Background: The treatment of older adults with pain is complex and affected by age-related changes in pharmacokinetics and pharmacodynamics. Chronic pain encompasses a complex array of sensory-discriminatory, motivational-affective, and cognitive-evaluative components. Because of this complexity, both pharmacologic and nonpharmacologic approaches should be considered to treat pain. Aims: Given the large number of older persons with pain at the end of life and the few data about this issue, the objective of this article is to review the treatment of pain in this population. Patients and Methods: We searched The Cochrane Library, MEDLINE and LILACS from 1990 to 2011 and the references in retrieved manuscripts. The search terms were pain AND elderly AND end of life. Results: There are evidences of undertreatment among elderly people. The association of nonpharmacologic resources with the pharmacological treatment can help reduce the use of analgesics minimizing the side effects of long term medication. Pharmacological treatment is escalated in an orderly manner from non-opioid to weak opioid to strong opioid. Adjuvant drugs like anticonvulsants and antidepressants may be necessary. Conclusions: The sequential use of analgesics drugs and opioids are considered effective and relatively inexpensive for relieving pain, but no well designed specific studies in the elderly patient are available. There are not specific recommendations about the long-term use of complementary and alternative therapies and although their effectiveness remains unproven they should not be discouraged. Palliative sedation may be a valid palliative care option to relieve suffering in the imminently dying patient.

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Background: Peripartum hysterectomy is a major operation and is invariably performed in the presence of life threatening hemorrhage during or immediately after abdominal or vaginal deliveries. Material and Methods: A Medline search was conducted to review the recent relevant articles in English literature on emergency peripartum hysterectomy. The incidence, indications, risk factors and outcome of emergency peripartum hysterectomy were reviewed. Results: The incidence of emergency peripartum hysterectomy ranged from 0.24 to 8.7 per 1000 deliveries. Emergency peripartum hysterectomy was found to be more common following cesarean section than vaginal deliveries. The predominant indication for emergency peripartum hysterectomy was abnormal placentation (placenta previa/accreta) which was noted in 45 to 73.3%, uterine atony in 20.6 to 43% and uterine rupture in 11.4 to 45.5 %. The risk factors included previous cesarean section, scarred uterus, multiparity, older age group. The maternal morbidity ranged from 26.5 to 31.5% and the mortality from 0 to 12.5% with a mean of 4.8%. The decision of performing total or subtotal hysterectomy was influenced by the patient's condition. Conclusion: Emergency peripartum hysterectomy is a most demanding obstetric surgery performed in very trying circumstances of life threatening hemorrhage. The indication for emergency peripartum hysterectomy in recent years has changed from traditional uterine atony to abnormal placentation. Antenatal anticipation of the risk factors, involvement of an experienced obstetrician at an early stage of management and a prompt hysterectomy after adequate resuscitation would go a long way in reducing morbidity and mortality.

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Context : Pseudomonas aeruginosa is a gram negative opportunistic bacteria causes several infections commonly colonize these devices and developing biofilms. Bacteria in biofilm can be up to 1,000 times more resistant to antibiotics than the same bacteria circulating in a planktonic state. Case Report: A total of 10 isolates of Pseudomonas aeruginosa were isolated from catheter associated urinary tract infections. While carbenicillin was the most effective antibiotic, all isolates developed multidrug resistant. Both crude and purified bacteriocin showed marked inhibition activity against planktonic and biofilm of the highly resistant isolate P. aeruginosa P7. Conclusion: Bacteriocin extracted from a locally isolated L. acidophilus has an anti P. aeruginosa biofilm activity also it can be used as a therapeutic agent after adequate in vivo experimentation.

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Background : The prevalence of chronic rhinitis is increasing rapidly; its pathogenesis is to be further understood; immune inflammation is one of the possible causative factors. Antigen specific CD8+ T cells play a critical role in the induction of chronic inflammation. Aims : This study aimed to investigate the role of antigen specific CD8+ T cells in the pathogenesis of chronic atypical allergic rhinitis. Material and Methods : Nasal mucosal epithelial surface scratching samples were obtained from patients with chronic obstruction atypical allergic rhinitis. Exosomes were purified from the scratching samples and examined by immune gold electron microscopy. The effect of exosomes on modulating dendritic cell's properties, the effect of exosome-pulsed dendritic cells on naïve T cell differentiation and the antigen specific CD8+ T cell activation were observed by cell culture models. Results : Exosomes purified from patients with chronic atypical allergic rhinitis carried microbial products, Staphylococcal enterotoxin B (SEB), and airborne antigen, Derp1. Dendritic cells pulsed by SEB/Derp1-carrying exosomes showed high levels of CD80, CD86 and the major histocompatibility class I (MHCI). Exosome-pulsed dendritic cells could induce the naïve CD3+ T cells to differentiate into CD8+ T cells. Upon the exposure to a specific antigen, the CD8+ T cells released granzyme B and perforin; more than 30% antigen specific CD8+ T cells proliferated. Conclusions : Antigen specific CD8+ T cells play an important role in the pathogenesis of chronic obstruction atypical allergic rhinitis.

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Context : Endovascular aneurysm repair (EVAR) has well documented advantages over traditional open repair and has been widely adopted as the alternative treatment modality for abdominal aortic aneurysm. However, endoleaks specifically type II can be a significant problem with this technique leading to aortic sac expansion and potential rupture. A large number of type II endoleaks are caused by persistent inferior mesenteric artery (IMA) retrograde bleeding. Various methods to try to manage this complication have been previously described. IMA embolization via the marginal artery of Drummond, however, has not been adequately popularized as an alternative less invasive approach to the treatment of type II endoleak. Case Report : Two men, ages 77 and 81, underwent uneventful EVAR for 5.5 and 5.0 cm infrarenal abdominal aortic aneurysms, respectively, using Zenith Cook^; bifurcated stent grafts. Computed tomography angiography at 1 and 6 months postoperatively demonstrated small type II endoleaks in both cases which were followed clinically. Subsequent follow-up tomography scan at 12 months revealed persistent type II endoleaks related to retrograde filling from the IMA with significant enlargement of the aneurysm sacs. Both patients underwent successful IMA coil embolization via the marginal artery of Drummond. Conclusions : Percutaneous IMA embolization using standard endovascular techniques to access the marginal artery of Drummond is an alternative, and in our opinion, preferred technique for controlling type II endoleaks caused by a persistently patent IMA.

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Context: Existence of non-inflamed or inflamed vermiform appendix in an inguinal hernia is named Amyand's hernia in honor to the surgeon Claudius Amyand who successfully performed first perforated appendicitis. Case Report: A 69-year-old Turkish male patient with a slight right groin pain and swelling was presented to our clinic, and found to have a slightly tender and reducible right inguinal hernia. He underwent surgery under general anesthesia, and a adhesive caecum and an inflamed appendix were explored within the hernia sac. Adhesions were divided by sharp dissection and appendectomy was performed. After carrying out a Lichtenstein hernioplasty, a broad-spectrum antibiotic was postoperatively admitted for 3 days. He recovered uneventfully, and neither complication nor recurrence was detected during 52 months of follow-up. Conclusions: Although occurrence of an appendicitis in an inguinal hernia is rare, a surgeon should be vigilant for facing with it even in elective cases. Treatment can be provided only surgically, but surgical treatment is not standard except from appendectomy. In our opinion, application of mesh hernia repair should depend on the degree of inflammation of appendix and the presence of incarceration of hernia sac with a suitable antibiotic admission for 3-5 days postoperatively.

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Background Caspase-3 and granzyme B were claimed as apoptotic manipulative enzymes. Aims The present study was to determine the enzymes expression and activity in cancer and cancer immune therapeutic status and the possible association to cancer common pathological signs targeting the improvement of therapeutic conditions. Material and Methods Mice were immunized with cell lyaste or cell lysate + CKI in the right thigh and challenged with live cells of ehrlich ascites carcinoma (EAC) in the left thigh. The expression and activity of both enzymes in the spleenocytes derived from different subjects (normal, EAC and cell lysate or cell lysate + CKI immunized mice) after cultured with EAC viable cells were determined by colorimetric assay and western blot analysis. In addition, the subjects DNA ladder and serum metalloproteases (MMP 2 and 9) zymography were observed. Results The experimental data revealed over expression of caspase3 and granzyme B in the groups of cell lysate or cell lysate + CKI immunized mice compared to control while down expression were recorded in the EAC subject. The over expression of the 2 enzymes were accompanied with increases in the activities of caspase3 and granzyme B, changes in DNA fragmentation and inhibition of metalloproteases. Conclusion It could be suggested that, the parameter estimation within the present experimental framework could identify the efficiency of therapeutic vaccine protocols and elucidate the impact of CKI adjuvant with vaccines therapy.

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Background: Total body irradiation is a protocol used to treat acute lymphoblastic leukemia in patients prior to their bone marrow transplant. It involves the treatment of the whole body using a large radiation field with extended source-skin distance. Therefore, it is important to measure and monitor the skin dose during the treatment. Thermoluminescent dosimeters (TLDs) and the OneDose™ metal oxide semiconductor field effect transistor (MOSFET) detectors are used during treatment delivery to measure the radiation dose and compare it with the target prescribed dose. Aims: The primary goal of this study was to measure the variation of skin dose using OneDose MOSFET detectors and TLD detectors, and compare the results with the target prescribed dose. The secondary aim was to evaluate the simplicity of use and determine if one system was superior to the other in clinical use. Material and Methods : The measurements involved twelve adult patients diagnosed with acute lymphoblastic leukemia. TLD and OneDose MOSFET dosimetry were performed at ten different anatomical sites of each patient. Results : The results showed that there was a variation between skin dose measured with OneDose MOSFET detectors and TLD in all patients. However, the variation was not significant. Furthermore, the results showed for every anatomical site there was no significant different between the prescribed dose and the dose measured by either TLD or OneDose MOSFET detectors. Conclusion: There were no significant differences between the OneDose MOSFET and TLDs in comparison to the target prescribed dose. However, OneDose MOSFET detectors give a direct read-out immediately after the treatment, and their simplicity of use to compare with TLD detectors may make them preferred for clinical use.

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Background : A series has recently been done on whole blood viscosity. The first on the series proposed extrapolation chart with conventional reference range. Since the publication, two concerns have been received in personal communications. The first expressed concern over the use of serum proteins values in 'g/L' instead of 'g/dL' that was contained in the referenced material. The second enquired on suitability of the formula for determination of blood viscosity at low shear rate. Aim : This work sets out to compare different units-converted-modifications of the extrapolation with a view to develop a statement of comparison and suitability of units. Materials and Methods : The values of haematocrit and serum proteins were used in different unit-conversions on the mathematical formula to derive four modifications, which were compared. Five clinical cases that were specifically tested for whole blood viscosity, and had results for haematocrit and serum proteins were evaluated. The appropriateness of modifications for determination of viscosity at low shear rate was reviewed. Results : Except as modified and used in the series, determination of whole blood viscosity at low shear rate using other unit conversions on the formula yields negative values for all five cases. Conclusion : Given that it is unexpected for blood viscosity level to be zero let alone less, it is logical that negative values are invalid. A formula that gives the least invalid results may be most appropriate. Therefore, extrapolation modification used in the series is most appropriate.

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