Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries.

BACKGROUND: The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain. METHODS: We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale. RESULTS: A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P = 0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P = 0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events. CONCLUSIONS: Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000476336; Clinical Trials Registry-India number, CTRI/2017/04/008326.).

Pulmonary tuberculosis induces a systemic hypercoagulable state.

OBJECTIVES: Human tuberculosis (TB) remains an important cause of death globally. Bangladesh is one of the most affected countries. We aimed to investigate the impact of pulmonary TB on pro- and anticoagulant mechanisms. METHODS: This prospective study was conducted in Chittagong, Bangladesh. We performed an in-depth analysis of coagulation activation and inhibition in plasma obtained from 64 patients with primary lung TB and 11 patients with recurrent lung TB and compared these with 37 healthy controls. Additionally, in nine patients coagulation activation was studied in bronchoalveolar lavage fluid (BALF) harvested from the site of infection and compared with BALF from a contralateral unaffected lung subsegment. RESULTS: Relative to uninfected controls, primary and recurrent TB were associated with a systemic net procoagulant state, as indicated by enhanced activation of coagulation (elevated plasma levels of thrombin-antithrombin complexes, D-dimer and fibrinogen) together with impaired anticoagulant mechanisms (reduced plasma levels of antithrombin, protein C activity, free protein S, and protein C inhibitor). Activation of coagulation did not correlate with plasma concentrations of established TB biomarkers. Coagulation activation could not be detected at the primary site of infection in a subset of TB patients. CONCLUSIONS: Pulmonary TB is associated with a systemic hypercoagulable state.

Mesenteric venous thrombosis and factors associated with mortality: a statistical analysis with five-year follow-up.

OBJECTIVE: The objective was to study the factors associated with mortality in mesenteric venous thrombosis (MVT). METHODS: We reviewed all cases of bowel ischemia at our institute from 1984 to 2004 and identified 31 cases of MVT and compiled data concerning their demographics, risk factors, investigations, management, surgical procedures, and outcomes. Survival was analyzed for both 30-day and 5-year periods. RESULTS: Analysis of factors associated with mortality in our 31 case series revealed that 30-day mortality was strongly associated with colonic involvement in ischemia (p = .008) as well as short bowel syndrome (p = .028) and possibly failure to anti-coagulate the patient (p = .07). While 5-year mortality was strongly associated with "short bowel syndrome" as defined by small bowel remaining less than 100 cm (p = .031). Further study using a multivariate Cox proportional hazard analysis showed that mortality within the 30-day period was mainly related to colon ischemia with p value of .014 and an odds ratio of 17.4, while short-bowel syndrome was the predominated factor in the 5-year mortality analysis with a p value of .029 and an odds ratio of 5. CONCLUSION: Thirty-day mortality for MVT is strongly associated with colonic involvement as well as "short-bowel" syndrome, while anticoagulation may be protective. Five-year survival was found to be strongly associated with "short-bowel" syndrome.

HPTLC Method for the Simultaneous Estimation of Emtricitabine and Tenofovir in Tablet Dosage Form.

A simple, precise, accurate and rapid high performance thin layer chromatographic method has been developed and validated for the estimation of emtricitabine and tenofovir simultaneously in combined dosage form. The stationary phase used was precoated silica gel 60F 254. The mobile phase used was a mixture of chloroform: methanol (9:1 v/v). The detection of spots was carried out at 265 nm. The method was validated in terms of linearity, accuracy, precision and specificity. The calibration curve was found to be linear between 200 to 1000 ng with regression coefficient of 0.9995. The proposed method can be successfully used to determine the drug content of marketed tablet formulation.

Living related liver transplantation in 13 cases of progressive familial intrahepatic cholestasis.

Progressive familial intrahepatic cholestasis (PFIC) is a heterogenous group of disorders with various etiologies. Recent molecular and genetic studies have categorized the spectrum of types. Liver transplantation is a curative modality of treatment in this disease. We report our experience with 13 patients with PFIC who underwent living related liver transplantation. The follow-up periods ranged from 12 to 50 months. Two children died at 1 and 2 years posttransplantation, leading to a decrease in survival rate from 100% in the first year to 84.6%.

Patients' perspectives on the short- and long-term outcomes following surgery for benign parotid neoplasms.

Surgery for benign parotid gland salivary neoplasms is associated with sequelae: scar and divot defect and complications, facial nerve paresis/paralysis and Frey's syndrome. These potential sequelae and complications are discussed with all patients prior to operation. We contacted 212 patients who had undergone surgery for benign parotid disease during 1988-1997, by postal questionnaire. We enquired about their perception and recollection of the information they had received pre-operatively and to document and comment upon what problems they had experienced in the early and late post-operative period. The usable return rate was 75.5 per cent (173/212). Most patients (90 per cent) were satisfied with the information they had received pre-operatively. The complication and/or sequelae rates for facial nerve palsy (temporary 26.3 per cent, permanent 1.9 per cent), Frey's syndrome (12.5 per cent) and sensory deficit about the cheek and ear (30.6 per cent), are comparable to other published studies.

Living-related liver transplantation.

We report here, the first pediatric living-related liver transplant in Saudi Arabia and the Middle East. Our patient is a 2 year old girl with a diagnosis of progressive familial intrahepatic cholestasis, causing intractable pruritus and failure to thrive requiring liver transplantation. The child was successfully transplanted using a segment of her mother's liver for living-related liver transplantation. Two years post-transplantation the patient is doing well. With the ongoing crises in cadaveric organ availability and the high prevalence of pediatric liver disease, living related liver transplantation is an ideal solution to this difficult and challenging problem.

Rare bone infections "excluding the spine".

Bone infections are usually due to haematogenous spread from distant infected organs. Spread of local sepsis or contamination of open wounds are less frequent routes of infection. The commonest cause of osteomyelitis is Staphylococcus aureus. The term rare bone infections refers to diseases where only a few percent affect bone or diseases which are essentially rare; these include bacteria, fungi, parasites and non-specific conditions. Common examples are tuberculosis, salmonellosis, brucellosis, hydatidosis, madura, actinomycosis, aspergillosis and American fungal infections. Certain bone infections have become exceedingly rare, particularly atypical mycobacteria, viral embryopathies and spirochaetes. Rare bone infections are encountered in many parts of the world commonly in the tropics and in the U. S. Immunocompromise and ease of travel can lead to increased incidence. A high index of clinical suspicion is necessary for diagnosis. Specific laboratory diagnosis is not always possible. Radiographs, computed tomography, isotope studies and magnetic resonance are useful but may not make the diagnosis. Aspiration or biopsy is necessary. Rare bone infections may simulate non-infective bone lesions.

Osteomyelitis: a review of currently used imaging techniques.

Conventional radiographs remain the initial imaging modality involved in the diagnosis of osteomyelitis. Bone scintigraphy and its specific agents did not only eliminate the problems of inherent low sensitivity of conventional radiographs, but also increased the specificity to higher degrees. Spiral CT, on the other hand, has solved several diagnostic problems, such as osteomyelitis of the sterno-clavicular junction and hidden areas in the pelvic bones. Magnetic resonance imaging with its multiplanar capability, greater anatomic details and excellent soft tissue bone marrow contrast resolution has a significant role in surgical planning and limb preservation. Ultrasound and US-guided aspiration has recently been involved in the diagnosis and management of osteomyelitis with several advantages particularly in children. Our goal in this review is to outline the ability of various imaging techniques by comparing their strengths and weaknesses in the diagnosis of osteomyelitis. Finally, we suggest various imaging algorithms for specific clinical scenarios. Spondylitis and septic arthritis are not discussed in this review.

Radiological manifestations of liver and gastrointestinal parasitic infections.

There is a wide variation in the prevalence of parasitic diseases in different countries, particularly in the Tropics. The clinical status of affected patients varies from normal to severe ill health. Radiology has acquired a major role in the diagnosis and, in some instances, the management of a significant variety of parasitic infections. Plain films, ultrasound, computed tomography and magnetic resonance imaging, together with the help of clinical and laboratory tests, can reach a diagnosis with a high percentage of accuracy.

Needle track seeding following percutaneous ethanol injection for treatment of hepatocellular carcinoma.

We report two cases of needle track seeding in the subcutaneous tissue and intercostal muscles following percutaneous ethanol injection for the treatment of hepatocellular carcinoma. In one patient, tumor seeding was observed 11 months after a total of 12 alcohol injections, and in the other patient, tumor seeding was observed 30 months after a total of 18 alcohol injections. The cases reported in the literature are discussed.

Water enhanced "non-paralytic" transcutaneous ultrasound of the normal gastric wall layers (WETCUS).

BACKGROUND/AIMS: Barium studies, endoscopies and endoscopic ultrasound are the usual methods for gastrointestinal tract examinations. Endoscopic ultrasound was the only accurate equipment used for imaging the various layers of the stomach wall distinctly. METHODOLOGY: Twenty patients undergoing renal ultrasound were given 600 cc of water to drink. Gastric wall layers were demonstrated in all patients, namely mucosa; submucosa, musculosa and serosa. The echogenic layer of the water-mucosa interface was not included in gastric wall thickness measurement. RESULTS: The normal wall measurement varied from 3-5 mm. This is lower than in previous reports. CONCLUSIONS: Water enhanced "non-paralytic" transcutaneous ultrasound is a simple, safe, non-invasive, and accurate test for visualizing gastric wall layers.

Isolated hepatic mucormycosis in an immunocompetent child.

A case of isolated localized hepatic mucormycosis in an immunocompetent 3 1/2-yr-old girl with concomitant acute toxoplasmosis is described. Mucormycosis is rare in immunocompetent patients, and hepatic mucormycosis has so far been described only in the context of disseminated disease. The infection resolved spontaneously without surgical debridement and/or appropriate medical therapy with amphotericen B.

Osteoid osteoma and osteoblastoma: MRI appearances and the significance of ring enhancement.

We assessed the value of contrast-enhanced fat-suppressed MRI on nine patients with osteoid osteomas and osteoblastomas. The results were compared with plain films, bone scintigraphy, computed tomography (CT) and pathological specimens. On contrast-enhanced fat-suppressed T1-weighted images the non-calcified nidi showed homogeneous enhancement, whereas the calcified lesions showed a ring enhancement sign that was proportional in intensity to the extent of the remaining part of the vascularized nidus. The degree of bone marrow and soft tissue enhancement was relative to the size and reactive inflammatory changes of the lesions. Although CT was diagnostic in most of the cases and more specific to show the calcified lesions, MRI was confirmatory in one case. We concluded that, although CT is the primary diagnostic investigation in osteoid osteomas, MRI can be reserved for equivocal cases.

Role of CT and MR imaging in the management of tuberculous spondylitis.

Tuberculous spondylitis is an infection involving one or more of the components of the spine, namely the vertebral body, intervertebral disc and ligaments, paravertebral soft tissues, and the epidural space. The causative organism belongs to one of the different strains of Mycobacterium tuberculosis. The role of CT and MR imaging in the diagnosis and management of tuberculous spondylitis is reviewed, and the differential diagnosis of these appearances is discussed. The possible impact of HIV infection on the number of reported cases and their mode of presentation also is considered. The need for prompt diagnosis is emphasized.

Imaging features of musculoskeletal brucellosis.

Brucellosis is endemic in certain parts of the world. Musculoskeletal involvement is the most common complication of brucellosis, and the spine is most frequently affected. Between November 1985 and March 1993, 334 patients with radiologically proved musculoskeletal brucellosis were seen. Involvement of the spine was either focal or diffuse, with a predilection to the lumbar region. Erosions and sclerosis in vertebral end plates, changes of inflammation at scintigraphy or magnetic resonance (MR) imaging, and intact disks were hallmarks of the focal form. Osteomyelitis of neighboring vertebrae, involvement of the intervening disk, and moderate epidural extension were features of diffuse brucellar spondylitis. The great majority of joints with scintigraphic evidence of disease demonstrated normal radiographic findings. Evidence of osteomyelitis or destructive arthritis was encountered in only a few cases. Although radiography is sufficient for demonstrating focal brucellosis, MR imaging is better for assessing diffuse disease.

Case report: investigation of chyluria.

We present a case of chyluria in which the demonstration of abnormal lymphaticourinary communication was established by conventional lymphangiography. Radiocolloid lymphoscintigraphy failed to demonstrate the site of leakage, probably due to technical factors which are discussed.

Premature tracheobronchial, laryngeal and costochondral cartilage calcification in children.

Two children with premature tracheobronchial, laryngeal and costochondral cartilage calcification are described. Both patients had associated congenital cardiovascular anomalies; one of them having features of Keutel syndrome.