Precipitating factor of seizure in epilepsy: experience in a tertiary care hospital

Patients with epilepsy experience recurrent, unprovoked seizures. In most of the cases seizure occurs spontaneously, but there may be association with various triggers. These triggers may act as seizure precipitating factors (SPFs). This study was done to find out the most common SPFs and their relationship to different types epileptic patients attending a tertiary care hospital in Bangladesh. This cross sectional study was carried out in specialized epilepsy weekly outdoor clinic and Medicine outpatient department (OPD) of Dhaka Medical College Hospital from January 2008 to July 2011, which included 1168 epilepsy patients. All patients attending the clinic were included in the study. Epilepsy syndromes were broadly classified into four categories using the classification system of international league against epilepsy (ILAE) namely, generalized epilepsy (GE), localization related epilepsy (LRE), symptomatic and unclassified. Each patient was evaluated and classified by consultant neurologist. All participants were interviewed through a predesigned close ended questionnaire that included a long list of 30 precipitating factors. Among all the patients 71.5% were male, with most common age group 11-20 years (36.8%). About 62% could indentify at least one precipitator. Excitation (25.2%) was the most common SPF reported by patients followed by emotional stress in 17.7%. Fever precipitated seizure in 16.4% of the subjects. A good number of them (15.5%) noticed that whenever there was sleep deprivation, they had an attack of epilepsy. However, drug withdrawal, playing outside and head trauma were also common among the patients, about 11.7%, 11.3% and 8.4% respectively. Most of the patients can identify their seizure precipitant and clustering of many SPFs suggests a common patho-physiologic mechanism for these triggers. Excitation, sleep deprivation, fever, watching television and head trauma showed a strong association with generalized epilepsy. Patients with seizure disorder should be evaluated for presence of SPFs, because identification of these might help in proper management of epilepsy.

Progress achieved in the elimination of schistosomiasis from the Jazan region of Saudi Arabia

Among the inhabitants of the Jazan region of Saudi Arabia, the prevalence and intensity of Schistosoma haematobium infection have been kept very low for several years, by sustained control efforts. The success of the interventions, which were based on case finding, the treatment of infected individuals, and the chemical and environmental control of freshwater snails, led, in mid-2002, to a strategy to eliminate human infection with S. haematobium from Jazan. The strategy, which was based on regular chemotherapy, snail control (made easier by the focality of transmission in the area) and health education, with screening at primary-healthcare centres, by mobile teams and at diagnostic units, appears to have been successful. No infected snails can now be found in the region and new cases of human infection with S. haematobium are only being detected in border villages (and are attributed to infections beyond the region, in areas where active transmission is still taking place). Total elimination appears possible if the health authorities in neighbouring areas can be persuaded to adopt a similar strategy of control.

A simple method to combine multiple molecular biomarkers for dichotomous diagnostic classification

Background

In spite of the recognized diagnostic potential of biomarkers, the quest for squelching noise and wringing in information from a given set of biomarkers continues. Here, we suggest a statistical algorithm that – assuming each molecular biomarker to be a diagnostic test – enriches the diagnostic performance of an optimized set of independent biomarkers employing established statistical techniques. We validated the proposed algorithm using several simulation datasets in addition to four publicly available real datasets that compared i) subjects having cancer with those without; ii) subjects with two different cancers; iii) subjects with two different types of one cancer; and iv) subjects with same cancer resulting in differential time to metastasis.

Results

Our algorithm comprises of three steps: estimating the area under the receiver operating characteristic curve for each biomarker, identifying a subset of biomarkers using linear regression and combining the chosen biomarkers using linear discriminant function analysis. Combining these established statistical methods that are available in most statistical packages, we observed that the diagnostic accuracy of our approach was 100%, 99.94%, 96.67% and 93.92% for the real datasets used in the study. These estimates were comparable to or better than the ones previously reported using alternative methods. In a synthetic dataset, we also observed that all the biomarkers chosen by our algorithm were indeed truly differentially expressed.

Conclusion

The proposed algorithm can be used for accurate diagnosis in the setting of dichotomous classification of disease states.

Biological treatment of industrial wastes in a photobioreactor

An algal-bacterial consortium was tested for the treatment from a coke factory. A Chlorella vulgaris strain and a phenol-degrading Alcaligenes sp. were first isolated from the wastewater treatment plant to serve as inocula in the subsequent biodegradation tests. Batch tests were then conducted with samples from the real wastewater or using a synthetic wastewater containing 325 mg phenol/l and 500 mg NH4+/l as target pollutants. Direct biological treatment of the real wastewater was not possible due to the toxicity of organic compounds. Activated carbon adsorption and UV(A-B)-irradiation were efficient in detoxifying the effluent for subsequent biological treatment as inoculation of pretreated samples with the algal-bacterial consortium was followed by complete phenol removal and NH4+ removal of 45%. Complete phenol removal and 33% NH4+ removal were achieved during the fed-batch treatment of artificial wastewater at 6 d hydraulic retention time (HRT). Under continuous feeding at 3.6 d HRT, phenol and NH4+ removal dropped to 58 and 18%, respectively. However, complete phenol removal and 29% NH4+ removal were achieved when 8 g NaHCO3/l was added to the artificial wastewater to enhance algal growth. This study confirms the potential of solar-based industrial wastewater treatment based on solar-based UV pretreatment followed by algal-bacterial biodegradation.

Use of the buccal fat pad in the reconstruction and prosthetic rehabilitation of oncological maxillary defects

We evaluated the effectiveness of the buccal fat pad as a pedicled flap for intraoral reconstruction after partial maxillectomy for neoplastic disease in 24 patients, and subsequently, in providing support for a denture. In all patients the buccal fat pad was covered with a split-skin graft and an acrylic plate. There was complete healing of the buccal fat pad flap within 6 weeks in 18 patients with no major complications, and minimal effects on speech and eating. In six cases there was partial dehiscence of the flap, which healed spontaneously in one patient and was repaired with local flaps in two others. There were no cases of complete breakdown of the flap. Eight patients so far have been rehabilitated with small dentures. In conclusion, the buccal fat pad flap is a simple, quick, and reliable method of reconstruction of small to medium-sized posterior maxillary alveolar defects.

Platelet distribution width (PDW) is increased in vaso-occlusive crisis in sickle cell disease

Considering the multigenic and multifactorial nature of the disease, we argue that a generalized bone marrow hyperplasia-and not merely erythroid hyperplasia-will occur in sickle cell disease. Consequently, we expect the hematological parameters to depict erythroid, myeloid as well as megakaryocyte hyperplasia. In the light of this expectation, we hypothesized that platelet distribution width (PDW) will increase in sickle cell disease. Here, we report the results from a cross-sectional study of 216 children admitted with complaints suggestive of vaso-occlusive crisis. We observed a strong association between PDW and sickle cell disease as compared to children who had HbAA genotype. Our findings bridge previous inconsistencies relating to the role of platelets in sickle cell disease. Implications of this finding are discussed.

Congenital atresia of the orifice of the submandibular duct: a report of 2 cases and review

Two infants presented with unilateral cystic swellings in the floor of the mouth as a result of imperforate submandibular ducts. This is thought to result from a congenital failure of canalization of the terminal end of the duct. Both cases responded to simple incision and decompression of the fluid-filled duct. Early treatment is important to avoid feeding difficulties and to prevent later complications such as ranula or sialadenitis.

Fractalkine: a novel angiogenic chemokine in rheumatoid arthritis

Angiogenesis is an important aspect of the vasculoproliferation found in the rheumatoid arthritic (RA) pannus. We have previously implicated members of the CXC chemokine family as potent angiogenic mediators in RA. We investigated the possibility that the sole member of the CX(3)C chemokine family, fractalkine (fkn), induces angiogenesis and that fkn might mediate angiogenesis in RA. Recombinant human fkn significantly induced migration of human dermal microvascular endothelial cells (HMVECs), a facet of the angiogenic response, in the pmol/L range in a concentration-dependent manner (P < 0.05). Fkn also induced the formation of significantly more endothelial tubes on Matrigel than did a negative control (P < 0.05). Fkn significantly induced 2.3-fold more blood vessel growth than control in the in vivo Matrigel plug assays (P < 0.05). We identified HMVEC expression of the fkn receptor, CX(3)CR1. Next, we determined if RA synovial fluid (SF)-induced angiogenesis was fkn-dependent. SFs from six RA patients immunodepleted of soluble fkn induced 56% less migration of HMVECs than did sham-depleted RA SFs (P < 0.05). In vivo, immunodepletion of fkn from six RA SFs significantly inhibited their angiogenic activity in Matrigel plug assays (P < 0.05). Immunodepletion of fkn from five RA synovial tissue homogenates inhibited their ability to induce angiogenesis in in vivo Matrigel plug assays (P < 0.05). These results establish a new function for fkn as an angiogenic mediator and suggest that it may mediate angiogenesis in RA.

Clinical and radiological evidence to support superficial parotidectomy as the treatment of choice for chronic parotid sialadenitis: a retrospective study

We present a retrospective series of 23 consecutive parotidectomies, over a 10-year period (1989-1999) for 22 patients with chronic sialadenitis unresponsive to conservative measures. There were 10 male and 12 female patients. Mean age was 52 years (range 12-72), and mean duration of symptoms 4.5 years (range 8 months-30 years). All patients had preoperative sialography and 2 had computed tomography to exclude a neoplasm. A complete superficial parotidectomy with preservation of the main duct was done in all cases. Fifteen patients developed temporary facial nerve weakness postoperatively and 7 developed Frey's syndrome. There were no cases of permanent facial nerve palsy. Nineteen patients reported complete resolution of their symptoms and 3 patients had mild persisting symptoms that did not necessitate any further treatment. Histologically there was evidence of sialadenosis in one case and benign lymphoepithelial lesion in another; the others showed evidence of chronic sialadenitis of varying degrees of severity. Fifteen patients had postoperative sialograms, of which 11 showed evidence of some filling of residual parotid gland parenchyma and in 8 patients there was filling of a normal-looking accessory lobe. In this series, superficial parotidectomy with preservation of the main duct was safe and effective, with minimal long-term complications, for most patients with chronic parotid sialadenitis that was unresponsive to conservative measures and, in some patients, it allowed some preservation of function. The potential damage to the facial nerve and the cosmetic problems associated with a total or near-total parotidectomy were avoided.

Evidence of IL-18 as a novel angiogenic mediator

Angiogenesis, or new blood vessel growth, is a key process in the development of synovial inflammation in rheumatoid arthritis (RA). Integral to this pathologic proliferation are proinflammatory cytokines. We hypothesized a role for IL-18 as an angiogenic mediator in RA. We examined the effect of human IL-18 on human microvascular endothelial cell (HMVEC) migration. IL-18 induced HMVEC migration at 1 nM (p < 0.05). RA synovial fluids potently induced endothelial cell migration, but IL-18 immunodepletion resulted in a 68 +/- 5% decrease in HMVEC migration (p < 0.05). IL-18 appears to act on HMVECs via alpha(v)beta(3) integrin. To test whether IL-18 induced endothelial cell tube formation in vitro, we quantitated the degree of tube formation on Matrigel matrix. IL-18, 1 or 10 nM, resulted in a 77% or 87% increase in tube formation compared with control (p < 0.05). To determine whether IL-18 may be angiogenic in vivo, we implanted IL-18 in Matrigel plugs in mice, and IL-18 at 1 and 10 nM induced angiogenesis (p < 0.05). The angiogenesis observed appears to be independent of the contribution of local TNF-alpha, as evidenced by adding neutralizing anti-TNF-alpha Ab to the Matrigel plugs. In an alternative in vivo model, sponges embedded with IL-18 or control were implanted into mice. IL-18 (10 nM) induced a 4-fold increase in angiogenesis vs the control (p < 0.05). These findings support a novel function for IL-18 as an angiogenic factor in RA and may elucidate a potential therapeutic target for angiogenesis-directed diseases.

Diagnosis of deep vein thrombosis in the leg by using colour coded duplex sonography

BACKGROUND

Deep Vein Thrombosis (DVT) is regarded rare [not readable: see text] Asia. There is no documentation of the incidence of DVT in Pakistan. Clinical diagnosis of Deep Vein Thrombosis is inaccurate. Venography is the most reliable method of diagnosis, but it has several disadvantages. Many non-invasive diagnostic methods have therefore been developed in the past decade. Of these only duplex sonography has comparable accuracy.

METHODS

We studied 100 cases of suspected DVT by using colour coded duplex sonography. We report the results of a prospective study in patients with suspected deep vein thrombosis evaluated by both colour coded Doppler sonography and venography.

CONCLUSION

We conclude that colour coded duplex sonography is a highly accurate, simple, non-invasive method for detecting femoropopliteal thrombosis. Additional venography is not necessary. Its value in diagnosing isolated calf vein thrombosis remains to be established.

Delay in the diagnosis and prognosis of caecal carcinoma--a study of 20 cases

BACKGROUND

Caecum is the dilated part of the right colon situated in the right iliac fossa, therefore the etiology of this cancer is similar to those of the rest of the colon. Caecal carcinoma is more common in developed countries but it is not a rare disease in underdeveloped countries. This is more common in high socio-economic people who use less fibrous and purified diet. With improvement in health education and social status of the people of Pakistan, there is an emerging trend of Westernization in our society. This may increase the incidence of cancer in Pakistan. Carcinoma of caecum is curable disease is diagnosed early and treated. If we are aware of the pathogenesis, etiology, clinical presentation and management of the disease, we can offer a lot to these patients by diagnosing the caecal carcinoma at an earlier stage, this was the aim of this study.

METHODS

20 cases (15 males and 5 females) of Carcinoma of Caecum were studied from January 1997 to December 1999. Out of these six patients presented in emergency ward, 2 as acute appendicitis and 4 as intestinal obstruction. After routine non-specific investigations, our specific investigations included USG abdomen, barium contrast studies and colonoscopy, Barium study and USG remained of primary importance.

RESULTS

Most of the patients were between age 45-65 years, oldest patient being 80 years old and the youngest was of only 30 years. Most of the patients presented as mass in the right iliac fossa and only some patients as intestinal obstruction. Right hemicolectomy with primary ileo-transverse anastomosis was our standard surgical procedure and was done in about 14 cases. But in some cases ileo-transverse by-pass operation was done as the growth was locally advanced. However, only the omental biopsy was taken in the cases where carcinoma was too advanced.

CONCLUSIONS

We think that our sociodemographic factors put a hindrance in detection of this carcinoma at early stages and therefore curative procedures are difficult to bear good results.

IL-4 adenoviral gene therapy reduces inflammation, proinflammatory cytokines, vascularization, and bony destruction in rat adjuvant-induced arthritis

IL-4 is a cytokine with anti-inflammatory properties on activated macrophages. Rheumatoid arthritis, an autoimmune inflammatory disease, is characterized by a paucity of IL-4 and an abundance of synovial macrophage-derived mediators. Herein, the effect of a single injection of adenovirus-producing rat IL-4 (AxCAIL-4) or a control virus with no inserted gene was compared with the effect of PBS injection into rat ankles. Ankles were injected before arthritis onset or at maximal inflammation. Preventatively, AxCAIL-4 reduced adjuvant-induced arthritis (AIA)- and/or AIA/adenoviral-induced ankle inflammation, decreasing articular index scores, ankle circumferences, paw volumes, radiographic scores, mean levels of monocyte chemoattractant protein-1, the number of inflammatory cells, and the number of synovial blood vessels. Therapeutically, AxCAIL-4 also decreased ankle circumferences and paw volumes in comparison with a control virus with no inserted gene and PBS groups. After arthritis onset, mean levels of TNF-alpha, IL-1beta, macrophage inflammatory protein-2, and RANTES were decreased in AxCAIL-4 rat ankle homogenates compared with PBS-treated homogenates. Thus, increased expression of IL-4 via gene therapy administered in a preventative and/or therapeutic manner reduced joint inflammation, synovial cellularity, levels of proinflammatory cytokines, vascularization, and bony destruction in rat AIA, suggesting that a similar treatment in humans may be beneficial.

Treatment with sulfasalazine or sulfapyridine, but not 5-aminosalicyclic acid, inhibits basic fibroblast growth factor-induced endothelial cell chemotaxis

OBJECTIVE

Rheumatoid arthritis (RA) is characterized by leukocyte recruitment and angiogenesis. We investigated the effects of sulfasalazine (SSZ) and its metabolites, sulfapyridine (SP) and 5-aminosalicylic acid (5-ASA), on components of angiogenesis, namely, endothelial cell (EC) chemotaxis and proliferation, as well as on EC chemokine and soluble adhesion molecule expression.

METHODS

SSZ, SP, and 5-ASA were assayed for their effects on basic fibroblast growth factor (bFGF)-induced human dermal microvascular endothelial cell (HMVEC) chemotaxis and proliferation. EC were plated on Matrigel to assess the effect of SSZ on EC tube formation. Enzyme-linked immunosorbent assays were performed to determine changes in HMVEC production of interleukin-8 (IL-8), monocyte chemoattractant protein-1 (MCP-1), growth-related oncogene alpha (GROalpha), epithelial neutrophil-activating peptide 78 (ENA-78), soluble E-selectin (sE-selectin), and soluble intercellular adhesion molecule 1 (sICAM-1) upon treatment with SSZ or its metabolites.

RESULTS

HMVEC incubated with SSZ or SP exhibited reduced bFGF-induced chemotaxis (59%, [n = 7] and 22%, [n = 3], respectively) (P<0.05). SSZ and SP decreased basal HMVEC proliferation, while 5-ASA increased proliferation (P<0.05; [n = 5]). SSZ decreased bFGF-induced HMVEC proliferation (P<0.05 [n = 5]). SSZ inhibited phorbol 12-myristate 13-acetate-induced HMVEC tube formation (P<0.05; [minimum n = 5]). Tumor necrosis factor alpha-stimulated HMVEC shedding of sICAM-1 was reduced by incubation with either SSZ (19%) or 5-ASA (23%) (P<0.05; [n = 6]). SP inhibited cytokine-stimulated HMVEC expression of IL-8 and MCP-1 (P<0.05; [n = 4]). Neither SSZ nor its metabolites had any effect on HMVEC production of sE-selectin, GROalpha, or ENA-78.

CONCLUSION

These results demonstrate that SSZ and its metabolite SP may affect the pathogenesis of RA by inhibiting EC chemotaxis, proliferation, tube formation, and expression of sICAM-1, IL-8, and MCP-1.

Integration of schistosomiasis-control activities into the primary-health-care system in the Gizan region, Saudi Arabia

A few decades ago, the prevalence of Schistosoma haematobium infection in the human inhabitants of the Gizan region of Saudi Arabia was very high (43%-91%). A vertical programme for the control of the disease, by case finding, treatment of infected individuals and by chemical snail control, was begun in 1974 and led to significant reductions in prevalence in most areas. In 1989 the control activities were gradually integrated into the primary-health-care (PHC) system. Several schools in the area recently participated in the detection of ova (among schoolchildren and neighbouring communities) and organized health-education sessions. The records taken during the vertical and PHC programmes indicate that there were more diagnoses and higher chemotherapy coverage in the latter. The PHC programme has maintained the overall prevalence of infection at an extremely low level (< 1%) and the infection has been completely eradicated in several areas. The participation of schools proved to be particularly useful in terms of population coverage and health education.

Serum LDH and ALP isozyme activities in mice bearing solid Ehrlich carcinoma and/or treated with the maximum tolerated dose (MTD) of aloin

Determination of total LDH and ALP activities and their isozyme patterns in the sera of normal and tumour-bearing animals treated with aloin, a natural anthraquinone with potential antitumour activity, was carried out at 3, 6 and 9 weeks of treatment. Treatment of normal mice with the MTD of aloin (50 mg/Kg b.w.) showed non-significant changes in serum total LDH and ALP activities along with their isozymes throughout the experimental periods. In untreated tumour-bearing animals, serum LDH activity and its isozymes: LDH1-LDH5 showed highly significant increases (192, 32.4, 25.2, 24.7, 29.2 and 30.6%, respectively) after 3 weeks. Highly significant inhibition was recorded in serum total ALP activity and its intestinal and bone isozymes (64, 100 and 56%, respectively), while liver ALP isozyme was increased by 82.3%. Treatment of tumour-bearing mice with the MTD of aloin manifested a significant gradual improvement in both enzyme activities and their isozymes, which were normalized at the end of the experiment (9 weeks), with the exception of intestinal ALP isozyme. All results were reported in comparison to the normal control group.

Falls in the elderly

Finally, we conclude with a reminder that the causes of falls in the elderly are multifactorial and that some of these factors may be summative. Most falls result from interaction of intrinsic and extrinsic (environmental) factors. In the Emergency Department, it is very important to take a detailed history of the circumstances leading to the fall and to perform a thorough physical examination. Every attempt should be made to identify predisposing factors for the fall and for preventive measures to be initiated. These may include geriatric consultation or a home visit to evaluate home environment. There is a great need for additional research in this field. Falls are one of the syndromes common in the elderly that deserve more careful attention and are considered amenable to both primary and secondary prevention measures.

Domestic and wild animals naturally infected with Schistosoma mansoni in the Gezira Irrigated Scheme, Sudan

Domestic and wild animals were examined for natural infection with human schistosomiasis in Northern Gezira, Sudan. Postmortem examination of animals in a number of slaughterhouses revealed no infections in either sheep or goats but Schistosoma mansoni worms were found in two of the 98 cattle examined. Nile rats (Arvicanthus niloticus) were trapped and stray dogs were shot and examined for evidence of schistosome infection. The infection rate in Nile rats was 4.9% (8/164) and in dogs 27.3% (15/55) but whereas viable eggs were found in the excreta and tissues of the rats no eggs could be found in dog faeces. In the laboratory nine puppies were each exposed to 10 000 cercariae but there was no evidence that the infection had taken. It is concluded that A. niloticus, present in large numbers and often found in or near the canals, may be involved in S. mansoni transmission and could act as reservoir hosts, but that dogs are probably infected only in exceptional situations and are unlikely to play a major role in S. mansoni transmission.

Marking snails with nail varnish as a field experimental technique

The use of nail varnish to mark snails for release and recapture in aquatic habitats in the Gezira Irrigation Canals has been evaluated. The nail varnish withstood immersion in canal water and adhered to the snail shell. The recovery of marked snails from a backwater site in a slow moving canal was satisfactory and indicated the usefulness of the technique in predicting changing patterns of immigration and emigration of snails. The method may also indicate ecological changes which affect the stability and mobility of snail populations and yield data on growth rates and longevity.