Clinicopathological correlation of oral candidiasis - Our experience in a tertiary centre over two decades

INTRODUCTION

Oral candidiasis is one of the most common fungal infections that has been widely reported around the world. In Malaysia, the available studies for this infection are scarce.

MATERIALS AND METHODS

This is a 20-year retrospective study aimed to investigate the prevalence, demographic characteristics, clinical presentations, and the association of oral candidiasis with clinical parameters in oral candidiasis cases reported in the Faculty of Dentistry, Universiti Malaya from 1999 until 2019. A total of 12,964 histopathological records from the Oral Pathology Diagnostic and Research Laboratory (OPDRL) between 1999 to 2019 were retrieved. Oral candidiasis cases were selected according to the inclusion and exclusion criteria. Information of interest was obtained and analysed.

RESULTS

From the total records retrieved, 378 oral candidiasis cases were recorded and 82.8% were diagnosed from smear test. This study showed that oral candidiasis was predominantly reported in female (64.2%) and Indian population (64.2%). The peak incidence was in the sixth decades of life (27.0%). The most commonly affected site was tongue and coated tongue was the most common clinical presentation. More than 50% of the cases had comorbidity and 10.6% were associated with dentures. Ethnicity and site of occurrence were significantly associated (p<0.05) with oral candidiasis.

CONCLUSION

This is the first large-scale study of oral candidiasis cases in Malaysia. The findings of this study are useful for clinical assessment of patients suspected of oral candidiasis.

Immunoexpression of BRAF, EGFR and CD10 in ameloblastoma

The ameloblastoma is the most challenging odontogenic neoplasm to treat because of its locallyinvasive behaviour, severe clinical implication, risk of malignant transformation and high recurrence rate. Recent evidence suggests that BRAF, EGFR and CD10 have a role in the local invasiveness of ameloblastoma. However, the spatial distribution characteristics of these pro-invasive factors and their association with clinical parameters in this neoplasm are largely unexplored. We sought to address these issues in ameloblastoma subtypes and to determine their biological relevance. Nineteen unicystic (UA) and 20 conventional ameloblastoma (SMA) were subjected to immunohistochemical staining for BRAF, EGFR and CD10, and semiquantitative analysis was performed. All ameloblastoma cases (n=39/39; 100%) exhibited a BRAF+/EGFR+/CD10+immunoprofile. Their expression rates were significantly higher in SMA than UA (P<0.05). BRAF, essential for the progression and proliferation of ameloblastoma, was detected mainly in the cytoplasm of stellate reticulum-like>stromal>preameloblast- like cells (P<0.05). EGFR, a potent oncogenic protein, showed predominantly nuclear localisation. CD10, an apoptosis-inhibitory factor, was strongly expressed in the membrane of stellate reticulum-like cells. Taken together, present results suggest that the spatial distribution patterns of BRAF, EGFR and CD10 parallel the specific behaviours of SMA and UA. Their cellular and intracellular protein localisations have important targeted therapy implications.

How to safely and sustainably reorganise a large general radiography service facing the COVID-19 pandemic

Objectives

This paper aims to share our experience in reorganising our general radiography service during the coronavirus disease (COVID-19) pandemic from the viewpoint of a large tertiary referral medical centre.

Key findings

Re-organization of the radiography workforce, patient segregation, and modification of routine radiographic practices are key measures to help radiographic services deal with the COVID-19 pandemic. Specific emphasis on deploying more mobile radiographic units, segregating equipment, developing consistent image acquisition workflows, and strict adherence to infection control protocols are paramount to minimize the possibility of in-hospital transmission and ensure a safe environment for both patients and staff. Streamlining communication channels between leadership and ground staff allows quick dissemination of information to ultimately facilitate safe provision of services.

Conclusion

COVID-19 has drastically altered the way general radiography teams provide services. The institution of several key measures will allow hospitals to safely and sustainably provide radiographic services. To date, there have been zero incidences of radiographer healthcare worker transmission within our institution during the course of work.

Implication for practice

Radiographers are facing the challenge of providing high-quality services while simultaneously minimizing pathogen exposure to staff and patients. Our experience may lend support to other radiographic services responding to the COVID-19 outbreak and serve as a blueprint for future infectious disease outbreak contingency plans.

Coronoid hyperplasia: A review

Coronoid hyperplasia is one of the rare causes of progressive limitation of mouth opening due to impingement of the enlarged coronoid process of the mandible on the zygomatic bone. A review was performed on all cases reports and case series on coronoid hyperplasia. Gender, age at treatment, age of onset, types of hyperplasia (unilateral/bilateral), associated history, treatment, surgical approach, preoperative mouth opening, intraoperative mouth opening, mouth opening at follow up and follow up period were recorded and analyzed. A total of 82 articles which reported 115 cases were included. Coronoid hyperplasia was commonly reported at mean age of 22.64 years old with male preponderance. Most of the cases were diagnosed and treated between the age of 11-20 years old. This condition commonly involved bilateral coronoid process of mandible. The mean width of preoperative mouth opening was 16.5mm and was improved to a mean mouth opening of 36.3mm intraoperatively. Mean mouth opening was 34.8mm at an average follow up of 19 months. While the etiopathogenesis of coronoid hyperplasia is still not conclusive, treatment with either coronoidectomy or coronoidotomy produced good improvement in mouth opening.

High-resolution X-ray diffraction and micro-Raman scattering studies of Ge(:Ga) thin films grown on GaAs (001) substrates by MOCVD

Ga-doped Ge thin films grown on GaAs (001) substrates have been studied and compared with unintentionally doped Ge film by using HRXRD and Raman scattering in both surface and cross-section configurations.

Surface passivation and interface properties of bulk GaAs and epitaxial-GaAs/Ge using atomic layer deposited TiAlO alloy dielectric

High quality surface passivation on bulk-GaAs substrates and epitaxial-GaAs/Ge (epi-GaAs) layers were achieved by using atomic layer deposited (ALD) titanium aluminum oxide (TiAlO) alloy dielectric. The TiAlO alloy dielectric suppresses the formation of defective native oxide on GaAs layers. X-ray photoelectron spectroscopy (XPS) analysis shows interfacial arsenic oxide (As(x)O(y)) and elemental arsenic (As) were completely removed from the GaAs surface. Energy dispersive X-ray diffraction (EDX) analysis and secondary ion mass spectroscopy (SIMS) analysis showed that TiAlO dielectric is an effective barrier layer for reducing the out-diffusion of elemental atoms, enhancing the electrical properties of bulk-GaAs based metal-oxide-semiconductor (MOS) devices. Moreover, ALD TiAlO alloy dielectric on epi-GaAs with AlGaAs buffer layer realized smooth interface between epi-GaAs layers and TiAlO dielectric, yielding a high quality surface passivation on epi-GaAs layers, much sought-after for high-speed transistor applications on a silicon platform. Presence of a thin AlGaAs buffer layer between epi-GaAs and Ge substrates improved interface quality and gate dielectric quality through the reduction of interfacial layer formation (Ga(x)O(y)) and suppression of elemental out-diffusion (Ga and As). The AlGaAs buffer layer and TiAlO dielectric play a key role to suppress the roughening, interfacial layer formation, and impurity diffusion into the dielectric, which in turn largely enhances the electrical property of the epi-GaAs MOS devices.

Central venous catheter-related blood stream infections: incidence and an analysis of risk factors

Six hundred and fifty-five central venous catheters (CVC) in 496 patients in the intensive care unit of Hospital Sultanah Aminah were studied to determine the incidence and risk factors for central venous catheter-related blood stream infection (CR-BSI). CR-BSI was diagnosed in 38 catheters, giving an incidence of 9.43 CR-BSI per 1000 catheter days. The mean duration in situ was 8.4 +/- 4.9 days for infected CVCs and 6.0 +/- 3.8 days for non infected CVCs (p = 0.001). CVCs inserted in ICU had the highest infection rate (9.4%) compared to those inserted in the operating theatre (1.4%) and ward (2.8%) (p = 0.001). The highest rate of CR-BSI occurred with 4-lumen catheters (usually inserted when patients needed total parenteral nutrition) with a percentage of 15.8%. The majority of the CVCs (97.9%) were inserted via the subclavian or the internal jugular routes and there was no statistical difference in CR-BSI between them (p = 0.83). Number of attempts more than one had a higher rate of CR-BSI compared to single attempt with percentage of 7.0% vs 4.8% (p = 0.22). The top two organisms were Klebseilla pneumoniae and Pseudomonas aeruginosa. In conclusion, the incidence of CR-BSI in our ICU was 9.43 CR-BSI per 1000 catheter days. The risk factors were duration of CVC in situ, venue of insertion and use of 4 lumen catheter for total parenteral nutrition. The site of insertion, number of lumen up to 3 lumens and the number of attempts were not risk factors.

The current practice of sedation and analgesia in intensive care units in Malaysian public hospitals

We sought to review the current practice of sedation and analgesia in intensive care units (ICUs) in Malaysian public hospitals. A questionnaire survey was designed and sent by mail to 40 public hospitals with ICU facility in Malaysia. The anaesthesiologists in charge of ICU were asked to complete the questionnaire. Thirty seven questionnaires were returned (92.5% response rate). Only 35% respondents routinely assess the degree of sedation. The Ramsay scale was used prevalently. A written protocol for sedation was available in only 14 centers (38%). Although 36 centers (95%) routinely adjust the degree of sedation according to patient's clinical progress, only 10 centers (14%) interrupt sedation on a daily basis. Most respondents agreed that the selection of agents for sedation depends on familiarity (97%), pharmacology (97%), the expected duration for sedation (92%), patient's clinical diagnosis (89%) and cost (73%). Midazolam (89%) and morphine (86%) were the most commonly used agents for sedation and analgesia, respectively. Only 14% respondents still frequently use neuromuscular blocking agents, mostly in head injury patients. Our survey showed similarity in the choice of sedative and analgesic agents in ICUs in Malaysian public hospitals comparable to international practice. Nevertheless, the standard of practice could still be improved by implementing the practice of sedation score assessment and daily interruption of sedative infusion as well as having a written protocol for sedation and analgesia.

Epidemiology of pterygium on a tropical island in the Riau Archipelago

OBJECTIVES

To describe the epidemiology of pterygium among residents of an island in Indonesia and to examine the roles of age and gender as determinants of bilaterality and severity of the disease.

METHODS

Voluntary eye screening on Pulau Jaloh, Riau Archipelago, Indonesia. Gender difference was tested using the chi2 test. The difference in age between subjects with and without disease was tested using unpaired Student's t-test. Odds ratio (relative risk) for gender was calculated using logistic regression model with adjustment for age.

RESULTS

Of the 550 inhabitants, 477 (86.7%) responded to the eye screening. The overall prevalence rate of pterygium was 17.0%. Out of 211, 48 male (22.7%) and 33 out of 266 female subjects (12.4%) had the disorder, with the gender difference being statistically significant. Adjusted for age, the risk of disease was 3.1-fold higher among the males. In all, 71.6% of subjects with pterygium had bilateral disease. Subjects with pterygium were significantly older, their mean age being 42.9 years compared to 18.7 years among those without disease. The prevalence rates in male subjects increased from age 20 to reach a plateau of 63.6% at age 35 and remained stable thereafter. In the female subjects, the rates also increased with age, albeit at a slower rate, from age 20 to reach a plateau of 46.7% at age 55 and remained stable thereafter.

CONCLUSIONS

There is a high prevalence rate of pterygium among the study subjects, with the rates increasing rapidly with age.

Hypertension, antihypertensive agents and outcomes following renal transplantation

Hypertension is common following renal transplantation and adversely affects graft and patient survival. However, strategies for antihypertensive drug therapy and target blood pressure have not been clearly defined.

AIM

To assess the influence of achieved blood pressure and antihypertension drug therapy on graft and patient survival with the aim of identifying targets and event rates for future intervention studies.

METHODS

We undertook a longitudinal follow up study of 634 renal transplant patients. Patients were surveyed in December 1994 and followed up after 102 months. Blood pressure (BP) was determined from the mean of three clinic readings and antihypertensive drug therapy recorded.

RESULTS

Complete follow up data were available for analysis on 622 patients (57.2% male; mean age: 45.2 +/- 13.0 yr. There were 158 (25.4%) deaths and 115 (18.5%) death-censored graft failures. Lower systolic and diastolic blood pressure were associated with better graft survival in the Kaplan-Meier analysis. Univariate analysis showed serum creatinine (HR 1.012, p < 0.001), duration of renal replacement therapy (HR 0.946, p = 0.012), age (HR 0.979, p = 0.014) and pulse pressure (HR 1.017, p = 0.044) to be predictors of graft survival with serum creatinine and duration of renal replacement therapy as the only significant factors in the multivariate analysis. Lower systolic and pulse pressure were associated with better patient survival in the Kaplan-Meier analysis. Age (HR) 1.062, p < 0.0001), serum creatinine (HR 1.002, p = 0.021), diabetes (HR 3.371, p < 0.0001), and pulse pressure (HR 1.013, p = 0.036) were significant predictors of patient survival in the univariate and multivariate analysis. Patient survival was reduced with increasing number of antihypertensives (p < 0.05), as was graft survival (p < 0.05). Reduced patient and graft survival were seen in patients prescribed calcium channel antagonists (p < 0.01). There was no increased patient mortality in those patients on beta-blockers or angiotensin converting enzyme (ACE) inhibitors.

CONCLUSION

Hypertension is a risk factor, which remains despite the use of anti-hypertensives, for reduced patient and graft survival. The risk was not significant when blood pressure was entered together with serum creatinine in the multivariate analysis. Beta-blockers may have a beneficial effect on cardiovascular mortality, and ACE inhibitors a beneficial effect on both patient and graft survival. There is a pressing need for interventional studies to assess the impact of blood pressure targets on patient and graft survival and the effect of individual agents on these outcomes.

Percutaneous dilational tracheostomy--a 3 year experience in a general hospital in Malaysia

All percutaneous tracheostomies performed in the general intensive care unit (ICU), Hospital Sultanah Aminah, Johor Bahru, Malaysia, from July 1999 to June 2002 were studied. The tracheostomies were performed as an elective bedside technique in the ICU. A total of 352 percutaneous tracheostomies were performed. Eighty-eight percent of the tracheostomies were completed within 15 minutes. The most common complication was bleeding which occurred in 52 patients (14.7%). The rest of the complications encountered were:- transient hypoxia twelve (3.4%), inability/ difficulty to insert tracheostomy tube eight (2.3%), false passage four (1.1%), transient hypotension two (0.6%), pneumothorax two (0.6%), peristomal infection two (0.6%), subcutaneous emphysema one (0.3%), cuff rupture one (0.3%), oesophageal cannulation one (0.3%), and granuloma formation one (0.3%). Conversion to conventional tracheostomies were performed on 7 patients (2%). There was one unfortunate death related to percutaneous tracheostomy. In conclusion, percutaneous dilational tracheostomy can be used safely to manage the airway of critically ill patients.

Mandatory temperature monitoring in schools during SARS

During the SARS outbreak, temperature monitoring was mandatory for all Singapore schoolchildren. None of the Singapore children with SARS were detected through school temperature screening. However, temperature monitoring procedures have a powerful psychological effect of reassuring parents and the public that schools are safe during a SARS outbreak.

National disease management plans for key chronic non-communicable diseases in Singapore

In Singapore, chronic, non-communicable diseases, namely coronary heart disease, stroke and cancer, account for more than 60% of all deaths and a high burden of disability and healthcare expenditure. The burden of these diseases is likely to rise with our rapidly ageing population and changing lifestyles, and will present profound challenges to our healthcare delivery and financing systems over the next 20 to 30 years. The containment and optimal management of these conditions require a strong emphasis on patient education and the development of integrated models of healthcare delivery in place of the present uncoordinated, compartmentalised way of delivering healthcare. To meet these challenges, the Ministry of Health's major thrusts are disease control measures which focus mainly on primary prevention; and disease management, which coordinates the national effort to reduce the incidence of these key diseases and their predisposing factors and to ameliorate their long-term impact by optimising control to reduce mortality, morbidity and complications, and improving functional status through rehabilitation. The key initiatives include restructuring of the public sector healthcare institutions into two clusters, each comprising a network of primary health care polyclinics, regional hospitals and tertiary institutions. The functional integration of these healthcare elements within each cluster under a common senior administrative and professional management, and the development of common clinical IT systems will greatly facilitate the implementation of disease management programmes. Secondly, the Ministry is establishing National Disease Registries in coronary heart disease, cancer, stroke, myopia and kidney failure, which will be valuable sources of clinical and outcomes data. Thirdly, in partnership with expert groups, national committees and professional agencies, the Ministry will produce clinical practice guidelines which will assist doctors and healthcare professionals to better manage important aspects of the key diseases. Finally, the Ministry has committed funds to support selected National Disease Management programmes, illustrated by the disease management plan for asthma.

Prevention and control of non-communicable diseases in Singapore: a review of national health promotion programmes

The epidemiological transition in Singapore from infectious to chronic, non-communicable diseases created different challenges for our public health system. The population-based strategy is adopted in primary prevention, through the promotion of a healthy lifestyle--smoking cessation, physical activity, eating right and managing stress. Complementing this are measures to detect chronic conditions early through screening and optimal treatment of the disease. While improvements were seen in the common risk factors of smoking and physical inactivity, prevalence of measurable risk factors like hypertension increased between 1992 and 1998. In 2000, the Ministry of Health initiated a series of national disease management plans for major disease conditions affecting Singaporeans. This approach uses a comprehensive and systematic approach to integrate the various components, with identification of responsible parties to ensure successful implementation of initiatives. Chronic diseases will remain prevalent as our society rapidly ages. Close monitoring of our initiatives in disease management will provide information on the long-term efficacy of such strategies.

Influence of ZOE temporary restorations on microleakage in composite restorations

This study investigated the influence of zinc-oxide eugenol (ZOE) temporary restorations on microleakage in composite restorations. Class V cavities were prepared on the buccal surfaces of 32 freshly extracted, non-carious human premolars. The teeth were randomly divided into four groups of eight teeth. Specimens in Group 1 (control) received no temporary restoration. Group 2 and 3 specimens were covered with IRM (Type III ZOE cement) mixed at powder:liquid (P:L) ratio of 10g:1g and 10g:2g, respectively. Specimens in Group 4 were covered with poly-carboxylate cement (eugenol-free) mixed at a P:L ratio of 2.85g:1g. The temporary restorations were removed mechanically with an ultrasonic scaler after one week storage in distilled water at 37 degrees C. The preparations were washed and restored with Scotchbond Multi-Purpose Plus and Z100 according to manufacturers' instructions. The restorations were finished, thermally stressed for 400 cycles and subjected to dye penetration testing. Results were analyzed using Kruskal-Wallis and Mann-Whitney tests at a significance level of 0.05. At both enamel and dentin margins, the microleakage associated with Group 3 was significantly greater than for Groups 1, 2 and 4. For Groups 1 and 4, leakage at the dentin margins was significantly greater than in enamel margins. For the groups pretreated with IRM, no significant difference in dye penetration scores was observed between enamel and dentin. Pre-treatment with IRM mixed at a P:L ratio of 10g:2g significantly increased microleakage and is not recommended clinically.

Influence of eugenol-containing temporary restorations on bond strength of composite to dentin

This study investigated the influence of eugenol-containing temporary restorations on bond strength of composite to dentin. Thirty-two freshly extracted human molars were embedded and horizontally sectioned at a level 2 mm from the central fossa to obtain a flat dentin surface. The teeth were randomly divided into four groups of eight teeth. Specimens in Group 1 (control) received no pre-treatment with any temporary restorations. Group 2 and 3 specimens were covered with IRM (eugenol-containing) mixed at powder: liquid (P:L) ratio of 10 g: 1 g and 10 g: 2 g, respectively. Specimens in Group 4 were covered with polycarboxylate cement (eugenol-free) mixed at a P:L ratio of 2.85 g: 1 g. The temporary restorations were mechanically removed with an ultrasonic scaler after one-week storage in distilled water at 37 degrees C. The dentin surfaces were cleaned with pumice-water slurry and treated with Scotchbond Multi-Purpose Plus bonding system according to manufacturer's instructions. Composite (Z100) columns (3 mm diameter, 2 mm high) were applied and shear bond testing was carried out after 24 hours storage in distilled water at 37 degrees C using an Instron Universal testing machine with a cross-head speed of 0.5 mm/minute. The mode of failure was examined using a stereomicroscope at X40 magnification. Results were analyzed using one-way ANOVA/Scheffes's post-hoc test at significance level 0.05. Ranking of bond strengths was as follows: Group 1 (22.58 MPa) > Group 2 (21.14 MPa) > Group 4 (15.35 MPa) > Group 3 (13.02 MPa). Group 3 had significantly lower bond strength than Groups 1 and 2. No significant difference in dentin bond strength was observed between the Group 1 (control) and Groups 2 and 4. Although the predominant mode of failure for Groups 1, 2 and 4 was cohesive in dentin, all specimens in Group 3 exhibited adhesive failure. Pre-treatment with polycarboxylate cement or IRM mixed at P:L ratio of 10 g: 1 g did not affect shear bond strength of composite to dentin. IRM mixed at a lower P:L ratio of 10 g: 2 g significantly decreased bond strength.

Pyogenic liver abscess--a tropical centre's experience in management with review of current literature

AIM OF STUDY

To perform a retrospective study, with the help of literature review, of the management of patients with pyogenic liver abscess in a general hospital.

METHOD

A retrospective study of 73 consecutive patients treated atTanTock Seng Hospital between January 1994 and December 1997 was conducted to determine the demographic, clinical, laboratory, radiological and microbiological characteristics of these patients, as well as the management strategies employed.

RESULTS

Liver abscess was more common in males, occurring more frequently in the right hepatic lobe. Most patients presented with non-specific clinical and biochemical features. A raised alkaline phosphatase level was the most common biochemical abnormality found in about two-thirds of patients. Ultrasonography was not as sensitive as computed tomographic scans in detecting abscesses. Klebsiella pneumoniae was the most common etiological agent detected in cultures of blood and abscess aspirates. All patients were treated with intravenous antibiotics. Twenty-two (30%) needed percutaneous catheter drainage and five (7%) required surgical management. There was no hospital mortality in our series. Prolonged hospitalisation was associated with advanced age, degree of loculation within the abscess, concomitant diabetes mellitus and Klebsiella septicaemia.

CONCLUSION

Pyogenic liver abscesses require a high index of suspicion for early diagnosis. When appropriate therapy in the form of antibiotics in combination with percutaenous drainage or surgery is administered, mortality is very low. However, significant morbidity is still a problem, particularly in the elderly, diabetic patient.

An audit of percutaneous endoscopic gastrostomy in a general hospital in Singapore

OBJECTIVE

We conducted an audit on 50 percutaneous endoscopic gastrostomies (PEGs) performed by physician endoscopists from January 1996 up to November 1997.

DESIGN

A retrospective cohort study was conducted.

RESULTS

The mean age of the patients was 68.5 years (range 20-101) and the main indications were cerebrovascular accident in 40 (80%), neurological dysphagia in six (12%) and head injury in three (6%). The interval between the diagnosis of dysphagia and PEG was > 60 days in 19 patients (38%), 31-60 days in eight (16%) and < or = 30 days in 23 (46%). The commonest reason for PEG insertion was intolerance to nasogastric tube in 49 patients (98%). Twelve patients had antibiotics given concurrently for other infections and two had antibiotics given specifically to cover PEG insertion. There was evidence of post-PEG infection in two of 14 patients given antibiotics (14%) and in 14 of 36 patients not given antibiotics (39%). By Cox regression, the adjusted relative risk of infection in patients receiving antibiotics versus those not receiving was 0.6927 (95% CI 0.3396-1.4130; not significant). The 30-day mortality was 7/48 patients (15%), with two patients lost to follow-up before 30 days. There were no deaths directly attributable to PEG.

CONCLUSIONS

PEG is still not adequately requested by doctors for patients needing enteral feeding for more than 30 days. The use of antibiotics in this retrospective cohort study failed to show any benefit in reducing the rate of infective complications.

Cost effectiveness evaluation of the Ministry of Health Malaysia dialysis programme

We determine the cost effectiveness of centre and home haemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD) and intermittent peritoneal dialysis (IPD) treatment in the Ministry of Health (MOH) programme. The viewpoint taken for this evaluation is that of MOH. Cost categories identified were capital cost, dialysis operational cost, medical cost and general hospital cost. Cost estimates were mostly based on actual resource utilisation. Life years saved were estimated based on Dialysis Registry data on 2480 HD and 732 CAPD patients. Overall, the cost-effectiveness ratio (CER) of centre HD was RM21620/life year saved. Those of home HD, CAPD and IPD were RM23375, RM30469 and RM36016 respectively. Sensitivity analyses did not change the ranking of the CER. We conclude the MOH dialysis programme was cost-effective, and among the various dialysis modalities centre HD was the most cost-effective.

Outcome assessment of the Ministry of Health Malaysia dialysis programme

We describe the outcomes on haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) provided by the Ministry of Health (MOH). The assessment was based on data from the Malaysian Dialysis Registry on 2480 HD and 732 CAPD patients who commenced dialysis between 1980 and 1996. Young patients (age < 40) have remarkable long term survival (life expectancies of 16 years on HD, 18 years on CAPD). Adjusting for background mortality, relative survival of older patients was as good as younger ones. Diabetics did poorly. 52% of HD and 26% of CAPD patients were employed in 1996. 71% of HD patients scored 10(normal) on QL index (a measure of quality of life) while 60% of CAPD patients have similar score. Differences in rehabilitation and QL index scores by age, gender and diabetes were also observed. Outcomes of dialysis in the MOH programme are reassuring.

Genotype/phenotype correlations in X-linked dominant Charcot-Marie-Tooth disease

We have studied the relationship between genotype, clinical phenotype, and pathology in 13 families with dominant X-linked Charcot-Marie-Tooth (CMT) neuropathy. Connexin32 (Cx32) gene mutations were spread throughout the coding region and included eight missense mutations, one 8-bp deletion/4-bp insertion frame shifting mutation, two nonsense mutations, and one deletion of the entire coding sequence. One hundred sixteen affected CMTX patients (53 males and 63 females) and 63 unaffected, at-risk individuals were compared by neurological and electrophysiological examinations and analyzed by gender; nerve biopsies were available from seven index cases. It was found that mutations within all regions of the Cx32 gene coding sequence caused an identical clinical phenotype. Male CMTX patients were affected more severely and showed an age-dependent progression of clinical signs and of the pathology; there was, however, variability in the severity of disease expression, irrespective of age, among males within families of defined genotype. All but 10% of female CMTX patients had only mild signs. Motor nerve conduction velocities were moderately slowed (median nerve MNCV: males 34.5 +/- 6.2 m/sec; females 45.8 +/- 7.3 m/sec), and motor and sensory nerve amplitudes were reduced (median nerve CMAP: males 3.7 +/- 3.7 mV; females 7.8 +/- 3.4 mV), with electromyographic evidence of chronic denervation. Differences were significant between gender and between affected and unaffected individuals. In agreement with the electrophysiological observations, pathological studies showed evidence of paranodal demyelination and of a length-related axonal degeneration in motor and sensory nerve fibers. Correlations between genotype and clinical phenotype suggested that missense mutations located within the second transmembrane domain and/or cytoplasmic loop might be associated with milder clinical phenotype, and therefore might be less disruptive of connexin32 gap junction function. Missense, chain-terminating, or deletion mutations in all other locations of the connexin32 protein caused severe forms of CMTX and disease onset in the first decade. Observed variability of disease severity among males within kinships suggests the influence of other modifying factors.

Peptic ulcer and gastritis in uraemia, with particular reference to the effect of Helicobacter pylori infection

AIMS

To determine: (i) the prevalence of histological gastritis and peptic ulcer; and (ii) the clinical features of peptic ulcer, in patients with end-stage renal failure.

METHODS

Upper endoscopy was performed by a single observer in 268 patients with end-stage renal failure over a 6-year period. Gastric histology and Helicobacter pylori status were studied in 40 consecutive subjects in whom there were no contraindications for gastric biopsy and who had not used antibacterial drugs in the preceding 4 weeks. As there are only limited data for healthy volunteers in Singapore, 33 age-, sex- and race-matched patients with functional dyspepsia from an earlier drug trial and 18 healthy volunteers who were not age-matched were used as controls. The clinical features of 43 consecutive uraemic patients with peptic ulcer were compared with those of 118 consecutive non-uraemic peptic ulcer patients seen by the same author.

RESULTS

Among uraemic patients, histological gastritis was less common, compared with healthy volunteers and functional dyspepsia patients. Helicobacter pylori infection as assessed by histology was also less common among uraemic patients compared with functional dyspepsia patients, but the difference was not statistically significant on serological assessment. Uraemic patients with ulcer had an equal sex ratio, in contrast to a male preponderance among peptic ulcer patients with normal renal function. Uraemic patients with ulcer were more likely to be pain-free, to present with haemorrhage, to have multiple ulcers and postbulbar duodenal ulcers, but were less likely to have H. pylori infection. Among uraemic subjects, the prevalence of H. pylori infection was similar whether or not peptic ulcer was present.

CONCLUSIONS

The prevalence of histological gastritis was lower in uraemic patients when compared with patients with functional dyspepsia and healthy volunteers. Peptic ulcers in uraemic subjects have different clinical characteristics from peptic ulcer in non-uraemic subjects.

Once-daily intraperitoneal gentamicin is effective therapy for gram-negative CAPD peritonitis

OBJECTIVE

To report our 3-year experience with the use of once-daily intraperitoneal (IP) gentamicin in the treatment of gram-negative continuous ambulatory peritoneal dialysis (CAPD) peritonitis.

DESIGN

A prospective cohort study in prevalent CAPD patients.

SETTING

A tertiary care institution.

PATIENTS

All CAPD patients who presented with new episodes of peritonitis were studied. At presentation with peritonitis, IP vancomycin and gentamicin were administered as empirical therapy. IP gentamicin was given at a single daily dose of 40 mg/2 L in the overnight bag. The antimicrobial agents were reviewed when the culture results became available. Intraperitoneal ceftazidime was added for the treatment of pseudomonas peritonitis.

MAIN OUTCOME MEASURES

Results of microbiological cultures and clinical outcomes of peritonitis were analyzed.

RESULTS

Over a 36-month period, 190 episodes of peritonitis were recorded, of which 62/190 episodes (32.6%) isolated gram-negative organisms. The gram-negative organisms isolated were Escherichia coli, 15/62 episodes (24.1%); Pseudomonas aeruginosa, 12/62 episodes (19.4%); Acinetobacter spp, 12/62 episodes (19.4%); Klebsiella spp, 10/62 episodes (16.1%); and others, 13/62 episodes (21.0%). The overall treatment success rate was 66.1%. The treatment success rates were 74.0% if pseudomonas infections were excluded, 76.1% if gentamicin-resistant pathogens were excluded, and 80.5% if both pseudomonas infections and gentamicin-resistant pathogens were excluded.

CONCLUSIONS

Once-daily IP gentamicin appears to be effective in the treatment of gram-negative CAPD peritonitis.

Weils' syndrome and concomitant hepatitis B infection

Leptospirosis is a ubiquitous, spirochetal zoonosis which presents with a broad clinical spectrum. Weil's syndrome, characterised by jaundice, renal failure and bleeding manifestations is the most severe form. A high index of suspicion for the diagnosis is required to institute therapy promptly. We describe a case of serologically confirmed Weil's syndrome with concomitant hepatitis B infection.

Genetic relationship of populations in China

Despite the fact that the continuity of morphology of fossil specimens of modern humans found in China has repeatedly challenged the Out-of-Africa hypothesis, Chinese populations are underrepresented in genetic studies. Genetic profiles of 28 populations sampled in China supported the distinction between southern and northern populations, while the latter are biphyletic. Linguistic boundaries are often transgressed across language families studied, reflecting substantial gene flow between populations. Nevertheless, genetic evidence does not support an independent origin of Homo sapiens in China. The phylogeny also suggested that it is more likely that ancestors of the populations currently residing in East Asia entered from Southeast Asia.

Laser therapy combined with brachytherapy for the palliation of malignant dysphagia

BACKGROUND/AIM OF STUDY

Laser therapy is effective in relieving malignant dysphagia, but repeated treatments at 4 to 6 week intervals are usually required. This prospective randomised trial is designed to determine if addition of brachytherapy offers any advantages over laser therapy alone.

METHODS

Patients with inoperable carcinoma of the oesophagus were randomised to receive either endoscopic Nd:YAG laser therapy alone, or laser followed by brachytherapy. Patients who developed worsening dysphagia during follow-up were offered further treatment as appropriate.

RESULTS

Fourteen patients were randomised to receive laser only, and 12 to receive laser followed by brachytherapy. Of these 12, one was lost to follow-up and four did not receive brachytherapy because they were unfit, had extension into the cardia or had mainly extrinsic compression. These 4 are included on an 'intention-to-treat' basis. The mean therapeutic interval for the brachytherapy group was significantly longer, 83 days compared to 36 days for the laser group (p = 0.026). There were no differences in the degree of dysphagia relief, number of endoscopic procedures or survival times.

CONCLUSION

The preliminary results of this trial suggest that brachytherapy in addition to laser therapy prolongs the first therapeutic interval. However, no long-term advantages have been shown.

Leukemia-associated retinoic acid receptor alpha fusion partners, PML and PLZF, heterodimerize and colocalize to nuclear bodies

In acute promyelocytic leukemia (APL), the typical t(15;17) and the rare t(11;17) translocations express, respectively, the PML/RARalpha and PLZF/RARalpha fusion proteins (where RARalpha is retinoic acid receptor alpha). Herein, we demonstrate that the PLZF and PML proteins interact with each other and colocalize onto nuclear bodies (NBs). Furthermore, induction of PML expression by interferons leads to a recruitment of PLZF onto NBs without increase in the levels of the PLZF protein. PML/RARalpha and PLZF/RARalpha localize to the same microspeckled nuclear domains that appear to be common targets for the two fusion proteins in APL. Although PLZF/RARalpha does not affect the localization of PML, PML/RARalpha delocalizes the endogenous PLZF protein in t(15;17)-positive NB4 cells, pointing to a hierarchy in the nuclear targeting of these proteins. Thus, our results unify the molecular pathogenesis of APL with at least two different RARalpha gene translocations and stress the importance of alterations of PLZF and RARalpha nuclear localizations in this disease.

Magnetically levitated motor for rotary blood pumps

The noncontact rotary pumps under development for use as artificial heart pumps are highly efficient and can prevent thrombus formation. In these pumps magnetic bearings have been widely used to support the rotors to avoid any physical contact. The use of magnetic bearings, however, has led to requirements for the control of a large degree of freedom and for a separate driving motor. This paper introduces 2 types of levitated motors, each of which uses a combination of a rotary motor and a magnetic bearing. These motors are suitable for use in artificial blood pumps because they are small in size and can replace contact components. The radial type levitated motor has the merit of being small in size and capable of controlling the 2 degrees of freedom in the x and y directions. The axial type motor controls only one degree of freedom in the z direction. This paper also introduces the theoretical background of the functions of the motor and magnetic bearing. Experimental results of tests of the proposed motor show a great potential for its application in rotary blood pumps.

Effect of cisapride on functional dyspepsia in patients with and without histological gastritis: a double-blind placebo-controlled trial

In the present double-blind placebo-controlled study the effect of cisapride on functional dyspepsia was evaluated in patients with and without histological gastritis. Patients with functional dyspepsia and whose symptoms persisted after a 2 week run-in period with antacid treatment were randomized to receive cisapride (10 mg) or matching placebo three times daily for 4 weeks. Symptoms of epigastric pain, bloating, nausea, belching, early satiety and heartburn were graded on a four-point scale based on patients' feedback and diary card recording. A global response was also formulated by the investigators. One hundred and four patients entered the study and 76 completed the trial, comprising 36 patients with histological gastritis and 40 patients without gastritis. Symptom scores in both gastritis and non-gastritis groups were significantly improved by both cisapride and placebo; however, the improvement was not statistically different between the two treatment groups. Cisapride produced a good or better global response in 58% of subjects with histological gastritis and in 53% of subjects without gastritis compared with 47% and 52%, respectively, of patients on placebo; this difference was not statistically significant. Gastric histology did not influence the effect of cisapride on the symptoms of functional dyspepsia.

Erythropoietin production in rats with post-ischemic acute renal failure

To study the role of erythropoietin (Epo) in the pathogenesis of anemia in acute renal failure (ARF), organ Epo mRNA was measured by RNase protection assay in rats with ARF induced by a one hour-occlusion of the left renal artery. Hematocrit was significantly decreased two hours, 24 hours and one week after renal artery occlusion. A significant reduction in serum haptoglobin at two hours and an increase in serum LDH at 24 hours indicated that hemolysis was the likely cause of the initial fall in hematocrit. However, despite the reduced hematocrit, serum Epo concentrations were not significantly different from controls, suggesting that the anemia is maintained because of lack of an appropriate Epo response. Right renal Epo mRNA levels were not significantly different in all groups, but Epo mRNA levels in post-ischemic kidneys were 50 to 67% lower than in contralateral kidneys. However, Epo mRNA in the post-ischemic kidney was increased sixfold by acute hemorrhage, a rise comparable to the ninefold increase observed in contralateral kidneys. In ARF rats exposed to 7.5% O2 for four hours, right kidney Epo mRNA increased 200-fold over normoxic levels, to a value similar to sham-operated hypoxic controls. Epo mRNA in the post-ischemic kidney also increased 200-fold, to 50% of the level in the contralateral kidney. Hepatic Epo mRNA levels were elevated to comparable levels in both groups. In this ARF model, mild anemia is associated with relative Epo deficiency. In the post-ischemic kidney, a substantial capacity for Epo production is retained but the sensitivity of the Epo response to blood oxygen availability is significantly reduced.

Ampullary somatostatinoma associated with von Recklinghausen's neurofibromatosis presenting as obstructive jaundice

A case of von Recklinghausen's disease associated with a somatostatinoma of the pancreas causing obstructive jaundice is described. Discussion on the association of von Recklinghausen's disease with somatostatinoma is presented.

Ranitidine reduces phosphate binding in dialysis patients receiving calcium carbonate

BACKGROUND

In a previous controlled study we showed that ranitidine significantly reduced the phosphate binding of aluminium hydroxide in patients with renal failure, probably increasing intragastric pH.

METHODS

In this study we have investigated the effect of ranitidine on the phosphate binding of calcium carbonate in fifteen dialysis patients. Ranitidine 300 mg or a placebo tablet was taken before breakfast for two 4-week periods in a double-blind crossover trial with no washout period. The mean daily dose of calcium carbonate was 2 g and neither the dose nor the patient's diet was changed during the study period. Blood was taken at 2-weekly intervals for serum phosphate, calcium, albumin, and alkaline phosphatase measurements, and at the end of each treatment period for parathyroid hormone (PTH) level.

RESULTS

Serum phosphate concentrations were significantly higher during the ranitidine than the placebo phase, 1. 78 (+/-0.43 SD) versus 1.59 (+/-0.49 SD) mmol/l (P<0.001). Serum calcium, albumin, PTH, and alkaline phosphatase concentrations did not differ between the two treatment periods.

CONCLUSION

This study shows that ranitidine has a significant adverse effect on the phosphate binding of calcium carbonate in patients with renal failure.

Throat spray for upper gastrointestinal endoscopy is quite acceptable to patients

BACKGROUND AND STUDY AIMS

The use of sedation in upper gastrointestinal endoscopy is widespread, mainly because of the belief that patients are likely to tolerate the procedure better. The aim of the present study was to assess patients' response to the policy of actively persuading them to accept a throat spray for upper gastrointestinal endoscopy.

PATIENTS AND METHODS

Three hundred patients who had recently undergone endoscopy were sent a questionnaire; 244 of them responded (81%). Data on age, sex, procedure tolerance, anxiety levels, and future choice of sedation or throat spray for repeat procedures were sought. The results were analysed using the chi-squared test.

RESULTS

One hundred and ninety-two (79%) chose, or were persuaded to have, throat spray, and only nine (5%) had to be transferred to sedation. Thirty-two percent of patients who had throat spray tolerated endoscopy well, compared to 70% of those who chose sedation. One hundred and nineteen throat spray patients (62%) showed a low level of reluctance to undergo repeat endoscopy, compared to 37 (71%) sedated patients (not significant). One hundred and forty-four throat spray patients (76%) expressed satisfaction with the throat spray, but if given a choice, only 124 (66%) would choose throat spray again. Male patients, those with lower anxiety levels, and those over 50 years old, tolerated endoscopy with throat spray better, showed less reluctance to undergo repeat endoscopy, and were more likely to choose throat spray again. Those who had any previous experience of endoscopy under sedation were less likely to choose throat spray again.

CONCLUSION

The present study shows that the use of throat spray for diagnostic endoscopy is quite acceptable to patients. For safety reasons, we should be encouraging greater use of throat spray in routine diagnostic upper gastrointestinal endoscopy.

Plasma activity of contact coagulation factors in patients with IgA nephritis

Intraglomerular coagulation, initiated by the local activation of contact coagulation factors, has been suggested as one possible factor causing glomerular injury in IgA nephritis. The plasma activity of factor XII, prekallikrein and high molecular weight (HMW) kininogen were measured in 24 patients with biopsy-proven IgA nephritis and in 123 normal controls, using an activated partial thromboplastin time assay with the appropriate factor-deficient plasma as substrate. IgA patients had significantly lower plasma activity of factor XII (45.5% +/- 28.3% against 80.7% +/- 31.8%; mean +/- standard deviation, P < 0.001), prekallikrein (37.7% +/- 24.5% against 119.8% +/- 37.7%; P < 0.001) and HMW kininogen (72.8% +/- 37.8% against 119.1% +/- 42.8%; P < 0.001) when compared with controls. In the IgA patients, there was no significant correlation between factor XII, prekallikrein and HMW kininogen activity and 24-hour total urinary protein excretion, suggesting that the reduced plasma activity was not due to increased urinary loss of the coagulation factors. One possible explanation for these results is that the intrinsic coagulation pathway is activated in patients with IgA nephritis.

Paracetamol and its metabolites in saliva and plasma in chronic dialysis patients

1. Many pharmacokinetic studies on paracetamol are based on saliva paracetamol concentrations. The utility of saliva in patients with chronic renal failure is unclear. In this study, concentrations of saliva and plasma paracetamol and its major metabolites, sulphate and glucuronide conjugates were determined at 0.5, 1, 2 and 3 h after the ingestion of 1 g paracetamol in 20 patients with endstage renal failure. Ten haemodialysis patients were studied on a non-haemodialysis day and during a haemodialysis session. The other 10 patients were on chronic ambulatory peritoneal dialysis. 2. The plasma paracetamol concentrations attained in all groups were not different from those reported previously in healthy subjects. Mean +/- s.d. plasma paracetamol concentrations at 0.5 h in haemodialysis patients on a non-haemodialysis day, during haemodialysis and in those on chronic ambulatory peritoneal dialysis were 15.3 +/- 8.2, 21.5 +/- 10.9 and 18.2 +/- 12.3 micrograms ml-1 respectively. 3. The saliva paracetamol concentrations were highly variable and unpredictable. Saliva paracetamol concentrations at 1, 2 and 3 h after ingestion in the haemodialysis group during haemodialysis were 31.5 +/- 20.1, 14.1 +/- 10.4 and 7.3 +/- 3.8 micrograms ml-1 respectively, significantly (P < 0.05; paired t-test) higher than the corresponding plasma paracetamol concentrations which were 11.0 +/- 2.8, 6.5 +/- 2.8 and 3.2 +/- 0.9 micrograms ml-1 respectively. 4. Correlation coefficients between saliva and plasma paracetamol concentrations in haemodialysis patients on a non-haemodialysis day and during haemodialysis and in chronic ambulatory peritoneal dialysis patients were poor; r = 0.58 (P < 0.0002); r = 0.40 (P < 0.02); and r = 0.13 (P = 0.49) respectively. 5. Three hours after paracetamol ingestion, plasma paracetamol, sulphate and glucuronide concentrations were significantly (P < 0.05) reduced in haemodialysis patients during haemodialysis when compared with the same patients on a non-haemodialysis day (paired t-test) and to the chronic ambulatory peritoneal dialysis group (Kruskal-Wallis ANOVA) except for plasma glucuronide. This indicates the effective removal of paracetamol and metabolites by haemodialysis. In contrast, chronic ambulatory peritoneal dialysis seemed to remove glucuronide only. 6. In the light of the poor correlation between saliva and plasma paracetamol in dialysis patients in this study, we would like to caution against using saliva paracetamol concentrations for pharmacokinetic studies in this group of patients.