Atypical fundal perforation: a case report

Gastric perforations typically occur in the distal stomach, along the greater curvature or the antrum. The vast majority of upper gastrointestinal (GI) perforations are caused by peptic ulcer disease. We present a case of an atypical location of gastric perforation. A 31-year-old patient was experiencing nausea and severe abdominal pain. Explorative laparoscopy revealed a large fundal perforation. The patient underwent an abdominoplasty 5 days before with revisional surgery for hemorrhage. He had recently lost 42 kg after endoscopic sleeve gastroplasty (ESG) 8 months before. ESG is a minimally invasive alternative for bariatric surgery. Since its implementation, several studies have been published indicating the procedure as safe. However, some major adverse events, such as upper GI-bleeding, peri-gastric leak, and pneumoperitoneum, have been described. The atypical location of the perforation might be explained by a combination of events such as surgical stress, revisional surgery, major weight loss, and the history of ESG.

City Challenge: Sustainable Process or Temporary Gesture?

In this paper, the processes of governance within the UK government's recent urban policy initiative, City Challenge, are explored. This initiative targets the involvement, through “partnership”, of residents of “areas of concentrated disadvantage” in the processes of programme formulation and delivery. Underlying this is the objective of “incorporating” neighourhood residents in ‘mainstream’ political and economic life. In this paper, that objective is set in the context of contemporary conditions in such neighbourhoods. Experiences of the early stages of two City Challenge programmes are then discussed, in order to assess the character of the partnerships which are evolving. The two examples vary significantly in their style and in the strategy of the local authority, as well as in the characteristics of the areas. It is argued that, although central government's influence over the style of the programmes remains pervasive, the strategy of the local authority and the struggles by the participants in the partnerships have a significant influence on the content and style of the programmes. Further, the style of the programmes affects the balance of power within the programme and the terms of incorporation of the various partnerships in governance processes.

Invasive mould sinusitis in patients with haematological malignancies: a 10 year single-centre study

OBJECTIVES

Invasive mould sinusitis (IMS) is a severe infection in patients with haematological malignancies. Because of a paucity of contemporaneous data about IMS, we sought to evaluate clinical aspects and outcome of IMS in these patients.

METHODS

The records of adult haematological malignancy patients with proven or probable IMS over a 10 year period were reviewed retrospectively.

RESULTS

We identified 44 patients with IMS. Mucorales were isolated in 13 (35.1%) patients and Fusarium and Aspergillus were isolated in 9 (24.3%) patients each. Patients with IMS owing to Mucorales were more likely to have a history of diabetes mellitus (P = 0.003) and high-dose corticosteroid use (P = 0.03). Thirty-five (80%) patients received antifungal combinations and 36 (82%) underwent surgical debridement. The 12 week IMS-attributable mortality was 36.4% (16 patients). A relapsed and/or refractory haematological malignancy was an independent risk factor for 6 week IMS-attributable (P = 0.038), 12 week all-cause (P = 0.005) and 12 week IMS-attributable (P = 0.0015) mortality. Neutrophil count <100/µL and lymphocyte count <200/µL were associated with increased 12 week IMS-attributable and 6 week all-cause mortality, respectively (P = 0.044 and 0.013). IMS due to Aspergillus was an independent risk factor for both 12 week all-cause (P = 0.011) and IMS-attributable (P = 0.026) mortality. Initial antifungal therapy with a triazole-containing regimen was associated with decreased 6 week all-cause (P = 0.032) and IMS-attributable (P = 0.038) mortality. Surgery was not an independent factor for improved outcome.

CONCLUSIONS

Despite combined medical and surgical therapy, IMS had high mortality. Mortality risk factors were relapsed and/or refractory malignancy, cytopenia and Aspergillus infection in this study.

QuantiFERON-TB Gold In-Tube test for diagnosis of latent tuberculosis (TB) infection in solid organ transplant candidates: a single-center study in an area endemic for TB

BACKGROUND

The prevalence of Mycobacterium tuberculosis in transplant recipients is estimated to be 50 times higher than in the general population, with a mortality rate of around 40%. Diagnosis and treatment of latent tuberculosis (TB) infection (LTBI) is an essential strategy for TB control. In this study we compared the QuantiFERON-TB Gold In-Tube test (QFT) with the tuberculin skin test (TST) for detection of LTBI in solid organ transplant (SOT) candidates.

PATIENTS AND METHODS

Between March 2008 and September 2011, 187 transplant candidates, who were referred to the transplant clinic of Imam-Khomeini Hospital, were enrolled in the study. Patients were screened for LTBI with both QFT and TST. Twenty-three patients (12.3%) were excluded for failure to follow up. Concordance between the 2 tests, and variables associated with test discordance were assessed.

RESULTS

The mean age of patients was 40 years (range: 11-65) and male-to-female ratio was 1.2 (88/76). TST and QFT were positive in 26 (15.9%) and 33 (20.1%) patients, respectively. Five cases (3.1%) had indeterminate QFT. Overall agreement between QFT and TST was about 80% (k = 0.32, P-value = 0.0001).

CONCLUSION

Considering the fair overall agreement between the 2 tests, and greater ease of the QFT from the patient's point of view, QFT is recommended for detection of LTBI in SOT candidates.

Pulmonary Tuberculosis in Patients with HIV/AIDS in Iran

BACKGROUND

Pulmonary tuberculosis is still the most common form of tuberculosis in HIV infected patients having different presentations according to the degree of immunosuppression. This study appraised the impact of HIV infection on clinical, laboratory and radiological presentations of tuberculosis.

METHODS

The clinical, laboratory and radiological presentations of pulmonary TB in 56 HIV-infected patients were compared with 56 individually sex and age matched HIV-seronegative ones, admitted to Imam Hospital in Tehran (1999-2006) using paired t-test in a case control study.

RESULTS

All cases and the controls were male. Fever was found in 83.9% of the HIV positive patients compared to 80% of the HIV negative ones. Cough was the most common clinical finding in the HIV negative group (89.3% vs. 82.1% in HIV positive group). Among radiological features, cavitary lesions, upper lobe and bilateral pulmonary involvement were observed significantly less often in the HIV-infected group. On the contrary, lymphadenopathy was just present in the HIV positive group in this series of patients (12%) and primary pattern tuberculosis was more common, as well (71% vs. 39%, P= 0.02). The Tuberculin test was reactive in 29% of the HIV/TB patients.

CONCLUSION

The coexistence of both infections alters the picture of tuberculosis in many aspects and should be taken into account when considering a diagnosis of HIV infection and its potential for TB co-infection, and vice-versa.

Meningoencephalitis associated with hepatitis A infection: a case report and review of literature

Hepatitis A virus uncommonly causes neurological problems. Among these manifestations meningoencephalitis is very rare. We describe the clinical and laboratory features of a young boy with hepatitis A associated meningoencephalitis and compare it with other cases which had the same diagnoses.

Soy-diet has beneficial effects on cardiovascular parameters that are independent of its lipid effect in male hypercholesterolemic rats

Diet-induced atherosclerosis is lower in animals fed soy protein. The effects of various soy components have been extensively studied; however, little is known about the effect of crude soybean feeding on hypercholesterolemia-induced cardiovascular changes. This study investigated the effect of soy feeding on cardiovascular parameters in hypercholesterolemic male rats. Total cholesterol (TC), low density lipoprotein (LDL) and high density lipoprotein cholesterol (HDL), and triglyceride (TG) were measured. Rats were randomly assigned to control, high cholesterol (HC, 2% cholesterol) or HC + soy (HC+S) diets. In the HC+S group, rats received HC diet for 10 weeks followed by 2 weeks of soybean feeding. Arterial blood pressure, TC, TG, LDL and HDL were measured. TC, TG and LDL were higher in HC rats and were not significantly reduced by soybean feeding. Soy feeding reversed the HC-induced increase in arterial blood pressure and also restored the impaired vascular responses to acetylcholine in isolated aortic rings. Pre-incubation of HC+S aortic rings with L-NAME (10(-5) M for 20 min) partially reduced the effects of soy on acetylcholine responses, indicating that the beneficial vascular effects of dietary soy are partially mediated via nitric oxide pathway.

Th-1 cytokines gene polymorphism in human brucellosis

Brucellosis is a worldwide zoonosis. Infection with Brucella species results in the activation of cell-mediated immune response. The interaction between Th1and Th2 cytokines determines the outcome of disease. Production of each cytokine is in turn affected by genetic factors. In this study, we investigated the possible association between Th1 cytokines gene polymorphism and brucellosis. Different genotypes of TNF-alpha, IFN-gamma and IL-2 were determined by polymerase chain reaction-sequence-specific primer in 47 patients with brucellosis and in 166 healthy controls. Allele frequencies of these genotypes were compared using the chi2 test. The results showed a significant difference in the TNF-alpha genotype GG/GG in patients in comparison with controls (76.7% vs. 21%) (P = 0.001, OR = 12.42, 95%CI 5.7-27.7). There was no significant difference in the frequency distribution of the IFN-gamma genotypes between two groups. IL-2 GG genotype at position -330 was about two times more common in cases than in controls, but the difference was not significant (10.6 vs. 4.6 P value = 0.09). This study shows that genetically low producers of TNF-alpha are possibly susceptible to brucellosis and raise doubt about the role of gene polymorphism of INF-gamma in brucellosis which was demonstrated in previous studies. It seems that patients with brucellosis did not have a defect in producing IL-2 with even a trend towards producing higher amounts of this cytokine.