A modified method for intubation of a patient with ankylosing spondylitis using intubating laryngeal mask airway (LMA-Fastrach)--a case report

We present an instance of successful use of an intubating laryngeal mask airway (LMA-Fastrach) and a Cook airway exchanger (CAE) for ventilation and intubation in a patient with severe ankylosing spondilitis (AS) receiving total hip arthroplasty. This measure may serve as an effective alternative for airway management in patients with difficult airway. A 61-year-old male was scheduled for right total hip arthroplasty because of degenerative osteoarthritis. He had been suffering from extensive ankylosing spondylitis, with the cervical spine markedly fixed in anterior flexion. Besides he could not open his mouth widely (35 mm when fully open) also because of ankylosis of jaw. Although we advised an awake fiberoptic tracheal intubation for anesthesia but he refused owing to a previous painful experience. After induction of anesthesia with glycopyrrolate, fentanyl, thiamylal sodium and succinylcholine, we inserted a # 5 Fastrach ILMA for primary airway maintenance. Then through the lumen of the ILMA we introduced the CAE as a guide for endotracheal tube (ETT) intubation. After applying the RAPI-FIT adapter to the CAE, we connected it to the capnography monitor for the confirmation of airway. We finally inserted an endotracheal tube into the trachea using the CAE as a guide. The whole procedure was uneventful and smooth. In sum, the modified Fastrach intubation method may facilitate tracheal intubation in patients with severe ankylosing spondilitis. It may be an alternative way for successful airway management in patients with difficult airway.     

DNA methylation analysis: a powerful new tool for lung cancer diagnosis

Carcinoma of the lung is the most common cause of cancer death worldwide. The estimated 5-year survival ranges from 6-16%, depending on the cell type. The best opportunity for improving survival of lung cancer patients is through early detection, when curative surgical resection is possible. Although the subjects at increased risk for developing carcinoma of the lung (long-term smokers) can be identified, only 10-20% of this group will ultimately develop the disease. Screening tests of long-term smokers employed to date (radiography and sputum cytology) have not been successful in reducing lung cancer mortality. The application of molecular markers specific for lung cancer offers new possibilities for early detection. Hypermethylation of CpG islands in the promoter regions of genes is a common phenomenon in lung cancer, as demonstrated by the analysis of the methylation status of over 40 genes from lung cancer tumors, cell lines, patient sputum and/or serum. Determination of the methylation patterns of multiple genes to obtain complex DNA methylation signatures promises to provide a highly sensitive and specific tool for lung cancer diagnosis. When combined with the development of non-invasive methods to detect such signatures, this may provide a viable method to screen subjects at risk for lung cancer.     

Associations of polybrominated diphenyl ethers (PBDEs) in breast milk and dietary habits and demographic factors in Taiwan

The aim of this study was to examine levels of PBDEs in breast milk associated with seafood consumptions of Taiwanese mothers. Our participants were selected from healthy women recruited between December 2000 and November 2001 from a medical center in central Taiwan. The congeners of PBDEs in 20 milk samples were analyzed by a gas chromatograph with a high resolution mass detector. The mean level of BDE47 in breast milk from mothers with pre-pregnant BMI <22.0 kg/m² had a significantly higher magnitude compared to those with pre-pregnant BMI 22.0 kg/m² (1.59 vs. 0.995 ng/g lipid, p = 0.041). We did not find significant correlations between PBDEs exposure levels and women’s age, parity, blood pressure, annual household income, and education level. Women who ate more fish and meat did not show significantly higher PBDE levels than those who ate less, but a significant difference in PBDE levels was demonstrated between the higher (2.15 ng/g lipid) and lower (3.98 ng/g lipid) shellfish consuming subjects (p = 0.002) after an adjustment for the confounders. The ratios of PCB153/BDE47, PCB153/BDE153, and PCB153/PBDEs were significantly correlated with frequent consumption of fish and shellfish. The PCB153/BDE153 ratio was not associated with the other dietary habits (i.e. meat). The ratios of PCB153/PBDEs may therefore be a new indicator for exposure as a result of seafood consumption.     

Responses to questions by medical students about family practice

Medical students frequently have questions about the specialty of family practice. Responses to 30 questions commonly asked about family practice are presented with a review of recent literature. These responses may assist medical students and their advisors in considering the choice of family practice as a career.     

Diseases of comfort: primary cause of death in the 22nd century

CONTEXT: The world has started to feel the impact of a global chronic disease epidemic, which is putting pressure on our health care systems. If uncurbed, a new generation of "diseases of comfort" (such as those chronic diseases caused by obesity and physical inactivity) will become a major public health problem in this and the next century. OBJECTIVE: To describe the concept, causes, and prevention and control strategies of diseases of comfort. METHODS: Brokered by a senior research scientist specialised in knowledge translation, a chair, a president, and a past president of national public health associations contributed their views on the subject. RESULTS: Diseases of comfort have emerged as a price of living in a modern society. It is inevitable that these diseases will become more common and more disabling if human "progress" and civilisation continue toward better (more comfortable) living, without necessarily considering their effects on health. Modern technology must be combined with education, legislation, intersectoral action, and community involvement to create built and social environments that encourage, and make easy, walking, physical activity, and nutritious food choices, to reduce the health damaging effects of modern society for all citizens and not only the few. CONCLUSIONS: Public health needs to be more passionate about the health issues caused by human progress and adopt a health promotion stance, challenging the assumptions behind the notion of social "progress" that is giving rise to the burden of chronic disease and developing the skills to create more health promoting societies in which individual health thrives.     

Use of Prior Information for Bayesian Evaluation of Bridging Studies

The proportion ratio (PR) of a positive response between an experimental treatment and a standard treatment (or placebo) is often used to measure the relative treatment efficacy in a randomized clinical trial (RCT). For ethical reasons, it is almost inevitable to encounter some patients not complying with their assigned treatment. Furthermore, when there are confounders in a RCT or meta-analysis, we commonly employ stratified analysis to control the confounding effects on interval estimation of the PR. On the basis of a general risk multiplicative model, we focus our discussion on interval estimation of the PR in repeated binary data under a stratified RCT with noncompliance. We develop seven asymptotic closed-form interval estimators for the PR. We apply Monte Carlo simulation to study the finite-sample performance of these interval estimators in a variety of situations. We note that the two interval estimators with the logarithmic transformation based on the commonly used weighted least squares (WLS) approach can be liberal, while the three interval estimators with the Mantel–Haenszel (MH) weight derived from various methods can consistently perform well. We also note that the two estimators with the estimated optimal weight defined in the context using Fieller's Theorem and a randomization-based approach may not necessarily produce a confidence interval preferable to the MH-type interval estimators for the PR with respect to accuracy and precision.     

Sample Size Determination for a Specific Region in a Multiregional Trial

Recently, geotherapeutics have attracted much attention from sponsors as well as regulatory authorities. A bridging study defined by the International Conference on Harmonisation (ICH) E5 is usually conducted in the new region after the test product has been approved for commercial marketing in the original region due to its proven efficacy and safety. However, extensive duplication of clinical evaluation in the new region not only requires valuable development resources but also delays availability of the test product to the needed patients in the new regions. To shorten the drug lag or the time lag for approval, simultaneous drug development, submission, and approval in the world may be desirable. On September 28, 2007, the Ministry of Health, Labour and Welfare (MHLW) in Japan published the “Basic Principles on Global Clinical Trials” guidance related to the planning and implementation of global clinical studies. The 11th question and answer for the ICH E5 guideline also discuss the concept of a multiregional trial. Both guidelines have established a framework on how to demonstrate the efficacy of a drug in all participating regions while also evaluating the possibility of applying the overall trial results to each region by conducting a multiregional trial. In this paper, we focus on a specific region and establish statistical criteria for consistency between the region of interest and overall results. More specifically, four criteria are considered. Two criteria are to assess whether the treatment effect in the region of interest is as large as that of the other regions or of the regions overall, while the other two criteria are to assess the consistency of the treatment effect of the specific region with other regions or the regions overall. Sample size required for the region of interest can also be evaluated based on these four criteria.     

Community Outbreak of Adenovirus,Taiwan, 2011

In 2011, a large community outbreak of human adenovirus (HAdV) in Taiwan was detected by a nationwide surveillance system. The epidemic lasted from week 11 through week 41 of 2011 (March 14–October 16, 2011). Although HAdV-3 was the predominant strain detected (74%), an abrupt increase in the percentage of infections caused by HAdV-7 occurred, from 0.3% in 2008–2010 to 10% in 2011. Clinical information was collected for 202 inpatients infected with HAdV; 31 (15.2%) had severe infection that required intensive care, and 7 of those patients died. HAdV-7 accounted for 10%, 12%, and 41% of infections among outpatients, inpatients with nonsevere infection, and inpatients with severe infection, respectively (p<0.01). The HAdV-7 strain detected in this outbreak is identical to a strain recently reported in the People’s Republic of China (HAdV7-HZ/SHX/CHN/2009). Absence of circulating HAdV-7 in previous years and introduction of an emerging strain are 2 factors that caused this outbreak.     

Change in hepatitis A epidemiology after vaccinating high risk children in Taiwan, 1995-2008

Taiwan started to immunize children in 30 indigenous townships against hepatitis A since June 1995. The program was further expanded to 19 non-indigenous townships with higher incidence or increased risk of epidemic in 1997-2002, covering 2% of total population. Annual incidence of hepatitis A decreased from 2.96 in 1995 (baseline period) to 0.90/100,000 in 2003-2008 (vaccination period). The incidence in vaccinated townships and unvaccinated townships declined 98.3% (49.66-0.86/100,000) and 52.6% (1.90-0.90/100,000). In 2003-2008, incidence doubled in people aged >=30 years, mostly in unvaccinated townships (0.42-0.92). During 2003-2008, travel to endemic countries was the most commonly reported risk factor (13.5%). First dose vaccine coverage was 78.8% in 1994-2005 birth cohort. Taiwan's experience demonstrates the great, long-term efficacy of hepatitis A vaccine in disease control in vaccinated townships, and out-of-cohort effect in unvaccinated townships. Further reduction can be achieved by improving vaccination coverage of adults at risk.