Paracetamol overdose is the most common cause of drug-related poisoning and death worldwide. Although N-acetylcysteine is the widely accepted antidote for paracetamol poisoning, much debate persist regarding the appropriate route and duration of early N-acetylcysteine therapy. There is a paucity of studies comparing the effectiveness of oral and intravenous (IV) acetylcysteine for paracetamol poisoning. Methods: A literature search was performed using the keywords [paracetamol OR acetaminophen] AND [acetylcysteine OR n-acetylcysteine] on the PubMed and Ovid database. The literature search was limited to human exposure studies published in English between 1-Jan-1966 and 1-May-2015. The proportion of patients who developed hepatotoxicity (defined as serum transaminase greater than 1000 IU/L) for each route of administration was determined using multiple regression and the studies were further stratified by early (less than 10 hours from ingestion) and late treatment (longer than 10 hours from ingestion). Results: 3,981 full studies were reviewed for data. Studies with fewer than 20 subjects were excluded. Metaanalysis revealed that the overall proportion of patients who developed hepatotoxicity was 12.3% (95% confidence interval [CI]: 9.6% to 17.2%). The percentages were similar when studies were stratified by route of administration; the proportion for IV treated patients was 12.6% (95% CI: 8.7% to 19.4%) while the proportion for oral treated patients was 12.0% (95% CI: 8.2% to 18.8%). However, there was a marked difference in the percentage of patients who developed hepatotoxicity with early as compared to late N-acetylcysteine treatment. There was a statistically significant effect due to time (p < 0.001) but no significant effect due to route of administration (p = 0.716). Conclusion: Pooled analysis of studies did not find any significant difference in outcome between oral and IV N-acetylcysteine therapy, but these findings require confirmation by randomized controlled trials. However, overall hepatotoxicity was significantly worse if treatment was delayed beyond 8 to 10 hours. ASEAN Journal of Psychiatry, Vol. 17 (2): July – December 2016: XX XX.

Pancreaticopleural fistula is a rare diagnosis requiring a high index of clinical suspicion due to the predominant manifestation of thoracic symptoms. The current literature suggests that confirmation of elevated pleural fluid amylase is the most important diagnostic test. Magnetic resonance cholangiopancreatography is the recommended imaging modality to visualise the fistula, as it is superior to both computed tomography and endoscopic retrograde cholangiopancreatography (ERCP) in delineating the tract within the pancreatic region. It is also less invasive than ERCP. While a trial of medical regimen has traditionally been the first-line treatment, failure would result in higher rates of complications. Hence, it is suggested that management strategies be planned based on pancreatic ductal imaging, with patients having poor chances of spontaneous closure undergoing either endoscopic or surgical intervention. We also briefly describe a case of pancreaticopleural fistula in a patient who was treated using a modified Puestow procedure after failed endoscopic treatment.
Cholangiopancreatography, Endoscopic Retrograde ; adverse effects ; Cholangiopancreatography, Magnetic Resonance ; Endoscopy ; Humans ; Male ; Middle Aged ; Pancreatic Ducts ; physiopathology ; Pancreatic Fistula ; diagnosis ; epidemiology ; therapy ; Pleural Diseases ; diagnosis ; epidemiology ; therapy ; Treatment Outcome

Given the consensus that there is a causal relationship between Zika virus (ZIKV) infection in pregnancy and congenital Zika syndrome (CZS), clinicians must be prepared to manage affected patients despite the numerous gaps in current knowledge. The clinical course in pregnancy appears similar to that in non-pregnant women, although viraemia may be prolonged. ZIKV infection can be diagnosed by serum and urine reverse transcription-polymerase chain reaction, but commercially available serological tests are currently unreliable in dengue-endemic regions. Although vertical transmission can occur at any time during gestation, first- and second-trimester infections have the highest risk of developing central nervous system anomalies. Aberrant fetal growth and pregnancy loss may also occur. Serial ultrasonography should be conducted for infected cases. Without a vaccine, pregnant women should be advised to minimise mosquito bites and reduce sexual transmission risk. Overall, the absolute risk of CZS arising amid a ZIKV outbreak appears relatively low.

Severe primary mitral regurgitation (MR) is a progressive condition which engenders significant mortality and morbidity if left untreated. The optimal timing of surgery in patients with MR of degenerative origin continues to be debated, especially for those who are asymptomatic. Apart from symptoms, current authoritative guidelines recommend intervention when there is incipient left ventricular dysfunction, pulmonary hypertension or new onset atrial fibrillation. This review focuses on the asymptomatic subject with severe MR, and examines contemporary clinical decision-making and management strategies, including the 2012 European guidelines on valvular heart disease. We discuss the rationale for risk stratifying the asymptomatic individual, and highlight current and novel diagnostic tools that may have a useful role, with an emphasis on echocardiographic imaging.
Atrial Fibrillation ; Heart Valve Diseases ; Humans ; Hypertension, Pulmonary ; Mitral Valve Insufficiency ; Ventricular Dysfunction, Left

This review presents studies that support an inflammation-immunological model for the pathogenesis of post-infectious irritable bowel syndrome (IBS), and highlights recent studies that support a similar disease model in non-post-infectious IBS, in particular, diarrhoea-predominant IBS, as well as in post-infectious functional dyspepsia. These recent studies are highlighted to demonstrate that one line of research in functional gastrointestinal disorders has moved away from the old psychosomatic concepts. It is hoped that this will encourage future students of this field to explore the role of immunological events.
Dyspepsia ; Gastrointestinal Diseases ; Humans ; Inflammation ; Irritable Bowel Syndrome

Child ; Child Health Services ; organization & administration ; trends ; Forecasting ; Humans ; Singapore

Cholera ; epidemiology ; Disease Outbreaks ; Humans ; Zimbabwe ; epidemiology

INTRODUCTIONThe aim of this paper is to review the cardiovascular (CVS) risks associated with obesity in children and adolescents. Both short-term and long-term CVS consequences, the mechanisms of how these develop and the measures that can alter or reverse these CVS events are reviewed.

MATERIALS AND METHODSSelected publications include original articles and review papers that report on studies of CVS risks and consequences related to childhood obesity. Some papers that contain data from adults studies are also included if the contents help to explain some underlying mechanisms or illustrate the continuation of related CVS changes into adulthood.

RESULTSObese children and adolescents have an increased risk for CVS complications that include elevation of blood pressure, clustering of CVS risk factors (Metabolic Syndrome), changes to arterial wall thickness, elasticity and endothelium, as well as changes in left ventricular structure and function. Some of these cardiovascular problems may be initiated or potentiated by obstructive sleep apnoea that can accompany obesity in children. Many of such changes have been noted to reverse or improve with weight reduction.

CONCLUSIONSEarly development of CVS risks in obese children and the possible continuation of CVS complications into adulthood have been observed. Obstructive sleep apnoea in obese children can further contribute to such CVS risks. These findings underscore the importance of prevention of childhood obesity as a priority over management of obesity in children.