PREDICTED PROTEIN STRUCTURE VARIATIONS INDICATE THE CLINICAL PRESENTATION OF CYP4V2-RELATED BIETTI CRYSTALLINE DYSTROPHY

PURPOSE

To investigate the relationship between different CYP4V2 disease-causing variants and disease severity in Bietti crystalline dystrophy (BCD).

METHODS

Twenty-one subjects from 19 unrelated families with a clinical diagnosis of BCD were enrolled. A novel severity prediction score for BCD based on the predicted molecular impact of CYP4V2 variants was applied for grouping and subsequent analyses. The more severe variants led to less CYP4V2 protein function preservation and a higher severity prediction score.

RESULTS

All subjects harbored two alleles of CYP4V2 disease-causing variants, of which c.802-8_810del17insGC was the most prevalent (14/21, 66.67%) and c.1507G>C was novel. According to the severity score, the subjects were categorized into severe, moderate, and mild groups with different preservation of central vision (mean logMAR visual acuity 0.95 ± 0.82, 0.89 ± 1.22, and 0.56 ± 0.64, respectively). The patients with a lower severity score had slower disease progression.

CONCLUSION

This is the first cohort study of BCD in Taiwan, and we established a novel BCD severity index based on the molecular impact of different CYP4V2 variants. More severe impairment of CYP4V2 protein led to a more severe disease course with earlier progression. Our results could be helpful in identifying a therapeutic window for patients with BCD.

Prognostic factors for combined ranibizumab and prompt verteporfin photodynamic therapy for polypoidal choroidal vasculopathy

PURPOSE

To investigate the prognostic factors for the combined therapy of ranibizumab and prompt verteporfin photodynamic therapy (vPDT) for eyes with polypoidal choroidal vasculopathy (PCV).

METHODS

Sixty-two PCV eyes of 62 patients that received the initial treatment of intravitreal ranibizumab followed by vPDT within 1 week plus a 2nd intravitreal ranibizumab 1 month later in one single medical center were retrospectively enrolled. Best-corrected visual acuity (BCVA) and parameters obtained from optical coherence tomography at baseline, 3 months, 6 months and 1  year were measured and compared. Factors associated with polyp regression, recurrent hemorrhage and visual improvement were analyzed.

RESULTS

After the loading treatment, complete and partial polyp regression was achieved in 53.6% and 39.3% of cases, respectively at Month 3. The mean logarithm of the minimum angle of resolution of BCVA improved from 0.64 ± 0.38 to 0.55 ± 0.46 (P =  0.008) at Month 12. Recurrent hemorrhage (P =  0.001) and previous anti-vascular endothelial growth factor (VEGF) treatment (P =  0.017) were associated with poorer visual improvement at Month 12. Incomplete polyp regression (P =  0.038) and previous anti-VEGF treatment (P =  0.005) were associated with a higher risk of recurrent hemorrhage.

CONCLUSIONS

Recurrent hemorrhage was associated with poor visual improvement after combined ranibizumab and vPDT for PCV. Complete polyp eradication was associated with a lower risk of recurrent hemorrhage. Patients who had previously received anti-VEGF were associated with recurrent hemorrhage and poor visual improvement; more frequent follow-ups and more aggressive subsequent treatments may be needed for these cases.

Clinical and biochemical characteristics of infants with prolonged neonatal jaundice

INTRODUCTION

Protocols for investigating neonatal prolonged jaundice vary and the yield from screening has not been assessed. International guidelines recommend establishing cholestasis before proceeding to investigate the underlying pathology. However, in most hospitals administered by the Hospital Authority, full liver function is checked at the first neonatal jaundice clinic visit. To study the diagnostic yield of this approach, we carried out a retrospective study of all infants referred for prolonged jaundice.

METHODS

Attendance records from the neonatal jaundice clinic at the Tuen Mun Hospital, Hong Kong, the clinical management system, and electronic patient records were used to retrieve epidemiological, clinical, and laboratory data, and patients' clinical progress.

RESULTS

During the 8-month study period from 8 July 2015 to 8 March 2016, 1164 infants were referred to the neonatal jaundice clinic for prolonged jaundice. Among them, 16 (1.4%) infants had conjugated hyperbilirubinaemia. Diagnoses included biliary atresia (n=1), cytomegalovirus (CMV) infection (n=3), neonatal hepatitis syndrome (n=2), and transient cholestasis (n=10). In total, 98 (8.42%) infants had elevated alanine transaminase levels. Diagnoses included biliary atresia (n=1), hepatic congestion related to congestive heart failure (n=1), CMV infection (n=5), neonatal hepatitis syndrome (n=16), and non-specific elevated alanine transaminase (n=75). In total, 59 infants had elevated alkaline phosphatase levels.

CONCLUSIONS

A stepwise approach is recommended, in which full liver function is checked and the underlying cause of jaundice is investigated only after confirming cholestasis.

Comparison of the GlideScope® with the Macintosh Laryngoscope in Endotracheal Intubation during Uninterrupted Mechanical Chest Compression: A Randomised Crossover Manikin Study

Background

The GlideScope® (GS) has been shown to improve the first-attempt success rate of endotracheal intubation during continuous mechanical chest compressions compared with the conventional Macintosh laryngoscope (ML) in inexperienced hands. Yet, its value for operators with experience of emergency airway management has remained uncertain. We set out to compare their performance in the hands of experienced operators in a manikin receiving continuous mechanical chest compressions delivered by LUCAS®.

Method

This was a randomised crossover study. Thirty-five emergency physicians and intensivists performed intubation using GS and ML in 3 different scenarios: (1) normal airway without chest compressions; (2) normal airway with uninterrupted mechanical chest compressions; and (3) normal airway with cervical spine (C-spine) immobilisation and uninterrupted mechanical chest compressions. The sequence of scenarios and devices used were randomised. The primary outcome was the first-attempt success rate of intubation. Other data including demographics, the time required for successful intubation, complications during intubation, the visual analog scale of perceived difficulty of intubation and the preference on devices in each scenario were also collected and analyzed.

Results

In scenario 1, the first-attempt success rate with both laryngoscopes was 100%. In scenario 2, there was a higher first-attempt success rate with ML but it was not statistically significant (GS 97.14% vs ML 100%, p=1.00). In scenario 3, one participant failed to intubate in the first attempt with each of the laryngoscopes (GS 97.14% vs ML 97.14%, p=0.754). More dental compression was noted with GS but the difference was not statistically significant (GS 42.86% vs ML 22.86%, p=0.126). Overall, the median time for intubation with GS was significantly longer in all 3 scenarios (Scenario 1: GS 18.5s; interquartile range [IQR] 13.8 -22.2s vs ML 11.2s, IQR 9.5-14.2s, p<0.001; Scenario 2: GS 18.7s, IQR 13.1-25.2s vs ML 13.4s, 10.3-15.8s, p<0.001; Scenario 3: GS 20.8s, IQR 16.5-29.2s vs ML 14.0s, IQR 10.5-18.0s, p<0.001). More participants preferred GS in scenario 3, while ML remained the device of choice in the other two scenarios. Conclusion: GS is not superior to ML in terms of the first-attempt success rate of intubation and it takes significantly longer to intubate for experienced operator. Yet more participants prefer its use when the C-spine motion is limited. Further studies are warranted to explore its role in trauma resuscitation. (Hong Kong j.emerg.med. 2016;23:159-167)

Emergency Medicine Ward as a Step down Unit for Selected Poisoned Patients after Intensive Care Unit Management: A Pilot Study

Introduction

Starting from the 1st July 2009, poisoned patients who fulfilled the emergency medicine ward (EMW) admission criteria were transferred to the EMW for subsequent care after intensive care unit (ICU) management. This study was undertaken to review the impact of such a strategy on the length of stay (ALOS).

Study design

This was a retrospective study on consecutive poisoned patients discharged from the ICU from the 1st July 2009 to 31st December 2010. Poisoned patients from the 1st January 2008 to 30th June 2009, who were discharged to the general medical ward or to other specialty wards were used as historical controls for comparison.

Method

Medical records of eligible cases were reviewed and data were collected using a standardized data collection form. Disease severity during the ICU stay was assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The median ALOS and APACHE II scores of the 2 groups were compared.

Results

A total of 32 poisoned patients were transferred from the ICU to EMW during the study period, in which 28 patients were included as the study group. For the historical control group, 19 patients were identified for comparison. The study group had a significantly shorter median length of stay in the ICU (21.3 h vs. 36.0 h, p=0.013) and a significantly shorter median ALOS (28.8 h vs. 52.5 h, p=0.002) compared to the historical control group. All patients discharged to the EMW survived with no ICU re-admission.

Conclusion

The strategy of using the EMW as a step-down unit for selected poisoning cases after ICU discharge is feasible, safe and effective.

Clostridial Hepatic Gas Gangrene with Massive Intravascular Haemolysis and Acute Renal Failure: A Case Report and Literature Review

Clostridial hepatic gas gangrene is a rare but highly fatal disease. We report a complicated case of clostridial hepatic gas gangrene, presented with short history of fever, followed by severe back pain and systemic hypertension. Urgent contrast computed tomogram (CT) thorax and abdomen was performed to rule out aortic dissection. Instead, a gas-forming lesion was found in the liver, with multiple areas of hepatic venous gas. Also, CT showed poor renal contrast excretion, indicating acute renal failure. Unexpectedly, the patient developed cardiac arrest shortly after imaging and succumbed despite active resuscitation. Repeated biochemical tests showed gross hemolysis. Autopsy revealed generalised autolytic changes in internal organs with abundance of Gram positive bacilli. The overall picture was compatible with clostridial hepatic gas gangrene, with massive intravascular haemolysis and acute renal failure. Upon literature review, the importance of early diagnosis and aggressive management is highlighted.

Mechanical Cardiopulmonary Resuscitation Device in an Accident and Emergency Department: A Case Report and Literature Review

We present a case of resuscitation of a 38-year-old lady with ventricular fibrillation using the Lund University Cardiopulmonary Assist System (LUCAS), a mechanical cardiopulmonary resuscitation (CPR) device. Return of spontaneous circulation was obtained after prolonged resuscitation but the patient eventually succumbed nine days after admission to the coronary care unit. The role of mechanical CPR devices in resuscitation in the accident and emergency department is discussed.

The Use of Patient Education Video in Improving Patient Satisfaction in the Accident and Emergency Department

Objective

To study the impact of patient education video in improving patient satisfaction in the accident and emergency department (AED).

Methods

This was a descriptive questionnaire study. A 20-minute patient education video in Cantonese was produced. The video was shown in the waiting hall from 9 am to 5 pm during the weekdays of a week in January 2008. All category 4 (semi-urgent) and category 5 (non-urgent) patients were invited to fill in an evaluation questionnaire after watching the video. The demographics of the patients were collected. There were two parts in the questionnaire. Part 1 contained four questions to test patients' knowledge retention after watching the video. These included questions on pharmacy location, triage system, use of patient identification slip and scope of the AED service. Part 2 contained six evaluation items (based on the 5-point Likert scale) to assess patients' opinion on the education video, understanding of the AED workflow and level of satisfaction after watching. Statistical analysis was performed to compare the knowledge retention scores and the Likert responses between different age and education level subgroups.

Results

Altogether 177 questionnaires were returned; 72 were excluded due to incomplete answers or absent patient gum label; and 105 completed questionnaires were analysed. Of the latter, 83 (79%) respondents scored 75% or more in the questions on knowledge retention, 79 (75%) respondents agreed that they understood the workflow of the AED better, 63 (60%) respondents thought that the video covered most frequently asked questions, and 69 (66%) respondents agreed that their level of satisfaction had improved after watching the video. There was no statistically significant difference on comparing the knowledge retention scores between different age and education level subgroups. Respondents more than 60 years old stated a better understanding about the location of consultation rooms after watching the video.

Conclusion

A patient education video is useful in providing information about operation and improving patient satisfaction in the accident and emergency department.

Optic Disc Parameters of Myopic Children with Atropine Treatment

PURPOSE

To characterize optic disc parameters, retinal nerve fiber layer thickness (RNFLT), and the intraocular pressure (IOP) of myopic children under continual topical 0.25% atropine treatment.

METHODS

From October 1, 2010 to September 31, 2011, 67 eyes of 35 myopic children were recruited. The children were treated with 0.25% atropine nightly for myopia control. Visual acuity, refraction, IOP, axial length (AL, IOL Master), RNFLT, and optic disc parameters (Stratus OCT) were measured at enrollment and every 2 months. All patients had at least 1 year of follow-up.

RESULTS

Enrolled children had a mean age of 10.3 ± 2.4 years (5-15 years). Of the 67 studied eyes, the mean spherical equivalent (SE) was -2.60 ± 1.58 diopters (D) (-6.75--0.5 D). Under the treatment of 0.25% atropine, myopia increased by 0.53 ± 0.10D per year (P < 0.0001), and AL elongated by 0.245 ± 0.042 mm per year (P < 0.0001). No significant change was noted in the IOP and optic nerve parameters including peripapillary RNFLT, areas of optic disc, cup and rim, or cup/disc ratio over the follow-up period during atropine treatment (P > 0.05).

CONCLUSIONS

0.25% Atropine treatment for myopia control did not significantly affect the IOP, optic nerve parameters, and RNFLT in children over a mean of 15.2 ± 2.4 months treatment and follow-up. 0.25% Atropine is a relatively safe option for myopia control.

Triphenylene-based tris-N-heterocyclic stannylenes

Two planar tridentate N-heterocyclic stannylenes are synthesized from the corresponding 2,3,6,7,10,11-hexaamino-triphenylene and Sn[N(TMS)2]2. Multinuclear NMR and absorption spectra of these tris-stannylenes are reported. Molecular structure of the N-benzhydryl-substituted tris-stannylene is also realized.

Impact of nuchal cord on fetal outcomes, mode of delivery, and management: a questionnaire survey of pregnant women

OBJECTIVES

To explore pregnant women's views on the impact of nuchal cord on fetal outcomes, mode of delivery, and management.

DESIGN

Questionnaire survey.

SETTING

Antenatal clinic of two regional hospitals in Hong Kong.

PARTICIPANTS

A questionnaire survey of all pregnant women at their first visit to the antenatal clinic of United Christian Hospital and Tseung Kwan O Hospital in Hong Kong was conducted between August and October 2012.

RESULTS

Most participants (71.8%) were worried about nuchal cord, and 78.3% and 87.7% of them thought that nuchal cord could cause intrauterine death and fetal death during labour, respectively. Approximately 87.5% of participants thought that nuchal cord would reduce the chance of successful vaginal delivery and 56.4% thought that it would increase the chance of assisted vaginal delivery. Most (94.1%) participants thought that it was necessary to have an ultrasound scan at term to detect nuchal cord. In addition, 68.8% thought that it was necessary to deliver the fetus early and 72.8% thought that caesarean section must be performed in the presence of nuchal cord. Participants born in Mainland China were significantly more worried about the presence of nuchal cord than those born in Hong Kong. However, there was no difference between participants with different levels of education.

CONCLUSION

Most participants were worried about the presence of nuchal cord. Many thought that nuchal cord would lead to adverse fetal outcomes, affect the mode of delivery, and require special management. These misconceptions should be addressed and proper education of women is needed.

High levels of LDL-C combined with low levels of HDL-C further increase platelet activation in hypercholesterolemic patients

High levels of low-density lipoprotein cholesterol (LDL-C) enhance platelet activation, whereas high levels of high-density lipoprotein cholesterol (HDL-C) exert a cardioprotective effect. However, the effects on platelet activation of high levels of LDL-C combined with low levels of HDL-C (HLC) have not yet been reported. We aimed to evaluate the platelet activation marker of HLC patients and investigate the antiplatelet effect of atorvastatin on this population. Forty-eight patients with high levels of LDL-C were enrolled. Among these, 23 had HLC and the other 25 had high levels of LDL-C combined with normal levels of HDL-C (HNC). A total of 35 normocholesterolemic (NOMC) volunteers were included as controls. Whole blood flow cytometry and platelet aggregation measurements were performed on all participants to detect the following platelet activation markers: CD62p (P-selectin), PAC-1 (GPIIb/IIIa), and maximal platelet aggregation (MPAG). A daily dose of 20 mg atorvastatin was administered to patients with high levels of LDL-C, and the above assessments were obtained at baseline and after 1 and 2 months of treatment. The expression of platelets CD62p and PAC-1 was increased in HNC patients compared to NOMC volunteers (P<0.01 and P<0.05). Furthermore, the surface expression of platelets CD62p and PAC-1 was greater among HLC patients than among HNC patients (P<0.01 and P<0.05). Although the expression of CD62p and PAC-1 decreased significantly after atorvastatin treatment, it remained higher in the HLC group than in the HNC group (P<0.05 and P=0.116). The reduction of HDL-C further increased platelet activation in patients with high levels of LDL-C. Platelet activation remained higher among HLC patients regardless of atorvastatin treatment.

A novel way of visualizing the ductal and aortic arches by real-time three-dimensional ultrasound with live xPlane imaging

OBJECTIVE

To describe a novel method of visualizing the ductal and aortic arches by real-time three-dimensional echocardiography with live xPlane imaging.

METHODS

Live xPlane imaging was used to display the ductal- and aortic-arch views in 107 women with singleton pregnancies, including seven cases with suspected congenital heart defects (CHDs). The three vessels and trachea (3VT) view was obtained in such an orientation that either the pulmonary artery or the aorta was parallel to the direction of the ultrasound beam. The xPlane reference line was then placed across the targeted vessel, which in a normal case would provide an image of the corresponding arch view as a dual-image display.

RESULTS

Once the 3VT view had been obtained, live xPlane imaging showed the aortic and ductal arches in all 100 normal cases. In seven cases with suspected CHD, the 3VT view was abnormal in five cases and normal in the other two. However, the ductal-arch view demonstrated by live xPlane imaging was abnormal in five cases of conotruncal anomalies and normal in two cases in which conotruncal anomalies were excluded. CHDs were confirmed at autopsy following termination of pregnancy in five cases and on postnatal echocardiography in one case. The heart was found postnatally to be normal in one case of suspected CHD; in this case live xPlane imaging showed that the observed abnormal 3VT view was caused by a tortuous course of the thoracic aorta associated with an abnormal diaphragm.

CONCLUSION

Live xPlane imaging is a novel and relatively simple method of visualizing the ductal- and aortic-arch views, and may potentially be a useful tool in the screening of fetal conotruncal and aortic-arch anomalies.

Real-time three-dimensional ultrasound with Live xPlane imaging assists first-trimester acquisition of a true midsagittal section

OBJECTIVE

To determine whether real-time three-dimensional (3D) ultrasound with Live xPlane imaging, which enables the simultaneous display of two real-time high-quality image planes, can assist both operators certified by The Fetal Medicine Foundation (FMF) and non-FMF-certified operators in acquiring a true midsagittal plane in the first trimester.

METHODS

Eight operators, four of them FMF certified (FMF group) and the other four not (non-FMF group), were asked to acquire a fetal image that they believed to represent the true midsagittal plane using real-time 3D ultrasound with Live xPlane imaging as guidance. Each operator was asked to obtain such an image five times from each of five patients. A total of 200 images from 40 patients were obtained and stored for subsequent analysis. All pregnancies were between 11 + 0 and 13 + 6 weeks of gestation. The angle between the falx cerebri and vertical axis (angle of deviation) was then measured by a single operator. A true midsagittal section was defined as an angle of deviation equal to 0 degrees. The angle of deviation and the time taken to acquire each image were compared between FMF and non-FMF groups.

RESULTS

The median angle of deviation for each operator ranged from 1.2 degrees to 3.4 degrees. There was no significant difference in this angle between those who were FMF certified and those who were not (2.0 degrees vs. 2.2 degrees, P = 0.463). The interquartile range of the angle of deviation was also similar between the FMF- and non-FMF-certified operators. Although the time taken for image acquisition was longer among the non-FMF-certified operators (median, 45.5 s vs. 32.0 s), this difference did not reach statistical significance (P = 0.107).

CONCLUSION

Live xPlane imaging can provide a tool to assist the acquisition of a true midsagittal plane and to determine how true a 'midsagittal' plane really is.

Fetoscopic laser photocoagulation in the management of twin-twin transfusion syndrome: local experience from Hong Kong

OBJECTIVE

To review the perinatal outcome of monochorionic twin pregnancies treated by fetoscopic laser coagulation for twin-twin transfusion syndrome.

DESIGN

Retrospective study.

SETTING

A university teaching hospital in Hong Kong.

PATIENTS

Thirty consecutive cases of fetoscopic laser coagulation of placental anastomoses for twin-twin transfusion syndrome performed in a single centre.

MAIN OUTCOME MEASURES

Operative complications and perinatal survival rates.

RESULTS

The median gestational age at initial presentation, laser photocoagulation, and delivery were 22 (range, 16-27) weeks, 23 (18-28) weeks, and 32 (21-37) weeks, respectively. To improve the visualisation, in three cases amnio-exchange was undertaken; the procedure was abandoned in two due to poor visualisation. The overall fetal survival rate, the double infant survival rate, and survival rate for at least one twin were 72% (43/60), 60% (18/30), and 83% (25/30), respectively. The most common peri-operative complication was bleeding from the uterine wall into the amniotic cavity, which affected three (10%) patients.

CONCLUSIONS

Our results of fetoscopic laser surgery for twin-twin transfusion syndrome were similar to those in specialised centres in other countries.

Comparison of likelihood ratios of first-trimester nuchal translucency measurements: multiples of median, delta or mixture

OBJECTIVE

To compare the likelihood ratios (LR) determined for a measured nuchal translucency (NT) using the multiples of the median (MoM), delta-NT and mixture model approaches.

METHODS

This was a retrospective study of singleton pregnancies with known outcome screened at the 12(th) week of pregnancy between January 2006 and May 2008. NT, crown-rump length (CRL) and LR for trisomy 21 using the delta-NT approach (LRNT-delta) were extracted from The Fetal Medicine Foundation trisomy 21 risk-calculation software database. NT measurements were converted into their equivalent MoM by dividing by the expected CRL-specific median NT. LR for trisomy 21 based on the MoM (LRNT-MoM) of each case was then calculated as the ratio of the Gaussian probability density functions using published trisomy 21 risk-screening parameters. The LR using the mixture model (LRNT-mixture) was calculated as the ratio of individual composite probability densities reported for trisomy 21 and unaffected pregnancies. The intraclass correlation coefficient (ICC) was used to assess the agreement between the three different approaches while the paired t-test was used to perform pairwise comparisons.

RESULTS

Of the 5907 pregnancies with known outcome, 14 had trisomy 21. The ICC between the three approaches to determining an LR was 0.947 (95% CI, 0.943-0.951; P < 0.0001). Pairwise comparison indicated that differences between LR were statistically significant (P < 0.0001). Likelihood ratios determined via the delta-NT model were in general greater than those produced by both the mixture model (z = 5.58, P < 0.0001) and the MoM approaches (z = 32.8, P < 0.0001). For a 5% false-positive rate the detection rate of trisomy 21 (DR) was 78.6% (95% CI, 57.1-99.9%) The screen positive thresholds to achieve this DR were 1 : 200 for the delta-NT approach, 1 : 220 for the mixture approach and 1 : 290 for the MoM approach.

CONCLUSION

No single method of determining NT-associated LR outperformed the others in its ability to detect a trisomy 21-affected pregnancy.

Comparison of first-trimester contingent screening strategies for Down syndrome

OBJECTIVE

To assess the relative performance of a multi-stage first-trimester screening protocol for fetal Down syndrome.

METHODS

Data from 10,767 women who underwent combined ultrasound and biochemistry (BC) screening in the first trimester were reanalyzed using a contingent model approach. Amongst the 10,854 fetuses with known outcome, 32 had Down syndrome, 232 had other abnormalities and 10,590 were unaffected. Nuchal translucency (NT), BC and combined (NT-BC) gestational age-specific risks were calculated for each individual using The Fetal Medicine Foundation risk calculation algorithms (Mixture Model and Biochemistry). Individual patients were categorized as at low, high or intermediate risk according to one of the following three strategies. In 'Strategy-NT-BC' initial screening was performed using both NT and BC. In 'Strategy-BC' initial screening was undertaken using maternal serum markers followed by NT assessment in those with an intermediate risk (1 : 51 < risk <or= 1:1000) while in 'Strategy-NT' initial screening was undertaken using NT followed by serum marker assessment in those with an intermediate risk (1 : 51 < risk <or= 1:1000). The nasal bone was assessed in those with an intermediate risk as the final stage in each of the three strategies. Those with an adjusted risk of 1 in 100 or higher after nasal bone assessment were reclassified as high risk. Detection and false-positive rates were compared between differing strategies in our local population, and this analysis was also performed with the maternal age for our population standardized to the distribution found in England and Wales.

RESULTS

In our local population the detection rate for a 5% false-positive rate using a combined screening policy (NT-BC) was 88% (95% CI, 75.3-98.9%), and 2.3% had an absent nasal bone. The respective detection rate and false-positive rate of the three multi-stage screening strategies were: Strategy-NT-BC: 87.5 and 2.5%; Strategy-BC: 87.5 and 5%; Strategy-NT: 84.4 and 2.9%. In the contingent Strategy-BC only 29% of those initially screened using serum markers required an NT scan. If the model were applied to a hypothetical obstetric population standardized to the maternal age distribution in England and Wales, the detection and false-positive rates of the same three screening strategies would be: Strategy-NT-BC: 86.2 and 1.9%; Strategy-BC: 82.8 and 4%; Strategy-NT: 75.8 and 2.3%, respectively.

CONCLUSION

First-trimester contingent screening provides detection and false-positive rates comparable to those achieved using combined screening, but could be used to significantly reduce the number of scans performed.

Which ultrasound or biochemical markers are independent predictors of small-for-gestational age?

OBJECTIVES

To investigate which ultrasound or biochemical markers in both the first and the second trimesters are the best predictors for fetal growth and small-for-gestational age (SGA).

METHODS

This was a prospective study of 619 Chinese women with a singleton pregnancy. At 11 to 13 + 6 weeks, fetal crown-rump length (CRL), placental volume (PlaV), uterine artery pulsatility index (UtA-PI), and the maternal serum levels of pregnancy-associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotropin (beta-hCG) were measured. Fetal biparietal diameter, femur length, abdominal and head circumference, PlaV and UtA-PI were then measured at 18-22 weeks. All markers were transformed to gestational age-specific Z-scores or multiples of the median (MoM). Birth weights were also transformed to Z-scores using the individualized gestational age-related optimal weight based on a locally derived nomogram. The relationship between all markers and the customized birth weight were examined, and their predictive powers for SGA were examined by regression analysis.

RESULTS

Univariate analysis revealed that all markers except free beta-hCG correlated with birth weight Z-score. After multiple linear regression analysis, only PlaV, UtA-PI and CRL in the first trimester, and PlaV and UtA-PI in the second trimester, stood out as independent markers. Logistic regression analysis showed that PlaV was the only independent first-trimester predictor of SGA, and in the second trimester both PlaV and UtA-PI were independent predictors. The sensitivity of these first- and second-trimester markers in predicting SGA were 41% and 45%, respectively, at a false-positive rate of 20%. Combining them did not significantly improve prediction of SGA.

CONCLUSIONS

Among the various known ultrasound and biochemical markers, only the first-trimester PlaV and the second-trimester PlaV plus UtA-PI are independent predictors for SGA.

Ankrd17, an ubiquitously expressed ankyrin factor, is essential for the vascular integrity during embryogenesis

Ankyrin repeat domain 17 (Ankrd17) encodes an ubiquitously expressed protein with two clusters of ankyrin repeats. We have used gene targeting strategy to ablate the Ankrd17 gene in mouse. The Ankrd17-deficient mice died between embryonic day (E) 10.5 and E11.5 due to cardiovascular defects. Serious hemorrhages were detected and the vascular smooth muscle cells (vSMCs) surrounding the vessels were drastically reduced in the Ankrd17-deficient embryos, suggesting that the vascular maturation was not completed. Interestingly, vSMC differentiation marker genes were up-regulated in the mutant embryos. Our data have demonstrated the indispensability of Ankrd17 functioning for vascular maturation during early development. The Ankrd17-deficient mice also provide a new animal model for the analysis of the regulatory pathways of the differentiation of vSMC precursor cells.

First-trimester fetal nasal bone length in an ethnic Chinese population

OBJECTIVES

To determine reference ranges of fetal nasal bone length (NBL) in a Chinese population and to assess the value of NBL measurement in screening for chromosomal defects in the first trimester.

METHODS

In this prospective study the fetal profile was examined and the fetal NBL and crown-rump length (CRL) were measured in Chinese women presenting with singleton pregnancies for first-trimester screening for aneuploidy between January 2004 and June 2007. Screening was performed on the basis of nuchal translucency (NT) measurement and maternal serum free beta-human chorionic gonadotropin and pregnancy-associated plasma protein-A levels.

RESULTS

NBL was measured in 7543 fetuses, of which 7517 were euploid. The best fit equation for median NBL in euploid fetuses in relation to CRL was: NBL (mm) = 0.4593 + (0.0186 x CRL(mm)). The NBL for gestational age (GA, in days) was given by the equation NBL(mm) = 0.2392 + (0.0027 x GA). There was no correlation between log(10)(NBL multiples of the median (MoM)) and log(10)(NT MoM) in unaffected pregnancies (r = - 0.009; P = 0.43). Only two of the 11 cases with trisomy 21 had an NBL outside the 5(th) or 95(th) centiles of the reference range for euploid fetuses.

CONCLUSION

Reference ranges for NBL in a Chinese population suitable for screening for aneuploidy between 11 and 13 + 6 weeks' gestation have been derived. The NBL in Chinese fetuses is similar to that of other ethnic groups. However, unlike the determination of presence vs. absence of the nasal bone, NBL measurement is unlikely to further improve screening for aneuploidy.

Volumetric (3D) imaging reduces inter- and intraobserver variation of fetal biometry measurements

OBJECTIVE

To compare the inter- and intraobserver variation of fetal biometric measurements utilizing two-dimensional (2D) and three-dimensional (3D) ultrasound imaging.

METHODS

This prospective study, utilizing three pairs of doctors trained in sonography, evaluated singleton pregnancies in the mid-trimester. Measurements of the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL) were taken in duplicate by each doctor using 2D imaging and then again using 3D volume datasets. Each set of paired doctors evaluated 12 patients. Inter- and intraobserver variation were calculated as the SD of the difference between paired measurements performed by the doctor pairs and by the individual doctors, respectively. Bland-Altman plots were used to visually compare measurement bias and agreement by 2D and 3D methods.

RESULTS

Inter- and intraobserver variation for 2D and 3D ultrasound were small. The intraobserver variation of HC, AC and FL was significantly lower for 3D compared with 2D ultrasound. Interobserver variation was not significantly different when measured with 2D and 3D ultrasound, with the exception of FL, which was lower when measured with 3D ultrasound. The Bland-Altman plots showed that in 95% of the measurements, the percentage difference between 2D and 3D ultrasound techniques was within 5.3%, 4.6%, 9.6% and 9.6% for BPD, HC, AC and FL, respectively.

CONCLUSIONS

2D and 3D fetal biometric measurements are reproducible. The use of 3D ultrasound significantly reduces intraobserver variation for HC, AC and FL and reduces interobserver variation for FL.

Medians and correction factors for biochemical and ultrasound markers in Chinese women undergoing first-trimester screening for trisomy 21

OBJECTIVE

To establish normative values and distribution parameters of first-trimester maternal serum free beta-human chorionic gonadotropin (beta-hCG), pregnancy-associated plasma protein-A (PAPP-A) and fetal nuchal translucency (NT) thickness in Chinese women and to examine the effects of covariates on their levels.

METHODS

Maternal serum free beta-hCG, PAPP-A and fetal NT were measured in 9762 women presenting for first-trimester combined screening for Down syndrome at 11 to 14 weeks of gestation. Individuals' markers were converted to multiples of the median (MoM) using expected medians estimated by performing a weighted regression analysis. Multivariate regression analysis was performed to assess the influence of maternal weight, parity, ethnicity, chorionicity in twin pregnancies, smoking, insulin-dependent diabetes and mode of conception on individual marker MoM levels.

RESULTS

Both free beta-hCG and PAPP-A median values demonstrated an exponential relationship with gestational age in days. Multivariate regression analysis indicated that free beta-hCG MoM was statistically significantly dependent on maternal weight (P < 0.0001) and chorionicity in twin pregnancy (both monochorionic and dichorionic P < 0.0001), that PAPP-A MoM was dependent on maternal weight (P < 0.0001), parity (P < 0.0001), chorionicity in twin pregnancy (both monochorionic and dichorionic P < 0.0001) and mode of conception (P = 0.002), and that fetal NT-MoM was dependent on maternal weight (P = 0.0006) and mode of conception (P = 0.012).

CONCLUSION

Normative values have been generated to allow conversion of NT, free beta-hCG and PAPP-A to their MoM equivalents and correction factors have been determined to adjust for maternal and pregnancy characteristics for use in ethnic Chinese women undergoing first-trimester screening for aneuploidy.

Effect of oil loading on microspheres produced by spray drying

Oil-loaded microspheres were produced by spray drying emulsions consisting of fish oil and modified starch suspensions with different oil loadings. The emulsion stability was assessed by oil droplet size analysis. Microspheres were characterized in terms of size, morphology, yield and microencapsulation efficiency. It was found that an increase in oil loading resulted in emulsions containing larger oil droplets. This corresponded with larger mean microsphere diameters and rounder microspheres. However, high oil loadings produced lower yields and affected microencapsulation efficiencies.

Investigation of the release of aspirin from spray-congealed micro-pellets

The release behaviour of aspirin from spray-congealed hydrogenated soybean oil micro-pellets of different sizes was studied. The purpose of this study was to investigate the effect of particle size of micro-pellets on the drug release profile and mechanism. Micro-pellets produced were sieved into several fractions and their drug content and dissolution profiles in two media were determined. The dissolution mechanism was studied by fitting the data to release kinetic models. Micro-pellets with high encapsulation efficiency were successfully produced. The micro-pellets were able to sustain the release of aspirin in pH 1.2 and pH 6.8 dissolution media. As particle size of micro-pellets increased, the drug release rate decreased. The drug release mechanism was affected by the size of micro-pellets. Micro-pellets in the range of 90-250 microm tended to follow the first order or Higuchi model. However, micro-pellets in the range of 250-355 microm were found to follow zero-order release model. This result showed that drug release could be modified by controlling the size of micro-pellets and that controlled release of drug might be achieved by using larger size micro-pellets.

Side-effect and vital sign profile of nifedipine as a tocolytic for preterm labour

OBJECTIVE

To examine the side-effect and vital sign profile of nifedipine used as a tocolytic.

DESIGN

Retrospective audit.

SETTING

Tertiary care university hospital, Hong Kong.

PATIENTS

Women presenting with preterm labour (before 34 weeks of gestation) between March 2001 and September 2004.

MAIN OUTCOME MEASURES

Maternal heart rate, blood pressure, and foetal heart rate were monitored regularly. A four-point Likert scale multiple-choice questionnaire was used to assess the perceived degree of flushing, headache, nausea, dizziness, and shortness of breath. All assessments were performed at predefined intervals from the onset of treatment. Repeated measures analysis of variance was performed to identify any time-dependent association with nifedipine treatment.

RESULTS

In all, 212 episodes of preterm labour were treated with nifedipine in 203 women. In 120 episodes, preterm labour was suppressed for more than 48 hours. Treatment was discontinued in three women because of profound hypotension (<90/60 mm Hg), and in one because of severe flushing. Only one patient developed maternal tachycardia (>or=140 beats per minute), and in two foetal tachycardia (>or=180 beats per minute) was encountered. Moderate headache was experienced in nine women, flushing in nine, dizziness in four, nausea in three, and shortness of breath in one. Repeated measures analysis of variance with time of measurement revealed a significant reduction in maternal blood pressure and increase in maternal heart rate that plateaued after 1 hour of therapy. The foetal heart rate returned to baseline values 3 hours after commencing therapy.

CONCLUSION

In general, use of nifedipine as the first-line tocolytic was safe. However, severe maternal hypotension can occur and close monitoring of vital signs is warranted.

Impact of cross-linker on alginate matrix integrity and drug release

Sodium alginate, a biopolymer, was employed in the formulation of matrix tablets. They cracked or laminated at acidic pH, compromising their dissolution performance. Improved mechanical strength and reduced barrier permeability of calcium alginate gel provided the rationale for cross-linking the alginate matrix to sustain drug release. Studies had suggested that the incorporation of soluble calcium salts in alginate matrix tablets could sustain drug release at near-neutral pH due to in situ cross-linking. However, results from the present study showed otherwise when gastrointestinal pH conditions were simulated. Significant reduction in drug release rate was only observed when an external calcium source was utilized at low concentration. High calcium ion concentrations caused matrix disintegration. In contrast, matrices pre-coated by calcium alginate could sustain drug release at pH 1.2 followed by pH 6.8 for over 12h. The presence of cross-linked barrier impeded matrix lamination and preserved matrix structure, contributing to at least three-fold reduction in drug release at pH 1.2. Zero order release as well as delayed burst release could be achieved by employing appropriate grade of alginate and cross-linking conditions.

Prediction of birth weight by fetal crown-rump length and maternal serum levels of pregnancy-associated plasma protein-A in the first trimester

OBJECTIVE

To determine whether the first trimester crown-rump length (CRL), maternal serum levels of pregnancy-associated plasma protein A (PAPP-A) and free beta-human chorionic gonadotropin (fbeta-hCG) are independent predictors of birth weight.

METHODS

This was an observational study over 1.5 years in Chinese patients who underwent first-trimester combined screening for Down syndrome in a University fetal medicine unit. After excluding cases with multiple pregnancies, congenital malformations and in-utero deaths, the relationship between fetal CRL (expressed as standardized Z-score (Z-CRL)), maternal PAPP-A and fbeta-hCG levels (expressed as log(10) of multiples of the median) and birth weight (Z-BW) were analyzed by Pearson's correlation test followed by multiple regression to check for their independency. The predictive power of the independent predictors for small-for-gestational age (SGA, defined as birth weight < 10(th) centile) was then assessed using receiver-operating characteristics (ROC) curves, and the likelihood ratios were derived.

RESULTS

A total of 2760 cases were included. Z-CRL, log(10) PAPP-A(MoM), and log(10) fbeta-hCG were positively correlated with Z-BW (P < 0.0001), but only Z-CRL and log(10) PAPP-A(MoM) were independent predictors (P < 0.0001). The areas under the ROC curves of PAPP-A(MoM) and Z-CRL were 0.608 and 0.593, respectively (P < 0.0001). Likelihood ratios increased with decreasing PAPP-A(MoM) and Z-CRL, but were around 1 when the markers were at or above the mean.

CONCLUSION

First-trimester CRL and PAPP-A are independent factors that influence final birth weight. The lower the PAPP-A and the smaller the CRL, the higher the risk of a fetus becoming SGA. However, their predictive powers are not sufficiently good for them to be used alone for SGA screening.

Foetal intracranial teratoma: choosing the best time and mode of delivery

We present a case of foetal intracranial teratoma diagnosed at 28 weeks of gestation after prior normal sonographic examinations. A multidisciplinary team, involving obstetricians, neonatologists, and neurosurgeons, suggested management. The foetus was delivered by lower segment caesarean section at 30 weeks of gestation but the neonate succumbed 3 days after delivery, 1 hour after the withdrawal of active treatment. Issues governing the timing and mode of delivery, together with the role of cephalocentesis in the management of this condition, are discussed.

Epigenetic regulation of the Drosophila chromosome 4 by the histone H3K9 methyltransferase dSETDB1

The polytene chromosomes of Drosophila melanogaster consist of condensed heterochromatin regions most of which are in the chromocenter, telomeres, and the fourth chromosome. Whereas suppressor of variegation 3-9 [SU(VAR)3-9], a histone methyltransferase, is mainly responsible for lysine 9 of histone H3 (H3K9) methylation of the chromocenter and consequent binding of the heterochromatin-protein HP1, the enzyme for painting of the fourth chromosome by H3K9 methylation has been elusive. We show here that dSETDB1, the Drosophila ortholog of the mammalian SETDB1, is an authentic H3K9 methyltransferase and a pleiotropic regulator of the fly's development. Drosophila mutants hypomorphic or null in dSETDB1 expression lose most of the H3K9 methylation as well as HP1-binding on the fourth chromosome. We also show that binding of painting of fourth (POF), a known fourth chromosome-specific protein, and the dSETDB1-controlled H3K9 methylation of this chromosome are interdependent. Furthermore, POF and dSETDB1 interact with each other in vivo. The deregulation of H3K9 methylation, HP1-binding, and POF-binding resulted in, on the average, a global reduction of gene expression from the fourth chromosome but not the other chromosomes. Deficiency of dSETDB1 also up-regulated the expression of HP1. These results have suggested an interactive network, as controlled in part by dSETDB1, regulating the epigenetic modification and gene expression of Drosophila chromosome 4.

First-trimester combined screening for trisomy 21 in a predominantly Chinese population

OBJECTIVE

To examine the effectiveness of first-trimester fetal trisomy 21 screening using a combination of maternal age, nuchal translucency thickness (NT) and maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) levels in a predominantly Chinese population in Hong Kong.

METHODS

This was a prospective study over a 1.5-year period of 2990 women who underwent combined screening for trisomy 21 between 11+0 and 13+6 weeks of gestation in a university fetal medicine unit. NT was measured according to the criteria set by The Fetal Medicine Foundation (FMF), maternal serum free beta-hCG and PAPP-A levels were measured, and the risk of trisomy 21 was calculated using The FMF's algorithm. Fetal karyotyping was advised when the risk was 1 : 300 or above. All subjects were followed up for pregnancy and fetal outcome.

RESULTS

Of the 2990 women who underwent the screening program, 99% were Chinese. There were 57 twin pregnancies, giving a total of 3047 fetuses. Thirty-one percent of the women were 35 years old or above. One hundred and eighty-five (6.1%) fetuses were screen-positive; this included 14 cases of trisomy 21 and 17 cases of other chromosomal abnormalities. The positive predictive value was 16.7%. Among the 2862 screen-negative fetuses, only 18 (0.6%) cases had an unknown fetal outcome. There were no cases in which trisomy 21 was missed and the infant was liveborn.

CONCLUSION

First-trimester combined screening for fetal trisomy 21 is highly effective among Chinese subjects.

Role of radiation therapy in the treatment of unfavorable risk prostate cancer

Treatment of prostate cancer is extremely controversial because of the lack of evidence that most patients benefit from treatment. This general rule, however, does not apply to patients with unfavorable risk prostate cancer. There is a large body of literature that suggests that intervention impacts the natural history of patients with unfavorable risk prostate cancer. Thus, there are essentially no experts that would argue that such patients do not need to be treated. Controversies arise, however, as to what is the best treatment of patients with unfavorable risk prostate cancer. Before addressing this issue, however, it is critical to define unfavorable risk prostate cancer.

Use of swirling airflow to enhance coating performance of bottom spray fluid bed coaters

As there is strong interest in coating increasingly smaller particles or pellets for use in compacted dosage forms, there is a need for better small particle coating systems. This study explored the use of swirling airflow to enhance the performance of the bottom spray coating system. Firstly, pellet coating in the non-swirling airflow of conventional Wurster coating was compared with that of swirling airflow in precision coating under standardized conditions. Secondly, precision coating was studied in greater details at different airflow rates (60-100m(3)/h) and partition gaps (6-22mm). Precision coating was found to have higher Reynolds numbers (Re) than Wurster coating, indicating higher turbulence. It produced coated pellets of better properties than Wurster coating, having less agglomeration and gross surface defects, more uniform coats, increased flow and tapped density, and slower drug release. Higher surface roughness did not affect the yield. In precision coating, increasing airflow rates decreased the degree of agglomeration but had minimal effect on pellet quality attributes (colour intensity, colour uniformity and surface roughness) and yields. Increasing partition gaps increased the degree of agglomeration proportionally, but this effect was small. However, greater changes in yield, surface roughness, colour intensity and colour uniformity were detected. This study showed that precision coating, while having a higher drying ability, was able to maintain the same yield and produce coated pellets with superior quality compared to Wurster coating. In precision coating, airflow rate had greater influence on the drying of pellets while partition gap had greater influence on pellet quality attributes.

Comparative study of the fluid dynamics of bottom spray fluid bed coaters

Fluid dynamics of pellets processed in bottom spray traditional Wurster coating and swirl accelerated air (precision) coating were compared with the intent to understand and facilitate improvements in the coating processes. Fluid dynamics was described by pellet mass flow rate (MFR) obtained using a pellet collection system and images captured using high speed photography. Pellet flow within the partition column was found to be denser and slower in Wurster coating than in precision coating, suggesting a higher tendency of agglomeration during the coating process. The influence of partition gap and load on the MFR indicated that the mechanism of transport of pellets into the coating zone in precision coating depended on a strong suction, whereas in Wurster coating, pellets were transported by a combination of peripheral fluidization, gravity, and weak suction pressure. In precision coating, MFR was found to increase uniformly with air flow rate and atomizing pressure, whereas MFR in Wurster coating did not correlate as well with air flow rate and atomizing pressure. This demonstration showed that transport in precision coating was air dominated. In conclusion, fluid dynamics in precision coating was found to be air dominated and dependent on pressure differential, thus it is more responsive to changes in operational variables than Wurster coating.

Prediction of intrapartum Cesarean delivery for non-reassuring fetal status after a successful external cephalic version by a low pre-version pulsatility index of the fetal middle cerebral artery

OBJECTIVE

To determine whether a pre-version Doppler assessment of fetal cerebral and umbilical blood flow can predict the ultimate need for intrapartum Cesarean delivery after a successful external cephalic version (ECV).

METHODS

A prospective observational study on women undergoing ECV between 36 and 38 gestational weeks was performed over a 5-year period. The pulsatility index (PI) of the fetal middle cerebral artery (MCA) and umbilical artery, heart rate and amniotic fluid index were measured before ECV. Women who had successful ECV were then divided into three groups according to the mode of delivery: (1) vaginal delivery, (2) intrapartum Cesarean delivery for poor progress and (3) intrapartum Cesarean delivery for non-reassuring fetal status. The fetal blood flow parameters were compared between the groups. Potential predictors were further analyzed using receiver-operating characteristics curves.

RESULTS

Of 174 women with successful ECV, 140 (80.5%) had vaginal delivery, 19 (10.9%) required emergency intrapartum Cesarean delivery for non-reassuring fetal status and 15 (8.6%) for poor progress. MCA-PI was significantly lower in the group with non-reassuring fetal status. MCA-PI is predictive of intrapartum Cesarean delivery (area under the curve = 0.68, P = 0.021). The sensitivity and specificity at a cut-off level of 1.4 were 62.5% and 76%, respectively, while at a cut-off level of 1.5 they were 68.8% and 63.5%, respectively.

CONCLUSION

Intrapartum Cesarean delivery for non-reassuring fetal status after successful ECV is associated with a lower pre-version fetal MCA-PI.

First-trimester maternal serum levels of placental hormones are independent predictors of second-trimester fetal growth parameters

OBJECTIVE

To determine whether first-trimester maternal serum levels of pregnancy-associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotropin (fbeta-hCG) are independent predictors of second-trimester fetal growth parameters.

METHODS

This was a cohort study over a 1-year period involving 594 Chinese women who underwent both first-trimester combined screening for Down syndrome and a routine second-trimester ultrasound examination. Maternal PAPP-A and fbeta-hCG levels (expressed in log(10) of multiples of median (MoM)), crown-rump length (CRL) (expressed in standardized Z-score (Z-CRL)), and maternal height and weight, were correlated with the Z-score of biparietal diameter (Z-BPD), femur length (Z-FL) and abdominal circumference (Z-AC) measured in the second trimester, using the Pearson test, followed by multiple regression analysis.

RESULTS

Z-BPD, Z-FL and Z-AC were positively correlated with log(10) PAPP-A MoM, CRL and maternal height (all P < 0.05), while log(10) fbeta-hCG MoM was negatively correlated with Z-AC (P < 0.05). After controlling for the effects of CRL, maternal height and weight, log(10) PAPP-A MoM was found to be an independent positive predictor of Z-FL (r = 0.797, P < 0.001) and Z-AC (r = 0.305, P = 0.049), and log(10) fbeta-hCG MoM was an independent negative predictor of Z-FL (r = -0.381, P = 0.023) and Z-AC (r = -0.418, P = 0.002). Neither hormonal level was related to Z-BPD.

CONCLUSIONS

First-trimester PAPP-A and fbeta-hCG are independent factors that influence subsequent fetal growth. PAPP-A level is positively correlated with FL and AC in the second trimester, while fbeta-hCG level is negatively correlated with them. However, BPD is not affected by either of the hormones.

Investigation of Wetting Behavior of Nonaqueous Ethylcellulose Gel Matrices Using Dynamic Contact Angle

PURPOSE

This study reports the development of a method based on dynamic contact angle to investigate the wetting behavior of non-aqueous ethylcellulose (EC) gel matrices intended for topical drug delivery.

METHODS

Non-aqueous gel matrices were prepared from the three fine particle grades of EC and propylene glycol dicaprylate/dicaprate. Dynamic contact angle measurements of sessile drops of water and isopropylmyristate (IPM) on EC gel matrices were performed using a dynamic contact angle analyzer equipped with axisymmetric drop shape analysis of the sessile drop images. Gel density was determined by weighing known volumes of gel samples.

RESULTS

The EC gel matrices were wetted by both water and IPM, with much higher wettability by the latter. Increased EC concentration and polymeric chain length decreased the extent and rate of wetting. Linear correlation was observed between wetting parameters and rheological as well as mechanical properties of EC gel matrices.

CONCLUSIONS

The EC gel matrices exhibited both hydrophilic and lipophilic properties, with predominance of the latter. The extent and rate of wetting was governed by a balance of chemical and physical characteristics of the gel. EC gel matrices showed desirable wetting behavior in their function as a moisture-barrier, bioadhesive and vehicle for topical drug delivery.

First-trimester maternal serum level of pregnancy-associated plasma protein-A is an independent predictor of fetal maxillary bone length

OBJECTIVE

To derive a nomogram of fetal maxillary bone length (MAX) for a Chinese population and to study whether first-trimester maternal serum levels of pregnancy-associated plasma protein-A (PAPP-A) is an independent predictor of fetal MAX.

METHODS

This was a prospective observational study over 10 months examining Chinese women with a singleton pregnancy who attended the first-trimester screening program for Down syndrome. The subjects had the fetal crown-rump length (CRL), nuchal translucency, MAX, maternal serum PAPP-A and free beta-human chorionic gonadotropin (fbeta-hCG) levels measured. A nomogram of MAX was derived using normal pregnancies with reliable dates. The correlations between MAX, CRL, PAPP-A and fbeta-hCG levels were studied, after correction for gestational dependency using Z-score transformation for the ultrasound markers (Z-MAX and Z-CRL), and logarithmic transformation of multiple of gestation-specific medians for the biochemical markers (log10PAPP-A multiples of the median (MoM) and log10fbeta-hCG MoM), using the Pearson test and multiple regression analysis.

RESULTS

During the study period, 607 Chinese women met the inclusion criteria. The mean gestational age at the first-trimester screening was 12 + 4 weeks (SD, 4 days). Curve estimation analysis showed that a linear relationship fit best between MAX and CRL (MAX (mm) = -0.01 + 0.101 * CRL (mm); r = 0.826; P < 0.0001), and between MAX and gestational age (MAX (mm) = -8.465 + 0.170 * gestational age (day); r = 0.754; SD = 0.71; P < 0.0001). There were significant positive correlations between Z-MAX and Z-CRL (r = 0.627; P = < 0.0001), Z-MAX and log10PAPP-A MoM (r = 0.239; P = < 0.0001). Multiple regression analysis showed that both Z-CRL (P = < 0.0001) and log10 PAPP-A MoM (P = 0.048) were independent predictors for Z-MAX.

CONCLUSION

Both CRL and maternal levels of PAPP-A are independent predictors of the fetal MAX measured during the first trimester. The positive correlation between PAPP-A levels and fetal MAX is consistent with the known biological function of PAPP-A on bone growth. This association must be adjusted for when both PAPP-A and MAX are combined for screening of Down syndrome.

Influence of partially cross-linked alginate used in the production of alginate microspheres by emulsification

Spherical and discrete calcium alginate microspheres had been produced by the emulsification technique. The microencapsulation process was highly efficient, but drug release from microspheres was rapid. A more orderly chain arrangement of the polymeric chains would give rise to a stronger and less permeable matrix capable of sustaining drug release. Therefore, the potential of using partially cross-linked alginate in the production of microspheres by emulsification was explored. The size and roundness of the microspheres, its drug content and drug release property were determined. The more viscous alginate solutions when reacted with more calcium salt added resulted in larger microspheres produced. Microspheres made from partially cross-linked alginate exhibited lower drug content and higher T75% values in drug release studies. This was due to decreased flexibility of the polymer chains which were partially held together by calcium ions, reducing subsequent interaction with the calcium ions resulting in lower drug entrapment efficiency and a more permeable microsphere matrix.

17-year follow-up of a randomized prospective controlled trial of adjuvant intravesical doxorubicin in the treatment of superficial bladder cancer

PURPOSE

To evaluate the efficacy of adjuvant intravesical doxorubicin in superficial transitional cell carcinoma of the urinary bladder on long-term follow-up.

MATERIALS AND METHODS

Between July 1986 and November 1991, all patients harboring superficial bladder cancers (Ta or T1) with one or more of these criteria (stage>a, grade>1, size>1 cm, multiple or recurrent tumors) were randomized to receive either 50 mg doxorubicin or no adjuvant therapy. Patients with recurrences were allowed to receive doxorubicin or other intravesical agents. Recurrence, progression and survival were analyzed.

RESULTS

There were 82 patients included (64 males and 18 females). The mean age was 64 years. Forty-six patients were randomized to the doxorubicin group and 36 to the control group. Final analysis was made at median follow-up of 45, 128 and 131.5 months for recurrence, progression and survival, respectively. Recurrence free, progression free and disease specific survival did not differ significantly between groups. The 10-year Kaplan-Meier estimates for recurrence free, progression free and disease specific survival were 67%, 84% and 92%, respectively for the doxorubicin group, and were 50%, 89% and 97%, respectively for the control group. Tumor size predicted recurrence (p=0.013) and grade predicted progression (p=0.004) with multivariate analysis.

CONCLUSIONS

Adjuvant intravesical doxorubicin could not be shown to improve recurrence, progression and survival of superficial bladder cancer, compared with control on long-term follow-up. Tumor size and grade were shown to be prognostic factors for recurrence and progression, respectively.

The impact of urinary incontinence on quality of life among women in Hong Kong

OBJECTIVE

To determine the prevalence of female urinary incontinence in Hong Kong and its impact on quality of life.

DESIGN AND SETTING

Territory-wide telephone survey in Hong Kong.

PARTICIPANTS

Hong Kong women aged 10 to 90 years accessed by fixed residential telephone lines between June 2001 and July 2002.

MAIN OUTCOME MEASURES

The prevalence of urinary symptoms was assessed using telephone interview. The urinary symptoms investigated were as listed in a validated Chinese version of Urogenital Distress Inventory Short Form (UDI-6). The impact on quality of life was quantified using a validated Chinese version of Incontinence Impact Questionnaire Short Form (IIQ-7).

RESULTS

There were 749 valid respondents (response rate, 24.4%). Urinary symptoms were reported by 52% of women (95% confidence interval, 48.9-56.0%), of whom 12% believed it impaired their quality of life. Stress urinary incontinence was reported by 34% (95% confidence interval, 28.7-38.9%). Social (5.1%; 95% confidence interval, 2.8-7.4%) and emotional (5.6%; 95% confidence interval, 3.3-7.9%) factors were the quality-of-life areas most impacted by urinary incontinence.

CONCLUSIONS

Urinary symptoms are common among Hong Kong women. Quality of life is consequently impaired in 12% of affected women.

Development of Novel Nonaqueous Ethylcellulose Gel Matrices: Rheological and Mechanical Characterization

PURPOSE

This study reports the rheological and mechanical characterization of novel non-aqueous ethylcellulose gel matrices intended for topical drug delivery. An attempt was also made to explain the molecular interaction within the gel systems from a molecular conformational approach.

METHODS

Nonaqueous gel matrices were prepared from three fine particle grades of ethylcellulose and propylene glycol dicaprylate/dicaprate. Continuous and oscillatory shear rheometry was performed using a cone-and-plate rheometer and mechanical characterization was performed using a universal tensile tester.

RESULTS

The gel matrices exhibited prominent viscoelastic behaviour, yield stress and thixotropy. Rheological and mechanical properties showed significant upward trends with increased polymeric chain length and polymer concentrations. Good linear correlations were obtained between rheological and mechanical properties. The solvent molecular conformation was found to play a role in affecting the formation of gel networks via intermolecular hydrogen bonding between ethylcellulose polymer chains.

CONCLUSIONS

Ethylcellulose was successfully formulated as a nonaqueous gel with propylene glycol dicaprylate/dicaprate. The novel nonaqueous gel exhibited rheological profiles corresponding to a physically cross-linked three dimensional gel network, with suitable mechanical characteristics for use as a vehicle for topical drug delivery. Molecular conformation of the solvent was found to influence the molecular interactions associated with formation of ethylcellulose gel networks.

Expression and functional study of estrogen receptor-related receptors in human prostatic cells and tissues

Estrogen receptor-related receptors (ERRs; alpha, beta, gamma) are orphan nuclear receptors and constitutively active without binding to estrogen. Like estrogen receptors (ERs), ERRs bind to estrogen receptor elements and estrogen receptor element-related repeats. Growing evidence suggests that ERRs can cross-talk with ERs in different cell types via competition for DNA sites and coactivators. We hypothesize that ERRs might play regulatory roles in normal and neoplastic prostatic cells by sharing similar ER-mediated pathways or acting independently. In this study, we investigated mRNA and protein expression patterns of three ERR members in normal human prostate epithelial cells, established cell lines, cancer xenografts, and prostatic tissues. Additionally, effects of transient transfection of ERRs on prostatic cell proliferation and ER expression were also examined. RT-PCR showed that ERRalpha and ERRgamma transcripts were detected in most cell lines and xenografts, whereas ERRbeta was detected in normal epithelial cells and few immortalized cell lines but not in most cancer lines. Similar results were demonstrated in clinical prostatic specimens. Western blottings and immunohistochemistry confirmed similar expression patterns that ERR proteins were detected as nuclear proteins in epithelial cells, whereas their expressions became reduced or undetected in neoplastic prostatic cells. Transient transfection confirmed that ERRs were expressed in prostatic cells as nuclear proteins and transcriptionally active in the absence of estradiol. Transfection results showed that overexpression of ERRs inhibited cell proliferation and repressed ERalpha transcription in PC-3 cells. Our study shows that ERRs, which are coexpressed with ERs in prostatic cells, could regulate cell growth and modulate ER-mediated pathways via interference on ERalpha transcription in prostatic cells.