Echinococcosis of the rib with epidural extension: a rare cause of paraplegia

Skeletal echinococcosis is a relatively rare entity and that of the rib is exceptional. Less than 50 cases of costal echinococcosis have been reported in the literature so far. Accurate pre-operative diagnosis aids in appropriate management and helps to eradicate the disease. This also prevents the dissemination of parasite and further complications. We report a case of echinococcosis of the rib with epidural extension in a young adult who presented with paraparesis and back pain. His laboratory investigations were within normal limits. Plain radiographs of the dorsal spine, CT scan of thorax and MRI of dorsal spine were performed. The imaging features were suggestive of echinococcosis involving the rib with epidural extension. The cyst was completely resected. Histopathology of the resected specimen confirmed the diagnosis of echinococcosis.     

Arsenic drinking water regulations in developing countries with extensive exposure

The United States Public Health Service set an interim standard of 50 microg/l in 1942, but as early as 1962 the US Public Health Service had identified 10 microg/l as a goal which later became the World Health Organization Guideline for drinking water in 1992. Epidemiological studies have shown that about one in 10 people drinking water containing 500 microg/l of arsenic over many years may die from internal cancers attributable to arsenic, with lung cancer being the surprising main contributor. A prudent public health response is to reduce the permissible drinking water arsenic concentrations. However, the appropriate regulatory response in those developing countries with large populations with much higher concentrations of arsenic in drinking water, often exceeding 100 microg/l, is more complex. Malnutrition may increase risks from arsenic. There is mounting evidence that smoking and arsenic act synergistically in causing lung cancer, and smoking raises issues of public health priorities in developing countries that face massive mortality from this product. Also, setting stringent drinking water standards will impede short term solutions such as shallow dugwells. Developing countries with large populations exposed to arsenic in water might reasonably be advised to keep their arsenic drinking water standards at 50 microg/l.     

Effect of hypothyroidism and its treatment on the IGF system in infants and children

We performed a study on infants and children with hypothyroidism to determine the effect of hypothyroidism and its correction on components of the IGF system. A total of 35 patients were subdivided into four groups based on age and severity of the disease. Serum concentrations of immunoreactive IGF-I, free IGF-I, IGFBP-2 and IGFBP-3 were measured before and after treatment and compared to controls matched for age, sex and puberty. Baseline total IGF-I (TIGF-I) concentrations were significantly lower prior to treatment in the infants with severe hypothyroidism and increased significantly after thyroxine therapy. Baseline free IGF-I (FIGF-I) concentration was significantly lower prior to treatment in infants with severe hypothyroidism when compared to controls but did not increase significantly after treatment. In infants with severe and compensated hypothyroidism, IGFBP-3 concentrations prior to treatment were lower when compared to controls. These concentrations increased during treatment. Baseline IGFBP-2 levels did not differ from the control values in both these groups but decreased significantly after correction of the hypothyroidism. Although these changes appeared to occur with thyroxine therapy, multiple regression analysis suggested that age was a more important determinant of the changes observed in these parameters than serum thyroxine concentration. In children with acquired hypothyroidism no difference in any of these parameters was noted between hypothyroid patients and controls. TIGF-I increased significantly on thyroxine therapy, but the difference was small. No significant differences were noted in other measured parameters with thyroxine therapy. In older children with compensated hypothyroidism no significant differences were noted in any of the measured parameters in the pretreatment, post-treatment and control groups. In conclusion, although changes appear in TIGF-I, IGFBP-3 and IGFBP-2 in infants with congenital hypothyroidism when they are treated with thyroxine, age appears to be the more important determinant of these changes than does thyroxine concentration. In older children with acquired hypothyroidism, TIGF-I and FIGF-I levels were not significantly lower than in age- and sex-matched controls. After treatment only TIGF-I levels increased.     

Plasminogen activator inhibitor type 1 (PAI1) and platelet glycoprotein IIIa (PGIIIa) polymorphisms in Black South Africans with pre-eclampsia

BACKGROUND: Association of fibrin abnormalities with pre-eclampsia prompted this study to examine whether polymorphisms in the plasminogen activator inhibitor Type 1 and platelet glycoprotein IIIa genes constitute risk factors for this condition. METHODS: A group of 151 Black Zulu-speaking pre-eclamptics was examined for 4G/5G plasminogen activator inhibitor Type 1 and PlA1/A2 platelet glycoprotein IIIa polymorphic alleles using standard techniques. Results were compared with those found in 217 ethnically matched healthy normotensive pregnant women who had normal full-term gestations. RESULTS: Pre-eclamptic patients had a slightly higher frequency of the 4G plasminogen activator inhibitor Type 1 allele (15%) compared with the controls (12%); this was reflected also in the heterozygote frequency (28% and 22%) for the patients and the controls, respectively. These differences were not significant. Only 2% of this population was found to be homozygous for the 4G allele. No differences were observed in the platelet glycoprotein IIIa polymorphism genotype and allele frequency distribution between the patients and the controls. CONCLUSIONS: Neither the 4G allele of the plasminogen activator inhibitor Type 1 nor the PlA2 allele of the platelet glycoprotein IIIa have any significant role as risk factors in the patho-etiology of pre-eclampsia in Black South Africans, although these genes cannot yet be excluded as contributory to this disorder. It is possible that the underlying causes of pre-eclampsia may vary between different ethnic populations.     

Itemized bill: novel method to audit the process of laparoscopic cholecystectomy

One of the recurring obstacles to the successful completion of a medical audit cycle is the unavailability of accurate and complete information. This is particularly evident in the review of clinical processes, where the hand-written medical record is the source of information. We have attempted to bypass this information deficit by using information recorded primarily for financial transactions, using the itemized bill. The study was conducted in two parts. Initially information recorded as an itemized bill for the in-hospital process of laparoscopic cholecystectomies over a one-year period was analyzed. Areas for change in practice were identified, and recommendations were developed. These recommendations were presented to a multidisciplinary group consisting of consultants, residents, and nursing staff involved in caring for these patients. A clinical pathway was developed and implemented from these recommendations. One year after introduction, a review of the clinical pathway was undertaken using the same methodology. The in-hospital process consisted of 23 charge categories according to the itemized bill. Of these, 8 accounted for 95% of the total charge. The surgeons fee and the anesthesiologists fee accounted for 34% of the total; medical/surgical supplies, 20%; operating theater time, 17%; pharmacy, 7%; radiology, 5%; laboratory, 7%; and ward, 4%. Areas were identified in the latter 6 categories for change. Review of practice 1 year after implementation of the changes showed that a large number of recommendations were in place. We describe a new method for auditing the processes of medical care, using the itemized bill to adapt and use information primarily recorded for financial purposes.     

Imported malaria in Kuwait (1985-2000)

BACKGROUND: The objective of this study was to document the status of malaria infection and effect of preventive measures on the epidemiologic profile of imported malaria cases in Kuwait during 1985-2000. METHODS: The study included screening of two groups of individuals for malaria infection by microscopy; (1) all migrant workers from malaria-endemic countries on their first entry to Kuwait; and (2) all suspected malaria cases already residing in the country. The study period was divided into pre-war (1985-1990), postwar (1992-1997) and proactive preventive (1998-2000) periods. During the proactive preventive period, the home countries were also involved in screening for malaria infection in all prospective immigrants to Kuwait. RESULTS: The annual incidence of malaria cases detected during the pre-war, postwar and proactive preventive periods ranged between 465 and 1,229, 654 and 1,379, and 248 and 393, respectively. Plasmodium vivax infection was detected in 71% of the cases and P. falciparum in 27%. The number of malaria cases detected increased to >1,300 after the war during 1992-1993. However, the number of malaria cases dropped significantly to less than 400 during 1998-2000 (p80%) of malaria patients were young male adults between 21 and 40 years of age. The data on drug resistance were not well defined, due to limited testing. CONCLUSION: This study suggests that the proactive preventive program to screen all prospective immigrants for malaria infection in their home countries significantly reduced the numbers of imported infections to <400 cases/year, a drop of 52.6%. In addition, it also identified a group of settled immigrants, the majority of whom were at high risk for acquisition of malaria infection during their visit to home countries. There is an urgent need to target this group for prevention strategies such as education/information and other preventive measures against malaria infection.     

Surgical wound infection surveillance in general surgery procedures at a teaching hospital in Pakistan

BACKGROUND: A surveillance system was established at the Aga Khan University Hospital in Karachi, Pakistan, to determine surgical wound infection (SWI) rates, trends, and risk factors; and to compare rates with those reported by the National Nosocomial Infection Surveillance (NNIS) system of the Centers for Disease Control and Prevention. METHODS: Surveillance was performed from January 1997 to December 1999. Risk categorization was on the basis of the NNIS system. P <.05 was set for statistically significant difference between groups. Data were analyzed using the Epi-Info software (version 6.04, CDC, Atlanta, Ga). RESULTS: Overall SWI rates for the NNIS risk categories 0, 1, 2, and 3 were 1.9%, 3.7%, 6.7%, and 5.1%, respectively. SWI rate in 0 risk category decreased from 3% in 1997 to 1.1% in 1999 (P =.06). Multivariate analysis showed that SWI rates were higher after mastectomy (odds ratio [OR] 4.28, 95% confidence interval [CI] 1.8-10), hernia repair (OR 3.28, 95% CI 1.6-6.7), gastrointestinal resection (OR 2.2, 95% CI 0.88-5.9), skin procedures (OR 1.97, 95% CI 0.89-4.3), appendectomy OR 0.57, 95% CI 0.20-1.60, and miscellaneous procedures (OR 3.6, 95% CI 1.6-7.7), as compared with cholecystectomy. Other risk factors were contaminated type of operation (OR 2.6, 95% CI 1.2-5.5), and duration of operation exceeding the NNIS standard of "T" hours (OR 2.6, 95% CI 1.7-4). CONCLUSION: The SWI rates at the Aga Khan University Hospital are higher than the NNIS standards. There was a downward trend in the SWI rates during the surveillance period. A decrease in the duration of surgical procedures could further reduce the risk.