Validation and modification of the Ottawa subarachnoid haemorrhage rule in risk stratification of Asian Chinese patients with acute headache.

OBJECTIVE: To validate the Ottawa subarachnoid haemorrhage (SAH) rule in an Asian Chinese cohort and to explore the roles of blood pressure and vomiting in prediction of SAH in patients with nontraumatic acute headache. METHODS: A retrospective cohort study was conducted in two regional hospitals. All patients aged ≥16 years who presented with non-traumatic acute headache to the study centres from July 2013 to June 2016 were included. A logistic regression model was created for the variables of the Ottawa SAH rule and other potential predictors, including vomiting and systolic blood pressure (SBP) >160 mm Hg. Model discrimination was evaluated using the area under the receiver operating characteristic curve. Net reclassification improvement and integrated discrimination improvement indices were evaluated. The model's diagnostic characteristics, including sensitivities and specificities, were evaluated. RESULTS: A total of 500 eligible headache cases were included, in 50 of which SAH was confirmed (10%). In addition to the predictors of the Ottawa SAH rule, vomiting and SBP >160 mm Hg were found to be significant independent predictors of SAH. Net reclassification improvement and integrated discrimination improvement indices indicated that including vomiting and SBP >160 mm Hg would improve the model prediction. The Ottawa SAH rule had 94% sensitivity and 32.9% specificity. The modified Ottawa SAH rule that included both vomiting and SBP >160 mm Hg as criteria improved sensitivity to 100%, specificity to 13.1%, positive predictive value to 11.3%, and negative predictive value to 100%. CONCLUSIONS: The Ottawa SAH rule demonstrated high sensitivity. Addition of vomiting and SBP >160 mm Hg to the Ottawa SAH rule may increase its sensitivity.

Unh1, an Ustilago maydis Ndt80-like protein, controls completion of tumor maturation, teliospore development, and meiosis.

In this study, Ustilago maydis Ndt80 homolog one, unh1, of the obligate sexual pathogen U. maydis,is described. Unh1 is the sole Ndt80-like DNA-binding protein inU. maydis. In this model basidiomycete, Unh1 plays a role in sexual development, influencing tumor maturation, teliospore development and subsequent meiotic completion. Teliospore formation was reduced in deletion mutants, and those that did form had unpigmented, hyaline cell walls, and germinated without completing meiosis. Constitutively expressing unh1 in haploid cells resulted in abnormal pigmentation, when grown in both potato dextrose broth and minimal medium, suggesting that pigmentation may be triggered by unh1 in U. maydis. The function of Unh1 in sexual development and pigment production depends on the presence of the Ndt80-like DNA-binding domain, identified within Unh1. In the absence of this domain, or when the binding domain was altered with targeted amino acid changes, ectopic expression of Unh1 failed to complement the unh1 deletion with regards to pigment production and sexual development. An investigation of U. maydis genes with upstream motifs similar to Ndt80 recognition sequences revealed that some have altered transcript levels in Δunh1 strains. We propose that the first characterized Ndt80-like DNA-binding protein in a basidiomycete, Unh1, acts as a transcription factor that is required for teliospore maturation and the completion of meiosis in U. maydis.

Age, tumour stage, and preoperative serum albumin level are independent predictors of mortality after radical cystectomy for treatment of bladder cancer in Hong Kong Chinese.

OBJECTIVES: To evaluate the association between patient age, other clinical factors and mortality following radical cystectomy for treatment of bladder cancer. DESIGN: Historical cohort study. SETTING: A urology unit in Hong Kong. PATIENTS: The outcomes of 117 patients who had radical cystectomies performed in one urological unit from 2003 to 2011 were reviewed. Demographic and perioperative data, including tumour stage, Charlson Comorbidity Index, and preoperative serum albumin levels were retrieved from computerised medical records. Risk factors for 30-day mortality, and cancer-specific, other-cause, and overall death rates at 5 years were calculated. The data were subsequently stratified and analysed according to age. RESULTS: Of the 117 patients, 83 (71%) were aged 75 years or below. The mean follow-up duration was 31 (standard deviation, 29) months. Age, tumour stage, and preoperative serum albumin level, but not the Charlson Comorbidity Index, were found to be predictors of survival following radical cystectomy. The overall 30-day mortality rate was 3% in the full sample, 1% in patients aged 75 years or below, and 10% in patients aged over 75 years. There was no significant difference in 5-year cancer-caused mortalities between patients aged 75 years or below and those aged over 75 years (33% vs 33%, P=0.956). In patients older than 75 years, the 5-year other-cause and overall mortality rates were 47% and 80%, respectively; such rates were higher than those for younger patients (13% and 46%, respectively). CONCLUSION: Age, tumour stage, and preoperative serum albumin level were predictors of survival after radical cystectomy. Non-cancer-related death played a crucial role in the overall mortality rate in elderly patients having radical cystectomy for bladder cancer.

Hand-assisted laparoscopic versus total laparoscopic right colectomy: a randomized controlled trial.

AIM: Laparoscopic colectomy for colorectal cancer is associated with definite short-term benefits, and is increasingly practised worldwide. The limitations of a pure laparoscopic approach include a relative lack of tactile feedback and long procedural time. Hand-assisted laparoscopic surgery was introduced in an attempt to facilitate operation by improving the tactile sensation. To date, there is no consensus as to which approach is better. Herein we conducted a randomized controlled trial comparing hand-assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy (TLC) in the management of right-sided colonic cancer. METHODS: Adult patients with carcinoma of the caecum and ascending colon were recruited and randomized to undergo either HALC or TLC. Measured outcomes included operative time, blood loss, conversion rate, postoperative morbidities, postoperative pain, length of hospital stay, disease recurrence and patient survival. RESULTS: Sixty patients (HALC=30, TLC=30) were recruited. The two groups were comparable with regard to age, gender distribution, body mass index and final histopathological staging. No difference was observed between the groups in terms of operating time, conversion rate, operative blood loss, pain score and length of hospital stay. With a median follow-up of 27 to 33 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83%vs 80%, P=0.923). CONCLUSION: HALC is safe and feasible, but it does not show any significant benefits over TLC in terms of operating time and conversion rate. Routine use of the hand-assisted laparoscopic technique in right hemicolectomy is therefore not recommended.

The dynamics of indigenous epiphytic bacterial and fungal communities of barley grains through the commercial malting process in Western Canada.

Microbial activity is present at every step of the malting process. It is, therefore, critical to manage the grain-associated microbial communities for the production of high-quality malts. This study characterized barley and malt epiphytic microbiota by metabarcoding the internal transcribed spacer (ITS) 2 region and the 16S rRNA gene V1-V4 metabarcodes, respectively. We elucidated the changes in the diversity and the compositional and functional changes of the grain-associated microbiota and inferred the impact of such changes on malting efficiency and premature yeast flocculation (PYF) of the commercial malt end product. Through the malting process, the fungal diversity decreased while bacterial community diversity increased. Lactic acid bacteria (LAB) and some mycotoxin-producing fungi (e.g. Fusarium spp.) were found to be significantly enriched in malts. Most potential fungal pathogens, however, did not change in abundance through the malting process. Fungi (e.g. Aureobasidium, Candida) and bacteria (e.g. LAB, Arthrobacter, Brachybacterium) with the potential to generate organic acids or exhibit high hydrolytic enzymatic activity for degrading the endosperm cell walls and storage proteins were detected in greater abundance in kilned malt, suggesting their contribution to malting efficiency. Bacterial and fungal operational taxonomic units (OTUs) associated with PYF-positive malt were mainly identified as Aureobasidium, Candida, and Leuconostoc, while Pleosporaceae, Steptococcus, and Leucobacter were associated with PYF-negative malt. The ecological networks of the field and steeped barley samples were found to be larger and denser, while that of the malt microbiome was smaller and less connected. A decrease in the proportion of negative interactions through the malting process suggested that malting destabilized the microbial networks. In summary, this study profiled the microbiota of commercial malting barley and malt samples in western Canada; the findings expanded our knowledge in the microbiology of malting while providing potential insights regarding the management of microbial-associated problems, such as PYF, in commercial malting.

Laparoscopic sphincter-preserving total mesorectal excision: 10-year report.

AIM: Total mesorectal excision (TME) is currently the gold standard for resection of mid or low rectal cancer and is associated with a low local recurrence rate. However, few studies have reported the long-term oncological outcome following use of a laparoscopic approach. The aim of this study was to evaluate the long-term oncological outcome after laparoscopic sphincter-preserving TME with a median follow up of about 4 years. METHOD: Patients with mid or low rectal cancer who underwent laparoscopic sphincter-preserving TME with curative intent between March 1999 and March 2009 were prospectively recruited for analysis. RESULTS: During the 10-year study period, 177 patients underwent laparoscopic sphincter-preserving TME with curative intent for rectal cancer. Conversion was required in two (1%) patients. There was no operative mortality. At a median follow-up period of 49 months, local recurrence had occurred in nine (5.1%) patients. The overall metastatic recurrence rate after curative resection was 22%. The overall 5-year survival and 5-year disease-free survival in the present study were 74% and 71%, respectively. CONCLUSION: The results of this study show that laparoscopic sphincter-preserving TME is safe with long-term oncological outcomes comparable to those of open surgery.

The outcome of laparoscopic colorectal resection in T4 cancer.

AIM: Laparoscopic surgery for locally advanced tumours with extramural involvement is still controversial. It is believed that laparoscopic excision of T4 cancers is technically difficult and may result in prolonged operative time, increased conversion rate, added postoperative morbidity, and suboptimal oncological clearance. METHOD: Our unit has been practising laparoscopic colorectal surgery since 1992, and all data are entered into a database prospectively. Since 1999 we have routinely used the laparoscopic approach for colorectal cancer resections. Data regarding patients with a histologically T4 cancer operated on between 1999 and 2008 were analysed. Outcomes included operating time, conversion rate, postoperative complications and oncological outcome. RESULTS: Over a 10-year period, 146 patients (male 75) with a T4 cancer underwent laparoscopic resection. The median operating time was 125 (range, 46-285) min and the median blood loss was 50 (0-1800) ml. The conversion rate was 16%. Six (4.1%) patients experienced anastomotic leakage. The median number of lymph nodes harvested was 13 (2-40). One hundred and two (70%) patients underwent curative resection. The recurrence rates were 41% and 53% for stage II and III patients, respectively. Four (3.9%) patients had local recurrence. At a median follow up of 18 (1-118) months, the overall survival was 25 months, with median overall survival for patients with stage II, III and IV disease being 63, 36 and 12 months, respectively. CONCLUSION: Laparoscopic colectomy in histologically T4 cancer is safe. Oncological outcomes remain satisfactory. Based on our data, provided expertise is available, patients with locally advanced tumours should not be excluded from a laparoscopic approach.

Laparoscopic anterior resection.

Laparoscopic colectomy for cancer is increasingly practiced worldwide in the last 2 decades. However, due to procedural complexity, laparoscopic rectal cancer excision had not proceeded at a similar pace. This article deals with the technique of laparoscopic anterior resection. Resection of rectosigmoid or upper rectal tumors is first described, followed by the more difficult sphincter-saving total mesorectal excision. We have been using and modifying this technique of laparoscopic anterior resection for rectal cancer since 1990 s. In our recent review, the local recurrence rate was 7.4%, and the overall 5-year survival was 70%. Our data suggest laparoscopic resection for rectal cancer is safe and is the procedure of choice in selected patients.

Oncogenes in radioresistant, noncancerous skin fibroblasts from a cancer-prone family.

Li-Fraumeni syndrome is manifested in a variety of neoplasms that are transmitted in a dominantly inherited pattern. The noncancerous skin fibroblasts of family members exhibit a unique characteristic of being resistant to the killing effect of ionizing radiation. A three- to eightfold elevation in expression of c-myc and an apparent activation of c-raf-1 gene have been observed in these noncancerous skin fibroblasts. These results may provide insight into the heritable defect underlying the familial predisposition to a variety of cancers.

Obstructive complications of laparoscopically created defunctioning ileostomy.

PURPOSE: The use of defunctioning ileostomy is a common practice to reduce the septic complications after anastomotic leakage in colorectal surgery. In open surgery, the fashioning of ileostomy is a straightforward procedure. However, in the laparoscopic approach, this can be a difficult task and obstructive complications can occur postoperatively. METHODS: A retrospective review was undertaken for all patients who underwent laparoscopic colorectal resection and defunctioning loop ileostomy over a 15-year period. RESULTS: In this period, 161 patients underwent laparoscopic colorectal surgery with defunctioning ileostomy. Eight patients developed obstructive complications in the early postoperative period requiring surgical intervention (5 percent). All patients presented with intestinal obstruction from the fourth to the sixth postoperative day. The median time to reoperation was 9.5 days (range, 5 to 19). The causes of obstructive complications were twisting of the ileostomy (n = 3), adhesive kinking proximal to the ileostomy (n = 3), tight fascia (n = 1), and both tight fascia and twisting of ileostomy (n = 1). Six patients underwent laparotomy for diagnosis and refashioning of ileostomy. The seventh patient had endoscopic decompression of small bowel and refashioning of ileostomy. The last patient was successfully managed with combined endoscopic and laparoscopic approach. CONCLUSIONS: Various pitfalls can occur in laparoscopically created defunctioning ileostomy. Measures can be taken to minimize these technical errors. Various surgical reinterventions can be attempted to determine the cause. With combined uses of enteroscope and laparoscope, a laparotomy can be avoided.

Simultaneous determination of key bioactive components in Hedyotis diffusa by capillary electrophoresis.

A capillary zone electrophoresis (CZE) method based on systematic one-variable-at-a time approach was developed for the analysis of four important bioactive components (geniposidic acid, ursolic acid, quercetin and p-coumaric acid) in the extract of Hedyotis diffusa (HD). Separations were carried out in a fused-silica capillary tube with peak detection at 214 nm. Good separation was achieved using a 20 mM borate buffer containing 5% acetonitrile as organic modifier and pH adjusted to 10.0. Operating voltage was 15 kV and temperature was maintained at 25 degrees C while hydrodynamic injection was 5s. A good linearity, with correlation coefficients in the ranges of 0.997-0.999 was obtained in the calibration curves of each standard. Relative standard deviation (R.S.D.) of migration time was between 0.32 and 0.70% and deviation of corrected peak area was between 8.84 and 11.99%. These results indicate that this method could be used for rapid and simultaneous analysis of the bioactive components in HD and other herbal products.

Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus.

BACKGROUND: Conventional preoperative staging for esophageal carcinoma could be inaccurate. Laparoscopy has been applied for the staging of various upper gastrointestinal malignancies. It can identify peritoneal and liver deposits not shown by imaging, and could reduce the number of nontherapeutic laparotomies. This study aimed to evaluate the efficacy of laparoscopic staging for the management of squamous cell carcinoma involving the mid and distal esophagus. METHODS: A retrospective review was performed for all patients with esophageal cancer evaluated for surgical resection from January 1998 to January 2004. Laparoscopy was performed for all the patients with mid and distal esophageal cancer immediately before open gastric mobilization. The efficacy of laparoscopy for the management of squamous cell carcinoma of the esophagus was evaluated. RESULTS: Among the 63 patients with potentially resectable disease shown on conventional imaging, 54 (84%) underwent esophagectomy with curative intent after laparoscopic staging. Seven patients (11%) underwent laparoscopy alone because of abdominal metastases (n = 5) or other medical conditions (n = 2) that precluded esophagectomy. Two patients (3%) had exploratory right thoracotomy without esophagectomy despite normal laparoscopic findings. The sensitivity and specificity of laparoscopic staging were 100% in this series of patients (100% sensitivity and specificity means no false-positives or -negatives). CONCLUSION: Laparoscopic staging is valuable for the management of patients with mid and distal squamous cell carcinoma of the esophagus. Patients with metastatic disease and those with prohibitive surgical risk can thus avoid unnecessary laparotomy and be offered other treatment methods.

Spontaneous pneumomediastinum in a scuba diver.

Pneumomediastinum usually occurs following an airleak from the lungs, or from a perforated oesophagus. We report on a 30-year-old man who developed pneumomediastinum after scuba diving. The patient presented with acute onset of throat pain, odynophagia, and hoarseness of voice. The literature is reviewed for this condition.

Identification and quantification of base and nucleoside markers in extracts of Ganoderma lucidum, Ganoderma japonicum and Ganoderma capsules by micellar electrokinetic chromatography.

The present paper describes the development of a micellar electrokinetic chromatographic method for the determination of nucleoside (adenosine, uridine) and base (uracil) markers in aqueous extracts of Ganoderma medicinal preparations. The markers were successfully separated within 10 min using an 80 mM borate buffer, with 25 mM sodium dodecyl sulfate adjusted to pH 9.0, an operating voltage of 22 kV, temperature of 20 degrees C and a hydrodynamic injection time of 5 s. Separations were carried out in a fused-silica capillary with peak detection by direct UV at 254 nm. Following semi-validation of the method, with each analyte showing a good linear relationship over a 0.2 to 20 ppm concentration range (correlation coefficients from 0.9986 to 0.9998), the amounts of the three markers in the various forms of Ganoderma were easily determined using a relatively simple extraction procedure.

Determination of bioactive diterpenoids from Andrographis paniculata by micellar electrokinetic chromatography.

The present paper describes the development of a micellar electrokinetic chromatographic (MEKC) method for simultaneous determination of andrographolide, deoxyandrographolide and neoandrographolide in ethanol extracts of Andrographis paniculata. Separations were carried out in a fused-silica capillary tube with UV detection at 214 nm. Good separation was achieved using a 20 mM borate buffer, containing 20 mM sodium dodecyl sulphate and 10 mM sodium cholate, adjusted to pH 8.3 at an operating voltage of 25 kV, temperature of 35 degrees C and a hydrodynamic injection of 5 s. The method was validated with good correlation coefficients obtained (0.9986-0.9989) while relative standard deviation (RSD) of migration time was between 1.14 and 2.42. It is concluded that this method could be used for speedy and accurate qualitative and quantitative analysis of bioactive diterpenoids in andrographis herb and its derived products.

Rapid and simultaneous analysis of some bioactive components in Eucommia ulmoides by capillary electrophoresis.

A micellar electrokinetic chromatography method was established for the qualitative and quantitative determination of three groups of bioactive components, iridoids, flavonoids and phenolic compounds, in Eucommia ulmoides. Of the eleven bioactive components being studied, ten were successfully separated in 50 mM boric acid buffer at pH 9.5, with 50 mM sodium dodecylsulfate and 4% 1-butanol, at a voltage of 20 kV, temperature of 20 degrees C and injection under high pressure at 138 kPa for 5 s in a fused-silica capillary with peak detection at 214 nm. A high reproducibility and good linearity was obtained. The relative standard deviations of the migration times in eight injections of the standards ranged from 0.64 to 1.88% and those of the corrected peak area ranged from 2.79 to 6.62%. A good linearity, with correlation coefficients in the range of 0.995-1.000, was obtained in the calibration curves of each standard from 1 to 50 ppm. The amount of these bioactive components in the bark and leaves of Eucommia ulmoides were determined.

Two-port versus four-port laparoscopic cholecystectomy.

BACKGROUND: Two-port laparoscopic cholecystectomy has been reported to be safe and feasible. However, whether it offers any additional advantages remains controversial. This study reports a randomized trial that compared the clinical outcomes of two-port laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy. METHODS: One hundred and twenty consecutive patients who underwent elective laparoscopic cholecystectomy were randomized to receive either the two-port or the four-port technique. All patients were blinded to the type of operation they underwent. Four surgical tapes were applied to standard four-port sites in both groups at the end of the operation. All dressings were kept intact until the first follow-up 1 week after surgery. Postoperative pain at the four sites was assessed on the first day after surgery using a 10-cm unscaled visual analog scale (VAS). Other outcome measures included analgesia requirements, length and difficulty of the operation, postoperative stay, and patient satisfaction score on surgery and scars. RESULTS: Demographic data were comparable for both groups. Patients in the two-port group had shorter mean operative time (54.6 +/- 24.7 min vs 66.9 +/- 33.1 min for the four-post group; p = 0.03) and less pain at individual subcostal port sites [mean score using 10-cm unscaled VAS: 1.5 vs 2.8 ( p = 0.01) at the midsubcostal port site and 1.3 vs 2.3 ( p = 0.02) at the lateral subcostal port site]. Overall pain score, analgesia requirements, hospital stay, and patient satisfaction score on surgery and scars were similar between the two groups. CONCLUSION: Two-port laparoscopic cholecystectomy resulted in less individual port-site pain and similar clinical outcomes but fewer surgical scars compared to four-port laparoscopic cholecystectomy. Thus, it can be recommended as a routine procedure in elective laparoscopic cholecystectomy.

A chromatographic method for rapid and simultaneous analysis of codeine phosphate, ephedrine HCl and chlorpheniramine maleate in cough-cold syrup formulation.

The present paper describes a simple, accurate and precise reversed phase HPLC method for rapid and simultaneous quantification of codeine phosphate, ephedrine HCl and chlorpheniramine maleate in a cough-cold syrup formulation. Separations were carried out on a Zorbax XDB C8 column (150 x 4.6 mm ID), 5 microm particle size. A gradient elution system was developed using varying percentages of two mobile phases: methanol-glacial acetic acid-triethylamine (980:15:6 v/v) and water-glacial acetic acid-triethylamine (980:15:6 v/v). The elution of the analytes was achieved in less than 7 min with a flow rate of 1.5 ml/min. Detection was by UV absorbance at a wavelength of 254 nm. Quantification of the components in actual syrup formulations was calculated against the responses of freshly prepared external standard solutions. The method was validated and met all analysis requirements of quality assurance and quality control recommended by FDA of the USA.

Evaluation of glycine as an inactivator of glutaraldehyde.

Glycine was evaluated as an inactivator of the sporicidal activity of glutaraldehyde. Spores from glucose depleted cultures of Bacillus stearothermophilus grown in a chemically defined medium were used. When glycine is used as an inactivator of glutaraldehyde, it lowers the pH value of the solution. Glycine 1% failed to inactivate 0.5% or higher concentrations of alkaline glutaraldehyde in sporicidal studies. If viable counts cannot be performed within the first hour after inactivation, the concentration of glycine should be at least 2% to inactivate effectively 2% alkaline glutaraldehyde.

Metropolitan out-migration of elderly females in Canada: characterization and explanation.

PIP: Out-migration patterns of elderly females from the 23 Census Metropolitan Areas of Canada from 1971 to 1976 are analyzed using official data. The results suggest that environmental variables are more important than housing variables in determining the choice of destination.^ieng