Interpreting the real-time dynamic 'sliding sign' and predicting pouch of Douglas obliteration: an interobserver, intraobserver, diagnostic-accuracy and learning-curve study.

OBJECTIVE: To determine inter- and intraobserver agreement, diagnostic accuracy and the learning curve required for interpreting the 'sliding sign' and predicting pouch of Douglas (POD) obliteration. METHODS: This was an inter-/intraobserver, diagnostic-accuracy and learning-curve study involving six observers with different medical backgrounds, clinical skill sets and prior gynecological ultrasound experience: five non-specialist observers who had performed 0-750 previous gynecological scans and an expert sonologist who had performed > 15 000. Following a formal theoretical and practical training session, they each viewed 64 offline transvaginal ultrasound (TVS) 'sliding-sign' videos from two anatomical locations (retrocervix and posterior uterine fundus (PUF)) in 32 women presenting with chronic pelvic pain, interpreting the videos as positive or negative for sliding sign and predicting, on that basis, the POD status. For intraobserver agreement analysis they re-analyzed the same video sets, in a different order, at least 7 days later. The expert sonologist was the reference standard for interpreting the sliding sign and the gold standard, laparoscopy, was used for the POD analysis. Learning-curve cumulative summation (LC-CUSUM) tests were conducted to assess if observer performance reached acceptable levels, using LC-CUSUM score < -2.45 as a cut-off. RESULTS: With respect to interpretation of the sliding sign, the overall multiple-rater agreement was moderate (Fleiss' kappa, K = 0.499). Observers were more consistent in their interpretation of the second compared with the first observation set (K = 0.547 vs 0.453) and for the retrocervical compared with the PUF region (K = 0.556 vs 0.346). Regarding prediction of POD status, the accuracy, sensitivity, specificity and positive and negative predictive values for individual observers ranged from 65.4 to 96.2%, 80.0 to 100%, 64.7 to 100%, 50.0 to 100% and 94.7 to 100%, respectively. Using LC-CUSUM score < -2.45, the observer with experience of 200 previous gynecological scans reached acceptable levels for predicting POD obliteration and interpreting the sliding sign at each region (retrocervix and PUF) at 39, 54 and 28 videos and the observer with experience of 750 scans at 56, 53 and 53 videos. CONCLUSIONS: Performance of a minimum number of gynecological ultrasound examinations is necessary for interpreting offline videos of the real-time dynamic sliding sign and predicting POD obliteration. Non-specialist observers with prior experience of 200 or more gynecological scans were more consistent in interpreting the sliding sign at the retrocervix vs PUF. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Is routine chest X-ray after surgical and percutaneous tracheostomy necessary in adults: a systemic review of the current literature.

BACKGROUND: For many years, routine post-tracheostomy chest X-ray has been the standard of care for patients in many countries. However, recent evidence suggests that this is unnecessary and cost-ineffective. OBJECTIVE: To review the current literature and examine the role of routine post-tracheostomy chest X-ray in adult patients. TYPE OF REVIEW: Systemic review. SEARCH STRATEGY: Electronic databases (PubMed, EMBASE, Cochrane) were searched using the keywords 'chest X-ray/radiography/radiograph' and 'tracheostomy/tracheotomy' in various permutations. Search period ranged from 1960 to 2012. Inclusion criteria included systematic reviews, meta-analyses, randomised control trials, prospective and retrospective case series. Paediatric and non-English articles were excluded. Abstracts and subsequently full text articles were screened by two of the authors independently. References from obtained articles were also examined. EVALUATION METHOD: Specific outcome measures were collated to evaluate the usefulness of post-tracheostomy chest X-ray: Chest X-ray detected (tracheostomy-related) complication rates Proportion of cases requiring significant intervention Potential predictors of complications RESULTS: Routine post-tracheostomy chest X-ray is of a low yield, and its findings had limited impact on patient management. Complication detection rates for surgical and percutaneous tracheostomy are 2.2% and 3.2%, respectively. Only 0.7% and 1.8% of chest X-rays performed in surgical and percutaneous tracheostomy cases, respectively, required intervention. Certain groups of patients, however, are at higher risks of complications, and may benefit from post-tracheostomy chest X-ray. For surgical tracheostomy, these groups include those with post-operative signs and symptoms of complications or had emergent or 'difficult' tracheostomies. For percutaneous tracheostomy, high-risk patients include trauma cases (unspecified), patients with post-procedural signs and symptoms of complications, patients who have high ventilatory requirements, difficult tracheostomy cases or tracheostomy cases performed without bronchoscopic guidance. CONCLUSION: The practice of routine post-tracheostomy chest X-ray is debatable owing to its low yield and minimal impact on clinical management. However, certain groups of patients appear to be at higher risks of post-tracheostomy complications; currently, there is insufficient evidence to conclude the absolute need for routine chest X-ray in these groups of patients, although it may be prudent to do so based on available evidence in the literature and logical clinical reasoning.

Should mild obstructive sleep apnoea be treated? A systematic review from the standpoint of disease progression.

OBJECTIVE: This study was a systematic review to investigate the progression of untreated obstructive sleep apnoea in order to evaluate whether mild obstructive sleep apnoea should be treated from the standpoint of disease progression. METHOD: The database search study outcomes that were collected included Apnea Hypopnea Index and Respiratory Disturbance Index. A meta-analysis of obstructive sleep apnoea severity over time intervals was performed. RESULTS: A total of 17 longitudinal studies and 1 randomised, controlled trial were included for review. For patients with mild obstructive sleep apnoea, mean pre-study and post-study Apnea Hypopnea Index was 5.21 and 8.03, respectively, over a median interval of 53.1 months. In patients with moderate to severe obstructive sleep apnoea, mean pre-study and post-study Apnea Hypopnea Index was 28.9 and 30.3, respectively, over a median interval of 57.8 months. Predictors for disease progression in mild obstructive sleep apnoea are patients aged less than 60 years and those with a baseline body mass index less than 25. CONCLUSION: Mild obstructive sleep apnoea progression is observed, but it does not appear to reach any clinically significant progression to moderate or severe obstructive sleep apnoea.

Proof-of-Concept Study for an Enhanced Surrogate Marker of Endothelial Function in Diabetes.

Diabetes mellitus affects distal small vessels earlier and to a greater extent than proximal vessels. Vascular disease starts from activation of the endothelial cells, which if prolonged may lead to reduced distensibility of the vessel when maximally stimulated. Hence a device which measures distensibility of a distal vessel should be a good biomarker for subclinical disease. We have developed a device capable of measuring reactive hyperaemia induced changes in the radial artery flow, volumetric changes and accompanying effects on the vessel wall. The measurement is based on the magnetic flux disturbance upon haemodynamic modulation as blood flows through a uniformly applied magnetic field, and generates what we have termed the radial artery maximum distensibility index (RA-MDI). In a proof-of-concept study we found significant correlations between RA-MDI and cardiovascular risk factors, scoring systems and carotid artery intima-media thickness. Further large scale prospective studies need to be conducted to ascertain the correlations with cardiovascular events.

Multi-level obstruction in obstructive sleep apnoea: prevalence, severity and predictive factors.

OBJECTIVES: To characterise multi-level obstruction in terms of prevalence, obstructive sleep apnoea severity and predictive factors, and to collect epidemiological data on upper airway morphology in obstructive sleep apnoea patients. METHODS: Retrospective review of 250 obstructive sleep apnoea patients. RESULTS: On clinical examination, 171 patients (68.4 per cent) had multi-level obstruction, 49 (19.6 per cent) had single-level obstruction and 30 (12 per cent) showed no obstruction. Within each category of obstructive sleep apnoea severity, multi-level obstruction was more prevalent. Multi-level obstruction was associated with severe obstructive sleep apnoea (more than 30 events per hour) (p = 0.001). Obstructive sleep apnoea severity increased with the number of obstruction sites (correlation coefficient = 0.303, p < 0.001). Multi-level obstruction was more likely in younger (p = 0.042), male (p = 0.045) patients, with high body mass index (more than 30 kg/m2) (p < 0.001). Palatal (p = 0.004), tongue (p = 0.026) and lateral pharyngeal wall obstructions (p = 0.006) were associated with severe obstructive sleep apnoea. CONCLUSION: Multi-level obstruction is more prevalent in obstructive sleep apnoea and is associated with increased severity. Obstruction at certain anatomical levels contributes more towards obstructive sleep apnoea severity.

Definitive concurrent chemoradiotherapy in cervical cancer--a University of Malaya Medical Centre experience.

BACKGROUND: The efficacy of concurrent chemoradiotherapy in the treatment of locally advanced cervical cancer is well established. We aimed to investigate the long-term efficacy of definitive concurrent chemoradiotherapy for cervical cancer in the University of Malaya Medical Centre. MATERIALS AND METHODS: A cohort of 60 patients with FIGO stage IB2-IVA cervical cancer who were treated with definitive concurrent chemoradiotherapy with cisplatin followed by intracavitary brachytherapy or external beam radiotherapy (EBRT) boost between November 2001 and May 2008 were analysed. Patients were initially treated with weekly intravenous cisplatin (40 mg/m2) concurrent with daily EBRT to pelvis of 45-50 Gy followed by low dose rate brachytherapy or EBRT boost to tumour. Local control rate, progression free survival, overall survival and treatment related toxicities graded by the RTOG criteria were evaluated. RESULTS: The mean age was 56. At the median follow-up of 72 months, the estimated 5-year progression-free survival (PFS) (median PFS 39 months) and the 5-year overall survival (OS) (median OS 51 months) were 48% and 50% respectively. The 5-year local control rate was 67.3%. Grade 3-4 late gastrointestinal and genitourinary toxicity occurred in 9.3% of patients. CONCLUSIONS: The 5-year PFS and the 5-year OS in this cohort were lower than in other institutions. More advanced stage at presentation, longer overall treatment time (OTT) of more than fifty-six days and lower total dose to point A were the potential factors contributing to a lower survival.

Lemierre syndrome-should we anticoagulate? A case report and review of the literature.

Lemierre syndrome is an uncommon condition classically described in acute oropharyngeal infection with septic thrombophlebitis of the internal jugular vein and metastatic septic embolism particularly to the lungs. It is commonly described in young healthy adults with isolation of Fusobacterium necrophorum. We describe a case of Lemierre syndrome in a 50-year-old man with newly diagnosed diabetes mellitus presenting with a neck abscess secondary to Klebsiella pneumoniae. Our patient made good recovery to appropriate antimicrobial therapy, prompt surgical drainage, and anticoagulation. Anticoagulation remains controversial and we review the literature for its role in Lemierre syndrome.

An unexpected cause for aplastic anaemia in an elderly woman.

Aplastic anaemia is a rare clinical syndrome associated with diminished or absent precursors in the bone marrow. Acquired aplastic anaemia secondary to human immunodeficiency virus (HIV) is very rare. We present a 71-year-old woman with severe aplastic anaemia secondary to HIV infection, which was after extensive exclusion of other causes. She achieved undetectable viral load after 5 months of combination antiretroviral therapy but remains profoundly pancytopenic, complicated by recurrent infectious and bleeding complications. HIV infection should be considered in patients with pancytopenia.

Sequential cohort study comparing chlorine dioxide wipes with automated washing for decontamination of flexible nasendoscopes.

INTRODUCTION: Flexible nasoendoscope is an important tool in otorhinolaryngology practice. The endoscope needs to be decontaminated prior to use in the next patient. The 2005 ENT-UK guidance for cleaning fibre-optic laryngoscopes stated that the ideal disinfecting agent and process should be effective and have low capital and maintenance costs. OBJECTIVE: To compare the efficacy and cost-effectiveness of chlorine dioxide wipes versus automated washer, for decontamination of flexible nasendoscopes. METHODS: A sequential cohort, in vitro study was performed to test the efficacy of chlorine dioxide wipes and automated washer. Costs were also calculated. RESULTS: After deliberate bacterial contamination of the nasendoscope and subsequent decontamination, swab samples from the endoscope showed Staphylococcus epidermidis growth in 2 per cent (1/50 swabs) of the chlorine dioxide wipe group and in 28 per cent (14/50 swabs) of the automated washer group (p = 0.00). Based on a projected 10-year cost calculation, the automated washer was cheaper. CONCLUSION: Further studies are required to test whether these results are replicable. A similar study should be performed using real patients, to check the significance of improper decontamination.

Hoarseness secondary to haemodialysis: case report and literature review.

INTRODUCTION: Hoarseness is common and can have a major impact on patients' quality of life. We report a rare case of hoarseness secondary to haemodialysis. CASE REPORT: A 62-year-old man described developing transient hoarseness after haemodialysis sessions, which he underwent three times weekly. Fibre-optic nasendoscopy showed incomplete glottis closure due to bowing of the vocal folds. A computed tomography scan of the neck and thorax was unremarkable. Speech therapy was unhelpful. The renal physicians concluded that no change could be made to his dialysis regime. The patient subsequently underwent injection laryngoplasty with calcium hydroxylapatite, with marked improvement of his symptoms. DISCUSSION: A literature search found one relevant article reporting that 60 per cent of patients suffered post-dialysis hoarseness and decreased vocal fold thickness. It is postulated that dialysis causes dehydration of Reinke's space, affecting vocal fold thickness and the patient's voice. CONCLUSION: Hoarseness caused by haemodialysis is uncharted territory. Further research is required to determine its prevalence and contributing factors.

Retrospective analysis of results of treatment for nasopharyngeal carcinoma in Penang General Hospital from 2001-2005.

BACKGROUND: Nasopharyngeal carcinoma (NPC) is one of the commonest cancers encountered in Malaysia. This study aimed to evaluate the treatment outcomes for patients with NPC treated in Penang General Hospital with specific analysis of prognostic clinicopathological features and treatment modalities. MATERIALS AND METHODS: This retrospective study examined NPC patients between 1st January 2001 and 31st December 2005 in Penang General Hospital. Survival analyses were performed using the Kaplan-Meier method and comparisons between groups were made using the log-rank test. Important prognostic factors including patient demographics, tumour and treatment factors were analysed using the Cox proportional hazard model. RESULTS: A total of 285 patients were identified with a median age of 51 years, 72.6% being males. The majority were Chinese (66%) followed by Malays (31.9%). Primary tumour stages (T stages) 3 and 4 were present in 18.6% and 34% of patients respectively, and nodal disease was present in 80.4%. On overall AJCC staging, 29.1% had stage III and 50.2% had stage IV disease. Some 39.6% of patients had WHO type 3 histology and 7.4% had WHO type 1-2 histology with the remainder having NPC with no subtype reported. Concurrent chemo-irradiation was the commonest treatment received by patients (51.9%) followed by radiotherapy alone (41.8%). The 5 year overall survival and cause specific survival were 33.3% and 42.7% respectively. Age group, T stage, N stage and WHO histological subtype were independent prognostic factors for overall survival on multivariate analysis. For cause specific survival they were T stage and N stage. CONCLUSION: The 5 years overall survival rate was 33.3%. This low figure is primarily due to late presentation. Efforts to detect NPC at earlier stages in Malaysia are urgently needed. These should include public education to increase awareness of the prevalence of this highly treatable disease.

Prognostic factors for elderly breast cancer patients in University Malaya Medical Centre, Malaysia.

BACKGROUND: Information about elderly breast cancer patients' outcome is limited. This study aimed to evaluate the treatment outcomes in women aged 70 and above with specific analysis on prognostic clinicopathological features and treatment modalities. MATERIALS AND METHODS: This retrospective study examined breast cancer patients between 1st January 1994 and 31st December 2004 in UMMC. Survival analysis was performed using the Kaplan-Meier method and comparisons between groups using the log-rank test. Univariate and multivariate analysis on prognostic factors were carried out using the Cox's proportionate hazard model for patient demographics, and tumour and treatment factors. RESULTS: One hundred and thirty six patients were identified, with a median age at diagnosis of 75 years. Most had at least one co-morbidity (61.8%). Only 75.0% had a good performance status (ECOG 0-1). Mean tumour size was 4.4 cm. Primary tumour stages (T stages) 3 and 4 were present in 8.1% and 30.1% of patients respectively, and 30.9% had stage III and 8.8% had stage IV disease based on overall AJCC staging. ER positivity was 58.1%. PR status was positive in 30.1%. Surgery was performed in 69.1% of the patients and mastectomy and axillary clearance were the commonest surgical procedures (50.7%). Some 79.4% of patients received hormonal therapy, 30.1% radiotherapy and only 3.6% chemotherapy. Non-standard treatment was given to 39.0% of patients due to a variety of reasons. The cumulative 5 years overall, relapse free and cause specific survivals were 51.9%, 79.7% and 73.3% respectively. Performance status, T3-4 tumour, presence of metastasis, tumour grade and ER status were independent prognostic factors for overall survival. For cause specific survival they were T4 tumour, presence of metastasis and ER status. CONCLUSION: The 5 years overall survival rate was 51.9% and 41.8% of deaths were non-breast cancer related deaths. Low survival rate was related to low life expectancy in this population. Locally advanced disease, metastatic disease and high ER negative rates play a major role in the survival of elderly breast cancer patients in Malaysia.

Purification and antibacterial activities of an L-amino acid oxidase from king cobra (Ophiophagus hannah) venom

Some constituents of snake venom have been found to display a variety of biological activities. The antibacterial property of snake venom, in particular, has gathered increasing scientific interest due to antibiotic resistance. In the present study, king cobra venom was screened against three strains of Staphylococcus aureus [including methicillin-resistant Staphylococcus aureus (MRSA)], three other species of gram-positive bacteria and six gram-negative bacteria. King cobra venom was active against all the 12 bacteria tested, and was most effective against Staphylococcus spp. (S. aureus and S. epidermidis). Subsequently, an antibacterial protein from king cobra venom was purified by gel filtration, anion exchange and heparin chromatography. Mass spectrometry analysis confirmed that the protein was king cobra L-amino acid oxidase (Oh-LAAO). SDS-PAGE showed that the protein has an estimated molecular weight of 68 kDa and 70 kDa under reducing and non-reducing conditions, respectively. The minimum inhibitory concentrations (MIC) of Oh-LAAO for all the 12 bacteria were obtained using radial diffusion assay method. Oh-LAAO had the lowest MIC value of 7.5 µg/mL against S. aureus ATCC 25923 and ATCC 29213, MRSA ATCC 43300, and S. epidermidis ATCC 12228. Therefore, the LAAO enzyme from king cobra venom may be useful as an antimicrobial agent.(AU)

Immunological changes during progressive stages of vitamin A deficiency in the rat.

The immune status of rats fed a vitamin A-deficient diet (-A) was studied before they reached the weight plateau (stage 1), during the first 5 d of the weight plateau (stage 2) and during late stages of vitamin A deficiency (stage 3). Compared to vitamin A-supplemented (+A) animals, there were no significant differences in the relative splenic weights during the early and later stages of deficiency, but the total yield of isolated splenocytes was lower in -A rats during stages 2 and 3. The weights of the cervical and mesenteric lymph nodes were higher during the later stages of deficiency. In the spleen, concanavalin A (Con A)-induced responses were significantly depressed in -A rats at all three stages of deficiency. In stages 2 and 3 splenic pokeweed mitogen (PWM) responses were lower in -A than in +A rats. There were no changes in lymph node responses in stage 1. The Con A and PWM-induced responses of cervical lymph nodes of -A animals were higher in stages 2 and 3. Mesenteric lymph node responses were also higher in -A rats in stage 3. The alterations in the transformation responses of -A rats could not be explained by changes in the relative proportions of T-cell subsets.