Open Access Published by De Gruyter Open Access

Volume 3 Issue 4

December 2008

Issue of Open Medicine

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Contents
Journal Overview

Open Access October 22, 2008

Chronic pain in urological diseases: a clinical review

Domenico Prezioso, Raffaele Galasso, Gennaro Iapicca, Emanuele Annunziata, Mario Martino, Fabrizio Iacono

Page range: 381-389

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Abstract

Chronic pain is the central problem in a variety of urological diseases. Pain is an unpleasant sensory and emotional experience associated with either actual or potential tissue damage, or described in terms of such damage. The aim of this research was to update knowledge about the ultrastructural, clinical, psychological and therapeutic aspects of chronic pain in urological diseases, in particular in chronic pelvic syndrome. In this paper we have revisited the most significant and discussed articles published in the last twenty five years, with particular references on the 2008 European Guidelines, searching key words (chronic pelvic pain syndrome, chronic pelvic pain, chronic prostatitis, interstitial cystitis, prostatodynia, urological disease) and data with a high level of evidence. The articles that we have analyzed show that pain is characterized by an initial tissue injury that can lead to sensitization, which is a decrease in the intensity of the stimulus needed to elicit a response by the nerve, involving the peripheral and central nervous systems. The chronic pain state is characterized by loss of inhibitory interneurons, establishment of aberrant excitatory synaptic connections and long-term potentiation of response due to changes in sensitivity of nerve synapses. Stress and hormones might also play a role in central sensitization. Pain also has a cognitive and emotional component. It is very difficult to treat, given the complex nature of the response and the interaction of physiological aspects

Open Access October 22, 2008

Caveat patiens — ethical dilemmas in decision -making

June McKoy, Judith McKoy

Page range: 390-395

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Abstract

More than 99,358 men, women and children are on organ transplant lists in the United States. Pressure on family members to donate organs can therefore be intense. The medical excuse was created to address this potential coercion. It is a fabricated anatomical or physiological reason given to a donor (with or without the donor’s request) that provides an immediate shield against coercive pressure by family and friends on the potential donor. While the long-term risks and benefits of the medical excuse have not been studied, they could arguably include: 1) Reinforced perception that donation is expected; hence, declining donation is aberrant, and requires legitimization by external authority; 2) Eroded family trust of transplant physicians; 3) Eroded family trust in the individual reporting a “true” medical excuse; 4) Falsification of potential donor’s medical record; 5) Development of “toxic secrets” in the family unit; 6) Paternalism; and 7) General erosion of trust in both health care providers and the healthcare system. This author proposes a system of transparent and balanced communication where both the potential donor and the transplant team are clearly cognizant of the voluntary nature of the purported donation and where provisions for “opting-out” occur at any point along the pre-transplantation continuum.

Open Access October 22, 2008

Genetic bottleneck among daghestan highlanders migrating to lowlands

Kazima Bulayeva, Elizabeth Marchani, Olga Kurbatova, Scott Watkins, Oleg Bulayev, Henry Harpending

Page range: 396-405

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Abstract

We present results of Short tandem repeat polymorphisms (STRPs) analysis and epidemiology study of indigenous ethnic highlanders of Daghestan and of the migrants from highlands to the lowland area in 1944, in comparison with native lowlanders. Results obtained show that demographically ancient highland ethnics have achieved a relatively stable equilibrium in their native environment and are characterized by optimal level of the main viability parameters (fertility, mortality, lifespan and morbidity). Migrants from highlands to the lowlands experienced dramatically increased morbidity and mortality in 1944–1947: up to 65–70% of total migrants had suffered malaria, typhus and other new infections and about 35–37% of total migrants had died. Genetic-epidemiological study support that non-survived migrants were characterized by a higher inbreeding rate, lower heterozygosity and higher physiological sensitivity to the environmental stress. This inter-connected complex had advantage for adaptation of the highlanders to the native environment but diminished their adaptability in the new and/or changing environment. A detailed study using STRP we performed in 1995–1999 in one highland isolate of ethnic Avars of whom about 50% were moved to the lowland area. We found significant differences in genetic and demographical structures between these highland and migrant parts of the isolate: the genetic bottleneck among migrants had a great qualitative and quantitative impact on their gene pool, i.e., lost of rare native population alleles, as well as of about 1/3 of total migrants with certain genotypes. Survived migrants demonstrate shorter lifespan and higher morbidity rate that support their still ongoing genetic adaptation to the lowland environment.

Open Access October 22, 2008

Ketanserin reduces the postischemic EEG and behavioural changes following Endothelin-1-induced occlusion of the middle cerebral artery in conscious rats

Slavianka Moyanova, Lidia Kortenska, Roumen Kirov, Dimitar Itzev, Kamen Usunoff

Page range: 406-416

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Abstract

We modeled the common clinical conditions of human stroke in fully conscious rats through an occlusion of the middle cerebral artery (MCAO) by means of unilateral microinjection of Endothelin-1 (ET1) in the vicinity of the artery (EMCAO model). Since the role of serotonin (5-HT) system in the regulation of the cerebral blood flow has been known for long time and no data are available at present for the effects of 5-HT antagonists in focal ischemia models, we further tested whether a blockade of the serotonin-2A (5-HT2A) receptors by ketanserin (20 min post-ET1) would diminish the late EMCAO-induced functional and morphological changes. The long-term neurological (postural reflex) and electroencephalogram (EEG) changes in the somatosensory cortical region (S1FL) were used to assess the effects of ketanserin on the post-ischemic changes. The study was supplemented by a histopathological examination of S1FL area and striatum of both hemispheres. The EMCAO/ ketanserin-treated rats showed much smaller neurological deficits than the EMCAO rats treated with vehicle. This effect was observed on day 3 and lasted until the end of experiments-14 days after EMCAO. The depression of alpha and beta EEG frequencies found after EMCAO was significantly and earlier restored following ketanserin. Notably, there was not augmentation of the pathological slow EEG waves at day 3 post-ET1 in the EMCAO ketanserin-treated rats compared with that observed in the EMCAO vehicle-treated rats. Although there were mild morphological changes in the penumbral S1FL cortical region after EMCAO, ketanserin reduced the histopathological difference between the ipsilateral and contralateral cortical S1FL regions, but did not change the difference between striatum of both sides. Ketanserin reduced the infarct size in ipsilateral hemisphere (mainly cortex). In conclusion, the results showed that treatment with ketanserin at the early stage of stroke may reduce the consequences of ischemia by improvement of functional and morphological recovery at later stages. Ketanserin appears to be a promising candidate for mitigating the consequences of stroke.

Open Access October 22, 2008

Comparison of octenidine dihydrochloride (Octenisept®), polihexanide (Prontosan®) and povidon iodine (Betadine®) for topical antibacterial effects in Pseudomonas aeruginosa-contaminated, full-skin thickness burn wounds in rats

Fatih Uygur, Mustafa Özyurt, Rahmi Evinç, Tugrul Hosbul, Bahattin Çeliköz, Tuncer Haznedaroglu

Page range: 417-421

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Abstract

Pseudomonas aeruginosa is one of the most frequently isolated organisms from infected burn wounds and a significant cause of nosocomial infection and septic mortality among burn patients. In this animal study, three antiseptic agents which were Octenidine dihydrochloride (Octenisept®, Schülke & Mayr, Norderstedt, Germany), polyhexanide (Prontosan®, B. Braun, Melsungen AG, Germany) and povidon iodine (Betadine, Purdue Pharma L.P, Stamford, USA) were compared to assess the antiseptic effect of their applications on experimental burn wounds in in rats contaiminated with P. aeruginosa. All treatment modalities were effective against P. aeruginosa because there were significant differences between treatment groups and control groups. The mean eschar concentrations were not different between polyhexanide and povidon iodine groups, but there were significant differences between the octenidine dihydrochloride group and the other treatment groups, indicating that the Octenidine dihydrochloride significantly eliminated P. aeruginosa more effectively in the tissues compared to the to other agents. All treatment modalities were sufficient to prevent the P. aeruginosa invasion into the muscle and to cause systemic infection. In conclusion, Octenidine dihydrochloride is the most effective antiseptic agent in the treatment of the P. aeruginosa-contaminated burn wounds; Octenidine dihydrochloride can be considered as a treatment choice because of its peculiar ability of limit the frequency of replacing wound dressings.

Open Access October 22, 2008

The correlation of apolipoprotein B, apolipoprotein B/apolipoprotein A-I ratio and lipoprotein(a) with myocardial infarction

Lucia Agoston-Coldea, Teodora Mocan, Marc Gatfossé, Dan Dumitrascu

Page range: 422-429

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Abstract

Recent evidence shows that apolipoprotein (apo) B, apoB/apoA-I ratio and lipoprotein(a) are better indicators of coronary risk than the conventional lipid profile. The aim of this study was to evaluate the correlation of apoA-I and B, and lipoprotein(a) with myocardial infarction (MI). We performed a cross-sectional study including 208 patients (100 men and 108 women), with and without previous MI evaluated by coronary angiography. The severity of coronary heart disease was scored on the basis of the number and extent of lesions in the coronary arteries. Lipid levels were measured by the enzymatic method and apolipoprotein levels were measured by the immunoturbidimetric method. The MI group had higher plasmatic levels of lipoprotein(a) (0.37±0.28 vs. 0.29±0.23 g/L, p<0.05), apoB (1.13±0.40 vs. 0.84±0.28 g/L, p<0.05) and of the apoB/apoA-I ratio (0.77±0.37 vs. 0.68±0.20, p<0.05) compared to controls. The area under the receiver operating characteristic (ROC) curves (AUC) suggested a good reliability in the diagnose of coronary heart disease for the apoB/apoA-I ratio (0.756, p<0.05), apoB (0.664, p<0.05), lipoprotein(a) (0.652, p<0.05) and total cholesterol/HDL-cholesterol (0.688, p<0.05). Multivariate analysis performed with adjustments for cardiovascular risk factors, showed that the levels of lipoprotein(a), apoB and apoB/apoA-I ratio are significant independent cardiovascular risk factors. Our results indicate that there is an important relationship among high plasma apoB concentration, lipoprotein(a) concentration, the apoB/apoA-I ratio, and MI. We showed that the apoB/apoA-I ratio has a stronger correlation with MI than the total cholesterol/HDL cholesterol ratio. We therefore suggest using apoB/apoA-I ratio and lipoprotein(a) in clinical practice as a markers of MI risk.

Open Access October 22, 2008

Diastolic blood pressure cut-off predicts major cerebrovascular events after minor ischaemic stroke: a post-hoc modelling study

Penka Atanassova, Nedka Chalakova, Borislav Dimitrov

Page range: 430-437

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Abstract

Only few follow-up studies have studied in detail the role of most important risk factors, but no reports were found on critical values (cut-offs) for such factors in prospectively predicting cerebrovascular events (CVE) in patients with minor ischaemic stroke (MIS). Estimates of predictive importance of such cut-offs may better inform and contribute to optimize treatment. This was a post-hoc modelling study with unique data from Bulgaria on 54 consecutive patients with MIS, aged ł 40, followed for 12 months for nonfatal or fatal CV events. A set of routine clinical demographic and known risk factors (SBP, DBP, HDL cholesterol, etc.) were explored using univariate statistics and multivariate regression models to identify the most important independent predictors of secondary CVE. An artificial neural network (ANN) model, irrespective of usual statistical constraints, also confirmed the specific role and importance of identified predictors. A receiver operating characteristics (ROC) curve and stratified survival analyses were used to define the best cut-off of most important predictors and validate the final model. During follow-up period of 11.1±2.4 months, 8 secondary CV events (14.8%) were observed only in males with MIS at the 5.8±2.7 months mark. No difference in age of patients with CV event (61.1±12.6 years) vs. those without (62.1±9.6 years) was found (p>0.05). The one-year risk for CVE was.15% (95%CI 7.1, 27.7%). The two most important risk factors in patients with versus without CV events were acute MIS onset (62.5 vs. 13.0%) and mean DBP at day 30 post-MIS (101.3±9.9 vs. 92.3±10.8 mmHg), with a relative importance by ANN of 20.92 versus 15.9 points, respectively. At multivariate logistic analysis only MIS onset and DBP were independently associated with the risk for secondary CVE (79.6% model accuracy, p model=0.0015). An increase of DBP with 1 mmHg was associated with 8% higher risk of CVE [adjusted OR=1.08 (95%Cl 1.004, 1.158)]. With this method, a novel cut-off predictive DBP value of 95 mmHg (ROCAUC=0.79, 95%Cl 0.60, 0.99, p=0.009) for CV events in patients with MIS has been found. In conclusions the new DBP cut-off (sensitivity >87%, specificity >69%) clearly discriminated between absence and presence of secondary CVE as also confirmed by stratified survival analysis (7 vs. 1 events, plog-rank =0.0103). This cut-off may be applied to better precisely evaluate and define, as earlier as possible, MIS patients at increased risk of secondary CV events.

Open Access October 22, 2008

Optimizing the degree of distension and reducing discomfort in CT colonography by means of a microprocessor interface system for air insufflation

Nikolay Sirakov, Athanas Kristev, Plamen Zagorchev, Russin Nikolov, Vladimir Sirakov, Kichka Velkova

Page range: 438-445

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Abstract

The patients’ discomfort during CT colonography determines which method is used and its frequency of use. The discomfort is largely associated with the colon’s insufflation with gas. A system for an automatic room-air insufflation has been developed that ensures a continuous and steady air insufflation and an increase in colonic pressure and enables a relatively fast decompression. This system provides constant pressure monitoring and can alert the operator, if necessary. The degree of discomfort was evaluated for 36 patients, who were subjected to manual and automated air insufflation. The degree of the colonic distension achieved by the two methods was compared. The data analysis showed a significantly lower level of discomfort in patients with automated air insufflation. The degree of colonic distension was evaluated by comparing the diameters of similar segments of the colon, as well as by the subjective opinion of the operator. The distension with automated air insufflation was higher than that with manual air insufflation. In some cases there was a significant difference (P<0,05). In conclusion, the results show that the automatic insufflation of air at room temperature can be used to optimize CT colonography.

Open Access October 22, 2008

Cross-resistance and associated resistance in Escherichia coli isolates from nosocomial urinary tract infections between 2004–2006 in a Turkish Hospital

Mustafa Ozyurt, Oral Oncul, Suleyman Ceylan, Tuncer Haznedaroglu, Fatih Sahiner, Nurittin Ardic

Page range: 446-452

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Abstract

In this study, antimicrobial resistance profiles were determined for 748 isolates of Escherichia coli from patients with acute nosocomial urinary tract infections (UTIs) at a Turkish Training Hospital. Thirteen antibiotics were included. Resistance to ampicillin alone (45.1%) and ciprofloxacin alone (20.6%) were the most commonly identified ‘single resistances’. Multiple resistance was found in 49.7% of the strains. The most common multiple antibiotic resistance profiles included ampicillin-sulbactam/amoxycilline-clavulonate (4.0%) and ampicillin-sulbactam/trimethoprim-sulfamethoxazole/amoxycilline-clavulonate (2.8%). From 2004 to 2006, ampicillin, trimethoprim-sulfamethoxazole and ciprofloxacin resistant strains increased to 76% from 57%, 53% from 43% and 55% from 41%, respectively. The percentage of extended-spectrum β-lactamase (ESBL) producing strains was 7.8% and imipenem resistance was seen in 5.2% of ESBL positive strains. We conclude that clinically important E.coli strains have now emerged with broader multidrug resistance. Periodical evaluation of laboratory results and clinical surveillance are crucially important for optimal antibiotic management of UTIs and infection control policies.

Open Access October 22, 2008

Clinicopathological features and survival rates of patients with renal cell carcinoma under 50 years of age

Ali Atmaca, Ömer Bayrak, Olcay Kandemir, Ege Şerefoğlu, Ílke Çulha, Abdullah Canda, M. Balbay

Page range: 453-458

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Abstract

We analyzed the clinicopathological features and survival rates of the patients with renal cell carcinoma younger than 50 years old. Between 2004 and 2007, 28 patients between 19–49 years underwent surgery for renal cell carcinoma. Presenting symptoms, type of the surgery performed, postoperative outcomes and duration of follow-up were recorded. Mean age was 41.5±7.6 years and 75% of patients were male. The tumor was symptomatic in 19(67.9%) and incidental in 9(32.1%) patients. Radical nephrectomy and nephron-sparing surgery were performed in 18(64.3%) and 10(35.7%) patients, respectively. The most common histologic type was clear cell(67.9%). The mean tumor diameters were 3.5±0.95 and 7.4±5.2 cm in the incidental and symptomatic groups, respectively(p=0.035). Incidentally discovered tumors and tumors treated by NSS did not include Fuhrman grade 4. There were no differences regarding pathological stage and Fuhrman grades when patients were grouped according to their symptomatology(p=0.242 and p=0.265, respectively). Overall mortality was 17.9%(n=5) whereas 4 patients(14.3%) died because of cancer. The mean survival was 30.6 months and cancer specific survival rate was 85.2%. Most of the tumors in this age group were symptomatic and most common histologic subtype was clear cell carcinoma. Incidentally discovered tumors had statistically significant lower tumor size.

Open Access October 22, 2008

Serum levels of cortisol and prolactin in patients treated under total intravenous anesthesia with propofol-fentanyl and under balanced anesthesia with isoflurane-fentanyl

Zlata Mujagić, Elsada Čičko, Vesna Vegar-Brozović, Mirsada Prašo

Page range: 459-463

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Abstract

The study was designed to determine pre-, intra-and postoperative serum cortisol and prolactin (PRL) concentrations in patients subjected to low abdominal surgery under total intravenous anesthesia (TIVA) with propofol-fentanyl, and under general balanced anesthesia with isoflurane-fentanyl. The prospective study included 50 patients of both sexes, aged between 35 and 60 years, subjected to elective low abdominal surgery. Patients were randomly divided into two groups: an experimental group, consisting of 25 ASA I/II (American Society of Anesthesiologists I/II classification) patients treated under TIVA with propofol-fentanyl, and a control group consisting of 25 ASA I/II patients treated under balanced anesthesia with isoflurane-fentanyl. The length of the surgery and the degree of the surgical trauma did not differ significantly between the two anesthesia groups. Blood samples for cortisol and PRL measurements were drawn at exact time points: 30 minutes before the beginning of the surgery (T0), 30 minutes after the beginning of the surgery (T1), at the end of the surgery (T2), 2 hours after the surgery (T3), and 24 hours after the surgery (T4). Serum levels of cortisol and PRL were measured using commercially available kits. The results were evaluated with the nonparametric Mann-Whitney test. The serum concentration of cortisol measured at T1 time point in patients treated under TIVA was significantly lower (p=0.04) than that in patients treated under general balanced anesthesia. The average circulating levels of PRL measured at T1, T2 and T3 time points in patients treated under TIVA were significantly lower (p=0.003; p=0.002; p<0.05; respectively) than those in patients treated under balanced anesthesia. The results obtained suggest that the endocrine stress response developed in response to surgery is probably attenuated in patients treated under TIVA with propofol-fentanyl and, thus, that these patients are less stressed in comparison to patients treated under general balanced anesthesia with isoflurane-fentanyl.

Open Access October 22, 2008

The major clinical outcomes of diabetic foot infections: One center experience

Adem Ozkara, Tuncay Delibası, Yusuf Selcoki, Mehmet Fettah Arikan

Page range: 464-469

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Abstract

Diabetes mellitus with its limb and life-threatening complications such as diabetic foot infection and amputation are increasing at epidemic rates all over the world. The objective of this study was to determine the rate of lower extremity amputation, the risk factors and the bacteriologic profile for diabetic foot lesions. The records of all 84 patients with diabetic foot infections of a large general hospital over a 4-year period were retrospectively included. The most commonly isolated pathogens were Staphylococcus aureus (39%), Pseudomonas aeruginosa (14%), Proteus mirabilis (14%), Escherichia coli (14%), Group B streptococci (12%), and Klebsiella pneumonia (8%). The variables, independently associated with higher foot infections, were inadequate diabetic regulation (93%), peripheral neuropathy (88.1%), peripheral vascular disease (73.8%), smoking (56%), past history of ulcer (28.5%), penetrating injury (20.3%), inadequate foot wear (15%) and Charcot osteoartropathy (10.7%). The general amputation rate was 38.1%. Diabetic foot ulcers and its complication rates including infection, gangrene and lower extremity amputation in Turkey are still high. Preventive care of the foot in patients with diabetes mellitus is extremly important. Therefore early diagnosing of risk factors for diabetic foot infections in the primary care setting and their adequate therapy under multidisciplinary approach should not be neglected.

Open Access October 22, 2008

The comparison of cultures, widal agglutination test and polymerase chain reaction as a diagnostic tool in typhoid fever

Ilker Devrim, Koray Ergünay, Ates Kara, Hasan Tezer, Inci Yiğitkanl, Ali Bülent Cengiz, Mehmet Ceyhan, Deniz Gür, Gülten Seçmeer, Şemsettin Ustaçelebi

Page range: 470-474

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Abstract

Typhoid fever caused by Salmonella typhi, paratyphi A and B, is an important cause of morbidity and mortality in many developing countries. A rapid and sensitive method for the detection of S. typhi is essential for early diagnosis of typhoid fever and effective therapy. In this study 45 febrile patients who were suspected to have enteric fever were enrolled, and the results of blood cultures, widal agglutination tests and Polymerase Chain Reaction in these cases were evaluated. Group I consisted of 11 patients with diseases other than salmonella infections, group II represented 6 patients with positive cultures, and group III represented 28 patients with negative blood cultures negative but who were clinically suspected cases that had a medical history of using variable antimicrobial agents. Two positive PCR results were present; one of them was in culture positive group (16,6%) and the other was in culture negative group (3,5%). In our study widal agglutination tests and cultures were found not to be helpful in differential dignosis. Although PCR based detection of S. typhi is reported to be a sensitive and specific test for the diagnosis of enteric fever, in our study the benefit of this method in the diagnosis of especially patients who were treated with antimicrobial therapy was not clearly determined. Other methods to increase sensitiviy and specificity to levels such as those of real time PCR should be developed and large-scaled studies should be done in endemic and non-epidemic regions.

Open Access October 22, 2008

Blood vessels of the normal and pathologically changed wall of the human vena saphena magna

David Kachlik, Vaclav Baca, Petr Fara, Alois Lametschwandtner, Bernd Minnich, Vladimir Musil, Bohuslav Sosna, Josef Stingl, Zdenek Straka, Marek Setina

Page range: 475-481

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Abstract

The vascular supply of the wall of human vena saphena magna was qualitatively studied by the use of several morphological methods on both normal and pathologically changed veins. The material was obtained from patients undergoing aortocoronary bypass or surgery of the varices, and material from cadavers. Under physiological conditions, the wall of vena saphena magna is supplied by delicate system of vasa vasorum, organized in a form of feeding vessels branched into an irregular loose adventitial mesh and continuing further as a microcirculatory network supplying the two outer thirds of the media. Small local dilatations and tortuosities of adventitial veins were found on heavy varicose veins. Slight increase of vasa vasorum growing into the innermost layer of media was detected, but the hyperplastic intima remained avascular. In patients with recurrent varices or with vein thrombophlebitis intimal hyperplasia, degradation of media and thrombosis, were found. Apparent massive increase of vasa vasorum growing into the whole media, hyperplastic intima and into the organizing thrombi, were regularly observed. The increase of vasa vasorum is a part of the complex of pathophysiological reactions of the vein wall on the hypoxia developing during the most serious pathological changes, and not as the primary varicogenic factor. The vascular supply of the wall of the human vena saphena magna was qualitatively studied by the use of several morphological methods on both normal and pathologically changed veins. The material was obtained from patients undergoing aortocoronary bypass grafting or surgery of varices, as well as materials from cadavers. Under physiological conditions the wall of vena saphena magna is supplied by a delicate system of vasa vasorum. It is organized in a form of feeding vessels branched into an irregular loose adventitial mesh, which continues further as a microcirculatory network supplying the outer two thirds of the media. Small local dilatations and tortuosities of adventitial veins were found on severe varicose veins. A slight increase of the vasa vasorum growing into the innermost layer of media was detected, but the hyperplastic intima remained avascular. In patients with recurrent varices or vein thrombophlebitis, intimal hyperplasia, degradation of media and thrombosis, were found. It was regularly observed that there was an apparent, massive increase of the vasa vasorum growing into the entire media, hyperplastic intima, and into the organizing thrombi. The increase of the vasa vasorum is due to the pathophysiological reaction of the vein wall as a result of hypoxia, which develops during the most serious pathological changes. The increase is not the primary varicogenic factor.

Open Access October 22, 2008

Effect of tonsillectomy and/or adenoidectomy on pulmonary arterial pressure in adults

Saeed Abdelwhab, Khaled. Dessoukey, Gamal Lotfy, Ashraf Alsaeed, Hesham Anwar

Page range: 482-486

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Abstract

The aim of the study was to determine the mean pulmonary pressure in adult with hypertrophic tonsils and adenoids and to clarify whether tonsillectomy and adenoidectomy has any effect on mean pulmonary arterial pressure of these adult. The study was carried out on 50 patients with diagnosis of upper airway obstruction resulting from hypertrophied tonsils and adenoids (group1). 25 adults were assigned as control with similar age and sex distribution (group2). For study subjects Routine general Examinations, BMI, ECG, Chest X ray, Arterial blood gases and Echocardiography were done. Mean pulmonary arterial pressure was measured by using Doppler Echocardiography preoperatively and mean 3–4 months postoperatively in all subjects. Elevated PAP (pulmonary artery pressure) was found in 15 patients (30%) in group 1 preoperatively. Mean PAP was 28.34 ±5.11 mmHg preoperative in group 1 and 19.84 ± 5.0 mmHg in group 2 (p <0.001). PAP decrease to 22.38 ±4.28 mmHg postoperatively in group 1 (p <0.001). Arterial oxygen saturation (spo2%) increase from 93.5 ± 1.9% preoperatively to 95.3 ± 1.3% post operatively (p < 0.001). percent reduction of PAP postoperatively correlates to age (t=−2.3, p= 0.02), preoperative PAP (p =0.01) but no correlation was found with BMI. In conclusions, this Study showed that obstructed adenoid and hypertrophy of tonsils causes higher mean pulmonary artery pressure in adult & revealed that tonsil& adenoid is effective therapeutic measure in such patients. With early intervention is necessary to avoid progressive cardiopulmonary disease.

Open Access October 22, 2008

Sedation for middle ear surgery: prospective clinical trial comparing propofol and midazolam

Janez Benedik, Aleksander Manohin

Page range: 487-493

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Abstract

During middle-ear-surgery under local anaesthesia (MES-LA), patients report hearing noises, feeling anxious, and experiencing earache. In a prospective randomized clinical trial, we compared propofol and midazolam for sedation in 68 patients scheduled for MES-LA. The starting dose of propofol was 1 to 1.5 mg per kilogram intravenously, followed by 1 to 2 mg per kilogram per hour given by infusion. The starting dose of midazolam was 0.02 to 0.05 mg per kilogram intravenously, followed by 0.01 to 0.02 mg per kilogram intravenously. Metamizol and fentanyl were added when required. Sedation was titrated to a Ramsay score of 3 to 4 and a bispectral index value of 70 to 80. Patients were assessed for vital parameters and sedation and pain scores. In the recovery room, readiness for discharge and satisfaction of both patient and surgeon with the procedure were assessed. The group receiving propofol had a significantly lower heart rate, shorter duration of sedation, and earlier readiness for discharge (p<0.05). There were no significant differences in other parameters evaluated. Seventy-nine per cent of patients in the group receiving propofol and 91.1% receiving midazolam would choose the same method of anaesthesia and sedation for any further MES-LA. Our results suggest that, compared to midazolam, propofol is more suitable for sedation in patients undergoing MES-LA. However, appropriate patient selection, adequate preparation, and careful monitoring are mandatory.

Open Access October 22, 2008

Career choice motivations of medical students and some characteristics of the decision process in Hungary

Regina Molnár, Tibor Nyári, Anikó Hazag, Adriána Csinády, Péter Molnár

Page range: 494-502

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Abstract

The changed circumstances of medical work, raises the question of how socio-economic changes over the last few decades has affected the professional socialisation of medical students. This paper explores the career choice motivations of medical students, as well as some characteristics of the process of making that choice and their effects on professional socialisation. The study was carried out with a self-administered questionnaire with 503 students in general medicine, randomly selected from two Hungarian Medical Schools. More than half of the students contemplated becoming a doctor as early as in their childhood. Their final decision was typically made in high school. Significant differences can be demonstrated in professional socialisation between those individuals identifying with the profession in early childhood and others turning to the profession later. Altruistic motivations were the most significant career choice reasons. In conclusions, the medical career choice must have deeper roots, yielding to an evolutionary psychological analysis as well, one aspect of which is altruism.

Open Access October 22, 2008

Venous aneurysms — a neglected pathology

Mazda Turel, Edwin Stephen, Sukria Nayak, Sunil Agarwal

Page range: 503-504

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Abstract

Venous aneurysms are not often recognised nor given importance due to the more serious and challenging nature of their arterial counterpart. They are uncommon entities that generally present as a painless swelling, can be accurately diagnosed by duplex venous scanning and are completely cured by surgical excision. We present a short report of 14 cases treated at a tertiary care centre in India over seven years from June 2001 to June 2008, to increase awareness of this easily treatable condition.

Open Access October 22, 2008

Young syncopal man and decision about permanent cardiac pacing

Malgorzata Lelonek, Adam Stanczyk, Jan Goch

Page range: 505-509

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Abstract

A 20-year old man experienced recurrent syncope, that suggested a partially neutrally-mediated mechanism, but in some cases were without a prodrome. The tilt test was negative. The 12-lead ECG and electrophysiological study showed first-degree AV block. Syncope in bradyarrhythmia was suspected and an implantable loop recorder was indicated. In the first month after implantation the patient experienced one syncopal episode. In the stored ECG, AV junctional rhythm was detected. The patient received a pacemaker and symptoms improved.

Open Access October 22, 2008

Ruptured right sinus of Valsalva aneurysm with bicuspid aortic valve

Abdul Hakeem, Telal Mudawi, William Morrison

Page range: 510-513

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Abstract

The sinus of Valsalva aneurysm is a relatively rare condition that may be congenital or acquired. We present a case of a young man who was admitted to the emergency department with acute dyspnoea whilst playing football. After investigation, the diagnosis of a ruptured right sinus of Valsalva aneurysm into the right atrium was made. The patient also had a bicuspid aortic valve. Percutaneous approach to close the fistula was unsuccessful and the patient underwent surgical closure of the fistula with replacement of his bicuspid aortic valve.

Open Access October 22, 2008

Hypercalcemia: A rare cause of cerebral infarction

Shahzad Riyaz, James Tymms

Page range: 514-516

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Abstract

Hypercalcemia is a definite but rare cause of acute pancreatitis. It is often overlooked in the presence of more common etiological factors such as gallstones, alcohol and trauma. Cerebral infarction secondary to hypercalcemia has also been described. We have done a literature review to explore the possible pathological processes causing cerebral infarction in hypercalcemic patients.

Open Access October 22, 2008

Intracranial meningioma in a patient with osteogenesis imperfecta

Parmenion Tsitsopoulos, Ioannis Anagnostopoulos, Vasileios Tsitouras, Ioannis Venizelos, Philippos Tsitsopoulos

Page range: 517-520

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Abstract

Osteogenesis imperfecta (OI) is a heritable disorder characterized mainly by connective tissue manifestations. In dinstinct cases, several neurological features have also been described. A 46-year-old male with a known family history of OI type I presented with progressive gait disturbances and diminished muscle strength. Brain MRI scans revealed an infiltrative intracranial mass occupying both frontoparietal lobes. The patient underwent surgical intervention. The histological diagnosis was an atypical (Grade II) meningioma. The bony parts demonstrated a mixture of osseous defects due to OI and infiltration by the tumor. At one-year follow up the patient′s muscle power partially returned while repeat MRI scans were negative for tumor recurrence.

Open Access October 22, 2008

Henoch-Schönlein purpura presenting with multiplex gastrointestinal manifestations and massive nephrotic syndrome in adulthood — a case report

Farkas Klaudia, Molnár Tamás, Nagy Ferenc, Tiszlavicz László, Németh István, Kemény Éva, Varga Erika, Wittmann Tibor

Page range: 521-524

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Abstract

Henoch-Schönlein purpura (HSP) is a systemic small vessel vasculitis mainly affecting children. We report a case of a 49-year-old woman with severe gastrointestinal and renal involvement of HSP. Endoscopy revealed more characteristic findings in the terminal ileum than in the gastric antrum. Histological examinations of the biopsy samples from the ileum, antrum, skin and kidney confirmed the diagnosis of HSP. Parenteral corticosteroid therapy led to a rapid improvement of the gastrointestinal symptoms, but because of the excessive proteinuria intravenous cyclophosphamide therapy had to be introduced.

Open Access October 22, 2008

Laparoscopic distal pancreatectomy of an acinar cell carcinoma

Yin Hao, Shen Yong, Deng Xing, Peng Hong

Page range: 525-527

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Abstract

Acinar cell carcinoma (ACC) of the pancreas is relatively rare, accounting for only approximately 1% of all exocrine pancreatic tumors. Because ACC of the pancreas is rare, strategy for management needs to be explored. The patient was a 50-year-old man who presented with left upper quadrant pain over 6 months. A mass lesion, located at the pancreatic tail, measuring approximately 4 cm in diameter was found on ultrasound, abdominal dynamic CT. The patient underwent a laparoscopic distal pancreatectomy. Immunohistochemical stains and electron microscopic examination of the tumor was consistent with ACC. No complication occurred, and the patient was discharged in good condition on 10th postoperative day. During the 10 months of follow-up, CT and tumor markers revealed no recurrence. In conclusions, Laparoscopic distal pancreatectomy can be performed safely for selected patients with nonmetastatic ACC at a favorable anatomic position. This operative strategy offers a minimally invasive surgery with the aim of a potential cure.

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