Stiff Person syndrome: a case report

Stiff person syndrome (SPS) is rather unique among neurologic diagnoses. At relaxation, motor- unit activation, continuous agonist and antagonist muscular contractions, as well as contractions triggered by tactile triggers, quiescent stretch, and involuntary movement of affected or unaffected musculature, startled sounds and emotional stimuli are the clinical signs of SPS. Sleep, general anesthesia, myoneural, and peripheral nerve blockage all help to reduce rigidity and spasms. The syndrome may be a sporadic autoimmune syndrome (associated with anti–glutamic acid decarboxylase (GAD) antibodies and often accompanied by other autoimmune diseases such as type 1 diabetes) or paraneoplastic (associated with anti–amphiphysin antibodies). People with SPS respond to high doses of diazepam and several anti-convulsants, gabapentin and tiagabine. Immunomodulatory drugs including steroids, plasmapheresis, and intravenous immunoglobulin appear to help significantly. The symptoms of our patient progressed slowly over time. Neuroimaging and electrophysiological studies ruled out other possible causes of comparable symptoms such as neuromyotonia. Raised anti-GAD autoantibodies titer in serum found by immunocytochemistry assays, our patient's history, clinical examination findings, and reaction to benzodiazepines all pointed to SPS.

Assessment of Knowledge, Attitude and Practice of Molar-Incisor Hypomineralisation among a Group of Egyptian Dentists (Observational Cross-Sectional Study)

Abstract: Introduction: Molar Incisor Hypomineralisation (MIH) is one of qualitative DED. MIH is increasing dramatically in the new generations, which is considered to be challenging for the majority of dentists. MIH was found to be prevalent in 14.2% of the world\u27s population, with the high incidence 18% in South America and the least (10.9%) in Africa. This study was carried out to assess the knowledge, attitude, and practice of graduated Egyptian dentists\u27 group regarding MIH condition and compare the outcome information among different dental specialists. Material and methods: A google based questionnaire based on previously validated published papers distributed electronically through different social media by direct message or public social media link. Eligibility criteria including Graduated Egyptian licensed dentists excluding students, interns and other medical specialties. Model answer prepared by researchers in 3 rounds based on most recent published papers. Results: 416 participants enrolled in this study with response rate reach to 16.7% for direct message and 1.4% for public share link. 79.1% of PDs, 45.8% of GPs and 45.0% of other specialties are familiar with both MIH condition and terminology. A prevalence of 10-20 % was notice by participants during their practice (21.9% PDs, 22.0% GPs and 22.2 other specialties). Most of participants believe that there is a lack of information regarding MIH between Egyptian dentists. The majority of the participant used Full coverage for posterior teeth and composite resin for anterior teeth as treatment choice. 53.1% of PDs are encountered MIH in monthly bases. Conclusion: MIH is a clinical problem that Egyptian dentists well recognize and frequently encounter in clinical practice. There is a need to include MIH in academic curriculum to increase the awareness regarding the condition and clinical management

Hydroxychloroquine Induced Cardiomyopathy

Hydroxychloroquine (HCQ) is one of the immunomodulatory medications used in treatment of autoimmune diseases. Rarely, HCQ can cause serious complications, such as cardiotoxicity. We present a rare case of HCQ-induced cardiomyopathy. 60-year-old female patient with a medical history of SLE on chronic HCQ therapy for 28 years, preexisting non-ischemic cardiomyopathy and heart failure with reduced ejection fraction for 7 years, and complete heart block status post pacemaker insertion presented with acute chest pain and severe weight loss. Patient underwent coronary angiogram that showed normal coronaries and right-sided heart catheterization that showed acute heart failure. Echocardiogram showed LVEF of 30% with global hypokinesis. Patient was started on dobutamine with an improvement of her symptoms. As HCQ-induced cardiomyopathy was suspected, patient underwent an endomyocardial biopsy that revealed a pathognomonic finding of myocyte vacuolization, consistent with HCQ-induced cardiomyopathy. HCQ was discontinued immediately. However, patient was a poor candidate for heart transplantation and durable mechanical circulatory support due to severe malnutrition secondary to end-stage heart failure. Patient accepted hospice care and passed away peacefully. This case highlights the need for high index of clinical suspicion, careful medication reconciliation for patients with non-ischemic cardiomyopathy, and tissue biopsy with careful histopathological examination to diagnose this rare complication

Encryption Efficiency Analysis and Security Evaluation of RC6 Block Cipher for Digital Images

This paper investigates the encryption efficiency of RC6 block cipher application to digital images, providing a new mathematical measure for encryption efficiency, which we will call the encryption quality instead of visual inspection, The encryption quality of RC6 block cipher is investigated among its several design parameters such as word size, number of rounds, and secret key length and the optimal choices for the best values of such design parameters are given. Also, the security analysis of RC6 block cipher for digital images is investigated from strict cryptographic viewpoint. The security estimations of RC6 block cipher for digital images against brute-force, statistical, and differential attacks are explored. Experiments are made to test the security of RC6 block cipher for digital images against all aforementioned types of attacks. Experiments and results verify and prove that RC6 block cipher is highly secure for real-time image encryption from cryptographic viewpoint. Thorough experimental tests are carried out with detailed analysis, demonstrating the high security of RC6 block cipher algorithm. So, RC6 block cipher can be considered to be a real-time secure symmetric encryption for digital images

The medical and biochemical knowledge of health care professionals regarding the management of MERS-CoV: lessons from 2019 pilgrimage season in Al-Madinah, Saudi Arabia: A cross-sectional study

Background: Middle East respiratory syndrome coronavirus (MERS-CoV) epidemic was a serious healthcare concern not responding to conventional anti-viral therapies between 2012 and 2017 with high fatality rates. Saudi Arabia is still among the best world examples in combating both MERS-CoV and COVID-19 pandemics. Objectives: Investigating the medical and biochemical knowledge of healthcare professionals in Al-Madinah, Saudi Arabia on preventive, diagnostic and therapeutic measures against MERS-CoV epidemic. Subjects and methods: In 2019, this cross-sectional study included 416 healthcare personnel of which 402 participants answered the questions with a response rate of 96.7%. Specialties of participants were medical students (1.4%), physicians (64.4%), nurses (23.6%) and others (10.7%). Results: The vast majority of the investigated healthcare personnel gave the right answers. 96.7% of the participants answered that washing hands using water helps prevent MERS-CoV. 90.8% of the participants answered that wearing a clean non-sterile long-sleeved gown and gloves does helps prevent MERS-CoV infection. 94.7% of participants answered that using alcohol-based hand rub helps prevent MERS-CoV infection. 92.03% of the participants thought that wearing protective equipment does help preventing MERS-CoV infection. 86.1% answered that there is no vaccine available against MERS-CoV infection and 86.1% answered that taking vaccines is suitable for preventing MERS-CoV infection. 90.04% of the participants answered that MERS-CoV patients should be diagnosed using PCR and 84.3% thought that the highest levels of anti-CoV antibodies are in abattoir workers while 87.8% thought that isolation of suspected cases helps preventing MERS-CoV infection. Conclusion: The investigated healthcare workers had a satisfactory knowledge on the preventive and therapeutic measures and biochemical knowledge against MERS-CoV epidemic at mass gatherings as pilgrimage season

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)