Otolaryngology residents' perceptions of endoscopic ear surgery during surgical training.

BACKGROUND: The introduction of endoscopic ear surgery has implications for the training of otolaryngology residents. OBJECTIVES: To report on the status of endoscopic ear surgery and assess the effects of this new technology on otolaryngology training in Singapore, from the residents' perspective. METHODS: An anonymous survey was conducted amongst all Singaporean otolaryngology residents. Residents' exposure to, and perceptions of, endoscopic ear surgery were assessed. RESULTS: Residents from institutions that practise endoscopic ear surgery were more positive regarding its efficacy in various otological surgical procedures. Of residents in programmes with exposure to endoscopic ear surgery, 82.4 per cent felt that its introduction had adversely affected their training, with 88.3 per cent of residents agreeing that faculty members' learning of endoscopic ear surgery had decreased their hands-on surgical load. Both groups expressed desire for more experience with endoscopy. CONCLUSION: The majority of residents view endoscopic ear surgery as an expanding field with a potentially negative impact on their training. Mitigating measures should be implemented to minimise its negative impact on residents' training.

Effects of meaningful weight loss beyond symptomatic relief in adults with knee osteoarthritis and obesity: a systematic review and meta-analysis.

Existing clinical guidelines recommend weight loss for adults with knee osteoarthritis and obesity, but the supporting evidence to date remains inadequate. There is also no pooled data on physical function and quality of life. This study aims to examine the efficacy of weight loss on pain, self-reported disability, physical function and quality of life in adults with knee osteoarthritis and obesity. A systematic database search (from 1990 to June 2017) was conducted, and seven studies were eligible for inclusion. The meta-analyses demonstrated that a 5% to 10% weight loss significantly improved pain (effect size 0.33, 95% confidence intervals 0.17 to 0.48), self-reported disability (effect size 0.42, 95% confidence intervals 0.25 to 0.59) and quality of life (physical) (effect size 0.39, 95% confidence intervals 0.24 to 0.54). The results were based on adults with mean body mass index 33.6 to 36.4 kg m-2 and mild to moderate knee osteoarthritis. Results for physical function were inconclusive due to the lack of eligible studies and incomprehensive outcome measures used.

Results of the treatment of keratocystic odontogenic tumours using enucleation and treatment of the residual bony defect with Carnoy's solution.

This retrospective study aimed to investigate the recurrence rate of keratocystic odontogenic tumours (KCOTs) treated by enucleation and the application of Carnoy's solution, and to assess the surgical morbidities associated with this treatment. KCOTs treated using a standard protocol of enucleation and the application of Carnoy's solution between 1990 and 2013 were evaluated. One hundred and five KCOTS in 105 patients (54 male, 51 female) were analysed. The mean follow-up period was 86.6 months (range 24-313 months). The recurrence rate was 11.4%. A postoperative inferior alveolar nerve neurosensory deficit occurred in 30.1% of the mandibular cases, with 16% of these being permanent. The postoperative infection and fracture rates were 1.9% and 0.9%, respectively. Younger age, multilocular KCOTs, larger tumour size, and longer antero-posterior lesion length on the radiograph were found to be risk factors for recurrence. It is concluded that enucleation and the application of Carnoy's solution to treat KCOTs results in a relatively low recurrence rate and a low rate of surgical morbidities.

Latest developments in allergic rhinitis in Allergy for clinicians and researchers.

Research efforts in allergic rhinitis have always been intense. Over the past 3 years, numerous breakthroughs in basic science and clinical research have been made, augmenting our understanding of this condition that afflicts a significant proportion of the global population. New epidemiological findings, novel insights into the molecular and cellular mechanisms of allergy, enhancement of current developmental theories, new concepts of the goals and endpoints of management, and latest therapeutic modalities that includes the harnessing of information technology and big data are some areas where important advances were made. We attempt to bring you a summary of the key research advances made in the field of allergic rhinitis from 2013 to 2015.

Real-time polymerase chain reaction correlates well with clinical diagnosis of Clostridium difficile infection.

AIM: To determine the clinical utility of a rapid molecular assay for Clostridium difficile infection (CDI) in an acute hospital setting. METHODS: From March to September 2011, stool specimens from inpatients in two acute hospitals with suspected CDI were tested prospectively by routine cell culture cytotoxin neutralization assay (CCNA), real-time polymerase chain reaction (PCR) using the GeneXpert (Cepheid Inc., Sunnyvale, CA, USA), and a dual testing algorithm [glutamate dehydrogenase (GDH)/toxin enzyme immuno-assay, Premier, Launch Diagnostics, Longfield, UK]. All patients with positive PCR, CCNA or discrepant results were reviewed by a multi-disciplinary team (treating clinician, gastroenterologist, microbiologist and infection control nurse). RESULTS: C. difficile detection rates were 11.7% (PCR), 6% (CCNA) and 13.8% (GDH). Out of 1034 stool specimens included in the study, 974 (94.1%) had concordant CCNA and PCR results. Eighty-nine percent (886/985) had concordant CCNA, PCR and GDH results, and 94.4% (930/985) had concordant GDH and PCR results. Using clinical diagnosis as the reference, PCR had sensitivity of 99.1%, specificity of 98.9%, positive predictive value (PPV) of 91.9% and negative predictive value (NPV) of 99.9%. CCNA on a single sample had sensitivity of 51%, specificity of 99.4%, PPV of 91.9% and NPV of 94.3%. GDH had sensitivity of 83.8%, specificity of 94.5%, PPV of 64.7% and NPV of 97.9%. Almost twice as many patients were positive by PCR compared with CCNA (121 vs 62); 54/59 of those with discrepant results were clinically confirmed as CDI. CONCLUSION: Rapid diagnosis of CDI using PCR was timely, accurate and correlated well with clinical diagnosis.

A Randomised, Cross-Over, Placebo-Controlled Study of Aloe vera in Patients with Irritable Bowel Syndrome: Effects on Patient Quality of Life.

Background. Irritable bowel syndrome (IBS) is a chronic, difficult to treat condition. The efficacy of Aloe vera in treating IBS symptoms is not yet proven. The purpose of this study was to determine if Aloe vera is effective in improving quality of life. Methods. A multicentre, randomised, double-blind, cross-over placebo controlled study design. Patients were randomised to Aloe vera, wash-out, placebo or placebo, washout, Aloe vera. Each preparation (60 mL) was taken orally twice a day. Patient quality of life was measured using the Gastrointestinal Symptoms Rating Score, Irritable Bowel Syndrome Quality of Life, EuroQol and the Short-Form-12 at baseline and treatment periods 1 and 2. Results. A total of 110 patients were randomised, but only 47 completed all questionnaires and both study arms. Statistical analysis showed no difference between the placebo and Aloe vera treatment in quality of life. Discussion. This study was unable to show that Aloe vera was superior to placebo in improving quality of life. Drop outs and other confounding factors may have impacted on the power of the study to detect a clinically important difference. Conclusion. This study failed to find Aloe vera superior to placebo in improving quality of life proven Irritable Bowel Syndrome patients.

Human amniotic membrane as a chondrocyte carrier vehicle/substrate: in vitro study.

Human amniotic membrane (HAM) is an established biomaterial used in many clinical applications. However, its use for tissue engineering purposes has not been fully realized. A study was therefore conducted to evaluate the feasibility of using HAM as a chondrocyte substrate/carrier. HAMs were obtained from fresh human placenta and were process to produced air dried HAM (AdHAM) and freeze dried HAM (FdHAM). Rabbit chondrocytes were isolated and expanded in vitro and seeded onto these preparations. Cell proliferation, GAG expression and GAG/cell expression were measured at days 3, 6, 9, 12, 15, 21, and 28. These were compared to chondrocytes seeded onto plastic surfaces. Histological analysis and scanning electron microscopy was performed to observe cell attachment. There was significantly higher cell proliferation rates observed between AdHAM (13-51%, P=0.001) or FdHAM (18-48%, p = 0.001) to chondrocytes in monolayer. Similarly, GAG and GAG/cell expressed in AdHAM (33-82%, p = 0.001; 22-60%, p = 0.001) or FdHAM (41-81%, p = 0.001: 28-60%, p = 0.001) were significantly higher than monolayer cultures. However, no significant differences were observed in the proliferation rates (p = 0.576), GAG expression (p = 0.476) and GAG/cell expression (p = 0.135) between AdHAM and FdHAM. The histology and scanning electron microscopy assessments demonstrates good chondrocyte attachments on both HAMs. In conclusion, both AdHAM and FdHAM provide superior chondrocyte proliferation, GAG expression, and attachment than monolayer cultures making it a potential substrate/carrier for cell based cartilage therapy and transplantation.

Cost of medical education, financial assistance and medical school demographics in Singapore.

INTRODUCTION: Medical tuition fees have been rising in many countries, including in Singapore. No formal study has been conducted to evaluate the financial situation of medical students in relation to the cost of medical education in Singapore. This study was conducted to determine the financial profile of Singaporean medical students and the financial expenses they incur over the five-year duration of their undergraduate medical course. METHODS: A questionnaire study was conducted among Year one to Year five medical students in the Yong Loo Lin School of Medicine, National University of Singapore. The following quantifiable parameters were analysed: monthly household income, financial assistance, monthly allowances and expenses. RESULTS: 64.3 percent (735) of the 1,143 undergraduates completed the survey. 21.9 percent came from families with a monthly income of less than S$3,000, with another 26.2 percent from families with monthly incomes of S$3,000-S$5,000. The total tuition fees for a five-year medical course amounted to S$87,450. The average annual expenditure of medical students amounted to S$4,470. 31.1 percent of respondents were on loans. 14.6 percent received scholarships or bursaries. CONCLUSION: A five-year medical course can cost more than S$100,000 and pose a significant financial burden for students. The proportion of students who came from lower-income families was lower in medical school than at the national level, while the proportion from high-income families was significantly higher than at the national level. A significant proportion of students took loans to pay for tuition, and a smaller percentage was under scholarships and bursaries. More substantial financial assistance is required, particularly for students from lower-income families.

Colonies in engineered articular cartilage express superior differentiation.

In view of poor regeneration potential of the articular cartilage, in-vitro engineering of cartilage tissue offers a promising option for progressive joint disease. This study aims to develop a biologically engineered articular cartilage for autologous transplantation. The initial work involved determination of chondrocyte yield and viability, and morphological analysis. Cartilage was harvested from the knee, hip and shoulder joints of adult New Zealand white rabbits and chondrocytes were isolated by enzymatic digestion of the extra-cellular matrix before serial cultivation in DMEM/Ham's F12 media as monolayer cultures. No differences were noted in cell yield. Although chondrocytes viability was optimal (>93%) following harvest from native cartilage, their viability tended to be lowered on passaging. Chondrocytes aggregated in isogenous colonies comprising ovoid cells with intimate intracellular contacts and readily exhibited Safranin-O positive matrix; features typically associated with articular cartilage in-vivo. However, chondrocytes also existed concurrently in scattered bipolar/multipolar forms lacking Safranin-O expression. Therefore, early data demonstrated successful serial culture of adult chondrocytes with differentiated morphology seen in established chondrocyte colonies synthesizing matrix proteoglycans.

Prospective study of liver dysfunction in pregnancy in Southwest Wales.

BACKGROUND: Liver dysfunction in pregnancy has serious consequences. Its frequency and characteristics have not been systematically documented in Britain. We have prospectively determined incidence, causes, and outcome of liver dysfunction in pregnancy in an obstetric unit in Southwest Wales, UK. METHODS: A central laboratory identified all abnormal liver tests (bilirubin >25 micro mol/l, aspartate transaminase >40 U/l, or gamma glutamyl transpeptidase >35 U/l) from patients in antenatal clinics and wards of an obstetric unit serving a population of 250 000. Patients with abnormal liver tests were assessed and followed throughout and after pregnancy [corrected]. Medical advice was provided to obstetric teams. FINDINGS: There were 4377 deliveries during the 15 month study. A total of 142 patients had abnormal liver tests. There were 206 contributing diagnoses, the great majority being pregnancy specific. Among the most important were pre-eclampsia (68), HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome (30), obstetric cholestasis (23), hyperemesis gravidarum (11), acute fatty liver of pregnancy (five), and hepatic infarct (one). Sepsis, postoperative factors, and placental pathology (51) were not uncommonly responsible but incidental or pre-existing hepatobiliary disease was infrequent (17). Sixty five patients were delivered early by induction or caesarean section because of liver dysfunction. Despite substantial liver related morbidity, there were no maternal deaths and only two intrauterine deaths. CONCLUSIONS: Liver dysfunction was seen in 3% of deliveries during a 15 month prospective study and was usually directly related to pregnancy with spontaneous recovery in the puerperium. Incidence of the most serious conditions, acute fatty liver of pregnancy and HELLP syndrome, was much greater than previously reported. Profound effects on maternal and infant health were observed but close medical and obstetric collaboration ensured low mortality.

Upregulated eotaxin expression and T cell infiltration in the basal and papillary epithelium in cows' milk associated reflux oesophagitis.

BACKGROUND: Cows' milk sensitive reflux oesophagitis is an emerging clinical entity in children, normally indistinguishable from primary gastro-oesophageal reflux (GOR) apart from the response to dietary antigen exclusion. It is conjectural whether a tendency towards mucosal eosinophilia distinguishes this group from primary GOR. AIMS: To determine whether there may be differences in the mucosal lesion within the oesophagus in those children with reflux in association with cows' milk induced small bowel pathology, particularly in relation to the eosinophil chemokine eotaxin. METHODS: A total of 29 children underwent endoscopic assessment, including nine with cows' milk sensitive enteropathy (CMSE) and associated GOR, seven histologically normal controls, six with primary GOR, and seven disease controls. Oesophageal biopsy specimens were examined immunohistochemically for the chemokines eotaxin and MCP-2, and T cell lineage and activation markers. RESULTS: Strong upregulation of eotaxin expression, limited to basal and papillary epithelium, occurred in all CMSE patients. By contrast, weak expression was seen in a minority of controls and in 50% of primary GOR patients. Infiltration of CD3, CD4, and CD8 lymphocytes occurred in similar distribution in CMSE patients, significantly increased above controls. Significant upregulation of activation markers (CD25, HLA-DR) was also seen in the CMSE group within basal and papillary epithelium compared to controls and primary GOR. CONCLUSION: Basal and papillary epithelial eotaxin expression, with focal lymphocyte activation, was seen in infants with CMSE associated GOR. This preliminary study provides early evidence to suggest a pathogenesis distinct from primary GOR, in which specific recruitment of T cells and eosinophils may contribute to oesophageal dysmotility.

Enteric-release glyceryl trinitrate in active Crohn's disease: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Mucosal ischaemia may contribute to the pathogenesis of Crohn's disease. Microvascular abnormalities have been found in colonic resection specimens, and mucosal levels of constitutive nitric oxide synthase are reduced. AIM: To assess the efficacy of a novel, enteric-release formulation of the nitric oxide donor, glyceryl trinitrate, aimed at increasing the mucosal circulation and relaxing smooth muscle in the affected bowel. METHODS: The trial was randomized, double-blind and placebo-controlled. Baseline disease activity was assessed by a structured symptom diary, with blood tests and a quality of life assessment. Patients with a Crohn's disease activity index of > or = 150 and < 450 were randomized to receive 12 weeks of either glyceryl trinitrate (initially 6 mg twice daily, increasing to 9 mg twice daily after 6 weeks) or an identical placebo. Assessments were repeated at 6 and 12 weeks. RESULTS: Seventy patients (22 male) entered the study; 34 were given glyceryl trinitrate and 36 placebo. At 12 weeks, there were no differences between the treatment groups in terms of Crohn's disease activity index, pain, stool frequency, inflammatory markers or quality of life scores. CONCLUSIONS: Enteric-release glyceryl trinitrate did not benefit patients with mild to moderately active Crohn's disease. Whilst ischaemia may contribute to the pathogenesis of Crohn's disease, our results fail to provide supportive evidence for this hypothesis.

Scoring systems and risk assessment for upper gastrointestinal bleeding.

Mortality associated with acute upper gastrointestinal bleeding remains high despite advances in diagnosis and therapy. This was emphasized by the findings of the seminal English National Audit of acute gastrointestinal haemorrhage undertaken by Rockall and associates in the mid-1990s. The apparent lack of progress is largely due to less selective reporting in an ageing population with greater co-morbidity. Thus some deaths will be unavoidable even with exemplary treatment. Managing high risk patients in a dedicated area with close cooperation between medical and surgical gastroenterologists has been shown to improve outcome. The challenge is to select those patients who have most to gain from such a scarce and expensive resource so that their treatment can be optimized. Various risk factors have been identified to help achieve this end. Rockall's national audit data suggest that avoidable deaths remain a problem in most district general hospitals. A simple numerical score was derived from these audit data (Rockall score) to predict rebleeding and mortality. The score is based on five variables: age, shock, co-morbidity, endoscopic diagnosis and stigmata of recent haemorrhage. It has the advantage that pre-endoscopic assessment can be made by inexperienced medical or nursing staff. The system was validated internally in a second audit by Rockall and co-workers, and subsequent external validation has come from New Zealand and the Netherlands. The score is less reliable at predicting rebleeding than death and so is, as yet, an imperfect instrument. The scoring system has also proven valuable in selecting low risk patients for early discharge (resulting in health care economies) and for comparing outcome data from different hospitals or populations. Endoscopic treatment has recently been shown to reduce rebleeding rates and perhaps mortality. These advances in therapy are becoming more widely adopted and may influence the predictive ability of the Rockall score. The study from Edinburgh, in this issue, although small and with wide confidence intervals, supports the ability of the Rockall score to identify high risk cases amongst those given endoscopic treatment. It also suggests that an adjustment of the score may be required in these circumstances to prevent overcalling the risk of rebleeding and death.

The Moberg pickup test: results of testing with a standard protocol.

The purpose of this study was to propose a standard protocol for administering the Moberg pickup test. One hundred subjects (53 male and 47 female subjects, aged 11 to 77 years) volunteered. A wide variety of occupations were represented. No subjects had a history of upper extremity dysfunction. The materials and the testing procedures were clearly described to the subjects. Both hand dominance and gender difference were found to have significant effects on test performance. Norms were established for dominant/nondominant hands and for male/female subjects. Standard scores were calculated and used for comparison. The inter-rater reliability of the test was also determined. Administered with a standard protocol, the Moberg pickup test is a valuable test of functional sensibility. It is simple and quick to administer, easy to replicate, and inexpensive to acquire.

Determination of pharmaceuticals and related impurities by capillary electrophoresis.

In the first part of this work, the use of capillary electrophoresis (CE) for the separation of two groups of pharmaceuticals, namely a metabolite of tamoxifen and a basic drug substance, DS1 was investigated. The effects of pH and types of modifiers, e.g. surfactant, bile salt, gamma-cyclodextrin and hydroxypropyl-beta-cyclodextrin on selectivity, separation and peak shape were studied. Besides achieving complete separation of the compounds, the CE system was capable of providing separation with significant improvements in overall peak shape of the compounds compared with HPLC. In the case of the basic drug substance DS1, validation of the CE system developed in terms of linearity, selectivity, sensitivity and reproducibility was satisfactorily performed. At the same time, a study of the sample solvent matrix effects on the separation of this group of compounds was examined. The system was successfully applied to the analysis of laboratory-synthesized samples. Good correlation was observed between CE and HPLC, although higher efficiency and faster speed of separation were obtained using the CE system developed. For the tamoxifen metabolite, special emphasis was placed on the use of CE for the separation of the pair of isomers. This was readily achieved through the introduction of gamma-cyclodextrin in the electrolyte. Resolution of at least 1.5 was obtained for the isomers using the CE method.

The use of mixed surfactants in micellar electrokinetic chromatography.

The use of mixed surfactants for the separation of nine phenylthiohydantoin amino acids (PTH amino acids) by micellar electrokinetic chromatography (MEKC) was examined. The potential of a mixed surfactant system, consisting of cationic and anionic surfactants, for enhancing the selectivity of MEKC separations was explored. Both sodium dodecyl sulfate (SDS) and cetyltrime-thylammonium bromide (CTAB) in the electrophoretic medium were found to improve the separation of the PTH-amino acids compared to the use of CTAB or SDS alone. Complete separation of the PTH amino acids was achieved using a buffer containing 2.5 mM CTAB and 40 mM SDS. The analysis was performed without the need to reverse the polarity of the electrodes, typically required if oppositely charged micelles are used. The migration behavior of the nine PTH amino acids using the mixed surfactant system was compared with MEKC in presence of SDS alone.

A biometric study of ocular changes during accommodation.

We performed a biometric study that used A-mode ultrasonography on 106 subjects during ocular accommodation. The subjects were divided into two groups; group 1 included 76 subjects and group 2 included 30 subjects. In group 1, we measured the anterior chamber depth, lens thickness, and axial length in the right eye while the left eye, wearing corrective spectacles, focused at distances of 6 m, 33 cm, and 33 cm with an additional correction of +3.0 diopters to offset any accommodative effect. In group 2, we measured the anterior chamber depth, lens thickness, and axial length in the right eye while the left eye focused at distances of 6 m, 33 cm, and 12.5 cm. Similar to the left eyes in group 1, the left eyes in group 2 wore corrective spectacles during all procedures. During accommodation, decreased anterior chamber depth and thickening of the lens were noted in all cases. In group 1, axial length significantly increased an average of 0.06 +/- 0.01 mm (P < .0005) while the left eye focused at a distance of 33 cm. There were no significant changes with the additional +3.0 diopters (P < .05). In group 2, axial length significantly increased an average of 0.05 +/- 0.01 mm (P < .0005) when the left eye focused at a distance of 33 cm, and there was further significant elongation of 0.05 +/- 0.01 mm when the left eye focused at a distance of 12.5 cm. Collectively, these results suggest that axial length increases along with changes in the lens and anterior chamber depth during ocular accommodation.