Effectiveness of preoperative multimedia educational sessions on the levels of anxiety and satisfaction among women undergoing cesarean: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to explore the effectiveness of preoperative multimedia educational sessions on the levels of anxiety and satisfaction among women undergoing cesarean section (CS). The Scopus, PubMed, and Cochrane databases were searched without language limitations for eligible randomized controlled trials (RCTs) published from their inception up to October 15, 2023. A random-effect meta-analysis was conducted, and the quality of this meta-analysis was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Seven RCTs (n = 1006 women) met the inclusion criteria. Preoperative multimedia sessions were found to significantly reduce anxiety levels (n = 6 RCTs, weighted mean difference: -3.10; 95 percent confidence intervals (CI): -4.48, -1.73; I2 = 44.24 percent, moderate certainty of evidence) compared to the control group. However, there was no significant difference between the two groups regarding women's satisfaction after surgery (n = 5 RCTs, risk ratio: 1.37; 95 percent CI: 0.76, 2.50; I2 = 98.26 percent, moderate certainty of evidence). Leave-one-out sensitivity analysis showed robustness of the outcomes. The findings of this meta-analysis suggest that providing multimedia educational programs before surgery could potentially have a beneficial effect on the levels of anxiety experienced by women undergoing CS. However, it is imperative to validate these results through larger samples and multi-centered RCTs.

Association between endometriosis and obstetric complications: Insight from the National Inpatient Sample

OBJECTIVE

This study aimed to investigate the relationship between endometriosis and adverse obstetric outcomes using data from the National Inpatient Sample (NIS) database.

METHODS

The ICD-10 coding system was used to identify codes for endometriosis and obstetric outcomes, and data from the NIS (2016-2019) were analyzed. Descriptive statistics were used to summarize variables, while the chi-square test was used to detect significant differences for categorical variables. Univariate and multivariate regression analyses were conducted to assess the association between endometriosis and obstetric outcomes. On multivariate analysis, adjustment was done for age, race, hospital region, smoking status, and alcohol misuse. Forest plots were used to visualize odds ratios and their 95% confidence intervals.

RESULTS

Overall, 2,854,149 women were included in this analysis, of whom 4,006 women had endometriosis. The post-hoc Bonferroni correction was applied to account for multiple comparisons, and our analyses revealed several statistically significant associations (p < 0.004). Specifically, on univariate analysis, significant associations with endometriosis were identified for ruptured uterus, placenta previa, placental abruption, postpartum hemorrhage, preeclampsia, amniotic fluid abnormality, gestational diabetes, preterm labor, and multiple gestation. On multivariate analysis, significant associations with endometriosis were observed for placenta previa, placental abruption, postpartum hemorrhage, preeclampsia, amniotic fluid abnormality, preterm labor, premature rupture of membranes, and multiple gestation.

CONCLUSION

The present findings provide important insights into the potential relationship between endometriosis and various adverse obstetric outcomes and may help inform clinical practice and future research. Further studies that use more detailed clinical data and longitudinal designs are needed to solidify the presented conclusions.

Exploring the impact of chronic medical conditions on maternal mental health: A National Inpatient Sample analysis

BACKGROUND

Pregnancy and postpartum period are associated with stress and pain. Chronic medical conditions can aggravate depressive and psychotic mental illnesses in the peripartum period.

AIM

The study aimed to investigate the association between different chronic medical conditions and mental illnesses during pregnancy and the postpartum period using the National Inpatient Sample (NIS).

METHODS

Pregnant women or women in the postpartum period were retrieved from the NIS 2016-2019 database using the International Classification of Diseases (ICD)-10 and set as our targeted population. Postpartum depression, puerperal psychosis, and mental illnesses related to pregnancy were also retrieved as our outcomes of interest. STATA 15 was used to analyze the data and investigate the relationship between chronic medical conditions and pregnancy-related mental illnesses.

RESULTS

2,854,149 admissions were retrieved from the database with a mean age of 29 ± 6 years old. Univariate and multivariate analyses showed a significant association between chronic medical conditions and postpartum depression, puerperal psychosis, and other mental illnesses. On univariate analysis, heart failure (odds ratio [OR] = 13.9; 95% confidence interval [CI] = 3.5-55.88; P < 0.001), alcohol misuse (OR = 5.3; 95% CI = 1.7-16.4; P = 0.004), and migraine (OR = 3.9; 95% CI = 2.8-5.3; P < 0.001) showed high association with postpartum depression. Epilepsy (OR = 54.37; 95% CI = 7.4-399.34; P < 0.001), systemic lupus erythematosus (OR = 24.66; 95% CI = 3.36-181.1; P = 0.002), and heart diseases (OR = 15.26; 95% CI = 3.6-64.5; P < 0.001) showed the highest association with puerperium psychosis. Alcohol misuse (OR = 8.21; 95% CI = 7.4-9.12; P < 0.001), osteoarthritis (OR = 6.02; 95% CI = 5.41-6.70; P < 0.001), and migraine (OR = 5.71; 95% CI = 5.56-5.86; P < 0.001) showed the highest association with other mental illnesses during pregnancy and the postpartum period.

CONCLUSION

Heart diseases, alcohol misuse, migraine, systemic lupus erythematosus, and epilepsy were the most important chronic medical conditions associated with mental diseases during pregnancy and the postpartum period. This investigation recommends integrating management of chronic diseases and mental health care together. Specifically, screening for mental illnesses should be a routine part of care for patients with chronic medical conditions, especially during pregnancy and early postpartum. By identifying and addressing mental health issues early on, healthcare providers can improve the overall health and well-being of these patients, ultimately leading to better maternal and fetal outcomes.

Telocytes in Cutaneous Biology: A Reappraisal

The telocytes (TCs) are novel interstitial cells that have been overlooked for a long time due to their histologic similarity to other stromal cells. TCs can be separated from the stromal cells based on their distinct immunohistochemical, ultrastructural, and molecular features. Functionally, TCs are involved in the tissue renewal, mechanical support, and immune modulation. These cells are also involved in the signal transduction either through their direct interactions with the neighboring cells or through the paracrine signaling via extracellular vesicles. TCs are damaged in several inflammatory and fibrotic conditions such as ulcerative colitis, Crohn's disease, hepatic fibrosis, psoriasis, and systemic sclerosis. The transplantation of TCs in the damaged tissue can promote tissue regeneration. Therefore, enhancing tissue TCs either by their transplantation or by promoting their survival and growth using novel medications represents novel therapeutic strategy in the future. In this review, we addressed several aspects of TCs including their origin, distribution, morphologic features, and functions. We also discussed their involvement of the cutaneous TCs in the development various pathologic conditions.

Characterization of Antimicrobial Resistance Genes of Pasteurella multocida Isolated from Diseased Chickens in Egypt

 In this study, the prevalence of Pasteurella multocida in diseased chickens, capsular genotyping, antimicrobial resistance patterns and some resistance genes were determined. Lungs, liver and spleen samples were collected from 250 diseased chickens from layers and broiler flocks from El-Gharbia and Kafr El-Sheikh governorates in Egypt for isolation of P. multocida in the period from June 2018 to December 2019. Confirmatory identification was done by using PCR for capsular type A antigen. P. multocida was isolated from 3.6 % of the diseased chicken. Six isolates of P. multocida that examined for detection of capsular type A showed positive results. Antimicrobial resistance patterns were evaluated for all isolates against twenty antimicrobial agents and the results showed 100% resistance totrimethoprim/sulfamethazole, oxacillin and nitrofurantion. Also, strains expressed highly resistant to penicillin, chloramphenicol, rifampicin and ampicillin \sulbactam, while they were sensitive to norfloxacin, clindamycin, cephalexin and cefotaxime. The antimicrobial resistance genes were detected by using PCR and the results showed  that all isolates harbored  β-lactam-resistantgene BlaROB-1 (100%), followed by sulfonamide resistant gene  sul1 (50%), tetracycline-resistant gene tetH (33.3%) and trimethoprim-resistant dihydrofolate reductase dfrA (16.6%).

Clinical and Haematological Findings in Dengue Fever

From 2000 onwards dengue fever has been occurring at regular intervals in Bangladesh. Ultrasonography is a useful diagnostic procedure. This study was done, keeping this background in mind. Objective of this study was to identify the role of ultrasonography as a useful tool in early diagnosis of dengue haemorrhagic fever. This was a cross-sectional descriptive type of observational study. Results of ultrasonography, haematogy an immunology were observed in 2004 and 2019 in 32 patients on each occasion. In 2004 out of 32 patients 29 had positive ultrsonographic findings supported by corresponding haematological and immunological findings. In 2019 ultrsonography was done in three out of thirty two patients, all three had had positive ultra sonographic findings which were supported by haematological and immunological findings. Dengue fever has serious complications like plasma leakage which manifest in the form of ascites, pleural effusion, thick gallbladder wall etc. If such complications can be detected at an early stage many lives can be saved.

Removal of iron, zinc, and nickel-ions using nano bentonite and its applications on power station wastewater

Removal of high concentrations of toxic heavy metals from wastewater is very important within the environmental field because heavy metals pollution a serious environmental problem due to them being nonbiodegradable. This study shed some light on the use of Nano bentonite as an adsorbent for the elimination of Iron, Zinc, and Nickel ions from wastewater, and the optimum conditions were evaluated to find out thermodynamic and kinetic parameters and equilibrium adsorption models have been applied. The results showed that adsorption percentage increases with increasing temperature, speed of rotation, and volume of solution, but decreases with adsorbent dose and initial concentration increase. The adsorption process has fit pseudo-second-order kinetic model Langmuir and Freundlich adsorption isotherm models were applied to analyze adsorption data and both were found to apply to these adsorption processes. Thermodynamic parameters e.g., ΔG^o, ΔS^o, and ΔH^o of the adsorption process were found to be endothermic. Finally, the Nano bentonite was observed to be more powerful for the removal of Fe (III), Zn (II), and Ni (II) at the same experimental conditions.

Thymoquinone and curcumin modify inducible nitric oxide synthase, caspase 3, and thioredoxin immunohistochemical expression in acetaminophen hepatotoxicity

BACKGROUND

Acetaminophen (APAP) hepatotoxicity is characterised by an extensive oxidative stress due to depletion of glutathione (GSH), which results in massive lipid peroxidation and subsequent liver injury. The current paradigm suggests that mitochondria are the main source of reactive oxygen species (ROS), which impair mitochondrial function and are responsible for cell signalling resulting in cell death. This study was designed to compare the potential impact of thymoquinone (THQ), and/or curcumin (CURC) on liver injury induced by APAP toxicity in rats.

MATERIALS AND METHODS

Serum levels of alanine transaminase, aspartate transaminase, total bilirubin, and total protein were measured. In addition, liver nitric oxide (NO), malondialdehyde, reduced glutathione (GSH), and superoxide dismutase (SOD) were estimated. Moreover, these biochemical parameters were confirmed by histopathological and immunohistochemical investigations for the expression of thioredoxin, iNOS and caspase 3.

RESULTS

Acetaminophen toxicity elevated most of the above-mentioned parameters but decreased GSH, SOD, and total protein levels. Histologically, liver sections demonstrated liver injury characterised by hepatocellular necrosis with nuclear pyknosis, karyorrhexis and karyolysis. Immunohistochemical study revealed increased expression of iNOS and caspase 3 proteins, while the thioredoxin protein expression was decreased.

CONCLUSIONS

Treatment with the THQ and CURC regulated the biochemical and histopathological alterations induced by APAP toxicity. It was concluded that the combination strategy of THQ and CURC might be considered as a potential antidote in combating liver injury induced by APAP with minimal side effects.

Silver nanoparticles enhance the larvicidal toxicity of Photorhabdus and Xenorhabdus bacterial toxins: an approach to control the filarial vector, Culex pipiens

Mosquito-control is still based mostly on chemical insecticides which are toxic and cause environmental deprivation. This study investigates synthesizing silver bio-nanoparticles (AgNPs) from nematode-symbiotic bacterial toxin complexes as an alternative larvicidal bioinsecticide agent against Culex pipiens larvae. Five species/strains of nematode-symbiotic bacteria, Xenorhabdus indica, Xenorhabdus spp., Photorhabdus luminescens laumondii HP88, Photorhabdus luminescens akhurstii HRM1 and Photorhabdus luminescens akhurstii HS1 were used. AgNPs were characterized by scanning electron microscopy and x-ray diffraction analysis. Larvae were initially exposed to descending concentrations (300, 150, 75, 37.5 and 18.75 µg/ml) of each of the five bacterial toxins (as positive controls) or to the bio-AgNPs synthesized from the same bacterial toxins (200, 100, 50, 25, 12.5, 6.25, 3.12 and 1.5 µg/ml) for 48 hours. Results of toxicity bioassays showed that mortality of treated larvae was concentration-dependent, toxins from X. indica, P. luminescens laumondii HP88 and P. luminescens akhurstii HS1 showed LC₅₀ of 29, 28 and 2002 µg/ml, respectively. While, toxins from P. luminescens akhurstii HRM1 and Xenorhabdus sp. showed LC₅₀ of 199, 318 µg/ml, respectively. Bio-AgNPs synthesized from, X. indica or Xenorhabdus sp. toxins have significantly increased their larvicidal activities (LC₅₀ of 1.6, 3.7 µg/ml ) at 48h post-treatment. Moreover, bio-AgNPs synthesized from P. luminescens laumondii HP88, P. luminescens akhurstii HRM1 or P. luminescens akhurstii HS1 toxins significantly increased their larvicidal activities (LC₅₀ of 2.1, 1.5, 13.9 µg/ml, respectively) at 48h post treatment. In conclusion, the highest larval toxicity was observed when larvae were treated with bio-AgNPs synthesized from P. luminescens akhurstii HRM1 and X. indica, followed by P. luminescens laumondii HP88 and Xenorhabdus sp. Subsequently, data of the present study suggest these bio-AgNPs toxin complexes as potentially effective bio-control candidates in the battle against mosquito. However, testing other types of bio-synthesized nanomaterials, and their synergistic combinations against different mosquito species still under investigation.

Peste des petits ruminants infection in domestic ruminants in Sudan

The existence of peste des petits ruminants (PPR) in domestic ruminants and camels in Sudan during 2008-2012 was investigated. Lung tissues and serum samples were randomly collected from sheep, goats, cattle, and camels at different areas of Sudan. A total of 12,384 serum samples were collected from clinically healthy 7413 sheep, 1988 camels, 1501 cattle, 1459 goats, and 23 gazelles at different areas in the Sudan. They were examined for PPR antibodies using competitive ELISA (cELISA). The overall detected seroprevalence of PPR in tested sera was 49.4%; seroprevalence values within species were 67.1, 48.2, 25.8, 2.1, and 21.7% in sheep, goat, cattle, camels, and gazelles, respectively. The highest seroprevalence (68.1%) was observed in sera collected from Darfur states, then the central states (54.3%). A total of 1276 lung tissue samples (623 sheep, 324 cattle, 220 camels, and 109 goats) were collected. The majority of lung samples were collected from clinically healthy animals that showed lesions on PM in slaughterhouses (95%) and during PPR outbreaks; samples were tested for PPR antigen using immunocapture ELISA (IcELISA). PPR antigen was detected in 233 out of the 1276 tested samples (18.3%). Positive results were observed in samples collected from clinically healthy and diseased animals. The observed prevalence values in each species were 33.6, 21.1, 15.4, and 12.3% in camel, goat, sheep, and cattle, respectively. PPR antigen was detected in samples from different areas; however, the highest prevalence (63.9%) was found in samples collected from the eastern states, then Khartoum state (28%). Trials for virus isolation were done in different cell cultures. Out of 30 IcELISA-positive samples inoculated in primary bovine and ovine kidney cells, Vero cells, the PPR virus was successfully isolated from 15 (eight sheep, five camels, and two goats) samples in the three cell culture types. Using RT-PCR, PPRV nucleic acid was detected in all 25 IcELISA-positive tested samples.

Adrenal medulla of AS/AGU rats: a histological and immunohistochemical study

BACKGROUND

The outcome of the autograft therapy for Parkinson's disease including autologous cells from adrenal medulla was disappointing. This could be attributed to the pathological process in Parkinson's disease affecting cells of the adrenal medulla. This study was performed to investigate the histopathological changes in the adrenal medulla of AS/AGU rat, a model of Parkinson's disease, in comparison with Albino Swiss (AS) rats.

MATERIALS AND METHODS

A total of 24 male AS rats were divided into four groups, each of 6 animals: AS W1 - AS rats aged 1 week; AS adult - AS adult rats; AS/ /AGU W1 - AS/AGU rats aged 1 week; and AS/AGU adult - AS/AGU adult rats. The rats were sacrificed and the adrenal glands were dissected and processed for histological staining with haematoxylin and eosin and periodic acid Schiff and for immunohistochemical staining for S100 protein, ubiquitin and tyrosine hydroxylase.

RESULTS

The histological investigation of the adrenal medulla of AS/AGU rats showed vascular congestion, inflammatory cellular infiltration, pyknotic nuclei, necrotic chromaffin cells and medullary inclusion bodies. The immunohistochemical investigation of AS/AGU rats showed a statistically significant decrease in the expression of S100 protein, ubiquitin and tyrosine hydroxylase compared to AS rats.

CONCLUSIONS

The histological and immunohistological changes in the adrenal medulla could explain the failure of outcome of adrenal autograft therapy in Parkinson's disease.

Immunohistochemical study of sustentacular cells in adrenal medulla of neonatal and adult rats using an antibody against S-100 protein

BACKGROUND

This study was performed to investigate the light microscopic features of sustentacular cells in adrenal medulla in neonatal and adult male albino rats using an antibody against S-100 protein. S-100 expression in sustentacular cells is considered a reliable cell marker for this type of cells.

MATERIALS AND METHODS

Twenty-four male albino rats were allocated into two groups, neonatal group (1 week old, 12 rats) and adult group (3 months old, 12 rats). Paraffin sections of the adrenal glands were immunostained for the expression of S-100 protein.

RESULTS

The results demonstrated differences in distribution, arrangement and structure of sustentacular cells in adrenal medulla in neonatal and adult rats. All sustentacular cells of adrenal medulla in all animals showed intense immunoreactivity for S-100 protein in their nuclei, perikarya, and cytoplasmic processes. Most of S-100 immunopositive sustentacular cells in adrenal medulla of neonatal rats are few, dispersed, small in size, and oval in shape with thin short bipolar cytoplasmic processes. These cells in adult rats are more numerous, larger in size, and stellate in shape with numerous slender, longer branched cytoplasmic processes.

CONCLUSIONS

This study indicated that adrenal medullary sustentacular cells showed obvious morphological postnatal changes with aging suggesting structural and functional maturation.

[Rates of prostate-specific antigen testing for early detection of prostate cancer: a first comparison of German results with current international data]

OBJECTIVE

Measurement of prostate-specific antigen (PSA) is not only used as a screening instrument by urologists, but also by general practitioners and internal specialists (GP-IS). Until now, there are neither data on the approach of German GP-IS in practicing this nor have data been classified in the context of available international literature on this topic.

MATERIALS AND METHODS

Between May and December 2012, a questionnaire containing 16 items was sent to 600 GP-IS in Brandenburg and Berlin. The response rate was 65% (392/600). Six indicator questions (IQ1-6) were selected and results were set in the context of available international data. The quality of present studies was evaluated by the Harden criteria.

RESULTS

Of the 392 responding physicians, 317 (81%) declared that they would use PSA testing for early detection of PCA (IQ1) and, thus, formed the study group. Of these GP-IS, 38% consider an age between 41 and 50 years as suitable for testing begin (IQ2), while 53% and 14% of the GP-IS perform early detection until the age of 80 and 90 years, respectively (IQ3). A rigid PSA cut-off of 4 ng/ml is considered to be reasonable by 47% of the involved GP-IS, whereas 16% prefer an age-adjusted PSA cut-off (IQ4). Patients with pathological PSA levels were immediately referred to a board-certified urologist by 69% of the GP-IS. On the other hand, 10% first would independently control elevated PSA levels themselves after 3-12 months (IQ5). Furthermore, 14% of the interviewed physicians consider a decrease of PCA-specific mortality by PSA screening as being proven (IQ6). Knowledge regarding PCA diagnostics is mainly based on continuous medical education for GP-IS (33%), personal contact with urologists (6%), and guideline studies (4%). While 53% indicated more than one education source, 4% did not obtain any PCA-specific training. The results provided by this questionnaire evaluating response of German GP-IS to six selected indicator questions fit well into the international context; however, further studies with sufficient methodical quality are required.

CONCLUSIONS

Despite current findings and controversial recommendations of the two large PCA screening studies on this issue, German GP-IS still frequently use PCA screening by PSA measurement. Primary strategies of early detection as well as follow-up after assessment of pathologically elevated PSA levels poorly follow international recommendations. Thus, an intensification of specific education is justified.

Health-related quality of life and its determinants in HIV patients with post herpetic neuralgia

BACKGROUND

Postherpetic neuralgia is a neuralgia caused by the varicella zoster virus. Its natural history involves slow resolution of the pain syndrome. A subgroup of patients may develop severe, long-lasting pain that does not respond to medical therapy. It also accounts for 11-15% of all referrals to pain clinics but little is known about the quality of life of patients with this condition in our locality Nigeria.

METHOD

Fifty three Post herpetic Neuralgia patients aged between 25 and 56 years (mean = 37.47 +/- 8.29 years) receiving antiretroviral therapy/treatment at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria participated in this study. The short-form 36 (SF-36) generic health-related Quality of Life questionnaire was used to assess the QoL. Spearman rank correlation procedure was used to evaluate the relationship of HRQoL outcomes with medical and socio-demographic factor.

RESULT

Physical functioning), Role limitations due to physical health (LPH), Role limitations due to emotional problems (LEP), Social functioning (SF), General health perceptions (GH) scores were below average (35.59 +/- 19.85, 34.28 +/- 33.16, 33.70 +/- 23.26, 49.07 +/- 17.04, 44.09 +/- 9.72 respectively) while Emotional well being/Mental health (EM) was above average (50.13 +/- 11.56). An average (moderate) symptom scale score was Energy/Fatigue (EF) (51.32 +/- 12.87) while Bodily pain (BP) was severe (31.09 +/- 20.46). Age and sex had no significant influence on any of the functional and symptom scale scores as well as the overall QOL. Inverse relationship was observed between age and each of the LPH, LEP, SF, GH, overall QoL and the entire symptom scales. The overall QoL and each of the symptom scale scores were significantly related (P > 0.05). The functional scale score PF, RPH, REP EM and GH were significantly related to overall QoL while SF was not significantly related (P > 0.01).

CONCLUSION

This study has shown that the overall QoL of PHN in HIV positive patients undergoing adjuvant therapy is below average. The predictor factors of the overall QoL of this group of patients have been brought to light. These patients would require ways to improve the QoL, there is the need for health care provider to address the factors uncovered by this study. Four of the determinant factors (PF, LP, BP and EF) are issues that fall within the corridor of physical therapy. Physical therapist should arise to address these significant aspects of the management this group of patients.

Flock dynamics of desert Barki sheep in relation to age structure

Reproduction data of 8689 ewe records spread over 40 years (from 1960 to 2000) representing 2952 breeding Barki ewes were used in this study. The flock belonged to the Desert Research Center in Egypt. Flock dynamics of nine age groups (2-10 yrs) were assessed. Two parameters were used to evaluate flock dynamics, net reproduction rate (R(o)) (number of ewe- lambs reaching joining age and produced by each ewe during its lifetime in the flock) and intrinsic rate of increase (r(m)) (flock growth when no resource is limiting). Age of ewe had a highly significant (P < 0.01) effect on number of ewes lambing per ewe joined (E(PJ)), number of lambs born per ewe joined (L(BJ)), number of lambs weaned per ewe joined (L(WJ)) and number of ewe lambs reaching joining age per ewe joined (L(EJ.J)). All estimates tended to increase with dams age up to four years and decreased thereafter. The results of R(o) and r(m) showed that the studied flock must consist of 5 age groups to maintain its size and replace itself. It may be recommended to cull the breeding ewe at the age of 6 years to accelerate genetic improvement.

Staphylococcus aureus isolated from a horse in a sudden death condition in Kassala state, eastern Sudan

In this study, Staphylococcus aureus was isolated from a draught horse presented to Kassala Veterinary Research Laboratory (KVRL) for investigation and diagnosis. The affected animal was previously treated with Gentamycin and Tetracycline before submitted to this laboratory, but the animal was not cure. Thereafter, the animal was attended to the laboratory; it was suffering from inguinal abscess and some clinical signs. Clinical and laboratory examinations were carried out however, the animal was suddenly fallen and died immediately. Then post-mortem, bacteriological and histopathological examinations were done. S. aureus was isolated as pure culture from the lungs and peritoneum of the necropsied animal. This isolate showed highly sensitivity to Erythromycin and Clindamycin and it was resistant to Penicillin, Cloxacillin, Cefotaxime, Co-Trimoxazole, Cephalexin and Tetracycline. It was concluded from this study, the shock resulted from S. aureus was the causative agent of the death in this case.

Patterns of lipid changes among type 2 diabetes patients in Sudan

This study investigated the patterns and determinants of lipid disorders among a group of 250 type 2 adult diabetic patients and 60 age- and sex-matched healthy controls in Sudan. Demographic and clinical data, body mass index and waist circumference, and fasting blood samples were taken to estimate the glucose and lipid profile. The mean duration of diabetes was 9.4 years and 46.0% of patients had poor glycaemic control. Compared to controls we detected a statistically significant increase in triglycerides level and a decrease in HDL-C levels. Other lipid values showed a slight increase compared to controls. There was a statistically significant association of triglycerides and HDL-C with increasing age, female sex, obesity, physical inactivity and poor glycaemic control of diabetes.

Towards sustainable delivery of health services in Afghanistan: options for the future

Disruption caused by decades of war and civil strife in Afghanistan has led many international and national nongovernmental organizations (NGOs) to assume responsibility for the delivery of health services through contracts with donor agencies. Recently the Afghan Government has pursued the policy of contracting for a basic package of health services (BPHS) supported by funds from three major donors - the World Bank, the United States Agency for International Development (USAID) and the European Commission. With the gradual strengthening of the public health ministry, options for the future include pursuing the contracting option or increasing public provision of health services. Should contracting with NGOs be pursued, a clear strategy is required that includes developing accreditation instruments, better contracting mechanisms and a system for monitoring and evaluating the entire process. Should the government opt for an increasing role, problems to be solved include securing the transition to public provision, obtaining guarantees that appropriate financing will be provided and reconfiguration of the public health delivery system. Large-scale contracting with the private for-profit sector cannot be recommended at this stage, although this option could be explored via subcontracting by larger NGOs or small-scale trial contracts initiated by the public health ministry. Irrespective of the option chosen, an important challenge remaining is the recalcitrant problem of high out-of-pocket payments. Sustainable delivery of health services in Afghanistan can only be achieved with a clear national strategy in which all stakeholders have roles to play in the financing, regulation and delivery of services.

Use of the Internet by Sudanese doctors and medical students

Patterns of use of the Internet were investigated by a questionnaire survey of 102 hospital doctors and 123 medical students in Khartoum, Sudan, in January 2005. More doctors (84.3%) had used the Internet than had students (78.9%). Half of consultants (55.0%) used the Internet daily, compared with only 18.2% of junior doctors. Many consultants and junior doctors rated their abilities as poor (60.0% and53.1%). One-third of students (33.3%) used the Internet only for personal and not for academic purposes. Barriers to greater use of the Internet by doctors included: time constraints (80.2%), poor skills (54.6%), no access to full texts of journal articles (53.4%), difficulty in verifying the quality of information (47.6%) and high costs (41.8%). Students faced similar barriers but also listed poor knowledge of the English language.

Expression of cyclooxygenase-2 and 12-lipoxygenase in human breast cancer and their relationship with HER-2/neu and hormonal receptors: impact on prognosis and therapy

BACKGROUND

A number of studies have shown over-expression of cox-2 in breast cancer. Also it has been recorded that human breast cancer expresses high level of cox-2 and 12-lipoxygenase which may be beneficial in future therapy plan for those patients.

AIMS

The present study aims to examine the level of transcripts of cox-2 and 12-lipoxygenase in Egyptian breast cancer patients and to compare between the expressions of both enzymes and TNM staging, hormone receptors status (including estrogen and progesterone) and HER2/neu expression.

MATERIALS AND METHODS

Total cellular RNA was extracted from 64 frozen tissue samples of breast carcinoma and their corresponding normal adjacent tissues. Cox-2 and 12-lipooxygenase expressions were detected using RT-PCR. Hormonal receptors as well as HER2/neu were detected immuno-histochemically for each patient.

RESULTS

About 47 and 62.5% of carcinoma samples showed over-expression of cox-2 and 12-lipooxygenase respectively as compared to their corresponding normal tissues. The results revealed that cox-2 significantly associated with TNM staging (P = 0.0047) and hormonal receptors status (P = 0.0201). The relationship between cox-2 and HER2/neu expression was close to a significant value (P = 0.0747). 12-lipooxygenase showed only significant association with TNM staging (P = 0.0076). Neither hormonal receptors nor HER2/neu showed significant association with this enzyme.

CONCLUSION

Elevated levels of cox-2 and 12-lipoxygenase expression were detected in human breast cancer. Also, the results revealed that cox-2 and 12-lipooxygenase mRNA expressions are associated with TNM staging in human breast cancer. Furthermore, there is an inverse association between cox-2 expression and hormonal receptor status. This observation may drive us to the possible role of those two enzymes in determining the plan of therapy of breast cancer patients.

Towards sustainable delivery of health services in Afghanistan: options for the future

Disruption caused by decades of war and civil strife in Afghanistan has led many international and national nongovernmental organizations (NGOs) to assume responsibility for the delivery of health services through contracts with donor agencies. Recently the Afghan Government has pursued the policy of contracting for a basic package of health services (BPHS) supported by funds from three major donors-the World Bank, the United States Agency for International Development (USAID) and the European Commission. With the gradual strengthening of the public health ministry, options for the future include pursuing the contracting option or increasing public provision of health services. Should contracting with NGOs be pursued, a clear strategy is required that includes developing accreditation instruments, better contracting mechanisms and a system for monitoring and evaluating the entire process. Should the government opt for an increasing role, problems to be solved include securing the transition to public provision, optining guarantees that appropriate financing will be provided and reconfiguration of the public health delivery system. Large-scale contracting with the private for-profit sector cannot be recommended at this stage, although this option could be explored via subcontracting by larger NGOs or small-scale trial contracts initiated by the public health ministry. Irrespective of the option chosen, an important challenge remaining is the recalcitrant problem of high out-of-pocket payments. Sustainable delivery of health services in Afghanistan can only be achieved with a clear national strategy in which all stakeholders have roles to play in the financing, regulation and delivery of services.

Deficiencies in medical prescriptions in a Sudanese hospital

We determined the quality of medical prescription in Ribat University Hospital, Khartoum through detecting errors in doctors' prescriptions. We randomly selected 1000 medical prescriptions and checked them for completeness and legibility. The total number of doctors responsible for writing the prescriptions was 46. The patient's full name was written on only 18.8% of prescriptions and that of the doctor on only 6.7%. In only 19.5% of prescriptions were drugs prescribed by their generic names, 59.7% lacked the quantity of the drug, 25.7% lacked the duration of treatment and 15.8% were difficult to read. The quality of drug prescriptions written by our hospital doctors is seriously deficient.

Attitudes towards euthanasia among final-year Khartoum University medical students

To investigate the attitudes of final-year medical students at Khartoum University towards euthanasia an anonymous questionnaire was answered by 141 students. Most were familiar with the concept of euthanasia. The majority, 108 (76.6%) opposed euthanasia and their reasons included religious beliefs, belief that euthanasia was unethical and fear of misuse. The supporters of euthanasia (23.4%) stated reasons such as preventing the suffering of patients and respecting their autonomy and dignity. More students who described themselves as strongly religious were opponents of euthanasia (83/87, 95.4%) than those who were moderately religious (25/54, 46.3%).

History of disorders of thyroid dysfunction

The first description of thyroid diseases as they are known today was that of Graves disease by Caleb Parry in 1786, but the pathogenesis of thyroid disease was not discovered until 1882-86. Thyroidectomy for hyperthyroidism was first performed in 1880, and antithyroid drugs and radioiodine therapy were developed in the early 1940s. Thomas Curling first described hyopothyroidism (myxoedema) in 1850 and the cause and suitable treatment were established after 1883. This paper reviews the main landmarks in the history of thyroid disease, supplemented by a brief discussion of the historically relevant scientific aspects of the thyroid gland, and the evolution of endocrinology as a formal discipline.

A study of domestic violence among women attending a medical centre in Sudan

To investigate domestic violence in the Sudanese family, we studied 394 literate, married women attending the Arda Medical Centre, Omdurman, from October 2001 to February 2002. Through self-administered questionnaires, the women provided data on sociodemographic characteristics and abuse by the husband. Abuse was reported by 164 women (41.6%), who suffered 525 violent episodes in the previous year, classified into controlling behaviour (194), threatening behaviour (169) and physical violence (162). Frequency of violent episodes varied from 1 (25%) to > 6 (20.7%). Violence during pregnancy was reported by 27 women (16.5%). Provoking events included suspicion of illicit relations, talking back and inadequate home care. Common reactions reported by the women included staying quiet, crying and resistance.

Three-dimensional morphometry of the femoral condyles

OBJECTIVE

The present study describes the geometry of the three-dimensional articular surfaces of the human femoral condyles based on measurements of surface coordinates.

DESIGN

The purpose was not to obtain a complex representation of one single condyle, but to describe the femoral condyles using simple geometric parameters based on measurements using a number of specimens.

BACKGROUND

In joint modeling, a representative knee joint geometry is often desired which requires an approximation of the irregular joint geometry while taking into account interspecimen variations.

METHODS

An optical device was used to measure the condylar articular surfaces of 12 human femurs in the femorotibial contact region. The sagittal profiles were reconstructed by means of two circular arcs and the radial profiles by means of one circular arc.

RESULTS

The results provide the geometric parameters necessary for the three-dimensional reconstruction of the articular surfaces of the femoral condyles. The results indicate that the medial and lateral condyles of the distal femur are significantly asymmetric in a number of morphological features.

CONCLUSION

The primary application of the results is expected to be in the formulation of finite element models of the knee joint for static contact problems.

RELEVANCE

Numerical models of the knee joint are being widely used to study the mechanics of the joint. However, formulation of such models demands a prior knowledge of the complex three-dimensional geometry of the articular surfaces of the natural joint to establish the input parameters of the model.

In vitro measurement of the restraining role of the anterior cruciate ligament during walking and stair ascent

The study aimed to test the hypothesis that the restraining role of the anterior cruciate ligament (ACL) of the knee is significant during the activities of normal walking and stair ascent. The role of the ACL was determined from the effect of ACL excision on tibiofemoral displacement patterns measured in vitro for fresh-frozen knee specimens subjected to simulated knee kinetics of walking (n = 12) and stair ascent (n = 7). The knee kinetics were simulated using a newly developed dynamic simulator able to replicate the sagittal-plane knee kinetics with reasonable accuracy while ensuring unconstrained tibiofemoral kinematics. The displacements were measured using a calibrated six degree-of-freedom electromechanical goniometer. For the simulation of the walking cycle, two types of knee flexion/extension moment patterns were used: the more common "biphasic" pattern, and an extensor muscle force intensive pattern. For both of these patterns, the restraining role of the ACL to tibial anterior translation was found to be significant throughout the stance phase and in the terminal swing phase, when the knee angle was in the range of 4 degrees to 30 degrees. The effect of ACL excision was an increase in tibial anterior translation by 4 mm to 5 mm. For the stair ascent cycle, however, the restraining role of the ACL was significant only during the terminal stance phase, and not during the initial and middle segments of the phase. Although, in these segments, the knee moments were comparable to that in walking, the knee angle was in the range of 60 degrees to 70 degrees. These results have been shown to be consistent with available data on knee mechanics and ACL function measured under static loading conditions.

Internal migration, earnings, and the importance of self-selection

This paper analyzes the impact of internal migration on earnings within the human capital model framework. Since migrants constitute a non-random sample of population, the endogenous nature of migration decision warrants necessary correction for the selectivity bias in their earnings function. The Mincer-type earnings model is thus augmented to determine the extent of this bias. Besides estimating the standard Mincerian earnings model, the paper also attempts to verify the learn-as-you-go proposition by introducing migration duration variables in the earnings model. Based on the household level Population, Labor Force, and Migration (1979-80) survey data, the analysis yields the following important conclusions: (i) the data allowed a meaningful estimation of Mincerian earnings function for migrants and non-migrants; (ii) the level of schooling was one of the important determinants of the distribution of income both for migrants and nonmigrants--the four categorical variables of education were in general statistically significant with expected signs, implying that the hypothesis of a positive relationship between income and education was accepted; (iii) the rates of return to education improved systematically with higher levels of education, thus confirming the notion that education serves as a signalling device; (iv) the age-income profile was almost linear for migrants but showed concavity for nonmigrants; (v) the presence of sample-selection was observed for migrants; and (vi) even after controlling for the influence of personal characteristics, i.e., education and experience, the long-standing migrants earned relatively more at the destination than the more recent migrants.

Evaluation of groundwater and soil pollution in a landfill area using electrical resistivity imaging survey

Landfills are sources of groundwater and soil pollution due to the production of leachate and its migration through refuse. This study was conducted in order to determine the extent of groundwater and soil pollution within and around the landfill of Seri Petaling located in the State of Selangor, Malaysia. The condition of nearby surface water was also determined. An electrical resistivity imaging survey was used to investigate the leachate production within the landfill. Groundwater geochemistry was carried out and chemical analysis of water samples was conducted upstream and downstream of the landfill. Surface water was also analyzed in order to determine its quality. Soil chemical analysis was performed on soil samples taken from different locations within and around the landfill in the vadose zone (unsaturated zone) and below the water table (in the soil saturated zone). The resistivity image along line L-L1 indicated the presence of large zones of decomposed waste bodies saturated with highly conducting leachate. Analysis of trace elements indicated their presence in very low concentrations and did not reflect any sign of heavy metal pollution of ground and surface water or of soil. Major ions represented by Na, K, and Cl were found in anomalous concentrations in the groundwater of the downstream bore hole, where they are 99.1%, 99.2%, and 99.4%, respectively, higher compared to the upstream bore hole. Electrical conductivity (EC) was also found in anomalous concentration downstream. Ca and Mg ions represent the water hardness (which is comparatively high downstream). There is a general trend of pollution towards the downstream area. Sulfates (SO4) and nitrates (NO3) are found in the area in low concentrations, even below the WHO standards for drinking water, but are significantly higher in the surface water compared to the groundwater. Phosphate (PO4) and nitrite (NO2), although present in low levels, are significantly higher at the downstream. There is no significant difference in the amount of fluoride (F) in the different locations. In the soil vadose zone, heavy metals were found to be in their typical normal ranges and within the background concentrations. Soil exchangeable bases were significantly higher in the soil saturated zone compared to the vadose zone, and no significant difference was obtained in the levels of inorganic pollutants. With the exception of Cd, the concentration ranges of all trace elements (Cu, Zn, Cr, Pb, and Ni) of Seri Petaling landfill soils were below the upper limits of baseline concentrations published from different sources.

MALARIA-INDUCED APOPTOSIS IN MOSQUITO OVARIES

Many insects are able to adjust their egg production according to physiological conditions such as nutrient supply and mating success. One way in which this is achieved is by resorption of some, or all, of the ovarian follicles at some stage during oogenesis. We have shown that the mosquito Anopheles stephensi responds in this manner when ookinetes of the malaria parasite Plasmodium yoelii nigeriensis first begin to invade the midgut. Little is known about the initiation and regulation of follicle resorption in any insect. Here, we demonstrate that there is a significant positive correlation between follicle resorption and the presence of follicular epithelial cells that are undergoing apoptosis. The parasite causes significantly more follicles to contain apoptotic cells from 16 h post-infection onwards. Injection of a caspase inhibitor immediately after feeding on an infective blood meal prevents parasite-induced resorption of follicles and thus demonstrates that apoptosis precedes resorption. Ultrastructural studies show that patches of follicular epithelial cells contain condensed nuclear chromatin, a characteristic of apoptosis, and that no patency develops in these cells. Our work suggests that apoptosis plays a role in malaria-initiated inhibition of mosquito oogenesis and that caspase is central to this process. Follicle resorption is one of the main factors contributing to malaria-induced fecundity reduction in mosquitoes.

Effects of malaria infection on vitellogenesis in Anopheles gambiae during two gonotrophic cycles

We report changes in the abundance of vitellogenin (Vg) mRNA, and concentration of haemolymph Vg and ovarian vitellin (Vn) in Anopheles gambiae following infection with Plasmodium yoelii nigeriensis. A parasite-induced reduction in Vg mRNA abundance was first detected 24 h after feeding on an infective blood meal, when ookinetes were invading the midgut. During a second gonotrophic cycle post-infection, developing oocysts reduced Vg mRNA abundance by up to 33% and the effect was detected from 2 h post blood meal. Concentrations of Vg were initially reduced by infection during the second cycle, as predicted from Vg mRNA measurements. However, after 24 h, excess Vg had accumulated in the haemolymph. This accumulation may be due to impaired uptake, since ovarian vitellin accumulation was significantly decreased by infection during both gonotrophic cycles.

Attitudes towards euthanasia and assisted suicide among Sudanese doctors

An anonymous questionnaire was used to survey the attitudes of 382 doctors towards euthanasia and assisted suicide at Khartoum's two main hospitals. Of the 382, 248 responded (65% response rate). The mean age was 38 +/- 13.5 years; male:female ratio was 130:118; 66% were house staff, 34% specialists; 92% Muslim, 8% Christian. The vast majority (85%) strongly opposed the practices, while 15% thought they should be performed only in certain situations, subject to strict safeguards. Reasons given for opposition included religious beliefs, inconsistency with the doctor's role, presence of subtle pressures on patients, and potential for misuse among the physically and intellectually handicapped.

Effect of femoral component designs on the contact and tracking characteristics of the unresurfaced patella in total knee arthroplasty

OBJECTIVES

To determine the effect of 5 different femoral components used in total knee arthroplasty (TKA) on the contact area and tracking characteristics of the nonresurfaced patella and to identify any design features that might adversely affect these characteristics.

DESIGN

An in-vitro study.

SETTING

The biomechanics laboratory, Department of Mechanical Engineering, McGill University, Montreal.

SPECIMENS

Six fresh-frozen cadaveric knee-joint specimens.

INTERVENTIONS

An unconstrained quadriceps simulator was used to apply the conditions of static lifting to the specimens first in their normal state and then sequentially implanted with femoral and tibial components of various designs (Miller/Galante II, Anatomic Modular Knee [AMK] System, Whiteside Ortholoc Modular, press-fit condylar and Insall-Burstein II).

OUTCOME MEASURES

Patellar 3-dimensional tracking characteristics, determined by using a 6 degrees-of-freedom electromechanical goniometer attached directly to the patella, and patellar contact pressure measurements, obtained using low-range Fuji Prescale film.

RESULTS

Articulation of the normal patella on a prosthetic femoral component resulted in alterations in the normal patellofemoral contact and tracking characteristics. The exact departure depended on the design of the prosthetic trochlea. Although all of the selected prostheses demonstrated satisfactory contact characteristics near extension, marked alterations occurred at higher flexion angles. With 90 degrees or more of flexion, there was incompatibility between the geometries of the prosthetic notch of 2 femoral designs (AMK and PFC) and the normal knee.

CONCLUSION

The design of the prosthetic femoral component must be taken into account when determining whether or not to resurface the patella at the time of TKA.

Sagittal profile of the femoral condyles and its application to femorotibial contact analysis

Measurements of the sagittal profiles of the articular surfaces of 24 femoral condyles were performed using a laser range finder. An algebraic algorithm was developed to reconstruct the measured sagittal profiles with simple geometry. In particular, it has been shown that a two-circular-arc model provides a very accurate reconstruction of the actual profiles in the femorotibial contact region. The average sagittal profile was used for a femorotibial contact analysis of TKA implants. The contact analysis was performed by using a rigid-body-spring model extended to the case of nonlinear force-deformation behavior of the tibial polyethylene component.

Thyroid functional status in leprosy patients in Sudan

We studied 45 adult patients with untreated lepromatous leprosy and borderline leprosy, presenting at clinics in Khartoum and Omdurman, to assess clinical and biochemical effects of the disease on thyroid function. A matching control group of 30 subjects, without symptoms or signs of thyroid disease, were included for comparison. Thyroxine, triiodothyronine and thyrotrophin levels were within normal range. Mean serum thyroxine was low in both groups (significant in lepromatous leprosy patients only). Mean serum triiodothyronine was high in both groups (significant in neither group). Mean thyrotrophin was significantly higher in both groups compared with controls.

Diabetic autonomic neuropathy

OBJECTIVE

The diabetic autonomic neuropathy is a poorly studied subject in our medical literature. This study is aimed at investigating the presence of diabetic autonomic neuropathy in a group of Sudanese diabetic patients and its relationship to factors like glycemic control, duration of diabetes and presence of peripheral neuropathy.

METHODS

During one year we examined 120 diabetic patients and an age-matched control group of 42 by applying a battery of 5 cardiovascular autonomic tests, beside a full history and clinical examination. The patients were also tested for glycemic control and presence of peripheral neuropathy.

RESULTS

Diabetic autonomic neuropathy was diagnosed in 48 patients (40%) of a mean age of 48.411 +/- 12.50 years, type 1/2 diabetes was 10/38, mean duration of diabetes 16.2 +/- 7.3 years, 41 with poor glycemic control (81%) and peripheral neuropathy was present in 32 patients (66%). We found a significant association between diabetic autonomic neuropathy and prolonged duration of diabetes (P<0.001), poor glycemic control (0.01>P>0.001) and presence of peripheral neuropathy (0.02>P>0.01).

CONCLUSION

Diabetic autonomic neuropathy (both asymptomatic and symptomatic) is a common problem among our diabetic patients. It is significantly associated with prolonged duration, poor control of diabetes and presence of peripheral neuropathy. We need to augment the awareness of diabetes care providers to the occurrence, and peculiar features and tests of this syndrome.

Correlation of patellar tracking pattern with trochlear and retropatellar surface topographies

The study was aimed to test the hypothesis that in the knee extension range 100 to 30 deg, the patellar "out-of-plane" tracking pattern is controlled by the passive restraint provided by the topographic interaction of the patellofemoral contacting surfaces. The out-of-plane tracking pattern, i.e., the pattern of patellar displacements not in the plane of knee extension/flexion, consists of translation in the medial-lateral direction, and rotations about the anterior-posterior axis (spin) and the proximal-distal axis (tilt). Using 15 fresh-frozen knees subjected to extensor moment magnitudes comparable to those in the "static-lifting" activity (foot-ground reaction = 334 N), the patellar displacements were measured using a calibrated six-degree-of-freedom electromechanical goniometer. The topographies of the trochlear and retropatellar surfaces were then measured using a calibrated traveling dial-gage arrangement and the same coordinate system used for the displacement measurements. Three indices were defined to quantify particular natural features of the three-dimensional topographies that are expected to control the patellar displacements. Correlation of the indices with their corresponding displacements showed that topographic interaction was significant in the control of all three displacements. However, for patellar spin, unlike for the other two displacements, the direction of the active quadriceps tension vector was also a significant controlling factor. Patellar medial-lateral translation was found to be controlled dominantly by the trochlear topography, while retropatellar topography also had a significant role in the control of the other two displacements.

Diabetic autonomic neuropathy

OBJECTIVE

The diabetic autonomic neuropathy is a poorly studied subject in our medical literature. This study is aimed at investigating the presence of diabetic autonomic neuropathy in a group of Sudanese diabetic patients and its relationship to factors like glycemic control, duration of diabetes and presence of peripheral neuropathy.

METHODS

During one year we examined 120 diabetic patients and an age-matched control group of 42 by applying a battery of 5 cardiovascular autonomic tests, beside a full history and clinical examination. The patients were also tested for glycemic control and presence of peripheral neuropathy.

RESULTS

Diabetic autonomic neuropathy was diagnosed in 48 patients (40%) of a mean age of 48.411 + 12.50 years, type 1/2 diabetes was 10/38, mean duration of diabetes 16.2 + 7.3 years, 41 with poor glycemic control (81%) and peripheral neuropathy was present in 32 patients (66%). We found a significant association between diabetic autonomic neuropathy and prolonged duration of diabetes (P<0.001), poor glycemic control (0.01>P>0.001) and presence of peripheral neuropathy (0.02>P>0.01).

CONCLUSION

Diabetic autonomic neuropathy (both asymptomatic and symptomatic) is a common problem among our diabetic patients. It is significantly associated with prolonged duration, poor control of diabetes and presence of peripheral neuropathy. We need to augment the awareness of diabetes care providers to the occurrence, and peculiar features and tests of this syndrome.

Post carotid endarterectomy seizure

Post carotid endarterectomy seizure is a known clinical presentation in patients who suffer from hyperperfusion syndrome. This case focuses on the importance of identification of high risk patients for developing this syndrome and delaying their discharge from the hospital after successful carotid endarterectomy.

Post carotid endarterectomy seizure

Post carotid endarterectomy seizure is a known clinical presentation in patients who suffer from hyperperfusion syndrome. This case focuses on the importance of identification of high risk patients for developing this syndrome and delaying their discharge from the hospital after successful carotid endarterectomy.

Gastroparesis diabeticorum: A clinical study in Sudanese patients

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