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Higher level of serum homocysteine could be used as a biomarker for Polycystic ovary syndrome (PCOS)

homocysteine in diagnosed cases of polycystic ovary syndrome p. 291
Rojeen Rasheed Suleiman, Dhia Mustafa Sulaiman
DOI:10.4103/MJBL.MJBL_94_18  
Background: Polycystic ovary syndrome (PCOS) is an endocrine disorder characterized by an ovulatory infertility, menstrual dysfunction, and hirsutism. The pathophysiology behind PCOS is complex. Comorbidities associated with PCOS are hypertension, diabetes, dyslipidemia, and cardiovascular events. Objective: The aim of this study was to estimate the level of homocysteine in women with PCOS. Materials and Methods: In the current case–control study, 50 female patients diagnosed with PCOS and 40 apparently healthy controls were recruited. The diagnosis of PCOS was established according to Rotterdam criteria. The serum homocysteine level was measured using Cobas 6000 and compared between two study groups. Results: Results found that high percentage of patients in the case group had abnormal level of homocysteine (74.0%) compared to control with normal level of homocysteine. Mean homocysteine level was significantly higher in patients with PCOS (17 μmol/L) compared to its level in control patients (9 μmol/L), P < 0.0001. Results also revealed that the mean levels of homocysteine between the body mass index categories and marital status showed no significant difference in cases and controls, P > 0.05. Conclusions: The present investigation suggests that higher level of serum homocysteine could be used as a biomarker for PCOS.
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Anti-müllerian hormone level in patients with polycystic ovary syndrome

Anti-müllerian hormone level in patients with polycystic ovary syndrome p. 295
Salar Mohammed Saadullah, Dhia Mustafa Sulaiman
DOI:10.4103/MJBL.MJBL_98_18  
Background: Polycystic ovary syndrome (PCOS) is one of the common causes of chronic anovulation and hyperandrogenism in women between the age of 13 and 45 years old. PCOS is characterized by an increased number of follicles at all growing stages particularly in the preantral and small antral follicles, those who primarily produce Anti-Müllerian hormone (AMH). Objective: The aim of the study is to measure the AMH levels in serum of the women with PCOS. Materials and Methods: The study included 90 women (50 cases with PCOS and 40 control cases healthy women). PCOS patients were diagnosed according to the Rotterdam definition; serum AMH was measured using the ultrasensitive AMH enzyme-linked immunosorbent assay. Results: Mean serum of AMH in PCOS patients was 11.52 ng/ml and for the control group was 3.36 ng/ml and was statistically significant with the P < 0.0001. Conclusions: AMH is elevated in PCOS patients, which can be used in the future as a marker for the diagnosis of PCOS.
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Sutureless focus harmonic thyroidectomy

Sutureless focus harmonic thyroidectomy versus conventional clamping and knot-tying technique p. 300
Ibrahim Falih Noori, Mansour Amin Mohammad
DOI:10.4103/MJBL.MJBL_45_18  
Background: Thyroidectomy is the most frequent procedure in endocrine surgery. Since thyroid is the highly vascular organ, therefore, prompt and meticulous hemostasis is extremely important. Although conventional thyroidectomy is used frequently with acceptable outcomes, it is time-consuming and resulted in significant intraoperative blood loss with possible risk of injury to parathyroid glands and laryngeal nerves. The advent of ultrasonically activated focus harmonic device in thyroid surgery was encouraging for improving safety, effectiveness, and reduction of operative time. Aim of this Study: The purpose of this study was to analyze the effectiveness and surgical outcomes of using ultrasonic harmonic scalpel for thyroid surgery compared to conventional techniques (clamping and suture ligation (knots tying) and electrocautery. Patients and Methods: This is a prospective, randomized study in which 64 patients with various types of goiters presented for thyroidectomy. The patients were divided into two comparable groups. Group A (32 patients) included patients who had focus harmonic thyroidectomy and Group B (32 patients) included patients who received conventional thyroidectomy. Results: Focus harmonic thyroidectomy showed significant reduction in operative time, intraoperative blood loss, volume of postoperative fluid drainage, and postoperative pain scores compared with conventional thyroidectomy. There were no significant differences in the incidence of postoperative hypocalcemia and laryngeal nerve injury between both the groups. The total cost of focus harmonic thyroidectomy and hospital stay were also less compared with conventional techniques. Conclusions: Focus harmonic thyroidectomy was a safe, effective, faster, and beneficial alternative to conventional technique since it reduces the time of surgery, blood loss, postoperative drainage, and pain with comparable postoperative complications.
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Orbital tumors

: A prospective study of 95 cases p. 334
Mohammed Jaber Al-Mamoori
DOI:10.4103/MJBL.MJBL_69_18  
Background: A wide variety of tumors and pseudotumors can involve the orbit. Although the incidence of orbital tumors is relatively low, the diagnosis and the treatment strategy for such tumors are of great concern to neurosurgeons and ophthalmologists. Objectives: The main aim of this study is to determine the distribution of patient age, sex, pathology, origin, and location of orbital tumors for optimum management because the delay in the diagnosis and treatment is the most preventable cause of morbidity and mortality. Materials and Methods: In this study, 95 cases of orbital tumors are studied prospectively during 10 years' period in the Hilla Teaching Hospital in Babylon-Iraq from 2008 to 2018. The parameters dealt with in this study included; the distribution of patient age and sex, clinical manifestations, investigations, pathology, origin of tumors and tumor location in the orbit, management, surgical procedures, and mortality in 95 patients (aged from 6 months to 75 years, the mean age is 29.8). Results: In this study, the highest age group incidence of orbital tumors is in the first decade of life which constitutes (24.2%), the second peak is in the fourth decade of life which constitutes (17.9%). 42 (44.2%) of the patients are males and 53 (55.8%) of the patients are females. Among the 95 cases, 76 (80%) are primary orbital tumors, 15 (15.8%) are secondary orbital tumors (tumors that originating from contiguous regions), and 4 (4.2%) are metastatic orbital tumors. Orbital tumors location; 83 (87.4%) are extraconal and 12 (12.6%) are intraconal. The two most common orbital tumors are dermoid cyst (27.4%) and pseudotumor (16.8%). Overall mortality is seven patients (7.4%). Conclusion: Orbital tumors are a relatively rare and challenging group of tumors. The age of onset, state of vision, tumor location in the orbit and other radiological findings provide the most important information for the diagnosis of orbital tumor prior biopsy or surgical resection and to make decision about other further treatment modality. For any patient complain from visual loss, proptosis, and impaired ocular motility, it is better to undergo magnetic resonance imaging and computed tomography-scan imaging to detect or exclude intraorbital or intracranial diseases.
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Role of hepcidin in hearing loss

 p. 376
Sami R Al-Katib, Yasir L Hasson, Rawaa H Shareef
DOI:10.4103/MJBL.MJBL_106_18  
Background: Hearing loss is considered as a public health problem that affects the population at all ages. Hepcidin is an important protein with a crucial role in the homeostasis and metabolism of iron. Objective: The objective of this study was to evaluate the association between hepcidin and hearing loss and to find out the mechanisms that lead to this association. Materials and Methods: A total of 300 persons included in this study, 150 as a patients' group who are suffering from hearing loss and attended Al-Sadder Teaching Hospital in Al-Najaf Al-Ashraf City, Iraq, while the other 150 participants who are selected randomly as controls' group and are free from hearing loss.  The ages of all participants ranged between 18 and 70 years, and controls were matched with patients by gender and age (within 5 years). Many parameters are measured such as hepcidin, C-reactive protein (CRP), interleukin-6 (IL-6), advanced glycation end products (AGEs), and glutathione peroxidase-3 (GPX-3). Results: The results of this study revealed that sensorineural hearing loss was the most common type followed by mixed one.  Furthermore, it was shown that hepcidin and CRP were significantly higher in patients compared with controls, while there were no significant differences between patients and controls in the levels of IL-6, AGEs, and GPX-3.  The correlation analyses showed a significant positive correlation between hepcidin and CRP and hepcidin and IL-6. Conclusion: Hepcidin and CRP have a negative impact on hearing, increase significantly with hearing loss, and have role in the development of hearing loss.
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Alligator attacks,Caiman's bite

CASE REPORT

Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 24-26

Thoracic trauma by black caiman's bite in the Amazon region

João José Corrêa Bergamasco, Raquel Magalhães Pereira, Juan Eduardo Rios Rodriguez, Brígida Thaine Fernandes Cabral
Department of General Surgery, Getúlio Vargas University Hospital – HUGV, Federal University of Amazonas, Manaus, Amazonas, Brazil

Date of Web Publication

20-Dec-2018

Correspondence Address:

João José Corrêa Bergamasco

Department of General Surgery, Getúlio Vargas University Hospital – HUGV, Federal University of Amazonas, Manaus, Amazonas 
Brazil

Abstract

Alligator attacks are rare, being mostly by accidental causes, for lack of care in regions where the presence of these animals is confirmed or by provocation of them. There are few reports of accidents by these animals. The reported species hereafter is the Melanosuchus niger from the Amazon rainforest. The patient aged 32 years, coming from the countryside of Amazonas, was admitted to the emergency room 3 days after the accident with black caiman's bite. Alligator attacks of the species M. niger are very severe, due to its size around 6 m of length and overwhelming strength, being capable to cause extensive and deep lacerations with its bite. Cases like this are not easy to conduct. Since the injury was on an atypical place, the severity of the symptoms was increased, leading to dyspnea and huge blood loss.

Keywords: Bites and stings, penetrating, wounds, wounds and injuries

Introduction

Alligator attacks are rare, even in the Amazon region, being mostly by accidental causes, for lack of care in regions where the presence of these animals is confirmed or by provocation of them. We must consider that the Amazon region has two species of different genera that are passing through an intense moment of population recovering for the last two decades after a period of predatory exploitation, and they are still the most abundant crocodilians on the region being them the spectacled caiman (Caiman crocodilus) and the black caiman (Melanosuchus niger).^[1] There are few reports of accidents by these animals, most related to smaller species, such as Caiman yacare (Yacare caiman) and Caiman latirostris (broad-snouted caiman). However, the reported species hereafter is the M. niger, or the black caiman, from the Amazon rainforest, it presents a large size compared to the others, and it attacks humans for predation, not being considered just accidents as with other species.^[2],[3] Another important factor to be quoted is the seasonal period of alligator appearance, mostly present on low water level periods of the river, facilitating attacks on the surface; moreover, it is a common period of animals' egg's incubation. At this time of year, there are many other species that feed on these eggs, which increase the rate of aggressive alligators on the surroundings.^[4]

Case Report

The patient, a 32-year-old man, coming from the countryside of Amazonas, was admitted to the emergency room 3 days after the accident with black caiman's bite (M. niger). According to the reports, the victim was fishing in a river near his city on a canoe, followed by his wife on another canoe, when the animal with approximately 5 m length got on the patient's boat, attacking his chest, releasing him only because his wife attacked the alligator with wood pieces. In his admission, he appeared to be slightly dyspneic and has chest pain, respiratory rate of 22 rpm, heartbeat of 106, and normal values of blood pressure.

The physical examination showed extensive lacerations at the left hemithorax [Figure 1] and [Figure 2], with loss of soft parts at the thoracic wall, rib fractures, lung parenchyma exposure, and muscular tissue wounds. The first step was inserted a chest drain of 28 French inside a wound to drain a severe purulent fluid. The leukogram showed a raise of leukocytes rate (20,451).

Figure 1: Thoracic region with wounds sutured or not Click here to view

Figure 2: Extensive thoracic lesions Click here to view

The patient was immediately forwarded to surgery center, where was performed a left anterolateral thoracotomy showing pleural adhesions at the chest wall, pleural cavity cleaning, partial pulmonary decortication, cleaning and debridement of the thoracic wall muscles, partial excision of the ribs (ribs 7/8/9), and a closed chest drain with water seal, associated with collagenase dressing. After 24 h of evolution at intensive care, the vital signals were stable, blood pressure levels were 90/50 mmHg, cardiac frequency: 72 bpm, saturation: 96%, and temperature: 36.5°C, accepting oral diet, without pulmonary symptoms, but with chest tube inserted. Thorax radiography showed opacity at left lung, more intense between superior and inferior lobe [Figure 3]. At the 3^rd day after the surgery, the levels of blood in chest drain had an important decrease but still with bubbles and serous liquid, without smell. At 10 day of postoperatory, thorax radiography was solicited, with a residual opacification between superior and inferior lung lobe [Figure 4]. After 11 days, the drainage tube had no bubbles or serous liquid and was removed after this.

Figure 3: Chest radiography (before surgery) Click here to view

Figure 4: Chest radiography (14 days after surgery) Click here to view

He remained hospitalized for 15 days with parenteral antibiotic therapy (6 days of cefepime +8 days of meropenem) because of extensive and unspecific microbiota of alligator jaws. He evolved well at postoperative, with radiological and drainage volume control, withdrawn at the 14^th day after surgery and decrease of leukocytes levels. Received discharge clinically well with residual pulmonary opacification at the left hemithorax.

Discussion

Alligator attacks of the species M. niger are very severe, due to its size around 6 m of length and overwhelming strength, being capable to cause extensive and deep lacerations with its bite, lethal against children and small-sized people. The main complications due an attack of this kind are tissue lesions that depending on the affected region may compromise functions or losing limbs; blood loss, due the wound depth, hits blood vessels, leading to hypovolemic shock in cases, like the one related above; and infection, due the bacterial flora present in the alligator's mouth.^[5],[6],[7] The most attacked anatomic parts are the inferior limbs, being able to lead to amputation if the initial medical care takes too long.

The early debridement and the hypovolemic and infectious states stabilization are the initial goals on this situation because they are the main causes of death.^[8] It is important to mention that great thoracic traumas are very complicated to handle due the vital organs and easily traumatized when submitted to high strength, like an alligator bite, that can be ranged from 217 to 13,172 N, leading to an increase of the mortality in similar cases, which tends to be the focus of researches in the next years.^[9],[10]

Acknowledging few published reports by trustful sources, a case like the reported above fits in every way like a hard situation to care. Since the injury was on an atypical place (the thorax), the severity of the symptoms was increased, leading to dyspnea and huge blood loss. Added to this, there is the difficulty of the Amazon region, mostly on the riverside communities, which does not have a good emergency support in cases of this magnitude, needing to go to a specialized center, most of the time in Manaus to receive a proper care. So, considering infectious factors, prognosis was poor due to the late beginning of antibiotics and surgical cleaning of the wounds (on the third day after trauma), what makes this case even more relevant for its favorable outcome.

 

References

1.	Vasconcelos WR. Genetic Diversity and Structure Population of Crocodilians Genetic Age and Structure Population of Crocodilians Jacaré-Açú (Melanosuchus niger) and Jacaré-Tinga (Caiman crocodilus) of the Amazon - Dissertation. Manaus - Amazonas National Research Institute of Amazonia.; 2005. p. 1-97.
2.	Langley RL. Alligator attacks on humans in the United States. Wilderness Environ Med 2005;16:119-24.
3.	de Neto MC, Stolf H, Haddad Junior V. Alligator attack on fisherman in the Pantanal of Mato Grosso (Brazil): Case report Diagn Trat 2013;18:21-3.
4.	Torralvo K, Botero-Arias R, Magnusson WE. Temporal variation in black-caiman-nest predation in Varzea of central Brazilian Amazonia. PLoS One 2017;12:e0183476.
5.	Brook I. Management of human and animal bite wound infection: An overview. Curr Infect Dis Rep 2009;11:389-95.
6.	Haddad V, Fonseca WC. Fatal attack on a child by a black caiman (Melanosuchus niger). Wilderness Environ Med 2011;22:62-4.
7.	Sartain SE, Steele RW. An alligator bite. Clin Pediatr (Phila) 2009;48:564-7.
8.	Doering EJ, Fitts CT, Rambo WM, Bradham GB. Alligator bite. JAMA 1971;218:255-6.
9.	Erickson GM, Lappin AK, Parker T, Vliet KA. Comparison of bite-force performance between long-term captive and wild American alligators (Alligator mississippiensis). J Zool 2004;262:21-8.
10.	Grubmüller M, Kerschbaum M, Diepold E, Angerpointner K, Nerlich M, Ernstberger A, et al. Severe thoracic trauma – Still an independent predictor for death in multiple injured patients? Scand J Trauma Resusc Emerg Med 2018;26:6.

Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]