Echocardiography and strain analysis in Malaysian elite athletes versus young healthy adults.

Background: Athletes have changes that can mimic pathological cardiomyopathy. Methods: Echocardiographic study of 50 male, female athletes (MA, FA) and non-athletes (MNA, FNA) age 18 to 30 years. These athletes participate in sports with predominantly endurance component. All participants exhibit no known medical illnesses or symptoms. Results: MA have thicker wall (IVSd) than MNA. No MA have IVSd > 1.2 cm and no FA have IVSd > 1.0 cm. Left ventricle internal dimension (LVIDd), left ventricle end diastolic volume index (LVEDVi) is bigger in athletes. None have LVIDd > 5.8 cm. Right ventricle fractional area change (FAC) is lower in athletes. (MA vs MNA, p = 0.013, FA vs FNA, p = 0.025). Athletes have higher septal and lateral e' (Septal e'; MA 13.57 ± 2.66 cm/s vs MNA 11.46 ± 2.93 cm/s, p < 0.001, Lateral e'; MA 17.17 ± 3.07 cm/s vs MNA 14.82 ± 3.14 cm/s, p < 0.001), (Septal e'; FA 13.46 ± 2.32 cm/s vs FNA 12.16 ± 2.05 cm/s, p = 0.04, Lateral e'; FA 16.92 ± 2.97 cm/s vs FNA 15.44 ± 2.29 cm/s, p = 0.006).No difference in Global longitudinal (GLS), Right ventricle free wall (RVFWS) and Global circumferential strain (GCS). Left atrial reservoir (LArS) and left atrial booster strain (LAbS) is smaller in athletes. (LArS, MA 44.12 ± 9.55% vs MNA 52.95 ± 11.17%, p < 0.001 LArS, FA 48.07 ± 10.06% vs FNA 53.64 ± 8.99%, p = 0.004), (LAbS, MA 11.59 ± 5.13% vs MNA 17.35 ± 5.27%, p < 0.001 LAbS FA 11.77 ± 4.65% vs FNA 15.30 ± 4.19%, p < 0.001). Conclusion: Malaysian athletes have thicker wall and bigger left ventricle than controls. No athletes have IVSd > 1.2 cm and/or LVIDd > 5.8 cm. There is no difference in GLS, RVFWS and GCS but athletes have smaller LArS and LAbS.

Echocardiographic and electrocardiographic presentations of patients with endomyocardial biopsy-proven cardiac amyloidosis.

OBJECTIVE: Cardiac amyloidosis is under diagnosed and its prevalence is unknown. This is a retrospective, nonrandomised, single centre study of patients with endomyocardial biopsy-proven cardiac amyloidosis focusing on their echocardiographic and electrocardiogram (ECG) presentations. This is the first case series in Malaysia on this subject. METHODS: We identified all of our endomyocardial biopsyproven cardiac amyloidosis patients from January 2010 to January 2018 and reviewed their medical records. All patients echocardiographic and ECG findings reviewed and analysed comparing to basic mean population value. RESULTS: In total there are 13 biopsy-proven cardiac amyloidosis patients. All of the biopsies shows light chain (AL) amyloid. Majority of the patients (8, 61.5%) is male, and most of our patients (8, 61.5%) is Chinese. All seven patients on whom we performed deformation imaging have apical sparing pattern on longitudinal strain echocardiogram. Mean ejection fraction is 49.3%, (SD=7.9). All patients have concentric left ventricular hypertrophy and right ventricular hypertrophy. Diastolic dysfunction was present in all of our patients with nine out of 13 patients (69.2%) having restrictive filling patterns (E/A ≥2.0 E/e' ≥15). On electrocardiogram, 12 (92%) patients have prolonged PR interval (median 200ms, IQR 76.50ms) and 9 (69.2%) patients have pseudoinfarct pattern. CONCLUSION: Echocardiography plays an important role in diagnosing cardiac amyloidosis. The findings of concentric left ventricular hypertrophy with preserved ejection fraction without increased in loading condition should alert the clinician towards its possibility. This is further supported by right ventricular hypertrophy and particularly longitudinal strain imaging showing apical sparing pattern.

Catastrophic antiphospholipid syndrome and heparin-induced thrombocytopenia-related diseases or chance association?

Antiphospholipid syndrome (APS) and heparin-induced thrombocytopenia (HIT) are thrombotic disorders due to specific autoimmune-mediated antibodies. Catastrophic APS (CAPS), also known as Asherman's syndrome, is a life-threatening severe form of APS. Diagnostic criteria for CAPS include the development of a thrombotic event of three or more organs in less than a week with the presence of antiphospholipid antibodies and microvascular thrombosis on histology. Thrombocytopenia is seen in more than 60% of cases of CAPS. HIT is a life-threatening disorder with the clinical presentation of thrombocytopenia and arterial or venous thrombosis in patients who develop antibodies to heparin and platelet factor 4 typically within 10 days after starting heparin treatment. Due to the multiple similarities in clinical features and pathophysiology of CAPS and HIT, it has been postulated that these two antibody-mediated disorders may be related. We report two cases in which patients diagnosed with CAPS developed HIT very soon during the same admission as well as a case of a patient initially diagnosed with HIT who presented with CAPS years later.

An unusual cause of pancytopenia: Whipple's disease.

Whipple's disease is a systemic infectious disease caused by the bacteria Tropheryma whipplei. The most common clinical manifestations of Whipple's disease are weight loss (92%), hypoalbuminemia and steatorrhea (91%, respectively), diarrhea (72%), arthralgia (67%), and abdominal pain (55%). Neurological signs and symptoms from dementia to oculomasticatory myorhythmia or oculofacioskeletal myorhythmia (pathognomonic of Whipple's disease), lymphadenopathy, and fatigue can also be present. Pancytopenia is a rare and less recognized clinical feature in Whipple's disease patients. We are describing a case where a middle-aged Caucasian male diagnosed with Whipple's disease was found to have pancytopenia. Etiology of pancytopenia is postulated to be due to the invasion of bone marrow by T. whipplei. It is important to recognize that bone marrow involvement by the Whipple bacillus is not uncommon. In the presence of lymphadenopathy and pancytopenia, clinicians should think of Whipple's disease as a differential diagnosis apart from lymphoma or other non-specific granulomatous reticuloendothelial disorders.

Unusual Course of Splenic Marginal Zone Lymphoma.

A 53-year-old woman was diagnosed with splenic marginal zone lymphoma by pathological examination on left submandibular lymph node and bone marrow biopsies and markedly enlarged spleen. Four cycles of Rituximab chemotherapy were given. Seven months after finishing Rituximab chemotherapy, she developed left upper extremity swelling without evidence of deep venous thrombosis. Repeat PET/CT scan demonstrated multiple left axillary lymph nodes extending to left retroclavicular region and a new lymph node posterior to the left scapula. Biopsy of the lymph node demonstrated marginal zone lymhoma pattern with increased numbers of large cells, but not outright diffuse large B-cell lymphoma. Despite resuming rituximab, patient had persistent leukocytosis and severe anemia. Restaging PET/CT showed 3 new left anterior cervical lymph nodes and 1 new right axillary lymph node. Spleen has further enlarged. R-CHOP chemotherapy was started, which improved leukocytosis.After 4 cycles of R-CHOP, PET/CT showed new metabolic activity within right inguinal and abdominal lymph nodes. Patient was given one cycle of Bendamustine. She developed a possible "hematoma" in right medial elbow. However, MRI study revealed a subcutaneous deposit of the lymphoma. Patient needs consistently blood transfusion and she deteriorated quickly. Our patient had an aggressive course of splenic marginal zone lymphoma, not responding to four trials of chemotherapy although SMZL is well-known to be an indolent low grade lymphoma. This case report emphasizes the importance to individualize the treatment in SMZL patients and repeat bone marrow biopsy if the disease recurs.

An investigation of the effects of touchpad location within a notebook computer.

This study evaluated effects of the location of a notebook computer's integrated touchpad, complimenting previous work in the area of desktop mouse location effects. Most often integrated touchpads are located in the computer's wrist rest, and centered on the keyboard. This study characterized effects of this bottom center location and four alternatives (top center, top right, right side, and bottom right) upon upper extremity posture, discomfort, preference, and performance. Touchpad location was found to significantly impact each of those measures. The top center location was particularly poor, in that it elicited more ulnar deviation, more shoulder flexion, more discomfort, and perceptions of performance impedance. In general, the bottom center, bottom right, and right side locations fared better, though subjects' wrists were more extended in the bottom locations. Suggestions for notebook computer design are provided.

Stress and nursing in the pig: role of HPA axis and endogenous opioid peptides.

To determine the effect of stress on nursing, and the roles of HPA activity and opioid peptides, nine sows had their piglets removed for 2 h and were treated as follows: (a) control; (b) nose-snare restraint for 20 min; (c) naloxone injections (i.v. 2 mg/kg); and (d) snare + naloxone. After the treatment, the piglets were returned, milk ejections were timed, and the sows' blood sampled every 10 min for cortisol, growth hormone (GH), and prolactin assays. Piglet removal increased cortisol and decreased prolactin and GH. This was reversed when the piglets were returned. Restraint increased cortisol and decreased GH, but did not affect prolactin. Naloxone alone increased cortisol and decreased GH but did not increase the effect of restraint. The rise in GH following the piglets' return was abolished by the combination of restraint and naloxone. Neither restraint nor naloxone delayed the latency to first milk ejection or reduced the frequency. No unsuccessful nursings were observed. First milk ejections occurred when cortisol levels were elevated. Stress-induced activity of the hypothalamo-pituitary-adrenocortical (HPA) axis does not inhibit milk ejection in the pig, but this is not due to a protective opioid action. Endogenous opioids protect lactogenic hormones against inhibition by stress.

A model legal-financial education workshop for families caring for neurologically impaired elders.

A program is described through which families become acquainted with the issues, legal terminology, and resources for planning to provide and finance care to neurologically impaired elders. A survey of 68 participating families indicated over 90% had taken one or more planning actions following the workshop, including developing a specific plan for providing and financing services and developing a power-of-attorney for decision-making. Implications for other programs are discussed.

The significance of certain skin characters of sheep in resistance and susceptibility to fleece-rot and body strike.

Micro-anatomical differences in skin structure associated with resistance and susceptibility of sheep to fleece-rot and body strike were identified, and found to be of similar magnitude in 2 genetically divergent flocks of medium-woolled Merino ewes. Susceptible sheep were characterised by smaller follicle groups, resulting in higher densities of follicle populations with greater concentrations of the primary follicles (and sudoriferous glands) than in the resistant sheep. From these smaller follicle groups of susceptible sheep, thicker wool fibres grew than were found in the resistant sheep. The significance of these findings is discussed in relation to the pathogenesis of fleece-rot and body strike of sheep, and the value of the measured skin characters as a method for identifying resistant sheep.

Inheritance of some sweat gland and hair follicle characteristics in cattle.

Using measurements made in cows in the herds of the Hannah Research Institute (Ayrshire), the West of Scotland Agricultural College (Ayrshire and Friesian) and in the twin herd of the Animal Breeding Research Organisation (Ayrshire), repeatability and heritability estimates were obtained for three hair follicle and four sweat gland traits. Average repeatability was high (50-70%) for all characters except angle of slope of the hair (18%). Heritability estimates were extremely variable among the different herds and methods of measurement but there was evidence of considerable genetic variation, particularly for sweat gland traits. The most consistent heritability estimate (30-45%) was given by the ratio of sweat gland length to diameter. The potential of skin types for the selection of cattle for tropical regions is discussed.

The sweat glands and hair follicles of different species of bovidae.

Measurements were made of hairs and sweat glands in the skins of a number of different Bovidae. The principal differences between the Bovinae and the one member of the Cephalophinae (the duiker) studied were in the dimensions of the skin and its component organs and in hair density; secondary hairs were not present, although in the American bison small primary follicles which appeared to provide a woolly undercoat were seen. In contrast, secondary hair follicles were found in the skins of all the Caprinae, Antilopinae and most of the Hippotraginae studied. The sweat glands of the Bovidae varied in shape from simple sacs as seen in the oryx to the coiled tubes of the wildebeest, and different markedly in size, the largest being found in the wisent.