Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis.

The aim was to evaluate the efficacy and safety of volatile anaesthetic for postoperative sedation in adult cardiac surgery patients through a systematic review and meta-analysis. We retrieved randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Web of Science, clinical trials registries, conference proceedings, and reference lists of included articles. Independent reviewers extracted data, including patient characteristics, type of intraoperative anaesthesia, inhaled anaesthetic used, comparator sedation, and outcomes of interest, using pre-piloted forms. We assessed risk of bias using the Cochrane Tool and evaluated the strength of the evidence using the GRADE approach. Eight studies enrolling 610 patients were included. Seven had a high and one a low risk of bias. The times to extubation after intensive care unit (ICU) admission and sedation discontinuation were, respectively, 76 [95% confidence interval (CI) -150 to - 2, I2=79%] and 74 min (95% CI - 126 to - 23, I2=96%) less in patients who were sedated using volatile anaesthetic. There was no difference in ICU or hospital length of stay. Patients who received volatile anaesthetic sedation had troponin concentrations that were 0.71 ng ml-1 (95% CI 0.23-1.2) lower than control patients. Reporting on other outcomes was varied and not suitable for meta-analysis. Volatile anaesthetic sedation may be associated with a shorter time to extubation after cardiac surgery but no change in ICU or hospital length of stay. It is associated with a significantly lower postoperative troponin concentration, but the impact of this on adverse cardiovascular outcomes is uncertain. Blinded randomized trials using intention-to-treat analysis are required. PROSPERO registry number: 2016:CRD42016033874. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016033874.

Parent-adolescent conflict and adolescent antisocial and prosocial behavior: a longitudinal study in a Chinese context.

This longitudinal study examined the relationships between parent-adolescent conflict and antisocial and prosocial behavior in Chinese adolescents. Results showed that father-adolescent conflict and mother-adolescent conflict were concurrently related to adolescent antisocial and prosocial behavior. Longitudinal analyses showed that parent-adolescent conflict predicted antisocial behavior but not prosocial behavior. Adolescent antisocial and prosocial behavior was also found to be related to father-adolescent conflict across time. The findings suggest that the linkage between father-adolescent conflict and adolescent social behavior is stronger than that between mother-adolescent conflict and adolescent social behavior.

Parental, peer, and teacher influences on the social behavior of Hong Kong Chinese adolescents.

Intensive interviews and self-report questionnaires were used to investigate parental, peer, and teacher influences on the prosocial and antisocial behaviors of Hong Kong Chinese adolescents. Students came from 5 academically different high schools. Results indicated that perceived parental influence was positively associated with frequency of prosocial behavior and negatively associated with frequency of delinquent behavior. Students with good relationships with their parents and peers showed lower frequencies of antisocial behaviors than did students with bad relationships. Adolescents in different identity statuses (achievement, moratorium, foreclosure, diffusion; E. H. Erikson, 1968) showed different patterns of prosocial and antisocial behaviors. For example, adolescents in the identity achievement group exhibited high frequencies of prosocial behaviors and low frequencies of antisocial behaviors, but those in the identity moratorium group exhibited quite high frequencies of both prosocial and antisocial behaviors.

Tumour markers and their prognostic value in adenocarcinoma of the cervix.

Ninety-one patients with adenocarcinoma of the cervix had 4 tumour markers (TMs) assayed before treatment. Serum squamous cell carcinoma antigen (SCC) (n = 91) was raised in 25%; tissue polypeptide antigen (TPA) (n = 78) was raised in 35%; carcinoembryonic antigen (CEA) (n = 34) was raised in 26% and CA 125 (n = 64) was raised in 27% of these patients. In 47 of these 91 patients (52%), 1 or more of the markers were raised. The percentage of patients with raised TM increased with advancing stage. Univariate survival analysis showed that age, stage, raised TPA, raised CA 125, and raised TMs (any one or more) were of prognostic significance. When multivariate analysis was done and each TM was individually analysed, only age, stage and raised CA 125 were of prognostic significance. Rising SCC or TPA or CA 125 levels in serial estimations correlated well with the occurrence of recurrence. Thus, pretreatment estimation of SCC, TPA and CA 125 can be used to identify the patients who can subsequently be monitored by serial TM estimation.

Intrascleral dissemination of infectious scleritis following pterygium excision.

AIMS: To assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision. METHODS: The records of patients with infectious scleritis after pterygium excision who developed multifocal scleral abscesses presenting from 1988 to the end of 1995 were reviewed. Early culture of abscesses was performed, and topical, systemic antimicrobials, or both were given to all patients. Fourteen eyes were operated on in addition to antimicrobial treatment. RESULTS: The initial culture reports of scleral ulcers identified Pseudomonas species in 12 of these 18 patients, Aspergillus in one, Mycobacterium fortuitum in one, and mixed organisms in four. Subsequent abscess cultures were taken from 15 of the infected eyes, and revealed the same organism as the initial culture in 12. Associated complications included four serous retinal detachments, three choroidal detachments, two double detachments, five complicated cataracts, and four recurrences of the initial infection. Four eyes required eventual enucleation and 11 eyes regained useful vision. CONCLUSIONS: With subsequent abscess cultures proving to be the same organism as found in the initial ulcer, the abscess formation appears to represent intrascleral dissemination. Early diagnosis and appropriate, prolonged topical plus systemic antimicrobial treatment are essential to halt the progression of such severe infections.

Conceptions of success: their correlates with prosocial orientation and behaviour in Chinese adolescents.

Data from a sample of 673 Chinese adolescents lent support to the hypothesis that conceptions of success or achievement goals affect both the inclination to and the actual performance of prosocial acts. With regard to attitude, it was found that: (a) task orientation (belief that success is gaining skill or understanding) and collaboration orientation (belief that success is working productively with one or more collaborators) increased with the inclination to help others, to co-operate and share things with others, to maintain an affective relationship with others, and to behave in compliance with social norms; and (b) ego orientation (belief that success is establishing one's competence as superior) was not generally associated with the inclination to perform prosocial acts. With regard to action, it was found that task orientation and collaboration orientation, but not ego orientation, increased with the number of normative and altruistic acts in the past year. The similarity between the belief-attitude correlation and the belief-action correlation indicates the robustness of the influence of conceptions of success. Also, sex differences and grade differences in the relationship between conceptions of success and prosocial and antisocial behaviours were found. Implications of the findings are discussed.

The relation of prosocial and antisocial behavior to personality and peer relationships of Hong Kong Chinese adolescents.

The prosocial and antisocial behaviors of 2,862 Hong Kong Chinese adolescents were investigated. The major findings were as follows: (a) boys were more antisocial than girls: (b) negative peer influences were significantly stronger in boys than in girls, whereas positive peer influences were significantly stronger in girls than in boys; (c) antisocial adolescents tended to perceive their best friend as antisocial and exerting more negative influences on them, whereas prosocial adolescents tended to perceive their best friend as prosocial and exerting more positive influences on them; (d) antisocial behavior was positively associated with psychoticism and neuroticism; and (e) academic achievement tended to have a positive relation with prosocial behavior and a negative relation with antisocial behavior.

A multicentre study to investigate the prevalence of abnormal carbohydrate metabolism in Chinese pregnant women.

OBJECTIVES: To determine the prevalence of abnormal carbohydrate metabolism in Chinese pregnant women. To study the inter-relationship between maternal body habitus, maternal serum glucose and birth weight of the baby. METHODS: Multicentre observational study involving 713 pregnant Chinese women, attending antenatal clinics in Beijing, Shanghai, Guangzhou and Hong Kong. RESULTS AND CONCLUSION: The overall prevalence of abnormal glucose tolerance was 6.9%. The prevalence was 6.8%, 5.5%, 7.2% and 8.1% in Beijing, Shanghai, Guangzhou and Hong Kong, respectively. The differences among the centres did not reach statistical significance (p = 0.9). The mean ponderal index of women with abnormal glucose tolerance was significantly higher than that of women with normal glucose tolerance (15.2 vs 14.3, p < 0.01). The birth weight ratio of the babies was positively correlated with the maternal height (correlation coefficient 0.23, 95% C.I. 0.15-0.30), weight (0.32, 95% C.I. 0.25-0.39) and to a lesser extent, the fasting level of serum glucose (0.10, 95% C.I. 0.02-0.28) but not with the 2 hour level of serum glucose.

Prognostic significance of serum tumour markers in carcinoma of the cervix.

PURPOSE: The purpose was to evaluate the prognostic significance of serum tumour markers and other potential prognostic factors in cervical cancer. MATERIALS AND METHODS: Five hundred and thirty-one patients with cervical cancer were studied. The pre-treatment levels of SCC (squamous cell carcinoma antigen), TPA (tissue polypeptide antigen), CEA (carcinoembryonic antigen), CA125 and hCG (human chorionic gonadotrophin) were assayed in these patients. Possible association between raised tumour markers and potential prognostic factors and their prognostic significance were sought by univariate and multivariate Cox analysis. RESULTS: SCC was raised in 65% of squamous cell carcinoma of the cervix and TPA was raised in 50%. Other markers were raised in less than 25%. No tumour markers were raised more than 30% in adenocarcinoma of the cervix. Raised SCC and TPA were related to advancing age, stage and grade of differentiation. Univariate analysis showed that age, stage, grade, raised SCC and TPA were significant prognostic factors on survival. Multivariate Cox analysis showed that stage was the most significant factor. CONCLUSION: Stage, age, grade of differentiation, raised pre-treatment levels of SCC and TPA were significant prognostic factors in cervical cancer using univariate analysis. However, only stage remains the most important independent prognostic factor in multivariate analysis. The prognostic value of these other factors in early stage disease needs further exploration.

Pregnancies complicated by acute appendicitis.

Appendicitis is one of the most common acute abdominal conditions that requires operation during pregnancy. The maternal and fetal complications occurring in such situations are well known. However, the diagnostic and therapeutic challenges of acute appendicitis complicating pregnancy persist in current surgical practice. Thirty-eight obstetric cases who had an appendicetomy performed during pregnancy between 1986 and 1993, were reviewed. In 31 cases, acute appendicitis was proven at laparatomy, and by subsequent histopathology. In the confirmed cases, seven occurred in the first trimester, 12 in the second trimester, eight in the third trimester and four in the immediate postpartum period. Two miscarriages occurred in the first trimester group, and two late abortions and two preterm (26 and 28 weeks) deliveries occurred in the second trimester group. In the third trimester/postpartum group, all babies survived, but four patients had Caesarean sections with the appendicetomy and the incidence of perforated/gangrenous appendices was highest. Perinatal outcome was worst, with the highest fetal wastage rate if the acute appendicitis occurred in the second trimester, although maternal morbidity appeared to be the same across different gestational periods.

Reducing the induction to abortion interval in termination of second trimester pregnancies: a comparison of mifepristone with laminaria tent.

OBJECTIVE: To determine whether mifepristone (RU486) is more effective than laminaria tent in shortening the induction-abortion interval in termination of second trimester pregnancies with gemeprost. DESIGN: Prospective randomised comparative trial. SETTING: Department of Obstetrics and Gynaecology in a University teaching hospital. SUBJECTS: Sixty-two women undergoing termination of pregnancy in the second trimester. INTERVENTIONS: The women were allocated at random to one of the two treatment groups. The first group received 600 mg of mifepristone 36 h before administration of gemeprost. In the second group, a medium-sized laminaria tent was inserted 12 h before gemeprost. The pregnancies in both groups were terminated with vaginal gemeprost, 1 mg every 3 h up to a maximum of 5 mg/day. MAIN OUTCOME MEASURES: Induction-abortion intervals, amount of gemeprost required, and incidence of side effects. RESULTS: The median induction-abortion interval in the mifepristone group (7.5 h) was significantly shorter than that in the laminaria tent group (11 h) and significantly fewer gemeprost pessaries were required. There was no significant difference in the amount of narcotic analgesics required or the incidence of side effects between the two groups. CONCLUSIONS: Mifepristone is more effective than laminaria tent in shortening the induction-abortion interval in termination of second trimester pregnancies.

Oral misoprostol versus placebo for cervical dilatation before vacuum aspiration in first trimester pregnancy.

Intravaginal misoprostol has been shown to be effective for cervical priming before a surgically induced abortion. The objective was to investigate the effectiveness of oral misoprostol in cervical dilatation prior to vacuum aspiration between the 6th and 12th weeks of pregnancy. The results showed that in nulliparous patients, the median cervical dilatation in the treatment group (7.8 mm) was significantly greater than that in the placebo group (3.7 mm). In multiparous patients, the difference was also statistically significant (9.8 versus 6.0 mm). The ease of dilatation, assessed subjectively by the operating surgeons, was significantly improved in the treatment group. There was also a significant reduction in the duration of the operation and in the mean blood loss in the treatment group. The side-effects encountered in the treatment group were mild and well accepted by the women. Oral misoprostol is an effective and safe method for cervical dilatation prior to vacuum aspiration in first trimester pregnancy.

PIP: The effectiveness of oral misoprostol for cervical dilatation prior to first-trimester (6-12 weeks of pregnancy) vacuum aspiration was evaluated in a case-control study of 75 women referred to a Hong Kong clinic for induced abortion. 36 women were randomly assigned to receive misoprostol (400 mcg 12 hours before the procedure), while 39 women were given a placebo; 21 women in the treatment group and 22 controls were nulliparous. Among nulliparous women, median cervical dilatation was significantly greater in the treatment group (7.8 mm) than the placebo group (3.7 mm). In multiparous women, these medians were 9.8 and 6.0 mm, respectively. The ease of further dilatation, subjectively assessed by operating surgeons, was rated easier than normal in 88% of women in the treatment group compared with 26% of controls. There was also a significant reduction in the median duration of vacuum aspiration in nulliparous cases (4.5 minutes) compared with controls (5.5 minutes) and in median blood loss (20 and 28 ml, respectively). Side effects (lower abdominal pain, vaginal spotting, nausea) were mild and well-tolerated in both groups. These findings suggest that oral misoprostol is a safe, cost-effective (US$0.40 per tablet) alternative for cervical priming prior to vacuum aspiration.

The prevalence and clinical significance of pulmonary infection due to non-tuberculous mycobacteria in Hong Kong.

An unexpected increase in positive sputum cultures of non-tuberculous mycobacteria (NTM) was noted in Hong Kong in 1990 compared to previous years, in contrast to a steady decline in the number of positive cultures of Mycobacterium tuberculosis. A retrospective case note study was therefore undertaken to ascertain the clinical importance of the rise in NTM isolates. A representative sample of 183 of the 675 patients with NTM isolates from sputum during 1990 was identified. Cases were assigned to groups according to whether there was evidence of progressive pulmonary disease due to NTM (group 1), persisting colonization without evidence of progressive disease (group 2) or transient isolation of NTM without evidence of progressive disease (group 3). Of 168 cases with adequate clinical and radiological records, 28 (16.7%) represented progressive disease due to NTM and 6 (3.6%) represented persisting colonization. The remainder were both transient and clinically insignificant. Most patients (71%) with progressive pulmonary disease due to NTM had pre-existing lung damage, and 50% had received anti-tuberculous therapy for documented M. tuberculosis previously. The commonest organism involved was the M avium complex. Eighty-six percent of patients with progressive disease and 83% of those with persisting colonization had at least one smear positive sputum specimen, whereas only 2% of patients with sputum contamination had a smear positive sputum sample (P < 0.0001). M. malmoense, M. xenopi and M. fortuitum all appear to be rare causes of significant NTM disease in Hong Kong. However, M. chelonei caused four cases of progressive disease within the study population, two of which were fatal.(ABSTRACT TRUNCATED AT 250 WORDS)

Problems in the use of urinary hCG-beta-core as a tumor marker in gynecologic cancer.

Urinary human chorionic gonadotrophin beta-core (hCG-betaC) was detected in 55-77% of gynecologic malignancies. The use of spot and early morning urine hCG-betaC as a tumor marker was explored with regard to the stability of the hCG-betaC level in serial spot urine samples collected within 24 hours and in early morning urine collected over 3 days. Thirteen patients with gynecologic malignancies were asked, before treatment, to collect serial urine samples voided within 24 hours. Nine of these 13 patients were also asked to save early morning urine for 2-3 consecutive days. Their urine was assayed for creatinine and hCG-betaC using an immunoradiometric assay. Variation of urine concentration was corrected by using the hCG-betaC/creatinine (betaC/Cr) ratio expressed in pmolg-1. Wide fluctuations of betaC/Cr ratios were found both in the serial spot urine within 24 hours and in early morning urine within 3 days. Eight per cent of the patients had one or more spot hCG-betaC level double or half the median of their own serial urine samples. Neither spot urine nor early morning urine hCG-betaC were suitable for use as a tumor marker for continuous monitoring because of the large fluctuation in hCG-betaC levels. The reason for such a wide fluctuation is not clear.

Detection of heterozygous XY complete hydatidiform mole by chromosome in situ hybridization.

Complete hydatidiform mole has a substantial risk of developing persistent gestational trophoblastic disease (PTD). Whether heterozygous complete moles, arising from dispermy, have a higher risk of such progression than their homozygous counterparts is controversial. In this study, the frequency of heterozygous XY complete mole in 93 consecutive cases of histologically proven complete moles managed in Hong Kong was assessed by the technique of chromosome in situ hybridization (CISH) using DNA probes specific for the short arm of the Y chromosome. The incidence of Y-chromosome positive complete mole in the groups of patients with spontaneous remissions and the group with PTD with or without metastasis was also compared. The presence of Y chromosome was identified in 6 of the 93 cases (6.5%), and this incidence fell within the range reported in the world literature. Of these 93 patients, 5 patients defaulted follow-up, while 10 patients developed PTD, with evidence of metastasis in 2 of them. The presence of Y chromosome was also assessed in another 15 patients with documented metastatic PTD. It was found that CISH signals for Y chromosome were identified in 5.1% (4/78) of complete moles with spontaneous remission and 8% (2/25) with PTD with or without metastasis (P > 0.05). Y chromosome was detected in 5.9% (1/17) of the complete moles that developed metastasis and in 5.8% (5/86) of the complete moles that either developed spontaneous remission or developed nonmetastatic PTD (P > 0.05). There is no correlation between the presence of Y chromosome and development of persistent gestational trophoblastic disease.

Maternal mortality in Hong Kong 1986-1990.

PIP: The reported rate of maternal mortality in Hong Kong fell from 45/100,000 births in 1961 to 5/100,000 in 1985. The most commonly reported cause of maternal mortality over the period was hemorrhage during pregnancy and childbirth. Other major causes of maternal mortality included pre-eclampsia and ectopic pregnancy. Reviewing annual departmental reports of the Director of Medical and Health Services in Hong Kong over the period 1986-90, the authors found 15 reported maternal deaths and 357,297 total births for a maternal mortality rate of 4/100,000 total births. Eight deaths were due to obstetrical pulmonary embolism, five from hemorrhage during pregnancy and childbirth, and two due to pregnancy with abortive outcome. Although Hong Kong has a low rate of maternal mortality by international standards, it is necessary to monitor it and notice changes in causes so that appropriate action may be taken when needed. The authors discuss potential rationale for the predominance of pulmonary embolism observed in this recent study.^ieng

Cardiac blood flow studies in fetuses with haemoglobin Bart's disease.

Blood flow across the atrioventricular valves and outflow tracts was measured in 55 normal fetuses and 32 fetuses with haemoglobin (Hb) Bart's disease between 18 and 26 weeks of gestation. The mean velocities remained unchanged in both normal and affected fetuses over the gestations studied. The volume flow across both atrioventricular valves and outflow tracts increased as the gestation advanced in both normal and affected fetuses, but was significantly higher in affected than in normal fetuses. The same magnitude of increased flow was found in both hydropic and non-hydropic fetuses with Hb Bart's disease. These findings suggest that fetuses with severe and long-standing anaemia have a remarkable cardiac compensatory mechanism for the maintenance of tissue oxygenation. In response to anaemia and circulatory loading, the cardiac chambers and outflow tracts enlarge proportionately up to twice the normal values. Because of this response and the operation of the Frank-Starling mechanism, the heart is able to maintain a normal mean velocity of propulsion and the net output is increased to two to three times that in normal fetuses. Hydropic changes in these anaemic fetuses appear unrelated to cardiac failure as cardiac failure is not observed at the time that hydropic changes develop.

HPV and p53 in cervical cancer.

OBJECTIVE: To determine the prevalence of HPV 16 and 18 E6 by DNA detection and p53 abnormal protein expression in cervical cancers in Hong Kong. MATERIALS AND METHODS: Seventy-three squamous cell cervical cancer biopsy were analysed. Detection of HPV DNA was carried out by the polymerase chain reaction and Southern blotting (PCR/SB) technique using primers to the HPV16 & 18 E6 region and consensus primers to the L1 region. Abnormal expression of the p53 protein was detected by immunohistochemical staining (IHS) using the antibody CM1 on frozen sections of 55 cervical cancer samples. Forty-six samples were analysed for both the presence of HPV DNA and abnormal expression of p53. RESULTS: 67.2% of the 64 samples showed the presence of HPV 16 E6 DNA and 39.1% showed the presence of HPV 18 E6 DNA. 32.8% showed the presence of both HPV 16 and 18 E6 DNA. No HPV DNA was shown in 10.9% of samples. Only 3.6% (2) of 55 samples showed positive IHS with CM1. One occurred in a HPV negative sample and the other in a HPV positive sample. CONCLUSION: A high prevalence of HPV DNA was detected in cervical cancer in Hong Kong using the PCR/SB technique. However, abnormal expression of p53 was uncommon amongst patients with or without HPV 16 or 18 infection.

Expression of the p53 gene in trophoblastic cells in hydatidiform moles and normal human placentas.

In this study we compared the expression of p53 in six early placentas and eight hydatidiform moles using Northern blotting. A higher expression of p53 in hydatidiform moles as compared to normal placentas of comparable gestational age was observed. Immunohistochemical studies did not detect mutant protein of p53 in the hydatidiform moles. DNA sequencing was performed on four of the hydatidiform moles with increased expression of p53, but no mutations could be detected. The possible role of p53 in the pathogenesis of hydatidiform mole is discussed.