26.04.2015

Medical journals in saudi arabia

Objectives: To compare the serum levels of inflammatory mediators in high altitude (HA) native rats, and to search for the possible underlying mechanism(s).
Results: The HA native rats showed significant increases in the serum levels of inflammatory cytokines, lipid profiles, as well as a significant increase in the urinary norepinephrine with a concomitant decrease in the serum levels of Mg+2 and increased lipid peroxidation.
Table 1 - General geographic and meteorological information in Riyadh (low altitude) and Abha (high altitude) in Saudi Arabia.
Figure 3 - Magnesium levels in the serum of low altitude (LA) and high altitude (HA) native rats. Figure 5 - Levels of urinary serotonin (A), dopamine (B), and norepinephrine (C) in the low altitude (LA) and high altitude (HA) native rats. Figure 6 - Levels of malondialdehyde (MDA) (A), interleukin-6 (IL-6) (B), tumor necrosis factor-alpha (TNF-?) (C), and high sensitivity C-reactive protein (hsCRP) (D) in high altitude (HA) native rats at baseline, and after 10 days treatment with normal saline, propanolol, or prazosin in comparison with baseline levels in LA. In contrast to the previous research, which examined the inflammatory response in either animals or humans after acute exposure to HA using natural or simulated hypoxic chambers, our study is considered unique because it analyzes the inflammatory reaction in relation to its possible causes in native HA rats, which were from the same lineage and bred and maintained in 2 natural areas of different altitudes. From our data, elevated serum catecholamine levels but not OxLDL are implicated to be the most stimulating force for the systemic inflammatory reaction through direct up-regulation of the inflammatory cytokines, or indirectly through oxidative stress-related mechanisms, an effect that is mediated by ? and ?-adrenergic receptors. To search for the sustained increase of catecholamines under HA conditions, we studied the levels of serum Mg+2 in both LA and HA native rats. Human studies also indicate that a low Mg+2 status is associated with increased inflammatory and oxidative stress.39 Several studies have found that Mg+2 intake was inversely related to elevated serum or plasma C-reactive protein (CRP). In conclusion, our study shows that living under HA conditions results in an increased systemic inflammatory reaction due to sustained rise in catecholamine levels, which could up-regulate the expression of inflammatory markers and increase oxygen free radical generation possibly by up-regulation of oxidative-induced stress transcriptional factors (NF-kB and AP-1), an effect that is mediated through ? and ?-adrenergic receptors and could be attributed to low Mg+2 levels. From the Departments of Physiology (Al-Hashem, Alkhateeb), Cardiology (Assiri, Shatoor), and Biochemistry (Alessa), College of Medicine, and the Department of Pharmacology (Elrafaey), College of Pharmacy, King Khalid University, Abha, Kingdom of Saudi Arabia. Saudi Medical Journal is copyright under the Berne Convention and the International Copyright Convention.
This is a blind, crossover clinical trail conducted between July and August 2013 in Albaha province, Saudi Arabia.
AM) until dusk (7 PM), and ate and drank only during the night throughout the 8-day study period. Saliva was obtained by asking the subjects to spit into a test tube without any stimulation. Figure 1 -Mean volatile sulfur compounds (VSCs) in parts per million (ppb) for each group at every assessment point. Objectives: To report nephrotoxicity in the form of acute tubular necrosis (ATN) related to vancomycin.
Methods: This study was conducted at Johns Hopkins Aramco Healthcare, Saudi Aramco, Dharan, Saudi Arabia between June and August 2013. Vancomycin, a tricyclic glycopeptide antibiotic, is a widely used antibiotic for the treatment of infections caused by gram positive organisms, especially methicillin resistant Staphylococcus aureus (MRSA). Figure 1 - Urine microscopy findings showing granular casts (large arrow), and renal tubular epithelial cells (small arrows) in patient 1 (40? magnification).
Vancomycin, a tricyclic glycopeptide antibiotic, is a widely used antibiotic for the treatment of a variety of infections, especially those caused by methicillin resistant MRSA. Due to the widespread infection with MRSA and Clostridium difficile, the use of vancomycin has accelerated around the globe.10 As a result, health care professionals should be vigilant to the development of side effects and complications, such as nephrotoxicity. From the Internal Medicine Services Division, Nephrology Section (Alkhunaizi), General Internal Medicine Unit (Hinedi), Johns Hopkins Aramco Healthcare, Dhahran, Kingdom of Saudi Arabia. Guillain-Barre syndrome (GBS) usually presents in a symmetrical ascending fashion of weakness. Guillain-Barre syndrome (GBS) is an acute immune-mediated demyelinating polyradiculoneuropathy, and the most common cause of acute flaccid paralysis in infants and children.1 We present a 6-month-old male infant who manifested acute hemiplegia and head lag after a febrile illness.
Figure 1 - Reduced motor nerves compound muscle action potential and slow conduction velocity with low distal amplitude of A) left median, and B) tibial nerves. Figure 2 - MRI of spine showing: A) Saggital, T2 high signal intensity in the cervical spinal cord at the level of C2 to C5. Figure 3 - Normal compound muscle action potential (NCS), conduction velocity and F-wave for age.
The diagnosis of GBS was confirmed by: 1) The presence of cyto-albuminologic dissociation with high CSF protein and normal CSF white blood cells.
Acute hemorrhagic or ischemic neurovascular injury within the CNS is an important differential diagnosis in our case that was ruled out by brain imaging. Many infectious etiologies that can affect brain parenchyma, anterior horn cells and nerves should be excluded in an infant who presents with acute flaccid paralysis. Each case of acute paralysis should be reported to local authorities for the possibility of poliomyelitis. Neurometabolic causes of sudden weakness are rare, but should be considered in communities with a high rate of consanguineous marriage. Our patient had no history of trauma; however, thorough enquiry and clinical and radiological investigations for the possibility of both accidental and non-accidental trauma are necessary.
Early diagnosis and treatment of GBS have a better prognosis in children as compared with adults, though recovery may still take 6-12 months.10 Treatment with IVIG is widely used in children with GBS and can hasten the recovery and alter the autoimmune reaction. In conclusion, GBS is a rare diagnosis in infants but is an important differential diagnosis in acute onset weakness as delayed diagnosis can increase morbidity and mortality. From the Department of Pediatrics (Muthaffar), Faculty of Medicine, King Abdulaziz University, Jeddah, and the Department of Pediatric Neurology (Mahmoud, Al-Saman), National Neurosciences Institute, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia. Toe tourniquet syndrome refers to external, mechanical, circumferential constriction of the toes.
The term toe tourniquet syndrome (TTS) was introduced by Quinn1 in 1971 when he reported 5 cases and implicated leotard-type clothing as an important cause of this condition. Figure 1 - Left foot showing a circular deep cut wound with erythema and edema distal to the hair tourniquets at the middle phalanges of the second (most affected), third, and fourth toes. Figure 2 - Hair coiled around the second right toe imbedded deep in the skin with distal swelling and erythema.
Figure 3 - Examination of toe swelling showing: A) Deep cut wound involving the left third toe, with erythema and edema distal to the hair tourniquets. Figure 4 - Extensive edema, erythema, and color changes are seen distal to the hair tourniquet affecting the left fourth toe. The time period was not certain in all the series, but roughly patients presented after 48 hours of excessive crying. In 2010, Cevik and Kavalci8 pointed to the importance of maternal postpartum telogen effluvium with excessive hair shedding as a causative agent. Post-decompression, all our patients returned to their usual states without any complications. From the Department of Pediatrics (Kamal), Faculty of Medicine, Cairo University, Cairo, Egypt, the Department of Pediatrics (Kamal), and the Department of Pediatric Surgery (Khan, Mirza, Al-Malki), Alhada Armed Forces Hospital, Taif, Kingdom of Saudi Arabia.
Fifty male rats from the same genetic pool were bred at either a HA or low altitude (LA) area. Blockage of the ? and ? adrenergic receptors of the HA rats caused partial or complete decreases in both inflammatory and oxidative stress mediators. Interestingly, some previous studies showed that there was an association between chronic inflammatory stressor response and low serum magnesium (Mg+2) levels.8 However, such an effect has not been measured in native HA dwellers either in animals or in humans. This study was conducted with 2 separate groups of male Wistar rats that were from the same gene pool, and from the same breeding colony, which was transferred from a low altitude (LA) area to a HA area and allowed to bred there.
Ten rats bred and maintained at an LA area, and 40 rats bred and maintained at a HA were used in the experimental procedures. Unpaired student’s t-test with Welch’s correction was used for all comparisons between LA and HA rats (stage 1).
The differences in serum lipids including TG, TC, LDL, HDL, and OxLDL, and changes in the AI between HA and LA native rats are depicted inFigure 2. All rats in the 2 areas were housed under the same laboratory conditions and were fed the same diet; thus, the observed biochemical changes were not due to dietary factors or to adaptive evolutionary changes. Although the present study was not designed to clarify a possible relationship between catecholamines and increased oxidative stress in HA natives, our data are compatible with such a relationship as administration of ? and ?-blockers ameliorated or completely abolished the increased MDA levels in HA native rats. Unfortunately, one limitation of our study is that the tissues responsible for the adrenergic-induced surge in plasma IL-6 levels have not been identified as we did not use Mg+2 therapy to demonstrate such effect.
The authors gratefully acknowledge the staff at the Animal House of the College of Pharmacy at King Saud University, Riyadh, Saudi Arabia, for supplying us with low altitude animals and for helping us to perform the low altitude experiments at their laboratories.
Authors have no conflict of interests, and the work was not supported or funded by any drug company. The role of genetic polymorphisms in endothelial nitric oxide synthase and beta2-adrenergic receptors with risk of hypertension in a sample of Lebanese people.
Then the 2 protocols, SSM and TM were evaluated in a crossover study in an 8-day period without mechanical plaque management. Prevalence of halitosis in the population of the city of Bern, Switzerland: a study comparing self-reported and clinical data. Geographical distribution of dental caries prevalence and associated factors in young adults in Finland.
Relationship between halitosis and periodontal disease - associated oral bacteria in tongue coatings. The relationship between physiologic halitosis and periodontopathic bacteria of the tongue and gingival sulcus. Investigation of probiotic bacteria as dental caries and periodontal disease biotherapeutics. Distribution and persistence of probiotic Streptococcus salivarius K12 in the human oral cavity as determined by real-time quantitative polymerase chain reaction. A randomized double blind crossover placebo-controlled clinical trial to assess the effects of a mouthwash containing chlorine dioxide on oral malodor. Effect of chewing gums containing the probiotic bacterium Lactobacillus reuteri on oral malodour. Comparative effects of different chlorhexidine mouth-rinse formulations on volatile sulphur compounds and salivary bacterial counts. Effect of toothpaste on the plaque inhibitory properties of a cetylpyridinium chloride mouth rinse. All patients who received intravenous vancomycin as a part of the hospital’s vancomycin stewardship program were monitored for the development of ATN. Three patients developed ATN attributed to high levels of vancomycin, with an incidence of 3.4%.
The medical community must be aware of the potential risks of vancomycin associated nephrotoxicity.
Oral preparations of vancomycin are increasingly used in the treatment of Clostridium difficile-induced colitis. An 82-year-old female with hypertension, seizure disorder, and Alzheimer’s dementia was admitted with poor intake, altered mental status, and seizure activity. A 21-year-old female, a known case of methylmalonic aciduria secondary to cobalamin D deficiency.
In addition, oral preparations are increasingly used in the treatment of Clostridium difficile-induced colitis.


We present a 6-month-old male infant who presented to our emergency room with acute left-sided limb weakness and head lag 3 days after a febrile upper respiratory tract infection.
The diagnosis of GBS was confirmed through laboratory, neurophysiologic, and neurorardiologic investigations.
A previously healthy 6-month-old male infant presented to our emergency room with acute left hemi-body limb weakness and head lag 3 days after an acute febrile upper respiratory tract infection. Acute inflammatory demyelinating polyradiculoneuropathy is commonly known as Guillain-Barre syndrome. 2) The electrophysiological evidence decreased CMAP amplitude and prolonged conduction velocity (Tables 2 & 3, Figure 3).
In our case, Epstein-Barr virus, cytomegalovirus, herpes simplex virus, varicella zoster virus, and, mycoplasma pneumonia was ruled out by CSF culture and PCR studies. Stool samples taken after 14 days of paralysis are usually the standard method to isolate poliovirus. Serum lactate and MRS were normal in our patient, however, mitochondrial diseases like mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes, should be suspected when there is a high lactate in serum, CSF, and on MRS that is concordant with stroke-like presentation at any age. Base line hematological work up can be carried out to explore causes like sickle cell disease and thrombotic abnormalities if suspected.
Plasma exchange is another treatment modality, but sometimes clinicians prefer less invasive methods.
Cyto-albuminologic dissociation, electrophysiological tests, and spinal cord MRI are helpful tools in confirming the diagnosis and hence initiating the appropriate treatment. We report a series of 4 infants with toe tourniquet syndrome from Saudi Arabia who presented during wintertime with very similar symptoms (approximately 48 hours of inconsolable crying and irritability), similar involved region (toes), and similar constricting agent (hairs).
Hair TTS is a rare condition with only around 20 reported cases in which a hair or thread encircles and becomes tightly wrapped around a toe and results in ischemic strangulation with acute digital ischemia.
Toe tourniquet syndrome is neither very rare nor new but is under reported and many clinicians remain unaware of it.
The prompt diagnosis and treatment of the condition are vital to attain a good outcome and prevent complications. Colorimetric determination kits of total serum cholesterol (TC), triglyceride (TG), LDL, and high density lipoprotein-cholesterol (HDL) were purchased from Human Company, Wiesbaden, Germany, while the OxLDL determination kit was supplied from Uscn Life Science Inc Houston, Texas, USA. Group A was bred and maintained at LA (LA group; in King Saud University, College of Pharmacy, Riyadh, Saudi Arabia), and group B was bred and maintained in HA (HA group at King Khalid University, College of Medicine, Physiology Department, Abha, Saudi Arabia). Then, the samples were filtered with 0.2 µm millipore filters and stored at -78°C to measure the levels of dopamine, serotonin, and norepinephrine (only 8 samples of 10 were available for analysis in each group). Two-way ANOVA with post hoc comparisons (Tukey’s t-test) were used to compare all parameters analyzed between all groups used in stage 2 of the study. Data on hematocrit (Hct) values, serum levels of cortisol, and MDA are presented in Figure 1.
Serum levels of all these parameters in HA native rats were not significantly different after 10 days administration of normal saline as compared to their basal levels. Data were expressed as mean ± standard deviation for a group of 6 rats and statistical significance was assigned at p?0.05 level.
After 10 days of treating the HA native rats with propanolol, a ? blocker, the levels of all inflammatory cytokines and MDA levels were partially ameliorated and significantly reduced as compared with HA rats, while ?-adrenergic blockade with prazosin for the same time interval completely abolished the increase in these inflammatory cytokines and mediators and resulted in normal levels of MDA suggesting that OxLDL is not responsible for the HA-induced inflammatory response. In agreement with these findings, a study carried out by Shimosawa et al36 showed that Mg+2 blocks mainly N-type Ca+2 channels at nerve endings, and thus inhibits norepinephrine release, which decreases blood pressure independent of its direct vasodilatory action. Future research at the gene level is required to study the relationship between catecholamines and the up-regulation of stress transcriptional factors under hypoxic conditions. Elevated production of tumor necrosis factor-alpha by monocytes in patients with obstructive sleep apnea syndrome.
Hypoxia-inducible factor-dependent induction of netrin-1 dampens inflammation caused by hypoxia. Interleukin-6 response to exercise and high-altitude exposure: Influence of alpha-adrenergic blockade. Beta-adrenoceptor antagonists suppress elevation in body temperature and increase in plasma IL-6 in rats exposed to open field. Comparative studies of moderate and high altitude stress on humans: studies on plasma lipid profiles.
Vitamins E and C co-administration attenuates acute swimming-induced hepatorenal oxidative damage and improves lipid profile in untrained Wistar rats native to low and high altitude. Oxidized LDL enhances pro-inflammatory responses of alternatively activated M2 macrophages: a crucial role for Kruppel-like factor 2.
Indirect role of beta2-adrenergic receptors in the mechanism of anti-inflammatory action of NSAIDS. The role of central mechanisms in the anti-inflammatory effect of amitriptyline on carrageenan-induced paw edema in rats. Immobilisation stress may increase plasma interleukin-6 via central and peripheral catecholamines. Beta-Adrenergic regulation of IL-6 release from adipose tissue: in Vivo and in Vitro Studies.
IL-6 gene expression in human adipose tissue in response to exercise--effect of carbohydrate ingestion. Paeonol inhibits oxidized low density lipoprotein-induced monocyte adhesion to vascular endothelial cells by inhibiting the mitogen activated protein kinase pathway.
Oxidized low density lipoprotein induces inflammatory responses in cultured human mast cells via Toll-like receptor 4. Interdependent roles for hypoxia inducible factor and nuclear factor-kappaB in hypoxic inflammation. Physiology of magnesium metabolism and the important role of magnesium in potassium deficiency.
Magnesium supplementation attenuates, but does not prevent, development of hypertension in spontaneously hypertensive rats. Effects of magnesium supplementation in hypertensive patients: assessment by office, home, and ambulatory blood pressures.
Magnesium deficiency and hypertension: correlation between magnesium-deficient diets and microcirculatory changes in situ.
Magnesium inhibits norepinephrine release by blocking N-type calcium channels at peripheral sympathetic nerve endings.
Al-Hashem, Department of Physiology, College of Medicine, King Khalid University, Abha 61421, Kingdom of Saudi Arabia. A randomized controlled clinical trial of alpha-1 and selective beta-1 adrenoceptor blockade. Saudi Medical Journal is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). The side effect profile of vancomycin can range from the rather benign red-man syndrome (related to rapid infusion of the drug) to the most serious complications, such as Stevens-Johnson syndrome and toxic epidermal necrolysis. The side effect profile of vancomycin can range from the rather benign red-man syndrome (related to rapid infusion of the drug) to the most serious complications such as Stevens-Johnson syndrome, and toxic epidermal necrolysis.
Biopsy-proven anuric acute tubular necrosis associated with vancomycin and one dose of aminoside. Vancomycin-induced nephrotoxicity: mechanism, incidence, risk factors and special populations. Immunocytochemistry for vancomycin using a monoclonal antibody that reveals accumulation of the drug in rat kidney and liver.
A diagnosis of GBS was established by confirming high cerebrospinal fluid protein, motor nerve reduced amplitude, and prolonged conductions, and MRI T2 high signal intensity affecting the ventral roots of the spinal cord. The clinical improvement following intravenous immunoglobulin (IVIG) treatment and physiotherapy was noted. There was no history of change in his sensorium, seizure, head trauma, or recent vaccination. It is an inflammatory, demyelinating disorder of the spinal nerve roots and peripheral nerves of acute to subacute onset, associated with a T-cell-mediated immune response.
3) The spinal cord nerve roots enhancement on MRI.5 4) The clinical improvement following IVIG treatment.
Prospective evaluation of MRI lumbosacral nerve root enhancement in acute Guillain-Barre syndrome.
Inheretied metabolic disorders and stroke part 2: homocystinuria, organic acidurias, and urea cycle disorders.
Muthaffar, Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, PO Box 80215, Jeddah 21589, Kingdom of Saudi Arabia.
Immediate removal of the hair fibers was carried out in all patients, fortunately followed by fast healing with no signs of tissue necrosis. A 6-months-old girl presented to the pediatric emergency room (ER) in December 2013 with irritability and persistent severe crying for 48 hours. The incident seemed to be accidental, but we feel that if the mothers were more vigilant in checking their infants, the incident might not have happened or at least been discovered earlier. All doctors should be aware of this entity, and those children presenting with irritability should have their digits examined for signs of strangulation with awareness that numerous strands of hair may be involved.
Tourniquet syndrome: interest of a systematic analysis of families’ social conditions to detect neglect situations.
Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis.
Hair thread tourniquet syndrome in adolescents: a presentation and review of the literature.
Kamal, Associate Professor, Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
In the first stage, serum levels of inflammatory markers, adhesive molecules, lipid profiles, catecholamines, magnesium (Mg+2), and lipid peroxidation were compared between theses 2 groups. High-sensitivity C-reactive protein (hsCRP) ELISA determination kit was purchased from ASSAYPRO, Saint Charles, MO, USA. After 3 generations of breeding in each area, rats from each bred colony of each area were used in the experimental procedure in both group A and B. Two days later, and after overnight fasting, all rats were anesthetized with light diethyl ether. In both cases, GraphPad prism (version 6, La Jolla, CA, USA) was used for analysis and graphing. However, serum levels of TG and HDL were not significantly different between the 2 groups).
In contrast, administration of propanolol (?-blocker) or prazosin (?-blocker) significantly depressed the increases in the levels of these parameters seen in the HA native rats after 10 days of drug administration (Figure 6). X significantly different when compared with baseline level in the LA group, *significantly different when compared with its baseline level, ?significantly different when compared with the same period of the HA+ normal saline, ? significantly different when compared with the same period of HA+ propanolol group. In our study, we showed that both ? and ? adrenergic receptors are involved in this HA-induced inflammatory response. On the other hand, urinary levels of norepinephrine and dopamine were significantly higher while serotonin levels were significantly lower in HA native rats as compared with LA native rats, suggesting a sustained alteration in response to HA stress and occurrence of depression in the HA native rats.


Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work. Earlier reports of renal failure related to vancomycin were mainly linked to the impurities of vancomycin preparations.1 Nephrotoxicity related to the new preparations of vancomycin is believed to be a rare phenomenon, and mainly in the form of interstitial nephritis. Urine culture grew Escherichia coli, for which she received intravenous ceftriaxone for several days.
Earlier reports of renal failure related to vancomycin were mainly linked to the impurities of vancomycin preparations.1 With the advent of more purified forms of vancomycin, renal failure has become a rare event, and mainly attributed to the concomitant use of nephrotoxic agents, such as aminoglycosides and non-steroidal anti-inflammatory agents.
Alkhunaizi, Johns Hopkins Aramco Healthcare, Saudi Aramco, PO Box 10955, Dhahran 31311, Kingdom of Saudi Arabia. He showed remarkable clinical and neurophysiological improvement after intravenous immunoglobulin and intensive physiotherapy. A literature review for GBS presenting in infants as hemiplegia revealed no previous reports.
Intensive physical and occupational therapy is a key determinant of clinical improvement and led to a remarkable clinical improvement in our patient, who 6 months later was able to stand with support and to use both hands symmetrically. The prompt diagnosis and treatment of the condition were vital in attaining the good outcome and preventing ischemic complications. Immediate diagnosis and surgical intervention with removal of the constricting agent are necessary to prevent permanent tissue necrosis and loss of the affected digit.2 We report 4 cases of TTS affecting multiple toes to highlight the importance of meticulous examination of any infant with unexplained prolonged excessive crying, keeping in mind TTS as an important differential diagnosis. Meticulous thorough examination revealed erythema, swelling, and tenderness affecting the left second, third, and fourth toes with constriction rings at the level of the middle phalanges (Figure 1). Mothers should also be counseled regarding telogen effluvium and new parents should avoid using coverings on their infant’s extremities for extended periods of time without inspection, launder children’s clothes inside-out and carefully check their infants regularly to make sure that no hairs are becoming entangled in the fingers or toes.Acknowledgment.
In the second stages, inflammatory response and lipid peroxidation were analyzed in HA native rats after treatment with either ? (Prazosin) or ? (propranolol) adrenergic blockage. However, there is a lack of studies that monitored the inflammatory responses in native animals or people under natural hypoxic conditions provided by HA areas.
Serum IL-6 and intracellular adhesive molecule (ICAM-1) ELISA determination kits were purchased from Ray Biotech Inc, Norcross GA, USA. The experiment was started in both groups once they reached 80 days old, and the animals included in the study weighted between 240-250 g. Blood was collected from the rat’s eye directly into hematocrit tubes to measure hematocrit value (Hct %), and another 2 ml blood was collected into plain tubes and centrifuged at 5000 rpm for 10 minutes at room temperature. However, the baseline serum levels of cortisol were not significantly different between the HA and LA groups (p=0.97) (Figure 1B).
However, in addition to the pivotal role of catecholamine in fuel metabolism and the response to changes in energy demand during flight or fight, it is now well evident that IL-6 synthesis and secretion are under the regulation of catecholamines. She was admitted with portacath infection, and was hemodynamically stable with no signs of metabolic decompensation. Our objective in presenting this particular case is to highlight the importance of considering GBS in the differential diagnosis so that early effective treatment may be started. He had remarkable head lag and very much reduced tone, power, and deep tendon reflexes (DTRs) in the left upper and lower limbs in comparison with normal motor examination on the right.
The acute presentation of focal weakness in an infant warrants considering a broad differential diagnoses.
Testing for anti-GM1 ganglioside antibodies also could aid in the diagnosis of GBS as it can possibly being associated with C. Early diagnosis and proper immediate intervention of TTS will prevent catastrophic ischemic complications of the affected toe.
Several tightly wrapped hairs were found encircling the affected toes with a circumferential deep cut wound in the second toe.
All the 4 patients presented with excessive crying, local swelling, and erythema along with coiled hair around the toes. There is a lack of consensus how and when the offending ligature wraps so tightly around a structure! Also, there are limited studies regarding the involvement of catecholamines and Mg+2 levels in this inflammatory response in those natives. The ELISA kit for determination of vascular cell adhesive molecule (VCAM-1), tumor necrosis factor alpha (TNF-?), and malondialdehyde (MDA) were purchased from TSZ scientific, Lexington, MA, USA. Stage 2: This stage was carried out to investigate the role of increased norepinephrine on the inflammatory response seen in HA rats based on the results obtained in stage 1. This study was conducted at the Johns Hopkins Aramco Healthcare, Saudi Aramco, Dharan, Saudi Arabia between June and August 2013. During the course of hospitalization, the patient developed line infection with Staphylococcus epidermidis, and received intravenous vancomycin. The blood culture was positive for coagulase negative Staphylococcus, for which she received intravenous vancomycin. This report highlights the importance of considering GBS in the differential diagnosis so that early effective treatment may be started. The third and fourth toes were less severely involved with superficial circumferential wounds. Excessive and protracted crying may be the only symptom in babies, although some cases have been reported without any irritability despite having TTS for weeks.6 Circumferential digital strangulation causing distal edema was encountered in all patients who, fortunately, were discovered early before the development of tissue ischemia. Hence, in this study, we examined and compared serum levels of the main mediators of the inflammatory cascade in relation to lipid peroxidation, SNS, hypothalamic-pituitary-adrenal (HPA) axis functions, and serum Mg+2 levels in native rats from same genetic pool, which bred and lived for many generations at either low or high altitudes. The ELISA kits for determination of norepinephrine, dopamine, and serotonin were purchased from Abnova, Walnut, CA, USA. Abha city is located in the Aseer mountains, in the southwest of Saudi Arabia, and has an altitude of 2800 m above sea level. We have recently started a vancomycin stewardship program where patients needing vancomycin were prescribed the antibiotic by our pharmacy team according to body weight and creatinine (Cr) clearance. Sivathasan and Vijayarajan7 highlighted that circumferential digital strangulation impairs lymphatic and venous drainage causing distal edema, and that further obstruction may cause arterial occlusion and ischemic injury. On the other hand, Riyadh is located in the center of Saudi Arabia at an altitude of 600 m above sea level. A similar procedure was carried out for rats of stage 2, but serum only was collected at both baseline (before drug treatment), and after 10 days of either normal saline, or interventional drugs to measure the levels of the circulatory levels of IL-6, TNF-?, hsCRP, VCAM, and ICAM. Supporting this, hypoxia is well reported to increase plasma and tissue MDA levels at HA and even in in-vitro conditions by different mechanisms,22 and our results are in accordance with earlier studies.
Nerve conduction study (NCS) showed a reduced motor nerves compound muscle action potential (CMAP), and slow conduction velocity (Table 1, Figure 1). She was taken to the operating room (OR) and the wound repaired after refreshing the margins under general anesthesia. Based on these findings, we therefore, hypothesize that the observed increase in these pro-inflammatory and cell adhesion molecules could be partially attributed to enhanced NF-kappa B levels in the tissues of HA native rats, but the mechanism remains unclear.
Vancomycin was discontinued, and the serum Cr went back to baseline by the time of discharge. She was then admitted to the Pediatric ward where the swelling resolved with good wound healing, and she was discharged home after 4 days. All patients were monitored prospectively for the development of side effects, and had their renal function closely monitored.
Vancomycin was discontinued, and 7 days later the kidney function started to recover, as shown in Figure 2.
A spinal cord MRI (Figure 2) showed T2 high signal intensity affecting the ventral roots and thickened enhancing filum roots of the cervical and lower vertebral segments. Cold weather may be a factor due to a lot of clothes being used by the parents for their babies to achieve warmth where hair may be entangled, and the toes being covered may delay the diagnosis. A 79-year-old female was diagnosed 2 years earlier with breast cancer, for which she underwent modified mastectomy followed by hormonal therapy. A 5-months-old female infant presented to the pediatric surgery clinic in December 2013 with persistent crying for 48 hours associated with swelling of the right second toe, which was just discovered by the mother. Alharbi, Consultant Pediatrician, Head of Pediatric Department, Alhada Armed Forces Hospital, Taif, Kingdom of Saudi Arabia, for their advice and help in the production of the current work. The ATN was defined as AKI in addition to the presence of microscopic urinary finding of renal tubular injury, such as renal tubular epithelial cells, in addition to granular casts. She was admitted with pneumonia and received treatment with ceftriaxone, azithromycin, and vancomycin. Physical examination revealed multiple hair coils around the second right toe with swelling and erythema (Figure 2). Patients who had other reasons to cause AKI, such as sepsis, hypotensive episodes, or were exposed to nephrotoxic agents were excluded. He showed remarkable clinical and neurophysiological improvement, and 6 months later he was able to support his neck, stand with support, and use both hands symmetrically to grasp objects and play with toys. This study was approved by the Institutional Review Board at Johns Hopkins Aramco Healthcare, Dharan, Saudi Arabia.Results. It was observed that the wound was not deep; hence, the baby was discharged from the clinic with advice of daily dressing and follow-up after a week. A total of 89 patients were enrolled in the program, and received 89 courses of vancomycin. Urine microscopy showed typical findings of ATN with numerous brown, muddy, and granular casts, in addition to renal tubular epithelial cells (Figure 1). A 3-months-old male infant presented to the pediatric ER in January 2014 with a history of crying for 2 days with swelling and redness noticed by the mother on the left foot on the morning of the day of presentation. The ATN was attributed to vancomycin as there were no other identifiable causes to explain the kidney injury.
According to the mother, she changed the baby’s clothes 2 days ago followed by the problem of continuous crying, and the toe swelling started a day later.
One patient received ceftriaxone prior to the administration of vancomycin, while the third patient received ceftriaxone concomitantly with vancomycin. On examination, there was left third toe swelling and redness with hair-threads encircling the toe and cutting deeply into the skin.
The absence of eosinophiluria and eosinophilia does not eliminate interstitial nephritis, but makes it a less likely etiology of the acute renal injury. The ATN was diagnosed by the rapid rise of Cr, and documented by the urine microscopy finding of granular casts and renal tubular epithelial cells. A 6-months-old male infant presented to the pediatric ER in February 2014 with a history of excessive crying for one day. The mother noticed a constriction followed distally by massive swelling of the left fourth toe a few hours before presentation.
On examination, there was multiple hair coils encircling the left fourth toe and extending into the deep tissues (Figure 4). Urgent removal of the constricting hair was carried out in the OR, and he was discharged home after 2 days with no complications noted on follow-up and the digit survived well.



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