Predicting Cognitive Decline for Non-Demented Adults with High Burden of Tau Pathology, Independent of Amyloid Status.

BACKGROUND: Abnormal tau proteins are independent contributors to cognitive impairment. Nevertheless, not all individuals exposed to high-level tau pathology will develop cognitive dysfunction. We aimed to construct a model to predict cognitive trajectory for this high-risk population. METHOD: Longitudinal data of 181 non-demented adults (mean age= 73.1; female= 45%), who were determined to have high cerebral burden of abnormal tau by cerebrospinal fluid (CSF) measurements of phosphorylated tau (ptau181) or total tau, were derived from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. Cognitive decline was defined as Mini-Mental State Examination scores decline ≥ 3 over three years. A predictive nomogram was constructed using stepwise backward regression method. The discrimination, calibration, and clinical usefulness of the nomogram were evaluated. The model was validated in another 189 non-demented adults via a cross-sectional set (n=149, mean age = 73.9, female = 51%) and a longitudinal set (n= 40, mean age = 75, female = 48%). Finally, the relationships of the calculated risk scores with cognitive decline and risk of Alzheimer's disease were examined during an extended 8-year follow-up. RESULT: Lower volume of hippocampus (odds ratio [OR] = 0.37, p< 0.001), lower levels of CSF sTREM2 (OR = 0.76, p = 0.003), higher scores of Alzheimer's Disease Assessment Scale-Cognitive (OR = 1.15, p = 0.001) and Functional Activities Questionnaire (OR = 1.16, p = 0.016), and number of APOE ε4 (OR = 1.88, p = 0.039) were associated with higher risk of cognitive decline independent of the amyloid status and were included in the final model. The nomogram had an area of under curve (AUC) value of 0.91 for training set, 0.93 for cross-sectional validation set, and 0.91 for longitudinal validation set. Over the 8-year follow-up, the high-risk group exhibited faster cognitive decline (p< 0.001) and a higher risk of developing Alzheimer's dementia (HR= 6.21, 95% CI= 3.61-10.66, p< 0.001 ). CONCLUSION: APOE ε4 status, brain reserve capability, neuroinflammatory marker, and neuropsychological scores can help predict cognitive decline in non-demented adults with high burden of tau pathology, independent of the presence of amyloid pathology.

Anti-Hypertensive Drugs Moderate the Relationship of Blood Pressure with Alzheimer's Pathologies and Neurodegenerative Markers in Non-Demented Hypertensive Older Adults.

BACKGROUND: We aimed to explore whether the relationships of blood pressures (BPs) with Alzheimer's disease (AD) endophenotypes varied by usage of antihypertensive drugs (AHDs). METHODS: A total of 765 non-demented older adults (mean age: 74.4 years; female: 43.1%) with a self-reported history of hypertension were followed for 6 years. Multiple linear regression and linear-mixed effect models were used to investigate the interaction effects of five categories of AHDs (angiotensin-converting enzyme inhibitors [ACEI], angiotensin II receptor blockers [ARBs], ß-blocker, calcium channel blockers [CCB], diuretic) with BPs (systolic blood pressure [SBP], diastolic blood pressure [DBP], and pulse pressure [PP]) on AD core pathology and neurodegenerative markers. RESULTS: After Bonferroni correction, significant interaction effects of BPs with AHDs were observed. Elevated SBP or PP in late-life was associated with higher levels of cerebral Aß burden (diuretic alone/ß-blocker × SBP), higher levels of CSF tau proteins (diuretic × SBP/PP, ARBs/CCB × SBP), and lower volume of entorhinal region (ß-blocker × SBP, diuretic × PP) only among hypertensive patients who received no anti-hypertensive treatments, while these associations became compromised or null for users of specific AHDs except for ACEI. Compared to taking other classes of AHDs, elevated SBP in late-life was associated with lower cerebral Aß burden in diuretic users (padjusted = 0.08) and was associated with higher CSF tau proteins in ACEI alone users (padjusted = 0.03). Longitudinal data validated the above-mentioned interaction effects on changes of cerebral Aß burden (padjusted < 0.05), CSF tau proteins (padjusted < 0.10), and brain atrophy (padjusted < 0.05). CONCLUSIONS: The relationships of late-life BP with AD pathology and neurodegeneration could be modified by anti-hypertensive treatments and varied by AHD classification. These findings provide preliminary evidence for tailored BP management strategy for preventing AD among late-life hypertensive adults.

Relationships of Hypnotics with Incident Dementia and Alzheimer's Disease: A Longitudinal Study and Meta-Analysis.

BACKGROUND: Evidence describing the association between hypnotics use and dementia risk is conflicting. It is unknown if the controversy is related to the type or dose of hypnotics or if hypnotics affect different populations. OBJECTIVES: We sought to derive lessons learned and future projections based on evidence from longitudinal studies. MEASUREMENTS: In the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort, 1,543 older adults without dementia (mean age = 73.3 years, female = 45%) were followed for four years. The association between hypnotics and the risk of Alzheimer's disease (AD) was investigated using Cox proportional hazards regressions. Next, electronic databases were searched until March 2022 to conduct the evidence synthesis of the associations of hypnotics with incident risk of dementia. RESULTS: In the ADNI cohort, ever use of hypnotics was associated with an increased risk of AD (hazard ratio = 1.96, 95% confidence intervals = 1.23-3.11, p < 0.01). This association was significant for benzodiazepines and Z-drugs but not for melatonin. The association was stronger in long-term (more than one year) users and those with high cumulative doses. A meta-analysis of 26 longitudinal studies with 3,942,018 participants revealed a correlation between the use of hypnotics and the risk of dementia (relative risk = 1.23, 95% confidence intervals = 1.13-1.33, p < 0.001, median risk difference = 4%). It is a linear dose-response relationship, if a person takes the daily recommended dose for 100 days, their risk of developing dementia increases by 5% relative to non-users. According to subgroup analyses, neither association was significant among patients with a history of insomnia. CONCLUSIONS: Individuals who use hypnotics, especially high-dose or long-term users, are at a higher risk of dementia and AD. The main issue with conclusion credibility is heterogeneity.

Clinicopathological correlation of oral candidiasis - Our experience in a tertiary centre over two decades.

INTRODUCTION: Oral candidiasis is one of the most common fungal infections that has been widely reported around the world. In Malaysia, the available studies for this infection are scarce. MATERIALS AND METHODS: This is a 20-year retrospective study aimed to investigate the prevalence, demographic characteristics, clinical presentations, and the association of oral candidiasis with clinical parameters in oral candidiasis cases reported in the Faculty of Dentistry, Universiti Malaya from 1999 until 2019. A total of 12,964 histopathological records from the Oral Pathology Diagnostic and Research Laboratory (OPDRL) between 1999 to 2019 were retrieved. Oral candidiasis cases were selected according to the inclusion and exclusion criteria. Information of interest was obtained and analysed. RESULTS: From the total records retrieved, 378 oral candidiasis cases were recorded and 82.8% were diagnosed from smear test. This study showed that oral candidiasis was predominantly reported in female (64.2%) and Indian population (64.2%). The peak incidence was in the sixth decades of life (27.0%). The most commonly affected site was tongue and coated tongue was the most common clinical presentation. More than 50% of the cases had comorbidity and 10.6% were associated with dentures. Ethnicity and site of occurrence were significantly associated (p<0.05) with oral candidiasis. CONCLUSION: This is the first large-scale study of oral candidiasis cases in Malaysia. The findings of this study are useful for clinical assessment of patients suspected of oral candidiasis.

Adult Renal Dysfunction and Risk of Dementia or Cognitive Decline: Brain-Kidney Axis Hypothesis Based on a Systematic Review and Meta-Analysis.

OBJECTIVE: The brain-kidney axis was proposed to emphasize roles of kidney functioning in modulating neurodegeneration. We aimed to evaluate the associations of renal diseases and blood markers with risk of dementia or cognitive decline among non-demented adults. METHODS: The PubMed, EMBASE, and Cochrane library were searched until February 1st, 2022, to include longitudinal studies. Multivariate adjusted effects were pooled by random-effects models. The robust error meta-regression models were used for dose-response analyses. The credibility of meta-analyses was graded and an innovative index (Sdifference) was developed to evaluate the evidence tendency. RESULTS: A total of 41 longitudinal studies (6,480,136 participants, mean age range: 58.5-83.5 years) were included, of which 33 were for meta-analyses. Though with low level of evidence, five indicators of kidney were associated with increased risk of dementia or cognitive decline, including acute kidney injury (hazard ratio [HR] = 2.24, p = 0.0001), chronic kidney disease (HR = 1.29, p = 0.0001), higher serum creatinine (HR = 1.35, p = 0.0001), higher urine albumin creatine ratio (UACR, HR = 1.23, p = 0.0001), and lower estimated glomerular filtration rate (eGFR, HR = 1.18, p = 0.0001). A linear relationship was revealed for eGFR (p = 0.0217) or UACR (p = 0.0006). Heterogeneity is a main concern to jeopardize the evidence robustness, especially for eGFR (Sdifference = 0.05). CONCLUSION: Some renal indicators were associated with a higher risk of dementia, though the evidence base warrants further strengthening. Renal function management might serve as a promising target for dementia prediction and prevention.

Immunoexpression of BRAF, EGFR and CD10 in ameloblastoma.

The ameloblastoma is the most challenging odontogenic neoplasm to treat because of its locallyinvasive behaviour, severe clinical implication, risk of malignant transformation and high recurrence rate. Recent evidence suggests that BRAF, EGFR and CD10 have a role in the local invasiveness of ameloblastoma. However, the spatial distribution characteristics of these pro-invasive factors and their association with clinical parameters in this neoplasm are largely unexplored. We sought to address these issues in ameloblastoma subtypes and to determine their biological relevance. Nineteen unicystic (UA) and 20 conventional ameloblastoma (SMA) were subjected to immunohistochemical staining for BRAF, EGFR and CD10, and semiquantitative analysis was performed. All ameloblastoma cases (n=39/39; 100%) exhibited a BRAF+/EGFR+/CD10+immunoprofile. Their expression rates were significantly higher in SMA than UA (P<0.05). BRAF, essential for the progression and proliferation of ameloblastoma, was detected mainly in the cytoplasm of stellate reticulum-like>stromal>preameloblast- like cells (P<0.05). EGFR, a potent oncogenic protein, showed predominantly nuclear localisation. CD10, an apoptosis-inhibitory factor, was strongly expressed in the membrane of stellate reticulum-like cells. Taken together, present results suggest that the spatial distribution patterns of BRAF, EGFR and CD10 parallel the specific behaviours of SMA and UA. Their cellular and intracellular protein localisations have important targeted therapy implications.

How to safely and sustainably reorganise a large general radiography service facing the COVID-19 pandemic.

Objectives: This paper aims to share our experience in reorganising our general radiography service during the coronavirus disease (COVID-19) pandemic from the viewpoint of a large tertiary referral medical centre. Key findings: Re-organization of the radiography workforce, patient segregation, and modification of routine radiographic practices are key measures to help radiographic services deal with the COVID-19 pandemic. Specific emphasis on deploying more mobile radiographic units, segregating equipment, developing consistent image acquisition workflows, and strict adherence to infection control protocols are paramount to minimize the possibility of in-hospital transmission and ensure a safe environment for both patients and staff. Streamlining communication channels between leadership and ground staff allows quick dissemination of information to ultimately facilitate safe provision of services. Conclusion: COVID-19 has drastically altered the way general radiography teams provide services. The institution of several key measures will allow hospitals to safely and sustainably provide radiographic services. To date, there have been zero incidences of radiographer healthcare worker transmission within our institution during the course of work. Implication for practice: Radiographers are facing the challenge of providing high-quality services while simultaneously minimizing pathogen exposure to staff and patients. Our experience may lend support to other radiographic services responding to the COVID-19 outbreak and serve as a blueprint for future infectious disease outbreak contingency plans.

Coronoid hyperplasia: A review.

Coronoid hyperplasia is one of the rare causes of progressive limitation of mouth opening due to impingement of the enlarged coronoid process of the mandible on the zygomatic bone. A review was performed on all cases reports and case series on coronoid hyperplasia. Gender, age at treatment, age of onset, types of hyperplasia (unilateral/bilateral), associated history, treatment, surgical approach, preoperative mouth opening, intraoperative mouth opening, mouth opening at follow up and follow up period were recorded and analyzed. A total of 82 articles which reported 115 cases were included. Coronoid hyperplasia was commonly reported at mean age of 22.64 years old with male preponderance. Most of the cases were diagnosed and treated between the age of 11-20 years old. This condition commonly involved bilateral coronoid process of mandible. The mean width of preoperative mouth opening was 16.5mm and was improved to a mean mouth opening of 36.3mm intraoperatively. Mean mouth opening was 34.8mm at an average follow up of 19 months. While the etiopathogenesis of coronoid hyperplasia is still not conclusive, treatment with either coronoidectomy or coronoidotomy produced good improvement in mouth opening.

Screening for impaired renal function in outpatients before iodinated contrast injection: Comparing the Choyke questionnaire with a rapid point-of-care-test.

RATIONALE AND PURPOSE: To determine the usefulness of the Choyke questionnaire with a creatinine point-of-care test (POCT) to detect impaired renal function amongst outpatients receiving intravenous iodinated contrast in a tertiary centre. MATERIALS AND METHODS: Between July and December 2012, 1361 outpatients had their serum creatinine determined by POCT and answered the Chokye questionnaire just before their examination. RESULTS: Four hundred and eighty (35.2%) patients had at least one 'Yes' response. Forty-four patients (3.2%) had estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2) and 14 patients (1.0%) have eGFR <45 mL/min/1.73 m(2). Sensitivity, specificity, positive predictive value and negative predictive value of the Choyke criteria in detecting patients with eGFR <60 mL/min/1.73 m(2) are respectively: 65.9%, 65.8%, 6.0% and 98.3% and to detect eGFR <45 mL/min/1.73 m(2): 92.9%, 65.3%, 2.7% and 99.9%. Only 'Yes' responses to 'Have you ever been told you have renal problems?' and 'Do you have diabetes mellitus?' were statistically significant in predicting eGFR <45 mL/min/1.73 m(2), with odds ratio 98.7 and 4.4 respectively. CONCLUSION: The Choyke questionnaire has excellent sensitivity and moderate-to-good specificity in detecting patients with <45 mL/min/1.73 m(2), below this level it has been shown that risk of contrast induced nephropathy increases significantly, making it an effective screening tool. Also the use of POCT can potentially reduce waiting time.

Bilateral emphysematous pyelitis: a rare encounter in urology.

Gas-forming infection of the kidneys can affect either the parenchyma or the collecting system. They are known as emphysematous pyelonephritis (EPN) and emphysematous pyelitis (EP) respectively. Bilateral EPN is a fairly established entity and numerous articles about this condition have been published. However, much less is known about bilateral EP. We report a rare case of bilateral EP and a literature review of this disease. A 66-year-old woman with long-standing bilateral staghorn calculi presented with bilateral EP and severe sepsis. She was treated with antibiotics and bilateral double-J stents to drain the upper urinary tracts. She recovered after 1 month of intensive care and medical therapy. Percutaneous nephrolithotomy (PCNL) had been scheduled to treat her staghorn calculi. A literature search on MEDLINE and Google Scholar with the terms "bilateral emphysematous pyelitis" only found 1 case report in English and another 2 reports in the Korean language that discussed bilateral EP. The collective experience of these few cases, including the present case, suggests that bilateral EP runs a more benign course than bilateral EPN. It should be diagnosed as soon as possible with computed tomography (CT) scans of the renal system. Current evidence shows that can be treated successfully with timely antibiotics. Drainage of the collecting system either percutaneously or with placement of double-J stents might facilitate recovery.

Surface passivation and interface properties of bulk GaAs and epitaxial-GaAs/Ge using atomic layer deposited TiAlO alloy dielectric.

High quality surface passivation on bulk-GaAs substrates and epitaxial-GaAs/Ge (epi-GaAs) layers were achieved by using atomic layer deposited (ALD) titanium aluminum oxide (TiAlO) alloy dielectric. The TiAlO alloy dielectric suppresses the formation of defective native oxide on GaAs layers. X-ray photoelectron spectroscopy (XPS) analysis shows interfacial arsenic oxide (As(x)O(y)) and elemental arsenic (As) were completely removed from the GaAs surface. Energy dispersive X-ray diffraction (EDX) analysis and secondary ion mass spectroscopy (SIMS) analysis showed that TiAlO dielectric is an effective barrier layer for reducing the out-diffusion of elemental atoms, enhancing the electrical properties of bulk-GaAs based metal-oxide-semiconductor (MOS) devices. Moreover, ALD TiAlO alloy dielectric on epi-GaAs with AlGaAs buffer layer realized smooth interface between epi-GaAs layers and TiAlO dielectric, yielding a high quality surface passivation on epi-GaAs layers, much sought-after for high-speed transistor applications on a silicon platform. Presence of a thin AlGaAs buffer layer between epi-GaAs and Ge substrates improved interface quality and gate dielectric quality through the reduction of interfacial layer formation (Ga(x)O(y)) and suppression of elemental out-diffusion (Ga and As). The AlGaAs buffer layer and TiAlO dielectric play a key role to suppress the roughening, interfacial layer formation, and impurity diffusion into the dielectric, which in turn largely enhances the electrical property of the epi-GaAs MOS devices.

The changing pattern of primary glomerulonephritis in Singapore and other countries over the past 3 decades.

This review of 2,586 renal biopsies over the past 3 decades in Singapore documents the changing pattern of glomerulonephritis (GN) from that of a third world country to that of a developed nation. In the 1st decade, mesangial proliferative glomerulonephritis was the most common form of primary GN, just as it was in the surrounding Asian countries. In the 2nd decade, the prevalence of mesangial proliferative GN decreased with a rise in membranous, GN which is also seen in China and Thailand. In the 3rd decade, there was a dramatic increase in focal sclerosing glomerulosclerosis. This increase reflects aging and obesity in keeping with more developed countries like Australia, India, Thailand and the United States of America. IgA nephritis remains the most common GN. Apart from the geographical influence, other socioeconomic factors play a significant role in the evolution of the renal biopsy pattern. Mesangial proliferative GN remains prevalent in many Asian countries, but in Singapore the prevalence is decreasing just as it is in Japan, Korea and Malaysia. Worldwide, the prevalence of focal sclerosing glomerulosclerosis continues to increase in many countries.

Beneficial effects of high-dose losartan in IgA nephritis.

AIM: Several short-term studies have reported the efficacy of high-dose ARB in reducing proteinuria in patients with diabetic nephropathy. The benefits of long-term high-dose ARB losartan in IgA nephritis have not been explored. METHOD: This was a 6-year randomized trial in 207 patients with IgA nephritis comparing high-dose ARB (losartan 200 mg/day) with normal dose ARB (losartan 100 mg/day), normal dose ACEI (20 mg/day) and low-dose ACEI (10 mg/day). Multivariate ANOVA was used to test the effect of drug treatment on both eGFR and total urinary protein (TUP). RESULTS: Comparing patients on high-dose ARB (n = 63) with those on normal dose ARB (n = 43), normal dose ACEI (n = 61) and low-dose ACEI (n = 40), patients on high Dose ARB had significantly higher eGFR (p < 0.0005) and lower proteinuria (p < 0.005) at the end of the study. The loss in eGFR was 0.7 ml/min/year for high-dose ARB compared to 3.2 - 3.5 ml/ min/year for the other 3 groups (p = 0.0005). There were more patients on high-dose ARB with improvement in eGFR compared to other 3 groups (p < 0.001). CONCLUSION: Data from this study suggest that high-dose ARB therapy is more efficacious in reducing proteinuria and preserving renal function when compared with normal dose ARB and ACEI. In Year 5, patients on high-dose ARB had a gain in eGFR suggesting that there is possibility of recovery of renal function in these patients on long-term high-dose therapy.

The current practice of sedation and analgesia in intensive care units in Malaysian public hospitals.

We sought to review the current practice of sedation and analgesia in intensive care units (ICUs) in Malaysian public hospitals. A questionnaire survey was designed and sent by mail to 40 public hospitals with ICU facility in Malaysia. The anaesthesiologists in charge of ICU were asked to complete the questionnaire. Thirty seven questionnaires were returned (92.5% response rate). Only 35% respondents routinely assess the degree of sedation. The Ramsay scale was used prevalently. A written protocol for sedation was available in only 14 centers (38%). Although 36 centers (95%) routinely adjust the degree of sedation according to patient's clinical progress, only 10 centers (14%) interrupt sedation on a daily basis. Most respondents agreed that the selection of agents for sedation depends on familiarity (97%), pharmacology (97%), the expected duration for sedation (92%), patient's clinical diagnosis (89%) and cost (73%). Midazolam (89%) and morphine (86%) were the most commonly used agents for sedation and analgesia, respectively. Only 14% respondents still frequently use neuromuscular blocking agents, mostly in head injury patients. Our survey showed similarity in the choice of sedative and analgesic agents in ICUs in Malaysian public hospitals comparable to international practice. Nevertheless, the standard of practice could still be improved by implementing the practice of sedation score assessment and daily interruption of sedative infusion as well as having a written protocol for sedation and analgesia.

Central venous catheter-related blood stream infections: incidence and an analysis of risk factors.

Six hundred and fifty-five central venous catheters (CVC) in 496 patients in the intensive care unit of Hospital Sultanah Aminah were studied to determine the incidence and risk factors for central venous catheter-related blood stream infection (CR-BSI). CR-BSI was diagnosed in 38 catheters, giving an incidence of 9.43 CR-BSI per 1000 catheter days. The mean duration in situ was 8.4 +/- 4.9 days for infected CVCs and 6.0 +/- 3.8 days for non infected CVCs (p = 0.001). CVCs inserted in ICU had the highest infection rate (9.4%) compared to those inserted in the operating theatre (1.4%) and ward (2.8%) (p = 0.001). The highest rate of CR-BSI occurred with 4-lumen catheters (usually inserted when patients needed total parenteral nutrition) with a percentage of 15.8%. The majority of the CVCs (97.9%) were inserted via the subclavian or the internal jugular routes and there was no statistical difference in CR-BSI between them (p = 0.83). Number of attempts more than one had a higher rate of CR-BSI compared to single attempt with percentage of 7.0% vs 4.8% (p = 0.22). The top two organisms were Klebseilla pneumoniae and Pseudomonas aeruginosa. In conclusion, the incidence of CR-BSI in our ICU was 9.43 CR-BSI per 1000 catheter days. The risk factors were duration of CVC in situ, venue of insertion and use of 4 lumen catheter for total parenteral nutrition. The site of insertion, number of lumen up to 3 lumens and the number of attempts were not risk factors.

Epidemiology of pterygium on a tropical island in the Riau Archipelago.

OBJECTIVES: To describe the epidemiology of pterygium among residents of an island in Indonesia and to examine the roles of age and gender as determinants of bilaterality and severity of the disease. METHODS: Voluntary eye screening on Pulau Jaloh, Riau Archipelago, Indonesia. Gender difference was tested using the chi2 test. The difference in age between subjects with and without disease was tested using unpaired Student's t-test. Odds ratio (relative risk) for gender was calculated using logistic regression model with adjustment for age. RESULTS: Of the 550 inhabitants, 477 (86.7%) responded to the eye screening. The overall prevalence rate of pterygium was 17.0%. Out of 211, 48 male (22.7%) and 33 out of 266 female subjects (12.4%) had the disorder, with the gender difference being statistically significant. Adjusted for age, the risk of disease was 3.1-fold higher among the males. In all, 71.6% of subjects with pterygium had bilateral disease. Subjects with pterygium were significantly older, their mean age being 42.9 years compared to 18.7 years among those without disease. The prevalence rates in male subjects increased from age 20 to reach a plateau of 63.6% at age 35 and remained stable thereafter. In the female subjects, the rates also increased with age, albeit at a slower rate, from age 20 to reach a plateau of 46.7% at age 55 and remained stable thereafter. CONCLUSIONS: There is a high prevalence rate of pterygium among the study subjects, with the rates increasing rapidly with age.

Hypertension, antihypertensive agents and outcomes following renal transplantation.

UNLABELLED: Hypertension is common following renal transplantation and adversely affects graft and patient survival. However, strategies for antihypertensive drug therapy and target blood pressure have not been clearly defined. AIM: To assess the influence of achieved blood pressure and antihypertension drug therapy on graft and patient survival with the aim of identifying targets and event rates for future intervention studies. METHODS: We undertook a longitudinal follow up study of 634 renal transplant patients. Patients were surveyed in December 1994 and followed up after 102 months. Blood pressure (BP) was determined from the mean of three clinic readings and antihypertensive drug therapy recorded. RESULTS: Complete follow up data were available for analysis on 622 patients (57.2% male; mean age: 45.2 +/- 13.0 yr. There were 158 (25.4%) deaths and 115 (18.5%) death-censored graft failures. Lower systolic and diastolic blood pressure were associated with better graft survival in the Kaplan-Meier analysis. Univariate analysis showed serum creatinine (HR 1.012, p < 0.001), duration of renal replacement therapy (HR 0.946, p = 0.012), age (HR 0.979, p = 0.014) and pulse pressure (HR 1.017, p = 0.044) to be predictors of graft survival with serum creatinine and duration of renal replacement therapy as the only significant factors in the multivariate analysis. Lower systolic and pulse pressure were associated with better patient survival in the Kaplan-Meier analysis. Age (HR) 1.062, p < 0.0001), serum creatinine (HR 1.002, p = 0.021), diabetes (HR 3.371, p < 0.0001), and pulse pressure (HR 1.013, p = 0.036) were significant predictors of patient survival in the univariate and multivariate analysis. Patient survival was reduced with increasing number of antihypertensives (p < 0.05), as was graft survival (p < 0.05). Reduced patient and graft survival were seen in patients prescribed calcium channel antagonists (p < 0.01). There was no increased patient mortality in those patients on beta-blockers or angiotensin converting enzyme (ACE) inhibitors. CONCLUSION: Hypertension is a risk factor, which remains despite the use of anti-hypertensives, for reduced patient and graft survival. The risk was not significant when blood pressure was entered together with serum creatinine in the multivariate analysis. Beta-blockers may have a beneficial effect on cardiovascular mortality, and ACE inhibitors a beneficial effect on both patient and graft survival. There is a pressing need for interventional studies to assess the impact of blood pressure targets on patient and graft survival and the effect of individual agents on these outcomes.

Mandatory temperature monitoring in schools during SARS.

During the SARS outbreak, temperature monitoring was mandatory for all Singapore schoolchildren. None of the Singapore children with SARS were detected through school temperature screening. However, temperature monitoring procedures have a powerful psychological effect of reassuring parents and the public that schools are safe during a SARS outbreak.

Percutaneous dilational tracheostomy--a 3 year experience in a general hospital in Malaysia.

All percutaneous tracheostomies performed in the general intensive care unit (ICU), Hospital Sultanah Aminah, Johor Bahru, Malaysia, from July 1999 to June 2002 were studied. The tracheostomies were performed as an elective bedside technique in the ICU. A total of 352 percutaneous tracheostomies were performed. Eighty-eight percent of the tracheostomies were completed within 15 minutes. The most common complication was bleeding which occurred in 52 patients (14.7%). The rest of the complications encountered were:- transient hypoxia twelve (3.4%), inability/ difficulty to insert tracheostomy tube eight (2.3%), false passage four (1.1%), transient hypotension two (0.6%), pneumothorax two (0.6%), peristomal infection two (0.6%), subcutaneous emphysema one (0.3%), cuff rupture one (0.3%), oesophageal cannulation one (0.3%), and granuloma formation one (0.3%). Conversion to conventional tracheostomies were performed on 7 patients (2%). There was one unfortunate death related to percutaneous tracheostomy. In conclusion, percutaneous dilational tracheostomy can be used safely to manage the airway of critically ill patients.