Prenatal diagnosis of a giant foetal lymphangioma and haemangiolymphoma in the second trimester using 2D and 3D ultrasound

Lymphangiomas are benign tumours of the lymphatic system. Early prenatal diagnosis is important to permit a planned delivery and provide adequate postnatal care. It thereby improves prognosis and allows the option of terminating the pregnancy if poor outcome is predicted. We report two cases, a giant haemangiolymphoma and a lymphangioma. 2D and 3D US findings are presented and differential diagnosis, therapeutic options and prognosis are discussed.

Effect of tiotropium bromide on circadian variation in airflow limitation in chronic obstructive pulmonary disease

BACKGROUND

In chronic obstructive pulmonary disease (COPD), the degree of circadian variation in forced expiratory volume in 1 second (FEV1) and the influence of anticholinergic blockade is not known. Tiotropium is a long acting inhaled anticholinergic bronchodilator that increases daytime FEV1 in COPD. We hypothesised that tiotropium would modify the overnight change in FEV1, and this would be unaffected by the timing of drug administration.

METHODS

A double blind, randomised, placebo controlled trial was conducted with tiotropium 18 mg once daily in the morning (09.00 hours), evening (21.00 hours), or an identical placebo. Patients with stable COPD (n=121, FEV1=41% predicted) underwent spirometric tests every 3 hours for 24 hours at baseline and after 6 weeks of treatment.

RESULTS

There were no significant differences at baseline between the groups. Tiotropium improved mean (SE) FEV1 (over 24 hours) in the morning (1.11 (0.03) l) and evening (1.06 (0.03) l) groups compared with placebo (0.90 (0.03) l), and nocturnal FEV1 (mean of 03.00 and 06.00 hours) in the morning (1.03 (0.03) l) and evening (1.04 (0.03) l) groups compared with placebo (0.82 (0.03) l) at the 6 week visit (p<0.01). FEV1 before morning or evening dosing was similar, while the peak FEV1 moved later in the day with active treatment. The mean percentage change in FEV1 from 09.00 hours to 03.00 hours (the nocturnal decline in FEV1) was -2.8% in the morning group, -1.0% in the evening group, and -12.8% in the placebo group. The magnitude of the peak to trough change in FEV1 was not statistically different.

CONCLUSIONS

Tiotropium produced sustained bronchodilation throughout the 24 hour day without necessarily abolishing circadian variation in airway calibre.

Longitudinal evaluation of GCF IFN-γ levels and periodontal status in HIV+ patients

BACKGROUND/AIM

Loss of periodontal support and related tooth loss is a common finding among HIV+ patients. The etiology of this destruction may be an increase in the levels of pro-inflammatory cytokines and subsequent increase in periodontal disease activity. The purpose of this study was to investigate the associations between gingival crevicular fluid interferon gamma (GCF IFN-gamma) and clinical measures of periodontal disease in HIV+ individuals. We monitored GCF IFN-gamma and periodontal status of selected sites in 33 HIV+ subjects over a 6-month period.

METHOD

Clinical measurements including gingival index, plaque index, bleeding on probing, probing depth, attachment loss (AL), and GCF samples were taken from four lower incisors and the upper right posterior sextant of each patient at baseline and 6-month visits by means of sterile paper strips. GCF levels of IFN-gamma were determined by sandwich ELISA assays. A progressing site was defined as a site that had 2 mm or more AL during the 6-month study period.

RESULTS

Twenty-five of the 264 examination sites showed 2 mm or more clinical AL during the 6-month study period. Significantly higher GCF levels of IFN-gamma were found at progressing sites than in nonprogressing sites (p < 0.001). GCF levels of IFN-gamma were highly correlated with clinical measurements taken at baseline and 6-month visits (0.001<p<0.01).

CONCLUSION

These data indicate that sites with high GCF levels of IFN-gamma are at significantly greater risk for progression of periodontitis in HIV+ patients.

Severe acute respiratory syndrome: a challenge for public health practice in Hong Kong

Severe acute respiratory syndrome (SARS) is now a global challenge affecting more than 8000 patients in different continents. The dictum of public health practice especially for infectious disease is "prevention better than cure". It is especially true for SARS as the treatment strategies remain diverse and experimental. Maintaining a healthy and hygienic environment can be one of the effective public health measures to combat infectious disease. The major challenge is that some of the most important public health measures are to be taken outside the health sector. The community also needs to be strengthened and equipped with the health skills to promote better health and hygiene. There is also the need to create a supportive environment conducive to health for long term sustainability. The WHO approach of promoting health through setting approach would be one possible solution to face the challenge. This paper will describe some of the public health initiatives in Hong Kong through "setting approach" and "community development model" in helping the society fight against SARS. With the emergence of SARS, this might be the time to globalise public health medicine as an important component of medical practice.

A whole blood immunoassay using gold nanoshells

A rapid immunoassay capable of detecting analyte within complex biological media without any sample preparation is described. This was accomplished using gold nanoshells, layered dielectric-metal nanoparticles whose optical resonance is a function of the relative size of its constituent layers. Aggregation of antibody/nanoshell conjugates with extinction spectra in the near-infrared was monitored spectroscopically in the presence of analyte. Successful detection of immunoglobulins was achieved in saline, serum, and whole blood. This system constitutes a simple immunoassay capable of detecting sub-nanogram-per-milliliter quantities of various analytes in different media within 10-30 min.

Reality monitoring and visual hallucinations in Parkinson's disease

Between 8 and 40% of Parkinson disease (PD) patients will have visual hallucinations (VHs) during the course of their illness. Although cognitive impairment has been identified as a risk factor for hallucinations, more specific neuropsychological deficits underlying such phenomena have not been established. Research in psychopathology has converged to suggest that hallucinations are associated with confusion between internal representations of events and real events (i.e. impaired-source monitoring). We evaluated three groups: 17 Parkinson's patients with visual hallucinations, 20 Parkinson's patients without hallucinations and 20 age-matched controls, using tests of visual imagery, visual perception and memory, including tests of source monitoring and recollective experience. The study revealed that Parkinson's patients with hallucinations appear to have intact visual imagery processes and spatial perception. However, there were impairments in object perception and recognition memory, and poor recollection of the encoding episode in comparison to both non-hallucinating Parkinson's patients and healthy controls. Errors were especially likely to occur when encoding and retrieval cues were in different modalities. The findings raise the possibility that visual hallucinations in Parkinson's patients could stem from a combination of faulty perceptual processing of environmental stimuli, and less detailed recollection of experience combined with intact image generation.

A comprehensive "Healthy Schools Programme" to promote school health: the Hong Kong experience in joining the efforts of health and education sectors

Both health and education are linked to economic performance. The success of education depends on good health, and vice versa. Modern education should help young people to determine values, and accept responsibility for their health and social behaviour. The success of health promotion in schools requires the joint efforts of both the health and education sectors. A comprehensive programme is needed to include teachers' training, curriculum development, community participation, changing policies and practices, and research. All these components are needed to build up a successful model of a health promoting school. The "Healthy Schools Programme" in Hong Kong gives a good example of close partnership between the health and education sectors, and moves towards a multidisciplinary approach and active learning towards health promotion.

Children's representation of family mealtime in the context of maternal eating disorders

BACKGROUND

Recent research provides evidence for specific disturbance in feeding and growth in children of mothers with eating disorders.

AIM

To investigate the impact of maternal eating disorders during the post-natal year on the internal world of children, as expressed in children's representations of self and their mother in pretend mealtime play at 5 years of age.

METHODS

Children of mothers with eating disorders (n = 33) and a comparison group (n = 24) were videotaped enacting a family mealtime in pretend play. Specific classes of children's play representations were coded blind to group membership. Univariate analyses compared the groups on representations of mother and self. Logistic regression explored factors predicting pretend play representations.

RESULTS

Positive representations of the mother expressed as feeding, eating or body shape themes were more frequent in the index group. There were no other significant group differences in representations. In a logistic regression analysis, current maternal eating psychopathology was the principal predictor of these positive maternal representations. Marital criticism was associated with negative representations of the mother.

CONCLUSIONS

These findings suggest that maternal eating disorders may influence the development of a child's internal world, such that they are more preoccupied with maternal eating concerns. However, more extensive research on larger samples is required to replicate these preliminary findings.

Multivariate analysis of factors associated with umbilical arterial pH and standard base excess after Caesarean section under spinal anaesthesia

We have investigated the factors predicting umbilical arterial pH (UA pH) and standard base excess (UA BE) in 337 consecutive elective Caesarean sections performed under spinal anaesthesia. Multiple linear regression analysis was performed with UA pH and UA BE as the dependent factors. We found that the significant factors predicting UA pH were: use of ephedrine, uterine incision-to-delivery time, maximum decrease in systolic arterial pressure and the interaction between ephedrine use and duration of hypotension (adjusted R2 = 0.39, F15,321 = 15.4, p < 0.0001). The significant factors predicting UA BE were: use of ephedrine and the interaction between ephedrine use and duration of hypotension (adjusted R2 = 0.52, F15,321 = 25.0, p < 0.0001). We conclude that, in order to minimise the risk of fetal acidosis, ephedrine should not be used before delivery, uterine incision-to-delivery time should be as short as possible, and alpha-agonists such as metaraminol or phenylephrine should be used to minimise both the magnitude and duration of hypotension.

Diagnosis disclosure in cancer patients--when the family says "no!"

It is not uncommon for family members to thwart a doctor's attempt at disclosure of cancer diagnosis to the patient. This stems from concern and love as well as fear of the negative psychological impact of such revelation. Indeed, collusion of this nature was the norm in medical practice till the not too distant past. In this era of patient autonomy and the right to information, we must be careful not to allow attitudes of medical staff or patients' families, language difficulties and organisational issues become barriers to patient's access to information and their psychological coping of the illness. At the same time, we also need to be acutely aware of the unique cultural environment we work in and the families' emotional needs even as we aim to match the patient's desire for information.

Breast conservation treatment in Hong Kong-early results of 203 patients: retrospective study

OBJECTIVE

To study the clinical outcomes of patients with invasive or non-invasive breast cancer after breast conservation treatment.

DESIGN

Retrospective study.

SETTING

Clinical oncology department of a public hospital, Hong Kong.

PATIENTS

Two hundred and three patients who received postlumpectomy radiotherapy at the Pamela Youde Nethersole Eastern Hospital between January 1994 and June 1999.

INTERVENTIONS

Adjuvant radiotherapy with or without systemic adjuvant treatment.

MAIN OUTCOME MEASURES

Actuarial local control rate, progression-free survival rate, disease-specific survival rate, and cosmetic score.

RESULTS

The median follow-up was 3.5 years. Two of the 25 patients with carcinoma in situ only developed local recurrence; the 5-year actuarial local control rate was 91.3%. Among the 178 patients with invasive cancer, seven had a local recurrence and 12 developed distant metastases without local failure. The 5-year actuarial local control, progression-free survival, and disease-specific survival rates for patients with invasive cancer were 95.5%, 85.8%, and 95.2%, respectively. The risk of local recurrence was significantly increased for younger patients (age <40 years) and those with positive final margins. Cosmetic scores were rated good to excellent by 95.6% of patients.

CONCLUSIONS

The early clinical outcomes of these patients are comparable to those in large overseas trials, which have demonstrated the equivalence of mastectomy and breast conservation treatment in terms of survival. In addition to mastectomy, with or without breast reconstruction, breast conservation treatment should be offered as an alternative to suitable Chinese women. To maximise local control, further excision or mastectomy is recommended for patients with positive final margins.

Low frequency of HLA-B*2706 in Taiwanese patients with ankylosing spondylitis

The presence of HLA-B27 in patients affected with ankylosing spondylitis (AS) was well established prior to the advent of DNA typing of various genes within the major histocompatibility complex (MHC) in humans. However, molecular typing of the MHC genes revealed that B27 comprises a motley assortment of alleles, some of which are strongly positively associated with the disease and some of which are negatively associated with the disease. B*2706 was reported to have a negative association with AS in the Thai population and in Chinese Singaporeans. We report here our finding of an absence of B*2706 in 184 Taiwanese AS patients.

The effects of miglitol on glucagon-like peptide-1 secretion and appetite sensations in obese type 2 diabetics

BACKGROUND

Previous studies reported that administration of first generation alpha-glucosidase inhibitors (AGIs), such as voglibose or acarbose, produced exaggerated and sustained postprandial responses of glucagon-like peptide-1 (GLP-1), an incretin hormone from the enteroinsular axis, in healthy humans. Little is known about the postprandial release of GLP-1 after AGI therapy in diabetics. GLP-1 plays a role to mediate satiety. Any agent that substantially elevates GLP-1 levels may theoretically reduce hunger, increase satiation and limit food intake.

OBJECTIVES

This study was performed to analyse the effect of miglitol, a more potent second generation AGI with fewer gastrointestinal side-effects, on the regulation of meal-related GLP-1 secretion and on the change of insulin-glucose dynamics as well as the release of gastric inhibitory polypeptide (GIP), another incretin hormone, after stimulation by an ordinary meal in obese type-2-diabetic subjects. Miglitol's subsequent influences on appetite sensations and food intake were also measured.

DESIGN

In total, 8 obese type-2-diabetic women were randomized to receive treatment with 100 mg of miglitol or placebo three times a day for 2 days (six doses total) in a double-blind fashion. On day 3 of each treatment period (miglitol or placebo), measurements of GLP-1, GIP, insulin and glucose were taken periodically during 3 h after eating a 720 kcal breakfast. Appetite ratings with visual analogue scales (VASs) were used to assess ingestive behaviour hourly just before breakfast and hourly after for 6 h until immediately before lunch. The number of tuna sandwiches eaten at lunch was used to measure food consumption.

RESULTS

The plasma GLP-1, glucose, insulin and GIP levels in response to the mixed meal were compared after the miglitol and placebo treatment. Miglitol effectively enhanced postprandial GLP-1 release and suppressed plasma GIP secretion. The ingestion of a mixed meal induced a remarkable rise in GLP-1 after miglitol as compared with placebo in overweight diabetic subjects. The meal-related rise in GLP-1 after miglitol was significantly greater at all time-points between 30 and 180 min than after the placebo. The postprandial incremental area under the curve for GLP-1 with miglitol treatment was about twofold that with the placebo. The GLP-1 level reached a maximum at 120 min after the mixed meal and steadily rose throughout the rest of the 3-h study period. In the miglitol-treated condition, the average caloric intake at lunch during a 30-min eating period was 12% lower (p < 0.05) as compared with that after the placebo in six out of the eight subjects who exhibited a GLP-1 rise after the breakfast meal by greater than 30% from the placebo-treated condition. Correspondingly, the average rating scores were significantly lower for hunger feelings and markedly greater for sensations of satiety under the miglitol treatment; beginning 2 and 3 h, respectively, before the lunch test.

CONCLUSIONS

Miglitol induced an enhanced and prolonged GLP-1 release at high physiological concentrations after ingesting an ordinary meal in glycaemic-controlled diabetics. The excessive postprandial GLP-1 elevation after miglitol therapy modified feeding behaviour and food intake, and thereby has potential value in regulating appetite and stabilizing body weight in obese type-2-diabetic patients.

Multiple milia due to radiotherapy

We report the appearance of multiple milia in a 61 year old woman appearing 7 years after irradiation for breast cancer. The lesions were confined to the irradiated field.

The comparative gastrointestinal responses of children and adults following consumption of sweets formulated with sucrose, isomalt and lycasin HBC

OBJECTIVES

To determine the gastrointestinal responses of children and adults following consumption of sucrose, isomalt and lycasin HBC and to compare these at two different dose levels in adults.

DESIGN

Both studies were randomised, double-blind, cross-over designs.

SUBJECTS

Fifty-one children aged 6-9 y were recruited from primary schools in the Salford area of Greater Manchester. Forty-eight children completed the study. Fifty healthy adult volunteers aged 18-24 y were recruited from the student population of the University of Salford. All subjects completed the study.

INTERVENTIONS

Children consumed either 25 g of sucrose, isomalt or lycasin HBC and adults 25 and 40 g in hard boiled sweets per day for two consecutive test days. Test periods of 2 days were separated by 7 day washout periods. Children consumed sweets throughout test days and adults in no less than 30 min but no more than 90 min. Subjects reported the prevalence and magnitude of flatulence, borborygmi, bloating, colic, bowel movements and watery faeces.

RESULTS

Consumption of 25 g isomalt provoked a mild laxative effect in children but not in adults. Consumption of 25 g isomalt significantly increased the prevalence and magnitude of gastrointestinal responses in both children and adults. Consumption of 25 g lycasin HBC significantly increased borborygml in children and adults but no other gastrointestinal responses. Consumption of 40 g lycasin HBC or isomalt by adults significantly increased the mean frequency of bowel movements and the number of subjects passing watery faeces. In adults, 40 g isomalt and lycasin HBC provoked significantly more gastrointestinal responses compared to 25 g of either product.

CONCLUSIONS

Consumption of 25 g lycasin HBC does not provoke an unacceptable laxative effect or gastrointestinal response in children or adults compared to 25 g isomalt, which is associated with a mild laxative effect and increase in gastrointestinal responses. In adults gastrointestinal responses following consumption of products were found to be dose dependent.

Sero-epidemiology and risk factors of positive hepatitis B surface antigen amongst Chinese adolescents

This paper reports the prevalence rate of hepatitis B antigen (HBsAg) amongst the Hong Kong Chinese adolescents (age 11 to 19), and the risk factors associated with HBsAg positive. The study is cross sectional and 1,580 students were randomly selected from 12 secondary schools in four regions of Hong Kong. For those subjects who agreed to participate and were randomly selected, their blood was tested for HBsAg and anti-HBs. The overall prevalence of HBsAg positive was reported to be 5.8% (7.9% in male and 4.1% in female), lower than 8.1% in 1978. Males, those born in Mainland China and family history of carriers had higher prevalence of HBsAg positive (7.9% vs 4.1%, 12.2% vs 4.7%, 52.9% vs 3.8% respectively) with statistical significance. Males and those born in mainland China were found to have significantly higher odds ratio 1.8 (95% CI. 0.98-3.52) and 4.4 (95% CI. 2.2-8.8) respectively of HBsAg positive by multivariate analysis. Findings suggest that family history of carriers and those born in endemic area are at a higher risk. Therefore it is worthwhile to consider vaccination programme for adolescents to reduce the carrier rate, and to also reduce the injection amongst the adults by horizontal transmission.

Comparison between the Datex-Ohmeda M-COVX metabolic monitor and the Deltatrac II in mechanically ventilated patients

OBJECTIVE

To compare the M-COVX and the Deltatrac II metabolic monitors under clinical conditions.

DESIGN

Prospective clinical comparison.

SETTING

A general Intensive Care Unit of a university hospital.

PATIENTS

Twenty mechanically ventilated critically ill patients.

INTERVENTIONS

The monitors were compared at FiO(2) 0.3, 0.5, and 0.7 in each patient where possible.

MEASUREMENTS AND RESULTS

Pulmonary gas exchange measurements were recorded using the two monitors sequentially (Deltatrac(before), M-COVX, Deltatrac(after)). Each measurement consisted of five consecutive 1-min readings of VO(2) and VCO(2). We compared the Deltatrac(before) with the Deltatrac(after) and the mean of the Deltatrac with the M-COVX. There was no clinically significant bias between the two monitors for VO(2) or VCO(2) but the limits of agreement (LOA) were wide (bias +/-95% LOA: VCO(2) -13 +/- 30 ml/min, -8 +/- 36 ml/min, 7 +/- 50 ml/min; VO(2) -7 +/- 50 ml/min, -5 +/- 56 ml/min, 6 +/- 64 ml/min, at FiO(2) 0.3, 0.5, and 0.7, respectively). The Deltatrac before and after measurements displayed good agreement for VCO(2) but poorer agreement for VO(2) (bias +/- 95% LOA: VCO(2) 0 +/- 18 ml/min, -6 +/- 16 ml/min, -1 +/- 12 ml/min; VO(2) 2 +/- 12 ml/min, 3 +/- 38 ml/min, 10 +/- 42 ml/min, at FiO(2) 0.3, 0.5, and 0.7, respectively). Using within-patient standard deviation as a measure of reproducibility suggested that for VO(2) the M-COVX performed better than the Deltatrac at high FiO(2), and for VCO(2) Deltatrac was better at lower FiO(2).

CONCLUSIONS

The M-COVX is a suitable integrated device for measuring metabolic gas exchange in ventilated patients.