Cancer of the gastric cardia is rising in incidence in an Asian population and is associated with adverse outcome.

BACKGROUND: Tumors arising from the esophagogastric junction (OGJ) are increasing in incidence in the west, but data from Asian populations are conflicting. Singapore has a mixed-Asian population with an international lifestyle. This study was designed to examine the changing trends in incidence of gastric cardia cancer (type III) within this population and to compare the clinicopathological characteristics and outcome of these tumors with gastric tumors. METHODS: Trends in cancer incidence were obtained from the Singapore Cancer Registry. Clinicopathological data were prospectively collected from patients undergoing surgery for gastric cancer who presented to the National University Hospital between 2000 and 2005. Patients underwent surgery with or without (neo)adjuvant therapy. Survival duration was analyzed. RESULTS: The incidence of cardia tumors has increased each decade since 1968 (1968-1982, 6.3%; 1983-1992, 7.6%; 1993-1997, 8.4%; 1998-2002, 9.1%; 2003-2007, 16.2%). Among the study population (n = 159) cardia tumors were associated with male sex (p < 0.01) and dysphagia (p < 0.01). Although R0 resection rates were similar, systemic recurrence rates were higher among patients with cardia cancer (p = 0.031) and survival was reduced compared with patients with non-cardia gastric cancer (median survival 26 vs. 69 months; p < 0.001). Cardia location of the tumor and metastatic lymph node ratio were identified as independent adverse prognostic indicators on multivariate analysis. CONCLUSIONS: Similar to western societies, the incidence of proximal gastric cancer is increasing in Singapore. Cardia tumors are associated with poorer outcomes, suggesting that cardia cancer is a distinct disease from true gastric cancer requiring different management strategies to improve the outcome for these patients.

National anti-tuberculosis drug resistance survey, 2002, in Myanmar.

SETTING: Thirty townships of Myanmar. OBJECTIVES: To determine the proportions of drug-resistant tuberculosis (TB) in new and previously treated pulmonary tuberculosis (PTB) cases in Myanmar. DESIGN: A cross-sectional study. Drug susceptibility was tested by the proportion method at the National Tuberculosis Reference Laboratory, Yangon. RESULTS: Of 874 TB patients included from 30 sites, 849 isolates obtained from individual patients (733 from new cases and 116 from previously treated cases) were tested for susceptibility to four primary anti-tuberculosis drugs. Of 733 isolates tested from new TB patients, 10% were resistant to any one of the anti-tuberculosis drugs, 6.5% to isoniazid (INH), 4.6% to rifampicin (RMP) and 4.0% were multidrug-resistant (MDR). Of the 116 previously treated patients, 30.2% were resistant to any one of the drugs, 26.7% to INH, 15.5% to RMP and 15.5% were MDR. Previous anti-tuberculosis treatment of more than 1 month was strongly associated with the development of MDR-TB (adjusted OR 4.8, 95% CI 2.5-9.1). CONCLUSION: The first national drug resistance survey in Myanmar revealed 4% and 15.5% MDR-TB among new and retreatment cases, respectively. Previous antituberculosis treatment was an important risk factor for MDR-TB. Continuous monitoring of drug resistance trends is needed

Oesophageal-impacted denture requiring open surgery.

The successful removal of impacted denture in the oesophagus in a patient is reported, with a review of the literature. A 36-year-old Malay man complained of dysphagia after swallowing his denture. Following unsuccessful attempts at removal via a rigid oesophagoscope, open surgery was performed. Without further delay, the impacted denture was removed by cervical oesophagotomy, and the patient recovered uneventfully. Oesophageal foreign bodies are usually removed by endoscopy. However, in situations where this appears potentially hazardous, such as with impacted denture, open surgical extraction that is promptly performed is a safe option.

Leiomyoma of the oesophagus managed by thoracoscopic enucleation.

The authors document two patients with oesophageal leiomyoma. In the first patient, a 41-year-old man, enucleation of the oesophageal leiomyoma was initially attempted by a thoracoscopic approach, but because of adherence of the tumour to the oesophageal mucosa, enucleation was completed by thoracotomy. Thoracoscopic enucleation was successfully performed in the second patient, a 62-year-old man. This paper includes a literature review on the pathology, diagnosis and surgical approach in the management of oesophageal leiomyoma. In conclusion, prudent use of thoracoscopic approach in the enucleation of oesophageal leiomyoma could potentially result in shorter hospital stay, decreased postoperative pain and reduced requirement for postoperative analgesia.

A model of biliary pancreatic reflux.

A primate model for the study of biliary pancreatic reflux under relatively physiological conditions is described. Cannulas were inserted into the gallbladder and the common bile duct of rhesus monkeys, and a pedicled segment of small bowel was used to create a pancreaticocutaneous fistula after resection of the spleen and pancreatic tail. Following recovery, Hypaque was instilled into the gallbladder with maintenance of common duct pressure within a normal range. The pancreatic duct was visualized in 21 of 34 radiographic studies (19 monkeys). Small amounts of iodine were detected in the fistula effluent of nine of 11 animals that refluxed radiologically. Radioactive polyethylene glycol (PEG-C14) was instilled into the gallbladder and pancreatic fistula drainage sampled by aspiration (26 studies, four monkeys). When compared to controls without PEG instillation (six studies, four monkeys), there was a significant rise in fistula counts beginning 50 minutes after injection and peaking at 180 minutes. In a second series of studies, pancreatic fistula aspiration was replaced by a flush technique using a triple-lumen cannula which allowed constant monitoring and control of fistula pressure. A statistically significant rise and fall of radioactivity after PEG introduction again was demonstrated. These data demonstrate taht biliary pancreatic reflux can occur and be quantitated under these experimental conditions.

The effect of dapsone-pyrimethamine on immunoglobulin concentrations in malaria chemoprophylaxis.

Immunoglobulins IgG, IgM, IgA were estimated on 3 occasions in 59 male volunteers who were taking dapsone-pyrimethamine once weekly (dapsone: 100 mg + pyrimethamine: 12.5 mg) for malaria chemoprophylaxis. Immunoglobulins IgG and IgM measured at the 7th week of chemoprophylaxis were significantly lower than baseline values (using Students' t-test for paired data), but none of the values were below 700 mg% for IgG or 30 mg% for IgM. Immunoglobulin concentrations estimated in 45 of the 59 men 6 weeks after discontinuation of chemoprophylaxis showed a return to baseline for IgM but not IgG, which remained low. On all 3 occasions there was no significant change in the IgA concentrations. The clinical implication of these findings is not known. Further studies are required to define the effects of antimalarial drugs on the antibody response to infection and immunization.

Severe abdominal pain in low dosage clofazimine.

We describe a 41 yr old leprosy patient treated for 10 yrs with clofazimine who underwent laparotomy for severe abdominal pain. At surgery, the only significant findings were that the coeliac lymph nodes were enlarged and stained purplish black as were the omentum and the intraperitoneal fat. No other cause of abdominal pain was identified. On histological examination, reddish-purple crystals were identified at frozen section but not in the paraffin sections.

Antimicrobial resistance problem in a university hospital.

In a study conducted in 1991 in the National University Hospital, Singapore, the susceptibilities of a total of 2156 recent clinical isolates were tested against 25 antimicrobial drugs. The organisms were those isolated from routine specimens received in the microbiology laboratory. About 40% Staphylococcus aureus isolations in the hospital were resistant to methicillin. A high incidence of the resistance was noted among Staphylococcus aureus and coagulase negative staphylococci to antistaphylococcal drugs. Acinetobacter sp. and Klebsiella sp. are becoming major threats with regard to antimicrobial treatment as they are multi-drug resistant. Pseudomonas aeruginosa did not show a resistance problem except to pefloxacin (74%). Ampicillin resistance of Acinetobacter sp. (93%) was reduced to 71% by ampicillin/clavulanic acid and to 7% by ampicillin/sulbactam. With regards to the urinary isolates higher rates of resistance were noticed with Pseudomonas aeruginosa to antipseudomonas drugs and for co-trimoxazole with other Gram negative organisms, compared to non-urinary isolates.

Use of laparoscopy in the management of mesenteric venous thrombosis.

Mesenteric vein thrombosis is a relatively rare cause of intestinal ischemia. We present a case of idiopathic superior mesenteric and portal vein thrombosis, which was not associated with any infarcted bowel. The patient was treated successfully with anticoagulation using low-molecular weight heparin and warfarin, and did not require bowel resection. This case highlights the value of diagnostic laparoscopy for assessing intestinal viability in this situation, showing how it avoids the morbidity and complications associated with a formal laparotomy.

Interventions for treating melioidosis.

BACKGROUND: Melioidosis is an infectious disease that occurs in tropical regions, particularly in Thailand. It is caused by the bacterium Burkholderia pseudomallei and is a serious condition which can be fatal. Beta-lactam antibiotics have dramatically reduced the risk of death, but mortality still remains high. OBJECTIVES: To summarize reliable evidence on the effects of treatment regimens on death and relapse. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register (July 2002), the Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (1966 to July 2002), EMBASE (1980 to May 2002), BIOSIS (up to July 2002), Health Star (up to July 2002), and reference lists of articles. We also contacted pharmaceutical companies and researchers in the field. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing antibiotic regimens in people with melioidosis. DATA COLLECTION AND ANALYSIS: We independently assessed the eligibility of studies and the methodological quality of the trials. Adverse effects information was collected from the trials. MAIN RESULTS: Nine trials, all from Thailand, involving a total of 872 participants were included. For intravenous therapy in the acute phase, we identified six trials with a total of 619 participants. Chloramphenicol, doxycycline, and co-trimoxazole (trimethoprim-sulphamethoxazole) combination regimens were associated with a mortality of 50% or more (two studies). Participants randomized to regimens including ceftazidime were more likely to survive (relative risk [RR] 0.46; 95% confidence interval [CI] 0.30 to 0.71). When ceftazidime-containing regimens were compared with beta-lactam or alternative beta-lactamase inhibitor regimens such as co-amoxiclav (amoxycillin-clavulanic acid) and cefoperazone-sulbactam, or with imipenem, mortality rates were similar (RR 1.06; 95% CI 0.81 to 1.39). For oral therapy in the maintenance phase, we found three trials of 253 participants. They compared the conventional regimen (chloramphenicol, doxycycline, and trimethoprim-sulphamethoxazole) with other regimens (amoxycillin-clavulanic acid, ciprofloxacin-azithromycin, and doxycycline alone). There were fewer deaths with the conventional regimen, but no statistically significant differences demonstrated. REVIEWER'S CONCLUSIONS: Regimens for the acute phase of illness should contain ceftazidime or imipenem. It is not yet clear if combinations of treatments in the early phase reduce relapse. For oral therapy after the acute phase of treatment, trials suggest that conventional four drug regimens can be used for treatment.

Interventions for treating melioidosis.

BACKGROUND: Melioidosis is an infectious disease caused by a bacterium (Burkholderia pseudomallei) found particularly in some areas in the tropics. It is a serious condition which can be fatal. Beta lactam antibiotics have dramatically reduced the risk of death, but mortality still remains high. OBJECTIVES: To summarise evidence from randomised trials on the effects of treatment regimens on death and relapse. SEARCH STRATEGY: Cochrane Controlled Trials Register, MEDLINE, EMBASE, BIOSIS from 1966 to September 2000 using MeSH terms "pseudomallei", "melioidosis" together with the terms "randomized-controlled-trial", "random allocation"; reference lists in articles on melioidosis; contact with trialists. SELECTION CRITERIA: Randomised and quasi-randomised trials assessing treatments in patients with melioidosis. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality was assessed by two reviewers independently. MAIN RESULTS: For intravenous therapy in the acute phase, we identified five trials with a total of 519 patients. Chloramphenicol, doxycycline, and co-trimoxazole (trimethoprim-sulphamethoxazole) combination regimens were associated with a mortality of 50% or more (two studies). Patients randomised to regimens that included ceftazidime were more likely to survive (relative risk [RR] 0.46, 95% confidence interval [CI] 0.30 to 0.71). When ceftazidime-containing regimens were compared with beta lactam or alternative beta lactamase inhibitor regimens such as co-amoxiclav (amoxycillin-clavulanic acid) and cefoperazone-sulbactam, mortality rates were similar (RR 1.10, 95% CI 0.83 to 1.46), as was the case in one trial of imipenem. For oral therapy in the maintenance phase, we found two trials of 188 participants. Results showed that treatment with the conventional regimen (chloramphenicol, doxycycline, and trimethoprim-sulphamethoxazole) resulted in fewer fatalities in patients compared to a regimen of amoxycillin-clavulanic acid and doxycycline alone. REVIEWER'S CONCLUSIONS: Regimens for the acute phase of illness should contain ceftazidime or imipenem. It is not yet clear if combinations of treatments in the early phase reduce relapse. For oral therapy after the acute phase of treatment, trials suggest that conventional four drug regimens can be used for treatment.

Increase in bile secretion after water ingestion in cholecystectomised patients.

The effect of water ingestion on bile secretion was investigated in nine cholecystectomised patients with T-tube biliary drainage. The effect of ingestion of a standard meal on bile secretion was also studied in these patients. Water ingestion produced a significant increase in bile secretion compared with fasting levels. This increase in bile secretion was comparable to that produced by a standard meal. Ingestion of water or meal did not produce any significant change in bile osmolality or sodium and potassium concentrations of bile.

Surgical approach and results of surgery in adenocarcinoma of the gastro-oesophageal junction.

AIM OF STUDY: This paper attempts to determine the appropriate surgical procedure in relation to the pathological types of adenocarcinoma of the gastro-oesophageal junction in Singapore. METHODS: Data on population characteristics, clinical presentation, pathology, surgical procedures and results of treatment were gathered from the case records of a personal series of 32 patients resected for adenocarcinoma of the gastro-oesophageal junction. RESULTS: The 32 patients with adenocarcinoma of the gastro-oesophageal junction (Type I, 9; II, 20 and III, 3), presented at a late stage (Stage I-II, 5; III, 14; IV, 13). In 19 patients with Stages I-III disease, attempted curative surgery was performed--extended total gastrectomy for Types II and III disease (13 patients) and oesophagectomy for Type I (6 patients). There was one operative mortality following curative resection. Palliative resection was performed on 13 patients with Stage IV disease with one operative mortality. The main operative morbidity was anastomotic leakage, occurring in 5 patients; both operative deaths were associated with this complication. The actuarial 5-year survival was 20%. CONCLUSION: Although gastro-oesophageal cancer presents late, it can be resected safely by extended total gastrectomy for Types II and III disease and oesophagectomy for Type I disease, taking precautions to minimise anastomotic leakage. Although usually palliative, Stages I and II and to a lesser extent Stage III, are curable by these surgical procedures which ensure a tumour free surgical margin and adequate lymphadenectomy.

Five year survival following surgery for 50 cases of colorectal cancer--a personal series.

In a personal series of 56 patients with colorectal cancer operated over a 3-year period from 1984 to 1986, 50 patients were followed up until death or for at least 5 years. The age, distribution, clinical features and stage of disease at presentation appear to be similar to those in the West. All 5 of Dukes A, 10 of 11 cases of Dukes B and 8 of 16 cases of Dukes C disease have survived at least 5 years. The 5-year survivors include a patient who had undergone right hepatectomy for a large liver metastasis. The 5-year survival in this small personal series appears encouraging.

Primary gastric lymphoma.

Primary gastric lymphoma is a rare gastrointestinal lymphoma. The treatment of this condition remains controversial, especially the extent of surgical resection. Ten cases were operated on over a five-year period at our institution and the outcome was reviewed. Early results suggest no difference in survival whether the margin of resection was clear or not so long as postoperative chemotherapy was given. The outcome appear to depend more on the extent of the disease at the time of surgery. Full thickness involvement of the stomach wall with lymph node involvement were bad prognostic indicators.

Necrotizing fasciitis--an unusual presentation of miliary mycobacterium tuberculosis.

We report an immunocompromised patient who presented with necrotizing fasciitis as the initial presentation of miliary tuberculosis. The diagnosis of miliary tuberculosis was delayed resulting in prolonged morbidity and hospital stay. The lesson from this report is that tuberculosis should be recognised as an uncommon cause of necrotizing fasciitis in an immunocompromised patient, especially if the response to prompt and standard initial treatment is unsatisfactory.

Pasteurella multocida osteomyelitis of the cervical spine in a patient on chronic haemodialysis.

Osteomyelitis due to Pasteurella multocida has been frequently documented but virtually all previous cases have resulted from direct inoculation of the organism or contiguous spread of local infection, following animal bites or scratches. Infections often occur in patients with serious underlying illnesses. Haematogenous osteomyelitis due to P multocida has very rarely been reported particularly in patients with chronic renal failure. We describe a patient on chronic haemodialysis who developed an acute febrile illness, two months following a monkey bite, caused by haematogenous cervical vertebral osteomyelitis due to P multocida.

Hospital acquired pneumonia in the medical intensive care unit--a prospective study.

AIM OF STUDY: The aim of the study was to define the prevalence, risk factors, spectrum of organisms and sensitivity patterns, and the outcome in patients with severe hospital acquired pneumonia (HAP) in the Medical Intensive Care Unit (SCU) in a hospital in Singapore. METHOD: Consecutive patients admitted to the MICU over a 6-month period were studied and assessed daily to determine whether patients had developed HAP based on defined clinical criteria. Sputum or endotracheal aspirate was obtained and results recorded from each patient on admission and every subsequent three days throughout the stay in the MICU. Mortality during hospital stay was the main outcome measure recorded. RESULTS: A total of 136 patients (150 admissions) were studied; 24 patients were identified as having HAP. The prevalence of HAP was 17% [both ventilator-associated pneumonia (VAP) and pneumonia acquired from the ward (WAP)]. Cerebral disease was the main risk factor for VAP (OR 4.94, 95% CI 1.33-18.4). The spectrum of organisms which caused HAP were polymicrobial, Klebsiella pneumoniae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus and coagulase negative Staphylococcus. The mortality of patients with VAP and WAP were 72.7% and 76.9% respectively. CONCLUSION: This study concludes that HAP in the MICU is common with a high mortality. The spectrum of organisms was comparable to previous studies.

Tuberculosis and invasive pulmonary aspergillosis in a young woman with a myelodysplastic syndrome.

A 29-year-old Chinese woman developed pyrexia, multiple skin abscesses and bilateral fine nodular lung infiltrates about 3 months after the commencement of therapy for idiopathic thrombocytopenic purpura (ITP). Pseudomonas aeroginosa was isolated from the abscesses but multiple blood and sputum cultures, as well as a broncho-alveolar lavage did not yield any microorganisms. The persistence of fever and pulmonary infiltrates warranted an open lung biopsy which provided a definitive diagnosis of tuberculous-aspergillus granulomatous lung disease. Bone marrow re-examination revised the primary haematological disorder to that of a trisomy 8 associated myelodysplastic syndrome.

Serodiagnosis of melioidosis in Singapore by the indirect haemagglutination test.

Melioidosis is endemic in Singapore, with diagnosis dependent upon both bacteriological culture and serodiagnosis. Using the polysaccharide (melioidin)-sensitized turkey red cells in the indirect haemagglutination test (IHAT), 20 (100%) of the Pseudomonas pseudomallei culture-positive cases were detectable by the IHAT with titles ranging from 1:16 to 1:32, 768. Eight of these patients who died within a few days after the IHAT was performed had titres ranging from 1:16 to 1:1028. Five culture-negative patients, with clinical symptoms suggestive of melioidosis infection and who responded to treatment with ceftazidime, showed IHA titres between 1:64 and 1:8,192. One hundred and twenty one sera from patients with pneumonia, abscesses, or diabetes mellitus were IHAT negative. The IHAT showed good specificity since negative titres were seen in tests using sera from 2 patients with culture-positive Pseudomonas aeruginosa and 4 patients positive for Legionella. IHAT negative results were obtained from tests of 50 normal blood donors and 50 sewerage workers. Of 683 national servicemen tested, 5 (0.73%) had IHAT titres ranging from 1:16 to 1:128. Unlike hyperendemic areas such as Thailand where interpretation of IHAT is seriously hampered by IHA titres found in one-third to half of the population, serodiagnosis of melioidosis by the sensitive IHAT may be employed in Singapore as a routine procedure since background IHA titres are low.