Infantile esotropia in Malaysian children: The impact of surgery on health-related quality of life assessment in patients and their parents.

INTRODUCTION: Limited information is available on healthrelated quality of life (HRQoL) in children with strabismus in South East Asia. We aimed to evaluate the HRQoL and associated factors pre- and post-strabismus surgery in Malaysian children with infantile esotropia and their parents/guardians. METHODS: A prospective study was conducted on children with infantile esotropia aged 8-17 years old and their parents/guardians who attended two tertiary hospitals with a paediatric ophthalmology service from 2017 to 2018. The patients and parents answered the Intermittent Exotropia Questionnaire (IXTQ), translated into Malay, at the time of enrolment and three months after the surgery. RESULTS: Thirty-four children and one (each) of their parents/guardians were enrolled. Thirteen (38.2%) children had esotropia with angles of deviation of more than 50 prism dioptres. A total of 33 (97.1%) children achieved successful alignment correction three months after surgery. Surgery significantly improved the total mean scores of the children, which were 62.87 (17.05) preoperatively and 87.13 (13.26) postoperatively (p<0.001). There was statistically improvement in the total mean scores in the parent/guardian group, which was 37.07 (22.01) preoperatively and 75.39 (22.09) postoperatively (p<0.001). The parents/guardians functional, psychosocial and surgery subscales also had a significant increment in the score postoperatively (p<0.001). Older children and children with poorer visual acuity on presentation had a lower score preoperatively, while girls scored better postoperatively (p<0.05). Mothers scored significantly lower preoperatively and postoperatively (p<0.05). CONCLUSION: Surgery significantly improved the HRQoL score in Malaysian children with infantile esotropia and their parents/guardians. The score was significantly higher in female children after the surgery. Mothers exhibited poor scores before and after surgery.

Study on ABO and RhD blood grouping: Comparison between conventional tile method and a new solid phase method (InTec Blood Grouping Test Kit).

INTRODUCTION: 'InTec Blood Grouping Test kit' using solid-phase technology is a new method which may be used at outdoor blood donation site or at bed side as an alternative to the conventional tile method in view of its stability at room temperature and fulfilled the criteria as point of care test. This study aimed to compare the efficiency of this solid phase method (InTec Blood Grouping Test Kit) with the conventional tile method in determining the ABO and RhD blood group of healthy donors. METHODS: A total of 760 voluntary donors who attended the Blood Bank, Penang Hospital or offsite blood donation campaigns from April to May 2014 were recruited. The ABO and RhD blood groups were determined by the conventional tile method and the solid phase method, in which the tube method was used as the gold standard. RESULTS: For ABO blood grouping, the tile method has shown 100% concordance results with the gold standard tube method, whereas the solid-phase method only showed concordance result for 754/760 samples (99.2%). Therefore, for ABO grouping, tile method has 100% sensitivity and specificity while the solid phase method has slightly lower sensitivity of 97.7% but both with good specificity of 100%. For RhD grouping, both the tile and solid phase methods have grouped one RhD positive specimen as negative each, thus giving the sensitivity and specificity of 99.9% and 100% for both methods respectively. CONCLUSION: The 'InTec Blood Grouping Test Kit' is suitable for offsite usage because of its simplicity and user friendliness. However, further improvement in adding the internal quality control may increase the test sensitivity and validity of the test results.

A rare case of methicillin resistant Staphylococcus aureus (MRSA) cerebral abscess secondary to conjunctivitis.

This case report discusses the rare association of cerebral abscess related to conjunctivitis in an otherwise healthy child. A 6 year old boy presented with conjunctivitis was treated with topical antibiotics and resolved after a week. Conjunctival swab cultures grew MRSA. A month later he developed status epileptics and CT scans revealed a large cerebral abscess. He was treated with intravenous antibiotics which covered for MRSA, along with an incision and drainage for the cerebral abscess. Pus cultures grew MRSA. The patient recovered well with no disturbance in visual acuity or visual field. On post-operative follow ups, he had no other neurological deficit apart from a slight limp.

Knowledge and attitudes of dentists toward shortened dental arch therapy in Saudi Arabia.

OBJECTIVE: The aim of this study was to assess and compare the knowledge and attitudes of dentists toward shortened dental arch (SDA) therapy in Saudi Arabia. MATERIALS AND METHODS: In this cross-sectional study, self-designed-structured questionnaires were distributed among specialists (SP), residents (RES), and general dental practitioners (GDP) in Saudi Arabia. The questionnaire enquired about dentists' opinion regarding function, esthetic, and comfort in patients with SDA. It also enquired about the risks associated with SDA treatment (tooth wear, temporomandibular dysfunction (TMD), and tooth migration). Participants also graded SDA decision-making factors for their significance. Frequency distribution and Chi-square test were performed to compare the responses. RESULTS: A total of 300 questionnaires were completed. 53.9% of SP applied SDA therapy in <10% of patients. However, 54.8% of RES and 46.6% of GDP never used SDA therapy. SDA was considered by dentists to provide a satisfactory or acceptable function (76.4%), esthetics (76.1%), and comfort (76.8%). There was a significant difference in opinions of SP, GDP, and RES, in relation to the effect of SDA on esthetics (P = 0.039), tooth-wear (P < 0.001), TMD (P < 0.001), and tooth migration (P = 0.002). CONCLUSION: The knowledge of SP and GDP with regards to SDA therapy was broadly in line with current standards. Less than 10% of patients had objections towards SDA therapy. SDA therapy was clinically applied in fewer than 10% of cases.

Meta-analysis of vagus nerve stimulation treatment for epilepsy: correlation between device setting parameters and acute response.

BACKGROUND: Vagus nerve stimulation (VNS) is an adjunctive neurophysiological treatment for those patients who have pharmacoresistant or surgically resistant partial onset epilepsy. OBJECTIVE: The aim of this study is to determine the effects of high and low stimulation paradigms on a responder rate of ≥50 and ≥75% reduction in seizure frequency and associated adverse effects in adults and children. METHOD: A literature search was performed using Medline, PubMed, EMBASE, and Cochrane library for studies using vagus nerve stimulation published from January 1980 until July 2014 for medically or surgically resistant partial onset seizures, in children and adults. No restrictions on languages were imposed. DATA COLLECTION AND ANALYSIS: Four authors reviewed and selected studies for inclusion and exclusion. The search identified five randomized control trials that fit with our inclusion criteria. The following outcomes were evaluated: 50% or greater reduction in total seizure frequency, 75% or greater reduction in total seizure frequency, and adverse effects. RESULTS: Four randomized controlled trials were analyzed in this meta-analysis. Results indicate high stimulation is more effective in adult patients who experienced ≥50 and ≥75% reduction in seizure frequency with a significant difference within both high and low stimulation groups. In children, there was no significant difference between the two groups and patients with ≥50 % reduction in seizures. Adverse effects such as hoarseness and dyspnea were more common in the high stimulation group where the remaining side effects were not statistically different among both groups. CONCLUSION: High stimulation is more effective than low stimulation in producing a greater reduction in seizure frequency in patients with medically and surgically resistant epilepsy.

Investigation of a PAX6 gene mutation in a Malaysian family with congenital aniridia.

Mutations in the PAX6 gene that cause aniridia have been identified in various ethnicities but not in the Malaysian population. Therefore, the objective of this study was to investigate the PAX6 mutation in a Malaysian family with congenital aniridia. In this study, a complete ophthalmic examination was performed on a Dusun ethnic family with aniridia. Genomic DNA was extracted from the peripheral blood of the subjects and screened for the PAX6 gene mutation using polymerase chain reaction amplification high-resolution melting curve analysis (PCR-HRM) followed by confirmation via direct DNA sequencing. A heterozygous G deletion (c.857delG) in exon 7 causing a frame shift in PAX6 was identified in all affected family members. Genotype-phenotype correlation analysis revealed congenital cataract and all affected family members showed a similar spectrum of aniridia with no phenotypic variability but with differences in severity that were age-dependent. In summary, by using a PCR-HRM approach, this study is the first to report a PAX6 mutation in a Malaysian family. This mutation is the cause of the aniridia spectra observed in this family and of congenital cataract.

Field evaluation of the efficacy of copper nanoparticles against mites associated with orange trees.

Phytophagous mites are dangerous pests, causing economic losses to the world's crops. Nanotechnology is a promising field for pests and disease management, and enhancement of agricultural productivity. The aim of the study was to evaluation of the effectiveness of copper nanoparticles (CuNP) against all stages of eriophyid mite, the citrus rust mite, Phyllocoptruta oleivora (Ashmead) (Acari: Eriophyidae) and tetranychid mite, the citrus brown mite Eutetranychus orientalis (Klein) (Acari: Tetranychidae), and Tenuipalpid mite, the false spider mite, Brevipalpus obovatus Donnadieu (Acari: Tenuipalpidae). This includes its impacts on predacious mites, Amblyseius swirskii Athias-Henriot and Euseius scutalis (Athias-Henriot) (Acari: Phytoseiidae), on orange trees under field conditions. Five different concentrations of copper nanoparticles (40, 80, 160, 240, and 320 ppm), as well as the control (well water) were examined. The obtained results indicated that the mortality rate of both phytophagous and predacious mites was associated with an increase in the concentrations of copper nanoparticles. Copper nanoparticles were significantly effective in killing P. oleivora, E. orientalis and B. obovatus with minimal effects on A. swirskii and E. scutalis. The mortality percentage was 15.24, 20.32, 46.32, 78.97 and 86.37% for P. oleivora, 6.87, 9.86, 28.91, 56.30 and 77.52% for E. orientalis and 8.38, 23.50, 48.83, 68.80 and 84.08% for B. obovatus while the mortality percentage was 0.00, 0.56, 5.83, 9.91 and 15.19% for A. swirskii and 0.44, 3.96, 6.93, 8.63 and 21.39% for E. scutalis one week after exposure to 40, 80, 160, 240 and 320 ppm of copper nanoparticles, respectively. Moreover, the results showed that copper nanoparticles caused a reduction in the percentage of eggs hatching. The percentages of larvae hatching from eggs were 96.29, 80.00, 64.13, 45.66 and 32.17% for P. oleivora, 97.38, 83.28, 69.41, 48.01 and 35.29 for E. orientalis and 96.60, 76.92, 56.38, 40.55 and 33.28% for B. obovatus one week after exposure to copper nanoparticles at 40, 80, 160, 240 and 320 ppm respectively, compared with the control (well water). According to the results, the use of copper nanoparticles significant effect on reducing the population of phytophagous mites associated with orange trees, with low detrimental effects on predatory mites.

The miticidal activity of silver nanoparticles towards date palm mite (Oligonychus afrasiaticus (McGregor)): efficacy, selectivity, and risk assessment.

Promising bioactivities of silver nanoparticles SNP urged researchers of different specialties to evaluate their field-respective activities. Bioactivity towards agricultural pests were the subject of limited publications. In the current study, SNP were synthesized and miticidal activity was evaluated towards old world date mite Oligonychus afrasiaticus (McGregor) (Acari: Tetranychidae) and an associated predatory mite Neoseiulus barkeri Hughes (Phytoseiidae). Under laboratory conditions, SNP displayed significantly higher activity towards O. afrasiaticus (LC50 was 39.7 µg/mL) than N. barkeri (LC50 was 1587.9 µg/mL) which accounts for about 40 folds of selectivity against the pest. SNP exhibited ovicidal activity against laid eggs of O. afrasiaticus (LC50 was 67.8 µg/mL). In field, SNP (at 216 µg/mL) achieved slightly higher efficiency than in laboratory study, 86.5% of population reduction of O. afrasiaticus was achieved and only 18.5% of N. barkeri population was affected. SNP suppressed hatching of 57.1% of laid eggs of O. afrasiaticus. Residues of silver were determined using ICP-OES spectrometry. Initial residues reached 1.83 µg/mL after application then declined with time passing. Estimated daily intake (EDI) reached 1.28 µg/kg/day, calculated for the highest residues obtained and the highest consumption rate of date in the world. Hazard index (Hi) was 0.17 in average. The obtained level of residues appeared to be safe in terms of acute and chronic toxicity references.

The Incidence of Fracture-Related Infection in Open Tibia Fracture with Different Time Interval of Initial Debridement.

Introduction: The primary aim of open fracture management is to prevent fracture-related infection by early antibiotic administration, debridement and wound coverage. However, the timing of the initial debridement is still controversial, and 6 to 24 hours is commonly advocated. Studies have yet to provide substantial evidence regarding the best time for surgical debridement. Thus, this study was conducted to compare the incidence of fracture-related infection at different time intervals of initial debridement of the open tibia fracture. Materials and methods: A total of 91 patients with grade I, II and IIIa open tibia fractures were recruited from 2016 to 2018, and their data were obtained from the consensus book and medical records. Participants were divided into four groups based on the time of initial debridement: (1) less than 6 hours, (2) 6 to less than 12 hours, (3) 12 to less than 24 hours, and (4) 24 hours and more. Fracture-related infection was determined by using Metsemakers confirmative criteria. Association between time and infection were determine by Binary Logistic Regression analysis by remerged the group into three; (1) less than 12 hours, (2) 12 to less than 24 hours and (3) 24 hours and more. The collected information was analysed using SPSS version 24 and Microsoft Excel 2010. Results: The mean age of the participants was 31.9 years old, with male predominant (n=80, 87.0%). Most participants had delayed initial debridement of more than 24 hours and predominantly Gustilo-Anderson type IIIa (n=47). A total of 8 fractures complicated with infection (8.7%), majority in grade IIIa and debridement performed within 12 to less than 24 hours. Binary logistic regression showed increased odds of infection with a delayed wound debridement both in clinical presentation and positive culture, but the association was not statistically significant. The commonest organism isolated was Pseudomonas aeruginosa. Conclusion: Comparing to different time interval, initial wound debridement of more than 24 hours did not have strong association with increasing infection rate. However, even though statistically not significant, the odds of infection was increase with increasing time of initial wound debridement of an open tibia fracture, thus it should be performed early.

Study of Deep Vein Thrombosis Screening by using Ultrasound Doppler in Patients with Pelvic and Acetabulum Fractures Requiring Operative Intervention.

Introduction: Pelvic and acetabulum fractures are commonly caused by high impact injuries, increasing the risk of patients developing thromboembolic diseases such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Therefore, this study was performed to determine the incidence of lower extremity DVT in patients with pelvic and acetabulum fractures and the importance of preoperative screening with Doppler ultrasound prior to surgical intervention. Materials and methods: This retrospective study involved 78 patients with pelvic and acetabulum fractures requiring surgical intervention from January 2015 until December 2019. Patients who underwent surgical interventions were screened pre-operatively with Doppler ultrasound to detect lower limb DVT and later compared with the incidence of lower limb DVT post-operatively. Descriptive statistical analysis was performed using IBM SPSS Statistics Version 24. Results: The participants of this study consisted of 30.8% females and 69.2% males. Pre-operative screening with Doppler ultrasound showed that three patients (3.8%) were diagnosed with lower limb DVT, whereas one of them (1.3%) was symptomatic and diagnosed with PE. Postoperatively, one patient developed DVT, and one patient developed PE. Both patients were negative for DVT preoperatively. Conclusion: The incidence of DVT in patients with pelvic and acetabulum fractures requiring operative intervention was significant despite the initiation of mechanical and pharmacological thromboprophylaxis upon admission. Despite the low incidence of DVT in our study, it has a high impact on patients' morbidity and mortality; thus, preoperative screening is important for early detection and the subsequent reduction of the risk of developing PE. The compulsory use of Doppler ultrasound of bilateral lower limbs as a part of pre-operative screening is highly recommended because it is cost-effective, efficient and readily available in most tertiary hospitals nationwide.

The prevalence and characteristics associated with mother-infant bed-sharing in Klang district, Malaysia.

This was a cross-sectional study to determine the prevalence and characteristics of mother-infant bed-sharing practice in Klang district, Malaysia. Data was collected by face-to-face interview using a structured questionnaire for a four month period in 2006. A total of 682 mother-infant pairs attending government health clinics were included in the study. Data regarding socio-demographic characteristics of the mothers, information on the infants, bed-sharing and breastfeeding practices were collected. The mean maternal age was 28.4 +/- 5.1 years while the mean infant gestational age was 38.8 +/- 1.8 weeks. The study showed the prevalence of bed-sharing was 73.5% (95% CI: 70.0, 76.7). In multivariate analysis; area of interview, maternal occupation, family income, breastfeeding and infant birth weight were associated with bed-sharing after adjusted for maternal ethnicity, age, marital status, educational level, parity, infant gender and infant gestational age. In conclusion, bed-sharing is a common practice in Klang district, Malaysia, not specific to ethnicity, but strongly associated with low family income and breastfeeding.

The cardiac proteome in patients with congenital ventricular septal defect: A comparative study between right atria and right ventricles.

Right ventricle (RV) remodelling occurs in neonatal patients born with ventricular septal defect (VSD). The presence of a defect between the two ventricles allows for shunting of blood from the left to right side. The resulting RV hypertrophy leads to molecular remodelling which has thus far been largely investigated using right atrial (RA) tissue. In this study we used proteomic and phosphoproteomic analysis in order to determine any difference between the proteomes for RA and RV. Samples were therefore taken from the RA and RV of five infants (0.34 ±â€¯0.05 years, mean ±â€¯SEM) with VSD who were undergoing cardiac surgery to repair the defect. Significant differences in protein expression between RV and RA were seen. 150 protein accession numbers were identified which were significantly lower in the atria, whereas none were significantly higher in the atria compared to the ventricle. 19 phosphorylation sites (representing 19 phosphoproteins) were also lower in RA. This work has identified differences in the proteome between RA and RV which reflect differences in contractile activity and metabolism. As such, caution should be used when drawing conclusions based on analysis of the RA and extrapolating to the hypertrophied RV. SIGNIFICANCE: RV hypertrophy occurs in neonatal patients born with VSD. Very little is known about how the atria responds to RV hypertrophy, especially at the protein level. Access to tissue from age-matched groups of patients is very rare, and we are in the unique position of being able to get tissue from both the atria and ventricle during reparative surgery of these infants. Our findings will be beneficial to future research into heart chamber malformations in congenital heart defects.

Comparison of findings on stress myocardial perfusion imaging in men with versus without erectile dysfunction and without prior heart disease.

Erectile dysfunction (ED) has been associated with a future risk of myocardial infarction, yet the findings on stress testing in men with ED and without previous coronary artery disease are unknown. Stress myocardial perfusion single-photon emission computed tomographic imaging (MPI) allows detection of coronary artery disease and predicts cardiovascular prognosis. Our goal was to determine the association between ED and findings at stress MPI testing in men without previous coronary artery disease. Five hundred seventy-five men without previous coronary artery disease referred for stress MPI were prospectively screened for ED with the validated International Index of Erectile Function. ED was present in 46% of subjects, and ED was associated with more mild (summed stress score >or=4) and severe (summed stress score >8) coronary artery disease and with more composite high-risk stress MPI findings (summed stress score >8, left ventricular ejection fraction <40%, transient ischemic dilation). In patients referred for exercise, ED was associated with a lower Duke treadmill score. On multivariate analysis, ED was found to be an independent predictor of a summed stress score >or=4, a summed stress score >8, and composite high-risk MPI findings. In conclusion, in men without known coronary artery disease referred for stress MPI testing, ED is associated with adverse prognostic indicators at MPI testing including coronary artery disease and high-risk MPI findings.

Corrosion and surface modification on biocompatible metals: A review.

Corrosion prevention in biomaterials has become crucial particularly to overcome inflammation and allergic reactions caused by the biomaterials' implants towards the human body. When these metal implants contacted with fluidic environments such as bloodstream and tissue of the body, most of them became mutually highly antagonistic and subsequently promotes corrosion. Biocompatible implants are typically made up of metallic, ceramic, composite and polymers. The present paper specifically focuses on biocompatible metals which favorably used as implants such as 316L stainless steel, cobalt-chromium-molybdenum, pure titanium and titanium-based alloys. This article also takes a close look at the effect of corrosion towards the implant and human body and the mechanism to improve it. Due to this corrosion delinquent, several surface modification techniques have been used to improve the corrosion behavior of biocompatible metals such as deposition of the coating, development of passivation oxide layer and ion beam surface modification. Apart from that, surface texturing methods such as plasma spraying, chemical etching, blasting, electropolishing, and laser treatment which used to improve corrosion behavior are also discussed in detail. Introduction of surface modifications to biocompatible metals is considered as a "best solution" so far to enhanced corrosion resistance performance; besides achieving superior biocompatibility and promoting osseointegration of biocompatible metals and alloys.

A review of biocompatible metal injection moulding process parameters for biomedical applications.

Biocompatible metals have been revolutionizing the biomedical field, predominantly in human implant applications, where these metals widely used as a substitute to or as function restoration of degenerated tissues or organs. Powder metallurgy techniques, in specific the metal injection moulding (MIM) process, have been employed for the fabrication of controlled porous structures used for dental and orthopaedic surgical implants. The porous metal implant allows bony tissue ingrowth on the implant surface, thereby enhancing fixation and recovery. This paper elaborates a systematic classification of various biocompatible metals from the aspect of MIM process as used in medical industries. In this study, three biocompatible metals are reviewed-stainless steels, cobalt alloys, and titanium alloys. The applications of MIM technology in biomedicine focusing primarily on the MIM process setting parameters discussed thoroughly. This paper should be of value to investigators who are interested in state of the art of metal powder metallurgy, particularly the MIM technology for biocompatible metal implant design and development.

Psychosocial outcomes derived from an acid burned population in Bangladesh, and comparison with Western norms.

Assault by acid burns typically results in severe disfigurement, yet the psychosocial impact of this injury is so far unreported. This study provides the first empirical data using standardised assessment scales, from 44 acid burns survivors in Bangladesh. Compared with published norms, individuals show high levels of psychological distress including social anxiety and avoidance, anxiety and depression. Consistent with the published literature, there is no relationship between severity of injury and level of psychological distress. One interesting feature of this population is the relative preservation of perceived self-concept, and this is discussed with relation to the supportive and therapeutic environment of the clinic where this group were studied. We also note an interesting sub-group who were attacked by members of their own family and for whom psychological morbidity seems particularly pronounced.

A review of hydroxyapatite-based coating techniques: Sol-gel and electrochemical depositions on biocompatible metals.

New promising techniques for depositing biocompatible hydroxyapatite-based coatings on biocompatible metal substrates for biomedical applications have continuously been exploited for more than two decades. Currently, various experimental deposition processes have been employed. In this review, the two most frequently used deposition processes will be discussed: a sol-gel dip coating and an electrochemical deposition. This study deliberates the surface morphologies and chemical composition, mechanical performance and biological responses of sol-gel dip coating as well as the electrochemical deposition for two different sample conditions, with and without coating. The review shows that sol-gel dip coatings and electrochemical deposition were able to obtain the uniform and homogeneous coating thickness and high adherent biocompatible coatings even in complex shapes. It has been accepted that both coating techniques improve bone strength and initial osseointegration rate. The main advantages and limitations of those techniques of hydroxyapatite-based coatings are presented. Furthermore, the most significant challenges and critical issues are also highlighted.

Adsorption behaviour of Fe(II) and Fe(III) ions in aqueous solution on chitosan and cross-linked chitosan beads.

A batch adsorption system was applied to study the adsorption of Fe(II) and Fe(III) ions from aqueous solution by chitosan and cross-linked chitosan beads. The adsorption capacities and rates of Fe(II) and Fe(III) ions onto chitosan and cross-linked chitosan beads were evaluated. Chitosan beads were cross-linked with glutaraldehyde (GLA), epichlorohydrin (ECH) and ethylene glycol diglycidyl ether (EGDE) in order to enhance the chemical resistance and mechanical strength of chitosan beads. Experiments were carried out as function of pH, agitation period, agitation rate and concentration of Fe(II) and Fe(III) ions. Langmuir and Freundlich adsorption models were applied to describe the isotherms and isotherm constants. Equilibrium data agreed very well with the Langmuir model. The kinetic experimental data correlated well with the second-order kinetic model, indicating that the chemical sorption was the rate-limiting step. Results also showed that chitosan and cross-linked chitosan beads were favourable adsorbers.

Management studies in medical education.

In 1977, the World Health Assembly (WHA) set the social target--the "Health For All" goal and in 1995, urged member states to "re-orientate medical education and medical practice for "Health For All" (resolution WHA 48.8). This led to World Health Organisation to enunciate the "5-star doctor" needing skills in healthcare management, quality assurance and health economics. The Faculty of Medicine, University of Malaya introduced the New Integrated Curriculum (NIC) in 1995. The objective was aimed at producing a competent doctor with a holistic approach to the practice of medicine. This was to be achieved by having 3 strands of studies i.e. The Scientific Basis of Medicine (SBM), the Doctor, Patient, Health and Society (DPHS), and Personal and Professional Development (PPD) over the 5-year programme, split into 3 phases. Elements of the "5-star doctor" were introduced in strand 2--DPHS and strand 3--PPD. Management studies were introduced in the Personal and Professional Development (PPD) strand. This led to an instructional module--"Principles of Management in Health Care Services (PMGT)" comprising of the Management of Self, Resources and People and incorporating a three week field programme. Evaluation is undertaken at the end of the phase IIIA of the studies. This NIC approach will be able to produce a "5-star doctor", a team player, leader, communicator and an effective manager.

A phase II study of ifosfamide/mesna with doxorubicin for adult soft tissue sarcoma.

In a phase II study, 16 adult patients with locally advanced or metastatic soft tissue sarcomas were treated with i.v. infusions of ifosfamide/mesna 5 g/m2 plus i.v. doxorubicin 40 mg/m2. Courses were given every 3 weeks up to a maximum of six courses in responding patients. Six patients (37.5%) had either complete (1 patient) or partial responses (5 patients). Confidence limits for this response rate were 15.2%-64.5% (95% confidence level). There was one toxic death in association with encephalopathy, renal and bone marrow failure. Unilateral pneumothoraces occurred in 2 patients with large pulmonary metastases. Recurrent severe ifosfamide/mesna encephalopathy occurred in 2 patients at risk for this complication; patients who develop severe ifosfamide/mesna encephalopathy should not be retreated with this drug. Ifosfamide/mesna with doxorubicin is an active combination to treat adult soft tissue sarcoma but, despite the feasibility of the combination, sequential monotherapy with these drugs might provide similar or better clinical benefit.