Intravenous thrombolysis for multi-ethnic Asians with acute ischaemia stroke in Malaysian public primary stroke centres versus acute stroke ready hospitals: Comparison of real-world clinical outcomes.

INTRODUCTION: Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator is beneficial in acute ischaemic stroke (AIS). We aim to compare the realworld clinical outcomes and service efficiency of IVT in Malaysian primary stroke centres (PSCs) versus acute stroke ready hospitals (ASRHs). MATERIALS AND METHODS: We conducted a multi-centre cohort study involving 5 PSCs and 7 ASRHs in Malaysia. Through review of medical records of AIS patients who received IVT from 01 January 2014 to 30 June 2021, real-world data was extracted for analysis. Univariate and multivariate regression models were employed to evaluate the role of PSCs versus ASRHs in post-IVT outcomes and complications. Statistical significance was set at p<0.05. RESULTS: A total of 313 multi-ethnic Asians, namely 231 from PSCs and 82 from ASRHs, were included. Both groups were comparable in baseline demographic, clinical, and stroke characteristics. The efficiency of IVT delivery (door-toneedle time), functional outcomes (mRS at 3 months post- IVT), and rates of adverse events (intracranial haemorrhages and mortality) following IVT were comparable between the 2 groups. Notably, 46.8% and 48.8% of patients in PSCs and ASRHs group respectively (p=0.752) achieved favourable functional outcome (mRS≤1 at 3 months post-IVT). Regression analyses demonstrated that post-IVT functional outcomes and adverse events were independent of the role of PSCs or ASRHs. CONCLUSION: Our study provides real-world evidence which suggests that IVT can be equally safe, effective, and efficiently delivered in ASRHs. This may encourage the establishment of more ASRHs to extend the benefits of IVT to a greater proportion of stroke populations and enhance the regional stroke care.

Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review.

OBJECTIVES: Patient safety incidents can impact not only patients and families but also healthcare providers, who may experience negative emotions and symptoms, such as anxiety, guilt, stress, and loss of confidence. To identify and support these "second victims," a screening tool called the Second Victim Experience and Support Tool (SVEST) has been developed. This scoping review aims to map our current knowledge of the SVEST in terms of its scope of use, validation and limitations. STUDY DESIGN: Scoping review. METHODS: In accordance with the framework outlined by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews, we conducted a literature search in MEDLINE, CINAHL, Cochrane Library, SCOPUS, Embase and PsycINFO databases from database inception up till 1 March 2023. RESULTS: A total of 31 studies were reviewed. The SVEST has been cross-culturally adapted from English into other languages. The SVEST has been successfully used in different contexts and with various healthcare professionals, including doctors, nurses, allied health professionals, midwives and pharmacists. The tool has been used to assess the impact of second victim experiences and the effectiveness of support interventions in addressing the phenomenon. Validity assessment of translated versions of SVEST in the reviewed studies revealed good content validity in most cases, although some studies did not report clear values for scale-level Content Validity Index. On the whole, SVEST is generally a reliable and valid tool, although further refinements and modifications may improve its validity and reliability. CONCLUSIONS: The review highlights the significance of SVEST as a crucial resource for healthcare providers and organisations that prioritise well-being and safety in health care. It also underscores the importance of recognising the needs of second victims and offering them appropriate interventions to manage the aftermath of adverse events.

In Search of Safe Spaces: An Exploratory Study of the Anticipated Help-Seeking Needs and Preferences of Protestant Christian Women in Singapore with Respect to a Hypothetical Abortion Scenario.

Research suggests that religious beliefs may contribute to abortion stigma, resulting in increased secrecy, reduced social support and help-seeking as well as poor coping and negative emotional consequences such as shame and guilt. This study sought to explore the anticipated help-seeking preferences and difficulties of Protestant Christian women in Singapore with regard to a hypothetical abortion scenario. Semi-structured interviews were conducted with 11 self-identified Christian women recruited through purposive and snowball sampling. The sample was largely Singaporean and all participants were ethnically Chinese females of a similar age range (late twenties to mid-thirties). All willing participants were recruited regardless of denomination. All participants anticipated experiences of felt, enacted and internalized stigma. These were affected by their perceptions of God (e.g., how they see abortion), their personal definitions of "life" and their perceptions of their religio-social environment (e.g., perceived social safety and fears). These concerns contributed to participants choosing both faith-based and secular formal support sources with caveats, despite a primary preference for faith-based informal support and secondary preference for faith-based formal support. All participants anticipated negative post-abortion emotional outcomes, coping difficulties and short-term decision dissatisfaction. However, participants who reported more accepting views of abortion also anticipated an increase in decision satisfaction and well-being in the longer term.

Intensity-modulated Radiotherapy for Rectal Cancer in the UK in 2020.

AIMS: Preoperative (chemo)radiotherapy followed by total mesorectal excision is the current standard of care for patients with locally advanced rectal cancer. The use of intensity-modulated radiotherapy (IMRT) for rectal cancer is increasing in the UK. However, the extent of IMRT implementation and current practice was not previously known. A national survey was commissioned to investigate the landscape of IMRT use for rectal cancer and to inform the development of national rectal cancer IMRT guidance. MATERIALS AND METHODS: A web-based survey was developed by the National Rectal Cancer IMRT Guidance working group in collaboration with the Royal College of Radiologists and disseminated to all UK radiotherapy centres. The survey enquired about the implementation of IMRT with a focus on the following aspects of the workflow: dose fractionation schedules and use of a boost; pre-treatment preparation and simulation; target volume/organ at risk definition; treatment planning and treatment verification. A descriptive statistical analysis was carried out. RESULTS: In total, 44 of 63 centres (70%) responded to the survey; 30/44 (68%) and 36/44 (82%) centres currently use IMRT to treat all patients and selected patients with rectal cancer, respectively. There was general agreement concerning several aspects of the IMRT workflow, including patient positioning, use of intravenous contrast and bladder protocols. Greater variation in practice was identified regarding rectal protocols; use of a boost to primary/nodal disease; target volume delineation; organ at risk delineation and dose constraints and treatment verification. Delineation of individual small bowel loops and daily volumetric treatment verification were considered potentially feasible by most centres. CONCLUSION: This survey identified that IMRT is already used to treat rectal cancer in many UK radiotherapy centres, but there is heterogeneity between centres in its implementation and practice. These results have been a valuable aid in framing the recommendations within the new National Rectal Cancer IMRT Guidance.

A mismatch in care: results of a United Kingdom-wide patient and clinician survey of gynaecological services for women with Lynch syndrome.

OBJECTIVE: To describe the current testing practice, referral pathways and gynaecological services available to women with Lynch syndrome (LS) in the UK. DESIGN: Cross-sectional nationwide survey of gynaecological oncologists and women with LS. SETTING: United Kingdom. METHODS: Gynaecological oncologists were contacted directly. Women with LS were identified from national and regional clinical databases and the patient support group, Lynch syndrome UK. MAIN OUTCOME MEASURES: Gynaecological oncologists were asked to report rates of LS testing and current practice regarding risk-reducing strategies and gynaecological surveillance for women with LS. Women with LS were asked to describe their experiences of gynaecological care. RESULTS: In total, 41 gynaecological oncologists and 298 women with LS responded to the survey. Of the gynaecological oncologists surveyed, 37% were unfamiliar with any clinical guidelines for the management of LS. Only 29% of gynaecological oncologists supported universal testing of endometrial cancer for LS; one centre routinely performed such testing. In all, 83% said they perform risk-reducing gynaecological surgery and 43% were aware of a local gynaecological surveillance service for women with LS. Of women with LS, most had undergone a hysterectomy (n = 191/64.1%), most frequently to reduce their gynaecological cancer risk (n = 86/45%). A total of 10% were initially referred for LS testing by their gynaecologist and 55% of those eligible regularly attended gynaecological surveillance; however, 62% wanted more regular surveillance. Regional variation was evident across all standards of care. CONCLUSIONS: There is widespread variation in the services offered to women with LS in the UK. As a community, gynaecological oncologists should move towards a nationally agreed provision of services. TWEETABLE ABSTRACT: A mismatch in care for mismatch repair. Survey finds significant variation in gynaecological care for #Lynchsyndrome in the UK.

Second- and third-trimester serum levels of growth-differentiation factor-15 in prediction of pre-eclampsia.

OBJECTIVE: Pre-eclampsia (PE) is a significant contributor to adverse maternal and perinatal outcome; however, accurate prediction and early diagnosis of this condition remain a challenge. The aim of this study was to compare serum levels of growth-differentiation factor-15 (GDF-15) at three different gestational ages between asymptomatic women who subsequently developed preterm or term PE and healthy controls. METHODS: This was a case-control study drawn from a prospective observational study on adverse pregnancy outcomes in women attending for their routine second- and third-trimester hospital visits. Serum GDF-15 was determined in 300 samples using a commercial GDF-15 enzyme-linked immunosorbent assay: 120 samples at 19-24 weeks of gestation, 120 samples at 30-34 weeks and 60 samples at 35-37 weeks. Multiple linear regression was applied to logarithmically transformed GDF-15 control values to evaluate the influence of gestational age at blood sampling and maternal characteristics on GDF-15 results. GDF-15 multiples of the normal median (MoM) values, adjusted for gestational age and maternal characteristics, were compared between pregnancies that subsequently developed preterm or term PE and healthy controls. RESULTS: Values of GDF-15 increased with gestational age. There were no significant differences in GDF-15 MoM values between cases of preterm or term PE and normotensive pregnancies at 19-24 or 35-37 weeks of gestation. At 30-34 weeks, GDF-15 MoM values were significantly increased in cases of preterm PE, but not in those who later developed term PE. Elevated GDF-15 MoM values were associated significantly with a shorter interval between sampling at 30-34 weeks and delivery with PE (P = 0.005). CONCLUSION: Serum GDF-15 levels at 19-24 or 35-37 weeks of gestation are not predictive of preterm or term PE. At 30-34 weeks, GDF-15 levels are higher in women who subsequently develop preterm PE; however, this difference is small and GDF-15 is unlikely to be useful in clinical practice when used in isolation. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Proton vs photon: A model-based approach to patient selection for reduction of cardiac toxicity in locally advanced lung cancer.

PURPOSE/OBJECTIVE: To use a model-based approach to identify a sub-group of patients with locally advanced lung cancer who would benefit from proton therapy compared to photon therapy for reduction of cardiac toxicity. MATERIAL/METHODS: Volumetric modulated arc photon therapy (VMAT) and robust-optimised intensity modulated proton therapy (IMPT) plans were generated for twenty patients with locally advanced lung cancer to give a dose of 70 Gy (relative biological effectiveness (RBE)) in 35 fractions. Cases were selected to represent a range of anatomical locations of disease. Contouring, treatment planning and organs-at-risk constraints followed RTOG-1308 protocol. Whole heart and ub-structure doses were compared. Risk estimates of grade⩾3 cardiac toxicity were calculated based on normal tissue complication probability (NTCP) models which incorporated dose metrics and patients baseline risk-factors (pre-existing heart disease (HD)). RESULTS: There was no statistically significant difference in target coverage between VMAT and IMPT. IMPT delivered lower doses to the heart and cardiac substructures (mean, heart V5 and V30, P < .05). In VMAT plans, there were statistically significant positive correlations between heart dose and the thoracic vertebral level that corresponded to the most inferior limit of the disease. The median level at which the superior aspect of the heart contour began was the T7 vertebrae. There was a statistically significant difference in dose (mean, V5 and V30) to the heart and all substructures (except mean dose to left coronary artery and V30 to sino-atrial node) when disease overlapped with or was inferior to the T7 vertebrae. In the presence of pre-existing HD and disease overlapping with or inferior to the T7 vertebrae, the mean estimated relative risk reduction of grade⩾3 toxicities was 24-59%. CONCLUSION: IMPT is expected to reduce cardiac toxicity compared to VMAT by reducing dose to the heart and substructures. Patients with both pre-existing heart disease and tumour and nodal spread overlapping with or inferior to the T7 vertebrae are likely to benefit most from proton over photon therapy.

International Variation in Criteria for Internal Mammary Chain Radiotherapy.

AIMS: Evidence has emerged that internal mammary chain (IMC) radiotherapy reduces breast cancer mortality, leading to changes in treatment guidelines. This study investigated current IMC radiotherapy criteria and the percentages of patients irradiated for breast cancer in England who fulfilled them. MATERIALS AND METHODS: A systematic search was undertaken for national guidelines published in English during 2013-2018 presenting criteria for 'consideration of' or 'recommendation for' IMC radiotherapy. Patient and tumour variables were collected for patients who received breast cancer radiotherapy in England during 2012-2016. The percentages of patients fulfilling criteria stipulated in each set of guidelines were calculated. RESULTS: In total, 111 729 women were recorded as receiving adjuvant breast cancer radiotherapy in England during 2012-2016 and full data were available on 48 095 of them. Percentages of patients fulfilling IMC radiotherapy criteria in various national guidelines were: UK Royal College of Radiologists 13% (6035/48 095), UK National Institute for Health and Care Excellence 18% (8816/48 095), Germany 32% (15 646/48 095), Ireland 56% (26 846/48 095) and USA 59% (28 373/48 095). Differences between countries occurred because in Ireland and the USA, treatment may be considered in some node-negative patients, whereas in the UK, treatment is considered if at least four axillary nodes are involved or for high-risk patients with one to three positive nodes. In Germany, treatment may be considered for all node-positive patients. CONCLUSIONS: There is substantial variability between countries in criteria for consideration of IMC radiotherapy, despite guidelines being based on the same evidence. This will probably lead to large variations in practice and resource needs worldwide.

Autologous bone marrow clot as an alternative to autograft for bone defect healing.

OBJECTIVES: Long bone defects often require surgical intervention for functional restoration. The 'gold standard' treatment is autologous bone graft (ABG), usually from the patient's iliac crest. However, autograft is plagued by complications including limited supply, donor site morbidity, and the need for an additional surgery. Thus, alternative therapies are being actively investigated. Autologous bone marrow (BM) is considered as a candidate due to the presence of both endogenous reparative cells and growth factors. We aimed to compare the therapeutic potentials of autologous bone marrow aspirate (BMA) and ABG, which has not previously been done. METHODS: We compared the efficacy of coagulated autologous BMA and ABG for the repair of ulnar defects in New Zealand White rabbits. Segmental defects (14 mm) were filled with autologous clotted BM or morcellized autograft, and healing was assessed four and 12 weeks postoperatively. Harvested ulnas were subjected to radiological, micro-CT, histological, and mechanical analyses. RESULTS: Comparable results were obtained with autologous BMA clot and ABG, except for the quantification of new bone by micro-CT. Significantly more bone was found in the ABG-treated ulnar defects than in those treated with autologous BMA clot. This is possibly due to the remnants of necrotic autograft fragments that persisted within the healing defects at week 12 post-surgery. CONCLUSION: As similar treatment outcomes were achieved by the two strategies, the preferred treatment would be one that is associated with a lower risk of complications. Hence, these results demonstrate that coagulated BMA can be considered as an alternative autogenous therapy for long bone healing.Cite this article: Z. X. H. Lim, B. Rai, T. C. Tan, A. K. Ramruttun, J. H. Hui, V. Nurcombe, S. H. Teoh, S. M. Cool. Autologous bone marrow clot as an alternative to autograft for bone defect healing. Bone Joint Res 2019;8:107-117. DOI: 10.1302/2046-3758.83.BJR-2018-0096.R1.

A global meta-analysis of the economic values of provisioning and cultural ecosystem services.

Despite a growing demand to integrate ecosystem services into sustainability decision-making, our understanding of the global distribution of the economic value of ES is scarce. We extracted information from provisioning and cultural ecosystem services (PCES) from The Economics of Ecosystems and Biodiversity (TEEB) database using a meta-analytical approach. We then employed geostatistical methods to analyze the relationship between economic values and environmental and socio-economic predictors. Here we show that anthropogenic related factors such as accessibility, spatially explicit gross domestic product and ecosystem services scarcity explain global trends of PCES economic values. We observe higher PCES values in agricultural areas of strong human presence such as the British Isles, Southwest of Brazil and India and lower values in less disturbed natural areas. These findings highlight the decisive role that human systems play in the economic realization of PCES and caution that single-criterion sustainability and conservation policies aimed at maximizing the economic returns of PCES may not overlap with wild nature.

pSTAT3 and MYC in Epstein-Barr virus-positive diffuse large B-cell lymphoma.

INTRODUCTION: Epstein-Barr Virus (EBV) is associated with several B-cell non-Hodgkin's lymphoma (NHL), but the role of EBV in diffuse large B-cell lymphoma (DLBCL) is poorly defined. Several studies indicated the expression of phosphorylated STAT3 (pSTAT3) is predominant in EBV(+)- DLBCL, of which its activated form can promote the downstream oncogenes expression such as c-MYC. c-MYC gene rearrangements are frequently found in aggressive lymphoma with inferior prognosis. Furthermore, EBV is a co-factor of MYC dysregulation. JAK1/STAT3 could be the downstream pathway of EBV and deregulates MYC. To confirm the involvement of EBV in JAK1/ STAT3 activation and MYC deregulation, association of EBV, pSTAT3 and MYC in EBV(+)- DLBCL cases were studied. The presence of pSTAT3 and its upstream proteins: pJAK1 is identify to delineate the role of EBV in JAK1/STAT3 pathway. MATERIALS AND METHODS: 51 cases of DLBCL paraffin-embedded tissue samples were retrieved from a single private hospital in Kuala Lumpur, Malaysia. EBER-ISH was performed to identify the EBV expression; ten EBV(+)-DLBCL cases subjected to immunohistochemistry for LMP1, pJAK1, pSTAT3 and MYC; FISH assay for c-MYC gene rearrangement. RESULTS: Among 10 cases of EBV(+)-DLBCL, 90% were non-GCB subtype (p=0.011), 88.9% expressed LMP1. 40% EBV(+)-DLBCL had pJAK1 expression. CONCLUSION: 66.7% EBV(+)-DLBCL showed the positivity of pSTAT3, which implies the involvement of EBV in constitutive JAK/STAT pathway. 44.5% EBV(+)-DLBCL have co-expression of pSTAT3 and MYC, but all EBV(+)-DLBCL was absence with c-MYC gene rearrangement. The finding of clinical samples might shed lights to the lymphomagenesis of EBV associated with non-GCB subtypes, and the potential therapy for pSTAT3-mediated pathway.

Murine HPV16 E7-expressing transgenic skin effectively emulates the cellular and molecular features of human high-grade squamous intraepithelial lesions.

Currently available vaccines prevent HPV infection and development of HPV-associated malignancies, but do not cure existing HPV infections and dysplastic lesions. Persistence of infection(s) in immunocompetent patients may reflect induction of local immunosuppressive mechanisms by HPV, providing a target for therapeutic intervention. We have proposed that a mouse, expressing HPV16 E7 oncoprotein under a Keratin 14 promoter (K14E7 mice), and which develops epithelial hyperplasia, may assist with understanding local immune suppression mechanisms that support persistence of HPV oncogene-induced epithelial hyperplasia. K14E7 skin grafts recruit immune cells from immunocompetent hosts, but consistently fail to be rejected. Here, we review the literature on HPV-associated local immunoregulation, and compare the findings with published observations on the K14E7 transgenic murine model, including comparison of the transcriptome of human HPV-infected pre-malignancies with that of murine K14E7 transgenic skin. We argue from the similarity of i) the literature findings and ii) the transcriptome profiles that murine K14E7 transgenic skin recapitulates the cellular and secreted protein profiles of high-grade HPV-associated lesions in human subjects. We propose that the K14E7 mouse may be an appropriate model to further study the immunoregulatory effects of HPV E7 expression, and can facilitate development and testing of therapeutic vaccines.

Virgin coconut oil and diabetic wound healing: histopathological and biochemical analysis

Delayed wound healing (the diabetic ulcer) is one of the major complications of diabetes mellitus (DM), which has shown an increasing trend over previous decades to affect almost 15% of diabetic patients. Virgin coconut oil (VCO) is a natural oil rich in vitamins and antioxidants and possesses antimicrobial and antiviral activities. In the current study, we evaluated the effects of topical application of VCO on wound healing in diabetes-induced Sprague-Dawley rats. A total of 72 animals were divided into 4 groups: i.e. (I) non-diabetic nontreated (NN), (II) diabetic non-treated (DN), (III) diabetic treated with VCO (VCO), and (IV) diabetic treated with silver sulfadiazine cream (SS). Wounds were inflicted on all groups using punch biopsy needles, and the animals were treated for 14 days. Wound closure rate (WCR) was measured on day 5, 10, and 14. Histological analysis was performed on day 7 and 14. Total protein content and superoxide dismutase (SOD) activity were measured on day 1, 7, and 14. WCR in VCO group was higher on all days compared to DN. Histological analysis revealed that VCO promoted re-epithelialization and increased collagen content of wound tissue. Total protein content in VCO group was higher on day 7 and 14 compared to both DN and SS groups. VCO showed insignificant effects on SOD levels. In summary, VCO was found to be better than silver sulfadiazine cream in the healing of diabetic wounds via promoting reepithelialization and collagen synthesize as well as increasing WCR and total protein content

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The potential role of herbal products in the treatment of Parkinson's disease.

Parkinson's disease (PD) is a multifactorial disorder of the nervous system in which there is a progressive loss of dopaminergic neurons. There is a disturbance in the movement in PD and these include resting tremors, rigidity, bradykinesia or akinesia, disturbance, posture and freezing (motor block). The substantia nigra and other parts of the brain are commonly affected. The disorder could be related to oxidative stress and there is an important role of reactive oxygen species (ROS). A number of herbal products contain active components which are known to possess antioxidant action. Hence, the potential role of herbal products in treating PD cannot be undermined. In the present narrative review, the main aim is to discuss the pathogenesis of PD, define the role of different potential herbal extracts on its pathogenesis which may form the basis of treatment. We also discuss in detail the active chemical compounds present each herb which are effective in the treatment of PD. These herbs include Baicalei, Erythrina velutin, Resveratrol, Peganum Harmal, Curcuma longa (Zingiberaceae), Carthamus tinctorius L. (Safflower), Pueraria lobate, Juglandis Semen (Walnut), Tianma Gouteng Yin (TGY), Lycium barbarum L fruit, Mucuna pruriens (Velvet bean), Chunghyuldan (CHD), Paeoniae Alba Radix. The present review may be beneficial for designing future drugs for effective treatment of PD.

Patients' blood pressure control and doctors' adherence to hypertension clinical practice guideline in managing patients at health clinics in Kuala Muda district, Kedah.

BACKGROUND: blood pressure (bP) control among Malaysian is poor and doctor's adherence to clinical practice guideline (cPG) has been a well-known factor that may improve it. this study was designed to evaluate patients' bP control, doctors' adherence to the latest hypertension cPG and their association. Factors associated with bP control and cPG adherence was also examined. METHODS: A cross-sectional study was conducted in Kuala Muda district's health clinics. 331 medical records were selected using stratified random sampling and standard proforma was used for data collection. the latest edition of the Malaysian cPG on hypertension was employed to define related variables. RESULTS: A total of 160 patients (48.3%) had controlled bP and it was significantly associated with patients' age (adjusted Odds ratio, aOr= 1.03, 95% cI: 1.004, 1.05, p= 0.016) and systolic bP at presentation (aOr= 0.95, 95% cI: 0.93, 0.96, p< 0.001). About 60.7% of the medical records showed doctor's good level of cPG adherence. this adherence has significant association with presence of chronic kidney disease (aOr= 0.51, 95% cI: 0.31, 0.85, p= 0.007) and cardiovascular disease (aOr= 2.68, 95% cI: 1.04, 6.95, p= 0.030) in the patients and physicians' treatment intensification (aOr= 2.00, 95% cI: 1.26, 3.19, p= 0.009). However, no association was found between bP control and cPG adherence. CONCLUSION: Hypertension control in this study was poor and the prevalence of physicians with good level of cPG adherence was slightly above average. these findings are important for relevant stakeholders to strategise an action plan to improve hypertension management outcome.

Mechanical compatibility of sol-gel annealing with titanium for orthopaedic prostheses.

Sol-gel processing is an attractive method for large-scale surface coating due to its facile and inexpensive preparation, even with the inclusion of precision nanotopographies. These are desirable traits for metal orthopaedic prostheses where ceramic coatings are known to be osteoinductive and the effects may be amplified through nanotexturing. However there are a few concerns associated with the application of sol-gel technology to orthopaedics. Primarily, the annealing stage required to transform the sol-gel into a ceramic may compromise the physical integrity of the underlying metal. Secondly, loose particles on medical implants can be carcinogenic and cause inflammation so the coating needs to be strongly bonded to the implant. These concerns are addressed in this paper. Titanium, the dominant material for orthopaedics at present, is examined before and after sol-gel processing for changes in hardness and flexural modulus. Wear resistance, bending and pull tests are also performed to evaluate the ceramic coating. The findings suggest that sol-gel coatings will be compatible with titanium implants for an optimum temperature of 500 °C.

Rectal Radiotherapy--Intensity-modulated Radiotherapy Delivery, Delineation and Doses.

The use of intensity-modulated radiotherapy in rectal cancer is attractive in that it may reduce acute and late toxicities and potentially facilitate dose escalation. Intensity-modulated radiotherapy probably has a role in selected patients, but further investigation is required to identify the parameters for selection. Delineation of specific nodal groups allows maximal sparing of bladder and small bowel. In locally advanced tumours a simultaneous integrated boost allows dose escalation incorporating hypofractionation and a shorter overall treatment time. However, due to a sparsity of data on late toxicity in doses ≥ 60 Gy, doses at this level should be used with caution, ideally within prospective trials. Future studies investigating dose escalation must ascertain late toxicity as well as local control, as both can significantly affect quality of life and without both, the risk-benefit ratio cannot be calculated.

Angry patient with fibromyalgia: Diagnosis and management in primary care.

I report a case of 40-year-old lady who presented with symptoms and signs suggestive of fibromyalgia but was disregarded by attending doctor. She was infuriated and lodged a complaint to Family Medicine Specialist (FMS) whereby further assessment confirmed the diagnosis of fibromyalgia and subsequently treated in primary care setting.

Pneumoperitoneum or Chilaiditi's sign.

Chilaiditi's sign describes the incidental radiographic finding of the bowel positioned between the right diaphragm and the liver. This is often misdiagnosed as pneumoperitoneum or free air under the diaphragm, which may lead to unnecessary investigations or surgical procedures. Here, we report two incidental chest radiograph findings of air under the diaphragm in patients who were being screened for pulmonary tuberculosis. This case series highlights the importance of awareness of the diagnosis of Chilaiditi's sign to avoid unnecessary hospital referrals.

Mononuclear dioxomolybdenum(VI) thiosemicarbazonato complexes: Synthesis, characterization, structural illustration, in vitro DNA binding, cleavage, and antitumor properties.

Four dioxomolybdenum(VI) complexes were synthesized by reacting [MoO2(acac)2] with N-ethyl-2-(5-bromo-2-hydroxybenzylidene) hydrazinecarbothioamide (1), N-ethyl-2-(5-allyl-3-methoxy-2-hydroxybenzylidene) hydrazinecarbothioamide (2), N-methyl-2-(3-tert-butyl-2-hydroxybenzylidene) hydrazinecarbothioamide (3), and N-ethyl-2-(3-methyl-2-hydroxybenzylidene) hydrazinecarbothioamide (4). The molecular structures of 1, 2, and all the synthesized complexes were determined using single crystal X-ray crystallography. The binding properties of the ligand and complexes with calf thymus DNA (CT-DNA) were investigated via UV, fluorescence titrations, and viscosity measurement. Gel electrophoresis revealed that all the complexes cleave pBR 322 plasmid DNA. The cytotoxicity of the complexes were studied against the HCT 116 human colorectal cell line. All the complexes exhibited more pronounced activity than the standard reference drug 5-fluorouracil (IC50 7.3µM). These studies show that dioxomolybdenum(VI) complexes could be potentially useful in chemotherapy.