Concurrent myocardial infarction in the setting of thrombotic thrombocytopenic purpura secondary to systemic lupus erythematosus: A case report

Key Clinical Message

In acute thrombotic thrombocytopenic purpura (TTP), apart from urgent treatment, assessing the patient's medical history, especially conditions like systemic lupus erythematosus that could trigger TTP, is crucial. Rarely, TTP patients may experience cardiac conditions as severe as a myocardial infarction.

Abstract

A 45-year-old woman manifested severe and acute thrombotic thrombocytopenic purpura (TTP) of unknown origin. The patient's symptoms, the laboratory data, the detection of the reduction in ADAMTS13 activity, and the presence of schistocytes on the peripheral smear confirmed the diagnosis. The patient was then planned for therapeutic plasma exchange (TPE). Prior to the scheduled TPE, she suddenly experienced extreme shortness of breath and chest pain. An electrocardiogram was obtained immediately after reporting signs of an inferior myocardial infarction. Further examinations to acquire information about the patient's underlying medical conditions in order to study the secondary causes of TTP, combined with the results of the laboratory tests, resulted in the patient being diagnosed with systemic lupus erythematosus.

Upper gastrointestinal bleeding: Diagnosis of Helicobacter pylori infection-Descriptive study

Background and Aim

The presence of blood in the stomach has been thought to affect the performance of diagnostic tests used in detecting Helicobacter pylori (H. pylori) in the stomach. This study evaluates the effect of upper gastrointestinal bleeding on the efficacy of a rapid urease test (RUT) and compares the results with the pathologic method.

Methods

In this descriptive study, 100 patients presented with upper gastrointestinal bleeding, confirmed from endoscopy, referred to Shahid Rahimi Hospital in Khorramabad were enrolled. Antral biopsy was performed in all the patients and the samples were extracted for histopathology and RUT. A questionnaire was used to collect rapid urease test outcomes and associated parameters (antibiotic, bismuth, and proton pump inhibitors), histology and demographic data. Histopathology was used as the gold standard for diagnosis of H. pylori.

Results

Of the 52 patients who were reported positive for H. pylori in pathology, 36 had RUT-positive H. pylori, sensitivity 69.2%, and of 48 patients whose pathology was negative, 25 had negative RUT, specificity 52.1%. Of 59 RUT, 36 had positive pathology, positive predictive value was 61% and from 41 with negative RUT, 25 had negative pathology, negative predictive value was 61%. The prevalence of H. pylori infection was significantly associated with the age of 50 years and above, p = 0.042, and previous history of bleeding, p = 0.019.

Conclusion

Gastrointestinal bleeding can reduce the sensitivity of RUT. The negative results of these tests in acute upper gastrointestinal bleeding should therefore be interpreted carefully.

A clinician's guide to gallstones and common bile duct (CBD): A study protocol for a systematic review and evidence-based recommendations

Background and Aims

Gallstones are one of the most common and costly diseases of the gastrointestinal tract and occur when a combination of deposits consisting of fat or minerals accumulate in the gallbladder or common bile duct (CBD). This paper provides a comprehensive review of gallstone epidemiology, diagnosis, and management, focusing on current clinical guidelines and evidence-based approaches.

Methods

A systematic literature review gathered information from various sources, including PubMed, Trip, Google Scholar, Clinical Key, and reputable medical association websites. Keywords related to gallstones, CBD stones, cholelithiasis, choledocholithiasis, and guidelines were used to extract relevant recommendations. Expert consultations and consensus meetings localized the recommendations based on the target population and available resources.

Results

The paper discusses demographic factors, dietary habits, and lifestyle influences contributing to gallstone formation. Gallstones are categorized into cholesterol and pigment types, with varying prevalences across regions. Many individuals with gallstones remain asymptomatic, but complications can lead to serious and potentially life-threatening conditions. Diagnosis relies on history, physical examination, laboratory tests, and transabdominal ultrasound. Specific predictive factors help categorize patients into high, moderate, or low probability groups for CBD stones.

Conclusion

Evidence-based recommendations for gallstone diagnosis and management are presented, emphasizing individualized treatment plans. Surgical interventions, nonsurgical treatments like oral litholysis with UDCA, and stenting are discussed. The management of gallstones in pregnant women is also addressed, considering the potential risks and appropriate treatment options during pregnancy.

An epidemiological investigation of gallstone disease among patients admitted to Shahid Rahimi teaching hospital in Khorramabad in 2016-2020

Background

Gallstones are a significant global health issue, imposing enormous costs to patients and the healthcare system, annually.

Objectives

This epidemiological study aimed to explore the prevalence of gallstones among inpatients who were admitted to Shahid Rahimi Hospital in Khorramabad City, Iran, from 2016 to 2020.

Methods

This was a retrospective and descriptive-analytical study. The study population included patients who were admitted to Shahid Rahimi Hospital in Khorramabad City, Iran, who underwent abdominal ultrasounds from 2016 to 2020. The required data were collected using a checklist and patients' records. The logistic regression analysis method was used to analyse the obtained data in SPSS at the significance level of P<0.05.

Results

Of the 927 explored subjects, 232(25%) presented gallstones. The mean age of the patients with gallstones was 62.9 years. The most frequent symptom in individuals with gallstones was right upper quadriceps abdominal pain (63%). There was a significant relationship between gallstone and age, gender, epigastric pain, upper quadrant pain, hypertension, anemia, and family history.

Conclusion

The present study findings indicated that increasing age, female gender, the lack of epigastric pain, upper quadrant pain, anemia, hypertension, and a family history of this disease increased the risk of generating gallstone disease.

In-vivo and in vitro assessments of the radioprotective potential natural and chemical compounds: a review

PURPOSE

The study of the radioactive role of natural and chemical substances on human and animal studies has been the subject of research by some researchers. Therefore, the review of some of the past and current studies conducted in this field, can provide helpful information to elucidate of the importance of radioprotective components in reducing radiation exposure side effects.

METHODS

The authors search for keywords including In vitro, In vivo, Radioprotective, Ionizing radiation, and Vitamin in ScienceDirect, Scopus, Pubmed, and Google Scholar databases to access previously published articles and search for more reference articles on the role of radioprotective materials from natural and chemical compounds.

RESULTS

Radiation exposure can produce reactive oxygen species (ROS) in the body, however most of which are eliminated by the body's natural mechanisms, but when the body's antioxidant systems do not have enough ability to neutralize free radicals, oxidative stress occurs, which causes damage to DNA and body tissues. Therefore, it is necessary use of alternative substances that reduce and inhibit free radicals.

CONCLUSION

In general, recommended that antioxidant component(s) can be protect tissue damages in humans or animals, due to the their ability to scavenge free radicals generated by ionizing radiation.

Comparison of the prevalence of perforated appendicitis during and before COVID19 pandemic

Objective

Coronavirus disease 2019 has significantly impacted the rate of emergency department visits among patients with the non-repository disease. Patients with acute appendicitis are also likely to delay their visit to the health care center, which can lead to complications including perforated appendicitis. The aim of this study was to compare the prevalence of perforated appendicitis during the COVID19 and pre-pandemic periods.

Methods

This retrospective study was performed on all appendectomies performed during COVID-19, Group A, and one year earlier, Group B. A questionnaire comprising demographic variables (age, gender, occupation, education), clinical variables (white blood cell count, fever), location and type of appendicitis, the status of appendectomy, and duration of hospitalization was completed for all the patients included in the study.

Results

The demographic variables were not significantly different among the two groups. The perforation appendicitis rate during the COVID19 pandemic increased compared to the previous year, The difference was not statistically significant. The number of negative appendectomy in group A was significantly less compared to group B. The mean time from the onset of pain to the time of referral was significantly lesser in group A. The mean length of hospital stay in group B was longer than in group A. In terms of fever, patients with perforated appendicitis in group B had a higher fever than in group A, which was statistically significant.

Conclusion

A non-significant increase in the number of perforated appendicitis cases during the pandemic period. Duration of hospitalization and fever was significantly greater in pre-pandemic perforated appendicitis cases.

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Coronavirus disease has significantly impacted the rate of emergency department visits.

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Patients with acute appendicitis are also likely to delay their visit to the health care center.

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Which can lead to complications including perforated appendicitis.

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A non-significant increase in the number of perforated appendicitis cases during pandemic period.

Evaluation of antibiotic resistance of Helicobacter pylori bacteria obtained from gastric biopsy samples: A cohort study

Objective

Helicobacter pylori infection is associated with a wide range of gastrointestinal diseases and is very common in developing countries. Overuse and self-prescribed antibiotics have led to antibiotic resistance and failure of complete eradication of the bacterium. The aim of this study is to evaluate the antibiotic resistance of h. pylori from samples obtained from gastric biopsy.

Methods

In this descriptive-analytical study was performed on 205 patients’ samples positive for h. pylori infection. Following h. pylori testing, the sample were culture with different antibiotics to obtain data regarding the resistance. Demographic information of the patients such as age, sex, employment status, area of residence and patient-related factors such as reason for referral, and previous history of treatment were obtained and evaluated for the correlation with antibiotic resistance.

Results

In this study, the mean age of the subjects was 42.32 ± 16.65 years. The most common reason for referral of patients in the present study was epigastric pain in 49.3% (101 patients). Antibiotic resistance to amoxicillin was 46.8%, tetracycline was 41%, metronidazole was 33.2%, clarithromycin was 70.7%. levofloxacin was 36.1% and bismuth was 19.5%. Sex, age, type of living (rural or urban), employment, reason for referral and history of treatment was not associated with any antibiotic resistance, p > 0.05.

Conclusion

Our study showed that clarithromycin resistance is the most common in our population followed by amoxicillin and tetracycline. Excessive use of these antibiotics and self-prescription should be analyzed in future studies and public-awareness programs might be required.

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H.pylori infection is associated with a wide range of gastrointestinal diseases.

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Self-prescribed antibiotics have led to antibiotic resistance and failure of complete eradication.

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Clarithromycin resistance is the most common in our population followed by amoxicillin and tetracycline.

Hypocalcemia following total and subtotal thyroidectomy and associated factors

BACKGROUND

Thyroidectomy is one of the common endocrinological surgeries for the treatment of thyroid disorders. Hypocalcemia is the potential complication after thyroidectomy, where is persistency can lead to serious systemic effects. The aim of this study is to evaluate the incidence of hypocalcemia in thyroidectomy patients.

METHODS

In this cross-sectional study, patients referred to (XXX) for thyroidectomy from 2019 to 2020 were enrolled. Preoperative serum calcium and postoperative 24- and 48-h calcium levels were evaluated in these patients. Demographic data (sex and gender), calcium levels, type of thyroidectomy and duration of surgery was recorded for all the patients. SPSS v22 was used for statistical analysis. P < 0.05 was considered as statistically significant.

RESULTS

Of 143 patients included in the study, the mean age was 49.7 ± 10.9 years and 61.5% were females and 38.5% were males. 49% patients had hypocalcemia in the first 24 hours after surgery and 63.6% following 48 hours of the surgery. The difference in calcium levels at three intervals were statistically significant, p = 0.001. The incidence of hypocalcemia was significantly more in women at 48 postoperative hours, p = 0.025. The age and duration of surgery was not significantly correlated with hypocalcemia, p > 0.05, whereas, patients who underwent total thyroidectomy had greater incidence of hypocalcemia 24 hours after the surgery, p = 0.021.

CONCLUSIONS

The incidence of hypocalcemia is greater in total thyroidectomy and female patients. Our study did not report significant correlation between duration of the surgery and age of the patients.

Evaluation of one-year incidence of vocal dysfunction and associated demographic factors in thyroidectomy patients: A descriptive analytical study

Background

Voice changes are common complaint following thyroidectomy that might or might not be associated with laryngeal nerve damage. Objective: The aim of this study is to evaluate the effect thyroidectomy on voice alteration and its association with gender and age.

Methods

In this descriptive analytical study, patients who underwent thyroidectomy at (XXX) without laryngeal nerve damage were included. These patients were evaluated based on subjective (self-reported) and objective (videostroboscopy) voice assessment. The data was collected immediately after the surgery and 6 months after the surgery during the follow-up.

Results

Of 76 patients included, the mean age of patients was 46.3 year. 25 (43.4%) were males and 51 (56.6%) were female. 28.9% patients were presented with apparent damage to the vocal cords, of which 8 (10.5) had voice changes. There was no statistically significant difference between sex and postoperative vocal cord dysfunction (P = 0.592). However, in male gender, late postoperative voice changes were significantly more, p = 0.013. The age was also not associated with immediate or late postoperative changes and damage to vocal cords, p > 0.05.

Conclusion

Our study reported that male gender can be an important factor in deterring voice changes after thyroidectomy nonetheless, it can not predict the risk of vocal cord damage. Furthermore, age might not a risk factor either. Studies with greater sample size are required to confirm these findings.

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Voice changes are common complaint following thyroidectomy.

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That might or might not be associated with laryngeal nerve damage.

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Male gender can be an important factor in deterring voice changes after thyroidectomy.

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Studies with greater sample size are required to confirm these findings.

Comparison of clinical symptoms after Helicobacter pylori eradication in functional dyspepsia patients based on endoscopic view of antral gastropathy

Functional dyspepsia is a common gastric disease that can be associated with Helicobacter pylori infection. The aim of this study is to evaluate antral endoscopy of individuals who presented with functional dyspepsia, H. pylori infection status and the effects of eradication therapy on the symptoms. Following the diagnosis of dyspepsia as per Rome III criteria, 260 individuals who were eligible for the study underwent upper gastrointestinal endoscopy and were divided into four groups of 65 according to the endoscopic view, grades I, II, III and IV (negative). Stool antigen test was also performed for all patients to identify H. pylori infection. The early signs of dyspepsia were assessed by a standard questionnaire. In all groups, omeprazole, amoxicillin, clarithromycin and metronidazole were used for eradication treatment, and 1 month after the treatment, a faecal antigen test was repeated to evaluate the eradication of H. pylori. There was no statistically significant difference between the groups in terms of clinical symptoms before treatment. The highest response to eradication treatment was seen in individuals with antral gastropathy grade III (66.2%) and the lowest response was in patients without antral gastropathy Grade IV (32.3%). This difference was statistically significant. There was no statistically significant relationship between the participants in terms of family history, age, gender and response to treatment. Eradicating H. pylori reduces the symptoms of dyspepsia. The response of eradication therapy was greatest among the patients with grade III antral gastropathy.

Levofloxacin based vs clarithromycin based sequential therapy in helicobacter pylori eradication; a randomized clinical trial

AIM

This study was aimed to evaluating the efficacy of levofloxacin based sequential therapy vs clarithromycin based sequential therapy in h.pylori (HP) eradication.

BACKGROUND

Several therapeutic regimen were investigated to treat HP infection. Sequential therapy is an alternative to classic triple therapy.

METHODS

In this randomized clinical trial, 200 HP infected patients randomly divided into two therapeutic groups .1-Levofloxacin based sequential regimen (group A); omeprazole and amoxicillin for 7days followed by omeprazole, amoxicillin and levofloxacin for 7days. 2-clarithromycin based sequential regimen (group B): omeprazole and amoxicillin for 7days followed by omeprazole, amoxicillin and clarithromycin for 7days. HP eradication was evaluated with urea breath test with carbon 13 (UBT) 6 weeks after the end of treatment.

RESULTS

Per protocol eradication rates of group A and B were 87.6% and 76% respectively. By intention to treat analysis, eradication rate of group A and B groups were 85.1% and 73% respectively. Levofloxacin based sequential regimen was more effective than clarithromycin based sequential regimen (Pv=0.028). Adverse events were seen in 19.6% and 15.6% in group A and B respectively. Drug compliance was 97% in group A and 96% in group B. There was no significant difference between two groups in term of adverse events (p=0.470) and compliance (p=0.651).

CONCLUSION

Levofluxacin based sequential therapy was more effective than Clarithromycin based sequential therapy in HP eradication. The suggested Levofluxacin based sequential therapy could be an alternative therapy in area with high clarithromycin resistance. Further studies are needed to confirm these findings.

Levofloxacin-based sequential therapy versus classic triple therapy in Helicobacter pylori eradication: A randomized clinical trial

Introduction: During the past two decades, eradication rates with triple therapy for Helicobacter (H.) pylori eradication have decreased. The decline of effectiveness of the triple therapy have led to investigations to achieve more effective and safe therapeutic strategies. Sequential, concomitant and hybrid therapeutic regimens are new therapies that have been introduced over the past two decades. The purpose of this study was to compare levofloxacin-based sequential therapy versus classic triple therapy in H. pylori eradication in a randomized clinical trial. Methods: All eligible cases were divided into two groups using a randomized block method. The first group (classic group) was treated with triple therapy; patients received omeprazole, amoxicillin and clarithromycin for 14 days. The second group received the levofloxacin-based sequential (lev-seq) regimen; the patients were treated with omeprazole and amoxicillin for the first 7 days and then with omeprazole, levofloxacin and metronidazole for the latter 7 days. In this clinical trial, 200 patients with H. pylori infection were enrolled. Ultimately, 192 patients completed the study. Of these, 95 patients (46 males and 49 females) were treated with triple therapy (classic group) and 97 patients (46 males and 51 females) were treated with the lev-seq regimen. The average age in the classic group and lev-seq groups were 41.4±12.4 years and 40.2±11.8 years, respectively. Results: The levofloxacin based sequential regimen was more effective than triple therapy regimen. It is recommended that the lev-seq regimen be used as the first-line therapy, especially in areas with high levels of resistance to clarithromycin (over 20%). Conclusion: Further studies with large numbers of samples are required to be conducted in different parts of the country for further evaluation of efficacy of this regimen. Peer Review Details Peer review method: Single-Blind (Peer-reviewers: 02) Peer-review policy Plagiarism software screening?: Yes Date of Original Submission: 05 November 2017 Date accepted: 25 November 2017 Peer reviewers approved by: Dr. Lili Hami Editor who approved publication: Dr. Phuc Van Pham  

Bentonite supplementation can improve performance and fermentation parameters of chronic lead-exposed lambs

Two experiments were conducted to investigate the effect of supplemental bentonite on performance, blood, and fermentation characteristics in Zandi lambs. In experiment 1, 20 Zandi male lambs (initial BW, 17.5 ± 1.6 kg and 110 ± 5 days old) were randomly assigned into four groups of five animals in each. The experimental treatments were (1) control (no Pb and bentonite), (2) 15 mg/kg DM Pb as Pb acetate and no bentonite, (3) 15 mg/kg DM Pb as Pb acetate and 1.5% bentonite, and (4) 15 mg/kg DM Pb as Pb acetate and 3% bentonite. The dietary treatments had no significant effect on dry matter intake of experimental lambs. Feed required per unit of weight gain was more (P < 0.05) in lead-exposed lambs in group 2 compared to the control and bentonite supplemented groups. Serum glucose, urea nitrogen, cholesterol, HDL, and LDL concentrations was similar among the treatments. In experiment 2, an in vitro gas production technique was used to evaluate the effects of bentonite supplementation on the gas production parameters of lead-polluted diets. The rate and amount of gas production was higher for bentonite supplemented groups (P < 0.01). Asymptotic gas production (b), metabolizable energy, and concentration of short chain fatty acids were lower (P < 0.05) for lead-polluted non-supplemented diet (group 2) as compared to the bentonite supplemented and control groups. It was concluded that bentonite supplementation favorably modified ruminal fermentation pattern and improved feed conversion ratio in growing lead-exposed lambs.

Association between proto-oncogene mutations and clinicopathologic characteristics and overall survival in colorectal cancer in East Azerbaijan, Iran

Background

Colorectal cancer (CRC) is the third-most common cancer in Iran. The increasing incidence of CRC in the past three decades has made it a major public health burden in the country. This study aimed to determine any relationship of specific mutations in CRCs with clinicopathologic aspects and outcome of patients.

Materials and methods

This study was conducted on 100 CRC patients by the case-only method. Polymerase chain-reaction products were analyzed by Sanger sequencing, and sequence results were compared with the significant KRAS and BRAF gene mutations in the My Cancer Genome database. Logistic regression models were used to detect associations of clinicopathologic characteristics with each of the mutations. Kaplan–Meier and Cox regression models were constructed to estimate overall survival in patients.

Results

A total of 26 subjects (26%) had heterozygote-mutant KRAS, and mutations were not detected in the amplified exon of BRAF in both tumor and normal tissues of the 100 CRCs. Rectal tumors had 1.53-fold higher likelihood of KRAS mutations than colon tumors, and men had 1.37-fold higher odds than women. The presence of metastasis increased the likelihood of KRAS mutations 2.36-fold over those with nonmetastatic CRCs. Compared to patients with KRAS wild-type cancers, those with KRAS mutations had significantly higher mortality (hazard ratio 3.74, 95% confidence interval 1.44–9.68; log-rank P=0.003).

Conclusion

Better understanding of the causality of CRC can be established by combining epidemiology and research on molecular mechanisms of the disease.