Type B Lactic Acidosis: A Very Rare but Fatal Complication of Gastrointestinal Solid Tumor.

Type B lactic acidosis, secondary to solid cancer, is very rare. It is mostly seen in patients with hematological malignancies. Although its exact pathogenesis is unknown, it is believed to be caused by overproduction and the inability of tumor cells to remove lactate. In the last 26 years, a systematic review of the literature only identified two previous reports of colorectal cancer-related type B lactic acidosis. Here, we report the third case of severe type B lactic acidosis due to stage IV colorectal with liver metastasis. Besides, this case is unique in that serum lactate levels reaching as high as 24 mmol/L were not reported in association with colorectal cancer. In most cases, the prognosis is still very poor because there are no standardized treatment recommendations. Early chemotherapy is still the only intervention that provides some survival benefits.

Prevalence and correlates of university students' perceived stress in southwestern Saudi Arabia.

ABSTRACT: The university period can be stressful for most students. It may be due to exposure to various stressors. Objectives: To establish the prevalence and factors associated with high perceived stress among university undergraduates in south-western Saudi Arabia.A self-administered survey was conducted among a representative sample of King Khalid University students through a cross-sectional study. Data obtained included socio-economic, academic characteristics, and grade point average (GPA) scores. Stress was assessed using the Perceived Stress Scale.This study included 2467 students. The average Perceived Stress Scale score was 19.13 ±â€Š6.56, which was notably higher (P = .02) among health care undergraduates (19.45 ±â€Š6.49) compared to others (18.85 ±â€Š6.61). High perceived stress prevalence rate was 12.7% (13.6% in health care institutions and 12.0% in non-healthcare institutions). Multivariable analysis revealed that high perceived stress was considerably greater among females (adjusted odds ratio [aOR] = 2.35, 95% confidence interval:167-3.30), smokers (aOR = 1.65), those with an unsatisfactory income (aOR = 3.10), and healthcare students (aOR=1.33). In contrast, it was negatively associated with the GPA score (aOR= 0.77).High perceived stress is a substantial problem among university students. Female students and healthcare students are at a greater risk. High stress is correlated with smoking, lower GPA scores, and perceived insufficient family income.

Iodine Deficiency Disorders as a Predictor of Stunting among Primary School Children in the Aseer Region, Southwestern Saudi Arabia.

OBJECTIVES: To investigate the present occurrence of stunting and explore the role of iodine deficiency disorders (IDDs) as a predictor of stunting among primary school children in the Aseer Region. METHODS: In a cross-sectional investigation on school children in the Aseer region, thyroid enlargement was evaluated clinically. Urine was collected to evaluate iodine content. RESULTS: The present study involved 3046 school-age pupils. The study disclosed a total goiter rate of 24.0% (95% CI: 22.5-25.5%). The median urinary iodine content (UIC) was 17.0 µg/L. A prevalence of stunting (height for age z score of less than -2) of 7.8% (95% CI: 6.9-8.8%) was found. In a logistic regression model, pupils having clinical goiter (aOR = 1.739; 95% CI: 1.222-2.475) and students having UIC of less than 17 µg/L (aOR = 1.934; 95% CI: 1.457-2.571) were considerably related with stunting. In the receiver operating characteristic (ROC) curve, urinary iodine content to forecast stunting was good (AUC = 0.611, 95% CI: 0.594-0.629). The curve recognized the optimum cutoff point of urinary iodine content to be ≤19.0 µg/L. The sensitivity was 59.66% (95% CI: 53.1-66.0) and the specificity was 57.62% (95% CI: 55.8-59.5). Conclusion: The present study showed that stunting among school-aged children presents a mild public health problem. On the other hand, a severe iodine deficiency situation was revealed among school children in the Aseer region. Continuous monitoring of iodine status among school children is therefore necessary. Concerted interventions that blend nutrition-sensitive with nutrition-specific approaches are expected to influence decreasing stunting significantly.

Acute Acalculous Cholecystitis Due to COVID-19, an Unusual Presentation.

Although the Coronavirus Disease 2019 (COVID-19) infection mainly affects the lung, its gastrointestinal (GI) involvements are also well-known, especially hepatic involvement presenting as mild to moderate transaminitis. However, COVID-19 infection presenting with gall bladder involvement with acalculous cholecystitis is extremely rare in the medical literature. So far, only two cases have been reported, and herein, we are reporting the third case of a patient who developed COVID-19 presenting as an acute acalculous cholecystitis.

Atypical Presentation of Fatal Disease: Painless Aortic Dissection.

Aortic dissections (ADs) are uncommon but they are highly lethal. Due to atypical signs and symptoms, diagnosis of type B AD can be easily missed or delayed. Our patient presented to the emergency center with dizziness and fall for which he was evaluated and treated for hypertension. Two weeks later, he again presented to the hospital with painless right groin swelling: computed tomography (CT) of the abdomen incidentally showed type B AD. The patient might have an AD presenting with dizziness and hypertension during previous presentation. From this case, we learn how it is challenging to diagnose painless AD especially when patient comes with atypical symptoms. In high-risk patients with unexplained dizziness and fall, a high degree of suspicion may help for early diagnosis and management.

A Sporadic Case of Disseminated Fusobacterium Causing Pylephlebitis and Intracranial and Hepatic Abscesses in a Healthy Young Patient.

Fusobacterium species is known for being a causative agent for Lemierre's syndrome, which is characterized by thrombophlebitis of the jugular vein. However, Fusobacterium species causing Lemierre's variant gastrointestinal syndrome has only been reported in case reports. We present a case of Fusobacterium causing hepatic vein pylephlebitis, multiple brain abscesses, and hepatic abscess. To the best of our knowledge, there have only been four other case reports of Fusobacterium causing hepatic abscesses with associated septic pylephlebitis in the literature.

A Fatal, Post-Intubation, Tracheoesophageal Fistula.

Despite the use of safer tubes with high-volume, low-pressure cuffs, post-intubation injury is still the leading cause of benign, acquired, tracheoesophageal fistula (TEF). Cuff pressure, which is their primary pathogenetic driver, is not routinely monitored as a quality metric. To highlight the devastating consequences, we report this case of a fatal, iatrogenic fistula in a 64-year-old Asian male. He had undergone tracheostomy due to amyotrophic lateral sclerosis (ALS) and had a series of hospitalizations due to recurrent episodes of pneumonia. A TEF was eventually diagnosed to be the underlying cause. Esophageal stenting was ineffective. We intend to present teaching points aimed at reducing the risk of TEF in ventilator-dependent patients.

A Case of Isolated Pulmonary Mycobacterium Avium Complex Being the First Presentation of a Newly Diagnosed HIV/AIDS.

We report a case of a 39-year-old HIV positive transgender female with isolated manifestations of pulmonary Mycobacterium avium complex (MAC) infection. Although MAC infection is common in immunocompromised patients, the classical presentation is extra-pulmonary. Pulmonary MAC infection is extremely rare. The majority of cases involve patients with underlying structural lung disease. There are no case reports of isolated pulmonary MAC in HIV/AIDS patients without any structural lung disease in the last 17 years. Also, we have not found any cases of newly diagnosed HIV/AIDS patients with pulmonary MAC being the initial presentation.

Severe Pulmonary Hypertension and Cholestatic Liver Injury: Two Rare Manifestations of Graves' Disease.

Graves' disease is seen in the majority of patients diagnosed with hyperthyroidism. The usual symptoms of Graves' disease are tremors, weight loss, sweating, exophthalmos, pretibial edema, anxiety, and palpitations. However, there could be unusual manifestations such as hepatic failure and pulmonary hypertension. We present the case of a 31-year-old female with Graves' disease with these two rare complications, which resolved with medical management in about three months. To the author's knowledge, this is the second case of a patient with this type of presentation.

Diagnosis and Management of 1:1 Atrial Flutter in the Setting of Aortic Valve Endocarditis and Embolic Stroke.

Atrial flutter is a rapid, regular atrial tachyarrhythmia that occurs most commonly in patients with underlying structural heart disease. Spontaneous 1:1 conduction of atrial flutter is indeed rare, but its diagnosis and management is of critical importance. We describe a case of a 65-year-old man with hypertension, preserved ejection fraction heart failure, end-stage renal disease, Parkinson's disease, and Alzheimer's dementia, in whom atrial flutter was associated with 1:1 atrioventricular conduction. Our patient was hemodynamically unstable with aortic valve endocarditis and recent septic embolic stroke. This case report emphasizes the importance of recognition and management to avoid hemodynamic compromise.

Introducing Normalized Centrifugation for a More Accurate Thermodynamic Analysis of Molybdenum Disulfide Dispersions: A Study on Mixed Solvents of Alcohols and Amines with Water.

A more accurate solution thermodynamic analysis of colloidal molybdenum disulfide (MoS2) nanosheets dispersed in 91 combinations of organic solvent (alcohols and amines)/water mixtures is made possible by the application of a viscosity- and density-normalized centrifugation method to the post-sonication stock solution. This centrifugation method accounts the solvent mixture's density and viscosity in order to apply different centrifugation times based on Stoke's law and in effect eliminates the kinetic interferences arising from different densities and viscosities of the solvent mixtures used as the dispersing media. This allows us to reveal that the solvent's molecular size and hydrogen-bonding strength are additional important factors that determine the Gibbs free energy of mixing, other than the matching of the Hansen solubility parameters between the dispersed nanosheet and the dispersing medium. In addition, ζ potential turns out to be a negligible factor for the nanosheet dispersibility since surface charges are mainly localized on the edge sites. This is because restacking mainly occurs via the basal planes, which are virtually chargeless. This study further extends our understanding of the dispersibility mechanism of 2D nanosheets in various solvent/water mixtures.

Pediatric intracranial hypertension. Experience from 2 Tertiary Centers.

OBJECTIVE: To review the experience of 2 tertiary centers in Saudi Arabia with intracranial hypertension (IH) in the pediatric population. METHODS: We retrospectively reviewed and analyzed pediatric patients diagnosed with IH from June 2002 to May 2017 in 2 institutes. RESULTS: We identified 53 patients (30 females and 23 males) with a mean age of 7 years at the time of presentation. Among them, 41 patients were younger than 12 years, and 12 were older. Obese and overweight patients constituted 27.00% (n = 14) of all cases, 8 (66.7%) of whom were older than 12 years. The most common presenting feature was papilledema followed by headache. Vitamin D deficiency, which constituted the most common associated condition, was identified in 12 (22.6%) patients. Acetazolamide was the treatment option in 98.11% of patients, and only 5.7% underwent surgical interventions. The length of follow-up ranged from 6 months to 8 years. CONCLUSION: Intracranial hypertension is rare in children and commonly seen in overweight females older than 12 years similar to adults. Patients younger than 12 years tend to develop secondary IH. More studies are needed to characterize the clinical presentation and guide the management plan.

Iodine-deficiency disorders in the Aseer region, south-western Saudi Arabia: 20 years after the national survey and universal salt iodization.

OBJECTIVE: To study (i) the current prevalence of iodine-deficiency disorders among schoolchildren in south-western Saudi Arabia after universal salt iodization and (ii) the iodine content of table salts and water. DESIGN: Cross-sectional study on a stratified proportional allocation sample of children. Thyroid gland enlargement was assessed clinically and by ultrasound scanning. Urine, table salt and water samples were taken to measure iodine content. Settings The Aseer region, south-western Saudi Arabia. SUBJECTS: Schoolchildren aged 8-10 years. RESULTS: The study included 3046 schoolchildren. The total goitre rate amounted to 24·0 %. Prevalence of enlarged thyroid by ultrasound was 22·7 %. The median urinary iodine concentration of the study sample amounted to 17·0 µg/l. The iodine content of table salt ranged from 0 to 112 mg/kg; 22·5 % of the table salt samples were below the recommended iodine content (15 mg/kg) set by WHO. The total goitre rate increased significantly from 19·8 % among children using table salt with iodine content ≥15 mg/kg to reach 48·5 % among children using table salt with 0 mg iodine/kg. Analysis of water samples taken from schools showed that the majority of water samples (78·8 %) had an iodine content of 0 µg/l. CONCLUSIONS: The study documented that 18 years after the national study, and after more than a decade of universal salt iodization in Saudi Arabia, the problem of iodine-deficiency disorders is still endemic in the Aseer region. Efforts should focus on fostering advocacy and communication and ensuring the availability of adequately iodized salt.

Flourescein Angiogram and Funduscopic Features of Radiation Induced Retinopathy: A Descriptive Value of Retinopathy Severity in Patients with Nasopharyngeal Carcinoma

Radiation retinopathy (RR) is a known complication after radiotherapy for Nasopharyngeal Carcinoma (NPC). This study aims to relate the relationship of RR and radiation dose in patients with NPC through assessment with clinical funduscopy and fundus fluorescein angiogram (FFA). A cross sectional study was conducted on patients with NPC who had completed radiotherapy treatment in the Oncology Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Eighty two eyes of 42 patients were examined and the prevalence of RR was found to be 35.4%. The severity of RR is strongly associated with the dose of radiation to the retina (Spearman correlation value=0.48; p<0.001). The common features of RR assessed by FFA were telangiectatic vessels (26.2%) and capillary non-perfusion (14.3%). Retinal neovasularization occurred in 10.7% of eyes. The level of visual deterioration correlated with the severity of RR with 26% of eyes experiencing a visual acuity of 6/18 or worse. More than one third of patients developed RR, with radiation maculopathy being the commonest cause for significant visual loss. FFA is a useful tool in detecting early signs of radiation retinopathy and maculopathy. Keywords:

The contribution of reproductive factors and family history towards premenopausal breast cancer risk in Kuala Lumpur, Malaysia.

Breast cancer is the most common cancer among Malaysian women. This study aimed to determine the reproductive for premenopausal breast cancer risk in Kuala Lumpur, Malaysia. A case-control study was conducted in 216 histopathologically confirmed cases of premenopausal breast cancer and 216 community-based controls that were matched by age within a 5-year period and ethnicity. The results of this study showed that premenopausal breast cancer risks were strongly related to parity, number of live births and family history of breast cancer. Premenopausal women with these known reproductive and family history risk factors should take extra measures to undergo appropriate screening method for early detection of breast cancer.

Identification of different subtypes of breast cancer using tissue microarray.

Breast cancer may be classified into luminal A, luminal B, HER2+/ER-, basal-like and normal-like subtypes based on gene expression profiling or immunohistochemical (IHC) characteristics. The main aim of the present study was to classify breast cancer into molecular subtypes based on immunohistochemistry findings and correlate the subtypes with clinicopathological factors. Two hundred and seventeen primary breast carcinomas tumor tissues were immunostained for ER, PR, HER2, CK5/6, EGFR, CK8/18, p53 and Ki67 using tissue microarray technique. All subtypes were significantly associated with Malay ethnic background (p=0.035) compared to other racial origins. The most common subtypes of breast cancers were luminal A and was significantly associated with low histological grade (p<0.000) and p53 negativity (p=0.003) compared to HER2+/ER-, basal-like and normal-like subtypes with high histological grade (p<0.000) and p53 positivity (p=0.003). Luminal B subtype had the smallest mean tumor size (p=0.009) and also the highest mean number of lymph nodes positive (p=0.032) compared to other subtypes. All markers except EGFR and Ki67 were significantly associated with the subtypes. The most common histological type was infiltrating ductal carcinoma, NOS. Majority of basal-like subtype showed comedo-type necrosis (68.8%) and infiltrative margin (81.3%). Our studies suggest that IHC can be used to identify the different subtypes of breast cancer and all subtypes were significantly associated with race, mean tumor size, mean number of lymph node positive, histological grade and all immunohistochemical markers except EGFR and Ki67.

A profile of cancer patient outcomes from a tertiary care teaching hospital in Malaysia.

INTRODUCTION: The aim of this paper was to determine the sociodemographic and cancer characteristics of patients with cancer at a tertiary care centre. METHODS: For the study, 80 newly-diagnosed cancer patients were selected and interviewed using structured questionnaires that included sociodemographic and cancer characteristic profiles. At the end of the study period of two years, the survivorship status of the patients was determined. RESULTS: Gender, occupational status, type of cancer and stage of cancer were found to be significantly associated with the survival status among the study group of cancer patients. Results of logistic regression analysis showed that deceased patients were significantly more likely to be pensioners rather than employed, aged 60-69 years rather than 40-49 years, to have all other types of cancer rather than breast cancer, and to be in Stage 3 or 4 of the disease rather than in Stage 1 of the disease. CONCLUSION: There is a greater necessity for psychosocial research in order to achieve optimal health for patients with cancer, and in turn, to improve the survival of cancer patients.

C-erbB-2 onco-protein expression in breast cancer: relationship to tumour characteristics and short-term survival in Universiti Kebansaan Malaysia Medical Centre.

Breast cancer is the commonest cancer affecting females in Malaysia, contributing 31% of all newly diagnosed cases amongst Malaysian women. The present retrospective cohort study evaluated the relationship between cerbB- 2 onco-protein overexpression with various tumour characteristics and survival rate of breast cancer patients treated at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 1996-2000. CerbB- 2 oncoprotein overexpression was determined by immunohistochemistry (IHC) and tumors showing 2+ positivity were verified by Fluorescence In Situ Hybridization (FISH). One hundred and seventy two patients were eligible for the study with a short-term follow-up (median) of 5.1 years. C-erbB-2 oncoprotein overexpression correlated with lymph node positivity, oestrogen receptor (ER) and progesterone receptor (PR) negativity. Univariate analyses showed shorter disease free survival (DFS) and overall survival (OS) in patients with cerbB- 2 oncoprotein overexpression, Malay ethnicity, higher tumour grade, lymph node positivity, ER and PR negativity. In a subgroup of patients with c-erbB-2 oncoprotein overexpression, a shorter OS was observed in those with lymph node positivity, ER and PR negativity. In multivariate prognostic analysis, lymph node status, ER status and tumour grading were the strongest independent prognostic factors for both OS and DFS. However, c-erbB-2 status was not a significantly independent prognostic factor, even in subsets with lymph node positive or negative group. C-erbB-2 oncoprotein overexpression correlated well with lymph node status, ER and PR. Shorter OS and DFS were significantly observed in patients with c-erbB-2 oncoprotein overexpression. Lymph node status, ER status and tumour grading were the only three independent prognostic factors for OS and DFS in this study. Although c-erbB-2 expression is obviously important from a biological standpoint, multivariate analysis showed that it is not an independent prognostic indicator in breast carcinoma in the local population.

Psychological distress, quality of life and coping in cancer patients: a prospective study.

We present the results and conclusions of an observational prospective cohort design study using self-administered questionnaires to determine correlation between psychosocial factors and cancer outcome among 80 consecutive newly diagnosed treatment naïve cancer subjects who were being referred to the Oncology Clinic, Hospital Universiti Kebangsaan Malaysia. Subjects were recruited over a period of 43 weeks from October 2000 till July 2001. Follow-up assessments were carried out at 6-months and 12 to 26 months later. The prediction of survival time was performed by the Cox Regression Analysis method with adjustments for biological and psychosocial risk factors. It was noted that depression (p = 0.001), stage 4 cancer disease (p = 0.016), neurological (p = 0.032), gastrointestinal tract (p = 0.04), head and neck (p = 0.011), gynaecological (p = 0.005) and bone and soft tissue (p = 0.030) malignancies were independent and statistically significant prognostic factor of survival during the study period. It was further shown than depressed patients were found to have almost four fold greater risk of dying than non-depressed patients and patients with stage 4 cancer illness have a five fold greater risk of dying than patients with stage 1 disease. Furthermore, based on tumour types subjects with neurological, gynaecological, head and neck, bone and soft tissue and gastro intestinal tract malignancies were found to have approximately thirty-six, twenty-five, twenty-two, sixteen and seven fold greater risk of dying respectively when compared to subjects with genitourinary cancers. This study further affirms the need for health care providers to be aware of the psychological aspects of the cancer patient and provide appropriate therapy so as to ensure that this group of individuals would have enhanced survival rates.