Achalasia cardia: A five-year review in Hospital Tuanku Ja'afar, Seremban.

INTRODUCTION: Achalasia cardia is an oesophageal motility disorder that affects various age groups. This study focused on the epidemiological features of achalasia, its risk factors, treatment modalities offered and the clinical outcomes in a tertiary hospital. MATERIALS AND METHODS: A retrospective search was carried out on all patients with a diagnosis of achalasia cardia in Hospital Tuanku Ja'afar (HTJ), Seremban, Malaysia between 2014 and 2018. Demographic data, patient symptomatology, and definitive management options were determined from the records. Telephone interviews were conducted to evaluate patient satisfaction with the outcome of treatment. RESULTS: There were 30 patients with a newly diagnosed achalasia cardia in that 5-year period, with an equal incidence among men and women. The mean age of presentation was 44.63 ± 18.21 years. Malays formed the largest group. The mean weight and body mass index were 46.8 ± 10.4 kg and 18.0 ± 4.4 kg/m2 respectively. There was a wide range of duration of symptoms at presentation with a mean of 30.11 ± 35.29 months. Almost all patients presented with dysphagia (96.7%) while 70% also noted loss of weight. All patients underwent oesophagogastroduodenoscopy (OGDS) and 26 patients (86.7%) had barium swallow as part of diagnostic workup. A total of 18 patients underwent a laparoscopic Heller myotomy with or without Dor Fundoplication and/or cruroplasty while two patients (6.7%) underwent pneumatic dilatation as first treatment. Iatrogenic mucosal perforations were detected in 8 patients who underwent myotomy and fundoplication and were repaired intraoperatively. Of the patients who underwent myotomy and fundoplication, the mean weight increase was 15.6kg, increasing from 43.0 ± 8.4 kg to 58.6 ± 13.7 kg. All the patients who underwent treatment were satisfied with their treatment outcomes. CONCLUSION: Most patients with achalasia cardia deemed suitable for surgery and counselled accordingly accept surgery resulting in high levels of satisfaction and weight gain in almost all these patients. A small minority who opt for pneumatic dilatation may also achieve satisfactory outcomes comparable to surgery in the short term. Although rare, clinicians should be able to recognise this disease early as early intervention often leads to satisfactory longterm outcomes.

The impact of anaemia and iron deficiency in chronic obstructive pulmonary disease: A clinical overview.

INTRODUCTION: Anaemia is increasingly recognised as an important comorbidity in the context of chronic obstructive pulmonary disease (COPD), but remains undervalued in clinical practice. This review aims to characterise the impact of anaemia and iron deficiency in COPD. METHODS: Literature review of studies exploring the relationship between anaemia/iron deficiency and COPD, based on targeted MEDLINE and Google Scholar queries. RESULTS: The reported prevalence of anaemia in COPD patients, ranging from 4.9% to 38.0%, has been highly variable, due to different characteristics of study populations and lack of a consensus on the definition of anaemia. Inflammatory processes seem to play an important role in the development of anaemia, but other causes (including nutritional deficiencies) should not be excluded from consideration. Anaemia in COPD has been associated with increased morbidity, mortality, and overall reduced quality of life. The impact of iron deficiency, irrespective of anaemia, is not as well studied, but it might have important implications, since it impacts production of red blood cells and respiratory enzymes. Treatment of anaemia/iron deficiency in COPD remains poorly studied, but it appears reasonable to assume that COPD patients should at least receive the same type of treatment as other patients. CONCLUSIONS: Anaemia and iron deficiency continue to be undervalued in most COPD clinical settings, despite affecting up to one-third of patients and having negative impact on prognosis. Special efforts should be made to improve clinical management of anaemia and iron deficiency in COPD patients as a means of achieving better patient care.

Delay in Diagnosis of Upper Gastrointestinal Cancer: whose fault is it?

BACKGROUND: Stomach and esophageal cancers are both deadly and difficult to diagnose early. Stomach cancer is the second most common cancer in Asia. Both these are one of the most common causes of cancer related death in the world. AIM: To determine the mean time delay from appearance of the symptoms to the endoscope procedure [OGDS] and rationalized the reason for this delay in diagnosis. METHOD: This is a cross sectional study of stomach and esophageal cancer data from Jan 2004- July 2008. All patients' records of histologically confirmed stomach or esophageal cancers during the study period were reviewed. RESULT: Total of 112 consecutive patients with stomach and esophageal cancer were analysed. 86 cases of stomach and 26 cases of esophageal cancer were reviewed. The average age for stomach and esophageal cancers are 60.8 years and 58.4 years respectively. The mean duration from the first appearance of cancer symptoms to endoscope procedure was 32.4 weeks for stomach cancer patient and 16.7 weeks for esophageal cancer patients. The reasons for the delays are due to 1) self-medication, 2) Empirical treatment for dyspepsia using antacid and H2 antagonist, 3) Delay in endoscope procedure for high risk patients. CONCLUSION: Reducing the delay in endoscope procedure may lead to early detection of cancer and thereby may improve the prognosis of these patients.

[Phacoemulsification cataract surgery in vitrectomized eyes]. / Facoemulsificación en ojos post-vitrectomía pars plana.

OBJECTIVE: This study focuses on determining the intra- and post-operative complications stemming from technical difficulties, anatomical aspects, intraoperatory management and visual outcome of post-vitrectomized patients that undergo phacoemulsification. METHOD: In this prospective, longitudinal, observational and descriptive study phacoemulsification was performed in 25 post-vitrectomized eyes that required cataract surgery. Pre-surgical variables: sex, age, affected eye, visual accuity, underlying vitreoretinal disease, anterior segment morphological findings such as: cataract density and pupil alterations. Intrasurgical variables: characteristic of anterior chamber and pupil, phacoemulsification technique and time and the presence of complications. Post-surgical variables were also registered: visual capacity and the presence of complications. Minimum six-month follow-up period. RESULTS: The average interval between pars plana vitrectomy and phacoemulsification was 18.5 months. Silicone oil was the most frequent tamponade used in our serie (44%). Biomicroscopical findings were miosis 28% and posterior synechies 24%. The average interval of phaco time was 2.26 minutes. The intraoperative findings were fluctuations in the anterior chamber depth (24%) and anterior capsular tears (12%). The postoperative complications most frequently seen were posterior capsular plaque (28%) and corneal edema (16%). CONCLUSIONS: Phacoemulsification is a safe and effective technique in eyes after pars plana vitrectomy that require cataract surgery. The surgeon must be aware of the morphological and anatomical findings of these eyes. Visual rehabilitation will generally be determined by the presence of an underlying vitreo-retinal pathology.

Facoemulsificación en ojos post-vitrectomía pars plana / Phacoemulsification cataract surgery in vitrectomized eyes

Objetivo: Determinar las complicaciones intra y postoperatorias en ojos de pacientes post-vitrectomizados que ameritan cirugía de catarata con técnica de facoemulsificación. Método: Estudio prospectivo, longitudinal observacional y descriptivo en 25 ojos de 25 pacientes, previa vitrectomía pars plana que requerían cirugía de catarata. Variables prequirúrguicas: edad, sexo, ojo afectado, capacidad visual, patología vitreorretiniana, características morfológicas del segmento anterior tales como grado de opacidad del cristalino, características de la cámara anterior y de la pupila. Variables intraoperatorias: técnica, tiempo de facoemulsificación y complicaciones intraoperatorias. Variables post-operatorias: Complicaciones y capacidad visual. Seguimiento no menor de 6 meses. Resultados: El tiempo promedio entre la vitrectomía pars plana y la facoemulsificación fue de 18,5 meses. La silicona fue el material de tamponamiento utilizado con mayor frecuencia 44%. Hallazgos biomicroscópicos: miosis 28% y sinequias posteriores 24%. El tiempo promedio de facoemulsificación: 2,26 minutos. Complicaciones intraoperatorias: cámara anterior inestable 24% y el desgarro de la capsulorrexis anterior 12%. La complicación post-operatoria más frecuente fue la placa subcapsular posterior 28% y el edema corneal 16%. Conclusiones: La facoemulsificación en ojos con vitrectomía pars plana previa que ameriten cirugía de catarata, es una técnica bastante segura y efectiva. El cirujano debe familiarizarse con los hallazgos y modificaciones anatómicas que sufren estos ojos. La rehabilitación visual por lo general va a estar limitada por la patología vitreo-retiniana de base(AU)

Objective: This study focuses on determining the intra- and post-operative complications stemming from technical difficulties, anatomical aspects, intraoperatory management and visual outcome of post-vitrectomized patients that undergo phacoemulsification. Method: In this prospective, longitudinal, observational and descriptive study phacoemulsification was performed in 25 post-vitrectomized eyes that required cataract surgery. Pre-surgical variables: sex, age, affected eye, visual accuity, underlying vitreoretinal disease, anterior segment morphological findings such as: cataract density and pupil alterations. Intrasurgical variables: characteristic of anterior chamber and pupil, phacoemulsification technique and time and the presence of complications. Post-surgical variables were also registered: visual capacity and the presence of complications. Minimum six-month follow-up period. Results: The average interval between pars plana vitrectomy and phacoemulsification was 18.5 months. Silicone oil was the most frequent tamponade used in our serie (44%). Biomicroscopical findings were miosis 28% and posterior synechies 24%. The average interval of phaco time was 2.26 minutes. The intraoperative findings were fluctuations in the anterior chamber depth (24%) and anterior capsular tears (12%). The postoperative complications most frequently seen were posterior capsular plaque (28%) and corneal edema (16%). Conclusions: Phacoemulsification is a safe and effective technique in eyes after pars plana vitrectomy that require cataract surgery. The surgeon must be aware of the morphological and anatomical findings of these eyes. Visual rehabilitation will generally be determined by the presence of an underlying vitreo-retinal pathology(AU)

Transient spatial attention modulates distinct components of the auditory ERP.

We recorded ERPs to pairs of externally presented tones, T1 and T2, in the absence of attentional cues to determine whether attention is momentarily sustained at the location of a behaviourally relevant sound, and what effect this focusing of attention might have on the neural response to target stimuli. ERPs to T2 were more negative when the preceding T1 was presented on the same side of fixation than when T1 was presented on the opposite side of fixation. This negative difference consisted of an early, parietal phase and a later, frontocentral phase. These results confirm and extend previously reported effects of transient spatial attention on auditory ERPs, and they demonstrate that transient spatial attention has a distinct and robust effect on the early stages of stimulus processing in the auditory system.

Liver pathology in children with AIDS: a comparison between the South American and North American population.

Liver tissue from autopsies of twenty-nine cases of children with AIDS were collected from three major South America (S.4) pediatric hospitals. The hepatopathologic findings were classified in the same fashion as in a series of sixty-one children with AIDS from North America (NA): inflammation, non-specific, lymphoproliferative disorders, and giant cell transformation. By comparing both groups. we noted that the SA children were Younger at time of death consistent with a more rapid progression of the disease. Opportunistic infections varied with a higher prevalence of Cytomegalovirus (CMV) infection in SA children. The histopathologic features of CMV in the liter of SA children were associated with a conspicuous inflammation absent in the NA group. Finally, different non-specific hepatic changes were found in SA children, including one case of peliosis hepatis.

Peripheral neuropathy in chronic alcoholism: a retrospective cross-sectional study in 76 subjects.

A consecutive sample of 76 chronic alcoholic patients was studied clinically, biochemically and electrophysiologically to assess clinical and/or subclinical signs of alcohol-related neuropathy as well as the most important and disputed risk factors for neuropathy such as age, parental history of alcoholism, nutritional status, alcoholic disease duration and total lifetime dose of ethanol (TLDE). The results show that alcohol-related neuropathy, especially when subclinical, seems to be frequent and mostly characterized by axonal degeneration of peripheral nerve fibres with earlier and more frequent involvement of sensory fibres and lower limbs. Moreover, positive family history of alcoholism, but above all alcoholic disease duration and TLDE, could be more important factors than malnutrition in determining neuropathy.

Spontaneous activity of rat dorsal horn cells in spinal segments of sciatic projection following transection of sciatic nerve or of corresponding dorsal roots.

Natural forms of stimulation were used to compare the spontaneous and evoked activity of dorsal horn neurons in three groups of rats: controls with no surgical lesion, rats with transection of the sciatic nerve and rats with transection of the dorsal roots at the same segmental level. In control rats, cells encountered in the dorsal horn were classified according to their peripheral field as tactile specific, convergent tactile and nociceptive, nociceptive, or movement driven. In 20 control animals, only 20% of the 140 cells with a peripheral field were spontaneously active. After sciatic nerve transection made on the side of recording a few days previously (18 rats), all of the 141 cells studied showed spontaneous activity, only 69 of them having a peripheral field. After dorsal root transections a few days previously (nine rats), 25 spontaneously active cells were found in the dorsal horn ipsilateral to the section, none with a peripheral field. Spontaneous activities of cells without a peripheral field were separated into three types as a function of bursting pattern, which were similar following both types of transection. The spontaneous activity shown by dorsal horn cells without peripheral fields following dorsal root transection precludes attribution of spontaneous spiking in such cells to abnormal input from the periphery, and shows that abnormal activity can develop in deafferented dorsal horn cells themselves. A possible role played by this spontaneous activity in deafferentation pain is considered.

A prospective comparison of stereotaxic fine-needle aspiration versus stereotaxic core needle biopsy for the diagnosis of mammographic abnormalities.

BACKGROUND: Confidence in a negative stereotaxic breast biopsy result allows for safe clinical and mammographic follow-up, whereas a positive or equivocal diagnosis leads to excision. Direct comparison of stereotaxic core needle biopsy (SCBX) and fine-needle aspiration (SFNA) is needed, and should be based on the use of appropriate current methods of practice, and address the indication of each for different types of mammographic lesions. METHODS: The diagnostic accuracy of SFNA, SCBX, and combined SFNA with SCBX performed at a community radiology practice were assessed for different mammographic lesions and levels of radiologic suspicion. Negative predictive values (NPVs) measured the confidence that a negative diagnosis (failure to identify atypia or malignancy) was benign and therefore suitable for follow-up. A benign outcome was accepted only after surgical excision or > or =24 months' follow-up of the lesion. Positive predictive values (PPVs) [final diagnoses at least atypical (A) or carcinoma (CA)] also were calculated. RESULTS: SFNA was performed for 495 lesions and was combined with SCBX for 252 of these. Nondiagnostic (SFNA, 2%; SCBX, 8%) and atypical (SFNA, 7%; SCBX, 3%) rates were low. The authors obtained 94% follow-up (81% > or = 24 months). NPVs were all SFNAs, 99%; SCBXs, 95% (corresponding SFNAs, 98%); and SFNA with SCBX, 99%. NPVs were 100% for masses, ill-defined densities, and architectural distortions. NPVs for microcalcifications (for low, moderate, and high suspicion) were all SFNAs, 97% (100, 95, and 75); SCBXs, 93% (94, 93, and 67), corresponding SFNAs, 96% (100, 94, 75); and SFNA with SCBX, 98% (100, 97, 75). All false-negative lesions were microcalcifications. Calcium was recognized in 98% of SFNA specimens and in 89% of SCBX specimens from microcalcifications. No calcium was identified in the histologic sections in 63% (5 of 8) SCBX false-negative specimens. PPVs(A) were atypical (SFNA, 46%; SCBX, 88%) and suspicious (SFNA, 93%). PPVs(CA) were SFNA carcinoma, 100%; SCBX in situ, 89%; and SCBX invasive, 100%. CONCLUSIONS: SFNA identified benign lesions more reliably for follow-up, particularly microcalcifications. Based on these results, the authors suggest 1) added SCBX if on-site SFNA assessment is nondiagnostic, atypical, or positive (and needs preoperative confirmation of invasion); 2) either SCBX or SFNA for masses, architectural distortions, and ill-defined densities; 3) SFNA for microcalcifications, with SCBX added for moderately and highly suspicious lesions; and 4) surgical excision for all highly suspicious microcalcifications.

Immobilized yeast bioreactor systems for continuous beer fermentation

Two different types of immobilized yeast bioreactors were examined for continuous fermentation of high-gravity worts. One of these is a fluidized bed reactor (FBR) that employs porous glass beads for yeast immobilization. The second system is a loop reactor containing a porous silicon carbide cartridge (SCCR) for immobilizing the yeast cells. Although there was some residual fermentable sugar in the SCCR system product, nearly complete attenuation of the wort sugars was achieved in either of the systems when operated as a two-stage process. Fermentation could be completed in these systems in only half the time required for a conventional batch process. Both the systems showed similar kinetics of extract consumption, and therefore similar volumetric productivity. As compared to the batch fermentation, total fusel alcohols were lower; total esters, while variable, were generally higher. The yeast biomass production was similar to that in a conventional fermentation process. As would be expected in an accelerated fermentation system, the levels of vicinal diketones (VDKs) were higher. To remove the VDKs, the young beer was heat-treated to convert the VDK precursors and processed through a packed bed immobilized yeast bioreactor for VDK assimilation. The finished product from the FBR system was found to be quite acceptable from a flavor perspective, albeit different from the product from a conventional batch process. Significantly shortened fermentation times demonstrate the feasibility of this technology for beer production.

Prevalence of asthma related symptoms in school children in Port-of-Spain, Trinidad

A cross-sectional study was done to determine the prevalence of asthma related symptoms in schoolchildren in Trinidad. This is the first study of this nature that has been undertaken in this island. The aims were to assess the prevalence and the severity of asthma and to obtain baseline measures for future assessment of this disease in school children aged 12 to 15 years attending secondary schools in Port-of-Spain, Trinidad. Written and video questionnaires developed for the International Study of Asthma and Allergies in Childhood (ISAAC) project were administered to 1161 such students. The overall cumulative and 12 month prevalence of wheezing were 36.6 percent and 25.1 percent, respectively. The prevalence of diagnosed asthma was 13.3 percent. Multiple logistic regression analysis showed that a high prevalence of wheeze and diagnosed asthma was associated with males and subjects with a positive family history of asthma. Most severe asthma related symptoms were most often present in females than in males. Asthma in schoolchildren in Port-of-Spain is severely underdiagnosed with a prevalence of 11.8 percent. This study emphasizes the fact that children in Trinidad are unnecessarily suffering from asthma and its related symptoms, as effective treatment is available.(AU)

A comparison of proliferative activity and atypical mitoses in cervical condylomas with various HPV types.

Cervical condylomas associated with HPV types 6/11 rarely progress to dysplasia; this progression is more commonly seen in cervical condylomas with HPV types 16/18/31/33/35. This investigation was undertaken to determine if more frequent atypical mitotic figures (MFs) and higher proliferative activity are seen in high-risk condylomas. HPV types present in cervical condylomas were determined by in situ hybridization with biotinylated probes. The cases were also stained immunohistochemically for MIB1. The percentage staining of basal, parabasal, and suprabasal cells was determined by counting 100 cells in the most intensely stained areas. MFs and atypical MFs were counted per 10 high-power-fields (HPFs). Condylomas with HPV 6/11 showed higher MIB1 expression in the basal layer than condylomas with HPV 16/18 and 31/33/35 (p = 0.013). Atypical MFs were seen more frequently in condylomas with HPV types 16/18/31/33/35 (p = 0.02). Differences in mitotic activity and in MIB1 expression in parabasal and suprabasal layers did not reach statistical significance. The presence of atypical MFs may make a greater contribution than increased proliferative activity to progression to dysplasia in cervical condylomas.

Sinus histiocytosis mimicking metastatic melanoma in lymph nodes of a patient with a large joint prosthesis: case report and review of the literature.

Malignant melanoma metastases to regional lymph nodes may be mimicked by several non-neoplastic processes, including sinus histiocytosis induced by fragments shed from joint prostheses. A patient who had an elective lymph node dissection for malignant melanoma and was found to have "post-prosthesis lymph node histiocytosis" resembling metastatic disease is described. Knowledge of the patient's past history of a total shoulder joint replacement along with the use of polarized light microscopy to identify birefringent particles of prosthetic debris allows for an accurate histologic diagnosis.

Cyclic AMP regulation of tylosin biosynthesis and secondary metabolism in Streptomyces fradiae.

Adenosine 3':5' cyclic monophosphate seems to regulate antibiotic biosynthesis and secondary metabolism in tylosin-producing cultures of Streptomyces fradiae C373.1. A dose-dependent response is observed by exogenous additions of dibutyryl cyclic AMP (cAMP), and is related to the nutritional status of the culture. Addition of cAMP to cultures growing in nutritionally lean media caused higher cumulative antibiotic tigers and some cellular differentiation compared with the control. In nutritionally rich media, a qualitatively different behavior resulted: an almost instantaneous shift toward secondary metabolism occurred. The response is characterized by extensive cellular differentiation with little growth and only a trace of antibiotic production. The possible role of cyclic AMP n the regulation of tylosin biosynthesis and secondary metabolism and its relation to specific nutrient limitations in synthetic, defined media in Streptomyces fradiae is discussed.

Melanocyte halo explained.

Electron microscopic examination was performed of skin biopsy specimens processed for electron microscopy directly after formaldehyde fixation, after retrieval from paraffin blocks, and as for paraffin embedding but with retrieval after clearing with xylene, the last step before paraffin infiltration. The halos surrounding melanocytes in the epidermis are a retraction artifact that develops during paraffin infiltration of the tissue. It is proposed that this artifact is related to the high temperature of the paraffin bath.

Daily fluctuation of plasma levels with conventional and controlled-release carbamazepine: correlation with adverse effects.

The pharmacokinetics, tolerability, and efficacy of carbamazepine (CBZ) and the pharmacokinetics of carbamazepine-10, 11-epoxide (CBZE) were studied after chronic administration of a conventional tablet formation or of the controlled-release (CR) formulation of CBZ 400 mg (Tegretol 400) to 20 patients with epilepsy treated with carbamazepine and complaining of intermittent adverse effects. To compare the two formulations at the same doses and dose schedules, the study design had to be open, within-patient, with an initial 4 week period to individually adjust the dosage schedule with conventional CBZ followed by a 4 week period in which the CR formulation was substituted for conventional CBZ at the same daily dose and given by the same schedule. A further 4 week period was also studied to evaluate the same dosage of the CR formulation but given b.i.d. In this latter period six patients required an increase in dosage (200 mg/day). Before the beginning of the study and at the end of each period seizure frequency and tolerability were assessed. Tolerability was estimated with a specifically prepared scale that assesses the main items and with an overall rating scale. At the end of each treatment period, serum levels of CBZ and CBZE were determined at various times over a 10 h period. Peak plasma concentrations (Cmax) of CBZ and the fluctuation index (FI) were significantly lower for the CR CBZ, although minimal and mean plasma concentrations were the same in the three periods of the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Visceral leishmaniasis in the acquired immunodeficiency syndrome: report of two cases.

Core biopsies of the bone marrow are indispensable in the evaluation of fever of unknown etiology in human immunodeficiency virus-positive patients. We report two patients in whom visceral leishmaniasis was diagnosed based on the typical morphology, staining characteristics, and ultrastructure of the organisms.

Bilateral occipital calcification, epilepsy and coeliac disease: clinical and neuroimaging features of a new syndrome.

Twenty patients affected by bilateral occipital cortical-subcortical calcification (BOC) are described, 19 (95%) had epilepsy. In 8 of 16 cases studied, intestinal biopsy revealed coeliac disease. Fourteen patients had occipital partial epilepsy with a relatively benign outcome, while 4 patients were affected by a severe form of epilepsy, with very frequent, drug-resistant, generalised and partial seizures with mental deterioration. One patient had a single episode of convulsive status epilepticus at four months of age. The neurological examination was normal in all patients. CT showed flocculo-nodular, cortico-subcortical BOC, without enhancement and without lobar or hemispheric atrophy. MRI was normal. The clinical and neuroimaging features of these patients are different therefore from those with the Sturge-Weber Syndrome. The study confirms a high prevalence of coliac disease in patients with BOC, but the relationship between these two pathologies still needs to be clarified.

Membranous nephropathy associated with giant lymph node hyperplasia. A case report with histological and ultrastructural studies.

A young woman presented with nephrotic syndrome due to membranous nephropathy and a localized form of giant lymph node hyperplasia (Castleman's disease) occurring as a large intra-abdominal mass. Five months after surgical removal of the mass, only mild proteinuria persisted. Twenty months later a second kidney biopsy showed a near-normal morphology. Six years later the patient was free of symptoms and had normal urinalysis. Reviewing the pertinent literature, it seems to be the first case of a biopsy-proven cure of membranous nephropathy in a patient with membranous nephropathy and Castleman's disease.