Expulsion of a Lacrimal Dacryolith by Sneezing: A Rare Event

Purpose

To describe the case of a man presenting with intermittent epiphora of the right eye and a low grade dacryocystitis due to a dacryolith.

Methods/Results

He was treated conservatively and was offered a Dacryocystorhinostomy. A few weeks before surgery, he developed swelling and pain over the right medial canthus followed by violent sneezing with spontaneous extrusion of the dacryolith.

Discussion

The authors propose that the dacryolith fragmented spontaneously and once it reached the nasal cavity, was expelled by violent sneezing to the nostril, a mechanism not previously reported.

Conclusions

Reformation of dacryolith is a likely possibility, and recurrence of symptoms in such cases may ultimately require a Dacryocystorhinostomy.

Comparative efficiency of rice husk-derived biochar (RHB) and steel slag (SS) on cadmium (Cd) mobility and its uptake by Chinese cabbage in highly contaminated soil

Cadmium (Cd) contamination in red soil has been considered as a severe threat due to its toxic effects on plants and food security. This study aims to evaluate the comparative efficiency of rice husk-derived biochar (RHB) and steel slag (SS) metal stabilizer on decreasing Cd mobility and bioavailability to Chinese cabbage grown on acidic contaminated red soil. Several extraction techniques: a sequential extraction procedure, the European Community Bureau of Reference, toxicity characteristics leaching procedure, ammonium nitrate, and simple bioaccessibility extraction test were used to measure Cd mobility after amelioration of the investigated soil. The results indicated that application of stabilizer significantly increased soil chemical properties including soil pH, cation exchange capacity, nutrients, and organic matter. The soluble portion of Cd in soil was significantly decreased by 17.6-31.2% and 7.8-11.7% for RHB and SS at 1.5% and 3% application rate, respectively. Moreover, Cd bioaccessibility was significantly declined by 37.08% with RHB and 11.3% with SS at 3% rate. Inlcorporation of RHB at 3% can effectively immobilize Cd and thereby, reduce its phytoavailability to cabbage in Cd-contaminated soil to mitigate food security risks.

Giant retrocardiac foregut duplication cyst presenting with left atrial compression and palpitations

A 35-year-old man presented with a 3-month history of palpitations and shortness of breath. An ECG showed premature atrial contractions and episodes of supraventricular tachycardia. A subsequent echocardiogram showed a retrocardiac cystic mass that was compressing the left atrium. A CT scan confirmed these findings by showing a large left-sided posterior mediastinal cyst compressing the left atrium and pulmonary veins. The cyst was successfully excised from the retrocardiac position via left thoracotomy after which there was complete resolution of the palpitations. Histopathology showed it to be a mediastinal cyst, most likely a foregut duplication of the enterogenic variant. This is an extremely unusual case of foregut duplication cyst presenting with compression of the left atrium and pulmonary veins leading to atrial arrhythmias.

Medical Professional and Usage of Social Media

Social media connect people by sharing text, photos, audio and videos among themselves. Medical professional and patients also communicate through social media; however, issues of privacy and confidentiality of medical professions in regards to medical and health care decisions contradict with the openness of the usage of social media. Member of the medical profession can use social media but need to abide by the code of conduct of medical ethics in order to render the best possible services. This paper emphasizes on the needs of inclusion of social media usage in future health care providers’ curriculum by the higher educational institutions in order to aware of the ethical and professional aspect.Bangladesh Journal of Medical Science Vol.16(4) 2017 p.606-609

Rare Presentation of a Posterior Mediastinal Cystic Schwannoma as a Large Pleural Effusion

A 46-year-old man presented with shortness of breath and recurrent, left-sided pleural effusions. A computed tomography (CT) scan of the chest showed a large, left-sided pleural effusion with a mass in the posterior mediastinum. A pleural tap showed lymphocytic exudate. The biopsy of the mass was inconclusive. A left posterolateral thoracotomy was performed, which showed a large posterior mediastinal mass adherent to the left lung. The mass was completely excised and the histopathology proved it to be giant predominantly cystic schwannoma. The pleural effusion resolved after tumor resection.

Outcomes for severe aponeurotic ptosis using posterior approach white-line advancement ptosis surgery

PurposeThe purpose of the study was to report the outcome of posterior approach white-line advancement surgery for severe involutional aponeurotic ptosis.Patients and methodsThis was a retrospective review of an interventional case series of all patients undergoing surgery for severe involutional aponeurotic ptosis during a 42-month period at a single center. The inclusion criteria were severe involutional ptosis (upper eyelid margin reflex distance (MRD) ≤1 mm) undergoing posterior approach surgery. There was minimum 3-month follow-up. The main outcome measures were type of ptosis (primary or recurrent), preoperative margin reflex distance, levator function and eyelid skin crease height, presence of visible iris sign (VIS), documented unusual intraoperative findings, postoperative complications, and follow-up time.ResultsOf the 836 procedures for ptosis, 122 procedures (76 patients) met the inclusion criteria for this study. Mean postoperative follow-up was 28 (median 18, range 12-98) weeks. Success rates were 80.3% (98/122) overall, 81.5% (66/81) in the non-VIS group, and 78% (32/41) in the VIS group. There was no significant difference between the two groups (P=0.411). Failures were due to undercorrection, with <2 mm MRD in 75% (18/24), overcorrection with >4.5 mm MRD in 16.7% (4/24), and inter-eyelid height asymmetry of >1 mm in 8.3% (2/122).ConclusionsOutcomes of ptosis surgery for severe aponeurotic ptosis using a posterior approach white-line advancement are comparable to, and possibly better than, anterior approach in eyelids with VIS.

Flt3-L Augments the Engraftment of Donor-Derived Bone Marrow Cells When Combined with Sublethal Irradiation and Costimulatory (CD28/B7 and CD40/CD40L) Blockade

T-cell costimulatory blockade as a constituent for recipient conditioning prior to bone marrow transplantation has led to the development of less toxic protocols for the establishment of donor cell chimerism. We therefore hypothesized that the addition of the hematopoietic growth factor, Flt3-ligand (Flt3-L), to the perioperative inhibition of the CD28/B7 and CD40/CD40 ligand costimulatory pathways would enhance the engraftment of allogeneic bone marrow. Recipient BALB/c ByJ (H-2d, Mlsc, Vβ6+/Vβ8+ TCR) received a single sublethal dose of total body irradiation (300 rad) 6 h prior to transplantation IV with unfractionated donor CBA/J (H-2k, Mlsd, Vβ6-/Vβ8+ TCR) bone marrow cells. CTLA4-Ig and/or MR1 were administered at 500 μg IP on days 0, 2, 4, and 6 posttransplantation. Flt3-L was administered at 10 μg IP on days 0–6. Donor cell chimerism was determined on days 30–90 by flow cytometric analysis. Donor-specific tolerance was assessed by skin grafting. In vitro TCR cross-linking assays and flow cytometry were utilized to explore the deletion of donor-reactive T cells. Recipients receiving CTLA4-Ig and MR1 engrafted allogeneic bone marrow cells in the peripheral blood (3/6; 50%) with chimerism being detected at 2–31%. Addition of Flt3-L to this preconditioning regimen enhanced the incidence of engraftment of donor bone marrow cells (10/13; 3–70%). Long-term survival of donor but not third-party-specific skin grafts demonstrated that donor-specific tolerance had been achieved in the chimeric recipients. Deletion of the donor-reactive T cells within the chimeric recipients was also observed. The addition of hematopoietic growth factors and cytokines to the nonmyeloablative regimen of sublethal irradiation and T-cell costimulatory blockade provides a novel strategy for the establishment of donor cell chimerism and for the induction of stable and robust donor-specific tolerance. The deletion of donor-reactive T cells using this protocol suggests the reliability and feasibility of this protocol for clinical transplantation.

Diabetic ketoacidosis characteristics and differences In type 1 versus type 2 diabetes patients

BACKGROUND

Diabetes is undoubtedly one of the most challenging health problems of the 21st century. It is well known that diabetes once develop can lead to several complications. Diabetic ketoacidosis (DKA) is one of the life-threatening complications of diabetes. This study was designed to determine the frequency of DKA in diabetes patients and find out the clinical and biochemical determinants of DKA.

METHODS

This descriptive study was conducted at Aga Khan University Hospital (AKUH) Karachi, Pakistan from January 2010 to February 2016. All known or newly diagnosed diabetic patients of >16 years of age irrespective of gender and type of diabetes were included. Information regarding patient's demographics, presenting symptoms, precipitating causes of DKA, biochemical profiles and outcome at the time of discharge was collected.

RESULTS

Majority (54.7%) had moderate and 12.4% had severe DKA at presentation. Previous history of DKA was found higher in type 1 diabetes patients (T1DM) (14%) as compare to (4%) type 2 diabetes patients (T2DM) (p<0.05). DKA severity was observed more (12%) in newly diagnosed (T1DM) (p<0.05). Comorbidities were found more (81%) in (T2DM) (p<0.05) Mortality was also observed higher in Type 2 diabetes patients (p<0.05).

CONCLUSIONS

Majority of the diabetics had moderate to severe DKA at presentation. Mortality and morbidity related with DKA was found considerably higher among patients with T2DM while infection, myocardial infarction and stroke found as triggering factors in these patients.

Rare mycotic aneurysms of internal jugular vein and innominate vein secondary to untreated parapharyngeal abscess: A case report

We report a 31 year old woman presented with three months history of large untreated parapharyngeal abscess and bleeding from the mouth. On evaluation chest CT scan identified the abscess extending down to the superior mediastinum and multiple small lung abscesses. Echocardiography showed tricuspid valve insufficiency. Patient was brought to the operating room (OR) and intra-operatively it was found that she had multiple large mycotic pseudoaneurysms of the internal jugular vein and right brachiocephalic veins. All these pseudoaneurysms were repaired with pericardial patches under cardiopulmonary bypass. Patient did well in the short postoperative follow up and was then referred to plastic surgery and ENT for further surgical interventions.

Levels of Organotin Compounds in Selected Fish Species from the Arabian Gulf

In the present work, data on the levels of hazardous Organotin compounds in eight commercially important fish species, caught from Arabian Gulf, has been reported. Highest levels of tributyltin (TBT) (98.5 ng/g dry weight) were detected in Epinephelus Tauvina whereas minimum (43.7 ng/g) were found in Acanthoparagus Bifasciatus. Highest levels of triphenyltin (TPT) were detected in Lethrinus Miniatus (107.5 ng/g) whereas lowest were encountered in Acanthoparagus Bifasciatus (64.9 ng/g). Highest value of total butyltin compounds (∑BT) were found in emperors (Lethrinus Miniatus) (228.4 ng/g) whereas minimum was found in Acanthoparagus Bifasciatus (126.4 ng/g). Similarly highest value of total phenyltin compounds (∑PT) was encountered in Epinephelus Tauvina (281.9 ng/g) followed closely by Acanthoparagus Bifasciatus (281.7 ng/g). In addition, the estimated daily intake (EDI) of the local population from consumption of these fish was also evaluated. Highest EDI was found to be 10.8 ng/kg bw/day for epinephelus microdan. The data are also compared internationally.

Enhanced Chiral Discriminatory van der Waals Interactions Mediated by Chiral Surfaces

We predict a discriminatory interaction between a chiral molecule and an achiral molecule which is mediated by a chiral body. To achieve this, we generalize the van der Waals interaction potential between two ground-state molecules with electric, magnetic, and chiral response to nontrivial environments. The force is evaluated using second-order perturbation theory with an effective Hamiltonian. Chiral media enhance or reduce the free interaction via many-body interactions, making it possible to measure the chiral contributions to the van der Waals force with current technology. The van der Waals interaction is discriminatory with respect to enantiomers of different handedness and could be used to separate enantiomers. We also suggest a specific geometric configuration where the electric contribution to the van der Waals interaction is zero, making the chiral component the dominant effect.

Tutors Perception on a Training Workshop on Simulation Based Medical Education

Background: The notion of ‘learning by doing’ has become less acceptable especially when invasive procedures are needed. Simulation provides learners the opportunity for deliberate practice. Universiti Kebangsaan Malaysia Medical Centre (UKMMC) is one of the promoter of Simulation-based medical education (SBME), conducting regularly “train the trainer workshop” aimed to increase the efficiency of learner. The objective of this paper is to provide an insight from the learners’ perspective on a SBME workshop.Methods: It was a pre and post-test design survey, done on a total of 21 participants of UKMMC who attended a 2-day train-the-trainer workshop on SBME held in April 2014 at Simulation Lab of Emergency Department. Participants were exposed to interactive-lectures, hands-on with scenario design-development using high fidelity simulator and trying out the scenario with simulation. Each simulation session lasted around 30 minutes, followed by a 15-minute debriefing and 10-minute didactic session. During debriefing, video clips of what participants did were shown. Participants completed pre-post evaluation on their pre-experience, usefulness of SBME and as feedback-method, and meeting the objectives of SBME-workshop. Results: Post-test evaluation showed 100% participants reported simulation was very useful compared to 43% in the pre-test. While 83% agreed feedback was better served by video-re-run in post-test compared to 43% in the pre-test. Most expressed that the workshop achieved the desired objectives.Conclusion: The SBME is an effective method to gain medical-procedural experience and is well accepted by the participants. Medical schools should use simulation as an educational tool in order to increase the efficiency of learners.Bangladesh Journal of Medical Science Vol.15(2) 2016 p.195-200

Professionalism perspectives among medical students of a novel medical graduate school in Malaysia

Defining professionalism in this constantly evolving world is not easy. How do you measure degrees of benevolence and compassion? If it is so obvious to our profession, what professionalism is, then why is it so difficult to teach it to medical students and residents? Today's definition of medical professionalism is evolving - from autonomy to accountability, from expert opinion to evidence-based medicine, and from self-interest to teamwork and shared responsibility. However, medical professionalism is defined as the basis for the trust in the patient-physician relationship, caring and compassion, insight, openness, respect for patient dignity, confidentiality, autonomy, presence, altruism, and those qualities that lead to trust-competence, integrity, honesty, morality, and ethical conduct. The purpose of this study is to explore professionalism in terms of its fundamental elements among medical students of Universiti Sultan Zainal Abidin (UniSZA). This was a cross-sectional study carried out on medical students of UniSZA. The study population included preclinical and clinical medical students of UniSZA from Year I to Year V of academic session 2014/2015. The simple random sampling technique was used to select the sample. Data were collected using a validated instrument. The data were then compiled and analyzed using SPSS Version 21. Out of 165 questionnaires distributed randomly among Year I to Year V medical students of UniSZA, 144 returned, giving a response rate of 87%. Among the study participants, 38% (54) and 62% (90) were males and females, respectively. The grand total score was 170.92±19.08. A total of 166.98±20.15 and 173.49±18.09 were the total professionalism score of male and female study participants, respectively, with no statistically significant (P=0.61) differences. This study found almost similar levels of familiarity with all fundamental issues of professionalism with no statistically (P>0.05) significant differences. Medical faculty members should give more effort for the professional development of medical doctor. Henceforth, researchers believe and expect that the country will produce more rational and holistic medical doctors.

PBL triggers in relation to students' generated learning issues and predetermined faculty objectives: Study in a Malaysian public university

OBJECTIVES

Foundational elements of problem based learning (PBL) are triggers, tutors and students. Ineffective triggers are important issues for students' inability to generate appropriate learning issues. The objective of this study was to evaluate PBL triggers and to determine similarities of students' generated learning issues with predetermined faculty objectives.

METHODS

It was a retrospective study conducted in 2014 analyzing all 24 PBL-triggers used at Centre for Foundation Studies, International Islamic University Malaysia, in four semesters during two consecutive years 2011 and 2012. Triggers were used as textual and illustration format equally in each semester. Total 16 PBL-triggers with highest and lowest achieving similarities of learning issues with predetermined faculty objectives were selected equally from each semester and format. The trigger quality and learning issues related to predetermine faculty objectives were analyzed and presented as mean and percent distribution.

RESULTS

Mean similarities score of students' generated learning issues were 3.4 over 5 predetermined faculty objectives which was 68%, varied from 58% to 79%. More than 70% similarities were generated from five textual and four illustrated triggers, while <70% similarities observed from four illustrated and three textual triggers.

CONCLUSION

Whatever the trigger formats in PBL, it is the designing considering influential variables that influence higher outcomes. Triggers should have planned clues that lead students to generate issues correlate with faculty objectives. Educational institution should emphasize on training needs of faculty at regular interval to develop and re-in force teachers' skills in trigger design, thereby to promote a sustainable educational and organizational development.

Identifying the Core Content of a Dermatology Module for Malaysian Medical Undergraduate Curriculum Using a Modified Delphi Method

BACKGROUND

Dermatology is a minor module in internal medicine undergraduate curriculum. Limited time is allocated for its teaching. Most graduates are inadequately prepared to diagnose and manage skin diseases. We aimed to identify the core content of a more effective dermatology module.

METHODS

A modified Delphi method was used to reach a consensus. A questionnaire was developed by a selected panel and sent to 20 dermatologists, family physicians and general practitioners (GPs), respectively. They were asked to rate diseases according to importance. The participants then answered the questionnaire again with results of the first round made available to them. The final module content was identified based on the panel's collective opinions.

RESULTS

Eleven topics had mode and median values of 1 with an agreement level of more than 70%. They were as follows: (1) skin structure and function; (2) infections and infestations; (3) the skin in systemic diseases; (4) dermatology emergencies; (5) drug eruptions; (6) psoriasis; (7) eczema; (8) sexually transmitted infections; (9) leprosy; (10) acne; and (11) clinical skills and diagnostic procedures. A total of 56 diseases were identified as important.

CONCLUSION

Results of this study reflect the importance of understanding the influence of regional factors on common and important skin diseases. These topics may be used to develop a more effective dermatology module for the Malaysian undergraduate medical curriculum.

Undergraduate Medical Education Research in Malaysia: Time for a Change

Objective:

Special Study Module (SSM) is a mandatory research module implemented in Universiti Kebangsaan Malaysia (UKM). The objective of this paper is to provide a brief overview on the student research activities and to find out the outcome measures in terms of publication.

Methods:

It was a retrospective study done on SSM research projects at UKM. The SSM research is conducted from beginning of year-4 until 1^st seven weeks of year-5. In year-4, students are assigned to a faculty-supervisor in small groups and spend every Thursday afternoon to plan and carry the research. Whole first seven weeks of year-5, students are placed with their supervisor continuously to collect data, do analysis, write report and present in the scientific conference. Outcomes of 5-years SSM research-projects starting from 2008/2009 to 2012/2013 academic session were analyzed.

Results:

Total 257 projects were completed and presented in annual scientific meetings from which 57 (22.2%) articles were published in peer reviewed journals.

Conclusion:

Mandatory undergraduate student research project brings an opportunity to develop students’ capacity building from conception to final report writing and thereby narrowing the gap between education and practice. Medical schools should implement research module to bring changes in research and publication culture of undergraduate medical education.

Stress among First and Third Year Medical Students at University Kebangsaan Malaysia

Objective:

To identify the stress-prevalence and coping-strategies among University Kebangsaan Malaysia (UKM) medical students.

Methods:

This was an observational study conducted among 234 UKM first and third year medical students. Standardized questionnaire on stress and coping strategies was used. Stress data was related to subjective experiences on some positive and negative adjectives such as tense, relaxed etc. Positive adjectives were measured by sign “++” and “+” scoring “1” while stress-negative adjectives were measured by sign “?” and “–“ scoring “0”. Forty-eight coping items under task, emotion and avoidance strategies were measured using 5-point Likert-scale.

Results:

Overall stress-prevalence was 49%. Female and Malay respondents were more stressed. Significant differences of stress-level was observed between Malays and non Malays in first year (p=0.04) and in third year (p=0.01). Most common strategies used to cope stress was task-oriented while emotion oriented was least.

Conclusion:

Stress-prevalence and stress-level in UKM medical students was high. Most of the respondents coped stress using task-oriented strategies. Stressor and its effective management must be ensured. Educational institutions should act as a creative designer of learning environment to get relieve from educational stressor.

Clinical and anthropological perspectives on chemical relaxing of afro-textured hair

The culturally engrained practice of 'relaxing' afro-textured hair has been linked with hair and scalp disorders. Herein, we discuss the evolution of human hair types, focusing in particular on afro-textured hair. We explore the biological features of this hair type, and discuss the different methods employed to straighten afro-textured hair, focusing in particular on chemical straightening. We also examine clinical, anthropological, and psychological issues associated with this latter practice. Examples of common scalp pathologies associated with chronic hair relaxing, such as alopecia, hair breakage, caustic burns and irritant contact dermatitis, are also highlighted. The data presented herein should enable clinicians to engage in culturally appropriate discussions with their patients about issues of appearance and conformity.