The association of angiotensin-converting enzyme inhibitors and angiotensin 2 receptor blockers with renal protection in patients with SARS-CoV-2

Background

Kidney dysfunction is a prevalent disease that leads to many complications over time, such as hypertension, heart disease, and death. ACEI/ARBs are known to be renoprotective. However, few studies describe the association between ACEI/ARB use and kidney dysfunction in patients with SARS-CoV-2 infection.

Purpose

To explore the association between patients with SARS-CoV-2 and kidney dysfunction in patients taking an ACEI/ARB. We hypothesize a negative association between patients with SARS-CoV-2 taking an ACEI/ARB and kidney dysfunction.

Methods

A retrospective query between March 2020 and April 2021 was performed in patients 18 years and older who tested positive for SARS-CoV-2 using a polymerase chain reaction test. Patients were divided into two groups: kidney dysfunction and no kidney dysfunction. Kidney dysfunction was defined as any diagnosis of chronic kidney disease or acute kidney injury. Primary outcomes were all-cause mortality and hospitalization rate. Secondary outcomes included myocardial infarction (MI), hypotension, intubation, vasopressor use, ventricular tachycardia, and ventricular fibrillation. We used multivariate logistic regression to adjust for baseline characteristics.

Results

We identified 996 patients with kidney dysfunction and 22,106 without kidney dysfunction who tested positive for SARS-CoV-2. The incidence was 258 (25.9%) for ACEI/ARB use in patients with kidney dysfunction. Adjusted odds ratio (OR) for patients with kidney dysfunction was 5.705 (95% Confidence Interval [CI]: 4.554–7.146; p<0.001) for hospitalization, 0.895 (95% CI: 0.707–1.135; p<0.361) for patients taking ACEI/ARB, and 0.529 (95% CI: 0.333–0.838; <0.007) for mortality in patients with kidney dysfunction who took ACEI/ARB. All secondary outcomes had significantly greater adjusted OR (p<0.001), except for MI (p<0.339), ventricular tachycardia (p<0.697), and ventricular fibrillation (p<0.060).

Conclusion

To date, the benefits of ACEI/ARB in SARS-CoV-2 patients have been controversial. While ACEI/ARB is known to have renoprotective properties, we did not find a significant association between ACEI/ARB and kidney dysfunction in patients with SARS-CoV-2. However, we found the use of ACEI/ARB in patients with kidney dysfunction to be associated with lower mortality. Therefore, clinicians should continue using this medication for its mortality benefits in patients with kidney dysfunction and its cardioprotective effects.

Funding Acknowledgement

Type of funding sources: None.

Association between cardiovascular comorbidities and hospital admission in SARS-CoV-2 patients

Background

SARS-CoV-2 infection affects the cardiovascular system and can result in vascular dysregulation and dysfunction. However, the hospitalization rates due to pre-existing cardiovascular disease and concomitant SARS-CoV-2 infection are not fully known.

Purpose

To further elucidate the association between hospitalization and SARS-CoV-2 patients with pre-existing cardiovascular disease. We hypothesize that pre-existing cardiovascular disease is positively associated with hospitalization in patients who test positive for SARS-CoV-2.

Methods

This is a retrospective study of patients 18 years and older who tested positive for SARS-CoV-2 between March 2020 and April 2021. Patients with cardiovascular co-morbidities, specifically hypertension, coronary artery disease (CAD), heart failure, were analyzed. The primary outcome was hospitalization. Secondary outcomes were all-cause mortality, myocardial infarction (MI), vasopressor use, hypotension, intubation, and acute kidney injury. Multivariate logistic regression analysis adjusted for demographics and comorbidities.

Results

We identified 23,076 patients who tested positive for SARS-CoV-2; the hospitalization rate was 11.8% (2,721 patients). The incidence was 722 (26.5%) for CAD, 2068 (76%) for hypertension, 534 (91.3%) for heart failure, 188 (6.9%) for ESRD, 1484 (58.6%) for diabetes in patients who were hospitalized. The adjusted odds ratio (OR) of hospitalization was of 1.54 (95% Confidence Interval [CI]: 1.112–2.125; p<0.009) in patients with CAD, 5.730 (95% CI: 4.685–7.009; p<0.001) in patients with hypertension, 3.639 (95% CI: 2.308–5.737; p<0.001) in patients with heart failure. Use of angiotensin-converting enzyme inhibitor (ACEI) (p<0.001) was associated with reduced hospitalization, while the use of hydralazine (p<0.001), beta-blockers (p<0.001), and calcium channel blockers (p<0.001) were associated with increased hospitalization.

Conclusion

SARS-CoV-2 positive patients with CAD, hypertension or heart failure were associated with increased hospitalization. Admitted patients were more likely to be taking calcium channel blockers, beta-blockers, and hydralazine. In contrast, these patients were also less likely to be taking ACEI.

Funding Acknowledgement

Type of funding sources: None.

Social capital in the prevention and management of non-communicable diseases among migrants and refugees: a systematic review and meta-ethnography

Globally, the burden of non-communicable diseases (NCDs) falls disproportionately on underserved populations. Migrants and refugees are particularly vulnerable due to economic instability and systemic poverty. Despite the myriad of health risks faced by migrants and refugees, access to appropriate healthcare is hindered by structural, cultural and socioeconomic barriers. We conducted a systematic review and meta-ethnography to obtain critical insight into how the interplay of social capital and structural factors (eg, state policies and socioeconomic disadvantage) influences the prevention and treatment of NCDs in migrant and refugee populations. We included 26 studies of 14 794 identified articles, which reported qualitative findings on the structure and functions of social capital in NCD prevention and management among migrants and refugees. We synthesised findings, using the process outlined by Noblit and Hare, which indicated that migrants and refugees experienced weakened social networks in postmigration settings. They faced multiple barriers in healthcare access and difficulty navigating healthcare systems perceived as complex. Family as the core of social capital appeared of mixed value in their NCD prevention and management, interacting with cultural dissonance and economic stress. Community organisations were integral in brokering healthcare access, especially for information diffusion and logistics. Healthcare providers, especially general practitioners, were important bridges providing service-user education and ensuring a full continuum of quality care. While social capital reduced immediate barriers in healthcare access for NCD prevention and management, it was insufficient to address structural barriers. System-level interventions appear necessary to achieve equitable healthcare access in host countries. PROSPERO registration number: CCRD42020167846.

Estimating direct and spill-over impacts of political elections on COVID-19 transmission using synthetic control methods

Mass gathering events have been identified as high-risk environments for community transmission of coronavirus disease 2019 (COVID-19). Empirical estimates of their direct and spill-over effects however remain challenging to identify. In this study, we propose the use of a novel synthetic control framework to obtain causal estimates for direct and spill-over impacts of these events. The Sabah state elections in Malaysia were used as an example for our proposed methodology and we investigate the event's spatial and temporal impacts on COVID-19 transmission. Results indicate an estimated (i) 70.0% of COVID-19 case counts within Sabah post-state election were attributable to the election's direct effect; (ii) 64.4% of COVID-19 cases in the rest of Malaysia post-state election were attributable to the election's spill-over effects. Sensitivity analysis was further conducted by examining epidemiological pre-trends, surveillance efforts, varying synthetic control matching characteristics and spill-over specifications. We demonstrate that our estimates are not due to pre-existing epidemiological trends, surveillance efforts, and/or preventive policies. These estimates highlight the potential of mass gatherings in one region to spill-over into an outbreak of national scale. Relaxations of mass gathering restrictions must therefore be carefully considered, even in the context of low community transmission and enforcement of safe distancing guidelines.

Effect of diarrhoea on Tacrolimus trough level in a post liver transplant patient

Tacrolimus, which bonds to an immunophilin, FK506 binding protein (FKBP) has emerged as one of the most widely used immunosuppressant post solid organ transplantation. It offers excellent patient survival rates post-transplantation and a lesser number of acute rejections as compared to cyclosporine. Tacrolimus has a narrow therapeutic window with overexposure leading to acute and chronic forms of nephrotoxicity. Remarkably few data have been published on the overexposure to tacrolimus following mild diarrhoea in post-transplant patients who received treatment with tacrolimus. We observed a post-liver transplant patient with increased trough level of tacrolimus during severe diarrhoea with no complications following a timely adjustment on the dose of tacrolimus.

Cross-cultural adaptation and psychometric evaluation of the Malay version of the Neck Disability Index

Purpose: Translating the Neck Disability Index (NDI) into the Malay language (NDI-M); evaluation of psychometric properties in patients with neck pain.Methods: The NDI-M was translated according to established guidelines. In the first visit, 120 participants completed the NDI-M, visual analogue scale (VAS) for pain and demographic details. 98 participants returned to complete similar questionnaires and the Global Rating of Change (GRoC) scale. The NDI-M was evaluated for internal consistency, test-retest reliability, content validity, construct validity and responsiveness.Results: The NDI-M demonstrated excellent internal consistency (Cronbach's α = 0.84) and good test-retest reliability (ICC_2,1 = 0.79). Content validity was confirmed with no floor or ceiling effects. Construct validity was established revealing three-factor subscales explaining 68% of the total variance. The NDI-M showed a moderate correlation with VAS (R_p = 0.49, p < 0.001). Regarding responsiveness, a moderate correlation between NDI-M change scores and VAS change scores was found (R_p = 0.40, p < 0.001). However, there was no significant correlation between NDI-M with GRoC (R_s = 0.11, p = 0.27).Conclusions: The NDI-M is a reliable and valid tool to measure functional outcomes in patients with neck pain. It is responsive in detecting changes in pain intensity during a patient's rehabilitation journey.Implications for rehabilitationThe NDI was translated into the Malay language and culturally adapted for Malay-speaking patients with neck pain.The NDI-M demonstrated an excellent level of internal consistency and good test-retest reliability. It demonstrated content and construct validity, with three-factor subscales, and moderate responsiveness for pain intensity.The NDI-M is a reliable, valid and responsive instrument to measure functional limitations in patients with neck pain for rehabilitation.

Healthcare is not universal if undocumented migrants are excluded

Helena Legido-Quigley and colleagues examine the barriers that migrants face in accessing healthcare and argue they are counterproductive for host countries

Health System Responses to the Health Needs of Refugees and Asylum-seekers in Malaysia: A Qualitative Study

Background: This study was conducted to examine the responses and challenges in addressing the health needs of refugees and asylum-seekers in Malaysia from a health systems and policy perspective. Methods: Twenty semi-structured in-depth interviews were conducted with key informants comprising experts, healthcare professionals and program personnel with professional experience in refugee health issues. Deductive and inductive analyses were conducted to identify themes. Results: Our study identified a broad range of actors involved in the response to refugee health locally, of which a greater alignment of interests, collaboration and sharing of responsibility is needed. From a health systems and policy perspective, financial constraints are among the key challenges in addressing the health needs of the refugee and asylum-seeker population in Malaysia. While participants reported high quality healthcare being present in Malaysia, this was not affordable to refugees and asylum seekers. Cultural and language discordance are also key challenges faced by healthcare workers in the delivery of services; accentuating the need for greater cultural competence and language support. Improved access to medication is needed for those with chronic illnesses in order to effectively address the comprehensive health needs of the refugee and asylum-seeker population. Conclusions: Suggested ways forward include adopting a comprehensive health advocacy strategy grounded in the right to healthcare for all; adopting a multi-sectoral approach; tackling the social determinants of health; seeking diversified funding at the global and national level; and improving coordination and collaboration between the various actors.

The social determinants of chronic disease management: perspectives of elderly patients with hypertension from low socio-economic background in Singapore

Background

In Singapore, the burden of hypertension disproportionately falls on the elderly population of low socio-economic status. Despite availability of effective treatment, studies have shown high prevalence of sub-optimal blood pressure control in this group. Poor hypertension management can be attributed to a number of personal factors including awareness, management skills and overall adherence to treatment. However, these factors are also closely linked to a broader range of community and policy factors. This paper explores the perceived social and physical environments of low socio-economic status and elderly patients with hypertension; and how the interplay of factors within these environments influences their ability to mobilise resources for hypertension management.

Methods

In-depth interviews were conducted in English, Chinese, Chinese dialects and Malay with 20 hypertensive patients of various ethnic backgrounds. Purposive sampling was adopted for recruitment of participants from a previous community health screening campaign. Interviews were translated into English and transcribed verbatim. We deductively analysed leveraging on the Social Model of Health to identify key themes, while inductive analysis was used simultaneously to allow sub-themes to emerge.

Results and discussion

Our finding shows that financing is an overarching topic embedded in most themes. Despite the availability of multiple safety nets, some patients were left out and lacked capital to navigate systems effectively, which resulted in delayed treatment or debt. The built environment played a significant role in enabling patients to access care easily and lead a more active lifestyle. A closer look is needed to enhance the capacity of patients with mobility challenges to enjoy equitable access. Furthermore, the establishment of community based elderly centres has enabled patients to engage in meaningful and healthy social activities. In contrast, participants’ descriptions showed that their communication with healthcare professionals remained brief, and that personalised and meaningful interactions that are context and culturally specific are essential to advocate for patients’ overall treatment adherence and lifestyle modification.

Conclusion

Elderly patients with hypertension from lower socio-economic background have various unmet needs in managing their hypertension and other comorbidities. These needs are closely related to broader societal factors such as socio-demographic characteristics, support systems, urban planning and public policies, and health systems factors. Policy decisions to address these needs require an integrated multi-sectoral approach grounded in the principles of health equity.

The health needs and access barriers among refugees and asylum-seekers in Malaysia: a qualitative study

BACKGROUND

In Malaysia, refugees and asylum-seekers are a vulnerable group that often face circumstances in which their health and wellbeing can be compromised. This qualitative study sought to examine the key health concerns and barriers to healthcare access among refugees and asylum-seekers in Malaysia through the lens of healthcare professionals, program staff and experts on refugee and migrant health.

METHODS

We conducted 20 semi-structured in-depth interviews with experts, healthcare professionals, program managers or executives from UN agencies, public healthcare facilities, civil society organizations, and academic institutions in Malaysia. Interviews were transcribed and analyzed both deductively and inductively using thematic analysis.

RESULTS

Participant narratives highlight that the health needs of refugees and asylum-seekers in Malaysia are complex. As reported, access to healthcare is underpinned by numerous social, cultural and economic determinants compounded by a legal environment that lacks inclusivity of refugees and asylum-seekers. Apart from the health risks associated with the migration process, limited access to comprehensive healthcare post-arrival remain a problem for refugees and asylum-seekers in Malaysia. Key barriers to healthcare access are linked to poor health literacy and the lack of awareness on one's right to healthcare; language and cultural differences; protection issues resulting from a lack of legal status; and an inability to afford healthcare due to inadequate livelihoods. Overall, poor access to healthcare is perceived to have detrimental consequences on the health status of refugees, asylum-seekers and its host population, and may incur greater costs to the health system in the long run.

CONCLUSION

Comprehensive efforts in practice and research that tackle the social, cultural and economic determinants of health, and more inclusive health policies are crucial in strengthening healthcare access among refugees and asylum-seekers in Malaysia. Practical recommendations include improving the health literacy of refugees and asylum-seekers for better navigation of the health system; bridging language and cultural gaps through translation support and inter-cultural orientation; implementing policies grounded in the right to healthcare for all regardless of legal status and in the interest of public health; and establishing a larger evidence base to drive policy development and implementation for refugee health within the Malaysian context.

Prevalence and predictors of suicidality among medical students in a public university

BACKGROUND

Undergraduate medical students have been the most distressed group among the student population. Depression and anxiety have been found to be more prevalent in this group of students compared to others.

OBJECTIVE

This study was conducted to determine the prevalence and predictors of suicidality among undergraduate medical students in a public university.

METHODS

This was an analytical cross-sectional study, conducted in a public university in Selangor, Malaysia. Data were collected using self-administered questionnaires from January to February 2013, and analysed using the Statistical Package for Social Sciences Software (version 21).

RESULTS

Out of 625 undergraduate medical students, 537 (85.9%) participated in the study. The prevalence of the suicidality among undergraduate medical students was 7.0%. The significant predictors of suicidality based on multiple logistic regression were the respondent's lifetime suicide attempts (Adjusted Odds Ratio, AOR 10.4, 95% CI 2.7 to 40.9); depression (AOR 5.9, 95% CI 1.5 to 23.0); breaking off a steady love relationship (AOR 5.4, 95% CI 1.3 to 22.4); hopelessness (AOR 4.9, 95% CI 1.1 to 21.6); and something valued being lost or stolen (AOR 4.4, 95% CI 1.2 to 15.9).

CONCLUSION

These findings indicate that mental health care services should be strengthened at university level. The results show a need for an intervention programme to reduce suicidality among the undergraduate medical students.

Treatment of infantile haemangioma with captopril

BACKGROUND

Infantile haemangioma (IH) has recently been reported as an aberrant proliferation and differentiation of a primitive mesoderm-derived haemogenic endothelium regulated by the renin-angiotensin system (RAS), leading us to propose angiotensin converting enzyme (ACE) as a potential therapeutic target.

OBJECTIVES

To present initial results of our open-labelled observational clinical trial using captopril, an ACE inhibitor (ACEi), in the treatment of problematic proliferating IH.

METHODS

After initial screening investigations, infants with problematic IH were admitted for initiation of captopril with a 0·1 mg kg(-1) test dose orally, followed by 0·15 8-hourly over 24 h. This was then followed by dose escalation to 0·3 mg kg(-1) 8-hourly for another 24 hours. The dosage was increased to 0·5 mg kg(-1) 8-hourly 1 week later, if a noticeable involution had not already occurred. The response of IH to captopril was documented clinically and photographically before and after treatment and any side-effect was recorded.

RESULTS

Two boys and six girls aged 5-22 weeks (mean 12·9) with problematic IH were recruited with the lesions located in nasal tip (n = 1), cervicofacial (n = 3), periorbital (n = 1) and perineal (n = 2) areas, and shoulder (n = 1). Transient mild renal impairment occurred in one subject but resolved spontaneously. No other complication was observed. The IHs in all patients responded to captopril at a dosage of 1·5 mg kg(-1) daily which led to a dramatic response in three, moderate response in two, and slow response in three patients. Continued involution of IHs was observed during the follow-up period of 8-19 months (mean 15·8) in all subjects. Treatment was ceased at 14 months of age in seven patients with no rebound growth. In the remaining patient, rapid healing occurred with ongoing gradual reduction in the size and colour of a large ulcerated retroauricular lesion following 5·5 months of treatment. The lesion was excised to address its persistent distortion of the ear.

CONCLUSIONS

The response of IH to an ACEi supports a critical role for the RAS in IH and represents a paradigm shift in the understanding and treatment of this enigmatic condition.

Pretibial injury: key factors and their use in developing laboratory test methods

Aims were to 1 characterize pretibial injuries and evaluate protection offered by garments/fabrics; and 2 develop a laboratory test to determine the potential protection provided by such fabrics. Most (>85%) of 75 patients treated for pretibial injury at Hutt Hospital, New Zealand sustained injury to one site and required surgery. Injuries were typically grade 3 or 4, 10-250 mm wide 30-350 mm long, and at the mid- to lower third of the tibia. The severity grade was lower when at least one fabric layer covered the site, slightly lower again with more than one layer, and when a knitted fabric/garment was worn, and a trouser type garment. Laboratory test methods and their application reflected these known variables. The force transmitted through multiple fabric layers was less then through one layer: thick pantyhouse and either denim or fabrics used in 'sweat pants' would minimize transmitted force and maximize impulse.

Cerebral oximetry in cardiac surgery

There is a need for monitoring of cerebral perfusion during cardiac surgery to reduce neurological complications. Cerebral perfusion is a major factor for regional and global imbalance in oxygen supply-demand, which may result in brain injury following cardiac surgery. Cerebral oximetry (near infrared spectroscopy) is a means to monitor regional cerebral perfusion. It was developed as a non-invasive technology, similar to pulse oximetry, for the continuous assessment of cerebral blood flow. Published studies have demonstrated that the use of cerebral oximetry reduces both postoperative cognitive impairment and the length of hospital stay.

Malignant peripheral nerve sheath tumour of the cervical vagus nerve in a neurofibromatosis type 1 patient

One serious complication of neurofibromatosis type 1 (NF1) is the development of malignant peripheral nerve sheath tumours (MPNSTs). These malignancies often develop within pre-existing plexiform neurofibromas and their development is now thought to be associated with both tumour suppressor gene mutations and dysregulated growth factor signalling. Recent work demonstrates that the lifetime risk of malignant transformation is significantly greater than previously thought. Ionising radiation, a long-standing disease, particularly the presence of a large number of plexiform neurofibromas from an early age, are suggested risk factors. We present an NF1 patient who developed an MPNST of the cervical vagus nerve which was successfully treated with surgery. Close monitoring of patients with NF and a high level of suspicion towards rapidly enlarging and painful swellings is merited as these features may signify malignant transformation. Whether a positive history of MPNST in other affected family members predisposes the individual to a higher risk of malignant transformation is unclear.

The clinical implication of the vocal cords–carina distance in anaesthetized Chinese adults during orotracheal intubation

BACKGROUND

Previous studies have identified no strong correlation between patients' height and tracheal length in anaesthetized patients. We have attempted to compare vocal cords-carina distance (VCD) in Chinese patients with the dimensions of five commonly used tracheal tubes. In addition, we attempted to find a surface anatomy measurement that would identify patients with 'short tracheas'.

METHODS

We measured VCD in 130 anaesthetized Chinese patients with a fibreoptic bronchoscope. Also measurements were obtained of the distal ends of five commonly used tracheal tubes. We undertook various surface anatomy measurements on the patients' chest and neck region to predict those patients with short tracheas.

RESULTS

VCD averaged 12.6 (SD 1.4) cm. In seven patients (5%) this distance was particularly short (between 8.8 and 10.4 cm). Many of the commonly used tracheal tubes would be placed close to or beyond the carina when the black intubation guide mark(s) is (are) at the level of the vocal cords. The VCD of <or=11 cm (short trachea) could be predicted by patient height of <or=167.5 cm and a thyrosternal distance of <or=28.5 cm with limited reliability.

CONCLUSIONS

A significant number of patients with short VCD in our study group could be at risk of endobronchial intubation with many of the tracheal tubes. Patient height and thyrosternal distance can be useful in predicting short tracheas.

Parotid metastasis--an independent prognostic factor for head and neck cutaneous squamous cell carcinoma

BACKGROUND

Metastatic parotid cutaneous squamous cell carcinoma (SCC) is the most common parotid gland malignancy in New Zealand and Australia. The current AJCC TNM staging system does not account for the extent of nodal metastasis. A staging system that separates parotid (P stage) from neck disease (N stage) has been proposed recently.

AIM

To review the outcome of patients with metastatic head and neck cutaneous SCC treated at our multidisciplinary Head and Neck Service using the proposed staging system.

METHOD

Consecutive patients were culled from our Head and Neck/Skull Base Database, 1990-2004. These patients were restaged according to the proposed staging system: P stage: P0 = no disease in the parotid (i.e., neck disease only); P1 = metastatic node < or = 3 cm; P2=metastatic node > 3 cm and < or =6 cm, or multiple nodes; and P3 = metastatic node > 6 cm, or disease involving the facial nerve or skull base. N stage: N0=no disease in the neck (i.e., parotid disease only); N1 = single ipsilateral metastatic node < or = 3 cm; and N2 = multiple metastatic nodes, or any node > 3 cm, or contralateral neck involvement. Loco-regional recurrence and disease-specific survival were calculated using the Kaplan-Meier method and comparison of graphs made with the log-rank test. Multivariate analysis using the Cox regression model was carried out to assess the impact of various parameters.

RESULTS

Sixty-seven patients with metastatic head and neck cutaneous SCC were identified. Thirty-seven patients had parotid metastasis (of whom 13 also had neck disease) while 21 had neck metastasis alone. Nine patients had dermal or soft tissue metastasis. These nine patients were excluded from this series, and data analysis was carried out on the remaining 58 (46 men, 12 women, mean age 71 years) patients. Sixty-seven percent of the patients underwent post-operative adjuvant radiotherapy. The five-year disease-specific survival rate was 54%. Among 56 patients followed up to disease recurrence or for a minimum period of 18 months, the loco-regional recurrence rate was 52%. The presence of parotid disease was an independent prognostic factor on survival (p < 0.01), and P3 fared significantly worse than P1 and P2. Those patients who had both parotid and neck disease fared worse than those who had parotid or neck disease alone (p = 0.01). N2 had a significantly poorer outcome compared with N1 (p < 0.01). Immunosuppression (p = 0.01) and a positive surgical margin (p < 0.01) were significant adverse prognostic factors for survival. Adjuvant radiotherapy, extracapsular spread, and perineural and vascular invasion did not influence survival. Our study demonstrates that the extent of parotid disease is an independent prognostic factor for metastatic head and neck cutaneous SCC.

Evaluation of the new Viewmax laryngoscope in a simulated difficult airway

BACKGROUND

In this study, we evaluated the learning curve and performance of the Viewmax laryngoscope during simulated difficult laryngoscopy in an intubation manikin (Laerdal Airway Management Trainer).

METHODS

To determine the learning curve, 25 anaesthesiologists without previous experience with the Viewmax laryngoscope performed 10 successive intubations in an intubation manikin with a normal airway. Time to intubation and failed intubation attempts were recorded. Another manikin was modified to enable comparison of the Viewmax laryngoscope with Macintosh and McCoy laryngoscopes. The time to intubation, number of failed intubation attempts, modified Cormack and Lehane (MCL) laryngeal view grading, percentage of glottic opening (POGO score), use of gum elastic bougie and subjective rating of degree of difficulty were recorded.

RESULTS

The learning curve for the Viewmax laryngoscope showed a progressive decrease in time to successful intubation and reached a plateau at the sixth attempt. In simulated difficult laryngoscopy, the Viewmax laryngoscope demonstrated significantly better laryngeal view than the Macintosh and McCoy laryngoscopes in terms of MCL grading (Macintosh, P = 0.01; McCoy, P < 0.01) and POGO score (Macintosh, P < 0.01; McCoy, P < 0.01). The time required for intubation in simulated difficult laryngoscopy for the Viewmax laryngoscope was significantly longer than that for the Macintosh (P = 0.02) and McCoy (P < 0.01) laryngoscopes. There was no significant difference in the degree of difficulty, number of failed intubations and use of gum elastic bougie.

CONCLUSION

When compared with the Macintosh and McCoy laryngoscopes in a manikin, the Viewmax laryngoscope appears to improve the view of the larynx but requires a longer time for tracheal intubation.

Growth mechanism of tubular ZnO formed in aqueous solution

Tubular ZnO microstructural arrays were fabricated by a hydrothermal decomposition method. The dependence of the morphologies on the growth time and temperature was investigated in detail. An experiment was carried out to determine the mechanism of tubular ZnO formation. Our results showed that ZnO microtubes originated from an ageing process from ZnO microrods at a lower temperature (compared to the temperature when hydrothermal deposition of ZnO microrods was dominant) due to the preferential chemical dissolution of the metastable Zn-rich (0001) polar surfaces. A growth model was proposed based on the coexistence of hydrothermal deposition and dissolution of ZnO in the fabrication process.

An Octree Approach to Rough Machining

This paper presents an octree subdivision based algorithm of automatic cutter path generation for machining on a numerical control machining centre. Both the stock and the part are represented by solid models. The machining strategy is based on a layer by layer approach taking care of the cutter strength and the variation of the part geometry. This approach allows the problem to be reduced from a three-dimensional to a two-dimensional cutter path generation problem which is solved by a quadtree representation of the plane. The method can be easily extended to include the jigs and fixtures and any other obstacles which would be represented by solid models. Algorithms are described in Pascal-like structure.

Pulsed dye laser therapy for rosacea

Rosacea is a chronic and progressive inflammatory skin disorder affecting the facial convexities for which no curative measure is currently available. Forty consecutive patients with rosacea were treated with the Cynosure PhotoGenica V pulsed dye laser. The improvement following laser therapy was assessed according to a sliding scale: 1 (worse after treatment), 2 (no improvement), 3 (slight improvement), 4 (moderate improvement), 5 (marked improvement). Following an average of 2.4 (range 1-10) laser treatments, a mean score of 4.4 and 4.3 for overall improvement was achieved as judged by the patients and independently assessed by a family member or a close friend of the patients, respectively. The response of erythema and telangiectasia to laser therapy, evaluated by an independent panel of 10 members, showed a mean score of 3.7. Three patients experienced an exacerbation of rosacea during the treatment period requiring antibiotic therapy. During the follow-up period of 6.0-55.5 (mean, 23.3) months after completion of laser therapy, no patient (including 13 patients in whom papulation and pustulation which were amongst the presenting symptoms) required medical treatment. Six patients developed post-inflammatory hyper-pigmentation necessitating skin bleach but no other complication such as scarring was observed. Three patients reported that the residual erythema had progressed after an initial improvement during follow-up periods of 52.4, 15.8 and 6.0 months. All patients felt that laser therapy was worthwhile. We conclude that pulsed dye laser therapy is a useful treatment for rosacea.

Acute-on-chronic subdural haematoma: a rare complication after spinal anaesthesia

An 88-year-old woman with an undiagnosed chronic subdural haematoma underwent emergency repair of a femoral hernia under spinal anaesthesia. The patient complained of headache postoperatively, and a subsequent computed tomography brain scan showed an acute-on-chronic subdural haematoma, with midline shift and impending coning. The patient recovered completely after surgical decompression. The difficulty in diagnosing chronic subdural haematoma in the elderly patient with no history of trauma is discussed, along with the differential diagnosis of headache following spinal anaesthetic in this age-group.

Effects of five commonly used glucocorticoids on haemangioma in vitro

1. High-dose systemic or intralesional steroids are the first-line pharmacological treatments for haemangioma. However, the mechanism of action of steroids is unknown. Using the in vitro model developed by us, the present study examined some of the effects of five commonly used glucocorticoids on haemangioma biopsies taken from two patients. 2. At 12 micro mol/L, triamcinolone and dexamethasone consistently exhibited capillary growth inhibition, whereas methylprednisolone displayed an inhibitory effect during the first 7 days of culture. At this concentration, inhibition of capillary growth was observed in betamethasone-treated cultures derived from one patient but not in those derived from the other. However, hydrocortisone had a negligible effect on capillary growth. 3. Transcription of various factors considered important for haemangioma development were studied by reverse transcription-polymerase chain reaction. Neither vascular endothelial growth factor nor fibroblast growth factor-2 played a vital role in steroid-induced inhibition of capillary growth. All glucocorticoids induced a marked decrease of interleukin (IL)-6 transcripts. 4. Capillary growth inhibition in cultures treated with all glucocorticoids, except triamcinolone, was associated with an increased transcription of clusterin/apolipoprotein J (clust/apoJ), an apoptotic gene. There was increased transcription of mitochondrial cytochrome (cyt) b in the inhibited cultures resulting from triamcinolone, dexamethasone or methylprednisolone treatment that was associated with capillary growth inhibition, suggesting an important role of mitochondria in glucocorticoid-induced regression of haemangioma. 5. Our results indicate that glucocorticoids may modulate haemangiogenesis via an upregulation of cyt b, clust/apoJ and/or IL-6. The variable effects of different glucocorticoids on one or more of these factors may explain the interindividual variation in the in vivo response of haemangioma to the steroids.

Altered mitochondrial cytochrome b gene expression during the regression of hemangioma

Hemangioma is a primary tumor of microvasculature. Its development typically exhibits a proliferative phase followed by an involuting phase that continues into the involuted phase. Although apoptosis has been reported, the mechanisms regulating the spontaneous regression of hemangioma are largely unknown. The authors recently demonstrated up-regulation of the mitochondrial cytochrome b gene in hemangioma associated with steroid-induced regression. The present study investigated whether a similar change occurred during spontaneous regression. Biopsy material was obtained from 11 patients with hemangiomas at different phases of development. In one of these patients, a biopsy was taken from the proliferative, involuting, and involuted areas of the hemangioma. In another patient, a biopsy was taken before and 5 weeks after the intralesional administration of steroids. From each tissue specimen, RNA was isolated and subjected to reverse transcriptase-polymerase chain reaction analysis by use of specific primers for the human mitochondrial cytochrome b gene. Semiquantitative reverse transcriptase-polymerase chain reaction analysis revealed that the strongest expression of the mitochondrial cytochrome b transcripts was in specimens taken from hemangiomas in the involuting phase compared with those from the proliferative and involuted phases. The authors concluded that mitochondrial cytochrome b is associated with both the spontaneous and the steroid-induced regression of hemangioma, probably by regulating apoptosis.

Cellular and extracellular markers of hemangioma

Several cellular and extracellular markers that distinguish the phases of the hemangioma life cycle have been described previously. However, details of the phenotypic changes of; the various cellular elements during hemangioma development have not been fully reported, and the extracellular matrix composition, especially in the vicinity of the proliferating endothelial cells, is poorly described. This study examined the expression of cellular and extracellular molecules and cytokines in the proliferative, involuting, and involuted phases of hemangioma. Paraffin-embedded hemangioma specimens, four from each phase, were examined histochemically and immunohistochemically. Throughout the three phases, vascular endothelial cells stained positive for CD31 and von Willebrand factor, although in the involuted phase, not all vessels in the tissue expressed these endothelial markers. Proliferating cell nuclear antigen was expressed by the majority of endothelial cells and pericytes in the proliferative and early involuting phases, but its expression was negligible in the involuted phase. In addition to finding that the total number of mast cells was highest in the involuting phase, the authors observed that the proportion of chymase-positive mast cells decreased with the progression of hemangioma and that virtually all mast cells expressed the biogenic amine phenotype throughout the hemangioma life cycle. The localization of vascular endothelial growth factor predominantly to the pericytes and endothelial cells during the proliferative phase and of basic fibroblast growth factor to the endothelial cells in both the proliferative and early involuting phases is consistent with previous reports, although the latter growth factorwas also observed in mast cells. Type IV collagen and the beta chain of laminin and perlecan were detected in the basement membranes in all phases. Interestingly, collagen types I, III, and V were present in basal membranes throughout the phases and with increasing density in the stromal areas with involution, although type I collagen was less prominent during the proliferative phase. Short-chain collagen type VIII was localized extracellularly throughout the development of hemangioma but, during the early proliferative phase, it was also detected within mast cells. The expression of specific cytokines and cellular and extracellular markers may help distinguish the different clinical phases of the hemangioima life cycle. These results provide further insight into the biology of hemangioma.

Paralysis of the marginal mandibular branch of the facial nerve: treatment options

Isolated paralysis of the marginal mandibular branch of the facial nerve results in an asymmetrical smile with elevation of the lower lip on the affected side. We discuss the surgical options for its correction and present a series of 26 patients who underwent either botulinum toxin injection, anterior belly of digastric transfer or free extensor digitorum brevis transfer as treatment. Botulinum toxin injection provided satisfactory results although these were temporary. Anterior belly of digastric transfer was the surgical procedure of choice. It yielded superior cosmetic results, less donor-site morbidity and required a shorter operating time. In more complex congenital facial hypoplastic syndromes, or following extensive surgery in the digastric triangle, the anterior belly of the digastric muscle may be absent or damaged. Extensor digitorum brevis transfer is the preferred option in these cases.

Clusterin/apoJ expression during the development of hemangioma

Hemangioma is the most common tumor of infancy. This vascular tumor is characterized by an initial rapid proliferation followed by an inevitable regression. The life cycle of hemangioma is divided into proliferative, involuting, and involuted phases. The cellular and molecular mechanisms responsible for controlling the biological behavior of hemangioma are largely unknown. Differential display analysis using mRNA isolated from biopsy specimens representative of the 3 different phases showed increased expression of clusterin/apoJ (clust/apoJ) in the involuting samples. Clust/apoJ is a multifunctional glycoprotein that has been associated with apoptosis. Reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry showed that both the transcription and protein expression of clust/apoJ were increased in hemangioma as the tumor progressed from the proliferative to the involuting and involuted phases. This suggests that clust/apoJ is involved in regulating apoptosis during the spontaneous regression of hemangioma. It has been suggested that mast cells (MC) play a role in the regression of hemangioma. The increase in the number and proportion of clust/ apoJ-positive MC with progression of hemangioma, along with the localization of clust/apoJ to MC granules, supports this hypothesis. We suggest that MC may be synthesizing/releasing this apoptotic modulator, leading to the regression of the tumor. Better understanding of the pathogenesis of hemangioma by identification of the relevant factors involved in its regression such as clust/apoJ will result in the development of novel therapies for this condition and tumors that do not undergo spontaneous regression.

Steroid therapy of a proliferating hemangioma: histochemical and molecular changes

OBJECTIVES

Hemangioma is a primary tumor of the microvasculature in which angiogenesis is initially excessive, followed by regression of the newly formed vessels. Intervention is necessary in up to 20% of cases, high-dose systemic or intralesional steroids being the first-line treatment. As the mechanism of action of steroids is unknown, we undertook an investigation of the cellular and molecular effects of their action.

STUDY DESIGN

A unique opportunity to study the effect of steroid treatment was presented when biopsy material was obtained from an infant with an ulcerated proliferating hemangioma before and after intralesional triamcinolone injection, which resulted in an accelerated regression of the lesion. Histochemical quantitation of mast cells, molecular analysis by reverse transcriptase-polymerase chain reaction (RT-PCR) for 7 growth factor transcripts and differential display RT-PCR (DD RT-PCR) were conducted.

RESULTS

After steroid therapy, the mast cell number increased (untreated = 2.22 +/-.27 [standard error of the mean ¿SEM¿]; treated = 8.7 +/-.71 [SEM] mast cells per field, respectively; P <.0001; n = 40 fields for each group), and the transcriptional expression of cytokines: platelet-derived growth factor-A and -B; interleukin-6; transforming growth factor-beta1 and -beta3 decreased, while that of basic fibroblast growth factor (bFGF) and vascular endothelial cell growth factor remained unaltered. Elevated urinary bFGF levels noted in cases of proliferating hemangioma, persisted even after steroid treatment. Using DD RT-PCR an amplicon that shared 100% sequence homology with the human mitochondrial cytochrome b gene was detected in the hemangioma biopsy after steroid treatment.

CONCLUSIONS

The regression of this hemangioma subsequent to steroid therapy was accompanied by a significant increase in mast cell density, reduced transcription of several cytokines, and an enhanced expression of the mitochondrial cytochrome b gene.

A novel in vitro human model of hemangioma

Hemangioma, the most common tumor of infancy, is characterized by a proliferation of capillary endothelial cells with multilamination of the basement membrane and accumulation of cellular elements, including mast cells. The initial rapid growth is followed by an inevitable but slow involution. The currently available therapies are empirical and unsatisfactory because what is known of the cellular and molecular basis of hemangioma development is rudimentary. Advances in the understanding of its programmed biologic behavior has been hampered by the lack of a valid human model. We report here a novel in vitro culture system that is a useful human model of hemangioma. A small fragment of hemangioma biopsy is embedded in fibrin gel in a well of culture plates and incubated in a serum-free, buffered-salt, minimal medium. A complex network of microvessels grows out from the tissue fragments. Biopsies taken from all three phases of hemangioma development were cultured successfully; proliferative phase samples developed microvessels in 1 to 4 days, involuting phase in 5 to 7 days, and involuted phase in 7 to 12 days. The relative growth rates of the microvessels in the culture of biopsies taken from different stages of hemangioma development reflect the growth patterns seen clinically. This model has been validated using histochemistry, immunohistochemistry, and reverse transcriptase-polymerase chain reaction. Comparison of the number, localization, and phenotype of endothelial and mast cells and the distribution of basement membrane constituents (type IV collagen, perlecan, and laminins) and growth factors (basic fibroblast growth factor, vascular endothelial growth factor, transforming growth factor-betas) in the biopsy and the tissue after culture shows that many of the characteristics of the original tissues were retained in culture. This in vitro human model of hemangioma overcomes some of the deficiencies associated with earlier models. It offers an opportunity for studying the precise cellular, biochemical, and molecular basis of hemangioma It may also help to elucidate the mechanisms of action of existing therapies and may lead to the identification of novel treatments for hemangioma.

Pulsed dye laser therapy for viral warts

Twenty-eight patients with 103 recalcitrant and 20 simple viral warts were treated with the Cynosure PhotoGenica V pulsed dye laser at 585 nm, and fluencies of 6.0-9.0 J/cm(2). An eradication rate of 92% for recalcitrant warts after an average of 2.1 (range 1-7) treatments and 75% for simple warts after an average of 1.6 (range 1-2) treatments was achieved with a mean follow-up period of 7.2 (range 3-15) months. Mild hypopigmentation was noted in one patient and superficial infection in another. Unlike ablative treatment modalities, with pulsed dye laser therapy, no wound was created thus avoiding prolonged postoperative pain, disability and scarring. Treatment was well tolerated by patients, most of whom returned to work or normal activities immediately postoperatively. Pulsed dye laser is an effective treatment for both recalcitrant and simple warts. It is the treatment of choice for these lesions in cosmetically sensitive areas.

Anomalous extensor muscles of the hand: a review

Anomalous extensor muscles of the hand are not uncommon. Well-recognized anomalies anomalous extensor indicis proprius, extensor digitorum brevis manus, extensor medii proprius, and extensor indicis et medii communis are reviewed and discussed in detail. Anomalous extensor indicis proprius and extensor digitorum brevis manus may occasionally give rise to dorsal wrist pain and the diagnosis is often confused especially in the presence of other pathologic findings such as a ganglion. An analysis of the embryologic development of the extensor muscle mass with phylogenetic comparisons between species of the animal kingdom is presented to underscore the clinical relevance of these anomalous extensors.

Modified Antia-Buch repair for full-thickness upper pole auricular defects

Various reconstructive techniques have been described for repair of full-thickness upper pole auricular defects. The wedge excision commonly used for treatment of upper pole tumors allows excision and reconstruction in a single stage. However, this technique suffers from major deficiencies. We apply the concept of crescentic scaphal excision and the Antia-Buch advancement-rotation flap principle to repair various full-thickness upper pole auricular defects resulting from excision of skin lesions in eight consecutive patients. The technique achieves a natural auricular shape in three dimensions with minimal disruption of the anatomic landmarks and avoids conspicuous scars. It has several advantages over the original Antia-Buch repair and other techniques used for reconstruction of full-thickness upper pole auricular defects.

Hormone responses to stress in patients with major burns

The responses of the plasma stress hormones corticotrophin (ACTH), vasopressin (AVP), cortisol and corticotrophin releasing hormone (CRH) have been studied in seven consecutive patients aged between 15 and 65 years who suffered from burns of 15-95% total body surface area. There was a distinct peak in AVP (up to 100 pmol/l) and ACTH levels well above the upper limit of normal in all except one patient within 24 h of burn injury. Following the initial rise, AVP and ACTH tended to fall. Plasma CRH with one exception remained within the normal range. Concurrent measurement of plasma renin activity (PRA), haemoglobin (Hb), haematocrit (Hct) and plasma sodium (Na), to assess hydration, showed that PRA was increased in all except one patient during the first 4 days of hospital admission. The correlation between ACTH and cortisol was highly significant (P < 0.001), as was the correlation between ACTH and AVP, AVP and Na, PRA and Hb, and Hct and Na. Other significant correlations were ACTH and Hct (P = 0.023), ACTH and Na (P = 0.017), AVP and Hct (P = 0.029), CRH (P = 0.018), CRH and Hb (P = 0.001). No significant correlation could be demonstrated between CRH and ACTH or AVP. Our findings suggest that AVP plays a role in the hypercortisolaemia which accompanies major burns. The possible detrimental effect of very high levels of AVP leading to progression of burn depth and reduction of skin graft take by its potent vasoconstrictive action and water retention effect (resulting in oedema) deserves further study. As AVP has the potential to reduce tissue perfusion, the possible use of antagonists in major burns merits further consideration. Persistently raised PRA levels, despite normal biochemical and haematological parameters, may indicate that volume expansion therapy may not be adequate, and that both hypovolaemia and stress may contribute to the AVP response. Stress hormone monitoring may lead to better treatment and a reduction in burn stress.

Molding therapy for infants with deformational auricular anomalies

Congenital auricular anomalies can be categorized as either malformed or deformational. Auricular deformations most commonly affect the helix and antehelix. Surgical correction involves sutural modeling, wedge excision, reshaping and reversing cartilage segments, and morselization. Since neonatal auricular cartilage is extremely pliable, we used early splinting to correct deformational ear anomalies. Splints were constructed of leadfree, soft soldering wire threaded into polyethylene tubing and held in place with Steri-Strips. From August 1995 through February 1996 we treated 19 infants with 32 deformed auricles: 10 infants were male and 9 were female, ranging in age from 1 day to 10 weeks. Thirteen infants had both ears affected. There were 8 prominent ears, 23 lop ears, 2 Stahl's ears, and 1 infant with an inverted concha. For prominent ears, the helical-mastoid distance decreased from an average of 16.8 to 12.2 mm, after an average of 13 weeks of splinting. Fourteen corrected lop ears had a normal appearance, and 9 were improved with minor residual deformity. There was only one complication: skin irritation requiring adjustment of the prosthesis. Five children had molding started after 3 months of age and all had no significant improvement. In addition, the parents of 5 children refused therapy and 12 children had either poor compliance to therapy or were lost to follow-up. Our experience with auricular molding confirmed that it is easy, effective, and inexpensive. If molded sufficiently early, most auricular deformations should not need surgical correction in childhood.

Hypertelorism: nosologic analysis of 90 patients

The word hypertelorism is used to describe increased interorbital distance, a condition that is causally and pathogenically heterogeneous. Because not all wide-set eyes are the same, accurate terminology and nosology are critical to understanding and management. Orbital hypertelorism signifies an increased distance between both medial sides and lateral sides of the orbits. Interorbital hypertelorism denotes increased distance only between the inner orbital walls. In this retrospective analysis of 90 patients with hypertelorism, the most common cause was frontonasal malformation (n = 30), a heterogeneous category of nonfamilial disorders including a newly described subgroup, rugose frontonasal malformation. The second most common cause was craniofrontonasal dysplasia (n = 18), a genetic syndrome comprising coronal synostosis, frontonasal anomalies, "frizzy" hair, narrow/sloping shoulder girdle deformity, and longitudinal ridging of nails in association with various truncal and extremity anomalies. Paramedian craniofacial cleft(s) (n = 10) and (sincipital) encephalocele (n = 6) were infrequent causes of hypertelorism. The fifth, miscellaneous category comprised well-defined, mostly chromosomal and syndromic disorders (n = 26). Patients in the various diagnostic categories were designated as having either orbital or interorbital hypertelorism. Hypertelorism also was graded as either first, second, or third degree based on deviation from age- and gender-matched normative data. The etiology and type of hypertelorism influence the selection of operative procedure, whereas the grade of severity indicates the need for surgical correction.

Vertical orbital dystopia

Many pathologic processes may lead to vertical orbital dystopia. We reviewed 47 consecutive cases seen over a 13-year period. Twenty-nine patients underwent eye leveling procedures to improve cosmesis, 2 of these by camouflage procedures and 27 by orbital translocation. Ten patients had 16 secondary operations. There was one death, serious complications occurred in 3 patients, and nuisance complications occurred in 20 others. Seven patients developed diplopia postoperatively, and in 6 patients it was troublesome. In these, it resolved fully in 2 patients, improved to be of no consequence in 2, and in the remaining 2 troublesome symptoms persisted requiring inferior oblique muscle recession in 1. Binocular vision was never restored when not present preoperatively, and in 3 patients temporary loss occurred. There was an overall modest but significant improvement in appearance after surgery. It is concluded that vertical orbital translocation is rewarding and worthwhile.

Isolation and characterization of a novel Deinococcus radiodurans mutant abnormally susceptible to mutation induction by UV, gamma-ray, and mitomycin C

We isolated and characterized a novel, radiation 'hypermutable' mutant of Deinococcus radiodurans. Compared with the wild-type strain D. radiodurans IR, this mutator strain, designated S101, exhibited sensitivity to UV light, gamma-ray, mitomycin C, and N-methyl-N'-nitro-N-nitrosoguanidine. Spontaneous revertants of S101 that restored wild-type phenotype (non-mutability and resistance to these DNA-damaging agents) were also isolated. Furthermore, the increased susceptibility to DNA-damaging agents and mutability observed in S101 could be mimicked by treating D. radiodurans IR with Mn(II) ions. Our results suggest a putative new pathway of DNA repair in the extremely radioresistant bacterium D. radiodurans.

Hemifacial hypoplasia and hypomelanosis of Ito

We present three cases of hemifacial hypoplasia associated with hypomelanosis of Ito. The facial deformity is often severe with marked soft tissue shortage and underlying skeletal hypoplasia posing difficulty in reconstruction. The external ear is relatively uninvolved, although a degree of hypoplasia is usually present. The hallmark of hypomelanosis of Ito is linear depigmentation of skin often associated with asymmetric abnormalities. It is a heterogenous disorder due to chromosomal mosaicism, but cytogenetic confirmation of the diagnosis may be difficult. The relationship between mosaicism and anatomical asymmetry is discussed.

A splint for correction of congenital ear deformities

Fourteen non-hypoplastic congenitally deformed ears were treated with a simple splint with satisfactory results in all but one. These deformities can be treated non-surgically in the early neonatal period, effectively, without anaesthetic, and with minimal cost. We confirm other reports that better results are obtained and a shorter duration of splintage is needed if treatment is started early in the neonatal period. Our neonatal paediatric colleagues and midwives should be encouraged to manage these deformities in this way, and the need for surgical correction may be largely avoided in the future.

When do ears become prominent?

Non-hypoplastic congenital ear deformities are amenable to non-surgical treatment with splinting in the neonatal period. It is therefore important to determine when the deformity occurs. 100 postal questionnaires were sent to parents to study, retrospectively, the evolution of the prominent ear deformity in their children. 79 questionnaires were returned. As remembered by parents, the deformity was first noted at birth in 48 (61%) children, in 68 (86%) by 6 months and in all cases by 5 years. Therefore a large number of patients with prominent ears could be treated effectively, non surgically, early in life, without anaesthetic and with minimal cost.

A comparison of Zenoderm with DuoDERM E in the treatment of split skin graft donor sites

A prospective, randomised, controlled study compared Zenoderm (ZM) with DuoDERM E (DE) in the treatment of split skin graft donor areas in 64 patients. The donor site comfort was similar in the two groups. DE usage resulted in significantly faster healing but also a higher leakage rate than ZM. Two patients in the ZM group developed infection in their donor sites. The cost is significantly less with ZM than DE.

Comparing DuoDERM E with scarlet red in the treatment of split skin graft donor sites

A prospective, randomised, controlled study compared DuoDERM E (DE) with scarlet red (SR) in the treatment of split skin graft donor areas in 60 patients. Healing and donor site comfort were significantly better in the DE group. There was no clinical infection in either group. The wound leakage rate was higher in the DE group, requiring an average of 0.8 replacement dressings per donor site as compared with an average of 0.04 for the SR group. An estimate of the cost per donor site for the first ten days of dressing is given.

Development of a method for the determination of zopiclone in whole blood

Mass spectrometry in both electron-impact and positive chemical ionisation modes has been used to elucidate the structures of the decomposition products of zopiclone after gas chromatography. A high-performance liquid chromatographic method has been developed for the determination of zopiclone in whole blood. After selective extraction (butyl chloride) the extracts are chromatographed on Spherisorb ODS-5 (5 microns) using dibasic ammonium phosphate-acetonitrile (40:60). The zopiclone is measured by ultraviolet detection with a limit of quantitation of 4 ng/ml. This method has been successfully applied to the determination of zopiclone in post-mortem blood. Zopiclone levels found in five post-mortem cases are presented.