Cauda equina thickening: an approach to MRI findings.

There are many causes of cauda equina (CE) thickening on neuroimaging of the lumbar spine. The imaging features of CE thickening for the various conditions often overlap and are non-specific to clinch a definite diagnosis. Hence, the imaging findings have to be discerned in accordance with the patient's presenting history, clinical examination findings, and results from electrophysiology and laboratory studies. In this review, the authors aim to supplement the existing literature on imaging findings of CE thickening with a diagnostic framework for clinical workup. The authors also aim to familiarise readers with the interpretation of CE thickening on magnetic resonance imaging (MRI) and would like to illustrate the normal variants and pitfalls that could be mistaken for abnormal results.

Otalgia and Facial Nerve Palsy: Common Symptoms Revealing the Uncommon Pathology of Middle Ear Lymphoma.

Lymphoma of the middle ear and mastoid is uncommon and is rarely diagnosed early. The clinical presentation occurs due to consequences of extensive progressive disease. It can manifest as benign middle ear pathologies such as otitis media; other presentations include facial nerve palsy, hearing loss, and vestibular dysfunction. We treated a case of a 38-year-old male who presented with extranodal involvement of diffuse large B-cell lymphoma (DLBCL) of the middle ear, mastoid, and temporalis muscle, which mimicked an acute otitis media complicated with facial nerve palsy and hearing loss. He has underlying mediastinal and cervical DLBCL diagnosed 20 months before the current presentation. He underwent cortical mastoidectomy and chemotherapy. Despite treatment, he succumbed to the disease. We discuss the clinical significance of middle ear lymphoma by reviewing similar cases in the literature. To conclude, refractory middle ear disease should alert the surgeon of a more sinister underlying pathology in a patient with malignancy.

Routine Esophagograms After Hiatus Hernia Repair Minimizes Reoperative Morbidity: A Multicenter Comparative Cohort Study.

OBJECTIVE: Determine the utility of routine esophagograms after hiatus hernia repair and its impact on patient outcomes. BACKGROUND: Hiatus hernia repairs are common. Early complications such asre-herniation, esophageal obstruction and perforation, although infrequent, incur significant morbidity. Whether routine postoperative esophagograms enable early recognition of these complications, expedite surgical management, reduce reoperative morbidity, and improve functional outcomes are unclear. METHODS: Analysis of a prospectively-maintained database of hiatus hernia repairs in 14 hospitals, and review of esophagograms in this cohort. Results: A total of 1829 hiatus hernias were repaired. Of these, 1571 (85.9%) patients underwent a postoperative esophagogram. Overall, 1 in 48 esophagograms resulted in an early (<14 days) reoperation, which was undertaken in 44 (2.4%) patients. Compared to those without an esophagogram, patients who received this test before reoperation (n = 37) had a shorter time to diagnosis (2.4 vs 3.9 days, P = 0.041) and treatment (2.4 vs 4.3 days, P = 0.037) of their complications. This was associated with lower rates of open surgery (10.8% vs 42.9%, P = 0.034), gastric resection (0.0% vs 28.6%, P = 0.022), postoperative morbidity (13.5% vs 85.7%, P < 0.001), unplanned intensive care admission (16.2% vs 85.7%, P < 0.001), and decreased length-of-stay (7.3 vs 18.3 days, P = 0.009). Furthermore, we identified less intraoperative and postoperative complications, and superior functional outcomes at 1-year follow-up in patients who underwent early reoperations for an esophagogram-detected asymptomatic re-herniation than those who needed surgery for late symptomatic recurrences. CONCLUSIONS: Postoperative esophagograms decrease the morbidity associated with early and late reoperations, and should be considered for routine use after hiatus hernia surgery.

A delayed presentation of traumatic right hemidiaphragm injury repaired via a laparoscopic approach: A case report.

INTRODUCTION: Diaphragmatic injury is a rare clinical entity which presents a diagnostic and therapeutic challenge. It is three times more common following blunt trauma than penetrating trauma and results in larger tears. A high index of suspicion is required to diagnose diaphragmatic injury. A missed diagnosis following acute injury can later result in life-threatening complications. CASE PRESENTATION: We describe the successful management of a right hemidiaphragmatic injury presenting two weeks following blunt thoracoabdominal trauma using a laparoscopic mesh repair. DISCUSSION: Diaphragmatic injury is rare, with right-sided injuries less common due to the buffering effect of the liver. The diagnosis is made within 24 hours of injury in 75% of cases (Haranal and et al., 2018) [1]. In our patient, symptoms of a right-sided diaphragmatic injury manifested two weeks following a motor vehicle collision. A CT scan of the chest and abdomen confirmed the diagnosis. According to DeBlasio, intermittent symptoms of visceral herniation or incorrect x-ray interpretation are the main reasons for a delayed diagnosis (DeBlasio et al., 1994) [2]. Contrary to common practice where thoracotomy is the preferred method for repair in the absence of associated abdominal injuries, we demonstrated that a right-sided diaphragmatic injury can be successfully managed with a laparoscopic mesh repair. CONCLUSION: Traumatic diaphragmatic injury remains a challenge to emergency physicians and trauma surgeons. Clinicians should be aware of the differing clinical presentations, investigations, and management. Surgical repair can be achieved via laparoscopy, thoracoscopy, laparotomy, and/or thoracotomy. In the case of an isolated right-sided diaphragmatic injury, laparoscopic mesh repair should be considered.

Endocan expression in placenta of women with hypertension.

AIM: The aim of our study was to determine the endocan-1 expression in placenta of hypertensive women, and its association with maternal and fetal outcomes. METHODS: This was a cross-sectional study consisted of 21 pregnant women with hypertension and 23 without hypertension. The gestational age ranged from 28 to 39 weeks (hypertensive) and 32 to 40 weeks (normotensive). The paraffin embedded formalin fixed placenta tissue blocks were retrieved from the pathology archives. Endocan immunohistochemistry was performed on tissue sections of full thickness and maternal surface of the placenta. The endocan expression was determined in fetal endothelial cells, maternal endothelial cells, cytotrophoblasts, syncytiotrophoblasts and decidual cells. The differences in endocan expression in placenta between hypertensive and normotensive subjects were evaluated by Pearson chi-square test and t-test were used in the statistical analysis. RESULTS: The endocan expression was significantly higher in fetal endothelial cells (P < 0.001), maternal endothelial cells (P = 0.003) and decidual cells (P < 0.001) in the placenta of women with hypertension. When comparing positive and negative endocan expression in maternal outcomes, endocan was associated with the development of pre-eclampsia (P = 0.03). Also, a positive endocan expression was associated with low birthweight (P = 0.001) and prematurity (P = 0.005) in the fetal outcomes. CONCLUSION: This study showed endocan is highly expressed in fetal endothelial cells, maternal endothelial cells and decidual cells in placenta of hypertensive women. In addition, its expression was associated with poorer maternal and fetal outcomes. These findings suggest endocan may play an important role in the progression of hypertension in pregnancy.

Risk of metabolic syndrome among children living in metropolitan Kuala Lumpur: a case control study.

BACKGROUND: With the increasing prevalence of childhood obesity, the metabolic syndrome has been studied among children in many countries but not in Malaysia. Hence, this study aimed to compare metabolic risk factors between overweight/obese and normal weight children and to determine the influence of gender and ethnicity on the metabolic syndrome among school children aged 9-12 years in Kuala Lumpur and its metropolitan suburbs. METHODS: A case control study was conducted among 402 children, comprising 193 normal-weight and 209 overweight/obese. Weight, height, waist circumference (WC) and body composition were measured, and WHO (2007) growth reference was used to categorise children into the two weight groups. Blood pressure (BP) was taken, and blood was drawn after an overnight fast to determine fasting blood glucose (FBG) and full lipid profile, including triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC). International Diabetes Federation (2007) criteria for children were used to identify metabolic syndrome. RESULTS: Participants comprised 60.9% (n = 245) Malay, 30.9% (n = 124) Chinese and 8.2% (n = 33) Indian. Overweight/obese children showed significantly poorer biochemical profile, higher body fat percentage and anthropometric characteristics compared to the normal-weight group. Among the metabolic risk factors, WC ≥90th percentile was found to have the highest odds (OR = 189.0; 95%CI 70.8, 504.8), followed by HDL-C≤1.03 mmol/L (OR = 5.0; 95%CI 2.4, 11.1) and high BP (OR = 4.2; 95%CI 1.3, 18.7). Metabolic syndrome was found in 5.3% of the overweight/obese children but none of the normal-weight children (p < 0.01). Overweight/obese children had higher odds (OR = 16.3; 95%CI 2.2, 461.1) of developing the metabolic syndrome compared to normal-weight children. Binary logistic regression showed no significant association between age, gender and family history of communicable diseases with the metabolic syndrome. However, for ethnicity, Indians were found to have higher odds (OR = 5.5; 95%CI 1.5, 20.5) compared to Malays, with Chinese children (OR = 0.3; 95%CI 0.0, 2.7) having the lowest odds. CONCLUSIONS: We conclude that being overweight or obese poses a greater risk of developing the metabolic syndrome among children. Indian ethnicity is at higher risk compared to their counterparts of the same age. Hence, primary intervention strategies are required to prevent this problem from escalating.

Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions.

BACKGROUND: Poor quality prescribing has been identified as one of the leading causes of medication error and adverse drug events. The aim of this study was to improve the quality of written prescriptions in a general hospital by a combination of serial audits and interventions designed to address identified deficiencies. METHODS: Inpatient medication charts were audited annually from 1998 to 2007. Charts were assessed against predetermined standards for good-quality prescribing. RESULTS: Initially an unacceptable proportion of medication charts failed to document adequately one or more of the following: prescriber identification (58%), legible prescriptions (14%), route of administration (14%), a dose (11%), date (11%) or adequate patient identification (8%). Only 53% of charts had any information about medication alerts and 15% contained at least one verbal order. Interventions designed to address these deficiencies included educational strategies (e.g. feedback of audit results, education sessions for doctors and nurses on prescribing and medication errors) and changes to systems (e.g. modifications to medication charts, development of hospital wide prescribing standards and an alert notification system). Serial audits showed progressive improvements in all items by 2007 including; legibility (97%), patient identification (100%), documentation of date (98%), drug dose (99%) and route (97%), use of medication alerts (98%) and the prevalence of verbal orders (<1%). Identification of prescribers remained suboptimal (81% in 2006, 53% in 2007). CONCLUSION: Serial audits of the quality of prescribing on hospital medication charts can rapidly identify the extent of deficiencies in prescribing practice, facilitate interventions specifically designed to address these and monitor their influence.

DrhoGEF3 encodes a new Drosophila DH domain protein that exhibits a highly dynamic embryonic expression pattern.

The Rho GTPases regulate many different cellular and developmental processes, and activation of Rho GTPase signalling is mediated through interaction with the Dbl homology (DH) protein domain. We describe the expression pattern of DrhoGEF3 (cytological position 61B1-B3), which encodes a new member of the DH domain protein family from Drosophila and is a homologue of the human protein hPEM-2. During gastrulation and germ band extension, DrhoGEF3 exhibits a segmented expression pattern. DrhoGEF3 is subsequently expressed in the visceral mesoderm, at the sites of muscle attachment and in specific groups of sub-epidermal cells. The possible function of such a dynamically expressed signalling molecule is discussed.