Validation of the emergency surgery score (ESS) in a UK patient population and comparison with NELA scoring: a retrospective multicentre cohort study

INTRODUCTION

Accurate risk scoring in emergency general surgery (EGS) is vital for consent and resource allocation. The emergency surgery score (ESS) has been validated as a reliable preoperative predictor of postoperative outcomes in EGS but has been studied only in the US population. Our primary aim was to perform an external validation study of the ESS in a UK population. Our secondary aim was to compare the accuracy of ESS and National Emergency Laparotomy Audit (NELA) scores.

METHODS

We conducted an observational cohort study of adult patients undergoing emergency laparotomy over three years in two UK centres. ESS was calculated retrospectively. NELA scores and all other variables were obtained from the prospectively collected Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database. The primary and secondary outcomes were 30-day mortality and postoperative intensive care unit (ICU) admission, respectively.

RESULTS

A total of 609 patients were included. Median age was 65 years, 52.7% were female, the overall mortality was 9.9% and 23.8% were admitted to ICU. Both ESS and NELA were equally accurate in predicting 30-day mortality (c-statistic=0.78 (95% confidence interval (CI), 0.71-0.85) for ESS and c-statistic=0.83 (95% CI, 0.77-0.88) for NELA, p=0.196) and predicting postoperative ICU admission (c-statistic=0.76 (95% CI, 0.71-0.81) for ESS and 0.80 (95% CI, 0.76-0.85) for NELA, p=0.092).

CONCLUSIONS

In the UK population, ESS and NELA both predict 30-day mortality and ICU admission with no statistically significant difference but with higher c-statistics for NELA score. Both scores have certain advantages, with ESS being validated for a wider range of outcomes.

Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis

BACKGROUND

To compare the difference in outcomes in laparoscopic large hiatus hernia (LHH) repair using suture-based and mesh-based repair techniques.

METHODS

A systematic search of articles was conducted in PubMed, Medline and Embase using the PRISMA guidelines. Studies comparing recurrences and reoperations in those patients with large hiatal hernia repair (> 30% stomach in the chest, > 5 cm hiatal defect, hiatal surface area > 10 cm²) who had mesh vs no mesh were assessed quantitatively. The impact of mesh on significant intraoperative/postoperative surgical complications was qualitatively assessed.

RESULTS

Pooled data included six randomized controlled trials and thirteen observational studies with 1670 patients (824 with no mesh, 846 with mesh). There was a significant reduction in the total recurrence rate with mesh (OR 0.44, 95% CI 0.25-0.80, p = 0.007). Mesh use did not cause significant reduction in recurrences > 2 cm (OR 0.94, 95% CI 0.52-1.67, p = 0.83) or in reoperation rates (OR 0.64, 95% CI 0.39-1.07, p = 0.09). None of the specific meshes assessed were found to be superior in the reduction of recurrence or reoperation rates. Cases of mesh erosion with eventual foregut resection were noted and were associated with synthetic meshes only.

CONCLUSION

Mesh reinforcement seemed protective against total recurrence in LHH although this has to be interpreted with caution given the level of heterogeneity introduced by the inclusion of observational studies in the analysis. There was no significant reduction in large recurrences (> 2 cm) or reoperation rate. If the synthetic mesh is to be used patients need to be informed of the risk of mesh erosion.

1039 RECEIVING ASSISTANCE FROM DOMESTIC ROBOTS: WHAT ARE ELDERS’ PREFERENCES?

Introduction

Aging leads to decline in physical and functional ability. Strengthening the domestic support enables elders to manage their health and living at home and reduce their need for residential service. Domestic robots can potentially provide a broad range of support to the elders. However, relatively little research attention has investigated elders’ preferences on it. This study aims to investigate elders’ preferences on receiving assistance from domestic robots.

Methods

This cross-sectional descriptive study recruited a convenient sample of 365 robotic inexperienced elders (65-99 years old). It used the Assistance Preference Checklist to assess participants’ preferences on receiving assistance from domestic robots in 48 home-based tasks under six aspects including personal care, leisure activities, health assistance, chores, information management, and manipulating objects. It used t-test and one-way analysis of variance to compare the difference in preferences between participants with different demographic and health characteristics.

Results

Overall, participants preferred domestic robots to assist in tasks under the aspect on chores, information management, and manipulating objects. Specifically, males indicated a higher preference for domestic robots to assist in maintaining lawn or raking leaves than females (p = 0.05). Married participants indicated a higher preference for domestic robots to assist in getting information on weather/news than unmarried participants (p = 0.049). In contrast, participants who were partially dependent and fully dependent indicated a higher preference for domestic robots to assist in tasks under the personal care aspect such as shaving, bathing, washing/combing hair, getting dressed, walking, and brushing teeth (p < 0.001), comparing to participants who were physically independent.

Conclusion

This study provides insight for manufacturers to develop domestic robots with specific capabilities which are important to support elders’ living in the community. Moreover, it helps the care providers to identify domestic robots with the required capabilities that meet elders’ specific preferences.

Fate of thiamethoxam from treated seeds in mesocosms and response of aquatic invertebrate communities

Thiamethoxam is a neonicotinoid insecticide widely applied in the Canadian Prairies. It has been detected in surface waters of agro-ecosystems, including wetlands, but the potential effects on non-target invertebrate communities in these wetlands have not been well characterized. In an effort to understand better the fate of thiamethoxam in wetlands and the response of invertebrates (zooplankton and emergent insects), model systems were used to mimic wetland flooding into planted fields. Outdoor mesocosms were treated with a single application of thiamethoxam-treated canola seeds at three treatment levels based on a recommended seeding rate (i.e., 6 kg/ha; 1×, 10×, and 100× seeding rate) and monitored over ten weeks. The mean half-life of thiamethoxam in the water column was 6.2 d. There was no ecologically meaningful impact on zooplankton abundances or community structure among treatments. Statistically significant differences were observed in aquatic insect abundance between control mesocosms and the two greatest thiamethoxam treatments (10× and 100× seeding rate). The observed results indicate exposure to thiamethoxam at environmentally relevant concentrations likely does not represent a significant ecological risk to abundance and community structure of wetland zooplankton and emergent insects.

Fascial defect closure versus bridged repair in laparoscopic ventral hernia mesh repair: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Several studies have examined effectiveness of primary fascial defect closure (FDC) versus bridged repair (no-FDC) during laparoscopic ventral hernia mesh repair (LVHMR). The purpose of this study was to systematically review and meta-analyse randomized controlled trials (RCTs) which compared safety and effectiveness of two techniques.

METHODS

Systematic literature searches (EMBASE, MEDLINE, PubMed, and CINAHL) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines using predefined terms. RCTs comparing FDC and no-FDC in LVHMR were identified and retrieved. Primary outcomes were risk of recurrence and risk of major complications analyzed as a single composite outcome. Secondary outcomes were risks of seroma formation, clinical or radiologically confirmed eventration, incidence of readmission to hospital, postoperative changes in quality of life (QoL), and postoperative pain. Random effects modeling to summarize statistics were performed. The risk of bias was assessed using Cohrane's Risk of Bias tool 2.

RESULTS

Three RCTs that enrolled total of 259 patients were included. There was clinical heterogeneity present between studies related to patients' characteristics, hernia characteristics, and operative techniques. There was no difference found in primary outcomes, risks of seroma formation, eventration, and chronic pain. There is conflicting evidence on how both techniques affect postoperative QoL or early postoperative pain.

CONCLUSIONS

Both techniques were detected to have equal safety profile and do not differ in risk of recurrence, seroma formation, risks of clinical or radiological eventration. Giving uncertainty and clinical equipoise, another RCT examining FDC vs no-FDC laparoscopic mesh repair separately for primary and secondary hernias using narrow inclusion criteria for hernia size on well-defined population would be ethical and pragmatic.

PROSPERO REGISTRATION

CRD42021274581.

Safety and effectiveness of switching to Abacavir/Lamivudine plus rilpivirine for maintenance therapy in virologically suppressed HIV-1 individuals in Singapore (SEALS)

BACKGROUND

The efficacy and tolerability of an antiretroviral regimen are important considerations for selection of HIV-1 infection maintenance therapy. Abacavir/lamivudine plus rilpivirine (ABC/3TC + RPV) has been shown in international studies to be effective and well-tolerated in virologically suppressed individuals. This study evaluated the effectiveness and safety of switching to ABC/3TC + RPV as maintenance therapy in virologically suppressed HIV-1 infected individuals in Singapore.

METHODS

In this retrospective, single-centre study, we included individuals who were prescribed ABC/3TC + RPV, had HIV-1 viral load (VL) < 50 copies/ml immediately pre-switch, and had no documented history of resistance mutations or virologic failure to any of the components. The follow-up period was 48 ± 12 weeks. The primary outcome was the proportion of individuals who maintained virologic suppression of HIV-1 VL < 50 copies/ml at the end of follow-up period based on on-treatment analysis. The secondary outcomes were the resistance profiles associated with virologic failure, changes in immunologic and metabolic parameters, and the safety profile of ABC/3TC + RPV.

RESULTS

A total of 222 individuals were included in the study. The primary outcome was achieved in 197 individuals [88.8%, 95% confidence interval: 83.7-92.4%]. There were 21 individuals (9.5%) who discontinued treatment for non-virologic reasons. The remaining 4 individuals experienced virologic failure, of whom, 3 of these individuals had developed emergent antiretroviral resistance and had HIV-1 VL > 500 copies/ml at the end of the 48 ± 12 weeks follow-up period. The remaining individual experienced sustained low level viremia and subsequently achieved viral suppression without undergoing resistance testing. A total of 49 adverse events were observed in 31 out of 222 individuals (14.0%), which led to 13 individuals discontinuing therapy. Neuropsychiatric adverse events were most commonly observed (53.1%). A statistically significant increase in CD4 was observed (p < 0.01), with a median absolute change of 31 cells/uL (interquartile range: - 31.50 to 140.75). No significant changes in lipid profiles were detected.

CONCLUSION

ABC/3TC + RPV is a safe and effective switch option for maintenance therapy in virologically suppressed HIV-1 individuals with in Singapore.

1586 Systematic Review and Meta-analysis of Randomised Controlled Trials of Intra-operative Surgical Drainage in Oesophagectomy

Aim

Three surgical approaches to oesophagus have been described. Drain placement in oesophagectomy remains controversial and is associated with complications. The review evaluates the effectiveness of surgically placed drain after oesophagectomy.

Method

Main electronic databases were searched for studies reported clinical outcomes or effects of cervical (neck), transthoracic (chest) and transabdominal drain placement. The systematic review was conducted according to PRISMA guidelines and meta-analysis was analysed using fixed and random-effects models.

Results

There were only two randomised controlled trials to date. Neither of these approaches (drain versus no drain) has convincing benefits in any particular oesophagectomy approach in early detection of anastomotic leakage, pleural effusion, and chylothorax nor disadvantages associated with significant morbidity and mortality and prolonged hospital stay.

Conclusions

Surgical drain in oesophagectomy may not confer additional benefit and routine practice of placement is surgeons preferential. The results do not reach statistical significance. Further work is required.

Metformin with neoadjuvant chemoradiation to improve pathologic response in rectal cancer: A pilot phase I/II trial

•

A prospective pilot phase I/II study on metformin given concurrently with neoadjuvant chemoradiation (CRT) in non-diabetic rectal cancer patients.

•

Three patients had a clinical complete response (cCR) and did not have surgical resection.

•

Of the 12 patients who underwent surgery, there were two pCRs. For the combined pCR/cCR rate of 33% (95% CI 19–47%), a total of 85 patients will be required to yield a 95% CI with a 10% margin of error.

•

These pilot results are encouraging, and will serve to refine the design and conduct of a future phase 2 trial to determine whether adding metformin to CRT improves pCR/cCR rates.

Purpose

Neoadjuvant radiotherapy with or without chemotherapy decreases the risk of local recurrence after surgery for rectal cancer. Emerging data suggest that diabetic patients on metformin may have improved cancer outcome after radiotherapy. A single institutional pilot study was performed to determine if metformin given concurrently with long course chemoradiation (CRT) may improve pathologic complete response (pCR) in non-diabetic rectal cancer patients. The study was designed to construct a confidence interval (CI) for the pCR rate to determine the sample size for a phase 2 trial.

Methods

Non-diabetic patients with biopsy confirmed rectal cancer deemed candidates for long course neoadjuvant CRT were invited to participate. Radiation consisted of 50.4 Gy in 28 daily fractions with concurrent daily capecitabine (825 mg/m² twice daily). Participants self-administered metformin (500 mg of twice daily) 2 weeks prior to, during and for 4 weeks after CRT.

Results

A total of 16 patients were accrued. One patient withdrew from the study. Only grade 1 or 2 adverse events were observed. Three patients had a clinical complete response (cCR) and did not undergo surgery. Of the 12 patients who underwent surgery, there were two pCRs. For the combined pCR/cCR rate of 33% (95% CI 19–47%), a total of 85 patients will be required to yield a 95% CI with a 10% margin of error.

Conclusions

Adding metformin to neoadjuvant CRT for rectal cancer does not appear to enhance toxicities. These results will be used to refine the design and conduct of a future phase 2 trial to determine whether adding metformin to CRT improves pCR/cCR rates.

Evaluation of cold-weather wastewater nitrification technology for removal of polar chemicals of emerging concern from rural Manitoba wastewaters

Aerated lagoons, typically used by small communities, often provide limited removal of wastewater nutrients. Given increasingly stringent wastewater standards, it is imperative that effective, but economical and easy-to-operate, treatment technologies be developed. The Submerged Attached Growth Reactor (SAGR®) is a treatment process developed to perform nitrification near freezing temperatures. Previous tests on full-scale installations have shown that SAGR could consistently remove ammonia to below current Canadian standards and provide additional total suspended solids and biochemical oxygen demand removal. In this study, we evaluated removal of polar chemicals of emerging concern (CECs), including pharmaceuticals, personal care products, and pesticides, at SAGR installations in two Manitoba First Nations communities (MCN and LPFN) under cold winter conditions. Both showed some removal of diclofenac, naproxen, clarithromycin, metoprolol, and trimethoprim, likely by biotransformation. Average naproxen removal was 21% (2.53 × 10³ ng L^-1) in MCN and 64% (1.58 × 10³ ng L^-1) in LPFN. Atenolol was well-removed by SAGR, by 80% on average (range of 64%-94%). Clarithromycin, metoprolol, and trimethoprim removal was similar within and between systems, ranging from 54% to 76% (30.8-3.07 × 10² ng L^-1 removed). Carbamazepine was detected in nearly all samples, but was not well-removed, consistent with other treatment studies. Overall, results showed that SAGR technology could moderately remove CECs, while providing the designed treatment performance for other parameters. This work will help to improve our understanding of wastewater treatment in small and/or remote communities with limited infrastructure and challenging cold-weather conditions.

Comparison of CTVHR and organs at risk contours between TRUS and MR images in IB cervical cancers: a proof of concept study

Purpose

To compare CTV_HR and OAR dimensions and inter-rater agreement between magnetic resonance (MR) and trans-rectal ultrasound (TRUS) images in IB cervical cancer patients.

Methods

IB cervical cancer patients treated with (chemo)radiotherapy plus MR-guided brachytherapy (BT) were prospectively enrolled in this study. Radiation oncologists contoured CTV_HR and OARs in pre-BT MR images (MRI) and intra-operative TRUS images. These contours were subsequently compared in regard to volume and dimension. Contour inter-rater agreement analysis was also investigated using kappa index (KI). Stata 15.0 was used for statistical analysis and a p-value < 0.05 was considered statistically significant.

Results

TRUS CTV_HR volumes were statistically smaller than the respective MRI contoured volumes. TRUS CTV_HR thickness was found to be consistently smaller than MRI contours in all patients. No statistical difference was seen in width and height between the two different imaging modalities. MRI contours had a median KI of 0.66 (range: 0.56–0.77) while TRUS-based contours had a median KI of 0.64 (range: 0.47–0.77). Bladder and rectum had very satisfactory KI in both imaging modalities. Vaginal contours had moderate agreement in MR (0.52) and in TRUS images (0.58).

Conclusion

TRUS images allow good visualization of CTV_HR and OARs in IB cervical cancer patients. Inter-rater contour variability was comparable between TRUS and MR images. TRUS is a promising modality on its own for image-guided BT.

Scope and Applications of Nanomedicines for the Management of Neuropathic Pain

Neuropathic pain, resulting from the dysfunction of the peripheral and central nervous system, occurs in a variety of pathological conditions including trauma, diabetes, cancer, HIV, surgery, multiple sclerosis, ischemic attack, alcoholism, spinal cord damage, and many others. Despite the availability of various treatment strategies, the percentage of patients achieving adequate pain relief remains low. The clinical failure of most effective drugs is often not due to a lack of drug efficacy but due to the dose-limiting central nervous system (CNS) toxicity of the drugs that preclude dose escalation. There is a need for cross-disciplinary collaborations to meet these challenges. In this regard, the integration of nanotechnology with neuroscience is one of the most important fields. In recent years, promising preclinical research has been reported in this field. This review highlights the current challenges associated with conventional neuropathic pain treatments, the scope for nanomaterials in delivering drugs across the blood-brain barrier, and the state and prospects of nanomaterials for the management of neuropathic pain.

Manganese Oxide Nanozymes Ameliorate Mechanical Allodynia in a Rat Model of Partial Sciatic Nerve-Transection Induced Neuropathic Pain

BACKGROUND

Reactive oxygen species (ROS) induced oxidative stress is linked to numerous neurological diseases, including neuropathic pain. Natural ROS scavenging enzymes like superoxide dismutase (SOD) and catalase have been found to be efficient in alleviating neuropathic pain. However, their sensitivity towards extreme pH and a short half-life limit their efficacy in vivo. Manganese oxide nanoparticles (MONPs) are recently known to possess ROS scavenging properties. In this study, MONPs were examined for their therapeutic effect on neuropathic pain.

METHODS

The MONPs were synthesized by a hydrothermal method. The synthesized MONPs were characterized by UV/Vis, TEM, SEM, FTIR, NTA and XRD. The biocompatibility of the nanoparticles is evaluated in neural cells using LDH assay. MONPs were evaluated for their antioxidant activity by DPPH assay. In addition, in vitro ROS scavenging properties were examined in bone marrow-derived macrophage (BMDM) cells using 2',7'-dichlorofluorescin diacetate (DCFDA) assay. To evaluate the in vivo efficacy of nanoparticles, neuropathic pain was induced in Wistar rats by partial sciatic nerve transection (PSNT). On post-transection days 14 to 18, rats were intrathecally injected with MONPs and paw withdrawal threshold was measured. The spinal cords were collected and processed for Western blotting and histological analysis.

RESULTS

The synthesized MONPs were biocompatible and showed effective antioxidant activity against DPPH free radical scavenging. Further, the nanoparticles scavenged ROS efficiently in vitro in BMDM and their intrathecal administration significantly reduced mechanical allodynia as well as the expression of cyclooxygenase-2 (COX-2), an important mediator of chronic and inflammatory pain in the spinal dorsal horns of PSNT rats.

CONCLUSION

As ROS play a significant role in neuropathic pain, we expect that MONPs could be a promising tool for the treatment of various inflammatory diseases and might also serve as a potential nanocarrier for the delivery of analgesics.

Febrile neutropenia and its associated hospitalization in breast cancer patients on docetaxel-containing regimen: A retrospective cohort study on duration of prophylactic GCSF administration

PURPOSE

To compare febrile neutropenia (FN) incidence and hospitalization among breast cancer patients on docetaxel with no granulocyte colony-stimulating factors (GCSF) primary prophylaxis (PP), 4/5-day PP, or 7-day PP.

METHODS

We identified 3916 breast cancer patients using docetaxel-cyclophosphamide (TC), doxorubicin-cyclophosphamide then docetaxel (AC-T), fluorouracil-epirubicin-cyclophosphamide then docetaxel (FEC-T), docetaxel-carboplatin-trastuzumab (TJH), or docetaxel-doxorubicin-cyclophosphamide (TAC) from a hospital pharmacy dispensing database in Hong Kong between 2014 and 2016. Patients were offered GCSF within 5 days since administering docetaxel. Outcomes included FN incidence, time to first hospitalization, hospitalization rate, and duration.

RESULTS

In TC regimen, FN incidence (with odds ratio, OR) of patients with no PP, 4/5-day PP, and 7-day PP was 21.69%, 7.95% (OR 0.31, p < 0.001), and 5.33% (OR 0.20, p < 0.001), respectively. In TJH regimen, FN incidence of patients with no PP, 4/5-day PP, and 7-day PP was 38.26%, 8.33% (OR 0.15, p < 0.001), and 8.57% (OR 0.15, p < 0.001), respectively. FN incidence of patients on AC-T regimen with no PP and 4/5-day PP was 20.93% and 6.84%, respectively (OR 0.28, p = 0.005); with FEC-T regimen, the incidence was 9.91% and 4.77%, respectively (OR 0.46, p = 0.035). Only 3.27% FN cases were not hospitalized. Mean (±standard deviation, SD) time to first hospitalization was 8.21 ± 2.44 days. Mean (±SD) duration of hospitalization for patients with no PP, 4/5-day PP, and 7-day PP was 4.66 ± 2.60, 4.37 ± 2.85, and 5.12 ± 2.97 days, respectively.

CONCLUSION

GCSF prophylaxis in breast cancer patients on docetaxel could reduce FN incidence and hospitalization. 4/5-day PP demonstrated similar efficacy to 7-day PP with superior saving benefits on healthcare expenditure.

Socioecological differences in factors associated with inconsistent condom use with female sex workers and casual partners: an observational study of heterosexual men attending an anonymous HIV testing clinic in Singapore

Sexual practices among heterosexual men may differ between female sex workers (FSWs) and casual partners. We surveyed 203 heterosexual men and investigated the attributes associated with inconsistent condom use among them. Lower educational attainment was positively associated with inconsistent condom use with FSWs (adjusted prevalence ratio (aPR) 2.63; P = 0.018) and casual partners (aPR 1.55; P = 0.022), whereas early age of sexual debut (aPR 3.00; P = 0.012) and alcohol use during sex (aPR 7.95; P < 0.001) were positively associated with inconsistent condom use with FSWs. Socioecological factors may explain such differences.

Melatonin MT2 receptor agonist IIK-7 produces antinociception by modulation of ROS and suppression of spinal microglial activation in neuropathic pain rats

Background

In recent years, several melatonin (MLT) receptor agonists have been approved by FDA for the treatment of sleep disorders and depression. Very few studies have shed light on their efficacy against neuropathic pain (NP). IIK-7 is an MT-2 agonist known to promote sleep. Whether IIK-7 suppresses NP has not been reported, and the signaling profile is unknown.

Objective

To investigate the effect of melatonin type 2 receptor agonist IIK-7 on partial sciatic nerve transection-induced NP in rats and elucidate the underlying molecular mechanisms.

Methods

NP was induced by the PSNT in the left leg of adult male Wistar rats. On post-transection day 7, rats were implanted with intrathecal (i.t) catheter connected to an infusion pump and divided in to four groups: sham-operated/vehicle, PSNT/vehicle, PSNT/0.5 μg/hr IIK-7 and PSNT/0.5 μg IIK-7/1 μg 4-p/hr. To test the MT-2 dependence on IIK-7 activity, the animals were implanted with a single i.t catheter and injected MT-2 antagonist 4-Phenyl-2-propionamidotetralin (4-p) 20 mins prior to IIK-7 injection on day 7 after PSNT. The antinociceptive response was measured using a mechanical paw withdrawal threshold. Activation of microglial cells and the expression of NP-associated proteins in the spinal cord dorsal horn was assessed by immunofluorescence assay (IFA) and Western blotting (WB). Reactive oxygen species (ROS) scavenging ability of IIK-7 was evaluated by using bone marrow-derived macrophages (BMDM).

Results

Treatment with the MT-2 agonist IIK-7 significantly alleviated PSNT-induced mechanical allodynia and glial activation along with the inhibition of P44/42 MAPK, HMGB-1, STAT3, iNOS and casp-3 proteins.

Conclusion

IIK-7 attenuates NP through the suppression of glial activation and suppression of proteins involved in inflammation and apoptosis. MT-2 receptor agonists may establish a promising and unique therapeutic approach for the treatment of NP.

Depression and anxiety among university students in Hong Kong

INTRODUCTION

Entry into tertiary education is a critical juncture where adolescents proceed to adulthood. This study aimed to determine the prevalence of depression and anxiety, and factors associated with such symptoms, among university undergraduate students in Hong Kong.

METHODS

A cross-sectional questionnaire study was employed. A total of 1200 undergraduate students from eight University Grants Committee-funded universities were invited to complete three sets of questionnaires, including the 9-item patient health questionnaire for screening of depressive symptoms, the 7-item generalised anxiety disorder scale for screening of anxiety symptoms, and a socio-demographic questionnaire.

RESULTS

Among the valid responses (n=1119) analysed, 767 (68.5%) respondents indicated mild to severe depressive symptoms, which were associated with mild to severe anxiety symptoms. Several lifestyle and psychosocial variables, including regular exercise, self-confidence, satisfaction with academic performance, and optimism towards the future were inversely related with mild to severe depressive symptoms. A total of 599 (54.4%) respondents indicated mild to severe anxiety symptoms, which were associated with level of academic difficulty. Satisfaction with friendship, sleep quality, and self-confidence were inversely associated with mild to severe anxiety symptoms.

CONCLUSION

More than 50% of respondents expressed some degree of depressive and anxiety symptoms (68.5% and 54.4%, respectively). Approximately 9% of respondents exhibited moderately severe to severe depressive symptoms; 5.8% exhibited severe anxiety symptoms. Respondents reporting regular exercise, higher self-confidence, and better satisfaction with both friendship and academic performance had fewer depressive and anxiety symptoms.

Fate of thiamethoxam in mesocosms and response of the zooplankton community

Thiamethoxam is a neonicotinoid insecticide that can reach wetlands in agro-ecosystems through runoff. The fate and effects of thiamethoxam on non-target organisms in shallow wetland ecosystems have not been well characterized. To this end, a mesocosm study was conducted with a focus on characterizing zooplankton community responses. A single pulse application of thiamethoxam (0, 25, 50, 100, 250, and 500 μg/L; n = 3) was applied to experimental systems and monitored for 8 weeks. The mean half-life of thiamethoxam among the different treatments was 3.7 days in the water column with concentrations of <0.8 μg/L in the majority of mesocosms by 56 days. Principal response curve analysis did not show any significant concentration-dependent differences in the zooplankton community among treatments over the course of the study. The minimum detectable difference (MDD%) values for abundance of potentially sensitive arthropod taxa (nauplius larvae, cyclopoid copepods) allowed the detections from controls as low as 42 and 59% effect, respectively. The MDD% values for total abundance of zooplankton (including the potentially less sensitive taxonomic group of Rotifera) allowed the detection from controls as low as 41% effect. There were no statistically significant differences in zooplankton abundance or diversity between control and treated mesocosms at the end of the study. There were also no statistically significant differences for individual taxa that were sustained between sampling points, or manifested as a concentration-response. We conclude that acute exposure to thiamethoxam at environmentally relevant concentrations (typically ng/L) likely does not represent a significant adverse ecological risk to wetland zooplankton community abundance and structure.

A rare case of retroperitoneal synovial sarcoma

Management of retroperitoneal soft tissue sarcomas is complex. Treatment is usually multimodal; involving surgery, chemotherapy and radiotherapy.

P53 regulates disruption of neuronal development in the adult hippocampus after irradiation

Inhibition of hippocampal neurogenesis is implicated in neurocognitive dysfunction after cranial irradiation for brain tumors. How irradiation results in impaired neuronal development remains poorly understood. The Trp53 (p53) gene is known to regulate cellular DNA damage response after irradiation. Whether it has a role in disruption of late neuronal development remains unknown. Here we characterized the effects of p53 on neuronal development in adult mouse hippocampus after irradiation. Different bromodeoxyuridine incorporation paradigms and a transplantation study were used for cell fate mapping. Compared with wild-type mice, we observed profound inhibition of hippocampal neurogenesis after irradiation in mice deficient in p53 despite the absence of acute apoptosis of neuroblasts. The putative neural stem cells were apoptosis resistant after irradiation regardless of p53 genotype. Cell fate mapping using different bromodeoxyuridine incorporation paradigms revealed enhanced activation of neural stem cells and their consequential exhaustion in the absence of p53 after irradiation. Both p53-knockout and wild-type mice demonstrated similar extent of microglial activation in the hippocampus after irradiation. Impairment of neuronal differentiation of neural progenitors transplanted in irradiated hippocampus was not altered by p53 genotype of the recipient mice. We conclude that by inhibiting neural progenitor activation, p53 serves to mitigate disruption of neuronal development after irradiation independent of apoptosis and perturbation of the neural stem cell niche. These findings suggest for the first time that p53 may have a key role in late effects in brain after irradiation.

Simultaneous depth-profiling of electrical and elemental properties of ion-implanted arsenic in silicon by combining secondary-ion mass spectrometry with resistivity measurements

A method is proposed to extract the electrical data for surface doping profiles of semiconductors in unison with the chemical profile acquired by secondary-ion mass spectrometry (SIMS)-a method we call SIMSAR (secondary-ion mass spectrometry and resistivity). The SIMSAR approach utilizes the inherent sputtering process of SIMS, combined with sequential four-point van der Pauw resistivity measurements, to surmise the active doping profile as a function of depth. The technique is demonstrated for the case of ion-implanted arsenic doping profiles in silicon. Complications of the method are identified, explained, and corrections for these are given. While several techniques already exist for chemical dopant profiling and numerous for electrical profiling, since there is no technique which can measure both electrical and chemical profiles in parallel, SIMSAR has significant promise as an extension of the conventional dynamic SIMS technique, particularly for applications in the semiconductor industry.

Sound production in the tiger-tail seahorse Hippocampus comes: Insights into the sound producing mechanisms

Acoustic signals of the tiger-tail seahorse (Hippocampus comes) during feeding were studied using wavelet transform analysis. The seahorse "click" appears to be a compounded sound, comprising three acoustic components that likely come from two sound producing mechanisms. The click sound begins with a low-frequency precursor signal, followed by a sudden high-frequency spike that decays quickly, and a final, low-frequency sinusoidal component. The first two components can, respectively, be traced to the sliding movement and forceful knock between the supraorbital bone and coronet bone of the cranium, while the third one (purr) although appearing to be initiated here is produced elsewhere. The seahorse also produces a growling sound when under duress. Growling is accompanied by the highest recorded vibration at the cheek indicating another sound producing mechanism here. The purr has the same low frequency as the growl; both are likely produced by the same structural mechanism. However, growl and purr are triggered and produced under different conditions, suggesting that such "vocalization" may have significance in communication between seahorses.

Preliminary evidence of the effects of high-frequency repetitive transcranial magnetic stimulation (rTMS) on swallowing functions in post-stroke individuals with chronic dysphagia

BACKGROUND

There is growing evidence of potential benefits of repetitive transcranial magnetic stimulation (rTMS) in the rehabilitation of dysphagia. However, the site and frequency of stimulation for optimal effects are not clear.

AIMS

The aim of this pilot study is to investigate the short-term effects of high-frequency 5 Hz rTMS applied to the tongue region of the motor cortex on swallowing functions and the quality of life of post-stroke individuals with dysphagia.

METHODS & PROCEDURES

Two male and two female participants were assigned randomly to active and sham groups. The participants in the active group received 10 sessions of active rTMS for 2 weeks, whereas the sham participants received 10 sessions of sham rTMS for 2 weeks. Each participant received a total of 3000 pulses of 5 Hz active or sham rTMS per day for 10 days. Outcome measures were taken at baseline, 1 week and 1 month post-rTMS.

OUTCOMES & RESULTS

Participants who received active rTMS had improved swallowing functions and swallowing-related quality of life at 1 week and 1 month post-stimulation.

CONCLUSIONS & IMPLICATIONS

The study showed that excitatory rTMS applied over the tongue motor cortex is a feasible approach in individuals with chronic post-stroke dysphagia. Further investigation with larger sample population is warranted to support the benefit of this stimulation protocol.

Optimisation of preoperative assessment in patients diagnosed with rectal cancer

AIMS

Treatment decision making for patients with rectal cancer is complex and optimal preoperative assessment is important to ensure patients receive appropriate and high-quality care. Therefore, our objective was to develop an evidence-based, multidisciplinary guideline to assist physicians treating rectal cancer to ensure that preoperative assessment is optimal.

MATERIALS AND METHODS

A multidisciplinary expert panel of physicians who treat rectal cancer was selected as members of the Cancer Care Ontario Preoperative Assessment for Rectal Cancer Guideline Development Group (GDG). This group initially met to identify important clinical questions with respect to optimisation of preoperative assessment in patients diagnosed with rectal cancer. A systematic review, specific to each of these clinical questions, was then conducted using MEDLINE, EMBASE and the Cochrane Library databases. The GDG met at regular intervals to review the evidence and to develop guidelines to address each of the clinical questions.

RESULTS

The GDG identified seven important clinical questions with respect to the optimisation of preoperative assessment in patients diagnosed with rectal cancer. The clinical questions pertained to: (i) investigations required to assess distant metastasis (one question); (ii) imaging for local staging of rectal cancer (five questions); (iii) multidisciplinary cancer conference (MCC) (one question); (iv) restaging-magnetic resonance imaging (one question). The systematic reviews related to these clinical questions yielded 31 articles that were abstracted and reviewed by the GDG. Based on the systematic reviews, a guideline was developed containing seven recommendations that were either adapted from existing guidelines, based on review of the evidence or by consensus when evidence was limited.

CONCLUSIONS

A set of seven recommendations have been developed in order to optimise pretreatment assessment in patients with rectal cancer by promoting evidence-based practice. These guidelines are based on the best available evidence and have been peer reviewed by two independent multidisciplinary expert panels for relevance and validity.

Remote preconditioning and major clinical complications following adult cardiovascular surgery: systematic review and meta-analysis

BACKGROUND

A number of 'proof-of-concept' trials suggest that remote ischaemic preconditioning (RIPC) reduces surrogate markers of end-organ injury in patients undergoing major cardiovascular surgery. To date, few studies have involved hard clinical outcomes as primary end-points.

METHODS

Randomised clinical trials of RIPC in major adult cardiovascular surgery were identified by a systematic review of electronic abstract databases, conference proceedings and article reference lists. Clinical end-points were extracted from trial reports. In addition, trial principal investigators provided unpublished clinical outcome data.

RESULTS

In total, 23 trials of RIPC in 2200 patients undergoing major adult cardiovascular surgery were identified. RIPC did not have a significant effect on clinical end-points (death, peri-operative myocardial infarction (MI), renal failure, stroke, mesenteric ischaemia, hospital or critical care length of stay).

CONCLUSION

Pooled data from pilot trials cannot confirm that RIPC has any significant effect on clinically relevant end-points. Heterogeneity in study inclusion and exclusion criteria and in the type of preconditioning stimulus limits the potential for extrapolation at present. An effort must be made to clarify the optimal preconditioning stimulus. Following this, large-scale trials in a range of patient populations are required to ascertain the role of this simple, cost-effective intervention in routine practice.

Neo-adjuvant chemoradiotherapy and multivisceral resection to optimize R0 resection of locally recurrent adherent colon cancer

BACKGROUND

Neo-adjuvant chemoradiotherapy reduces local recurrence in rectal cancer, but there is a paucity of evidence regarding its role for colon cancer. The aim of this study was to evaluate the feasibility and outcomes of a neo-adjuvant chemoradiotherapy (NCRT) approach for locally recurrent adherent colon cancer (LRACC).

METHODS

All patients with non-metastatic LRACC treated with NCRT and multi-visceral resection (MVR) from January 2000 to July 2010 were included. The primary outcome was the rate of R0 resection (negative microscopic margins). Secondary outcomes were toxicities, post-operative morbidity and mortality, local recurrence, overall survival (OS) and disease-free survival (DFS).

RESULTS

Fifteen patients were identified. Nine primary cancers were located in the sigmoid and 4 in the left colon. Patients were treated with 45-50 Gy in 25 daily fractions and concurrent 5-FU infusion (225 mg/m(2)/day). En-bloc MVR included between 2 and 5 adjacent organs/structures. All but two resulted in R0 resection. One patient had a complete pathologic response and one had minimal residual tumour cells in the resected specimen. Post-operative major morbidity was 33.3%. No mortality occurred. At a median follow-up of 54 months, there were 2 local, 1 regional, and 2 distant lung recurrences. No grade 3 or 4 acute or late toxicities were observed. 5-year OS and DFS were 90.0% and 63.5% respectively.

CONCLUSIONS

NCRT followed by MVR is a feasible option for the treatment of highly selected LRACC to achieve R0 resection, while maintaining acceptable treatment toxicity. Short-term oncological results appear satisfactory, including good local control.

Indicators for serious kidney complications associated with toxic exposures: an analysis of the National Poison Data System

CONTEXT

Over two million poisoning exposures are reported to U.S. poison control centers annually. A broad population-based survey of toxic exposures and the correlated patterns of reported kidney injury (acute or chronic) have not been systematically characterized.

OBJECTIVE

Our objective was to study the demographic and exposure patterns associated with indicators for serious kidney complications (ISKC), as defined by the variables in the NPDS.

MATERIALS AND METHODS

This was a retrospective, case-control study using the data elements available in the NPDS. We assessed data related to patient characteristics, substance exposure, and management. Cases and controls were derived from adult and pediatric exposures documented in NPDS (2001-2007) as having "renal effects." For substance-specific analyses, cases were restricted to those involving single substances or single entity pharmaceutical preparations. ISKC cases presented with one or more of the following NPDS codes: increased creatinine, and/or oliguria/anuria, and/or renal failure. Controls were subjects with "renal effects" but did not have increased creatinine, nor anuria/oliguria, nor renal failure. Univariate and multivariate logistic regression analyses identified factors associated with ISKC and determined the relationship between these factors.

RESULTS

From the approximate 16.8 million exposures reported to the NPDS within the study timeframe, there were 16,444 single substance exposures with renal effects of which 9,074 cases experienced ISKC (55.2%) compared to 7,370 controls without ISKC. Cases with ISKC tended to be males, adults, and reported to involve intentional exposures. Cases with ISKC had higher rates of reported hemodialysis/hemofiltration (27.7%; N = 2,517) and death (10.9%; N = 990) compared to controls, respectively, (2.1%; N = 155) and (0.8%; N = 60), p < 0.001. Substances considered a priori to be nephrotoxic were associated with a higher risk of ISKC.

DISCUSSION AND CONCLUSION

The NPDS provided insight into the subjects and types of exposures that associate with ISKC. Subjects with ISKC experienced higher rates of morbidity and mortality compared to subjects without ISKC. We identified subject characteristics and classes of compounds associated with ISKC. We hope that the hypotheses generated from this study of the NPDS will raise awareness of the possible risk factors and complications associated with ISKC.

Impact of dose hot spots on spinal cord tolerance following stereotactic body radiotherapy: a generalized biological effective dose analysis

The purpose of this study was to investigate the effects of high-dose inhomogeneous irradiation to small volumes of spinal cord with a new generalized biological effective dose (gBED) analysis for spine stereotactic body radiotherapy (SBRT). The gBED was applied to spinal cord dosimetric data (contoured per the thecal sac) at specified volumes for a cohort of five patients with radiation-induced myelopathy (RM) and compared to nineteen patients without RM post-SBRT. The spinal cord gBED was calculated and normalized to a conventional 2-Gy equivalent dose fraction scheme (α/β = 2 Gy for late toxicity). Differences between the conventional BED and those gBED calculations by accounting for small-volume dosing within the spinal cord was observed. Statistically significant differences in the mean gBED between the RM group and the non-RM group was observed both at the maximum point volume (gBED of 66 Gy vs. 37 Gy (p = 0.01), respectively) and at the 0.1 cm(3) volume (gBED of 53 Gy vs. 28 Gy (p = 0.01), respectively). No significant difference at the 0.1 cm(3) volume was observed based on the mean BED comparisons. No significant differences were observed at the larger 1 cm(3), 2 cm(3) or 5 cm(3) volumes for either BED or gBED comparisons. We conclude that differences in dose hot spots characteristics within small inhomogenously irradiated volumes of spinal cord can affect spinal cord tolerance following SBRT treatments.

Neoadjuvant chemoradiotherapy and multivisceral resection for primary locally advanced adherent colon cancer: a single institution experience

BACKGROUND

Although there is an extensive body of literature on the role of neoadjuvant chemoradiotherapy (CRT) in the management of rectal cancer, its role in primary locally advanced adherent colon cancer (LAACC) is unclear.

OBJECTIVE

To analyzed the outcomes of neoadjuvant CRT and multivisceral resection in the management of LAACC patietns.

METHODS

We retrospectively reviewed our institutional Colorectal Carcinoma Database for 33 patients with potentially resectable, non-metastatic primary LAACC who received neoadjuvant CRT followed by multivisceral resection. CRT consisted of external beam radiation (45-50 Gy in 25 daily fractions) and concurrent 5-FU infusion (225 mg/m(2)/day).

RESULTS

There were 21 males and 12 females. Median age was 64 (31-83) and median follow-up was 36 months. All patients had microscopically clear resection margins (R0). Complete pathologic response was documented in 1 patient (3%) and 66% had ypT4b disease. Post-operative complications were observed in 36% of patients with no 30-day mortality. The 3-year overall survival and 3-year disease-free survival were 85.9% and 73.7% respectively. Two patients developed a local recurrence.

CONCLUSIONS

Neoadjuvant CRT and en-bloc multivisceral resection may result in high rates of R0 resection and excellent local control with acceptable morbidity and mortality in selected patients with LAACC.

Acute HIV infection in Singapore: predominance of men who have sex with men

INTRODUCTION

The incidence of human immunodeficiency virus (HIV) infection in Singapore is on the rise. We aimed to study the clinical epidemiology of acute HIV infection in Singapore.

METHODS

All patients that fulfilled the criteria for definite and probable acute HIV infection were prospectively identified from January 1, 2003 to June 30, 2006. Demographic, clinical and laboratory data were recorded.

RESULTS

A total of 16 out of 34 patients had definite acute HIV infection, and 68 percent of the entire cohort comprised men who have sex with men (MSM). Ten percent of the patients were co-infected with hepatitis B and C viruses, while 27 percent were infected with syphilis. Signs and symptoms were nonspecific, with fever, rash and diarrhoea being the three most common symptoms. Only 35 percent of the patients required hospitalisation.

CONCLUSION

Men who have sex with men account for the majority of patients with acute HIV infections in Singapore, many of them also being co-infected with syphilis. Safer sex campaign among MSM should be implemented or intensified.

Mammographic density and its interaction with other breast cancer risk factors in an Asian population

BACKGROUND

Joint effects of mammographic density and other risk factors on breast cancer risk remain unclear.

METHODS

From The Singapore Breast Screening Project, we selected 491 cases and 982 controls. Mammographic density was measured quantitatively. Data analysis was by conditional logistic regression.

RESULTS

Density was a significant risk factor, adjusting for other factors. Density of 76-100% had an odds ratio of 5.54 (95% CI 2.38-12.90) compared with 0-10%. Density had significant interactions with body mass index and oral contraceptive use (P=0.02).

CONCLUSIONS

Percent density increases breast cancer risk in addition to effects of other risk factors, and modifies the effects of BMI and OCs.

In vivo 31P MRS detection of an alkaline inorganic phosphate pool with short T1 in human resting skeletal muscle

Non-invasive determination of mitochondrial content is an important objective in clinical and sports medicine. 31P MRS approaches to obtain information on this parameter at low field strength typically require in-magnet exercise. Direct observation of the intra-mitochondrial inorganic phosphate (Pi) pool in resting muscle would constitute an alternative, simpler method. In this study, we exploited the higher spectral resolution and signal-to-noise at 7T to investigate the MR visibility of this metabolite pool. 31P in vivo MR spectra of the resting soleus (SOL) muscle were obtained with 1H MR image-guided surface coil localization (six volunteers) and of the SOL and tibialis anterior (TA) muscle using 2D CSI (five volunteers). A resonance at a frequency 0.38 ppm downfield from the cytosolic Pi resonance (Pi(1); pH 7.0 ± 0.04) was reproducibly detected in the SOL muscle in all subjects and conditionally attributed to the intra-mitochondrial Pi pool (Pi(2); pH 7.3 ± 0.07). In the SOL muscle, the Pi(2)/Pi(1) ratio was 1.6 times higher compared to the TA muscle in the same individual. Localized 3D CSI results showed that the Pi(2) peak was present in voxels well away from blood vessels. Determination of the T1 of the two Pi pools in a single individual using adiabatic excitation of the spectral region around 5 ppm yielded estimates of 4.3 ± 0.4 s vs 1.4 ± 0.5 s for Pi(1) and Pi(2), respectively. Together, these results suggest that the intra-mitochondrial Pi pool in resting human skeletal muscle may be visible with 31P MRS at high field.

Atmospheric carbon dioxide, the southern oscillation, and the weak 1975 el nino

The observed rate of change of the atmospheric carbon dioxide concentration at the South Pole, Fanning Island, Hawaii, and ocean weather station P correlates with an index of the southern oscillation and with El Niño occurrences. There are changes at all four stations that seem to be in response to the weak 1975 El Niño. Thus, even poorly developed El Niño events may affect the atmospheric carbon dioxide concentration.

Retroperitoneal schwannoma: a common tumour in an uncommon site

We describe a female adult patient who presented with acute retention of urine and vague abdominal discomfort. A provisional diagnosis of ovarian tumour was made after cross-sectional imaging. At laparotomy a very large retroperitoneal mass was biopsied and found to be a schwannoma after pathological examination. The clinical, radiological, and pathological features of this disease are discussed in this report.

An appraisal of timely magnetic resonance imaging in diagnosing spinal cord compression

INTRODUCTION

Spinal cord compression is a very debilitating condition and could be secondary to many causes. Urgent magnetic resonance (MR) imaging of the spine is crucial in making the diagnosis and guiding further management. Our objectives were to assess the nature of MR imaging requests, the diagnostic yield, and the subsequent management according to relevant MR imaging findings.

METHODS

We focused on all the urgent MR imagings of the spine conducted from July 1, 2007 to December 31, 2007. Clinical data, including the demographical information, presenting symptoms, radiological diagnosis, waiting time for MR imaging and treatment, was reviewed.

RESULTS

A total of 33 cases of urgent MR imaging of the spine were performed. Patients were aged 29-85 years, with 18 males and 15 females. Most of them (84.8 percent) presented with neurological symptoms. 84 percent of the MR imaging was performed within 24 hours. 76 percent of the examinations yielded significant cord compression, of which 56 percent were due to vertebral metastasis, while others were due to epidural haematoma (12 percent), infective spondylodiscitis (8 percent), vertebral fracture (8 percent) and disc herniation (16 percent). Of the vertebral metastasis patients, 43 percent had one region imaged. 64 percent of the cord compression patients received surgical treatment or radiotherapy, with a mean waiting time of 1.7 days.

CONCLUSION

The urgent MR imaging spine service was able to react promptly with a high diagnostic yield. One-third of the patients with vertebral metastasis had multiple levels involved, and imaging of the whole spine would be useful.

Is ultrasonography-guided modified coaxial core biopsy of the breast a better technique?

OBJECTIVE

To compare the diagnostic rate, patient comfort, and complications of ultrasonography-guided breast biopsy using a modified coaxial technique with ultrasonography-guided fine needle aspiration and traditional core biopsy. A secondary objective was to describe the use of the coaxial technique for the biopsy of breast lesions and our initial experience.

DESIGN

Retrospective study.

SETTING

A regional hospital in Hong Kong.

PATIENTS

Patients, who were referred for ultrasonography-guided fine needle aspiration or biopsy from 23 November 2007 to 19 March 2008, were divided into three groups. For breast lesions of 8 mm or smaller, fine needle aspirations were performed. For breast lesions larger than 8 mm, the patients were randomly divided into groups receiving traditional core biopsies and coaxial biopsies. The pathological reports were reviewed.

MAIN OUTCOME MEASURES

Diagnostic rate, patient comfort assessed in terms of pain, and any procedural complications.

RESULTS

A total of 45 ultrasonography-guided fine needle aspirations or biopsies of breast lesions were performed. All core biopsies using the traditional core technique (n=15) and coaxial technique (n=16) were diagnostic. While for fine needle aspirations, three (21%) of 14 were not diagnostic and repeat biopsies were undertaken for the corresponding patients. Except for one breast lesion biopsied with the coaxial technique that revealed invasive ductal carcinoma, all others yielded benign lesions. The average pain score for coaxial biopsies was 2.2, while for traditional core biopsies and fine needle aspirations, average scores were 3.7 and 3.8, respectively (P=0.022). No procedure-related complication was documented with either of the three techniques.

CONCLUSION

Modified coaxial core biopsy of the breast has an optimal diagnostic rate and hence avoids the need for repeat biopsies. It is associated with better patient comfort and no increase in the risk of complications.

Inflammatory epidermolysis bullosa acquisita mimicking toxic epidermal necrolysis and dermatitis herpetiformis

We report a patient with a spectrum of clinical features simulating toxic epidermal necrolysis, bullous erythema multiforme and later, dermatitis herpetiformis (DH). The histological features were suggestive of DH, bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA). Direct immunofluorescence results suggested BP or EBA. Indirect immunofluorescence on salt-split skin and immunoblotting analysis on normal human dermal extracts gave results that were diagnostic for EBA.

Survival advantage of pediatric recipients of a first kidney transplant among children awaiting kidney transplantation

The mortality rate in children with ESRD is substantially lower than the rate experienced by adults. However, the risk of death while awaiting kidney transplantation and the impact of transplantation on long-term survival has not been well characterized in the pediatric population. We performed a longitudinal study of 5961 patients under age 19 who were placed on the kidney transplant waiting list in the United States. Of these, 5270 received their first kidney transplant between 1990 and 2003. Survival was assessed via a time-varying nonproportional hazards model adjusted for potential confounders. Transplanted children had a lower mortality rate (13.1 deaths/1000 patient-years) compared to patients on the waiting list (17.6 deaths/1000 patient-years). Within the first 6 months of transplant, there was no significant excess in mortality compared to patients remaining on the waiting list (adjusted Relative Risk (aRR) = 1.01; p = 0.93). After 6 months, the risk of death was significantly lower: at 6-12 months (aRR = 0.37; p < 0.001) and at 30 months (aRR 0.26; p < 0.001). Compared to children who remain on the kidney transplant waiting list, those who receive a transplant have a long-term survival advantage. With the potential for unmeasured bias in this observational data, the results of the analysis should be interpreted conservatively.

Clinical and radiological features of generalised lymphangiomatosis

We report a paediatric patient who presented with fever, shortness of breath, and vague abdominal discomfort. Lesions removed surgically proved to be generalised lymphangiomatosis and were treated conservatively. The spectrum of abnormalities and radiological features are discussed.

Oesophageal gastro-intestinal stromal tumour presenting with rupture into pleural cavity

Gastro-intestinal stromal tumours are rarely found in the oesophagus and it is uncommon for these tumours to present with rupture. In this paper, we report a case where the tumour ruptured through the distal oesophagus. As a result, the patient underwent surgical tumour dissection. A histopathological examination of the tumour mass confirmed that it was a gastro-intestinal stromal tumour. In this report, we review the diagnosis, pathology, and treatment of a patient presenting with a ruptured oesophageal gastro-intestinal stromal tumour.

Prevalence of childhood asthma and control in children assessed in a pilot school-based intervention programme in Singapore

AIM

Because of a high childhood asthma burden in Singapore, assessment of disease control status is essential for formulating school-based strategy of childhood asthma control. The aim of the present study is to assess childhood asthma prevalence and control in Singapore and the socio-demographic and help-seeking correlates.

METHODS

School-based survey using parental self-administered questionnaire, conducted from February to April 2004. Four mixed-gender primary schools selected from geographically distinct zones of Singapore. All primary one (modal age - 6.5 years) and six (modal age - 11.9 years) students from selected schools were invited to participate. Questionnaire respondents were the students' parents or guardians. The response rate was 75.2% (2123/2825).

RESULTS

Prevalence of current asthma was 8.9% (190/2123). Among them, 26.3% (46/175) were assessed to have inadequate control. Asthma was more prevalent, and less adequately controlled in children from lower socio-economic backgrounds (lower-end housing type). Children with poorly controlled asthma were more likely to be treated by emergency room physicians and hospital specialists, and to be on preventer medications.

CONCLUSIONS

In Singapore, poor asthma control is found in a sizeable proportion of school children with asthma, is identifiable for high-risk groups of children from lower socio-economic backgrounds and having asthma-related attendance at the emergency rooms.

Functional and Pharmacokinetic Outcomes after a Single Intravenous Infusion of Recombinant Human Erythropoietin in Patients with Malignant Extradural Spinal Cord Compression

AIMS

To determine the cerebrospinal fluid concentrations and the functional and pain outcomes after a single intravenous infusion of erythropoietin at the start of a standard radiotherapy and steroid protocol.

MATERIALS AND METHODS

Ten paraparetic patients with malignant extradural spinal cord compression who were eligible for radiotherapy, lumbar puncture and intravenous epoetin alpha were enrolled. The patients received epoetin alpha 1500 IU/kg intravenously over 30 min followed by a standardised dexamethasone and radiotherapy protocol. A lumbar puncture and venipuncture were carried out 24-30 h after the epoetin alpha infusion. The patients were followed closely at defined intervals.

RESULTS

Erythropoietin was detectable in the cerebrospinal fluid in all eight patients sampled (median 92.5 mIU/ml, range 17.8-214.0 mIU/ml). Before treatment, eight patients were non-ambulatory and two patients were ambulatory with assistance. After treatment, eight (80%, 95% confidence interval [CI] 44-97%) improved at least one functional class and recovered or maintained ambulation. Five of seven patients (71%; 95% CI 29-96%) with objective sensory deficits and one of seven (14%; 95% CI 0-58%) catheter-dependent patients recovered. Overall, 78% (95% CI 40-97%) had a pain response.

CONCLUSIONS

After an intravenous infusion of epoetin alpha, radiotherapy and steroids, high concentrations of erythropoietin were detectable in the cerebrospinal fluid. Patients with malignant extradural spinal cord compression showed encouraging improvements in neurological function and pain.