Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

BACKGROUND

Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.

METHODS

This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.

RESULTS

There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.

CONCLUSIONS

Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Post-mortem computed tomography differentiation of putrefactive gas and air embolism: A case of traumatic carotid-jugular arteriovenous fistula

INTRODUCTION

PMCT is superior to autopsy for identification of intravascular or extravascular gas pockets and their distribution. However, differentiation between air embolism and putrefactive gas can prove challenging due to overlapping imaging findings.

CASE REPORT

We report a case of a healthy young man who was involved in a fight, sustained a slash wound to the right side of his head by a kitchen knife and died at the scene. Pre-autopsy PMCT demonstrated complex fractures of the right mastoid bone extending to the right petrous apex and jugular bulb, exposing the right sigmoid sinus. There was also asymmetric intravascular air distribution suspicious of air embolism with ancillary findings of traumatic carotid-jugular pseudoaneurysm and arteriovenous fistulous formation. Post-mortem examination revealed a slash wound measuring 12x2 cm at the right side of the head, cutting through the scalp, right temporal bone, right temporal meninges, right sigmoid venous sinus and part of the right occipital lobe. No intracranial haemorrhage was found on both PMCT and autopsy.

DISCUSSION

PMCT findings of air embolism versus putrefactive air on PMCT are discussed in this case. Detailed history on mechanism, circumstances, time of death and careful analysis of intravascular and extravascular air distribution patterns on PMCT are essential in guiding differentiation of true fatal air embolism and "normal" post-mortem putrefactive air. Needless to say, it is recommended that PMCT be performed as early as possible after death to reduce the chances and presence of artifactual decomposition changes.

Cognitive Stimulation for Persons with Dementia: a Systematic Review and Meta-Analysis

OBJECTIVE

We aim to provide an up-to-date systematic review and meta-analysis of the effects of cognitive stimulation (CS) on cognition, depressive symptoms, and quality of life in persons with dementia. Factors affecting the treatment effect were examined.

METHODS

A literature search was performed on databases of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, and Cochrane Library up to 7 March 2019. Only randomised controlled trials investigating the effects of CS in persons with dementia were included. The outcome measures were cognitive function, depressive symptoms, and quality of life.

RESULTS

20 randomised controlled trials with a total of 1251 participants (intervention group: 674; control group: 577) were included for meta-analysis. Most participants had mild to moderate dementia. CS had a significant positive small-to-moderate effect on cognition (Hedges's g = 0.313, p < 0.001). Heterogeneity of CS was low to moderate (Q=30.5854, df=19, p < 0.05, I2 = 37.877%). Inconclusive results were found for depressive symptoms and quality of life.

CONCLUSION

CS has a significant positive effect on cognitive function, but its effect on depressive symptoms and quality of life was inconclusive. Future studies with more robust methodology establishing evidence of its efficacy are required.

Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project

OBJECTIVES

We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients.

METHODS

The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions.

RESULTS

Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05).

CONCLUSIONS

Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.

Creation of an asymmetrical gradient of back muscle activity and spinal stiffness during asymmetrical hip extension

BACKGROUND

Low back pain is often associated with increased spinal stiffness which thought to arise from increased muscle activity. Unfortunately, the association between paraspinal muscle activity and paraspinal stiffness, as well as the spatial distribution of this relation, is unknown. The purpose of this investigation was to employ new technological developments to determine the relation between spinal muscle contraction and spinal stiffness over a large region of the lumbar spine.

METHODS

Thirty-two male subjects performed graded isometric prone right hip extension at four different exertion levels (0%, 10%, 25% and 50% of the maximum voluntary contraction) to induce asymmetric back muscle activity. The corresponding stiffness and muscle activity over bilateral paraspinal lumbar regions was measured by indentation loading and topography surface electromyography, respectively. Paraspinal stiffness and muscle activity were then plotted and their correlation was determined.

FINDINGS

Data from this study demonstrated the existence of an asymmetrical gradient in muscle activation and paraspinal stiffness in the lumbar spine during isometric prone right hip extension. The magnitude and scale of the gradient increased with the contraction force. A positive correlation between paraspinal stiffness and paraspinal muscle activity existed irrespective of the hip extension effort (Pearson correlation coefficient, range 0.566-0.782 (P<0.001)).

INTERPRETATION

Our results demonstrate the creation of an asymmetrical gradient of muscle activity and paraspinal stiffness during right hip extension. Future studies will determine if alterations in this gradient may possess diagnostic or prognostic value for patients with low back pain.

Cervical cancer screening attitudes and beliefs of Malaysian women who have never had a pap smear: a qualitative study

BACKGROUND

Attitudes toward cervical cancer and participation in early detection and screening services are well known to be profoundly affected by cultural beliefs and norms.

PURPOSE

This study explored the attitudes and sociocultural beliefs on cervical cancer screening among Malaysian women.

METHOD

In this qualitative study, in-depth interviews were conducted with 20 Malaysian women, ages 21 to 56 years, who have never had a Papanicolaou (Pap) smear.

RESULTS

Respondents generally showed a lack of knowledge about cervical cancer screening using Pap smear, and the need for early detection for cervical cancer. Many believed the Pap smear was a diagnostic test for cervical cancer, and since they had no symptoms, they did not go for Pap screening. Other main reasons for not doing the screening included lack of awareness of Pap smear indications and benefits, perceived low susceptibility to cervical cancer, and embarrassment. Other reasons for not being screened were related to fear of pain, misconceptions about cervical cancer, fatalistic attitude, and undervaluation of own health needs versus those of the family.

CONCLUSION

Women need to be educated about the benefits of cervical cancer screening. Health education, counseling, outreach programs, and community-based interventions are needed to improve the uptake of Pap smear in Malaysia.

Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Pap smear: a qualitative study

INTRODUCTION

Cervical cancer is one of the commonest cancers in women worldwide. Despite the existence of effective screening using Pap smear, the uptake of screening is poor. A qualitative study was undertaken using face-to-face in-depth interviews to investigate knowledge, attitudes and beliefs on cervical cancer screening of Malaysian women.

METHODS

In-depth interviews were conducted with 20 Malaysian women aged 21-56 years and who have never had a Pap smear test, with the aim to explore their knowledge and awareness of cervical cancer and its screening.

RESULTS

A lack of knowledge on cervical cancer and the Pap smear test was found among the respondents. Many women did not have a clear understanding of the meaning of an abnormal cervical smear and the need for the early detection of cervical cancer. Many believe the purpose of the Pap smear test is to detect existing cervical cancer, leading to the belief that Pap smear screening is not required because the respondents had no symptoms. Despite considerable awareness of a link between cervical cancer and sexual activity, as well as the role of a sexually-transmitted infection, none of the respondents had heard of the human papillomavirus.

CONCLUSION

The findings highlight the importance of emphasising accurate information about cervical cancer and the purpose of Pap smear screening when designing interventions aimed at improving cervical cancer screening for Malaysian women.

Queen Mary Utilization of Antihypertensive Drugs Study: side-effects of antihypertensive drugs

BACKGROUND AND OBJECTIVE

Effective prevention of cardiovascular events in hypertensive patients requires good control of blood pressure. Side-effects of antihypertensive drugs affect tolerability and compliance. Accordingly, we surveyed side-effects in the hypertension outpatient clinic.

METHODS

A total of 228 patients (109 men, 119 women) were interviewed in April-May 2004 in the Queen Mary Utilization of Antihypertensive Drugs Study.

RESULTS

The percentage of patients receiving no drug (life-style modification), one, two, three and over three drugs were 3, 30, 40, 22 and 6% respectively. The proportion of patients taking calcium channel blockers, beta-blockers (BB), angiotensin-converting enzyme inhibitors, thiazide diuretics, alpha-blockers and angiotensin receptor blockers were 65, 64, 33, 24, 4 and 7% respectively. Blood pressure on treatment was 144+/-21/82+/-11 mmHg. Among patients on antihypertensive drug therapy, 34% reported adverse effects: dizziness (9%), ankle swelling (7%), headache (5%), fatigue (4%), chest discomfort (3%) and cough (3%). Fewer patients on BBs reported side-effects (OR 0.46, P=0.008). The likelihood of experiencing side-effects was unrelated to sex, age, weight, BMI, years of treatment, number of drugs used, heart rate on treatment or compliance.

CONCLUSIONS

To achieve good blood pressure control, multiple drugs are used. Thiazides are underused whereas BBs are popular. The popularity of the latter may be related to its tolerability.

Attitudes of medical students towards euthanasia in a multicultural setting

A cross-sectional survey of 400 medical students of multicultural backgrounds at the University of Malaya was conducted to understand their attitudes towards euthanasia and factors related to medical decisions and ethical reasoning concerning the prolongation of life, the right to die and euthanasia. The student respondents completed self-administered questionnaires that comprised of twelve questions with multiple stems addressing personal perceptions, knowledge, attitudes, and decisions about euthanasia and the relief of suffering. The majority of respondents (52%) were for the withdrawal of active therapy in a patient suffering from a terminal painful disease while 48% of them were against it. Seventy-one percent of the students involved in the study were against the idea of active euthanasia i.e. the administration of a lethal injection. However, 27% of the respondents felt that there was a moral justification to assist patients to die. Thirty-two percent of the respondents favoured the legalization of euthanasia in Malaysia while 67% of them were strongly against it. The majority (61%) of respondents would not practice euthanasia as a doctor nor would they have performed on themselves if or when it became legal. The main issue surrounding euthanasia that concerned the respondents was the misuse of it by unethical practitioners and they felt that further debate on the matter was essential, both within the local and international communities.

Retinoblastoma gene expression in human non-melanoma skin cancer

BACKGROUND

The aberrant expression of both the retinoblastoma and p53 tumor suppressor genes has been associated with more aggressive tumors, metastasis and lower survival.

METHODS

We have evaluated immunohistochemically the expression of pRB in a panel of non-melanoma skin cancers containing p53 somatic mutations.

RESULTS

Nuclear anti-p53 staining was detected in 18 (72%) differentiated squamous cell carcinomas, six (100%) undifferentiated squamous cell carcinomas and seven (28%) basal cell carcinomas. A correlation was observed between p53 expression and the proliferative activity of differentiated squamous cell carcinomas (P < 0.066), undifferentiated squamous cell carcinomas (P < 0.05) and basal cell carcinomas (P < 0.01). Tumors were selected for mutant p53 expression by PCR-directed DNA sequencing and pRB expression measured immunohistochemically. Anti-pRB reactivity was detected in the nuclei of basal and suprabasal layer cells of normal epidermis, and in the proliferative compartment of all the differentiated squamous cell carcinomas, and basal cell carcinomas. A correlation was observed between pRB expression and the proliferative activity of the differentiated squamous cell carcinomas (P < 0.01) and basal cell carcinomas (P < 0.025). However, anti-pRB reactivity was not detected in the six anti-p53 reactive undifferentiated squamous cell carcinomas.

Malaysian cultural differences in knowledge, attitudes and practices related to erectile dysfunction: focus group discussions

This qualitative study aimed to examine cultural differences in knowledge, attitudes and practices related to erectile dysfunction (ED) utilizing focus group discussion. Six focus groups consisting of 66 men, 45-70-y-old were conducted-two Malay groups (n=18), two Chinese groups (n=25) and two Indian groups (n=23). Participants were purposely recruited from the general public on a voluntary basis with informed consent. Transcripts were analyzed using qualitative data analysis software ATLASti. The Malay and Chinese traditional remedies for preventing or treating ED are commonly recognized among all races. Many have a negative perception of someone with ED. Malay and Chinese men tended to blame their wife for their problem and thought that the problem might lead to extra-marital affairs, unlike the Indian men who attributed their condition to fate. Malays would prefer traditional medicine for the problem. The Chinese felt they would be more comfortable with a male doctor whilst this is not so with the Malays or Indians. Almost all prefer the doctor to initiate discussion on sexual issues related to their medical condition. There is a need for doctors to consider cultural perspectives in a multicultural society as a lack of understanding of this often contributes to an inadequate consultation.

Knowledge, attitudes and beliefs related to HIV/AIDS among adolescents in Malaysia

Findings on knowledge, attitudes and beliefs related to HIV/AIDS among 520 Malaysian adolescents, aged 15 to 21 years, based on a survey conducted in Peninsular Malaysia showed that the average score for knowledge on HIV/AIDS was high, and majority showed a positive attitude towards the disease. However, misconceptions regarding transmission and gender bias related to sexual behaviour and contracting the disease prevailed. Although 72 percent of the sexually-experienced did not use protection at first sexual intercourse, 80 percent did not perceive themselves to be at risk of contracting HIV/AIDS. A critical review of existing HIV/AIDS prevention programmes to focus on adolescent risk-taking behaviour and sexuality issues, including male-female negotiation skills, is warranted.

What Malaysian women believe about Viagra: a qualitative inquiry

This paper highlights women's perceptions of sildenafil citrate (Viagra, Pfizer). It is based on a qualitative study on perceptions of erectile dysfunction in the Malaysian multicultural society. Six focus groups were conducted, consisting of 69 women, aged between 40 and 70 years, recruited from the general public and who had given informed consent. The findings revealed that the women were aware of erectile dysfunction and Viagra. Due to their concern about the negative aspects of Viagra, the Chinese and Malay traditional methods of treatment were commonly mentioned. The women from three ethnic groups viewed the possibility of their husband starting to take Viagra with lots of suspicion, mistrust and fear. They would prefer their husband discussing with them the issue of resorting to taking Viagra. The Chinese and Indian women perceived that if a man takes Viagra, it will boost his ego and he will feel more manly. Indian women felt that a man taking Viagra is proof of his love for his wife. The Malay women felt that a man would be ashamed and have a low self-esteem if he were to resort to taking Viagra. Although Viagra is meant for the male, understanding of women's perception of it is beneficial for a couple's sexual relationship.

Mitochondrial thiol status in the liver is altered by exposure to hyperoxia

Patients with poorly functioning lungs often require treatment with high concentrations of supplemental oxygen, which, although often necessary to sustain life, can cause lung injury. The mechanisms responsible for hyperoxic lung injury have been investigated intensely and most probably involve oxidant stress responses, but the details are not well understood. In the present studies, we exposed adult male C57/Bl6 mice to >95% O2 for up to 72 h and obtained lung and liver samples for assessment of lung injury, measurements of tissue concentrations of coenzyme A (CoASH) and the corresponding mixed disulfide with glutathione (CoASSG), as possible biomarkers of intramitochondrial thiol redox status. Subcellular fractions were prepared from both tissues for determination of glutathione reductase (GR) activities. Lung injury in the hyperoxic mice was demonstrated by increases in lung weight to body weight ratios at 48 h and by increases in bronchoalveolar lavage protein concentrations at 72 h. Lung CoASH concentrations declined in the hyperoxic mice, but CoASSG concentrations were not increased nor were CoASH/CoASSG ratios decreased, as would be expected for an oxidant shift in mitochondrial thiol-disulfide status. Interestingly, CoASSG concentrations increased (from 6.72+/-0.54 to 14.10+/-1.10 nmol/g of liver in air-breathing controls and 72 h of hyperoxia, respectively, P<0.05), and CoASH/CoASSG ratios decreased in the livers of mice exposed to hyperoxia. Some apparent effects of duration of hyperoxia on GR activities in lung or liver cytosolic, mitochondrial, or nuclear fractions were observed, but the changes were not consistent or progressive. Yields of isolated hepatic nuclear protein were decreased in the hyperoxic mice within 24 h of exposure, and by 72 h of hyperoxia, protein recoveries in purified nuclear fractions had declined from 41.8 to 14.8 mg of protein/g animal body weight. Concentrations of 10-formyltetrahydrofolate dehydrogenase were diminished in hepatic mitochondria of hyperoxic mice. A second protein in hepatic mitochondria of approximately 25 kDa showed apparent decreases in thiol content, as determined by fluorescence intensities of monobromobimane derivatives separated by SDS-PAGE. The mechanisms responsible for the observed effects and the possible implications for the adverse effects of hyperoxic therapies are not known and need to be investigated.

Gender issues in medical and public health education

There is no doubt that gender bias has been inherent in medical and public health education, research, and clinical practice. This paper discusses the central question for medical and public health educators viz. whether women's health concerns and needs could be best addressed by the conventional biomedical approach to medical and public health education, research, and practice. Gender inequalities in health and gender bias in medical and public health education are revealed. It is found that in most public health and prevention issues related to women's health, the core issue is male-female power relations, and not merely the lack of public health services, medical technology, or information. There is, thus, an urgent need to gender-sensitize public health and medical education. The paper proposes a gender analysis of health to distinguish between biological causes and social explanations for the health differentials between men and women. It also assessed some of the gender approaches to public health and medical education currently adopted in the Asia-Pacific region. It poses the pressing question of how medical and public health educators integrate the gender perspective into medical and public health education. The paper exhorts all medical and public health practitioners to explore new directions and identify innovative strategies to formulate a gender-sensitive curriculum towards the best practices in medicine and public health that will meet the health needs of women and men in the 21st century.

Stressors, resources, and distress among homeless persons: a longitudinal analysis

Relations among stressors, resources, and psychological distress were examined using two waves of data obtained from a probability sample of homeless persons (N = 430) residing in a large, demographically diverse county in North California. The focus of research was to examine whether and how social resources and housing resources directly affect distress and mediate the impact of stress factors on depressive symptoms. Path analysis results revealed that levels of psychological distress were responsive to change in objective housing circumstances, with the attainment of domicile status being associated with fewer distress symptoms. Our findings, however, indicated only modest effects of social resources on psychological distress through direct effects and mediating effects of life stressors on distress. Overall, the study suggests that the relationships among stressors, resources, and distress for homeless persons may be understood within the same analytical framework for the general population.

Lonidamine and analogue AF2785 block the cyclic adenosine 3', 5'-monophosphate-activated chloride current and chloride secretion in the rat epididymis

The cystic fibrosis transmembrane conductance regulator (CFTR) or the small conductance cAMP-activated chloride channel encoded by the CFTR gene has been shown to play an important role in the formation of the epididymal fluid microenvironment. Mutation of the gene has led to widespread effects on male reproduction. Like other ion channels, CFTR is amenable to pharmacological intervention. Blocking CFTR in the epididymis could in principle lead to disruption of the epididymal fluid environment. We report for the first time two indazole compounds: lonidamine and 1-(2, 4-dichlorobenzyl)-indazole-3-acrylic acid (AF2785) are potent blockers of CFTR in the epididymis. When added to the external solution under whole-cell patch clamp conditions, AF2785 and lonidamine inhibited the cAMP-activated chloride current in rat epididymal cells with apparent IC(50) values of 170.6 and 631.5 microM, respectively; by comparison the IC(50) value for diphenylamine-2-carboxylate, a well-known chloride channel blocker was 1294 microM. In cultured rat epididymal epithelia mounted in a Ussing chamber, AF2785 and lonidamine inhibited the cAMP-stimulated short-circuit current (a measure of chloride secretion) when added to the apical bathing solution with potency greater than any known chloride channel studied. It is proposed that in view of the important role CFTR plays in male reproduction, further study with these and other new indazole compounds for their CFTR blocking actions can provide a new avenue of research into the development of novel male contraceptives.

Measurement properties of the Center for Epidemiologic Studies-Depression Scale in a homeless population

The measurement properties of the Center for Epidemiologic Studies--Depression Scale (CES-D; L. S. Radloff, 1977) were evaluated in a probability sample of homeless adults residing in a large and demographically diverse community. The findings from this investigation suggest that the CES-D is a reliable measure of depressive symptoms among homeless adults and that the factor structure of the scale replicates the factor structure found in the general population. Change in the CES-D scores was associated with change in residential status, with participants who had made a transition from homelessness to regular domicile, reporting significantly lower levels of depressive symptomatology. This result indicates the scale's sensitivity to current depressive mood, as affected by significant life events encountered by homeless persons.

Measurement properties of the Center for Epidemiologic Studies-Depression Scale in a homeless population

The measurement properties of the Center for Epidemiologic Studies--Depression Scale (CES-D; L. S. Radloff, 1977) were evaluated in a probability sample of homeless adults residing in a large and demographically diverse community. The findings from this investigation suggest that the CES-D is a reliable measure of depressive symptoms among homeless adults and that the factor structure of the scale replicates the factor structure found in the general population. Change in the CES-D scores was associated with change in residential status, with participants who had made a transition from homelessness to regular domicile, reporting significantly lower levels of depressive symptomatology. This result indicates the scale's sensitivity to current depressive mood, as affected by significant life events encountered by homeless persons.

Regulation of anion secretion by cyclo-oxygenase and prostanoids in cultured epididymal epithelia from the rat

1. The role of cyclo-oxygenase (COX) in the regulation of anion secretion (measured as short- circuit current, Isc) in cultured epididymal epithelia from immature rats was investigated. 2. COX inhibitors attenuated the increase of anion secretion caused by bradykinin (LBK) but had no effect on that caused by PGE2, suggesting that prostaglandin synthesis mediates the secretory response of the tissues to LBK. 3. The apparent IC50 values for indomethacin, piroxicam and L-745,337 in inhibiting the LBK-induced Isc were 0.14, 1.34 and 15.7 microM, respectively. This order of potency: indomethacin > piroxicam > L-745,337 >> DFU suggests the involvement of the COX-1 isozyme in the mediation of the secretory response to LBK. 4. Among the COX products (prostaglandins, thromboxane and prostacyclins) tested, only PGE2 and, to a much lesser extent, PGF2alpha stimulated anion secretion by cultured rat epididymal epithelia. 5. The effect of PGE2 was mimicked by 11-deoxyl PGE1, a specific prostaglandin E (EP)2/4 receptor agonist, but not by sulprostone, a specific EP1/3 receptor agonist, indicating that cyclic AMP-coupled EP2/4 receptors are involved in the LBK-stimulated anion secretion. 6. A reverse transcriptase-polymerase chain reaction study detected the expression of COX-1 and COX-2 mRNA in intact rat epididymis and in cultured epididymal epithelia. The expression of COX-1 mRNA was reduced by LBK by 44 %. 7. Immunohistochemical studies demonstrated the presence of COX-1 immunoreactivity in the basal cells of the intact rat epididymis. By comparison, COX-2 immunoreactivity was detected in the apical pole of the principal cells. 8. The role of COX in the formation of the epididymal microenvironment and the implication of long term administration of non-steroidal anti-inflammatory drugs (NSAIDs) on male fertility are discussed.

Oestrogen and progesterone receptors in normal human endometrium: comparison of immunocytochemical analysis on frozen and paraffin sections with or without enzymatic pretreatment

Immunocytochemical study in paraffin sections of human endometrium showed that the receptor contents for both oestrogen and progesterone receptors were lower than in the frozen sections although the staining patterns were similar in these two section types. Pretreating the specimens with proteolytic enzymes like trypsin, DNase and pronase improved the oestrogen receptor staining but a better result with progesterone receptor staining was obtained when no enzymatic pretreatment was applied to the sections.

Assessment of cell proliferation in hydatidiform mole using monoclonal antibody MIB1 to Ki-67 antigen

AIMS

To assess the role of Ki67 immunoreactivity in predicting the clinical progress of hydatidiform mole.

METHODS

Tissue from 87 hydatidiform moles, 11 normal first trimester placentas, 11 normal term placentas and 17 spontaneous abortions were examined for expression of Ki67 antigen, using the monoclonal antibody MIB1.

RESULTS

Ki67 immunoreactivity was significantly higher in the tissue from normal first trimester placentas than in that from normal term placentas and spontaneous abortions. Among the 87 patients with hydatidiform moles studied, 20 developed persistent gestational trophoblastic disease and required subsequent treatment. There was no statistically significant difference in the Ki67 index between the 20 patients who developed persistent disease and those who did not.

CONCLUSION

Hydatidiform moles which give rise to persistent trophoblastic disease do not have a higher proliferative rate than those which do not. The Ki67 index is not useful for predicting the prognosis of molar pregnancies.

Study of oestrogen and progesterone receptors in normal human endometrium during the menstrual cycle by immunocytochemical analysis

Monoclonal antibodies to human oestrogen and progesterone receptors were applied to frozen sections of normal endometrium in various phases of the menstrual cycle. Both oestrogen and progesterone receptors were localised within the nuclei of target cells. There are no oestrogen or progesterone receptors in endometrial vessels. Oestrogen receptor contents remained fairly constant during the proliferative and early secretory phases but decreased markedly in the late secretory phase. This decline was more obvious in the glandular cells than in the stromal cells, where receptor staining disappeared in most cases. The receptors were localised predominantly in the glandular cells at most stages of the menstrual cycle except in the late secretory phase, where the reverse was observed. In contrast, progesterone receptors rose gradually throughout the proliferative and early secretory phases followed by a decrease to various degrees depending on the cell types in the late secretory phase. This decrease was more marked in the glandular cells where again receptor staining disappeared in most cases, whereas the receptor contents in the stromal cells only decreased to the level of the late proliferative phase. The progesterone receptors were also localised predominantly in the glandular cells at most stages in the cycle apart from the late secretory phase.

Crystal structure of phospholipase C from Bacillus cereus complexed with a substrate analog

We report the first crystal structure of a complex between PLC from Bacillus cereus (PLCBc) and a competitive inhibitor that is an analog of the natural phospholipid substrate. The structure has been determined at 1.9 A resolution and refined to a final R-factor of 15.7%. The inhibitor binds with its phosphonyl group to the three Zn ions in the active site of the enzyme and is also involved in a hydrogen bonded network including several water molecules and amino acid side-chains which appear to help orient the substrate for productive binding. The interactions within this complex provide some important information regarding the mechanism of PLC-catalyzed hydrolysis of membrane phospholipids. A water molecule, located approximately apical to the diacylglycerol leaving group, seems to be the most likely candidate for the attacking nucleophile which initiates the reaction.

Rapid sequence induction and tracheal intubation with vecuronium--with or without a priming dose

The purpose of this study was to determine whether prior administration of a small, sub-paralytic dose of nondepolarizing muscle relaxant, vecuronium, would have a better intubating condition than a single bolus dose when vecuronium was used as the muscle relaxant during rapid sequence induction and tracheal intubation. Six groups of 15 patients each (ASA class I or II) were involved in this study. Anesthesia was induced with fentanyl 2-3 micrograms/kg and thiopental 4-5 mg/kg. In group 1, 2 and 3, the patients were given the same priming dose of 0.1 mg/kg. Four min later, different doses of vecuronium were given to each group: 0.09 mg/kg (Gp1), 0.14 mg/kg (Gp2), and 0.19 mg/kg (Gp3). In group 4, 5 and 6, no priming vecuronium was given and the intubating doses given to each group were as follow: 0.1 mg/kg (Gp4), 0.15 mg/kg (Gp5) and 0.2 mg/kg (Gp6). At the end of a 60 sec, the percentage of patient with excellent intubating condition were 46.6%, 66.6%, 86.6%, 20%, 40% and 80% respectively for group 1, 2, 3, 4, 5 and 6 respectively. The percentage with good intubating condition were 46.6%, 33.4%, 13.4%, 46.6%, 53.2%, and 20% for group 1, 2, 3, 4, 5 and 6 respectively. The percentage of poor intubating condition were 6.8% in group 1, 33.4% in group 4, 6.8% in group 5 and 0% in group 2, 3, 6. All patients receiving a priming dose could sustain head lift for 5 sec and did not complain any respiratory discomfort 3 min after the priming dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Adverse effects of pharmaceutical excipients in drug therapy

Everyone who prescribes a modern formulated drug is aware of the risks of adverse reactions due to the properties inherent in the active ingredients, but not all are aware of the latent risks due to the excipients. The latter risks are compounded when inappropriate and inferior quality excipients are used. When investigating reports of adverse drug reactions, the possibilities of excipient-contributed reactions must not be overlooked, though such possibilities may appear to be remote. Tragic accidents attributable to excipients have occurred and are on record. Preventive measures include frequent inspection and laboratory examination of imported and locally manufactured formulated drugs to monitor the safety of their excipients and the quality of the raw materials used in their manufacture.

Child care services in Malaysia: an overview

In 1982, under the patronage of the Ministry of Social Welfare and with financial aid from UNICEF, three consultants from the University of Malaya conducted a National Child Care Survey to: provide an overview of child care services in Malaysia; to design a monitoring system to help child minders and relevant personnel to assess the standards of child care at the centres; and to develop a series of policy recommendations for implementing “better child care” in the country. This paper presents the first part of the National Child Care Survey, that is, an overview of child care services available in Malaysia.

The survey was conducted in five states in Peninsular Malaysia — Penang, Perak, Selangor, Kelantan and Melaka — and in two cities — Kuching and Kota Kinabalu — in East Malaysia. The national survey studied the type of care found at 537 centres where 824 minders looked after 7, 884 children. Four major aspects of child care were identified and subsequently examined: the physical conditions and environmental hygiene of the premises; profile of children under care; daily practices; and the personnel in the three basic types of centres, i.e., Institution-based, plantation-or estate-based and home-based.

Total and poly(A) RNA yields during an aluminum encephalopathy in rabbit brains

The yields of total and poly(A) RNA were examined in rabbit forebrains during an experimentally induced aluminum encephalopathy. Rabbits (35 day old) were injected intracranially with 13 mumole Al lactate and sacrificed 1, 3, 7, 10, or 12 days later. IRNA yields (total RNA minus transfer RNA) were not significantly altered during the encephalopathy. Poly(A) RNA yields, assayed by oligo(dT)-cellulose fractionation and by a [3H]poly(U) hybridization assay on IRNA, were increased significantly by the end of the asymptomatic stage of the encephalopathy (7 days post-Al injection). The increase in messenger RNA population may represent either a compensatory response to cell damage induced by aluminum or the accumulation of messenger RNA for proteins directly related to the expression of aluminum toxicity.