Open Access Case Study

Echo Lucent Space Occupying Lesion on Echocardiogram

Srinivas Mikkilineni, Jagadeesh K. Kalavakunta, Enoch Lule, Gaurav Dhar, Sanjay Mehra, Jimmy T. Efird

Journal of Advances in Medicine and Medical Research, Page 4050-4053
DOI: 10.9734/BJMMR/2014/10942

Left atrial space occupying lesions pose diagnostic challenge on echocardiography. We report a 79-year-old man with history of pheochromocytoma with left adrenal mass presented with heart failure symptoms after adrenalectomy. Echocardiogram revealed a large echo lucent structure (6.9 x5.9cm) compressing the posterior wall of the left atrium. Further investigation with computer tomography and barium swallow confirmed the diagnosis of hiatal hernia. In this report we explain the differential diagnosis and simple steps to assist the diagnosis of left atrial space occupying lesions noninvasively.

Open Access Case Study

Non-surgical Treatment of Peri-implant Inflammation with the Adjunctive Use of the Diode Laser (810nm) Case Presentation

A. Gariffo, M. Roncati

Journal of Advances in Medicine and Medical Research, Page 4105-4116
DOI: 10.9734/BJMMR/2014/9091

Objective: The aim of this study is to discuss the non-surgical periodontal instrumentation, (which is necessary and irreplaceable) with the adjuctive use of diode laser (810nm), in the treatment of peri-implant infalmmation. Data are limited to a case report.
Presentation of Case: After 12 years from implants insertion, which was carried out in 1992, a periodontally susceptible patient, shows signs of peri-implant inflammation (2004). Nowadays, after non-surgical periodontal laser-assisted therapy and 9 years of follow-up, implants shows no more signs of inflammation.
Periodontal Therapy and Supportive Treatment are Made of Two Indispensable Phases: professional oral hygiene and home care instruction. During professional oral hygiene appointment, in addition to mechanical (dedicated ultrasonic inserts) and manual (titanium curette) non-surgical periodontal instrumentation, a diode laser in pulsed wave, at of 1Watt (2Watt the first appointment) for 20sec in duplicate at each site, was used. Professional treatment included also air polishing with glycine powder and application of CHX 0,5%gel. The patient was instructed in proper home care.
Discussion and Conclusion: each treatment stage was carried out as required by the protocol and the patient has faithfully followed the oral hygiene instructions. Peri-implant clinical situation has remained fairly stable, showing normal periodontal parameters, after more than 20 years from implants insertion. The present case shows how, traditional protocols of non-surgical periodontal therapy, in conjunction with the diode (810nm) laser, seem to be an effective alternative treatment modality in non-surgical treatment of peri-implantitis, in a periodontal susceptible patient. Obviously, data are limited the present case report and should be validated by further longitudinal clinical studies.

Open Access Case Study

Case Report of Rupture of Splenic Artery Aneurysm during Pregnancy with Poor Outcomes

Raymond Anchan, Anju Sinha, Assia Stepanian, Jennifer S. Lindsey, Keith H. Nelson, Raymond A. Dombroski

Journal of Advances in Medicine and Medical Research, Page 4127-4133
DOI: 10.9734/BJMMR/2014/10204

Aims: To highlight the importance of considering non-obstetrical etiologies for acute abdominal pain in gravid patients with risk factors for vasculopathies including diabetes and hypertension. Specifically, we report a tragic case of splenic artery aneurysm (SAA) rupture during the third trimester in a diabetic patient resulting in maternal-fetal mortality. Traumatic vascular events during pregnancy may be associated with a high rate of maternal and fetal morbidity or mortality. Therefore early and rapid intervention is critical to the obstetrical outcome.
Presentation of Case: A 35 year old multiparous hypertensive diabetic patient presented with acute abdominal pain at 33 weeks of gestation. The presumptive diagnosis was concealed placental abruption with diabetic ketoacidosis. Although non-obstetrical diagnoses were not initially considered, postmortem analysis revealed a non-obstetrical etiology of SAA rupture with catastrophic consequences for the patient and fetus.
Discussion: The likelihood of aneurysm rupture of SAA is heightened due to vasculopathic medical comorbidities such as hypertension and diabetes. The vascular congestion of pregnancy increases flow through arteries, leading to increased likelihood of aneurysm rupture without warning or preceding symptoms. Preconception screening and imaging modalities to confirm splenic artery aneurysms and elective repair are also discussed. Early consideration and accurate identification of SAA rupture is critical to saving the lives of both mother and fetus.
Conclusion: SAA rupture, in the differential diagnosis of acute abdominal pain in pregnancy, should be considered more likely in multiparous patients and in the presence of comorbidities such as diabetes and hypertension.

Open Access Study Protocol

Age is the Best Marker to Predict Intracytoplasmic Sperm Injection Cycles Outcome

Hanan Al-Taee, Zeinab Al-Khfaji, Zeid Al-Madfai

Journal of Advances in Medicine and Medical Research, Page 4076-4089
DOI: 10.9734/BJMMR/2014/8461

Aims: To assess the ovarian reserve for subpopulations of Iraqi infertile couples seeking Intra Cytoplasmic Sperm Injection (ICSI) treatment. 2. To evaluate the effectiveness of ovarian reserve markers in predicting the response to Controlled Ovarian Stimulation and Intra cytoplasmic sperm injection cycles outcome.
Study Design: A prospective observational controlled trial.
Patients and Methods: Eighty -seven participants were enrolled during their attendance to the fertility center of Al-Sadar Medical Teaching city. Twenty subjects as a control group (N=20), and 67 as a study group (N=67). Ovarian reserve parameters were assessed and ICSI were performed. The female were divided into two groups: Those under 35 years of age and those above 35 years of age. They were compared for: Number (No.) of follicles obtained, No. of mature oocytes, Fertilization rate, Cleavage rate, Embryo scoring, No. of embryo transferred and Pregnancy rate (biochemical pregnancy).
Results: The old age group has significantly higher serum follicle stimulating hormone and body mass index while they have significantly lower anti mullerian hormone than the younger age group. The ICSI outcome parameters regarding No. of oocyte, No. of mature oocytes, fertilization rate, cleavage rate, No. of best quality embryos, and no. of embryo transferred and pregnancy rate were significantly lower in old age group.
Conclusion: Age is strongly associated with ovarian response and it provides the most powerful basal estimate for ICSI outcome.

Open Access Study Protocol

A Placebo-controlled Trial of Folate with B12 in Patients with Schizophrenia with Residual Symptoms in Ethiopia Using a Sequential Parallel Comparison Design

Christina P. C. Borba, Abebaw Fekadu, Solomon Teferra, Desalegn Bekele, Teshome Shibre, Claire E. Oppenheim, Silenat Biressaw, Anwar Mulugeta, David A. Schoenfeld, David C. Henderson

Journal of Advances in Medicine and Medical Research, Page 4090-4104
DOI: 10.9734/BJMMR/2014/10473

Background: Approximately 30% of patients with schizophrenia suffer from treatment-resistant psychotic symptoms, which can produce substantial distress, result in hospitalization and disrupt school or work functioning. Studies have found low blood folate concentrations in psychiatric populations and recent reports have consistently linked schizophrenia to low folate levels. We aim to examine the efficacy of a four-month trial of folate with B12 supplementation for reducing symptoms of schizophrenia.
Methods: This study is a randomized, sequential parallel comparison design (SPCD) for double-blind phase fixed dose, 4-month trial of folate plus B12 as add-on therapy to reduce symptoms of schizophrenia. Participants will be adults (ages 18 to 65 years) diagnosed with schizophrenia, any subtype, who are psychiatrically and medically stable, but have residual positive or negative symptoms of moderate or greater intensity, despite antipsychotic treatment. The study is divided into 2 double-blind phases of 56 days each. Two hundred total participants will be randomized to adjunctive treatment with either folate with vitamin B12 (n=50) or placebo (n=150), with a 2:3:3 ratio for random assignment to the treatment sequences drug/drug (DD; n=50), placebo/placebo (PP; n=75), and placebo/drug (PD; n=75), while all continue to receive their current antipsychotic agent for the duration of the study. Diagnosis will be established using the Structured Clinical Interview for DSM-IV for clinical trials (SCID-CT). The primary outcome measure will be change in symptom severity measured by the change from baseline in Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcome measures will include change in severity of psychotic symptoms as measured by the PANSS psychosis subscale score; and change in severity of negative symptoms as measured by the modified Scale for Assessment of Negative Symptoms (SANS) total score. Key assessments for primary and secondary outcomes will be conducted at baseline, week 8, and week 16.
Trial Registration: identifier: NCT01724476.

Open Access Original Research Article

A Pilot Study of Web Based Clinical Supervision for Clinicians Working with Adults with Autism Spectrum Disorders and Attention Deficit Hyperactive Disorders

Jane McCarthy, Eddie Chaplin, Susannah Whitwell, Lisa Underwood, Philip Asherson, Declan Murphy

Journal of Advances in Medicine and Medical Research, Page 4030-4043
DOI: 10.9734/BJMMR/2014/8661

Introduction: Currently there is little understanding of the factors that contribute to the successful implementation of clinical supervision in the development of new competencies for senior practitioners. The two linked studies reported are part of a wider inquiry to improve diagnostic services, interventions and outcomes for people with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).
Methodology: This study aimed to explore the feasibility of implementing web-based learning to deliver clinical supervision relating to the recognition, diagnosis and management of ADHD and ASD. Two series of three web-based supervision seminars, facilitated by clinical and academic experts, were held for two sets of practitioners. Prior to the start of the supervision process (time 1) each participant underwent an assessment of knowledge, skills and attitudes, which was repeated at the end of the study (time 2).
Participants who completed pre-study assessments were allocated to take part in either the web-based supervision or the control groups. In total, 31 participants took part: 13 in the ADHD study (seven received online supervision) and 18 in the ADHD study (seven received online supervision).
Results: Although the study sample sizes were too small to carry out any meaningful statistical analyses there were modest increases in clinical skills scores recorded by both studies for three of the four groups with no change in knowledge scores for the ASD supervision group.
Conclusion: Web Based Learning (WBL) encompasses any educational activity undertaken over the internet and is now considered part of the mainstream in medical education. The issues of accessibility to technology required for WBL may be a barrier to widespread implementation and may be a contributory factor to the lack of published evidence for the effectiveness of this approach.

Open Access Original Research Article

Calculated Haematocrit Gave a Better Prediction of Anaemia than Observed Haematocrit in Patients with Haemorrhage and under Aged Children in Central Nigeria

A. A. Abdulazeez, M. A. Muhibi

Journal of Advances in Medicine and Medical Research, Page 4044-4049
DOI: 10.9734/BJMMR/2014/9366

Background: In the north central Nigeria, observed haemoglobin concentration is often used to determine the packed cell volume of patients, especially by many laboratories that cannot afford the cost of micro-haematocrit centrifuge.
Aim: The study was carried out to determine the accuracy of 3-fold haemoglobin conversion to haematocrit level in anaemic conditions.
Materials and Methods: The study was conducted on 580 symptomatic (febrile) patients and 810 subclinically anaemic subjects attending some selected private medical laboratories, hospitals and clinics in Kuje Area Council of Federal Capital Territory (FCT), Abuja, Nigeria. Calculated haemotocrit was obtained by multiplying observed haemoglobin concentration by three while the observed haemoglobin was determined by colorimetric technique using Drabkin solution. Observed haematocrit was determined by using microhaematocrit technique. Mean observed and mean calculated haematocrit were statistically analyzed by students’ T-Test and findings compared.
Results: Findings revealed a significant bias for higher degree of anaemia when 3-fold haemoglobin (calculated haematocrit) was employed than when observed haematocrit was used to determine anaemia in children within 1-10 years of age (T=2.1630, P<0.05). Also, this study showed a significant difference between mean calculated haematocrit and mean observed haematocrit in post-haemorrhagic conditions (T=3.0151, P<0.05).
Conclusion: Use of direct haemoglobin estimation and derived haematocrit is advocated to diagnose anaemia in children and post-haemorrhagic conditions. Side laboratories are advised to enroll into proficiency testing programmes to monitor accuracy of their assay results.

Open Access Original Research Article

Calsequestrin is Decreased in the Thyroid Gland of Patients with Graves’ Disease – Further Evidence for a Role of Autoimmunity against this Protein in Graves’ Ophthalmopathy

Daniele Cultrone, Hooshang Lahooti, Senarath Edirimanne, Leigh Delbridge, Bernard Champion, Jack R. Wall

Journal of Advances in Medicine and Medical Research, Page 4065-4075
DOI: 10.9734/BJMMR/2014/9504

Background: The pathogenesis of Graves’ ophthalmopathy (GO) and the mechanism for its link to thyroid autoimmunity is poorly understood. Our present research focuses on the role of the skeletal muscle calcium binding protein calsequestrin (CASQ1). Earlier studies showed that the CASQ1 gene was up-regulated in thyroid tissue from patients with GO compared to those with Graves’ hyperthyroidism (GH) without eye signs, however, the protein levels remained the same in both groups, raising the possibility that the orbital autoimmune reaction begins in the thyroid gland. Here, we measured the concentration of the CASQ1 protein in normal and Graves’ thyroid tissue, correlating levels with parameters of the eye signs, CASQ1 antibody levels and the CASQ1 gene polymorphism rs3838216, shown previously to be a risk factor for ophthalmopathy.
Methods: The CASQ1 protein was measured by quantitative Western blotting. Following electrophoresis, samples were transblotted to polyvinyl difluoride (PVDF) membranes incubated with a 1:1000 dilution of a rabbit anti-CASQ1 antibody and incubated with an horseradish peroxidase (HRP)-conjugated goat anti-rabbit antibody, or anti-mouse antibodies for Glyceraldehyde 3-phosphate dehydrogenase (GAPDH). The protein concentrations were determined from density quantification using the Quantity One 4.4.0 ChemiDoc program and expressed as pmol/mg total protein by reference to CASQ1 standards.
Results: Western blot analysis showed the presence of two forms of CASQ1 in the thyroid, of 50 and 60 kDa molecular weight respectively. In thyroid tissues, the mean (± SD) (GO 54.9±86.8 pmol/mg) concentration of the CASQ1 protein (GH 37.1±51.8 pmol/mg) was significantly reduced in patients with Graves’ disease , with or without ophthalmopathy, compared to normal thyroid tissues from control subjects with multi-nodular goitre or thyroid cancer (144.3±162.5 pmol/mg). The difference between GO and GH was not significant. The decreased CASQ1 protein levels in Graves’ thyroid tissues correlated with the homozygous genotype of the rs3838216 CASQ1 polymorphism. A two-fold increase in Levels of CASQ1 protein in toxic nodules compared to Graves’ hyperthyroidism was markedly significant.
Conclusions: Decreased CASQ1 in the thyroid tissues of patients with Graves’ disease compared to normal thyroid tissues from control subjects may reflect consumption of the protein in the course of an autoimmune reaction against CASQ1 in the thyroid. Comparing CASQ1 protein levels in thyroid tissue from five patients with toxic nodular goitre (74.5±52.8) to controls showed no significance. The relative two fold increase in CASQ1 levels in toxic nodules compared to Graves’ disease suggests that this is due to the autoimmune reaction rather than the hyperthyroidism.

Open Access Original Research Article

Pattern of Presentations of Non-odontogenic Paininoral Medicine Clinic of Lagos University Teaching Hospital (Luth)

E. O. Oyetola, G. A. Agbelusi, A. F. Dayo

Journal of Advances in Medicine and Medical Research, Page 4117-4126
DOI: 10.9734/BJMMR/2014/8635

Background: Many patients visit dentists as a result of pain. It may have non-odontogenic causes such as lesions of vascular, neurologic/psychological, muscular, bone structures or referred from surrounding structures, or odontogenic, in which case the cause of the pain is the tooth and/or tooth supporting structures. Non odontogenic pain is often challenging to diagnose with consequent inappropriate treatment, leading to frustration of the patients and loss of confidence in the managing physician. Hence, attention on the pattern of distribution of these groups of facial pain would assist in their management.
Aims: To describe the pattern of presentation of non-odontogenic pain among patients who attend oral medicine clinic in LUTH
Methodology: A retrospective review of all cases of non odontogenic pain seen in oral medicine clinic of Lagos University Teaching Hospital (LUTH) between May 2010 and May 2011 was done using the clinic records and patients’ case notes. The recorded parameter includes patients' age, sex and the clinical diagnosis. The results were analysed with SPSS software
Results: A total number of 221 patients were seen, 144 (65%) were diagnosed with one form of non-odontogenic pain. The age distribution of subjects with non odontogenic pain ranged from 15 to 85 yrs (45yr+13.8) with the peak age of occurrence at 51-55yrs. On the other hand, those with odontogenic pain were most prevalent at the peak age of 21-40yr, mean age of 37.3+13.6. Female predilection was observed in all subjects. Dentine hypersensitivity, pulpitis and periodontits were some of the odontogenic pain diagnosed while the various non odontogenic pain diagnosed includes burning mouth 34(23.6%), Aphthous ulceration 28(19.4%), Trigeminal neuralgia 16(11.1%), Candidiasis 11(7.4%), Lichen planus 7(4.6%), Erythemamultiforme 7(4.6%), and Herpes zoster 3(1.9%). Others include mucous membrane pemphigoid and traumatic ulcer.
Conclusion: Non-odontogenicpain is relatively common presentations in oral medicine. Burning mouth sensation due to herbal toothpaste use was the most prevalent.

Open Access Review Article

Mechanisms and Drivers of Type 2 Diabetes in Children and Adolescents

M. Constantine Samaan, Jiaji Xia, Jetan Badhiwala

Journal of Advances in Medicine and Medical Research, Page 4054-4064
DOI: 10.9734/BJMMR/2014/11043

The rates of type 2 diabetes (T2D) in children and adolescents are rising globally, and this is closely linked to the obesity epidemic that is affecting millions of youth around the world. In this review, we examine the differences between type 1 diabetes and T2D, and highlight the mechanisms involved in T2D development including genetic, epigenetic and environmental factors. We also highlight the role of inflammation in causing insulin resistance, one of the main drivers of T2D genesis.