Underdiagnosis of Borderline oxacillin-resistant Staphylococcus aureus (BORSA) - Case series

Borderline oxacillin-resistant Staphylococcus aureus (BORSA) are mecA-negative strains with oxacillin minimum inhibitor concentration (MIC) close to the resistance breakpoint of ≥ 4μg/mL. Instead of producing penicillin-binding protein with low affinity to methicillin (oxacillin) mediated by mecA gene as in methicillin-resistant S. aureus (MRSA), BORSA strains are characterised by the hyperproduction of β-lactamase enzymes, thus able to break down methicillin. Common laboratory methods to detect MRSA such as cefoxitin disk diffusion alone may fail to detect methicillin resistance due to BORSA. We report five cases of BORSA blood-stream infections in a university teaching hospital. All isolates were found to be susceptible to cefoxitin using disk diffusion, resistant to oxacillin using automated MIC method, and did not harbour mecA gene. All patients were suscessfully treated with anti-MRSA antibiotics, and removal of primary sources were done if identified. A more cost-effective method for screening and diagnosis of BORSA is needed in addition to cefoxitin disk diffusion test, in order to monitor the spread, and to enable routine detection and treatment of this pathogen.

Preliminary screening and microbiological evaluation on the environmental hygiene for galley equipment, safety equipment and cabin common facilities of a local airline in Malaysia

Over the last two decades, only a handful of research have been conducted pertaining to food safety in the aviation industry. The gap of knowledge in in-flight food safety literature has long been silenced. Therefore, it was the objective of this study to conduct preliminary screenings to evaluate the environmental quality of the service equipment (GE), safety equipment (SE) and common facilities (CF) within the confinement of commercial aeroplanes in Malaysia. A total of 112 swab samples (n = 112) were analyzed to detect the prevalence of Escherichia coli, Vibrio, Salmonella and coliforms using conventional microbiological methods. The qualitative aerobic mesophilic plate count revealed that 99 (88.39%) and 13 (11.61%) were reported as positive and negative samples, respectively. It was reported that all 17 samples taken from the long-haul flight were positive, with 8 (9.14%), 4 (3.57%) and 5 (4.46%) samples belonging to the GE, SE, and CF, respectively. Forty-five positive swab samples taken from medium-haul flight sectors showed that 30 (26.79%), 8 (9.14%), 7 (6.25%) samples were that of the GE, SE, and CF, respectively. Meanwhile, 19 (16.96%), 8 (9.14%), and 10 (8.93%) of the shorthaul flights samples were that of the GE, SE, and CF, respectively. It was therefore concluded that GE, SE and CF were reported at 57 (50.89%), 20 (17.86%) and 22 (19.64%), respectively. In view of the large numbers and high percentages of positive sample results, it is our opinion that the cleaning, sanitizing and disinfecting procedures of the galley equipment, safety equipment and common facilities are revisited. The assurance in conformance to the hazard analysis and critical control points (HACCP) management system may enhance the safety and reliability of all stakeholders especially the flight attendants who are the final custodians of the environmental hygiene and that of themselves.

C50. Obstructive hypertrophic cardiomyopathy in young adult man: a case report

Background

Hypertrophic obstructive cardiomyopathy (obstructive HCM) is an autosomal dominant congenital disease characterized by obstruction of the left ventricular outflow tract with asymmetric septal hypertrophy. Obstructive HCM is predispose to the appearance of malignant ventricular arrhythmias, leading to syncope or sudden death.

Case Description

A 25-years-old male patient came to the hospital with chief complaint intolerance activity and previous syncope, without history of sudden cardiac death in his family member. ECG showed sinus rhytm with left axis deviation and left ventricular hypertrophy. Chest x ray showed cardiomegaly. The echocardiography showed asymmetric septal hypertrophy (septal/posterior wall thickness ratio 1.31), left atrium dilatation (LAVi 94.2 mL/m2), SAM and mild mitral regurgitation, mild aortic regurgitation, hyperdynamic ejection fraction (79%) with lower longitudinal strain values in basal and mid ventricular septal segment, grade I diastolic dysfunction, resting LVOT gradient 19.53 mmHg , provoked LVOT gradient 47.31 mmHg.

Discussion

Non-invasive treatment was given due to LVOT gradient below 50 mmHg. The patient prescribed diltiazem 100mg once daily and recommended clinical evaluation follow-up every year or any worsening of symptoms. The other family member suggested for familial screening echocardiography.

C96. The First Percutaneous Transvenous Mitral Commissurotomy guided by Three Dimensional Transesophageal Echocardiography in Haji Adam Malik General Hospital Medan

Background

Percutaneous Transvenous Mitral Commissurotomy (PTMC) has become the treatment of choice for patients with mitral stenosis. PTMC guided by three-dimensional Transesophageal Echocardiography (3D-TEE) promise of greater safety and efficacy.

Case Summary

We report a 29-year-old woman who came to our outpatient clinic with shortness of breath as a chief complaint for the past three months. ECG depicted sinus rhythm. Transthoracic Echocardiography (TTE) and 3D-TEE showed severe mitral stenosis with MVA planimetry: 0.8 cm2, MV mean PG 12 mmHg, MV PHT 403 ms, Wilkins score was 4 and no thrombus was found. Therefore, we decided to do PTMC. We successfully done the antegrade transseptal puncture by fluoroscopy guided by two-dimensional (2D) TEE . Then, we used Inoue-balloon catheter No. 24 to dilate the mitral valve. Afterthat, we did 3D-TEE evaluation of the mitral valve area and it showed a significant improvement, with MVA 3D planimetry: 2.0 cm2 and MV mean PG: 4 mmHg and we found moderate mitral regurgitation (MR VC 0.4 cm, MR PISA: 0.3 cm), so we decided to end the procedure.

Discussion

In this case, the PTMC procedure was carried with 2D and 3D-TEE guiding, where process run more easily because interventionist can ensure the targeted site during transeptal puncture, navigation to the mitral valve and post inflation inspection. 3D-TEE guiding can also directly ensure the success of PTMC in real time by evaluating the MVA planimetry (pre and post PTMC) and the mitral regurgitation.

C54. Infective Endocarditis with Ventricular Septal Defect and Ruptured Sinus of Valsalva: A Case Report

Background

Ventricular Septal Defect (VSD) is the most common congenital heart defect with incidence rate about 50% of all case in children. VSD is often followed by weakness of the wall in the sinus of Valsalva causing aneurysms, where 30-50% of cases of aneurysms in the sinus of Valsalva is associated with VSD. Congenital heart defects also increased risk factors for infective endocarditis (IE) with the risk of infection 15-140 times greater than the general population.

Case Description

A 7-year-old boy was reported with fever and shortness of breath, echocardiography examination showed subaortic VSD, ruptured sinus of Valsalva, multiple vegetation on left ventricular outflow tract, right coronary cusp, and right ventricle, moderate aortic, pulmonal and tricuspid regurgitation with mild pulmonal hypertension. Although there was no growth of bacteria from blood culture but result from kidney ultrasound showed sign of glomerulonephritis, suggesting additional findings in Duke criteria. The patient was treated with broad spectrum antibiotic and heart failure drugs. Then, Heart Team decided to refer the patient to Cardiac Center Harapan Kita for evacuating vegetations and repairing congenital heart defect.

Discussion

Infective endocarditis is one of the most arduous complication that must be treated immediately in patients with VSD. Besides reducing the symptoms that arise from heart defects, the clinicians also have to stop the process of infection. Adequate antibiotics and immediate surgery are the best strategy to evacuate the focus of infection as well as to repair congenital defects.

C79. Pseudonormalisation ECG Pattern in Wellens’ Syndrome : A Pitfall in front of Our Eyes

Background

Wellens’ syndrome is a syndrome characterized by biphasic (type A) or deeply inverted T-wave (type B) in the anterior lead, without Q-waves and significant ST elevation, no loss of precordial R-wave progression, normal to minimally elevated cardiac enzymes, and a history of angina.

Case Summary

A 37-years-old male patient was admitted to the emergency department with the chief complaint of typical chest pain lasting for about 1 h. He had type 2 diabetes and a history of smoking. First ECG showed non-specific ST-T changes in the lateral lead. On ECG which was taken two hours later in the pain-free period, deeply inverted T waves were seen in the lead V2 and V3. Troponin I was found as 0.25 ng/mL. The patient was admitted to CVCU and brought to the angiography laboratory next day. A 90%-99% critical proximal LAD occlusion was observed. PCI was successfully performed with drug-eluting stent implantation and good restoration of LAD flow. He was discharged from the hospital on the following day without any complication after coronary intervention.

Discussion

Pseudonormalisation of T wave in pain period could be misinterpreted as normal ECG and could delay coronary angiography and revascularization. We should aware if a patient with typical chest pain came with normal or non-specific ECG changes. Evaluation of ECG in the pain-free period is crucial and leads to the best decision in managing the patient with this syndrome.

C54. Infective Endocarditis with Ventricular Septal Defect and Ruptured Sinus of Valsalva: A Case Report

Background

Ventricular Septal Defect (VSD) is the most common congenital heart defect with incidence rate about 50% of all case in children. VSD is often followed by weakness of the wall in the sinus of Valsalva causing aneurysms, where 30-50% of cases of aneurysms in the sinus of Valsalva is associated with VSD. Congenital heart defects also increased risk factors for infective endocarditis (IE) with the risk of infection 15-140 times greater than the general population.

Case Description

A 7-year-old boy was reported with fever and shortness of breath, echocardiography examination showed subaortic VSD, ruptured sinus of Valsalva, multiple vegetation on left ventricular outflow tract, right coronary cusp, and right ventricle, moderate aortic, pulmonal and tricuspid regurgitation with mild pulmonal hypertension. Although there was no growth of bacteria from blood culture but result from kidney ultrasound showed sign of glomerulonephritis, suggesting additional findings in Duke criteria. The patient was treated with broad spectrum antibiotic and heart failure drugs. Then, Heart Team decided to refer the patient to Cardiac Center Harapan Kita for evacuating vegetations and repairing congenital heart defect.

Discussion

Infective endocarditis is one of the most arduous complication that must be treated immediately in patients with VSD. Besides reducing the symptoms that arise from heart defects, the clinicians also have to stop the process of infection. Adequate antibiotics and immediate surgery are the best strategy to evacuate the focus of infection as well as to repair congenital defects.

C64. New Onset PVC Bigeminy Post Covid-19 Infection: Another Covid-Cardiac Related Problem

Background

Covid-19 is an infectious disease caused by a newly discovered coronavirus that caused acute severe respiratory syndrome and other complication. Many cardiac complication already occurred such as carditis and acute heart failure. PVC bigeminy is a new complication that we found in our post covid-19 patient.

Case Summary

A 31-years-old female patient admitted to the outpatient department with chief complaint palpitation with chest discomfort in the past 1 month with a history covid-19 infection 3 months ago with prolong covid infection for 2 months. ECG showed sinus rhythm and bigeminy PVC with PVC LBBB morphology left inferior axis and transition zone in V4. The patient planned to do Electrophysiology study and ablation. From the EP study we found 2 type of PVC, both of the PVC have LBBB morphology with left inferior axis and transitional zone in V4. The first PVC had 42ms earliest activation time and the second PVC had 48ms earliest activation. We do ablation with non irrigating catheter on the first PVC but the PVC still remain. Then try with irrigating catheter and do the ablation. After the ablation the PVC already vanished and the ablation was successful.

Discussion

PVC bigeminy post covid-19 infection is a rare complication in covid-19 patient. PVC bigeminy cause several complain from palpitation, chest discomfort, and shortness of breath. Ablation is one of the best way to treat PVC bigeminy patient with symptoms and in the patient the ablation was successful.

C64. New Onset PVC Bigeminy Post Covid-19 Infection: Another Covid-Cardiac Related Problem

Background

Covid-19 is an infectious disease caused by a newly discovered coronavirus that caused acute severe respiratory syndrome and other complication. Many cardiac complication already occurred such as carditis and acute heart failure. PVC bigeminy is a new complication that we found in our post covid-19 patient.

Case Summary

A 31-years-old female patient admitted to the outpatient department with chief complaint palpitation with chest discomfort in the past 1 month with a history covid-19 infection 3 months ago with prolong covid infection for 2 months. ECG showed sinus rhythm and bigeminy PVC with PVC LBBB morphology left inferior axis and transition zone in V4. The patient planned to do Electrophysiology study and ablation. From the EP study we found 2 type of PVC, both of the PVC have LBBB morphology with left inferior axis and transitional zone in V4. The first PVC had 42ms earliest activation time and the second PVC had 48ms earliest activation. We do ablation with non irrigating catheter on the first PVC but the PVC still remain. Then try with irrigating catheter and do the ablation. After the ablation the PVC already vanished and the ablation was successful.

Discussion

PVC bigeminy post covid-19 infection is a rare complication in covid-19 patient. PVC bigeminy cause several complain from palpitation, chest discomfort, and shortness of breath. Ablation is one of the best way to treat PVC bigeminy patient with symptoms and in the patient the ablation was successful.

C47. Heparin Induced Thrombocytopenia (HIT) Associated with Multiple Deep Vein Thrombosis (DVT) and Intracardiac Thrombus Who Underwent Vena Cava Filter Prior to Surgical Thrombus Evacuation : a Case Report

Background

Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis.

Case

A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation.

Discussion

This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

OR23. Correlation of Right Ventricular Systolic Function by Right Ventricular Global Longitudinal Strain in Rheumatic Mitral Stenosis compared to Mitral Regurgitation before and after Intervention

Background and Aims

Right ventricle systolic dysfunction develop prior to the onset of clinical systemic congestion; thus, early detection is beneficial for both diagnostic and therapeutic value. We aim to asses changes of Right Ventricular Global Longitudinal Strain (RVGLS) in rheumatic mitral valve disease, and assess correlation between Right Ventricular Systolic Pressure (RVSP) and RVGLS before and after intervention.

Methods and Results

Our study consisted of 21 patients with an established diagnosis of significant MS or MR and normal RV function, who were admitted for either Balloon Mitral Valvulotomy (BMV) or Mitral Valve Replacement (MVR). 2D echocardiography and measurement of RVGLS was obtained from RV-focused A4CH view. Patients were divided into 2 groups: (1) significant MS consists of 11 patients, (2) significant MR consists of 10 patients. Prior to intervention, MS group had significantly lower RVGLS compared to MR group (-11.64 vs. -18.29; p = 0.001). After MVR, the RVGLS of MS group was significantly increased compared to MR group (MS -11.64 to -15.59, p = 0.001 vs. MR -18.29 to -19.39, p = 0.069). Both MS and MR groups showed significant negative correlation between RVSP and RVGLS before and after intervention (r=-0.642; p = 0.002; r=-0.670; p = 0.001).

Conclusion

Pre-intervention with a background normal RV function, RVGLS was impaired significantly in MS group compared to MR group. Post intervention RVGLS improved significantly in MS group compared to MR group. Both groups showed significant negative correlation between RVSP and RVGLS before and after intervention.

C50. Obstructive hypertrophic cardiomyopathy in young adult man: a case report

Background

Hypertrophic obstructive cardiomyopathy (obstructive HCM) is an autosomal dominant congenital disease characterized by obstruction of the left ventricular outflow tract with asymmetric septal hypertrophy. Obstructive HCM is predispose to the appearance of malignant ventricular arrhythmias, leading to syncope or sudden death.

Case Description

A 25-years-old male patient came to the hospital with chief complaint intolerance activity and previous syncope, without history of sudden cardiac death in his family member. ECG showed sinus rhytm with left axis deviation and left ventricular hypertrophy. Chest x ray showed cardiomegaly. The echocardiography showed asymmetric septal hypertrophy (septal/posterior wall thickness ratio 1.31), left atrium dilatation (LAVi 94.2 mL/m2), SAM and mild mitral regurgitation, mild aortic regurgitation, hyperdynamic ejection fraction (79%) with lower longitudinal strain values in basal and mid ventricular septal segment, grade I diastolic dysfunction, resting LVOT gradient 19.53 mmHg , provoked LVOT gradient 47.31 mmHg.

Discussion

Non-invasive treatment was given due to LVOT gradient below 50 mmHg. The patient prescribed diltiazem 100mg once daily and recommended clinical evaluation follow-up every year or any worsening of symptoms. The other family member suggested for familial screening echocardiography.

C96. The First Percutaneous Transvenous Mitral Commissurotomy guided by Three Dimensional Transesophageal Echocardiography in Haji Adam Malik General Hospital Medan

Background

Percutaneous Transvenous Mitral Commissurotomy (PTMC) has become the treatment of choice for patients with mitral stenosis. PTMC guided by three-dimensional Transesophageal Echocardiography (3D-TEE) promise of greater safety and efficacy.

Case Summary

We report a 29-year-old woman who came to our outpatient clinic with shortness of breath as a chief complaint for the past three months. ECG depicted sinus rhythm. Transthoracic Echocardiography (TTE) and 3D-TEE showed severe mitral stenosis with MVA planimetry: 0.8 cm2, MV mean PG 12 mmHg, MV PHT 403 ms, Wilkins score was 4 and no thrombus was found. Therefore, we decided to do PTMC. We successfully done the antegrade transseptal puncture by fluoroscopy guided by two-dimensional (2D) TEE . Then, we used Inoue-balloon catheter No. 24 to dilate the mitral valve. Afterthat, we did 3D-TEE evaluation of the mitral valve area and it showed a significant improvement, with MVA 3D planimetry: 2.0 cm2 and MV mean PG: 4 mmHg and we found moderate mitral regurgitation (MR VC 0.4 cm, MR PISA: 0.3 cm), so we decided to end the procedure.

Discussion

In this case, the PTMC procedure was carried with 2D and 3D-TEE guiding, where process run more easily because interventionist can ensure the targeted site during transeptal puncture, navigation to the mitral valve and post inflation inspection. 3D-TEE guiding can also directly ensure the success of PTMC in real time by evaluating the MVA planimetry (pre and post PTMC) and the mitral regurgitation.

C47. Heparin Induced Thrombocytopenia (HIT) Associated with Multiple Deep Vein Thrombosis (DVT) and Intracardiac Thrombus Who Underwent Vena Cava Filter Prior to Surgical Thrombus Evacuation : a Case Report

Background

Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis.

Case

A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation.

Discussion

This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

C79. Pseudonormalisation ECG Pattern in Wellens’ Syndrome : A Pitfall in front of Our Eyes

Background

Wellens’ syndrome is a syndrome characterized by biphasic (type A) or deeply inverted T-wave (type B) in the anterior lead, without Q-waves and significant ST elevation, no loss of precordial R-wave progression, normal to minimally elevated cardiac enzymes, and a history of angina.

Case Summary

A 37-years-old male patient was admitted to the emergency department with the chief complaint of typical chest pain lasting for about 1 h. He had type 2 diabetes and a history of smoking. First ECG showed non-specific ST-T changes in the lateral lead. On ECG which was taken two hours later in the pain-free period, deeply inverted T waves were seen in the lead V2 and V3. Troponin I was found as 0.25 ng/mL. The patient was admitted to CVCU and brought to the angiography laboratory next day. A 90%-99% critical proximal LAD occlusion was observed. PCI was successfully performed with drug-eluting stent implantation and good restoration of LAD flow. He was discharged from the hospital on the following day without any complication after coronary intervention.

Discussion

Pseudonormalisation of T wave in pain period could be misinterpreted as normal ECG and could delay coronary angiography and revascularization. We should aware if a patient with typical chest pain came with normal or non-specific ECG changes. Evaluation of ECG in the pain-free period is crucial and leads to the best decision in managing the patient with this syndrome.

Thrombin and factor Xa promote premature senescence and remodeling in areas at risk of the left appendage and in atrial endothelial cells: potential modulation by SGLT1 and/or SGLT2 inhibition

Introduction

Atrial fibrillation (AF), the most common cardiac arrhythmia, promotes prothrombotic responses particularly in the distal part of the left atrial appendage (LAA) characterized by reduced flow and low shear stress. AF occurrence and duration are closely associated with endothelial dysfunction and left atrium remodeling.

The contribution of coagulation factors thrombin and factor Xa (FXa) to LA remodeling remains poorly studied. This study investigated whether thrombin and FXa promote endothelial dysfunction and profibrotic and prothrombotic responses in the distal and proximal parts of the LAA. Since SGLT2 inhibitors have shown pronounced cardiac protection, the contribution of SGLT2 was examined.

Methods

LAAs were harvested from porcine hearts. Proximal (low stasis, high shear) and distal (high stasis, low shear) parts were cut and incubated with a coagulation factor (thrombin or FXa). Left atrial endothelial cells (AECs) were collected enzymatically, cultured and used at passage 1. The level of oxidative stress was assessed using the redox-sensitive probe dihydroethidium (DHE), fibrosis by Sirius red histological staining, senescence-associated β-galactosidase (SA-β-gal) activity using X-gal staining in tissues and the fluorogenic substrate C12FDG and flow cytometry in cells. The expression of target proteins was detected by immunofluorescence staining and Western blot analysis.

Results

The distal part of LAA displayed higher levels of oxidative stress in the endothelium and the atrial wall than the proximal part. SA-β-gal activity, ICAM-1, VCAM-1, and MMP-9 staining was more pronounced in the endothelium of the distal part compared to the proximal part whereas eNOS staining was decreased. The distal LAA wall showed higher levels of fibrosis. Western blot analysis showed higher expression levels of tissue factor (TF), VCAM-1, MCP-1, MMP-9, TGF-β and SGLT-2 in the distal part compared to the proximal one. Both thrombin and FXa increased these signals to a greater extent in the distal part of the LAA whereas the eNOS expression level was decreased. Exposure of AECs to either thrombin or FXa induced a pro-oxidant response and increased the expression level of ICAM-1, TGF-β, MMP-2, MMP-9, SGLT1 and SGLT-2. Thrombin promoted SA-β-gal activity in AECs. The selective SGLT-2 inhibitor empagliflozin and the dual SGLT1/2 inhibitor sotagliflozin prevented the pro-oxidant response and SA-β-gal activity in response to thrombin.

Conclusion

Thus, the distal part of the LAA is prematurely affected by endothelial dysfunction and senescence associated with a pro-oxidant, pro-remodeling and pro-inflammatory response that is further increased by thrombin and FXa. Hence, the coagulation cascade appears to prematurely promote atrial endothelium and wall dysfunction predominantly in areas at risk that may pave the way to thrombus formation. The findings also suggest a potential protective effect of SGLT1 and/or SGLT2 inhibition on atrial dysfunction.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Unrestricted research grant from Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany

Rethinking respite in Australia: A naturalistic effect study of a multicomponent community program to promote respite knowledge, attitudes and behaviours of carers of people with dementia

'Rethink Respite' was a prospective, naturalistic cohort study conducted in the Illawarra-Shoalhaven (NSW, Australia) to improve knowledge, attitudes and uptake of respite strategies in carers of people with dementia. A convenience sample of n = 70 carers were recruited in 2014-15 to establish a baseline for knowledge, attitudes and use of respite for a cohort of carers in the region. Carer perceived need for respite, burden and self-efficacy were also assessed. A co-designed multi-component community-based intervention was subsequently rolled at in the region from 2015 to 2016. The intervention supported: awareness raising media; carer education sessions; access to web and print respite information resources; and an option to participate in a tailored one-on-one in-home coaching program. At program completion, a follow-up survey was administered to the cohort, with n = 44/70 responding. All n = 44 respondents reported participation in and exposure to 'Rethink Respite' media, information and education during the intervention period. Eighteen of the 44 also self-selected to receive the active tailored coaching support. At follow-up, few positive results were reported on the assessed carer variables for the cohort over time. However, post hoc sub-group analyses found those who also self-selected to receive active support (provided through coaching) (n = 18), showed improvements to their respite knowledge, attitudes and self-efficacy (p < .05). Intention to use respite, and levels of personal gain from caring in this sub-group also increased (p < .05). In contrast, carers who only participated in the informational/educational aspects of the program (and did not self-select to the respite coaching), experienced negative changes over time to their respite beliefs and 'role captivity'. Overall, this pilot study suggests that passive respite information and educational strategies are insufficient, without more active supports (tailored respite coaching) to address observed carer decline over time. Future research should seek to replicate these results using a larger sample and an experimental design.

Anti-salmonellosis agent for foodborne illness from Mangifera odorata (kuini) extracts

Salmonellosis infection caused by Salmonella bacteria is a public endemic problem in Malaysia with long-term morbidity and mortality effects. Thus, this study aimed to explore the antipathogenic activity of natural extracts from Mangifera odorata against two Salmonella species causing Salmonellosis. The extracts were derived from peel, flesh, and kernel seed of M. odorata. The inhibition performance of the extracts against both Salmonella enterica serovar Typhimurium and Salmonella enterica serovar Enteritidis bacteria were subsequently tested by using a bioassay-guided fractionation method. Results showed that the extracts derived from the kernel seed had the highest inhibition percentage of 83-90% against the Salmonellosis infection, followed by the peel with an inhibition of 61-67%, and lastly the flesh with an inhibition of 53-69%. The inhibition activities of hexane extracted flesh (FCH), methanol extracted peel (PCM), and methanol treated kernel seed (KTM) against S. enterica ser. Typhimurium bacteria were 59, 67 and 83%, respectively. Furthermore, the S. enterica ser. Enteritidis bacteria were found to be highly susceptible against the methanol extracted kernel seed (KCM), followed by the hexane extracted peel (PCH) and flesh (FTH) with the inhibition percentage of 90, 69 and 59%, respectively. The highly active anti-Salmonellosis performance of M. odorata extracts was attributed to its intrinsically high total phenolics content at 8-10 g GAE/g extract, high ferric reducing antioxidant power value (FRAP) at 18-22 g Fe2+/g extract and excellent scavenging activity with the inhibition performance ranges between 86% and 90%. This study revealed the antipathogenic activity of methanol extracts of M. odorata kernel seed inhibited the growth of both S. enterica ser. Typhimurium and S. enterica ser. Enteritidis bacteria. This study also discovered the prophylactic property of natural compounds in M. odorata kernel seed extracts and could be used as an anti-Salmonellosis agent. In the near future, M. odorata can be developed as an innovative functional food source for specific groups that are vulnerable to Salmonellosis

Photonic Excitation of a Micromechanical Cantilever in Electrostatic Fields

We present a specific near-field configuration where an electrostatic force gradient is found to strongly enhance the optomechanical driving of an atomic force microscope cantilever sensor. It is shown that incident photons generate a photothermal effect that couples with electrostatic fields even at tip-surface separations as large as several wavelengths, dominating the cantilever dynamics. The effect is the result of resonant phenomena where the photothermal-induced parametric driving acts conjointly (or against, depending on electric field direction) with a photovoltage generation in the cantilever. The results are achieved experimentally in an atomic force microscope operating in vacuum and explained theoretically through numerical simulations of the equation of motion of the cantilever. Intrinsic electrostatic effects arising from the electronic work-function difference of tip and surface are also highlighted. The findings are readily relevant for other optomicromechanical systems where electrostatic force gradients can be implemented.

Private versus public? Examining hospital use by a privately insured population in New South Wales, Australia, using data linkage

Objective To examine hospital use characteristics of a privately insured cohort including hospital setting (public or private), declared insurance status and category of services received during hospital admission. Methods The study population consisted of 14276 people with membership of a private health insurance (PHI) fund in New South Wales, Australia. The final study cohort included 9004 people with at least one hospital admission over a 6-year period from 1 January 2010 to 31 December 2015. PHI claims data were linked with public hospital records from a Local Health District. Hospital utilisation measures include number of admissions and length of stay. Measures were categorised by hospital user group (public only, private only or both), declared insurance status (PHI or public patient), type of service and admission case weight. Results The study finds that despite having PHI, 40% of people receive services exclusively in a public hospital in the 6-year study period. Additionally, only 62% of overnight hospital admissions for the study population are claimed on PHI. There are differences in hospital utilisation for medical- and surgical-related admissions. Seventy percent of people with a medical admission receive services only in public hospitals, but a similar proportion of people (66%) receive services only in private hospitals for surgical admissions. Conclusions People with PHI make considerable use of public hospitals both as a public and a private patient. For this privately insured cohort, public hospitals are more frequently used for medical-related admissions and also for more resource-intensive admissions compared with private hospitals. What is known about the topic? There are multiple government incentives to encourage people to take out PHI policies in Australia. Although PHI is closely associated with private hospital utilisation, people with PHI can still use public hospitals as either a public patient, in which the service is fully government-funded, or as a private patient in which PHI contributes funding towards the cost of hospital admissions. What does this paper add? This study provides the first analysis of hospital utilisation of a privately insured cohort in Australia that reports on the interaction between public and private hospital use and declared insurance status, including utilisation differences based on service type. What are the implications for practitioners? Although there are financial incentives offered by the Australian Government to encourage uptake of PHI, the study findings show that people with PHI still make considerable use of public hospitals both as a public and private patient. Future policy reforms relating to the regulation of PHI in Australia should consider the nuanced differences in the way people with PHI use public and private hospitals to optimise resource allocation.

Reduced susceptibility of Burkholderia pseudomallei following exposure to carbapenem

Reduced susceptibility in Burkholderia pseudomallei during carbapenem therapy may lead to treatment failure. We isolated a clinical strain that had developed reduced susceptibility to carbapenems while on treatment. After reviewing the patient's clinical notes, the initial isolate (BUPS01/14) was exposed to carbapenem in vitro to mimic the clinical scenario. The stability of susceptibility of the carbapenem-exposed strain (BUPS01/14R) was examined by serial subculture in antibiotic-free broth. Biochemical and morphological comparison was performed by the VITEK® system and electron microscopy. MICs increased 32-fold following carbapenem exposure and became stable in the antibiotic-free environment. On electron microscopic examination, the BUPS01/14R cells were smoother and less wrinkled compared to BUPS01/14 cells. This report highlights a potential anti-melioidosis treatment failure due to the emergence of resistance while on carbapenem monotherapy. Further study of this strain is necessary to understand the mechanism of resistance at a molecular level.

Scar Endometriosis - A Rare Entity: Case Series

Endometriosis is a condition where there are functional endometrial glands and stroma in sites other than uterine mucosa. It is a unique condition which is benign but has a tendency of invasion and extension locally. Scar endometriosis is a rare entity where there is presence and proliferation of endometrial gland and stroma in the scar of the previous surgery. It is estimated to be only 0.03 to 0.15% of all cases of endometriosis. Because of its deceptive nature and lack of specific diagnostic tools, scar endometriosis is often difficult to diagnose. It is also a challenge for the clinicians as this condition is difficult to treat because it is nonresponsive to hormonal treatment and excision is often the only effective treatment. Here we present two cases of scar endometriosis that we have encountered in BIRDEM general hospital, Dhaka, Bangladesh in last five years.

P2253Intake of the omega 3 PUFAs formulation EPA:DHA 6:1 by aged rats reduced shedding of microvesicles from spleen-derived cultured leukocytes and their ability to promote senescence in endothelial cells

Introduction

Ageing is associated with the appearance of endothelial senescence promoting endothelial dysfunction and, ultimately, cardiovascular events. Circulating microvesicles (MVs) of patients with acute coronary syndrome promoted premature endothelial senescence by stimulating the local angiotensin system. Omega 3 PUFAs have been shown to reduce the risk of cardiovascular disease in patients at high risk.

Purpose

This study investigated whether a 7-day intake of the omega 3 formulation EPA:DHA 6:1 by rats affects the level of MVs released by spleen-derived cultured leukocytes as well as their ability to promote premature senescence in target endothelial cells (ECs), and, if so, to clarify the underlying mechanism.

Methods

Middle-aged male Wistar rats (M, 48-week old) received 500 mg/kg/d of either EPA:DHA 6:1, EPA:DHA 1:1, or vehicle (CTL) for 7 days. Thereafter, spleen-derived leukocytes, a rich source of MVs, were prepared and cultured for 24 h. Cultured ECs were prepared from porcine coronary arteries. Senescence-associated β-galactosidase activity (SA-β-gal) was assessed by C12FDG, protein expression level by Western blot analysis, oxidative stress by dihydroethidium using confocal microscopy, and procoagulant MVs by prothrombinase assay. Spleen-derived leukocytes from untreated young (Y, 12-week) and old (O, 72-week) rats were also studied.

Results

Shedding of MVs by spleen-derived leukocytes significantly increased with increasing age. Incubation of ECs with leukocyte-derived MVs (10 nM Phtd Ser eq.) from M and O but not those from Y induced premature senescence after 48 h. The stimulatory effect of M-MVs was prevented by losartan and associated with oxidative stress. M-MVs induced an upregulation of senescence markers (p16, p21, p53), pro-atherothrombotic markers (VCAM-1, ICAM-1, tissue factor), the pro-inflammatory marker cyclooxygenase-2 (COX-2) but not COX-1, and of the angiotensin system (angiotensin-converting enzyme and type 1 angiotensin receptor), whereas endothelial NO synthase was down-regulated. A one-week intake of EPA:DHA 1:1 and 6:1 by M rats decreased the leukocyte-derived MVs shedding by about 14% and 24%, and EPA:DHA 6:1 reduced their ability to induce ECs senescence by 38%. The stimulatory effect of M-MVs on the expression of target proteins was also observed with those from the EPA:DHA 1:1 but not with those from the 6:1 group.

Conclusion

These findings indicate that ingestion of EPA:DHA 6:1 by middle-aged rats reduces not only the shedding of MVs by spleen-derived leukocytes but also their ability to induce pro-senescent, pro-thrombotic and pro-inflammatory responses in endothelial cells most likely by decreasing the local angiotensin system. They further suggest that EPA:DHA 6:1 may help to delay ageing-related endothelial dysfunction.

Acknowledgement/Funding

Unrestricted research grant from PIVOTAL Therapeutics Inc.

P6266Circulating microparticules of patients with coronary artery disease up-regulate the expression of sodium-glucose cotransporters 1 and 2 in coronary artery endothelial cells: role of angiotensin II

Introduction

Circulating microparticles (MPs) from patients with coronary artery diseases (CAD) have been shown to promote endothelial senescence and dysfunction involving the pro-oxidant local angiotensin system. Sodium-glucose cotransporters (SGLTs)2 inhibitors decreased the risk of cardiovascular disease in patients with type 2 diabetes and this effect appears to be independent of glycemic control. Moreover, high glucose and H2O2 have been shown to cause a redox-sensitive upregulation of SGLT1 and 2 in coronary artery endothelial cells (ECs).

Aim

Therefore, this study examined whether angiotensin II (Ang II, a potent NADPH oxidase-dependent inducer of oxidative stress) and CAD MPs stimulate SGLT1 and 2 expression in ECs, and assessed their role in the induction of endothelial dysfunction.

Methods

ECs were isolated from porcine coronary arteries. The protein expression level was assessed by Western blot analysis and immunocytochemical staining, oxidative stress using dihydroethidium staining, and senescence by senescence-associated beta-galactosidase activity (SA-beta-gal activity). Circulating CAD MPs were collected from blood samples of patients (61–79 year) with established cardiovascular disease.

Results

Control ECs expressed low levels of SGLT1 and SGLT2 proteins. Exposure of ECs to Ang II caused a time- and concentration-dependent increase in the protein level of SGLT1 and SGLT2 with a significant increase observed at concentrations as low as 10 nM. Exposure of ECs to CAD MPs (10 nM PhtdSer eq) from 3/5 patients increased the SGLT1 and SGLT2 protein level. An increased SGLT1 and SGLT2 immunofluorescence signal was also observed in response to Ang II and H2O2. Ang II increased the level of oxidative stress, SA-beta-gal activity, senescence markers (p53, p21 and p16), VCAM-1, MCP-1, tissue factor (TF) and the local angiotensin system (ACE, AT1R), and down-regulated that of eNOS. CAD MPs from 4/5 patients decreased eNOS level and from 5/5 patients increased VCAM-1 level. All the Ang II-induced effects were prevented by the dual SGLT1/2 inhibitor LX-4211 and the selective SGLT2 inhibitor, empagliflozin.

Conclusions

The present findings indicate that CAD MPs and Ang II upregulate the expression of SGLT1 and SGLT2 protein levels in ECs, and that they promote endothelial dysfunction. They further suggest that inhibition of SGLT1 and/or SGLT2 might be an attractive strategy to protect the arterial wall and, hence, the development of cardiovascular diseases.

Acknowledgement/Funding

Unrestricted research grant from Boehringer Ingelheim Pharma GmbH & Co. KG

Emerging role of the Australian private health insurance sector in providing chronic disease management programs: current activities, challenges and constraints

Objective This study explored the current activities of a sample of Australian private health insurance (PHI) funds to support the care of people living with chronic conditions, following changes to PHI legislation in 2007 permitting funds to cover a broader range of chronic disease management (CDM) services. Methods A qualitative research design was used to gather perspectives from PHI sector representatives via semistructured interviews with eight participants. The interview data were analysed systematically using the framework analysis method. Results Three main types of activities were most commonly identified: (1) healthcare navigation; (2) structured disease management and health coaching programs; and (3) care coordination services. These activities were primarily conducted via telephone by a combination of in-house and third-party health professionals. PHI funds seem to be taking a pragmatic approach to the type of CDM activities currently offered, guided by available data and identified member need. Activities are focused on people with diagnosed chronic conditions exiting hospital, rather than the broader population at-risk of developing a chronic condition. Conclusions Despite legislation permitting PHI funds to pay benefits for CDM services being in place for more than 10 years, insurers are still in an early stage of implementation and evaluation of CDM activities. Primarily due to the regulated scope of PHI coverage in Australia, participants reported several challenges in providing CDM services, including identifying target groups, evaluating service outcomes and collaborating with other healthcare providers. The effectiveness of the approach of PHI funds to CDM in terms of the groups targeted and outcomes of services provided still needs to be established because evidence suggests that population-level interventions that target a larger number of people with lower levels of risks are likely to have greater benefit than targeting a small number of high-risk cases. What is known about the topic? Since 2007, PHI funds in Australia have been able to pay benefits for a range of out-of-hospital services, focused on CDM. Although a small number of program evaluations has been published, there is little information on the scope of activities and the factors influencing the design and implementation of CDM programs. What does this paper add? This paper presents the findings of a qualitative study reporting on the CDM activities offered by a sample of PHI funds, their approach to delivery and the challenges and constraints in designing and implementing CDM activities, given the PHI sector's role as a supplementary health insurer in the Australian health system. What are the implications for practitioners? Current CDM activities offered by insurers focus on health navigation advice, structured, time-limited CDM programs and care coordination services for people following a hospital admission. There is currently little integration of these programs with the care provided by other health professionals for a person accessing these services. Although the role of insurers is currently small, the movement of insurers into service provision raises considerations for managing potential conflicts in having a dual role as an insurer and provider, including the effectiveness and value of services offered, and how these programs complement other types of health care being received.

Utilisation patterns of privately funded mental health services in Australia

PURPOSE

The purpose of this paper is twofold: first, to present patient-level utilisation patterns of hospital-based mental health services funded by private health insurers; and second, to examine the implications of the findings for planning and delivering private mental health services in Australia.

DESIGN/METHODOLOGY/APPROACH

Analysing private health insurance claims data, this study compares differences in demographic and hospital utilisation characteristics of 3,209 patients from 13 private health insurance funds with claims for mental health-related hospitalisations and 233,701 patients with claims for other types of hospitalisations for the period May 2014 to April 2016. Average number of overnight admissions, length of stay and per patient insurer costs are presented for each group, along with overnight admissions vs same-day visits and repeat services within a 28-day period following hospitalisation. Challenges in analysing and interpreting insurance claims data to better understand private mental health service utilisation are discussed.

FINDINGS

Patients with claims for mental health-related hospitalisations are more likely to be female (62.0 per cent compared to 55.8 per cent), and are significantly younger than patients with claims for other types of hospitalisations (32.6 per cent of patients aged 55 years and over compared to 57.1 per cent). Patients with claims for mental health-related hospitalisations have significantly higher levels of service utilisation than the group with claims for other types of hospitalisations with a mean length of stay per overnight admission of 15.0 days (SD=14.1), a mean of 1.3 overnight admissions annually (SD=1.2) and mean hospital costs paid by the insurer of $13,192 per patient (SD=13,457) compared to 4.6 days (SD=7.3), 0.8 admissions (SD=0.6) and $2,065 per patient (SD=4,346), respectively, for patients with claims for other types of hospitalisations. More than half of patients with claims for mental health-related hospitalisations only claim for overnight admissions. However, the findings are difficult to interpret due to the limited information collected in insurance claims data.

PRACTICAL IMPLICATIONS

This study shows the challenges of understanding utilisation patterns with one data source. Analysing insurance claims reveals information on mental health-related hospitalisations but information on community-based care is lacking due to the regulated role of the private health insurance sector in Australia. For mental health conditions, and other chronic health conditions, multiple data sources need to be integrated to build a comprehensive picture of health service use as care tends to be provided in multiple settings by different medical and allied health professionals.

ORIGINALITY/VALUE

This study contributes in two areas: patient-level trends in hospital-based mental health service utilisation claimed on private health insurance in Australia have not been previously reported. Additionally, as the amount of data routinely collected in health care settings increases, the study findings demonstrate that it is important to assess the quality of these data sources for understanding service utilisation.

Analysing health data sources to inform chronic disease management decisions of health insurers: A mixed methods study

Background and Objective: Both health care providers and payers recognize the need to improve chronic disease care. Chronic disease management relies on high-quality health information for people with, and at risk of developing, chronic diseases. This article focuses on the health insurance sector and investigates ways that payment claims data and other data sources can provide useful information to support chronic disease management interventions. Methods and Results: In this mixed methods study, we first examine methods of selecting target populations from insurance claims data for common chronic conditions-diabetes, cardiovascular disease, and mental health disorders. The analysis of claims data reveals data quality issues and indicates that other data sources should be considered to provide additional information. We undertake a qualitative review of factors influencing the development of information systems for chronic disease management that use multiple data sources. Conclusions: Claims data should be supplemented with other data to inform chronic disease management. The article proposes a conceptual framework with four domains that need to be considered when developing chronic disease information systems using multiple data sources-information requirements, data sources, data collection, and information systems integration. There are policy and organizational factors that influence framework implementation.

Involvement of people with dementia in raising awareness and changing attitudes in a dementia friendly community pilot project

Low levels of public understanding can contribute to the fear, stigma and social exclusion associated with living with dementia. Dementia friendly communities aim to address this by empowering people with dementia and increasing their social inclusion. As a part of a Community Based Participatory Action Research (CBPAR) process, a multicomponent dementia friendly community intervention supported: research; the establishment of a Dementia Advisory Group and Alliance; an awareness campaign and education in community organisations. Educational events were co-designed and co-facilitated by people with dementia and their care partners. To assess project reach and changes in attitudes of community members, two cross sectional surveys were conducted with adults (aged over 18 years) using validated scales. Independent samples t-tests compared responses to the surveys prior to the commencement of the project (2014) and two years later (2016). In 2016, respondents showed increased agreement with the statements: ‘People with dementia participate in a wide variety of activities and interests,’ and, ‘It is easy to find out about dementia friendly services or organisations in Kiama’. Respondents who attended an educational event reported less negative views about how they themselves would feel if they were diagnosed with dementia compared with respondents who did not attend an event. CBPAR appears useful to support the involvement of people with dementia and the engagement of the community to improve awareness of dementia services. The direct involvement of people living with dementia as spokespeople and educators was an effective way to improve positive attitudes and reduce the negative stereotypes associated with living with dementia. Further research is needed to compare different approaches to the creation of dementia friendly communities in different locations, and to establish the extent to which local interventions are useful to complement efforts to raise awareness of dementia at a national level.

Examining the high users of hospital resources: implications of a profile developed from Australian health insurance claims data

Objective To develop and examine a profile of the demographic, hospital admission and clinical characteristics of high users of hospital resources within a cohort of privately insured Australians. Methods Hospital admissions claims data from a group of private health insurance funds were analysed. The top 1% of hospital users were selected based on three measures of resource utilisation: number of admissions, total bed days and total insurance benefits paid. The demographic, hospital admission and clinical characteristics data were compared for these three measures of resource utilisation. Results Compared with the general insured population, the three high-use cohorts are older, have more public hospital admissions and have more same-day admissions. The three high-use cohorts have the same top five principal diagnosis categories. These five categories account for more than two-thirds of admissions. The top 1% of users is responsible for a large proportion of total resource utilisation, accounting for 13% of total costs and 21% of total bed days. Conclusions The highest users of hospital resources have a distinct profile, accounting for a large proportion of total resource utilisation for a narrow range of health conditions. The age and hospital admission profile of this group suggest both policy and service considerations for the targeting of interventions to support this high-needs group. What is known about this topic? Statistics are regularly published on the uptake and use of private health insurance in Australia but there is little detailed information on resource utilisation in specific subgroups, particularly those with the highest levels of hospitalisation. What does this paper add? This paper provides a profile of high resource utilisation among a privately insured cohort, describing demographic, hospital admission and clinical characteristics across three measures of resource utilisation. Patterns of use are detailed in this profile, for example the top 1% of users have a higher proportion of public hospital admissions as a private patient. The clinical profile of admissions was similar for the three measures of resource utilisation and there was considerable overlap in the individuals categorised in each high-use group. What are the implications for practitioners? The narrow demographic and clinical profile of the high resource utilisation groups shows a chronic disease burden that is different to the focus of current chronic disease policy measures. The high-use conditions identified in this study are less amenable to preventive measures and new strategies may be required to target this high-needs group.

Assessment of health literacy among outpatient clinics attendees at Ain Shams University Hospitals, Egypt: a cross-sectional study

OBJECTIVES

The aim of conducting this study is to measure health literacy (HL) and to investigate the factors associated with inadequate HL in a sample of outpatient clinics attendees (i.e. patients and companions) at Ain Shams University (ASU) Hospitals.

STUDY DESIGN

It is a cross-sectional study.

METHODS

The study was conducted on 805 attendees of the outpatient clinics at El-Demerdash University Hospital of ASU Hospitals. The Arabic versions of the Swedish Functional Health Literacy Scale and the European Health Literacy Survey Questionnaire-short version-were used to assess HL. The level of HL and factors influencing it were analyzed using correlation and binary logistic regression tests.

RESULTS

It was found that 81% of the participants had limited comprehensive health literacy (CHL; 34.3% inadequate and 46.7% problematic), while only 18.9% had sufficient CHL. Regarding functional health literacy (FHL), it was found that 84% had limited FHL (50.6% inadequate and 33.4% problematic), while only 16.1% had sufficient FHL. Females were more likely to have inadequate FHL. On the other hand, males, individuals with low educational levels, and attendees identified as patients as well as participants with inadequate FHL were more likely to have inadequate CHL.

CONCLUSION

The majority of our study population has limited HL. Extensive research is warranted to explore the extent of the problem on multi-institutional and national levels and to investigate more explanatory factors.

PEComa of the terminal ileum mesentery as a secondary tumour in an adult survivor of embryonal rhabdomyosarcoma

Perivascular epithelioid cell tumours (pecomas) are rare mesenchymal tumours that are characterized by perivascular epithelioid cell differentiation and immunoreactivity to myogenic and melanocytic markers. These tumours can be classified as benign, uncertain malignant potential, or malignant. Because of the rarity of pecomas, their cause and clinical prognosis remain unclear. To the best of our knowledge, no reports in the literature describe a pecoma of the terminal ileum mesentery as a secondary tumour in an adult survivor of childhood embryonal rhabdomyosarcoma, let alone any childhood cancer. Here, we present the case of a 27-year-old man with a pecoma involving the mesentery of the terminal ileum. At the age of 5, he had been treated with a combination of chemotherapy and high-dose pelvic radiation therapy for embryonal rhabdomyosarcoma, most likely arising from the posterior bladder wall. During routine follow-up 22 years after this patient's initial treatment, computed tomography imaging revealed a mass within the terminal ileum mesentery. The tumour was successfully treated with surgical resection, and pathology examination determined the mass to be a pecoma with uncertain malignant potential. This first case of a pecoma of the terminal ileum mesentery arising within a high-dose radiation therapy field as a secondary tumour in an adult survivor of childhood cancer highlights the importance of screening and surveillance in high-risk childhood cancer survivors treated with high-dose radiation therapy. Further research to build a better understanding of this remarkably rare tumour is warranted.

Theory of the deformation of aligned polyethylene

Solitons are proposed as the agents of plastic and viscoelastic deformation in aligned polyethylene. Interactions between straight, parallel molecules are mapped rigorously onto the Frenkel-Kontorova model. It is shown that these molecular interactions distribute an applied load between molecules, with a characteristic transfer length equal to the soliton width. Load transfer leads to the introduction of tensile and compressive solitons at the chain ends to mark the onset of plasticity at a well-defined yield stress, which is much less than the theoretical pull-out stress. Interaction energies between solitons and an equation of motion for solitons are derived. The equation of motion is based on Langevin dynamics and the fluctuation-dissipation theorem and it leads to the rigorous definition of an effective mass for solitons. It forms the basis of a soliton dynamics in direct analogy to dislocation dynamics. Close parallels are drawn between solitons in aligned polymers and dislocations in crystals, including the configurational force on a soliton. The origins of the strain rate and temperature dependencies of the viscoelastic behaviour are discussed in terms of the formation energy of solitons. A failure mechanism is proposed involving soliton condensation under a tensile load.

Glucose excursions and glycaemic control during Ramadan fasting in diabetic patients: insights from continuous glucose monitoring (CGM)

AIM

Ramadan fasting represents a major shift in meal timing and content for practicing Muslims. This study used continuous glucose monitoring (CGM) to assess changes in markers of glycaemic excursions during Ramadan fasting to investigate the short-term safety of this practice in different groups of patients with diabetes.

METHODS

A total of 63 subjects (56 with diabetes, seven healthy volunteers; 39 male, 24 female) had CGM performed during, before and after Ramadan fasting. Mean CGM curves were constructed for each group for these periods that were then used to calculate indicators of glucose control and excursions. Post hoc data analyses included comparisons of different medication categories (metformin/no medication, gliptin, sulphonylurea and insulin). Medication changes during Ramadan followed American Diabetes Association guidelines.

RESULT

Among patients with diabetes, there was a significant difference in mean CGM curve during Ramadan, with a slow fall during fasting hours followed by a rapid rise in glucose level after the sunset meal (iftar). The magnitude of this excursion was greatest in the insulin-treated group, followed by the sulphonylurea-treated group. Markers of control deteriorated in a small number (n=3) of patients. Overall, whether fasting or non-fasting, subjects showed no statistically significant changes in mean interstitial glucose (IG), mean amplitude of glycaemic excursion (MAGE), high and low blood glucose indices (HBGI/LBGI), and number of glucose excursions and rate of hypoglycaemia.

CONCLUSION

The main change in glycaemic control with Ramadan fasting in patients with diabetes is in the pattern of excursions. Ramadan fasting caused neither overall deterioration nor improvement in the majority of patients with good baseline glucose control.

Absence status seen in an adult patient

Absence status epilepticus (ASE) is a type of nonconvulsive status epilepticus in which continuous or recurrent generalized epileptiform discharges are associated with a varying grade of consciousness impairment. Absence status epilepticus may be obtained during progress of many epileptic syndromes, in several metabolic disturbances and related to use of several drugs. Absence status epilepticus is generally seen in childhood; rarely it can be seen in adulthood. In this paper, the case which has never diagnosed until now in spite of many absence seizures for years, applied for absence seizures to our clinic and diagnosed for juvenile absence epilepsy, has been discussed.