M I D D L E E A S T J O U R N A L O F FA M I LY M E D I C I N E V O LU M E 7 , I S S U E 1 0
F R O M T H E E D I TO R
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Corresponding author:
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taking medications. Her symptoms and Su Jok Acupuncture is a two- highly trained medical practitioners,
medical side effects decreased. Despite dimensional system. The first dimension Su Jok Acupuncture offers one of the
her history of paraplegia for 7 years, she is physical treatment to give simple best,most affordable and effective
also found movement in her little left toe. stimuli to the points in the hands or feet solutions.
corresponding to the affected body
Discussion parts. The second dimension draws on References
MS is a chronic, inflammatory, classical acupuncture. The classical 1. Rosati G. The prevalence of multiple
demyelinating disease that affects 12 Main Meridians, the eight Extra sclerosis in the world: an update. Neurol
the central nervous system. Disease Meridians, and their attendant points are Sci. 2001; 22 (2): 117-39.
onset usually occurs in young adults, represented on the hands and feet.
is more common in women, and has a 2. The Royal College of Physicians.
prevalence that ranges between 2 and Multiple Sclerosis. National clinical
150 per 100,000[1]. MS likely occurs It is very difficult to predict an exact guideline for diagnosis and management
as a result of some combination of both expected length of treatment. It depends in primary and secondary care.
environmental and genetic factors [2]. on the duration of the disease. In Su Jok Salisbury, Wiltshire: Sarum ColourView
MS affects the areas of the brain and Acupuncture, response to treatment is Group. ISBN 1 86016 182 0. Free full
spinal cord known as the white matter usually immediate [10]. text. (2004-08-13). Retrieved on 2008-
then it results in a thinning or complete 03-15.
loss of myelin. These lesions cause
The experiences from the field, by their
some of the neurological symptoms. 3. Brunner LS, Smeltzer SC, Suddarth
nature are anecdotal and improvement
Between attacks, symptoms may DS, Bare BG. Brunner and Suddarths
after treatment may be due to
go away completely, but permanent Textbook of Medical-Surgical Nursing.
coincidental spontaneous improvement
neurological problems often persist [3]. 10th ed. Philadelphia: Lippincott Williams
or expectation rather than the treatment.
The course of MS is difficult to predict & Wilkins, 2003.
There are, however, several factors in
and the disease may at times either lie
this case that favor causality rather than
dormant or progress steadily. In 1996 4. Lublin FD & Reingold SC. Defining
coincidence. Firstly, in experience of this
the United States National Multiple the clinical course of multiple sclerosis:
condition, spontaneous improvement or
Sclerosis Society standardized the results of an international survey.
resolution is rare. The second is that this
following four subtypes or patterns National Multiple Sclerosis Society
patient had definite symptoms with CNS
of progression definitions: relapsing- (USA) Advisory Committee on Clinical
affecting her movements and muscles
remitting, secondary progressive, Trials of New Agents in Multiple
tone particularly in her hands, legs and
primary progressive and progressive Sclerosis. Neurology 1996; 46(4):907-11.
lumbar areas. So, it was attempted to
relapsing [4]. The prognosis of an
needle in the brain, spinal cord and
individual patient is unpredictable [2]. 5. Brusaferri F, Candelise L. Steroids for
lumbar meridians. Most importantly, the
multiple sclerosis and optic neuritis: a
patient remains well after putting by her
meta-analysis of randomized controlled
The disease does not have a cure, but medications.
clinical trials. J Neurol 2000; 247 (6):
several therapies have proven helpful. 435-42.
Treatments attempt to return function
The experiences from the field, by their
after an attack, prevent new attacks, and 6. Comi G, Filippi M, Barkhof F, et
nature are anecdotal and improvement
prevent disability. During symptomatic al. (2001). Effect of early interferon
after treatment may be due to
attacks administration of high doses of treatment on conversion to definite
coincidental spontaneous improvement
intravenous corticosteroids is effective multiple sclerosis: a randomized study.
or expectation rather than the treatment.
[5]. The treatment with interferons Lancet; 357 (9268): 1576-82.
There are, however, several factors in
during an initial attack can decrease MS
this case that favor causality rather than
development [6]. As with any treatment, 7. Farinotti M, Simi S, Di Pietrantonj
coincidence. Firstly, in experience of this
medications have several adverse C, et al. Dietary interventions for
condition, spontaneous improvement or
effects. multiple sclerosis. Cochrane database
resolution is rare. The second is that this
patient had definite symptoms with CNS of systematic reviews (Online) 2007;
affecting her movements and muscles (1): CD004192.oi:10.1002/14651858.
Different alternative treatments are
tone particularly in her hands, legs and CD004192.pub2
pursued by many patients. Examples
are dietary regimens [7], herbal lumbar areas. So, it was attempted to
needle in the brain, spinal cord and 8. Chong MS, Wolff K, Wise K, Tanton
medicine [8] and general exercise [9].
lumbar meridians. Most importantly, the C, Winstock A, Silber E. Cannabis use
Although, there are few publications
patient remains well after putting by her in patients with multiple sclerosis. Mult
on alternative treatment in MS, the
medications. Scler 2006; 12 (5): 646-51.
acupuncture approach used here has
not been reported previously.
Korean Su Jok acupuncture therapy 9. Oken BS, Kishiyama S, Zajdel D, et al.
Korean Su Jok acupuncture therapy may offer benefits to chronic MS Randomized controlled trial of yoga and
is a new system of acupuncture using sufferers without other conventional exercise in multiple sclerosis. Neurology
only the hands and feet to effect the and complementary therapies. It may 2004; 62 (11): 2058-64.
same results as body acupuncture. provide an additional treatment option
Su Jok means hand and foot. They for patients unable to follow or maintain 10. Jae PW. The Six Energy Theory, the
represent a small mirror image of the a common medical program. Nurses or Illustrated Handbook, Su Jok Academy,
anatomy of the human body (Fig 1). paramedics can easily learn and apply 2005
Su Jok Acupuncture is a general term the correspondence system of hand
describing this new system. and foot without any side effects. In and
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Figure 1: Su Jok
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Bilquis Afridi
Department of Gynaecology and
Obstetrics
Khyber Teaching Hospital,
Peshawar, Pakistan
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The majority of the patients in this series were non booked. Only 2 patients were booked out of 25 patients (8%). The non-
booked patients were received via emergency or referred by the peripheral hospitals .Most of these patients were in labour at
the time of admission. Among those who came with cord prolapse, the highest percentage was of those with overt compared
with occult prolapse; the highest percentage of cord prolapse was noted in multi and grand multi gravidas (80%) compared with
primary gravidas (20%).
In this series the most common associated factor was abnormal lie (32%). Out of these 87.5% of the patients had transverse lie
and 12.5% presented with oblique lie. The second highest incidence was in premature labour. Five out of twenty five patients
presented with abnormal presentation (3 as breech and 2 as compound presentation); flex breech was more commonly seen as
compared with extended breech. Three out of twenty five patients had major degree placenta previa. Two patients had twins. In
one patient cord prolapse was followed by amniotomy for induction of labour. (Table 2)
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fetal outcome is actually improved Upon diagnosis of umbilical cord 4% of the patients had cord prolapse
with better obstetric care 11,12,13 . We prolapse, various manoeuvers have following an amniotomy.
believe that the neonatal outcome is been advocated to alleviate pressure on
improved with the practice of immediate the prolapsed cord. We found that digit- When a patient has spontaneous rup-
caesarian section. In our study there ally elevating the presenting part was ture of membranes or an ominous
were 5 stillbirths and 6 babies died dur- quicker and the most important cardiotocographic tracing, immediate
ing the first week of life in the neonatal component in addition to other vaginal examination enables umbilical
care unit; the majority of them due to methods described in the literature cord prolapse to be diagnosed.
prematurity and low level of neonatal such as urinary bladder distension with
care facilities. The majority of the still- saline, pelvic elevation or tocolysis.15 In addition patients should be
births were due to referrals from remote educated on the early signs of labour
The German Society of Gynaecology or pre-labour rupture of membranes so
areas either mishandled by unqualified
and Obstetrics recommends a decision that they come to the hospital early for
birth attendants or reached late and the
to delivery time of less than 20 minutes. supervised delivery, as early delivery
fetal demise already occurred in utero
The American College of Obstetricians can make a difference between life and
or the fetus was severely asphyxiated.
and Gynaecologists believes a death for the baby.
The immediate management of umbili- decision to incision time of 30 minutes
cal cord prolapse is determined by 3 is appropriate. We believe that this rapid Conclusion
factors: fetal viability, fetal maturity and decision to delivery interval contributes Prolapse of umbilical cord is an
presence of any lethal fetal anomalies. to reducing the morbidity of the cord obstetrical emergency with a well
Emergency delivery is recommended prolapse. In our study of 25 cases, the documented grave fetal prognosis in
for a normally formed and sufficiently main cause for delay was a the literature. A high index of suspicion
mature fetus. In the first stage of labour, logistic problem in preparing an and recognition of predisposing factors
a caesarian section is the only way to operating theatre. may allow for early detection and timely
achieve early delivery, however with a delivery, thereby minimizing perinatal
completely dilated cervix, the In our series, a predisposing factor was morbidity and mortality. More and more
obstetrician has a choice between present in the vast majority of cases as stress on regular antenatal checkups
instrumental vaginal delivery and seen in the table above. These are and supervised hospital delivery is also
caesarian section. Several studies have abnormal lie, malpresentation, mandatory. A multidisciplinary approach
quoted more favourable outcomes with prematurity, multiple pregnancy, to the organization of an emergency
caesarian section even in the second polyhydramnios.16 There is a lack of caesarian section is essential to allow
stage of labour. 14 consensus as to whether obstetric inter- the rapid and safe conduct of an
ventions are associated with higher risk emergency caesarian section to mini-
of cord prolapse 17,18 In our series only mize maternal and fetal risks in such an
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emergency that threatens the life and 12) Prabulous AM, Philipson EH. Um-
well being of the fetus and indirectly of bilical cord prolapse. Is the time from
the mother. Immediate delivery is the diagnosis to delivery critical ? J Reprod
ideal if the fetus is alive and sufficiently Med 1998 Feb;43(2):129-32
mature.
13) Koonings PP,Paul RH,Campbell
K. Umbilical cord prolapse. A con-
References temporary look. J Reprod Med 1990
Jul;35(7):690-2
1) Lin MG. Umbilical cord prolapse. Ob-
stet Gynecol S URV 2006;61:269-77.
14) Critchlow CW, Leet TL, Benedetti
2) Dufour P, Vinatier D, Bennani S ,
TJ, Daling JR. Risk factors and infant
Tordjeman N, Fondras C, Monnier
outcomes associated with umbilical cord
JC et al .Cord prolapse. .Review of
prolapse: A population-based case-
the literature. A series of 50 cases. J
control study among births in Washing-
Gynaecol Obstet Biol Reprod (Par-
ton State. Am J Obstet Gynecol 1994
is)1996;25(8):841-5
Feb;170(2):613-8
3) Murphy DJ,MacKenzie IZ.The mortal-
15) Katz Z, Shoham Z, Lancet M ,
ity and morbidity associated with umbili-
Blickstein I, Mogilner BM, Zalel Y.
cal cord prolapse.Br J Obstet Gynaecol
Management of labor with umbilical cord
1995Oct;102(10):826-30.
prolapse: A 5-year study. Obstet Gyne-
col 1988 A ug;72(2):278-81.
4) Savage E.W.Kohl S.G. and Wunn
R.M (1970) Prolapse of the umbilical
16) Migliorini GD, Pepperell RJ. Pro-
cord.
lapse of the umbilical cord: a study
Obstet Gynaecol NY 36,502-9.
of 69 cases. Med J Aust 1977 Oct 15
;2(16):522-4.
5) Pahak UN. Presentation and pro-
lapse of the umbilical cord. Am.J.Obstet
17) Usta IM , Mercer BM, Sibai BM.
Gynecol
Current obstetrical practice and um-
1968;101:401-5.
bilical cord prolapse. Am J Perinatol
1999;16(9):479-84.
6) Clark D.O, Copeland W.and Ullery
J.c.(1968).Prolapse of the umbilical
18) Roberts WE, Martin RW, Roach
cord.
HH, Perry KG Jr, Martin JN Jr, Morrison
Am J Obstet Gynecol 101,84-90.
JC. Are obstetric interventions such as
cervical ripening, induction of labour,
7) Jacobson T,Madsen H. Unexpected
amnioinfusion, or amniotomy associated
survival after conservative management
with umbilical cord prolapse? Am J Ob-
of cord prolapse I two very preterm
stet Gynecol 1997 Jun;176(6):1181-3.
babies. Acta Obstet Gynaecol Scand
1990;69:663-4.
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Salem A Bin Selm MD, PhD
Aden, Yemen
ABSTRACT Introduction
Hepatitis C virus (HCV) infection is not
Methods
A number of 71 consecutive patients
BACKGROUND AND OBJECTIVES: confined to the liver, but can induce with CHC were prospectively evaluated.
Several investigators have suggested disturbances in many other organs and CHC infection was defined by the
insulin resistance overload as a systems 1, 2. Chronic hepatitis C has presence of anti-HCV for at least 6
possible explanation for the many features which suggest that this months and a positive HCV-viremia.
increased prevalence of metabolic disease must be viewed not only as a Patients with other etiology of chronic
syndrome among patients with viral disease, but also as a metabolic liver disease: hepatitis B, autoimmune
chronic hepatitis C virus (CHC) liver disease which implies: insulin liver disease, Wilson disease, hemo-
infection. Therefore, I performed this resistance (IR) 3, high prevalence of chromatosis, 1-antitripsin deficiency,
study to explore the steatosis 4, increased prevalence of patients with a history of hepatotoxic- or
relationship between CHC and the impaired glucose tolerance 5, type 2 steatosis-inducing drug use. Patients
metabolic syndrome and evaluate diabetes mellitus 6, and changes in lipid with chronic alcohol consumption, as
the value of insulin resistance as a metabolism 7. These findings together well as those with a history of diabetes
marker for risk factors in patients suggest that chronic HCV infection is mellitus were excluded from the study.
with chronic hepatitis C (CHC), closely related to the metabolic syn- All patients underwent a complete
according to the presence or drome (MS]. Accordingly, CHC should clinical and anthropometric evaluation,
absence of metabolic syndrome be divided into CHC with and CHC and an ultrasound scan of the liver, with
(MS). without MS. Metabolic steatosis occurs a HS 2000 device, using a 3.5 MHz
in non-3 genotype HCV infection and is convex probe, and the presence of
PATIENTS and METHODS: associated with host metabolic factors: fatty liver was defined as the increased
Seventy one patients with CHC were elevated body mass index (BMI] and echogenicity with a bright pattern of
prospectively studied. Parameters central adiposity 8. Insulin resistance the hepatic parenchyma and posterior
of MS according to the IDF criteria is the main feature of the MS. In CHC, attenuation. The five components of the
were evaluated. Insulin resistance there is a close association between IR MS were searched for in all patients,
(IR) was established by homeostasis [9], hepatic steatosis 3, 8, 9, progres- and subjects having 3 or more of the
model assessment (HOMA-IR]. An sion of fibrosis 10 and a lower rate of following criteria were labeled as MS:
index 2.0 was designated as IR. sustained virological response 11,12. central obesity (waist circumference >
The pathogenetic mechanisms of 94 cm for men and > 80 cm for women)
RESULTS:
metabolic steatosis are the IR induced or body mass index (BMI) (weight in
MS was found in 61.97% of cases.
by direct action of HCV on the insulin kilograms divided by the square of
HOMA-IR was significantly higher in
signaling pathways 1, 2 as well as the height in meters) was considered as
patients with CHC and MS vs those
host factors, especially obesity 9. The obesity (BMI > 30), plus any two of the
without MS (7.881.11 vs 4.29 0.5,
IDF consensus worldwide definition of following four factors: triglyceride levels
p=0.023].
the MS was used. It implies the >150 mg/dl or current use of fibrates;
presence of the central obesity HDL-cholesterol < 40 mg/dl (men) and
CONCLUSIONS:
(defined as waist circumference 94 cm < 50mg/dl (women); arterial pressure
CHC with MS associated with a
higher insulin resistance, and for men and > 80 cm for women) plus > 130/85 mmHg or pharmacologically
chronic hepatitis C has many two of the following four features: raised treated; fasting glucose > 100mg/dl.
features which suggest that this triglyceride levels > 150 mg/dl; reduced The laboratory evaluation included
disease must be viewed not only as HDL-cholesterol < 40 mg/dl in males measurement of the fasting blood glu-
a viral disease, but also as a and < 50 mg/dl in females; raised blood cose, fasting serum triglycerides, high-
metabolic liver disease. pressure: systolic > 130 or diastolic > 85 density lipoprotein cholesterol (HDL-C)
mmHg; raised fasting plasma glucose levels, alaninaminotransferase (ALT)
Key words: >100 mg/dl 13. To my knowledge there and aspartate aminotransferase (AST).
Chronic hepatitis C - metabolic are no studies from Aden who have Serum glucose, triglycerides, ALT, AST
syndrome - insulin resistance - reported on this subject up to now, so and HDL-C were measured by enzy-
Aden. in this direction I tried to determine matic colorimetric methods, and insulin
the prevalence of metabolic syndrome resistance was established by
among patients with chronic hepatitis C homeostasis model assessment
in Aden.
(HOMA-IR), by the formula:
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fasting insulin level (mUI/l] x fasting Insulin resistance in chronic HCV percentage of 63% among patients with
glucose level (mg/dl) / 405. A HOMA- infection could be caused by interplay CHC, and this result might explain the
IR index value of more than 2.0 was between viral and host factors 16. HCV role played by CHC in the development of
considered as the criterion of insulin infection per se generates multiple fatty liver.
resistance defects in hepatic insulin signaling
pathways 17, 18, 19. In this study insulin In conclusion CHC with Metabolic
Viral markers HBsAg and anti-HCV resistance was higher in patients with Syndrome was associated with a
were assessed using second-generation CHC and Metabolic Syndrome than in higher insulin resistance, and these
enzyme-linked immunosorbent assay those without it, and in the univariate findings together suggest that chronic
(ELISA) tests. analysis HOMA-IR was correlated with HCV infection is closely related to the
BMI and visceral obesity. Visceral obesity metabolic syndrome.
Ethically a written informed consent was estimated by waist circumference is
obtained from each patient. viewed as the phenotypic expression of References
IR 20 and we found that HOMA-IR was
almost two-fold higher in patients with 1. Koike K. Hepatitis C as a metabolic
Statistical Analysis CHC and MS than in those with CHC disease: Implication for the pathogenesis
Comparison between groups was alone. of NASH. Hepatol Res 2005; 33: 145-
performed using Students t-test for 150.
continuous variables and ?2 test for Our study revealed a positive correlation
categorical variables. The odds ratio between IR and activity. Most 2. Narita R, Abe S, Kihara Y, Akiyama T,
(OR), the 95% confidence intervals (CI), investigators have demonstrated that Tabaru A, Otsuki M. Insulin resistance
and p values were calculated. A p value IR has developed before the stage of and insulin secretion in chronic hepatitis
< 0.05 was considered significant. cirrhosis and that it is higher in patients C virus infection. J Hepatol 2004; 41:
with CHC 21, 22, and suggested the 132-138.
link between IR and hepatic steatosis.
Results In concordance with these studies, 3. Fartoux L, Poujol-Robert A, Guchot J,
According to the presence or absence we found that Metabolic Syndrome Wendum D, Poupon R, Serfaty L. Insulin
of MS the patients were divided in two correlated with NAFLD in large number. resistance is a cause of steatosis and
groups for comparison (Table I). In the This might be explained by a higher fibrosis progression in chronic hepatitis C.
univariate analysis, 9 variables were contribution of the metabolic versus viral Gut 2005; 54: 1003-1008.
significantly related to the Metabolic factors in this study, as in other studies
Syndrome associated with CHC: 23. Another unexpected finding of our 4. Adinolfi LE, Durante-Mangoni E,
female gender, increased BMI, visceral study was the correlation of IR with the Zampino R, Ruggiero G. Review article:
obesity, serum triglycerides, fasting necroinflammatory activity. This is not hepatitis C virus-associates steatosis
glucose, HOMA-IR, and presence of a singular finding. Another study found - pathogenic mechanisms and clinical
fatty liver (NAFLD), and the prevalence an association between IR, high serum implications. Aliment Pharmacol Ther
of metabolic syndrome, obtained was viral load and necroinflammation in 2005; 22(suppl 2]: 52-55.
61.97% (44/71cases), as illustrated in patients with CHC infected especially with
Table 1 (next page). genotype 1 or 4 24. Despite the major 5. Lecube A, Hernandez C, Sim
role played by HCV in the development R, Esteban JI, Genesca J. Glucose
of IR and hepatic steatosis, host abnormalities are an independent risk
Discussion metabolic factors might have a great factor for non-response to antiviral
treatment in chronic hepatitis C. Am J
contribution in chronic HCV infection.
Hepatitis C and Metabolic Syndrome A significant number of our patients Gastroenterol 2007; 102: 2189-2195.
are common conditions worldwide and had Metabolic Syndrome, and visceral
both have IR as a key pathogenetic obesity was the constant criterion for the 6. Mehta SH, Brancati FL, Sulkowski
factor 14. In this study we found that definition of Metabolic Syndrome. The MS, Strathdee SA, Szklo M, Thomas DL.
Metabolic Syndrome, according to the adipose tissue is no longer considered Prevalence of type 2 diabetes mellitus
IFD definition was present in 61.97% only as a storage organ, but rather a among persons with hepatitis C virus
(44 out of 71) patients with CHC. All of very active neuroendocrine organ, that infection in the United States. Ann Intern
them had visceral obesity, evaluated by produces and secretes a large number Med 2000; 133: 592-599.
waist circumference and a significantly of active peptides, collectively named
higher BMI as compared with patients adipocytokines or adipokines 25, 26, 7. Perlemuter G, Sabile A, Letteron P, et
without Metabolic Syndrome. Low HDL- 27, with significant implications in al. Hepatitis C virus core protein inhibits
cholesterol level (68.4%), raised plasma several metabolic processes. Among microsomal triglyceride transfer protein
glucose (59.8%), elevated blood pressure these cytokines, the role of adiponectin activity and very low density lipoprotein
(48%) and high triglyceride levels (30.2%) in NAFLD and CHC has been largely secretion: a model of viral - related
were also present in these patients. studied. These findings support the steatosis. FASEB J 2002; 16: 185-194.
hypothesis that IR is not only the result
Chronic hepatitis C and Metabolic of a direct action of the virus, but also 8. Adinolfi LE, Gambardella M, Andreana
Syndrome may coexist in the same of an imbalance of adipocytokines, A, Tripodi MF, Utili R, Ruggiero G.
individual 15, but chronic HCV infection mainly in patients with Metabolic Steatosis accelerates the progression
can also generate by itself some Syndrome, confirming the role of the of liver damage of chronic hepatitis C
metabolic abnormalities characteristic for metabolic factors in modulating insulin patients and correlates with specific
the Metabolic Syndrome. sensitivity 21,22. Our study revealed a HCV genotype and visceral obesity.
positive correlation between presence Hepatology 2001; 33: 1358-1364.
of metabolic syndrome and NAFLD, in
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CLINICAL RESEARCH AND METHODS
Mohamed H.,
AL-Maseeh F.,
Al-Lenjawi B., Introduction Case report
Al-Kozaaei D,
Al-Bader A., Varicose ulceration has a significant In February 2008, an otherwise healthy
Abdeen J. prevalence and morbidity and places a 38-year-old Egyptian male presented
considerable burden on health with a large varicose ulcer over the
resources internationally (1,2). Chronic medial aspect of the right lower limb
lower limb ulceration is common and (Figure 1) that had persisted in spite of
may have a protracted course when, de- intensive therapy for the previous six
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controversial treatment for varicose refused prophylactic compressive treat- Suggested modalities for the treatment
ulcers that is discussed further below. ment, although some authors believe of venous ulceration include elevat-
In this case it was used and covered that compressive therapy constitutes the ing the legs above the heart (19) and
with 3-layer bandaging including one most important part of the conservative compression therapy to improve ulcer
compression bandage applied in a 50% therapy of chronic venous insufficiency healing and prevent recurrence (20-22)
overlapping fashion to exert a gradual (43), but agreed to maintenance Da- with a recent meta-analysis suggesting
pressure greatest distal to the toes and flon therapy. Follow up of the patient at that multilayer compression therapy is
reducing progressively to the anterior three and six months showed intact skin superior to single-layer bandaging (23).
tibial tuberosity. Systemic treatment in- (Figure 4). Other options that have been studied
cluded oral micronized purified flavonoid with various degrees of success include
fraction (Daflon: Servier) 500mg twice compression sclerotherapy, echo
daily. The patient was instructed to rest Discussion sclerotherapy (31), ultrasound-guided
in bed with the limb elevated for the foam sclerotherapy (32), skin grafting
first three days. Bandages and dress- Recognised modifiable risk factors for (33), superficial venous surgery (34),
ing with silver cell were changed every varicose vein disease include occupa- and sub-fascial endoscopic perforator
three days. Re-epithalization started at tions involving long periods of standing, surgery (35) and sub-fascial endoscopic
the wound edges and, later, islands of and obesity (59,60) since it is thought perforator surgery (36) although endov-
epithelium could be seen in the middle of that obesity leads to an increase in enous laser therapy and vein surgery
the ulcer that represented keratinocyte intra-abdominal pressure that impedes with or without skin grafting should be
out-growth from the hair follicles (44,45) venous return from the lower extremities considered only as a final option when
producing complete resolution within (61). Sugerman and colleagues dem- all other measures have failed (17).
one month. (Figures 2,3,4). The patient onstrated that weight loss is associ- Tissue-engineered skin equivalent
was also counseled regarding an aver- ated with correction of venous stasis in (recently approved by the U.S. Food
age weight loss of 5 kg using the portion almost all patients (62). and Drug Administration) is an exciting
control (one dahoo-plate) method. He development in the treatment of venous
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ficiency and patient compliance J (31) Paul R . Weaver . Avaricose ulcer stimulating factor applied locally in low
Vase Surg. 1995;22:62936. [PMID: 7 healed by non surgical varicose vein doses enhances healing and prevents
494367].[Medline] treatment using ultrasound guided to recurrence of chronic venous ulcers
am sclerotherampy nzfp, vol 35, No. 1, Int J Dermatol. 1999;38:380-6. [PMID:
(21) Blair SD, Wright DD, Backhouse Feb 2008, P 32-33.. 10369552] [Medline].
CM, Riddle E, McCollum CN. Sus-
tained compression and healing of (32) Douglas WS, Simpson NB. (41) Da Costa RM, Ribeiro Jesus FM,
chronic venous ulcers BMJ. 1988;297: Guidelines for the management of Aniceto C, Mendes M. Randomized,
1159-61. [PMID: 3144330]. chronic venous leg ulceration. Re- double-blind, placebo-controlled, dose-
port of a multidisciplinary workshop. ranging study of granulocyte-mac-
(22) Partsch H. Compression therapy British Association of Dermatologists rophage colony stimulating factor in
of the legs. A review J Dermatol Surg and the Research Unit of the Royal patients with chronic venous leg ulcers
Oncol. 1991;17:799-805. [PMID: College of Physicians Br J Der- Wound Repair Regen. 1999;7:17-25.
1918586] [Medline]. matol. 1995;132:446-52. [PMID: [PMID: 10231502l] [Medline].
7718464].[Medline].
(23) Fletcher A, Cullum N, Sheldon TA. (42) Robson MC, Phillips T J, Falanga
A systematic review of compression (33) Olivencia JA Subfascial endo- V, Odenheimer OJ, Parish LC, Jensen
treatment for venous leg ulcers BMJ. scopic ligation of perforator veins JL, et al. Randomized trial of topically
1997;315:576-80. [PMID: 9302954]. (SEPS) in the treatment of venous applied repifermin (recombinant human
ulcers Int Surg. 2000;85:266-9. [PMID: keratinocyte growth factor-2) to accel-
(24) Weithmann KU. The influence of 11325008].[Medline] erate wound healing in venous ulcers
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IRCS Medical Science [microform]. RL, Anderson FA Jr, Malhotra R.
1980;8:293-4. Free flap valvular transplantation (43) V. SLohkova, Z . Navartilova, V .
for refractory venous ulceration J Semradova and J.Adler . Successful
(25) Colgan MP, Dormandy JA, Jones Vasc Surg. 1994;19:525-31. [PMID: treatment of chronic venous leg ulcer
PW, Schraibman IG, Shanik DG, Young 8126867][Medline]. with hyoplilized cultured epidermal al-
RA. Oxpentifylline treatment of venous lografts. Acta Dermatoven APA Vol 13,
ulcers of the leg BMJ. 1990;300:972-5. (35) Falanga V, Margolis D, Alvarez 0, 2004, No.4 Page 119-123.
[PMID: 2256974]. Auletta M, Maggiacomo F, Altman M, et
al. Rapid healing of venous ulcers and (44) Scondotto G, Aloisi D, Ferrai P,
(26) Dale JJ, Ruckley CV, Harper DR, lack of clinical rejection with an alloge- Martini L . Treatment of venous leg ul-
Gibson B, Nelson EA, Prescott RJ. neic cultured human skin equivalent. cers with sulodexide Angiology . 1999 ;
Randomised, double blind placebo Human Skin Equivalent Investigators 50:883-9.[PMID:10580352].
controlled trial of pentoxifylline in the Group Arch Dermatol. 1998; 134:293-
treatment of venous leg ulcers BMJ. 300. [PMID: 9521027] (45) Zacur H, Kirsner RS . Debride-
1999;319:875-8. [PMID: 10506039 H=] ment : rationale and therapeutic
(36) Compression sclera therapy is options Wounds . 2002 ;14(Suppl F
(27) Falanga V, Fujitani RM, Diaz C, useful in Vivien .Ref: A. Yu. Krylov, ):2ER-7E.
Hunter G, Jorizzo J, Lawrence PF, et A.M . Shulutko, E.C. Nagovitzyn,
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efficacy in a randomized, placebo- in idiopathic cyclic edema- effects of
controlled trial Wound Repair Regen. (37) Marques da Costa R, Jesus FM, Daflon 500 mg.
1999;7:208-13. [PMID: 10781212l.] Aniceto C, Mendes M. Double-blind Nuklearnedizin . 1998;27:105-7.
[Medline]. randomized placebo-controlled trial of
the use of granulocyte-macrophage (47) Al bert - Adrien .Ramelet MD,
(28) Jull AB, Waters J, Arroll B. colony stimulating factor in chronic pharmacologic Aspects of phototropic
Pentoxifylline for treating venous leg leg ulcers Am J Surg. 1997;173:165-8. drug in CVI - Associated edema . Angi-
ulcers. Cochrane-Database svst Rev. [PMID: 9124619].[Medline]. ology, Vol 51, No 1, 19-23, (200).
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11869606). (38) Halabe A, Ingber A, Hodak E, (48) Phillip D. Coleridge Smith . Micro-
David M. Granulocyte-macrophage col- nized & urified falconoid fraction and
(29) Guilhou JJ, Dereure 0, Marzin L, ony-stimulating factor--a novel therapy the treatment of chronic venous insuffi-
Ouvry P, Zuccarelli F, Debure C, et al. in the healing of chronic ulcerative le- ciency : micro circulatory mechanisms .
Efficacy of Daflon 500 mg in venous sions. Med Sci Res. 1995;23:65-6. Micro microcirculation, volume 7, issue
leg ulcer healing: a double-blind, rand- 6 supplement 1, Dec 2000.
omized, controlled versus placebo trial (39) Pojda Z, Struzyna J. Treatment
in 107 patients Angiology. 1997;48:77- of non-healing ulcers with rhGM- (49) Nicolaides AN. from symptoms to
85. [PMID: 8995348]. CSF and skin grafts [Letter] Lancet. leg edema : efficacy of Daflon 500 mg.
1994;343:1100 [PMID: 7909116] Angilogy.2003: 54: S33-S44.
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is useful in v. vein : AYu. Krylov, (50) Morgan DA . Alginate dressing .
AM.Shulutko, E.C.Najovitzyn, (40) Jaschke E, Zabernigg A, Gat- part 2: product guide . I bid 1997;7:9-
MV.Safonov . J Ang Vasc surg Vol tringer C. Recombinant human 14.
6.1/2000 ; P:54 granulocytemacrophage colony-
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stimulating factor applied locally in low (52) SMTL - Surgical material testing
doses enhances healing and prevents laboratory / JJWM (2003) Data on file
recurrence of chronic venous ulcers report RD 675(SMTL 03/1610/01).
Int J Dermatol. 1999;38:380-6. [PMID:
10369552] [Medline]. (53) Luciana Patricia Fernandes Ab-
bade, sidnei Lasttoria. management
(41) Da Costa RM, Ribeiro Jesus FM, of particuts with leg ulcer. An . Bras .
Aniceto C, Mendes M. Randomized, Dermatol, Vol 81, No .6. Rio de Janeiro
double-blind, placebo-controlled, Nov / Dec 2006.
dose- ranging study of granulocyte-
macrophage colony stimulating factor in (54) Rosie Pudner . Alginate and
patients with chronic venous leg ulcers hydrofibre dressing in wound manage-
Wound Repair Regen. 1999;7:17-25. ment . JCN, May 2001.Vol 15 issue 05,
[PMID: 10231502l] [Medline]. pp 1-5.
(42) Robson MC, Phillips T J, Falanga (55) Vanessa Jones, Joseph E Grey
V, Odenheimer OJ, Parish LC, Jensen and Keith G Harding . Wound dressing .
JL, et al. Randomized trial of topically BMJ 2006; 332;777-780.
applied repifermin (recombinant human
keratinocyte growth factor-2) to accel- (56)Morgan DA, wound management
erate wound healing in venous ulcers products the drug tariff . The pharma-
Wound Repair Regen. 2001 ;9:347-52. ceutical Journal, Vol 263 . No 3 7072, p
[PMID: 11896977].[Medline]. 820-825.Nov 20,1999.
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Corresponding author:
Enwereji, E. E. the death of loved ones, negatively study) , economic empowerment of HIV
College of Medicine influenced rights to family resources positive women should be given high
Abia State University of HIV positive women. The majority of priority in the society. There is growing
Uturu, Abia State, Nigeria the women were subjected to horrify- evidence that eliminating practices that
Phone:+2348036045884 ing experiences like beating, chas- discourage womens inheritance rights
E-mail: hersng@yahoo.com tisement, rejection and others which to family resources, especially those
resulted in interpersonal conflicts, HIV positive, will mitigate negative eco-
and violence for venturing to acquire nomic consequences of HIV and AIDS,
Enwereji, K.O. (co-author) material resources for the family. A and reduce poverty [1,2]. This is neces-
College of Medicine good number of the traditional rulers sary because womens lack of economic
Nnamdi Azikiwe UniversityTeaching interviewed did not support economic empowerment is the key factor in the
Hospital empowerment of women whether HIV spread of HIV and AIDS [3].
Awka , Anambra State, Nigeria positive or not. The premise is that
E-mail: drkayman@justice.com women are subordinate to men and The problem is that traditionally, cus-
should not be allowed to take over toms forbid women to own resources
family resources to the disadvantage like land, and houses that would bring
of men. They argue that women would them at par with men economically [
be obstinate if they are allowed much 4], yet womens rights to inherit hous-
ABSTRACT material goods. ing and land are enshrined under the
international human rights laws to which
As high as 85 (86.7%) of the women many countries including Nigeria are
Introduction: studied were denied rights to family signatories. The Nigerian legal system
Every country has different practices resources. To survive in the commu- is a combination of Nigerian legislation,
that influence rights to family resourc- nities, the women took two types of English law, customary law and judicial
es. In developing countries, includ- risks, acting as hired labourers and precedents [5]. Each of the legal sys-
ing Nigeria, cultural practices favour having sex without condoms. A total tems determines the right of the woman.
males for economic ventures more of 54 (55%) of them had sex without Under statutory marriage, women and
than females. There is evidence that a condom. Common reason proffered children could have property rights but
encouraging HIV positive womens for taking this risk was sex partners under customary law which is commonly
rights to family resources will lessen dislike for condom use. practiced in Nigeria, women do not have
risks they take to overcome negative the right to inherit family resources [6,7].
economic consequences of HIV and Usually, if a husband dies, the widow,
AIDS. This will help to achieve the her children and husbands property are
much needed reduction in HIV preva- Conclusion:
It is therefore plausible to recommend inherited by brothers and/or other male
lence in Nigeria. relations of the deceased husband. Tra-
that regular seminars and/or work-
shops should be organized to educate ditionally, a widow only escapes being
Materials and method: inherited if she is too old and/or frail to
Total sample of 98 HIV positive women the traditional rulers and others on the
need to accord HIV positive women be inherited [8-10].
in a network of people living with HIV
and AIDS and also 5 traditional rulers access to family resources so as to
enable them to cope with their health, In Abia State, property ownership is a
in charge of the communities studied, source of security for means of liveli-
were involved. economic and social needs .
hood and also a quick capital by which
Key words: inheritance rights, HIV/ additional economic resources are
Data collection instruments were acquired. It is this premise that encour-
questionnaire, focus group discussion AIDS, unprotected sex, policies,
Nigeria aged men to exclude women, including
and key informant interview. Using widows and those HIV positive from ac-
key informant interview with tradi- cess to and/or control of family resourc-
tional rulers helped to authenticate
responses of the women. Data were Introduction es [11-13]. Nowadays, the devastating
effects of HIV/AIDS due to economic
analyzed qualitatively and quantita- hardship requires that HIV positive
tively with percentages. One of Nigerias greatest challenges
is to discourage cultural practices that women should be encouraged to own
negatively affect the economic exist- resources to enable them cope with
Result: their economic demands [14, 15]. This
Findings showed that factors like wid- ence of HIV positive women. With
Nigerias high prevalence of HIV and is necessary because the economic
owhood inheritance, subordinate roles burdens of HIV and AIDS have reduced
of women, breadwinner roles of men, AIDS, 5% of women attending antena-
tal care services (Federal Ministry of household income by 80%, food con-
terming women as visitors, and seeing sumption by 15-30% and primary school
women as responsible for Health 2002 HIV and AIDS surveillance
enrolment by 20-40% [16,17]. Denying
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We have six children, yet our brothers- Table 2: Reasons for Family Members
in-law took all our husbands resources actions
because we refused to be inherited
barely one month after the death of From Table 2, the commonest reason
our husbands. When we complained, 38 (38.8%) HIV positive women gave for
we were chased out of our matrimonial their family members action against them
homes. was demand for husbands possessions.
Further, the marital status of the women
Result from the quantitative data also commonly chastised was explored. From
show horrifying experiences HIV positive the finding, respondents from all marital
women had with family relations see statuses were chastisements but the
Table 1. most commonly chastised were the
widowed 48 (49%). Table 3 contains this.
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From the Table, as high as 59 (60.2%) of the HIV positive women were chastised in all marital statuses.
Another important finding was that HIV positive women made a living by taking two types of risks. Firstly, 25 (25.5%) of them
earned their livelihood by acting as hired labourers in the farm while as high as 54 (55.1%) at various periods had sex without
a condom. These risks were more among women in the rural areas than those in urban areas. Table 4 contains details of their
sexual practice.
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Discussion
There were striking similarities between drugs, eating balanced food, treating Therefore, encouraging policies that
information given by the traditional rulers opportunistic infections, paying childrens would promote inheritance rights of HIV
and the responses of the HIV positive school fees and other family needs. positive women could reduce
women on factors that discourage Therefore HIV positive women should the risks they take to survive in the
HIV positive womens rights to family be allowed rights to family resources to communities. If HIV positive women are
resources. The HIV positive women enable them meet their health, financial continuously denied rights to possess
enumerated factors such as perceiving and social needs. This will reduce the family resources, governments efforts to
women as visitors in their families, tendency of depending on others for reduce the impact of HIV and AIDS on
seeing women as responsible for all assistance. Denying HIV positive women women would yield no significant result
deaths in the family, cultural rights for rights to family resources is at variance unless the government with the support of
men to inherit property of the deceased with the recommendations of (21, 22, traditional rulers enact policies that would
including the widow, breadwinner role of 23) that supreme court ruling of Mojekwu discourage some cultural practices that
men and others. On the other hand, the to allow females rights to inherit family negatively influence womens existence
traditional rulers deliberately and carefully resources be implemented. by denying them access to family
enumerated actions like cultural rights resources.
for men to inherit possessions of the In the present study, HIV positive women
deceased, perceiving women as visitors, took two types of risks in order to earn It is therefore plausible to recommend
subordinate role of women, seeing their livelihood: acting as hired labourers that government and traditional
women as the cause of all deaths in the in the farm, and having sex without rulers should discourage factors that
family, and others. condoms. The risks of acting as hired dehumanize women, pauperize them and
labourers could easily wear them down, deny them access to family resources.
Also, a good number of the HIV positive reduce their immunity and further expose This recommendation is necessary
women had horrifying experiences them to several infections especially because only the government with
like beating, rejection, discrimination, opportunistic infections. Also, HIV positive the help of traditional rulers can make
chastisement and others from family women having sex without condoms policies capable of changing social
members which resulted in denying increases actions that encourage HIV norms, customs, and other practices that
them access to family resources. Based infection. The finding that HIV positive negatively influence rights to possess
on this finding, it is safe to assume that women engaged in unprotected sex material It is felt that since the traditional
HIV positive women studied arguably agrees with that of [19, 20]. rulers decide what obtains in each
experienced domestic violence. community, that there is need to organize
. Although the traditional rulers had good seminars and/or workshops to enlighten
A good number of the HIV positive knowledge of modes of HIV infection, them on the benefits of empowering
women spoke at length about the their overall knowledge of health, financial HIV positive women and allowing them
difficulties and frustrations they had and social needs of HIV positive women access to family resources.
faced in the past or they anticipated remained poor. They exhibited little or no
having to overcome in future. One concern for the welfare of HIV positive Many questions are generated by this
of the most frequently mentioned women. This is shown by the traditional study. Although this particular study was
experiences was their lack of access rulers attitude of linking constant illness limited by the number of respondents,
to health care services. They worried and other life experiences of the HIV and the lack of generalization of result,
that during episodes of sickness that positive women with laziness and/or there are clear indications that the
neither the hospital authorities nor their lack of zeal for the women to engage concerns raised are as difficult as they
family members assist them financially in elaborate farming to raise enough are real. Marginalized groups of HIV
to receive prompt treatment rather, that food for sustenance like others. This is infected women both in the rural and
they would be scolded for being sickly. also shown by their negative attitude of urban areas are perceived to have
The inability of family members and discouraging economic empowerment of few resources and are at great risk of
hospital authorities to financially assist women. managing complex health problems
HIV positive women to receive adequate including poverty. In addition, exploration
treatment during health problems of the experiences of HIV positive women
shows that HIV positive women were Conclusions in the communities would yield important
not provided with their health needs. The findings of this research provide an information for HIV prevention.
This finding suggests lack of care and introduction to problems HIV positive References
support for the HIV positive women. women encounter in their attempt to 1. Mphale, M.M. Emmanuel G.R. And
Findings on lack of care and support for survive in the communities, as well as Mokhantso G.M. HIV/AIDS and its impact
HIV positive women agrees with that of issues and concerns of stakeholders on land tenure and livelihoods in Lesotho
(3, 6, 7) and is at variance with that of towards the wellbeing of HIV positive Background paper for FAO/SARPN
[12,14] which documented increased care women and how these women cope with workshop on HIV/AIDS and land tenure,
and support for people living with HIV/ these problems. The most crucial need is Pretoria South Africa 2002; 24- 25 June
AIDS. This finding presupposes that the the one the women identified themselves
family members of HIV positive women which is to create a society which will 2. Whiteside, A. poverty and HIV/AIDS in
are not aware of their basic needs. It support their rights to access family Africa. Third World Quarterly, 2002;23 (2)
is not to be over emphasized that HIV resources to reduce their dependence : 313 - 332.
positive women need finance to meet the on family members in their attempt to
demands of purchasing anti-retroviral mitigate the demands of HIV infection.
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3. World Bank HIV/AIDS and gender 16. Anyanwu , F.C. Udo, C.O. , 27. Oyajobi, A.U. Gender discrimination
equity. gender and development briefing Okpala, P.N. socio-cultural practices as and fundamental rights of women in
Notes. Washington, D C: World Bank 03 Correlates of Psychological disposition Nigeria. Journal of human rights law and
of widows in Imo State. Nigerian School practice . Civil liberty organization lagos :
4. Customary law manual , Enugu: Health Journal 1999; (1&2) . 11: 66-71. 1991;. 1 (1).
Government printer 1977
17. Ubesie ,T. Odinala ndi Igbo Ibadan: 28. Ipaye, O.A. some aspects of women
5. Ogbu, O.N., Human rights law and Oxford University Press 1978. and the law: the Nigerian experience.
practice in Nigeria: An introduction 1999 Journal of human rights law and practice.
constitution Enugu: Cidjap publishers. Civil Liberties Organization, Lagos: 1995
18. Odusanya, O. O. and Alakija, W. HIV: ; .5.(1).
6. Macmillan, J. HIV/AIDS, the law knowledge and sexual practice amongst
challenges for women paper presented Students of a school of community health
at the FAO/SARPN worship on HIV/AIDS in Lagos, Nigeria. African Journal of
and land tenure Pretoria South Africa: Medicine and Medical Sciences 2004;
2002; 24-25 June .33 .(1) : 45-49
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CASE REPORT
Email: khier2@yahoo.com
CASE REPORT
Mr. X, is a 51 year old man known
to be diabetic for 7 years. He is not
hypertensive and has no history
of cardiovascular diseases. He
is using Gliclazide 80mg BID and The Silver Spike Point device (SSP) The device had many advantages in
metformin 500mg OD. His blood comparison with traditional acupuncture
glucose is well controlled (HbA1c The prevalence of smoking among (Table 1).
6.5%), his blood pressure is also diabetics
well controlled (132/75mmHg). All Cigarette smoking is the leading The device is used by many antismoking
his lab investigations were within avoidable cause of mortality in the USA, clinics to help smokers to overcome the
normal limits except his serum total accounting for 400,000 deaths each withdrawal symptoms resulting from
cholesterol and total triglyceride year. (1) The Resistance Atherosclerosis smoking cessation.
(6mmol/L, 5mmol/L respectively). Study (IRAS) was a prospective study of
On his last visit, his doctor advised In 1999, clinical researchers reported
E S ford et al in their paper published that inserting acupuncture needles
him to quit smoking. Mr. X read about in the Journal of Preventive Medicine in
a new device which arrived at the local into specific body points triggers the
2004 analyzed data from the behavioral production of endorphins. (7)
anti-smoking clinic called Silver Spike risk factor surveillance system for 1990
Point (SSP) and he asked his doctor - 2001. They found that the prevalence
about this device and if it may affect In another study, a high level of
among adults with diabetes was 23.6% endorphins was noted to form in
his blood glucose if he decided to (Men 25.4%, Women 22.2%) in 1990
use it. cerebrospinal fluid after patients
and 25.2 (men 24.8%, women 21.9%) in underwent acupuncture. (8)
2001. (3)
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Endorphins are endogenous opoiod Beta endorphins are the most powerful the dopamine pathways causing more
polypeptide compounds. They are endorphins in the body. They are usually dopamine to be released (19).
produced by the pituitary gland and found in the hypothalamus and pituitary
the hypothalamus in vertebrates during gland. Opioid receptors have many other
certain circumstances and act via important roles in the brain and periphery
opioid receptors in the body (Table 2).
(12)(13)(14) The actions of endorphins (Table 4). (21)
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neurological systems involved in nicotine The relation between significant increase in peripheral plasma
glucagons levels (+44 +13ng). From
reinforcement interact with the midbrain endorphins and glucose this study the investigators concluded
dopamine system. These systems
include the opioid system.
homeostasis that naturally occurring opioid peptide
Stimulation of the dopamine system beta endorphin produced hyperglycemic
In an animal model study, investigators effects in man which appears to be
appears to be of critical importance for
examined the administration of beta mediated by Glucagon. The opioid
acute positive reinforcing properties of
endorphins introduced centrally on seems to have no direct effect on
nicotine.
glucose homeostasis on a conscious glucose metabolism.
dog. (28) Intracerebroventricular
Nicotine also affects the release of
administration of beta endorphin (0.2mg/ Back to animal model studies, an
endogenous opioid peptides. (26)
h) caused a 70% increase in plasma interesting study (30) aimed to determine
The endorphin system has been
glucose. whether supraphysiological levels
hypothesized to be involved in mood
regulation, psychomotor stimulation, of beta endorphin inhibit the ACTH
The mechanism of hyperglycemia was and CRH response to insulin induced
analgesia reproduction and temperature
thought through: hypoglycemia in human subjects. The
regulation. (27)
researchers in this study noted that IV
- Early increase of glucose production infusion of beta endorphin increases
How can endorphins help - Lack of inhibition of glucose clearance glucose and delays the onset of
in smoking cessation? hypoglycemia following insulin. (30)
The changes explains the marked
Endorphins compete with nicotine on increases in plasma epinephrine (30 fold) Conclusion
the receptors responsible from positive and norepinephrin (6 fold) that occurred
reinforcement feelings. While the during infusion. Interestingly intravenous Back to our patient, Mr Xs doctor
smokers begin to withdraw from the administration of beta-endorphin did explained to him the previous information
smoking habit, the endorphins produced not alter glucose homeostasis. The and encouraged him to try the SSP
by electrotherapy (SSP) continue to investigators in this study concluded device but also advised him to monitor
give the same feelings. After time the that beta endorphins act centrally to his blood glucose closely during the
body restarts to secrete endorphins cause hyperglycemia by stimulating period of using the device. Also he was
endogenously without the need of sympathetic out flow and pituitary - advised to contact his doctor if he noticed
nicotine. In such way the smoker can adrenal axis. (28) unexplained rising in his blood glucose.
quit smoothly without passing through
the vicious cycle of craving, smoking, In another study (29), Paolisso G et References
calming and craving. al evaluated the effect of human beta
endorphins on pancreatic hormone 1) American Diabetes Association.
levels and on glucose metabolism in Clinical Practice recommendations.
normal subjects. The study showed that Diabetes Care; 27(1):S74-S75. 2004
infusion of 143 nmol/h beta endorphins
in 7 subjects caused a significant rise 2) Capri GF, Ronny AB, Deborah FF,
in plasma glucose concentrations (+1.7 David CG and Lynne EW. Smoking and
+0.3 mmol/L) which was preceded by a incidence of diabetes among U.S Adults.
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32 M I D D LMIDDLE
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Corresponding author:
ABSTRACT
Warfarin induced skin necrosis is a rare
but serious complication of treatment with
anticoagulants. Doctors should consider
this reaction when suspicious skin lesions
appear, regardless of the manner in
which warfarin treatment was initiated;
early detection and proper management
are essential.
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Case 2.
A 19-year old female, previously healthy,
with family history of DVT, one week
post normal vaginal delivery started to
complain of right leg pain and swelling.
Doppler ultrasound showed extensive
deep vein thrombosis.
Discussion
The mechanism of action of warfarin
involves inhibition of vitamin K-dependent
coagulation factors. Inhibition of protein C
and Factor VII is stronger than inhibition
of the other vitamin K-dependent
coagulation factors II, IX and X. This
results from the fact that protein C and
Factor VII have shorter half lives. This
difference in effect is proportional to the
initial dose of vitamin K-antagonist [1, 2].
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References
1. McKnight JT, Maxwell AJ, Anderson
RL (1992). Warfarin necrosis. Arch FAM
Med 1 (1): 105-8.
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MEDICINE AND SOCIET Y
36 M I D D L E E A S T J O U R N A L O F FA M I LY M E D I C I N E V O LU M E 7 , I S S U E 1 0