Harnessing the potential of data-driven strategies to optimise transfusion practice

No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.

Attitudes towards family involvement in nursing care among psychiatric nurses in Hong Kong: A cross-sectional descriptive study

WHAT IS KNOWN ON THE SUBJECT?: Family-involved interventions can result in better outcomes than traditional mental health care for both service users and their families. Nurses' attitudes towards family involvement can affect family participation in care. Earlier studies on psychiatric nurses' attitudes towards family involvement in care report ambiguous findings. Hong Kong's unique integrated cultures may influence Hong Kong psychiatric nurses' attitudes towards family involvement in nursing care. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The majority of psychiatric nurses had positive views on family involvement in care in Hong Kong. Four variables (i.e. gender, clinical experience, nature of working unit and family nursing training) of psychiatric nurses are associated with their attitudes towards family involvement in care in Hong Kong. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Policy makers should develop strategies to increase psychiatric nurses' awareness of the importance of family involvement in patient care. Nurse educators help to design family nursing training to enhance psychiatric nurses' competence in collaborating with families of people suffering from mental disorders.

ABSTRACT

INTRODUCTION: In Hong Kong, involving the family in nursing care is still optional and mainly depends on nurses' attitudes and the willingness of the family. Hong Kong psychiatric nurses' attitudes towards family involvement in nursing care may be influenced by the unique integrated Eastern and Western cultures, however earlier studies report ambiguous findings.

AIMS

This study aimed to assess Hong Kong psychiatric registered nurses' attitudes towards family involvement in care and its associated factors.

METHODS

This study is a cross-sectional descriptive online survey with convenience sampling based on the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) instrument.

RESULTS

Most of the psychiatric nurses had supportive attitudes towards family involvement in care. Females with more clinical experience, working in a rehabilitation-related unit and having attended a family nursing education course were associated with positive attitudes towards family involvement in care.

DISCUSSION

The supportive attitude of psychiatric nurses may be explained by the shift of mental health nursing care from hospital care to community care in recent decades.

IMPLICATIONS FOR PRACTICE

Mental health nurse education and training in Hong Kong could place more emphasis on building family work skills, particularly for newly qualified nurses and those working in acute inpatient settings.

Can heart rate variability be a bio-index of hope? A pilot study

Background

Hope can affect the thinking habits, emotional regulations, and behaviors of individuals. Hope is considered as a positive trait by clinicians, who often assess the level of hope in psychological evaluations. Previous measurements of hope were largely based on self-reported questionnaires leading to the problem of subjectivity. Heart Rate Variability (HRV) is a bio index that is an objective, quick, cost effective, and non-invasive measurement. HRV has been used in the evaluation of physical health and some psychiatric conditions. However, it has not been tested for its potential to be a bio-index of the level of hope.

Method

This pilot cross-sectional observational study aimed to examine the relationships between HRV and the level of hope among adult Chinese people in Hong Kong. Convenience sampling was used and 97 healthy participants were recruited. Their level of hope was measured by the Dispositional Hope Scale-Chinese (DHS-C), and their HRV was quantified by emWave Pro Plus, a reliable sensor of HRV. Spearman's correlation coefficient analysis was performed on the HRV measurements and DHS-C.

Results

The DHS-C's overall mean score was 45.49. The mean scores of the subscale DHS-C (Agency) was 22.46, and the mean scores of DHS-C (Pathway) was 23.03. It was also revealed that there were significant, weak, and negative correlations between the level of hope and four out of ten HRV metrics. One HRV metric was found to have a significant, weak, and positive correlation with the level of hope.

Conclusion

This study provided initial evidence to support the use of HRV as a bio-index of hope. Implications of the current study and recommendations for future research directions are discussed.

Cross-Cultural Adaptation and Psychometric Validation of the Constipation Assessment Scale among Chinese Adult Psychiatric Patients

BACKGROUND

Constipation is a functional gastrointestinal disorder that presents with signs and symptoms, which are typically assessed subjectively. Various measurement scales, such as the Constipation Assessment Scale (CAS), are commonly used to evaluate constipation among the general population. However, the instruments should be culturally and contextually relevant in adult psychiatric patients to generate valid and reliable evidence.

PURPOSE

This study aimed to cross-culturally adapt and psychometrically validate the traditional Chinese version of the CAS among adult psychiatric patients in Hong Kong.

METHOD

Using the Brislin protocol and Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines, the CAS was translated into traditional Chinese and tested for internal consistency, test-retest reliability, content validity, and construct validity among psychiatric patients in Hong Kong.

RESULTS

The CAS was successfully translated into CAS-TC. The CAS-TC version demonstrated good content validity (scale level CVI = 97%), internal consistency (Cronbach's alpha = 0.79), and test-retest reliability (ICC = 0.722 [95% CI, 0.587-0.812]). The CAS-TC showed a two-factor loading for the construct validity, which explained 54% of the total variance.

CONCLUSIONS

The CAS-TC is valid and reliable and can be employed to assess constipation among adult psychiatric patients.

Nurses' attitudes towards the use of physical restraint in psychiatric care: A systematic review of qualitative and quantitative studies

WHAT IS KNOWN ON THE SUBJECT?: Application of physical restraint is a common practice to protect service users and staff in psychiatric care. Nurses' attitudes towards physical restraint and its influencing factors in psychiatric settings in different countries are variable. Previous reviews include studies on different coercive methods, making it difficult to differentiate attitudes specific to physical restraint. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint and consider it a necessary nursing intervention and a last resort. The barriers for restraint-free environment practice included contextual demand, lack of knowledge on restraint and lack of alternatives to restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurse educators should develop and evaluate related educational training programmes to promote the development of alternative effective skills in handling violence instead of physical restraint. Policy makers should develop strategies to remove the barriers to a restraint-free environments. ABSTRACT: Introduction Physical restraint is common in psychiatric care; nurses' attitudes are crucial as nurses often implement the procedure. Previous reviews include studies exploring coercive methods but do not specifically focus on physical restraint. Aims This integrated mixed-method systematic review aimed to examine nurses' attitudes towards the use of physical restraint in psychiatric care and the factors influencing these attitudes. Methods Six databases were searched from 2000 to 2021. Thematic integrative analysis was used to synthesize the data. Results Ten studies were included. Five themes encapsulate nurses' attitudes towards physical restraint: "emotional responses," "moral conflicts," "ensuring safety for all," "a necessary nursing intervention" and "a last resort." Three themes were identified for factors influencing attitudes: "contextual demands," "level of knowledge" and "alternatives to restraint." Discussion Nurses' attitudes were marked by negative feelings and moral conflict towards the use of physical restraint. However, nurses applied physical restraint as an ordinary nursing intervention. Educational interventions and the leadership role may facilitate the change of current practice to a restraint-free environment. Implications for Practice Mental health nurses should work to remove the barriers to restraint-free environment and develop effective skills that can be used as alternatives to physical restraint.

One- and Five-Ringgit Malaysia banknotes reader with counterfeit detection for visually impaired person using backlight mechanism and image processing techniques

Visually impaired persons face challenges in running business activities, especially in handling banknotes. Malaysia researchers had proposed some Ringgit banknotes recognition systems to aid visually impaired persons recognize and classify Ringgit banknotes. However, these electronic banknote readers can only recognize Malaysian Banknotes' Ringgit value, they have no counterfeit detection features. The purpose of this study is to develop a banknote reader that not only can help visually impaired persons recognize the banknote value, but also to detect the counterfeit of the banknote, safeguarding their losses. This paper proposed a Malaysian banknote reader using backlight mechanism and image processing techniques to read and detect counterfeit for one Ringgit and five Ringgit Malaysian banknotes. The developed handheld banknote reader used visual type sensor to capture banknote image, passed to raspberry pi controller to perform image processing on banknote value and the extracted watermarks features. The developed image processing algorithm will trace out the region of interests: 1)see-thru windows, 2)Crescent and Star, 3)Perfect see though register and detect the watermarks features accordingly. The processed result will be passed back to the handheld banknote reader and broadcast on an attached mini speaker to aid the visually impaired understand the holding banknote, whether it is a real one Ringgit, real five Ringgit or none of them. The experimental result shown by this approach able to accomplish numerous round of banknote reading attempts with successful outcomes. Confusion matrix is further employed to study the performance of the banknote reader, in terms of true positive, true negative, false positive and false negative. Details analysis had been focused on the critical false positive cases (predicted real banknote and actually is fake banknote) and false negative cases (predicted fake banknote and it is actually real banknote).

Impacts of climate change on drinking water quality in Norway

Climate change will lead to higher temperatures, increased precipitation and runoff, as well as more intense and frequent extreme weather events in Norway. More extreme rainfall and increased runoff are historically associated with higher concentrations of indicator bacteria, colour and turbidity in raw water of Norwegian waterworks. Regional information about the risk for drinking water deterioration by the end of the century is essential for evaluating potential treatment capacity upgrades at the waterworks. We combined locally downscaled future climate scenarios with historical associations between weather/runoff and water quality from a wide spread of waterworks in Norway. With continued climate change, we estimate higher concentrations of water quality indicators of raw water by the end of the century. The water quality is estimated to deteriorate mainly due to the projected increase in rainfall, and mainly in the Western and Northern parts of Norway. While large waterworks seem to be able to adapt to future conditions, the degradation of raw water quality may cause future challenges for the treatment processes at smaller waterworks. Combining these results with further studies of treatment effects and microbial risk assessments is needed to ensure sufficient treatment capacities of the raw water in the future.

Prevention and management of aggressive behaviour in patients at psychiatric hospitals: a document analysis of clinical practice guidelines in Hong Kong

Patient aggressive behaviour remains a significant public health concern worldwide. The use of restraint and seclusion remains a last resort but not an uncommon practice in clinical psychiatry in the management of aggressive events. There seems to be a paucity of evidenced-based research examining the policy framework guiding the use of restraint and seclusion in Asia contexts. The purpose of this study was to conduct an analysis on the guidelines in psychiatric hospitals in Hong Kong, and to explore the extent to which these guidelines were aligned with the international clinical guidelines for the prevention and management of patient aggression in psychiatry. A descriptive document analysis was used to analyse the guidelines from four psychiatric hospitals in Hong Kong in comparison with the NICE (National Institute of Health and Care Excellence UK) guidelines. Data were collected from December 2017 to June 2018. A total of 91 written documents were retrieved. Preventing violence and aggression has the highest level of agreement (31%,) while the use of restrictive interventions has the lowest level of agreement (12%). The sub-recommendation with most in line with the NICE guidelines were restrictive interventions, de-escalation, and improving service users' experiences. However, for example, staff training, working with police, and reduced use of restrictive interventions seemed to have no agreement with the NICE guidelines. Variation exists between the Asian (Hong Kong) local policy framework/guidelines and the European (UK) national policy framework. There are also large discrepancies in the written guidelines on patient aggressive behaviour when comparing local policy frameworks, cluster-based documents, and departmental practices.

Natural Wolbachia infection in field-collected Anopheles and other mosquito species from Malaysia

BACKGROUND

The endosymbiont bacterium Wolbachia is maternally inherited and naturally infects some filarial nematodes and a diverse range of arthropods, including mosquito vectors responsible for disease transmission in humans. Previously, it has been found infecting most mosquito species but absent in Anopheles and Aedes aegypti. However, recently these two mosquito species were found to be naturally infected with Wolbachia. We report here the extent of Wolbachia infections in field-collected mosquitoes from Malaysia based on PCR amplification of the Wolbachia wsp and 16S rRNA genes.

METHODS

The prevalence of Wolbachia in Culicinae mosquitoes was assessed via PCR with wsp primers. For some of the mosquitoes, in which the wsp primers failed to amplify a product, Wolbachia screening was performed using nested PCR targeting the 16S rRNA gene. Wolbachia sequences were aligned using Geneious 9.1.6 software, analyzed with BLAST, and the most similar sequences were downloaded. Phylogenetic analyses were carried out with MEGA 7.0 software. Graphs were drawn with GraphPad Prism 8.0 software.

RESULTS

A total of 217 adult mosquitoes representing 26 mosquito species were screened. Of these, infections with Wolbachia were detected in 4 and 15 mosquito species using wsp and 16S rRNA primers, respectively. To our knowledge, this is the first time Wolbachia was detected using 16S rRNA gene amplification, in some Anopheles species (some infected with Plasmodium), Culex sinensis, Culex vishnui, Culex pseudovishnui, Mansonia bonneae and Mansonia annulifera. Phylogenetic analysis based on wsp revealed Wolbachia from most of the mosquitoes belonged to Wolbachia Supergroup B. Based on 16S rRNA phylogenetic analysis, the Wolbachia strain from Anopheles mosquitoes were more closely related to Wolbachia infecting Anopheles from Africa than from Myanmar.

CONCLUSIONS

Wolbachia was found infecting Anopheles and other important disease vectors such as Mansonia. Since Wolbachia can affect its host by reducing the life span and provide resistance to pathogen infection, several studies have suggested it as a potential innovative tool for vector/vector-borne disease control. Therefore, it is important to carry out further studies on natural Wolbachia infection in vector mosquitoes' populations as well as their long-term effects in new hosts and pathogen suppression.

High seroprevalence of anti-Fasciola antibody among cattle farm workers and dwellers in Kelantan

Human fascioliasis is a public health problem particularly in areas where ruminants are raised. The aims of this study were to determine the seroprevalence of anti-Fasciola antibody and the associated risk factors among cattle farm workers and dwellers in Kelantan. A total of 90 blood samples were collected in this cross-sectional study. A set of validated questionnaire was used to obtain information on socio-demographic profiles and dietary habits of participants. The sera were subjected to enzyme linked immunosorbent assay (ELISA) for the detection of anti-Fasciola IgG antibody. The association between seropositivity and the significant risk factors were determined via logistic regression. From the result, serological screening revealed 60 (67%) participants positive for anti-Fasciola IgG antibody. The factors found to be significantly associated with seropositivity against anti-Fasciola IgG antibody were the age group of 18 years old and above with calculated odds ratio of 3.2 times (p=0.032) and the duration of farming activities of more than 5 years with calculated odds ratio of 2.6 times (p=0.036). In conclusion, Fasciola infection is prevalent among cattle farm workers and dwellers in Kelantan.

The metaphyseal sleeve: an unexplored option in the treatment of complex primary knee osteoarthritis

BACKGROUND

In an ever-aging society that as a whole has become more affluent, significant emphasis has been accorded to an improved quality of life. Knee osteoarthritis is ever-increasingly treated with total knee arthroplasty. The benefits and satisfaction experienced by those who have undergone total knee replacements (TKR) are well documented in the literature. The issue arises when osteoarthritis of the affected knee is more complex than simple osteoarthritis, i.e. the patient has complex primary osteoarthritis. This collective term encompasses conditions such as massive bone loss, ligamentous laxity, coronal defects and those with contractures. There are various classifications to describe massive bone loss but we utilized the Anderson Orthopaedic Research Institute (AORI) classification. Numerous treatment options are available and we report the use of metaphyseal sleeves as a highly successful treatment option.

METHODS

We retrospectively reviewed all the patients at our centre who underwent primary TKR using the metaphyseal sleeves. Patients were assessed on symptoms and functional status, and radiographs were also taken to assess for osseointegration. Only patients who completed 2 years of follow up were included in our study.

RESULTS

The updated (2011) Knee Society Score (KSS) was used in conjunction with radiological assessments at each follow up. Mean KSS scores improved from 53.83 preoperatively to 193.39 postoperatively. All patients demonstrated increasing osseointegration throughout follow up.

CONCLUSION

The metaphyseal sleeve is an excellent treatment option for complex primary osteoarthritic knees with good results objectively, functionally and radiologically and would be a great choice for all orthopaedic surgeons to include in their armamentarium.

Erysipelothrix Septicaemia and Hepatitis in a Colony of Humboldt Penguins (Spheniscus humboldti)

This report describes an outbreak of erysipelas in a colony of captive Humboldt penguins (Spheniscus humboldti). The only previously reported case in a related species was of an individual little blue penguin (Eudyptula minor). Five Humboldt penguins in a mixed colony displayed non-specific signs of illness, including lethargy, inappetence and regurgitation after movement for exhibit upgrading. There was no improvement after 5 days of treatment with oral enrofloxacin (10 mg/kg q24h). Four Humboldt penguins, including two that were not part of the original five displaying signs of illness, died during this outbreak and Erysipelothrix rhusiopathiae was cultured from organ samples collected post mortem. Oral clavulanic acid/amoxycillin (125 mg/kg q12h) was added to the treatment of the sick Humboldt penguins, as well as itraconazole (8.5 mg/kg q12h) and silymarin (10 mg/kg q24h) for 10 days (both per os), which resolved their clinical signs. The likely source of E. rhusiopathiae was the fish they were fed, but this could not be confirmed. Another contributing factor to the growth of E. rhusiopathiae in the exhibit pool was the increase in water temperature due to a fault in the water circulating system. The temperature of the pool water had increased to 29°C, which was rectified, and the water temperature decreased to 13°C. However, there was one further Humboldt penguin death after the decrease in water temperature. This episode suggests that E. rhusiopathiae infection should be high on the differential list of piscivorous avian species with non-specific clinical signs. A liver biopsy for bacterial culture and sensitivity may be required for definitive diagnosis.

Tests of General Relativity with GW170817

The recent discovery by Advanced LIGO and Advanced Virgo of a gravitational wave signal from a binary neutron star inspiral has enabled tests of general relativity (GR) with this new type of source. This source, for the first time, permits tests of strong-field dynamics of compact binaries in the presence of matter. In this Letter, we place constraints on the dipole radiation and possible deviations from GR in the post-Newtonian coefficients that govern the inspiral regime. Bounds on modified dispersion of gravitational waves are obtained; in combination with information from the observed electromagnetic counterpart we can also constrain effects due to large extra dimensions. Finally, the polarization content of the gravitational wave signal is studied. The results of all tests performed here show good agreement with GR.

Constraining the p-Mode-g-Mode Tidal Instability with GW170817

We analyze the impact of a proposed tidal instability coupling p modes and g modes within neutron stars on GW170817. This nonresonant instability transfers energy from the orbit of the binary to internal modes of the stars, accelerating the gravitational-wave driven inspiral. We model the impact of this instability on the phasing of the gravitational wave signal using three parameters per star: an overall amplitude, a saturation frequency, and a spectral index. Incorporating these additional parameters, we compute the Bayes factor (lnB_{!pg}^{pg}) comparing our p-g model to a standard one. We find that the observed signal is consistent with waveform models that neglect p-g effects, with lnB_{!pg}^{pg}=0.03_{-0.58}^{+0.70} (maximum a posteriori and 90% credible region). By injecting simulated signals that do not include p-g effects and recovering them with the p-g model, we show that there is a ≃50% probability of obtaining similar lnB_{!pg}^{pg} even when p-g effects are absent. We find that the p-g amplitude for 1.4  M_{⊙} neutron stars is constrained to less than a few tenths of the theoretical maximum, with maxima a posteriori near one-tenth this maximum and p-g saturation frequency ∼70  Hz. This suggests that there are less than a few hundred excited modes, assuming they all saturate by wave breaking. For comparison, theoretical upper bounds suggest ≲10^{3} modes saturate by wave breaking. Thus, the measured constraints only rule out extreme values of the p-g parameters. They also imply that the instability dissipates ≲10^{51}  erg over the entire inspiral, i.e., less than a few percent of the energy radiated as gravitational waves.

Paraneoplastic relapsing minimal change disease associated with type A thymoma in an elderly patient: A case report and literature review

Thymoma is a rare mediastinal tumour that can be accompanied by different paraneoplastic syndromes. Here we report a case of Type A thymoma associated with relapsing minimal change disease (MCD). This case highlights: (1) The need to balance rapid prednisolone weaning against risk for relapse in an elderly patient at risk for steroid-induced complications. (2) The addition of calcineurin inhibitor in relapsed thymoma-related MCD, to achieve steroid sparing effects. Resection of the offending tumour and prompt immunosuppressive therapy are critical in getting best renal and overall outcomes in this rare entity.

Search for Subsolar-Mass Ultracompact Binaries in Advanced LIGO's First Observing Run

We present the first Advanced LIGO and Advanced Virgo search for ultracompact binary systems with component masses between 0.2  M_{⊙}-1.0  M_{⊙} using data taken between September 12, 2015 and January 19, 2016. We find no viable gravitational wave candidates. Our null result constrains the coalescence rate of monochromatic (delta function) distributions of nonspinning (0.2  M_{⊙}, 0.2  M_{⊙}) ultracompact binaries to be less than 1.0×10^{6}  Gpc^{-3}  yr^{-1} and the coalescence rate of a similar distribution of (1.0  M_{⊙}, 1.0  M_{⊙}) ultracompact binaries to be less than 1.9×10^{4}  Gpc^{-3}  yr^{-1} (at 90% confidence). Neither black holes nor neutron stars are expected to form below ∼1  M_{⊙} through conventional stellar evolution, though it has been proposed that similarly low mass black holes could be formed primordially through density fluctuations in the early Universe and contribute to the dark matter density. The interpretation of our constraints in the primordial black hole dark matter paradigm is highly model dependent; however, under a particular primordial black hole binary formation scenario we constrain monochromatic primordial black hole populations of 0.2  M_{⊙} to be less than 33% of the total dark matter density and monochromatic populations of 1.0  M_{⊙} to be less than 5% of the dark matter density. The latter strengthens the presently placed bounds from microlensing surveys of massive compact halo objects (MACHOs) provided by the MACHO and EROS Collaborations.

GW170817: Measurements of Neutron Star Radii and Equation of State

On 17 August 2017, the LIGO and Virgo observatories made the first direct detection of gravitational waves from the coalescence of a neutron star binary system. The detection of this gravitational-wave signal, GW170817, offers a novel opportunity to directly probe the properties of matter at the extreme conditions found in the interior of these stars. The initial, minimal-assumption analysis of the LIGO and Virgo data placed constraints on the tidal effects of the coalescing bodies, which were then translated to constraints on neutron star radii. Here, we expand upon previous analyses by working under the hypothesis that both bodies were neutron stars that are described by the same equation of state and have spins within the range observed in Galactic binary neutron stars. Our analysis employs two methods: the use of equation-of-state-insensitive relations between various macroscopic properties of the neutron stars and the use of an efficient parametrization of the defining function p(ρ) of the equation of state itself. From the LIGO and Virgo data alone and the first method, we measure the two neutron star radii as R_{1}=10.8_{-1.7}^{+2.0}  km for the heavier star and R_{2}=10.7_{-1.5}^{+2.1}  km for the lighter star at the 90% credible level. If we additionally require that the equation of state supports neutron stars with masses larger than 1.97  M_{⊙} as required from electromagnetic observations and employ the equation-of-state parametrization, we further constrain R_{1}=11.9_{-1.4}^{+1.4}  km and R_{2}=11.9_{-1.4}^{+1.4}  km at the 90% credible level. Finally, we obtain constraints on p(ρ) at supranuclear densities, with pressure at twice nuclear saturation density measured at 3.5_{-1.7}^{+2.7}×10^{34}  dyn cm^{-2} at the 90% level.

Optimal designs for active controlled dose-finding trials with efficacy-toxicity outcomes

We derive optimal designs to estimate efficacy and toxicity in active controlled dose-finding trials when the bivariate continuous outcomes are described using nonlinear regression models. We determine upper bounds on the required number of different doses and provide conditions under which the boundary points of the design space are included in the optimal design. We provide an analytical description of minimally supported optimal designs and show that they do not depend on the correlation between the bivariate outcomes.

A Man with Head Injury

Head injury is common and can be associated with significant morbidity and mortality. We report a 71-year-old man with typical imaging findings of depressed skull fracture on plain film and computed tomography with images in multi-planar reformat and 3-dimensional volume rendering technique, followed by a brief review of the literature.

Testing psychometric properties of a Chinese version of perception of aggression scale

AIM

This study was to evaluate the psychometric properties of the Chinese version of the 12-item Perception of Aggression Scale (POAS).

METHOD

It consists of three phases of testing, including (1) translation and back-translation and content validity; (2) semantic equivalence between translated Chinese and original English version; and (3) construct validity, internal consistency and test-retest reliability.

RESULTS

The translated Chinese and back-translated English version showed excellent similarities and agreements between two independent translators. The Chinese version indicated high item- and scale-level content validity indexes (0.86-1.00) and satisfactory semantic equivalence with the original English language version (weighted kappa=0.48-0.90; intraclass correlation coefficient=0.91). Exploratory factor analysis in 249 nursing students resulted in three components (dysfunctional, functional and protective dimensions), explaining 64% of the total variance, with satisfactory internal consistency (Cronbach's alpha=0.76-0.83) and good 2-week test-retest reliability (Pearson's r=0.87). The Chinese version of POAS was found to be a valid and reliable tool to examine nurses' attitudes towards patient aggression.

DISCUSSION

Chinese nurses in this study viewed patient aggression to be an undesirable negative behaviour suggestive of uncontrollability behaviour presented by the patient under their care.

Prevalence and Distribution of Anti-Amoebic IgG Antibody among Orang Asli (Aborigines) in Peninsular Malaysia

Entamoeba species are commonly detected in stool samples of Orang Asli due to their substandard living conditions and poor hygiene. Among the Entamoeba spp., Entamoeba histolytica is the only known primary pathogenic species. This study determined the prevalence and distribution of anti-amoebic IgG antibody among Orang Asli in Peninsular Malaysia. The results would reflect the prevalence of amoebiasis in the population. This study analysed a total of 375 serum samples from archives of two Orang Asli projects conducted between 2011 and 2014. They were from six different states in Malaysia, namely Johor, Kedah, Kelantan, Pahang, Perak, and Selangor. Anti-amoebic IgG antibody was detected using an enzymelinked immunosorbent assay (ELISA) with crude soluble antigen produced from axenically grown E. histolytica trophozoites. From the analysis, the overall seropositivity was approximately 71% (266/375), while the seropositivity rates for each of the three Orang Asli tribes i.e. Senoi, Negrito and Proto-Malay, were 66% (137/208), 92% (103/112), and 43% (17/ 41) respectively. Orang Asli from Kedah [95% (52/55)] showed the highest seropositivity, followed by Kelantan [79% (54/68)], Perak [73% (78/107)], Pahang [60% (57/95)], Selangor [56% (14/25)], and Johor [48% (10/21)]. Orang Asli from rural [76% (192/254)] and peripheral urban [65% (69/106)] areas showed significantly higher seropositivity (p=0.002) than those from urban areas [36% (4/11)]. The high prevalences of anti-amoebic IgG antibody in these Orang Asli populations comprised both active and past infections. This study provides current insights of amoebiasis in selected Orang Asli settlements in Peninsular Malaysia. The high seropositivity of anti-amoebic IgG antibody suggests that the settlements are endemic for amoebiasis and there is a high risk of acquiring E. histolytica infection among the dwellers.

Endovascular Stent Graft Repair is an Effective and Safe Alternative Therapy for Arteriovenous Graft Pseudoaneurysms

OBJECTIVE/BACKGROUND

Pseudoaneurysm formation occurs in 2-10% of hemodialysis arteriovenous grafts (AVGs). Surgical repair often requires pseudoaneurysm resection, interposition graft placement, and insertion of a catheter as a bridge. Endovascular stent graft repair is a controversial alternative therapy. This study was performed to examine the effectiveness and mid-term outcomes of stent graft repair for AVG pseudoaneurysms.

METHODS

All patients who had undergone stent graft repair for AVG pseudoaneurysms between December 2012 and July 2015 were identified from hospital medical records for retrospective analysis. Outcome measures were technical success, early and late complications, and primary and secondary patency rates.

RESULTS

A total of 37 stent graft repairs of AVG pseudoaneurysms were performed in 35 patients (42.9% men; mean age 66.9 years). The mean time from AVG creation to pseudoaneurysm repair was 69 months. The indications of treatment (as per the institutional policy) were large pseudoaneurysm (56.7%), impending rupture (27.1%), and bleeding (16.2%). Mean pseudoaneurysm diameter was 23.0 mm. The most common diameter and length of stent graft used were 7 mm (67.6%) and 50 mm (48.6%), respectively. Technical success was 100%. Only one early complication occurred after stent graft repair, which was due to recurrence of the pseudoaneurysm as a result of a short landing zone. Late complications included infection (17.1%) and thrombosis (37.1%). The 1, 6, and 12 month primary patency rates were 89.2%, 55.5%, and 22.0%, respectively. The 1, 6, and 12 month secondary patency rates were 100%, 88.6%, and 78.6%, respectively. The median follow up was 12.3 months.

CONCLUSIONS

The study demonstrates that endovascular stent graft repair is an effective and safe alternative therapy for AVG pseudoaneurysms. However, the rate of thrombosis and infection was high and needs to be balanced against open surgery in future studies.

Primary ventriculoperitoneal shunting outcomes: a multicentre clinical audit for shunt infection and its risk factors

OBJECTIVES

To determine the frequency of primary ventriculoperitoneal shunt infection among patients treated at neurosurgical centres of the Hospital Authority and to identify underlying risk factors.

METHODS

This multicentre historical cohort study included consecutive patients who underwent primary ventriculoperitoneal shunting at a Hospital Authority neurosurgery centre from 1 January 2009 to 31 December 2011. The primary endpoint was shunt infection, defined as: (1) the presence of cerebrospinal fluid or shunt hardware culture that yielded the pathogenic micro-organism with associated compatible symptoms and signs of central nervous system infection or shunt malfunction; or (2) surgical incision site infection requiring shunt reinsertion (even in the absence of positive culture); or (3) intraperitoneal pseudocyst formation (even in the absence of positive culture). Secondary endpoints were shunt malfunction, defined as unsatisfactory cerebrospinal fluid drainage that required shunt reinsertion, and 30-day mortality.

RESULTS

A primary ventriculoperitoneal shunt was inserted in 538 patients during the study period. The mean age of patients was 48 years (range, 13-88 years) with a male-to-female ratio of 1:1. Aneurysmal subarachnoid haemorrhage was the most common aetiology (n=169, 31%) followed by intracranial tumour (n=164, 30%), central nervous system infection (n=42, 8%), and traumatic brain injury (n=27, 5%). The mean operating time was 75 (standard deviation, 29) minutes. Shunt reinsertion and infection rates were 16% (n=87) and 7% (n=36), respectively. The most common cause for shunt reinsertion was malfunction followed by shunt infection. Independent predictors for shunt infection were: traumatic brain injury (adjusted odds ratio=6.2; 95% confidence interval, 2.3-16.8), emergency shunting (2.3; 1.0-5.1), and prophylactic vancomycin as the sole antibiotic (3.4; 1.1-11.0). The 30-day all-cause mortality was 6% and none were directly procedure-related.

CONCLUSIONS

This is the first Hong Kong territory-wide review of infection in primary ventriculoperitoneal shunts. Although the ventriculoperitoneal shunt infection rate met international standards, there are areas of improvement such as vancomycin administration and the avoidance of scheduling the procedure as an emergency.

Non-tuberculous mycobacterial head and neck infections in children: Analysis of results and complications for various treatment modalities

OBJECTIVES

Analyze the results and complications of various surgical interventions in a large cohort of children with non-tuberculous mycobacterial (NTM) head and neck infections and suggest a heuristic treatment protocol for managing this condition while aiming to maximize cure and minimize complications.

METHODS

Retrospective chart review of 104 consecutive patients diagnosed with head and neck NTM at a tertiary paediatric hospital between January 1994 and December 2013 inclusive.

RESULTS

104 patients ranged in age between 8 months to 15 years (mean age 27 months) were reviewed and 97 patients were included in the final analysis. 6 patients excluded due to lack of follow-up and one excluded due to systemic immunocompromised condition. Sub-sites of NTM infections were submandibular (n=48, 46%), cervical (n=40, 38%), parotid (n=18, 17%) and submental (n=4, 4%). Some patients had more than one lesion so counted twice. Higher cure rates were demonstrated for primary excision (81%, p<0.01) versus incisional interventions (44%, p<0.01). Marginal mandibular nerve palsy following surgery was seen in 7 patients (7.2%). This was permanent in 4 patients (4%) and temporary in 3 patients (3%). All children who were complicated with marginal mandibular palsies had lesions in the submandibular region. The rate of palsy for submandibular disease alone was 15%, while 8% presented permanent palsy and 6% temporary. Marginal mandibular nerve palsy was more likely following excisional compared to incisional procedures (6 versus 1 patient, p<0.01). Hypertrophic scarring occurred in 7 patients: 3 patients following excision and 4 patients after an incisional procedure. One patient suffered long term spinal accessory nerve damage presented as winged scapula.

CONCLUSIONS

Excision of NTM provides better cure rates compared to incision although at the expense of long term post-surgical morbidity. Excision should probably be the first line of treatment when the risk for neural damage is low. Incision and drainage with or without antimycobacterial treatment may be the preferred option for at-risk sub-sites (submandibular or parotid) in order to reduce long term morbidity.

Omnidirectional Surveillance System Featuring Trespasser and Faint Detection for i-Habitat

This paper proposed an efficient omnidirectional surveillance system for i-habitat (intelligent habitat or smart home in another name) security. In this surveillance system, the omnidirectional scenes in a room, kitchen, balcony, dining hall, corridor, garage or backyard within an i-habitat are first captured using wireless webcam attached to a specially designed hyperbolic optical mirror. The captured scenes are then fed into a wireless router connected to laptop computer for image processing and alarm purposes. A mapping algorithm is developed to match the captured omnidirectional image into panoramic image, hence providing the observer or image processing tools a complete wide angle of view. An efficient trespasser detection algorithm is designed for trespasser detection purpose, and an efficient faint detection algorithm is designed to identify/monitor if there is any member who stay in i-habitat (old-folks or ill-patients) who fall down or faint and thus, immediate attention can be carried out. Based on the experimental findings, both the proposed trespasser and faint detection algorithm achieves high accuracy.

Self-administered acupressure for treating adult psychiatric patients with constipation: a randomized controlled trial

BACKGROUND

Constipation has a high prevalence rate (>30 %) in psychiatric patients with psychotropic drugs. Common pharmacological and non-pharmacological interventions for constipation might have longer-term negative and adverse effects that would outweigh their short-term efficacy in symptom reduction. This randomized controlled trial aims to investigate the effect of self-administered acupressure for the management of constipation, in hospitalized psychiatric patients.

METHODS

Seventy-eight patients were recruited in matched pairs in terms of gender, age and laxative use from five acute psychiatric wards in Hong Kong. Each of these matched pairs of patients was randomly assigned to either a self-administered acupressure (n = 39) or a sham group (n = 39), using computer-generated random numbers. After baseline measurement, the intervention and sham group received the same training in self-administered acupressure and supervised practice once per day for 10 days, except light pressure on non-acupoints was taught to the sham group. The acupoints chosen for acupressure included Zhongwan (RN12), right and left Tianshu (ST25), right and left Quchi (LI11). Participants' symptoms and quality of life regarding constipation were measured at baseline and immediately and 2 weeks after completion of the interventions with constipation assessment scale and patient assessment of constipation quality of life questionnaire, respectively.

RESULTS

After 2 weeks follow-up, participants who had received self-administered acupressure indicated significantly greater improvements in both symptom severity (P = 0.0003) and quality of life (P = 0.0004) when compared with the sham group.

CONCLUSION

The psychiatric patients with constipation who practiced self-administered acupressure for 10 days improved their symptom severity and perceived quality of life immediately and 2 weeks after completion of the intervention in comparison with the sham group.

TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov (Reg. No: NCT02187640).

Detection of carotid artery calcification on the panoramic images of post-menopausal females is significantly associated with severe abdominal aortic calcification: a risk indicator of future adverse vascular events

OBJECTIVES

Outcome studies among post-menopausal females with calcified carotid artery plaque (CCAP) on their panoramic images have not been previously undertaken. We sought to compare the extent of abdominal aortic calcification (AAC) on lateral lumbar spine radiographs (LLSRs), among groups of females with (CCAP+) and without (CCAP-) carotid lesions on their panoramic images. "Severe" levels of AAC have previously been validated as a risk indicator of future adverse cardiovascular events.

METHODS

This cross-sectional case-control study included a "CCAP+ group" consisting of females more than 50 years of age having the carotid lesion diagnosed by their dentists and an atherogenic risk factor (age, body mass index, hypertension, diabetes and dyslipidaemia)-matched "CCAP- group". A physician radiologist, using the Framingham index, evaluated the LLSRs for the magnitude of AAC. Summary statistics for key variables were computed and conditional logistic regression techniques were considered.

RESULTS

Members of the CCAP+ group were significantly (p=0.038) more likely to demonstrate "severe" levels of AAC on their LLSRs than members of the CCAP group.

CONCLUSIONS

This is the first published study demonstrating that CCAP on panoramic images of post-menopausal females is significantly associated with "severe" levels of AACs on LLSRs independent of traditional risk factors. Given that these levels of AAC are a validated risk indicator of future myocardial infarction and stroke, dentists must evaluate the panoramic images of post-menopausal females for the presence of CCAP. Patients with carotid atheromas should be referred to their physicians for further evaluation given the systemic implications.

A cautionary tale: dealing with missing data in clinical trials for rheumatic diseases

OBJECTIVES

Missing data are found in nearly all clinical trials and it is important to use appropriate statistical techniques to analyse clinical trials with missing data. We discuss common statistical methods for tackling missing data and how to handle results when the analyses give different results.

METHODS

Using data from a placebo-controlled, randomised bovine Type I collagen (CI) study in diffuse cutaneous systemic sclerosis (dcSSc), we apply different statistical approaches to handling missing data. We also describe simple ways to ascertain the type of missing data in the data set, to the extent possible.

RESULTS

We examine eleven different methods to impute missing data. An analysis based on completers alone (complete case analysis and available case analysis) and the last observation carried forward (LOCF) methods require underlying assumptions which are rarely met in practice. Multiple imputation, mixed effects, and repeated measures try to account for the differences among patients and account for patient's specific response patterns, although the assumption that the missing data is directly related to the observed characteristics may well not be true. The joint likelihood based model combines the mixed effect model and logistic regression model to explicitly handle data not missing at random and so it is more realistic and potentially takes an additional step toward decreasing bias.

CONCLUSIONS

We discussed various ways of handling missing data and provide recommendations on how to arrive at a conclusion when different statistical approaches to analyse missing data analysis in clinical trials give conflicting answers.

Sequence memory based on coherent spin-interaction neural networks

Sequence information processing, for instance, the sequence memory, plays an important role on many functions of brain. In the workings of the human brain, the steady-state period is alterable. However, in the existing sequence memory models using heteroassociations, the steady-state period cannot be changed in the sequence recall. In this work, a novel neural network model for sequence memory with controllable steady-state period based on coherent spininteraction is proposed. In the proposed model, neurons fire collectively in a phase-coherent manner, which lets a neuron group respond differently to different patterns and also lets different neuron groups respond differently to one pattern. The simulation results demonstrating the performance of the sequence memory are presented. By introducing a new coherent spin-interaction sequence memory model, the steady-state period can be controlled by dimension parameters and the overlap between the input pattern and the stored patterns. The sequence storage capacity is enlarged by coherent spin interaction compared with the existing sequence memory models. Furthermore, the sequence storage capacity has an exponential relationship to the dimension of the neural network.

Pinning controllability of complex networks with community structure

In this paper, we study the controllability of networks with different numbers of communities and various strengths of community structure. By means of simulations, we show that the degree descending pinning scheme performs best among several considered pinning schemes under a small number of pinned nodes, while the degree ascending pinning scheme is becoming more powerful by increasing the number of pinned nodes. It is found that increasing the number of communities or reducing the strength of community structure is beneficial for the enhancement of the controllability. Moreover, it is revealed that the pinning scheme with evenly distributed pinned nodes among communities outperforms other kinds of considered pinning schemes.

Efficacies of two in-house indirect ELISAs for diagnosis of amoebic liver abscess

Entamoeba histolytica causes amoebic diarrhoea, colitis and liver abscess (ALA). Diagnosis of ALA is difficult, as most patients do not have simultaneous intestinal amoebic infection. At Hospital Universiti Sains Malaysia (HUSM), diagnosis of ALA relies on a combination of clinical findings, ultrasound examination of the liver and serodiagnosis using a commercial kit. In this study, two in-house indirect ELISAs were developed and evaluated. One of the in-house assays utilises E. histolytica crude soluble antigen (CSA) to detect serum IgG specific to the parasite whereas the other uses E. histolytica ether extract antigen (EEA). Preparation of CSA requires a sonicator to lyse the amoeba whereas EEA was prepared by chemically solubilizing the trophozoites. Based on the cut-off value of mean optical density + 3SD, CSA-ELISA showed 100% (24/24) sensitivity and 93.33% (210/225) specificity; while EEA-ELISA showed 91.67% (22/24) sensitivity and 95.11% (214/225) specificity. In conclusion, both the in-house indirect ELISAs were found to be efficacious for diagnosis of ALA; and the EEA is easier to prepare than the commonly used CSA.

Current approaches to treatments for schizophrenia spectrum disorders, part II: psychosocial interventions and patient-focused perspectives in psychiatric care

Schizophrenia is a disabling psychiatric illness associated with disruptions in cognition, emotion, and psychosocial and occupational functioning. Increasing evidence shows that psychosocial interventions for people with schizophrenia, as an adjunct to medications or usual psychiatric care, can reduce psychotic symptoms and relapse and improve patients' long-term outcomes such as recovery, remission, and illness progression. This critical review of the literature was conducted to identify the common approaches to psychosocial interventions for people with schizophrenia. Treatment planning and outcomes were also explored and discussed to better understand the effects of these interventions in terms of person-focused perspectives such as their perceived quality of life and satisfaction and their acceptability and adherence to treatments or services received. We searched major health care databases such as EMBASE, MEDLINE, and PsycLIT and identified relevant literature in English from these databases. Their reference lists were screened, and studies were selected if they met the criteria of using a randomized controlled trial or systematic review design, giving a clear description of the interventions used, and having a study sample of people primarily diagnosed with schizophrenia. Five main approaches to psychosocial intervention had been used for the treatment of schizophrenia: cognitive therapy (cognitive behavioral and cognitive remediation therapy), psychoeducation, family intervention, social skills training, and assertive community treatment. Most of these five approaches applied to people with schizophrenia have demonstrated satisfactory levels of short- to medium-term clinical efficacy in terms of symptom control or reduction, level of functioning, and/or relapse rate. However, the comparative effects between these five approaches have not been well studied; thus, we are not able to clearly understand the superiority of any of these interventions. With the exception of patient relapse, the longer-term (eg, >2 years) effects of these approaches on most psychosocial outcomes are not well-established among these patients. Despite the fact that patients' perspectives on treatment and care have been increasingly concerned, not many studies have evaluated the effect of interventions on this perspective, and where they did, the findings were inconclusive. To conclude, current approaches to psychosocial interventions for schizophrenia have their strengths and weaknesses, particularly indicating limited evidence on long-term effects. To improve the longer-term outcomes of people with schizophrenia, future treatment strategies should focus on risk identification, early intervention, person-focused therapy, partnership with family caregivers, and the integration of evidence-based psychosocial interventions into existing services.

An analytic criterion for generalized synchronization in unidirectionally coupled systems based on the auxiliary system approach

An analytic criterion is developed to investigate generalized synchronization (GS) in unidirectionally coupled systems based on the auxiliary system approach. The criterion is derived by transforming the existence problem of generalized synchronization into an eigenvalue problem. Numerical simulations show that the analytic criterion is almost as accurate as the response Lyapunov exponents method, and may provide an estimation of the threshold of strong generalized synchronization. A significant result can be deduced from our analysis that the more the number of equilibria of the unidirectionally coupled systems, the greater the chance of generalized synchronization, but the harder it may be for strong generalized synchronization to occur.

Laparoscopic sleeve gastrectomy: a novel procedure for weight loss

INTRODUCTION

Morbid obesity is associated with increased morbidity and mortality. Bariatric surgery offers morbidly obese individuals substantial and sustainable weight loss and reduction in obesity-related comorbidities. Laparoscopic sleeve gastrectomy (LSG) is a new restrictive procedure in bariatric surgery. We aimed to evaluate our experience with LSG with regard to its safety and feasibility and early weight loss.

METHODS

The surgical outcome, complications and early clinical results of all patients who underwent LSG at Singapore General Hospital were studied.

RESULTS

30 patients underwent LSG between December 2008 and October 2010. The mean preoperative weight of the patients was 113.4 (range 91.0-170.0) kg, while the mean body mass index (BMI) was 42.6 (range 33.0-60.0) kg/m². Diabetes mellitus was present in 39 percent of the patients, hypertension in 43 percent, hyperlipidaemia in 35 percent, obstructive sleep apnoea in 30 percent and osteoarthritis in 22 percent. The majority of patients had two or more obesity-related comorbidities (52 percent). Mean operative time was 142 (range 80-220) minutes and median duration of postoperative stay was three days. At two weeks, one, three and six months post operation, the mean BMI was 38.6 kg/m², 37.8 kg/m², 34.5 kg/m² and 30.8 kg/m², the mean percentage of excess weight loss was 17.7 percent, 23.3 percent, 40.9 percent and 56.7 percent, and absolute weight loss was 8.00 kg, 11.52 kg, 18.77 kg and 26.85 kg, respectively.

CONCLUSION

LSG is a promising procedure for surgical treatment of obesity, with good early weight loss and low morbidity.

Guideline on training and credentialing in endoscopic retrograde cholangiopancreatography

The aim of the Endoscopic Retrograde Cholangiopancreatography (ERCP) Working Group was to examine the issues of training, credentialing and quality control in ERCP in Singapore. Published guidelines and clinical trials concerning issues of training, complications and quality control in ERCP have been reviewed. The Working Group recommended that a trainee reach a minimum threshold of 200 cases before the assessment of competency. The target for achievement of competency was set at an 85 percent successful cannulation rate for native papilla. To perform advanced ERCP, endoscopists should have undergone dedicated training either in a recognised training centre or in conjunction with and under the guidance of a more experienced colleague, until technical competency is achieved. Precut should only be performed by endoscopists with experience and expertise in performing Levels II and III ERCP, who have been formally proctored. An audit of ERCP should examine parameters such as appropriate indication, success rates of selective cannulation, technical success rate of commonly performed procedures and procedure-related complications. To maintain technical competency, an individual should be performing ERCP on a regular basis. In conclusion, the innate risks of ERCP necessitate that all ERCP practitioners should be appropriately trained, practise within their expertise level and maintain regular practice in order to minimise risks and improve patient outcome.

Multiobjective synchronization of coupled systems

In this paper, multiobjective synchronization of chaotic systems is investigated by especially simultaneously minimizing optimization of control cost and convergence speed. The coupling form and coupling strength are optimized by an improved multiobjective evolutionary approach that includes a hybrid chromosome representation. The hybrid encoding scheme combines binary representation with real number representation. The constraints on the coupling form are also considered by converting the multiobjective synchronization into a multiobjective constraint problem. In addition, the performances of the adaptive learning method and non-dominated sorting genetic algorithm-II as well as the effectiveness and contributions of the proposed approach are analyzed and validated through the Rössler system in a chaotic or hyperchaotic regime and delayed chaotic neural networks.

Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding

Background

Rebleeding from peptic ulcers is a major contributor to death. This study compared standard (40-mg intravenous infusion of omeprazole once daily for 3 days) and high-dose (80-mg bolus of omeprazole followed by 8-mg/h infusion for 72 h) in reducing the rebleeding rate (primary endpoint), need for surgery, duration of hospital stay and mortality in patients with peptic ulcer bleeding after successful endoscopic therapy.

Methods

This was a single-institution prospective randomized controlled study based on a postulated therapeutic equivalence of the two treatments. All patients who had successful endoscopic haemostasis of a bleeding peptic ulcer (Forrest classification Ia, Ib, IIa or IIb) were recruited. Informed consent was obtained and patients were randomized to receive standard- or high-dose infusions of intravenous omeprazole.

Results

Two (3 per cent) of 61 patients in the high-dose group and ten (16 per cent) of 61 in the standard-dose group exhibited rebleeding, a difference of − 13 (95 per cent confidence interval − 25 to − 2) per cent. The upper limit of the one-sided confidence interval exceeded a predefined equivalence absolute difference of 16 per cent. Equivalence of standard- and high-dose omeprazole in preventing rebleeding was not demonstrated.

Conclusion

Intravenous standard-dose omeprazole was inferior to high-dose omeprazole in preventing rebleeding after endoscopic haemostasis for peptic ulcer bleeding. Registration number: NCT00519519 (http://www.clinicaltrials.gov).

Stimulation with type I collagen induces changes in gene expression in peripheral blood mononuclear cells from patients with diffuse cutaneous systemic sclerosis (scleroderma)

An autoantigenic role for collagen type I (CI) has been suggested previously in diffuse cutaneous systemic sclerosis (dcSSc). Whether CI is indeed capable of affecting the immune system in dcSSc is not known. Patients with early (3 years or less) or late (>3 years) dcSSc and healthy controls donated blood. Peripheral blood mononuclear cells (PBMC) were cultured with or without CI, and expression of genes known for their involvement in autoimmune and inflammatory processes was assessed using cDNA arrays; results were confirmed by real-time polymerase chain reaction and enzyme-linked immunosorbent assay for selected genes. Patients with early and late dcSSc were similarly different from healthy controls in basal gene expression. When cultured with CI, PBMC from patients with early dcSSc differed from healthy controls in expression of 34 genes, whereas PBMC from patients with late dcSSc differed from healthy controls in expression of only 29 genes. Direct comparisons of matched PBMC samples cultured with and without CI revealed differences in expression of eight genes in healthy controls, of five genes in patients with early dcSSc, and no differences in patients with late dcSSc. Thus, PBMC from patients with dcSSc respond differently than do PBMC from healthy controls when cultured with CI. Exposure to CI in culture of PBMC from patients in the early stage of dcSSc in contrast to PBMC from patients with late-stage dcSSc evokes a greater degree of activation of immune-related genes, suggesting that CI is more dominant as an autoantigen in early versus late dcSSc.