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.

Tangled Throughout Life: A Case of Paediatric Ruptured Cerebral Arteriovenous Malformation

@#Arteriovenous malformation (AVM) in children is uncommon occurrence defined as presence of arteriovenous shunting through coiled and tortuous vascular connections. We discussed a case of a 3-year old girl presented with acute left facial asymmetry and right-sided limb weakness. Neurological examination revealed MRC scale of 0 out of 5 for power on her right side. Magnetic Resonance Angiography (MRA) revealed bilateral thalamic AVM. Surgical resection was not advisable in view of deep-seated location. Paediatric AVM most often become apparent following rupture with majority presents with headache. Ruptured paediatric AVM carries high burden of morbidity and mortality. Paediatric intracranial haemorrhage posed tremendous concern regarding its long-term outcome. Treatment would be more appropriate sooner rather than later especially for those presented with ruptured AVM. Surgical resection remains the gold standard treatment for all accessible paediatric AVMs with embolization and radiosurgery as adjunctive therapies. AVM in paediatric population is rare but carries grim prognosis.

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.

Multi-Epitope Peptide-Based and VacciniaBased Universal Influenza Vaccine Candidates Subjected to Clinical Trials

@#In light of the limited protection conferred by current influenza vaccines, immunisation using universal influenza vaccines has been proposed for protection against all or most influenza sub-types. The fundamental principle of universal influenza vaccines is based on conserved antigens found in most influenza strains, such as matrix 2, nucleocapsid, matrix 1 and stem of hemagglutinin proteins. These antigens trigger cross-protective immunity against different influenza strains. Many researchers have attempted to produce the conserved epitopes of these antigens in the form of peptides in the hope of generating universal influenza vaccine candidates that can broadly induce cross-reactive protection against influenza viral infections. However, peptide vaccines are poorly immunogenic when applied individually owing to their small molecular sizes. Hence, strategies, such as combining peptides as multi-epitope vaccines or presenting peptides on vaccinia virus particles, are employed. This review discusses the clinical and laboratory findings of several multi-epitope peptide vaccine candidates and vaccinia-based peptide vaccines. The majority of these vaccine candidates have reached the clinical trial phase. The findings in this study will indeed shed light on the applicability of universal influenza vaccines to prevent seasonal and pandemic influenza outbreaks in the near 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.

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.

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.

Universal Oral Vaccine for Influenza Infections / Jurnal Sains Kesihatan Malaysia

Each year, influenza A infections have caused tremendous death rate as high as 300,000-500,000 globally. Althoughthere are effective anti-influenza agents and vaccines, high mutational rate among influenza A viruses renders dramaticdecline in the effectiveness of anti-influenza agents or vaccines in certain individuals. The situation is further complicatedby limitations in influenza vaccine production, for instance, long production period, limited vaccine capacity and lackof cross-protection against various influenza A virus strains. To solve these issues, development of universal influenzavaccine based on conserved antigens such as non-stuctural protein 1 (NS1) has been endeavoured. NS1 protein is highlyconserved in all influenza A virus strains known by far, produced abundantly on infected cell surfaces and responsible formaintaining virulence. Furthermore, cytotoxic T-lymphocytes that are active against NS1 were also reported to be ableto avoid shedding of influenza in hosts. To better inhibit influenza infections, oral immunization has long been proposeddue to feasibility of this method to be implemented and safer for recipients while able to target influenza A viruses fromthe entry point. Lactobacillus has been vastly studied for its roles as bacterial carrier in oral vaccine development dueto its significant probiotic properties. For examples, stimulation of immune responses in oral and airway mucosal layers,high colonization in oral and airway mucosal layers and great natural adjuvant effects. In this light, influenza universaloral vaccine developed using NS1 dan Lactobacillus should be further studied in influenza oral vaccine design.

Study of coronary artery disease in patients of younger age group less than 40 years of age

Objective: To consider the aetiological factors for causing myocardial infarction in younger age group and to include these perspectives for the diagnosis of coronary artery disease. Study Design: A descriptive study. Place and Duration of Study: Study was carried out at CCU in the Department of Medicine, Avicenna Medical College and Hospital Lahore, from Jun 2012 to May 2013

Material and Methods: All patients within the age group of 26-35 years were admitted in CCU on the basis of multiple clinical symptoms by using approach of regular clinical investigations under the aspect of Ischemic heart disease. Clinical investigations were comprised upon cardiac monitoring, lipid profile, ECG and rate for cardiac enzyme included

Results: A total of 18 patients completed the study with age group of 26-35 years. MI was diagnosed in all patients and maximum number of patients with acute MI varied from age 28-33 years. All patients were heavy smokers with high rate of physical stress. On gross clinical examination it was revealed that majority of the patients included in age of 28-33 years was professionally van drivers

Conclusion: The essence of acute MI was observed and critically analyzed in younger age group of people with certain aetiological factors. This should be essentially important in redefining the criterion on clinical grounds for CAD and this should be recognized at International level. As the studies under clinical grounds with the aspect of CAD being reported at International level so, the amount of parameters in clinical diagnosis has to be considered in regular manners for the cure and prevention of CAD in patients especially of younger age groups less than 40

Item analysis of multiple choice questions

Any academic course or program is incomplete without an assessment plan. Of late, MCQs have been widely used for assessment of medical and dental undergraduate students. Often enough, poorly constructed MCQs are used that do not fulfil the requirement of an assessment. Therefore, it is neces-sary that quality of MCQs be frequently evaluated. A quality assessment of MCQs is known as "item analysis". Item analysis allows identification of good-quality MCQs based on their Difficulty Index [DIF I/P], Discrimination Index [DI] and Distractor efficiency [DE]. The aim of this paper was to conduct an item analysis to evaluate the quality of MCQs being used to assess final year BDS students in the subject of Prosthodontics. An internal assessment for the subject of Prosthodontics was undertaken by fifty dental undergraduate students of final year in March 2018. The test consisted of 40 'one best type' MCQs, each with four options a - d. Post-validation of the test was done by item analysis. Data were analyzed using SPSS version 24. Majority [52.5%] MCQs were "too difficult" with a Diff Index less than 30%. About 67.5% MCQs had a poor discrimination index [DI < 0.2]. Of the 120 distractors, 62 [51.6%] were non-functional and only 5 MCQs had no non-functional distractors. It can be concluded that the items administered in this test need careful revision to improve their quality before using them in any future assessments

Significant Replication Time-points of Avian Influenza A Virus Strain H5N1 in Madin-Darby Canine Kidney Cells / Jurnal Sains Kesihatan Malaysia

The occasional influenza pandemics and the seasonal influenza epidemics have destroyed millions of lives since the last century. It is therefore necessary to understand the virus replication patterns as this provides essential information on the virus infectivity, pathogenicity and spread patterns. This study aimed to investigate the replication of avian influenza A virus H5N1 (A/Chicken/Malaysia/5858/2004) in MDCK cells. In this study, the TCID50 (50% tissue culture infectious dose) of AIV H5N1 was first determined. The MDCK cells were then infected with AIV H5N1 at TCID50 for 0-48 h. The CPE (cytopathic effect) was observed and cell death was determined hourly. The virus-infected cells and media were subsequently collected for gene analysis. The results showed that the TCID50 of AIV H5N1 was 10-9 dilution. The CPE percentage showed a strong and positive correlation with the infection period (r = 1.0, n = 9, p 0.05) and infected cell (r = 0.73, n = 9, p < 0.05) were also positively correlated with the infection period. In conclusion, although CPE started to be observed in the early time points of infection, however, the M2 gene was only amplified from the infected media and cells after 48 h and 24 h, respectively. This signifies that AIV H5N1 used in this study is pathogenic and it is able to cause severe cytopathology to host cells even at low virus load.

Impact of Rating Scale Categories on Reliability and Fit Statistics of the Malay Spiritual Well-Being Scale using Rasch Analysis

Background: Few studies have employed the item response theory in examining reliability. We conducted this study to examine the effect of Rating Scale Categories (RSCs) on the reliability and fit statistics of the Malay Spiritual Well-Being Scale, employing the Rasch model. Methods: The Malay Spiritual Well-Being Scale (SWBS) with the original six; three and four newly structured RSCs was distributed randomly among three different samples of 50 participants each. Results: The mean age of respondents in the three samples ranged between 36 and 39 years old. The majority was female in all samples, and Islam was the most prevalent religion among the respondents. The predominating race was Malay, followed by Chinese and Indian. The original six RSCs indicated better targeting of 0.99 and smallest model error of 0.24. The Infit Mnsq (mean square) and Zstd (Z standard) of the six RSCs were “1.1”and “-0.1”respectively. The six RSCs achieved the highest person and item reliabilities of 0.86 and 0.85 respectively. These reliabilities yielded the highest person (2.46) and item (2.38) separation indices compared to other the RSCs. Conclusion: The person and item reliability and, to a lesser extent, the fit statistics, were better with the six RSCs compared to the four and three RSCs.

Older Adults With Cognitive Impairment Living In Malaysian Nursing Homes – Have We Met Their Needs?

Objective: Transition of people with cognitive impairment to nursing home is often an option when their disease progresses and their needs become too complex. The aim of this study was to identify the needs of people with cognitive impairment living in nursing homes and factors associated with higher level of needs. Methods: A cross sectional survey involving 110 respondents with cognitive impairment aged ≥60 was carried out. Respondents were assessed using the Short Mini Mental State Examination (SMMSE), Camberwell Assessment of Needs for Elderly (CANE), Barthel Index (BI), Friendship Scale (FS), and Geriatric Depression Scale (GDS). Results: Respondents with cognitive impairment had a mean of 2.81 (SD=3.72) for unmet needs and 11.95 (SD=3.14) for the met needs, with higher mean suggesting a better outcome measure. The most frequent unmet needs were intimate relationships (66.40%), company (40.00%), and daytime activity (34.50%). Unmet needs were significantly associated with depression, social isolation, and cognitive impairment. Conclusion: Most of the needs of people with cognitive impairment in nursing homes were fulfilled, except in social area. Therefore, attention should be given in improving the care system, which emphasizes collaboration between people with cognitive impairment, family members, community, and government in helping to reduce the risk of loneliness in those with cognitive impairment.

Nature of oral biopsies; Liaquat university hospital hyperabad

Biopsy is the removal of a tissue sample from a living body with the objective of providing the pathologist with a representative, viable specimen for histopathologic interpretation and diagnosis. Objectives: To find out frequency and nature of oral biopsies reported at liaquat university hospital Hyderabad. Design: Descriptive/Cross sectional. Period: 1st February 2012 to 31st January 2014 Setting: Oral and Maxillofacial Surgery Department, Liaquat University Hospital Hyderabad. Material and Methods: A total of 180 patients were reported at OPD and Oral and Maxillofacial Surgery ward of Liaquat University Hospital for oral incisional, excisional and punch biopsy purpose. Study design was descriptive/cross sectional study. All patients were treated both under general anesthesia as well as local anesthesiaandsedation. All the biopsies were sent to histopathology department for confirmation of diagnosis. Results:119 patients [66.1%] were males and 61 patients [33.8%] were females with age range from 10-80 years. Malignancy was diagnosed in 80 patients [44.4%] while odontogenic cysts were diagnosed as second common category with 38 patients [21.1%]. Conclusions: Squamous cell carcinoma was diagnosed as the most common malignant lesion which is rising danger to the society specially as the age advances.

Annona squamosa Linn: Cytotoxic activity found in leaf extract against human tumor cell lines

Cancer is a common cause of death in human populations. Surgery, chemotherapy and radiotherapy still remain the corner stone of treatment. However, herbal medicines are gaining popularity on account of their lesser harmful side effects on non-targeted human cells and biological environment. Annona squamosa Linn is a common delicious edible fruit and its leaf have been used for the treatment in various types of diseases

The objective of present study is to determine the anticancer potential of the organic and aqueous extracts of leaf of Annona squamosa L. MTT [3-[4, 5-dimethylthiazole-2yl]-2, 5-biphenyl tetrazolium bromide] assay against hepatocellular carcinoma cell line BEL-7404, lung cancer line H460, human epidermoid carcinoma cell line KB-3-1, prostatic cancer cell line DU145, breast carcinoma cell line MDA-MB-435, and colon cancer cell line HCT-116 Human primary embryonic kidney cell line HEK293 as control were used for the study

The crude extract [Zed] and Ethyl acetate extract [ZE] were found significant anticancer activity only on human epidermoid carcinoma cell line KB-3-1 and colon cancer cell line HCT-116