Erector spinae plane block for perioperative analgesia in an adolescent patient undergoing major thoracic surgery with multiple rib resection: A case report

Pain following thoracotomy incisions, particularly involving multiple rib resections, can be devastating. We report our experience using erector spinae plane block with catheter placement for perioperative pain management in a 16 year old patient with Ewing sarcoma. The patient required major thoracic surgery involving resection of the 7th, 8th, 9th and 10th ribs and part of the diaphragm to remove the tumour, followed by mesh reconstruction. Ultrasound guided erector spinae plane block is a simple technique that can provide excellent static and dynamic pain control following major thoracic surgery in adolescents.

Trends in prescribing and outcomes in obese versus non-obese patients receiving rivaroxaban therapy: an observational study using real-world data

PURPOSE

To investigate real-world prescribing trends and clinical outcomes based on body mass index (BMI) categorization in patients who received rivaroxaban therapy.

METHODS

This was a retrospective cohort study involving all patients who received rivaroxaban therapy across all Hamad Medical Corporation (HMC) hospitals from 2015 to 2020.

RESULTS

The number of patients initiated on rivaroxaban therapy significantly increased from 152 (3.3%) in 2015 to 1342 (28.9%) in 2020 (p <0.001). Within BMI categories, a similar increasing trend was observed in underweight, normal, and overweight patients, while from 2018 to 2020, there was a decreasing trend in rivaroxaban prescribing in all obese classes. The prevalence rate of all-cause mortality differed significantly between the BMI groups, with the highest mortality being among morbidly obese patients (BMI ≥ 40 kg/m2) (p< 0.001). On the other hand, no significant differences were found between the BMI groups in terms of bleeding, pulmonary embolism, deep vein thrombosis and stroke incidences. Multivariate logistic regression analyses showed that the likelihood of all-cause mortality was significantly higher in overweight and all categories of obese patients compared to underweight patients: overweight (OR: 5.3, 95% CI: 2.3-11.9, p< 0.001); obese class 1 (OR: 5.4, 95% CI: 2.3 - 12.2, p< 0.001); obese class 2 (OR: 6.5, 95% CI: 2.7 - 15.6, p< 0.001); and obese class 3 (OR: 3.7, 95% CI: 1.6 - 8.7, p = 0.003).

CONCLUSIONS

Rivaroxaban prescribing has significantly increased over the years across general population, with a noticeable decline in obese population during the last few years (from 2018 onwards). Furthermore, an appreciable association was evident between all-cause mortality and BMI of these patients.

Multidisciplinary biomarkers aggrieve morbidity in schistosomiasis

BACKGROUND

Biomarkers by definition are measurable molecules that mark the evidence of certain pathological processes. Collaboration of various biomarkers influences morbidity of schsitosomiasis in Egypt.

OBJECTIVES

To identify the biomarkers: CRP, IgE, hemoglobin, ferritin, vitamin D, and platelets in terms of relationship with active and chronic schistosomiasis; demographic data, and their interinfluence.

STUDY DESIGN

A cross-sectional study.

METHODS

Parasitological analysis of stool and urine samples, Indirect Hemagglutination Test, Enzyme linked Immunoassay, Hematology Analyzer, and Statistical Package SPSS (Statistical Package for the Social Sciences) version 25.

RESULTS

Out of 400 participants, 25% suffered of schistosomiasis: active S. mansoni infections in 7 cases (1.75%), S. haematobium infections in 6 cases (1.5%), and chronic schistosomiasis infections in 20 cases (5%). Creactive protein (CRP) likewise IgE levels were higher in active S. mansoni and S. haematobium infections when compared with chronic schistosomiasis. IgE levels appeared to affect infection intensity in S. haematobium. Inversely, hemoglobin (Hb) values were low in active schistosomiasis and upgraded in chronic infection (*p<0.05). Ferritin levels varied in active Schistosoma infection and normalized during chronicity. Vitamin D was reduced in active and chronic schistosomiais. Platelet counts were within normal ranges throughout the study groups. Distribution of ferritin, vit D, and platelets was statistically insignificant among Schistosoma infected population. Age affected only hemoglobin, CRP, and IgE biomarkers. CRP and IgE were in direct relationship together and inversely proportional with hemoglobin (*P <0.05).

CONCLUSION

Anemia increased proportionally with biomarkers of inflammatory stress (CRP and IgE) in early infections. Meanwhile, Hb and ferritin (iron stores) improved during chronicity. Hypovitaminosis-D associated the entire course of schistosomiasis while platelet counts were not affected.

Effect of quinine therapy on plasma glucose and plasma insulin levels in pregnant women infected with Plasmodium falciparum malaria in Gezira state

To determine if quinine has a metabolic effect during treatment of severe or complicated malaria, we studied its effects on plasma glucose and plasma insulin levels in 150 pregnant women with malaria referred to Madani maternity teaching hospital, Gezira state and 50 healthy pregnant controls. Levels were determined at baseline (day 0) before the start of quinine treatment, after 2 days of treatment (2 hours after the 4th dose) and after 7 days of treatment (day 8). There was a statistically significant increase in plasma insulin concentrations during the quinine infusion and fall in plasma glucose concentration (P < 0.001). Quinine administered at the recommended dose and rate can disrupt plasma glucose homeostasis although it is still the drug of choice for severe and complicated malaria in Sudan.

Assessment of essential and toxic elements in some kinds of vegetables

Vegetables provide the human body with the essential bioavailable trace elements, and a constant supply of these various elements is necessary and highly recommended for daily life. Minor elements such as Ca, Fe, K, Mg, and Na as well as trace elements such as Cd, Co, Cu, Mn, Ni, Pb, and Zn were determined using an atomic absorption spectrophotometer in 12 different species of vegetables from Saudi Arabia (the Al-Taif district). These vegetables were cucumber, vegetable marrow, tomato, potato, green pepper, eggplant, carrots, parsley, lettuce, spinach, salq, onion, leek, watercress, and cabbage. The results reveal that the different element concentrations of each vegetable depend upon the selective uptake of the elements by the plant. Salq and watercress exhibited higher element concentrations than the other vegetables. Cluster analysis, principle component analysis, and transfer factor analysis of elements from soil to plant were applied to the elements database and produced good interpretations of the data. The element concentrations of these vegetables were within safety baseline levels for human consumption.

Acute pancreatitis in Saudi patients

BACKGROUND

The epidemiology of acute pancreatitis in Saudi Arabia is greatly different from that in Western Countries.

AIM

To evaluate and compare the risk factors and clinical features of acute pancreatitis.

PATIENTS AND METHODS

The course of acute pancreatitis was retrospectively analyzed in 218 patients who had their first attack and were admitted at Riyadh Armed Forces Hospital during the period 1.01.85-31.05.97.

RESULTS

From these 218, 130 patients were in the age group of 20-55 yrs. (74+, 56>), 76 were > 55 yrs. Of age (42 +, 34>) and only 12 were < 20 yrs. (6 Females, 6 Males). The precipitating cause was biliary disease in 147, post-operative in ten, hyperlipidemia in seven, post-ERCP in five, infection in four and alcohol in four. Four had rare causes and 37 no obvious cause. Severe pancreatitis diagnosed in 70 patients, 51 of them were > 55 yrs. of age and 45 were precipitated by biliary disease. Twenty six developed complications (21 were > 55 yrs. old) and four deaths. Twenty two patients of these who had severe form had diabetes mellitus, 37 had fever at presentation and 56 had leukocytosis.

CONCLUSIONS

The commonest etiology of acute pancreatitis was biliary in 147 patients (67.5%) followed by postoperative pancreatitis in 10 patients (4.6%). Alcohol as etiological factor was rare (1.8%). The epidemiology and the risk factors differed markedly in Saudi Arabia, where alcohol is prohibited.

Hemophagocytic syndrome

This case report is about an elderly man who presented with a long-standing history of high-grade fever and weight loss. He initially had only hepatosplenomegaly, but then developed jaundice. He also had pancytopenia and raised liver enzymes. His septic screen was negative, but he had a positive Monospot test and immunoglobulin G for Epstein-Barr virus. The liver biopsy showed sinusoidal phagocytosis and the subsequent bone marrow aspiration and biopsy showed significant hemophagocytosis, hence Hemophagocytic syndrome was diagnosed. The fever was refractory to antibiotic and anti-tuberculosis therapy, but it responded only partially to steroids. Full response was only noticed following anti-viral treatment in the form of intravenous Ganciclovir. The patient's general condition, liver enzymes, bilirubin, hematological parameters and even the weight returned back to their normal range 2 weeks after Ganciclovir therapy. Cessation of this drug resulted in relapse of his symptoms and oral antivirals did not help. Splenectomy, steroid pulse therapy and immunosuppressive treatment were only partially helpful. Reintroduction of Ganciclovir did help for a short period. We conclude that our patient had virus-associated hemophagocytic syndrome most likely related to Epstein-Barr virus infection, which was then confirmed by the splenic biopsy, and that Ganciclovir can be of great help in eradicating the virus and treating the disease, provided that it is given for a long enough period.

Gastrointestinal parasites presentations and histological diagnosis from endoscopic biopsies and surgical specimens

OBJECTIVE

To diagnose parasitic ova or worms during endoscopy, surgery or by histology from endoscopic or surgical specimen in our patients.

METHODS

The diagnosis of parasitic disease in our patients was made by histological examinations from biopsies obtained either during an upper gastrointestinal or lower gastrointestinal endoscopy or from surgical specimens.

RESULTS

Parasites were seen in endoscopic biopsies from upper gastrointestinal tract in 21 patients. Schistosoma ova was seen in biopsies from stomach or duodenum (12 patients). Small intestine biopsies showed Giardiasis (8 patients) and strongyloides (1 patient). Colonic biopsies showed schistosoma ova by paraffin section or by squash technique in 216 patients. Surgical specimens from 12 patients, who presented with acute abdomen and had surgery, due to appendicitis in 8 patients, in whom specimens showed (Schistosoma in 5 patients, amoebiasis in 2 patients and Trichuria in 1 patient). Four other patients presented with acute abdomen, where ischemic bowel necrosis or mesenteric vein thrombosis was found during surgery, specimens showed schistosoma ova.

CONCLUSION

The diagnosis of gastrointestinal parasites is not only made by stool but the diagnosis can be made by histology from endoscopic biopsies or surgical specimens.

The effect of intravenous verapamil on cerebral hemodynamics in a migraine patient with hemiplegia

OBJECTIVE

To describe the use of intravenous verapamil in a migraine patient with hemiplegia to reverse the symptomatology and hemodynamics of the middle cerebral artery as determined by transcranial Doppler.

CASE SUMMARY

A 31-year-old white woman was admitted with an acute exacerbation of migraine with hemiplegia. A transcranial Doppler showed an increased flow velocity through the middle cerebral artery consistent with a migrainous process. The patient was treated with verapamil 5 mg iv and the hemiplegia gradually resolved. A transcranial Doppler indicated that the flow velocity through the middle cerebral artery was decreased after verapamil administration, indicating reversal of the vasospasm.

DISCUSSION

Transcranial Doppler has not been previously used to determine the effect of intravenous verapamil on the migrainous process. Intravenous verapamil reversed the altered hemodynamics of the middle cerebral artery as determined by transcranial Doppler. This finding correlated with the gradual resolution of hemiplegia. Whether both subjective and objective findings in this patient can be attributed to the reversal of the cerebral artery hemodynamics is not known.

CONCLUSIONS

Intravenous verapamil appears to reverse the vasospasm that may be associated with a migrainous process. Whether this effect is solely responsible for clinical improvement is not known. Verapamil may be a consideration for the treatment of intractable migraine, especially when there is evidence of spasm of the major cerebral arteries.

Upper gastrointestinal endoscopy findings at Riyadh Armed Forces Hospital

Full text is available as a scanned copy of the original print version.

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

BACKGROUND/AIMS

Barium studies, endoscopies and endoscopic ultrasound are the usual methods for gastrointestinal tract examinations. Endoscopic ultrasound was the only accurate equipment used for imaging the various layers of the stomach wall distinctly.

METHODOLOGY

Twenty patients undergoing renal ultrasound were given 600 cc of water to drink. Gastric wall layers were demonstrated in all patients, namely mucosa; submucosa, musculosa and serosa. The echogenic layer of the water-mucosa interface was not included in gastric wall thickness measurement.

RESULTS

The normal wall measurement varied from 3-5 mm. This is lower than in previous reports.

CONCLUSIONS

Water enhanced "non-paralytic" transcutaneous ultrasound is a simple, safe, non-invasive, and accurate test for visualizing gastric wall layers.

Combined albendazole and praziquantel versus albendazole alone in the treatment of hydatid disease

BACKGROUND/AIMS

This study was conducted to evaluate the effect of different regimens of medical treatment in hydatid disease at the Armed Forces Hospital, Riyadh.

METHODOLOGY

Between April 1985 and August 1990 albendazole was used alone in the treatment of 22 patients with hydatid disease, mainly of the liver. Since September 1990, we have used a combination treatment of albendazole and praziquantel in 19 patients.

RESULTS

For those patients treated only with albendazole, 8 patients (36.4%) showed a complete disappearance of the cyst, in 4 of which the treatment period ranged between 6 months to 2 years. The other 4 patients had ruptured liver cyst into biliary tree and had endoscopic treatment with complete recovery over a short period. For those patients treated with albendazole and praziquantel the following results were found. During a follow-up period of 2 months to 3 years and a treatment period of only 2-6 months there was complete disappearance of the hydatid cyst in 9 patients (47.4%) and over 50% reduction of the hydatid cyst in 5 patients (36.84%).

CONCLUSION

Combination treatment with albendazole and praziquantel for hydatid disease is more effective than albendazole alone.

Transcutaneous ultrasound of gastric pathology

BACKGROUND/AIMS

Examination of the stomach during transcutaneous upper gastrointestinal ultrasound is often ignored. Two thousand seven hundred and eighty patients were referred for endoscopy over the period of August 1994 until August 1995. Nearly half of those patients underwent transcutaneous ultrasound. We report on the ultrasonographic demonstration of gastric pathology in 18 patients.

METHODOLOGY

The stomach was examined in a collapsed state after an overnight fast. No paralytic agents or water distention were used.

RESULTS

Seven patients had gastric tumors. Six patients had diffuse gastric wall thickening. Large varices were seen in two patients. A patient with multiple ulcers showed irregular walls. Two patients had retained gastric contents.

CONCLUSIONS

Results of the ultrasound matched well with endoscopic findings. We recommend that in all abdominal ultrasounds, the stomach should be examined carefully and evaluated systematically.

Parasitic disease of the liver and biliary tree

Several parasites infest liver or biliary tree, either during their maturation stages or as adult worms. Bile iry tree parasites may cause pancreatitis, cholecystitis, biliary tree obstruction, recurrent cholangitis, biliary tree strictures and some may lead to cholangiocarcinoma. This review discusses the hepatobiliary parasites, and shows our experience in diagnosis and management of these parasites. Ultrasonography of the liver is diagnostic in schistosomiasis, hydatid cysts, amebic liver abscess, ascariasis and other biliary tree parasites showing bile duct dilatation. Percutaneous aspiration under ultrasonography guidance of hydatid liver cysts or amebic abscess are effective measures in management. Endoscopic retrograde cholangiopancreatography (ERCP) is safe and effective in diagnosis and management of biliary tree parasites.

Case report: radiological and endoscopic management of bile leak following laparoscopic cholecystectomy

Due to the ever increasing popularity of laparoscopic cholecystectomy (LC), many radiologists and gastroenterologists have noticed an epidemic of bile duct injuries due to subsequent complications. We report on five cases of post-LC minor bile duct injuries and document our preliminary experience in their management. Although the majority of minor bile leaks resolve spontaneously, particularly if a surgical drain has been left in situ, percutaneous drainage (PD) can be used alone or in addition to endoscopic management to treat symptomatic bile leaks and biloma formation. Bile leaks without associated abdominal collections should be first identified by endoscopic cholangiography followed by sphincterotomy and/or stenting. Surgery should only be reserved for cases of major bile duct injury if PD and endoscopic management have failed initially.

Non surgical management of pancreatic pseudocyst: two case reports and review of the literature

We report two patients who had non-surgical management of Pancreatic Pseudocyst. The first patient presented with acute pancreatitis and intestinal obstruction, had laparatomy and found to have hemorrhagic pancreatitis and impacted gallstone in terminal item which was removed. Two weeks after laparatomy U/S and CT showed a dilated CBD and two Pancreatic Pseudocysts. ERCP showed dilated CBD. Endoscopic sphincterotomy and stent insertion in CBD and Cystoduodenostomy was done. A percutaneous drainage was done for the pseudocyst involving the body of the pancreas. The second patient presented abdominal pain and clinically had an abdominal mass which was shown by CT as Pseudopancreatic cyst. This was drained percutaneously and given treatment with somatostatin with good outcome.

Protean manifestation of gastrointestinal tuberculosis: report on 130 patients

Over the past 8 years, 820 patients with tuberculosis were seen at the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia. A total of 292 of these patients (35.6%) had pulmonary tuberculosis, and 130 patients (15.8%) had alimentary tract tuberculosis, making this the second commonest site of involvement. In these 130 patients, the disease was located in the upper gastrointestinal tract in 11 patients (8.5%), small bowel 44 patients (33.8%), large bowel 29 patients (22.3%), peritoneum 40 patients (30.7%), and liver 19 patients (14.6%). The diagnosis in most patients was made by specimens from endoscopy or laparoscopy, or liver or surgical specimens. Gastrointestinal tuberculosis is not uncommon in developing countries, and its incidence is increasing in developed countries due to immigration and in patients with AIDS or those receiving immunosuppressive therapy. It can mimic any diseases affecting the gastrointestinal tract and may present with very different symptoms, so a high index of suspicion is required.

Alpha interferon in treatment of chronic hepatitis C viral infection (CHCV): Pilot study of 18 patients

Eighteen patients with chronic hepatitis C virus infection (CHCV) were treated with three million units of interferon (IFN) three times a week for a minimum of six months. Four (22.2%) had completely responded, two (11.1%) had partial response and the rest (eight or 44.4%) did not show any evidence of response. After stopping treatment, patients who had a complete or partial response developed a relapse during the follow-up period. Few reversible adverse effects of treatment were reported in more than half of the patients. So, we conclude that three million units of IFN three times weekly is not recommended for treating patients with CHCV. Perhaps a larger dose of five to six million units should be tried and for a longer duration.

Helicobacter pylori: Prevalence in 352 consecutive patients with dyspepsia

At the Riyadh Armed Forces Hospital (RAFH), 352 patients had gastroscopy and from each, antral gastric biopsies were taken for identification of Helicobacter pylori, by urease test and histopathology. In 217 (61.64%) of these 352 patients, the histology specimens showed Helicobacter pylori in 73.68% of patients with duodenal ulcer, 70% of patients with gastric ulcers and gastric erosions, 61% of patients with duodenitis and 52% of patients with gastritis. The urease test was positive at six hours in 164 (49.59%) of these 352 patients. The urease test was positive in 60% of each group of patients with endoscopic findings of gastric erosions, gastric ulcers and duodenal erosions.

Helicobacter pylori: incidence and comparison of three diagnostic methods in 196 Saudi patients with dyspepsia

One hundred and ninety-six symptomatic Saudi patients with dyspepsia underwent gastroscopy, and multiple biopsies were taken from the antrum of the stomach for identification of Helicobacter pylori. Three methods were studied for diagnosis of Helicobacter pylori, including urease test, culture and histopathology. The commonest gastroscopic findings were gastritis in 82 patients (41.84%) and duodenal ulcer in 40 patients (20.41%). Among the 196 patients, Helicobacter pylori was identified by histopathology in 145 patients (73.98%), the urease test was positive in 126 patients (64.29%), and a positive culture was obtained in 102 patients (52.04%). These results show that there is a high incidence of Helicobacter infection among Saudi patients with peptic ulcer disease or non-ulcer dyspepsia. Helicobacter pylori identification was more successful by histopathology than by the urease test or culture.

Frequency of gastroesophageal reflux in patients with liver cirrhosis

Twenty-five adult patients with liver cirrhosis, and another 30 patients with no liver disease but referred with symptoms suggestive of gastroesophageal reflux disease were selected at random. Twenty-four hour ambulatory intra-esophageal pH measurement and upper gastrointestinal endoscopy were carried out on all patients recruited. Applying the former test, 16 (64%) of the patients with liver cirrhosis have gastroesophageal reflux disease. This figure is comparable with the 70% (21/30) rate recorded in the group of dyspeptic patients clinically thought to have the disorder. A positive endoscopic diagnosis was much lower at 12% and 23%, respectively. No significant differences were observed among liver disease patients when they were subdivided in accordance with the etiology of liver cirrhosis and the grade of esophageal varices. We conclude that gastroesophageal reflux disease occurs at a high frequency (64%) in patients with liver cirrhosis and portal hypertension, irrespective of the etiology of cirrhosis and the grade of esophageal varices. It is therefore considered to be the main cause of esophagitis in these patients, and that it might play a role in initiating a variceal bleeding episode. The latter hypothesis needs further evaluation.

The need for three stool specimens in routine laboratory examinations for intestinal parasites

This study was designed to test whether three sequential stool specimens are necessary for reliable detection of intestinal parasites in routine laboratory examinations. There were 175 patients in whom a single species of intestinal parasite or ova was identified on at least one occasion when three stool specimens were examined over a period of 14 days from the first recorded specimen. Examination of a first stool specimen detected parasites and/or ova in 102/175 patients (58.3%); examination of a second specimen identified an additional 36 positive patients (20.6%) and examination of a third specimen yielded a final 37 previously undetected patients (21.1%). These findings indicate that at least three stool specimens should be examined to confirm the presence of intestinal parasites. Even with such practice, it is not possible to guarantee that there is no infestation, but examination of fewer specimens would run a definite risk of false negative results.

Alcohol consumption as a risk factor for hepatocellular carcinoma in urban southern African blacks

Our purpose was to ascertain whether alcohol abuse is a risk factor for the development of hepatocellular carcinoma in urban southern Africa blacks and, if so, to relate alcohol consumption to other possible risk factors such as persistent hepatitis-B-virus infection, smoking, male sex, in this subpopulation. A prospective, hospital-based, case-control format involving 101 patients with hepatocellular carcinoma and 101 controls was used. The mean age of the patients was 53.7 +/- 1.85 years and the male:female ratio 3.2:1. An increased risk was found, but only in urban men over the age of 40 years who habitually drank more than 80 g of ethanol daily. The risk remained after adjusting for chronic hepatitis-B infection, smoking, and sex (odds ratio 4.4, 95% confidence interval 1.3 to 16.6; p = 0.003). Smoking proved not to be a risk factor, either alone or in concert with alcohol consumption. Hepatitis-B infection was confirmed as a major risk in younger men and in women, but in urban men over the age of 40 years alcohol abuse was a greater risk. Current hepatitis-B infection and alcohol abuse were additive risks.

Limitations of faecal chymotrypsin as a screening test for chronic pancreatitis

Faecal chymotrypsin was measured in patients with chronic pancreatitis and in healthy black urban and rural control subjects. In the patients, significantly lower values of faecal chymotrypsin were obtained (mean (SD) 2.4 1.79 U/g stool) whereas in urban control subjects, values were within the normal range (mean (SD) 13.2 (11.9)). In rural black control subjects, however, the faecal chymotrypsin value was significantly lower (mean (SD) 7.1 (5.1)) than in urban black control subjects. It is suggested that faecal pH may influence faecal chymotrypsin values. The mean faecal pH in rural black subjects (pH 6.14) was significantly lower than that in urban control subjects (pH 6.77) and in patients with chronic pancreatitis (pH 6.61). Moreover, mean faecal chymotrypsin is high (20.0 U/g stool) at a pH greater than 7. Between pH 6 and 7 the mean value drops to 8.6 U/g stool and below pH 6 mean faecal chymotrypsin is in the abnormal range (4.4 U/g stool). Hence, low values for faecal chymotrypsin may be due to lower faecal pH (less than 6) in healthy control subjects. For diagnostic purposes, the faecal pH value should be determined if a low faecal chymotrypsin value is obtained.

Mesenteric vein thrombosis, non-invasive diagnosis and follow-up (US + MRI), and non-invasive therapy by streptokinase and anticoagulants

We report on the case of a young lady on oral contraceptives for only 1 month who experienced severe central abdominal pain of a progressive nature. Mesenteric vein thrombosis was diagnosed by ultrasound and confirmed by magnetic resonance imaging. The patient was treated initially with streptokinase followed by heparin and warfarin with subjective improvement, and gradual disappearance of the thrombus was observed on ultrasound and magnetic resonance imaging. In this report we wish to emphasize the feasibility of the early diagnosis of mesenteric vein thrombosis by ultrasound and magnetic resonance imaging, and the effectiveness of early thrombolytic therapy without the need for surgical intervention.

Analgesics and gastric ulcers. A case-control study in an urbanised black population

The patterns of analgesic ingestion in urbanised black patients with gastric ulcer disease were assessed. A strong statistical association was found between the quantity ingested and the disease. There was no difference in the type of analgesic and smoking and alcohol habits between gastric ulcer patients and controls in this study.

Pathological effects of pellagra on the esophagus

This study determined the pathological effects of niacin/tryptophan deficiency on the esophagus. Nine patients with severe clinical pellagra and 31 age- and sex-matched controls were assessed. All pellagrins had an esophagitis varying from severe to mild. The esophagitis improved in five patients following six to seven days of vitamin therapy. The relationship between vitamin deficiencies and esophageal cancer is discussed.

The prolonged course of gastrointestinal tuberculosis

Review of biopsy specimens showed that a patient incorrectly diagnosed 7 years ago as having Crohn's disease actually had histologically proven gastrointestinal tuberculosis of 7 years' duration. It is significant that gastrointestinal tuberculosis and Crohn's disease can mimic each other not only in their clinical, radiologic, and histologic manifestations but also temporally. We discuss the interrelationship between AIDS, tuberculosis, and inflammatory bowel disease.

Results of sclerotherapy in 100 patients comparison of the outcome between schistosomiasis and hepatitis B

One hundred patients received sclerotherapy for acutely bleeding esophageal varices. Seventy per cent of these patients had chronic liver disease due to schistosomiasis or hepatitis B. The remaining 30% had chronic liver disease of other etiology, including alcohol in 2%. Our study shows a favorable outcome of sclerotherapy in the schistosomal group during a mean follow-up period of 39 months. Esophageal varices were completely sclerosed in 53.3% of schistosoma patients, in 37.5% of hepatitis B, and in 42.3% of other groups. The rebleeding rate was 11.1% in schistosomiasis, 43.8% in hepatitis B and 33.3% in other groups. The overall mortality rate was 4.4% in the schistosomal group, 50.0% in the hepatitis B, and 40% in other groups. Rebleeding from gastric varices occurred in 17 patients, 13 of whom died, including 11 who were operated on for bleeding gastric varices and died following surgery.

Pulsed Doppler and two-dimensional echocardiographic findings in coronary arteriovenous fistula complicated by bacterial endocarditis. A case report

Coronary arteriovenous fistula (CAVF) may occasionally be complicated by bacterial endocarditis. The actual anatomical site of infection has not been clearly defined. A 13-year-old boy with a CAVF and Streptococcus viridans bacteraemia is described. The origin of the fistulous tract and a vegetation in close proximity to the distal drainage site into the right ventricle was demonstrated by Doppler two-dimensional echocardiography.

The Katayama syndrome in Saudis

Five Saudi boys visited an endemic area of schistosomiasis and developed 'swimmers itch' after swimming for the first time in infected ponds. After 4-6 weeks, they were admitted to hospital with fever and other symptoms. They were diagnosed as exhibiting Katayama syndrome because of marked eosinophilia and because the faeces showed Schistosoma mansoni eggs. On admission, schistosomal serological tests showed evidence of exposure in three patients. Four patients were treated with praziquantel, and the fifth was given oxamniquine. Following 3-6 days (mean 4.8 days) of treatment, they became asymptomatic. The eosinophilia decreased, liver functions improved and were normal 3 months later. Evidence is presented that early treatment of Katayama syndrome with anti-schistosomal drugs will alter the course of the acute illness and will halt the progress of the disease.

Determination of trace elements of Egyptian cane sugar (Naga Hammady factories) by neutron activation, atomic absorption spectrophotometric and inductively coupled plasma-atomic emission spectrometric analyses

INAA, AAS and ICP-AES techniques are applied to the determination of trace amounts of Ag, Al, As, Au, Ba, Br, Ca, Cd, Ce, Cl, Co, Cr, Cs, Cu, Dy, Eu, Fe, Ga, Hf, K, La, Li, Lu, Mg, Mn, Na, Nb, Ni, Pb, Sb, Sc, Se, Sm, Sn, Sr, Ta, Th, Ti, U, V, W and Zn in the stalks of sugar cane plant after extracting juice, raw juice principal (mixed) juice, juice withdrawn from the successive stages of sugar industry, sirup, deposits from evaporators, molasse, A-? and B-sugar and in the soil samples (collected from the field supplying the factories by cane plants) taken from the immediate vicinity of the plant roots at surface, 30 and 60 cm depth. The results obtained are in a good agreement of the safety baselines of using juice as beverage, molasse derivatives (honey, sweets, ...) as diet for common people in the developed countries and in industry (methanol, ethanol, acetone & acetic acid, ...) and sugar sweeting for many purposes (in beverages, desserts, ...). Differences of trace elements concentrations in soil samples may be reasoned to geochemical and biogeochemical fractionation while those in juice may be due to the changes in the environmental conditions, chemical composition and botanic structures. Variations in trace element contents in the products formed during the successive stages of sugar industry may be a result of evaporation, filtration processes, chemical treatments or corrosion of vessels, containers or engines. Trace elements are very important where they are responsible for enzymatic and biochemical reactions, matabolism, health and diseases.