Prevalence and Risk Factors for Obstructive Sleep Apnea Syndrome Among Children and Adolescents with Cleft lip and Palate: A Survey Study in Hong Kong.

OBJECTIVE: To investigate the prevalence of obstructive sleep apnea syndrome (OSAS) risk and related risk factors among children and adolescents of Hong Kong with cleft lip and/or palate (CL/P). DESIGN: Retrospective survey study adopting three questionnaires, obstructive sleep apnea-18 (OSA-18), pediatric sleep questionnaire-22 (PSQ-22), and modified Epworth Sleepiness Scale (ESS). SETTINGS: Multicenter study in two public hospitals. PATIENTS: A total of 351 Chinese children and adolescents with non-syndromic CL/P (6-18-year-old, 57% males) visited between September 2017 and November 2019, with primary palatal repair surgery done before 3-year-old. MAIN OUTCOME MEASURE: Positive OSAS risk was determined based on cut-off ≥60 for OSA-18, ≥8 for PSQ-22, and >8 for ESS. Age, sex, overweight presence, cleft type, embryonic secondary palate involvement, palatal repair surgery, palatal revision surgery, and orthodontic treatment were analyzed as possible risk factors. RESULTS: A total of 9.5% of patients had positive OSAS risk based on OSA-18, 13.6% based on PSQ-22, and 13.2% according to ESS. A higher prevalence of patients with positive OSAS risk was of younger age (OSA-18, p = .034), had cleft involving embryonic secondary palate (PSQ-22, p = .009), and history of fixed orthodontic treatment (ESS, p = .002). The regression model identified only involvement of embryonic secondary palate as a risk factor (PSQ-22, odds ratio = 3.7, p = .015). CONCLUSIONS: OSAS risk among children and adolescents of Hong Kong with CL/P was 9.5% to 13.6%. Patients at higher risk were those with cleft involving embryonic secondary palate. OSAS risk assessment may be influenced by different aspects of the disease spectrum, and a multimodal approach should be considered for such assessment.

Orthodontic plate for management of obstructive sleep apnoea in infants with Pierre Robin sequence: experience and protocol in Hong Kong.

OBJECTIVE: To present the application of the pre-epiglottic baton plate (PEBP) in infants with Pierre Robin sequence (PRS) in the Southern Chinese population (Hong Kong) and to present the diagnosis and management protocol of these infants in our centre. DESIGN: Retrospective case series of three patients with PRS. SETTING: Neonatal Intensive Care Unit in Kwong Wah Hospital and Craniofacial Orthodontic Centre in United Christian Hospital, Hong Kong. PARTICIPANTS: Three new-born infants (two girls, one boy) with PRS and upper airway obstruction due to glossoptosis. METHODS: A protocol for the diagnosis and management of these infants in the Southern Chinese population (Hong Kong) was presented. The three patients received nasal high-flow oxygen and/or continuous positive airway pressure (CPAP) as first-line respiratory support, followed by PEBP for 3-5 months. A two-stage approach was undertaken to ensure accurate positioning of the PEBP. RESULTS: All three infants had improvement in clinical signs, symptoms and polysomnography upon discharge. PEBP and other respiratory aids were weaned off at 3-6 months. CONCLUSIONS: The PEBP, combined with other respiratory support, is a useful modality in the treatment of obstructive sleep apnoea in infants with PRS.

Epidemiology and outcome of Candida bloodstream infection in an intensive care unit in Hong Kong.

OBJECTIVE: To study the epidemiology of Candida bloodstream infection in the Intensive Care Unit. DESIGN: Retrospective study. SETTING: A 22-bed, mixed medical and surgical Intensive Care Unit of a 1400-bed university teaching hospital in Hong Kong. PATIENTS: All adult patients (>18 years) who had at least one blood culture positive for Candida. RESULTS: During the 9 years of the study period, there were 128 patients with episodes of candidaemia (point prevalence, 9.6 per 1000 Intensive Care Unit admissions), 72 entailed albicans candidaemia and 56 non-albicans candidaemia. Albicans was still the predominant species, but the incidence of tropicalis was increasing. The median lengths of hospital and Intensive Care Unit stays prior to taking of the culture revealing candidaemia were 15 and 6 days, respectively. In all, 61% of patients did not have Candida colonisation within 2 weeks of their candidaemia. The main anti-fungal agents used were fluconazole and amphotericin B, but only 89 (70%) of the patients received appropriate anti-fungal treatment. Intensive Care Unit and hospital mortalities were 70% and 78%, respectively. Patients who did not receive appropriate treatment within 3 days had a worse outcome than those who did. CONCLUSIONS: Our data showed a high point prevalence of candidaemia in the Intensive Care Unit. Albicans was still the predominant species. Candidaemia occurred early during Intensive Care Unit stay, and a significant proportion of patients did not have prior fungal colonisation. Candidaemia in the Intensive Care Unit was associated with high morbidity and mortality. Many patients did not receive appropriately early anti-fungal therapy, and endured higher mortality than in the remainder.

Lifetime prevalence of suicide ideation, plan, and attempt in metropolitan China.

OBJECTIVE: This is the first community-based epidemiological study examining the prevalence of suicidal behaviors, their transitional pathways, and their relationship with mental disorders in metropolitan China. METHOD: Suicidal behaviors, including ideation, plans, and attempts were assessed by face-to-face household interviews among 5201 respondents in Beijing and Shanghai in 2001-2002. Lifetime prevalence and risk factors were examined using multivariate discrete-time survival models. RESULTS: The lifetime prevalence estimates of suicidal ideation, plans, and attempts were 3.1%, 0.9%, and 1.0% respectively. Among suicide ideators, the conditional probability of ever making a plan and an attempt was 29.5% and 32.3% respectively. Progression from ideation to plan and attempt was the highest during the first year after onset. Suicide attempt was predicted by young adulthood, being unmarried, recent onset of ideation and plan, and the presence of mental disorders, especially mood disorder. CONCLUSION: Suicidal behaviors in metropolitan China exhibit a low prevalence and an epidemiological profile resembling that found in Western countries.

Delay in initial treatment contact after first onset of mental disorders in metropolitan China.

OBJECTIVE: There has been no community-based research on treatment delay among people with mental disorders in China. This study examines lifetime treatment and treatment delay in metropolitan China. METHOD: A multi-stage probability survey of 5201 respondents was administered in Beijing and Shanghai. Age of first treatment contact after onset of each of the three lifetime DSM-IV/CIDI disorder classes was compared with retrospective information on age of disorder onset. Length and predictors of treatment delay were examined using survival analysis. RESULTS: Survival curves estimate that 44.7%, 25.7%, and 7.9% of people with anxiety, substance, and mood disorders, respectively, will ever make treatment contact. Delays in first treatment contact of anxiety (21 years) and substance (17 years) disorders are longer than that of mood disorders (1 year). These delays are largely unrelated to sociodemographic variables. CONCLUSION: Failure to receive treatment is a pervasive phenomenon among people with mental disorders in metropolitan China.

Intra-operative blood loss and operating time in orthognathic surgery using induced hypotensive general anaesthesia: prospective study.

We investigated the average operating time and extent of intra-operative blood loss in orthognathic surgeries performed using induced hypotensive general anaesthesia, with the intention of devising a practical guideline for blood unit preparation for these procedures. We prospectively studied 32 Chinese patients undergoing surgery to correct dentofacial deformities at a public hospital in Hong Kong from 1 December 1997 to 1 December 1998. Most patients (72. 4%) needed double-jaw surgery. The mean estimated blood loss was approximately 617.6 mL. The blood loss during simple Le Fort I osteotomies was about half that of multiple segmentalised osteotomies. For mandibular ramus osteotomies, the mean blood loss and operating time for were approximately 280 mL and 2 hours, respectively; for anterior mandibular osteotomies, the corresponding values were 171.3 mL and 1 hour 13 minutes. The average drop in the haematocrit value was 15.4%, and the crossmatch to transfusion ratio was 29. A bivariate correlation test between the blood loss and operating time gave a strong correlation (P<0.01), as did blood loss with a drop in haematocrit value (P<0.01). Orthognathic surgeries are thus safe and predictable in terms of intra-operative blood loss and operating time, and a 'type, screen, and save' policy for blood unit preparation is more appropriate than a 'crossmatch' policy.

Comparison of two techniques of patient-controlled sedation with midazolam.

OBJECTIVE: To compare patient-controlled sedation with 1-mg increments of midazolam at 1-min intervals with 0.1-mg increments of midazolam without a lock-out interval. DESIGN: Randomized cross over study. SUBJECTS: 32 patients aged 17-35 years having third molars removed. RESULTS: Doses of midazolam obtained, degree of sedation and operating conditions were similar in the two groups. The demands far exceeded the increments actually received by patients obtaining 0.1-mg increments. Some were extremely sedated with both techniques. CONCLUSIONS: In this age group, there were no significant advantages or disadvantages of one technique over the other. Patients obtained the degree of sedation they required to undergo the operation by pressing the button independently of the dose or incremental interval. So-called 'true' patient-controlled sedation is a misnomer. The cut-off interval proved to be an extremely important safety feature.

Double blind, randomised, placebo controlled study of oral vancomycin in prevention of necrotising enterocolitis in preterm, very low birthweight infants.

AIMS: To evaluate the effectiveness of oral vancomycin in the prophylaxis of necrotising enterocolitis in preterm, very low birthweight infants. METHODS: A prospective, double blind, randomised, placebo controlled study in a tertiary referral centre of a university teaching hospital was conducted on 140 very low birthweight infants consecutively admitted to the neonatal unit. The babies were randomly allocated to receive oral vancomycin (15 mg/kg every 8 hours for 7 days) or an equivalent volume of placebo solution. Prophylaxis was started 24 hours before the start of oral feeds. All suspected cases of necrotising enterocolitis were investigated with a full sepsis screen and serial abdominal radiographs. Necrotising enterocolitis was diagnosed and staged according to modified Bell's criteria. RESULTS: Nine of 71 infants receiving oral vancomycin and 19 of 69 infants receiving the placebo solution developed necrotising enterocolitis (p = 0.035). Infants with necrotising enterocolitis were associated with a significant increase in mortality (p = 0.026) and longer duration of hospital stay (p = 0.002). CONCLUSIONS: Prophylactic oral vancomycin conferred protection against necrotising enterocolitis in preterm, very low birthweight infants and was associated with a 50% reduction in the incidence. However, widespread implementation of this preventive measure is not recommended, as it would only be effective in necrotising enterocolitis caused by Gram positive organisms and could increase the danger of the emergence of vancomycin resistant or dependent organisms. Its use should be restricted to a high prevalence nursery for a short and well defined period in a selected group of high risk patients.

Posterior maxillary anatomy: implications for Le Fort I osteotomy.

The most common site of haemorrhage in maxillary osteotomies is the posterior maxilla. Better understanding of the anatomy in this region may minimize possible vascular complications. The aim of the study was to study the osteology of the posterior maxillary region and establish clinical safety guidelines for the Le Fort I osteotomy Thirty human dry skulls were selected and assessed by a combination of direct inspection, computerized imaging and computed tomography (CT) scan analysis. Results showed that the presence of maxillary third molars influenced the transverse angulation of the posterior vertical cut. Synostosis of the pterygomaxillary junction was noted in 12% of samples. The mean length of the medial sinus wall from the piriform rim to the descending palatine canal at the Le Fort I level was 34 mm. The three-dimensional CT-reconstructed descending palatine canal ran at 60 degrees anteroinferiorly to the palatine plane and slightly medially to the exit through the greater palatine foramen.

Genetic and structural analysis of a virulence determinant in polyomavirus VP1.

The LID strain of polyomavirus differs from other laboratory strains in causing a rapidly lethal infection of newborn C3H/Bi mice. This virulent behavior of LID was attenuated by dilution, yet at sublethal doses LID was able to induce tumors at a high frequency, like its parent virus PTA. By constructing and assaying LID-PTA recombinant viruses and by DNA sequencing, the determinant of virulence in LID was mapped to the major viral capsid protein, VP1. The VP1s of LID and PTA differed at two positions: at 185, LID has phenylalanine and PTA has tyrosine, and at 296, LID has alanine and PTA has valine. Results obtained with viruses constructed by site-directed mutagenesis showed that alanine at position 296 is sufficient to confer a fully virulent phenotype regardless of which amino acid is at position 185. However, with valine at position 296, an effect of phenylalanine at position 185 is apparent, as this virus possesses an intermediate level of virulence. A crystal structure of polyomavirus complexed with 3'-sialyl lactose previously indicated van der Waals contacts between the side chain of valine 296 and the sialic acid ring (T. Stehle, Y. Yan, T. L. Benjamin, and S. C. Harrison, Nature [London] 369:160-163, 1994). When this interaction was modeled with alanine, these contacts were greatly reduced. Direct confirmation that the substitutions in VP1 affected receptor binding was obtained by studying virus hemagglutination behavior. The ensemble of results are discussed in terms of the idea that a lower affinity of the virus for its receptor can result in more rapid spread and increased pathogenicity.

The epidemiology of leprosy in a high prevalence village in Papua New Guinea.

In a village of about 1000 people in Papua New Guinea the prevalence of clinical leprosy was 8.6% compared to about 3% in surrounding villages. This exceptionally high prevalence could not be explained by recent introduction of the disease or by social factors. Dapsone-resistant disease and faulty compliance with treatment are considered to be contributory to persistent infectivity of old cases which, together with the presence of 20 previously undiagnosed cases, comprised a large infective source. Social ostracism of cases was not observed and the extensive social mixing of all ages would facilitate widespread dissemination of infection. A high prevalence, particularly in children, of elevated levels of IgM antibody to phenolic glycolipid-1 Mycobacterium leprae specific antigen suggests frequent subclinical infection. The greater prevalence of clinical leprosy following childhood in the village favours altered susceptibility following exposure in childhood. There was a higher prevalence of leprosy in close relatives of cases when compared with the same relatives of age and sex matched leprosy-free controls. The occurrence of familial clustering of leprosy in a hyperendemic area with intense transmission suggests that unidentified inherited factors influence susceptibility to clinical leprosy. It is suggested that the clustering of adverse inherited traits through intermarriage may explain this hyperendemic focus on leprosy.

A controlled trial of prehospital advanced life support in trauma.

We compared the outcome of 472 trauma patients who required ambulance attention and who received prehospital advanced life support (ALS) with another similar 589 patients who received only basic life support (BLS). Nontrapped, critically injured ALS patients were treated for an average of 13 minutes at the scene of injury, compared with 17 minutes for BLS cases (P less than .05). Seventeen of 37 ALS deaths (36%) occurred within 24 hours of injury, compared with 24 of 33 BLS fatalities (73%) (P less than .05). However, the overall case fatality rate was similar in the two groups, and regression analyses did not demonstrate an impact of ALS care on mortality. ALS resuscitation did not reduce the duration of hospital or intensive care unit stay, or the incidence of disability after head injury. However, the incidence of respiratory failure in the critically injured patients was 5% (ALS) and 19% (BLS) (P less than .025). ALS care appeared to influence patient outcome during the first 24 hours after injury, but had little impact on the later clinical course. Our sample size was too small to rule out any effect of ALS on in-hospital mortality. However, the improved 24-hour survival associated with ALS care suggests some benefit of prehospital resuscitation in major trauma.

The Australian Mesothelioma Surveillance Program 1979-1985.

The Australian Mesothelioma Surveillance Program was planned in 1977 in order to improve diagnostic criteria, to monitor the incidence of the disease, to develop methods of counting lung fibres, and to explore occupational and other associations of mesothelioma. This paper presents a preliminary analysis of data that were collected between January 1, 1980 and December 31, 1985 on the pathological findings and the work and environmental history of 858 cases of mesothelioma. The annual incidence rate of mesothelioma in Australia was 15 per million population who were aged 20 years and over. This is more than the incidence rate of mesothelioma in any other country for which data are available. However, uncertainty over diagnostic criteria and the degree of ascertainment of cases places doubt on the validity of such comparisons. In 69% of cases, a history of work with or other exposure to asbestos was obtained. Due to the long interval between the first exposure to asbestos and the provisional diagnosis of a mesothelioma (up to 60 years), more than three-quarters of the 456 exposed cases first contacted asbestos in the years of its heavy use between 1930 and 1959. This article analyses cases by the industry and the occupation in which exposure to asbestos first occurred.

Effects of guanyl nucleotides on [3H]flunitrazepam binding to rat hippocampal synaptic membranes: equilibrium binding and dissociation kinetics.

The effects of guanyl nucleotides on the binding of [3H]flunitrazepam to rat hippocampal synaptic membranes were studied. In equilibrium binding studies, gamma-amino-n-butyric acid (GABA) increased and GTP decreased the binding affinity of [3H]flunitrazepam; GTP also caused a decrease in binding capacity. The effect, however, is variable. In studies of the dissociation kinetics of [3H]flunitrazepam using diazepam and the antagonist Ro 15-1788 as the displacers, there was evidence of two dissociation rate constants. GTP increased both the fast- and slow-dissociation rate constants and increased the ratio of the slow-dissociation binding state. The effect of GTP was mimicked by its nonhydrolyzable analogue 5'-guanylylimidodiphosphate but not by ATP and occurred when diazepam, but not when Ro 15-1788, was used as the displacer. GABA antagonized the effect of GTP on the dissociation of [3H]flunitrazepam. The nature of the benzodiazepine receptor, its actions, and the possible role of cyclic AMP as a second messenger are discussed.

Studies on the mechanism of modulation of [(3)H]noradrenaline release from rat hippocampal synaptosomes by GABA and benzodiazepine receptors.

Release of [(3)H]noradrenaline from rat hippocampal synaptosomes was triggered by pulses of 25 mM K(+), 5 ?M veratridine or superfusion with the Ca(2+) ionophore A23187. GABA with bicuculline or chlordiazepoxide depressed the release of [(3)H]noradrenaline evoked by depolarisation but not by the Ca(2+) ionophore. 8 Br-cAMP with [Ca(2+)](0) 0.3 mM had no effect on spontaneous or K(+)-evoked release of [(3)H]noradrenaline and completely blocked the effect of chlordiazepoxide and GABA with bicuculline. With [Ca(2+)](0) 1 mM 8 Br-cAMP enhanced spontaneous and K(+)-evoked release of [(3)H]noradrenaline, and reversed the depression caused by GABA with bicuculline. GABA alone evoked Ca(2+)-dependent release of [(3)H]noradrenaline which was sensitive to [Cl(?)](0). The results suggest that the GABA(A)-receptor mediated release of [(3)H]noradrenaline is due to depolarisation resulting from increased Cl(?) conductance whereas the depression of depolarisation-dependent release of [(3)H]noradrenaline by GABA(B) or benzodiazepine receptors is mediated by a cAMP-dependent decrease in the voltage-dependent Ca(2+) conductance.