Severe hyponatraemia due to high output external biliary drainage corrected with bile refeeding: A case report

Hyponatraemia is an uncommon complication of external biliary drainage. We report on a 62-year-old male with hilar cholangiocarcinoma who developed refractory severe hyponatraemia despite sodium replacement during preoperative external biliary drainage. Nasojejunal bile refeeding restored sodium levels to normal.

Accumulate and consolidate the traditional vernacular timber preservation technologies through a field survey

There are remarks on diverse types of timber structures in the tropics. This paper examines several case histories in Sri Lanka, focusing on the culturally varied and ecologically diverse traditional buildings with wood used for construction. The main objective was to gather data and document the knowledge on wood preservation. Information was gathered through face-to-face interviews with 270 individuals' reference to 138 structures. A holistic analysis was performed to understand the techniques used to overcome the degradation mechanisms and state of conservation. The demographic profile of the informants was evaluated and cross-relationships on the tabulated data were analyzed by SPSS statistical software following the snow-balling sampling technique. There were three main preservation techniques identified from the open-ended questions namely, wood kept under smoke pits, wood kept under paddy field mud, and wood kept under the river banks. Preserving wood by keeping it under paddy field mud (49.62 %) was the highest recorded answer. The most obtained material matrix of preservation was plant origins (48.88 %). For generations, people have transmitted traditional and cultural practices through oral knowledge. The results conclude this knowledge places a high value on protecting construction technologies and applications while preserving biodiversity. Unfortunately, by today this technology has started extinct. The results revealed the importance of social norms and cultural perceptions as a set of valuable information that was practiced with a great history in a tropical country.

A late presentation of acute iatrogenic aortic dissection following percutaneous coronary intervention: A case report

Acute iatrogenic aortic dissection following percutaneous coronary intervention is a rare but sinister cause of post-procedure morbidity and mortality. Delayed diagnosis increases the mortality significantly. We present a case of a 52-year-old male who presented with an iatrogenic aortic dissection following percutaneous coronary intervention for an inferior ST-elevation myocardial infarction. Although the diagnosis was initially missed by conventional imaging for a period of 5 months, it was later diagnosed assisted by cardiac computed tomography. The patient underwent aortic repair with a Dacron graft and had an uneventful recovery. The case highlights the importance of early diagnosis and selection of appropriate imaging for this rare but serious iatrogenic sequel following percutaneous coronary intervention to minimize morbidity.

Superior mesenteric artery syndrome treatment strategies: A case report

Superior mesenteric artery syndrome is a rare manifestation of small bowel obstruction caused by the compressed third part of the duodenum between the superior mesenteric artery and the abdominal aorta. We present the case of an 18-year-old female and presented with symptoms of duodenal outflow obstruction. Upon investigation, her cross-sectional imaging revealed partial obstruction of the distal duodenum at the crossing of superior mesenteric artery forming an acute angle between the superior mesenteric artery and aorta. Failing initial attempts at conservative management, the patient underwent laparotomy and duodenojejunostomy with complete relief of symptoms. Superior mesenteric artery syndrome is a rare but a sinister diagnosis in patients presenting with features of duodenal outflow obstruction. Cross-sectional imaging plays an important role in diagnosis.

Perforated sigmoid colon adenocarcinoma within an irreducible inguinal hernia: A case report

Inguinal hernia is a potentially occult common surgical condition. Its association with asymptomatic adenocarcinoma is uncommon. However, malignancy-associated perforation of the large bowel within an irreducible hernia is rare. We report a case of 78-year-old male presenting with a long-standing inguinal hernia with a 2-day history of irreducibility. Examination revealed a large left-sided irreducible inguinal hernia. Patient underwent urgent inguinal herniotomy, during which multiple perforations were noted in the sigmoid colon. Patient underwent Hartmann’s procedure following bowel resection. Histology revealed a mucinous adenocarcinoma with extensive metastasis involving the resection margins. Elderly patients with long-standing inguinal hernia presenting with acute symptoms should be evaluated further for this rare but sinister diagnosis.

The incidence and trends of laryngeal malignancies in Sri Lanka from 2001 to 2019: a Joinpoint analysis of the national cancer database

INTRODUCTION

Laryngeal cancer is the ninth commonest cancer among Asian males. Global and regional epidemiological analyses have shown varying patterns in the incidence and risk factors for laryngeal cancer. Therefore, we aimed to analyse the trends in the incidence and histological patterns of laryngeal cancers for the first time in Sri Lanka.

METHODS

We used the population-based Sri Lanka cancer registry data and pooled all newly diagnosed patients with laryngeal malignancies from 2001 to 2019 (a 19-year study period). The WHO age-standardised incidence rates (ASR) were calculated using the WHO standard pollution. We used the Joinpoint regression software to calculate the estimated annual percentage change (EAPC) and analysed the trends in the incidence by different age categories and sex.

RESULTS

From 2001 to 2019, 9808 new cases of laryngeal cancers (males = 8927, 91%, mean age = 62 years) were registered. The incidence of laryngeal cancers was greatest in the 70-74-year followed by 65-69-year age groups. Around 7.9% were reported as carcinoma not otherwise specified (NOS). Squamous cell carcinoma (90.1%) was the commonest documented histology type. A rise in the WHO-ASR was noted from 1.91 per 100,000 in 2001 [95% confidence interval (95% CI): 1.69-2.12] to 3.59 per 100,000 in 2017 [(95% CI: 3.34-3.84); EAPC: 4.4 (95% CI: 3.7-5.2), p < 0.05 for trend] followed by a decrease in the incidence [2.97 per 100,000 in 2019 (95% CI: 2.74-3.2), EAPC: - 7.2 (95% CI: - 21.1-9.1, p > 0.05)]. From 2001 to 2017, the proportional increase in incidence was greater in males than females [EAPC: 4.9 (95% CI: 4.1-5.7 vs. 3.7 (95% CI: 1.7-5.6)].

CONCLUSIONS

We identified an increasing incidence of laryngeal cancer in Sri Lanka from 2001 to 2017 followed by a slight decrease. Further studies are essential to identify the aetiological factors. Development of laryngeal cancer prevention and screening programmes for high-risk populations may be considered.

A case report on secondary mesentero-axial gastric volvulus

Mesentero-axial gastric volvulus is a rare presentation to a surgical casualty unit with sinister complications and significant mortality and morbidity. Clinical assessment should be done with high suspicion in the case of an associated anatomical defect. Accurate diagnosis and timely intervention would drastically reduce morbidity and mortality. The present patient is a 63-year-old male with an acute and chronic presentation of a secondary mesentero-axial gastric volvulus with a large hiatal hernia who underwent open surgical repair with unremarkable postop recovery.

Clinical characteristics and outcomes of acute pancreatitis following spinal surgery: a systematic review

Objective

This study reviewed the current evidence on the clinical characteristics and outcome of acute pancreatitis (AP) following spinal surgery.

Methods

A systematic search was performed to identify English articles published through May 2020 in PubMed, Scopus, EMBASE, Latin American & Caribbean Health Sciences Literature, and Cochrane Library. Data on clinical characteristics, risk factors, and outcomes were analyzed.

Results

Eleven papers (including six case reports) were included, with 306 patients (incidence, 23.0%) developing AP after spinal surgery (mean age, 14.2 years). Of the studies that specified symptoms (55 patients), abdominal pain (43.6%), nausea and vomiting (32.7%), and abdominal distension (7.27%) were most prevalent. The mean duration from surgery to symptom onset was 6.15 days (range, 1–7). The most common complications of AP were glucose intolerance (25%), peritonitis (2%), pseudocyst formation (2%), and fluid collection (2%) were most prevalent. Prolonged fasting time (13.6%), intraoperative blood loss (9.09%), gastroesophageal reflux disease (9.1%), age >14 years (9.1%), and low BMI (9.1%) were most commonly associated with AP. Two deaths (0.6%) were reported.

Conclusion

AP remains an important complication of spinal surgery because of its morbidity and mortality. Avoiding major risk factors can reduce the incidence of AP following spinal surgery.

Circulating Biomarkers in the Management of Breast Cancer

Circulating biomarkers have become a promising modality in the management of many cancers. Similarly, in breast cancer, circulatory biomarkers are useful, non-invasive methods in the diagnosis, prognostication, and evaluation of response to treatment. Invasive surgical biopsies can be potentially replaced by “liquid biopsy,” which involves analysing circulatory biomarkers that may reveal features of primary and metastatic disease. Therefore, providing an insight into the cancer biology can be utilised to monitor treatment response, treatment-induced adaptation and tumour and disease progression through non-invasive means. The objective of this review is to provide an overview of the current status of the circulating biomarkers highlighting their promising impact on the management of patients with breast cancer.

Circulating Biomarkers in Predicting Pathological Response to Neoadjuvant Therapy for Colorectal Cancer

Circulating biomarkers show promise in the management of many cancers. They have become the novel non-invasive approach to complement the current strategies in colorectal cancer (CRC) management. Their ability in guiding diagnosis, evaluating response to treatment, screening and prognosis is phenomenal, especially when it comes to their minimally invasive nature. These “liquid biopsies,” which show potential for replacing invasive surgical biopsies, provide useful information on the primary and metastatic disease by providing an insight into cancer biology. Analysis of blood and body fluids for circulating tumour DNA (ctDNA), carcinoembryonic antigen (CEA), circulating tumour cells (CTC), or circulating micro RNA (miRNA) shows potential for improving CRC management. Recognizing a predictive model to assess response to neoadjuvant chemotherapy would help in better patient selection. This review was conducted with the aim of outlining the use of circulatory biomarkers in current practice and their effectiveness in the management of patients having CRC with a focus on response to neoadjuvant therapy.

Management of medullary carcinoma of the thyroid: a review

Medullary thyroid carcinoma (MTC) is an uncommon malignancy of neuroendocrine origin derived from the parafollicular C cells. Although infrequent, the interest in this cancer exceeds its incidence owing to its distinctive features and its characteristic association with other endocrine tumors. Although the majority of MTCs are sporadic, hereditary varieties occur in isolation or as a part of multiple endocrine neoplasia type 2 syndrome (MEN 2). Currently, complete surgical resection of the tumor and nodal metastases with a curative intent remains the mainstay of therapy. The role of adjuvant therapy is limited, although radiotherapy and newer targeted therapies are routinely used for metastatic disease. The lack of consensus in the available guidance regarding the most appropriate diagnostic, therapeutic and follow-up strategies has caused substantial variability in clinical practice. Therefore, this review summarizes the latest available evidence and guidelines on the management of MTC with an emphasis on diagnosis, surgical treatment and follow-up.

Quality of the patient-oriented web-based information on esophageal cancer

This study was aimed to analyze the readability and quality of patient education websites on esophageal cancer. Yahoo!, Google, and Bing search engines were searched using keywords esophageal cancer, esophageal tumor, esophageal tumor, esophageal malignancy, esophageal cancer, esophageal tumor, esophageal tumor, and esophageal malignancy. The first 50 websites resulting in each keyword search were evaluated using validated FRES, LIDA, and DISCERN scores to assess readability, usability, and reliability, and quality of information, respectively. Non-parametric tests were used for statistical analysis. A total of 108 eligible websites were included in the analysis. Thirty (27.8%) out of the 108 eligible web sites had obtained Health on the Net (HON) code certification. The median FRES score of the included websites was 48.25 out of 100 (range: 15.6-70.1). The median LIDA usability and reliability scores were 46.5 out of 54 (range: 22-54) and 39.0 out of 51 (range: 10-51), respectively. The median DISCERN score was 50.5 out of 80 (range: 23-79). A low DISCERN score (≤ 50%) was found in 50% (n = 54) of the websites. The DISCERN score was found to be significantly associated with LIDA usability, reliability, LIDA overall scores (p < 0.001), and HON code certification (p = 0.01). The quality of the websites providing patient-centered information on the Internet ranged between moderate and low with regards to readability, usability, and reliability scores. Better informed decisions on treatment may be facilitated with the access to good quality information online. Therefore, strategies need to be implemented to regulate and standardize websites to provide good quality, accurate information.

Spontaneous omental infarction: A rare case of acute abdomen

Omental infarction is a rare but a sinister cause of acute abdomen. Preoperative diagnosis is challenging due to its rare nature. It poses nonspecific abdominal signs that can be easily mistaken with other more common intra-abdominal pathologies. We report a case of a 37-year-old male patient presented with right lower quadrant abdominal pain with an elevation of inflammatory markers. His cross-sectional imaging did not a reveal specific diagnosis; therefore, a diagnostic laparoscopy was performed which revealed a non-inflamed appendix and an inflammatory mass formed by the ischemic omentum attached to the ascending colon. Diagnostic laparoscopy and subsequent laparotomy revealed spontaneous omental infarction. The histology of the resected specimen was in keeping with the omental necrosis. This case reflects the importance of considering omental infarction in patients presenting with abdominal pain and raised inflammatory markers. He made an uneventful recovery following surgery.

Hepatic abscess following foreign body perforation of the colon: A case report

Liver abscess following foreign body perforation of the gastrointestinal tract is uncommon. Preoperative diagnosis is challenging as the ingestion of foreign body most often goes unnoticed with non-specific presentation. We report a case of a 68-year-old male patient presenting with abdominal pain and anorexia. His investigations and cross-sectional imaging revealed a liver abscess. A colonoscopy performed to find an etiology revealed an incidental finding of a colonic perforation from an impacted denture, which was successfully removed endoscopically. Therefore, pyogenic liver abscesses remain a therapeutic challenge despite advances in imaging and therapy. The case reflects the importance of investigating for etiology of unexplained liver abscesses. The patient made an uneventful recovery following abscess drainage by image-guided pigtail stent insertion. The colonic perforation was managed conservatively.

TP7.2.13 Clinical characteristics and outcomes of acute pancreatitis following spinal surgery: a systematic review

Aims

Acute pancreatitis (AP) is a rare post-operative complication of spinal surgery. This study reviews the current evidence on clinical characteristics and outcome of AP following spinal surgery.

Methods

A systematic search was performed on English articles published up to May 2020 using PubMed, Scopus, EMBASE, LILACS and Cochrane databases. Data on clinical characteristics, risk factors and outcomes were extracted and analysed.

Results

Eleven papers meeting the inclusion criteria which included a total of 306 (23.02%) patients developing AP out of 1,329 patients undergoing spinal surgery were included (mean age= 14.17 years). Of the 11 studies that specified symptoms (n = 55 patients) abdominal pain (43.6%), nausea and vomiting (32.7%) and abdominal distension (7.27%) were the commonest symptoms. The mean duration from surgery to onset of symptoms was 6.15 days (range:1-7). Almost all (n = 10, 90.9%) were treated non-operatively. Of the complications mentioned (n = 306 patients), glucose intolerance (25%), peritonitis (2%), pseudocyst (2%), and fluid collection (2%) were the commonest. Of the studies mentioning associated factors (n = 22 patients) prolonged fasting time (13.6%), intra-operative blood loss (9.09%), gastroesophageal reflux disease (9.09%), age &gt;14 years (9.09 %), low BMI (9.09 %), and anterior/combined approach (9.09%) were the commonest associated factors for AP. A total of 2 deaths (n = 2/306, 0.65%) were reported.

Conclusion

Although uncommon, AP remains an important post-operative complication of spinal surgery due to its associated morbidity and mortality. Avoiding major risk factors including prolong fasting and minimizing intra-operative blood loss may help reduce the incidence of AP in patients undergoing spinal surgery.

Post treatment quality of life among Sri Lankan women with breast cancer

BACKGROUND

Breast cancer and its treatment imposes a significant effect in the quality of life (QOL) of women. Being a developing country with contrasting social and cultural norms to the West, Sri Lankan women may have a different experience on QOL following surgical treatment of breast cancer. This study was conducted to evaluate post-treatment QOL in breast cancer patients and to determine its association with the type of surgery.

METHODS

A cross sectional study was carried out. Fifty four women with non-metastatic breast cancer who underwent surgery for breast cancer at the Professorial Surgical Unit, Colombo during 2015-2018 and completed a minimum of one year follow up after surgery were invited to participate. Fifty-four women who responded were assessed using the validated EORTC QLQ-C30 and QLQ-BR23 questionnaires. Non-parametric tests were used for statistical analyses.

RESULTS

The mean age was 59 years (range 36-81). A majority (61%, n = 35) underwent mastectomy and the rest (n = 19, 45%) breast conservation surgery (BCS). The mean QLQ-C30 score was 68.8 (range 8.3-100) and the mean scores for physical function, role function, emotional function, cognitive function, and social function were 71.4, 81.5, 77.0, 80.2, and 86.4, respectively. The mean scores for body image, sexual functioning, sexual enjoyment, future perspective, systemic therapy, breast symptoms, arm symptoms, and hair loss assessed by the QLQ-BR23 were 76.4, 18.3, 33.3, 73.6, 30.5, 16.2, 23.4 and 32.7, respectively. No significant differences (P > 0.05) were noted in global health status, physical function, role function, emotional function, cognitive function and social function between BCS and mastectomy. QLQ-BR23 body image, sexual functioning, sexual enjoyment and future perspective also did not differ significantly (p > 0.05) between the two groups.

CONCLUSIONS

Sexual functioning and enjoyment, breast and arm symptoms and hair loss contributed to poor QOL while the impact on global health status including physical, social and emotional functions were minimal. Type of surgery did not appear to be associated with QOL. Future studies with a larger sample sizes will be helpful to further study these factors.

Quality of online information for the general public on COVID-19

OBJECTIVES

To analyse the quality of information included in websites aimed at the public on COVID-19.

METHODS

Yahoo!, Google and Bing search engines were browsed using selected keywords on COVID-19. The first 100 websites from each search engine for each keyword were evaluated. Validated tools were used to assess readability [Flesch Reading Ease Score (FRES)], usability and reliability (LIDA tool) and quality (DISCERN instrument). Non-parametric tests were used for statistical analyses.

RESULTS

Eighty-four eligible sites were analysed. The median FRES score was 54.2 (range: 23.2-73.5). The median LIDA usability and reliability scores were 46 (range: 18-54) and 37(range:14-51), respectively. A low (<50 %) overall LIDA score was recorded for 30.9 % (n = 26) of the websites. The median DISCERN score was 49.5 (range: 21-77). The DISCERN score of ≤50 % was found in 45 (53.6 %) websites. The DISCERN score was significantly associated with LIDA usability and reliability scores (p < 0.001) and the FRES score (p = 0.024).

CONCLUSION

The majority of websites on COVID-19 for the public had moderate to low scores with regards to readability, usability, reliability and quality.

PRACTICE IMPLICATIONS

Prompt strategies should be implemented to standardize online health information on COVID-19 during this pandemic to ensure the general public has access to good quality reliable information.

CTCF genetic alterations in endometrial carcinoma are pro-tumorigenic

CTCF is a haploinsufficient tumour suppressor gene with diverse normal functions in genome structure and gene regulation. However the mechanism by which CTCF haploinsufficiency contributes to cancer development is not well understood. CTCF is frequently mutated in endometrial cancer. Here we show that most CTCF mutations effectively result in CTCF haploinsufficiency through nonsense-mediated decay of mutant transcripts, or loss-of-function missense mutation. Conversely, we identified a recurrent CTCF mutation K365T, which alters a DNA binding residue, and acts as a gain-of-function mutation enhancing cell survival. CTCF genetic deletion occurs predominantly in poor prognosis serous subtype tumours, and this genetic deletion is associated with poor overall survival. In addition, we have shown that CTCF haploinsufficiency also occurs in poor prognosis endometrial clear cell carcinomas and has some association with endometrial cancer relapse and metastasis. Using shRNA targeting CTCF to recapitulate CTCF haploinsufficiency, we have identified a novel role for CTCF in the regulation of cellular polarity of endometrial glandular epithelium. Overall, we have identified two novel pro-tumorigenic roles (promoting cell survival and altering cell polarity) for genetic alterations of CTCF in endometrial cancer.

Rapid rule out of myocardial infarction with the use of copeptin as a biomarker for cardiac injury

Copeptin is a non-specific marker of an endogenous stress response. A dual biomarker marker approach involving the simultaneous use of troponin and copeptin assays may assist early exclusion of acute coronary syndrome in Australian emergency departments. The utility and limitations of this approach are discussed.

Non-invasive investigation of chronic stable angina--a practical overview for medical practitioners

How does one decide on the best non-invasive test to investigate stable coronary ischaemia? This is a very common question faced by many medical practitioners. Chronic stable angina is a common presentation encountered in general practitice. Upon clinical assessment and risk stratification the patient needs to be investigated further to confirm the diagnosis. The first investigational modality involves a non-invasive test. It is important that practitioners possess a practical knowledge of the array of different tests that are available so that the best suited one for each patient can be chosen. This article aims to compare the efficacy and accuracy and the practical utility of the different non-invasive tests for coronary ischaemia and aid the practitioner in making sound decisions in this regard.

Suboptimal consideration and management of potential familial hypercholesterolaemia in patients with suspected premature coronary artery disease

INTRODUCTION

Familial hypercholesterolaemia (FH) is caused by an autosomal dominant mutation of the low density lipoprotein (LDL) receptor gene, resulting in high levels of LDL cholesterol and premature coronary artery disease (P-CAD). Studies have shown low detection rates of FH in patients admitted with P-CAD and suboptimal therapy at discharge.

METHODS

Males aged ≤ 55 years and females aged ≤ 60 years who were admitted with P-CAD to the Gold Coast Hospital during a 12-month period were included in the study. The demographics, cardiovascular risk factors, examination findings, admission and discharge cardiac medications and provisional diagnoses were recorded. Diagnosis of FH was made according to internationally accepted criteria.

RESULTS

210 patients were included in the study; 60% were male and 40% female (mean age 48 and 50 years, respectively). Only 96 (46%) patients' fasting lipid levels were documented (LDL-C 2.75 ± 1.0 mmol/L), and FH was considered in three (1%) cases. According to the Dutch Lipid Network criteria, three (1%) patients had probable FH, 50 (24%) had possible FH and 60 (29%) had unlikely FH. Of the 53 patients with probable or possible FH, 12 (23%) were discharged without statin therapy and 13 (25%) on the maximum recommended statin dose.

CONCLUSION

Our study has found inadequate documentation and screening for FH and suboptimal therapy in patients admitted with P-CAD. We propose a simple screening tool that can be applied to all patients admitted with suspected P-CAD in order to improve the detection rate of FH and its management.