on nodes. The developed system has been optimized for power consumption by having the nodes sleep when there is no communication via a bidirectional communication.

Wireless body sensor network using medical implant band.

A wireless body sensor network hardware has been designed and implemented based on MICS (Medical Implant Communication Service) band. The MICS band offers the advantage of miniaturized electronic devices that can either be used as an implanted node or as an external node. In this work, the prototype system uses temperature and pulse rate sensors on nodes. The sensor node can transmit data over the air to a remote central control unit (CCU) for further processing, monitoring and storage. The developed system offers medical staff to obtain patient's physiological data on demand basis via the Internet. Some preliminary performance data is presented in the paper.

Cutaneous leishmaniasis in expatriates in northern Saudi Arabia.

Cutaneous leishmaniasis is a protozoal disease transmitted by sandflies. It is endemic across the desert of the Middle East to Afghanistan and Africa. This paper reviews the findings in 148 expatriates with cutaneous leishmaniasis seen in Arar, northern Saudi Arabia, during a five year period. Cutaneous leishmaniasis was seen in all age groups. Farm workers, labourers and military personnel stationed in the region during the Gulf war were most affected. There was a seasonal variation with maximum incidence between November and January. The lesions were commonly multiple, the number of lesions per patient ranged from one to twelve. 18% of the lesions were located on the face, 34% on the upper extremity, 42% on the lower extremity and six per cent on other sites. The average duration of the lesions before diagnosis was two months. The most common complications were secondary bacterial skin infection (pyoderma and cellulitis) and residual scarring. The response to sodium stibogluconate was good. There has been a gradual reduction in the number of cases from a peak of 64 in 1991 to twelve in 1995. As compared to studies in the indigenous population, cutaneous leishmaniasis tends to be more frequent and server in expatriates from non endemic areas. There is a need for increased awareness of this disorder, especially in the home countries of these expatriates.

STDS in women attending family planning clinics: a case study in Addis Ababa.

For cultural reasons modern contraception has been slow to gain acceptance in Ethiopia. Knowledge about contraception and abortion is still limited in many family and community settings in which it is socially disapproved. By 1990 only 4% of Ethiopian females aged 15-49 used contraception. Little is known of sexually transmitted disease (STD) prevalence in family planning (FP) attenders in Africa in general and Ethiopia in particular, even though attenders of family planning clinics (FPCs) are appropriate target groups for epidemiological studies and control programmes. A study of 2111 women of whom 542 (25.7%) attended FPCs in Addis Ababa showed utilisation rates to be highest in women who were: Tigre (33%) or Amhara (31%), aged 20-34 years (30%), age 16 or older at first marriage/coitus (28%:38% in those first married after 25 years); who had a monthly family income of 10 Ethiopian Birr (EB) or more (33%:36% for those with income 100-500 EB), three or more children (37%), more than five lifetime husbands/sexual partners (39%); or were bargirls (73%) or prostitutes (43%). The seroprevalence rates for all STDs, higher in FPC attenders compared with other women, were syphilis (TPHA) 39%, Neisseria gonorrhoeae 66%, genital chlamydia 64%, HSV-2 41%, HBV 40% and Haemophilus ducreyi 20%. Only 4% of FPC attenders had no serological evidence of STD: 64% were seropositive for 3 or more different STD. Clinical evidence of pelvic inflammatory disease (PID) was also more common in the FPC attenders (54%), 37% having evidence of salpingitis. The FPC provides a favourable setting for screening women likely to have high seroprevalence of STD, who for lack of symptoms will not attend either an STD clinic nor a hospital for routine check up. We recommend that measures be taken to adequately screen, treat and educate FPC attenders, their partners, and as appropriate and when possible their clients, in an attempt to control STDs and ultimately HIV in the community. Social, economic and cultural factors in the occurrence of STDs, prostitution, family planning and modern contraception coverage in Ethiopia are identified and deficiencies of current programmes briefly discussed with the objective of targeting services more effectively.

Chlamydial infection in a population of Ethiopian women attending obstetric, gynaecological and mother and child health clinics.

The prevalence of chlamydial infection was assessed in 1,846 Ethiopian women attending clinics in Addis Ababa. Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGVI-3), and C. pneumoniae (CPn), in a micro-immunofluorescence (micro-IF) test. Three levels of chlamydial infection were established. Sera with: 1) antibodies to CTA-C, CTD-K, LGV 1-3 and CPn singly or in combination, are considered as evidence of overall exposure to chlamydial species (OEC); 2) antibodies to CTD-K and LGV 1-3 are considered as evidence of exposure to genital chlamydial pathogens (GENCI); 3) IgM titre > or = 1/8, or Ig G titre > or = 1/64 to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn is considered as being evidence of active genital chlamydial infection (AGCI). OEC was found in 84 pc, GENCI in 60 pc and AGCI in 42 pc. Infection was highest in family planning and lowest in antenatal clinic attenders. OEC increased progressively with age while GENCI and AGCI peaked at ages 35 to 49. Chlamydial infection was highest in those married and sexually active < 13 years of age (OEC 88 pc, GENCI 69 pc, AGCI 49 pc); the lowest income groups (OEC 85 pc, GENCI 65 pc, AGCI 45 pc); those with more than five sexual partners (OEC 92 pc, GENCI 78 pc and AGCI 65 pc); with highest prevalence in bargirls (OEC 97 pc, GENCI 84 pc, AGCI 75 pc). Fifty pc had clinical evidence of past or present infection in the urethra, salpinges or bartholin glands (USB). OEC, GENCI and AGCI were associated with PID. The association of seropositivity with USB was remarkably similar for both gonorrhoea and chlamydial infection: we recommend adoption of a treatment regimen effective for both infections. The micro-IF test is a useful epidemiological tool for identifying the of antibodies to chlamydial pathogens. Use of antigen pools CTA-C, CTD-K LGVI-3 and CPn enables a distinction to be made between genital and non-genital infections. The problem of symptomatic and asymptomatic chlamydial disease needs to be addressed urgently.

PIP: In Addis Ababa, Ethiopia, purified chlamydial antigens were used in a micro-immunofluorescence (micro-I) test to detect type-specific antibodies against various chlamydial species in blood samples from 1846 women attending family planning, prenatal, and postnatal clinics. The antigens were for Chlamydia trachomatis A-C (CTA-C), Chlamydia trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV 1-3), and C. pneumonia (CPn). The researchers considered sera with antibodies to CTA-C, CTD-K, LGV 1-3, and CPn independently or in combination as evidence of overall exposure to chlamydial species (OEC) and those to CTD-K and LGV 1-3 as evidence of exposure to genital chlamydial pathogens (GENCI). They considered sera with IgM titre of 1/8 or more, or IgG titre of 1/64 or more to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn as evidence of active genital chlamydial infection (AGCI). 84% were categorized as OEC. 60% were categorized as GENCI. 42% were categorized as AGCI. The prevalence of chlamydial infection was greatest in family planning clients and lowest in pregnant women (OECD: 88% vs. 78%, p = 0.004; GENCI: 63% vs. 54%, p 0.02; and AGCI: 46% vs. 31%) (p 0.01). The geometric mean of the titre was also highest in family planning clients and lowest in pregnant women (85% vs. 58%). The most significant factor for chlamydial infection was being married and having first coitus before age 13 (OEC: 88% vs. 75% for first coitus at 18 years; p 0.001). Other risk factors included low income (p 0.005), more than 5 sexual partners (p 0.01), bar-girl occupation (p 0.001), and Amhara and Oromo ethnic groups (p 0.001). 50% of all women had clinical evidence of past or present infection in the urethra, fallopian tubes, and/or bartholin glands. Women with pelvic inflammatory disease (PID) were more likely to have chlamydial infection than those with no infection in the urethra, fallopian tubes, or bartholin glands (OEC: 95% vs.83%; GENCI: 86% vs. 58%; AGCI: 72% vs. 38%) (p 0.001). PID was also associated with gonorrhea.

Teenage obstetric and gynaecological problems in an African city.

OBJECTIVE: To measure the prevalence of sexually transmitted diseases (STD), pelvic inflammatory disease (PID), cervical cancer, pregnancy and use of contraception in teenagers, and to determine socioeconomic factors associated with these conditions to aid planners of medical services and promotion of sexual health. SUBJECTS: 181 Ethiopian teenagers and 1,845 women aged 20 to 45 years for comparison. SETTING: Gynaecological outpatient department, antenatal, postnatal and family planning clinics, in two teaching hospitals and a mother and child heath centre in Addis Ababa, Ethiopia. METHODS: Results of serologic tests for STD, clinical evidence of PID, and cervical cytology were analysed against socio-economic factors. RESULTS: In teenagers early age at first marriage/coitus, more common in those of rural origin, was associated with poverty, a greater number of lifetime sexual partners, and prostitution: 40 pc were first sexually active before the menarche. Prevalence of seropositivity to specific STD pathogens was; Treponema pallidum (TPHA) 21 pc, Neisseria gonorrhoeae (gonococcal antibody test: GAT) 40 pc, genital chlamydiae 51 pc, hepatitis B virus 36 pc, herpes simplex virus (HSV-2) 32 pc, and Haemophilus ducreyi 16 pc: 92 pc of teenagers were seropositive to one or more STD's. STD seroprevalence was higher in those with more than one sexual partner, those sexually active by age 15 (very high in those sexually active by age 12), those involved in prostitution and those attending the family planning clinic. Forty three pc had clinical evidence of PID; one married at age 10 had invasive cervical cancer by age 18; 40 pc of teenagers were pregnant compared with 25 pc of those aged 20 to 45; 21 pc attended for family planning; of regular FPC attenders 81 pc were GAT seropositive. CONCLUSION: Despite legislation early age of sexual debut is common, STD and PID are widely prevalent, the pregnancy rate in adolescents is high and contributes to the national population growth rate. Action is required at family, medical and governmental level to encourage cultural acceptance that marriage and sexual activity should not occur before the age of 16 years, with education appropriate to culture to prevent STD. Similar studies are recommended in other countries to establish a baseline for informed strategy regarding prevention of STD and health education.

PIP: A survey of 181 Ethiopian females ages 14-19 years recruited from health facilities in Addis Ababa revealed a high incidence of obstetric and gynecologic problems. All subjects completed a questionnaire administered by a female health worker and underwent a gynecologic examination and serologic tests. 49% of subjects were married and 18% were divorced; 11% were prostitutes. Age at first intercourse was under 12 years in 18%, 13-15 years in 38%, and 16 years or above in 44%; 40% were sexually active before menarche. 92% of adolescents had at least one sexually transmitted disease (STD), predominantly gonorrhea (40%), genital chlamydia (51%), hepatitis B (36%), herpes simplex virus (32%), and syphilis (21%), and 43% had clinical signs of pelvic inflammatory disease (PID). 53% had had at least one pregnancy. The earlier the age at first intercourse, the more likely it was that the adolescent would have multiple sexual partners and several STDs; adolescents in this category were also more likely to be from poor families from rural areas. Only 21% were attending a family planning clinic for annual check-ups; 14% of these females were using contraception. Although only 8% were infertile at the time of assessment, 23% had clinical evidence of salpingitis--a risk factor for future infertility. Given the long-term health risks (e.g., infertility, cervical cancer, and gonorrhea-related infant morbidity) associated with the patterns observed among these adolescents, it is recommended that STD education receive higher priority and that the Ethiopian Government consider greater enforcement of the law prohibiting sexual intercourse and marriage before the age of 16 years.