Effect of Intrathecal Hal.23

Sudan Med J 2011 December;47(3)

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Published by The Sudan Medical Association

Editor-in-Chief Mohamed El Makki Ahmed (El Rasheid) Associate Editor Tarik Elhadd Mohamed-Elbagir Khalafala Ahmed Assistant Editors Aymen Nasr Tarig Abdu Editorial Board El Zein A Karrar Abdel Raouf Sharfi Qurashi Mohamed Ali Suliman Salih Fedail Ahmed Al Safi Amal Mahmoud Mahadi Shamad Shaikh ElSiddig President of Sudan Medical Association Abdel Azim Kabalo General Secretary Babikir Gabir Kaballo Co-opted Members Sid Ahmed Elrasheid Yasir Mahgoub International Editors Mustafa Abdallah Mohamed - KSA Osman A Hamour - KSA Zein Al Shareef - KSA Frank Branicki - UAE Abu Baker Abdelgaleel Imam - USA Isam Eldein Abdallah Eltoum - USA Abu Baker Elameen Ahmed - UK Abdel Rahman A Omer - UK Ahmed Mudawi - UK Ibrahim Fahal - UK Peter Newman - UK Rayaz A Malik - UK

National Advisory Board Abdel Gadir Kadaru Abdelsalam Gerais Ahmed Hassan Fahal Ahmed Mohamed El Hassan Alaa Hassan Ahmed Amar El Tahir Bakri Osman Saeed Bushra Ahmed Doumi Dirderi El Jaily Salah Elsheikh Mahgoub Jaafer Hassan Abu Asha Mamoun MA Homeida Matthew Atem Aduol Mohamed Ahmed Abd Alla Mohamed Ahmed Hassan Mohamed Ahmed Ibn Ouf Mohamed El Hassan Baldo Mohamed Saeed Khalifa Mohamed Yosif Sukar Mustafa Idris Omer Ahmed Mirghani Osman Khalafalla Peter Makol Nhial Salah Ahmed Ibrahim Timothy Tellar Dohl Copyrights All rights reserved. No part of this publication may be reproduced, stored in a computer retrieval system or transmitted in any form or by any means without prior written permission from the publisher. Disclaimer Although every effort has been made to ensure the completeness and accuracy of the information published in this Journal, editors and authors cannot be held responsible for any errors that have inadvertently occurred before, during or after publication and shall not be liable under any circumstances what-so-ever for any damages suffered as a result of any errors, emissions, or changes.


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Aims and scopes Sudan Medical Journal is published by Sudan Medical Association, the official academic branch of Sudan Doctors Union. This is a peer-reviewed journal published 4-monthly. Its main objective is to reflect local scientific research in various aspects of medicine as well as regional and international relevant research. Basic scientific research, clinical practice, experiences that help in patient management are also welcome. Review articles, original articles, case reports are welcome. Local research in medical education and history of medicine in the Sudan will be considered for publication. Manuscripts must be solely submitted to this journal. All authors must sign approving the submitted version. Any conflict of interest must be stated clearly. Ethical clearance must be presented in relevant submission. Manuscript submission: only electronic version sent to this e mail addressed to the Editor-in-Chief will be considered [email protected]. Instructions for authors Manuscript All parts of the manuscript should be prepared in a double-spaced typewritten on size A4 paper. A covering letter signed by all authors must be forwarded. The format contains Title page With full names of all authors and the highest degrees and affiliations. The corresponding author both e mail address and fax number should be provided. Keywords 3 - 6 keywords should be provided. Abstract Original articles must have an abstract of not more than 300 words and structured with subheadings as follows: objectives, methods, results and conclusion. Arabic summary will be needed from the next issue.

Review articles are submitted with special arrangement with the Editor-in-Chief. Case reports are welcome and should not have more than 10 references. Introduction It should give a short concise overview of the current state of affairs with background information. It will explain the justification to do the work and points to the gaps that needs to be addressed. This will state the main objectives of the work. Patient & Methods A clear description of the methodology used as well as the subjects selection. Inclusion and exclusion criteria should be mentioned. Results Can be presented in form of text, tables and figures. Avoid repetition of data in the three forms. Tables and figures should be accompanied with a clear descriptive legends. Discussion This part should focus on discussing the results obtained. Avoid repetition of the results. This part ends with a conclusion summarizing the final outcome of the study. References Vancouver style (References quotation number within brackets should be followed). Up to 6 authors should be all provided. If more than 6 authors, then write the first three authors and et al.

e.g. Journals Ahmed BG, Ali HJ, Hassan CG. Malaria in Khartoum. Sudan Med J 2008;23:23-7.

Books Hamid GH, Hasan MG. Mycetoma. Khartoum: University Press;2008.p.23-34. Chapter in a book Osman MD, Mohamed RF, Clinical representation of malaria. In: Malaria in the Sudan. Khartoum: University Press; 2001.p.25-45.


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Table of Contents

Aims and Scope ................................................................................................................................ i

Review Articles Lung cancer: review of recent advances

Omer Abdel Ghayoum BM Khair............................................................……….……….......125 Parkinson’s disease: more than a movement disorder

Abdelnassir M Abdelgabar............................................................………...........………........138 Original Articles

Clinical ability to accurately identify significant neonatal jaundice Hanadi Rimawi, Osama Abu-Salah..........................................................................................147

Effect of intrathecal morphine plus fentanyl versus pethidine on labor pain Hadab A Mohamed, Ehssan M Ziyada.................................................................................... 153

Fracture of the penis at El Obeid Hospital, Western Sudan; review of seven consecutive cases

El Bushra A Doumi, Mohamed I Mohamed, Mohamed Y Bakheit, Mohamed B Bashier......160

Case Reports A rare presentation of xanthogranulomatous appendicitis and caecal angiolipoma

in the same patient Tasabeeh A Omer, Lamymaa AM EL Hassan, Ahmed M EL Hassan, Ahmed H Fahal........ 165

A rare cause of nasogastric tube obstruction Abdulhadi M Elbashir, Mutasim Abdalla................................................................................ 169

Cardiac tamponade following sternal acupuncture Elnazeer O Ahmed, Davy Cheng, Daniel Bainbridge............................................................. 171

Massive hydrothorax from a ventriculopleural CSF shunt: a case report and review of the literature El Fatih MB El Malik, Mohammed EA Elameen, Ahmed AF Khalid.................................... 174 Letters to the Editor

Short communication on differences in prescription of sedative and analgesics Sohel MG Ahmed and Author’s Response Hadab A Mohamed............................................180

Towards a less paternalistic approach to patient care in Sudan Elnazeer O Ahmed....................................................................................................................183

Short Communication A commentary on the “short communication” on the 90th anniversary of Omdurman Midwifery Training School (OMTS)”: where are we now?

Mohamed H Baldo....................................................................................................................185 Journal Review

International journal harvest: interesting topics Mohamed-Elbagir Khalafalla Ahmed.......................................................................................190


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Review Article

Lung cancer: review of recent advances

Omer Abdel Ghayoum BM Khair, MB, MSc, PhD, FRCPE, FRCP

Consultant Physician and Senior Clinical Lecturer, University of Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham, United Kingdom

الدكتور عمر عبدالقيوم بابكر محمد خير

لقد أصبح سرطان الرئه والوفيات المتصله به فى إزدياد مضطرد فى جميع أنحاء العالم

ويعكس ذلك الى حد كبير الزيادة المستمرة فى معدالت التدخين حيث أن عامل خطره الرئيس ھو التدخين ن بين الرجال والنساء فى العالمھذا المرض ھو السبب االول فى الوفيات من السرطا

م تسبب فى وفاة ما يقارب من مليون مصاب2000وفى العام من المرضى المصابين بسرطان الرئه يتم تشخيصھم فى حاالت متقدمة يكون المرض قد إستفحل وإستعصى عالجة مما يتعذر معه % 75ما يقارب من

مستحيالعالجھم ويكون العالج والشفاء منه صعبا إن لم يكن ورغما من التطور المستمر فى طريقة عالج السرطان إال أن معدالت البقاء على قيد الحياه ومن يكتب هللا له

بالنسبة لجميع المرضى المصابين بھذا المرض% 16 الى 10 سنوات فى المتوسط بين 5عمرا لمده طان الرئه بعد تشجيع االقالع عن التدخين وھو أمر ضرورى حيث أنه يتسبب فى أكثر من الوقاية من ھذا المرض ھى االستراتيجية االكثر فعاليه للحد من سر

من حاالته% 90التشخيص المبكر للمرض وتصنيفة تصنيفا صحيحا ھو االمل الوحيد لتحقيق نتائج عالجية أفضل

Abstract Lung cancer and lung cancer-related deaths have been increasing in epidemic proportions worldwide, largely reflecting increased rates of smoking. This disease is the leading cause of cancer-related death among men and women globally with an estimated 1 million deaths in the year 2000. Nearly 75% of patients with lung cancer present with symptoms due to advanced local or metastatic disease that is not amenable to cure. Despite advances in therapy, five-year survival rates average between 10-16% for all individuals with lung cancer. Prevention, rather than screening, is the most effective strategy for reducing the burden of ____________________________________ Corresponding author Omer Abdel Ghayoum BM Khair MB, MSc, PhD, FRCPE, FRCP Consultant Physician and Senior Clinical Lecturer, University of Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham, United Kingdom Email: [email protected]

lung cancer. The promotion of smoking cessation is essential, as cigarette smoking is felt to be causal in almost 90% of all cases. Early diagnosis and correct staging is the only hope for a better treatment outcome. The emergence of newer diagnostic techniques and novel therapies has led to a renewed excitement in lung cancer management. Adoption of a new staging system, novel therapeutic targets and combination therapy has shown promising success. This review summarizes important recent clinical advances that could have a significant impact for the future care of patients with lung cancer. Keywords: lung cancer, NSCLC, SCLC, EBUS, EUS, PET, chemotherapy, molecular therapy. Introduction Lung cancer is the most common cause of cancer deaths worldwide. The number of death each year due to lung cancer is more than the total number of cancer deaths from breast, colon, and prostate cancer added together.


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Review Article Lung cancer Omer Abdel Ghayoum

One of the most disturbing trends in lung cancer is the explosion in rates in countries of the developing world. In 1985, it was estimated that there were 921,000 lung cancer deaths worldwide, an increase of 17% from 1980(1). The International Agency for Research on Cancer in France found that the rates of lung cancer in Africa in the early 1990s were similar to those in the United States in the 1930s, at about 5/100,000. By 1999, the rate of lung cancer in males of developing countries was 14/100,000 and on the rise, compared with a rate of 71/100,000 in developed countries, which continues to decline. These rates may actually be underestimates of the true rates of lung cancer, because many cases may go undiagnosed or under-reported in areas where health care is not readily available(1,2). In this review, the current practices for the diagnosis and staging of lung cancer will be discussed and broadly describes treatment strategy of this disease. Screening for lung cancer Clinical outcome for lung cancer is directly related to stage at the time of diagnosis, ranging from over 60% five year survival for stage I disease, to less than 5% for stage IV disease. In addition, within early lung cancers (stage I) there is a relationship between tumour size and survival(3). While the potential for screening to detect early cancers may increase the overall cure rate and allow more limited surgical resection to achieve cure, an overall decrease in mortality and morbidity remains uncertain. Imaging techniques and cytological analysis of sputum have been the focus of screening studies for lung cancer. However, systematic screening is not currently recommended by any major medical professional organization. The current position of the American Cancer Society and the U.S. Preventive Services Task Force is that there is no role for lung cancer screening, even in high-risk individuals(4). This position is based on the

results of five randomized, controlled trials that suggest that neither chest radiography nor sputum cytology satisfies the primary criterion of a beneficial screening test: reduction in lung cancer mortality(5,6). There continues to be ongoing debate about the interpretation of these studies. One deficiency is that most of these studies did not include a “no screening” arm. Others have argued that the sample size of the studies was inadequate. The Mayo Lung Project and the Czechoslovakian studies were powered to detect a 50% reduction in lung cancer mortality in the screened group and could have missed detecting a 20% to 30% reduction(4,7). The lack of a clear result from chest X-ray screening and the refinement of CT scanning techniques have led to the evaluation of CT for lung cancer screening(8). To date, results are only available from observational cohort studies(9,10). Randomized trials are ongoing, but available baseline data offer no compelling evidence in favour or against the use of low-dose spiral computed tomography (LDCT) screening for lung cancer(11). Presentation The symptoms of lung cancer are usually nonspecific, thereby delaying the diagnoses and leading to an advanced stage at the time of diagnosis. Cough is the commonest symptoms (75%) followed by chest pain in 25% to 50% of patients at the time of presentation(12,13). The latter is usually related to involvement of the pleura, but can be related to extension into the mediastinum or chest wall. Dyspnea is frequently a complaint occurring in half of all new patients at presentation(12). A partial list of the reasons for dyspnea related to lung cancer includes pulmonary embolism, superior vena cava syndrome, deconditioning, reactive airway disease, endobronchial obstruction with tumor, prior obstructive pneumonia, haemoptysis, hemorrhage, malignant pleural effusion, and extrinsic compression of the


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airway by tumor. Haemoptysis in a smoker should always raise the suspicion of lung cancer. Weight loss, a nonspecific symptom, in the right clinical setting should raise the suspicion of both lung cancer and metastatic disease. Weight loss alone has been correlated with an advanced presentation and poor outcome from lung cancer. Lung cancer staging Correct staging of patients with lung cancer is critical since it affects treatment options and predicts survival. It is intuitive that early-stage disease has a much better survival than late-stage disease. The treatment options for lung cancer have now evolved so that treatment for patients in different stages is vastly different. The staging of non small cell lung cancer (NSCLC) using the tumor-node-metastasis (TNM) classification underwent revision in 1997 and has recently undergone a major revision(14). The new staging system is remarkable in that it is based on over 100,000 cases of lung cancer from 23 institutions, 12 countries, and 3 continents. The data are robust, internally validated, and externally validated against the Surveillance Epidemiology and End Results (SEER) cancer registry(14). Whereas the TNM staging system is applied to NSCLC, a more simplified version is employed for patients with small cell lung cancer. In this classification, patients are classified as having limited or extensive disease. Limited disease (LD) is disease limited to one hemithorax, although it can include supraclavicular and mediastinal lymphadenopathy. Extensive disease (ED) is any disease outside of the hemithorax. The implication in this classification is that LD is treated with chemotherapy and radiotherapy and ED is treated with chemotherapy alone(15). Malignant pleural effusion can technically be categorized as LD in the staging classification for small cell lung cancer if the patient

otherwise meets criteria. However, for all intents and purposes, patients with malignant pleural effusions and small cell lung cancer have the same characteristics as those with ED, and the large cooperative group trials have treated them as such. Staging techniques Chest radiography The majority of lung cancers are detected initially by plain chest radiograph. This modality is readily available, inexpensive, and provides a lot of information with minimal radiation dose. However, it is insufficient for staging and insensitive measure of mediastinal lymph node involvement with cancer. Hence, most patients undergo CT scan of the chest unless they are so debilitated that no further evaluation or treatment is planned. Despite their limited utility in staging, chest radiographs have an important role in the assessment of a lung nodule or mass. Since patients are more likely to have had a chest radiograph than any other type of chest imaging, comparing a current chest radiograph to prior radiographs is often a good way to determine whether a lung lesion is new, enlarging, or stable. A new or enlarging lesion is more likely to be malignant than a lesion whose size and appearance have been stable for years. Computed Tomography of the chest (CT) Most patients who present with possible lung malignancy will require staging contrast CT scanning of the chest and upper abdomen. This investigation is helpful in defining the size, location, and characteristics of the primary mass (e.g., smooth-bordered, speculated, calcified), the presence or absence of lymphadenopathy and, the presence of abnormalities in the liver and adrenal glands. In addition, the bony structures of the thoracic cavity can also be evaluated by chest CT. A recent met-analysis assessing the performance characteristics of CT scan for staging the mediastinum including over 5000 evaluable patients in 35 studies(16). The


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median prevalence of mediastinal metastasis was 28% (range, 18 to 56%) and the pooled sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were 51% (95% confidence interval [CI], 47 to 54%) and 86% (95% CI, 84 to 88%), respectively. The corresponding positive and negative likelihood ratios were 3.4 and 0.6, respectively, suggesting that CT scanning has a limited ability either to rule in or exclude mediastinal metastasis. Based on the currently available data approximately 40% of all nodes that are deemed to be malignant by CT scan criteria are actually benign. In contrast, nearly 20% of all nodes that are deemed to be benign by the same criteria are actually malignant. This suggest that no node size that can reliably determine tumor stage and operability. Nonetheless, CT scanning continues to play an important and necessary role in the evaluation of these patients. This conclusion is supported by the most recent American Thoracic Society/European Respiratory Society statement(17) on the pretreatment evaluation of NSCLC and British Thoracic Society guidelines(18) on the selection of patients with lung cancer for surgery, both of which recommend CT scanning for the evaluation of the mediastinum and guides the selection of nodes for biopsy by mediastinoscopy or needle aspiration. CT can also be helpful in the evaluation of pleural effusion in patients with lung cancer and whether or not nodules or masses are present on the pleural surface. Positron Emission Tomography (PET) One of the most recent addition to the staging armamentarium for the evaluation of lung cancer is PET scan. With the image created by the biologic activity of neoplastic cells, PET is a metabolic imaging technique based on the function of a tissue rather than on its anatomy. Lung cancer cells demonstrate increased cellular uptake of glucose and a higher rate of glycolysis when compared with normal cells.

The radiolabeled glucose analogue [18F] fluoro-2-deoxy-d-glucose (FDG) undergoes the same cellular uptake as glucose but, after phosphorylation, is not further metabolized and becomes trapped in cells(19). Accumulation of the isotope can then be identified using a PET detector. In two well-performed studies that evaluated the use of PET in the preoperative setting for lung cancer(20,21), nearly 20% of patients were up or down staged by PET evaluation. Integrated PET/CT is a modality that combines PET and CT, thus providing both anatomic and metabolic information. As with any test, false positive and false negative results occur with FDG-PET. False positive results are generally due to metabolically active infectious or inflammatory lesions, and can produce substantial FDG accumulation. Examples include rheumatoid nodules, active tuberculous and fungal granulomas. In regions where infections with tuberculosis or endemic fungi (e.g. histoplasmosis, coccidio-idomycosis, blastomycosis) are common, FDG-PET may have a lower specificity(22). Additionally, brown adipose tissue in adults at the base of the neck, in the supraclavicular region, and in the superior mediastinum can exhibit strong uptake of FDG(23). Normal or hyperplastic thymic tissue can be glucose-avid, which can lead to high uptake of FDG in the anterior mediastinum(24). Tumors with relatively low metabolic activities may fail to concentrate enough FDG to be detected, as has been reported with some broncho-alveolar carcinomas, well differentiated adenocarcinomas, and carcinoid tumors(24-26). Rare metastatic lesions from renal cell, prostatic, or testicular carcinomas that do not concentrate detectable amounts of FDG have also been noted. Small tumors (<7 mm in diameter) may not be detected because of the small amount of FDG uptake(27,28).


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Magnetic Resonance Imaging (MRI) The role of magnetic resonance imaging (MRI) in the diagnosis and staging of lung cancer is limited by poorer spatial resolution, as compared with that of CT and affected by cardiac and respiratory motion artifacts. The magnitude of these limitations has diminished with newer MRI scanners. MRI may be helpful in the diagnosis of brain and adrenal metastasis, and in the assessment of mediastinal or chest wall invasion, as well as spinal cord involvement. MRI is superior to CT in assessing the pericardium, heart, and great vessels. Coronal images are useful in demonstrating the extent of tumor in the subcarinal region, aortopulmonary window, and superior vena cava. MRI is also valuable in assessing neurological involvement in Pancoast tumours and the identification of tumour rather than osteoporotic collapse in wedge fractures of the spine in lung cancer patients. This imaging modality may be used instead of CT in patients who have had previous adverse reactions to iodinated contrast media and in patients with significant renal impairment, as it does not require the use of intravenous enhancement with iodinated contrast media. Bone scanning Bone scan is indicated in patients who have focal bone pain or elevated alkaline phosphatase that are suspicious for bone involvement. Bone metastases can be identified with a technetium 99m MDP nuclear medicine scan. Such bone scans were once common, but they have been largely displaced by PET for two major reasons. First, PET detects bone metastases with similar sensitivity and better specificity than bone scans(20-21). Second, PET has the added advantage of being able to identify metastases in the visceral organs. Sputum cytology Sputum cytology has long been used as screening or diagnostic modality for early

detection of lung cancer. However, these methods have limitations in sensitivity, specificity or utility to some degree. In recent years, researchers all over the world have done lots of work on finding and identifying biomarkers for the early diagnosis of lung cancer. Three samples are commonly required giving a sensitivity and specificity of 66% and 99%, respectively(29). Central lesions are more likely to yield positive cytologic results than are peripheral lesions. Patients with haemoptysis with or without a mass on chest radiographs should have sputum cytology obtained. Transthoracic Needle Aspiration (TTNA) Transthoracic needle aspiration, usually under CT or fluoroscopic guidance, helps to establish a histological diagnosis and stage known or suspected cancer. The sensitivity and specificity of TTNA are 90% and 97%, respectively(29-31). Generally, if a lesion is less than 3 cm in size and lateral to the midclavicular line, bronchoscopy would not be the diagnostic procedure of choice. TTNA is an easy and relatively safe procedure but carries a risk of pneumothorax reported at 22% to 45%(30,31). Risk factors shown to increase the incidence of pneumothorax include the presence of emphysema, a smaller lesion size, and a greater depth of needle penetration from the pleural surface to the edge of the lesion. Fiberoptic bronchoscopy Bronchoscopy has a crucial role in assessment and biopsy of endobronchial tumours and sampling of mediastinal lymph nodes through transbronchial needle aspiration (TBNA). About 50% of patients with advanced-stage lung cancer will present with central airways involvement either by bulky endobronchial disease, extension into the airways, or extrinsic compression of the airways by the tumor or by lymphadenopathy. These patients commonly present with shortness of breath, unilateral wheezing, haemoptysis, and cough. Endobronchial lesions can be visualized easily


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and biopsied through a flexible bronchoscope. The yield with three or more biopsies is nearly 100% for centrally located lesions(32). Data from 4507 patients in 35 studies revealed that central endobronchial biopsies provide the highest sensitivity (74%), followed by brushings (61%) and washings (47%). The combination of these techniques provides a diagnosis in 88% of cases(29). Endoscopic ultrasound (EUS) Due to its superior ability to sample the posterior mediastinum through the esophageal wall, Endoscopic ultrasound (EUS) is a modality that has significantly impacted lung cancer staging. Pooled analysis of more than 1000 patients with lung cancer and mediastinal adenopathy in whom EUS with fine-needle aspiration is performed showed a sensitivity and specificity of 84% and 99.5%, respectively(33). Additionally, EUS has been studied in patients with known lung cancer without apparent enlarged mediastinal lymph nodes on CT, and it has detected mediastinal involvement (stage III or IV disease) in up to 42% of cases(34). Furthermore, using this modality it is possible to stage lung cancer from locations outside the mediastinum. Using EUS the left lobe of the liver, a substantial part of the right lobe of the liver, and the left adrenal gland can be identified and sampled in 97% of patients(35-

36). Endobronchial Ultrasound (EBUS) Endobronchial ultrasound with fine-needle aspiration (EBUS-TBNA) is a new technique which enables diagnosis of lung tumors and the assessment of mediastinal and hilar lymph nodes. This is a minimally invasive procedure which can be performed during bronchoscopy session on an outpatient basis using local anesthesia and conscious sedation, has a high sensitivity and specificity (90% and 100%, respectively)(33). It can be used to sample the high mediastinal, paratracheal, and subcarinal lymph nodes as well as the hilar lymph nodes. With a high diagnostic yield, EBUS renders

more invasive mediastinoscopy unnecessary. Complications are uncommon, especially when sampling is performed real-time which permits the sampling of lymph nodes that are smaller than 5 mm in short axis or near major blood vessels. Mediastinoscopy, anterior mediastinotomy and thoracoscopy Mediastinoscopy remains the gold standard for invasively staging the mediastinum in patients with known or suspected lung cancer. It allows direct inspection and biopsies of lymph nodes and masses in the superior mediastinum with a reported sensitivity of 78%, and specificity of 100%(33). This procedure provides large tissue samples for diagnosis from the paratracheal, and anterior subcarinal region and often performed prior to thoracotomy. An extended cervical mediastinoscopy can be carried out to reach aortopulmonary and para-aortic lymph nodes. As with any surgical procedure, mediastinoscopy has risks and limitations. It requires general anesthesia, with a morbidity of 2% and a mortality of 0.08%(33). Potential complications include pneumothorax, haemorrhage, recurrent laryngeal or phrenic nerve paralysis, injury to trachea, oesophagus or thoracic duct. The decision to perform mediastinoscopy or mediastinostomy for lung cancer staging remains a variable one that depends on local resources and personal experience. Video-assisted thoracoscopic surgery, is a valuable tool for the evaluation of pleural and lung abnormalities. Treatment of lung cancer Treatment of non small cell lung cancer The overall 5-year survival for patients diagnosed with lung cancer is a dismal 14%(37), and has not changed substantially since the 1980s. The survival curves vary by stage, with earlier-stage lung cancer patients enjoying a much better survival than do patients with late-stage disease. Lung cancer treatment is based on the disease stage and


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patients’ performance status. To improve outcomes, there has been a shift towards multimodality therapy (surgery, chemotherapy, radiotherapy, and molecular targeted therapies)(38,39). Hence a multi-disciplinary approach becomes mandatory and has currently been incorporated in a number of national and international guidelines. In these settings patients are evaluated by the major disciplines involved in their care. This “tumor board” includes chest physicians, thoracic surgeons, radiologists, pathologists, oncologists, as well as nursing and palliative care(40). Adoption of this approach will usually ensure that patients receive optimal treatment and can be considered for enrollment in clinical trials. In broad terms, early-stage lung cancer (Stage I) is treated with surgery alone. Stage II lung cancer is commonly treated with surgery followed by adjuvant chemotherapy. Locally advanced lung cancer (stage IIIA and B) is treated with a combination of chemotherapy and radiotherapy. Supportive care alone or with chemotherapy is usually indicated in the advanced and metastatic disease (Stage IV). However, there are important exceptions to these general rules. For example patients with Stages I, II or III NSCLC who have good performance status (WHO 0 or 1) and whose disease can be encompassed in a radiotherapy treatment volume without undue risk of normal tissue damage would be most suitable for radical radiotherapy. Prognostic factors for lung cancer Analysis of large databases evaluating more than 5,000 patients with inoperable tumor considered seventy-seven prognostic factors(41). The strongest predictors of survival are good performance score (Karnofsky scale), lower extent of disease (stage), age, and absence of weight loss. Some reports have shown female gender to be a predictor of better survival, but this varies between studies. Performance score and the presence or absences of symptoms are predictors of

outcome even with resectable early-stage disease(42,43). Absence of smoking or smoking cessation has been associated with improved survival. Moreover, there seems to be an inverse correlated with survival in the maximal standard uptake value of the primary tumor on PET scanning(44). In more recent years, there have been numerous reports that various molecular markers are associated with outcome. Some of the best known markers include K-Ras, epithelial growth factor receptor (EGFR), p53, p16, and Bcl-2. However, in many instances, the results are conflicting about the prognostic significance of these individual molecular markers(45). In a meta-analysis, K-Ras mutations were associated with poorer survival, especially in adenocarcinoma where the hazard ratio was 1.59 (95% CI 1.26–2.02)46). Molecular targeted therapy for lung cancer Although chemotherapy has recently produced promising results as neoadjuvant and adjuvant strategies for early-stage patients(47,48), treatment outcomes for NSCLC patients must still be considered disappointing. Study and testing of several molecular targets for NSCLC treatment has recently been facilitated by advances in the knowledge of tumor biology and mechanisms of oncogenesis. Targeted therapies are designed to interfere with specific aberrant biological pathways involved in tumorigenesis. To date, only a few of these new agents can offer hope of a substantial impact on the natural history of the disease, and negative results are more commonly reported than positive ones. Nevertheless, clinically meaningful advances have already been achieved. In chemotherapy-refractory advanced NSCLC patients, gefitinib (Iressa) and erlotinib (Tarceva), two epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), represent a further chance for tumor control and symptom palliation for a


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subset of patients otherwise eligible only for supportive care(49,50). In chemotherapy-naive advanced NSCLC patients, the combination of the anti–vascular endothelial growth factor (anti-VEGF) monoclonal antibody bevacizumab (Avastin®) with chemotherapy has been demonstrated to produce better survival outcomes than chemotherapy alone(51). In two large phase III trials named Iressa NSCLC Trial Assessing Combination Therapy (INTACT)-1 and INTACT-2, no survival benefit in favor of platinum-based polychemotherapy (cisplatin plus gemcitabine or carboplatin plus paclitaxel) plus gefitinib over chemotherapy alone was reported(52,53). As observed for the other EGFR-TKI gefitinib, the combination of erlotinib with platinum-based polychemotherapy (cisplatin plus gemcitabine or carboplatin plus paclitaxel) has been demonstrated to confer no survival advantage over chemotherapy alone in two large phase III randomized trials, named TALENT and TRIBUTE(54,55). Based on the promising results of a previous phase II randomized trial(56), a very recent randomized phase III trial compared the combination of bevacizumab with chemotherapy (carboplatin and paclitaxel) versus chemotherapy alone in the treatment of advanced non-squamous NSCLC(51). Patients with squamous histology were excluded because of the risk for grade 5 hemoptysis reported in previous studies. In more than 850 enrolled patients, a statistically significant advantage in median survival was reported in favor of the combination of bevacizumab plus chemotherapy (12.5 months vs. 10.2 months in the bevacizumab and chemotherapy-alone arms, respectively; p = .0075). In addition, the response rate (27% vs. 10%; p < .0001) and progression-free survival time (6.4 months vs. 4.5 months; p < 0.0001) favored the bevacizumab arm. Small Cell Lung Cancer (SCLC) Small cell lung cancer (SCLC) is typically

characterized by its rapid doubling time, high growth fraction, and the early development of widespread metastases. Usually it presents as a centrally located lung mass and can be associated with obstructive pneumonia. SCLC accounts for about 15% to 20% of all lung cancers. This cell type has the strongest association with cigarette smoking and is rarely observed in a never-smoker. It is the cell type most commonly associated with paraneoplastic syndromes such as the syndrome of inappropriate (excessive) antidiuretic hormone secretion (SIADH), ectopic corticotropin secretion, Lambert-Eaton myasthenic syndrome (LEMS), and sensory neuropathy. This tumour rarely (5%) present as a solitary pulmonary nodule/mass. It is generally staged according to the old Veterans Administration Staging System and classified as limited (LD) or extensive (ED) stage. LD-stage disease is confined to one hemithorax, the mediastinum, and the ipsilateral supraclavicular lymph nodes. It is a disease that can be safely encompassed within one radiation portal without irradiating too much normal lung. ED stage is any disease spread beyond these sites. Malignant pleural effusion or disease extending to the contralateral supraclavicular or hilar lymph nodes is generally considered to be ED. Approximately one third of patients have LD at diagnosis. LD-SCLC has a response rate of 70% to 80% with standard chemotherapy and thoracic radiotherapy, and a complete clinical response of 50% to 60%. In a meta-analysis of trials with chemotherapy alone versus combined chemotherapy and thoracic radiotherapy, survival was significantly better with combined-modality therapy(57). Chemotherapy usually consists of a platinum-based regimen. The two most commonly used regiments are etoposide and cisplatin or etoposide and carboplatin. Chemotherapy beyond four to six cycles has not been shown


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to prolong survival. Although considered highly responsive to chemotherapy and radiotherapy, SCLC usually relapses and becomes refractory to treatment within one to two years. The median survival time for LD-SCLC is now 18 to 20 months when patients are treated with concurrent chemoradiotherapy, and 20% to 25% of patients will be alive at 5 years(58-

60). By contrast, the median survival time for ED-SCLC is 8 to 9 months, with 10% of patients or fewer alive at 2 years(61,62) there are virtually no 5-year survivors with ED-SCLC. In the unusual case of SCLC that presents as a peripheral nodule, the treatment of choice is surgical resection followed by adjuvant chemotherapy and possibly sequential thoracic radiotherapy. Careful preoperative staging should be performed in these individuals to rule out metastatic disease. Pre-resection mediastinoscopy should also be performed. If there are mediastinal node metastases, then surgery should be abandoned, and the patient treated with concurrent chemoradiotherapy. Five-year survival for peripheral SCLC that is treated with surgery and adjuvant therapy is approximately 30% to 40%. Prophylactic cranial irradiation (PCI) is an area of controversy. Despite no agreement on optimal dose and possible neuropsychological sequelae, most oncologists recommend PCI in patients who achieve a complete remission with initial treatment. The reasons being that if a patient with SCLC achieves a complete remission, and then there is a 50% chance of development of cranial metastasis within the next 2 years. A meta-analysis of seven randomized trials of PCI versus no PCI for patients in complete remission reported an observed beneficial effect after PCI, with a 5.4% increase in absolute survival (20.7% vs. 15.3%) at 3 years(63). When patients relapse after initial therapy, the median survival is 3 to 4 months. There are no cures with second-line therapy. If a patient has

been off treatment for 6 months or greater, then it is reasonable to use the same agents that he or she received initially. If initial therapy did not include a platinum agent, then second-line therapy should be with a platinum-containing doublet. Palliative care Early integration of palliative care with standard oncologic care in patients with advanced lung cancer resulted improved survival by few weeks and a clinically meaningful improvements in quality of life and mood. Previous data have shown that a lower quality of life and depressed mood are associated with shorter survival among patients with metastatic cancer(64,65). Early integration of palliative care for patients with advanced disease is a clinically meaningful and feasible care model that has effects on survival and quality of life(66,67). This care model offers great promise for alleviating distress for patients with advanced disease and carers, and address critical concerns regarding the use of health care services at the end of life. Key Messages Lung cancer is the leading cause of cancer-related death and clinical outcome is directly related to stage at the time of diagnosis. Non-invasive diagnostic and staging techniques has recently expanded to include PET, MRI, EBUS, and EUS, reducing the need for invasive procedures. There is no role for lung cancer screening. NSCLC Stage I is treated with surgery alone. Stage II lung cancer is commonly treated with surgery followed by adjuvant chemotherapy. Locally advanced lung cancer (Stages IIIA and B) is treated with a combination of chemotherapy and radiotherapy. Supportive care alone or with chemotherapy is usually indicated in Stage IV. Promising novel targeted therapies designed to interfere with tumorigenesis, are currently been evaluated.


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Review Article

Parkinson’s disease: more than a movement disorder

Abdelnassir M Abdelgabar, FRCP Consultant Physician& Geriatrician, UK

عبد الناصر محمدين عبد الجبار.د

استشاري امراض الباطنية وامراض المسنين حدةالمملكة المت

.العالمات الحركية عند مصابي الشلل االرتعاشي عرفت منذ فترة طويلة كما تم دراستھا كثيرا مقارنه بالعالمات غير الحركية

ھذه العالمات غير الحركية تسود المراحل المتاخرة في الشلل االرتعاشي ولكنھا كذلك يمكن ان تكون اول عالمة من عالمات المرض عند بعض المرضي .ي ذات اثر سلبي كبير علي نوعيه حياة المريضوھ

. علي االطباء المھتمين بعالج ھذا المرض االھتمام الخاص بھذه العالمات .فاالكتشاف المبكر لھذه العالمات قد يساعد في التدخل العالجي المبكر والذي قد يساعد في تحسين نوعيه حياة المريض وتقليص درجة االعاقة

.مبكر لھذه العالمات قد يساعد في تحديد الشرائح ذات القابلية العالية لالصابة بمرض الشلل االرتعاشيكذلك االكتشاف ال

Abstract The classical motor symptoms of Parkinson’s disease has long been recognized, studied and researched. Recently, more interest is shown in non-motor symptoms of Parkinson’s disease due to their impact on patients’ quality of life (QOL). They usually dominate the advanced stages of Parkinson’s disease, but can as well predate the motor symptoms. Awareness of physicians with these symptoms is needed, not only for early intervention to avoid their negative impact on QOL, life expectancy, but these symptoms, may also give clues to early diagnosis of Parkinson’s disease in at risk population. Keywords: Parkinson’s disease, non-motor symptoms, sleep disorders Introduction The diagnosis of Parkinson’s disease (PD) has long been based on its motor features. Bradykinesia, rigidity, tremors and postural instability are the corner stones for the diagnosis of PD. These motor symptoms of PD are extensively studied and researched resulting in better understanding of its pathophysiology, improved diagnostic ________________________________ Corresponding author Abdelnassir M Abdelgabar FRCP Consultant Physician& Geriatrician, UK Email: [email protected]

accuracy and development of robust rating scales and treatment strategies. Recently, more attention and emphasis is shifting towards highlighting the non-motor symptoms (NMS) of PD. Indeed, these symptoms dominate the clinical presentation of late stages PD, but can of course predate the diagnosis of PD. They remain poorly understood compared to the motor symptoms, directly resulting from dopamine deficiency, as a consequence of degeneration of the substantia nigra. The understanding and recognition of these symptoms is of paramount importance since they contribute to poor quality of life, severe disability and even shortened life expectancy. Scale of the problem Large range of symptoms comprises the NMS of PD (Table 1). The prevalence of NMS as a whole is inadequately documented due to lack of community powered based studies on prevalence, effect and treatment. NMS of PD such as bowel and urinary symptoms, sleep disorders and erectile impotence might not be brought to the attention of health care professionals. This is because patients are embarrassed or unaware that these symptoms are linked to PD(1). This


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Review Article Parkinson’s disease Abdelnassir M Abdelgabar

under recognition of these symptoms can have social and therapeutic implications as these symptoms can adversely progress if left untreated, further worsening the quality of life. This can also lead to frequent hospitalization and institutionalisation increasing the cost of care for these patients(2). Table 1: Non-motor symptoms of PD

Neuropsychiatric symptoms

Depression, apathy, anxiety, anhedonia, hallucinations, illusions delusions, dementia, obsessional behaviour, confusion, panic attacks

Sleep disorders Restless leg syndrome and periodic limb movement, rapid eye movement (REM) sleep behaviour disorder and REM loss of atonia, non-REM-sleep related movement disorders, excessive daytime somnolence, vivid dreaming, insomnia, sleep disordered breathing

Autonomic symptoms

Bladder disturbances, urgency, nocturia, frequency, sweating, orthotastic hypotension falls, coat hanger pain, sexual dysfunction, hyper sexuality, erectile impotence, dry eyes

Gastrointestinal symptoms

Dribbling of saliva, dysphagia, reflux, constipation, unsatisfactory voiding of bowel, faecal incontinence

Sensory symptoms

Pain, paraesthesia, olfactory disturbance, visual disturbance

Other symptoms

Fatigue, hiccups, seborrhoea

Though NMS of PD occurs mainly in advanced stages of PD, some studies have shown that in up to 21% of PD patients these symptoms may predate the motor symptoms by more than a decade(3). Symptoms more likely to precede the motor symptoms are olfactory problems; depression, constipation and rapid-eye movement (REM) sleep behaviour disorder (RBD). Such a presentation can lead to inappropriate referrals and hence delayed diagnosis and treatment(4). The burden of the spontaneous or de novo NMS of PD can be exacerbated by the frequently induced iatrogenic NMS as side

effects of anti Parkinsonian treatment these include postural hypotension, hallucinations and sleep problems. Pathophysiology of NMS Although understanding of the neuroanatomical and neurochemical changes in PD continued to improve, the exact pathophysiology of NMS in PD remains speculative. The old perception that neurodegeneration of dopaminergic cells in the SN herald the pathological process in PD has been challenged by Braak and colleagues(5). Indeed, the motor symptoms of PD are overt when there is considerable loss of dopaminergic neurons in SN pars compacta. However, NMS predating the motor features of PD reflect the progression of lewy pathology in PD(5). A six-stage pathological process concept has been suggested by Braak and colleagues(5) as follows: Braak stage 1 The degeneration of the olfactory bulb and the anterior olfactory nucleus, clinically resulting as problems in the sense of smell. Braak stage 2 The progression of the Lewy pathology to lower brain stem; these areas are involved in the sleep - awake cycles and autonomic functions. In this area, some brain stem nuclei such as raphe nucleus (serotonin), locus coeruleus (norepinephrine) and the pedunculopontine nucleus are involved and thought to be major causes in REM sleep behavioural disorder (RBD) and visual hallucinations. Medullary nuclei are also important in controlling autonomic functions(6). Braak stages 3 and 4 Neurodegenerative changes affect SN, mid brain and forebrain. This is the stage when the motor symptoms of PD are clinically recognisable. Braak stages 5 and 6 These stages correlates with the presence of lewy bodies in the cerebral cortex and limbic


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structures. In these stages patients may manifest neuropsychiatric symptoms such as anxiety, depression, cognitive problems and visual hallucinations. Axons from the main dopaminergic areas in the basal ganglia (BG) project in an organised pattern forming sensorimotor, associative and limbic pathways with inputs in the subthalmic nucleus, the main target from deep brain surgery in PD(7). The palladium-subthalmic nucleus is regarded as the anatomical base for most of the NM functions of the BG(8). Spectrum of NMS in PD Sleep problems Sleep problems are amongst the most frequent NMS in PD(9) and usually start early in the disease course(10). They can be primary due to PD itself, but could also be exacerbated or secondary to a range of problems associated with PD. The primary sleep problems are, in general, a result of the degenerative pathological and chemical changes in the central sleep regulations centres in the brain stem and thalamocortical pathways. Dopamine and other neurotransmitters may also be important in the sleep problem in PD. Clinical evidence suggests that somnolence can be induced by some dopamine agonists particularly at lower doses, whereas wakefulness is induced at higher doses(11). Dopamine also shares some structural similarities with some wake-promoting drugs. Major dopaminergic areas such as the ventral tegmental areas receive hypothalamic peptides implicated in wakefulness. REM sleep behaviour disorder (RBD) A form of parasomnia, occurring in about a third of PD patients(12), during which there is lack of the muscle atonia expected at this age. This enables patients to perform complex movements to physically enact their dreams which can be vivid, frightening or unpleasant. Partners can report talking, shouting, verbal threats, violent assaults and falling out of bed during sleep. REM behaviour disorders can

precede the motor symptoms in up to 40% of PD patients(12). The exact pathway remains speculative, but seems to be more associated with degeneration of the lower brain stem nuclei. Imaging studies of isolated cases of REM sleep behaviour disorder has confirmed symmetrical small reductions of dopaminergic uptake. Some drugs that showed beneficial effect in treatment of RBD include pramipexole(13), levodopa(14), gabapentin and melalonin. However clonazepam is probably the most effective treatment of this disorder in PD patients(15).

Insomnia Either sleep onset insomnia, i.e. difficulty initiating sleep, or sleep maintenance insomnia with frequent awakenings.

Factors contributing to insomnia include:

• Restless leg syndrome RLS • Periodic limb movement in sleep • Nocturnal akinesia • Off-period dystoma • Nocturnal tremors • Pain • Nocturia:

Detrusor overactivity Diuretics Prostatic disease GORD Heart failure

Excessive daytime sleepiness (EDS) Excessive day time sleepiness (EDS) can occur in up to 50% of PD patients and may precede the typical motor symptoms(16). EDS is multifactorial likely resulting from the disturbance of the nocturnal sleep, the pathological changes in PD, and to the drug treatment. Physicians dealing with PD patients should ask patients about EDS due to its impact on patients’ quality of life and its dangers for those who drive.


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Neuropsychiatric problems Depression Depression is an important neuropsychiatric symptom in PD occurring in up to 45% of patients(17). Damage to serotoninergic, dopaminergic and norepinephrinergic projections in the limbic system is implicated(18). Depressed patients with PD have a low concentration of 5-hydroxy indolaletic acid, a serotonin metabolite, in the cerebrospinal fluid and reduced cortical 5-HT1A receptor binding compared to non-depressed PD patients(19). Symptoms of depression in PD include loss of interest and initiative, fatigue, indecisiveness, panic attacks, feeling of guilt and apathy. Although suicidal ideation is relatively common in PD, death by suicide is rare, with exception of patients undergoing subthalmic nucleus stimulation(20,21). Symptoms of depression can precede the development of PD(22). Pramipexole, a dopamine agonist, used in the treatment of the motor symptoms of PD had shown antidepressant activity similar to or even better than fluoxetine and sertraline(23). Prolonged release ropinirole has also shown positive effect in the mood of PD patients(24). In the case of the two dopamine agonists, motor improvement could be contributing to the improvement in the depressive symptoms. Anxiety Anxiety is common in PD and usually coexists with depression and can predate the motor symptoms(25). It can be present as a generalised anxiety disorder, panic attack, or social phobias. It is clinically more noticeable during the “wearing off” periods manifesting itself as panic attacks. Therefore, it can respond to dopaminergic medications targeting the wearing off. However, anxiety can persists independent of the dopaminergic state. Some studies suggest that depression and anxiety are more common with left sided motor symptoms(26).

Deep brain stimulation of the subthalamic nucleus has shown superiority in improving anxiety compared to conventional medical treatment(27). Apathy Apathy is an established symptom of PD independent of depression or anxiety, although it may coexist with both. Patients equally disabled as a result of diseases other than PD don’t show the same level of apathy compared to PD patients with the same disability, indicating neurodegenerative contribution(28). Other negative symptoms such as anhedonia and fatigue can also be due to degenerative changes in reward centres such as dopaminergic projections between the ventral tegmentum and nucleus accumbens or areas that mediate goal-directed behaviour, e.g. frontal subcortical areas(29-30). Apathy responds only partially to dopaminergic drugs indicating the involvement of other neurotransmitters. Testosterone deficiency is also thought to play a role in the occurrence of these negative symptoms (31). Cognitive impairment Subtle cognitive deficits are almost universally identified in PD patients even at early stages (32). However, frank dementia can occur in up to 40% of people with PD(33). Dementia is progressive and can manifest as frontal executive dysfunction with impaired problem-solving, organization and planning, and impairment of visuospatial abilities. It is associated with rapid progression of the disease with significant impact on the patients’ independence, resulting in increasing nursing home placements, and mortality (34). The underlining pathology includes degeneration of nigral and cholinergic cells and the presence of cortical and subcortical lewy bodies(35). Other pathologies contributing to dementia in PD include Alzheimer’s disease, vascular pathology and possible genetic association with APOE genotype(36).


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Volumetric MRI studies of PD patients with dementia have shown hippocampal volume reduction to a similar extent to that in Alzheimer’s disease(37). The clinical profile of PD dementia includes features of frontal dysexecutive syndrome as well as hallucination, psychosis, mood and personality disorders while language and praxis remain largely intact(38). Anticholinesterases have shown improvement in cognitive function and psychotic behaviour in PD dementia(38). Psychosis and visual hallucinations The prevalence of hallucination in PD is high occurring in up to 40% of patients(39) and with psychosis constitutes a major risk factor for Nursing Home placement(34). Hallucinations usually start as benign visual illusions but progress into more sinister symptoms of psychosis such as delusions, paranoid ideation and delirium. Auditory and tactile hallucinations are less common and when present usually occur in association with visual hallucinations(40). Risk factors for hallucinations include RBD, cognitive impairment and genetic predisposition. Degeneration of the pedunculopontine nucleus, locus coeruleus and the dopaminergic raphe nuclei, all implicated in the causation of RBD, may be causative(41). Hallucination, although benign at the start, can turn into nasty paranoid accusatory delusion distressing to both carers and relatives. Treatment of psychotic symptoms includes atypical antipsychotics (quetiapine and clozapine) and cholinesterase inhibitors. Dysautonomia Pathology of autonomic dysfunction in PD is complex and includes degeneration of nuclei mediating autonomic functions, such as the dorsal vagal nucleus, nucleus ambiguous and other medullary centres[6]. Unlike multisystem atrophy dysautonomia is a late manifestation in PD with possible exception of early cardiac sympathetic

denervation in PD and not multisystem atrophy(42). Clinically autonomic dysfunction in PD can be present with symptoms related to postural hypotension, bladder dysfunction, erectile dysfunction, constipation and hyperhidrosis. Autonomic function in PD can objectively be assessed by several tests such as QSART (quantitative sudomotor axon reflex test for sudomotor function), urodynamic studies, defecating proctography, tilt table test and pupil function test. Bladder dysfunction Urinary urgency is common in PD resulting from detrusor overactivity. This is thought to be due to a combination of underactive D1 receptor with possible over stimulated D2 receptor in the bladder. PD patients might also experience obstructive symptoms with voiding difficulties due to disorder of bladder contractility or abnormal sphincter action but seems to be reversible on apomorphine(43). Symptoms of voiding difficulties seems also to improve during the “on” phase with levodopa although urinary urgency is unchanged or worsened(44). Deep brain stimulation of the subthalamic nucleus has a positive effect on bladder function by improving bladder capacity(45). Nocturia is common in PD and may occur due to a combination of decreased bladder capacity, increased urine output at night and sleep impairment. Sexual dysfunction Sexual dysfunction is common in PD and can be part of the spectrum of dysautonomia. Presentation includes erectile dysfunction, decreased libido and hyper sexuality(46). Testosterone deficiency is thought to be implicated(31). Apparent sexual behaviour and hyper sexuality is a recognized side-effect of dopaminergic drugs and apomorphine has been reported to cause penile erection in PD patients(47). Gastro intestinal symptoms Constipation is common in PD occurring in up


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to 60% of patients(48). Although studies suggest loss of both central and colonic dopaminergic neurones, constipation poorly responds to dopaminergic treatment suggesting the implication of other mechanisms(49). Similar to olfactory problems, constipation may predate the motor features of PD.

Practical management of autonomic dysfunction in PD: • Postural hypotension

High salt intake Elastic stockings Adequate fluid intake Head up tilt Fluchocortisone 100 to 300µg daily Midodrine 2.5 to 10mg daily

• Bladder dysfunction Detrusor hyperreflexia: anticholinergics, oxybutynin, tolterodine, trospium chloride

Retention : bethanechol chloride 25 to 75mg a day, intermittent Self Catheterization

Nocturnal polyuria: desmopressin spray 10 to 40µg a night

• Erectile dysfunction Sildenafil Sublingual Apomorphine

• Constipation Stop anticholinergics Adequate fluid intake Rule out other causes (hypothyroidism, hypercalcaemia, low potassium)

Laxatives

Olfactory dysfunction Thought to be due to degeneration of the olfactory bulb and the anterior olfactory nucleus, is a potential preclinical maker of PD. Hyposmia has also been reported in asymptomatic relatives of PD patients, some of whom, developed clinical manifestation of the disease, while others had presynaptic abnormalities detected on SPECT following a period of follow-ups(50).

Pain in PD Unexplained pain is common in PD and constitutes a major component of the NMS. It has been reported in as many as 29% of PD patients(51) i.e. • Central pain is an endogenous pain

associated with hyperalgesia and reduced threshold for heat pain. This pain is thought to be secondary to impairment of autonomic functions.

• Burning mouth is present as a continuous burning sensation of the oral mucosa and tongue. Contributory factors may be vitamins and mineral deficiencies, xerostomia, candidal infections and malfunctioning dentures. It could also be associated with levodopa(52).

• Visceral pain can be due to constipation or the rare development of retroperitoneal fibrosis related to the use of some ergot dopamine agonist.

Types of pain in PD: • Musculoskeletal pain

Rigidity Dyskinesia Dystonia Off period generalised pain

• Nocturnal pain Restless leg syndrome

• Postural hypotension pain Pain around the shoulder area and neck

• Orofacial pain Tempro-mandibular joint pain Burning mouth syndrome

• Visceral pain Constipation Retroperitoneal fibrosis

• Primary central pain

Visual function in PD Colour and contrast discrimination has been noticed and could even be a premotor marker for PD(53,54). Retinal dysfunction in PD has been confirmed on Electroretinography and thought to be the result of reduced retinal dopamine concentration(55,56).


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In conclusion, the NMS in PD are complex and involve multi system dysfunctions, sensory, autonomic, and neuropsychiatric. Though significantly has impact on a patient’s quality of life they still remain frequently overlooked. There is increasing evidence that non motor symptoms antedate the clinical

motor manifestations by years or even decades and thus may turn out to be critical clues in early diagnosis and identification of at-risk populations. Quantitative and validated scales for assessment of non-motor symptoms are essential to improve early detection of these symptoms.

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147

Original Article

Clinical ability to accurately identify significant neonatal jaundice

Hanadi Rimawi, MD*, Osama Abu-Salah, MRCPCH** Specialist Paediatrician, Department of Paediatrics, Queen Alia Military Hospital, Amman, Jordan*, Neonatal Paediatrician, King Hussein Medical Centre, Amman, Jordan**

القدرة السريرية على تقدير نسبه اليرقان الوالدي بدقه

. صالحاسامه ابو, ھنادي ريماوي

.من إدارة طب األطفال في مستشفى الملكة علياء، عمان، األردن

لتحديد مدى دقة لألطباء في الكشف عن درجة اليرقان في حديثي الوالدة األصحاء:األھداف

المرضى واألسلوب: . أيام من قبل 7-2وتمت دراسة مائة وستين من الرضع المتتالين ، أعمارھم بين , )لتر/ ميكرو مول120-188(دل/ ملغ11- 7,)لتر/ ميكرو مول100(دل/ ملغ6اقل من : م تعيين اربع فئات حسب االنتشار الراسي العجزيطبيب األطفال وت

ثم أرسلت عينات , )لتر/ ميكرو مول342(دل/ ملغ20وفوق , )لتر/ميكرو مول3243-256(دل/ ملغ19- 15,)لتر/ ميكرو مول240-205(دل/ ملغ14- 12 ..تبر لقياس البيليروبين للمقارنهالمصل للمخ

% 13.1انتقص قياس بيليروبين المقدرة سريريا في ).144- 48من ( ساعة 102وكان متوسط العمر . كانو من الفتيان) في المائة57( اثنان وتسعين :النتائجحيث انة تم التقدير الى مستويات , يرية على انقاص التقديرال ترتبات سر. في المائة41.9% في المائة وحدد بشكل صحيح في 45.2% في المائة وافرط في

. دللجميع المواليد تلذين عندھم اكبر من ھذه النسب و اليرقان امتد إلى ما بعد الخط الحلمة/ملغ12تفوق

حيث انھاا طريقه دقيقه لتحديد .ل حديثي الوالده على الرغم من أنه بال قيمة في تقدير مستوى بيليروبين بدقة، التقييم السريري أداة فحص مفيدة لألطفا:خاتمةوھكذا يمكن أن يتم اتخاذ قرار بشأن ما إذا كان سيتم استخراج الدم لقياس بيليروبين حسب الواقع ) لتر/ ميكرو مول205(دل/ ملغ12وجود يرقان فوق

. وھذا يغني عن الحاجة إلى الكثير من ثقوب الجلد اللتي ال داعي لھا. السريري

l فرط بيليروبين الدم ، والمنطقة الجلديه و حديثي الوالدة :مفتاح الكلمات

Abstract Objectives To determine how accurately physicians can detect the degree of jaundice in terms of otherwise healthy newborns. Patients and Methods One hundred and sixty consecutive babies, ages ranging between 2-7 days, were studied. Newborns were assessed clinically and their bilirubin level was estimated by a trained pediatrician according to the level of the cephalocaudal progression of visible jaundice. Four categories were assigned; less than 6 mg/dl (100µmol/L), 7-11 mg/dl (120-188µmol/L), 12-14 mg/dl (205-240 µmol/L) ____________________________________ Corresponding author Osama Abu-Salah, MRCPCH PO Box 712996. Amman 11171, Jordan Email: [email protected]

and above 20mg/dl (342 µmol/L). Serum samples were then sent for laboratory measurement of bilirubin. Results Ninety two (57%) were boys. The mean age was 102 hours (range 48-144). Bilirubin measurement was under estimated clinically in 13.1% and over-estimated in 45.2% and correctly identified in 41.9%. Under estimation of bilirubin had no clinical implications as all babies with total serum bilirubin (TSB) levels above 12 mg/dl (205 µmol/L) were correctly estimated to have jaundice extending beyond the nipple line. Conclusion Although not of value in estimating bilirubin level accurately, clinical evaluation is a useful screening tool for newborns with serum bilirubin above 12 mg/dl (205 µmol/L). Thus decision on whether to extract blood for measurement of bilirubin can be made on


148

Original Article Neonatal jaundice Osama Abu-Salah

clinical grounds. This obviates the need of many unnecessary skin punctures. Keywords: hyperbilirubinemia, dermal zone, newborn. Introduction Virtually all babies have a transient rise in serum bilirubin. More than 60% of term baby become visibly jaundiced in their first week of life(1). Only 10% have bilirubin levels requiring phototherapy(2), and around 2% will develop jaundice with serum bilirubin more than 20 mg/dl (342 µmol/L) (1). Measurement of serum bilirubin in every jaundiced baby will result unnecessary blood test in the majority of them. Thus, this study was carried out to determine whether it is possible to clinically assess the need for serum bilirubin measurement without missing any baby with significant hyperbilirubinaemia which presents a risk of neurotoxicity due to bilirubin encephalopathy and risk of kernictirus as early identification, prevention and treatment of severe hyperbilirubinemia makes kernicterus a preventable disease(3,4,5). Many previous studies described the cephalocaudal progress of neonatal jaundice as first appearing in the face and forehead then progressing to the trunk and limbs as the serum bilirubin rises(6,7). The American Academy of Pediatrics(3) states that “the extent of caudal progression may be helpful in quantifying the degree of jaundice”.

This study was undertaken to test the validity of examining this caudal progression in Jordanian term newborns. It is agreed that physiological jaundice, should be below 12 mg/dl (205µmol/L)(3). We specifically examined the ability to clinically identify babies with serum bilirubin above and below this value. Subjects and Methods From January 2010 to August 2010, 160 term babies with clinical jaundice within their first 2-7 days of life were studied at Queen Alia Military Hospital and paediatric clinics. Exclusion criteria were for babies who previously received phototherapy or exchange transfusion, have had blood group incompatibility, conjugated hyper-bilirubinemia, jaundice appearing in the first 48 hours of life, or were otherwise unwell with other complaints. Bilirubin level clinical estimation was done by trained paediatricians. Blanching the skin in a well lit room as advised by the American Academy of Pediatrics(8). Observing the level of the cephalocaudal progression of jaundice, then visually deciding the position on the skin, where jaundiced and non-jaundiced skin meet. This was followed by categorizing the clinical estimation into one of five dermal zones (Table 1).

Table 1: Clinical Criteria Used in this Study to Estimate the Serum Bilirubin level, based on the Extent of the Cephalocaudal progression of Visible Jaundice.

Skin level Face and Neck

Reaching nipples line

Reaching above knees

Reaching below knees

Hands and Feet

SBR , mg/dl (µmol/L)

<6 (100)

7-11 ( 120-188 )

12-14 ( 205-240)

15-19 ( 256-324)

>20 ( 342 )

This is a modification of the method described in 1968 by Kramer (the Kramer rule)(9). This is done as soon as a baby with jaundice presented or as soon as jaundice appeared in an already hospitalized baby because of their mother’s hospitalization. Blood samples were

then taken to measure the level of serum bilirubin by heel prick and following centrifuging the bilirubin was measured by a bilirubin photometer. Average cost for sample collection and testing is about $10 (equivalent in United States Dollars) per test


149


Results Ninety two (57%) were boys. The mean age was 102 hours (range 48-144).

Table 2, shows the distribution of serum bilirubin values in 160 babies according to the extent of the cephalocaudal progression of visible jaundice.

Table 2: The distribution of the range of total serum bilirubin (TSB) in comparison with the estimated level of the

cephalocaudal progression of visible jaundice.

Clinically estimated bilirubin level mg/dl (µmol/L) Measured Bilirubin

mg/dl (µmol/L)

Total patients Number

(%)

<6(100 ) Number (%)

7-11( 120-188) Number (%)

12-14 ( 205-240)

Number (%)

15-19( 256-324) Number (%)

20++( 342) Number

(%) <6(100 ) 12 (3.8%) 1 (8.3%) 8 (66.7%) 3 (25%) 0 (0%) 0 (0%)

7-11 ( 120-188 ) 95 (59.4%) 5 (5.2%) 46 (48.4%) 42 (44.2%) 2 (2.1%) 0 (0%) 12-14 ( 205-240 ) 25 (15.6%) 0 (0%) 0 (0%) 11 (44%) 14 (56%) 0 (0%) 15-19 ( 256-324 ) 20 (12.5%) 0 (0%) 0 (0%) 2 (10%) 15 (75%) 3 (15%) 20+ ( 342 ) 8 (5%) 0 (0%) 0 (0%) 1 (12.5%) 2 (25%) 5 (62.5%)

Total 160 6 (3.8%) 54 (33.8%) 59 (36.9%) 33 (20.6%) 8 (5.0%)

Twelve had serum bilirubin below 6 mg/dl (100µmol/L), 8(66.7%) of them were estimated to have a level of 7-11 mg/dl (120-188µmol/L) and 3(25%) were estimated to have a level of 12-14 mg/dl (205-240µmol/L). Only 1(8.3%) was correctly estimated. Ninety five (59.4%) babies had serum bilirubin of 7-11 mg/dl (120-188µmol/L). The clinical estimation was less than 6 mg/dl (100 µmol/L) in 5(5.2%), correct estimation in 46 (48.4%), over estimation to 12-14 mg/dl (205-240µmol/L) in 42(44.2%) and to 15-19 mg/dl (256-324µmol/L) in 2(2.1%). Serum bilirubin values of 12-14 mg/dl (205-240µmol/L) were found in 25(15.6%). Of those, 11(44%) were correctly estimated. Overestimation to 15-19 mg/dl (256-324 µmol/L) was found in 14(56%). None was estimated to belong to other dermal zones. Babies with serum bilirubin values of 15-19 mg/dl (256-324µmol/L) were 20(12.5%). Of

those, 15(75%) were correctly estimated. and 3(15%), were under estimated to 12-14 mg/dl (205-240µmol/L). Overestimation to more than 20 mg/dl (342µmol/L) was found in 3(15%). None was estimated to belong to other dermal zones. There were 8(5%) with serum bilirubin values of 20 mg/dl (342µmol/L) or more. Of those, 5(62.5%) were correctly estimated, underestimation to 12-14 mg/dl (205-240 µmol/L) in 1(12.5%) and to 15-19 mg/dl (256-324µmol/L) in 2(25%). None was estimated to belong to other dermal zones. As a serum bilirubin of 12 mg/dl (205µmol/L) or above delineates the cut off between physiological and non-physiological jaundice, none of the patients with serum bilirubin above 12 mg/dl (205µmol/L) (non-physiological jaundice) were underestimated to a value below 12 mg/dl (205µmol/L). This is shown in Table 3.

Table 3: The distribution of total serum bilirubin (TSB) for patients with visible jaundice seen above and below

the nipple line. TSB

>12MG/DL( 205 µmol/L) TSB

<12MG/DL( 205 µmol/L) TOTAL

Jaundice extending beyond nipple line 53 47 100

Jaundice extending above nipple line 0 60 60

TOTAL 53 107 160 Sensitivity: 1.0000 95% CI: 0.9324 to 1 Specificity: 0.5607 95% CI: 0.4662 to 0.6511


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The total number of babies with measured serum bilirubin less than 12 mg/dl (205µmol/L) was 107(66.9%); 12 were between 7-11 mg/dl (120-188µmol/L). Only 42(39%) of the babies with serum bilirubin less than 12 mg/dl (205 µmol/L) had visible jaundice extending beyond the nipple line as shown in Table 3. Table 3, also shows that a total of 53 babies had serum bilirubin values above 12 mg/dl (205µmol/L). All of these babies had jaundice extending beyond the nipple line on dermal zone criteria. These values show that all babies with bilirubin of more than 12 mg/dl (205µmol/L) were correctly identified with 100% specificity but only 53% sensitivity. Of the 100 babies with visible jaundice extending distal to the nipple line, a total of 47(47%), had a false positive serum bilirubin value below 12 mg/dl (205 µmol/L). Discussion It is considered cost effective and less traumatic to the babies and their family(10,11) if only jaundiced babies with significant jaundice risk are selected to undergo blood sampling for serum bilirubin estimation. This is particularly of great use where health care resources are limited (12,13,). The American Academy of Pediatrics (AAP) guidelines for treatment of neonatal hyperbilirubinemia recommends measuring serum bilirubin levels when jaundice is clinically significant(3). No further explanation of what is considered a clinically significant jaundice is given. It is widely agreed, that neonatal jaundice is clinically visible when bilirubin level is above 5 mg/dl (85µmol/L)(14). The jaundice appears first in the face and then progresses in a cephalocaudal manner(6,7,).It was hypothesized that this cephalocaudal progression of jaundice in newborns is related to the transfer of bilirubin from plasma to skin through two different mechanisms: a) Leakage of bilirubin-albumin complexes

into extravascular spaces, and

b) Precipitation of bilirubin acid in phospholipid membranes which increases with cephalocaudal progression(15,16).

In our study, the clinical estimation was performed by one of two paediatricians. Previous studies have shown that, following training, physicians, health care workers and even parents were shown to be able to recognize significant jaundice(13,17,18). The American Academy of Pediatrics recommends that mother should be taught this method before discharging the baby(19). A serum bilirubin value of 12.0 mg/dl (205µmol/L) has been used to distinguish physiologic from non-physiologic jaundice. At levels above this value, further evaluation and management is indicated as it may increase to a value necessitating phototherapy, especially in the presence of rapidly rising bilirubin(3). In this study, no baby without visible jaundice extending below the nipple line had a serum bilirubin level above 12mg/dl (205µmol/L) with 100% specificity and a positive predictive value. However, the sensitivity was only 57.6% and a negative predictive value of 55.1%. This is useful in deciding which baby does not need to have the TSB measured. A previous study found that visible jaundice distal to the nipple line had a sensitivity of 97% and a specificity of 19% for serum bilirubin of 12 mg/dl (205µmol/L) or more(20). There was a tendency to over-estimate rather than under-estimate bilirubin at all levels. Thus the value of clinical evaluation is to provide a clinical screening tool to decide when serum bilirubin should not be measured and not to guide therapy of hyperbilirubinaemia. In our study, 47(29%) of the 160 patients had physiological jaundice that was visible beyond the nipple line and serum bilirubin below 12 mg/dl (205 µmol/L). Using our criteria, unnecessary blood testing would have been recommended in perfectly healthy babies. This is more cost effective than universal screening which previous


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studies found no conclusive evidence to recommend such screening(21). At all levels, the dermal zones criteria overestimated TSB. This shows that this method is safe and correctly identifies all babies with significant hyperbilirubinemia. However, the mid-chest sign is the only significant sign with clinical implications. Under-estimation of bilirubin in 13 patients did not have any clinical implications as the under estimation was at a level where follow-up and further management would have been indicated any way. It is recognized that dark skin infants are more prone to develop significant neonatal jaundice(22). In this group, jaundice may not be readily visible on the skin(23). Parents and health care workers are advised to look for yellow discolorations in the sclerae, gums, palms and soles(7). In a large multi centre study which included infants with dark skin tone, found that examining the palms and soles is sensitive and specific for determining serum bilirubin levels above 20 mg/dl (340mmol/L)(12). Other non-invasive and less expensive and , in some groups of infants, effective methods of determining significant neonatal jaundice is by the use of transcutaneous bilirubinometer icterometer(24), which is recommended for use in babies with a gestational age of 35 weeks or more and postnatal age of more than 24

hours(25). The correlation between the transcutaneous bilirubinometer and the clinical assessment of neonatal jaundice was studied in the United States and a conclusion was made that either can be used by parents, once trained, to determine significant jaundice(7). A study from Italy(26) concluded that the combined use of visual assessment and icterometer results in improved sensitivity and specificity as compared to serum blood sampling results. Although not covered into in our study, inter-observer disagreements are expected, due to the subjective nature of determining the line between jaundiced and non-jaundiced skin. This is analogous to subjective determinations of pallor or cyanosis. However, this issue was verified in a previous study and found acceptable agreements between different neonatologists in identifying clinical jaundice at bilirubin levels that do not require intervention(27,28). The validity of dermal zone use by health workers, doctors and mothers(13,14,28), even in different communities, further suggests that the inter-observer disagreements may be of little significance. This study concludes that the clinical impression of neonatal jaundice by the eye of an experienced clinician remains a powerful reliable screening tool to diagnose significant hyperbilirubinemia in daily practice.

References 1. Stevenson DK, Fanaroff AA, Maisels MJ,

et al. Prediction of hyper-bilirubinemia in near-term and term infants. Pediatrics 2001;108:31-9.

2. Sarici SU, Serdar MA, Korkmaz A, et al. Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns. Pediatrics 2004;113:775-80.

3. American Academy of Pediatrics, subcommittee on neonatal hyperbilirubinemia. Neonatal jaundice and kernicterus. Pediatrics 2001;108:763-5.

4. Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr 2002;140:396-403.

5. Cashore WJ. The neurotoxicity of bilirubin. Clin Perinatol 1990;17:437-47.

6. Ebbesen F. The relationship between the cephalo-pedal progress of clinical icterus and the serum bilirubin concentration in newborn infants without blood type sensitization. Acta Obstet Gynecol Scand1975;54:329-32.


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7. Thong YH, Rahman AA, ChooM, Tor ST,

Robinson MJ. Dermal icteric zones and serum bilirubin levels in neonatal jaundice. Singapore Med J 1976;17:184-5.

8. Provisional Committee for Quality Improvement and Subcommittee on hyperbilirubinemia. Practice parameter: management of hyperbilirubinemia in the healthy term newborn. Pediatrics 1994;94:558-65.

9. Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Amer J Dis Child 1969;118:454-8.

10. Kemper K, Forsyth B, McCarthy P. Jaundice, terminating breast-feeding, and the vulnerable child. Pediatrics 1989; 84:773-8.

11. Kemper K, Forsyth B, McCarthy P. Persistent perceptions of vulnerability following neonatal jaundice. Am J Dis Child 1990;144:238-41.

12. Hatzenbuehler L, Zaidi AK, Sundar S, et al. Validity of neonatal jaundice evaluation by primary health-care workers and physicians in Karachi, Pakistan. J Perinatol 2010 Sep;30(9):616-21.

13. Paul IM, Phillips TA, Widome MD, Hollenbeak CS. Cost-effectiveness of postnatal home nursing visits for prevention of hospital care for jaundice and dehydration. Pediatrics 2004 Oct; 114(4):1015-22.

14. Maisels MJ, Gifford K, Antle CE, Leib GR. Jaundice in the healthy newborn-- infant: a new approach to an old problem. Pediatrics1988;81(4):505-11.

15. Knudsen A. The cephalocaudal progression of jaundice in newborns in relation to the transfer of bilirubin from plasma to skin. Early Hum Dev 1990 Apr; 22(1):23-8.

16. Knudsen A. The influence of the reserve albumin concentration and pH on the cephalocaudal progression of jaundice in newborns. Early Hum Dev 1991;25(1): 37-41.

17. Madlon-Kay D. Recognition of the presence and severity of new-born jaundice by parents, nurses, physicians, and icterometer.

Pediatrics 1997;100:e3. 18. Madlon-Kay DJ. Home health nurse clinical

assessment of neonatal jaundice: comparison of three methods. Arch Pediatr Adolesc Med 2001;155:583-6.

19. American Academy of Pediatrics Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics 2004;113:1434-6.

20. Moyer V, Ahn C, Sneed S. Accuracy of clinical judgment in neonatal jaundice. Arch Pediatr Adolesc Med 2000;154:391-4.

21. American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Classifying recommend-ations for clinical practice guidelines. Pediatrics 2004;114(3):874-8.

22. Huang MJ, Kua KE, Teng HC, et al. Risk factors for severe hyperbilirubinemia in neonates. Pediatric Research 2004;56(5):682-9.

23. Tarnow-Mordi W, Pickering D. Missed jaundice in black infants: a hazard? Br Med J 1983;286:463-4.

24. Mishra S, Chawla D, Agarwal R, Deorari AK, Paul VK, Bhutani VK. Transcutaneous bilirubinometry reduces the need for blood sampling in neonates with visible jaundice. Acta Paediatr 2009 Dec;98(12):1916-9.

25. National Institute for Health and Clinical Excellence. CG98 Neonatal jaundice. London: National Institute for Health and Clinical Excellence; 2010.p.1-30.

26. De Luca D, Zecca E, Zuppa AA, Romagnoli C. The joint use of human and electronic eye: visual assessment of jaundice and transcutaneous bilirubinometry. Turk J Pediatr 2008;50(5):456-61.

27. Madlon-Kay DJ. Recognition of the presence and severity of newborn jaundice by parents, nurses, physicians, and icterometer. Pediatrics 1997;100(3):E3.

28. Arieh Riskin, Martha Abend-Weinger, David Bader. How accurate are neonatologists in identifying clinical jaundice in newborns? Clinical Pediatrics. Glen Head 2003 Mar; 42(2):153.


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Original Article

Effect of intrathecal morphine plus fentanyl versus pethidine on labor pain

Hadab A Mohamed, MD*, Ehssan M Ziyada, MD** Associate Professor of Anaesthesia, Faculty of Medicine, University of Khartoum, Shaab Teaching Hospital*, Anaesthesiologist, Kassala Teaching Hospital**

.إحسان محجوب زياده. دھداب أحمد محمد، . د

مقارنة األثر اإلكلينيكي إلعطاء كل من عقارالبثدين مقارنة بعقار المورفين تھدف ھذه الدراسة التجريبية التى تم إجراؤھا بمستشفي سوبا الجامعي إلي .مضاف إليه عقار الفنتنيل كمخدر نصفى تحت الغشاء العنكبوتى على ألم الوالدة

فقد تم ) ب( ملغم كمخدر نصفى ،أما المجموعة 10تم إعطاؤھا عقار البثدين ) ا(المجموعة . سيدة بكر وتم تقسيمھن إلى مجموعتين50أجريت الدراسة على

بعد ذلك تم قياس كل من بدء إزالة ".تحت الغشاء العنكبوتى" ميكروغرام كمخدر نصفى 25ليه عقار الفنتنيل ملغم مضاف إ0.25إعطاؤھا عقار المورفين،طريقة الوالدة، مقياس ابقر، " غثيان، قئ،حكة،ھبوط تنفسي"األلم،مدته ،نوعية األلم الذي أزيل ،تأثيرااللم على العالمات الحيوية لألم،اآلثار الجانبية للعقار

م لتكرار التجربهقابلية األ .

بدأ إزالة األلم في أقل من دقيقة مقارنة ب ) ب(من الحاالت فى المجموعه % 80وذلك أن ) ب(وجدت الدراسة أن بدء إزالة األلم كان أسرع في المجموعة دقائق في 3 ساعات و6 دقائق في حين أنه كان 9 ساعات و3ھو ) ا(كما وجد أن الزمن الكامل بدون إحساس لأللم في المجموعة ).ا(من المجموعة % 52

) ب(مقارنة بالمجموعة " دقيقة 58ساعات و 3) "ا(، لكن المرحلة النشطة من المرحلة األولي من الوالدة كانت أقصر في المجموعة )ب(المجموعة ) أ(، أما باقي األمھات فى المجموعه )ا(من المجموعة % 84 إطالقا مقارنة ب لم يعانين من أي ألم) ب(كل األمھات في المجموعة ". دقيقة25ساعات و 6"

.فقدعانين من ألم معتدلولم يحدث أي تغير في النبض، معدل التنفس او تشبع األكسجين في ) ب(من المجموعة % 20مقارنة ب) ا(من المجموعة % 16انخفض ضغط الدم في

.المجموعتين

من % 72مقارنة ب ) ا(من المجموعة % 48كما أنه حدثت الحكة في ) .ب(في المجموعة % 36مقارنة ب) ا(لمجموعة في ا% 52تم حدوث القئ في كما عبرت األمھات . طريقة الوالدة و مقياس ابقر لم يظھرا أي تغير يذكر في المجموعتين. ولم تحدث أي حالة ھبوط تنفس في المجموعتين) ب(المجموعة

لتجربةعن رضائھن التام عن ا . مع رضاء كامل لألمھات في المجموعتين،مع . ھي طريقة ناجعة"تحت الغشاء العنكبوتي"خلصت الدراسة إلي أن إزالة ألم الوالدة عن طريق المخدر النصفي

و الحكة في ) ا(انخفاض الضغط لوحظ في المجموعتين مع حدوث زيادة في القئ في المجموعة ). ب(بداية أسرع و مدة أطول للتأثير في المجموعة مع عدم حدوث أي تغير في النبض، معدل التنفس و تشبع في) ب(المجموعة .األكسجين كما أنه لم يحدث تغير في طريقة الوالدة أو مقياس ابقر

Abstract Objectives This prospective experimental cohort, single blinded study was conducted at Soba University Hospital to compare the clinical effects of intrathecal pethidine versus morphine plus fentanyl on labor pain as sole labor analgesia. Methods Fifty primiparaous patients, fulfilling the inclusion criteria, were randomly selected and ____________________________________ Corresponding author Hadab Ahmed Mohamed, MD Associate Professor of Anaesthesia, Faculty of Medicine, University of Khartoum, & Shaab Teaching Hospital, Sudan Email: [email protected]

into two groups. Patients in group A received 10 mg pethidine while those in group B received morphine (0.25mg) plus fentanyl (25µg). Opioids used in each group were injected in the subarachnoid space and patients were then monitored for the onset, duration and quality of analgesia, the effect of analgesia on maternal vital signs, the side effects of intrathecal opioid (nausea, vomiting, itching and respiratory depression), mode of delivery, neonatal Apgar score and maternal satisfaction. Results Intrathecal opioid is a good technique to provide labor analgesia, with a great degree of satisfaction to both study groups. Onset time of analgesia was more rapid, duration was


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Original Article Intrathecal morphine plus fentayl v pethidine Hadab A Mohamed

prolonged and analgesia was more intense in group B. Hypotension was noticed in both study groups, with an increased incidence of vomiting in group A and itching in group B. There were no significant changes in vital signs, variations in the mode of delivery or Apgar score among the study groups. Conclusions Intrathecal opioid is a good technique of labor analgesia, with minimal side effects and a great degree of acceptance by mothers. Keywords: analgesia, labour, intrathecal, fentanyl, morphine, pethidine. Introduction Labor pain has got one of the highest pain score, with varying intensity among mothers. Severe prolonged labour pain can lead to catastrophic results ranging from neurogenic shock, mother exhaustion (and consequently increased instrumental deliveries and cesarean section) to psychological fear from repeating the experience. Of all the possible methods of pain relief, neuraxial blockade (epidural, spinal, combined spinal epidural (CSE), continuous spinal) provides the most effective and least depressant way of analgesia. Some anaesthesiologists contend that intrathecal opioid administration has advantages over conventional epidural techniques during labor, and suggest that intrathecal opioid provides comparable analgesia with few serious side effects (1). Intrathecal opioid is gaining more special popularity in the developing countries because of its low cost and the less need for complex monitoring. Despite this fact, regional anaesthesia is still scarcely used in Sudan and it is just left for the educated mothers who ask for it. In this study, we are comparing the clinical effects of two types of intrathecal opioids on labor pain, using pethidine in one group and morphine plus fentanyl in the other.

Patients and Methods This prospective experimental, single blinded cohort study was conducted at Soba University Hospital, maternity unit in the period from November 2009 to May 2010. The approval for this study was obtained from the anaesthesia ethical committee, maternity department and the candidates of the study through a written consent. Randomized sampling was applied in the mentioned period to mothers who fulfilled the inclusion criteria and who accepted to be part of the study. Verbal information about the study was explained to mothers. Fifty parturients were selected and randomly allocated into two groups: Group A: included 25 mothers who received 10 mg of intrathecal pethidine.

Group B: included 25mothers who received 0.25mg morphine + 25 µg fentanyl intrathecally.

Mothers included were all primigravida, aged 20-35 years, full term, single tone, with uneventful pregnancy, cervical dilatation 2-4 cm, cephalic presentation and not receiving any other forms of analgesia The procedure was explained to the parturient and informed consent was obtained. Resuscitation equipments and drugs were prepared and kept within reach. Baseline blood pressure, heart rate, respiratory rate and pain score were recorded. Intravenous access was established using 18 G IV cannula for fluid and drugs administration. Lumber puncture was performed in the conventional way at the L3-L4 or L4-L5 interspaces using 27 gauge spinal needles, with all parturients in the sitting position. Parturients in group A received 10 mg intrathecal pethidine, diluted to 2 ml by adding distilled water, while parturients in group B received 0.25 mg morphine added to 25 µg fentanyl and were diluted to a total volume of 2 ml before intrathecal injection. Mothers were then placed supine with a left uterine tilt.


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Onset and duration of analgesia, outcome of labor, neonatal Apgar score and mothers’ satisfaction were recorded in the patient data form. Mothers were monitored every three minutes for the first ten minutes, then every half an hour for blood pressure, heart rate, respiratory rate and oxygen saturation. Pain score and the incidence of complications related to opioids (such as nausea, vomiting, itching and respiratory depression) were also assessed. Mothers were then monitored hourly for a continuous 24 hours, even after discharge, by telephone for symptoms of respiratory depression and were asked to feedback about even minor degree of respiratory affection. Data analyses were done using a master sheet and excel computer programme and SPSS. Hypotheses were tested and 0.05 probability level was predetermined as the level of significance. Results The age distribution has been predetermined in inclusion criteria and is shown in Fig 1. Fig 1: Age distribution

P= 0.011 Onset of analgesia was within less than 1 minute in 52% of parturients in group A compared to 80% in group B, while an onset time between 1-5 minutes was elicited in 48% of mothers in group A and in only 20% of those in group B (P=0.037). The onset time of analgesia was not delayed beyond 5 minutes in both study groups (Fig 2).

Fig 2: Onset time of analgesia

P= 0.037 A significant variation (P=0.00) in the duration of analgesia was observed among the study groups. The total duration of analgesia was 3.09 hours when pethidine was used, while it was 6.03 hours in morphine+ fentanyl group (Table 1). Table 1: Duration of analgesia Group Number of

parturients Mean (hours)

Std. Deviation

P-Value

A 25 3:09 1.21 B 25 6:03 4.05

0.000

All parturients in group B felt no pain after receiving the analgesia in contrast to 16% in group A, who felt only mild pain (Fig 3). Fig 3: Quality of analgesia

P= 0.037 Regarding the maternal vital signs, monitored before and after analgesia, 16% of parturients in group A suffered a reduction in blood


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pressure compared to 20% in group B (Table 2).

Table 2: Incidence of hypotension, respiratory depression and mother’s satisfaction Morphine +fentanyl Pethidine Incidence of hypotension 20% 16% Incidence of respiratory depression 0.0% 0.0% Mother’s satisfaction 100% 100%

There were insignificant changes in pulse rate, respiratory rate and oxygen saturation in both study groups (Table 3).

Table 3: Pulse, respiratory rate & SpO2 comparison before and after analgesia Morphine+fentanyl Pethidine Variable Range

After After After Before Less than 72 1 (4%) 0 (0%) 0 (0%) 0 (0%) 72-108 19 (76%) 17 (68%) 17 (68%) 19 (76%)

Greater than 108 5 (20%) 8 (32%) 8 (32%) 6 (24%) Less than 13 0 (0%) 0 (0%) 0 (0%) 0 (0%) From 13 - 16 9 (36%) 0 (0%) 0 (0%) 0 (0%) Greater than 16 16 (64%) 25 (100%) 25 (100%) 25(100%) Less than 92 0 (0%) 0 (0%) 0 (0%) 0 (0%) 92 - 100 25 (100%) 25 (100%) 25 (100%) 25 (100%)

Pulse rate (beats/min) Respiratory rate (breath/min) SpO2 in % Total

25 Parturients 25 Parturients Opioid related side effects were clearly noticeable in both groups. 52% of parturients in group A developed vomiting compared to 36% in group B, while 48% and 72% of the parturients developed itching in group A and B respectively (Fig 4). No respiratory depression was observed in both study groups (Table 2). Fig 4: Incidence of itching and vomiting

Outcome of labor was normal vaginal delivery in 80% and 96% of parturients in group A and

B respectively (Fig 5). Twenty percent of parturients in group A delivered with cesarean section (60% due to mal-rotation, 20% failure of progress and 20% due to fetal distress) (Fig 6), while cesarean section was the mode of delivery in only 4% of group B mothers (one case, who was operated due to fetal distress), with no incidence of instrumental deliveries. Fig 5: Outcome of labor

P= 0.082


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Fig 6: Indication of cesarean section

P= 0.301 Neonatal apgar score assessed in the first minute showed that 88% of the neonates of mothers in group A had good score and 12% had mild asphyxia, while 96% of the neonates of group B mothers were assessed as good and only 4% (one case) suffered severe asphyxia (Fig 7). Mothers in both groups were 100% satisfied with the procedure (Table 2). Fig 7: Neonatal apgar score

P =0.130 Discussion Regional analgesia is the most effective method of labour analgesia nonetheless it is still not playing a major role in our practice. The lack of medical information about this particular type of analgesia makes mothers afraid of such an experience and not asking for it. Physicians practicing modern obstetrics in rural and small urban centres might find single-dose intrathecal opioids a useful

alternative to parenteral or epidural analgesia for appropriately selected patients. In many small rural communities, epidural anaesthesia is unavailable to labouring women. An alternative intrathecal opioid using traditional lumbar puncture technique has been shown to provide good analgesia with few side effects for about 4 hours. A cocktail of several opioids (morphine plus fentanyl in this study) permits rapid onset and prolonged duration of action; fentanyl works within 5 minutes while morphine (even in low doses) lasts up to 4 hours. The literature indicates that intrathecal opioids can be used effectively and economically for intrapartum care when pain control is required. In this study, the effect of two types of opioids, given by the same route (intrathecally) as sole labor analgesia, were compared. The age range in both groups has been determined in the inclusion criteria of the study and the range selected has no strong influence on analgesia. The physiochemical properties of intrathecal opioids determine their onset time, duration of action, and potency. High lipid solubility results in a highly potent opioid with a rapid onset of effect, but limited duration of action, whereas decreasing lipophilicity increases the duration of action. Parturients in both groups experienced almost immediate relieve of pain irrespective of the type of opioid used (without a significant difference in onset time). In this study, the duration of pain relieve was significantly (P value = 0.00) longer (6.03 hours) when morphine with fentanyl was used for labour analgesia, than that produced by intrathecal pethidine (3.09 hours). This is compatible with the findings of Herpolsheimer A and Schretenthaler J who used intrathecal morphine plus fentanyl for labour analgesia (2). The total duration of analgesia in both groups completely covered the time of the time of


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active phase of the first stage of labour in most of cases. An exciting development in obstetric analgesia has been the observation that fentanyl injected into the intrathecal space seems to cause more rapid cervical dilation and to shorten the first stage of labor, the fact that encouraged its use. The effect of fentanyl on the time of first stage of labour was noticeable in this study. The same was observed by Wong CA et al, who found that intrathecal fentanyl decreased first stage of labour by 100 minutes(3). The duration of the first stage of labour was observed to be even less when intrathecal pethidine was used in this study. No pain was experienced in eighty four percent of parturients who received intrathecal pethidine for labour analgesia, compared to an effective labour pain relive in all parturients who received intrathecal morphine. This significant difference in the duration of pain relive (P=0.037) was related to the incomparable quality and duration of analgesia produced by morphine. Pethidine is the only member of the opioid family that has clinically important local anaesthetic activity in the dose range normally used for analgesia. It is unique in that it is effective as the sole agent for spinal anaesthesia(4). Pethidine, having local anaesthetic action, is supposed to be associated with more hypotension than with other opioids. In this study, low blood pressure was encountered in 16% of cases in whom pethidine has been used for labour analgesia, an incidence which was less than that (20%) when morphine with fentanyl was used. Unlike the morphine group, a significant reduction in blood pressure compared to the preanalgesic values was observed following pethidine administration, although there were no significant variations in the pre and post analgesic vital sign values when the study groups were compared.

Vomiting is one of the most common opioid side effects. In this study, the incidence of vomiting was found to be 52% when intrathecal pethidine was used for labour analgesia, compared to an incidence of 36% on using morphine plus fentanyl, with insignificant difference in incidence between the two groups. A compatible incidence of vomiting (44%) has been observed in the study of Herpolsheimer A and Schretenthaler J who used intrathecal morphine and fentanyl for labour analgesia. In our study, a higher incidence of itching (72%), which was mainly affecting the face, neck and upper thorax, was seen when using morphine with fentanyl, compared to an insignificantly lower incidence (48%) on using pethidine. This side effect responded to treatment with ondansetron (serotonin antagonist) in both study groups. Respiratory depression is a notorious side effect of opioids. Opioid related respiratory depression is mediated through their effect on the respiratory centre in the brain stem. Respiratory depression has been reported occasionally, usually in the context of concurrent parenteral narcotic administration or use of water-soluble intrathecal morphine, or in otherwise compromised patients(5,6). Respiratory depression can be managed with routine narcotic antagonists. These side effects were described when narcotic doses were approximately 10 times higher than those we currently use. Lowering the dose of morphine from 2.0 mg to 0.2 mg has reduced or eliminated many of these side effects and has not lessened the effect of analgesia. The incidence of respiratory depression in this study was found to be 0% in both groups, despite using opioids, compared to an incidence of 1.3% in Herpolsheimer A and Schretenthaler J study. Intrathecal opioids, used in this study for labour analgesia, were shown to have a negligible effect on the rate of cesarean section. 80% of parturients who received


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intrathecal pethidine had a normal vaginal delivery compared to 96% incidence when morphine plus fentanyl was used, with insignificant difference among the study groups. As most deliveries in our obstetric departments are followed up by registrars, the rate of conversion to cesarean sections is unjustifiable high. The last 20 years have seen a dramatic change in obstetric practice. Assisted outlet deliveries are now routinely done with the less traumatic vacuum extraction(7). In the 1990s, forceps use fell from 11% to 6% and episiotomies fell from 49% to 24%(7). This resulted in a substantial reduction in somatic discomfort during the second stage of labour for many women. Since our delivery methods are still less “perineal friendly”, a higher than expected cesarean sections are noticed in this study, although instrumental deliveries were not encountered. Neonatal Apgar score of the first minute was found to be good in 88% of the neonates delivered by mothers who received intrathecal pethidine, with the remaining 12% having mild asphyxia. The Apgar score was good in

96% of the neonates delivered by mothers who received morphine plus fentanyl while the remaining 4% (one neonate) from the same group had severe asphyxia. Concerning maternal satisfaction with the mode of analgesia used in this study, and as a fact that goes with the findings in Leighton et al study(8), all mothers included were 100% satisfied with the procedure and would like to receive intrathecal analgesia during future labor. Wang was the first to describe the intrathecal administration of morphine in a group of eight patients with genitourinary malignancies in 1979. Since that time, the use of intrathecal opioids has become a widely accepted technique for providing effective postoperative pain relief. One of the goals of all researches should be directed to find simple, cheap and effective form of labor analgesia that can be used routinely in the developing countries, like Sudan, with fewer side effects to both mother and baby and less requirement for expert hands and expensive monitoring devises.

References 1. Brenda A Bucklin, David H Chestnut, Joy L

Hawkins. Intrathecal opioids versus epidural local anesthetics for labor analgesia: A meta-analysis. Regional Anesthesia and Pain Medicine 2002 January;27(1):23-30.

2. Herpolsheimer A, Schretenthaler J. The use of intrapartum intrathecal narcotic analgesia in a community-based hospital. Obstet Gynecol 1994;84(6):931-6.

3. Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005;352(7):655-65.

4. WD Ngan Kee. Intrathecal pethidine: pharmacology and clinical applications. Anesthesia and Intensive Care 1998 April;26:137-46.

5. Zapp J, Thorne T. Comfortable labor with

intrathecal narcotics. Mil Med 1995;160(5):217-9.

6. Carton EG, McDonald N, McCarthy JR. Intrathecal morphine in labour-efficacy and side effects. Ir J Med Sci 1987;156(11):323-7.

7. Canadian Institute for Health Information. Giving birth in Canada: a regional profile. Ottawa, Ont: Canadian Institute for Health Information; 2004.p.9-15.

8. Leighton BL, DeSimone CA, Norris MC, Ben-David B. Intrathecal narcotics for labor revisited: the combination of fentanyl and morphine intrathecally provides rapid onset of profound, prolonged analgesia. Anesth Analg 1989;69(1):122-5.


160

Original Article

Fracture of the penis at El Obeid Hospital, Western Sudan; review of seven consecutive cases

El Bushra A Doumi, MCS, Mohamed I Mohamed, MD, Mohamed Y Bakheit, FSMSB, Mohamed B Bashier, FSMSB The University Surgical Department, El Obeid Hospital, Faculty of Medicine & Health Sciences, University of Kordofan,

.البشرى أحمد دومى، محمد إبراھيم محمد، محمد يوسف بخيت، محمد بابالرحمة بشير

.مراجعة سبع حاالت متتالية. كسر العضو الذكرى بمستشفى األبيض فى غرب السودان

:الملخصالت معالجة بعض الحاالت التى إستقبلناھا، الھدف من ھذه الدراسة بيان أسباب وأعراض ومآ. كسر العضو الذكرى من الحاالت الطارئة النادرة:الخلفية

.بغرص لفت النظر لحدوثھا وتبادل خبرات معالجتھا

لقد تم دراسة وتحليل بيانات الظواھر السريرية وطرق المعالجة ونتائجھا لسبع حاالت متتالية وردت لقسم الجراحة العامة بمستشفى :المرضى وطرق البحث . مختصرة لألدبياتاألبيض خالل عامين، مع مراجعة

كان التأخير فى التبليغ من خمسة إلى أربع وعشرين . تراوحت أعمار المرضى ما بين عشرين وخمسة وأربعين عاما. إستقبلنا سبع حاالت فى عامين:النتائج .للمعالجة الجراحية الفوريةولقد أخضع جميع المرضى . من اإلصابات بالجانب األيمن% 70أكثر من . وتباينت األسباب التى ذكرت. ساعة

بعد المتابعة تبين أن العمليات الجراحية الفورية ذات نتائج جيدة، تقلل مدة اإلقامة بالمستشفى . حاالت كسر العضو الذكرى أكثر مما يبلغ عنھا:الخالصة .وتسارع بالشفاء ومعاودة الوظائف العادية

Abstract Background Penile fracture is a rare surgical emergency. The objective of this study is to highlight the causes, clinical presentations and outcomes of penile fractures seen in a general surgical unit, in-order to raise the awareness and exchange experiences. Patients and Methods The clinical presentations, management and outcomes of seven consecutive cases of penile fractures seen in a district general surgical unit in two years were studied, analyzed and discussed in brief with literature review. Results There were seven patients. The ages ranged from 20 to 45 years (average 30.01 years ± SD=7.14). The time delay in presentation was _____________________________________ Corresponding author El Bushra Ahmed Doumi, MCS Email: [email protected]

from five to 24 hours (average 17). Sexual trauma was denied except in one patient. The injury was on the right side in 5 patients (>70%). There was no accompanying urethral damage among these cases. All patients were offered prompt surgery with excellent results. Conclusions Penile fracture is an under reported condition. Immediate surgical repair was associated with short hospital stay, speedy functional recovery and good outcomes. Keywords: Fracture penis, trauma, and surgical repair. Introduction The first documented report of this condition was credited to Albulkasem, the Arab physician, in Cordoba more than 1000 years ago(1). In the modern medical literature the first case of penile fracture was described in 1924(2). Since then more than 1600 cases were reported worldwide, the majority were from the United States and the Middle East(3).


161

Original Article Fracture of the penis El Bushra A Doumi

Normally the penis has 3 cylindrical bodies; two dorsal cylinders form the corpus cavernosa on the sides and one ventral cylinder is the corpus spongiosum which carries the penile urethra from below. The three cylinders are surrounded by fascia and contained within the stiff tunica albuginea which is a tough fibrous envelope 2 mm thick in the flaccid penis, but decreases to 0.25 mm during an erection(4). Engorgement of the corpus cavernosa with blood results in penile erection. Normal pressure inside the erect penis is the mean arterial pressure at approximately 100 mmHg. Intra corporeal pressure needed to rupture the tunica is about 1500 mm Hg(5). When a penis fractures, there is a traumatic tear of one or both of the corpus cavernosa which hold most of the blood during an erection. Bleeding from a leaking corpus cavernosa into the surrounding tissues produces haematoma deep to Buck’s fascia. Fracture of the penis usually results from direct trauma during sexual intercourse, masturbation, bending of the erect penis to achieve detumescence or accidental rolling over in bed. The leak is typically unilateral(5). The patient complains of an audible cracking sound (snap or pop), an intense pain, immediate swelling (penile deformity), and penile bruising (ecchymosis) with deviation to the side opposite the tear(4,5) (Fig 1). Fig 1: Deviation of the penis to the opposite side of the tear.

Although the penis has no bones, but the situation occurring in an erect penis mimics fracture sequences that occur in bones. Blood appearing in the external urinary meatus, haematuria, voiding difficulties or urine extravasations may indicate a urethral injury(6). On physical examination the patient appears apprehensive, anxious and usually points to the site of the injury. Locally the penis is flaccid, swollen with ecchymosis and deviated to one side (eggplant deformity)(7) (Fig 2). Fig 2: The eggplant deformity

There is severe tenderness at the injured point in the shaft shown as a gap or depression underneath the clot, over which the penile skin can be gently rolled. However, the scrotum is normal(7). Patients and Methods This is a retrospective descriptive study. The medical records of patients who presented with fracture of the penis to the University General Surgical Unit, in or at El Obeid Teaching Hospital, Western Sudan during or over two years were reviewed. The data were analyzed for causes; time elapsed since the incident, age, clinical presentations, diagnostic approach, treatment offered and outcomes. All patients had immediate surgical repair, after detailed informed consents were obtained and documented. The procedure was performed under spinal anaesthesia; via a sub-coronal hemi-circumferential incision (Fig 3).


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Fig 3: The sub-coronal hemi-circumferential

incision

Buck’s fascia was exposed over the area of maximal haematoma to reveal the tear in the corpus cavernosum. The haematoma was evacuated and thoroughly washed out. Ligation of any identified bleeding vessels was done. Intra-corporeal injection of normal saline through the tunica from within the glans penis to simulate erection (Fig 4) was found to be helpful in locating the injury site.

Fig 4: Intra-corporeal injection of normal saline

It was a transverse tear in all cases, which was repaired with inverted vicryl sutures (Fig. 5). The fascia and skin edges were re-opposed using 3/0 interrupted vicryl sutures. In all these patients there was no urethral injury, but an indwelling Foley’s catheter was used as a one-day-splint in two patients with tears more than five millimeters. Post-operative compression bandages, antibiotics and anti-inflammatory drugs were used in all patients, and all patients were

discharged in one to three days’ time. Patients were advised to abstain from coitus for six weeks. Fig 5:Identifying the tear

Six patients were followed-up for a period ranged between six months and one year. The seventh patient, who is still on follow-up, was seen after six weeks and three months. Results There were seven patients among the study group. The age distribution was between 20 and 45 years, mean 30.01 years with standard deviation 7.14. The main complaint was sudden penile pain and increasing penile swelling with apparent deformity. The condition was due to trauma of the erect penis due to falling down in three cases, casual impacted erect penis during rolled over in bed in two patients, road traffic accident in one case while one patient confessed sexual trauma. Right sided injury was found in five cases (71.4%). There were no bilateral injuries and no urethral injury among the study group. The mean hospital stay was 1.2 days (range 1-3 days). No early postoperative complications were seen in any of the patients. On follow-up, specific questioning about late sequale regarding pain, loss of sensation in the penile shaft, penile curvature and sexual dysfunction revealed no abnormality. Discussion Penile fracture is a rare surgical emergency, generally occurs after blunt trauma to the erect penis. Incidences are difficult to calculate as the condition is always under reported.


163


However, seven cases seen in our unit in two years is rather an unusual event. The aetiological factors found in our patients were different from other reported case series, probably due to the different cultural beliefs in different communities. Our patients seemed not accurately reporting the exact cause, due to what they consider as embarrassment. In 1,331 penile fracture cases reported in 183 papers between 1935 and 2001, coitus was the main aetiological factor ranging between 33% and 60% of cases(4). Gedik et al found coitus as the cause in 43% of their own series (107 patients)(4), Ibrahiem et al in 51% (155 patients)(6) and Agarwal et al in 88% (17 patients)(8). However, Zargooshi et al found coitus as the cause only in 8.1% (out of 172 patients), in which manually bending an erected penis for detumescence was incriminated in 69% of the cases(9). Other authors reported manual bending accounting for 61.9% (13 out of 21 patients)(10), 64% (16 out of 25 patients)(11) and 78% (25 out of 32 patients)(12) of their series. The diagnosis in our cases was established on clinical findings. All patients admitted the history of trauma, although only one patient attributed that to sexual act. The main presenting features were pain, penile swelling and deviation. All of them admitted an audible cracking sound or snap. The patient usually points to the side and site of the tear. When examined they were anxious. Locally, the penis was flaccid with the classic eggplant deformity(7,13) and local tenderness. The point of maximum tenderness in the shaft appeared as a gap or depression underneath the clot, over which the penile skin can be gently rolled (the rolling sign)(14). The scrotum was normal. We found ultrasound scan very useful in confirming the diagnosis and localizing the defect. Similar experiences were reported from elsewhere(15,16). Some authors recommended cavernography, urethrography (to exclude urethral injury) and magnetic

resonance imaging(7,13,14). Such techniques were not available in our setting and we do not have any experience regarding their usefulness and cost effectiveness. The surgical repair of penile fracture was first described by Fetter and Gartmen in 1936(17) and had further become popular in the 1980s(14). So, all our patients were offered immediate repair. We found that injection of intra-corporeal saline to simulate erection (Gittes test)(14) was useful in locating the tear. Right side injuries (71.4%) were more common than left side, similar to the reports of other authors(1,6,14), with no clear explanation. Although, it was reported that usage of post-operative diazepam was found to be helpful to prevent erections during the healing time(18), but no clear evidence was given and such medications were not used in our patients. The time delay in presentation was from five to 24 hours (average 17), because the patients expected that their symptoms may subside spontaneously or on over counter antibiotics. We did not notice any difference in the surgical outcomes, between those who reported immediately or after 24 hours, probably because the delay time was short and the number of patients was small. However, it was well documented that even late intervention, due to late presentation, is still advocated(14). Since then, the old conservative treatment is no longer practiced, as many other authors found shorter hospital stay, fewer complications and increased patient satisfaction on immediate surgical management(19-24). Muentener M et al compared surgical and conservative treatments and reported success rates of 92% and 59% respectively(25). Recently, Yapanoglu T et al(26) and Gamal WM(27) et al in two different similar studies found that immediate surgical repair gave good results and was also superior to conservative treatment.


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In conclusion, penile fracture is a rare surgical emergency which is mainly diagnosed clinically. Immediate surgical exploration and repair was associated with short hospital stay, rapid functional recovery and no substantial

long term sequale. We call the medical providers at the primary health care settings to be aware of the condition and that prompt surgical intervention is a useful, rational and justifiable practice.

References 1. Al-Shaiji TF, Amann J, Brock GB. Fractured

Penis. J Sex Med 2009;6:3231-40. 2. Malis J, Zur K. Der fractura penis. Arch Klin Chir

1924;129;651. 3. Eke N. Fracture of the penis. Br J Surg 2002;89:

555-65. 4. Gedik A, Kayan D, Yamis S, Yilmaz Y, Bircan K.

The diagnosis and treatment of penile fracture: our 19-year experience. Turkish Journal of Trauma & Emergency Surgery 2010;17(1):57-60.

5. De Rose AF, Giglio M, Carmignani G. Traumatic rupture of the corpora cavernosa: new physio-pathologic acquisitions. Urology 2001;57:319-22.

6. Ibrahiem EI, El-Tholoth HS, Mohsen T, Hekal IA, El-Assmy A. Penile Fracture: long-term outcome of immediate surgical intervention. Urology 2010; 75:108-11.

7. Ozcan S, Akpinar E. Diagnosis of penile fracture in primary care: a case report. Cases Journal 2009; 2:8065. Doi:10.4076/1757-1626-2-8065.

8. Agawal MM, Singh SK, Sharma DK, et al. Fracture of the Penis: a radiological or clinical diagnosis? A case series and literature review. Can J Urol 2009;16(2):4568-75.

9. Zargooshi J. Penile fracture in Kermanshah, Iran: report of 172 cases. J Urol 2000;164:364-6.

10. El-Sherif AE, Dauleh M, Allowneh N, Vijayan P. Management of fracture of the penis in Qatar. Br J Urol 1991;68:622-5.

11. Ozen HA, Erkan I, Alkibay T, et al. Fracture of the penis and long-term results of surgical treatment. Br J Urol 1986;58:551-2.

12. Asgari MA, Hosseini SY, Safarinejad MR, et al. Penile fractures: evaluation, therapeutic approaches and long-term results. J Urol 1996;155:149.

13. Khan RM, Malik MA, Jamil M, Khan D, Shah IH. Penile fracture: experience at Ayub Teaching Hospital. J Ayub Med Coll Abbottabad 2008;20(4):49-50.

14. Jack G S, Garraway I, Reznichek R, Rajfer J. Current treatment options for penile fractures. Rev Urol 2004;6(3):114-20.

15. Forman HP, Rosenberg HK, Snyder HM. Fractured Penis: sonographic aid to diagnosis. A J R 1989; 153:1009-10.

16. Sierra JM, Gureia HG, Perez CF, et al. Surgical repair and analysis of penile fracture complications. Urol Int 2011;86(4):439-43 (Epub 2011, Apr 7).

17. Fetter TR, Gartmen E. Traumatic rupture of penis. Case report. Am J Surg 1936;13:371-2.

18. Boncher NA, Vricella GJ, Jankowski JT, Ponsky LE, Cherullo EE. Penile fracture with associated urethral rupture. Hindawi Publishing Corporation: case reports in Medicine. 2010;doi:10.1155/2010/791948.

19. Kamdar C, Mooppan UM, Kim H, Gulmi FA. Penile fracture: pre-operative evaluation and surgical technique for optimal patient outcome. BJU Int 2008;102(11):1640-44.

20. Aderounmu AO, Salako AA, Olatoke SA, Eziyi AK, Agodinrin O. Penile fracture at LAUTECH Teaching Hospital, Osogbo. Niger J Clin Pract 2009;12(3):330-2.

21. Pandyan GV, Zaharani AB, Al Rashid M. Fracture penis: an analysis of 26 cases. Scientific World Journal 2006;6:2327-33.

22. Cole FL, Vogler RW. Fractured penis. J Am Acad Nurse Pract 2006;18(2):45-8.

23. Ateyah A, Mostafa T, Nasser TA, et al. Penile fracture: surgical repair and late effects on erectile function. J Sex Med 2008;5:1496-1502.

24. Nawaz H, Khan M, Tareem FM, Khan S. Penile facture: presentation and management. J Coll Physicians Surg Pak 2010;20(5):331-4.

25. Muentener M, Suter S, hauri D, Sulser T. Long-term experience with surgical and conservative treatment of penile fracture. J Urol 2004;172: 576-9.

26. Yapanoglu T, Aksoy Y, Adanur S, et al. Seventeen years’ experience of penile fracture: conservative vs surgical treatment. J Sex Med 2009;6(7): 2058-63.

27. Gamal WM, Osman MM, Hammady A, et al. Penile fracture: long-term results of surgical and conservative management. J trauma 2011;71(2): 491-3.


165

Case Report

A rare presentation of xanthogranulomatous appendicitis and caecal angiolipoma in the same patient

Tasabeeh A Omer, MBBS*, Lamymaa AM EL Hassan, MBBS, MD**, Ahmed M EL Hassan, MBBS, DCP, FRCPath, MD, PhD***, Ahmed H Fahal MBBS, FRCS, MD, MS, FRCP(London)**** House Surgeon*, Associate Professor of Pathology**, Professor of Pathology*** Professor of Surgery**** Department of Surgery, Soba University Hospital, University of Khartoum, Khartoum, Sudan.

, لمياء احمد محمد الحسن. د , تسبيح احمد عمر. د احمد محمد الحسن . د , احمد حسن الفحل. د

زانغوفراسلوما في الذائدة وانجلوليبوما في االعور: حالة نادرة

ة ازاله ذائدة كانت المريض ذكر في التاسعة واالربعين من العمر وقد حضر للحوداث بالتھاب في الذائدة وخراج وقد اجريت له عملي .متضخمة وكانت نتيجة المعمل وجود زانغوليبوما واحتمال وجود ورم خبيث مما استدعي ازاله الجزء االيمن في القولون

وقد اثبت العمل وجود انجلوليبوما في االعور

Abstract In this communication, we report on a 49-year-old male patient who presented with acute appendicitis and appendicular mass which was treated conservatively. However, his condition deteriorated and appendicular abscess was suspected. He underwent surgical exploration. A large hard and gelatinous appendicular mass was found, which proved to be xanthogranulomatous appendicitis. However, the histopathological appearance of the xanthogranulomatous appendicitis was confused with pseudomyxoma peritonei and signet ring carcinoma of the appendix. Based on that, he underwent right hemicolectomy. Incidental finding was a caecal angiolipoma. A meticulous literature search showed no reported combination of these two conditions in the same patient. ____________________________________ Corresponding author Ahmed Hassan Fahal, MBBS, FRCS, MD, MS, FRCP, Professor of Surgery, University of Khartoum, PO Box 102, Khartoum - Sudan E-mail: [email protected]

Keywords: angiolipoma, caecum Case Report The patient is a 49-year-old male from Central Sudan who presented to the Accident and Emergency Department with right lower quadrant abdominal pain. His condition started three days prior to presentation with vague lower abdominal pain. It was more pronounced on the right iliac fossa and was aggravated by coughing and movement. It increased gradually in severity and was associated with nausea, vomiting and anorexia. He is known to have mitral valve disease and was on aspirin 75mg and bisoprolol 0.5mg O.D. He had a past history of left ureteric colic caused by left ureteric stone. Systemic enquiry, drug, family or social history was not contributory to his presentation. On examination, the patient was ill and in pain. He was not pale, jaundiced or cyanosed. His temperature was 37ºC. Systemic examination was within normal apart from evidence of mitral valve disease. Local abdominal examination revealed a scaphoid abdomen. There was guarding and rebound tenderness on deep palpation. A


166

Case Report Appendicitis and caecal angiolipoma Osama Abu-Salah

palpable mass was felt in the right iliac fossa. The psoas sign was positive. His renal, hepatic function tests as well as the haematological profiles were within normal limits. Abdominal ultrasound examination showed a mass in the right iliac fossa suggestive of an appendicular mass. The patient was treated conservatively in the form of intravenous fluids, ceftriaxone and metronidazole for 10 days. His general condition suddenly deteriorated and he developed evidence of peritonitis. An abdominal ultrasound and CT scan examinations showed evidence of early abscess formation in the right iliac fossa lateral to the psoas muscle and an appendicular mass. He underwent exploration. A large hard and

gelatinous appendicular mass was found. It was tightly adherent to the caecum and terminal ileum. Appendicectomy was performed with uneventful post-operative recovery. The histopathological examination of the appendix showed a chronic inflammatory reaction composed of lymphocytes, plasma cells, and few neutrophils. The inflammation involved all the layers locally and was associated with mucin dissecting the muscles. There were several granulomas composed of foreign body giant cells, in line with the diagnosis of xanthogranulomatous appendicitis. However, it was incorrectly diagnosed by other pathologist as pseudomyxoma peritonei and signet ring carcinoma of the appendix. (Figs 1, 2, 3).

Fig 1: Wall of the appendix showing oedema, vascularity, chronic inflammatory cells and a pool of mucin at the top of the figure (H&Ex40)

Fig 2: Showing a pool of mucin in the wall of the appendix (Alcian blue stain x 40)

Fig 3: Showing a granuloma composed of multinucleated giant cells in the wall of the appendix. (H&E x 40)

Colonoscopy to assess the intraluminal extension of the pathology was done and it was normal apart from evidence of extra-luminal caecal compression. The patient had an abdominal CT scan which showed the presence of a caecal mass and left hydronephrosis due to a ureteric stone (Fig 4).


167


Fig 4: Abdominal CT scan showing a caecal mass

The patient underwent right hemicolectomy with uneventful post-operative recovery. The histopathological examination of the surgical specimen revealed evidence of angiolipoma of the caecum (Fig 5). Fig 5: Part of the angiolipoma of the cecum in the submucosa. (H&E x 40)

Discussion Xanthogranulomatous inflammation is a rare pathological condition. It had been reported in many organs, most frequently in the kidney (1)

and gallbladder.(2) There have been few reports of its occurrence in the appendix. (3) Appendicular histopathological examination in patients who undergone delayed appendicectomy have shown a strong association with granulomatous and xantho-

granulomatous appendicitis. It was postulated that, the ruptured acute appendicitis which is often treated with antibiotic therapy and interval appendectomy may develop granulomatous appendicitis. The reported patient, did not respond to antibiotics and had ruptured his appendix; and that was probably the cause for the of the xanthogranulomatous appendicitis. (4) It was reported that, delayed or interval appendicectomy specimens often have a characteristic inflammatory pattern that includes granulomas, xanthogranulomatous inflammation, mural fibrosis and thickening, and transmural chronic inflammation. These changes may be misinterpreted for Crohn’s disease. In the reported patient there was neither clinical nor histopathological evidence of Crohn’s disease in the small or large bowel. (5) Angiolipoma is benign neoplasm with characteristic vascular pattern that is frequently seen in the subcutaneous tissue but rarely reported in the gastrointestinal tract. (6) In the gastrointestinal tract they are usually asymptomatic but abdominal pain, bleeding and obstruction may be the presenting symptoms in some patients. (7) As far as we are aware only two cases of angiolipoma localised on the ileocecal valve were previously reported. (5,8) In the reported patient, the angiolipoma was a histopathological surprise as the CT scan findings were not specific. Although it is a rare entity it should be considered in the differential diagnosis of a caecal mass. In appendicular masses careful intra-operative examination of the terminal ileum and caecum is important to avoid missing such double pathology. It is interesting to note that, the histopathological appearance of the Xanthogranulomatous appendicitis in this patient was confusing and it was reported by other pathologist as pseudomyxoma peritonei and signet ring carcinoma of the appendix.


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References 1. Karla Laís Pegas, Maria Isabel Edelweiss,

Eduardo Cambruzzi, Cláudio Galleano Zettler. Liesegang rings in xanthogranulomatous pyelonephritis: a case report. Patholog Res Int 2010;4061 (2010):1-3.

2. Chang BJ, Kim SH, Park HY, et al. Distinguishing xanthogranulomatous cholecystitis from the wall-thickening type of early-stage gallbladder cancer. Gut Liver 2010;4(4):518-23.

3. Birch PJ, Richmond I, Bennett MK. Xanthogranulomatous appendicitis. Histopathology 1993;22(6):597-8.

4. Chuang YF, Cheng TI, Soong TC, Tsou MH. Xanthogranulomatous appendicitis. J Formos Med Assoc 2005;104(10):752-4.

5. Guo G, Greenson JK. Histopathology of

interval (delayed) appendectomy specimens: strong association with granulomatous and xanthogranulomatous appendicitis. Am J Surg Pathol 2003; 27(8):1147-51.

6. Saroglia G, Coverlizza S, Roatta L, Leli R, Fontana D. Angiolipoma of the cecum. Minerva Chir 1996;51(1-2):59-62.

7. Aminian A, Noaparast M, Mirsharifi R, et al. Ileal intussusception secondary to both lipoma and angiolipoma: a case report. Cases J 2009;30:2:7099.

8. Kato K, Matsuda M, Onodera K, et al. Angiolipoma of the colon with right lower quadrant abdominal pain. Dig Surg 1999; 16(5):441-4.


169

Case Report

A rare cause of nasogastric tube obstruction

Abdulhadi M Elbashir, MD (Surgery)*, Mutasim Abdalla, MD (Surgery)** Consultant Plastic and General Surgeon, KTH Sudan, Assistant Professor, Nejran University, KSA*, Abugibaiha Hospital**

التجميل استشاري الجراحة العامة وجراحة- عبدالھادي محمد البشير

مستشفى ابوجبيھة- الجراحة العامة-اختصاصي- معتصم عبدهللا

بعد مرات عديدة من . في معدي كجزء من معالجتھا عام تعانى انسداد األمعاء الدقيقة، قمنا بتثبيت أنبوب أن50 نسجل حالة لسيدة تبلغ من العمر :الخالصة

ھذا السبب غبر معتاد النسداد ). Teania Saginata(تم العثور على سبب انسداد أنبوب المعدة ليكون الشريطية العزالء. سحب السواٮل انقفل انبوب المعدة .ئع ان يكون الشريطية العزالء سبب لقفل انبوب المعدة من ھذه الحالةينبغي في البلدان االستوائية حيث اإلصابة بالديدان أمر شا. أنبوب أنفي معدي

Abstract A 50 years old lady presented with small bowel obstruction, had nasogastric tube for gastrointestinal decompression as part of her management. After many sessions of aspirations the nasogastic tube was blocked. The reason for the tube blockage was found to be tapeworm (Taenia Saginata). This is an unusal cause for nasogastric tube blockage. In tropical countries where helminthes infestation is common this should be considered as a cause. Keywords: nasogastric tube, tapeworm Introduction Placement of nasogastric tubes (NGTs) for gastric decompression is routine in the management of patients with small bowel obstruction. Obstruction of nasogastric tube can occur due to many causes, but some of the extremely rare causes should be considered especially in areas where rare causes like helminthes infestation should be considered. _____________________________________ Corresponding author Abdulhadi Mohamed Elbashir, MD (Surgery) Consultant Plastic and General Surgeon, Khartoum Teaching Hospital, Sudan Assistant Professor, Nejran University, KSA Email: [email protected]

Case report A 50 years old lady presented with small bowel obstruction. She had a previous pelvic surgery and therefore, the diagnosis was adhesive small bowel obstruction. A nasogastric tube was inserted for decompression of the stomach and aspiration of its content. After many sessions of aspiration of the stomach content the tube got blocked and no further aspiration was possible. The decision was to do a laparotomy in view of unrelieved obstruction. In the theatre and under anesthesia, we retrieved the tube and we found that it was blocked by a long tapeworm (Taenia Saginata) (Fig 1). Fig 1:Long tapeworm (Taenia saginata)


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Case Report Nasogastric tube Abdulhadi M Elbashir

The cause of the bowel obstruction was found to be adhesions due to previous pelvic surgery. The bowel was viable; so adhesion were released and the patient had an uneventful postoperative course. The patient was given praziquentel, a broad spectrum antihelmenthic drug. Discussion Rare causes of nasogastric tube obstruction were reported due to many reasons like self knotting(1) of the tube and ascaris lumbricoides(2). Taenia saginata is a common tapeworm in Sudan. Man is a known sole definitive host and is usually infected with one tapeworm. The worm can reach up to 6 meters length. The eggs are passed in stools when the gravid proglottids drop from the strobila and either rupture in the intestine allowing the eggs to pass in the stools or pass intact. The intermediate host is cattle that swallow the eggs and the larva cysts develop in the tissues. Man is infested when ingesting poorly cooked meat. Surgical complications of intestinal worms are generally very rare. Ascariasis commonly presents with abdominal complications in children. The incidence of surgical complications is directly related to the parasite mucosal interaction, being less with taeniasis and more with ascaris. Taeniasis was reported to cause small bowel obstruction, and colonic perforation in very rare situations. Also

taeniasis was reported to cause colonic anastomotic leak(3) and oesophageal anastomotic leak(4) However, upward migration of the worm to the stomach is unlikely. This is mainly due to the high gastric acidity. However, following intestinal obstruction, bile and pancreatic juice reflux might have changed the environment and allowed such migration. Then the tapeworm feeds itself in the opening of the tube as in our case. In an experimental work, rats infected with taenia worms led to retardation of gastric secretion and hypergastrinemia(4). The most common serious complication of adult tape-worm infection is appendicitis. Other reported complications include intestinal obstruction, obstruction of bile ducts or pancreatic duct, abnormal vaginal bleeding(5) and rarely anastomotic leak. Taeniasis invades the upper small bowel in humans. It is very unusual to see this parasite in the stomach. Nasal expulsion of taenia saginata was reported after repeated vomiting(6). However, nasogastric tube occlusion was not reported previously. Although tapeworms (Taenia saginata) inhabit the small bowel, under certain circumstances it migrates upwards to cause rare complications like oesophageal anastomotic leak and nasogastric tube occlusion. From this report tapeworm should be considered as a potential cause of nasogastric tube occlusion in tropical areas.

References 1. V Santhanam, M Margarson. Removal of

self-knotted nasogastric tube technical note. International Journal of Oral and Maxillofacial Surgery 2008 April;37(4):384-5.

2. U Mohan Gurjar, Bhaskar P Rao, Afzal Azim. Unusual obstruction of nasojejunal feeding tube. Saudi J Gastroenterol 2009 October;15(4):288.

3. Reem M Baleela, Mohamed Y Huessain, Mohamed E Ahmed. Anastomotic esophageal leak due to taenia saginata following, oesophagectomy for oeso-phageal cancer. Saudi Med J 2006; 27(2):241-3.

4. Alper Sozutek, Tahsin Colak, Ahmet Dag,

Ozgur Turkmenoglu. Mersin case report colonic anastomosis leakage related to taenia saginata infestation Clinics 2011;66(2):363-4.

5. Ahsan S, Zia SA, Ahmed J. A case of taenia saginata (tapeworm) infestation of the uterus presenting with abnormal vaginal bleeding. J Pak Med Assoc 2006;56:377-8.

6. M Sheikh, I Sheikh, I Ali, F Reshi. Nasal expulsion of taenia Saginata: a rare route of expulsion. The Internet, Journal of Surgery 2008;16(2):152-6.


171

Case Report

Cardiac tamponade following sternal acupuncture

Elnazeer O Ahmed, MBBS, MD, FRCSI*, Davy Cheng, MSc, FRCPC, FCAHS**, Daniel Bainbridge, MD, FRCPC** London Health Sciences Center, University Hospital, University of Western Ontario (UWO) London, Ontario, Canada, Cardiac Surgery Division, Department of Surgery, UWO*, Department of Anesthesia and Perioperative Care, UWO**

دانيال بينبردج, ديفي شينق, النذير عثمان

ملخص

نقدم اختالطا نادرا للوخز باإلبر الصينية في شاب حدث معه ھبوط حاد بعد إدخال إبرة صينية في عظم القص أدت إلى انصباب تاموري دموي وسطام قلبي . القلب بالصدى الذي أكد وجود اإلنصباب التاموري ي وأجري له بزل تاموري إسعافي بمساعدة تصويرالمريض بوضعه على جھاز التنفس الصناع تم إنعاش

استقرت بعدھا حالة المريض ولم يحتج تداخل جراحي آخر. إسعافية له وبعد ذلك تم إجراء نافذة تاموريةمخاطر وخيمة وعلى الممارسين لإلبر الصينية أن يتوخوا ير ينبه الحتمال حدوثأن اإلبر الصينية تعتبر من اإلجراءات اآلمنة إال أن ھذا التقر على الرغم من

دوما وذلك بإتقانھم لتشريح الجسم أثناء إدخالھم اإلبر في جدار الصدر الحذر وأن يكونوا مستعدين Abstract We present a rare complication of acupuncture in a young man who collapsed after the acupuncture needle advanced into his sternum resulted in hemopericardium and pericardial tamponade. The patient was resuscitated including intubation and mechanical ventilation. Emergency department pericardiocentesis was performed under echocardiographic guidance, which revealed hemopericardium, and then an emergency pericardial window was performed. The patient’s condition stabilized and required no further surgical intervention. Although acupuncture has the reputation of being safe, this case report should remind people of the potential catastrophic risks of this procedure and that acupuncture practitioners should exercise caution and be ___________________________________ Corresponding author Elnazeer Osman Ahmed, MBBS, MD, FRCSI London Health Sciences Center, University Hospital, University of Western Ontario (UWO), London, Ontario, Canada, Cardiac Surgery Division, Department of Surgery, UWO

E-mail: [email protected]

prepared with sound anatomical knowledge when passing needles through the chest wall. Keywords: acupuncture, cardiac tamponade Introduction Acupuncture is a relatively safe therapeutic intervention. However, a few traumatic life- threatening complications have been reported(1). Acupuncture related cardiac tamponade is a rare complication that has been reported both as an immediate and a delayed sequel(2,). Accumulation of blood or fluid in the pericardial sac results in impairment of the cardiac filling leading to cardiac tamponade and cardiogenic shock when tension develops within the pericardium. It is a life-threatening condition that requires immediate evacuation either percutaneously or through a surgical incision or both. Surgical placement of a pericardial drain can stabilize the patient until definitive management is available. We report a case of an acute cardiac tamponade that developed immediately after a sternal acupuncture. To our knowledge not more than six cases have been reported for acupuncture–associated cardiac tamponade(3-

7).


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Original Article Cardiac tamponade Elnazeer O Ahmed

Case description A forty-five year old healthy male patient collapsed with severe hypotension (SBP 60 mmHg) and diaphoresis following a sternal acupuncture performed for the purpose of treating bronchial asthma. The acupuncture needle was introduced through the lower end of the sternum. He was resuscitated in a community hospital for cardiogenic shock secondary to pericardial tamponade, as evidenced by echocardiography, with immediate intubation, mechanical ventilation and pericardiocentesis which revealed the presence of hemopericardium. Through subxiphoid approach the general surgeon at the community center perfomed an emergency pericardial window. More than 200 mls of blood was drained from the pericardial sac. A pericardial drain was placed and the patient was emergently transferred to our center for further possible pericardial surgical intervention. The details of the acupuncture needle caliber and the precise site of puncture could not be obtained. The patient was admitted to our cardiac surgery recovery unit in a stable hemodynamic condition, with further drainage of 25 mls over the next 12 hours; thereafter, a conservative management approach was pursued. A 12-lead ECG did not reveal myocardial ischemia as possible sequelae of needle induced coronary injury. A tans-thoracic echocardiography was performed 12 hours later, showed no recollection of pericardial fluid with normal heart function. The patient was extubated uneventfully and was discharged to the referring hospital after 24 hours in a stable condition for further follow-up. The pericardial drain was subsequently removed after 48 hours with no further immediate sequelae and the patient was discharged home in a stable condition. Discussion The use of “complementary and alternative medicine (CAM)” for the treatment of adults

and children is growing. This is particularly the case for bronchial asthma and other allergic diseases(8). Mechanical injuries may be observed following acupuncture leading to pneumothorax, cardiac tamponade or spinal injury. Our case report represents one of rare, but life-threatening complications of acupuncture which is acute cardiac tamponade. About six cases have been reported in the literature for this complication; one of these was related to a congenital foramen in the sternum that had ended with a fatal outcome(5). This congenital sternal defect occurs in 5-8% of the population. Bearing in mind the possibility of having this foramen is obviously important. A needle puncture through an area underlain by a bony structure should raise suspicion if the tissues yield to the needle after a certain depth. This is an essential technical skill that all acupuncturist should know for patient’s safety, especially when dealing with the chest wall. Our patient did not have a sternal foramen when assessed by simple clinical examination and chest radiography. A definitive testing by CT scan was not practical in this case. Of all the cases that have been reported, with the exception of one fatality, there had been a facility to treat this life threatening condition. This patient was properly managed by a general surgeon in a small community hospital. General surgeons trained in the initial management of cardiothoracic trauma can save lives in such community centers. This case report should not be taken, by any means, as an argument against this commonly practiced interventional procedure, but emphasizes the attention to extreme vigilance when breaching the chest wall with the acupuncture needle. Moreover, patients who seek acupuncture as a treatment should be counseled for all the potential serious complications, as there is a general belief that this procedure is devoid of any complications.


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Original Article Cardiac tamponade Elnazeer O Ahmed

References 1. Rosted P. Literature survey of reported

adverse effects associated with acupuncture treatment. Am J Acupunct 1996;24:27-34.

2. Hasegawa J, Noguchi N, Yamasaki J, et al. Delayed cardiac tamponade and hemothorax induced by an acupuncture needle. Cardiology 1991;78(1):58-63.

3. Nieda S, Abe T, Kuribayashi R, et al. Case of a cardiac injury resulting from acupuncture. Kyobu Geka1973;26(12): 881-3.

4. Cheng TO. Pericardial effusion from self-inserted needle in the heart. Eur Heart J 1991;12(8):958.

5. Halvorsen TB, Anda SS, Naess AB, et al. Fatal cardiac tamponade after acupuncture through congenital sternal foramen. Lancet 1995;345(8958):1175.

6. Kataoka H. Cardiac tamponade caused by penetration of an acupuncture needle into the right ventricle. J Thorac Cardiovasc Surg 1997;114(4):674-6.

7. Kirchgatterer A, Schwarz CD, Holler E, et al. Cardiac tamponade following acupuncture. Chest 2000;117(5):1510-1.

8. Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homeopathy. Brit Med J 1991;302:316-23.


174

Case Report

Massive hydrothorax from a ventriculopleural CSF shunt; a case report and review of the literature

El Fatih MB El Malik FRCSEd FRCS (Surgical Neurology) FACS, Mohammed EA Elameen FRCP FCCP*, Ahmed AF Khalid MD (UOK) The Neuro Spine Centre and Pulmonology Unit, Department of Medicine*, The National Ribat University, Faculty of Medicine & El Ribat University Hospital, Khartoum, Sudan

أحمد غبد الفتاح خالد. د محمد الباقر األمين و. الفاتح محمود بشير الملك، د. د

رباط الوطنيمستشفي الرباط الجامعى و كلية الطب بجامعة ال

الملخصمن التجاويف الدماغية بواسطة انبوب الي الشوكي ي تحويل السائل أ;الستسقاء الدماغ ھو التحويلة البطينية األكثر شيوعا العالج

من التجاويف الدماغية الشوكي اي تحويل السائل(التحويلة البلورية ). بسبب انسداد المجري الطبيعي للسئل (التجويف البطينيالصدر من المضاعفات الشائعة موه. بديل للتحويلة البطينية تستعمل نادرا كإجراء) واسطة انبوب الي التجويف البلوري بالصدرب

نحن ھنا نسجل حالة .و تحدث بمعدالت اقل مع التحويلة البطينية للتحويلة البلورية بسبب تجمع السلئل الدماغي في تجويف البلورةمن التجاويف الشوكي نتيجة لتحويل السائل في التجويف البلوري صدر ھائل موه نة حضر يعاني من س20نادرة لمريض عمره

أن نشدد نريد. الصدر و جراحة المخ و االعصاب إختصاصيي بالتعاون بين بنجاح بعد التشخيص مباشرة تم عالج الحالة. الدماغية .ات ذات الصلة في عالج مثل ھذه الحاالتألھمية التشخيص المبكر و التنسيق السريع بين التخصص ھنا

Abstract The commonest surgical treatment for hydrocephalus is ventriculoperitoneal shunting of the cerebrospinal fluid (CSF). Ventriculopleural shunt has been used scarcely as an alternative procedure. Hydrothorax due to excess CSF accumulation in the pleural cavity is a very rare complication of either way of shunting and is more likely to occur with the latter. We report a very rare case of a 20 years old man who presented with a massive CSF hydrothorax from a ventriculopleural shunt. As soon as the condition was recognised, the patient was ___________________________________ Corresponding author El Fatih M Bashir El Malik FRCSEd, FRCS (Surg. Neuro.) FACS Neuro Spine Centre, El Ribat University Hospital, Khartoum, Sudan Email: [email protected]

managed jointly by Pulmonologists and Neurosurgeons with a successful outcome. Early diagnosis and interdisciplinary planning of management are emphasised. Keywords: massive hydrothorax, hydrocephalus, ventriculopleural shunt Introduction CSF diversion procedures have been well established for decades for the treatment of hydrocephalus(1-2). Through the history, CSF has been shunted to different locations in the body that included the jugular vein, right atrium, pleural cavity, stomach, ureters, fallopian tubes, gallbladder, thoracic duct, ileum, salivary ducts, mastoid air cells and the peritoneal cavity(1-6). The latter site is the preferred and most commonly used nowadays. However, ventriculoatrial and ventriculopleural shunts are still used, though rarely, by some surgeons as alternative procedures when there are


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Review Article Massive hydrothorax El Fatih M Bashir

contraindications to ventriculoperitnoeal shunting(2,7-8). Due to complications like pleural effusion, ventriculopleural shunt is very rarely used now. We hereby report a rare case of CSF massive hydrothorax from a malfunctioning ventriculopleural shunt in a 20 years old Sudanese man highlighting the importance of early diagnosis and the role of interdisciplinary joint management planning in such cases. Case Report A 20-year-old man was referred to the Pulmonology Unit in El Ribat University Hospital in Khartoum by a chest physician elsewhere for thoracoscopy. The patient presented there with progressively worsening shortness of breath and right sided chest pain over a 2 months period. There was no cough, fever or weight loss. Investigations in the referring hospital revealed a massive right-sided pleural effusion for which repeated therapeutic pleurocentesis were performed with subsequent recurrences. Pleural fluid analysis there demonstrated clear colourless fluid with the following results: Protein 0.3 g/L, glucose 70 mg /Dl. Cytology, gram stain and Z N stain were all negative. The effusion was proven to be a tansudate, but there was no obvious explanation, in particular there was no cardiac, liver or renal disease and his serum albumin was normal. The reason for referral was to do further assessment by thoracoscopy with a view to taking pleural and/or lymph node biopsy under direct vision. On examination in El Ribat University Hospital, the patient looked ill and was tachypnoeic with a respiratory rate of 27/min. His pulse rate and blood pressure recordings were within normal. There were clinical and radiological evidence of massive right sided pleural effusion (Fig1) that obscured the shadow of the shunt tube. Neither the patient, who was then quite distressed, nor his escorts volunteered to give past history of CSF shunt surgery at this stage. The patient underwent thoracoscopy. The procedure started

smoothly. Thoracoscopic view confirmed the presence of a massive colourless pleural effusion with normal looking parietal pleural. Upon drainage of the effusion, the patient started to become irritable and confused and soon developed epileptic seizures. The procedure was terminated and an intercostal chest tube was inserted. After stabilizing his condition, Computerized Tomography (CT) scans of the chest and head with reconstruction of the chest image revealed the ventriculopleural shunt. Neurosurgical consultation was made accordingly. Fig 1: Initial Chest X- ray showing massive right sided pleural effusion (complete whiting of the right side hemithorax) causing mediastinal shift. Note that the shunt tube on the right side is obscured

Chest CT scan (Fig 2) showed the newly inserted intercostal tube together with another tube seen entering the fluid-filled pleural cavity anteriorly. Re-examination showed a wound scar on the mid anterior chest wall on the right side. A fine tube could be felt subcutaneously descending along the chest wall and disappearing at the level of the scar. The head CT scans (Fig 3) demonstrated a right sided ventricular shunt tube with signs of cerebrospinal fluid (CSF) overdrainage. There was evidence of an air bubble in the frontal horn of the collapsed right lateral ventricle. At this point it became apparent that this patient had had a ventriculopleural shunt


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Fig 2: CT scan of the Chest showing the distal shunt tube (yellow arrows) and the intercostal chest tube (red arrow) in the pleural cavity


that led to massive hydrothorax due to CSF overdrainage. History obtained from relatives confirmed past surgery for insertion of a shunt tube in early childhood. Apparently, this was a ventriculoperitnoeal shunt to start with. At

around age 16, as the distal tube shortened and pulled out of the peritoneal cavity, the treating surgeon simply inserted it into the pleural cavity instead of replacing or elongating it.

Fig 3: Head CT scan showing a ventricular catheter overdraining CSF and an air bubble (red arrow) in the frontal horn of the collapsed ventricle

This transformed the original ventriculoperitoneal shunt into a ventriculopleural system. As soon as we realized that, a management plan was set jointly by the Neurosurgery and Pulmonology teams. The chest tube was clamped

temporarily and the patient was taken urgently to the operating room for exteriorization of the ventricular shunt tube under local anaesthesia. The initial External Ventricular Drainage (EVD) pressure was set at 15 centimetres of water. The neurological condition of the patient improved and he regained full consciousness in due course. Later, an attempt was made to wean him from CSF shunting by gradually elevating the EVD pressure. The trial failed as the patient could not tolerate the process. A series of follow up chest x-rays demonstrated progressive clearance of the pleural effusion and the chest tube was eventually removed after the new shunt insertion (Fig 4). This was done under general anaesthesia 3 days later when a new CSF diversion procedure, namely a ventriculoperitoneal shunt was inserted on the left side. The old right sided ventricular catheter was removed but the distal tube to the pleural cavity was found stuck hence was tied off and left in place. The patient was discharged home well on the third post operative day.


177

Fig 4 (a) Fig 4 (b)


Fig 4: Chest X-rays following the insertion of a new left sided ventriculoperitnoeal shunt system (red arrow). The

pleural catheter of the old right sided ventriculopleural shunt (yellow arrow) could not be removed and was left in place. Figs (a) before and (b) after removal of the intercostal tube (white arrow)

Discussion CSF diversion procedures have long been practiced for the treatment of hydrocephalus(1-2). Although ventriculo-peritnoeal shunting is considered as the standard method of treatment, there are incidences where other sites, like the pleural cavity, are still chosen when for reasons that preclude the use of the peritoneal cavity. Examples of such contraindications include active inflammation within the peritoneal cavity, adhesions due to past operations and ascites. Ventriculopleural shunts were used more often in the 1980s and 1990s. Small pleural effusions associated with the procedure were considered acceptable and were treated conservatively while intervention was reserved for rare incidences of progressive symptoms and increase in size of effusion(9-10). Large hydrothorax due to excess CSF accumulation in the pleural cavity has been reported though rarely(11-16). Fox et al recommended that physicians treating patients with ventriculopleural shunts should make the patients and their caregivers aware of the condition and the associated risks so that complications like hydrothorax could be anticipated and treated at early stages(18). Technically speaking, there is a valve system

incorporated in the shunt tubing which is set to allow CSF drainage only when the intracranial pressure rises above the level of the valve pressure. More recently, anti siphon devices, that prevent CSF overdrainage due to the gravity factor, have been added to the valve system in order to help reduce the complication rate of CSF overdrainage(18). With the advent of such new devices some surgeons advocated more use of ventriculopleural shunts(19). Like all manufactured medical devices, these could fail or malfunction as happened with our case. Due to the large surface area available for CSF absorption in the peritoneal cavity and less complication rate as compared to the use of the pleural cavity, ventriculopleural shunting has been largely abandoned by many surgeons in favour of ventriculoperitnoeal shunts(1-2,7,14-16). However, the use of ventriculoperitnoeal shunts did not totally avert intrathoracic complications and cases of hydrothorax from intrathoracic migration of peritoneal shunt catheters have been reported(11-13). Causes include upward migration of the distal end tube through a congenital defect communicating the peritoneal and pleural cavities, pressure effect of repeated trauma to the diaphragm or


178


surgical trauma at the time of subcutaneous tunneling to place the peritoneal tube in place(11-13). Moreover, about 12 case reports of even more serious cases of intra cardiac migration of distal peritoneal shunt tubes have been reported in the literature(20-21). All these case reports imply the fact that physicians treating shunted hydrocephalic patients should bear in mind the rare possibility of such serious complications. The shunt valve system used in our patient was some 20 years old and most likely the valve failure lead to shunt malfunction with consequent CSF overdrainage into the pleural cavity. Rapid release of the CSF from the pleural cavity at the time of thoracoscopy lead to more siphoning of the ventricular CSF which caused sudden drop of the intracranial pressure. This lead to the irritability experienced by the patient and epileptic seizure. As soon as the patient’s condition was recognised a management plan was set jointly by the Neurosurgery and Pulmonology teams. First the intercostal chest drain was clamped temporarily to correct the negative intra pleural pressure causing intracranial hypotension. The patient was then taken to the Operating Room promptly to exteriorise the shunt tube as an EVD system. The proximal ventricular catheter was used as the distal catheter going into the pleural cavity was stuck there and could not be removed. It is advisable in such circumstances to try and wean the patient off the shunt system if that were feasible. However, this did not work in our case as the patient complained of headaches as soon as we started to raise the drainage pressure gradually. He was clearly shunt dependant and for that reason we planned to insert a new ventriculoperitoneal shunt system. Had we had the neuroendoscopy set at the time we would have performed an internal CSF diversion procedure, namely a third ventriculostomy, which would have obviated the need of further shunt insertion. The patient condition

improved rapidly from both the chest and brain aspects. It was clear from this case that joint interdisciplinary teamwork helped achieve a satisfactory outcome. The authors strongly encourage and recommend more joint interdisciplinary approach and team work in our country when treating patients with multisystem problems. Not only does that help offer patients the best available treatment but also promote exchange of knowledge and experience between different medical specialities. The morbidity that was encountered following the rapid drainage of CSF from the pleural cavity could have been avoided if it was known that the patient had had a ventriculopleural shunt tube in situ. This was not readily available under the circumstances encountered in this case. Despite just what has been said, we reemphasize on the importance of thorough history taking and full clinical examination to safeguard against medical mishaps. Ideally, and like those on long term steroid therapy, drug allergy, postspleenectomy, etc..., this kind of patients should be fully informed about their condition and be provided with Medical Alert Cards to carry all the time. In conclusion, when a previously shunted hydrocephalic patient presents with features of pleural effusion one should bear in mind that CSF overdrainage might be the cause. This rare phenomenon could happen not only from a malfunctioning rarely used ventriculopleural shunt, but also from migration of the distal end of the more commonly used ventriculoperitnoeal shunt. Timely recognition of the condition and appropriate treatment planning in a multidisciplinary approach can lead to satisfactory outcome and avoid morbidity. Bearing a high index of suspicion is a prerequisite to such result. Treating physicians must provide such patients and their caregivers’ full information about the condition and provide an alert card to be carried by them. It is high time for physicians and health care workers in Sudan to encourage


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and adopt the culture of more interdisciplinary links and teamwork for the best interest of our patients. References 1. Mccullough DC. History of the treatment of

hydrocephalus, in Scott MR (ed): Hydrocephalus. Baltimore: Williams & Wilkins;1990.p.1-10.

2. Jason I Lifshutz JL, Johnson WD. History of hydrocephalus and its treatments. Neuro Surg Focus 2001 Aug 15;11(2):E1.

3. Haynes IS. Congenital internal hydrocephalus: its treatment by the drainage of cisterna magna into the cranial sinuses. Ann Surg 1913;57:449

4. Harsh GR III. Peritoneal shunt for hydrocephalus, utilizing the fimbria of the fallopian tube for entrance to the peritoneal cavity. J Neurosurg 1954; 11:284-94.

5. Becker DP, Nulsen FE. Control of hydrocephalus by valve-regulated venous shunt: avoidance of complications in prolonged shunt maintenance. J Neurosurg 1968;28:215-26.

6. Bernstein RA, Hsueh W. Ventriculocholecystic shunt. A mortality report. Surg Neurol 1985;23:31-7.

7. Rekate HL. Treatment of hydrocephalus, in Cheek WR, Marlin AE, McLone DG, Reigel DH, Walker ML (eds): Pediatric Neurosurgery: surgery of the developing nervous system, ed 3. Philadelphia: WB Saunders; 1994.p.202-20.

8. Kupeli E, Yilmaz C, Akcay S. Pleural effusion following ventriculopleural shunt: case reports and review of the literature. Ann Thorac Med 2010 Jul;5(3):166-70.

9. Hoffman HJ, Hendrick EB, Humphreys RP: experience with ventriculopleural shunts. Child Brain 1983;10:404-13.

10. Piatt JH Jr. How effective are ventriculopleural shunts? Pediatr Neurosurg 1994;21:66-70.

11. Dickman CA, Gilbertson D, Pittman HW, Rekate HL, Daily WJ. Tension hydrothorax from intrapleural migration of a ventriculoperitoneal shunt. Pediatr Neurosci 1989;15:313-6.

12. Doh JW, Bae HG, Lee KS, Yun IG, Byun BJ. Hydrothorax from intrathoracic migration of a ventriculoperitoneal shunt catheter. Surg Neurol 1995 Apr;43(4): 340-3.

13. Martin LM, Donaldson-Hugh ME and Cameron MM. Cerebrospinal fluid hydrothorax caused by transdiaphragmatic migration of a ventriculoperitoneal catheter through the foramen of Bochdalek. Childs Nerv Syst 1997 May;13(5):282-4.

14. Beah C, Manthey DE. Tension hydrothorax due to ventriculopleural shunting. J Emerg Med 1998 Jan-Feb;16(1):33-6.

15. Wu TS, Kuroda R. Tension hydrothorax in a pediatric patient with a ventriculopleural shunt. J Emerg Med. 2010 Apr 2 [Epub ahead of print].

16. Irani F, Elkambergy H, Okoli K, Abou DS. Recurrent symptomatic pleural effusion due to a ventriculopleural shunt. Respir Care 2009 Aug;54(8):1112-4.

17. Fox BD, Nayar VV, Johnson KK, et al. Routine imaging in patients with ventriculopleural shunts; lessons learned from a case of tension hydrothorax. J Neurosurg Pediatr 2008 Dec;2(6)385.

18. Martinez-Lage JF, Torres J, Campillo H, et al. Ventriculopleural shunting with new technology valves. Childs Nerv Syst 2000;16(12):867-71.

19. Torres LJ, Rios ZA, Martinez LJF, et al. Ventriculopleural shunt to treat hydrocephalus. Arch Bronconeumol 2002 Nov;38(11):511-4.

20. Rizk E, Dias MS, Verbugge J, Boop FA. Intracardiac migration of a distal shunt catheter: an unusual complication of ventricular shunts. Report of 2 cases. J Neurosurg Pediatr 2009 Jun;3(6):525-8.

21. Ruggiero C, Spennato P, De Paulis D, Aliberti F, Cinalli G. Intracardiac migration of the distal catheter of ventriculoperitnoeal shunt: a case report. Chlds Nerv Syst 2010 Jul;26(7):957-62.


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Letter to the Editor

Short communication on differences in prescription of sedative and analgesics Sohel MG Ahmed, MBBS, FCARCSI, EDA&IC

Anaesthesia Clinical Fellow in Hepatobiliary & Liver Transplant

Dear Editor We would like to congratulate Dr Mohamed and Dr Elsaid on their efforts to explore the sedation and analgesia practices in Sudanese ICUs(1). However, we found the study severely limited by a number of methodological, factual and statistical flaws.

First, the study targeted 40 ICU physicians working in ICUs. There was no mentioning of the response rate they received or any information regarding the distribution of those physicians.

Second, the study failed to mention - or did not look into - the various types of ICUs involved e.g. adult vs. paediatrics, medical vs. surgical, neuro, cardiac, etc. Sedation practices differ significantly according to its ICU population(2-4); while some sedatives e.g. propofol could be widely used in adult medical and surgical ICUs, it’s use in paediatric settings would be considered obsolete in many units secondary to fears of Propofol Infusion Syndrome(5-7). Thiopentone infusions could be justified in cases of refractory seizures in neuro ICUs, but its routine use outside this setting would be difficult to comprehend.

Third, we strongly disagree with the statement that “sedation is a universal requirement for all patients in intensive care units”(1). As a matter of fact, many studies have looked into, and documented, the major disadvantages of “umbrella sedation” of ICU patients(2,3,5-7). Sedation holidays or interrupted sedation is a well recognized practice in many ICUs around the world(8,9). In our unit, a mixed surgical and medical adult ICU, sedation and analgesia is used very selectively, mainly to facilitate interventions e.g. central line insertions, chest drain insertions and removal, etc. This no-sedation approach has multiple merits, allowing routine reliable neurological assessment, spontaneous ventilation, and minimum haemodynamic interference in addition to early ICU and hospital discharges(8,9). In a recent study in Critical Care Medicine, Strom et al argued that “a protocol of no sedation applied to critically ill patients undergoing mechanical ventilation does not increase the risk of long-term psychological sequelae after intensive care compared to standard treatment with sedation”(10).

Fourth, it is not clear whether the study was single blinded or not. Physicians might tend to answer a self administrated questionnaire according to their best knowledge –i.e. in an exam fashion - rather than their current practice if there was a potential to be identified!

Fifth, stating that “the ICU practice in Khartoum State is representative to the ICU practice in Sudan”(1) is a groundless and misleading information. There are huge discrepancies in the allocation of medical services between Khartoum State and the remaining parts of the country, and by no means is intensive therapy services an exception(11).

Sixth, the authors failed to apply any meaningful statistical test to their results to reflect whether or not a statistical significance was present among the various practices.

Our critique to this study comes secondary to our solid believe in its importance. Intensive care therapy is in its infancy in our nation and studies looking into our early practices and outcomes could not be emphasized enough. The authors stated by exploring the current situation they aim to “help to reach a consensus towards establishment of protocols regarding the use of sedatives and analgesics in ICU”(1). In order for that to materialize, we believe that these studies must be well structured, more comprehensive and properly analysed if better outcomes, which would reflect on the practice, are sought.


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Letter to the Editor Sedative and analgesics Sohel MG Ahmed, Hadab A Mohamed

References 1. HA Mohamed, MM Elsaid. Differences in

prescription of sedative and analgesics in ICU practise in Sudan. Sudan Med J 2010;46(3):142-7.

2. SB Bavdekar, MD Mahajan, KV Chandu. Analgesia and sedation in paediatric intensive care unit. Journal of Postgraduate Medicine 1999;45(3),95-102.

3. Joly LM, Raggueneau JL. When and how to start sedation in a neuro-intensive care patient. Annual French Anaesthesia 2004 May;23(5):522-7.

4. J Clark, L Voss, J Barnard, et al. Implicit memory formation in sedated ICU patients after cardiac surgery. BJA 2003;91(6):810-814.

5. Bray RJ. Propofol infusion syndrome in children. Paediatric Anaesthesiology, 1998;8(6):491-9.

6. Parke TJ, Stevens JE, Rice AS, et al. Metabolic acidosis and fatal myocardial

failure after propofol infusion in children: five case reports. BMJ 1992 Sep 12; 305(6854):613-6.

7. Corbett SM, Montoya ID, Moore FA. Propofol-related infusion syndrome in intensive care patients. Pharmacotherapy 2008 Feb;28(2):250-8.

8. Curtis N Sessler, Wolfram Wilhelm. Analgesia and sedation in the intensive care unit: an overview of the issues. Critical Care 2008;12(Suppl 3):S1.

9. Thomas Stom, Torban Martnussen, Palle Toft. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. The Lancet 2010 February;375(9713):475-80.

10. Thomas Stom, M Stylsvig, Palle Toft. Psychological long-term effects of a no-sedation protocol in critically ill patients. Critical Care 2011;15(Suppl 1):359.

11. http://www.fmoh.gov.sd/yearlyReports/health_facilities_08.pdf. Visited 07/04/2011.

Author’s Response

Differences in prescription of sedative and analgesics Hadab A Mohamed, MD

Associate Professor of Anaesthesia and Intensive Care Faculty of Medicine, University of Khartoum, Sudan

Dear Editor

I would like to thank Dr Sohel M G Ahmed for his valuable short communication that revealed his interest in this subject.

I would like also to show that this is the first effort done in Sudan to expose the situation of sedation practice in our ICUs, that is to say, this is a descriptive observational study constituting an important first step in the search for the generation of a solid ground for other researchers towards more elaborate experimental studies and for the policy makers to allocate resources more efficiently.

Descriptive studies are observational studies which are often the first step or initial enquiry into a new topic. Common misuses of descriptive studies involve a lack of a clear, specific and reproducible case definition and establishing a casual relationship which the data cannot support. Descriptive studies do not have a comparison (control) group which means that they do not allow for inferences to be drawn about associations, casual or otherwise.


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Letter to the Editor Sedative and analgesics Sohel MG Ahmed, Hadab A Mohamed

The study targeted 40 ICU physicians working in Khartoum state ICUs because they are the only physician practicing ICU medicine in Sudan, and they responded completely to the short questionnaire.

All the study population used to practice this specialty in more than one hospital, which all lack the criteria of being specialized ICUs. The study has clearly mentioned, in its recommendation, the need for establishing more specialized ICUs.

Although sedation and analgesia allow the patient to tolerate the physical environment, and the unpleasant procedures and therapies that are necessary in the ICU, facilitate nursing care and management, and reduce both anxiety and stress, Dr Sohel disagreed with the statement mentioned by Ramsay MAE(1) who stated that virtually every patient admitted to the intensive care unit should be administered sedation therapy; this should be applied to all patients in ICU, whether mechanically ventilated or not. The statement of conflict is worth to be mentioned in the study discussion which is basically meant to reveal different ideas about sedation practice in ICU. However, the subjects for sedation in this study are mechanically ventilated patients, in whom I think D. Sohel will agree with me that they ALL need sedation. Nevertheless, Dr Sohel mentioned that sedation and analgesia is used very selectively in his unit to facilitate interventions e.g. central line insertions, chest drain insertions and removal, etc. I can’t imagine an ICU without this, in addition to routine unpleasant nursing procedures, being done on daily basis. So, all ICU patients at one time of the day may need a variable degree of sedation and analgesia and this does not entails that all patients in ICU are subjected to “umbrella sedation”, and overall, the study is exploring the real, not the ideal, situation of sedation practice in Sudanese ICUs.

It goes without saying that this study is a single blinded as we have no control group in our initial survey about an unexplored situation. Whether the physician might tend to answer the questionnaire according to their best knowledge rather than their current practice is obvious in the results seen in this study which revealed some deviations from what has been agreed upon as standard sedation practice.

Stating that “the ICU practice in Khartoum State is representative to the ICU practice in Sudan” is not a groundless and misleading information. I think Dr. Sohel, although he is Sudanese, is not exposed to ICU practice in Sudan, where priorities are lacking, he is thinking in an ideal way and seeking for perfection. I agree with him that there are huge discrepancies in the allocation of medical services between Khartoum State and the remaining parts of the country, and concerning the intensive therapy services, the exception is that there is neither such service in the remaining part of the country nor a single ICU physician.

In this observational study, which does not involve experimental manipulation nor control group, our descriptive statistics summarize the population data by describing what was observed in the sample numerically and graphically. We think that frequency and percentage are more useful in terms of describing categorical data and it is difficult to apply any meaningful statistical test to the results to reflect whether or not a statistical significance was present among the various practices.

Finally, I would like to thank again Dr Sohel for his tough and valuable critique to this study which is aiming to explore the current situation and I agree with him that intensive care therapy is in its infancy in Sudan, but this is not enough to withhold studies that ring a bell when a wrong practice is existing. I think this is a kick start for more comprehensive studies in the field of ICU. References Ramsay MAE, Savege TM, Simpson BRJ, Goodwin R. Controlled sedation with alpaxalone-alphadolone. British Med J 1974;2:656-9.


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Letter to the Editor

Towards a less paternalistic approach to patient care in Sudan Elnazeer O Ahmed, MBBS, MD, FRCS

Cardiac Surgery Division, King Abdullah Medical City, Mekkah, KSA

Dear Editor The physician-patient encounter in Sudan is generally characterized by physicians’ dominance. For quite a while, the dominant approach to making decisions about treatment in the medical encounter has been one of “paternalism”, whereby the physician assumes an attitude similar to the parent towards his child and reciprocally the patient would expects from his physician what the child expects from his parent. In recent years, this model has been challenged by doctors, medical ethicists, and researchers who advocate more of autonomy for patients(1). There are four defined models of interaction between patients and their physicians; the “paternalistic model” mentioned above, the “shared treatment decision making model”, the “informed model” and the “consumerism model”(2).

The paternalistic approach prevailed prior to the 1980s in North America because, by then, and for most illnesses, a single best treatment existed and that physicians generally would be well versed in the most current and valid clinical thinking. Moreover, because of their expertise and experience, physicians were in the best position to evaluate the trade-off between different treatments and to make the treatment decision. Most importantly is that physician legitimation in clinical practice in North America was buttressed by a punch of ethical codes and legislatures, an aspect that may exist in Sudan, but not solidly in the culture of neither the patient or a third party payer. Since the patient rather than the physician would have to live with the consequences of management trade-offs, the assumption that physicians were in the best position to evaluate and weigh these was increasingly challenged(2). Apparently, the paternalistic approach lingered around in the Sudan not only because of the illiteracy on the part of some of the Sudanese patients, but also because of, believably, a less positive attitude from the physician side who either has inherited this approach or is working in haste because of the time consuming shared treatment decision making and the informed models. Assumed values, such as personal loyalty and unquestioning obedience from the patient’s side and extreme benevolence (commitment to do good) from the physician’s side, are not reliable enough to ensure practice safety for an observer to the clinical arena both in public and private sectors.

The “shared treatment decision making model” involves bidirectional flow of information between the patient and the physician. It recognizes the autonomy and responsibility of both health professionals and patients(3). A reasonable literacy level is required from the patient’s side as well as skills, patience and honesty from the medical practitioner. Arguing that time constraints would limit adoption of this model is invalid because quick encounters with patients would lead to immature decisions and the need for further visits and more time and resources consumption.

In the ‘informed model’, the patient proceeds through the deliberation and decision making process on his own. The physician's role is limited to providing medical information that will enable the patient to make an informed decision. Underlying this model are two assumptions. The first is that, as long as patients possess current scientific information on treatment benefits and risks, they will be able to make the best decision for themselves. The second is that, physicians should not have an investment in the decision-making process or in the decisions made.


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Letter to the Editor Paternalistic approach Elnazeer O ahmed

Which works well in Sudan? To our knowledge there is no previous survey to examine Sudanese patient’s wishes with regards to this subject. However, physicians should offer patients the opportunity to participate by sharing responsibility and actively engaging patients in the process of making decisions. Physicians require accurate information regarding individual patients’ preferences in order to achieve this goal and to avoid inaccurate or biased assumptions about the patient’s wishes. Whilst more literacy is accrued, a hybrid approach would suit clinical practices in central hospitals with an attitude towards more patients’ participation where conditions allow. Moreover, trainees and physicians with prospects of future practicing abroad may want to be well versed with models with more patients’ participation in decision making process. References 1. Emanuel EJ, Emanuel LL. Four models of

the physician patient relationship. JAMA 1992;267:2221-6.

2. Levine MN, Gafni A, Markham B, et. A bedside decision instrument to elicit a patient's preference concerning adjuvant

chemotherapy for breast cancer. Ann Intern Med 1992;117:538. 3. Cribb A, Entwistle VA. Shared decision

making: trade-offs between narrower and broader conceptions. Health Expect 2011; 14(2):210-9.


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Short Communication

A commentary on the “short communication on the 90th anniversary of Omdurman Midwifery Training School (OMTS)”:

where are we now?

Mohamed H Baldo, MPH, FRCOG Professor of Obstetrics and Gynaecology, Al Zaiem AlAzhari University, Sudan

محمد حسن بلدو

عن الذكرى التسعين لمدرسة القابالت بام درمان التواصل القصيره تعقيب على رساله

:خالصهقرابة االربعين بخدمات القباله المعقب الحتكاك بام درمان و بالنظر الى مدرسة القابالت الذكرى التسعين النشاء بمناسبة القصيره التواصل رساله بقراءةعلى للتعليق مھنى ھناك التزام فقد رؤى أن -1989- 1978بين االعوام - النساء و الوالده بمستشفى الوالده بام درمان ه كاختصاصى ألمراضمنھاعشر, عاما

و ن الذاتو الثقه و نكرا باالتزام على االخص و جنينھا فى خطر كما و أن الفرد معجب فيھا حياة االم تكون التى للمواقف خاصة عند االعتبار و الرساله االھتمام يصاب باالحباط لقلة بعضنا احيانا و بالمقابل فالواحد منا م تنقص قد الشجاعه التى تتحلى بھا قابلة القريه و التى و االنقطاع للمھنه و احترام للنفس

يؤمن على جھد صاحب الرساله ويود المعلق أن كما والتراخى و عدم اتخاذ ما يلزم لحل مشاكل القابالت Abstract On reading the short communication on the 90th Anniversary of Omdurman Midwifery Training School (OMTS) and considering one’s involvement with midwifery care for about forty years, ten years as an obstetrician at Omdurman Maternity Hospital (OMH) between1978-1989, one felt obliged to comment on some aspects of interest in the communication. This is particularly so on considering situations where the life of a healthy woman and her baby are at a stake. One admires the midwife’s commitment, confidence, self-denial, self-respect, dedication, endurance and courage, which some of us may lack. Alternatively, one is distressed by the disinterest, ambivalence and inaction to adequately address midwifery problems. The authors’ of the short communication initiative is acknowledged. The aims of the commentary 1. To commend the author, a physician, and

the editor on publishing the short communication.

____________________________________ Corresponding author Mohamed Hassan Baldo Tel. Mob. 0912786400/Home 87511792 Email: [email protected]

2. To highlight the role of midwifery training in setting the stage for the establishment of the local Obstetric and Gynaecological specialty.

3. To describe the progress and current status of midwifery training/services, citing publications, mainly by local authors.

4. To emphasize the need for strengthening midwifery care with support of the Obstetric and Gynaecological Association.

An Arabic abstract It is worthwhile noting that the short communication was started by an Arabic abstract for non-English speaking health workers, such as health visitors, nurse midwives and partly literate village midwives (VMWS). Hopefully, the journal was distributed to paramedical schools, as well. The communicator’s initiative One commends Professor Tarik A ElHadd on his short communication on the 90th

anniversary of the (OMTS)(1). He, being a physician rather than an obstetrician or community health consultant, his zeal and interest in midwifery are appreciated, the management and technical aspects of midwifery being the sole functions of the above two specialties. One thus speculates what made a physician become concerned


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Short Communication OMTS Mohamed H. Baldo

with the issue. The publication is rather attractive and appealing to oneself for several reasons, most important of which, is that the commentator was exposed to midwifery as a student, which made him opt for Obstetrics and Gynaecology as a career. The role of the pioneers One’s comments also acknowledge the role of pioneers in initiating and developing midwifery and obstetrics and gynaecology services and their contribution to their promotion and the documentation. The leading role of Wolf sisters in establishing midwifery services in Sudan is highly acknowledged. Besides the establishment of the (OMTS) in 1922, they started the first ante-natal clinic (ANC) in 1930. By then, 624 midwives (MWs), 40 nurse midwives (NMWs) and 12 health visitors (HVs) were trained(2). Types of midwives It is important here to distinguish between nurse midwives, who are originally nurses, trained in midwifery at obstetrical and gynaecological units, to work there on graduation. A distinction is also made between village midwives (VMWs), trained at midwifery schools and the traditional birth attendants (TBAs) who are untrained (unskilled) attendants by inheritance, apprenticeship or interest. They are unrecognized officially and are expected to be phased out and replaced by trained VMWs, who may be their daughters. Historical perspectives and implications The communication reads: “the OMTS had very much set for a historic and unprecedented venture of training in modern times. It initially targeted training of traditional midwives (Dayat Al Habil) to modern midwives, propagating the concept of midwifery and child health care countrywide”. The latter statement preceded the later global emergence of Maternal and Child health and Family planning concept (MCH/FP) in 1978 as a major component of PHC. The Sudan

MCH/FP Project was thus launched in 1979 at OMH. The first revision and updating of the curriculum of HVs was undertaken at the Educational Development Center (EDC), Khartoum in 1982, with guidance by late Professor Abdul Rahman A/Salam, peace be on his soul. That workshop was jointly supported the Ministry of Health, the World Health Organization (WHO) /United Nations Fund for Population Activities (UNFPA), as part of the MCH/FP Programme. Later still, the Federal Ministry of Health issued the HVs and NMWs curricula in 1992. The population issue was alluded to in the communication on referring to the erection of Makwar Dam and the establishment of the Gezira Scheme after the Mahadia era. The population issue was later globally addressed in the sixties on the advent of contraceptive pill. In the early eighties, a success story by the community medicine department and Columbia University, USA was published, involving VMWs in the delivery of Family Planning services, mainly pill distribution(3). Midwifery training and services Recruitment of midwives and training them, initially for three months, was initiated in 1922 in the three towns of the capital, preceded by the medical assistants training at Port Sudan in 1918. Tutoring and coaching of midwives was the mainstay of teaching. The trainees attended 20 lectures and were to deliver a minimum of 20 cases and see another 20 cases together with another pupil midwife. Practical and oral exams were then conducted at the end of each study course by British Medical Officers from the MSD. Students who passed were given certificates to practice midwifery all over the country. Hygiene, cleanliness and safety were stressed from the start. Today the three cleans: clean hand, clean place and clean equipments are being stressed. Good manners, morals and cleanliness were similarly inculcated. Ethical issues are unfortunately not included in some


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current medical school curricula. Village midwives attend antenatal clinics at the health center and may accompany at-risk cases to hospital, to deliver a report on mothers’ condition. Supervisory tours were made to satellite training schools countrywide and to midwives by an HV or even an obstetrician, to follow-up the performance of MWs and have feedback from local communities. The visit might include selecting new recruits. Antenatal, infant and child welfare clinics were established and are continuing till the present time. The midwifery training activity, no doubt, set the stage for training medical students, as well as, registrars of obstetrics and gynaecology later on. Medical students, till recently, were required to conduct 20 normal deliveries, including home deliveries, at the end of fifth year, reported as a student’s book. Developments in midwifery The number of village midwifery schools now had reached to 40. Health visitors are responsible for village midwifery training and for providing MCH services at health centers. The history of establishing VM schools countrywide was presented to an earlier congress of obstetrics and gynaecology in 2003(4). Assistant HVs, originally literate VMWs, were later introduced by Dr Shallabi at the province of Atbra in the seventies, as a new cadre, to extend HVs services to rural areas and be a career pathway for VMWs. Personal perspectives In 1965, as a medical student, one conducted the required 20 deliveries at El Obeid midwifery school, Al Rahad, Um Ruaba, Ashana, coached by a VWF. The late Sit El Taya was the principal of El Obeid Midwifery School. Later on, she worked under oneself as Director of Maternal and Child Health in the Ministry. One could not dare to object to any of her views. Mentioning the establishment of midwifery schools, El Obeid one was opened in 1940, rather of interest to the commentator,

being born on 11th December 1940. The delivery was assisted by a VMW called Bit ElSharif. The role of obstetricians and gynaecologists The Obstetrical and Gynaecological Society, being challenged by the high maternal mortality ratio (MMR) and realizing the role of midwifery in reducing it, has made the future of midwifery services its main theme for the forthcoming Obstetrics and Gynaecology mid-term symposium, to be held in February 2012. Publications on midwifery, local and abroad Midwifery in Sudan was the subject for many publications by nationals as books, articles and conference papers and agency reports. The Internet has limited citations on midwifery in Sudan. As early as the seventies Professor Bayoumi highlighted midwifery services(5). He later studied the outcomes of Maternal and Child Health services at a Nuba Mountains’ communities, published locally(5). Replacing TBAs by VMWs described TBAs in countries was published by WHO(6). Professor Bella published his PhD thesis on the Sudanese VMW, obtained from London University in 1984(7). The role of VMs in ANC services was studied by interviewing mothers and midwives and was published. A total of 130 mothers delivered within six months were responders. Seventy per cent of pregnant mothers contacted a VMW at least once during pregnancy, the average number of visits being 3.6 times per mother. Half of the mothers were seen at the MWS own home, while 20% were seen at their mothers home. Seventy six per cent of the deliveries were attended by the VMW and 11% by a TBA and remainder at hospital. The VMWs had reasonable knowledge and competence, including referral. However, there was lack of support, supervision and supplies(8). Seventeen nurse-midwives from Khartoum and Omdurman hospital played a role in infibulation and


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Reinfibulation(9a, 9b ). In the US, obstetricians feel midwives could alleviate some pressure. Family physicians deliver babies when there are no complications. When there is shortage of physicians, midwives help in this situation, doing most of the normal deliveries. The need for the obstetrician is 30%, to do forceps and caesarean sections (CSs), the rest is done by the midwife, in the absence of family physicians. Most physicians do not oppose midwives. “A creative solution regarding lack of obstetricians is to develop a midwifery program for midwives to work in hospitals, where they can handle the uncomplicated births”(10). Where are we now? A situational assessment of midwifery services was provided by the Family Health Survey results in 2006. The road-map for reducing maternal and newborn mortality in Sudan, 2009 gave the coverage of villages by VMWs of 54.6%; home deliveries were 79.5% %(11). The Annual Health Report for 2009 is another source, but less accurate. The role of MWs in risk-detection was published(12). The Sudanese midwives receive great attention from the international community(13,14,15,16). What may be needed? Specific information needed includes the current number of VMWs, literate or illiterate, HVs, A/HVs and their distribution, taking into consideration the new Sudan. The number of

midwifery schools, their distributions, their requirements entails an accreditation process. Vital rates of births or deaths of mothers and their babies provide an indirect assessment of the quality of maternity care services, midwifery being at the frontline. Organization of midwifery services involves ensuring improving the quality of midwifery services through accurately implementing midwifery standards and indicators. This requires good supportive supervisory services, follow-up monitoring and evaluation. Referral and transfer services require ambulance services. Updating the information on midwifery services will require revising and updating the statistical system. The Head of State issued a decree in support of midwifery care(17). At present, some states are enrolling midwives in the official service examples are Khartoum and Gedarif. Recent developments of midwifery care The number of village midwifery schools now had reached up to 40. Health visitors are responsible for village midwifery training and for providing MCH services at health centers. The history of establishing VM schools countrywide was presented to an earlier congress of obstetrics and gynaecology in 2003(4). Assistant HVs, originally literate VMWs, were later introduced by Dr Shallabi at Atbra in the seventies, as a new cadre, to extend HVs services to rural areas and be a career pathway for VMWs.

References 1. Tarik A ElHadd. Short communication: On

the 90th Anniversary: OmdurmanMidwifery Training School. A history of the earlier beginnings. Sudan Med J 2011 August;47(2):103-10.

2. Kendell EM. A short history of training of midwives in the Sudan. 12261291 [PubMed- indexed for Medline]

3. El Tom AR, Mathews MH, Wessley S, Mubarak N, Lauro D. Introducing integrated

health services in a traditional society; the

Sudan community-based family health project. Int Q Community Health Educ 1984 Jan;5(3):187-202.

4. Asim Zaki. Midwifery in Sudan. Inception, progress and spotlights. In: A/Salam Gerais, Tawfik El-Deeb and A/Rahman Khalid (Editors). Khartoum: the proceedings of 19th congress of Obs & Gynae Conference 2003 March & June.p.32-41.


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5. Bayoumi A El Sayeh. The training and

activity of village midwives in the Sudan. Trop Doctor 1976;(6):118.

6. Hakim, Sobhi El. Replacing TBAs by village midwives, in Mangay-Maglacas A, & Pizurki H (Eds). The traditional birth attendant in seven countries”. World Health Organization, Geneva, 1981.

7. C:\Documents and Settings\ user\Desktop\The Sudanese village midwife sixty___- Hassan Bella Mohamed Elamin - Google Books.mht.

8. A Tigani. The Role of the Village Midwives in Antenatal Care Services in the Sudan J T. Paediatr 1992;38(1):43-48. Doi: 10-1093/Tropej/38/143.

C:\Documents and Settings\user\ Desktop\The Role of the Village Midwives in Antenatal Care Services in the Sudan.mht.

9a. Berggren V, Abdel Salam G, Bergström S, Johansson E, Edberg AK. An explorative study of Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth. Midwifery 2004 Dec;20(4):299-311.

9b.C:\Documents and Settings\user\ Desktop\ Science. Direct-Midwifery An explorative study of Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth.mht

10. Sue Hickey. G:\Ob-gyn feels midwives could alleviate some pressure-News-The

Advertiser.mht>Published 17th July 2008

http://www.gfwadvertiser.ca/News/2008-07-17/article-1405824/Obgyn-feels-midwives-could-alleviate-some-pressure/1

11. Unity Government & the Government Of Southern Sudan. The Sudan Survey for Family Health, 2006.

12. Ibrahim Salah A. The role of village midwives in the detection of high risk pregnancies and newborns. Gynecol & Obstet Int J 1992;39:117-22.

13. The UN agencies give special importance to the village midwives’ experience of Sudan (C:\Documents and Settings\user\ Desktop\Elsevier Article Locator.mht

14. UN Mission in Sudan: Sudan initiative to train more midwives Relief Web, July 2009.<http://unmiss.unmission.org/default.tabid=511&itl=details&mid aspix? 697 & itemID=4722.

15. Report. UN Mission. C:\Documents and Settings\user\Desktop\Sudan Initiative aims to train more midwives ReliefWeb.mht.

16. C:\Documents and Settings\user\ Desktop\Traditional Practitioners as Primary Health Care Workers REFERENCES.mht (WHO).

17. National Ministry of Health/UNFPA. The Directorate General of Preventive Medicine & PHC. Directorate of Maternal & Child health. The Reproductive Health Programme. A skilled Midwife for safe mother & child & a happy family. 5th May 2009.


190

Journal Review

International journal harvest: interesting topics

Mohamed-Elbagir Khalafalla Ahmed, MBBS MD MRCP FRCP (London) FACP FAATM Professor of Medicine, University of Medical Sciences & Technology, Khartoum, Sudan

Preventing malaria : a promising vaccine The WHO estimates that malaria infects 225 million, and kills 781,000 people each year. 92% of those who die of malaria are African children. To put this number in perspective, in 2009 malaria killed more African children than heart disease killed US adults. What if someone suddenly discovered a way to decrease the burden of heart disease by half? Well, today we hear of an intervention that has the potential to achieve a feat of a similar scale in Africa: a malaria vaccine. This week on NEJM.org, the RTS,S Clinical Trials Partnership presents the first results from its ongoing Phase III trial. This randomized, controlled, double-blind trial enrolled over 15,000 children from 7 African countries to assess the efficacy of a candidate malaria vaccine, otherwise known as RTS,S/AS01. The primary endpoint was vaccine efficacy, at one year, among two groups: 6-12 week-olds and 5-17 month–olds. The efficacy of the vaccine is reported among the older cohort of children, who were among the first 6000 enrolled. The control groups received a comparator vaccine — rabies for the older group and meningogoccal for the younger. A secondary analysis was also performed, looking at the rate of severe malaria among a combined age-group category. The results are promising. The vaccine was 55.8% effective against clinical malaria among the 5-17 month cohort. Severe malaria was defined as clinical malaria (fever 37.5° C and Plasmodium falciparum parasite density > 5000 parasites/mL), plus at least one additional clinical indicator of disease severity, such as hypotension, acute lung injury, or decreased urine output. The vaccine was 34.8% effective in reducing severe malaria for the combined age-group category. Safety and tolerability were also assessed. Though the authors conclude that the data thus far suggest that the malaria vaccine has a safety profile comparable to that of other pediatric vaccines, there was a slightly higher rate of convulsive seizure in the first week post-malaria vaccine. Given the overall

low rate of events, it remains difficult to tell if any true differences in safety exist. In looking through this study, and envisioning its potential impact, it is important to remember that more data are forthcoming. Data among the children in the younger cohort will help define the spectrum of safety and efficacy in that key, target population. The possibility of waning vaccine efficacy will be better understood with longer follow-up, which will also help define the impact of the booster vaccine, which is given at 14 months. “Overall, these data are very encouraging. However, a more complete evaluation - when the entire data set is available in about 2 years - will be important in determining the potential, this intervention may have on controlling malaria. Having another tool to deploy in the fight against malaria is an important advance. Of course, the ultimate success of the vaccine will depend not simply on efficacy and safety, but on ongoing public health efforts to make the vaccine widely available and affordable where it is most needed. The good news is that, through the efforts of international organizations, malaria prevention tools such as mosquito nets and indoor spraying are now being used widely. An effective vaccine against malaria would be a welcome addition.

High blood pressure in early pregnancy raises risk of birth defects, irrespective of medication (Research: Maternal exposure to angiotensin-converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study) http://www.bmj.com/cgi/doi/10.1136/bmj.d5931 (Editorial: Fetal risk from ACE inhibitors in the first trimester) http://www.bmj.com/cgi/doi/10.1136/bmj.d6667 Women with high blood pressure (hypertension) in the early stages of pregnancy are more likely to have babies with birth defects, irrespective of commonly prescribed medicines for their condition, finds new research published on

http://www.who.int/malaria/world_malaria_report_2010/en/index.html

http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf



http://www.nejm.org/doi/full/10.1056/NEJMoa1102287

http://www.nejm.org/doi/full/10.1056/NEJMoa1102287


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Journal Review Mohamed Elbagir-Khalafalla Ahmed

bmj.com today. The finding suggests that it is the underlying hypertension, rather than the use of antihypertensive drugs in early pregnancy, that increases the risk of birth defects. Angiotensin-converting enzyme (ACE) inhibitors are a type of antihypertensive medication commonly prescribed to treat hypertension. It is already known that they have a toxic effect on fetuses in the second or third trimesters, but their effects on a fetus during the mother's first trimester is still unclear. So researchers led by Dr De-Kun Li of the Kaiser Foundation Research Institute in California, set out to see if there was an association between using ACE inhibitors during a woman's first trimester and birth defects. They studied data on 465,754 mother-infant pairs from the Kaiser Permanente Northern Californian region between 1995 and 2008. Data was also available on which medications had been prescribed and dispensed to these women. Analysis showed that women who used ACE inhibitors in their first trimester were more likely to have a baby with some form of birth defect compared with women who did not have hypertension or who had not used any form of antihypertensive medication. However, a similar elevated risk was found among women who used other antihypertensive drugs and those with hypertension who did not take any antihypertensive medication. Conclusion: These finding suggests that it is likely the underlying hypertension rather than use of antihypertensive drugs in the first trimester that increases the risk of birth defects in offspring. Biggest ever study shows no link between mobile phone use and tumours (Research: Use of mobile phone and risk of brain tumours: update of Danish cohort study) http://www.bmj.com/cgi/doi/10.1136/bmj.d6387 (Editorial: Mobile telephones and brain tumours) http://www.bmj.com/cgi/doi/10.1136/bmj.d6605 There is no link between long-term use of mobile phones and tumours of the brain or central nervous system, finds new research published on bmj.com today. In what is described as the largest study on the

subject to date, Danish researchers found no evidence that the risk of brain tumours was raised among 358,403 mobile phone subscribers over an 18-year period. The number of people using mobile phones is constantly rising with more than five billion subscriptions worldwide in 2010. This has led to concerns about potential adverse health effects, particularly tumours of the central nervous system. Previous studies on a possible link between phone use and tumours have been inconclusive particularly on long-term use of mobile phones. Some of this earlier work took the form of case control studies involving small numbers of long-term users and were shown to be prone to error and bias. The International Agency for Research on Cancer (IARC) recently classified radio frequency electromagnetic fields, as emitted by mobile phones, as possibly carcinogenic to humans. The only cohort study investigating mobile phone use and cancer to date is a Danish nationwide study comparing cancer risk of all 420,095 Danish mobile phone subscribers from 1982 until 1995, with the corresponding risk in the rest of the adult population with follow-up to 1996 and then 2002. This study found no evidence of any increased risk of brain or nervous system tumours or any cancer among mobile phone subscribers. They studied data on the whole Danish population aged 30 and over and born in Denmark after 1925, subdivided into subscribers and non-subscribers of mobile phones before 1995. Information was gathered from the Danish phone network operators and from the Danish Cancer Register. Overall, 10,729 central nervous system tumours occurred in the study period 1990-2007. When the figures were restricted to people with the longest mobile phone use - 13 years or more - cancer rates were almost the same in both long-term users and non-subscribers of mobile phones. There was no overall increased risk for tumours of the central nervous system or for all cancers combined in mobile phone users. However, as a small to moderate increase in risk for subgroups of heavy users or after even longer induction periods than 10-15 years cannot be ruled out, further studies with large study populations, where the potential for misclassification of exposure and selection bias is minimized, are warranted."


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Coronary computed tomographic angiography (CCTA) is faster and cheaper for diagnosis of chest pain in ER the Journal of the American College of Cardiology, September 27, 2011 issue Low-risk patients presenting to the emergency department with chest pain can be diagnosed more efficiently with coronary computed tomographic angiography (CCTA) than myocardial perfusion imaging (MPI), results of trial published in the September 27, 2011 issue of the Journal of the American College of Cardiology suggest.. The Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial, randomized 699 patients at 16 emergency departments to either CCTA or MPI. All of the patients had symptoms of ischemia, but a normal or non-diagnostic rest ECG, no previous known coronary disease, a low TIMI score, and no other obvious indicators of acute coronary syndrome such as elevated biomarkers or arrhythmia. MPI is the standard test for this type of patient at most of the hospitals that participated in the trial. Over the six months of follow-up, the patients imaged with CCTA were diagnosed 54% faster than those imaged with MPI (median 2.9 hours vs 6.3 hours, p<0.0001). The total costs of care were 38% lower with the CCTA group (median $2137 vs $3458, p<0.0001), even though the cost of each MPI test itself was only a little more than the cost of each CCTA ($538 vs $507). The diagnostic strategies made no difference in major adverse cardiac events (0.8% in the CCTA arm vs 0.4% in the MPI arm, p=0.29). The CCTA patients were also exposed to less radiation than the MPI patients (11.5 mSvvs 12.8 mSv, p=0.02).. the CT-STAT trial provides additional evidence for the excellent negative predictive value of CCTA in patients at low risk for an ACS or at low-intermediate risk of having CAD as the cause of the chest-pain syndrome." They point out that the diagnostic utility of CCTA will probably improve in the future, with new techniques and technologies such as CCTA stress perfusion imaging and CCTA plaque characterization. Also, molecular imaging with positron-emission tomography may eventually be able to identify inflammation and vulnerable plaques, assessing both coronary anatomy and myocardial perfusion.

New Antibiotics in the pipeline, but situation still dire October 22, 2011. Infectious Diseases Society of America (IDSA) 49th Annual Meeting Infections that are resistant to all current antibiotics are occurring more often. The situation is now critical because several large pharmaceutical companies have ended the research and development of any new antimicrobials. Since the 2009 report, only telavancin and ceftaroline have reached the market. After a recent literature review, the use of the clinical trials registry, and interviews with pharmaceutical leaders, Dr. Boucher and colleagues have found that there are 9 intravenous compounds active against Gram-negative bacteria in development: one β-lactamase inhibitor combination in a phase 3 study of complicated urinary tract infections (cUTI), and 8 compounds (3 β-lactamase inhibitor combinations) in phase 2 studies to treat acute bacterial skin and skin structure infections, cUTI, and/or complicated intra- abdominal infections. There are other compounds in phase 1 or preclinical development. Only a few of the 9 compounds are active against the worst pathogens, such as Acinetobacter baumannii and Pseudomonas aeruginosa. Two of the compounds in phase 2 testing have novel mechanisms of action. One is a transfer RNA synthetase inhibitor and the other is a peptide mimetic. However, novel mechanisms of action raise safety concerns. The investigators found no ongoing studies of antimicrobials to treat community-acquired bacterial pneumonia, hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia, or bloodstream infections — all among the most dangerous infections that physicians treat and with the most severely limited therapeutic options. The problems are in the drug development pipeline and in terms of shortages of drugs that are currently approved for use. Thus, the world will face the threat of returning to the preantibiotic era. He also said that, hand-in-hand with the development of antimicrobials, there is a need for rapid point-of-care diagnostics to facilitate physicians' decisions about the selection of appropriate antibiotics to treat patients.


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Mammography wars BMJ 2011;343:d7623. The interesting editor’s choice in the latest BMJ reads as follows A Canadian taskforce has just published revised guidelines on breast cancer screening. The recommendations mirror those from the US Preventive Services Taskforce: in women who aren’t at high risk, don’t start routine mammography until age 50, screen only every two to three years, and stop routine clinical breast examination. Also, women have also been told not to do breast self-exams, and their doctors have been told not to perform breast examinations in the office. The well reasons quoted are that that regular screening for breast cancer with mammography, breast self-exam, and clinical examinations ,all practices that have been widely recommended to reduce breast cancer mortality — causes women too much anxiety, results in too many false positives, and is too costly. The US guidelines met with fierce opposition when they were published in 2009, and the Canadian guidelines are already under fire. The fact that both of these national task forces have

reached the same conclusion should give some confidence in the result, but there is no doubting the heat in this controversy. Nor are we dealing with a stationary target: new evidence is accruing all the time. Published online this week is a further contribution to the debate—a modeling study of mammography screening from France that suggests the harms may be lower than some have reported. The authors found a lower than expected rate of over diagnosis of invasive cancer in women aged 50-69 (doi:10.1136/bmj.d7017). Comments: These breast cancer screening guidelines will cost the lives of Canadian women, according to the American College of Radiology (ACR). They "ignore the results of landmark randomized controlled trials, which show that regular screening significantly reduces breast cancer deaths in these women. While implementation of these guidelines may save money each year on screening costs, the result will be thousands of unnecessary breast cancer deaths, which will be a tragic event caused by scientific research. I wonder if the recent conference held in Khartoum during the first week of December 2011 will discuss such recent data?

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