Journal of Clinical Case Reports

ISSN: 2165-7920

Open Access

Articles in press and Articles in process

    Case Report Pages: 1 - 2

    Rare Case of Ondansetron Induced Nephritis - A Case Report

    Shala Fathima S and Jefry Winner G*

    This case report depicts about an uncommon presentation of a commonly used drug. Ondansetron a commonly used antiemetic for various reasons and indications is implicated this. This is of importance because to the best of our knowledge this is the first case of nephritis reported with ondansetron. This clinical scenario is of immense clinical importance because this is one of the commonly used drugs and such rare adverse events should be kept in mind for early identification and prompt management of patient.

    Mini Review Article Pages: 1 - 3

    Thrombotic Thrombocytopenic Purpura (TTP): A Rare Presentation in COVID-19

    M Pedlakkal Jabir*, K Nikitha and N A Ismail

    A 22-year-old female with no previous morbidities presented with acute onset neurological symptoms in the form of hemi sensory phenomenon. On evaluation she had fever and routine COVID-19 RT-PCR testing turned out to be positive. During the course of hospital stay she developed classical features of acquired TTP. Her ADAMTS 13 level was 36% of normal activity suggestive of direct viral mediated thrombotic microangiopathy. High vWF levels and low ADAMTS 13 activity is reported in COVID-19 Infection. In rare cases like ours this can mimic classical TTP.

      Short Communication Pages: 7 - 7

      Relationship between self-concept clarity, positive and negative symptoms among patients with schizophrenia

      Sanaa Shaheen*, Gehad Mohamed Abou-Elmaaty

      Background: Disturbance in self-concept clarity is suggested to be considered as one of a core feature of schizophrenia. A growing body of research reflects that the incoherence or disorganization in sense of self may mask individuals with schizophrenia from perceiving reality accurately. Patients often perceived themselves as if they lost contact to themselves and usually spent a lot of time wondering about the kind of person they are. Objective: This study aimed to assess the self- concept clarity, as well as positive and negative symptoms among patients with schizophrenia. And, to identify the relationship between self- concept clarity and both positive and negative symptoms among patients with schizophrenia. Settings: The study was conducted at EL-Maamoura Hospital for Psychiatric Medicine, in Alexandria, Egypt. Subjects: A sampling of 200 inpatients with schizophrenia were randomly selected. Tools: The socio-demographic and clinical structured interview schedule was used to elicit data about the patient's socio-demographic and clinical characteristics such as age, sex, educational level, duration of illness, and age at the beginning of illness. The Brief Psychiatric Rating Scale (BPRS-version 4.0) to examine the existence and severity of different psychiatric symptoms and the Self-Concept Clarity Scale to measure the perceived internal consistency and temporal stability of self-beliefs. Results: Findings of the present study revealed that around half of the studied sample demonstrated low self-concept clarity (50.5%). Whereas, more than one third of the studied sample (38.5%) had moderate self-concept clarity. Moreover, a statistically significant correlations were found between self-concept clarity in relation to positive and negative symptoms among the studied schizophrenic patients (rs= 0.242, P<0.001, and rs= 0.225, P=0.001, respectively). The overall brief psychiatric rating scale (BPRS) was proved to be the independent predictor of the self-concept clarity Conclusion: The present study concludes that the studied subjects demonstrated low self-concept clarity and self-concept clarity was significantly correlated with psychopathology in relation to positive and negative symptoms among the studied patients with schizophrenia. Recommendations: Conducting psycho-educational program regarding how to develop clear, consistent and stable sense of self would directly foster patients’ wellbeing and integration into the community.

      Short Communication Pages: 1 - 2

      Challenges associated with ICT usage among nursing faculty members in the context of Lebanon

      Rona Nsouli

      Statement of the problem: Information, communication and technology form essential means of literacy in the 21st century. ICT has become an essential aspect of higher education recently, ICT has also become an essential aspect of medical institutions, that require graduating nurses to use it in their daily work. However, a major challenge for use of ICT in nursing education, is to find the means to encourage teachers to use it. Teachers’ ICT knowledge and beliefs paly and essential role in classroom practices, however lots of challenges and barriers prevent the structured use of ICT. Methodology and theoretical orientation: a qualitative research approach was used. Using an interview protocol, face to face interviews were conducted with eighteen nursing faculty members, from four private universities in Lebanon. Findings: ICT usage is varied among nursing faculty members, while some consider it essential for teaching and learning; some other faculty feel it is an extra burden to their busy schedules. Further to that, this study highlighted the challenges faced by nursing faculty members that prevent them from using ICT, and these range from the community/country’s level: like electricity shut down, and slow internet; to institutional level: absence of clear ICT policies and extra costs associated with ICT, to the personal level: like the lack of relevant ICT trainings and knowledge. Conclusion and significance: ICT is important for the nursing profession. Faculty members are proficient in ICT use, however there should be standardization and structure in the way ICT is used in nursing teaching and learning practices. Lots of challenges and barriers were identified and revealed by faculty members that hinder the use of ICT, working towards eliminating these challenges is essential towards improving the use of ICT.

      Short Communication Pages: 3 - 4

      Chair Massage on stress, heart rate and blood pressure in oncology nurses

      Souza TP*, Kurebayashi LFS, Souza-Talarico JN, Turrini RNT

      Problem statement: Nursing professionals work in a complex scenario, even before de pandemic situation. There is a high prevalence of moderate to high levels of chronic stress among nurses. In oncology unit presents elements which favor psychological overload due to prolonged hospitalizations of patients and dealing with the constant terminality and threat to life. In addition, chronic stress can compromise the quality of care and patient safety. The aim of this study was to evaluate the effectiveness of the massage chair to reduce chronic stress in the oncology nursing team. Methodology: A randomized clinical trial divided into two groups: massage chair and control without intervention. The intervention group received two 15-minute chair massage sessions twice a week for three weeks. The research was carried out in two university cancer hospitals, one public and the other private, in the city of São Paulo, Brazil. Main outcome measure: stress reduction as measured by the Signs and Symptoms List (LSS). Blood pressure and heart rate were measured before and after each massage. Results: 60 women from the Oncology Nursing team participated. The mean age was 32 (± 5.3) years, with a mean Body Mass Index (BMI) of 26.7 Kg/m2 (SD ± 5.0) presenting an overweight proflie. The stress analysis by the LSS showed that 6.7% (n=4) had a very high stress score, 65.0% (n=39) had a high level, and 28.3% (n=17) had medium level. There was a reduction in stress measured by the LSS with a statistical difference in the group-time interaction (p <0.001), with a Cohen's d value of 1.21 between groups. In the massage group, there was a reduction in heart rate and blood pressure (p <0.001). Conclusion: Chair massage, with 15 minutes, proved adequate to relieve signs and symptoms of stress in oncology nursing professionals.

      Short Communication Pages: 5 - 6

      Aromatherapy in Down Syndrome: Case report

      Souza TP*, Pinto CF, Ferreira AB

      Statement of the Problem: Children with Down syndrome (DS) have Neurodevelopmental Disorders including limited social awareness and sleep disorders. The use of integrative intervention is common in families with children who have DS. Aromatherapy is the therapeutic use of essential oils with benefits for pain, anxiety, sleep disorders and other conditions. The purpose of this study was to report the experience of aromatherapy in children with SD from 1 to 6 years of age, treated at a medical institution specialized in genetic syndromes. Methodology: Case report obtained through nursing consultations with aromatherapy. The choice of essential oils was based on age, complaints, use of other medications and olfactory test. Findings: Ten parents sought aromatherapy consultation voluntarily or by medical indication, due to: sleep latency period >40 minutes, agitation, low concentration and fear of being touched by other professionals. Each child had two to three of these complaints. The use of lavender essential oil (Lavandula augustifolia) was indicated for sleep and restlessness. Lemongrass essential oil (Citrus limon) to improve concentration and lemongrass EO (Cymbopogon citratus) to relax, improve interaction and agitation. Feedbacks occurred after 1 week of starting use and after 30 days. Parents reported an improvement in their own sleep and a decrease to 15 minutes (average) for their children's sleep latency (5); improved interaction with other children and professionals (5), improved concentration in rehabilitation (2). One mother did not notice a difference and two fathers did not adhere. Conclusion & Significance: The use of aromatherapy in children with DS demonstrated acceptance by parents and children, with promising results in sleep and behavioral areas. Field research is strongly encouraged.

      Short Communication Pages: 8 - 8

      The evolution of the socio-cultural and religious characteristics of cancer patients in Morocco: case of the National Institute of Oncology Rabat

      Fahd Elkhalloufi, Saber Boutayeb, and Hassan Errihani

      Background: In 2020, Morocco recorded more than 59,370 new cases of cancer and more than 35,265 cases of death (International Agency for Research on Cancer, Annual report Morocco, 2020). Cancer is always accompanied by socially constructed, differentiated, and contingent interpretations and practices according to the socio-cultural and religious characteristics of each region. The study aims at describing the evolution of the socio-cultural and religious aspects of Moroccan cancer patients followed at the National Institute of Oncology (NIO) of Rabat between 2010 and 2020. Methods: We have prospectively studied all cancer cases diagnosed at the National Oncology Institute (NIO), Rabat in 2019. We have collected 1102 cases. The data collected was compared with the results of the study carried out in 2010 (1600 cases). Statistical analysis has been assessed by SPSS 20 software and the correlations between sociocultural characteristics were examined using a chi-square test. Results: From a socio-economic point of view, almost all patients claim that cancer is a costly disease as well as a disease that leads to a drop in income and the inevitable impoverishment of Moroccan patients. The illiteracy rate is still high; rising from 38% in 2010 to 42.80% in 2020. On the psychological level, damage to body image (alopecia, mastectomy, hysterectomy,) can lead to stigmatizing and harms the marital relationship. The number of patients experiencing divorce and marital separation that seems to occur following cancer pathology remains high, despite a decrease of nearly 50% between 2010 and 2020. Concerning the spiritual aspect, in the Arab-AmazighMuslim culture, the impact of the occurrence of cancer is very particular, and the repercussions are assessed differently depending on the degree of conviction. For practicing believers, cancer is considered a divine test and an opportunity to improve. In the Qur’an, God tests the best of his disciples to reward them The rate of practicing believers has evolved from 49% in 2010 to 85.50% in 2020.But for non-practicing believers, cancer is regarded as a divine punishment coming from outside. New behaviors reported by this research concern the use of “roquia”. This spiritual cure is considered as an anti-cancer remedy. It uses Allah’s words from the holy “qur’an”, his faires names and his attributes. 42% of patients use “roquia”. Concerning phytotherapy, there was an increase in the percentage of participants using medicinal plants and even the most harmful plants (Arestiloch, Euphorbia) from 26% in 2010 to 51.50% in 2020. Conclusion: The precarious social level of cancer patients, the lack of social and medical coverage, illiteracy, and lack of knowledge of religion, as well as dissatisfaction with conventional medicine, may lead patients to the use of traditional medicine (medicinal plants, visit of “marabouts”, “roquia”). This can have a negative impact on the quality of access to oncology care.

        Short Communication Pages: 1 - 2

        A Sertoli-Leydig tumor in a 18-year-old patient

        Eugenia Lamas Majek

        Sertoli-Leydig cell tumor is a rare sex cord-stromal tumor of the ovary that accounts for less than 0.5% of all primary ovarian neoplasms. Since these tumors have testicular cell types (Sertoli and Leydig cells), androgenic symptoms are common, causing signs of virilization (e.g., hirsutism, acne, irregular menstrual periods, male-pattern baldness, loss of female fat distribution, and hoarse voice). In many cases, secondary amenorrhea is the only symptom of the disease. This leads to an intensive search for the source of the disorder. We report the case of an 18-year-old woman who presented with amenorrhea of two years’ duration and severe viriliza¬tion with hirsutism, clitoromegaly and hoarse voice. Her testosterone levels were in male ranges. Imaging examination showed a mass in her left ovary. The tumor was removed with surgery and the pathological examination revealed a “moderately differentiated Sertoli-Leydig tumor”. The patient’s serum testosterone levels normalized a few days after treatment and her menses resumed spontaneously one month after the operation.

        Short Communication Pages: 1 - 2

        Robotic vs. open surgery in obese women with low-grade endometrial cancer: comparison of costs and quality of life measures

        Zvi Vaknin

        Statement of the Problem: Low-grade-endometrial-cancer (LGEC) is the most common gynecological-cancer in developed-countries. Women who develop LGEC tend to be obese and to suffer from many co-morbidities that challenge the surgeon. The literature demonstrates the supremacy of minimal-invasive-surgeries (MIS) for this group of patients. Robotic-surgery (RS), an advanced MIS, costs are high and healthcare-systems do-not include specific reimbursement for this approach.

        Methodology &Theoretical-Orientation: This retrospective study compared perioperative-measures, costs, quality-of-life and survival after open (OS) vs. RS, among obese-women (BMI≥30) diagnosed with LGEC. in two tertiary-medical-centers in the center of Israel during 2013–2016. Quality-of-life was evaluated by Physical&Mental Components of the SF-36 and a recovery-from-surgery questionnaire. Overall-survival-outcomes were obtained from patients’ files. Surgical-outcomes (operating and anesthesia times, length of hospital-stay, and intraoperative&postoperative-complications according to the Clavien-Dindo-classification scale) were reviewed. Findings:  In all, 138 women underwent OS (n = 61) or RS (n = 77) during the study-period. The groups had similar BMI, comorbidities, demographics and tumor characteristics. RS was associated with shorter hospital-stays (mean 1.7 vs. 4.8 days; P<.0001) and fewer postoperative-complications (Clavien-Dindo > 2, 5.2% vs. 19.7%; P=.0008), but longer operating-theater time (3.8 vs. 2.8 h; P<.001). Costs are equivalent when at least 350 RSs are performed annually, without the initial system costs. Quality-of-life measures were better after RS. SF-36 showed better measures for RS. After RS, patients tended to recover quicker. Overall, 5-year-survival was 89.8% for the OS group vs. 94% for the RS group (log-rank, P=0.330). Conclusions: Obese-women with LGEC had better quality-of- life after RS vs. OS. They also had shorter hospital-stays and fewer postoperative-complications. Centers with high-volumes of RS can achieve similar costs when comparing both methods. These results were achieved without jeopardizing survival.

        Short Communication Pages: 1 - 2

        Serum lactate dehydrogenase levels in pre-eclampsia and its correlation with maternal and fetal outcome



        Hypertensive disorders are one of the most common medical disorders during pregnancy.It is a major cause of maternal& perinatal morbidity & mortality. In developing countries, they rank second only to anemia with approximately 7 to 10% of all pregnancies complicated by some form of hypertensive disorders. Identifying high risk patients & close monitoring can  reduce the complications. Lactate dehydrogenase is a useful biochemical marker &can be used to evaluate maternal complications like disseminated intravascular coagulation[DIC], HELLP syndrome,[haemolysis,elevated liver enzymes & lowered platelets] , Pulmonary edema, renal failure & fetal complications like fetal growth restriction[FGR], APGAR score</= 7 at 5 minutes & neonatal intensive care unit[ NICU] admissions.


        1. To estimate Serum LDH levels in Preeclampsia patients.

        2. To study the correlation between increased serum LDH levels & maternal & fetal outcome.


        It was a prospective study at M.S.Ramaiah hospitals from October 2015 - May 2017.


        The incidence of maternal & fetal complications were increased with higher serum LDH levels. With serum LDH > than 600IU/L the incidence of HELLP syndrome was 10% with p value <0.001,**significant, DIC was 1.7% with p value <0.004,**significant, Pulmonary edema was 2.6%, with p value 0.072+significant. It also correlated with increased creatinine levels & decreased platelets with p value < 0.001.** The fetal outcome was FGR in 84.2%, NICU admission in 94.7% and APGAR score <7 at 5 min in 73.6% with p value being statistically significant at 0.001.**

        The liver enzymes aspartate aminotransferase [AST] & alanine aminotransferase[ALT] values and serum creatinine were also correlating with increased LDH levels with p value <0.001**.

        Conclusion: With raised serum LDH levels, maternal & fetal complications are increased. LDH levels can be used as a biochemical marker. Monitoring of serum LDH levels  helps to achieve a better outcome for both mother and fetus.

        Short Communication Pages: 1 - 1

        Individual dynamic endometrial maturation: a new fact that leads to reconsider strategies for timing of embryo transfers

        Joachim Alfer

        Statement of the Problem: The knowledge about the endometrial receptive stage for embryo transfer in IVF treatment is very important but unknown as well. Measuring the endometrial thickness and trilaminar pattern by ultrasound provides only a hind of a sucessful start of the menstrual cycle at the end of the follicular phase. Aim of this study was to monitor the endometrial transformation process applying our Personal Endometrial Maturation Analysis (PEMA®). We wanted to get information about the transformation process and to exclude an arrest of that organ, which cannot be done by  one biopsy.  Methodology & Theoretical Orientation: Two biopsies were taken mainly at days +5 and +10 after ovulation (OV, n = 76)/hormone replacement therapy (HRT, n = 58) within one cycle. Endometrial dating is done with our new modified endometrial dating method, a combination of histomorphological analysis, based on the Noyes criteria, with a typical pattern of hormone receptors and the proliferation marker Ki-67 for each cycle day between OV/P +2 and +11. Findings: The results were correlated with the clinically expected day of the cycle and showed temporal delays or hypercompensations, diverging from the expected cycle days by 0.5–5 days. In comparison with the first biopsies, the transformation rate in the second biopsies showed constant transformation, compensation or augmented delay in 28.94, 48.69 and 22.37 % of cases for ovulation in natural cycles and 17.26, 56.89 and 25.85 % for HRT cycles respectively.

        Conclusion & Significance: The study revealed an individually dynamic transformation process of the endometrium using PEMA®, with the ability to compensate or enlarge an initial “delay”, which is now identified as a normal individual transformation process during the secretory phase. This information will lead to a new consideration of IVF procedures and will influence timing of embryo transfers.

        Short Communication Pages: 1 - 2

        Chorioangioma associated with premature rupture of preterm membranes in pregnancy obtained by in vitro fertilization. Presentation of a case

        Dr Esmeralda López

        Chorioangioma is the most common non-trophoblastic placental tumor, with an incidence of 1% of pregnancies. It was first described by Clarke in 1978. Although its etiology is not precisely known, it´s believed to consist of an abnormal proliferation of vessels in various stages of differentiation in the placental stroma. Prenatal diagnosis is made through ultrasound visualization of a rounded, hypoechoic, homogeneous-looking formation located on the fetal side of the placenta, with color Doppler inside.

        Short Communication Pages: 1 - 2

        New promise in correction of vulvovaginal laxity syndromes

        Sona Pankova

        Vulvovaginal laxity (VL) is caused particularly by vaginal delivery, excessive physical strain, ageing or due to hormonal changes. It is influenced by insufficient vaginal wetness, burning and itching in vaginal orifice, yeast infections and inflammations. The consequences are collagen changes, incontinence and worsening of sexual life, often followed by mental issues as well. The use of Jett Plasma For Her II (JPH II) device is a new promise in correction of weakened pelvic muscles and vaginal walls and improvement of the VL symptoms. Therapeutic effects are achieved through membrane depolarization, reversible electroporation and thermal stimulation. Collagen activation is started and tissue structure is strengthened. The procedure is painless, well tolerated, without anaesthetic, it solves rejuvenation of atrophied vaginal mucosa and symptoms cease significantly.

        The effect of the treatment with JPH II device is currently being verified by a prospective Post-Market Clinical Follow-up study (PMCF study) via questionnaires aimed at assessment of patient's VL symptoms and sexual satisfaction. Each patient's satisfaction recorded in questionnaire was monitored at the beginning of study and then gradually over the course of study, showing excellent results with substantial improvement during the treatment. Overall increase in patient's sexual satisfaction and improvement of VL symptoms was higher than 30 %. Furthermore, a collection of biopsy samples before first and after last treatment was gathered and compared with each other. As a result, comparison of all biopsy samples before and after treatment even showed 222 % average increase in epithelial thickness of vaginal wall. In conclusion, these outstanding results indicating significant improvement in patient's state show a great potential in JPH II treatment of vaginal laxity, stress incontinence and improvement of sexual function and often related mental issues. Altogether, Jett Plasma For Her II represents an elegant solution for women dealing with the sensitive issue of vaginal laxity..

          Short Communication Pages: 1 - -1

          MiR-191-5p is upregulated in culture media of implanted human embryo on day 5th of development

          Acuna-Gonzalez, Flores Herrera

          Statement of Background: Morphological features are the most common criteria used to select human embryos for transfer to a receptive uterine cavity. However, such characteristics are not valid for embryos in cellular arrest. Even aneuploid embryos can have normal morphology, and some euploid embryos have aberrant morphology. The aim of this study was to quantify the expression profile of hsa-miR-21-3p, -24-1-5p, -191-5p, and -372-5p in culture media on day 5 of in vitro embryo development, and compare the profiles of two groups of media classified by outcome: successful (n = 25) or unsuccessful (n = 25) implantation pregnancy. Methods: Fifty patients were accepted in the Department of Reproductive Biology of a Hospital in México City, based on the Institutional inclusion criteria for in vitro fertilization. Embryos were transferred to the women on day 5 of cultivation, and the culture media were collected. RNA was isolated from each culture medium with TRIzol reagent, and microRNA (miRNA) expression was detected through RT-PCR with specific primers. Expression bands were quantified by reading optical density. Results: There was a 5.2-fold greater expression of hsa-miR-191-5p in the pregnancy-related culture media (p ≤ 0.001) and a 1.6-fold greater level of hsa-miR-24-1-5p (p = 0.043) in the media corresponding to non-pregnant women. No significant difference existed between the two groups hsa-miR-21-3p (p = 0.38) or hsa-miR-372-5p (p = 0.41). Conclusions: Regarding adequate in vitro embryo development, hsa-miR-191-5p could possibly represent a positive biomarker, while has-miR-24-1-5p may indicate poor prognosis. This former miRNA modulates IGF2BP-1 and IGF2R, associated with the implantation window. On the other hand, hsa-miR-24-1-5p may be related to a poor prognosis of human embryo development. Keywords: MiRNA expression, Embryo development, Implantation, Embryo culture media, In vitro fertilization

          Short Communication Pages: 1 - 1

          Individual Delayed Vaginal Evisceration after radical cystectomy and hysterectomy

          WA Wan Hassan , V Narasimhan

          Statemen The incidence Vaginal evisceration is a rare surgical emergency where abdominal contents herniate through a vaginal wall defect. The estimated incidence is 0.032–1.2% after hysterectomy, trachelectomy or uppervaginectomy. We present a 78-year-old lady who developed vaginal evisceration 2 years after radical cystectomy and hysterectomy forbladder cancer.The key principle of early management involves an attempt to gently reduce the bowel into the peritoneal cavity, and packing the vagina with moistened gauze. If the bowel is unable to be reduced, it should be covered with moist gauze before definitive surgery. Given the rarity of this condition, there is no consensus on the optimal operative approach for vaginal cuff dehiscence and each case should be treated on its own merits. Surgical treatment can be transabdominal, transvaginal or both based largely on the expertise available and the clinical situation of the patient.Transvaginal approach is generally believed to be the least morbid, with primary closure of the vaginal vault if the tissue is healthy. Transabdominal assessment can be via laparoscopy or laparotomy, with repair of the vaginal vault essential to prevent recurrence. The use of mesh or omental flap to re-enforce the vaginal vault can be utilized based on the clinical situation. As our patient did not present with overt signs of bowel ischaemia, we opted for a transvaginal repair with the aim to proceed to laparotomy if unsuccessful. It is likely that a combination of the various risk factors led to her vaginal cuff breakdown. Despite the previous pelvic radiation, she had very good quality tissue, hence primary closure was performed.This case highlights a rare surgical emergency that requires prompt recognition and damage control with bowel reduction and packing. Definitive repair can then be performed once appropriate expertise is available

          Short Communication Pages: 1 - 3

          Clinical investigation of fertility after uterine artery embolization

          Olivier Serres Cousine

          Sertoli-Leydig Short Session Description: The session description should be no less than 10 and no more than 50 words. The description emphasizes focus on the content of the course or the learner/audience and should emphasize the benefits of attending the course and/or the value of the subject matter itself. Use complete sentences (no bullets) and avoid writing in first-person narrative. This description will be used as promotional material for the course/session and will be printed in the final program. Inviting, dramatic or otherwise interesting descriptions are encouraged.
          Since the 1990s, uterine artery embolization (UAE) has known considerable development, but controversy around fertility remains. In this session, we will put this widely accepted idea into question, by presenting new evidence showing that UAE may be a safe and effective option for women with a desire to procreate.
          Objectives: This study aimed to investigate the clinical, anatomic, and obstetrical results of uterine artery embolization in patients of childbearing age not eligible for myomectomy.
          Methods: This was a retrospective cohort study of 398 female patients under the age of 43 years treated by uterine artery embolization between 2003 and 2017 for symptomatic fibroids and/or adenomyosis. Uterine artery embolization was performed according to a standardized procedure (fertility-sparing uterine artery embolization technique), with ovarian protection in the event of dangerous utero-ovarian anastomosis. Magnetic resonance imaging and pelvic ultrasounds were performed before and after uterine artery embolization.
          Findings: The overall clinical success rate (ie, resolution of pre embolization symptoms such as heavy menstrual bleeding, iron-deficiency anemia, pelvic pressure) was 91.2%, and there were no major complications. One year after uterine artery embolization, we observed a mean 73% reduction in myoma volume. A total of 108 patients (49.3%) presented with dangerous utero-ovarian anastomosis and 33 (14.5%) benefited from ovarian protection. In our group, there were 148 pregnancies and 109 live births; 74 children were born at term; 23 were born preterm, on average at 35.12±2.78 weeks. Including preterm births, the mean birthweight and birth length of the children were within normal limits. Restoration of uterine anatomy and ovarian protection were identified as the main predictive factors for obstetrical success. Restoration was also a major predictive factor for clinical success and was associated with a lower rate of miscarriage.
          Conclusion: This study provided detailed clinical and obstetrical outcomes for 398 female patients who underwent uterine artery embolization for fibroid treatment; it contributes to the identification of anatomic and technical factors that could have an impact on fertility after uterine artery embolization. Further controlled clinical trials are needed to confirm our findings and reevaluate this procedure’s indications and limitations for women with a desire to procreate

          Short Communication Pages: 1 - 1

          From foetus to the newborn: what triggers the first breath?

          Daniela Polese

          Human birth is set by the transition from foetus to the newborn, through the passage from intrauterine condition to extrauterine environment. However, first breath is still considered the starting point of life, even if there are evidence of several physiological events occurring before breathing. Indeed, developmental neuroscience research has still not discovered all dynamics of human birth. That which triggers the first breath is not understood, nor has brain modification/activation at birth been clarified. First breath occurs around 20 seconds after birth. Before breathing, newborn is motionless and her/his heart rate decreases, in contrast with the previous foetal motory activity and elevated heart rate, which are regularly observed and measured into the intrauterine condition. During this very short time of newborn’s silence and immobility, a complex sequence of physiological events takes place, which then determine the muscle activity associated with the influx of air into the lung and the settling of a spontaneous and continuous respiration. Before breathing, Central Nervous System (CNS) should give its immediate response to the new environment, being involved in this sequence of events and in the dramatic changes which characterize the passage from foetus to the newborn. In this work we will consider the physiological events that occur at human birth before respiratory activity and wailing, highlighting the role of CNS and its interaction with the new extrauterine surrounding, in order to identify a putative neurobiological mechanism which triggers the first breath.

          Short Communication Pages: 1 - -1

          Use of cabergoline and post-collection GnRH antagonist administration for prevention of ovarian hyperstimulation syndrome

          Shrem Guy

          The Research question: Does the addition of a gonadotrophin-releasing hormone (GnRH) antagonist to cabergoline treatment during the luteal phase in fresh IVF cycles triggered with a GnRH agonist, and planned for freeze-all, reduce the rate of mild and moderate ovarian hyperstimulation syndrome (OHSS)?
          Design: Retrospective cohort study of 480 IVF patients at risk for OHSS with GnRH agonist trigger from 2011 to 2018, stratified into three groups based on treatment received: GnRH agonist trigger alone (Group 1, n = 208), GnRH agonist trigger + cabergoline (Group 2, n = 167) or GnRH agonist trigger + cabergoline + GnRH antagonist (Group 3, n = 105). Data on patient demographics, incidence, severity and symptomatology of OHSS and laboratory findings were collected.
          Results: Group 1 had more free peritoneal fluid than Group 2 (28% versus 19%, P = 0.04) or Group 3 (28% versus 5%, P = 0.001). Group 1 reported abdominal discomfort and bloating more than Group 2 (33% versus 21%, P = 0.01) or Group 3 (33% versus 18%, P = 0.006). Group 1 had more electrolyte abnormalities than Group 2, who had more than Group 3. No patients developed severe OHSS. Mild and moderate OHSS rate was higher in Group 1 (38%) than Group 2 (29%, P = 0.048) or Group 3 (18%, P = 0.006) and in Group 2 than Group 3 (P = 0.046).
          Conclusion: Addition of cabergoline to GnRH agonist triggering in high-risk OHSS patients, and subsequent addition of GnRH antagonist for 5 days in the luteal phase, sequentially reduces the risk of mild and moderate OHSS and improves patient comfort compared with GnRH agonist trigger alone.

          Short Communication Pages: 1 - 1

          Prediction and prevention of hypoxic-ischemic brain injury of the fetus and newborn

          Posokhova S.P.

          According to retrospective analysis, hypoxic-ischemic brain damage and the development of neonatal HIE contribute to perinatal hypoxia, which occurs in complicated pregnancy: extragenital pathology in the mother (OR 1090.81; 95% CI 64.50–18447.40); placental dysfunction and fetal growth retardation (OR 7.39; 95% CI 2.94–18.57); premature placental abruption (OR 10.89; 95% CI 0.59–199.58); polyhydramnios (OR 2.19; 95% CI 0.85–5.62).
          Pertrospective analysis of labor in cases of intranatal fetal hypoxia and HIE in newborns showed that the most significant risk factors are premature rupture of membranes and time without amniotic fluid over 24 hours (OR 6.25; 95% CI 1.36–28.70), chorioamnionitis (OR 17.6; 95% CI 2.28–135.40), anomalies of labor (OR 21.87; 95% CI 1.26–387.39); use of obstetric forceps (OR 357.62; 95% CI 21.60–5920.23).
          Independent risk factors for severe asphyxia of the fetus and newborn and subsequent adverse neurological consequences are gestational age at birth: 26–27 weeks (OR 21.87; 95% CI 1.26–378.39); 29–30 weeks (OR 29.02; 95% CI 1.70–495.10); 31–32 weeks (OR 42.017; 95% CI 2.66–752.83); 33–34 weeks (OR 44.79; 95% CI 2.66–752.83); fetal weight at birth 500–999 g (OR 15.15; 95% CI 0.85–268.86); 1000–1499 g (OR 34.04; 95% CI 2.00–577.21); 1500–1999 g (OR 39.04; 95% CI 2.33–663.489). Extremely low birth weight infants most often had severe complications such as RDS type 1 or 2, intraventricular hemorrhage, depression or excitation syndrome, necrotic enterocolitis, and birth trauma that required intensive care and artificial ventilation.
          Comparative analysis of neurospecific markers in umbilical cord blood and in the blood of newborns with hypoxic-ischemic lesions of the central nervous system showed that a highly specific marker of fetal brain damage is an increase in neuronspecific enolase (NSE) and S-100 protein in umbilical cord blood, which can be used as a prognostic test. NSE sensitivity was determined – 0.87 (95% CI 0.61– 0.97), specificity 0.58 (95% CI 0.52–0.61), S-100 protein sensitivity – 0.8 (95% CI 0.46–0.96), specificity – 0.54 (95% CI 0.49–0.56).
          Neuroprotection with magnesium sulfate in pregnant women at birth up to 32 weeks reduced the incidence of neonatal asphyxia and distant neurological complications in 92.8% of children, indicating high efficacy.

            Special Issue Article Pages: 1 - 1

            Spatial and temporal distribution of faecal indicators and multidrug resistant bacteria in a multiple-use freshwater lake: the case of Lake Hawassa, Ethiopia

            Deresse Daka

            Aquatic environments close to cities are frequently used as sources for water and at the same time overloaded with a variety of pollutants either through direct or indirect discharges of untreated wastes and sew¬age. This condition is also worsened by the indiscriminate disposal of untreated wastes and sewage vigorously into used water. Sewage contaminated waters are known to carry microorganisms, some of which are pathogenic to humans. The aim of this study was to assess the extent of temporal and spatial levels of microbial pollution and sources of pollution in Lake Hawassa. A cross-sectional study was conducted at Lake Hawassa, which was sampled twice during 2017. A total of 26 samples of lake water were collected from 14 stations using a boat. Entry points of incoming streams, waste receiving sites, and areas upstream of anthropogenic impact, recreational and bathing sites were considered. Microbiological characterisation was performed using selective media and basic biochemical tests. Antibiotic sensitivity was tested with different antibiotics using the Kirby-Bauer agar disk diffusion method. All samples were positive for pathogenic bacteria, including Gram-positive and Gram-negative bacteria. Enterobacteriaceae were the most common bacteria identified from the samples, including Escherichia coli, Salmonella spp, Shigella spp, Proteus spp and Gram-positive bacteria, such as Staphylococcus aureus. The pre¬dominant bacteria found in the samples include E. coli, which constituted 22/26 (84.6%) of the total samples, followed by Salmonella and Shigella spp. All bacterial isolates were resistant to penicillin and ampicillin. The Salmonella spp were sensitive only to norfloxacin and gentamicin. A spatial variation with the occurrence of bacterial isolates has been observed. High concentrations and many different species were found in areas of human activities and in areas receiving direct pollutants from the city. This study revealed that multidrug resistant (MDR) pathogenic bacteria are found in Lake Hawassa. There is a possibility of outbreak of diseases associated with the isolated antibiotic-resistant pathogens for which the antibiotic resistance genes are transportable within aquatic bacterial communities. We recommend that the city administration take care of the municipal wastewater or effluents from healthcare facilities that enter the lake. It is also recommended that the government take steps to control anthropogenic activities near the water body.

            Short Communication Pages: 2 - 2

            NCoR1 and SMRT fine-tune inflammatory versus tolerogenic balance in dendritic cells by differentially regulating STAT3 signaling

            Atimukta Jha

            Dendritic cells are professional antigen presenting cells that fine-tune tolerogenic versus inflammatory responses. Through a combinatorial action of transcription factors (nuclear receptors) and their co-regulators. Among the best characterized co-regulators, NCoR1 and NCoR2/SMRT are known to interact with a plethora of regulatory factors and our objective is to unravel their impact on immune function. Moreover, their role in immune regulation in DCs is an untouched theme. Our finding shows that NCoR1 and its ortholog NCoR2 can have opposing effects in DC immune function. Silencing of NCoR2/SMRT in DCs led to increase in activation and resulted in a pro-inflammatory phenotype marked by increased IL6, IL12 and IL23 and a concomitant decrease in IL10 production. Consequently, co-culture experiment displayed that priming of naïve T cells with SMRT KD DCs led to increased proliferation of CD4+ and CD8+ T cells complimented with an increased Th1, Th17 and cytotoxic T cell response compared to control cells. SMRT depletion repressed mTOR-STAT3-IL10 signaling in cDC1 by downregulating NR4A1. Besides, NFkBIA and SOCS3 were down-regulated in SMRT knockdown cDC1, supporting increased production of inflammatory cytokines. Moreover, adoptive transfer of SMRT knockdown cDC1 in OVA-DTH induced footpad inflammation led to increased Th1/Th17 and reduced tumor burden after B16 melanoma injection by enhancing oncolytic CD8+ T-cell frequency, respectively. We also depicted decreased Smrt expression in Rheumatoid Arthritis, a Th1/Th17 disease.

            Short Communication Pages: 3 - 3

            Ivermectin Use in COVID-19 Prophylaxis

            Prof. Abdelmonem Awad Hegazy

            Ivermectin is a safe, non-expensive and available drug. It has been previously approved by US FDA as a well-tolerable safe drug used previously for treatment and even mass prophylaxis of several parasitic drugs. It has been investigated in the current pandemic and proved a high effectiveness for chemoprophylaxis against SARS-CoV-2. Use of ivermectin can provide temporary protection that is not long-term immunity as occurs with a vaccine. Therefore, its use may be repeated. Ivermectin could be one of the hopes for ending the current dilemma of SARS-CoV-2 pandemic if used properly under medical supervision. It can be used for mass prophylaxis of the whole population at the same time especially for poor and middle-income countries that do not have the facilities to deliver good effective vaccines. Otherwise, it can be used as an emergency in case of exposure or contact with the patient and even used at the onset of infection. However, it may not be useful in treating severe cases because the virus can cause many organs to fail. We recommend further studies to confirm the effectiveness of ivermectin in preventing COVID- 19 rather than dismiss it on the basis of insufficient evidence. Studying is very easy, does not take much time and does not cause economic or health burden. This also does not require special equipment or abilities except for volunteers to join through the investigation.

            Short Communication Pages: 4 - 4

            Challenges to nutrition management among patients using antiretroviral therapy in primary health ?centres? in Addis Ababa, Ethiopia: A phenomenological study

            Helen Ali Ewune

            Introduction: Nutritional management is a fundamental practice of concern to all patients infected with the human immunodeficiency virus (HIV). The nature of HIV/AIDS and malnutrition impacts are interlocked and intensify one another. Objective: This study aimed to explore nutrition management challenges among people living with HIV on antiretroviral therapy (ART) in primary health centres in Addis Ababa, Ethiopia. Methods and materials: We used a hermeneutic (interpretive) phenomenological study design. The study used in-depth interviews to describe lived experiences among adult patients aged 18 and above. We selected the participants purposively until the saturation of the idea reached. We maintained the scientific rigor and trustworthiness by applying credibility, transferability, dependability, and conformability, followed by translation and re-reading of the data has been achieved. The data have been analyzed through inductive thematic analysis assisted by NVIVO version 12 pro software. Result: Nutrition management challenges for HIV patients have been described using six significant themes. The major themes were: acceptance of the disease and the health status; facilitators and barriers to treatment adherence; behavioural changes in eating patterns; experience of food insecurity issues; nutrition knowledge; and support. The themes have explained how patients using ART have been challenged to manage their nutrition ever since their diagnosis. Of all challenges, food insecurity is found to be the core reason for poor nutrition management. Conclusion and recommendation: We found that many factors in managing their nutrition challenged patients with HIV. There should be an increasing interest in managing food insecurity issues as food insecurity has been strongly related to other factors.

            Short Communication Pages: 5 - 5

            The impact of COVID-19 on Iraqi Community: a descriptive study based on data reported from the Ministry of Health in Iraq

            Mohammed Hadi Ali Al-Jumaili

            Introduction: Coronavirus is a new pandemic disease that has emerged in Wuhan, China, and then spreads around the world. The cases number of the COVID-19, which have been daily reported in Iraq, has risen slowly. However, no confirmed study has been undertaken to evaluate the situation of the COVID-19 in concerning the confirmed cases, death cases, and recovered. Methodology: The current study is undertaken to describe and assess the COVID-19 of the present situation in Iraq out of the range of the confirmed, deaths and recovered cases from the date 21 February to 30 April 2020 in Iraq. Results: The study findings have revealed that there is a gradual increase of COVID-19 cases onwards until the top peak in 7th Apr. in which the cases reach 684, then decrease regularly. The total infected people of the study scope are 2085 persons according to the Ministry of Health in Iraq, while the World Health Organization (WHO) states 2003 person. The spatial distribution quantile map showed the hot spots in the province of Babylon, Maysan, and Diyala. However, less was found in three provinces (Nineveh, Salahaddin, and Al Anbar). The result shows that 66.9% recovered and 4.6% death cases out of total infected people. Conclusions: COVID-19 in Iraq comes to be limited via the procedures of Iraqi government. However, the infected people will be increased gradual ly and many international reports that predict the end of this pandemic in the world will be doubtful as there are many vaccines developed and under development which led to reduce to effect of this pandemic.

            Short Communication Pages: 6 - 6

            Retrospective Vaccine cohort of COVID-19 patients

            Ahmet DOGAN

            Introduction: In the control of the COVID-19 pandemic, community immunity with vaccines is the main element. Method: Cases who were hospitalized and followed up in the pandemic service with the diagnosis of COVID-19 for 13 months were included in the study. Those who were not vaccinated against COVID-19, those who had 1 dose of Sinovac or BioNTech vaccine, and those who had 2 doses of vaccine and had COVID-19 within 2 weeks after the second dose were included in the inadequately vaccinated group. Those who received 2 doses or more of Sinovac / BioNTech vaccine and had COVID- 19 2 weeks after the 2nd dose were included in the full dose vaccine group. Mutation type of 360 cases were recorded. Results: 44.5% of the cases were male and 55.5% were female. The mean age (Mean±SD, Min-Max) of 191 under-vaccinated cases was (58.29±15.61), while it was (72.12±12.65) of 169 full-dose vaccinated cases. The mean age (p=0.000), comorbid disease (p=0.000) was lower in the undervaccinated group. However, no significant difference was observed in ward length of stay (p=0562), CO RADS score (p=0172), mortality rate (p=1,000), and IC U admission rate (p=0.390). Of all cases, 44.17% were unvaccinated, 6.94% were single-dose vaccinated, 38.89% were double-dose vaccinated, and 10% were three-dose vaccinated. When the mutation status was examined, 36.11% of them were Delta mutation, 5.28% of them were British mutations and 13.33% of them were suspicious for variants. While the rate of mortality and admission to the ICU was 5.2% in the English mutation, no mortality was observed in cases with delta mutations or suspected variants. The rate of going to the ICU was 3.8% in Delta mutation and 2% in suspected variant cases. Conclusion: According to the results of our study, COVID 19 vaccines reduce hospital admissions at young ages. However, the effect of vaccine and mutation types on prognosis was not observed in ward patients.

            Short Communication Pages: 7 - 7

            The relationship between established Immunity and the type of Covid-19 Vaccine

            Kimia Ghods

            Statement of problem: Corona virus epidemic which started in 2019, has caused a widespread disaster around the world. Many efforts have been to develop safe and effective vaccines to prevent Covid-19 disease, and eventually a number of vaccines with different platforms have been licensed for use in various countries. Numerous studies have shown that these different structures of Covid 19 vaccines each uniquely activate and strengthen the host immune system, and therefore the immunity obtained from each vaccine is different. In this article, we will discuss the difference between the structures of Covid 19 vac cines and its effect on immunity obtained. Methodology & Theoretical Orientation: An electronic search applying specific Mesh terms like Covid 19, Vaccines, Immunity was carried out in PubMed and Google Scholar databases to collect data from 2020 until 2021, considering basic, pre-clinical, clinical and review studies. 42 relevant articles, focused on "Covid-19 vaccines and immunity" were selected and explored. Findings: According to the latest studies, all the Covid-19 vaccines platform will establish an acceptable immunity in the host. However, it has been shown that vaccines containing killed or inactivated virus produce lower immune responses than vaccines containing live virus and require booster doses. Conclusion & Significance: Undoubtably, all different types of Covid-19 vaccines can exclusively establish a good host immunity response. Therefore, the best solution to overcome this pandemic is to accelerate global vaccination and trust the outcome.

              Short Communication Pages: 2 - 2

              Total hip arthroplasty after pelvic osteotomy for acetabular dysplasia: A systematic review

              Jacob Shapira

              The purposes were (1) to investigate and compare the findings of patients undergoing total hip arthroplasty (THA) following a corrective pelvic osteotomy (PO), to a control group of patients who underwent THA but not PO and (2) to evaluate the outcomes and complications for secondary THA after PO. Three studies recorded reduced cup anteversion in the osteotomy group. Two studies reported higher PROs for the control group. The most common complication after failed PAO was dislocations. PO may entail challenges on a subsequent THA, illustrated by higher intraoperative blood loss, lower consistency in cup positioning and compromised patients reported outcomes.

              Short Communication Pages: 1 - 1

              Percutaneous lumbar discal nucleoplasty (PLN): Initial experience in 53 patients affected by small/contained herniated disk

              Fabrizio Fasoli

              Statement of the Problem: The purpose of this study is to evaluate the medium-term (6 months) efficacy of Percutaneous lumbar nucleoplasty (PLN), finding positive outcome correlation with patient’s data and MRI morphological variables in patients with chronic lumbar back pain (LBP) with radiculopathy. Methodology & Theoretical Orientation: We included fifty-three patients with chronic LBP, who underwent PLN from October 2020 to February 2021. Clinical data are obtained using VAS indices (Visual analog scale) and ODI (Oswestry Disability Index) pre-and post-procedure at 1-3-6 months. In addition, all patients were advised to follow a rehabilitation program and MRI exams before and after treatment (3 months). Findings: 40/53 patients (75.4%) report positive results after six months; about 9/50 (16.9%) do not report any improvement, while 4/53 (7.5%) reported a clinical worsening. Postoperative at six months VAS and ODI scores showed an overall decrease from baseline of 4.11 points (p<0.001) and 23.45 points (p<0.001) with lower values (VAS -2.10 and ODI -15.11) in those who attended the rehabilitation. Postoperative MRI controls after three months showed an overall decrease in size of the disc protrusion (-1.4mm, p<0.001) compared to baseline, and an increase in the spinal canal area (SCSA) from baseline (+18mm^2); better values were registered in those patients who underwent the rehabilitation program. Conclusion & Significance: The technique we used provided us with excellent intradiscal maneuverability and precision, with no postoperative complications. Furthermore, PLN has shown excellent short-term clinical outcome results, significantly if associated with conservative rehabilitation techniques. That confirms the need for further studies and a multidisciplinary approach to chronic low back pain.

              Short Communication Pages: 4 - 4

              Inversed V-shaped high tibial osteotomy for severe varus deformity due to Blount disease

              Seiju Hayashi

              Introduction: Blount disease is a growth disorder of the medial proximal tibial physis causing a multi-planar deformity of the lower limb. Several types of surgical approaches have been described for the correction of angular deformity including external fixation, opened-/closed wedge high tibial osteotomy (HTO), and tibial condylar valgus osteotomy. However, they are associated with various disadvantages such as limb length discrepancy, risk of infections , and delayed union at the osteotomy site, especially in cases of severe varus deformity. Case presentation: We report a case of 16-year-old boy with unilateral severe genu varum caused by Blount disease. Although, several types of surgical approaches have been described for the correction of angular deformity of the knee, they are associated with various disadvantages such as limb length discrepancy, risk of infections, and delayed union or non-union at the osteotomy site, especially in case of such severe varus deformity. Considering that the current case patient was severely obese and a highly active young boy with severe unilateral genu varum, with the epiphyseal line almost closed, and with no abnormalities with respect to the intra-articular anatomical structures, inverted V-shaped HTO. After the treatment, the boy was not only able to perform his daily activities but was also able to participate in sports quite early. Although the required correction angle was quite large, inverted V-shaped HTO successfully correct the deformity with minimal disadvantages. Conclusion: Inverted V-shaped HTO would be selected as one of the effective treatments for a severely obese, young, and highly active patient suffering from severe genu varum caused by Blount disease.

              Short Communication Pages: 3 - 3

              Lateral Trochanteralgia: A new concept for an old concept

              Aquiles Martinez

              Statement of the problem: Certain medical terms used to describe different syndromes for musculoskeletal conditions such as Greater Trochanteric Pain Syndrome (GTPS) can be long and large enough to need an acronym. Objective of the study: The objective of the article is to propose a new concept using neologism to describe a broad spectrum of causes of lateral hip pain previously known as GTPS. Methodology and Theoretical orientation: Literature review of medical terms including Greco-Latin words that are widely used to refer to different anatomical areas and specific symptomatology was performed. Use of neologism was performed to create new words that can be short, meaningful, and straightforward to describe the broad spectrum of causes of lateral hip pain. Results: The medical terms facilitate scientific communication, standardized procedures, publication, and research. For this reason, m edical terminology must be as short, simple, straightforward, but meaningful as possible. The Greco – Latin words were found to be broadly used in the medical terminology. Discussion: The current term to describe the lateral hip pain syndrome is Greater Trochanteric Pain Syndrome (GTPS). And is large enough to need an acronym. This term is used to describe a broad spectrum of conditions that include disorders of the tendons, muscles, bursa, bones, and other structures surrounding the greater trochanter. The most common chief complaint is pain (“algia”) over the lateral aspect of the hip. The neologism Lateral Trochanteralgia is a shorter, simpler, clearer, and more meaningful term that can be used to describe this syndrome. Conclusion: Lateral Trochanteralgia is a short, simple, clear, and meaningful term to describe the broad spectrum of musculoskeletal conditions involving the pain in the lateral aspect of the hip. The standardized and universal use of this neologism will favor all processes of medical publi cation, communications, and digital search of related topics

              Short Communication Pages: 5 - 5

              Radiologic evaluation and clinical effect of calcification in medial epicondylitis

              Hee Dong Lee

              Background: Although most radiologic findings of medial epicondylitis (ME) are normal, up to 25% show calcification, and little is known about the clinical relevance of soft tissue calcification in ME. The purpose of this study was to reveal the characteristics of calcification in ME, and to identify their clinical relevance. Methods: This study included 187 patients (222 elbows) who were diagnosed with ME. We classified calcification according to its anatomic location, and further evaluated its distribution. Logistic regression analysis was performed to calculate the odds ratios and 95% confidence intervals for possible factors that may affect calcification in ME: age, sex, laterality, hand dominance, visual analog scale (VAS) pain score, Mayo elbow performance score, symptom duration, history of steroid injection, number of steroid injections, concomitant ulnar neuropathy, and treatment method in terms of conservative treatment or surgery. Results: In a total of 222 elbows, 53% (118 of 222 elbows) showed calcification in radiologic findings. The VAS pain score, number of steroid injections, and concomitant ulnar neuropathy were significantly associated with calcification in ME. Calcification was most commonly identifi ed at the anatomical insertion site of the common flexor tendon (33%), followed by the pronator teres (18%), and the medial collateral ligament (10%). Of the total cases of calcification, 45% were distributed at multiple sites, and age was strongly associated with multiple distributions. Conclusions: Calcification in ME was more commonly identified than previously reported and was distributed over a relatively broad area. Calcification was associated with a higher VAS pain score, history of steroid injection, and combined ulnar neuropathy. The anatomical insertion site of the common flexor tendon most commonly showed calcification, and age was a strong indicator of a broad distribution of calcification.

                Special Issue Article Pages: 2 - 2

                Mortality in Two Reference Hospitals in the City of Yaounde (Cameroon): Epidemiological, Clinical and Prognostic Aspects

                Armand Kamga Talom*, Florent Fouelifack Ymele, Edmond Mesumbe Nzene, Jeanne Fouedjio, Pascal Foumane

                Objectives: The objective of this work was to determine the epidemiological, clinical and prognostic aspects of maternal mortality (MM) in the city of Yaounde. Methods: We conducted a descriptive cross-sectional study with retrospective data collection of maternal deaths according to the World Health Organization (WHO) definition, from January 1, 2017 to December 31, 2019, in two tertiary centers of Yaounde: The Yaounde Gyneco-Obstetric and Pediatric Hospital (YGOPH) and the Yaounde Central Hospital (YCH). Results: During the study period, 208 maternal deaths were identified, with 4/5 (78.4%) from referred cases. The MM ratio was 1532.8 per 100,000 live births (LB) vs. 609.5 per 100,000 live births at YCH and YGOPH respectively. The Main causes where hemorrhage (49%) followed by hypertensive diseases and their complications (21.2%), maternal mortality was associated with 50% of cases of foetal or neonatal deaths (57.4% in YCH vs 28.3% in YGOPH, P < 0.001). Health service systems were related to MM. Conclusion: Our study shows a large increase in maternal mortality ratios in YCH and YGOPH maternities since 2017. The main causes of MM found were hemorrhage followed by hypertensive diseases. These causes can be prevented. Our health systems should be improved if we want to significantly reduce the maternal mortality ratio

                Special Issue Article Pages: 1 - 1

                Gynecological Surgery- Case Report

                Raghad Aljishi

                Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital anomaly characterized by triad of uterus didelphys, obstructed hemi vagina, and ipsilateral renal  agenesis. The most common presentation is abdominal pain, dysmenorrhea, and abdominal mass secondary to hemi-hematometrocolpos. We report an emergency  presentation of this syndrome during the pandemic of COVID-19 in Qatif Central Hospital, Saudi Arabia, April 2020. An 11-year-old Saudi girl presented to the  emergency room with three months history of cyclical lower abdominal pain. The pain was progressive, continuous and not relieved by analgesics. Abdominal  examination revealed a tender abdominal mass mainly in the left iliac fossa, Ultrasound evaluation showed two uterine bodies. The left uterus was distended with  complex fluid. Pelvic MRI findings consistent with Herlyn-Werner-Wunderlich (HWW) syndrome were found with uterine didelphys and left sidedhematometra  resulting from obstructed Hemi-vagina and ipsilateral agenesis of the left kidney. Resection of the vaginal septum and drainage of hematometra was done. The  patient recovered with normal cyclical menstruation. Cyclical or continuous lower abdominal pain with or without amenorrhea is the usual presentation of HWW  syndrome during adolescence. Diagnosis is made by ultrasonography and MRI. Early diagnosis and accurate management can provide pain relief, prevent future  complications, and preserve fertility.

                Special Issue Article Pages: 3 - 3

                Mixed Gonadal Dysgenesis ? A Case Study


                Gonadal dysgenesis refers to various clinical conditions in which abnormal development of the fetal gonad is present. It consists of 46 XY gonadal dysgenesis, mixed gonadal dysgenesis, and 45 X turner syndrome. Mixed gonadal dysgenesis is a condition of unusual and asymmetrical gonadal development leading to unassigned sex differentiation. A number of differences have been reported in the karyotype, most commonly a mosaicism 45 X / 46 XY.1 We herein report an interesting and rare case of mixed gonadal dysgenesis in a 23-year-old nulliparous unmarried woman. Case: A 23-year-old nulliparous unmarried woman with primary amenorrhea with short stature, webbed neck, breast developed according to Tanner’s stage was presented to our clinic. She had normal external genitalia with axillary and absence of pubic hair. The evaluation of her uterus on ultrasound revealed a hypoplastic uterus measuring 2.6 x 1.4 x 0.9 cm with poorly formed endometrium and myometrium with bilateral ovaries being small and hypoplastic. Her follicle-stimulating hormone (FSH), testosterone, luteinizing hormone, and anti-mulleins hormone levels was 120 IU/L, 15 ng/dL, 24.5 IU/L and 0.02 ng/Ml respectively. Karyotype test showed mosaicism mixed gonadal dysgenesis, i.e., 45 X0 and 46 XY. She underwent laparoscopic bilateral salpingectomy (gonadectomy and salpingectomy).The postoperative period was uneventful. Intraoperatively streak gonads with elongated tubes were visualized. An infantile uterus with no pelvic abnormality was also observed intraoperatively. The histopathology report showed a cut dissection of ovaries. Discussion: Mixed gonadal dysgenesis (MCG) is a rare intersexual disorder, characterized by the presence of a testis and a contralateral streak gonad; in some cases the contralateral gonad may be rudimentary not having differentiated into an ovary or into a testis and in other cases it may be absent. On evaluation of 23-year-old nulliparous unmarried women’s uterus on ultrasound revealed a hypoplastic uterus measuring 2.6 x 1.4 x 0.9 cm with poorly formed endometrium and myometrium with bilateral ovaries being small and hypoplastic. Karyotype investigation revealed mosaicism mixed gonadal dysgenesis, i.e., 45 X0 and 46 XY. Johansen and coworkers reported structural rearrangement of the Y chromosome in 63% of mixed gonadal dysgenesis patients.2,3 Arora R et al reported that in 16-year-old person, karyotype analysis revealed 46XY karyotype and diagnosed with 46XY mixed gonadal dysgenesis.4 With this study, treatment recommended was laparoscopic bilateral salpingectomy (gonadectomy and salpingectomy). Sheela S et al also found similar kind of presentation where right sided gonads and adjacent tubal structures were visualized laparoscopically and performed gonadectomy.5 Similarly, Yadav P et al reported right streak ovary, left sided fallopian tube and streak ovary were noted in exploratory laparoscopy and later it was excised by doing gonadectomy.6. Conclusion: Gonadectomy was done as a prophylaxis measure in a 23-year-old nulliparous unmarried woman presented with gonadoblastoma or dysgerminoma. It was learned from the experience of the present study that patients with mixed gonadal dysgenesis have a different presentation and variant of chromosomal abnormalities. A multidisciplinary approach is essential for early diagnosis and proper management of patients diagnosed with rare mixed gonadal dysgenesis in order to prevent mental and social sequels

                Special Issue Article Pages: 4 - 4

                GOTTA LOVE THE TUBE: A case report

                Hawa Obeid

                Background: Diagnosis of ectopic pregnancy prior to rupture is an arduous task even with the availability of many new investigative methods and imaging modalities. Above all, a high index of suspicion is necessary when dealing with woman who present in early pregnancy with abdominal pain and vaginal bleeding. The use of transvaginal ultrasonography (TVS) will help in earlier diagnosis because of it is advantages over transabdominal ultrasosnography (TAS). Case presentation: A 36 years old woman, G2P0+1 presented at POA of 5 weeks and 5 days with history of an acute abdominal pain for 3 days’ duration and PV bleeding for 1 day. She has a history of primary infertility due to female factors and a laparoscopic ovarian drilling was performed 5 years back. A 2cm uterine fibroid was also noted during that laparoscopy. Subsequently, 3 IUI were performed the following two years but all were failed. She was also diagnosed with Diabetes Mellites one month ago and it is currently well controlled with diet, Metformin and Glibencarmide. Upon examination, she had tenderness of left iliac fossa. There was no palpable abdominal mass. A transvaginal scan done and revealed an empty uterus, no free fluid, no adnexal mass, complex mass at Pouch of Douglas size of 3.3?3.6cm. On review the next day, transvaginal scan repeated with finding of right ovarian cyst with solid cystic component and left adnexal mass size of 3.5?3.5cm. An laparpscopic was done, with operative finding of left tubal pregnancy over the lenght of fallopian tube (4?2cm), left fimbriae cyst of 1?1cm, subserosal fibroid at fundus (8?5cm) and intramural fibroid (3?3cm), right paratubal cyst (3?1cm) containing strawed coloured fluid, minimal adhesion seen over right pelvic wall with bowel, both ovaries were normal, bowel and liver were normal. A left sulphingectomy was carried out. Postoperative period was uneventful. Conclusion: Ectopic pregnancy carries a high morbidity and mortality partly due to the difficulty in establishing and early diagnosis prior to the rupture of the ectopic gestation. A high index of suspicion is necessary. With the recent advances in ultrasonography particularly transvaginal sonogram, diagnosis is made easier and more accurate.

                Special Issue Article Pages: 5 - 5

                Comparison of clinical and reproductive outcomes of women undergoing Cytoreductive procedure for diffuse Adenomyosis with patients undergoing myomectomy

                Kristyna Helenicka

                It is well known that the incidence of Adenomyosis and uterine fibroids increases significantly with age. In times when the first pregnancy is postponed into the fourth or even fifth decade, there is a growing demand for fertility saving procedures for these uterine diseases. To date, the literature contains a limited number of reports describing the reproductive outcomes of patients after adenomyomectomy for severe diffuse adenomyosis, and no report has compared the reproductive, obstetrical, and surgical outcomesbetween the two different uterus-sparing surgical procedures, namely, adenomyomectomy and intramural myomectomy. Therefore,we have tried to investigate it. Two groups of women who underwent different fertility-saving procedures were compared. Thepregnancy and delivery rates were 52.0% and 43.5%, respectively, in adenomyosis group versus 96.0% and 70.8%, respectively, infibroid group, with no significant differences between the two groups, except for pregnancy rate. The perinatal outcomes of the groupswere also comparable, including the low frequency of severe peripartum complications, such as the abruption or abnormal invasion ofthe placenta. The pregnancy rate was significantly lower in the group with severe form of adenomyosis. It appears, that the severity ofthe disease and the extent of the surgical resection of the uterus may influence the likelihood of a successful gestation. The clinicaloutcomes of women after cytoreductive resection of adenomyosis seems to be comparable with the different types of fertility sparingsurgery on uterine muscularity, namely myomectomy. Despite the technical challenges resulting in longer operation times and a higheconversion rate in comparison witmyomectomy, cytoreductive resection of adenomyosis seems to be feasible option for women withsevere adenomyosis and reproductive plans.

                Special Issue Article Pages: 6 - 6

                Search for the Causes of the Development of Reproductive System Disorders

                Evgeniya V Kirakosyan*, Tatyana A. Nazarenko, Stanislav V. Pavlovich

                Introduction: The continuous development of assisted reproductive technologies (ART) has led to the fact that now all forms of male and female infertility have been overcome, however, the effectiveness of using ART methods remains limited and is considered to be approximately 30%. Why is this so? Purpose: Determine the possible role of genetic, immunological causes, disorders of intra-ovarian steroid?- and folliculogenesis, leading to the formation of an oocyte defect, mitochondrial dysfunction, which, in turn, can contribute to the disruption of early embryogenesis. Materials and methods: The review of world literature was conducted in the databases Scopus, Web of Science, MedLine, Cochrane CENTRAL, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), EMBASE, Global Health, CyberLeninka, RSCI for a comprehensive study of the contribution of various factors to the development of reproductive system disorders. Results: The findings are promising, but further research is needed to study the etiopathogenesis of reproductive system disorders in order to optimize the algorithm of diagnosis and treatment. Particular attention is paid to the most demonstrative clinical model of reproductive system disorders – infertility of unknown origin when the reproductive system appears anatomically and functionally normal, but conception does not occur. Conclusion: We present the algorithm that is currently relevant from a clinical point of view for the diagnosis and treatment of patients with infertility of unknown origin.

                  Short Communication Pages: 1 - 1

                  The Impact of Virtual Reality Simulation as Teaching Strategy in Nursing Education

                  Samar Thabet Jallad

                  Learning via virtual reality simulation in practice is viewed as one strategy of outlining the gap between theory (concepts, features, limitation,…, etc.) and practice (performing skills, and experience in clinical settings) that has several advantages as preventing the probably disastrous consequences of errors occurring in clinical settings.Traditionally, higher education was instructive, providing form of theory-based lectures, with structured clinical hours undertaken in the clinical environment. Whereas, traditional practice happens within physical laboratories, using mannequins, human actors, and task instructors to duplicate procedural tasks and clinical scenarios. While, the transfer into the digital age has seen a move into blended learning methods which have become progressively common since the mid-2000s, and occurs on mixed structure, a constructive, and consisted of several strategies of teaching as audio-visual elements, online learning, self-directed learning modules, lectures and/or workshops, and critical-thinking exercises. Thus, virtual reality simulation plays a vital role within nursing education, with a diversity of software applications a supplement to face-to-face training, and ‘serious games’ being used as a replacement for it. Acquisition of psychomotor skills is an essential portion of nursing education as well as the basis upon which teaching/learning strategies are chosen, it linked with understanding, the cognitive, and affective field features as an attraction for values and attitude. Moreover, the acquisition of skills is directly related to nursing performance to answer the patients' needs. So, nurses should be masters the skills related to nursing interventions. Key words: virtual reality simulation; nursing education; teaching strategy; nursing skills

                  Short Communication Pages: 2 - 2

                  Evaluation of Hypertension Self-Care scales for Psychometric and Practical Quality: A Systematic Review 2011 to 2020

                  Khitam ALSAQER

                  Background: Most of the existing studies that investigated the self-care of hypertension focused specifically on medication adherence. However, hypertension self-care is a comprehensive concept that includes multiple dimensions. Last year, there was no review carried out assessing the new instruments for hypertension self-care which captured almost all the hypertension selfcare domains. Objective: This systematic review aimed to (1) identify the existing multiple-dimension hypertension self-care assessment scales from 2011 to 2020, (2) describe their characteristics, (3) and evaluate their psychometric and practical considerations. Methods: Database of PubMed, Web of Science, and EBSCO-host were used to identify all studies published between 2011 and 2020. Search limited to full-text, clinical and randomized trial articles, English language, and using terms (self-care AND hypertension). Scales were evaluated for their psychometric and practical considerations using an evaluation criterion for assessing the quality of measures. Results: The search resulted in 29 articles, and they identified five scales; H-SCALE, SCHI, Hypertension self-care questionnaire, HTN-SCP, and HSMBQ. HTN-SCP and HSCALE were the most used scales (11 times). The reliability was tested in different approaches. Overall, internal consistency was well reported with Cronbach ranging from 0.70 to 0.95. At least one type of validity measure was reported for each scale. The scales included multiple-dimensions of all critical domains and all of them were statistically significant (p< 0.05). The SC-HI and HTN-SCP scales were theoretically based on a theory. Conclusion: Although the identified scales well captured all critical domains of HTN self-care, there was a poor understanding of the process underlying the self-care of hypertensive patients. The HTN-SCP scale seems to be the highest psychometric and practical consideration quality of existing HTN self-care measures. Key words: Hypertension, Self-Care, measures, H-SCALE, SC-HI, HTN-SCP, HSMBQ.

                  Short Communication Pages: 3 - 3

                  How does the utilization of an Automated Early Warning Score (EWS) improve patients outcome

                  Phang Moon Leng

                  Statement of the Problem: Automated Early Warning Scores is a newly developed clinical decision tool that is used to streamline and improve the process of obtaining a patient’s vital signs so a clinical decision can be made at an earlier stage to prevent the patient from further deterioration. This technology provides immediate update on the score and clinical decision to be taken based on the outcome. This paper aims to study the use of an automated early warning score system on whether the technology has assisted the hospital in early detection and escalation of clinical condition and improve patient outcome. Methodology & Theoretical Orientation: The hospital developed and adopted the Modified Early Warning Scores (MEWS) Scoring System (Figure 1) and MEWS Clinical Response (Figure 2) into Philips IntelliVue Guardian Automated Early Warning Score equipment and studied whether the process has been leaned, whether the use of technology improved the usage & experience of the nurses, and whether the technology has improved patient care and outcome. It was found the steps required to obtain vital signs has been significantly reduced. The nurses are using the convenient equipment more frequently to obtain patient vital signs. The number of deaths, and length of stay has significantly decreased as clinical decisions can be made and escalated more quickly with the Automated EWS. Conclusion & Significance: the automated early warning score equipment has helped improve work efficiency by removing the need for documenting into patient’s EMR. The technology streamlines clinical decision-making and allows faster care and intervention to be carried out and improves overall patient outcome. As the use of the technology is simple and convenient, the vital signs is taken more often which translates to better care for patient.

                  Short Communication Pages: 4 - 4

                  Implementing the Ideal Clinic Program at Selected Primary Healthcare Facilities in South Africa

                  Masenyani Oupa Mbombi

                  Background: Primary healthcare (PHC) in South Africa often experiences crucial challenges that lead to patients’ negative experiences regarding their care, compromising the significant role that PHC services could play in health promotion and disease prevention. The primary purpose of implementing the Ideal Clinic (IC) in South Africa was to improve patients’ care quality at the clinics. There seems to be a paucity of studies determining professional nurses’ experiences when implementing the IC. Purpose: This study aimed to explore and describe professional nurses’ experiences regarding implementing the IC at three selected clinics in the Makhado local area. Study method: A qualitative phenomenological research design was used to explore professional nurses’ experiences regarding IC implementation. Purposive sampling was used to select 15 professional nurses working at the three selected clinics. Data were collected using semi-structured one-on-one interviews. Interviews were conducted until saturation was reached. Trustworthiness was ensured by applying Lincoln and Guba’s four criteria, i.e., credibility, transferability, dependability, and confirmability. Ethical clearance was obtained from the University of Limpopo Turfloop Research and Ethics Committee, and permission to conduct the study was obtained from Limpopo Province Department of Health Research and Ethics Committee. Thematic analysis was used to analyze data. Results: The following themes emerged from the study findings: perceived benefits of the IC on the primary healthcare services provided to the community, challenges experienced by professional nurses when implementing the IC program, and challenges related to the supply of resources for implementing the IC. The study results revealed that, although the IC aimed to improve the overburdened PHC facilities in SA, the professional nurses still experienced some challenges when implementing the IC program. Some of the challenges faced were a lack of knowledge and training in the IC program, poor infrastructure and the shortage of equipment, and inadequate provision of support by line managers, all of which resulted in poor-quality patient care. Conclusion: This study revealed that the introduction and implementation of the IC can have potential benefits to the community and the primary healthcare system. However, it was not introduced and appropriately implemented, which resulted in professional nurses experiencing several challenges. The national department of health needs to strengthen the program’s implementation through proper training, consultation, and continuous support of the nurses. Provision of quality equipment and supplies is also recommended.

                  Short Communication Pages: 5 - 5

                  4Active Intervention for Promoting Physical Activity and Cognitive Flexibility in Older Adults

                  Weiyun Chen

                  Background: Physical activity is essential to delaying cognitive decline and preventing cognitive impairment in older adults. We used the Social Ecological Model as the framework for designing an interpersonal-level and individual-level multicomponent PA intervention, 4Active, to increase PA participation and cognitive function in older adults living in retirement communities. The purpose of this study was to examine the effectiveness of the 4Active intervention to promote physical activity and cognitive function in older adults. Methods: Fifty-eight eligible older adults with a mean age of 83.83 years (76.3% females) living in two retirement communities voluntarily participated in this study. Forty subjects participated in the two-level 4Active intervention for 12 weeks and 18 subjects were in the control group. Each participant was pre- and posted tested on physical activity (PA) and cognitive flexibility. Data were analyzed by means of descriptive statistics, independent sample t-tests, and Analysis of Covariance (ANCOVA) with repeated measures Results: ANCOVA with repeated measures indicated that the intervention group had overall higher levels of the total PA and the moderate PA than the control group (F = 8.71, p = 0.005, η2 =0.141; F = 8.85, p = 0.004, η2=0.143). In addition, the intervention group showed pronounced increases in light PA (walking) over time, while the control group decreased light PA from baseline to the post-test (F = 6.91, p = 0.011, η2 =0.115). Regarding the results of cognitive flexibility, the ANCOVA with repeated measures revealed that intervention group had overall higher levels of cognitive function compared to the control group (F = 7.88, p = 0.007, η2 =0.129). Both groups showed significant increases in cognitive flexibility over time (F = 6.68, p = 0.013, η2 =0.112), but the intervention group had a smaller change in cognitive flexibility over time compared to the control group (F = 6.75, p = 0.012, η2 =0.113). Conclusions: The study indicated that engaging in technology-enhanced multicomponent exercises is an effective approach to contributing to physically active and cognitively competent aging. Keywords: Ideal Clinic; infrastructure; professional nurses

                    Case Report Pages: 1 - 3

                    Endoscopic Diverticulectomy For a Large ZenkeraEsophageal Diverticula: A Case Report

                    Pezhman Alavinejad, Jedidah Vika Muli, Samira Mohammadi

                    Here we report a 95-years-old woman presenting with a chronic history of frequent cough, dysphagia for solids and later difficulty in swallowing fluids along with decreased appetite and weight loss from 6 months ago who diagnosed with large Zenker diverticula. According to the patient’s age and general condition, the surgeon consultation considered her as inoperable so an endoscopic diverticulectomy performed as a therapeutic option by using flexible endoscope under deep sedation and the patient discharged from hospital 5 days after procedure.

                      Review Article Pages: 1 - 4

                      A Rare Case of Ossifying Fasciitis at the Lower Boarder of the Mandible in a 19-Months-Old Child

                      Rahaf Alhabbab*

                      Ossifying fasciitis is a very rare benign tumor of reactive character that can mimic malignant lesions, especially osteosarcoma. We report a
                      case of a 19-months-old boy, who experienced a rapidly growing hard painless swelling at the right side of the mandible. Resection of the
                      mass, and a detailed correlation with a clinicopathological and radiological analysis led to the final diagnosis of ossifying fasciitis of the
                      submandibular region at the lower boarder of the mandible.

                      Case Report Pages: 1 - 3

                      Solitary Juvenile Polyp at a Rural Ugandan Hospital Presenting with Recurrent Rectal Bleeding. Case Report

                      Gideon K. Kurigamba*, Vivian V. Akello, Asaph Owamukama, Irene Nanyanga

                      Juvenile polyps may also present with prolapse of the polyp from the anus, abdominal pain due to intussusception or may even be asymptomatic. All such polyps should be removed by colonoscopy or transanal resection.
                      Objective: To share the experience of Juvenile polyposis, at Bwindi community hospital Uganda.
                      Design and methods: These are case reports of two children second degree relatives, who presented with recurrent rectal bleeding for 4 months after every passage of stool, with prolapse of a mass and were managed at Bwindi community hospital
                      Results: These patients were all admitted for a total of two days in Hospital. Average hemoglobin was 11.5 mg/dl. Both had a preoperative colonoscopy that revealed a solitary polyp in the rectal canal. They both underwent Examination Under Anesthesia (EUA) and transanal polypectomy.
                      Conclusion: Juvenile Polyps (JP) are rare, but a key cause of rectal bleeding in children and in low resource settings, transanal polypectomy remains the treatment of choice.

                        Research Article Pages: 1 - 3

                        Visual Hallucinations in a Patient with Pons Ischemia and Bipolar Disorder Diagnosis-A Case Report with a Review of the Literature

                        Andrea Leone*, I. Mancinelli and F. Fiasche

                        Background: Visual hallucinations are disturbances of perception present in various pathologies. Peduncular hallucinosis is complex visual hallucinations involving animals or often terrifying people that occur after pontine injuries. In this case report we present the clinical history of a middle-age man who reported peduncular hallucinosis due to mild but numerous ischemic lesions in the pontine region. This is a peculiar condition as the literature reports PH for much more severe injuries. Case presentation: A 55-year-old Caucasian man with hypertension, dyslipidemia, carotid atheromatosis and a previous diagnosis of bipolar disorder was admitted to the psychiatry ward of the Sant'Andrea Hospital due to the appearance of a mixed mood state with psychomotor agitation, ideic acceleration, anguish, auditory hallucinations, severe anxiety, panic attacks, total insomnia, disturbances in concentration and suicidal ideation. During hospitalization, he had complex visual hallucinations. On MRI of the brain, there were numerous ischemic areas in the pontine paramedian ventral region. On audiometric examination, there was bilateral sensorineural hearing loss. The patient was discharged with Valproic Acid 1000 mg/day, Quetiapine 200 mg/day. After discharge he underwent a neuropsychological evaluation that showed a cognitive decline. Conclusion: There are various cases in the literature of pontine ischemias that have given simple and complex, terrifying and beautiful visual hallucinations. Patients generally had a normal state of consciousness, no delusions, and had sleep disturbances. Lesions of the pons involving the dorsal raphe nucleus result in the loss of ascending serotonin inhibition to the dorsal lateral geniculate nucleus. Consequently, an over-excited geniculate can generate visual hallucinations at the cortical level. These ischemias in the paramedian ventral pontine region may have damaged the nucleus of the acoustic nerve causing a bilateral sensorineural hearing loss and the nuclei of the lenticular formation which, through the serotinenrgic and dopaminergic dysregulation, gave rise to visual hallucinations. These visual hallucinations can be considered PH. Considering the cognitive impairment, assessed through neuropsychological assessment, and the cardiometabolic risk factors, we can also affirm that the previous psychiatric diagnosis of bipolar disorder could have delayed the neurological diagnostic investigations.

                          Research Pages: 1 - 3

                          Cecal and Ilial Intubation Rates in Colonoscopy; Comparative Study

                          Osamah Tahir Muslim* and Hasan Osamah Al-Obaidi

                          Background: Colonoscopy is considered to be the procedure of choice for both the diagnosis and treatment of large bowel diseases. Inspection of the whole colonic and distal portion of terminal ilial mucosa is usually feasible during colonoscopy.Colonoscopy is the best diagnostic tool to evaluate the large intestine and distal Ilium in patients complaining from bowel symptoms, anemia resulting from malabsorption, those with radiographic abnormalities of the colon, screening for colorectal carcinoma, after both polypectomy and cancer resection surveillance, surveillance in Ulcerative Colitis, and in those with suspicion of neoplastic masses. Quality examination of large bowel includes intubation of the whole colon and a thorough mucosal visualization. The investigators demonstrate that terminal ilium intubation is possible in endoscopy practice and at many times yields additional clinical details. Furthermore, it may be used as an indicator of colonoscopy completion.

                          Objectives: Is to estimate the rate of Cecal and Ilial Intubation in by a single well trained endoscopist as quality Indicator of colonoscopy and compare it with the same rates of heterogeneous group of endoscopists.

                          Patients and Method: This is a retrospective comparative study that estimate the rate of Cecal and Ilial Intubation in a Private Endoscopy Center in which all endoscopic procedures conducted by a single endoscopist who has fellowship in gastroenterology and compare it with the rates of a governmental center in which colonoscopy is done by five endoscopists including general surgeons, general physicians and trained in endoscopy as well as gastroenterologists who has gastroenterology fellowship. The study population included (442 patients); 245 males (55.42%) and 197 females (44.58%); ranging from 14 up to 85 years age.

                          Results: Overall Cecal and Ilial intubation rates were 88% and 47.5% Respectively; After considering cases of anatomic colonic obstruction and when the clinical indications don’t justify total colonic intubation; the adjusted rates were 49.2% & 50.8% for cecal & Ilial intubations respectively; and these figures were superior in comparison to the results of multioperator study in which the cecal intubation rate was 51.81% and the ilila intubation rate was 30.69%.

                          Conclusions: Cecal and Ilial intubation are important quality indicators for colonoscopy and in this study they are found to be superior in qualified gastroenterologist than in general surgeons & physicians; this result points to the importance of providing endoscopy units in Iraq with qualified well trained endoscopy personnel.

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