Is metabolically healthy obesity a useful concept?

Obesity poses significant public health concerns, including Type 2 diabetes mellitus, cardiovascular disease and stroke. Although deleterious metabolic profiles typically accompany individuals with obesity, various epidemiological studies have identified a subset of patients with a favourable metabolic phenotype referred to as the metabolically healthy obese. Metabolically healthy obesity is a novel concept that stratifies obese individuals according to their respective metabolic status. It has important implications for healthcare policies, particularly the efficient allocation of resources in the targeted treatment of obesity and prevention of metabolic ill-health. However, conflicting evidence in the literature regarding its risk profile questions its clinical relevance. In addition, the lack of a unified definition of metabolically healthy obesity and agreement on its progression further impede its utility as a stratification strategy. This review aims to describe current concepts of metabolically healthy obesity within the literature, evidence of this metabolic phenotype, the clinical implications of patient stratification and limitations of the concept.

Extended interval dosing of natalizumab in multiple sclerosis.

BACKGROUND: Natalizumab (NTZ), a monoclonal antibody to human α4ß1/ß7 integrin, is an effective therapy for multiple sclerosis (MS), albeit associated with progressive multifocal leukoencephalopathy (PML). Clinicians have been extending the dose of infusions with a hypothesis of reducing PML risk. The aim of the study is to evaluate the clinical consequences of reducing NTZ frequency of infusion up to 8 weeks 5 days. METHODS: A retrospective chart review in 9 MS centres was performed in order to identify patients treated with extended interval dosing (EID) regimens of NTZ. Patients were stratified into 3 groups based on EID NTZ treatment schedule in individual centres: early extended dosing (EED; n=249) every 4 weeks 3 days to 6 weeks 6 days; late extended dosing (LED; n=274) every 7 weeks to 8 weeks 5 days; variable extended dosing (n=382) alternating between EED and LED. These groups were compared with patients on standard interval dosing (SID; n=1093) every 4 weeks. RESULTS: 17% of patients on SID had new T2 lesions compared with 14% in EID (p=0.02); 7% of patients had enhancing T1 lesions in SID compared with 9% in EID (p=0.08); annualised relapse rate was 0.14 in the SID group, and 0.09 in the EID group. No evidence of clinical or radiographic disease activity was observed in 62% of SID and 61% of EID patients (p=0.83). No cases of PML were observed in EID group compared with 4 cases in SID cohort. CONCLUSIONS: Dosing intervals up to 8 weeks 5 days did not diminish effectiveness of NTZ therapy. Further monitoring is ongoing to evaluate if the risk of PML is reduced in patients on EID.

Isolated amygdala enlargement in temporal lobe epilepsy: A systematic review.

OBJECTIVE: The objective of this study was to compare the seizure characteristics and treatment outcomes in patient groups with temporal lobe epilepsy (TLE) identified with isolated amygdala enlargement (AE) on magnetic resonance imaging studies. METHODS: PubMed, Embase, and the Cochrane Library were searched for relevant studies using the keywords 'amygdala enlargement', 'epilepsy', and 'seizures' in April 2015. Human studies, written in English, that investigated cohorts of patients with TLE and AE were included. RESULTS: Of 204 abstracts initially identified using the search strategy, 14 studies met the inclusion criteria (11 epilepsy studies and 3 psychiatry studies). Ultimately, 8 full studies on AE and TLE involving 107 unique patients were analyzed. Gender distribution consisted of 50 males and 57 females. Right amygdala enlargement was seen in 39 patients, left enlargement in 58 patients, and bilateral enlargement in 7 patients. Surgical resection was performed in 28 patients, with the most common finding being dysplasia/hamartoma or focal cortical dysplasia. Most studies involved small samples of less than 12 patients. There was a wide discrepancy in the methods used to measure amygdala volume, in both patients and controls, hindering comparisons. Most TLE with AE studies observed a later age of seizure onset (mean: 32.2years) compared with studies involving TLE with HS (mean of mid- to late childhood). A higher frequency of complex partial seizures compared with that of convulsive seizures is seen in patients with AE (67-100% vs. 26-47%), and they have an excellent response to antiepileptic drugs (81.8%-100% of seizure-free patients). All studies that included controls also found a significant difference in frequency of seizure types between their cases and controls. CONCLUSIONS: Reliable assessment of amygdala volume remains a critical issue hindering better understanding of the clinical management and research of this focal epilepsy syndrome. Within these limitations, the literature suggests characteristics of an older age of epilepsy onset, a greater tendency to nonconvulsive seizures, and a good response to antiepileptic drugs in this interesting group of epilepsies.

An empirical study of characteristics and types of homicide-suicides in Hong Kong, 1989-2005.

BACKGROUND: Clinical classification of types of homicide-suicide (HS) was proposed, but no information on empirical-based classification and prevalence of different types of HS was available. This paper aimed to empirically classify HS events into different clusters and to discuss specific evidence-based prevention initiatives. METHOD: Data of HS offenders from Coroner's Court were analyzed through a two-step cluster analysis. Number of clusters and appropriate allocations of cases were obtained. External background variables were tested through post hoc tests to explore the differences among clusters. RESULTS: Two hundred and thirty-one people died in 98 episodes in the study period (1989-2005). The majority of HS offenders were male (n=68, 68.7%) and aged 30-49 (n=62, 62.6%). Domestic killing was the major type of HS in which over 60% of the homicide motivation was related to spousal conflicts or altruistic reasons. Spouses (n=46, 46.5%) and children (n=47, 47.5%) were predominantly the victims. The common killing methods included chopping with weapons (n=33, 33.3%) and charcoal burning (n=22, 22.2%). Six clusters of HS were derived from the cluster analysis and were further reduced to four major classes. Four major classes were dispute, conflicts in a relationship, altruistic, and mental illness. These classes could be differentiated by methods of homicide and suicide, gender of perpetrator, relationship with victim, and indebtedness. CONCLUSIONS: Financial problem, dispute and domestic violence are significant precipitants of HS in Hong Kong. Those people associated with the precipitating factors should be the targets for intervention and prevention.

Formulation of chelating agent with surfactant in cloud point extraction of methylphenol in water.

Cloud point extraction (CPE) is a separation and preconcentration of non-ionic surfactant from one liquid phase to another. In this study, Sylgard 309 and three different types of additives for CPE, namely CPE-Sylgard, CPE-Sylgard-BMIMBr and CPE-Sylgard-GLDA, are investigated to extract methylphenol from water samples. The methylphenols are well separated by reversed-phase high-performance liquid chromatography (HPLC) with isocratic elution of acetonitrile : water; 60 : 40 (v/v) and detection at 260 nm. The optimized parameters for the effect of salt, surfactant, temperature, time of extraction, pH, interference study and the performance of different additives on methylphenol extraction are investigated. CPE-Sylgard-GLDA is chosen because it gives us a high peak and good peak area compared with CPE-Sylgard and CPE-Sylgard-BMIMBr. The recovery extractions of CPE-Sylgard-GLDA are obtained in the range of 80-99% as the percentage of relative standard deviation (RSD) is less than 10. The LOD and LOQ are 0.05 ppm and 0.18 ppm, respectively. The method developed for CPE-Sylgard-GLDA coupled with HPLC is feasible for the determination of methylphenol because it is simple, effective, cheap, and produces a high percentage of recovery.

Homicide-suicide in Hong Kong, 1989-1998.

This study provides the first systematic research of homicide-suicide (HS) in a Chinese society. Data were drawn from the HK Homicide Monitoring Data-base computer file derived from investigation and death reports held by the HK Police Force and the Coroner's Court. During the 10-year study period, 56 events involving 133 deaths were identified. The majority of offenders were males (75%) and most victims were female (64%). The mean age of offenders and victims were 41.9 and 32.3 years, respectively. Spouses and lovers comprised the majority of victims (46.4%) followed by child victims (36%). Most HS events were motivated by separation or termination of marital or sexual relations (39%), economic reasons (25%) and other domestic disputes (20%). The most frequent modes of killing were strangulation/suffocation (26%), stabbing/chopping (24%), followed by gassing/poisoning (14%) and falling from a height (14%). The commonest method of suicide was falling from a height (48%). It was followed by gassing/poisoning (22%) and strangulation/suffocation (13%). Depression (18.3%) was found to be the commonest mental disorder. Most offenders were from low-socio-economic background. Two-third were unemployed and 76.6% had 9 or less years of education. HS in HK were distinguished from those reported in the western literature in respect to the high relevance of economic factors, the absence of mercy killing between old couples, a higher percentage of pedicide-suicides and the infrequent use of firearms.

Homicide-suicide in Hong Kong, 1989-1998.

This study provides the first systematic research of homicide-suicide (HS) in a Chinese society. Data were drawn from the HK Homicide Monitoring Data-base computer file derived from investigation and death reports held by the HK Police Force and the Coroner's Court. During the 10-year study period, 56 events involving 133 deaths were identified. The majority of offenders were males (75%) and most victims were female (64%). The mean age of offenders and victims were 41.9 and 32.3 years, respectively. Spouses and lovers comprised the majority of victims (46.4%) followed by child victims (36%). Most HS events were motivated by separation or termination of marital or sexual relations (39%), economic reasons (25%) and other domestic disputes (20%). The most frequent modes of killing were strangulation/suffocation (26%), stabbing/chopping (24%), followed by gassing/poisoning (14%) and falling from height (14%). The commonest of suicide was falling from height (48%). It was followed by gassing/poisoning (22%) and strangulation/suffocation (13%). Depression (18.3%) was found to be the commonest mental disorder. Most offenders were from low-socio-economic background. Two-third were unemployed and 76.6% had 9 or less years of education. HS in HK were distinguished from those reported in the western literature in respect to the high relevance of economic factors, the absence of mercy killing between old couples, a higher percentage of pedicide-suicides and the infrequent use of firearms.

The likely implications of the 1997 Coroners Ordinance on the autopsy service of a teaching hospital.

The new Hong Kong Coroners Ordinance was published in April 1997. It introduced an expanded set of guidelines for reporting deaths to the coroner as well as the threat of criminal proceedings for non-compliance. The Ordinance is due to be implemented in early 1998. The aim of this study is to determine the likely effect of the new law on the relative proportion of coroner's and hospital (consent) autopsies. A total of 352 consecutive autopsy cases were reviewed; 170 (48.3%) were referred for coroner's autopsies and 182 (51.7%) for hospital autopsies. But applying the criteria of the current ordinance, there should have been 213 (60.5%) coroner's cases and 139 (39.5%) hospital autopsies-that is, 43 hospital autopsies should have been coroner's autopsies. Under the new Coroners Ordinance, there would be 300 (85.2%) coroner's autopsies and only 52 (14.8%) hospital autopsies. The new Coroners Ordinance is likely to result in a greater number of requests for coroner's autopsies with a corresponding decline in hospital autopsies---in our case, a shift from 48.3% of all autopsies performed to 85.2%! This increase would be due largely to the requirement for reporting stillbirths but would also be due to increased reporting for fear of 'criminal proceedings' for non-compliance. An absolute increase in the number of autopsies is also anticipated, although the magnitude cannot as yet be predicted.

Initial experience of laparoscopic management of apparent early endometrial cancer.

The traditional treatment for endometrial cancer is a staging laparotomy. In patients with apparent early stage disease, laparoscopic assisted vaginal hysterectomy has been employed as an alternative. We present a retrospective uncontrolled case series of 16 cases with apparent stage I endometrial cancer from November 1994 to April 2001 managed by laparoscopic assisted surgical staging (LASS) at the Gynaecological Oncology Department, KK Women's and Children's Hospital, Singapore. We have analysed outcome measures in terms of intra-operative complications, surgical morbidity and length of hospital stay, and have evaluated treatment success in terms of conversion to laparotomy, recurrent disease and mortality. Our findings indicate that LASS is a viable option in selected patients with apparent early endometrial cancer. Our initial experience with this modality of treatment thus proves that it has great potential in both treatment success and reduction of surgical morbidity. A larger case controlled trial would be ideal in order to substantiate these benefits.

A three year review on surgical treatment of tubo-ovarian abscess.

The authors made a 3-year retrospective study of cases of tubo-ovarian abscess surgically treated in KK Women's and Children's Hospital. In the period studied (1998 through 2000), there were 36 such cases. A total of 11 patients underwent laparoscopic treatment while 25 patients underwent laparotomy. The study demonstrates the differences in the patient profile and the short term morbidity in each mode of surgical treatment and the changing trends in the surgical treatment of tubo-ovarian abscess.

Injury patterns of sharp instrument homicides in Hong Kong.

This study focuses on investigating injury patterns found on deceased victims caused by sharp instruments. It investigates the number, severity, types and locations of injuries and their possible relationship against three levels of victim-offender relationships (VORs) in sharp instrument homicides. Data of one hundred and forty-one fatal victims were extracted for the 10-year period from 1996 to 2005 from the Hong Kong Homicide Monitoring Database. These cases are solved cases with known identity of the suspects. Statistical analysis was performed to test the injury numbers, injury severity, injury types and injury locations against three levels of VORs (intimate partners, acquaintance and strangers) and their possible correlation. The present research is the first study to investigate homicide in Hong Kong using autopsy findings. This study pinpoints the importance of injury patterns found on the body and their significance with the VORs. This research also pinpoints the importance of the number, types and locations of injuries on the body and their correlations with the victim-offender relationships, and suggests factors that could be useful in investigating sharp instrument homicide.

Midbrain and forebrain patterning delivers immunocytochemically and functionally similar populations of neuropeptide Y containing GABAergic neurons.

Neurons differentiated in vitro from embryonic stem cells (ESCs) have the potential to serve both as models of disease states and in drug discovery programs. In this study, we use sonic hedgehog (SHH) and fibroblast growth factor 8 (FGF-8) to enrich for forebrain and midbrain phenotypes from mouse ESCs. We then investigate, using Ca(2+) imaging and [(3)H]-GABA release studies, whether the GABAergic neurons produced exhibit distinct functional phenotypes. At day 24 of differentiation, reverse transcriptase-PCR showed the presence of both forebrain (Bf-1, Hesx1, Pgc-1α, Six3) and midbrain (GATA2, GATA3) selective mRNA markers in developing forebrain-enriched cultures. All markers were present in midbrain cultures except for Bf-1 and Pgc-1α. Irrespective of culture conditions all GABA immunoreactive neurons were also immunoreactive to neuropeptide Y (NPY) antibodies. Forebrain and midbrain GABAergic neurons responded to ATP (1 mM), L-glutamate (30 µM), noradrenaline (30 µM), acetylcholine (30 µM) and dopamine (30 µM), with similar elevations of intracellular Ca(2+)([Ca(2+)](i)). The presence of GABA(A) and GABA(B) antagonists, bicuculline (30 µM) and CGP55845 (1 µM), increased the elevation of [Ca(2+)](i) in response to dopamine (30 µM) in midbrain, but not forebrain GABAergic neurons. All agonists, except dopamine, elicited similar [(3)H]-GABA release from forebrain and midbrain cultures. Dopamine (30 µM) did not stimulate significant [(3)H]-GABA release in midbrain cultures, although it was effective in forebrain cultures. This study shows that differentiating neurons toward a midbrain fate restricts the expression of forebrain markers. Forebrain differentiation results in the expression of forebrain and midbrain markers. All GABA(+) neurons contain NPY, and show similar agonist-induced elevations of [Ca(2+)](i) and [(3)H]-GABA release. This study indicates that the pharmacological phenotype of these particular neurons may be independent of the addition of the patterning factors that direct neurons toward forebrain and midbrain fates.

Paratubal cyst complicated by tubo-ovarian torsion: computed tomography features.

Paratubal cysts complicated by tubo-ovarian torsion are an uncommon cause of acute right iliac fossa pain in children and very rarely diagnosed accurately preoperatively. We report a constellation of diagnostic CT features in a 12-year-old pubertal girl.

Cultivating psychological well-being in Hong Kong's future doctors.

There has been much recent attention on psychological well-being and pastoral care for medical students. This study examines psychological morbidity (depression, anxiety and stress) in Hong Kong medical students, as well as their concerns, coping mechanisms and their help-seeking. Medical students in Hong Kong reported a higher level of psychological morbidity as compared with other tertiary education students. Their main concerns include examinations, stress, career, adjusting to the new medical curriculum and commitment to the course. The coping skills adopted were largely adaptive. Maladaptive coping skills like 'denial', 'self-blame' and 'behavioural disengagement' were highly correlated with depression, anxiety and stress scores. Most of the students concerned wanted support services that were specifically tailored to their needs and at least partly provided by people who had been through medical training themselves. The faculty at the University of Hong Kong is establishing a Programme for Effective Transition and Student Support (PETSS) to provide a multi-faceted support system for its medical students. The findings in this study help to ensure that the services provided will be relevant, accessible and acceptable to the students.