A Comparison of the P-POSSUM and NELA Risk Score for Patients Undergoing Emergency Laparotomy in Singapore.

BACKGROUND (AIMS, HYPOTHESES, OR OBJECTIVES): Emergency laparotomy (EL) is a high-risk surgical procedure associated with considerable morbidity and mortality around the world. A reliable risk-assessment tool that is specific to patients undergoing EL allows the early identification of high-risk patients and enables appropriate healthcare resource allocation. The objective of this study was to compare the commonly used Portsmouth-physiologic and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) with the recently developed National Emergency Laparotomy Audit (NELA) score in terms of their accuracy for identifying patients at increased risk of 30-day mortality in a predominantly Asian population. METHODS: Physiological and operative data from a prospectively collected audit of adult patients undergoing EL in 2018 and 2019 across two tertiary hospitals in Singapore were used to retrospectively calculate both the P-POSSUM and NELA scores for each patient encounter. This was then compared to actual mortality rates to determine each model's accuracy and precision. RESULTS: 830 patients were included in the study with a 30-day mortality of 5.66%. The area under the receiver operating characteristics curve (AUROC) was similar for both the NELA (0.86, p < 0.001, 95% CI 0.81-0.91) and the P-POSSUM models (0.84, p < 0.001, 95% CI 0.78-0.89). While the models over-predicted mortality, overall O:E ratios showed that the NELA model performance was superior to that of P-POSSUM (0.58 [95% CI 0.43-0.77] compared to 0.34 [95% CI 0.26-0.46]). CONCLUSION: The NELA risk-prediction model accurately predicts 30-day mortality in this large cohort of patients undergoing EL and outperforms the current P-POSSUM model. We recommend that the NELA score should replace the P-POSSUM score as a model to distinguish between high- and low-risk patients undergoing EL.

Immune responses induced by co-infection with Capillaria hepatica in Clonorchis sinensis-infected rats.

Clonorchis sinensis and Capillaria hepatica are zoonotic parasites that mainly infect the liver and cause serious liver disorders. However, immunological parameters induced by co-infection with these parasites remain unknown. In this study, for the first time, we investigated immunological profiles induced by co-infection with C. hepatica (CH) in C. sinensis (CS)-infected rats (Sprague-Dawley). Rats were infected primarily with 50 metacercariae of C. sinensis; 4 weeks later, they were subsequently infected with 1000 infective C. hepatica eggs. Significantly higher levels of C. sinensis- or C. hepatica-specific IgG antibodies were found in the sera of rats. Interestingly, no cross-reacting antibody was observed between C. sinensis and C. hepatica infections. Significantly raised eosinophil levels were found in the blood of C. sinensis/C. hepatica co-infected rats (CS + CH) compared to the blood of rats infected singly with C. sinensis. Co-infected rats showed significantly higher levels of lymphocyte proliferation and cytokine production compared to a single C. sinensis infection. The worm burden of C. sinensis was significantly reduced in co-infected rats compared to the single C. sinensis infection. These results indicate that the eosinophils, lymphocyte proliferation and cytokine production induced by subsequent infection with C. hepatica in C. sinensis-infected rats might contribute to the observed C. sinensis worm reduction.

Endoscopic total extraperitoneal repair of recurrent inguinal hernia: a 5-year review.

PURPOSE: The experience of endoscopic total extraperitoneal (TEP) repair of recurrent inguinal hernia in a major teaching hospital is reviewed. METHODS: Between 2003 and 2008, 37 consecutive patients underwent 46 TEP repairs for recurrent inguinal hernia. Patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured. Twenty-eight patients had unilateral hernia and nine patients had bilateral hernias. The mean age was 59 years old (range 22-88 years). RESULTS: The mean operation duration was 88 min (range 60-120 min). Bilateral repairs took 38% longer than for unilateral repairs (108 vs 78 min). Three patients (8.1%) had conversion to open surgery. Seroma developed in two patients, which was subsequently resolved. Within 1 year of follow up evaluation, there was 1 recurrence (2.7%). The mean inpatient hospital stay was 1.6 days, and 24.3% of the operations were performed as outpatients. CONCLUSION: Repair of recurrent hernia using the TEP approach can be achieved with minimum morbidity, good clinical outcomes and acceptable recurrence rates. Endoscopic repair has become the procedure of choice for the treatment of the majority of recurrent inguinal hernias at our institution.

Ethanol-induced liver injury and changes in sulfur amino acid metabolomics in glutathione peroxidase and catalase double knockout mice.

BACKGROUND/AIMS: Oxidative stress via generation of reactive oxygen species is suggested to be the major mechanism of alcohol-induced liver injury. We investigated the effects of glutathione peroxidase-1 and catalase double deficiency (Gpx-1(-/-)/Cat(-/-)) on liver injury and changes in the sulfur amino acid metabolism induced by binge ethanol administration. METHODS: Ethanol (5 g/kg) was administered orally to the wild-type and the Gpx-1(-/-)/Cat(-/-) mice every 12 h for a total of three doses. Mice were sacrificed 6 h after the final dose. RESULTS: The Gpx-1/Cat deficiency alone increased malondialdehyde levels in liver significantly. Hepatic methionine adenosyltransferase (MAT) activity and S-adenosylmethionine levels were decreased, however, glutathione contents were not changed. Ethanol administration to the Gpx-1(-/-)/Cat(-/-) mice increased the elevation of serum alanine aminotransferase activity, plasma homocysteine levels, hepatic fat accumulation and lipid peroxidation compared with the wild-type animals challenged with ethanol. Also the reduction of MAT activity and S-adenosylmethionine levels was enhanced, but MATI/III expression was increased significantly. CONCLUSIONS: The results indicate that Gpx-1 and Cat have critical roles in the protection of liver against binge ethanol exposure. Augmentation of ethanol-induced oxidative stress may be responsible for the impairment of the transsulfuration reactions and the aggravation of acute liver injury in the Gpx-1(-/-)/Cat(-/-) mice.

NSAID-induced antral ulcers are associated with distinct changes in mucosal gene expression.

BACKGROUND: The basis for individual variation in gastroduodenal vulnerability to NSAIDs is not well understood. AIM: To assess whether a gene expression signature is associated with susceptibility to gastroduodenal ulcerations. METHODS: Twenty-five Helicobacter pylori negative adults were treated for 7 days with naproxen 500 mg b.d. Subjects underwent baseline and post-treatment endoscopy, during which biopsies were taken from antrum and duodenum. RNA extraction and cDNA synthesis were performed, followed by PCR of 23 genes relevant to mucosal injury and repair. Fold changes in gene expression were compared between subjects who developed ulcers and those who did not. RESULTS: Compared with subjects who did not develop ulcers (n = 18), subjects who developed antral ulcers (n = 7) had significantly greater mucosal up-regulation of interleukin-8 [Fold change = 33.5 (S.E.M. = 18.5) vs. -7.7 (3.2)] and of cyclo-oxygenase-2 [2.3 (1.7) vs. -10.8 (2.2)]. Conversely, non-ulcer subjects had significantly greater up-regulation of toll-like receptor-4, cyclo-oxygenase-1 and hepatocyte growth factor [14.0 (2.2) vs. -0.8 (1.0), 9.8 (2.4) vs. 0.0 (0.7) and 8.2 (2.6) vs. -2.2 (0.3) respectively]. CONCLUSIONS: NSAID-induced antral ulcers are associated with a specific pattern of gastroduodenal mucosal gene expression. These patterns may provide an insight into the molecular basis of individual susceptibility to mucosal injury.

Vitamin D: molecular mechanism of action.

Vitamin D maintains calcium homeostasis and is required for bone development and maintenance. Recent evidence has indicated an interrelationship between vitamin D and health beyond bone, including effects on cell proliferation and on the immune system. New developments in our lab related to the function and regulation of target proteins have provided novel insights into the mechanisms of vitamin D action. Studies in our lab have shown that the calcium-binding protein, calbindin, which has been reported to be a facilitator of calcium diffusion, also has an important role in protecting against apoptotic cell death in different tissues including protection against cytokine destruction of osteoblastic and pancreatic beta cells. These findings have important implications for the therapeutic intervention of many disorders including diabetes and osteoporosis. Recent studies in our laboratory of intestinal calcium absorption using calbindin-D(9k) null mutant mice as well as mice lacking the 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) inducible epithelial calcium channel, TRPV6, provide evidence for the first time of calbindin-D(9k) and TRPV6 independent regulation of active calcium absorption. Besides calbindin, the other major target of 1,25(OH)(2)D(3) in intestine and kidney is 25(OH)D(3) 24 hydroxylase (24(OH)ase), which is involved in the catabolism of 1,25(OH)(2)D(3). In our laboratory we have identified various factors that cooperate with the vitamin D receptor in regulating 24(OH)ase expression including C/EBP beta, SWI/SNF (complexes that remodel chromatin using the energy of ATP hydrolysis) and the methyltransferases, CARM1 and G9a. Evidence is also presented for C/EBP beta as a nuclear coupling factor that coordinates regulation of osteopontin by 1,25(OH)(2)D(3) and PTH. Our findings define novel mechanisms that may be of fundamental importance in understanding how 1,25(OH)(2)D(3) mediates its multiple biological effects.

Molecular cloning and expression of a cDNA encoding the luciferase from the firefly, Pyrocoelia rufa.

To clone a cDNA encoding the luciferase of the firefly, Pyrocoelia rufa, we have constructed a cDNA library and isolated the luciferase gene using PCR with gene specific primers. Sequence analysis of the cDNA encoding the luciferase of P. rufa revealed that the 1647 bp cDNA has an open reading frame of 548 amino acid residues. The deduced amino acid sequences of the luciferase gene of P. rufa showed 98.9% homology to that of P. miyako. Phylogenetic analysis further confirmed the deduced amino acid sequences of the P. rufa luciferase gene belonged to the same subfamily, Lampyrinae. Southern blot analysis suggested possible presence of the P. rufa luciferase gene as a single copy and Northern blot analysis confirmed light organ-specific expression pattern at the transcriptional level. The cDNA encoding the luciferase of P. rufa was expressed as a 69 kDa band in baculovirus-infected insect cells and the recombinant baculovirus-infected cell extracts emitted luminescence in the luciferase activity assay.

Tissue-/stage-dependent expression of a cloned Bombyx mandarina QM homologue.

QM, a novel gene that was firstly isolated as a putative tumor suppressor gene from Wilms' tumor cell line. Although it is well known that the QM gene product plays an important role within the tumor cells, the precise role of QM in the non-tumor cells has remained elusive. With in this mind we isolated a cDNA encoding QM homologue from Bombyx mandarina to understand the function of QM. The 596 bp cDNA has an open reading frame of 219 amino acids and a predicted mol. wt. of 25 kDa. The protein has more than 88% amino acid sequence identity to the QM protein from Drosophila melanogaster. mRNA expression gradually increased from 1-2 days after egg laying to 2 days of finial instar, while very low expressions were detected for either the pupae and the moth stages. The organs, posterior/middle division of silkgland, midgut, fat body and malpighian tubes, also show relatively high mRNA expression levels, respectively. The high degree of conservation and expression of the B. mandarina QM homologous suggest that it has a selectively conserved amino acid sequence due, presumably, to an important biological role which is associated with pupae formation.

Molecular genetic relationships between Bombycidae and Saturniidae based on the mitochondria DNA encoding of large and small rRNA.

The phylogenetic relationships between Bombycidae (Bombyx mori and Bombyx mandarina) and Saturniidae (Antheraea yamamai and Antheraea pernyi) were investigated based on large and small mitochondiral rRNA genes. About 430 bp of four kinds of PCR-amplified fragments were sequenced and aligned. For the 16S rRNA gene, B. mori shared a 98, 87 and 86% sequence homology with B. mandarina, A. yamamai and A. pernyi, and for the 12S rRNA gene, B. mori shared a 99, 89 and 88% sequence homology with B. mandarina, A. yamamai and A. pernyi, respectively. DNA sequence data were also used for a phylogenetic analysis. All of the trees showed monophyly for both Bombycidae and Saturniidae. The monophyly confidence limits of these trees were estimated using bootstrapping tests and measured more than 99% for all trees for both Bombycidae and Saturniidae.

The comparative molecular study between Bombycidae and Saturniidae based on mtDNA RFLP and cytochrome oxidase I gene sequences: implication for molecular evolution.

The phylogenetic relationships between Bombyx mori and Bombyx mandarina species of Bombycidae, and Antheraea yamamai and Antheraea pernyi species of Saturniidae were investigated based on mtDNA RFLP and cytochrome oxidase I gene. The sizes of the mtDNA of all the species were estimated at approximately 16 kbp +/- 500 bp by total length of all the restricted fragments and no variation in size was recognized. Of the fourteen different restriction endonucleases used, BamHI, HindIII, PstI, EcoRI and XbaI showed RFLP. Among these, only HindIII showed RFLP between B. mori and B. mandarina. A comparative analysis of sequences was also conducted with the mitochondrial cytochrome oxidase I genes of each species. The results indicated that B. mori shared a 97%, 85% and 87% sequence identity with B. mandarina, A. yamamai and A. pernyi, respectively. B. mandarina shared a 87% and 88% sequence identity with A. yamamai and A. pernyi, respectively. A. yamamai shared 92% sequence identity with A. pernyi. The results of the phylogenetic analysis exhibited monophyly and confidence limits of more than 99% in all trees for both Bombycidae and Saturniidae.

Molecular cloning and characterization of a cDNA encoding a transferrin homolog from Bombyx mori.

We isolated a cDNA representing a message that was strongly induced by injection with E. coli in Bombyx mori. The 2160 bp cDNA has an open reading frame of 644 amino acids and the deduced product a predicted molecular mass of 71 kDa. The cDNA sequence shared high homology with the transferrins known so far, and its deduced peptide had unique features of transferrins, that is, sites of cystein residues and iron binding. We suggest that the B. mori transferrin plays an important role in the self-defense system.

Modern medicine in Taiwan (II).

Taiwan's population has undergone rapid growth. From 3000000 in 1906. It had grown to 6000000 by 1941. By the end of 1996 the total population has reached 21500000. This large population is served by over 120000 health professionals. For every 10000 people there are 12.91 doctors (including 11.52 Western medical doctors and 1.39 Chinese medical doctors), 3.37 dentists and 9.36 pharmacists. There has been a huge change in causes of mortality. Under the Japanese occupation, the main causes of death were malaria, pneumonia, dysentery, enteritis, and pulmonary tuberculosis. After the return to Chinese control, the main causes were acute contagious diseases and digestive tract disease. At present, malignant tumors, cerebrovascular accident, heart disease, and diabetes are the main causes of death. With the development of the health-care system, infectious diseases have been controlled or eliminated. Malaria was eradicated from the island in 1956.

[The efficacy of intravenous fentanyl patient-controlled analgesia for postoperative pain relief].

The safety and efficacy of patient-controlled analgesia used for postoperative pain relief were evaluated. Cumulative 24-hour requirements were analyzed for possible correlation with patient characteristics. All patients who used a patient-controlled analgesia device for postoperative pain relief were reviewed from June to October 1991. The device Baxter's basal/bolus infusor with patient control module, was used to deliver fentanyl in 379 patients. The fentanyl requirement, verbal analog pain score, first passage of flatus, side effects, sedative score, and degree of satisfaction were examined. The fentanyl requirement during the first 24 hours after operation was analyzed with regard to age, body weight, and sex. The daily fentanyl consumption in the first three postoperative days was 928 +/- 352 micrograms (n = 338), 553 +/- 259 micrograms (n = 220), and 490 +/- 222 micrograms (n = 71), respectively. The requirement for fentanyl during the first 24 hours after surgery was significantly higher than for the next two days (p-value < 0.001). Fentanyl consumption correlated well with body weight, and inversely with age. No difference was found between fentanyl consumption and sex (p-value = 0.4687). The mean time to the first passage of flatus in patients with abdominal surgery was 54.6 +/- 26.4 hours. The incidence of nausea, vomiting, and dizziness was similar, about 20% of patients. Itching was noted in 7% of patients. Oversedation (class 4) was found in three patients during the first operative day, the sedative score for other patients were around class 1-3. No patient exhibited signs of respiratory depression or withdrawal syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

[A comparison of patient-controlled analgesia with traditional intramuscular administration for postoperative pain relief].

The use of a disposable non-electronic patient-controlled analgesia (PCA) device (Baxter) was evaluated in this study. Every patient under trial was instructed thoroughly how to use the PCA device before operation. The PCA device delivers a 25 mg IV injection of pethidine upon patient demand with a delay of 15 min between allowable administrations. The degree of patient satisfaction, the drug consumption, and the duration of using analgesia were compared with those in IM pethidine group. The results showed that, in the PCA group, the duration of using analgesic was longer; the drug consumption was greater (especially during the first 20 h after operation); and the degree of patient satisfaction was higher. The series comprised a total of 54 patients, 14 of whom complained of mild dizziness or nausea which did not require specific treatment. In sum, giving analgesic by the Baxter PCA device was a safe and effective alternative for IM analgesic in postoperative pain control.

Acute poisoning with a glyphosate-surfactant herbicide ('Roundup'): a review of 93 cases.

Between 1 January 1980, and 30 September 1989, 93 cases of exposure to herbicides containing glyphosphate and surfactant ('Roundup') were treated at Changhua Christian Hospital. The average amount of the 41% solution of glyphosate herbicide ingested by non-survivors was 184 +/- 70 ml (range 85-200 ml), but much larger amounts (500 ml) were reported to have been ingested by some patients and only resulted in mild to moderate symptomatology. Accidental exposure was asymptomatic after dermal contact with spray (six cases), while mild oral discomfort occurred after accidental ingestion (13 cases). Intentional ingestion (80 cases) resulted in erosion of the gastrointestinal tract (66%), seen as sore throat (43%), dysphagia (31%), and gastrointestinal haemorrhage (8%). Other organs were affected less often (non-specific leucocytosis 65%, lung 23%, liver 19%, cardiovascular 18%, kidney 14%, and CNS 12%). There were seven deaths, all of which occurred within hours of ingestion, two before the patient arrived at the hospital. Deaths following ingestion of 'Roundup' alone were due to a syndrome that involved hypotension, unresponsive to intravenous fluids or vasopressor drugs, and sometimes pulmonary oedema, in the presence of normal central venous pressure.

[Cerebral infarction after resection of epidermoid carcinoma of buccal mucosa under general anesthesia--report of one case].

A 60 year-old hypertensive male was operated with resection of epidermoid carcinoma of buccal mucosa. He was expired postoperation complicated with left middle cerebral artery infarction. The cerebral infarction may be induced by acute hypotension, improper position during operation and underlying disease associated with old age. Prevention methods included preoperative evaluation, immediately injection vasopressor when acute hypotension occurred during anesthesia, and avoidance of improper position to compress vertebral or carotid artery which may leading to cerebral perfusion insufficiency.