Referrals and shared or collaborative care: managing relationships with complementary and alternative medicine practitioners

In this article we discuss steps that clinicians should take after deciding to include a complementary and alternative medicine (CAM) treatment that is beyond the clinician's expertise in a patient's treatment plan. We use the example of an adolescent patient with chronic recurrent headaches that have not been relieved by medication or other therapies and whose physician refers her to an acupuncturist for treatment. We focus on (1) circumstances under which referral is appropriate, (2) the nature of the relationship between the referring clinician and the practitioner to whom the referral is made (considering conventional health care and CAM, regulated and unregulated practitioners), and (3) considerations when undertaking shared or collaborative care with other health care practitioners (conventional health care or CAM). We also suggest best practices in managing such relationships.     

Perinatal outcome in pregnancy with polyhydramnios in comparison with normal pregnancy in department of obstetrics at Shiraz University of Medical Sciences

Objective: Polyhydramnios can lead to maternal and fetal complication during pregnancy, so diagnosis and management can decrease some perinatal complications.

Study design: One hundred and fourteen singleton pregnancies were diagnosed with idiopathic polyhydramnios in the department of obstetrics at Shiraz University of Medical Sciences between January 2000 and January 2011 and were compared with 114 normal pregnancies for their perinatal outcome. Variables include birth weight, admission to neonatal intensive care unit (NICU), meconium staining, respiratory distress, fetal death, neonatal death, low 1-min and 5-min APGAR score, primary cesarean section (C/S), preterm delivery (<37?weeks), postpartum bleeding, and placental abruption.

Results: Low birth weight (<2500?g), macrosoma (>4000?g), NICU admission, fetal distress, fetal death, lower 1-min and 5-min APGAR score, preterm delivery, and neonatal death were higher in the case group. However, meconium staining and malpresentation were equal between the two groups. Except for prematurity and 1-min and 5-min APGAR scores, there were no significant differences in other maternal or fetal outcomes considering the severity of polyhydramnios.

Conclusion: Idiopathic polyhydramnios should be considered as a high-risk pregnancy that warrants close surveillance. More studies should be done to detect the best time and interval of fetal surveillance in these patients. Chromosomal and torch studies can determine the definite cause of polyhydramnios.     

Obesity and gut–microbiota–brain axis: A narrative review

IntroductionObesity is a major health problem that is associated with many physiological and mental disorders, such as diabetes, stroke, and depression. Gut microbiota has been affirmed to interact with various organs, including the brain. Intestinal microbiota and their metabolites might target the brain directly via vagal stimulation or indirectly through immune‐neuroendocrine mechanisms, and they can regulate metabolism, adiposity, homoeostasis and energy balance, and central appetite and food reward signaling, which together have crucial roles in obesity. Studies support the concept of bidirectional signaling within the gut–brain axis (GBA) in the pathophysiology of obesity, mediated by metabolic, endocrine, neural, and immune system mechanisms.Materials and methodsScopus, PubMed, Google Scholar, and Web of Science databases were searched to find relevant studies.ResultsThe gut–brain axis (GBA), a bidirectional connection between the gut microbiota and brain, influences physiological function and behavior through three different pathways. Neural pathway mainly consists of the enteric nervous system (ENS) and vagus nerve. Endocrine pathway, however, affects the neuroendocrine system of the brain, particularly the hypothalamus–pituitary–adrenal (HPA) axis and immunological pathway. Several alterations in the gut microbiome can lead to obesity, by modulating metabolic pathways and eating behaviors of the host through GBA. Therefore, novel therapies targeting the gut microbiome, i.e., fecal microbiota transplantation and supplementation with probiotics and prebiotics, can be a potential treatment for obesity.ConclusionThis study corroborates the effect of gut microbiome on physiological function and body weight. The results show that the gut microbiota is becoming a target for new antiobesity therapies.     

Isolation,characterization, and genotyping of Ornithobacterium rhinotracheale isolated from broiler and broiler breeder flocks in Mazandaran province,Northern Iran

Background: Ornithobacterium rhinotracheale (ORT) is one of the most important pathogenic bacteria which cause significant economic losses in poultry breeder countries every year. Aims: The present study was conducted to isolate and investigate the ORT isolates’ biochemical, antibiotic resistance, and genotypic characteristics of in industrial poultry flocks with respiratory signs in northern Iran. Methods:After sampling from 60 different flocks and cultivation of the samples on a selective medium, suspected colonies were subjected to biochemical and molecular identification of ORT. Then, confirmed isolates were aimed to antibiotic resistance assay, hemagglutination test, detection of pOR1 plasmid, and DNA fingerprinting to survey the variability of the isolates. Results:A total of 13 isolates, including seven isolates from broiler flocks (19.44%) and six isolates from broiler breeder flocks (25%) were obtained. Almost all isolates showed similar results in terms of basically important biochemical tests. The most resistance rates among all ORT isolates were obtained for ampicillin, erythromycin, ceftriaxone, and penicillin (100%). The majority of ORT isolates were susceptible to furazolidone. The pOR1 plasmid was detected in only two isolates, and analysis of the DNA fingerprinting phylogenetic tree showed four specific genotypic clusters. Conclusion:According to the results, the isolates showed different antibiotic resistance profiles, and most of the strains proved multiresistant. This can indicate the circulation of various multi-drug resistant strains among poultry farms in northern Iran. Isolates from broilers and broiler breeders were grouped into different clusters by genotyping.Key Words: Antibiotic resistance, ERIC-PCR, Ornithobacterium rhinotracheale, pOR1 plasmid     

Silent HDV epidemics culminates in high levels of liver cirrhosis in endemic region despite 20 years of HBV vaccination

The hepatitis delta virus (HDV) is believed to be a vanishing infection in countries with successful hepatitis B virus (HBV) vaccination programs. We assessed the current status of HDV infection in Tuva, a region of the Russia that has been highly endemic for HBV. The proportion of HDV-infected patients among HBsAg-positive patients in the regional registry in 2020 was 32.7% (786/2401). An analysis of the medical records of 514 HDV patients demonstrated that 37.5% (193/514) had liver cirrhosis at the first doctor's visit, and 7.4% of patients lived in families where another family member had HDV. All HDV patients were infected with genotype HDV-1, 94.5% had HBV genotype D, and 5.5% had genotype A. A serosurvey conducted among 1170 healthy volunteers showed that the average detection rate of HBsAg with anti-HDV was 1.0% (95% CI: 0.57–1.81%). No anti-HDV positive samples were detected in participants aged under 30 years. The HBsAg/anti-HDV positivity rate peaked at 7.4% in patients aged 50–59 years, which was significantly higher than in a similar age cohort surveyed in 2008 (1.6%, p < .0001). A Bayesian analysis showed that HDV circulation in Tuva resulted from two waves of introduction, the first in the 1810s (95% HPD: 1741–1834) from Central Asia, and the second in the 1960s (95% HPD: 1953–1979) from Russia. HBV has a much longer history of circulation in Tuva with the MRCA for the predominant genotype HBV-D dated to 972 (95% HPD: 535–1253) for subtype D1, 1274 (95% HPD: 936–1384) for D2, and 1173 (95% HPD: 1005–1618) for D3. A SkyGrid reconstruction of population dynamics showed an increase in the intensity of HDV spread in recent decades. This situation shows the need for HDV screening and prevention measures among people living with HBV.     

Depigmentation of the vulvar area: Is it an alarming sign?

A 34‐year‐old female patient presented with recurrent bilateral hypopigmented macules on the labia majora. The lesions were treated with topical steroids, which led to mild improvement, but erosive plaques developed after discontinuing the treatment. Histopathological findings were compatible with extramammary Paget disease (EMPD), which was treated with radical vulvectomy with no recurrence in the next months of follow‐up.     

Simultaneous spontaneous pneumomediastinum and pneumopericardium in a critically ill patient with COVID-19

Case in the paper is of a 24-year-old woman presenting to Baqiyatallah hospital, Tehran, Iran with the occasional fever, weakness, myalgia, fatigue, body aches, and headache who was diagnosed with Coronavirus disease-19 (COVID-19) PCR test. Chest computed tomography (CT) showed spontaneous pneumomediastinum (SPM) and pneumopericardium (SPP). Here, we described SPM, and SPP in a patient with COVID-19, presenting a severe course of the disease.