Acute aortic dissection (AAD) is rare in the paediatric and young adult population. We present a fatal case of acute aortic dissection Stanford B in a young male diagnosed with hypertension. He presented with severe acute abdominal pain with malignant hypertension. He did not have any trauma to the chest or did not have history of an illicit drug abuse. He had no features suggestive of connective tissue disease as well as other typical signs of aortic dissection. The complain of acute, severe abdominal pain which was out of proportion and required multiple doses of intravenous opioid, raised the suspicion of aortic dissection in this case. Point of care sonography (POC) was done in Emergency Department (ED). However, due to its highly operator dependability, the intimal flap was missed. Computed tomography (CT) scan of abdomen was done and confirmed the diagnosis of AAD. Unfortunately, his clinical condition rapidly deteriorated few hours later with no response to surgical intervention and succumbed within 36 hours of admission. We highlighted the importance of the early recognition of this disease as well as the point of care sonography in ED as a diagnostic tool to tackle this time-sensitive disease.

OBJECTIVES: To determine efficacy of continuous heparin infusion vs placebo on maintenance of peripherally inserted central catheter line among neonates admitted at the NICU. METHODS: This is a meta-analysis of randomized controlled trials reported in accordance with PRISMA checklist. Cochrane Risk-of-bias tool was used in assessment of reporting biases. Pooled risk ratios were estimated using random- or fixed-effects model. RESULTS: Of 4519 studies identified, 4 studies were included, and all have low risk of bias. Meta-analysis showed that continuous heparin infusion on PICCs had significantly higher duration of catheter patency compared to the placebo group (MD=2.22, 95%CI=1.03-3.14, pvalue<0.00001). Heparin group also had decreased risk of occlusion (RR=0.47, 95%CI=0.94, pvalues=0.03) compared to control. The risk for other adverse events such as thrombosis, infection, IVH progression, and mortality was comparable between the two groups. CONCLUSION: Continuous heparin infusion in PICC fluids can prolong duration of catheter patency by 2.2 days and reduce risk of catheter-related occlusion by 50%, without having significant effect on incidence of other adverse events. RECOMMENDATIONS Continuous heparin infusion on PICC fluids should be part of maintenance and care policy at the NICU, but precautions should be followed to prevent adverse outcomes. Systematic review of intermittent heparin flushing can be a window of opportunity.

Objectives: To determine the efficacy of low-dose heparin in preventing central catheter occlusion and its safety among neonates. Materials and Methods: A randomized controlled trial was conducted among 42 neonates requiring peripherally inserted central catheter (PICC) lines. The neonates were divided into two groups: low dose heparin (0.5 units/kg/hr =0.2 units/ml) and control group (0.5 units/ml). The efficacy outcomes were duration of catheter patency, completion of catheter use, and the presence of catheter occlusion or thrombosis. The safety outcomes include heparin complications. Results: The study participants had a mean age of 17 days old at 35 weeks gestational age and mean weight of 1.97 kg. The participants given low dose heparin were 36% more likely to complete the use of central line and 12% less likely to develop catheter occlusion. Analyses showed non-statistically significant risk ratio of active bleeding, thrombocytopenia, and deranged prothrombin time in the low dose heparin group. Conclusion The use of low dose heparin (0.5 units/kg/hr = 0.2 units/ml) appears as effective as the control dose in completion of catheter use and prevention of catheter occlusion. There was also no significant difference in the adverse effects. Low dose heparin can be used as continuous infusion for preventing central line occlusion; however, it has no advantage in lowering the risk of complications.
Hemorrhage

BACKGROUND: Angiogenesis plays an important role in determining the fat graft survival. However, clinical preconditioning techniques that target angiogenesis during fat grafting have not been established so far. Adenosine has emerged as a regulator of angiogenesis under hypoxic conditions; therefore, the aim of this study was to investigate the effects and underlying mechanisms of adenosine prefabrication on fat graft survival. METHODS: In the first animal study, a total of 32 mice were transplanted with fat prefabricated with vehicle (Control, N = 16) or adenosine (Adenosine, N = 16). In the second animal study, 24 mice were divided into three groups based on the type of fat graft: Control (N = 8), Adenosine (N = 8), and Axitinib (cotreatment of adenosine with axitinib, N = 8). At 1- and 4-weeks post-transplantation, grafts were evaluated by histopathological and biochemical assessment. Adenosineinduced vascular endothelial growth factor (VEGF) production and angiogenesis were determined using cell cultures. RESULTS: The retention volumes of fat grafts in the adenosine group were significantly increased until 4 weeks. Fat grafts from the adenosine group exhibited greater structural integrity, reduced fibrosis, and increased blood vessels. The expression levels of angiogenesis-related genes, Vegfa, Vegfr1, Vegfr2, and Vwf, were elevated in the adenosine group. Furthermore, adenosine upregulated VEGF production in preadipocytes, thereby enhancing the migration of endothelial cells. Treatment with the axitinib, VEGF receptor inhibitor, abrogated the adenosine-induced angiogenesis in the fat grafts. CONCLUSION Adenosine prefabrication in fat improved the graft survival by enhancing angiogenesis through the VEGF/VEGFR axis in the preadipocytes and endothelial cells. Therefore, this method may be used as a novel strategy to increase the retention rate in fat grafts.

BACKGROUND: Mycosis fungoides (MF) is the most common cutaneous T-cell lymphoma. Diagnosis relies on clinicopathological correlation.

OBJECTIVE: To describe the clinicodemographic characteristics of patients with MF and to identify histologic criteria that will signify adequate treatment.

METHODS: Registries from years 2004 to 2009 were searched for biopsy-proven MF. Charts were retrieved and clinicodemographic data gathered. Pre- and post-treatment biopsy slides were reviewed by a dermatopathologist blinded to the patients's treatment status. Pre-selected histologic criteria were evaluated for each slide. Pearson's chi-square and Fisher's exact test were used to analyze for statistical significance of each criteria.

RESULTS: There were 34 biopsy-proven MF from years 2004 to 2009. Male-to-female ratio was 1:1.8. Mean age at initial diagnosis was 46.7 years (13-81). Among the 16 patients with fully retrievable records, the most common presentation was that of hypopigmented patches. Age ? 60 years seemed to have significant association with relapse (P=0.02). Epidermotropism of ? 5 (P=0.03), absent to focal lymphocyte tagging (P=0.04), and dropping of haloed lymphocytes from >10 to ? 10 (P=0.01) somehow differentiated treated from untreated MF.

CONCLUSIONS: The hypopigmented variant of MF may be more common in Asian countries. Age ? 60 years old may be associated with higher risk of relapse. Grading epidermotropism, lymphocyte tagging and haloed lymphocytes may be helpful in determining adequacy of treatment of MF. However, given the small sample size of the present study, future larger studies are needed to confirm these findings.

INTRODUCTION: There is paucity of data on the occurrence of cardiovascular events (CVEs) in critically ill patients with sepsis. We aimed to describe the incidence, risk factors and impact on mortality of CVEs in these patients. METHODS: This was a retrospective cohort study of critically ill patients admitted to the medical intensive care unit (ICU) between July 2015 and October 2016. The primary outcome was intra-hospital CVEs, while the secondary outcomes were in-hospital mortality, ICU and hospital length of stay. RESULTS: Patients with sepsis (n=662) had significantly more CVEs compared to those without (52.9% versus 23.0%, P<0.001). Among sepsis patients, 350 (52.9%) had 1 or more CVEs: 59 (8.9%) acute coronary syndrome; 198 (29.9%) type 2 myocardial infarction; 124 (18.7%) incident atrial fibrillation; 76 (11.5%) new or worsening heart failure; 32 (4.8%) cerebrovascular accident; and 33 (5.0%) cardiovascular death. Factors associated with an increased risk of CVEs (adjusted relative risk [95% confidence interval]) included age (1.013 [1.007-1.019]); ethnicity-Malay (1.214 [1.005-1.465]) and Indian (1.240 [1.030-1.494]) when compared to Chinese; and comorbidity of ischaemic heart disease (1.317 [1.137-1.527]). There were 278 patients (79.4%) who developed CVEs within the first week of hospitalisation. Sepsis patients with CVEs had a longer median (interquartile range [IQR]) length of stay in the ICU (6 [3-12] vs 4 [2-9] days, P<0.001), and hospital (21 [10-42] vs 15 [7-30] days, P<0.001) compared to sepsis patients without CVEs. There was no difference in in-hospital mortality between the 2 groups (46.9% vs 45.8%, P=0.792). CONCLUSION CVEs complicate half of the critically ill patients with sepsis, with 79.4% of patients developing CVEs within the first week of hospitalisation, resulting in longer ICU and hospital length of stay.
Cardiovascular Diseases/epidemiology* ; Critical Illness/epidemiology* ; Hospital Mortality ; Humans ; Intensive Care Units ; Length of Stay ; Retrospective Studies ; Risk Factors ; Sepsis/epidemiology*

Objective: This study determined the clinical characteristics of retinoblastoma (RB) from 1998 to 2008 and compared the epidemiological and clinical patterns with those of the period from 1967 to 2001. Methods: We reviewed the clinical records of 152 patients with RB from 1998 to 2008 in terms of demographic and ophthalmological data and clinical staging or classification. Results: Sixty-three percent of cases were unilateral and 37% were bilateral. Three (3%) of 95 unilateral cases and 7 (12%) of 57 bilateral cases had family history of RB (p = 0.038). The mean age at onset was 17.8 months for unilateral and 7.4 months for bilateral cases, while the mean age at diagnosis was 26.4 months and 13.7 months respectively. The delay from onset to diagnosis was 69% in unilateral and 56% in bilateral RB groups. Financial cost (71.4%) was the leading reason for delay, followed by misdiagnosis (24.5%), and inaccessibility of medical facility (2.0%). The most common manifestations were leukocoria (77%), extraocular findings of orbital mass (9%), and proptosis (6%). Advanced intraocular stage was seen in 63 – 71.6% among those with unilateral and 56 – 60% in those with bilateral tumor. Conclusion The onset of disease had not changed over the years, but patients in general were brought earlier for consultation. Most cases presented in the advanced stage. Decreasing the occurrence of extraocular RB through early consultation and treatment can improve patient survival.
Retinoblastoma ; Epidemiology

OBJECTIVE: To compare the presence and severity of meibomian gland (MG) dysfunction among eyes of female subjects with and without eyelid margin tattoos using infrared meibography and colored photographs. METHODS: This is a cross-sectional, descriptive study that involved 38 Filipino females with and without eyelid margin tattoos. Infrared meibography was performed on the upper and lower eyelids of each eye to assess total or partial MG dropout. Colored photographs were taken to evaluate vascularity, irregularity, thickening of the lid margins, and plugging of MG orifices. Severity of MG dysfunction (MGD) was assessed using Arita’s MGD proposed grading scale. Independent t-test was used to compare MG dropout and other lid margin parameters between the two groups. Prevalence ratio and prevalence odds ratio were calculated to measure the likelihood of MGD among eyes with eyelid tattoos. RESULTS: Seventy-four (74) eyes were included in the study (36 in the tattoo group and 38 in the control group). Scores for abnormal vascularity, irregularity, and thickening of the lid margins were significantly higher in the tattoo group compared to the control group (p<0.0000001). However, plugging of gland orifices scores between the two groups were found to be similar (upper eyelid: p=0.65; lower eyelid: p=0.91). Total MG dropout was significantly greater in the tattoo group (upper eyelid: -1.11 ± 0.82; lower eyelid: 1.37 ± 0.75) compared to the control group (upper eyelid: 0.53 ± 0.83; lower eyelid: 0.45 ± 0.76) (upper eyelid: p=0.003; lower eyelid: p=0.000001) for the upper and lower eyelid, respectively). Analysis of total MG dropout between the two groups showed a prevalence ratio of 2.13. CONCLUSION: Eyelid margin tattoos are associated with several eyelid margin abnormalities and increase the risk of meibomian gland droupout.
Meibomian Gland Dysfunction ; Tattooing ; Margins of Excision