Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis

The aim was to evaluate the efficacy and safety of volatile anaesthetic for postoperative sedation in adult cardiac surgery patients through a systematic review and meta-analysis. We retrieved randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Web of Science, clinical trials registries, conference proceedings, and reference lists of included articles. Independent reviewers extracted data, including patient characteristics, type of intraoperative anaesthesia, inhaled anaesthetic used, comparator sedation, and outcomes of interest, using pre-piloted forms. We assessed risk of bias using the Cochrane Tool and evaluated the strength of the evidence using the GRADE approach. Eight studies enrolling 610 patients were included. Seven had a high and one a low risk of bias. The times to extubation after intensive care unit (ICU) admission and sedation discontinuation were, respectively, 76 [95% confidence interval (CI) -150 to - 2, I2=79%] and 74 min (95% CI - 126 to - 23, I2=96%) less in patients who were sedated using volatile anaesthetic. There was no difference in ICU or hospital length of stay. Patients who received volatile anaesthetic sedation had troponin concentrations that were 0.71 ng ml-1 (95% CI 0.23-1.2) lower than control patients. Reporting on other outcomes was varied and not suitable for meta-analysis. Volatile anaesthetic sedation may be associated with a shorter time to extubation after cardiac surgery but no change in ICU or hospital length of stay. It is associated with a significantly lower postoperative troponin concentration, but the impact of this on adverse cardiovascular outcomes is uncertain. Blinded randomized trials using intention-to-treat analysis are required. PROSPERO registry number: 2016:CRD42016033874. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016033874.

The Effect of Oral Contraceptives on Coagulation and Fibrinolytic Parameters in the Chinese – A Prospective Study

Thirty-two Chinese and 7 Caucasians were studied prospectively for 12 months for the effects of oral contraceptives (OC) on certain coagulation and fibrinolytic parameters. In both ethnic groups there was an increase in α1 antitrypsin level. There was no significant change in antithrombin III concentration measured either by radioimmunoassay (At-III-RIA) or chromogenic assay (anti Xa-chromogenic) in the Chinese, but a significant decrease in anti Xa-chromogenic at 7 months and At-III-RIA at 12 months in the Caucasians. Also, α2 plasmin inhibitor (α2PI) levels were unchanged in the Chinese but a significant increase occurred in the Caucasians at 12 months. Enhanced fibrinolytic response to venous occlusion was demonstrated in the Chinese at 12 months but not in the Caucasians.

Cesarean section under combined spinal epidural in parturient with frontal glioma

Our patient presented to hospital in acute asthma exacerbation and foetal distress. Past history was remarkable for pregnancy at 35 weeks, morbid obesity, uncontrolled asthma, seizure disorder and known frontal glioma. Here we highlight the neuraxial management of this patient for cesarean section and discuss the central dogma of neuraxial technique in the face of known intracranial neoplasm.

Parent-adolescent conflict and adolescent antisocial and prosocial behavior: a longitudinal study in a Chinese context

This longitudinal study examined the relationships between parent-adolescent conflict and antisocial and prosocial behavior in Chinese adolescents. Results showed that father-adolescent conflict and mother-adolescent conflict were concurrently related to adolescent antisocial and prosocial behavior. Longitudinal analyses showed that parent-adolescent conflict predicted antisocial behavior but not prosocial behavior. Adolescent antisocial and prosocial behavior was also found to be related to father-adolescent conflict across time. The findings suggest that the linkage between father-adolescent conflict and adolescent social behavior is stronger than that between mother-adolescent conflict and adolescent social behavior.

Tumour markers and their prognostic value in adenocarcinoma of the cervix

Ninety-one patients with adenocarcinoma of the cervix had 4 tumour markers (TMs) assayed before treatment. Serum squamous cell carcinoma antigen (SCC) (n = 91) was raised in 25%; tissue polypeptide antigen (TPA) (n = 78) was raised in 35%; carcinoembryonic antigen (CEA) (n = 34) was raised in 26% and CA 125 (n = 64) was raised in 27% of these patients. In 47 of these 91 patients (52%), 1 or more of the markers were raised. The percentage of patients with raised TM increased with advancing stage. Univariate survival analysis showed that age, stage, raised TPA, raised CA 125, and raised TMs (any one or more) were of prognostic significance. When multivariate analysis was done and each TM was individually analysed, only age, stage and raised CA 125 were of prognostic significance. Rising SCC or TPA or CA 125 levels in serial estimations correlated well with the occurrence of recurrence. Thus, pretreatment estimation of SCC, TPA and CA 125 can be used to identify the patients who can subsequently be monitored by serial TM estimation.

Parental, peer, and teacher influences on the social behavior of Hong Kong Chinese adolescents

Intensive interviews and self-report questionnaires were used to investigate parental, peer, and teacher influences on the prosocial and antisocial behaviors of Hong Kong Chinese adolescents. Students came from 5 academically different high schools. Results indicated that perceived parental influence was positively associated with frequency of prosocial behavior and negatively associated with frequency of delinquent behavior. Students with good relationships with their parents and peers showed lower frequencies of antisocial behaviors than did students with bad relationships. Adolescents in different identity statuses (achievement, moratorium, foreclosure, diffusion; E. H. Erikson, 1968) showed different patterns of prosocial and antisocial behaviors. For example, adolescents in the identity achievement group exhibited high frequencies of prosocial behaviors and low frequencies of antisocial behaviors, but those in the identity moratorium group exhibited quite high frequencies of both prosocial and antisocial behaviors.

Conceptions of success: their correlates with prosocial orientation and behaviour in Chinese adolescents

Data from a sample of 673 Chinese adolescents lent support to the hypothesis that conceptions of success or achievement goals affect both the inclination to and the actual performance of prosocial acts. With regard to attitude, it was found that: (a) task orientation (belief that success is gaining skill or understanding) and collaboration orientation (belief that success is working productively with one or more collaborators) increased with the inclination to help others, to co-operate and share things with others, to maintain an affective relationship with others, and to behave in compliance with social norms; and (b) ego orientation (belief that success is establishing one's competence as superior) was not generally associated with the inclination to perform prosocial acts. With regard to action, it was found that task orientation and collaboration orientation, but not ego orientation, increased with the number of normative and altruistic acts in the past year. The similarity between the belief-attitude correlation and the belief-action correlation indicates the robustness of the influence of conceptions of success. Also, sex differences and grade differences in the relationship between conceptions of success and prosocial and antisocial behaviours were found. Implications of the findings are discussed.

Intrascleral dissemination of infectious scleritis following pterygium excision

AIMS

To assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision.

METHODS

The records of patients with infectious scleritis after pterygium excision who developed multifocal scleral abscesses presenting from 1988 to the end of 1995 were reviewed. Early culture of abscesses was performed, and topical, systemic antimicrobials, or both were given to all patients. Fourteen eyes were operated on in addition to antimicrobial treatment.

RESULTS

The initial culture reports of scleral ulcers identified Pseudomonas species in 12 of these 18 patients, Aspergillus in one, Mycobacterium fortuitum in one, and mixed organisms in four. Subsequent abscess cultures were taken from 15 of the infected eyes, and revealed the same organism as the initial culture in 12. Associated complications included four serous retinal detachments, three choroidal detachments, two double detachments, five complicated cataracts, and four recurrences of the initial infection. Four eyes required eventual enucleation and 11 eyes regained useful vision.

CONCLUSIONS

With subsequent abscess cultures proving to be the same organism as found in the initial ulcer, the abscess formation appears to represent intrascleral dissemination. Early diagnosis and appropriate, prolonged topical plus systemic antimicrobial treatment are essential to halt the progression of such severe infections.

The relation of prosocial and antisocial behavior to personality and peer relationships of Hong Kong Chinese adolescents

The prosocial and antisocial behaviors of 2,862 Hong Kong Chinese adolescents were investigated. The major findings were as follows: (a) boys were more antisocial than girls: (b) negative peer influences were significantly stronger in boys than in girls, whereas positive peer influences were significantly stronger in girls than in boys; (c) antisocial adolescents tended to perceive their best friend as antisocial and exerting more negative influences on them, whereas prosocial adolescents tended to perceive their best friend as prosocial and exerting more positive influences on them; (d) antisocial behavior was positively associated with psychoticism and neuroticism; and (e) academic achievement tended to have a positive relation with prosocial behavior and a negative relation with antisocial behavior.

A multicentre study to investigate the prevalence of abnormal carbohydrate metabolism in Chinese pregnant women

OBJECTIVES

To determine the prevalence of abnormal carbohydrate metabolism in Chinese pregnant women. To study the inter-relationship between maternal body habitus, maternal serum glucose and birth weight of the baby.

METHODS

Multicentre observational study involving 713 pregnant Chinese women, attending antenatal clinics in Beijing, Shanghai, Guangzhou and Hong Kong.

RESULTS AND CONCLUSION

The overall prevalence of abnormal glucose tolerance was 6.9%. The prevalence was 6.8%, 5.5%, 7.2% and 8.1% in Beijing, Shanghai, Guangzhou and Hong Kong, respectively. The differences among the centres did not reach statistical significance (p = 0.9). The mean ponderal index of women with abnormal glucose tolerance was significantly higher than that of women with normal glucose tolerance (15.2 vs 14.3, p < 0.01). The birth weight ratio of the babies was positively correlated with the maternal height (correlation coefficient 0.23, 95% C.I. 0.15-0.30), weight (0.32, 95% C.I. 0.25-0.39) and to a lesser extent, the fasting level of serum glucose (0.10, 95% C.I. 0.02-0.28) but not with the 2 hour level of serum glucose.

Pregnancies complicated by acute appendicitis

Appendicitis is one of the most common acute abdominal conditions that requires operation during pregnancy. The maternal and fetal complications occurring in such situations are well known. However, the diagnostic and therapeutic challenges of acute appendicitis complicating pregnancy persist in current surgical practice. Thirty-eight obstetric cases who had an appendicetomy performed during pregnancy between 1986 and 1993, were reviewed. In 31 cases, acute appendicitis was proven at laparatomy, and by subsequent histopathology. In the confirmed cases, seven occurred in the first trimester, 12 in the second trimester, eight in the third trimester and four in the immediate postpartum period. Two miscarriages occurred in the first trimester group, and two late abortions and two preterm (26 and 28 weeks) deliveries occurred in the second trimester group. In the third trimester/postpartum group, all babies survived, but four patients had Caesarean sections with the appendicetomy and the incidence of perforated/gangrenous appendices was highest. Perinatal outcome was worst, with the highest fetal wastage rate if the acute appendicitis occurred in the second trimester, although maternal morbidity appeared to be the same across different gestational periods.

Reducing the induction to abortion interval in termination of second trimester pregnancies: a comparison of mifepristone with laminaria tent

OBJECTIVE

To determine whether mifepristone (RU486) is more effective than laminaria tent in shortening the induction-abortion interval in termination of second trimester pregnancies with gemeprost.

DESIGN

Prospective randomised comparative trial.

SETTING

Department of Obstetrics and Gynaecology in a University teaching hospital.

SUBJECTS

Sixty-two women undergoing termination of pregnancy in the second trimester.

INTERVENTIONS

The women were allocated at random to one of the two treatment groups. The first group received 600 mg of mifepristone 36 h before administration of gemeprost. In the second group, a medium-sized laminaria tent was inserted 12 h before gemeprost. The pregnancies in both groups were terminated with vaginal gemeprost, 1 mg every 3 h up to a maximum of 5 mg/day.

MAIN OUTCOME MEASURES

Induction-abortion intervals, amount of gemeprost required, and incidence of side effects.

RESULTS

The median induction-abortion interval in the mifepristone group (7.5 h) was significantly shorter than that in the laminaria tent group (11 h) and significantly fewer gemeprost pessaries were required. There was no significant difference in the amount of narcotic analgesics required or the incidence of side effects between the two groups.

CONCLUSIONS

Mifepristone is more effective than laminaria tent in shortening the induction-abortion interval in termination of second trimester pregnancies.

Oral misoprostol versus placebo for cervical dilatation before vacuum aspiration in first trimester pregnancy

Intravaginal misoprostol has been shown to be effective for cervical priming before a surgically induced abortion. The objective was to investigate the effectiveness of oral misoprostol in cervical dilatation prior to vacuum aspiration between the 6th and 12th weeks of pregnancy. The results showed that in nulliparous patients, the median cervical dilatation in the treatment group (7.8 mm) was significantly greater than that in the placebo group (3.7 mm). In multiparous patients, the difference was also statistically significant (9.8 versus 6.0 mm). The ease of dilatation, assessed subjectively by the operating surgeons, was significantly improved in the treatment group. There was also a significant reduction in the duration of the operation and in the mean blood loss in the treatment group. The side-effects encountered in the treatment group were mild and well accepted by the women. Oral misoprostol is an effective and safe method for cervical dilatation prior to vacuum aspiration in first trimester pregnancy.

The prevalence and clinical significance of pulmonary infection due to non-tuberculous mycobacteria in Hong Kong

An unexpected increase in positive sputum cultures of non-tuberculous mycobacteria (NTM) was noted in Hong Kong in 1990 compared to previous years, in contrast to a steady decline in the number of positive cultures of Mycobacterium tuberculosis. A retrospective case note study was therefore undertaken to ascertain the clinical importance of the rise in NTM isolates. A representative sample of 183 of the 675 patients with NTM isolates from sputum during 1990 was identified. Cases were assigned to groups according to whether there was evidence of progressive pulmonary disease due to NTM (group 1), persisting colonization without evidence of progressive disease (group 2) or transient isolation of NTM without evidence of progressive disease (group 3). Of 168 cases with adequate clinical and radiological records, 28 (16.7%) represented progressive disease due to NTM and 6 (3.6%) represented persisting colonization. The remainder were both transient and clinically insignificant. Most patients (71%) with progressive pulmonary disease due to NTM had pre-existing lung damage, and 50% had received anti-tuberculous therapy for documented M. tuberculosis previously. The commonest organism involved was the M avium complex. Eighty-six percent of patients with progressive disease and 83% of those with persisting colonization had at least one smear positive sputum specimen, whereas only 2% of patients with sputum contamination had a smear positive sputum sample (P < 0.0001). M. malmoense, M. xenopi and M. fortuitum all appear to be rare causes of significant NTM disease in Hong Kong. However, M. chelonei caused four cases of progressive disease within the study population, two of which were fatal.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of heterozygous XY complete hydatidiform mole by chromosome in situ hybridization

Complete hydatidiform mole has a substantial risk of developing persistent gestational trophoblastic disease (PTD). Whether heterozygous complete moles, arising from dispermy, have a higher risk of such progression than their homozygous counterparts is controversial. In this study, the frequency of heterozygous XY complete mole in 93 consecutive cases of histologically proven complete moles managed in Hong Kong was assessed by the technique of chromosome in situ hybridization (CISH) using DNA probes specific for the short arm of the Y chromosome. The incidence of Y-chromosome positive complete mole in the groups of patients with spontaneous remissions and the group with PTD with or without metastasis was also compared. The presence of Y chromosome was identified in 6 of the 93 cases (6.5%), and this incidence fell within the range reported in the world literature. Of these 93 patients, 5 patients defaulted follow-up, while 10 patients developed PTD, with evidence of metastasis in 2 of them. The presence of Y chromosome was also assessed in another 15 patients with documented metastatic PTD. It was found that CISH signals for Y chromosome were identified in 5.1% (4/78) of complete moles with spontaneous remission and 8% (2/25) with PTD with or without metastasis (P > 0.05). Y chromosome was detected in 5.9% (1/17) of the complete moles that developed metastasis and in 5.8% (5/86) of the complete moles that either developed spontaneous remission or developed nonmetastatic PTD (P > 0.05). There is no correlation between the presence of Y chromosome and development of persistent gestational trophoblastic disease.

Cardiac blood flow studies in fetuses with haemoglobin Bart's disease

Blood flow across the atrioventricular valves and outflow tracts was measured in 55 normal fetuses and 32 fetuses with haemoglobin (Hb) Bart's disease between 18 and 26 weeks of gestation. The mean velocities remained unchanged in both normal and affected fetuses over the gestations studied. The volume flow across both atrioventricular valves and outflow tracts increased as the gestation advanced in both normal and affected fetuses, but was significantly higher in affected than in normal fetuses. The same magnitude of increased flow was found in both hydropic and non-hydropic fetuses with Hb Bart's disease. These findings suggest that fetuses with severe and long-standing anaemia have a remarkable cardiac compensatory mechanism for the maintenance of tissue oxygenation. In response to anaemia and circulatory loading, the cardiac chambers and outflow tracts enlarge proportionately up to twice the normal values. Because of this response and the operation of the Frank-Starling mechanism, the heart is able to maintain a normal mean velocity of propulsion and the net output is increased to two to three times that in normal fetuses. Hydropic changes in these anaemic fetuses appear unrelated to cardiac failure as cardiac failure is not observed at the time that hydropic changes develop.

HPV and p53 in cervical cancer

OBJECTIVE

To determine the prevalence of HPV 16 and 18 E6 by DNA detection and p53 abnormal protein expression in cervical cancers in Hong Kong.

MATERIALS AND METHODS

Seventy-three squamous cell cervical cancer biopsy were analysed. Detection of HPV DNA was carried out by the polymerase chain reaction and Southern blotting (PCR/SB) technique using primers to the HPV16 & 18 E6 region and consensus primers to the L1 region. Abnormal expression of the p53 protein was detected by immunohistochemical staining (IHS) using the antibody CM1 on frozen sections of 55 cervical cancer samples. Forty-six samples were analysed for both the presence of HPV DNA and abnormal expression of p53.

RESULTS

67.2% of the 64 samples showed the presence of HPV 16 E6 DNA and 39.1% showed the presence of HPV 18 E6 DNA. 32.8% showed the presence of both HPV 16 and 18 E6 DNA. No HPV DNA was shown in 10.9% of samples. Only 3.6% (2) of 55 samples showed positive IHS with CM1. One occurred in a HPV negative sample and the other in a HPV positive sample.

CONCLUSION

A high prevalence of HPV DNA was detected in cervical cancer in Hong Kong using the PCR/SB technique. However, abnormal expression of p53 was uncommon amongst patients with or without HPV 16 or 18 infection.

Expression of the p53 gene in trophoblastic cells in hydatidiform moles and normal human placentas

In this study we compared the expression of p53 in six early placentas and eight hydatidiform moles using Northern blotting. A higher expression of p53 in hydatidiform moles as compared to normal placentas of comparable gestational age was observed. Immunohistochemical studies did not detect mutant protein of p53 in the hydatidiform moles. DNA sequencing was performed on four of the hydatidiform moles with increased expression of p53, but no mutations could be detected. The possible role of p53 in the pathogenesis of hydatidiform mole is discussed.

Vaginal template implant for cervical carcinoma with vaginal stenosis or inadvertent diagnosis after hysterectomy

PURPOSE

For cervical carcinoma patients with poor geometry for conventional intracavitary radiotherapy, a simple vaginal template for interstitial implantation as a substitute was used. This template has also been used to treat patients who had hysterectomy done without knowledge of an early tumor in the cervix, and for patients with recurrent disease. This is a report of the treatment results.

METHODS AND MATERIAL

A total of 21 patients were treated over from July 1987 to June 1991 with this vaginal template implant forming part of the treatment, 12 of these were performed for vaginal stenosis. The applicator consists of a front piece and an end piece. Holes were drilled in the front piece to guide the implantation of the cervix or vaginal vault. The diameter of applicators varied from 2 cm to 3.5 cm. Depending on the diameter of the applicators, six to eight needles on the periphery, or eight peripheral plus one central needle were used. The activity of the needles were around 8 mCi with a total length of 5.5 cm. The end piece was locked onto the front piece by a bayonet-type locking device. The purpose of the end piece was two-fold: to make up the length of the whole applicator to fit the vagina and to keep the implanted needles in place without being extruded. The implantation was performed under general anesthesia.

RESULTS

One of the twelve patients treated with the vaginal template implant for vaginal stenosis had relapsed centrally but subsequently died of intercurrent disease. Two other patients died of intercurrent disease at 26.2 and 41.9 months, respectively, without evidence of relapse. Nine other patients had been followed with no evidence of local relapse for 23.7 to 54.6 months.

CONCLUSION

This vaginal template implantation is a satisfactory means of treating patients with vaginal stenosis and those who had hysterectomy done without knowledge of an early tumor in cervix.

The prognostic value of TPA and SCC in squamous cell carcinoma of the cervix

Three hundred two patients with squamous cell carcinoma of the cervix had pretreatment measurement of serum levels of tissue polypeptide antigen (TPA) and squamous cell carcinoma antigen (SCC) to assess their prognostic value. Both markers were of prognostic significance in relation to stage, recurrence, and poor survival. The addition of TPA to SCC did not increase the percentage of patients with elevated pretreatment tumor marker level nor improve the prognostic significance. One hundred thirty-five of these patients also had serial assay of both markers during follow-up. Rise from normal or persistently elevated markers after treatment was associated with recurrence. The median lead time to recurrence was 2 months for SCC and 2.5 months for TPA. The addition of TPA to SCC in serial monitoring increased the sensitivity of detection of recurrence but decreased its specificity. The cost of assay of two markers over one may not justify the slight improvement in sensitivity of detection of recurrence. For squamous cell carcinoma of the cervix, SCC is a better tumor marker than TPA.

Shared antenatal care between family health services and hospital (consultant) services for low risk women

Four thousand four hundred and seventy-two patients were recruited into a project to test the efficacy of a Shared Care System in the management of low risk antenatal patients. The patients were scored according to a simple point scoring system. Three thousand three hundred and fourty-seven (74.8%) were scored as low risk. Fifty point two percent (1,682) of these low risk patients received the conventional system of care and acted as controls; while 49.8% (1,665) received shared care, where they were seen jointly by midwives, general doctors and hospital specialists. It was found that with the use of shared care, there was a significant decrease in workload to the hospital specialty clinics. Not only was the antenatal diagnostic rate of intrauterine growth retardation (IUGR) significantly improved, but the mean gestations at which IUGR, malpresentations, and pregnancy induced hypertension were diagnosed were also significantly earlier. The number of antenatal cardiotocographs performed, as well as the number of hospital admissions and mean duration of stay were decreased in the study group. The overall cost savings to the hospital was calculated if the shared care system was generally adopted.

Dose-tumor response of carcinoma of cervix: an analysis of 594 patients treated by radiotherapy

This is a retrospective study of 594 histologically proven carcinomas of the uterine cervix treated with radiotherapy alone between January 1970 and December 1986. The age of this group of patients ranged from 22 to 86 years, and the median age was 57 years. There were 544 (91.6%) patients with squamous carcinoma and 36 (6.1%) with adenocarcinoma. There were 24 (4.0%) patients who were treated by two sessions of intracavitary brachytherapy only using intrauterine tandem and vaginal ovoids; 513 (86.4%) patients received whole pelvis irradiation followed by two sessions of brachytherapy at 1-week intervals, with or without additional boost to the parametrium. The dose to point A ranged from 40 to 100.9 Gy for the patients with stage IB to IIIB disease. The 5- and 10-year survival for stages IB, IIA, IIB, IIIA, and IIIB were 90.0, 82.1, 72.0, 50.0, 51.5, and 86.9, 71.0, 67.5, 41.7, and 46.9%, respectively. There was no long-term survivor for stage IV disease; the median survivals for patients with stages IVA and IVB were 15.2 and 9.3 months, respectively. Dose response was demonstrated for stages IIB and III tumors; dose to point A greater than 85 Gy was associated with better central control (P = 0.0036 and 0.0234, respectively). However, further increase in dose to point A beyond 85 Gy was not associated with improvement in central control (P = 0.3128 and 0.3394, respectively, for stages IIB and III). It was also found that the occurrences of rectosigmoid and bladder complications were correlated with the rectal and point A dose. Thus, for these patients, there is no need to increase the dose to point A beyond 85 Gy so that the risk of radiation sequelae can be cut down.

Termination of second trimester pregnancy with sulprostone and mifepristone: a randomized double-blind placebo-controlled trial

A prospective randomized double-blind placebo-controlled trial was conducted in 13 subjects to find out whether mifepristone treatment could facilitate termination of second trimester pregnancy by sulprostone. The women received either 600 mg oral mifepristone or placebo tablets 36 hours before the administration of intramuscular sulprostone 0.5 mg every 6 hours. The median interval between the administration of sulprostone and abortion in the mifepristone group (4.6 hours) was significantly shorter than that in the placebo group (20 hours). The amount of sulprostone required was also significantly less in the mifepristone group. There was no significant difference in the incidence of side effects or analgesic requirement between the two groups. We conclude that oral mifepristone is useful in facilitating termination of second trimester pregnancies by sulprostone.

Blood loss in termination of early pregnancy by vacuum aspiration and by combination of mifepristone and gemeprost

Blood loss was measured in 17 subjects undergoing surgical termination of pregnancy and in 96 subjects undergoing medical termination of pregnancy with sequential mifepristone (200 mg, 400 mg, 600 mg) and 1 mg prostaglandin analogue gemeprost. The median blood loss were 53.2, 84.1, 99.9 and 101.4 ml, respectively. There was a statistically significant difference between the surgical and each of the medical termination group of subjects but there was no difference among the subgroups in the medical termination group. The pattern of bleeding was also similar, being heaviest on the day and the days shortly after prostaglandin administration. Majority of them (> 90%) experienced blood loss of < 300 ml and there was no significant drop in hemoglobin level during the 6-week follow-up period. A few women experienced heavy bleeding and, hence, strict supervision on medical termination of pregnancy is recommended.

Clinical significance of mucin production in post-irradiated cervical carcinoma

Histological sections from 50 patients with clinical stage Ib to stage IIb squamous cell carcinoma of the cervix, initially treated by radiotherapy and followed by Wertheim hysterectomy, were reviewed and stained for mucin. The tissues from 17 (34%) of the patients contained no residual carcinoma. Mucin production was demonstrated in tumour tissue from 18 (55%) of the patients with residual tumour, none of who died of disease during the 5 to 10 years of follow up. Two patients who died of recurrent carcinoma had no mucin production in the post-irradiated tumour tissues. The presence of mucin in irradiated carcinoma of cervix seems to infer a better prognosis and this may prove useful in the follow-up of irradiated carcinomas.

Narcotic addiction in pregnancy with adverse maternal and perinatal outcome

A retrospective case controlled study was carried out on 51 Chinese gravidas who had abused narcotics and who were delivered in a teaching hospital in Hong Kong. Heroin was the most commonly abused drug. The number of patients who changed from heroin to methadone was small. The major antenatal complications were late antenatal booking (average 28 weeks), prematurity (41%), small for gestational age baby (27.5%), antepartum haemorrhage (13.7%) and high prevalence of venereal disease (23.5%). The babies born to drug addicted mothers were on average 629 g lighter at birth, 5 cm smaller in head circumference and 7 cm shorter in body length. Neonatal withdrawal symptoms occurred in 83% of all drug exposed neonates. The perinatal mortality rate was 19.6 per 1,000 total birth which was 2.5 times that of the control group. There was one maternal death in our series. Drug addiction in pregnancy poses a major risk to both mother and child.

The effect of smoking during pregnancy on the incidence of low birth weight among Chinese parturients

The incidence and effect of smoking in Chinese parturients are not well known. In a retrospective case-controlled study of 213 patients who smoked during pregnancy, it was found that the incidence of low birth-weight was doubled. On average the babies were smaller by 200 g, shorter by 1 cm and the head circumference was smaller by 0.3 cm. These anthropometric deficits may have significant long-term effects. Although the incidence of smoking in Chinese parturients is low (2%), the rising trend in recent years should prompt all physicians to advise expectant mothers to avoid smoking before and during pregnancy.

Born before arrival--uncovering the hazards

In a retrospective case controlled study the demographic background and outcome of 193 mothers whose babies were born before arrival at hospital was compared to that of a control group who delivered within the maternity units of 2 teaching hospitals in Hong Kong. Mothers who delivered before arrival at hospital were significantly more likely to be single, to have received no antenatal care, to have an unplanned pregnancy, low family income and to come from a socially disadvantaged group such as Vietnamese refugees and illegal immigrants from China. Lacerations to the genital tract, postnatal anaemia and blood transfusions were more common in the study group. Results of cervical cytology and rubella status were available in significantly fewer of these mothers. They were more likely to be ambivalent about contraception and less likely to attend the postnatal clinic. The perinatal mortality and morbidity was significantly increased.

Grand multiparity: a reappraisal of the risks

An excellent maternal and perinatal outcome is reported in a group of grand multipara of low socioeconomic status. These observations on a group of patients who are traditionally considered to be high risk show that in a healthy population with access to modern medical care and hospital delivery, a favorable outcome can be achieved despite a low socioeconomic or refugee status.

A case controlled study of pregnancy complicated by severe maternal anaemia

The perinatal outcome of 96 patients who had an antenatal haemoglobin value of less than 8.0 g/dl was compared with that of a similar number of controls who were matched for age and parity. Sixty-one patients (63%) had iron deficiency anaemia, 25 (26%) had alpha or beta thalassaemia minor, 7 (7.3%) had iron deficiency and thalassaemia trait, 2 had idiopathic pancytopenia and 1 had haemolytic anaemia due to systemic lupus erythematosus. Patients in the study group attended the antenatal booking clinic later, had less weight gain during pregnancy and their babies had lower birth-weights (2,984 g versus 3,177 g p less than 0.01) although there was no significant difference in the period of gestation at delivery. Six patients in the study group had placental abruption and another 2 patients had stillbirths but neither of these complications occurred in the control group. Although 37 patients (39%) in the study group received an antenatal blood transfusion, 53 (55%) of this group also had postnatal anaemia.

Primary mixed neuroendocrine and mucinous carcinoma of the ovary

A rare case of mixed carcinoma of ovary with a predominant malignant neuroendocrine and a lesser mucinous tumor component is described. Extensive areas of enteric-type epithelium containing endocrine cells were present in both the mucinous borderline tumor element and in the small foci of mucinous adenocarcinoma. Transition from the mucinous tumor to the malignant neuroendocrine component provides evidence for the derivation of some neuroendocrine or carcinoid tumors direct from mucinous tumors without necessarily being a component of a teratoma. Contrary to reported examples of mucinous carcinoid, the overgrowth and spread of the neuroendocrine component characterised the aggressive and lethal nature of this tumor.

The impact of multiple induced abortions on the outcome of subsequent pregnancy

The obstetric outcome of 285 women with a history of previous multiple induced abortions is compared to that of 285 age matched primigravidas. In the study group, 219 women had 2 previous induced abortions and 66 had 3 or more, the maximum number being 8. There was a higher incidence of unmarried women and smokers in this group but a lower incidence of uneducated women. There was no difference in the incidence of antenatal complications between the 2 groups. The mean gestation at delivery, duration of labour and mode of delivery were comparable. There was an increased incidence (p less than 0.01) of retained placenta in the subgroup of women with 3 or more previous induced abortions. There were no maternal or perinatal deaths. The mean birth-weight was comparable and there were no infants weighing less than 1,500 g in either group. We conclude that multiple previous induced abortions appear to have minimal impact on the obstetric outcome of subsequent pregnancy in this population, and in the absence of other risk factors there is no need to alter standard obstetric management in this group of women.

Discrepancy between laboratory determination and visual estimation of blood loss during normal delivery

Blood loss during normal delivery was measured in 37 primiparas and 25 multiparas who had no obstetric or medical complications and who underwent normal delivery in a teaching hospital following spontaneous onset of labour at term. Measured blood loss was significantly greater than the estimated volume of blood loss. In primigravidas, the mean ( +/- SE, standard error of the mean) estimated blood loss was 260 +/- 12 ml and the mean measured blood loss was 401 +/- 29 ml. In multiparas the mean estimated blood loss was 220 +/- 10 ml and the mean measured blood loss was 319 +/- 41 ml. The mean estimated blood loss was significantly lower (P less than 0.05) than the mean measured blood loss in both groups. The size of the discrepancy between measured and estimated blood loss was proportional to the measured blood loss. These findings show that visual estimation of blood loss was grossly inaccurate.

Obstetric outcome among Vietnamese refugees in Hong Kong: an age-matched case-controlled study

The obstetric performance of 308 Vietnamese refugees is compared with that of 308 age-matched Hong Kong Chinese patients. Vietnamese women were of higher parity and had an increased incidence of late booking and unreliable dates. Significant differences were found in the incidence of previous termination of pregnancy, iron-deficiency anemia, parasitic infestation, tuberculosis (TB) and syphilis. There was no significant difference in the mean birthweight between the two groups. However, there were twice as many low birthweight (less than 2500 g) infants amongst the Vietnamese whereas the Chinese patients had a higher incidence of macrosomic (greater than 4 kg) infants. There were no perinatal deaths and no significant perinatal morbidity.

Etoposide combination chemotherapy in refractory ovarian malignant germ cell tumor

Thirty-three patients with malignant germ cell tumor of the ovary received postoperative vincristine, dactinomycin, and cyclosphosphamide (VAC) treatment. Eight failed VAC treatment and received etoposide, bleomycin, and cisplatin (PEB) combination chemotherapy. Three were cured and remained disease free 24-79 months after completion of PEB therapy.

Sexually transmitted diseases amongst pregnant Vietnamese refugees in Hong Kong

In a prospective study the prevalence of syphilis amongst a group of pregnant Vietnamese refugees in Hong Kong was found to be 3.4%. No cases of gonorrhoea, genital warts or genital ulcers were found in the same group of patients. The implications of these results are discussed and the importance of adequate screening, treatment, contact tracing and health education amongst this group are emphasised.

Vaginal metastases in gestational trophoblastic disease

From 1976 to 1988, 320 patients with gestational trophoblastic disease were treated in the Department of Obstetrics and Gynaecology, University of Hong Kong. Eighteen patients had vaginal metastases. The clinical features and behaviour of the disease were analysed. The prognosis depends mainly on the extent of the disease. Similar favourable response to chemotherapy was observed in low-risk patients with vaginal metastases.

Human papillomavirus infection in the cervix of pregnant females in Hong Kong

Routine cytological examination and HPV-DNA probing were performed on cervical cells obtained from 215 pregnant Chinese females. The procedure utilized the specific binding of a mixture of complementary [32P]-labelled RNA probes to membrane-bound target HPV DNA types 6, 11, 16, 18, 31, 33 and 35. Positive results for HPV-DNA were obtained in 11/215 (5%) of the cases. The cervical smears were routinely processed and in 3/215 (1.5%) cases a cytological diagnosis of wart virus infection was made. All three were included in the 11 probe-positive cases. Using similar molecular biological techniques, pregnant Western females have an incidence of HPV infection of the cervix which is up to five times that of the present series. This is an unexpected finding in view of the fact that the incidence of cervical cancer is higher in Chinese women than American women.

Serum squamous cell carcinoma antigen in the monitoring of radiotherapy treatment response in carcinoma of the cervix

In this study, squamous cell carcinoma antigen (SCC) was detected in 96 of 157 patients with squamous cell carcinoma of the cervix and the percentage of patients with raised SCC levels increased with the stage of disease (P less than 0.01). The use of serial SCC assays and cervical biopsy histology during the course of radiotherapy to predict tumor response to irradiation was assessed. In patients who were given external irradiation before intracavitary radium, a high SCC level or the presence of viable tumor cells in the biopsy was found to be of no predictive value. However, at completion of radiotherapy, i.e., after intracavitary radium application, patients with persistently high SCC levels had a significantly higher incidence of residual tumor than patients whose SCC levels returned to normal (P less than 0.01). In 60% of patients with a persistently high SCC level, viable tumor was found in the cervical biopsy at the end of radiotherapy. On the other hand, only 5.4% of patients whose SCC level returned to normal had residual tumor.

Long-term neurological sequelae following vacuum extractor delivery

Two hundred and ninety-five children delivered by vacuum extractor (VE) 10 years ago were studied to determine if they had an increased incidence of neurological abnormality; 302 children delivered spontaneously in the same hospital looked after by the same doctors in the same year matched for maternal age, gestational age and birthweight were used as controls. Fine- and gross-motor control, perceptual integration and behavioural maturity were screened by 4 tasks selected from the Quick Neurological Screening Test. Intelligence assessment was based on scholastic performance, speech ability and ability of self-care as commented by teachers and parents. Similar scorings were found between the 2 groups. Mental subnormality or severe neurological abnormality was found in 3 children delivered by VE and in 3 children delivered spontaneously and there was no evidence that it was birth-related.

Routine serological screening for syphilis during pregnancy--disposable anachronism or fundamental necessity?

Between 1984 and 1988 inclusive 34 patients with syphilis during pregnancy were identified in this unit by routine serological screening. There were 2 stillbirths in this group of patients giving a perinatal mortality rate of 59 per 1,000 total births. Analysis of the patients' history and physical examination findings did not reveal any predictive factors for sexually transmitted diseases in most cases. Despite the dramatic fall in the prevalence of syphilis both during pregnancy and the general population in Hong Kong, routine serological screening for syphilis during pregnancy must continue.