Asthma admission among children in Hong Kong during the first year of the COVID-19 pandemic

BACKGROUND

Multiple nonpharmaceutical interventions (NPIs) had been introduced in Hong Kong during coronavirus disease 2019 (COVID-19) pandemic. The impact on asthma admission, which was closely related to viral infection, was of concern.

OBJECTIVE

The study aimed to identify the impact of NPIs on pediatric asthma admissions and their association with respiratory viruses.

METHODS

We conducted a retrospective observational study to compare the difference in pediatric asthma hospital admission rates between pre-COVID-19 and COVID-19 periods. Information on demographics, nasopharyngeal specimen results, ventilatory support, intensive care admission, hospital stay duration, asthma control therapy, and previous admission episodes was collected. Weather parameters including temperature, rainfall, humidity, and air quality data that was reflected by the air quality health index were recorded.

RESULTS

A total of 1808 pediatric asthma admissions were recorded during the pre-COVID-19 period while there were 62 admissions during COVID-19 period, among which 54 admissions from the pre-COVID-19 period and 4 admissions from COVID-19 period were excluded. Weekly pediatric asthma admissions per total pediatric admissions during COVID-19 was one-third of that during the pre-COVID-19 period (0.3% vs. 0.9%, p < 0.001). During COVID-19 period, a significantly lower percentage of respiratory virus isolates was noted (58.6% vs. 72.6%, p = 0.019). Poisson regression analysis showed that the COVID-19 period (odds ratio [OR] = 0.202, 95% confidence interval  [CI, 0.16-0.26]; p ≤ 0.001), summer vacation period (OR = 0.512, 95% CI [0.43-0.62]; p ≤ 0.001), and humidity (OR = 0.99, 95% CI [0.98-1.00]; p = 0.004) were independent protective factors for asthma admission.

CONCLUSIONS

There was a significant reduction in pediatric asthma hospitalizations and respiratory virus isolates in the first year of COVID-19 pandemic in Hong Kong with the implementation of NPIs. Rhinovirus remained the key respiratory virus isolate. Incorporation of appropriate NPIs in long run could reduce virus infection-related pediatric asthma admission.

Implementing hybrid telerehabilitation following major cardiac surgery during COVID-19 pandemic in Hong Kong

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Department budget

Background

Aerobic exercise is a critical component of cardiac rehabilitation (CR) for patients (pts) who have undergone cardiac surgery. Exercise-based CR is ideally home-based and directly supervised by a trained physiotherapist. During COVID-19 pandemic in Hong Kong, there was increasing emphasis on social distancing and caregiving strategies to better reach pts outside hospital. As most cardiac surgeries were performed on urgent clinical needs including heart transplantation and aortic dissection, we implemented hybrid telerehabilitation (HTR) with transition to the use of remote care in order to continue comprehensive CR. We report the functional outcome of HTR group compared with usual care (UC) group.

Methods

From 7/2020 to10/2021, 36 pts ( 67% men, mean age 57±9.2 years) were enrolled into HTR (n=18) and UC (n=18) groups respectively for 12 weeks’ duration. Demographics in both groups were similar. Types of cardiac surgeries were heart transplant (n=5; 14%), CABG (n=6;17%), valvular surgery (n=17; 47%) and aorta operation (n=8; 22%). An individualized exercise prescription for HTR at home was determined based on initial standardized assessments in hospital and tailored to fit lifestyle and home environment. For HTR group, the goal is set at 150 minutes of low to moderate-intensity aerobic exercise per week at home. Exercise is progressed weekly based on daily metrics recorded by wearable device (exercise log and % target heart rate reserve (THRR) attained) and rate of perceived exertion (RPE). These were reported by pts through an online survey after each exercise session which were reviewed daily, with progress follow-up by phone calls or text messages on a weekly basis.

Functional capacity parameters were evaluated using symptom limited exercise treadmill test (ETT) and 6 minute walk test (6MWT). The advised level is based on the current activity level of the patient using a MET score list at intake by the physiotherapist. Handgrip and quadriceps strength were measured.

Results

All pts participated the programs. Both groups demonstrated significant improvement in MET scores and 6MWT after completion of CR programs.(Table ) Average exercise time at home was reported to be 379 ±98 minutes/ week (72% achieved &gt;150 minutes/ week). Compared with UC, HTR showed significantly increased % change in MET score at baseline and upon completion of CR (22.1% vs 7%; p=0.02) and 6MWT (11.1% vs 5.3%; p=0.01). The effect muscle strength were similar in both groups with improving trend but no significant % change at baseline and end of CR.

Conclusion

Significant improvement in functional status can be demonstrated in comprehensive individualized HTR program in pts after major cardiac surgery. Adoption of digital technology with full integration into standard cardiac rehabilitation program should be recommended.

P100 Prospective mid-term assessment of frailty in patients implanted with left ventricular assist devices- any reversibility within different domains?

Background

The coalescence of the frailty phenotype and advanced heart failure (HF) presents a unique opportunity to assess any LVAD mediated improvement of cardiac output that may potentially improve the slowness, weakness, fatigue, weight loss and physical inactivity that comprise the frailty phenotype. We sought to determine whether implantation of LVAD could improve frailty in Chinese population.

Methods

From March 2015 to May 2018, 24 patients (pts) with advanced HF underwent LVAD implantation and 16 pts who remained on LVAD support for 18 months were assessed serially every six months. A new multi-disciplinary objective assessment of frailty with relevance to local Chinese population was designed to enable serial reassessment of patient’s clinical progress. The total maximum scores ranged from 0-7 [1. Physical score 0-5 namely exhaustion, poor appetite, weak hand grip, 6 minute hall walk test &lt;400m and reduced physical activity; 2. Cognitive (Montreal Cognitive Assessment-Hong Kong) &lt;22= 1; 3. Depression (Hospital Anxiety and Depression Scale) &gt; = 1].

Results

During the period studied, 5 pts received heart transplantation and 3 pts died. Mean age of remaining 16 pts (94% men) was 53 ± 13 years old. There was significant reduction in total frailty score mainly driven by significant reduction in physical domain. However, frailty was only completely reversible in 8 pts (50%). Improvement in frailty post LVAD were not associated with significant differences in measures of mood or cognition. (Figure 1)

Conclusions

The components of the frailty phenotype in pts with post LVAD surgery all have significant improvements. Absences of any association between improvements in the frailty phenotype and mood or cognition warranted further focused attention in the rehabilitation program for LVAD pts.

Abstract P100 Figure.

P101 Cardiac rehabilitation program for end-stage heart failure patients with left ventricular assist devices in Hong Kong

Background

Implantation of modern durable left ventricular assist device (LVAD) in advanced heart failure (HF) patients is associated with increased survival and improved quality of life. Exercise-based cardiac rehabilitation (EBCR) has been demonstrated to exercise capacity in HF patients but data on effect of EBCR in advanced HF patients with LVAD are limited.

Objectives

To evaluate the effect of EBCR program  on the functional capacity of advanced heart failure patients with LVAD

Methods

Out of  the current 64 LVAD recipients in Hong Kong, 43 patients who have had LVAD implanted and survived 1 year were screened.  The EBCRP consisted of cardiorespiratory and strength training exercise once a week for a total of 24 sessions (6 months). The functional rehabilitation outcome  was evaluated by 6 minute walk test (6MWT) at baseline, before LVAD implantation, pre-EBCR and by end of EBCP ( 6 months). The muscle strength was evaluated by an isokinetic knee extension strength test defined by 10 repetitive maximum (RM) torque of quadriceps strength before starting EBCR and at 6 months upon termination of EBCR.

Results

A total of 33 LVAD patients were recruited into our EBCR program. There were 27 (82%) men with mean age of 48.7± 13.6 years. Average duration from LVAD surgery to commencement of EBCR was 5.3 months. Baseline 6MWT could not be performed in 21 patients due to extreme poor functional class (NYHA class IV) with prolonged hospitalizations requiring inotropes and circulatory support. For the other 12 patients, there were no significant differences in 6 MWT at baseline and post LVAD before starting EBCP. Overall 6MWT significantly improved by end of EBCR (pre- EBCR mean 382.2, ±95.2m vs  post -EBCR mean 440.8 ±88.2m  p= 0.001). There were significant improvement in quadriceps strength by the end of EBCRP program. (pre- CRP 1.8 ± 2.5 kg vs post CRP 3.5 ± 3.5 kg p &lt; 0.001).

Conclusions

LVAD patients show high level of impairment of functional capacity despite after LVAD imaplntation with improved circulatory output. EBCR program allowed greater improvement in exercise capacity evolution and peripheral physiology such as muscle strengthening.

Validation study of the Brief Medication Adherence Scale (BMAS) in patients with schizophrenia and related disorders in Hong Kong

The purpose of this study was to develop and test an original self-rating instrument known as Brief Medication Adherence Scale (BMAS) to assess antipsychotic adherence level of Hong Kong Chinese patients with schizophrenia. On the interview day, BMAS and three other validated rating scales were given to local patients with schizophrenia and related disorders for completion. BMAS was required to fill in a second time after two weeks for the study of test-retest reliability. Results of BMAS were matched with those of other scales and blood level of prescribed mood stabilizers to test for construct validity. Data analysis was performed for 84 patients. Median BMAS scores recorded at both times were identical at 89/100, and a cutoff score of 70 was considered medication adherent with a sensitivity of 98.61% (CI 92.50%-99.96%). BMAS was positively and significantly correlated with the established Medication Adherence Rating Scale -Taiwanese (Spearman's ρ = 0.56, p < 0.05) and with variation in serum mood stabilizer level (Pearson's r = 0.55, p < 0.05). On the other hand, correlations with scales measuring mental condition and medication side effects were weak. Principal component analysis found two components (i.e. medication taking behaviors and attitudes) for the 10-question BMAS. Test-retest BMAS total scores were significantly correlated (intraclass correlation alpha = 0.87, p < 0.05), and Cronbach's alpha measuring internal consistency was 0.68. The current study confirms that BMAS is a valid and reliable scale that assesses medication adherence in patients with schizophrenia.

Hip fractures, preceding distal radius fractures and screening for osteoporosis: should we be screening earlier? A minimum 10-year retrospective cohort study at a single centre

Both men and women who sustain a fracture of the distal forearm run an increased risk of sustaining a subsequent hip fracture. Our study implies that these patients may not necessarily constitute a group in which osteoporosis screening is warranted.

INTRODUCTION

People who sustain a distal radius fracture run an increased risk of sustaining a subsequent hip fracture. However, many institutions only screen for osteoporosis at the time of a hip fracture. We aimed to determine the true incidence of preceding distal radius fractures in an Asian population of patients with a hip fracture aged 60 years or older and whether screening for osteoporosis earlier would be beneficial.

METHODS

We reviewed 22 parameters of 572 patients aged 60 years or older admitted after sustaining a hip fracture over a 3-year period. This included the occurrence or absence of a distal radius fracture in the 10 years preceding their hip fracture.

RESULTS

Twenty-nine patients (5 %) had a fracture of the distal radius in the preceding decade. Univariate analyses suggested that hip fracture patients who had preceding distal radius fractures were older, female, have lower mean haemoglobin levels, and right-sided hip fractures. Of these factors, only age was found to have significant predictive value in a multivariate analysis.

CONCLUSIONS

A number of institutions have started to screen for osteoporosis when a patient presents with a fracture of the distal radius because these patients may have an increased risk of a subsequent hip fracture. Our study implies that this may not be warranted. Implementing such a screening service from both cost and resource utilization point of view must be studied prospectively and in greater detail considering earlier screening may only be beneficial to a very small percentage of patients.

Calcaneal fractures: selection bias is key

In this paper, we critically appraise the recent publication of the United Kingdom Heel Fracture Trial, which concluded that when patients with an absolute indication for surgery were excluded, there was no advantage of surgical over non-surgical treatment in the management of calcaneal fractures. We believe that selection bias in that study did not permit the authors to reach a firm conclusion that surgery was not justified for most intra-articular calcaneal fractures.

Adding computed tomography and transcranial Doppler findings to the ABCD2 score to predict long-term risk of stroke after transient ischaemic attack or minor stroke

BACKGROUND AND PURPOSE

The ABCD(2) score can predict the early risk of stroke after transient ischaemic attack or minor stroke. However, there is no simple and practical assessment method for the long-term risks. Computed tomography (CT) and transcranial Doppler (TCD) findings were added to the ABCD(2) score to build an ABCD(2) L(2) score and whether the new scoring system could improve the predictive value of the ABCD(2) score for the long-term risk of stroke was determined.

METHODS

From January 2004 to December 2005, all patients with a definite diagnosis of transient ischaemic attack or minor stroke at the Prince of Wales Hospital were consecutively enrolled and followed up until August 2008. CT and TCD were performed. The areas under the curve were used to quantify the ABCD(2) and ABCD(2) L(2) scores and related items.

RESULTS

All 481 patients completed the follow-up. The shortest follow-up time was 0.17 months (until death), the longest follow-up time was 55.60 months and the mean follow-up time was 40.3 ± 11.0 months. In total, 277 (57.6%) patients showed lesions on CT scans and 195 (40.6%) patients were found with intracranial large artery atherosclerosis. Further strokes occurred in 74 (15.4%) patients, including four (0.83%) patients who died of ischaemic stroke during the follow-up period. The area under the curve increased from 0.650 (0.586-0.715) for the ABCD(2) score to 0.700 (0.637-0.764) for the ABCD(2) L(2) score.

CONCLUSION

Adding CT and TCD results to the ABCD(2) score to increase its predictability for long-term risk of stroke recurrence might be a meaningful exploration.

Consensus statements on adherence issues in schizophrenia for Hong Kong

AIM

In view of the clinical importance of the adherence issues in schizophrenia management, a consensus group of experienced local psychiatrists and nurse specialists gathered to outline a number of consensus statements for clinicians to consider enhancing adherence in their patients.

PROCESS

Prior to the consensus group meeting, three core members drafted eight statements on the issue of adherence in schizophrenia. Using a modified Delphi method, published literature and published guidelines regarding the management of schizophrenia were reviewed by the full panel during the group meeting. After discussion and reflection from each individual member of the consensus group, the eight statements were reworded and electronically voted on anonymously in two steps: acceptance on quality of evidence and practicability in implementation.

RESULTS

After modifications of the original statements, there was very high overall level of agreement and acceptance (reaching international standard) on all the five areas of adherence within the eight statements of the finalised statement.

CONCLUSIONS

The present consensus statements are the first in Hong Kong to address systematically adherence issues in schizophrenia management. They include areas on adherence assessment and definition, treatment strategies in enhancing adherence, and treatment considerations at specific phases of schizophrenia. They are tailored to be of practical utility in the local Hong Kong setting.

Abstract P2-01-10: Immunocytochemistry staining for estrogen and progesterone receptor in circulating tumor cells: Concordance between primary and metastatic tumors

Introduction: Estrogen (ER) and progesterone receptor (PR)) status is recommended by immunohistochemistry (IHC) and is considered standard practice for selection of treatment options in all breast cancer patients. Because biopsy is not often feasible in every patient presenting with recurrent and/or metastatic disease, circulating tumor cells (CTCs) offer an attractive alternative source of tumor tissue for determining ER/PR status. In addition, CTCs enable monitoring for more effective course of treatment.

Experimental Design: Twenty ml of peripheral blood was collected prospectively from 34 patients diagnosed with late stage metastatic/recurrent breast cancer. CTCs were isolated using the microfluidic OncoCEE platform. A cocktail of antibodies was utilized for CTC capture, and detection was accomplished with an expanded anti-cytokeratin (CK) cocktail mixture and anti-CD45. ER/PR protein expression was assessed by immunocytochemistry (ICC) on CK+/CD45- CTCs captured directly within the microchannel and then compared to IHC performed on the primary and/or metastatic tumor.

Results: CK+/CD45−/DAPI+ cells were detected in 22 of 34 (65%) patients with late stage breast cancer and assessed for ER/PR immunocytochemistry. Among the 22 cases with one or more CTCs, a concordance of 75% (15/20) and 90% (9/10) in ER/PR status between primary and metastatic tumor was observed, respectively. An overall concordance of 86% (19/22) was achieved. Five cases were discordant based on primary tissue alone; however, two of these cases are concordant when compared to the metastatic biopsy. Thus, only three cases were found to be discordant: all three were positive by IHC on the primary and/or metastatic tumor but negative by CTCs and all three had relatively low numbers of CTCs detected.

Conclusions: There is significant heterogeneity of ER/PR protein expression in CTCs and primary/metastatic tumor biopsy. In addition, hormonal status may change over time due to therapy. ER/PR ICC on CTCs using the OncoCEE platform is shown to be feasible, with high concordance (86%) as compared to primary and/or metastatic biopsy (by IHC). The significance of heterogeneity at the ER/PR protein level in CTCs related to the prognosis and predictive response to anti-estrogen therapy needs further evaluation in larger prospective clinical trials.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-10.

P1-07-13: Efficiency of a Laboratory Developed HER2 FISH Test on Circulating Tumor Cells

INTRODUCTION: Most circulating tumor cell (CTC) platforms rely on EpCAM for capture and cytokeratin (CK) for detection. However, an important population of cells that are CK-negative (i.e. cells with epithelial-mesenchymal transition (EMT) phenotype) will be missed. We report a new strategy to efficiently isolate a more heterogeneous population of CTCs using an antibody cocktail.

METHODS: In the first prospective study, blood (20 mL) was collected from 89 patients diagnosed with various late stage metastatic/recurrent cancers (breast, CRC, lung, prostate) following IRB approval. PBMCs were incubated with either EpCAM alone or a mixture of 10 capture antibodies to target both epithelial and mesenchymal cells. CTCs were subsequently captured in the OncoCEE™ channels and detected with cytokeratin (CK) and CD45. A second prospective IRB approved study involving 54 patients diagnosed with late stage metastatic/recurrent breast cancer was performed using similar detection strategies (CK cocktail mixture and anti-CD45) with the addition of HER2 FISH to determine amplification status among captured CK+/CD45- and CK-/CD45-cells.

RESULTS: In the first study, overall detection of CK+ cells was 83% with EpCAM alone and 93% with antibody cocktail. In addition, a median of 0.4 CK+ cells/mL and 1.0 CK+ cells/mL was observed using EpCAM and antibody cocktail, respectively. In the second study, CK+/CD45- cells were detected in 43 of 54 cases (80%). Among the 43 cases in which CK+/CD45- cells were detected, high concordance (93%) in HER2 status between primary tumor and CTCs was observed with HER2 amplification noted in both CK+/CD45- (50%) and CK-/CD45- (50%) cells.

CONCLUSIONS: We have developed a novel and robust method for CTC enumeration that utilizes a cocktail of antibodies for the detection of a heterogeneous (CK+ and CK-) population of CTCs. Our findings suggest an important population of CK- cells is being missed by current stain criteria in breast cancer patients. Data also demonstrate that recovery of CTCs from peripheral blood using the OncoCEE™ platform is efficient and suitable for FISH-based laboratory testing.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-13.

P5-01-08: Immunocytochemistry Staining of Estrogen Receptor in Circulating Tumor Cells as Compared to Primary Tumor

Introduction: Estrogen receptor (ER) status in all breast cancer patients is recommended by immunohistochemistry (IHC) and is considered standard practice for selection of treatment options. However, the analytical sensitivity of IHC in detecting low levels of ER is often poor and likely due to methodological variation. Because biopsy is not often feasible in all patients presenting with recurrent and/or metastatic breast disease, circulating tumor cells (CTCs) offer an attractive alternative source of tumor tissue for determining ER status and can be monitored more readily to enable a more effective course of treatment.

Experimental Design: Twenty ml of peripheral blood was collected prospectively from # patients diagnosed with late stage metastatic/recurrent breast cancer. CTCs were isolated using the microfluidic OncoCEE™ platform. A cocktail of antibodies was utilized for CTC capture and detection with an expanded anti-cytokeratin (CK) cocktail mixture and anti-CD45. ER protein expression was assessed by immunocytochemistry (ICC) on the cells captured within the microchannels and compared to IHC performed on the primary tumor.

Results: CK+/CD45- cells were detected in 23 of 27 cases (85%). Among the 23 cases in which CK+ cells were detected, only moderate concordance (16/23; 70%) in ER status between primary tumor and CTCs was observed.

Conclusions: There is significant heterogeneity between ER protein expression in CTCs and primary tumor. ER ICC on CTCs from peripheral blood using the OncoCEE™ platform is shown to be feasible but the comparison likely compromised by lack of tumor staging at the time of blood draw. Given that IHC was in some cases performed 5–10 years pre-blood draw and that tumors have the potential to convert, ER status only moderately correlates to the IHC status in the primary tumor. The significance of heterogeneity at the ER protein level in CTCs ascertaining to the prognosis and predictive response to anti-estrogen therapy needs further evaluation in larger prospective clinical trials.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-01-08.

Differential effects of anti-metastatic mechanism of Tian-Xian liquid (TXL) and its bioactive fractions on human colorectal cancer models

AIM OF STUDY

This study aimed to elucidate and compare the anti-metastatic mechanism of Tian-Xian liquid (TXL) and its bioactive components namely butanol (BU), ethyl-acetate (EA) and aqueous (WA) fractions on human colorectal cancer in vitro (HT-29 cancer cells) and in vivo (nude mouse xenografts).

MATERIALS AND METHODS

The anti-proliferative effects of TXL and its bioactive components in HT-29 cells were determined by MTT assay. Their modulations on the potential angiogenic and metastatic marker expressions on HT-29 cells and xenografts were investigated by real-time PCR and Western blot at transcriptional and translational levels, respectively. For the in vitro study, migration abilities of HT-29 cells were determined using wound healing assay. For the in vivo study, daily measurements of the tumor size and volume of the xenografts were also performed.

RESULTS

TXL, BU, EA and WA effectively inhibited the proliferation of HT-29 cells in a dose- and time-dependent manner. The IC(50) value of TXL on HT-29 cells was obtained after incubation with 1% (v/v) TXL for 4h; whereas IC(50) values were obtained for the following bioactive components: BU at 1.25% (v/v); EA at 5% (v/v); and WA at 0.3125% (v/v). It was found that 1% (v/v) TXL significantly down-regulated MMP2 and MMP7 expression at both transcriptional and translational levels and it reduced MMP9 and VEGF protein expression in vitro. TXL decreased the metastatic ability of HT-29 cells as demonstrated by wound healing assay. TXL and its bioactive fractions caused no significant changes in the body weight indicating lack of toxicity to the xenografts.

CONCLUSIONS

In summary, TXL multi-targeted to down-regulate the metastatic markers in both in vitro and in vivo models. However, the effects of its bioactive fractions were not obvious. This study profoundly elucidated the anti-proliferative mechanism of TXL, which is vital for the development of future anti-cancer regime in Chinese medicinal formulations.

Usefulness of resistant gene markers for predicting treatment outcome on second-line anti-tuberculosis drugs

AIM

Mutations in rrs [nucleotide (nt) 1401], gyrA gene (codons 90, 91 or 94), tlyA, ethA and thyA genes of Mycobacterium tuberculosis (MTB) were evaluated for their usefulness in predicting treatment outcome of kanamycin (KM), capreomycin (CPM), ofloxacin (OFX), ethionamide (ETH) and para-aminosalicylic acid (PAS).

METHODS AND RESULTS

DNA sequence analyses of these genes were performed against 188 MTB isolates obtained from patients put on second-line anti-TB drugs (SLDs) with well-documented clinical history and treatment outcome. Mutations in rrs and gyrA have 100% positive predictive value (PPV) in predicting treatment failure for KM and OFX, while 88·9 and 80% were obtained, respectively, when tlyA and rrs mutations were considered in CPM. For ETH and PAS, the PPV of using ethA and thyA mutations to predict treatment failure was 82·5 and 89·3%, respectively.

CONCLUSIONS

Our study demonstrated high specificities of gene mutations in predicting poor treatment outcome; however, further technical advancement is required to make the molecular detection of resistances to other SLDs feasible in clinical laboratories.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first study to correlate different polymorphisms of major SLD resistance gene markers with predicted treatment outcome, using an international set of well-documented clinical MTB strains.

The molecular components of human transferrin type C

Immunologically pure human transferrin type C (TfC) was isolated from the plasmas of 11 individual healthy donors. After conversion into the 2Fe-form, the preparations were analysed by polyacrylamide gel electrophoresis and chromatography on DEAE-cellulose. In all samples studied by either method the presence of three components, designated A, B and C, was observed. Calculations from eight chromatograms yielded the following relative proportions for the components: A:6%, B:62% and C:32%. The quantity of iron bound played no role in this chromatographic resolution. The components were immunologically identical but their sialic acid content increased inthe order of A less than B less than C. The presence of galactose as an ultimate residue of the oligosaccharide chains in TfC component A was confirmed by a biological test. This observation together with the results of earlier analyses for hexose, hexosamine and galactose in the subfractions from Behringwerke human transferrin, suggests that sialic acid is probably the only variable among TfC components A, B and C. Loss of sialic acid from component C during the isolation of TfC was excluded as an explanation for the presence of the other two components. The electrophoretic appearance of TfC samples from five patients with liver disease (chronic active hepatitis, cirrhosis or alcoholic liver) did not noticeably differ from that of TfC FROM HEALTHY PERSONS. Baboon transferrin resembles TfC with respect to sialic acid heterogeneity. This species was therefore studied to decide whether sialic acid is gradually lost from transferrin in the circulation or whether transferrin is not fully sialylated before discharge from the hepatocyte. Using DEAE-cellulose chromatography no difference was found between baboon transferrin molecules which were less than 6h old and those which had a mean age of 8.9 days. By inference it is suggested that the reason for the multiplicity of TfC is also likely to be biosynthetic.

Some observations on the carbohydrate composition of purified transferrin

Five subfractions were isolated on DEAE-cellulose from samples of a commercially available human transferrin preparation and their carbohydrate composition was analysed. Hexosamine, galactose and total hexose were determined in four subfractions and sialic acid in all five. The data obtained indicate that the excess number of electrophoretic bands observed in transferrin from this source is due to the loss of carbohydrates which only affects sialic acid and none of the other sugar types. The availability of the penultimate galactose residues as the terminal residues in the subfractions deficient in sialic acid was also confirmed by a biological test utilizing the rat liver. The reason for the gradual loss of sialic acid from transferrin is unknown. Freezing-thawing and lyophilization did not detectably affect the sialic acid content of purified transferrin. However, free sialic acid did appear in some preparations on storage. It is concluded that similar changes in the carbohydrate composition of other plasma glycoproteins before, during, or after purification can be expected to exert an adverse effect on their usefulness as metabolic tracers.

Microtearing instabilities and electron transport in the NSTX spherical tokamak

We report a successful quantitative account of the experimentally determined electron thermal conductivity chi(e) in a beam-heated H mode plasma by the magnetic fluctuations from microtearing instabilities. The calculated chi(e) based on existing nonlinear theory agrees with the result from transport analysis of the experimental data. Without using any adjustable parameter, the good agreement spans the entire region where there is a steep electron temperature gradient to drive the instability.

Regulation of steroidogenesis by Cordyceps sinensis mycelium extracted fractions with (hCG) treatment in mouse Leydig cells

The in vitro effect of extracted fractions of Cordyceps sinensis (CS) mycelium on hCG-treated testosterone production from purified normal mouse Leydig cells was examined. Different fractions extracted from CS (F1-water soluble polysaccharide, F2- water soluble protein and F3- poorly water soluble polysaccharide, and protein) were added to Leydig cells with hCG, and the production of testosterone was determined by radioimmunoassay (RIA). Testosterone productions stimulated by hCG in mouse Leydig cells were suppressed by F2 at 10 mg/ml and F3 at doses from 3 to 10 mg/ml, respectively. F2 and F3 at 10 mg/ml did inhibit dbcAMP-stimulated testosterone productions which indicated that F2 and F3 might affect steroidogenesis at the site after the formation of cyclic AMP. Finally, cycloheximide inhibited F2- and F3-treated mouse Leydig cell testosterone production.

A molecule carrier

We found that anthraquinone diffuses along a straight line across a flat, highly symmetric Cu111 surface. It can also reversibly attach one or two CO2 molecules as "cargo" and act as a "molecule carrier," thereby transforming the diffusive behavior of the CO2 molecules from isotropic to linear. Density functional theory calculations indicated a substrate-mediated attraction of approximately 0.12 electron volt (eV). Scanning tunneling microscopy revealed individual steps of the molecular complex on its diffusion pathway, with increases of approximately 0.03 and approximately 0.02 eV in the diffusion barrier upon attachment of the first and second CO2 molecule, respectively.

Halogen-substituted thiophenol molecules on Cu(111)

Para-halosubstituted thiophenols (X-TPs, where X is Br, Cl, or F) form ordered islands and monolayers on Cu(111) at temperatures as low as 81 K. At incomplete coverages, all X-TPs adsorb with the dehydrogenated thiol group attached to the substrate and the substituted ring inclined toward the surface, as verified experimentally and theoretically. The structure of ordered islands has a pronounced dependence on the nature of the halogen substituent: while unsubstituted TP and pentafluoro-TP molecules do not self-assemble into extended ordered patterns at 81 K, X-TP molecules form a range of different structures which depend both on the size and electronegativity of the substituent, as well as on the coverage.

Alpha-channeling simulation experiment in the DIII-D tokamak

Alfvén instabilities can reduce the central magnetic shear via redistribution of energetic ions. They can sustain a steady state internal transport barrier as demonstrated in this DIII-D tokamak experiment. Improvement in burning plasma performance based on this mechanism is discussed.

Isolation and characterization of viruses related to the SARS coronavirus from animals in southern China

A novel coronavirus (SCoV) is the etiological agent of severe acute respiratory syndrome (SARS). SCoV-like viruses were isolated from Himalayan palm civets found in a live-animal market in Guangdong, China. Evidence of virus infection was also detected in other animals (including a raccoon dog, Nyctereutes procyonoides) and in humans working at the same market. All the animal isolates retain a 29-nucleotide sequence that is not found in most human isolates. The detection of SCoV-like viruses in small, live wild mammals in a retail market indicates a route of interspecies transmission, although the natural reservoir is not known.

X-ray spectral measurements and collisional radiative modeling of Ni- to Kr-like Au ions in electron beam ion trap plasmas

The line emission of n=7-->3, 6-->3, 5-->3, and 4-->3 transitions in Ni- to Kr-like gold ions produced in the Livermore electron beam ion traps EBIT-I and EBIT-II has been recorded with an x-ray crystal spectrometer and a photometrically calibrated microcalorimeter. The plasmas had either monoenergetic electron beams with E(beam)=2.66, 3.53, or 4.54 keV or an experimentally simulated thermal electron distributions with T(e)=2.5 keV. The electron densities were approximately 10(12)cm(-3). The measured spectra have been compared to atomic structure calculations and synthetic spectra provided by the Hebrew University Lawrence Livermore Atomic Code atomic data package. Line identifications and accurate photon energy measurements have been made for many collisionally excited transitions. Approximately 140 lines have been identified in nine charge states. Agreement within 20-30 % exists between the measured and modeled line intensities for most lines excited by the monoenergetic electron beam plasmas, although some larger discrepancies can be found for some weaker features.

Determination of the charge state distribution of a highly ionized coronal Au plasma

We present the first definitive measurement of the charge state distribution of a highly ionized gold plasma in coronal equilibrium. The experiment utilized the Livermore electron beam ion trap EBIT-II in a novel configuration to create a plasma with a Maxwellian temperature of 2.5 keV. The charge balance in the plasma was inferred from spectral line emission measurements which accounted for charge exchange effects. The measured average ionization state was 46.8+/-0.75. This differs from the predictions of two modeling codes by up to four charge states.

Complications of thermal capsulorrhaphy of the shoulder

BACKGROUND

The purpose of this study was to evaluate the rate of recurrence and the prevalence of complications related to the use of thermal energy for the treatment of glenohumeral instability.

METHODS

A survey was conducted of all members of the American Shoulder and Elbow Surgeons, the Arthroscopy Association of North America, and the American Orthopaedic Society for Sports Medicine. The survey focused on the rate of recurrence, the number of axillary nerve injuries, and the prevalence of capsular insufficiency seen in revision surgery after thermal capsulorrhaphy of the shoulder.

RESULTS

Three hundred and seventy-nine surgeons responded to the survey. Of 236,015 shoulder procedures performed over the last five years, 14,277 (6%) involved the use of thermal energy (1,077 involved laser energy; 9,013, monopolar radiofrequency; and 4,187, bipolar radiofrequency) for the treatment of glenohumeral instability. The rates of recurrent instability after laser, monopolar radiofrequency, and bipolar radiofrequency capsulorrhaphy were 8.4%, 8.3%, and 7.1%, respectively. Of the patients with recurrent instability, 363 (twenty-one treated with laser energy, 220 treated with monopolar radiofrequency, and 122 treated with bipolar radiofrequency) required revision surgery. In this group of patients with revision surgery, seven (33%) of the twenty-one treated primarily with laser energy, thirty-nine (18%) of the 220 treated primarily with monopolar radiofrequency, and twenty-five (20%) of the 122 treated primarily with bipolar radiofrequency exhibited signs of capsular attenuation at the time of the revision. A total of 196 patients (1.4%) (three treated with laser energy; 133, with monopolar radiofrequency; and sixty, with bipolar radiofrequency) had a postoperative axillary neuropathy; 93% of the 196 had a sensory deficit only. Of these patients, 95% recovered completely, with the sensory deficits lasting an average of 2.3 months and the combined deficits, an average of four months.

CONCLUSIONS

The use of thermal energy for the treatment of shoulder instability has promising short-term results. The rates of recurrent instability are low. However, when recurrent instability occurs, capsular insufficiency may be present. Axillary nerve injury was reported in 1.4% of the patients, in most of whom it resolved spontaneously.

Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast

Fractures of the hip in children have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). Over a period of 20 years, we have treated displaced fractures by early anatomical reduction, internal fixation and immobilisation in a spica cast to try to reduce these complications. We have reviewed 18 patients who had a displaced non-pathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (2 to 13). They returned for examination and radiography at a mean follow-up of eight years (2 to 17). Each patient had been treated by early (" 24 hours) closed or open reduction with internal fixation and 16 had immobilisation in a spica cast. By Delbet's classification, there was one type-I, eight type-II, eight type-III, and one type-IV fractures. There were no complications in 15 patients. Avascular necrosis occurred in one patient (type-III), nonunion in one (type-II, one of the two patients who did not have a cast) and premature physeal closure in one (type-I). There were no cases of infection or complications as a result of the cast. Our treatment of displaced hip fractures in children by early reduction, internal fixation, and immobilisation in a spica cast gave reduced rates of complications compared with that of large published series in the literature.

Displaced fractures of the hip in children

Fractures of the hip in children have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). Over a period of 20 years, we have treated displaced fractures by early anatomical reduction, internal fixation and immobilisation in a spica cast to try to reduce these complications.

We have reviewed 18 patients who had a displaced non-pathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (2 to 13). They returned for examination and radiography at a mean follow-up of eight years (2 to 17). Each patient had been treated by early (″24 hours) closed or open reduction with internal fixation and 16 had immobilisation in a spica cast.

By Delbet’s classification, there was one type-I, eight type-II, eight type-III, and one type-IV fractures. There were no complications in 15 patients. Avascular necrosis occurred in one patient (type-III), nonunion in one (type-II, one of the two patients who did not have a cast) and premature physeal closure in one (type-I). There were no cases of infection or complications as a result of the cast.

Our treatment of displaced hip fractures in children by early reduction, internal fixation, and immobilisation in a spica cast gave reduced rates of complications compared with that of large published series in the literature.

Inhibitory effect of stevioside on calcium influx to produce antihypertension

Stevioside is a sweet-tasting glycoside occurring abundantly in the leaves of Stevia rebaudiana (Compositae). It has been used popularly in Japan and Brazil as a sugar substitute for decades. Previous study has shown that it lowered blood pressure in spontaneously hypertensive rats (SHRs) when administered intravenously. This study shows that intraperitoneal injection of stevioside 25 mg/kg also has antihypertensive effect in SHRs. In isolated aortic rings from normal rats, stevioside could dose-dependently relax the vasopressin-induced vasoconstriction in both the presence and absence of endothelium. However, stevioside had no effect on phenylephrine- and KCl-induced phasic vasoconstriction. In addition, stevioside lost its influence on vasopressin-induced vasoconstriction in Ca(2+)-free medium. The results indicate that stevioside caused vasorelaxation via an inhibition of Ca(2+) influx into the blood vessel. This phenomenon was further confirmed in cultured aortic smooth muscle cells (A7r5). Using 10(-5) M methylene blue for 15 min, stevioside could still relax 10(-8) M vasopressin-induced vasoconstriction in isolated rat aortic rings, showing that this vasorelaxation effect was not related to nitric oxide. The present data show that the vasorelexation effect of stevioside was mediated mainly through Ca(2+) influx inhibition.

The effect of articular malposition after total shoulder arthroplasty on glenohumeral translations, range of motion, and subacromial impingement

The articular surface of the normal humeral head has a variable posterior and medial offset with respect to the central axis of the humeral shaft. Recreation of the normal humeral head shaft offset is postulated to be an important consideration during shoulder arthroplasty. However, the effect of humeral head malposition is unknown. The purpose of this study was to determine the effect of articular malposition after total shoulder arthroplasty on glenohumeral translation, range of motion, and subacromial impingement. Twenty-one human cadavers were dissected and tested with the use of an active or passive shoulder model. Range of motion and translation were recorded by means of an electromagnetic tracking device. The experiment was performed in 2 phases. For kinematics study, 11 cadaver shoulders were positioned both passively and actively from maximum internal rotation to maximum external rotation at 90 degrees of total elevation in the scapular plane. Three rotator cuff and 3 deltoid muscle lines of action were simulated for active joint positioning. Passive joint positioning was accomplished with the use of a torque wrench and a nominal centering force. The testing protocol was used for the natural joint as well as for 9 prosthetic head locations: centered and 2- and 4-mm offsets in the anterior, posterior, inferior, and superior directions. Repeated-measures analysis of variance was used to test for significant differences in the range of motion and translation between active and passive positioning of the natural joint as well as all prosthetic head positions. (2) For impingement study, 10 cadaver shoulders were used in a passive model, loading the tendons of the rotator cuff with a 30-N centering force. The humerus was passively rotated from maximum internal rotation (1500 Nmm) to maximum external rotation (1500 Nmm) by means of a continuous-recording digital torque wrench. Trials were performed with the use of centered, 4-, 6-, and 8-mm offset heads in the anterior, posterior, superior, and inferior positions before and after removal of the acromion and coracoacromial ligament. The relation between change in mean peak torque (with and without acromion), passive range of motion, and humeral head offset was analyzed by means of repeated-measures analysis of variance. In the kinematics study, total range of motion and all humeral translations were greater with passive joint positioning than with active positioning (P =.01) except for total superior-inferior translation and superior-inferior translation in external rotation. Anterior to posterior humeral head offset was associated with statistically significant changes in total range of motion (P =.02), range of internal rotation (P =.02), range of external rotation (P =.0001), and total anterior-posterior translation (P =.01). Superior to inferior humeral head offset resulted in statistically significant changes in total range of motion (P =.02), range of internal rotation (P =.0001), anterior-posterior translation during external rotation (P =.01), and total superior-inferior translation (P =.03). In the impingement study, there was a significant increase in torque from centered to 4-mm inferior offset (P =.006), 6-mm inferior offset (P <.001), and 8-mm inferior offset (P <.001). There was no significant increase in torque with superior, anterior, and posterior offsets. Glenohumeral motion significantly decreased from 129 degrees for centered head to 119 degrees for 8-mm superior (P =.002), 119 degrees for 8-mm anterior (P =.014), 118 degrees for 8-mm inferior (P <.001), and 114 degrees for 8-mm posterior (P =.001). Humeral articular malposition of 4 mm or less during prosthetic arthroplasty of the glenohumeral joint may lead to small alterations in humeral translations and range of motion. Inferior malposition of greater than 4 mm can lead to increased subacromial contact; offset of 8 mm in any direction results in significant decreases in passive range of motion. Therefore if subacromial contact is to be minimized and glenohumeral motion maximized after shoulder replacement, anatomic reconstruction of the humeral head-humeral shaft offset to within 4 mm is desirable.

Spherical growth and surface-quasifree vibrations of Si nanocrystallites in Er-doped Si nanostructures

Si-based Er-doped Si nanostructures were fabricated for exploring efficient light emission from Er ions and Si nanocrystallites. High-resolution transmission electron microscopy observations reveal that Si nanocrystallites are spherically embedded in the SiO2 matrix. Energy-dispersive x-ray analysis indicates that the Er centers are distributed at the surfaces of nanocrystallites surrounded by the SiO2 matrix. Low-frequency Raman scattering investigation shows that Lamb's theory can be adopted to exactly calculate the surface vibration frequencies from acoustic phonons confined in spherical Si nanocrystallites and the matrix effects are negligible.

Simplified technique to remove posteriorly dislocated lens implants

Visual loss caused by posterior dislocation of an intraocular lens (IOL) may be managed by placement of a secondary IOL without removal of the dislocated IOL. However, the improved visual acuity may lead to visual disturbances from the mobile, dislocated IOL. Removal of dislocated implants through the pars plana entails risks of a large pars plana incision to include hemorrhage, hypotony, and a greater potential for vitreous traction caused by extraction across the vitreous base. Removal via the corneal limbus lessens these risks but is made more difficult in the presence of a coexisting posterior chamber IOL. The technique reported allows a controlled conversion from posterior to anterior segment surgical techniques that may aid in either the removal or repositioning of posteriorly dislocated lens implants.

Internal kink instability during off-axis electron cyclotron current drive in the DIII-D tokamak

Experimental evidence is reported of an internal kink instability driven by a new mechanism: barely trapped suprathermal electrons produced by off-axis electron cyclotron heating on the DIII-D tokamak. It occurs in plasmas with an evolving safety factor profile q(r) when q(min) approaches 1. This instability is most active when ECCD is applied on the high field side of the flux surface. It has a bursting behavior with poloidal/toroidal mode number = m/n = 1/1. In positive magnetic shear plasmas, this mode becomes the fishbone instability. This observation can be qualitatively explained by the drift reversal of the barely trapped suprathermal electrons.

Ionization processes and charge-state distribution in a highly ionized high- Z laser-produced plasma

The charge-state distribution in a well-characterized highly ionized Au plasma was accurately determined using time-resolved x-ray spectroscopy. Simultaneous measurements of the electron temperature and density allow the first direct comparisons with nonlocal thermodynamic equilibrium model predictions for the charge-state distribution of a highly ionized high- Z plasma in a nonradiative environment. The importance of two-electron atomic processes is clearly demonstrated.

Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning

Surgical management of two-part and three-part proximal humerus fractures is difficult and requires familiarity with more than one method of fixation. Poor bone quality, comminution, and the deforming forces of the rotator cuff on the tuberosities influence the choice of operative approach and fixation techniques. Closed reductions and percutaneous pinning offer the potential advantage of minimal soft-tissue dissection; however, good bone quality and minimal comminution are prerequisites. Selected two-part surgical neck fractures and valgus-impacted fractures lend themselves well to this technique. Open reduction and internal fixation is indicated in two-part surgical neck fractures with poor bone quality or extensive comminution, two-part greater tuberosity or lesser tuberosity fractures, and most three-part fractures. The choice of surgical approach is dictated by the fracture pattern and includes an extended deltopectoral approach and a superior deltoid-splitting approach. Fixation techniques are myriad and are dependent on the fracture pattern. Potential fixation methods include intramedullary rods, interfragmentary sutures or wires, and extramedullary plates and screws or blade plates. Successful results are predicated on obtaining adequate enough fixation to allow early passive motion. Results also are influenced by the quality of the reduction and patient compliance.

Therapeutic benefits of infrared (810-nm) diode laser macular grid photocoagulation in prophylactic treatment of nonexudative age-related macular degeneration: two-year results of a randomized pilot study

OBJECTIVE

This pilot study collected preliminary information on the effectiveness and safety of infrared (810-nm) diode laser macular grid photocoagulation in patients with nonexudative age-related macular degeneration (AMD). Results from this pilot study were used in designing a larger, multicenter, randomized clinical trial.

DESIGN

A multicenter, randomized, controlled, clinical trial.

PARTICIPANTS

A total of 229 eyes of 152 patients with AMD were enrolled in the pilot study. Seventy-five patients with 1 eye eligible (75 eyes) were enrolled in the unilateral arm of the study; 77 patients with both eyes eligible (154 eyes) were enrolled in the bilateral arm of the study. In the unilateral study arm, 32 eyes were randomized to the observation group, 27 eyes were treated with visible endpoint burns, and 16 eyes were treated with invisible endpoint (subthreshold) lesions. In the bilateral study arm, 77 eyes were in the observation group, 36 eyes were treated with visible burns, and 41 eyes were treated with subthreshold (invisible) lesions.

INTERVENTION

Eyes were treated with infrared (810-nm) diode laser macular grid photocoagulation using either visible burns or subthreshold (invisible) lesions and compared to eyes receiving no treatment.

MAIN OUTCOME MEASURES

Reduction of drusen, change in visual acuity, and rate of choroidal neovascularization (CNV) membrane formation.

RESULTS

At 12 months after treatment, 62% of eyes treated with visible burns had a clinically significant reduction in drusen, whereas this proportion (65%) was reached in 18 months for eyes treated with subthreshold lesions. At 24 months' follow-up, treated eyes had a significant reduction in drusen compared to observation eyes (P < 0.0001). Visual acuity was significantly improved in treated eyes at 12, 18, and 24 months compared to observation eyes (P < 0.001). Choroidal neovascularization formation was similar in treated and observation eyes through 24 months' follow-up. Complications included CNV associated with six eyes treated with visible burns and a juxtafoveal laser scar in one eye treated with visible burns.

CONCLUSIONS

Infrared (810-nm) diode laser macular grid photocoagulation in patients with nonexudative AMD significantly reduces drusen levels (P < 0.0001) and significantly improves visual acuity (P < 0.001) when either visible endpoint burns or subthreshold endpoint lesions are used. Complications were fewer using subthreshold endpoint lesions. A larger, multicenter, prospective clinical trial with longer follow-up is needed to determine the efficacy of treatment in reducing the rate of CNV formation. Data from this clinical pilot study have been used to design the Prophylactic Treatment of AMD Trial (PTAMD), a multicenter, randomized, prospective clinical trial currently in progress comparing subthreshold (invisible) treatment to observation in eyes with nonexudative AMD.

Views of obstetric patients who refuse regional anesthesia in cesarean section

BACKGROUND

Regional anesthesia for cesarean section has gained widespread popularity. However, there are still a good few of obstetric patients who refuse it. This study was to investigate the reasons for refusing regional anesthesia in order to gain some insights into the attitudes and concerns of patients.

METHODS

Three hundred and twenty-four obstetric patients scheduled for Cesarean section were interviewed just before entering the operating room. They were asked to give one or two reasons for refusing regional anesthesia.

RESULTS

Two hundreds of them refused regional anesthesia. The most frequent reasons were apprehension of witnessing the operation (auditory or visional) (45.42%) and fear of backache following regional anesthesia (14.58%).

CONCLUSIONS

Anesthesiologists should be aware of patients' feeling or concern and could be capable and willing to discuss with them the relevant problems.

Comparison of local infiltration of tenoxicam and intravenous tenoxicam for postoperative analgesia in herniorrhaphy

BACKGROUND

The major complaint of herniorrhaphy is postoperative pain which occurs during the first 24 h after operation. Tenoxicam has a long half-life of 60-80 h. Local infiltration of the drug concentrates the pain control effects in the local area. The local infiltration dose can be smaller than the recommended systemic dose needfully to reach the target area to be effective. Therefore we studied the effect of preoperative local infiltration of tenoxicam on postoperative pain.

METHODS

Sixty patients, belonging to ASA classes I and II, undergoing unilateral herniorrhaphy, were randomly assigned to 4 groups. General anesthesia was induced with thiamylal 5 mg/kg, fentanyl 2 micrograms/kg, and atracurium 5 mg/kg. Group 1 (G1) patients were preoperatively injected with 10 mg of tenoxicam in 10 ml normal saline or distilled water, in the operative area. Group 2 (G2) and Group 3 (G3) patients were preoperatively given intravenous tenoxicam, 20 mg and 10 mg, respectively. Group 4 (G4) patients were not given preoperative local infiltration or intravenous tenoxicam to serve as control group. The pain score was assessed at 2 h, 9 h, 24 h postoperatively in all groups. We recorded the total amount of acetaminophen used and the form of administration of the analgesic drug. All patients received general anesthesia in uniform technique.

RESULTS

Pain score and amount of analgesic drug required in G1 (local infiltration group) patients were significantly decreased compared with the other groups. The postoperative pain score of Visual Analog Scale (VAS) and analgesic requirement in the four groups were ranked as follows: G1 < G2 < G3 < G4. No significant difference was observed between G2, G3 and G4. Only the pain score in G2 patients significantly decreased (p < 0.05) during the late postoperative period (24 h) when compared with G4 patients.

CONCLUSIONS

Preoperative local infiltration of tenoxicam can decrease postoperative pain score significantly during the most painful period (24 h) in herniorrhaphy.

Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation

BACKGROUND

Risk stratification of patients with end-stage congestive heart failure is a critical component of the transplant candidate selection process. Accurate identification of individuals most likely to survive without a transplant would facilitate more efficient use of scarce donor organs.

METHODS AND RESULTS

Multivariable proportional hazards survival models were developed with the use of data on 80 clinical characteristics from 268 ambulatory patients with advanced heart failure (derivation sample). Invasive and noninvasive models (with and without catheterization-derived data) were constructed. A prognostic score was determined for each patient from each model. Stratum-specific likelihood ratios were used to develop three prognostic-score risk groups. The models were prospectively validated on 199 similar patients (validation sample) by calculation of the area under the receiver operating characteristic curve for 1-year event-free survival, the censored c-index for event-free survival, and comparison of event-free survival curves for prognostic-score risk strata. Outcome events were defined as urgent transplant or death without transplant. The noninvasive model performed well in both samples, and increased performance was not attained by the addition of catheterization-derived variables. Prognostic-score risk groups derived from the noninvasive model in the derivation sample effectively stratified the risk of an outcome event in both samples (1-year event-free survival for derivation and validation samples, respectively: low risk, 93% and 88%; medium risk, 72% and 60%; high risk, 43% and 35%).

CONCLUSIONS

Selection of candidates for cardiac transplantation may be improved by use of this noninvasive risk-stratification model.

Dyspnea resulting from phrenic nerve paralysis after interscalene brachial plexus block in an obese male--a case report

Phrenic nerve paralysis is a common complication in interscalene brachial plexus block. This complication is often ignored by most anesthesiologists because no clinical symptoms occur in patients who have no underlying lung disease. We present a case of an obese male suffering from dyspnea due to phrenic nerve block after interscalene brachial plexus block. The decreased respiratory reserve and direct compressing effect of the abdominal organs on the diaphragm in the supine position are thought to be the risk factors in this obese patient. Also discussed are the incidence, diagnostic methods, clinical presentation and treatments of phrenic nerve paralysis during interscalene brachial plexus block.