How have US colorectal cancer mortality trends changed in the past 20 years?

In the last two decades, colorectal cancer (CRC) mortality has been decreasing in the United States. However, the mortality trends for the different subtypes of CRC, including different sides of colon, rectosigmoid, and rectal cancer remain unclear. We analyzed the mortality trends of different subtypes of CRC based on Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research data from 1999 to 2020. We calculated age-adjusted mortality rates (AAMR) per 100,000 individuals and examined the trends over time by estimating the average annual percent change (AAPC) using the Joinpoint Regression Program. Our study shows that the overall CRC rates decreased significantly from 26.42 to 15.98 per 100,000 individuals, with an AAPC of -2.41. However, the AAMR of rectosigmoid cancer increased significantly from 0.82 to 1.08 per 100,000 individuals, with the AAPC of +1.10. Men and Black individuals had the highest AAMRs respectively (23.90 vs. 26.93 per 100,000 individuals). The overall AAMR of CRC decreased for those aged ≥50 years but increased significantly from 1.02 to 1.58 per 100,000 individuals for those aged 15-49 years, with an AAPC of +0.75. Rural populations had a higher AAMR than the urban populations (22.40 vs. 19.60 per 100,000 individuals). Although overall CRC mortality declined, rising trends in young-onset CRC and rectosigmoid cancer warrant attention. Disparities persist in terms of sex, race, and geographic region, and urbanization level, emphasizing the need for targeted public health measures.

Adverse events of immune checkpoint therapy alone versus when combined with vascular endothelial growth factor inhibitors: a pooled meta-analysis of 1735 patients

Background

Combining immune checkpoint therapy (ICT) and vascular endothelial growth factor inhibitors (VEGFi) may result in increased treatment-related and immune-related adverse events (TRAEs and irAEs) compared to ICT alone. This metanalysis was conducted to identify prospective phase II or III clinical studies that evaluated the toxicity profile of ICT + VEGFi compared to ICT alone.

Methods

A systematic search was performed across all cancer types and major databases until August 10, 2022, and screening was done by two independent investigators. Inclusion criteria included phase 2 or 3 studies with at least one arm of patients treated with combination therapy and one arm treated with monotherapy. Adverse event data were pooled using a restricted maximum likelihood fixed effects model, and heterogeneity using Cochran's Q (chi-square) test.

Results

7 out of 9366 studies met the inclusion criteria, and 808 and 927 patients were treated with ICT monotherapy and a combination of ICT with VEGFi, respectively. Only one study reported irAEs, so the analysis was restricted to TRAEs. The total number of TRAEs was significantly higher in the ICT + VEGFi group (RR:1.49; 95% CI 1.37 -1.62; p=1.5×10-21), and more frequent treatment withdrawals were attributed to TRAEs (RR:3.10; 95% CI 1.12-8.59; p=0.029). The highest TRAE effect size increases noted for rash (RR 6.50; 95% CI 3.76 - 11.25; p=2.1×10-11), hypertension (RR:6.07; 95% CI 3.69-10.00; p=1.3×10-12), hypothyroidism (RR:5.02; 95% CI 3.08 - 8.19; p=8.9×10-11), and diarrhea (RR:4.94; 95% CI 3.21-7.62; p=3.8×10-13). Other significantly more frequent TRAEs included nausea, anemia, anorexia, and proteinuria.

Conclusion

Combination therapy with ICT and VEGFi carries a higher risk of certain TRAEs, such as rash, hypertension, hypothyroidism, diarrhea, nausea, anorexia, and proteinuria, compared to ICT monotherapy. More granular details on the cause of AEs, particularly irAEs, should be provided in future trials of such regimens.

Pseudo-Progression of Melanoma Treated with Nivolumab/Ipilimumab: A Case Report

BACKGROUND Melanoma is an aggressive skin cancer that can be difficult to manage. Its treatment has been transformed by immunotherapy. Melanoma cells frequently have mutations that make them vulnerable to attack by the immune system, and this is how immunotherapy can fight this cancer. Immunotherapy with checkpoint inhibitors targets mechanisms that malignant cells use to evade immune system detection, blocking proteins produced by the tumor, and allowing the immune system to identify and attack cancerous cells. CASE REPORT A 74-year-old woman presented with a lump on the right side of her chest. Tests revealed a metastatic malignant tumor with melanocytic differentiation. Stage IV melanoma was diagnosed, and the patient started therapy with nivolumab/ipilimumab for palliative intent, which she tolerated without adverse effects. However, she was hospitalized for Clostridioides difficile colitis after 3 treatment cycles, and computed tomography (CT) scan findings suggested disease progression. Positron emission tomography (PET)-CT obtained after her discharge from the hospital showed a complete metabolic response at all disease sites, indicating the initial progression was most likely a pseudo-progression from the use of immunotherapy. The patient continued with nivolumab as a single agent and has been doing well. CONCLUSIONS This case highlights the importance of careful evaluation of immunotherapy response in patients with melanoma. The initial progression noted in this patient was most likely pseudo-progression, which resolved with further immunotherapy. Clinicians should consider PET-CT imaging in cases of suspected pseudo-progression to avoid unnecessary changes in therapy. Patient response to immunotherapy demonstrates the effectiveness of immunotherapy in treating advanced melanoma.

Association of Elevated Glycated Hemoglobin (HbA1c) in COVID-19 Patients Admitted to the Intensive Care Unit and Their Clinical Outcomes

Aim The study aimed to collect retrospective data to investigate the association between elevated glycated hemoglobin (HbA1c) levels and clinical outcomes in COVID-19 patients admitted to the ICU, including in-hospital mortality and 90-day mortality.  Methods This is an observational retrospective study using electronic health records of patients with diabetes admitted to the ICU with COVID-19 across the University of Pittsburgh Medical Center (UPMC) in Central PA Hospitals. Our retrospective analysis was performed on patients admitted to the ICU between May 1^st, 2021, to May 1^st, 2022. The HbA1c level obtained within three months before their admission was evaluated and stratified to show their association with clinical outcomes, including in-hospital mortality and 90-day mortality. Additionally, the need for insulin drip and ICU and hospital length of stay were compared among these patients.  Results We analyzed 384 patients, which were distributed in three groups. The majority of the patients (183 patients or 47.66%) had an HbA1c below 7%, 113 patients (29.43%) had an HbA1c between 7-9%, and 88 patients (22.92%) had an HbA1c above 9%. The group with an HbA1c<7% had a mortality rate of 54.1% during the hospital stay, with a median stay of 13 days. The patients with an HbA1c between 7-9% had a higher mortality rate of 65.49% with a median stay of 12 days. The patients with HbA1c>9% had a mortality rate of 43.18% with a median stay of 11.5 days.  Conclusion This retrospective study found that there was no linear association between higher HbA1c levels and a higher risk of mortality during hospitalization. The 90-day mortality rate was not statistically different among the three HbA1c groups. The need for insulin drip was higher in patients with higher HbA1c levels. The majority of patients in all three groups were classified as low-risk based on their BMI, and there were no significant differences in the distribution of patients across BMI categories in the HbA1c groups.

Insights into the tumor microenvironment of B cell lymphoma

The standard therapies in lymphoma have predominantly focused on targeting tumor cells with less of a focus on the tumor microenvironment (TME), which plays a critical role in favoring tumor growth and survival. Such an approach may result in increasingly refractory disease with progressively reduced responses to subsequent treatments. To overcome this hurdle, targeting the TME has emerged as a new therapeutic strategy. The TME consists of T and B lymphocytes, tumor-associated macrophages (TAMs), myeloid-derived suppressor cells (MDSCs), cancer-associated fibroblasts (CAFs), and other components. Understanding the TME can lead to a comprehensive approach to managing lymphoma, resulting in therapeutic strategies that target not only cancer cells, but also the supportive environment and thereby ultimately improve survival of lymphoma patients. Here, we review the normal function of different components of the TME, the impact of their aberrant behavior in B cell lymphoma and the current TME-direct therapeutic avenues.

Increasing tissue requirements in lymphoma trials may exclude patients with high-risk disease or worse prognosis

An enhanced understanding of the molecular heterogeneity of diffuse large B-cell lymphoma (DLBCL) has opened the door to clinical trials evaluating novel agents with subtype-specific activity. It is an emerging question whether core needle biopsies (CNB) can adequately meet the increasing tissue requirements of these clinical trials. This can potentially lead to selective enrollment of patients who can undergo excisional biopsy (EB). It is also important to know whether patients who can undergo extensive diagnostic work up differ in their disease characteristics and outcomes from those who cannot. In this observational study, we describe the characteristics, outcomes, and adequacy of diagnostic tissue in patients with newly diagnosed DLBCL and primary mediastinal large B-cell lymphoma who underwent EB vs CNB. Of the 1061 patients, 532 (49.8%) underwent EB and 529 (50.1%) underwent CNB. A significantly higher proportion of patients with CNB had advanced stage disease, an international prognostic index of ≥3, and inadequate tissue for molecular analyses. Patients with CNB had significantly worse 5-year event-free survival (67.6% vs 56.9%; hazard ratio [HR], 0.76; confidence interval [CI]95, 0.6-0.9, P < .001) and 5-year overall survival (76.4% vs 69.2%; HR, 0.8; CI95, 0.6-0.9, P < .001). Thus, patients who underwent CNB have poor-risk features and inferior outcomes on frontline chemoimmunotherapy, are more likely to have inadequate tissue for molecular analyses, and might not meet the tissue requirements of biomarker-driven clinical trials. Thus, the increasing tissue requirements of biomarker-driven clinical trials may result in the exclusion of patients with high-risk DLBCL who need novel agents.

Survey of Patient Knowledge and Awareness of "Sick Day Rules" in Rheumatology Patients on Long Term Glucocorticoid Therapy

Aims Rheumatic disease (RMD) patients treated with long-term glucocorticoids (GC) are at risk of developing tertiary adrenal insufficiency. With this survey we aimed to assess the knowledge of RMD patients taking long-term glucocorticoid therapy regarding risk of adrenal insufficiency and understanding of the "steroid sick day rules". Methods RMD patients taking ≥2.5 mg prednisolone daily for ≥3 months were recruited from the Rheumatology outpatient department in Beaumont Hospital, Dublin. Patient knowledge and previous counselling of steroid sick day rules was determined using an 8-point questionnaire carried out face-to-face or via phone call. Results 51 RMD patients on GC therapy were recruited. 3/51 (5.9%) of patients reported that they had been counselled on the Sick Day Rules. 2/51 (3.9%) carried a steroid emergency card or MedicAlert bracelet. Few patients would increase their steroid dose appropriately in response to infection, vomiting or peri-procedure [14/51 (27.5%); 9/51 (17.7%) and 5/51 (7.2%), respectively]. Conclusion We demonstrate a significant deficit of patient knowledge around the precautions for long-term GC use in rheumatic diseases. We suspect that our results may be generalisable to many other RMD units. We are currently reviewing our procedures around healthcare professional and patient education, issuing of information leaflets, emergency cards or MedicAlert bracelets etc. to at risk patients.

Minimally Invasive versus Conventional Open Surgery for Fixation of Spinal Fracture in Ankylosed Spine

Introduction:

This was a retrospective study aimed to investigate the perioperative outcomes of long construct minimally invasive spinal stabilisation (MISt) using percutaneous pedicle screws (PPS) versus conventional open spinal surgery in the treatment of spinal fracture in ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH).

Material and Methods:

Twenty-one patients with AS and DISH who were surgically treated between 2009 and 2017 were recruited. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union rate.

Results:

Mean age was 69.2 ± 9.9 years. Seven patients had AS and 14 patients had DISH. 17 patients sustained AO type B3 fracture and 4 patients had type B1 fracture. Spinal trauma among these patients mostly involved thoracic spine (61.9%), followed by lumbar (28.6%) and cervical spine (9.5%). MISt using PPS was performed in 14 patients (66.7%) whereas open surgery in 7 patients (33.3%). Mean number of instrumentation level was 7.9 ± 1.6. Mean operative time in MISt and open group was 179.3 ± 42.3 minutes and 253.6 ± 98.7 minutes, respectively (p=0.028). Mean intra-operative blood loss in MISt and open group was 185.7 ± 86.4ml and 885.7 ± 338.8ml, respectively (p<0.001). Complications and union rate were comparable between both groups.

Conclusion:

MISt using PPS lowers the operative time and reduces intra-operative blood loss in vertebral fractures in ankylosed disorders. However, it does not reduce the perioperative complication rate due to the premorbid status of the patients. There was no significant difference in the union rate between MISt and open surgery.

Evaluating the concurrent validity of body mass index (BMI) in the identification of malnutrition in older hospital inpatients

BACKGROUND

Nutrition screening and assessment tools often include body mass index (BMI) as a component in identifying malnutrition risk. However, rising obesity levels will impact on the relevancy and applicability of BMI cut-off points which may require re-evaluation. This study aimed to explore the relationship between commonly applied BMI cut-offs and diagnosed malnutrition.

METHODS

Data (age, gender, BMI and Subjective Global Assessment (SGA) ratings) were analysed for 1152 inpatients aged ≥65 years across annual malnutrition audits (2011-2015). The receiver operation characteristic (ROC) curve analysed the optimal BMI cut-off for malnutrition and concurrent validity of commonly applied BMI cut-offs in nutritional screening and assessment tools.

RESULTS

Malnutrition prevalence was 36.0% (n = 372) using SGA criteria (not malnourished, moderate or severe malnutrition). Median age was 78.7 (IQR 72-85) years, median BMI 25.4 (IQR 21.8-29.7) kg/m²; 52.1% male and 51.2% overweight/obese. ROC analysis identified an optimal BMI cut-off of <26 kg/m², 80.8% sensitivity and 61.5% specificity (AUC 0.802, 95% CI 0.773, 0.830; p < 0.0001). Commonly applied BMI cut-offs (between 18.5 and 23 kg/m²) failed to meet the alpha-priori requirement of 80% sensitivity and 60% specificity. However, BMI <23 kg/m² had the highest agreement (κ = 0.458) with malnutrition diagnosed using the SGA.

CONCLUSIONS

Both malnutrition and overweight/obesity are common in older inpatients. Continuing increases in the prevalence of overweight and obesity will impact on the sensitivity of BMI as a screening component for malnutrition risk. The current study suggests tools developed over a decade ago may need to be revisited in future.

Does intentional weight loss improve daytime sleepiness? A systematic review and meta-analysis

Obesity is associated with excessive daytime sleepiness, but its causality remains unclear. We aimed to assess the extent to which intentional weight loss affects daytime sleepiness. Electronic databases were searched through 24 October 2016. Studies involving overweight or obese adults, a weight loss intervention and repeated valid measures of daytime sleepiness were included in the review. Two independent reviewers extracted data on study characteristics, main outcome (change in daytime sleepiness score standardized by standard deviation of baseline sleepiness scores), potential mediators (e.g. amount of weight loss and change in apnoea-hypopnoea index) and other co-factors (e.g. baseline demographics). Forty-two studies were included in the review. Fifteen before-and-after studies on surgical weight loss interventions showed large improvements in daytime sleepiness, with a standardized effect size of -0.97 (95% confidence interval [CI] -1.21 to -0.72). Twenty-seven studies on non-surgical weight loss interventions showed small-to-moderate improvement in daytime sleepiness, with a standardized effect size of -0.40 (95%CI -0.52 to -0.27), with no difference between controlled and before-and-after studies. We found a nonlinear association between amount of weight loss and change in daytime sleepiness. This review suggests that weight loss interventions improve daytime sleepiness, with a clear dose-response relationship. This supports the previously hypothesized causal effect of obesity on daytime sleepiness. It is important to assess and manage daytime sleepiness in obese patients.

Circulating tumour cells and the epithelial mesenchymal transition in colorectal cancer

Circulating tumour cells (CTCs) hold great potential as liquid biopsies to prognosticate disease and guide treatment in colorectal cancer. However, their emerging role in determining the molecular phenotype of tumour metastasis carries even more promising clinical use in the provision of comprehensive biomarker detection for targeted therapies and determination of drug resistance. The isolation of CTCs is technology dependent, and in the case of epithelial cell adhesion molecule-based platforms, the ability to detect cells that have undergone the epithelial to mesenchymal transition (EMT) is ineffective. CTCs displaying a mesenchymal phenotype are believed to have an increased metastatic potential. The rarity of CTCs provides another challenge in the enumeration of these cells. The future will likely involve the analysis of individual CTCs at any stage of the EMT in order to provide real-time phenotypic and molecular snapshots capable of tracking the dynamic evolution of tumour progression over time.

Accuracy and reliability of the i-STAT point-of-care device for the determination of haemoglobin concentration before and after major blood loss

We investigated the accuracy of i-STAT(®) (Abbott Point of Care Inc., Princeton, NJ, USA) haemoglobin (Hb) measurement in surgical patients with an estimated blood loss of ≥25% of total blood volume. Blood tests for i-STAT(®) Hb, laboratory Hb (Sysmex XE-2100(™), Sysmex Corporation, Kobe, Japan) and total plasma proteins were obtained at the start of surgery (T=0) and when an estimated 25% total blood volume loss had occurred (T=1). Thirty-one patients were recruited. The coefficient of variation of the paired i-STAT(®) Hb estimates was 2.8% and 2.9% at T=0 and T=1, respectively. The mean difference between i-STAT(®) and laboratory Hb was -7.6 g/l (standard deviation 6.5) at T=0 and -5.1 g/l (standard deviation 12) at T=1. The mean total plasma protein difference (total plasma protein T=0 minus T=1) was 13.6 g/l (95% confidence interval 10.2 to 17.0). There was poor correlation between total plasma protein and bias in i-STAT(®) measurements. The i-STAT(®) Hb had an acceptable coefficient of variation, but the Hb levels were lower than those estimated by the laboratory. The standard deviation of i-STAT(®) Hb was greater after ≥25% estimated total blood volume loss. Clinicians should not use the i-STAT(®) Hb in isolation for clinical decision-making when considering blood transfusion in a situation of 25% or greater blood loss.

OCT4 as a target of miR-34a stimulates p63 but inhibits p53 to promote human cell transformation

Human cell transformation is a key step for oncogenic development, which involves multiple pathways; however, the mechanism remains unclear. To test our hypothesis whether cell oncogenic transformation shares some mechanisms with the process of reprogramming non-stem cells to induced pluripotent stem cells (iPSC), we studied the relationship among the key factors for promoting or inhibiting iPSC in radiation-transformed human epithelial cell lines derived from different tissues (lung, breast and colon). We unexpectedly found that p63 and OCT4 were highly expressed (accompanied by low expressed p53 and miR-34a) in all transformed cell lines examined when compared with their non-transformed counterparts. We further elucidated the relationship of these factors: the 3p strand of miR-34a directly targeted OCT4 by binding to the 3′ untranslated region (3′-UTR) of OCT4 and, OCT4, in turn, stimulated p63 but inhibited p53 expression by binding to a specific region of the p63 or p53 promoter. Moreover, we revealed that the effects of OCT4 on promoting cell oncogenic transformation were by affecting p63 and p53. These results support that a positive loop exists in human cells: OCT4 upregulation as a consequence of inhibition of miR-34a, promotes p63 but suppresses p53 expression, which further stimulates OCT4 upregulation by downregulating miR-34a. This functional loop contributes significantly to cell transformation and, most likely, also to the iPSC process.

Circulating tumour cells and circulating free nucleic acid as prognostic and predictive biomarkers in colorectal cancer

The detection of circulating tumour cells or circulating free tumour nucleic acids can potentially guide treatment and inform prognosis in colorectal cancer using minimally invasive "liquid biopsies". Current literature supports the notion that high circulating tumour cell counts or presence of tumour nucleic acid correlate with inferior clinical outcomes for patients, but they are not yet part of routine clinical care. Future research evolves around the examination of the molecular phenotype of circulating tumour cells. The key unanswered areas include differentiating between circulating tumour cell presence and their proliferative capacity and dormancy, identifying tumour heterogeneity and understanding the epithelial-mesenchymal transition.

Morphometric sex determination of Milky and Painted Storks in captivity

Logistic regression was applied to develop a morphometric sexing method of two closely related stork species that were previously sexed through amplification of the CHD gene. Tarsus length (TL) and bill length (BL) measurements were recorded from captive populations of adult Milky Stork (Mycteria cinerea) (n = 60) and Painted Stork (Mycteria leucocephala) (n = 58) at Zoo Negara Malaysia. Despite having monomorphic plumages, both stork species exhibited normal sexual size dimorphism in which males were significantly larger than females in the tested variables. Based on logistic regression analysis, BL correctly classified the sex of sampled individuals from Painted and Milky stork with an overall predicted accuracy of 94.8 and 90.0%, respectively. However, TL measurements generated a lower predicted accuracy level of 86.2% and a same accuracy level of 90% on the sex classification of individuals from Painted and Milky stork, respectively. By comparing the measurements of both species, only the average BL measurements of the Milky storks were significantly lower than that of Painted storks (t-test, P80.001). The logistic regression equation in this study may serve as a simple and more practical option for sexing Milky and Painted storks for their breeding and conservation programmes.

Very long-term outcome of pure lupus membranous nephropathy treated with glucocorticoid and azathioprine

The aim of this study is to report the long-term outcome of pure membranous lupus nephropathy (MLN) treated with glucocorticoid and azathioprine (AZA). A cohort of patients with SLE who had biopsy-confirmed pure MLN was treated initially with prednisone (0.8-1.0 mg/kg/day) and AZA (targeted to 2 mg/kg/day). Patients were followed for the following outcomes: remission rate at 12 months, renal flares, extra-renal flares and renal function deterioration. The cumulative risks of renal flares and renal function decline were studied by Kaplan-Meier analysis. Thirty-eight patients were studied (31 women; age 35.0 +/- 9.2 years; mean SLE duration 48.5 +/- 59 months; WHO Class Va 45%, Vb 55%). Twenty-two (58%) patients were nephrotic and four (11%) were hypertensive at presentation. All patients were treated with prednisolone (0.85 +/- 0.24 mg/kg/day) and AZA (1.72 +/- 0.43 mg/kg/day). At 12 months, 24 (67%) patients achieved complete response (CR), 8 (22%) had partial response (PR) and 4 (11%) were treatment resistant. After a follow-up of 12 +/- 5.8 years, 19 episodes of renal flares (15 proteinuric and 4 nephritic) occurred in 13 (34%) patients. The cumulative risks of renal flares at 5, 10 and 15 years were 19.4, 32.0 and 36.8%, respectively. Retreatment with an augmented dosage of prednisolone, +/- another immunosuppressive agent, resulted in CR and PR in 15 (79%) and 4 (21%) of these flare episodes, respectively. At last visit, three (8%) patients had doubling of serum creatinine, whereas six (16%) patients had decline of creatinine clearance by >/=30% (none developed end stage renal failure). Seven episodes of thromboembolic complications occurred in five (13%) patients and 11 episodes of infective complications (five major, six minor) were reported in seven (18%) patients. In the absence of co-existing proliferative lesions, MLN runs a relatively benign course with low risk of renal function deterioration. Treatment with high-dose prednisolone and AZA is effective, inexpensive and well-tolerated. Prolonged observation shows that one of three patients develop renal flares, which are often proteinuric and responsive to reinduction therapy.

Nodular regenerative hyperplasia of the liver associated with systemic lupus erythematosus: three cases

Nodular regenerative hyperplasia of the liver, characterised by regenerative nodules distributed throughout the liver in the absence of fibrosis, is a rare but important complication of systemic lupus erythematosus. The main consequence of nodular regenerative hyperplasia of the liver is non-cirrhotic portal hypertension. This condition is probably underdiagnosed, as many of these patients may remain asymptomatic. Furthermore, nodular regenerative hyperplasia of the liver may be misdiagnosed as cirrhosis. We describe three female patients with nodular regenerative hyperplasia of the liver associated with systemic lupus erythematosus. All three patients have clinical manifestations of portal hypertension, and all were initially misdiagnosed as having cryptogenic cirrhosis.

Spontaneous intra-hepatic haemorrhage in a patient with fever of unknown origin

Polyarteritis nodosa is a systemic necrotising vasculitis that affects the small- and medium-sized arteries. Multifocal aneurysmal formation in the renal, hepatic, and mesenteric vasculature is a hallmark of this condition, and spontaneous aneurysmal rupture may occur, resulting in life-threatening haemorrhage. We describe a 42-year-old man who initially presented with fever of unknown origin. A diagnosis could not be reached at that time despite extensive investigations. The fever subsided spontaneously after 8 weeks, and the patient remained well for 6 years until he was admitted again for evaluation of fever. During his hospital stay, he developed a spontaneous massive intra-hepatic haemorrhage resulting in hepatic rupture and a haemoperitoneum. The bleeding was controlled at emergency laparotomy. An abdominal angiography demonstrated multiple microaneurysms in the hepatic and mesenteric arterial vasculature. The clinical findings suggested polyarteritis nodosa, and the source of bleeding was probably a ruptured intra-hepatic artery aneurysm.

Seroprevalence of hepatitis C in intravenous opioid users presenting in the early phase of injecting drug use in Singapore

INTRODUCTION

All over the world, Hepatitis C virus (HCV) accounts for an estimated 130 million chronic infections. Injection drug use has become one of the most important risk factors for HCV, and within the injection drug user population, the prevalence of HCV antibody ranges from 70 to 95 percent depending on an individual's length of use and the prevalence of infection in the community. This study was undertaken to determine the prevalence of and the risk factors for Hepatitis C antibodies in injecting drug users presenting to the Community Addictions Management Programme (CAMP) in Singapore.

METHODS

Eligibility criteria for inclusion in this study were all intravenous buprenorphine users presenting to CAMP. 106 subjects, who consented to the study, completed an interviewer-administered questionnaire, and underwent a urine and blood analysis.

RESULTS

The prevalence rate for HCV was 42.5 percent among the subjects included in our study. The odds of seroprevalence in those sharing needles were 5.6 times that of those who were not, and the odds of seroprevalence among those using with others (peers or partners) were 6.3 times, as compared to among those who were individual users. Racial differences were also seen, but these could be accounted for by the sharing of needles.

CONCLUSION

This study provides important local data at the onset of an early buprenorphine-injecting epidemic in Singapore. This data is useful for disease prevention and healthcare planning.

Non-typhoid Salmonella mycotic aneurysm of the aortic arch

Salmonella mycotic aneurysm is a rare but potentially fatal condition. Mortality is high without timely intervention. The clinical presentation is protean and early diagnosis requires a high degree of clinical alertness. Prompt surgical intervention and prolonged antimicrobial therapy are keys to successful treatment. We report an 81-year-old man with an atypical presentation of Salmonella mycotic aneurysm in the aortic arch. The case highlights the need to evaluate all patients over 50 years with non-typhoid Salmonella bacteraemia for possible endovascular infections. Contrast-enhanced computed tomography is useful for making an early diagnosis of this disease.

Unique hepatic imaging features in a patient with nodular regenerative hyperplasia of the liver associating with systemic lupus erythematosus

Nodular regenerative hyperplasia (NRH) of the liver, characterized by regenerative nodules distributed throughout the liver in the absence of fibrosis, is a rare but important complication of systemic lupus erythematosus (SLE). The main consequence of NRH is non-cirrhotic portal hypertension. We describe a female patient who had immune thrombocytopenia in association with elevated liver enzymes and evidence of portal hypertension as initial manifestations of SLE. Computed tomographic scan and magnetic resonance imaging of the liver in this patient showed enhancing periportal tubular structures distributed throughout the liver. The diagnosis of NRH was eventually disclosed by transcutaneous needle liver biopsy. The pattern of radiological abnormality in this patient has not been described previously in NRH. In addition, we believe this is a first reported case of SLE presenting with immune thrombocytopenia in association with NRH.

Lymphopenia at presentation is associated with increased risk of infections in patients with systemic lupus erythematosus

BACKGROUND

Patients with systemic lupus erythematosus (SLE) frequently suffer from infections, but the predisposing risk factors, as well as the exact frequency and nature of such infections, are not fully understood.

AIM

To describe the frequency, types and risk factors for infections in a group of Chinese patients in the early stage of SLE in Hong Kong.

DESIGN

Retrospective record study.

METHODS

We reviewed the case records of 91 Chinese SLE patients, presenting <12 months after SLE diagnosis. Details of major infections (requiring intravenous antimicrobial therapy, or any confirmed mycobacterial infection) and minor infections were reviewed. Clinical and laboratory features, the systemic lupus erythematosus disease activity index (SLEDAI) at presentation and drug treatment were recorded and analysed.

RESULTS

There were 48 major infections and 62 minor infections during 260 patient-years of follow-up. A lymphocyte count < or =1.0 x 10(9)/l at presentation was independently associated with an increased risk for major infection: hazard ratio 4.7 (95%CI 1.6-13.7), p = 0.005. SLEDAI, use of corticosteroids and immunosuppressive therapy were all not associated with increased risk of infection.

DISCUSSION

Lymphopenia was an important risk factor for major infections in this group of Chinese patients in the early stages of SLE. SLE patients with lymphopenia at presentation should be closely monitored for the development of infective complications.

The impact of diabetes mellitus on the prognostic value of a normal dobutamine stress echocardiogram in patients with intermediate to high cardiovascular risk

INTRODUCTION

There is currently limited data on the prognostic value of a normal dobutamine stress echocardiogram (DSE) in patients with intermediate to high cardiovascular risk. The impact of diabetes mellitus, recently recognised as a cardiovascular risk-equivalent, has not been previously evaluated. This study aims to determine the prognostic value of a normal DSE in these patients.

METHODS

The study population includes all patients with two cardiovascular risk factors or diabetes mellitus and a normal DSE (baseline and peak stress) with three months follow-up. A total of 122 patients (47 females, 75 males; mean age 59.6 years) were recruited. Impact of diabetes mellitus on subsequent cardiovascular events was determined.

RESULTS

Diabetes mellitus was present in 32.8 percent, hypertension in 72.1 percent, smoking in 27.0 percent, family history of premature coronary artery disease in 15.6 percent, and hypercholesterolemia in 66.4 percent. On follow-up until 6.4 years (mean 4.1 years), there were four myocardial infarctions (0.8 percent per patient/year) and five revascularisation procedures (1.0 percent per patient/year). The majority of adverse events occurred among patients with diabetes mellitus (three out of four myocardial infarctions; four out of five revascularisations). Diabetes mellitus independently predicted subsequent cardiac events on both univariate and multivariate analyses (p value is equal to 0.015 and 0.011, respectively). Presence of diabetes mellitus also conferred a worse outcome on survival analysis (p value is equivalent to 0.0046).

CONCLUSION

The presence of diabetes mellitus adversely affects clinical outcome despite a normal DSE. Patients without diabetes mellitus, but with intermediate to high cardiovascular risk, and a normal DSE have a better medium term outcome.

Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study

BACKGROUND

We investigated the temporal progression of the clinical, radiological, and virological changes in a community outbreak of severe acute respiratory syndrome (SARS).

METHODS

We followed up 75 patients for 3 weeks managed with a standard treatment protocol of ribavirin and corticosteroids, and assessed the pattern of clinical disease, viral load, risk factors for poor clinical outcome, and the usefulness of virological diagnostic methods.

FINDINGS

Fever and pneumonia initially improved but 64 (85%) patients developed recurrent fever after a mean of 8.9 (SD 3.1) days, 55 (73%) had watery diarrhoea after 7.5 (2.3) days, 60 (80%) had radiological worsening after 7.4 (2.2) days, and respiratory symptoms worsened in 34 (45%) after 8.6 (3.0) days. In 34 (45%) patients, improvement of initial pulmonary lesions was associated with appearance of new radiological lesions at other sites. Nine (12%) patients developed spontaneous pneumomediastinum and 15 (20%) developed acute respiratory distress syndrome (ARDS) in week 3. Quantitative reverse-transcriptase (RT) PCR of nasopharyngeal aspirates in 14 patients (four with ARDS) showed peak viral load at day 10, and at day 15 a load lower than at admission. Age and chronic hepatitis B virus infection treated with lamivudine were independent significant risk factors for progression to ARDS (p=0.001). SARS-associated coronavirus in faeces was seen on RT-PCR in 65 (97%) of 67 patients at day 14. The mean time to seroconversion was 20 days.

INTERPRETATION

The consistent clinical progression, shifting radiological infiltrates, and an inverted V viral-load profile suggest that worsening in week 2 is unrelated to uncontrolled viral replication but may be related to immunopathological damage.

Inflammatory pseudotumor of the heart causing aortic regurgitation

Inflammatory pseudotumor is a tumor-like reactive lesion of unknown etiology that rarely affects the heart. We describe an unusual case of a cardiac inflammatory pseudotumor that involved the aortic valve and caused regurgitation in a 62-year-old man. The lesion was excised and the aortic valve was replaced, resulting in a favorable outcome for the patient.

An efficient room-temperature silicon-based light-emitting diode

There is an urgent requirement for an optical emitter that is compatible with standard, silicon-based ultra-large-scale integration (ULSI) technology. Bulk silicon has an indirect energy bandgap and is therefore highly inefficient as a light source, necessitating the use of other materials for the optical emitters. However, the introduction of these materials is usually incompatible with the strict processing requirements of existing ULSI technologies. Moreover, as the length scale of the devices decreases, electrons will spend increasingly more of their time in the connections between components; this interconnectivity problem could restrict further increases in computer chip processing power and speed in as little as five years. Many efforts have therefore been directed, with varying degrees of success, to engineering silicon-based materials that are efficient light emitters. Here, we describe the fabrication, using standard silicon processing techniques, of a silicon light-emitting diode (LED) that operates efficiently at room temperature. Boron is implanted into silicon both as a dopant to form a p-n junction, as well as a means of introducing dislocation loops. The dislocation loops introduce a local strain field, which modifies the band structure and provides spatial confinement of the charge carriers. It is this spatial confinement which allows room-temperature electroluminescence at the band-edge. This device strategy is highly compatible with ULSI technology, as boron ion implantation is already used as a standard method for the fabrication of silicon devices.

Safety of disease modifying anti-rheumatic agents in rheumatoid arthritis patients with chronic viral hepatitis

OBJECTIVE

To examine the safety of the use of disease modifying anti-rheumatic drugs (DMARDs) in rheumatoid arthritis (RA) patients with chronic viral hepatitis (CVH).

METHODS

Records of 600 Chinese patients satisfying the ARA criteria for RA in two rheumatology centers were reviewed. Patients with CVH were studied. Liver enzymes were checked before (baseline) and during DMARD use at 3-month intervals or more frequently if necessary. Drug-episodes (D-Ep), defined as the continuous use of DMARD, singly or in combination, for more than 6 months in a patient, were analysed. Changes in serum liver alanine transaminase (ALT) levels as multiples of the upper range of normal were taken to reflect the severity of hepatotoxicity. Changes of ALT to > or = 1.5 times the upper range of normal if they were measured at baseline or > or = 2 times the upper range of normal if they were measured during and after the use of DMARD were considered as abnormal. Control patients included those with CVH alone (n = 623) or RA without CVH (n = 62) matched for age, sex and D-Ep.

RESULTS

30 RA patients were found to have concomitant CVH. One patient was excluded because of use of NSAID alone (n = 1). Among the 29 patients, 23 were HBsAg +ve and 6 were anti-HCV Ab +ve. A total of 47 D-Ep were analysed. 20/47 (42.6%) of D-Ep in 16/29 (55.2%) RA + CVH patients developed abnormal ALT levels after a mean 1.9-year duration of DMARD use. This was statistically significant when compared with 13/94 (13.8%) of D-Ep which ended with abnormal ALT levels in 13/62 (21%) patients with RA alone (p < 0.0001 for D-Ep which ended up with abnormal ALT, and p < 0.02 for the number of patients who developed abnormal ALT) and 128/623 (20.5%) patients with CVH alone (p < 0.005). 53% (9/17) of hydroxychloroquine (HCQ) D-Ep were associated with an abnormal outcome. Corresponding figures for sulphasalazine (SAZP) and oral or intramuscular gold preparations were 55.6% (5/9) and 0% (0/3) respectively. Two patients on methotrexate, used either singly or in combination, had normal ALT levels throughout the study period. One patient on azathioprine developed reactivation of hepatitis B infection. When D-Ep of the RA + CVH group were further analysed, 16/43 (37.2%) and 4/4 (100%) D-Ep which started with normal and abnormal baseline ALT respectively developed further liver enzyme derangement.

CONCLUSION

The use of DMARD in RA + CVH patients is associated with a high incidence of hepatotoxicity. The effect is likely to be synergistic. This includes drugs such as HCQ, which is generally believed to be less hepatotoxic.

Cloning and characterization of two hydrophobin genes differentially expressed during fruit body development in Lentinula edodes

Hydrophobins play important roles in morphogenesis and pathogenesis in fungi and fruit development in mushrooms. Two genes encoding hydrophobins (Le.hyd1 and Le.hyd2) were isolated during sequencing of random clones from a primordial cDNA library of Lentinula edodes. The nucleotide sequences of these two genes were determined. These two genes are 760 and 738 bp in length and the deduced amino acid sequences are homologous to various fungal hydrophobins with characteristic cysteine spacing. These hydrophobin genes are Class I hydrophobins judging by their conserved domains and hydropathy patterns. The transcript level of Le.hyd1 is high in primordium and that of Le.hyd2 is high in dikaryotic mycelial tissues. Poor expression of these two genes in monokaryotic parents indicates that these two genes are under mating-type regulation. We thus suggest that differential expression of these two L. edodes hydrophobins during fruit development may contribute to their distinct roles in fruiting of this mushroom.

Initial experience of radiofrequency catheter ablation of supraventricular tachycardia in paediatric patients

INTRODUCTION

The management of supraventricular tachycardia (SVT) in paediatric patients until recently has frequently been pharmacologic therapy, but this approach suffers from the drawbacks of treatment failure, development of drug intolerance and/or side-effects.

AIM

In keeping with recent advances in paediatric cardiology, we share our experience with radiofrequency catheter ablation as an alternative and definitive modality of therapy.

MATERIALS AND METHOD

4 young patients with recurrent SVT underwent electrophysiologic study followed by radiofrequency ablation of the accessory pathways.

RESULTS

Resolution of symptoms was achieved in all patients and no major complication was encountered.

CONCLUSIONS

The ability to ablate permanently the reentrant circuit responsible for SVT has now permitted cure by non-surgical means, and is an important alternative to drug therapy in the management of SVT in children.

Diagnosis of pacemaker lead infection using transoesophageal echocardiography: a case report

INTRODUCTION

Vegetative lead infection is an uncommon complication of permanent pacemaker implantation. The diagnosis is difficult using conventional imaging methods.

CLINICAL PICTURE

An elderly Indian woman with a history of diabetes mellitus developed Staphylococcus aureus infection after implementation of a permanent pacemaker. Following a non-diagnostic transthoracic echocardiogram, transoesophageal echocardiography was performed and showed a large vegetative mass attached to the pacemaker lead within the right atrium.

TREATMENT

The pacemaker was removed and intravenous vancomycin administered for six weeks.

OUTCOME

She was discharged well but demised two months later from a second episode of septicaemia.

CONCLUSIONS

Pacemaker lead infection remains a challenging management problem. Transoesophageal echocardiography can facilitate its diagnosis.

Negative selection: a method for obtaining low-abundance cDNAs using high-density cDNA clone arrays

The identification of the entire complement of genes expressed in a cell, tissue, or organism provides a framework for understanding biological properties and establishes a tool set for subsequent functional studies. The large-scale sequencing of randomly selected clones from cDNA libraries has been successfully employed as a method for identifying a large fraction of these expressed genes. However, this approach is limited by the inherent redundancy of cellular transcripts reflecting widely variant levels of gene transcription. As a result, a high percentage of transcript duplications are encountered as the number of sequenced clones accrues. To address this problem, we have developed a negative hybridization selection method that employs the hybridization of complex cDNA probes to high-density arrays of cDNA clones and the subsequent selection of clones with a null or low hybridization signal. This approach was applied to a cDNA library constructed from normal human prostate tissue and resulted in the reduction of highly expressed prostate cDNAs from 6.8 to 0.57% with an overall decline in clone redundancy from 33 to 11%. The selected clones also reflected a more diverse cDNA population, with 89% of the clones representing distinctly different cDNAs compared with 67% of the randomly selected clones. This method compares favorably with cDNA library re-association normalization approaches and offers several distinct advantages, including the flexibility to use previously prepared libraries, and the ability to employ an iterative screening approach for continued accrual of cDNAs representing rare transcripts.

Prostate cancer expression profiling by cDNA sequencing analysis

Prostate cancer is a frequently diagnosed solid tumor that is originated mostly from prostate epithelium. One of the key issues in prostate cancer research is to develop molecular markers that can effectively detect and distinguish the progression and malignancy of prostate tumors. Automated, single-pass cDNA sequencing was utilized to rapidly identify expressed genes in a number of cDNA libraries constructed from various normal and tumor prostatic tissues. These included cell lines as well as short-term epithelial culture. A total of 6604 expressed sequence tags (ESTs) were generated and searched against on-line nucleotide and protein databases. A relational database centric software system was constructed to process, store, and analyze EST data rapidly. cDNA contigs were also obtained by assembly of multiple EST sequences. Protein structural signatures were annotated using motif analysis tools including BLOCKS and an in-house-designed neural network. Cross-library comparisons revealed their unique gene expression profiles. Several differentially expressed cDNA clones were identified, and their expression patterns were confirmed by RNA dot blot and RT-PCR analyses.

Spontaneous aortic laceration causing flail aortic valve and acute aortic regurgitation

Spontaneous laceration of the aorta is an unusual cause of flail aortic valve. We report a case of acute aortic regurgitation caused by flail aortic valve as a result of spontaneous laceration of the ascending aorta. The role of transesophageal echocardiography in the diagnosis of this condition is discussed.

Co-existing left atrial thrombus and myxoma in mitral stenosis--a diagnostic challenge

We report an unusual case of an adult who underwent a mitral valve replacement with concomitant excision of the left atrial myxoma and thrombus. Echocardiography showed the presence of a large "thrombus" within the left atrial appendage, body and atrial septum. There was difficulty in trying to distinguish between the atrial thrombus and myxoma due to their morphological similarities. At time of surgery, frozen section confirmed the atrial septal component of the thrombus to be an atrial myxoma and the atrial septum was excised to obtain a clear margin.

Gastroesophageal reflux disease is a common cause of noncardiac chest pain in a country with a low prevalence of reflux esophagitis

Gastroesophageal reflux disease is believed to be uncommon in the East. This study aimed to determine if such a condition was a significant cause of noncardiac chest pain in Singapore. Eighty consecutive patients with recurrent chest pain, who had cardiac and other obvious causes excluded, underwent esophagogastroduodenoscopy, standard manometry, acid perfusion test, and prolonged ambulatory pH and pressure monitoring. Endoscopic esophagitis, positive acid perfusion tests, pathologic reflux, and positive chest pain-reflux correlation were detected in 7/80 (8.8%), 11/70 (15.7%), 14/61 (23.0%), and 12/25 (48.0%) patients, respectively. Among those with pathologic reflux, endoscopic esophagitis was present in only two (14.3%). Overall, 32 (40%) patients had gastroesophageal reflux disease. Esophageal motility disorder, alone or in association with gastroesophageal reflux disease, was demonstrated in only five (6.3%) patients. Our results confirmed western reports that gastroesophageal reflux disease was a common cause of noncardiac chest pain, whereas motility disorder was an infrequent cause of such pain.

Non-cardiac, non-oesophageal chest pain: the relevance of psychological factors

BACKGROUND

No cause has been determined for chest pain that is neither cardiac nor oesophageal in origin.

AIMS

To compare the prevalence of life-time psychiatric disorders and current psychological distress in three consecutive series of patients with chronic chest or abdominal pain.

PATIENTS

Thirty nine patients with non-cardiac chest pain and no abnormality on oesophagogastroduodenoscopy, oesophageal manometry, and 24 hour pH monitoring; 22 patients with non-cardiac chest pain having endoscopic abnormality, oesophageal dysmotility, and/or pathological reflux; and 36 patients with biliary colic.

METHODS

The Diagnostic Interview Schedule and the 28 item General Health Questionnaire were administered to all patients.

RESULTS

Patients with non-cardiac chest pain and no upper gastrointestinal disease had a higher proportion of panic disorder (15%), obsessive-compulsive disorder (21%), and major depressive episodes (28%) than patients with gallstone disease (0%, p < 0.02; 3%, p < 0.02; and 8%, p < 0.05, respectively). In contrast, there were no differences between patients with non-cardiac chest pain and upper gastrointestinal disease and patients with gallstone disease in any of the DSM-111 defined lifetime psychiatric diagnoses. Using the General Health Questionnaire, 49% of patients with non-cardiac chest pain without upper gastrointestinal disease scored above the cut off point (that is, more than 4), which was considered indicative of non-psychotic psychiatric disturbance, whereas only 14% of patients with gallstones did so (p < 0.005). The proportions of such cases were however similar between patients with non-cardiac chest pain and upper gastrointestinal disease (27%) and patients with gallstones.

CONCLUSIONS

Psychological factors may play a role in the pathogenesis of chest pain that is neither cardiac nor oesophagogastric in origin.

A telemedicine system for high-quality transmission of paper electrocardiographic reports

To overcome problems associated with the faxing of ECGs, we developed a telemedicine system providing fast transmission of ECGs between physicians and cardiologists at different locations. It digitized ECGs at a resolution of 300 dots/inch (118 dots/cm), processed them, and transmitted them over a standard telephone line in under one minute. The system also paged the cardiologist in order to direct him or her to the location where the ECG would be waiting for interpretation. The system enabled physicians at remote locations to consult using voice, images and simultaneous cursor pointers. A transmitting site was set up at the Medical Centre of the Ministry of Defence and a receiving site at the National University Hospital, about 5 km away. During a six-month trial, 200 ECG reports were transmitted from one site to the other. They were rated excellent in quality by the cardiologists, being virtually indistinguishable from the originals. Our telemedicine system transmits high-quality ECGs rapidly and at low cost.

An expressed-sequence-tag database of the human prostate: sequence analysis of 1168 cDNA clones

The human prostate is a complex glandular organ with functional development under hormonal regulation. Diseases of the prostate result in significant morbidity and mortality in the form of benign prostatic hypertrophy and prostate adenocarcinoma. The characterization of the molecular framework of the human prostate at the level of expressed genes will facilitate the understanding of normal and pathological prostate biology. The purposes of this study were to acquire an initial assessment of the qualitative and quantitative diversity of gene expression in the normal human prostate and to determine the extent that genes with prostate-restricted expression can be assessed using an expressed sequence tag approach. We have constructed a directional cDNA library from normal adult human prostate tissue and partially sequenced the 5' end of 1168 randomly selected cDNA clones, resulting in more than 400 kb of DNA sequence. Homology searches of the sequenced cDNAs against the GenBank and dbEST databases revealed that 43% of the sequences are identical to human genes whose functions are known, 5% are similar but not identical to known genes in humans or lower organisms, 5% match the mitochondrial genome, 9% are composed of interspersed DNA repeats, 30% are homologous to sequences in the dbEST database without a described function, and 6% are novel sequences. A total of 780 distinct species were identified. In addition to the 74 novel transcripts, 4 genes, prostate-specific antigen (PSA), prostate secretory protein (PSP), prostate acid phosphatase (PAP), and human glandular kallekrein 2 (HK2), have no homologous sequences in the databases that originate from sources other than prostate and thus may represent genes with prostate-restricted expression. Sequences matching PSA, PSP, and PAP each accounted for > 1% of the total ESTs and represent highly abundant transcripts, correlating with the abundance of these proteins in the prostate gland. No novel transcripts were represented by more than one EST and thus are expressed at levels much lower than the known prostate-specific genes.

Electrocardiographic abnormalities in right ventricular infarction associated with right bundle branch block

An 80-year-old woman with pre-existing complete right bundle branch block presented with severe chest pain. The 12-lead electrocardiogram, together with right-sided chest leads, showed complete right bundle branch block and ST segment elevation in leads II, III, aVF, V5, V6 and V4R to V6R. These electrocardiographic abnormalities indicate acute 'Q wave' inferolateral and right ventricular infarction coexisting with right bundle branch block.

Dobutamine stress echocardiography in the elderly Asian patients

Dobutamine stress echocardiography (DSE) is an established non-invasive technique for the evaluation of coronary artery disease (CAD). It has been shown to be both safe and accurate. However, its utility and safety in the elderly, in particular, elderly Asian patients has not been studied. Between September 1992 and December 1994, we performed a total of 75 consecutive DSE studies in patients over the age of 65. Of these, 50 (67%) were females. Forty-nine patients had hypertension, 26 had diabetes mellitus, 10 were smokers, 5 had a recent or previous myocardial infarction and another 4 had a history of heart failure. Indications for DSE were, inability to perform the standard treadmill exercise test (40 patients), an abnormal resting electrocardiogram (ECG) (14 patients), a prior false positive or inconclusive treadmill test, risk stratification post myocardial infarction (4 patients) or preoperative cardiac evaluation (23 patients). The test was terminated in the majority of patients following attainment of the target heart rate. Atropine stimulation was required in 61 (81%) patients. Chest pain was provoked in 11 patients. No death or myocardial infarction occurred. Minor non-cardiac symptoms occurred in another 6 patients but this did not necessitate termination of the procedure. Three patients had transient hypotension, none of which was symptomatic. Arrhythmia occurred in 23 patients but the majority were isolated atrial or ventricular premature beats (20); 1 patient had atrial fibrillation and another developed transient junctional rhythm. Only one patient developed ventricular tachycardia but this was not haemodynamically significant and terminated easily with an intravenous dose of lignocaine. A conclusive result could be obtained in 72 (96%) patients. We concluded that DSE could be performed and interpreted in the majority of elderly Asian patients studied. Despite supplemental atropine, an aggressive dosing protocol and the inclusion of patients with a myocardial scar or history of heart failure, adverse effects were rare and often did not require any specific therapy.

Bilateral ankylosis of temporomandibular joint secondary to ankylosing spondylitis in a male Chinese

A case of bilateral temporomandibular joint (TMJ) ankylosis in a Chinese male patient with ankylosing spondylitis is presented. A review of the literature emphasizes the rarity of this arthro-pathology in ankylosing spondylitis. The importance in the recognition of this complication by clinical examination supplemented by computed tomography is stressed.

High-throughput plasmid mini preparations facilitated by micro-mixing

We have developed a reliable high-throughput plasmid isolation system using a 96-well plate format. This system combines a novel glass bead micro-mixing method with modified alkaline lysis and Sephacryl S-500 DNA purification procedures. Mechanical forces generated by vortexing glass beads inside each well of the 96-well plates ensure that the bacterial pellets are homogeneously resuspended, the cells are completely lyzed, and the resulting bacterial lysates are thoroughly mixed with the potassium acetate solution. The vortexing speed and duration for glass bead mixing have been standardized to facilitate plasmid DNA yields without significant adjustments.

Dobutamine stress echocardiography: angiographic correlates

We started a dobutamine stress echocardiography (DSE) programme in September 1992. Until January 1994, we had performed 300 such procedures. Of these patients, 81 underwent cardiac catheterisation within 6 months of DSE without a cardiac event in the interim. Eleven DSEs were performed to assess myocardial viability and another 6 were inconclusive for myocardial ischaemia. The remaining 64 were correlated with the angiographic data to determine the utility of this technique in our institution. The mean age of the cohort was 57 years. Thirty-six patients were referred for DSE in the workup for chest pain, either anginiform (22) or atypical (14). Fourteen patients had a recent (6) or remote (8) myocardial infarction. Thirteen patients were asymptomatic. Significant obstructive coronary artery disease (CAD) was identified in 36 patients of whom 17 and 19 had single and multivessel disease respectively. The sensitivity of DSE in the entire cohort was 89% and the specificity 82%. Positive and negative predictive values of DSE were 86% and 85% respectively. Although the numbers involved were small, sensitivity figures for single and multivessel disease were 94% and 84% respectively. Of the patients with single vessel CAD, prediction of the artery involved by presumed territorial supply was accurate in 81%. DSE is a highly accurate tool for evaluating CAD, identifying both the patient with CAD and the location of disease.