Endoscopic variceal ligation as primary prophylaxis for oesophageal variceal bleeding at a Malaysian tertiary hospital.

OBJECTIVE: Approximately one-third of patients with esophageal varices will develop bleeding which is a major cause of morbidity and mortality in patients with liver cirrhosis. Currently, the two most widely used modalities to prevent variceal bleeding are pharmacologic and oendoscopic variceal band ligation (EVL). However, EVL has been associated with significant complications. Hence we aim to evaluate and to identify the epidemiology, demography, and complications of EVL at our local Malaysian tertiary hospital. METHOD: This is a retrospective study of all the patients that had undergone endoscopic variceal surveillance at the Gastroenterology endoscopy unit, Serdang Hospital from 1st January 2015 to 31st March 2017. Patients' demography, aetiologies of liver cirrhosis, platelet level and international normalised ratio (INR) prior banding procedure, and the post EVL complications were recorded and further analysed with SPSS version 16. RESULTS: In this study, 105 patients were screened for varices. Fifty-five of them had undergone EVL, with a quarter of the patients requiring repeated ligation. There was a male preponderance with 76.4%. 56.4% of patients were in age from 40-59 years. The majority of our patients were of the Malay ethnicity. The major aetiology for liver cirrhosis in our patients was viral hepatitis with Hepatitis C (31.0%), and Hepatitis B (20.0%). Most of our patients had platelet count >50,000 and INR <1.5 prior to EVL. There was no major complication in all of our subjects. CONCLUSION: EVL is relatively safe and feasible treatment for prevention of oesophageal variceal bleeds with a low complication rate.

Assessing the clinical value of targeted massively parallel sequencing in a longitudinal, prospective population-based study of cancer patients.

INTRODUCTION: Recent discoveries in cancer research have revealed a plethora of clinically actionable mutations that provide therapeutic, prognostic and predictive benefit to patients. The feasibility of screening mutations as part of the routine clinical care of patients remains relatively unexplored as the demonstration of massively parallel sequencing (MPS) of tumours in the general population is required to assess its value towards the health-care system. METHODS: Cancer 2015 study is a large-scale, prospective, multisite cohort of newly diagnosed cancer patients from Victoria, Australia with 1094 patients recruited. MPS was performed using the Illumina TruSeq Amplicon Cancer Panel. RESULTS: Overall, 854 patients were successfully sequenced for 48 common cancer genes. Accurate determination of clinically relevant mutations was possible including in less characterised cancer types; however, technical limitations including formalin-induced sequencing artefacts were uncovered. Applying strict filtering criteria, clinically relevant mutations were identified in 63% of patients, with 26% of patients displaying a mutation with therapeutic implications. A subset of patients was validated for canonical mutations using the Agena Bioscience MassARRAY system with 100% concordance. Whereas the prevalence of mutations was consistent with other institutionally based series for some tumour streams (breast carcinoma and colorectal adenocarcinoma), others were different (lung adenocarcinoma and head and neck squamous cell carcinoma), which has significant implications for health economic modelling of particular targeted agents. Actionable mutations in tumours not usually thought to harbour such genetic changes were also identified. CONCLUSIONS: Reliable delivery of a diagnostic assay able to screen for a range of actionable mutations in this cohort was achieved, opening unexpected avenues for investigation and treatment of cancer patients.

Autosomal dominant polycystic kidney disease caused by somatic and germline mosaicism.

Autosomal dominant polycystic kidney disease (ADPKD) is a heterogeneous genetic disorder caused by loss of function mutations of PKD1 or PKD2 genes. Although PKD1 is highly polymorphic and the new mutation rate is relatively high, the role of mosaicism is incompletely defined. Herein, we describe the molecular analysis of ADPKD in a 19-year-old female proband and her father. The proband had a PKD1 truncation mutation c.10745dupC (p.Val3584ArgfsX43), which was absent in paternal peripheral blood lymphocytes (PBL). However, very low quantities of this mutation were detected in the father's sperm DNA, but not in DNA from his buccal cells or urine sediment. Next generation sequencing (NGS) analysis determined the level of this mutation in the father's PBL, buccal cells and sperm to be ∼3%, 4.5% and 10%, respectively, consistent with somatic and germline mosaicism. The PKD1 mutation in ∼10% of her father's sperm indicates that it probably occurred early in embryogenesis. In ADPKD cases where a de novo mutation is suspected because of negative PKD gene testing of PBL, additional evaluation with more sensitive methods (e.g. NGS) of the proband PBL and paternal sperm can enhance detection of mosaicism and facilitate genetic counseling.

The primary prevention of pancreatic fistula using a vascularised rectus abdominis muscle flap - A porcine model.

Background: A pancreatic fistula is one of the most devastating complications following a Whipple's procedure. Fistula rates remain high despite various modifications to surgical techniques. We propose the use of a vascularised muscle flap in the primary prevention of pancreatic fistulas. Method: A distal pancreatectomy was performed on 5 pigs in our porcine model. A pancreaticojejunal (PJ) anastomotic leak was simulated. The pigs were divided into treatment (4 pigs) and control groups (1 pig). A left pedicled rectus abdominis flap was wrapped around the PJ anastomosis for the treatment group and omitted for the control group. Serum and drain amylase levels were recorded. The PJ-rectus abdominis flap complex was evaluated histologically. Results: There was no biochemical evidence of anastomotic leak in the treatment group. The drain-serum amylase ratio was less than 1.5 in the treatment group (p=0.006). Microscopically, the muscle adjacent to the anastomotic leak showed mild necrotic changes with an affected muscle depth of less than 10%. Conclusion: The vascularised rectus abdominis muscle is a durable flap to withstand proteolytic pancreatic enzymes. It is able to provide a water-tight seal around the PJ anastomosis and mitigate intraperitoneal haemorrhage and infection caused by erosion from the pancreatic fistula.

Unbalanced synaptic inhibition can create intensity-tuned auditory cortex neurons.

Intensity-tuned auditory cortex neurons have spike rates that are nonmonotonic functions of sound intensity: their spike rate initially increases and peaks as sound intensity is increased, then decreases as sound intensity is further increased. They are either "unbalanced," receiving disproportionally large synaptic inhibition at high sound intensities; or "balanced," receiving intensity-tuned synaptic excitation and identically tuned synaptic inhibition which neither creates enhances nor creates intensity-tuning. It has remained unknown if the synaptic inhibition received by unbalanced neurons enhances intensity-tuning already present in the synaptic excitation, or if it creates intensity-tuning that is not present in the synaptic excitation. Here we show, using in vivo whole cell recordings in pentobarbital-anesthetized rats, that in some unbalanced intensity-tuned auditory cortex neurons synaptic inhibition enhances the intensity-tuning; while in others it actually creates the intensity-tuning. The lack of balance between synaptic excitation and inhibition was not always apparent in their peak amplitudes, but could sometimes be revealed only by considering their relative timing. Since synaptic inhibition is essentially cortical in origin, the unbalanced neurons in which inhibition creates intensity-tuning provide examples of auditory feature-selectivity arising de novo at the auditory cortex.

Sulphate conjugation of minoxidil in rat skin.

Minoxidil sulphotransferase (MST) activity was determined in the cytosolic fraction of rat skin and liver. MST of rat skin is similar to the P (phenol)-form of phenosulphotransferase (PST) of human tissues with respect to thermostability and inhibition by 2,6-dichloro-4-nitrophenol (DCNP). p-Nitrophenol, a prototype substrate of human P-PST form, inhibits MST at micromolar concentration while millimolar concentrations of dopamine and tyramine, substrates of human M-(monoamine)-PST, are required to elicit a similar degree of inhibition. The enzymatic transfer of 35S from sodium 35sulphate to minoxidil was also demonstrated suggesting that the rat skin is potentially capable of synthesizing 3'-phosphoadenosine-5'-phosphosulphate (PAPS) from inorganic sulphate and utilizing it for the biosynthesis of minoxidil sulphate, its active metabolite. Thus, it is conceivable that the pharmacological action of minoxidil as a promoter of hair growth could be carried out by the cutaneous tissues without the contribution of hepatic or other extrahepatic organs.

Hepatitis B antigen in the liver cells in cirrhosis and hepatocellular carcinoma.

The demonstration of hepatitis B antigen in the liver cells in formalin fixed paraffin embedded tissues by Shikata's orcein staining method affords an opportunity to conduct retrospective studies on necrospy materials. Such a study in Singapore showed orcein-positive liver cells in 22 out of 52 (42.3%) and 37 out of 50 (74.0%) cases of cirrhosis of the liver and hepatocellular carcinoma respectively, while only 5 out of 113 (4.4%) 'normal' livers gave positive results. There is a significant difference in the frequency of hepatocellular carcinoma in orcein-positive and orcein-negative cirrhotic livers (28 out of 50, 10 out of 40 respectively). These results suggest a possible aetiological relationship between hepatitis B antigen and hepatocellular carcinoma.

Major blinding complications of intraocular implantation.

Modern implant surgery for cataract by trained ophthalmologists gives excellent results in the vast majority of patients. All eye surgeons have a grave responsibility to ensure that blinding complications are avoided. The major blinding postoperative complications include endophthalmitis, problems with lens implants, corneal decompensation, uveitis and glaucoma, retinal complications and inadequate microsurgical training. The most disastrous of these is postoperative endophthalmitis which is preventable and can result in total blindness.

A spontaneous state of weakly correlated synaptic excitation and inhibition in visual cortex.

Cortical spontaneous activity reflects an animal's behavioral state and affects neural responses to sensory stimuli. The correlation between excitatory and inhibitory synaptic input to single neurons is a key parameter in models of cortical circuitry. Recent measurements demonstrated highly correlated synaptic excitation and inhibition during spontaneous "up-and-down" states, during which excitation accounted for approximately 80% of inhibitory variance (Shu et al., 2003; Haider et al., 2006). Here we report in vivo whole-cell estimates of the correlation between excitation and inhibition in the rat visual cortex under pentobarbital anesthesia, during which up-and-down states are absent. Excitation and inhibition are weakly correlated, relative to the up-and-down state: excitation accounts for less than 40% of inhibitory variance. Although these correlations are lower than when the circuit cycles between up-and-down states, both behaviors may arise from the same circuitry. Our observations provide evidence that different correlational patterns of excitation and inhibition underlie different cortical states.

The impact of clinical protocols in the management of severe sepsis: a prospective cohort study.

This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU). The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes. Hospital mortality was 39% for 128 patients. Fewer than half of the ICUs had protocols for early goal-directed therapy, blood cultures, antibiotics, steroids, lung-protective ventilation and weaning. Compliance rates with the resuscitation and management bundles were 18 and 3% respectively. Units with protocols were generally not more likely to achieve associated bundle targets. Steps from the Johns Hopkins model to measure performance, engage teams and sustain and extend interventions were taken in fewer than half of the available protocols. However, on logistic regression analysis, the number of protocols available per ICU was independently and inversely associated with mortality. In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.

Balanced tone-evoked synaptic excitation and inhibition in mouse auditory cortex.

The recent characterization of excitatory and inhibitory synaptic receptive fields in rat auditory cortex laid the basis for further investigation of the roles of synaptic excitation and inhibition in cortical computation and plasticity. The mouse is an increasingly important model system because of the wide range of genetic tools available for it. Here we present the first in vivo whole-cell voltage-clamp measurements of synaptic excitation and inhibition in the mouse cortex. We find that a substantial population of auditory cortical neurons receives balanced synaptic excitation and inhibition, whose amplitude ratios and relative time courses remain approximately constant across tone frequency. We conclude that the synaptic mechanisms underlying tone-evoked auditory cortical responses in mice closely resemble those in rats, supporting the mouse as a suitable model for synaptic processing in auditory cortex.

Comparison between use of neuromuscular blocking agent and placebo with the intubating laryngeal mask airway.

INTRODUCTION: The intubating laryngeal mask airway (ILMA) is a specially-designed airway device that can be used for endotracheal intubation without direct laryngoscopy. The advantage of this device is that it allows blind endotracheal intubation with a predictably high success rate. The use of neuromuscular blocking agents in facilitating the use of the ILMA has been investigated in the Western population with a quoted successful intubation rate of 88-96 percent. This randomised, double-blind study aimed to see if the use of neuromuscular blocking agent is necessary for successful intubations. METHODS: A total of 150 patients, rated categories 1 and 2 on the American Society of Anesthesiology Physical Status Classification System, were induced with propofol 2.5 mg/kg and fentanyl 2 microg/kg. After insertion of the ILMA, the patients received either saline or 0.6 mg/kg of rocuronium. After 90 seconds, tracheal intubation was attempted using the specially-designed silicon endotracheal tube. In addition to the success rate of intubation, the incidence of complications was also recorded. RESULTS: The success rate for tracheal intubation within three attempts was 93.3 percent for the saline group and 92.0 percent for the rocuronium group; this was statistically insignificant. The time to securing the airway was 11.5 seconds for the saline group, compared to 10.0 seconds in the rocuronium group, but this was statistically insignificant. The incidence of coughing during insertion of the endotracheal tube was 42.7 percent in the saline group as compared to 1.3 percent in the rocuronium group (p-value is less than 0.001). 12 percent of the patients in the saline group moved during intubation, while none was reported to move in the rocuronium group (p-value is 0.003). These results compared favourably with rates quoted in studies conducted on Western populations. CONCLUSION: The intubating laryngeal mask airway-assisted intubation yields a high success rate, which was similar between the paralysed and non-paralysed patients, with no statistical significance. However, the non-paralysed patients were prone to coughing and movements during intubation, requiring supplemental propofol.

Parents' perceptions towards their child's use of inhaled medications for asthma therapy.

OBJECTIVE: Understanding patients' and their parents' perceptions towards asthma medication is important in developing strategies to ensure patient compliance. In this study, parents' perceptions towards their children's use of inhaled medication for asthma treatment were evaluated. METHODOLOGY: A questionnaire was administered by interviewing parents of 210 asthmatic children attending the Department of Paediatrics, National University Hospital. RESULTS: Our results showed that 76/210 (36%) of parents either felt opposed to inhaler therapy and/or preferred oral medications. The main reasons for their reluctance to use inhalers were related to fear of dependence, side effects and overdosage, and the child's dislike for inhalers. A third of these parents felt that inhalers were only indicated for very severe asthma. CONCLUSIONS: We conclude that a significant proportion of parents have reservations regarding the use of inhalers for the treatment of asthma. These factors should be taken into consideration when planning an effective asthma education programme.

Risk factors for breakthrough varicella in healthy children.

AIM: To evaluate the risk factors for breakthrough varicella in a follow up study of a cohort of 181 healthy children immunised when aged 9-24 months with a reformulated Oka strain varicella vaccine (SmithKline Beecham Biologicals/Oka). DESIGN: The children were randomised in a double blind manner into one of four groups to receive one of two production lot vaccine batches, at two different titres (high titre, 10(3.9) and 10(4.0) plaque forming units (pfu); low titre (heat exposed), 10(2.7) and 10(2.8) pfu). The overall seroconversion rate after immunisation was 99%. RESULTS: One hundred and sixty-eight patients were available for review after a mean (SD) follow up of 35 (9) months after vaccination. Multivariate analysis indicated that risk factors for breakthrough varicella were household contact with varicella (adjusted odds ratio (OR), 19.89; 95% confidence interval (CI), 18.39 to 21.39), vaccination age of < or = 14 months (adjusted OR, 2.30; 95% CI, 1.69 to 2.90), and receiving low titre (10(2.7) pfu) vaccine (adjusted OR, 2.13; 95% CI, 1.54 to 2.73). All children who developed breakthrough varicella, had a modified varicella illness, except for three, all of whom had received low titre vaccine. CONCLUSION: The identification of young immunisation age (< or = 14 months) and low titre vaccine as risk factors for breakthrough varicella have important implications for the implementation of varicella vaccination programmes in healthy children.