jams-second issue "summer issue" -july 2011

JAMS , team and board… 2

Genome 5

Alien’s hand syndrome 7

Management of childhood migraine 9

Fibromyalgia 11

Therapeutic principles based on monoclonal antibodies 13

Medical news 15

New strain of E. coli behind German outbreak 17

Medical technology 22

Emotional intelligence 24

Clinical trials 25

Nobel prize in Medicine 26

Case discussion 29

1 Journal of Alexandria Medical Students

Welcome to JAMS the first medical journal designed to be from

students to students. JAMS is a platform for medical students to

share & present medical articles about all what is new in medicine,

articles written in simple & attractive way …

Vision:

Journal of Alexandria Medical students is the first medical journal in

Alexandria, even in Egypt designed to be from students to students. Our

vision is to make JAMS one of the important medical student journal in

Egypt and worldwide aiming to raise the Alexandria medical students'

scientific level.

Mission:

Our mission is to provide a platform for medical students to share &

present their medical articles... We had a "board of supervisors" from

our dear professors who support us and guide us to make good scientific

work…We publish our jams as online version in private site which is

linked to Alexandria faculty of medicine site and as board version under

the Academic building in the faculty and as hard-copy version that will

be in the hand of every medical student and doctor.

Objectivs:

1. To provide a medium for Alexandria medical students to publish their

work and share ideas with their peers.

2. To provide a suitable forum for students to make the transition

between assignment-writing and producing publishable academic

work.

3. To inform students about medical topics and issues not typically

addressed in core curricula.

4. To facilitate discussion of current issues relevant to medical students.

5. To foster the next generation of Alexandria medical researchers and

physician-scientists.


Mohammed Abd Elfattah mohammed Darwesh

Fifth Year Medicine (Undergraduate) Faculty of medicine, Alexandria University

Mohammed Mostafa Abd

El-Hameed Fifth Year Medicine (Undergraduate)

Faculty of medicine, Alexandria University

Mohammed Sabry Rostom


Yehia Attito Mohamed Fifth Year Medicine (Undergraduate)


Mohammed Abd-Rabboh Attia Badawey


Mohamed Abd El-Moneim

Ghonaim Fifth Year Medicine (Undergraduate)


Amr El-Daqaq


Mai Al Kosiry Fifth Year Medicine (Undergraduate)


Jams team at the opening ceremony


Prof. Mahmoud El-Zalabany

Dean and professor of pediatrics

Prof. Abd El-Aziz Belal

Ex Dean and Professor of ENT

Prof. Yasser Mazloum

Professor of Radiology

Prof. Ashraf Saad Galal

Professor of Ophthalmology

Prof. Samir Naeem

Professor of Endocrinology

Prof. Samir Helmy Asaad

Professor of Diabetes & Metabolism

Prof. Osamah Ebadaa

Professor of gastroenterology

Prof. Salah abd El-Meneem

Professor of Oncology

Prof. Fathy Elsewy

Professor of diabetes and metabolism

Prof. Mahmoud IBRAHIM

Professor of chest and sleep disorders

Prof. Mahmoud Hassanein

Professor of Cardiology

Prof. Osamah Ebadah

Professor of gastroenterology

Prof. Maha Hegazy

Professors of Physiology

Prof. Gehan Gewevel

Professor of community medicine

Assist. Prof. Hisham El-

Shishtawy

Professors of psychiatry

Assist. Prof. Nihal El

Habachi

Professors of Physiology

Assist. Prof. Ayman El-

Shayeb

Professor of Tropical medicine

Board of supervisors


BY: Mohamed seif El-Nassr Fifth year medicine (undergraduate)

During the past two decades, tremendous

progress has been made in genetics and

genomics. Diseases that run in families have

been recognized for many centuries, but it

was only in the early 1980s that the first

mutations in a gene responsible for a disease

could be identified. Subsequently, numerous

discoveries of disease-related mutations in

other genes have been found, initially in rare

single-gene disorders, but more recently also

in common disorders such as Alzheimer's

disease and cancer.

What is meant by genome?

The genome is the entirety of an organism's

hereditary information which is needed to

construct and maintain it living.

Most genomes including human genome are

made of DNA "deoxyribonucleic acid" but

many types of viruses have RNA "ribonucleic

acid" genomes. DNA and RNA are polymeric

molecules made up of chains of monomeric

subunits called nucleotides.

The vast majority of DNA molecules are

stored within the nucleus of the cell. The

nuclear human genome has about 3.2 billion

nucleotides.

What is DNA and what are

chromosomes?

DNA is the structure in which our inherited

information is encoded. DNA inside the

nucleus is covered with proteins, together

forming chromosomes.

In humans, each somatic cell contains diploid

number of chromosomes (46 chromosomes:

44 are autosomal + 2 sex chromosomes – XY

for males and XX for females). These 46

chromosomes comprise nearly 2 identical

copies of the the whole genome "one copy is

inherited from the father (22+X or 22+Y) and

the other copy from the mother (22+X)",

autosomal chromosomes derived from the

father and the mother are homologous i.e.

they comprise variants of the same genes,

therefore the nucleus looks like a library

which contains 2 copies of each book

although there may be different editions of

each specific book.

In germ cells only one copy of homologous

chromosomes is present (22 autosomal + 1

sex chromosome).

What is the structure of DNA?

The DNA looks like a long chain of connected

letters (nucleotides) without any spaces or

punctuation marks.

Four nucleotides form the structural units of

DNA:

Adenine "A", Cytosine "C", Guanine "G",

Thymine "T", these nucleotides are

connected by a deoxyribose phosphate

backbone. To this chain another strand is


attached which is the exact complement of

the 1st one.

Adenine is attached to Thymine and Guanine

is attached to Cytosine via hydrogen bonds.

These attachments are referred to as

complementary base pairs (bp).

The two strands are wound around each

other to form a double helix structure.

Genes in the genome:

The gene is the unit of information in the

DNA and is represented by a DNA sequence

that code for the production of a specific

protein as well as the regulatory sequences

that determine when this specific protein will

be produced and in what quantity. There is

still a large debate about the number of

genes present, average estimate of experts is

around 60,000 genes. Very interestingly, the

regions in DNA which encode for proteins

account for less than 5% of the complete

human genome.

The significance of the other 95% of the

genome is at present largely unknown and/or

poorly understood.

The Human Genome Project:

In 1987, a worldwide scientific effort called

the Human Genome Project was initiated to

determine the complete DNA sequence of

the human genome. Recently, a draft

covering 85%-90% of the complete human

genome sequence (3.12 billion bp) has been

announced. Experts anticipate that the entire

sequence will soon be known.

Clinical significance of studying

genomes:

Mutations are considered the genetic basis of

disease production i.e. there are changes in

the nucleotide sequence of specific gene

which result in genetic variation,

consequently, a different amino acid will be

inserted in a specific position in the protein

which result in disease production. Similarly

the genetic variation between different

individuals is the basis of human diversity

(personal characteristics).

There is major interest among scientists in

studying variations in genes because such

variations might be directly related to

specific diseases.

Many genes related to specific diseases have

been identified (BRCA1 and BRCA2 in familial

breast cancer and presenilin genes in early

onset Alzheimer's)

Clinical applications of studying

genomes:

1. The design of new genetic tests to

diagnose or predict human diseases

based on genetic markers.

2. Redefinition of diseases and

understanding of their pathogenesis

based on molecular mechanisms.

3. Identification of new molecular targets

for drug action and identification of

new disease-causing genes.

In conclusion, it might be expected that

genomics and genetics will largely impact

future medical practice. It will be the key for

clinicians of the 21st century to be well

prepared and open-minded.

References:

1. The Human Genome: An Introduction By Jeroen Aerssens, Martin Armstrong, Ron Gilissen, Nadine Cohen Department Pharmacogenomics, Janssen Research Foundation, Beerse, Belgium.

2. Genomes, 2nd edition by T.A.Brown.


BY: Mohamed Tarek Rashed Fourth year medicine (IUMP)

“Believe me, you will not see that in

Mars or when those saucers will land on

our beloved Earth.”

Actually Alien’s hand syndrome is a

neurological disorder also named as anarchic

hand or Dr. Strangelove syndrome in which

the afflicted person is expressing

uncontrolled behave-or or feeling of

strangeness of one extremity, most

commonly the left hand.

A large variety of complex, abnormal, involu-

ntary motor behaviors have been described

following callosal lesions (corpus callosum)

which may or may not be accompanied by

hemispheric damage, especially in the frontal

medial region. The alien’s hand is most com-

monly observed after traumatic brain lesions,

but has also been recently described in neur-

odegenerative diseases such as Creutzfeldt-

Jacob disease and corticobasal degeneration.

Some authors have classified these syndrom-

es into a “posterior” or “sensory” form and

an “anterior” or “motor” form.

Corpus Callosum: Damage to it, can give rise

to "purposeful" actions in the sufferer's non-

dominant hand (an individual who is left-

hemisphere-dominant will experience the

left hand becoming alien, and the right hand

will turn alien in the person with right-

hemisphere dominance) When there is a

major disconnection between the two hemis-

pheres resulting from callosal injury, the

language-linked dominant hemisphere agent

which maintains its primary control over the

dominant limb loses, to some degree, its

direct and linked control over the separate

"agent" based in the nondominant hemisph-

ere, and the nondominant limb. As well as a

problem termed "intermanual conflict" in

which the two hands appear to be directed at

opposing purposes.

Frontal lobe:

Unilateral injury to it, can trigger reaching,

grasping and other purposeful movements in

the contra lateral hand. With anteromedial

frontal lobe injury, these movements are

often exploratory reaching movements in

which external objects are frequently

grasped and utilized functionally, without the

simultaneous perception on the part of the

patient that they are "in control" of these

movements. Once an object is maintained in

the grasp of this "frontal variant" form of

alien hand, the patient often has difficulty

with voluntarily releasing the object from

grasp and can sometimes be seen to be

peeling the fingers of the hand back off the

grasped object using the opposite controlled

hand to enable the release of the grasped

object.

Dr. Strange Love movie (The most famous alien’s hand sufferer).


http://en.wikipedia.org/wiki/Dr._Strangelove

It is theorized that alien hand syndrome

results when disconnection occurs between

different parts of the brain that are engaged

in different aspects of the control of bodily

movement. As a result, different regions of

the brain are able to command bodily

movements, but cannot generate a conscious

feeling of self-control over these movements.

As a result, the "sense of agency" that is

normally associated with voluntary

movement is impaired or lost. There is

dissociation between the process associated

with the actual execution of the physical

movements of the limb and the process that

produces an internal sense of voluntary

control over the movements, with this latter

process thus normally creating the internal

conscious sensation that the movements are

being internally initiated, controlled and

produced by an active self.

One theory posed to explain these

phenomena proposes that the brain has

separable neural "premotor" or "agency"

systems for managing the process of

transforming intentions into overt action. An

anteromedial frontal premotor system is

engaged in the process of directing

exploratory actions based on "internal" drive

by releasing or reducing inhibitory control

over such actions. Damage to this system

produces disinhibition and release of such

actions which then occur autonomously.

When the anteromedial frontal system is

damaged, involuntary but purposive

movements of an exploratory reach-and-

grasp nature what was referred to as a

positive cortical tropism are released in the

contra lateral limb.

Treatment:Although there is no known

formal (primary) treatment for alien hand

syndrome at this time, the symptoms can be

reduced and managed to some degree by

keeping the alien hand occupied and

involved in a task, for example by giving it an

object to hold in its grasp. Specific learned

tasks can restore voluntary control of the

hand to a significant degree. One patient

with the "frontal" form of alien hand who

would reach out to grasp onto different

objects (e.g., door handles) as he was walking

was given a cane to hold in the alien hand

while walking, even though he really did not

need a cane.

REFERENCES:

1. Neurol Sci magazine (2003) 24:252–257 DOI 10.1007/s10072-003-0149-4 by: F. Aboitiz • X. Carrasco • C. Schröter • D. Zaidel • E. Zaidel • M. Lavados

2. Della Sala S, Marchetti C, Spinnler H (1991) Right-sided

anarchic (alien) hand: a longitudinal study. Neuropsychologia


http://en.wikipedia.org/wiki/Sense_of_agency

BY: Mai Al-Kosiry Fifth year medicine (undergraduate)

Treatment of migraine begins with making

a diagnosis, explaining it to the patient and

parents, and making a treatment plan.

Pharmacological therapy is often justified for

headaches of moderate and severe intensity

accompanied by significant disability and

prominent nausea.

Acute (Abortive) treatment requires an

individually tailored approach; medication

should be taken as soon as possible in

appropriate dosage and overuse avoided.

Analgesics and rest are first-line therapy.

Evidence suggests use of

(pharmacological measures):

Paracetamol 10-15mg/kg/dose.

NSAID (ibuprofen) 5-10mg/kg/dose contraindicated in children with asthma.

Triptans (5-hydroxytryptamine agonists) oral and nasal for children.

Nasal sumatryptan (5, 10,20 mgs) should be considered for adolescent older than 12 years ,particularly tryptans should be avoided in children with cardiac disorder or hypertension .

Non-pharmacological measures:

Application of ice to the head.

Sleeping in a quiet dark room and avoiding known triggers.

Bio-behavioral strategies including sleep hygiene regular aerobic exercise , dietary modifications and stress management are often effective

About one-third of children with migraine

report a dietary association and a diet

cause. Common precipitants are cheese,


chocolate, citrus fruit, caffeine, processed

meat, yoghurt, fried foods, monosodium

glutamate, aspartame and alcoholic drinks.

Regular meals should be encouraged and

meal skipping should be avoided.

Prevention

Preventive /prophylactic therapy should be

recommended if the child/adolescent has a

minimum of 2 headaches per month that

interfere with lifestyle ( missed school days

or in ability to participate in social activities

.because of the cyclic nature of migraine , the

daily agent should be used for a definitive

period , the recommendation is to provide

treatment through the calendar school year ,

then taper it during the summer vacation .

the quality of evidence available for use of

drug prophylaxis in pediatric migraine is

poor.

Medications which have shown

efficacy include:

Propranolol 1-4mg/kg/day in 3 divided doses , contraindicated in asthma

Amitriptyline (starting with 10 mg dose at night, going up to 25mg for adolescents) this is more effective in children with associated depression.

Uncontrolled data suggest a beneficial effect with flunarizine (calcium-channel blocker), cyprohebtadine, naproxen and anticonvulsants topiramate, divalproex, valproate and gabapentin.

Antiemetics.

Children and adolescent with acute

migraine accompanied by nausea or

vomiting may benefit from anti-emetic

therapy. Use promethazine oral formulation

in case of nausea without vomiting every 4-6

hours as needed. Patients who cannot use

oral acute medications are probably best

treated with nasal spray or injectable

triptans (recommended only for 12 years

and over) domperidone, prochlorperazine

maleate and metoclopramide are also

effective but should be used with caution

because of their potential extrapyramidal

side effects. Injectable antiemetics do have a

role as emergency treatment, but are

probably best restricted to use in 2ry care.

Combination medications are also effective.

In addition to producing an analgesic effect,

these medications may produce alteration of

emotional state, sedation and psychological

dependence. antiemetics can be used in

combination with acute therapies to treat

moderate to severe migraine in children and

adolescents .


Triptans alleviate migrane by blocking the

release of CGRP

By Nora Hassan Abd Abd Elkawy Fifth year medicine (undergraduate)

What is fibromyalgia?

Fibromyalgia is a chronic condition that

causes pain, stiffness, and tenderness of the

muscles, tendons and joints.

Diagnostic criteria for fibromyalgia

According to American college of rheumatology 1990 criteria for the classification of fibromyalgia, The following criteria should be involved : [1]

1. History of wide spread pain

Definition : pain is considered wide spread when all of the following are present : pain in the left side of the body , pain in the right side of the body , pain above the waist , pain below the waist , In addition, axial skeletal pain ( cervical spine or anterior chest or thoracic spine or low back ) must be present .In this definition , shoulder and buttock pain is considered as pain for each involved side .( Low back pain is considered lower segment pain)

2. Pain in 11 of 18 tender point sites on digital palpation

Definition in digital palpation must be present in at least 11 of the following 18 tender point’s sites:

Occiput: bilateral at suboccipital muscle insertion Lower cervical: bilateral at the anterior aspects of the inter transverse spaces at C5-C7 Trapezius: bilateral at the midpoint of the upper border Supraspinatus: bilateral at origins , above the scapula spine near the medial border Second rib: bilateral at the second costochondral junction just lateral to the junction on the upper surfaces Lateral epicondyle: bilateral 2 cm distal to the epicondyles Gluteal: bilateral in upper outer quadrant s of buttocks in anterior fold of muscle Greater trochanter: bilateral posterior to the trochanteric prominence Knee: bilateral at medial fat of pad proximal to the joint line

Digital palpation should be performed with an approximate force of 4 kg for a tender point to be considered (positive) the subject must state that the palpation was painful. (Tender) is not to be considered painful.

For classification purposes patient will said to have fibromyalgia if both criteria are satisfied. Wide spread pain must have present for at least 3 months. The presence of second clinical disorder doesn't exclude the diagnosis of fibromyalgia


The American College of Rheumatology Preliminary Diagnostic Criteria for fibromyalgia. [2]

A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:

1) Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3–6 and SS scale score ≥9. 2) Symptoms have been present at a similar level for at least 3 months. 3) The patient does not have a disorder that would otherwise explain the pain.

Ascertainment

1) WPI: Note the number areas in which the patient has had pain over the last week. In how many areas has the patient had Shoulder girdle, left Hip (buttock, trochanter), left Jaw, left Upper back Shoulder girdle, right Hip (buttock, trochanter), right Jaw, right Lower back Upper arm, left Upper leg, left Chest Neck Upper arm, right Upper leg, right Abdomen Lower arm, left Lower leg, left Lower arm, right Lower leg, right 2) SS scale score:

Fatigue Waking unrefreshed

Cognitive symptoms

For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale: 0. no problem 1. slight or mild problems, generally

mild or intermittent 2. moderate, considerable problems,

often present and/or at a moderate level

3. severe: pervasive, continuous, life-disturbing problems

Considering somatic symptoms in general, indicate whether the patient has: 0. No symptoms 1. Few symptoms 2. A moderate number of symptoms 3. A great deal of symptoms

The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.

Somatic symptoms that might be

considered:

Musculoskeletal Symptoms: muscle pain, fatigue/tiredness, muscle weakness GIT Symptoms: pain/cramps in the abdomen, constipation, pain in the upper abdomen, nausea, diarrhea, dry mouth, vomiting, oral ulcers, loss of/change in taste, loss of appetite, irritable bowel syndrome. CNS symptoms : thinking or remembering problem, headache, numbness/tingling, dizziness, insomnia, depression, nervousness, blurred vision, seizures Others : chest pain, fever, itching, wheezing, Reynaud's phenomenon, hives/welts, ringing in ears, heartburn, dry eyes, shortness of breath, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.

References:

1. Frederick Wolf, Hug A Smith, Mohamed b Yunus, Robert M. Bennett . American college of rheumatology 1990 criteria for the classification of fibromyalgia, The following criteria should be involved. Arthritis and Rheumatism 1990;33:163-169

2. Frederick Wolfe , Daniel J. Clauw, Mary-Ann , Fitzcharles. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity . Arthritis Care & Research 2010;62:600-610


BY: Alaa Omar Fourth year medicine (undergraduate)

Most of the progress made over the past

years for the treatment of chronic

inflammatory and autoimmune diseases is

based on a method for the preparation of

monoclonal antibodies on a large scale, as

published 1975 by Köhler, Milstein and Jerne,

who won the Nobel Prize in 1984. Today,

therapeutic antibodies are essential assets

for physicians fighting cancer, inflammation

and infections.

Diseases where the medication with

monoclonal antibodies have significantly

changed our treatment options for patients

are autoimmune rheumatic diseases such as

rheumatoid arthritis, ankylosing spondylitis,

psoriatic arthritis, juvenile idiopathic arthritis,

psoriasis and chronic inflammatory bowel

diseases such as Crohn's disease. Using

monoclonal antibodies or fusion proteins in

quite a number of these diseases it was

demonstrated not only to block the chronic,

progressive tissue destructive inflammatory

process and to achieve low disease activity

but also in some situations to achieve a

remission. Before the introduction of these

new treatment principles most of these

diseases led very early to a disabling status of

the patient combined with disability to

continue to work, leading to unemployment.

The major targets for the therapeutic

monoclonal antibodies are proinflammatory

cytokines such as tumour necrosis factor

alpha and interleukin-12/interleukin-23.

More recently it has also been demonstrated

that targeting B- or T cells might be

efficacious in treating chronic inflammatory

diseases.

Since, with this new medications, only up to

70% of patients will benefit and partly only to

a limited extend, it is necessary to develop

new and maybe even more specific

medications. These new approaches include

the interference with intracellular signalling

mechanisms, the definition of new molecules

such as cytokines and chemokines and B- and

T cells not only as targets but also with

regard to their immunomodulating capacity

such as regulatory T cells.

"Specifically, the introduction of

monoclonal antibodies in the treatment of

chronic inflammatory diseases is an

outstanding example, how results obtained

by basic science might be translated into

clinical application", says Kalden.

Beside a symposium co-organized by the

National Academy of Science Leopoldina and

EFIS new aspects of immune intervention will

be discussed in a variety of workshops and

symposia during this conference. Now, new

and efficacious therapeutic strategies come

up not only for chronic inflammatory

diseases but also for cancers, specifically

lymphomas and leukemias, and disease

entities such as asthma and sepsis.

13 Journal of Alexandria Medical Students 13 Journal of Alexandria Medical Students

Guidelines of article submission:

Pages: one page for board, not more than three pages for online version, up to

six pages for in-depth window.

Size: A4 document.

Language: English

Title: interesting, clear, related to the topic.

Content: clear, concise, interesting, only in medical field, updated and

undergraduate level.

Editing: 1. Microsoft Word 97-2003 (*.doc) or 2007-2010 (*.docx) format.

2. At least one picture related to the topic.

3. Two columns.

4. 12-point sized font.

5. "Calibri" font.

6. Leave a blank line after each new paragraph.

7. Margins of 2.5cm on all sides.

8. Orientation "Portrait".

9. Revised well …No Misspelled words.

References: should be listed in the order in which they first appear in the

article. The publishable articles will be reviewed by the "board of

supervisors"

Of course, you can share with us with medical comics, crosswords, medical "do you know?" medical notes and case discussion.

Address: Alexandria Faculty of Medicine - Azarita - Alexandria – Egypt.

Website: www.jams-online.com

Email: [email protected]

Facebook group: Journal of Alexandria Medical Students


mailto:[email protected]

http://www.facebook.com/pages/Journal-of-Alexandria-Medical-Students/231574336860054

BY: Mohammed Sabry Rostom Fifth year medicine (undergraduate)

What are enterovirulent E. coli (EEC)?

Enterovirulent Escherichia coli (E. coli) are comprised of a number of serotypes (strains of related bacteria identified by their slightly different antigenic structures) of bacteria that have a strong propensity to cause infections, initially in the gastrointestinal tract ("entero" in Greek means intestine; virulent means deadly or disease-causing). Enterovirulent Escherichia coli (EEC) are members of the bacterial genus Escherichia, named after T. Escherich, who first isolated the bacteria in 1885. The majority of the genus Escherichia is composed of one species termed "coli" (Latin for colon); however there are over 700 serotypes of this bacterial species.

Escherichia coli (E. coli) are gram-negative bacteria that are rod-shaped, have the ability to survive in aerobic and anaerobic environments (termed a facultative anaerobe), and may or may not produce

flagella and pili (thin hair-like projections) depending on environmental needs.

E. coli strains are found worldwide and live in significant numbers in humans and other animals as part of the normal bacterial population found in their large intestines. The organisms have likely co-existed with humans for eons in the normal flora (bacterial populations usually found in healthy individuals) of human and other animal colons. However, among the 700 strains of E. coli, there are a few strains that cause disease. These E. coli strains are some of the most frequent causes of many common bacterial infections, including diarrhea, cholecystitis, bacteremia, cholangitis, urinary tract infection (UTI), traveler's diarrhea, and other clinical infections such as neonatal meningitis, pneumonia, abdominal abscesses and hemolytic uremic syndrome (HUS).

A classic example of such an E. coli strain is E. coli 0157:H7. The name E. coli 0157:H7 seems complex; however scientists use the numbers and letters to specifically designate small differences in E. coli strains. The 0157 is the "O" serotype antigen that identifies one of the over 700 strains and the "H" of H7 represents the antigen type on the bacterium's flagella. Some E. coli also possess K antigens (protein/polysaccharide surface components) that have been used to identify certain strains. These designations (O, H, and K) may be used to identify strains causing specific diseases and have been utilized to identify outbreaks of disease.


What are the symptoms caused by enterovirulent E. coli (EEC)?

The major symptom that all enterovirulent E. coli (EEC) produce in common is diarrhea. However, the type of diarrhea (for example, bloody, chronic, or self-limiting) and the complications that may accompany the infections differ from each other. Similarities of symptoms have caused researchers and clinicians to arrange E. coli serotypes into groups according to their symptoms and common pathogenic mechanisms. Depending on which research or clinical physicians publications are read, there are 4 to 6 groups of E. coli that comprise all of the enterovirulent E. coli (EEC). Unfortunately, some investigators have more than one term for some members of the groups. The following is a summary of the groups that are

currently in the literature and the symptoms group members cause:

EHEC (enterohemorrhagic E. coli): bloody diarrhea, hemorrhagic colitis, hemolytic uremic syndrome (HUS), and thrombotic thrombocytopenic purpura (TTP); additional terms for EHEC are VTEC and STEC which stand for Vero toxin-producing E. coli and Shiga toxin-producing E. coli, respectively. One serotype, E. coli 0157:H7 is responsible for the

majority of the bloody diarrhea that occurs due to the production of Shiga toxins.

ETEC (enterotoxigenic E. coli): traveler's diarrhea, a watery diarrhea with nausea, abdominal cramping, and fever, caused by several serotypes of E. coli (0169:H47, 0148:H28 and several others) that produce two toxins that cause the gastrointestinal tract to secrete fluid (secretory exotoxins)

EPEC (enteropathogenic E. coli): childhood diarrhea, caused by E. coli bacteria (many different serotypes) that can attach to gastrointestinal tissues, especially in infants, and produces a watery or bloody diarrhea in infants by producing a toxin similar to that produced by the bacterium named Shigella dysenteriae.

EIEC (enteroinvasive E. coli): Shigella-like dysentery with blood and mucus, due to E. coli that invade epithelial cells of people of all ages, also producing vomiting, fever and chills. These serotypes are closely related to Shigella spp. (a few children develop HUS)

EAEC (enteroadherent E. coli): childhood watery diarrhea, some cases of traveler's diarrhea in adults, and some urinary tract infections. This group is composed of E. coli strains (for example, 0119 or 055) that are able to adhere to human cells (gastrointestinal and other cell types). About one-half of this group are able to cause mild diarrhea, usually in children, while other E. coli serotypes that can adhere, do not cause any disease. Like EAggEC, these enteroadherent E. coli do not produce any Shiga toxins or secretory-causing exotoxins.

18Journal of Alexandria Medical Students

Picture taken with electron microscope shows

EHEC bacteria

http://www.medicinenet.com/script/main/art.asp?articlekey=110403



EAggEC (enteroaggregative E. coli): persistent diarrhea in developing countries especially in children that usually lasts more than 14 days. The diarrhea is watery, mucus-containing, and in about one-third of individuals, bloody. Those with EAggEC usually have only a low fever (less than 101 F or 38.3 C) and almost no vomiting. These E. coli serotypes (for example, 042 and 044) do not produce any Shiga toxins or secretory exotoxins that cause secretions but cause intestinal inflammation that is linked to abnormally high intestinal secretion that leads to watery diarrhea. These strains are unique because they "aggregate" (form small masses comprised of cultured tissue cells and bacteria) human gastrointestinal cells by attaching via fimbriae (pili).

As one can surmise, there are unfortunate

overlaps in disease syndromes and that is

one reason that authors disagree on the

actual number of groups (EPEC, EAEC, and

EAggEC or EACE and EAggEC are often

lumped together). It seems unlikely that the

group names will remain stable in the future.

How do enterovirulent E. coli groups cause disease?

In general, all EEC groups cause disease by disruption of the normal secretory mechanisms of the intestines which leads to diarrhea. As outlined above, different groups use different methods that ultimately results in diarrhea; the type of diarrhea and the intensity of the disease are related to the mechanisms used by the bacteria.

EHEC secrete Shiga toxins that can not only destroy intestinal cells, but can be spread to other organ systems to cause additional disease. E. coli 0157:H7 is the major EHEC pathogen responsible and is considered to be one of the most virulent organisms in all of the EEC groups because of Shiga toxin production.

EPEC group organisms also can produce a toxin closely related to Shigella toxin that has many of the same properties of Shiga toxin although the serotypes cause the disease (sometimes milder) mainly in children.

The ETEC group does not produce Shiga toxins or their closely related toxins, but ETEC do produce two other exotoxins that stimulate the intestines to secrete fluid and mucus.

EIEC organisms, these bacteria have the ability to penetrate the epithelial cells that line areas of the human intestines. EIEC organisms then cause many of the cells to lyse thus disrupting the fluid adsorption and secretion capacity of the intestines.

Both EAEC and EAggEC groups of

bacteria, by attaching to intestinal cells,

cause irritation or inflammation of the

intestinal cells. This physiologic and

immunologic response also disrupts

adsorption and secretion in the

intestines.


A nurse cares for a patient infected with virulent

E. coli and undergoing dialysis treatment

A new EEC group? (The E. coli 0104:H4 outbreak in Germany)

It recently arose in Germany in early 2011 and has now been documented in 11 European countries. In most people, the exposure to the infection source occurred while people were visiting Germany, most likely through contaminated food (salads).

The strain has been identified as E. coli 0104:H4 (also termed STEC 0104:H4). As stated in the previous paragraph, there are unfortunate overlaps in ECC caused disease and this new strain seems to exhibit some of the worst overlap features of the ECC group members. For example, E. coli 0104:H4 is reported to contain about 93% of the genome of EHEC and produces the Shiga (Vero) toxin; however, it also seems to have the ability like EAEC strains to attach well to gastrointestinal cells.

Currently, the outbreak is the third largest ever reported for E. coli (about 2200 infected patients) and the most lethal (at least 22 dead as of 6/6/2011). In addition, most strains isolated are resistant to multiple antibiotics (aminoglycosides, macrolides and Beta-lactams). The source of the infection may be contaminated bean sprouts grown organically and then shipped to many German restaurants. One major difference in E. coli 0104:H4 from other E. coli that cause hemolytic uremic syndrome or HUS (mainly E. coli 0157:H7) is that the organism is causing HUS in young adult females and other adults. Often, HUS caused by E. coli 0157:H7 is seen in children and the elderly,

not relatively healthy adults. However, this outbreak of E. coli 0104:H4 is still new and being studied intensively; other differences may become evident as time progresses.

The most recent (June 3, 2011) guidelines from the CDC are as follows:

It is not recommended to give antibiotics to patients with suspected STEC infections until complete diagnostic testing can be performed and STEC infection is ruled out. Some studies have shown that administering antibiotics in patients with STEC infections might increase their risk of developing HUS. However, clinical decision making must be tailored to each individual patient. There may be indications for antibiotics in patients with severe intestinal inflammation if perforation is of concern. Of note, isolates of STEC O104:H4 from patients in Germany have demonstrated resistance to multiple antibiotics.

German Health Minister wears a protective mask as he visits an isolation area of the

university hospital Eppendorf in Hamburg on 5th June, 2011




Physician checks the infusion of an E. coli

patient undergoing a kidney dialysis

Guidelines to ensure as complete as possible detection and characterization of STEC infections include the following:

All stools submitted for testing from patients with acute community-acquired diarrhea should be cultured for STEC O157:H7. These stools should be simultaneously assayed for non-O157 STEC with a test that detects the Shiga toxins or the genes encoding these toxins.

Clinical laboratories should report and send E. coli O157:H7 isolates and Shiga toxin-positive samples to state or local public health laboratories as soon as possible for additional characterization.

Specimens or enrichment broths in which Shiga toxin or STEC are detected, but from which O157:H7 STEC isolates are not recovered, should be forwarded as soon as possible to a state or local public health laboratory so that non-O157:H7 STEC can be isolated.

It is often difficult to isolate STEC in stool by the time a patient presents with HUS. Immunomagnetic separation (IMS) has been shown to increase recovery of STEC from HUS patients. For any patient with HUS without a culture-confirmed STEC infection, stool can be sent to a public health laboratory that performs IMS

or to the CDC (through a state public health laboratory). In addition, serum can be sent to CDC (through a state public health laboratory) for serologic testing of common STEC serogroups.

All patients with Shiga toxin-positive diarrheal illness or HUS should be reported to health departments, regardless of a travel history to Germany.

The benefits of adhering to the recommended testing strategy include early diagnosis, improved patient outcome, and detection of all STEC serotypes.

The outbreak is already considered the third-largest involving E. coli in recent world history, and it may be the deadliest. Twelve people died in a 1996 Japanese outbreak that reportedly sickened more than 9,000, and seven died in a Canadian outbreak in 2000.

references

CDC.gov. CDC Health Advisory: Notice to Health Care Providers — Shiga Toxin-producing E. coli O104 (STEC O104:H4) Infections in U.S. Travelers Returning from Germany. June 3, 2011. Itskowitz , M., Bacterial Diarrhea, N. Engl. J. Med., 2010; 362:558-559, 2010 Sodha SV, Griffin PM, Hughes JM. Foodborne Disease. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone, Chapter 99, 2009


Physician checks the infusion of an E. coli

patient undergoing a kidney dialysis

Mohammed Abd-Rabboh Attia

Fifth Year Medicine (Undergraduate)

Robotic surgery has the potential to

eliminate tremor and enhance dexterity, significantly improving upon the precision of unassisted human hands. Although it has revolutionized many surgical specialties, robot-assisted surgery has yet to make clinical inroads in ophthalmology. Demands for greater precision from robots, as well as smaller size and better maneuverability inside the eye, have all raised the bar for designers of robotics systems in the ophthalmic OR (operational

research). This tiny device is small enough to be injected into the eye without anesthetic. And could be how eye surgery is performed in the future according to its developers. The team at the Swiss Federal Institute of Technology in Zurich, say the size of their robots could herald a new type of non-invasive surgery. Professor of robotics and intelligent systems at ETH is Brad Nelson says, “Our first

applications are in targeted delivery, treating diseases like age-related macular degeneration or retinal vein occlusions in which we try to deliver drugs to specific locations on the retina.” The device is essentially a tiny magnet, which is controlled by an electro-magnetic field outside the eye.

“It requires that we very precisely control

the fields and the currents through our electro-magnets and being able to do that and do that in a stable, controlled fashion has been a challenge – something we’ve been able to over-come here in the last couple of years,” said Nelson. So far, the research has used the synthetic eyes or the eyes of dead animals. This is the eye of dead pig. But they do have plans to move onto living animal trials, followed by human trials. Nelson says, “If we can make it small enough to fit in a 23 gauge needle it can actually be injected into the eye with just topical anesthetic or even no anesthetic and

it doesn’t also require a suture.” In 1966, the science-fiction film Fantastic Voyage saw a submarine miniaturized and injected into a vein… 45 years on, it sounds less far-fetched. Bottom line: Researchers in Switzerland are perfecting a robot small enough to be injected into your eye without anesthetic. The team says their device could carry drugs to the exact position they are needed or even carry out minor operations.


Bassem Mohamed AbdelGhany Fifth year undergraduate

What is it? A new approach treats recurrent

glioblastoma multiforme (GBM). The

NovoTTF-100A System is a portable battery

or power-supply operated device which

produces changing electrical fields, called

tumor treatment fields (“TTFields”) within

the human body. TTFields are applied to the

head of the patient by electrically-insulated

surface electrodes.

TTFields stop the growth of tumor cells

resulting in cell death of the rapidly dividing

cancer cells. The geometrical shape and

scattering of the electrical charges within

the dividing tumor cells allows TTF electrical

fields to physically break up the tumor cell

membrane. The frequency of the TTFields

used for a particular treatment is specific to

the size of the cell type being treated.

It is intended as a treatment for adult

patients (22 years of age or older) with

confirmed glioblastoma multiforme,

following confirmed recurrence in an upper

region of the brain (supratentorial) after

receiving chemo-therapy. The device is

intended to be used as a second line therapy

after the standard medical therapy for

recurrent GBM after surgical and radiation

options have been exhausted.

Device-treated subjects experienced a lower

frequency of the classic adverse events as

seen with chemotherapy (such as,

gastrointestinal, hematological and infectious

adverse events) with best standard of care.

Quality of life surveys indicated an improved

quality of life in the device recurrent GBM

subjects compared to the best standard of

care recurrent GBM subjects.

When should it not be used? The device

should NOT be used in patients with any of

the conditions below that apply:

An active implanted medical device or a

skull defect. Use of the device together with

implanted electronic devices has not been

tested and may theoretically lead to

malfunctioning of the implanted device. Use

of the device together with implanted

medical devices or skull defects (that is,

missing bone with no replacement), a shunt,

or bullet fragments has not been tested and

may possibly lead to tissue damage or cause

the device stimulation ineffective.

Examples of active electronic devices

include: deep brain stimulators, spinal cord

stimulators, vagus nerve stimulators,

pacemakers, defibrillators, and

programmable shunts

Any known sensitivities to conductive

hydrogels like the gel used on

electrocardiogram (ECG) stickers or TENS

(transcutaneous electrical nerve

stimulation) electrodes.

References:

http://www.accessdata.fda.gov/cdrh_docs/pdf10/p100034a.

pdf


Prof. Hesham sheshtawy ASS. Prof. of neuropsychiatric

Is it a new term you are hearing for the first

time in your life or you have heard about it

before? Before continuing reading this

article, please ask yourself what do you know

about this term? Yes you heard before about

"intelligence", but "emotional intelligence"

may be a new term for some of us. "by the

way it was the first time to me to hear about

it just 2 years ago". So, what is meant by

"emotional intelligence"? Simply it is the art

of dealing with emotions either our emotions

or emotions of others.

What is the importance of

it? In 2001, Harvard

University published a

research that was done on

those who are eminent in

their fields. The researchers

found that 7 % of their

eminence was attributed to

"knowledge in their fields"

and 93% of their eminence

was attributed to "emotional

intelligence". You can

observe that in the real life.

You can hear a sentence like

"My marks in the college were better than

him but now he is my boss!" No it is not

always due to corruption but emotional

intelligence play a major role.

Peter Solvey and John Meiyer said that

emotional intelligence has 5 components:

1. Self-awareness.

2. Control of the self-emotions.

3. Self-motivation.

4. Empathy.

5. Social intelligence.

To be continued… Keep in Touch…


Dr. Nihal El Habachi ASS. Prof. of Physiology and Director of Alex. CRC

Uses of Clinical Trials Treatment: test experimental

treatments, combinations of drugs, new approaches.

Prevention: look for better way to prevent disease or its recurrence.

Diagnostic: develop better tests.

Screening: to detect diseases or health conditions.

Quality of Life (or Supportive Care): improve comfort and QOL in chronic disease states.

Clinical Trial Design

Example:

• In early smaller studies, where the drug is being tested for safety and dose, each person who participates gets the new drug being tested.

• In the following larger trials, doctors compare the new drug with another treatment to see which works better on participants.

• The later larger trials, may work like this:

a) One group of participants gets the new drug.

b) The other group gets a drug that is used to treat the problem or gets a

“look alike” pill that contains no drug (called a placebo)

Doctors then compare the progress of the two groups to see if the participants who got the new drug had better results than people in the other group. Did their symptoms improve? Did they stay healthy longer? Did they have side effects from the

drug?

These are some of the questions that clinical trials answer.

Common Clinical Trial Terms

CONTROLLED STUDY: A study in which a test article is compared with a treatment that has known effects. A test drug is given to one group of

people. This group is often called the “treatment group.”

Another drug, or no drug, is given to a second group of people with the same illness. This is often called the “control group.”

Then the results of the two groups are compared.

PLACEBO: A pill, liquid, or powder that contains no drug and has no treatment value. A placebo looks just like the real drug.

Randomized Study: A study that assigns research subjects to one or more treatment or control groups by chance in order to reduce bias.

Blinded Study: A study in which the research subject or the investigator (or both) are unaware of what trial product the subject is taking

Single-Blinded: Subjects do not know what treatment they are getting but their research doctor and team do.

Double-Blinded: Neither the subject nor the research doctor knows which treatment the subject is getting.

To be continued… Keep in Touch…


By: Mohammed Abd El-fattahFifth Year Medicine (Undergraduate)

Robert Edwards is awarded the 2010

Nobel Prize for the development of human in vitro fertilization (IVF) therapy. His achievements have made it possible to treat infertility, a medical condition afflicting a large proportion of humanity including more than 10% of all couples worldwide.

As early as the 1950s, Edwards had the vision that IVF could be useful as a treatment for infertility. He worked systematically to realize his goal, discovered important principles for human fertilization, and succeeded in accomplishing fertilization of

human egg cells in test tubes (or more precisely, cell culture dishes). His efforts were finally crowned by success on 25 July, 1978, when the world's first "test tube baby" was born. During the following years, Edwards and his co-workers refined IVF technology and shared it with colleagues around the world.

Approximately four million individuals have so far been born following IVF. Many of them are now adult and some have already become parents. A new field of medicine has emerged, with Robert Edwards leading the

process all the way from the fundamental discoveries to the current, successful IVF therapy. His contributions represent a milestone in the development of modern medicine.

Basic research bears fruit The British scientist Robert Edwards began his fundamental research on the biology of fertilization in the 1950s. He soon realized that fertilization outside the body could represent a possible treatment of infertility.

Other scientists had shown that egg cells from rabbits could be fertilized in test tubes when sperm was added, giving rise to offspring. Edwards decided to investigate if similar methods could be used to fertilize human egg cells.

It turned out that human eggs have an entirely different life cycle than those of rabbits. In a series of experimental studies conducted together with several different co-

workers, Edwards made a number of fundamental discoveries. He clarified how human eggs mature, how different hormones regulate their maturation, and at which time point the eggs are susceptible to the

fertilizing sperm. He also determined the conditions under which sperm is activated and has the capacity to fertilize the egg. In 1969, his efforts met with success when, for the first time, a human egg was fertilized in a test tube.

In spite of this success, a major problem remained. The fertilized egg did not develop beyond a single cell division. Edwards suspected that eggs that had matured in the ovaries before they were removed for IVF would function better, and looked for


possible ways to obtain such eggs in a safe way.

From experiment to clinical medicine Edwards contacted the gynecologist Patrick Steptoe. He became the clinician who, together with Edwards, developed IVF from experiment to practical medicine. Steptoe was one of the pioneers in laparoscopy, a technique that was new and controversial at the time. It allows inspection of the ovaries through an optical instrument. Steptoe used the laparoscope to remove eggs from the ovaries and Edwards put the eggs in cell

culture and added sperm. The fertilized egg cells now divided several times and formed early embryos, 8 cells in size (see figure).

These early studies were promising but the Medical Research Council decided not to

fund a continuation of the project. However, a private donation allowed the work to continue. The research also became the topic of a lively ethical debate that was initiated by Edwards himself. Several religious leaders, ethicists, and scientists demanded that the project be stopped, while others gave it their support.

The birth of Louise Brown - a historic event Edwards and Steptoe could continue their research thanks to the new donation. By analyzing the patients' hormone levels, they could determine the best time point for fertilization and maximize the chances for success. In 1977, Lesley and John Brown came to the clinic after nine years of failed attempts to have a child. IVF treatment was carried out, and when the fertilized egg had developed into an embryo with 8 cells, it was returned to Mrs. Brown. A healthy baby, Louise Brown, was born through Caesarian section after a full-term pregnancy, on 25 July, 1978. IVF had moved from vision to reality and a new era in medicine had begun.

IVF is refined and spreads around the world Edwards and Steptoe established the Bourn Hall Clinic in Cambridge, the world's first center for IVF therapy. Steptoe was its medical director until his death in 1988, and Edwards was its head of research until his retirement. Gynecologists and cell biologists from all around the world trained at Bourn Hall, where the methods of IVF were continuously refined. By 1986, 1,000 children had already been born following IVF at Bourn Hall, representing approximately half of all children born after IVF in the world at that time.

Today, IVF is an established therapy throughout the world. It has undergone several important improvements. For example, single sperm can be microinjected directly into the egg cell in the culture dish. This method has improved the treatment of male infertility by IVF. Furthermore, mature eggs suitable for IVF can be identified by ultrasound and removed with a fine syringe rather than through the laparoscope.


IVF is a safe and effective therapy. 20-30% of fertilized eggs lead to the birth of a child.

Complications include premature births but are very rare, particularly when one egg only is inserted into the mother. Long-term follow-up studies have shown that IVF children are as healthy as other children.

Approximately four million individuals have been born thanks to IVF. Louise Brown and several other IVF children have given birth to children themselves; this is probably the best evidence for the safety and success of IVF therapy. Today, Robert Edwards' vision is a reality and brings joy to infertile people all over the world.

Robert G. Edwards

He was born in 1925 in Batley, England. After military service in the Second World War, he studied biology at the University of Wales in Bangor and at Edinburgh University in Scotland, where he received his PhD in 1955 with a Thesis on embryonal development in mice. He became a staff scientist at the National Institute for

Medical Research in London in 1958 and initiated his research on the human fertilization process. From 1963, Edwards worked in Cambridge, first at its university and later at Bourn Hall Clinic, the world's first IVF center, which he founded together with Patrick Steptoe. Edwards was its research director for many years and he was also the editor of several leading scientific journals in the area of fertilization. Robert Edwards is currently professor emeritus at the University of Cambridge.

References:

Edwards RG. Maturation in vitro of human ovarian oocytes. Lancet 1965; 2:926-929.

Edwards RG, Bavister BD, Steptoe PC. Early stages of fertilization in vitro of human oocytes matured in vitro. Nature 1969; 221:632-635.

Edwards RG, Steptoe PC, Purdy JM. Fertilization and cleavage in vitro of human oocytes matured in vivo. Nature 1970; 227:1307-1309.

Steptoe PC, Edwards RG. Birth after the reimplantation of a human embryo. Lancet 1978; 2:366.

Edwards RG. The bumpy road to human in vitro fertilization. Nature Med 2001; 7:1091-4.


It's your turn now… Do you want to share with us???

Here, we will discuss new cases …and think about them …and sometimes

know how to deal with them…

Compete with your colleagues … who will answer these cases first??

Let us discuss …and compete with us!!!

1-An old patient presented in emergency ward with history of weakness of

the right side of the body of rapid onset. The most helpful first line

investigation for management of this

patient is:

a) Cerebral angiography.

b) Cerebro-spinal fluid

examination.

c) CT scan.

d) Nerve conduction study.

2-A forty years old lady gives history of

weight gain and hoarseness of voice.

On examination her pulse is 64 / min

and skin is pale, coarse and dry. The

most important investigation to find

diagnosis in this case is:

A) ACTH.

B) Cortisol level.

C) Gonadotrophins level.

D) Thyroid function test.

E) Insulin like growth factor.

We will discuss the answers in the next issue...

Keep in touch

By: Yehia Atitto Mohammmed Fifth Year Medicine (Undergraduate)

The winner in first issue is

Mohamed Tarek Rashed 4th year IUMP (The international

undergraduate medical program)

Send your answers to us. And be the first

one to share.

Send to our e-mail

[email protected]


We want to thank all our professors who help and encourage us in this issue

and the board of professors who revise the articles and of course the

management of our faculty.

Also we want to thank our colleagues who participate in release of the first

and the second issues of JAMS and who help jams to get out into the light…

Alyaa Adel.

Amr El-Daqaq.

Amr Youssef Sharaf.

Bassem Mohammed AbdelGhany.

Basem Gamal.

Mai Mohammad Mansour.

Mai Al Kosiry.

Mohammed Abd Elfattah.

Mohamed Abd El-Moneim Ghonaim.

Mohammed Abd-Rabboh Attia (MAAB).

Mohammed El-Nemr.

Mohammed Eliwa.

Mohammed Esaam Abdou.

Mohammed Kamal Seliman.

Mohammed Mostafa Abd El-Hameed.

Mohammed Saad.

Mohammed Sabry Rostom.

Mohammed Seif El-Nassr.

Mohammed Tarek Rashed.

Mohammed Wagdi.

Mohammed Zaatout.

Nora Hassan Abd El-Kawy.

Yehia Attito Mohamed.


http://www.facebook.com/Mohammed.AbdRabboh

jams-second issue "summer issue" -july 2011

Documents

medical journal

medical technology

medical news

medical topics

alexandria university

present medical articles

professor of ent

professor of pediatrics