Journal of Advances in Medicine and Medical Research

Aims: To present five patients with thumb clinodactyly and the results of surgical treatment in two patients who were followed till skeletal maturity.
Case Presentation: Four patients (five thumbs) exhibited an ulnar interphalangeal angulation and were all associated with a triphalangeal thumb, while in only one patient a radial deviation associated with a longitudinal epiphyseal bracket of the proximal phalanx was noted.
Three patients (four thumbs) received primary surgical treatment for thumb polydactyly. A three-phalangeal thumb was retained in all. Two of these thumbs were also treated surgically for clinodactyly. Removal of the accessory delta phalanx and reconstruction of the soft tissues was performed in a 3-year-old girl. Follow-up at 18 years of age revealed reduced size of the thumb, limitation of flexion and a secondary radial interphalangeal deviation. A closing wedge osteotomy of the shaft of the proximal phalanx, leaving the delta phalanx undisturbed, was performed in a 12-year-old girl. Follow-up at 18 years of age revealed no loss of thumb alignment but not improved function.
Discussion: The aim of surgical reconstruction of thumb clinodactyly is to create a painless thumb of adequate mobility, stability, alignment and size. Removal of an angulated middle phalanx in a very young child should be associated with a ligament reconstruction from the soft tissues. In an older child or adult, an osteotomy of the shaft of the proximal phalanx or fusion of the oblique joint and realignment with bone resection may be indicated. The real value of a surgical procedure may be evaluated only when the satisfactory result remains unimpaired beyond skeletal maturity.
Conclusion: Surgical reconstruction of thumb clinodactyly may require specific challenges and techniques to obtain a painless, properly aligned, stable thumb with improved function that will retain the satisfactory result beyond skeletal maturity.

Guillain Barre Syndrome (GBS) is an acute neuromuscular weakness and paralysis associated with areflexia and often spontaneous recovery, but carries the potential risk of respiratory depression owing to muscle weakness. Worldwide, 1 to 3 cases/100,000 are reported. The syndrome is most commonly reported as symmetrical ascending weakness in arms and legs accompanied by hyporeflexia or areflexia. Sensory disturbances are not required for diagnosis, but may or may not be present. Acute inflammatory demyelinating poly-radiculoneuropathy (AIDP) is the most common variant, but acute motor and sensory axonal neuropathy (ASMAN) is more severe and usually leads to partial or slow recovery. We present a case of GBS presenting with asymmetric weakness and sensory disturbance in a patient with bloody diarrhea of unknown etiology. This patient had asymmetrical paralysis mimicking stroke, but the physical findings, laboratory studies, normal CT and MRI of the brain, Electromyogram (EMG) and the patient’s improvement with Intravenous Immunoglobulin (IVIG) support the diagnosis of GBS. People with inflammatory bowel disease are at increased risk of developing GBS. Persons with antecedent Campylobacter jejuni infections are 77 percent more likely to contract GBS compared to the general population, and Cytomegalovirus (CMV) and Epstein Barr virus (EBV) are also implicated risk factors.

Aim: To highlight the need to consider multiple myeloma as a probable diagnosis while evaluating a patient presenting with paraparesis and backache.
Presentation of Case: A 55 year old woman presented to a hospital in Calabar, Nigeria with complaints of low back pain and progressive difficulty in walking for three months. There was associated constipation and weight loss. She had received two units of whole blood prior to presentationon account of severe anaemia. Physical examination revealed marked cachexia, pallor, dehydration and oral candidiasis. There was bilaterallower extremity weakness and exaggerated deep tendon reflexes. Investigation revealed anaemia, elevated erythrocyte sedimentation rate, hypoalbuminemia and increased serum globulin. Corrected serum calcium and uric acid were also elevated. Radiographic studies revealed generalized osteopenia and gross reduction in vertebral body height of T6, T9, T11 and L2 with lytic lesions on the ribs and skull. She was managed with blood transfusions and cycles of systemic chemotherapy comprising of vincristine, adriamycin and dexamethasone and referred for radiotherapy.
Discussion: This case posed a diagnostic challenge. The presenting complaints suggested a compressive myelopathy which is more commonly caused by tuberculosis in our setting. Other considerations were benign or malignant tumours, HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) and neurolathyrism.
Conclusion: In the evaluation of a patient with paraparesis and backache, multiple myelomashould be considered. Failure to investigate for multiple myeloma will lead to delays in diagnosis and treatment. Early diagnosis can be made by demonstrating M proteins in either serum or urine, and showing more than 10% of these malignant plasma cells in the bone marrow.

Aim: To determine the prevalence of cholelithiasis in Nigerians with sickle cell disease in steady state, using ultrasonography.
Study Design: A prospective cross-sectional study.
Place and Duration of Study: Haematology Clinic, University of Benin Teaching Hospital, Benin City and Sickle Cell Centre, Benin City, Nigeria between July and December 2011.
Methodology: The study population was made up of non-pregnant sickle cell disease patients not in crisis and who have not had cholecystectomy. They were confirmed to have sickle cell disease through haemoglobin electrophoresis. All the patients were examined with a B-mode ultrasound machine with a curvilinear multifrequency transducer 2.5-7.5MHZ after an overnight or at least six hour fast. Calculi were diagnosed if highly echogenic structures, with acoustic shadowing were detected in the lumen of the gallbladder.
Results: There were 79 females and 71 males, aged between 10 months and 51 years. Of the 150 patients, 140 were homozygous for sickle cell disease (HbSS), while the remaining 10 were heterozygous for sickle cell disease (HbSC). The prevalence of cholelithiasis was 16.0%. It was related to age, sex and haemoglobin genotype. There was progressive increase in cholelithiasis with age which was more pronounced in the third and fourth decades. Cholelithiasis was also significantly more commonly seen in the HbSS group 23 (16.4%) out of 140 patients compared with the HbSC group 1 (10.0%) out of 10 patients. Cholelithiasis did not correlate with sex, although it was more commonly observed in females. The youngest patient with gall stones in this study was 2 years.
Conclusion: The prevalence of cholelithiasis in Nigerians with sickle cell disease was 16.0% and it was related to age and haemoglobin genotype.

Aims: The objectives were to determine the impact of health seeking behaviour, educational attainment and financial Strength on home management of malaria in rural communities in Imo State, Nigeria.
Study Design: A descriptive survey design was used.
Place and Duration of Study: Imo State, Nigeria, between February 2013 and April 2013 Methodology: The sample size was 2674 adults (1650 males, 1024 females, age range 20-70 years). A structured, validated and reliable questionnaire (r=0.81) was used to collect data from 2674 consenting respondents.
Results: The result showed that the health seeking behaviours of respondents when they suspect malaria was as follows; 25.7 percent patronized patent medicine stores/chemist, 22.3 percent visited health centers/ hospitals,18.6 percent consulted family members/friends/ neighbor for help. This statistically had a significant influence on the pattern adopted in managing malaria at home (Chi-square = 263.98, P -value < 0.001). Furthermore, 25.4 percent of those who visited the health centers/hospitals used more of Artemisinin-based Combination Therapy in managing malaria. Those who patronized patent medicine/chemist used more of chloroquine/quinine (25.7 percent), only 18.1 percent used a special herb, dogonyaro/Akum shut up leaf (Azadirachta Indica) in managing malaria at home. Those who visited herbalists (20.5%) also used chloroquine/quinine while those that visited prayer houses also used more of chloroquine/quinine (22.3%) and less of ACT (15.5%). The impact of educational attainment on pattern of home management of malaria was statistically significant (Chi-square=155.47,P-value<0.001). Those who had no formal education used more of Chloroquine/Quinine in managing malaria at home while those who attained secondary and tertiary education adopted more of Artemisinin-based combination Therapy (ACT) in managing malaria. Herbal treatment (Dogonyaro/Akum shut up leaf (Azadirachta Indica), seven leaves and application of local ointment/lotion) were less used by respondents with higher educational attainment. Financial strength was also found to be statistically associated with the pattern of management adopted by the rural dwellers (Chi-square=118.46, P-value<0.001). Those whose average monthly income was above 30,000 Naira used more of conventional medication and less of herbs.
Conclusion: The findings showed that the rural communities need more enlightenment and education on home management of malaria.

Objective: To assess the prevalence of diabetic vascular complications and cardiovascular risk factors control in type 2 diabetic patients at tertiary settings.
Methods: This cross-sectional study was conducted among 313 patients diagnosed with type 2 diabetes mellitus (T2DM) at two tertiary referral hospitals in Malaysia. Data regarding socio-demographics, macro- and microvascular complications, family health history, blood pressure, anthropometric indices, glycaemic control, and lipid profile were obtained from medical records, face-to-face interview and physical examination.
Results: The mean age of patients was 55.7±9.2 years, mean diabetes duration was 10.1±8.1 years, and 52.1% were females. Approximately 36.1% patients had cardiovascular disease (CVD). There were high prevalence of established coronary artery disease (30.7%), cerebrovascular disease (10.2%), and peripheral vascular disease (5.1%). Peripheral neuropathy, diabetic nephropathy and retinopathy were present in 41.5%, 17.6% and 15.0% patients respectively. Only 14.1% of the patients reached optimal HbA1c level and 21.1% patients achieved target fasting plasma glucose. The overall prevalence of dyslipidemia was 89.1%, hypertension was 80.2%, and obesity was 35.9% (BMI) and 86.5% (waist-to-hip ratio).
Conclusions: Diabetic vascular complications were highly prevalent among the type 2 diabetic patients. Cardiovascular risk factors control was suboptimal. Both awareness and application of recommended guidelines need to be reinforced.

Background: Lactose intolerance is highly prevalent in Mediterranean area. Substantial portions of patients remain symptomatic in spite of fair lactose-free diet.
Aims: Assess in a series of IBS consecutive patients: 1) the prevalence of lactose intolerance; 2) the frequency of association of lactose intolerance with SIBO; 3) the possibility of SIBO as a cause of symptom persistence in patients with lactose intolerance on lactose-free diet; 4) the ability of LHBT to diagnose SIBO.
Place and Duration of the Study: Patients were recruited from November 2011 to July 2012 at the Gastroenterology Unit of Mauriziano Hospital U.I^st , Turin, Italy.
Methodology: Lactose malabsorption was assessed by means of LHBT and SIBO by means of GHBT and LHBT, using Breath Tracker digital microlyzer on 500 IBS patients and 50 controls. SIBO was treated, with rifaximin 1200 mg a day for 2 weeks, randomly, on 1 to 1 basis.
Results: Prevalence of lactose intolerance resulted to be 59% in IBS patients and 6% in controls, with a statistically significant difference (p<.001). SIBO was present in 72% of patients with lactose intolerance in IBS group, ad in none of the subjects with lactose malabsorption (3) in control group. After 6 months, 105 out of 106 patients affected by LI + SIBO treated with rifaximin + lactose free diet, and 34 out of 107 patients affected by LI + SIBO treated only with a lactose free diet resulted completely asymptomatic. Concordance between LHBT and GHBT for SIBO diagnosis was 98%.
Conclusions: Lactose intolerance is a common condition in patients with IBS in Northwest Italy (59%) very frequently associated with SIBO (72%). This association turned out to be a major cause of symptom persistence in patients on lactose-free diet until successful eradication of SIBO was achieved. LHBT is a simple test able to diagnose simultaneously lactose malabsorption and SIBO.

Aims: To assess the therapeutic effect of curcumin supplementation in modulating the expression of NF-κB in the joints of collagen-induced arthritis (CIA) rats.
Place and Duration of Study: Department of Postgraduate Studies and Research, International Medical University, between July 2011 and May 2012.
Methodology: Arthritis was induced in each group of Dark Agouti (DA) rats, by intradermal injection with collagen emulsified in complete Freund’s adjuvant. Treatment groups which were induced with CIA were treated with: 500 mg/kg curcumin; 1000 mg/kg curcumin; 2000 mg/kg curcumin; 25 mg/kg aspirin. Combination treatment groups which were induced with CIA were treated with: 500 mg/kg curcumin and 25 mg/kg aspirin; 1000 mg/kg curcumin and 25 mg/kg aspirin; 2000 mg/kg curcumin and 25 mg/kg aspirin from day 25 to 38. Efficacy was assessed based on ability to reduce paw oedema, histopathological changes, NF-κB expression, serum tumour necrosis factor alpha (TNF-α), interleukin 1-beta (IL-1β) and gluthathione peroxidase (GPx) levels.
Results: Based on histopathological study, immunohistochemical scoring of NF-κB and ELISA analysis of TNF-α, IL-1β and GPx levels, our study found that curcumin given after arthritis in high doses, shows effects of healing and this results were comparable to positive control group, which is the arthritic group treated with 25 mg/kg aspirin. Curcumin given in combination with aspirin, showed better reduction in pathology in arthritic group compared to positive control group, especially with higher doses of curcumin.
Conclusion: Curcumin was effective in reducing inflammatory changes seen in CIA joints which were proved through histopathological, immunohistochemical and biochemical analysis, however only at high doses.

Copper is widely used in industry. It has been associated with several health hazards among exposed workers.
Aim: to measure the indicators of oxidative stress as malondialdehyde level and superoxide dismutase enzyme activity and their association with copper and arsenic levels among copper smel=ter workers.
Subjective and methods: This study was conducted on forty workers in a secondary copper smelting factory, who were occupationally exposed to copper. They were compared with forty non-exposed individuals. Full history, clinical examinations were done. Serum copper, serum arsenic, urinary arsenic, malondialdehyde and superoxide dismutase were measured. Environmental measurements of copper and arsenic dusts were carried out at different workplace areas.
Results: Environmental measurements in the workplace were within the normal permissible limits in Egypt. Statistically significant differences were found between exposed and control as regards the prevalence of the respiratory and neurological symptoms. Compared to the control group, serum copper, serum arsenic, urinary arsenic and malondialdehyde blood levels were significantly higher among the exposed worker (P<0.01). Each one was positively correlated with the duration of employment. Superoxide dismutase activities in blood were significantly decreased and negatively correlated with the duration of employment.
Conclusion: The disruption of hemostasis induced by oxidative stress may promote the development of health hazards with continued occupational exposure to copper fumes. Recommendation: Blood levels of malondialdehyde and superoxide dismutase enzyme activity can be used as indicators of oxidative stress among exposed workers.

Aims: The aim of the present study was to find out the periodontal health status among pregnant women attending various government hospitals in Faridabad city.
Methodology: This was a descriptive cross sectional single study carried on 800 pregnant women attending various government hospitals in Faridabad city, Haryana. The format consisted of a questionnaire to assess the demographic profile, type of diet, trimester, number of pregnancies, and medical complications if any, perceived oral health problems, oral hygiene attitudes, oral hygiene practices and visit to dentist. The type III clinical examination of all the subjects was done by a single examiner using Plane mouth mirrors and CPITN probe within the Gynaecology section of the hospitals. Periodontal health status was assessed by Community Periodontal index and Loss of attachment index.
Results: Mean age of study participants was 24.53±4.23. More subjects were in third trimester (62.96%). A highest CPI score 2 was found among 53% subjects, where as score 3 was seen among 44.25% and score 4, among 2.75% subjects. Mean number of sextants recorded with CPI score of 2 were 4.06. 78.5% subjects used toothbrush and 81.25% toothpaste for oral hygiene maintenance.
Conclusion: Overall prevalence of periodontitis was 47% and increased with poor oral hygiene practices, thus requiring the necessity of interventions and preventions.

Aim: To determine risk factors for first-line antiretroviral treatment failure in HIV-1 infected children attending Jos University Teaching Hospital, Jos.
Study Design: Retrospective cohort study.
Place and Duration of Study: Paediatric HIV clinic at the Jos University Teaching Hospital, Jos, between February 2006 and December 2010.
Methodology: Data on demographic, clinical and laboratory variables for 580 HIV-1 infected children aged 2 months to 15 years on antiretroviral therapy (ART) were analysed. A comparison of the data on children with and without treatment failure was made. Variables associated with treatment failure in a univariate analysis were then fit in a multivariate logistic model to determine the factors that were associated with treatment failure.
Results: The rate of treatment failure among the children was 18.8%. Previous antiretroviral drugs (ARV) exposure for treatment, not receiving cotrimoxazole prophylaxis before commencement of ART and having severe immune suppression at HIV diagnosis were the factors independently associated with treatment failure. Children with previous ARV exposure for treatment were 4 times more likely to fail treatment compared to those without previous exposure (AOR=4.20 (1.93-9.15); p <0.001). Children who did not receive cotrimoxazole prophylaxis were twice more likely to develop treatment failure compared to those who did (AOR=2.26 (1.06-4.79); p=0.03) and children with severe immune suppression at HIV diagnosis were twice more likely to develop treatment failure compared to those without severe immune suppression (AOR=2.34 (1.47-3.72); p<0.001).
Conclusion: HIV-infected children with previous ARV exposure for treatment and severe immune suppression should be monitored closely and given frequent adherence counseling to minimize the risk of treatment failure. Cotrimoxazole prophylaxis should be encouraged in HIV-infected children while they await commencement of ART, which may improve ART adherence and thus reduce the risk of treatment failure.

Aims: To study the morphology and do the morphometric analysis of placenta and to correlate with the foetal parameters, in order to help in the assessment of the state of well being of foetus. To study the histomorphological features of placenta in various conditions complicating the pregnancy.
Study Design: Descriptive type of study.
Place and Duration of Study: Department of Pathology and Department of Obstetrics and Gynaecology, Sri Manakula Vinayagar Medical College, Puducherry, between July 2013 and August 2013.
Methodology: We included 51 fresh placentae. Gross examination including weight, shape, thickness, feto-placental ratio, placental co-efficient was calculated. Later, histo-morphological study was done.
Results: Out of the 51 placentae, 48 were circular in shape and 3 were oval in shape. In the present study the mean (± SD) diameter of the placenta was 14.65 cm and thickness of the placenta was 1.42 cm. The thickness of placenta was reduced (<1.5cm) in all cases of Pregnancy induced hypertension (PIH), Isoimmunisation, twin pregnancy, prematurity and anemia. Placental weight was reduced in all cases of PIH, low birth weight baby, prematurity and Increased placental weight was seen in the gestational diabetes. Feto-placental ratio was 5.39:1(both sexes considered together) and placental coefficient was 0.19. In PIH, the average foeto-placental ratio was 5.20:1and the average placental coefficient was 0.19. Gestational diabetes showed a foeto-placental ratio of 5.30:1, the placental coefficient being 0.18 with a considerable increase in the birth weight and in the placental weight. Anaemia showed a significant reduction in the placental weight, with a foeto-placental ratio of 5:1 and an increase in the number of ill-defined cotyledons. In prematurity, average foeto-placental ratio was 4.43:1, while Rh isoimmunisation did not show any decrease in the foeto- placental ratio.
Conclusion: As anticipated, in case of PIH complicating pregnancies, the morphometric values of the placenta like the diameter, number of cotyledons and the average placental and foetal birth weights were found to be lower than that of the normal, uncomplicated pregnancies. At the same time, all these parameters were increased in cases of diabetes. So morphometric investigation of the placenta will be tremendously useful in the early assessment of placental insufficiency and also the state of foetal well being.

Aims: To systematically identify and summarize prognostic indicators in patients with acute liver failure and to evaluate their predictive value. To analyse a wide spectrum of indicators used worldwide for prediction of outcome in patients with acute liver failure as a starting point for a better prognostic index.
Methodology: Online databases MEDLINE® (1950-2014) and EMBASE® (1980-2014) were searched and studies published up to 01 January 2014 were considered. Articles were included if they reported original data from a clinical trial or observational study on patients with diagnosis of acute liver failure or fulminant hepatic failure and if one of their main objectives was evaluating prognostic indicators of acute liver failure outcome. Of 1835 identified studies 119 were included for detailed analysis.
Results: Based on 289 selected indicators and their effect on patient outcome following 8 categories were formed: general markers (n=32), bio-markers (n=131), hemodynamic (n=14), liver function tests (n=7), imaging/morphology (n=15), scoring systems (n=53), time intervals (n=17), and treatments (n=20). The most frequently reported indicators were: bilirubin, age creatinine, coagulopathy expressed by prothrombin time or INR and hepatic encephalopathy.
Conclusion: This review provides a large amount of information, including the extensive list of worldwide used indicators to predict outcome in patients with acute liver failure. There is large heterogeneity in prognostic indicators of acute liver failure, methods of measurement, complexity of calculation and threshold values. Based on this large list of indicators we suggest that an ideal prognostic index should preferentially be based on pathophysiological aspects and has to be applied in a dynamic way. Future studies on acute liver failure can profit from this inventory.

The importance of screening and diagnosis of gestational diabetes mellitus (GDM) is universally accepted but there is controversy and uncertainty about the most suitable method of screening among various populations.
The majority of the patients are asymptomatic. After nearly 60 years of research the screening and diagnosis of GDM, universal screening evades uniform acceptance and remains debatable. Multiple studies, numerous global consensus conferences and several multicenter trials had not identified the unique procedure. Surprisingly still there is uncertainty regarding the most effective method of screening among various populations.
The prevalence of GDM varies from less than 1% to more than 10%
It is increasing due to dietary habits, overweight, maternal age, ethnicity, family history and past history .Prevalence vary due to the use of a wide range of definitions and diagnostic test criteria, as well as variations across regions and ethnic groups.
The merits of available screening methods such as urine testing for glycosuria, 50g glucose challenge test (GCT), random blood sugar testing, fasting blood glucose (FBS) , estimation of glycosylated haemoglobin , fructosamine ,75g oral Glucose Tolerance Test (75g OGTT) and two step approach (Combination of methods) are analysed.
In countries where funds are limited, certainly the selective screening is cost effective compared to whole population screening.
After many decades of research, only up-to-date considerations are Random blood glucose, O’Sullivan, 75g and Complete OGTT.

Identifying “competent embryos” (those with the greatest potential to develop into normal concept) for transfer to the uterus has been a matter of the highest priority and the subject of both hot debate and ongoing research, since the very inception of human in vitro fertilization (IVF). A thorough literature search was performed to evaluate the correlation between pronuclear morphology, early embryo cleavage speed, cleavage stage embryos, embryo/blastocyst development, “omics”, sHLA-G expression, PGS, and implantation/pregnancy-generating potential in ART. Based on available literature, an array/combination of laboratory observations could assist the scientist with embryo selection. The pronuclear stage morphology, the early embryo division, cleavage embryo stage and quality of the day 3 embryos provides limited guidance. We conclude that use of (invasive) PGS in specific patient populations is appropriate; however, more data are needed to determine its true value for overall impact in ART. Non-invasive selection of blastocysts on day 5 with optimal sHLA-G expression provides a very high degree of confidence to yield a viable pregnancy and potentially reduce multiple gestations.