A Systematic Review of Non-Seriously Ill Community-Dwelling Asians' Views on Advance Care Planning

OBJECTIVES

To systematically synthesize the views of community-dwelling Asians on Advance care planning and to summarize the factors and reasons affecting their uptake of ACP.

DESIGN

Mixed-methods systematic review (PROSPERO: CRD42018091033).

SETTING AND PARTICIPANTS

Asian adults (≥18 years old) living in the community globally.

METHODS

Medline (Ovid), Web of Science, CINAHL (EBSCO), Open Grey, and Google Scholar were searched from inception to June 30, 2022. Qualitative, quantitative, or mixed-methods studies reporting on the views of non-seriously ill community-dwelling Asian adults on ACP or the factors influencing their ACP uptake were included. Secondary research, studies not published in English, or studies not available as full text were excluded. Two independent teams of researchers extracted data, assessed methodologic quality, and performed the data analysis. Data analysis was conducted using the multistep convergent integrated approach based on Joanna Briggs Institute methodology for mixed-methods systematic review.

RESULTS

Fifty-eight studies were included. Non-seriously ill community-dwelling Asians were willing to engage in ACP (46.5%-84.4%) although their awareness (3.1%-42.9%) and uptake of ACP remained low (14.0%-53.4%). Background factors (sociodemographic factors, and health status, as well as experience and exposure to information) and underlying beliefs (attitude toward ACP, subjective norm, and perceived behavioral control) were found to affect their uptake of ACP. A conceptual framework was developed to facilitate a proper approach to ACP for this population.

CONCLUSIONS AND IMPLICATIONS

A flexible approach toward ACP is needed for non-seriously ill community-dwelling Asians. There is also a need to raise end-of-life and ACP literacy, and to explore ways to narrow the gap in the expectations and implementation of ACP so that trust in its effective execution can be built.

Abnormal Pap smear among pregnant women - Feasibility of opportunistic cervical screening

Objective

The uptake of cervical cancer screening is poor, especially in developing countries. Thus, pregnancy represents a good opportunity to have the test done. The aim of this study is to determine the prevalence of abnormal Pap smear among pregnant women during their antenatal check-ups.

Study design

A prospective study involving five hundred and ninety-six women was recruited over a 1-year duration from 15th January 2018 until 14th January 2019 in a tertiary referral center, in Malaysia. Pap smears were performed on all consented pregnant women using liquid-based cytology and the results were obtained to evaluate the prevalence of abnormal Pap smear during pregnancy. Maternal risk factors associated with abnormal Pap smear were identified and the outcomes of abnormal Pap smear were followed up.

Results

A total of 670 participants were approached and 596 participants agreed to participate, giving a response rate of 89.0 %. Therefore, 587 participants were available for analysis. There were nine unsatisfactory smears (1.5 %). The prevalence of premalignant lesions reported on p % ap smear was 0.8 %. Three respondents had atypical squamous cells of undetermined significance (ASCUS) (0.5 %) and two respondents had low-grade squamous intraepithelial lesions (LSIL) (0.3 %). Almost one-third (30.3 %) of respondents had an infection and 24 (4.1 %) smears were reported as reactive changes associated with inflammation. Respondents between the age of 20-30 years old had a significant association with an abnormal pre-cancerous smear (p = 0.000) as well as nulliparity (p = 0.0.40). There was no significant association between height, weight, BMI, sexual partner, age of first intercourse, smoking habit, history of sexually transmitted disease and history of abnormal Pap smear.

Conclusion

The prevalence of abnormal pre-cancerous smears during pregnancy is low. However, it is desirable to perform cervical screening as it provides an opportunity to no screening at all.

Maternal and fetal outcomes of pregnant women with bacterial vaginosis

Background

Bacterial vaginosis (BV) is a common infection in women of reproductive age group because of vaginal dysbiosis. The impact of BV during pregnancy is still not well defined. The objective of this study is to assess the maternal-fetal outcome in women with BV.

Materials and Methods

A prospective cohort study over one-year duration was conducted from December, 2014 until December, 2015, involving 237 women who presented with abnormal vaginal discharge, preterm labour or preterm prelabour rupture of membrane between 22- and 34-weeks period of gestation. Vaginal swabs were sent for culture and sensitivity, BV® Blue testing and PCR for Gardnerella vaginalis (GV).

Results

BV was diagnosed in 24/237 (10.1%) cases. The median gestational age was 31.6 weeks. GV was isolated from 16 out of 24 (66.7%) in the BV positive group. There was a significantly higher preterm birth rate, below 34 weeks (22.7% vs. 6.2%, p = 0.019) in women with BV. There was no statistically significant difference in maternal outcome such as clinical chorioamnionitis or endometritis. However, placental pathology revealed more than half (55.6%) of women with BV had histologic chorioamnionitis. Neonatal morbidity was significantly higher with exposure to BV, with a lower median birth weight, higher rate of neonatal intensive care unit admission (41.7% vs. 19.0%, p = 0.010), increased intubation for respiratory support (29.2% vs. 7.6%, p = 0.004) and respiratory distress syndrome (33.3% vs. 9.0%, p = 0.002).

Conclusion

More research is needed to formulate guidelines for prevention, early detection and treatment of BV during pregnancy to reduce intrauterine inflammation and the associated adverse fetal outcomes.

Prevalence, Knowledge and Awareness of Pelvic Floor Disorder among Pregnant Women in a Tertiary Centre, Malaysia

Pelvic floor disorders are common and of concern, as the majority of maternity healthcare providers seldom discuss this issue with patients compared to other antenatal issues. The aim of this study is to determine the prevalence and to assess the knowledge and awareness of pelvic floor disorder (PFD) among pregnant women in a tertiary centre in Malaysia. We also aim to assess the association between women’s risk factors regarding their knowledge and awareness of pelvic floor disorder so that primary prevention strategies can be planned, initiated and implemented in the future. This is a cross-sectional study with a total of four hundred twenty-four pregnant women that were recruited over a 6-month duration from May to November 2017 in a tertiary centre in Malaysia. The Pelvic Floor Distress Inventory (PFDI-20) was used to evaluate pelvic floor distress symptoms during pregnancy, namely urinary incontinence, pelvic organ prolapse and faecal incontinence. A validated Prolapse and Incontinence Knowledge Questionnaire (PIKQ), which consists of 24 items, was used to assess respondents’ knowledge about urinary incontinence (UI) and pelvic organ prolapse (POP). A total of 450 participants were approached, but 424 participants agreed to participate, showing a response rate of 94.3%. The median age was 31.5 years old, and 33.3% were primiparity. Overall, 46.1% of pregnant women had at least one symptom of pelvic floor disorder during pregnancy. Of these, 62.3% experienced urinary incontinence, 41.1% experienced symptoms of pelvic organ prolapse, and 37.8% experienced symptoms of faecal incontinence. The overall median score of PIKQ was 12.0 (8.0, 17.0). The median score for PIKQ—UI was 7.0 (5.0, 9.0) and the median score for PIKQ—POP was 6.0 (4.0, 8.0). There were 341 (80.4%) pregnant women that had a low level of knowledge in UI, and 191 (45.0%) had a low level of knowledge in POP. Having a tertiary level of education and receiving antenatal specialist care were both associated with better proficiency in both the PIKQ—UI (p < 0.001) and PIKQ—POP (p < 0.001) subscales. Pelvic floor disorder during pregnancy was common. A knowledge of pelvic floor disorder was lacking among pregnant women in this study. Having a tertiary education and receiving antenatal specialist care were both associated with better knowledge proficiency. This study hopefully serves as a basic platform for future educational programs to bridge the knowledge gaps in PFD among pregnant women.

Antenatal Corticosteroids to Asian Women Prior to Elective Cesarean Section at Early Term and Effects on Neonatal Respiratory Outcomes

This exploratory study aimed to evaluate the effects of antenatal corticosteroids in singleton pregnancies of Asian women prior to elective cesarean section (CS) at early term on neonatal respiratory outcomes.

METHODS

This is a pilot and pragmatic randomized trial conducted at a university hospital in Malaysia. Women with singleton pregnancies planned for elective CS between 37+0 and 38+6 weeks gestation were randomly allocated into the intervention group, where they received two doses of IM dexamethasone 12 mg of 12 h apart, 24 h prior to surgery OR into the standard care, control group, and both groups received the normal routine antenatal care. The primary outcome measures were neonatal respiratory illnesses, NICU admission and length of stay.

RESULTS

A total of 189 patients were recruited, 93 women in the intervention group and 96 as controls. Between the steroid and control groups, the mean gestation at CS was similar, 266.1 ± 3.2 days (38 weeks) vs. 265.8 ± 4.0 days (37+6 weeks), p = 0.53. The mean birthweight of infants was 3.06 ± 0.41 kg vs. 3.04 ± 0.37 kg, p = 0.71. Infants with respiratory morbidities were primarily due to transient tachypnea of newborn (9.7% vs. 6.3%), and congenital pneumonia (1.1% vs. 3.1%) but none had respiratory distress syndrome. Only four infants required NICU admission (2.2% vs. 3.1%, p = 0.63). Their average length of stay was not statistically different; 3.5 ± 2.1 days vs. 5.7 ± 1.5 days, p = 0.27.

CONCLUSIONS

Elective CS at early term before 39 weeks was associated with a modest overall incidence of neonatal respiratory illness (10.1%) in this Asian population. Antenatal dexamethasone did not diminish infants needing respiratory support, NICU admission and length of stay.

Knowledge, attitude and practice of community-dwelling adults regarding advance care planning in Malaysia: a cross-sectional study

OBJECTIVES

This study aimed to assess the knowledge, attitude and practice (KAP) among community-dwelling adults in Malaysia regarding advance care planning (ACP), and its associated factors.

DESIGN

This cross-sectional study was conducted from July-September 2018.

SETTING

This study was conducted at the University Malaya Medical Centre, Kuala Lumpur, Malaysia.

PARTICIPANTS

We recruited community-dwelling adults (ambulatory care patients or their accompanying persons) who were ≥21 years old and able to understand English or Malay. A 1:10 systematic sampling procedure was used. Excluded were community-dwelling adults with intellectual disabilities or non-Malaysian accompanying persons. A trained researcher administered the validated English or Malay Advance Care Planning Questionnaire at baseline and 2 weeks later.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the KAP regarding ACP. The secondary outcomes were factors associated with KAP.

RESULTS

A total of 385/393 community-dwelling adults agreed to participate (response rate 98%). Only 3.1% of the community-dwelling adults have heard about ACP and 85.7% of them felt that discussion on ACP was necessary after explanation of the term. The desire to maintain their decision-making ability when seriously ill (94.9%) and reducing family burden (91.6%) were the main motivating factors for ACP. In contrast, resorting to fate (86.5%) and perceived healthy condition (77.0%) were the main reasons against ACP. Overall, 84.4% would consider discussing ACP in the future. Community-dwelling adults who were employed were less likely to know about ACP (OR=0.167, 95% CI 0.050 to 0.559, p=0.004) whereas those with comorbidities were more likely to favour ACP (OR=2.460, 95% CI 1.161 to 5.213, p=0.019). No factor was found to be associated with the practice of ACP.

CONCLUSIONS

Despite the lack of awareness regarding ACP, majority of community-dwelling adults in Malaysia had a positive attitude towards ACP and were willing to engage in a discussion regarding ACP after the term 'ACP' has been explained to them.

Antioxidant-rich Clove Extract, A Strong Antimicrobial Agent against Urinary Tract Infections-causing Bacteria in vitro

Clove (Syzygium aromaticum) is an exotic culinary spice that has been used for centuries due to its known antimicrobial and antioxidant properties. The main aim of this study is to compare the antimicrobial activity and antioxidant capacity of clove ethanolic extract (CEE) and commercial clove essential oil (CEO) at a standardised eugenol content. Disk diffusion assay showed that CEE (2000 μg) was able to exhibit broad-spectrum inhibition against both Gram negative and Gram positive Urinary Tract Infections (UTIs)-causing pathogens: Proteus mirabilis (19.7 ± 0.6 mm) > Staphylococcus epidermidis (18 mm) > Staphylococcus aureus (14.7 ± 0.6 mm) > Escherichia coli (12.7 ± 0.6 mm) > Klebsiella pneumoniae (12.3 ± 0.6 mm) (according to the size of inhibition zone). Interestingly, the comparison between CEE and commercial CEO revealed that the former demonstrated stronger antimicrobial and antioxidative properties at similar eugenol concentration. The EC₅₀ of DPPH (1,1-diphenyl-2-picrylhydrazyl), ABTS (2,2′-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) and reducing power assay for CEE were determined as 0.037 mg/mL, 0.68 mg/mL and 0.44 mg/mL, respectively. Besides eugenol, High Performance Liquid Chromatography (HPLC) analyses identified the presence of kaempferol, gallic acid and catechin in CEE. As a conclusion, we concluded that there was a possible synergistic effect between eugenol and the others active compounds especially kaempferol which led to the observed bioactivities in CEE.

Pencil Beam Scanning Proton Therapy Case Selection for Paediatric Abdominal Neuroblastoma: Effects of Tumour Location and Bowel Gas

AIMS

Pencil beam scanning (PBS) proton therapy is an increasingly used radiation modality for childhood malignancies due to its ability to minimise dose to surrounding organs. However, the dosimetry is extremely sensitive to anatomical and density changes. The aims of this study were to investigate if there is a dosimetric benefit or detriment with PBS for paediatric abdominal neuroblastoma, assess gastrointestinal air variability and its dosimetric consequences, plus identify if there are factors that could assist case selection for PBS referral.

MATERIALS AND METHODS

Twenty neuroblastoma cases were double-planned with PBS and intensity-modulated arc therapy (IMAT). Cases were divided into unilateral, midline unilateral and midline bilateral locations in relation to the kidneys. Plans were recalculated after the gastrointestinal volume was simulated as air (Hounsfield Units -700) and water (Hounsfield Units 0), then compared with nominal plans (recalculated - nominal, ΔD). Forty-three weekly cone beam computed tomography scans were analysed to quantify gastrointestinal air variability during treatment.

RESULTS

PBS reduced the mean dose to normal tissues at all tumour locations, particularly unilateral tumours. However, 15% had better dosimetry with IMAT, all of which were midline tumours. Increased gastrointestinal air caused significant compromises to PBS versus IMAT plans for midline tumours [median/maximum ΔD95% clinical target volume (CTV) -2.4%/-15.7% PBS versus 1.4%/0% IMAT, P = 0.003], whereas minimal impact was observed for unilateral tumours (ΔD95% CTV -0.5%/-1.9% PBS versus 0.5%/-0.5% IMAT, P = 0.008). D95% CTV was significantly decreased in PBS plans if planning target volume (PTV) ≥400 cm3 (median -4.1%, P = 0.001) or PTV extension ≥60% anterior to vertebral body (-2.1%, P = 0.002). A larger variation in gastrointestinal air was observed in patients treated under general anaesthesia (median 38.4%) versus awake (11.5%); P = 0.004.

CONCLUSION

In this planning study, tumours at the unilateral location consistently showed improved dose reductions to normal tissue with minimal dose degradation from increased gastrointestinal air with PBS plans. Tumour location, PTV volume and anterior extension of PTV are useful characteristics in facilitating patient selection for PBS.

Perineal skin tear repair following vaginal birth; skin adhesive versus conventional suture - a randomised controlled trial

This was a prospective randomised controlled trial comparing the effects of first-degree perineal tear repair using adhesive glue versus conventional suturing in terms of pain score, wound complication and patient's satisfaction. One hundred and twenty one women were randomised. The skin adhesive group had a significantly lower pain score at rest as well as during sitting, walking and micturition during the first week of delivery compared to the suture group. The time taken to become pain free was significantly shorter in the tissue adhesive group (3.18 vs. 8.65 days, p < .001). Only two patients who had skin glue experienced wound gaping. No significant difference was observed in the level of satisfaction between the adhesive and suture groups. Tissue adhesive is better than subcuticular suture for repairing first-degree perineal tear as it causes less pain and has shorter recovery time.Impact statementWhat is already known on this subject. First- and second-degree tears following vaginal delivery are common and involved a third of women. Suturing of these tears is advocated to avoid wound gaping and poor healing.What the results of this study add. For first-degree tear repair, tissue adhesive is better than conventional suture in terms of pain reduction and recovery time.What the implications are of these findings for clinical practice and/or further research. Skin adhesive is an ideal method for first-degree perineal tear repair especially in out of hospital settings such as home birth or midwifery-led centre. A larger scale study is needed to establish its feasibility for second- and third-degree tears repair.

Validation of the Malay version of the p-QOL questionnaire

INTRODUCTION

This study aimed to translate and validate the P-QOL questionnaire in the Malay language.

METHODS

The P-QOL questionnaire was translated into the Malay language and subsequently back-translated to English. Test-retest reliability and internal consistency were tested. All patients who visited the gynecology outpatient clinic of UKMMC, UMMC and IIUM between January 2016 and May 2017 completed the P-QOL questionnaires and were assessed for POP-Q staging.

RESULTS

One hundred twenty patients with symptomatic pelvic organ prolapse and 180 asymptomatic patients were included. The Cronbach's alpha for each domain was > 0.70, which confirmed that there was a highly acceptable internal consistency. The value varied between 0.88 (role limitation) and 0.912 (sleep/energy). Test-retest reliability showed a significant correlation between the total scores for each domain (p < 0.001). There was a significant correlation between P-QOL domain scores and vaginal examination findings (POP-Q). With a higher POP-Q stage, a higher impact on the quality of life was detected in symptomatic patients. The total scores from all domains were significantly higher in symptomatic patients.

CONCLUSION

The Malay translated version of the P-QOL questionnaire is a reliable, consistent, and valid instrument for assessing the severity of the symptoms and impact on the quality of life among women with uterovaginal prolapse. It is easily understood, administered, and self-completed by patients.

Is First Trimester Maternal 25-Hydroxyvitamin D Level Related to Adverse Maternal and Neonatal Pregnancy Outcomes? A Prospective Cohort Study among Malaysian Women

Information on the role of 25-hydroxyvitamin D (25(OH)D) in preventing adverse pregnancy/neonatal outcomes is limited in Malaysia. This study aims to determine the relationship between the level of maternal 25(OH)D in the first trimester of pregnant women and their pregnancy/neonatal outcomes. A total of 60 pregnant women in the first trimester were recruited and followed until the end of their pregnancy. The occurrence of any antenatal, delivery, and neonatal complications was recorded. Their blood was collected in the first trimester for total serum 25(OH)D determination using enzyme-linked immunosorbent assay. Overall, 10% of the women had vitamin D deficiency, while 57% had vitamin D insufficiency in their first trimester. No statistically significant difference in 25(OH)D level/status was observed between women with or without antenatal and delivery complications (p > 0.05). No difference in maternal serum 25(OH)D level and vitamin D status was observed between neonates with or without complications (p > 0.05). In conclusion, there is a high prevalence of vitamin D insufficiency among Malaysian pregnant women, but it is not associated with adverse maternal and neonatal outcomes. More comprehensive studies should be planned to verify this relationship.

Reviewing the role of progesterone therapy in endometriosis

Endometriosis is a benign, chronic inflammatory condition characterized by the presence and growth of endometrial implants outside the uterine cavity. The cause of endometriosis is multifactorial. It is due to the diversity of hypothesis and plausibility of hormonal alterations which could play a major role. Evidence has shown that progesterone resistance is a key factor for endometriosis sufferers. Medical therapy can avoid surgical intervention, which may lead to a reduced in ovarian reserve, and its effects of earlier menopause and reduced fecundity. Progesterone receptor isoform has provided new insight as the potential treatment. Progestin, anti-progestin and selective progesterone receptor modulators usage, which target these receptors, could avoid hypo-estrogenic side effects, which can be debilitating. Numerous types of these medications have been used on and off labeled to treat endometriosis with varying success. This review aims to consolidate series of clinical trials using progestins in endometriosis.

Antenatal scoring system in predicting the success of planned vaginal birth following one previous caesarean section

This was a prospective observational study to determine the predictive factors for a successful vaginal birth after caesarean section (VBAC) and to develop a relevant antenatal scoring system. Patients with one previous caesarean section were included in this study. All data including maternal demographics, obstetric history, pregnancy progress and outcomes were collected and analysed. A total of 142 out of the 186 women (76.3%) had successful VBAC. History of previous vaginal delivery and non-recurrent indications for previous caesarean section were the significant predictive factors for a successful VBAC. Five variables for our scoring tool were selected. By using a proposed mean score of 4 out of 7, the scoring system had a sensitivity of 81.0%, specificity of 52.3% and a positive predictive value of 84.6%. VBAC antenatal scoring system was potentially a useful predictive tool in antenatal counselling. Impact statement What is already known on this subject: Planned vaginal birth after caesarean section (VBAC) is an important strategy to limit the overall caesarean section rate, which is related to maternal morbidities. However, trial of vaginal delivery does involve potential complications including scar dehiscence, postpartum haemorrhage and emergency hysterectomy. What the results of this study add: Clinical predictors of a successful VBAC include non-recurrent indications for the previous caesarean section, previous vaginal delivery, spontaneous onset of labour and birthweight less than 4kg. There were multiple screening tools developed to predict the likelihood of successful VBAC. These scoring systems involved various variables such as age, ethnicity, Bishop's score and previous caesarean indication. We had prospectively developed an antenatal scoring system based on five variables. Our result showed that patient with a score of four and above will have around 85% chance of successful VBAC. What the implications are of these findings for clinical practice and/or further research: We have also found that, estimated foetal weight based on ultrasound scan is a potential predictor for successful VBAC. This simple scoring method will be useful in-patient counselling regarding mode of delivery after one previous caesarean section. A multicentre study involving large cohort of patients is ideal to validate our scoring system.

Bowel endometriosis: a diagnostic and therapeutic challenge

Bowel endometriosis is the most common extragenital manifestation of endometriosis. Clinical suspicion is of utmost importance for achieving its diagnosis. Management of this condition is, however, always challenging to the gynaecologist. We report a case of bowel endometriosis in which the patient presented with dyschezia and haematochezia prior to her menses for the past 2 years. A 44-year-old para two woman presented with worsening dysmenorrhea and dyspareunia. She also experienced dyschezia and haematochezia prior to her menses for the past 2 years. An examination revealed a fixed retroverted uterus. A computed tomography scan showed focal bowel thickening. She underwent a colonoscopy examination and biopsy that revealed stromal endometriosis. She was subsequently treated with dienogest and became asymptomatic. Diagnosis and management of this debilitating illness was revisited and discussed.

Back pain in pregnancy among office workers: risk factors and its impact on quality of life

Background Back pain is a common presenting complaint during pregnancy and it is often being considered as part of the pregnancy process. The purpose of the study is to investigate the prevalence of back pain in pregnancy, risk factors and its impact on the quality of life in pregnant women. Materials and methods Three hundred and fifty-eight pregnant women who attended the antenatal clinic in Universiti Kebangsaan Malaysia (UKM) Medical Centre were recruited in this cross-sectional study from October 2011 until April 2012. The back pain was further classified into lumbar pain and posterior pelvic pain. The severity of back pain was assessed using visual analoque scale (VAS) and the functional limitation was assessed using the Oswestry Disability Questionnaire (ODQ). Result The prevalence of back pain in pregnancy was 84.6%. Occupation and previous history of back pain were associated with back pain in pregnancy. In terms of functional limitation disability, total ODQ score was statistically significant correlate with severity of pain (VAS score). Personal care, sitting, standing, sex life and social life were significantly affected. Conclusion The risk factors for back pain in pregnancy were type of occupation and history of back pain. The higher VAS score, the more ODQ will be affected. Personal care, sitting, standing, sex life and social life were significantly affected.

Comparison of 25-hydroxyvitamin D and metabolic parameters between women with and without polycystic ovarian syndrome

Background There is increasing evidence that supports the contribution of vitamin D deficiency in metabolic disturbances among women with polycystic ovarian syndrome (PCOS). The aim of this study was to compare 25-hydroxyvitamin D level and the prevalence of metabolic syndrome in the PCOS and normal women. Materials and methods A case-controlled study was conducted in a teaching hospital over a 6-month duration from June 2015 to January 2016. A total of 90 women, who consisted of 45 women with PCOS (study group) and 45 women without PCOS (control group), were recruited. Results The final analysis was of 80 women only and the prevalence of vitamin D deficiency (<20 ng/mL) was high between both groups, i.e. 93.7% but there was no significant difference (p = 0.874). Nevertheless, the prevalence of metabolic syndrome was significantly higher in the study group as compared to the control group (27.5% vs. 5.0%, p = 0.013). There was no statistically significant correlation between vitamin D level with clinical [age, weight, body mass index (BMI), waist and hip circumference, systolic and diastolic blood pressure (SBP and DPB, respectively)] and metabolic parameters (fasting glucose, triglycerides, cholesterol, high-density lipoprotein and low-density lipoprotein) among women with PCOS. However, height was positively correlated (r = 0.338, p = 0.033) and the contrary waist-hip ratio was negatively correlated with vitamin D level (r = -0.605, p = 0.048). Conclusion The prevalence of vitamin D deficiency was high in our study population. Nevertheless, the prevalence of metabolic syndrome was higher among women with PCOS as compared to women without PCOS.

Use of hydroxyprogesterone caproate to prevent preterm labour in uterine didelphys: a case report

Congenital uterine anomalies have been associated with poor reproductive outcome, which include recurrent miscarriage, abruptio placenta, intra-uterine growth restriction and preterm delivery. Here, we report a case: 36 years old, G3P2, known case of uterine didelphys, with history of preterm birth, who successfully carried her pregnancy till term with weekly intramuscular injection of 250 mg hydroxyprogesterone caproate (®Proluton Depot, Zuellig Pharma).

Update on the management of ovarian torsion in children and adolescents

BACKGROUND

Ovarian torsion is commonly seen in young girls. Unfortunately it is often misdiagnosed because of its non-specific symptoms and lack of diagnostic modalities. This article focuses on the diagnostic challenge and also the changes in the management of ovarian torsion.

DATA SOURCES

We reviewed original reports on the management of ovarian torsion in young girls published from 1984 till 2014. A literature search was conducted by electronic scanning of five electronic database: MEDLINE, EMBASE, SCI, SSCI and CINAHL. In addition, relevant papers and review articles were hand-searched. The search was limited to English language and human studies. The search was conducted by combining the textwords "ovarian torsion", "adnexal torsion", "adolescents" and "oophoropexy".

RESULTS

There are no specific symptoms that can be identified as a pathognomonic feature of ovarian torsion. Ultrasound is a useful diagnostic tool, but it is not always reliable in absence of an enlarged ovary. Laparoscopic detorsion is recognized as the mainstay of treatment regardless the condition of the ovaries. Reports have shown favorable ovarian function after detorsion. The role of oopheropexy remains controversial.

CONCLUSIONS

Clinicians should be aware of ovarian torsion in girls presenting with abdominal pain. A timely management in this young population can help preserve their ovaries and fertility.

Retained placenta: Do we have any option?

Retained placenta is a known cause of post-partum haemorrhage and maternal mortality. A recent systemic review has confirmed that the incidence of retained placenta had increased all over the world, which is more common in developed countries. Failure of retro-placental myometrium contraction is the main cause of retained placenta. Maternal age greater than 35 years, grandmultipara, preterm labor, history of previous retained placenta, and caesarean section were the risk factors for retained placenta. Manual removal of the placenta has been the treatment of choice. Attempts had been made by clinician and researchers to find a safe, effective and reliable method to avoid the need for surgical intervention. The efficacy and safety of prostaglandin, nitroglycerin or acupuncture in the management of retained placenta are yet to be further evaluated. Nonetheless, till date only intra-umbilical vein oxytocin has been studied extensively but with varied success. More randomized clinical trials are needed to address this issue. However, if immediate manual placenta removal service is unavailable, a trial of intra-umbilical vein oxytocin 100 IU at a total volume of at least 40 mL while preparing for transfer to a tertiary center or theatre may result in spontaneous expulsion of the placenta.

Outpatient versus inpatient intravaginal misoprostol for the treatment of first trimester incomplete miscarriage: a randomised controlled trial

BACKGROUND

Study objective To assess the efficacy of outpatient misoprostol administration versus inpatient misoprostol administration for the treatment of first trimester incomplete miscarriage.

MATERIALS AND METHODS

A prospective randomised controlled trial was conducted at a tertiary hospital from May 2012 to April 2013. A total of 154 patients with first trimester incomplete miscarriage were randomised to receive misoprostol either as outpatient or inpatient. Intra-vaginal misoprostol 800 mcg was administered eight hourly to a maximum of three doses. Complete evacuation is achieved when the cervical os was closed on vaginal examination or ultrasound showed no more retained products of conception evidenced by endometrial thickness of less than 15 mm. Treatment failure was defined as failure in achieving complete evacuation on day seven hence surgical evacuation is offered.

RESULTS

Outpatient administration of misoprostol was as effective as inpatient treatment with success rate of 89.2 and 85.7 % (p = 0.520). The side effects were not significantly different between the two groups. Side effects that occurred were minor and only required symptomatic treatment. Duration of bleeding was 6.0 days in both groups (p = 0.317). Mean reduction in haemoglobin was lesser in the outpatient group (0.4 g/dl) as compared to in the inpatient group (0.6 g/dl) which was statistically significant (p = 0.048).

CONCLUSION

Medical evacuation using intra-vaginal misoprostol 800 mcg eight hourly for a maximum of three doses in an outpatient setting is as effective as in inpatient setting with tolerable side effects.

Utero-cutaneous fistula after caesarean section secondary to red degeneration of intramural fibroid

A 33 year-old woman had an emergency caesarean section for retained second twin which was complicated by utero-cutaneous fistula due to red degeneration of intramural fibroid. The utero-cutaneous communication was demonstrated by an examination under anaesthesia using dye test. She then underwent excision of the fistula tract and myomectomy. She recovered well following the surgery. This is the first case of utero-cutaneous fistula where the communication is between the endometrial cavity and skin lesion via a necrotic intramural fibroid following caesarean section. Fistulogram might fail to demonstrate the communication. In highly suspected case, other modalities of investigations could be utilised.

Umbilical vein oxytocin in the management of retained placenta: an alternative to manual removal of placenta?

PURPOSE

Retained placenta is potentially life threatening due to possible complications associated with manual removal. Our aim was to determine whether umbilical vein injection of oxytocin in saline reduces the need for manual removal of placenta.

METHODS

This was a randomised controlled trial conducted at a tertiary hospital from December 2002 to March 2004. A total of 61 women delivering singletons, who had no sign of placental separation 20 min after vaginal delivery, were randomised to receive either intra-umbilical oxytocin 100 IU diluted in 30 ml of saline or controlled cord traction only. Manual removal was done if the placenta was not expelled in another 30 min in both arms.

RESULTS

There was a significant reduction in the rate of subsequent manual removal of placenta (30 vs. 67.7%, p < 0.05), incidence of uterine atony (3.3 vs. 25.8%, p < 0.05) and the need for uterotonic agents (33.3 vs. 64.5%, p < 0.05) in the oxytocin group when compared with the control group. No significant differences were found in the need for blood transfusion, uterine curettage, incidence of postpartum haemorrhage and haemoglobin level reduction.

CONCLUSION

Intra-umbilical vein oxytocin injection is clinically effective for the management of a retained placenta.

Dydrogesterone in threatened abortion: pregnancy outcome

OBJECTIVE

To determine whether therapy with dydrogesterone in threatened abortion during the first trimester of pregnancy will improve pregnancy outcome.

DESIGN

Prospective open study.

SUBJECTS

Pregnant women presenting to the obstetric and gynaecology clinic admitting center with vaginal bleeding before 13 weeks gestation were evaluated for entry into the study. Women were excluded if they had a history of recurrent miscarriage.

METHOD

Eligible subjects were randomized to receive either dydrogesterone 40 mg stat dose followed by 10 mg twice a day for one week or conservative therapy.

RESULTS

One hundred and 54 women were recruited. There was no statistically significant differences between the two groups with regard to pre-treatment status. The continuing pregnancy success rate was significantly (p=0.037) higher in women treated with dydrogesterone (95.9%) compared with women who received conservative treatment (86.3%). The odds ratio of the success rate between dydrogesterone treatment and non-treatment was 3.773 (95% confidence interval: 1.009-14.108).

CONCLUSION

Corpus luteal support with dydrogesterone has been shown to reduce the incidence of pregnancy loss in threatened abortion during the first trimester in women without a history of recurrent abortion.

Bone health in urban midlife Malaysian women: risk factors and prevention

The aim of this study was to identify risk factors associated with osteoporosis in urban midlife Malaysian women and to assess the effectiveness of lifestyle intervention in bone loss prevention with hormone replacement therapy (HRT) as a positive control. A total of 514 disease-free, uterus-intact, non-HRT-using women aged 45 years and older were recruited into the study. After initial bone mineral density (BMD) assessments, they were randomized into three groups: GI (control), G2 (lifestyle intervention), and G3 (lifestyle intervention with HRT). The study group was composed of 67.5% Chinese, 27.8% Malay, and 4.2% Indians with a mean age of 51.07+/-5.28 years. Two-fifths were postmenopausal, and the prevalence of osteoporosis was 24.1%, seen predominantly at the hip. Postmenopausal women had significantly lower mean BMD and a higher incidence of osteoporosis compared with the premenopausal women, 42.1% vs. 11.1% (p<0.0005). A lower incidence of osteoporosis was found in women who took calcium supplementation regularly as opposed to those who do not, 18.7% vs. 29.3% (p=0.036). Age and a greater postmenopausal duration showed a significant negative association with BMD, whereas higher family income, weight, body mass index, and waist and hip circumference were positively correlated. After 18-20 months, the effect of intervention was assessed based on BMD values of 279 women at baseline and after intervention. Lifestyle intervention alone was effective in premenopausal women, preventing over 90% of spinal bone loss compared with the controls, who lost 11.6% (0.046 g/cm2) bone mass with similar losses of hip bone, 2.0% (0.026 g/cm2) vs. 1.5% (0.020 g/cm2). Premenopausal women on HRT also showed a substantial decrease in spine and hip BMD, 18.6% (0.081 g/cm2) and 9.0% (0.122 g/cm2), respectively. The lifestyle intervention program retarded postmenopausal bone loss by 21% and 37% compared with controls, who lost 9.6% (0.141 g/cm2) and 6.0% (0.138 g/cm2) bone mass at the spine and hip. In comparison, lifestyle intervention with HRT increased postmenopausal BMD by 12.7% (0.216 g/cm2) at the spine and 1.9% (0.042 g/cm2) at the hip. The changes in hip BMD were influenced by current age, ethnicity, and income, while intervention had the strongest effect on spine BMD changes. In conclusion, lifestyle intervention prevented spinal bone loss in premenopausal women and retarded postmenopausal spine and hip bone loss compared with controls. The benefits of physical activity on spine and hip BMD highlight its potential as a safe and cost-effective alternative to HRT, which is not advocated because of its potential adverse effects.

A study on SARS awareness and health-seeking behaviour - findings from a sampled population attending National Healthcare Group Polyclinics

INTRODUCTION

The study aimed to assess the effectiveness of massive SARS public education effort on SARS awareness and the conduct of those suspected of having SARS.

MATERIALS AND METHODS

Five hundred and ninety-three respondents attending the National Healthcare Group Polyclinics (NHGP) participated in the survey from 9 to 13 June 2003. Associations between awareness of SARS symptoms and (i) first action to be taken and (ii) mode of transportation used, if the respondent was suspected of having SARS, were analysed using Chi-square or Fisher's exact tests. Logistic regression was performed to adjust for relevant covariates.

RESULTS

The majority (92.7%) of the respondents were aware of SARS symptoms. Television (91.6%), newspaper (65.2%) and radio (30.4%) formed the top 3 sources of information on SARS. Slightly more than half (51.6%) of those who suspect themselves of having SARS would choose to visit their primary health care doctors, while 22.7% of the respondents would go to Tan Tock Seng Hospital (TTSH). If they suspected themselves to have SARS, most (84.9%) of the 578 respondents would react appropriately by taking the SARS ambulance or driving themselves to TTSH. However, 60 respondents would nonetheless take public transport to TTSH [by taxi 8.5%, mass rapid transit (MRT) or bus 1.9%]. In particular, the retired with lower educational levels were likely to be oblivious both to the symptoms of SARS and the possible consequences of travelling by inappropriate transport.

CONCLUSION

Despite more than 2 months of intensive SARS public education in Singapore, there remain important gaps in knowledge and appropriate behaviour that have to be bridged.

Renal oncocytoma in acquired renal cystic disease

Renal oncocytoma is a rare benign tumor of the kidney that accounts for about 5% of renal tumors. Acquired renal cystic disease (ARCD) is commonly seen in dialyzed patients. However, the occurrence of renal oncocytoma in ARCD has rarely been reported. We report such a case in a 67-year-old man who had hypertension-associated end-stage renal disease and had received regular hemodialysis for 5 years. Radiologic diagnostic studies demonstrated a renal mass in the left atrophic cystic kidney that increased in size from 2 cm to 4 cm during 2 years of follow-up. Under the diagnosis of renal cell carcinoma, he received left radical nephrectomy. The pathologic examination revealed renal oncocytoma with a well-cirumscribed, homogenous, mahogany-brown tumor on a background of ARCD. Although patients with ARCD have a higher incidence of renal malignancies, renal oncocytoma may occur in these patients and may be managed conservatively.

Evidence for alterations in circulating low-molecular-weight antioxidants and increased lipid peroxidation in smokers on hemodialysis

BACKGROUND/AIM

Cardiovascular disease is the major cause of mortality in dialysis patients, accounting for about 40% of deaths in most large registries. Oxidative stress has been strongly implicated in the pathogenesis of these events. As end-stage renal disease is a state of elevated free radical activity, the aim of the present study was to investigate the negative impact of smoking in 57 male hemodialysis patients.

METHODS

The patients, who were 20-85 years of age (mean age 51.0 +/- 14 years), had been on hemodialysis for at least 6 months before participating in this study. Fasting blood sampling for serum lipid, albumin, urate and lipophilic antioxidants such as tocopherols, carotenes, ascorbate and lipid peroxides was performed.

RESULTS

The plasma malondialdehyde (MDA) concentration was significantly higher in hemodialysis patients who smoked compared to hemodialysis patients who were nonsmokers (1.92 +/- 0.52 vs. 1.59 +/- 0.42 nmol/ml, p = 0.006). No association was found between levels of MDA in smokers and parameters such as body mass index, serum cholesterol, serum triglycerides and smoking index. There were no significant differences in the plasma levels of uric acid, alpha-tocopherol, gamma-tocopherol, delta-tocopherol, alpha-carotene, beta-carotene and retinol between the two groups. A significantly lower level of plasma ascorbate was observed in hemodialysis patients who smoked compared to the nonsmoking hemodialysis patients or healthy controls (4.59 +/- 4.0 vs. 9.57 +/- 4.0 and 10.16 +/- 4.6 microg/ml, p < 0.05). Moreover, in smokers, the plasma levels of ascorbate were negatively correlated with the levels of plasma MDA (r = -0.43, p < 0.001) of each patient. Partial correlation analysis of the plasma levels of the measured antioxidants and the smoking index revealed a negative correlation between the plasma levels of lipid-normalized lycopene and the smoking index (r = -0.53, p < 0.05).

CONCLUSION

Our data suggest that cigarette smoking further increases plasma-circulating products of lipid peroxidation, which are already increased in nonsmoking hemodialysis patients as compared to matched healthy controls. The lower plasma levels of ascorbate in hemodialysis patients who smoke suggest that these patients may be more susceptible to oxidative tissue damage caused by smoking.

Use of isomalto-oligosaccharide in the treatment of lipid profiles and constipation in hemodialysis patients

Chronic constipation and hyperlipidemia, one of the many atherogenic risk factors, were common complications in hemodialysis (HD) patients. The present trial evaluates the therapeutic efficacy of isomaltose-oligosaccharide (IMO) in the treatment of chronic severe constipation and its effect on lipid profiles in 20 HD patients. After a 2-week basal period, these patients were allocated to receive 30 g of IMO for a 4-week period. After the study period, these patients were observed for another 4 weeks. Bowel frequency, gastrointestinal symptomatology, biochemical parameters, and lipid profiles were assessed. All patients completed this study. IMO induced a significant increase in number of bowel movements and hence improvement of constipation in 76.3% + 30.9% of patients during the 4-week treatment. Some, but well-tolerated gastrointestinal side effects were noted. Statistically significant decreases in total cholesterol and triglycerides (TG) and increases in high density lipoprotein-cholesterol (HDL-C) were noted after IMO treatment (P <.05 compared with baseline and controls). After the study period, those patients receiving IMO had reductions in levels of total cholesterol -17.6%, TG -18.4%, and elevations of levels of HDL-C by +39.1%. In conclusion, IMO once a day is well tolerated and effective in increasing bowel frequency and improving constipation in HD patients. In addition, IMO treatment was effective in lowering total cholesterol and triglycerides and in raising HDL-C in HD patients.

Biomarkers of DNA damage in patients with end-stage renal disease: mitochondrial DNA mutation in hair follicles

BACKGROUND

DNA damage was noted in patients with end-stage renal disease (ESRD). Mitochondrial DNA (mtDNA) mutations have been proposed as a genomic biomarker in the process of human ageing, degenerative diseases and carcinogenesis.

METHODS

Polymerase chain reaction (PCR) techniques were applied to detect mtDNA deletions in hair follicles, an appendage of skin, from 162 patients with ESRD.

RESULTS

The incidences of the 4977 bp deletion of mtDNA in hair follicles were found to increase with age in normal control and ESRD patients. As compared with normal subjects, ESRD patients had 3.5, 2.3, 2.7, 2.3 and 1.4 times higher incidences of the 4977 bp deletion of mtDNA in the age groups of 20-30, 31-40, 41-50, 51-60 and 61-70 years, respectively. Moreover, the difference in the proportion of mtDNA with the 4977 bp deletion was statistically significant between ESRD patients and normal subjects >50 years of age.

CONCLUSION

We suggest that the 4977 bp deletion of mtDNA in hair follicles may serve as one of the tissue biomarkers of genetic instability of the mitochondrial genome in ESRD patients.

Polymorphism in methylenetetrahydrofolate reductase gene: its impact on plasma homocysteine levels and carotid atherosclerosis in ESRD patients receiving hemodialysis

The methylenetetrahydrofolate reductase (MTHFR) gene polymorphism has been shown to be associated with cardiovascular disease in healthy subjects as well as in patients with end-stage renal disease (ESRD). In this study, we examined the allelic frequency and genotype distribution of the MTHFR gene in 151 Chinese ESRD patients receiving hemodialysis and 135 healthy controls. In addition, we investigated the relationship between the MTHFR gene polymorphism and the plasma homocysteine (Hcy) level as well as the intima-media thickness of common carotid artery (CC-IMT) in these patients. The allelic frequency of the MTHFR gene with the C677T mutation in ESRD patients was 24.5% and that in healthy controls was 23%. Mean plasma Hcy level of the ESRD patients (23.1 +/- 7.4 micromol/l) was significantly higher than that of the controls (10.1 +/- 5.0 micromol/l), but did not correlate with vitamin B(6) and vitamin B(12) status. Moreover, the extent of hyperhomocysteinemia was genetically affected by the C677T mutation of the MTHFR gene. The plasma Hcy levels for the patients with the CC, CT and TT genotypes of the MTHFR gene were 22.3 +/- 6.8, 22.8 +/- 7.3, and 28.3 +/- 2.8 micromol/l, respectively. In addition, we found that the patients bearing the TT genotype had the highest CC-IMT (0.93 +/- 0.07 mm), whereas the lowest values (0.79 +/- 0.13 mm) were observed in those who had the CC genotype. One-way ANOVA showed that the CC-IMT in the patients with the TT genotype was significantly greater than that of the patients with the CC genotype (p < 0.05). Moreover, the mean CC-IMT of the patients carrying either TT or CT genotype of the MTHFR gene was significantly higher than that of the patients bearing the CC genotype (0.86 +/- 0.14 vs. 0.79 +/- 0.13 mm, p = 0.002). Multiple regression analysis, in which the change in CC-IMT was used as the dependent variables, identified age, smoking, the MTHFR genotype (CC = 0, CT = 1, TT = 2) and diabetes mellitus as the independent variables significantly associated with the increase of CC-IMT (p < 0.001). These risk factors jointly explained 43.9% of the CC-IMT variation and age explained most of the variation (R(2) = 0.34). We conclude that both the TT genotype and the T allele of the MTHFR gene are associated with the increase of CC-IMT in hemodialysis patients. The C677T mutation of the MTHFR gene may be an independent risk factor that predicts the development of carotid atherosclerosis in ESRD patients.

Effect of age and sex on plasma total homocysteine in Taiwanese subjects

Plasma total homocysteine (tHcy) is now established as a clinical risk factor for coronary artery disease, as well as for other arterial and venous occlusive diseases. Therefore, we measured the plasma tHcy concentrations in 385 healthy Chinese subjects in Taiwan and in 40 patients with occluded coronary artery disease or maintenance hemodialysis. The plasma tHcy levels in Taiwanese male and female volunteers were found to increase gradually with age (age group: 20-29, 30-39, 40-49, 50-59, and >60; mean +/- SD 8.22 +/- 2.00, 8.51 +/- 2.67, 8.87 +/- 2.22, 11.41 +/- 2.50 and 13.28 +/- 2.31 microM for male volunteers and 6.49 +/- 1.75, 7.15 +/- 1.20, 7.40 +/- 1.30, 9.57 +/- 3.01 and 10.95 +/- 2.11 microM for female volunteers). At the same age, male volunteers were shown to have higher tHcy levels than female volunteers. In addition, the mean concentrations of plasma tHcy in occluded coronary artery disease (13.62 +/- 5.43 microM) or in maintenance hemodialysis (21.28 +/- 4.32 microM) were statistically higher than in age-matched normal subjects (11.02 +/- 2.85 microM). This study emphasizes the significance of age and sex-associated difference in the plasma tHcy levels, and underlines the importance of the range for plasma homocysteine in normal Taiwanese subjects.

Lipophilic antioxidants and iron status in ESRD patients on hemodialysis

Cardiovascular disease remains the major cause of mortality in hemodialysis patients. Abnormal oxidative stress and impaired antioxidant defense may contribute to accelerated atherogenesis associated with uremia. As oxidative modification of lipids appears to be a prerequisite for the development of atherosclerotic lesions, lipophilic antioxidants may be protective. The aim of this study was to determine the plasma levels of lipophilic antioxidants in 82 hemodialysis patients and 30 controls and to investigate the influence of body iron status on the levels of lipophilic antioxidants. The patients were categorized into 3 groups according to their serum ferritin levels. We found that the plasma levels of lycopene, delta-tocopherol, gamma-tocopherol and retinol of hemodialysis patients were lower than those of controls. On the other hand, both absolute and lipid-normalized plasma lycopene levels were significantly reduced in those patients in the groups with higher ferritin levels as compared to those with lower ferritin levels. In addition, our study showed that the lipid-normalized plasma levels of beta-carotene and alpha-carotene of hemodialysis patients with higher ferritin levels were lower than those of the patients with lower levels. These data suggest that the plasma levels of lipophilic antioxidants are altered in end-stage renal disease on hemodialysis and may be considered as markers of oxidative stress in these patients. Most importantly, elevated serum ferritin levels may affect the levels of these lipophilic antioxidants.

Effects of treatment of secondary hyperparathyroidism on the lipid profile in patients on hemodialysis

Abnormalities in circulating lipoprotein concentrations are a characteristic finding in patients undergoing dialytic therapy. A substantial number of these patients display type IV hyperlipoproteinemia. Certain data suggest that secondary hyperparathyroidism may induce disturbances in lipid metabolism. To evaluate the effects of pulse calcitriol therapy on the lipid profile in these patients, we undertook a prospective study in 12 patients on stable bicarbonate hemodialysis. Lipid parameters comprising cholesterol and the low- as well as the high-density lipoprotein subfractions, triglycerides, apolipoproteins A and B, serum parathyroid hormones (iPTH), alkaline phosphatase, calcium, phosphorus, hematocrit, and blood urea were obtained prior to commencement of pulse calcitriol therapy and again 8-10 weeks later. Calcitriol therapy was associated with a decrease in serum iPTH levels (701 +/- 103.9 vs. 220.3 +/- 50.5 pmol/l; p < 0.001). Significant increases in high-density lipoprotein cholesterol (32.8 +/- 2.7 vs. 38.8 +/- 2.3 mmol/l; p < 0.05) and apolipoprotein A-I (107.8 +/- 6.1 vs. 121.8 +/- 5.8 g/l; p < 0.05) were noted during the course of the study. Moreover, serum iPTH correlated inversely with high-density lipoprotein cholesterol and apolipoprotein A-I. There were no changes in other lipid parameters except for low-density lipoprotein cholesterol which showed a tendency to increase. We conclude that in short-term study, pulse oral calcitriol therapy is associated with an improvement in the lipid profile in patients with secondary hyperparathyroidism. However, it remains to be established whether ameliorating the uremic dyslipidemia results in any long-term clinical benefits.

Large-scale mitochondrial DNA deletions in skeletal muscle of patients with end-stage renal disease

End-stage renal disease (ESRD) is associated with enhanced oxidative stress. This disease state provides a unique system for investigating the deleterious effect of exogenous sources of free radicals and reactive oxygen species (ROS) on mitochondrial DNA (mtDNA). To test the hypothesis that uremic milieu might cause more severe damage to mtDNA, we investigated the prevalence and abundance of mtDNA deletions in the skeletal muscles of ESRD patients. The results showed that the frequencies of occurrence of the 4977 bp and 7436 bp deletions of mtDNA in the muscle tissues of the older ESRD patients were higher than those of the younger patients. The frequency of occurrence of the 4977 bp-deleted mtDNA in the muscle was 33.3% for the patients in the age group of < 40 years, 66.6% in the 41-60-year-old group, 100% in the 61-80-year-old group, and 100% in patients >80 years of age, respectively. Only 22% of the normal aged controls carried the 4977 bp mtDNA deletion, whereas 77% (17/22) of the ESRD patients exhibited the mtDNA deletion. Using a semiquantitative PCR method, we determined the proportion of the 4977 bp-deleted mtDNA from the muscles that had been confirmed to harbor the deletion. We found that the proportions of the 4977 bp-deleted mtDNA in the muscle were significantly higher than those of the aged matched controls. Using long-range PCR techniques, a distinctive array of mtDNA deletions was demonstrated in the muscle of uremic patients. In summary, we found diverse and multiple mtDNA deletions in the skeletal muscles of ESRD patients. These deletions are more prevalent and abundant in ESRD patients than those found in normal populations. Accumulation of uremic toxins and impaired free radical scavenging systems may be responsible for the increased oxidative stress in ESRD patients. Such stress may result in oxidative damage and aging-associated mutation of the mitochondrial genome.

Enhanced oxidative stress in haemodialysis patients receiving intravenous iron therapy

BACKGROUND

Iron balance is critical for adequate erythropoiesis and there remains much debate concerning the optimal timing and dosage of iron therapy for haemodialysis patients receiving recombinant human erythropoietin therapy.

METHODS

In this study, we examined the influence of baseline ferritin level and intravenous infusion of 100 mg ferric saccharate on the oxidative status of the patients on maintenance haemodialysis. The levels of antioxidant enzymes and lipid peroxides were determined in erythrocytes and plasma of 50 uraemic patients on haemodialysis. These patients were divided into groups 1, 2, and 3, based on their baseline serum ferritin levels of <300, 301-600, and >601 microg/l, respectively.

RESULTS

We found that the mean superoxide dismutase (SOD) activities in the erythrocytes were similar in the three groups of patients and did not differ from those of the age-matched controls. On the other hand, all the haemodialysis patients showed significantly higher plasma SOD activity as compared to controls. After intravenous iron infusion, group 3 patients showed the largest decrease in plasma SOD activity. The plasma glutathione peroxidase (GSHPx) activities of the patients in all three groups and the erythrocyte GSHPx activities of the patients in the groups 2 and 3 were lower than those of the healthy controls. In all three groups of patients, no difference in GSHPx activity was found before and after intravenous iron infusion. On the other hand, we found that the average baseline levels of plasma lipid peroxides of all three groups of patients were significantly higher than that of the controls. The patients in group 3 with the highest serum ferritin levels showed the highest levels of plasma lipid peroxides. More importantly, we found that after iron infusion, the patients in all three groups, particularly those in group 3, showed significantly elevated levels of plasma lipid peroxides.

CONCLUSION

We demonstrated that increased oxidative stress in the blood circulation of the uraemic patients on haemodialysis is exacerbated by the elevated baseline serum ferritin levels and intravenous iron infusion. The resultant oxidative damage may contribute to the increased incidence of atherosclerosis in the patients with end-stage renal disease on long-term haemodialysis.

Evaluation of pre- and postdilutional on-line hemodiafiltration adequacy by partial dialysate quantification and on-line urea monitor

On-line highflux hemodiafiltration (HDF) is a clinically interesting and effective mode of renal replacement therapy, which offers the possibility to obtain an increased removal of both small and large solutes. The fundamental role of urea kinetic monitoring to assess dialysis adequacy in conventional hemodialysis has been widely studied. Both direct measurement of the urea removed by the modified direct dialysate quantitation (mDDQ) based on partial dialysate collection (PDC) and dialysate-based urea kinetic modeling (DUKM) using urea monitor have been advocated. The validity of this assessment tool in the patients with on-line HDF remained unclear. The aims of this investigation were (1) to compare the delivered Kt/V, urea mass removal (UMR), solute removal index (SRI) and normalized protein catabolic rate (nPCR) between pre- and postdilutional high-flux HDF; (2) to verify and compare the efficiency of pre- and postdilutional HDF using DUKM with on-line dialysate urea sensor, and mDDQ with partial dialysate collection. During both mode of HDF, the paired analysis urea removed and Kt/V showed no significant difference. Using mDDQ, mean values for predilutional mode were as follows: Kt/V 1.53 +/- 0.01 UMR, 16.8 +/- 0.3 g/session; urea clearance 178 +/- 18 ml/min; SRI 75.5 +/- 7.7%; urea distribution volume (V) 28.3 +/- 1.2 liters; nPCR 1.34 +/- 0.18 g/kg/day; on the other hand, mean values for postdilutional mode were Kt/V 1.58 +/- 0.01; UMR 17.10 +/- 0.28 g/session; urea clearance 184 +/- 21 ml/min; SRI 77.2 +/- 3.5%; urea distribution volume, 27.8 +/- 1.5 liters; nPCR 1.34 +/- 0.19 g/kg/day. The mean value of urea generation rate was 5.82 +/- 1.12 mg/min during HDF. Our results showed that dialysis adequacy was achieved with both high-volume predilutional HDF and postdilutional HDF. These two modes of HDF provided similar and adequate small solute clearance. In addition, we found that on-line analysis of urea kinetics is a reliable tool for quantifying and assuring delivery of adequate dialysis.

Repeat tear of postoperative meniscus: potential MR imaging signs

PURPOSE

To determine the usefulness of five magnetic resonance (MR) signs of repeat tears of the postoperative meniscus.

MATERIALS AND METHODS

Fat-saturated proton-density-weighted and T2-weighted MR images in 20 patients who had undergone at least two knee surgeries were reviewed. Second-look arthroscopic confirmation of meniscal status was available in all patients. MR images of 39 menisci (10 repeat tears, 11 postoperative menisci without repeat tears, three tears in previously normal menisci, and 15 normal menisci) were evaluated for (a) a linear area of abnormal signal intensity extending to an articular surface on intermediate-weighted images, (b) abnormal meniscal morphology, (c) likelihood of a typical postoperative appearance, (d) fluid extending into the linear area on T2-weighted images, and (e) cartilage defects. Two radiologists rated their confidence on a five-point scale for the presence of these signs and were compared for level of agreement.

RESULTS

The intraclass correlation coefficient (range, 0.75-0.91) indicated a high level of agreement. Areas under the receiver operating characteristic curves were large (range, 0.70-0.87) for all five signs, with a line (grade 3 signal intensity) and fluid within a line having the highest areas. These two signs also had the highest statistical scores (chi 2 = 14.12 and 13.30; P < .002; odds ratio, 1.588 and 1.599 for the line and the fluid within the line, respectively).

CONCLUSION

The two best MR signs of repeat tear of the postoperative meniscus were the presence of a line and fluid within the line extending to an articular surface.