Fecal incontinence as the sole presentation of focal epilepsy; a case report

Focal epilepsy is a surge in brain activity arising from a localised area of the cerebral cortex; it can be sub-classified in different categories including motor, sensory, autonomic and cognitive subtypes. A clinical case report of a 11-year-old girl was diagnosed with frequent fecal incontinence four or more times daily for more than two months. An electroencephalogram (EEG) study suggested a prominent interictal spike and sharp wave discharge on the left hemisphere, mainly at the frontotemporal region without loss of consciousness or even speech disruption. This could be due to the normal EEG study of the dominant hemisphere. A magnetic resonance imaging study was done to exclude space-occupying lesions or focal lesions of the left hemisphere of the brain. An impression was made with abnormal EEG showing focal epileptiform activity as a final diagnosis. The patient was treated with Leviteracetam anti-epileptic drug 250 mg twice daily with significant clinical improvement at a 3-month follow-up.

Maternal and neonatal outcomes in adolescent pregnant women with prior one Cesarean section in Baghdad

Objective

Repeat adolescent pregnancy is a hot topic worldwide and imposes a challenge to the health system especially when accompanied with limited resources. We aimed to assess maternal and neonatal outcomes in adolescent pregnant women with prior one Cesarean section (CS).

Material and Methods

Singleton adolescent pregnant women with prior one CS scar were involved and divided into two groups based on the obstetrical decision of delivery and/ or mother`s wish, either trial of labor (TL) or elective CS (ECS). If TL was failed, an emergency CS was opted.

Results

Out of the total 109 involved women, TL and ECS groups were [(78(71.6%), and 31(28.4%)], respectively. Emergency CS was done for 57(52.3%) women from TL group due to failure of TL, leaving only 21(19.3%) women having successful TL who had statistically significant (non-recurrent) indications of the prior CS [12(57.1%)]. Malpresentation [24(77.4%)] was the major indication of ECS group, while fetal distress [29(50.9%)] was the main cause of failed TL. Total maternal morbidities in TL group were higher significantly in adjusted [1.5(1.1-4.2)] and nonadjusted odds ratios [2.4(1.6-5.6)]. Neonatal complications (like admission to neonatal intensive care unit) were higher in TL group without touching significance. However, perinatal asphyxia was significant in the adjusted odds ratio [1.9 (1.1-3.3)].

Conclusion

Maternal morbidities and perinatal asphyxia were significantly higher in TL group of adolescent women when compared with ECS group in Baghdad city, the capital of Iraq country.

Obstetric and neonatal complications in large for gestational age pregnancy with late gestational diabetes

Objective

Gestational diabetes (GDM) is increasing in prevalence with effects starting in-utero, leading to excessive fetal growth. It is the leading cause of many perinatal complications. The aim was to determine the rate of obstetric and neonatal complications in pregnant women with high fetal weight and a recent diagnosis of GDM during the third trimester, despite normal earlier glycemic control.

Material and Methods

Prospective cohort study over four years involving pregnant women regularly visiting a single center who had normal glycemic index at 24-28 gestational weeks and ultrasonography (US) suggested high fetal weight during the third trimester. Oral glucose tolerance test was given, dividing the sample into the late GDM (LGDM) and the non-LGDM group.

Results

Of 176 women, 24 (13.64%) had LGDM, and 152 (86.36%) had non-LGDM. After exclusions these groups' sizes were (n=21) in LGDM and (n=132) in non-LGDM. Hemoglobin A1c level was significantly higher in LGDM than non-LGDM (5.9% versus 5.1%). However, obstetric and neonatal complications were largely comparable (p≥0.05) but higher in LGDM than non-LGDM women. Exceptions to this were birth weight (3219 g versus 3326 g), large for gestational age at delivery (85.72% versus 88.64%), and gestational age at delivery (37.9 versus 38.2 weeks) in the LGDM vs. non-LGDM groups, respectively. There was a significantly higher cesarean section (CS) rate (76.19% versus 51.52%; p<0.05) in the LGDM group.

Conclusion

The rate of newly diagnosed LGDM in pregnant women with high fetal weight during the third trimester by US was 13.64%. They had comparable obstetric and neonatal complications with non-GDM women, except for the rate of CS that was significantly higher in LGDM women.

Differences in perinatal outcomes in teenage mothers with their first and third pregnancies and predictors of adverse neonatal events: A cross-sectional study

Background

Repeated teenage pregnancy is a major burden on the healthcare system worldwide.

Objective

We aimed to compare teenagers with their first and third pregnancies and to evaluate the likelihood of neonatal complications.

Materials and Methods

This cross-sectional study was performed on female teenagers (aged ≤ 19 yr) with singleton pregnancies. The subjects (n = 298) were screened over 12 months. Ninety-six women were excluded, based on the exclusion criteria. The remaining subjects (n = 202) were divided into two groups: teenagers with first pregnancy (n = 96) and teenagers with third pregnancy (n = 47). The subjects were observed throughout pregnancy and delivery. The final sample size of the first and third pregnancy groups was 96 and 47, respectively.

Results

There was a significant risk of preeclampsia in the first pregnancy group (p = 0.01). Low birth weight, five-min Apgar score < 7, and neonatal intensive care unit admission were the most significant neonatal outcomes in the first pregnancy group. In the third pregnancy group, significant predictors of neonatal complications included very young age in the first pregnancy ( ≤ 15 yr), an inter-pregnancy interval < 2 yr, current anemia, and history of obstetric and/or neonatal complications in previous pregnancies.

Conclusion

Based on the results, teenagers with their first pregnancy had comparable obstetric outcomes (except for preeclampsia) as teenagers with their third pregnancy, whereas neonatal complications occurred more frequently in the first pregnancy group. Overall, we can predict high-risk neonates in the third pregnancy, based on the abovementioned parameters.

Treatment options of Adolescent Gestational Diabetes: Effect on Outcome

Objectives:

Teenage pregnancy with gestational diabetes mellitus (GDM) offers a real challenge to the health system and needs a special care. We aimed to evaluate possible obstetrical and neonatal adverse events of different treatment protocols in adolescent GDM including lifestyle, metformin (MTF), and insulin.

Methods:

All teen pregnant women ≤ 19 years old visiting Baghdad Teaching Hospital throughout four years (from June 1, 2016 till May 31, 2020) diagnosed with GDM were included in this cohort study and followed-up closely throughout pregnancy and after delivery. Included adolescents were put on lifestyle alone during the first week of presentation. Adolescents who reached target glucose measurements were categorized into lifestyle group, while other adolescents were randomly allocated into MTF and insulin groups. Also, adolescent pregnant women without GDM were recruited as control group using computer randomization.

Results:

The GDM (110 cases) and control (121 individuals) groups had matched general features at recruitment except for diabetes family history. Also, GDM treatment groups had matched features. Glycemic readings (fasting and random) was significantly (p< 0.05) higher in insulin group having odds ratio (OR) of 1.41, and 1.57, respectively. In MTF group, significant protective OR was found in preeclampsia (OR=0.76, p< 0.05). MTF showed non-significant protective OR regarding prematurity and five minutes Apgar score>7 [(OR=0.83, p=0.24), and (OR=0.94, p=0.73), respectively], and significant protective association with large for gestational age and admission to neonatal intensive unit. Insulin had significantly higher prematurity, small for gestational age, and hypoglycemia [OR=1.89, 2.53, and 2.84, respectively].

Conclusion:

Metformin (MTF) showed less pregnancy and neonatal complications in adolescent GDM than insulin and lifestyle.

Iraqi Women with Preeclampsia: Maternal and Neonatal Outcomes

BACKGROUND: Preeclampsia (PE) is a possible etiology of obstetrical and neonatal complications which are increased in resource-limited settings and developing countries. AIM: We aimed to find out the prevalence of PE in Iraqi ladies and specific outcomes, including gestational weight gain (GWG), cesarean section (CS), preterm delivery (PD), and low birth weight (LBW). METHODS: All singleton pregnant women visiting our tertiary center for delivery were involved over 3 years. PE women were compared with non-PE ladies. Complete history and examination were done during pregnancy and after delivery by the attending obstetrician and neonatologist with full documentation in medical records. RESULTS: PE prevalence was 4.79%, and the affected women had significant (p < 0.05) higher age, body mass index, and GWG, but lower gestational age at delivery. The mean significant difference of GWG in PE and non-PE patients was 1.82 kg. PD and LBW had significant higher frequencies in PE. After considering several confounding factors, crude and adjusted odds ratio (OR) of PE with 95% confidence interval (95% CI) were significant in CS (crude OR = 2.25 and 95% CI = 1.42-2.87 while adjusted OR = 2.89 and 95% CI = 1.43–3.06) and PD (crude OR = 2.41 and 95% CI = 1.73–2.46 while adjusted OR = 3.96 and 95% CI = 2.65–6.37). On the other hand, only the crude model touched significance in LBW (crude OR = 3.67 and 95% CI = 2.51–4.99). CONCLUSIONS: Prevalence of PE in Iraqi pregnant females was higher than other neighboring developing countries. In PE ladies, maternal parameters, including GWG and operative delivery, and neonatal complications, including PD and LBW, were significantly higher than pregnant women without PE.

Tuberculosis versus COVID-19 Mortality: A New Evidence

BACKGROUND: Coronavirus current pandemic (COVID-19) is the striking subject worldwide hitting countries in an unexplained non-universal pattern. Bacillus Calmette–Guérin (BCG) vaccine was an adopted recent justification depending on its non-specific immune activation properties. Still the problem of post-vaccine short duration of protection needs to be solved. The same protective mechanism was identified in active or latent tuberculosis (TB). For each single patient of active TB, there are about nine cases of asymptomatic latent TB apparently normal individuals living within the community without restrictions carrying benefits of immune activation and involved in re-infection cycles in an excellent example of repeated immunity training sessions of the whole community. AIM: We aimed to asses the correlation between TB burden and COVID-19 mortality in all affected countries having different BCG vaccination policies. METHODS: Publicly available data were extracted for 191 countries including population size, TB estimations, national BCG vaccination policy, the World Health Organization regions and economic classification, and COVID-19 mortality and number of cases. The analysis was performed using Spearman’s correlation test. RESULTS: Significant large negative correlation (−0.539, p < 0.001) was found between TB prevalence and COVID-19 mortality rate worldwide. Medium negative significant correlations were found between TB cases and COVID-19 mortality in the high and lower middle-income countries, and those having current BCG vaccination programs (−0.395, p = 0.001, −0.365, p = 0.015, and −0.476, p < 0.001, respectively). CONCLUSION: Countries with high TB prevalence have higher chances of protection against COVID-19 mortality through the theory of widely distributed natural immune activation within community. Confounders should be assessed separately.

Green tea influence on iron overload in thalassemia intermedia patients: a randomized controlled trial

Background: Although iron chelation therapies have been available for many years for thalassemia intermedia patients, iron accumulation remains the major cause of death. Therefore, the need for additional chelation options is in demand. This randomized controlled study aimed to understand the effects of green tea on iron balance in thalassemia intermedia patients. Methods: Using a random selection method, 141 thalassemia intermedia patients were initially screened for inclusion in this trial; only 68 patients included after applying exclusion criteria. Two equal groups were generated (n=34/group): green tea (three cups/day after meals) + usual treatment (deferasirox iron chelator and on demand blood transfusion); and control (only usual treatment). The study lasted for a period of 12 months. Patients failing to comply to the trial methodology were excluded, leaving a final total of 29 patients in the green tea group and 28 patients in the control group. Liver iron concentration, and serum ferritin were assessed at baseline and 12 months, while hemoglobin levels were assessed monthly. Results: At baseline, both groups were matched regarding general demographics. At 12 months, the net drop of liver iron concentration in the green tea group (7.3 mg Fe/g dry weight) was significantly higher than the control group (4.6 mg Fe/g dry weight) (p<0.05). This was also seen with serum ferritin; net reduction in green tea and control groups were 1289 ng/ml and 871 ng/ml, respectively (p<0.05). Hemoglobin levels were slightly higher in the green tea group compared with the control group, but this was not significant. Conclusions: Regular green tea consumption had a significant capability to improve iron deposition in thalassemia intermedia patients who already undergo deferesirox iron chelation therapy. Trial registration: UMIN-CTR Clinical Trials Registry, UMIN000040841 (retrospectively registered June 21, 2020).

Maternal Anemia Prevalence and Subsequent Neonatal Complications in Iraq

BACKGROUND: Anemia during pregnancy is still a challenge throughout the world, and it may cause severe health consequences in the maternal and fetal sides. AIM: This study aims to find out the prevalence of maternal anemia and potential adverse outcomes in Iraq. METHODS: In Medical City Tertiary Center in Baghdad, singleton pregnant ladies came for delivery were involved over 6 months’ period. Based on hemoglobin (Hb) readings; they were divided into no anemia group (Hb>11 g/l) and anemia group which were further subdivided into mild, moderate, and severe (Hb =10–10.9, =7.1–9.9, and <7 g/l, respectively). Full history and examination were performed by attending obstetrician and pediatrician for the upcoming babies. RESULTS: Maternal anemia prevalence was 84.84% out of 4473 cases. No anemia group was 15.16%, mild 40.73%, and moderate 40.73%, while severe anemia group (24.93%). Maternal occupation, educational status, and Hb levels were significantly associated with anemia (p < 0.001), unlike parity, body mass index, and delivery mode. Neonatal preterm delivery, birth weight and length, small for gestational age (SGA), Apgar score, respiratory distress, and high death rate were strongly related to mothers’ anemia (p < 0.001), on the contrary of septicemia, birth asphyxia, and hypoglycemia, in spite of their higher frequency rates in anemia groups. Birth weight, and length, and gestational age were lowered significantly in moderate and severe anemia, while Apgar score was low throughout all anemia categories. SGA was significant in severe anemia. CONCLUSION: Maternal anemia is highly prevalent in Iraq with significant adverse neonatal events and elevated rates of mortality.

Deferasirox in thalassemia: a comparative study between an innovator drug and its copy among a sample of Iraqi patients

Background:

The health care industry is witnessing an increasing trend in the use of generic medicines because of their presumed low cost compared with innovator medicines. The aim of this study was to determine and compare the performance of the copy drug Osveral^® and its innovator drug deferasirox (Exjade^®).

Methods:

A prospective observational study including 223 patients receiving the branded medicine Exjade^® and 101 patients receiving the copy Osveral^® was carried out. Data were assessed for a 1-year period and included clinical symptoms, serum ferritin (SF), serum creatinine (SC), and alanine aminotransferase (ALT). Data were analyzed with SPSS version 22 software (SPSS, Chicago, IL, USA).

Results:

The median age of the sample was 8 years. There was no significant difference in gender distribution between the two groups (p = 0.625). Nausea was the most frequently reported adverse effect followed by diarrhea and abdominal pain in both groups. Patients receiving Exjade^® had a higher relative reduction of SF at the end of the study compared with the Osveral^® group (19.9% versus 9.93%, p = 0.028). SC was found to be significantly higher in the Osveral^® group than in the Exjade^® group throughout the study period. The mean platelet count was higher in the Exjade^® group. ALT was significantly higher among patients receiving Osveral^® over the last three months of the study.

Conclusions:

Exjade^® showed a better ability to reduce SF, with less liver toxicity, and better hemostasis profile. No congenital anomalies associated with short-term use of both drugs during pregnancy were observed or reported.

Relationship between liver iron concentration determined by R2-MRI, serum ferritin, and liver enzymes in patients with thalassemia intermedia

Background

Iron overload is a risk factor affecting all patients with thalassemia intermedia (TI). We aimed to determine whether there is a relationship of serum ferritin (SF) and alanine aminotransferase (ALT) with liver iron concentration (LIC) determined by R2 magnetic resonance imaging (R2-MRI), to estimate the most relevant degree of iron overload and best time to chelate in patients with TI.

Methods

In this cross-sectional study, 119 patients with TI (mean age years) were randomly selected and compared with 120 patients who had a diagnosis of thalassemia major (TM). Correlations of LIC, as determined by R2-MRI, with SF and ALT levels, were assessed in all participants. A P-value <0.05 was considered statistically significant.

Results

SF and LIC levels were lower in patients with TI than in those with TM; only ferritin values were significant. We found a statistically significant relationship between SF and LIC, with cut-off estimates of SF in patients with TI who had splenectomy and those who entered puberty spontaneously (916 and 940 ng/mL, respectively) with LIC >5 mg Fe/g dry weight (P<0.0001). A significant relationship was also found for patients with TI who had elevated ALT level (63.5 U/L), of 3.15 times the upper normal laboratory limit, using a cut-off for LIC ≥5 mg Fe/g dry weight.

Conclusion

We determined the cut-off values for ALT and SF indicating the best time to start iron chelation therapy in patients with TI, and found significant correlations among iron overload, SF, and ALT.