Plasma DNA End-Motif Profiling as a Fragmentomic Marker in Cancer, Pregnancy, and Transplantation

Plasma DNA fragmentomics is an emerging area of research covering plasma DNA sizes, end points, and nucleosome footprints. In the present study, we found a significant increase in the diversity of plasma DNA end motifs in patients with hepatocellular carcinoma (HCC). Compared with patients without HCC, patients with HCC showed a preferential pattern of 4-mer end motifs. In particular, the abundance of plasma DNA motif CCCA was much lower in patients with HCC than in subjects without HCC. The aberrant end motifs were also observed in patients with other cancer types, including colorectal cancer, lung cancer, nasopharyngeal carcinoma, and head and neck squamous cell carcinoma. We further observed that the profile of plasma DNA end motifs originating from the same organ, such as the liver, placenta, and hematopoietic cells, generally clustered together. The profile of end motifs may therefore serve as a class of biomarkers for liquid biopsy in oncology, noninvasive prenatal testing, and transplantation monitoring. SIGNIFICANCE: Plasma DNA molecules originating from the liver, HCC and other cancers, placenta, and hematopoietic cells each harbor a set of characteristic plasma DNA end motifs. Such markers carry tissue-of-origin information and represent a new class of biomarkers in the nascent field of fragmentomics.This article is highlighted in the In This Issue feature, p. 627.

Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSHL) with or without tinnitus is common and presents a health problem with significant effect on quality of life. Hyperbaric oxygen therapy (HBOT) may improve oxygen supply to the inner ear and, it is postulated, may result in an improvement in hearing and/or a reduction in the intensity of tinnitus.

OBJECTIVES

To assess the benefits and harms of HBOT for treating ISSHL and/or tinnitus.

SEARCH STRATEGY

We initially searched in June 2004 and repeated the search in June 2006. Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2 2006), MEDLINE (1951 to 2006), EMBASE (1974 to 2006), CINAHL, Database of Randomised Trials in Hyperbaric Medicine (DORCTHIM), AMED, LILACS, KOREAMED, INDMED, National Research Register (NRR), CSA, ISI PROCEEDINGS and ZETOC.

SELECTION CRITERIA

Randomised studies comparing the effect on ISSHL and/or tinnitus of therapeutic regimens which include HBOT with those that exclude HBOT.

DATA COLLECTION AND ANALYSIS

Three authors independently evaluated the quality of the relevant trials using the validated Oxford-Scale (Jadad 1996) and extracted the data from the included trials.

MAIN RESULTS

Six trials contributed to this review (308 subjects). Pooled data from two trials involving 114 patients did not show any significant improvement in the chance of a 50% increase in hearing threshold on Pure Tone Average (PTA) when HBOT was used (relative risk [RR] with HBOT 1.53, 95% CI 0.85 to 2.78, P = 0.16), but did show a significantly increased chance of a 25% increase in PTA (RR 1.39, 95% CI 1.05 to 1.84, P = 0.02). There was a 22% greater chance of improvement with HBOT, and the number needed to treat (NNT) to achieve one extra good outcome was five (95% CI 3 to 20). A single trial involving 50 subjects also suggested significantly more improvement in the mean PTA threshold with HBOT, expressed as a percentage of baseline (WMD 37%, 95% CI 22% to 53%, P < 0.001). The significance of any improvement following HBOT in a subjective rating of tinnitus could not be assessed due to poor reporting. There were no significant improvements in hearing or tinnitus reported in the single study to examine chronic presentation (six months) of ISSHL and/or tinnitus.

AUTHORS' CONCLUSIONS

For people with early presentation of ISSHL, the application of HBOT significantly improved hearing loss, but the clinical significance of the level of improvement is not clear. We could not assess the effect of HBOT on tinnitus by pooled data analysis. The routine application of HBOT to these patients cannot be justified from this review. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously, and an appropriately powered trial of high methodological rigour is justified to define those patients (if any) who can be expected to derive most benefit from HBOT. There is no evidence of a beneficial effect of HBOT on chronic presentation of ISSHL and/or tinnitus and we do not recommend use of HBOT for this purpose based on the single study available.

Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2005 and previously updated in 2007 and 2009.Idiopathic sudden sensorineural hearing loss (ISSHL) is common and has a significant effect on quality of life. Hyperbaric oxygen therapy (HBOT) may improve oxygen supply to the inner ear and result in an improvement in hearing.

OBJECTIVES

To assess the benefits and harms of HBOT for treating ISSHL and/or tinnitus.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; Database of Randomised Trials in Hyperbaric Medicine (DORCTHIM); CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 2 May 2012, following previous searches in 2009, 2007 and 2004.

SELECTION CRITERIA

Randomised studies comparing the effect on ISSHL and tinnitus of HBOT and alternative therapies.

DATA COLLECTION AND ANALYSIS

Three authors evaluated the quality of trials using the 'Risk of bias' tool and extracted data from the included trials.

MAIN RESULTS

Seven trials contributed to this review (392 participants). The studies were small and of generally poor quality. Pooled data from two trials did not show any significant improvement in the chance of a 50% increase in hearing threshold on pure-tone average with HBOT (risk ratio (RR) with HBOT 1.53, 95% confidence interval (CI) 0.85 to 2.78, P = 0.16), but did show a significantly increased chance of a 25% increase in pure-tone average (RR 1.39, 95% CI 1.05 to 1.84, P = 0.02). There was a 22% greater chance of improvement with HBOT, and the number needed to treat (NNT) to achieve one extra good outcome was 5 (95% CI 3 to 20). There was also an absolute improvement in average pure-tone audiometric threshold following HBOT (mean difference (MD) 15.6 dB greater with HBOT, 95% CI 1.5 to 29.8, P = 0.03). The significance of any improvement in tinnitus could not be assessed.There were no significant improvements in hearing or tinnitus reported for chronic presentation (six months) of ISSHL and/or tinnitus.

AUTHORS' CONCLUSIONS

For people with acute ISSHL, the application of HBOT significantly improved hearing, but the clinical significance remains unclear. We could not assess the effect of HBOT on tinnitus by pooled analysis. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously. An appropriately powered trial is justified to define those patients (if any) who can be expected to derive most benefit from HBOT.There is no evidence of a beneficial effect of HBOT on chronic ISSHL or tinnitus and we do not recommend the use of HBOT for this purpose.

Voice changes and thyroid surgery: is pre-operative indirect laryngoscopy necessary?

BACKGROUND

Indirect laryngoscopy (IDL) is often performed prior to thyroid surgery to detect pre-existing vocal cord pathology.

METHODS

A retrospective chart review of 201 patients undergoing thyroid surgery at the Prince of Wales Hospital was undertaken in order to study the patterns of pre-operative and postoperative voice changes and IDL findings.

RESULTS

A total of 9% of patients had pre-operative voice symptoms, and 22% of this group had abnormalities detected on pre-operative IDL. Of 160 documented IDL, 4% revealed vocal cord pathology in asymptomatic patients, including an asymptomatic recurrent laryngeal nerve palsy.

CONCLUSIONS

Indirect laryngoscopy remains a useful but flawed pre-operative screening tool for patients with voice symptoms, but the literature suggests that more advanced phoniatric tests will provide superior diagnostic sensitivity. The role of routine pre-operative laryngoscopy for asymptomatic patients is of debatable value.

Malignancies of the external auditory canal and temporal bone: a review

BACKGROUND

Malignancies of the external auditory canal and temporal bone are uncommon. A retrospective review was conducted of a large series treated at the Prince of Wales hospital between 1974 and 1995.

METHODS

Retrospective review of 59 cases of ear canal and temporal bone malignancies. These were analysed according to histopathology, disease extent, surgery, margin status and survival. A TNM-type staging system was applied to 51 cases and Kaplan-Meier survival analysis applied to this group.

RESULTS

The 5-year cancer-specific survival (CSS) for the series was 54%. For stages 1, 2, 3 and 4 disease, the CSS were 90, 45, 40 and 19%, respectively. Survival was significantly higher where clear surgical margins were achieved (80 vs 35%).

CONCLUSIONS

Carcinoma of the external ear canal is rare and, in Australia, is often related to recurrence of periauricular cutaneous malignancy. Surgical extirpation with clear margins provides the best survival.

Radioimmunoassay for trifluoperazine in human plasma

1 A new sensitive and rapid radioimmunoassay procedure for the determination of the plasma concentrations of the neuroleptic drug trifluoperazine is described. 2 The antiserum developed for trifluoperazine cross-reacted with N-desmethyltrifluoperazine and 7-hydroxytrifluoperazine to the extent of 26 and 24% respectively but its cross-reactivity with commonly co-administered tricyclic antidepressants and antianxiety agents tested was negligible. 3 The assay, based on the above antiserum, enabled the quantitation of 50 pg of the drug in 200 microliters of plasma with a coefficient of variation of about 2% and therefore should be applicable for singly dose pharmacokinetic and bioavailability studies. It should be applicable to therapeutic monitoring of the drug in patients.

Presence of Donor-Derived DNA and Cells in the Urine of Sex-Mismatched Hematopoietic Stem Cell Transplant Recipients: Implication for the Transrenal Hypothesis

Background: The term “transrenal DNA” was coined in 2000 to signify that DNA in urine may come from the passage of plasma DNA through the kidney barrier. Although DNA in the urine has the potential to provide a completely noninvasive source of nucleic acids for molecular diagnosis, its existence remains controversial.

Methods: We obtained blood and urine samples from 22 hematopoietic stem cell transplant (HSCT) recipients and used fluorescence in situ hybridization, PCR for short tandem repeats, mass spectrometry, quantitative PCR, and immunofluorescence detection to study donor-derived DNA in the urine.

Results: All HSCT recipients exhibited high amounts of donor-derived DNA in buffy coat and plasma samples. Male donor–derived DNA was detected in supernatants of urine samples from all 5 female sex-mismatched HSCT recipients. Surprisingly, the amount of DNA in urine supernatants was not correlated with the plasma value. Moreover, cell-free urine supernatants contained DNA fragments &gt;350 bp that were absent in plasma. Donor-derived polymorphs were detected in urine by fluorescence in situ hybridization. Coincidentally, donor-derived cytokeratin-producing epithelial cells were discovered in urine samples from 3 of 10 sex-mismatched HSCT recipients as long as 14.2 years after transplantation.

Conclusions: This report is the first to demonstrate the presence of donor-derived DNA in the urine of HSCT recipients; however, we show that much of this DNA originates from donor-derived cells, rather than from the transrenal passage of cell-free plasma DNA. Our discovery of donor-derived cytokeratin-producing epithelial cells raises interesting biological and therapeutic implications, e.g., the capacity of marrow stem cells to serve as an extrarenal source for renal tubule regeneration.

Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus: a systematic review of randomized controlled trials

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSHL) and tinnitus are common. Hyperbaric oxygen therapy (HBOT) may improve hearing loss and/or reduce the intensity of tinnitus.

METHODS

We performed a systematic search of the literature for randomized controlled trials, and made pooled analyses of pre-determined clinical outcomes where possible.

RESULTS

Six trials contributed to this review (304 subjects). Pooled analysis suggested a significantly increased chance of a 25 per cent improvement in hearing threshold on pure tone average with HBOT (relative risk (RR) 1.39, 95 per cent confidence interval (CI) 1.05-1.84, p = 0.02; number-needed-to-treat 5, 95 per cent CI 3-20), but not a 50 per cent increase (RR 1.53, 95 per cent CI 0.85-2.78, p = 0.16). The significance of any improvement in tinnitus following HBOT could not be assessed due to poor reporting.

CONCLUSIONS

HBOT improved hearing, but the clinical significance of the level of improvement is not clear. Routine application of HBOT to patients with ISSHL is not justified by this review. More research is needed.

Effect of low-frequency deep brain stimulation on sensory thresholds in Parkinson's disease

OBJECTIVE Chronic pain is a major distressing symptom of Parkinson's disease (PD) that is often undertreated. Subthalamic nucleus (STN) deep brain stimulation (DBS) delivers high-frequency stimulation (HFS) to patients with PD and has been effective in pain relief in a subset of these patients. However, up to 74% of patients develop new pain concerns while receiving STN DBS. Here the authors explore whether altering the frequency of STN DBS changes pain perception as measured through quantitative sensory testing (QST). METHODS Using QST, the authors measured thermal and mechanical detection and pain thresholds in 19 patients undergoing DBS via HFS, low-frequency stimulation (LFS), and off conditions in a randomized order. Testing was performed in the region of the body with the most pain and in the lower back in patients without chronic pain. RESULTS In the patients with chronic pain, LFS significantly reduced heat detection thresholds as compared with thresholds following HFS (p = 0.029) and in the off state (p = 0.010). Moreover, LFS resulted in increased detection thresholds for mechanical pressure (p = 0.020) and vibration (p = 0.040) compared with these thresholds following HFS. Neither LFS nor HFS led to changes in other mechanical thresholds. In patients without chronic pain, LFS significantly increased mechanical pain thresholds in response to the 40-g pinprick compared with thresholds following HFS (p = 0.032). CONCLUSIONS Recent literature has suggested that STN LFS can be useful in treating nonmotor symptoms of PD. Here the authors demonstrated that LFS modulates thermal and mechanical detection to a greater extent than HFS. Low-frequency stimulation is an innovative means of modulating chronic pain in PD patients receiving STN DBS. The authors suggest that STN LFS may be a future option to consider when treating Parkinson's patients in whom pain remains the predominant complaint.

Assessing Fluctuating Cognition in Dementia Diagnosis: Interrater Reliability of the Clinician Assessment of Fluctuation

Fluctuating cognition (FC) is a core feature of dementia with Lewy bodies (DLB) but is challenging to assess. This study assessed the reliability and validity of the Clinician Assessment of Fluctuation (CAF), which assesses FC in patients with dementia. Interrater agreement of CAF outcomes (FC present and FC severe) was evaluated between physicians and nonphysicians in 141 patients with Alzheimer's disease (AD) or DLB. Frequency of CAF outcomes by clinical and neuropathological diagnosis was examined. We found that interrater reliability was fair on FC present and almost perfect on FC severe, and both outcomes were higher in patients with clinical DLB than with clinical AD and were qualitatively more often endorsed in cases with neuropathological evidence of Lewy bodies. We conclude that the CAF is a reliable measure of FC and can be valuable in differential dementia diagnosis.

Distribution of mesothelioma cases in different occupational groups and industries in Australia, 1979-1995

Australia was a producer and user of asbestos and has one of the highest national incidences of mesothelioma in the world. The incidence is still rising and expected to do so for another 10-20 years. A study was conducted in 1996 to examine the past and current incidence rates of mesothelioma in a number of industries and occupations as the basis for predicting future outcomes. Occupational histories of a total of 3758 mesothelioma cases collected by two sequential national schemes--the Australian Mesothelioma Surveillance Program (1979-1985) and Australian Mesothelioma Register (1986-1995)--were reviewed and coded by the authors. The building industry contributed the largest number of cases nationwide followed by shipbuilding and repair, asbestos cement production, crocidolite mining and milling, railway locomotive construction and repair, coal-fired power stations, and other engineering operations. The mean latency between initial occupational asbestos exposure and diagnosis of the disease was 37.4 years (range = 4-66 years) for cases notified between 1979 and 1985, and 41.4 years (range = 6-84 years) for those between 1986 and 1995. Trends for each industry group have been changing considerably in the past 16 years, with the traditional primary asbestos industry cases from crocidolite mining and milling now on the decline and cases from asbestos cement production having plateaued. In contrast, more recently, more cases were observed from the asbestos user industries such as the building industry, and from occupations such as plumbers, carpenters, machinists, and car mechanics. These increases might be a reflection of the longer latency effects of the intermittent and less severe exposures in these larger occupational groups.

Subjective word-finding difficulty reduces engagement in social leisure activities in Alzheimer's disease

OBJECTIVES

To assess the influence of subjective word-finding difficulty on degree of engagement in social leisure activities among individuals with Alzheimer's disease (AD).

DESIGN

Analysis of data collected from the second cohort of the Multicenter Study of Predictors of Disease Course in Alzheimer's disease.

SETTING

Four study sites in the United States and France.

PARTICIPANTS

Individuals diagnosed with mild to moderate AD (N = 236).

MEASUREMENTS

On separate questionnaires, participants were asked to 1) report whether they had trouble finding the right word when speaking (subjective word-finding difficulty) and 2) rate their frequency and enjoyment of social and nonsocial leisure activities. Objective language measures included object naming and verbal fluency. Measures of dependence, depression, cognitive status, age, sex, and education were also included as covariates in regression analyses.

RESULTS

Fifty-two percent of the sample reported word-finding difficulty, and subjective complaints were correlated with poorer verbal fluency scores. Subjective word-finding difficulty was selectively related to social but not nonsocial activity measures. Endorsers of word-finding difficulty reported less frequency and enjoyment of social leisure activities, controlling for effects of covariates and objective word-finding ability. In contrast, lower engagement in nonsocial activities was associated with older age and higher depression scores but not with word-finding complaints. Caregivers' reports of study participants' activities corroborated these results.

CONCLUSION

Individuals with AD who are aware of increasing word-finding failures are less likely to participate in and enjoy socially oriented leisure activities. This finding may have significant implications for clinical and health outcomes in AD. Failure to evaluate subjective language complaints could result in social withdrawal symptoms, threatening the individual's quality of life and increasing caregiver burden. Reduced social interaction may ultimately exacerbate language symptoms over time.

An occupation-industry matrix analysis of mesothelioma cases in Australia 1980-1985

Australia has one of the highest national incidences of mesothelioma in the world and the rate is still rising. An industry-occupation matrix analysis was conducted for the 858 mesothelioma cases that were reported to the Australian Mesothelioma Surveillance Program between 1980 and 1985. Definite, probable, or possible occupational exposure had occurred in 57 percent (492/858) of the subjects. The primary asbestos production or manufacturing industry constituted the largest number of cases (137/492, 27.8%), followed by shipbuilding, repair and demolition (114/492, 23.2%), the building industry (69/492, 14.1%), and the railway locomotive construction and maintenance industry (47/492, 9.6%). Laborers constituted 14.8 percent (n = 73) of the occupations with a history of exposure to asbestos, followed by carpenters (13.0%, n = 64), boilermakers (10.6%, n = 52), and fitters/turners (8.1%, n = 40). The distribution of occupations in specific industries is presented in this article.

Functional profile of the isolated uremic nephron: intrinsic adaptation of phosphate transport in the rabbit proximal tubule

The maintenance of phosphate homeostasis in uremia appears to be governed both by parathyroid hormone (PTH) and by PTH-independent adaptations in renal tubular function. The relative contributions of these two mechanisms that control phosphate excretion by the diseased kidney have been difficult to define in intact animals. The present study was designed to examine the nature of the adaptation of phosphate handling by the proximal tubule of subtotally nephrectomized, uremic rabbits in vitro. Euparathyroid and hyperparathyroid uremic rabbits were studied. Tubular sensitivity to PTH was examined in vitro. The dose-response relationship between bath PTH concentration and inhibition of lumen-to-bath phosphate flux (Jp-lb) in isolated perfused proximal straight tubules (PSTs) revealed that PTH sensitivity was increased in the euparathyroid uremic rabbits and was decreased in hyperparathyroid uremic rabbits. The dose-response to dibutyryl cAMP was the same as normal in both uremic groups. These data strongly suggest the existence of a receptor-mediated adaptation in the effects of PTH on the uremic proximal tubule. In addition to an altered PTH-sensitivity the uremic PST also exhibited an alteration in the basal rate of phosphate transport studied in the presence of normal rabbit serum. Although net volume flux across the PST increased in both uremic groups as a possible consequence of hypertrophy, net phosphate flux per unit length was unchanged. Considering the increase of luminal area in these tubules, net phosphate flux per unit reabsorptive surface area was actually decreased. This dissociation is supportive of the existence of an intrinsic tubular adaptation which is independent of the size of the tubule per se. These studies indicate that there is an intrinsic adaptation of the basal rate of phosphate transport by the uremic rabbit proximal tubule and that the sensitivity of the tubule to PTH is altered. The data are strongly suggestive of an increase in the number of PTH receptors in the proximal tubule of the euparathyroid uremic rabbit and suggest that "down regulation" or persistent occupancy of these receptors occurs when hyperparathyroidism supervenes.

Control of intra-oesophageal pH in patients with Barrett's oesophagus on omeprazole-sodium bicarbonate therapy

BACKGROUND

Approximately 30-40% of patients with Barrett's oesophagus (BE) patients manifest abnormal oesophageal pH profiles despite proton pump inhibitor (PPI) therapy.

AIM

To determine control of oesophageal reflux using Bravo pH monitoring in patients BE on omeprazole-sodium bicarbonate oral suspension powder (Ome-NaBic) 40 mg twice daily.

METHODS

Initial pH monitoring off PPI for 1 week was performed. All patients underwent repeat pH testing on Ome-NaBic administered before breakfast and at bedtime after 21-28 days of therapy depending upon the prior PPI therapy. The goal was to enroll 30 subjects, however, the trial was terminated prematurely when the sponsor lost financing due to a change in business strategy.

RESULTS

A total of 88 patients responded to the study invitation, 27 patients signed informed consent, and 21 patients underwent pH testing of PPI. A total of 15 patients completed the protocol (13 men, 2 women). Demographic information for patients completing at least one Bravo study included a mean (±s.d.) age 62 ± 9 years; body mass index 31 ± 8 kg/m(2) (range 23-48); mean BE length of 2.6 ± 2 cm; 9 (43%) patients with long segment BE. All (100%) patients demonstrated normalisation of supine pH on both days of Ome-NaBic therapy. One patient (6%) demonstrated abnormal upright reflux on the second day of monitoring on Ome-NaBic therapy; all the other patients demonstrated normal pH scores on therapy.

CONCLUSIONS

Administration of twice daily Ome-NaBic demonstrated control of nocturnal oesophageal reflux in 100% of patients with Barrett's oesophagus, and complete control of oesophageal pH during 97% of the 24-h recording periods.

Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSHL) with or without tinnitus is common and presents a health problem with significant effect on quality of life. Hyperbaric oxygen therapy (HBOT) may improve oxygen supply to the inner ear and thereby result in an improvement in hearing and/or a reduction in the intensity of tinnitus.

OBJECTIVES

To assess the benefits and harms of HBOT for treating ISSHL and tinnitus.

SEARCH STRATEGY

We searched the Cochrane ENT Specialist Register (June 2004), CENTRAL (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to 2004), EMBASE (1974 to 2004), CINAHL (1982 to 2004), DORCTHIM (1996 to 2004), and reference lists of articles. Researchers in the field were contacted.

SELECTION CRITERIA

Randomised studies comparing the effect on ISSHL and/or tinnitus of therapeutic regimens which include HBOT with those that exclude HBOT.

DATA COLLECTION AND ANALYSIS

Three reviewers independently evaluated the quality of the relevant trials using the validated Jadad 1996 Oxford-Scale and extracted the data from the included trials.

MAIN RESULTS

Five trials contributed to this review (254 subjects, 133 receiving HBOT and 120 control). Pooled data from two trials involving 114 patients (45% of the total) suggested there was a trend towards, but no significant increase in, the chance of a 50% increase in hearing threshold on Pure Tone Average (PTA) over four frequencies when HBOT was used (relative risk (RR) for good outcome with HBOT 1.53, 95% confidence interval (CI) 0.85 to 2.78, P = 0.16). The chance of achieving a 25% increase with HBOT was, however, statistically significant (RR 1.39, 95% CI 1.05 to 1.84, P = 0.02). Fifty-six per cent of the control subjects achieved this outcome versus 78% of the HBOT subjects, with the number-needed-to-treat (NNT) to achieve one extra good outcome being 5 (95% CI 3 to 20). A single trial involving 50 subjects (20% of the total) also suggested a significant improvement in the mean PTA threshold expressed as a percentage of baseline (61% improvement with HBOT, 24% with control, WMD 37%, 95% CI 22% to 53%). The effect of HBOT in tinnitus could not be assessed due to poor reporting. There were no significant improvements in hearing or tinnitus reported in the single study to examine the effect of HBOT on a chronic presentation (six months) of ISSHL and/or tinnitus.

AUTHORS' CONCLUSIONS

For people with early presentation of ISSHL, the application of HBOT significantly improved hearing loss, but the clinical significance of the level of improvement is not clear. We could not assess the effect of HBOT on tinnitus by pooled analysis. The routine application of HBOT to these patients cannot be justified from this review. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously, and an appropriately powered trial of high methodological rigour is justified to define those patients (if any) who can be expected to derive most benefit from HBOT. There is no evidence of a beneficial effect of HBOT on chronic presentation of ISSHL and/or tinnitus.

Performing slow vital capacity in older people with and without cognitive impairment--is it useful?

BACKGROUND

most patients with moderate cognitive impairment are unable to perform forced spirometry. It has been suggested that slow vital capacity (SVC) is easier to perform than forced vital capacity (FVC) because it requires less understanding and co-ordination. We conducted a study to determine whether that assertion is correct.

METHODS

we studied 83 inpatients, mean age 83 years (range 67-95, 51 female). They had measurements made of FVC, SVC and the Mini-Mental State Examination (MMSE). The spirometry was conducted using the European Respiratory Society/American Thoracic Society standards.

RESULTS

of the 83 subjects, 38 were able to do both FVC and SVC and 32 were unable to do either. The overall concordance was 84%. Twelve were able to do SVC but not FVC (eight due to excessive cough, two due to weakness and two had an MMSE < 24 with poor co-ordination). An inability to do neither FVC nor SVC was predicted by an MMSE < 24/30 (P < 0.0001) with a sensitivity of 88% and specificity of 67%.

CONCLUSION

SVC is not a usable substitute for FVC for elderly patients with cognitive impairment but is of some utility for those who tend to cough. An MMSE < 24/30 is predictive of inability to perform FVC and SVC.

Nm23 gene expression in gastric carcinoma: an immunohistochemical study

BACKGROUND

The gene Nm23 is thought to play a role in the suppression of tumour metastasis. Reduced expression of Nm23 is seen in a number of human cancers, and is associated with increased metastasis and reduced survival, most strongly in ductal breast and colorectal carcinomas.

METHODS

Nm23 gene expression was compared in gastric carcinoma and normal gastric mucosa. Twenty-three gastric carcinomas were graded for differentiation as either well, moderately or poorly differentiated. Metastatic deposits from seven of the cases were also examined, along with 10 samples of normal gastric mucosa. Specimens were incubated with a murine monoclonal antibody against the protein product of Nm23, and examined by immunohistochemical staining. A semiquantitative immunostaining index was used.

RESULTS

All normal mucosa showed moderate to strong staining; 8 of 15 poorly differentiated carcinomas showed absent or weak staining; 1 of 6 moderately differentiated carcinomas stained weakly. Both well-differentiated carcinomas stained strongly; 1 of 7 metastatic deposits stained weakly. The difference in Nm23 expression between normal mucosa and carcinomas was statistically significant (P=0.024). However, there was no statistically significant difference between the three grades of carcinomas (P=0.51), or between primary and metastatic tumour (P=0.25, all by Chi-squared test).

CONCLUSIONS

These results suggest that Nm23 may have a role in gastric carcinoma pathogenesis, but do not show a correlation with metastasis. A larger study, involving detailed clinical staging and follow-up, may be of benefit.

Measuring fragmentation of ambulatory care in a tripartite healthcare system

BACKGROUND

Hong Kong has a tripartite healthcare system, where western medicine provided in both public and private sectors coexist with Chinese medicine practice. The purpose of this study is to measure fragmentation of ambulatory care experienced by the non-institutionalized population aged 15 and over in such a tripartite system, thus shed light on the ongoing primary care reform.

METHODS

This is a cross-sectional secondary data analysis using the Thematic Household Survey, which was conducted by the Hong Kong Census and Statistics Department during November 2009 to February 2010 to collect territory-wide health-related information. Among 18,226 individuals with two or more ambulatory visits during the past 12 months before interview, we grouped each visit into one of the three care segments-public western, private western and Chinese medicine. Two individual-level measures were used to quantify longitudinal fragmentation of care across segments over the one-year period: Most Frequent Provider Continuity Index (MFPC) and Fragmentation of Care Index (FCI). Both are analyzed for distribution and subgroup comparison. A Tobit model was used to further examine the determinants of fragmentation.

RESULTS

More than a quarter of individuals sought care in two or all three segments, with an average MFPC of 65% and FCI of 0.528. Being older, female, married, unemployed, uninsured, or born in mainland China, with lower education, lower income, higher number of chronic conditions or poorer health were found to have experienced higher fragmentation of care. We also found that, fragmentation of care increased with the total number of ambulatory care visits and it varied significantly depending on what segment the individual chose to visit most frequently-those chose private western clinics had lower FCI, compared with those chose public western or Chinese medicine as the most frequently visited segment.

CONCLUSIONS

Even measured at healthcare segment level, people in Hong Kong experienced modest fragmentation of care. Individuals' health beliefs-as a result of the persistent habitual tendency and latitude incentivized by the system-may be behind the fragmented care we saw. Efforts are needed to alter health beliefs, targeting subgroups of vulnerable population, and create environments that promote better coordinated primary care.

Intratubal pressure before and after transcervical catheterization of the fallopian tubes

OBJECTIVE

To assess the intratubal pressure (ITP) and patency status of the fallopian tubes before and after transcervical catheterization of the fallopian tubes (TCFT).

DESIGN

Prospective procedural assessment.

SETTING

Pope Paul VI Institute for the Study of Human Reproduction.

PATIENT(S)

Two hundred thirty-four women with either primary or secondary infertility.

INTERVENTION(S)

Patients underwent selective hysterosalpingography and, in some cases, TCFT with measurement of the ITP before and after the procedure.

MAIN OUTCOME MEASURE(S)

The ITP before and after TCFT.

RESULT(S)

The mean (+/-SD) ITP in freely patent tubes was 0.53 +/- 0.06 atm, that in partially obstructed tubes was 1.23 +/- 0.52 atm, and that in completely obstructed tubes was 2.79 +/- 1.40 atm. After TCFT, the mean (+/-SD) ITP in partially obstructed tubes decreased to 0.64 +/- 0.31 atm and that in completely obstructed tubes decreased to 1.86 +/- 1.35 atm. The ITP was normalized in 76% of partially obstructed tubes and in 29.5% of completely obstructed tubes. In all cases of complete obstruction in which surgical correction was attempted, organic pathology was identified.

CONCLUSION(S)

The procedure described is a safe and easy means of obtaining reliable and significant information on the status of the proximal fallopian tube.

Genetic variation in ABCB5 associates with risk of hepatocellular carcinoma

Expression of ATP‐binding cassette B5 (ABCB5) has been demonstrated to confer chemoresistance, enhance cancer stem cell properties and associate with poor prognosis in hepatocellular carcinoma (HCC). The aim of this study was to evaluate the genetic variations of ABCB5 in HCC patients with reference to healthy individuals and the clinicopathological significance. A pilot study has examined 20 out of 300 pairs HCC and paralleled blood samples using conventional sequencing method to cover all exons and exon/intron regions to investigate whether there will be novel variant sequence and mutation event. A total of 300 HCC and 300 healthy blood DNA samples were then examined by Sequenom MassARRAY genotyping and pyrosequencing for 38 SNP and 1 INDEL in ABCB5. Five novel SNPs were identified in ABCB5. Comparison of DNA from blood samples of HCC and healthy demonstrated that ABCB5 SNPs rs75494098, rs4721940 and rs10254317 were associated with HCC risk. Specific ABCB5 variants were associated with aggressive HCC features. SNP rs17143212 was significantly associated with ABCB5 expression level. Nonetheless, the paralleled blood and tumour DNA sequences from HCC patients indicated that ABCB5 mutation in tumours was not common and corroborated the TCGA data sets. In conclusion, ABCB5 genetic variants had significant association with HCC risk and aggressive tumour properties.