Thrombolysis failure with streptokinase in acute myocardial infarct using ECG criteria - HUSM experience

Streptokinase has high thrombolysis failure rate despite being cheap and widely used in acute myocardial infarction. Electrocardiogram criteria using more than 50% reduction in ST elevation in the worst infarct lead predicted TIMI Ill flow with good sensitivity and specificity. The primary objective of this study was to determine the failure rate of thrombolysis with streptokinase in acute myocardial infarction using electrocardiogram criteria in Hospital Universiti Sains Malaysia (HUSM). The secondary objective was to compare the association between independent variables, treatment and outcome parameters with failure of thrombolysis with streptokinase. A total of 192 subjects were recruited into this retrospective cohort observational study. 109 patients (56.8%) has failed thrombolysis with streptokinase. Seven variables were significantly associated with thrombolysis failure using streptokinase in a univariate analysis including anterior location of myocardial infarct (p<0.001 ), longer symptom-to-needle time (p=0.01 ), longer door-to-needle time (mean 114 ± 82.9 min, p=0.03), history of hypertension (p=0.04), higher heart rate (mean 79.3 ± 18.3 beats per min, p=0.01 ), higher systolic blood pressure (mean 136.7 + 28.9 mmHg, p=0.02) and higher diastolicblood pressure (mean 83.8 .± 20.9 mmHg, p=0.003). Five variables were associated with streptokinase failure as thrombolytic agent in multiple logistic regression analysis (backward stepwise method) including anterior location of myocardial infarct (p<0.001; OR 0.07, 95% Cl 0.03 - 0.16), longer door-to-needle time (p=0.02; OR 1.01, 95% Cl 1.00 - 1.02), diabetes mellitus (p=0.03; OR 3.13, 95% Cl 1.13 - 8.69), hypertension (p=0.08; OR 2.06, 95°/o Cl 0.92 - 4.60) and high total white cell count (p=0.03; OR 1.12, 950fc, Cl 1.01 - 1.24). Both recurrent acute coronary syndrome (p=0.02; crude OR 2.49, 95o/o Cl 1.16 - 5.32) and death after one year (p= 0.04; crude OR 7.61, 95°/o Cl 0.95 - 61.24) were associated with increase in the rate of thrombolysis failure with streptokinase in univariate analysis. In conclusion, the result of this study has shown that streptokinase has higher failure rate of thrombolysis in acute myocardial infarction using electrocardiogram criteria in HUSM. History of diabetes mellitus, history of hypertension, anterior location of myocardial infarction, longer door-to-needle time and high total white cell count were highly predictive of increase in the rate of thrombolysis failure using streptokinase. This group of patients may benefit from other early reperfusion strategy including tissue plasminogen activators (tPA), PCI or CABG

An Unusual Association between Unilateral Intracranial Vessels Occlusion with Iron Deficiency Anaemia and Alpha-Thalassemia Trait: A Case Report

We report a 33-year-old Malay woman presented with acute left dense hemiparesis and an NIHSS score of 11/15. Computed tomography (CT) scan brain showed a massive right middle cerebral artery (MCA) territory infarct. The right internal carotid artery (ICA) and right proximal MCA were shown occluded from digital substraction angiography (DSA). Carotid dissection, carotid canal anomaly, and intercavernous communication were systematically ruled out. She had no risk factors for atherosclerosis. The connective tissue screening and thrombophilic markers were negative. However, she was anaemic on admission and subsequent investigations revealed that she had alpha-thalassemia and iron deficiency anaemia. The right ICA remained occluded from a repeat CT cerebral angiogram after one year, but otherwise she was neurologically stable. This case illustrates an unusual association between intracranial vessel occlusion with iron deficiency anaemia and alpha-thalassemia trait

An in-depth study on the movement and location of the gastro-oesophageal junction

Understanding the physiology of gastro-oesophageal junction (GOJ) is important as failure of its function is associated with reflux disease, hiatus hernia and cancer. It has been suggested that the increased intra-abdominal pressure produced by central obesity may increase acid reflux during transient lower oesophageal sphincter relaxations (TLOSRs) and also predispose to short segment reflux. In recent years, we have seen impressive developments in high resolution technologies allowing measurement of luminal pressure, pH and impedance. One obvious deficiency is our lack of technique to monitor the movement and location of the GOJ over a prolonged period of time. Both in-vitro and in-vivo studies indicated that it was possible to monitor the position of the GOJ by means of clipping a magnet to the squamo-columnar junction and which was detected by a novel linear probe consisting of a series of Hall Effect sensors. The accuracy for detection of position of the GOJ with this new technique was superior to 10 mm and was as good as fluoroscopy in the detection of position with a correlation co-efficient of 0.96. Without the risk of radiation associated with fluoroscopy, the new probe could be applied over a much longer period than had been previously possible. Three factors were identified from in-vitro studies which could limit accuracy of the Hall Effect-based probe. These factors were firstly, poor magnet orientation and distance, secondly, the effect of temperature, and thirdly the presence of other ferromagnetic materials. Newer probe having 3-dimensional capabilities is in development. The temperature effect could be reduced by calibrating the probe within a water bath heated to body temperature prior to insertion. Using alongside a 2.7 mm manometer, the ferromagnetic effect could be reduced. While oesophageal shortening during TLOSRs is due to longitudinal muscle contraction but relatively little is known about the behaviour of the GOJ during its restitution. The return movement of the GOJ is particularly important as failure of this process will produce a persisting hiatus hernia. Detailed examination on migration of the GOJ during TLOSRs and swallows had been performed in 12 healthy subjects. Proximal displacement of the GOJ was present transiently during TLOSRs and swallows but the displacement of up to 9 cm (median 4.3 cm) during TLOSRs represented very severe herniation of the GOJ. In addition, there was a rapid initial return of the GOJ following TLOSRs when the CD was relaxed and its correlation with amplitude suggested it is due to elastic recoil of the POL. This marked stretching of the POL during TLOSRs may contribute to its weakening and development of established hiatus hernia. Epidemiological evidence suggests an association between obesity, reflux disease and hiatus hernia but mechanisms are unclear. Study was performed to assess the structure and function of the GOJ in asymptomatic subjects with and without obesity and the effects of elevating intra-abdominal pressure with waist belt. Sixteen subjects were recruited to achieve two groups defined by normal (eight) or increased (eight) waist circumference, matched for age and gender. Our studies demonstrated that increased WC and waist belt caused marked changes in the functioning of the GOJ and LOS leading to increased gastric acid penetration within the high pressure zone. This appears to occur by retrograde flow within the closed sphincter and by increased short segment reflux during TLOSRs and subsequent impaired clearance. This increased intra-sphincteric acid exposure is occurring in asymptomatic volunteers and may explain the high incidence of inflammation and columnar metaplasia observed at the GOJ in asymptomatic subjects. Our observations may also be relevant to the aetiology of adenocarcinoma of the cardia which shares epidemiological risk factors of the oesophageal adenocarcinoma but has a much weaker association with reflux symptoms. To conclude, a new technique has been developed allowing accurate and prolonged detection of position and movement of the GOJ without any radiation risk. Using alongside high resolution manometry and pHmetry, the new technique allows detailed examination of the structure and function of the GOJ providing important insights on the pathophysiology of reflux disease in normal subjects with and without central obesity and waist belt

Frequency patterns of core constipation symptoms among the Asian adults: a systematic review

Background: In clinical practice, assessment of constipation depends on reliability, consistency and frequency of several commonly reported or core symptoms. It is not known if frequency patterns of constipation symptoms in adults are different between the West and the East. This review aimed to describe core constipation symptoms and their frequency patterns among the Asian adults. Methods: Articles published in PubMed, MEDLINE, CINAHL and Science Direct from 2005 to 2015 were searched systematically. Studies were included if constipation satisfied the Rome II and or III criteria. Study populations consisted of Asian adults above 18 years old and with sample size above 50. Results: Of 2812 articles screened, 11 met the eligibility criteria. Constipation among Asian adults was characterized by three core symptoms of ‘straining’ at 82.8%, ‘lumpy and hard stool’ at 74.2% and ‘sensation of incomplete evacuation’ at 68.1% and the least frequent symptom was ‘manual maneuver to facilitate defecation’ at 23.3%. There was heterogeneity in frequency patterns of core symptoms between different Asian studies but also differences in core symptoms between constipation subtypes of functional constipation and irritable bowel syndrome with constipation. Conclusions: In general, Asian adults perceive constipation symptoms in a similar but not equivalent manner to the West. Recognition of core symptoms will increase the diagnostic confidence of constipation and its subtypes but more studies of the various specific Asian populations are needed to address their differences

Corrigendum: Food Allergy and Helicobacter pylori Infection: A Systematic Review

Introduction: Based on the hygiene hypothesis, a low prevalence of Helicobacter pylori (H. pylori) infection may explain the recent high prevalence of allergic diseases including food allergy. However, there are very few studies that investigate the relationship between H. pylori and food allergy. Summary: We searched for PubMed, Ovid Medline and the Cochrane library for relevant articles published in English from inception to November 2015. The inverse relationship between H. pylori and food allergy remains unproven because of contradictory and limited evidence at the moment. Likewise, only limited studies have examined the relationship between CagA; one of H. pylori virulence factor and food allergy. On the other hand, in vitro evidence seems to point out a role of H. pylori in the causation of food allergy. The inconsistent results from epidemiological data may be due to small sample size, heterogeneous populations and unstandardised methods or food allergens

Barrett's Esophagus in an Area with an Exceptionally Low Prevalence of Helicobacter pylori Infection

Objective. This study was undertaken to gain an insight into the relationship between Helicobacter pylori (H. pylori) infection, Barrett's esophagus and reflux esophagitis in an area of exceptionally low prevalence of H. pylori infection. Methods. A total of 1895 consecutive upper endoscopies performed between January 2005 and July 2007 were reviewed. 120 cases of columnar-lined esophagus and endoscopic esophagitis were evaluated. H. pylori infection was determined using the urease test and/or histology. Results. The rate of endoscopic esophagitis was 5.49% (80 Malays, 24 non-Malays) while histological reflux esophagitis was found in 3.75% (56 Malays, 15 non-Malays). Barrett's esophagus was present in 0.79% (11 Malays, 4 non-Malays). H. pylori infection was present in 8/120 or 6.67% subjects. Conclusion. The low rate of Barrett's esophagus in this population does not support the hypothesis that the absence of H. pylori infection is more than a minor risk factor for Barrett's esophagus

A Survey On Medical Digital Imaging Of Endoscopic Gastritis.

This paper focuses on researches related to medical digital imaging of endoscopic gastritis

Irritable bowel syndrome and inflammatory bowel disease overlap syndrome: pieces of the puzzle are falling into place

Irritable bowel syndrome (IBS), a common gastrointestinal disorder involving the gut-brain axis, and inflammatory bowel disease (IBD), a chronic relapsing inflammatory disorder, are both increasing in incidence and prevalence in Asia. Both have significant overlap in terms of symptoms, pathophysiology, and treatment, suggesting the possibility of IBS and IBD being a single disease entity albeit at opposite ends of the spectrum. We examined the similarities and differences in IBS and IBD, and offer new thoughts and approaches to the disease paradigm

Psychometric evaluation of a newly developed elderly - Constipation Impact Scale

Background. Chronic constipation is a common symptom among the elderly, and it may affect their quality of life (QoL). A lack of available research focused on the elderly means that this effect is not well understood. This study aimed to develop and validate a new scale (Elderly-Constipation Impact Scale (E-CIS)) to measure the impact of chronic constipation on QoL among the elderly. Methods. A pool of items was generated from a qualitative study, literature reviews, and expert reviews. Exploratory factor analysis (EFA) was performed on the original 40 items of the E-CIS and followed by 27 items for confirmatory factor analysis (CFA). A total of 470 elderly people with chronic constipation were involved. Results. The mean age of the participants was 68.64 ± 6.57. Finally, only 22 items were indicated as appropriately representing the E-CIS, which were grouped into seven subscales: ‘daily activities’, ‘treatment satisfaction’, ‘lack of control of bodily function’, ‘diet restriction’, ‘symptom intensity’, ‘anxiety’ and ‘preventive actions’. The scale was confirmed as valid (root mean square error of approximation (RMSEA) = 0.04, comparative fit index (CFI) = 0.961, Tucker-Lewis index (TLI) = 0.952 and chisquare/degree of freedom (chiSq/df) = 1.44) and reliable (Cronbach’s alpha: 0.66–0.85, composite reliability (CR) = 0.699–0.851) to assess the impact of chronic constipation on the elderly’s QoL. Conclusions. The E-CIS is useful to measure the impact of chronic constipation on the elderly’s QoL. A further test is needed to determine the validity and reliability of this scale in other elderly population