Journal of Advances in Medicine and Medical Research

Ludwig’s angina is a potentially lethal deep neck infection associated with rapid airway obstruction due to swelling of the neck, tongue and submandibular areas. Despite the name, it has no relation to angina pectoris. We report a case of an 80-year-old gentleman who presented with the unusual symptom of chest pain and previous history of diabetes mellitus and treated lymphoma, who was later diagnosed with Ludwig’s angina. Despite of early intravenous antibiotics, airway support and intensive care treatment patient died within 24 hours.
This case highlights the need for a high index of suspicion for Ludwig’s angina in patients with chest pain and neck swelling, as although it’s lethal condition but early, rapid and aggressive intervention can save lives.

Aims: Sinus of Valsalva aneurysms are rare anomalies. Aneurysmal dilatation of the sinuses of Valsalva in Marfan syndrome has been extensively studied. The aim of this study was to investigate clinical manifestation, diagnosis, histopathological findings and management of sinus of Valsalva aneurysms in non-Marfan patients.
Study Design: Retrospective analysis, case-series.
Methodology: A search of digital echocardiographic recordings, histopathology and electronic patient databases in our institution for the period 2004 – 2012 was performed. All patients with asymmetrical dilatation of at least one coronary sinus of Valsalva at postmortem and ruptured (or dissected) aneurysms on echocardiogram were included. Patients with Marfan syndrome and those with non-ruptured sinus of Valsalva aneurysms on echocardiogram were excluded.
Results: A total of 12 patients (7 males; mean age 36.1 years) were studied. The right coronary sinus was the most commonly affected (9/12). Involvement of more than 1 sinus was seen in 3/12 cases. Four patients died suddenly and another 6 had acute or rapidly worsening symptoms. Three sudden deaths were due to dissection or rupture with haemopericardium and tamponade. Five cases had concomitant congenital heart defects.
Conclusion: Sinus of Valsalva aneurysms are an uncommon cause of morbidity and mortality in non-Marfan patients. They are associated with certain congenital heart defects. There is often associated aortopathy. Sudden death can be the first manifestation and is most commonly due to aneurysm rupture or aortic dissection into the pericardial space. Echocardiography is the investigation of choice for diagnosis and follow-up. Prompt surgical or percutaneous intervention has an excellent long-term outcome.

Aim: Although guidelines and pharmacological interventions exist to manage pain, poor assessment and under-medication are prevalent. It was reported that inadequacy of pain management can be due to nurses’ lack of knowledge and training regarding pain management. Therefore, this study conducted to evaluate the impact of education on nurses’ knowledge and attitude regarding pain management.
Study Design: This study utilized the simple pre-post test design.
Sample: Seventy nurses participated in the study using convenience sampling and they were recruited from eleven hospitals in Jordan. The Knowledge and Attitudes Survey regarding pain was used to evaluate the effects of educational intervention on nurses’ knowledge and attitudes regarding pain management.
Place and Duration of Study: Al Al-Bayat University, between May to June 2012
Results: It was found that 54% of the participants were females and the average age was 29.5 (SD 8.4). The most important findings of the study were the following: a) low level of knowledge regarding pain management in the pre-test phase, the mean number of the correct answers was 19.20 (SD 5.4) out of 40 (total score if all items answered correctly; b) nurses` knowledge and attitudes were significantly improved after the course (Wilcoxon matched-pairs exact p < .001).
Conclusion: This study proved that short pain course could improve nurses’ knowledge and attitudes regarding pain management. However, the sustainability of the change needs to be further investigated.

Aims: One of the ways to treat HIV/AIDS is Antiretroviral therapy (ART), which consists different schemes and includes numbers of drugs. However, in view of the HLA polymorphism it is necessary to determine the best association of ART with the HLA class II haplotypes. The purpose of the current study is to evaluate various HLA class II haplotypes with ART effectiveness in HIV-infected patients.
Study Design: This study is a retrospective follow up on the association of ART with the HLA class II haplotypes of HIV/AIDS patients. From 254 Latvian HIV/AIDS infected patients - 195 men and 59 women blood was collected and HLA class II heliotypes were defined. Main ART therapy parameters were observed and compared.
Place and Duration of Study: Riga Stradiņš University, the Laboratory of Clinical Immunology and Immunogenetics, Riga, Latvia
Riga Stradiņš University, the Department of Infectology, Riga, Latvia
Riga Eastern clinical university hospital, Infectology Centre of Latvia, Riga
Methodology: The research included 254 Latvian HIV/AIDS infected patients - 195 men and 59 women. For monitoring immunological parameters were used: amount of CD4 + lymphocytes and HIV viral load, which were observed in 24-48 weeks. The efficacy criterias of ART were HIV RNA viral load <400 cop/ml - after 16-24 weeks, increase of CD4 + cell amount of 30-70 cells/µl after first 12 weeks and of 100-150 cells/µl after a year, and absence of new opportunistic infections after 12 weeks of ART treatment. For DNA extraction venous blood was used. HLA class II alleles DRB1 *, DQA1 *, DQB1 * genotyping was performed using PCR method.
Results: During examining the HLA class II haplotypes the most credible association with high immunological efficacy showed haplotypes 01:01/06:02-8/01:03, 01:01/03:01/01:02, 13:01/06:02-8/01:02.
After 12 weeks of treatment, CD4 + lymphocytes amount in a given group increased to 600-700 cells/µl, HIV RNA viral load decreased to 5 000 copy/ml, after 24-48 weeks of therapy - CD4 + lymphocytes amount increased to 806-900 cells/µl, and HIV viral load RNA decrease <400 copy/ml.
Low immunological association of effectiveness: HLA-DRB1*/ DQB1*/DQA1* 15:01/03:01/03:01, 17:01/05:01/02:01, 17:01/03:01/05:01, 07:01/03:01/02:01, 11:01/03:01/05:01, 15:01/03:02/01:02. The frequency of HLA-DRB1 and DQB1, each allele and genotype was compared between the patients and the controls using the chi-square test. The P value and odds ratio (OR) were calculated using EPI INFO software, version 06, with 95% confidence intervals and Fisher exact correction for small numbers.[16]
Conclusion: The given data shows the efficiency of ART therapy. No clinical progression of HIV (worsening of latent opportunistic infections) was observed during the ART treatment in study groups with existing haplotypes.

Aims: The purpose of this study was to compare the effectiveness QuikClot Combat Gauze (QCG) to a control group on hemorrhage control and investigate the effects of intravenous volume resuscitation on rebleeding and movement on hemostasis in a porcine model of hypothermia.
Design: This was a prospective, between subjects, experimental design. Twenty-two Yorkshire swine were randomly assigned to two groups: QCG (n = 11) or control (n=11).
Methods: The femoral artery and vein were transected. After 1 minute of uncontrolled hemorrhage, the hemostatic agent QCG was placed into the wound followed by standard wound packing. The control group underwent the same procedures without QCG. After 5 minutes of manual pressure, a pressure dressing was applied to the injury site. Initial resuscitation was performed with 500 mL of rapidly administered IV 6% Hetastarch. Following 30 minutes of observation, the dressings were removed and any additional blood loss was collected and total blood loss calculated. Hemostasis was defined as <2% total blood volume or ~ 100 mL in a 70 kg swine. If hemostasis occurred, 5 Liters of IV crystalloid were rapidly administered and the wound was again observed for rebleeding. If no bleeding occurred, the extremity on the side of the injury was systematically moved through flexion, extension, abduction and adduction sequentially 10 times or until rebleeding occurred.
Results: There were significant differences in hemorrhage (P=.01), the amount of volume resuscitation (P =.01) and movement (P =.03) between the QCG and control groups.
Conclusion: QCG is effective and statistically superior at controlling hemorrhage, allows for greater fluid resuscitation, and tolerates significant movement without rebleeding compared to the standard pressure dressing control in this hypothermic porcine model of uncontrolled hemorrhage.

Introduction: Patients with hypertension have an increased prevalence of type II diabetes mellitus and impaired glucose tolerance. Prevalence of prediabetes is increasing worldwide and experts have projected that more than 470 million people will have pre-diabetes by 2030. A proportion of 5-10% of people per year with pre-diabetes will progress to diabetes, with the same proportion converting back to normoglycemia. Blockade of Renin Angiotensin System [RAS] either by an Angiotensin converting enzyme (ACE) inhibitor or an Angiotensin receptor blocker (ARB) would slow down the progression of prediabetic state to diabetes.
Methods: This was an open labeled, prospective, observational cohort study and a total of 71 prediabetic hypertensive patients who were prescribed either an ACE inhibitor or ARB monotherapy were enrolled into the study. An oral Glucose Tolerance Test (GTT) was done in all the patients at baseline, end of 6 months and end of 1 year of treatment with RAS blockade.
Results: At the end of 1 year, out of cohort of 59 prediabetic hypertensive patients who completed the study, 28.81% were in the Normal glucose tolerance (NGT) group, 23.72% developed diabetes whereas 47.45% remained prediabetic at the end of study. In the prediabetic group, significant negative correlation was observed between Initial Systolic Blood Pressure (SBP1), Age, their interaction (Age × SBP1) and fall in GTT. Significant regression of fall in GTT with SBP1 and interaction of age and initial SBP (Age × SBP1) implies that initiation of treatment at an early age, at lower initial systolic blood pressure levels have a beneficial effect on the glucose tolerance state.
Conclusion: In prediabetic hypertensive patients, the blockade of RAS with either ACE inhibitor or ARB has significant preventive effect on the progression of Type II DM. The beneficial effect is more marked if the RAS based pharmacotherapy is initiated at low initial systolic blood pressure, especially at a relatively younger age. The exact nature of beneficial role of RAS blockade in addition to their hypotensive effect should be investigated by further studies.

Aim: Relationship between virus titers of live Infectious Bursal disease (IBD) vaccines and their serum-conversion abilities was studied.
Study design and Methodology: Five batches of each, of five IBD vaccine brands used in Nigeria, were tested for virus titers. Each of the vaccine brands was also used to vaccinate a group of fifteen 12-days old chicks to study their serum-conversion abilities. Mean antibody titers of the groups of chicks were plotted, on a graph, against virus titers of the vaccine brands used to vaccinate them.
Results: Mean Modified Passive Haemagglutination titers of IBD virus in the vaccines,were:1,065.60±780.03,1,472.00±748.55,2,112.00±1984.00,2,176.00±1920. 00 and 2,585.00±926.92 while mean antibody titers they elicited were, 1,356.80±241.51, 1,280.00±174.88, 448.00±79.25, 998.40±196.27 and 332.80±51.20, respectively. Line of best fit of graph of antibody titers of vaccinated chicks on vaccine titers, showed that reducing titers of the live IBD vaccines improved their immunogenicity.
Conclusions: The inverse relationship between virus titers of the vaccines and their serum conversion abilities, suggests that, if viral titers of live IBD vaccines are too high, immune-suppression instead of enhancement of immune response may occur.

Background: Dichotomizing a continuous outcome variable is a common approach to estimate the odds ratio (OR) as a measure of association. In the present study we aimed to compare a non-dichotomizing technique with logistic regression which exploits dichotomizing the response for estimating OR.
Method: Data including a total of 17,152 Iranian individuals aged 25–65 years were derived from the third national survey of non-communicable Diseases Risk Factors in Iran. To measure the associations between fasting blood glucose and attributed risk factors two distinct techniques were used. Using a non-dichotomizing technique, an approach proposed by B.K. Moser and L. Coombs (2004) was employed to estimate odds ratios and associated 95% confidence intervals (CI_s); A binary logistic regression model was also applied to fit the data as a common dichotomizing approach. Finally the results of two methods were compared by use of relative efficiencies and relative length of CI_s.
Results: The odds ratios provided by both approaches are approximately the same, but relative efficiencies and relative length of CI_s are greater than 2 which reflected better results for the technique used a non-dichotomizing approach compared to Logistic Regression Model.
Conclusions: Dichotomizing continues outcome variable is not necessary to estimate OR_s, especially when there is no pre-specified optimal cut-off point for the response variable.

Purpose: Starting the Conversation was a pilot project to test an intervention for childhood obesity, a major public health epidemic, using a free smartphone application (app). The primary aim was to assess students’ knowledge of nutritional indicators, physical exercise and use of screen time before and after the intervention.
Methods: The study was conducted in 2011-2012. The sample, recruited from seven high schools in Snohomish County, Washington, was 65.3% minority participants. Of the 118 participants in the sample (n=118), 79 handwrote their responses (n=78) and 36 responded via the app (n=39). We compared the frequency and types of physical exercise, frequency of screen time, and nutritional variables of high school students. Participants used the cell phone app or a handwritten log to record their daily entries for 20 days.
Results: Both males (n=43) and females (n=75) grades 9-12 used the app or handwritten entries. Participants who used the app ate less fast food and exercised more, as compared with those who recorded their entries by hand. Screen time usage decreased over the course of the study, based on a comparison of the post-survey level and the pre-survey level. Knowledge of recommended daily consumption of vegetables increased post-test in the app group and knowledge of water consumption increased significantly in both groups. There was no significant difference in BMI pre and post-test.
Conclusions: Patterns of nutritional intake, physical exercise and knowledge of these issues varied pre and post-test. It is critical to further examine factors associated with lack of physical activity and food intake patterns of youth using social media to further address the childhood obesity epidemic. Future research should focus on specific ethnic subgroups and an intervention at the school level aimed at the students with BMI ≥ 95th percentile.

Aims: To determine the prevalence and severity of cardiac arrhythmias in a rural Australian population using ECG assessment.
Study Design: This is a University-based research project. Comparative design with random samples used.
Place and Duration of Study: School of Community Health, Charles Sturt University, Albury, NSW, Australia.
Methodology: Five hundred and eight participants with or without a known history of cardiovascular disease were recruited via public media announcements indicating a health screening opportunity carried out at the local university. Their medical history was obtained and a 12-lead electrocardiography (ECG) was recorded. ECG recordings were classified into severity and prevalence determined in each category. The number of participants that had to be referred and had follow-up by the general practitioner was determined.
Results: Moderate to severe ECG anomalies, which included atrial fibrillation or left bundle branch block were identified in 58 (11.4%) of the participants. Forty (7.9%) individuals with ECG anomalies were referred to the general practitioner for further evaluation. Eight participants did not seek further advice. Twenty-two (68.8%) participants that made an appointment to see their general practitioner were either commenced on treatment, had their treatment changed or received surgery. A further 85 (16.7%) of individuals required regular follow-up in line with their ECG characteristics and other health information, presenting with non-clinical ECG changes that had the potential for adverse health outcomes in the future including long QT interval, right bundle branch block or left ventricular hypertrophy for instance.
Conclusion: Our study has demonstrated that a substantial number of patients in this rural community have both ECG abnormalities and or cardiac arrhythmias that required regular review or commencement of treatment by their doctor.

Aim: To describe a case of acute hepatic injury related to the use of Grifola frondosa in a patient with colon cancer.
Case Presentation: Patient is a 67 year old female with stage IV poorly differentiated adenocarcinoma of the colon, who presented with epigastric pain one month after resection of her primary tumor. A staging PET scan revealed metastasis to regional lymph nodes without solid organ involvement. Her home medications include longstanding amlodipine and losartan, and a recently started Grifola frondosa derivative. Her laboratory data was significant only for acute transaminitis (AST:967 U/L, ALT:768 U/L) without hyperbilirubinemia. Alcohol, acetaminophen, and a viral panel (EBV, CMV, hepatitis A/B/C) were all negative. A CT scan revealed heterogenous liver parenchyma without focal lesions. A subsequent liver biopsy demonstrated active portal inflammation with eosinophilic infiltration.
Discussion: The etiologies of significant acute transaminitis include viral hepatitis, ischemic liver injury, acetaminophen toxicity and drug-induced liver injury (DILI). Viral and ischemic hepatitis and acetaminophen toxicity were excluded based on laboratory analysis and imaging studies. Liver biopsy findings demonstrating the characteristic eosinophilic infiltration of a drug reaction favored DILI as the etiology of transaminitis in this case. With a RUCAM score of 7 calculated based on history, clinical course, and objective data, DILI was concluded to be probably attributed to the patient’s recent use of the Grifola frondosa extract.
Conclusion: A diagnosis of drug induced liver injury probably secondary to the use of Grifola frondosa extract was made after excluding all other causes of significant acute transaminitis.

Aims: This study aims to analyze the dose and length of hypnotic and sedative drug prescriptions under a free-to-visit health insurance system.
Study Design: Outpatients aged 15 years and older covered by the Taiwan National Health Insurance during 2007 (N=1,337,444) are included in this study.
Methodology: The total amount of prescriptions for each patient was described according to the WHO Defined Daily Dosage (DDD) equivalent. Participants were categorized into 4 groups by dimensions of length (90 days) and dose (3 DDD per day). Patient characteristics and prescription drug use patterns were examined using a multinomial logit regression.
Results: Although most prescription doses fell within the recommended ranges, the average flunitrazepam dose was substantially higher than that recommended for both long-term and high-dose users. Our results indicate that male sex, a psychiatric illness diagnosis, and receiving care at more than one institute were positively correlated with long-term use. However, these factors were negatively correlated with high-dose user. Distinct differences between the characteristics associated with long-term and high-dose use were observed, compared with normal users.
Conclusion: These findings call for clinicians and policy makers to focus their attention on potential safety and efficiency issues. The alignment of prescribing practices and guidelines is highly recommended.

Aims: Despite their high analgesic efficacy, opioids can provide only partial pain relief during a migraine attack and their tolerability profile is unsatisfactory. The aim of the present study was to investigate the potentiating properties of Hypericum perforatum L. (SJW) to identify a safe and tolerable adjuvant to opioid analgesia in migraine therapy.
Study Design: Experimental study.
Place and Duration of Study: Department of Neuroscience, Psychology, Drug Research, and Child Health (NEUROFARBA), University of Florence, Florence, Italy, between September 2008 and July 2009.
Methodology: A mouse model of meningeal nociception induced by administration of the nitric oxide donor sodium nitroprusside (SNP) was used. The following treatment groups were used: saline, SNP, morphine, SJW, SNP+morphine, SNP+SJW, SNP+morphine+SJW. The presence of thermal allodynia was evaluated through the cold plate test. The presence of behavioural side effects was determined by the evaluation of locomotor activity (rotarod test), spontaneous mobility and inspection activity (hole board test).
Results: SNP induced a long lasting thermal allodynia that appeared after 1 h, peaked after 3-4 h and disappeared 6 h after administration. The co-injection of a single low dose of SJW (1 mg/kg) with morphine (2-5 mg/kg) greatly increased the opioid analgesia (P<.05). SJW, when administered alone,was unable to counteract SNP-induced allodynia. Among the main components of this herbal drug, hypericin produced a potentiating activity comparable to that induced by SJW whereas hyperforin and flavonoids were ineffective. Animal gross’ behavior and locomotor activity were not altered by co-administrationof morphine and SJW.
Conclusion: Present results showed the potentiating activity of SJW on morphine antinociception in an animal model of migraine. This herbal drug might be proposedas adjuvant to opioid agonists to produce analgesia using lower, safer doses of opioids. This combination might represent a therapeutic perspective for migraine pain.

Aims: The objective of this review is to explore the methods of eye protection from corneal abrasions during general anesthesia as they relate to procedures utilizing visual evoked potentials (VEP) monitoring. Because these protective measures may lower the accuracy of the VEP equipment, we wish to establish through existing literature current effective eye protection (with a focus on Tegaderm™) and why they could potentially interfere with VEP recording.

Aims: A stroke is a neurological disorder and muscle weakness is the most prominent impairment. Whole-body vibration (WBV) is a possible modality of exercise that is useful for improving physical capacity, bone mass, balance, proprioception and the quality of life in healthy subjects and in patients with several diseases and among them, the neurological disorders. Considering the undesirable clinical conditions of the stroke patients, the aim of this review is to discuss about the benefits of the vibrations generated in the oscillating/vibratory platforms to those patients.
Methodology: A search was performed in the PubMed using the keywords stroke or "cerebrovascular accident" and "whole body vibration". An isolated search was performed with the term “whole body vibration”. Inclusion and exclusion criteria to select the publications were determined.
Results: It is found a limited number of publication involving WBV and the stroke with 16 articles. Of these, 9 publications were rejected for inclusion in this systematic review, due to they did not match the proposed inclusion criteria. Considering the studies that were analysed, about 57% of these have reported an improving in the clinical conditions of the stroke patients with statistical significance. Most probably the reason of the controversial results obtained with WBV findings can be attributed to the diversity of methods to measure the outcomes and the experimental design and the clinical characteristics of the subjects used, as well as the time elapsed post stroke.
Conclusion: Putting together the findings and considering the divergence of the results reported, it is suggested that the use of the vibration generated in the vibratory platform could be suitable to try to improve disorders of the stroke patients. However, it is important to consider the limited number of publications available in the PubMed involving searches evaluating the effect of the WBV in stroke patients.