Evaluation of Mycotube, a modified version of Lowenstein-Jensen (LJ) medium, for efficient recovery of Mycobacterium tuberculosis (MTB).

Timely diagnosis of tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB), is only achieved for ~58% cases. An improved, accurate, time- and cost-effective method for bacteriological confirmation of MTB is necessary. We evaluated Mycotube, a new variant of Lowenstein-Jensen (LJ) culture medium, by comparing it with Mycobacterium Growth Indicator Tube (MGIT) 960 (gold standard), local LJ, and bioMérieux LJ-T in terms of isolation rate and time-to-growth. Pulmonary and extra-pulmonary samples from treatment-naïve suspects (n = 207) were decontaminated by the N-acetyl-L-cysteine-sodium hydroxide method and used to inoculate the four media. Subjective and objective parameters were used for evaluation. Mycotube yielded 140 positive results, compared to 162, 69, and 141 from MGIT, local LJ, and LJ-T, respectively. Of these, 139 (67%) were true-positive results and 1 (0.5%) was false-positive. The mean time-to-growth detection was 17.4 days for Mycotube, compared to 14.5, 28.1, and 16.5 days for MGIT, local LJ, and LJ-T, respectively. The mean time-to-growth for local LJ significantly differed from that for MGIT, but not those for LJ-T and Mycotube. No contamination was observed. Mycotube had a sensitivity of 85.8% and a specificity of 97.8% as compared to MGIT. Mycotube offers good results, comparable with those observed for conventional LJ. It requires only basic laboratory infrastructure. The overall cost of the test should be nearly three times lower than that of MGIT. Mycotube helps with TB diagnosis and generates pure isolates for drug susceptibility testing.

Primary resection and anastomosis in obstructed descending colon due to cancer.

Intraoperative colonic irrigation followed by one-stage resection is gaining popularity as the optimal surgical treatment for left-sided colonic obstruction. However, its efficacy and potential hazards have not been adequately tested in obstruction due to colonic cancer. We analyzed the early results of 23 consecutive patients with obstructive left-sided colonic carcinoma treated by primary resection and anastomosis following intraoperative antegrade colonic lavage. Two patients (8.6%) died, one from complication of anastomotic leakage. The significant postoperative complications were chest infection in three (13%) and wound infection in seven (30.4%). The average hospital stay was 16.5 days. The results of this study suggest that intraoperative bowel irrigation permits one-stage resection and anastomosis to be conducted with reasonable safety provided care is taken in operative techniques.

Studies on multiple feeding by Anopheles gambiae s.l. in a Sudan savanna area of north Nigeria.

The detection of haptoglobins in Anopheles gambiae s.l. has been used to obtain an estimate of the incidence of multiple feeding for the village of Barmawa, Garki District, Kano State, Nigeria. The results indicated that the incidence of multiple feeding was approximately 10% but problems were encountered by the high incidence of ahaptoglobinaemia in the population. In four villages in Garki District the incidence of ahaptoglobinaemia varied between 65 and 76% while in young children and personnel under constant malaria chemoprophylaxis it was less than 30%. A strong correlation between ahaptoglobinaemia and malaria infections was seen. The results show evidence of selection of hosts by mosquitoes at Barmawa although this does not necessarily imply a preference per se. The results provide evidence of movement of blood-fed mosquitoes, between houses and from houses to resting sites.

Particle transport in asymmetric scanning-line optical tweezers.

We describe a scanning-line optical tweezing technique with an asymmetric beam profile in the back focal plane of the microscope objective. The motion of a trapped particle along the scan line is studied as a function of beam asymmetry, and it is shown that this technique can be used to exert a constant lateral force on the particle, realizing purely optical constant-force tweezing. The observed effect is attributed in a geometric optics model to a non-zero lateral component of the scattering force.

Malignant melanoma of the oesophagus--a case report.

Primary malignant melanoma of the oesophagus is a rare presentation for melanoma and is also an unusual and aggressive form of oesophageal neoplasm. We present a 57-year-old Chinese gentleman who underwent successful resection of a primary malignant melanoma of the oesophagus.

Malignant axillary lymphadenopathy--a problem for management.

Axillary lymph node enlargement can be the first and only manifestation of malignancy. Although lymphoma and metastasis from melanoma, breast and lung cancers are known causes, the primary tumour may remain undetected in some cases despite exhaustive investigations. Therefore, once the diagnosis of malignancy is confirmed by clinical examination followed by histology, further investigations should be limited to a search for treatable malignancies only. Extensive investigations with a hope of discovering the primary is useless and not cost effective. Close follow up may occasionally reveal new clinical signs when further investigations can be justified. This paper reports the clinical approach to diagnosis and management of such cases with examples of illustrative cases.

Major surgery in the elderly--a study of outcome in 295 consecutive cases.

The results of major surgery in 295 consecutive patients over the age of sixty years were analysed. In this series, 70% were electives and 30% emergency cases with a male preponderance of 3:2. The overall mortality was 11.2%. Mortality following emergency operations was three times more than electives. Seventy percent (70%) of deaths after elective surgery followed palliative operations for advanced cancer. For elective surgery, complications of peptic ulcers were associated with a high mortality rate whereas deaths were fairly uniform in the emergency group. In general, concomitant medical diseases and postoperative complications were the major determinants of outcome of surgery in the elderly.

Fine needle aspiration cytology in the management of solitary thyroid nodules--a comparison with other diagnostic modalities in cost-effectiveness.

This paper assesses the cost effectiveness of fine needle aspiration cytology (FNAC) as a selection criteria for surgery in solitary thyroid nodules compared to scintigraphy and ultrasonography. 98 patients who had FNAC and histological confirmation, scintigraphy and/or ultrasonography were studied. The use of combined diagnostic discriminants of positive FNAC, clinical suspicion and age above 50 years detected all malignancies and would have resulted in fewer patients being subjected to surgery--51% (FNAC) vs 90% (Scans, U/S). This resulted in cost savings of $800 per patient seen. We conclude therefore that FNAC should be the diagnostic modality of choice and that the routine use of scintigraphy and ultrasonography is not justifiable.

Cancer of the colon and rectum.

A study was made of 300 surgically treated cases of colorectal cancer during an eight year period. The average age for the disease was 60 years with no sex difference but a low incidence in the younger age group. About 1/3 of the cases presented as emergency and 1/4 with palpable mass. Rectum and sigmoid were the commonest sites, while anal carcinoma was rare. The overall mortality for surgical treatment was 10%. 67.3% were resectable with a mortality of 5%. Although well differentiated adenocarcinoma was the commonest variety, mucinous, colloid and other types were rare. Less than 1/3 of the cases were in favourable Stage A and B, while the majority were advanced. This was the main difference from the reports of western series apart from the rarity of inflammatory and premalignant conditions.

Transsacral approach to the rectum.

While the proximal or upper third of the rectum is readily accessible through the lower abdomen, lesions of the distal rectum are difficult to reach both from abdomen and the perineum. The transsacral approach (Kraske) gives excellent exposure of the mid and lower rectum. The experience using this approach in sixteen cases for various indications which include local excision of benign tumours, segmental excision, repair of recto-vesical fistula, perineal excision of rectum and abdominal excision of rectal carcinoma and low colo-rectal anastomosis with preservation of ano rectal sphincters is reported. In some cases where wider exposure of the rectum is required, this was easily achieved by excising the last three pieces of sacrum and/or extending below by dividing the external sphincter. While incontinence is not a long term problem, attention to technical details and creation of a temporary colostomy are necessary for all cases of excision and end-to-end anastomosis to prevent leakage and septic complications. Temporary colostomy is not required for excision of part of the circumference of the rectum as in the treatment of most benign lesions.

General surgery in an era of superspecialisation--what is the future?

The present century has seen extraordinary scientific advances and enormous social changes unparalleled in all medical history. Of these, specialisation and superspecialisation are significant developments that have made major impact on the practice of surgery. While specialisation is intended to improve the quality of care, excessive specialisation resulting in separation into narrow areas can have a deleterious effect on the total care of the patient, teaching, training and surgical research. General Surgery which is the foundation of surgical practice has been affected more than any other in this process and the problem has received world wide attention. General Surgery is a broad speciality responsible for the care of the surgical patient as a whole including diagnosis, preoperative, operative and postoperative management of all common surgical conditions. In addition, it requires the special expertise to manage the surgical problems of the alimentary tract, abdomen, endocrines, vascular and head and neck and comprehensive care of trauma and critical care. The general surgeon will continue to play a major role in future to suit the changing trends in surgical practice especially with the recent advances in endoscopic and laparoscopic surgery. The general surgeon of the future should continue to have a broad based training, be knowledgeable in basic sciences and responsible for total care of the patient and at the same time, have a special interest and expertise in subspecialty. General Surgery should continue to provide the basic training for all specialties, foster basic and clinical research and provide a solid foundation for all surgical trainees and above all continue the leadership role in the teaching of undergraduate students.

Whole bowel irrigation--an alternative to traditional bowel washout.

The objective of this study was to determine whether or not whole bowel irrigation through oral route was a safe and acceptable alternative to traditional bowel washout per rectum in preparation for large bowel surgery. Out of a total of 114 patients, 32 had whole bowel irrigation, 71 had traditional washout and 11 had no bowel preparation. The irrigation involved approximately 12 litres of normal saline over an average period of 3 1/4 hours. The preparation of the colon by whole bowel irrigation was better as indicated by total absence of faeces and the cleanliness of the colon at operation. However, there was no significant difference in wound infection rate between the two groups although the severity of wound infection was lesser in the first group. There were no major complications like anastomotic breakdown, burst abdomen, abscess or fistula formation and septicaemia in this group. Based on this experience we believe that whole bowel irrigation is a good alternative method of bowel preparation. The advantages of this method are that it is short and rapid, avoiding prolonged pre-operative hospitalisation and is acceptable to most patients.

Surgery in Singapore: the Scottish link.

The History of Surgery in Singapore is over a hundred years old. The major land marks are, the starting of the Medical School, the rapid development of health and hospital services after the war and the establishment and growth of major specialities and postgraduate education in the last 15 years. This paper traces the significant Scottish influence in the various stages of developmental history of Surgery in Singapore.

Multiple splenic abscesses following Pseudomonas sepsis.

Splenic abscess is an unusual clinical entity, which in most cases is secondary to metastatic spread of bacteria from a primary site of infection. Before the antibiotic era, Salmonella typhi was a common offending organism but now staphylococci and streptococci are predominant organisms. We report two rare cases of multiple splenic abscesses caused by Pseudomonas infection. One case followed Pseudomonas septicaemia and the other was secondary to Pseudomonas pseudomallei osteomyletis of the femur. Both cases underwent splenectomy and promptly recovered.

Is preoperative shaving really necessary?

A randomised prospective study was done to assess the necessity of shaving before operation. Seven hundred and sixteen cases were included in this study. The traditional method of preoperative skin preparation which employs routine shaving and using cetrimide and chlorhexidine in alcohol for cleansing was compared with an alternate method without preoperative shaving. The clean wound infection rate was 5.08% for the traditional method group and 5.56% for the alternate method group. The results suggest that routine shaving, as part of preoperative preparation, has no advantage in reducing wound infection rate.

Breast cancer--the need for early diagnosis.

A retrospective study was undertaken of 265 women with breast cancer treated at the Department of Surgery, Toa Payoh Hospital, Singapore, during 8 years from 1977 to 1985. The average patient was aged 51.0 years, with a tumour 4.9 cm in diameter, staged at T2aN1bMO (Stage II). In comparison with an earlier series from the same Unit, an increase in the number of younger patients was noted, although overall a larger proportion of 'early' cases (TNM Stage I) was found. In contrast to recent western series, breast cancer in Singapore is diagnosed at a later stage and generally unsuitable for conservative treatment by lumpectomy and radiotherapy. The standard treatment was modified radical mastectomy, or simple mastectomy with axillary clearance, followed by Radiotherapy if ipsilateral axillary lymphnodes were histologically involved.

Gastrointestinal and retroperitoneal sarcoma--local experience and review of the literature.

Gastrointestinal and retroperitoneal sarcoma are uncommon tumours. Out of 26 cases treated over the last 6 years, there were 16 smooth muscle tumours (SMT) and 10 non Hodgkin Lymphomas (ML). 7 cases of SMT were leiomyosarcoma. The majority of the cases were found in the stomach. 8 cases presented as acute emergencies while the non acute cases had non specific complaints. Despite the use of barium studies, gastroscopy and CT scan, only 5 cases were diagnosed preoperatively. The majority underwent curative resection. ML cases had a combination of radiotherapy and chemotherapy. 2 patients with large and high grade leiomyosarcomas have died. 4 patients with ML have also died, 2 with locally advanced disease and 2 with distant metastases. We conclude that most cases are not diagnosed preoperatively due to their rarity and nonspecific clinical presentation. The important prognostic factors are size and mitotic index for SMT and stage of the disease for ML.

Thyroid carcinoma--problems in management.

A retrospective review of surgically treated cases of thyroid carcinomas in this department during a 10 year period of 1976 to 1985 was performed. From a detailed analysis of 71 cases three features are highlighted. Firstly, the rising incidence of thyroid carcinomas and papillary carcinomas with age has been clearly demonstrated. Secondly, with current clinical and investigative modalities using thyroid scans, ultrasonography and frozen section histology, the preoperative and operative diagnosis of malignancy has been limited resulting in only 27% of patients confirmed to have carcinoma histologically. This resulted in 35% of patients requiring staged procedures to achieve total thyroidectomy. Finally from the prognostic factors of survival that were evaluated, age at diagnosis, local invasiveness, and distant metastases were found to be significant factors.

Palliative gastrojejunostomy for advanced carcinoma of the stomach.

The outcome of 51 patients who underwent gastrojejunostomy for unresectable gastric cancer with outlet obstruction was studied to evaluate the palliative benefit. The operative mortality and postoperative complication rates were 22% and 55% respectively. The mean duration of postoperative hospital stay was 13 days and median survival period 14 weeks. Delayed gastric emptying occurred in 21%, mostly in patients with extensive tumour involvement of the stomach and was associated with a poor outcome. Among the survivors, 87.5% were able to take a soft diet by the eighth postoperative day and 60% could cope with the progression of the disease at home. We conclude that gastrojejunostomy offers satisfactory palliation in patients with advanced gastric cancer.

Synchronous primary hepatocellular carcinoma and multiple early gastric cancer--a case report.

A rare case of synchronous primary hepatocellular carcinoma and multiple early gastric cancer in a patient is reported. Both the tumours were successfully resected at one operation.