Libyan Journal of Medicine

Published by Co-Action Publishing
Online ISSN: 1819-6357
Print ISSN: 1993-2820
Publications
Ultrasound scan showing a uterus of normal structure with an empty cavity, a placenta, and a non-viable foetus of 17 week's gestation outside the myometrial structure. 
Full thickness uterine rupture of 6cm involving the remaining hemi-uterus, and a dead foetus with a placenta presenting no sign of placental insertion in the abdomino-pelvic cavity 
Pregnancy in a rudimentary horn is a very rare condition. It is responsible for several complications. Prognosis is reserved because the natural evolution generally leads to a cataclysmic uterine rupture at the beginning of the second trimester. Classically, the treatment after foetal extraction consists of ablation of the rudimentary horn and associated fallopian tube. We report the obstetric outcome of a patient with history of rudimentary uterine horn rupture, the treatment of which was ablation of the rudimentary horn.
 
Two questionnaires were translated into Arabic and culturally adapted to measure chronic pain and neuropathic pain in the general population in Derna, Libya, and then in a country-wide survey. A point prevalence of chronic pain and neuropathic pain in Libya was determined. The findings of this series of studies suggested that the prevalence of chronic pain in Libya, which was 19.6%, is similar to the average European estimate despite the cultural dissimilarities of the two regions and the environmental differences surrounding the surveyed samples.
 
To The Editor: Gender re-assignment after attainment of puberty is a challenging exercise. The problem is further compounded in places with limited diagnostic and counseling facilities. We report on a teenager who was raised as a boy until he started to have regular menstruation. The difficulties encountered in the management of this case are highlighted.
 
Resistance to antimicrobial agents is a major health problem that affects the whole world. Providing information on the past state of antimicrobial resistance in Libya may assist the health authorities in addressing the problem more effectively in the future. Information was obtained mainly from Highwire Press (including PubMed) search for the period 1970-2011 using the terms 'antibiotic resistance in Libya', 'antimicrobial resistance in Libya', 'tuberculosis in Libya', and 'primary and acquired resistance in Libya' in title and abstract. From 1970 to 2011 little data was available on antimicrobial resistance in Libya due to lack of surveillance and few published studies. Available data shows high resistance rates for Salmonella species in the late 1970s and has remained high to the present day. High prevalence rates (54-68%) of methicillin-resistant Staphylococcus aureus (MRSA) were reported in the last decade among S. aureus from patients with burns and surgical wound infections. No reports were found of vancomycin-resistant S. aureus (VRSA) or vancomycin-intermediate-resistant S. aureus (VISA) using standard methods from Libya up to the end of 2011. Reported rates of primary (i.e. new cases) and acquired (i.e. retreatment cases) multidrug-resistant tuberculosis (MDR-TB) from the eastern region of Libya in 1971 were 16.6 and 33.3% and in 1976 were 8.6 and 14.7%, in western regions in 1984-1986 were 11 and 21.5% and in the whole country in 2011 were estimated at 3.4 and 29%, respectively. The problem of antibiotic resistance is very serious in Libya. The health authorities in particular and society in general should address this problem urgently. Establishing monitoring systems based on the routine testing of antimicrobial sensitivity and education of healthcare workers, pharmacists, and the community on the health risks associated with the problem and benefits of prudent use of antimicrobials are some steps that can be taken to tackle the problem in the future.
 
Cryptosporidium is the causative agent of cryptosporidiosis. The disease is self-limited in immunocompetent persons but potentially life-threatening in immunocompromised individuals. The data included in the present review were obtained mainly from a Highwire Press (including PubMed) search for the period 2002-2011. Information on cryptosporidiosis is lacking in some Arab countries; however available data show prevalence rates of <1-43% (mean = 8.7%) of Cryptosporidium infection in diarrheic immunocompetent pediatrics and <1-82% (mean 41%) in immunocompromised patients (including children and adults). Infection rate with Cryptosporidium species among pediatrics in rural and semiurban areas was higher than in urban areas. Cryptosporidium-associated diarrhea occurs mainly in younger children and inversely correlates with age, being more prevalent in children aged 1 year or less, particularly in rural and suburban regions. Although most Arab countries are characterized by a hot summer and a mild winter, infection with Cryptosporidium appears to occur at a higher rate of incidence during the rainy months that are usually associated with the cold season of the year. Contact with animals and contaminated waters are the main modes of transmission of cryptosporidia. Reports of C. hominis from the region indicate that person-to-person transmission is also important. Foreign housekeepers in oil-rich countries may be a source of Cryptosporidium. Cryptosporidium species, mainly C. parvum, are important causes of diarrhea in countries of the Arab world, particularly in children. In addition to educational programs that promote personal, household, as well as food hygiene, improving water treatment processes and protection of treated waters from contamination should be implemented by the health and environmental authorities in each country. More studies employing molecular testing methods are needed in the future to provide data on circulating species/genospecies and subtypes and their modes of transmission in the community.
 
Our retrospective study was conducted at Riyadh military Hospital, Riyadh, Saudi Arabia, which is a tertiary health care center with a capacity of 1,200 beds. Identification of the microorganism was done using the microbiology laboratory protocol, and those non-repetitive clinical cultures that showed positive for A. baumannii during a 5-year period from January 2005 to December 2010 were included in the study. Blood cultures were performed using the BACTEC 9,240 system (Becton–Dickinson Sparks, MD, USA). A total of 380 A. baumannii blood isolates were identified in blood cultures between January 2005 and December 2010 and confirmed by API 20 NE (bioMerieux Inc., France). Isolation and identification was followed by antibiotic typing of these 380 blood isolates by MicroScan WalkAway (Dade Behring Inc., West Sacramento, CA, USA) according to manufacturer specifications. Antibiotic patterns were determined in accordance with CLSI guidelines. The antimicrobial agents used in this study were amikacin (AK), ampicillin–sulbactam (AM–S), cetazidime (CFZ), ceftriaxone (CFN), ciprofloxacin (CIP), gentamicin (GEN), meropenem (MERO), netilmicin (NET), piperacillin/tazobactam (PT), trimethoprim/sulfamethoxazole (TM-SXT), and tetracycline (TET). Intermediately, susceptible strains were considered to be resistant. All laboratory testing was performed according to manufacturer specifications for that instrument in accordance with practices recommended by CLSI. Multidrug resistant A. baumannii (MDR-AB) is classically recognized and defined if it is resistant to three or more classes of antibiotics. Statistical analysis was done using a t-test, and P<0.05 was considered significant.
 
Graphical depiction of the total number of patients admitted to Al-Jalaa hospital from 2001 to 2011. 
The number of road traffic accidents plotted against the months in 2010 and 2011. 
Road traffic injuries (RTIs) are a major public health concern in Libya. In the light of the armed conflict in Libya that broke out on February 2011 and the subsequent instability, the rate and pattern of RTIs was studied. RTI patient data were gathered from Al-Jalaa hospital, the main trauma center in Benghazi, from 2010 to 2011. Various parameters [i.e. age, gender, nationality, method of entry, receiving department, intensive care unit (ICU) admission, duration of stay, method of discharge, and fatalities] were compared with data from the previous year (2010), and statistical analyses were performed (t-test, chi-square, and Poisson regression). During the conflict period, 15.8% (n=2,221) of hospital admissions were RTIs, that is, a rate of 6.08 RTI cases per day, levels not seen for 5 years (t=-5.719, p<0.001). The presence of armed conflict was found to have caused a significant 28% decrease in the trend of RTIs over the previous 10 years (B=-0.327, CI=-0.38--0.28, p<0.001). February and March, the peak period of active combat in Benghazi, witnessed the lowest number of RTIs during the conflict period. The average age of an RTI decreased to 28.35±16.3 years (t=-7.257, p<0.001) with significantly more males (84.1%, n=1,755) being affected (χ(2)=4.595, p=0.032, df=1). There was an increase in the proportion of younger aged patients (from 0 to 29 years) (χ(2)=29.874, p<0.001, df=8). More patients required admission to the ICU (χ(2)=36.808, p<0.001, df=8), and the mortality of an RTI increased to 5.2% (n=116) (χ(2)=48.882, p<0.001, df=6). There were fewer RTIs during the conflict period; however, those that occurred had higher morbidity and mortality. The profile of an RTI victims also changed to an increased prominence of young males and motorcyclists. Further research is required to propose and analyze possible interventions.
 
CASE PRESENTATIONA 22-year-old woman was referred to our unit for capsule endoscopy because of recurrent iron deficiency anaemia and gastrointestinal bleeding since childhood. Cutaneous vascular lesions had been surgically removed when she was a child.During the preceding year she required blood transfusions every month and had a total of 9 iron infusions. Gastroscopy and colono-scopy at another hospital had shown small vascular lesions in the stomach, duodenum and colon. Clinical examination revealed pallor. Blood investigations showed a haemoglobin level of 9.6 g/dl and a MCV of 67 fl.The capsule endoscopy (PillCam, Given Imaging) was performed. Fifteen lesions similar to those shown in figures 1 and 2 were noted through-out small bowel. She underwent a laparotomy with intra-operative entero-scopy; the lesions were removed and the histology is shown in Figure 3.
 
miRNAs are initially transcribed as several hundred nucleotide long primary or pri-miRNAs and are then processed to approximately 60-nucleotide (nt) hairpin pre-miRNAs in the nucleus by the double-stranded RNA (dsRNA)-specific ribonuclease (Drosha). The ribonuclease Drosha requires a dedicated dsRNA-binding protein to convert long, nuclear pri-miRNA transcripts into shorter pre-miRNA hairpin stem-loops. The pre-miRNAs are exported to cytoplasm where they are further excised by a RNA-induced silencing complex (RISC) enzyme. These miRNAs are further processed into numerous specific 19 to 23 nt miRNAs, with the ability to target various endogenous and exogenous genes (8).
Triple infection (TI) with HIV-1, HCV, and HBV (TI) is highly prevalent in intravenous drug users (IDUs). These TI patients have a faster progression to AIDS, and even after antiretroviral therapy (ART) the prognosis of their disease is poor. The use of microRNA (miRNA) to silence genes holds potential applications for anti-HCV therapy. We analyzed the role of human miRNAs (hsa-miRs) in TI by computational analyses for HCV, HIV-1, and HBV showing identity to these three viral genomes. We identified one unique miRNA, hsa-miR-3065-3p, that shares significant mutual identity to these three viral genomes (∼61-83%). In addition, hsa-miR-99, hsa-miR-548, and hsa-miR-122 also showed mutual identity with these three viral genomes, albeit at a lower degree (∼52-88%). Here, we present evidence using essential components of bioinformatics tools, and hypothesize that utility of hsa-miR-3065-3p and perhaps miR-548 would be potential antiviral therapeutic agents in the treatment of TI patients because it shows near perfect alignment in the seed region for all three viruses. We also make an argument that current proposed therapy with hsa-miR-122 may not be the optimal choice for HCV patients since it lacks essential gene alignment and may be harmful for the patients.
 
Characteristics of some cases reported in literature
MRI brain showing demyelinating lesions.
MRI brain 3 months later
There are few case reports documenting a new onset of demyelinating processes in patients receiving anti-tumour necrosis factor alpha therapy (anti-TNF alpha) for chronic inflammatory arthropathies. Whether anti-TNF alpha therapy induces new onset demyelination or just exacerbates pre-existing latent multiple sclerosis is not fully understood. We are reporting a 51-year-old woman without a prior history of multiple sclerosis, who developed demyelinating brain lesions three months after starting Etanercept. Her symptoms partially resolved on cessation of the drug. Our case was unusual compared to some previous case reports, as the patient's age at presentation was beyond that for idiopathic multiple sclerosis. This may strengthen the hypothesis of a causal relationship between new onset demyelination and Etanercept; however, exacerbation of pre-existing demyelinating process by Etanercept in this patient still cannot be totally excluded. We recommend doing magnetic resonance imaging (MRI) of the brain before starting patients on anti-TNF alpha therapy to exclude latent demyelination. In addition, new onset demyelination following anti-TNF alpha therapy should be reported and studied thoroughly as this may yield a significant advancement in our understanding of the pathogenesis of multiple sclerosis. Long-term follow-up of these cases is also important to determine the long-term prognosis and the rate of relapse of demyelinating process in this group of patients.
 
Correlation of highÁrisk pregnancy and developmental delay (and 5 domains of development)
Risk factors associated with developmental delay in children aged 4Á60 months
The future development of children is considered more than ever now due to the advances in medical knowledge and thus the increase in survival rates of high-risk infants. This study investigated the correlation between high-risk pregnancy and developmental delay in children aged 4-60 months. This descriptive study was conducted on 401 mothers and their children (4-60 months) who visited health service centers affiliated to Isfahan University of Medical Sciences, Iran, in 2011. Sampling was carried out in several stages, and the Ages and Stage Questionnaire was completed by the participants. Data were analyzed with SPSS 18 software and independent t-test; Mann-Whitney and logistic-regression tests were used. The average age of children in the low-risk pregnancy group was 22±16 months, and that in the high-risk pregnancy group was 18.9±14.8 months. The majority of children were female (53.1%). The prevalence of high-risk pregnancies was 80.5%, and the prevalence of developmental delay was 18.7%. Multiple pregnancies, low birth weight, habitual abortions, maternal medical disorders in pregnancy, and gestational diabetes had significant correlations with developmental delay in children (P<0.04). In the logistic model, male gender, low birth weight, family marriage, and maternal medical disorders during pregnancy showed significant correlations with developmental delay in children (P<0.05). Additionally, abnormal body mass index (BMI) and social and economic status showed probability values close to the significance level (P = 0.05), whereas other high-risk pregnancy variables had no correlation with developmental delay in children. A correlation between high-risk pregnancy and developmental delay (P = 0.002) and fine motor delay was observed (P = 0.02), but no correlation was observed between high-risk pregnancy and other developmental domains. This study showed that some high-risk pregnancy variables had a significant correlation with developmental delay. Moreover, a significant correlation was observed between high-risk pregnancy and fine motor developmental delay.
 
M/F trends for Israel, Egypt, and Kuwait. 
In mammals, gender is determined at conception and male births occur slightly in excess. The male to female ratio of live births is technically incorrectly referred to as M/F as this is given as male divided by total births, and it is expected to approximate 0.515. A declining M/F has been observed in many industrialised countries since 1950 as the more fragile male foetus may be spontaneously aborted at a higher rate than the more robust female foetus when exposed to hypothetical deleterious environmental factor/s. Stress has been shown to decrease M/F, while long-duration warfare (such as the World Wars) increases it. Adverse environmental factors or traumatic experiences that affect entire populations have both been shown to lower M/F. For example, M/F declines after warfare, earthquakes, and a multiplicity of environmental disasters. It appears that such events promote stressed pregnant women to spontaneously abort male foetuses to a greater extent than female foetuses. M/F has therefore been proposed as a potential surrogate sentinel health indicator. (Published: 9 April 2014) Citation: Libyan J Med 2014, 9 : 23448 - http://dx.doi.org/10.3402/ljm.v9.23448
 
Regarding risk factors, neither the antenatal nor the birth history proved to be risk factor. Furthermore, family history of consanguinity was reported in 38 (45.2%) patients, family history of autism was reported in seven (8.3%) patients, and family history of global developmental delay was reported in 19 (22.6%) patients. The total period of follow-up ranged from a few months to 3 years. Investigations including brain MRI, chromosomal analysis standard and fragile X, and phenylalanine level were requested in all of the patients. Many parents (28 patients, 33.3%) did not continue the work-up. All of the work-up done was normal apart from fragile X testing, which was abnormal in two patients (4.7%), and phenylalanine level, which was abnormal in two patients (4.3%).
 
Ultrasound showed the typical 'target' sign.  
a and b: Axial (a) and reformatted coronal; (b) CT scan images show the concentric irregular colonic wall thickening with multiple mesenteric nodes.  
Two weeks post-treatment CT scan shows dramatic resolution of the right-sided colonic mass.  
Amebic colitis is common in tropics, usually presenting with variable and non-specific symptoms. Amebomas occur rarely, usually in cecum and ascending colon, when they can masquerade as colon carcinoma. This report describes the case of a 27-year-old male who presented with right abdominal mass. Radiological examination prompted us to the differential diagnosis of ameboma and he was treated with metronidazole and broad-spectrum antibiotics for two weeks. Amebic colitis should be considered as a possible diagnosis when dealing with right-sided abdominal mass.
 
Relationship between irritable bowel syndrome and personal, sociodemographic characteristics of medical students and interns in King Abdul-Aziz University 2012 
Relationship between irritable bowel syndrome and habits, and health background of medical students and interns in King Abdulaziz University, 2012 
Relationship between irritable bowel syndrome and family history, health background of medical students and interns in King Abdulaziz University, 2012 
Relationship between irritable bowel syndrome and psychological aspect of medical students and interns in King Abdulaziz University, 2012 
Background: Irritable bowel syndrome (IBS) is a frequent, costly, and potentially disabling gastrointestinal disorder. Medical education is among the most challenging and the most stressful education, and this may predispose to high rates of IBS. Objective: To determine the prevalence and predictors of IBS among medical students and interns in King Abdulaziz University, Jeddah, Saudi Arabia. Methods: A cross-sectional study was conducted among 597 medical students and interns selected by multistage stratified random sample method in 2012. A confidential, anonymous, and self-administered questionnaire was used to collect personal and sociodemographic data, level of emotional stress, and food hypersensitivity during the past 6 months. Rome III Criteria and the Standardized Hospital Anxiety and Depression Scale were also used. Results: The prevalence of IBS was 31.8%. Multiple logistic regression analysis revealed that the first predictor of IBS was female gender (aOR=2.89; 95.0% CI: 1.65-5.05). The second predictor was presence of morbid anxiety (aOR=2.44; 95.0% CI: 1.30-4.55). Living in a school dormitory, emotional stress during 6 months preceding the study, and the academic year were the next predictors. Conclusions: High prevalence of IBS prevailed among medical students and interns. Female gender, morbid anxiety, living in school dormitory, emotional stress, and higher educational level (grade) were the predictors of IBS. Screening of medical students for IBS, psychological problems, and reducing stress by stress management are recommended.
 
Programme emphasis of the 25 organizations included in the study Programs Frequency
types of services provided by the 25 organizations
Causes of displacement
Unlabelled: Internally displaced persons are faced with several problems, such as sexual violence, and deserve appropriate intervention, especially in view of the increasing prevalence of HIV/AIDS and other infections in Nigeria. This study attempts to assess interventions offered by governmental authorities and organizations to internally displaced persons and to identify gaps in services as well as to identify what needs to be strengthened. Method: The author reviewed relevant published and unpublished documents and collected data by interviews with semi-structured questions. Twenty-five organizations and government and police departments and 55 internally displaced persons were interviewed. Results: None of the organizations, including governmental institutions, provided social services or assistance in prevention of HIV/AIDS to internally displaced persons. The main services provided by 17 (68%) organizations to 43 (78.2%) of internally displaced persons were provision of food, clothing and money, but these were provided on an ad hoc basis. Only 3 organizations (12%) included spiritual counseling and resolution of communal conflicts in their services. Conclusion: The fact that most organizations, including the government, do not have services for internally displaced persons indicates lack of support for internally displaced persons. The government should be urged to include these people in most prevention services, including HIV/AIDS prevention and treatment. This should help reduce the national prevalence of HIV/AIDS.
 
A 35-year-old man with pre-existing rheumatic heart disease and aortic regurgitation (AR) presented with intermittent fever, ankle swelling and clinical evidence of endocarditis. Transoesophageal echocardiogram (TEE) revealed vegetations and destruction of the aortic valve (AV). Blood cultures grew a gram positive coccobacillus which was phenotypically identified as Abiotrophia defectvia (A.defectiva). A diagnosis of infective endocarditis (IE) due to A.defectiva was made. Treatment, with penicillin and gentamicin, was administered for 4 weeks. Mechanical valve replacement was required few days after starting the antibiotic therapy. The patient had a favorable outcome on follow up. Although A.defectiva is an uncommon cause of endocarditis, early and correct identification of this pathogen is important to improve the outcome and the prognosis of patients with IE due to this organism.
 
Photomicrograph of a typical TAM blast cell seen on a blood film (600 ) oil immersion objective).  
A three-week-old boy with Down syndrome presented with poor feeding and jaundice. He had been born at term by normal delivery at home. The pregnancy had been uneventful and the mother had declined antenatal testing so the diagnosis of Down syndrome was made in the postnatal period. The infant required oxygen at birth and was admitted to the neonatal unit for a few days after birth. He started to become jaundiced after discharge. There was no family history of note and the infant has three siblings who are healthy. The mother is Rh D positive. On examination the infant was jaundiced, with neither hepatosplenomegaly, nor signs of sepsis but had hypotonia typical of Down syndrome. Investigations revealed unconjugated jaundice with a negative direct antiglobulin test. A full blood count showed thrombocytopenia with a platelet count of 65x109/L, a white cell count of 8.6x 109/L, neutrophil count of 1.9x109/L and haemoglobin level of 18.0 g/dL. Blast cells of medium to large size with cytoplasmic blebs were found on the blood film. Immunophenotyping showed the blasts to have myeloid markers with expression of CD41 and CD61. (Published: 13 January 2010) Citation: Libyan J Med 2010, 5: 4635 - DOI: 10.3402/ljm.v5i0.4635
 
Association of blood groups with diabetes mellitus type 2 
ABO blood groups percentage distribution in patients with diabetes mellitus 
Distribution of ABO blood groups between genders for both controls and patients 
So far no studies have been performed in Malaysia to look at association of diabetes mellitus (DM) with blood groups. We studied the association of ABO blood groups with DM type 2. It was a case control study conducted at Kepala Batas Hospital Batas, Penang, Malaysia in the year 2009, involving 70 patients with DM type 2 and 140 healthy controls. Ethical approval was obtained from Universiti Sains Malaysia. Blood samples were collected from the patients after consent. Samples were tested for ABO blood groups using ID-Card gel method. Chi-square test results showed that there was an association between the ABO blood groups and DM type 2. It was found that A and O blood groups were negatively associated with DM type 2 (P<0.05) with higher percentage of A and O groups individuals were non-diabetic. No significant association was noted between DM type 2 and blood groups B (P=0.423) and AB (P=0.095). It was also noted that B blood group was distributed with highest percentage among patients with DM type 2 (53.71%) compared to controls (22.52%), but no statistical significance achieved. The results obtained suggest that there was a negative association between ABO blood groups A and O with DM type 2, with A and O group having less chances of diabetes. Large studies in other ethnic groups are needed to confirm these results.
 
Radicular cysts arise from non-vital teeth. They are inflammatory in nature and are the most common cystic lesion found in the jaw. We present a case of a massive maxillary radicular cyst in a 20 year-old man, diagnosed following an alleged assault and facial fracture. Subsequent abscess formation was initially thought to be infection secondary to haematoma due to fracture, but further investigation showed that it was to be due to a massive cyst.
 
As we start the New Year, we anticipate a very productive year that will include advancement in science and increased collaboration among the members of the medical community. This editorial consists of discussion topics/points that were brought up among the members of the ljm editorial office, which we would like to share with our readers.
 
Liraglutide is a glucagon-like peptide 1 (GLP-1) agonist that is 97% homologous to the endogenous human GLP-1. By mimicking the effects of native GLP-1, it enhances the glucose-dependent secretion of insulin from beta cells of pancreatic islets, suppresses elevated glucagon secretion, and slows down gastric emptying and increases satiety. It results in a 0.5-1.5% reduction in HbA1c and can be used as a monotherapy or as an add-on therapy to metformin, sulfonylurea, thiazolinediones, and/or insulin. It was approved by the European Medicines Agency in 2009 and by the US Food and Drug Administration in 2010.
 
To The Editor: In his outstanding article regarding Road Traffic Accidents (RTAs) in Libya [1], Dr Abdulmajid Ali has raised awareness and started a debate about this extremely important issue. Before responding to some points in Dr Ali’s article, I would like to tell a real story of a tragic accident that happened last week, which highlights several issues related to RTAs in Libya. A 55 year old driver left after Fajr prayer to the vegetable market to buy a few things for his daughter’s wedding lunch. While trying to avoid a big pothole in the middle of the road, he was hit by a truck without headlights coming from the opposite direction. The truck driver continued driving as if nothing had happened. None of the road users cared to help the victim but he was able to contact his son by mobile phone to come and help him out of the wreckage. His son took him to the main Trauma Hospital in Tripoli. The patient had no external injuries. He was admitted for observation only. A few hours later the patient died as a result of major internal haemorrhage. Further information revealed that the truck driver had no driving licence and the truck was not road worthy.This story is not unique However, it highlights the complex and intermingled issues that need to be addressed to have any real impact on this disastrous problem in Libya. The specific points I would like to add to Dr Ali’s article are:There is no doubt that RTAs are a major killer in Libya especially in the young age group. The annual reporting of road causalities is considered to be the yard stick to measure the effectiveness of any national traffic policy,; in the UK for example the target is to reduce fatalities from RTAs by 50% by 2010 [2]. It is a disgrace not to have accurate official statistics published at least annually of fatalities, injuries, disabilities and the economic consequences of this undeclared war in Libya. There is evidence to support that there could be a positive impact when national health challenges are tackled systematically [3-5]. It is perplexing not to have a Libyan National Traffic Policy to deal with this very serious issue comprehensively.The majority of serious accidents in Libya occur on motorways. Internationally, motorways are organised in such a way that traffic can only leave or join the motorway through specified junctions. In contrast, in Libyan motorways, other vehicles can join the motorway unpredictably at any point, left or right and sometimes from above or below! Personally I think that the lack of a Highway Code or its implementation is a major contributing cause for serious RTAs.The Libyan Traffic Police Force needs a shakeup to root out the few corrupt officers who brought what used to be a highly regarded force into disrepute because of their indiscipline. The force needs support, respect and incentives, one of which is to link their pay rise to the national reduction of RTAs.To be slightly provocative, I would like to call for a public inquiry into the issue of RTAs in Libya. This is a very robust way to learn lessons and implement corrective changes (please see www.hse.gov.uk Railway Public inquiries). Dr Ali touched on the importance of ATLS. As we can learn from the above story the issue is not as simple as we think. I will not scratch the issue of the role of Blood transfusion Service in this situation. Suffice it to say this is a colossal national challenge and deserves equal resources.I would like to express my disagreement with Dr Ali’s suggestion to exert our pressure on the Libyan Ministry of Health. I do not believe that we have any power to exert over the politicians!
 
To The Editor: It is estimated that 1.26 million people worldwide died in 2000 from road traffic accidents, 90% of them in low and middle-income countries. In 2000, the road traffic injury mortality rate for the world was 20.8 per 100,000 populations (30.8 in males, 11.0 in females) [1].The Arab population constitutes 3.6% of the world’s population and it owns 1% of the world’s vehicles. Its human losses as a result of road traffic accidents (RTA) account for 4.8% of that of the world’s losses [2]. It is estimated that the annual cost of road crashes is about 1% of the Gross National Product (GNP) in developing countries, 1.5 in transitional countries and 2% in highly motorised countries [3].In Libya the situation is worse. It is a sad fact that road traffic accidents are the number one killer in Libya. As a matter of fact I consider it to be an ‘epidemic’ in all sectors of the Libyan society. There is not a day that goes by in Libya without us hearing about families, young men, women and children getting killed in horrific car accidents.It is alarming that young children are knocked down on a daily basis by speeding young drivers, whose understanding of driving skills may have been acquired from "playstation games"! (You can watch some of the shameful video clips sent by some of these drivers on this link http://www.youtube.com/watch?v=doWEDjiHlVo)I feel it is our responsibility as physicians observing the situation to raise awareness about the scale of the problem, possible causes, and how to tackle it. POSSIBLE CAUSES:• A driving licence in Libya is not issued on the basis of how much you know. Therefore the majority of drivers know little or nothing about the law.• Wearing seat belts is not compulsory in most parts of Libya. In some places, especially in the Eastern part of Libya, you could be penalised for wearing one. I was stopped many years ago by the traffic police in the Eastern part of Libya because I was wearing sunglasses and a seatbelt. I had to apologize profusely to the young traffic policeman and explain that I was wearing sunglasses because I was driving facing the sun! The reason for wearing the seatbelt was a habit from living abroad for many years and I was not a "show off" as he put it! This incidence made me wonder how much the traffic police knew about the law?• In Libya the way we behave in the street, the way we drive and our attitude towards pedestrians is not taught in schools at an early age. As a matter of fact, many drivers think it is "cool" to scare pedestrians.• Most of the accidents in Libya occur at school times but unfortunately no measures are taken by the traffic police to help young children to cross roads safely.• Most of the road traffic accidents happen at the same areas but these are never identified as "black spots" to warn drivers of the possible dangers.• Although Zebra Crossings exist in some parts of Libya, they actually do not serve the purpose. We just need to count how many pedestrians (especially foreign visitors) have been knocked down at Zebra Crossings.• There is a need for new road signs, clear road markings (lanes), and new traffic lights to replace old and often non-functioning ones.• One study demonstrated that speeding was responsible for about 70% of accidents [4]. There are no speed cameras or road humps to slow down speeding cars, therefore residents who have lost children to road traffic accidents resort to building their own version of street humps made from old pipes, thick ropes or cement.• Most of the main roads are full of holes and in desperate need of maintenance.• Car seats for children are not compulsory.• When accidents happen in Libya, what number do we dial? Do emergency services exist?• It is a known fact that most of the deaths and permanent disabilities in road traffic accidents are caused by people trying to help due to the lack of Advanced Trauma and Life Support (ATLS) trained personnel [5,6].• It is well documented that Advanced Trauma and Life Support (ATLS) and Advanced Life Support (ALS) courses improve survival [5].Unfortunately in Libya they are not compulsory for nurses or doctors. Some doctors and nurses working in the Emergency department are even unaware that these courses exist. Therefore, it is no surprise that the majority of car accident causalities dies or sustain permanent disabilities despite reaching the hospital in redeemable condition.WHAT CAN WE DO TO HELP?A. Ministry of Health:1. We must put pressure on the ministry of health and offer our services in running ATLS, ALS and Trauma courses to all medical personnel and paramedics. These courses should become a prerequisite for qualifying to work in the Medical field especially for those who directly deal with trauma patients.2. All hospitals dealing with trauma must have well trained and well equipped trauma and cardiac arrest teams whose ATLS/ ALS knowledge is revalidated periodically.3. Emphasise the importance of introducing the Bleep/Page System.4. Train paramedics and improve the Emergency Service [5,6].5. Emergency phone numbers should exist and should be made free of charge to dial.B. Ministry of Education:1. Educate children at an early age about behaviour in the street and dangers on the road.2. The schools should share the responsibilities with the traffic police in ensuring the safety of pupils.3. Supply posters and educate the public.4. The United Nations invited member states and the international community to recognize the third Sunday in November of every year as the World Day of Remembrance for Road Traffic Victims as the appropriate acknowledgement for victims of road traffic crashes and their families.I think a union should be formed in Libya, of people who have lost relatives to car accidents to campaign and educate drivers as per recommendation of the UN [7].C. Ministry of Transport:1. Re-validate the traffic police on their behaviour and knowledge of the law.2. Revise and re-enforce the traffic law with strict monitoring and speed cameras.3. Re-enforce Zebra Crossings with lights and give penalties to drivers who do not adhere.4. It is a well known fact that financial penalties are more effective than other forms of penalties on re-enforcing the law.5. Improve the conditions of the roads i.e. regular maintenance, road markings, road humps, traffic lights, road mirrors and road signs.6. Re-validate the driving licences with written and practical exams.7. Roadside assistance through a mobile workshop / emergency phones by the roadside.8. Only road-worthy vehicles should be allowed on the road through re-enforcement of a safety certification system for vehicles.9. Regulate the issue and distribution of driving licences and vehicle safety certification through the use of IT (Information Technology) systems.10. It is about time that a national policy for injury prevention and control in Libya should be formed thorough the coordination between different ministries, departments and the various agencies concerned.These are the suggestions and visions of one person but I am sure that many of you will share my views.
 
Cochlear implantation has become established worldwide as a safe and effective method of auditory rehabilitation of selected severely and profound deaf children and adults. Over 100,000 patients have received cochlear implants worldwide with the paediatric population proving to be the main beneficiaries. The Libyan cochlear implant programme was set up in 2004. Data relating to the patients who received cochlear implantation at Tripoli Medical Centre between October 2007 and February 2010 were analysed. Implant operations were performed on 37 patients. All patients received Med-El SONATA(TI) (100) devices. Thirty-four (91.9%) of these patients were children, whilst three (8.1%) were adults. Combined, congenital hearing loss (56.8%) and perinatal/neonatal (29.7%) were the two main aetiological factors in children. Seventeen patients (45.9%) had a positive family history of deafness. Sixteen patients (43.2%) were born to blood-related parents. The overall rate of minor and major complications was 16.2%, which is comparable to previous studies.
 
Infections caused by Achromobacter xylosoxidans cause significant morbidity and mortality in debilitated individuals. Eradication of these infections requires prolonged therapy with antimicrobial agents and removal of any infected central venous catheter. The outcome is usually poor in patients with high risk malignancy, septic complications, and/or multi-organ dysfunction.
 
Alprazolam is effective as an anxiolytic and in the adjunct treatment of depression. In this study, the effects of calcium channel antagonists on the antidepressant action of alprazolam and imipramine were investigated. A forced swimming maze was used to study behavioral despair in albino mice. Mice were divided into nine groups (n = 7 per group). One group received a single dose of 1% Tween 80; two groups each received a single dose of the antidepressant alone (alprazolam or imipramine); two groups each received a single dose of the calcium channel blocker (nifedipine or verapamil); four groups each received a single dose of the calcium channel blocker followed by a single dose of the antidepressant (with same doses used for either in the previous four groups). Drug administration was performed concurrently on the nine groups. Our data confirmed the antidepressant action of alprazolam and imipramine. Both nifedipine and verapamil produced a significant antidepressant effect (delay the onset of immobility) when administered separately. Verapamil augmented the antidepressant effects of alprazolam and imipramine (additive antidepressant effect). This may be due to the possibility that verapamil might have antidepressant-like effect through different mechanism. Nifedipine and imipramine combined led to a delay in the onset of immobility greater than their single use but less than the sum of their independent administration. This may be due to the fact that nifedipine on its own might act as an antidepressant but blocks one imipramine mechanism that depends on L-type calcium channel activation. Combining nifedipine with alprazolam produced additional antidepressant effects, which indicates that they exert antidepressant effects through different mechanisms.
 
Effect of atenolol on the onset of immobility 
Effect of propranolol on the onset of immobility 
Alprazolam is an anti-anxiety drug shown to be effective in the treatment of depression. In this study, the effect of sympathetic receptor antagonists on alprazolam-induced antidepressant action was studied using a mouse model of forced swimming behavioral despair. The interaction of three sympathetic receptor antagonists with benzodiazepines, which may impact the clinical use of alprazolam, was also studied. Behavioral despair was examined in six groups of albino mice. Drugs were administered intraperitoneally. The control group received only a single dose of 1% Tween 80. The second group received a single dose of alprazolam, and the third group received an antagonist followed by alprazolam. The fourth group was treated with imipramine, and the fifth group received an antagonist followed by imipramine. The sixth group was treated with a single dose of an antagonist alone (atenolol, a β1-selective adrenoceptor antagonist; propranolol, a non selective β-adrenoceptor antagonist; and prazocin, an α1-adrenoceptor antagonist). Results confirmed the antidepressant action of alprazolam and imipramine. Prazocin treatment alone produced depression, but it significantly potentiated the antidepressant actions of imipramine and alprazolam. Atenolol alone produced an antidepressant effect and potentiated the antidepressant action of alprazolam. Propranolol treatment alone produced depression, and antagonized the effects of alprazolam and imipramine, even producing depression in combined treatments.In conclusion, our results reveal that alprazolam may produce antidepressant effects through the release of noradrenaline, which stimulates β2 receptors to produce an antidepressant action. Imipramine may act by activating β2 receptors by blocking or down-regulating β1 receptors.
 
To The Editor: We would like to thank both Dr. A. Ali [1] and Dr. A. Salamat [2] for highlighting the issue of road traffic accidents in Libya.
 
Tobacco smoking is hazardous for health. However, not all forms of tobacco use entail the same risks and the latter should be studied and compared in a sound realistic way. Smoking machines for cigarettes (which are consumed in a few minutes) were early designed as a tool to evaluate the actual intake of toxic substances ('toxicants') by smokers. However, the yields (tar, nicotine, CO, etc.) provided by such machines poorly reflect the actual human smoking behaviour known to depend on numerous factors (anxiety, emotions, anthropological situation, etc.). In the case of narghile smoking, the problems are even more complex, particularly because of the much longer duration of a session. A recent study from the US-American University of Beirut was based on a field smoking topography and claimed consistency with a laboratory smoking machine. We offer a point by point critical analysis of such methods on which most of the 'waterpipe' antismoking literature since 2002 is based.
 
Socio-demographics and clinical characteristics of 467 male patients with (324 patients) or without (143 patients) metabolic syndrome ACS patients
Prevalence of metabolic components in male patients presenting with acute coronary syndrome with or without metabolic syndrome. Data are expressed in percentage of patients. ACS: acute coronary syndrome, MS: metabolic syndrome, non-MS: non-metabolic syndrome, WC: elevated waist circumference, TG: elevated triglyceride, HDL-c: reduced high-density lipoprotein-cholesterol, BP: elevated blood pressure, FPG: elevated fasting plasma glucose levels.
Individual metabolic abnormalities among a male population with acute coronary syndrome (N=467). Data are expressed as number (%) of patients. ACS: acute coronary syndrome.
Background: Mortality from cardiovascular disease in the Middle East is projected to increase substantially in the coming decades. The prevalence of metabolic syndrome (MS) in acute coronary syndrome (ACS) continues to raise interest, but data from the Middle East is limited, especially in non-diabetic patients. This study was conducted to ascertain the prevalence of MS and frequency of its components, individually and in combination, in a male population presenting with ACS, but without a previous diagnosis of diabetes mellitus (DM). Methods: This is a prospective study of 467 consecutive male patients hospitalized for ACS. They were categorized according to the specific criteria stated in the latest joint statement for the global definition of MS. Results: The mean age was (49.7±10.7 years). Of the 467 patients, 324 (69.4%) fulfilled the criteria for MS. ST-Elevation Myocardial Infarction (STEMI) was identified in 178 patients (54.9%), and non-ST elevation ACS (NSTE-ACS) in 146 patients (45.1%). These proportions were not significantly different from those without MS (STEMI 51.7% vs. NSTE-ACS 48.3%, respectively). However, patients with MS were older (50.6±10 vs. 47.9±11 years; p=0.012), and more than half of those with MS were above 50 years. The most common abnormal metabolic components were reduced high-density lipoprotein cholesterol (HDL-c; 94.1%), elevated fasting blood glucose (FBG; 89.8%), and elevated triglycerides (81.8%), followed by increased waist circumference (61.7%) and raised blood pressure (40.4%). The majority of patients with MS had three or more metabolic components (326 patients, 69.4%), and 102 (21.8%) had two components, but only 37 (8.4%) had a single component. Conclusions: In ACS patients, without previous history of DM, MS is highly prevalent. Reduced HDL, elevated FBG and triglycerides were the most frequent metabolic components. The majority had multiple components. These findings raise alarm and show that drug therapy alone may not be fully effective, unless the underlying risk factors causing MS, such as weight and exercise, are also tackled.
 
The inflammatory response to tissue injury. Traumatic injury signals various cell types to produce cytokines, chemokines, and DAMPs. In turn, DAMPs re-activate and further propagate the production of inflammatory mediators, setting in motion a positive feedback loop of inflammationdamageinflammation. 
The spectrum of cytokines, chemokines, and DAMPs in T/HS and TBI. The inflammatory response generated in response to T/HS or TBI can be assessed by measuring a panoply of cytokines, chemokines, DAMPs, and ultimate markers of endorgan damage. Some of these biomarkers may also be candidates for therapeutic intervention. 
A vision for the future of drug design for T/HS and TBI. The future of rational drug design for T/HS and TBI may involve the use of in silico (computer simulated) that would be based on a mechanistic understanding of the inflammatory response as well as pharmacokinetic and pharmacodynamic principles and used to determine the optimal properties, dosage, timing, and inclusion/exclusion criteria for a given drug candidate's clinical trial. Key aspects of these simulations would be tested iteratively in cell culture experiments and pre-clinical animal models, streamlining the process (and reducing the time and cost) of clinical trial design and implementation. 
Traumatic injury/hemorrhagic shock (T/HS) elicits an acute inflammatory response that may result in death. Inflammation describes a coordinated series of molecular, cellular, tissue, organ, and systemic responses that drive the pathology of various diseases including T/HS and traumatic brain injury (TBI). Inflammation is a finely tuned, dynamic, highly-regulated process that is not inherently detrimental, but rather required for immune surveillance, optimal post-injury tissue repair, and regeneration. The inflammatory response is driven by cytokines and chemokines and is partially propagated by damaged tissue-derived products (Damage-associated Molecular Patterns; DAMP's). DAMPs perpetuate inflammation through the release of pro-inflammatory cytokines, but may also inhibit anti-inflammatory cytokines. Various animal models of T/HS in mice, rats, pigs, dogs, and non-human primates have been utilized in an attempt to move from bench to bedside. Novel approaches, including those from the field of systems biology, may yield therapeutic breakthroughs in T/HS and TBI in the near future.
 
MRI of spine showing long segment of intramedullary spinal cord T2 abnormal subtle bright signal consistent myelitis.
Gram staining of CSF showing gram-negative intracellular diplococci suggestive of meningococci. 
Acute myelopathy with sudden paraplegia is a very rare manifestation of meningococcal meningitis, with only a few cases reported in the literature. In almost all previously reported cases, other clinical manifestations of meningitis, such as fever, headache, and neck stiffness preceded acute myelopathy. In this paper, we report a case of acute myelopathy with sudden paraplegia as the sole manifestation of meningococcal meningitis, in the absence of other clinical manifestations of meningitis.
 
Plasma urea, creatinine, DAO (diamine oxidase), and citrulline levels in groups and the comparisons among the groups
Morphological changes of the intestine in the short-term ischemia group. Panel a demonstrates the score Grade 3 (*: minimal necrosis of the surface epithelium at the tip of the villus). Panel b shows the score Grade 4 with (#) necrosis at the tip of the villi (H-E, ×200).
Morphological changes of the intestine in the prolonged ischemia group. Panel a demonstrates the score Grade 5 with full thickness mucosal necrosis. Panel b shows the score Grade 6 with transmural necrosis (H-E, ×200).
Introduction There is no valid and reliable diagnostic test for early diagnosis of acute mesenteric ischemia (AMI). The aim of this study was to measure the plasma levels of diamine oxidase (DAO) and citrulline in AMI to gain insight into its early diagnosis. Material and methods A total of 21 Wistar albino rats were divided into three groups, that is, control group, short-term ischemia group, and prolonged ischemia group. The superior mesenteric artery was occluded for 15 min in the short-term ischemia group and for 12 h in the prolonged ischemia group. Twelve hours later, the experiment was terminated and plasma DAO and citrulline levels were measured. Intestinal tissue was evaluated for the histopathological changes. Results Compared to the control group, the short-term and prolonged ischemia groups showed significant increases in the plasma levels of DAO, whereas the plasma citrulline levels decreased significantly. Prolonged ischemia caused a larger increase in the plasma DAO levels and a larger decrease in the plasma citrulline levels compared to the short-term ischemia (p=0.011 and p=0.021, respectively). Intestinal damage was shown to develop more in the prolonged ischemia group (p=0.001). Conclusion In the early period of AMI, the plasma DAO levels increase while citrulline levels decrease, and the extent of these changes depends on the duration of ischemia.
 
Liver function tests at different time points after induction of liver injury 
Incidence of Bacterial translocation in experimental groups at different time intervals 
Histological appearance of the liver 24 hours after the injury (Hematoxylin-Eosin, x100). The liver injury control group (Fig. 3A) showing hepatocellular necrosis and inflammatory cell infiltration. The liver injury + L-NAME group (Fig. 3B) showing more hepatocellular necrosis and inflammatory cell infiltration. 
Nitric oxide may have a protective effect on the liver during endotoxemia and chronic inflammation. There is evidence that it maintains liver and intestinal tissue integrity during inflammatory processes. We evaluated the impact of altering nitric oxide release on acute liver injury, the associated gut injury and bacterial translocation, at different time intervals. An acute rat liver injury model induced by D-galactosamine was used. Sprague Dawley rats were divided into four main groups: normal control, acute liver injury control, acute liver injury + N-nitro-L-arginine methyl ester (L-NAME), acute liver injury + L-NAME + L-arginine. Each group was divided into three subgroups according to the different time intervals (6, 12, 24 hours) after the induction of the liver injury. Liver enzymes and bilirubin were evaluated, as well as bacterial translocation, cecal and colonic microflora, and histological study of liver, ileum and cecum. Liver enzymes increased significantly at all time intervals in acute liver injury + L-NAME compared to liver injury control groups. Bacterial translocation increased significantly in liver injury + L-NAME groups; at 6 hours to the liver, at 12 hours to the liver and mesenteric lymph nodes (MLNs), and at 24 hours to arterial and portal blood, liver and MLNS. Inhibition of nitric oxide increased significantly the Enterobacteriaceae count in cecum compared to normal and liver injury control groups. The G-negative anaerobes increased significantly in the colon compared to the liver injury control group. Inhibition of nitric oxide in an acute liver injury model potentiates the liver injury as evidenced by increased appearance of hepatocellular necrosis and elevated liver enzymes and bilirubin. It increases the Enterobacteriaceae in both cecum and colon and Gnegative anaerobes in the colon. It also increases bacterial translocation to extra-intestinal sites. The increased bacterial translocation could be one of the mechanisms potentiating liver injury and nitric oxide may be pathophysiologically involved. Further studies are required to confirm this hypothesis.
 
Libyan dental faculties and oral health–related research.
Libya is a vast country situated in North Africa, having a relatively better functioning economy with a scanty population. This article is the first known attempt to review the current state of oral health care in Libya and to explore the present trends and future challenges. Libyan health system, oral health care, and human resources with the present status of dental education are reviewed comprehensively. A bibliographic study of oral health research and publications has been carried out. The results point toward a common indicator that oral health-related research is low. Strategies have to be developed to educate the medical and dental professionals, to update the current curriculum and enable the system to be competent in all aspects of oral health care management.
 
Domestic violence (DV) is quite prevalent and negatively impacts the health and mental wellbeing of those affected. Victims of DV are frequent users of health service, yet they are infrequently recognized. Physicians tend to treat the presenting complaints without addressing the root cause of the problem. Lack of knowledge on adequately managing cases of DV and on appropriate ways to help survivors is commonly presented as a barrier. This article presents the magnitude of the problem of DV in the Arab world, highlights the role of the primary care physician in addressing this problem, and provides practical steps that can guide the clinician in the Arab world in giving a comprehensive and culturally sensitive service to the survivors of DV.
 
Assessment is a powerful driver of student learning: it gives a message to learners about what they should be learning, what the learning organisation believes to be important, and how they should go about learning. Assessment tools allow measurement of student achievement and thereby give teachers insight into their students' learning, and enable teachers to make systematic judgements about progress and achievement. It is vital then that assessment tools drive students to learn the right things as well as measure student learning appropriately. Any attempts to reform curricula and teaching methods must consider the role of assessment in the learning process. Libyan doctors and medical students have been calling for changes to teaching and assessment methods at undergraduate and postgraduate levels. A team from the Academic Centre for Medical Education at University College, London have been running workshops in conjunction with the Libyan Board of Medical Specialties since 2006 to discuss strategic aims of assessment in medical education in Libya for the 21st century and to deliver an assessment skills course to Libyan educators. This article outlines the course and the outcomes of preliminary discussions between academics from the UK, participants in the assessment courses and representatives from the Libyan Board of Medical Specialties. As a result of these discussions it was agreed by all that Libyan Medical School assessment methods need updating and, despite significant challenges, changes in assessment must be made as soon as possible. There is a real need for support in both addressing these changes and for practical training for assessors in contemporary assessment methods.
 
Correlation between anthropometric indices and atherogenic index of plasma 
Background: The increase in cardiovascular events has necessitated the identification of possible predictors that can help in predicting atherogenicity. Objective: The study sought to identify the anthropometric measures of adiposity that are associated with atherogenic risk in sedentary, non-obese, young male adults. Methods: A cross-sectional design was used to recruit a purposive sample of 414 sedentary males in a university campus. Anthropometric measures of adiposity, lipid parameters, and atherogenic index of plasma (AIP) were assessed. Pearson correlation and stepwise multiple regression were used to analyze the data collected. Alpha level was set at p<0.05. Results: There was a high risk of cardiovascular events (AIP=0.36±0.04 SD) among the participants. A significant correlation (p=0.000) was obtained between each of the anthropometric measures (except conicity index) and AIP. Body mass index, body adiposity index, and percent body fat were significant predictors accounting for 38.9, 3.1, and 2.2% of the variance due to AIP. Conclusions: Sedentary status among young males is associated with high atherogenic risk in the presence of normal lipid and anthropometric parameters. Both central and general measures of adiposity predict less than half of the atherogenic risk in sedentary young males.
 
Eat what your body wants not what you can. 
Gluttony kills more than the sword. (George Herbert (1593-1633) English poet of the metaphysical school) A gourmet is just a glutton with ‘brains.’ (Philip W. Haberman) The life style ‘gluttony and sloth’ has become the central point of morbidity and the biochemical consequences of these are explained in the form of an extended arm of lipotoxicity resulting in hyperinsulinemia (1). It is suggested that certain selective activation of genes like proprotein convertase subtilin/kexin type 9(PCSK9) involved in LDL receptor metabolism could help eliminate gluttonous and slothful members of society. It is speculated that such an elimination would guarantee the youngest members of the society a fair share of the food available during periods of limited food supply. Society’s strength lies in its health and a young generation, which are human investments of a country’s well-being. (Published: 16 June 2010) Citation: Libyan J Med 2010, 5: 5294 - DOI: 10.3402/ljm.v5i0.5294
 
Gender and age distribution of patients. 
Distribution of acute upper gastrointestinal bleeding by bleeding site 
Frequency of smoking and non-steroidal anti-inflammatory drugs use by acute upper gastrointestinal bleeding aetiology 
Acute upper gastrointestinal bleeding (UGIB) is a common reason for hospital admissions worldwide. Aetiological causes of UGIB vary according to geographic region and socioeconomic status. However, despite the implementation of early endoscopy as the standard method for the diagnosis and treatment of UGIB, data on the characteristics of patients with UGIB in Libya are still minimal. In this study, we describe patient demographics, aetiological causes for UGIB, and possible risk factors for upper gastrointestinal bleeding in patients admitted to the Gastroenterology Department at Tripoli Medical Center from January 2001 through June 2006. This is a retrospective case-series analysis of all adult patients with upper gastrointestinal bleeding admitted to the Gastroenterology Department at TMC. Patients' medical records were individually reviewed and relevant data abstracted. A total of 928 cases with diagnoses of UGIB were admitted to Tripoli Medical Center during the study period. Of these cases, 60.3% were males and 39.7% females (3:2) and males were significantly younger than females (49.6 years vs. 53.9 years, p=0.001). The most common cause of UGIB was peptic ulcer (37.1%) of which duodenal ulcer was the most common (30.7% of all UGIB), especially amongst male patients (36.4%). The second most common cause was bleeding due to varices (29.8%), especially amongst females (35.1%). Additionally, smoking and NSAIDs use were reported by 18.6% and 9.7% of cases and both were significantly associated with bleeding due to peptic ulcers. This study has investigated the characteristics of adults with UGIB at a tertiary referral center in Libya. The high frequency of bleeding due to varices amongst females mandates further investigations into the possible underlying hepatic causes and their management, and the potential impact on patient outcome and prognosis.
 
Unenhanced Abdominal CT of Left Retroperitoneal Collection & Adrenal Mass.  
Adrenal gland removed containing phaechromocytoma and cut open showing central haemorrhagic necrosis  
Adrenal gland removed containing phaechromocytoma and cut open showing central haemorrhagic necrosis References 1-Frankel F. Classics in oncology. A case of bilateral completely latent adrenal tumor and concurrent nephritis with changes in the circulatory system and retinitis. CA A Cancer Journal For Clinicians 1984; 34(2): 93-106. 2-Lenders WM et al. Phaeochromocytoma. Lancet 2005; 366(9846): 665-675. 3-Kobayashi T et al. Spontaneous Rupture Of Adrenal Pheochromocytoma: Review and Analysis Of Prognostic factors. Journal Of Surgical Oncology 2005; 90: 31-35. 4-Park JH et al: A case of a ruptured pheochromocytoma with an intra-tumoral aneurysm managed by coil embolization. Endocrine Journal 2003; 50(6): 653-656.
CASE PRESENTATIONA 58-year-old male patient presented to the Emergency Department with a 6-8 hour history of left upper quadrant pain associated with general malaise, dizziness, nausea and vomiting. There were no other gastrointestinal or genitourinary symptoms; in particular the patient denied any evidence of gastrointestinal bleeding. He had a past medical history of hypertension, which was being treated with lisinopril. On examination, the patient appeared unwell. He was fully alert but anxious with a Glasgow Coma Score (GCS) of 15. He was tachypnoeic (respiratory rate 25/min) with normal oxygen saturations (98%, FiO2 0.21) and temperature (36°C). He was sweaty with a tachycardia (heart rate 140 bpm) and prolonged capillary refill time (>5 seconds). The patient was also very hypertensive (BP 220/120 mmHg), but the rest of the cardiovascular and respiratory examination was normal. Abdominal examination demonstrated tenderness with guarding over the left upper quadrant and normal bowel sounds. There were no palpable masses. Blood tests showed a leucocytosis (27.54 x 106) with a neutrophilia (24.97 x 106), normal haemoglobin (14.9g/dL) and platelet count (445,000/L). The urea and creatinine were raised (9.6mmol/L and 160mmol/L respectively). He also had an elevated alkaline phosphatase (249mmol/L), alanine aspartase (41nmol/L) and C-reactive protein (9nmol/L). He was also hyperglycaemic (random glucose 12.6mmol/L). A chest radiograph showed an elevated left hemi-diaphragm. A computed tomography (CT) scan of the abdomen revealed a left peri-renal collection consistent with a haematoma and left adrenal mass measuring 12cm in diameter (see Figure 1). Also of note was a large left pleural effusion and moderate right pleural effusion.
 
Sleepwalking consists of a series of behavioral activities that occur during sleep. These activities may be simple, complex or aggressive in nature. They include motor activities, confusion, and amnesia for the events. Sleepwalking is a disorder of arousal from non-rapid eye movement (NREM) sleep. In children, episodes of sleepwalking are rarely violent; in adults, however, sleepwalking might include violence, which could endanger the patient or others and might precipitate legal issues. There is inadequate information on the prevalence and demographic correlates of sleepwalking in Nigeria. One objective of this study was to determine the lifetime prevalence rate of sleepwalking in an adult population in Ile-Ife, in Southwestern Nigeria. Another objective was to determine the age and sex distribution of sleepwalking among those who have experienced it at least once in their lifetime. A random sample of 228 healthy individuals aged 18-60 years was obtained and the members were asked to fill out a survey form about lifetime prevalence rate of sleepwalking. The overall lifetime prevalence rate of sleepwalking was 7% (16 of 228 participants). It was 10.4% in males and 3.5% in females, but the difference was not statistically significant (p=0.07). This study has shown that sleepwalking is common in the population. In view of the psychological effects of sleepwalking and the potential physical and legal problems associated with it, adequate efforts should be made for early detection and prompt management of the condition.
 
Top-cited authors
A. Kameli
  • Ecole Normale de Kouba, Algeria
Khalil Jamil Ashkar
  • American University of Beirut
Maya Romani
  • American University of Beirut
Khalifa Sifaw Ghenghesh
  • Independent Researcher