Clinico-etiolological study of vocal cord paralysis

The purpose of this study was to identify patients of vocal cord paralysis and to establish an etiological diagnosis. Patients with vocal cord paralysis have been followed prospectively at a tertiary referral center. 120 patients identified with vocal cord paralysis by laryngeal endoscopy were evaluated clinically, radiologically and pathologically to make an etiological diagnosis. Those patients in whom no cause was found, a CT scan from base of skull to thorax was done before labeling them as idiopathic. Most of the patients presented in 5th (26.67 %) and 6th (21.67 %) decade. Males out numbered females in the ratio 2.3:1.0. The most common symptom of vocal cord paralysis was change in voice (98.21 %). Bilateral vocal cord palsy was found in 6.67 % patients and unilateral vocal cord palsy was found in 93.33 % patients. Among patients of unilateral vocal cord paralysis left vocal cord was paralyzed in 69.64 % and right cord in 30.36 %. Malignant (34.16 %) causes accounted for largest number of patients followed by central (15.00 %) and idiopathic causes (14.16 %). VCP has got a variable etiology which varies with the laterality of the vocal cord involvement. Malignant causes predominated in our series, occurring in 34.16 %, followed by central and idiopathic causes.

Recent progress in understanding pathogenesis and liver pathology in biliary atresia

Biliary atresia is an infantile destructive inflammatory cholangiopathy that causes obliteration of both intrahepatic and extrahepatic bile ducts and eventually liver cirrhosis. So far, the exact etiology and pathogenesis of biliary atresia remain unclear, and possible etiologies include congenital and genetic factors, infection, inflammation, immune reaction, maternal factors, and vascular factors. Immunoinflammatory theory has been accepted by most researchers, which is supported by liver pathological changes. This review focuses on the recent progress in understanding pathogenesis and liver pathology in biliary atresia.

Plastic bronchitis in an adult with asthma

Plastic bronchitis is a rare disease characterized by marked airway obstruction, via the formation of large gelatinous or rigid airway cast. In Korea, there were a few case reports with plastic bronchitis not in adults, but in children. So we report a case of an adult who was diagnosed as plastic bronchitis with eosinophilic casts, with no history of atopic and cardiac disease.

Analysis of patients with hemoptysis in a tertiary referral hospital

Background

This study attempted to investigate the main causes of hemoptysis, the type of examinations used for diagnosis, the treatment modalities and outcomes.

Methods

A retrospective study was conducted on the medical records of 221 patients admitted to the Chonnam National University Hospital, between January 2005 and February 2010, with hemoptysis.

Results

Bronchiectasis (32.6%), active pulmonary tuberculosis (18.5%), fungus ball (10.8%), and lung cancer (5.9%) accounted for most causes of hemoptysis. Computed tomography scan was the most sensitive diagnostic test when employed alone, with positive yield of 93.2%. There were 161 cases of conservative treatment (72.9%), 42 cases of bronchial artery embolization (BAE) (19.0%), and 18 cases of surgery (8.1%). Regarding the amount of hemoptysis, 70 cases, out of 221 cases, were mild (31.5%), 36 cases moderate (16.2%), and 115 cases massive hemoptysis (52.0%). Most of the patients were treated conservatively, but if there was more bleeding present, BAE or surgery was more commonly performed than the conservative treatment (p≤0.0001). In the multivariate model, severe hemoptysis and lung cancer were independently associated with short-term recurrence. BAE was independently associated with long-term recurrence, and lung cancer was associated with in-hospital mortality. The overall in-hospital mortality rate was 11.3%.

Conclusion

Hemoptysis is a common symptom with a good prognosis in most cases. However, patients exhibiting massive bleeding or those with malignancy had a poorer prognosis. In-hospital mortality was strongly related to the cause, especially in lung cancer.

Oral lichen planus - Review on etiopathogenesis

Oral lichen planus (OLP) is a chronic mucocutaneous disease of uncertain etiopathogenesis. Several factors including stress, genetics, systemic diseases, viruses, dental restorative materials and drugs have been implicated as causative agents. The disease seems to be mediated by an antigen specific mechanism, activating cytotoxic T cells, and non specific mechanisms like mast cell degranulation and matrix metalloproteinase activation. Further clarity on the pathogenesis will aid in modifying therapeutic interventions, thus significantly reducing the morbidity of OLP patients.

Acute kidney injury applying pRifle scale in Children of Hospital Universitario del Valle in Cali, Colombia: clinical features, management and evolution

OBJECTIVE

To know the epidemiology of Acute Kidney Injury (AKI) in the pediatric population at Hospital Universitario del Valle (HUV), a tertiary University Hospital in Cali, Colombia.

METHODS

We obtained a series of cases through daily surveillance for a seven-month period (June 1 to December 31, 2009) in patients older than 30 days and under 18 years at HUV. We excluded patients with previous diagnosis of chronic renal failure. The new pRIFLE scale was used to define AKI.

RESULTS

27 patients were detected, with mean age of 36 months. Incidence of AKI was 0.38% from pediatric admissions and 6.2% from the pediatric intensive care unit (pICU) admissions. The pRIFLE scale at study entrance was: Risk: 2 patients, Injury: 8, Failure: 17. Etiology of AKI was: pre-renal in 89%, primary renal disease in 3.7%, and post-renal in 7.4%. There was an association of AKI with sepsis in 66.7% and 48.2% progressed to septic shock. Six patients required renal replacement therapy, all required peritoneal dialysis. The AKI was multi-factorial in 59.3% and associated with systemic multi-organ failure in 59.3%. At study entry, 63% patients were in pICU. The average hospital stay was 21.3 ± 9.2 days. Six children died, 16 resolved AKI, and nine were left with renal sequelae.

CONCLUSIONS

We recommended pRIFLE scale for early diagnosis of AKI in all pediatric services. Education in pRIFLE scale, prevention of AKI, and early management of sepsis and hypovolemia is recommended.

Pyogenic liver abscesses associated with nonmetastatic colorectal cancers: An increasing problem in Eastern Asia

AIM: To elaborate the clinicopathologic features of colorectal cancer-related pyogenic liver abscess (PLA).

METHODS: Reported cases of colorectal cancer-related PLAs were collected from the literature published up to October 2011 and evaluated for their clinicopathologic features. Data of collected cases included demographics, clinical presentation, microbial findings and treatment. Categorical variables were compared by χ² analysis and continuous variables were evaluated using Student’s t test.

RESULTS: A total 96 cases of colorectal cancer-related PLA were collected from the previous literature. Most patients (60%) were male and 40% cases occurred in the age group of 61-70 years. Apart from some special types of PLA, there were significant differences in the microbiological spectrum between Eastern Asia and non-Eastern Asian countries, which implied different risk factors and courses of the disease. Gram negative bacteria especially Klebsiella pneumoniae (K. pneumoniae) PLA was predominant in Eastern Asia (80.0%) in contrast to non-Eastern Asian countries (P < 0.01). Meanwhile, most of the Eastern Asian patients exhibited smaller size of liver abscess and atypical presentation. Sigmoid colon and rectum (72.73%) were the main sites of tumor in Eastern Asian patients, whereas tumor sites were uneven among most of the non-Easter Asian PLA patients.

CONCLUSION: K. pneumoniae PLA was strongly associated with colorectal cancer, especially those occurring in sigmoid colon and rectum, in elderly Eastern Asian male patients.

Causes and treatment outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in 82 adult patients

BACKGROUND/AIMS

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are predominantly known as medication-induced diseases. However, at our institution, we have experienced more cases of non-drug-related SJS and TEN than expected. Therefore, we studied the difference between non-drug-related and drug-related SJS and TEN in terms of clinical characteristics and prognoses.

METHODS

The etiologies, clinical characteristics, and treatment outcomes for 82 adult patients with SJS and TEN were retrospectively reviewed.

RESULTS

A total of 71 patients (86.6%) were classified as having SJS, and the other 11 patients (13.4%) were classified as having TEN. Drug-related cases were more common (43, 52.4%) than non-drug-related cases (39, 47.6%). Anticonvulsants (12/82, 14.6%) and antibiotics (9/82, 11%) were the most common causative medications. Anemia (p = 0.017) and C-reactive protein of ≥ 5 mg/dL (p = 0.026) were more common in the drug-related cases than in the non-drug-related cases. Intravenous steroid therapy was used as the main treatment regimen (70/82, 85.4%). Of the 82 patients, 8 (9.8%) died during the clinical course. A univariate analysis for mortality showed statistical significance for the following: kidney function abnormality, pneumonia, hemoglobin of < 10 g/dL, and combined underlying diseases. In a multivariate analysis, only pneumonia was statistically significant (odds ratio, 25.79; p = 0.009).

CONCLUSIONS

Drugs were the most frequent cause of these diseases. However, non-drug-related causes also contributed to a significant proportion of cases. Physicians should keep this in mind when documenting patient history. In addition, early recognition and treatment may be important for better outcomes.

Do child abuse and maltreatment increase risk of schizophrenia?

INTRODUCTION

Although childhood abuse is a recognised risk factor for depression, post-traumatic stress disorder, and substance misuse, its role in the aetiology of psychotic disorder remained controversial. This is in part because the putative effect of childhood trauma on psychosis has been mostly evaluated by small, cross sectional, uncontrolled studies that raised methodological issues.

METHODS

Papers concerning the association between childhood trauma and psychotic disorders (to November, 2011) were identified using a comprehensive search of PubMed, Psychinfo, and Scopus and analysing reference list of relevant papers. A narrative synthesis was used to summarise results.

RESULTS

An association between childhood abuse and psychotic symptoms was consistently reported by large cross sectional surveys with an effect ranging from 1.7 to 15. However, we cannot conclude that the relationship is causal as lack of longitudinal studies prevent us from fully excluding alternative explanations such as reverse causality. Gender, cannabis use, and depressive and post-traumatic stress disorder symptoms appear to moderate the effect of childhood trauma on psychotic disorders. However, specificity of childhood abuse in psychotic disorders and, particularly, in schizophrenia has not been demonstrated.

CONCLUSION

Although the association between childhood abuse and psychosis has been replicated, the etiological role of such early adversity has yet to be fully clarified. So far none of the studies reported support the hypothesis that childhood abuse is either sufficient or necessary to develop a psychotic disorder. It seems likely that any effect of childhood abuse on schizophrenia needs to be understood in terms of genetic susceptibility and interaction with other environmental risk factors.

Causes of adverse pregnancy outcomes and the role of maternal periodontal status - a review of the literature

Preterm (PT) and Low birth weight (LBW) are considered to be the most relevant biological determinants of newborn infants survival, both in developed and in developing countries. Numerous risk factors for PT and LBW have been defined in the literature. Infections of the genitourinary tract infections along with various biological and genetic factors are considered to be the most common etiological factors for PT/LBW deliveries. However, evidence suggests that sub-clinical infection sites that are also distant from the genitor-urinary tract may be an important cause for PT/LBW deliveries. Maternal periodontal status has also been reported by many authors as a possible risk factor for PT and LBW, though not all of the actual data support such hypothesis. The aim of this paper is to review the evidence from various published literature on the association between the maternal periodontal status and adverse pregnancy outcomes. Although this review found a consistent association between periodontitis and PT/LBW, this finding should be treated with great caution until the sources of heterogeneity can be explained.

Etiology of inflammatory bowel disease: a unified hypothesis

Inflammatory bowel disease (IBD), including both ulcerative colitis (UC) and Crohn's disease (CD), emerged and dramatically increased for about a century. Despite extensive research, its cause remains regarded as unknown. About a decade ago, a series of findings made me suspect that saccharin may be a key causative factor for IBD, through its inhibition on gut bacteria and the resultant impaired inactivation of digestive proteases and over digestion of the mucus layer and gut barrier (the Bacteria-Protease-Mucus-Barrier hypothesis). It explained many puzzles in IBD such as its emergence and temporal changes in last century. Recently I further found evidence suggesting sucralose may be also linked to IBD through a similar mechanism as saccharin and have contributed to the recent worldwide increase of IBD. This new hypothesis suggests that UC and CD are just two symptoms of the same morbidity, rather than two different diseases. They are both caused by a weakening in gut barrier and only differ in that UC is mainly due to increased infiltration of gut bacteria and the resultant recruitment of neutrophils and formation of crypt abscess, while CD is mainly due to increased infiltration of antigens and particles from gut lumen and the resultant recruitment of macrophages and formation of granulomas. It explained the delayed appearance but accelerated increase of CD over UC and many other phenomena. This paper aims to provide a detailed description of a unified hypothesis regarding the etiology of IBD, including the cause and mechanism of IBD, as well as the relationship between UC and CD.

Collapsing focal segmental glomerulosclerosis: Current concepts

Collapsing focal segmental glomerulosclerosis (cFSGS), also known as collapsing glomerulopathy is currently classified under the rubric of FSGS. However, its defining morphological features are in stark contrast to those observed in most other variants of FSGS. During the early stage of the disease, the lesion is characterized pathologically by an implosive segmental and/or global collapse of the glomerular capillary tufts, marked hypertrophy and hyperplasia of podocytes, and severe tubulointerstitial disease. With advancement of the disease, segmental and/or global glomerulosclerosis is also observed in association with the collapsing lesions. The etiology of this enigmatic disorder is still elusive, but a growing list of diseases/conditions is being reported in association with this morphological pattern of renal parenchymal injury. The pathogenesis of cFSGS involves discreet epithelial cell injury leading to cell cycle dysregulation and a proliferative cellular phenotype. From the clinical perspective, cFSGS is notorious for its propensity to affect black people, a high incidence and severity of nephrotic syndrome, marked resistance to empirical therapy, and rapid progression to end-stage renal disease. The lesion has also been reported in transplanted kidneys either as recurrent or de novo disease, frequently leading to graft loss. Most cases have been reported in western countries, but the lesion is also being increasingly recognized in the tropical regions. The recent increase in reporting of cFSGS partly reflects a true increase in the incidence and partly a detection bias. There is no specific treatment for the disorder at present. Newer insights into the pathogenesis may lead to the development of targeted and specific therapy in near future. There is an urgent need to increase awareness of the lesion among pathologists and nephrologists, especially those from developing countries, to ensure accurate diagnosis and appropriate managment. With the accumulation of more and more data, it is hoped that the prevailing confusion about the nosological identity of the lesion will also be resolved in a more logical way.

Thirty years of research on infection and prostate cancer: no conclusive evidence for a link. A systematic review

BACKGROUND

The potential role of genitourinary infection in the etiology of prostate cancer (CaP) has been extensively investigated for 30 years. Two basic approaches have been used: tissue-based methods (polymerase chain reaction, immunohistochemistry, and in situ hybridization) and serologic assays (enzyme-linked immunosorbent assay, immunofluorescence, etc.). The objective of this review was to answer the question of whether infection of the male genitourinary tract may have a role in the etiology of CaP.

MATERIALS AND METHODS

We have carried out a systematic review of the evidence that was published in the MEDLINE/PubMed database until December 2011. The search terms included "prostate cancer," "infection," and the explicit names of the various infectious agents. Additional studies were identified using a reference search. A total of 74 papers were included in the review, which cover the following infectious agents: human papillomavirus, cytomegalovirus, herpes simplex virus, Epstein-Barr virus, human herpesvirus, BK virus, JC virus, chlamydia, mycoplasma, ureaplasma, trichomonas, neisseria, treponema, Propionibacterium acnes, xenotropic murine leukemia virus-related virus and Candida albicans.

RESULTS

Despite the variable study designs and methodological approaches that were used, most of the pathogens that were studied were unlikely to be directly involved in prostate carcinogenesis.

CONCLUSIONS

The role of infection in the etiology of CaP has yet to be determined despite 30 years of research efforts. A discovery of an infectious agent that is associated with CaP would be of great medical importance; however, such a link would have to be firmly established before impacting on patient care.

Benign prostatic hyperplasia: from bench to clinic

Benign prostatic hyperplasia (BPH) is a prevalent disease, especially in old men, and often results in lower urinary tract symptoms (LUTS). This chronic disease has important care implications and financial risks to the health care system. LUTS are caused not only by mechanical prostatic obstruction but also by the dynamic component of obstruction. The exact etiology of BPH and its consequences, benign prostatic enlargement and benign prostatic obstruction, are not identified. Various theories concerning the causes of benign prostate enlargement and LUTS, such as metabolic syndrome, inflammation, growth factors, androgen receptor, epithelial-stromal interaction, and lifestyle, are discussed. Incomplete overlap of prostatic enlargement with symptoms and obstruction encourages focus on symptoms rather than prostate enlargement and the shifting from surgery to medicine as the treatment of BPH. Several alpha antagonists, including alfuzosin, doxazosin, tamsulosin, and terazosin, have shown excellent efficacy without severe adverse effects. In addition, new alpha antagonists, silodosin and naftopidil, and phosphodiesterase 5 inhibitors are emerging as BPH treatments. In surgical treatment, laser surgery such as photoselective vaporization of the prostate and holmium laser prostatectomy have been introduced to reduce complications and are used as alternatives to transurethral resection of the prostate (TURP) and open prostatectomy. The status of TURP as the gold standard treatment of BPH is still evolving. We review several preclinical and clinical studies about the etiology of BPH and treatment options.

Spontaneously reported hepatic adverse drug events in Korea: multicenter study

Hepatic adverse drug reactions (ADRs) to certain drugs may differ within each country, reflecting different patterns of prescription, socioeconomic status, and culture. The purpose of this study was to assess the suspected cause of hepatic ADRs using the spontaneously reported pharmacovigilance data from Korea. A total of 9,360 spontaneously reported adverse drug events (ADEs) from nine Pharmacovigilance Centers were analyzed. Risk of hepatic ADEs was assessed by calculating the reporting odds ratio (ROR). Of the 9,360 cases, 567 hepatic ADEs were reported. The most frequently prescribed drug classes inducing hepatic ADEs were anti-tuberculotics, cephalosporins, valproic acids, penicillins, quinolones, non-steroidal anti-inflammatory drugs (NSAIDs), anti-viral agents, and statins. ROR values were especially high in anti-tuberculosis drugs, systemic antifungal drugs for systemic use, anti-epileptics, propylthiouracil, and herbal medicines. Underlying diseases such as tuberculosis (6.9% vs 0.9%), pneumonia (4.9% vs 1.7%), intracranial injury including skull fracture (4.5% vs 0.9%), HIV (3.4% vs 0.4%), subarachnoid hemorrhage (2.8% vs 0.5%), and osteoporosis (2.4% vs 1.4%) were significantly more common in hepatic ADE group. In conclusion, anti-infective drugs, anti-epileptics, NSAIDs and statins are the most common suspects of the spontaneously reported hepatic ADEs, in Korea. Careful monitoring for such reactions is needed for the prescription of these drugs.

Aortic regurgitation caused by cusp bending of aortic valve leaflet

Pure aortic regurgitation (AR) is caused by primary disease of the aortic leaflet and/or the aortic root. However, there are many patients with AR with unclear etiology and mechanism. The assessment of mechanism is critical to the decision of surgical modality for AR. Echocardiography, particularly a detailed analysis of the aortic leaflets and root by transesophageal echocardiography (TEE), could be an important diagnostic step to assess its mechanism. In this report, we present a case of AR in which the TEE images led to diagnosis of cusp bending of aortic leaflet without specific findings indicating this pathology.

Etiologic factors in falls from height in pediatric cases

OBJECTIVE

In this study, factors causing falls from height and precautions taken for their prevention were investigated.

METHODS

The study was carried out prospectively between June 2009 and June 2010. Patients under 18 years of age presenting at the emergency department of a university hospital, for whom the primary reason for admission was an accidental fall from a height of at least one meter, were included in the study. The demographic characteristics of the patients, the characteristics of the falls, and clinical features were recorded.

RESULTS

Data for 133 patients were evaluated. Among these patients, 72 (54.1%) were male; the median age was 4 (IQR 2-7). The most common fall site was a balcony (38%). Falls frequently happened in the spring and the summer. The mean fall height was 2.9 ± 2.5 m, the median GCS score was 15 (IQR 14-15), and the median PTS was 10 (IQR 9-11). The fall heights was higher in patients who lost consciousness (p < 0.001). Among the 95 patients who were 0-6 years old, it was found that about 55% were unaccompanied by their parents. The most common pathology in the patients was head trauma (63%), while 17.3% had multiple traumas.

CONCLUSION

Since the vast majority of the fall cases were in the pre-school age group, most were due to falls from a balcony, and more than half of the cases were unaccompanied by parents or caregivers, there are two issues that need to be addressed in relation to pediatric falls from height: family education and legal regulations considering child safety in the design of doors, windows, and balconies of buildings.

Photoanthropometric study of dysmorphic features of the face in children with autism and asperger syndrome

OBJECTIVE

Childhood autism is a neurodevelopmental disorder characterized by impairments in social interactions, verbal and non-verbal communication and by a pattern of stereotypical behaviors and interests. The aim of this study was to estimate the dysmorphic facial features of children with autism and children with Asperger syndrome.

METHODS

The examination was conducted on 60 children (30 with childhood autism and 30 with Asperger syndrome). The photo anthropometric method used in this study followed the protocol established by Stengel-Rutkowski et al.

RESULTS

The performed statistical analysis showed that in patients with childhood autism, the anteriorly rotated ears and the long back of the nose appeared more often. In the group of children with autism, there was a connection between the amount of dysmorphies and the presence of some somatic diseases in the first-degree relatives. There was also a connection between the motor coordination and the age the child began to walk.

DISCUSSION

In patients with childhood autism, there were certain dysmorphies (like the anterior rotated ears and the long back of the nose) which appeared more often. Although the connection was not statistically significant, it seemed to concur with data from the literature.

CONCLUSION

Formulation of the other conclusions would require broader studies e.g. dealing with a familial analysis of dysmorphic features.

Prevalence of otitis media with effusion among primary school age-children and etiopathogenic examination

A prevalence study was carried out in order to look into the etiopathogenic relation of otitis media with effusion (OME) in primary school-age children. The study included ENT examination and a questionnaire that was carried out in 4 randomly selected schools on 1,165 children. 143 of the cases (12.2%) had OME. A significant relation between OME and adenoid vegetation was found (P<0.01) while no significant relation between EOM and recurrent tonsillitis and allergic rhinitis was found (P>0.05). As a result, OME is a common disease that can lead to other hard-to-cure health problems and be costly if etiopathogenic factors are not resolved on time.

Epidemiological aspects of Budd-Chiari in Egyptian patients: A single-center study

AIM: To describe the socio-demographic features, etiology, and risk factors for Budd-Chiari syndrome (BCS) in Egyptian patients.

METHODS: Ninety-four Egyptian patients with confirmed primary Budd-Chiari syndrome were presented to the Budd-Chiari Study Group (BCSG) and admitted to the Tropical Medicine Department of Ain Shams University Hospital (Cairo, Egypt). Complete clinical evaluation and laboratory investigations, including a thrombophilia workup and full radiological assessment, were performed to determine underlying disease etiologies.

RESULTS: BCS was chronic in 79.8% of patients, acute or subacute in 19.1%, and fulminant in 1.1%. Factor V Leiden mutation (FVLM) was the most common etiological cause of disease (53.1%), followed by mutation of the gene encoding methylene tetrahydrofolate reductase (MTHFR) (51.6%). Current or recent hormonal treatment was documented in 15.5% of females, and BCS associated with pregnancy was present in 17.2% of females. Etiology could not be determined in 8.5% of patients. Males had significantly higher rates of MTHFR gene mutation and Behçet’s disease, and females had significantly higher rates of secondary antiphospholipid antibody syndrome. A highly significant positive relationship was evident between the presence of Behçet’s disease and inferior vena caval occlusion, either alone or combined with occlusion of the hepatic veins (P < 0.0001).

CONCLUSION: FVLM is the most common disease etiology and MTHFR the second most common in Egyptian BCS patients. BCS etiology tends to vary with geographic region.

Acute infectious conjunctivitis in childhood

OBJECTIVE

To review the etiology, clinical features and management of acute infectious conjunctivitis in children after the newborn period.

DATA SOURCES

Articles obtained from MEDLINE published before March 2000.

DATA SELECTION AND EXTRACTION

Representative articles on the etiology and clinical features were selected. Twenty-four clinical trials were also selected. From these articles, the main findings from three placebo controlled trials and two comparative clinical trials involving children are summarized in detail. The main findings from 19 comparative clinical trials in adults are briefly summarized.

DATA SYNTHESIS AND CONCLUSIONS

Acute infectious conjunctivitis caused by bacteria or viruses is a very common problem in children after the neonatal period. The most common bacterial pathogens are nontypable Haemophilus influenzae and Streptococcus pneumoniae. Diagnostic microbiology tests are not indicated for uncomplicated cases but may be useful for very young or very ill children if there is no response to initial therapy; for nosocomial cases; for cases suspected to be caused by sexually transmitted pathogens; and for outbreaks. Conjunctivitis is usually a mild, self-limited disease, but topical antibiotics are superior to placebo in reducing the duration and severity of symptoms. Most topical agents have equivalent efficacy; therefore, the selection of first-line agents should include inexpensive drugs with few adverse effects. Good choices include polymyxin/gramicidin, polymyxin/trimethoprim or sulfacetamide. Referral to an ophthalmologist should be considered in situations in which the diagnosis of uncomplicated conjunctivitis is in doubt or if there is no prompt response to therapy.

Advance in understanding the epidemiology and etiology of pancreatic cancer

Pancreatic cancer is a life-threatening digestive system neoplasm with a low rate of surgical resection and poor prognosis. Symptoms of pancreatic cancer are so insidious that it is difficult to identify them at early stage. Due to changes in human lifestyle and diet, the incidence of pancreatic cancer has been increasing worldwide. Both genetic and environmental factors contribute to the pathogenesis of pancreatic cancer. Some hereditary factors, such as genetic mutations and genetic polymorphisms, have been demonstrated to be related to the development of pancreatic cancer. Many risk factors associated with pancreatic cancer, such as smoking, obesity, alcohol consumption, chronic pancreatitis, and diabetes, have also been identified. Here we review the recent advances in understanding the epidemiology and etiology of pancreatic cancer.

Etiology of chronic pancreatitis: an analysis of 430 cases in Yunnan Province

AIM: To investigate the etiology of chronic pancreatitis (CP) in Yunnan Province.

METHODS: The clinical data for 430 patients with CP who were treated in six provincial and municipal general hospitals in Yunnan Province between January 1, 2003 and December 31 were retrospectively analyzed to analyze etiological factors for this disease.

RESULTS: Of all patients, 37.2% suffered from biliary diseases, 42.1% were drinkers, 29.5% had pancreatic stone disease, 22.8% had acute pancreatitis, 30.2% had undergone abdominal surgery, and 66.0% had multiple etiological factors. The ratio of the number of patients with CP in the first four years to that in the second four years was 1：1.59. The percentages of patients suffering from biliary diseases and drinkers accounted for 39.8% and 36.1% in the first four years and 35.6% and 45.8% in the second four years. The male to female ratio was 2.9：1. In male patients, alcohol is the main etiological factor (56.3%), while in females, biliary disease is the main etiological factor (32.7%).

CONCLUSION: Biliary disease and alcohol factor are the main etiological factors for CP in Yunnan Province. In recent years, alcohol has replaced biliary disease to become the major etiological factor for CP.

The role of ultrasonography in primary congenital hypothyroidism

BACKGROUND

The aim of this study was to compare the usefulness of ultrasonography and scintigraphy in diagnosing the etiology of primary congenital hypothyroidism (CH).

METHODS

The newborns that were examined by both thyroid scintigraphy and ultrasonography during CH screening program in Isfahan were included in this study. The ultrasonographic findings were compared with the scintigraphic findings and the sensitivity and specificity of the ultrasonography was determined.

RESULTS

During this study, 102 CH newborns were studied. According to the ultrasonographic results, 61.8%, 26.5%, 2.9% and 8.8% of them had normal thyroid gland, agenesia, ectopia and hypoplasia, respectively, and according to scintigraphic results, 55.9%, 35.3% and 8.8% of them had normal thyroid gland, agenesia and ectopia, respectively. Ultrasound detected sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio were 77%, 92%, 89%, 84%, 9.6 and 0.25, respectively. The sensitivity and specificity of ultrasonography compared with thyroid scintigraphy in diagnosis of thyroid gland ectopia was 33% and 100%, respectively.

CONCLUSIONS

Though thyroid ultrasonography failed to diagnose 67% of ectopic cases and nonfunctioning thyroid gland, it had the ability to determine the anatomy of thyroid gland. So, considering some limitations of scintigraphy, we concluded that ultrasonography is a relatively appropriate imaging tool for diagnosing CH etiologies, especially in the initial phase of CH screening.

Progress in understanding the etiology of chronic pancreatitis

Chronic pancreatitis (CP) is irregularly distributed around the world, and the pathogenic factors and incidence rates of CP vary greatly among different countries and regions. The main pathogenic factor for CP is alcohol in Western countries and biliary tract disease in China. Changes in the lifestyle also change the main pathogenic factors for CP. In recent years, alcohol has gradually replaced biliary tract disease to become the main etiological factor for CP in China. A deeper understanding of the etiology of CP provides new insights into the treatment of the disease.

Schizophrenia, cancer and obstetric complications in an evolutionary perspective-an empirically based hypothesis

OBJECTIVE

Patients diagnosed with schizophrenia have reduced fecundity and premature mortality (both accidental and violent) with no obvious compensatory advantages among kin. The prevalence of the disorder is around 0.7/1%, higher than the expected prevalence of spontaneous mutations. Genes favoring schizophrenia may have been positively selected in the environment of evolutionary adaptation. Literature on potential adaptive genes is reviewed within an evolutionary framework.

METHODS

Literature search on major scientific search engine (PubMed/Medline, Ovid/PsychInfo) on papers aimed at investigating potential pathways justifying a mutation-selection balanced model. Findings are presented with a narrative touch to favor readability and understanding.

RESULTS

Reduced incidence of cancer in both patients diagnosed with schizophrenia and their siblings was reported worldwide. Such findings are notable given higher cancer risk factors in schizophrenia, i.e., smoking, alcohol abuse, obesity, poor diet, and poor adherence to therapy. Some genes involved in cancer proliferation might as well confer protective advantage in immune-surveillance, inflammation, vascular proliferation or apoptosis that otherwise will adversely affect early neurodevelopment.

CONCLUSION

Evidence that reduced risk of certain somatic diseases is associated with schizophrenia is quite significant to progress in the evolutionary epidemiological analysis of psychopathology.

The surgical anatomy and etiology of gastrointestinal fistulas

BACKGROUND

Fistulas are abnormal communications between two epithelial surfaces, either between two portions of the intestine, between the intestine and some other hollow viscus, or between the intestine and the skin of the abdominal wall. The etiology of intestinal fistulas is in most cases a result of multiple contributing factors. Despite significant advances in their management over the past decades, intestinal fistulas remain a major clinical problem, with a high overall mortality rate of up to 30% due to the high rate of complications. This paper aims to describe classification systems based on the anatomy, physiology and etiology that may be helpful in the clinical management of intestinal fistulas.

METHODS

On the basis of anatomical differences, fistulas can be classified based by the site of origin, by site of their openings, or as simple or complex. Physiologic classification as low, moderate or high output fistulas is most useful for the non-surgical approach. Concerning the etiology, we classified the possible causes as (postoperative) trauma, inflammation, infection, malignancy, radiation injury or congenital.

CONCLUSION

Fistula formation can cause a number of serious or debilitating complications ranging from disturbance of fluid and electrolyte balance to sepsis and even death. They still remain an important complication following gastrointestinal surgery.

Diagnosis and management of pericardial effusion

Pericardial effusion is a common finding in everyday clinical practice. The first challenge to the clinician is to try to establish an etiologic diagnosis. Sometimes, the pericardial effusion can be easily related to a known underlying disease, such as acute myocardial infarction, cardiac surgery, end-stage renal disease or widespread metastatic neoplasm. When no obvious cause is apparent, some clinical findings can be useful to establish a diagnosis of probability. The presence of acute inflammatory signs (chest pain, fever, pericardial friction rub) is predictive for acute idiopathic pericarditis irrespective of the size of the effusion or the presence or absence of tamponade. Severe effusion with absence of inflammatory signs and absence of tamponade is predictive for chronic idiopathic pericardial effusion, and tamponade without inflammatory signs for neoplastic pericardial effusion. Epidemiologic considerations are very important, as in developed countries acute idiopathic pericarditis and idiopathic pericardial effusion are the most common etiologies, but in some underdeveloped geographic areas tuberculous pericarditis is the leading cause of pericardial effusion. The second point is the evaluation of the hemodynamic compromise caused by pericardial fluid. Cardiac tamponade is not an "all or none" phenomenon, but a syndrome with a continuum of severity ranging from an asymptomatic elevation of intrapericardial pressure detectable only through hemodynamic methods to a clinical tamponade recognized by the presence of dyspnea, tachycardia, jugular venous distension, pulsus paradoxus and in the more severe cases arterial hypotension and shock. In the middle, echocardiographic tamponade is recognized by the presence of cardiac chamber collapses and characteristic alterations in respiratory variations of mitral and tricuspid flow. Medical treatment of pericardial effusion is mainly dictated by the presence of inflammatory signs and by the underlying disease if present. Pericardial drainage is mandatory when clinical tamponade is present. In the absence of clinical tamponade, examination of the pericardial fluid is indicated when there is a clinical suspicion of purulent pericarditis and in patients with underlying neoplasia. Patients with chronic massive idiopathic pericardial effusion should also be submitted to pericardial drainage because of the risk of developing unexpected tamponade. The selection of the pericardial drainage procedure depends on the etiology of the effusion. Simple pericardiocentesis is usually sufficient in patients with acute idiopathic or viral pericarditis. Purulent pericarditis should be drained surgically, usually through subxiphoid pericardiotomy. Neoplastic pericardial effusion constitutes a more difficult challenge because reaccumulation of pericardial fluid is a concern. The therapeutic possibilities include extended indwelling pericardial catheter, percutaneous pericardiostomy and intrapericardial instillation of antineoplastic and sclerosing agents. Massive chronic idiopathic pericardial effusions do not respond to medical treatment and tend to recur after pericardiocentesis, so wide anterior pericardiectomy is finally necessary in many cases.

Characteristics of anemia in elderly: a hospital based study in South India

Anemia is a common concern in older people and can have significant morbidity and mortality. Because anemia is a sign, not a diagnosis, an evaluation is almost always warranted to identify the underlying cause. The purpose of this study was to study the clinical profile of elderly patients with anemia and to study characteristics of hematological types of anemia in such patients as well as the closest possible etiological profile. Hundred patients above the age of 60 years were included in the study. Clinical profile with laboratory studies of Hemoglobin and diagnostic tests to fix the etiology. Majority of patients had normocytic blood picture. Renal failure was the most common underlying chronic disease. Significant number of patients were on non steroidal anti-inflammatory drugs which could contribute to the anaemia. 14% of the patients had an underlying malignancy. 73.3% of the patients in the microcytic group had an underlying GI lesion on endoscopy. Identifying anemia as an important aspect of a comprehensive geriatric assessment is absolutely essential further to clinical detection. Confirming the type of anemia is critical to direct the investigation for profiling the etiology since it is well known that the treatment of anemia goes a long way in improving the overall outcome and quality of life.

Posttraumatic giant extradural intradiploic epidermoid cysts of posterior cranial fossa : case report and review of the literature

We reported a unique case of posttraumatic giant infratentorial extradural intradiploic epidermoid cyst. A 54-year-old male, with a previous history of an open scalp injury and underlying linear skull fracture in the left occipital region in childhood, presented with a painful subcutaneous swelling, which had been developed gradually in the same region and moderate headache, nausea, vomiting and cerebellar ataxia. The duration of symptoms on admission was 3 months. Imaging studies revealed occipital bone destruction and giant extradural intradiploic lesion. The preoperative diagnosis was giant infratentorial extradural intradiploic epidermoid cyst. Surgery achieved total removal of the lesion, which was histologically confirmed and the postoperative course was uneventful. To our knowledge, this is the first case of giant infratentorial extradural intradiploic epidermoid cyst with a traumatic etiology described in the literature.

The study of substructures of addiction phenomena in high school students using problem finding workshops

BACKGROUND

Addiction is one of the complicated problems in Iranian young population. The social and cultural dimensions of this social disease are less considered. So considering socio-cultural and environmental resources, this study investigated the substructures of addiction according to the viewpoints of high-school students of Kerman, Iran in 2007-2008.

METHODS

This qualitative study accomplished in ten high schools through a one-day problem finding workshop and continued until data saturation. The resulted terms and phrases were analyzed by content analysis. To assure about the validity and reliability, the outputs reviewed by workshops participants, and classification and codification of the data were executed separately by two experts.

FINDINGS

A total of 212 students, 45.3% girls and 54.7% boys, participated in the study. The students introduced the followings as the addiction substantial fundaments: lack of knowledge, positive attitude and interpretation of addiction as a value, family or friends' habit, economy status, psycho-personality problems and availability. Rules infirmity or non-implementation of the current rules enforcement, geographical status and addiction as a conspiracy were also observed in students' statements.

CONCLUSION

The positive attitudes and historical roots of addiction along with the process of changing the values caused the growth of drug addiction in young population which could neutralize the security measures, legislations policy and even the knowledge. Therefore, intensification of personal protective factors and culturalization addressed for improving inner layers of values are recommended.

Aetiology and severity of gingival recession in an adult population sample in Greece

BACKGROUND

Gingival recession is the most common and undesirable condition of the gingiva. The aim of study was to investigate the aetiology and severity of gingival recession in a Greek adult population sample.

METHODS

The study was performed on 165 males and 179 females, 18-68 years old who sought dental treatment in a private dental practice and showed gingival recession. All subjects were clinically examined and answered questions regarding their oral hygiene habits such as the type of toothbrush, frequency of brushing and method of brushing. The association between gingival recession and the following parameters was assessed: plaque score, gingival score and tooth position. Statistical analysis of the results was accomplished using chi-square test (α = 0.05).

RESULTS

The majority (79.4%) of the patients showed grade I gingival recession and 15.3% showed grade II gingival recession. The maxillary 1(st) and 2(nd) molars (35.3%) and the mandibular 1(st) and 2(nd) molars (28.7%) were the teeth most frequently affected by root surface exposure. Patients with sub-gingival calculus, bacterial plaque and gingival inflammation (P <60; 0.05), malpositioned teeth (P <60; 0.001), horizontal brushing method, medium type of toothbrush (P <60; 0.001) and brushing once daily (P <60; 0.001) appeared to be the most common precipitating aetiological factor for gingival recession.

CONCLUSION

According to the results of the present study, gingival recession was the result of more than one factor acting together. Horizontal brushing method, usage of medium type toothbrush and tooth brushing once daily were found to be more associated with gingival recession.

Intrauterine intussusception causing ileal atresia

Intrauterine intussusception (IUI) is the one of the rarest recognized causes of jejuno-ileal atresia (JIA). We report on a 15-day old full-term neonate presenting with features of intestinal obstruction, wherein on exploration, a visible ileo-ileal intussusception resulting in ileal atresia was found. The relevant literature has been reviewed.

Mandibular cephalometric characteristics of a Saudi sample of patients having impacted third molars

OBJECTIVE

To evaluate the cephalometric characteristics of mandibles of Saudi patients having impacted third molars and to compare them to those of patients having normally erupted third molars.

MATERIAL AND METHODS

One hundred and twenty-one Saudi adult subjects (59 females and 62 males; age: 20-40 years) were divided into two groups based on the status of the mandibular third molars: (1) impaction group and (2) normal group. Means and standard deviations of 21 cephalometric measurements related to mandibular geometry were measured and compared between the two groups using the unpaired t-test. Males and females in the impaction group were also compared with their equivalent subgroups in the normal group using the unpaired t-test.

RESULTS

Anteroposteriorly, space distal to second molar, ramal width and mandibular body length were significantly less in the impaction group than in the control group. In addition, posterior teeth were more upright in the impaction group. Vertically, posterior alveolar height was significantly less in the impaction group. The Y-axis was significantly increased in the impaction group. The significance of these measurements was variable between males and females.

CONCLUSIONS

Third-molar impactions in the Saudis living in the Western region of Saudi Arabia were more likely to occur when inadequate retromolar space is present. This can be attributed to certain mandibular skeletal and dental features, among which the increased width of mandibular ramus and backward inclination of posterior teeth seem to be the most influencing factors in both sexes.

Age trends in the prevalence of Budd-Chiari syndrome in Henan Province

AIM: To analyze the changes in the age of patients with Budd-Chiari syndrome in Henan Province, China between 1995 and 2009, and to analyze the possible etiological factors contributing to such changes.

METHODS: The clinical data for 909 patients with Budd-Chiari syndrome treated at the Department of Interventional Radiology of the First Affiliated Hospital of Zhengzhou University from 1995 to 2009 were analyzed using the SPSS 13.0 statistical software.

RESULTS: The mean age of patients with Budd-Chiari syndrome is 39.17 ± 11.40. An ascending trend was observed for the mean age of patients with Budd-Chiari syndrome in Henan Province from 1995 to 2009 (P < 0.05). Patients aged 35-44 years accounted for 19.87% during 1995-1997, and 38.51% during 2007-2009. The percentage of patients aged 35-44 years showed an upward trend. In contrast, the percentage of patients aged 25-34 years showed a downward trend during this period. The percentages of other age groups of patients did not change greatly (all P > 0.05).

CONCLUSION: The age at diagnosis of patients with Budd-Chiari syndrome shows an upward trend in Henan Province from 1995 to 2009.

Non-viral causes of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and represents an international public health concern as one of the most deadly cancers worldwide. The main etiology of HCC is chronic infection with hepatitis B and hepatitis C viruses. However, there are other important factors that contribute to the international burden of HCC. Among these are obesity, diabetes, non-alcoholic steatohepatitis and dietary exposures. Emerging evidence suggests that the etiology of many cases of HCC is in fact multifactorial, encompassing infectious etiologies, comorbid conditions and environmental exposures. Clarification of relevant non-viral causes of HCC will aid in preventative efforts to curb the rising incidence of this disease.

Simultaneous occurrence of a hepatocellular carcinoma and a hepatic non-Hodgkin's lymphoma infiltration

To investigate the simultaneous occurrence of hepatocellular carcinoma and non-Hodgkin's lymphoma, we report the case of a 70 year old patient with a primary diagnosis of non-Hodgkin's lymphoma in 2002. In a routine follow up investigation of his chronic lymphocytic leukemia a newly detected mass in the Couinaud's segments 2 and 3 was found. No hepatitis C virus or hepatitis B virus infection or cirrhosis was evident. After laparoscopic segmentectomy the histological examination revealed a hepatocellular carcinoma. While the relation between liver parenchyma damages and hepatocellular carcinoma or non-Hodgkin's lymphoma is well known, only a few publications have focused on the coexistence of hepatocellular carcinoma and non-Hodgkin's lymphoma. With this case we demonstrate the coexistence of these diseases without having a predamaged liver parenchyma.

The causative organisms of bacterial meningitis in Korean children in 1996-2005

Bacterial meningitis remains a serious cause of morbidity and mortality in childhood, despite the availability of effective vaccines against Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae. The purpose of this study was to analyze data on bacterial meningitis cases in Korea from 1996 through 2005. The information of all hospitalized bacteria-proven meningitis cases was obtained from 17 university hospitals nationwide. A total of 402 cases were identified. Of these, 125 (29.9%) cases were neonates. Streptococcus agalactiae was the most common bacteria responsible for 99 (24.6%) of all cases regardless of age, followed by S. pneumoniae for 91 (22.6%) and H. influenzae for 67 (16.7%) patients. The common etiology beyond the neonatal period was S. pneumoniae for 91 (33.0%) followed by H. influenzae for 63 (22.8%) patients. The overall case fatality rate was 9.4%, which was similar with that in 1986-1995. In conclusion, S. agalactiae, S. pneumoniae and H. influenzae were important etiologic agents of bacterial meningitis in children in the last 10 yrs. It is required to establish the preventive strategy of the three bacteria. The nationwide epidemiologic study should be continued to evaluate immunization strategy and efficacy.

Acute lung injury and ARDS in acute pancreatitis: Mechanisms and potential intervention

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in acute pancreatitis still represents a substantial problem, with a mortality rate in the range of 30%-40%. The present review evaluates underlying pathophysiological mechanisms in both ALI and ARDS and potential clinical implications. Several mediators and pathophysiological pathways are involved during the different phases of ALI and ARDS. The initial exudative phase is characterized by diffuse alveolar damage, microvascular injury and influx of inflammatory cells. This phase is followed by a fibro-proliferative phase with lung repair, type II pneumocyte hypoplasia and proliferation of fibroblasts. Proteases derived from polymorphonuclear neutrophils, various pro-inflammatory mediators, and phospholipases are all involved, among others. Contributing factors that promote pancreatitis-associated ALI may be found in the gut and mesenteric lymphatics. There is a lack of complete understanding of the underlying mechanisms, and by improving our knowledge, novel tools for prevention and intervention may be developed, thus contributing to improved outcome.

Sacrococcygeal pilonidal disease: analysis of previously proposed risk factors

PURPOSE

Sacrococcygeal pilonidal disease is a source of one of the most common surgical problems among young adults. While male gender, obesity, occupations requiring sitting, deep natal clefts, excessive body hair, poor body hygiene and excessive sweating are described as the main risk factors for this disease, most of these need to be verified with a clinical trial. The present study aimed to evaluate the value and effect of these factors on pilonidal disease.

METHOD

Previously proposed main risk factors were evaluated in a prospective case control study that included 587 patients with pilonidal disease and 2,780 healthy control patients.

RESULTS

Stiffness of body hair, number of baths and time spent seated per day were the three most predictive risk factors. Adjusted odds ratios were 9.23, 6.33 and 4.03, respectively (p<0.001). With an adjusted odds ratio of 1.3 (p<.001), body mass index was another risk factor. Family history was not statistically different between the groups and there was no specific occupation associated with the disease.

CONCLUSIONS

Hairy people who sit down for more than six hours a day and those who take a bath two or less times per week are at a 219-fold increased risk for sacrococcygeal pilonidal disease than those without these risk factors. For people with a great deal of hair, there is a greater need for them to clean their intergluteal sulcus. People who engage in work that requires sitting in a seat for long periods of time should choose more comfortable seats and should also try to stand whenever possible.

Analysis of the pathogens in infectious diarrhea (other than cholera, dysentery, typhoid and paratyphoid) cases reported in China in 2008

AIM: To analyze the etiological and epidemiological characteristics of infectious diarrhea (other than cholera, dysentery, typhoid and paratyphoid) cases reported in China in 2008.

METHODS: The data of infectious diarrhea (other than cholera, dysentery, typhoid and paratyphoid) cases reported in China in 2008 were retrieved from Chinese Information System for Diseases Control and Prevention and analyzed.

RESULTS: Of more than 70 million cases of infectious diarrhea (other than cholera, dysentery, typhoid and paratyphoid) reported, 50.98% of the cases and 69.64 % of the deaths occurred in children aged ≤ 5 years. In nearly 30000 cases with pathogen information, viruses (90.65%) and bacteria (8.97%) were found to be major pathogens. In bacterial diarrhea, Vibrio parahaemolyticus (65.26%) and Salmonella (20.70%) are major pathogens, accounting for 85.96%. In viral diarrhea, rotavirus (92.75%) and adenovirus (4.34%) are major pathogens, accounting for 97.09%.

CONCLUSION: Infectious diarrhea (other than cholera, dysentery, typhoid and paratyphoid) mainly affects children aged less than 5 years. The diagnostic information concerning the pathogens of infectious diarrhea has important implications for public health. However, the quality and timeliness of the reported information need to be improved, and the data need to be enriched.

Advances in understanding the pathogenesis of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a highly prevalent gastrointestinal motility disorder characterized by abdominal discomfort/pain associated with altered bowel habits. At present, the pathophysiology of IBS is still unknown. Genetic factors, psychosocial factors, and changes in gastrointestinal motility and visceral hypersensitivity are traditionally thought to play a crucial role in symptom generation in IBS. Recent studies have identified new additional factors (such as dysregulation of the brain-gut axis, gastrointestinal infection, and activation of mast cells in the intestinal mucosa with consequent release of bioactive substances) that are correlated with the pathogenesis of IBS. In this article, we will review the recent advances in the research on the pathogenesis of IBS.

Combined hyperactive dysfunction syndrome of the cranial nerves

OBJECTIVE

Combined hyperative dysfunction syndrome (HDS) defined as the combination of HDSs such as trigeminal neuralgia (TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN), which may or may not occur simultaneously on one or both sides. We reviewed patients with combined HDS and demonstrated their demographic characteristics by comparing them with those of patients with a single HDS.

METHODS

Between October 1994 and February 2006, we retrospectively studied a series of 1,720 patients who suffered from HDS and found 51 patients with combined HDSs. We analyzed several independent variables in order to evaluate the prevalence and etiologic factors of combined HDS.

RESULTS

The combined HDS group accounted for 51 of 1,720 (2.97%) patients with HDS; 27 cases of bilateral HFS, 10 cases of bilateral TN and 14 cases of HFS with TN. Their mean age was 52.1 years (range, 26-79 years). There were 5 men and 46 women. Seven patients had synchronous and 44 patients metachronous onset of HDSs. By comparison of combined and single HDS groups, we found that age and hypertension were closely associated with the prevalence of combined HDS (p < 0.05).

CONCLUSION

This study revealed that combined HDS was very rare. Hypertension and age might be the most important causative factors to evoke combined HDS.

Hepatitis C virus genotype 3a infection and hepatocellular carcinoma: Pakistan experience

AIM: To assess the association between chronic hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) in Pakistan, and the genotype distribution among these HCC patients.

METHODS: One hundred and sixty-one subjects with HCC were included in this study. Liver biopsy was performed on 145 of the patients; sixteen were excluded because they failed to fulfill the inclusion criteria. Qualitative polymerase chain reaction (PCR) was performed for hepatitis B virus and HCV. Samples positive for HCV RNA were genotyped using genotype-specific PCR and confirmed by HCV 5’ noncoding region sequencing analysis.

RESULTS: Chronic HCV infection was identified a major risk factor (63.44% of tested HCC patients) for the development of HCC. The time from HCV infection to appearance of cancer was 10-50 years. In the HCC patient population, broader distributions of genotypes were present with genotype 3a as the predominant genotype. Using the type-specific genotyping method, we found HCV genotype 3a in 40.96%, 3b in 15.66%, 1a in 9.63%, and 1b in 2.40% of HCC tissue samples. About 28% of cases were found with mixed genotypes. Two cases were unable to be genotyped because of low viral load. Sixty-six percent of treated patients with cirrhosis had an end of treatment response, but unfortunately they relapsed quickly when the treatment was discontinued, and HCC developed during a median 3.8 years.

CONCLUSION: There was a strong association between chronic HCV infection and HCC in Pakistan, and between HCV genotype 3a and HCC.

Hallucinations: Etiology and clinical implications

The literature on hallucinations is reviewed, including history; theoretical background from physiological, biochemical and psychological points of view; classification; causation; presentation in different psychiatric and neurological disorders and in normal persons. The available evidence suggests that hallucinations result from a failure of the metacognitive skills involved in discriminating between self-generated and external sources of information. Management of hallucinations is briefly discussed.

Severe acute cholestatic hepatitis of unknown etiology successfully treated with the Chinese herbal medicine Inchinko-to (TJ-135)

Severe acute hepatitis of unknown etiology is difficult to treat and often progresses to subacute fulminant hepatitis or late-onset hepatic failure. A 45-year-old well-nourished, healthy man had progressive fatigue and his liver function tests showed severe liver dysfunction. The etiology of sever acute cholestatic hepatitis was unknown. The liver function tests normalized gradually, which excluded high persistent total bilirubin after starting on predonine. A liver biopsy showed chronic active hepatitis with mild fibrosis (A2, F1). Oral Inchinko-to, a Chinese herbal medicine, at 7.5 g daily was prescribed. The treatment was effective with no adverse effects. We present a successfully treated case and discuss hepatoprotective and choleretic effects of Inchinko-to.

Acute pancreatitis: Etiology and common pathogenesis

Acute pancreatitis is an inflammatory disease of the pancreas. The etiology and pathogenesis of acute pancreatitis have been intensively investigated for centuries worldwide. Many causes of acute pancreatitis have been discovered, but the pathogenetic theories are controversial. The most common cause of acute pancreatitis is gallstone impacting the distal common bile-pancreatic duct. The majority of investigators accept that the main factors for acute billiary pancreatitis are pancreatic hyperstimulation and bile-pancreatic duct obstruction which increase pancreatic duct pressure and active trypsin reflux. Acute pancreatitis occurs when intracellular protective mechanisms to prevent trypsinogen activation or reduce trypsin activity are overwhelmed. However, little is known about the other acute pancreatitis. We hypothesize that acute biliary pancreatitis and other causes of acute pancreatitis possess a common pathogenesis. Pancreatic hyperstimulation and pancreatic duct obstruction increase pancreatic duct pressure, active trypsin reflux, and subsequent unregulated activation of trypsin within pancreatic acinar cells. Enzyme activation within the pancreas leads to auto-digestion of the gland and local inflammation. Once the hypothesis is confirmed, traditional therapeutic strategies against acute pancreatitis may be improved. Decompression of pancreatic duct pressure should be advocated in the treatment of acute pancreatitits which may greatly improve its outcome.

Breastfeeding and genetic factors in the etiology of inflammatory bowel disease in children

Inflammatory bowel disease is a chronic, debilitating disorder of the gastrointestinal tract. The etiology of inflammatory bowel disease has not been elucidated, but is thought to be multifactorial with both environ-mental and genetic influences. A large body of research has been conducted to elucidate the etiology of inflammatory bowel disease. This article reviews this literature, emphasizing the studies of breastfeeding and the studies of genetic factors, particularly NOD2 polymorphisms.

Rational diagnosis and therapy for recurrent acute pancreatitis: a clinical analysis of 84 cases

AIM: To investigate the characteristics of etiology, clinical features and endoscopic manifestations and prevention methods of recurrent acute pancreatitis.

METHODS: The clinical data of 84 patients with recurrent acute pancreatitis (recurrence group) and 67 patients with incipient acute pancreatitis (control group) at our hospital from September 2001 to December 2007 were retrospectively analyzed; the results of imaging changes and endoscopy therapy were reviewed as well.

RESULTS: Incidence rate of biliary tract diseases was significantly higher in relapse group than in the control group (60.7% vs 38.8%, P < 0.01). Radiation pain, jaundice, intestinal obstruction were increased in the relapse group than in the control group, but there was no marked difference. Crude echo (38.3%), pancreatic duct dilation (21.3%), cholecystitis, the common bile duct stone were also significantly higher in relapse group than in control group. ERCP showed that stones and common bile duct dilation were significantly higher in relapse group than in control group (35.8% vs 11.6%, 32.1% vs9.3%, P < 0.05). Of 84 RAP cases, 20 underwent surgical treatment, 48 conservative treatment, and 16 endoscopy therapy. Three died in each surgery group and conservative treatment group, and none in endoscopy therapy group.

CONCLUSION: Recurrent acute pancreatitis often results from biliary tract diseases including cholelithiasis, chronic cholecystitis, inappropriate eating habit and alcohol use. Rational diagnosis and therapy is important measure to prevent relapse. Endoscopy therapy for RAP is safe, minimally invasive and effective, and is recommended for wide use.

Ventricular dyssynchrony: 12-month evaluation in ischemic versus nonischemic CRT patients

OBJECTIVE

Few data exist about the potential differences in the dyssynchrony status of cardiac resynchronization therapy (CRT) candidates stratified by etiology of heart failure, and about the evolution of dyssynchrony at long-term follow-up. We provided a description of intra-ventricular dyssynchrony at baseline, 6 months and 12 months in ischemic and nonischemic CRT patients.

METHODS

Tissue Doppler Imaging was performed in 35 CRT candidates (18 ischemic, 17 nonischemic) at baseline, and at 6-month and 12-month follow-up. A group of 11 healthy subjects was considered for comparison.

RESULTS

At baseline, the standard deviation and the maximum activation delay between any 2 segments were significantly greater in ischemic (38+/-33ms, 94+/-76ms) and nonischemic (38+/-24ms, 96+/-62ms) patients versus controls (9+/-7ms, 22+/-15ms) (all p<0.05). The average time to activation for posterior and lateral wall was significantly higher in nonischemic patients, while the anterior septum activated later in ischemic patients. At 6-month follow-up, standard deviation and maximum delay did not vary in nonischemic while decreased in ischemic group. All changes persisted at 12 months.

CONCLUSIONS

No baseline differences were observed between ischemic and nonischemic patients using studied indices. At 6- and 12-month follow-up, only ischemic patients presented a significant reduction in dyssynchrony values, although in both groups CRT did not lead to a complete normalization of LV synchronism.