Amniotic fluid gamma-glutamyl transferase for prediction of biliary atresia in cases of non-visualisation of the fetal gallbladder: a retrospective study using a validated analytical platform and local reference range.

INTRODUCTION: The level of amniotic fluid gamma-glutamyl transferase (AFGGT) may help identify biliary atresia (BA) in cases of non-visualisation of the fetal gallbladder (NVFGB). This study aimed to validate a serum/plasma matrix-based gamma-glutamyl transferase (GGT) assay for amniotic fluid (AF) samples, establish a local gestational age-specific AFGGT reference range, and evaluate the efficacy of AFGGT for predicting fetal BA in pregnancies with NVFGB using the constructed reference range. METHODS: The analytical performance of a serum/plasma matrix-based GGT assay on AF samples was evaluated using a Cobas c502 analyser. Amniotic fluid gamma-glutamyl transferase levels in confirmed euploid singleton pregnancies (16+0 to 22+6 weeks of gestation) were determined using the same analyser to establish a local gestational age-specific reference range (the 2.5th to 97.5th percentiles). This local reference range was used to determine the positive predictive value (PPV) and negative predictive value (NPV) of AFGGT level <2.5th percentile for identifying fetal BA in euploid pregnancies with NVFGB. RESULTS: The serum/plasma matrix-based GGT assay was able to reliably and accurately determine GGT levels in AF samples. Using the constructed local gestational age-specific AFGGT reference range, the NPV and PPV of AFGGT level <2.5th percentile for predicting fetal BA in pregnancies with NVFGB were 100% and 25% (95% confidence interval=0, 53), respectively. CONCLUSION: In pregnancies with NVFGB, AFGGT level ≥2.5th percentile likely excludes fetal BA. Although AFGGT level <2.5th percentile is not diagnostic of fetal BA, fetuses with AFGGT below this level should be referred for early postnatal investigation.

Design and preliminary experience of a transportable equine operating theatre.

BACKGROUND: Equine surgical facilities are not always available, even in situations where high-value horses are involved in relatively high-risk activities. OBJECTIVES: To develop a self-contained equine surgical unit that can be relocated and transported by road. STUDY DESIGN: Proof of concept. METHODS: A modular operating suite for horses, which included a theatre, scrub room, instrument preparation and storage room, and an anaesthetic induction/recovery box: Transportable Equine Operating Theatre (TEOT) was designed, constructed and tested. A second, larger unit was then built following the same design criteria. RESULTS: Both units were based on modifications of standard 6.06 × 2.35 m (20 × 8 ft), steel shipping containers that were fitted out to provide anaesthetic and surgical facilities in a functional and safe working environment. The two TEOTs consisted of either two or three containers that had selected sections of their sides removed so that they could be joined together to create a single large internal space. This space was subdivided to create separate working areas. A dedicated anaesthetic induction/recovery box was fabricated from a modular steel frame that could be disassembled for transport. The component parts could be loaded onto the bed of a standard lorry for road transport. The unit was designed to incorporate equipment that is found in any high-quality equine operating theatre. Surgical procedures on adult Thoroughbred horses have been successfully completed in both units. MAIN LIMITATIONS: The two units have had minimal use to date, and there is little data on their performance. CONCLUSIONS: The equipment described here is a way to provide equine surgical facilities that can be assembled and disassembled to allow their relocation to different sites.

The preparedness of Hong Kong medical students towards advance directives and end-of-life issues.

OBJECTIVES: To explore the preparedness of medical students towards advance directives and related end-of-life issues, and to examine background factors such as knowledge, attitudes, and experience concerning advance directives and related end-of-life issues. METHODS: In 2007, 448 medical students in years 3 to 5 were surveyed at the Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong. Their knowledge, attitudes, and experiences of advance directives and related end-of-life issues, and their self-perceived preparedness to discuss these matters with patients were evaluated. RESULTS: A total of 220 (49%) of the eligible students responded, of whom 79% supported the use of advance directives. Only 65 (30%) students were certain of what advance directives meant and 198 (90%) students felt that their knowledge of advance directives was inadequate. Also, 197 (90%) students felt unprepared about advance directives and end-of-life issues. Factors associated with positive attitude towards advance directives included religion and knowledge. No factors were found to be associated with self-perceived preparedness towards advance directives or end-of-life issues. CONCLUSIONS: Most of the medical students surveyed demonstrated a positive attitude towards advance directives and recognised the importance of advance directives. However, they felt that they were unprepared and lacking in knowledge and experience of advance directives and end-of-life issues. Wider range and more depth of education is needed to better equip medical students for future practice.

Laparoscopic cholecystectomy: two-port technique.

BACKGROUND AND STUDY AIMS: Conventional laparoscopic cholecystectomy requires four ports. The present study describes a new laparoscopic cholecystectomy technique using two ports only. PATIENTS AND METHODS: Sixty-two consecutive patients with symptomatic gallstones underwent laparoscopic cholecystectomy using this two-port technique. The operation requires a straightforward laparoscope and a percutaneous sling to retract the gallbladder laterally and cephalad. RESULTS: The two-port method was successful in 52 patients; eight required an additional port, and two required conversion to open surgery. Our results showed that the operating time and complication rate were comparable to those in other series using the conventional laparoscopic method. CONCLUSION: The two-port method is technically more demanding, and should only be used to remove simple, uncomplicated gallbladders. The surgeon should always be prepared to insert more trocars or convert to open procedures when necessary.