Angiography alone versus angiography plus intracoronary imaging to guide emergency percutaneous coronary intervention: outcomes from a single-centre retrospective analysis

Funding Acknowledgements

Type of funding sources: None.

Background

There is emerging evidence showing improvement in clinical outcomes with optical coherence tomography (OCT) and intravascular ultrasound (IVUS)-guided elective percutaneous coronary intervention (PCI). Yet data supporting their use in emergency setting are still conflicting.

Purpose

We aim to compare the immediate angiographic outcomes, short and long-term clinical outcomes in patients undergoing emergency PCI with intracoronary imaging to those with angiography guidance only.

Methods

We included 426 patients from May 2012 to December 2020 who presented with ST-elevation myocardial infarction (STEMI) and underwent emergency PCI within 24 hours of hospital admission. Intracoronary imaging was used in 196 of them to guide PCI. Immediate angiographic outcomes in terms of TIMI flow grade (TFG), myocardial blush grade (MBG) and corrected TIMI frame count (CTFC) are compared. Clinical outcomes including major adverse cardiac events (MACE), target vessel revascularization (TVR), hospitalization for heart failure and all-cause mortality were also compared.

Results

196 patients (46%) underwent intracoronary imaging-guided PCI. Use of imaging was associated with a higher post procedural CTFC (27.0 vs. 25.8, p=0.11), yet it failed to reach statistical significance. Comparing with angiography-guided PCI, imaging-guided PCI was associated with significantly larger proportion of high CTFC post procedure (slow coronary flow) (OR, 0.62; 95% CI: 0.38-1.0, P=0.05), and this result was consistent after adjustment of variables (adjusted OR, 0.57; 95% CI 0.34-0.98, P=0.04). Subjective measures of TIMI flow grade and MBG, however, were not different between the 2 groups. In the subgroup of patients with high Syntax score and American Heart Association (AHA)/American College of Cardiology (ACC) type C culprit lesion morphology, imaging guided PCI was associated with significantly worse post procedural MBG (OR, 0.36; 95% CI 0.17-0.78, P=0.01 vs. OR, 0.40; 95% CI 0.18-0.94, P=0.04), and the results were consistent after adjusting for variables. In the subgroup of patients with high Syntax score, imaging guided PCI was associated with significantly worse post procedural TIMI flow grade (adjusted OR, 0.35; 95% CI 0.12-0.95, P=0.05) and a trend towards higher CTFC (adjusted OR, 0.26; 95% CI: 0.06-0.94, P=0.05) after adjusting for variables. The cumulative incidences of all clinical outcome measures were not significantly different between the 2 groups before and after adjusting for confounders.

Conclusions

Imaging-guided PCI was not associated with improved angiographic or clinical outcomes in patients with STEMI who underwent emergency PCI. Use of intracoronary imaging in emergency PCI may associate with worse immediate angiographic outcomes.

Dietary patterns of 5-year-old children and their correlates: findings from a multi-ethnic Asian cohort

There is limited data on the dietary patterns of 5-year-old children in Asia. The study examined childhood dietary patterns and their maternal and child correlates in a multi-ethnic Asian cohort. Based on caregiver-reported 1-month quantitative FFQ of 777 children from the Growing Up in Singapore Towards healthy Outcomes cohort, cluster analysis identified two mutually exclusive clusters. Children in the 'Unhealthy' cluster (43·9 %) consumed more fries, processed meat, biscuits and ice cream, and less fish, fruits and vegetables compared with those in the 'Healthy' cluster (56·1 %). Children with mothers of lower educational attainment had twice the odds of being assigned to the 'Unhealthy' cluster (adjusted OR (95 % CI) = 2·19 (95 % CI 1·49-3·24)). Children of Malay and Indian ethnicities had higher odds of being assigned to the 'Unhealthy' cluster (adjusted OR = 25·46 (95 % CI 15·40, 42·10) and 4·03 (95 % CI 2·68-6·06), respectively), relative to Chinese ethnicity. In conclusion, this study identified two dietary patterns in children, labelled as the 'Unhealthy' and 'Healthy' clusters. Mothers' educational attainment and ethnicity were two correlates that were associated with the children's assignments to the clusters. These findings can assist in informing health promotion programmes targeted at Asian children.

Gene expression profiling of giant fibroadenomas of the breast

INTRODUCTION

Fibroadenomas of the breast present as two phenotypic variants. The usual variety is 5 cm or less in diameter and there is another large variant called giant fibroadenoma which is greater than 5 cm in diameter. Despite of its large size, it is not malignant. The aim of our study is to determine whether this large variant is different from the usual fibroadenoma in terms of its biological pathways and biomarkers.

METHODS

mRNA was extracted from 44 fibroadenomas and 36 giant fibroadenomas, and transcriptomic profiling was performed to identify up- and down-regulated genes in the giant fibroadenomas as compared to the fibroadenomas.

RESULTS

A total of 40 genes were significantly up-regulated and 18 genes were significantly down-regulated in the giant fibroadenomas as compared to the fibroadenomas of the breast. The top 5 up-regulated genes were FN1, IL3, CDC6, FGF8 and BMP8A. The top 5 down-regulated genes were TNR, CDKN2A, COL5A1, THBS4 and BMPR1B. The differentially expressed genes (DEGs) were found to be associated with 5 major canonical pathways involved in cell growth (PI3K-AKT, cell cycle regulation, WNT, and RAS signalling) and immune response (JAK-STAT signalling). Further analyses using 3 supervised learning algorithms identified an 8-gene signature (FN1, CDC6, IL23A, CCNA1, MCM4, FLT1, FGF22 and COL5A1) that could distinguish giant fibroadenomas from fibroadenomas with high predictive accuracy.

CONCLUSION

Our findings demonstrated that the giant fibroadenomas are biologically distinct to fibroadenomas of the breast with overexpression of genes involved in the regulation of cell growth and immune response.

Potential Residual Contaminants in Edible Bird's Nest

Edible bird’s nest (EBN) is recognized as a nourishing food among Chinese people. The efficacy of EBN was stated in the records of traditional Chinese medicine and its activities have been reported in many researches. Malaysia is the second largest exporter of EBNs in the world, after Indonesia. For many years, EBN trade to China was not regulated until August 2011, when a safety alert was triggered for the consumption of EBNs. China banned the import of EBNs from Malaysia and Indonesia due to high level of nitrite. Since then, the Malaysia government has formulated Malaysia Standards for swiftlet farming (MS 2273:2012), edible bird’s nest processing plant design and management (MS 2333:2010), and edible bird’s nest product quality (MS 2334:2011) to enable the industry to meet the specified standards for the export to China. On the other hand, Indonesia's EBN industry formulated a standard operating procedure (SOP) for exportation to China. Both countries can export EBNs to China by complying with the standards and SOPs. EBN contaminants may include but not limited to nitrite, heavy metals, excessive minerals, fungi, bacteria, and mites. The possible source of contaminants may come from the swiftlet farms and the swiftlets or introduced during processing, storage, and transportation of EBNs, or adulterants. Swiftlet house design and management, and EBN processing affect the bird’s nest color. Degradation of its optical quality has an impact on the selling price, and color changes are tied together with nitrite level. In this review, the current and future prospects of EBNs in Malaysia and Indonesia in terms of their quality, and the research on the contaminants and their effects on EBN color changes are discussed.

Impact of Microplastics and Nanoplastics on Human Health

Plastics have enormous impacts to every aspect of daily life including technology, medicine and treatments, and domestic appliances. Most of the used plastics are thrown away by consumers after a single use, which has become a huge environmental problem as they will end up in landfill, oceans and other waterways. These plastics are discarded in vast numbers each day, and the breaking down of the plastics from micro- to nano-sizes has led to worries about how toxic these plastics are to the environment and humans. While, there are several earlier studies reported the effects of micro- and nano-plastics have on the environment, there is scant research into their impact on the human body at subcellular or molecular levels. In particular, the potential of how nano-plastics move through the gut, lungs and skin epithelia in causing systemic exposure has not been examined thoroughly. This review explores thoroughly on how nanoplastics are created, how they behave/breakdown within the environment, levels of toxicity and pollution of these nanoplastics, and the possible health impacts on humans, as well as suggestions for additional research. This paper aims to inspire future studies into core elements of micro- and nano-plastics, the biological reactions caused by their specific and unusual qualities.

Molecular Mechanisms and Potential Therapeutic Reversal of Pancreatic Cancer-Induced Immune Evasion

Pancreatic cancer ranks high among the causes of cancer-related mortality. The prognosis of this grim condition has not improved significantly over the past 50 years, despite advancement in imaging techniques, cancer genetics and treatment modalities. Due to the relative difficulty in the early detection of pancreatic tumors, as low as 20% of patients are eligible for potentially curative surgery; moreover, chemotherapy and radiotherapy (RT) do not confer a great benefit in the overall survival of the patients. Currently, emerging developments in immunotherapy have yet to bring a significant clinical advantage among pancreatic cancer patients. In fact, pancreatic tumor-driven immune evasion possesses one of the greatest challenges leading to immunotherapeutic resistance. Most of the immune escape pathways are innate, while poor priming of hosts' immune response and immunoediting constitute the adaptive immunosuppressive machinery. In this review, we extensively discuss the pathway perturbations undermining the anti-tumor immunity specific to pancreatic cancer. We also explore feasible up-and-coming therapeutic strategies that may restore immunity and address therapeutic resistance, bringing hope to eliminate the status quo in pancreatic cancer prognosis.

Therapeutic challenges and current immunomodulatory strategies in targeting the immunosuppressive pancreatic tumor microenvironment

BACKGROUND

Pancreatic cancer is one of the most lethal type of cancers, with an overall five-year survival rate of less than 5%. It is usually diagnosed at an advanced stage with limited therapeutic options. To date, no effective treatment options have demonstrated long-term benefits in advanced pancreatic cancer patients. Compared with other cancers, pancreatic cancer exhibits remarkable resistance to conventional therapy and possesses a highly immunosuppressive tumor microenvironment (TME).

MAIN BODY

In this review, we summarized the evidence and unique properties of TME in pancreatic cancer that may contribute to its resistance towards immunotherapies as well as strategies to overcome those barriers. We reviewed the current strategies and future perspectives of combination therapies that (1) promote T cell priming through tumor associated antigen presentation; (2) inhibit tumor immunosuppressive environment; and (3) break-down the desmoplastic barrier which improves tumor infiltrating lymphocytes entry into the TME.

CONCLUSIONS

It is imperative for clinicians and scientists to understand tumor immunology, identify novel biomarkers, and optimize the position of immunotherapy in therapeutic sequence, in order to improve pancreatic cancer clinical trial outcomes. Our collaborative efforts in targeting pancreatic TME will be the mainstay of achieving better clinical prognosis among pancreatic cancer patients. Ultimately, pancreatic cancer will be a treatable medical condition instead of a death sentence for a patient.

Mutational Signatures in Mandibular Ameloblastoma Correlate with Smoking

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

Morphology of Glycycometus malaysiensis, a domestic mite in Malaysia

Glycycometus malaysiensis is an allergenic domestic mite found in houses. G. malaysiensis is known to be highly similar to and is often mistaken as Blomia tropicalis, one of the major house dust mite species that causes asthma and allergic diseases in many tropical and subtropical regions. It was also suggested that these mites cross-react with each other and that the prevalence of G. malaysiensis might be higher than previous reports. A review on the taxonomic keys as well as light and scanning electron micrographs of G. malaysiensis are presented to appreciate the fine morphological structures of G. malaysiensis. The mouth, setae, legs (trochanter, femur, genu, tibia and tarsus) and the sexual organs (genital openings, genital setae and genital suckers) of G. malaysiensis are outlined. The morphology of G. malaysiensis is also compared with that of B. tropicalis to delineate the key features for the differentiation between these two mite species.

Parasites in soil samples from Signy island, Antarctica

Studies on parasite populations in Antarctic soils are scarce and thus little is known about the threat of these parasites towards either the natural fauna or human visitors. However, human presence in Antarctica, mainly through research and tourism, keeps increasing over time, potentially exposing visitors to zoonotic infections from Antarctic wildlife and environment. Most available literature to date has focused on faecal samples from Antarctic vertebrates. Therefore, this study addressed the possible presence of parasites in Antarctic soil that may be infectious to humans. Soil samples were obtained from five locations on Signy Island (South Orkney Islands, maritime Antarctic), namely North Point and Gourlay Peninsula (penguin rookeries), Pumphouse (relic coal-powered pump house), Jane Col (barren high altitude fellfield) and Berntsen Point (low altitude vegetated fellfield close to current research station). Approximately 10% of the soil samples (14/135) from 3 out of the 5 study sites had parasites which included Diphyllobotridae spp. eggs, Cryptosporidium sp., an apicomplexan protozoa (gregarine), Toxoplasma gondii, helminths (a cestode, Tetrabothrius sp., and a nematode larva) and mites. The presence of parasites in the 3 sites are most likely due to the presence of animal and human activities as two of these sites are penguin rookeries (North Point and Gourlay Peninsula) while the third site (Pumphouse Lake) has human activity. While some of the parasite species found in the soil samples appear to be distinctive, there were also parasites such as Cryptosporidium and Toxoplasma gondii that have a global distribution and are potentially pathogenic.

The first pilot study of expanded newborn screening for inborn errors of metabolism and survey of related knowledge and opinions of health care professionals in Hong Kong

INTRODUCTION

Newborn screening is important for early diagnosis and effective treatment of inborn errors of metabolism (IEM). In response to a 2008 coroners' report of a 14-year-old boy who died of an undiagnosed IEM, the OPathPaed service model was proposed. In the present study, we investigated the feasibility of the OPathPaed model for delivering expanded newborn screening in Hong Kong. In addition, health care professionals were surveyed on their knowledge and opinions of newborn screening for IEM.

METHODS

The present prospective study involving three regional hospitals was conducted in phases, from 1 October 2012 to 31 August 2014. The 10 steps of the OPathPaed model were evaluated: parental education, consent, sampling, sample dispatch, dried blood spot preparation and testing, reporting, recall and counselling, confirmation test, treatment and monitoring, and cost-benefit analysis. A fully automated online extraction system for dried blood spot analysis was also evaluated. A questionnaire was distributed to 430 health care professionals by convenience sampling.

RESULTS

In total, 2440 neonates were recruited for newborn screening; no true-positive cases were found. Completed questionnaires were received from 210 respondents. Health care professionals supported implementation of an expanded newborn screening for IEM. In addition, there is a substantial need of more education for health care professionals. The majority of respondents supported implementing the expanded newborn screening for IEM immediately or within 3 years.

CONCLUSION

The feasibility of OPathPaed model has been confirmed. It is significant and timely that when this pilot study was completed, a government-led initiative to study the feasibility of newborn screening for IEM in the public health care system on a larger scale was announced in the Hong Kong Special Administrative Region Chief Executive Policy Address of 2015.

Sero-prevalence study of IgE responses to allergens from Malaysian house dust (HDM) and storage mites (SM)

Allergens of Dermatophagoides and Blomia species are well-characterized but not for other species. This study was conducted to determine the prevalence of allergic sensitization to house dust (HDM) and storage mites (SM). One hundred adult subjects (aged ≥ 18) were recruited. The mite specific IgE of all allergic subjects were higher compared with healthy subjetcs despite being not statistically significant except for D. farinae and G. malaysiensis. The mean serum IgE levels against HDM and SM for allergic subjects were significantly higher compared with those in healthy subjects. They were mainly sensitized to Dermatophagoides farinae (35%) and Glycycometus malaysiensis (37%). Immunoblots revealed not all allergic subjects showed positive immuno-reactivity against the mites tested. Single or multiple bands were observed for different species. The subjects were commonly sensitized to Group 2 (9-12 kDa), 10 (38 kDa) and 18 (40-48 kDa) allergens. Twenty-one out of 60 allergic subjects were sensitized to either one or more species. The majority of them (71%) were sensitized to single species. The allergic subjects were mainly sensitized to D. pteronyssinus, followed by Tyrophagus putrecentiae and Aleuroglyphus ovatus. Seven were solely sensitized to HDM while 10 were solely sensitized to SM. Four subjects were sensitized to both. Pre-adsorption study revealed no cross-reactivity. There was difference between the prevalence and reactivity to allergens of HDM and SM in these subjects. Both ELISA and immunoblot did not correlate well but can complement each other in improving the detection of mite allergens to the species level.

Isolation and identification of mites associated with raw and commercial farm edible bird nests

The global demand for edible bird nests (EBNs) is high, especially from Hong Kong and Peoples Republic of China. Recently, this industry was greatly affected when China banned the import of all the EBNs from Malaysia (except for canned version) due to detection of high levels of nitrites. Several cases of anaphylaxis following ingestion of EBNs were reported. The source(s) of these allergens remain unknown. Mites have been reported to trigger allergic responses. Hence, this study was designed to quantify, isolate and identify the mites that are associated with EBNs. The raw EBNs were purchased from swiftlet farms in five locations in Peninsular Malaysia while the commercial nests were purchased from five different Chinese traditional medicinal shops. The average mite density of all the raw nests was 285 ± 603 mites per gram of EBN while the commercial nests had a much lower mean value of 21 ± 32 mites per gram of EBN (p = 0.082). Among the raw EBNs, the nests from Kajang had the highest average mite density (946 ± 1443 mites/g of EBN) whereas the nests from Kuala Sanglang had the lowest (54 ± 34 mites/g of EBN). Among the commercial EBNs, the nests from Company D had the highest average mite density (76 ± 18 mites/g of EBN) whereas the nests from Company A were free of mites. Overall, the average densities of mites in the raw nests obtained from southern regions of Malaysia (Selangor and Johor) were higher than those nests obtained from the northern regions (Kedah and Kelantan). Thirty types of mites were isolated from both the raw and commercial nests. Among these, some are probably feather mites (Eustathia cultrifer, Pteroherpus garrulacis, Pterodectes amaurochalinus, Laminalloptes sp., Berlesella alata and Neochauliacia sp.), house dust and storage mites (Suidasia sp., Austroglycyphagus sp., and Aleuroglyphus ovatus), mesostigmatid mites (Dermanyssus sp.), prostigmatid mites (Cheyletus sp., tarsonemid and cunaxid mites), astigmatid mites (Collocalidectes sp., Streetacarus sp. and Hemisarcoptes sp.) and oribatid mites. This study provides baseline information on the density and type of mites that are probably associated with EBNs. This study also heightens the importance of mites as a possible source of EBN-associated anaphylaxis.

Association between pregnancy-associated plasma protein-A levels in the first trimester and gestational diabetes mellitus in Chinese women

INTRODUCTION

Several studies have shown that women with pre-existing diabetes mellitus have significantly lower pregnancy-associated plasma protein-A levels than those without. This study aimed to evaluate whether first-trimester pregnancy-associated plasma protein-A multiple of median is associated with gestational diabetes mellitus in Chinese pregnant women.

METHODS

This prospectively collected case series was conducted in a regional hospital in Hong Kong. All consecutive Chinese women with a singleton pregnancy who attended the hospital for their first antenatal visit (before 14 weeks' gestation) from April to July 2014 were included. Pregnancy-associated plasma protein-A multiple of median was compared between the gestational diabetic (especially for early-onset gestational diabetes) and non-diabetic groups. The correlation between pregnancy-associated plasma protein-A level and glycosylated haemoglobin level in women with gestational diabetes was also examined.

RESULTS

Of the 520 women recruited, gestational diabetes was diagnosed in 169 (32.5%). Among them, 43 (25.4%) had an early diagnosis, and 167 (98.8%) with the disease were managed by diet alone. The gestational diabetic group did not differ significantly to the non-diabetic group in pregnancy-associated plasma protein-A (0.97 vs 0.99, P=0.40) or free β-human chorionic gonadotrophin multiple of median (1.05 vs 1.02, P=0.29). Compared with the non-gestational diabetic group, women with early diagnosis of gestational diabetes had a non-significant reduction in pregnancy-associated plasma protein-A multiple of median (median, interquartile range: 0.86, 0.57-1.23 vs 0.99, 0.67-1.44; P=0.11). Pregnancy-associated plasma protein-A and glycosylated haemoglobin levels were not correlated in women with gestational diabetes (r=0.027; P=0.74).

CONCLUSIONS

Chinese women with non-insulin-dependent gestational diabetes did not exhibit significant changes to pregnancy-associated plasma protein-A multiple of median nor a correlation between pregnancy-associated plasma protein-A with glycosylated haemoglobin levels. Pregnancy-associated plasma protein-A multiple of median was not predictive of non-insulin-dependent gestational diabetes or early onset of gestational diabetes. There was a high prevalence of gestational diabetes in the Chinese population.

Field evaluation of a rapid diagnostic test to detect antibodies in human toxocariasis

Human toxocariasis which is caused mainly by the larvae of Toxocara canis and Toxocara cati, is a worldwide zoonotic disease that can be a potentially serious human infection. The enzyme-linked immunosorbent assay (ELISA) using T. canis excretory-secretory (TES) antigens harvested from T. canis larvae is currently the serological test for confirming toxocariasis. An alternative to producing large amounts of Toxocara TES and improved diagnosis for toxocariasis is through the development of highly specific recombinant antigens such as the T. canis second stage larva excretory-secretory 30 kDa protein (recTES-30). The aim of this study was to evaluate the sensitivity and specificity of a rapid diagnostic kit (RDT, named as iToxocara kit) in comparison to recTES-30 ELISA in Serendah Orang Asli village in Selangor, Malaysia. A total of 133 subjects were included in the study. The overall prevalence rates by ELISA and RDT were 29.3% and 33.1%, respectively, with more positive cases detected in males than females. However, no association was found between toxocariasis and gender or age. The percentage sensitivity, specificity, positive predictive value and negative predictive value of RDT were 85.7%, 90.1%, 80% and 93.2%, respectively. The prevalence for toxocariasis in this population using both ELISA and RDT was 27.1% (36/133) and the K-concordance test suggested good agreement of the two tests with a Cohen's kappa of 0.722, P<0.01. In addition, the followed-up Spearman rank correlation showed a moderately high correlation at R=0.704 and P<0.01. In conclusion, the RDT kit was faster and easier to use than an ELISA and is useful for the laboratory diagnosis of hospitalized cases of toxocariasis.

Mutant p53-R273H mediates cancer cell survival and anoikis resistance through AKT-dependent suppression of BCL2-modifying factor (BMF)

p53 is the most frequently mutated tumor-suppressor gene in human cancers. Unlike other tumor-suppressor genes, p53 mutations mainly occur as missense mutations within the DNA-binding domain, leading to the expression of full-length mutant p53 protein. Mutant p53 proteins not only lose their tumor-suppressor function, but may also gain new oncogenic functions and promote tumorigenesis. Here, we showed that silencing of endogenous p53-R273H contact mutant, but not p53-R175H conformational mutant, reduced AKT phosphorylation, induced BCL2-modifying factor (BMF) expression, sensitized BIM dissociation from BCL-X_L and induced mitochondria-dependent apoptosis in cancer cells. Importantly, cancer cells harboring endogenous p53-R273H mutant were also found to be inherently resistant to anoikis and lack BMF induction following culture in suspension. Underlying these activities is the ability of p53-R273H mutant to suppress BMF expression that is dependent on constitutively active PI3K/AKT signaling. Collectively, these findings suggest that p53-R273H can specifically drive AKT signaling and suppress BMF expression, resulting in enhanced cell survivability and anoikis resistance. These findings open the possibility that blocking of PI3K/AKT will have therapeutic benefit in mutant p53-R273H expressing cancers.

Structural analysis of raw and commercial farm edible bird nests

Edible bird nests (EBNs) are consumed worldwide for various health benefits. EBNs are nests built from the saliva of swiftlets of Aerodramus species. The global market for EBNs is on the rise, especially from Hong Kong and mainland China. In the past, EBNs were harvested mainly from natural caves; however in the recent years, there has been a rapid growth of swiftlet farming. Little is known about the actual composition of EBNs except for protein, carbohydrate, ash and lipid contents, amino acids, vitamins and macro/ micronutrients. Besides the biochemical components of EBNs, are there any other structures that are associated with EBNs? This paper reports on the structural analysis of raw unprocessed farm and processed commercial EBNs. The raw EBNs were purchased from swiftlet farms in five locations in Peninsula Malaysia: Kuala Sanglang (Perlis; 6° 16' 0"N, 100° 12' 0"E), Pantai Remis (Perak; 4º 27' 0" N, 100º 38' 0" E), Kluang (Johor; 02º 012 303N 103º 192 583E), Kajang (Selangor; 2º 59' 0"N, 101º 47' 0"E) and Kota Bharu (Kelantan; 6º 8' 0"N, 102º 15' 0"E). The commercial nests were purchased from five different Chinese traditional medicinal shops (Companies A-E). A portion of each EBN was randomly broken into small fragments, attached to carbon tape and coated with gold and palladium particles for examination and photography under a scanning electron microscope. Structural analysis revealed the presence of mites, fungi, bacteria and feather strands on both the raw and commercial nests. Mite eggshells and faecal pellets, and body parts of other arthropods were seen only in the raw nests. The commercial nests had a variety of unidentified structures and substances coated on the nests' surfaces that were not found on the raw nests. The presence of these contaminants may jeopardise the quality of EBNs and pose health risks to consumers. Further identification of the mites and their allergens, fungi and bacteria are on-going and will be reported separately.

Multicenter retrospective analysis of metastatic colorectal cancer (CRC) with high-level microsatellite instability (MSI-H)

BACKGROUND

The microsatellite instability-high (MSI-H) phenotype, present in 15% of early colorectal cancer (CRC), confers good prognosis. MSI-H metastatic CRC is rare and its impact on outcomes is unknown. We describe survival outcomes and the impact of chemotherapy, metastatectomy, and BRAF V600E mutation status in the largest reported cohort of MSI-H metastatic colorectal cancer (CRC).

PATIENTS AND METHODS

A retrospective review of 55 MSI-H metastatic CRC patients from two institutions, Royal Melbourne Hospital (Australia) and The University of Texas MD Anderson Cancer Center (United States), was conducted. Statistical analyses utilized Kaplan-Meier method, Log-rank test, and Cox proportional hazards models.

RESULTS

Median age was 67 years (20-90), 58% had poor differentiation, and 45% had stage IV disease at presentation. Median overall survival (OS) from metastatic disease was 15.4 months. Thirteen patients underwent R0/R1 metastatectomies, with median OS from metastatectomy 33.8 months. Thirty-one patients received first-line systemic chemotherapy for metastatic disease with median OS from the start of chemotherapy 11.5 months. No statistically significant difference in progression-free survival or OS was seen between fluoropyrimidine, oxaliplatin, or irinotecan based chemotherapy. BRAF V600E mutation was present in 14 of 47 patients (30%). BRAF V600E patients demonstrated significantly worse median OS; 10.1 versus 17.3 months, P = 0.03. In multivariate analyses, BRAF V600E mutants had worse OS (HR 4.04; P = 0.005), while patients undergoing metastatectomy (HR 0.11; P = <0.001) and patients who initially presented as stage IV disease had improved OS (HR 0.27; P = 0.003).

CONCLUSIONS

Patients with MSI-H metastatic CRC do not appear to have improved outcomes. BRAF V600E mutation is a poor prognostic factor in MSI-H metastatic CRC.

Local perspective on a rare brain tumour: adult medulloblastoma

BACKGROUND

Little contemporary data are available regarding Australian patterns of care in adult medulloblastoma. It is unclear whether treatment, extrapolated from paediatric protocols despite known differences between the two groups, results in comparable efficacy.

AIM

To perform a retrospective review of patterns of care in adult medulloblastoma, especially with respect to adjuvant chemotherapy, in Australian patients.

METHODS

All medulloblastoma patients aged 15 years or older at two neuro-oncology institutions were identified from January 1995-May 2011. Patients with supratentorial or peripheral tumours were excluded. Standardised data were extracted from each institution regarding symptoms, disease staging, treatments received, toxicities and survival outcomes.

RESULTS

Seventeen eligible patients were identified. Median age was 37 years (range 20-67 years). All had good performance status (Eastern Cooperative Oncology Group 0-1). There were 11 standard-risk de novo patients, three high-risk de novo patients and three patients with recurrent disease. Median overall survival (OS) had not been reached for standard-risk patients with median follow up of 58 months. The median OS for high-risk de novo patients was 21 months, while the median OS was 15 months for patients with recurrent disease. Treatment was well tolerated, with haematological toxicities being most common.

CONCLUSIONS

Combined modality therapy (surgery followed by postoperative radiotherapy and adjuvant chemotherapy) was well tolerated and associated with good outcomes in standard-risk de novo patients. High-risk and recurrent disease patients do extremely poorly regardless of treatment and better treatment strategies are needed in these patients.

Marantic endocarditis presenting with multifocal neurological symptoms

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, has been reported to occur in 0.3-9.3% of the adult population at autopsy. NBTE associated with malignancy is an underrecognised cause of thromboembolic disorders. The clinical spectrum encountered and investigation results can be non-specific, often mimicking other acute conditions such as infective endocarditis. We describe the case of a 34-year-old woman with non-localising and multifocal neurological symptoms, who was subsequently diagnosed with NBTE secondary to a resectable primary lung adenocarcinoma.

Towards complete eradication of hepatitis B infection from perinatal transmission: review of the mechanisms of in utero infection and the use of antiviral treatment during pregnancy

Hepatitis B infection remains the most common form of chronic hepatitis. Mother to child transmission occurs despite immunoprophylaxis with vaccination and immunoglobulin. In utero infection is suggested to account for most of the cases with immunoprophylaxis failure. Infants who suffer from hepatitis B infection at birth have a higher risk of becoming chronic carriers and may develop liver cirrhosis or hepatocellular carcinoma in the future. Infected germ cells, transplacental infection, invasive prenatal diagnostic tests and various perinatal factors are possible factors leading to in utero infection and subsequent immunoprophylaxis failure. Hepatitis B e antigen positive status and high viral load increase the risk of immunoprophylaxis failure. Recent evidence shows promising results regarding the use of antiviral treatment in late gestation to suppress viral load, so as to decrease the risk of vertical transmission. This review discusses the possible mechanisms of in utero infection and the use of antiviral treatment during pregnancy.

A single centre study of the treatment of relapsed primary central nervous system lymphoma (PCNSL) with single agent temozolomide

Primary central nervous system lymphoma (PCNSL) is a rare form of extra-nodal non-Hodgkin lymphoma. Although recommendations for first-line treatment usually incorporate high-dose methotrexate, there is substantial heterogeneity in the types of salvage therapies used at relapse. Phase II data supported the use of temozolomide as a well-tolerated treatment modality in this setting. Therefore, we reviewed the treatment and outcomes of patients with relapsed PCNSL who were treated with salvage temozolomide at our institution. Seven patients were treated with salvage temozolomide between January 2000 and May 2011. The objective response rate was 14%. Progression-free survival was 2 months (95% confidence interval [CI]: 0-5.9) and median overall survival was 4 months (95% CI: 0-13). Toxicity was mild, with one episode of grade 3 neutropenia during 25 cycles of chemotherapy. Although these results are consistent with previous phase II results, the outcomes for these patients remain extremely poor. The low toxicity of temozolomide raises the possibility of combining temozolomide with other chemotherapeutic agents or targeted agents in future clinical trials.

Differential expression of the angiogenesis growth factors in psoriasis vulgaris

Background

Angiogenesis has been reported to be one of the contributory factors to the pathogenesis of psoriasis vulgaris. This study aims to compare the expression of different angiogenesis growth factors namely (1) the vascular endothelial growth factor (VEGF) subfamily: A, B, C, D and placenta growth factor (PlGF); (2) nerve growth factor (NGF) and (3) von Willebrand factor (vWFr) in the skins of patients with psoriasis vulgaris and non-psoriatic volunteers.

Results

Comparative immunohistochemistry study was performed on the paraffin-sectioned psoriatic and healthy skins with the abovementioned markers. VEGF-C (p = 0.016) and NGF (p = 0.027) were expressed intensely in the cases when compared with the controls. The NGF was the only marker that was solely expressed in the cases and absent in all the controls.

Conclusion

The NGF (angiogenesis) and VEGF-C (lymphangiogenesis) might play a crucial role in the pathogenesis of psoriasis vulgaris and could be researched further as potential new targeted therapies for psoriasis vulgaris.

Antigenic profile of Blomia tropicalis, Aleuroglyphus ovatus and Glycycometus malaysiensis

House dust mites and storage mites are well-known causes for allergenic diseases. The aim of this study was to investigate the immunogenic sites of Blomia tropicalis, Aleurogyphus ovatus and Glycycometus malaysiensis. The mites were maintained in a culture medium at 25ºC and 75% relative humidity. Mites were harvested either with heat escape or floatation method, purified, homogenized, quantified and used for the production of polyclonal antibody and immunostaining. For each species of mites, five male mice and five male rats were randomly selected and immunized intraperitoneally with respective crude mite extract at two-weekly intervals. Blomia tropicalis, A. ovatus or G. malaysiensis whole mites and paraffin-embedded mite sections were immunostained with the respective polyclonal antibody. The faecal pellets of mites were intensely stained for all the three species in the present study. The legs of sectioned A. ovatus were not immunogenic as compared with those of G. malaysiensis and B. tropicalis. The outer layer (cuticle) of whole mites and the eggs for these species were very immunogenic. Hence, the polyclonal antibodies obtained in this study may serve as potential tools in detecting the eggs and immature mites in environmental samples. Future studies should focus on the antigenic components of eggs since they were relatively abundant in dust and highly antigenic as seen in the present study.

Ductus venosus velocimetry in monitoring pregnancy in women with pregestational diabetes mellitus

OBJECTIVE

The purpose of this research was to assess the ability of ductus venosus (DV) Doppler velocimetry to predict adverse perinatal outcome in pregnancies complicated by pre-existing diabetes mellitus.

METHODS

This was a prospective study conducted at a tertiary referral obstetric facility in Brisbane, Australia. The study group included women with pregestational diabetes mellitus who delivered in the hospital between 1 January 1995 and 31 December 2006. The DV Doppler index was defined as abnormal if the DV peak velocity index for veins (PVIV) was equal to or greater than the 95(th) percentile for gestation. Adverse perinatal outcome included one or more of the following criteria: small-for-gestational-age infant; Cesarean section for non-reassuring fetal status; fetal acidemia at delivery; a 1-min Apgar score of <or= 3; a 5-min Apgar score of < 7; hypoxic ischemic encephalopathy; and stillbirth or neonatal death. The maternal characteristics and perinatal outcomes of pregnancies with normal or abnormal DV Doppler indices were compared.

RESULTS

Eighty-two pregestational diabetic pregnancies were studied and an abnormal DV-PVIV was identified in 25 (30.5%). Adverse perinatal outcome was identified in eight of 25 (32.0%) pregnancies with an abnormal DV-PVIV compared to seven of 57 (12.3%) pregnancies with a normal DV-PVIV (P < 0.05). The sensitivity of the DV-PVIV in predicting adverse perinatal outcomes in pregestational diabetic pregnancies was 53.3%, the specificity was 74.6%, the positive predictive value was 32.0% and the negative predictive value was 87.7%.

CONCLUSION

It may be useful to include DV-PVIV in the antenatal screening of pregnancies complicated by pregestational diabetes.

Influence of polyhydramnios on perinatal outcome in pregestational diabetic pregnancies

OBJECTIVE

This study was carried out to evaluate the perinatal outcomes of pregnancy with pregestational diabetes mellitus complicated by polyhydramnios.

METHODS

This was a retrospective study of singleton pregnancies, with an antepartum diagnosis of polyhydramnios, seen at the maternal fetal medicine department of Mater Mothers' Hospital, a tertiary-level facility. All pregnancies in women with pregestational diabetes with a singleton pregnancy beyond 24 weeks of gestation, from 1996 to 2006, were reviewed (n = 314), and pregnancies complicated by polyhydramnios were identified (n = 59). Pregnancy outcomes of women whose pregnancy was complicated with polyhydramnios were compared to those without this complication.

RESULTS

The incidence of polyhydramnios in the study population was 18.8%. Women with polyhydramnios had increased hemoglobin A1c (HbA1c) levels throughout the pregnancy, and the difference was significant during the prepregnancy period and in the third trimester (P = 0.003 and P = 0.025, respectively). Significantly more mothers in the polyhydramnios group delivered preterm (54.2% vs. 33.3%, P = 0.004), the majority of which were iatrogenic preterm deliveries (44.1%). More pregnancies with polyhydramnios were delivered by Cesarean section (83.0% vs. 62%; P = 0.006), with the majority being performed electively in both groups (79.6% and 70.3%, respectively). Regardless, there were no significant differences in perinatal mortality rates, congenital abnormality rates, the incidences of low Apgar score, acidemia, hypoglycemia requiring intravenous therapy, phototherapy and ventilatory needs between the babies of the two groups.

CONCLUSION

Pregestational diabetic pregnancy with polyhydramnios is associated with poor diabetic control. Despite this, there is no significant increase in adverse perinatal outcome in these pregnancies, apart from a higher iatrogenic preterm birth rate.

Health Promotion Board-Ministry of Health clinical practice guidelines: functional screening for older adults in the community

The Health Promotion Board (HPB) and the Ministry of Health (MOH) publish clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HPB-MOH clinical practice guidelines on Functional Screening for Older Adults in the Community, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Health Promotion Board website (http://www.hpb.gov.sg/uploadedFiles/HPB_Online/Publications/CPGFunctionalscreening.pdf). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

A comparative histopathological study of systemic candidiasis in association with experimentally induced breast cancer

Systemic candidiasis is a fungal infection which coupled with solid malignancies places patients at high risk of succumbing to the disease. Few studies have shown evidence of the relationship between systemic candidiasis and malignancy-induced immunosuppression disease especially in breast cancer. At present, animal studies that exclusively demonstrate this relationship have yet to be conducted. The exact causative mechanism of systemic candidiasis is currently under much speculation. This study therefore aimed to demonstrate this relationship by observing the histopathological changes of organs harvested from female Balb/c mice which were experimentally induced with breast cancer and inoculated with systemic candidiasis. The mice were randomly assigned to five different groups (n=12). The first group (group 1) was injected with phosphate buffer solution, the second (group 2) with systemic candidiasis, the third (group 3) with breast cancer and the final two groups (groups 4 and 5) had both candidiasis and breast cancer at two different doses of candidiasis, respectively. Inoculation of mice with systemic candidiasis was performed by an intravenous injection of Candida albicans via the tail vein following successful culture methods. Induction of mice with breast cancer occurred via injection of 4T1 cancer cells at the right axillary mammary fatpad after effective culture methods. The prepared slides with organ tissues were stained with hematoxylin and eosin, periodic acidic schiff and gomori methenamine silver stains for a histopathological analysis. Grading of primary tumour and identification of metastatic deposits, as well as scoring of inflammation and congestion in all the respective organs was conducted. Statistical tests performed to compare groups 2 and 4 showed that group 4 exhibited a highly statistically significant increase in organ inflammation and congestion (p<0.01). The median severity of candidiasis in the kidneys and liver also increased in group 4 as compared to group 2. In conclusion, based on the above evidence, systemic candidiasis significantly increased in mice with breast cancer.

Pregnancy in type 2 diabetes mellitus--problems & promises

The parallel epidemics of obesity and Type 2 diabetes (T2DM) are progressing rapidly in Australia. The high prevalence of obesity and sedentary lifestyle in the population, compounded by later child bearing, has led to an increase in the prevalence of T2DM pre-dating pregnancy. In some centers, pregnant women with T2DM now outnumber those with type 1 diabetes (T1DM). Although there is controversy as to whether T2DM is associated with worse outcomes than T1DM in pregnancy, modern reports clearly acknowledge the seriousness of this condition. There is a clear association between obesity and adverse pregnancy outcomes (cesarean section, gestational diabetes, hypertensive disorders, birth defects and prematurity). Aside from obesity and the metabolic syndrome, additional factors may contribute to these adverse outcomes: A lack of preconception planning, a failure to achieve tight glycaemic control early in pregnancy and socio-economic disadvantage. It's likely that obesity and diabetes have compounding effects on pregnancy outcomes. In this review, we evaluate both the underlying pathogenesis of T2DM and obesity in the pregnancy context and the adverse clinical maternal and perinatal outcomes described in pregnancies complicated by maternal T2DM and obesity. We highlight the need for a comprehensive strategy to improve clinical outcomes in these pregnancies.

Women with placenta praevia and antepartum haemorrhage have a worse outcome than those who do not bleed before delivery

We set out to assess the maternal and neonatal outcomes of women with placenta praevia and antepartum haemorrhage (APH) between 1991 and 1997, compared with woman with a diagnosed placenta praevia who did not bleed. The demographic data, maternal and perinatal outcomes of 159 women with antepartum haemorrhage were compared with 93 women without antepartum haemorrhage in a retrospective study. Women with antepartum haemorrhage had the diagnosis of placenta praevia confirmed at an earlier gestation. More women with antepartum haemorrhage received antenatal steroids and tocolytic agents, and had emergency caesarean sections. The majority of women with bleeding had an emergency caesarean section for antepartum haemorrhage and more delivered early because of fetal distress. There were more preterm deliveries in women with antepartum haemorrhage. The mean birth weight was 2.69 kg in the women with antepartum haemorrhage and 3.06 kg in those without. More infants in the bleeding group had a low Apgar score at the first minute, respiratory distress syndrome, and admission to special baby care and neonatal intensive care unit. It is concluded that there is an increased risk of premature delivery in women with antepartum haemorrhage and placenta praevia. Aggressive management, tocolysis and cervical cerclage should be explored further to improve the perinatal outcome. Women without antepartum haemorrhage can be managed on an outpatient basis.

Comparison of nuchal and detailed morphology ultrasound examinations in early pregnancy for fetal structural abnormality screening: a randomized controlled trial

OBJECTIVE

To compare the effectiveness of a nuchal scan at 10 to 14 + 6 weeks and a detailed morphology scan at 12 to 14 + 6 weeks in screening for fetal structural abnormalities.

METHODS

From March 2001 to November 2004, 8811 pregnant women were randomized into either the control group (10 to 14 + 6-week nuchal scan followed by routine 16-23-week scan) or the study group (10 to 14 + 6-week nuchal scan and 12 to 14 + 6-week detailed scan followed by routine 16-23-week scan).

RESULTS

We analyzed 7642 cases of singleton pregnancies with viable fetuses at first-trimester ultrasound examination and with known pregnancy outcome. In the control group, the detection rate of structural abnormalities in the first trimester was 32.8% (21/64; 95% CI, 21.6-45.7%) and the overall detection rate was 64.1% (41/64; 95% CI, 51.1-75.7%). In the study group, the detection rate in the first trimester was 47.6% (30/63; 95% CI, 34.9-60.6) and the overall detection rate was 66.7% (42/63; 95% CI, 53.7-78.0%). The overall detection rate in the control group did not differ significantly from that in the study group (P > 0.05).

CONCLUSIONS

When the nuchal scan is offered, a basic anatomical survey can be done in conjunction with nuchal translucency thickness measurement. A detailed ultrasound examination at this early gestational age may not be superior to the nuchal scan in screening for fetal abnormalities in the low-risk population. Though a wide range of abnormalities can be detected at 10 to 14 + 6 weeks, the routine 16-23-week scan cannot be abandoned.

Rapid aneuploidy testing (knowing less) versus traditional karyotyping (knowing more) for advanced maternal age: what would be missed, who should decide?

OBJECTIVES

The application of rapid aneuploidy testing as a stand-alone approach in prenatal diagnosis is much debated. The major criticism of this targeted approach is that it will not detect other chromosomal abnormalities that will be picked up by traditional karyotyping. This study aimed to study the nature of such chromosomal abnormalities and whether parents would choose to terminate affected pregnancies.

DESIGN

Retrospective study on a cytogenetic database.

SETTING

Eight public hospitals in Hong Kong.

PARTICIPANTS

The karyotype results of 19 517 amniotic fluid cultures performed for advanced maternal age (>or=35 years) from 1997 to 2002 were classified according to whether they were detectable by rapid aneuploidy testing. The outcomes of pregnancies with abnormal karyotypes were reviewed from patient records.

RESULTS

In all, 333 (1.7%) amniotic fluid cultures yielded abnormal karyotypes; 175 (52.6%) of these were detected by rapid aneuploidy testing, and included trisomy 21 (n=94, 28.2%), trisomy 18 or 13 (n=21, 6.3%), and sex chromosome abnormalities (n=60, 18.0%). The other 158 (47.4%) chromosomal abnormalities were not detectable by rapid aneuploidy testing, of which 63 (18.9%) were regarded to be of potential clinical significance and 95 (28.5%) of no clinical significance. Pregnancy outcomes in 327/333 (98.2%) of these patients were retrieved. In total, 143 (42.9%) of these pregnancies were terminated: 93/94 (98.9%) for trisomy 21, 20/21 (95.2%) for trisomy 18 or 13, 19/60 (31.7%) for sex chromosome abnormalities, and 11/63 (17.5%) for other chromosomal abnormalities with potential clinical significance. There were no terminations in the 95 pregnancies in which karyotyping results were regarded to be of no clinical significance.

CONCLUSIONS

'Knowing less' by the rapid aneuploidy stand-alone testing could miss about half of all chromosomal abnormalities detectable by amniocentesis performed for advanced maternal age. Findings from two fifths of the latter were of potential clinical significance, and the parents chose to terminate one out of six of the corresponding pregnancies. If both techniques are available, parents could have enhanced autonomy to choose.

New mechanical disruption method for extraction of whole cell protein from Candida albicans

Cell disruption or lysis is a crucial step to obtain cellular components for various biological studies. We subjected different concentrations of Candida albicans to 5, 10, 15 and 20 cycles of disruption. The degree of cell lysis was observed using light microscopy and the yields obtained were measured and analysed. The optimum extraction with 1 x 10(10) yeast cells/ml was achieved after 5 cycles of disruption with 1.0 mm diameter glass beads at 5,000 rpm. Approximately 80% of the cells were lysed and the protein yield was 6,000 microg/ml. SDS-PAGE analysis revealed approximately 25 distinct protein bands with molecular weights ranging from 8 kDa to 220 kDa. We conclude that this mechanical disruption of fungal cells is a rapid, efficient and inexpensive technique for extracting whole cell proteins from yeast cells.

Pulmonary artery/aorta ratio in simple screening for fetal outflow tract abnormalities during the second trimester

OBJECTIVES

Congenital heart disease is associated with high mortality and morbidity rates, being the most life-threatening defect in the first month of postnatal life and accounting for approximately half of all childhood mortality from birth defects. Despite this, the prenatal detection rate for congenital outflow tract anomalies by ultrasound imaging is relatively low. The aim of this study was to establish a nomogram for the pulmonary artery/aorta (PA/AO) ratio measured in the three-vessel view plane. This ratio was investigated as a simple screening tool for congenital cardiac outflow tract abnormalities.

METHODS

The study was a prospective evaluation of 966 singleton fetuses at 16-24 weeks of gestation and 46 fetuses with congenital cardiac outflow tract abnormalities. The diameters of the pulmonary artery and aorta were measured in the three-vessel view. The PA/AO ratio was calculated and a nomogram was constructed. The mean and 95% CI for the ratio were defined and the PA/AO ratios of cases with outflow tract abnormalities were plotted against the values for normal fetuses.

RESULTS

The gestational age of the normal group ranged from 16 to 24 weeks, with a median of 19 weeks. The pulmonary artery diameter measured between 2.1 and 4.93 mm (mean, 3.3 mm) and the aorta measured between 2.1 and 5.2 mm (mean, 2.93 mm). The mean (SD) PA/AO ratio was 1.16 (0.18) (95% CI, 0.87-1.58; range 0.61-1.86; median, 1.14). For fetuses with outflow tract abnormalities, the median gestation was 19 weeks and 37/43 (86%) had a PA/AO ratio outside the 95% CI.

CONCLUSIONS

The PA/AO ratio derived from measurements in the three-vessel view plane can be used as an initial screening tool for outflow tract anomalies and may have a sensitivity of up to 86%, with a 5% false-positive rate.

Transabdominal ultrasound assessment of the fetal head and the accuracy of vacuum cup application

OBJECTIVE

To investigate whether the accuracy of vacuum cup placement can be improved by intrapartum ultrasound assessment of the fetal head position during the second stage of labor prior to vacuum extraction for prolonged second stage.

METHODS

50 women undergoing vacuum extraction for prolonged second stage were randomly allocated to either digital examination (n=25) or digital examination together with transabdominal intrapartum ultrasound (n=25) prior to vacuum extraction by the attending obstetrician. The distance between the centre of the chignon and the flexion point was then measured by a midwife immediately after delivery. The flexion point was defined as 6 cm posterior to the anterior fontanelle or 3 cm anterior to the posterior fontanelle.

RESULTS

There were no statistically significant differences in the demographic data, duration of labor, incidence of induction/augmentation, and intrapartum complications between the two groups. The mean distance between the centre of the chignon and the flexion point was 2.1+/-1.3 cm in the group with digital examination and ultrasound assessment and 2.8+/-1.0 cm in the group with digital examination alone. The difference in the mean distance between the two groups was statistically significant (p=0.039).

CONCLUSION

Intrapartum transabdominal ultrasound assessment of the fetal head position during the second stage of labor improves the accuracy of vacuum cup placement during vacuum extraction for prolonged second stage.

Inhalation of glutamic acid decarboxylase 65-derived peptides can protect against recurrent autoimmune but not alloimmune responses in the non-obese diabetic mouse

Systemic administration of islet-derived antigens has been shown to protect against diabetes in the non-obese diabetic (NOD) mouse by the induction of antigen-specific regulatory T cells. Bystander regulation to related and unrelated islet-derived antigens (intramolecular and intermolecular recognition) in this context is recognized. We tested if intranasal administration of glutamic acid decarboxylase 65 (GAD 65)-derived peptides could protect against both autoimmune and, through bystander regulation, alloimmune responses in a NOD mouse model. Spontaneously diabetic female NOD mice underwent islet transplantation from either C57Bl/6 or NOD islet donors. Islet recipients were treated with intranasal GAD 65-derived peptides or control (ovalbumin) peptide pre- and post-transplantation. In-vitro analysis of the effect of inhalation was defined using lymph node proliferation assays and supernatant analysis for cytokines. GAD 65-derived peptide inhalation resulted in significant protection against recurrent autoimmune disease, with the generation of an interleukin (IL)-10-producing immune phenotype in a syngeneic islet transplant model. This phenotype, however, was not robust enough to protect against alloimmune responses. Inhalation of GAD-derived peptides induces an immunoregulatory response that protects against recurrent autoimmune, but not alloimmune responses in the NOD mouse.

Fetal growth patterns in fetuses of women with pregestational diabetes mellitus

OBJECTIVE

To assess the effect of glucose control on the rate of growth of fetuses in women with pregestational diabetes mellitus (Types 1 and 2).

METHODS

All pregestational diabetic women booked at Mater Mothers' Hospital, Brisbane, Australia, between 1 January 1994 and 31 December 2002, were included. Pregnancies with congenital fetal anomalies, multiple pregnancies, and pregnancies terminated prior to 20 weeks' gestation were excluded. Dating scans were performed before 14 weeks' gestation and serial scans were performed at 18, 24, 28, 32 and 36 weeks. Fetal parameters, including biparietal diameter, femur length and abdominal circumference, were recorded. The daily growth rates for biparietal diameter, femur length, and fetal abdominal area were calculated and compared with those in a low-risk (non-diabetic) population. The growth rates in fetuses of women with satisfactory diabetic control (HbA1c < 6.5%) and unsatisfactory control (HbA1c > or = 6.5%) in the three trimesters were compared.

RESULTS

A total of 174 diabetic pregnancies were included and a total of 997 ultrasound scans were performed. The growth rates for fetuses of mothers with diabetes mellitus were significantly higher than for those in the low-risk population. The z-scores for biparietal diameter, femur length, and fetal abdominal area were 0.18, 0.59 and 1.44, respectively. Fetuses of diabetic mothers with high HbA1c in the first trimester had significantly greater fetal abdominal area growth rate than those with normal HbA1c (fetal abdominal area z-score of 1.7 vs. 0.75, P = 0.009). Although the fetal abdominal area z-scores in fetuses of diabetic mothers with high HbA1c in the second or third trimesters were also higher than those with normal HbA1c levels, the differences did not reach statistical significance. Maternal obesity did not influence the fetal growth rate.

CONCLUSION

The rate of growth of fetuses of diabetic mothers differs from that of the normal population. Growth acceleration persists until the late third trimester. Moreover, periconceptional glucose control appears to have a significant effect on accelerated growth of the fetal abdominal area.

The placentas of patients with severe acute respiratory syndrome: a pathophysiological evaluation

Aims

The pathology of the placentas delivered from pregnant women who had severe acute respiratory syndrome (SARS) in Hong Kong was studied.

Methods

The pathology of the placentas was retrospectively studied in detail and compared with control sets. The clinical data of the women and neonates were also reviewed.

Results

A total of seven placentas were studied. The placentas from two women convalescent from SARS in the first trimester were normal. In three placentas delivered in the acute stage of SARS, there were increases in intervillous or subchorionic fibrin which might be related to disturbances in maternal placental blood flow due to the hypoxic respiratory disease. Extensive fetal thrombotic vasculopathy (FTV) with sharply demarcated zones of avascular fibrotic villi was noted in the placentas of two patients convalescent from SARS in the third trimester. Both pregnancies had intrauterine growth retardation, oligohydramnios and newborns small for gestation. The aetiology of the FTV might be related to thrombotic tendency due to SARS or placental hypoxia.

Conclusions

This report highlights placental pathology that was probably the result of pathophysiological alteration of the maternal fetal unit during SARS. Further studies are required to delineate the relationship between severe maternal respiratory disease, placental pathology and pregnancy outcome.

Three-dimensional ultrasound findings of spondylocostal dysostosis in the second trimester of pregnancy

Spondylocostal dysostosis (SCD) is a rare congenital disorder that is characterized by vertebral segmentation and formation defects, and asymmetrical rib anomalies. We describe a case diagnosed during the second trimester of pregnancy with the sonographic features of abnormal alignment of the spine, hemivertebrae in the thoracic spine and kyphoscoliosis. Three-dimensional ultrasound demonstrated a 'fan-like' rib cage with fusion of the ribs. The postmortem findings confirmed the ultrasound findings and were consistent with SCD.

Continuous dynamic spinal motion analysis

STUDY DESIGN

Continuous dynamic lumbar intervertebral flexion-extension is assessed by a videofluoroscopy with a new auto-tracking system.

OBJECTIVES

To develop and validate a new method for the continuous assessment of lumbar kinematics.

SUMMARY OF BACKGROUND DATA

Instability of the lumbar spine is thought to be associated with low back pain, but the diagnosis remains difficult. Functional radiographs have been used for diagnosis of spinal instability but error and limitation exist, whereas videofluoroscopy provides a cost-effective way for such analysis. However, common approaches of image analysis of videofluoroscopic video are tedious and time-consuming because of the low quality of the images. Physicians have to extract the vertebrae manually in most cases; thus, continuous motion analysis is hardly achieved.

METHODS

A new system that can perform automatic vertebrae segmentation and tracking is developed. In vitro and in vivo validity were evaluated. Intervertebral flexion and extension was assessed in 30 healthy volunteers.

RESULTS

In vitro and in vivo validity tests have been conducted with good results. A linear-liked pattern of the intervertebral flexion-extension (IVFE) curves in different levels was found, and the IVFE decreased in descending order from L1-L5 at different points of range of motion in flexion. Conversely, extension is evenly contributed at different levels, and the concavity of lumbar lordosis increases steadily in backward movement.

CONCLUSIONS

The newly developed technique in assessing the dynamic lumbar motion is reliable and able to analyze the lumbar intervertebral movement from videofluoroscopic images automatically and accurately. The proposed system requires less human intervention than common approaches. It may have a potential value in the evaluation of spinal "instability" in clinical practice.

Assessment of the Pediatric Index of Mortality (PIM) and the Pediatric Risk of Mortality (PRISM) III score for prediction of mortality in a paediatric intensive care unit in Hong Kong

OBJECTIVE

To compare two models (The Pediatric Risk of Mortality III score and Pediatric Index of Mortality) for prediction of mortality in a paediatric intensive care unit in Hong Kong.

DESIGN

Prospective case series.

SETTING

A five-bed paediatric intensive care unit in a general hospital in Hong Kong.

PATIENTS

All patients consecutively admitted to the unit between April 2001 and March 2003.

MAIN OUTCOME MEASURES

Scores for both models compared with observed mortality.

RESULTS

A total of 303 patients were admitted to the paediatric intensive care unit during the study period. The median age was 2 years, with an interquartile range of 7 months to 7 years. The male to female ratio was 169:134 (55.8%:44.2%). The median length of hospital stay was 3 days. The overall predicted number of deaths using The Pediatric Risk of Mortality III score was 10.2 patients whereas that by Pediatric Index of Mortality was 13.2 patients. The observed mortality was eight patients. The area under the receiver operating characteristics curve for the two models was 0.910 and 0.912, respectively.

CONCLUSION

The predicted mortality using both prediction models correlated well with the observed mortality.

Bacteriological screening of expressed breast milk revealed a high rate of bacterial contamination in Chinese women

A screening programme for expressed breast milk (EBM) revealed the alarming fact that our study group had the highest rate of contamination ever reported. The programme started in July 2002 and involved a group of Chinese women whose premature babies were in the neonatal intensive care unit. EBM was considered to be contaminated if there was any growth of pathogens, including Gram-negative bacteria, enterococci or Staphylococcus aureus, or if the total bacterial count was >10(5) cfu/mL. Of 59 samples from 23 mothers, 63% were contaminated. This high contamination rate could be due to the Chinese tradition of avoiding bathing for one month after childbirth. Previous studies have shown that feeding EBM rather than premature infant formula milk has advantages in terms of decreased incidence of necrotizing enterocolitis and neonatal sepsis. However, in this population, with such a high incidence of contaminated EBM, this may not be the case. Further studies to compare EBM with premature infant formula in this population are required.

Cardiac function in fetuses of poorly-controlled pre-gestational diabetic pregnancies--a pilot study

OBJECTIVE

Cardiac impairment is frequently found in babies of diabetic mothers. It is still controversial whether this is due to poor glucose control. The aim of this study is to compare the cardiac function in fetuses of well- and poorly-controlled pre-gestational diabetic pregnancy in third trimester.

METHODS

Women with type 1 pre-gestational diabetes were enrolled at 30-32 weeks. Cardiac size and interventricular septal wall thickness were measured by M-mode at end-diastolic phase. The right and left ventricular ejection fractions were calculated. At the mitral and tricuspid valves inflow, the ratio between early ventricular filling and active atrial filling (E/A) at both atrioventricular valves were measured by Doppler echocardiography. Peak velocities of ascending aorta and pulmonary artery were assessed. The angle of isonation was kept at <20 degrees. Women with poorly-controlled diabetes (HbA1c>6.5%) were compared with those with satisfactorily controlled diabetes (HbA1c < or = 6.5%).

RESULTS

A total of 21 women with pre-gestational diabetes were recruited for this study. Eight women with well-controlled diabetes were compared with 9 women who had poorly-controlled diabetes. HbA1c in the poorly-controlled group was 7.3% and in the well-controlled group it was 5.4% (p<0.001). There was no difference between the two groups in cardiac size, interventricular septal wall thickness, ejection fraction, aorta and pulmonary artery peak flow velocities. The right atrioventricular E/A ratio was significantly lower among the poorly-controlled diabetic pregnancies (0.71 vs. 0.54; p<0.05).

CONCLUSION

Fetuses of poorly-controlled diabetic mothers had a lower right atrioventricular E/A ratio. This may be due to metabolic acidosis, non-hypertrophic cardiac dysfunction or fetal polycythemia.

Correlates of habitual walking and sports/leisure-time physical activity in older persons in Singapore: interaction effects between educational attainment and gender

INTRODUCTION

We examined for demographic and psychosocial correlates on the participation of habitual walking and sports/leisure-time physical activity (LTPA) among older persons in Singapore.

MATERIALS AND METHODS

In an observational study, 177 Chinese, community/urban-dwelling, ambulant, non-disabled participants > or = 50 years old were recruited from a health promotion programme. The main outcome measures were self-reported participation in habitual walking and sports/LTPA. Variables examined include highest educational attainment, demographic and health characteristics, social contact and health knowledge. Interaction between gender and educational attainment was also examined.

RESULTS

The mean age of participants was 62.5 +/- 7.8 years. The effects of educational level were significant on habitual walking (P = 0.02), while that of age, self-rated health and interaction between gender and educational level were significant for sports/LTPA (P = 0.012, P = 0.002 and P = 0.019, respectively). Men with higher education had a higher self-reported sport/LTPA, while in women; those with lower education attainment had a higher participation.

CONCLUSION

Unlike findings from Western developed nations, previous studies done in Japan and Singapore found that educational level and health behaviours may not be positively associated. In this study, there is a negative correlation between educational attainment and participation in habitual walking and sports/LTPA, especially among older Singaporean women.

Histopathological findings of the nose of Down syndrome abortuses

Recent reports of absent nasal bone in fetuses with Down syndrome have sparked much interest in the use of this finding for the screening of Down syndrome. We describe the histopathological findings of nasal bones of two fetuses with Down syndrome, one with absence and the other with normal ossification of the nasal bone. We propose that histopathological examination of the nasal bone could improve the accuracy of diagnosis of nasal hypoplasia among Down syndrome abortuses.