A challenging road to diagnosing transthyretin cardiac amyloidosis and using technetium-99m pyrophosphate bone scintigraphy in nuclear cardiology - A case report.

Cardiac amyloidosis (CA) is a rare form of protein deposition disease, leading to restrictive cardiomyopathy that often presents with signs and symptoms of unexplained heart failure with preserved ejection fraction (HFpEF). There are two main subtypes of CA, namely light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), which are conventionally confirmed by endomyocardial biopsy (EMB). The prognosis and treatment of the subtypes differ extensively, making it crucial to distinguish between the two. Although echocardiography (ECHO) and cardiac magnetic resonance imaging (CMR) are useful to aid in the diagnosis, they are unable to differentiate between the subtypes. Advantageously, the transthyretin cardiac amyloidosis (ATTR-CA) subtype can be diagnosed based on nuclear medicine bone scintigraphy imaging using Technetiumlabelled bone-seeking radiotracers. We report a case of a previously well, elderly gentleman who presented with acute heart failure symptoms, whereby ECHO findings were suspicious for CA. Technetium-99m pyrophosphate (99mTc- PYP) bone scintigraphy performed with complementary single photon emission computed tomography/computed tomography (SPECT/CT) at three hours post-injection revealed radiotracer uptake in the myocardium that was higher than the skeletal bone uptake. This corresponded to Perugini score of 3 along with an increased heart to contralateral lung ratio (H:CL) of 1.69. The bone scintigraphy findings together with his symptoms, ECHO, CMR, and laboratory results enabled the diagnosis of ATTR-CA to be made. In summary, bone scintigraphy offers a reliable and non-invasive method for the diagnosis of ATTR-CA. We also highlight the diagnostic pitfalls and recommendations in reporting bone scintigraphy for the indication of typing cardiac amyloidosis.

Characteristics of unplanned hospitalisations among cancer patients in Singapore.

INTRODUCTION: Cancer is a pervasive global problem with significant healthcare utilisation and cost. Emergency departments (EDs) see large numbers of patients with oncologic emergencies and act as "gate-keepers" to subsequent hospital admissions. A proportion of such hospital admissions are rapidly discharged within 2 days and may be potentially avoidable. METHODS: Over a 6-month period, we conducted a retrospective audit of active cancer patients presenting to the ED with subsequent admission to the Department of Medical Oncology. Our aims were to identify independent factors associated with a length of stay ≤2 days; and characterise the clinical and resource needs of these short admissions. RESULTS: Among all medical oncology admissions, 24.4% were discharged within 2 days. Compared to longer stayers, patients with short admissions were significantly younger (P=0.010), had lower National Early Warning Scores (NEWS) (P=0.006), and had a lower proportion of gastrointestinal and hepatobiliary cancers (P=0.005). Among short admissions, common presenting medical problems were infections (n=144, 36.3%), pain (n=116, 29.2%), gastrointestinal complaints (n=85, 21.4%) and respiratory complaints (n=76, 19.1%). These admissions required investigations and treatments already available at the ED. CONCLUSION: Short admissions have low resource needs and may be managed in the ED. This may help save valuable inpatient bed-days and reduce overall healthcare costs.

Smoking cessation advice in limb reconstruction: An opportunity not to be missed.

The adverse health effects of smoking are well known, including its effects on the musculoskeletal system. Limb reconstruction using external fixators is a high intensity process with high levels of patient contact time, complications and cost. The aim of this study was to examine smoking patterns in this group and in particular to assess trends in smoking cession. Data was collected from 41 patients all undergoing treatment using circular frame external fixation, for a variety of pathologies, most commonly acute tibial trauma. A patient reported questionnaire was used. Data was collected over a six-month period. In our population 56.1% of patients were smokers. During the study 47.8% patients stopped smoking and a further 39.1% decreased their smoking behaviour. 78.3% of patients could recall being given smoking cessation advice. In our group, 87% of patients were unaware of the effects of smoking on bone healing. Once made aware during discussion of proposed treatment, 73.9% stated that it was, in part, this knowledge that prompted them to positively change their smoking habits. The results of this study show that advice regarding smoking cessation during limb reconstruction treatment can potentially have a positive impact on patients smoking habits. The effect of smoking should be linked to the patient pathology and discussed during the consent process. Taking the time with the patient for this simple free intervention can have a positive impact on patient health, and potentially on the outcome of their current treatment, and is an opportunity not to be missed.

The role of RNA metabolism in neurological diseases.

Neurodegenerative disorders are commonly encountered in medical practices. Such diseases can lead to major morbidity and mortality among the affected individuals. The molecular pathogenesis of these disorders is not yet clear. Recent literature has revealed that mutations in RNA-binding proteins are a key cause of several human neuronal-based diseases. This review discusses the role of RNA metabolism in neurological diseases with specific emphasis on roles of RNA translation and microRNAs in neurodegeneration, RNA-mediated toxicity, repeat expansion diseases and RNA metabolism, molecular pathogenesis of amyotrophic lateral sclerosis and frontotemporal dementia, and neurobiology of survival motor neuron (SMN) and spinal muscular atrophy.

PCR amplification-independent methods for detection of microbial communities by the high-density microarray PhyloChip.

Environmental microbial community analysis typically involves amplification by PCR, despite well-documented biases. We have developed two methods of PCR-independent microbial community analysis using the high-density microarray PhyloChip: direct hybridization of 16S rRNA (dirRNA) or rRNA converted to double-stranded cDNA (dscDNA). We compared dirRNA and dscDNA communities to PCR-amplified DNA communities using a mock community of eight taxa, as well as experiments derived from three environmental sample types: chromium-contaminated aquifer groundwater, tropical forest soil, and secondary sewage in seawater. Community profiles by both direct hybridization methods showed differences that were expected based on accompanying data but that were missing in PCR-amplified communities. Taxon richness decreased in RNA compared to that in DNA communities, suggesting a subset of 20% in soil and 60% in groundwater that is active; secondary sewage showed no difference between active and inactive populations. Direct hybridization of dscDNA and RNA is thus a viable alternative to PCR-amplified microbial community analysis, providing identification of the active populations within microbial communities that attenuate pollutants, drive global biogeochemical cycles, or proliferate disease states.

The association between clubfoot and developmental dysplasia of the hip.

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV.

Model-based advanced process control of coagulation.

The drinking water treatment industry has seen a recent increase in the use of artificial neural networks (ANNs) for process modelling and offline process control tools and applications. While conceptual frameworks for integrating the ANN technology into the real-time control of complex treatment processes have been proposed, actual working systems have yet to be developed. This paper presents development and application of an ANN model-based advanced process control system for the coagulation process at a pilot-scale water treatment facility in Edmonton, Alberta, Canada. The system was successfully used to maintain a user-defined set point for effluent quality, by automatically varying operating conditions in response to changes in influent water quality. This new technology has the potential to realize significant operational cost saving for utilities when applied in full-scale applications.

Epidemiology of salmonellosis and its sensitivity in Karachi.

Over the past five years 25,000 blood cultures were screened for septicaemia. Of these 6.7% were positive for salmonella species, the commonest being salmonella typhi accounting for 92% of total salmonella isolates. Over the years, S. typhi showed a gradual decline ranging from 96.7 to 87%. While salmonella paratyphi A has shown a gradual increase ranging from 2.5% to 11.4%. Salmonellosis peaked in the year 1990 suggesting an epidemic. The antibiotic sensitivity pattern showed a gradual increase in resistance over the years and even resistance to the new quinolones has emerged. Thus salmonellosis poses a major threat to the community and we must look into the alternative antibiotics to combat the threat.

Vitamin E suppresses increased lipid peroxidation in cigarette smokers.

Cigarette smoke contains many xenobiotics, including oxidants and free radicals, which can increase lipid peroxidation. Recently, breath pentane output (BPO) has been recognized as a good indicator of lipid peroxidation. Vitamin E is known to be a potent free radical scavenger which can protect biological membranes against oxidative damage. We investigated the effect of vitamin E (dl-alpha-tocopherol) on lipid peroxidation in 13 healthy smokers. The results showed (1) smokers had increased BPO as compared with 19 healthy non-smokers (16.3 +/- 1.9 vs 5.8 +/- 0.5, pmol/kg body weight/min, p less than 0.001) although both groups had comparable plasma vitamin E and selenium concentrations, (2) supplementation with vitamin E (800 mg/day for 2 weeks) decreased BPO in smokers, and (3) the concentration of plasma selenium-dependent glutathione peroxidase was restored to normal in those smokers (five out of 13) in whom this was low initially. We conclude that a normal plasma concentration of vitamin E does not prevent this increase of lipid peroxidation in smokers but that substantial doses of vitamin E will significantly reduce this increased lipid peroxidation. If a major function of vitamin E is to protect lipids from peroxidation, then smokers have a conditioned insufficiency of vitamin E on a normal diet.

Increased lipid peroxidation after lipid infusion as measured by breath pentane output.

We studied the effect of intravenous lipid infusion on lipid peroxidation as measured by breath pentane. Pentane, plasma alpha-tocopherol (alpha-tox) and plasma gamma-tocopherol (gamma-toc), selenium, and Se-dependent glutathione peroxidase (Se-GSHPx) were measured in 10 normal control subjects and in 10 home parenteral nutrition (HPN) patients before and after infusion of 100 mL Nutralipid 10% over 30 min. Before infusion, breath pentane was significantly higher and alpha-toc was significantly lower in the HPN group than in the control subjects. These two measurements were significantly negatively correlated (r = -0.54, p less than 0.05). Pentane, alpha-toc, and Se-GSHPx were significantly increased in both groups after lipid was infused but were still significantly higher in HPN patients than in control subjects. Thus, infusion of a small amount of lipid rich in linoleic acid induced a significant increase in breath pentane, reflective of increased lipid peroxidation.