Wandering spleen: Case report and literature review

The spleen is fixed in the left upper abdominal quadrant by various ligaments. Any ligament laxity or defect will result in a rare condition called “wandering spleen.” <500 cases have been reported in the literature. This study presents the case of 22-year-old female who was presented with nonspecific chronic abdominal pain and distention although; she had normal abdominal examination and laboratory investigations. A computed tomography scan showed a homogenous pelvic mass, suggesting a wandering spleen; therefore, a laparoscopic splenectomy was performed. The objective of this study was to report and review a rare condition that requires a high index of suspicion to make a correct diagnosis

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

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

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 &lt; 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

Mechanical properties of Self-Consolidating Concrete incorporating Cement Kiln Dust

Self-Consolidating Concrete (SCC) has been widely used in both practical and laboratory applications. Selection of its components and their ratios depends, mainly, on the target mechanical and physical properties recommended by the project consultant. Partial replacement of cement in SCC with cheap available industrial by-product could produce environmentally durable concrete with similar properties of normal concrete. In the current research, SCC was produced by blending Cement Kiln Dust (CKD) with cement in different ratios. Four mixes incorporating cement kiln dust with partial cement replacement of 10%, 20%, 30%, and 40% were produced and compared with a control mix of Normally Vibrated Concrete (NVC). Superplasticizer was used to increase the flow-ability of SCC mixes. The fresh and hardened mechanical properties of all mixes were determined and evaluated. Moreover, time-dependent behavior was investigated for all mixes in terms of drying shrinkage test. The shrinkage strain was measured for all specimens for a period of 120 days. Based on the experimental results, it was found that SCC mixture containing 20% cement replacement of CKD exhibited the highest mechanical strength compared to other SCC mixes and NVC mix as well. It was observed that the volumetric changes of specimens were directly proportional to the increase of the cement replacement ratio

EFFICACY OF COSUPPLEMENTATION THERAPY WITH VITAMINS B9, B12, AND D ON ENDOTHELIAL DYSFUNCTION IN STREPTOZOTOCIN-INDUCED DIABETIC RATS

Objective: This study evaluated the effects of Vitamins D, B9, and B12 given individually or combined in ameliorating some biochemical parameters related to endothelial dysfunction in diabetic rats.Methods: A total of 50 Sprague-Dawley male rats were divided into five groups: Control, diabetic, diabetic received Vitamin D, diabetic received Vitamins B9 and B12, and diabetic received Vitamins B9, B12, and D. At the end of 6 weeks, the rats were sacrificed and a set of assays was carried out to determine: Fasting blood sugar (FBS), lipid profile, nitric oxide (NO), homocysteine (Hcy), malondialdehyde (MDA), and serum levels of Vitamins B9, B12, and D.Results: Diabetic rat received Vitamin D and diabetic rat received Vitamins B9 and B12 had a significant decline in the levels of FBS, lipid profile, and Hcy with reduced MDA (p&lt;0.05) release but significant increase in NO level. On the same hand, diabetic rat received combined supplementation of Vitamins B9, B12, and D had more pronounced effect (p&lt;0.00).Conclusion: Given these findings, the combined vitamins therapy had antiatherosclerotic effects by inhibiting lipid peroxidation and stimulating NO production, resulting in amelioration the endothelial dysfunction in diabetic rat

Ectopic pregnancy in a uterine perforation site

Uterine perforation can occur following first-trimester abortion or more commonly postpartum after evacuation of retained placental tissues. We report a case of a pregnancy at the site of a recent uterine perforation. Possible mechanisms of this rare condition and different therapeutic options are mentioned

Practice and attitudes towards immunization among Lebanese obstetricians and gynecologists

We designed our study to evaluate the knowledge and immunization practices among Lebanese obstetricians and gynecologists (OBGYN) for women of different age groups. Anonymous questionnaires were used to assess the knowledge and immunization practices among OBGYN. The survey was conducted at the annual meeting of the Lebanese Society of Obstetrics and Gynecology on November 13–15, 2014. Data collected included demographics, type of practice, academic background and familiarity with vaccine guidelines. Descriptive statistical methods were used to evaluate the responses. The response rate was 54.8% (114/208). Only 62.3% (71/114) recommend vaccination(s) to pregnant women with only 25.9% of those who recommend the Tdap vaccine for pregnant women giving it during the recommended third trimester. In addition, 52.6% are unaware of the CDC/ACIP immunization schedule for women in general. However, 83.0% (93/112) of respondents are willing to integrate vaccination in their practice. Our study highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in addition to practices that are not in full accordance with common guidelines. Measures should be taken to spread proper awareness of the proper guidelines among Lebanese practitioners

Practice patterns of obstetric care in twin gestations: the value of MFM consultation

Objectives To evaluate the practice patterns among Lebanese obstetricians regarding obstetric care of twins and to compare selected practice patterns between general obstetricians and maternal fetal medicine physicians. Methods Questionnaires distributed during the annual meeting of the Lebanese Society of Obstetrics and Gynecology. Results Questionnaires were returned by 69.2% of the 296 physicians approached. Ten percent had fellowship training in Maternal Fetal Medicine (MFM). Thirty-nine percent perform cervical length measurement at 20-24 weeks of gestation and 34% recommend vaginal progesterone in case of a short cervix. When comparing selected practice patterns between MFM & general obstetricians, MFM specialists were less likely to perform cervical cerclage in the first trimester (5.9% versus 49%,p = .001), more likely to offer prenatal screening for aneuploidy (66.6% vs 46.4%,p = .03), less likely to use vaginal progesterone in the second trimester in the case of a short cervix (42.1% vs 61.8%,p = .04), less likely to perform serial ultrasound exam in the third trimester to assess fetal growth (50% vs 78%,p = .005) and more likely to deliver monoamniotic twins at 32-34 weeks of gestation (55% vs 37%,p = .05). Conclusion Because of the different background of the Lebanese physicians, MFM specialists are more likely to follow obstetric care guidelines in twin gestation