Mohd Hashairi Fauzi

Expression of DNA methylation marker of paired-like homeodomain transcription factor 2 and growth receptors in invasive ductal carcinoma of the breast.

BACKGROUND Paired-like homeodomain transcription factor 2 (PITX2) is another new marker in breast carcinoma since hypermethylation at P2 promoter of this gene was noted to be associated with poor prognosis. We investigated the expression of PITX2 protein using immunohistochemistry in invasive ductal carcinoma and its association with the established growth receptors such as estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth receptor 2 (HER2). METHODS We conducted a cross sectional study using 100 samples of archived formalin-fixed paraffin embedded tissue blocks of invasive ductal carcinoma and stained them with immunohistochemistry for PITX2, ER, PR and HER2. All HER2 with scoring of 2+ were confirmed with chromogenic in-situ hybridization (CISH). RESULTS PITX2 protein was expressed in 53% of invasive ductal carcinoma and lack of PITX2 expression in 47%. Univariate analysis revealed a significant association between PITX2 expression with PR (p=0.001), ER (p=0.006), gland formation (p=0.044) and marginal association with molecular subtypes of breast carcinoma (p=0.051). Combined ER and PR expression with PITX2 was also significantly associated (p=0.003) especially in double positive cases. Multivariate analysis showed the most significant association between PITX2 and PR (RR 4.105, 95% CI 1.765-9.547, p=0.001). CONCLUSION PITX2 is another potential prognostic marker in breast carcinoma adding significant information to established prognostic factors of ER and PR. The expression of PITX2 together with PR may carry a very good prognosis.

Molecular detection of leptospirosis and melioidosis co-infection: A case report

Leptospirosis and melioidosis are important tropical infections caused by Leptospira and Burkholdheria pseudomallei, respectively. As both infections share similar clinical manifestations yet require different managements, complementary laboratory tests are crucial for the diagnosis. We describe a case of Leptospira and B. pseudomallei co-infection in a diabetic 40-year-old woman with history of visit to a freshwater camping site in northern Malaysia. To our knowledge, this is the first case of such double-infection, simultaneously demonstrated by molecular approach. This case highlights the possibility of leptospirosis and melioidosis co-infections and their underlying challenges in the rapid and accurate detection of the etiologic microorganism.

Keratinous inclusion cyst of oesophagus: unusual finding

Cysts of the oesophagus are unusual findings and they are classified according to the embryological site of origin. It may represent inclusion cysts, retention cysts and developmental cysts. We present a case of keratinous inclusion cyst of the lower oesophagus in a 71-year-old Malay woman who presented with dyspepsia and severe epigastric pain. An oesophago-gastro-duodenoscopy demonstrated a sliding hiatus hernia with whitish ulcer-like lesion at the lower oesophagus. Biopsy from the lesion revealed a keratinous inclusion cyst. The patient was given pantoprazole and put on regular follow-up for monitoring any other development.

Unintended Consequences: Fluid Resuscitation Worsens Shock in an Ovine Model of Endotoxemia

Rationale: Fluid resuscitation is widely considered a life‐saving intervention in septic shock; however, recent evidence has brought both its safety and efficacy in sepsis into question. Objectives: In this study, we sought to compare fluid resuscitation with vasopressors with the use of vasopressors alone in a hyperdynamic model of ovine endotoxemia. Methods: Endotoxemic shock was induced in 16 sheep, after which they received fluid resuscitation with 40 ml/kg of 0.9% saline or commenced hemodynamic support with protocolized noradrenaline and vasopressin. Microdialysis catheters were inserted into the arterial circulation, heart, brain, kidney, and liver to monitor local metabolism. Blood samples were recovered to measure serum inflammatory cytokines, creatinine, troponin, atrial natriuretic peptide, brain natriuretic peptide, and hyaluronan. All animals were monitored and supported for 12 hours after fluid resuscitation. Measurements and Main Results: After resuscitation, animals that received fluid resuscitation required significantly more noradrenaline to maintain the same mean arterial pressure in the subsequent 12 hours (68.9 mg vs. 39.6 mg; P = 0.04). Serum cytokines were similar between groups. Atrial natriuretic peptide increased significantly after fluid resuscitation compared with that observed in animals managed without fluid resuscitation (335 ng/ml [256‐382] vs. 233 ng/ml [144‐292]; P = 0.04). Cross‐sectional time‐series analysis showed that the rate of increase of the glycocalyx glycosaminoglycan hyaluronan was greater in the fluid‐resuscitated group over the course of the study (P = 0.02). Conclusions: Fluid resuscitation resulted in a paradoxical increase in vasopressor requirement. Additionally, it did not result in improvements in any of the measured microcirculatory‐ or organ‐specific markers measured. The increase in vasopressor requirement may have been due to endothelial/glycocalyx damage secondary to atrial natriuretic peptide‐mediated glycocalyx shedding.

Abstract P-559: FLUID RESUSCITATION WITH 0.9% SALINE IMPAIRS MYOCARDIAL CONTRACTILITY IN AN OVINE MODEL OF ENDOTOXEMIC SHOCK

During the 2 week audit period a total of 20 patients were included. We grouped patients with RACHS 1&2 scores (n=11), RACHS 3&4 scores (n=9) and RACHS 5&6 scores (n=0). Four patients required peritoneal dialysis; all survived to discharge. Daily fluid balance and cumulative balance (in ml/kg) is shown (table 1). In the RACHS 3&4 group, there was both a higher fluid balance on ‘day 2’ and in cumulative balance.

Unscheduled early revisit to emergency department

Background: Unscheduled revisits to the emergency department may present a considerable additional workload. Objectives: This study investigated the risk factors contributing to adverse event during unscheduled early revisit to Emergency Department Hospital Universiti Sains Malaysia. Methods: A retrospective cohort study was conducted from January 2014 to January 2015 to character the nature of unscheduled early revisits to Emergency Department Hospital Universiti Sains Malaysia. It included all patients 18 years old and above, revisited emergency department within 9 days post discharge from emergency department. Results: Data were collected from 492 case records. The rate of emergency department unplanned revisits within 9 days of previous emergency department discharge was 0.66% for the study period. Risk factors for revisit included advance age, pre-existing co-morbidities, duration spent during first emergency department visit and health care system–related error. The independent predictors of morbidity were diabetes mellitus (odds ratio, 2.07; 95% confidential interval, 1.08–3.96), respiratory disease (odds ratio, 2.42; 95% confidential interval, 1.18–4.98), gastrointestinal disease (odds ratio, 5.93; 95% confidential interval: 1.29, 27.35), nervous system disease (odds ratio, 4.65; 95% confidential interval: 1.27, 17.02), duration spent more than 6 h during first emergency department visit (odds ratio, 3.05; 95% confidential interval: 1.53, 6.07), and medical error leading to admission (odds ratio, 8.85; 95% confidential interval: 4.43, 17.67). The overall mortality rate was 0.2% (1/492). Conclusion: Emergency department physicians need to be extra vigilant when managing patients with risk factors, particularly the modifiable risk factors, to curb emergency department revisit.