Clinicopathological study of gastric cancer in a Malaysian tertiary public health care centre.

INTRODUCTION: Gastric cancer (GC) is one of the leading causes of all new cancer cases globally. Although it is no longer reported in the top 10th most common cancer in Malaysia, geographical distribution and ethnic influences still obviously exist. MATERIALS AND METHODS: This is a retrospective analysis of histopathological records in a public tertiary health care centre in Malaysia. The computerised laboratory information system from the histopathology department of the hospital was retrieved for the period of 2005-2018. Descriptive analysis was done using Microsoft Excel. RESULTS: There was a total of 233 histologically confirmed GC cases. The burden of GC was observed to be an increasing trend from 2016 onwards. Among them, 64% were male and 36% were female. The youngest age of diagnosis was 19, while the oldest one was 93. Malaysian Chinese were found to have the highest incidences (41.63%), followed by Malays (32.19%) and Malaysian Indians (23.61%). All cases were of adenocarcinoma cell types and were found to have poorly differentiated in majority at the time of diagnosis. CONCLUSION: Although this report only represents one tertiary health care centre in Malaysia, the Indian Enigma was still observed, as stated in other literatures. Over time, the incidence of GC in Malays has increased. Consideration of lifestyle modifications, health education and Helicobacter pylori eradication in various nations' National Health Insurance plans, are encouraged as prevention is always better than treatment or cure, including the cost load.

A 5-year clinicopathological study on microscopic colitis at a Malaysian tertiary hospital.

INTRODUCTION: Microscopic colitis (MC) is a well-recognised cause of chronic diarrhoea in Western countries. It is classically associated with normal endoscopic findings and a higher prevalence among patients with autoimmune disease. Local information regarding this disease remains scarce. We identified patients diagnosed with MC over a five-year period, and then proceeded to analyse the clinical characteristics of these cases. MATERIALS AND METHODS: A retrospective study was conducted by identifying all histologically confirmed colitis cases diagnosed at Hospital Universiti Sains Malaysia from January 2015 until December 2019. Clinicodemographic data was retrieved from case notes of patients. RESULTS: Of the 299 cases with histological colitis, 23 (7.7%) were initially identified as MC. Two cases had incomplete data, while two others were excluded as the diagnoses were revised to inflammatory bowel disease. An incidence of 14 MC cases/1000 case-year was obtained using the 21 MC cases seen within the five-year period. MC subtypes for the 19 analysed cases i.e., lymphocytic colitis and collagenous colitis accounted for 13 (68.4%) and 6 (31.6%) cases, respectively. Eleven patients (57.9%) were females (M:F ratio 1:1.5) with a median age of 51 years. Only nine (47.3%) presented with diarrhoea; one subject (5.4%) had an autoimmune condition (Hashimoto thyroiditis). Normal endoscopic findings were found in 89.5% of patients. CONCLUSION: Approximately half of the subjects in our study who had histologically confirmed MC did not present with diarrhoea. Adequate biopsy samples despite normal colonoscopy findings are important in order to not miss the diagnosis of MC.

The effect of a consortium of Penicillium sp. and Bacillus spp. in suppressing banana fungal diseases caused by Fusarium sp. and Alternaria sp.

AIMS: This study sought to utilize indigenous soil micro-organisms to suppress wilt-causing fungal pathogens of the banana. METHODS AND RESULTS: Fungal pathogens were isolated from wilt-affected rhizospheric soil, and potential antagonistic bacterial strains were isolated from healthy rhizospheric soil in the same area from which fungal pathogens were isolated. The antifungal activity of isolated micro-organisms against fungal pathogens was studied both in vitro and in vivo against fungal pathogens. It was found that Fusarium oxysporum and Alternaria sp. were pathogenic, while Penicillium sp., Bacillus velezensis and Bacillus subtilis were antagonistic. Moreover, it was seen that B. velezensis, B. subtilis and Penicillium sp. inhibited the growth of the two fungal pathogens in both in vitro and in vivo experiments. Further investigation indicated that B. velezensis, B. subtilis and Penicillium sp. were able to produce enzymatic antifungal compounds (chitinase and ß-1,3-glucanase). The spray application around rhizome revealed that a combination of Bacillus spp. and Penicillium sp. in greenhouse conditions gave the highest reduction in disease severity by up to 60% to both fungal pathogens among the treatments. CONCLUSIONS: Banana disease is seen to be induced not only by F. oxysporum but also by Alternaria sp. The isolated indigenous micro-organisms can effectively control both the pathogens. The combination of isolated antagonistic micro-organisms has thus demonstrated substantial potential for suppressing banana disease. SIGNIFICANCE AND IMPACT OF THE STUDY: An antagonistic consortium isolated in this study has demonstrated remarkable potential for controlling fungal diseases caused by Fusarium sp. and Alternaria sp. Therefore, the use of indigenous microflora to improve disease suppression of banana plants against soil-borne pathogens is a preferable approach.

Biosecurity in endemic foot and mouth disease settings: a case study of foot and mouth disease vaccination in South-East Asia.

Foot and mouth disease (FMD) is a highly contagious viral infection affecting cloven-hoofed animals including cattle, buffalo, sheep, goats and pigs. The disease is endemic in several parts of Asia, as well as most of Africa and the Middle East. In 1997, the World Organisation for Animal Health (OIE) established the South-East Asia Foot and Mouth Disease Campaign with the aim of increasing livestock sector productivity and economic output through the control and eradication of FMD in South-East Asia. Large-scale vaccination of livestock against FMD has in the past led to the successful eradication (or control) of the disease, for example in the Philippines. However, despite the benefit associated with large-scale vaccination, biosecurity risks can be created by vaccination teams moving between locations. It is therefore recommended that biosecurity measures are used by vaccination teams to prevent inadvertent disease spread. The majority of existing guidelines are focused on high-risk situations such as exotic animal disease outbreaks in developed countries, or agents posing a risk to human health. This paper describes the development of novel biosecurity guidelines for vaccination teams in South-East Asia. To achieve this, available literature was scanned followed by in-country workshops and field-testing of draft materials. Entry and exit procedures are laid out within the context of five core rules that follow the biosecurity principles of situational awareness, segregation, cleaning and disinfection. Guidelines and accompanying fact sheets were translated into local languages and included in a comprehensive vaccination training programme for all vaccination teams undertaking cattle FMD vaccination programmes in the New Zealand OIE FMD control project target countries (Myanmar and Laos). The material developed has wide practical relevance to veterinarians, traditional healers and village or community animal health workers, who all pose a heightened risk of spreading infectious agents.

La fièvre aphteuse est une maladie virale extrêmement contagieuse affectant les artiodactyles (dont les bovins, les buffles, les ovins, les caprins et les porcins). La maladie est présente à l'état endémique dans plusieurs régions d'Asie, dans presque toute l'Afrique et au Moyen-Orient. En 1997, l'Organisation mondiale de la santé animale (OIE) a lancé la Campagne de lutte contre la fièvre aphteuse en Asie du Sud-Est afin d'améliorer la productivité et la rentabilité économique du secteur de l'élevage à travers la lutte contre la fièvre aphteuse voire son éradication de la sous-région. Grâce à la vaccination à grande échelle du bétail, certains pays ont pu éradiquer (ou du moins contrôler) la fièvre aphteuse dans le passé, par exemple les Philippines. Si la vaccination à grande échelle est en soi bénéfique, elle comporte certains risques de biosécurité, liés aux déplacements des équipes de vaccination d'un site à l'autre. Il est donc recommandé que ces équipes appliquent des mesures de biosécurité visant à prévenir toute propagation accidentelle de la maladie. La plupart des lignes directrices existantes sont axées sur les situations présentant un niveau de risque élevé, par exemple la survenue de foyers de maladies animales exotiques dans les pays développés, ou d'agents pathogènes qui constituent un risque pour la santé publique. Dans cet article, les auteurs décrivent la méthodologie suivie pour élaborer des lignes directrices innovantes de biosécurité en Asie du Sud-Est, destinées aux équipes de vaccination. Ces lignes directrices ont été rédigées en passant en revue la littérature sur le sujet lors d'ateliers nationaux et en testant sur le terrain les projets de documents. Les procédures d'entrée et de sortie ont été établies en suivant cinq règles fondamentales fondées sur les grands principes de la biosécurité, à savoir la connaissance de la situation, la ségrégation, le nettoyage et la désinfection. Les lignes directrices et les fiches explicatives qui les accompagnent ont été traduites en langues locales et utilisées dans le cadre d'un programme complet de formation à la vaccination destiné à l'ensemble des équipes de vaccination participant aux programmes de vaccination du cheptel bovin contre la fièvre aphteuse dans les pays couverts par le projet Nouvelle-Zélande­OIE de lutte contre la fièvre aphteuse (Myanmar et Laos). Les matériels proposés présentent une utilité concrète pour les vétérinaires, les guérisseurs traditionnels et les auxiliaires communautaires ou villageois de santé animale, qui sont tous particulièrement exposés au risque de propager involontairement des agents de maladies infectieuses.

La fiebre aftosa es una infección vírica muy contagiosa que afecta a animales biungulados como el ganado vacuno, el búfalo, la oveja, la cabra o el cerdo. La enfermedad es endémica en varias zonas de Asia y en la mayor parte de África y Oriente Medio. En 1997, la Organización Mundial de Sanidad Animal (OIE) instituyó la «Campaña de lucha contra la fiebre aftosa en el Sudeste asiático¼ con el objetivo de que el control y la erradicación de la enfermedad en la región se tradujeran en un aumento de la productividad y la rentabilidad económica del sector ganadero. En ocasiones anteriores la vacunación a gran escala del ganado ya ha resultado eficaz para erradicar (o controlar) la fiebre aftosa, por ejemplo en Filipinas. Sin embargo, pese a los beneficios que depara la vacunación a gran escala, los equipos que la llevan a cabo, al desplazarse de una a otra localidad, también pueden vehicular nuevos riesgos biológicos. Por ello se recomienda que esos equipos apliquen medidas de seguridad biológica destinadas a impedir la propagación accidental de la enfermedad. La mayoría de las directrices existentes al respecto están centradas en situaciones de gran riesgo, como brotes de enfermedades animales exóticas en países desarrollados o presencia de agentes infecciosos que entrañan peligro para la salud pública. Los autores describen la elaboración de nuevas directrices de seguridad biológica dirigidas a los equipos de vacunación que operan en el Sudeste asiático. Para empezar se hizo un repaso de la bibliografía existente, tras lo cual se celebraron talleres nacionales y se ensayaron sobre el terreno las medidas preconizadas en un primer borrador. Como parte de las directrices se instauran procedimientos de entrada y salida encuadrados en cinco reglas básicas que se ajustan a los grandes principios de seguridad biológica: conocimiento de la situación, segregación, limpieza y desinfección. Las directrices y las fichas descriptivas que las acompañan, una vez traducidas a los idiomas locales, fueron incluidas en un programa integral de formación en vacunaciones dirigido a todos los equipos que se disponían a intervenir en programas de vacunación antiaftosa del ganado en Myanmar y Laos, países beneficiarios del proyecto Nueva Zelanda­OIE de lucha contra la fiebre aftosa. El material elaborado reviste gran utilidad práctica para los veterinarios, curanderos tradicionales y trabajadores zoosanitarios de aldeas y comunidades, todos ellos portadores de un riesgo especialmente importante de propagar agentes infecciosos.

IPT during HIV treatment in Myanmar: high rates of coverage, completion and drug adherence.

Setting: A southern Myanmar district providing isoniazid preventive therapy (IPT) in one of the last countries to formally recommend it as part of human immunodeficiency virus (HIV) care. Objective: To assess coverage and adherence and the feasibility of IPT scale-up in a routine care setting in Myanmar. Design: A retrospective analysis of people living with HIV (PLHIV) screened for tuberculosis (TB) and enrolled in IPT over a 3-year period (July 2011-June 2014) using clinical databases. Results: Among 3377 patients under HIV care and screened for TB, 2740 (81.1%) initiated IPT, with 2651 (96.8%) completing a 6- or 9-month course of IPT; 83 (3.1%) interrupted treatment for different reasons, including loss to follow-up (n = 41), side effects (n = 15) or drug adherence issues (n = 9); 6 (0.2%) died. Among the IPT patients, 33 (1.2%) were diagnosed with TB, including 9 (0.3%) while on IPT and 24 (0.9%) within 1 year of completion of therapy. Among the PLHIV who completed IPT, one case of isoniazid resistance was detected. Conclusion: Scaling up IPT in Myanmar HIV settings is feasible with high rates of drug adherence and completion, and a low rate of discontinuation due to side effects. IPT scale-up should be prioritised in HIV clinical settings in Myanmar.

Contexte : Un district du sud du Myanmar fournissant le traitement préventif par isoniazide (IPT) dans l'un des derniers pays à le recommander formellement comme élément de la prise en charge de l'infection par le virus de l'immunodéficience humaine (VIH).Objectif : Evaluer la couverture, l'adhérence et la faisabilité d'une accélération de l'IPT dans un contexte de soins de routine au Myanmar.Schéma : Analyse rétrospective de personnes vivant avec le VIH (PVVIH) dépistés pour la tuberculose (TB) et enrôlés dans l'IPT sur une période de 3 ans, de juillet 2011 à juin 2014, grâce à des bases de données cliniques.Résultats : Sur 3377 patients pris en charge pour le VIH et dépistés pour la TB, 2740 (81,1%) ont mis en route le TPI, dont 2651 (96,8%) ont achevé un traitement préventif de 6 ou 9 mois ; 83 (3,1%) ont interrompu leur traitement pour différentes raisons incluant les pertes de vue (n = 41), les effets secondaires (n = 15) ou des problèmes d'adhérence au médicament (n = 9), et six (0,2%) sont décédés. Parmi les patients IPT, 33 (1,2%) ont eu un diagnostic de TB, dont 9 (0,3%) pendant la prophylaxie et 24 (0,9%) dans l'année qui a suivi la fin de l'IPT. Un cas de résistance à l'isoniazide a été détecté parmi les PVVIH qui ont achevé l'IPT.Conclusion: L'accélération de l'IPT dans les structures VIH du Myanmar est faisable, avec un taux élevé d'adhérence au médicament et d'achèvement et un taux faible d'arrêt du traitement dû à des effets secondaires. L'accélération de l'IPT devrait être considérée comme une priorité dans les structures cliniques VIH du Myanmar.

Marco de referencia: Un distrito del sur de Birmania que provee el tratamiento preventivo con isoniazida (IPT). Birmania es uno de los últimos países que incluyó esta profilaxis en las recomendaciones formales de atención de la infección por el virus de la inmunodeficiencia humana (VIH).Objetivo: Evaluar la cobertura, el cumplimiento terapéutico y la factibilidad de ampliar la escala de aplicación del IPT en un entorno de tratamiento corriente en Birmania.Método: Fue este un análisis retrospectivo de personas con infección por el VIH, en quienes se practicó la detección sistemática de la tuberculosis (TB) y se registraron para recibir el IPT. Se obtuvo la información a partir de las bases de datos clínicos durante un período de 3 años, de julio del 2011 hasta junio del 2014.Resultados: De los 3377 pacientes que recibían atención por infección por el VIH, con investigación sistemática de la TB, 2740 iniciaron el TPI (81,1%) y 2651 completaron un esquema de 6 o 9 meses de profilaxis (96,8%). Ochenta y tres pacientes interrumpieron por razones diversas el tratamiento (3,1%), entre ellas, la pérdida durante el seguimiento (n = 41), los efectos secundarios (n = 15) o los problemas de cumplimiento terapéutico (n = 9) y seis pacientes fallecieron (0,2%). De los pacientes que recibieron IPT, en 33 se diagnosticó TB (1,2%), en 9 de ellos durante la profilaxis (0,3%) y en 24 casos durante el primer año después de haber completado el esquema (0,9%). Se detectó un caso de resistencia a isoniazida en las personas infectadas por el VIH que completaron el IPT.Conclusiôn: La ampliación de escala del IPT en los entornos de atención de la infección por el VIH es factible en Birmania y se pueden alcanzar altas tasas de cumplimiento terapéutico y compleción del esquema, con una baja tasa de interrupción debida a efectos colaterales. Es importante dar prioridad a la ampliación de escala del IPT en los medios de atención de la infección por el VIH en el país.

Primary mediastinal large B-cell lymphoma and its mimickers: a rare case report with literature review.

Primary mediastinal large B-cell lymphoma (PMLBL) is an uncommon non-Hodgkin lymphoma with a distinct clinicopathological entity in the WHO classification of lymphoid malignancies. It is known to originate from B-cells of the thymus. It mimics thymic neoplasms and other lymphomas clinically and histopathologically. We reported a 33-year-old obese man who presented with shortness of breath off and on for 4 years. Radiologically, there was a huge anterior mediastinal mass. Tru-cut biopsy was initially diagnosed as type-A thymoma. Histopathological examination of the excised specimen revealed PMLBL with stromal fibrosis and sclerosis which created a diagnostic difficulty. The neoplastic cells varied from medium-sized to large pleomorphic cells, including mononuclear cells with centroblastic and immunoblastic features as well as bi-lobed Reed Sternberg (RS)-like cells and horse-shoe like hallmark cells. Some interlacing spindle cells and epithelioid cells were also present. Immunohistochemically, tumour cells expressed diffuse positivity for LCA, CD20, CD79a, CD23, Bcl2, MUM-1 and heterogenous positivity for CD30 and EMA, and were negative for CD10, CD15 and ALK. Ki67 scoring was very high. Tumour cells infiltrated into peri-thymic fat and pericardium. No malignant cells were detected in the pleural fluid and there was no bone marrow infiltration. The patient showed partial response to 6 cycles of RICE chemotherapy, and was planned for second line chemotherapy using hyper-CVAD regimen followed by autologous stem cell transplantation. This case illustrates the importance of thorough sampling and immunohistochemistry in differentiating PMLBL from its differential diagnoses.

Timing of antiretroviral therapy and TB treatment outcomes in patients with TB-HIV in Myanmar.

SETTING: Integrated HIV Care programme, Mandalay, Myanmar. OBJECTIVES: To determine time to starting antiretroviral treatment (ART) in relation to anti-tuberculosis treatment (ATT) and its association with TB treatment outcomes in patients co-infected with tuberculosis (TB) and the human immunodeficiency virus (HIV) enrolled from 2011 to 2014. DESIGN: Retrospective cohort study. RESULTS: Of 1708 TB-HIV patients, 1565 (92%) started ATT first and 143 (8%) started ART first. Treatment outcomes were missing for 226 patients and were thus not included. In those starting ATT first, the median time to starting ART was 8.6 weeks. ART was initiated after 8 weeks in 830 (53%) patients. Unsuccessful outcome was found in 7%, with anaemia being an independent predictor. In patients starting ART first, the median time to starting ATT was 21.6 weeks. ATT was initiated within 3 months in 56 (39%) patients. Unsuccessful outcome was found in 12%, and in 20% of those starting ATT within 3 months. Patients with CD4 count <100/mm(3) had a four times higher risk of an unsuccessful outcome. CONCLUSIONS: Timing of ART in relation to ATT was not an independent risk factor for unsuccessful outcome. Extensive screening for TB with rapid and sensitive diagnostic tests in HIV-infected persons and close monitoring of anaemia and immunosuppression are recommended to further improve TB treatment outcomes among patients with TB-HIV.

Contexte : Programme intégré de prise en charge du virus de l'immunodéficience humaine (VIH), Mandalay, Myanmar.Objectifs : Chez les patients atteints de tuberculose (TB) et VIH enrôlés entre 2011 et 2014, déterminer la date du début du traitement antirétroviral (TAR) en relation avec le traitement antituberculeux (ATT) et son association avec le résultat d'ATT.Schéma : Etude rétrospective de cohorte.Résultats : Sur 1708 patients TB-VIH, 1565 (92%) ont débuté l'ATT en premier et 143 (8%) ont commencé le TAR en premier. Le résultat du traitement a été manquant pour 226 patients qui n'ont pas été inclus. Chez les patients ayant débuté l'ATT en premier, le délai médian de mise en route du TAR a été de 8,6 semaines. L'initiation du TAR a été retardée d'un délai médian de 8 semaines chez 830 (53%) patients. Parmi ces patients, 7% ont eu un résultat médiocre, avec une anémie qui a constitué un facteur de risque indépendant. Chez les patients ayant débuté le TAR en premier, le délai médian de mise en route de l'ATT a été de 21,6 semaines. L'ATT a été initié au cours des 3 mois chez 56 (39%) patients. Le traitement a échoué chez 12% des patients et chez 20% de ceux qui ont débuté l'ATT dans les 3 mois. Les patients ayant des CD4 <100/mm3 ont eu un risque quatre fois plus élevé d'échec.Conclusions: La chronologie du TAR en rapport avec l'ATT n'a pas été un facteur de risque indépendant d'échec du traitement. Un dépistage extensif de la TB avec des tests de diagnostic rapides et sensibles chez les personnes infectées par le VIH et un suivi étroit de l'anémie et de l'immunosuppression sont recommandés afin d'améliorer encore le résultat du traitement de TB parmi les patients TB-VIH.

Marco de referencia: El programa integrado de atención de la infección por el virus de la inmunodeficiencia humana (VIH) en Mandalay, en Birmania.Objetivos: Determinar el lapso entre el comienzo del tratamiento antirretrovírico (ART) y el inicio del tratamiento antituberculoso (ATT) en los pacientes coinfectados registrados del 2011 al 2014 y su asociación con el desenlace del ATT.Método: Fue este un estudio retrospectivo de cohortes.Resultados: De los 1708 pacientes coinfectados por el VIH y la tuberculosis (TB), 1565 iniciaron primero el ATT (92%) y 143 comenzaron en primer lugar el ART (8%). Se excluyeron 226 casos que carecían de registro del desenlace terapéutico. En los pacientes que iniciaron en primer lugar el ATT, la mediana del lapso hasta el comienzo del ART fue 8,6 semanas; este tratamiento se inició después de 8 semanas en 830 pacientes (53%). Se observó un desenlace terapéutico desfavorable en 7% de estos pacientes; la principal variable independiente asociada fue la presencia de anemia. Cuando el ART se inició en primer lugar, la mediana hasta el comienzo del ATT fue 21,6 semanas; este tratamiento se inició durante los 3 primeros meses en 56 pacientes (39%). Se observó un desenlace terapéutico desfavorable en 12% de estos pacientes y en 20% de los pacientes que iniciaron el ART en los primeros 3 meses. El riesgo de un desenlace desfavorable fue cuatro veces más alto en los pacientes con un recuento de linfocitos CD4 <100 células/mm3.Conclusión: La coordinación cronológica del ART y el ATT no representó un factor independiente de riesgo de obtener un desenlace desfavorable. Se recomienda la detección sistemática de la TB en los pacientes infectados por el VIH mediante pruebas diagnósticas rápidas y sensibles y una supervisión cuidadosa de la anemia y la inmunodepresión, con el objeto de obtener aun mejores desenlaces del ATT en los pacientes aquejados de coinfección TB-VIH.

Tratamiento endovascular exitoso de aneurisma de aorta torácica secundario a infección de catéter de arteria umbilical en un recién nacido pretérmino / Successful endovascular treatment of thoracic aortic aneurysm secondary to infection of the umbilical artery catheter in preterm infants

Los aneurismas aórticos en la población pediátrica son poco frecuentes. El uso de catéteres de arteria umbilical en neonatos se ha asociado a infección y en algunas oportunidades a formación de aneurismas aórticos. La reparación quirúrgica de estos aneurismas es una forma de terapia; sin embargo, la intervención percutánea con stents pudiese proveer una vía alternativa de tratamiento con menores complicaciones. El objetivo de este reporte es dar a conocer el alcance terapéutico de un procedimiento híbrido, en el que el desarrollo de la técnica quirúrgica y percutánea en conjunto ofrece otra alternativa terapéutica menos invasiva que la cirugía vascular abierta, para la reparación de aneurismas aórticos o de sus ramas principales. Caso clínico: Recién nacido de pretérmino, 30 semanas, peso 1.335 g. Se instaló catéter en arteria umbilicar que se retiró a los 14 días por infección. Evolucionó con sepsis a Staphylococcus aureus. Ecocardiograma y angiotac confirman AAT, se manejó mediante procedimiento híbrido, cirugía e instalación endovascular de 2 stents recubiertos (Atrium V12 XR Medical Corp, Hudson, NH). Los controles clínicos post procedimiento como la ecotomografía abdominal confirmaron el éxito del tratamiento. Conclusión: El procedimiento endovascular de reparación de aneurisma de la aorta en recién nacidos prematuros puede ser considerado en el momento de decir la terapéutica de esta enfermedad y podría evitar los riesgos asociados a cirugía abierta. Sin embargo, obliga a un seguimiento y control durante el crecimiento del paciente por la eventual necesidad de redilatar los stents implantados. Se desconoce cómo será la evolución de los procedimientos endovasculares neonatales en el futuro.

Aortic aneurysms (AA) in the paediatric population are uncommon. The use of umbilical catheters in neonates has been associated with infections and, on some occasions, the formation of aortic aneurysms. The surgical repair of these aneurysms is one type of treatment; however, percutaneous intervention with stents could provide an alternative treatment route, with fewer complications. The aim of this report is to present the therapeutic scope of a hybrid procedure, in which the combined surgical and percutaneous technique offers a less invasive alternative to open surgery for the repair of aortic aneurysms or their main branches. Clinical case: The case concerns a pre-term newborn of 30 weeks weighing 1,335 g. An umbilical catheter was introduced, which was withdrawn at 14 days due to an infection. It developed as Staphylococcus aureus with sepsis. The echocardiogram and Angio-CT confirmed AA, which were managed using a hybrid procedure of surgery and the endovascular implantation of 2 coated stents (Atrium V12 XR Medical Corp, Hudson, NH). The post-procedure clinical follow-ups, including abdominal echo-tomography, confirmed the success of the treatment. Conclusion: The endovascular aortic aneurysm repair procedure in premature newborns may be considered when deciding treatment of this disease, and could avoid the risks associated with open surgery. However, follow-up and monitoring is required while the patient grows up, due to the possibility that the implanted stents require re-dilating. The outcomes of neonatal endovascular procedures in the future are unknown.

[Successful endovascular treatment of thoracic aortic aneurysm secondary to infection of the umbilical artery catheter in preterm infants]. / Tratamiento endovascular exitoso de aneurisma de aorta torácica secundario a infección de catéter de arteria umbilical en un recién nacido pretérmino.

UNLABELLED: Aortic aneurysms (AA) in the paediatric population are uncommon. The use of umbilical catheters in neonates has been associated with infections and, on some occasions, the formation of aortic aneurysms. The surgical repair of these aneurysms is one type of treatment; however, percutaneous intervention with stents could provide an alternative treatment route, with fewer complications. The aim of this report is to present the therapeutic scope of a hybrid procedure, in which the combined surgical and percutaneous technique offers a less invasive alternative to open surgery for the repair of aortic aneurysms or their main branches. CLINICAL CASE: The case concerns a pre-term newborn of 30 weeks weighing 1,335 g. An umbilical catheter was introduced, which was withdrawn at 14 days due to an infection. It developed as Staphylococcus aureus with sepsis. The echocardiogram and Angio-CT confirmed AA, which were managed using a hybrid procedure of surgery and the endovascular implantation of 2 coated stents (Atrium V12 XR Medical Corp, Hudson, NH). The post-procedure clinical follow-ups, including abdominal echo-tomography, confirmed the success of the treatment. CONCLUSION: The endovascular aortic aneurysm repair procedure in premature newborns may be considered when deciding treatment of this disease, and could avoid the risks associated with open surgery. However, follow-up and monitoring is required while the patient grows up, due to the possibility that the implanted stents require re-dilating. The outcomes of neonatal endovascular procedures in the future are unknown.

Treatment of Myasthenia Gravis in Patients with Elderly Onset at Advanced Age.

The number of patients with late-onset myasthenia gravis (MG) among patients ≥50 years has been increasing recently. We encountered three patients who developed elderly-onset MG at a particularly advanced age (≥80 years). All were female and positive for anti-acetylcholine receptor antibodies. About 4 years have passed since MG onset in all three patients and symptoms have been controlled without recurrence using a combination of oral low-dose prednisolone and tacrolimus. As many cases of elderly-onset MG do not require strong immunosuppression, we recommend minimum immunosuppressive treatment to avoid adverse events, particularly in patients at an advanced age of ≥80 years.

Strongyloides stercoralis induced bilateral blood stained pleural effusion in patient with recurrent Non-Hodgkin lymphoma.

Infections and malignancies are common causes of pleural effusion. Among infectious causes, hyperinfection syndrome of Strongyloides stercoralis may occur in immunosuppressive patient. A 62-year-old man, known case of Non-Hodgkin lymphoma (NHL) was presented with recurrent NHL stage IV and had undergone salvage chemotherapy. Patient subsequently developed pneumonia with bilateral pleural effusion and ascites. We reported rhabditiform larvae of S. stercoralis in pleural fluid of both lungs without infiltration by lymphoma cells. Stool for microscopic examination also revealed rhabditiform larvae of S. stercoralis. This patient was a known case of NHL receiving chemotherapy resulting in immunosuppression state. Although S. stercoralis infection is not very common compared to other parasitic infections, it is common in immunosuppressive patients and may present with hyperinfection. Therefore, awareness of this parasite should be kept in mind in immunosuppressive patients.

Clinics in diagnostic imaging (133). Retained placenta from an intra-abdominal pregnancy.

A 29-year-old Indonesian woman presented with abdominal pain seven months after an intra-abdominal pregnancy. Ultrasonography revealed a cystic mass in the pelvis and magnetic resonance imaging showed an umbilical stump within it, indicating a retained placenta. This was removed surgically, and on histology, an infarcted placenta was confirmed.

Characterisation of commercially available linear alkylbenzenesulfonates by LC-SPE-NMR/MS (liquid chromatography-solid phase extraction-nuclear magnetic resonance spectroscopy-mass spectroscopy).

Commercially available linear alkylbenzenesulfonates (LASs) are a mixture of various homologues and isomers, leading to 20 major species. In this work we investigated the commercial product by liquid chromatography-solid phase extraction-nuclear magnetic resonance spectroscopy-mass spectrometry (LC-SPE-NMR/MS). The commercial product was separated into 17 fractions by liquid chromatography (LC). After chromatographic separation, 5% of the flow was split to a mass spectrometer (MS) while 95% was send to post-column solid phase extraction cartridges for enrichment of the analytes (LC-SPE). After elution from the SPE-cartridges a NMR-spectrometer equipped with a cryo-probe was used for the characterisation of the different LASs species. For the first time (1)H-1D and H-H-COSY spectra for 14 LASs species out of 20 major isomers are presented, whereas the 6 remaining species are detected as mixtures in 3 (1)H-1D and H-H-COSY spectra. These data were used to correlate the chromatographic retention of the LASs isomers to the substitution pattern of the alkyl chain.

ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy).

A collaboration of multidisciplinary experts on the functional evaluation of lung cancer patients has been facilitated by the European Respiratory Society (ERS) and the European Society of Thoracic Surgery (ESTS), in order to draw up recommendations and provide clinicians with clear, up-to-date guidelines on fitness for surgery and chemo-radiotherapy. The subject was divided into different topics, which were then assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. The draft reports written by the experts on each topic were reviewed, discussed and voted on by the entire expert panel. The evidence supporting each recommendation was summarised, and graded as described by the Scottish Intercollegiate Guidelines Network Grading Review Group. Clinical practice guidelines were generated and finalized in a functional algorithm for risk stratification of the lung resection candidates, emphasising cardiological evaluation, forced expiratory volume in 1 s, systematic carbon monoxide lung diffusion capacity and exercise testing. Contrary to lung resection, for which the scientific evidences are more robust, we were unable to recommend any specific test, cut-off value, or algorithm before chemo-radiotherapy due to the lack of data. We recommend that lung cancer patients should be managed in specialised settings by multidisciplinary teams.

Comparison of shuttle walk with measured peak oxygen consumption in patients with operable lung cancer.

BACKGROUND: The relationship between the shuttle walk test and peak oxygen consumption in patients with lung cancer has not previously been reported. A study was undertaken to examine this relationship in patients referred for lung cancer surgery to test the hypothesis that the shuttle walk test would be useful in this clinical setting. METHODS: 125 consecutive patients with potentially operable lung cancer were prospectively recruited. Each performed same day shuttle walking and treadmill walking tests. RESULTS: Shuttle walk distances ranged from 104 m to 1020 m and peak oxygen consumption ranged from 9 to 35 ml/kg/min. The shuttle walk distance significantly correlated with peak oxygen consumption (r = 0.67, p<0.001). All 55 patients who achieved more than 400 m on the shuttle test had a peak oxygen consumption of at least 15 ml/kg/min. Seventy of 125 patients failed to achieve 400 m on the shuttle walk test; in 22 of these the peak oxygen consumption was less than 15 ml/kg/min. Nine of 17 patients who achieved less than 250 m had a peak oxygen consumption of more than 15 ml/kg/min. CONCLUSION: The shuttle walk is a useful exercise test to assess potentially operable lung cancer patients with borderline lung function. However, it tends to underestimate exercise capacity at the lower range compared with peak oxygen consumption. Our data suggest that patients achieving 400 m on the shuttle walk test do not require formal measurement of oxygen consumption. In patients failing to achieve this distance we recommend assessment of peak oxygen consumption, particularly in those unable to walk 250 m, because a considerable proportion would still qualify for surgery as they had an acceptable peak oxygen consumption.

Taurine analogues; a new class of therapeutics: retrospect and prospects.

Taurine was discovered more than two hundred years ago from animal sources. It is distributed in both mammals and non-mammals and its content is high in several tissues. For more than a century-and-a-half, taurine was regarded just as an end product of sulfur metabolism. Recently, taurine has been rediscovered and its beneficial effects in processes like epilepsy, hypertension, congestive heart failure and diabetes have been well-documented. It was patented and found some clinical utility, but being an amino acid, therapeutic use confronts limitations like restricted permeability and more. This necessitates the development of pro-drugs (analogues) mainly derivatives of taurine. A large number of taurine derivatives have been reported in the literature with partial to marked activity. Taurine derivatives like taltrimide, acamprosate and tauromustine, are already in the market as anti-convulsant, anti-alcoholic and anti-cancer agents. Many other analogues are effective in experimental models. The in depth analysis of these analogues and their biological actions can provide certain clues for further consideration. In the present review, attempts have been made to provide synopsis, synthesis and symbiosis of chemical and biological actions, which may provide future guidance and facilitate further research in this area. The successful journey of these analogues to clinical utility is a healthy and happy sign and an index of bright future, and we hope that this review will provide enough input to ignite the minds.

Relationship between pulmonary function and lung cancer surgical outcome.

The British Thoracic Society and American College of Chest Physician guidelines outline criteria for investigating patients for lung cancer surgery. However, the guidelines are based on relatively old studies. Therefore, the relationship between pulmonary function test results and surgical outcome were studied prospectively in a large cohort of lung cancer patients. From January 2001 to December 2003, 110 patients underwent surgery for lung cancer. All underwent full lung function testing in order to predict post-operative lung function. The hospital mortality rate was 3% and major complication rate 22%. There was poor overall outcome in 13%. Mean pre-operative lung function values were: forced expiratory volume in one second (FEV1) 2.0 L (79.4% of the predicted value), and carbon monoxide diffusing capacity of the lung (D(L,CO)) 73.6% pred. The mean post-operative lung function values were: FEV1 1.4 L (55.6% pred), and D(L,CO) 51.3% pred. All lung function values were better predictors of poor surgical outcome when expressed as a percentage of the predicted value. Using a threshold of pre-operative FEV1 of 47% pred resulted in the most useful positive and negative predictive probabilities, 0.90 and 0.67, respectively. Lung function values expressed as a percentage of the predicted value are more useful predictors of post-operative outcome than absolute values. The threshold of predicted forced expiratory volume in one second for surgical intervention could be lower (45-50% pred) than is currently accepted without increased mortality.

gamma-L-glutamyltaurine.

The discovery of the dipeptide gamma-glutamyltaurine (gamma-GT; glutaurine, Litoralon) in the parathyroid in 1980 and later in the brain of mammals gave rise to studies on intrinsic and synthetic taurine peptides of this type. It was suggested that gamma-glutamyltransferase (GGT; gamma-glutamyltranspeptidase) in the brain is responsible for the in vivo formation of this unusual dipeptide. gamma-GT has been prepared by both synthetic and enzymatic methods. The chemical syntheses included the use of protecting groups and coupling methods. A wide spectrum of analytical and spectroscopic methods was used to confirm the structure of the synthetic compounds and to elucidate the position of the peptide bond. Enzymatic preparation of gamma-GT from taurine takes advantage of the selective transpeptidation action of GGT on L-glutamine, glutathione, gamma-glutamyl-p-nitroanilide or other glutamine donors. Although the functional roles of gamma-GT in the brain are only poorly understood, many of its established CNS effects have been reported in the last 25 years. Its effect on emotional arousal and its anti-conflict potencies are synergistic with the anxiolytic drug diazepam. gamma-GT exhibits anti-conflict potency, which is exerted by reducing aversion or phobia and/or the anxiety levels. gamma-GT also acts as endogenous modulator in excitatory aminoacidergic neurotransmission. It is suggested that such acidic peptides through N-methyl-D-aspartic acid receptors could be part of the neurochemical substrate underlying self-stimulation of the medial prefrontal cortex. Other gamma-GT effects in neural systems include: effects on the monoamine concentration in the brain; effects on aggressive behavior in the cat; effects on thyroid hormones in the rat; amelioration of electroshock-induced amnesia; potent and long-lasting antiepileptic action (on intra-amygdaloid injection); affect the glutamatergic system in schizophrenic disorders. Roles for gamma-GT in non-neural systems have also been reported, e.g., effects on the metamorphosis of amphibians; on plasma rennin regulation; on radiation protection; on uric acid levels; on human antibody-dependent cell-mediated cytotoxicity (ADCC) and many more.

The distribution of microvascular response in Achilles tendonopathy assessed by colour and power Doppler.

OBJECTIVES: To assess the distribution of microvascular response on colour Doppler (CD) and power Doppler (PD) ultrasound (US) of the tendo Achilles (TA) in tendonopathy, and to look for any relationship between tendon morphology and symptoms. DESIGN AND PATIENTS: A retrospective, observational study was carried out on consecutive ambulant US patients with suspected tendonopathy, presenting with pain or an Achilles mass. Exclusion criteria were: use of steroids, and previous or possible rupture or surgery in either tendon or arthropathy. Using a 5-12 MHz linear array probe (ATL HDI 3000) both TAs were scanned. Tendonopathy was defined as tendon swelling and/or hypoechogenicity of the TA. The site, number and distribution of microvascularity, on CD and PD, and the anteroposterior size were recorded, with the analysis masked. RESULTS: Fifty-two patients presented with TA pain and six also with swelling. There were 34 males and 18 females, aged from 11 to 78 years (mean 45 years). Fifty-five TAs that showed tendonopathy with hypoechogenic areas were all observed to be over 5.9 mm (mean 11.1 mm, range 5.9-20 mm), of which 45 were symptomatic with abnormal PD and 24 with abnormal CD flow. It was observed that the extent and completeness of vessel branching was more extensive on PD than CD. All TAs demonstrating tendonopathy were over 5.9 mm in adults and all TAs that showed PD flow were over 6.5 mm. All microvessels originated towards the TA from the ventral surface usually into tendonopathy, and were 16-fold more frequent around the margins. There were 49 TAs with normal spectral US, and with no PD flow, with a mean size of 4.5 mm (range 3.0-7.4 mm). For the right and left TAs independently analysed and taking the 40 patients with a paired asymptomatic and symptomatic tendon: (1) There was a highly significant difference in size (P<0.00001) using the paired t-test (parametric) between the asymptomatic tendon (mean 5.2+/-1.4 mm (1 SD)), and the contralateral morphologically abnormal and symptomatic side (mean 9.7+/-1.4 mm). (2) There was no linear Pearson correlation (0.25) between TA size and duration of symptoms (P=0.11) for symptomatic tendons. (3) There was a positive Spearman correlation (0.84) between the number of vessels and TA size (P<0.00001). (4) There was a significant difference in the number of PD vessels using the non-parametric Wilcoxon signed test (P<0.00001) between the symptomatic and asymptomatic groups. CONCLUSIONS: (1) PD shows more tendon microvascularity than CD in TA tendonopathy. (2) All microvessels arise on the ventral side of the TA. (3) There is a non-linear relationship between tendonopathy, TA size and the amount of microvascularity, but not between PD and duration of symptoms. (4) Morphologically abnormal adult TAs were larger than 5.9 mm, and PD flow was only seen in TAs above 6.5 mm.