SMA Syndrome – Wait & Nurture

@#Superior mesenteric artery (SMA) syndrome is rare with the common presentation of megaduodenum from entrapment of the third part of the duodenum (D3) by the SMA. We present a case report of a thin, fit 16-year-old boy, active smoker complaining of generalized colicky abdominal pain associated with persistent postprandial vomiting. Small bowel study demonstrated partial duodenal obstruction from compression of the third part of the duodenum by the SMA. Computed tomography of the abdomen shows an aorto-mesenteric angle of 13 degrees with aorto-mesenteric distance of 0.32 cm, indicating SMA syndrome. His symptoms resolved spontaneously with watchful waiting and nutritional care plan. The success was contributed to restoring the fat cushion around the SMA, hence, widening the aorto-mesenteric angle. In conclusion, watchful waiting with a nutritional care plan is a feasible initial strategy in the approach to SMA syndrome. However, should this strategy be unsuccessful, the choice of surgical treatment is duodenojejunostomy.

Conversion rate and risk factors of conversion to open in laparoscopic appendicectomy

Purpose@#Laparoscopic appendicectomy (LA) has several advantages over conventional open appendicectomy (OA). However, about 5% to 10% of LA patients still need to be converted to open surgery. Identifying risk factors that contribute to conversion to OA allows for early identification of patients who may benefit from primary OA. This study aimed to determine the conversion rate of LA to OA and to identify its associated risk factors among patients with acute or perforated appendicitis. @*Methods@#A retrospective review of medical records was performed among patients with acute or perforated appendicitis who underwent LA between December 2015 and January 2017. With the use of multivariable logistic regression analyses, the predictors of conversion from laparoscopic to OA were investigated. @*Results@#Out of 120 patients, 33 cases were converted to OA which gives a conversion rate of 27.5%. Among 33 patients who were converted to OA, 27 patients (81.8%) had perforated appendix, while in the LA group, perforated appendix cases consisted of 34.5% (P<0.001). Histopathology of the appendix was the predictor of conversion from LA to OA (adjusted odds ratio, 8.82; 95% confidence interval, 3.13–24.91; P<0.001). @*Conclusion@#The result from our study shows that the overall conversion rate for the study period was high. Patients with perforated appendicitis had a higher risk of conversion to OA. Therefore, preoperative diagnosis of perforated appendicitis may be paramount in predicting conversion to OA.

Biliary ascariasis – A vicious cycle

@#Biliary ascariasis is a rare disease in a non-endemic area. However, it is one of the possible etiological factors for retarded growth as well as malnutrition in children. It may cause intestinal obstruction, appendicitis, biliary obstruction, liver abscess, hepatolithiasis, and pancreatitis in adults. Herein, we report a patient with ascending cholangitis secondary to biliary ascariasis who was successfully managed with Endoscopic Retrograde Cholangio Pancreaticography.

The Use of M2-Pyruvate Kinase as a Stool Biomarker for Detection of Colorectal Cancer in Tertiary Teaching Hospital: A Comparative Study

Purpose@#Guaiac fecal occult blood test (gFOBT) has been the standard for colorectal screening but it has low sensitivity and specificity. This study evaluated the use of fecal tumor M2-pyruvate kinase (M2-PK) for detection of colorectal cancer and to compare with the current surveillance tool; gFOBT in symptomatic adult subjects underwent colonoscopy. @*Methods@#Stool samples were collected prospectively from symptomatic adults who had elective colonoscopy from September 2014 to January 2016 and were analyzed with the ScheBo M2-PK Quick test and laboratory detection of fecal hemoglobin. @*Results@#The results were correlated to the colonoscopy findings and/or histopathology report. Eighty-five subjects (age of 56.8 ± 15.3 years [mean ± standard deviation]) were recruited with a total of 17 colorectal cancer (20.0%) and 10 colorectal adenoma patients (11.8%). The sensitivity of M2-PK test in colorectal cancer detection was higher than gFOBT (100% vs. 64.7%). M2-PK test had a lower specificity when compared to gFOBT (72.5% vs. 88.2%) in colorectal cancer detection. The positive and negative predictive values were 47.2% and 100% for M2-PK test and 57.9% and 90.9% for gFOBT. @*Conclusion@#Fecal M2-PK Quick test has a high sensitivity for detection of colorectal cancer when compared to gFOBT, making it the potential choice for colorectal tumor screening biomarker in the future.

The Use of M2-Pyruvate Kinase as a Stool Biomarker for Detection of Colorectal Cancer in Tertiary Teaching Hospital: A Comparative Study

Purpose@#Guaiac fecal occult blood test (gFOBT) has been the standard for colorectal screening but it has low sensitivity and specificity. This study evaluated the use of fecal tumor M2-pyruvate kinase (M2-PK) for detection of colorectal cancer and to compare with the current surveillance tool; gFOBT in symptomatic adult subjects underwent colonoscopy. @*Methods@#Stool samples were collected prospectively from symptomatic adults who had elective colonoscopy from September 2014 to January 2016 and were analyzed with the ScheBo M2-PK Quick test and laboratory detection of fecal hemoglobin. @*Results@#The results were correlated to the colonoscopy findings and/or histopathology report. Eighty-five subjects (age of 56.8 ± 15.3 years [mean ± standard deviation]) were recruited with a total of 17 colorectal cancer (20.0%) and 10 colorectal adenoma patients (11.8%). The sensitivity of M2-PK test in colorectal cancer detection was higher than gFOBT (100% vs. 64.7%). M2-PK test had a lower specificity when compared to gFOBT (72.5% vs. 88.2%) in colorectal cancer detection. The positive and negative predictive values were 47.2% and 100% for M2-PK test and 57.9% and 90.9% for gFOBT. @*Conclusion@#Fecal M2-PK Quick test has a high sensitivity for detection of colorectal cancer when compared to gFOBT, making it the potential choice for colorectal tumor screening biomarker in the future.

Predictors of early postoperative hypocalcemia after total parathyroidectomy in renal hyperparathyroidism

PURPOSE: Patients with secondary hyperparathyroidism are at high risk for developing postoperative hypocalcemia. However, there are limited data regarding predictors of postoperative hypocalcemia in renal failure patient with secondary hyperparathyroidism. This study aimed to determine the clinical presentations of renal hyperparathyroidism and the predictors of early postoperative hypocalcemia after total parathyroidectomy.METHODS: Data of patients with renal hyperparathyroidism who underwent total parathyroidectomy between January 2007 to December 2014 were reviewed retrospectively. Patients were divided into 2 cohort groups according to their serum calcium levels within 24 hours of parathyroidectomy: the hypocalcemia group (calcium levels of 2 mmol/L or less), and the normocalcemia group (calcium levels more than 2 mmol/L). With the use of multivariable logistic regression analyses, the predictors of early postoperative hypocalcemia after total parathyroidectomy in patients with renal hyperparathyroidism were investigated.RESULTS: Among 68 patients, 56 patients (82.4%) were symptomatic preoperatively. Fifty patients (73.5%) presented with bone pain and 14 patients (20.6%) had muscle weakness. Early postoperative hypocalcemia occurred in 25 patients (36.8%). Preoperative alkaline phosphatase level was the predictor of early postoperative hypocalcemia (adjusted odds ratio, 1.004; 95% confidence interval, 1.001–1.006; P = 0.002).CONCLUSION: Results from our study show that most of the patients with renal hyperparathyroidism were symptomatic preoperatively and the most common clinical presentations were bone pain and muscle weakness. The significant predictor of early postoperative hypocalcemia after total parathyroidectomy was the preoperative alkaline phosphatase levels.

Analysis of enamel and material wear by digital microscope: an in-vitro study

Abstract: The objective of the study was to analyze the surface area (SA) of the wear caused by simulated chewing on human enamel and opposing restorative material, namely: composite resin (CR), porcelain fused to metal (PFM), lithium disilicate (LD), or monolithic zirconia (MZr). Forty-eight premolars were selected as enamel specimens and divided randomly into 4 groups (n = 48; n =12) used as antagonists in chewing simulation (250,000 loading cycles) against one of the four selected test materials. Enamel and material specimens were scanned and evaluated under digital microscope, and wear SA (mm2) were recorded. Descriptive statistics, paired t-test, one-way ANOVA, and post-hoc Tukey-HSD tests were used for statistics (p < 0.05). The smallest and largest SA were exhibited by enamel against LD (0.80 mm2) and PFM (1.74 mm2), respectively. PFM (3.48 mm2) showed the largest SA and CR (2.28 mm2) showed the smallest SA. Paired t-test for SA values showed significant difference (p < 0.05) in all wear comparisons between materials and enamel antagonists. The wear of materials were greater than that of their respective enamel antagonists (p < 0.05). One-way ANOVA of the logarithmic means of wear SA revealed significant differences (P<0.05). Post-hoc Tukey test revealed significance for PFM (p < 0.05) with other materials. Wear of all test materials was greater compared to the wear of enamel antagonists. PFM and LD caused the largest and the smallest enamel wear, respectively. CR, LD, and MZr are more resistant than PFM to wear after simulated chewing against enamel.

A Cross-Sectional Study of Neutrophilto- Lymphocyte Ratio in Diagnosing Acute Appendicitis in Hospital Melaka

@#Background: Acute appendicitis is one of the most common surgical emergencies. However, its proper diagnosis is complicated. This study aims to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR) to diagnose acute appendicitis in pre-operative state. Methods: Histopathological examination of appendicectomies conducted between 2016 and 2017 in Melaka Hospital, Malaysia were traced and categorised into three groups: i) G1 (normal appendix), ii) G2 (acute appendicitis) and iii) G3 (perforated appendicitis). The reports were randomised and a total of 338 samples were collected. NLR values were compared between the three different groups and analysed. Results: The median values of NLR for G1, G2 and G3 were 2.37, 5.25 and 9.27, respectively. We found a statistically significant difference in NLR between G1 and G2 (P < 0.001), and G2 and G3 (P < 0.001). The diagnostic values of NLR for acute appendicitis and perforated appendicitis were 3.11 (sensitivity: 75.23%, specificity: 68.70%) and 6.17 (sensitivity: 76.32%, specificity: 58.72%), respectively. There was a substantial correlation between NLR and disease severity, and a moderate correlation between NLR and duration of admission. Conclusion: NLR, with a sensitivity of 75.23% and specificity of 68.70%, is a useful and reliable adjunct in diagnosing acute appendicitis. Hence, it will help in reducing the rate of negative appendicectomies.

Identification of commonly regulated genes in HPV18-and HPV16-infected cervical cancer cells treated with the curcumin analogue 1,5-bis(2-hydroxyphenyl)-1,4-pentadiene-3-one

Objective:To identify commonly regulated genes in HPV-infected HeLa and CaSki cervical cancer cells treated with curcumin analogue 1,5-bis(2-hydroxyphenyl)-1A-pentadiene-3-one (MS17) and to explore potential mechanisms that underfie its eytotoxic,anti-proliferative and apoptotic activity,Methods:HeLa and CaSki cells were treated with 2 × EC5o and 3 × EC50 doses of MS 17 for 24 h and the RNA extracts were subjected to one-colour microarray-based gene expression profiling.Pair-wise significant genes (false discovery rate-corrected,P＜0.05)were analysed for fold change (FC) compared to control samples.Differentially expressed genes with FC≥2.0 (up-regulated;FC≥2.0 and down-regulated;FC≤-2.0) compared to the control samples were filtered through and analysed to create a global gene expression profile.Mutually regulated genes were ranked by FC and categorised by gene ontology.Results:Our data indicated dose-dependent regulation by MS 17 and identified top 20 mutually upand down-regulated genes each in HeLa and CaSki cells.Amongst these 17 were commonly regulated in both cell lines.These include the up-regulation of CCL26,DEFB103B,IL1RL1,LY96,GCNT3,MMPI0,MMP3,GADD45G and HSPA6,and the down-regulation of TENM2,NEBL,KIFC1,CTDSP1,IGFBP5,LTBP1,NREP and MXD3.These genes were associated with key biological functions that were proposed to mediate the anticancer activity of MS 17 in cervical cancer cells such as immune response,metabolic processes,proteolysis,programmed cell death,unfolded protein response,cell adhesion,cytoskeletal organisation,phosphatase activity,signal transduction and transcription regulator activity.Conclusions:Identification of seventeen common genes modulated by MS 17 could be used as potential therapeutic targets in both cervical cancer cell lines and the findings of this study could be used to present an insight into the potential antitumor activity of MS 17 in cervical cancer.

Sociodemographic Determinants Of Obesity Among 12 Years Old School Adolescents In Kuala Terengganu And Besut Districts, Malaysia

@#Worldwide prevalence of obesity among children and adolescents increased substantially over decades. Addressing potential risk factors of obesity among adolescents is very important for a successful intervention program in this population. The present study aimed to identify the sociodemographic determinants of obesity among school adolescents in Terengganu. A cross-sectional survey involving 3,798 school adolescents age 12 years old from 136 government primary schools in Kuala Terengganu and Besut districts were carried out from November 2014 to June 2015. For the purpose of this paper, the data for 2,842 school adolescents classified as either normal BMI (< +1SD) (n= 2,305) or obese (+2SD) (n= 537) based on WHO cut-off points were taken for analysis. Sociodemographic information on subjects and their parents were obtained from self-reported questionnaire. Anthropometric measurements were conducted by Physical Education teachers and uploaded into a specific developed database. The prevalence of obesity was relatively high in both genders in this study. Binary logistic regression analysis found gender, parental BMI, household income, household size and maternal working status were independently associated with obesity among school adolescents in this population. In the final model, being male, having working mother, and having obese parents were identified to be potential risk factors for obesity whilst having large household size lower the risk of obesity among these adolescents. Prevention programs are needed to increase awareness about the risk factors of obesity in adolescent and interventions should now focus on family member as well mainly the parents.

Sociodemographic Determinants Of Obesity Among 12 Years Old School Adolescents In Kuala Terengganu And Besut Districts, Malaysia

Worldwide prevalence of obesity among children and adolescents increased substantially over decades. Addressing potential risk factors of obesity among adolescents is very important for a successful intervention program in this population. The present study aimed to identify the sociodemographic determinants of obesity among school adolescents in Terengganu. A cross-sectional survey involving 3,798 school adolescents age 12 years old from 136 government primary schools in Kuala Terengganu and Besut districts were carried out from November 2014 to June 2015. For the purpose of this paper, the data for 2,842 school adolescents classified as either normal BMI (< +1SD) (n= 2,305) or obese (+2SD) (n= 537) based on WHO cut-off points were taken for analysis. Sociodemographic information on subjects and their parents were obtained from self-reported questionnaire. Anthropometric measurements were conducted by Physical Education teachers and uploaded into a specific developed database. The prevalence of obesity was relatively high in both genders in this study. Binary logistic regression analysis found gender, parental BMI, household income, household size and maternal working status were independently associated with obesity among school adolescents in this population. In the final model, being male, having working mother, and having obese parents were identified to be potential risk factors for obesity whilst having large household size lower the risk of obesity among these adolescents. Prevention programs are needed to increase awareness about the risk factors of obesity in adolescent and interventions should now focus on family member as well mainly the parents.

Relative effectiveness of aminosalicylates in the management of acute ulcerative colitis – Mesalamine vs Sulfasalazine

Introduction: Inflammatory bowel disease (IBD) is not a single condition. It is the term for a group of disorders that cause prolonged inflammation of the digestive tract. The most common types of inflammatory bowel disease (IBD) are ulcerative colitis and Crohn’s disease. Aim: The study was designed to compare the efficacy, safety, incidence of ADR’S in patients of inflammatory bowel disease with regard to the use of mesalamine, sulfasalazine and using combination of mesalamine and steroids. Materials and methods: This observational, non interventional study conducted in General Medicine Department and Gastroenterology department, Princess Esra hospital, shahali banda, within 6 months of duration. Patients selected randomly according to inclusion and exclusion criteria. A 110 patients aged 18 to 90 years, and presenting with complaints of abdomen pain, diarrhoea, bloody diarrhoea, painful defecation, altered appetite, bleeding per rectum were screened for the study after taking their informed consent. Patients were categorized into 4 groups; group I (control), group II (Mesalamine), group III (sulfasalazine), and group IV (Mesalamine + steroids) Results: Patients with age group from 18-80yrs were included in the study. The age group of 31- 50age was found more prone to disease. The total percentage of male and female in 110 patients was found to be 40% (male) and 60% (female). Patients with percentage of 60% male and 40% female underwent treatment with mesalamine (Group-I), 36.6%male and 63.3%female with mesalamine + steroids (Group-II), and 30% male and 70% female with sulfasalazine (Group-III) respectively. The Syed Ibrahim Hassan, Syed Mohd Akbar Hassan, Haleema Begum. Relative effectiveness of aminosalicylates in the management of acute ulcerative colitis - Mesalamine vs Sulfasalazine. IAIM, 2016; 3(12): 137-147. Page 138 most common symptom was abdomen pain present in 74% patients and rectal bleeding was the next common symptom (67.21%) and other symptoms include vomiting (55.2%), loose stools (52.3%), painful defecation (44%), and reduced appetite (43.3%). The adverse effects observed during sulfasalazine treatment was abdominal pain (50%), nausea (35%), dizziness (21.6%), anorexia (16.6%), rashes (10%), gastric distress (10%), sleeping disorders (3.30%), cyanosis (3.3), hemolytic anaemia (1.60%) and mesalamine treatment was abdominal pain 21.08%, nausea 3.50%, heartburn 22%, bloated stomach 7.7% and weakness 6.64% and with mesalamine + steroids was abdomen pain 48.3%, rectal bleeding 33.3%, painful defecation 18.3%, loose tools 45%, vomiting 50% and reduced appetite 28.3%. The percentage recovery of symptoms with sulfasalazine was 60% abdomen pain, 30% rectal bleeding, 15% painful defecation, 44% loose stools, 65% vomiting, and 0% reduced appetite, with mesalamine was 40% abdomen pain, 20% rectal bleeding, 0% painful defecation, 15% loose stools, 0% vomiting, 10% reduced appetite and mesalamine + steroids was 21.6% abdomen pain, 13.3 rectal bleeding, 8.3% painful defecation, 26.6% loose stools, 15% vomiting, 18.3% reduced appetite. Conclusion: Patients of acute IBD- acute ulcerative colitis of mild type respond faster to mesalamine with or without steroids compared to sulfasalazine alone although both drugs showed good response

Chronic atrophic antral gastritis and risk of metaplasia and dysplasia in an area with low prevalence of Helicobacter pylori.

Introduction The Northeastern region of Peninsular Malaysia is an area with exceptionally low prevalence for Helicobacter pylori infection. The risk of intestinal metaplasia and dysplasia in patients with chronic atrophic gastritis (CAG) and its association with Helicobacter pylori is unknown in this region. Methods This was a cross-sectional study on gastric biopsies from 234 consecutive patients (mean age 53.5 [14.8] years) who underwent upper gastrointestinal endoscopy between January 2006 and December 2006. Results There were 137 (59%) men and 185 (79%) Malay patients. Among 234 biopsies, CAG was found in 99 and non-atrophic gastritis in 135. Intestinal metaplasia and dysplasia were detected in 8 and 6 atrophic gastritis biopsies, respectively, and in 10 and 3 of non-atrophic gastritis biopsies, respectively. H. pylori were detected in 16 (9 Malays, 7 non- Malays) biopsies (p=0.024); intestinal metaplasia was detected in 4 biopsies (p=0.3) and dysplasia in 5 biopsies (p=0.3). Of the 218 biopsies negative for H. pylori, intestinal metaplasia was found in 14 and dysplasia in 4. The risk of intestinal metaplasia as well as dysplasia was associated with presence of H. pylori infection (p=0.029 and p<0.001 respectively). Conclusion Even in a setting of low prevalence of H. pylori, intestinal metaplasia and dysplasia were significantly associated with H. pylori infection. The frequency of intestinal metaplasia and dysplasia was similar different between biopsies with atrophic gastritis and non-atrophic gastritis.

Esophageal stricture following electrical injury.

Esophageal injury resulting from electrical shock is rare. Stricture of esophagus following external electrical injury has not been reported yet. We report a 24-year-old electric lineman who developed esophageal stricture following external electrical shock. He responded to dilatation with Savary-Gilliard dilators.