Systematic evaluation of the safety and therapeutic effects of para-aortic lymphadenectomy for advanced gastric cancer: a systematic review and meta-analysis.

OBJECTIVE: At present, there is still no definite conclusion on whether advanced gastric cancer (GC) requires additional para-aortic nodes dissection (PAND). The purpose of this study is to summarize current evidence on the potential benefits of the extended systemic lymphadenectomy (D2+) compared to D2 lymphadenectomy in the treatment of gastric cancer. MATERIALS AND METHODS: Systematic literature search was performed across PubMed, Embase, Cochrane library, Web of Science, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, VIP Database for Chinese Technical Periodicals, and China Biology Medicine disc using the following terms: gastric cancer, para-aortic lymphadenectomy, D2+ lymphadenectomy and D3 lymphadenectomy. RevMan 5.3 software was used for the meta-analysis. RESULTS: A total of 20 studies involving 5,643 patients were included, consisting of 6 randomized controlled trials (RCT) and 14 non-randomized controlled trials (nRCT). Compared with the D2 group, the operating time in the D2+ group was longer [mean difference (MD)=99.45 min, 95% confidence interval (CI) (48.93, 149.97), p<0.001], with more intra-operative blood loss [MD=262.14 mL, 95% CI (165.21, 359.07), p<0.001]. There were no significant differences in five-year overall survival (OS) [HR=1.09, 95% CI (0.95, 1.25), p=0.22] and post-operative mortality [RR=0.96, 95% CI (0.59, 1.57), p=0.88] between the two groups. The rate of post-operative complications in group D2+ was higher than that in group D2 [RR=1.42, 95% CI (1.11, 1.81), p<0.001]. CONCLUSIONS: Prophylactic D2+ surgery is not recommended, since D2+ surgery is associated with an increased rate of post-operative complications and does not improve the long-term survival rate of patients with advanced gastric cancer. However, D2+ surgery (especially D2+PAND) has certain survival advantages for specific patients, and D2+PAND surgery combined with chemotherapy may potentially improve long-term survival rate.

Minimal agreement between basophil activation test and immunoassay in diagnosis of penicillin allergy

INTRODUCTION: Basophil activation test (BAT) and immunoassays are the most widely used in vitro tests to diagnose IgE-mediated allergic reactions to penicillin. However, studies to determine if one test is interdependent from another are limited. OBJECTIVE: The present study aimed to measure the agreement between BAT and immunoassay in diagnosis of penicillin allergy. METHOD: BAT was performed using penicillin G (Pen G), penicillin V (Pen V), penicilloyl-polylysine (PPL), minor determinant mix (MDM), amoxicillin (Amx) and ampicillin (Amp) in 25 patients. Immunoassay of total IgE (tIgE) and specific IgE (sIgE) antibodies to Pen G, Pen V, Amx and Amp were quantified. Skin prick test (SPT) using PPL-MDM, Amx, Amp and Clavulanic acid were also performed. RESULTS: Minimal agreement was observed between BAT and immunoassay (k = 0.25). Of two BAT-positive patients, one patient is positive to Amx (59.27%, SI = 59) and Amp (82.32%, SI = 82) but sIgE-negative to all drug tested. This patient is also SPT-positive to both drugs. Another patient is BAT-positive to Pen G (10.18%, SI = 40), Pen V (25.07%, SI = 100) and Amp (19.52%, SI = 79). In sIgE immunoassay, four patients were sIgE-positive to at least one of the drugs tested. The sIgE level of three patients was between low and moderate and they were BAT-negative. One BAT-positive patient had a high level of sIgE antibodies (3.5-17.5kU/L) along with relatively high specific to total IgE ratio ≥ 0.002 (0.004-0.007). CONCLUSIONS: The agreement between BAT and immunoassay is minimal. Performing both tests provides little increase in the sensitivity of allergy diagnosis work-up for immediate reactions to penicillin

No disponible

Effect of atorvastatin on pulmonary hypertension rats through regulating notch signaling pathway.

OBJECTIVE: To study the effect of atorvastatin on pulmonary hypertension (PAH) rats through regulating the Notch signaling pathway. MATERIALS AND METHODS: The rat model of PAH was established via hypoxic feeding and the Control group (n=10), PAH model group (Model group, n=10) and atorvastatin treatment group (ATO group, n=10) were set up. The right ventricular systolic pressure (RVSP) and right ventricular hypertrophy index (RVHI) in each group were determined, the wet/dry weight (W/D) ratio of lung tissues was determined, and the tumor necrosis factor-α (TNF-α), myeloperoxidase (MPO) and interleukin-6 (IL-6) were detected via enzyme-linked immunosorbent assay (ELISA). Moreover, the pathological changes in lung tissues of rats were detected via hematoxylin-eosin (HE) staining and the apoptosis level was detected via terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay. Finally, the Notch signaling pathway and apoptosis level in tissues were detected via quantitative Polymerase Chain Reaction (qPCR), and the protein expression level of Notch pathway in lung tissues was determined through Western blotting. RESULTS: Both RVSP and RVHI in Model group were significantly higher than those in Control group and ATO group (p<0.05). In Model group, the levels of inflammatory factors MPO, IL-6, and TNF-α were significantly increased, and the W/D ratio was also significantly increased compared with those in Control group (p<0.05). The results of HE staining showed that the lung tissue injury in Model group was severe (p<0.05). According to the TUNEL staining results, the number of apoptotic cells in lung tissues was markedly larger in Model group than that in ATO group (p<0.05), and the expression levels of Caspase-3 and IL-6 in Model group were remarkably higher than those in ATO group (p<0.05), while the expression level of B-cell lymphoma-2 (Bcl-2) in Model group was remarkably lower than that in ATO group (p<0.05). Besides, the gene and protein expression levels of Notch1 in ATO group were evidently lower than those in Model group (p<0.05), indicating that atorvastatin can effectively suppress the expression of Notch. CONCLUSIONS: Atorvastatin can inhibit PAH in rats by suppressing the Notch pathway.

Gene polymorphism of adiponectin in restenosis after coronary stenting.

OBJECTIVE: The objective of the present study was to investigate the relationship between adiponectin (APN)+45T/G and +276G/T polymorphisms and in-stent restenosis (ISR). PATIENTS AND METHODS: A total of 150 patients treated with percutaneous coronary intervention (PCI) were divided into the ISR group and non-ISR group. The levels of blood biochemical indicators were measured, and APN+45T/G and +276G/T polymorphisms were detected by TaqMan probes. RESULTS: Cholesterol levels in the IRS group were significantly higher than those in the non-ISR group (p<0.05). The frequency of the GG genotype and G allele of the APN+45T/G locus in the ISR group were significantly higher than those in the non-ISR group (p<0.05). The frequency of the GG genotype and G allele of the APN+276G/T locus in the ISR group were significantly higher than those in the non-ISR group (p<0.05). CONCLUSIONS: APN+45T/G and +276G/T polymorphisms were associated with susceptibility to ISR, and carrying the G allele of the APN+45T/G and +276G/T loci can significantly increase the risk of ISR.

Effect of oral or pulse cyclosphosphamide in recalcitrant pemphigus: an audit of eighteen patients

Background Autoimmune pemphigus is a potentially life threatening bullous disease. The cornerstone of treatment is systemic corticosteroids. However, adjuvant therapy with immunosuppressant drugs is commonly used to improve disease control and alleviate the high morbidity and mortality associated with the use of corticosteroids. Adjunctive treatment with pulse intravenous cyclophosphamide may be more efficacious and less toxic than other immunosuppressants. Objective To retrospectively review the clinical outcome of 18 patients with recalcitrant pemphigus who were treated with cyclophosphamide over the past 10 years. Methodology A retrospective study was conducted between 1985 and 2009 in thirteen Malaysian dermatology centres. Data collected were analysed for comparison of relapse rates, compliance rates and adverse drug effects between the 2 regimes. Results Eighteen patients were included in this audit of which 12 patients had pemphigus vulgaris and 6 patients had pemphigus foliaceous. Prior to treatment with cyclophosphamide, fourteen patients were on azathioprine, three were given intravenous immunoglobulin, and two were prescribed dapsone; however all these patients were either unresponsive, intolerant or suffered serious side-effects with these drugs. Subsequently, 7 patients (median age: 31 years) received a combination of pulse intravenous cyclophosphamide and either intravenous dexamethasone or methylprednisolone. These seven patients received between 2 to 21 pulses of intravenous cyclophosphamide and steroids at monthly intervals with oral prednisolone and cyclophosphamide (50-100mg) in between pulses. The remaining 11 patients (median age: 46 years) received oral cyclophosphamide and corticosteroids. Of the 18 patients in our cohort, 15 achieved control and consolidation of disease activity at an average of 4 weeks and 10 weeks respectively. The remaining three patients are yet to achieve disease control. The total duration of treatment with cyclophosphamide ranged from 2 to 62 months with a cumulative dose ranging from 2.95g to 93.55g. Four patients achieved partial remission on minimal therapy and 3 achieved complete remission. None of patients experienced serious side effects. Conclusion Cyclophosphamide may be an alternative treatment option in patients in patients with pemphigus who fail to respond to standard therapy. Controlled trials are needed to further evaluate the efficacy and safety of this therapy.

Antibiotic sensitivity of propionibacterium acnes isolated from patients with acne vulgaris in Hospital Kuala Lumpur, Malaysia

Background Antibiotic therapy directed against Propionibacterium acnes (P. acnes) has been a mainstay of treatment in acne vulgaris for more than 40 years. Prolonged antibiotic usage has been associated with emergence of antibiotic-resistant P. acnes and is linked to treatment failure. Little work has been done in Malaysia on drug resistance in P. acnes and there is no surveillance data on this aspect to guide the clinical decision. Objective This study aims to evaluate antibiotic sensitivity of P. acnes isolated from patients with acne vulgaris in Kuala Lumpur Hospital, Malaysia. Methods This is a non interventional, single centered, cross-sectional hospital-based survey of antibiotic sensitivity of P. acnes isolated from patients with acne vulgaris in Kuala Lumpur Hospital from January 2010 to June 2010. Results A total of 100 patients were recruited in our study. P. acnes was isolated in 53% of patients and 11% had gram negative organism. Antibiotic resistant P. acnes was found in 15.1% of positive isolates. Clindamycin resistance was the highest (15.1%) followed by erythromycin (7.5%), doxycycline (5.7%), tetracycline (1.9%) and minocycline (0%). Isolates of antibiotic resistant P. acnes was significantly higher in patients treated with antibiotics within the last 6 months (29%) as compared with non antibiotic treated patients (0%) (p<0.05).The mean duration of prior antibiotic treatment was significantly longer in the group of antibiotic resistant P. acnes as compared with antibiotic sensitive P. acnes (17.13 weeks vs 5.74 weeks, p<0.05). Conclusion Antibiotic resistant P. acnes is present locally with clindamycin and erythromycin accounting for the highest resistance. Longer duration of antibiotic treatment predisposes to antibiotic resistant P. acnes and may also induce emergence of gram negative organisms. Strategies to reduce antibiotic resistance should be emphasized when prescribing antibiotic for acne vulgaris in order to achieve optimal therapeutic results while reducing the potential for antibiotic resistance.

Primary Cutaneous Anaplastic Large Cell Lymphoma: Report of 3 cases from Hospital Kuala Lumpur

Primary cutaneous anaplastic large cell lymphoma (c-ALCL) is an uncommon type of cutaneous T cell lymphoma currently classified as one of the CD30+ lymphoproliferative disorders of the skin under the WHO-EORTC classification1. We describe a series of three patients with c-ALCL from 2005-2009 in the Department of Dermatology, Hospital Kuala Lumpur.

Severe adverse cutaneous drug reactions: The 5 year Kuala Lumpur Hospital experience

Introduction: Stevens Johnson syndrome (SJS), Stevens Johnson Syndrome - toxic epidermal necrolysis overlap syndrome (SJS-TEN overlap), toxic epidermal necrolysis (TEN) and drug-induced hypersensitivity syndrome (DHS) are well known severe adverse cutaneous drug reactions (SACDRs). All clinicians are responsible for the diagnosis and management of SACDR. Objective: To retrospectively review the clinical patterns, management strategies and outcome of 134 patients with severe adverse cutaneous drug reactions managed at the Department of Dermatology, Kuala Lumpur Hospital between 2006 and 2010. Results: The mean age of presentation was 44.8 years (13-83). The male: female ratio was 1:1. There were 68 cases (50.7%) of SJS, 10 cases (7.5%) SJS-TEN overlap, 32 cases (23.9%) TEN and 24 cases (17.9%) DHS. The five commonest drugs associated with SACDRs were allopurinol (26.9%), carbamazepine (13.4%), phenytoin (9.7%), non-steroidal anti-inflammatory drugs (11.2%) and co-trimoxazole (7.5%). The mean duration of drug exposure before the onset of reaction was 2.8 weeks. A hundred and thirty patients (97%) were managed as in-patient. The mean duration of in-patient stay was 12.4 days. All identified culprit drugs were withheld. Systemic corticosteroids was given to 96% cases of DHS with mean duration of 9.7 weeks; 52.9% of SJS with mean duration of 2.8 weeks; 60% of SJS-TEN overlap with mean duration of 2.3 weeks; and 62.5% of TEN with mean duration of 3.3 weeks. Thirteen patients (42%) with TEN were treated with intravenous immunoglobulin. Eight patients (6%) died, of which 7 were TEN and one DHS. Conclusion: SACDRs are life-threatening emergencies which not only results in significant morbidity and mortality; but also potentially increases the health care cost and burden. Clinicians should recognize high risk medications and prescribe them with great caution.

Wegener’s Granulomatosis: A case report and literature review

Wegener’s granulomatosis is a rare multisystem necrotizing granulomatous vasculitis aff e c t i n g small - and medium-sized vessels. Its clinical manifestations can be nonspecific during the initial stages and indistinguishable from a variety of neoplastic, infectious, and inflammatory diseases. The disease may run a course from indolence to one of rapid progression leading to life-threatening multiorgan failure. We report a rare case of rapidly progressing Wegener’s granulomatosis.

Pemphigus foliaceous and thymoma: a report of 2 cases

Pemphigus foliaceous (PF) is an autoimmune blistering disease resulting from acquired immunoglobulin G autoantibodies against desmoglein 1 of the skin, which is one of the adhesion molecules of keratinocytes. Clinically patients with PF develop crusted and scaly erosions mainly over the seborrhoeic distribution i.e. the face, scalp and upper trunk. Mild cases of PF may be localized but in some cases it may progress to erythrodermic exfoliative dermatitis. There is however no mucosal involvement in PF in contrast to pemphigus vulgaris and paraneoplastic pemphigus. Light microscopy of lesional biopsy shows subcorneal acantholysis. Direct immunofluorescence study of perilesional skin reveals presence of intraepithelial intercellular deposit of IgG and C3. We describe 2 cases of PF in the presence of thymoma, a relatively rare association, which could further support the fact of thymoma associated autoimmune disease.

The effect of explanation and demonstration of topical therapy on the clinical response of atopic eczema

Background Atopic eczema is a common dermatological condition seen in our practice in which the mainstay of treatment is topical medications. One of the main reasons for poor clinical response to therapy in atopic eczema is the lack of understanding of topical preparation usage and thus poor adherence to treatment. Objectives The aim of this study is to determine the effect of explanation and demonstration of topical medication on the clinical response of atopic eczema. Methodology Twenty newly diagnosed patients with atopic eczema who fulfilled the study criteria were recruited and randomized consecutively into 2 groups - A & B. All patients were assessed on the severity of the eczema using the six area, six sign atopic dermatitis severity score (SASSAD) and patients’ assessment of itch, sleep disturbance and irritability were recorded on 10-cm visual analogue scales. They were also assessed on their level of understanding on the proper usage of topical medications using a questionnaire. Group A then received explanation and demonstration on how to apply the topical medications while Group B was not educated on these. They were followed up 2 weeks after treatment and were re-evaluated on their understanding and the severity of their skin condition. This was followed by education by a dermatology nurse on the proper usage of topical medications for both groups. A third evaluation was done 2 weeks later. Results At baseline, 70% of the patients did not understand the potency of topical corticosteroid and between 20-30% of them did not know the correct sites, frequency, time and duration of each topical application prescribed. About two thirds of the patients claimed that they did not receive any explanation or demonstration from either their doctors or the pharmacy dispensers. After education on the proper usage of topical medications, the level of understanding improved to 100% for group A at visit 2 and group B at visit 3. A clinical improvement as measured by SASSAD score reduction was seen in both groups. In group A, a significant SASSAD score reduction of 49.5% (P=0.003) was seen after 2 weeks and it was sustainable, as evidenced by a further reduction to 67% (p=0.001) by week 4. In group B, a significant SASSAD score reduction (64.8%; p=0.002) was seen only at week 4 after patient education and demonstration. The magnitude of improvement in patients’ symptoms which included itch, sleep disturbance and irritability, measured by the patient using visual analog score, were only significant for group A after 4 weeks. Conclusions This study reinforces the importance of explanation and demonstration on the proper usage of topical medications in achieving better clinical response. Failure to explain on the use of topical medications may lead to patient dissatisfaction, poor compliance and lack of treatment efficacy.

Autoimmune Bullous Diseases in Ipoh, Malaysia: A 5-year Retrospective Study

Background Autoimmune bullous diseases (ABD) represent a group of chronic blistering dermatoses in which management is often challenging. Epidemiologic data on these diseases in Malaysia has been limited. Objectives Our purpose was to study the spectrum of the various ABD presented to the Department of Dermatology, Ipoh Hospital, and to determine the clinico-epidemiological pattern of the 2 main ABD, namely pemphigus and bullous pemphigoid. Methodology We performed a retrospective review of records for all patients who were diagnosed with ABD confirmed by histopathology and direct immunofluorescence test in this centre between 2001 and 2005. The data were analyzed with regard to age, sex, ethnicity, subtypes of ABD, treatment provided and outcome. Results There were a total of 79 cases of ABD presented to us during this period. Bullous pemphigoid was observed to be the commonest (60.8%) followed by the pemphigus group (36.7%) with the mean incidence of 0.45/100,000/year and 0.28/100,000/year respectively.44% of patients were of ethnic Chinese origin. There was an overall female preponderance. The mean age of presentation was 65.5 years for bullous pemphigoid and 55 years for pemphigus group. The mean duration of disease before presentation was 1.6 months for bullous pemphigoid and 6.3 months for pemphigus. Various combinations of immunosuppressive agents were used to treat the patients. 48% of bullous pemphigoid cases were controlled with prednisolone alone while 67.9% of pemphigus group required at least 2 immunosuppressive agents to achieve disease control. Conclusion In our study population, bullous pemphigoid was more frequently seen than pemphigus.

Atypical Presentation of Genital Herpes in an HIV Infected Man

Herpes simplex virus (HSV) infection is one of the common opportunistic viral infections that may occur in human immunodeficiency virus (HIV) - infected patients. The natural history of HSV infection is often altered in this group of patients. Characteristically, genital herpes presents with multiple painful vesicles and erosions in immunocompetent patients. However, clinical presentations in immunocompromised patients are frequently severe and atypical which may lead to a delay in diagnosis and treatment. Genital herpes enhances transmission of HIV infection and hence early detection of this condition is important to reduce transmission of HIV and HSV.