Many different factors can temporarily or permanently impair movement and impairs cortical organization, e.g. hand immobilization. Such changes have been widely studied using electroencephalography. Within this context, we have investigated the immobilization effects through the theta band coherence analysis, in order to find out whether the immobilization period causes any changes in the inter and intra-hemispheric coherence within the cerebral cortex, as well as to observe whether the theta band provides any information about the neural mechanisms involved during the motor act. We analyzed the cortical changes that occurred after 48 hours of hand immobilization. The theta band coherence was study through electroencephalography in 30 healthy subjects, divided into two groups (control and experimental). Within both groups, the subjects executed a task involving flexion and extension of the index finger, before and after 48 hours. The experimental group, however, was actually submitted to hand immobilization. We were able to observe an increase in the coupling within the experimental group in the frontal, parietal and temporal regions, and a decrease in the motor area. In order to execute manual tasks after some time of movement restriction, greater coherence is present in areas related to attention, movement preparation and sensorimotor integration processes. These results may contribute to a detailed assessment of involved neurophysiological mechanism in motor act execution.
Hand immobilization; qEEG coherence; Sensorimotor integration; Theta band
HE are common acute complications of diabetes mellitus (DM) and include diabetic ketoacidosis (DKA), normo-osmolar hyperglycemic state (NHS) and hyperosmolar hyperglycemic state (HHS). They contribute a lot to the mortality and morbidity of DM. The clinical features include dehydration, hyperglycemia, altered mental status and ketosis. The basic mechanism of HE is a reduction in the net effective action of circulating insulin, resulting in hyperglycemia and ketonemia (in DKA) causing osmotic diuresis and electrolytes loss. Infection is a common precipitating factor.
Measurement of serum C-peptide provides an accurate assessment of residual β-cell function and is a marker of insulin secretion in DM patients.
Aim and objectives
To assess the level of pancreatic beta cell function in HE patients, using the serum C-peptide.
The biodata and clinical characteristics of the 99 subjects were collated using a questionnaire. All subjects had their serum C-peptide, glucose, electrolytes, urea, creatinine levels, urine ketones determined at admission. Results of statistical analysis were expressed as mean ± standard deviation (SD). A p value <0.05 was regarded statistically significant. Correlation between levels of serum C-peptide and admission blood glucose levels and the duration of DM respectively was done.
The mean age of the subjects was 51 (SD ± 16) years and comparable in both sexes. Mean duration of DM was 6.3 (SD ± 7.1) years, with 35% newly diagnosed at admission.
The types of HE in this study are: DKA (24.7%), NHS (36.1%), and HHS (39.2%). Mean blood glucose in this study was 685 mg/dL, significantly highest in HHS and lowest in NHS. Mean serum C-peptide level was 1.6 ng/dL. It was 0.9 ng/dL in subjects with DKA and NHS while 2.7 ng/dL in HHS (p>0.05).
Main precipitating factors were poor drug compliance, new-onset of DM and infection.
Most (70%) of subjects had poor pancreatic beta cell function, this may be a contributory factor to developing HE. Most subjects with high C-peptide levels had HHS.
Electronic supplementary material
The online version of this article (doi:10.1186/1755-7682-7-50) contains supplementary material, which is available to authorized users.
The human brain is a system consisting of various interconnected neural networks, with functional specialization coexisting with functional integration occurring both; temporally and spatially at many levels. The current study ranked and compared fast and slow participants in processing information by assessing latency and amplitude of early and late Event-Related Potential (ERP) components, including P200, N200, Premotor Potential (PMP) and P300. In addition, the Reaction Time (RT) of participants was compared and related to the respective ERP components. For this purpose, twenty right-handed and healthy individuals were subjected to a classical ERP “Oddball” paradigm. Principal Component Analysis (PCA) and Discriminant Function analyses (DFA) used PRE components and the Reaction Time (RT) to classify individuals. Our results indicate that latencies of P200 (O2 electrode), N200 (O2), PMP (C3) and P300 (Pz) components are significantly reduced in the group of fast responding participants. In addition, the P200 amplitude is significantly increased in the group of fast responding participants. Based on these findings, we suggest that the ERP is able to detect even minimal impairments, in the processing of somatosensory information and cognitive and motor stages. Hence, the study of ERP might also be capable of assessing sensorimotor dysfunctions in healthy old-aged people and in neuropsychiatric patients (suffering from dementia, Parkinson’s disease, and other neurological disorders).
Slow- and fast-participants; Odd-ball; Event-related potential; P200; N200; Pre-motor potential; P300; Reaction time
In the light of the impact that pain has on patients, emergency department (ED) physicians need to be well versed in its management, particularly in its acute presentation. The goal of the present study was to evaluate the prevalence of unrelieved acute pain during ED stay in a Moroccan ED, and to identify risk factors of unrelieved pain.
Prospective survey of patients admitted to the emergency department of Ibn Sina teaching university hospital in Rabat (Morocco). All patients with acute pain over a period of 10 days, 24 hours each day were included. From each patient, demographic and clinical data, pain characteristics, information concerning pain management, outcomes, and length of stay were collected. Pain intensity was evaluated both on arrival and before discharge using Numerical Rating Scale (NRS). Comparison between patient with relieved and unrelieved pain, and factors associated with unrelieved pain were analyzed using stepwise forward logistic regression.
Among 305 patients who complained of acute pain, we found high levels of intense to severe pain at ED arrival (91.1%). Pain intensity decreased at discharge (46.9%). Unrelieved pain was assessed in 24.3% of cases.
Patients with unrelieved pain were frequently accompanied (82.4% vs 67.1%, p = 0.012), and more admitted daily than night (8 am-20 pm: 78.4% vs 64.9%; 21 pm-7 am: 21.6% vs 35.1%, p = 0.031), and complained chiefly of pain less requently (56.8% vs 78.8%, p<0.001). They had progressive pain (73% vs 44.2%, p<0.001), and had a longer duration of pain before ED arrival (72-168 h: 36.5% vs 16.9%; >168 h: 25.5% vs 17.7%, p<0.001).
In multivariate analysis, predictor factors of unrelieved pain were: accompanied patients (OR = 2.72, 95% CI = 1.28- 5.76, p = 0.009), pain as chief complaint (OR = 2.32, 95% CI = 1,25-4.31, p = 0.007), cephalic site of pain (OR = 6.28, 95% CI = 2.26-17.46, p<0.001), duration of pain before admission more than 72 hours (72-168 h (OR = 7.85, 95% CI = 3.13-25.30, p = 0.001), and >168 h (OR = 4.55, 95% CI = 1.77-14.90, p = 0.02).
This study reported high levels of intense to severe pain at ED arrival. However, one quarter patients felt on discharge from the ED that their pain had not been relieved. The relief of pain in ED depend both sociodemographic, clinical, and pain characteristics factors.
Emergency department; Pain; Pain relief; Unrelieved pain
Uterine tumors resembling ovarian sex cord tumors (UTROSCT) are uterine neoplasms of unknown histiogenesis which show near complete differentiation towards ovarian sex cord elements and are postulated to arise from pluripotential uterine mesenchymal cells or endometrial stromal cells with secondary sex cord differentiation.
A 48 year old post-menopausal women presented with abnormal uterine bleeding for which she underwent total abdominal hysterectomy with bilateral salpingo-ophorectomy. Gross examination revealed a gelatinous grayish white tumor confined to the myometrium, 7 cm in maximum dimention. Microscopic examination revealed monomorphic round to oval tumor cells in anastomosing cords and trabeculae with myxoid background. Immunohistochemically, tumor cells showed diffuse positivity for vimentin, CD99 and S100, while focal positivity was seen with pancytokeratin immunostain. The case was diagnosed as UTROSCT. No evidence of metastasis was found on systemic clinical and radiologic workup.
UTROSCT are rare uterine tumors which can be diagnosed with certainty on morphologic and immunohistochemical grounds. It is important to recognize these tumors as they behave differently from endometrial stromal tumors with sex cord like elements (ESTSCLE).
Uterine tumors resembling ovarian sex cord tumors (UTROSCT); Endometrial stromal tumor with sex cord like elements (ESTSCLE); CD99
Thyroid swelling is common problem among South Asian women. Although benign nodules far outnumber cancerous lesions, the risk of malignancy needs to be evaluated preoperatively for which fine needle aspiration cytology (FNAC) is widely used. Bethesda system for reporting thyroid cytopathology (BSRTC) was introduced to streamline the reporting of thyroid aspirates. We aimed to evaluate the disease spectrum of thyroid cytopathology and correlation of BSRTC with final histopathology in our setup.
The study was conducted at Histopathology department of Liaquat National Hospital, Karachi, involving 528 patients with thyroid swelling who underwent FNAC. Out of these 528 cases, 61 patients subsequently underwent surgical excision. Results of final histopathology were correlated with cytologic diagnosis.
Mean age of the patients included in the study was 39.7 ± 13(14–84) and male to female ratio was 1:3.6. Out of total 528 cases, 403 cases were diagnosed as benign (Bethesda 2) and 67 were Bethesda 3 (follicular lesion of undetermined significance, FLUS) while 22 cases were categorized as either malignant or suspicious for malignancy (Bethesda 6 and 5). Histopathologic correlation was done in 61 cases. For Bethesda 5 and 6 categories, 100% concordance was found, however for Bethesda 2 category, 5 out of 45 cases were found to have malignant diagnosis on final histopathology. The incidence of malignancy in Bethesda categories 2 through 4 were 11.1%, 33.4%, 25%, 100% and 100% respectively. Overall accuracy of FNA cytology was 80.3% with 64.3% sensitivity and 85.1% specificity.
Our study validated the accuracy of BSRTC in our setup. Therefore we recommend routine use of BSRTC for reporting thyroid cytopathology for initial workup of patients with thyroid nodule. However, risk of malignancy was found to be significantly high in Bethesda 3 category to warrant further workup including ultrasound/thyroid scan in addition to repeat FNAC.
Bethesda system for reporting thyroid cytopathology (BSRTC); Fine needle aspiration cytology (FNAC); Thyroid nodule
Stroke is a major health issue in Nigeria and it is also a common cause of emergency admissions. Stroke often results in increased morbidity, mortality and reduced quality of life in people thus affected. The risk factors for stroke include metabolic abnormalities such as dyslipidaemia and diabetes mellitus (DM). The stress of an acute stroke may present with hyperglycaemia and in persons without a prior history of DM, may be a pointer to stress hyperglycaemia or undiagnosed DM.
This was a cross sectional study carried out over a period of one year in a teaching hospital in Lagos, Nigeria. Patients with acute stroke admitted to the hospital within three days of the episode of stroke and who met other inclusion criteria for the Study were consecutively recruited. Clinically relevant data was documented and biochemical assessments were carried out within three days of hospitalization. Tests for lipid profile, glycosylated haemoglobin(HbA1c), and blood glucose at presentation were carried out. The presence of past history of DM, undiagnosed DM, stress hyperglycaemia and abnormal lipid profile were noted. Students t test and Chi square were the statistical tests employed.
A total of 137 persons with stroke were recruited of which 107 (76%) met the defining criteria for ischaemic stroke. The mean age and age range of the Study subjects were 62.2 (11.7) and 26–89 years respectively. The Study subjects were classified according to their glycaemic status into the following categories viz; stress hyperglycaemia, euglycaemia, DM and previously undiagnosed DM. Stress hyperglycaemia occurred commonly in the fifth decade of life and its incidence was comparable between those with cerebral and haemorrhagic stroke. The commonly occurring lipid abnormalities were elevated LDL-C and low HDL.
The detection of abnormal metabolic milieu is a window of opportunity for aggressive management in persons with stroke as this will improve outcome. Routine screening for hyperglycaemia in persons with stroke using glycosylated haemoglobin tests and blood glucose may uncover previously undiagnosed DM.
A web-based tool was developed and piloted by being made available to healthcare staff in Wales from September 2012 to March 2013. This evaluation included two primary outcome measures: general health and mental well-being, and six secondary outcome measures: sickness absence, alcohol use, healthy eating, smoking, physical activity and maintaining a healthy BMI. The aim was to assess the feasibility of a web-based tool to improve health behaviours in healthcare staff.
Healthcare staff joined via a website, chose two of five challenges, and recorded their health behaviours using an online tool on a regular basis. Evaluation was undertaken by comparing baseline and follow up questionnaires.
1708 individuals explored the programme’s website, of whom 1320 selected two lifestyle challenges to address. Of these 346 individuals (26.2%; 346/1320) completed the end of project evaluation questions for the main outcome and provided the basis of the evaluation. Comparing pre:post data among respondents who engaged with the programme as a whole, self-reported general health status improved in 35.3% (n = 122, p = 0.001); mental health status improved in 33% (n = 110, p = 0.02); alcohol consumption score (AUDIT-C classification) fell in 27.2% (n = 71, p = 0.001); reported fruit and vegetable consumption (7 day recall) increased (p = 0.001); average time spent on vigorous exercise increased from 40.6 minutes a week to 67.6 minutes a week (p = 0.001); and 41 individuals noted a positive change to their BMI classification category (p = 0.001).
Combining interactive web-based tools as part of a multi-media programme is feasible, increases health behaviours and generates interest among a proportion of the healthcare workforce. Further work is required to improve maintenance of engagement over time.
The literature indicates that chronic obstructive pulmonary disease (COPD) affects cardiac autonomic control. In this study, we conducted a literature review in order to investigate the heart rate variability (HRV) in COPD subjects.
A search was performed in Medline database, using the link between the keywords: “autonomic nervous system”, “cardiovascular system”, “COPD” and “heart rate variability”.
The search resulted in a total of 40 references. Amongst these references, the first exclusion resulted in the barring of 29 titles and abstracts, which were not clearly related to the purpose of review. This resulted in a total of 11 articles that were then read and utilized in the review. The selected studies indicated that there is significant reduction of HRV in patients with COPD, characterized by reduction of indices that assess parasympathetic activity in addition to dealing with the global autonomic modulation. We also established that supervised exercise can reduce these harmful effects in COPD patients. Also, it was reported that the use of non-invasive ventilation in these patients may contribute to the improvement of respiratory symptoms, with no impairing, and may even induce positive responses in cardiac autonomic regulation.
The studies indicate a need for further investigations to guide future therapies to improve the treatment of cardiovascular system in the respiratory diseases.
Autonomic nervous system; COPD; Heart rate variability; Cardiovascular system
Spinal muscular atrophies (SMAs) are a group of disorders characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem. It is transmitted by autosomal recessive inheritance and most of these conditions are linked to SMN gene. Even if the clinical picture is mainly dominated by the diffuse muscular atrophy, some patients can also show atypical clinical features such as myoclonic epilepsy (“SMA plus”), which may be related to other genes. In particular, the association of SMA and progressive myoclonic epilepsy (PME) has been previously described.
We present a case of two brothers with late onset SMA associated with a unique form of non progressive myoclonic epilepsy without cognitive impairment or ataxia. They had identical clinical and electrophysiological features.
The association of SMA with myoclonic epilepsy may constitute a separate and genetically independent syndrome with unique clinical and electrophysiological findings. Collection of similar cases with genetic studies is needed to define the phenotype clearly and to identify new genes and molecular pathogenetic mechanisms involved in this condition.
Spinal muscular atrophy; Myoclonic epilepsy
The objective of this study is to determine the time interval from decision to seek medical help and arrival of the patients to the emergency department (ED). The duration of stay in ED was also calculated. This study also assesses factors responsible delayed presentation to hospital. This prospective study was conducted during day timings (9 am to 3 pm) from May 2012 to August 2012 in ED at Civil Hospital, Karachi. Patients older than 18 years and meeting the inclusion criteria were considered to be eligible for the study. Statistical analysis was done using SPSS version 17. The study sample consisted of 4,226 patients with a response rate of 96.5%. The median decision time was 146 minutes (IQR = 74–339), median transit time was 84 minutes (IQR = 42–188), median physician time was 58 minutes (IQR = 47–103), median diagnostic time was 148 minutes (IQR = 135–192), median transfer time was 155 minutes (IQR = 118–274) and the median ED LOS was 327 minutes (IQR = 209–488). Patient beliefs regarding spontaneous resolution of the symptoms was the most common reason (44.8%) cited for increased time spent in taking decision to seek medical help. Mode of transportation other than ambulance and traffic gridlock were the most common reasons found to be significantly associated with increased transit time (p < 0.05). The time intervals calculated from our study were found to be higher than studies reported from countries. This calls for urgent intervention for formulation of triage systems to improve patient treatment and satisfaction.
Emergency; Medicine; Civil Hospital; Karachi; Pakistan; Prehospital; Hospital; Delay; Decision time; Transit time; Physician time; Diagnostic time; Transfer time; Chest pain; Abdominal; Respiratory; Neurologic; Urogenital; Musculoskeletal; Trauma; Poisoning; Firearm
Flexible poles are tools used to provide rapid eccentric and concentric muscle contractions. It lacks in the literature studies that analyze acute cardiovascular responses in different exercises performed with this instrument. It was investigated the acute effects of exercise with flexible poles on heart period in healthy women.
The study was performed on 32 women between 18 and 25 years old. It was evaluated the heart rate variability (HRV) in the time (SDNN, RMSSD and pNN50) and frequency domain (HF, LF and LF/HF ratio). The subjects remained at rest for 10 minutes. After the rest period, the volunteers performed the exercises with the flexible poles. Immediately after the exercise protocol, the volunteers remained seated at rest for 60 minutes and HRV were analyzed.
It was observed no significance changes in the time domain (SDNN: p = 0.14; RMSSD: p = 0.8 and pNN50: p = 0.86) and frequency domain indices (LF (nu): 0.4; LF (ms2): p = 0.34; HF (nu): p = 0.4; HF (ms2): p = 0.8 and LF/HF ratio: p = 0.3) between before and after single bout of exercise with flexible pole.
A single bout of exercise with flexible pole did not significantly change cardiac autonomic regulation in healthy women.
Cardiovascular system; Autonomic nervous system; Exercise therapy
Paroxysmal Nocturnal Hemoglobinuria (PNH) is a rare type of acquired hemolytic anemia that is frequently associated with thrombophilia. It may rarely present with cerebral venous sinus thrombosis, which manifests clinically with signs of raised intracranial pressure and requires lifelong anticoagulation therapy. One such rare presentation was seen in a 28 years old male who had history of recurrent episodes of passing red colored urine and this time presented with severe headache. He was diagnosed to have cerebral venous sinus thrombosis and on further workup was found to be suffering from PNH.
Endocarditis is a type of infection that is common in internal medicine wards and in haemodialysis clinics. The location that is most affected are the heart valves. Herein, we report a case of an uncommon abscess, a sub-endothelial abscess between the transition of the superior vena cava and the right atrium. There were several emboli to the lung and foot, and the agent was related to Staphylococcus aureus and a double-lumen catheter. Usually, this type of abscess is located in valves, either the tricuspid valve if related to catheters or injection drug use or the mitral valve if related to other causes. An exhaustive review was made, but we found no information about the location of this abscess and the rarity of the event motivating the report of infection.
Endocarditis; Central venous catheters; Renal dialysis; Hospitalisation
Current grading system in application by WHO/ISUP divides urothelial malignancies in low and high grade by morphologic criteria while strict segregation may become cumbersome in limited tissue specimens. As grading these carcinomas are of utmost prognostic significance after depth of invasion, therefore we evaluated the role of immunohistochemical expression of p53 and cytokeratin 20 as an adjuctive tool in grading urothelial carcinoma.
The study was conducted in Aga khan university hospital, Histopathology section from December 2010 till June 2011 for duration of six months. It involved 95 cases of urothelial carcinomas diagnosed on trans-uretheral resection specimens of bladder growth. Immunohistochemical expression of p53 and cytokeratin 20 was performed according to standard protocols and correlated with grade and depth of invasion.
There were 48 cases (50.5%) of low grade and 47 cases (49.5%) of high grade urothelial carcinoma included in the study. Male to female ratio was 4.3:1. Majority of patients (80%) were seen in 45 to 90 years age group. Diffuse positive expression of cytokerain 20 was noted in 33 cases (68.8%) of high grade and 19 (40.4%) low grade tumors. Strong positive expression of p53 was seen in 35 cases (72.9%) of high grade while only 17 cases (36.2%) of low grade tumors showed strong p53 expression.
Significant difference in expression of Cytokeratin 20 and p53 was found between low and high grade urothelial carcinoma. Therefore we suggest combined use of these markers may be helpful in assigning grade to urothelial carcinoma especially when histologic features are borderline.
Papillary urothelial carcinoma; p53; Cytokeratin 20
Tuberculosis is a contagious infectious disease mainly caused by the bacteria Mycobacterium tuberculosis that still meets the priority criteria - high magnitude, transcendence and vulnerability - due to the threat it poses to public health. When taking into consideration the vulnerability conditions that favor the onset of the disease, this article aimed to investigate the implications originated from individual and social vulnerability conditions in which tuberculosis patients are inserted. Databases like MEDLINE, LILACS and SciELO were searched in Portuguese, Spanish and English using the descriptors tuberculosis and vulnerability, and 183 articles were found. After the selection criterion was applied, there were 22 publications left to be discussed. Some of the aspects that characterize the vulnerability to tuberculosis are: low-income and low-education families, age, poor living conditions, chemical dependency, pre-existing conditions/aggravations like diabetes mellitus and malnutrition, indigenous communities, variables related to health professionals, intense border crossings and migration, difficulty in accessing information and health services and lack of knowledge on tuberculosis. Much as such aspects are present and favor the onset of the disease, several reports show high incidence rates of tuberculosis in low vulnerability places, suggesting that some factors related to the disease are still unclear. In conclusion, health promotion is important in order to disfavor such conditions or factors of vulnerability to tuberculosis, making them a primary target in the public health planning process and disease control.
Tuberculosis; Vulnerability; Social vulnerability; Vulnerability analysis; Vulnerability study; Health vulnerability; Transmissible diseases prevention
The epidemic of nutrition related non-communicable diseases such as type 2 diabetes mellitus and obesity has reached to epidemic portion in the Sri Lanka. However, to date, detailed data on food consumption in the Sri Lankan population is limited. The aim of this study is to identify energy and major nutrient intake among Sri Lankan adults.
A nationally-representative sample of adults was selected using a multi-stage random cluster sampling technique.
Data from 463 participants (166 Males, 297 Females) were analyzed. Total energy intake was significantly higher in males (1913 ± 567 kcal/d) than females (1514 ± 458 kcal/d). However, there was no significant gender differences in the percentage of energy from carbohydrate (Male: 72.8 ± 6.4%, Female: 73.9 ± 6.7%), fat (Male: 19.9 ± 6.1%, Female: 18.5 ± 5.7%) and proteins (Male: 10.6 ± 2.1%, Female: 10.9 ± 5.6%).
The present study provides the first national estimates of energy and nutrient intake of the Sri Lankan adult population.
Dietary survey; Nutrition survey; Energy intake; Sri Lanka; Adults
Glial tumors are most common brain tumors in our population. While the exact etiology and pathogenesis is unknown, the evaluation of current trends in the frequency and morphology of glial tumors is imperative to constitute better diagnostic and treatment protocols. Data pertaining to frequency and spectrum of glial tumors is scarcely available in our population. The aim of this study was to determine the morphologic spectrum of glial tumors prevalent in our population.
126 cases of glial tumors were retrospectively analyzed over a period of 5 years. Patients from all age groups and both genders were included in this study. Glial tumors were classified and graded according to WHO classification.
Glial tumors were more common in males with a sex ratio of 2:1 and mean age of 38.26 years. Astrocytomas were most common glial tumors (51.6%) followed by oligodendrogliomas (23%). Glioblastoma was the most frequent astrocytic tumor and was incomparably frequent in older age group.
In our study, Oligodendrogliomas and mixed oligoastrocytomas represent major pattern of disease in comparison with available regional data. Knowledge of these changing trends and patterns of glial tumor morphology and frequency can help in improvements and applications of newly emerging diagnostic and treatment modalities.
Glial tumors; Astrocytoma; Oligodendroglioma; Glioblastoma; Mixed oligoastrocytoma
Mitral valve stenosis is a common manifestation of chronic rheumatic heart disease. The presence of spontaneous echo contrast in the left atrium and left atrial appendage has been reported to be an independent predictor of thrombo-embolic risk in patients with mitral stenosis. The objective of this study was to retrospectively investigate various clinical and echocardiographic variables to predict the spontaneous echo contrast in these patients.
This is a bicentric retrospective study which includes 159 cases of symptomatic mitral stenosis from January 2011 to June 2012. All of the patients had transthoracic and transesophageal echocardiography. Patients who had significant mitral regurgitation (> Grade I), significant aortic valve disease, previous mitral valvulotomy and anticoagulation or antiplatelet therapy were excluded from the study. Our study population was divided into two groups based on the presence (Group I) or absence (Group II) of spontaneous echo contrast.
Left atrial spontaneous contrast was present in 34.6% of cases. Patients in this group have more frequent atrial fibrillation (P = 0.001), larger left atrial area (P = 0.027) and diameter (P=0.023), smaller mitral valve area (P = 0.025), and higher mean transmitral diastolic gradient (p = 0.003) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean age (p = 0.38), duration of symptoms (p = 0.4) and left ventricular ejection fraction (p = 0.7) between patients with and without spontaneous echo contrast. On multivariate analysis, only mitral valve area and transmitral diastolic gradient (OR: 18.753, 1.21, CI [1,838-191,332], [1,064-1,376], p: 0.013, 0.004, respectively) were found to be independently associated to the presence of spontaneous echo contrast.
Patients with severe rheumatic mitral stenosis in atrial fibrillation or sinus rhythm have a higher risk of developing spontaneous echo contrast. These patients might benefit from prophylactic anticoagulation. The long-term outcomes can be ascertained in a study over a longer period and with periodic follow-up.
Mitral stenosis; Left atrial spontaneous contrast; Transesophageal echocardiography; Anticoagulation
Pheochromocytoma crisis typically presents as paroxysmal episodes of headache, tachycardia, diaphoresis or hypertension. We describe an uncommon case of recurrent non-hypertensive heart failure with systolic dysfunction in a young female due to pheochromocytoma compression. It presented as acute pulmonary oedema while straining during pregnancy and later on as cardiogenic shock after a recreational body massage. Such crisis occurring during pregnancy is rare. Moreover, of the few reported cases of pheochromocytoma-induced cardiogenic shock, recreational body massage has not yet been reported as a trigger for this condition.
Body massage; Cardiogenic shock; Heart failure; Pheochromocytoma; Pregnancy
Leptospirosis presents diagnostic challenges to clinicians, in settings where other acute febrile illness are prevalent. The patterns of serial changes in haematological parameters in leptospirosis has not been evaluated previously.
Clinical and laboratory data were collected prospectively from patients with leptospirosis in two hospitals in Sri Lanka. Leptospirosis was diagnosed based on WHO clinical criteria with confirmation using Microscopic Agglutination Test titre > 400 or 4 fold rise between acute and convalescent samples. Full blood count parameters were analysed up to the 14th day of illness.
Data from 201 patients with leptospirosis were available. Leukocyte counts and absolute neutrophil counts showed a decline over the first 5 days of illness, then rose until the end of the second week. On day 3 of fever, the majority (75%) had normal leukocyte counts, and by day 5, leukocytosis was seen only in 38.1%; leucopenia was an uncommon finding. Lymphopenia was seen in over half on day 5, declining to just under a quarter of patients by day 10. Platelets declined over the first 6 days and then gradually rose. Thrombocytopenia was seen in nearly three-fourths of patients by day 5. Haemoglobin and haematocrit levels declined over the course of illness. Total white cell and neutrophil counts were higher, and haemoglobin and haematorcrit were significantly lower, in patients with severe disease.
Neither leukocytosis nor lymphopenia were prominent features, while thrombocytopenia was seen during the 3rd to 5th day of illness, with dropping haemoglobin levels. Neutrophilia and low haemoglobin levels appear to predict severe disease. These findings may be of use to clinicians in differentiating leptospirosis from other acute infections like dengue, and could help in predicting severe leptospirosis.
Leptospirosis; Platelets; Neutrophils; Lymphocytes
The ventral tegmental area is strongly associated with the reward system. Dopamine is released in areas such as the nucleus accumbens and prefrontal cortex as a result of rewarding experiences such as food, sex, and neutral stimuli that become associated with them. Electrical stimulation of the ventral tegmental area or its output pathways can itself serve as a potent reward. Different drugs that increase dopamine levels are intrinsically rewarding. Although the dopaminergic system represent the cornerstone of the reward system, other neurotransmitters such as endogenous opioids, glutamate, γ-Aminobutyric acid, acetylcholine, serotonin, adenosine, endocannabinoids, orexins, galanin and histamine all affect this mesolimbic dopaminergic system. Consequently, genetic variations of neurotransmission are thought influence reward processing that in turn may affect distinctive social behavior and susceptibility to addiction. Here, we discuss current evidence on the orquestic regulation of different neurotranmitters on reward-seeking behavior and its potential effect on drug addiction.
Dopamine; Orexin; Serotonin; Galanin; Histamine; Endocannabinoids; Reward-seeking behavior; Drug addiction
Cardiac arrhythmias occur during the acute stage of Dengue Haemorrhagic Fever. Dengue myocarditis is the most likely cause of the arrhythmias.
We report a 55-year-old patient with Dengue Haemorrhagic Fever presenting with transient ventricular trigeminy which has not been reported before.
Among many other known cardiac arrhythmia seen in DHF, ventricular trigeminy is also a possibility. Clinicians should be aware of this cardiac rhythm abnormality that can occur in dengue patients.
Dengue fever; Ventricular trigeminy; Dengue myocarditis
Chronic classical music was reported to increase parasympathetic activitywhen evaluating heart rate variability (HRV). It is poor in the literature investigation of the acute effects of baroque and heavy metal styles of musical auditory stimulation on HRV. In this study we evaluated the acute effects of relaxant baroque and excitatory heavy metal music on the geometric indices of HRV in healthy men.
The study was performed in 12 healthy men between 18 and 30 years old. We excluded persons with previous experience with music instrument and those who had affinity with the song styles. We analyzed the following indices: RRtri, TINN and Poincaré plot (SD1, SD2 and SD1/SD2 ratio). HRV was recorded at rest for ten minutes. Subsequently they were exposed to relaxant baroque or excitatory heavy metal music for five minutes through an earphone. After the first music exposure they remained at rest for more five minutes and them they were exposed again to Baroque or Heavy Metal music (65–80 dB). The sequence of songs was randomized for each individual.
The RRTri and SD2 indices were reduced during the heavy metal musical auditory stimulation (p < 0.05). No changes were observed regarding TINN, SD1 and SD1/SD2 ratio (p > 0.05).The qualitative Poincaré plot analysis indicated that during relaxant classical baroque music there was observed a higher beat-to-beat dispersion of RR intervals compared with no music exposure and during excitatory heavy metal musical auditory stimulation, showing higher HRV.
We suggest that excitatory heavy metal music acutely decreases global HRV.
Autonomic nervous system; Auditory stimulation; Cardiovascular system; Music
Dementia is a major health problem in advancing age with no definitive treatment. Occupational therapy interventions are recognized strategies in treatment of dementia. Quality of life (QOL) assessment has been reliably used as an objective index of an individual’s well being pertaining to interventions in dementia. A randomized controlled trial was conducted to study the effects of a novel occupational therapy program in improving QOL of subjects having mild to moderate dementia.
273 subjects older than 60 years were screened. 196 were excluded having cognitive impairment with no dementia (CIND). Remaining 77 subjects after satisfying DSM IV criteria for diagnosis of dementia were included in the study and were randomly assigned to experimental and control groups. Experimental group received a novel occupational therapy regimen along with medical treatment, while control group received only medical treatment for 5 weeks. Outcome measures included standard occupational therapy assessment and WHOQOL-BREF. Subjects were assessed at baseline and post intervention.
The mean age of participants was 69.39 years with male preponderance (80.5% male, 19.5% female). The quality of life (QOL) scores of physical and psychological domain in experimental groups significantly increased from 37.30 ± 5.42 and 45.13 ± 3.52 to 45.43 ± 7.32 and 51.50 ± 6.46 respectively. The QOL scores in social and environmental domains did not change significantly. The QOL scores in control groups declined in all domains with statistical significance found in social and environmental domain. (29.67 ± 4.58 and 38.49 ± 1.77 to 28.45 ± 5.26 and 38.18 ± 2.15 respectively).
This novel occupational therapy program improved the short term physical performance and psychological well being domain of quality of life in older adults with dementia. An improved physical performance is achieved by physical exercise of novel program and it creates sense of independency, increased motivation, positive outlook and reduced behavioral and psychological symptoms. The long term effects of the intervention can be ascertained in a study with longer period of intervention and follow-up.
Dementia; Occupational therapy; Quality of life; WHOQOL-BREFF