Four cancer cases after esophageal atresia repair: Time to start screening the upper gastrointestinal tract

Esophageal atresia(EA) is one of the most common congenital digestive malformations and requires surgical correction early in life. Dedicated centers have reported survival rates up to 95%. The most frequent comorbidities after EA repair are dysphagia(72%) and gastroesophageal reflux(GER)(67%). Chronic GER after EA repair might lead to mucosal damage, esophageal stricturing, Barrett's esophagus and eventually esophageal adenocarcinoma. Several long-term follow-up studies found an increased risk of Barrett's esophagus and esophageal carcinoma in EA patients, both at a relatively young age. Given these findings, the recent ESPGHAN-NASPGHAN guideline recommends routine endoscopy in adults born with EA. We report a series of four EA patients who developed a carcinoma of the gastrointestinal tract: three esophageal carcinoma and one colorectal carcinoma in a colonic interposition. These cases emphasize the importance of lifelong screening of the upper gastrointestinal tract in EA patients.     

Comparison of Three Methods for Diagnosis of Cutaneous Leishmaniasis

Background

Leishmaniasis is one of the infectious parasitic diseases of highest incidence in the world. Cutaneous Leishmaniasis (CL) has long been reported in Shiraz, Southern Iran. There is a need to find a sensitive and specific method for treatment and control of the disease.

Methods

We have compared the sensitivity of the conventional methods microscopy and cultivation of lesion scrapes against PCR amplification of parasite kinetoplast DNA from these samples. The samples (n=219) were obtained from the patients clinically suspected of CL. The smears were stained with Giemsa for microscopy and cultured in Novy-Nicolle-McNeal (NNN) blood agar for promastigote growth. For PCR, the dry smears were scraped off the slides and DNA was extracted.

Results

The positive rates from 219 specimens were 76.71%, 50.68%, and 93.61% for microscopy, cultivation, and PCR, respectively. The highest correlation was found between PCR and microscopy method (P=0.014). In PCR assay, 95.61%, 3.9%, and 0.49% of the samples were identified as Leishmania major, L. tropica, and dermatropic L. infantum, respectively.

Conclusion

The PCR method appears to be the most sensitive for the diagnosis of CL and is valuable for identifying the other species of Leishmania with confusing dermatropic signs.     

Comparing lignocaine-adrenaline-tetracaine gel with lignocaine infiltration for anesthesia during repair of lacerations: A randomized trial

BACKGROUND:

This study aimed to compare the topical anesthetic lignocaine, adrenaline, and tetracaine (LAT) (4% lignocaine, 1:2 000 adrenaline, 1% tetracaine) with the conventional lignocaine infiltration(LI) for repair of minor lacerations, for the comfort of anesthetic administration, efficacy, adverse effects and cost.

METHODS:

This was a prospective randomized clinical trial. Forty Asian patients who required toilet and suture for minor lacerations in the emergency department of the Singapore General Hospital over a 4-month period. The patients were assigned randomly to 2 arms of treatment. The first was the LAT gel group who had LAT gel applied to the laceration prior to suturing. The second was the control group in whom the anesthetic administered was lignocaine infiltration (LI) via a syringe. The pain of the process of administering anesthetic and efficacy of anesthesia were scored using the visual pain scale included within. The efficacy of LAT vs. lignocaine infiltration as an anesthetic prior to the toilet and suture of minor lacerations and complications of therapy.

RESULTS:

Twenty patients were randomized to LAT gel and 16 to LI on an intention to treat analysis. The mean pain score by patients in the LAT gel group was 2.5 (0.52 SE), and 2.5 (0.58 SE) in the LI group. The pain score for pain during application of the anesthetic was 1.5 (0.40) in the LAT gel group, and 3.5 (0.46) in the LI group. There was no difference in complications between the LAT and LI groups

CONCLUSION:

LAT gel prior to the toilet and suture of minor lacerations is proven to be as efficacious as LI in terms of patient comfort and effectiveness of anesthesia. The complications are also comparable to those treated with LI.KEY WORDS: Lignocaine infiltration, Lacerations, Emergency department, Pain score     

Tumor necrosis factor-α and interleukin-6 in cirrhotic patients with spontaneous bacterial peritonitis

AIM: To evaluate the role of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in cirrhotic patients who have hepatic and renal impairment with spontaneous bacterial peritonitis (SBP).METHODS: We prospectively studied 120 cirrhotic patients with SBP and 80 cirrhotic patients with sterile ascitic fluid. They included 144 males and 56 females with ages ranging between 34 and 62 years. The diagnosis of cirrhosis was established by clinical and laboratory criteria that did not require histological confirmation. The severity of underlying liver disease was evaluated using Pugh’s modification of Child’s criteria (Child-Pugh scores). Ascitic fluid was sent to the laboratory for cell count, culture, sensitivity testing, and measurement of chemical elements (i.e., albumin, glucose). Specimens were inoculated into aerobic and anaerobic blood culture bottles. Serum and ascitic fluid were also collected in sterile tubes at study entry (before the initiation of antibiotic treatment) and 48 h later. Assays for TNF-α and IL-6 in the serum and ascitic fluid were performed with an immunoenzymometric assay using manufacture’s instructions.RESULTS: Cytokine levels in serum and ascitic fluid were significantly higher in the patients with SBP. (plasma TNF-α: 135.35 ng/mL ± 11.21 ng/mL vs 92.86 ng/mL ± 17.56 ng/mL, P < 0.001; plasma IL-6: 32.30 pg/mL ± 7.07 pg/mL vs 12.11 pg/mL ± 6.53 pg/mL, P < 0.001; ascitic fluid TNF-α: 647.54 ± 107.11 ng/mL vs 238.43 ng/mL ± 65.42 ng/mL, P < 0.001); ascitic fluid IL-6: 132.84 ng/mL ± 34.13 vs 40.41 ± 12.85 pg/mL, P < 0.001). About 48 (40%) cirrhotic patients with SBP developed renal and hepatic impairment and showed significantly higher plasma and ascitic fluid cytokine levels at diagnosis of infection. [(plasma TNF-α: 176.58 ± 17.84 vs 135.35 ± 11.21 ng/mL) (P < 0.001) and (IL-6: 57.83 ± 7.85 vs 32.30 ± 7.07 pg/mL) (P < 0.001); ascitic fluid TNF-α: 958.39 ± 135.72 vs 647.54 ± 107.11 ng/mL, (P < 0.001), ascitic fluid IL-6: 654.74 ± 97.43 vs 132.84 ± 34.13 pg/mL, (P < 0.001)]. Twenty nine patients (60.4%) with SBP and renal impairment died whereas, only four patients (5.55%) with SBP but without renal impairment died from gastrointestinal hemorrhage (P < 0.0005).CONCLUSION: It appears that TNF-α production may enhance liver cell injury and lead to renal impairment. This correlated well with the poor prognosis and significantly increased mortality associated with SBP in cirrhotic patients.     

Autism and the Cognitive Processing Triad: A Case for Revising the Criteria in the Diagnostic and Statistical Manual

TOPIC: The next iteration of the Diagnostic and Statistical Manual of Mental Disorders is due for release in May 2013. The current diagnostic criteria for autism are based on a behavioral triad of impairment, which has been helpful for diagnosis and identifying the need for intervention, but is not useful with regard to developing interventions. Revised diagnostic criteria are needed to better inform research and therapeutic intervention. PURPOSE: This article examines the research underpinning the behavioral triad of impairment to consider alternative explanations and a more useful framing for diagnosis and intervention. SOURCES: Contemporary research and literature on autism were used in this study. CONCLUSIONS: It is proposed that the cognitive processing triad of impaired abstraction, impaired theory of mind, and impaired linguistic processing become the triad of impairment for autism in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. These are investigable at the diagnostic level and can usefully inform intervention. Further, in addressing the debate on whether restrictive and repetitive behavior should remain central to diagnosis or be replaced by a deficit in imagination, the authors argue that both behavioral manifestations are underpinned by impaired abstraction.     

Management of childhood asthma in Western Australia

Aims:   The study aimed to determine how childhood asthma is managed in Western Australia by general practitioners (GPs) and specialist paediatricians.
Methods:   A questionnaire survey was sent to 992 GPs and specialist paediatricians, asking about practice and preferences regarding maintenance management of childhood asthma and treatment of acute asthma. Questions about asthma in infants, pre-school and school-aged children were asked separately.
Results:   The overall response rate was 24.7%, with 188/878 (21.4%) of GPs and 44/62 (71.0%) of paediatricians returning the questionnaire. The decision to start maintenance therapy was generally based on symptom frequency and severity. The first choice for maintenance treatment in all age groups was inhaled corticosteroids (ICS). The second most common treatment varied according to age group, with short-acting β₂-agonist (SBA) preferred for infants, montelukast or short-acting β₂-agonist for pre-schoolers and combination therapy (ICS + long action β₂-agonist) for school-aged children. Objective monitoring of lung function with peak flow or spirometry, was used by 40% of GPs and 59% of paediatricians. Acute asthma was primarily managed with inhaled salbutamol and oral corticosteroids. There were few differences in treatment choice between GPs and paediatricians. Many GPs indicated that they did not treat asthma in infants without specialist consultation.
Conclusions:   These data show good compliance by the minority of GPs responding to the survey and by paediatricians practising in Western Australia with current Australian asthma management guidelines. Major differences in treatment preferences between the groups were not detected.     

二膦酸盐相关性颌骨骨质坏死的影像学表现

目的：探讨二磷酸盐相关性颌骨骨质坏死的影像学特点。方法：回顾性分析5例二膦酸盐相关性颌骨骨质坏死患者的CT及曲面体层资料,所有患者均有长期大剂量静脉使用二膦酸盐类药物的病史,平均用药时间约31个月。结果：5例患者均有下颌骨病变,1例患者上颔骨同时受累,所有患者影像学表现为牙缺失,牙槽窝经久不愈或残存,牙槽骨及颌骨的骨质硬化及骨质破坏并存,伴死骨形成及软组织肿胀。结论：二膦酸盐相关性颌骨骨质坏死的影像学表现多样,影像学检查有助于本病的诊断。     

Pregnancy and radiotherapy: Management options for minimising risk,case series and comprehensive literature review

This article reviews the efficacy and safety of radiotherapy in patients with cancer who are pregnant. Our review provided extended follow‐up results in nine cases, presents a technical discussion on measures taken to minimise foetal radiation exposure and provides a comprehensive summary of the literature. Nine patients who received radiotherapy while pregnant are described. The clinical presentation and outcomes of these and 100 additional cases identified on a systematic literature review are presented. Comparisons of scattered radiation doses from three linear accelerators are presented. The average maternal follow‐up in our series was 8.9 years with one patient having a recurrence of their astrocytoma. In terms of foetal outcome, there were one death in utero, one elective termination of pregnancy and one on which no data were available. Six children, on whom long‐term follow‐up (average 10.3 years) was obtainable, were in good health. Overall, there had been 109 cases of radiotherapy in pregnancy that met our search criteria with 13 adverse outcomes and a median follow‐up of 37 months. Comparisons of three linear accelerators demonstrated significant differences in the amount of scattered radiation to the abdominal surface. In summary radiotherapy during pregnancy can be associated with a significant number of adverse outcomes. While it may be difficult for a patient not to attribute these effects to radiotherapy, it is also difficult to define the mechanisms by which radiotherapy would have caused them, if that were the case.