An audit of upper gastrointestinal bleeding at Seremban Hospital

We retrospectively analyzed all patients presenting with upper gastrointestinal bleeding to Seremban Hospital over a one-year period. A quarter of the oesophagogastro-duodenoscopies (OGD) performed were performed as emergency for upper gastrointestinal tract bleeding. Gastric ulcers and duodenal ulcers were the two most common findings. Our results suggest that there is a male preponderance of 2:1, the Chinese were more likely to be affected and the elderly (> 60 years) were at highest risk.

Cross sectional review of children with ADHD presenting to an outpatient psychiatric institute in Pakistan

OBJECTIVE

To establish baseline demographic information for Attention Deficit Hyperactivity Disorder (ADHD) in the children of Pakistan and to compare the results with similar studies elsewhere.

MATERIALS AND METHODS

This study was a cross sectional review. We reviewed medical records of all children less than 14 years of age, presenting to The Institute of Behavioural Sciences (IBS), Karachi during a two year period. Twenty-six children diagnosed with ADHD were included in the study. The data was entered and analyzed using SPSS.

RESULTS

Among the twenty-six children, there were 20 boys and 6 girls (male to female ratio 3:1). Mean age at onset of symptoms was 4.48 years. Fifteen children were diagnosed with the combined subtype, seven with the hyperactive subtype and four with the inattentive subtype. The most significant comorbids included mental retardation (MR) (53.8%) and epilepsy (23.1%). The combined subtype was found to be significantly associated with MR. Risk factors for brain damage, and hence ADHD, found in the history included maternal problems like eclampsia and prolonged labor, and perinatal problems like sepsis and low birth weight. Delayed milestones were present in 61.5% of children.

CONCLUSION

Our study provides a broad view of ADHD in Pakistani children. This study can provide a platform for future analytical studies about this challenging research issue.

Effect of rituximab on peripheral blood stem cell mobilization and engraftment kinetics in non-Hodgkin's lymphoma patients

Rituximab is used for in vivo tumor cell purging for non-Hodgkin's lymphoma (NHL) patients prior to autologous peripheral blood stem cell transplantation (PBSCT). However, its effects on PBSC mobilization and function are poorly understood. We compared the mobilization characteristics and engraftment kinetics of 13 NHL patients receiving and 34 NHL patients not receiving rituximab 6 months before PBSC mobilization. In the rituximab group, there was a significantly longer time to neutrophil engraftment (P=0.0466), a trend toward the need for BM harvest to supplement low-yield PBSC collections (31 vs 9%, P=0.08) and a significantly increased rate of bacteremia episodes (62 vs 26%, P=0.025). Median progression-free survival (PFS) and overall survival (OS) were significantly longer in the rituximab compared to the nonrituximab patients (P=0.049 and 0.042, respectively). However, patients in the nonrituximab group were at high risk for recurrence and expected to have shorter survival. Rituximab used within 6 months prior to collection may have a detrimental effect on PBSC mobilization and engraftment. However, rituximab is a major therapeutic breakthrough for NHL treatment and this negative effect may be offset by improved survival. Further studies are warranted in larger populations to determine the impact of rituximab on engraftment, PFS and OS.

An evaluation of topical and local anesthesia in phacoemulsification

OBJECTIVE

To assess the comparative efficacy of topical and local anesthesia in phacoemulsification.

MATERIAL AND METHODS

The medical records of 186 men and women between the ages of 45-85 years, who underwent elective cataract surgery by phacoemulsification technique, under the care of one surgeon, over a period of one year, from March 1999-March 2000 were reviewed.

RESULTS

Of 186 patients who underwent small incision, self-healing phacoemulsification cataract surgery, 124 received topical and 62 local anesthesia. The most common cataract types were nuclear sclerosis. The duration of surgery with topical anesthesia was shorter. Sutures and eye padding were more frequently applied for procedures done under local anesthesia. Uncorrected visual acuity in the first post-op week was between 20/20-20/50 for 53.6% of the cases done under topical compared to 30.9% in local anesthesia. A similar trend was noted in the visual acuity one month post operatively.

CONCLUSION

The uncorrected visual acuity improves faster and the duration of surgery is shorter when topical anesthesia is used.

Comparative analysis of knowledge, attitudes and perceptions about induced abortions among medical and non-medical students of Karachi

OBJECTIVE

To determine the knowledge, attitudes and perceptions regarding induced abortions among university students of Karachi and compare these aspects among medical and non-medical students.

STUDY DESIGN

Cross sectional opinion survey.

METHODS

The study is a cross sectional opinion survey of medical and non-medical students from four educational institutions of Karachi using a pretested questionnaire.

RESULTS

Of the 381 students interviewed, 201 were medical and 180 were non-medical. More medical students were aware of the correct definition of induced abortion. An encouraging finding was the awareness of our study population about the only legally acceptable circumstance for induced abortion in Pakistan, that is, if conceptus is a risk to maternal health (p<0.001). More medical students cited complications that were technical like uterine perforation (p<0.001), cervical trauma (p<0.001), DIC (p<0.001), and sepsis (p<0.001). More medical students thought induced abortion to be a health issue (p=0.001) as compared to non-medical students. Most of the medical students felt the need to modify Pakistan's law regarding abortion (p=0.008) especially for fetal anomalies (13.9%) and rape (7%).

CONCLUSION

Though medical students were more knowledgeable about induced abortions as compared to the non-medical population, there is a need to improve awareness regarding induced and unsafe abortions and their consequences.

The importance of intraoperative evaluation in the management of anorectal atresia

We report a neonate with anorectal atresia in whom preoperative evaluation prior to definitive operation revealed a short gap atresia. However, bidigital evaluation at operation revealed a septal atresia that was easily perforated from below through the anus. Unnecessary division of the anorectal sphincter complex was thus avoided.

Comparative audit of intravenous lorazepam and diazepam in the emergency treatment of convulsive status epilepticus in children

There is little evidence on which to judge the optimal treatment for convulsive status epilepticus (CSE) in children. This study compares the effect of intravenous (iv) lorazepam with iv diazepam as the first line of treatment of CSE. We studied all children with prolonged seizures arriving in the Accident and Emergency (A&E) Department in two separate periods. In the first 6-month period iv diazepam was used as standard treatment, in the second 1-year period iv lorazepam was used. We measured latency to stopping of seizure and any adverse events. A successful treatment was defined as one in which the seizure clinically ceased within 15 minutes after siting the iv cannula, requiring no further treatment.Intravenous diazepam (0.32 mg kg (-1)) was used in 17 of 26 patients, whilst iv lorazepam (0.13 mg kg (-1)) was used in 31 of 59. There were no differences between the two groups regarding age, sex and seizure type.The seizure was successfully controlled 15 minutes after siting the iv cannula in 11 (65%) patients treated with diazepam (median time of 3 minutes) and in 20 (65%) patients treated with lorazepam (median time of 5 minutes). These preliminary results suggest that iv lorazepam may be as effective as iv diazepam.

Plasma from rheumatoid patients taking low dose methotrexate enhances platelet aggregation

Methotrexate (MTX) in low doses is commonly used to treat rheumatoid arthritis (RA). At least 36 deaths have been attributed to bone marrow cytotoxicity associated with low dose MTX. The goal was to determine if plasma from arthritis patients taking low dose MTX induces platelet aggregation in platelet rich plasma from healthy volunteers. Plasma from patients on MTX alone caused a 3-fold increase in aggregation vs plasma from controls (P<0.05). Plasma from patients not taking MTX or taking MTX with diclofenac caused aggregation to a lesser extent. Diclofenac, along with several others NSAIDs and cyclooxygenase inhibitors, depressed aggregation produced by arachidonic acid in platelet rich plasma from healthy volunteers. A precise mechanism for amplification of aggregation by MTX plasma and its relationship to MTX toxicity remains unknown. However, a serum factor may be produced by MTX that modulates the activity of cyclooxygenase, thereby influencing aggregation.

IgM anticardiolipin antibodies are associated with stenosis of vascular access in hemodialysis patients but do not predict thrombosis

AIM

The prevalence of anticardiolipin antibodies (ACA) is elevated amongst hemodialysis patients as compared with the general population. Previous studies have disagreed as to whether the presence of ACA represents a risk factor for access thrombosis. Other risk factors for access thrombosis (decreased blood flow, elevated venous pressure) have also been described.

MATERIALS AND METHODS

We performed a combination retrospective and prospective cohort study of a single outpatient dialysis unit to assess the association between these potential risk factors and access thrombosis. ACA, access blood flow, presence of stenosis, and venous pressures were measured in 100 patients. Information on episodes of access thrombosis was gathered for 12 months prior to and 12 months after ACA measurement.

RESULTS

ACA were present in 19% of patients with equal numbers of IgG- and IgM-ACA. The presence of IgM-ACA was significantly associated with the use of aspirin and the presence of stenosis by Doppler at the time of ACA testing (p < 0.05). A logistic regression model was used to estimate the association between clinical factors and access thrombosis. In this multivariate analysis, the presence of access stenosis and a history of access thrombosis were both significantly associated with the development of access thrombosis. Adjusted for these variables, neither IgG- nor IgM-ACA was significantly associated with access thrombosis. The presence of an ACA was not associated with episodes of access thrombosis in either the prospective or retrospective analyses.

CONCLUSION

Further investigation is required to determine if the association between aspirin use and IgM-ACA, or of IgM-ACA and access stenosis, has implications for underlying pathogenetic mechanisms of access stenosis.

Adenocarcinoma of rectum metastasizing to penis

An elderly gentleman with adenocarcinoma of the rectum who had abdominoperineal resection presented with scrotal skin and penile metastasis. Adenocarcinoma of the rectum metastasizing to the groin and penis is very rare and few cases have been reported.

The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. Americans Associations for Neurologic Surgeons

BACKGROUND

Traumatic brain injury poses a serious public health challenge. Treatment paradigms have dramatically shifted with the introduction of the American Association of Neurologic Surgeons (AANS) Guidelines for the Management of Severe Head Injury. Implementation of the AANS guidelines positively affects patient outcomes and can be successfully introduced in a community hospital setting.

METHODS

Data were collected both retrospectively and prospectively from the records of all trauma patients between 1994 and 1999. A cohort of 93 patients was selected. Thirty-seven patients were treated before the implementation of the AANS guidelines, and these were statistically compared with 56 patients treated after the implementation of the guidelines.

RESULTS

Implementation of the recommendations in the AANS guidelines in a standardized protocol resulted in a 9.13 times higher odds ratio of a good outcome relative to the odds of a poor outcome or death compared with a group managed before the practice change. A Glasgow Coma Scale (GCS) admission score > 8 was associated with a 6.58 times higher odds ratio of a good outcome compared with a GCS admission score < or = 8. Odds ratio of a good outcome decreased by a factor of 0.92 for each year increase in age of patients starting at age 9. A dedicated neurotrauma team and comprehensive treatment algorithms are critical elements to this success. Hospital charges increased by more than $97,000 per patient, but are justifiable in the face of significantly improved outcomes.

CONCLUSION

Implementation of a traumatic brain injury protocol in a community hospital setting is practical and efficacious. Appropriate invasive monitoring of systemic and cerebral parameters guides care decisions. The protocol results in an increase in resource usage, but it also results in statistically improved outcomes justifying the increase in expenditures.

The yield for colorectal cancer and adenoma by indication at colonoscopy

Colonoscopy is an integral part of the clinician armamentarium in the diagnosis of colorectal cancer and its precursor, the adenoma. Polypoid lesions when identified can be excised at colonoscopy and in turn reduce the risk of colorectal cancer. We prospectively evaluated the yield of colorectal cancer and adenomatous polyps by indication for colonoscopy over a one-year period. A total of 375 colonoscopies were carried out. The more common indications of colonoscopy were rectal bleeding, abdominal pain, surveillance of colorectal cancer and altered bowel habit. The highest yield for cancer was for rectal bleeding with 12.5% while surveillance of patients with a history of polyps yielded the highest percentage of new polyps. We conclude that rectal bleeding as an indication for colonoscopy yielded the highest number of cancers.

Intrahepatic stones: the UKM experience

Intrahepatic stones remain a major source of morbidity and mortality. With improving techniques in hepatobiliary surgery, the management and the outcome of intrahepatic calculi is reviewed. Forty-nine cases referred from all over Malaysia between January 1993 to June 1996 were analyzed retrospectively. There were thirty-two females and seventeen males. The median age was 46 years. Biliary diseases encountered in association with intrahepatic calculi included benign strictures (n = 14), ascariasis (n = 3), cholangiocarcinoma (n = 1), Caroli's disease (n = 1), and thalassaemia, (n = 1), fifty-six percent of stones were located in both the intrahepatic ducts while 34% were found in the left intrahepatic duct. Thirty-one patients underwent common bile duct exploration either alone or in combination with liver resection or bilioenteric anastomosis. Despite the various combinations of surgical and non-surgical intervention 28 (57.1%) patients had residual stones. Despite the availability of newer techniques in hepatobiliary surgery, residual stones were common, resulting in higher treatment costs.

The impact of automatic prescriptions on reducing low-density lipoprotein cholesterol levels

CONTEXT

Compliance with the National Cholesterol Education Program (NCEP) guidelines for secondary prevention of atherosclerotic disease has been poor.

OBJECTIVE

To determine whether an automatic prescription would improve compliance with NCEP guidelines on low-density lipoprotein (LDL) cholesterol for secondary prevention of atherosclerotic disease.

DESIGN

Observational study in which physicians chose whether to use an automatic prescription system.

PATIENTS

126 patients with established coronary or cerebrovascular disease whose LDL cholesterol level was greater than 100 mg/dL.

INTERVENTION

By signing the automatic prescription, physicians allowed the study team (medical director and pharmacist) to change lipid-lowering medications. One member of the team then contacted the patient, advising him or her of any changes to medications and treatment. The patient was told that his or her doctor was recommending this change on the basis of recent laboratory tests.

OUTCOME MEASURES

The proportion of patients reaching the LDL cholesterol goal of 100 mg/dL or less.

RESULTS

Physicians used the automatic prescription for 25 patients. Eighteen of the 25 patients in the intervention group (72.0%) achieved the LDL cholesterol goal compared with only 43 of the 101 controls (42.6%) (P = 0.004). After adjustment for differences in age, sex, triglyceride levels, total cholesterol levels, high-density lipoprotein cholesterol levels, and preintervention LDL cholesterol levels, the likelihood of achieving the LDL cholesterol goal was 1.74 times higher in the automatic prescription group than in the control group (P = 0.025).

CONCLUSION

An automatic prescription can help physicians comply with the NCEP guidelines.

Poor bowel preparation in patients undergoing colonoscopy

A prospective analysis of 500 consecutive patients undergoing colonoscopy at the endoscopy unit of Hospital UKM under the care of the surgical unit was analysed. All colonoscopies were supervised by one of two consultant surgeons. The bowel preparation was graded from grade 1 to 4 according to established criteria. All patients had 3 litres of colonic lavage solution as bowel preparation. One hundred and two patients (20.4%) were considered to have poor bowel preparation, while 398 patients (79.6%) had good bowel preparation. Statistically significant factors that resulted in poor bowel preparation included age <20 years and >60 years (p<0.0001), and inpatients (p<0.0193). There was no significant difference in respect to sex, ethnic groups and the indication for colonoscopy. We conclude that young adults and the elderly as well as inpatients are more likely to have a poor bowel preparation using the standard regime.

7alpha-hydroxytheonellasterol, a cytotoxic 4-methylene sterol from the Philippines sponge Theonella swinhoei

A new 4-methylene sterol, 7alpha-hydroxytheonellasterol (3), was isolated from the Philippines sponge Theonella swinhoei, along with the known compounds theonellasterol (1) and bistheonellide A. The structure of 3 was elucidated by interpretation of its spectroscopic data, which were compared with those of 1.

Pancreatic insulinomas--a study of 15 cases from 1978-98

Fifteen cases of insulinoma were managed at HUKM over a period of 20 years. Although all patients presented with neurological symptoms, the diagnosis was delayed in all. Fasting hypoglycaemia and the measurement of C-peptide levels eventually made the diagnosis. Pre-operative localization investigations were not particularly useful. Intraoperative ultrasound (IOUS) detected 72% of the insulinomas, while 93% of the insulinomas were identified intraoperatively by palpation. All the insulinomas were detected intraoperatively with the combination of the two techniques. Twelve of 15 patients had benign adenomas including one patient with MEN-1 syndrome. Two patients had malignant insulinomas. One patient refused surgery. Nine patients underwent pancreatic resections and the remaining 5 patients had the adenomas enucleated.

COX-2 inhibitors: a potential target for drug therapy in the management of colorectal cancer

Colorectal cancer is currently the third most common cancer in Malaysia. Elevated expression of COX-2, an induced cyclooxygenase isoenzyme, has been seen in colonic adenomas and colorectal carcinoma. There is evidence that inhibition of this COX-2 can decrease the risk of colorectal cancer. Selective COX-2 inhibitors may have a role in reducing the risk of colorectal cancer in high-risk individuals.

Massive bleeding from colonic diverticular disease with NSAID use

Non-steriodal anti-inflammatory drugs (NSAID) are not only associated with bleeding in the stomach and duodenum, but can also complicate pre-existing diverticular disease of the colon. Here, a 58 year-old male with severe per rectal bleeding is presented and the role of NSAID as a causative factor of his problem is discussed.

Homo- and nor-plakotenin, new carboxylic acids from the Palauan sponge Plakortis lita

A specimen of Plakortis lita from Palau yielded the new carboxylic acids, homo-plakotenin (2a), the sodium salt of homo-plakotenin (2b), the sodium salt of nor-plakotenin (3), the sodium salt of plakotenin (1b), and the known compound plakotenin (1a). The structures of the new acids were elucidated by interpretation of spectral data and by comparison with the known compound. Compounds 1a, 1b, and 2a were found to significantly reduce proliferation of rheumatoid synovial fibroblasts.

Characteristics of acute pancreatitis in University Kebangsaan Malaysia

We analyzed the characteristics of patients presenting with acute pancreatitis to our unit. A total of 71 patients were admitted to the Surgical Department at University Kebangsaan Malaysia (UKM) over a period of seven years, between January 1990 to December 1996 with acute pancreatitis. There was a fourfold increase in incidence of acute pancreatitis in our hospital from January 1990 to December 1996. The commonest identifiable aetiology was gallstones followed by alcohol. There were two deaths. We conclude that acute pancreatitis is increasingly being diagnosed in our local population. This may be due to either greater awareness or changes in lifestyle of the population.

An uncoupling protein 2 gene variant is associated with a raised body mass index but not Type II diabetes

AIMS/HYPOTHESIS

Linkage between markers close to the uncoupling protein 2 and 3 genes (11q13) and resting metabolic rate and a pre-diabetic phenotype have been found. The syntenic region in mouse has been found to be linked to quantitative traits associated with obesity and diabetes. UCP2 and UCP3 could therefore have an important role in body weight regulation and susceptibility to diabetes. We investigated a recently identified variant of the UCP2 gene in exon 8 as a marker for glucose and weight homeostasis.

METHODS

Length variation of the UCP2 exon 8 variant was studied by the polymerase chain reaction and agarose gel electrophoresis. Sequence variants of the UCP3 gene were sought by semi-automated DNA sequencing.

RESULTS

In 453 South Indian subjects, we found an association in women between the UCP2 exon variant and body mass index (p = 0.018). These findings were replicated in a separate group of South Indian subjects (n = 143, p < 0.001) irrespective of sex. Although no association was found between the UCP2 exon 8 variant and overt obesity in British subjects, the UCP2 genotype of obese women (n = 83) correlated with fasting serum leptin concentration (p = 0.006) in the presence of extreme obesity. These observations could not be explained by tight linkage disequilibrium with a coding region variant in the region of the UCP3 gene of biological significance. Lastly, no association was found between UCP2 and Type II (non-insulin-dependent) diabetes using either a family based design (85 families) or case control study (normal glucose tolerance n = 335, impaired glucose tolerance n = 42, Type II diabetes n = 76).

CONCLUSION/INTERPRETATION

We have described a UCP2 gene exon 8 variant that may affect susceptibility to weight gain by influencing regulation of leptin.

Human immunodeficiency virus-1 infection requires pertussis toxin sensitive G-protein-coupled signalling and mediates cAMP downregulation

The human immunodeficiency virus-1 (HIV-1) utilises CD4 and certain beta-chemokine receptors, mainly CCR-5 and CXCR4, for attachment and virus entry into T-lymphocytes and monocytes/macrophages. CD4 and beta-chemokine receptors participate in intracellular signalling via protein tyrosine kinases and G-protein-coupled signalling. The factors which influence HIV-1 replication and the intracellular signalling mechanisms elicited by the virus are not well understood. In this study, it was demonstrated that exposure of peripheral blood lymphocytes (PBLs) to a T-cell tropic strain of HIV-1 evokes signal(s) which results in downregulation of intracellular cAMP. In addition, pre-incubation of PBLs with the Gi-protein inhibitor Pertussis toxin mediated a significant inhibition of HIV-1 replication. These data strongly suggest that HIV-1 employs CD4 receptors and Gi-coupled proteins for entry into target cells and that productive HIV-1 infection is dependent on an active signalling event.

Intravascular ultrasound and histology in in vitro assessment of iliac artery angioplasty

PURPOSE

Intravascular ultrasound (IVUS) was used to assess in vitro the morphologic and quantitative effects of balloon angioplasty (PTA) of the iliac artery.

METHODS

Forty human iliac arteries (>/= 30% area stenosis) were studied with IVUS in vitro before and after PTA and the findings were validated with histology.

RESULTS

The sensitivity of IVUS for dissection was 74% and for media rupture 59%. The incidence of vascular damage was higher when the whole segment was analyzed rather than the target site alone. Dissections occurred at the thinnest region of the plaque, unrelated to plaque calcification. Following PTA, quantitative changes at the target site were greater compared with the overall data derived from all cross-sections. The increase in lumen area was caused solely by an increase in vessel area.

CONCLUSIONS

IVUS is sensitive in detecting dissections, which occurred irrespective of calcification at the thinnest region of the plaque. The increase in lumen area after PTA was caused by stretching of the vessel.

Expression of an extracellular calcium-sensing receptor in rat stomach

BACKGROUND & AIMS

Circulating levels of Ca2+ can influence secretory functions and myoelectrical properties of the stomach. A Ca2+-sensing receptor (CaR) has recently been identified in tissues that regulate systemic Ca2+ homeostasis. The aim of this study was to evaluate expression of CaR in the stomach of the rat.

METHODS

In forestomach and glandular stomach, reverse-transcription polymerase chain reaction was used to amplify a 380-base pair product, which is 99% homologous with transcripts obtained in parathyroid and kidney.

RESULTS

Northern analysis of gastric mucosal polyA+ RNA revealed 7. 5- and 4.1-kilobase transcripts, similar to those obtained in rat parathyroid and kidney. Immunohistochemistry revealed CaR expression in regions of the submucosal plexus and myenteric neurons. In sections of intact tissue, preparations of primary culture surface cells and surgically dissected gastric glands, staining was observed consistently in epithelial cells of the gastric glands and in gastric surface cells. In parietal cells in isolated gastric glands, intracellular levels of Ca2+ responded to conditions that are known to activate CaR.

CONCLUSIONS

These are the first reported observations that CaR is expressed in different epithelial cells of mammalian gastric mucosa and its enteric nerve regions. The effects of extracellular Ca2+ on gastric function may be attributable to activation of CaR.

Antidiuretic hormone infusion reduces taurine and NaCl-induced hypernatremia in the rat

Rats drinking taurine and hypertonic saline (T + S) develop severe hypernatremia, but rats drinking either T or S alone do not. One hypothesis for this disruption of homeostasis is that the T + S combination interferes with the actions of antidiuretic hormone (ADH). Rats drinking T + S developed severe hypernatremia (170 mmol/L) by day 8 when infused with distilled water by osmotic minipumps, but maintained plasma sodium below 150 mmol/L when infused with ADH. Cumulative water balance in T + S drinkers receiving ADH was consistently higher than in those not receiving ADH. However the ratio of cumulative sodium balance to cumulative water balance suggests little uniform advantage to rats receiving ADH nor does comparison of urine osmolality in the two groups. Precisely how ADH administration reduces hypernatremia in T + S drinking rats remains unclear, but the hypothesis that T + S interferes with the action of ADH in its regulation of extracellular fluid volume and osmolality remains viable.

New cyclic peroxides from the Philippine sponge Plakinastrella sp

Three new cyclic peroxides 5-7 and a new carboxylic acid ester 8 were isolated as minor metabolites from the hexane extract of a Plakinastrella species from the Philippines. The structures of compounds 5-8 were elucidated by interpretation of spectral data and by chemical interconversion, and the absolute stereochemistry of peroxide 6 was determined by application of Mosher's method to a derivative. Although the major compounds in the sponge showed activity against Candida albicans prior to decomposition, the minor metabolites 5-8 are essentially inactive.

Primary inguinal hernia repair: how audit changed a surgeon's practice

Over 10 years one senior consultant surgeon performed 114 standard plication darn herniorraphies on 92 patients with primary inguinal hernias. These patients were contacted and were reviewed if there was any suspicion of recurrence. Four recurrences were detected, giving an overall recurrence rate of about 3.5%. According to actuarial life-table analysis the risks of recurrence at 1 year, 5 years and 10 years were 0.94%, 3.02% and 9%. This level of recurrence is unacceptable in modern practice and, as a result of the audit, the surgeon changed his technique of primary inguinal hernia repair.

Discrepancy between stent deployment and balloon size used assessed by intravascular ultrasound

OBJECTIVES

This study was designed to assess the discrepancy in stent deployment seen on intravascular ultrasound and its relation to the balloon size selected for stent delivery.

DESIGN

Prospective study.

MATERIALS AND METHODS

The study group comprised 27 patients treated using a stent (n = 18) or stent-graft combination (n = 9). Following angiographically optimal stent deployment (< 10% residual stenosis) intravascular ultrasound was used to compare the smallest intra-stent lumen area with measurements at both stent edges and the lumen area of the proximal and distal reference sites.

RESULTS

In 14 of the 27 stents the intra-stent dimension was the same as the dimension of the stent edge (difference < or = +/- 10%). Of the remaining stents the intra-stent dimension was smaller (difference > 10%) than the proximal stent edge in seven stents (range 11-39%), smaller than the distal stent edge in three stents (range 11-20%) and smaller than both stent edges in three stents (range 12-37%). Both in patients treated with a stent or stent-graft combination, the resulting smallest intra-stent lumen area was smaller than the balloon size used (mean difference 32% and 42%, respectively) and smaller than the mean lumen area of the reference sites (mean difference 25% and 23%, respectively).

CONCLUSION

This intravascular ultrasound study shows a discrepancy between intra-stent lumen area, the area of the stent edges and the balloon size used.

n-Butyl cyanoacrylate adhesive for skin closure of abdominal wounds: preliminary results

Tissue adhesives offer significant potential advantages over traditional methods of wound closure. A new n-butyl 2-cyanoacrylate adhesive formulation was utilised for the closure of abdominal wounds after general and laparoscopic gastrointestinal surgery. One hundred and two patients with 240 wounds were recruited. Wounds were classified as > 10 cm, n = 39; 5-9 cm, n = 27; and < 5 cm, n = 176. Complications included one small seroma and two partial superficial dehiscences. There were no incidences of wound infection. This preliminary study indicates that this tissue adhesive can safely and effectively be utilised for general abdominal wound closure. It should now be subjected to the rigorous of a randomised controlled trial to compare its performance against the more traditional methods of wound closure.

The Use of Intermittent Pneumatic Calf Compression in Isolated Femoral Vein Reconstruction

Objective:

To report two cases of isolated femoral vein injury reconstruction and a review of the literature.

Design:

Case report.

Setting:

Hull Royal Infirmary, Kingston Upon Hull.

Patients:

Two patients presenting with civilian trauma.

Interventions:

Spiral vein graft interposition and postoperative intermittent pneumatic calf compression.

Main outcome measure:

Limb salvage, vein patency and limb swelling.

Results:

Satisfactory limb salvage, femoral vein patency and absent limb swelling in both cases.

Inhibition of atherosclerosis in CD4 T-cell-ablated and nude (nu/nu) C57BL/6 hyperlipidemic mice

T lymphocytes and monocyte/macrophages are prominent components of atherosclerotic lesions, and many of these cells are activated and secreting cytokines. To determine the role of these cells in the pathogenesis of atherosclerosis, we studied its development in T-cell-deficient mice fed a high fat atherogenic diet. Depleting euthymic mice of their CD4+ lymphocytes by 20 weekly injections of CD4 monoclonal antibodies reduced the mean area of their aortic lesions by approximately 70%. Similarly, the mean lesion area of T-cell-deficient nude (nu/nu) mice was 10% of the size of that of their heterozygote (nu/+) litter mates. Flow cytometric studies of splenic T cells and analyses of serum total and HDL cholesterol of these mice indicated that the differences in mean lesion areas among the experimental groups were most closely correlated with differences in splenic T cells content. These studies suggest that in these two models T lymphocytes contribute to the pathogenesis of early atherosclerotic lesions and that a further understanding of this phenomenon may provide future approaches toward the prevention and treatment of the disease.

Chromosome 9 related aberrations and deletions of the CDKN2 and MTS2 putative tumor suppressor genes in human chondrosarcomas

Deletions on the short arm of chromosome 9 (9p21 region) have been reported in a number of hematopoietic and solid tumors. These aberrations on 9p have been previously associated with the loss of the interferon gene cluster and the gene for methylthioadenosine phosphorylase (MTAP), localized to the 9p21-22 region. Recently, two putative tumor suppressor gene(s) CDKN2 and MTS2 have been mapped to the 9p21 region, and shown to be deleted in a large number of tumors including leukemias, melanomas, bladder cancers and brain tumors. We have previously reported a similar 9p21 abnormality and deletions of the CDKN2 and MTS2 genes in a myxoid chondrosarcoma cell line and its subclones. In this study we report consistent abnormalities of chromosome 9 in additional chondrosarcomas examined by a detailed cytogenetic and molecular analysis. Seven chondrosarcoma cell lines, one primary chondrosarcoma, and a benign chondroma were examined. Four of the seven tumor cell lines examined showed grossly visible aberrations of chromosome 9. Molecular analysis of these chondrosarcoma cell lines revealed hemizygous deletions of the interferon genes, and the absence of the MTAP gene, protein or activity. In addition, four of the seven chondrosarcoma cell lines also showed deletions of the CDKN2 and/or MTS2 putative tumor suppressor genes, or the absence of the CDKN2 protein product. No such chromosome 9 related aberrations were detected in the benign chondroma. These data suggest that chromosome 9p21 abnormality, and deletions of the CDKN2 and MTS2 tumor suppressor genes may be a significant event in the development of chondrosarcomas.

Primary adenocarcinoma of the appendix

Images

Intracranial space occupying lesions--review of 386 cases

An analysis of 386 cases of Intracranial Space Occupying Lesions (SOL) including neoplastic and inflammatory masses diagnosed and treated at Jinnah Postgraduate Medical Centre, Karachi over a period of 2 years is presented. C.T. Scan and MRI were used for the diagnosis of midline, multiple and very small lesions. S.O.L. were more common in males in the age group 11-20 years. Gliomas comprised 32.1% of the total cases followed by meningiomas 13.7%, abscesses 13.2% and pituitary tumours 13.2%. Tuberculomas constituted 5.5% and therefore, should always be considered in the differential diagnosis.

Role of ventriculoperitoneal shunt in post-tuberculous meningitic hydrocephalous

Thirty-two patients with post-tuberculous meningitic hydrocephalous were admitted. Thirty were subjected to ventriculoperitoneal shunt. Diagnosis was based on CSF analysis and CT scan. Five patients at a Glasgow Coma Score of 3-7 underwent an external ventricular drainage as an initial procedure followed by shunt in 3 patients when condition improved, 17 patients who were conscious at the time of admission made good recovery as compared to 13 patients with altered consciousness who either died (5 patients), or were disabled (8 patients) even after surgery. A mortality of 22% was noted. An early detection and referral is desired to improve the prognosis.

Violence against physicians

OBJECTIVE

To ascertain the incidence of violence against internists.

SETTING

A county-operated tertiary care center in Nassau County, New York.

DESIGN AND PARTICIPANTS

Questionnaires were distributed to 100 internal medicine residents and attending physicians. They were asked to report: whether they had ever been assaulted or battered either by patients or by relatives of patients; the point in their medical training at which such episodes had occurred; the nature and severity of the violent episodes; and the circumstances surrounding such episodes.

RESULTS

Questionnaires were returned by 63 physicians (response rate, 63%). Ten physicians (16% of the respondents) reported that they had been battered, three (5%) on multiple occasions. Twenty-six physicians (41%) reported that they had been assaulted, 15 (24%) on multiple occasions. The majority (54%) of violent episodes had been instigated either by intoxicated patients or by patients with psychiatric histories. In this small sample, no injury was reported.

CONCLUSIONS

Violence against medical residents and attending physicians exists and is most commonly associated with patients who are intoxicated or who have psychiatric histories.

Oxygen free radical activity in experimental colonic carcinoma

Oxygen free radical activity has been implicated in carcinogenesis through DNA lysis. This study measured chemiluminescence and superoxide dismutase (SOD) inhibition as an index of oxygen free radical activity in azoxymethane-induced colonic carcinoma. After 3 weeks of acclimatization, ten Fisher 344 rats were injected with azoxymethane (7 mg kg-1 week-1) over 10 weeks. All animals were killed at 37 weeks and colonic mucosa (5-25 mg wet weight) was sampled from sites of histologically confirmed gross tumour and sites 3-5 cm distant from tumour as well as from ten paired normal controls. The samples were processed in buffered luminol and chemiluminescence was measured in a luminometer. Each sample was then placed in a solution of SOD for 3 min before a second chemiluminescence estimation. Mean(s.e.m.) chemiluminescence from control mucosal samples decreased from 8.1(1.0) to 3.9(1.1) mV per 100 mg tissue (P < 0.05) after incubation in SOD, suggesting that oxygen free radical activity was being measured. There was an increase to 20.2(0.9) mV per 100 mg in azoxymethane-treated colon remote from tumour and to 53.9(2.1) mV per 100 mg at tumour sites; both were reduced significantly after incubation with SOD to 6.7(0.7) and 11.0(0.8) mV per 100 mg respectively (P < 0.001). Chemiluminescence was significantly increased in azoxymethane-induced colonic carcinoma, both remote from and maximally at the tumour site, suggesting a field change in carcinogenesis associated with oxygen free radical activity.