Absence of Ductus Venosus: A Comparison of 2 Distinctive Fetal Autopsy Cases and Embryologic Perspectives

In fetal circulation, oxygenated blood from the placenta flows through the umbilical vein into the ductus venosus (DV), then enters the inferior vena cava, and subsequently reaches the right atrium of the heart. The DV serves as a shunt, allowing this oxygen-rich blood to bypass the liver. The absence of the DV (ADV), also known as agenesis of the DV, is a rare congenital anomaly. Without a DV, blood from the umbilical vein must follow alternative routes to the heart. In ADV cases, blood from the umbilical vein must follow 1 of 2 primary drainage patterns: either an extrahepatic shunt or an intrahepatic shunt. This report details the antenatal ultrasound and postmortem findings of 2 fetuses diagnosed with ADV by prenatal imaging studies. The first case involved a fetus with a persistent right umbilical vein connected directly to the suprahepatic IVC, accompanied by early obliteration of the left umbilical vein and true agenesis of the DV. This fetus also had additional congenital anomalies. In contrast, the second case involved a fetus with a normal left umbilical vein that entered the liver. However, despite an ultrasound diagnosis of "absence" of the DV, a DV was present, though markedly hypoplastic and probably minimally functional or non-functional. In this case, blood from the umbilical vein likely followed an alternate intrahepatic route through the portal and hepatic veins, before reaching the heart (intrahepatic shunt). These contrasting cases emphasize the heterogeneity of vascular anomalies and embryologic origins captured by the term "ADV." Additionally, the terminology of "absence" or "agenesis" may be misleading in some purported ADV cases. Specifically, in the second case, the DV was not absent; it was markedly hypoplastic instead. This also appears to be the first reported case of a hypoplastic DV in a fetus. Both cases underscore the importance of effective collaboration and clear communication between maternal-fetal medicine specialists and pathologists.

Maturation of metastases in peripheral neuroblastic tumors (neuroblastoma) of children

Peripheral neuroblastic tumors of childhood exhibit 3 principal neural crest lineages: primitive neuroblastoma, ganglioneuroblastoma, and ganglioneuroma. They are unique in undergoing maturation of neurons (ganglion cells) and Schwann cells, thereby recapitulating normal fetal neuronal development in the brain. Precision in estimating neurogenesis is enhanced by immunoreactivities of markers of neuronal maturation. Whether organ tissue factors in different sites of metastases influence rates of maturation and whether metastases are similar to their primary neuroblastic tumor are incompletely documented. Four young children, 1 with a mixed primary adrenal tumor and 3 with metastases were studied at surgery or autopsy. Immunocytochemical reactivities included microtubule-associated protein-2, synaptophysin, chromogranin-A, somatostatin, keratan sulfate, vimentin, S-100β protein, and PHOX2B. Primary tumors were non-uniform with regions of either poor or enhanced maturation. Both neuronal and Schwannian lineages were represented in each tumor type but differed in proportions. Bi- or multi-nucleated ganglion cells matured equal to mononuclear forms. Ganglion cell maturation was similar in metastases regardless of the target organ. Metastases resembled primary tumors. Immunocytochemical markers of neuronal and of Schwann cell maturation provide greater diagnostic precision to supplement histological criteria. Interval between diagnosis of primary tumor and metastases, metastatic target tissues, and chemotherapy over an interval of time do not appear to influence neuroblastic or Schwann cell differentiation.

Maternal Hemoglobin A1c in the Third-Trimester May Underestimate Maternal Hyperglycemia and Its Impact on Offspring in Perinatal Demise Associated With Gestational Diabetes Mellitus: An Autopsy Case Series

INTRODUCTION

Gestational diabetes mellitus (GDM) is a common metabolic disorder linked to adverse pregnancy outcomes. Recent research indicates that HbA1c is reliable in detecting maternal glycemia during the first trimester but may underestimate glucose intolerance in the late second to third trimesters. Therefore, it is reasonable to hypothesize that mothers with GDM, despite apparently normal HbA1c levels in the third trimester, may give birth to infants displaying characteristic features often seen in infants of diabetic mothers with suboptimal glycemic control. This study aimed to describe a case series of autopsy cases involving stillborn or deceased neonates delivered in the third trimester to mothers diagnosed with GDM and having normal HbA1c levels at or around the time of delivery. The primary focus was on identifying and documenting the characteristic features commonly associated with "infants of diabetic mothers" with suboptimal glycemic control in this series of cases.

MATERIALS AND METHODS

We conducted a retrospective review of autopsy reports from our institution spanning 7.5 years. The study included cases that met the following criteria: (1) stillborn or infants who died in the early neonatal period, delivered in the third trimester; (2) mothers diagnosed with GDM; (3) normal maternal HbA1c levels of ≤6.1% at or around the time of delivery; (4) birthweight or femoral length exceeding the 90th percentile for gestational age; and (5) absence of genetic aberrations. We also examined these cases for other characteristic features associated with "infants of diabetic mothers."

RESULTS

Ten autopsy cases met our inclusion criteria, including 9 stillbirths and 1 neonatal death. Gestational age at delivery ranged from 32 to 39 weeks (mean: 35.7 weeks). Femoral length exceeded the 90th percentile in all cases, and 6 cases had birthweights above the 90th percentile. Puffy facies were observed in 6 cases. Among the 9 cases with complete autopsies including internal examination, 6 exhibited excess adipose tissue, 4 had cardiomegaly, and 3 showed pancreatic islet hyperplasia. Hypoxic-ischemic encephalopathy was detected in 7 cases. No structural abnormalities were noted.

DISCUSSION

Our findings demonstrated that fetuses and neonates born to mothers with apparently normal HbA1c levels in the third trimester could still display characteristic features commonly observed in infants of diabetic mothers with poor glycemic control, also known as "infants of diabetic mothers." This study underscores the potential of third-trimester maternal HbA1c measurements to underestimate maternal glycemia and its consequential impact on fetal development, as well as the subsequent manifestation of features of "infants of diabetic mothers."

Time Required for Gross Examination of Routine Second and Third Trimester Singleton Placentas by Pathologists' Assistants

INTRODUCTION

In both Canada and the United States, workload measurement for anatomic pathology is mainly based on complexity and clinical significance of specimens, with gross examination being a considerable contributor. While Pathologists' Assistants (PAs) play an increasing role in gross examination, there is little known regarding the time required for PAs to complete grossing tasks. This information is essential for effective staffing and workload management in pathology laboratories. The objective of our study was to determine the time required for PAs to gross second and third trimester singleton placentas in a large tertiary hospital with a significant perinatal pathology service.

MATERIALS AND METHODS

For our study, 7 certified PAs each grossed a minimum of 10 second and third trimester singleton placentas using a standard placental grossing protocol, an electronic laboratory information system, and voice recognition dictation software. Placental specimens requiring photography, sampling for ancillary studies, or immediate pathologist's consultation were excluded. We calculated average and standard deviation of grossing times for each PA, overall average grossing time, and 95% confidence interval using a mixed linear regression model. We analyzed the impact of PA job experience, degree obtained, and number of blocks prepared on overall average in a multivariate analysis.

RESULTS

The mean grossing times for each PA ranged from 11.0 (standard deviation [sd] = 2.0) to 17.8 (sd = 4.5) minutes. The overall average grossing time was 14.5 minutes, with a 95% confidence interval of 11.7 to 17.3 minutes. In multivariate analysis, an increase in the number of blocks prepared was significantly associated with longer overall average grossing time. If 4 blocks were prepared consistently, the model predicted a slightly lower overall average of 13.3 minutes, with a 95% confidence interval of 10.9 to 15.7 minutes.

DISCUSSION

To our knowledge, our study is the first to objectively report time required for PAs to perform gross examinations of routine second and third trimester singleton placentas. The methodology of our study is replicable and can be applied to other specimen types and laboratory settings. Previously, estimated grossing times for specimens were primarily based on retrospective surveys, which were susceptible to recall errors and subjectivity. However, our study demonstrates objective data collection is achievable. Furthermore, the data collected from this study offer valuable insights into the accuracy of previous and current pathology workload models for second and third trimester singleton placentas.

C4d Staining Is Present in Normal Placentas From Pregnancies Prior to Pregnancy Loss Associated With Chronic Histiocytic Intervillositis and Is Reduced by Immunomodulatory Therapy in Subsequent Pregnancies

INTRODUCTION

Chronic histiocytic intervillositis (CHI) is associated with adverse pregnancy outcomes and high recurrence risk. Recent studies suggest that CHI may represent a host-vs-graft rejection, and that C4d immunostain can be used as a marker for complement activation and antibody-mediated rejection in the CHI.

MATERIALS AND METHODS

This retrospective cohort study focused on 5 fetal autopsy cases associated with CHI (5 index cases) from 5 women. We analyzed placentas from the index cases (fetal autopsy cases associated with CHI) and placentas from the women's previous and subsequent pregnancies. We assessed the presence and extent of CHI and C4d immunostaining in these placentas. We evaluated each available placenta and graded the severity of CHI as either <50% or ≥50%. Additionally, we conducted C4d immunostaining on one representative section from each placenta and graded the staining levels as follows: 0+ for staining <5%; 1+ for staining between 5% and <25%; 2+ for staining between 25% and <75%; and 3+ for staining ≥75%.

RESULTS

Three of the 5 women had pregnancies prior to their index cases (fetal autopsy cases associated with CHI). Despite the absence of CHI in their initial pregnancies, the placentas displayed positive C4d staining with grades of 1+, 3+, and 3+, respectively. These results suggest the presence of complement activation and antibody-mediated rejection in placentas from their prior pregnancies without CHI. Three of the 5 women received immunomodulatory therapy after experiencing pregnancy losses associated with CHI. After treatment, 2 of these women had live births at 35 and 37 gestational weeks, respectively, while the third had a stillbirth at 25 gestational weeks. The severity of CHI and the degree of C4d staining in the placentas decreased in all 3 cases following immunomodulatory therapies. Specifically, the level of C4d staining decreased from 3+ to 2+, 2+ to 0+, and 3+ to 1+ in these 3 cases, respectively.

DISCUSSION

In women with a history of recurrent pregnancy loss associated with CHI, C4d immunostaining was present in the placentas from their previous non-CHI pregnancies, suggesting activation of the classical complement pathway and antibody-mediated reaction in their prior non-CHI pregnancies before the development of CHI in subsequent pregnancies. Immunomodulatory therapy may improve pregnancy outcomes by reducing complement activation, as shown by the reduction of C4d immunopositivity in the placentas after immunomodulatory treatment. Although we believe that the study provides valuable insights, we acknowledge that there are limitations to the findings. Therefore, to further elucidate the pathogenesis of CHI, additional research efforts with a collaborative and multidisciplinary approach are necessary.

Congenital SARS-CoV-2 Infection in Two Neonates with Confirmation by Viral Culture of the Placenta in One Case

Congenital infections with SARS-CoV-2 are uncommon. We describe two confirmed congenital SARS-CoV-2 infections using descriptive, epidemiologic and standard laboratory methods and in one case, viral culture. Clinical data were obtained from health records. Nasopharyngeal (NP) specimens, cord blood and placentas when available were tested by reverse transcriptase real-time PCR (RT-PCR). Electron microscopy and histopathological examination with immunostaining for SARS-CoV-2 was conducted on the placentas. For Case 1, placenta, umbilical cord, and cord blood were cultured for SARS-CoV-2 on Vero cells. This neonate was born at 30 weeks, 2 days gestation by vaginal delivery. RT-PCR tests were positive for SARS-CoV-2 from NP swabs and cord blood; NP swab from the mother and placental tissue were positive for SARS-CoV-2. Placental tissue yielded viral plaques with typical morphology for SARS-CoV-2 at 2.8 × 10² pfu/mL confirmed by anti-spike protein immunostaining. Placental examination revealed chronic histiocytic intervillositis with trophoblast necrosis and perivillous fibrin deposition in a subchorionic distribution. Case 2 was born at 36 weeks, 4 days gestation. RT-PCR tests from the mother and infant were all positive for SARS-CoV-2, but placental pathology was normal. Case 1 may be the first described congenital case with SARS-CoV-2 cultivated directly from placental tissue.

Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) - A Fetal Autopsy Case

BACKGROUND

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) is a rare congenital anomaly characterized by uterus didelphys, unilateral obstructed hemivagina, and ipsilateral renal anomaly.

CASE

Autopsy performed on a third trimester stillborn fetus unexpectedly revealed uterine didelphys, an obstructed left hemivagina, and a left pelvic, atrophic, duplex kidney, with both left ureters entering the obstructed left hemivagina. Furthermore, the fetus had an imperforate anus, a single right umbilical artery, and spina bifida occulta.

SUMMARY AND CONCLUSION

Although rare, OHVIRA is a well-documented congenital anomaly. However, prior to this case, there had been no description of OHVIRA in an autopsy or in a fetus. Furthermore, the association of OHVIRA, anorectal malformation, and spinal bifida has never been reported. By sharing this case, we hope to increase the awareness of this entity among perinatal healthcare providers and to help further elucidate genitourinary embryology, which is still not fully understood.

CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy

Background

Oral immunotherapy (OIT) is an emerging approach to the treatment of patients with IgE-mediated food allergy and is in the process of transitioning to clinical practice.

Objective

To develop patient-oriented clinical practice guidelines on oral immunotherapy based on evidence and ethical imperatives for the provision of safe and efficient food allergy management.

Materials and methods

Recommendations were developed using a reflective patient-centered multicriteria approach including 22 criteria organized in five dimensions (clinical, populational, economic, organizational and sociopolitical). Data was obtained from: (1) a review of scientific and ethic literature; (2) consultations of allergists, other healthcare professionals (pediatricians, family physicians, nurses, registered dieticians, psychologists, peer supporters), patients and caregivers; and patient associations through structured consultative panels, interviews and on-line questionnaire; and (3) organizational and economic data from the milieu of care. All data was synthesized by criteria in a multicriteria deliberative guide that served as a platform for structured discussion and development of recommendations for each dimension, based on evidence, ethical imperatives and other considerations.

Results

The deliberative grid included 162 articles from the literature and media reviews and data from consultations involving 85 individuals. Thirty-eight (38) recommendations were made for the practice of oral immunotherapy for the treatment of IgE mediated food allergy, based on evidence and a diversity of ethical imperatives. All recommendations were aimed at fostering a context conducive to achieving objectives identified by patients and caregivers with food allergy. Notably, specific recommendations were developed to promote a culture of shared responsibility between patients and healthcare system, equity in access, patient empowerment, shared decision making and personalization of OIT protocols to reflect patients' needs. It also provides recommendations to optimize organization of care to generate capacity to meet demand according to patient choice, e.g. OIT or avoidance. These recommendations were made acknowledging the necessity of ensuring sustainability of the clinical offer in light of various economic considerations.

Conclusions

This innovative CPG methodology was guided by patients' perspectives, clinical evidence as well as ethical and other rationales. This allowed for the creation of a broad set of recommendations that chart optimal clinical practice and define the conditions required to bring about changes to food allergy care that will be sustainable, equitable and conducive to the well-being of all patients in need.

Massive ascites and severe pulmonary hypoplasia in a premature infant with meconium peritonitis and congenital cytomegalovirus infection

Background: Meconium peritonitis (MP) is an infrequent prenatal complication. Association between MP and pulmonary hypoplasia has never been reported. Case Report: A female infant with antenatally diagnosed MP and ascites was delivered at 36 gestational weeks. She died shortly after birth due to pulmonary insufficiency. Autopsy confirmed the presence of MP and ascites, and additionally revealed intestinal malrotation, volvulus, necrosis and perforation, and pulmonary hypoplasia. Congenital cytomegalovirus (CMV) infection was also noted. This was an unexpected finding as the mother was tested negative for CMV IgM at 26 gestational weeks after sonographic detection of fetal ascites. Conclusions: This is the first reported case of lethal pulmonary hypoplasia in a neonate with MP-associated ascites complicated by congenital CMV infection. This case illustrates that a negative maternal CMV IgM might not be sufficient to rule out congenital CMV, and that a concomitant infectious etiology should always be considered even when a primary cause for fetal ascites (e.g., MP in this case) is identified.

Atypical Prenatal Ultrasound Presentation and Neuropathological Findings in a Neonate With Alpha Thalassemia Major: A Case Report

Alpha thalassemia major is a hemoglobinopathy caused by the inactivation or deletion of all 4 α-globin alleles. We describe a case of α-thalassemia major with atypical ultrasound and neuropathological findings. The mother had her first prenatal visit at 27 4/7 gestational weeks. Ultrasound revealed a hydropic fetus with multiple anomalies. However, the middle cerebral artery peak systolic velocity (MCA-PSV) suggested that the likelihood of fetal anemia was low. Given the poor prognosis of hydrops fetalis, the parents opted for termination of pregnancy. The neonate died shortly after birth. Autopsy revealed a markedly hydropic female infant with severe limb reduction defects and, in contrast to what was suggested by the prenatal MCA-PSV measurement, unequivocal signs of severe anemia. The brain showed diffuse white matter gliosis. Genetic testing subsequently identified HBA1 and HBA2 deletions, consistent with α-thalassemia major. This case highlights the potential pitfall of MCA-PSV, which is nowadays considered the gold standard for noninvasive detection of fetal anemia. In addition, this is 1 of 2 published case reports detailing neuropathological findings in a fetus or neonate with α-thalassemia major and the first to link α-thalassemia major with diffuse white matter gliosis.

Tumor inhibitory effects of intravesical Ganoderma lucidum instillation in the syngeneic orthotopic MB49/C57 bladder cancer mice model

ETHNOPHARMACOLOGICAL RELEVANCE

Ganoderma lucidum (GL) has been traditionally used in oriental medicine as superior health tonic, and there are numerous scientific evidences of its antitumorigenic activities.

AIM OF THE STUDY

To evaluate the intravesical chemopreventive effects of ethanol extract of GL (GLe) on bladder cancer.

MATERIALS AND METHODS

Intravesical therapy is defined as the direct instillation of a liquid drug into bladder through a catheter. Bacille Calmette-Guerin(BCG) solution is applied intravesically as a conventional immunotherapy for preventing recurrence of bladder cancer. By adopting the MB49/C57 bladder cancer mice model, an overall 60 MB49-implanted mice were randomized into 3 groups and treated according to 3 treatment arms, including GLe, BCG and PBS. Additionally, wild-type mice without MB49 cell inoculation and treated with PBS were used as the negative control group. Testing agents were instilled intravesically for 2 h and repeated after one week for evaluating the effects on preventing the tumor formation and growth. The treated-mice were closely monitored for major adverse effects.

RESULTS

GLe demonstrated more potent cytotoxic effects than BCG on MB49 cells, although both in dose-dependent manner. In the MB49-implanted mice, 80 µg/ml GLe was shown to delay the tumor formation by one week, whereas the averaged tumor volume measured at endpoint was 3.6-fold and 4.6-fold smaller than that of the BCG or PBS, respectively. However, no significant effects were observed on body weight and hematuria.

CONCLUSION

Current findings in mice suggested intravesical GLe therapy as an effective and safe chemopreventive strategy for inhibiting bladder tumor formation.

Bathroom greywater recycling using polyelectrolyte-complex bilayer membrane: Advanced study of membrane structure and treatment efficiency

Polyelectrolyte-complex bilayer membrane (PCBM) was fabricated using biodegradable chitosan and alginate polymers for subsequent application in the treatment of bathroom greywater. In this study, the properties of PCBMs were studied and it was found that the formation of polyelectrolyte network reduced the molecular weight cut-off (MWCO) from 242kDa in chitosan membrane to 2.71kDa in PCBM. The decrease in MWCO of PCBM results in better greywater treatment efficiency, subsequently demonstrated in a greywater filtration study where treated greywater effluent met the household reclaimed water standard of <2 NTU turbidity and <30ppm total suspended solids (TSS). In addition, a further 20% improvement in chemical oxygen demand (COD) removal was achieved as compared to a single layer chitosan membrane. Results from this study show that the biodegradable PCBM is a potential membrane material in producing clean treated greywater for non-potable applications.

Immunohistochemical expression of glypican-3 in pediatric tumors: an analysis of 414 cases

Glypican-3 (GPC3) is a proteoglycan thought to play an important role during development. Germline GPC3 mutations are seen in the rare Simpson-Golabi-Behmel syndrome (SGBS), which predisposes patients to Wilms tumor, hepatoblastoma, and neuroblastoma. While numerous adult tumors have been evaluated by immunohistochemistry for GPC3, no comprehensive assessment has been done in pediatric tumors. We therefore investigated GPC3 expression in 143 pediatric central nervous system (CNS) tumors and 271 non-CNS tumors. Among non-CNS tumors, GPC3 expression was seen in 9/9 (100%) hepatoblastomas, 4/6 (67%) malignant rhabdoid tumors, 5/13 (38%) Wilms tumors, 11/37 (30%) alveolar rhabdomyosarcomas, and 8/45 (18%) embryonal rhabdomyosarcomas. All 136 neuroblastomas, 14 Ewing sarcoma/primitive neuroectodermal tumors, and 11 synovial sarcomas were immunonegative for GPC3. Among CNS tumors, GPC3 had restricted expression, with positivity in 6/6 (100%) atypical teratoid rhabdoid tumors and 1/4 (25%) craniopharyngiomas. The remaining 136 CNS tumors-23 medulloblastomas, 21 pilocytic astrocytomas, 13 gangliogliomas, 12 ependymomas, 12 glioblastomas, 11 choroid plexus neoplasms, 10 diffuse astrocytomas (grade II/III), 10 meningiomas, 8 dysembryoplastic neuroepithelial tumors, 8 oligodendrogliomas, 3 craniopharyngiomas, 3 germinomas, and 2 neurocytomas-were entirely negative for GPC3. These results showed GPC3 positivity in a number of non-CNS tumors, with no consistent discrimination between tumors that were or were not associated with SGBS. Within the CNS, GPC3 positivity was limited to a small subset of CNS neoplasms and may thus serve as a useful positive diagnostic biomarker (P < 0.0001) in addition to negative INI1/BAF47/SMARCB1 staining to differentiate atypical teratoid rhabdoid tumors from other high-grade pediatric brain tumors.

Effect of temperature and salt concentration on rheological behavior of whey protein isolate–starch mixed dispersions

Extensive studies have been carried out on the effect of temperature and salt concentration on the theological behavior of whey proteins and different starches individually, but not on mixed dispersions of whey protein isolates and starches. In the present studies, the rheological behavior of cross-linked waxy maize starch and whey protein isolate mixed dispersions during heating at 60-85 degrees C was investigated. Further, the effect of CaCl2 (25-100 mM ionic strengths) on the gelatinization of these dispersions was determined. It was found that at a 2:3 ratio and a 3:2 ratio of cross-linked waxy maize starch to whey protein isolate mixed gels form a compatible networkmM concentration the solution viscosity was higher.

In vitro inhibition of head and neck cancer-cell growth by human recombinant interferon-alpha and 13-cis retinoic acid

Three nasopharyngeal carcinoma (NPC) cell lines (CNE-1, CNE-2 and NPC/HK-1), two squamous cell carcinoma (SCC) cell lines (T2/CUHK and PWH-S1) and six head and neck cancer specimens (NPC [n = 4], SCC tongue [n = 1] and a thyroid cancer [n = 1]) were incubated with interferon (IFN)-alpha (5 x 10(4) iu/mL) and/or 13-cis retinoic acid (13RA; 10(-5) mol/L) for two days at 37 degrees C. In vitro chemosensitivity was measured using MTT assay. Mild growth inhibition of the five cell lines by IFN-alpha ranged from 7.1% to 51.8% (mean: 18.5%), whereas with 13RA it was zero to 19.7% (mean: 7%). Greater inhibition (14.8-51.0%, mean: 31.8%) was achieved when the two drugs were used in combination. Growth inhibition of the six surgical specimens ranged from 6.9% to 21% (mean: 13.6%) with IFN-alpha; zero to 10.3% (mean: 6.0%) with 13RA; and 6.6-26.5% (mean: 17.7%) when the two agents were combined. Four of the 11 samples showed synergistic antitumour effect when IFN-alpha and 13RA were combined, and six showed subadditive effect. The results show that IFN-alpha and 13RA have a mild in vitro antitumour effect on head and neck cancer cells, and the drug synergistic effect demonstrated in this study suggests that the two agents should be used in combination in clinical application.

Epinephrine for the out-of-hospital (first-aid) treatment of anaphylaxis in infants: is the ampule/syringe/needle method practical?

BACKGROUND

Little information is available about administration of an accurate epinephrine dose to infants experiencing anaphylaxis outside the hospital setting.

OBJECTIVE

Our purpose was to perform a prospective, controlled study of (1) the time needed by parents to draw up an infant epinephrine dose from an ampule and (2) the dose accuracy.

METHODS

We gave 18 parents written instructions and asked them to draw up epinephrine 0.09 mL. We timed them by means of a stopwatch and measured the epinephrine content (in micrograms) in each dose by using HPLC-UV. Eighteen resident physicians, 18 general duty nurses, and 18 emergency department nurses served as controls.

RESULTS

The parents took significantly longer (P < .05) than the controls to draw up the dose; the mean (+/- SEM) times were 142 +/- 13 seconds (range, 83-248) for the parents, 52 +/- 3 seconds (range, 30-83) for the physicians, 40 +/- 2 seconds (range, 26-71) for the general duty nurses, and 29 +/- 0.09 seconds (range, 27-33) for the emergency department nurses. The control groups did not differ significantly from each other in speed (P > .05). The epinephrine content of the doses drawn up by the parents ranged 40-fold in contrast to the physicians' doses (7- to 8-fold), general duty nurses' doses (3-fold), and emergency department nurses' doses (2-fold). The mean epinephrine content did not differ significantly (P > .05) among the 4 groups.

CONCLUSIONS

Most parents were unable to draw up an infant epinephrine dose rapidly or accurately. Most health care professionals drew up the dose rapidly; however, their accuracy was compromised by inherent variations of epinephrine concentrations in the ampules (United States Pharmacopeia compendial limits, 90% to 115%) and the inherent difficulty of measuring low volumes (<0.1 mL) of epinephrine. User-friendly premeasured epinephrine doses suitable for infants should be developed.

Immune complexes and IFN-gamma decrease cholesterol 27-hydroxylase in human arterial endothelium and macrophages

The enzyme cholesterol 27-hydroxylase, expressed by arterial endothelium and monocytes/macrophages, is one of the first lines of defense against the development of atherosclerosis. By catalyzing the hydroxylation of cholesterol to 27-hydroxycholesterol, which is more soluble in aqueous medium, the enzyme promotes the removal of cholesterol from the arterial wall. Prior studies have suggested that immune reactants play a role in the pathogenesis of atherosclerosis; we report here that immune reactants, IFN-gamma and immune complexes bound to C1q, but not interleukin-1 and tumor necrosis factor, diminish the expression of cholesterol 27-hydroxylase in human aortic endothelial cells, peripheral blood mononuclear cells, monocyte-derived macrophages, and the human monocytoid cell line THP-1. In addition, our studies demonstrate that immune complexes down-regulate cholesterol 27-hydroxylase only after complement fixation via interaction with the 126-kD C1qRp protein on endothelial cells and THP-1 cells. These results are consistent with the prior demonstration that IFN-gamma contributes to the pathogenesis of atherosclerosis and suggest a role for C1q receptors in the atherogenic process. Moreover, these observations suggest that one mechanism by which immune reactants contribute to the development of atherosclerosis is by down-regulating the expression of the enzymes required to maintain cholesterol homeostasis in the arterial wall.

Dermal fibroblasts do not enhance the graft take rate of autologous, cultured keratinocyte suspension on full-thickness wounds in rats

Dermal fibroblasts are known to play an important role in wound healing. In this study, cultured autologous keratinocyte suspension was applied with fibrin glue to the full-thickness wounds in rats (N = 20). Histological analysis on day 14 showed regenerated epithelium in 10 wounds (50%). Keratinocytes were also premixed with allogeneic dermal fibroblasts in a ratio of 3:1 and 5:1 before application to other full-thickness wounds (N = 20) with fibrin glue. Regeneration of epithelium was observed in 10 (50%) and 9 (45%) wounds respectively. Acute inflammatory reaction and mild to moderate proliferation of fibroblasts in the subepithelial layer of the allogeneic fibroblasts were noted. The addition of dermal fibroblasts to keratinocytes/fibrin glue does not enhance the take rate of the cultured keratinocyte suspension.

A new technique to resurface wounds with composite biocompatible epidermal graft and artificial skin

BACKGROUND

The incorporation of cultured epidermal autograft on the neodermis of artificial skin (Integra, Integra LifeSciences, Plainsboro, NJ) has been met with some difficulties. A new engraftment technique to resurface the wounds with Integra and composite biocompatible epidermal graft (CBEG) has been successfully applied on three patients for elective reconstructive procedures.

METHODS

A small skin biopsy was taken from the normal edge of the lesion for keratinocytes and dermal fibroblast cultures 2 weeks before surgery. When sufficient cells were grown, the patient was admitted for the excision of the lesions or scars. The wounds of the patients, ranging from 125 to 250 cm2, were covered with Integra. When the neodermis of the Integra was fully vascularized, the silicone membrane of the Integra was removed and replaced with the CBEG, which consisted of autologous keratinocytes cultivated on a hyaluronate-derived membrane (Laserskin; Fidia Advanced Biopolymers, Abano Terme, Italy)) using human dermal fibroblasts as a feeder layer.

RESULTS

Clinically, there was good initial "take" of the CBEGs in these three patients, ranging from 50% to 100%. Biopsy specimens of the grafted wounds were taken 1 to 3 weeks after the application of the CBEGs. Epithelialization was noted in all patients.

CONCLUSION

This engraftment technique has several advantages. The CBEG is much easier to handle than the conventional cultured epidermal autograft. It eliminates the invasive second procedure for skin harvesting, with resulting pain and scarring. The application of the CBEG can be easily performed at the bedside.

Meta-analyses of clinical drug trials--gold standard reviews or statistical alchemy?

Renewed emphasis on the critical appraisal of published evidence has in turn led to critical appraisal of the way clinical studies have been reviewed. Reviews perform the vital function of summarising a wealth of research information in an efficient and trustworthy manner, but traditional narrative reviews have fallen short in this area, not because they are narrative, but because they have allowed reviewer and publication bias to creep in under the guise of expert authority. Meta-analysis or systematic review emphasises the use of a review protocol based on logical principles to minimise bias, together with qualitative and appropriate quantitative summaries of the data. Like any review, the perceived impact of a meta-analysis is dependent on the quality of the reviewed studies, therefore randomised clinical trials are the favoured substrate for the meta-analysis of drug efficacy because of their potentially high internal validity. The importance of meta-analysis as a tool for clinical drug evaluation has prompted this selective account of its nature, theory, practice and interpretation, with particular emphasis on meta-analysis as a review methodology rather than a statistical methodology, the critical distinction between design and result homogeneity and the need to explore issues of heterogeneity rather than gloss over them by using some statistical shortcut.

In vivo trial comparing patients' tolerance of Q-switched Alexandrite (QS Alex) and Q-switched neodymium:yttrium-aluminum-garnet (QS Nd:YAG) lasers in the treatment of nevus of Ota

BACKGROUND AND OBJECTIVES

Different types of Q-switched lasers have been found to be effective in the treatment of nevus of Ota. However, a clinical trial involving in vivo comparison of the use of different laser systems has not been performed. The aim of the present study was to compare the patient tolerance of Q-switched Alexandrite (QS Alex) and Q-switched neodymium:yttrium-aluminum-garnet (QS Nd:YAG) lasers in the treatment of nevus of Ota.

STUDY DESIGN/MATERIALS AND METHODS

Thirty-three patients (11 male, 22 female) were recruited for this study, and 45 treatment sessions were performed. Half of each lesion was treated with QS Alex and the other half with QS Nd:YAG laser. Patients were interviewed with a visual analog scale questionnaire immediately after treatment and 1 week later. Questions included the degree of pain, swelling, and bleeding.

RESULTS

The immediate pain after treatment was more severe for QS Alex than for QS Nd:YAG laser. However, 1 week after laser therapy, most patients found QS Alex to be superior.

CONCLUSION

Patients tolerate QS-Alex better than QS Nd:YAG. This finding is important because patients with nevus of Ota are often children, and multiple laser sessions are necessary for complete resolution of the lesion.

The effects of hydrocolloid dressing and gentian violet on radiation-induced moist desquamation wound healing

The aim of the study was to compare the effect of a gentian violet topical application with that of a moist dressing (hydrocolloid) on the rate and efficacy of radiotherapy-induced moist desquamation wound healing and the patients' satisfaction level with each method. This prospective randomized clinical trial used a stratified sampling design. A sample of 39 patients with 60 wounds had their wounds assessed on alternate days in terms of several wound-healing parameters including wound size, wound pain, incidence of infection, and time required for healing. Patient satisfaction with each treatment was evaluated at the completion of the study. Gentian violet significantly decreased wound size and reduced wound pain. However, this treatment received significantly lower ratings for dressing comfort and dressing aesthetic acceptance. Nevertheless, the time required for healing was not statistically different in the two groups. These findings suggest that the lower score of dressing satisfaction level in the gentian violet group may result from the skin discoloration and drying effects of the treatment, which renders patients unable to move or stretch their skin. Although the aim is to have complete wound healing, this may not be realistic for many lesions such as radiotherapy-induced moist desquamation wounds. The best evidence on which to make decisions about individual care can now be based on patients' own perception of quality.

Pediatric burn patients from Vietnamese camps in Hong Kong from 1989 to 1997

Over the 9 years from 1989 to 1997, many children who suffered from scald burns in the Vietnamese camps in the New Territories of Hong Kong were treated. The profile of these children was examined and analyzed.

Failure patterns and factors affecting prognosis of salivary gland carcinoma: retrospective study

OBJECTIVES

To investigate the failure patterns and the prognostic factors following postoperative radiotherapy for salivary gland carcinoma.

DESIGN

Retrospective study.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Fifty patients who had non-disseminated salivary gland carcinoma and who received primary treatment from 1984 through 1993.

MAIN OUTCOME MEASURES

Demographic data, cancer T- and N-stages, histological type, site of origin, completeness of surgery, whether postoperative radiotherapy was given, and the clinical outcome.

RESULTS

Two (4%) patients had been treated with radiotherapy alone, six (12%) had undergone radical resection alone, and 42 (84%) had been radically treated by using both modalities. The 5-year overall survival and relapse-free survival rates were 78.4% and 63.1%, respectively. The free from local failure and free from distant metastasis rates at 5 years were 77.2% and 72.8%, respectively. The N-stage was a significant prognostic factor. The site of the primary tumour, T-stage, completeness of surgery, and use of postoperative radiotherapy were not significant independent prognosticators; however, among the T-stage tumours, the b-substage carcinomas had significantly fewer local failures (P=0.040) and better survival rates (P=0.038) than the a-substage carcinomas. There were seven (14%) locoregional failures without distant metastasis, seven (14%) cases of distant metastasis without locoregional failures, and four (8%) locoregional failures preceding distant metastasis; isolated regional relapse was rare (1/50; 2%). All regional failures (5/50; 10%) occurred ipsilateral to the primary lesion. There were no deaths due to lymphoepithelioma-like carcinoma or acinic cell carcinoma.

CONCLUSIONS

The N-stage is the main prognostic factor of overall survival, relapse- and metastasis-free recovery, and success of treatment for salivary gland carcinoma. Optimal locoregional treatment can help reduce distant metastasis, and the maximal use of postoperative radiotherapy may contribute to improved locoregional control. Elective ipsilateral neck radiotherapy is indicated for lymphoepithelioma-like carcinoma.

Interventions for treating oral lichen planus

BACKGROUND

Oral lichen planus is a chronic autoimmune disease of unknown aetiology that affects the inner surface of the mouth. The symptomatic forms are painful,tend to worsen with age and with remissions being rare. Current treatment is palliative and not curative, many topical and systemic agents have been tried with little hard evidence for efficacy.

OBJECTIVES

To assess the effectiveness and safety of any form of palliative therapy against placebo for the treatment of symptomatic oral lichen planus.

SEARCH STRATEGY

Electronic databases, handsearching of conference proceedings and specific journals, researchers in the field, drug manufacturers.

SELECTION CRITERIA

Any placebo-controlled trial of palliative therapy for symptomatic oral lichen planus, using a randomised or quasi-randomised design that measured changes in symptoms and/or clinical signs.

DATA COLLECTION AND ANALYSIS

Change in symptoms (pain, discomfort) and clinical signs (visual impression, lesion measurements) at the end of therapy. Odds ratio of improvement vs no improvement for each trial outcome and pooling where appropriate.

MAIN RESULTS

A total of nine RCTs were identified. The nine interventions were grouped into four separate classes (cyclosporines, retinoids, steroids and phototherapy) for comparison. No therapy was replicated exactly, the closest replication involved two trials using high and low dose cyclosporine mouthwash. Only trials recording the same outcomes in each therapeutic class were pooled. The largest number of pooled trials was three. Large odds ratios with very wide confidence intervals indicating a statistically significant treatment benefit were seen in all trials. However this has to be tempered by considerations of the small study sizes, the lack of replication, the difficulty in measuring outcome changes and the very high likelihood of publication bias. Only systemic agents were associated with treatment toxicities, all other side-effects were mild and mainly limited to local mucosal reactions.

REVIEWER'S CONCLUSIONS

The review provides only weak evidence for the superiority of the assessed interventions over placebo for palliation of symptomatic OLP. The results highlight the need for larger placebo-controlled RCTs with more carefully selected and standardised outcome measures before between-treatment comparisons can be properly interpreted.

Neoadjuvant and adjuvant therapy for operable hepatocellular carcinoma

OBJECTIVES

To determine the efficacy and adverse effects of different neoadjuvant and adjuvant therapies compared to surgery alone or surgery and placebo/supportive therapy when given to improve relapse and survival rates for operable hepatocellular carcinoma.

SEARCH STRATEGY

Electronic databases, conference proceedings, bibliographies of identified publications.

SELECTION CRITERIA

All truly randomised and quasi-randomised clinical trials that compared hepatocellular carcinoma patients who were given and not given neoadjuvant/adjuvant therapy as a supplement to curative liver resection.

DATA COLLECTION AND ANALYSIS

Study data was extracted independently by two reviewers and discrepancies were resolved by consensus. A total of eight randomised controlled clinical trials were identified, totaling 548 randomised patients. Seven of the eight trials reported survival and disease-free survival curves and the results of hypothesis testing (log-rank test). The remaining trial reported only the mean survival times. None reported the hazard ratio and only one did a sample size calculation. The survival and disease-free survival curves were compared using their one, two and three-year survival rates, median survival times and the result of the hypothesis tests.

MAIN RESULTS

The size of the randomised clinical trials ranged from 40 to 115 subjects. Both preoperative (neoadjuvant) and postoperative (adjuvant), systemic and locoregional (+/- embolization), chemo- and immunotherapy interventions were tested. None were comparable in terms of both treatment regimen and participants selected, so no pooling was done. Only one regimen using preoperative transcatheter arterial chemoembolization with doxorubicin was approximately duplicated. Seven of the eight trials reported no survival benefit from adjuvant therapy. Only one trial reported a statistically significant difference for survival and disease-free survival for the treatment arm, but the results of both its arms were very poor when compared to other studies. Two of the trials that did not report any absolute survival advantage reported statistically significant differences in disease-free survival. Five of the eight trials did not perform intention-to-treat analysis. The highest toxicity rate was in a trial using oral 1-hexylcarbamoyl 5-fluorouracil which resulted in 12 out of 38 subjects stopping because of adverse events.

REVIEWER'S CONCLUSIONS

There is no evidence for efficacy of any of the adjuvant protocols reviewed. In order to detect a realistic treatment advantage, larger trials will have to be conducted.

A new system for the cultivation of keratinocytes on acellular human dermis with the use of fibrin glue and 3T3 feeder cells

The growth of human keratinocytes on human acellular dermis in 4 different culture systems was compared. Epidermis was completely separated and removed from dermis after skin samples had been soaked in 0.1% trypsin at 4 degrees C for 1 week. Forty pieces of saline-washed dermis, 1 cm2 each, were randomized into 4 groups: in group A, human keratinocytes that had undergone 2 to 3 cell passages were seeded (30 x 10(4) cell/cm2) onto the dermis and sprayed with a thin layer of fibrin glue and proliferative 3T3 feeder cells that had been growing separately on the culture dish; in group B, the dermis was only sprayed with fibrin glue; in group C, the dermis was treated with 3T3 cells only; and in group D, the dermis was not sprayed with anything. The dermis samples in all groups were raised on a grid to provide an air-liquid culture system. Histology results of the composite grafts at 2 weeks were assessed as having either scanty colonies of keratinocytes (SCK), continuous stratified epithelium (CSE), or no observable keratinocyte growth. Eight out of the ten dermis samples (80%) in group A demonstrated CSE, and 30% of the samples in group B showed SCK. There were 10% SCK and 20% CSE in group C, and in group D, 30% SCK and 10% CSE were found. The good results in group A indicated that the fibrin glue facilitated the seeding efficiency of the keratinocytes on the dermis and that the vital factors released from the 3T3 feeder cells enhanced the growth and differentiation of the keratinocytes. This model provides an optimal system for the cultivation of keratinocytes on acellular dermis.

The efficacy of collagen dermis membrane and fibrin on cultured epidermal graft using an athymic mouse model

A human skin substitute consisting of human cultured keratinocytes, collagen dermis, and fibrin was evaluated in athymic mice. Eighty athymic mice were divided randomly into four groups. A 1.5x1.5-cm full-thickness wound defect was created on the back of each athymic mouse under anesthesia. These wounds were covered by sheets of cultured epidermal graft (group A), cultured epidermal graft with collagen dermis and fibrin (group B), cultured epidermal graft with collagen dermis (group C), or cultured epidermal graft with fibrin (group D). The grafts were secured and kept moist by specially designed saline gauze chambers. The take rates of the cultured graft with more than 50% of the wound covered were 65%, 15%, 50%, and 45% respectively. Group B had a significantly lower graft take rate, however the difference was not significant among groups A, C, and D. Light microscopy of biopsies of the grafted sites at 12 days showed complete epithelialization. The incidence of discharge from wound beds in groups A, B, C, and D was 0%, 15%, 15%, and 10% respectively. The results suggest that cultured cells are best grafted directly onto the wound bed or in combination with either a thin layer of collagen or fibrin but not both because the collagen dermal membrane and the fibrin together may impose too great a diffusion barrier for the cultured cell graft to become vascularized.

Development and evaluation of a new composite Laserskin graft

BACKGROUND

Tremendous effort has been made to improve the graft take rate of cultured epidermal autograph. The purpose of this study is to develop and evaluate a new composite Laserskin graft (CLSG) as a human skin substitute for wound resurfacing.

METHODS

The seeding efficacy of cultured keratinocytes on plain Laserskin was compared with the 3T3 cell-seeded Laserskin and allogenic fibroblast-populated Laserskin. Three different types of CLSG, 2 cm in diameter each, were prepared and tested in rats. Type A CLSG consisted of proliferative allogenic rat fibroblasts on both sides of the Laserskin with autologous keratinocytes also on the upper side. Fibroblasts and keratinocytes were seeded only on the upper side of the Laserskin in type B CLSG. Keratinocytes alone were seeded on plain Laserskin in type C CLSG. Type B CLSG consisting of autologous keratinocytes and autologous dermal fibroblasts was tested on five selected wounds (5x5 cm each) of a patient with full-thickness burn. In another burn patient, type B CLSG consisting of autologous keratinocytes and allogenic dermal fibroblasts was grafted onto three wounds (5x5 cm each).

RESULTS

The seeding efficacy of human keratinocytes on plain Laserskin increased from 75% to 95% when proliferative allogenic fibroblasts were grown as a feeder layer on the Laserskin. The seeding efficacy of rat keratinocytes increased from 36% to 88% in the presence of a proliferative allogenic fibroblast feeder layer, whereas human/rat keratinocytes had respective seeding efficacy of 98%/91% on Laserskin preseeded with mitomycin C-treated 3T3 cells. Skin biopsies of grafted type A CLSG on day 14 after grafting showed complete epithelialization without severe inflammation in 16 of 20 (80%) grafted surgical wounds in rats. There were eight (40%) and seven (35%) "takes" of the CLSG in types B and C, respectively. The infection rate in type B CLSG was two (10%). There was one (5%) infection in types A and C. The respective take rates on the two patients grafted with type B CLSG were 60% and 100%.

CONCLUSION

The animal experiment and the preliminary clinical data showed that the CSLGs consisting of autologous keratinocytes and of autologous/allogenic fibroblasts are good human skin substitutes in terms of durability, biocompatibility, high seeding efficacy for keratinocytes, high graft take rate, and low infection rate.

Head and neck cancers associated with Madelung's disease

BACKGROUND

Madelung's disease is a rare lipodystrophy that presents with multiple fatty masses in the neck, trunk, and upper extremities. The fatty accumulation is considered a benign disease, but compression of the aerodigestive tract may occur in long-standing disease.

METHODS

Eight Chinese patients with Madelung's disease were reviewed. All were male, aged 48 to 67 years, with a history of disease ranging from 4 to 20 years. Two of the eight patients developed aerodigestive symptoms and were subsequently found to have head and neck cancers. These two patients are described.

RESULTS

The possible mechanism that may account for an increase in malignant tumors of the airway in this group of patients is the synergistic effect of smoking and alcohol abuse as risk factors for both Madelung's disease and malignant tumors of the airway. Currently it is recommended that these patients should have their fatty lesions removed surgically. The removal of fat facilitates examination of the neck for signs of cervical lymphadenopathy in malignant disease.

CONCLUSIONS

Patients with Madelung's disease should be followed regularly. The development of aerodigestive symptoms should be fully investigated with endoscopy and imaging. The cause of symptoms should not be attributed to fatty compression until a carcinoma of the upper airway has been excluded.

Burn injuries during paint thinner sniffing

Thinner sniffing is popular among school children in Asian countries because it is readily available at low cost. Besides its toxicity to major organs, thinner inhalation is associated with various burn accidents. Four teenagers were admitted to the Burns Unit of the Prince of Wales Hospital over the period of 1996-1997. They sustained 3-25% TBSA flame burn and two of them had inhalation injuries as a result of the ignition of a cigarette during thinner sniffing. None of them had evidence of thinner intoxication as shown by blood tests. In the management of their acute burn injuries, their hidden social and family problems were explored. With the cooperation of different disciplines, early psychosocial intervention was given and their behavioral and psychological disturbances were successfully managed.

Late complications of nasal augmentation using silicone implants

Alloplastic nasal augmentation with silicone elastomer (Silastic) is popular in areas of Asia. Although the silicones are bio-inert, they have been implicated in a number of adverse reactions after implantation. We report our experience of three patients who presented with late complications after nasal augmentation using Silastic implants. The mechanisms of implant failure are proposed. It is advised that this material should only be used on an individual basis in carefully selected cases.

Carcinoma showing thymiclike differentiation (CASTLE tumor)

A 67-year-old woman had had a neck mass for 10 years, which recently increased in size. Sonographic, CT, and MR examinations showed a mass in the carotid and posterior spaces (triangle) extending from below the submandibular gland to the supraclavicular fossa, displacing the common carotid artery and the sternomastoid anteriorly. The mass was solid, noncalcified with lobulated outlines, hypoechoic on sonograms, of soft-tissue density on CT scans, isointense on T1-weighted MR images, hyperintense on T2-weighted MR images, and enhanced mildly after injection of contrast material on CT and MR studies. Histologic examination revealed a carcinoma showing thymiclike differentiation, a rare tumor of the neck and thyroid gland.

Madelung disease: distribution of cervical fat and preoperative findings at sonography, MR, and CT

PURPOSE

Our goal was to document the distribution of excess fat in the neck and to determine the preoperative role of sonography, CT, and MR imaging in patients with Madelung disease.

METHODS

Eight patients with Madelung disease were examined preoperatively with sonography, CT, and MR imaging of the neck, and the extent to which each technique provided answers to the surgeons' questions--such as distribution of fat, course of the major vessels within the fat, and presence of tracheal compression and nonlipomatous lesions--was studied.

RESULTS

Excess fat was seen predominantly in the posterior part of the neck (eight patients), under the trapezius (eight patients) and sternomastoid (six patients) muscles, in the supraclavicular fossa (five patients), between the paraspinal muscles (five patients), in the anterior part of the neck (suprahyoid in seven patients and infrahyoid in three patients), in the superior mediastinum (three patients), and in the prevertebral space (two patients). Excess fat deposition was also seen in the pretracheal space (one patient), extrapleural space (two patients), and over the cheeks (one patient), sites previously not described.

CONCLUSION

As a preoperative investigative tool for Madelung disease, both MR imaging and noncontrast CT provide the surgeon with adequate information; sonography is less helpful.

Mammogram screening of Chinese women in Kwong Wah Hospital, Hong Kong

The incidence of primary carcinoma of the breast in Hong Kong has been rising. A screening team including radiologists, breast surgeons, cytopathologists, a full-time gynaecologist and mammographers was set up at Kwong Wah Hospital. The screening method includes a clinical breast examination (CBE) and two-view mammography. The target age group is 40-70. A total of 13,033 women were screened from March 1993 to March 1995 and 8504 mammograms were performed. A double reading system was used, with an experienced mammographer as the first reader. The films were then read by radiologists and were reported. All abnormal films and normal films with palpable masses or clinical symptoms were reviewed in a weekly meeting. A total of 113 biopsies were performed including 86 stereotactic-guided fine needle aspirations (FNA) and 27 stereotactic-guided hook-wire biopsies. Four FNA showed malignant cells and another five showed suspicious cells. Eleven hook-wire biopsies showed carcinoma. The benign to malignant ratio of the hook-wire biopsies was 16:11 (< 1.5). The total number of carcinomas disclosed was 42, and 16 of these were not palpable. Four palpable tumours were not detected by mammography. The overall carcinoma of the breast detection rate was 4.94/1000, with a rate of 4.61/1000 for the 40-49-year age group and a rate of 6.46/1000 for the over 50 years of age group. The incidence of ductal carcinoma in situ plus T1 tumours was 2.82/1000.

Boiling wax burn in mid-autumn festival in Hong Kong

An unusual cause of burn, contact with boiling wax by children and adolescents during the annual mid-autumn festival in Hong Kong is presented. 57 patients who suffered from hot wax burn over the period 1986-1996 were admitted to the Burns Unit of the Prince of Wales Hospital. This special burn should be preventable by public education.

The clinical and radiological features of the empty sella syndrome

The importance of the empty sella syndrome has increased with recent interest in pituitary micro-adenomas, trans-sphenoidal hypophysectomy and computerised tomography. Four cases of the empty sella syndrome which illustrate the clinical and radiological features are reported, and the literature is reviewed. Headache, visual symptoms and endocrine disturbances are commonly found in association with the empty sella syndrome, and the coexistence of pituitary micro-adenomas is well recognised. Symmetrical ballooning of the sella turcica without changes in configuration is the typical finding with plain radiography, but occasionally more extensive destructive changes in the region of the pituitary fossa may occur. Provided that the correct angulation, collimation and level of cut are chosen, computerised tomography now may be used to make a definitive diagnosis, making air encephalography unnecessary.