Establishing Reference Intervals for Serum and Salivary Cortisol in a Selected Population in Kano, Nigeria.

OBJECTIVE: Serum cortisol has long been used in the assessment of disorders of the hypothalamic-pituitary-adrenal axis. The reference interval for cortisol in both serum and saliva depends on the analytical methodology and the population studied; hence, a locally derived population-based reference interval is recommended. To our knowledge, there are no studies on reference interval determination in the study area, raising concerns about the use of reference intervals established in European and North American populations. This work aimed to establish reference intervals for baseline serum and salivary cortisol levels among healthy adults in Kano, Nigeria, using methods available in our laboratory. METHODS: A cross-section of 148 apparently healthy reference individuals aged 16 to 67 years were recruited from a local community in Kano, Nigeria, using a systematic sampling technique. Baseline serum cortisol was analyzed using highly sensitive and specific electrochemiluminescence quantitative measurements on an automated immunology analyzer. Salivary cortisol levels were measured using Salimetrics' competitive enzyme-linked immunosorbent assay test kits. Parametric methods with a 95% confidence interval were used to calculate reference intervals. RESULTS: The reference intervals for cortisol in serum and saliva were 72.0 nmo/L to 554.0 nmol/L and 0.40 nmol/L to 18.0 nmol/L, respectively. There was a weak positive correlation between serum and salivary cortisol values, but this association was not statistically significant. CONCLUSION: The development of locally derived adult reference intervals can improve the diagnostic utility of serum and salivary cortisol assessment and strengthen the reliability of adrenal insufficiency diagnoses in our population.

Prostate cancer presentation and management in the Middle East.

BACKGROUND: Although prostate cancer is a prevalent malignancy worldwide, its clinical presentation and management in the Middle East are not well-documented. This study aims to provide insights into the initial clinical presentation and management of prostate cancer in this region. METHODS: A retrospective review was conducted on seven institutional databases from six Middle Eastern countries, including Türkiye, Lebanon, Iraq, Syria, Bahrain, and Jordan, to identify patients diagnosed with prostate cancer in 2021. Descriptive analysis was performed on the collected data to provide an overview of the demographic, clinical, and treatment variables. RESULTS: A total of 1,136 patients were identified with a median age of 70 (range, 50-84). Most patients (78%) received their prostate cancer diagnosis after presenting with symptoms, as opposed to routine PSA screening. At the time of diagnosis, 35% of men had clinical T3 or T4 disease, 54% with Stage IV disease and 50% with Gleason score ≥ 8. Regarding treatment, 20% of non-metastatic and 22% of metastatic patients received no treatment. CONCLUSION: Most men in this study sought prostate cancer evaluation due to symptoms and were subsequently diagnosed with advanced-stage disease, providing a foundation for future research aimed at understanding the underlying factors behind the observed trends and enabling informed interventions.

Management of Garden-I and II Femoral Neck Fractures: Perspectives on Primary Arthroplasty.

This review compares internal fixation versus arthroplasty in the treatment of nondisplaced femoral neck fractures (FNFs) calling attention to evolving areas of consensus that influence clinical decision-making. The Garden classification system, typically dichotomized into nondisplaced (types I and II) and displaced (types III and IV) fractures, has been used as a guide for surgical decision-making. Conventionally, treatment of nondisplaced FNF in the elderly has been with internal fixation, and treatment of a displaced FNF has been hemi-, or more recently total hip, arthroplasty. Studies over the last decade have raised concern over the appropriate treatment of nondisplaced FNFs due to high rates of reoperation of nondisplaced FNFs treated with internal fixation. Avascular necrosis (AVN), failure of internal fixation, secondary malunion, and pin/nail penetration through the femoral head have all been observed. Several studies have attributed fixation failure to a degree of femoral neck tilt ≥20°, either posteriorly or anteriorly as seen on the lateral X-ray. Because of these observations of fixation failures, the suggestion has been made that arthroplasty be used when the degree of posterior tilt exceeds a threshold of ≥20° tilt with the expectation of diminishing failure of fixation, decreasing the risk of reoperation and preserving function without increasing mortality rate. Frustrating additional analyses are uncertainties over the mechanisms of failure of internal fixation with ≥20° tilt and the persistently substantial 1-year mortality rate after FNF, which has not been influenced by fixation or replacement type. Due to the lack of consensus regarding the determination of the appropriate surgical intervention for nondisplaced FNFs, an improved algorithm for surgical decision-making for these fractures may prove useful.

Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions.

BACKGROUND: Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions. METHODS: This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years). RESULTS: Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05). CONCLUSIONS: Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA. LEVEL OF EVIDENCE: This is a level III prognostic study.

Postoperative Angiotensin Receptor Blocker Use is Associated With Decreased Rates of Manipulation Under Anesthesia, Arthroscopic Lysis of Adhesions, and Prosthesis-Related Complications in Patients Undergoing Total Knee Arthroplasty.

BACKGROUND: The cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA. METHODS: Patients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities. RESULTS: ARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA. CONCLUSIONS: ARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association.

Prevalence and Determinants of Endothelial Dysfunction among Adults Living with HIV in Northwest Nigeria.

Background: Endothelial dysfunction constitutes an early pathophysiological event in atherogenesis and cardiovascular disease. This study aimed to assess the prevalence, determinants, and degree of endothelial dysfunction in antiretroviral therapy (ART)-treated people living with HIV (PLWH) in northwestern Nigeria using brachial flow-mediated dilatation (FMD). Methods: This was a comparative, cross-sectional study. A total of 200 ART-treated adults living with HIV with no evidence of kidney disease were compared with 200 HIV-negative participants attending a tertiary hospital in Kano, Nigeria, between September 2020 and May 2021. Endothelial function was evaluated by measuring FMD with a high-resolution vascular ultrasound transducer. FMD was calculated as the ratio of the brachial artery diameter after reactive hyperemia to baseline diameter and expressed as a percentage of change. Blood and urine samples were obtained from participants in both arms. Urine albumin-to-creatinine ratio (uACR) was calculated using the 2021 CKD-EPI estimated glomerular filtration rate (eGFR) creatinine-cystatin C equation without the race variable, and low-density lipoprotein (LDL) cholesterol was measured using enzymatic method. Results: The overall mean age (± standard deviation) of the study participants was 42 ± 11 years. Participants in the comparison arm were younger than PLWH (38 ± 11 versus 46 ± 10 years, respectively). The median (interquartile range) uACR was 41.6 (23.2-162.9) mg/g for the ART-treated PLWH versus 14.5 (7.4-27.0) mg/g for healthy controls. PLWH had a significantly lower mean percent FMD when compared to HIV-negative participants (9.8% ± 5.4 versus 12.1% ± 9.2, respectively). Reduced FMD was independently associated with HIV infection (ß = -2.83%, 95% CI, -4.44% to -1.21%, p = 0.001), estimated glomerular filtration rate (ß = -0.04%, 95% CI, -0.07% to -0.01%, p = 0.004) and LDL cholesterol (ß = -1.12%, 95% CI, -2.13% to -0.11%, p = 0.029). Conclusion: HIV-positive status, lower estimated GFR, and higher LDL cholesterol levels were independently associated with endothelial dysfunction. Future prospective studies with larger cohorts of persons living with HIV (and age- and sex-matched HIV-negative controls) are needed to gain further insight into these important findings. In the interim, aggressive management of modifiable risk factors is warranted.

Influence of Basic Health Care Provision Fund in improving primary Health Care in Kano state, a descriptive cross-sectional study.

BACKGROUND: The Basic Health Care Provision Fund (BHCPF) is a direct financial investment that funds Primary Healthcare (PHC) to improve the quality of services. This study assessed the influence of the BHCPF in improving PHC services. METHODS: A descriptive cross-sectional study was conducted among PHC workers in 100 facilities randomly selected from the 484 designated PHCs for implementing the BHCPF project in Kano state. Using multiple sampling methods, 200 healthcare workers in PHC facilities were selected and assisted by trained data collectors to respond to the questionnaires. Chi-square analysis was used to show associated factors, while binary regression analysis was used to determine the relationship between factors influencing the BHCPF implementation in PHC. RESULT: The findings showed healthcare workers had higher awareness (61.7%) and good utilization (57.1%) of BHCPF. Challenges of the BHCPF implementation were insufficiently skilled health professionals (85%), lack of data management capacity (52.6%), low community participation and awareness (52.0%), delay in releasing funds (60.7%), poor infrastructure (87.8%), and weak financial management and accountability system (58.2%). Healthcare professionals having a diploma were four times more likely to have the National Health Management Information System (NHMIS) in their facilities (AOR = 4.955, 95% CI = 1.120-21.036; P-value 0.035) than those without. Primary healthcare facilities were two times more likely to have the NHMIS (AOR = 2.549, 95% CI = 1.167-5.566: P-value 0. 019) than health post. CONCLUSION: The factors that influenced PHC facilities to promote the implementation of BHCPF included: periodic evaluation of the facilities, availability of functional storage facilities, and improving the standard of care in PHC facilities. There is a need for retraining healthcare workers and creating more community awareness of the BHCPF.

Extensor Carpi Ulnaris Instability: A Comprehensive Review of Pathology and Operative Techniques.

The extensor carpi ulnaris (ECU) is primarily responsible for extension and ulnar deviation at the wrist. Secondary to repetitive loading of, or acute trauma to the flexed, supinated and ulnarly deviated wrist, the ECU tendon can be a common source of ulnar-sided wrist pain. Common pathology includes ECU tendinopathy, tenosynovitis, tendon instability, and tendon rupture. Extensor carpi ulnaris pathology commonly occurs in athletes and patients with inflammatory arthritis. Given the multitude of available methods to treat ECU tendon pathology, the aim of our study was to outline operative management of ECU tendon pathology, with emphasis on reviewing techniques for addressing ECU instability. We acknowledge a continuing debate between anatomical and nonanatomical techniques for ECU subsheath reconstruction. However, use of a portion of the extensor retinaculum for nonanatomical reconstruction is commonly used and demonstrates successful outcomes. Future comparative studies on ECU fixation are required to increase data on patient outcomes, to further define and standardize these techniques.

Toxicological evaluation of aqueous leaf extract of Terminalia catappa linn (combretaceae) in pregnant rats.

Introduction: Terminalia catappa (T. catappa) leaves are used in the treatment of hypertension, diabetes, cough, jaundice, indigestion etc, while the bark is used to treat diarrhea, dysentery, abscesses etc. Due to the acceptance and increased use of medicinal plants in pregnancy, there is a need to evaluate their toxicological profiles in pregnancy for safe use. This study aims to evaluate the toxicological effects of aqueous leaf extract of T. catappa in pregnant rats. Methods: acute toxicity study was carried out using Organization of Economic Corporation Development (OECD) 423 guidelines. Seventy-five rats (50 females and 25 males) were used at the age of 2 weeks just after weaning. The male rats were separated from the female rats in different cages and allowed to mature for 10 weeks. Then the rats were allowed to mate. After mating, 20 female rats with viable spermatozoa counts were selected and divided into 4 groups of 5 rats each (n=5). The control group received distilled water while the treatment groups II, III, and IV were administered with aqueous leaf extract of T. catappa orally at graded doses of 100, 200, and 400 mg/kg respectively for 21 consecutive days. The daily food and water intake, and weight were recorded. On the 22th day, the rats were anesthetized by chloroform inhalation, and blood samples were collected for haematological and biochemical analysis. The maternal livers, kidneys, and hearts were collected and weighed, and histological studies were carried out. The fetuses were removed and examined. An isolated tissue experiment was carried out on the myometrium of the pregnant rat uterus. The isometric reading of the uterine contractions was recorded. Results: the oral LD50 was found to be ≤2000-5000 mg/kg. There was a significant (p<0.05) increase in the mean food intake at the 100, 200, and 400 mg/kg doses of the extract used on the 14th and 21st days when compared to the 7th day. The renal function test showed a significant (p<0.05) increase for chloride. The liver function test revealed that the extract at 100 mg/kg dose, significantly (p<0.05) increased only Alkaline Phosphatase (ALP) liver enzyme, while at 200 mg/kg dose, only AST liver enzyme was significantly (p<0.05) increased, while at 400 mg/kg dose, ALT, AST, ALP, and albumin increased significantly (p<0.05) when compared to the control group. There was a significant (p<0.05) decrease in the relative organ weight of the liver at 400 mg/kg dose of the extract. The liver histology showed moderate hepatic vacuolation and necrosis, while the histology of the kidney showed slight tubular necrosis. Conclusion: this study has shown that the aqueous leaf extract of T. catappa is relatively not safe in the pregnant rats. Although it is non-toxic to the fetus, it exhibited tocolytic effect by inhibiting uterine contractions, thus it should be used with caution during pregnancy, especially in the third trimester or during labor.

Pembrolizumab-Induced Lichen Planus in a Patient With Non-Small-Cell Lung Carcinoma (NSCLC) That Correlates to Therapeutic Response.

Immune checkpoint inhibitors are increasingly being used in the treatment of various solid organ and hematologic malignancies. Dermatologic toxicities associated with programmed cell death protein-1 (PD-1) and programmed death ligand-1 (PD-L1) therapy have been widely reported in the literature. Lichen planus is an inflammatory disease frequently seen in areas of the skin and oral mucous membrane lining. This autoimmune disorder is T-cell mediated with multiple contributing factors like emotional stress, genetic predisposition, isotopic response, or drugs. With increasing use of immunotherapy, early recognition and prompt treatment of associated adverse events are critical to ensure patient safety. Cutaneous toxicities are among the most commonly observed adverse events with this class of drugs. Here, we report a case of lichen planus in a 66-year-old male patient receiving pembrolizumab for stage IV non-small cell lung cancer (NSCLC). He was diagnosed 56 months ago with advanced lung cancer with brain metastasis. He has received 62 cycles of pembrolizumab and continues to be in complete clinical and radiographic remission. Pembrolizumab is a drug that helps immune cells in killing cancer cells by binding to the PD-1 protein. This case highlights the potential cutaneous side effects that may result in a patient with pembrolizumab and the fact that it can serve as a "clinical biomarker" and show therapeutic effectiveness of the treatment.

Monoclonal Gammopathies in a Fracture Liaison Service.

Monoclonal gammopathies are a spectrum of disorders characterized by the overproduction of plasma B-cells and immunoglobulin. Monoclonal gammopathy of uncertain significance (MGUS), a pre-malignant form of multiple myeloma, is defined by relatively low bone marrow concentration of clonal plasma cells and asymptomatic clinical presentation. New evidence, however, points to an association of MGUS with osteoporosis, microarchitectural bone deficiency, and fractures, and it has been suggested that it be renamed "Monoclonal Gammopathy of Skeletal Significance." The prevalence of MGUS in the general geriatric population is estimated to be 3-8%, while the prevalence in geriatric vertebral fracture patients is 15%, and the prevalence in all fracture patients within the Rhode Island Fracture Liaison Service is 10%. Therefore, MGUS and other monoclonal gammopathies should be suspected in all patients diagnosed with osteoporosis or an osteoporotic fracture, and patients diagnosed with monoclonal gammopathies should be evaluated for osteoporosis and fracture risk and treated appropriately.

Treatment with oral vitamin D alone, topical minoxidil, or combination of both in patients with female pattern hair loss: A comparative clinical and dermoscopic study.

BACKGROUND: One of the most common dermatological complaints among female is female pattern hair loss (FPHL). Serum vitamin D is a factor lately taken into consideration in approaching patients complaining of hair loss. AIM: To evaluate the serum level of 25-hydroxy vitamin D in patients with FPHL and to evaluate the efficacy of vitamin D therapy alone or combined with minoxidil in the treatment of this disease. METHODS: 45 patients with FPHL and 15 controls to measure serum level of vitamin D were enrolled in the study. Patients then were subdivided into 3 groups: group I received topical minoxidil and oral vitamin D, group II received topical minoxidil, and group III received oral vitamin D for 6 months. Clinical and dermoscopic evaluation was done for the three groups before and after treatment. RESULTS: Vitamin D level was significantly decreased in patients compared to controls. After treatment, as regard Ludwig scale, there was statistically significant improvement in group I than II while no significant improvement was found in group III. Dermoscopy revealed that thin hair and single-hair unit were significantly improved in groups I and II, while it was not significantly improved in group III. CONCLUSION: Oral vitamin D combination to topical minoxidil is recommended to treat patients with FPHL; they had better results than vitamin D or topical minoxidil alone.

Atraumatic Displaced Femoral Neck Insufficiency Fracture Because of Severe Hypocalcemia in a Pediatric Patient: A Case Report.

CASE: This is a case of a 14-year-old autistic boy who presented with an atraumatic transcervical femoral neck fracture in the setting of significant hypocalcemia and vitamin D deficiency. We discuss his surgical and medical management and metabolic derangements associated with atraumatic femoral neck fractures. CONCLUSION: Pediatric femoral neck fractures in the absence of trauma are uncommon and often have underlying metabolic abnormalities. In addition, autism poses unique challenges in caring for these patients who are at an increased risk of complications. Interdisciplinary care is integral to achieving successful outcomes.

Platelet rich plasma injection versus topical erythromycin 2% in treatment of acne vulgaris.

BACKGROUND: Acne vulgaris is a common inflammatory skin disease that affects the pilosebaceous glands. There are different modalities of treatment of acne but there is no standard treatment free of side effects. Platelet rich plasma (PRP) is an autologous concentration of platelets in a small volume of plasma. When platelets are activated, multiple growth factors are released. They play an important role in angiogenesis, inflammatory process and wound healing. AIM: was to evaluate and compare the therapeutic efficacy of platelet rich plasma versus topical erythromycin 2% in treatment of acne vulgaris. METHODS: 40 patients with inflammatory acne lesions were included. All patients received PRP injection sessions in one side of the face (group A) every 2 weeks for 6 sessions and topical erythromycin 2% in the other side (group B). RESULTS: There was significant difference between both groups in which better improvement was reported in group A (55% of patients showed good to excellent improvement and 35% showed moderate improvement, especially the inflammatory lesions). Group A showed better patients' satisfaction and lower rate of recurrence than group B. CONCLUSION: PRP is effective and safe treatment option for inflammatory acne and alternative to other systemic modalities especially if they are contraindicated.

Evaluation of the efficacy and safety of platelet rich plasma injection in treatment of rosacea.

Rosacea is a chronic relapsing inflammatory skin disease, with a high prevalence among adults. Treatment of rosacea is difficult, with high rate of recurrence. Due to the strong anti- inflammatory and antibacterial effects of platelet rich plasma (PRP), it was used in the medicine for treating many inflammatory diseases. To evaluate the role of PRP injection in treatment of rosacea. The study was carried on 40 patients with rosacea. They were treated by PRP injection in right side of the face (group A) and platelet poor plasma injection in left side (group B). They underwent one session every 2 weeks for 3 months (6 sessions). The patients were assessed clinically before and after treatment by the rosacea grading scale. Skin biopsies were taken to evaluate the clinical results. There was a statistically significant decrease in rosacea grading scale after treatment with PRP injection, 50% of the patients showed excellent improvement and 50% showed good improvement. The improvement was significantly better in group A than B. There was marked decrease in inflammatory cells by hematoxylin and eosin stain, and decrease in expression of nuclear factor kappa ßeta after treatment with PRP. PRP was effective and safe technique in treatment of rosacea and alternative to other systemic modalities, especially if they are contraindicated.

Cor-Triatriatum Dexter with Associated Cyanosis in a 3-Month-Old Girl.

Cor-triatriatum is uncommon and cor-triatriatum dexter is rarer, and patients may remain asymptomatic in isolated cases especially if the partitioning is mild and nonobstructing. There may be other cardiac defects associated with it which are mostly right-sided cardiac defects such as atrial septal defect, Ebstein anomaly, and pulmonary stenosis. However, left-sided heart anomaly such as aortic regurgitation has been associated with it, but its association with transposition of the great vessels has not been documented before now. Therefore, the case of a 3-month-old girl with cor-triatriatum dexter with transposition of the great vessels, and atrial septal defect is reported.

Sleep quality among nurses in a tertiary hospital in North-West Nigeria.

BACKGROUND: Sleep is a necessity; it is nourishing, refreshing and healing. The nursing profession is associated with busy and difficult work schedules, especially the running of shifts which has been associated with cardiovascular and metabolic complications. There is a dearth of local data on sleep disorders, especially among nurses. In this study, we evaluated the quality of sleep and the tendency of daytime sleepiness among nurses. SUBJECTS AND METHODS: This study was cross-sectional in nature involving 100 nurses working with Federal Medical Centre Birnin Kebbi, Kebbi State; the study was carried out between October 2016 and February 2017. The Pittsburg Sleep Quality Index was used to determine poor sleepers; while the Epworth Sleepiness Scale (ESS) was adopted to determine the presence of tendency of daytime sleepiness; 0-7 was considered normal, 8-9 represented average tendency of daytime sleepiness, 10-15 represented excessive daytime sleepiness, while 16-24 represented daytime sleepiness requiring medical intervention. P < 0.05 was set as statistically significant. RESULTS: There were 23 (23%) males and 77 (77%) females, with a male-to-female ratio of 0.3:1. The age range was 18-50 years, with a mean age of 31.4 ± 8.6 years. The ESS score ranged from 0.0-17.0, with a mean score of 7.3 ± 3.5; while the Pittsburg score ranged between 1 and 15, with a mean score of 5.7 ± 2.7, and 61% of the nurses had a poor sleep quality. There was unlikely tendency of excessive sleepiness across all the age groups, though this was not statistically significant (χ2 = 7.258, P = 0.283), and poor sleep quality was most prevalent among the 25-40-year-old group but this observation was also not statistically significant (χ2 = 2.259, df = 2, P = 0.334). CONCLUSION: Poor sleep quality is a problem among nurses, though less tendency to daytime sleepiness was observed in this report.