Public knowledge of emergency medicine in Beirut,Lebanon

Introduction

To examine the public’s level of knowledge and expectations of Emergency Medicine (EM) in Beirut, Lebanon.

Methods

A nested cross-sectional study was conducted exploring participants’ knowledge and expectations of EM; the skillset, role and scope of practice of the emergency physician, and the dynamics of the Emergency Department (ED).

Results

A majority understand EM physicians perform minor procedures (83%), have specialized training (79%) and that they should be treated by a specialized EM physician (74%). However, they also believed they should visit the ED for faster service (81%) or whenever they cannot be seen by their doctor (71%); most also expected to see their personal doctors in the ED (88%). There were significant misconceptions that ED physician could be a general doctor (84%), a specialist (81%) or a family doctor (70%). Half believe patients have the right to order blood tests (46%) or X-rays (50%) and to be admitted to the hospital at their preference (51%). Most (90%) expected patients with a possibly life-threatening problem to be treated immediately, and 48% a wait of less than thirty minutes for a non-life threatening problem. Half (54%) expected test results returned within thirty minutes, and 62% expected to spend less than sixty minutes in the ED.

Conclusion

There is poor recognition of the role of the EM physician and the dynamics of the ED among the Lebanese population. Awareness campaigns targeted to improve understanding may help align expectations with the reality of the practice of EM.

     

The role of B type natriuretic peptide in the assessment of post myocardial infarction prognosis

Recently cardiac peptides have received close attention as cardiovascular markers. Brain (B type) natriuretic peptide is a neurohormone synthesized predominantly in ventricular myocardium. Previous studies have shown that this hormone can provide prognostic information in patients with myocardial infarction. The aim of this review is to evaluate the impact of plasma levels of BNP on prediction of left ventricular ejection fraction and remodelling and major cardiac events after myocardial infarction.     

Parietal thoracic tuberculosis in the absence of immunosuppression by HIV infection

Parietal thoracic abscess formation of a tuberculous nature is a rare form of extrapulmonary tuberculosis, usually described in cases of severe tuberculosis encountered in HIV-infected patients. We report 13 cases of parietal tuberculosis in patients without HIV infection who were investigated between October 1988 and December 1999. During this period, we cared for 2 663 patients with tuberculosis. The series included 9 women and 4 men age 17 to 60 years, mean age 39 years. The clinical aspect of the parietal abscess was variable. Cold fluctuating abscess was dominant in 10 cases. In 3 cases, the parietal abscess had a hard consistence simulating a malignant tumor. The parietal abscess was in a posteriosuperior or posteriobasal location in 4 cases, and in an anterosuperior, anterobasal or axillary location in 6. Multiple thoracic abscesses were observed in only 3 cases. The size of the abscess varied from 2 to 2.5 cm. Radiologically, rib damage was present in 4 cases, scapular damage in 1, with bone lysis in 3 cases. Other localizations of tuberculosis were observed in 4 cases. one patient had multiple peripheral node enlargement, another had parenchymal lung damage and a third had a vertebral localization. Culture of abscess pus provided the diagnosis in 10 cases. the diagnosis was confirmed by pathology in 8 cases on a biopsy of the abscess border. Anti-tuberculosis drugs allowed successful recovery in all patients. We analyzed the clinical aspects of cold thoracic abscesses and discuss differential diagnosis. Early diagnosis and treatment is essential.     

The principles of metabolic therapy for heart disease

Metabolic therapy involves the administration of a substance normally found in the body to enhance a metabolic reaction within the cell. This may be achieved in two ways. First, for some systems, a substance can be given to achieve greater than normal levels in the body so as to drive an enzymic reaction in a preferred direction. Second, metabolic therapy may be used to correct an absolute or relative deficiency of a cellular component. Thus, metabolic therapy differs greatly from most standard cardiovascular pharmacologic therapy such as the use of ACE Inhibitors b-blockers, statins and calcium channel antagonists that are given to block rather than enhance cellular processes. In this review we highlight some metabolic substances that have potential benefit in treating heart disease or improving outcomes after cardiovascular interventions. Glucose-insulin-potassium therapy is protective against myocardial ischaemia by elevating myocardial glycogen levels. Coenzyme Q(10) is a lipid-soluble antioxidant that plays a crucial role in cellular ATP production. Magnesium orotate, a key intermediate in the biosynthetic pathway of glycogen, has been shown to improve the energy status of the cell and improve recovery from cardioplegic arrest. The amino acid aspartate plays an important role in providing energy substrates for oxidative phosphorylation in the myocyte. By improving cellular energy production, metabolic therapy has the potential to benefit cardiac function during the stress of cardiac surgery, myocardial infarction and cardiac failure.     

Audit of management of chronic obstructive pulmonary disease by general practitioner in Morrocco

OBJECTIVE: The purpose of this study initiated in January 2003 was to evaluate the awareness of general practitioners in Morrocco concerning the diagnosis and initial management of chronic obstructive pulmonary disease (COPD). METHOD AND RESULTS: Ten percent of the COPD patients, selected at random, participated in the study, i.e; 223 patients/2186. The proportion of COPD patients among patients attending consultations was 5 to 10% for 40% of general practitioners. Only 48.9% of the general practitioners were aware of international guidelines for the management of COPD. For 97.8%, chronic bronchial symptoms were the predominant reasons for suspecting the diagnosis of COPD; other symptoms included exercise induced dyspnea (95.1%). Only 10.8% of the general practitioners ordered a spirometry examination. Only 30.5% managed patients themselves. CONCLUSION: Our findings show that general practitioners should be implicated in the diagnosis and early management of COPD but that management practices could be improved.     

Réactions cutanées paradoxales sous traitement par tocilizumab

Introduction

Tocilizumab (TCZ) is a humanized antihuman interleukin (IL)-6 receptor antibody recommended for the treatment of moderate to severe active rheumatoid arthritis, adult-onset Still disease, Castleman disease and more recently, systemic juvenile idiopathic arthritis. Like anti-TNFα, rituximab and less frequently abatacept, TCZ can induce paradoxical cutaneous eruption like psoriasis with predominantly palmoplantar presentation.

Case report

We report a 47-year-old woman with psoriastic arthritis who developed under anti-TNFα therapy and later under tocilizumab a paradoxical palmoplantar eruption.

Conclusion

The specific underlying mechanisms of this side effect are unclear but relapse of these lesions seems to be observed with certain biological agents.     

Biliary stenting versus surgical bypass for palliation of periampullary malignancy

Background

Patients with periampullary cancers may not be suitable for curative resection due to locally advanced disease, metastases, or poor health. Biliary stenting and surgical bypass are utilized for symptom control, but the true benefit of one technique over the other is not clear.

Methods

A retrospective analysis of case records was undertaken of patients with periampullary (pancreatic head/uncinate process, distal bile duct, and ampulla of Vater and surrounding duodenum) malignancy treated between June 2004 and June 2010 in a tertiary center by palliative biliary stenting or palliative surgical bypass.

Results

Of the 69 patients included in the analysis, combined biliary and gastric bypass was performed on 28, while 41 underwent biliary stent (metallic, n?=?39) insertion. Patients undergoing stenting were significantly older and less likely to be offered chemotherapy than those from the surgical bypass group. Overall, there were significantly more complications in the stent insertion group (85 %) than the surgical bypass group (36 %) (p?=?0.003). The stent group required significantly more subsequent procedures than the surgical bypass group. Metal stent obstruction occurred in 16 of 39 (41 %) patients, with a median stent patency of 224 days. The overall median survival of patients in this study was 7 months with no significant difference between the groups (p?=?0.992). The presence of metastases at presentation was the only independent factor associated with decreased survival.

Conclusion

There was no survival difference between stenting vs. surgical bypass for palliation of periampullary cancer. There was, however, a high rate of stent occlusion and need for repeat procedures in patients treated by metal stenting, suggesting that stenting may be best suited to patients predicted as having the shortest survival.     

Association of hepatitis C virus infection and diabetes in central Tunisia

AIM：To investigate hepatitis C virus （HCV） seroprevalence in Tunisian patients with diabetes mellitus and in a control group. METHODS： A cross-sectional study was conducted to determine the HCV seroprevalence in 1269 patients with diabetes （452 male, 817 female） and 1315 nondiabetic patients, attending health centers in Sousse, Tunisia. HCV screening was performed in both groups using a fourth-generation enzyme immunoassay. RESULTS： In the diabetic group, 17 （1.3%） were found to be HCV-infected compared with eight （0.6%） in the control group, although the difference was not significant （P = 0.057）. Quantitative PCR was performed in 20 patients. Eleven patients were positive and showed HCV genotype lb in all cases. CONCLUSION： Frequency of HCV antibodies was low in patients with diabetes and in the control group in central Tunisia, with no significant difference between the groups.     

HLA-DQB1 CAR1/CAR2, TNFa IR2/IR4 and CTLA-4 polymorphisms in Tunisian patients with rheumatoid arthritis and Sj?gren's syndrome.

OBJECTIVES: To evaluate the contribution of HLA class II region and the CTLA-4 gene in genetic susceptibility to rheumatoid arthritis (RA) and Sj?gren's syndrome (SS) in the Tunisian population. METHODS: The polymorphisms of a (CA)n microsatellite of HLA-DQB1 CAR1/CAR2, TNFa IR2/IR4 and an (AT)n microsatellite in the 3'-untranslated region of exon 3 of the CTLA-4 gene were analysed after specific polymerase chain reaction (PCR) amplification. Typing of CTLA-4 A/G exon 1 polymorphism was achieved by the PCR-restriction fragment length polymorphism method. RESULTS: Genomic DNA from 60 patients with RA, 58 patients with SS and 150 healthy individuals was genotyped. The distribution of HLA-DQ CAR1/CAR2 allele frequencies differed between patients and controls in both diseases (RA, P<10(-15); SS, P=7.6x10(-15); RA+SS, P<10(-15)). The analysis of TNFa IR2/IR4 and CTLA-4 A/G polymorphisms did not show any differences in allele or genotype frequencies between patients and control subjects in either disease. The distribution of CTLA-4 (AT)n allele frequencies differed between patients with RA and controls (P=10(-3)), whereas no significant difference was detected between patients with SS and controls. CONCLUSION: These data suggest the involvement of HLA-DQ CAR1/CAR2 polymorphisms in genetic susceptibility to RA and SS and the participation of the CTLA-4 gene, or a gene closely associated with it, in the development of RA.     

Unexpectedly high indoor hydroxyl radical concentrations associated with nitrous acid

The hydroxyl (OH) radical is the most important oxidant in the atmosphere since it controls its self-oxidizing capacity. The main sources of OH radicals are the photolysis of ozone and the photolysis of nitrous acid (HONO). Due to the attenuation of solar radiation in the indoor environment, the possibility of OH formation through photolytic pathways indoors has been ignored up to now. In the indoor air, the ozonolysis of alkenes has been suggested as an alternative route of OH formation. Models and indirect measurements performed up to now according to this hypothesis suggest concentrations of OH radicals on the order of 10⁴–10⁵ molecules per cubic centimeter. Here, we present direct measurements of significant amounts of OH radicals of up to 1.8⋅10⁶ molecules per cubic centimeter during an experimental campaign carried out in a school classroom in Marseille. This concentration is on the same order of magnitude of outdoor OH levels in the urban scenario. We also show that photolysis of HONO is an important source of OH radicals indoors under certain conditions (i.e., direct solar irradiation inside the room). Additionally, the OH concentrations were found to follow a linear dependence with the product J(HONO)⋅[HONO]. This was also supported by using a simple quasiphotostationary state model on the OH radical budget. These findings force a change in our understanding of indoor air quality because the reactivity linked to OH would involve formation of secondary species through chemical reactions that are potentially more hazardous than the primary pollutants in the indoor air.The hydroxyl (OH) radical is the key species of the photooxidation cycles in the atmosphere that oxidize primary volatile organic compounds (VOCs) to form secondary oxygenated gas species and aerosols, which can be toxic and often carcinogenic (1).Considering that people spend on average 80–90% of their time indoors, knowledge about the formation processes of OH radicals (2) and their concentration levels indoors is of crucial importance to assess the impact of human exposure to the secondary pollutants potentially derived from indoor photooxidation processes (3).Until now, only indirect techniques have been applied to estimate OH concentrations indoors (3–5), which have determined values up to 7⋅10⁵ molecules per cubic centimeter (molecules cm⁻³). These studies measure the decay of organic tracers reacting rapidly and exclusively with OH radicals. The OH concentrations determined in this way are averaged over the entire volume of the room with a time resolution in the hour range. However, local and short-term concentrations of OH radicals can be considerably higher. These considerations led Weschler to conclude in his 2011 review (6) that indirect techniques were not fully appropriate to determine OH radical concentrations and that there is a critical need for real-time OH measurements.In addition, modeling studies (7–10) have been carried out to assess indoor air quality and OH concentrations. Carslaw (10) predicted indoor OH concentrations up to 4⋅10⁵ molecules cm⁻³. Potential sources of OH radicals considered in those studies included the reaction between hydroperoxyl (HO₂) and nitric oxide (NO); the reaction between ozone (O₃) and alkenes; and the photolysis of O₃ (λ < 320 nm), nitrous acid (HONO; λ < 400 nm), and hydrogen peroxide (λ < 360 nm). In the work of Carslaw (10), HONO photolysis was assigned a minor contribution of 12% to the total production of OH radicals in indoor environments compared with the 88% attributed to the ozonolysis of alkenes/monoterpenes. The impact of these two reactions on OH radical concentrations in indoor environments was also modeled by White et al. (5). The outcome of this model study (5) exhibited OH values on the order of ∼10⁴ molecules cm⁻³.Maisey et al. (11) carried out another modeling study on the effect of structural characteristics of buildings on the chemistry of the air indoors by changing four model variables: attenuation of photolysis rates determined by window size and glass composition and surface-to-volume ratios based on room size and air exchange rates. Much higher OH concentrations were calculated from this model (11) than previously reported. However, to perform such calculations, significantly high transmission values of visible (VIS) and UV light through glass were used [up to 0.8 in the VIS light and 0.6 in the UVA light for their high tailored (HT) model reference].Maisey et al. (12) modeled the seasonal influence on reactive indoor air pollution chemistry. In that study, estimations on OH concentrations were in agreement with Carslaw''s reported values (10). However, unrealistically low HONO concentration values (300 parts per trillion, ppt) (13) were assumed for the calculations, which in reality are more typical outdoors.Weschler and Shields (14) assessed the effect of air exchange rates. Certain chemicals found indoors can hydrolyze under commonly occurring indoor conditions (ref. 6 and references therein). Weschler (6) stated that in the gas phase, these hydrolysis reactions tend to occur too slowly to compete with air exchange processes. However, there is ample time for such reactions to occur on surfaces, on which water adsorbs, particularly in areas of high relative humidity (RH) like the kitchen or the bathroom.Since the study of Weschler and Shields (8), other indoor pollutants have been identified that may react with O₃ to generate OH. These include terpene alcohols (e.g., terpineol, linalool) and constituents of skin oils, such as squalene and unsaturated fatty acids (15). Although O₃/squalene reactions on surfaces may not be a substantial source of gas phase OH, this reaction generates 6-methyl-5-hepten-2-one and geranyl acetone in the gas phase, and O₃ can react with these unsaturated gas phase products to generate OH (16).On the other hand, depending on the fraction of UV-VIS light used as input in the model, a drastic impact on the balance of OH radicals can be predicted. Carslaw (10) recommended the determination of photolysis frequencies of key indoor species over the range of wavelengths commonly observed indoors, since the only two available (17, 18) studies show important discrepancies on the attenuation of light to the indoor environment.In addition, indoor electric lighting, such as compact fluorescent lamps and lamps using light-emitting diodes (19), could provide sufficient light to initiate photochemistry in the indoor environment. The information on the fluxes at different wavelengths emitted by various types of indoor lighting that could have sufficient flux in the 300- to 400-nm range to photolyze HONO should be the subject of future research.Photolysis of HONO occurring at wavelengths shorter than 405 nm (20), which are available indoors, makes HONO a good candidate for OH production through the following reaction:In the reaction above, h is the Planck constant and ν represents light frequency.