Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study

BACKGROUND

Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking.

METHOD

This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT.

RESULTS

A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (- 40.5%). Patients were younger (median age, 63 [45-77] vs. 61[44-74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158-480] vs. 263[180-674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025).

CONCLUSION

We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

Lethal abdominal compartment syndrome after extracorporeal cardiopulmonary resuscitation in a patient with out-of-hospital cardiac arrest: a case report

BACKGROUND

Clinical attempts of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) have increased in recent years; however, it also has life-threatening complications. Massive fluid and transfusion resuscitation, shock status, or low cardiac output status during ECPR may lead to ascites and interstitial edema, resulting in secondary abdominal compartment syndrome (ACS).

CASE PRESENTATION

A 43-year-old male patient was admitted to the emergency department due to cardiac arrest. Due to refractory ventricular fibrillation, ECPR was initiated. Approximately, 3 h after extracorporeal membrane oxygenation support, abdominal distension and rigidity developed. Therefore, ACS was suspected. Decompression laparotomy was required to relieve elevated intra-abdominal pressure.

CONCLUSIONS

We report a case of a patient with OHCA who developed lethal ACS after ECPR. Despite this, the patient was able to recover from several major crises. Regardless of how lethal the patient is, if compartment syndrome develops in any part of the body, we should aggressively consider surgical decompression.

Comparison of incidence and outcome between occupational and non-occupational motorcycle injuries in Korea: A 7-years observational study

Motorcycles are widely used in various workplaces. Motorcycle use for occupational purposes continues to increase owing to growing e-commerce. Here, we aimed to highlight the importance of occupational motorcycle injuries by analyzing their epidemiologic characteristics and outcomes. We analyzed retrospective data from the Emergency Department-based Injury In-depth Surveillance program from 2012 to 2018. Motor vehicle injuries involving riders aged ≥16 years were included. Patients were divided into occupational motorcycle and non-occupational motorcycle injury groups based on whether or not the injury occurred during work time. General characteristics, injury details, and clinical outcomes such as injury severity and in-hospital mortality were analyzed. Of the 37,194 study patients, 24.2% (8,991) experienced occupational motorcycle injuries. The number of injuries in both groups increased yearly, as did the proportion of occupational injuries among total injuries. In both the groups, patients aged 20-29 years had the highest proportion of injuries. Regarding collision pattern and injury counterpart, side-to-side collisions and injuries involving small four-wheel vehicles were the most frequent. Alcohol intake was significantly lower, while helmet usage was higher in the occupational motorcycle injury group. Moreover, patients with occupational motorcycle injuries had lower injury severity, admission rate, and in-hospital mortality. On multivariable logistic regression analysis, increasing age, time of the injury, alcohol intake, not using a helmet, and collision with a human or animal were associated with higher odds of severe injury. Patients with occupational injuries had higher helmet usage, lower injury severity, lower mortality, and lower admission rate than did patients with non-occupational injuries. Injury severity was associated with the time of injury, collision with other living objects, alcohol consumption, and helmet usage.

Laparoscopic repair of colonoscopy-induced adult Bochdalek hernia: Case report

Introduction

Bochdalek hernias are congenital diaphragmatic malformations caused by a failure to close the pleuroperitoneal cavity in the posterolateral area. Bochdalek hernias are very rare in adult, with congenital diaphragmatic defects being even rarer.

Presentation of case

A 35-year-old man presented to our emergency room with epigastric pain after colonoscopy. The patient had no history of trauma. Plain chest X-ray revealed bowel gas patterns and haziness in the left lower lung field. Abdominal computed tomography revealed a left diaphragmatic defect in the posterolateral area, with herniation of the omentum and colon. The patient successfully underwent laparoscopic herniorrhaphy.

Discussion

The diaphragm comprises fibrous tissue and muscle. Therefore, direct damage by a colonoscope is almost impossible. Normal chest X-ray as a part of a health screening was performed 9 days prior to admission, and the size of the diaphragmatic defect could be covered by the spleen; therefore, the patient was considered hernia-free for over 30 years.

Conclusion

We report a rare case of delayed Bochdalek hernia that may have been induced by the difficult insertion of a colonoscopy. Although rare, this disorder should be recognized, examined and treated appropriately to avoid complications.

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Bochdalek hernia found in adult is very rare.

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The small size of the diaphragm defect appears to have been blocked by the spleen.

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Herniation of colon was induced by the difficult insertion of a colonoscopy.

715 Implementation of Enhanced Recovery After Surgery (ERAS) in Total Laryngectomies

Aim

The Enhanced Recovery After Surgery (ERAS) protocol for total laryngectomies was first implemented in our tertiary head and neck centre from November 2019. It includes pre-operative carbohydrate loading and an early swallow test which facilitates recommencement of oral intake to improve outcomes. Protocol adherence rate and patient outcomes were measured to determine the effectiveness and benefits of ERAS in laryngectomy patients.

Method

22 total laryngectomy patients from November 2019 to September 2021 were enrolled onto the ERAS protocol, 18 primary and 3 salvage cases. An analysis of the respective patient cohorts was performed to determine adherence to the ERAS protocol and outcomes such as complications and length of inpatient stay were measured.

Results

19 patients (86%) received pre-operative carbohydrate loading successfully, while 3 patients were contraindicated due to background of diabetes. Early swallow test was performed in 59% of patients. Potential reasons for delay were stoma dehiscence or clinical suspicion of neo-pharyngeal leak. 59% of primary cases were deemed medically fit for discharge within the target timeframe of 12–14 days whereas no target was set for salvage cases due to expected poor healing. Main complication in primary cases was neo-pharyngeal leak followed by stoma dehiscence with 28% and 11% respectively.

Conclusion

Limitations of our study include small sample size due to the COVID-19 pandemic. Despite its infancy, the ERAS protocol has achieved good outcomes in early recommencement of oral intake post-laryngectomy and encouraging early safe discharge from hospital. Future plans include establishment of Prehab Clinic and application of ERAS to neck dissection patients.

Risk factors of trauma-induced thrombotic microangiopathy-like syndrome: A retrospective analysis

Patients with trauma may develop thrombocytopenia. We encountered cases wherein patients experienced symptoms resembling thrombotic microangiopathies (TMAs) following severe trauma. As the condition of these patients did not meet the diagnostic criteria of thrombotic thrombocytopenic purpura and there was no mention of trauma among the several causes of TMAs, it was termed as "trauma-induced thrombotic microangiopathy-like syndrome" (t-TMAS). In this study, we aimed to analyze the risk factors that may affect the incidence of t-TMAS in patients with severe trauma. This retrospective study was conducted in the trauma intensive care unit at the Kyungpook National University Hospital between January 2018 and December 2019. The medical records of 1164 of the 1392 enrolled participants were analyzed. To assess the risk factors of t-TMAS, we analyzed age, sex, mechanism of trauma, abbreviated injury scale (AIS) score, injury severity score (ISS), hematological examination, and red blood cell volume transfused in 24 hours. Among the 1164 patients, 20 (1.7%) were diagnosed with t-TMAS. The univariate analysis revealed higher age, ISS, and myoglobin, lactate, creatine kinase-myocardial band (on admission), creatine phosphokinase, lactate dehydrogenase (LDH), and lactate (day 2) levels in the t-TMAS group than in the non-t-TMAS group. The red blood cell volume transfused in 24 hours was higher in the t-TMAS group than in the non-t-TMAS group. t-TMAS was more common in patients with injuries in the chest, abdomen, and pelvis (AIS score ≥3) than in those with head injuries (AIS score ≥3) alone. The higher the sum of AIS scores of the chest, abdomen, and pelvis injuries, the higher the incidence of t-TMAS. Multivariate analysis revealed age, ISS, and LDH level (day 2) to be independent predictors of t-TMAS. Trauma surgeons should consider the possibility of t-TMAS if thrombocytopenia persists without any evidence of bleeding, particularly among older patients with multiple severe torso injuries who have high LDH levels on day 2. Early diagnosis and treatment of t-TMAS could improve patients' prognosis.

Traumatic iliac vein rupture managed using a bare-metal stent

Iliac vein rupture resulting from blunt trauma is rare but can be fatal and challenging to diagnose despite thorough clinical investigation and image workup. Here, we present a case of traumatic iliac vein rupture managed by emergent endovascular repair using a bare-metal stent. Low pressure traumatic venous rupture is different from arterial rupture, and a bare-metal stent can be a sufficient tool to control bleeding.

Complete Transection of the Cystic Duct and Artery after Blunt Trauma: A Case Report

Extrahepatic biliary tract and gallbladder injuries following blunt abdominal trauma are uncommon. Traumatic cystic duct transection is even rarer, which has frequently caused missed diagnosis and delayed treatment. An 18-year-old female patient with no past medical history was transferred to the Trauma Center of Kyungpook National University Hospital after falling from a height of approximately 20 meters. She became hemodynamically stable after initial resuscitation, and initial contrast-enhanced abdominal computed tomography (CT) showed right kidney traumatic infarction and multiple intrahepatic contusions with minimal fluid collection but no extravasation of the contrast. She was admitted to the intensive care unit. On the second day of hospitalization, her abdomen became distended, with follow-up CT showing a large collection of intra-abdominal fluid. Laparoscopic exploration was then performed, which revealed devascularization of the gallbladder with complete transection of the cystic duct and artery. Laparoscopic cholecystectomy was performed, as well as primary closure of the cystic duct orifice on the common bile duct using a 4-0 Prolene suture. After surgery, no clinical evidence of biliary leakage or common bile duct stricture was observed.

Risk factors and outcome of community onset Pseudomonas aeruginosa bacteraemia in two Malaysian district specialist hospitals

INTRODUCTION

Despite the ever-growing number of community onset (CO) Pseudomonas aeruginosa (P. aeruginosa) bacteraemia, there is a dearth of district hospital-based research examining this significant infection, which is associated with high mortality. The objectives of this study were as following: (1) to determine the risk factors of CO P. aeruginosa bacteraemia, (2) to compare the 30-day mortality rate between P. aeruginosa and Escherichia coli bacteraemia and (3) to identify the predictors of 30-day mortality for CO gram negative bacteraemia.

METHODS

This is a retrospective case control study in Hospital Seri Manjung and Hospital Teluk Intan, Perak, Malaysia. P. aeruginosa bacteraemia cases that occurred between 1st January 2015 to 31st December 2019 were included, whilst E. coli bacteraemia cases that occurred within the same period were recruited successively until 1:2 case control ratio was achieved. Subjects below 12-year-old and those with polymicrobial bacteraemia were excluded. Demographic, clinical and treatment data were collected using pre-tested data collection forms by trained investigators.

RESULTS

A total of 61 patients with P. aeruginosa bacteraemia and 122 patients with E. coli bacteraemia were included. Recent admission in the earlier three months, regular haemodialysis, immunosuppressive therapy in the past 30 days, chronic wound/pressure sore at presentation and indwelling urinary catheter at presentation were identified as independent predictors of CO pseudomonal bacteraemia. Whilst older age was identified as a negative predictor of CO Pseudomonal bacteraemia (all p<0.05). The 30-day mortality rate was 34.4% in subjects with P. aeruginosa bacteraemia and 27.0% in those with E. coli bacteraemia (p=0.302). Predictors of 30-day mortality for community onset gram negative bacteraemia were as follow: older age, underlying solid tumours, neutropaenia at presentation, in-patient mechanical ventilation, and inpatient nasogastric tube insertion. Unexpectedly, receipt of inappropriate empirical antibiotics which was switched later (delayed and non-delayed switching) was identified as the negative predictors of mortality (all p<0.05).

CONCLUSION

It is prudent to restrict the usage of empirical anti-pseudomonal antibiotics among individuals at risk as liberal usage of broad-spectrum antibiotics engenders emergence of drug resistant organism, particularly in district setting where community onset pseudomonal bacteraemia remains scarce. Subjects with elevated risk of mortality should receive early escalation of care as per sepsis management guidelines.

PesTrapp mobile app: A trap setting application for real-time entomological field and laboratory study

Diseases such as malaria, dengue, Zika and chikungunya remain endemic in many countries. Setting and deploying traps to capture the host/vector species are fundamental to understand their density and distributions. Human effort to manage the trap data accurately and timely is an exhaustive endeavour when the study area expands and period prolongs. One stop mobile app to manage and monitor the process of targeted species trapping, from field to laboratory level is still scarce. Toward this end, we developed a new mobile app named "PesTrapp" to acquire the vector density index based on the mobile updates of ovitraps and species information in field and laboratory. This study aimed to highlight the mobile app's development and design, elucidate the practical user experiences of using the app and evaluate the preliminary user assessment of the mobile app. The mobile app was developed using mobile framework and database. User evaluation of the mobile app was based on the adjusted Mobile App Rating Scale and Standardized User Experience Percentile Rank Questionnaire. The process flows of system design and detailed screen layouts were described. The user experiences with and without the app in a project to study Aedes surveillance in six study sites in Selangor, Malaysia were elucidated. The overall mean user evaluation score of the mobile app was 4.0 out of 5 (SD=0.6), reflects its acceptability of the users. The PesTrapp, a one-stop solution, is anticipated to improve the entomological surveillance work processes. This new mobile app can contribute as a tool in the vector control countermeasure strategies.

Prevalence and clinical impact of vitamin D deficiency in critically ill Korean patients with traumatic injuries: a single-center, prospective, observational study

Background

This study investigated the prevalence and impact of 25-hydroxyvitamin D (25(OH) vitamin D) deficiency in critically ill Korean patients with traumatic injuries.

Methods

This prospective observational cohort study assessed the 25(OH) vitamin D status of consecutive trauma patients admitted to the trauma intensive care unit (TICU) of Kyungpook National University Hospital between January and December 2018. We analyzed the prevalence of 25(OH) vitamin D deficiency and its impact on clinical outcomes.

Results

There were no significant differences in the duration of mechanical ventilation (MV), lengths of TICU and hospital stays, and rates of nosocomial infection and mortality between patients with 25(OH) vitamin D <20 ng/ml and those with 25(OH) vitamin D ≥20 ng/ml within 24 hours of TICU admission. The duration of MV and lengths of TICU and hospital stays were shorter and the rate of nosocomial infection was lower in patients with 25(OH) vitamin D level ≥20 ng/ml on day 7 of hospitalization. The duration of MV, lengths of TICU and hospital stays, and nosocomial infection rate were significantly lower in patients with increased concentrations compared with those with decreased concentrations on day 7 of hospitalization, but the mortality rate did not differ significantly.

Conclusions

The 25(OH) vitamin D level measured within 24 hours after TICU admission was unrelated to clinical outcomes in critically ill patients with traumatic injuries. However, patients with increased 25(OH) vitamin D level after 7 days of hospitalization had better clinical outcomes than those with decreased levels.

Single center experience of inferior vena cava filter retrieval in trauma patients: contrast-enhanced CT-based retrieval within hospital stay

PURPOSE

To assess the safety and retrieval rate of a predischarge inferior vena cava (IVC) filter retrieval strategy based on contrast computed tomography (CT).

METHODS

IVC filter insertion for trauma patients from 2010 to 2018 were reviewed. An active filter retrieval strategy was established in March 2017. The strategy sought early evaluation of venous thromboembolism (VTE) status and filter retrieval before a patient's discharge. The possibility of early IVC filter retrieval was evaluated by a multidisciplinary team based on pre-filter retrieval VTE-CT findings. Overall VTE-CT findings, retrieval rate, indwelling time, and recurrence of venous thromboembolic events were compared before and after the filter retrieval strategy setup.

RESULTS

177 IVC filters were inserted in trauma patients. All patients underwent pre-filter retrieval VTE-CT. VTE-CT findings were as follows: completely resolved VTE, n = 108 (61%); partially improved, n = 58 (33%); no change, n = 8 (5%); aggravated, n = 3 (2%). The overall retrieval rate was 84% with a mean indwelling time of 32 days. In subgroup analyses, 95 (53%) had filter retrieval with the before strategy (BS) setup and 82 (47%) with the after strategy (AS) setup. The retrieval rate was significantly higher in the AS group [81/82 (99%) vs. 68/95 (72%), (p < 0.001)]. No patients had recurrent VTE during the follow-up period.

CONCLUSIONS

The active strategy of VTE-CT-based filter retrieval during the hospital stay markedly improved the filter retrieval rate from 72% to 99% without evidence of recurrence of VTE. Hazards of low retrieval rate versus CT-related radiation exposure should be studied in the future.

Current status of initial antibiotic therapy and analysis of infections in patients with solitary abdominal trauma: a multicenter trial in Korea

Purpose

Proper use of antibiotics during emergency abdominal surgery is essential in reducing the incidence of surgical site infection. However, no studies have investigated the type of antibiotics and duration of therapy in individuals with abdominal trauma in Korea. We aimed to investigate the status of initial antibiotic therapy in patients with solitary abdominal trauma.

Methods

From January 2015 to December 2015, we retrospectively analyzed the medical records of patients with solitary abdominal trauma from 17 institutions including regional trauma centers in South Korea. Both blunt and penetrating abdominal injuries were included. Time from arrival to initial antibiotic therapy, rate of antibiotic use upon injury mechanism, injured organ, type, and duration of antibiotic use, and postoperative infection were investigated.

Results

Data of the 311 patients were collected. The use of antibiotic was initiated in 96.4% of patients with penetrating injury and 79.7% with blunt injury. Initial antibiotics therapy was provided to 78.2% of patients with solid organ injury and 97.5% with hollow viscus injury. The mean day of using antibiotics was 6 days in solid organ injuries, 6.2 days in hollow viscus. Infection within 2 weeks of admission occurred in 36 cases. Infection was related to injury severity (Abbreviated Injury Scale of >3), hollow viscus injury, operation, open abdomen, colon perforation, and RBC transfusion. There was no infection in cases with laparoscopic operation. Duration of antibiotics did not affect the infection rate.

Conclusion

Antibiotics are used extensively (84.2%) and for long duration (6.2 days) in patients with abdominal injury in Korea.

Conservative treatment of acute traumatic left renal vein occlusion: Importance of left gonadal vein, case report

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A blunt renal injury commonly leads to thrombotic partial renal infarct, but only rarely to an isolated acute renal vein occlusion.

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The surgical approach of thrombosed renal vein for preserving the kidney is likely to be an extensive operation, otherwise nephrectomy.

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Collateral pathway of the left renal venous drainage may be well known to urologists, but may be unfamiliar to trauma surgeons.

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If the gonadal vein is patent, left renal vein occlusion could be treated conservatively.

Introduction

Isolated acute traumatic renal vein occlusion is rare. As both kidneys have limited capsular and peripelvic vein collaterals, acute renal vein occlusion could lead to renal infarction. However, the left renal vein has potential collateral pathways through the gonadal vein.

Presentation of case

A 56-year-old woman was transferred to our trauma center after a pedestrian accident. Computed Tomography (CT) with contrast enhancement showed that no delineation of left renal vein with adjacent retroperitoneal hematoma around renal vessels, but left renal venous flow was being drained through left gonadal vein, therefore, left kidney was not congested. Her serum creatinine concentration was normal. We elected to treat her left renal vein occlusion conservatively because of the collateral pathway into the gonadal vein.

Discussion

Collateral pathway of the left renal venous drainage may be well known to urologists or vascular surgeons, but may be unfamiliar to trauma surgeons. Therefore, trauma surgeon’s attempts for revascularization of thrombosed left renal vein may lead to massive bleeding or nephrectomy.

Conclusion

Acute left renal vein occlusion close to the inferior vena cava can result in temporary venous hypertension and congestion followed by complete or nearly complete return of function as collateral veins enlarge. If the gonadal vein is patent, left renal vein occlusion could be treated conservatively.

Changing pattern of pheochromocytoma and paraganglioma in a stable UK population

Context

Pheochromocytomas and paragangliomas (PCC/PGLs) are diagnosed variously with increasing incidence and changing clinical and pathology pattern.

Objective

The aim was to further characterize PCC/PGLs in a stable population.

Methods

A retrospective, single institution study analysed adrenalectomies for PCC/PGLs between January 2010 - January 2019. Demographics, symptoms, blood pressure, preoperative hormones, imaging, histology, hospital stay, complications and three subgroups [based on the modality of diagnosis - incidentaloma group (IG), genetic group (GG) and symptomatic group (SG)] were noted.

Results

86 patients included IG 51 (59.3%), GG 10 (11.62%) and SG 25 patients (29.06%). Incidence was 5.30 cases/1 million population. 33.34% of the IG had a delayed diagnosis with a mean interval of 22.95 months (4-120 months). Females presented more often with paroxysmal symptoms (PS) (p=0.011). Patients with PS and classic symptoms were younger (p=0.0087, p=0.0004) and those with PS required more inotropes postoperatively (p=0.014). SG had higher preoperative hormone levels (p=0.0048), larger tumors (p=0.0169) and more likely females. GG are younger compared with those from the IG (p=0.0001) or SG (p= 0.178).

Conclusion

Majority of patients had an incidental and delayed diagnosis. If symptomatic, patients are more likely to be young females with higher hormone levels and larger tumors.

Prevalence and characteristics of e-cigarette users among Malaysian current and ex-smokers

INTRODUCTION

Electronic cigarettes (ECs) are new devices that have been accepted widely by both smokers and non-smokers. However, the evidence on EC used in Malaysia is scarce. The objective of this study was to determine the prevalence of EC use and the socio-demographic and smoking characteristics associated with current EC use among Malaysian current and ex-smokers.

METHODS

This was a sub-analysis of data from a cross-sectional, national-population- based EC study conducted from May to June in 2016 in Malaysia. A detailed description of the sampling methods can be found in the National E-cigarette Survey (NECS) 2016 report. Briefly, data were obtained from 1396 individuals who had ever been smokers, i.e., 957 (68.6%) current smokers and 439 (31.4%) ex-smokers.

RESULTS

Current EC use was found predominantly among current smokers (8.0%) as compared with ex-smokers (4.3%). Among current smokers, the main reasons given for smoking ECs were wanting to try it (44.7%), followed by intention to quit tobacco smoking (15.8%) and to reduce tobacco smoking (10.5%). Using multiple logistic regression analysis, we found that among current smokers, current EC users were more likely to be younger, i.e., 18-44 years (aOR= 4.83, 95% CI= 1.97-11.86, p=0.001), urban residents (aOR= 1.89, 95% CI= 1.15-3.11, p=0.012), single/ divorced/ widowed (aOR= 2.11, 95% CI= 1.24-3.61, p=0.006) and students (aOR= 2.25, 95% CI= 1.01-5.01, p=0.048). Among exsmokers, only younger respondents (18-44 years old) was reported as being more likely to be current EC users (aOR= 3.81, 95% CI= 1.14-12.76, p=0.030).

CONCLUSION

This study showed that currently using and ever having used ECs were more prevalent among current smokers. The reasons given for initiating EC use among current smokers were mainly wanting to try it, followed by intention to quit and to reduce tobacco smoking. Current EC use appears to be common among current smokers who are younger, urban residents, single/divorced/widowed and students. Therefore, EC cessation intervention strategies and policies should target these high-prevalence groups.

Traumatic severe tricuspid regurgitation diagnosis after the progression of right ventricle function deterioration

Traumatic tricuspid regurgitation is a rare complication of blunt cardiac injury and frequently misdiagnosed during the initial assessment. Unfortunately, it may be diagnosed after deterioration of right ventricle function, which may be fatal to the patient. Here, we report a case of a patient with blunt chest injury complicated by a diagnosis of traumatic severe tricuspid regurgitation after deterioration of the right ventricle function even after the patient was subjected to serum cardiac enzyme normalization. The patient was a driver and admitted to the hospital owing to multiple traumatic injuries. Echocardiography was performed suspicious of blunt cardiac injury, which revealed no abnormal findings. Initial cardiac enzyme levels were high, but after serial follow-up, the levels improved. However, on day 4 of hospitalization, hemodynamic deterioration occurred owing to severe tricuspid regurgitation and delayed right ventricle dysfunction. Immediate tricuspid valve replacement was performed, however, the patient had a pronged recovery period. We believe that it is important to take into account the nature of the accident and the presentation of clinical signs and symptoms and not be blinded by laboratory test results alone; it is also important to consider performing repeated serial echocardiographic examinations for blunt cardiac injury patients.

Mid-term outcomes of endovascular repair for traumatic thoracic aortic injury: a single-center experience

PURPOSE

Thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury (TTAI) reports short-term benefits. However, long-term durability and the need of reintervention remain unclear. Here, we determined mid-term outcome of TEVAR for TTAI and investigated the influence of the length of proximal landing zone on aorta.

METHODS

Between October 2009 and February 2018, 69 patients diagnosed TTAI and 42 included patients underwent TEVAR. Patients were divided into two groups by the length of proximal landing zone; ≤ 20 mm and > 20 mm. The primary endpoint was success and survival rate, and the secondary endpoint was the increase of aorta size and the need of reintervention.

RESULTS

The mean follow-up period was 47.9 ± 29.6 months and 100% success rate. No endoleaks or additional reinterventions during the follow-up period. The cumulative survival of all-cause death was 90.5 ± 2.3%, 85.7 ± 4.1% and 61.7 ± 8.4% at 1, 5 and 7 years, respectively. There was no statistically significant difference in the increase of aorta size due to the length of the proximal landing zone (p = 0.65).

CONCLUSION

In selective TTAI patients for TEVAR, the length of proximal landing zone did not considerably influence the aorta size or needed further reintervention.

Hybrid Approach of Ruptured Type B Aortic Dissection with an Aberrant Subclavian Artery in a Single Patient with Turner Syndrome: A Case Report

Turner syndrome, also described as 45, X, may present with most serious cardiovascular anomalies including risk of aortic dissection and rupture. In emergency situation, management for aortic dissection with complicated anatomy accompanying vascular anomaly is challenging. Here, we report a rare case of ruptured type B aortic dissection with aberrant subclavian artery and partial anomalous pulmonary venous connection in a Turner syndrome. Through right carotid-subclavian artery bypass and thoracic endovascular aortic repair, successful hybrid endovascular management correlated with a favorable result in this emergency situation.

ABO incompatible living donor liver transplantation using dual grafts and pure laparoscopic donor right hepatectomy: A case report

RATIONALE

Because of the shortage of deceased donors, living donor liver transplantation (LDLT) has become the main procedure to treat patients with end-stage liver disease in Asian countries. However, many potential donors are excluded because of donor safety and graft volume issues. In addition, large abdominal wounds after open surgery for hepatectomy could be a reason for hesitating to agree to liver donation, particularly when attempting to recruit young female donors.

PATIENT CONCERNS

On volumetric computed tomography (CT) examination, remnant liver volume was too small to guarantee the safety of the male donor, and the right hemiliver volume of the female donor was not sufficient to meet the recipient's metabolic demand. The young female donor also worried about a large abdominal wound following open surgery.

INTERVENTIONS

We performed ABO-incompatible LDLT using dual grafts and right-sided graft was obtained by pure laparoscopic donor right hepatectomy in a young female donor.

OUTCOMES

The postoperative course was uneventful in both donors and the recipient is presently doing well in satisfactory condition 7 months after liver transplantation.

LESSONS

We overcame these volumetric and cosmetic issues through dual living donor liver grafts using a combination of conventional surgery for 1 donor and laparoscopic right hepatectomy for a second ABO-incompatible donor. We think this procedure can be a good option for the expansion of donor pools.

Successful conservative treatment of acute traumatic occlusions of the celiac artery and superior mesenteric artery: A case report emphasizing the importance of the visceral collateral circulations

RATIONALE

Blunt injury of major visceral arteries such as celiac artery (CA) and superior mesenteric artery (SMA) are very rare but fatal, therefore, these injuries are challenging to trauma surgeons. The patient with occlusion of CA or SMA is theoretically viable by visceral collateral circulation. However, there are very rare cases in clinics. To date, there have been few reports of both CA and SMA occlusions after blunt trauma. Herein we describe our successful conservative treatment of patients with both CA and SMA occlusions.

PATIENT CONCERNS

Fifteen-year-old girl suffering from schizophrenia was transferred to our hospital after a fall from 3-floor-height with a purpose of suicide.

DIAGNOSES

An abdominal computed tomography (CT) scan with contrast enhancement showed proximal CA and proximal SMA occlusions with surrounding retroperitoneal hematoma, however, distal parts of occlusion were supplied by the collateral vessels (enlarged marginal artery of left colon from inferior mesenteric artery and pancreaticoduodenal arcade).

INTERVENTIONS

She was treated by only supportive care without anticoagulant due to retroperitoneal hematoma.

OUTCOMES

The patient was discharged 25 days after admission without complications.

LESSONS

We think that our patient could survive because her vascular status was healthy and collateral circulations were plenty according to the young age. We believe that this case can provide a basis for ligation in these forbidding and handless major visceral arterial injuries such as CA or SMA.

Blunt traumatic diaphragmatic rupture: Single-center experience with 38 patients

Blunt traumatic diaphragmatic rupture (BTDR) is uncommon, but is associated with high rates of morbidity and mortality. The purpose of this study was to present our experience with management of this injury. Medical records of 38 patients with BTDR who were treated in our hospital from January 2001 to June 2016 were analyzed retrospectively. The sex, age, cause of injury, location of rupture, mode of diagnosis, time to diagnosis, the presence of herniation and bowel perforation, the presence of preoperative shock and intubation, Injury Severity Score (ISS), associated injuries, comorbidity, the operative procedure, morbidity and mortality, and the predictive factors affecting the outcome of BTDR were evaluated. There were 32 men (84.2%) and 6 women (15.8%) with a mean age of 51.2 years (range 18-84 years). The diagnosis could be preoperatively established in 28 patients (73.7%) with a plain chest X-ray or computed tomography scan. Rupture of diaphragm was left-sided in 31 patients (81.6%), right-sided in 6 (15.8%), and bilateral in 1 (2.6%). Sixteen patients had preoperative shock (systolic blood pressure <90 mm Hg, heart rate >120/min). Initial operative approaches were laparotomy in 22 patients (57.9%) and thoracotomy in 16 (42.1%). Eleven required additional exploration. The rate of additional exploration was higher in patients who initially underwent thoracotomy than laparotomy (56.2% vs 9.1%, P = .003). Patients who underwent additional exploration had a significantly longer operation time (330 minutes vs 237.5 minutes, P = .012), and a significantly higher morbidity rate (72.7% vs 22.2%, P =.008). Overall mortality was observed in 6 patients (15.8%). The mortality was associated with right-sided TDR (P = .042) and preoperative shock (P = .003). Neither ISS nor delay in diagnosis posed a statistically significant risk to the outcome of patients. Intra-abdominal organ injuries are more common than intrathoracic injuries in patients with BTDR, indicating that laparotomy should be the initial approach in these patients. Preoperative shock and right-sided TDR are predictive of mortality after BTDR.

Endovascular treatment of renal arterial perforation after blunt trauma: Case report

INTRODUCTION

Isolated renal arterial perforation is a rare consequence of blunt abdominal trauma. Meticulous surgical control of retroperitoneal active bleeding is difficult due to oozing of soft connective tissue, the deep position of operative field, and the presence of friable vascular tissue. Therefore, endovascular treatment is often preferred.

PRESENTATION OF CASE

An 83-year-old man was transferred to our trauma center due to retroperitoneal active bleeding after a car accident, in which his right upper abdomen struck the steering wheel. Contrast-enhanced abdominal computed tomography (CT) showed a retroperitoneal hematoma behind the inferior vena cava and contrast medium extravasation on the medial side of the right kidney. Selective right renal arteriography confirmed a perforation in the proximal right main renal artery, approximately 3 cm from the ostium. We successfully placed a covered stent across the perforation site.

DISCUSSION

Endovascular management may reduce the likelihood of extensive abdominal surgery, surrounding organ damage, risk of bleeding, and postoperative morbidity. We regarded embolization as inappropriate for kidney salvage in our patient, and therefore used a self-expanding covered stent to treat the perforation.

CONCLUSION

Endovascular management of a traumatic renal arterial injury is the best approach to preserve renal function in hemodynamically stable patients who cannot tolerate laparotomy, due to risks associated with general anesthesia, and who can tolerate anticoagulation therapy.

Acute superior mesenteric vein thrombosis associated with abdominal trauma: A rare case report and literature review

RATIONALE

Acute mesenteric vein thrombosis (MVT) is defined as new-onset thrombosis of the mesenteric vein without evidence of collateralization, finally resulting in extensive intestinal infarction. MVT may be idiopathic or be caused by conditions responsible for thrombophilia and acquired risk factors. To date, there have been few reports of MVT after trauma. Herein we describe our experiences treating three patients with MVT.

PATIENT CONCERNS

Case 1 was a 44-year-old man with transverse colon mesenteric hematoma after blunt abdominal trauma. Case 2 was a 55-year-old man with jejunal transection after a traffic accident. Case 3 was a 26-year-old man presented with multiple abdominal stab bowel injury.

DIAGNOSES

A 1-week follow-up abdominal computed tomography scan showed superior mesenteric vein thrombosis in all of three patients.

INTERVENTIONS

All patients were treated with anticoagulant for 3 or 6 months.

OUTCOMES

MVTs were completely resolved without any complications.

LESSONS

If early diagnosis and treatment could be available, anticoagulation alone might be adequate for the treatment of SMVT associated with trauma. Early anticoagulation in patients with acute SMVT may avoid the grave prognosis observed in patients with arterial thrombosis.

Validity of self-reported weight and height: a cross-sectional study among Malaysian adolescents

Background

Self-reported weight and height are commonly used in lieu of direct measurements of weight and height in large epidemiological surveys due to inevitable constraints such as budget and human resource. However, the validity of self-reported weight and height, particularly among adolescents, needs to be verified as misreporting could lead to misclassification of body mass index and therefore overestimation or underestimation of the burden of BMI-related diseases. The objective of this study was to determine the validity of self-reported weight and height among Malaysian secondary school children.

Methods

Both self-reported and directly measured weight and height of a subgroup of 663 apparently healthy schoolchildren from the Malaysian Adolescent Health Risk Behaviour (MyAHRB) survey 2013/2014 were analysed. Respondents were required to report their current body weight and height via a self-administrative questionnaire before they were measured by investigators. The validity of self-reported against directly measured weight and height was examined using intraclass correlation coefficient (ICC), the Bland-Altman plot and weighted Kappa statistics.

Results

There was very good intraclass correlation between self-reported and directly measured weight [r = 0.96, 95% confidence interval (CI): 0.93, 0.97] and height (r = 0.94, 95% CI: 0.90, 0.96). In addition the Bland-Altman plots indicated that the mean difference between self-reported and direct measurement was relatively small. The mean difference (self-reported minus direct measurements) was, for boys: weight, −2.1 kg; height, −1.6 cm; BMI, −0.44 kg/m² and girls: weight, −1.2 kg; height, −0.9 cm; BMI, −0.3 kg/m². However, 95% limits of agreement were wide which indicated substantial discrepancies between self-reported and direct measurements method at the individual level. Nonetheless, the weighted Kappa statistics demonstrated a substantial agreement between BMI status categorised based on self-reported weight and height and the direct measurements (kappa = 0.76, 95% CI: 0.67, 0.84).

Conclusion

Our results show that the self-reported weight and height were consistent with direct measurements and therefore can be used in assessing the nutritional status of Malaysian school children from the age of 13 to 17 years old in epidemiological studies and for surveillance purposes when direct measurements are not feasible, but not for assessing nutritional status at the individual level.

Steroid Responsive Mononeuritis Multiplex in the Cronkhite-Canada Syndrome

The Cronkhite-Canada syndrome (CCS) is a rare disorder of unknown origin characterized by generalized gastrointestinal polyposis, alopecia, hyperpigmentation, and onychodystrophy. We report a case of CCS with concomitant presentation of mononeuritis multiplex. The electrophysiological findings and steroid responsiveness suggests presence of an autoimmune mechanism.

Prevalence of smoking and its associated factors with smoking among elderly smokers in Malaysia: findings from a nationwide population-based study

BACKGROUND

The determination of smoking prevalence and its associated factors among the elderly could provide evidence-based findings to guide the planning and implementation of policy in order to will help in reducing the morbidity and mortality of smoking-related diseases, thus increase their quality of life. This paper describes the rate of smoking and identifies the factor(s) associated with smoking among the elderly in Malaysia.

METHODS

A representative sample of 2674 respondents was obtained via a two-stage sampling method in proportion to population size. Face-to-face interviews were conducted using a set of standardized validated questionnaire. Data was weighted by taking into consideration the complex sampling design and non-response rate prior to data analysis. Univariable and multivariable logistic regression were used to determine the factor/s associated with smoking.

RESULTS

The prevalence of non-smokers, ex-smokers and current smokers among Malaysians aged 60 years and above were 36.3 % (95 % CI = 32.7-39.8), 24.4 % (95 % CI = 21.2-27.5) and 11.9 % (95 % CI = 9.5-14.3), respectively. Current smokers were significantly more prevalent in men (28.1 %) than in women (2.9 %), but the prevalence declined with advancing age, higher educational attainment, and among respondents with known diabetes, hypertension and hypercholesterolemia. Multivariable analysis revealed that males (aOR, 18.6, 95 % CI 10.9-31.9) and other Bumiputras (aOR 2.58, 95 % CI 1.29-5.15) were more likely to smoke. in addition, elderly with lower educational attainment (aOR, 1.70, 95 % CI 1.24-7.41) and those without/unknown hypertension also reported higher likelihood to be current smokers (aOR 1.98, 95 % CI 1.35-2.83). However, there were no significant associations between respondents with no/unknown diabetes or hypercholesterolemia with smoking.

CONCLUSIONS

In short, smoking is common among elderly men in Malaysia. Therefore, intervention programs should integrate the present findings to reduce the smoking rate and increase the smoking cessation rate among the elderly in Malaysia and subsequently to reduce the burden of smoking-related disease.

Gastrointestinal stromal tumor of the vermiform appendix mimicking Meckel's diverticulum: Case report with literature review

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We present the case of gastrointestinal stromal tumor of the vermiform appendix mimicking Meckel’s diverticulum on CT image.

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Primary appendiceal GISTs are extremely rare, with only 15 reported cases in the English literature to date.

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Rare tumors of appendix including GISTs should be considered in the differential diagnosis of atypical symptoms or image findings.

Introduction

Gastrointestinal stromal tumors (GISTs) of the appendix are extremely rare. To date, only 15 cases have been reported in the English literature. Here, we present a new case of an appendiceal GIST with appendicitis.

Presentation of case

A 68-year-old man who complained of right lower abdominal tenderness underwent surgery for a cystic mass mimicking Meckel’s diverticulum. Laparoscopy revealed a mass protruding from the proximal appendix with distal appendicitis. Complete resection with adequate margins was performed. Histology showed a spindle cell GIST without mitotic activity as well as a strong expression of CD117 and CD34.

Conclusion

Primary appendiceal GIST occur at a very low rate and their symptoms are nonspecific. Accordingly, rare tumors of appendix including GISTs should be considered in the differential diagnosis of atypical symptoms or image findings.

Eosinophilic gastroenteritis: Clinical profiles and treatment outcomes, a retrospective study of 18 adult patients in a Singapore Tertiary Hospital

BACKGROUND

Eosinophilic gastroenteritis (EG) can mimic symptoms of common gastrointestinal (GI) disorders but responds well to appropriate treatment. Accurate diagnosis is central to effective management. Data on EG in Southeast Asia is lacking. We aim to describe the clinical profiles and treatment outcomes of adult patients with EG in a Singapore Tertiary Hospital.

MATERIALS AND METHODS

This retrospective study involved archival search of patients with GI biopsies that showed eosinophilic infiltration from January 2004 to December 2012. Patients' clinical data from computerised hospital records and clinical notes was reviewed. Diagnostic criteria for EG included presence of GI symptoms with more than 30 eosinophils/high power field on GI biopsies. Patients with secondary causes for eosinophilia were excluded.

RESULTS

Eighteen patients with EG were identified (mean age 52 years; male/female: 11/7). Fifteen patients (83%) had peripheral blood eosinophilia. Seven patients (39%) had atopic conditions. Most common symptoms were diarrhoea and abdominal pain. Small intestine was the most common site involved. Endoscopic finding was non-specific. Ten patients were treated with corticosteroids (nine prednisolone, one budesonide): eight patients (89%) responded clinically to prednisolone but four patients (50%) relapsed following tapering-off of prednisolone and required maintenance dose. One patient each responded to diet elimination and montelukast respectively. Half of the remaining six patients who were treated with proton-pump inhibitors, antispasmodic or antidiarrheal agents still remained symptomatic.

CONCLUSION

Prednisolone is an effective treatment though relapses are common. Small intestine is most commonly involved. EG should be considered in the evaluation of unexplained chronic recurrent GI symptoms.

A Case of Perimembranous Ventricular Septal Defect Associated with Sinus of Valsalva Aneurysm Mimicking Membranous Septal Aneurysm

Sinus of Valsalva aneurysms are rare. Sinus of Valsalva aneurysms are frequently associated with ventricular septal defect (VSD) and aortic regurgitation. They often remain asymptomatic until abruptly presenting with acute chest pain and heart failure secondary to rupture. Here, we describe a case of 20-year-old man who presented with chest pain with a history of VSD. Initial work-up concluded that the patient had VSD associated membranous septal aneurysm. Four years later, the patient presented with symptoms of heart failure. Work-up showed that the ruptured sinus of Valsalva aneurysm was the cause of symptoms. Due to its close proximity to the aortic annulus, sinus of Valsalva aneurysm should be differentiated from membranous septal aneurysm.

Laparoscopic surgery in abdominal trauma: a single center review of a 7-year experience

INTRODUCTION

Laparoscopic surgery has greatly improved surgical outcome in many areas of abdominal surgery. But many concerns of safety have limited its application in abdominal trauma. We hypothesized that laparoscopy could be safe and efficacious in treatment of patients with abdominal trauma, and reduce the laparotomy related complications (i.e. wound infection, pain, or long hospital stay) as avoiding unnecessary laparotomy.

METHODS

From January 2006 to August 2012, a total of 111 patients underwent emergent surgical exploration (laparoscopic, 41; open laparotomy, 70) in Andong General Hospital. Of the 41 patients subjected to laparoscopy, 30 patients had suffered blunt trauma, the remaining 11 patients had sustained penetrating trauma. 31 patients were treated exclusively by laparoscopy and 10 patients underwent laparoscopy-assisted surgery.

RESULTS

The conversion rate was 18%. Major complication was none without postoperative mortality. Comparing laparoscopic surgery with open laparotomy, lesser wound infection, early gas passage, and shorter hospital stay. Otherwise operative times were similar, and neither approach was complicated by missed injury or postoperative intra-abdominal abscess.

CONCLUSIONS

Laparoscopic surgery can be performed safely whether injuries are blunt or penetrating, given hemodynamic stability and proper technique. Patients may thus benefit from the shorter hospital stays, greater postoperative comfort (less pain), quicker recoveries, and low morbidity/mortality rates that laparoscopy affords.

Prevalence, awareness, treatment and control of diabetes mellitus among the elderly: The 2011 National Health and Morbidity Survey, Malaysia

Diabetes mellitus is an important cardiovascular risk factor. The objective of this study was to provide population-based estimates on the prevalence, awareness, treatment and control rate of diabetes among the older persons in Malaysia. Analysis of secondary data from a cross-sectional national population-based survey was done, which was conducted in 2011 throughout Malaysia. A total of 2764 respondents (15.5%) were older persons. The overall prevalence of diabetes among older persons was 34.4% in which 65.2% were aware of their diabetes status. Out of those who were aware, 87.5% had been treated. Only 21.8% of those treated had their diabetes controlled. The results of multiple logistic regression showed that the factors associated with higher awareness rates were women, Indians and higher income groups; factors associated with higher treatment rates were urban residents and those who were married and widow/widower/ divorcee. There was a high overall prevalence, awareness and treatment rate of diabetes among older persons in Malaysia but with suboptimal control rate.

Duplication of the vermiform appendix in an adult patient

Duplication of the appendix is extremely rare. A 69-year-old woman was admitted with a 2-day history of right lower quadrant abdominal pain. Physical examination was consistent with acute appendicitis. Ultrasonography and colonoscopy gave a clinical impression of an inflammatory appendiceal mucocoele. Operative findings were an enlarged and inflamed appendix with distal cystic changes. Laparoscopic wedge resection of the caecum was performed. A tubular structure with a true lumen was found in the appendix. Haematoxylin and eosin staining and trichrome staining showed both structures had a true mucosa and a muscular layer. The duplication in this case does not belong to any of the previously described types of duplication.

The prevalence of physical activity and its associated factors among Malaysian adults: findings from the National Health and Morbidity Survey 2011

OBJECTIVES

Despite the health-enhancing benefits of physical activity, a large segment of the Malaysian population does not engage in regular physical activity at the recommended level. This study aimed to determine physical activity patterns and the associated sociodemographic correlates of physical activity.

STUDY DESIGN

Data on physical activity were obtained from the National Health and Morbidity Survey (NHMS) 2011, a nationally representative, population-based cross-sectional study. A two-stage stratified sampling method was used to select a representative sample of Malaysian adults aged 16 years and above.

METHODS

A total of 19,145 adults aged 16 years and above were recruited, and face-to-face interviews were conducted using the International Physical Activity Questionnaire (IPAQ), short version. The correlates for physical activity were identified using multivariate analysis.

RESULTS

In this study, 64.3% (95%CI: 63.1-65.5) of Malaysian adults aged 16 and above were physically active, but overall physical activity levels decreased with advancing age. Men, rural residents, 'other' ethnic groups, and married women were more likely to demonstrate higher levels of physical activity.

CONCLUSION

Approximately 65% of Malaysian adults were physically active. However, it is recommended that health promotions for active lifestyles should be targeted to the least active segments, which constitute more than a quarter of the Malaysian population.

Correlation of blood pressure and the ratio of S1 to S2 as measured by esophageal stethoscope and wireless bluetooth transmission

Objective : Esophageal stethoscope has the advantage of being non-invasive, easily placed and capability to monitor the heart sound. This study was designed to determine whether the ratio of S1 to S2 analyzed by esophageal stethoscope and wireless bluetooth transmission can be accurate indicator that express the correlation with blood pressure.

METHODS

Total 33 adult male and female without cardiac disorder and with normal heart rhythm were selected randomly as the subjects of this Study. Two microphones were used with one for acquisition of heart sound by connecting it to the esophageal stethoscope while the other was used to measure the background noise in the operating room. After having transmitted the heart sound measured with the esophageal stethoscope to the receiver by using bluetooth module, it was saved in PC and outputted, following removal of noise in the operating room and the respiratory sound. S1 and S2 were measured with computation of the ratio of S1 to S2. Correlations between the systolic blood pressure with each of the S1, S2 and ratio of S1 to S2 were examined by using correlation analysis.

RESULTS

The ratio of S1 to S2 displayed the highest correlation with the systolic blood pressure, with S1 and S2 also displaying positive correlation with the systolic blood pressure.

CONCLUSION

As the result of analysis of the heart sound and the systolic blood pressure measured by using the esophageal stethoscope, the radio of S1 to S2 displayed greater correlation with the systolic blood pressure in comparison to the S1.

A novel technique of percutaneous stone extraction in choledocholithiasis after cholecystostomy

BACKGROUND/AIMS

To evaluate the technical feasibility and clinical efficacy of percutaneous common bile duct stone extraction via cystic duct after percutaneous cholecystostomy.

METHODOLOGY

Twenty-five consecutive patients with choledocholithiasis underwent percutaneous stone extraction under conscious sedation. The stones were extracted through the 12-Fr sheath using Wittich nitinol stone basket under fluoroscopic guidance via cystic duct after percutaneous trnas-hepatic cholecystostomy.

RESULTS

Common bile duct stones were successfully removed in 22 of the 25 patients (88%) by this new technique. The causes of failure in three patients were bile leakage, hematoma of the gallbladder and failure of cystic duct cannulation. Cystic duct injury during this procedure did not occur and there was no post-procedure mortality. The mean period of indwelling catheter was 8.7±4.6 days and the mean duration of hospitalization was 13.4±5.9 days.

CONCLUSIONS

Percutaneous commmon bile duct stone extraction via the cystic duct through percutaneous cholecystostomy route is effective and feasible for treating choledocholithiasis.

Heaviness of smoking index, number of cigarettes smoked and the Fagerstrom test for nicotine dependence among adult male Malaysians

Two methods of identifying smokers with high nicotine dependence, the heaviness of smoking index (HSI) and number of cigarettes per day (CPD) were compared with the Fagerstrom test for nicotine dependence (FTND). The HSI, CPD and the FTND were administered to 316 adult Malaysian male, daily smokers aged between 25-64 years old in the Malaysian NCD Surveillance-1 Survey using a two-stage stratified random sampling of enumeration blocks and living quarters, via an interview based on a validated questionnaire. The cut-off point for classification of high nicotine dependence on the HSI was a score of four or higher, and for the heavy smoking category, smoking more than 20 cigarettes per day. Classification using each method was compared with classification by the FTND (score of six or more) as the reference standard. Sensitivity, specificity and kappa statistics for concordance between both measures and the FTND were evaluated. The HSI gave a similar prevalence rate of high nicotine dependence as the FTND. There was substantial agreement between the HSI and the FTND (kappa=0.63.), with moderate sensitivity (69.8%) and high specificity (92.5%). However, prevalence of high nicotine dependence using the CPD was 7% lower than the FTND. The heavy smoking category also showed fair agreement with the FTND (kappa=0.45) and moderate sensitivity (67.0%), but specificity was high (86.9%). The findings indicate that the HSI can be used as an alternative to the FTND in screening for high nicotine dependence among daily smokers in large population-based studies, while CPD may not be a suitable alternative to the FTND.

Inflammatory myofibroblastic tumour of the duodenum

Inflammatory myofibroblastic tumours (IMTs) of the duodenum and head of the pancreas are rare. They are of probable immunological aetiology and preoperatively indistinguishable from adenocarcinomas of the pancreatic head. We describe a patient with duodenal IMT and gastric outlet obstruction, and present a review of pancreatic head and duodenal IMTs in the literature. IMTs of the pancreatic head present as obstructive jaundice, while those of the duodenum present as gastric outlet obstruction. Surgery is the primary modality of treatment. Adjuvant chemotherapy and radiotherapy are controversial and reserved for incomplete resections and IMTs of a pathologically aggressive nature. Otherwise, recurrence is uncommon and surgery curative.

Sensitivity and specificity of waist circumference as a single screening tool for identification of overweight and obesity among Malaysian adults

Generalised obesity and central obesity are risk factors for Type II diabetes mellitus and cardiovascular diseases. Waist circumference (WC) has been suggested as a single screening tool for identification of overweight or obese subjects in lieu of the body mass index (BMI) for weight management in public health program. Currently, the recommended waist circumference cut-off points of > or = 94cm for men and > or =80cm for women (waist action level 1) and > or = 102cm for men and > or = 88cm for women (waist action level 2) used for identification of overweight and obesity are based on studies in Caucasian populations. The objective of this study was to assess the sensitivity and specificity of the recommended waist action levels, and to determine optimal WC cut-off points for identification of overweight or obesity with central fat distribution based on BMI for Malaysian adults. Data from 32,773 subjects (14,982 men and 17,791 women) aged 18 and above who participated in the Third National Health Morbidity Survey in 2006 were analysed. Sensitivity and specificity of WC at waist action level 1 were 48.3% and 97.5% for men; and 84.2% and 80.6% for women when compared to the cut-off points based on BMI > or = 25kg/m2. At waist action level 2, sensitivity and specificity were 52.4% and 98.0% for men, and 79.2% and 85.4% for women when compared with the cut-off points based on BMI (> or = 30 kg/m2). Receiver operating characteristic analyses showed that the appropriatescreening cut-off points for WC to identify subjects with overweight (> or = 25kg/m2) was 86.0cm (sensitivity=83.6%, specificity=82.5%) for men, and 79.1cm (sensitivity=85.0%, specificity=79.5%) for women. Waist circumference cut-off points to identify obese subjects (BMI > or = 30 kg/m2) was 93.2cm (sensitivity=86.5%, specificity=85.7%) for men and 85.2cm (sensitivity=77.9%, specificity=78.0%) for women. Our findings demonstrated that the current recommended waist circumference cut-off points have low sensitivity for identification of overweight and obesity in men. We suggest that these newly identified cut-off points be considered.

Acalypha wilkesiana extracts induce apoptosis by causing single strand and double strand DNA breaks

ETHNOPHARMACOLOGICAL RELEVANCE

The seeds of Acalypha wilkesiana have been used empirically by traditional healers in Southwest Nigeria together with other plants as a powder mixture to treat patients with breast tumours and inflammation.

AIM OF THE STUDY

There is an increasing interest among researchers in searching for new anticancer drugs from natural resources, particularly plants. This study aimed to investigate the anticancer properties of Acalypha wilkesiana extracts and the characteristics of DNA damage against brain and lung cancer cells.

MATERIALS AND METHODS

The antiproliferative activity of Acalypha wilkesiana extracts (ethyl acetate, hexane, and ethanol) was examined on human glioma (U87MG), human lung carcinoma (A549), and human lung fibroblast (MRC5) cells.

RESULTS

Cell viability MTT assay revealed that ethyl acetate extract of the plant possessed significant antiproliferative effects against both U87MG (GI(50)=28.03 ± 6.44 μg/ml) and A549 (GI(50)=89.63 ± 2.12 μg/ml) cells (p value<0.0001). The hexane extract was found to exhibit crucial antiproliferative effects on U87MG (GI(50)=166.30 ± 30.50 μg/ml) (p value<0.0001) but not on A549 cells. Neither plant extract possessed noticeable antiproliferative effects on the non-cancerous MRC5 cells (GI(50)>300 μg/ml). The ethanol extract showed no antiproliferative effects on any cell line examined. Haematoxylin & Eosin (H & E) staining and single cell gel electrophoresis (SCGE) comet assay confirmed that plant extract-treated cells underwent apoptosis and not necrosis. SCGE comet assays confirmed that plant extracts caused both single strand (SSB) and double strand (DSB) DNA breaks that led to the execution of apoptosis.

CONCLUSION

The extracts (especially ethyl acetate and hexane) of Acalypha wilkesiana possess valuable cytotoxic effects that trigger apoptosis in U87MG and A549 cancer cells through induction of DNA SSBs and DSBs.

Doxycycline induced acute erosive oesophagitis and presenting as acute dysphagia

INTRODUCTION

Drug induced oesophageal disease is common. Doxycycline is one of the commonest cause of drug induced oesophageal ulcers. The medical community often under recognizes the importance of drug induced oesophageal lesions and fails to deliver proper advice and instructions related to drug ingestion. The diagnosis is usually clinical although endoscopy is the gold standard diagnostic tool. Treatment is symptomatic with discontinuation of the drug often being sufficient. Long-term sequelae are infrequent and acute complications uncommon.

CLINICAL PICTURE

A 22-year-old college student was prescribed doxycycline capsules for acne and developed dysphagia. Upper gastrointestinal endoscopy revealed acute erosive oesophagitis.

TREATMENT AND OUTCOME

She was managed symptomatically with proton pump inhibitors and her dysphagia improved over a period of three days. She was discharged with proper advice regarding medication ingestion and proton pump inhibitor for four weeks.

CONCLUSION

Drug induced oesophageal disease is a preventable self-limiting condition. Proper advice regarding medication ingestion is essential for prevention.

Prevalence and factors associated with smoking among form four students in Petaling District, Selangor, Malaysia

A cross-sectional study was conducted among form four students of secondary schools in the District of Petaling, Selangor, Malaysia from February 2008 to June 2008 with the aim of quantifying the prevalence of smoking and identifying the psychosocial factors related to smoking among adolescents in this district. A two-stage stratified sampling strategy was used to obtain a sample of 1300 students based on an estimated prevalence of 10%. The response rate was 80.5% (1045 out of 1298 students). Results showed that prevalence of smoking was higher among male students (22.3%) compared to females (5.5%) and the median age at smoking initiation was lower among males compared to female smokers (14 years old vs 15 years old). Modifiable risk factors associated with smoking were "percentage of friends who smoke" (OR 2.94, 95% CI [1.71- 5.06]) and "having a brother who smokes" (OR 1.97, 95% CI [1.20-3.31]). There was also a correlation between smoking prevalence and the number of risk factors present. Intensification of health education and anti-smoking programmes and modification of external factors in early adolescence are recommended to prevent smoking initiation.