Absence Of Identifiable Risk Factors Research Articles

Placenta Accreta Spectrum in Unscarred Uterus: A Case Report in a Tertiary Facility

Background: Placenta accreta spectrum (PAS) is a broad term that includes placenta accreta, placenta increta, and placenta percreta. The major risk factor is a scarred uterus commonly as a result of prior cesarean delivery, myomectomy, or uterine instrumentation. We report a case of placenta increta in the absence of identifiable risk factors. Case presentation: A 22-year-old, para 2 living 2, presented with postpartum hemorrhage due to retained placenta post vaginal delivery at a gestational age of 38 weeks and 4 days, manual removal of placenta was attempted general anesthesia without success; necessitating explorative laparotomy where the placenta was found deeply invading into the myometrium. Intractable bleeding necessitated supracervical hysterectomy. Histopathological results later revealed placenta increta. Conclusion: PAS in an unscarred uterus in the absence of other identifiable risk factors is quite uncommon; however, carries high maternal morbidity and mortality. This case serves as an eye opener on the need to evaluate for radiological features of PAS during antenatal visits even in low-risk group.

Placenta accreta spectrum in unscarred uterus: A case report in a tertiary facility

Background: Placenta Accreta Spectrum (PAS) is a broad term that includes placenta accreta, placenta increta, and placenta percreta. The major risk factor is a scarred uterus commonly as a result of prior cesarean delivery, myomectomy, or uterine instrumentation. We report a case of placenta increta in the absence of identifiable risk factors. Case presentation: A 22-year-old, para 2 living 2, presented with postpartum hemorrhage due to retained placenta post vaginal delivery at a gestational age of 38 weeks and 4 days, manual removal of placenta was attempted general anesthesia without success; necessitating explorative laparotomy where the placenta was found deeply invading into the myometrium. Intractable bleeding necessitated supracervical hysterectomy. Histopathological results later revealed placenta increta. Conclusion: PAS in an unscarred uterus in the absence of other identifiable risk factors is quite uncommon; however, carries high maternal morbidity and mortality. This case serves as an eye opener on the need to evaluate for radiological features of PAS during antenatal visits even in low-risk group.

Recurrence Risk after First Symptomatic Distal versus Proximal Deep Vein Thrombosis According to Baseline Risk Factors

Background It remains unclear whether the distal location of deep vein thrombosis (DVT) is independently associated with a lower risk of recurrence in all patients, or represents a marker of the presence and severity of provoking factors for venous thromboembolism (VTE). Methods We investigated the impact of distal (vs. proximal) DVT location on the risk of developing symptomatic, objectively confirmed recurrent VTE in 831 patients with a first acute symptomatic DVT not associated with pulmonary embolism (PE), who were stratified by the presence of transient or persistent risk factors at baseline. The primary outcome was symptomatic, objectively diagnosed recurrent VTE, including proximal DVT and PE. Results A total of 205 (24.7%) patients presented with a transient risk factor, 189 (22.7%) with a minor persistent risk factor, 202 (24.3%) with unprovoked DVT, and 235 (28.3%) with cancer-associated DVT. One-hundred twenty-five patients (15.0%) experienced recurrent DVT or PE. The largest relative difference between patients with distal (vs. proximal) DVT was observed in the absence of identifiable risk factors (adjusted hazard ratio [aHR]: 0.11; 95% CI [confidence interval]: 0.03–0.45). In patients with cancer, distal and proximal DVT had a comparable risk of recurrence (aHR: 0.70; 95% CI: 0.28–1.78]). Conclusions The distal (vs. proximal) location of first acute symptomatic DVT represented, in the absence of any identifiable transient or persistent risk factors, a favorable prognostic factor for recurrence. In contrast, the prognostic impact of DVT location was weaker if persistent provoking risk factors for VTE were present, notably cancer.

Prevalence of Hepatitis C Virus Infection among People Attending A Voluntary Screening Centre in Masaka, Nasarawa State, Nigeria

Hepatitis C virus (HCV) is an emerging public health problem in Nigeria. This study therefore determined the seroprevalence of this virus among people of a rural settlement in Nigeria during which 600 people were screened for HCV infection. Five ml of blood was collected from each participant, the serum harvested and screened for anti- HCV using a Chromatographic rapid test kit (ACON Inc. USA) according to the manufacturer’s instructions .The overall prevalence of HCV infection in this population was 24.2% being higher among males (23.7%) than females (23.7%) (p 0.05). Only Educational level had a significant association with infection (p < 0.05). When stratified by age infection was highest among those aged 21 -30 years (27.4%) and least among those aged 51 years and above (3.6%) (p 0.05). Occupation and marital status also had no statistically significant relationship with viral infection. The 24.2% infection rate reported in this population is a cause for alarm because it means there is a high viral reservoir in the area. There is also a high number of persons likely to have end- stage liver diseases among these participants. The absence of identifiable risk factors is a major challenge to prevention and control and demonstrates the need for reevaluation of transmission routes in the locality. Screening should be available and affordable.

Uterine Clostridial Myonecrosis After Thermal Balloon Endometrial Ablation

We present a case of a patient who had development of uterine clostridial myonecrosis after elective thermal balloon endometrial ablation in the absence of identifiable risk factors. A 51-year-old woman underwent uneventful thermal balloon endometrial ablation for the treatment of menorrhagia. The next day, she presented with acute inflammatory syndrome, severe intravascular hemolysis, and acute kidney injury. The blood cultures and the high vaginal swab showed moderate growth of Clostridium species. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Her postoperative course was uneventful, and renal function gradually recovered. Clostridial myonecrosis after uncomplicated surgery, although rare, should be considered in the differential diagnosis of the acutely septic patient with massive hemolysis, regardless of the presence of patient's risk factors.

Manipulative and Antisocial Behavior in an 11-Year-Old Boy with Epilepsy

Brian is an 11-year-old boy who presented to the emergency room with suicidal ideation and hearing voices. In the preceding weeks, he had escalating symptoms of oppositional defiant disorder, attention-deficit hyperactivity disorder (ADHD), and bipolar disorder. His medical history was notable for complex partial epilepsy with onset at age 4 that had been well controlled with divalproate. He had several mental health diagnoses by various practitioners including oppositional defiant disorder, ADHD, and bipolar disorder. Brian's family and social history was notable for the absence of identifiable risk factors for seizures or psychiatric problems. Over the course of a week-long psychiatric hospitalization, his complaints of depression and hearing voices seemed incongruent with his behavior. His parents endorsed a long history of Brian manipulating family and friends, such as conning his friends into stealing money and giving it to him. There was increasing suspicion that Brian was contriving his presenting symptoms for secondary gains. When his parents visited, he consistently bargained for prized items such as a long sought after cell phone and his own bedroom to improve his mood. His prior diagnoses (ADHD, a mood disorder, and oppositional defiant disorder) did not capture what seemed to be his core problem--an ability and willingness to manipulate others for his own self-serving purposes. Three months later, he was seen in the pediatric neurology clinic for increased seizure frequency. In the interim, he had several very serious altercations including setting fire to his family church, an attempted break-in-and-entry, assaulting his principal and resisting the arresting officer, and a malicious planned attack on his father where he struck him in the head with a crescent wrench "in cold blood, without any emotion."

Isolated metastasis of colon cancer to the scapula: is surgical resection warranted?

BackgroundDistant metastases from colon cancer spread most frequently to the liver and the lung. Risk factors include positive lymph nodes and high grade tumors. Isolated metastases to the appendicular skeleton are very rare, particularly in the absence of identifiable risk factors.Case reportThe patient was a 55 year old male with no previous personal or family history of colon cancer. Routine screening revealed a sigmoid adenocarcinoma. He underwent resection with primary anastomosis and was found to have Stage IIA colon cancer. He declined chemotherapy as part of a clinical trial, and eight months later was found to have an isolated metastasis in his right scapula. This was treated medically, but grew to 12 × 15 cm. The patient underwent a curative forequarter amputation and is now more than four years from his original colon surgery.DiscussionStage IIA colon cancers are associated with a high five year survival rate, and chemotherapy is not automatically given. If metastases occur, they are likely to arise from local recurrence or follow lymphatic dissemination to the liver or lungs. Isolated skeletal metastases are quite rare and are usually confined to the axial skeleton. To our knowledge, this is the first reported case of an isolated scapular metastasis in a patient with node negative disease. The decision to treat the recurrence with radiation and chemotherapy did not reduce the tumor, and a forequarter amputation was eventually required.ConclusionThis case highlights the importance of adequately analyzing the stage of colon cancer and offering appropriate treatment. Equally important is the early involvement of a surgeon in discussing the timing of the treatment for recurrence. Perhaps if the patient had received chemotherapy or earlier resection, he could have been spared the forequarter amputation. The physician must also be aware of the remote possibility of an unusual presentation of metastasis in order to pursue timely work up.

Blastomycotic hand infections

We report two cases of disseminated blastomycotic infections with involvement of the hand occurring in the absence of identifiable risk factors.

Small bowel cancer risk in Lynch syndrome

<h3>Background</h3> Paraneoplastic neurological syndromes are usually associated with small cell lung cancer, gynaecological, lymphomas and renal cell carcinomas. A few studies report the association of neurological syndromes with squamous cell...

Hepatobiliary and pancreatic: Hepatocellular carcinoma without cirrhosis

A 56-year-old woman presented to our Emergency Service with a 1-week history of upper abdominal pain, nausea and vomiting. On examination of her abdomen, she had a large tender mass in the right upper quadrant. Abnormalities on blood tests included an elevated white cell count (13.2 × 109/L) and a mild elevation of plasma alkaline phosphatase and gamma glutamyltransferase. The serum level of alpha fetoprotein was markedly elevated at 32 311 u/mL (R < 10 U/mL). Serological tests for hepatitis B and hepatitis C were negative. A magnetic resonance imaging scan (T2-weighted) showed a hypervascular mass, 21 cm × 15 cm in size, in the right lobe of the liver (Fig. 1). In some slices, there were extensive areas of necrosis. Upper gastrointestinal endoscopy and colonoscopy were normal. At laparotomy, an extended right hepatectomy was performed. A macroscopic examination of the specimen showed an ill-defined tumor with areas of necrosis (asterisk) including one area of necrosis that perforated through the hepatic capsule (Fig. 2). Microscopic evaluation revealed a moderately differentiated hepatocellular cancer with a predominant microtrabecular pattern but with areas of acinar and tubular formation. The mitotic count was high showing 11 mitoses/10 high power fields (400x). There was no evidence of fibrosis in liver tissue adjacent to the tumor. She was subsequently treated with thalidomide, 300 mg per day, and eight months after surgery, is asymptomatic with normal levels of alpha fetoprotein. Hepatocellular cancer is the fifth most common cancer world-wide. Approximately 50% of cases have been attributed to hepatitis B and 25% to hepatitis C. Most of these patients have coexisting cirrhosis. The remaining 25% of cases have been associated with other causes of cirrhosis such as alcohol abuse and hemochromatosis and to exposure to carcinogens such as aflotoxins. The development of hepatocellular cancer in the absence of cirrhosis appears to be rare in hepatitis C but may be more common in hepatitis B. Another uncommon hepatocellular carcinoma that occurs in the absence of cirrhosis is the fibrolamellar variant. This typically occurs in young adults, does not secrete alpha fetoprotein and is not associated with either hepatitis B or C. The patient described above represents an unusual situation where a typical hepatocellular carcinoma developed in the absence of identifiable risk factors.

High frequency of colonization and absence of identifiable risk factors for methicillin-resistant Staphylococcus aureus (MRSA)in intensive care units in Brazil.

Colonization of hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) is of increasing concern. To evaluate this problem in Intensive Care Units (ICUs) in Brazil, we studied 100 patients admitted to two ICUs from April to June, 1997. Of the 100 patients, 70 were male, 53 were age 60 years or older, 55 were previously hospitalized, 78 were transferred to the ICU from other hospital units, 49 had received antibiotic therapy, and 66 had undergone recent surgery. Nasal and axillary swab cultures were obtained on admission and every 48 hours thereafter until discharge. MRSA were identified by plating any cultured S. aureus on Mueller-Hinton agar containing 6 microg/ml of oxacillin. At the time of admission, 46 (46%) of the patients were colonized with MRSA. No associated risk factors for acquiring MRSA (age, previous hospitalization, prior surgery) could be identified. Of the 54 patients negative for MRSA on admission, 28 (52%) became colonized while in the ICU. Sixteen (22%) of the 74 colonized patients (colonized either on admission or during ICU stay) had associated respiratory or urinary tract infections due to MRSA, and 9 (56%) died. No correlation with special risk factors (invasive procedures, antibiotic use, age, chronic disease) was identified. MRSA occurred frequently, but there was minimal evidence of associated risk factors. Thus, control of MRSA cannot be accomplished by targeting special factors alone, but requires attention to preventing microbial spread in all areas. Of special concern is the high frequency of acquiring the organism in the ICU (52%). Education concerning the importance of hand washing, environmental surface cleaning, and barrier protection from infected patients is needed.

Prevalence of asymptomatic hepatitis B infection in pregnant Mexican-American women

Recent reports document high rates of asymptomatic hepatitis B virus infection in pregnant Hispanic women of Caribbean and Latin American origin, frequently in the absence of identifiable risk factors. We hypothesized that the prevalence of asymptomatic hepatitis B virus infection in Mexican-American women was much lower and that most belonged to established risk groups. Three thousand seven hundred eight-nine pregnant women, 77% of whom had Hispanic surnames, were screened for hepatitis B surface antigen upon admission in labor to Medical Center Hospital in San Antonio. Twelve women, six of whom had Hispanic surnames, were found to have asymptomatic hepatitis B infections. The prevalence of asymptomatic infections was 3.2 per 1000 (95% confidence interval 1.6-5.5) in the total population, 2.0 per 1000 (95% confidence interval 0.7-4.5) in those with Hispanic surnames, and 7.0 per 1000 (95% confidence interval 2.5-15.0) in those with non-Hispanic surnames. Risk factors, as defined by the Centers for Disease Control, were found in five (42%) of the positive patients overall and in only one (17%) of the positive patients with an Hispanic surname. We conclude that, although asymptomatic hepatitis B infection is uncommon in these pregnant Mexican-American women, the absence of identifiable risk factors in the majority of those infected suggests that routine screening in this population is justified.

Use of routine viral cultures at delivery to identify neonates exposed to herpes simplex virus.

We obtained specimens for viral culture from mothers, infants, or both at the time of 6904 deliveries, without regard to the mothers' history of genital herpes. Herpes simplex virus (HSV) was recovered in cultured specimens from 14 of the 6904 deliveries (0.20 percent); all 14 mothers were asymptomatic. All viral isolates were herpes simplex virus type 2 (HSV-2). Only 1 of the 14 women (7 percent) had a history of genital herpes, whereas 12 (86 percent) had serologic evidence of a previous infection with HSV-2. None of the infants born to these 12 women contracted neonatal herpes. However, one of the two infants born to women with serologic evidence of a primary HSV infection at the time of delivery contracted neonatal herpes. Our findings show that most infants at risk of exposure to HSV at delivery will not be identified if concern about asymptomatic shedding of virus is limited to women with a history of genital herpes infection. Most neonatal exposure to an asymptomatic maternal HSV infection at delivery is not predictable or preventable. Therefore, physicians caring for newborns need to consider neonatal herpes in the differential diagnosis when infants become ill during the first weeks of life, regardless of the presence or absence of identifiable risk factors for HSV infection.

Epidemiologic study of necrotizing enterocolitis among low-birth-weight infants: Absence of identifiable risk factors

Necrotizing enterocolitis has been associated with a variety of perinatal problems which have been purported to be risk factors predisposing the neonate to NEC. The present investigation compares the perinatal histories of 48 low-birth-weight infants (less than 1,500 gm) with NEC to those of 553 high-risk infants of equivalent birth weight who did not have NEC but who were present in the nursery during a four-year observation period. The two populations were equivalent with regard to maternal factors such as socioeconomic status, education, race, and age. Both the antenatal and intrapartum risk scores were similar, as were the position of presentation and mode of delivery. The incidence of pre-eclampsia, prolonged rupture of the membranes, and placenta previa was also equivalent. Birth weight and gestational age were identical, as well as intrauterine growth retardation and low Apgar scores. The placement of umbilical artery catheters or the performance of exchange transfusions were not more frequent among patients with NEC. Infants who developed NEC demonstrated significantly different incidences of only three variables. Mothers of these infants were usually married, and their infants had less respiratory distress syndrome; the only adverse factor present more frequently was abruptio placenta. These data raise further questions concerning the significance of previously reported risk factors of NEC.