Management of patent foramen ovale in embolic stroke of undetermined source patients: Malaysian experts' consensus.

INTRODUCTION: About 20 to 40% of ischaemic stroke causes are cryptogenic. Embolic stroke of undetermined source (ESUS) is a subtype of cryptogenic stroke which is diagnosed based on specific criteria. Even though patent foramen ovale (PFO) is linked with the risk of stroke, it is found in about 25% of the general population, so it might be an innocent bystander. The best way to treat ESUS patients with PFO is still up for discussion. MATERIALS AND METHODS: Therefore, based on current evidence and expert opinion, Malaysian expert panels from various disciplines have gathered to discuss the management of ESUS patients with PFO. This consensus sought to educate Malaysian healthcare professionals to diagnose and manage PFO in ESUS patients based on local resources and facilities. RESULTS: Based on consensus, the Malaysian expert recommended PFO closure for embolic stroke patients who were younger than 60, had high RoPE scores and did not require long-term anticoagulation. However, the decision should be made after other mechanisms of stroke have been ruled out via thorough investigation and multidisciplinary evaluation. The PFO screening should be made using readily available imaging modalities, ideally contrasttransthoracic echocardiogram (c-TTE) or contrasttranscranial Doppler (c-TCD). The contrast-transesophageal echocardiogram (c-TEE) should be used for the confirmation of PFO diagnosis. The experts advised closing PFO as early as possible because there is limited evidence for late closure. For the post-closure follow-up management, dual antiplatelet therapy (DAPT) for one to three months, followed by single antiplatelet therapy (APT) for six months, is advised. Nonetheless, with joint care from a cardiologist and a neurologist, the multidisciplinary team will decide on the continuation of therapy.

Substrate effects on surface morphologies and magnetic properties of nanostructured FePt thin films.

The substrate effects on surface morphologies, crystal structures, and magnetic properties of the sputter-deposited FePt thin films on Corning 1737, normal glass, and Si wafer substrates, respectively, were investigated. High in-plane coercivities of 10 kOe were obtained for the air-annealed films on Corning 1737 and Si wafer, where both films similarly have granular-like morphologies. Besides, increasing grain size and surface roughness of all the FePt films with the post-anneal temperature were observed. Moreover, partially separated grains were seen in the film on Si wafer, where the formation of Fe silicides during post-anneal is suspected, in which has enhanced the magnetic ordering.

A structural rearrangement in the sodium channel pore linked to slow inactivation and use dependence.

Voltage-gated sodium (Na(+)) channels are a fundamental target for modulating excitability in neuronal and muscle cells. When depolarized, Na(+) channels may gradually enter long-lived, slow-inactivated conformational states, causing a cumulative loss of function. Although the structural motifs that underlie transient, depolarization-induced Na(+) channel conformational states are increasingly recognized, the conformational changes responsible for more sustained forms of inactivation are unresolved. Recent studies have shown that slow inactivation components exhibiting a range of kinetic behavior (from tens of milliseconds to seconds) are modified by mutations in the outer pore P-segments. We examined the state-dependent accessibility of an engineered cysteine in the domain III, P-segment (F1236C; rat skeletal muscle) to methanethiosulfonate-ethylammonium (MTSEA) using whole-cell current recordings in HEK 293 cells. F1236C was reactive with MTSEA applied from outside, but not inside the cell, and modification was markedly increased by depolarization. Depolarized F1236C channels exhibited both intermediate (I(M); tau approximately 30 ms) and slower (I(S); tau approximately 2 s) kinetic components of slow inactivation. Trains of brief, 5-ms depolarizations, which did not induce slow inactivation, produced more rapid modification than did longer (100 ms or 6 s) pulse widths, suggesting both the I(M) and I(S) kinetic components inhibit depolarization-induced MTSEA accessibility of the cysteine side chain. Lidocaine inhibited the depolarization-dependent sulfhydryl modification induced by sustained (100 ms) depolarizations, but not by brief (5 ms) depolarizations. We conclude that competing forces influence the depolarization-dependent modification of the cysteine side chain: conformational changes associated with brief periods of depolarization enhance accessibility, whereas slow inactivation tends to inhibit the side chain accessibility. The findings suggest that slow Na(+) channel inactivation and use-dependent lidocaine action are linked to a structural rearrangement in the outer pore.

Treatment of pain in cancer patients by intrathecal administration of dynorphin.

Dynorphin-(1-13) and -(1-10) were administered by intrathecal injection into six terminal cancer patients at doses of 7.5, 15, 30 and 60 micrograms. Compared with saline, both analogues of dynorphin were effective in suppressing pain. The duration of relief at doses of 15 micrograms and above was more than 4 hours on the average for both peptides. However, no proportional increase in response was observed when the dose applied was doubled. This lack of response might have been due to the development of tolerance.

Intrathecal administration of beta-endorphin and dynorphin-(1-13) for the treatment of intractable pain.

Seven cases of chronic pain were treated by intrathecal administration of 30 micrograms of beta-endorphin and dynorphin-(1-13). Compared with saline, both peptides were able to suppress pain for periods up to 4.5 and 7 hours on the average, respectively. No significant side reactions were noticed during the entire investigation.

Sporotrichosis: a case report and successful treatment with itraconazole.

We report the case of a 51-year-old man who presented with a six-month history of a slowly growing plaque on the right ring finger and nodules over the right arm. Cultures grew Sporothrix schenckii. He was treated with itraconazole, 100 mg daily, with complete resolution of the lesions after five months of therapy. The differential diagnoses and the various modalities of treatment are emphasized.

Cutaneous leishmaniasis: a report of two cases seen at a tertiary dermatological centre in Singapore.

Cutaneous leishmaniasis (CL) is not common in South-East Asia and often presents as a granulomatous plaque on the exposed areas, with a high index of suspicion required for diagnosis. Two such cases were seen at the National Skin Centre recently, and both were Gurkha men with a history of travel to Belize. They were treated with intravenous sodium stibogluconate with success. A discussion on CL and its management follows.

Primary malignant lymphoma of the cervix uteri: a case report.

Primary reticuloendothelial disease of the genital tract is an extremely rare condition. We encountered one such patient with diffuse large cell malignant lymphoma of the cervix uteri who presented with irregular vaginal bleeding. After complete haematological and radiological investigations, satisfactory treatment of the Stage I disease was achieved with total hysterectomy, bilateral salpingo-oophorectomy and post-operative pelvic irradiation.

Cutaneous metastases--an uncommon and unusual mode of presentation of gastric carcinoma.

Cutaneous and oral mucosal metastases from gastric carcinoma are very uncommon. It is even more uncommon and unusual to have a patient with gastric carcinoma whose mode of presentation is that of "skin nodule" (cutaneous metastases). We report one such patient, who was first seen in a skin clinic, then in a dental clinic, and finally was referred to a medical clinic. Current literature on cutaneous metastases of gastric carcinoma is reviewed in this case report.

Cutaneous Rosai-Dorfman disease--a pathologic review of 2 cases.

Rosai-Dorfman disease, also known as sinus histiocytosis with massive lymphadenopathy, is a rare but distinct clinicopathologic entity characterised histologically by a benign s histiocytic proliferation. Isolated involvement of extranodal sites without concomitant nodal disease is rare. We describe the pathological features of 2 cases of Rosai-Dorfman disease that were clinically confined to the skin. In both male adult Chinese patients, proliferation of histiocytes was accompanied by S-100 protein expression demonstrated immunohistochemically within the histiocytes. The pathology of Rosai-Dorfman disease and its microscopic differential diagnoses are discussed.

Clinicopathological and immunohistological correlation of malignant lymphomas of the skin.

The study utilised monoclonal antibodies for T and B cells to study the immunophenotype in our lymphomas and to correlate with the clinicopathological aspects of eight cases of malignant lymphomas, of which four are cutaneous T cell lymphoma and four malignant lymphomas. The method used was immunohistochemical staining of tissue section by the alkaline phosphatase anti-alkaline phosphatase (APAAP) procedure. For four cases of cutaneous T cell lymphoma, three were in stage 1 and one in stage 2. The immunophenotypes were typical of mycosis fungoides-type cutaneous T cell lymphoma. They were predominantly T cells with many mature T cells. The CD4 to CD8 ratio fell within the normal range. There was no specific loss of CD7. For four cases of malignant lymphoma, T cell type, the pattern was again T cell phenotype with all of CD2, CD5, CD7 and CD4. The CD4 to CD8 ratios fell within the normal range except for one case, which showed a reversal of CD4/CD8, and this patient perished. His T suppressor cells were increased and had several cycles of malignant flare-up. One case showed mycosis fungoides, converting to lymphoma. This study demonstrates that monitoring of the progress is possible and can detect downgrading of malignant lymphomas.

Multicentric reticulohistiocytosis.

This is a short report on the first case of a multicentric reticulohistiocytosis diagnosed at Middle Road Hospital in 1987. He presented with multiple reddish brown papules and nodules but without arthritis. Systemic review did not show any associated malignancies. Treatment with methotrexate has not been useful. Multicentric Reticulohistiocytosis is a proliferative histiocytic disorder that is benign. It is characterised by a dermatoarthritis, extensive red nodule and a rheumatoid-like arthritis. Histologically, multinucleated giant cells in ground glass cytoplasma and mononuclear histiocytes form the granulomatous infiltrate that invades the dermis, mucosa, synovium and others--bone, plasma, pericardium etc.

Bowenoid papulosis: a recent entity in sexually transmitted diseases.

Bowenoid papulosis is a recent phenomenon of multiple lesions with a histology of carcinoma in situ appearing on the genitals of young men. We report 6 male patients with this condition presenting with warty and/or lichen planus like lesions on the genitals. The histology shows carcinoma in situ. Three (50%) showed spontaneous regression, and the rest had persistence and recurrence. Repeat biopsy of one recurrent lesion showed a verruca. The evidence for a possible viral aetiology will be discussed. Long term studies are required to assess any oncogenic potential. As it is thought to be presently a viral infection with epidermal atypia, effective conservative management is sufficient.

A case of angiosarcoma of the scalp.

This is a report of a second case of angiosarcoma of the scalp occurring in an Oriental. In spite of surgical excision, radiotherapy and chemotherapy the tumour not only recurred but new lesions appeared. She developed liver metastases and died from chest complications 4 1/2 years after the initial presentation of the tumour. The clinical features, histology and treatment of angiosarcomas of the scalp are briefly discussed.

Erythema nodosum leprosum in Singapore.

Erythema Nodosum Leprosum (ENL) or Type II reaction is an immune complex syndrome seen in multibacillary leprosy. 20 patients with histological confirmation of ENL in leprosy were studied from 1982 to 1986. These patients had a range of clinical signs, from fever, tender dusky nodules, bullae, ulcers to lymphadenopathy, arthralgia and neuritis. The four major histological patterns are: a) classical pattern showing heavy infiltrations of neutrophils in three cases, b) sub-epidermal bulla pattern with marked oedema of the upper dermis, and collections of neutrophils in five cases, c) vasculitis pattern, affecting superficial and mid-dermal vessels, leading to epidermal necrosis, bulla formation and ulceration. Dilated vessels, congestion, lumenal fibrin clots and fibrinoid necrosis of vessels were seen, d) non-specific picture in nine cases with mild oedema, infiltration with neutrophils, and two cases with minimal reaction had chronic ENL with clinical vasculitis. All the five cases with vasculitis showed C1q, C3 and fibrinogen in the vessels. Comparing ENL reactions reported in Asia, our pattern is similar to that of Malaysians with the majority showing sub-epidermal oedema. Vasculitis is more common in India. Oedema with collagen necrosis as seen in acute ENL with iritis in New Guinea. The Lucio's phenomenon was not seen in any of the countries in Asia.

Carcinosarcoma of the urinary bladder--case report and literature review.

We describe a patient who presented with gross haematuria and dysuria. Investigations confirmed a bladder tumour, for which transurethral resection was done. The histology showed a carcinosarcoma, which was muscle invasive but organ-confined. The patient refused radical surgery and underwent a course of radical radiotherapy. He died 14 months later. Carcinosarcoma of the urinary bladder is a rare, mixed malignant tumour, composed of mesenchymal and epithelial elements. It is commoner in elderly men. It is an aggressive tumour with a short clinical course, and must be distinguished from collision tumours and spindle cell tumours. Immunohistochemical stains are useful in its diagnosis. It is probably best managed by radical surgery with or without adjuvant therapy, but because of the small number of incidences reported, there is no universal agreement on its therapy.

Malignancy arising in seborrheic keratosis: a report of two cases.

We describe the pathological features of two cases of malignant transformation occurring in seborrheic keratosis. The lesions affected elderly individuals: a 79-year-old Chinese lady and a 79-year-old Chinese gentleman, both of whom had long-standing seborrheic keratoses with recent increase in size. Histologically, the malignancies identified were invasive well-differentiated squamous cell carcinoma and Bowen's disease (squamous carcinoma in situ), respectively. Pre-existing seborrheic keratoses demonstrating a zone of transition into the malignant foci were present. Aetiologic factors that have been proposed to explain these exceedingly rare occurrences have included prolonged sun damage and chronic low dose radiation exposure.

Renal cell carcinoma presenting as a solitary thyroid nodule.

An unusual case of renal cell carcinoma of the right kidney with a solitary thyroid metastasis as the only presenting symptom is reported. Right thyroid lobectomy was done followed by right radical nephrectomy. A solitary metastasis of the renal cell carcinoma has a much better prognosis than the usual stage IV tumours and an aggressive management with radical nephrectomy and excision of the solitary metastasis is advocated.

Coexisting follicular mucinosis and mycosis fungoides--a case report.

This is a case report of a patient with mycosis fungoides coexisting with follicular mucinosis. The simultaneous occurrence of these two conditions has been documented. There is controversy as to whether mycosis fungoides in patients with follicular mucinosis arises de novo or whether follicular mucinosis can evolve into mycosis fungoides. The relationship between the two conditions is discussed.

Squamous cell carcinoma arising in a cutaneous epidermal cyst--a case report.

INTRODUCTION: Cutaneous epidermal cysts are common lesions, but fortunately, malignant transformation of their epithelium is rare. There are only a few cases mentioned in recent literature, mostly occurring in epidermal cysts in the head and neck region. CLINICAL PICTURE: We present a case of malignant transformation in a long-standing buttock epidermal cyst, presenting a month after trauma to the cyst. TREATMENT: An excision biopsy and rotation flap was done. When the pathology was confirmed, a second resection was carried out and the defect covered with a free latissimus dorsi flap, a buttock rotation flap and a posterior thigh rotation flap. CONCLUSION: Although malignant transformation is rare, this case illustrates the importance of routine histology in excision of epidermal cysts.