Dating Ultrasounds are Fundamental to Modern Obstetric Care.

Aims Dating ultrasounds for all women remains a goal of the National Maternity Strategy. We sought to examine the utility of guideline based first trimester scanning when performed in a tertiary maternity unit. Methods A retrospective review of all public dating ultrasound scans was preformed over a one year period. Results 6,077 scans were reviewed. Viability was confirmed in 97.9% (n=5953), 1.5% (n=94) were deemed non-viable, and 0.48% (n=29) required follow up for uncertain viability. There were 97.9% (n=5,951) singleton pregnancies, 1.8% (n=112) multiple pregnancies, and 0.2% (n=14) with an absent fetal pole. Of those attending for a first dating ultrasound, 81.7% (n=4,966) were between 10 and 13+6 weeks. 16% (n=977) of women relied on dating scans rather than last menstrual period (LMP) to estimate gestational age. Overall, the mean difference between ultrasound scan and recalled menstrual dates was 3.9 gestational days. Other findings of significance included 0.4% (n=25) pregnancies with fetal anomalies diagnosed and 1.2% (n=78) of women were reported as having uterine anomalies. Conclusion Dating ultrasound confirms viability, pregnancy number and due date. These factors are the basis of antenatal care. This study reinforces the need for routine scanning of all pregnancies in the first trimester.

The changing trend of diverticular disease in a developing nation.

AIM: Left-sided diverticular disease (LDD) is associated with reduced dietary intake, whereas right-sided diverticular disease (RDD) is more common amongst Oriental populations. We aimed to determine whether the prevalence, site and distribution of diverticular disease in our Oriental population has changed over the past two decades. METHOD: A total of 1663 barium enema studies performed between January 2001 and August 2002 were reviewed retrospectively. The site of disease was correlated with age, gender and ethnicity of the patient. RESULTS: Forty-five per cent of patients in the study population had diverticular disease. Older patients were more likely to have LDD, whereas the Chinese ethnic group was more likely to have RDD. Right-sided diverticular disease peaks at in the sixth decade, while for LDD this occurred in the seventh and eighth decades. Right-sided diverticular disease was more common in all age groups overall. When compared with two barium enema studies carried out in Singapore two decades earlier, there was a statistically significant increase in the incidence of RDD and LDD. CONCLUSION: There is a positive association of RDD and LDD with Chinese race and increasing age. There is an increasing incidence of both LDD and RDD compared with two decades previously.

Short communication: determination of inulin in milk using high-performance liquid chromatography with evaporative light scattering detection.

The objective of this study was to develop an HPLC method for the determination of inulin in a dairy matrix. Inulin is often added to dairy products to act as a source of dietary fiber as well as to provide technological functionality (e.g., water-holding or fat-replacing functions). The method includes hydrolysis of inulin with inulinase enzyme and determination of released fructose and glucose by HPLC coupled with evaporative light scattering detection, using water as the mobile phase. The effect of the milk background was investigated, preparing standards in milk, whey, or permeate and subjecting them to inulinase treatment. The developed method showed satisfactory linearity (R(2)=0.98 for glucose and 0.99 for fructose), good repeatability (relative standard deviation, RSD, ranging from 2.2 to 7.3% for glucose and from 0.6 to 2.3% for fructose), satisfactory reproducibility (RSD from 8.1 to 12.9% for glucose and from 3.1 to 4.9% for fructose), and good recovery (98.4 to 103.6%).

Influenza-like illness in residential care homes: a study of the incidence, aetiological agents, natural history and health resource utilisation.

BACKGROUND: Influenza-like illness (ILI) among elderly people living in residential care homes (RCHEs) is a common cause for hospitalisation. A study was undertaken to examine the incidence, underlying aetiology, natural history and associated healthcare resource utilisation related to ILI in the RCHE population. METHODS: A prospective study of ILI in four RCHEs in Shatin, Hong Kong was conducted from April 2006 to March 2007. Each RCHE was monitored daily for the occurrence of ILI and followed up until resolution of illness or death. Clinical features were recorded and sputum, nasopharyngeal aspirate, blood and urine specimens were examined for underlying aetiology. RESULTS: 259 episodes of ILI occurred in 194 subjects, with mild peaks in winter and summer, over a sustained level throughout the year. The infectious agent was identified in 61.4% of all episodes, comprising bacterial infection in 53.3% and viral in 46.7%. Multiple infections occurred in 16.2% of subjects. The most frequent organism was Streptococcus pneumoniae, followed by respiratory syncytial virus, Pseudomonas aeruginosa, metapneumovirus and parainfluenza virus types 1 and 3. Clinical features did not vary according to the underlying aetiology, the common presenting features being a decrease in general condition, cognitive and functional deterioration, and withholding of food in addition to fever and respiratory symptoms. Overall, mortality at 1 month/discharge was 9.7%. Infection with methicillin-resistant Staphylococcus aureus, low body mass index and poor function predisposed to mortality. No association was observed between influenza vaccination status and underlying aetiology, clinical features or outcome. CONCLUSIONS: The clinical presentation of ILI is non-specific and is mainly due to bacterial and viral infections other than influenza in the RCHE population.

Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults.

BACKGROUND: Patients with paroxysmal supraventricular tachycardia frequently present to the Emergency Department. Where vagal manoeuvres fail, the two most commonly used drugs are adenosine and calcium channel antagonists. Both are known to be effective but both have a significant side-effect profile. OBJECTIVES: To examine the relative effects of adenosine and calcium channel antagonists and, if possible, to determine which is most appropriate for the management of supraventricular tachycardia. SEARCH STRATEGY: Studies were identified from The Cochrane Central Register of Controlled Trials (CENTRAL), Issue 3 2006, MEDLINE (1966 to June 2006), Pre-MEDLINE and EMBASE (1980 to June 2006). Bibliographies of identified studies were also examined. No language restrictions were applied. INCLUSION CRITERIA: randomised trials comparing adenosine and a calcium channel antagonist in patients of any age with supraventricular tachycardia, where one of the defined outcomes was reported. Outcomes of interest were: reversion rate, mortality, time to reversion, rate of relapse, minor adverse events, major adverse events, length of hospital stay and patient satisfaction. Major adverse events were defined as cardiac arrest, prolonged hypotension, symptomatic bradycardia requiring treatment and acute cardiac failure. Minor adverse events were any other reported event. DATA COLLECTION AND ANALYSIS: Two reviewers independently checked the results of searches to identify relevant studies. Dichotomous outcomes were reported as Peto Odds ratios and continuous outcomes as weighted mean differences. MAIN RESULTS: Eight trials were identified. In the pooled analysis there was no significant difference in reversion rate or relapse rate between the two drugs. Time to reversion was slower for verapamil than adenosine in all studies that reported this outcome, but the data were not suitable for combining. Minor adverse events such as nausea, chest tightness, shortness of breath and headache were reported much more frequently in patients treated with adenosine with 10.8 % of patients reporting at least one of these events, compared with 0.6% of those treated with verapamil (OR 0.15, 95% CI 0.09 to 0.26, P<0.001). There was no significant difference in the rate of major adverse events between the two groups, although hypotension was reported exclusively in the verapamil treatment group (3/166 patients treated with verapamil, 0/171 treated with adenosine). AUTHORS' CONCLUSIONS: Adenosine and verapamil are both effective treatments for supraventricular tachycardia in the majority of patients. However, given the high incidence of minor but unpleasant side effects in patients treated with adenosine and the potential for hypotension with verapamil, patients should be fully informed of these risks prior to treatment.

Laparoscopic-assisted colon and rectal surgery - lessons learnt from early experience.

INTRODUCTION: Current evidence shows that laparoscopic bowel surgery is associated with a lower incidence of postoperative ileus, lower postoperative pulmonary and wound complication rates, shorter hospital stays and a quicker return to activity than open surgery. This paper aims to report our early experience with laparoscopic-assisted colorectal procedures in our Centre for Advanced Laparoscopic Surgery and the important lessons we have learnt from this. MATERIALS AND METHODS: All laparoscopic-assisted colon and rectal surgical (LAC) procedures performed between January 2000 and December 2003 were reviewed. Clinical and operative records of these patients were reviewed. Data retrieved included patient demographics, selected intraoperative parameters, and postoperative outcomes. In order to provide a comparable reference, an equal number of matched open procedures over the same period were accrued and similarly analysed. All patients were managed on a standard carepath. All data were entered into a database and analysed using a statistical software package. RESULTS: Forty-two laparoscopicassisted colorectal procedures were performed from June 2000 to December 2003. A similar number of diagnosis-matched patients with open colorectal procedures were used as comparison. The diagnoses included cancer (68.5% versus 73.8%), diverticulosis (5.7% versus 9.5%) and polyps (14.3% versus 9.5%). Seven were converted to open surgery because of bleeding, adhesions and locally advanced disease. Laparoscopic-assisted procedures performed included 1 right hemicolectomy, 5 left hemicolectomies, 9 anterior resections, 1 abdominal-perineal resection, 3 sigmoid colectomies, 11 colostomies and 1 Hartmann's procedure. Mean perioperative time (146 min versus 125 min, P = 0.173) was comparatively longer. Mean duration for analgesic requirement (2.25 days versus 2.64 days, P = 0.05), mean length of stay (5.31 days versus 9.07 days, P < 0.05), mean time to commencement of diet (2.91 days versus 4.05 days, P < 0.001) and mean time to first bowel movement (2.57 days versus 4.10 days, P < 0.001) were all comparatively shorter. General morbidity rates (17.1% versus 21.4%, P = 0.35) were lower. No local wound complications were found in our laparoscopic-assisted group. Patients who had undergone open surgery instead of the planned laparoscopic-assisted procedures fared more poorly. CONCLUSIONS: Laparoscopic-assisted colorectal procedures performed in well-selected patients are associated with shorter hospital stays, quicker return of bowel function and lower morbidity when compared to the matched open procedures. Early experience should be acquired from performing technically simple procedures in patients with benign conditions before progressing to definitive resections in those with cancer.

Benign familial hyperphosphatasaemia as a cause of unexplained increase in plasma alkaline phosphatase activity.

AIMS: To consider a possible genetic origin for the persistent unexplained increase in plasma alkaline phosphatase (ALP) in five non-related patients referred over an 18 month period. METHODS: Plasma ALP isoenzyme activities were measured in patients and their first degree relatives. RESULTS: In each patient there was a noticeable increase in intestinal plasma ALP, either alone or accompanied by an increase in bone or liver ALP. Family studies showed an unexpected increase in plasma ALP and similar isoenzyme changes in first degree relatives. The findings were consistent with autosomal dominant inheritance. CONCLUSION: Inherited raised plasma ALP activity is a reasonably common cause of persistent unexplained hyperphosphatasaemia which deserves wider recognition.

Identification of bone and liver metastases from breast cancer by measurement of plasma alkaline phosphatase isoenzyme activity.

Plasma alkaline phosphatase isoenzyme activities were determined in patients with breast cancer to diagnose and monitor bone and liver metastases. Bone alkaline phosphatase activity was increased in 21 of 50 patients (42%) with radiologically confirmed bone metastases, while total alkaline phosphatase activity was increased in only 10 of 50 (20%); liver alkaline phosphatase activity was raised in 12 of 25 patients (48%) with liver metastases. All patients with liver metastases had bone metastases. Bone alkaline phosphatase activity was significantly higher in patients with symptomatic bone disease. Isoenzyme determination provided additional information that would have changed patient management in five of 20 patients who were monitored serially. Measurement of alkaline phosphatase isoenzyme activity, though less sensitive than imaging procedures, can assist in screening for, and in early detection of, a high proportion of bone and liver metastases, and can provide useful objective evidence of their response to treatment.

Plasma intestinal alkaline phosphatase and intermediate molecular mass gamma glutamyltransferase activities in the differential diagnosis of jaundice.

An assessment was made of the value of: (i) the demonstration of intestinal alkaline phosphatase in plasma for the differentiation of intrahepatic from post-hepatic jaundice in 122 jaundiced patients; and (ii) the demonstration of an intermediate molecular mass gamma glutamyltransferase in plasma for the identification of post-hepatic cholestasis in 74 jaundiced patients. The first test had a diagnostic sensitivity of only 32% with a specificity of 86%; the second test had a sensitivity of 50% and specificity of 75%. It is concluded that neither procedure is worth while.

Measurement of biliary alkaline phosphatase by mini-column chromatography and by electrophoresis and its application to the detection of liver metastases in patients with breast cancer.

We describe a simple, rapid, and reproducible ion exchange mini-column chromatographic method for the quantitative measurement of biliary alkaline phosphatase in plasma. We have used this method to evaluate a cellulose acetate electrophoretic method, which was used to assess the value of measuring biliary alkaline phosphatase in 85 patients with breast cancer investigated for possible hepatic metastases. Biliary alkaline phosphatase activity was abnormal in 19 of 24 patients (79%) with liver metastases, but abnormalities were also found in 12 of 61 patients (20%) without hepatic metastases; in only 37% of patients with positive test results was this a consequence of liver metastases. For the identification of liver metastases, therefore, the method has useful sensitivity but limited specificity. Neither sensitivity nor specificity was significantly better than that of plasma gamma-glutamyltransferase activity, which was measured concomitantly.

Conserved and variant epitopes of target antigens of transmission-blocking antibodies among isolates of Plasmodium falciparum from Malaysia.

Monoclonal antibodies (MAbs) directed against different epitope regions on three sexual stage-specific gamete surface proteins of Plasmodium falciparum, Pfs 25, Pfs 230, and Pfs 48/45, were used to study the genetic diversity of these epitopes among fresh isolates of P. falciparum from Malaysia, using immunofluorescence microscopy (IFA). Among 45 Malaysian isolates, one epitope of Pfs 25, designated region I, showed evidence of variable reactivity with MAbs among different isolates; the Pfs 25 epitope, region II, was universally recognized by MAbs in all isolates. Two apparently distinct epitope regions of Pfs 230 were defined by MAbs, one of which was universally recognized by MAbs among the 45 isolates; the other was conserved in all but three isolates. The epitope regions of gamete-surface protein Pfs 48/45, designated regions I, IIa, IIb, IIc, III, and IV, were examined for reactivity by IFA in 33 isolates. Epitope regions I, IIb, III, and IV were conserved in all isolates; regions IIa and IIc existed in variant forms.

Amylase measurement with 2-chloro-4-nitrophenyl maltotrioside as substrate.

The use of 2-chloro-4-nitrophenyl maltotrioside (CNP-G3) as substrate to measure amylase (EC 3.2.1.1) activity in serum directly without the use of auxiliary enzymes was evaluated at two centres. The method was precise (within-run C.V. < 2% and between-run C.V. < 3%), there was no lag phase, background absorbance was low and there were minimal effects of pH changes. When compared with a method which uses 4,6-ethylidene (G7)-p-nitrophenyl (G1)-alpha-D-maltoheptaoside (EPS-G7) as substrate, the CNP-G3 method had greater sensitivity and longer reagent stability (21 days compared with 2 days at 4 degrees C). The activity measured with the CNP-G3 method correlated well with methods using either EPS-G7 and maltotetraose as substrates.

Hydroxyapatite - a reagent for the separation of free and antibody-bound steroid during the radioimmunoassay.

The use of hydroxyapatite to absorb antibody-bound steroid and thus separate free and antibody-bound steroid during radioimmunoassay has been examined using three steroid antisera (to testosterone, to 17-hydroxyprogesterone and to estradiol-17beta). For all three antisera studied the separation was shown to be independent of length of time in contact with hydroxyapatite (up to 1h); temperature variations from 4 degrees -37 degrees and pH over the range 4.9-8.0. The presence of protein affected the absorption of antibody-bound steroid but this effect could be overcome by the addition of increasing amounts of hydroxyapatite. Further increase in the amount of hydroxyapatite added had no effect on the separation of free and bound steroid. Sodium phosphate buffers of molarity greater than 0.01M eluted antibody-bount steroid from hydroxyapatite, but Tris-HC1 buffers up to molarities of 0.1 M had no effect. Hydroxyapatite when used as a dry powder had the same effects as suspensions. No effect on the cross-reactivities of the antisera used could be demonstrated when hydroxyapatite was used and plasma testosterone assays on 22 plasma samples using hydroxyapatite gave essentially the same results as assays on the plasma using a coated-tube assay. Hydroxyapatite can also be successfully pumped along small bore plastic tubing without settling and can thus be used in automated immunoassay systems.

A new fluorescence method for gamma-glutamyltransferase isoenzyme demonstration.

A new fluorescence method for demonstrating gamma-glutamyltransferase isoenzymes using gamma-glutamyl-5-amino-4-methyl coumarin, a commercially available, non-carcinogenic substrate is described. The procedure can readily detect gamma-glutamyltransferase isoenzymes in samples with total activity as low as 5 U/l at 30 degrees C.

Comparison of procedures for the measurement of the anodal isoenzymes of lactate dehydrogenase in serum.

Lactate dehydrogenase (LD) isoenzyme-1 levels (LD1) determined after immunoprecipitation of M-subunits, LD1 activity by electrophoresis, and the activities of alpha-hydroxybutyrate dehydrogenase (HBD), urea-stable LD, and heat-stable LD, by Association of Clinical Biochemists Proposed Methods, were examined for their ability to differentiate between serum samples from patients with cardiac or liver disease. Compared with total LD, all methods gave higher serum activity in patients with cardiac disease than in those with liver disease. Differentiation between patient groups was greatest for LD1 by immunoprecipitation, followed by heat-stable LD and LD1 by electrophoresis. HBD and urea-stable LD both gave less discrimination, with negligible difference between these two procedures. LD1 activity by immunoprecipitation correlated well with LD1 activity determined by isoenzyme electrophoresis with densitometric scanning. The advantages and disadvantages of the various procedures are considered.

Renal isoamylase clearance as a measure of altered renal charge selectivity in patients with diabetes mellitus.

Microalbuminuria is well established as a marker for early renal damage in diabetic patients. Differences in charge selectivity in glomerular protein filtration may also be an early marker of renal damage. We investigated the possible usefulness of the renal clearances of pancreatic and salivary amylases, and the ratio of the two, as markers of early renal damage in 55 diabetic subjects and 21 healthy controls. Diabetic patients with established albuminuria and microalbuminuria had increased clearance of salivary amylase and a trend toward lower pancreatic/salivary amylase clearance ratios compared to healthy controls and diabetic subjects without albuminuria, but the overlap with controls and diabetics without albuminuria was too large for the test to be useful.

A new alkaline phosphatase isoenzyme abnormality.

We report on a new alkaline phosphatase isoenzyme abnormality occurring as an incidental finding in a male infant aged 4 months. Isoenzyme electrophoresis on cellulose acetate showed a prominent, diffuse alkaline phosphatase staining band in the alpha 1-globulin position together with a second band in the alpha 2/beta region and minor 'trailing' in the intermediate alpha 2 region. Normal liver and bone alkaline phosphatase were absent and intestinal phosphatase was not detected. On acrylamide gel electrophoresis a marked origin band was detectable suggesting the presence of high molecular weight enzyme. In addition, a series of compact bands in the alpha 2/beta position was present cathodal to the usual liver and bone isoenzymes. Total alkaline phosphatase activity was marginally elevated and was heat labile, L-phenylalanine resistant and partially L-homoarginine and L-leucine sensitive.

Efficacy of bronchodilators in the treatment of bronchiolitis.

UNLABELLED: Bronchiolitis is a common respiratory infection affecting young children. Much controversy revolves around the efficacy of bronchodilators in the treatment of bronchiolitis. This study was conducted to address this issue. AIM: To determine the efficacy of bronchodilators in the treatment of bronchiolitis. METHOD: All children less than 2 years old with bronchiolitis were randomly assigned to receive nebulisations of Salbutamol, Ipratropium bromide or normal saline. A fourth group given only humidified oxygen without nebulisation were used as a control. RESULTS: Data were obtained for 120 patients. Fifty-one (42%) had respiratory syncytial virus (RSV) isolated from their nasopharyngeal aspirates. The demographic characteristics of the 4 groups were similar. There was no significant difference between the groups in terms of severity score, number of nebulisations required in the nebulised groups and the outcome as measured by the length of hospitalisation. CONCLUSION: The use of bronchodilators did not alter the course of the disease and is therefore not effective in the treatment of bronchiolitis.

Oviposition site preference of Aedes albopictus in the laboratory.

Several parameters on the oviposition site preference of Aedes albopictus were studied, including color, container type, salinity, and water type. Dark-colored glass jars, especially black, blue, and red ones were preferred over light-colored jars. The black-colored ovitrap with a paper strip performed better than other types of containers. Seasoned tap water had the highest egg count when compared with a saline water series. In addition, water that had previously been used for the culture of Ae. albopictus was the most preferred for oviposition. The significance of this study in conjunction with the present Aedes mosquito surveillance and monitoring program is discussed.

Comparative bioassays of Bacillus thuringiensis H-14 formulations against four species of mosquitoes in Malaysia.

Comparative laboratory bioassays of three formulations of Bacillus thuringiensis H-14 (IPS-78, San 402-I and Bactimos) were conducted against late 3rd/early 4th instar larvae of four species of mosquito, viz., Aedes aegypti, Culex quinquefasciatus, Anopheles balabacensis and Mansonia (Mansonioides) indiana, in Malaysia. From the average response of the mosquito larvae to the three formulations of B. thuringiensis H-14, Ae. aegypti was found to be most susceptible, followed by Cx. quinquefasciatus, An. balabacensis and M. (M.) indiana in decreasing order. The LC50 values for Ae. aegypti, Cx. quinquefasciatus, An. balabacensis and M. (M.) indiana after a 48-hour exposure to IPS-78 formulation were 50.9, 129.3, 117.8 and 169.6 International Toxic Unit (ITU) Ae. ae./l; to San 402-I formulation were 54.6, 223.1, 405.1 and 177.6 ITU Ae. ae/l and to Bactimos formulation were 57.2, 175.7, 35.6 and 514.5 ITU Ae. ae./l respectively. The efficacy of the bacterial product was also found to be determined by its formulation in relation to the feeding and resting habits of the mosquito larvae. No delayed pupation or emergence was observed on the larvae exposed to B. thuringiensis H-14 at sub-lethal concentrations.