Improvement in quality of life among Sri Lankan patients with haemorrhoids after invasive treatment: a longitudinal observational study

Background

Haemorrhoids is a common chronic disease that can significantly impact patients’ quality of life. Yet, few studies have evaluated health-related quality of life (HRQoL) of patients with haemorrhoids before and after treatment. This study investigated the HRQoL of patients with haemorrhoids before and after treatment and the change in HRQoL from baseline.

Methods

A prospective observational study of patients with haemorrhoids was conducted at two public hospitals in Kandy, Sri Lanka. Two questionnaires assessing symptom severity and haemorrhoid-specific QoL were administered at initial consultation and at 4- and 8-week follow-ups after treatment (sclerotherapy, rubber band ligation (RBL), haemorrhoidectomy or evacuation of haematoma). The primary outcome was the least squares (LS) change of HRQoL score from baseline, measured using the Short Health Scale adapted for Haemorrhoidal Disease (4 domains: symptom load, interference with daily activities, concern, general well-being).

Results

In 48 patients selected for this study, LS mean change from baseline showed significant improvement in HRQoL across all domains and total Short Health Scale adapted for Haemorrhoidal Disease score at 4- and 8-week follow-ups (P < 0.001). Difference in LS mean change from baseline also showed continued improvement of HRQoL from week 4 to week 8 (P < 0.010). ‘Concern’ showed greatest improvement at 4 and 8 weeks (P < 0.001). Averaged LS mean changes from baseline showed RBL had greater improvement of HRQoL compared with sclerotherapy (P = 0.004).

Conclusion

Patients with haemorrhoids had improved HRQoL after invasive treatment. Haemorrhoid-specific QoL is an important component of the extent of disease and can serve as an aid to guide treatment, assess outcomes and monitor disease.

Impact of Radiotherapy on Neck Dissection Nodal Count in Patients With Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

Our study aimed to review the impact of preoperative radiotherapy (RT) and other factors on the lymph node count of neck dissection (ND) specimens from patients with head and neck cancer (HNC). A retrospective study was conducted on all patients with head and neck cancers who had undergone NDs in Singapore General Hospital between 1992 and 2013.

STUDY DESIGN

Retrospective study.

METHODS

Patients were categorized into two groups: patients treated with RT with or without chemotherapy before ND and patients who had undergone ND surgery without previous history of RT. The primary endpoint for this study would be the lymph node count from ND.

RESULTS

The study cohort consists of 1,024 NDs on 829 patients. There were 597 (58.3%) radical/modified radical NDs involving levels I-V. Within this group, 75 (12.6%) NDs had preoperative RT. Preoperative RT and age were found to significantly reduce nodal yield in both univariate and multivariate analysis in the radical/modified radical ND subgroup. In our multivariate analysis, preoperative RT was shown to decrease the nodal yield by 7.464 (P = .0002, 95% confidence interval [CI]: -11.35 to -3.58). Advanced age independently decreases nodal yield, even after accounting for the effect of RT (P = .0002, 95% CI: -0.27 to -0.08). In addition, preoperative RT has a more pronounced effect in reducing lymph node count in the older age group.

CONCLUSIONS

Preoperative RT and advanced age are independent and synergistic factors that reduce nodal count from NDs in patients with head and neck cancers.

LEVEL OF EVIDENCE

4 Laryngoscope, 130: 1947-1953, 2020.

A cellular and proteomic approach to assess proteins extracted from cryopreserved human amnion in the cultivation of corneal stromal keratocytes for stromal cell therapy

Background

Human corneal stromal keratocytes propagated in culture media supplemented with human amnion extract (AME) can correct early corneal haze in an animal model. Clinical application of cultivated keratocytes is limited by infectious disease screening before amnion products can be used in humans. It remains unclear if AME from cryopreserved versus fresh human amnion can support human keratocyte propagation, and which components of the extract promote keratocyte growth.

Methods

Three placentas were collected for the preparation of fresh and cryopreserved amnion tissues followed by homogenization and protein extraction. AME protein profiles were studied using isobaric tagging for relative and absolute quantitation (iTRAQ) proteomics. Enriched gene ontology (GO) terms and functional classes were identified. Primary human keratocytes from 4 donor corneas were cultured in media supplemented with fresh AME (F-AME) or cryopreserved AME (C-AME). Cell viability, proliferation and keratocyte marker expression were examined by confocal immunofluorescence and flow cytometry.

Results

AME proteomics revealed 1385 proteins with similar expression levels (between 0.5- and 2-fold) between F- and C-AME, while 286 proteins were reduced (less than 0.5-fold) in C-AME. Enriched GO term and biological pathway analysis showed that those proteins with comparable expression between F-AME and C-AME were involved in cell metabolism, epithelial-mesenchymal transition, focal adhesion, cell-extracellular matrix interaction, cell stress regulation and complement cascades. Human corneal stromal keratocytes cultured with F-AME or C-AME showed similar morphology and viability, while cell proliferation was mildly suppressed with C-AME (P > 0.05). Expression of aldehyde dehydrogenase 3A1 (ALDH3A1) and CD34 was similar in both cultures.

Conclusion

AME from cryopreserved amnion had limited influence on keratocyte culture. It is feasible to use protein extract from cryopreserved amnion to propagate human keratocytes for potential translational applications.

Mutational Signatures in Mandibular Ameloblastoma Correlate with Smoking

Ameloblastoma is a rare tumor of odontogenic epithelium, the low incidence rate of which precludes statistical determination of its molecular characterizations. Despite recent genomic and transcriptomic profiling, the etiology of ameloblastomas remains poorly understood. Risk factors of ameloblastoma development are also largely unknown. Whole exome sequencing was performed on 11 mandibular ameloblastoma samples. We identified 2 convergent mutational signatures in ameloblastoma: 1) a signature found in multiple types of lung cancers with probable etiology of tobacco carcinogens (COSMIC signature 4) and 2) a signature present in gingivobuccal oral squamous cell carcinoma and correlated with tobacco-chewing habits (COSMIC signature 29). These mutational signatures highlight tobacco usage or related mutagens as one possible risk factor of ameloblastoma, since the association of BRAF mutations and smoking was demonstrated in multiple studies. In addition to BRAF hotspot mutations (V600E), we observed clear inter- and intratumor heterogeneities. Interestingly, prior to BRAF mutation, important genes regulating odontogenesis mutated (e.g., corepressor BCOR), possibly playing important roles in tumorigenesis. Furthermore, recurrent mutations in the CDC73 gene, the germline mutations of which predispose patients to the development of jaw tumors, were found in 2 patients, which may lead to recurrence if not targeted by therapeutic drugs. Our unbiased profiling of coding regions of ameloblastoma genomes provides insights to the possible etiology of mandibular ameloblastoma and highlights potential disease risk factors for screening and prevention, especially for Asian patients. Because of the limited sample size and incomplete habitual, dietary, and occupational data, a causal link between tobacco usage and ameloblastoma still requires further investigations.

Use of the EndoMaster robot-assisted surgical system in transoral robotic surgery: A cadaveric study

BACKGROUND

The EndoMaster is a novel robot-assisted surgical system originally designed for endoscopic resection of gastrointestinal polyps and tumours. It incorporates two robotic arms (a grasper and a probe for monopolar diathermy) into the end of a flexible endoscope, creating improved manoeuvrability, with two arms allowing for 9 degrees of movement and triangulation; this enables fine manipulation and dissection of tissues.

METHODS

The EndoMaster was used in two human cadavers to perform 4 radical tonsillectomies to evaluate its performance in transoral robotic surgery (TORS).

RESULTS

The EndoMaster allowed for good visualization of the surgical field and its compact form factor allowed for quick docking and avoided the problem of clashing of the working arms.

CONCLUSION

The EndoMaster system shows promising potential for use in TORS. Further refinements to movements of the effector arms are required.

Platelet Loss across the Hemofilter during Continuous Hemofiltration

BACKGROUND

Thrombocytopenia is a common finding in patients in the intensive care unit receiving continuous renal replacement therapy (CRRT). It is unknown if the hemofilter itself contributes to the platelet loss.

OBJECTIVE

To measure the direct effect of the hemofilter on platelet counts during CRRT.

DESIGN

Prospective, observational study.

SETTING

Intensive care unit of a University hospital.

PATIENTS

Critically ill patients with acute renal failure receiving CRRT.

METHODS

Two samples of blood were drawn simultaneously, pre-filter and post-filter, and analyzed for platelet count. A correction factor was applied to the post-filter platelet count to adjust for the hemoconcentrating effect of net ultrafiltration.

RESULTS

Forty-eight sets of paired data from 22 patients were studied. There was a small but significant decrease in mean platelet count across the hemofilter. The mean platelet count drop was 2.32 x 10(9)/L (s.e. 1.06, p = 0.0487, 95% CI (0.01, 4.62)). Blood flow was strongly related to degree of platelet loss, with a decreased loss of 0.07 x 10(9)/L for every ml/min increase in blood flow (p = 0.015). There was no overall decrease in concurrently measured red cell counts across the hemofilter. However, there was a machine-specific affect on red cell loss (p < 0.0001). The total calculated daily platelet loss across the filter was 625 x 10(9) cells.

CONCLUSION

The hemofilter may contribute to the thrombocytopenia seen during CRRT, by means of either destruction or retention of platelets during passage. This affect appears attenuated by higher blood flows. This information is useful in the assessment of a low platelet count in patients receiving CRRT.

Phenotype-driven precision oncology as a guide for clinical decisions one patient at a time

Genomics-driven cancer therapeutics has gained prominence in personalized cancer treatment. However, its utility in indications lacking biomarker-driven treatment strategies remains limited. Here we present a "phenotype-driven precision-oncology" approach, based on the notion that biological response to perturbations, chemical or genetic, in ex vivo patient-individualized models can serve as predictive biomarkers for therapeutic response in the clinic. We generated a library of "screenable" patient-derived primary cultures (PDCs) for head and neck squamous cell carcinomas that reproducibly predicted treatment response in matched patient-derived-xenograft models. Importantly, PDCs could guide clinical practice and predict tumour progression in two n = 1 co-clinical trials. Comprehensive "-omics" interrogation of PDCs derived from one of these models revealed YAP1 as a putative biomarker for treatment response and survival in ~24% of oral squamous cell carcinoma. We envision that scaling of the proposed PDC approach could uncover biomarkers for therapeutic stratification and guide real-time therapeutic decisions in the future.Treatment response in patient-derived models may serve as a biomarker for response in the clinic. Here, the authors use paired patient-derived mouse xenografts and patient-derived primary culture models from head and neck squamous cell carcinomas, including metastasis, as models for high-throughput screening of anti-cancer drugs.

Prognostic significance of lymph node density in squamous cell carcinoma of the tongue

BACKGROUND

The prognostic significance of lymph node density in oral squamous cell carcinoma (OSCC) has been well recognized. However, its use in a specific subsite of the tongue has not been evaluated. The purpose of this study was to determine the prognostic significance of lymph node density in tongue squamous cell carcinoma (SCC).

METHODS

A retrospective analysis of 99 patients with tongue SCC who underwent primary curative resection and neck dissection was conducted. Overall survival (OS) and disease-specific survival (DSS) was used to evaluate the prognostic significance of lymph node density.

RESULTS

Lymph node density (using a cutoff of 0.06) was shown to be an independent predictor of OS and DSS. The impact of lymph node density on OS and DSS remained significant on multivariate analysis, whereas conventional nodal staging was not. An alternative staging strategy incorporating depth of invasion and lymph node density performs better than conventional TNM staging in predicting survival.

CONCLUSION

Our data suggest that lymph node density is a reliable and applicable predictor of prognosis in patients with tongue SCC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E859-E866, 2016.

Randomized trial comparing surgery and adjuvant radiotherapy versus concurrent chemoradiotherapy in patients with advanced, nonmetastatic squamous cell carcinoma of the head and neck: 10-year update and subset analysis

BACKGROUND

The current study was performed to report the long-term results of a trial comparing concurrent chemotherapy and radiotherapy (CCRT) with surgery and adjuvant radiotherapy (RT) in patients with stage III/IV nonmetastatic head and neck squamous cell carcinoma.

METHODS

Patients with stage III/IV resectable head and neck squamous cell carcinoma were randomized to surgery followed by RT or CCRT. The trial was halted prematurely due to poor accrual. Human papillomavirus status was tested on archival material using polymerase chain reaction sequencing.

RESULTS

Of the total of 119 patients, 60 patients were randomized to primary surgery (S arm) and 59 patients were randomized to CCRT (C arm). Human papillomavirus status was tested in 75 patients, and only 3 were found to be positive. The median follow-up for surviving patients was 13 years. Analysis of the entire cohort demonstrated no statistically significant difference in overall survival and disease-specific survival (DSS): 5-year rates were 45% versus 35% for overall survival (P = .262) and 56% versus 46% for DSS (P = .637) for the S arm and C arm, respectively. Analysis by subsites indicated that this difference favoring the S arm was mainly driven by survival data among patients with cancers of the oral cavity and maxillary sinus. For patients with oral cavity cancer, survival was significantly better in those who underwent primary surgery compared with CCRT; the 5-year DSS rate was 68% versus 12% for the S arm and C arm, respectively (P = .038). For patients with cancers of the maxillary sinus, the 5-year DSS rate was 71% for patients on the S arm and 0% for patients on the C arm (P = .05).

CONCLUSIONS

These long-term results demonstrate a significant advantage for primary surgery in patients with cancers of the oral cavity or maxillary sinus, providing strong support for primary surgery as the main modality of treatment for these subsites. In other subsites, CCRT and surgery with adjuvant RT were found to demonstrate similar efficacy for survival in patients with advanced resectable tumors.

Serglycin expression: An independent marker of distant metastases in nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) has a high propensity for metastasis. The purpose of this study was for us to determine whether serglycin expression can be used to predict distant metastases.

METHODS

Serglycin expression of tumor tissue of 112 patients with NPC was assessed based on percentage of tumor cells expressing serglycin, staining intensity, percentage of tumor-infiltrated lymphocyte (TIL) expressing serglycin and TIL-staining intensity.

RESULTS

Risk factors for distant metastases include sex, smoking status, tumor intensity, and TIL percentage for serglycin. The odds of distant metastases was 4.13 and 0.18 in patients with strong tumor intensity and >50% TIL percentage, respectively. Based on a nomogram incorporating predictors, patients were stratified into 2 prognostic groups. The proportion of distant metastases in the high-risk group (strong tumor intensity and ≤50% TIL percentage) was 78% versus 19% in the low risk group (p < .001).

CONCLUSION

Patients with NPC with tumors showing strong tumor intensity and low TIL percentage with serglycin may be at high risk for distant metastases.

Severe hypoglycaemia in type 1 diabetes mellitus: underlying drivers and potential strategies for successful prevention

Hypoglycaemia remains an over-riding factor limiting optimal glycaemic control in type 1 diabetes. Severe hypoglycaemia is prevalent in almost half of those with long-duration diabetes and is one of the most feared diabetes-related complications. In this review, we present an overview of the increasing body of literature seeking to elucidate the underlying pathophysiology of severe hypoglycaemia and the limited evidence behind the strategies employed to prevent episodes. Drivers of severe hypoglycaemia including impaired counter-regulation, hypoglycaemia-associated autonomic failure, psychosocial and behavioural factors and neuroimaging correlates are discussed. Treatment strategies encompassing structured education, insulin analogue regimens, continuous subcutaneous insulin infusion pumps, continuous glucose sensing and beta-cell replacement therapies have been employed, yet there is little randomized controlled trial evidence demonstrating effectiveness of new technologies in reducing severe hypoglycaemia. Optimally designed interventional trials evaluating these existing technologies and using modern methods of teaching patients flexible insulin use within structured education programmes with the specific goal of preventing severe hypoglycaemia are required. Individuals at high risk need to be monitored with meticulous collection of data on awareness, as well as frequency and severity of all hypoglycaemic episodes.

The impact of hypoglycaemia on patients admitted to hospital with medical emergencies

AIMS

To quantify the frequency of biochemical hypoglycaemia in acutely unwell patients in the medical assessment unit and relate this to their subsequent outcomes.

METHODS

A retrospective audit was conducted on all emergency medical patients attending the medical assessment unit between November 2010 and April 2011. Capillary blood glucose measurements were obtained and electronically stored for all patients. Admission details, presence of diabetes, type of diabetes and treatment, length of stay in hospital and death in hospital were obtained from the hospital clinical coding data and electronic discharge summary. The incidence of hypoglycaemia in patients with and without diabetes was quantified. The mean age, length of stay and percentage of death in hospital were compared between groups with and without hypoglycaemia.

RESULTS

One hundred and thirty-eight (9.5%) patients with diabetes and 70 (2.7%) patients without diabetes had an episode of hypoglycaemia in the medical assessment unit. Patients with diabetes and hypoglycaemia on admission had a significantly longer length of stay (mean ± sd) (10.3 ± 11.2 vs. 7.3 ± 9.5 days, P = 0.001) and higher rate of hospital mortality (14.5 vs. 5.2%, P < 0.001) compared with those without hypoglycaemia. Patients without diabetes with hypoglycaemia had a longer length of stay (mean ± sd) (9.1 ± 10.5 vs. 6.7 ± 9.9 days, P = 0.05) and a higher rate of hospital mortality (24.3 vs. 5.4%, P < 0.001) compared with those without hypoglycaemia.

CONCLUSION

Hypoglycaemia is associated with an increased length of stay in hospital and an increased in-hospital mortality rate. Hypoglycaemia may have contributed to the poorer outcome, but would also appear to be a marker of disease severity in unwell patients, especially patients with sepsis.

Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) of urinary protein in acute kidney injury

Recent experimental and clinical studies have shown the importance of urinary proteomics in acute kidney injury (AKI). We analyzed the protein in urine of patients with clinical AKI using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) for its diagnostic value, and followed them up for 40 months to evaluate prognosis. Urine from 31 consecutive cases of AKI was analyzed with SDS-PAGE to determine the low, middle and high molecular weight proteins. Fractional excretion of sodium (FENa) was estimated from serum and urine creatinine and sodium (Na). The cases were followed-up for 40 months from the end of the recruitment of study cases. Glomerular protein was higher in the hematuria group when compared with the non-hematuria group (P <0.04) and in the AKI group than in the acute on chronic renal failure (AKI-on-CRF) group (P <0.002). Tubular protein was higher in the AKI-on-CRF group (P <0.003) than in the AKI group. Tubular protein correlated with FENa in groups with diabetes mellitus (DM), AKI-on-CRF, and without hematuria (P <0.03, P <0.02 and P <0.004, respectively). Pattern of protein did not differ between groups with and without DM and clinical acute tubular necrosis (ATN). At the end of 40 months follow-up, category with predominantly glomerular protein progressed to chronic renal failure (CRF) or end-stage renal failure in higher proportion (P <0.05). In clinical AKI, we observed that glomerular protein dominated in cases with glomerular insult, as indicated by hematuria. Tubular protein was common in the study cases with CRF, DM and cases without hematuria. This indicates tubulo-interstitial injury for AKI in these cases. Patients with predominantly glomerular protein had an adverse outcome.

Ministry of health clinical practice guidelines: screening of cardiovascular disease and risk factors

The Ministry of Health (MOH) publishes clinical practice guidelines on Screening of Cardiovascular Disease and Risk Factors to provide doctors and patients in Singapore with evidence-based guidance on the screening of cardiovascular disease and risk factors. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Screening of Cardiovascular Disease and Risk Factors, for the information of readers of the Singapore Medical Journal. Page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=25776). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Impact of patterns of proteinuria on renal allograft function and survival: a prospective cohort study

BACKGROUND

Proteinuria is an important complication in renal transplant recipients. The aim of this prospective study was to evaluate the long-term impact of transplant proteinuria patterns on allograft function and survival.

METHODS

We analyzed urinary protein of a cohort of 83 renal transplants with proteinuria ≥0.5 g/d by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and radial immunogel diffusion assay. After initial stratification and analysis, the cohort was followed up for 16 yr. The graft outcome and survival were analyzed using Cox regression model to determine their association with different patterns of initial transplant proteinuria.

RESULTS

Group with predominantly glomerular (middle- and high-molecular-weight with or without low-molecular-weight) proteinuria (61%) had higher serum creatinine (p < 0.001) than the group with predominantly tubular (low-molecular-weight) proteinuria (39%). The incidences of chronic graft dysfunction and graft loss had increased in the glomerular proteinuria group (p < 0.001, hazard ratio 3.6, 95% confidence interval 1.7-7.5 and p < 0.001, hazard ratio 4.9, 95% confidence interval 1.9-12.1, respectively). Patient death did not differ (p = 0.434, hazard ratio 1.5, 95% confidence interval 0.5-4.5).

CONCLUSION

  Proteinuria in renal transplants can be differentiated into glomerular and tubular types based on molecular weight. Glomerular proteinuria is associated with significant increase in graft dysfunction and graft loss.

Rapid aneuploidy screening with fluorescence in-situ hybridisation: is it a sufficiently robust stand-alone test for prenatal diagnosis?

OBJECTIVES

To assess the clinical utility of fluorescence in-situ hybridisation with chromosomes 13, 18, 21, X and Y as a stand-alone test in detecting chromosomal abnormalities, and the types of chromosomal abnormalities missed.

DESIGN

Retrospective analysis.

SETTING

A restructured Government hospital in Singapore and an academic hospital in the United States.

PARTICIPANTS

Cytogenetic data of prenatal specimens and results of fluorescence in-situ hybridisation of 5883 patients performed between January 2000 and August 2007 were reviewed.

RESULTS

Fluorescence in-situ hybridisation detected 558 (9.5%) patients with chromosomal abnormalities. Abnormal ultrasounds (70%) and maternal serum screens (21%) were the most indicative of chromosomal abnormalities. When comparing fluorescence in-situ hybridisation data with karyotype results for the five chromosomes of interest, the sensitivity and specificity were 99.3% and 99.9%, respectively. When comparing fluorescence in-situ hybridisation data with karyotype results for all chromosomes, the sensitivity decreased to 86.8%, whereas the specificity remained at 99.9%. Of 643 cases with karyotype abnormalities, 85 were fluorescence in-situ hybridisation-negative (false negative rate, 13.2%), which included structural rearrangements, chromosome mosaicism, and other trisomies. Despite abnormal ultrasound indications, fluorescence in-situ hybridisation missed 32 cases which included structural rearrangements, mosaicisms, and other trisomies.

CONCLUSION

This study does not support fluorescence in-situ hybridisation as a stand-alone test. Institutions supporting fluorescence in-situ hybridisation as a stand-alone test must seriously consider the risks of a missed diagnosis.

Subglottic stenosis in infants and children

INTRODUCTION

This study aimed to examine the epidemiology and outcome of subglottic stenosis in infants and children, and to evaluate the current techniques used in its diagnosis and management at the KK Women's and Children's Hospital, Singapore.

METHODS

A retrospective review and long-term follow-up was conducted in all infants and children diagnosed with subglottic stenosis between January 1997 and December 2008.

RESULTS

A total of 18 patients (nine male and nine female) with a median age of 7.5 months were identified. Two patients were diagnosed with definite congenital stenosis and 16 patients with acquired stenosis. The majority had Grade I stenosis (55.6 percent), followed by Grade II (27.8 percent) and Grade III (16.7 percent). None had Grade IV stenosis. 17 patients were intubated, and seven underwent tracheostomy. The most common surgical intervention performed was microlaryngoscopy and bronchoscopy with bougie dilation. The other surgical interventions included cricoid split, laryngotracheal reconstruction and cricotracheal resection. As of December 2008, the median duration of treatment was four years, with an overall recovery rate of 66.7 percent. The successful decannulation rate was 57.1 percent. Two mortalities were reported due to reasons unrelated to subglottic stenosis. Two patients were still undergoing treatment at the time of the study, and two were lost to follow-up.

CONCLUSION

Conservative management alone may be required in the majority of Grade I stenosis cases. We observed that the mean number of reconstructive procedures performed per patient increased with the increase in the severity of stenosis. Each laryngeal framework procedure has to be customised to suit the individual.

Quantitative methylation analyses of resection margins predict local recurrences and disease-specific deaths in patients with head and neck squamous cell carcinomas

This study sought to determine whether the presence of hypermethylated genes in the surgical margins can predict local recurrences in head and neck squamous cell carcinomas (HNSCCs). We prospectively collected tumour and surgical margin specimens from patients with HNSCCs who had undergone surgical resections. Quantitative methylation-specific PCR (QMSP) of CDKN2A, CCNA1 and DCC were performed in these specimens and correlated with clinical data. Of the 42 patients eligible for the study, 27 were hypermethylation informative for the above three genes. This latter group was associated with longer disease-free survivals (P=0.007) and longer time to disease-specific deaths (P=0.004). Multivariate analyses confirmed hypermethylation non-informative tumours as an independent prognosticating factor for disease-specific deaths (risk ratio 3.8, P=0.026). Quantitative MSP of the margins of 24 hypermethylation informative tumours revealed that 11 patients had molecularly positive margins, of which, five developed disease-specific events (DSEs, three local recurrences and two metastases), compared to none in patients with molecularly negative margins, after a median follow-up of 48 months. Log-rank analyses showed that molecularly positive margins were associated with shorter time to local recurrences and disease-specific deaths (P=0.03 and 0.01, respectively). This study demonstrated that QMSP of hypermethylated promoters in surgical margins predicted all the local recurrences in our series of HNSCC patients. We have also identified hypermethylation non-informative tumours as an independent predictor for the development of DSEs.

Ultrasonographical features of morbidly-adherent placentas

Morbidly-adherent placentas manifest as placenta accreta, increta or percreta, depending on the depth of placental invasion. These conditions present high risks of severe obstetrical haemorrhage at delivery. The underlying pathology is due to defects in the decidua basalis caused by a variety of insults, such as previous surgery, excessive curettage or infection. The incidence of morbidly-adherent placentas is rising as the frequency of caesarean sections increase. Imaging plays an important role in the antenatal detection of this condition. Based on the case series seen at our local institution, we describe the imaging characteristics of this condition as seen on grayscale ultrasonography, colour/power Doppler ultrasonography, three-dimensional ultrasonography and magnetic resonance imaging.

Toxoplasmic retinochoroiditis presenting in childhood: clinical findings in a UK survey

AIM

To compare the clinical findings in children with symptomatic toxoplasmic ocular lesions attributable to infection acquired before or after birth.

METHODS

Cases were prospectively ascertained for 24 months through national surveillance units and reference laboratories in the British Isles. Age and presenting symptoms, site of lesion and visual impairment in children who were classified as acquiring infection either before or after birth on the basis of clinical and serological findings were compared.

RESULTS

31 children had toxoplasmic retinochoroiditis, 15 had congenital infection and all but three of these presented before the age of 4 years. The remaining 16 children acquired toxoplasmosis postnatally, and 14 of 16 presented after the age of 10 years. A further four children had retinochoroiditis due to other causes. The presence of bilateral, multiple or posterior pole lesions did not distinguish between the two groups, but most children (16/19; 84%) presenting with acute ocular symptoms had postnatally acquired infection. Unilateral visual impairment (Snellen < or =6/18) was equally prevalent in the two groups (4/9 before birth v 7/16 after birth; p>0.5). Only two children had bilateral visual impairment, both of whom had congenital infection. No child was blind.

CONCLUSIONS

About 50% of children with ocular lesions due to toxoplasmosis had postnatal infection. Retinochoroidal lesions due to infection before and after birth were indistinguishable. The prognosis for bilateral visual function was good, regardless of when infection was acquired.

Intrapartum maternal sinus bradycardia with spontaneous resolution following delivery

Pregnancy is a normal physiological state that is characterised by significant adaptive changes, many of which take place in the cardiovascular system. These adaptations are believed to be the cause for the increased incidence in cardiac arrhythmias in pregnancy and particularly, in labour. We report an unusual case of a healthy 32-year-old primigravida who developed profound intrapartum bradycardia which persisted throughout labour. Spontaneous recovery to pre-labour baseline heart rate occurred following spontaneous vaginal delivery. Maternal and foetal statuses remained satisfactory during labour. This case report underscores the importance of recognising that arrhythmias in various forms are common in labour. In the absence of detectable underlying cardiac disease or maternal and foetal compromise, continuation of the labour with a view to vaginal delivery should be the goal.

Symptomatic toxoplasma infection due to congenital and postnatally acquired infection

AIMS

To determine the incidence and severity of symptomatic toxoplasma infection presenting during childhood due to congenital or postnatally acquired infection.

METHODS

Between 2002 and 2004, newly diagnosed children (<16 years) with signs or symptoms of congenital or ocular toxoplasmosis were reported by clinicians to the British Paediatric and Ophthalmic Surveillance Units or by toxoplasma referral laboratories. Confirmed cases were estimated to have a greater than 50% probability of congenital and/or ocular toxoplasmosis, based on clinical and serological findings.

RESULTS

Thirty eight children had confirmed toxoplasma infection. Twenty two (58%) were classified with congenital infection (cumulative incidence for England and Wales 1.62[corrected]/100,000 live births; 95% CI 0.85[corrected] to 2.83[corrected]), of whom 2 (9%) were stillborn, 7 (32%) live births had intracranial abnormalities and/or developmental delay (5 of whom had retinochoroiditis), and 10 (45%) had retinochoroiditis with no other abnormalities reported. A further 16 (42%) children were classified as infected after birth; all had retinochoroiditis.

CONCLUSIONS

The low burden of symptomatic congenital toxoplasmosis combined with the lack of evidence of an effective treatment support current policy not to offer prenatal or neonatal screening for toxoplasma infection. Primary prevention strategies need to address acquisition of infection in childhood which accounts for half the ocular disease due to toxoplasma infection in children in the UK and Ireland.

Double pylorus

Double pylorus is a rare abnormality and it occurs most commonly secondary to chronic peptic ulcer disease. It is usually treated conservatively with anti-ulcer therapy. However, refractory cases may require surgery.

Tocolytic treatment for the management of preterm labour: a systematic review

Spontaneous preterm labour and delivery accounts for approximately one-third of preterm births, which is the predominant cause of perinatal mortality and morbidity. This review aims to evaluate the evidence on the benefits and harms of five classes of tocolytic therapy, namely: betamimetics, calcium channel blockers, magnesium, non-steroidal anti-inflammatory agents, and atosiban. We performed a systematic review of the effectiveness of tocolytics to stop uterine contractions (first-line therapy). Reports of randomised controlled trials from searches of MEDLINE, bibliographies of review articles, Cochrane Collaboration and its Pregnancy and Childbirth Review Group between 1966 and 2003 were identified, using the search terms "randomised controlled trial" (RCT), "preterm labor", "tocolysis", "betamimetics", "ritodrine", "prostaglandin synthetase inhibitors", "indomethacin", "calcium channel blockers", "nifedipine", "oxytocin receptor blockers", "atosiban", and "magnesium sulphate". Studies on women with preterm labour comparing the effects of a tocolytic with a placebo or no treatment that met our inclusion criteria, were included. To our knowledge, the trials were conducted mainly before 1999 and there were no placebo-controlled trials after that. Of the 86 articles identified and evaluated, 14 first-line studies met more stringent requirements for meta-analyses. Tocolytics were associated with significant decreases in the odds of delivery within 24 hours (odds-ratio [OR] 0.54, 95 percent confidence interval [CI] 0.32-0.91) and 48 hours (OR 0.47, 95 percent CI 0.30-0.75). These effects were significant for beta-agonists, atosiban and indomethacin, but not magnesium sulphate. Maternal side-effects significantly associated with betamimetics were pulmonary oedema, cardiac arrhthymias and hypokalaemia. Although calcium antagonists have not been evaluated against placebo, comparative trials with beta-agonists have shown more favourable neonatal outcomes and better prolongation of gestation. In conclusion, the management of threatened preterm labour with first-line tocolytic therapy can prolong gestation. However, the time gained in-utero need to be optimised. There is no clear first-line tocolytic agent. The use of tocolytic agents should be individualised and based on maternal condition, potential side-effects and gestational age.

Plasma filtration

Therapeutic plasma exchange (TPE) or plasmapheresis involves the separation of plasma from whole blood. In so doing, plasma-borne humoral disease mediators are removed from the body. This can attenuate the course and severity of the underlying disease. Diseases that can be treated with TPE are classified into the following categories: (1) endocrinological, (2) neurological, (3) renal/rheumatological, and (4) haematological. TPE is adjuvant in most of these settings. Disease-specific pharmacological treatment remains the cornerstone of treatment in many of these conditions. Plasma separation can be achieved with either (1) centrifugation (CF) or (2) membrane plasma filtration (PF). The latter is the focus of this review. It can be performed using either a continuous renal replacement therapy (CRRT) or haemodialysis (HD) machine. Standard plasma filtration has also been modified to incorporate sorbent technology which obviates the need for plasma volume replacement fluids. Larger clinical issues such as timing of initiation and intensity of therapy are examined.

Determinants of response to a parent questionnaire about development and behaviour in 3 year olds: European multicentre study of congenital toxoplasmosis

BACKGROUND

We aimed to determine how response to a parent-completed postal questionnaire measuring development, behaviour, impairment, and parental concerns and anxiety, varies in different European centres.

METHODS

Prospective cohort study of 3 year old children, with and without congenital toxoplasmosis, who were identified by prenatal or neonatal screening for toxoplasmosis in 11 centres in 7 countries. Parents were mailed a questionnaire that comprised all or part of existing validated tools. We determined the effect of characteristics of the centre and child on response, age at questionnaire completion, and response to child drawing tasks.

RESULTS

The questionnaire took 21 minutes to complete on average. 67% (714/1058) of parents responded. Few parents (60/1058) refused to participate. The strongest determinants of response were the score for organisational attributes of the study centre (such as direct involvement in follow up and access to an address register), and infection with congenital toxoplasmosis. Age at completion was associated with study centre, presence of neurological abnormalities in early infancy, and duration of prenatal treatment. Completion rates for individual questions exceeded 92% except for child completed drawings of a man (70%), which were completed more by girls, older children, and in certain centres.

CONCLUSION

Differences in response across European centres were predominantly related to the organisation of follow up and access to correct addresses. The questionnaire was acceptable in all six countries and offers a low cost tool for assessing development, behaviour, and parental concerns and anxiety, in multinational studies.

Healthcare worker seroconversion in SARS outbreak

Serum samples were obtained from healthcare workers 5 weeks after exposure to an outbreak of severe acute respiratory syndrome (SARS). A sensitive dot blot enzyme-linked immunosorbent assay, complemented by a specific neutralization test, shows that only persons in whom probable SARS was diagnosed had specific antibodies and suggests that subclinical SARS is not an important feature of the disease.

Molecular adsorbent recirculating system (MARS)

INTRODUCTION

Molecular adsorbent recirculating system (MARS) for albumin liver dialysis has been used as a bridge to liver transplantation in patients with fulminant hepatic failure (FHF). This review examines the available data on its clinical use, its technical aspects and present gaps in knowledge.

METHODS

Peer-reviewed journals and monographs on the subject were covered.

RESULTS

FHF is associated with elevation in various substances including bilirubin, ammonia, lactate, free fatty acids and aromatic amino acids. Some of these toxic metabolites, such as ammonia and bilirubin, are believed to be central to the clinical manifestations of hepatic encephalopathy and acute renal failure. MARS ameliorates both biochemical and clinical manifestations of FHF by removing both water-soluble and protein-bound toxins. Among the benefits of MARS is the attenuation of severe cerebral oedema and raised intracranial pressure found in FHF, possibly through reduction in high concentrations of these toxins. Although MARS has been shown to be useful in FHF, its clinical efficacy in subfulminant hepatic failure and less severe forms of acute liver failure (ALF) remains uncertain. The current literature also suggests that it may be beneficial to treat cases of acute-on-chronic liver failure (AoCLF). Deranged systemic chemistries can be similarly ameliorated, but the impact of MARS on the natural history of AoCLF remains uncertain. The difficulty lies in being able to accurately quantify residual liver function and variability in the course of acute intercurrent events. The broader question is whether MARS can favourably change the natural history of ALF and FHF. For this, large multi-centre, randomised controlled trials are needed. Furthermore, it is also uncertain how hepatic excretory-assist devices, such as MARS, compare with bio-artificial liver-assist devices which have both synthetic and excretory hepatic functions in ALF treatment in intensive care unit patients. Nevertheless, MARS has proven to be a valuable homeostatic tool that may be useful in restoring the biochemical and clinical status quo in much the same way that continuous veno-venous haemofiltration and mechanical ventilation provide temporary artificial organ support while these organs are in distress. This is the evolving concept of multi-organ support therapy. Other major unresolved issues with MARS include the timing of initiation of albumin liver dialysis, the clinical and/or biochemical parameters to base this decision on, the intensity of MARS therapy (continuous versus intermittent) and the saturation capacity of the system for different metabolites in intermittent MARS.

CONCLUSIONS

MARS is an effective and, thus far, safe homeostatic tool in treating FHF. More studies are needed to delineate its role as a homeostatic tool in less severe forms of ALF, including that which occurs in multi-organ failure and in AoCLF. Other studies need to focus on the optimal timing of initiation of and intensity of MARS albumin liver dialysis. The larger issue is to compare MARS with bio-assist liver devices in treating the whole spectrum of ALF.

MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report

BACKGROUND/METHODS

Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died.

RESULTS

Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation.

CONCLUSIONS

MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.

Audit of 'crash' emergency caesarean sections due to cord prolapse in terms of response time and perinatal outcome

OBJECTIVE

The objective was to audit 'crash' emergency caesarean sections (CS) with respect to response time (the diagnosis to delivery interval [DDI]) and perinatal outcome.

MATERIALS AND METHODS

The computerised database at the Singapore General Hospital (SGH) delivery suite was used to identify all cases of 'crash' emergency CS activated for the diagnosis of cord prolapse from 1992 to 2002. Patients' case notes and neonatal charts were reviewed and the following variables were evaluated: parity, gestational age at the time of delivery and the DDI. Neonatal outcome was measured by Apgar scores at 1 and 5 minutes, cord pH and admission to the neonatal intensive care unit (NICU).

RESULTS

A total of 34 cases of umbilical cord prolapse were identified from 29,867 deliveries, giving an incidence of 0.11% (1 in 900). The median gestational age was 38.5 weeks (range, 25 to 41 weeks). The median time from diagnosis to delivery was 20 minutes (range, 10 to 40 minutes). Seventy-six percent (19/30) were delivered within 30 minutes. The time of diagnosis was not recorded for 5 cases. Sixty-three percent of neonates had an Apgar score < or = 7 at 1 minute of life, increasing to 97% at 5 minutes. There were 3 NICU admissions for reasons of prematurity. There was no perinatal mortality. Cord pH was not performed for 47% of (14/30) neonates. Among the remaining 16 neonates, an umbilical cord pH of < or = 7.20 was found in 62% (10/16). There was poor correlation between the DDI and umbilical cord pH.

CONCLUSION

Three-quarters of our 'crash' emergency CS for cord prolapse were performed within 30 minutes with a good perinatal outcome. However, we have identified areas for improvement to optimise further the operational efficiency of 'crash' emergency CS.

The acid-base effects of continuous hemofiltration with lactate or bicarbonate buffered replacement fluids

OBJECTIVE

To evaluate, quantify and compare the effects of continuous veno-venous hemofiltration (CVVH) with lactate or bicarbonate-buffered replacement fluids on acid-base balance.

DESIGN

Randomized double crossover study.

SETTING

Intensive Care Unit of Tertiary Medical Center.

PARTICIPANTS

Eight patients with severe acute renal failure.

INTERVENTIONS

Random allocation to either 2 hours of isovolemic lactate-buffered (treatment A) CVVH or 2 hours of bicarbonate-buffered (treatment B) CVVH with cross over and with same procedure repeated the following day (double cross over).

MEASUREMENTS AND RESULTS

Timed collections of arterial blood and ultrafiltrate (UF), measurement of blood and UF gases and lactate concentrations and calculation of buffer-base mass balance. At baseline, both groups of patients had a similar, slight metabolic alkalosis (pH: 7.45 vs. 7.45; BE 3.9 mEq/L for treatment A and 4.0 for treatment B) and a serum bicarbonate of 28.1 mmol/L for treatment A vs. 28.3 mmol/L for treatment B; all NS. This alkalosis was present despite slight hyperlactatemia in both groups (A: 2.4 mmol/L vs. B 2.8 mmol/; NS). Within 60 minutes of treatment, however, treatment A led to a significantly higher lactate concentration (3.9 vs 2.5 mmol/L; p = 0.0011), a significantly lower BE (2.3 vs 4.1 mEq/L; p = 0.0019) and a significantly lower bicarbonate concentration (26.7 vs. 28.3 mmol/L; p = 0.0038) in the presence of an unchanged PaCO2. These differences persisted during the study period. The UF of patients receiving treatment A contained more lactate (10.2 vs 2.9 mmol/L; p < 0.0001) and less bicarbonate (25.6 vs. 30.8 mmol/L; p < 0.0001) than treatment B resulting in a mean buffer-base balance of +20.4 mEq/h compared to -2.6 mEq/h for treatment B; p < 0.0001).

CONCLUSIONS

CVVH with lactate-buffered replacement fluids induces iatrogenic hyperlactatemia. Such hyperlactatemia is associated with an acidifying effect despite a positive buffer-base balance.

Pregnancy after renal transplantation: experience in Singapore General Hospital

INTRODUCTION

Renal transplantation offers the best hope for those women with end-stage renal disease who wish to have children. However, pregnancy after renal transplantation is associated with increased maternal and fetal morbidity. The aim of this retrospective study was to review the outcome of pregnancy in renal transplant patients in Singapore General Hospital.

MATERIALS AND METHODS

Forty-two pregnancies, occurring between December 1986 and December 2000, in 25 out of 141 renal transplant women in their reproductive age group (18 to 45 years old) were identified from our high-risk pregnancy record and retrospectively analysed.

RESULTS

Thirteen (31%) pregnancies were unsuccessful; 10 abortions, 2 ectopic pregnancies and 1 stillbirth. The remaining 29(69%) successful pregnancies were complicated by maternal anaemia (65.5%), superimposed hypertension (44.8%), premature rupture of membranes (27.6%), urinary (17.2%) and lower genital tract (13.8%) infections, abnormal glucose tolerance test (13.8%), premature delivery (44.8%), low-birth-weight babies (44.8%), small-for-gestational-age babies (20.7%) and intrauterine growth restriction (20.7%). There were no documented cases of multiple pregnancies, congenital anomalies or deterioration of renal function. The outcome of pregnancy was not statistically influenced by preconception renal function and transplant-conception interval.

CONCLUSIONS

Successful pregnancy is possible in women after renal transplantation. Such pregnancy is often associated with increased maternal and fetal complications and should be managed by a multidisciplinary approach in a tertiary centre. The function and survival of renal allograft was not adversely affected by pregnancy.

The course of pregnancy in a patient with nail-patella syndrome

INTRODUCTION

The nail-patella syndrome is a rare autosomal dominant condition with high penetrance. Pregnancy in such a patient is rare and we believe this to be the first report of a live birth occurring in a patient with nail-patella syndrome.

CLINICAL PICTURE

A 25-year-old patient presented in her first pregnancy with nephrotic syndrome associated with characteristic bone abnormalities and nail dysplasia and was later diagnosed to have nail-patella syndrome. In her second pregnancy, the course of her pregnancy was complicated by further deterioration of renal function with superimposed pre-eclampsia resulting in early delivery at 28 weeks.

CONCLUSION

Such pregnancies should be regarded as high risk and managed jointly with the renal physician in a tertiary care centre to ensure an optimal outcome to the mother and baby.

Gestational diabetes mellitus: a call for systematic tracing

INTRODUCTION

Women with history of gestational diabetes mellitus (GDM) have up to 50% lifetime risk of developing frank diabetes mellitus (DM). They are an ideal group of patients to implement early interventional measures to halt the progression to diabetes. The success of any early intervention programme would depend largely on postpartum follow-up. We set out to study the response rate to postpartum oral glucose tolerance test (OGTT) and to profile the non-responders on 105 women who attended our Gestational Diabetes Joint Clinic (GDJC).

MATERIALS AND METHODS

We divided these women into 3 groups according to their response to postpartum OGTT and compared their weights, glycaemic parameters and other clinical characteristics during gestation. Group A comprised non-responders or those who did not turn up for postpartum OGTT; group B comprised responders with a normal postpartum OGTT; and group C comprised responders with an abnormal postpartum OGTT defined as 2-hour plasma glucose equal or more than 7.8 mmol/L.

RESULTS

The non-respondent rate to postpartum diabetes screening was 37.1%. The non-responders were found to be significantly heavier, with more severe hyperglycaemia during their pregnancy (in terms of glycosylated haemoglobin and results of antepartum OGTT) and had bigger babies compared to the responders with normal postpartum OGTT. Their features instead resembled those who had failed their postpartum OGTT.

CONCLUSION

The group of non-responders was probably at similar risk of developing glucose intolerance postpartum as those who were tested abnormal. A more effective call and recall system and education programme is, therefore, needed to ensure postpartum attendance of all patients with GDM.

Outcome of pregnancy in Asian women with systemic lupus erythematosus: experience of a single perinatal centre in Singapore

OBJECTIVE

To study maternal and fetal outcomes in women with systemic lupus erythematosus (SLE).

MATERIALS AND METHODS

Retrospective study of 27 pregnancies in 18 women with SLE in a single centre.

RESULTS

The mean age was 30 years and most patients were nulliparous. Twenty-six of 27 pregnancies were in disease remission at the time of booking. Renal impairment was present in 7 pregnancies (6 women), of whom 2 were in end-stage renal disease on dialysis. Gestational diabetes developed in 4 pregnancies. There were 6 cases of pre-existing hypertension and 5 with superimposed pre-eclampsia. One woman developed intrapartum eclampsia. Two women had secondary antiphospholipid syndrome (APS) and suffered late fetal losses; in addition, they also developed SLE flares in the form of autoimmune haemolytic anaemia in the postpartum period. There was no maternal mortality. There was one termination of pregnancy for severe renal disease. The median gestational age at delivery was 38 weeks (range, 24 to 40 weeks) and the mean birth weight was 3047 g; the median Apgar scores were 8 and 9 at 1 and 5 minutes of life, respectively. There were 5 cases of intrauterine growth restriction (IUGR), 4 of which occurred in women with renal impairment. There were no cases of congenital heart block or neonatal lupus. There was a late fetal loss at 24 weeks in a woman with secondary APS. There were 2 preterm deliveries (7.4%) due to intervention for IUGR.

CONCLUSION

Good pregnancy outcomes can be expected in women with SLE in remission. Pre-pregnancy counselling is crucial to achieve this. All pregnancies should still be considered high risk and be managed jointly between the obstetricians, the perinatologists and the physicians. In particular, those with renal impairment are at increased risk of IUGR, superimposed pre-eclampsia and preterm births. Co-existing APS augurs a poorer prognosis for pregnancy outcome, and may present atypically as autoimmune haemolytic anaemia in the postpartum period.

High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance

AIMS

To study the effect of combined continuous veno-venous hemodiafiltration (CVVHDF) and high (2.5 g/kg/day) parenteral amino acid supplementation on nitrogen balance, amino acid losses and azotemic control in a cohort of patients with severe acute renal failure (ARF).

METHODS

We administered 2.5 grams/kg/day of amino acids intravenously to seven critically ill patients with ARF. We obtained paired blood and ultrafiltrate (UF) samples (n=20) and calculated amino acid clearances and losses, nitrogen balance, protein catabolic rate and total nitrogen losses.

RESULTS

The median total serum amino acid concentration was high at 5.2 mmol/L with particularly high concentrations of ornithine, lysine, and phenylalanine, but a low level of histidine. The median overall amino acid clearance was 18.6 ml/min (range: 12 to 29 ml/min). UF losses as percentage of administered dose were high for tyrosine (53.6%) but low for methionine (3.0%) and arginine (2.3%). A positive nitrogen balance was achieved in 7 (35%) of the 20 study days with an overall median nitrogen balance of -1.8 g/day. Urea levels were maintained at a median of 26.6 mmol/L.

CONCLUSIONS

High protein intake increases the serum concentrations of most amino acids. Such protein supplementation, when coupled with CVVHDF achieves a slightly negative overall nitrogen balance in extremely catabolic patients while still allowing adequate azotemic control.

Prevalence of gestational thyrotoxicosis in Asian women evaluated in the 8th to 14th weeks of pregnancy: correlations with total and free beta human chorionic gonadotrophin

OBJECTIVES

The prevalence of gestational transient thyrotoxicosis (GTT) in Europeans evaluated during the 8th to 14th weeks of pregnancy is 2-3%. However, there is evidence that GTT may be more common in some Asian populations. The aims of this study were to evaluate the prevalence of thyroid hormone abnormalities in Asian women in their 8th to 14th weeks of pregnancy using highly sensitive free T4 and TSH assays and to correlate these with total and free beta-hCG levels.

DESIGN AND PATIENTS

One hundred and eighty-four consecutive unselected Asian (Singaporean) pregnant women seen at ante-natal clinics for the first time and who were in their 8th to 14th weeks of pregnancy were tested.

MEASUREMENTS

Serum free T4, free T3, TSH, total beta-hCG and free beta-HCG levels were measured on the Vitros ECi system (Johnson & Johnson Ortho-Clinical Diagnostics, Amersham, UK) which employs chemiluminescent immunochemical technology. This free T4 assay is free of biases related to serum binding capacity. The TSH assay used was a third generation assay. Thyrotrophin-receptor antibody (TRAb) levels were measured using LUMItest TRAK (BRAHMS Diagnostica, Berlin, Germany).

RESULTS

Two subjects (1.1%) were found to have Graves' disease. Elevated free T4, free T3, total T3 and suppressed TSH were seen in 14.8%, 3.3%, 26.4% and 33.0% of the remaining 182 pregnant women, respectively. Total and free beta-hCG correlated negatively with TSH (r = -0.30, P < 0.0001 and r = -0.29, P < 0.0001, respectively), positively with fT4 (r = 0.283, P < 0.001 and r = 0.253, P < 0.001) and fT3 (r = 0.273, P < 0.001 and r = 0.204, P < 0.01). 11.0% of cases had gestational thyrotoxicosis (GT) defined as elevated free T4 (> 19.1 pmol/l), suppressed TSH (< 0.36 mIU/l) and TRAb levels within the reference interval (0-0.9 U/l). The prevalence of GT was significantly higher in patients tested at 8-11 weeks compared to those evaluated at 12-14 weeks (14.4% vs. 4.7%, P < 0.05). Total beta-hCG (P = 0.0002), free beta-hCG (P < 0.0001) and free T4 (P = 0.02) levels were higher and TSH levels (P = 0.01) lower in patients tested at 8-11 weeks. Significant positive correlations between both total and free beta-hCG with free T4 were seen at 8-11 weeks but not in patients tested at 12 weeks or later. TT3 levels were similar in the two groups.

CONCLUSIONS

Using sensitive assays, the prevalence of gestational thyrotoxicosis in Asian women was found to be 11.0% and was significantly higher in subjects at 8-11 weeks of gestation than at 12-14 weeks. The positive correlation between hCG and free T4 seen in patients tested at 8-11 weeks was absent in patients tested at later stages of the first trimester. Future studies investigating the entity of gestational thyrotoxicosis, at least in Asian patients, should focus on patients at earlier stages of gestation than currently practised.

Disruption of the GluR2-NSF interaction protects primary hippocampal neurons from ischemic stress

A specific interaction between the AMPA receptor subunits GluR2 and GluR3 and the fusion protein NSF has recently been identified. Disruption of this interaction by adenoviral-mediated expression of a peptide (pep2m) corresponding to the NSF-binding region of GluR2 results in a dramatic reduction in surface expression of AMPA receptors in primary hippocampal neurons. Here we report that expression of pep2m from a recently developed neuronal-specific adenoviral system gave significant neuroprotection to primary CA1-CA3 hippocampal neurons following stimulation with kainate (KA) and this was accompanied by a reduction in Ca(2+) influx. Protection was also observed following glucose deprivation and exposure to ischemic buffer in the absence of any NMDA receptor antagonists. These results provide strong evidence that AMPA receptors play a direct role in mediating postischemic neurotoxicity.

Phosphatemic control during acute renal failure: intermittent hemodialysis versus continuous hemodiafiltration

BACKGROUND

Achieving "adequacy of dialysis" includes the maintenance of normal serum phosphate concentrations and is an important therapeutic goal in the treatment of acute renal failure (ARF). It is unknown whether this goal is best achieved with intermittent or continuous renal replacement therapy.

METHODS

We compared the effects of continuous veno-venous hemodiafiltration (CVVHDF) and intermittent hemodialysis (IHD) on serum phosphate concentrations using daily morning blood tests in 88 consecutive intensive care patients half of which were treated with IHD and half with CRRT RESULTS: Mean patient age was 54+/-14 years for IHD and 60+/-14 years for CVVHDF (NS). However, patients who received CVVHDF were more critically ill (mean APACHE II scores: 24.4+/-5.1 for IHD vs. 29.2+/-5.7 for CVVHDF, p<0.003). Before treatment, the serum phosphate concentration was 2.04+/-0.16 mmoll L for IHD and 1.96+/-0.17 mmoll L for CVVHDF (NS), with abnormal values in 79.4% of IHD patients and in 64.8% of CVVHDF patients (NS). During treatment, CVVHDF induced a greater reduction in serum phosphate (p=0.02) during the first 48 hours and conferred superior subsequent control of hyperphosphatemia (achieved in 64.6% of observations during CVVHDF vs. 41.8% during IHD; p<0.0001). The serum phosphate concentration was also more likely to be within the normal range during CVVHDF (55.3% vs.36.2%; p<0.0001). There was a trend toward more frequent hypophosphatemia (9.3% vs. 5.6%; P<0.1) during CVVHDF CONCLUSIONS: Abnormal serum phosphate concentrations are frequent in ARF patients before and during renal replacement, however, normalization of phosphatemia is achieved more frequently with CVVHDF.

Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery

BACKGROUND

The aim of this study was to test whether early and intensive use of continuous venovenous hemofiltration (CVVH) achieved a better than predicted outcome in patients with severe acute renal failure undergoing cardiac operations, and whether a simple and yet accurate model could be developed to predict their outcome before starting CVVH.

METHODS

Medical record analysis with collection of demographic, clinical, and outcome information was used.

RESULTS

Sixty-five consecutive patients were treated with early and intensive CVVH (mean operation to CVVH time, 2.38 days; pump-controlled ultrafiltration rate, 2 L/h) after coronary artery bypass grafting (56.9%), single valve procedure (16.9%), or combined operations (26.2%). In 32.3% of patients, intraaortic balloon counterpulsation was required and 20% of patients were emergencies. Sustained hypotension despite inotropic and vasopressor support occurred in 40% of patients and prolonged mechanical ventilation in 58.5%. Using an outcome prediction score specific for acute renal failure, the predicted risk of death was 66%. Actual mortality was 40% (p = 0.003). Using multivariate logistic regression analysis and neural network analysis, patient outcome could be predicted with good levels of accuracy (receiver operating characteristic 0.89 and 0.9, respectively).

CONCLUSIONS

Early and aggressive CVVH is associated with better than predicted survival in severe acute renal failure after cardiac operations. Using readily available clinical data, the outcome of such patients can be predicted before the implementation of CVVH.

Airway foreign bodies (FB): a 10-year review

A retrospective chart review of children who had airway foreign body removed via direct laryngoscopy and bronchoscopy (DLB) from 1987-1997 was conducted in Children's Hospital, Boston. Patient characteristics noted included age, sex, and clinical presentation. Pre-operative radiographic findings, reason for delay in evaluation, DLB findings, length of procedure, reason for repeat DLB, and types of foreign body etc. were recorded. Serious complications from aspirated foreign bodies such as severe airway obstruction and death tend to occur in infants and younger children because of their small airway size. A history compatible with foreign body aspiration dictates diagnostic endoscopy with or without radiologic confirmation. Chest and airway radiographs supplemented by fluoroscopy can increase the ratio of correct and early diagnosis. Fluoroscopy should be universally accepted as an initial diagnostic technique in airway foreign body evaluation. Fluoroscopy is not a worthwhile investigation if a preceeding chest radiograph suggests the presence of a foreign body. Long-standing airway foreign bodies are associated with considerable morbidity, and early diagnosis remains the key to successful and uncomplicated management of foreign body aspiration. Education aimed at increasing diagnostic acumen of the physicians and heightening of public awareness are the most important steps needed to reduce the morbidity and mortality. Parents should be instructed to abstain from feeding nuts and seeds to young children and to keep small, potentially ingestible objects out of their reach.

Continuous veno-venous hemofiltration without anticoagulation in high-risk patients

OBJECTIVE

To study the safety and operative efficacy of continuous veno-venous hemofiltration (CVVH) without anticoagulation in patients at high risk of bleeding.

DESIGN

Prospective cohort study and comparison to control group.

SETTING

Tertiary, multidisciplinary intensive care unit.

PATIENTS

Forty hemofiltration circuits in 12 patients with severe acute renal failure (ARF) deemed at high risk of bleeding. Forty control circuits in 14 patients treated with low-dose pre-filter heparin infusion.

INTERVENTIONS

CVVH at 21/h of pump-controlled ultrafiltration without anticoagulation or saline flush in patients at high risk of bleeding. Collection of data at the bedside.

MEASUREMENTS AND MAIN RESULTS

Mean circuit life was 32 h (95% CI: 20-44.4) in patients receiving CVVH without anticoagulation. Forty-three per cent of filters lasted longer than 30 h. Circuit lifespan did not correlate with international normalized ratio (INR), activated partial thromboplastin time (APTT) or platelet count. There were no bleeding complications and azotemic control was not compromised by lack of circuit anticoagulation with a mean serum urea of 16.0 mmol/l (95% CI: 14.9-18.1) during treatment. A control group of consecutive similarly ill patients not at high risk of bleeding received low-dose pre-filter heparin (mean dose 716 IU; 95% CI: 647-785). Their mean filter life was 19.5 h (95% CI: 14.2-23.8), significantly shorter than in the study patients (p = 0.017).

CONCLUSIONS

Critically ill patients at high risk of bleeding who require continuous renal replacement therapy (CRRT) can be safely managed without circuit anticoagulation. This strategy minimizes bleeding risks and is associated with an acceptable filter life. CRRT without anticoagulation should be strongly considered in high-risk patients.

Otogenic lateral sinus thrombosis--a case report

INTRODUCTION

We portray and discuss a case of lateral sinus thrombosis following acute otitis media and mastoiditis.

CLINICAL PICTURE

The patient presented with otorrhoea, otalgia, neck pain, fever and chills.

TREATMENT

Cortical mastoidectomy was performed. Intravenous antibiotics and heparin were administered.

OUTCOME

The patient had a complete recovery with no sequelae.

CONCLUSIONS

Neurotologic complications of suppurative otitis media like meningitis, cerebral abscess, extradural abscess and dural sinus thrombosis are rare in the antibiotic era. Hence, doctors today have to maintain extra vigilance and a high index of suspicion for such complications.