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   2014| October  | Volume 6 | Issue 10  
    Online since October 20, 2014

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Effectiveness of D-dimer as a screening test for venous thromboembolism: An update
Swaroopa Pulivarthi, Murali Krishna Gurram
October 2014, 6(10):491-499
DOI:10.4103/1947-2714.143278  PMID:25489560
Venous thromboembolism (VTE) is the leading cause of morbidity and mortality among hospitalized patients. We searched the PubMed database and reviewed the articles published until June 2011. Articles related to the D-dimer and VTE were considered to write this paper. Many factors play a key role in changing the sensitivity and specificity of D-dimer testing, including the extent of thrombosis and fibrinolytic activity, duration of symptoms, anticoagulant therapy, comorbidity due to surgical or medical illnesses, inflammatory diseases, cancer, elderly age, pregnancy and the postpartum period, and previous VTE. Many previous studies have shown that the D-dimer test is highly sensitive (>95%) in acute deep venous thrombosis or pulmonary embolism, usually with a cut-off value of 500 μg FEU/l, which reasonably rules out acute VTE, particularly in patients with low clinical probability (LCP) or intermediate clinical probability. Patients with high D-dimer levels upon presentation may prompt a more intense diagnostic approach, irrespective of pretest probability. Studies performed after a negative D-dimer for 3 months proved the high negative predictive value (NPV) of D-dimer testing together with LCP in patients with suspected VTE. Among oncology patients, D-dimer testing has the highest sensitivity and NPV in excluding VTE. The new cutoff values of D-dimer testing were analyzed in a recent prospective study of pregnant women; they are 286 ng DDU/ml, 457 ng DDU/ml, and 644 ng DDU/ml for the first, second, and third trimesters, respectively.
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Thimerosal-containing hepatitis b vaccination and the risk for diagnosed specific delays in development in the united states: A case-control study in the vaccine safety datalink
David A Geier, Janet K Kern, Brian S Hooker, Paul G King, Lisa K Sykes, Mark R Geier
October 2014, 6(10):519-531
DOI:10.4103/1947-2714.143284  PMID:25489565
Background: Within the first 3 years of life, the brain develops rapidly. Its development is characterized by critical developmental periods for speech, vision, hearing, language, balance, etc.; and alteration in any of the processes occurring in those critical periods can lead to specific delays in development. Aims: The present study evaluated the potential toxic effects of organic-mercury exposure from Thimerosal (49.55% mercury by weight) in childhood vaccines and its hypothesized possible relationship with specific delays in development. Materials and Methods: A hypothesis testing case-control study was undertaken to evaluate the relationship between exposure to Thimerosal-containing hepatitis B vaccines administered at specific intervals in the first 6 months among cases diagnosed with specific delays in development and controls born between 1991-2000, utilizing data in the Vaccine Safety Datalink database. Results: Cases were significantly more likely than controls to have received increased organic-mercury from Thimerosal-containing hepatitis B vaccine administered in the first, second, and sixth month of life. Conclusion: Though routine childhood vaccination may be an important public health tool to reduce the morbidity and mortality associated with infectious diseases, the present study supports an association between increasing organic-mercury exposure from Thimerosal-containing childhood vaccines and the subsequent risk of specific delays in development among males and females.
  8,054 478 8
Glycogen and the propensity for atrial fibrillation: intrinsic anatomic differences in glycogen in the left and right atria in the goat heart
Abraham A Embi, Benjamin J Scherlag, Jerry W Ritchey
October 2014, 6(10):510-515
DOI:10.4103/1947-2714.143282  PMID:25489563
Background: Previous experimental studies have demonstrated electrophysiological and structural remodeling in pacing induced atrial fibrillation. The latter has been characterized by glycogen accumulation but no connection to atrial fibrillation induction and maintenance has as yet been proposed. Aims: We determined the presence of glycogen in the right and left atrial appendages in the goat heart, in order to find any intrinsic disparity in distribution and concentration between these sites. Materials and Methods: Atrial appendages from 5 goats were stained by the Periodic acid Schiff method to determine the presence of glycogen and the concentration of glycogen by morphometric analysis. Results: We are reporting for the first time that the right atrial appendage showed scattered glycogen granules throughout the atrial myocytes which delineated the intercalated discs; whereas glycogen in the left atrial appendage was more dense within cells and coalesced against the intercalated discs and side to side junctions between myocytes. Also, morphometric analysis determined that the stained regions of the right atrial appendages averaged, 0.8 ± 1.3 μm 2 compared to the left atrial appendage sections, 2.6 ± 3 μm 2 , p = 0.02. We show that glycogen is heterogeneously distributed in both atria in the normal goat heart; however, the density of glycogen deposits concentrating against the intercalated discs and side to side connections in the left atrial appendage is a critically distinct difference. Impediment of cell to cell conduction could result in a non-uniform wavefront of activation, with areas of slowed conduction, predisposing the left atrium to reentrant based atrial fibrillation. Conclusion: These findings provide a basis for the well-known greater propensity for atrial fibrillation in the left versus the right atrium.
  1,938 304 7
Reliability of the identification of functional ankle instability (Idfai) scale across different age groups in adults
Reshma S Gurav, Sneha S Ganu, Vrushali P Panhale
October 2014, 6(10):516-518
DOI:10.4103/1947-2714.143283  PMID:25489564
Background: Functional ankle instability (FAI) is the tendency of the foot to 'give way'. Identification of Functional Ankle Instability questionnaire (IdFAI) is a newly developed questionnaire to detect whether individuals meet the minimum criteria necessary for inclusion in an FAI population. However, the reliability of the questionnaire was studied only in a restricted age group. Aim: The purpose of this investigation was to examine the reliability of IdFAI across different age groups in adults. Materials and Methods: One hundred and twenty participants in the age group of 20-60 years consisting of 30 individuals in each age group were asked to complete the IdFAI on two occasions. Test-retest reliability was evaluated by intraclass correlation coefficient (ICC 2,1 ). Results: The study revealed that IdFAI has excellent test-retest reliability when studied across different age groups. The ICC 2,1 in the age groups 20-30 years, 30-40 years, 40-50 years and 50-60 years was 0.978, 0.975, 0.961 and 0.922, respectively with Cronbach's alpha >0.9 in all the age groups. Conclusion: The IdFAI can accurately predict if an individual meets the minimum criterion for FAI across different age groups in adults. Thus, the questionnaire can be applied over different age groups in clinical and research set-ups.
  1,872 341 10
Insulin resistance in moderate to severe obstructive sleep apnea in nondiabetics and its response to continuous positive airway pressure treatment
Archana Baburao, George D Souza
October 2014, 6(10):500-504
DOI:10.4103/1947-2714.143280  PMID:25489561
Background: The effects of nasal continuous positive airway pressure (CPAP) on insulin resistance (IR) in obstructive sleep apnea (OSA) are still under discussion especially in nondiabetics. Trials have found conflicting results in this regard. Aims: The study was to measure IR in nondiabetic patients with moderate to severe OSA and to evaluate the effect of nasal CPAP on IR in these patients. Materials and Methods: A total of 30 consecutively newly diagnosed patients with moderate to severe OSA was enrolled in the study. OSA was diagnosed by doing an overnight polysomnography. Plasma glucose and insulin levels were measured at baseline and after 1 month of CPAP treatment. IR was calculated by homeostasis model assessment (HOMA) method. Results: Of 30 OSA patients, 21 were males, and 9 were females. The mean age of the subjects was 49.9 years, and mean body mass index (BMI) was 29.33. All 30 patients had moderate to severe OSA with a mean apnea and hypopnea index (AHI) of 80.46/h. The Epworth sleepiness score (ESS) showed a significant change with 1 month of treatment with CPAP from baseline of 13 to 9.7 (P ≤ 0.0001). There was a significant reduction in fasting insulin levels from 21.75 to 19.39 (P = 0.009). There was a small fall in fasting glucose, but it was not significant. The HOMA IR also reduced from 5.78 to 4.82 which was significant (P = 0.024) without any significant change in BMI (P = 0.916). The HOMA IR did not showed any positive correlation with different variables of OSA severity, ESS (r = 0.156) (P = 0.410), AHI (r = 0.177) (P = 0.349), and percentage of test time <90% saturation (r = −0.296) (P = 0.112). Conclusion: Moderate to severe OSA is associated with an increase in IR and effective treatment with CPAP rapidly improves the insulin sensitivity in nondiabetic patients with OSA without any change in BMI.
  1,816 329 6
A rare cause of seizures, parkinsonian, and cerebellar signs: Brain calcinosis secondary to thyroidectomy
Rakesh Agarwal, Durjoy Lahiri, Amrita Biswas, Jotideb Mukhopadhyay, Pranab Maity, Manoj Kumar Roy
October 2014, 6(10):540-542
DOI:10.4103/1947-2714.143287  PMID:25489568
Context: Post-thyroidectomy hypoparathyroidism presenting with Parkinsonian features and seizures with extensive intracranial calcifications is uncommon. Acquired intracranial calcification that affects structures other than the basal ganglia is rare. Case Report: We report a case of a 45-year-old woman with a history of total thyroidectomy who presented with Parkinsonian features, cerebellar signs, and seizures. Brain imaging revealed extensive intracranial calcifications secondary to long-standing hypoparathyroidism. The patient was treated with intravenous (IV) calcium gluconate therapy and shifted to oral calcium and calcitriol therapy. Her symptoms improved markedly. At four months of follow up, the patient had not suffered another episode of seizure and was being gradually weaned off anti-Parkinsonian therapy. Conclusion: This case describes the rare finding of extensive intracranial calcifications in a case of iatrogenic hypoparathyroidism secondary to thyroidectomy with its wide array of features and its remarkable response to restoration of calcium levels to normal limits.
  1,887 248 5
Acute confusional state: A manifestation of toxoplasma and CMV co-infection in HIV patient
Waqas Jehangir, Romil Sareen, Shuvendu Sen, Nazar Raoof, Abdalla Yousif
October 2014, 6(10):545-548
DOI:10.4103/1947-2714.143290  PMID:25489570
Context: When dealing with a patient with HIV that presents with an altered mental status, there are various infections and disease etiologies a physician has to rule out that may play a role in complicating the inherent complex nature of HIV. Toxoplasma gondii (T. gondii) and cytomegalovirus (CMV) affect a large part of the world's population and lead to a varied and broad symptomatology depending upon the severity of HIV, the CD4 count and how early the infection is diagnosed. Case Report: We report an HIV+ patient in his early 50s and with a low CD4 count that presented with severe lethargy and confusion. Imaging studies that were performed after stabilizing the patient revealed a ring-enhancing lesion in the brain and after further testing, a diagnosis of reactivated T. gondii with co-infection with CMV was made. Patients infected with T.gondii that are already immune-compromised deteriorate rapidly and the disease diagnosis poses several challenges. Conclusion: Clinicians have to be extremely careful about making a prompt diagnosis and initiate treatment without delay before the infection takes a deadly toll on the patient. Since our patient was not on the required prophylactic medication to prevent infection with T. gondii, it was imperative to start treatment in a timely manner and to monitor the patient for any further decline in functioning.
  1,774 262 -
Giant choledochal calculosis: Surgical treatment
Hasan Bektas, Yigit Duzkoylu, Ekrem Cakar, Kenan Buyukasık
October 2014, 6(10):536-539
DOI:10.4103/1947-2714.143286  PMID:25489567
Context: Gallstone disease is one of the most common surgical pathologies. Choledocholithiasis may occur in some of these cases and require surgical intervention. Although there are relatively non-invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP), this technique is usually unsuccessful in patients with stones larger than 10 mm. In our case, we aimed to report a giant choledochal stone (15 cm × 4.5 cm), which is rare in surgical practice and our treatment with open surgery. Case Report: The patient was a 59-year-old woman. Magnetic resonance cholangiopancreatography (MRCP) had showed a hydropic gallbladder with an excessively dilated CBD and a 110 mm × 41 mm stone. In the operation, an excessively dilated CBD was seen and after choledochotomy and a very large calculus that filled CBD completely. Choledochotomy incision was carried forward and a T-tube choledochostomy with choledochoduodenostomy (CD) was performed. The patient was discharged without any complications on postoperative 8 th day. Conclusion: Benign gallstone disease is a multifactorial process, with risk factors such as obesity, hemolytic diseases, diabetes mellitus, and pregnancy. Risk factors for choledocholithiasis are similar to those for gallstone disease. MRCP is a non-invasive technique in detecting choledocholithiasis. The gold standard intervention for CBD stones is ERCP. Stones in CBD may reach very considerable dimensions without causing serious symptoms. The most common symptom is jaundice. During preoperative radiological examination, giant stones may be interfered with malignancies. Surgeons should obey conventional algorithms in diagnosis and open surgery must be kept in mind in earlier stages without being too insistent on endoscopic interventions.
  1,772 253 -
Prevalence of varicocele among primary and secondary infertile men: Association with occupation, smoking and drinking alcohol
Hamid Shafi, Seddigheh Esmaeilzadeh, Mouloud Agajani Delavar, Fatemeh Hosseinpour Haydari, Neda Mahdinejad, Sharare Abedi
October 2014, 6(10):532-535
DOI:10.4103/1947-2714.143285  PMID:25489566
Background: Existing data suggests that varicocele plays a central role in progressive infertility. Aims: This study was designed to assess the occupational and lifestyle factors of development of varicocele among male infertile, for a better prevention and management of the varicocele. Materials and Methods: All males with infertility, who presented at Fatemezahra Infertility and Reproductive Health Research Center between April 2010 and February 2011, were examined. Their occupations, smoking, and drinking alcohol, presence or absence of varicocele were evaluated. The lifestyle factors associated with varicocele were analyzed. Results: The data of 816 men, aged 21-71 years, were included in the study. Two hundred and sixty-one men (32%) with varicocele and 555 (68%) without varicocele were found. Percentage of varicocele was significantly higher in smokers compared with non-smokers (P = 0.035). The adjusted OR for varicocele in smokerswas significantly higher than that in non-smoker (OR = 2.420; 95% CI = 1.04, 5.61). No significant differences were seen between varicocele and occupation or alcohol drinking for the prevalence of varicocele. Conclusions: The findings of the present study indicated that a high frequency of varicocele was indentified among male infertile. Therefore, it is necessary for those male cigarette-smokers to evaluate their possibilities of infertility and varicocele.
  1,653 281 6
Topical single-dose vascular endothelial growth factor has no effect on soft tissue healing
Nilufer Bolukbasi, Huseyin Avni Balcioglu, Birkan T Ozkan, Merva Soluk Tekkesin, Duran Ustek
October 2014, 6(10):505-509
DOI:10.4103/1947-2714.143281  PMID:25489562
Background: Vascular endothelial growth factor (VEGF) production in dermal wounds has been evaluated for evidence that it plays a probable role in wound healing. Events such as increased vascular permeability and concentration of inflammatory cells on the site of injury, produced by VEGF, were linked to tissue repair. Aim: The present study aimed to evaluate the effects of single-dose topical administration of VEGF on wound healing. Materials and Methods: A total of 30 male Wistar albino rats weighing 250-280 g were used in this study. In addition, 2-cm-long skin incisions were created over bilaterally exposed skin of the tibia region in each rat. VEGF plasmid 2 μg was administered locally into the right side wound bed of each animal. No other procedure besides skin closure was administered on the left side. To determine histologic assessments, skin samples were obtained from six anesthetized rats at each interval (4, 8, 12, 16 and 30 days) through excisional biopsy. The tissues were fixed in 10% neutral-buffered formalin for 1 week and then embedded in paraffin wax. Transverse sections of the embedded tissue 5-7 μm thick were stained with hematoxylin and eosin (H and E). Results: There was no significant difference regarding necrosis, epithelialization, inflammation, fibroblast activity, ulcerative formation, or hemorrhage between experimental and control groups. No statistically significant difference was found between the groups regarding granulation tissue formation and epidermal thickness. Conclusion: The administration method and dosage of VEGF is a major factor in terms of its effectiveness. The results of the present study did not evaluate the effectiveness of single-dose 2 μg topical administration of VEGF; however, various doses of VEGF plasmid should be tested in future studies in order to provide beneficial effects from topical administration of VEGF.
  1,597 280 2
An unusual presentation of childhood vasculitis presenting in adulthood: A challenging diagnosis of Henoch-Schönlein Purpura
Charat Thongprayoon, Wisit Cheungpasitporn, Natanong Thamcharoen, Jackrapong Bruminhent
October 2014, 6(10):543-544
DOI:10.4103/1947-2714.143289  PMID:25489569
Context: Henoch-Schφnlein purpura (HSP), a systemic IgA vascultitis, is uncommon in adults, with an incidence rate of 0.1 to 1.2 per million in adults over 20 years old. This vasculitic syndrome can present as an uncommon cause of intestinal obstruction in older patients. We report a case of an older woman with HSP presenting with small bowel obstruction and vasculitic rash. Case Report: We report a 67-year-old woman who presented with small bowel obstruction and skin rash. Skin biopsy revealed leukocytoclastic vasculitis with +IgA granular deposition within the walls of superficial dermal vessels. Kidney biopsy confirmed the diagnosis of HSP with mild mesangial proliferative IgA nephropathy. Her abdominal pain and small bowel obstruction were improved with conservative treatment. She continued to do well with normal kidney function at a 3-month follow-up visit. Conclusion: HSP, a systemic IgA vasculitis, is a predominantly pediatric vasculitis and is uncommon in adults. In adults, the disease process is identical to that in children. However, gastrointestinal manifestation is less common in older patients, and bowel perforation and obstruction are rare. Intestinal obstruction with skin rash and renal involvement should raise suspicions of HSP.
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