Infected pancreatic pseudocyst following severe dengue infection.

Severe dengue infection is life threatening as it can result in fatal complications such as intractable bleeding from coagulopathy, multiorgan failure from shock and haemophagocytic syndrome. There have been case reports of atypical manifestation of severe dengue infection such as pancreatitis, Guillian-Barre's syndrome, perforated viscus and myocarditis. However, to our knowledge, pancreatic pseudocyst from dengue-related pancreatitis has never been reported in the literature. We hereby report a case of infected pancreatic pseudocyst in a patient with persistent pyrexia, abdominal pain and raised inflammatory markers 10 weeks from the onset of severe dengue infection. Endoscopic ultrasound (EUS) guided transluminal drainage of the infected pancreatic pseudocyst with lumen-apposing metallic stent (LAMS) was performed with good clinical and radiological outcome.

Resistant hypertension during antituberculosis treatment: how is rifampicin implicated?

A 67-year-old mental institute resident was treated for smear-positive pulmonary tuberculosis. His background history included chronic essential hypertension which was well-controlled with amlodipine 10mg daily. However, his blood pressure became suboptimal one week into antitubercular treatment, necessitating escalation of antihypertensive therapy up to six medications. Following completion of antitubercular treatment, his blood pressure improved markedly. The number of antihypertensives was able to be reduced to only two after a month. We postulate that rifampicin has attenuated the therapeutic effect of amlodipine via potent induction of hepatic CYP3A4 but the failure to control the blood pressure even with medications unrelated to cytochrome P450 pathways raises the spectre of an additional interaction.

Correction to: In utero exposure to gestational diabetes and adiposity: does breastfeeding make a difference?

In the original version of this article, the Publisher incorrectly listed the affiliation of the author, G.M. Leung. The correct affiliation for this author should be: School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Immuno-oncology for surgeons.

Cancer has traditionally been treated with surgery, cytotoxic chemotherapy and/or radiotherapy. The focus of treatment has been the mutated neoplastic cell. Critical advances in genomic and molecular techniques herald the potential for personalized treatments. Incremental breakthroughs in immunology have translated to a step-change in care by providing a mechanistic understanding of the immune system and how it may be mobilized to target cancer cells. As a result, clinical trials of immune-modifying agents have increased at an exponential rate and are revolutionizing cancer care. It is increasingly likely that the surgical oncologist will find themself caring for patients who have had immuno-oncology therapies as part of their neoadjuvant or adjuvant treatment. This review provides an update on immuno-oncology for the surgeon, covering the mechanisms of action of the agents in use. Emerging and surgically relevant toxicities are discussed, and available data on combining and sequencing cancer surgery with immuno-oncology treatments are summarized.

El paradigma del tratamiento del cáncer está evolucionando rápidamente. Tradicionalmente, el cáncer se ha tratado con cirugía, quimioterapia citotóxica y/o radioterapia, pero el foco de atención de su tratamiento se ha polarizado en las mutaciones que dan lugar a la célula neoplásica. Los progresos fundamentales en las técnicas genómicas y moleculares han precedido a los tratamientos personalizados y fármacos dirigidos a dianas terapéuticas, pero los resultados de ensayos clínicos con dichos fármacos han sido en general decepcionantes. En los últimos años, los avances rigurosos y progresivos en inmunología se han traducido en un cambio sustancial en el tratamiento al proporcionar una comprensión mecanicista de cómo interviene el sistema inmune y cómo puede movilizarse mejor para atacar a las células cancerosas. Como resultado, las indicaciones y ensayos clínicos con fármacos modificadores del sistema inmune han aumentado a un ritmo exponencial y están revolucionando el tratamiento del cáncer. Por consiguiente, cada vez es más probable que los cirujanos oncólogos se encuentren tratando pacientes que recibirán terapias inmunooncológicas (immuno-oncology, IO) como parte de los tratamientos neoadyuvantes o adyuvantes. Esta revisión describe y proporciona una guía concisa y exhaustiva de la IO, abarcando los mecanismos de acción de los fármacos en uso. Se discuten las nuevas toxicidades con relevancia para la cirugía y se resumen los datos disponibles sobre la combinación y secuencia de la cirugía oncológica con los tratamientos IO.

In utero exposure to gestational diabetes and adiposity: does breastfeeding make a difference?

BACKGROUND/OBJECTIVES: Short-term breastfeeding from mothers with gestational diabetes (GDM) may programme metabolism and increase offspring diabetes risk. We examined the association of in utero GDM exposure with adiposity from infancy to adolescence, and whether any association was modified by breastfeeding during early infancy. METHODS: In the prospective Chinese birth cohort "Children of 1997" (n = 7342, 88% follow-up rate), generalised estimate equations with multiple imputation were used to assess associations of in utero GDM exposure with age- and sex-specific body mass index (BMI) z-score during infancy (3 and 9 months), childhood (2- < 8 years) and adolescence (8-16 years), adjusted for sex, parity, maternal age, birth place, preeclampisa, smoking, and family socio-economic position. We also tested whether the associations differed by mode of infant feeding (always formula-fed, mixed, always breastfed) during the first three months of life. RESULTS: In utero GDM exposure (7.5%) was associated with a lower BMI z-score during infancy (-0.13, 95% confidence interval (CI) -0.22, -0.05) but higher BMI z-scores during childhood (0.14, 95% CI 0.03, 0.25) and adolescence (0.25 95% CI 0.11, 0.38). Breastfeeding for the first three months did not modify the association of in utero GDM status with subsequent BMI (all p values for interaction >0.4). CONCLUSIONS: In utero GDM exposure was associated with greater adiposity during childhood and adolescence. Breastfeeding in early infancy from mothers with GDM was not associated with greater adiposity in children and thus should still be encouraged.

Okur-Chung neurodevelopmental syndrome: Eight additional cases with implications on phenotype and genotype expansion.

Okur-Chung syndrome is a neurodevelopmental condition attributed to germline CSNK2A1 pathogenic missense variants. We present 8 unreported subjects with the above syndrome, who have recognizable dysmorphism, varying degrees of developmental delay and multisystem involvement. Together with 6 previously reported cases, we present a case series of 7 female and 7 male subjects, highlighting the recognizable facial features of the syndrome (microcephaly, hypertelorism, epicanthic fold, ptosis, arched eyebrows, low set ears, ear fold abnormality, broad nasal bridge and round face) as well as frequently occurring clinical features including neurodevelopmental delay (93%), gastrointestinal (57%), musculoskeletal (57%) and immunological (43%) abnormalities. The variants reported in this study are evolutionary conserved and absent in the normal population. We observed that the CSNK2A1 gene is relatively intolerant to missense genetic changes, and most variants are within the protein kinase domain. All except 1 variant reported in this cohort are spatially located on the binding pocket of the holoenzyme. We further provide key recommendations on the management of Okur-Chung syndrome. To conclude, this is the second case series on Okur-Chung syndrome, and an in-depth review of the phenotypic features and genomic findings of the condition with suggestions on clinical management.

Observation of Anomalous Meissner Screening in Cu/Nb and Cu/Nb/Co Thin Films.

We have observed the spatial distribution of magnetic flux in Nb, Cu/Nb, and Cu/Nb/Co thin films using muon-spin rotation. In an isolated 50-nm-thick Nb film, we find a weak flux expulsion (Meissner effect) which becomes significantly enhanced when adding an adjacent 40 nm layer of Cu. The added Cu layer exhibits a Meissner effect (due to induced superconducting pairs) and is at least as effective as the Nb to expel flux. These results are confirmed by theoretical calculations using the quasiclassical Green's function formalism. An unexpected further significant enhancement of the flux expulsion is observed when adding a thin (2.4 nm) ferromagnetic Co layer to the bottom side of the Nb. This observed cooperation between superconductivity and ferromagnetism, by an unknown mechanism, forms a key ingredient for developing superconducting spintronics.

Supplement of autologous ooplasm into porcine somatic cell nuclear transfer embryos does not alter embryo development.

Somatic cell nuclear transfer (SCNT) is considered as the technique in which a somatic cell is introduced into an enucleated oocyte to make a cloned animal. However, it is unavoidable to lose a small amount of the ooplasm during enucleation step during SCNT procedure. The present study was aimed to uncover whether the supplement of autologous ooplasm could ameliorate the oocyte competence so as to improve low efficiency of embryo development in porcine SCNT. Autologous ooplasm-transferred (AOT) embryos were generated by the supplementation with autologous ooplasm into SCNT embryos. They were comparatively evaluated with respect to embryo developmental potential, the number of apoptotic body formation and gene expression including embryonic lineage differentiation, apoptosis, epigenetics and mitochondrial activity in comparison with parthenogenetic, in vitro-fertilized (IVF) and SCNT embryos. Although AOT embryos showed perfect fusion of autologous donor ooplasm with recipient SCNT embryos, the supplement of autologous ooplasm could not ameliorate embryo developmental potential in regard to the rate of blastocyst formation, total cell number and the number of apoptotic body. Furthermore, overall gene expression of AOT embryos was presented with no significant alterations in comparison with that of SCNT embryos. Taken together, the results of AOT demonstrated inability to make relevant values improved from the level of SCNT embryos to their IVF counterparts.

Infection associated haemophagocytic syndrome in severe dengue infection - a case series in a district hospital.

Haemophagocytic lymphohistiocytosis (HLH) is a potentially fatal disorder resulting from uncontrolled hyperinflammatory response. There had been increase in cases of one of the secondary form of HLH, i.e., infectionassociated haemophagocytic syndrome (IAHS) in severe dengue in recent years. However, the condition remains under diagnosed due to lack of awareness compounded by the lack of validated diagnostic criteria. Severe hepatitis with prolonged cytopenias, severe hyperferritinemia, hypofibrinogenemia and persistent fever were evident in all four cases reported. All the subjects survived with supportive care and adjuvant steroid therapy. Prospective controlled studies are needed to develop diagnostic criteria and management protocol for IAHS in severe dengue.

Perforated gastric ulcer in severe dengue infection: A case report.

Abdominal pain is one of the common presentations in severe dengue infection. We report a rare case of perforated gastric ulcer in a young man diagnosed with severe dengue infection and the challenges we faced in managing this patient. Perforated gastric ulcer need to be considered if there are signs of peritonitis and persistent abdominal pain that does not conform to the natural history of dengue. Proper imaging and early surgical intervention in perforated gastric ulcer is vital in preventing further complication and reducing the risk of mortality.

Childhood physical activity body contact risk: feasibility of a novel technique for objective measurements of impact speed, frequency, and intentionality.

INTRODUCTION: Children at risk for bleeding injuries are restricted from body contact during physical activity but current recommendations are based on expert opinion. AIM: Evaluate high-speed digital video recording as an objective measure of body contact risk during physical activity. METHODS: Observational study of physical activities among healthy children, grouped according to participation in teams (vs. individual) and on their perceived risk of injury (high/low). High speed digital video recordings documented the collision target (floor/ground/ice, people, wall, equipment), estimated speed, and impact rates for team and individual activities, with and without expected body contact. RESULTS: Among 348 participating children (3-16 years, 51% female), 32% to 78% experienced at least one contact. Impact type varied significantly (chi-square, p < 0.001) by activity category. Unstructured and Team high risk activity impacts were primarily with the floor/ground, whereas Individual low risk activities were characterized by equipment impacts. Impact speeds were typically 1.0 to 2.1 m s(-1) . Higher impact speeds occurred during instructional classes (2.1 m s(-1) ), unstructured free swim (1.9 m s(-1) ) and ball hockey (1.7 m s(-1) ). Impact rates were higher during Team high risk and Team low risk sports (3.0 and 1.8 impacts per minute, respectively) compared to Individual (high or low risk) or Unstructured activities (0.2-0.3 impacts per minute). CONCLUSIONS: High speed video recordings of childhood physical activity are a feasible method for characterizing the frequency, type, direction and speed of impacts. Quantifying the impacts that occur during childhood physical activity could inform the guidelines for physical activity participation among children with identified bleeding risks.

Relevance of hepatoduodenal ligament lymph nodes in resectional surgery for gastric cancer.

BACKGROUND: Hepatoduodenal lymph node (HDLN) positivity is considered distant metastasis in gastric cancer according to the seventh American Joint Committee on Cancer (AJCC) classification. In contrast, the International Union Against Cancer seventh edition and the Japanese Gastric Cancer Association both consider HDLN as a regional lymph node that can be included in the context of a curative resection. The purpose of this study was to determine whether there was justification for considering HDLN involvement as a distant metastasis for which resectional surgery could not have survival benefit. METHODS: This study enrolled consecutive patients with gastric cancer having D2 or greater resections, with removal and pathological assessment of the HDLN, between 1989 and 2009. The pathological stage of all patients was determined based on the seventh AJCC criteria, with HDLN included as a regional lymph node. RESULTS: A total of 1872 patients had their HDLN removed, of whom 68 had a metastatic lymph node in the hepatoduodenal ligament. The 5-year survival rate of these 68 patients was 30 per cent, compared with 47·7 per cent for those with stage III (P < 0·001) and 9·8 per cent for those with stage IV (P = 0·007) HDLN-negative tumours. The 5-year survival rate of 41 patients with HDLN metastasis and no evidence of distant metastasis at any other site was significantly higher than that among 120 patients with stage IV disease without HDLN metastasis (P < 0·001), whereas 5-year survival did not differ between the 41 patients with stage I-III disease with HDLN metastasis and 568 patients with stage III tumours without HDLN metastasis (P = 0·184). HDLN metastasis was not a significant factor for survival in multivariable analysis. CONCLUSION: It is inappropriate to include the HDLN in the distant metastatic lymph node group in gastric cancer. The seventh AJCC criteria for node grouping should be revised.

Parkinson disease loci in the mid-western Amish.

Previous evidence has shown that Parkinson disease (PD) has a heritable component, but only a small proportion of the total genetic contribution to PD has been identified. Genetic heterogeneity complicates the verification of proposed PD genes and the identification of new PD susceptibility genes. Our approach to overcome the problem of heterogeneity is to study a population isolate, the mid-western Amish communities of Indiana and Ohio. We performed genome-wide association and linkage analyses on 798 individuals (31 with PD), who are part of a 4,998 member pedigree. Through these analyses, we identified a region on chromosome 5q31.3 that shows evidence of association (p value < 1 × 10(-4)) and linkage (multipoint HLOD = 3.77). We also found further evidence of linkage on chromosomes 6 and 10 (multipoint HLOD 4.02 and 4.35 respectively). These data suggest that locus heterogeneity, even within the Amish, may be more extensive than previously appreciated.

Muon-spin rotation measurements of an unusual vortex-glass phase in the layered superconductor Bi2.15Sr1.85CaCu2O8+δ.

Muon-spin rotation measurements, performed on the mixed state of the classic anisotropic superconductor Bi(2.15)Sr(1.85)CaCu(2)O(8+δ), obtain quantities directly related to two- and three-body correlations of vortices in space. A novel phase diagram emerges from such local probe measurements of the bulk, revealing an unusual glassy state at intermediate fields which appears to freeze continuously from the equilibrium vortex liquid but differs both from the lattice and the conventional high-field vortex glass state in its structure.

Foetal exposure to maternal passive smoking is associated with childhood asthma, allergic rhinitis, and eczema.

OBJECTIVE: We examined the hypothesis that foetal exposure to maternal passive smoking is associated with childhood asthma, allergic rhinitis, and eczema. METHODS. The study was a population-based cross-sectional survey of Hong Kong Chinese children aged ≤14 years carried out in 2005 to 2006. RESULTS. Foetal exposure to maternal passive smoking was significantly associated with wheeze ever (OR 2.05; 95% CI 1.58-2.67), current wheeze (OR 2.06; 95% CI 1.48-2.86), allergic rhinitis ever (OR 1.22; 95% CI 1.09-1.37), and eczema ever (OR 1.61; 95% CI 1.38-1.87). Foetal exposure to maternal active smoking was significantly associated with asthma ever (OR 2.10; 95% CI 1.14-3.84), wheeze ever (OR 2.46; 95% CI 1.27-4.78), and current wheeze (OR 2.74; 95% CI 1.24-6.01) but not with allergic rhinitis ever (OR 1.01; 95% CI 0.70-1.46) or eczema ever (OR 1.38; 95% CI 0.87-2.18). The dose response relationship between wheeze ever and current wheeze with increasing exposure, from no exposure to maternal passive smoking and then to maternal active smoking, further supports causality. CONCLUSION. There is significant association between foetal exposure to maternal passive smoking and maternal active smoking with childhood asthma and related atopic illnesses. Further studies are warranted to explore the potential causal relationship.

Clinicians' knowledge, beliefs and acceptance of intravenous-to-oral antibiotic switching, Hospital Pulau Pinang.

A cross-sectional study was conducted to explore clincians' baseline knowledge, practice beliefs and acceptance of intravenous (IV)-to-oral antibiotic switching practice in Hospital Pulau Pinang. The factors most highly rated for antibiotic conversion were the ability to maintain oral intake (85.6%) and microbiology etiology (85.0%). Majority of the clinicians (76%) agreed with the traditional clinical rule that "patient should be afebrile for 24 hours before IV-to-oral switch". Specialists and consultants had the highest knowledge score among the clinicians. However, they were generally less positive about a guideline being integrated into practice.