Tracing the Change and Contribution of Subcutaneous Adipose to Skin Expansion Using a Luciferase-Transgenic Fat Transplantation Model

BACKGROUND

During skin expansion, subcutaneous adipose tissue undergoes the greatest change. The adipose layer appears to gradually thin or even disappear in long-term expansion. The response and contribution of adipose tissue to skin expansion remain to be elucidated.

METHODS

The authors established a novel expansion model by transplanting luciferase-transgenic adipose tissue into the rat dorsum, followed by integrated expansion, to trace the dynamic changes in subcutaneous adipose tissue during expansion and the migration of adipose tissue-derived cells. In vivo luminescent imaging was performed to continuously track the adipose tissue changes. Histologic analysis and immunohistochemical staining evaluated the regeneration and vascularization of the expanded skin. Growth factor expression in expanded skin with or without adipose tissue was determined to evaluate the paracrine effect of adipose tissue. Adipose tissue-derived cells were traced in vitro by anti-luciferase staining, and their fate was determined by costaining for PDGFRα, DLK1, and CD31.

RESULTS

In vivo bioimaging showed that cells in adipose tissue were alive during expansion. After expansion, the adipose tissue exhibited fibrotic-like structures, with more DLK1 + preadipocytes. Skin expanded with adipose tissue was significantly thicker than that without adipose tissue, with more blood vessels and cell proliferation. Vascular endothelial growth factor, epidermal growth factor, and basic fibroblast growth factor expression was higher in adipose tissue than in skin, indicating paracrine support from adipose tissue. Luciferase-positive adipose tissue-derived cells were observed in expanded skin, indicating direct participation in skin regeneration.

CONCLUSION

Adipose tissue transplantation can effectively promote long-term skin expansion by contributing to vascularization and cell proliferation by means of various mechanisms.

CLINICAL RELEVANCE STATEMENT

The authors' findings suggest that it would be better if the expander pocket is dissected over the superficial fascia to preserve a layer of adipose tissue with skin. In addition, their findings support the treatment of fat grafting when expanded skin presents with thinning.

Identifying characteristics of dermal fibroblasts in skin homeostasis and disease

Heterogeneous dermal fibroblasts are the main components that constitute the dermis. Distinct fibroblast subgroups show specific characteristics and functional plasticity that determine dermal structure during skin development and wound healing. Although researchers have described the roles of fibroblast subsets, this is not completely understood. We review recent evidence supporting understanding about the heterogeneity of fibroblasts. We summarize the origins and the identified profiles of fibroblast subpopulations. The characteristics of fibroblast subpopulations in both healthy and diseased states are highlighted, and the potential of subpopulations to be involved in wound healing in different ways was discussed. Additionally, we review the plasticity of subpopulations and the underlying signalling mechanisms. This review may provide greater insights into potential novel therapeutic targets and tissue regeneration strategies for the future.

A reinforced framework construction technique using unilateral auricular cartilage in Asian rhinoplasty to prevent long-term nasal tip drooping

BACKGROUND

Enhancing nasal tip projection is an important objective in Asian rhinoplasty. Nasal tip enhancement using auricular cartilage is simple and suitable for Asian patients. However, the long-term retraction problem of the auricular framework still needs to be solved for optimal results.

OBJECTIVES

The authors propose a modified auricular cartilage framework construction technique that provides stronger long-term support to the nasal tip and columellar base.

METHODS

Eighty-one patients underwent augmentation rhinoplasty between January 2016 and December 2019. The cymba and cavum conchae were harvested from one ear in all cases. The cymba concha was carved and folded to form a caudal septal extension graft (CSEG). The cavum concha was divided into an integrated cap/shield graft and a columella base graft. The columella base graft was diced into particles in size of 1 mm3, and inserted into the gap between CSEG, anterior nasal spine, and the medial crus to strengthen the foundation. The nasal profile was analyzed before the operation and at least 12 months after the operation. The patient satisfaction score was assessed 12 months after surgery.

RESULTS

Patients were followed up for 12-36 months. The nasal tip projection from both the lateral and basal views was significantly improved. The columella-labial angle was increased from 83.15° (6.20°) to 96.50° (7.40°) (p < 0.05). The nostril tip proportion increased from 0.83 (0.14) to 1.17(0.16) (p < 0.01). A stable long-term outcome was achieved.

CONCLUSIONS

With the modified framework construction technique, long-term nasal tip drooping can be prevented. This method can be a practical choice for Asian patients seeking augmentation rhinoplasty.

Autologous Concentrated Growth Factor Increases Skin Thickness and Area during Tissue Expansion: A Randomized Clinical Trial

BACKGROUND

Mechanical stretching of the skin (ie, tissue expansion) could generate additional skin, but it is limited by the intrinsic growth capacity. The authors conducted a study of autologous concentrated growth factor (CGF) to promote skin regeneration by increasing skin thickness and area during tissue expansion.

METHODS

A single-center randomized controlled trial was conducted from 2016 to 2019. Participants undergoing skin expansion received either CGF or saline by means of intradermal injection on the expanded skin (0.02 mL/cm 2 ), for a total of three treatments at 4-week intervals. The primary endpoint was the expanded skin thickness at 12 weeks, which was measured by ultrasound. The secondary endpoints included skin thickness at 4 and 8 weeks and surface area, expansion index, and skin texture score of the expanded skin at 12 weeks. Safety assessments, for infection symptoms and nodule formation, were assessed at 24 weeks.

RESULTS

In total, 26 patients were enrolled and assigned to the CGF or control group. Compared with the control group, the CGF group had significantly increased skin thickness at 8 (control, 1.1 ± 0.1 mm; CGF, 1.4 ± 0.1 mm; -0.6 to 0.0 mm; P = 0.047) and 12 weeks (control, 1.0 ± 0.1 mm; CGF, 1.3 ± 0.1 mm; -0.6 to 0.0 mm; P = 0.047). Compared with the baseline thickness (control, 1.6 ± 0.1 mm; CGF, 1.5 ± 0.1 mm; -0.3 to 0.5 mm; P = 0.987), skin thickness was sustained in the CGF group at 8 weeks after treatment (-0.1 to 0.3 mm; P = 0.711) but decreased in the control group (0.3 to 0.7 mm; P < 0.001). At 12 weeks, the CGF group showed greater increases in surface area (control, 77.7 ± 18.5 cm 2 ; CGF, 135.0 ± 15.7 cm 2 ; 7.2 cm 2 to 107.4 cm 2 ; P = 0.027) and expansion index (control, 0.9 ± 0.1; CGF, 1.4 ± 0.2; 0.0 to 0.8; P = 0.030) than the control group. In addition, CGF-treated skin showed an improvement in texture [CGF: grade 3, n = 2 (15.8%), grade 2, n = 4 (30.7%); control: grade 3, n = 0 (0.0%), grade 2, n = 3 (23.0%)]. No severe adverse events occurred.

CONCLUSION

CGF treatment increases skin thickness and area during tissue expansion, and represents a safe and effective strategy for managing skin expansion.

CLINICAL RELEVANCE STATEMENT

The findings of this study indicate that it is practically feasible to improve skin regeneration by applying autologous platelet concentrate therapy for skin expansion management.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Racial Disparities in the Cost of Unplanned Hospitalizations after Breast Reconstruction

BACKGROUND

Given the national attention to disparities in health care, understanding variation provided to minorities becomes increasingly important. This study will examine the effect of race on the rate and cost of unplanned hospitalizations after breast reconstruction procedures.

METHODS

The authors performed an analysis comparing patients undergoing implant-based and autologous breast reconstruction in the Healthcare Cost and Utilization Project. The authors evaluated the rate of unplanned hospitalizations and associated expenditures among patients of different races. Multivariable analyses were performed to determine the association among race and readmissions and health care expenditures.

RESULTS

The cohort included 17,042 patients. The rate of an unplanned visit was 5%. The rates of readmissions among black patients (6%) and Hispanic patients (7%) in this study are higher compared with white patients (5%). However, after controlling for patient-level characteristics, race was not an independent predictor of an unplanned visit. In our expenditure model, black patients [adjusted cost ratio, 1.35 (95% CI, 1.11 to 1.66)] and Hispanic patients [adjusted cost ratio, 1.34 (95% CI, 1.08 to 1.65)] experienced greater cost for their readmission compared with white patients.

CONCLUSIONS

Although race is not an independent predictor of an unplanned hospital visit after surgery, racial minorities bear a higher cost burden after controlling for insurance status, further stimulating health care disparities. Adjusted payment models may be a strategy to reduce disparities in surgical care. In addition, direct and indirect measures of disparities should be used when examining health care disparities to identify consequences of inequities more robustly.

Concentrated ultrasound-processed fat (CUPF): More than a mechanically emulsified graft

INTRODUCTION

Autologous fat grafting is still an evolving technique. Researchers have attempted to increase the survival rate of grafts by concentrating adipose-derived stem cells (ASCs). In this study, we investigate a novel method that combines ultrasonic processing and centrifugation to generate small fat particles termed concentrated ultrasound-processed fat (CUPF) for grafting.

METHODS

The standard approach for obtaining CUPF is described. The properties of processed fat, including CUPF, microfat, centrifuged fat, and nanofat, were investigated using histological observation. Comparative analyses were conducted on the cell number, viability, and immunophenotypic profile of stromal vascular fraction cells (SVFs). Cultured ASCs were evaluated for cell proliferation and adipogenic, osteogenic, and chondrogenic potential. The processed fats were transplanted and evaluated using in vivo and histological studies.

RESULTS

Compared with microfat, centrifuged fat, and nanofat, CUPF had a condensed tissue content and higher concentration of viable cells in a small tissue structure and could smoothly pass through a 27-gauge cannula. In the CUPF group, SVFs were isolated in great numbers, with high viability and a high proportion of CD29- and CD105-positive cells. ASCs from the CUPF group exhibited high proliferation and multilineage differentiation potential. The grafts from the CUPF group were well preserved, and histological quantification revealed an increase in the abundance of Ki67- and CD31-positive cells in the tissue.

CONCLUSIONS

Our study established a new fat processing strategy that combines ultrasonic processing and centrifugation to harvest small particle grafts named CUPF. CUPF concentrated a large number of ASCs and has great potential for regenerative therapy.

The effect of glycerol as a cryoprotective agent in the cryopreservation of adipose tissue

Background

Long-term preservation of adipose tissue is crucial for clinical applications. Researchers should consider both efficiency and biosafety when choosing a cryoprotective agent (CPA) for adipose tissue preservation. Glycerol has been applied as a nontoxic CPA for multiple tissues but not adipose tissue. We aimed to evaluate the efficacy of glycerol as a CPA for adipose tissue cryopreservation.

Methods

Fresh human adipose tissues were obtained from patients who underwent liposuction and divided into 1 mL samples. Each sample was randomly mixed with 1 mL of CPA: 60–100% glycerol, 0.25 mol/L trehalose or DMSO + FBS and cryopreserved in − 196 °C liquid nitrogen for one month. After thawing and elution, the tissues were immediately evaluated for activity and structural integrity in vitro. Then, 0.2 mL of each sample was transplanted subdermally to the nude mouse dorsum and harvested after one month for histological examination to assess the effect of the cryopreserved fat in transplantation.

Results

After cryopreservation, the samples treated with DMSO + FBS, trehalose, 60% and 70% glycerol had a more integrated structure than the samples in other groups. Tissues preserved with 70% glycerol had the highest G3PDH activity of 24.41 ± 0.70, comparable to 24.76 ± 0.48 in fresh tissue (p > 0.05). Adipose-derived stem cells (ASC) viability, proliferation and differentiation capability were also better preserved in 70% glycerol group. In vivo analysis showed that tissue preserved with 70% glycerol had a retention rate of 52.37 ± 7.53%, significantly higher than other groups. Histological observation demonstrated better structural integrity and viability in 70% glycerol group. Compared to the DMSO + FBS and trehalose groups, the glycerol groups showed lower tissue inflammation.

Conclusion

Glycerol (70%) is efficient in adipose tissue cryopreservation. Glycerol-based CPAs, which are nontoxic and show biosafety, are a promising solution for clinical tissue cryopreservation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-02817-z.

Adipose tissue aging: mechanisms and therapeutic implications

Adipose tissue, which is the crucial energy reservoir and endocrine organ for the maintenance of systemic glucose, lipid, and energy homeostasis, undergoes significant changes during aging. These changes cause physiological declines and age-related disease in the elderly population. Here, we review the age-related changes in adipose tissue at multiple levels and highlight the underlying mechanisms regulating the aging process. We also discuss the pathogenic pathways of age-related fat dysfunctions and their systemic negative consequences, such as dyslipidemia, chronic general inflammation, insulin resistance, and type 2 diabetes (T2D). Age-related changes in adipose tissue involve redistribution of deposits and composition, in parallel with the functional decline of adipocyte progenitors and accumulation of senescent cells. Multiple pathogenic pathways induce defective adipogenesis, inflammation, aberrant adipocytokine production, and insulin resistance, leading to adipose tissue dysfunction. Changes in gene expression and extracellular signaling molecules regulate the aging process of adipose tissue through various pathways. In addition, adipose tissue aging impacts other organs that are infiltrated by lipids, which leads to systemic inflammation, metabolic system disruption, and aging process acceleration. Moreover, studies have indicated that adipose aging is an early onset event in aging and a potential target to extend lifespan. Together, we suggest that adipose tissue plays a key role in the aging process and is a therapeutic target for the treatment of age-related disease, which deserves further study to advance relevant knowledge.

Mechanical stretching can modify the papillary dermis pattern and papillary fibroblast characteristics during skin regeneration

Clinical application of mechanical stretching is a reconstructive method for skin repair. Although studies have reported dermal fibroblast heterogeneity, whether stretching affects individual fibroblast subpopulations equally remains unclear. Here, we show the changes in dermal structure and papillary fibroblast (Fp) in regenerated human skin. Exhausted skin regeneration caused dermal-epidermal junction (DEJ) flattening, papillary dermis thinning, and an increase in the type III collagen (COL3)/type I collagen (COL1) ratio with upregulated hallmarks of aging. Well-regenerated skin displayed a notable increase in the Fp population. Consistent changes were observed in the rat expansion model. Moreover, we found that TGFβ1 expression was especially increased in skin showing good regeneration. Activation of the TGFβ1/Smad2/3 pathway improved exhausted skin regeneration and resulted in increased collagen content and Fp proliferation, while pharmacological inhibition of TGFβ1 action impacted well-regenerated skin. Short-term mechanical stretching that promoted skin regeneration enhanced Fp proliferation, extracellular matrix (ECM) synthesis, and increased TGFβ1 expression, leading to good regeneration. Conversely, long-term stretching induced premature Fp senescence, leading to poor regeneration. This work shows the mechanism of mechanical stretching in well skin regeneration that enhances Fp proliferation and ECM synthesis via the TGFβ1/Smad2/3 pathway, and highlights a crucial role of Fps in stretching-induced skin regeneration.

Dedifferentiated Schwann cell-derived TGF-β3 is essential for the neural system to promote wound healing

Rationale: Wound healing is among the most complicated physiological processes and requires the synchronization of various cell types with distinct roles to re-establish the condition of the original skin. Patients affected by peripheral neuropathies often experience failure to heal. Loss of Schwann cells (SCs), a crucial population of peripheral nervous system cells in skin, may contribute to chronic wounds. However, the role of SCs in wound healing are poorly understood.

Methods: The activity of SCs was investigated by using a cell atlas of the wound healing process, which was generated by integrating single-cell RNA sequencing (scRNA-seq) libraries covering different states of mouse back skin. The results of in silico analysis were validated by in vitro cell culture and in vivo mouse model. Selective inhibitors and conditional RNAi by virus transfection were utilized to investigate the role of SCs in wound healing. Findings from mouse experiments were further verified in scRNA-seq analysis of diabetic patients.

Results: Our in silico analysis revealed the heterogeneous cellular components of skin and the dynamic interactions of neural crest derived cells (NCs) with other cell types. We found that SCs dedifferentiated at an early stage of wound repair with upregulated Wnt signaling. We also identified dedifferentiated SC (dSC) defect in diabetic wounds in both mouse and human. Wnt inhibition at the wound site repressed SC dedifferentiation, leading to defective repair. Furthermore, dSCs derived TGF-β3, which is context-dependent, promoted the migration of fibroblasts and keratinocytes. Moreover, TGF-β3 supplementation enhanced the healing of chronic wounds in diabetic mice with impaired SCs.

Conclusion: Our study thus advances the understanding of the roles of neural-derived cells in skin regeneration and suggests a potential therapeutic strategy for wound healing disorders.

Superiority of Adipose-derived CD34 + Cells over Adipose-derived Stem Cells in Promoting Ischemic Tissue Survival

BACKGROUND

Tissue ischemia usually leads to necrosis and is a threatening condition associated with reconstructive surgery. Promoting the survival of ischemic tissue is critical for improving clinical outcomes. Although various solutions based on stem cells have been reported, there are still limitations to clinical translation. The aim of this study was to develop an effective method to promote the survival of ischemic tissue.

METHODS

Adipose-derived CD34 + and CD34- cells were obtained by magnetic bead sorting from the stromal vascular faction (SVF). Adipose-derived stem cells (ADSCs) were collected by subculture. The angiogenic capacities of CD34 + cells, CD34- cells and ADSCs were evaluated in vitro by comparing mRNA and protein expression. Random axial flaps in nude mice were used to evaluate the efficacy of these cells in protecting tissue from necrosis. The effect of these cells in preventing inflammation was also evaluated.

RESULTS

Our data suggest that CD34 + cells expressed higher levels of angiogenetic factors and lower levels of inflammatory factors than the other cell types. More vessel branches were formed when human umbilical vein endothelial cells (HUVECs) were treated with conditioned medium from CD34 + cells than conditioned medium from the other cell types. Compared to ADSCs, CD34 + cells showed significantly higher efficacy in promoting tissue survival. More CD31 + cells and higher levels of angiogenic factors were observed in tissues from the CD34 + group than in those from the other groups. Lower levels of the proinflammatory factors TNF-α and IL-1b and higher levels of anti-inflammatory factors were found in the CD34 + group than in the other groups.

CONCLUSION

Adipose-derived CD34 + cells showed better efficacy in improving ischemic tissue survival than ADSCs by reducing tissue inflammation and promoting angiogenesis. CD34 + cells can be obtained easily and may be suitable for clinical applications.

A Strategy for Integrative Reconstruction of Midface Defects Using an Extended Forehead Flap

Background: Midface reconstruction is challenging because the structures and deformities involved are complicated. In this study, we present a strategy for integrally reconstructing nasal and midface defects, including hair-bearing defects, using extended forehead-expanded flaps. Methods: From 2015 to 2018, a total of 22 patients with midface defects underwent reconstruction with extended forehead-expanded flaps. The far end of the expanded flap, which included scalp hair, was used to cover the upper lip defect (Type 1). In cases with large perioral defects (Type 2), we designed two separate supratrochlear artery flaps, one with a shorter pedicle for nasal reconstruction and the other with a longer pedicle for partial reconstruction. The pedicle of the longer flap was saved for upper lip recovery after pedicle interruption. Results: Among the 22 patients (13 male and 9 female), 17 were caused by burns and 5 by trauma. Nineteen patients had Type 1 defects, and three had Type 2 defects. The average postoperative follow-up was 17.6 ± 4.3 months. Patient satisfaction was excellent in most patients. Conclusions: Our extended forehead flap strategy can achieve aesthetic recovery of nasal and perioral defects with a single expansion treatment. The expanded flap can be flexibly designed to fit diverse midface defects.

The combination of trehalose and glycerol: an effective and non-toxic recipe for cryopreservation of human adipose-derived stem cells

Background

Adipose-derived stem cells (ADSCs) promote tissue regeneration and repair. Cryoprotective agents (CPAs) protect cells from cryodamage during cryopreservation. Safe and efficient cryopreservation of ADSCs is critical for cell-based therapy in clinical applications. However, most CPAs are used at toxic concentrations, limiting their clinical application.

Objective

The aim of this study is to develop a non-toxic xeno-free novel CPA aiming at achieving high-efficiency and low-risk ADSC cryopreservation.

Methods

We explored different concentrations of trehalose (0.3 M, 0.6 M, 1.0 M, and 1.25 M) and glycerol (10%, 20%, and 30% v/v) for optimization and evaluated and compared the outcomes of ADSCs cryopreservation between a combination of trehalose and glycerol and the commonly used CPA DMSO (10%) + FBS (90%). All samples were slowly frozen and stored in liquid nitrogen for 30 days. The effectiveness was evaluated by the viability, proliferation, migration, and multi-potential differentiation of the ADSCs after thawing.

Results

Compared with the groups treated with individual reagents, the 1.0 M trehalose (Tre) + 20% glycerol (Gly) group showed significantly higher efficiency in preserving ADSC activities after thawing, with better outcomes in both cell viability and proliferation capacity. Compared with the 10% DMSO + 90% FBS treatment, the ADSCs preserved in 1.0 M Tre + 20% Gly showed similar cell viability, surface markers, and multi-potential differentiation but a significantly higher migration capability. The results indicated that cell function preservation can be improved by 1.0 M Tre + 20% Gly.

Conclusions

The 1.0 M Tre + 20% Gly treatment preserved ADSCs with a higher migration capability than 10% DMSO + 90% FBS and with viability higher than that with trehalose or glycerol alone but similar to that with 10% DMSO + 90% FBS and fresh cells. Moreover, the new CPA achieves stemness and multi-potential differentiation similar to those in fresh cells. Our results demonstrate that 1.0 M Tre + 20% Gly can more efficiently cryopreserve ADSCs and is a non-toxic CPA that may be suitable for clinical applications.

Autologous Concentrated Growth Factors Combined with Topical Minoxidil for the Treatment of Male Androgenetic Alopecia: A Randomized Controlled Clinical Trial

Background: Minoxidil (MXD) is an U.S. Food and Drug Administration-approved drug for the topical treatment of androgenetic alopecia (AGA) with minor side effects, but its hair growth (HG) effect is unsatisfactory. Methods: A double-blinded within-subjects randomized clinical trial was conducted on 16 male AGA patients who showed limited improvement after MXD treatment. Eligible participants received three concentrated growth factor (CGF) injections on half of the scalp and the placebo on the other side at 4-week intervals, and MXD was applied twice daily on both sides throughout the follow-up period. The primary endpoint was the HG ratio at V4. The secondary endpoints included the HG ratios at V2, V3, and V5; hair density and T/V ratio at V2, V3, V4, and V5; Global Aesthetic Improvement Scale (GAIS) scores at V4 and V5; and participant satisfaction at V4. Results: Each group included 16 subjects; each half of the scalp was randomly assigned to the MXD+CGF or MXD group. The HG ratio at V4 was higher in the MXD+CGF group than in the MXD group. The MXD+CGF group had significant improvements in hair density, HG ratio, and T/V ratio compared with the MXD group over the follow-up period. The GAIS scores and participant satisfaction were higher in the MXD+CGF group than in the MXD group. Unexpectedly, the MXD+CGF treatment hastened HG, which was sustained for 3 months after discontinuation. No severe adverse events occurred. Conclusions: The combined treatment of MXD and CGF is safe and more efficient for AGA patients. Combining CGF can expedite the potency of MXD and provide patients with fast and lasting HG.

Twelve-hour fasting compared with expedited oral intake in the initial inpatient management of hyperemesis gravidarum: a randomised trial

OBJECTIVE

To evaluate fasting for 12 hours compared with expedited oral feeding in hospitalised women with hyperemesis gravidarum (HG).

DESIGN

Randomised trial.

SETTING

University Hospital, Malaysia: April 2016-April 2017.

POPULATION

One hundred and sixty women hospitalised for HG.

METHOD

Women were randomised upon admission to fasting for 12 hours or expedited oral feeding. Standard HG care was instituted.

MAIN OUTCOME MEASURE

Primary outcome was satisfaction score with overall treatment at 24 hours (0-10 Visual Numerical Rating Scale VNRS), vomiting episodes within 24 hours and nausea VNRS score at enrolment, and at 8, 16 and 24 hours.

RESULTS

Satisfaction score, median (interquartile range) 8 (5-9) versus 8 (7-9) (P = 0.08) and 24-hour vomiting episodes were 1 (0-4) versus 1 (0-5) (P = 0.24) for 12-hour fasting versus expedited feeding, respectively. Repeated measures analysis of variance of nausea scores over 24 hours showed no difference (P = 0.11) between trial arms. Participants randomised to 12-hour fasting compared with expedited feeding were less likely to prefer their feeding regimen in future hospitalisation (41% versus 65%, P = 0.001), to recommend to a friend (65% versus 84%, P = 0.01; RR 0.8, 95% CI 0.6-0.9) and to adhere to protocol (85% versus 95%, P = 0.04; RR 0.9, 95% CI 0.8-1.0). Symptoms profile, ketonuria status at 24 hours and length of hospital stay were not different.

CONCLUSION

Advisory of 12-hour fasting compared with immediate oral feeding resulted in a non-significant difference in satisfaction score but adherence to protocol and fidelity to and recommendation of immediate oral feeding to a friend were lower. The 24-hour nausea scores and vomiting episodes were similar.

TWEETABLE ABSTRACT

Women hospitalised for hyperemesis gravidarum could feed as soon, as much and as often as can be tolerated compared with initial fasting.

A randomised trial of caesarean wound coverage: exposed versus dressed

OBJECTIVE

To evaluate the superficial surgical site infection (SSI) rate to 28 days and patient satisfaction with wound coverage management when their transverse suprapubic caesarean wound is left exposed compared with dressed after skin closure.

DESIGN

Randomised trial.

SETTING

University Hospital, Malaysia: April 2016-October 2016.

POPULATION

331 women delivered by caesarean section.

METHOD

Participants were randomised to leaving their wound entirely exposed (n = 165) or dressed (n = 166) with a low adhesive dressing (next day removal).

MAIN OUTCOME MEASURES

Primary outcomes were superficial SSI rate (assessed by provider inspection up to hospital discharge and telephone questionnaires on days 14 and 28) and patient satisfaction with wound coverage management before hospital discharge.

RESULTS

The superficial SSI rates were 2/153 (1.3%) versus 5/157 (3.2%) (relative risk [RR] 0.4, 95% CI 0.1-2.1; P = 0.45) and patient satisfaction with wound management was 7 [5-8] versus 7 [5-8] (P = 0.81) in exposed compared with dressed study groups, respectively. In the wound-exposed patients, stated preference for wound exposure significantly increased from 35.5 to 57.5%, whereas in the wound-dressed patients, the stated preference for a dressed wound fell from 48.5 to 34.4% when assessed at recruitment (pre-randomisation) to day 28. There were no significant differences in inpatient additional dressing or gauze use for wound care, post-hospital discharge self-reported wound issues of infection, antibiotics, redness and inflammation, swollen, painful, and fluid leakage to day 28 across trial groups.

CONCLUSION

The trial is underpowered as SSI rates were lower than expected. Nevertheless, leaving caesarean wounds exposed does not appear to have detrimental effects, provided patient counselling to manage expectations is undertaken.

TWEETABLE ABSTRACT

An exposed compared with a dressed caesarean wound has a similar superficial surgical site infection rate, patient satisfaction and appearance.

Maternal lipids are associated with newborn adiposity, independent of GDM status, obesity and insulin resistance: a prospective observational cohort study

OBJECTIVE

To determine the association between maternal lipaemia and neonatal anthropometrics in Malaysian mother-offspring pairs.

DESIGN

Prospective observational cohort study.

SETTING

Single tertiary multidisciplinary antenatal clinic in Malaysia.

POPULATION

A total of 507 mothers: 145 with gestational diabetes mellitus (GDM); 94 who were obese with normal glucose tolerance (NGT) (pre-gravid body mass index, BMI ≥ 27.5 kg/m² ), and 268 who were not obese with NGT.

METHODS

Maternal demographic, anthropometric, and clinical data were collected during an interview/examination using a structured questionnaire. Blood was drawn for insulin, C-peptide, triglyceride (Tg), and non-esterified fatty acid (NEFA) during the 75-g 2-hour oral glucose tolerance test (OGTT) screening, and again at 36 weeks of gestation. At birth, neonatal anthropometrics were assessed and data such as gestational weight gain (GWG) were extracted from the records.

MAIN OUTCOME MEASURES

Macrosomia, large-for-gestational-age (LGA) status, cohort-specific birthweight (BW), neonatal fat mass (NFM), and sum of skinfold thickness (SSFT) > 90th centile.

RESULTS

Fasting Tg > 95th centile (3.6 mmol/L) at screening for OGTT was independently associated with LGA (adjusted odds ratio, aOR 10.82, 95% CI 1.26-93.37) after adjustment for maternal glucose, pre-gravid BMI, and insulin sensitivity. Fasting glucose was independently associated with a birthweight ratio (BWR) of >90th centile (aOR 2.06, 95% CI 1.17-3.64), but not with LGA status, in this well-treated GDM cohort with pre-delivery HbA1c of 5.27%. In all, 45% of mothers had a pre-gravid BMI of <23 kg/m² and 61% had a pre-gravid BMI of ≤ 25 kg/m² , yet a GWG of >10 kg was associated with a 4.25-fold risk (95% CI 1.71-10.53) of BWR > 90th centile.

CONCLUSION

Maternal lipaemia and GWG at a low threshold (>10 kg) adversely impact neonatal adiposity in Asian offspring, independent of glucose, insulin resistance and pre-gravid BMI. These may therefore be important modifiable metabolic targets in pregnancy.

TWEETABLE ABSTRACT

Maternal lipids are associated with adiposity in Asian babies independently of pre-gravid BMI, GDM status, and insulin resistance.

Continuous glucose monitoring results in lower HbA1c in Malaysian women with insulin-treated gestational diabetes: a randomized controlled trial

AIMS

To determine if therapeutic, retrospective continuous glucose monitoring (CGM) improves HbA_1c with less hypoglycaemia in women with insulin-treated gestational diabetes mellitus (GDM).

METHODS

This prospective, randomized controlled, open-label trial evaluated 50 women with insulin-treated GDM randomized to either retrospective CGM (6-day sensor) at 28, 32 and 36 weeks' gestation (Group 1, CGM, n = 25) or usual antenatal care without CGM (Group 2, control, n = 25). All women performed seven-point capillary blood glucose (CBG) profiles at least 3 days per week and recorded hypoglycaemic events (symptomatic and asymptomatic CBG < 3.5 mmol/l; non-fasting < 4.0 mmol/l). HbA_1c was measured at 28, 33 and 37 weeks. In Group 1, both CGM and CBG data were used to manage diabetes, whereas mothers in Group 2 were managed based on CBG data alone.

RESULTS

Baseline characteristics (age, pre-pregnancy BMI, HbA_1c , total insulin dose) were similar between groups. There was a lower increase in HbA_1c from 28 to 37 weeks' gestation in the CGM group [∆HbA_1c : CGM + 1 mmol/mol (0.09%), control + 3mmol/mol (0.30%); P = 0.024]. Mean HbA_1c remained unchanged throughout the trial in the CGM group, but increased significantly in controls as pregnancy advanced. Mean HbA_1c in the CGM group was lower at 37 weeks compared with controls [33 ± 4 mmol/mol (5.2 ± 0.4%) vs. 38 ± 7 mmol/mol (5.6 ± 0.6%), P < 0.006]. Some 92% of the CGM group achieved an HbA_1c ≤ 39 mmol/mol (≤ 5.8%) at 37 weeks compared with 68% of the control group (P = 0.012). Neither group experienced severe hypoglycaemia.

CONCLUSION

CGM use may be beneficial in insulin-treated GDM because it improves HbA_1c compared with usual antenatal care without increasing severe hypoglycaemia. (Clinical Trials Registry No.: NCT02204657).

Immediate compared with on-demand maternal full feeding after planned caesarean delivery: a randomised trial

OBJECTIVE

To evaluate immediate compared with on-demand full maternal oral feeding after caesarean delivery STUDY DESIGN: A randomised trial.

SETTING

Obstetric unit of a university hospital in Kuala Lumpur, Malaysia.

POPULATION

Women admitted for a planned caesarean under spinal anaesthesia.

METHODS

Participants were randomised to a sandwich meal served immediately on return to the ward or on-demand.

MAIN OUTCOME MEASURES

Primary outcomes were patient satisfaction VAS (visual analog scale of 100 mm) on the feeding regimen and vomiting at 24 hours.

RESULTS

453 women were initially enrolled, 395 were randomised and available for analysis. Median (full range) patient satisfaction VAS scores were 82 (15-100) versus 84 (0-100) mm, P = 0.88 and vomiting rates were 1/197 (0.5%) versus 2/198 (1.0%), P > 0.99 for immediate compared with on-demand feeding, respectively. The immediate versus on-demand arms first ate at a median of 105 (35-210) versus 165 (45-385) minutes, P < 0.001, had second meal at 5.3 (1.2-15.5) versus 5.8 (2.2-29.7), P < 0.001, flatus passage at 9.5 (3.1-29.0) versus 10.3 (2.8-24.6), P = 0.023 hours post-caesarean and opiate analgesia use was 10/197 (5.1%) versus 23/198 (11.6%), P = 0.028, RR 0.4 (95% CI 0.2-0.9), NNTb 16 (95% CI 8-89). The median visual numerical rating scale (0-10 scale) for nausea and bloating at 8, 16 and 24 hours was similarly scored at zero in both arms. Other outcomes were similar.

CONCLUSION

Immediate full feeding has some advantage over on-demand feeding. Both regimens are tolerated well. Patients probably should be fed as soon as practicable after a caesarean.

TWEETABLE ABSTRACT

Full maternal oral feeding should commence as soon as practicable after an uncomplicated caesarean section.

Non-invasive prenatal diagnosis using fetal DNA in maternal plasma: a preliminary study for identification of paternally-inherited alleles using single nucleotide polymorphisms

OBJECTIVES

Single nucleotide polymorphism (SNP) with a mutation can be used to identify the presence of the paternally-inherited wild-type or mutant allele as result of the inheritance of either allele in the fetus and allows the prediction of the fetal genotype. This study aims to identify paternal SNPs located at the flanking regions upstream or downstream from the β-globin gene mutations at CD41/42 (HBB:c.127_130delCTTT), IVS1-5 (HBB:c.92+5G>C) and IVS2-654 (HBB:c.316-197C>T) using free-circulating fetal DNA.

SETTING

Haematology Lab, Department of Biomedical Science, University of Malaya.

PARTICIPANTS

Eight couples characterised as β-thalassaemia carriers where both partners posed the same β-globin gene mutations at CD41/42, IVS1-5 and IVS2-654, were recruited in this study.

OUTCOME MEASURES

Genotyping was performed by allele specific-PCR and the locations of SNPs were identified after sequencing alignment.

RESULTS

Genotype analysis revealed that at least one paternal SNP was present for each of the couples. Amplification on free-circulating DNA revealed that the paternal mutant allele of SNP was present in three fcDNA. Thus, the fetuses may be β-thalassaemia carriers or β-thalassaemia major. Paternal wild-type alleles of SNP were present in the remaining five fcDNA samples, thus indicating that the fetal genotypes would not be homozygous mutants.

CONCLUSIONS

This preliminary research demonstrates that paternal allele of SNP can be used as a non-invasive prenatal diagnosis approach for at-risk couples to determine the β-thalassaemia status of the fetus.

Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery-VMI): lessons from exploration of cultural variations in visual-motor integration performance of preschoolers

BACKGROUND

Visual-motor integration (VMI) is important in children's development because it is associated with the performance of many functional skills. Deficits in VMI have been linked to difficulties in academic performance and functional tasks. Clinical assessment experience of occupational therapists in Singapore suggested that there is a potential difference between the VMI performance of Singaporean and American children. Cross-cultural studies also implied that culture has an influence on a child's VMI performance, as it shapes the activities that a child participates in. The purpose of this study was to (1) explore if there was a difference between the VMI performance of Singaporean and American preschoolers, and (2) determine if there were ethnic differences in the VMI performance of Singaporean preschoolers.

METHODS

The Beery-VMI, which was standardized in America, is commonly used by occupational therapists in Singapore to assess the VMI ability of children. We administered the Beery-VMI (fifth edition) full form test (excluding the supplemental tests) to 385 preschoolers (mean age = 63.3 months) from randomly selected schools in Singapore. We compared the scores of Singaporean preschoolers with those of the American standardization norms using the one-sample t-test. Scores of different ethnic groups among the Singapore population were also compared using a one-way anova, followed by the Bonferroni post-hoc test.

RESULTS

Singaporean preschoolers and the standardization sample of American children performed significantly differently in all age groups (P < 0.05). Among the Singapore population, the scores were also significantly different (P < 0.05) between the (i) Chinese and Malay and (ii) Chinese and Indians ethnic groups.

CONCLUSION

Preschoolers from different cultural and ethnic groups had different VMI performance. Certain cultural beliefs and practices may affect VMI performance. Clinicians should exercise caution when using an assessment in communities and cultures outside the ones on which it was standardized.

Predominance of Blastocystis sp. subtype 4 in rural communities, Nepal

Blastocystis sp. is a common intestinal parasite. To date, there have been sporadic and scanty studies on Blastocystis sp. carried out in rural communities in Nepal. We surveyed the prevalence of Blastocystis sp. and its possible associated risk factors, and reported the predominant Blastocystis sp. subtype in two rural communities, Bolde Phediche and Bahunipati, in Nepal. Human faecal samples were collected from 241 participants, cultured using in vitro cultivation and examined for Blastocystis sp. The presence of Blastocystis sp. in faecal samples was further confirmed by polymerase chain reaction (PCR) and subsequently genotyped using subtype-specific sequence tagged site (STS) primers. There were 26.1% (63/241) of the participants that were infected by Blastocystis sp. We detected 84.1% (53/63) of Blastocystis sp. subtype 4 infections in these rural communities. The unusually high prevalence of Blastocystis sp. subtype 4 can be attributed to the rearing of family-owned animals in barns built close to their houses. Eighty one percent (51/63) of the Blastocystis sp. infected participants drank not boiled or unfiltered water. The present study revealed that Blastocystis sp. could pose a health concern to the communities and travellers to the hilly area in Nepal. Infection may be transmitted through human-to-human, zoonotic and waterborne transmissions. We provide recommendations to ensure good public health practices.

Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial

OBJECTIVE

To compare oral nifedipine with intravenous labetalol in their rapidity to control hypertensive emergencies of pregnancy.

DESIGN

A double-blind randomised trial.

SETTING

A university hospital in Malaysia.

POPULATION

Pregnant women with severe gestational hypertension≥160/110 mmHg who required immediate treatment.

METHODS

Patients were randomised to receive nifedipine (10 mg tablet, orally, up to five doses) and intravenous placebo saline injection or intravenous labetalol injection (in an escalating dose regimen of 20, 40, 80, 80 and 80 mg) and a placebo tablet every 15 minutes until the target blood pressure of ≤150/100 mmHg was achieved. Crossover treatment was effected if the initial treatment regimen was unsuccessful. MAIN OUTCOME MEASURE  The time taken to achieve a blood pressure of ≤150/100 mmHg.

RESULTS

The median time taken to achieve target blood pressure was 30 minutes (interquartile range, IQR 22.5-67.5 minutes) versus 45 minutes (IQR 30-60 minutes) for nifedipine and labetalol, respectively (P=0.59). Repeated measures analysis of variance indicated that in the first hour both systolic (F=87.6, P<0.001) and diastolic (F=55.8, P<0.001) blood pressure significantly decreased, but there was no difference between the nifedipine and labetalol groups for both systolic (F=0.12, P=0.74) and diastolic (F=0.92, P=0.34) blood pressure trends over time. Crossover treatment was required in 20% of women from each group.

CONCLUSIONS

Oral nifedipine and intravenous labetalol regimens are similarly effective in the acute control of severe hypertension in pregnancy.

Maternal hemoglobin level and red cell indices as predictors of gestational diabetes in a multi-ethnic Asian population

OBJECTIVE

To evaluate maternal hemoglobin levels and red cell indices as predictive factors for gestational diabetes (GDM).

METHOD

Data from 1,538 women were analyzed. At the first visit for prenatal care, the 50-gram glucose challenge test was followed by the 75-gram glucose tolerance test in those who screened positive. GDM was diagnosed based on the WHO (1999) criteria. Maternal complete blood count was obtained at the first visit, hospitalization for birth, and after birth. Receiver operator characteristic curves were generated to establish thresholds. Multivariable logistic regression analyses were performed to establish independent predictors of GDM.

RESULTS

GDM was diagnosed in 182/1,538 (11.8%). GDM was associated with hemoglobin level, hematocrit and erythrocyte count at the first visit for prenatal care only. Hemoglobin threshold at the first visit was established at 11.5 g/dl. After adjustment, high hemoglobin [AOR 1.5 (95% CI 1.0-2.1); p = 0.027] remained predictive of GDM.

CONCLUSIONS

High maternal hemoglobin level at the first prenatal visit is independently predictive of GDM.

Coitus and orgasm at term: effect on spontaneous labour and pregnancy outcome

INTRODUCTION

Coitus and orgasm in late pregnancy are believed to facilitate the onset of labour. We aim to evaluate the relationship at term of reported coitus and orgasm with spontaneous labour.

METHODS

Women at term scheduled for non-urgent labour induction were asked to keep a coitus and orgasm diary. These women were recruited for a randomised trial on the effect of coitus to promote spontaneous labour. For this analysis, the women were categorised into coitally-active and abstinent groups according to their coital diary. Spontaneous labour prior to the date of scheduled labour induction was the primary outcome. Labour, delivery and neonatal outcome were also evaluated. Multivariable logistic regression analysis was used to control for significant variables.

RESULTS

On univariate analysis, the inverse association of coitus with spontaneous labour was borderline (odds ratio [OR] 0.6; 95 percent confidence interval [CI] 0.3-1.0; p-value is 0.052). Orgasm was not associated with spontaneous labour (p-value is 0.33). After adjustment, coitus (adjusted OR 0.4; 95 percent CI 0.2-0.8; p-value is 0.009) displayed a significant inverse association with spontaneous labour. Coitus and orgasm were not associated with any other adverse pregnancy outcome.

CONCLUSION

Women who reported coitus were less likely to go into spontaneous labour prior to their scheduled labour induction. Reported coitus and orgasm were not associated with adverse pregnancy outcome.

Transvaginal sonography of cervical length and Bishop score as predictors of successful induction of term labor: the effect of parity

OBJECTIVE

To evaluate the predictive value for successful labor induction of transvaginal ultrasound (TVS) of cervical length according to parity.

METHOD

TVS of the cervix was performed before term labor induction. Induction was considered successful if vaginal delivery was achieved within 24 hours; 231 women were available for final analysis.

RESULTS

Analysis of the receiver operator characteristics curve showed an optimal cut-off for cervical length of < or = 20 mm for successful induction. Following multivariate logistic regression analysis, a sonographic short cervix (AOR 5.6; p < 0.001) was an independent predictor of successful induction but not a favorable Bishop score (p = 0.47). Among multiparas with a short cervix, positive and negative predictive values for successful induction were 98% (95% CI 90-100%) and 21% (95% CI 13%-32%) and among nulliparas, predictive values were 69% (95% CI 53%-82%) and 77% (95% CI 64%-87%) respectively.

CONCLUSION

In nulliparas, cervical length can usefully predict labor induction outcome.

Alpha-thalassaemia in association with beta-thalassaemia patients in Malaysia: a study on the co-inheritance of both disorders

BACKGROUND/AIMS

Individuals with double heterozygosity for alpha- and beta-thalassaemia and heterozygous beta-thalassaemia show a similar haematological picture. Co-inheritance of alpha- and beta-thalassaemia in both partners may result in pregnancies with either Hb Bart's hydrops foetalis or beta-thalassaemia major, or pregnancies with both disorders.

METHODS

The co-inheritance of alpha-thalassaemia in 322 beta-thalassaemia carriers in Malaysia was studied.

RESULTS

The frequency of alpha-thalassaemia in the beta-thalassaemia carriers was 12.7% (41/322), with a carrier frequency of 7.8% for the SEA deletion, 3.7% for the -alpha(3.7) deletion, 0.9% for Hb Constant Spring and 0.3% for the -alpha(4.2) deletion.

CONCLUSION

Double heterozygosity for alpha- and beta-thalassaemia was confirmed in 5 out of the 41 couples and the risk of the fatal condition Hb Bart's hydrops foetalis was confirmed in two of these couples. Detection of the Southeast Asian (SEA) deletion in the Malaysian Malays in this study confirms that Hb Bart's hydrops foetalis can occur in this ethnic group. Results of this study have provided new information on the frequency and different types of alpha-thalassaemia (--(SEA), -alpha(3.7) and -alpha(4.2) deletions, Hb Constant Spring) in Malaysian beta-thalassaemia carriers.

Predictors of newborn admission after labour induction at term: Bishop score, pre-induction ultrasonography and clinical risk factors

INTRODUCTION

Following labour induction at term, 12 percent of neonates can expected to be admitted to the neonatal intensive care unit. We aimed to evaluate the Bishop score, pre-induction ultrasonography (US) assessment of amniotic fluid, foetal weight and cervical length, and pre-induction and intrapartum risk factors as predictors of neonatal admission.

METHODS

152 women at term, scheduled for labour induction, consented to participate in this prospective study. Transabdominal US was performed to obtain foetal biometry and amniotic fluid index, followed by transvaginal US to measure cervical length. US findings were concealed. The Bishop score was obtained at initiation of labour induction. Pre-induction and intrapartum risk factors were also considered in the multivariate logistic regression analysis. All study women received standard care.

RESULTS

On univariate analysis, factors associated with neonatal admission were: gestational age at less than or equal to 40 weeks, labour induction for diabetes mellitus, Bishop score of less than 5 at initiation of labour induction, estimated foetal weight of less than 2.5 kg by US, induction to delivery interval of more than 24 hours, caesarean delivery and umbilical cord blood pH of less than 7.1. Cervical length of greater than 20 mm on transvaginal US (p-value is 0.10) was not significant. After multivariate logistic regression analysis, controlling for the significant variables, only the unfavourable Bishop score (adjusted OR 4.2; 95% CI 1.2-13.8; p-value is 0.02) and caesarean delivery (adjusted OR 3.9; 95% CI 1.1-13.7; p-value is 0.035) were independent predictors of neonatal admission.

CONCLUSION

The identification of an unfavourable Bishop score as an independent predictor of neonatal admission is useful in the counselling of women who are considering labour induction.

Predictors for caesarean delivery and neonatal admission after trial of labour in women with one previous lower segment caesarean scar

INTRODUCTION

Caesarean delivery rates are still increasing, and reliable predictors of adverse outcomes at a subsequent trial of scar are important as they guide decision-making on the best mode of delivery. We aimed to evaluate whether there are any predictors for caesarean delivery and neonatal admission, following trial of labour after one lower transverse caesarean section.

METHODS

768 women at term with singleton gestation and who had undergone a trial of labour between June 2002 and December 2005, were retrospectively identified using the labour ward register. 51 infants were admitted to a neonatal unit. Case notes for these cases were retrieved. Emergency repeat caesarean delivery and neonatal admission were the main outcome measures.

RESULTS

Following multivariate logistic regression analysis, no previous vaginal birth (adjusted odds-ratio [AOR] 3.4), diabetes mellitus or hypertension in pregnancy (AOR 1.7), induction of labour (AOR 2.0), oxytocin use in labour (AOR 2.4), and meconium-stained liquor (AOR 4.9) were independent predictors of emergency caesarean delivery. Diabetes mellitus or hypertension in pregnancy (AOR 3.1), prelabour rupture of membranes (AOR 4.7) and caesarean delivery (AOR 6.0) were independent predictors of neonatal admission.

CONCLUSION

Predictors for emergency caesarean delivery and neonatal admission following a trial of labour can be identified. This information should be incorporated into the counselling of women contemplating a trial of labour. The strongest predictor for neonatal admission was emergency caesarean delivery, further emphasising the need for careful case selection in a trial of labour to minimise the risk of failure.

Inhibitory effects of propofol on neuron firing activities in the rostral ventrolateral medulla

The effect of propofol on neuronal activity in the rostral ventrolateral medulla (RVLM) is not well established. Therefore, we performed extracellular recording on neurons of the RVLM to investigate neuronal activity before and after administration of intravenous propofol. The mean systemic arterial pressure (MSAP), heart rate and integrated neuronal firing rate (INFR) in the RVLM were continuously recorded in anesthetized cats before and after intravenous injection of 2 mg/kg propofol or supplemental injections of 1, 2 and 4 mg/kg propofol that were given respectively. Additionally, we compared the MSAP, heart rate (HR), and INFR in the RVLM following intravenous injection of 2 mg/kg propofol or 12.5 microg/kg nitroprusside. Neuronal firing was dose-dependently and reversibly inhibited after the supplemental doses of 1, 2 and 4 mg/kg propofol. The control INFR was 14.2 +/- 9.9 Hz, and this decreased to 12.1 +/- 9.4 Hz after the first dose of propofol (P = 0.085 vs. control), and further decreased to 9.3 +/- 7.7 Hz (P = 0.001 vs. control) and 7.5 +/- 7.7 Hz (P < 0.001 vs. control) after the second and third doses of propofol, respectively. Besides, SAP and HR were dose-dependently decreased by propofol as well. However, the effects of propofol and nitroprusside on neuronal activity in the RVLM differed. Propofol inhibited neuronal firing, whereas nitroprusside activated neuronal firing. In conclusion, propofol may dose-dependently inhibit spontaneous neuronal activity and the baroreflex in the RVLM.

Concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction of nulliparas with an unfavourable cervix: a randomised placebo-controlled trial

OBJECTIVE

To compare concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction for nulliparas with an unfavourable cervix.

DESIGN

A randomised double-blind study.

SETTING

University Malaya Medical Centre, Malaysia.

POPULATION

Nulliparas at term with intact membranes, Bishop score < or = 6 and admitted for labour induction.

METHODS

All women received 3 mg dinoprostone pessary for labour induction. Those randomised to the oxytocin arm received oxytocin infusion started at 1 micro/minute and doubled every 30 minutes to a maximum 16 micro/minute. Women assigned to placebo received identical volume of saline infusion. After 6 hours, infusion was stopped and vaginal reassessment performed to guide further management.

MAIN OUTCOME MEASURES

Primary outcome was vaginal delivery within 24 hours.

RESULTS

Concurrent oxytocin infusion with dinoprostone pessary did not significantly increase vaginal delivery rate within 24 hours (48.6 versus 35.9%; P = 0.07, relative risk [RR] 1.4 [95% CI 1.0-1.9]). It reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P = 0.001, RR 0.61 [95% CI 0.45-0.81]) and improved maternal satisfaction with the birth process (median score of 3 versus 5 on a 10-point visual analogue scale, P = 0.007). Caesarean rates were not different (41.9 versus 44.7%, P = 0.52).

CONCLUSIONS

Labour induction with concurrent oxytocin infusion and vaginal dinoprostone could be considered for nulliparas with an unfavourable cervix. Larger studies are needed.

Transvaginal sonographic measurement of cervical length vs. Bishop score in labor induction at term: tolerability and prediction of Cesarean delivery

OBJECTIVES

To compare transvaginal sonography for cervical length measurement and digital examination for Bishop score assessment in women undergoing labor induction at term, to assess their tolerability (in terms of pain) and ability to predict need for Cesarean delivery.

METHODS

A prospective study was performed on 249 women admitted for labor induction. Cervical length was measured using transvaginal ultrasound examination. A 10-point visual analog scale (VAS) for procedure-related pain was obtained. Bishop score was determined just before labor induction and another pain score was obtained. Delivery outcome was recorded. Analyses were by t-test, Fisher's exact test, receiver-operating characteristics (ROC) curves and multivariate logistic regression.

RESULTS

Transvaginal sonography was significantly less painful than digital examination for Bishop score assessment (mean difference in VAS score 3.46; P<0.001). Analyses of the ROC curves for cervical length and Bishop score indicated that both were predictors of Cesarean delivery (area under the curve 0.611 vs. 0.607; P=0.012 vs. P=0.015, respectively) with optimal cut-offs for predicting Cesarean delivery of >20 mm for cervical length and Bishop score<or=5. Cervical length had superior sensitivity (80% vs. 64%) and marginally better positive (30% vs. 27%) and negative (89% vs. 83%) predictive values. Multivariate logistic regression analysis revealed that only nulliparity (adjusted odds ratio (AOR) 4.1; 95% CI, 2.1-8.1; P<0.001) and transvaginal sonographic cervical length>20 mm (AOR 3.4; 95% CI, 1.4-8.1; P=0.006) were independent predictors of Cesarean delivery.

CONCLUSIONS

Transvaginal sonography for cervical length measurement is better tolerated than digital examination for Bishop score assessment. Both cervical length and Bishop score are useful predictors of the need for Cesarean delivery following labor induction. A cervical length>20 mm at labor induction at term is an independent predictor of Cesarean delivery.

The fetal sex ratio and metabolic, biochemical, haematological and clinical indicators of severity of hyperemesis gravidarum

The association between female fetal sex and hyperemesis gravidarum is well established in European and North American populations. The association between female fetuses and severity of hyperemesis remains uncertain. A retrospective study based on case notes review of 166 Asian women hospitalised for hyperemesis was performed. Female fetuses were significantly associated with hyperemesis in our population (P= 0.004, OR 1.6, 95% CI 1.2-2.2) as well as associated with severe ketonuria and high urea. When both severe ketonuria and high urea were present at initial hospital admission for hyperemesis, 83% (95% CI 66-93) of the fetuses were female.

Rapid and cost-effective antenatal diagnosis of haemoglobin Bart's hydrops foetalis syndrome using a duplex-polymerase chain reaction

Haemoglobin Bart's hydrops foetalis syndrome (--SEA/--SEA) is not compatible with life and contributes to a majority of the hydropic foetuses in the Malaysian Chinese alpha-thalassaemia carriers who possess the 2-alpha-gene deletion in cis (--SEA/alphaalpha). A duplex-PCR which simultaneously amplifies a normal 136 bp sequence between the psialpha-alpha2-globin genes and a 730 bp Southeast Asian deletion-specific sequence (--SEA) between the psialpha2-theta1-globin genes was established. The duplex-PCR which detects the --SEA deletion in both chromosomes serves as a rapid and cost-effective confirmatory test in the antenatal diagnosis of Haemoglobin Bart's hydrops foetalis syndrome in Malaysia. In addition, the duplex-PCR is simple to perform as both the normal and deletion-specific alpha-globin gene sequences are amplified in the same PCR reaction.

Molecular defects in the β-globin gene identified in different ethnic groups/populations during prenatal diagnosis for β-thalassemia: a Malaysian experience

Beta-thalassemia is the most-common genetic disorder of hemoglobin synthesis in Malaysia, and about 4.5% of the population are heterozygous carriers of the disorder. Prenatal diagnosis was performed for 96 couples using the Amplification Refractory Mutation System and Gap-Polymerase Chain Reaction. We identified 17 beta-globin defects-initiation codon for translation (T-G), -29 (A-G), -28 (A-G), CAP +1 (A-C), CD 8/9 (+G), CD 15 (G-A), CD 17 (A-T), CD 19 (A-G), Hb E (G-A), IVS1-1 (G-T), IVS1-5 (G-C), CD 41/42 (-CTTT), CD 71-72 (+A), IVS2-654 (CT), poly A(A-G), 100-kb Ggamma(Agammadeltabeta) degrees and 45-kb Filipino deletions. The 192 beta-alleles studied comprised Chinese (151 patients), Malay (21), Orang Asli from East Malaysia (15), Filipino (1), Indian (1), Indonesian Chinese (2), and Thai (1). In the Chinese, 2 beta-globin defects at CD 41/42 and IVS2-654 were responsible for 74% of beta-thalassemia. beta-mutations at CD 19, IVS1-1 (G-T), IVS1-5, poly A, and hemoglobin E caused 76% of the hemoglobin disorders in the Malays. The Filipino 45-kb deletion caused 73.3% of bthalassemia in the Orang Asli. Using genomic sequencing, the rare Chinese beta-mutation at CD 43 (G-T) was confirmed in 2 Chinese, and the Mediterranean mutation IVS1-1 (G-A) was observed in a Malay beta-thalassemia carrier. The beta-globin mutations confirmed in this prenatal diagnosis study were heterogenous and 65 (68%) couples showed a different globin defect from each other. The use of specific molecular protocols has allowed rapid and successful prenatal diagnosis of beta-thalassemia in Malaysia.

Comparison of nasal trauma associated with nasopharyngeal airway applied by nurses and experienced anesthesiologists

BACKGROUND

Insertion of a nasopharyngeal airway by nurses is considered to be invasive. We compared the incidence and severity of nasal injury associated with nasopharyngeal airway insertion by trained nurses to those by anesthesiologists to determine the safety of inserting a nasopharyngeal airway by nurses in cardiopulmonary resuscitation (CPR).

METHODS

One hundred and sixteen male and 96 female patients scheduled for general anesthesia were included in the study. The male and female patients were randomly assigned to two groups respectively. Anesthesia was induced with sodium thiopental and fentanyl intravenously. The patients were then ventilated with a bag-valve-mask by trained nurses or anesthesiologists. In the unsuccessfully ventilated patients, nasopharyngeal airways were inserted to facilitate subsequent ventilation. The nasopharyngeal airway, oropharynx, and nostrils were then examined. The incidence and severity of nasal trauma induced by trained nurses or by anesthesiologists were compared.

RESULTS

The study revealed that nasopharyngeal airways applied by trained nurses did not induce more severe nasal trauma than those by anesthesiologists.

CONCLUSION

We suggest that nasopharyngeal airways may be applied safely by trained nurses in CPR.

ATP sensitive potassium channel and myocardial preconditioning

KATP channels play an important role in physiology and pathophysiology of many tissues. As in the pancreatic beta cells, they couple the change of blood glucose with insulin release. The data coming from Baukrowitz et al. and Shyng and Nichols gave the possible answers to the two old enigmas of KATP channels, i.e., different ATP sensitivity reported in the same tissue and how the channel opened under intracellular millimolar ATP concentration, in which they showed the lipids and lipid metabolites are essential for KATP channel regulation by altering ATP sensitivity. This new information rises several further considerations. How does PIP2 reduce the sensitivity of the channel to ATP? In order to clarify the possibility of direct competing or allosteric effect on the ATP binding site, competitive binding assay should be performed. Since the PIP2 theory seems to be the key event to determine the ATP sensitivity and thus control the channel open probability, then what is the resting concentration of PIP2 in the cell membrane? Is it sufficient to account for the difference in the ATP sensitivity of the intact cell and excised patch from different tissues? Quantitative studies either immunoblotting by PIP2 antibody or fluorescence-labeled lipid assay-may obtain some basic but useful data for further studies to answer these questions. Furthermore, the ATPi mediated restoration of activity was inhibited by antibodies against PIP2. The dualistic behavior of KATP channels to intracellular NDPs should be reexamined with respect to PIP2. The vast majority of preconditioning studies has been performed in intact animals in which myocardial infarct size was used as the end point to define the cardio-protective effect of ischemic PC. These results suggest a key role for the KATP channel as both a trigger and as an end effector of both acute and delayed ischemic PC. The persistent activation of KATP channels during the early reperfusion phase is essential for a smooth and full recovery of contractile function, as well as for maintenance of electrical stability in heart that has been exposed to ischemia. Though activate adenosine A1 receptor coupled with Gi protein can open the KATP channels, adenosine is quickly released during ischemia and exerts potent coronary vasodilatation to maintain coronary blood flow through A2 receptors. This adenosine-induced coronary vasodilatation could be coupled with KATP channels based on the evidence of the augmentation effect of KCOs. Nitric oxide may also play some role in both first and second window of myocardial protection. It is possible that rapid and reversible phosphorylation and activation of constitutive expressed myocardial NOS or by direct KATP channel phosphorylation and activation leads to the first window of myocardial protection. This hypothesis can be further investigated either by using site direct mutagenesis of iNOS or KATP channel, or by applying the dominant negative iNOS in the cell ischemic model, or by building the adenosine or iNOS knock-out mice to study the relationship of these possible mechanisms. Recently, Kontos further showed that KCOs need L-lysine or L-arginine to dilate cerebral arterioles. This suggests that there may be an amino acid binding site inside the KATP channel and nitric oxide can open the KATP channel either by direct acting on the channel protein or by modulating the affinity of the amino acid binding site for L-lysine or L-arginine. Other KATP channel openers in need of additional characterization are the Type III KCOs (nicorandiol). They open the KATP channel only in the presence of elevated intracellular NDPs, which may make them specifically target to the ischemic region, because the intracellular NDP increases mostly in ischemic region. It is possible that type III KCOs can selectively improve blood flow to ischemic areas without diverting blood away to non-ischemic region, and prevents the "steal phenomenon". (ABSTRACT TRUNCATED)

Cytokine modulatable signalling through macrophage HLA class II. 1. IFN-gamma upregulates the efficiency of Ca2+ mobilization in response to ligation of macrophage HLA-DP

The human macrophage line 2MAC, established recently from peripheral blood, expresses a number of lineage-specific markers as well as a broad array of intercellular adhesion molecules, including high levels of HLA class I and class II. We have presented evidence elsewhere that 2MAC can be productively applied to the study of signal transduction through macrophage HLA class II. Namely, we showed that ligation of 2MAC HLA class II, but not HLA class I, by monoclonal antibody (mAb) elicits an increase in free cytoplasmic Ca2+ concentration [Ca2+]i. Moreover, this Ca2+ flux appears to be functionally relevant: ligation of HLA-DR, but not HLA class I, by mAb results in the Ca2+ mobilization-dependent induction of tissue factor, the high-affinity cellular receptor for factor VII/VIIa. Here we show that 2MAC is uniquely valuable for addressing the efficiency of signal transduction through HLA class II. Namely, we show here that prior culture of 2MAC cells with interferon-gamma (IFN-gamma) profoundly upregulates subsequent Ca2+ mobilization in response to ligation of HLA-DP in the absence of increased cell surface HLA-DP expression. Because IFN-gamma has no effect on 2MAC HLA-DP expression, IFN-gamma must upregulate Ca2+ mobilization by increasing the efficiency of signal transduction through HLA class II (HLA-DP), by targeting some other component of the macrophage HLA class II signalling pathway.

Characterization of a new human macrophage cell line 2MAC. 1. Expression of functional macrophage CD16 (Fc gammaRIIIA/gamma) and tissue factor induction on ligation of HLA-DR

A human macrophage-like line, designated 2MAC, has been established from peripheral blood. 2MAC expresses a number of lineage-specific markers as well as a broad array of intercellular adhesion molecules. In particular, 2MAC expresses CD16/Fc gammaRIII, the low-affinity Fc receptor for IgG, as well as high levels of HLA class I and class II. Consistent with this macrophage assignment, we present evidence that 2MAC expresses the macrophage form of CD16, namely, Fc gammaRIIIA/gamma. By several criteria also applicable to signal transducing NK CD16 and T cell CD3/TCR complexes, including modulation from the cell surface and Ca2+ mobilization in response to ligation by specific monoclonal antibody, CD16 expressed by 2MAC is functional. Ligation of 2MAC HLA class II, but not HLA class I, by specific mAb induces an increase in free cytoplasmic Ca2+ concentration ([Ca2+]i). This Ca2+ flux appears to be physiologically relevant, as ligation of HLA-DR, but not HLA class I, by mAb results in the efficient, Ca2+ mobilization-dependent induction of tissue factor by 2MAC. 2MAC, therefore, should prove useful for studying signal transduction through macrophage CD16 and HLA class II.

Phenotypic and functional characterization of a new human macrophage cell line K1m demonstrating immunophagocytic activity and signalling through HLA class II

A human macrophage line, designated K1m, has been established from peripheral blood. K1m expresses a number of lineage-specific markers as well as a broad array of intercellular adhesion molecules. In particular, K1m expresses high levels of human leucocyte antigen (HLA) class I and class II. In response to ligation of HLA class II (HLA-DR), but not in response to ligation of HLA class 1, K1m forms tighter homotypic aggregates and develops a striking 'stellate' culture phenotype. K1m also expresses Fc receptors for immunoglobulin G (IgG) (CD64, CD32, and CD16) and can be shown to phagocytose polystyrene latex beads, as well as neuroblastoma cells in the presence of tumour-specific monoclonal antibody (mAb). The K1m cell line should therefore prove useful for studying both signalling through macrophage HLA class II and immunophagocytosis.

Do fertility intentions predict subsequent behavior? Evidence from Peninsular Malaysia

Data from the 1984 Malaysian Population and Family Survey were matched with birth registration records for 1985-87 to determine the accuracy of statements regarding desired family size that were reported in a household survey in predicting subsequent reproductive behavior. The findings of this study were that stated fertility intention provides fairly accurate forecasts of fertility behavior in the subsequent period. In other words, whether a woman has another child is predicted closely by whether she wanted an additional child. Informational, educational, and motivational activities of family planning programs would, therefore, have greater success in reducing family size if fertility intentions were taken into account.

Implications of changing family structures on old-age support in the ESCAP region

"This article considers the various types of old-age support and care, and the implications of changing family structures [in the Asia-Pacific region]. It concludes that long-term development planning should cater for the need to increase social support services in line with changing demographic scenarios."

Abnormal muscle response in microvascular decompression of hemifacial spasm

In 1976, Jannetta et al, suggested that microvascular compression caused by arteries and veins crossing the root entry zone of the facial nerve, was the major etiology of hemifacial spasm (HFS). Surgical treatment has become a major trend. Microvascular decompression (MVD) with teflon patches has a high cure rate. However, the possible occurrence of multiple vessel compression makes it difficult to decide which of these vessels are responsible for the symptom during operation. Recently, a method of abnormal EMG was elaborated upon by Møller and Jannetta in 1987, to ensure the quality of MVD intraoperatively. In this study, we report 6 cases who underwent the procedure successfully. After general anesthesia and muscle relaxation, the abnormal EMG was not suppressed. When the offending vessel was lifted up from the facial nerve, the abnormal EMG disappeared immediately. In each case, postoperative improvement of facial spasm correlated with intraoperative abnormal EMG changes. This method is not only able to guide the surgeon to the vessel that induces HFS but also guarantees the quality of MVD.

Changing patterns of marriage and household formation in Peninsular Malaysia

"Based on surveys conducted among different ethnic groups in rural and urban settings in Peninsular Malaysia in 1981-82, this paper analyses changes in patterns of marriage and household formation among Malays, Chinese, and Indians. Aspects covered include social mixing before marriage, choice of spouse, comparison of spouses' characteristics, and place of residence after marriage. There are important cultural differences between the main Malaysian ethnic groups in matters related to marriage, but in many important respects, attitudes and practice are tending to converge...."