The challenges and possibilities of public access defibrillation

Out-of-hospital cardiac arrest (OHCA) is a major health problem that affects approximately four hundred and thousand patients annually in the United States alone. It is a major challenge for the emergency medical system as decreased survival rates are directly proportional to the time delay from collapse to defibrillation. Historically, defibrillation has only been performed by physicians and in-hospital. With the development of automated external defibrillators (AEDs), rapid defibrillation by nonmedical professionals and subsequently by trained or untrained lay bystanders has become possible. Much hope has been put to the concept of Public Access Defibrillation with a massive dissemination of public available AEDs throughout most Western countries. Accordingly, current guidelines recommend that AEDs should be deployed in places with a high likelihood of OHCA. Despite these efforts, AED use is in most settings anecdotal with little effect on overall OHCA survival. The major reasons for low use of public AEDs are that most OHCAs take place outside high incidence sites of cardiac arrest and that most OHCAs take place in residential settings, currently defined as not suitable for Public Access Defibrillation. However, the use of new technology for identification and recruitment of lay bystanders and nearby AEDs to the scene of the cardiac arrest as well as new methods for strategic AED placement redefines and challenges the current concept and definitions of Public Access Defibrillation. Existing evidence of Public Access Defibrillation and knowledge gaps and future directions to improve outcomes for OHCA are discussed. In addition, a new definition of the different levels of Public Access Defibrillation is offered as well as new strategies for increasing AED use in the society.

[Circulation and etiological characterization of Salmonella enterica serotype in human in Guangdong province, 2007-2016]

Objective: To understand the circulation, drug resistance and molecular characteristics of Salmonella1, 4, [5], 12: i:- in human in Guangdong province. Methods:Salmonella1, 4, [5], 12: i:- isolated from diarrhea patients in Guangdong during 2007-2016 were detected for drug resistance, genes and PFGE characteristics. Results: A total of 2 960 strains Salmonella1, 4, [5], 12: i: - were isolated from human diarrhea cases during this period. The positive rates of the isolation increased year by year. The male to female ratio of the infection cases was 1.58∶1, and the infection mainly occurred in infants and young children. Except imipenem, Salmonella1, 4, [5], 12: i: - was resistant to other 17 antibiotics to some extent. The drug resistant rates to ceftazidime, cefotaxime and ciprofloxacin increased from 2011 to 2016. Multi-drug resistance was serious, for example, the multi-drug resistant strains with ASSuT accounted for 70.62% (435/616) and the multi-drug resistant strains with ACSuGSTTm accounted for 27.11% (167/616). The lack of fljA, fljB and hin genes, as well as the retaining of iroB, STM2740, STM2757 genes, resulted in the unable expression of FljBenx gene with 8 different defection profiles. There were 934 different PFGE patterns observed in 2 347 strains, which displayed a relatively large fingerprint polymorphism. The major PFGE pattern was JPXX01. GD0226, which was found in 97 strains, accounting for 4.13% (97/2 347). The PFGE patterns in 168 Salmonella1, 4, [5], 12: i: - strains were consistent with that of Salmonella typhimurium. Conclusions:Salmonella1,4,[5], 12: i: - strains has become the major serotype of Salmonella that cause diarrhea in human in Guangdong. The multi-drug resistance of Salmonella1,4, [5], 12: i: - was serious, and since the defection of fljA, fljB and hin genes, the expression of FljBenx protein failed. The PFGE results were diverse, which displayed polymorphism in inheritance.

[Etiologic characteristics of Shigella sonnei strains isolated from some areas of Guangdong province and Guangxi Zhuang Autonomous Region of China, 2014-2016]

Objective: To investigated the etiologic characteristics of Shigella (S.) sonnei strains causing outbreaks and sporadic cases in some areas of Guangdong province and Guangxi Zhuang Autonomous Region during 2014-2016. Methods: Fourteen S. sonnei strains isolated from outbreaks and 6 S. sonnei strains from sporadic cases from Guangdong and Liuzhou of Guangxi Zhuang Autonomous Region were tested for antimicrobial resistance and analyzed by pulsed-field gel electrophoresis (PFGE). Six typical strains were selected for whole genome sequencing typing and compared with 51 strains isolated both at home and abroad from NCBI genome database. Results: The antibiotic resistance test indicated the isolates had high resistance rate to ampicillin, tetracycline, gentamicin, trimethoprim/sulfamethoxazole and nalidixic acid, while sensitive to azithromycin, chloromycetin and imipenem. PFGE showed high similarity (93.2%) among the strains isolated from different areas. The whole genome sequencing analysis also revealed that all the typical strains were clustered into a same evolution branch, close to some strains from Korea. Conclusions: The S. sonnei strains isolated from some areas of Guangdong and Guangxi Zhuang Autonomous Region showed high resistance to commonly used antibiotics, but they were sensitive to azithromycin, chloramphenicol and imipenem. The isolates in this study also showed similar PFGE patterns and close phylogenic evolution.

[The role of autophagy in the invasion and metastasis of the squamous cell carcinoma of head and neck]

Objective:The aim of this study is to explore the effects of autophagy on the metastasis of the Squamous Cell Carcinoma of Head and Neck (SCCHN) via epithelial to mesenchymal transition (EMT) induced by TGF-β1. Method:Establish the EMT model induced by TGF-β1 in the SCCHN in time/concentration, and the expression of autophagy related protein microtubule associated protein 1 light chain3 (LC3) detected by western blot; Autophagy inhibitor chloroquine (CQ), depressing autophagy, the expression of E-cadherin, cytokeratin, Vimentin and LC3 were examined by Western blot. Wound healing and Transwell invasion assay indicate the effects to metastasis for SCCHN. Result:Autophagy was activated within TGF-β1 induced EMT model in the SCCHN in time/concentration dependently. After autophagy was suppressed, the expression of E-cadherin and cytokeratin increased while vimentin and the capacity of metastasis was reduced compared with control group. Conclusion:TGF-β1 induce EMT and Autophagy in the SCCHN. Autophagy could enhances metastasis in the SCCHN via EMT induced by TGF-β1.

Respiratory Complications in Children with Prader Willi Syndrome

Prader Willi syndrome, resulting from the partial deletion or lack of expression of a region of genes on the paternal chromosome 15, has a number of phenotypic features which predispose affected patients to ventilatory problems. These include generalised hypotonia, abnormal arousal and ventilatory responses to hypoxia and hypercapnia, scoliosis and frequently, obesity. The spectrum of the resulting respiratory complications thus runs from sleep disordered breathing, to aspiration and respiratory functional impairment. While the use of growth hormone, in conjunction with multidisciplinary clinical management, is currently the cornerstone of clinical care of these patients, concerns have been raised following reports of sudden death shortly after growth hormone initiation. This review summarizes the respiratory complications commonly seen and draws together the published literature on the impact of growth hormone in relation to various respiratory parameters, aiming to provide the reader with the necessary information to manage these patients as safely as possible.

[Study on Salmonella serotyping by use of Microsphere-based Liquid Array method]

OBJECTIVE

To understand the effect of serotyping on Salmonella isolates, by use of Microsphere-based Liquid Array method, among diarrhea patients, in Guangdong.

METHODS

Salmonella isolated from humans in Guangdong province were serotyped on the Microsphere-based Liquid Array platform with SSA kit.

RESULTS

A total of 4 942 Salmonella strains with 189 serotypes, were identified in Guangdong province in 2010-2014. The top 100 serotypes accounted for 98.08% (4 847/4 942) of all the strains. 98% of the top 100 species serotypes could completely be serotyped with SSA kit. In order to detect O antigen among 198 isolates with SSA kit, 181 strains were carrying the O antigen, with the coincidence rate as 100%. However, under the SSA, 98.32% (528/537) of the H antigen could be detected and were consistent with the traditional serum agglutination test. The coincidence rate of fljB gene was 93.09% (175/188), with false negative rate and false positive rate of fljB gene as 7.35% (9/134) and 7.41% (4/54) respectively. The coincidence rate of sdf gene and Vi gene were 100%. 11 out of the 12 Salmonella strains could not be serotyped under the traditional methods but were successfully serotyped by the molecular serotyping method.

CONCLUSIONS

Using the SSA kit, more than 96% of the anthropogenic Salmonella strains could be serotyped in Guangdong province. Comparing with the traditional methods, the coincidence rate of serotyping appeared over 98% . Under the Microsphere-based Liquid Array techniques, the molecular serotyping method appeared faster and more accurate on Salmonella serotyping than those traditional methods.

Is arterial base deficit still a useful prognostic marker in trauma? A systematic review

BACKGROUND

Arterial base deficit (BD) has been widely used in trauma patients since 1960. However, trauma management has also evolved significantly in the last 2 decades. The first objective of this study was to systematically review the literature on the relationship between arterial BD as a prognostic marker for trauma outcomes (mortality, significant injuries, and major complications) in the acute setting. The second objective was to evaluate arterial BD as a prognosis marker, specifically, in the elderly and in patients with positive blood alcohol levels.

METHODS

MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched from January 1, 1990, to August 6, 2015. Bibliographies of articles were also hand searched for relevant citations.

RESULTS

Thirty-four studies were included in this review. The studies consistently showed that a higher arterial BD was associated with increased mortality, significant injuries, and major complications. The threshold BD value of 6 mmol/L was also useful in discriminating for poorer outcomes. The presence of alcohol did not affect the ability of arterial BD to discriminate between major and minor injuries. Elderly patients had higher mortality in all arterial BD categories compared to the younger age group.

CONCLUSIONS

Despite the advances in trauma care in the last 2 decades, arterial BD remains a useful prognostic marker in trauma patients, even in elderly patients and in patients who had consumed alcohol. The threshold BD value of 6 mmol/L was useful to prognosticate poorer outcomes.

In-Hospital Haloperidol Use and Perioperative Changes in QTc-Duration

OBJECTIVES

Haloperidol may prolong ECG QTc-duration but is often prescribed perioperatively to hip-fracture patients. We aimed to determine (1) how QTc-duration changes perioperatively, (2) whether low-dose haloperidol-use influences these changes, and (3) which clinical variables are associated with potentially dangerous perioperative QTc-prolongation (PD-QTc; increase >50 ms or to >500 ms).

DESIGN

Prospective cohort study.

SETTING

Tertiary university teaching-hospital.

PARTICIPANTS

Patients enrolled in a randomized controlled clinical trial of melatonin versus placebo on occurrence of delirium in hip-fracture patients.

MEASUREMENTS

Data from ECGs made before and after hip surgery (1-3 days and/or 4-6 days post-surgery) were analyzed. QTc-duration was measured by hand, blinded for haloperidol and pre/post-surgery status. Clinical variables were measured at baseline. Mixed model analysis was used to estimate changes in QTc-duration. Risk-factors for PD-QTc were estimated by logistic regression analysis.

RESULTS

We included 89 patients (mean age 84 years, 24% male); 39 were treated with haloperidol. Patients with normal pre-surgery QTc-duration (male ≤430 ms, female ≤450 ms) had a significant increase (mean 12 ms, SD 28) in QTc-duration. A significant decrease (mean 19 ms, SD 34) occurred in patients with prolonged pre-surgery QTc-duration (male >450ms, female >470 ms). Haloperidol-use did not influence the perioperative course of the QTc-interval (p=0.351). PD-QTc (n=8) was not associated with any of the measured risk-factors.

CONCLUSION

QTc-duration changed differentially, increasing in patients with normal, but decreasing in patients with abnormal baseline QTc-duration. PD-QTc was not associated with haloperidol-use or other risk-factors. Low-dose oral haloperidol did not affect perioperative QTc-interval.

Short-segment posterior instrumentation combined with calcium sulfate cement vertebroplasty for thoracolumbar compression fractures: radiographic outcomes including nonunion and other complications

OBJECTIVE

To evaluate the radiographic outcomes of short-segment posterior instrumentation plus vertebroplasty using injectable calcium sulfate cement (CSC) for thoracolumbar compression fractures.

MATERIALS AND METHODS

Twenty-eight patients with a single-level thoracolumbar compression fracture, who underwent short-segment pedicle screw fixation and CSC vertebroplasty, were included in the study. The anterior vertebral body height ratio, local kyphosis angle, and the height of the intervertebral disc adjacent to the fractured vertebra were used to evaluate the radiographic results. Complications including bone nonunion, instrument failure, cement leakage, and disc vacuum formation were also assessed.

RESULTS

The patients were followed up for an average of 24.20±5.40 months. The relative preoperative anterior body height was 55.71±15.29%, which improved to 94.93±5.39% immediately after surgery (P<0.001), and at final follow-up showed a 6.50±3.89% loss of height correction (P<0.001). The mean preoperative local kyphosis angle was 22.23±5.65°, which corrected to 2.67±4.43° immediately after surgery (P<0.001), but reverted to 6.71±4.95° at final follow-up, showing a 4.04±1.91° loss of correction (P<0.001). The mean height of the intervertebral disc proximal to the fractured vertebra was 9.87±0.91 mm before surgery, 12.53±0.98 mm after operation (P<0.001), and the loss of correction at final follow-up was 2.35±1.15 mm with a significant difference compared to immediate postoperative values (P<0.001). Bone nonunion occurred in 7 patients, 2 patients had hardware failure, 9 patients had cement leakage, and 10 patients had disc vacuum phenomenon adjacent to the fractured vertebra.

CONCLUSIONS

The patients who underwent this procedure had a loss of correction of vertebral height and local kyphosis. Complications such as bone nonunion, instrument failure, cement leakage, and disc vacuum may occur. Rapid CSC resorption accounts for these radiographic outcomes and complications.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Increased prevalence of ECG markers for sudden cardiac arrest in refractory epilepsy

BACKGROUND AND AIM

People with epilepsy are at increased risk of sudden cardiac arrest (SCA) due to ECG-confirmed ventricular tachycardia/fibrillation, as seen in a community-based study. We aimed to determine whether ECG-risk markers of SCA are more prevalent in people with epilepsy.

METHODS

In a cross-sectional, retrospective study, we analysed the ECG recordings of 185 people with refractory epilepsy and 178 controls without epilepsy. Data on epilepsy characteristics, cardiac comorbidity, and drug use were collected, and general ECG variables (heart rate (HR), PQ and QRS intervals) assessed. We analysed ECGs for three markers of SCA risk: severe QTc prolongation (male >450 ms, female >470 ms), Brugada ECG pattern, and early repolarisation pattern (ERP). Multivariate regression models were used to analyse differences between groups, and to identify associated clinical and epilepsy-related characteristics.

RESULTS

People with epilepsy had higher HR (71 vs 62 bpm, p<0.001) and a longer PQ interval (162.8 vs 152.6 ms, p=0.001). Severe QTc prolongation and ERP were more prevalent in people with epilepsy (QTc prolongation: 5% vs 0%; p=0.002; ERP: 34% vs 13%, p<0.001), while the Brugada ECG pattern was equally frequent in both groups (2% vs 1%, p>0.999). After adjustment for covariates, epilepsy remained associated with ERP (ORadj 2.4, 95% CI 1.1 to 5.5) and severe QTc prolongation (ORadj 9.9, 95% CI 1.1 to 1317.7).

CONCLUSIONS

ERP and severe QTc prolongation appear to be more prevalent in people with refractory epilepsy. Future studies must determine whether this contributes to increased SCA risk in people with epilepsy.

Genetic, clinical and pharmacological determinants of out-of-hospital cardiac arrest: rationale and outline of the AmsteRdam Resuscitation Studies (ARREST) registry

Introduction

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. Recognising the complexity of the underlying causes of OHCA in the community, we aimed to establish the clinical, pharmacological, environmental and genetic factors and their interactions that may cause OHCA.

Methods and analysis

We set up a large-scale prospective community-based registry (AmsteRdam Resuscitation Studies, ARREST) in which we prospectively include all resuscitation attempts from OHCA in a large study region in the Netherlands in collaboration with Emergency Medical Services. Of all OHCA victims since June 2005, we prospectively collect medical history (through hospital and general practitioner), and current and previous medication use (through community pharmacy). In addition, we include DNA samples from OHCA victims with documented ventricular tachycardia/fibrillation during the resuscitation attempt since July 2007. Various study designs are employed to analyse the data of the ARREST registry, including case–control, cohort, case only and case-cross over designs.

Ethics and dissemination

We describe the rationale, outline and potential results of the ARREST registry. The design allows for a stable and reliable collection of multiple determinants of OHCA, while assuring that the patient, lay-caregiver or medical professional is not hindered in any way. Such comprehensive data collection is required to unravel the complex basis of OHCA. Results will be published in peer-reviewed journals and presented at relevant scientific symposia.

Dietary sorbitol and mannitol: food content and distinct absorption patterns between healthy individuals and patients with irritable bowel syndrome

BACKGROUND

Sorbitol and mannitol are naturally-occurring polyol isomers. Although poor absorption and induction of gastrointestinal symptoms by sorbitol are known, the properties of mannitol are poorly described. We aimed to expand data on food composition of these polyols, and to compare their absorptive capacities and symptom induction in patients with irritable bowel syndrome (IBS) and healthy individuals.

METHODS

Food samples were analysed for sorbitol and mannitol content. The degree of absorption measured by breath hydrogen production and gastrointestinal symptoms (visual analogue scales) was evaluated in a randomised, double-blinded, placebo-controlled study in 21 healthy and 20 IBS subjects after challenges with 10 g of sorbitol, mannitol or glucose.

RESULTS

Certain fruits and sugar-free gum contained sorbitol, whereas mannitol content was higher in certain vegetables. Similar proportions of patients with IBS (40%) and healthy subjects (33%) completely absorbed sorbitol, although more so with IBS absorbed mannitol (80% versus 43%; P = 0.02). Breath hydrogen production was similar in both groups after lactulose but was reduced in patients with IBS after both polyols. No difference in mean (SEM) hydrogen production was found in healthy controls after sorbitol [area-under-the-curve: 2766 (591) ppm 4 h(-1) ] or mannitol [2062 (468) ppm 4 h(-1) ] but, in patients with IBS, this was greater after sorbitol [1136 (204) ppm 4 h(-1) ] than mannitol [404 (154) ppm 4 h(-1) ; P = 0.002]. Overall gastrointestinal symptoms increased significantly after both polyols in patients with IBS only, although they were independent of malabsorption of either of the polyols.

CONCLUSIONS

Increased and discordant absorption of mannitol and sorbitol occurs in patients with IBS compared to that in healthy controls. Polyols induced gastrointestinal symptoms in patients with IBS independently of their absorptive patterns, suggesting that the dietary restriction of polyols may be efficacious.

Reduced in-hospital survival rates of out-of-hospital cardiac arrest victims with obstructive pulmonary disease

AIM

Out-of-hospital cardiac arrest (OHCA) due to sustained ventricular tachycardia/fibrillation (VT/VF) is common and often lethal. Patient's co-morbidities may determine survival after OHCA, and be instrumental in post-resuscitation care, but are poorly studied. We aimed to study whether patients with obstructive pulmonary disease (OPD) have a lower survival rate after OHCA than non-OPD patients.

METHODS

We performed a community-based cohort study of 1172 patients with non-traumatic OHCA with ECG-documented VT/VF between 2005 and 2008. We compared survival to emergency room (ER), to hospital admission, to hospital discharge, and at 30 days after OHCA, of OPD-patients and non-OPD patients, using logistic regression analysis. We also compared 30-day survival of patients who were admitted to hospital, using multivariate logistic regression analysis.

RESULTS

OPD patients (n=178) and non-OPD patients (n=994) had comparable survival to ER (75% vs. 78%, OR 0.9 [95% CI: 0.6-1.3]) and to hospital admission (56% vs. 57%, OR 1.0 [0.7-1.4]). However, survival to hospital discharge was significantly lower among OPD patients (21% vs. 33%, OR 0.6 [0.4-0.9]). Multivariate regression analysis among patients who were admitted to hospital (OPD: n=100, no OPD: n=561) revealed that OPD was an independent determinant of reduced 30-day survival rate (39% vs. 59%, adjusted OR 0.6 [0.4-1.0, p=0.035]).

CONCLUSION

OPD-patients had lower survival rates after OHCA than non-OPD patients. Survival to ER and to hospital admission was not different between both groups. However, among OHCA victims who survived to hospital admission, OPD was an independent determinant of reduced 30-day survival rate.

Ferulic acid induces heme oxygenase-1 via activation of ERK and Nrf2

This study investigated the effect of ferulic acid (FA) on the up-regulation of heme oxygenase-1 (HO-1) in lymphocytes and the molecular mechanisms involved. Lymphocytes were treated with FA (0.001-0.1 μM) for certain times. Cell viability, the activity and level of expression of HO-1, and signal pathways were analyzed. FA significantly upregulated HO-1 expression both at the level of mRNA and protein in lymphocytes. Moreover, FA induced NF-E2-related factor (Nrf2) nuclear translocation and transcriptional activity, which is upstream of FA induced HO-1 expression. In addition, lymphocytes treated with FA exhibited activation of extracellular regulated kinase (ERK) and treatments with U0126 (an ERK kinase inhibitor) attenuated the FA induced activation of Nrf2, resulting in a decrease in HO-1 expression. Zinc protoporphyrin (ZnPP, a HO-1 inhibitor) markedly suppressed cytoprotection from radiation-induced cell damage by FA. Results suggested that the ERK signaling pathway controlled the anti-oxidation of FA by regulating the expression of the antioxidant enzyme HO-1.

Assessment of stem cell markers during long-term culture of mouse embryonic stem cells

Embryonic stem (ES) cells have been in the fore front of scientific literature lately as having the potential for regeneration of many tissue types. Two important issues that need to be addressed are the culture conditions for maintaining ES cells and the accuracy of ES cell markers in monitoring the undifferentiated state. Leukaemia inhibitory factor (LIF) is routinely used to sustain mouse ES cells (mES) in a pluripotent fashion. In this paper, we assessed three markers during long-term maintenance of ES cells with various concentrations of LIF to see if decreasing concentration would lead to changes in marker expressions and growth behavior. Common markers of pluripotency such as alkaline phosphatase enzyme activity (ALP), surface staining for stage specific embryonic antigen 1 (SSEA-1), Oct-4 transcription factor, cell doubling time, as well as visual observations of cell morphology were analyzed during long-term maintenance of mES cells with LIF concentrations ranging from 0 to 500 pM. The morphology of the cells at LIF concentrations of 0 25 pM changed from being tight clusters to more flattened shapes while cells in 50-500 pM retained the clustered shape but growth rates remained essentially identical at between 10 and 16 h. ES cells at all concentrations of LIF continued expressing ALP, SSEA-1 and Oct-4 markers over a period of 6 weeks, which indicate that mES cells are capable of either producing autocrine LIF or are able to proliferate at very low levels of LIF. Pluripotency markers such as Oct-4 and SSEA-1 are only moderately reduced after 5-6 weeks. Oct-4 mRNA expression levels were partially diminished in LIF free conditions only at weeks 5 and 6 compared to controls with LIF at 500 pM. Changes in morphology of cells by visual observation seemed to be a faster indication of the onset of differentiation in mES cells, although other reliable means also include decreased levels of Oct-4, SSEA-1 and ALP markers. It is preferable to maintain long-term cultures of mES cells above 50 pM of LIF to have a more homogenous, stable population of pluripotent cells.

Clinical outcomes for cancer patients using complementary and alternative medicine

CONTEXT

Over half of cancer patients in Singapore use some form of complementary or alternative medicine (CAM) to improve their immunity and general health status. The effectiveness of CAM, however, in reducing acute complications is currently unknown. Concerns also exist as to whether CAM may cause toxic effects in patients with cancer.

OBJECTIVE

To investigate the changes in general health status, immunity, and organ function over a 6-month period in CAM and non-CAM users with cancer.

DESIGN

The authors designed a single-center, retrospective cohort study. The patients had participated previously in a cross-sectional prevalence survey about the types of oral CAM they were using in addition to chemotherapy. The authors used the data from the survey and clinical and medication-use information from patients' medical and pharmaceutical records to complete the current study.

SETTING

The study occurred at the National Cancer Centre Singapore (NCCS), which is the largest ambulatory cancer center in Singapore and treats two-thirds of the solid-tumor patients in Singapore. The study excluded patients if their medical records were incomplete and/or if the patients had not received any cytotoxic or targeted therapies at the time of survey.

PARTICIPANTS

The authors reviewed the records of a total of 403 patients and excluded 46 patients because their records were missing (n=20) or because they had not received any form of anticancer treatment at the time of survey (n=26). They included 357 patients in the current study. The authors did not contact patients for this follow-up study.

OUTCOME MEASURES

The authors collected data on clinical characteristics for each patient and assessed the differences between each characteristic at baseline (at the time of the survey) and at 6 months after baseline measurement. The authors evaluated clinical characteristics using the National Cancer Institute's Common Terminology Criteria for Adverse Events version 3.

RESULTS

As a whole, CAM use provided an absolute reduction of infection episodes by 11.9% (P=.045) and of antibiotic use by 10.3% (P=.022). Subgroup analysis showed a reduction of documented infection by 17.9% (P=.02) and a 13% decrease in hospitalizations due to infections (P=.043) among metastatic cancer patients who used CAM. CAM usage was not associated with significant changes of hepatic and renal function.

CONCLUSION

CAM use in patients with cancer was associated with a reduction in hospitalizations and requirements for antibiotics. CAM use was not associated with significant changes in hepatic and renal function. There is a need for well-designed, prospective clinical studies to confirm these findings.

Clinical and laboratory features of invasive community-onset methicillin-resistant Staphylococcus aureus infection: a prospective case-control study

Differences between the features of invasive community-onset methicillin-resistant Staphylococcus aureus (cMRSA) and methicillin-susceptible S. aureus (cMSSA) infections are incompletely understood. Fifty-seven patients with invasive cMRSA infection were prospectively identified at two teaching hospitals; for each cMRSA case, two cases of invasive cMSSA infection acted as controls. The primary outcome was 30-day all-cause mortality. Patients with invasive cMRSA infection were more likely to be Aboriginal (25% vs. 14%, age-adjusted odds ratio [OR] 2.5, p = 0.037), reside in a long-term care facility and/or have been hospitalised in the previous year (51% vs. 34%, p = 0.04) and less likely to have endocarditis (2% vs. 12%, p = 0.02) or require admission to an intensive care unit or high-dependency area (7% vs. 21%, p = 0.02). All-cause mortality at 30 days was similar in the cMRSA and cMSSA groups (9% vs. 7%, p = 0.68). Panton-Valentine leukocidin (PVL) genes were detected in a similar proportion of cMRSA and cMSSA isolates (32% vs. 27%, p = 0.49) and the presence of PVL genes was associated with younger age (35 years vs. 55 years, p < 0.001), Aboriginal ethnicity (38% vs. 10%, p < 0.001), skin and soft-tissue infection (54% vs. 19%, p < 0.001), lower illness severity at presentation (SAPS II score 9 vs. 21, p = 0.001) and shorter hospitalisation (9 days vs. 24 days, p < 0.001). Patients with "PVL-positive" and "PVL-negative" S. aureus infection had similar 30-day all-cause mortality (4% vs. 9%, p = 0.28). Few clinical features differentiated patients with invasive cMRSA infection from those with infection caused by cMSSA. Invasive "PVL-positive" S. aureus infection was associated with less morbidity but similar mortality to "PVL-negative" infection.

zVAD-induced necroptosis in L929 cells depends on autocrine production of TNFα mediated by the PKC-MAPKs-AP-1 pathway

It is intriguing that some pan-caspase inhibitors such as zVAD-fmk (zVAD) are capable of inducing necrotic cell death in a selected group of cells. As earlier reports from our laboratory have ruled out the original notion that zVAD-induced necrosis in mouse fibrosarcoma L929 cells was autophagic cell death, the main objective of this study was thus to determine the underlying mechanism of this form of cell death. In this study, we provided clear evidence that zVAD-induced necroptosis in L929 cells and such cell death is dependent on autocrine production of tumor necrosis factor-α (TNFα) at the transcriptional level. More importantly, we identified that activating protein-1 (AP-1), but not nuclear factor κ-B, is the transcription factor controlling zVAD-induced TNFα transcription. Moreover, zVAD is able to activate AP-1 through activation of two upstream mitogen-activated kinases (MAPKs), c-Jun N-terminal kinase and extracellular signal-regulated kinase. Finally, we found that protein kinase C is the important upstream signaling molecule in mediating zVAD-induced activation of MAPKs and AP-1, and subsequent autocrine production of TNFα and cell death. Data from this study reveal the molecular mechanisms underlying zVAD-induced necroptosis, an important form of programmed necrotic cell death with increasing understanding of its biological significance in health and diseases.

Rehmanniae Radix provides most of the free fructose and glucose in Si-Wu-Tang decoction

Our previous study showed that free fructose is an important active constituent responsible for Si-Wu-Tang's (SWT) effect promoting hematopoiesis and immunity. However, the contribution from SWT's four ingredient drugs to the free fructose content in the SWT decoction was not clear. To answer this question, in this study, the fructose, glucose and sucrose content in the SWT decoction, in the decoctions of each single ingredient drug, and in the decoctions of the four formulae lacking each single ingredient drug were determined by HPLC-ELSD. The results showed that the fructose and glucose content in the decoction of single Rehmanniae Radix were almost the same as those in the SWT decoction. In the single Rehmanniae Radix decoction concentrations were: 4.25 ± 0.53 mg/mL for fructose, and 3.43 ± 0.60 mg/mL for glucose; in the SWT decoction concentrations were: 4.10 ± 0.43 mg/mL for fructose, and 3.42 ± 0.32 mg/mL for glucose, while the content of fructose and glucose in the decoctions of single Angelica Radix, single Paeoniae Radix, single Chuanxiong Rhizoma and the formula lacking Rehmanniae Radix were either very small or undetectable. On the other hand, the fructose and glucose content in the decoctions of the formulae lacking Angelica Radix, lacking Paeoniae Radix and lacking Chuanxiong Rhizoma also were approximately the same as those in the SWT decoction. This indicated that Rehmanniae Radix provides most of the free fructose and glucose in the SWT decoction, and therefore plays an important role in SWT's effect promoting hematopoiesis and immunity. As for sucrose in the SWT decoction, Angelica Radix was shown to be a major donor.

Serum fructose concentration in rats after single dose oral administration of Si-Wu-Tang

Our previous study showed that fructose is an important active constituent that is responsible for Si-Wu-Tang's (SWT) effects promoting hematopoiesis and immunity. In order to provide primary data for analysis of the mechanism of fructose's bioactivity, the concentration of serum fructose in rats after a single oral administration dose of Si-Wu-Tang was determined. The concentration of serum fructose in fasting rats was 0.34 ± 0.24 mg/dL. After oral administration of 7.2 mL per kg body weight of SWT extract (1 mL extract corresponds to 1 g SWT dried herbs), serum fructose levels reached a peak concentration of 1.03 ± 0.25 mg/dL within 60 min, and then declined to the baseline level within 180 min, a pattern which is similar to the one reported for oral administration of pure fructose. The peak concentration was only 2-3 times higher than the baseline serum fructose concentration. These results showed that the increase of blood fructose concentration after oral administration of SWT is small and transient, which is very probably due to the quick metabolism of fructose by the liver. We suggest, for future research, it is necessary to consider the probability that fructose's bioactivity on hematopoiesis and immunity is not exerted by fructose in its original form, but after it is metabolized by the liver.

Long-term prognosis of patients diagnosed with Brugada syndrome: Results from the FINGER Brugada Syndrome Registry

BACKGROUND

Brugada syndrome is characterized by ST-segment elevation in the right precordial leads and an increased risk of sudden cardiac death (SCD). Fundamental questions remain on the best strategy for assessing the real disease-associated arrhythmic risk, especially in asymptomatic patients. The aim of the present study was to evaluate the prognosis and risk factors of SCD in Brugada syndrome patients in the FINGER (France, Italy, Netherlands, Germany) Brugada syndrome registry.

METHODS AND RESULTS

Patients were recruited in 11 tertiary centers in 4 European countries. Inclusion criteria consisted of a type 1 ECG present either at baseline or after drug challenge, after exclusion of diseases that mimic Brugada syndrome. The registry included 1029 consecutive individuals (745 men; 72%) with a median age of 45 (35 to 55) years. Diagnosis was based on (1) aborted SCD (6%); (2) syncope, otherwise unexplained (30%); and (3) asymptomatic patients (64%). During a median follow-up of 31.9 (14 to 54.4) months, 51 cardiac events (5%) occurred (44 patients experienced appropriate implantable cardioverter-defibrillator shocks, and 7 died suddenly). The cardiac event rate per year was 7.7% in patients with aborted SCD, 1.9% in patients with syncope, and 0.5% in asymptomatic patients. Symptoms and spontaneous type 1 ECG were predictors of arrhythmic events, whereas gender, familial history of SCD, inducibility of ventricular tachyarrhythmias during electrophysiological study, and the presence of an SCN5A mutation were not predictive of arrhythmic events.

CONCLUSIONS

In the largest series of Brugada syndrome patients thus far, event rates in asymptomatic patients were low. Inducibility of ventricular tachyarrhythmia and family history of SCD were not predictors of cardiac events.

Accuracy of serum transferrin receptor levels in the diagnosis of iron deficiency among hospital patients in a population with a high prevalence of thalassaemia trait

The diagnosis of iron deficiency in hospital patients can be difficult in the presence of inflammation. A raised serum transferrin receptor (sTfR) level is useful as a marker of iron deficiency as it is unaffected by inflammation. However, diseases that cause an increase in erythropoietic activity can also result in a raised sTfR level. In South-East Asia, the prevalence of thalassaemia trait is high. As thalassaemia trait is associated with ineffective erythropoiesis and therefore an increase in the sTfR level, we studied the influence of thalassaemia trait on the diagnosis of iron deficiency in hospital patients. Among 431 patients with different combinations of iron deficiency, alpha- and beta-thalassaemia trait, we found that the sTfR level is an excellent diagnostic test for iron deficiency only in patients without thalassaemia trait. alpha-Thalassaemia trait worsened its diagnostic accuracy and beta-thalassaemia trait rendered it a non-diagnostic test. We conclude that in populations with a high prevalence of thalassaemia trait, the sTfR level is not useful in diagnosing iron deficiency unless the patient's thalassaemia status is known.

Gastric foveolar cell hyperplasia and its role in postoperative vomiting in patients with infantile hypertrophic pyloric stenosis

BACKGROUND

Foveolar cell hyperplasia (FCH) has been reported as a rare cause of persistent gastric outlet obstruction in patients with infantile hypertrophic pyloric stenosis (IHPS), which, if present, requires excision of the gastric foveolar folds to resolve the persistent obstruction. This is a review of patients with IHPS diagnosed on abdominal ultrasound to determine the incidence of FCH in IHPS and to evaluate whether it has a causal role in postoperative vomiting following pyloromyotomy for IHPS.

METHODS

The ultrasound images of all children presenting with suspected IHPS to our institution from January 2001 to May 2006 were independently reviewed by our radiology department for evidence of FCH. Three hundred and twenty-nine ultrasounds were performed during this period for suspected IHPS, and 93 cases of IHPS were diagnosed. Eleven of 93 patients with IHPS had FCH, amounting to an incidence of 12 %. FCH was not seen in any of the remaining 236 patients who did not have IHPS.

RESULTS

FCH appears to be a common condition in patients with IHPS (12 %) and may be responsible for postoperative vomiting. In patients in whom FCH was diagnosed preoperatively, an extended pyloromyotomy was performed in all except one patient. One patient with FCH and IHPS had persistent postoperative vomiting following extended laparoscopic pyloromyotomy but vomiting resolved after conservative measures. The only patient who underwent a non-extended pyloromyotomy by the open method was readmitted with significant persistent vomiting and underwent a second laparotomy with excision of redundant mucosa and an extended pyloromyotomy, resulting in resolution of vomiting.

CONCLUSION

An extended pyloromyotomy appears to be adequate surgical treatment for patients with IHPS and FCH.