High regeneration may not contribute to the forest's carbon storage: a case study in the mangrove forest of Rajang-Belawai-Paloh delta, Sarawak.

The alarming rate of the mangrove ecosystem loss poses a threat of losing valuable carbon sinks. This study was conducted to (i) determine the growth structure in different vegetation types and (ii) compare the aboveground biomass (AGB) and carbon storage in different vegetation types. The study was conducted at four vegetation types within the Rajang-Belawai-Paloh delta i.e., Matured Bakau-Berus Forest (MBBF), Bakau-Nipah Forest (BNF), Regenerating Forests (Debris pile) [RF-D], and Regenerating Forests (Machinery track) [RF-M]. Inventory plots (20 m × 20 m) are systematically located along the main waterways and smaller rivers/streams. Trees (≥ 5 cm diameter-at-breast height [DBH]), seedlings (< 2-cm stem diameter), and saplings (2-4.9-cm stem diameter) were measured. The trend of total trees per hectare is found to be decreasing across the least disturbed vegetation (MBBF) to the most disturbed vegetation (RF-M). The trends of total seedlings and saplings per hectare are found to be going upwards from the least disturbed vegetation to the most disturbed vegetation. Kruskal-Wallis H-test showed that there is a significant difference in the AGB and carbon storage between different vegetation types, χ2(2) = 43.98, p = 0.00 with the highest mean rank AGB and carbon storage in BNF (612.20 t/ha) and lowest in RF-M (287.85 t/ha). It can be concluded that although the most disturbed vegetations have higher regeneration, it may not contribute to the forest's carbon storage The naturally regenerated seedlings may not grow beyond the sapling stage unless sustainable forest management is conducted to ensure survivability and growth.

A novel homozygous truncating variant of NECAP1 in early infantile epileptic encephalopathy: the second case report of EIEE21.

We report the second case of early infantile epileptic encephalopathy (EIEE) arising from a homozygous truncating variant of NECAP1. The boy developed infantile-onset tonic-clonic and tonic seizures, then spasms in clusters. His electroencephalogram (EEG) showed a burst suppression pattern, leading to the diagnosis of Ohtahara syndrome. Whole-exome sequencing revealed the canonical splice-site variant (c.301 + 1 G > A) in NECAP1. In rodents, Necap1 protein is enriched in neuronal clathrin-coated vesicles and modulates synaptic vesicle recycling. cDNA analysis confirmed abnormal splicing that produced early truncating mRNA. There has been only one previous report of a mutation in NECAP1 in a family with EIEE; this was a nonsense mutation (p.R48*) that was cited as EIEE21. Decreased mRNA levels and the loss of the WXXF motif in both the families suggests that loss of NECAP1 function is a common pathomechanism for EIEE21. This study provided additional support that synaptic vesicle recycling plays a key role in epileptogenesis.

A rare presentation of chronic myeloid leukaemia with priapism treated with corporoglandular shunting.

Priapism is a rare clinical presentation of a patient with chronic myeloid leukaemia (CML). Herein, we present a young Nepalese man that presented to the emergency department with an acute and painful penile erection for two days. Clinically, he was pale and abdominal examination revealed hepatomegaly. Combined oncologic and initial urological intervention with carvernosal aspiration and intracavernosal phenylephrine failed to achieve detumescence. The patient underwent an emergency corporoglandular shunting eventually. In this case report, we discuss the management compared with previously reported cases.

Major tracheobronchial injuries: Management of two rare cases.

Tracheobronchial injuries are uncommon and a high level of suspicion is needed for immediate diagnosis and prompt treatment. In this case series, two rare cases of tracheobronchial injuries is described showing variable clinical presentations with different levels of injury. Our first case was seen in a 20 years old male whom had a direct impact on the neck and presented with upper tracheal injury. On arrival, this patient was in respiratory distress and had bilateral pneumothorax. Bilateral chest tube was inserted with subsequent neck exploration. During the neck exploration, anastomosis of the injured trachea was performed. The second case was represented by a 35 years old man with right main bronchial injury. Upon initial presentation, this patient appeared well and was comfortable under room air. However he gradually deteriorated one week after the trauma requiring surgical intervention. Eventually a thoracotomy with primary anastomosis of the bronchial tear was performed. Details of both cases including clinical presentation, imaging and procedures done will be discussed in this article.

Large adrenal leiomyoma presented as adrenal incidentaloma in an AIDS patient: A rare entity.

The literature on adrenal gland tumour in HIV-infected patients is scarce. We report a 46-year-old Malay man with HIV and Hepatitis C infection presenting with a large nonfunctioning adrenal tumour. Computed tomography showed a large right adrenal tumour with heterogeneous enhancement and central necrosis. A high index of suspicion of a malignant tumour or pheochromocytoma led us to surgical removal of the adrenal gland. In this case report, we highlight important features to look for during pre-op evaluation of a large adrenal mass. Appropriate action should be taken when there is a suspicion of a pheochromocytoma or malignancy.

Rockall risk score in predicting 30 days non-variceal upper gastrointestinal rebleeding in a Malaysian population.

OBJECTIVE: the aim of this study was to determine the usefulness of Rockall score in predicting outcomes of 30 days rebleeding, mortality and need for surgical intervention of bleeding gastric and duodenal ulcers. METHODS: this is a retrospective cohort study of all the emergency endoscopies performed in Hospital sultan Ismail from January 2009 to October 2014 for indications of upper gastrointestinal bleeding (UGIb). Data was extracted from hospital's electronic database and only non-variceal bleeds were included. Rockall score was calculated and outcomes of 30 days rebleeding, mortality and need for surgery was recorded. For each outcome, calibration was done using the Goodness-of-fit tests and discriminative ability was reflected by area under the receiver operating characteristic curve (AUROc). RESULTS: A total of 1323 patients were included with a male preponderance of 64%. the overall rates of rebleeding were 11.2%, mortality rate of 8.7% and need for surgery was 2%. Low AUROc values for rebleeding (0.63), mortality (0.58) and surgery (0.67) showed poor discriminative ability of Rockall score. the Goodness-of-fit test also revealed that the scoring system was poorly calibrated in outcomes of rebleeding (p <0.001), mortality (p = 0.001) and surgery (p = 0.038) with p-value <0.05. Patients with high risk (scores ≥8) displayed highest rebleeding and mortality rates of 20% respectively in comparison to the moderate (score 3-7) and low (score ≤2) risk groups. CONCLUSION: Rockall score has a poor discriminative ability and is poorly calibrated for rebleeding, mortality and need for surgery in upper gastrointestinal bleeding. However, it is the best tool we have now to stratify patients into risk groups.

Case report of a high voltage electrical injury and review of the indications for early fasciotomy in limb salvage of an electrically injured limb.

Electrical injuries make up a relatively small portion of burn injuries. Safety measures in place on domestic electricity supply have reduced the occurrence of high voltage electrical injuries. We present the case of a young man who sustained a high voltage electrical injury on all four limbs. Early fasciotomy was performed on both his hands and forearms. Despite early compartment release, the left upper limb deteriorated and required amputation. In this article we discuss the indications, outcomes and complications of early fasciotomy.

Les atteintes électrothermiques représentent une faible proportion des brûlures. Les brûlures par haut voltage à domicile ont vu leur incidence diminuer grâce aux protections automatiques. Nous présentons le cas d'un jeune homme ayant subi des brûlures par haut voltage au niveau des 4 membres. Des aponévrotomies ont été réalisées précocement au niveau des avant bras et des mains. Malgré la prise en charge rapide du syndrome compartimental, le membre supérieur gauche a dû être amputé. Nous discutons ici des indications, des complications et de l'intérêt des aponévrotomies précoces.

Effects of ketoprofen and mesosalpinx infiltration on postoperative pain after laparoscopic sterilization.

OBJECTIVE: To determine whether preoperative ketoprofen and mesosalpinx infiltration, either alone or in combination, favorably influence postoperative recovery after outpatient laparoscopic sterilization. METHODS: In a double-blind, randomized, placebo-controlled study, 20 women received 100 mg of oral ketoprofen preoperatively, and each mesosalpinx was infiltrated with 5 mL of saline plus epinephrine 1:200,000; 20 women were given oral ketoprofen, and each mesosalpinx was infiltrated with 5 mL of bupivacaine 0.5% with epinephrine 1:200,000; and 20 women received a placebo capsule with mesosalpinx infiltration. Pain was assessed by a visual analogue scale and a self-assessment 11-point scale; outcome was assessed by discharge time, consumption of analgesics, incidence of nausea and vomiting, and the number of postoperative days to full recovery. RESULTS: Pain ratings in the ketoprofen-only group were significantly higher than in the two other groups (P < .001). Preoperative ketoprofen alone provided insufficient postoperative pain relief, necessitating the use of opiates and peripheral analgesics. Nausea and vomiting were highest in these subjects, as was intake of peripheral analgesics at home. Times to discharge were also the longest in this group (median 385 minutes, range 260-510) and differed significantly from both other groups (P < .001). It took 4-13 days to recover. In contrast, women with only a mesosalpinx block ambulated and recovered sooner, but times to discharge were still prolonged (median 240 minutes, range 105-375). Recovery usually occurred by the fourth postoperative day. The combination of preoperative ketoprofen and mesosalpinx block resulted in the shortest times to discharge (median 190 minutes, range 80-330), the least consumption of peripheral analgesics, and the lowest incidence of nausea and vomiting. Recovery occurred by the fourth postoperative day. CONCLUSION: Mesosalpinx infiltration has a favorable effect on postoperative recovery after day-surgery laparoscopic sterilization. Still better results can be obtained with a multimodal analgesic approach, combining mesosalpinx infiltration with preoperative ketoprofen.

Effects of recombinant activated factor VII on coagulation measured by thromboelastography in liver transplantation.

Besides the conventional laboratory tests, thromboelastography (TEG) is used to monitor hemostasis during liver transplantation. A previous pilot study suggested a beneficial effect of recombinant activated factor VII (rFVIIa) on transfusion requirements in liver transplantation. In the present study, we assess the effects of rFVIIa on coagulation variables and TEG. In six study patients, the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and TEG variables [reaction time (r), kinetic time (k), or clot formation time, alpha angle (alpha), and maximal amplitude (MA)] were recorded before and after the administration of a bolus of 80 microg/kg rFVIIa. These patients were compared with six controls who did not receive rFVIIa. In contrast with the control group, a significant shortening of PT (P = 0.028) and aPTT (P = 0.028), r (P = 0.046) and k (P = 0.043) values, and a significant incline of the alpha angle (P = 0.028) were noticed after injection of rFVIIa, whereas MA increased not significantly (P = 0.075). rFVIIa rapidly improved coagulation variables in liver transplant patients including PT and aPTT. Of the TEG variables, r, k and alpha angle significantly improved, and MA showed a trend to increase. These data suggest that rFVIIa not only influences the speed of clot formation, but also the physical properties of the clot, which cannot be detected by routine coagulation tests.

Ondansetron, a new antiemetic therapy for oncology. An overview.

The nausea and emesis associated with chemotherapy still constitute an important problem in anticancer treatment. The new specific 5-HT3 receptor antagonists appear to be effective against vomiting induced by chemotherapy and radiation. An overview is given of the current theories on the physiology of emesis and the available literature on ondansetron (GR38032F) as an antiemetic.

Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision.

OBJECTIVES: To determine whether a transverse incision is an alternative to a midline incision in terms of incisional hernia incidence, surgical site infection, postoperative pain, hospital stay and cosmetics in cholecystectomy. Incisional hernias after midline incision are commonly underestimated but probably complicate between 2 and 20% of all abdominal wall closures. The midline incision is the preferred incision for surgery of the upper abdomen despite evidence that alternatives, such as the lateral paramedian and transverse incision, exist and might reduce the rate of incisional hernia. A RCT was preformed in the pre-laparoscopic cholecystectomy era the data of which were never published. METHODS: One hundred and fifty female patients were randomly allocated to cholecystectomy through midline or transverse incision. Early complications, the duration to discharge and the in-hospital use of analgesics was noted. Patients returned to the surgical outpatient clinic for evaluation of the cosmetic results of the scar and to evaluate possible complications such as fistula, wound dehiscence and incisional hernia after a minimum of 12 months follow-up. RESULTS: Two percent (1/60) of patients that had undergone the procedure through a transverse incision presented with an incisional hernia as opposed to 14% (9/63) of patients from the midline incision group (P = 0.017). Transverse incisions were found to be significantly shorter than midline incisions and associated with more pleasing appearance. More patients having undergone a midline incision, reported pain on day one, two and three postoperatively than patients from the transverse group. The use of analgesics did not differ between the two groups. CONCLUSIONS: In light of our results a transverse incision should, if possible, be considered as the preferred incision in acute and elective surgery of the upper abdomen when laparoscopic surgery is not an option.

Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation.

Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child-Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0-18.8 l) in the re-intervention group compared with 1.5 l (range 0-13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.

Prevention of postoperative nausea and vomiting using ondansetron, a new, selective, 5-HT3 receptor antagonist.

The effect of ondansetron, a 5-HT3 antagonist, in preventing postoperative nausea and vomiting was investigated in a randomized, double-blind, placebo-controlled study of 84 patients undergoing gynecologic operation and receiving the same general anesthetic. The patients received premedication with either 16 mg oral ondansetron, or a matching placebo. The same medication was given postoperatively 8 h after the first dose. During the first hour after recovery from anesthesia, the frequencies of nausea and vomiting were 52% and 40%, respectively, in patients given placebos. In the ondansetron group nausea and vomiting developed in 17% and 12%, respectively, values significantly different from those with placebos (P less than 0.005). Similar differences were observed throughout the entire 24-h period after recovery, the incidence of nausea and vomiting being 67% and 60%, respectively, in the placebo group and 29% and 26% in the ondansetron treatment group. Ondansetron appears to be a promising antiemetic for the prevention of postoperative nausea and vomiting.

Efficacy of orally administered ondansetron in the prevention of postoperative nausea and vomiting: a dose ranging study.

In a placebo-controlled, double-blind study, we have compared the efficacy of ondansetron 16 mg, 8 mg and 1 mg administered 8-hourly for prevention of postoperative nausea and vomiting. We studied 995 patients undergoing major gynaecological surgery; 982 were included in the analysis. Study medication was administered 1 h before induction of anaesthesia and second and third doses were given 8 and 16 h after the first. The treatment groups were similar for patient characteristics, surgical procedures, anaesthetics administered and opioids given. The frequency of nausea was 75%, 70%, 56% and 55% after placebo and ondansetron 1 mg, 8 mg and 16 mg, respectively; the corresponding frequencies of vomiting were 60%, 55%, 37% and 37%. Ondansetron 8 mg was as effective as 16 mg and both resulted in significant reductions in nausea and vomiting compared with placebo and ondansetron 1 mg (P less than 0.001).

Effects of preoperative treatment with diltiazem on diastolic ventricular function after coronary artery bypass graft surgery.

OBJECTIVE: To examine whether preoperative treatment with diltiazem could ameliorate left ventricular (LV) diastolic dysfunction in patients after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective, nonrandomized clinical study. SETTING: University hospital. PARTICIPANTS: Thirty-four patients with preserved LV function undergoing elective CABG surgery. INTERVENTIONS: According to medical history, patients were divided into 2 groups: patients not receiving diltiazem (n = 17) and patients treated with once-daily oral diltiazem for at least 2 weeks (n = 17). All patients received preoperative beta-blockers. MEASUREMENTS AND MAIN RESULTS: After induction of anesthesia, after sternal closure, and 4 hours after cardiopulmonary bypass (CPB), mitral and pulmonary venous flow velocities were measured with pulsed Doppler. LV short-axis end-diastolic area by Doppler transesophageal echocardiography (TEE) and hemodynamic variables were obtained simultaneously at comparable pulmonary capillary wedge pressures. Postoperatively, increased peak E and A velocities were observed in patients with diltiazem and controls and returned to baseline 4 hours post-CPB in controls. Changes in these velocities did not result in a decreased E/A ratio. Peak A velocity, E/A ratio, and E wave deceleration time were significantly dependent on heart rate, not peak E velocity. End-diastolic area at comparable pulmonary capillary wedge pressure remained unchanged. In relation to diltiazem, only peak A velocity and time velocity integral of the A wave (TVI-A) at 4 hours post-CPB differed from controls. CONCLUSION: Diastolic function is preserved after CABG surgery and is not altered by diltiazem in patients with preserved LV systolic function. The persistence of increased peak A velocity and TVI-A into the postoperative period suggests improved atrial systolic function with diltiazem.

Haemodynamic effects of vecuronium.

Three hundred and twenty adults (ASA grade I, both sexes), received diazepam 10 mg by mouth (50% received atropine 7 micrograms kg-1 in addition) i.m. 45 min before operation. Patients were then allocated randomly to undergo general anaesthesia with either a nitrous oxide-neurolept technique or nitrous oxide-halothane. Vecuronium was administered to 50% of the patients in each anaesthetic group and heart rate and arterial pressure were monitored. Vecuronium did not influence heart rate, or systolic or diastolic arterial pressures.