Morbidity patterns and healthcare utilisation among older people in Malaysia: 1996-2015.

OBJECTIVE: This article examines the trends in morbidities and healthcare utilisation in Malaysian older people aged 60 years and above. STUDY DESIGN: This is a repeated cross-sectional study. METHODS: Data from three nation-wide community-based surveys, which were conducted in 1996, 2006, and 2015 were analysed. Multivariate analysis was performed for 2015 data to identify factors associated with healthcare utilisation. RESULTS: Analysis noted increasing trends in the prevalence of diabetes, hypertension, hypercholesterolaemia and obesity from 1996 to 2015. Decreasing trends were noted in the prevalence of current smokers and drinkers over this 20-year period, whereas health service utilisation increased with age in all surveys. In 2015, both inpatient and outpatient care are significantly associated with increasing age and diabetes. CONCLUSIONS: Increasing trends of health problems and healthcare utilisation were observed among older people in Malaysia. Policymakers should plan for appropriate resources to meet the challenges of an ageing population in Malaysia.

Ascorbic acid ameliorates renal injury in a murine model of contrast-induced nephropathy.

BACKGROUND: Contrast induced nephropathy (CIN) is the commonest cause of iatrogenic renal injury and its incidence has increased with the advent of complex endovascular procedures. Evidence suggests that ascorbic acid (AA) has a nephroprotective effect in percutaneous coronary interventions when contrast media are used. A variety of biomarkers (NGAL, NGAL:creatinine, mononuclear cell infiltration, apoptosis and RBP-4) in both the urine and kidney were assayed using a mouse model of CIN in order to determine whether AA can reduce the incidence and/or severity of renal injury. METHODS: Twenty-four BALB/c mice were divided into 4 groups. Three groups were exposed to high doses of contrast media (omnipaque) in a well-established model of CIN, and then treated with low or high dose AA or placebo (saline). CIN severity was determined by measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL):creatinine at specific time intervals. Histological analysis was performed to determine the level of mononuclear inflammatory infiltration as well as immunohistochemistry to determine apoptosis in the glomeruli by staining for activated caspase-3 and DNA nicking (TUNEL assays). Reverse transcriptase PCR (rtPCR) of mRNA transcripts prepared from mRNA extracted from mouse kidneys was also performed for both lipocalin-2 (Lcn2) encoding NGAL and retinol binding protein-6 (RBP4) genes. NGAL protein expression was also confirmed by ELISA analysis of kidney lysates. RESULTS: Urinary NGAL:creatinine ratio was significantly lower at 48 h with a 44% and 62% (204.3µg/mmol versus 533.6µg/mmol, p = 0.049) reduction in the low and high dose AA groups, respectively. The reduced urinary NGAL:creatinine ratio remained low throughout the time period assessed (up to 96 h) in the high dose AA group. In support of the urinary analysis ELISA analysis of NGAL in kidney lysates also showed a 57% reduction (12,576 ng/ml versus 29,393 ng/ml) reduction in the low dose AA group. Immunohistochemistry for apoptosis demonstrated decreased TUNEL and caspase-3 expression in both low and high dose AA groups. CONCLUSIONS: Ascorbic acid reduced the frequency and severity of renal injury in this murine model of CIN. Further work is required to establish whether AA can reduce the incidence of CIN in humans undergoing endovascular procedures.

Delayed Gastric Emptying after Pancreatic Surgery: Analysis of Factors Determinant for the Short-term Outcome.

BACKGROUND: Delayed gastric emptying (DGE) frequently complicates pancreatoduodenectomy (PD). Mainly DGE develops as consequence of postoperative intra-abdominal complications (secondary), while the incidence of primary DGE (i.e., not related to surgical complications) has rarely been studied. Moreover, the pathogenesis of DGE is complex and needs to be further elucidated. The present study aimed at highlighting potential mechanisms behind primary and above all secondary DGE by studying a variety of different pancreatic surgical procedures. PATIENTS AND METHODS: During the time period 2008-2011, 327 patients underwent pancreatic resective procedures at Karolinska University Hospital. Of these, 242 were PD and 56 tail resections, 17 had a duodenal preserving pancreatectomy for chronic pancreatitis, and 15 patients with familial duodenal polyposis had a pancreas preserving duodenectomy. All postoperative courses were assessed and scored according to Clavien-Dindo. The presence of DGE was evaluated and recorded according to the definition launched by the International Study Group for Pancreatic Surgery (ISGPS). Crude associations were studied in a univariate model, followed by a multivariate analysis of the respective factors. The associations were presented as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: In total DGE emerged during the postoperative course in about 40% of the PD cases. About half of those (n = 47) were scored as being primary. The majority of the primary DGEs were classified as A (n = 26) and only four as grade C, whereas among the secondary cases significantly more patients were scored as grade C (p < 0.01). In those submitted to a pancreatic body and tail resection 25% reported DGE. The distribution of the different grades of DGE in patients with a tail resection followed the same pattern with a predominance of Grade A cases with an equal distribution between those being scored as primary and secondary. Duodenal preservation, as well as keeping the pancreas intact following duodenectomy, was not followed by primary DGE. Multivariate risk factor analyses for the development of primary GE revealed no specific risk profile except for high age. CONCLUSION: DGE is frequently seen after different surgical procedures directed toward the pancreatic gland. DGE is most commonly seen after PD, and half of these cases are scored as primary DGE. Primary and secondary DGE are seen in one-quarter of the cases even after pancreatic tail resection emphasizing the complex nature of the pathogenesis. Resection of the duodenum as an important mechanism behind DGE is not supported by the present results.

Assessment of penetration of dorsal screws after fixation of the distal radius using ultrasound: cadaveric study.

INTRODUCTION: Volar locking plates are used to treat unstable and displaced fractures of the distal radius. Potential advantages of stable anatomical reduction (eg early mobilisation) can be limited by penetration of dorsal screws, leading to synovitis and potential rupture of extensor tendons. Despite intraoperative imaging, penetration of dorsal screws continues to be a problem in volar plating of the distal radius. Ultrasound is a well recognised, readily available, diagnostic tool used to assess soft-tissue impingement by orthopaedic hardware. In this cadaveric study, we wished to ascertain the sensitivity and specificity of ultrasound for identification of protrusion of dorsal screws after volar plating of the distal radius. METHODS: Four adult, unpaired phenol-embalmed cadaveric distal radii were used. A VariAx™ Distal Radius Volar Locking Plate system (Stryker, Kalamazoo, MI, USA) was employed for instrumented fixation. A portable SIUI CTS 900 ultrasound machine (Providian Medical, Eastlake, OH, USA) was used to image the dorsal cortex to ascertain screw penetration. RESULTS: Specificity and sensitivity of ultrasound for detection of screw protrusion through the dorsal cortex was 100%. CONCLUSIONS: Ultrasound was found to be a safe and accurate method for assessment of dorsal-screw penetration through the dorsal cortex of the radius after volar plating of the distal radius. It also aids diagnosis of associated tendon disorders (eg tenosynovitis) that might cause pain and limit wrist function.

Systematic review of sentinel lymph node biopsy in anal squamous cell carcinoma.

BACKGROUND: Anal squamous cell carcinoma with lymph node metastases carries a poor outcome. There remains a need for a better method to diagnose inguinal lymph node metastases which is minimally invasive, accurate and avoids unnecessary irradiation to the groin with its associated significant co-morbidity. The aim of this study was to evaluate the role of sentinel lymph node (SLN) biopsy in anal squamous cell carcinoma. METHODS: The systematic review was conducted in accordance with PRISMA guidelines. The Medline, Central and Embase databases were searched using the terms 'sentinel lymph node' and 'anus neoplasms'. RESULTS: The systematic review identified 17 studies, containing 270 patients. SLN detection rate varied from 47% to 100%. The presence of nodal metastases varied from 0 to 44%. The complication rate varied from 0 to 59%. The rate of development of subsequent inguinal lymph node metastases in those previously SLN biopsy-negative (a surrogate marker for false negative rate) ranged from 0 to 18.75%. CONCLUSION: SLN biopsy is a feasible method of assessing lymph node status in patients with anal squamous cell carcinoma. Longer follow up is required to evaluate the proportion of patients who are SLN biopsy-negative and subsequently develop nodal metastases. More studies are required to ascertain whether SLN biopsy should be the main method of assessing inguinal lymph node involvement in patients with anal squamous cell carcinoma.

Subacute physeal abscess: case report to illustrate treatment with a minimally invasive incision and drainage technique.

INTRODUCTION: Brodie's abscess is a form of subacute osteomyelitis characterised by a low grade pyogenic abscess found most commonly in the metaphysis. One rare form found in children crosses the physeal growth plate and into the epiphysis. Due to the rarity of this subtype and apprehension associated with treatment of the transphyseal abscess, no clear guidance exists on its management. CASE HISTORY: We present a case of delayed diagnosis of Brodie's abscess crossing the physis in a 14-year-old boy. He gave a one-year history of pain in the right knee and early x-rays had shown lucent areas in the tibia. However, these were only noted to be significant at presentation one year later. We also describe an improvised minimally invasive and atraumatic technique of modifying a laminar suction catheter for accessing and draining the abscess. CONCLUSIONS: From our experience and reports in the literature it is clear that antibiotic treatment is generally advocated with varying degrees of surgical intervention. Outcomes are largely favourable. Nevertheless, initial drainage allows samples to be sent for microbiological and histological assessment to aid subsequent management and may prevent subsequent leg length discrepancy from failed conservative treatment. We believe that management of a transphyseal abscess must include early drainage and a prolonged course of antibiotics. The antibiotic choice and duration will be governed by culture results and local policy but is commonly given for up to six weeks in the literature and must include one antistaphylococcal drug.

Mid-term outcomes following emergency endovascular aortic aneurysm repair for ruptured abdominal aortic aneurysms.

OBJECTIVE: Emergency Endovascular Aortic Aneurysm Repair (eEVAR) is a rapidly evolving approach to ruptured Abdominal Aortic Aneurysms (rAAA). Yet longer-term outcomes following eEVAR remain unclear. This study compares mid-term outcomes of eEVAR and open rAAA. METHODS: A prospective database for all patients undergoing eEVAR and open rAAA from January 2006 to April 2010 was analysed. Patients were offered eEVAR if anatomically suitable. RESULTS: 52 patients (45 male, median age 78 years (62-92 years), underwent eEVAR, 50 patients (44 male, median age = 71 (62-95 years) underwent open rAAA repair. In-hospital mortalities were 12% (6/52) for eEVAR, 32% (16/50) for open repair. There were five re-interventions (10%) in the eEVAR group. The peri-operative survival benefits of eEVAR over open rAAA repair were maintained at 1 and 2 years post-operatively with open repair demonstrating a two-fold increased risk of mortality (Hazard ratio 2.2, Fisher Exact test, 95% Confidence Interval (CI) 1.108-4.62, p = 0.0122). Overall survival was 81% at 1 year, 73% at 2 years for eEVAR, and 62% at 1 year and 52% at 2 years for open rAAA repair. CONCLUSION: EEVAR is associated with excellent mid-term survival in this cohort. We would recommend eEVAR as the management of choice for rAAA in anatomically suitable patients where local facilities and expertise exist.

Long-term effects of EVAR. Suprarenal versus infrarenal fixation.

Endovascular aortic aneurysm repair (EVAR) is the first line management of abdominal aortic aneurysms in many institutions. The relationship between EVAR and renal impairment, especially in the longer term remains unclear. Suprarenal graft fixation is widely used in order to achieve stable graft anchorage. Numerous studies have tried to answer the question about whether suprarenal fixation affects renal outcome. We reviewed the literature to investigate the relationship between endograft fixation and post-operative renal function.

Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery.

BACKGROUND: Surgical-site infection increases morbidity, mortality and financial burden. The preferred topical antiseptic agent (chlorhexidine or povidone-iodine) for preoperative skin cleansing is unclear. METHODS: A meta-analysis of clinical trials was conducted to determine whether preoperative antisepsis with chlorhexidine or povidone-iodine reduced surgical-site infection in clean-contaminated surgery. RESULTS: The systematic review identified six eligible studies, containing 5031 patients. Chlorhexidine reduced postoperative surgical-site infection compared with povidone-iodine (pooled odds ratio 0.68, 95 per cent confidence interval 0.50 to 0.94; P = 0.019) . CONCLUSION: Chlorhexidine should be used preferentially for preoperative antisepsis in clean-contaminated surgery.

Entrapment syndromes.

Entrapment syndromes represent a pathological process that vascular specialists encounter infrequently. However symptomatic patients are often young with impaired quality of life and successful treatment can produce great benefit, making knowledge of these conditions essential. The purpose of this review was to bring together the entrapment syndromes to understand and gain consensus on the aetiology, pathogenesis, diagnosis and modern management of these rare and interesting vascular disorders. This includes entrapment syndromes of the popliteal artery, superior mesenteric artery, coeliac artery, renal vein and iliac vein.

Gene therapy as a novel therapeutic option in the treatment of peripheral vascular disease: systematic review and meta-analysis.

BACKGROUND: Stimulation of therapeutic angiogenesis using gene therapy is a novel intervention for peripheral vascular disease (PVD). Despite encouraging outcomes from animal studies and phase 1 trials, results from larger trials in this area have been conflicting. We undertook a systematic review and meta-analysis of randomised controlled trials in this field, to clarify the current situation. METHODS: Medline, Embase, trial registries, the American Heart Association (AHA) abstract database and article reference lists were searched to identify randomised controlled trials of gene therapy for treatment of PVD. The outcomes were change in peak walking time and claudication onset time at 90 and 180 days post-treatment, and change in ankle-brachial pressure index (ABPI) at 90 days. Weighted mean differences (WMD) were calculated for these outcomes. RESULTS: Five eligible randomised clinical trials were identified, containing 508 patients. There were no significant differences between control and intervention groups for any outcomes, irrespective of whether low-dose or high-dose gene therapy was tried. CONCLUSION: The available data suggests that gene therapy confers no benefit on patients with PVD. Closer examination of the individual trials shows that several have an excessive placebo response, which may go some way to explaining our result. Further research in this area in needed.

Non-attendance at the colorectal clinic: a prospective audit.

INTRODUCTION: Non-attendance in the out-patient department has financial costs for the NHS and clinical implications to the non-attender and those awaiting an appointment. The aim of this audit was to quantify the percentage of non-attenders at colorectal clinics in a UK teaching hospital, assess which factors affected attendance, establish why individuals fail to attend and to implement appropriate change. PATIENTS AND METHODS: The number of 'did-not-attend' patients was recorded initially for 686 appointments. Non-attenders were contacted by post or telephone to ask why this was so. The study was then repeated following telephone reminders to 391 patients due to attend clinic. The 'did-not-attend' rates in the two limbs of the completed audit cycle were then compared. RESULTS: The initial study revealed a 'did-not-attend' rate of 21%, with significantly more males than females failing to attend (males, 28.6%; females, 16.9%; P = 0.001). The 'did-not-attend' rate was not significantly affected by the day of the week, time of appointment or by the weather. There were 51.7% responses to either the postal or telephone questionnaire regarding non-attendance. Of these, 27.7% did not receive an appointment letter or received it after the appointment. Hospital administration problems were cited as accounting for 34.2% of 'did-not-attends'. In the post-intervention limb, 87 patients (22%) replied to the reminder telephone call, of whom 9 (10%) cancelled their appointment and 78 (90%) confirmed that they would attend. The 'did-not-attend' rate fell to 19.7% although this was not a significant reduction. CONCLUSIONS: Telephoning patients before their appointments is labour intensive and did not significantly improve the 'did-not-attend' rate. Although hospital administration errors account for a significant number of the 'did-not-attends', patients also have a responsibility to notify the hospital if they are unable to attend.

Efficacy of TNP on lower limb wounds: a meta-analysis.

This meta-analysis of the three RCTs that have compared topical negative pressure with conventional treatment in patients with lower limb ulcers found that it significantly reduced healing times and increased the number of healed wounds.

The role of MRI in the diagnosis of proximal femoral fractures in the elderly.

The diagnosis of an undisplaced hip fracture cannot always be made on plain radiographs alone. The use of MRI scanning in detecting occult hip fractures is well documented. However, no previous studies have suggested which specific patient group would benefit most from this investigation. Thirty-five patients with hip pain and normal plain radiographs underwent MRI scanning. Pathology was detected in 29 of the patients, of which 21 involved a neck of femur fracture. Patients were divided into two groups based on age. In patients over 70 years, pathology detected resulted in surgical intervention in 13 cases. This is in contrast with those below the age of 70 years, in whom no neck of femur fractures were found and no surgical intervention was indicated (p<0.001). We recommend that an MRI scan be performed on such patients, above 70 years of age. These are the patients in whom management is significantly altered due to the imaging process used.

Displacement of the common peroneal nerve in posterolateral corner injuries of the knee.

We reviewed the relationship between the pattern of damage to the posterolateral corner of the knee and the position of the common peroneal nerve in 54 consecutive patients with posterolateral corner disruption requiring surgery. We found that 16 of the 18 patients with biceps avulsions or avulsion-fracture of the fibular head had a displaced common peroneal nerve. The nerve was pulled anteriorly with the biceps tendon. None of the 34 proximal injuries resulted in an abnormal nerve position. Whenever bone or soft-tissue avulsion from the fibular head is suspected, the surgeon should expect an abnormal position of the common peroneal nerve and appreciate the increased risk of iatrogenic damage.

A new structural class of selective and non-covalent inhibitors of the chymotrypsin-like activity of the 20S proteasome.

We describe the identification and in vitro characterization of a series of 2-aminobenzylstatine derivatives that inhibit non-covalently the chymotrypsin-like activity of the 20S proteasome. Our initial SAR data demonstrate that the 2-aminobenzylstatine core structure can effectively serve as the basis for designing potent, selective and non-covalent inhibitors of the chymotrypsin-like activity of the 20S proteasome.