Association between chronic pancreatitis and pancreatic cancer at a central hospital in KwaZulu-Natal, South Africa.

BACKGROUND: The frequency of histological chronic pancreatitis (CP) evidence in the resident pancreas of resected periampullary cancers (PACs) has never been studied in Africa. This study aims to describe the spectrum of pathology and outcomes of pancreatic surgeries and address this deficit from a South African central hospital cohort. METHODS: A retrospective audit of patients undergoing pancreatic surgery at Inkosi Albert Luthuli Central Hospital (IALCH) between 2003 and 2023 was conducted. The patient demographics, human immunodeficiency virus (HIV) status, histological subtypes, type and extent of surgery, and 30-day and overall mortality were captured from medical records. The presence of CP in the resident pancreas of patients resected for pancreatic and PAC was obtained from the pathology reports. RESULTS: Of the cohort, 72% were Africans, presenting at an earlier average age than other races. Surgery was performed on 126 (107 for cancer, 19 for CP) patients. Of these, 77 were pancreaticoduodenectomy (PD), of which 34 were for pancreatic ductal adenocarcinoma (PDAC). The prevalence of CP in the resident pancreas was 29.9%, and 55.9% in PDAC. Age was the only factor significantly associated with 30-day mortality, as well as long-term survival amongst patients with pancreatic and PAC. The overall median survival for patients with PAC was seven months; 11 patients are alive. CONCLUSION: In a predominantly African cohort undergoing pancreatic surgery, PDAC presents at a younger age. The high perioperative mortality and low overall survival (OS) in the setting of high CP prevalence in the resident pancreas requires further investigation of its role in the aetiopathogenesis and prognosis in PDAC.

The clinicopathological spectrum and treatment outcomes in metastatic colorectal cancer in the KwaZulu-Natal province of South Africa.

BACKGROUND: In high-income countries (HICs) 17-20% of colorectal cancer (CRC) patients have metastatic CRC (mCRC) at the time of diagnosis, of which 10-25% are or become resectable, and a further 4-11% of patients will develop metachronous metastases. The study aimed to establish the prevalence and pattern of metastatic CRC to document treatment outcomes in KwaZulu-Natal (KZN), and to compare results to international norms. METHODS: The study population comprised patients with mCRC presenting between 2000 and 2019. Demographics, primary tumour site, spectrum of metastatic disease and resection rate were assessed. RESULTS: MCRC occurred in 33% of the CRC patient population. Eight hundred and thirty-six patients had metastatic disease, comprising Africans (325, 38.8%), Indians (312, 37.3%), Coloureds (37, 4.4%) and Whites (161, 19.2%). Six hundred and fifty-four patients (79%) had synchronous metastases and 182 patients had metachronous metastases (21%). Single organ metastases occurred in 596 patients (71.2%) (M1A) and multiple organ metastasis occurred in 240 patients (28.7%) (M1B). Metastases occurred in the liver (613), lung (240) and peritoneum (85). Fifty-two patients (6.2%) underwent resection of their metastases. CONCLUSION: The prevalence of stage IV CRC in our setting is at the upper limit of international norms. mCRC occurred in 33%, with similar proportions in all races. Resection rate for metastases is low.

A South African central hospital's experience with malignant colorectal obstruction.

BACKGROUND: The spectrum and outcome of colorectal cancer (CRC) presenting with obstruction is not well studied in low- to middle-income countries (LMIC) and could have implications for health policy. This study aimed to address this deficit in an LMIC setting. METHODS: A retrospective analysis was conducted of patients with large bowel obstruction, during the period 2000-2019 from the prospective Inkosi Albert Luthuli Central Hospital (IALCH) CRC registry data. Data analysed included the site of CRC, tumour differentiation, management of patients with obstructive CRC, resection margins post resection, oncological management and reasons for failure to receive oncological therapy. Patient follow-up and recurrence were recorded. RESULTS: Malignant obstruction from CRC occurred in 510 patients (20% of the CRC registry). Median age at presentation was 57 years (IQR 48-67). One hundred and seventy-six (34.5%) and 135 (26.5%) had stage III and IV disease respectively. Moderately differentiated cancer was seen in 335 (65.6%). Management was resection (370; 72.5%), diverting colostomy (123; 24.1%) and stent insertion (55; 10.8%). Twenty-one patients (5.7%) had positive resection margins. Recurrence occurred in 34 patients (6.7%), all of whom had initially undergone resection, giving a recurrence rate of 9.8% in those receiving surgery. Median disease-free interval for patients developing recurrence was 21 months (IQR 12-32). CONCLUSION: One in five patients with CRC presented with obstruction. These patients were younger than in high incomecountry (HIC) series. Over 70% underwent resection. Stomas were used twice as frequently as stents to relieve the obstruction, a finding that is the reverse of that in HICs.

Outcomes of haemorrhagic radiation proctitis at a South African tertiary hospital.

BACKGROUND: Haemorrhagic radiation proctitis occurs in 5-10% of patients undergoing radiotherapy. In our resourceconstrained South African setting, this study aimed to describe the clinicopathological spectrum and management of radiation proctitis referred to a tertiary centre, to address the deficit in our setting-specific understanding of the condition. METHODS: This was a sub-analysis of data from an existing colorectal cancer registry at the Inkosi Albert Luthuli Central Hospital in Durban. We reviewed the registry for all patients between 2008 and 2019 with haemorrhagic radiation proctitis and describe the various patient characteristics, treatments and outcomes for these patients. RESULTS: Fifty-eight patients with haemorrhagic radiation proctitis were identified. Colonoscopy findings included bleeding (58 patients), endoscopic proctitis (30 patients) and rectal stricture (7 patients). The median time elapsed between radiotherapy and development of symptoms was 16.5 months (IQR 12-25). Median number of argon plasma coagulation (APC) sessions for endoscopic healing or symptom resolution was three sessions (IQR 2-4). At follow-up, 35 patients had complete healing and 19 patients had symptom improvement. Complications occurring during or after APC therapy included rectal ulceration (2 patients) and rectovaginal fistula (1 patient). CONCLUSION: APC is a safe and effective treatment modality with complete resolution or significant improvement in symptomatology in the vast majority of patients with three or four treatments. Morbidity is likely to be related to ongoing radiation effects.

Efficacy of Intra-peritoneal Tramadol Instillation for Postoperative Pain Management after Laparoscopic Cholecystectomy.

Gall stone disease is one of the most common conditions encountered in general surgical practices in adult population. The gold standard treatment for symptomatic gall stone disease is laparoscopic cholecystectomy. It results in less post-operative pain as compared to open cholecystectomy but post-operative pain may be mild, moderate or even severe in some patients. This Randomized control trail was conducted to In-patient department of Surgery, Mymensingh Medical College & Hospital (MMCH), Mymensingh, Bangladesh from April 2018 to September 2018. It was undertaken to evaluate the analgesic effect of intra-peritoneal tramadol instillation in patients undergoing laparoscopic cholecystectomy. Total 70 patients with symptomatic gallstone disease undergoing laparoscopic cholecystectomy were randomized equally in two groups. Then patients were selected in according to the inclusion and exclusion criteria. In first group (Group A), patients were received intra-peritoneal tramadol 100mg (diluted in 20.0ml distilled water). Sprayed 10.0ml diluted tramadol into the sub diaphragmatic area, 5.0ml into the area of gall bladder bed and 5.0ml into the space between the liver and kidney under direct vision just before removal of trocars. In second group (Group B) the conventional operative procedure was followed. Postoperatively, patient was extubated and shifted to recovery room. Data recorded and analyzed, such as post-operative pain score at 1, 4, 8, and 24 hour; cumulative 1, 8 and 24 hour analgesic consumption. In addition that postoperative hospital period monitoring of heart rate, blood pressure, respiratory rate, temperature at 0, 4, 8, 24 hours was also analyzed. Intensity of pain was assessed by Visual Analogue Scale (VAS) scoring system. Patients showed a VAS ≥3 or patients who requested for analgesia was administrated a supplemental dose of analgesic. In the present study the mean pain scores in Group A were found to be low at1hourpost-operative was 0.60±0.56 and there was a gradual increase in score in respect of time interval with peak of 2.07±0.91 at 24 hours. Whereas, in Group B the mean pain scores immediate post-operative period were at its peak was, 2.50±0.82 which decreased to 1.30±0.84 at 1 hour and further there was rise at 4 hours (2.10±0.71) and 24 hours (2.33±0.0.71). But at any point of time the mean VAS remained significantly low (p<0.050) in patients with Group A compared to Group B except at 1st 24 hours (p=0.210). Intra-peritoneal instillation of tramadol for postoperative pain control in laparoscopic cholecystectomy has beneficial effect in terms of postoperative pain relief following laparoscopic cholecystectomy.

Assessment of novel biomarkers: sTREM-1, pentraxin-3 and pro-adrenomedullin in the early diagnosis of neonatal early onset sepsis.

BACKGROUND: Early onset bacterial sepsis in neonates (EOS) is recognized as an important health condition. Early diagnosis is crucial. However, blood culture results are released in 48-72 hours. Many biomarkers have been investigated but none have been accepted as the gold standard. This study aimed to investigate the diagnostic value of the molecules: soluble form of triggering receptor expressed on myeloid cells-1 (sTREM-1), pentraxin-3 (PTX-3) and pro adrenomedullin (pro-ADM) in EOS and compare with currently used biomarkers. METHODS: In this multicenter prospective study, patients were enrolled from different NICUs around the Turkey. Patient data were collected via web-based registry system from attending centers. Neonates, hospitalized with a suspicion of EOS were enrolled. Blood culture and routine blood tests were collected and a serum sample was obtained and kept in - 80°C for studying the molecules. According to laboratory results, patients were divided into three groups as; proven sepsis, clinical sepsis and control group. Groups were compared in terms of demographic, clinical and laboratory findings. The primary outcome of the study was to assess any difference between groups in terms of the diagnostic value of the markers aforementioned. RESULTS: A total of 130 patients were enrolled; proven sepsis (n = 36), clinical sepsis (n = 53) and control (n = 41) groups. Groups were similar in terms of demographic findings; mean WBC (P = 0.445), procalcitonin (PCT) (P = 0.083) and IL-6 (P = 0.814) levels. Mean C-reactive protein (CRP) level was significantly higher in clinical sepsis and proven sepsis groups compared to control group (P < 0.001). Mean PTX-3 (P = 0.547), pro-ADM (P = 0.766) and sTREM-1 (P = 0.838) levels were similar between groups. CONCLUSION: These promising molecules failed to help in early diagnosis of EOS. Their relation to correlation with disease progression may make more sense as they seem to be expressed in higher amounts with the progression of the disease in previous studies. CRP was the most frequently used biomarker for detecting the sepsis in our study population.

Genetic basis of resistance waves among methicillin resistant Staphylococcus aureus isolates recovered from milk and meat products in Egypt.

Antimicrobial resistance of methicillin-resistant Staphylococcus aureus (MRSA) poses a serious problem for clinicians worldwide. The present study attempted to evaluate the susceptibility patterns of MRSA to various antimicrobials and the prevalence of inducible clindamycin resistance as well as the relevant antibiotic and antiseptic resistance genes among these isolates. Totally, 40 MRSA isolates were recovered from examined milk and meat product samples (18.60%). Multi-drug resistance (MDR) was remarkably observed among 85% of these isolates. There was a good correlation between phenotypic determination of methicillin, amoxicillin/clavulinic acid and tetracycline resistances and PCR detections of mecA, blaZ and tet(K) genes, respectively, but norA gene was not detected in the four ciprofloxacin resistant isolates. Although, 55% of MRSA expressed resistance to benzalkonium chloride (BC), neither qacA/B nor smr gene was detected. Of 20 isolates exhibiting erythromycin- clindamycin discordant resistance pattern, 8 displayed positive double disk diffusion (D-zone) test denoting inducible macrolide-lincosamide-streptogramin B (MLSB) resistance phenotype with the inducibly expressed erm(A) and erm(C) genes in 87.5% of these isolates. Besides, the remaining 12 isolates showed MS phenotype (resistant to macrolides and type B streptogramins only) with a variety of erm(A), mph(C), msr(A) or a combination of these genes including erm(C). Finally, the constitutive MLSB phenotype with the constitutive expression of erm(A), erm(B) and erm(C) genes was comprised in 2 isolates with higher minimum inhibitory concentration (MIC) values for erythromycin (512 and 1024 µg/ml) and clindamycin (16 and 32 µg/ml). These findings suggested the importance of monitoring the evolution of MRSA resistance.

Weight reduction improves markers of hepatic function and insulin resistance in type-2 diabetic patients with non-alcoholic fatty liver.

OBJECTIVE: The incidence of non-alcoholic fatty liver disease (NAFLD) is increasing dramatically affecting up to 30% of the population worldwide. At present, treatment options are limited and pharmacological management of NAFLD has had disappointing results. Some of the best available evidence to improve NAFLD concerns lifestyle modification. OBJECTIVE: To detect the degree of weight reduction needed to improve the markers of hepatic function and insulin resistance in type-2 diabetics with NAFLD. METHODS: One hundred type-2 diabetic male patients with NAFLD were included into this study and divided into two equal groups. Group (A) received aerobic exercise training in addition to diet regimen. Group (B) received no treatment intervention. RESULTS: There was a 26.99%, 40.8%, 33.81%, 32.73%, 37.8% and 15 % reduction in mean values of Alkaline Phosphatase (ALP), Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST), Gamma - Glutamyltransferase (GGT) and Homeostasis Model Assessment-Insulin Resistance-index (HOMA-IR) and BMI respectively in group (A) at the end of the study. While there were significant differences between mean levels of the investigated parameters in group (A) and group (B) after treatment. CONCLUSION: About 15 % reduction in BMI is effective to improve the liver condition and insulin resistance in type-2 diabetics with NAFLD.

Bilateral, symmetrical and extensive cerebral calcification in pseudohypoparathyroidism.

Pseudohypoparathyroidism (PHP) is a heterogeneous group of disorders characterized by hypocalcemia, hyperphosphatemia, increased serum concentration of parathyroid hormone (PTH), and insensitivity to the biological activity of PTH. Pseudohypoparathyroidism is rare sporadic or autosomal dominant disorder having several subtypes (type Ia, Ib, Ic, type II). We report a case who was 27 years old married lady having two children presented in the summer season 2009. Her trousseau's sign was positive, serum calcium 5.5 mg/dl, PTH 137 pgm/ml and CT scan of brain shows bilateral and symmetrical calcification. She had occasional doubtful seizure and headache for 7 years. Initially clinicians could not reach the diagnosis due to inadequate investigations.

Absolute myocardial blood flow determination using real-time myocardial contrast echocardiography during adenosine stress: comparison with single-photon emission computed tomography.

OBJECTIVE: To assess the feasibility and diagnostic accuracy of real-time myocardial contrast echocardiography (MCE)-derived absolute myocardial blood flow for detection of myocardial perfusion abnormalities compared with simultaneous technetium 99 m sestamibi single-photon emission computed tomography (SPECT). DESIGN: Prospective study. SETTING: Tertiary-care medical institution. PATIENTS: 79 patients with known or suspected coronary artery disease. INTERVENTIONS: Simultaneous SPECT and real-time MCE during adenosine stress. MAIN OUTCOME MEASURES: Absolute myocardial blood flow (MBF, ml/min/g), microbubble velocity (beta, min(-1)), and reserve values. Endpoints included sensitivity, specificity, positive likelihood ratio (LR+) or negative likelihood ratio (LR-) and area under the curve (AUC) of the receiver operating characteristic curve. RESULTS: Reserve measurements were feasible in 975 of 1343 segments (73%); of these, 130 segments (13%) were abnormal by SPECT. MCE perfusion parameters clearly distinguished abnormal from normal segments for beta reserve (1.13 (0.99) vs 2.22 (1.36), p<0.001) and MBF reserve (1.80 (2.29) vs 3.69 (2.79), p<0.001). The beta reserve cut-off of 1.60 provided the following: AUC, 0.787; sensitivity, 82%; specificity, 66%; LR+, 2.40; and LR-, 0.28. The MBF reserve cut-off of 1.90 provided the following: AUC, 0.779; sensitivity, 73%; specificity, 72%; LR+, 2.69; and LR-, 0.37. MBF reserve had an AUC of 0.773 for the left anterior descending coronary artery, 0.885 for the left circumflex coronary artery and 0.739 for the right coronary artery. CONCLUSIONS: Real-time MCE-derived absolute MBF, beta, and reserve values are feasible and accurate for detecting myocardial perfusion abnormalities as defined by SPECT.

Risk Factors for Anaemia in Pregnancy in Rural KwaZulu-Natal - South Africa: Implication for Health Education and Health Promotion

Background: Anaemia in pregnancy is a major public health problem in developing countries. It is associated with an increased risk of maternal and perinatal morbidity and mortality. A high rate of anaemia in pregnancy in the rural population of KwaZulu-Natal (30according to national and 57according to the World Health Organization [WHO] definition of anaemia in pregnancy) is observed. The risk factors for anaemia; particularly during pregnancy; are multiple and complex and their relative contributions are known to vary by geographic areas and by seasons. In order to design an intervention for treatment and prevention of anaemia in pregnancy; studies to assess the aetiological factors are necessary. The aim of this study was to evaluate the strength of association between intestinal helminthiasis; urinary schistosomiasis and HIV infection on anaemia in pregnancy. Methods: A retrospective case-control study design was used in a rural district hospital of South Africa. A total of 300 pregnant women; 100 of them with anaemia (haemoglobin less than 10 gm/dL according to the national definition of anaemia in pregnancy) referred as cases and 200 controls were studied from Empangeni Hospital. Both cases and controls were matched for age; parity and gestational age. Data were collected from the antenatal clinic and prevention of mother-to-child transmission of HIV (PMTCT) programme registers for cases and controls at their booking visit during the months of May; June and July of 2004. Univariate and multiple logistic regression were performed to analyse the data. Results: Of the cases; 48and 1among the controls had intestinal helminthiasis; resulting in the odds ratio of 42 (p = 0;000 and 95CI 9;96 -176.59). The risk of anaemia was related to urinary schistosomiasis; as 27of the cases compared to 1of controls was found with anaemia. The odds ratio was 12 (p = 0;000 and 95CI 3.58 - 41.02). These parasitic infestations are known to cause chronic haemorrhage and iron deficiency resulting in the development of anaemia in pregnancy. Transmissions of intestinal parasitic infestation occur through the faecal-oral route. Personal hygiene and other environmental factors are therefore an important factor for the transmission of the disease. To reduce the transmission of faecaloral diseases (e.g. intestinal helminthiasis and urinary schistosomiasis) key interventions recommended are: 1) safe disposal of human excreta; 2) hand-washing practices with soap after defecation; and 3) maintenance of drinking water free from faecal contamination. Similarly; HIV infection increased the chance of developing anaemia in pregnancy twofold as HIV infection was more common among cases (56) than among controls (37); resulting in an odds ratio of 2.11 (p = 0;003 and 95CI 1.123 - 3.21). The prevention of HIV infection and transmission can be achieved through the improvement of knowledge of these conditions. These can be achieved through health education and health promotion. Conclusion: These findings confirm and conform to other studies on the association between anaemia in pregnancy and parasitic and HIV infections. Antenatal care should promote de-worming and education on personal hygiene and HIV (risk factors; mode of transmission; etc.). The provision of safe water supply and toilet facilities for the rural communities should be considered urgently to prevent and promote better health for all; including pregnant women

Evaluation of Cervical Cancer Screening Program at a Rural Community of South Africa

Objective: Cervical cancer is a leading cause of deaths among women worldwide. But the condition is preventable through regular screening of women those are 'at risk' for abnormal changes in the cervix and treating them who have positive results. Although screening facilities are available in South Africa; the incidence and mortality from cervical cancer remains very high and many women present health facilities with late stage diseases. Purpose of the study is to determine the baseline information on knowledge and practices on risk factors for cervical cancer and Pap smear and to design an intervention to improve Pap smear uptake. Methods: A cross-sectional population based descriptive study was undertaken at a rural community of South Africa targeting women 30 years and over. The assessment was performed by means of a questionnaire survey. Outcome measures were percentage of women with the knowledge on risk factors for cervical cancer and use of Pap smear test and had undertaken Pap smear test. Binary logistic regression analysis was carried out to identify possible predictors of Pap smear test undertaken. A total of 611 women (random samples) were recruited from the selected households. Results: The mean age of the sample was 43 years and 54of them had no education. Only 6knew all and 65knew any one of the risk factors of cervical cancer whereas less than half (49) of them knew that Pap smear is used for prevention of cervical cancer. Only 43respondents received information on Pap smear from health care workers. Among all the respondents only 18(95CI; 15-21) had ever done Pap smear test. Conclusions: This study showed low uptake of Pap smear test and low level of knowledge on prevention of cervical cancer and risk factors thus warrants urgent extensive health education program for this rural communities

Injury Profile in KwaZulu-Natal; South Africa: Implications for Prevention

Background: Prevention and control of injuries require generating relevant information on the magnitude; characteristics and determinants of injuries. Objective: The objective of this study was to describe the characteristics of injuries and predict the severity of injury with other variables. Design: A cross - sectional descriptive study was conducted at the hospitals of KwaZulu - Natal. Information was gathered from a total of 428 injured patients randomly selected from hospital attendances. Multivariate logistic regression analysis was performed to identify the risk factors for severity of injury. Results: Over 60of injury victims were below the age of 30 years. The economically active group (21 - 60 years) also constituted about 60of injury victims. Over half of the victims reported that the scene of incidence was private house; yard and road. One fifth was transport related injury whereas majority was violence (50). Unintentional injury was 28.8. Most of the injuries were minor (42.3) to moderate (41.1) in severity. Odds Ratio for alcohol related violence was 11. Conclusion: In order to reduce injuries appropriate multisectoral interventions; broader policies and strategies; regulating transport and alcohol use; routine testing of alcohol to identify the problem-drinkers for rehabilitation. Interventions should also include health education and health promotion and law enforcement

Combined occurrence of hyperthyroid Graves' and Hashimoto's thyroiditis.

A 40 years old, married Govt. servant from Sadar upazila, Mymensingh was admitted in Mymensingh Medical College Hospital on 9(th) February, 2005 with the complaints of excessive sweating for 1 year, gradual loss of weight for 6 months, swelling in front of the neck for 1(1/2) months, and hoarseness of voice for 1 month. He was nervous, irritable, emotionally labile. Thyroid gland was symmetrically enlarged, firm in consistency with scalloped surface. Palms were warm and sweaty with fine tremor in outstretched hands. Lid lag, lid retraction and proptosis were the occular manifestations. All the reflexes were exaggerated. Radioactive iodine uptake showed enlarged gland with homogenously increased radiotracer concentration, ultrasonogram findings were enlarged gland with hypoechoic parenchyma with fibrous septa, T(3), T(4), TSH values were 6.56 nmol/L, 241.09 nmol/L and 0.14 mIU/L respectively. Thyroid microsomal antibody level was 32.87%. Thyroid FNAC findings were sheets of regular follicular cells, some large cells with granular basophilic cytoplasm, macrophages, a few inflammatory cells and giant cells. All the above findings were in favour of a diagnosis of hyperthyroid Graves' with Hashimoto's thyroiditis.

First derivative ratio spectrophotometric, HPTLC-densitometric, and HPLC determination of nicergoline in presence of its hydrolysis-induced degradation product.

Three methods are presented for the determination of Nicergoline in presence of its hydrolysis-induced degradation product. The first method was based on measurement of the first derivative of ratio spectra amplitude of Nicergoline at 291 nm. The second method was based on separation of Nicergoline from its degradation product followed by densitometric measurement of the spots at 287 nm. The separation was carried out on HPTLC silica gel F(254) plates, using methanol-ethyl acetate-glacial acetic acid (5:7:3, v/v/v) as mobile phase. The third method was based on high performance liquid chromatographic (HPLC) separation and determination of Nicergoline from its degradation product on a reversed phase, nucloesil C(18) column using a mobile phase of methanol-water-glacial acetic acid (80:20:0.1, v/v/v) with UV detection at 280 nm. Chlorpromazine hydrochloride was used as internal standard. Laboratory prepared mixtures containing different percentages of the degradation product were analysed by the proposed methods and satisfactory results were obtained. These methods have been successfully applied to the analysis of Nicergoline in Sermion tablets. The validities of these methods were ascertained by applying standard addition technique, the mean percentage recovery +/- R.S.D.% was found to be 99.47 +/- 0.752, 100.01 +/- 0.940, 99.75 +/- 0.740 for the first derivative of ratio spectra method, the HPTLC method and the HPLC method, respectively. The proposed methods were statistically compared with the manufacturer's HPLC method of analysis of Nicergoline and no significant difference was found with respect to both precision and accuracy. They have the advantage of being stability indicating. Therefore, they can be used for routine analysis of the drug in quality control laboratories.

Effect of a practice guideline on the process of emergency department care of falls in elder patients.

OBJECTIVE: To determine the effect of a practice guideline on the process of ED care in a health maintenance organization. METHODS: A prepost-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods. RESULTS: During the two years of the study, 1,140 pre-intervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre-intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the "get up and go test" (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%. CONCLUSIONS: The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls.

Effect of a practice guideline for emergency department care of falls in elder patients on subsequent falls and hospitalizations for injuries.

OBJECTIVE: To determine the effect of a practice guideline for the ED management of falls in community-dwelling elders on selected health outcomes. METHODS: The experimental design was a prepost-intervention comparison with one-year pre- and post-intervention phases. The guideline was presented to emergency physicians and nurses during a two-week interval between these two periods. The intervention also included health information provided to the subjects and a one-time educational intervention directed at primary care providers. The number of falls in the year following the ED visit was determined by telephone interview. The number of hospitalizations for falls was determined from the HMO database of all health care encounters. RESULTS: 1,899 patients were eligible for the study; 1,140 pre-intervention and 759 post-intervention patients. Of these, 1,504 (79%) were interviewed by telephone 12 to 15 months after their initial ED visits. Eighteen percent of the pre-intervention and 21% of the post-intervention subjects reported at least one fall in the 12 months following their ED visits (p = 0.162). The rate of falls per 100 patient years was 36.2 in both groups. Three percent of both groups were hospitalized at least once for a fall in the year following their ED visits. One percent in each group were hospitalized for a hip fracture. CONCLUSIONS: The attempted implementation of a practice guideline for the ED management of falls in community-dwelling elders did not result in a reduction in total falls, or in hospitalizations for falls, injuries, or fractures.

A study on the relation between proton pump inhibitor and gastric giardiasis.

Thirty patients treated with proton pump inhibitor and still having symptoms related to gastritis or peptic ulcers were subjected to upper gastrointestinal endoscopy and gastric biopsy for detection of giardiasis in these cases. Results showed presence of 3 (10%) cases of gastric giardiasis, intestinal metaplasia and presence of H. pylori in these cases. It is concluded that there may be a relation between the presence of gastric giardiasis and the intake of proton pump inhibitor. The endoscopists have to search for gastric giardiasis especially in the presence of H. pylori and/or intestinal metaplasia.

Biochemical and virological response (by PCR) to interferon therapy in chronic hepatitis C.

Interferon-alpha has been established for the treatment of chronic hepatitis C virus infection. However, the complete responding rate is not higher than 20-25%. Our study was carried out on sixty patients with chronic HCV infection with the following criteria: elevated serum ALT levels, positive antibodies to HCV (by second generation ELISA and RIBA tests) and positive HCV in serum by PCR. All patients had negative tests for hepatitis B virus and liver histopathological findings consistent with chronic hepatitis +/- cirrhosis. Patients were treated with 3 Mu interferon-alpha thrice weekly for 6 months. The results showed response in 14 out of the 60 patients (23.3%) with normalization of the ALT levels within 2-3 months of IFN therapy. Complete response (CR) was present in 6/14 (42.9%) of the responders with negative PCR in serum up to 6 months after stoppage of therapy. Response with relapse (unsustained response) was noticed in 8/14 (57.1%) of the responders with elevation of ALT level 2 months after stoppage of treatment. Forty six patients 46/60 (76.7%) were non-responders (NR) with significant elevation of ALT level and positive PCR in serum all through the course of treatment. The response in cirrhotic patients was significantly lower than in noncirrhotic cases. In conclusion, prolonged treatment courses should be further evaluated in controlled studies.

Causes of minimal hepatic periportal fibrosis present in Egypt.

This study aimed to elucidate the common causes of minimal periportal fibrosis in Egypt. Out of 50 patients having minimal periportal fibrosis, 22 (44%) had schistosomiasis as a sole aetiology, 33 (66%) had combined schistosomiasis with both HBV and HCV. Rare causes were tuberculosis in 4% of the patients and HIV in 2%. No cause could be elicited in 14% of the patients. It is concluded that although schistosomiasis is the commonest cause of minimal hepatic fibrosis in Egypt, yet it is not the sole aetiological factor.