Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow

Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.

Precision endoscopy in the era of climate change and sustainability

Global warming caused by increased greenhouse gas (GHG) emissions has a direct impact on human health. Gastrointestinal (GI) endoscopy contributes significantly to GHG emissions due to energy consumption, reprocessing of endoscopes and accessories, production of equipment, safe disposal of biohazardous waste, and travel by patients. Moreover, GHGs are also generated in histopathology through tissue processing and the production of biopsy specimen bottles. The reduction in unnecessary surveillance endoscopies and biopsies is a practical approach to decrease GHG emissions without affecting disease outcomes. This narrative review explores the role of precision medicine in GI endoscopy, such as image-enhanced endoscopy and artificial intelligence, with a focus on decreasing unnecessary endoscopic procedures and biopsies in the surveillance and diagnosis of premalignant lesions in the esophagus, stomach, and colon. This review offers strategies to minimize unnecessary endoscopic procedures and biopsies, decrease GHG emissions, and maintain high-quality patient care, thereby contributing to sustainable healthcare practices.

Asia-Pacific survey on green endoscopy

BACKGROUND AND AIM

Greenhouse gas emissions are the fundamental cause of global warming, with CO2 being the most contributive. Carbon reduction has been widely advocated to mitigate the climate crisis. The endoscopy unit is the third highest waste-generating department in a hospital. The awareness and acceptance of the practice of green endoscopy among healthcare workers is unclear.

METHOD

An online survey was conducted over a 5-week period from July to August 2023 in the Asia-Pacific region, which targeted endoscopists, nurses, and other healthcare professionals of the endoscopy unit. The primary outcome was the agreement to adopt green endoscopy. The secondary outcomes included views on sustainable practices, factors associated with increased acceptance of green endoscopy, the acceptance of different carbon reduction measures, and the perceived barriers to implementation.

RESULTS

A total of 259 valid responses were received. Overall, 79.5% of participants agreed to incorporate green endoscopy into their practice. Nevertheless, existing green policies were only reported by 12.7% of respondents. The level of understanding of green endoscopy is the only significant factor associated with its acceptance (odds ratio 3.10, P < 0.007). Potential barriers to implementation include healthcare cost increment, infection risk, inadequate awareness, and lack of policy and industrial support.

CONCLUSION

Green endoscopy is well accepted among healthcare workers but not widely implemented. The level of understanding is highly associated with its acceptance, highlighting the importance of education. A reliable assessment tool is needed to quantify the environmental impact of endoscopy. Further studies are needed to ascertain its benefit and cost effectiveness.

Bat coronavirus was detected positive from insectivorous bats in Krau Wildlife Reserve Forest

Bats are flying mammals with unique immune systems that allow them to hold many pathogens. Hence, they are recognised as the reservoir of many zoonotic pathogens. In this study, we performed molecular detection to detect coronaviruses, paramyxoviruses, pteropine orthoreoviruses and dengue viruses from samples collected from insectivorous bats in Krau Reserve Forest. One faecal sample from Rhinolophus spp. was detected positive for coronavirus. Based on BLASTN, phylogenetic analysis and pairwise alignment-based sequence identity calculation, the detected bat coronavirus is most likely to be a bat betacoronavirus lineage slightly different from coronavirus from China, Philippines, Thailand and Luxembourg. In summary, continuous surveillance of bat virome should be encouraged, as Krau Reserve Forest reported a wide spectrum of biodiversity of insectivorous and fruit bats. Moreover, the usage of primers for the broad detection of viruses should be reconsidered because geographical variations might possibly affect the sensitivity of primers in a molecular approach.

Utility of a standardized training program for endoscopic diagnosis of early gastrointestinal neoplasia

Background and study aims  Image enhanced endoscopy (IEE) allows endoscopists to improve recognition and characterization of gastrointestinal neoplasia. The Asian Novel Bio-Imaging and Intervention Group (ANBIG) conducted a standardized training program in endoscopic diagnosis and treatment of early gastrointestinal cancers in Asia. We embarked on a study to investigate the effect of this module on endoscopic diagnosis of early gastrointestinal neoplasia. Methods  This prospectively collected database was from workshops conducted on training for endoscopic diagnosis of early gastrointestinal neoplasia. All workshops were conducted in a standardized format, which included a pretest, a learning phase consisting of didactic lectures, case discussion, and live demonstration followed by a post-test to assess knowledge gained. The pretest and post-training tests were standardized questions addressing four domains, including basic knowledge of imaging and diagnosis of esophageal, gastric, and colonic neoplasia. Results  From November 2013 to November 2016, 41 ANBIG workshops were conducted in 13 countries. A total of 1863 delegates and 40 faculty participated in these workshops. Of the delegates, 627 completed both tests. There was a significant improvement after training in all domains of the tests. There was a trend in general lack of knowledge across all domains for delegates from "low" healthcare cost countries before training. All delegates demonstrated significant improvement in knowledge of all domains after the workshop irrespective of whether they were from "high" or "low" healthcare cost per capita countries. Conclusion  A standardized teaching program on IEE improved the diagnostic ability and quality of endoscopists in recognizing early gastrointestinal neoplasia in Asia.

Ambulance use affects timely emergency treatment of acute ischaemic stroke

INTRODUCTION

For acute ischaemic stroke patients, treatment with intravenous tissue plasminogen activator within a 4.5-hour therapeutic window is essential. We aimed to assess the time delays experienced by stroke patients arriving at the emergency department and to compare ambulance users and non-ambulance users.

METHODS

We performed a prospective cohort study in a tertiary hospital in Hong Kong. All acute stroke patients attending the emergency department from January to June 2017 were recruited. Patients who were in hospital at the time of stroke onset and those who transferred from other hospitals were excluded. Three phases were compared between ambulance users and non-ambulance users: phase I, between stroke onset and calling for help; phase II, between calling for help and arriving at the emergency department; and phase III, between arriving and receiving medical assessment.

RESULTS

Of 102 consecutive patients recruited, 48 (47%) patients arrived at the emergency department by ambulance. The percentage of stroke patients attending emergency department within the therapeutic window was significantly higher for ambulance users than for non-ambulance users (64.6% vs 29.6%; P<0.001). For phases I, II and III, the median times were significantly shorter for ambulance users (77.5, 32 and 8 min, respectively) than for non-ambulance users (720, 44.5 and 15 min, respectively; all P<0.001).

CONCLUSION

Transport of patients to the emergency department by ambulance is important for timely and effective stroke treatment.

Telemedicine for gastrointestinal endoscopy: The Endoscopic Club E-conference in the Asia Pacific Region

Background and study aims An Endoscopic Club E-conference (ECE) was set up in May 2014 to cater to increased demand for gastrointestinal endoscopy-related teleconferences in the Asia-Pacific region which were traditionally organized by the medical working group (MWG) of Asia-Pacific Advanced Network. This study describes how the ECE meeting was run, examines the group dynamics, outlines feedback and analyzes factors affecting the enthusiasm of participants. It is hoped that the findings here can serve as guidance for future development of other teleconference groups. Methods The preparation, running of and feedback on the ECE teleconference were evaluated and described. The country's economic situation, time zone differences, connectivity with a research and education network (REN) and engineering cooperation of each member were recorded and analyzed with regard to their association with participant enthusiasm, which was taken as participation in at least 50 % of the meetings since joining. Associations were calculated using 2-way table with chi-square test to generate odds ratio and P value. Results To date, ECE members have increased from 7 to 29 (increment of 314 %). Feedback received indicated a high level of satisfaction with program content, audiovisual transmission and ease of technical preparation. Upper gastrointestinal luminal endoscopy-related topics were the most favored program content. Those topics were presented mainly via case studies with a focus on management challenges. Time zone differences of more than 6 hours and poor engineering cooperation were independently associated with inactive participation (P values of 0.04 and 0.001 respectively). Conclusions Good program content and high-quality audiovisual transmission are keys to the success of an endoscopic medical teleconference. In our analysis, poor engineering cooperation and discordant time zones contributed to inactive participation while connectivity with REN and a country's economic situation were not significantly associated with participant enthusiasm.

Initial results of selective renal parenchymal clamping with an adjustable kidney clamp in nephron-sparing surgery: an easy way to minimise renal ischaemia

INTRODUCTION

A renal parenchymal clamp has been used at our centre since March 2012. It is used in position over the kidney to achieve optimal vascular control of a tumour while minimising parenchymal ischaemia. This study aimed to report the feasibility, surgical outcome, and oncological control of a kidney clamp in partial nephrectomy.

METHODS

This study was conducted at a teaching hospital in Hong Kong. Partial nephrectomies performed from January 2009 to March 2015 were reviewed. The tumour characteristics and surgical outcomes of kidney clamp were studied and compared with traditional hilar clamping.

RESULTS

A total of 92 patients were identified during the study period. Kidney clamps were used in 20 patients and hilar clamping in 72, with a mean follow-up of 27 and 37 months, respectively. For patients in whom a kidney clamp was applied, all tumours were exophytic to a different extent and the majority (90%) were located at the polar region. The PADUA (preoperative aspects and dimensions used for an anatomical) classification nephrometry score was also lower than those in whom hilar clamping was used (7.07 vs 8.34; P=0.002). The clamp was used in open, laparoscopic, and robot-assisted surgery. Operating time was shorter (207 ± 72 mins vs 306 ± 80 mins; P<0.001) and estimated blood loss was lower (205 ± 191 mL vs 331 ± 275 mL; P=0.045) with kidney clamp. No acute kidney injury occurred. Postoperative renal function was comparable between the two groups.

CONCLUSIONS

Partial nephrectomy using parenchymal clamping is safe and feasible in selected cases. The postoperative renal function and oncological control were satisfactory.

Development of an E-learning System for the Endoscopic Diagnosis of Early Gastric Cancer: An International Multicenter Randomized Controlled Trial

Background

In many countries, gastric cancer is not diagnosed until an advanced stage. An Internet-based e-learning system to improve the ability of endoscopists to diagnose gastric cancer at an early stage was developed and was evaluated for its effectiveness.

Methods

The study was designed as a randomized controlled trial. After receiving a pre-test, participants were randomly allocated to either an e-learning or non-e-learning group. Only those in the e-learning group gained access to the e-learning system. Two months after the pre-test, both groups received a post-test. The primary endpoint was the difference between the two groups regarding the rate of improvement of their test results.

Findings

515 endoscopists from 35 countries were assessed for eligibility, and 332 were enrolled in the study, with 166 allocated to each group. Of these, 151 participants in the e-learning group and 144 in the non-e-learning group were included in the analysis. The mean improvement rate (standard deviation) in the e-learning and non-e-learning groups was 1·24 (0·26) and 1·00 (0·16), respectively (P < 0·001).

Interpretation

This global study clearly demonstrated the efficacy of an e-learning system to expand knowledge and provide invaluable experience regarding the endoscopic detection of early gastric cancer (R000012039).

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This report establishes that an e-learning system on the Internet can improve the diagnostic ability of endoscopists.

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Countless endoscopists worldwide can access the system to learn how to make an endoscopic diagnosis of early gastric cancer.

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The e-learning system could be modified to provide education regarding endoscopic diagnosis in other organs.

This is the first report to demonstrate how an e-learning system based on the Internet can improve the diagnostic ability of gastrointestinal endoscopists worldwide. There is no limit to the number of endoscopists who can access the system and benefit from this opportunity to learn how to make an endoscopic diagnosis of early gastric cancer. This e-learning system could be modified to provide education regarding endoscopic diagnosis in other organs such as the large intestine and the esophagus, as well as the stomach. It may contribute to human welfare and health by reducing the mortality from gastrointestinal cancer.

Basic principles and practice of gastric cancer screening using high-definition white-light gastroscopy: Eyes can only see what the brain knows

Endoscopic diagnosis of gastrointestinal tumors consists of the following processes: (i) detection; (ii) differential diagnosis; and (iii) quantitative diagnosis (size and depth) of a lesion. Although detection is the first step to make a diagnosis of the tumor, the lesion can be overlooked if an endoscopist has no knowledge of what an early-stage 'superficial lesion' looks like. In recent years, image-enhanced endoscopy has become common, but white-light endoscopy (WLI) is still the first step for detection and characterization of lesions in general clinical practice. Settings and practice of routine esophagogastroduodenoscopy (EGD) such as use of antispasmodics, number of endoscopic images taken, and observational procedure are customarily decided in each facility in each country and are not well standardized. Therefore, in the present article, we attempted to outline currently available evidence and actual Japanese practice on gastric cancer screening using WLI, and provide tips for detecting EGC during routine EGD which could become the basis of future research.

Differences in routine esophagogastroduodenoscopy between Japanese and international facilities: A questionnaire survey

BACKGROUND AND AIM

The mortality rate of gastric cancer (GC) is close to the incidence rate worldwide. However, in Korea and Japan, the mortality rate of GC is less than half of the incidence rate. We hypothesized that good-quality routine esophagogastroduodenoscopy (EGD) contributes to a high detection rate for early GC (EGC) and improves mortality in these countries.

METHODS

To clarify the differences in routine EGD, a questionnaire survey was conducted in 98 Japanese and 53 international institutions.

RESULTS

Prevalence of screening examination among routine EGD was higher in Japanese than in international institutions. Japanese endoscopists noted that endoscopic mucosal atrophy was the most significant risk factor for GC, whereas international endoscopists paid more attention to clinical information such as age, symptoms and family history. Antispasmodics, mucolytics and defoaming agents were used more frequently in Japanese institutions. The examination time was similar (mostly 5-10 min) between Japanese and international institutions. Japanese endoscopists took more pictures (>20 in almost all institutions) than international endoscopists (≤20 in two-thirds of institutions). In Japanese institutions, biopsy specimens were more frequently taken from areas of mucosal discoloration, unevenness or spontaneous bleeding rather than from obvious endoscopic lesions such as ulceration or polyps. In most Japanese institutions, one or two biopsy specimens were taken per lesion, compared with ≥three in international institutions.

CONCLUSION

There were some discrepancies between Japanese and international institutions for routine EGD. Thus, standardization is required for adequate risk assessment, proper techniques, and knowledge of endoscopic diagnosis of EGC.

Genotype 3 is the predominant hepatitis C genotype in a multi-ethnic Asian population in Malaysia

BACKGROUND

Genotypes of hepatitis C virus (HCV) are distributed differently across the world. There is a paucity of such data in a multi-ethnic Asian population like Malaysia. The objectives of this study were to determine the distribution of HCV genotypes between major ethnic groups and to ascertain their association with basic demographic variables like age and gender.

METHODS

This was a cross-sectional prospective study conducted from September 2007 to September 2013. Consecutive patients who were detected to have anti-HCV antibodies in the University of Malaya Medical Centre were included and tested for the presence of HCV RNA using Roche Cobas Amplicor Analyzer and HCV genotype using Roche single Linear Array HCV Genotyping strip.

RESULTS

Five hundred and ninety-six subjects were found to have positive anti-HCV antibodies during this period of time. However, only 396 (66.4%) were HCV RNA positive and included in the final analysis. Our results showed that HCV genotype 3 was the predominant genotype with overall frequency of 61.9% followed by genotypes 1 (35.9%), 2 (1.8%) and 6 (0.5%). There was a slightly higher prevalence of HCV genotype 3 among the Malays when compared to the Chinese (P=0.043). No other statistical significant differences were observed in the distribution of HCV genotypes among the major ethnic groups. There was also no association between the predominant genotypes and basic demographic variables.

CONCLUSIONS

In a multi-ethnic Asian society in Malaysia, genotype 3 is the predominant genotype among all the major ethnic groups with genotype 1 as the second commonest genotype. Both genotypes 2 and 6 are uncommon. Neither genotype 4 nor 5 was detected. There is no identification of HCV genotype according to ethnic origin, age and gender.

Endoscopic ablation therapy for biliopancreatic malignancies

Biliopancreatic malignancies such as cholangiocarcinoma (CCA) has notoriously been diagnosed late. As such most therapy have been palliative in nature. Cholangioscopy allows for an earlier diagnosis to be made. Brachytherapy with the insertion of catheter with iridium-132 seeds, percutaneously or through endoscopic retrograde cholangiopancreatography (ERCP) was the earliest ablative techniques used. It has been shown to have a beneficial effect only in prolonging survival. Photodynamic therapy (PDT) has also been used for several years. stenting with PDT versus stenting alone for unresectable CCA showed a marked survival benefit with the addition of PDT. However the most exciting endoscopic ablative modality appears to be intraductal radiofrequency ablation using the Habib catheter and device. Several case series have shown the effectiveness of this technique in ablating tumors. This technique is evolving and coupled with early diagnosis of CCA through cholangioscopy will allow for a curative therapy. The crux to the effective treatment of early cancerous lesions in the bile or pancreatic duct is the early diagnosis of such lesions. Effective endoscopic ablative therapy is now available with the advent of radiofrequency ablation probes that can be passed through the duodenoscope via ERCP.

Preoperative drainage for malignant biliary strictures: is it time for self-expanding metallic stents?

Palliation of jaundice improves the general health of the patient and, therefore, surgical outcomes. Because of the complexity and location of strictures, especially proximally, drainage has been accompanied by increased morbidity due to sepsis. Another concern is the provocation of an inflammatory and fibrotic reaction around the area of stent placement. Preoperative biliary drainage with self-expanding metallic stent (SEMS) insertion can be achieved via a percutaneous method or through endoscopic retrograde cholangiopancreatography. A recently published multicenter randomized Dutch study has shown increased morbidity with preoperative biliary drainage. A Cochrane meta-analysis has also shown a significantly increased complication rate with preoperative drainage. However, few of these studies have used a SEMS, which allows better biliary drainage. No randomized controlled trials have compared preoperative deployment of SEMS versus conventional plastic stents. The outcomes of biliary drainage also depend on the location of the obstruction, namely the difficulty with proximal compared to distal strictures. Pathophysiologically, palliation of jaundice will benefit all patients awaiting surgery. However, preoperative drainage often results in increased morbidity because of procedure-related sepsis. The use of SEMS may change the outcome of preoperative biliary drainage dramatically.

Mandarin version of the Leeds Dyspepsia Questionnaire: A valid instrument for assessing symptoms in Asians

OBJECTIVE

To develop and validate a Mandarin version of the Leeds Dyspepsia Questionnaire (M-LDQ) in Asian patients with dyspepsia.

METHODS

The M-LDQ was developed according to standardized methods. The validity, internal consistency, test-retest reliability and responsiveness of the instrument were evaluated in both primary and secondary care patients.

RESULTS

A total of 184 patients (mean age 54.0 ± 15.8 years, of whom 59% were women and 72.3% of whom had at least secondary level education) were recruited between August 2012 and March 2013, from both primary (n = 100) and secondary care clinics (n = 84). Both the internal consistency of all components of the M-LDQ (Cronbach's α 0.79) and test-retest reliability (Spearman's correlation coefficient 0.78) were good. The M-LDQ was valid in diagnosing dyspepsia in primary care (area under the receiver operating characteristics curve 0.84) and was able to discriminate between secondary and primary care patients (median cumulative LDQ score 13.0 vs 3.0, P < 0.0001). Among eight patients with organic dyspepsia, the median M-LDQ score reduced significantly from 21.0 (pretreatment) to 9.5 (4 weeks post-treatment) (P < 0.0001).

CONCLUSION

The M-LDQ is a valid and responsive instrument for assessing ethnic Chinese adults with dyspepsia.

Novel use of a self-expandable metal stent with an anti-migration system for palliative drainage of a pancreatic cystic neoplasm

CONTEXT

There is scanty data on endoscopic palliative management of pancreatic cystic lesions that cause gastric outlet obstruction (GOO). This is the first case report that illustrates the use of a covered self-expandable metal stent (CSEMS) with an anti-migration system in the management of a symptomatic neoplastic cystic pancreatic lesion.

CASE REPORT

A 92-year-old Chinese female presented with partial GOO for 3 months. Examination revealed a non-tender epigastric mass with moderate abdominal distension. Esophagogastroduodenoscopy (EGD) showed a significant bulge at the posterior wall of the gastric antrum and food residue in the stomach. A CT scan of the abdomen showed a large pancreatic tail cystic lesion. Endoscopic ultrasound (EUS) showed a clear, non-septated cystic lesion measuring 9.7x10 cm arising from the pancreatic tail. Analysis of the aspirate revealed the following: Amylase: 3,200 units/L, CEA: 411 ng/mL, CA 19-9 812 U/mL and no malignancy. A Niti-S™ Biliary Stent (NAGI™) was used for a cystogastrostomy. This procedure was complicated by a self-limiting intra-abdominal leak, stent migration and bleeding from a splenic artery pseudoaneurysm which was arrested with coil embolization. She progressed well after that with significant symptom improvement and no further complications.

CONCLUSION

This is the first case of a CSEMS with an anti-migration system that was used for decompression of a pancreatic cystic neoplasm (PCN). Novel use of this stent is a viable option as palliative management of a PCN in those not fit for surgery but caution needs to be exercised as there can be significant complications.

Toxicity of repeated intravenous injection of gene therapeutics for X-CGD in mice

We made gene therapeutics for X-chronic granulomatous disease (CGD) by transducing murine bone marrow-derived stem cells with MT-gp91 retrovirus and evaluated possible toxicity in mice as a prerequisite for human clinical trials. Male C57BL/6 mice were injected intravenously with gene therapeutics for X-CGD twice at an interval of two weeks at 5 × 107 cells/kg and sacrificed 2 weeks after the last administration. Significant changes noted in gene therapeutics for X-CGD-treated animals were an increase in white blood cell counts and a slight decrease in albumin/globulin ratio. The red pulp hyperplasia in the spleen accompanied with an increase in organ weight was considered to result from the accumulation of gene therapeutics for X-CGD, bone marrow-derived stem cells, in the spleen. No anti-gp91 antibody was detected in the sera collected from the animals treated with gene therapeutics for X-CGD. No integration of gp91 DNA from retroviral vector was detected in chromosomal DNA of gonads in animals dosed with the test substance, indicating no potential of genomic integration. In conclusion, the repeated dose of gene therapeutics for X-CGD exerted no toxicity. The splenic red pulp hyperplasia and the increase observed in white blood cell counts and in spleen weights were considered as pharmacological changes induced by the treatment.

C. elegans SIN-3 and its associated HDAC corepressor complex act as mediators of male sensory ray development

Mab21 gene family members are required for embryonic development and sensory organ formation in both invertebrates and vertebrates. However, their mechanistic role on differentiation is largely unexplored. We report here the isolation of SIN-3 as a MAB-21 interacting molecule. sin-3 is co-expressed with mab-21 in the ray structural cells and genetically interacts with mab-21 to control sensory organ development. Using pharmacological and RNAi approaches, we demonstrated that histone deacetylase and conserved SIN-3-associated components are required for ray patterning. Conserved physical interactions between these components were also observed, implicating the recruitment of HDAC complex by MAB-21/SIN-3 may occur to determine ray identity in males.

Recurrent prostatic stromal tumour of uncertain malignant potential (STUMP) presenting with urinary retention 6 Years after transurethral resection of prostate (TURP)

CLINICAL PRESENTATION

A 56-year-old Chinese male with previously diagnosed prostatic stromal tumour of uncertain malignant potential (STUMP) presented with urinary retention 6 years after transurethral resection of prostate (TURP).

TREATMENT AND OUTCOME

Cystoscopy showed a papillary tumour of the prostatic urethra causing near-complete obstruction. Repeat TURP was performed. He has been asymptomatic since.

CONCLUSION

There has been fewer than 100 cases of this lesion reported worldwide. Definitive treatment is not well established. Longterm follow-up to monitor progression and possible recurrence is required, and repeat TURP or radical surgery may be necessary.

Extracorporeal shockwave lithotripsy and intracorporeal lithotripsy for proximal ureteric calculi--a comparative assessment of efficacy and safety

INTRODUCTION

Extracorporeal shockwave lithotripsy (ESWL) is the treatment modality of choice of many urologists for proximal ureteric calculi. In this study, we compared the efficacy and safety of ESWL versus ureteroscopy with holmium laser lithotripsy for the treatment of this group of stones.

MATERIALS AND METHODS

Between May 1999 and October 2000, 50 patients had ESWL and another 51 patients underwent ureteroscopy with holmium laser lithotripsy for proximal ureteric calculi. The two groups were similar in age, sex ratio and stone size. ESWL was performed with the Dornier Compact lithotriptor whereas holmium laser lithotripsy was performed via retrograde ureteric access with a Wolf 7.5 Fr semirigid ureteroscope.

RESULTS

Ureteroscopy with holmium laser lithotripsy was significantly better in terms of the mean procedure time (56 min in ESWL; 25 min in ureteroscopy; P < 0.001) and the 1-month stone free rate (50% in ESWL; 80% in ureteroscopy; P = 0.001). The 3-month stone free rate was also higher for ureteroscopy (78% in ESWL; 90% in ureteroscopy) but this difference was not statistically significant (P = 0.09). Minor complications of steinstrasse (6%) occurred in ESWL and proximal stone migration (8%) occurred during ureteroscopy.

CONCLUSION

Ureteroscopy with holmium laser lithotripsy is a viable and safe alternative to ESWL for the management of proximal ureteric calculi.

STR data for the PowerPlex 16 loci for the Chinese population in Hong Kong

Allele frequencies for the 15 STR loci included in the PowerPlex 16 kit were obtained from a sample of 247 unrelated Chinese in Hong Kong.

Penile colour duplex ultrasonography as a screening tool for venogenic erectile dysfunction

INTRODUCTION

Vasculogenic impotence is one of the major causes of erectile dysfunction. Cavernosometry and cavernosography is traditionally the gold standard for evaluation of venogenic impotence. However, it is invasive and there are potentially significant complications. Penile colour flow Doppler imaging (PCDI) is non-invasive and can be used to assess venous incompetence.

MATERIALS AND METHODS

One hundred and sixty-eight patients were referred for PCDI assessment from March 1998 to February 2001. Forty-three of these also had cavernosogram and cavernosometry done and were included in the study.

RESULTS

The sensitivity was 93.9%, the specificity was 90.0%, the accuracy was 93.0% with a negative predictive value of 81.8% and a positive predictive value of 96.9%. Kappa value of 0.81 was obtained, indicating excellent agreement between PCDI and cavernosogram and cavernometry.

CONCLUSIONS

Penile colour flow Doppler imaging is accurate in the assessment of venogenic erectile dysfunction. It can replace cavernometry and cavernosogram as a screening tool. Cavernometry and cavernosogram should only be done in cases when PCDI suggests venogenic impotence, and when surgery is contemplated.

Holmium laser lithotripsy in the management of ureteric calculi

INTRODUCTION

To evaluate the efficacy and safety of the holmium:YAG laser in retrograde ureteroscopic laser lithotripsy of ureteric calculi.

METHODS

Three hundred and twenty-five patients (256 males and 69 females) with mean age of 45 years underwent 328 retrograde ureteroscopic laser lithotripsy as the primary therapy for ureteric calculi using semirigid mini-ureteroscopes and the holmium:YAG laser (Coherent, Palo Alto, California, USA). Four consultants and three registrars performed the procedures over a period of 31 months.

RESULTS

The mean largest diameter of the calculi was 8.4 mm. The mean hospital stay was 1.8 days and the mean duration for the operation was 25 minutes. One hundred and twenty-two (37%) procedures were done as day surgery cases. Complete stone-free rates after single primary treatment using only the holmium:YAG laser were 75% and 91% at 4 weeks and 12 weeks of follow-up, respectively. Including 22 (7.6%) renal units which required additional procedures, the overall stone-free rate was 97%. Seventeen cases (5.2%) needed additional extracorporeal shock wave lithotripsy (ESWL) and 5 cases (1.5%) needed an additional repeat ureteroscopy and lithotripsy for complete stone clearance. Significant complications include 1 case of ureteric perforation.

CONCLUSIONS

The holmium:YAG is a safe and effective intracorporeal lithotripter when deployed in a retrograde manner in conjunction with a mini-ureteroscope.

Postembryonic expression of Caenorhabditis elegans mab-21 and its requirement in sensory ray differentiation

The male tail sensory rays in Caenorhabditis elegans are complex copulatory structures, the normal patterning of which requires a number of regulatory genes. Among them, mab-21 specifies the identity of sensory ray 6. By using green fluorescent protein reporters, we identify multiple cis-acting elements that control the developmental expression of mab-21. Traced with a functional mab-21:gfp gene driven by authentic regulatory sequences, mab-21 expression could be detected in hypodermal, neuronal, muscle, and ray cells. We showed here that the expression of mab-21 in the hypodermis and neuronal cells was dispensable for its function in ray 6. In contrast, its expression in the ray 6 structural cell and neurons as conferred by its 3' enhancer was crucial for determining the correct ray 6 identity.

Data mining approach to policy analysis in a health insurance domain

This study examined the characteristics of the knowledge discovery and data mining algorithms to demonstrate how they can be used to predict health outcomes and provide policy information for hypertension management using the Korea Medical Insurance Corporation database. Specifically, this study validated the predictive power of data mining algorithms by comparing the performance of logistic regression and two decision tree algorithms, CHIAD (Chi-squared Automatic Interaction Detection) and C5.0 (a variant of C4.5) using the test set of 4588 beneficiaries and the training set of 13,689 beneficiaries. Contrary to the previous study, the CHIAD algorithm performed better than the logistic regression in predicting hypertension, and C5.0 had the lowest predictive power. In addition, the CHIAD algorithm and the association rule also provided the segment-specific information for the risk factors and target group that may be used in a policy analysis for hypertension management.

Rapid streptococcal testing in Vietnamese children with pharyngitis

Streptococcal pharyngitis has been a significant public health problem in Vietnam for many years. Accurate diagnosis of the infection, however, has been difficult. We carried out a clinical trial of a rapid streptococcal antigen detection test (Quick-Vue (R) Flex Strep A) on a population of 777 children with pharyngitis seen at the Institute for the Protection of Children's Health (Children's Hospital) in Hanoi, Vietnam. Bacterial culture was performed in parallel with the rapid test on simultaneously obtained throat swab specimens. The rapid test was found to be 89% sensitive and 92% specific (96% in children not on prior antibiotics) compared to culture. The test was also found to be convenient and acceptable to patients and clinicians. A significant benefit of the test is that those children found positive are more likely to be treated with penicillin rather than a broad spectrum antimicrobial, which in turn will reduce the likelihood of resistant infections in the future.

Comparison of two bioassay methods for determining deltamethrin resistance in German cockroaches (Blattodea: Blattellidae)

Susceptibility to deltamethrin of 10 strains of the German cockroach, Blattella germanica (L.), trapped in hotel kitchens in Singapore was determined. Two resistance detection bioassay methods (topical application and World Health Organization glass jar method) were compared. Resistance ratios based on 50% knockdown, obtained by comparison with the S strain, ranged from 17.7 to 4,235 for topical application and from 2.2 to 22 for the glass jar method. A field strain, with consistently low resistance ratios (topical method = 17.7, glass jar method = 2.2), was identified as a potential field strain to be used as a baseline for comparison with other field strains. Resistance ratios for the other field strains obtained by comparison with the R5 strain ranged from 24.5 to 239 for topical application and from 1.2 to 9.8 for the glass jar method. The results of our study demonstrate that deltamethrin-resistant German cockroaches are numerous in Singapore. Comparison between the two bioassay methods showed that there was significant correlation between KD50 and KT50 values. The glass jar method is similar to field situations but topical application is sensitive enough to define the magnitude of resistance. Differences between the two detection bioassays and the factors governing the choice of bioassay in monitoring resistance in German cockroaches are discussed.

Bioactivities of methyl allyl disulfide and diallyl trisulfide from essential oil of garlic to two species of stored-product pests, Sitophilus zeamais (Coleoptera: Curculionidae) and Tribolium castaneum (Coleoptera: Tenebrionidae)

Two of the major constituents of the essential oil of garlic, Allium sativum L., methyl allyl disulfide and diallyl trisulfide, were tested against Sitophilus zeamais Motschulsky and Tribolium castaneum (Herbst) for contact toxicity, fumigant toxicity, and antifeedant activity. The contact and fumigant toxicities of diallyl trisulfide were greater than that of methyl allyl disulfide to the adults of these two species of insects. These two compounds were also more toxic to T. castaneum adults than to S. zeamais adults. Older T. castaneum larvae were more susceptible to the contact toxicity of the two compound, whereas younger larvae were more susceptible to the fumigant toxicity of these compounds. Both compounds reduced egg hatching of T. castaneum and subsequent emergence of progeny. Diallyl trisulfide totally suppressed egg hatching at 0.32 mg/cm2, and larval and adult emergence at 0.08 mg/cm2. Methyl allyl disulfide significantly decreased the growth rate, food consumption, and food utilization of adults of both insect species, with feeding deterrence indices of 44% at 6.08 mg/g food for S. zeamais and 1.52 mg/g food for T. castaneum. However, it did not affect any nutritional indices of T. castaneum larvae. Diallyl trisulfide significantly reduced all of the nutritional indices in all of the insects tested. Feeding deterrence indices of 27 and 51% were obtained in S. zeamais adults and T. castaneum larvae, respectively, at the concentration of 2.98 mg/g food, whereas feeding deterrence of 85% was achieved in T. castaneum adults at a much lower concentration of 0.75 mg/g food. Hence, diallyl trisulfide is a more potent contact toxicant, fumigant and feeding deterrent than methyl allyl disulfide.

Startle responses to electric shocks: measurement of shock sensitivity and effects of morphine, buspirone and brain lesions

The present study developed a new protocol to assess shock sensitivity in rats. Male Wistar rats were subjected to footshock stimuli ranging from 0 to 1.6 mA (0.1 s) in a startle apparatus and startle responses elicited by shocks were measured. Acoustic stimuli (95, 105, or 115 dB) were dispersed within the shock series serving as a control measurement of motor performance. Results indicated that the magnitude of shock startle responses significantly increased with the shock intensity in a linear trend. Morphine (8.0 mg/kg) and buspirone (1.0, 2.5, or 5.0 mg/kg), both of which possessing analgesic effects, depressed shock startle but had no such effect on acoustic startle. The effect of morphine was readily reversed by pretreatment of naloxone (1.0 mg/kg). To investigate the neural basis underlying this response, radio-frequency lesions of various structures implicated in processing of nociceptive or aversive information were undertaken. Lesions of the ventroposterior thalamic nucleus, insular cortex, or amygdala decreased startle reactivity to electric shocks but not to acoustic stimuli. Lesions of the anterior cingulate gyrus or medial prefrontal cortex, while altered the reactivity to acoustic stimuli, had no effect on the shock-elicited startle. These results suggested that the amplitude of startle in response to electric shocks provide a quantitative measurement of shock sensitivity within an extended range of stimulus intensities. Performing this response may engage the the central nociceptive pathway.

Subjective visual experience during phacoemulsification and intraocular lens implantation under topical anesthesia

OBJECTIVE

The aim of this study was to investigate the subjective visual experience of patients during phacoemulsification and intraocular lens (IOL) implantation under topical anesthesia.

DESIGN

Postoperative questionnaire survey.

PARTICIPANTS

The study cohort consisted of 52 patients with cataracts. There were 18 male (34.6%) and 34 female (65.4%) patients. Their mean (+/- SD) age was 67.5 (+/-10.8) years.

INTERVENTION

The patients underwent routine phacoemulsification and IOL implantation under topical anesthesia.

MAIN OUTCOME MEASURES

The patients were interviewed on the same day after their operation regarding their visual experience in the operated eye during surgery.

RESULTS

All patients (100%) reported that they could see at least some light during the surgery. Some patients reported they could also see one or more colors (50 patients, 96.2%), movements (32 patients, 61.5%), flashes (24 patients, 46.2%), the surgeon's fingers/hands (13 patients, 25%), instruments (12 patients, 23.1%), and/or the surgeon (4 patients, 7.7%). The colors seen included red (24 patients, 46.2%), yellow (23 patients, 44.2%), blue (12 patients, 23.1%), green (7 patients, 13.5%), and orange (6 patients, 11.5%). Eight patients (15.4%) saw the spectrum of colors similar to that of the rainbow. Twenty-four patients (46.2%) reported that the brightness of light changed during the course of the operation. Eight patients (15.4%) found their visual experience frightening. There was no statistically significant association between those who found the visual experience frightening and the sex or age of the patient, a history of cataract operation in the fellow eye, the type of visual sensation experienced, or the presence of coexisting ocular pathology.

CONCLUSION

All patients undergoing phacoemulsification under topical anesthesia experience a variety of visual sensations that may be frightening in a small proportion of patients.

Induction of NG108-15 cells differentiation by human bone marrow stromal cells

The survival and differentiation of neuronal cells is dependent on factors such as neurotrophins, cytokines and components of extracellular matrix. Bone marrow stromal cells have been shown to support the growth and differentiation of neuroblastoma cells. In an attempt to study the effects of bone marrow stromal cells on neuronal differentiation, we have co-cultured neuroblastoma x glioma hybrid NG108-15 cells with human bone marrow stromal cells. After co-culturing, clones exhibiting morphological differentiated phenotype and high level of neurofilament expression were isolated. Interestingly, these clones maintain their ability to proliferate in contrast to differentiated NG108-15 cells induced by dibutyryladenosine 3',5'-cyclic monophosphate. These results suggested that bone marrow stromal cells can induce partial differentiation of NG108-15 cells.

The effects of removal and reconstruction of the anterior cruciate ligament on patellofemoral kinematics

Patellofemoral pain may be associated with anterior cruciate ligament deficiency or may occur after anterior cruciate ligament reconstruction. We investigated the effects of the removal and reconstruction of the anterior cruciate ligament on the kinematics of the tibiofemoral and patellofemoral joints during physiologic levels of quadriceps muscle loads in seven cadaveric knees. A bone-patellar tendon-bone graft was used for intraarticular reconstruction of the anterior cruciate ligament. The spatial positions of the tibiofemoral and patellofemoral joints were measured between 0 degrees and 90 degrees of knee flexion in 15 degrees increments with a six degree-of-freedom digitizing system. Excision of the anterior cruciate ligament resulted in statistically significant increases in anterior tibial translation between 0 degrees and 90 degrees and valgus tibial rotation between 30 degrees and 90 degrees; intraarticular reconstruction returned these to levels not significantly different from those of the intact knee. Excision of the anterior cruciate ligament resulted in significant increases in lateral patellar tilt, ranging from 6.3 degrees to 9.0 degrees between full extension and 90 degrees of knee flexion, and in lateral patellar shift, ranging from 2.9 mm at 15 degrees of knee flexion to 5.9 mm at 90 degrees; intraarticular reconstruction returned these to levels not significantly different from those of the intact knee. Neither removal nor reconstruction of the anterior cruciate ligament significantly affected tibial internal-external rotation, patellar flexion, patellar mediolateral rotation, patellar anteroposterior translation, or patellar proximodistal translation.

Structural modeling of differential diagnosis, treatment, and results for allergic rhinitis

This paper analyzed the relationship among the differential diagnosis, treatment, and results for allergic rhinitis using the covariance structural model. The data were collected from 274 patients with suspected allergic rhinitis who visited the Otorlaryngology Department of the Paik Hospital during 1991-1993. After each patient's characteristics was categorized and combined into several common factors, covariance structure analysis was performed to analyze the structural relationships among the differential diagnosis, treatment, and results of treatment using the significant factors obtained from discriminant analysis. The significant characteristics influenced the diagnosis were the results of skin test from mite/animal, and from mugworts, the results from laboratory tests, rhinorrhea and sneezing, and nasal polyps. The significant characteristics that influenced the method of treatment were: nasal polyps, headache/general symptom, family history/medication, and septal deviation. Headache/general symptom was the only significantly influencing factor for the treatment results.

Reactions of serum creatine kinase in early phase of spherical steel bullet injury

On the basis of experimental study on 17 dogs, this paper reports on the variation of serum creatine kinase (SCK) with time in the early phase of wounding by spherical steel bullets at three different velocities and its relation with the kinetic energy absorbed by the tissue and with the amount of the excised necrotic tissue surrounding the wound tracks. The results showed that the energy absorbed by the tissue and the amount of the excised necrotic tissue surrounding the wound tracks increased with increasing velocity. Within a period of 6 hours after wounding the SCK activity increased correspondingly.

Differential labeling of the subunits of respiratory complex III with [3H]succinic anhydride, [14C]succinic anhydride, and p-diazobenzene-[35S]sulfonate

Exposure of antimycin-treated Complex III (ubiquinol-cytochrome c reductase) purified from bovine heart mitochondria to [3H]succinic anhydride plus [35S]p-diazobenzenesulfonate (DABS) resulted in somewhat uniform relative labeling of the eight measured subunits of the complex by [3H]succinic anhydride. In contrast, relative labeling by [35S]DABS was similar to [3H]succinic anhydride for the subunits of high molecular mass, i.e., core proteins, cytochromes, and the iron-sulfur protein, but greatly reduced for the polypeptides of molecular mass below 15 kDa. With Complex II depleted in the iron-sulfur protein the relative labeling of core protein I by exposure of the complex to [3H]succinic anhydride was significantly enhanced, whereas labeling of the polypeptides represented by SDS-PAGE bands 7 and 8 was significantly inhibited. Dual labeling of the subunits of Complex III by 14C- and 3H-labeled succinic anhydride before and after dissociation of the complex by sodium dodecyl sulfate, respectively, was measured with the complex in its oxidized, reduced, and antimycin-inhibited states. Subunits observed to be most accessible or reactive to succinic anhydride were core protein II, the iron-sulfur protein, and polypeptides of SDS-PAGE bands 7,8, and 9. Two additional polypeptides of molecular masses 23 and 12kDa, not normally resolved by gel-electrophoresis, were detected. Reduction of the complex resulted in a significant change of 14C/3H labeling ratio of core protein only, whereas treatment of the complex with antimycin resulted in decreases in 14C/3H labeling ratios of core proteins I and II, cytochrome c1, and a polypeptide of molecular mass 13kDa identified as an antimycin-binding protein.

Detection of antimycin-binding subunits of complex III by photoaffinity-labeling with an azido derivative of antimycin

Deformamidoazidoantimycin A (DAA), a photoactive derivative of antimycin A containing an azido group substituting for the formamido group attached to the phenyl ring, was synthesized. The ultraviolet spectrum of DAA was almost identical to that of antimycin A, indicating little alteration of the electronic structure of the substituted phenyl ring by the azido substitution. However, the inhibitory effectiveness of DAA toward ubiquinol-cytochrome c reductase (Complex III) purified from bovine heart (Ki = ca. 0.5 microM) was considerably less than that of antimycin (Ki less than or equal to 3 pM), indicating a direct rather than a supporting role of the formamido group in the inhibitory activity of antimycin. Exposure of purified Complex III to [3H]DAA plus ultraviolet light caused a major labeling by tritium of SDS-PAGE band 7 (m = 13 kDa by SDS-PAGE) and lesser but significant labeling of bands 3, 6, 8, and 9. Pretreatment of Complex III with antimycin greatly suppressed the labeling of bands 5, 6, and 7 but caused an apparent increased labeling of bands 8 and 9 by [3H]DAA, respectively. The labeling of band 7 by [3H]DAA also was strongly suppressed by reduction of Complex III by either sodium borohydride or ascorbate. Based on magnitude of labeling by [3H]DAA and the degree of suppression of labeling by antimycin, the protein of band 7 qualified as the principal component for specific binding of antimycin with the protein of band 6 (m = 16 kDa) showing a lesser but significant amount of specific binding.

Deltamethrin as a potential ovicidal pyrethroid against Plutella xylostella L

The effect of deltamethrin on the hatching of eggs of two strains, susceptible (S) and resistant (R), of Plutella xylostella was investigated. Daily observations were made on the development of the embryos, hatching and larval mortality after treatment with different dosages of deltamethrin. This compound exhibited a dosage-mortality response against the S-strain eggs. The hatching of the R-strain eggs was also affected by deltamethrin but to a lesser extent. At least 50% of the S-strain larvae that hatched from the treated eggs died within a few hours, but the larvae of the R strain were more resistant. Seedlings treated with different dosages also showed a drop in egg hatching and less damage on the leaves. Deltamethrin had no effect on embryonic development.

Toxicity of deltamethrin and cypermethrin to the larvae of the diamond-back moth, Plutella xylostella L

Two photostable pyrethroids, deltamethrin and cypermethrin, were tested against fourth instar larvae of a susceptible (S) strain and a resistant (R) strain of Plutella xylostella L. by topical application. Both compounds were very effective against the S strain larvae (LD50 for deltamethrin = 0.0014 micrograms/larva, LD50 for cypermethrin = 0.0046 micrograms/larva, at 48 h). However, the R strain collected from the field was greater than 1600-fold resistant to deltamethrin and greater than 30 000-fold resistant to cypermethrin. Deltamethrin was poorly synergised with piperonyl butoxide in the S strain, but much stronger synergism was obtained in the R strain. The possible reasons for such high levels of resistance and the potential use of synergised pyrethroids in Plutella control programmes are discussed.

The effects of phorate and some of its metabolites incorporated in an artificial diet on liquid uptake by Aphis fabae scop

[14C]Phorate and some of its metabolites were incorporated in an artificial diet and their effects on liquid uptake by Aphis fabae were studied. At sublethal and very low toxicity levels of phorate there was a tendency for a reduction in feeding with increasing concentrations. [14C]Phorate sulphone, [14C]phorate sulphoxide and [14C]phoratoxon sulphoxide at high concentrations gave very low mortality figures, but a significant drop in liquid uptake occurred with increasing concentrations. The results demonstrate that the presence of the insecticide rendered the diet less acceptable to the aphids which exhibited a wandering behaviour that might promote transmission of virus diseases.

Complete separation by high performance liquid chromatography of metabolites of arachidonic acid from incubation with human and rabbit platelets

Separation of all major cyclooxygenase and lipoxygenase metabolites of arachidonic acid were obtained by high performance liquid chromatography (HPLC). A C18 reverse-phase column was used in ion suppression mode to separate underivatized metabolites of arachidonic acid isolated from human and rabbit platelets. The metabolites were monitored by measuring radioactivity or ultraviolet light absorption at 192 nm (absorption by double bonds). Comparisons of TLC and HPLC separations demonstrated that the HPLC separation of metabolites of [1-14C]arachidonic acid was quantitative. HPLC also resolved several metabolites that were not detected by scanning of TLC separations.