Anti-hypertensive prescription practices in private hospitals in Malaysia: a prospective, non-interventional, observational study

INTRODUCTION

In managing hypertension, monotherapy and sometimes a combination of more than one agent are used to achieve blood pressure (BP) control. The objective of this prospective, observational, multi-centre study was to assess the level of BP control in patients receiving one or more anti-hypertensive drugs in private medical centres in Malaysia according to the treatment regimens (monotherapy, free drug combinations and single pill combinations).

MATERIALS AND METHODS

Data were collected through medical records and interview sessions with patients on current pharmacotherapy for hypertension management at baseline and 2-3 months later. Results are expressed as mean ± SD for continuous data and as frequencies and percentages for categorical data.

RESULTS

Among 182 recruited patients, 89 (49%) achieved BP control by the end of the study. Majority (62/89) patients were on single-pill (monotherapy or SPC) antihypertensives. Majority (63/89) required more than two antihypertensives to achieve BP control.

CONCLUSION

Both SPC and free drug combination antihypertensives reduced BPs, but physicians preferred SPC to improve BP control and increase treatment compliance.

Composite Hemangioendothelioma With Neuroendocrine Marker Expression: Report of a "Paraganglioma-Like" Paravertebral Case

Composite hemangioendothelioma is a rare vascular tumor morphologically comprising several distinct vascular components and exhibits a borderline malignant potential. We described the case of a 53-year-old female who presented with an infiltrative mass in the paravertebral soft tissue. The tumor showed discrete nests of synaptophysin-expressing epithelioid cells accompanied by rich vasculature, features highly reminiscent of sympathetic paraganglioma. Further analysis revealed areas resembling spindle cell hemangioma, retiform hemangioendothelioma, cavernous hemangioma/lymphangioma, and epithelioid hemangioendothelioma without the myxohyaline matrix in the tumor, and a final diagnosis of composite hemangioendothelioma with synaptophysin expression was made. Critical appraisal of this recently described entity and its possible pathogenic relationship with retiform hemangioendothelioma were discussed.

Updates in the management of Dyslipidaemia in the high and very high risk individual for CV risk reduction

Cardiovascular disease (CVD) has been the main cause of mortality and an important cause of morbidity in Malaysia for several years. To reduce global cardiovascular (CV) risk in the population, primary preventive strategies need to be implemented. Hypercholesterolaemia is one of the major risk factors for CVD. This paper is an expert review on the management of hypercholesterolemia focusing on high and very high risk individuals. In low and Intermediate risk individuals, therapeutic lifestyle changes (TLC) and a healthy lifestyle alone may suffice. In high and very high risk individuals, drug therapy in conjunction with TLC are necessary to achieve the target LDL-C levels which have been shown to slow down progression and sometimes even result in regression of atherosclerotic plaques. Statins are first-line drugs because they have been shown in numerous randomized controlled trials to be effective in reducing CV events and to be safe. In some high risk individuals, despite maximally tolerated statin therapy, target Low Density Lipoprotein Cholesterol (LDL-C) levels are not achieved. These include those with familial hypercholesterolaemia and statin intolerance. This paper discusses non-statin therapies, such as ezetimibe and the newer Proprotein convertase subtilisin/kexin type 9 Inhibitors (PCSK9-i).

Tibiotalocalcaneal (TTC) arthrodesis with reverse PHILOS plate and medial cannulated screws with lateral approach

BACKGROUND

Tibiotalocalcaneal arthrodesis is most common and effective surgical treatment for severe hindfoot pathology, but the fusion rate is often lower than the ordinary tibiotalar arthrodesis because of the more serious joint disease associated with obvious deformity and osteoporosis. Recent literature describe tibiotalocalcaneal arthrodesis with reverse PHILOS plate with good clinical outcome result, though some patients non-union, due to eccentric force of the plate may be hidden. The purpose of this study was to evaluate clinical outcome of the lateral approach for tibiotalocalcaneal (TTC) arthrodesis with reverse PHILOS Plate and medial cannulated screw.

METHODS

Between Jun, 2013 to April, 2015 12 patient with hindfoot pathology had TTC arthrodesis with a reverse PHILOS plate with medial cannulated screw through a lateral approach with resection of the distal fibula and bone graft. Perioperatively observe for wound and neurovascular status. Patients were follow-up from post-operative 1, 3, 6 and12 months, to observation of wound healing, ankle pain, subtalar Joint Fusion, internal fixation and ankle function. Ankle function were scored according to the American Orthopaedic Foot and Ankle Society(AOFAS) Ankle-Hindfoot Scale system.

RESULTS

Twelve ankle fusion all patient follow-up, with mean time to surgery 18.6 months (12-36 month). No cases infection and issue necrosis; one patient complaint of lateral foot numbness we observe and follow-up was spontaneously recovery after 3 months. After 3 months of operation, no obvious pain of ankle joint and internal fixations loose were found. Almost fusion and good axial alignment of TTC joint also were found by X-ray and CT examination. After final fellow-up of each case, no case complain of pain of ankle joint, good fusion and axial alignment of TTC joint were also all found through Terminology. The mean American Orthopaedic Foot and Ankle society (AOFAS) score average was 77.5.

CONCLUSION

TTC arthrodesis with reverse PHILOS Plate and medial cannulated screw have advantages of clear incision, effective bone orthopaedic and graft fully secure, stable internal fixation, high fusion rate and less complications, can effectively correct deformities, alleviate hindfoot pain and improve function, and is an effective method of treatment of after severe hindfoot disease.

TRIAL REGISTRATION

This trial is registered on ClinicalTrials.gov with reference number: ID: NCT02977910 . Registered 26 Nov 2016, retrospectively registered.

Analysis of nano drug carriers towards optimum release rate

The aim of this paper is to determine which polymer shape (sphere, hemisphere, cylinder, tablet, cuboid, tetrahedron or octahedron) is best for zero kinetics drug delivery and for sustained nanoparticle release. We applied the Carslaw and Jaeger heat diffusion equations of a sphere with same order of its effective surface area to volume ratio as a reference, to predict how drug delivery would occur in other shapes. The assumption of the heat diffusion analogy in the present study of negligible drug particles is sensible since the drug at nano scale is tiny and thus nearly 'massless'. From tests involving changing the micro-carrier configuration, we can confirm that shape is an important factor to consider when examining drug release rates, to achieve zero-order design. The preliminary analysis suggests that a hemisphere shape is more promising in achieving zero-order drug release rate, followed by a tablet shape of L = 2R(s), 3R(s), a tetrahedron, a cylindrical shape with L = 3R(s), 2R(s), a sphere, a cuboid shape with L = 3R(s), 2R(s), and finally an octahedron. This is due to the larger effective surface area, given the same parameters and surrounding conditions. In other words, a hemisphere shape reaches zero order in the shortest possible time and thus permits sustained zero-order particle release rate. Based on the ratio between the surface area of a micro-carrier and its volume, we further derived the drug release equation of cylinder/tablet shaped micro-carrier. By introducing h as an index of the similarity of the drug release rate to a desirable zero-order drug release rate, we obtained a relationship between different length/radius (L/R) values of cylinder/tablet shapes and the index h. From this relationship, we find the best L/R ratio that can achieve a drug release process most similar to a zero-order drug release process. Future work is to include optimization of the lipid matrixes.

Pleuroscopy: our initial experience in Hong Kong

OBJECTIVE

To report our preliminary experience using pleuroscopy for patients with pleural diseases.

DESIGN

Prospective cohort study.

SETTING

Tertiary referral hospital with service input from respiratory physicians and cardiothoracic surgeons in Hong Kong.

PATIENTS

Between April and November 2007, patients with undiagnosed exudative pleural effusions and proven malignant pleural effusions were recruited for diagnostic evaluations and therapeutic interventions, respectively.

INTERVENTION

Pleuroscopy with a semi-rigid thoracoscope performed under local anaesthesia and conscious sedation.

RESULTS

A total of 20 patients (16 males and 4 females; mean age, 63 years) underwent the procedure and were followed up for a mean of 19 weeks. For the 14 patients having diagnostic pleuroscopy, the yield was 79% (11 patients). The 3-month success rate for the six patients undergoing pleurodesis was 83% (five patients). Complications were mild and included self-limiting fever (20%, four patients) and localised subcutaneous emphysema (20%, four patients). No major complications or mortality were noted.

CONCLUSION

Pleuroscopy using a semi-rigid instrument is a safe and efficacious procedure for the management of pleural diseases in suitable patients.

Adenocarcinoma of the duodenum

Adenocarcinoma of the duodenum is an exceedingly rare disorder. Its vague and non-specific symptoms often lead clinicians and patients to suspect other more benign differential diagnoses. Improved endoscopy and radiology have enabled more of these cases to be unearthed. Definitive surgery is the only means of potential cure, with the prognosis being significantly better for node-negative patients. We present a case of a 52-year-old man who underwent a Whipple's operation for this uncommon disease and a literature review of the subject.

Solid-phase low temperature steam-assisted synthesis of thermal stable alumina nanowires

A simple steam-assisted solid phase synthesis method was developed for synthesis of boehmite nanowires in the presence of TEAOH surfactant. The boehmite nanowires had uniform diameters (12-16 nm) and length up to 1-2 microm. The morphology of the nanostructured wires was well preserved after being converted to pure gamma-Al2O3 by thermal treatment at 600 degrees C for 5 h. The nanowires of Al2O3 exhibited excellent thermal stability by retarding the phase transformation and maintaining the wires-like nanostructure after being aged up to 1300 degrees C by preventing sintering between particles at high temperatures. The surface areas of Al2O3 nanowires could be maintained as high as 68 m2/g at 1300 degrees C while the surface areas of Al2O3 micropowder shrank to 0.89 m2/g after same thermal treatment. Both in-situ XRD and 27Al NMR results indicated that the crystal structure of gamma-Al2O3 nanowires was not transformed to alpha-Al2O3 at 1300 degrees C whereas micropowder Al2O3 was fully converted to alpha-Al2O3 at 1100 degrees C.

Numerical modelling of biopotential field for detection of breast tumour

Breast cancer is a disease characterised by the uncontrolled growth of abnormal cells. These cancer cells can travel through the body by way of blood or lymph nodes. Previous studies have indicated that, changes in the electrical properties of abnormal breast are more significant compared to the breast normal tissues. In the present study, a simple 2D models of breast (close to realistic), with and without artificially inserted malignant cancer were simulated, based upon electrical activity within the breast. We developed an inhomogeneous female breast model, closer to the actual, by considering a breast as a hemisphere with various layers of unequal thickness in supine condition. In order to determine the potential distribution developed due to a dipole source, isotropic homogeneous conductivity was assigned to each of these compartments and the volume conductor problem was solved using finite element method. Significant changes in the potential distribution were recoded in the malignant and normal breast regions. The surface potential decreases about 0.5%, for the small malignant region of surface area 13 mm(2) (spherical diameter=2mm). And it (surface potential) decreases about 16.4% for large malignant surface area of 615 mm(2) (spherical diameter=14 mm). Hence, the results show that, the sizes of tumours result in the reduction of surface potential and follows a fourth order polynomial equation. Thus, biofield analysis yields promising results in the detection of the breast cancer of various sizes.

Pyothorax-associated large B-cell lymphoma: case report with emphasis on the potential diagnostic challenge

A rare case of pyothorax-associated large B-cell lymphoma occurring in Hong Kong is reported. The patient was a 64-year-old Chinese male who presented with shortness of breath and pleuritic pain. Radiological examination revealed left pleural thickening associated with bilateral pleural effusion. Open biopsy of the thickened parietal pleura revealed occasional large malignant lymphoid cells of B lineage admixed with fibrin and hyalinised fibrous tissue. These lymphoma cells were shown to harbour both Epstein-Barr virus and human herpesvirus type 8 by in situ hybridisation and immunohistochemical study, respectively. There was no associated lymphadenopathy and hepatosplenomegaly. The clinicoradiological presentation and pathological findings thus fulfilled the criteria of the so-called pyothorax-associated large B-cell lymphoma. Awareness of this rare entity, together with diligent histological examination and proper application of ancillary investigative techniques, are essential for making a correct diagnosis. The co-infection with Epstein-Barr virus and human herpesvirus type 8 in this case also suggests a possible pathogenetic relationship between pyothorax-associated large B-cell lymphoma and primary effusion lymphoma.

Peritoneal washing cytology findings of disseminated myxoid leiomyosarcoma of uterus: report of a case with emphasis on possible differential diagnosis

We report the cytology findings of a rare case of myxoid leiomyosarcoma of the uterus with intraabdominal dissemination. The cytology showed uniformly dispersed spindly to polygonal "epithelioid" tumor cells focally linked by background matrix. Spindly tumor cells attaching to and radiating from branching capillary structures were also present. Occasionally, scattered "signet-ring" cells were found, mimicking metastatic poorly differentiated adenocarcinoma. The background mucoid substance was more conspicuous in the cell block sections. Gross and histologic examination of the surgical specimen revealed a large uterine leiomyosarcoma with prominent myxoid change. Ultrastructural study showed that the "signet-ring" appearance was mainly due to degenerative cytoplasmic change with ballooning of mitochondria, dilatation of endoplasmic reticulum, and elevation of outer nuclear membrane. In contrast to other spindle cell malignancies such as sarcomatoid mesothelioma, sarcomatoid carcinoma, or malignant melanoma, true sarcoma cells in general carry a distinctive cytologic appearance in washing/effusion fluid. In a correct clinical setting, the peculiar association with mucoid matrix and absence of classic lipoblasts should also raise the suspicion of metastatic myxoid leiomyosarcoma.

Thyroid transcription factor-1 is highly sensitive and specific in differentiating metastatic pulmonary from extrapulmonary adenocarcinoma in effusion fluid cytology specimens

BACKGROUND

Thyroid transcription factor-1 (TTF-1) is a homeodomain-containing transcription factor selectively expressed in thyroid, lung and diencephalon. It has been shown to label pulmonary adenocarcinoma, thyroid tumors, and small cell carcinoma (pulmonary and extrapulmonary) with relatively high sensitivity and specificity. The usefulness of this immunostain in cytology specimens has not been thoroughly discussed in the literature.

METHODS

The authors evaluated 36 effusion cytology cases (17 pleural effusion, 18 ascitic fluid, and 1 pericardial effusion) diagnosed as metastatic adenocarcinoma and with cell blocks prepared from the file of Pamela Youde Nethersole Eastern Hospital, Hong Kong, during a three-year period from 1998 to early 2001. The clinical, radiologic, cytologic, and histologic (if any) findings were reviewed. A provisional diagnosis of the primary site was deduced for each of the 36 cases by clinical, radiologic, and/or histologic correlation. Immunohistochemical study was performed on the cell block sections of the effusion cytology specimens using mouse monoclonal antibody against TTF-1, after microwave heat-antigen retrieval. The results were correlated with the primary origin of the metastatic adenocarcinoma.

RESULTS

Among the 17 cases of metastatic pulmonary adenocarcinoma, 15 cases showed nuclear staining for TTF-1 in most of the tumor cells (sensitivity, 88.2%). None of the 19 cases of metastatic extrapulmonary adenocarcinoma expressed TTF-1 (specificity, 100%).

CONCLUSIONS

The current study validates TTF-1 as a highly sensitive and specific immunomarker for distinguishing between metastatic pulmonary and extrapulmonary adenocarcinoma in effusion cytology specimens, which are known to be associated with intrinsic artifact due to less than ideal cellular preservation.

Dirofilariasis of breast: report of two cases diagnosed by fine-needle aspiration biopsy

We report on 2 cases of dirofilariasis of the breast occurring in adult Chinese females residing in Hong Kong. The diagnosis was made by fine-needle aspiration biopsies. The direct smears contained numerous acute inflammatory cells, including eosinophils. A partially necrotic adult nematode of about 400-450 microm in diameter was identified in the cell-block sections of each case. The worm was characterized by a thick cuticle with longitudinal cuticular ridges and fine transverse surface striations, abundant somatic muscle, an intestine, and a reproductive tube or uterus. The morphologic features of this round worm were most compatible with those of Dirofilaria repens. While the clinical and radiologic findings of dirofilariasis of the breast are nonspecific and mimic those of breast neoplasms or inflammatory conditions, a definitive diagnosis is possible with fine-needle aspiration biopsy. A correct diagnosis of dirofilariasis may help to spare patients from unnecessary medical and surgical interventions.

Crush preparation findings of "sarcomatoid" chordoma of the sacrum: report of a case with histologic, immunohistochemical, and ultrastructural correlation

We report on the crush preparation findings of a case of "sarcomatoid" chordoma occurring in the sacral region of a 78-yr-old Chinese male. The smears showed clumps and small cords of polygonal tumor cells containing bubbly cytoplasm and round to oval nuclei. Focally, there were also aggregates of long filamentous spindle cells and stellate bizarre cells with marked nuclear pleomorphism. Occasional tumor cells were seen in association with dense amorphous material. Histologic examination of the excised specimen showed features of the so-called "sarcomatoid" chordoma which consisted of prominent foci of mitotically inactive spindle and pleomorphic cells, in addition to the conventional chordoma areas. An osteosarcoma-like pattern of probably metaplastic nature was also seen within the tumor. Immunohistochemical study showed that most tumor cells expressed cytokeratins. Ultrastructural examination revealed the characteristic rough endoplasmic reticulum-mitochondria complexes. While there are many spindle and pleomorphic cells seen in crush preparations, the distinction from other true high-grade malignancies is important. Recognition of these "pseudoanaplastic" cytologic features also helps to expand the morphologic spectrum of chordoma.

Fine needle aspiration cytology of invasive micropapillary carcinoma of the breast: review of cases in a three-year period

OBJECTIVE

To describe the fine needle aspiration cytology findings of invasive micropapillary carcinoma and correlate them with the histologic appearance.

STUDY DESIGN

We reviewed the cytologic features of three cases of pure invasive micropapillary carcinoma in the files of Pamela Youde Nethersole Eastern Hospital from 1998 through 2000. Immunohistochemical study for epithelial membrane antigen was performed retrospectively on the cell block sections. Ultrastructural examination was also carried out on one of the cases.

RESULTS

Two of the tumors were at pathologic stage II, and the remaining case was at stage III. Ipsilateral axillary lymph node metastases with similar morphology were seen in two of them. Cytologically, the smears were of moderate cellularity and composed of three-dimensional tumor cell balls, abortive and sometimes branching papillae, angulated tumor cell clusters, morules and occasional acini. Some of the tumor cell balls possessed scalloped borders. Focally, the tumor morules clustered together and were separated from each other by small, slitlike spaces. A small number of isolated malignant cells was also present in the background. The cell block sections showed mainly dispersed acini of tumor cells. The "reverse polarity" highlighted in histologic sections by immunohistochemical study for epithelial membrane antigen was not consistently demonstrated in the cell block material. Ultrastructural examination confirmed the focal presence of surface microvilli on the periphery of the tumor cell morules.

CONCLUSION

Invasive micropapillary carcinoma of the breast possesses some subtle but distinctive cytologic features. With the help of cell block morphology and ancillary techniques, the preoperative suspicion of this rare subtype of ductal carcinoma, which carries a high propensity for lymphatic permeation, is possible.

Sclerosing hemangioma of lung: A close cytologic mimicker of pulmonary adenocarcinoma

We report the fine-needle aspiration biopsy findings of sclerosing hemangioma of lung occurring in a 40-yr-old Chinese woman. Cytologically, there were hyalinized stromal tissue fragments admixed with clusters of nondescript mononuclear tumor cells. Scattered foamy macrophages and red blood cells were also noted in the background. Focal papillary and acinar configurations were seen. However, some of the epithelial cells show nuclear pleomorphism with nuclear hyperchromasia, prominent nucleoli, and occasional intranuclear inclusions. Mitotic activity was virtually absent. The cytologic atypia present may result in misdiagnosis of well-differentiated pulmonary adenocarcinoma, especially bronchioloalveolar carcinoma. Recognition of the subtle cytologic differences, together with cell block examination, immunocytochemistry, and proper clinicoradiologic correlation, is crucial for an accurate preoperative diagnosis.

Conceptual dilemmas in evaluating individuals with severely impaired consciousness

States of severely impaired consciousness (SIC) are characterized by cognitive and motor limitations. This case report describes a 45-year-old female with impaired consciousness who began to 'walk'. She initially presented to the hospital unresponsive and was subsequently diagnosed with metabolic encephalopathy due to severe hypoglycaemia. Traditional indices of consciousness indicated a low level of responsiveness; however, during physical therapy, she displayed reciprocal walking movements when lifted to a standing position by two therapists. Despite her ability to walk increased distances during and after neurorehabilitation, she was unable to consistently demonstrate responses indicative of higher levels of consciousness. This case illustrates the challenge of rating patients with limited behavioural repertoire using established measures of impaired consciousness.

Fine needle aspiration cytology of invasive cribriform carcinoma of the breast with osteoclastlike giant cells: a case report

BACKGROUND

Nonneoplastic osteoclastlike giant cells are occasionally associated with carcinoma of the breast, pancreatobiliary and gastrointestinal systems. In the breast, this uncommon stromal response is seen mainly in invasive carcinoma with low grade cytology, among which invasive cribriform carcinoma is the classic example. Details of the fine needle aspiration cytology of this phenomenon, especially in thin-layer preparations, have been described rarely.

CASE

The fine needle aspiration cytology of an invasive cribriform carcinoma of the breast occurred in a 66-year-old woman. Cytology showed cohesive sheets and three-dimensional cribriform clusters of bland-looking and mitotically inactive ductal cells in a blood-stained background. Scattered multinucleated, osteoclastlike giant cells, some containing hemosiderin granules, were also seen. Myoepithelial cells and naked nuclei were not obvious. The cellular composition was more discernible in liquid-based cytologic preparations. Histologic examination of the excisional biopsy showed an invasive cribriform carcinoma associated with many osteoclastlike giant cells in a hypervascular stroma.

CONCLUSION

In view of the extremely low grade cytology of the malignant ductal cells, invasive cribriform carcinoma may closely mimic benign proliferative breast diseases on fine needle aspiration biopsy. Recognition of this special relationship with osteoclastlike giant cells, which are rarely present in certain subtypes of breast cancer but not benign lesions, can help to arrive at a correct cytologic diagnosis.

Arias-Stella atypia in a paratubal cyst: a rare phenomenon with potential diagnostic pitfalls

BACKGROUND

Arias-Stella reaction is commonly encountered in the endometrium during the gestational period and puerperium. Similar changes in the tubal epithelium are exceedingly rare. The cytologic findings of this phenomenon have never been described before.

CASE

Cytologic findings of Arias-Stella changes in the lining cells of a left paratubal cyst in a 41-year-old woman were examined. The smears showed occasional small clusters or isolated tubal epithelial cells consisting of a mixture of ciliated and secretory cells. Some of the ciliated cells showed a marked increase in nuclear and cytoplasmic volume and possessed coarse chromatin, prominent, angulated nucleoli, dense, amphophilic cytoplasm; and a discrete cell membrane. The nuclear membrane was still thin and regular, and these cells were mitotically inactive. The preservation of apical cilia in some of them ensured their benign nature. In some areas, clusters of secretory cells with an increase in both nuclear and cytoplasmic volume and ample, clear cytoplasm were also found. There were small, monolayered sheets of regular and benign-looking epithelial cells with a honeycomb arrangement, suggesting that the Arias-Stella atypia was focal.

CONCLUSION

In view of the presence of scattered giant cells with coarse chromatin and angulated macronucleoli, a false positive cytologic diagnosis of malignancy can be made if one does not pay attention to the coexistence of apical cilia and other subtle changes, including the usual nuclear/cytoplasmic ratio, thin and regular nuclear membrane and absence of mitotic activity.

Sudden death from massive pulmonary tumor embolism due to hepatocellular carcinoma

Massive pulmonary embolism in cancer patients can be due to detached thrombi or tumor. Pulmonary tumor embolism is often undiagnosed antemortem. We report a 52-year-old Chinese man admitted for management of hepatocellular carcinoma (HCC). Computerized tomography showed tumor involvement of hepatic vein and inferior vena cava. He died suddenly on the day of admission. At autopsy the main pulmonary arteries of both lungs were blocked by large tumor emboli, the immediate cause of death. Although rapid death in patients with HCC is usually caused by intraperitoneal hemorrhage from spontaneous rupture of tumor, massive pulmonary tumor embolism should also be considered in these patients, especially when antemortem evidence of hepatic vein and/or inferior vena cava invasion is present.

Metamerism in aesthetic prostheses under three standard illuminants--TL84, D65 and F

This study looks at the effect of metamerism in colour-matching and the assessment of multi-layered silicone rubber finger prostheses. The aim was to identify the choice of illuminants for colour matching the prostheses that would give rise to the least metameric effect between the prostheses and the human skin or the best colour match. The prostheses were prepared and colour matched to a fair-skinned subject under 3 reference illuminants--TL84, D65, F and a combination of illuminants--TL84, D65 and F. The prostheses were then measured for colour using a spectrophotometer based on the CIE indices L*, a*, b* with each prosthesis assessed separately against the subject's index finger under the reference illuminants--TL84, D65 and F. The prostheses were also assessed by a panel of 50 observers and scored according to colour-match. Colour differences between the skin and prosthesis were measured in the illuminant under which the prostheses were prepared and then under the other reference illuminants. A relationship was obtained between the measured mean colour difference, deltaE*, and the mean visual assessment score for each prosthesis. This paper points out the concerns related to the optical phenomenon of metamerism with the colour pigments used. This can affect the colour match of the prosthesis as perceived by the patient. The findings seem to suggest that this metameric colour difference can be minimised if the prosthesis is matched under a combination of lights, which were found to give the best-perceived match.

Fine needle aspiration cytology of epithelial-myoepithelial carcinoma of salivary glands. A report of three cases

BACKGROUND

Epithelial-myoepithelial carcinoma is a rare, low grade malignant tumor of the salivary glands. Histologically, it has a biphasic cellular composition and exhibits a high degree of differentiation. The fine needle aspiration cytology of this rare tumor is rarely described in the literature.

CASES

We report the fine needle aspiration cytology of three epithelial-myoepithelial carcinomas, arising in the right parotid, left parotid and minor salivary gland of the hard palate. Cytology showed a biphasic population consisting of cells of ductal epithelial and myoepithelial origin arranged in small clusters and sheets. The myoepithelial cells had small, uniform nuclei; ample, clear cytoplasm and distinct cell borders, while the ductal epithelial cells had larger, mildly pleomorphic nuclei and scanty cytoplasm. These ductal cells tended to form tubules among background sheets of clear myoepithelial cells. This feature, if present, was an important diagnostic clue. Hyaline material surrounding cell clusters and focal adenoid cystic carcinoma-like areas with orangeophilic globules were also not uncommon.

CONCLUSION

While the cytologic appearance of epithelial-myoepithelial carcinoma may closely mimic that of other salivary gland tumors, such as adenoid cystic carcinoma, pleomorphic adenoma and basal cell adenoma, certain peculiar cytologic features may allow a distinction to be made on fine needle aspiration biopsy.

Actin inclusions in stromal cells of fibroepithelial tumor of breast: immunohistochemical and ultrastructural studies

An uncommon occurrence of actin inclusions in the stromal cells of a benign fibroepithelial tumor of breast is reported. Histologically, many of the stromal cells contained round and eosinophilic intracytoplasmic inclusions identical to those seen in inclusion body fibromatosis. Ultrastructurally, these inclusions represented dense spherical clumps of microfilaments derived from rough endoplasmic reticulum. The literature was reviewed and follow-up data showed that the clinical course of these morphologically distinctive benign fibroepithelial tumors was relatively indolent if completely excised, in contrast to inclusion body fibromatosis, which commonly recurs. The pathogenesis may be related to abnormal production of truncated actin filaments or alteration in microenvironment.

Creating a model for fabricating a partial hand glove prosthesis using the realigned casts of the contralateral digits

A method for creating a model for fabricating a partial hand glove prosthesis is described. The realigned casts of the corresponding digits of the contralateral uninjured hand were used to substitute for the lost digits on a cast of the stump. The technique allows an exact reproduction of the anatomical and fine surface details of the digits. It has the advantage of customisation, allowing a close match in the size, shape and surface characteristics of the prosthesis to that of the remaining digits of the hand.

Desmoplastic malignant melanoma on the buttock of an 18-year-old girl: differentiation from desmoplastic nevus

Melanocytic proliferation in young people may sometimes pose a diagnostic dilemma. This is particularly so when a desmoplastic component is present. Because the two main differential diagnoses, desmoplastic malignant melanoma and desmoplastic Spitz nevus, share some morphologic features, the diagnosis of desmoplastic malignant melanoma may be overlooked. Distinction between the two is important because they show completely different biological behavior. The age of patient, site of lesion, histologic findings of melanocytic atypia, neurotropism, mitosis, and maturation help to distinguish the two entities. We report a case of desmoplastic malignant melanoma occurring in the buttock of an 18-year-old Chinese girl. Histologically, it had typical features of desmoplastic malignant melanoma with junctional melanocytic atypia and prominent neurotropism. Clinical and histologic differences between desmoplastic malignant melanoma and desmoplastic Spitz nevus are reviewed. We conclude that although desmoplastic Spitz nevus occurs much more commonly in adolescents, desmoplastic malignant melanoma can occur in this age group and even in non-sunexposed skin. Microscopic findings remain the mainstay that guides the final diagnosis.

Ego-syntonic alien hand syndrome after right posterior cerebral artery stroke

The alien hand syndrome classically consists of involuntary movements accompanied by a feeling of foreignness and personification of the affected limb. Autocriticism, in which patients criticize and express astonished frustration with the behavior of the autonomous limb, is a commonly noted feature. Most cases of alien hand are associated with lesions of the supplementary motor areas of the frontal lobes, the corpus callosum, or both. The authors report on a 79-year-old man who sustained a right posterior cerebral artery distribution infarction and developed alien hand syndrome in the absence of callosal involvement. Also unique is that the patient perceived the alien hand as acceptable and positive, not hostile and repugnant. This case suggests not only that the neuroanatomic regions responsible for alien hand syndrome may require re-examination, but also that its definition may need expansion.

Fine needle aspiration cytology of myxopapillary ependymoma. A case report

BACKGROUND

Myxopapillary ependymoma is a variant of ependymoma that usually occurs in the sacrococcygeal region. Histologically, it is characterized by arborizing papillary fronds of capillaries with mucinous stroma rimmed by ependymal cells. The fine needle aspiration cytology of this rare tumor is rarely described in the literature.

CASE

We report the fine needle aspiration cytology of a primary sacrococcygeal myxopapillary ependymoma occurring in a 18-year-old female. Cytology showed "fernlike" papillae and globules of mucinous and myxoid substance containing central capillaries. These structures were rimmed by one to several layers of mitotically inactive, mildly pleomorphic cuboidal to columnar cells with occasional pseudonuclear cytoplasmic inclusions. Some of these ependymal cells sent fibrillary processes toward the capillaries, suggestive of perivascular pseudorosettes. There were also numerous isolated tumor cells in the background.

CONCLUSION

Because of the prominent mucinous elements and papillary fronds, myxopapillary ependymoma may mimic other myxoid or papillary tumors cytologically. Recognition of the characteristic cytologic features may allow a distinction to be made on fine needle aspiration biopsy.

Raised serum hCG in a male patient caused by primary jejunal choriocarcinoma

A rare case of primary choriocarcinoma of the jejunum occurred in a 45 year old Chinese man. This tumour was associated with massive melaena and a markedly raised serum human chorionic gonadotrophin (beta-hCG) concentration. Necropsy examination showed no primary lesion in other possible sites including testes, mediastinum, and pineal gland. Histologically, the tumour showed morphology typical of choriocarcinoma with no adenocarcinomatous element identified. The presence of choriocarcinoma in non-gonadal sites may be explained by retrodifferentiation or metaplasia of a conventional carcinomatous component to primitive trophoblasts. Serum beta-hCG level may represent a useful marker in earlier diagnosis and monitoring of this potentially treatable disease.

Chromic oxide inclusion in the diet does not affect glucose utilization or chromium retention by channel catfish, Ictalurus punctatus

This study was conducted to determine if the level of dietary chromic oxide will affect glucose utilization and tissue chromium retention by channel catfish. Purified diets containing graded levels of supplemental chromic oxide (0, 50, 100, 200, 400, 1000, 5000 and 10,000 mg/kg diet) and glucose as the carbohydrate source were fed to channel catfish fingerlings for 10 wk. Another diet containing dextrin as the carbohydrate source and without chromic oxide supplementation was also fed and served as the control diet. Fish fed the dextrin diet had significantly (P < 0.05) greater weight gain, feed efficiency ratio and protein efficiency ratio but lower plasma glucose concentrations than fish fed the glucose diets irrespective of the level of chromic oxide supplementation. The growth performance and postprandial plasma glucose concentrations of channel catfish fed glucose diets supplemented with various chromic oxide levels were not significantly different. No obvious trends were observed in the whole-body composition of fish fed glucose diets containing various chromic oxide levels. Carbohydrate source or the level of dietary chromic oxide did not significantly affect chromium concentrations in the whole-fish carcass. These results suggest that the level of dietary chromic oxide had no significant effect on glucose utilization or chromium retention by channel catfish. It is suggested that chromic oxide is sufficiently inert to be used as an external marker in digestibility studies in channel catfish.

A technique of acrylic nail fixation in multilayered silicone finger prostheses

A technique for the secure fixation of acrylic nails in multilayered silicone finger prostheses is described. The secure fixation of the nail to the prosthesis is achieved by a method of "sandwiching" portions of the nail between the silicone layers of the prosthesis akin to the overlapping of the nail by the anatomical nail fold and nail wall. In addition the use of a cynoacrylate adhesive ensures strong surface to surface bonding.

Coronary revascularisation in young adults

OBJECTIVE

To evaluate the long-term outcome of coronary artery bypass surgery (CABG) in patients < 40 years old and to determine factors predictive of adverse outcomes.

METHODS

Retrospective review of data on 220 patients who underwent isolated CABG at Green Lane Hospital, New Zealand from 1970 to 1992.

RESULTS

The actuarial survival after surgery was 91, 74 and 50% at 5, 10 and 15 years, respectively. Recurrence of ischaemic symptoms occurred at a median time of 72 months, and only 20% of patients remained asymptomatic 10 years after CABG. Univariate analysis of potentially adverse surgical factors showed that patients who had prolonged bypass time (> or = 100 min, P < 0.007) had increased late mortality. There were two distinct operative eras with respect to the use of IMA conduits (4% pre 1985, 87% post 1984) The relationship between IMA conduits use and survival was significant on time independent analysis (P < 0.02), but was not using the log-rank test. Preoperative clinical characteristics associated with increased late mortality were impaired left ventricular function (end-systolic volume (ESV) > or = 80 ml, P = 0.008; ejection fraction < 40%, P = 0.0005), and lack of aspirin use either pre- or post-operatively (P < 0.0001). Multivariate analysis indicated that reduced ejection fraction (P = 0.04) and prolonged bypass time (P = 0.05) was associated with an increased risk of late death. Aspirin therapy (P = 0.001) was associated with decreased late mortality. Cumulative events rate of reintervention and mortality was reduced in female patients (P = 0.0009). At review, 45% of patients had total cholesterol > 6.5 mmol/l.

CONCLUSION

To avoid the early recurrence of symptoms, the need for reintervention and late mortality, young patients should receive IMA conduits, cardioplegia as myocardial protection, aspirin and therapy to modify/ameliorate their risk factors including dyslipidaemia, diabetes and left ventricular dysfunction.

Cutaneous epithelioid angiosarcoma: a potential diagnostic trap for cytopathologists

We report on the cytologic features of a rare case of cutaneous epithelioid angiosarcoma of the scalp occurring in a 65-yr-old Chinese male. The prominent epithelioid features may cytologically mimic poorly-differentiated carcinoma, malignant melanoma, and even epithelioid sarcoma. Recognition of subtle cytologic features of vasoproliferation, immunohistochemical demonstration of endothelial markers, and ultrastructural examination are necessary before a final conclusion may be drawn.

Diagnostic significance and possible pitfalls of nuclear grooves in extrathyroid cytology

The diagnostic significance of grooved nuclei in the cytology of extrathyroid lesions is not well-described in the literature. Isolated cases of metastatic adult granulosa cell tumor, reactive mesothelial hyperplasia, Langerhans' cell histiocytosis, recurrent renal cell carcinoma, and round cell liposarcoma were reviewed, and their cytologic features were discussed. While nuclear grooving can be present to a different extent in all these conditions, the significance of this feature in diagnostic cytology varies. The integration of clinical information, radiologic findings, different morphologic features, and immunohistochemistry is necessary before a final conclusion is reached.

Cytologic Diagnosis of "CASTLE" of thyroid gland: report of a case with histologic correlation

We report on the cytologic and histologic features of a rare form of lymphoepithelioma-like carcinoma of the thyroid i.e., carcinoma showing thymus-like element (CASTLE). Sixteen cases of cervical lymph node aspirates with metastatic nasopharyngeal carcinoma are also reviewed. While it is important to recognize CASTLE of the thyroid because of its distinctly good prognosis, its cytologic features closely resemble those in metastatic nasopharyngeal carcinoma.