Life After Surviving Fontan Surgery: A Meta-Analysis of the Incidence and Predictors of Late Death.

AIM: We now know that 20-40% of patients with a single ventricle will develop heart failure after the second decade post-Fontan surgery. However, we remain unable to risk-stratify the cohort to identify patients at highest risk of late failure and death. We conducted a systematic review of all reported late outcomes for patients with a Fontan circulation to identify predictors of late death. METHODS: We searched MEDLINE, Embase and PubMed with subject terms ("single ventricle", "Hypoplastic left heart syndrome", "congenital heart defects" or "Fontan procedure") AND ("heart failure", "post-operative complications", "death", "cause of death", "transplantation" or "follow-up studies") for relevant studies between January 1990 and December 2015. Variables identified as significant predictors of late death on multivariate analysis were collated for meta-analysis. Survival data was extrapolated from Kaplan-Meier survival curves to generate a distribution-free summary survival curve. RESULTS: Thirty-four relevant publications were identified, with a total of 7536 patients included in the analysis. Mean follow-up duration was 114 months (range 24-269 months). There were 688 (11%) late deaths. Predominant causes of death were late Fontan failure (34%), sudden death (19%) and perioperative death (16%). Estimated mean survival at 5, 10 and 20 years post Fontan surgery were 95% (95%CI 93-96), 91% (95%CI 89-93) and 82% (95%CI 77-85). Significant predictors of late death include prolonged pleural effusions post Fontan surgery (HR1.18, 95%CI 1.09-1.29, p<0.001), protein losing enteropathy (HR2.19, 95%CI 1.69-2.84, p<0.001), increased ventricular end diastolic volume (HR1.03 per 10ml/BSA increase, 95%CI 1.02-1.05, p<0.001) and having a permanent pacemaker (HR12.63, 95%CI 6.17-25.86, p<0.001). CONCLUSIONS: Over 80% of patients who survive Fontan surgery will be alive at 20 years. Developing late sequelae including protein losing enteropathy, ventricular dysfunction or requiring a pacemaker predict a higher risk of late death.

A hybrid approach for fusing 4D-MRI temporal information with 3D-CT for the study of lung and lung tumor motion.

PURPOSE: Accurate visualization of lung motion is important in many clinical applications, such as radiotherapy of lung cancer. Advancement in imaging modalities [e.g., computed tomography (CT) and MRI] has allowed dynamic imaging of lung and lung tumor motion. However, each imaging modality has its advantages and disadvantages. The study presented in this paper aims at generating synthetic 4D-CT dataset for lung cancer patients by combining both continuous three-dimensional (3D) motion captured by 4D-MRI and the high spatial resolution captured by CT using the authors' proposed approach. METHODS: A novel hybrid approach based on deformable image registration (DIR) and finite element method simulation was developed to fuse a static 3D-CT volume (acquired under breath-hold) and the 3D motion information extracted from 4D-MRI dataset, creating a synthetic 4D-CT dataset. RESULTS: The study focuses on imaging of lung and lung tumor. Comparing the synthetic 4D-CT dataset with the acquired 4D-CT dataset of six lung cancer patients based on 420 landmarks, accurate results (average error <2 mm) were achieved using the authors' proposed approach. Their hybrid approach achieved a 40% error reduction (based on landmarks assessment) over using only DIR techniques. CONCLUSIONS: The synthetic 4D-CT dataset generated has high spatial resolution, has excellent lung details, and is able to show movement of lung and lung tumor over multiple breathing cycles.

A spatiotemporal-based scheme for efficient registration-based segmentation of thoracic 4-D MRI.

Dynamic three-dimensional (3-D) (four-dimensional, 4-D) magnetic resonance (MR) imaging is gaining importance in the study of pulmonary motion for respiratory diseases and pulmonary tumor motion for radiotherapy. To perform quantitative analysis using 4-D MR images, segmentation of anatomical structures such as the lung and pulmonary tumor is required. Manual segmentation of entire thoracic 4-D MRI data that typically contains many 3-D volumes acquired over several breathing cycles is extremely tedious, time consuming, and suffers high user variability. This requires the development of new automated segmentation schemes for 4-D MRI data segmentation. Registration-based segmentation technique that uses automatic registration methods for segmentation has been shown to be an accurate method to segment structures for 4-D data series. However, directly applying registration-based segmentation to segment 4-D MRI series lacks efficiency. Here we propose an automated 4-D registration-based segmentation scheme that is based on spatiotemporal information for the segmentation of thoracic 4-D MR lung images. The proposed scheme saved up to 95% of computation amount while achieving comparable accurate segmentations compared to directly applying registration-based segmentation to 4-D dataset. The scheme facilitates rapid 3-D/4-D visualization of the lung and tumor motion and potentially the tracking of tumor during radiation delivery.

Cross-reactive neutralizing antibody epitopes against Enterovirus 71 identified by an in silico approach.

Currently, infections of hand, foot and mouth disease (HFMD) due to Human Enterovirus 71 (EV71) cannot be prevented or treated, as there are no suitable vaccines or antiviral drugs. This study aimed to identify potential vaccine candidates for EV71 using in silico analysis of its viral capsid proteins. A combined in silico approach utilizing computational hidden Markov model (HMM), propensity scale algorithm, and artificial learning, identified three 15-mer structurally conserved B-cell epitope candidates lying within the EV71 capsid proteins. Peptide vaccine candidates incorporating a target B-cell epitope and a promiscuous T-cell epitope from the related polio virus were synthesized using solid-phase Fmoc chemistry. Inbred BALB/C mice which were inoculated with two 10µg doses of the synthetic peptide, generated anti-peptide antibodies. Purified IgG isolated from pooled sera of the inoculated mice neutralized EV71 infections in vitro. Furthermore, these neutralizing antibodies were cross-reactive against other members of the Picornaviridae family, demonstrating greater than 50% virus neutralization. This indicates that the current approach is promising for the development of synthetic peptide-based vaccine candidates against Picornaviridae. Development of effective vaccines is of paramount importance in managing the disease in the Asia Pacific regions where this virus is endemic and has significant social, economic and public health ramifications.

Novel multiplex oligonucleotide-conjugated bead suspension array for rapid identification of enterovirus 71 subgenogroups.

A high-throughput multiplex bead suspension array was developed for the rapid subgenogrouping of EV71 strains, based on single nucleotide polymorphisms observed within the VP1 region with a high sensitivity as low as 1 PFU. Of 33 viral isolates and 55 clinical samples, all EV71 strains were successfully detected and correctly subgenogrouped.

Utilisation of emergency medical service among Singapore patients presenting with ST-segment elevation myocardial infarction: prevalence and impact on ischaemic time.

BACKGROUND: Previous studies in Western countries found that the emergency medical service (EMS) was under-used in patients with myocardial infarction. AIM: We sought to determine the prevalence of immediate EMS utilisation among Singapore patients presenting with ST-segment elevation myocardial infarction (STEMI), and correlated the use of the EMS with the symptom-to-balloon and door-to-balloon times. METHODS: We studied 252 patients admitted with STEMI to our institution from August 2008 to September 2009. Information regarding demographic characteristics, whether EMS was used, reperfusion procedural details and mortality rates were collected prospectively. RESULTS: Among the recruited patients, 89 (35.3%) used the EMS (EMS group) and 163 (64.7%) did not use the EMS (non-EMS group). In the latter group, 98 (60.1%) arrived at our institution through their own transport, 56 (34.4%) first consulted general practitioners, and 9 (5.5%) initially consulted another hospital without acute medical services. Among the 245 (out of 252, 97.2%) patients who received percutaneous coronary intervention (PCI), the EMS group was more likely to undergo primary PCI (P= 0.003) while the non-EMS group was more likely to undergo non-urgent PCI (P= 0.002). In patients who underwent primary PCI, the EMS group had a shorter symptom-to-balloon time (average difference 81.6 min, P= 0.002). The door-to-balloon time was similar for both groups. CONCLUSION: Despite the availability of a centralised EMS, 64.7% of patients with STEMI did not contact EMS at presentation. These patients were less likely to receive primary PCI and had a significantly longer symptom-to-balloon time.

Prevalence and predictors of premature discontinuation of dual antiplatelet therapy after drug-eluting stent implantation: importance of social factors in Asian patients.

AIM: Premature discontinuation of antiplatelet therapy is an independent predictor of late stent thrombosis. We sought to determine the prevalence and predictors of premature discontinuation of antiplatelet therapy after drug-eluting stent implantation among patients in Asia. METHODS: A total of 207 consecutive patients who underwent drug-eluting stent implantation at our institution was followed up after 1 year. Premature discontinuation of antiplatelet therapy was defined as omission of aspirin and/or clopidogrel for 1 week or more. RESULTS: Four (1.9%) patients died and the remaining 203 patients formed the study population. Prevalence of premature discontinuation of antiplatelet therapy was 12.8% (n= 26, aspirin, n= 12; clopidogrel, n= 9; both, n= 5). The median duration between stent implantation and discontinuation of antiplatelet therapy was 2.8 months. Reasons for discontinuation included cost (n= 1), gastric discomfort (n= 1), allergy (n= 3), bleeding (n= 3), advice from doctors (n= 7) and no reason (n= 11). Logistic regression showed that living alone was the only independent predictor of premature discontinuation of dual antiplatelet therapy (50.0% vs 11.3%, P= 0.001). CONCLUSION: Among Asian patients who have undergone drug-eluting stent implantation, 12.8% discontinued dual antiplatelet therapy within 12 months. Living alone is associated with a fivefold increase in risk of premature drug discontinuation.

The largest outbreak of hand; foot and mouth disease in Singapore in 2008: the role of enterovirus 71 and coxsackievirus A strains.

BACKGROUND: During 2008, Singapore experienced its largest ever outbreak of hand, foot and mouth disease (HFMD), resulting in 29686 cases, including four cases of encephalitis and one fatality. METHODS: A total of 51 clinical specimens from 43 patients with suspected HFMD at the National University Hospital, Singapore were collected for virus isolation and identification by reverse transcription polymerase chain reaction (RT-PCR) and sequencing. RESULTS: Enteroviruses were identified in 34 samples (66.7%), with 11 samples (21.6%) being positive for enterovirus 71 (EV71). Other non-EV71 enteroviruses (including coxsackievirus A4, A6, A10, and A16) were identified in 23 samples (45.1%). The most prevalent virus serotypes were CA6, CA10, and EV71. CA6 and CA10 accounted for 35.3% of all HFMD cases, which may explain the high transmissibility and low fatality that characterized this unprecedented epidemic associated with relatively mild disease. Phylogenetic analyses of 10 circulating EV71 strains indicated that they belonged to two subgenogroups, i.e., B5 (80%) and C2 (20%). The VP1 sequences of the 2008 EV71 strains also exhibited continuous mutations during the outbreak, reflecting the relatively high mutation rate of the EV71 capsid protein, which may have implications for future vaccine development. CONCLUSIONS: A safe and effective vaccine against EV71 is certainly warranted in view of its potential neurovirulence and its role in HFMD epidemics of recurring frequency with resultant fatalities in Asia, as well as other parts of the world.

Experimental analysis of spectral characteristics of antiresonant guiding photonic crystal fibers.

Both numerical and experimental analyses are carried out to investigate the spectral characteristics of antiresonant guiding photonic crystal fibers. The transmission minima were observed at the wavelengths where LP(ml) (m

Identification of immunodominant VP1 linear epitope of enterovirus 71 (EV71) using synthetic peptides for detecting human anti-EV71 IgG antibodies in Western blots.

A major IgG-specific immunodominant VP1 linear epitope of enterovirus 71 (EV71) strain 41 (5865/SIN/00009), defined by the core sequence LEGTTNPNG, was identified by Pepscan analysis. Oligonucleotides corresponding to the amino-acid sequence of synthetic peptide SP32 were cloned and over-expressed in Escherichia coli as a recombinant glutathione-S-transferase (GST)-SP32 fusion protein. In ELISAs, this protein did not react with human anti-EV71 IgG antibodies, but there was significant immunoreactivity according to western blot analysis. The amino-acid sequence of SP32 was highly specific for detecting EV71 strains in western blot analysis, and showed no immunoreactivity with monoclonal antibodies raised against other enteroviruses, e.g., CA9 and Echo 6.

Cartilage thickness visualization using 2D WearMaps and TrackBack.

Osteoarthritis (OA) has a significant impact in terms of morbidity, quality of life, economic and social cost. It is the most prevalent form of arthritis - affecting a large proportion of the population, internationally. The use of Magnetic Resonance (MR) Imaging (MRI) has gained significant support. MRI allows detailed, multi-planar analysis of the joint anatomy, as well as cartilage and underlying bone status; with the ability to view articular surfaces at any angle. In this paper we describe a user interface to visualize the articular cartilage thickness using 2D WearMap derived using MR knee images. The user interface comprises an interactive function (TrackBack) which allows to the Clinician to easily and rapidly refer to the radiological information (e.g. MR images), while maintaining the geometric integrity between the WearMap and the MR image.

An MRI derived articular cartilage visualization framework.

OBJECTIVE: We present a multi-dimensional framework for the visualization of femoral articular cartilage. The framework comprises methods for visualizing and quantifying changes in cartilage thickness and surface morphology derived from MRI based cartilage segmentation. Adequate visualization of cartilage allows accurate and clinically meaningful assessment of cartilage surface morphology and thickness. In current practice the routine use of conventional 2D MR images provides limited qualitative information and is inconvenient because the imaged volume has to be reviewed slice by slice. METHOD: A Graphical User Interface (GUI) that encapsulates the framework described above was developed. In the first stage of the analysis MR images of the knee are segmented to delineate cartilage boundaries. Cartilage thicknesses are subsequently measured. The detected points and corresponding thickness data are utilized to produce a visualization framework. RESULTS: The system was tested using data from six example patients. The spatial distribution of cartilage on the articular surface was visualized using a 3D WearMap. The 2D WearMap allowed the entire cartilage surface to be studied at once. Quantitative interaction with the 2D WearMap was assisted by the ability to ascertain cartilage surface dimensions and TrackBack from a point of interest to the original MR image. As a result, the detection of wear patterns and lesions was efficiently carried out. CONCLUSION: A means of quantitatively visualizing cartilage defects non-invasively is presented. This stands to reduce clinician reporting times, as well as allowing quantitative follow-up that facilitates osteoarthritis (OA) screening and planning/evaluating interventions.

Geometric Framework linking different levels of the Biological Continuum.

With the increasing importance of molecular and cellular biology, a new type of medicine, molecular based medicine, is now developing. This will significantly alter the way in which medicine is practiced. Central to these developments is the concept of the Biological Continuum (BC). Medicine today is often practiced at one or two of these levels, i.e. there is generally no vertically integrated approach. In any area of application there will be a wide range of data (both 2-D and 3-D) across the BC. Hence, there is a need to readily access and view the full range of data. In this paper we describe a web-based interface which allows the user to view images and other data, and to navigate seamlessly from one level of the BC to another level (e.g. from Visceral to Tissue). We present a geometric framework to link images from these two levels. The interface was developed using SVG and Javascript. An example case study, which focuses on the knee, is presented MR images of knee at the visceral level and histology images of cartilage at the tissue level. We have shown that with such an interface it is possible to view images from different levels of the BC in a vertically integrated manner.

Viewing interfaces for segmentation and measurement results.

In the paper we describe a web-based interface to view 2-D and 3-D results generated from segmentation and measurement process interactively. Our implementation takes a fully web-based approach to provide universal access and visualization to a wide range of patient data (i.e. at multiple locations). An example case study is presented: thickness measurement of articular cartilage from MR knee images used in the diagnosis of osteoarthritis (OA).

Identification of amino acid residues essential for catalytic activity of gentisate 1,2-dioxygenase from Pseudomonas alcaligenes NCIB 9867.

Gentisate 1,2-dioxygenase (GDO, EC 1.13.11.4) is a ring cleavage enzyme that utilizes gentisate as a substrate yielding maleylpyruvate as the ring fission product. Mutant GDOs were generated by both random mutagenesis and site-directed mutagenesis of the gene cloned from Pseudomonas alcaligenes NCIB 9867. Alignment of known GDO sequences indicated the presence of a conserved central core region. Mutations generated within this central core resulted in the complete loss of enzyme activity whereas mutations in the flanking regions yielded GDOs with enzyme activities that were reduced by up to 78%. Site-directed mutagenesis was also performed on a pair of highly conserved HRH and HXH motifs found within this core region. Conversion of these His residues to Asp resulted in the complete loss of catalytic activity. Mutagenesis within the core region could have affected quaternary structure formation as well as cofactor binding. A mutant enzyme with increased catalytic activities was also characterized.

Isolation and characterization of group II introns from Pseudomonas alcaligenes and Pseudomonas putida.

Group II introns isolated from Pseudomonas alcaligenes NCIB 9867, Pseudomonas putida NCIB 9869, and P. putida KT2440 were closely related with nucleotide sequence identities of between 87 and 96%. The genome of P. alcaligenes also harbored a truncated group II intron of 682 bp that lacks the gene for the intron-encoded protein (IEP). Unlike most bacterial group II introns, the Pseudomonas introns were found to lack the Zn domains in their IEPs, did not appear to interrupt any genes, and were located downstream of open reading frames which were adjacent to hairpin loop structures that resemble rho-independent terminators. These structures also contain the intron binding sites 1 and 2 (IBS1 and IBS2 sequences) that were required for intron target site recognition in transposition. One of the group II introns found in P. alcaligenes, Xln3, was shown to have transposed from the chromosome to the endogenous pRA2 plasmid at a site adjacent to IBS1- and IBS2-like sequences.

Molecular analysis of the pRA2 partitioning region: ParB autoregulates parAB transcription and forms a nucleoprotein complex with the plasmid partition site, parS.

The partitioning locus (par) of plasmid pRA2 belongs to a recently discovered subgroup of plasmid partitioning systems that are evolutionarily distinct from the P1, F and R1/NR1 prototypes. The pRA2 par region was effective in stabilizing both pRA2 and F mini-replicons. Analysis of the nucleotide sequence revealed three potential coding regions that were designated parA, parB and parC. Through mutagenesis, parA and parB were found to be essential for partitioning function, whereas parC did not appear to be required. Using transcriptional reporter systems, it was demonstrated in vivo that ParB repressed par promoter activity by 60-fold and that ParA had little effect on transcriptional activity. Primer extension analysis revealed that the par transcriptional start point was located 47 nucleotides upstream of the parA translational start codon. Based on this information, putative -10 and -35 transcriptional signals were identified, and their subsequent deletion resulted in a dramatic reduction in promoter activity. The par promoter region was also demonstrated to exert incompatibility towards a plasmid with an active pRA2 par system. Nested deletions in this region allowed the incompatibility determinant, designated parS, to be localized. Recombinant ParA and ParB proteins were overexpressed and purified by affinity chromatography. Through in vitro binding experiments, purified ParB was shown to interact specifically with the par promoter region. DNase I footprinting revealed that ParB not only binds to the conserved sequence 5'-TCA AA(T/C) (G/C)CT CAA (A/T)A, which is present in three copies in the par promoter region, but also binds to the pRA2 partitioning site, parS. It appears that ParB has a dual role in pRA2 partitioning, being responsible for both the regulation of par transcription and the formation of a partition nucleoprotein complex at parS.

RT-PCR, nucleotide, amino acid and phylogenetic analyses of enterovirus type 71 strains from Asia.

A specific and sensitive method based on RT-PCR was developed to detect enterovirus 71 (EV71) from patients with hand, foot and mouth disease, myocarditis, aseptic meningitis and acute flaccid paralysis. RT-PCR primers from conserved parts of the VP1 capsid gene were designed on the basis of good correlation with sequences of EV71 strains. These primers successfully amplified 44 strains of EV71 including 34 strains isolated from Singapore in 1997 and 1998, eight strains from Malaysia isolated in 1997 and 1998, one Japanese strain and the neurovirulent strain EV71/7423/MS/87. RT-PCR of 30 strains of other enteroviruses including coxsackievirus A and B, and echoviruses failed to give any positive amplicons. Hence, RT-PCR with these primers showed 100% correlation with serotyping. Direct sequencing of the RT-PCR products of 20 EV71 strains revealed a distinct cluster with two major subgroups, thus enabling genetic typing of the viruses. The genetic heterogeneity of these strains culminated in amino acid substitutions within the VP1, VP2 and VP3 regions. The sequencing of a 2.9 kb fragment comprising the capsid region and the major part of 5' UTR of two Singapore strains revealed that they belonged to a group distinct from the prototype EV71/BrCr strain and the EV71/7423/MS/87 strain. The dendrogram generated from 341 bp fragments within the VP1 region revealed that the strains of Singapore, Malaysia and Taiwan belong to two entirely different EV71 genogroups, distinct from the three genogroups identified in another recent study.

Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates from pediatric patients in Singapore.

One hundred eighty Streptococcus pneumoniae strains isolated from children at a pediatric hospital in Singapore from 1997 to 1999 were serotyped and their antimicrobial susceptibility patterns were determined. Sixty-three percent of the isolates were resistant to penicillin. Significantly large numbers of the strains investigated were resistant to trimethoprim-sulfamethoxazole (87.8%), tetracycline (71.7%), erythromycin (67.8%), and chloramphenicol (40%). Penicillin and multidrug resistance was mostly associated with the frequently isolated S. pneumoniae isolates of serotypes (serotypes 19F, 23F, 6B, and 14). Isolates of serotype 19F, the serotype most commonly encountered in Singapore (41.1%), had the highest prevalence of penicillin (78.4%) and multidrug resistance (94.6%). Most of the invasive S. pneumoniae isolates (8 of 17; 47. 1%) were of serotype 14.