Anti-hypertensive prescription practices in private hospitals in Malaysia: a prospective, non-interventional, observational study.

INTRODUCTION: In managing hypertension, monotherapy and sometimes a combination of more than one agent are used to achieve blood pressure (BP) control. The objective of this prospective, observational, multi-centre study was to assess the level of BP control in patients receiving one or more anti-hypertensive drugs in private medical centres in Malaysia according to the treatment regimens (monotherapy, free drug combinations and single pill combinations). MATERIALS AND METHODS: Data were collected through medical records and interview sessions with patients on current pharmacotherapy for hypertension management at baseline and 2-3 months later. Results are expressed as mean ± SD for continuous data and as frequencies and percentages for categorical data. RESULTS: Among 182 recruited patients, 89 (49%) achieved BP control by the end of the study. Majority (62/89) patients were on single-pill (monotherapy or SPC) antihypertensives. Majority (63/89) required more than two antihypertensives to achieve BP control. CONCLUSION: Both SPC and free drug combination antihypertensives reduced BPs, but physicians preferred SPC to improve BP control and increase treatment compliance.

Composite Hemangioendothelioma With Neuroendocrine Marker Expression: Report of a "Paraganglioma-Like" Paravertebral Case.

Composite hemangioendothelioma is a rare vascular tumor morphologically comprising several distinct vascular components and exhibits a borderline malignant potential. We described the case of a 53-year-old female who presented with an infiltrative mass in the paravertebral soft tissue. The tumor showed discrete nests of synaptophysin-expressing epithelioid cells accompanied by rich vasculature, features highly reminiscent of sympathetic paraganglioma. Further analysis revealed areas resembling spindle cell hemangioma, retiform hemangioendothelioma, cavernous hemangioma/lymphangioma, and epithelioid hemangioendothelioma without the myxohyaline matrix in the tumor, and a final diagnosis of composite hemangioendothelioma with synaptophysin expression was made. Critical appraisal of this recently described entity and its possible pathogenic relationship with retiform hemangioendothelioma were discussed.

Updates in the management of Dyslipidaemia in the high and very high risk individual for CV risk reduction.

Cardiovascular disease (CVD) has been the main cause of mortality and an important cause of morbidity in Malaysia for several years. To reduce global cardiovascular (CV) risk in the population, primary preventive strategies need to be implemented. Hypercholesterolaemia is one of the major risk factors for CVD. This paper is an expert review on the management of hypercholesterolemia focusing on high and very high risk individuals. In low and Intermediate risk individuals, therapeutic lifestyle changes (TLC) and a healthy lifestyle alone may suffice. In high and very high risk individuals, drug therapy in conjunction with TLC are necessary to achieve the target LDL-C levels which have been shown to slow down progression and sometimes even result in regression of atherosclerotic plaques. Statins are first-line drugs because they have been shown in numerous randomized controlled trials to be effective in reducing CV events and to be safe. In some high risk individuals, despite maximally tolerated statin therapy, target Low Density Lipoprotein Cholesterol (LDL-C) levels are not achieved. These include those with familial hypercholesterolaemia and statin intolerance. This paper discusses non-statin therapies, such as ezetimibe and the newer Proprotein convertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

Tibiotalocalcaneal (TTC) arthrodesis with reverse PHILOS plate and medial cannulated screws with lateral approach.

BACKGROUND: Tibiotalocalcaneal arthrodesis is most common and effective surgical treatment for severe hindfoot pathology, but the fusion rate is often lower than the ordinary tibiotalar arthrodesis because of the more serious joint disease associated with obvious deformity and osteoporosis. Recent literature describe tibiotalocalcaneal arthrodesis with reverse PHILOS plate with good clinical outcome result, though some patients non-union, due to eccentric force of the plate may be hidden. The purpose of this study was to evaluate clinical outcome of the lateral approach for tibiotalocalcaneal (TTC) arthrodesis with reverse PHILOS Plate and medial cannulated screw. METHODS: Between Jun, 2013 to April, 2015 12 patient with hindfoot pathology had TTC arthrodesis with a reverse PHILOS plate with medial cannulated screw through a lateral approach with resection of the distal fibula and bone graft. Perioperatively observe for wound and neurovascular status. Patients were follow-up from post-operative 1, 3, 6 and12 months, to observation of wound healing, ankle pain, subtalar Joint Fusion, internal fixation and ankle function. Ankle function were scored according to the American Orthopaedic Foot and Ankle Society(AOFAS) Ankle-Hindfoot Scale system. RESULTS: Twelve ankle fusion all patient follow-up, with mean time to surgery 18.6 months (12-36 month). No cases infection and issue necrosis; one patient complaint of lateral foot numbness we observe and follow-up was spontaneously recovery after 3 months. After 3 months of operation, no obvious pain of ankle joint and internal fixations loose were found. Almost fusion and good axial alignment of TTC joint also were found by X-ray and CT examination. After final fellow-up of each case, no case complain of pain of ankle joint, good fusion and axial alignment of TTC joint were also all found through Terminology. The mean American Orthopaedic Foot and Ankle society (AOFAS) score average was 77.5. CONCLUSION: TTC arthrodesis with reverse PHILOS Plate and medial cannulated screw have advantages of clear incision, effective bone orthopaedic and graft fully secure, stable internal fixation, high fusion rate and less complications, can effectively correct deformities, alleviate hindfoot pain and improve function, and is an effective method of treatment of after severe hindfoot disease. TRIAL REGISTRATION: This trial is registered on ClinicalTrials.gov with reference number: ID: NCT02977910 . Registered 26 Nov 2016, retrospectively registered.

A simple screening test for the detection of metallo-ß-lactamase-producing Pseudomonas aeruginosa and Acinetobacter in a tertiary care hospital.

Clinical utilization of carbapenems remains under threat with the emergence of acquired carbapenemase-producing bacteria, particularly metallo-ß-lactamases (MBL). Rapid detection of MBL-producing Gram-negative bacilli is essential to prevent their widespread dissemination. However, no standardized detection method is available for routine laboratory use. The purpose of the study was to evaluate a chelating-agent based double disk synergic test and disk potentiation test for MBL-producing strain detection and to determine the isolation rate of MBL-producing Pseudomonas aeruginosa and Acinetobacter from clinical samples in our tertiary teaching hospital. A total of 22 and 66 imipenem-resistant P. aeruginosa and Acinetobacter isolates respectively were tested with ceftazidime (CAZ) disk by modified double disk synergic test and disk potentiation test using ethylenediaminetetraacetic acid (EDTA) and 2-mercaptopropionic acid (as chelating agents) to detect MBL production. The tests were compared with EDTA-phenanthroline-imipenem (EPI) microdilution MIC test as gold standard. MBL positive strains were detected in 17 (77.3%) P. aeruginosa and 2 (3.5%) Acinetobacter isolates. The disk potentiation test with 2-mercaptopropionic acid (2-MPA) dilution of 1:12 provided the most acceptable sensitivities and specificities (88.2% sensitivity and 100% specificity in P. aeruginosa; 100% sensitivity and specificity in Acinetobacter) compared to other screening methods used in this study. This study provided useful information on the local prevalence of MBL-producing P. aeruginosa and Acinetobacter in our hospital. Disc potentiation test with CAZ/2-MPA disc appears to be reliable and convenient MBL detection method in the routine clinical laboratory.

A simple screening test for the detection of metallo-β-lactamase-producing Pseudomonas aeruginosa and Acinetobacter in a tertiary care hospital

Clinical utilization of carbapenems remains under threat with the emergence of acquired carbapenemase-producing bacteria, particularly metallo-β-lactamases (MBL). Rapid detection of MBL-producing Gram-negative bacilli is essential to prevent their widespread dissemination. However, no standardized detection method is available for routine laboratory use. The purpose of the study was to evaluate a chelating-agent based double disk synergic test and disk potentiation test for MBL-producing strain detection and to determine the isolation rate of MBL-producing Pseudomonas aeruginosa and Acinetobacter from clinical samples in our tertiary teaching hospital. A total of 22 and 66 imipenem-resistant P. aeruginosa and Acinetobacter isolates respectively were tested with ceftazidime (CAZ) disk by modified double disk synergic test and disk potentiation test using ethylenediaminetetraacetic acid (EDTA) and 2-mercaptopropionic acid (as chelating agents) to detect MBL production. The tests were compared with EDTA-phenanthroline-imipenem (EPI) microdilution MIC test as gold standard. MBL positive strains were detected in 17 (77.3%) P. aeruginosa and 2 (3.5%) Acinetobacter isolates. The disk potentiation test with 2-mercaptopropionic acid (2-MPA) dilution of 1:12 provided the most acceptable sensitivities and specificities (88.2% sensitivity and 100% specificity in P. aeruginosa; 100% sensitivity and specificity in Acinetobacter) compared to other screening methods used in this study. This study provided useful informationon the local prevalence of MBL-producing P. aeruginosa and Acinetobacter in our hospital. Disc potentiation test with CAZ/2-MPA disc appears to be reliable and convenient MBL detection method in the routine clinical laboratory.

Aspergillus pachymeningitis mimicking nasopharyngeal carcinoma.

OBJECTIVES: We report a case of otogenic fungal pachymeningitis in a diabetic patient who presented with multiple cranial nerve palsies and nasopharyngeal swelling. METHODS: We present a case report, we describe the investigations, management and clinical course of fungal pachymeningitis, and we present a review of the world literature on fungal and non-fungal pachymeningitis. RESULTS: To our knowledge, this is the first report of fungal pachymeningitis with magnetic resonance imaging features suggestive of nasopharyngeal carcinoma. It is also the first reported case with aspergillus cultured from both a dural biopsy and the ear canal. CONCLUSION: Fungal pachymeningitis is a rare condition which may present to otorhinolaryngologists. Its clinical and radiological findings can be confused with those of nasopharyngeal carcinoma; fungal pachymeningitis should thus be included in the differential diagnosis of nasopharyngeal carcinoma.

Influence of polymer content on stabilizing milled amorphous salbutamol sulphate.

The study investigates the influence of polyvinyl pyrrolidone (PVP) concentration on stabilizing the amorphous form of salbutamol sulphate (SS) before and after storage under ambient and elevated humidity conditions. Different mass ratios of SS and PVP (0-90wt%) were co-milled using a planetary ball mill. X-ray powder diffraction (XRPD), high sensitivity differential scanning calorimetry (HSDSC), dynamic vapor sorption (DVS), infrared spectroscopy (FT-IR), scanning electron microscopy (SEM) and Raman microscopy (RM) were used to analyze the stability of the co-milled mixtures against heat and humidity treatments as well as storage at different humidity conditions. Prior storage, DSC and DVS analyses revealed that re-crystallization of amorphous SS was suppressed above PVP content of 33 wt%. Probable hydrogen bond interaction between SS and PVP was found in FT-IR analysis. XRPD diffractograms and SEM analysis showed stability against re-crystallization was achieved in the co-milled mixtures with a minimum PVP content of 80 wt% after storage. Homogeneous distribution of SS and PVP from RM analysis showed fine clustering of SS and PVP, suggesting the formation of an amorphous dispersion at molecular level. The results provide insights on the application of thermal and humidity treatments, accelerated stability testing and investigations on drug-excipient interactions to predict the minimum ratio of an excipient for stabilizing the amorphous state of a milled API.

Pleuroscopy: our initial experience in Hong Kong.

OBJECTIVE: To report our preliminary experience using pleuroscopy for patients with pleural diseases. DESIGN: Prospective cohort study. SETTING: Tertiary referral hospital with service input from respiratory physicians and cardiothoracic surgeons in Hong Kong. PATIENTS: Between April and November 2007, patients with undiagnosed exudative pleural effusions and proven malignant pleural effusions were recruited for diagnostic evaluations and therapeutic interventions, respectively. INTERVENTION: Pleuroscopy with a semi-rigid thoracoscope performed under local anaesthesia and conscious sedation. RESULTS: A total of 20 patients (16 males and 4 females; mean age, 63 years) underwent the procedure and were followed up for a mean of 19 weeks. For the 14 patients having diagnostic pleuroscopy, the yield was 79% (11 patients). The 3-month success rate for the six patients undergoing pleurodesis was 83% (five patients). Complications were mild and included self-limiting fever (20%, four patients) and localised subcutaneous emphysema (20%, four patients). No major complications or mortality were noted. CONCLUSION: Pleuroscopy using a semi-rigid instrument is a safe and efficacious procedure for the management of pleural diseases in suitable patients.

Optimization of nanoparticle drug microcarrier on the pharmacokinetics of drug release: a preliminary study.

Ideal drug delivery process would exhibits zero-order kinetics. However, in practical, most drug delivery process is first-order kinetics. This study is aimed to mathematically model, analyze and determine the optimal polymer shape of the drug micro-carrier that achieves a near zero-order release. We also extend study in deriving and optimizing theoretically the optimal distance between the two optimal micro-carrier shapes. A mathematical model that derived from Carslaw and Jaeger equation of conduction of heat is used to model the relationship between the geometry shape of the carrier and the drug concentration. An optimization objective function is formulated from the mathematical model and MATLAB Optimization Toolbox is used to perform the numerical analysis. The results suggest that reducing the k value (ratio of volume of the fluid to that of the sphere) gives a near zero-order kinetics drug delivery response for all the microcarrier geometry shapes (with equivalent surface area/volume ratio to a sphere with radius R(s)) investigated. Our preliminary results showed that tetrahedron microcarrier exhibits the best response and the worst response is for tablet (with R = R(s)/2).

Adenocarcinoma of the duodenum.

Adenocarcinoma of the duodenum is an exceedingly rare disorder. Its vague and non-specific symptoms often lead clinicians and patients to suspect other more benign differential diagnoses. Improved endoscopy and radiology have enabled more of these cases to be unearthed. Definitive surgery is the only means of potential cure, with the prognosis being significantly better for node-negative patients. We present a case of a 52-year-old man who underwent a Whipple's operation for this uncommon disease and a literature review of the subject.

Biofield potential simulation as a novel adjunt modality for continuous monitoring of breast lesions: a 3D numerical model.

Breast cancer is a disease characterized by the uncontrolled growth of abnormal cells. Early detection of this disease is the most effective way to reduce mortality. Although several new technologies show promise for improved capability of diagnosis, none have yet proved superior to traditional, X-ray film mammography in screening for breast cancer. More evaluation and development of new imaging tools and of promising skin surface electrical potential techniques is required and warranted. In the present study, we propose a theoretical three-dimensional, simplified and realistic model of the female breast to distinguish the surface biopotential in different types of breast abnormalities. We developed an inhomogeneous female breast model, closer to the actual, by considering the breast as a hemisphere with various layers of unequal thickness in supine condition. In order to determine the potential distribution developed, isotropic homogeneous conductivity was assigned to each of these compartments and the volume conductor problem was solved using finite element method. Richardson extrapolation for grid invariance test was used to ensure the results are of reliable accuracy. The simulation results show that the surface potentials are sensitive to the presence of tumour, location and placement of the electrodes.

The engineering analysis of bioheat equation and penile hemodynamic relationships in the diagnosis of erectile dysfunction: part I-theoretical study and mathematical modeling.

The extent to which skin surface bioheat perfusion predicts penile physiological response such as an erection has not been extensively investigated. A biomechanical engineering study was performed to compare bioheat distribution on penile skin surface resulting from an induced erection at steady state to examine the efficacy of such method as an adjunct tool for the diagnosis and classification of erectile dysfunction (ED) due to different etiology. We based our arguments on the principle that blood vessel activity and perfusion to corpus cavernosa at the erect state are almost always higher than that in the flaccid state. Our results showed that a difference of 0.1-0.3 degrees C can be observed and hence used to develop database of 'smart diagnosis' for ED using the machine artificial intelligence. It is anticipated that such basic research into blood flow is critical, as blood perfusion into corpus cavernosa is the most influential factor determining functional erectile quality contributing to successful coitus. Increased understanding of the hemodynamic response profile contributes toward optimal treatment and thus enables clinicians to adopt an appropriate management scheme for ED.

The engineering analysis of bioheat equation and penile hemodynamic relationships in the diagnosis of erectile dysfunction: part II-model optimization using the ANOVA and Taguchi method.

The authors aimed to study the skin surface bioheat perfusion model described in part I numerically. The influence of each constituent in the determination of surface temperature profile was statistically examined. The theoretically derived data will then be benchmarked with clinically measured data to develop the artificial intelligence system for the diagnosis of erectile dysfunction (ED). The new approach is based on the hypothesis that there exists a constitutive relationship between surface temperature profiles and the etiology of ED. By considering the penis model as a group of reservoirs with irregular cavities, we built a numerical model, simplified to save computational costs while still realistically able to represent the actual for partial differential calculation. Incompressible blood flow was assumed coupled with the classical bioheat transfer equation which was solved using the finite element method. Isotropic homogeneous heat diffusivity was assigned to each tissue layer. The results of simulations were tested for sensitivity analysis and further optimized to obtain the 'best' signal from the simulations using the Taguchi method. Four important parameters were identified and analysis of variance was performed using the 2(n) design (n=number of parameters, in this case, 4). The implications of these parameters were hypothesized based on physiological observations. Our results show that for an optimum signal-to-noise (S/N) ratio, the noise factors (thermal conductivity of skin, A and tunica albuginea, B) must be set high and low, respectively. Hence, at this setting, the signal will be captured based on the perfusion rate of the boundary layer of the sinusoidal space and the blood pressure (perfusion of sinusoidal space, C and blood pressure, D) will be optimal as their S/N ratios (C (low) and D (low)) are larger than the former.

Solid-phase low temperature steam-assisted synthesis of thermal stable alumina nanowires.

A simple steam-assisted solid phase synthesis method was developed for synthesis of boehmite nanowires in the presence of TEAOH surfactant. The boehmite nanowires had uniform diameters (12-16 nm) and length up to 1-2 microm. The morphology of the nanostructured wires was well preserved after being converted to pure gamma-Al2O3 by thermal treatment at 600 degrees C for 5 h. The nanowires of Al2O3 exhibited excellent thermal stability by retarding the phase transformation and maintaining the wires-like nanostructure after being aged up to 1300 degrees C by preventing sintering between particles at high temperatures. The surface areas of Al2O3 nanowires could be maintained as high as 68 m2/g at 1300 degrees C while the surface areas of Al2O3 micropowder shrank to 0.89 m2/g after same thermal treatment. Both in-situ XRD and 27Al NMR results indicated that the crystal structure of gamma-Al2O3 nanowires was not transformed to alpha-Al2O3 at 1300 degrees C whereas micropowder Al2O3 was fully converted to alpha-Al2O3 at 1100 degrees C.

Analysis of nano drug carriers towards optimum release rate.

The aim of this paper is to determine which polymer shape (sphere, hemisphere, cylinder, tablet, cuboid, tetrahedron or octahedron) is best for zero kinetics drug delivery and for sustained nanoparticle release. We applied the Carslaw and Jaeger heat diffusion equations of a sphere with same order of its effective surface area to volume ratio as a reference, to predict how drug delivery would occur in other shapes. The assumption of the heat diffusion analogy in the present study of negligible drug particles is sensible since the drug at nano scale is tiny and thus nearly 'massless'. From tests involving changing the micro-carrier configuration, we can confirm that shape is an important factor to consider when examining drug release rates, to achieve zero-order design. The preliminary analysis suggests that a hemisphere shape is more promising in achieving zero-order drug release rate, followed by a tablet shape of L = 2R(s), 3R(s), a tetrahedron, a cylindrical shape with L = 3R(s), 2R(s), a sphere, a cuboid shape with L = 3R(s), 2R(s), and finally an octahedron. This is due to the larger effective surface area, given the same parameters and surrounding conditions. In other words, a hemisphere shape reaches zero order in the shortest possible time and thus permits sustained zero-order particle release rate. Based on the ratio between the surface area of a micro-carrier and its volume, we further derived the drug release equation of cylinder/tablet shaped micro-carrier. By introducing h as an index of the similarity of the drug release rate to a desirable zero-order drug release rate, we obtained a relationship between different length/radius (L/R) values of cylinder/tablet shapes and the index h. From this relationship, we find the best L/R ratio that can achieve a drug release process most similar to a zero-order drug release process. Future work is to include optimization of the lipid matrixes.

Numerical modelling of biopotential field for detection of breast tumour.

Breast cancer is a disease characterised by the uncontrolled growth of abnormal cells. These cancer cells can travel through the body by way of blood or lymph nodes. Previous studies have indicated that, changes in the electrical properties of abnormal breast are more significant compared to the breast normal tissues. In the present study, a simple 2D models of breast (close to realistic), with and without artificially inserted malignant cancer were simulated, based upon electrical activity within the breast. We developed an inhomogeneous female breast model, closer to the actual, by considering a breast as a hemisphere with various layers of unequal thickness in supine condition. In order to determine the potential distribution developed due to a dipole source, isotropic homogeneous conductivity was assigned to each of these compartments and the volume conductor problem was solved using finite element method. Significant changes in the potential distribution were recoded in the malignant and normal breast regions. The surface potential decreases about 0.5%, for the small malignant region of surface area 13 mm(2) (spherical diameter=2mm). And it (surface potential) decreases about 16.4% for large malignant surface area of 615 mm(2) (spherical diameter=14 mm). Hence, the results show that, the sizes of tumours result in the reduction of surface potential and follows a fourth order polynomial equation. Thus, biofield analysis yields promising results in the detection of the breast cancer of various sizes.