Early vs. standard reversal ileostomy: a systematic review and meta-analysis.

BACKGROUND: Formation of a defunctioning loop ileostomy is common after mid and low rectal resection. Historically, they were reversed between 3 and 6 months after initial resection. Recently, earlier closure (< 14 days) has been suggested by some current randomised controlled trials. The aim of this study was to investigate the effect of early stoma closure on surgical and patient outcomes. METHODS: A systematic review of the current randomised controlled trial literature comparing early and standard ileostomy closure after rectal surgery was performed. Specifically, we examined surgical outcomes including; morbidity, mortality and quality of life. RESULTS: Six studies met the predefined criteria and were included in our analysis. 275 patients underwent early stoma closure compared with 259 patients having standard closure. Overall morbidity was similar between both groups (25.5% vs. 21.6%) (OR, 1.47; 95% CI 0.75-2.87). However, there tended to be more reoperations (8.4 vs. 4.2%) (OR, 2.02, 95% CI 0.99-4.14) and small bowel obstructions/postoperative ileus (9.3% vs. 4.4%) (OR 0.44, 95% CI 0.22-0.90) in the early closure group, but no difference across the other domains. CONCLUSIONS: Early closure appears to be a feasible in highly selective cases after good perioperative counselling and shared decision-making. Further research on quality of life outcomes and long term benefits is necessary to help define which patients are suitable candidates for early closure.

Comparing the 1997 update of the 1982 American College of Rheumatology (ACR-97) and the 2012 Systemic Lupus International Collaborating Clinics (SLICC-12) criteria for systemic lupus erythematosus (SLE) classification: which enables earlier classification of SLE in an urban Asian population?

OBJECTIVE: We compared the 1997 update of the 1982 American College of Rheumatology (ACR-97) and the 2012 Systemic Lupus International Collaborating Clinics (SLICC-12) criteria, for earlier classification of systemic lupus erythematosus (SLE) in a multiethnic urban Asian SLE population. METHODS: Patients from a retrospective, nested case-control study of the influence of lupus nephritis on mortality in SLE were studied. For each patient, dates of first manifestations of each criteria (both ACR-97 and SLICC-12) were recorded, and the date of disease classification using ACR-97 or SLICC-12 criteria was compared to determine which criteria resulted in earlier classification. RESULTS: Among 182 SLE patients (74.2% Chinese, 18.1% Malay, 4.4% Indian and 3.3% Other ethnicities), 10 (5.5%) did not fulfill the ACR-97 criteria and 2 (1.1%) did not fulfill the SLICC-12 criteria. Using the SLICC-12 criteria, 18% of subjects showed earlier classification, whereas 7% of subjects showed earlier classification using the ACR-97 criteria. The SLICC hematologic criteria of "Leukopenia or lymphopenia" contributed most significantly to earlier diagnosis by SLICC-12. "Leukopenia or lymphopenia'' was present in 59% (19/32) of patients where SLICC-12 criteria allowed for earlier classification than ACR-97, compared with 15.4% (2/13) of patients where ACR-97 allowed earlier classification than SLICC-12 ( p = 0.02). The immunologic criterion that is considered a strength of the SLICC-12 criteria did not appear to contribute significantly to earlier diagnosis in this study. CONCLUSION: SLICC-12 criteria allow for earlier classification of SLE in a multiethnic cohort of Asian patients, supporting the validity of the SLICC-12 criteria and its use in clinical care and research.

Adding a PECS II block for proximal arm arteriovenous access - a randomised study.

BACKGROUND: Brachial plexus block is often utilised for proximal arm arteriovenous access creation. However, the medial upper arm and axilla are often inadequately anaesthetised, requiring repeated, intraoperative local anaesthetic supplementation, or conversion into general anaesthesia. We hypothesised that the addition of a PECS II block would improve anaesthesia and analgesia for proximal arm arteriovenous access surgery. METHODS: In this prospective, double-blinded, randomised proof-of-concept study, 36 consenting adults with end-stage renal disease aged between 21 and 90 years received either a combined supraclavicular and PECS II block (Group PECS, n = 18), or combined supraclavicular and sham block (Group SCB, n = 18) for proximal arm arteriovenous access surgery. Primary outcome was whether patients required intraoperative local anaesthetic supplementation by the surgeon. RESULTS: In Group PECS, 33.3% (6/18) needed local anaesthetic supplementation vs. 100% (18/18) in Group SCB. Group SCB had three times (RR 3.0, 95% CI 1.6-5.8; P < 0.001) the risk of requiring intraoperative local anaesthetic supplementation. Group PECS required lower volume of supplemental local anaesthetic compared to Group SCB (0.0 ml, IQR 0.0-6.3 ml vs. 15.0 ml, IQR 7.4-17.8 ml; P < 0.001). Group SCB had twice [RR 2.2, 95% CI 1.1-4.4; (P = 0.019)] the risk of needing additional sedation or analgesia. There were no significant differences between the groups with respect to postoperative visual analogue scale pain scores, time to first rescue analgesia or patient satisfaction. CONCLUSION: The results suggest that adding a PECS II block to a supraclavicular block improves regional anaesthesia for patients with end-stage renal disease undergoing proximal arm arteriovenous access surgery.

Development of SNP markers and their application for genetic diversity analysis in the oil palm (Elaeis guineensis).

The genetic evaluation of oil palm germplasm collections is required for insight into the variability among populations. The information obtained is also useful for incorporating new genetic materials into current breeding programs. Single nucleotide polymorphisms (SNPs) have been widely used in many plant genetic studies due to the availability of large numbers of genomic sequences and expressed sequence tags. The present study examined 219 oil palms collected from two natural Angolan populations, a few hundred kilometers apart. A total of 62 SNPs were designed from oil palm genomic sequences and converted to cleaved amplified polymorphic sequence (CAPS). Of these, nine were found to be informative across the two populations. The nine informative SNPs revealed mean major allele frequency of 0.693. The average expected and observed heterozygosities were 0.398 and 0.400, respectively. The mean polymorphism information content was 0.315 (ranging between 0.223 and 0.375). None of the loci deviated from Hardy-Weinberg equilibrium and no rare alleles were detected. In cluster analysis using unweighted pair group method with arithmetic, the 219 oil palms fell into two clusters. This was further supported by the population structure analysis result (K = 2), suggesting that the samples were divided into two main genetic groups. However, the two groups did not coincide with the geographic populations. Analysis of molecular variance indicated that within-population variation contributed 93% of the total genetic variation. This study showed that SNP-based CAPS markers are useful for studying the genetic diversity of oil palm and have potential application for marker-trait association studies.

Experience of symptoms indicative of gynaecological cancers in UK women.

BACKGROUND: Gynaecological cancers account for ∼12% of female cancer incidence in the United Kingdom. Encouraging prompt help-seeking for potential symptoms could help improve outcomes. However, before developing help-seeking interventions, it is important to estimate the number of women with symptoms potentially indicative of a gynaecological cancer to help estimate the impact of such interventions on primary care. METHODS: As part of a face-to-face, population-based survey, women aged ≥16 (n=911) were shown a list of symptoms potentially indicative of a gynaecological cancer and were asked to indicate any experienced in the last 3 months. Those who reported symptoms were asked about their responses to one randomly selected index symptom. RESULTS: Just under half (44%) of the respondents reported a symptom, with 35% reporting a frequent and/or severe symptom. Younger (P<0.001), lower socioeconomic status (P<0.01) and non-White women (P<0.05) were significantly more likely to report symptoms. Few (14%) respondents were both older (≥45 years) and had a frequent and/or severe symptom. Of these women, 38% had seen a GP. CONCLUSION: Symptoms that potentially indicate a gynaecological cancer, even if limited to those that are frequent and/or severe, appear to be common. Consequently, encouraging prompt help-seeking may increase the burden on primary care. However, targeting those at increased risk (older women with frequent or severe symptoms) should avoid unmanageable increases in primary care consultations for gynaecological conditions.

Cancer survivors' and employers' perceptions of working following cancer treatment.

BACKGROUND: Earlier diagnosis and improvements in treatment survival rates have led to an increase in the number of cancer survivors for whom returning to work is a realistic outcome. However, cancer survivors face a number of challenges when returning to the workplace. Little is known about how patients' illness and treatment beliefs affect return to work or of employers' beliefs about the impact of cancer on work. AIMS: To determine patient and employers' beliefs about the impact of cancer on returning to work and to identify differences in the beliefs held by patients and employers. METHODS: Patients absent from work due to breast, urological, gynaecological or head and neck cancers completed a questionnaire within 4 weeks of completing treatment. Unlinked employer respondents from medium to large organizations completed the same questionnaire. The questionnaire focused on the perceived impact of cancer and its treatment on work and an adapted version of the Brief Illness Perceptions Questionnaire. RESULTS: One hundred and ninety four patients (response rate of 82%) and 252 employers (response rate 31%) completed the questionnaire. Organizational respondents consistently reported more negative beliefs about the impact of cancer and treatment on work and in general held more negative illness perceptions about cancer in relation to work. CONCLUSIONS: A discrepancy between beliefs of organizational respondents and cancer survivors could impact on an employees' management of their work and on employers' responsiveness to the needs of survivors. Therefore, it is important that return to work plans include the elicitation of employee beliefs.

Sedation with oral chloral hydrate in children undergoing MRI scanning.

In the absence of a general anaesthetic facility for MRI scanning in children, we introduced a sedation protocol using chloral hydrate. Our aim was to evaluate the success and safety of our protocol. This was a retrospective study enrolling 36 children over a 7 month period. The overall success rate was 86% with no child experiencing respiratory complications. In those less than one year, the success rate was 100%, aged 1-5 years 91%, with 50% successful at 80 mg/kg and 50% at 100 mg/kg dose. For children greater than 5 years of age the success rate was 70%. 92% of developmentally normal children and 83% of developmentally delayed children were successfully sedated. Success rates were poorer in children older than 5 years and in those with developmental delay. Our findings suggest that this protocol could be safely used in units where general anaesthetic facilities are unavailable for MRI and for other radiological investigations.

Monitoring cerebral oxygenation of preterm infants using a neonatal specific sensor.

INTRODUCTION: Cerebral oxygenation (rcSO2) monitoring in preterm infants may identify periods of cerebral hypoxia or hyperoxia. We hypothesised that there was a relationship between rcSO2 values and short term outcome in infants of GA < 32weeks. METHODS: RcSO2 values were recorded for the first 48 h of life using an INVOS monitor with a neonatal sensor. The association between cranial ultrasound scan measured brain injury and rcSO2 was assessed. RESULTS: 120 infants were included. Sixty-nine percent (83) of infants had a normal outcome (no IVH, no PVL, and survival at 1 month); less than one-quarter, 22% (26), had low grade IVH 1 or 2 (moderate outcome); and 9% (11) of infants had a severe outcome (IVH ≥ 3, PVL or died before 1 month age). rcSO2 values were lower for infants GA < 28weeks when compared with those GA 28-32, p < 0.001. There was no difference in absolute rcSO2 values between the three outcome groups but a greater degree of cerebral hypoxia was associated with preterm infants who had low grade 1 or 2 IVH. CONCLUSION: Infants of GA < 28 weeks have lower cerebral oxygenation in the first 2 days of life. A greater degree of hypoxia was seen in infants with grade 1 or 2 haemorrhage. Normative ranges need to be gestation specific.

Listeriosis associated with upper gastrointestinal endoscopy in an HIV-infected patient.

An HIV-infected man developed listeriosis six days after an upper gastrointestinal (GI) endoscopy. Although listeriosis has been rarely described following lower GI endoscopy, we believe this is the first case related to upper GI endoscopy.

Taeniasis and neurocysticercosis among Malaysians.

Taeniasis, endemic in Southeast Asia, is caused by Taenia saginata (for beef) or Taenia solium and Taenia asiatica (for pork). T. solium also causes cysticercosis which can affect various organs. Taeniasis and cysticercosis cases are rarely reported in Malaysia. We report here two separate cases of beef taeniasis, and an interesting case of neurocysticercosis in a Malay Muslim. The taeniasis cases involved a Malaysian Chinese and a native Sabahan. Proglottids were recovered from them, and identification of the tapeworm done either from the microscopic examination of the egg or using PCR-based molecular diagnosis. Upon confirmation of taeniasis, both cases were given praziquantel and had been asymptomatic since. The neurocysticercosis case involving a Muslim who presented with seizure, was confirmed by histopathological examination of tissue sections taken from craniotomy excision of the brain lesion. He was given one month course of albendazole 400 mg bid and dexamethasone, and had been well and seizure free since. The two cases of taeniasis documented here had acquired the disease through eating raw or undercooked contaminated beef. For the neurocyticercosis case, it is suspected that he might have acquired the infection in one of his travels through human to human transmission via contaminated food or water consumption, given that Malaysia is not T. solium endemic area. Lastly praziquantel is an effective drug for beef taeniasis, while a combination of albendazole and dexamethasone work well for neurocysticercosis.

In-depth performance analysis of an EEG based neonatal seizure detection algorithm.

OBJECTIVE: To describe a novel neurophysiology based performance analysis of automated seizure detection algorithms for neonatal EEG to characterize features of detected and non-detected seizures and causes of false detections to identify areas for algorithmic improvement. METHODS: EEGs of 20 term neonates were recorded (10 seizure, 10 non-seizure). Seizures were annotated by an expert and characterized using a novel set of 10 criteria. ANSeR seizure detection algorithm (SDA) seizure annotations were compared to the expert to derive detected and non-detected seizures at three SDA sensitivity thresholds. Differences in seizure characteristics between groups were compared using univariate and multivariate analysis. False detections were characterized. RESULTS: The expert detected 421 seizures. The SDA at thresholds 0.4, 0.5, 0.6 detected 60%, 54% and 45% of seizures. At all thresholds, multivariate analyses demonstrated that the odds of detecting seizure increased with 4 criteria: seizure amplitude, duration, rhythmicity and number of EEG channels involved at seizure peak. Major causes of false detections included respiration and sweat artefacts or a highly rhythmic background, often during intermediate sleep. CONCLUSION: This rigorous analysis allows estimation of how key seizure features are exploited by SDAs. SIGNIFICANCE: This study resulted in a beta version of ANSeR with significantly improved performance.

Isometric force development, isotonic shortening, and elasticity measurements from Ca2+-activated ventricular muscle of the guinea pig.

Isometric tension and isotonic shortening were measured at constant levels of calcium activation of varying magnitude in mechanically disrupted EGTA-treated ventricular bundles from guinea pigs. The results were as follows: (a) The effect of creatine phosphate (CP) on peak tension and rate of shortening saturated at a CP concentration more than 10 mM; below that level tension was increased and shortening velocity decreased. We interpreted this to mean that CP above 10 mM was sufficient to buffer MgATP(2-) intracellularly. (b) The activated bundles exhibited an exponential stress-strain relationship and the series elastic properties did not vary appreciably with degree of activation or creatine phosphate level. (c) At a muscle length 20 percent beyond just taut, peak tension increased with Ca(2+) concentration over the range slightly below 10(-6) to slightly above 10(-4)M. (d) By releasing the muscle length-active tension curves were constructed. Force declined to 20 percent peak tension with a decrease in muscle length (after the recoil) of only 11 percent at 10(-4)M Ca(2+) and 6 percent at 4x10(-6)M Ca(2+). (e) The rate of shortening after a release was greater at lower loads. At identical loads (relative to maximum force at a given Ca(2+) level), velocity at a given time after the release was less at lower Ca(2+) concentrations; at 10 M(-5), velocity was 72 percent of that at 10(-4)M, and at 4x10(-6)M, active shortening was usually delayed and was 40 percent of the velocity at 10(-4) M. Thus, under the conditions of these experiments, both velocity and peak tension depend on the level of Ca(2+) activation over a similar range of Ca(2+) concentration.

Disaster relief and initial response to the earthquake and tsunami in Meulaboh, Indonesia.

The Singapore Humanitarian Assistance Support Group deployed a team of 32 medical relief workers to Meulaboh, Indonesia to provide medical assistance for victims of the 26 December earthquake and tsunami disaster. The team was deployed at a primary healthcare clinic at an internally displaced persons' (IDP) camp and at the sole hospital's emergency and surgical departments. The team saw a total of 1841 patients, 1371 at the clinic and 446 at the hospital's emergency department, and performed surgery on 24 patients. Tsunami-related trauma cases accounted for 31.8% (142) of cases at the emergency department, 1.6% (22) of cases at the clinic, and 91.7% (22) of surgeries. This paper details the difficulties and lessons learnt by the team, including the lack of important resources for healthcare delivery. Water, sanitation, hygiene, and vector control were some of the problems faced, with the goal to provide the most effective public health for the greatest number of people given the limited resources available.

Women's interpretation of and responses to potential gynaecological cancer symptoms: a qualitative interview study.

OBJECTIVE: To explore women's experiences of symptoms potentially indicative of gynaecological cancer in a community-based sample without imposing a cancer perspective. DESIGN: A qualitative interview study with thematic analysis of transcripts. PARTICIPANTS: 26 women aged ≥30 years, who had experienced a symptom that might indicate gynaecological cancer in the past 3 months, were recruited using a screening questionnaire distributed online and in community settings. SETTING: London, UK. RESULTS: Women attributed gynaecological symptoms to existing illnesses/conditions or considered themselves to be predisposed to them, either through their 'genes' or previous personal experience. Normalising symptoms by attributing them to demographic characteristics (eg, age, sex) was common, as was considering them a side effect of hormonal contraception. When women raised cancer as a possible cause, they often dismissed it as unlikely. Responses to symptoms included self-management (eg, self-medicating, making lifestyle changes), adopting a 'lay system of care', or consulting a healthcare professional. Triggers to help-seeking included persistent, painful or debilitating symptoms, concern about symptom seriousness, and feeling that help-seeking was legitimised. Barriers to help-seeking included lack of concern, vague symptoms, unusual symptom location, competing time demands, previous negative experiences with the healthcare system, and not wanting to be perceived as a time-waster. CONCLUSIONS: Attributions of symptoms potentially indicative of a gynaecological cancer were varied, but most often involved women fitting symptoms into their expectations of what was 'normal'. Normalising acted as a barrier to seeking help from a healthcare professional, alongside competing time demands and negative attitudes towards help-seeking. These barriers may lead to later diagnosis and poorer cancer survival. Our findings could be used to inform the development of interventions to encourage appropriate help-seeking.

Unusual conformational effect in alpha-aminoorganostannanes.

[formula: see text] Dynamic NMR analysis of conformationally mobile and rigid 2-tributylstannyl-N-methylpiperidines revealed an unexpected conformational effect that is manifested in a small energy difference between conformers in which the tin is equatorial and axial. The major reason appears to be a distortion of the conformer in which the C-2-Sn bond is synclinal to the nitrogen lone pair.

In situ detection of specific p53 mutations in cultured cells using the amplification refractory mutation system polymerase chain reaction.

Accurate molecular detection of genetic mutations involved in tumorigenesis has been based predominantly on analysis of extracted DNA, but this does not provide detailed information on the location, number, type or clonal distribution of mutated cells and their precise anatomic location and clonal distribution. This study has used a sensitive and specific application of the amplification refractory mutation system (ARMS)-polymerase chain reaction (PCR) in situ, combined with in situ hybridization to localize and identify cells with defined p53 mutations. The ARMS-PCR was performed in situ in SW480 cells in suspension and in cells either cultured or cytospun onto glass slides. Amplified mutant DNA PCR products were detected in SW480 cells using digoxigenin-labeled probes, visually identifying cells harboring specific mutations in the p53 gene. In situ hybridization alone of the mutant cells without the amplification step was negative. Normal human fibroblasts or endothelial cells were refractory to in situ amplification. This reaction was mutation-specific as CEM cells with different p53 mutations reacted negatively. Mutant messenger RNA (mRNA) in tumor cells was also selectively amplified in situ by ARMS-PCR following reverse transcription (RT). This study demonstrates the potential of in situ ARMS-PCR or RT-ARMS-PCR for mutation analysis in situ and could have useful clinical applications.

Gas chromatographic determination of aromatic amines in water samples after solid-phase extraction and derivatization with iodine. II. Enrichment.

A procedure for the enrichment of aromatic amines via solid-phase extraction was developed. A HR-P phase based on styrene-divinylbenzene was used for the investigations, generally followed by derivatization with iodine and determination via GC-ECD. The recoveries of 53 aromatic amines in a drinking water matrix at pH 9 were determined. Most anilines showed relative recoveries between 80-120% with relative standard deviations of< or = 5% at concentration levels between 10 and 20 micrograms 1(-1). The comparison with a wastewater matrix led to similar results. The enrichment procedure was applied to real samples, e.g., samples of ammunition wastewater.

Gas chromatographic determination of aromatic amines in water samples after solid-phase extraction and derivatization with iodine. I. Derivatization.

A new method for the selective determination of aromatic amines is presented, which is based on the solid-phase extraction at pH 9 and subsequent derivatization of the analytes to the corresponding iodobenzenes. These can selectively and sensitively be determined with gas chromatography and electron-capture detection. Separation of at least 30 compounds in a single chromatographic run in 30 min is possible. With this method, 56 aromatic amines were investigated, and only in six cases no derivatives were obtained. Limits of quantitation were between 0.5 and 8 micrograms 1(-1), but may still be lowered with higher sample volumes or different injection techniques. The application to water samples revealed the suitability for the investigation of ground, leachate and wastewater.

Prevention of tumour seeding following thoracoscopy in mesothelioma by prophylactic radiotherapy.

To determine the usefulness of prophylactic radiotherapy following thoracoscopy or pleural aspiration in patients with mesothelioma we reviewed the case notes of patients treated at St Mary's Hospital between 1990 and 1994. Twenty patients have received treatment to 38 sites and tumour seeding was prevented in all patients available for follow-up. Four patients acted as their own controls by developing nodules at untreated sites. Prophylactic radiotherapy is highly effective in preventing tumour seeding in mesothelioma.

A further study of the anaerobic biotreatment of malt whisky distillery pot ale using an UASB system.

Pot ale from a pilot-scale malt whisky distillery was treated using a mesophilic upflow anaerobic sludge blanket (UASB) digester. Stable operation was observed at organic loading rates (OLRs) of 5.46 kg COD/m3 day or less when the pot ale was diluted with tap water. Digester failure occurred when undiluted pot ale was used, even though OLR was less than 5 kg COD/m3 day. Overall performance was worse than that observed previously when UASB digesters were used to treat pot ale from a different source supplemented with trace elements. A substantial proportion of effluent chemical oxygen demand (COD) was present as volatile fatty acids (VFA), particularly during periods of reactor stress, indicating that overall performance was limited by the rate of VFA conversion. Wastewater alkalinity rose during digestion. The sludge which developed in the reactor was flocculent but did not form compact granules.