Interocular optical biometry differences as predictors of postoperative cataract surgery refractive outcomes: A retrospective cohort study

INTRODUCTION

Few studies have reported the impact of preoperative interocular discrepancy in optical biometry (axial length, corneal power, white-to-white, central corneal thickness) on postoperative refractive outcomes. This study aims to investigate any predictive value of preoperative optical biometry differences between eyes on postoperative refractive outcomes.

MATERIALS AND METHODS

A retrospective cohort study of patients who have undergone optical biometry measurement before unilateral phacoemulsification in the Queen Elizabeth Hospital, Sabah, Malaysia from 2018 to 2020. Biometry data of interest includes axial length (AL), keratometry(K), white-to-white (WTW) and central corneal thickness (CCT). The postoperative outcomes of interest were the patient's preoperative refractive target, postoperative best-corrected visual acuity (BCVA), postoperative refractive outcomes, and optical biometry prediction error.

RESULTS

The interocular biometry discrepancies which were associated with higher odds of prediction error >0.5D from the refractive target were Interocular Corneal Power Difference (IKD)-average≥0.8 D (Odds Ratio, OR=1.97; 95% Confidence Intervals, 95%CI: 1.06, 3.67) and Interocular WTW Difference ≥1.5 mm (OR=2.77; 95%CI: 1.11, 6.92). In cases with prediction error >1.0D, the measurements were Interocular AL Difference ≥0.4 mm (OR=2.99; 95%CI: 1.11, 8.06), IKD flat≥0.4D (OR=2.76; 95%CI: 1.31, 5.82) and Interocular CCT Difference ≥15μm (OR=3.53; 95%CI: 1.29, 9.64).

CONCLUSION

Interocular axial length difference ≥0.4mm and interocular central corneal thickness difference ≥15μm are associated with refractive error >1.0D from the pre-operative target. Interocular average corneal power difference ≥0.8D and interocular white-to-white difference ≥1.5mm have higher odds of refractive drift >0.5D from the refractive aim. The above cutoff values help clinicians to identify which patients have a higher risk of refractive shift post-cataract surgery and counsel the patient before cataract operation.

Disease activity and damage in hospitalized lupus patients: a Sabah perspective

OBJECTIVE

Systemic lupus erythematosus (SLE) is a complex multi-systemic autoimmune disease with variable levels of activity that may wax and wane within the same patient over the years. In view of the scarcity of data about lupus in the East Malaysian population, we aimed to study the disease activity and damage index in patients with SLE hospitalized in a tertiary center in Sabah, East Malaysia.

METHODS

We retrospectively studied all patients with SLE admitted from 1 January 2013 to 31 December 2015. Demographic data, clinical features, treatment received, SLEDAI and SLICC/ACR (Systemic Lupus International Collaborating Clinics/American College of Rheumatology) criteria and outcomes were collected.

RESULTS

There were 108 patients studied whereby 88.9% were females. They had a mean age of 31.4 ± 11.02 years at admission and were multiethnic in origin. The mean number of ACR criteria for SLE was 5.03 ± 1.5 at the time of diagnosis. There were 158 hospitalizations during the 3 years. The main causes of hospitalization were flare of SLE (66.5%), infection (57.6%), renal biopsy (15.5%) and others (11.4%). Active nephritis (65%), cutaneous (44.4%) and hematological involvement (40.2%) were the three commonest manifestations. There was concurrent flare of SLE and infection in 41.1% of the admissions. The mean SLEDAI score at admission was 10.8 ± 7.20, with a mean SLEDAI of 9.3 ± 6.9 in those without damage and 11.9 ± 7.21 in those with damage (p-value = 0.026). The median SLICC score was 1 with a mean of 0.93 ± 1.07. There were nine deaths (5.6%) during the study period and all patients were females. Compared with those who survived, they had a significantly higher SLEDAI score of 15.80 ± 8.2 (p-value = 0.0207) and a SLICC score of 2.70 ± 1.6 (p-value <0.001).

CONCLUSION

SLE is more common among the indigenous population of Sabah, the Kadazan-Dusun, which has not been shown before this study. Disease characteristics were, however, similar to reports from the Asia-Pacific region. Acute flare of SLE and infection remained the main causes of admission and readmissions and was present in 44.4% of the mortalities in our cohort.

Systematic Knowledge Auditing: A Case Study in a Power Utility Company

Managing knowledge of plant maintenance in a power utility company is vital to the provision of a safe and reliable electricity supply to two million domestic and commercial customers. The business is built on a lot of expertise, techniques and experience of all of its employees from engineering, maintenance, safety and environmental control, to quality assurance. Knowledge auditing is usually carried out as the first critical step in the implementation of any Knowledge Management programmes in power utility companies. Although various knowledge auditing approaches have been proposed by some researchers and practitioners, there is a lack of a systematic approach in the way it is conducted, and the audit practice varies with different industries and companies. This paper presents a systematic knowledge audit approach, which has been successfully trial-implemented in a power plant.

Use of radiosynovectomy in recurrent warfarin-related haemarthrosis in degenerative arthritis

Radiosynovectomy is a local and minimally invasive radiotherapy for treating various chronic inflammatory arthritis such as rheumatoid arthritis, osteoarthritis and haemophilic arthropathy. In haemophilic arthropathy, it reduces the frequency of haemarthrosis and delays the development of severe joint destruction, which ultimately requires surgical intervention. Its role in warfarin-related haemarthrosis is less clear. Haemarthrosis is an uncommon complication of warfarin use, and anticoagulation may need to be discontinued. We describe yttrium-90 radiosynovectomy use in a 74-year-old man with underlying ischaemic heart disease, atrial fibrillation, previous embolic stroke and recurrent haemarthrosis of an osteoarthritic right knee. Anticoagulation was vital and could not be permanently stopped. Due to continuing anticoagulation, he had multiple hospitalisations with recurrent right knee haemarthrosis. Intraarticular right knee yttrium-90 citrate colloid injection led to a cessation of haemarthrosis for eight months. We examined the available literature for the role of radiosynovectomy in such circumstances.

Anaphylaxis during general anaesthesia: one-year survey from a British allergy clinic

INTRODUCTION

Anaphylaxis during general anaesthesia is a major concern. Early recognition and management of anaphylaxis, as well as its future prevention, remain a challenge for the anaesthetists, while for the allergists, the elucidation of the causal agents may be difficult. We aimed to describe our experience in our drug allergy clinic.

METHODS

We retrospectively reviewed 23 consecutive adult patients who presented with anaphylaxis during anaesthesia from March 1, 2005 to February 28, 2006.

RESULTS

Out of the 23 patients (12 females, 11 males) with mean age (+/- SD) of 53.1 +/- 15.8 years, 15 patients were found to have a positive skin test to at least one neuromuscular blocking agent (NMBA); all of them showed cross-sensitivity with one or more NMBA(s). Three patients had a positive skin test to opioids, two patients to gelofusine, two patients to penicillin, and one patient each to povidone-iodine and chlorhexidine. Two patients had negative test results to agents used during their anaesthesia. Four patients had double positive skin tests to different families of drugs/agents. 18 patients had severe reaction-grade 3, and 15 of them tested positive for NMBA(s). Serum tryptase levels were known in nine patients. We did not encounter any latex or hypnotics sensitisation.

CONCLUSION

NMBA was the commonest cause of anaphylaxis during general anaesthesia, occurring in 65% in our series.

Klebsiella pneumoniae respiratory isolates from 2000 to 2004 in a Malaysian hospital: characteristics and relation to hospital antibiotics consumption

INTRODUCTION

Klebsiella pneumoniae ranks high as a cause of community-acquired pneumonia in hospitalised patients in Malaysia.

METHODS

A retrospective study of 5,990 clinical respiratory specimens in patients, with a mean age of 54 (standard deviation 18.5) years, admitted to an urban-based general hospital between 2000 and 2004, was conducted.

RESULTS

The percentages of K. pneumoniae isolates during these years were 11, 19.1, 41.4, 27.8 and 16.6 percent, respectively. During this time, the percentage of isolates resistant to ampicillin were consistently in excess of 80 percent, those resistant to cephalosporins were relatively stable between eight and 23 percent, while those resistant to beta-lactam/beta-lactamase inhibitors [amoxicillin clavulanic acid/ ampicillin-sulbactam] and aminoglycosides steadily increased between six and 58 percent. Compared with hospital consumption of these corresponding antibiotic classes, only beta-lactam/beta-lactamase inhibitors and aminoglycosides showed a clear trend of eight- and four-fold increases, respectively. Co-resistance rates in isolates resistant to ampicillin and amoxicillin-clavulanic acid/ampicillin-sulbactam were generally low to second to third generation cephalosporins (less than 20 percent).

CONCLUSION

Our local findings highlighted the changing trend in respiratory K. pneumoniae over a five-year period, and its escalating resistance to beta-lactam/beta-lactamase inhibitors and aminoglycosides that is possibly attributable to the widespread use of these antibiotics in our hospital.

Rapid presumptive diagnosis of hantavirus cardiopulmonary syndrome by peripheral blood smear review

Hantavirus cardiopulmonary syndrome (HCPS) is a rare but frequently lethal acute zoonotic viral infection in rural North America. The rapidity of progression from febrile prodrome to cardiogenic shock and noncardiogenic pulmonary edema requiring intensive care creates high diagnostic urgency and a need for a rapid screening tool. In this retrospective cohort study, 2 pathologists scored blinded peripheral blood smears from 52 patients with HCPS and 128 seronegative patients referred for diagnosis of suspected hantavirus infection. During the prodromal phase, thrombocytopenia was the only consistent abnormality and could be used to indicate hantavirus serologic testing. After the onset of pulmonary edema detected radiographically, the presence of 4 of 5 findings (thrombocytopenia, myelocytosis, hemoconcentration, lack of significant toxic granulation in neutrophils, and more than 10% of lymphocytes with immunoblastic morphologic features) has a sensitivity for HCPS of 96% and a specificity of 99% and missed no patients with HCPS who required intensive care. While each abnormality is commonly seen, the combination of at least 4 of these CBC count data and peripheral blood smear findings can guide early treatment and patient transport decisions until rapid, specific, serologic testing becomes widely available.

Benign hematogone-rich lymphoid proliferations can be distinguished from B-lineage acute lymphoblastic leukemia by integration of morphology, immunophenotype, adhesion molecule expression, and architectural features

Distinction of normal B-lymphoid proliferations including precursors known as hematogones from acute lymphoblastic leukemia (ALL) is critical for disease management. We present a multiparameter assessment of 27 bone marrow samples containing at least 25% hematogones (range, 25%-72%) by morphologic review. We used flow cytometry to evaluate B-cell differentiation antigen and adhesion molecule expression and immunohistochemistry on clot sections to evaluate architectural distribution. Flow cytometry revealed that intermediately differentiated cells (CD19+, CD10+) predominated, followed in frequency by CD20+, surface immunoglobulin-positive cells, with CD34+, terminal deoxynucleotidyl transferase (TdT)-positive cells as the smallest subset. Adhesion molecules (CD44, CD54) were expressed more heterogeneously compared with expression in acute lymphoblastic leukemia. Immunohistochemistry revealed that CD34+, TdT-positive cells were dispersed without significant clustering, while CD20+ cells exceeded CD34/TdT-positive cells in 24 of 25 cases. This multidisciplinary study demonstrates that hematogone-rich lymphoid proliferations exhibit a spectrum of B-lymphoid differentiation antigen expression with predominance of intermediate and mature B-lineage cells, heterogeneity of adhesion molecule expression, and nonclustered bone marrow architectural distribution.

Congenital acute megakaryoblastic leukemia (M7) with chromosomal t(1;22)(p13;q13) translocation in a set of identical twins

Chromosomal translocations at t(1;22)(p13;q13) have been reported to occur in a number of infants with acute megakaryoblastic leukemia. A set of female twins with acute megakaryoblastic leukemia are reported with this unique translocation of 1p13 to 22q13. The twins presented at 2 months of age with fever and poor feeding and subsequently developed progressive hepatosplenomegaly. One twin died before treatment could be started; the other became septicemic 5 days after initiation of chemotherapy and eventually died.

A case report of neutrophilic eccrine hidradenitis in a patient receiving chemotherapy for acute myeloid leukaemia

Neutrophilic eccrine hidradenitis (NEH) is a neutrophilic dermatosis primarily affecting the eccrine glands and occurs in patients undergoing chemotherapy. It must be distinguished from infections, drug eruptions, leukaemia cutis or other forms of skin diseases. As it is self-limiting, establishing the diagnosis will avoid unnecessary treatment for infections or changes in drug therapy.

Acute promyelocytic leukemia with a dicentric chromosome involving chromosomes 11, 17, and 18

We report a case of acute promyelocytic leukemia with dicentric chromosome resulting from translocation of chromosomes 11, 17, and 18.

Highly complex chromosomal rearrangement of chromosome 9 in a case of chronic myeloid leukemia

A 63-year-old man with chronic myeloid leukemia (CML) was found to have a new complex Philadelphia translocation. All of the bone marrow cells had a rearrangement of a five-way translocation, t(9;22;10;12;1), involving a single chromosome 9. The patient went into blast crisis two years after initial diagnosis and the karyotype remained unchanged. He died in blast crisis 10 months later. We believe this case is a unique 5-way translocation in which four chromosomes were translocated to a single chromosome.

A case of t(8;14) with total and partial trisomy 3 in Waldenstrom macroglobulinemia

A case of Waldenstrom macroglobulinemia with Burkitt-type t(8;14)(q24.1;q32) and total and partial trisomy 3 is reported. This is an unusual combination of chromosomal abnormalities in Waldenstrom macroglobulinemia.

The binge eating and emotional change in a patient with postinfectious encephalomyelitis

Postinfectious encephalomyelitis is a kind of demyelinating disease with pathological characteristics and a monophasic clinical course. Herein, we describe a patient who had the symptoms of binge eating, fatigue, memory impairment, hypotalkativeness, hypoactivity, lethargy, incoherent speech, dysphoric mood, and episodic disorientation. Only elevation of CSF protein was noted upon initial admission; however, blurred vision of the eyes developed progressively after discharge. A magnetic resonance image (MRI) scanning of the brain demonstrated scattered lesions of low signal intensity on T1-weighted images and high areas on T2-weighted images in the left thalamus, bilateral hypothalamus and midbrain. The findings of MRI image, CSF, and clinical course all suggested postinfectious encephalomyelitis. After a treatment of prednisolone, a follow-up MRI revealed evidence of improvement, and the binge eating also improved.

A comparison of clinical and endoscopic features of bleeding and non-bleeding peptic ulcer in Singapore

Two hundred and seventy-seven consecutive cases of peptic ulcer patients were compared. Of these, 103 presented with acute gastrointestinal haemorrhage and 174 presented with pain. The median age of those who bled (53 years) was not significantly higher than those who presented with pain (50 years) (P > 0.05). Bleeding peptic ulcer patients, when compared to non-bleeding ulcer patients, tended to present with a past history of gastrointestinal haemorrhage, have ingested non-steroidal anti-inflammatory drugs, and have, at endoscopy, ulcers greater than 1.5 cm in diameter. The site and number of ulcers did not influence the mode of presentation. About 60% of bleeding ulcers were found in the duodenum and this proportion of duodenal ulcers was not significantly different in both groups of patients. Gastric ulcer patients who bled tended to be significantly associated with ingestion of non-steroidal anti-inflammatory drugs. Gender and ethnic distribution, smoking and alcohol ingestion were all not associated with the presentation of haemorrhage.

Acute lymphoblastic leukemia with myeloperoxidase activity

The French-American-British (FAB) classification of acute leukemias is based on the light microscopic detection of myeloperoxidase (MPO) activity in blast cells. Cells with MPO activity in > 3% of cells are classified as acute myeloid leukemia (AML) and usually express myeloid cell surface antigens. We describe a case of acute leukemia in which the blast cells have lymphoid morphology, ultrastructure, immunophenotype, and molecular rearrangements, but express significant amounts of MPO. We discuss the incidence, features, and outcome of MPO-positive acute lymphoblastic leukemia (ALL).

Endoscopic adrenaline injection in treatment of bleeding peptic ulcers

This study aimed to compare the results of bleeding peptic ulcer treated by endoscopic adrenaline injection with controls treated conventionally. Between January 1991 and December 1993, 69 patients with actively bleeding peptic ulcers with visible vessel received endoscopic adrenaline injection. This group of patients was compared with 31 endoscopically similar patients treated conventionally, using H2 blockers with or without surgery, from October 1987 to December 1990 prior to the introduction of endoscopic injection therapy in this hospital. Both groups of patients were comparable in terms of age, haemoglobin level on admission and site of ulcer (gastric or duodenal). Permanent haemostasis was attained with endoscopic adrenaline injection in 97% of our patients. Rebleeding occurred in 9% in the injected group vs 39% in the historical control group (p < 0.005). Three percent of patients in the injected group had emergency surgery compared with 48% in the control group (p < 0.005). The median hospital stay and transfusion requirements in the injected group were 6 days and 2 units respectively vs 8 days and 3 units in the control group but the difference was not statistically significant. We conclude that endoscopic adrenaline injection is effective in the treatment of bleeding peptic ulcer leading to a reduction in rebleeding rate and emergency surgery.

Peptic ulcer disease in the elderly in Singapore

Of 460 patients with peptic ulcer disease seen over a 30-month period, there were 174 elderly patients (defined as > or = 60 years old), constituting 38%. In this group of elderly, gastric ulcers (GU) were observed more frequently than duodenal ulcers (DU) with a ratio of 1.6:1 and the male to female ratio was 1.7:1. In patients < 60 years old, there were more DU than GU with a ratio of 2.7:1, and a higher male to female ratio of 3.7:1. Seventy-two per cent of the elderly had at least one other medical condition with 20% having three or more medical problems. Hypertension and ischaemic heart disease were the most frequently encountered illnesses. Half the elderly presented with upper abdominal pain and one-third had an atypical presentation. Analgesic ingestion in the preceding 4 weeks was present in 29% of the elderly. In the elderly, bleeding was the most frequent complication occurring in 50%; perforation occurred in 2%. In those with bleeding ulcers, 44% had history of analgesic usage. The mortality of bleeding peptic ulcer in the elderly, was 11% and this was largely due to concurrent medical conditions. Only two deaths occurred due to bleeding ulcer.

A proposed pathogenetic process in the formation of Aspergillus mycotic aneurysm in the central nervous system

By selectively infiltrating and destroying the internal elastica of a major cerebral artery, Aspergillus fungus (Af) induces disruption and incipient dilatation of the vascular wall with or without inflammation. This unique pathogenetic mechanism of forming "true" fungal mycotic aneurysms (FMAs) was clearly demonstrated in a middle-aged adult male who died of a pontine stroke. The latter was secondary to thrombosis in the basilar artery of which the internal elastica was infiltrated and replaced by Af hyphae. The patient had diabetes, liver cirrhosis with oesophageal varices, and received multiple blood transfusions. However, leukopenia was not present and immunosuppressive drugs were not used. This case prompted comparison of the natural history and pathogenesis of bacterial and fungal mycotic aneurysms in cerebral arterial branches. Selective destruction of the internal elastica with progressive dilation at a segment of vascular wall insinuates a potential pathogenetic process involved in the formation of saccular or berry aneurysm. Management and therapeutic approaches for FMA are discussed.

Nizatidine versus cimetidine in the treatment of duodenal ulcers

An open comparative trial of nizatidine in the treatment of duodenal ulcer (DU) was carried out with cimetidine as control. Forty-three patients with endoscopically proven DU were recruited into the study. Twenty-three patients were assigned to treatment with nizatidine 300 mg daily and 20 patients (controls) were on cimetidine 800 mg daily. Both groups were comparable in age and sex distribution - age range 21 to 74 years; mean 53.4 years and 43 years in the nizatidine and cimetidine groups respectively. Liver function tests, full blood counts, platelets, urea, electrolytes were done together with endoscopy at four, eight, twelve weeks. In the nizatidine group, 16 patients completed the study whilst 17 patients on cimetidine completed the study. Healing rates at four and eight weeks on nizatidine were 9/16 (56%) and 14/16 (87.5%) respectively. On cimetidine, healing rates at four and eight weeks were 14/17 (80%) and 16/17 (94%) respectively. There was no statistical difference in healing rates between the two groups at four and eight weeks (p = 0.1, p = 0.47). One patient on nizatidine developed urticaria rash which resolved on drug withdrawal. No other adverse clinical or biochemical effects were observed in the cohort after twelve weeks of treatment. Nizatidine is as effective as cimetidine in healing DU at four and eight weeks.

Lichen planus: a study of 72 cases in Singapore

Seventy-two patients attending this hospital with a diagnosis of lichen planus were examined. There was a striking predominance of Indians (69%) and a surprisingly low incidence of Chinese (24%) and Malays (4%) in the study population, compared to the racial composition of the general clinic population. The age distribution curve of the study population was bimodal with peaks at age groups 21-30 (22%) and 41-60 (33%) years. The most common morphologic variant was lichen planus vulgaris (common type) which we observed in 46 (64%) patients, followed by lichen planus hypertrophicus in 8 (11%) and lichen planus atrophicus in 2 (3%). Lichen planus confined to the skin was observed in 49 (68%) patients. Mucous membrane involvement was seen in 21 (29%)-17 (24%) had oral mucosa membrane involvement and 4 (6%) genital mucous membrane involvement. In 16 (22%) cases, mucous membranes were exclusively involved--12 (17%) had oral mucous membrane involvement and 4 (6%) genital mucous membrane involvement. Nail changes were only observed in 2 (3%) patients. Eight (11%) patients had associated diabetes mellitus. Overall, lichen planus appeared to pursue a protracted course with only 4 (6%) patients clearing completely after a disease duration of 5-12 months.