[Predictive value of stress-induced hyperglycemia on 28 d risk of all-cause death in intensive care patients]

OBJECTIVE

To investigate the relationship between stress glucose elevation and the risk of 28 d all-cause mortality in intensive care unit (ICU) patients, and to compare the predictive efficacy of different stress glucose elevation indicators.

METHODS

ICU patients who met the inclusion and exclusion criteria in the Medical Information Mart for Intensive Care Ⅳ (MIMIC-Ⅳ) database were used as the study subjects, and the stress glucose elevation indicators were divided into Q1 (0-25%), Q2 (>25%- 75%), and Q3 (>75%-100%) groups, with whether death occurred in the ICU and the duration of treatment in the ICU as outcome variables, and demographic characteristics, laboratory indicators, and comorbidities as covariates, Cox regression and restricted cubic splines were used to explore the association between stress glucose elevation and the risk of 28 d all-cause death in ICU patients; and subject work characteristics [receiver operating characteristic (ROC) and the area under curve (AUC)] were used to evaluate the predictive efficacy of different stress glucose elevation indicators, The stress hyperglycemia indexes included: stress hyperglycemia ratio (SHR1, SHR2), glucose gap (GG); and the stress hyperglycemia index was further incorporated into the Oxford acute severity of illness score (OASIS) to investigate the predictive efficacy of the improved scores: the AUC was used to assess the score discrimination, and the larger the AUC indicated, the better score discrimination. The Brier score was used to evaluate the calibration of the score, and a smaller Brier score indicated a better calibration of the score.

RESULTS

A total of 5 249 ICU patients were included, of whom 7.56% occurred in ICU death. Cox regression analysis after adjusting for confounders showed that the HR (95%CI) for 28 d all-cause mortality in the ICU patients was 1.545 (1.077-2.217), 1.602 (1.142-2.249) and 1.442 (1.001-2.061) for the highest group Q3 compared with the lowest group Q1 for SHR1, SHR2 and GG, respectively, and The risk of death in the ICU patients increased progressively with increasing indicators of stressful blood glucose elevation (P_trend < 0.05). Restricted cubic spline analysis showed a linear relationship between SHR and the 28 d all-cause mortality risk (P>0.05). the AUC of SHR2 and GG was significantly higher than that of SHR1: AUC_SHR2=0.691 (95%CI: 0.661-0.720), AUC_GG=0.685 (95%CI: 0.655-0.714), and AUC_SHR1=0.680 (95%CI: 0.650-0.709), P < 0.05. The inclusion of SHR2 in the OASIS scores significantly improved the discrimination and calibration of the scores: AUC_OASIS=0.820 (95%CI: 0.791-0.848), AUC_OASIS+SHR2=0.832 (95%CI: 0.804-0.859), P < 0.05; Brier score_OASIS=0.071, Brier score_OASIS+SHR2=0.069.

CONCLUSION

Stressful glucose elevation is strongly associated with 28 d all-cause mortality risk in ICU patients and may inform clinical management and decision making in intensive care patients.

Surgical subspecialty training outside Malaysia during COVID-19 Pandemic: Perspectives and experiences of Trainees

Subspecialty surgical training is an integral part of continuous professional development. It represents a unique opportunity for surgeons to enhance and develop specific advanced skills in their sub-disciplines. Hence, hands-on training in an international training centre abroad allows one to bring home new technical and management skills in the expansion of Malaysian surgical services to raise to be on par with the international standards. The unexpected onset of the COVID-19 pandemic brought in previously unknown hindrances to the training both locally and abroad but our success in engagement with international centres despite the pandemic restrictions serves as a valuable experience towards maintaining international networking for future collaborations.

Factors predicting clinical outcomes of continuous ambulatory peritoneal dialysis associated peritonitis - A single centre study

BACKGROUND

Peritonitis is the common complication among Continuous Ambulatory Peritoneal Dialysis (CAPD) patients. This study is aimed to identify the factors predicting clinical outcomes of peritonitis in patients undergoing CAPD and the demographic, clinical and microbiological features of CAPD patients who were diagnosed with peritonitis.

MATERIALS AND METHODS

This is a retrospective observational study conducted to identify factors predicting clinical outcomes of CAPD associated peritonitis over a four-year period in Taiping Hospital, Malaysia.

RESULTS

A total of 109 episodes of CAPD associated peritonitis in 54 patients was enrolled with a median age being 56.5 years. In all 43.1% of these were complicated peritonitis. About half (n=54, 49.5%) of the peritonitis was caused by a single gram-positive organism. Coagulase negative Staphylococcus (CoNS) and Escherichia coli was the most often isolated gram-positive and gram-negative microorganism, respectively. We observed that less likelihood of developing complicated peritonitis in presence of abdominal pain (Odd ratio, OR 0.25, 95% confidence interval, 95%CI: 0.10, 0.63). In contrast, presence of more than one previous episode of peritonitis (OR 2.79, 95%CI: 1.11, 7.04) and previous migration and readjustment of Tenkchoff catheter (OR 7.48, 95%CI: 1.39, 40.41), were factors significantly associated with complicated peritonitis.

CONCLUSION

Presence of abdominal pain, more than one previous episode of peritonitis, and previous migration and readjustment of Tenkchoff catheter, were found as significant factors in predicting clinical outcomes of CAPD associated peritonitis.

Deoxygenation of pyrolysis vapour derived from durian shell using catalysts prepared from industrial wastes rich in Ca, Fe, Si and Al

Catalysts prepared from industrial wastes rich in Fe, Ca, Si, and Al were used in catalytic upgrading of pyrolysis vapour derived from durian shell and their effect on product yield and properties were compared. With same silica-to-alumina ratio, catalyst prepared from oil palm ash (AS-OPA) with lower Fe and Ca contents gave higher liquid yield (8.32 wt%) with alcohols (28.90%), hydrocarbons (46.00%), and nitrogen-containing compounds (21.46%) while catalyst prepared from electric arc furnace slag (AS-EAF) with higher Fe and Ca contents produced lower liquid yield (50.21 wt%) with high amount of esters (25.80%) and hydrocarbons (72.82%). The presence of AS-OPA and AS-EAF catalysts enhanced deoxygenation degree of bio-oil to 81.13% and 85.49%, respectively. The catalytic performance of AS-EAF at different temperatures (400-600 °C) and AS-EAF/durian shell ratios (1:30, 2:30, 3:30) was investigated. Increasing catalytic temperature enhanced production of bio-oil, reduced oxygenates and enhanced formation of esters. The liquid yield and yield of esters decreased with increasing catalyst loading. Hydrocarbons (mainly neopentane) were the major chemical compounds found in bio-oil produced over AS-EAF. Besides that, AS-EAF showed good deoxygenation performance with highest selectivity of hydrocarbons at 500 °C and AS-EAF/durian shell ratio of 2:30. Catalytic fast pyrolysis of durian shell using waste-derived catalysts is an effective waste management strategy as the bio-oil produced can be a potential alternative source of energy or chemical feedstocks.

[Interpretation for the group standards in technical specification of long-term follow-up for end point in large population-based cohort study]

Long-term follow-up for end point is an extremely important and arduous task in large population-based cohort studies, which is also the key to the success of large cohort studies. Thus, the fundamental question of the achievements above is how to construct a large population- based cohort in a standardized way. The Chinese Preventive Medicine Association coordinated experienced researchers from Zhejiang Provincial Center for Disease Control and Prevention and other professional institutes to write up the group standard entitled Technical specification of long-term follow-up for end point in large population-based cohort study (T/CPMA 002-2019). The standard is drafted with principles of emphasizing the scientific, normative, applicability, and feasible nature. This group standard recommended the follow-up target population, time, content, methods, quality control, and indicators assessment. The standard aims to guide the large population-based cohorts that have been or intended to be established in China, including national cohorts, regional population cohorts, and special population cohorts, hence, to improve domestic scientific research level and the international influence, and to support decision-making and practice of disease prevention and control.

[Study on correlation between alcohol consumption and obesity in adults in China]

Objective: To evaluate the correlation between alcohol consumption and obesity in adults in China. Methods: The information about alcohol consumption were collected at the baseline survey of the China Kadoorie Biobank. The general obesity and central obesity were defined by BMI and waist circumference (WC) respectively. Logistic regression model was employed to examine the relationship of drinking behavior with general obesity and central obesity. Results: A total of 249 873 adults were included. A J-shaped relationship was observed between alcohol consumption and obesity measurement index (BMI and WC) in men. Compared with non-drinkers, the proportion of general obesity and central obesity were lower in light drinkers (men: OR=0.65, 95%CI: 0.59-0.71 and OR=0.93, 95%CI: 0.88-0.98; women: OR=0.77, 95%CI: 0.65-0.91 and OR=0.89, 95%CI: 0.80-0.99). In men, the proportion of general obesity and central obesity was highest in heavy drinkers (OR=1.21, 95%CI: 1.12-1.32; OR=1.33, 95%CI: 1.27-1.40). BMI and WC were higher in those with a drinking frequency of 3-5 d/week, with largest of proportion of central obesity (men: OR=1.23, 95%CI: 1.16-1.31; women: OR=1.13, 95%CI: 0.99-1.28). The risk for central obesity in men who began drinking every week before 20 years old was 1.24 times higher than non-drinkers (95%CI: 1.16-1.33). Those who drank beer had lower proportion of general obesity (men: OR=0.74, 95%CI: 0.67-0.82; women: OR=0.54, 95%CI: 0.43-0.68). Conclusion: The proportion of obesity was lower in light drinkers but higher in heavy drinkers; and the earlier drinking started, the higher the risk for obesity was.

[Levels of skeletal muscle mass and handgrip strength in adults from 10 regions of China]

Objective: To describe the regional and population-related differences in skeletal muscle mass and handgrip strength across the 10 regions of China. Methods: 24 533 participants aged 38-88 years from the second resurvey of China Kadoorie Biobank were included in our analyses. Appendicular and trunk skeletal muscle mass were assessed using the bioelectrical impedance analysis (TANITA). Handgrip strength was measured using Jamar hand-held dynamometer. Low muscle mass and low muscle strength were defined as the lowest quintile of height-adjusted appendicular muscle mass or handgrip strength according to the Consensus Report of the Asian Working Group for Sarcopenia. We analyzed the mean value of absolute muscle mass, height-adjusted muscle mass, weight-adjusted muscle mass and handgrip strength. We also reported the prevalence of low muscle mass and low muscle strength. Results: The average appendicular and total skeletal muscle mass were (22.0±0.02) kg and (49.7±0.05) kg in men, which were higher than in women [(15.9±0.02) kg and (37.2±0.04) kg, respectively]. The handgrip strength was (32.6±0.06) kg in men, which was higher than (19.9±0.05) kg in women. The absolute muscle mass was higher in north area and urban region (P<0.001). The weight-adjusted muscle mass showed reverse patterns of regional difference compared with height-adjusted muscle mass. Both muscle mass and handgrip strength decreased by age (trend P<0.001), with a larger decline observed in handgrip strength. According to AWGS criteria, the proportions of low muscle mass and strength increased by age. Among participants over 80 years old, the prevalence of low muscle mass and strength were 56.2% and 74.5% in men, and 35.7% and 66.0% in women. Conclusions: Levels of skeletal muscle mass and strength varied greatly among people from 10 regions and among participants with different demographic characteristics. The prevalence of low muscle mass and strength was extremely high in elderly.

[Association between the frequency of bowel movements and the risk of colorectal cancer in Chinese adults]

Objective: To examine the association between the frequencies of bowel movement (BMF) and the risk of colorectal cancer (CRC). Methods: In this study, 510 134 participants from the China Kadoorie Biobank (CKB) were included, after excluding those who reported as having been diagnosed with cancer at the baseline survey. The baseline survey was conducted from June 2004 to July 2008. The present study included data from baseline and follow-up until December 31, 2016. We used the Cox proportional hazards regression models to estimate the HR and the 95%CI of incident CRC with BMF. Results: During an average follow-up period of 9.9 years, 3 056 participants were documented as having developed colorectal cancer. In the site-specific analysis, 1 548 colon cancer and 1 475 rectal cancer were included. Compared with participants who had bowel movements on the daily base, the multivariable-adjusted HR (95%CI) for those who had more than once of BMF were 1.24 (1.12-1.39) for CRC, 1.12 (0.95-1.31) for colon cancer, and 1.37 (1.18-1.59) for rectal cancer. We further examined the association between BMF and CRC, according to the stages of follow-up, the corresponding HR (95%CI) for CRC, colon and rectal cancer were 1.59 (1.36-1.86), 1.43 (1.14- 1.80), and 1.76 (1.41-2.19) for the first five years, while such associations became statistically insignificant in the subsequent follow-up (P for all interactions were <0.05), as time went on. As for CRC, colon or rectal cancers among participants who had lower bowel movements, the risks were not significantly different from those who had bowel movements everyday. Conclusions: Participants who had BMF more than once a day, appeared an increased risk of CRC in the subsequent five years. Since abnormal increase of bowel movements is easily recognizable, programs should be set up on health self- management and early screening for CRC.

[Epidemiological characteristics of household fuel use in 10 areas of China]

Objective: To describe the characteristics of cooking and heating fuel use in participants from the China Kadoorie Biobank (CKB) study. Methods: The CKB study recruited 512 891 adults from 10 areas in China during 2004-2008. Information on cooking fuel and heating fuel was collected using a questionnaire in baseline survey. The proportions of various fuels used in different areas, in different populations, and at different time points were calculated and compared. Results: Overall, 52.1% participants used solid fuel for cooking or heating. Rural areas had higher prevalence of solid fuel use than urban areas. The percentage of participants using solid fuel for cooking was 36.1% (coal 20.1%, wood/charcoal 16.0%); The percentage of participants using solid fuel for heating was 36.7% (coal 22.7%, wood/charcoal 14.0%). The prevalence of solid fuel use and the fuel type mainly used varied widely across 10 areas. The proportion of clean fuel use was lower in less-educated and lower-income people. Household coal and wood/charcoal use showed a declining trend, which was more remarkable in urban areas. Conclusion: There are still a large number of rural residents and people with low income relying on solid fuel in China, which is a serious public health concern.

[Prevalence of 'healthy lifestyle' in Chinese adults]

Objective: To examine the prevalence of 'healthy lifestyle' from data extracted from the China Kadoorie Biobank (CKB) of 0.5 million adults from ten areas across China. Methods: After excluding participants with self-reported histories of coronary heart disease, stroke or cancer, a total of 487 198 participants at baseline (2004-2008) and 22 604 participants at second survey (2013- 2014), were included for analysis. 'Healthy lifestyle' was defined as haing the following characteristics: a) never smoking or having stopped smoking for reasons other than illness; b) alcohol drinking <25 g/day (men)/<15 g/day (women); c) diet rich in vegetables, fruits, legumes and fish, but low in red meat; d) upper quarter of the physical activity level; e) body mass index of 18.5-23.9 kg/m(2) and waist circumstance <85 cm (men)/80 cm (women). We calculated the healthy lifestyle scores (HLS) by counting the number of all the healthy lifestyle factors, with a range from 0 to 6. Results: At baseline, prevalence rates of the above five healthy lifestyles (except physical activity) were 70.6%, 92.6%, 8.7%, 52.6% and 59.0%, respectively, with the mean HLS being 3.1±1.2. Most participants (81.4%) had2-4 healthy components, while only 0.7% (0.2% in men and 1.0% in women) of all the participants had all six healthy lifestyles. Participants who were women, at younger age, with more schooling and rural residents, were more likely to adhere to the healthy lifestyle. After ten years, the mean HLS showed a slight decrease. Conclusion: The prevalence of optimal lifestyles in Chinese adults appeared extremely low. Levels of 'healthy lifestyle' varied greatly among those populations with different socio-demographic characteristics across the ten areas in China.

[Interpretation for the group standards in data management for large population-based cohorts]

Precision medicine became the key strategy in development priority of science and technology in China. The large population-based cohorts become valuable resources in preventing and treating major diseases in the population, which can contribute scientific evidence for personalized treatment and precise prevention. The fundamental question of the achievements above, therefore, is how to construct a large population-based cohort in a standardized way. The Chinese Preventive Medicine Association co-ordinated experienced researchers from Peking University and other well-known institutes to write up two group standards Technical specification of data processing for large population-based cohort study (T/CPMA 001-2018) and Technical specification of data security for large population-based cohort study (T/CPMA 002-2018), on data management. The standards are drafted with principles of emphasizing their scientific, normative, feasible, and generalizable nature. In these two standards, the key principles are proposed, and technical specifications are recommended in data standardization, cleansing, quality control, data integration, data privacy protection, and database security and stability management in large cohort studies. The standards aim to guide the large population-based cohorts that have been or intended to be established in China, including national cohorts, regional population cohorts, and special population cohorts, hence, to improve domestic scientific research level and the international influence, and to support decision-making and practice of disease prevention and control.

[Relationship between educational level and long-term changes of body weight and waist circumference in adults in China]

Objective: To evaluate the association of educational level with anthropometric measurements at different adult stages and their long-term changes in adults who participated in the second re-survey of China Kadoorie Biobank (CKB). Methods: The present study excluded participants who were aged >65 years, with incomplete or extreme measurement values, or with major chronic diseases at baseline survey or re-survey. The weight at age 25 years was self-reported. Body height, body weight and waist circumference at baseline survey (2004-2008) and re-survey (2013-2014) were analyzed. Results: The present study included 3 427 men and 6 320 women. Both body weight and waist circumference (WC) increased with age. From age 25 years to baseline survey (mean age 45.2±6.5), the mean weight change per 5-year was (1.70±2.63) kg for men and (1.27±2.10) kg for women. From baseline survey to re-survey (53.2±6.5), the mean changes per 5-year for body weight were (1.12±2.61) kg for men and (0.90±2.54) kg for women; and that for WC was (3.20±3.79) cm for men and (3.83±3.85) cm for women. Among women, low educational level was consistently associated with higher body mass index (BMI) and WC at age 25 years, baseline survey and re-survey. Among men, low educational level was associated with higher BMI at age 25 years. At baseline survey and re-survey, the educational level in men was not statistically associated with BMI; but men who completed junior or senior high school showed slight higher WC and increase of WC from baseline survey to re-survey than other male participants. Conclusions: Body weight and WC increased with age for both men and women. The associations of educational level with BMI and WC were different between men and women.

[Association between central obesity and risk for heart disease in adults in China: a prospective study]

Objective: To understand the association between central obesity, assessed by waist circumference, and the risks for ischemic heart disease (IHD), major coronary event (MCE), and IHD death. Methods: After excluding participants with heart disease, stroke, cancer, COPD, and diabetes at baseline survey, we included a total of 428 595 participants from the China Kadoorie Biobank for the analysis. The baseline survey was conducted from June 2004 to July 2008. We used Cox proportional hazards model to estimate the hazard ratio (HR) and 95%CI. Results: During an average 9.1 years of follow-up (3 803 637 person-years), we documented 26 900 incident cases of IHD, 4 320 cases of MCE, and 2 787 of deaths from IHD. After adjustment for possible confounders and BMI, central obesity was found to be associated with increased risks for IHD, MCE, and IHD death. The adjusted HRs (for the participants who had waist circumference of 85.0-89.9 cm in men and 80.0-84.9 cm in women were 1.13 (95%CI: 1.09-1.17) for IHD, 1.15 (95%CI: 1.05-1.26) for MCE and 1.11 (95%CI: 0.98-1.24) for IHD death. The respective HRs for those central obese participants (men ≥90.0 cm, women ≥85.0 cm) were 1.29 (95%CI: 1.24-1.34), 1.30 (95%CI: 1.17-1.44) and 1.32 (95%CI: 1.16-1.51). Further stratification analysis according to BMI showed that the risks for incident IHD, MCE, and IHD death increased along with the increase of waist circumference even in the participants with normal weight. Conclusion: This large-scale prospective study revealed that central obesity was an independent risk factor for IHD in adults in China, and the risk of IHD would increase with the increase of waist circumference.

Catalytic fast pyrolysis of durian rind using silica-alumina catalyst: Effects of pyrolysis parameters

Silica-alumina catalyst was prepared and used in the catalytic fast pyrolysis of durian rind in a drop-type two-stage reactor. The effects of catalytic temperature (400 °C-600 °C) and catalyst-to-durian rind ratio (1:30-3:30) were evaluated. Bio-oil yield was increased with increased catalytic temperature due to considerable dehydration process, but it was reduced with high catalyst loading due to the overcracking of organics into light gases. Silica-alumina catalyst possessed good selectivity and the products changed according to the temperature. The major components in bio-oil were hydrocarbons, furan derivatives, and aromatic compounds at 400 °C, 500 °C, and 600 °C, respectively. The hydrogen and carbon contents of bio-oil were reduced with high catalyst loading due to the overcracking of organics, and the deoxygenation process became unfavorable. The silica-alumina catalyst worked well in catalytic fast pyrolysis of durian rind, and the condition may be adjusted based on the desired products.

Ryzophagia secondary to PCOS -related menorrhagia

We report the peculiar case of a patient who consumed raw rice daily and had iron-deficiency anaemia secondary to menorrhagia with underlying polycystic ovarian syndrome. A 32-year-old lady of Asian descent presented with symptoms of fatigue, lethargy and prolonged, irregular periods for the last two months. There was noticeable increase in body weight, male pattern alopecia and facial acne. In addition, she experienced sudden, unexplained predilection towards consumption of raw rice (up to 300- 400g/day). The patient was treated with oral iron and cyclical progestin. After three weeks, her haemoglobin improved and her ryzophagia subsided. Gynaecologists should be vigilant of pica, which can occur outside of the context of pregnancy and also poses potential health risks including tooth attrition, electrolyte imbalance, intestinal obstruction and poisoning.

[Sex-specific associations between tobacco smoking and risk of cardiovascular diseases in Chinese adults]

Objective: To examine the sex-specific associations between tobacco smoking and risk of cardiovascular diseases in Chinese adults. Methods: The present analysis included 487 373 participants from the China Kadoorie Biobank after excluding those with cancer, heart diseases, stroke at baseline survey. The baseline survey was conducted from June 2004 to July 2008. The number of follow-up years was calculated from the time that the participants completed baseline survey to the time of any event: CVD incidence, death, loss of follow-up, or December 31, 2015, whichever occurred first. We used Cox proportional hazards regression models to estimate the HRs and 95%CI of incident cardiovascular diseases with tobacco smoking. Results: During a median follow-up of 8.9 years(a total of 4.1 million person years), we documented 33 947 cases of ischemic heart diseases, 6 048 cases of major coronary diseases, 7 794 cases of intracerebral hemorrhage, and 31 722 cases of cerebral infarction. The prevalence of smoking was much higher in men (67.9%) than in women (2.7%). Smoking increased risk of all subtypes of cardiovascular diseases. Compared with nonsmokers, the multivariable-adjusted HRs (95% CI) for current smokers were 1.54 (1.43-1.66) for major coronary event, 1.28 (1.24-1.32) for ischemic heart disease, 1.18 (1.14-1.22) for cerebral infarction, and 1.07 (1.00-1.15) for intracerebral hemorrhage, respectively. Female smokers tended to have greater risk of developing major coronary event associated with amount of tobacco smoked daily (interaction P=0.006) and age when smoking started (interaction P=0.011). There was no sex difference in these two effects for ischemic heart diseases, intracerebral hemorrhage and cerebral infarction (all interaction P>0.05). Conclusions: This prospective study confirmed increased risk of all subtypes of cardiovascular diseases in current smokers. Smoking was more harmful to women than to men for major coronary event.

[Family history and risk of coronary heart disease]

Objective: To evaluate the association of family history with risk of major coronary events (MCE) and ischemic heart disease (IHD). Methods: After excluding participants with heart disease, stroke or cancer at baseline survey, a total of 485 784 participants from the China Kadoorie Biobank, who had no missing data on critical variables, were included in the analysis. Cox regression analysis was used to estimate the hazard ratios (HR) and 95% CI. Subgroup analyses were performed according to the baseline characteristics. Results: During a median of 7.2 years of follow-up, we documented 3 934 incident cases of MCE and 24 537 cases of IHD. In multivariable-adjusted models, family history was significantly associated with risk of MCE and IHD. The adjusted HRs (95%CI) were 1.41 (1.19-1.65) and 1.25 (1.18-1.33), respectively. History of disease among siblings was more strongly associated with early-onset MCE than parental history (HR=2.97, 95%CI: 1.80-4.88). Moreover, the association of family history with MCE and IHD was stronger in persons who were overweight or obesive, and the association between family history and MEC was stronger in smokers. Conclusion: This large-scale, prospective study indicated that family history was an independent risk factor for MCE and IHD in China. The intervention targeting major known lifestyle risk factors and the management of chronic diseases should be strengthened for Chinese population, especially for the individuals with family history were at high risk.

Adult human metapneumovirus encephalitis: A case report highlighting challenges in clinical management and functional outcome

We report a rare case of adult human metapneumovirus (HMPV) in a healthy 32-year-old man. There was dramatic deterioration in his condition developing pneumonia with Type-I respiratory failure and encephalitis. He needed mechanical ventilation in the intensive care setting and was treated with intravenous ribavirin. Post-extubation he remained severely physically and cognitively impaired despite rehabilitation. Treatment of HMPV pneumonia is at present, still without specific antiviral therapy. Managing HMPV-encephalitis remained supportive and challenging. More definite treatment strategies are needed.

[Gender differences in stressful life events and depression in Chinese adults aged 30-79 years]

Objective: To investigate gender specific differences in the association between stressful life events (SLEs) and depression in Chinese adults aged 30-79 years. Methods: In the baseline survey during 2004-2008, the China Kadoorie Biobank (CKB) recruited 512 891 men and women aged 30-79 years from 10 areas of China. Detailed information on SLEs, including demographic and socio-economic status, smoking, alcohol drinking and history of chronic disease, as well as depression symptoms and major depressive episodes (MDEs) in preceding 12 months, was collected by using standardized questionnaire. Multinomial logistic regression model was employed to estimate the relative risk ratio (RRR) and 95%CI of SLEs (3 categories, 10 items) on depression and the dose-response relationship between the number of SLEs experienced and depression. The interactions between gender and SLEs on depression were examined with likelihood ratio test. Results: Among the 512 891 participants, 35 085 (6.8%) reported family-related events, 5 972 (1.2%) reported finance-related events, and 4 453 (0.9%) reported other stressful life events. Females had a higher occurrence of family-related events, while males had a higher occurrence of finance-related and other events (all P-value <0.001). After adjusted for potential confounders, SLEs were significantly associated with MDEs (RRR=11.99, 95%CI: 10.49-13.71 for males; RRR=14.15, 95%CI: 12.97-15.43 for females), and with depressive symptoms (RRR=7.43, 95%CI: 6.94-7.95 for males; RRR=8.30, 95%CI: 7.91-8.72 for females). And the associations were stronger in females than in males (P for interaction=0.049). In the three categories of SLEs, family-related events showed stronger association in female (P for interaction <0.001), while no gender specific differences were observed for the other two categories (all P-value>0.05). Furthermore, the effect of the number of SLEs experienced increased in a dose-response manner on depressive symptoms and MDEs for both genders, but no gender specific differences were found. Conclusions: The gender modifies the association between stressful life events and depression in Chinese adults, and women experienced family-related events have a greater risk of depression. The more the stressful events experienced, the more likely to have depression.

[Associations between airflow obstruction and the risks of morbidity on major chronic diseases in Chinese adults: a prospective cohort study]

Objective: To examine the prospective associations between airflow obstruction (AFO) and risks of major chronic diseases morbidity in Chinese adults. Methods: Samples of this study were from the China Kadoorie Biobank. A total of 486 996 participants aged 30 to 79 years (mean 51.5 years) at the baseline study, were included after excluding those who self-reported of having heart disease, stroke and cancer at baseline. AFO was defined under the Global Initiative on Obstructive Lung Disease (GOLD) criteria and forced expiratory volume per one second in percentage of the expected one (FEV(1)% P). Cox regression models were used to investigate the associations of AFO with incidence rates of ischemic heart disease, cerebrovascular disease and lung cancer after adjusted for potential confounders. Results: Over a period of 7 years through the follow-up program, the incident cases of ischemic heart disease, cerebrovascular disease and lung cancer appeared as 24 644, 36 336 and 3 218, respectively. Compared with people without AFO, the HR (95% CI) of GOLD-1 to GOLD-4 were 0.89 (0.78-1.01), 1.05 (0.98-1.12), 1.29 (1.18-1.40) and 1.65 (1.42-1.91) respectively for ischemic heart disease. The HR (95%CI) of GOLD-1 to GOLD-4 were 0.96 (0.70-1.26), 1.12 (0.96-1.31), 1.38 (1.14-1.65) and 1.48 (1.05-2.02) respectively for lung cancer. No statistically significant differences in the associations between GOLD level and cerebrovascular disease morbidity were found. However, each 10% decrease in FEV(1)% P was associated with 7.2% (95%CI: 6.4%-8.0%), 3.6% (95%CI: 3.0%-4.3%) and 10.5% (95%CI: 8.4%-12.6%) increased the risks of ischemic heart disease, cerebrovascular disease and lung cancer respectively. The results were persistant when stratified by smoking status. Conclusion: Higher degree of AFO seemed to be associated with the risks of ischemic heart disease, cerebrovascular disease and lung cancer morbidity among the Chinese adults.

[Distributions and associations between duration of sleep, daytime naps and insomnia symptoms among Chinese adults]

Objective: To investigate the distribution of sleep duration, daytime naps habits, and insomnia-related symptoms among participants from the China Kadoorie Biobank (CKB) study, and to examine the associations between the sleep-associated factors. Methods: A self-designed computer-based questionnaire was adopted to collect social-demographic information and lifestyle-related factors of the participants. A total of 452 829 Chinese adults aged 30-79 years, without self-reported histories of coronary heart disease, stroke, chronic obstructive pulmonary diseases or cancer, were included in this study. General linear regression and multinomial logistic regression models were used to estimate the distributions on duration of sleep, daytime naps habits, and insomnia-related symptoms in different populations, after adjusted for gender, age, and residential regions. Gender-specific logistic regression model was adopted to examine the associations between the above mentioned sleep-related factors. Results: The average sleep duration of the participants was 7.41 hours per day, with 20.3% of them having daytime naps all year round, but 40.1% only had daytime naps in summer, and 39.6% had no habits of daytime naps. 11.0%, 10.0%, and 2.1% of the participants reported having had symptoms as difficulty in falling asleep, waking up too early or with daytime dysfunction, respectively. There were significant differences on the distributions in sleep-related factors between participants with different gender, age, residential areas, education levels,household income, and marital status (P<0.05). Results from the logistic regression showed that longer sleep duration was associated with lower risks of insomnia-related symptoms trend (P<0.001). Factor as without habits of daytime naps seemed to be associated with higher risks of insomnia-related symptoms (P<0.05). Participants with longer sleep duration were more likely to have the habit of taking daytime naps (P<0.05). Conclusions: The distributions of sleep duration, habits on daytime naps and insomnia-related symptoms varied according to the differences on social-demographic factors. There were associations existed between the sleeping-related factors, which would influence the promotion on optimal sleep duration and better quality of sleep.

The SNP-set based association study identifies ITGA1 as a susceptibility gene of attention-deficit/hyperactivity disorder in Han Chinese

Genome-wide association studies, which detect the association between single-nucleotide polymorphisms (SNPs) and disease susceptibility, have been extensively applied to study attention-deficit/hyperactivity disorder (ADHD), but genome-wide significant associations have not been found yet. Genetic heterogeneity and insufficient genomic coverage may account for the missing heritability. We performed a two-stage association study for ADHD in the Han Chinese population. In the discovery stage, 1033 ADHD patients and 950 healthy controls were genotyped using both the Affymetrix Genome-Wide Human SNP Array 6.0 and the Illumina Infinium HumanExome BeadChip. The genotyped SNPs were combined to generate a powerful SNP set with better genomic coverage especially for the nonsynonymous variants. In addition to the association of single SNPs, we collected adjacent SNPs as SNP sets, which were determined by either genes or successive sliding windows, to evaluate their synergetic effect. The candidate susceptibility SNPs were further replicated in an independent cohort of 1441 ADHD patients and 1447 healthy controls. No genome-wide significant SNPs or gene-based SNP sets were found to be associated with ADHD. However, two continuous sliding windows located in ITGA1 (P-value=8.33E-7 and P-value=8.43E-7) were genome-wide significant. The quantitative trait analyses also demonstrated their association with ADHD core symptoms and executive functions. The association was further validated by follow-up replications for four selected SNPs: rs1979398 (P-value=2.64E-6), rs16880453 (P-value=3.58E-4), rs1531545 (P-value=7.62E-4) and rs4074793 (P-value=2.03E-4). Our results suggest that genetic variants in ITGA1 may be involved in the etiology of ADHD and the SNP-set based analysis is a promising strategy for the detection of underlying genetic risk factors.

Flexor Digitorum Superficialis Tendon Sling Volar Plate Reconstruction for Swan-Neck Deformity in the Spastic Finger

The condition of proximal interphalangeal joint (PIPJ) locking in hyperextension may occur in the athetoid or spastic hand with moderate or severe swan-neck deformity at the 'opening' phase of prehension. The patient's complaints are of complete or incomplete locking that may require passive assistance to initiate PIPJ flexion. Surgical procedures to overcome this include rerouting the lateral band, stabilisation or reconstruction procedure for the volar instability of the PIPJ, etc. Volar stabilisation may be achieved by Flexor digitorum superficialis (FDS) tenodesis procedures or criss-cross tendon graft for volar plate reconstruction. We report a case of successful stabilisation using the criss-cross tendon sling procedure for volar plate reconstruction using a slip of the FDS tendon instead of a free tendon graft. This is a simple and safe procedure that effectively corrects the swan-neck deformity and improves the prehension function in the hand.

[Association between body mass index and both total and cause-specific mortality in China: findings from data through the China Kadoorie Biobank]

Objective: To evaluate the associations between body mass index (BMI) and both total and cause-specific mortality. Methods: After excluding participants with heart disease, stroke, cancer, chronic obstructive pulmonary disease, and diabetes at baseline study, 428 593 participants aged 30-79 in the China Kadoorie Biobank study were chosen for this study. Participants were categorized into 9 groups according to their BMI status. Cox regression analysis was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of mortality on BMI. Results: Among 3 085 054 person-years of the follow-up program between 2004 and 2013 (median 7.2 years), a total of 7 862 men and 6 315 women died. After adjusting for known or potential confounders, an increased risks of all-cause deaths were shown among participants with a BMI less than 18.5 (HR=1.40, 95%CI: 1.31-1.50), between 18.5-20.4 (HR=1.11, 95%CI: 1.05-1.17), and more than 35.0 (HR=2.05, 95%CI: 1.60-2.61), when compared to those with BMI between 20.5-22.4. Ranges of BMI with lower risk of cause-specific mortality were: 18.5-23.9 for ischemic heart disease, <26.0 for cerebro-vascular disease, 26.0-34.9 for cancers, and 24.0-25.9 for respiratory diseases. Conclusions: In this large prospective study, both underweight and obesity were associated with the increased total and certain cause-specific mortality, which were independent from other risk factors of death. Programs related to extensive follow-up, thorough analysis BMI and the risks of incidence on major chronic diseases all need to be developed, in order to better understand the impact of BMI on human health.

[Associations between airflow obstruction and total and cause-specific mortality in adults in China]

Objective: To examine the prospective associations between airflow obstruction and total and cause-specific mortality. Methods: The study was based on China Kadoorie Biobank, in which 199 099 men and 287 895 women aged 30-79 years at baseline survey were included after excluding those with heart disease, stroke and cancer. The Global Initiative on Obstructive Lung Disease (GOLD) guideline was used to classify airflow obstruction. Cox regression models were used to estimate adjusted HR and 95%CI. Results: During 3 494 079 person-years of follow-up between 2004 and 2013 (median 7.2 years), a total of 21 649 people died. Absolute mortality rates were 5.5, 9.9, 13.1, 32.4 and 63.3 deaths per 1 000 person-years for participants who had normal airflow, GOLD-1 to GOLD-4 airflow obstruction, respectively. After adjusting potential confounders, compared with participants with normal lung function, the HRs for death were 0.98 (95%CI: 0.88-1.09), 1.03 (95%CI: 0.97-1.09), 1.62 (95% CI: 1.53-1.73) and 2.83 (95% CI: 2.59-3.10) for those whose airflow obstruction were classified as GOLD-1 to GOLD-4, respectively. The airflow obstruction was also associated with increased risk for deaths due to ischemic heart disease, cerebrovascular disease and chronic obstructive pulmonary disease. Conclusion: Airflow obstruction is associated with total and certain cause-specific mortality, the higher the airflow obstruction degree is, the higher the death risk is.

[Major depressive disorder in relation with coronary heart disease and stroke in Chinese adults aged 30-79 years]

OBJECTIVE

To investigate the associations of major depressive disorder with coronary heart disease (CHD) and stroke in Chinese adults aged 30-79 years.

METHODS

In 2004-2008, China Kadoorie Biobank was conducted in 10 geographically defined regions (5 urban and 5 rural) of China. A total number of 512 891 participants aged 30-79 years were recruited in the baseline survey. A laptop-based electronic questionnaire was administrated face-to-face by trained health workers, collecting the general demographic and socio-economic status, dietary and other lifestyle behaviours (e.g. smoking, alcohol drinking, physical activity), medical history and family history of common chronic diseases. Major depressive episodes (MDE) in the past 12 months were assessed with the World Health Organization composite international diagnostic interview-short form (CIDI-SF). The physical measurements included the heights and weights, which were used to calculate the body mass indexes (BMI).Chi squared and t test were used to compare the differences in participants characteristics according to their major depressive disorder. Logistic models were employed to estimate the odds ratios (OR) and 95% CI of their major depressive disorder with prevalent coronary heart disease and stroke.

RESULTS

Among the 512 891 participants, 3 281 (0.6%) showed an MDE in the preceding 12 months, 15 472 (3.0%) reported prevalent CHD, and 8 884 (1.7%) reported prevalent stroke. Major depressive disorder was significantly associated with an increased risk of CHD and risk of stroke. Age- and gender-adjusted ORs (95% CI) were 1.80 (1.53-2.12) for CHD and 2.53 (2.09-3.05) for stroke. The associations were significant after further adjustment for potential confounders, such as other socio-demographic status, smoking, alcohol drinking, physical activity, and BMI, prevalent hypertension, diabetes as well as family history of cardiovascular diseases (OR=1.83, 95% CI=1.54-2.18 for CHD; OR=2.19, 95% CI=1.79-2.69 for stroke). Moreover, gender significantly interacted with MDE on prevalent stroke (P for multiplicative interaction=0.013). The men with an MDE in the past 12 months had the highest risk of stroke in the joint analyses of gender and depression disorder (OR=5.02, 95% CI=3.70-6.82).

CONCLUSION

The findings from this large cross-sectional study suggest that the presence of MDE is a risk factor for both CHD and stroke in Chinese adults aged 30-79 years, but further prospective studies are warranted to validate the results.

Prophylactic bilateral internal iliac artery balloon occlusion in the management of placenta accreta: A 36-month review

BACKGROUND

The contemporary obstetrician is increasingly put to the test by rising numbers of pregnancies with morbidly adherent placenta. This study illustrates our experience with prophylactic bilateral internal iliac artery occlusion as part of its management.

METHODS

Between January 2011 to January 2014, 13 consecutive patients received the intervention prior to scheduled caesarean delivery for placenta accreta. All cases were diagnosed by ultrasonography, color Doppler imaging and supplemented with MRI where necessary. The Wanda balloon(TM) catheter (Boston Scientific, Natick, MA, U.S.A) were placed in the proximal segment of the internal iliac arteries preceding surgery. This was followed by a midline laparotomy and classical caesarean section, avoiding the placenta. Both internal iliac balloons were inflated just before the delivery of fetus and deflated once haemostasis was secured. Primary outcomes measured were perioperative blood loss, blood transfusion requirement and the need for ICU admission.

RESULTS

The mean and median intraoperative blood loss were 1076mls±707 and 800mls (300-2500) respectively while mean perioperative blood loss was 1261mls±946. Just over half of the patients in our series required blood and/or blood products transfusion. Two patients (15.4%) required ICU admission.

CONCLUSION

Our study suggests that preoperative prophylactic balloon occlusion of bilateral internal iliac arteries reduces both blood loss and transfusion requirement in patients with placenta accreta, scheduled to undergo elective caesarean hysterectomy. It is an adjunct to be considered in the management of a modern day obstetric problem, although the authors are cautious about generalizing its benefit without larger, randomized trials.

Incidence and predictors of new-onset constipation during acute hospitalisation after stroke

OBJECTIVES

We investigated new-onset constipation in patients with stroke compared with orthopaedic conditions and explored the predictors associated with constipation during acute hospitalisation.

METHODS

This was a prospective matched cohort study of 110 patients comparing stroke patients (n = 55) with orthopaedic patients (n = 55) admitted to a large tertiary acute hospital. Both cohorts were matched by age and sex. The incidence of new-onset constipation which occurred during a patient's acute hospitalisation was determined. Demographics, comorbidity, clinical factors, laboratory parameters and medications were evaluated as possible predictors of constipation.

RESULTS

The incidence of new-onset constipation was high for both stroke (33%) and orthopaedic patients (27%; p = 0.66). Seven stroke patients (39%) and four orthopaedic patients (27%) developed their first onset of constipation on day 2 of admission. Mobility gains (RR 0.741, p < 0.001) and the use of prophylactic laxatives (RR 0.331, p < 0.01) had a protective effect against constipation. Bedpan use (RR 2.058, p < 0.05) and longer length of stay (RR 1.032, p < 0.05) increased the risk of developing new-onset constipation.

CONCLUSIONS

New-onset constipation is common among patients admitted for stroke and orthopaedic conditions during acute hospitalisation. The early occurrence, on day 2 of admission, calls for prompt preventive intervention for constipation.

Gangrenous small bowel obstruction secondary to congenital internal herniation: a case report

Congenital internal herniation is a rare condition presenting as recurrent abdominal pain or acute intestinal obstruction. In cases in which bowel incarceration or strangulation develop, rapid progression to bowel ischemia, necrosis or perforation is inevitable. Mortality in such cases has been reported to be as high as 50%. Despite advances in imaging modalities, arriving at a pre-operative diagnosis of a congenital internal herniation remains a challenge. We report such a case where imaging was unsuccessful in determining the cause of intestinal obstruction in a 3 year old child. Congenital internal herniation may result in disastrous consequences if not addressed in a timely fashion due to its rarity. Hence a high index of clinical suspicion is needed to avoid missing this diagnosis in a child presenting with recurrent abdominal pain or acute intestinal obstruction.

Rabeprazole vs esomeprazole in non-erosive gastro-esophageal reflux disease: A randomized, double-blind study in urban Asia

AIM: Gastro-esophageal reflux disease (GERD) is becoming increasingly common in Asia. Data on the efficacy of proton pump inhibitors in patients with non-erosive GERD (NERD) in Asia is lacking. This double-blind study compared the efficacy and safety of rabeprazole with esomeprazole in relief of symptoms in patients with NERD.

METHODS: One hundred and thirty-four patients with reflux symptoms of NERD and normal endoscopy were randomized to receive rabeprazole 10 mg or esomeprazole 20 mg once daily for 4 wk. Symptoms were recorded in a diary and changes in severity of symptoms noted.

RESULTS: At 4 wk of treatment, rabeprazole 10 mg and esomeprazole 20 mg were comparable with regards to the primary endpoint of time to achieve 24-h symptom-free interval for heartburn 8.5 d vs 9 d and regurgitation 6 d vs 7.5 d. Rabeprazole and esomeprazole were also similarly efficacious in term of patient’s global evaluation with 96% of patients on rabeprazole and 87.9% of patients on esomeprazole, reporting that symptoms improved (P = NS). Satisfactory relief of day- and night-time symptoms was achieved in 98% of patients receiving rabeprazole and 81.4% of patients receiving esomeprazole. Adverse events were comparable in both groups (P = NS).

CONCLUSION: Rabeprazole 10 mg has a similar efficacy and safety profile in Asians with NERD as esomeprazole 20 mg. Further study is necessary to investigate whether the small differences between the two drugs seen in this study are related to the improved pharmacodynamic properties of rabeprazole. Both drugs were well tolerated.

Nonlinear filtering for the estimation of glycated hemoglobin in the presence of fetal hemoglobin using microcolumn ion-exchange chromatography

In this paper, an improved method based on nonlinear least-squares to estimate the percentage concentration of glycated hemoglobin levels HbA1ab, HbA1c, HbF, and other Hb variants is presented. If the existing method is enhanced with the improved method, the use of microcolumn ion-exchange chromatography for estimating glycated hemoglobin levels even for patients with elevated fetal hemoglobin (HbF) would provide a more realistic estimate.

[Efficacy of replenishing kidney therapy on biological activity of serum luteinizing hormone in aged subjects]

There have been many research reports about changes of aging of hypothalamus-pituitary-gonad axis, but no satisfactory explanation on the constancy or elevation of serum gonadotropin level in aging. However it is important in revealing the mechanism for aging gonadal axis of and its function in regulating gonadal gland as well as the senility delaying process with therapy for replenishing the Kidney. Serum luteinizing hormone (LH) of 48 men at various age was investigated with Rat Interstitial Cell Testosterone Assay (RICT) and Radioimmunoassay (RIA) techniques. The serum level of RICT (B-LH) tended to decrease and the B-LH/I-LH ratio was significantly lower (P < 0.01) than that in aged group (> or = 50 years old) in comparing with the young group (< or = 44 years old). The result suggested that the biological activity of LH decreased with age and the stimulative function of pituitary to testes also diminished. With the recipe "Bao Chun Pill" in replenishing the Kidney for 3 months, the biological activity was markedly enhanced (P < 0.05), the serum testosterone (T) was also escalated (P < 0.01). Both of them in treated group were higher than those in control group (P < 0.05). The study and our previous works showed that the therapy for replenishing the Kidney could improve the function of gonadal axis in aging subjects at all levels of hypothalamus, pituitary, gonad.

Localization of functional projections from corpus callosum to cerebral cortex

In 30 patients with intractable generalized epilepsy treated with cerebral commissurotomy, the corpus callosum was stimulated intraoperatively at a 1 cm interval with electric current, and evoked potentials (EPs) were recorded from different areas of the brain for determining the distribution patterns of functional projections from the corpus callosum to the cerebral cortex. The surface of the corpus callosum in man was 12 cm long and it was divided into 12 segments (1 cm each). Stimulation of the first segment resulted in EPs only in the frontal lobe. Stimulation of segments 2-4 produced EPs mainly in the anterior, middle and posterior frontal lobe, anterior and central temporal lobe, rarely in parietal and occipital lobes. Stimulation of segments 5-8 induced EPs mainly in the frontal and temporal lobes, but rarely in the parietal and occipital regions; on stimulation of segments 9-11, EPs occurred only in the parietal and occipital regions. These results were confirmed electrophysiologically in 5 cats and anatomically in 8 cats. These data provide an anatomical basis for selective cerebral commissurotomy in the treatment of intractable epilepsy. Hence in patients with a concentration of epileptic discharges in the frontal lobe, the 4 anterior segments of the corpus callosum should be incised. Epileptic discharges in the frontotemporal region indicates that the middle segments should be incised and epileptic activities originating from the parieto-occipital regions can be treated effectively by selective section of the posterior corpus callosum (segments 9-12).