Migraine headache (MH) classification using machine learning methods with data augmentation

Migraine headache, a prevalent and intricate neurovascular disease, presents significant challenges in its clinical identification. Existing techniques that use subjective pain intensity measures are insufficiently accurate to make a reliable diagnosis. Even though headaches are a common condition with poor diagnostic specificity, they have a significant negative influence on the brain, body, and general human function. In this era of deeply intertwined health and technology, machine learning (ML) has emerged as a crucial force in transforming every aspect of healthcare, utilizing advanced facilities ML has shown groundbreaking achievements related to developing classification and automatic predictors. With this, deep learning models, in particular, have proven effective in solving complex problems spanning computer vision and data analytics. Consequently, the integration of ML in healthcare has become vital, especially in developing countries where limited medical resources and lack of awareness prevail, the urgent need to forecast and categorize migraines using artificial intelligence (AI) becomes even more crucial. By training these models on a publicly available dataset, with and without data augmentation. This study focuses on leveraging state-of-the-art ML algorithms, including support vector machine (SVM), K-nearest neighbors (KNN), random forest (RF), decision tree (DST), and deep neural networks (DNN), to predict and classify various types of migraines. The proposed models with data augmentations were trained to classify seven various types of migraine. The proposed models with data augmentations were trained to classify seven various types of migraine. The revealed results show that DNN, SVM, KNN, DST, and RF achieved an accuracy of 99.66%, 94.60%, 97.10%, 88.20%, and 98.50% respectively with data augmentation highlighting the transformative potential of AI in enhancing migraine diagnosis.

Extra Biliary Complications of Laparoscopic Cholecystectomy: Experience from a Study of 1420 Cases

To evaluate the extra biliary complications of laparoscopic cholecystectomy and the outcome of management of those complications. This descriptive observational study was carried out at CMH Dhaka and CMH Jashore, Bangladesh from March 2016 to March 2022. A total of 1420 patients who underwent Laparoscopic cholecystectomy were included in this study. Extra biliary complications of laparoscopic cholecystectomy were divided into i) Access related ii) Intraoperative (procedure related) and iii) Postoperative complications. The incidence of access-related, intra-operative or procedure-related and postoperative complications was 2.88%, 4.91% and 1.82% respectively. Access related complications were extra-peritoneal insufflations 1.34%, port site bleeding 1.26%, small bowel laceration 0.21% and transverse colon injury 0.07%. Intraoperative or procedural extra biliary complications were liver injury 0.56%, duodenal perforation 0.07%, colon injury 0.07%, bleeding through cystic artery 0.49% and bleeding from gall bladder bed 1.12%. Postoperative complications were port site infection (PSI) 1.05%, port site hernia (PSH) 0.56%, major sepsis 0.14% and ischemic stroke 0.07%. Two of colonic injuries were the major complications encountered in this series, diagnosed during the procedure and converted to open procedure. Duodenal perforation encountered in one case during difficult dissection in the Callot's triangle, diagnosed during the procedure and managed laparoscopically by intra-corporeal suturing. No mortality reported in this series. Extra biliary complications are almost equally common as biliary complications in laparoscopic cholecystectomy and can be life-threatening. An early diagnosis and effective management of complications accordingly, are the utmost requirement for favorable outcome in laparoscopic cholecystectomy.

Data augmentation and deep neural networks for the classification of Pakistani racial speakers recognition

Speech emotion recognition (SER) systems have evolved into an important method for recognizing a person in several applications, including e-commerce, everyday interactions, law enforcement, and forensics. The SER system's efficiency depends on the length of the audio samples used for testing and training. However, the different suggested models successfully obtained relatively high accuracy in this study. Moreover, the degree of SER efficiency is not yet optimum due to the limited database, resulting in overfitting and skewing samples. Therefore, the proposed approach presents a data augmentation method that shifts the pitch, uses multiple window sizes, stretches the time, and adds white noise to the original audio. In addition, a deep model is further evaluated to generate a new paradigm for SER. The data augmentation approach increased the limited amount of data from the Pakistani racial speaker speech dataset in the proposed system. The seven-layer framework was employed to provide the most optimal performance in terms of accuracy compared to other multilayer approaches. The seven-layer method is used in existing works to achieve a very high level of accuracy. The suggested system achieved 97.32% accuracy with a 0.032% loss in the 75%:25% splitting ratio. In addition, more than 500 augmentation data samples were added. Therefore, the proposed approach results show that deep neural networks with data augmentation can enhance the SER performance on the Pakistani racial speech dataset.

Multi-label emotion classification of Urdu tweets

Urdu is a widely used language in South Asia and worldwide. While there are similar datasets available in English, we created the first multi-label emotion dataset consisting of 6,043 tweets and six basic emotions in the Urdu Nastalíq script. A multi-label (ML) classification approach was adopted to detect emotions from Urdu. The morphological and syntactic structure of Urdu makes it a challenging problem for multi-label emotion detection. In this paper, we build a set of baseline classifiers such as machine learning algorithms (Random forest (RF), Decision tree (J48), Sequential minimal optimization (SMO), AdaBoostM1, and Bagging), deep-learning algorithms (Convolutional Neural Networks (1D-CNN), Long short-term memory (LSTM), and LSTM with CNN features) and transformer-based baseline (BERT). We used a combination of text representations: stylometric-based features, pre-trained word embedding, word-based n-grams, and character-based n-grams. The paper highlights the annotation guidelines, dataset characteristics and insights into different methodologies used for Urdu based emotion classification. We present our best results using micro-averaged F1, macro-averaged F1, accuracy, Hamming loss (HL) and exact match (EM) for all tested methods.

Predictors of Malignancy in Thyroid Nodules

Thyroid swellings are common clinical problem throughout the world and also in Bangladesh. Most of thyroid swellings are multinodular, but a good percentage is solitary thyroid nodule. There is no robust, feasible method for malignancy differentiation has not been well established. The study evaluated thyroid nodules for risk of malignancy and compared history, clinical, sonographic features and FNAC findings with histopathology. This was a cross sectional study on 160 consecutive subjects of thyroid nodules done in the department of ENT and Head Neck Surgery of Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh during from July 2018 to December 2019. All patients were admitted and diagnosed by detail history, clinical examination, investigations and underwent thyroidectomy. Detailed history, clinical examination, ultrasonographic finding and FNAC variables were documented retrospectively and a mathematical model was established for malignancy prediction. In this study mean age of the patients of thyroid nodules was 37.54±11.49 years and majority of the patients were within 21-40 years of age. Frequency of thyroid nodules is more in female with male female ratio 1:7. Most of the thyroid nodules appeared in this study within 0-2 years (61.9%). In this series of thyroid nodules constituted 88.1% firm, 8.8% hard, 3.1% cystic. Among the patients 89(55.6%) cases have solitary thyroid nodule and 71(44.4%) cases have multinodular goitre Majority of the nodules were warm 57.5% followed by cold 42.5%. FNAC showed nodular goitre 72.5%, Follicular neoplasm 1.3%, Papillary carcinoma of thyroid 7.5%, colloid goitre 9.4%, suspicious papillary carcinoma 3.8% and lymphocytic thyroiditis 1.3%. In this study out of 85 solid nodule, 69(81.18%) were benign and 16(18.82%) was malignant and out of 3 cystic nodule 3(100%) were benign. In this study most of the benign and malignant nodules were predominantly solid. Study showed the malignancy is significantly (p=0.001) more in solid than cystic nodules. Final diagnosis in this study was done on the basis of histopathological reports. Out of 160 patients, histopathologically benign lesion was 120(75%) and malignant was 40(25%). Among malignant cases 36(22.5%) cases were papillary carcinoma, 1 case was medullary carcinoma and 3 cases were follicular carcinoma.

Effect on speech emotion classification of a feature selection approach using a convolutional neural network

Speech emotion recognition (SER) is a challenging issue because it is not clear which features are effective for classification. Emotionally related features are always extracted from speech signals for emotional classification. Handcrafted features are mainly used for emotional identification from audio signals. However, these features are not sufficient to correctly identify the emotional state of the speaker. The advantages of a deep convolutional neural network (DCNN) are investigated in the proposed work. A pretrained framework is used to extract the features from speech emotion databases. In this work, we adopt the feature selection (FS) approach to find the discriminative and most important features for SER. Many algorithms are used for the emotion classification problem. We use the random forest (RF), decision tree (DT), support vector machine (SVM), multilayer perceptron classifier (MLP), and k-nearest neighbors (KNN) to classify seven emotions. All experiments are performed by utilizing four different publicly accessible databases. Our method obtains accuracies of 92.02%, 88.77%, 93.61%, and 77.23% for Emo-DB, SAVEE, RAVDESS, and IEMOCAP, respectively, for speaker-dependent (SD) recognition with the feature selection method. Furthermore, compared to current handcrafted feature-based SER methods, the proposed method shows the best results for speaker-independent SER. For EMO-DB, all classifiers attain an accuracy of more than 80% with or without the feature selection technique.

1069 Diverticular Disease: An Audit of Adherence to NICE Guidelines

Introduction

Diverticular disease is a common surgical problem ranging from diverticulosis to uncomplicated diverticulitis to complicated diverticulitis. The NICE Guidelines for diverticular disease recommended that antibiotics should only be given in patients who are systemically unwell, background of immunosuppression or have complicated diverticulitis. We aimed to access the compliance to these guidelines with regards to the use of antibiotics at our local institute.

Method

This was a retrospective audit reviewing the management of patients with Computed Tomography Scan findings of uncomplicated acute diverticulitis (Hinchey Ia) at the surgical emergency unit at Basildon University Hospital between August 2018 and May 2020. Data obtained included demographic data, presenting symptoms (fever, abdominal pain), haematological investigations (full blood count and c-reactive protein) and use of intravenous/oral antibiotics.

Results

Twenty patients were included, the M:F ratio was 1:1.9, the age range was between 36-80 years. 13 patients (65%) had left iliac fossa pain as part of their presenting symptom while only three (15%) had pyrexia. Seventeen patients(85%) had NEWS score between 0-1 with 60% of the patients presenting with elevated white blood cell count and 75% with c-reactive protein >5. All our patients were prescribed antibiotics.

Conclusions

There was no discrimination in the use of antibiotics/admission for uncomplicated diverticulitis as all patients had antibiotics and as such there is need for increased awareness about the guidelines among the surgical team and adherence to the protocol to prevent indiscriminate use of antibiotics.

Efficacy of Clotrimazole 1% Solution Compared to Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% Cream in Patient with Otomycosis

Fungal infection of the ear canal is called Otomycosis. It is more common in hot and humid condition. There are many modalities of treatment or therapeutic agent for treatment of otomycosis. Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% cream is a topical antifungal agent described to be effective in the treatment of otomycosis. This study was performed to compare the efficacy of topical application clotrimazole 1% solution and Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% cream in the treatment of otomycosis. A controlled, randomized and open clinical trial was carried out in ENT department of Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2020 to July 2020. Patients diagnosed with fungal otitis externa who were treated with topical antifungals were included in this study. They were randomized into two treatment groups: i) Clotrimazole 1% solution, 2) Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% cream. Patients were microscopically evaluated at two weeks of treatment to determine resolution of disease. Recurrence and complications were recorded. Demographic and clinical variables were collected and analyzed, follow up and final outcomes (absence of infection) were compared between two groups. One hundred & two (102) patients were included, 51 in the clotrimazole 1% solution group and 51 in the Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% cream group. Predominant symptoms are pain, pruritus, aural fullness and hearing loss. Aspergillus organism was isolated most frequently (63.73%). Treatment with clotrimazole 1% solution groups resulted in 88.23% resolution vs. 80.39% resolution with Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% cream at 2 weeks of treatment. Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% cream group demonstrated higher treatment failure 11.76 and 19.60 respectively. Clotrimazole 1% solution is more effective than Econazole Nitrate 1% + Triamcinolone Acetonide 0.1% cream for uncomplicated otomycosis. More study is needed to corroborate our results.

Comparison between Efficacy of Combined Use of Hyaluronidise and Triamcinolone versus Hyaluronidise, Triamcinolone Acetonide and Oral Colchicine in the Treatment of Oral Submucous Fibrosis

Oral submucous fibrosis (OSF) is a chronic complex potentially pre-malignant condition caused by chewing areca nut and other irritants. It is an insidious process characterized by Juxta-epithelial deposition of fibrous tissue in the oral cavity and pharynx. OSF is very common in Southeast Asia and also now a days increase in Europe and North America. The aim of this study to compare the effectiveness of intralesional injection of triamcinolone and hyalurunidase versus intralesional injection of triamcinolone plus injection hyalurunidase with oral colchicine. The study included 60 patients of clinically diagnosed case of oral submucous fibrosis. Patients were divided into two Groups A and B. Group A patients received combination intralesionsl injection of triamcinolone acetonide 10mg/ml in 1ml with injection hyalurunidase 1500IU in 2ml with injection 2% lidocaine 7ml. 15 days interval in 3 months and Group B received intralesional injection of triamcinolone acetonide 10mg/ml in 1ml with injection hyalurunidase 1500IU in 2ml with injection 2% lidocaine 7ml in each 15 days interval for 3 months with oral colchicine 0.5mg twice daily for 3 months. Diagnosis based on burning sensation of mouth, blanching of mucosa, ulceration in oral cavity and also reduced mouth opening. Follow up assessment was done at intervals 1st follow up on 21st days after starting of treatment then 2nd follow up after 3 months and last 3rd follow up after 6 months. Before starting of treatment all patients were properly explained about the study and took their written consent. Much more improvement occurred in Group B patients, reducing in burning sensation and also increases in opening of mouth. In both groups blanching mucosae were improved. Treatment regimen of Group B is more effective in increasing mouth opening and improves burning sensation of oral cavity. No side effects were seen in both groups' patients.

Cartilage Ossiculoplasty from Stapes to Tympanic Membrane in One-Stage Intact Canal Wall Tympanoplasty for Cholesteatoma

This prospective study was conducted at Department of ENT, Mymensingh Medical College Hospital, a tertiary care center in Bangladesh January 2017 to December 2018 to report hearing results and post operative complications of cartilage interposition ossiculoplasty in one-stage intact canal wall (ICW) tympanoplasty for cholesteatoma where ossicular chain is eroded or has to be removed either partially or totally. Total 42 patients underwent Intact canal wall (ICW) tympanoplasty for cholesteatoma with at least intact stapes footplate and in conjunction, cartilage ossiculoplasty was done during the same procedure. Patients were followed up regularly at 1 week, 1 month, 3 month, 6 month and at 1 year as usual follow up protocol to note complications and hearing status in 1 year follow up. In intact stapes suprastructure group, in the preoperative period, the mean air conduction thresholds (AC), bone conduction threshold (BC) and air-bone gap (ABG) were 48.3db, 9.5db and 38.8db respectively. Postoperatively, with a mean follow-up of 12 months, AC, BC and ABG were 27.6db, 9.7db and 17.9db respectively. In missing stapes supra structuregroup, in the preoperative period, the mean air conduction thresholds (AC), Bone conduction threshold (BC) and air-bone gap (ABG) were 57.4db 13.5db and 43.9db respectively. Postoperatively, with a mean follow-up of 12 months, AC, BC and ABG, were 33.9db, 14.2db and 19.7db respectively. For management of cholesteatoma cases, cartilage ossiculoplasty can be done effectively in conjunction with of intact canal wall tympanoplasty in a single setting. Complications are a few and easily manageable. Hearing results are at least as good as with other prosthesis and helps in avoiding subsequent surgery, discomfort and cost to the patients.

Comparison between Outcomes of Endoscopic Sinus Surgery and Surgical Excision in Case of Rhinosporiodiosis

Rhinosporiodiosis is a chronic granulomatous infection of the mucus membranes caused by Rhino sporidium seeberi that manifest as vascular friable polyps and arise in the nasal mucosa. The mode of infection is probably trans-epithelial penetration. Rhinosporiodiosis is endemic in India, Pakistan and Srilanka. It occurs sporadically in the United States of America. The aim of this study was to compare betweenthe outcomes of endoscopic sinus surgery andsurgical excision in rhinosporiodiosis. The cross sectional comparative study was conducted among 40 patients with rhinosporiodiosis from January 2018 to April 2019 in the department of Otolaryngology and Head-neck surgery of Mymensingh Medical College Hospital, Bangladesh. All the patients were following up to 6 month after surgery. Most of them are male 24(60.0%) and female are 16(40.0%). Age of the patients in this study was (Mean±SD) 34.8±13.5 years. More than half of the patients had rhinosporiodiosis in the inferior turbinate (25, 62.5%) followed by 8(20.0%) in nasal septum and 7(17.5%) in the nasal floor. Endoscopic Sinus Surgery was done purposively among 20 patients and surgical excision was done purposively among another 20 patients. At the time of operation no complication occurs in case of endoscopic sinus surgery but in case of surgical excision small of amount bleeding was present. All the patients were followed up to 6 month after surgery. No recurrence was found in patients with endoscopic sinus surgery but 7(35.0%) patients who underwent surgical excision had recurrence of rhinosporiodiosis at follow up after six months of surgery. Chi-square test showed that the incidence of recurrence after 6 months of surgery was significantly lower in endoscopic sinus surgery (p=0.004). The study results concluded that endoscopic sinus surgery is better option for rhinosporiodiosis.

CHANGES IN IRISIN RELEASE IN RESPONSE TO PERIPHERAL KISSPEPTIN-10 ADMINISTRATION IN HEALTHY AND OBESE ADULT MEN

Context

Kisspeptin role in metabolism has been implicated recently. However, the nature of the signals that may connect body fat/muscle tissues with the central nervous system governing energy homeostasis remains to be elucidated.

Objective

The present study was designed to investigate the effects of peripheral kisspeptin-10 administration on irisin release in human males.

Subjects and methods

Kisspeptin-10 was administered to normal weight (n=8) and obese (n=8) men. Sequential blood sampling was performed for 30 minutes pre and 210 minutes post kisspeptin injection at 30 minutes interval. ELISA kit was used to detect plasma irisin levels.

Results

There is a significant (P<0.0001) effect of Kisspeptin-10 administration on irisin release in both normal weight and obese participants. Mean irisin levels (96.24 ± 1.351 ng/mL) at 210 minutes were significantly (P<0.0001) enhanced as compared to pre-kisspeptin (59.18 ± 4.815 ng/mL) in normal weight subjects. In obese subjects mean irisin levels (75.76 ± 4.06 ng/mL) were significantly (P<0.0001) elevated at 180 minutes post-kisspeptin when compared with pre-kisspeptin irisin levels (41.28 ± 2.89 ng/mL).

Conclusion

Our findings suggest that kisspeptin may have a novel therapeutic potential to induce irisin release in humans which may have anti-obesity effects.

Standardized technique for single-docking robotic rectal surgery

AIM

The aim of this technical note is to describe our standardized technique for rectal surgery using a single-docking totally robotic approach.

METHOD

The data related to patients who underwent single-docking robotic rectal surgery were analysed for the feasibility of this approach.

RESULTS

This technique was used in 124 consecutive patients who underwent rectal resection since July 2013. Male to female ratio of patients was 2:1 while median age was 67 years (range 24-92). The median operating time was 240 min (range 105-456), whilst blood loss was 10 ml (range 0-200). There was no evidence of intra-operative complications or conversions to either a laparoscopic or an open procedure. The median length of stay was 7 days (range 3-48).

CONCLUSION

A single-docking technique for robotic rectal surgery is safe and feasible. It can be considered as standard approach for pelvic robotic surgery.

Predictors of recurrence after radiotherapy for non-melanoma skin cancer

Predictive factors of recurrence were examined in 448 non-melanoma skin cancers (72% basal cell carcinoma, 28% squamous cell carcinoma) treated with radiotherapy. The overall recurrence rate was 15.8% at a median follow-up of 18.4 months. In multivariate analysis, significant factors for recurrence were age (p = 0.0197), tumour size 2 cm or greater (p = 0.0095), immunosuppression (p = 0.0082), and treatment modality (p = 0.0009).

Benign breast myoepithelioma

Myoepithelioma of the breast is very rare. Breast myoepithelioma can develop in women from their early 20s right up to their 80s, but it is most common in women over 50. We report a case of 20-year-old female, who presented with a well-defined breast lump of 3 × 3 cm in size. Fine needle aspiration was performed. The cytological findings revealed good cellularity comprising monomorphic loosely cohesive sheets of plasmacytoid, round to polygonal cells with round to ovoid eccentrically placed nuclei, finely dispersed chromatin, and moderate amount of cytoplasm. On the basis of cytological findings, a diagnosis of benign myoepithelioma (plasmacytoid type) was made which was confirmed on histopathologic examination. The breast is a very rare localization for this type of tumor. The benign character of the disease in conjunction with its slow progression could delay its detection and diagnosis. A detailed pathology examination is a prerequisite for avoidance of misleading diagnosis.

Inter-rater reliability between musculoskeletal radiologists and orthopedic surgeons on computed tomography imaging features of spinal metastases

INTRODUCTION

The primary objective of this pilot study was to examine the inter-rater reliability in scoring the computed tomography (ct) imaging features of spinal metastases in patients referred for radiotherapy (rt) for bone pain.

METHODS

In a retrospective review, 3 musculoskeletal radiologists and 2 orthopedic spinal surgeons independently evaluated ct imaging features for 41 patients with spinal metastases treated with rt in an outpatient radiation clinic from January 2007 to October 2008. The evaluation used spinal assessment criteria that had been developed in-house, with reference to osseous and soft tissue tumour extent,presence of a pathologic fracture,severity of vertebral height loss, andpresence of kyphosis.The Cohen kappa coefficient between the two specialties was calculated.

RESULTS

Mean patient age was 69.2 years (30 men, 11 women). The mean total daily oral morphine equivalent was 73.4 mg. Treatment dose-fractionation schedules included 8 Gy/1 (n = 28), 20 Gy/5 (n = 12), and 20 Gy/8 (n = 1). Areas of moderate agreement in identifying the ct imaging appearance of spinal metastasis included extent of vertebral body involvement (κ = 0.48) and soft-tissue component (κ = 0.59). Areas of fair agreement included extent of pedicle involvement (κ = 0.28), extent of lamina involvement (κ = 0.35), and presence of pathologic fracture (κ = 0.20). Areas of poor agreement included nerve-root compression (κ = 0.14) and vertebral body height loss (κ = 0.19).

CONCLUSIONS

The range of agreement between musculoskeletal radiologists and orthopedic surgeons for most spinal assessment criteria is moderate to poor. A consensus for managing challenging vertebral injuries secondary to spinal metastases needs to be established so as to best triage patients to the most appropriate therapeutic modality.

Cause Identification from Aviation Safety Incident Reports via Weakly Supervised Semantic Lexicon Construction

The Aviation Safety Reporting System collects voluntarily submitted reports on aviation safety incidents to facilitate research work aiming to reduce such incidents. To effectively reduce these incidents, it is vital to accurately identify why these incidents occurred. More precisely, given a set of possible causes, or shaping factors, this task of cause identification involves identifying all and only those shaping factors that are responsible for the incidents described in a report. We investigate two approaches to cause identification. Both approaches exploit information provided by a semantic lexicon, which is automatically constructed via Thelen and Riloff's Basilisk framework augmented with our linguistic and algorithmic modifications. The first approach labels a report using a simple heuristic, which looks for the words and phrases acquired during the semantic lexicon learning process in the report. The second approach recasts cause identification as a text classification problem, employing supervised and transductive text classification algorithms to learn models from incident reports labeled with shaping factors and using the models to label unseen reports. Our experiments show that both the heuristic-based approach and the learning-based approach (when given sufficient training data) outperform the baseline system significantly.

Analysis of heat and mass transfer during condensation over a porous substrate

Condensing heat exchangers are important in many space applications for thermal and humidity control systems. The International Space Station uses a cooled fin surface to condense moisture from humid air that is blown over it. The condensate and the air are "slurped" into a system that separates air and water by centrifugal forces. The use of a cooled porous substrate is an attractive alternative to the fin where condensation and liquid/gas separation can be achieved in a single step. We analyze the heat and mass transfer during condensation of moisture from flowing air over such a cooled, flat, porous substrate. A fully developed regime is investigated for coupled mass, momentum and energy transport in the gas phase, and momentum and energy transport in the condensate layer on the porous substrate and through the porous medium.

Stillbirths in Qatar: a review of 83 cases

To evaluate the aetiology, diagnostic procedures and current management of stillbirths in Qatar, 83 stillbirths with a birth weight of more than 500 g were studied. The validity of the cause of death was classified as certain, probable and unexplained. Frequency and descriptive statistics were used. The stillbirth rate was 8.15 per 1000. The cause of death was certain in 29%, probable in 62% and remained entirely unexplained in 9% of the cases. The major factors that might be the causes of fetal death were intrauterine growth retardation (23%), abruptio placentae (16.3%), congenital anomalies (13.3%), gestational diabetes (9.6%) and hydrops fetalis (7.2%). The cause of death was found unavoidable in 24 cases (29%). The autopsy rate was terribly low (1/80) and far away from the recommended rate of 75%. The introduction of a stillbirth programme, that includes post-mortem autopsy, in any maternity hospital, is considered crucial to reach a specific diagnosis for almost all stillbirths and to prevent fetal death in future pregnancies. However, if the patient or her family refused autopsy, a combination of patience and learned communication can pave the way to their understanding and acceptance of the procedure. Postmortem magnetic resonance imaging may be used as alternative to autopsy if it is refused.

Cloning, sequencing and partial characterisation of sorbitol transporter (srlT) gene encoding phosphotransferase system, glucitol/sorbitol-specific IIBC components of Erwinia herbicola ATCC 21998

A DNA fragment of approximately 1500 bp, harbouring the sorbitol transport gene (srlT), was amplified from the chromosomal DNA of Erwinia herbicola ATCC 21998 by PCR and cloned in Escherichia coli JM109. Degenerate oligonucleotide primers used were designed based on the conserved regions in the gene sequences within the gut operon of E. coli (Gene Bank accession no. J02708) and the srl operon of Erwinia amylovora (Gene Bank accession no. Y14603). The cloned DNA fragment was sequenced and found to contain an open reading frame of 1473 nucleotides coding for a protein of 491 amino acids, corresponding to a mass of 52410 Da. The nucleotide sequence of this ORF was highly homologous to that of the gutA gene of Escherichia coli gut operon, the srlE gene of Shigella flexrni and the sorbitol transporter gene sequence of Escherichia coli K12 (Gene Bank accession nos. J02708, AE016987 and D90892 respectively). The protein sequence showed significant homology to that of the phosphotransferase system i.e. the glucitol/sorbitol-specific IIBC components of Escherichia coli and Erwinia amylovora (P56580, O32522). The cloned DNA fragment was introduced into a pRA90 vector and the recombinant was used for developing srlT mutants of Erwinia herbicola, by homologous recombination. Mutants obtained were unable to grow on minimal medium with sorbitol. The insertion of the pRA90 vector inside the srlT gene sequence of the mutants was confirmed by DNA-DNA hybridisation.

Bcl-2 and Bcl-X(L) block thapsigargin-induced nitric oxide generation, c-Jun NH(2)-terminal kinase activity, and apoptosis

The proteins Bcl-2 and Bcl-X(L) prevent apoptosis, but their mechanism of action is unclear. We examined the role of Bcl-2 and Bcl-X(L) in the regulation of cytosolic Ca(2+), nitric oxide production (NO), c-Jun NH(2)-terminal kinase (JNK) activation, and apoptosis in Jurkat T cells. Thapsigargin (TG), an inhibitor of the endoplasmic reticulum-associated Ca(2+) ATPase, was used to disrupt Ca(2+) homeostasis. TG acutely elevated intracellular free Ca(2+) and mitochondrial Ca(2+) levels and induced NO production and apoptosis in Jurkat cells transfected with vector (JT/Neo). Buffering of this Ca(2+) response with 1, 2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid tetra(acetoxymethyl) ester (BAPTA-AM) or inhibiting NO synthase activity with N(G)-nitro-L-arginine methyl ester hydrochloride (L-NAME) blocked TG-induced NO production and apoptosis in JT/Neo cells. By contrast, while TG produced comparable early changes in the Ca(2+) level (i.e., within 3 h) in Jurkat cells overexpressing Bcl-2 and Bcl-X(L) (JT/Bcl-2 or JT/Bcl-X(L)), NO production, late (36-h) Ca(2+) accumulation, and apoptosis were dramatically reduced compared to those in JT/Neo cells. Exposure of JT/Bcl-2 and JT/Bcl-X(L) cells to the NO donor, S-nitroso-N-acetylpenacillamine (SNAP) resulted in apoptosis comparable to that seen in JT/Neo cells. TG also activated the JNK pathway, which was blocked by L-NAME. Transient expression of a dominant negative mutant SEK1 (Lys-->Arg), an upstream kinase of JNK, prevented both TG-induced JNK activation and apoptosis. A dominant negative c-Jun mutant also reduced TG-induced apoptosis. Overexpression of Bcl-2 or Bcl-X(L) inhibited TG-induced loss in mitochondrial membrane potential, release of cytochrome c, and activation of caspase-3 and JNK. Inhibition of caspase-3 activation blocked TG-induced JNK activation, suggesting that JNK activation occurred downstream of caspase-3. Thus, TG-induced Ca(2+) release leads to NO generation followed by mitochondrial changes including cytochrome c release and caspase-3 activation. Caspase-3 activation leads to activation of the JNK pathway and apoptosis. In summary, Ca(2+)-dependent activation of NO production mediates apoptosis after TG exposure in JT/Neo cells. JT/Bcl-2 and JT/Bcl-X(L) cells are susceptible to NO-mediated apoptosis, but Bcl-2 and Bcl-X(L) protect the cells against TG-induced apoptosis by negatively regulating Ca(2+)-sensitive NO synthase activity or expression.

Rupture of the pregnant uterus--a 21-year review

OBJECTIVES

To review the incidence of ruptured uteri at the Women's Hospital, Hamad Medical Corporation (HMC) and to analyze the causative factors of uterine rupture with a view to its prevention and to highlight the management approach taken to preserve the patient's reproductive potential.

METHODS

Case notes were reviewed for all patients (except for eight which were not available) with a ruptured uterus at the Women's Hospital in Doha for a period of 21 years from 1 July 1977 to 30 June 1997, relevant data relating to the clinical features characteristics of labor, operative procedures, and maternal perinatal outcome were assessed.

RESULTS

There were 31 cases of ruptured uteri. The incidence of ruptured uteri was calculated to be 0.017%, 23 cases being available for the study. Ten cases (43.5%) occurred in patients with previous cesarean scars, while 13 cases (56.5%) were grand multiparous (para 5 or more). In 10 cases (43.5%) uterine rupture was associated with oxytocin use, and four cases (18.2%) were associated with PGE2 use. The ruptures occurred in the lower segment of 19 cases (90.9%). Fetal heart abnormalities were observed in all cases except one in which the uterus ruptured during labor. Abdominal hysterectomy was performed in 15 cases (65.2%). The remaining eight patients had suture repair, two of them had suture repair with sterilization and the other six cases (26.1%) had suture repair without sterilization. Five of them became pregnant and were delivered by cesarean section.

CONCLUSIONS

Even though rupture of the uterus was rare in our study, its occurrence should be suspected when there are sudden fetal heart abnormalities during labor or unexpected postpartum shock. Suture repair should be considered whenever possible in order to maintain the patient's future fertility.

Fluoxetine in treatment of adolescent patients with autism: a longitudinal open trial

Retrospective chart reviews of seven adolescent and young adults with autistic disorder treated with fluoxetine alone or in combination with other medications were performed. Patient's ages varied from 9-20 years (M +/- SD, = 16 +/- 3.87). Fluoxetine doses ranged from 20-80 mg per day (M +/- SD of final doses 37.14 +/- 21). Duration of treatment ranged from 1.3-32 months (M 18.04 +/- 10.39). Patients' symptoms were monitored using the Aberrant Behavior Checklist (ABC) rating scale during every visit. Side effects included initial appetite suppression, vivid dreams, and hyperactivity. Improvement from baseline was seen in four subscales: irritability (21%), lethargy (37%), stereotype (27%), and inappropriate speech (21%). Lethargy subscales improved significantly during treatment (p < .029). Hyperactivity subscale increased by 14% but did not attain statistical significance. Fluoxetine appears to have important behavioral effects in treatment of clinic-referred autistic children. Future double-blind placebo controlled studies evaluating core and associated symptom response with fluoxetine are warranted.

Nutritional pharmacology and malignant disease: a therapeutic modality in patients with cancer

It is now established that certain nutrients have a significant effect on cellular metabolism and growth, tissue repair and regeneration, and modulation of host defences. So far, however, potential clinical benefits have been difficult to demonstrate. Nevertheless, the use of nutrients in combinations seems to have promise and may be associated with a reduction in infectious complications and length of hospital stay. Nutritional pharmacology in the future may be able to improve tumour response to chemotherapy and may minimize the metabolic effect of cachexia.

13beta,14beta-dihydroxy-13alpha-isopropylabietic acid, an elicitor of contact allergy

Abietic acid isolated from colophony (W.W. grade) was selectively oxidized in the presence of KMnO4, into 13beta,14beta-dihydroxy-14alpha-isopropylabietic acid. The structure of the compound was elucidated using UV, IR, and NMR spectroscopy. Epicutaneous application of the dihydroxy acid to colophony-sensitized guinea pigs suggested the compound as an elicitor of contact allergy that had not been tested before in contact-sensitization reactions.

Reduction in postoperative vomiting after surgical correction of prominent ears

There is a high incidence of postoperative nausea and vomiting after surgical correction of prominent ears. A prospective, randomized study was performed to determine if the method of dressing the ears influenced the incidence of postoperative vomiting. Avoidance of packing the external auditory meatus and concha produced a significant reduction in postoperative nausea (83% vs 30%; P < 0.005) and vomiting (63% vs 22%; P < 0.01).

Are free radicals and not quinones the haptenic species derived from urushiols and other contact allergenic mono- and dihydric alkylbenzenes? The significance of NADH, glutathione, and redox cycling in the skin

The induction of allergic contact dermatitis to urushiols from poison ivy and related plants is generally believed to involve an initial oxidation event by which a protein-reactive quinone is formed. However, this does not readily account for the contact allergenicity of closely related mono- and dihydric alkylbenzenes such as the alkylphenols and alkylresorcinols which are not so easily oxidised to quinones in vitro. When the redox processes known to occur in living tissues are taken into consideration, a more plausible unifying mechanism involving the formation of protein-reactive radical species becomes apparent. Experiments described here examine the autoxidation of p-benzoquinone and various mono- and dihydric benzenes and alkylbenzenes, and their reactions with the diphenylpicrylhydrazyl radical, cysteine, glutathione, and NADH. We have also demonstrated that administration to mice of 2-oxo-4-thiazolidine carboxylate, a compound known to elevate intracellular glutathione levels, inhibits the irritancy and sensitising activity of 3-pentadecylphenol. This work suggests that redox cycling in the skin following penetration of allergenic mono- and dihydric alkylbenzenes initially depletes local levels of endogenous reducing equivalents such as glutathione and NADH; once depleted, further cycling results in the uncontrolled generation of radical species which may reasonably be expected to exhibit protein reactivity.