Getting Physical before a Medical Physical and How It Leads to Doctor Becoming Patient: A Curious Case of Transient Raised Transaminases

This case report sheds light on a curious case of rhabdomyolysis in an otherwise healthy twenty-eight-year-old male and its direct effect on liver function tests. This case report provides a fresh perspective on the doctor-patient dynamic where a medic becomes a doctor. Attention is also drawn to the mental and socioeconomic repercussions of having a health issue whilst applying for a home loan.

The Incidence of Endophthalmitis Cases in an Island Nation

Endophthalmitis is a severe ocular infection which can have sight threatening complications and should be treated urgently. Malta is an archipelago in the middle of the Mediterranean sea, with one main hospital (Mater Dei Hospital), where all emergency ophthalmic cases are referred during the years audited. This allowed the authors to review all the cases of endophthalmitis which presented to Mater Dei Hospital from 2009 to 2020 and to be able to reliably compare incidence of local endophthalmitis cases with worldwide quoted incidence rates. All theatre logbooks documenting procedures locally from 2009 to 2020 were reviewed and patients undergoing intravitreal tap and antibiotics injections were included in this audit. This was based on the assumption that all endophthalmitis cases which presented underwent these procedures. Data was analyzed and the average incidence of endophthalmitis cases noted and compared with international numbers. The local numbers are higher than the accepted average, taking into consideration sources of error during data collection for this audit. The authors suggest that a local standard operating procedure in terms of response of suspected endophthalmitis is needed as well as a register for local endophthalmitis cases.

Evaluation of the Current Care Pathway for Diabetic Eye Screening in Malta

Diabetic retinopathy is a leading cause of preventable vision impairment and a common complication of diabetes. Diabetic retinopathy screening can identify early changes in the retina so treatment can be given before vision impairment or blindness occurs. The aim of this audit is to evaluate the diabetic eye screening pathway in Malta to reduce the risk of vision impairment among diabetic patients through the identification and effective management of sight-threatening diabetic retinopathy by evaluating adherence to diabetic retinopathy screening guidelines and identifying areas for improvement within the screening pathway at Mater Dei Hospital (MDH). The practical implications of the audit’s findings highlight the importance of more awareness of current guidelines on the recommended time of first eye examination and routine minimum follow up interval at the Endocrinology Department at MDH. 26.7% of the doctors participating in this audit perform fundoscopy on initial assessment only, while 13.3% perform fundoscopy every visit. On the other hand, 60% of the participants never perform fundoscopy.

Complete spontaneous regression of giant focal nodular hyperplasia of the liver: Magnetic resonance imaging evaluation with hepatobiliary contrast media

Focal nodular hyperplasia(FNH) of the liver is a benign lesion occurring in 0.6%-3% of the general population that probably reflects a local hyperplastic response of hepatocytes to a vascular abnormality. Most lesions are diagnosed incidentally and the natural history of the disease remains largely unknown. It has been shown that most FNH remain stable, or even regress, over a long follow-up period. We present a patient with FNH of the liver who was followed up for 7 years. A 26-yearold woman with a 5-year history of oral contraceptive use was referred to our hospital in February 2005 for further examination of a liver tumour. The diagnosis of FNH was made using magnetic resonance(MR) imaging with hepatospecific contrast media; this technique allows a correct diagnosis, in particular distinguishing FNH from hepatic adenoma, avoiding an invasive procedure such as the lesion biopsy. After 7-year from the diagnosis, we observed the complete spontaneous regression of the lesion by enhanced MR scanning. In this patient, discontinuation of oral contraceptive use and two childbirths may have influenced the natural history of FNH. To our knowledge, in the English literature there is no report illustrating a complete regression of giant FNH but only studies of decreasing in size. The present case suggests that a young patient with giant FNH should be managed conservatively rather than by resection, because FNH has the potential for spontaneous regression.

Clinical outcome of pediatric collagenous gastritis: Case series and review of literature

Collagenous gastritis (CG) is characterized by patchy subepithelial collagen bands. Effective treatment and the clinical and histological outcome of CG in children are poorly defined. The aim of this study is to summarize the published literature on the clinical outcome and response to therapy of pediatric CG including two new cases. We performed a search in Pubmed, OVID for related terms; articles including management and clinical and/or endo-histologic follow up information were included and abstracted. Reported findings were pooled in a dedicated database including the corresponding data extracted from chart review in our patients with CG. Twenty-four patients were included (17 females) with a mean age of 11.7 years. The clinical presentation included iron deficiency anemia and dyspepsia. The reported duration of follow up (in 18 patients) ranged between 0.2-14 years. Despite most subjects presenting with anemia including one requiring blood transfusion, oral iron therapy was only documented in 12 patients. Other treatment modalities were antisecretory measures in 13 patients; proton pump inhibitors (12), or histamine-2 blockers (3), sucralfate (5), prednisolone (6), oral budesonide in 3 patients where one received it in fish oil and triple therapy (3). Three (13%) patients showed no clinical improvement despite therapy; conversely 19 out of 22 were reported with improved symptoms including 8 with complete symptom resolution. Spontaneous clinical resolution without antisecretory, anti-inflammatory or gastroprotective agents was noted in 5 patients (4 received only supplemental iron). Follow up endohistopathologic data (17 patients) included persistent collagen band and stable Mononuclear cell infiltrate in 12 patients with histopathologic improvement in 5 patients. Neither collagen band thickness nor mononuclear cell infiltrate correlated with clinical course. Intestinal metaplasia and endocrine cell hyperplasia were reported (1) raising the concern of long term malignant transformation. In summary, CG in children is a chronic disease, typically with a variable clinical response and an indolent course that is distinct from the adult phenotype. Long term therapy usually inclused iron supplementation but cannot be standardized, given the chronicity of the disease, variability of response and potential for adverse events.

HER2 in gastric cancer: Comparative analysis of three different antibodies using whole-tissue sections and tissue microarrays

AIM:To compare the performance of three commercially available anti-human epidermalgrowth factor receptor 2(HER2)antibodies in whole-tissue sections and tissue microarrays(TMAs)of a series of gastric tumors.METHODS:We present a comparative analysis of three anti-HER2 antibodies(HercepTest,4B5 and SP3)using TMA and whole-tissue sections prepared from the same paraffin blocks of 199 gastric adenocarcinomas operated upon between January 2004 and December2008 at a Brazilian cancer hospital.The data on the patients’age,sex,the anatomical location of the tumor and the Lauren’s histological classification were collected from clinical and pathological records.The immunohistochemical(IHC)results were examined by two pathologists and the cases were classified as positive(3+),equivocal(2+)and negative(0 or 1+),according to the criteria of the IHC scoring system of gastric cancer.TMAs and whole-tissue sections were evaluated separately and independently.All cases yielding discordant IHC results and/or scored as 2+were subjected to dual-color in situ hybridization in order to determine the final HER2 status.Besides determining the sensitivity and predictive value for HER2-positive status,we measured the accuracy of each antibody by calculating the area under the receiver operating characteristic(ROC)curve.The agreement between the results obtained using the TMAs and those obtained using the whole-tissue sections was assessed by means of Kappa coefficient.RESULTS:Intratumoral heterogeneity of HER2 expression was observed with all antibodies.HER2-positive expression(3+)in the whole-tissue sections was observed in 23 cases(11.6%)using the 4B5 antibody,in 18 cases(9.1%)using the SP3 antibody and in 10 cases(5.1%)using the HercepTest antibody.In the TMAs,11 positive cases(5.6%)were identified using SP3 antibody,9(4.6%)using the 4B5 antibody and 6(3%)using the HercepTest antibody.The sensitivity using whole-tissue sections and TMA,respectively,was 95.2%and 42.9%with 4B5,90.5%and 66.7%with SP3 and 47.6%and42.9%with HercepTest.The accuracy,calculated from the area under the ROC curve,using whole-tissue sections and TMA,respectively,was 0.91 and 0.79 by 4B5,0.86 and 0.80 by SP3 and 0.73 and 0.71 by HercepTest.The concordance of the results obtained using wholetissue sections and TMA was 97.4%(Kappa 0.75)using HercepTest,85.6%(Kappa 0.56)using SP3 and 84.1%(Kappa 0.38)using 4B5.CONCLUSION:The use of the 4B5 antibody on wholetissue sections was the most accurate IHC method for evaluating HER2 expression in gastric adenocarcinoma.

Early urological complications after kidney transplantation: An overview

Urological complications, especially urine leaks, remain the most common type of surgical complication in the early post-transplant period. Despite major advances in the field of transplantation, a small minority of kidney transplants are still being lost due to urological problems. Many of these complications can be traced back to the time of retrieval and implantation. Serial ultrasound examination of the transplanted graft in the early post-operative period is of key importance for early detection. The prognosis is generally excellent if recognized and managed in a timely fashion. The purpose of this narrative review is to discuss the different presentations, compare various ureterovesical anastomosis techniques and provide a basic overview for the management of post-transplant urological complications.

Strenuous Exercise—An Unusual Cause of Deranged Liver Enzymes

Liver enzymes and function tests are routinely taken in clinical practice. Deranged liver enzymes however, do not always necessarily imply an underlying liver pathology. The standard liver enzymes measured include alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl-transpeptidase (GGT) and alanine phosphatase (ALP). These enzymes, especially ALT and AST, can be released by other organs in the body. We report an unusual case of a 48-year-old patient with deranged enzymes related exclusively to intensive exercise that resolved on discontinuing such exercise.

The Initial Implementation of the Sentinel Lymph Node Biopsy (SLNB) for Breast Cancer Management in Malta

Over the past two decades, the sentinel lymph node biopsy (SLNB) based on sentinel node (SN) being the first lymph node that harbors metastases, revolutionized breast cancer management. SLNB presents much less morbidity when compared to radical axillary lymph node dissection (ALND) where all nodes are dissected irrespective of their metastatic involvement. The purpose of this study was to evaluate the effectiveness of SLNB by investigating whether the histological characteristics of the SNs identified using scintigraphy are predictive of the histological characteristics of the ALN basin. Methods: Fifty-five female breast cancer patients underwent lymphoscintigraphy and SLNB followed by ALND. The histological status of the SN/s was correlated to the histological status of the ALNs to determine whether the SN accurately stages the ALNs in breast cancer. Results: During surgery, SNs were successfully isolated in 52 out of 55 cases (94.5%) (range, 0 to 9). No SNs were identified in 3 cases (5.5%). Results demonstrate a significant association (p = 0.05) between the metastatic status of SNs and the corresponding ALNs in 42 out of 52 patients (80.8%), but with a high false-negative rate (FNR) of 37.5%. Conclusion: The findings of this study show that the sentinel node concept provides the benefits of SLNB in the majority of instances. However, further work is required in reducing the FNR. Once the effectiveness of SLNB as a staging technique is locally established, the need of ALND in SN-negative patients would be limited, thus improving the quality of life of Maltese breast cancer patients.

Macrophage sequestration of HIV-1 enhances homeostatic-related systems in promoting viral spread and replication

Decisive modulatory systems of compromise and systems of dynamic turnover in lymphoid cells and macrophages are activated by repeated bursts of viremia and as promotional schemes of representation of subsequent spread and replication of HIV-1. In such operative systems of micro-environmental conditioning and reconditioning, a significant mechanism towards the turnover of specific cell-types occurs within context of sequestration within macrophages and circulating monocytes. Dendritic cells in germinal follicles and within specific organs such as the Langerhans cells of the skin are allied to dysfunctionality of such cellular subtypes as exemplified by the resident microglia of the central nervous system. Decisive perturbation in cell-type number and in dysfunctional activation indicate an exquisite modulatory role for HIV-1 in promoting homeostatic-related mechanisms within organs and tissues towards utilization in terms of viral dynamics and cytokine operability. In such manner, HIV-1 replication is itself a system of promotion in spread of viruses across cell-type and host cell specificities that tend to characterize and recharacterize systems of cytokine network operability in particular.

Operative sequentiality in tumor differentiation and progression as protein molecular structure and sequence context in modulating alternative splicing events

This review article discusses dimensional reconstruction of alternative splicing that not only affects primarily the distributional dimensions of isoforms of various protein species but especially influences the nature of interactivity events between various protein species and also the structure of the given protein molecules. In such terms, disorders of differentiation of individual tumors and of tumor types and subtypes would correlate with distinctive dimensions of expression of a limited number of genes in various modes of expressed selectivity programs. In particular, the differentiation programs of normal tissues would correlate with combinatorial systems of splicing factors and of auxiliary factors in the development of patterns of gene expression. The significance of mis-splicing events is consonant with the wide range of phenotypic expression of neoplastic lesions and in the great variety of differentiation patterns and also of the variable degrees of differentiation of various components of a given neoplasm. The structure of given protein isoforms resulting from alternative splicing correlate with the sequence context of exons in the enhancement or inhibition of splicing events and would also influence pathobiologic behavior patterns of given neoplastic lesions. The development of abnormal cell signalling pathways and of interactivity patterns in a combinatorial way would directly influence the stability and trafficking dynamics of given protein molecular species in inducing an abundance of protein isoform production. Series of multi-component systems ranging from receptivity to consequential pathways of development of differential phenotype would allow for a high degree of modulatory effect within systems implicating in particular the interactions of individual tumor cells with each other and with the matrix components. It is within the context of constitutive versus alternative splicing events that this review article proposes that proportional recreation of differentiation pathways promotes a self-progression of the pathobiologic processes of a given neoplastic lesion.

HIV-1 Primarily Targets the Innate Immune System and Only Secondarily Modulates Adaptive Immune Cell Depletion

Persistence of HIV-1 infection allows for permissive microenvironmental conditioning in terms of contextual innate immune participation. The progression of host cell injury constitutes an additional parametric formulation in self-amplifying modulation of the adaptive immune response in a manner that inclusively promotes the emergence of a final stage of AIDS that is both depletive and permissive for opportunistic infections and various forms of neoplasia. It is within contextual indices of promotion of depleted T-helper lymphocytes and of augmented viremic loads that manifestations of classic lesions emerge as the AIDS phenomenon. It is further to be realized that an apoptotic response of multiple cell subtypes including T-lymphocytes includes host-cell participation within formulated settings of further persistence of the retroviral infection. An all-inclusive phenomenon of dendritic cell-lymphocyte synapse formulation corresponds to the establishment of HIV-1 infection that specifically conditions all subsequent stages in depletion of the injured host cells regardless of the dynamics or kinetics of the retroviral replicative infectious process itself.

Distinctive parameters of action of stem cells and modulatory microenvironmental microcirculation in gliomagenesis

Definition of the malignant transformation event is central to a distinction between neural stem cells and cancer stem cells. In such manner, the descriptive analysis of various tumors such as gliomas would allow for the distinction of genetic injury and probably epigenetic events that transform gene transcription pathways. Hypoxia is a major conditioning influence acting on stem cell niche microenvironments that evolve in terms particularly of micro-vascular dynamics. The incremental involvement of entire fields of cancerization allows for the establishment of permissive conditions of repetitive nature and within the contextual involvement of multiple clones of injured cells that condition, in turn, the stem cell niche. In view of the establishment of progressive malignant change, it is significant to view the cancerization as an integral involvement of both sequential and concurrent events in defining the roles of stem cells and cancer stem cells in terms of a primal process of dedifferentiation beyond simple markers of morphologic transformation.

Long-Term Impact in Hepatitis C Virus Infection in Post Renal Transplantation

Purpose: The authors have evaluated the impact of the kidney transplantation associated with chronic hepatitis C virus (HCV) infection, analyzing the complications, patients and graft survival. Methods: Retrospective study with 40 kidney transplant recipients with HCV infection and 40 kidney transplant recipients without HCV infection in the same post transplantation period. Results: the average follow-up after transplantation was 12.3 ± 4.5 years in patients with HCV infection and 12.5 ± 2.9 years in patients without HCV infection (p = 0.49). There was no statistical difference related to age and gender of the recipient nor donor age and type. The current renal function in patients with HCV infection was 47.3 ± 24.9 mL/min and 54.9 ± 27.2 mL/min in the HCV negative group (p = 0.54). The incidence of graft and patient survival was similar in both groups. The main cause of death in both groups was bacterial infection (10% in patients with HCV infection and 12.5% in HCV negative patients (p = 0.63). The most common complication in the two groups were acute allograft rejection and bacterial infection. The incidence of diabetes mellitus did not differ statistically in both groups. Abnormal liver enzymes levels and cirrhosis were observed only in patients with HCV infection. Conclusion: HCV infection did not impact patient or graft survival and post-transplant complications were similar in both groups during a mean follow-up period of 12 years.

European Specialty Examination in Gastroenterology and Hepatology examination-improving education in gastroenterology and hepatology

The Federation of Royal Colleges,the British Society of Gastroenterology(BSG)and the European Section and Board of Gastroenterology and Hepatology developed the European Specialty Examination in Gastroenterology and Hepatology(ESEGH)from the United Kingdom Specialty Certificate Examination,which was the original examination.Since 2018 the Specialty Certificate Examination and the ESEGH were combined into a single exam,identical across Europe and the rest of the world.The ESEGH is mandated in 4 countries(United Kingdom,Switzerland,The Netherlands and Malta)and the number of entries increased from 50 in 2014 to 490 in 2019.Candidates from countries were the ESEGH is not mandated are sitting the Exam,showing us they realize the enormous interest of holding a certificate for knowledge in their Curriculum.We also have an increasing number of candidates from countries outside Europe.

Elevated levels of the pollutant PM2.5 in crowded subways of cities with high COVID-19 related mortality-when COVID-19 went underground

Background:Recent literature indicates that the pollutant,particulate matter PM2.5,may have an impact on COVID-19 related infection and mortality.Genes coding for SARS-CoV-2 has been found adherent to PM2.5 and possibly the COVID-19/PM2.5 complex may be involved in the transmission and the exacerbation of COVID-19 infection.PM2.5 levels in deep underground subways have been found up to 90 times higher than roads closer to the surface.Method:The levels of PM2.5 were retrieved from literature assessing particulate matter PM2.5 measured on subway platforms in two groups of cities.These cities were differentiated by the COVID-19 population percentage mortality rate(0.007%vs 0.19%)(P<0.0004).Data regarding the number of stations,length of the networks(km)and the annual ridership were also obtained from literature related to underground commuting.Results:The population percentage mortality related to SARS-CoV-2 infection correlated significantly for both minimum(P<0.01)and maximum(P<0.00001)levels of PM2.5.The cities’subways with low COVID-19 mortality had minimum platform PM2.5 levels of 27.4(SD+/-17.2μg/m3)compared to 63.4μg/m3(SD+/-10.8μg/m3)in cities with high SARS-CoV-2 associated mortality(P<0.01).Subway maximum levels of PM2.5 in cities with low COVID-19 mortality was 53.4μg/m3(SD+/-21.8μg/m3)while that of underground networks with high COVID-19 mortality had maximum platform PM2.5 levels of 172.1μg/m3(SD+/-98μg/m3)(P<0.001).Conclusion:Underground networks may have inherent characteristics accelerating spread of SARSCoV-2 infection and consequent mortality.The highly elevated levels of PM2.5 in overcrowded subways with extensive reach,may have acted as a co-factor to disseminate the pandemic in a number of metropolises.

Single-stage tubular urethral reconstruction using oral grafts is an alternative to classical staged approach for selected penile urethral strictures

Penile urethral strictures have been managed by a staged surgical approach.In selected cases,spongiofibrosis can be excised,a neo-urethral plate created using buccal mucosa graft(BMG)and tubularized during the same procedure,performing a“twoin-one”stage approach.We aim to identify stricture factors which indicate suitability for this two-in-one stage approach.We assess surgical outcome and compare with staged reconstruction.We conducted an observational descriptive study.The data were prospectively collected from two-in-one stage and staged penile urethroplasties using BMG in a single center between 2007 and 2017.The minimum follow-up was 6 months.Outcomes were assessed clinically,radiologically,and by flow-rate analysis.Failure was defined as recurrent stricture or any subsequent surgical or endoscopic intervention.Descriptive analysis of stricture characteristics and statistical comparison was made between groups.Of 425 penile urethroplasties,139 met the inclusion criteria:59 two-in-one stage and 80 staged.The mean stricture length was 2.8 cm(single stage)and 4.5 cm(staged).Etiology was lichen sclerosus(LS)52.5%(single stage)and 73.8%hypospadias related(staged).40.7%of patients had previous failed urethroplasties in the single-stage group and 81.2%in the staged.The most common stricture locations were navicular fossa(39.0%)and distal penile urethra(59.3%)in the single-stage group and mid or proximal penile urethra(58.7%)in the staged group.Success rates were 89.8%(single stage)and 81.3%(staged).A trend toward a single-stage approach for select penile urethral strictures was noted.We conclude that a single-stage substitution penile urethroplasty using BMG as a“two-in-one”approach is associated with excellent functional outcomes.The most suitable strictures for this approach are distal,primary,and LS-related strictures.

Aneurysmal dilatation of the aortic sinuses of Valsalva -- beyond Marfan syndrome： a single centre experience and review of the literature

Aneurysmal dilatation of the aortic sinuses of Valsalva has been most extensively documented in the setting of aortopathies, particularly Marfan syndrome. On the other hand, there is limited data in the literature about congenital sinus of Valsalva aneurysms outside this context. For the purpose of this review, we carried out a literature search on aneurysmal dilatation of the sinuses of Valsalva in Marfan syndrome, and compared this with congenital sinus of Valsaiva aneurysms, also including data from a case series from our institution. In conclusion, there are differences in management of aortic dilatation in Marfan syndrome and congenital sinus of Valsalva aneurysms. Though less weil-recognised, congenital aneurysms are often associated with significant morbidity and mortality and timely intervention is necessary.