Negative exploration for pyloric stenosis – Is it preventable?

Background

The diagnosis of infantile hypertrophic pyloric stenosis (IHPS), although traditionally clinical, is now increasingly dependent on radiological corroboration. The rate of negative exploration in IHPS has been reported as 4%. The purpose of our study was to look at elements of supportive clinical evidence leading to positive diagnosis, and to review these with respect to misdiagnosed cases undergoing negative exploration.

Methods

All infants undergoing surgical exploration for IHPS between January 2000 and December 2004 were retrospectively analysed with regard to clinical symptoms, examination findings, investigations and operative findings.

Results

During the study period, 343 explorations were performed with a presumptive diagnosis of IHPS. Of these, 205 infants (60%) had a positive test feed, 269 (78%) had a positive ultrasound scan and 175 (55%) were alkalotic (pH ≥7.45 and/or base excess ≥2.5). The positive predictive value for an ultrasound (US) diagnosis was 99.1% for canal length ≥14 mm, and 98.7% for muscle thickness ≥4 mm. Four infants (1.1%) underwent a negative surgical exploration; Ultrasound was positive in 3, and negative in 1(who underwent surgery on the basis of a positive upper GI contrast). One US reported as positive had a muscle thickness <4 mm. Two false positive US were performed at peripheral hospitals. One infant had a false positive test feed following a positive ultrasound diagnosis. Two infants had negative test feeds.

Conclusion

A 1% rate of negative exploration in IHPS compares favourably with other studies. However potential causes of error were identified in all 4 cases. Confident diagnosis comprises a combination of positive test feed and an 'in house US' in an alkalotic infant. UGI contrast study should not be used in isolation to diagnose IHPS. If the test feed is negative, strict diagnostic measurements should be observed on US and the pyloric 'tumour' palpated on table under anaesthetic before exploration.     

Development of Construction Material Using Wastewater: An Application of Circular Economy for Mass Production of Bricks

Water is one of the necessary ingredients for construction materials. Billions of gallons of clean water are wasted during the development of fired clay bricks. Similarly, the waste of clean water is a global issue. In this study, we develop fired clay bricks with the help of wastewater for the first time and compare these with clay bricks produced using groundwater, which is the conventional method. Both destructive (i.e., compressive strength (CS)) and non-destructive (i.e., ultrasonic pulse velocity (UPV)) tests are conducted on all fired clay brick specimens as per the American Society for Testing and Materials (ASTM). Physical (i.e., dimensions) and durability (water absorption, efflorescence, etc.) tests are also conducted. All kinds of brick satisfied the standard requirements of physical and durability characteristics. Similar or better strength of bricks were achieved using wastewater. The study concludes that the testing results of wastewater bricks were significantly 15–25% higher compared with groundwater-fired clay bricks. A large amount of wastewater can be used to develop bricks, and clean water can be saved to attain circular economy goals. Therefore, this study will help not only in developing low-cost bricks but also in saving clean water.     

Expanded dengue syndrome presented with rhabdomyolysis,compartment syndrome,and acute kidney injury: A case report

Rationale:Expanded dengue syndrome (EDS) is the phenomenon coined by the World Health Organization for cases of dengue fever (DF) with rare but dangerous consequences. EDS mainly leads to complications involving the vital organs, thus is also associated with a higher mortality rate. This case report presents the first-ever case where a patient developed EDS with both rhabdomyolysis-induced acute kidney injury and compartment syndrome of the limbs.Patient concerns:Our patient, an 18-year-old Pakistani male, presented with fever, colicky abdominal pain, vomiting, diarrhea, dark-colored urine, and oliguria.Diagnoses:Dengue rapid NS-1 test came back positive. Along with myoglobinuria both serum creatine phosphokinase and creatine levels were abnormal. Hence, the patient was diagnosed with rhabdomyolysis-induced acute kidney injury. On physical examination, his right arm was painful and tender with restricted movement at the elbow. A Doppler ultrasound of the arm revealed thickening of the skin and underlying muscles, as well as edematous abnormalities affecting the entire right upper limb, both of which are indications of compartment syndrome.Interventions and outcome:The management included rehydration, administration of dextrose and bicarbonate (bicarbonate infusion) prepared by adding 150 mEq sodium bicarbonate in 850 mL dextrose 5%, pain killers, along with platelet, and packed red cell transfusions. Additionally, right upper limb was kept elevated at 90° for 30 minutes every 2 hours to reduce edema and crept bandages were applied. The patient was discharged after 11 days and the follow-up was uneventful.Lesson:Physicians should be aware that rhabdomyolysis-induced acute kidney damage and limb compartment syndrome are also possible DF consequences, and they should be on the lookout for any indications pointing to these complications in DF. A prompt diagnosis can prevent further complications and fatality.     

Predicting the Compressive Strength of Concrete Containing Fly Ash and Rice Husk Ash Using ANN and GEP Models

Climate change has become trending news due to its serious impacts on Earth. Initiatives are being taken to lessen the impact of climate change and mitigate it. Among the different initiatives, researchers are aiming to find suitable alternatives for cement. This study is a humble effort to effectively utilize industrial- and agricultural-waste-based pozzolanic materials in concrete to make it economical and environmentally friendly. For this purpose, a ternary blend of binders (i.e., cement, fly ash, and rice husk ash) was employed in concrete. Different variables such as the quantity of different binders, fine and coarse aggregates, water, superplasticizer, and the age of the samples were considered to study their influence on the compressive strength of the ternary blended concrete using gene expression programming (GEP) and artificial neural networking (ANN). The performance of these two models was evaluated using R², RMSE, and a comparison of regression slopes. It was observed that the GEP model with 100 chromosomes, a head size of 10, and five genes resulted in an optimum GEP model, as apparent from its high R² value of 0.80 and 0.70 in the TR and TS phase, respectively. However, the ANN model performed better than the GEP model, as evident from its higher R² value of 0.94 and 0.88 in the TR and TS phase, respectively. Similarly, lower values of RMSE and MAE were observed for the ANN model in comparison to the GEP model. The regression slope analysis revealed that the predicted values obtained from the ANN model were in good agreement with the experimental values, as shown by its higher R² value (0.89) compared with that of the GEP model (R² = 0.80). Subsequently, parametric analysis of the ANN model revealed that the addition of pozzolanic materials enhanced the compressive strength of the ternary blended concrete samples. Additionally, we observed that the compressive strength of the ternary blended concrete samples increased rapidly within the first 28 days of casting.     

Development and validation of a questionnaire for anxiety and depression in Pakistan

BACKGROUND: Currently clinicians and researchers in Pakistan have to use translated western instruments to screen for anxiety and depressive disorders. This study investigated the local idioms of emotional distress in Pakistan to develop a culturally valid and easy-to-use instrument to screen for common mental disorders in general clinical settings. METHODS: A systematic survey was conducted of psychiatric case notes of patients attending clinics in Peshawar and Lahore, diagnosed with anxiety or depressive disorders, to identify the range of common idioms of psychological distress. A pilot version of the questionnaire was refined and validated among a composite sample of 330 patients in inpatient, outpatient and rural community settings. ICD-10 Diagnostic Criteria for Research were used to define cases and patients' relatives acted as normal controls. RESULTS: The pilot version of the questionnaire was reduced to 42 items based on odds ratios between cases and controls. Anxiety symptoms were generally reported by depressed patients, but not vice versa. Finally 30 items were selected, in two sub-scales. This final version achieved sensitivity, specificity, and positive and negative predicted values of over 90% when comparing cases and controls. LIMITATIONS: This questionnaire was based on what patients tell doctors and may not capture the entire repertoire of local idioms of distress. The validation study was conducted only in an Urdu/Punjabi speaking population, in Lahore and surrounding areas. CONCLUSIONS: The Pakistan Anxiety and Depression Questionnaire consists of an anxiety/depression scale and a depression scale, each of 15 items. It demonstrates excellent validity as screening instrument for anxiety and depressive disorders in clinical settings in Pakistan.     

Acceptability of human papillomavirus vaccination among male university students in the United Arab Emirates

Objective

To assess the knowledge about and acceptability of human papillomavirus (HPV) vaccination among male university students in the United Arab Emirates (UAE).

Methods

Between June and August 2012 we approached 356 male university students from the UAE and asked them to fill out a 12-item self-administered questionnaire.

Results

Knowledge of HPV was low among the university students who participated (32%). Less than half of the students (46%) indicated they would accept HPV vaccination, and around 30% were unsure of their decision. Safety (68%), protection of their female partner (65%) and doctor's recommendation (64%) were rated as the factors most likely to increase the uptake of HPV vaccination among participating students. The factors rated most likely to stop students from using the vaccine were fear of side effects (85%), absence of clear benefits (38%) and objections from a religious authority (25%). Marital status and sexual activity were associated with greater knowledge of HPV but not with greater acceptance of vaccination among university students in the UAE.

Conclusion

Overall acceptability of and knowledge about HPV infection and vaccination were low in a sample of male university students in the UAE. Marital status and sexual activity are associated with greater knowledge of HPV infection but have no effect on the acceptability of HPV vaccination.