Highlights on Medicine and Medical Research Vol. 6

Cerebral aneurysm and posterior circulation stroke are very dangerous and/or fatal disease pertaining to variant and/or anomalous vertebral arteries. Besides, if subclavian artery is occuluded, this causes antegrade and retrograde flow (subclavian steal syndrome). The first two diseases described above are caused by vertebral artery anomalies whereas the last one, subclavian steal syndrome involves vertebral artery but is caused by occulusion of subclavian artery. Therefore, a thorough comprehension of vertebral artery anomalies is of paramount importance while performing diagnostic and interventional angiography for vascular, cardiothoracic, head, neck and anterior cervical surgery. Therefore variations of vertebral arteries and their configuration are described in this chapter.

Vertebral arteries are one of the principal arteries irrigating brain specifically spinal cord, medulla and part of cerebellum. There are two vertebral arteries, one on each side of the neck. Each vertebral artery sprouts from the postero-superior aspect of 1^st part of bilateral subclavian artery at the root of neck. These follow a long course and end in the cranial cavity by uniting with their counterpart forming basilar artery at the lower border of pons. Their courses are divided into four parts. The first three segments are extracranial and the last one is intracranial. Besides, originating from subclavian artery, left vertebral arteries is also reported to arise from the aortic arch between left common carotid artery and left subclavian artery or lateral to it and also from a common trunk formed by left subclavian and left vertebral artery but the right vertebral artery emanate from thyrocervical trunk, the brachiocephalic trunk, the common carotid artery and external carotid artery. Beside these variations, there may be agenesis, hypoplasia, stenosis and asymmetry of these arteries. Agenesis, hypoplasia, asymmetry and stenosis of vertebral arteries may cause cerebral aneurysm and posterior circulation stroke besides, iatrogenic complications. Thus knowledge of vertebral artery is of utmost use in preventing misdiagnosis and mismanagement of diseases pertaining to vertebral arteries.

Therefore, the objective of this chapter is to give clear picture of normal vertebral arteries and description of variations coupled with anomalies to diagnose these diseases by imagery (ultrasound, angiography or MRI) in association with signs and symptoms. The knowledge of normal and variant Anatomy of vertebral arteries is very essential which has been described vividly in this chapter.

Objectives: The gingival crevicular blood (GCB) obtained during routine periodontal probing may be a source for blood glucose measurements. The aim of this study was to compare gingival crevicular blood and fingerstick blood glucose measurements using a glucometer against the conventional laboratory methods.

Materials and Methods: The study group comprised of three groups. In the first group 30 patients with periodontitis and positive bleeding on probing were chosen. Blood samples of two sites intraorally were analyzed using a glucose self-monitoring device. The second and third group comprised of 50 diabetic and 50 non-diabetic patients. After testing fasting plasma glucose (FPG), fasting glucose levels in gingival crevicular blood (GCBG) and fasting capillary fingerstick blood (CFBG) samples were analyzed using same device.

Results: Significant correlation (r= 0.93, p<0.001) was found between gingival crevicular blood glucose levels and capillary finger stick blood glucose levels. Considerable correlation (r=0.75, p<0.001) was found between levels of fasting gingival crevicular blood glucose and fasting blood glucose both in diabetic patients and the normal population.

Conclusion: It is evident that the blood obtained during routine periodontal probing can be used for estimation of blood glucose levels. GCB can be used as a marker for blood glucose estimation using glucometer. The technique described is safe, easy to perform and helps to increase the frequency of diabetes screening in dental office.

Background: Highly Active Antiretroviral Therapy (HAART) is associated with significant mortality decreased and risk in AIDS progression. However, complications due to long-standing HIV infection and treatment have become increasingly important. Complications include hepatic and nephrotoxic effects of HAART. Studies on honeybee (Apis mellifera) venom proved its anticancer effects, antimicrobial activity, immunomodulatory and vasoconstrictor effects. Current study evaluates the effect of dilutions of Apis mellifera on metabolic alterations induced in mice subjected to antiretroviral therapy (HAART).

Material and Methods: Each experimental group comprised 10 animals: (I) animals treated with HAART diluted in 1.2 mL water gavage/day, (II) animals treated with HAART diluted in 1.2 mL water gavage/day + Apis mellifera diluted 1x10¹² in water 1.0 mL once daily added to the drinking water (1:10 mL) available ad libitum, (III) animals treated with HAART diluted in 1.2 mL water gavage/day + Apis mellifera diluted 1x10⁶⁰ in water 1.0 mL once daily added to the drinking water (1:10 mL) available ad libitum, (IV) untreated (control group) received 1.2 mL water by gavage/day. The experimental groups were treated for 15 days. Clinical evaluation (body weight, water intake and ration, excretion products, behavior) was performed before and after treatment and the serum cholesterol, triglycerides; hepatic enzymes (AST, ALT) and creatinine were assessed by specific methods. Results were analyzed with Graph Pad Prism using Student´s t test.

Results:. Animals treated with HAART and Apis mellifera  diluted (II and III) had higher body weight gain, lower levels of triglycerides (20%), cholesterol (20%) and creatinine (50%) when compared to animals treated with antiretroviral therapy.

Conclusion: Our studies demonstrate that Apis mellifica extract used in diluted form has beneficial effects for animals treated with antiretroviral therapy. There is an improvement in the levels of cholesterol, triglycerides, liver enzymes and renal profile.

Apis mellifera diluted 1x10¹² and 1x10⁶⁰ showed a significant effect on creatinine levels when compared to HAART group and demonstrated possible effect on kidney injury.

Phytonutrients or phytochemicals are plant-based ingredients that preserve, protect, and enhance our health and wellness, including cancer-prevention and other pre-emptive actions in our body. They are present in all fruits, vegetables, greens, and herbs. Marine organisms, such as algae, seaweed, and sponge also contain large amount of bioactive compounds/nutrients. They have various health benefits, including antioxidant, anti-cancer, antimicrobial, anti-inflammatory, anti-diabetic, and antibiotic properties. It is great that researchers are exploring the characterization of various traditional plants and plant constituents and marine organisms against a number of cancers, such as lung cancer and cervical cancer. There exists thousands of phytochemicals, which provide notable health benefits. Most spices, fruits and vegetables contain phytochemicals and their nutritional constituents are being intensively studied to evaluate their effects on health and cancer treatment. In this review, the phytochemicals, such as alkaloids, tannins, saponins, steroid, terpenoid, flavonoids, phenolic compounds, etc. in various fruits, medical plants, and marine red algae are discussed.

Background: Study of floating bilayer tablets of Ranitidine HCl, H₂ receptor antagonist used in the treatment of peptic ulcers is presented. Ranitidine HCl is absorbed only in the initial part of the small intestine and has 50% absolute bioavailability.  

Materials and Methods: The gas releasing component, necessary for the tablet to float, is added to the food grade rice bran wax matrix layer and the delayed release component, HPMC K100M, formed a separate layer of the bi-layer matrix tablet. The granulated powder blends were evaluated for their properties like Carr’s Index and Hausner’s ratio and compressed into a bilayer tablet. The tablets were evaluated for properties like drug content, buoyancy lag time, buoyancy time, dissolution rate and kinetics of drug dissolution.

Results: The gas released made the tablet buoyant. The buoyancy lag time decreased with increase in the rice bran wax amount of the floating component layer. This layer erodes slowly keeping the tablet buoyant for almost 6 hrs. The drug release from the HPMC K100M matrix is delayed for nearly 10 hrs.

Conclusion: The concentration of HPMC K100M used in the delayed release component layer can be mucoadhesive. The floating component layer shall keep the tablet buoyant and when it erodes off from the swollen matrix of the delayed release component layer, the swollen matrix being mucoadhesive shall allow the tablet to remain confined to the upper GIT, where the drug has preferential absorption site. This shall improve the bioavailability of the drug.

Unutilized, enormous intracellular glucose in insulin-nondependent tissues, including retina, leads to several consequences: (i) increased formation of advanced glycation end products, (ii) activation of polyol pathway, (iii) anaerobic glycolysis, (iv) glutamate toxicity, (v) lipid peroxidation and oxidative stress, and all of these, finally, resulting in convergence to up regulation of antigenic VEGF and VEGFR2, the crucial player in the development of DR. The purpose of the present pilot study is to assess the effects of one kind of intervention on the development of DR: supplementation of B-vitamins (B1, B2, B3, B5 and B6), vitamin C and vitamin E on amelioration of biochemical derangements related to development of DR. 400 diagnosed type 2 diabetic patients were identified for the study, of which subjects were randomised 1:1 to receive oral antidiabetic medication along with B-vitamins, vitamin C and vitamin E or only antidiabetic medication to give the study and controlled population in this unblended randomized trial since December 2004 to December 2017. The following preliminary tasks were completed: firstly, baseline detailed fundoscopic examinations were enough to exclude the presence of retinopathy. Secondly, had baseline biochemical parameters like blood concentration of NAD⁺, NADH, advanced glycation end products (AGEs), malondialdehyde (MDA), VEGF and VEGFR2 determined? Lastly, yearly fundoscopic examinations were documented to detect the features of DR. These efforts revealed the following findings: 32 among 187 (17.11%) patients who received supplementation with B-vitamins, vitamin C and vitamin E developed very mild microangiopathy; whereas 92 patients among 200 (46%) controlled ones developed mild to moderate non proliferative diabetic retinopathy (NPDR). 13 patients of the study group who didn’t follow up were counted as lost from the observation of the study. The findings lead to this conclusion: Glycolysis and citric acid cycle should run uninterruptedly by supplementation of precursors of oxidized cofactors and antioxidants to prevent biochemical derangements which lead to increased expression of VEGF.

Background: Delayed tuberculosis (TB) treatment raises the rate of spread of bacilli in the population and increases mortality rates. Rapid diagnosis and early TB treatment initiation are crucial to successful outcomes and delays affect TB control programs. In Namibia, there is a paucity of data on the demographic factors affecting TB treatment initiation since GeneXpert MTB/RIF (Xpert) assay was introduced in 2017.

Methods: This was a descriptive cross-sectional retrospective study conducted at Katutura Hospital TB clinic from 1^st July 2018 to 31^st March 2019. A total of seventy-two (72) participants comprising twenty-five (25) rifampicin resistant-TB (RR-TB) and forty-seven (47) non- RR-TB adult patients were enrolled using consecutive sampling. Patients’ medical records, Xpert results and a questionnaire were used to collect data. The data were analyzed using Stata statistical software version 12. Association between socio-demographic factors and treatment initiation delays were established using logistic regression analysis.

Results: Staying with a TB patient (AOR=17.22, 95% CI: 2.29-129.773), employment status (AOR=1.23, 95% CI, 002-129), previous TB treatment (AOR=2.19, 95% CI: 0.076-0.86) and being HIV positive (AOR= 1.23, 95% CI: 0.0034-057) were the socio-demographic factors that were significantly associated with treatment initiation delays. Treatment initiation delay median time at Katutura Intermediate Hospital TB Clinic was 10 days (IQR: 1-32) and 3 days (IQR: 0-12) for RR-TB and non- RR-TB respectively.

Conclusion: The prolonged treatment initiation delays among HIV positive RR-TB patients might be due to low adherence to HIV care interventions. Staying with a household TB patient and those who were previously treated for TB were also associated with treatment initiation delays. Poor health systems infrastructure and stigma could be the determinants of this delay in these groups. An integrated family-based approach to TB and HIV care involving health care workers can mitigate TB treatment delays post-diagnosis. Further studies should explore the factors associated with late initiation to second-line treatment from a community perspective. Lastly, there is a need to assess the cost-utility of bedaquiline and delamanid drugs roll-out in Namibian health care in comparison with the standard treatment. Based on the SEM model, an integrated, family-based approach to TB and HIV care involving health worker needs to be piloted to see its feasibility to reduce treatment initiation. This approach may go a long way in improving the management of TB among women, children, and other vulnerable groups.

Objective: To determine the factors associated with remission at 3, 6, 9 and 12 months among depressive adult patients in primary care (PHC) in Chile.

Methods: This is a one-year naturalistic study that followed 297 patients admitted for treatment for depression in eight primary care clinics in Chile. Initially, patients were evaluated using: The international mini-neuropsychiatric interview (MINI), a screening for childhood trauma events (CTEs), the Life Experiences Survey and a partner violence scale. The Hamilton Depression Scale (HDRS) was used to follow the patients during the observation time. Association between the factors studied and the primary outcome remission (HDRS \(\leq\) 7) were assessed using a dichotomous logistic regression and a multivariate Poisson regression. The significance level was 0.05.

Results: Remission (HDRS \(\leq\) 7) ranged between 36.7% at 3 months and 53.9% at 12 months. Factors that predicted poor remission during the observation- time were: CTEs (Wald X2 = 4,88 Exp B=0.94 CI 0.90- 0.92 p=0.27); psychiatric comorbidities (Wald X2 = 10.73 Exp B=0.9 CI 0.85- 0.96 p=0.01); suicidal tendencies (Wald X2 = 4,66 Exp B=0.88 CI 0.79- 0.98 p=0.031) prior treatment depression (Wald X2 = 4.50 Exp B=0.81 CI 0.68- 0.85 p=0.03).

Discussion: Almost 50% of this sample failed remission in depression at 12 months. Psychiatric comorbidities and CTEs are factors that should be considered for a poor outcome in depressive Chilean patients. These factors need more recognition and a better approach in PHC. The findings of this study indicate that other strategies aimed at improving the recognition of these clinical and psychosocial factors in depressed patients should be incorporated in PHC.

Orthodontic implants have become a reliable method in orthodontic practice for providing temporary additional anchorage. These devices are useful to control skeletal anchorage in less compliant patients or in cases where absolute anchorage is necessary. There are a great number of advantages in this new approach which include: easy insertion, decreased patient discomfort, low price, immediate loading, reduced diameter, versatility in the forces to be used, ease of cleaning, and ease of removal. However, proper management of the screws by the practitioner is necessary to increase the success rate of the technique. The purposes of orthodontic implants and dental implants are different. The purpose of this paper is to update practitioners on the current concepts of orthodontic implants and orthodontic mechanics.

Hemolytic uremic syndrome (HUS), characterized by the triad of micro-angiopathic hemolytic anemia, thrombocytopenia, and acute renal insufficiency, is a common cause of acute renal failure in children. It usually follows an episode of gastroenteritis with enterotoxigenic Escherichia coli and is termed typical HUS. However, HUS is also a complication of invasive pneumococcal infection. Reasons for not diagnosing this condition include the absence of a specific laboratory test, the lack of consistent case definitions, unfamiliarity, a misdiagnosis of disseminated intravascular coagulation (DIC) and cases with micro-angiopathic hemolytic anemia and only mild renal injury. The aim of our study is to describe the epidemiology, the treatment and the evolution of HUS after invasive pneumococcal infections in Tunisia. Cases were identified between 2008 and 2016. Infection with S. pneumoniae was confirmed with culture of cerebrospinal fluid, pleural fluid, or blood. Eight children fulfilled our criteria for inclusion in the study. Primary patterns were fever, respiratory signs, neurological signs and uncommon patterns. Pneumonia was a presenting feature in 6 of 8 cases (75%), two patients had confirmed pneumococcal meningitis. Pneumococcal invasive infection was confirmed by positive yield for S. pneumoniae by culture in pleural levy or drainage in two cases, cerebrospinal fluid in two cases and blood in four cases. The mean duration of hospitalization was 23.5 days. Antibiotic therapy was initiated in all patients. Six patients from eight required dialysis for a median 27.8 days. No patients received plasma exchange therapy. Two patients died and. One patient with pneumococcal pneumatocele and presented a sepsis complicated with a nosocomial infection following a prolonged stay in the intensive care unit. One patient had bronchiectasis leading to recurrent broncho-pulmonary infections. One patient who was dialysis dependent at discharge died 4 months later.

Anti-NMDA receptor (NMDAR) encephalitis is a recently identified autoimmune disorder with prominent psychiatric symptoms. Patients usually present with acute behavioral change, psychosis, catatonic symptoms, memory deficits, seizures, dyskinesias and autonomic instability. In female patients an ovarian teratoma is often identified. We describe a 32-year-old woman who presented with acute psychosis. Shortly after admission, she developed generalized seizures and deteriorated into a catatonic state. Although ancillary tests including MRI, electroencephalogram and cerebrospinal fluid (CSF) analysis were unremarkable, the presentation of acute psychosis in combination with recurrent seizures and a relentless course suggested autoimmune encephalitis. The patient underwent pelvic ultrasound which disclosed an ovarian tumor, leading to an urgent cystectomy with pathological confirmation of a mature cystic ovarian teratoma. Plasmapheresis was then initiated, yielding partial response over the next two weeks. Following the detection of high titers of anti-NMDAR antibodies in the CSF, the patient ultimately received second line immunosuppressive treatment with rituximab. Over several months of cognitive rehabilitation, a profound improvement was eventually noted, although minor anterograde memory deficits remained. In this report we call attention to the inclusion of anti-NMDAR encephalitis in the differential diagnosis of acute psychosis. The inclusion of this disorder in the differential diagnosis is critical, as prompt initiation of immunotherapy and tumor removal, if appropriate, could dramatically affect outcome.