CT and MR imaging in young stroke patients

BACKGROUND

This study investigates the role of CT and MR imaging in the diagnosis and management of young stroke patients.

METHODS

CT scan findings of 108 patients and MR findings of 30 patients between 15-45 years of age were reviewed retrospectively. The variables included the territory of infarct on CT and MR imaging, the cortical distribution and size of infarct.

RESULTS

About 80% of the patients had infarcts of the carotid territory and 20% the vertebro-basilar distribution. More than half of the infarcts were cortical (56%). The yield of MR imaging was much higher for deeper structures such as basal ganglia, thalamus and brainstem. In half the cases, the infarct size was more than 3 cm.

CONCLUSION

The ratio of carotid to vertebro-basilar infarcts was similar to that reported previously. A large proportion of the carotid territory infarcts were cortical. Deeper infarcts were better imaged with MR scan. There was a high proportion of large infarcts.

Sequential serum hepatitis C viral RNA levels longitudinally assessed by branched DNA signal amplification

The aim of this study was to determine the stability of viral load over an extended period in patients with chronic hepatitis C virus (HCV). Sequential serum specimens collected from fourteen non-alcoholic adult patients with chronic HCV between 1990 and 1997 were tested retrospectively for HCV RNA levels by branched DNA assay (Quantiplex HCV RNA 2.0 [Chiron Diagnostics, Emeryville, CA]). A minimum of three serum samples was obtained at various intervals from each patient. None of the patients received antiviral therapy. Liver biopsies, available for 10 of 14 patients, showed mild or moderate hepatitis in seven and cirrhosis in three (one developed cirrhosis during follow-up). RIBA strip immunoassay showed that 7, 3, and 4 patients had viral genotypes 1, 2, and 3, respectively. The follow-up time averaged 5.3 years (range, 3.7 to 6.6 years). Eight patients (57.2%) showed increased viral levels from baseline to follow-up, the remaining six patients (42.8%) showed decreased viral levels. The three cirrhotic patients had the highest viral levels over time. The mean change was a 0.29-fold decrease (median, +1.14 [corrected]; range, -17.49 to +7.32). A less than twofold change in either direction was demonstrated for six patients (42.8%), and a less than threefold change was demonstrated for 10 patients (71.4%). Variation from baseline to last follow-up as calculated by log determination showed that the viremic load varied less than one log10 in all but one individual. These results show that viral load remains relatively stable over prolonged periods in most untreated patients with chronic hepatitis C.

Short-course ceftriaxone therapy in spontaneous bacterial peritonitis

Forty patients with spontaneous bacterial peritonitis, three of whom had complicating acute hepatitis syndrome, eight late-onset hepatic failure, and 29 with cirrhosis, were treated with ceftriaxone 2 g intravenously once daily for 5 days. Ascitic fluid culture was positive in 28 patients, with Escherichia coli and Klebsiella as common isolates. All the bacteria isolated were sensitive to ceftriaxone except Enterococcus faecalis, which was isolated in a cirrhotic patient. All culture-positive patients sensitive to ceftriaxone showed bacteriological cure and 26 (65%) patients showed cytological cure after 48 hours of treatment. A total of 95% were cured of their infection after 5 days of treatment. Twelve (30%) patients died during hospitalisation after documented cure of their spontaneous bacterial peritonitis (renal failure, gastrointestinal bleed and cerebral oedema were the primary causes of death). Infection-related mortality due to Pseudomonas septicaemia was seen in one cirrhotic patient.

Outcome of in-hospital pediatric cardiac arrest

BACKGROUND

The outcome of pediatric cardiac arrest is poor, and attempts to improve it have not been very successful. The aim of this study was to analyze the outcome of a large number of in-hospital pediatric cardiac arrest patients, and to determine the factors that influence this outcome.

PATIENTS AND METHODS

The records of hospital inpatients at King Faisal Specialist Hospital and Research Centre who received external cardiac massage as part of their cardiopulmonary resuscitation were reviewed. Success of resuscitation was analyzed as: 1) short-term (restoration of spontaneous circulation); and 2) long-term (discharge from hospital).

RESULTS

Of 234 such patients, 171 (73.1%) survived the initial resuscitation, and 66 (28.2%) were discharged from hospital. Success of outcome was not related to age, time of day, or location of arrest. Longer resuscitation time was associated with less chance of restoration of spontaneous circulation (P<0.001), and lower hospital discharge rate. RESULTS for patients with congenital heart disease were similar to those with other medical or surgical conditions. Restoration of spontaneous circulation from asystole was more difficult when compared to other arrest rhythm, but once circulation was restored, long-term outcome was not influenced by rhythm.

CONCLUSION

Asystole and longer resuscitation time are associated with poorer outcome, however, successful restoration of spontaneous circulation with long-term survival can be achieved after prolonged resuscitation.

Percutaneous drainage compared with surgery for hepatic hydatid cysts

BACKGROUND

In recent years percutaneous drainage has been used successfully to treat the hepatic hydatid cysts of echinococcal disease. We performed a controlled trial to compare the safety and efficacy of percutaneous drainage with those of surgical cystectomy, the traditional treatment.

METHODS

In a prospective study, we randomly assigned 50 patients with hepatic hydatidosis to treatment with percutaneous drainage (25 patients) or cystectomy (25). Albendazole (10 mg per kilogram of body weight per day for eight weeks) was administered to the patients who underwent percutaneous drainage. Serial assessments included clinical and biochemical examinations, ultrasonography, and serologic tests of echinococcal-antibody titers.

RESULTS

The mean (+/-SD) hospital stay was 4.2+/-1.5 days in the drainage group and 12.7+/-6.5 days in the surgery group (P<0.001). Over a mean follow-up period of 17 months, the mean cyst diameter decreased from 8.0+/-3.0 to 1.4+/-3.5 cm (P<0.001) after percutaneous drainage and from 9.1+/-3.0 to 0.9+/-1.8 cm (P<0.001) after surgery. The final cyst diameter did not differ significantly between the two groups (P=0.20). The cysts disappeared in 22 patients (88 percent) in the drainage group and in 18 (72 percent) in the surgery group (P=0.29). After an initial rise, the echinococcal-antibody titers fell progressively and at the last follow-up were negative (<1:160) in 19 patients (76 percent) in the drainage group and 17 (68 percent) in the surgery group (P=0.74). There were procedure-related complications in 8 patients (32 percent) in the drainage group and 21 (84 percent) in the surgery group, 17 of whom had fever postoperatively (P<0.001).

CONCLUSIONS

Percutaneous drainage, combined with albendazole therapy, is an effective and safe alternative to surgery for the treatment of uncomplicated hydatid cysts of the liver and requires a shorter hospital stay.

A comparison of omeprazole and placebo for bleeding peptic ulcer

BACKGROUND

The role of medical treatment for patients with bleeding peptic ulcers is uncertain.

METHODS

We conducted a double-blind, placebo-controlled trial in 220 patients with duodenal, gastric, or stomal ulcers and signs of recent bleeding, as confirmed by endoscopy. In 26 patients the ulcers showed arterial spurting, in 34 there was active oozing, in 35 there were nonbleeding, visible vessels, and in 125 there were adherent clots. The patients were randomly assigned to receive omeprazole (40 mg given orally every 12 hours for five days) or placebo. The outcome measures studied were further bleeding, surgery, and death.

RESULTS

Twelve of the 110 patients treated with omeprazole (10.9 percent) had continued bleeding or further bleeding, as compared with 40 of the 110 patients who received placebo (36.4 percent) (P<0.001). Eight patients in the omeprazole group and 26 in the placebo group required surgery to control their bleeding (P<0.001). Two patients in the omeprazole group and six in the placebo group died. Thirty-two patients in the omeprazole group (29.1 percent) and 78 in the placebo group (70.9 percent) received transfusions (P<0.001). A subgroup analysis showed that omeprazole was associated with significant reductions in recurrent bleeding and surgery in patients with nonbleeding, visible vessels or adherent clots, but not in those with arterial spurting or oozing.

CONCLUSIONS

In patients with bleeding peptic ulcers and signs of recent bleeding, treatment with omeprazole decreases the rate of further bleeding and the need for surgery.

A prospective study of VEC-POB and POCE chemotherapy in aggressive non-Hodgkin's lymphoma

The optimal combination and scheduling of chemotherapy for aggressive non-Hodgkin's lymphoma is unclear, and the elderly have a poor tolerance to treatment. A Phase II prospective study was undertaken using outpatient weekly combination chemotherapy: the VEC-POB (etoposide, epirubicin, cyclophosphamide, cisplatin, Oncovin, bleomycin, and prednisone) regimen in patients < 60 years and less intensive POCE (etoposide, Oncovin, cyclophosphamide, and epirubicin) in patients > or = 60 years. All patients with intermediate and high-grade lymphoma (International Working Formulation) with bulky disease and/or advanced stages (III, IV) seen between January 1991 and June 1992 were entered. Of 29 patients treated with VEC-POB, 23 patients (79%) achieved complete remission (CR), with one (3%) toxic death. Overall survival at 29 months is 67%, and disease-free survival at 60 months is 60%. Of 29 patients treated with POCE, 14 achieved CR, with three (10%) toxic deaths. Overall survival is 58% at 18 months, and disease-free survival at 10 months is 50%. Adverse prognostic factors were analyzed. The results are comparable to the best results achieved with other regimens, and toxicity is acceptable.

Anti-oxidant effects of curry leaf, Murraya koenigii and mustard seeds, Brassica juncea in rats fed with high fat diet

Status of lipid peroxidation was studied in rats induced high fat diet and some commonly used spices, viz. Murraya koenigit and Brassica juncea. The study revealed that these species alter the peroxidation (thiobarbituric acid reactive substances) level to a beneficial extent. Histological studies also focus on modulation of hepatic functions to near normal level.

Biochemical response in rats to the addition of curry leaf (Murraya koenigii) and mustard seeds (Brassica juncea) to the diet

Three groups with 12 weanling male albino rats were group fed for 90 days on a standard laboratory rat diet plus 20% coconut oil either without a supplement or with the addition of 10% curry leaf or 10% mustard seeds. Feed was offered at a level of 10% body weight. At the end of the trial, measurements were made on the total serum cholesterol, high density lipoproteins, low density lipoproteins, and very low density lipoproteins fractions, release of lipoproteins into the circulation, lecithin cholesterol acyl transferase activity and lipoprotein lipase activity. Feed intake and mean body weight of the rats on each treatment was not significantly different. Both spices resulted in a reduction in total serum cholesterol and LDL + VLDL, an increase in the HDL, lower release of lipoproteins into the circulation and an increase in the LCAT activity.

Role of Murraya koenigii (curry leaf) and Brassica juncea (Mustard) in lipid peroxidation

The status of lipid peroxidation was investigated in rats fed M. Koenigii (curry leaf) and B. juncea (Mustard). Concentration of malondialdehyde showed a significant decrease, while hydroperoxides and conjugated dienes were significantly increased in liver and heart of both the experimental groups. SOD and catalase activity was found to be increased in liver and heart of both the spices administered groups. Glutathione levels in liver, heart and kidney were lowered in rats administered these spices. Glutathione reductase, glutathione peroxidase and glutathione S-transferase activity showed a sharp increase in the experimental groups compared to the controls.

Murraya koenigii and Brassica juncea--alterations on lipid profile in 1-2 dimethyl hydrazine induced colon carcinogenesis

The influence of the two commonly used spices Murraya koenigii (curry leaf) leaf and Brassica juncea (mustard) seeds on the levels of lipids, fecal bile acids and neutral sterols was studied in rats administered 1,2-dimethyl hydrazine (1,2 DMH). The levels of cholesterol and phospholipids decreased in the experimental groups when compared with the control. The cholesterol phospholipid ratio showed an elevated level in the DMH treated control compared with the species group. Bile acids and neutral sterols showed a sharp increase in the spices treated groups in liver and feces when compared with the control. Morphological and histological studies revealed that the mean number of neoplasms in the colon and intestine were significantly low in the spices fed groups.

Haematological & histological studies after curry leaf (Murraya koenigii) & mustard (Brassica juncea) feeding in rats

Whole curry leaf and mustard fed to rats at doses equal to normal human intake did not cause any adverse effect on food efficiency ratio (FER), red blood cell count (RBC), white blood cells (WBC), total count, differential counts or on the levels of blood constituents, like serum electrolytes, blood urea, haemoglobin, total serum protein, albumin-globulin ratio, fibrin level, glycosylated haemoglobin and the activity of glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT) and alkaline phosphatase in serum. No histopathological changes were observed in the liver of rats administered curry leaf and mustard.

Elevated serum creatinine level in thyroid cancer patients undergoing withdrawal of thyroxine therapy for radioiodine scan/treatment

Chronic hypothyroidism is known to cause a significant reversible decrease in glomerular filtration rate (GFR). However, the effect on GFR of acute hypothyroidism, routinely induced in thyroid cancer patients in preparation for radioiodine scan/treatment, is not known. We studied the prevalence of abnormal serum creatinine level and the degree of its increase in hypothyroid patients with thyroid cancer four weeks after the withdrawal of thyroxine therapy. Creatinine level was measured in 116 patients on 191 hypothyroid episodes and in 56/116 and 18/116 patients while euthyroid or mildly hyperthyroid respectively. Abnormal creatinine level was significantly more prevalent in the hypothyroid state (34.5% vs 4% in the euthyroid or mildly hyperthyroid states) and significantly more common in males (50% vs 29% in females), in patients </=31 years old (48% vs 26% in older patients) and in patients with a TSH level >150 mU/L (55% vs 30% with TSH </=150 mU/L). Analyzing data on females only or including all hypothyroid episodes did not significantly alter the results. Further, compared to patients with normal creatinine level, patients with abnormal creatinine levels were significantly younger (in the whole group, mean age 35.1 vs 42.5 years; in the subgroup of patients with a TSH level > 150 mU/L, 29.8 vs 41.4 years; in females, 28.3 vs 42.5 years) and there was a significant negative association between the presence of abnormal creatinine levels and different age groups. Compared to levels obtained in the euthyroid or mild hyperthyroid states, creatinine levels increased in the hypothyroid state on average 32% (23microM/L, P=0.0001) with 24% of patients having >/=50% increase. Elevated serum creatinine levels are rather common in thyroid cancer patients undergoing temporary withdrawal of thyroxine treatment and more so in males, younger patients or in association with higher TSH levels. Since the clearance of iodine is linearly related to GFR, our study suggests that in the setting of hypothyroidism, the bioavailability of a given dose of radioiodine may have significant individual variation.

Antibodies to carbonic anhydrase in patients with immune cholangiopathies

BACKGROUND/AIMS

Bile duct epithelia contain an abundance of carbonic anhydrase. Antibodies to this enzyme have been described in autoimmune disorders. Serum from patients with immune-mediated liver diseases was studied to determine whether antibodies to carbonic anhydrase II and/or pyruvate dehydrogenase could distinguish autoimmune cholangitis as immunologically distinct from primary biliary cirrhosis.

METHODS

Antibody assays to carbonic anhydrase II (Western blot) and pyruvate dehydrogenase (flow cytometry) were performed on the sera of patients with autoimmune cholangitis (6), primary biliary cirrhosis (12), primary sclerosing cholangitis (12), autoimmune hepatitis (12), and control (Gilbert syndrome; 8).

RESULTS

Reactivity to carbonic anhydrase II was detected in 5 of 6 patients with autoimmune cholangitis, 1 of 12 patients with primary biliary cirrhosis, 1 of 12 patients with autoimmune hepatitis, and no other patients. Individuals with autoimmune cholangitis were more likely than the other patients to be reactive to carbonic anhydrase II (P < 0.001). Patients with primary biliary cirrhosis were more reactive to pyruvate dehydrogenase compared with all other groups (P < 0.001).

CONCLUSIONS

An antibody to human carbonic anhydrase II is frequently detected in the sera of patients with autoimmune cholangitis and is uncommon or not present in other cholangiopathies. These data provide evidence that autoimmune cholangitis and primary biliary cirrhosis represent distinct entities with unique patterns of immunoreactivity.

Hypoglycemic action of Murraya koenigii (curry leaf) and Brassica juncea (mustard): mechanism of action

Effect of Murraya koenigii and Brassica juncea on carbohydrate metabolism has been studied using rats as experimental animals. Both showed significant hypoglycemic action. There was increase in the concentration of hepatic glycogen and glycogenesis, as evident from the increased activity of glycogen synthetase, and decrease in glycogenolysis and gluconeogenesis as evident from the decreased activity of glycogen phosphorylase and gluconeogenic enzymes.

Post-irradiation DNA synthesis inhibition and G2 phase delay in radiosensitive body cells from non-Hodgkin's lymphoma patients: an indication of cell cycle defects

In the present study, both post-irradiation DNA synthesis and G2 phase accumulation were analyzed in lymphoblastoid cell lines (LCLs) and fibroblast cell strains derived from (Saudi) patients with non-Hodgkin's lymphoma (NHL), ataxia telangiectasia (AT), AT heterozygotes and normal subjects. A comparison of the percent DNA synthesis inhibition (assayed by 3H-thymidine uptake 30 min after irradiation), and a 24 h post-irradiation G2 phase accumulation determined by flow cytometry placed the AT heterozygotes and the NHL patients in an intermediate position between the normal subjects (with maximum DNA synthesis inhibition and minimum G2 phase accumulation) and the AT homozygotes (with minimum DNA synthesis inhibition and maximum G2 accumulation). The similarity between AT heterozygotes and the NHL patients with respect to the two parameters studied after irradiation was statistically significant. The data indicating a moderate abnormality in the control of cell cycle progression after irradiation in the LCLs and fibroblasts from NHL patients may explain the enhanced cellular and chromosomal radiosensitivity in these patients reported by us earlier. In addition to demonstrating a link between cell cycle abnormality and radiosensitivity as a possible basis for cancer susceptibility, particularly in the NHL patients, the present studies emphasized the usefulness of the assay for 24 h post-irradiation G2 phase accumulation developed by Lavin et al. (1992) in characterizing AT heterozygote-like cell cycle anomaly in cancer patients irrespective of whether they carried the AT gene or any other affecting the cell cycle.

Increased radiosensitivity and radioresistant DNA synthesis in cultured fibroblasts from patients with coronary atherosclerosis

Cultured skin fibroblasts from five patients with atherosclerosis who underwent coronary artery bypass graft surgery were compared with those from one ataxia telangiectasia (AT) homozygote, three AT heterozygotes, and five healthy subjects to determine their sensitivity to gamma radiation as determined by a colony survival assay. Fibroblasts from four of these patients were also compared with those from two AT homozygotes, two AT heterozygotes, and three healthy subjects to determine postirradiation [3H]thymidine incorporation, indicating the levels of radioresistant DNA synthesis (RDS). On the basis of colony survival assay, after long-term irradiation (at low dose rate, ie, 0.007 Gy/min), fibroblasts from all five patients with atherosclerosis exhibited radiosensitivity that was intermediate between that of the healthy subjects and that of patients with the known radiosensitive syndrome AT. However, there was a considerable interstrain difference in the radiosensitivity of fibroblasts from patients with atherosclerosis, with their mean D10 values (radiation dose resulting in 10% cell survival) varying between 2.3 and 6.2 Gy, whereas the mean D10 values for the cells from the AT homozygote, AT heterozygotes, and healthy subjects were 2.0, 3.8, and 9.0 Gy, respectively. One of the patients with atherosclerosis showed cellular radiosensitivity quite similar to that of the AT homozygote, up to 2% to 10% of survival levels after short- (at a dose rate of 8 Gy/min) and long-term irradiation, respectively. The results of [3H]thymidine incorporation showed an AT heterozygote-like RDS in fibroblasts from patients with atherosclerosis that appeared to be intermediate between that of AT homozygotes and that of healthy subjects, suggesting a partial deregulation of cell cycle in the patients with atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Spectrum of hepatitis E virus infection in India

A solid phase enzyme linked immunosorbent assay (ELISA) that detects IgM and IgG to hepatitis E virus (HEV) was used to study seroepidemiology in 40 healthy subjects and 227 consecutive patients with liver diseases in an endemic area. Fifty-two of the liver diseases patients (22.9 percent) had acute hepatitis E. In contrast, none of the 40 healthy subjects were positive for IgM anti-HEV, validating the ELISA assay. Twenty-three of 25 (92%) patients with epidemic non-A, non-B hepatitis were confirmed as having acute hepatitis E. Only 1 of the 10 patients with sporadic, fulminant hepatic failure of non-A, non-B, non-C etiology was positive for IgM anti-HEV. Five (31.2%) of the 16 patients with acute hepatitis in HBsAg carriers were positive for IgM anti-HEV. One patient with acute hepatitis B was coinfected with acute hepatitis E. Acute hepatitis was a disease of the adult population, with peak attack rates in the second and third decades of life. This disease was seen in only 4 (16%) of the 25 patients with acute viral hepatitis occurring below 14 years of age. Cholestasis was predominant in 25% of patients, enzyme elevation was monophasic, and all patients had clinical and biochemical recovery from the disease. The data suggest that the majority of patients with acute sporadic non-A, non-B, non-C hepatitis in India have hepatitis E. However, fulminant hepatic failure to sporadic nature is rarely from hepatitis E.

Malignant cystosarcoma phyllodes: A review of the clinical experience at King Faisal Specialist Hospital and Research Centre

Twelve females with cystosarcoma phyllodes of the breast were referred to King Faisal Specialist Hospital and Research Centre (KFSH&RC) between 1980 and 1990, representing 0.8% of breast cancer patients seen during this period. Median age was 45 years (range 16 to 65 years). Seven patients (58%) were premenopausal. All patients presented with breast mass, which measured >10 cm in 58% of them. The median duration of symptoms was 15 months (range two to 174). Neither axillary lymph nodes nor distant metastases were seen at presentation. Surgery was the cornerstone of primary treatment (wide local excision in three and mastectomy in nine). Two patients received adjuvant chemotherapy and locoregional irradiation. All patients had malignant tumors histologically. Of the four tumors assayed for hormonal receptors, one was positive for estrogen and progesterone receptors. At a median follow-up of 17 months (range two to 77), four patients had relapsed; one died at 19 months and the projected five year survival is 83%. This limited data supports the observation that malignant cystosarcoma phyllodes is a distinctive clinicopathological entity of female breast cancer with a different natural history from carcinoma of the breast. Our survival results are similar to reported experience from the literature.

Worm extraction and biliary drainage in hepatobiliary and pancreatic ascariasis

From December 1989 to March 1992, 50 (32%) of 156 patients with hepatobiliary and pancreatic ascariasis underwent various endoscopic interventional procedures. Endoscopic intervention was performed when patients did not respond to energetic symptomatic treatment within the first few days of hospitalization (n = 45) or when worms had not moved out of the ducts into the duodenum at 3 weeks (n = 5). Worm extraction was successful in all 18 patients from the ampullary orifice and in 34 (89.5%) of 38 patients from the bile or pancreatic duct. In five patients with pyogenic cholangitis, endoscopic nasobiliary drainage was performed to decompress the bile ducts. After worm extraction/nasobiliary drainage, 41 (91%) of the 45 patients with biliary disease (n = 42) or acute pancreatitis (n = 3) had rapid relief of symptoms. Three patients developed complications related to endoscopy, including cholangitis (n = 2) and hypotension (n = 1).

Serial cholangiographic appearances in recurrent pyogenic cholangitis

From December 1982 to December 1991, cholangiograms were obtained in 227 patients with recurrent pyogenic cholangitis. Cholangiographic abnormalities included biliary dilation, calculi, sludge, excessive branching, and arrowhead formation of intrahepatic ducts and biliary strictures. In 21 patients, previous evidence of biliary ascariasis was seen. Repeat cholangiograms were performed in 55 patients in a follow-up period of 18.0 +/- 1 months. Of these patients, 12 treated conservatively continued to get recurrent cholangitis and revealed worsening abnormalities on repeat cholangiograms. Another 25 patients had successful endoscopic sphincterotomy and extraction of biliary calculi. These patients remained free of symptoms on follow-up, with significant resolution of abnormalities on repeat cholangiograms. The remaining 18 patients with failed surgical or endoscopic interventions continued to get recurrent episodes of cholangitis and worsening of abnormalities on repeat cholangiograms. This retrospective study indicates that the natural course of recurrent pyogenic cholangitis is a progressive, destructive cholangiopathy. Ascaris lumbricoides invasion of the biliary tree is an initiating event in a sub-group of patients.