Revisiting HERQL, the hernia-specific quality-of-life assessment instrument, to extend the clinical applicability for abdominal wall hernias.

PURPOSE: In the past we have developed and validated the hernia-specific quality of life assessment instrument, HERQL, for groin hernias. In current study we evaluated the conceptual structure and validated HERQL for abdominal wall hernias. METHODS: Subjective quality-of-life perceptions from abdominal wall hernia patients were assessed. Clinical responsiveness was evaluated comparing treatment naïve with follow-up hernia patients. Measurement invariance between groin and abdominal wall hernias was approached with structural equation modeling (SEM). Subgroup comparisons were conducted between primary ventral and incisional hernias, as well as the presence of co-morbidity, hernia incarceration, surgical complications, and recurrent abdominal wall hernias. RESULTS: A total of 775 HERQL assessments, including 167 from abdominal wall hernias, were successfully performed. Cronbach's alpha coefficients for the summative pain, worse symptoms for treatment-naïve patients, and improving summative pain scores across the pre-operative, immediately post-operative, and post-operative 3-month assessments indicating clinical responsiveness were observed and comparable between groin and abdominal wall hernias. Configural invariance was evidenced by that the same model held true for both types of hernias with multi-group SEM, while mean structure exploration showed that abdominal wall hernia patients reported less latent summative pain (- 0.535, p < 0.0001) but worse latent quality-of-life score (0.207, p < 0.0001). Patients with peri-operative complications suffered from worse pain during mild activities (2.7 versus 1.5, p = 0.01), and patients with recurrent hernias reported compromised global health/quality of life (2 versus 1.6, p = 0.001). CONCLUSIONS: The study successfully validated and extended the clinical applicability of HERQL across distinct types of hernias. Measurement invariance was ascertained and the same HERQL construct could be administered for both abdominal wall and groin hernias in Taiwan.

Prevalence and profile of females at risk of eating disorders in Singapore.

INTRODUCTION: The objective of this study was to assess the prevalence of young females at risk of developing eating disorders (ED) and the associated socio-demographical variables. METHODS: A set of self-administered questionnaires consisting of an Eating Attitude Test (EAT), an Eating Disorder Inventory (EDI) and a socio-demographical questionnaire was administered to 4,461 young females. Based on scores for EAT and/or EDI-drive for thinness (EDI-DT) subscale, subjects were categorised into either "normal" (NM) or "at risk" (AR) of ED. RESULTS: Mean age of the subjects was 16.7 years (range 12-26 years). The ethnic composition was 78.8 percent Chinese, 11.7 percent Malay, 6.6 percent Indian and 3 percent other ethnic groups. Prevalence of AR was 7.4 percent (95 percent confidence interval [CI] 6.7-8.2 percent). Mean EAT and EDI-DT scores for AR were significantly higher than that of NM (EAT: mean difference is 22.1, 95 percent CI 20.7-23.4, p-value is less than 0.0001; EDI-DT: mean difference is 10.9, 95 percent CI 10.5-11.4, p-value is less than 0.0001). Female Malays constituted a significantly larger proportion of AR (20.6 percent) as compared to NM (10.9 percent). AR females are more likely to use Malay as a spoken language at home (prevalence rate ratio 1.70, p-value is 0.001) and to be better educated with completion of General Certificate of Education (GCE) "O" levels. However, the parents of AR females are likely to be less well educated (below GCE "A" levels). CONCLUSION: The prevalence of females at risk of developing ED is 7.4 percent. Malay ethnic group, using Malay language at home and the educational levels of both the subjects and their parents appear to be associated with an increased risk for development of ED.

Gene expression, purification and characterization of recombinant human neutrophil collagenase.

Human neutrophil collagenase (HNC) is a member of a family of matrix metalloproteinases (MMP). HNC is capable of cleaving all three alpha-chains of types I, II and III collagens. In rheumatoid and osteo-arthritis, MMP members have been implicated in the pathology associated with these diseases due to the accelerated breakdown of the extracellular matrix of articular cartilage. A cDNA coding for the HNC catalytic domain (lacking both the propeptide and C-terminal fragments) was sub-cloned into the pETlla prokaryotic expression vector. The cloned fragment encodes a protein that extends from amino acids (aa) Met100 through Gly262 of the full-length proenzyme, which as a result, would not require proteolytic or chemical activation. The HNC construct was expressed in Escherichia coli and recombinant mature, truncated neutrophil collagenase (re-mNC-t) was produced at high levels (approx. 30% of total bacterial protein). The re-mNC-t protein was extracted from inclusion bodies by solubilization in 6 M urea, followed by ion-exchange chromatography. The protein was refolded to an active conformation in the presence of Ca2+ and Zn2+. A final purification step on size-exclusion chromatography yielded 30 mg per liter of active re-mNC-t with minor autodegradative products. Alternatively, hydroxamate affinity chromatography was used to obtain pure, non-degraded re-mNC-t (20-25 mg per liter). The catalytic activity of re-mNC-t was abolished by known MMP inhibitors and the Ki measurement against actinonin was similar to that of HNC prepared from human blood.

Production of selenomethionine-labeled recombinant human neutrophil collagenase in Escherichia coli.

Molecular analogs of amino acids can be incorporated into proteins. The amino acid analog selenomethionine (SeMet) has been shown to be efficiently incorporated into the proteins of growing Escherichia coli. SeMet-containing proteins are known to produce sufficiently strong anomalous scatter permitting the solution of the selenomethionyl crystal structure by multiwavelength anomalous diffraction (MAD) techniques. The recombinant protein chosen for these studies is mature, truncated neutrophil collagenase (rmNC-t). The rmNC-t protein is a monomer of 163 amino acid residues featuring one active site and two Met residues. We developed a T7 polymerase expression system allowing incorporation of SeMet into rmNC-t protein produced in E. coli. Substitution of Met with SeMet was accomplished by culturing E. coli DL41(DE3), a SeMet-tolerant strain with metA lesion, in a defined medium containing SeMet as the sole source of Met. The SeMet-labeled rmNC-t was isolated from inclusion bodies by solubilizing in urea, purified by anion column chromatography, and then refolded in the presence of Ca2+ and Zn2+. Analysis of SeMet-labeled rmNC-t demonstrated that Met replacement was 100%. Enzymatic characterization revealed no obvious differences in activity or inhibitor binding between rmNC-t and the SeMet-labeled product. We have produced pure, active SeMet-labeled rmNC-t in sufficient quantities for macromolecular crystallography studies.

Effect of norathyriol, isolated from Tripterospermum lanceolatum, on A23187-induced pleurisy and analgesia in mice.

A23187-induced pleurisy in the mouse was demonstrated in this study. The protein leakage, leukocyte accumulation, LTB4 and PGE2 production in the pleural cavity of mice were increased by A23187 in a dose-dependent manner. At 7.5 nmole A23187 intrapleural injection, the protein level peaked at 0.5-2 h, PMN leukocytes accumulation peaked at 3-4 h, and LTB4 and PGE2 production peaked at 0.5-1 h. In this in vivo model we investigated the anti-inflammatory effect of norathyriol, isolated from Tripterospermum lanceolatum. A23187-induced protein leakage was reduced by norathyriol (ID50 was about 30.6 mg/kg i.p.), indomethacin and BW755C. A23187-induced PMN leukocytes accumulation was suppressed by norathyriol (ID50 was about 16.8 mg/kg, i.p.) and BW755C, while enhanced by indomethacin. Like BW755C, norathyriol reduced both LTB4 and PGE2 production (ID50 was about 18.6 and 29.1 mg/kg i.p., respectively), while indomethacin reduced PGE2 but not LTB4 generation. We also demonstrated the analgesic effect of norathyriol on the acetic acid-induced writhing response. Acetic acid-induced writhing response was depressed by norathyriol (ID50 was about 27.9 mg/kg i.p.), indomethacin and ibuprofen. These results suggest that norathyriol, like BW755C, might be a dual, yet weak, cyclooxygenase and lipoxygenase pathway blocker. The inhibitory effect of norathyriol on the A23187-induced pleurisy and acetic acid-induced writhing response in mice is proposed to be dependent on the reduction of eicosanoids mediators formation in the inflammatory site.

Anti-inflammatory effect of magnolol, isolated from Magnolia officinalis, on A23187-induced pleurisy in mice.

In the present study, A23187-induced pleurisy in mice was used to investigate the anti-inflammatory effect of magnolol, a phenolic compound isolated from Chinese medicine Hou p'u (cortex of Magnolia officinalis). A23187-induced protein leakage was reduced by magnolol (10 mg kg-1, i.p.), indomethacin (10 mg kg-1, i.p.) and BW755C (30 mg kg-1, i.p.). A23187-induced polymorphonuclear (PMN) leucocyte infiltration in the pleural cavity was suppressed by magnolol and BW755C, while enhanced by indomethacin. Like BW755C, magnolol reduced both prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) levels in the pleural fluid of A23187-induced pleurisy, while indomethacin reduced PGE2 but increased LTB4 formation. In the rat isolated peripheral neutrophil suspension, magnolol (3.7 microM) and BW755C (10 microM) also suppressed the A23187-induced thromboxane B2 (TXB2) and LTB4 formation. These results suggest that magnolol, like BW755C, might be a dual cyclo-oxygenase and lipoxygenase inhibitor. The inhibitory effect of magnolol on the A23187-induced pleurisy is proposed to be, at least partly, dependent on the reduction of the formation of eicosanoids mediators in the inflammatory site.

A 2-year clinical study of two glass ionomer cements used in the atraumatic restorative treatment (ART) technique.

The purpose of the study was to evaluate, in a clinical study over 2 years, the deterioration of two glass ionomer cements used with the atraumatic restorative treatment (ART) technique or approach. Fifty-five Fuji IX and 45 ChemFil Superior restorations were placed randomly in 23 adult patients, mainly in small occlusal preparations in molar teeth. The restorations were placed in a dental hospital by one dentist using the ART technique. Photographs, radiographs and replicas were obtained at baseline and subsequent recalls. Both cements were easy to mix and place, but the radiolucency of ChemFil Superior was a disadvantage. Both cements also showed early high losses of sealant and restorative material. After 2 years, 34.5% of the sealants appeared to be completely lost, with caries recorded in 5.3% of the exposed fissures. In some instances, these small lesions may have been present, but not detected clinically, at the time of sealing. Restoration failures of 7.0% were from wear and fracture of the cements and recurrent caries. Mean cumulative wear was 83.1 microm for Fuji IX and 104.0 microm for ChemFil Superior, which was not statistically significant. The cements became darker after their placement to more closely match the restored teeth, but there were few exact matches. There was no surface staining and only minor marginal discrepancies and staining associated with the restorations. Although the short-term clinical performance of the two glass ionomer cements was reasonable, the materials require further improvements in their mechanical properties, to reduce sealant losses and wear. The cements evaluated appear suitable for restricted use only, in posterior teeth.

Ultrasonic systolic blood pressure gradient between upper and lower limbs in normal term Chinese neonates.

The determination of a normal pattern of systolic blood pressure (SBP) gradient between upper limbs (UL) and lower limbs (LL) in neonates is important in the diagnosis of the coarctation syndrome. The scarcity of studies of normal neonates and the conflict of opinion prompted us to evaluate this problem. The UL and LL systolic blood pressures of 100 normal term Chinese neonates were measured by the Doppler Ultrasonic method (Roche Arteriosonde 1020). Under resting condition, the majority (89%) of our neonates had a negative SBP gradient (LL greater than UL). The mean LL SBP (70.1 mmHg) was significantly higher than that of the UL (59.5 mmHg), p less than 0.001. Eleven out of 100 of our neonates had a positive (UL greater than LL) SBP gradient. Eight of these were less than 1 week old. None had a positive gradient of more than 20 mmHg. According to the results of our study, during the first week of life, normal neonates may have upper limb pressure greater than lower limb of up to 20 mmHg.

Reliability of transcutaneous oxygen monitoring of critically ill children in a general pediatric unit.

While transcutaneous continuous monitoring of partial pressure of oxygen (TcPO2) is a proven valuable diagnostic tool in intensive care of sick neonates, its use in older children is less well defined. The purpose of this study is to establish the accuracy and reliability of TcPO2 as a reflection of arterial partial pressure of oxygen (PaO2) in critically ill pediatric patients. Twenty-six children, age ranging from 4 days to 13 years, were studied. The main diagnostic categories were cardiac 54 per cent, respiratory 27 per cent, gastrointestinal 15 per cent, and neurologic 4 per cent. Forty three estimations of PaO2 (by radial arterial sampling) and TcPO2 (by cutaneous monitor) were obtained simultaneously. Their correlation coefficient, regression equation, and confidence limits were calculated by standard statistical methods with the aid of a microcomputer. Our data show that the high degree of correlation between TcPO2 and PaO2 is highly significant (r = 0.90, p less than 0.001) for the full range of PaO2 between 0 to 200 mm Hg. At the lower range of PaO2 (0-79 mm Hg), the degree of correlation (r = 0.91, p less than 0.001) is better than that (r = 0.77, p less than 0.001) at the higher range (80-200 mm Hg), although the difference between the two correlation coefficients is not significant (p greater than 0.05). It is important to note that TcPO2 consistently underestimates the PaO2 and the 95% confidence limits are rather wide. We conclude that TcPO2 is a reasonably accurate reflection of PaO2 in critically ill pediatric patients. Its main advantage is in predicting and showing trends in tissue oxygenation by noninvasive means. However, when critical assessment of the degree of hypoxemia is required, TcPO2 is no substitute for PaO2.

Preference for thinness in Singapore--a newly industrialised society.

BACKGROUND/AIMS: A cultural preference for thinness has been implicated in the development of eating disorders in Western, post-industrialised societies. In transitional societies like Singapore, a shift in expectations of ideal body size (toward thinness) may lead to an increase in eating disorders. This study investigated perceptions about body size and shape in over 200 youths living in Singapore, and the influences of adiposity, gender, Westernization and parents' education. METHODS: A self-administered questionnaire was used to gather social and cultural information from 137 males and 143 females, aged 17-22 years. It included questions relating to eating behaviour and body satisfaction from which a "preference for thinness score" was derived. Westernization was indicated by language spoken at home. Adiposity was measured by triceps skinfold and body mass index. Multiple linear regression analysis was used to assess the associations of adiposity, mother's education, father's education, and language spoken at home with the preference for thinness score. RESULTS: Dissatisfaction with body size and shape increased with tertile of adiposity among females, and thoughts about dieting and becoming thinner were present even among underweight girls. Unlike the females, the highest proportion of males satisfied with their body size and shape, was associated with the middle tertile of BMI. Speaking English at home, but not parents' education, was positively associated with body dissatisfaction after controlling for BMI. CONCLUSION: Chinese Singaporean female youths have a preference for thinness as an ideal body size. The epidemiology of eating disorders in Singapore and other newly industrialised societies warrants further investigation.

Infantile hypertrophic pyloric stenosis: surgical experience of 24 cases.

Twenty-four patients with infantile hypertrophic pyloric stenosis were admitted to the University Department of Paediatrics, Singapore General Hospital, from 1974 to 1980 were reviewed. The male to female ratio was 2.4:1. The age of onset of vomiting ranged from birth to 7-week. All except 2 had palpable pyloric tumour. Barium meal studies were required in these two patients to confirm the diagnosis preoperatively. Significant abnormal laboratory findings on admission were: metabolic alkalosis (71%), hypochloraemia (63%), hyponatraemia (54%), hypokalaemia (21%), haemoconcentration (39%) and pre-renal azotaemia (17%). Two-thirds of the patients were operated within 24 to 48 hours after intravenous correction of fluid deficit and electrolyte imbalance. Common complications after Ramstedt's pyloromyotomy were vomiting and fever which were, however, mild and subsided in two to three days. Serious complications were uncommon and there was no mortality in this series. Majority of the patients were discharged well after one to two weeks of hospitalization.

Automated blood pressure reading--its claims and its reliability.

Advances in technology have made available automated devices for rapid and easy measurements of arterial blood pressure. This study evaluates the performance of one such device, the Hitachi Digital Blood Pressure and Pulse Monitor, Model HME-20, against a standard mercury sphygmomanometer, the Accoson . Fifty four sets of systolic and diastolic readings were simultaneously obtained using the two instruments. The readings obtained by both methods correlated significantly with each other (p less than 0.001). However, the mean diastolic pressure obtained by HME-20 is significantly lower than that obtained by the Accoson (p less than 0.05). There is also a consistent underestimation of systolic and diastolic pressures of 8 mm Hg by HME-20. Moreover, linear correlation studies between HME-20 and Accoson readings reveal that the 95% confidence limits are fairly wide, which limit, therefore, the value of a single reading by HME-20. Our preliminary evaluation suggests that HME-20 is more suited to monitor the trend of blood pressure changes rather than to provide precise determination of arterial blood pressures.

Normal standards of in vitro induced platelet aggregation.

Measurement of in vitro induced platelet aggregation by turbidimetric method is a very important investigative tool when patients are evaluated for bleeding diasthesis due to possible underlying platelet functional disorders. As commercial controls are not available, it is important that each laboratory establishes its own normal pattern of platelet aggregation induced by standard aggregating agents. The aggregation curves in terms of maximal % aggregation, Vmax and lag time in 50 normal Chinese controls are reported. The final concentrations of the aggregating agents used, namely adenosine diphosphate, adrenaline, collagen and ristocetin, are 20 microM, 10 microM, 0.2 mg/ml and 1.0 mg/ml, respectively. 20% of the controls had either no aggregation or only primary aggregation with adrenaline. Lag time by collagen-induced aggregation is significantly longer, but other parameters of platelet aggregation by adenosine diphosphate, adrenaline and collagen in Chinese are comparable to one reported control study. The maximal % aggregation induced by ristocetin in Chinese does not differ significantly from the reported values in whites but is significantly higher than in Blacks at a concentration of 1.0 mg/ml. Interpretation of platelet aggregometry in patients with bleeding tendency should be based on the normal patterns established from a group of normal controls in each laboratory rather than by comparison with a single control alone.

Transcutaneous estimation of oxygen tension in unusual clinical situations.

Transcutaneous oxygen monitoring has been used successfully in the assessment of trend in tissue oxygenation in neonates and children. This study highlights the application of transcutaneous oxygen monitoring in three unusual clinical situations: dual channel oxygen monitoring in persistent foetal circulation, hyperoxia test in the differentiation of cardiac or pulmonary central cyanosis and the effect of endotracheal intubation on tissue oxygenation. Its usefulness and potential application in these situations are discussed.

Assessment of ventricular septal defect by colour flow mapping.

The purpose of this study was to evaluate the usefulness of colour flow mapping (CFM) in the diagnosis and classification of congenital ventricular septal defect (VSD) and in the confirmation of spontaneous and surgical closure. Between August 1988 and March 1990, a total of 102 patients with isolated VSD (82 preoperative and 20 postoperative), age ranging from one day to 14 years, were subjected to 176 echocardiographic examinations. Sequential cross sectional imaging and CFM were the main modalities of assessment with conventional Doppler interrogation for quantitative measurements. In the preoperative group, there were 56 (68.3%) perimembranous (pm) VSD, 14 (17.1%) muscular (m) VSD and 12 (14.6%) doubly committed subarterial (dcsa) VSD. Ventricular septal defect was detected by CFM only in 88.9% of m/VSD, 57.6% of dcsa/VSD and 11.8% of pm/VSD (p less than 0.01). Spontaneous closure rate was highest in m/VSD (28.6%) followed by pm/VSD (8.9%) (p = 0.05). None of the dcsa/VSD closed as assessed by CFM. In the postoperative group, CFM served to quickly confirm complete closure without residual left to right shunt in 20 patients. In addition, CFM was useful in the assessment of haemodynamics and flow directed Doppler interrogation. Hence, CFM is a useful adjunct to cross sectional imaging in the assessment of children with isolated VSD.

Serum lipid & lipoprotein profiles of obese Chinese children.

The serum lipid and lipoprotein levels of 59 obese Chinese children with a mean age of 13.0 years and mean relative weight of 164.2% were analysed. Between 40% to 54% of these children had elevated lipid and lipoprotein levels and about 78% had reduced high density lipoprotein (HDL) level when compared to healthy American and Japanese children. The obese children also had higher mean levels of total cholesterol (TC) and lower HDL compared to male adults in the local population. Those with elevated TC had higher mean relative weight (170% vs 159%, p < 0.05). In view of the close association between hyperlipidaemia and atherosclerosis, obese children should be carefully screened and managed to prevent long term morbidity and mortality of coronary artery disease.