Successful pregnancy after recurrent hysteroscopic polypectomy

This case demonstrates that hysteroscopic polypectomy can enhance fertility. A 35-year-old woman was being evaluated for assisted conception. She was referred from an in vitro fertilisation clinic for polypectomy, which she had undergone on two occasions. She conceived spontaneously, had an uneventful antenatal period, and delivered a healthy baby at 39 weeks' gestation.     

The clinical and biochemical effects of vitamin C supplementation in short-stay hospitalized geriatric patients

A double-blind placebo trial has been undertaken on 199 elderly patients admitted to an "acute" geriatric assessment ward. Clinical and biochemical assessment was made on admission (0) and at 2, 4, 8, 16 and 24 weeks (after admission). Ninety-four patients were supplemented with vitamin C (200 mg per day) and 105 had placebo tablets. Biochemical assessment included estimations of plasma and leucocyte (buffy layer) vitamin C, plasma folate, vitamin B12, cortisol and total white cell count. Plasma and leucocyte vitamin C levels remained low for several weeks in a substantial proportion of the non-supplemented patients, whereas low levels were virtually eliminated in the supplemented group. The results from this study suggest that the leucocyte vitamin C levels may give some indication of prognosis in this category of patients (ie. "acute" geriatric admissions) as evidenced by: i) the significantly higher mortality rate during the trial period of patients who started with low initial leucocyte vitamin C levels compared with those starting with higher levels, despite similar mean initial "severity of illness scores" between the two groups. ii) the marked trend, amongst placebo subjects, for those commencing the study with higher leucocyte vitamin C levels to fare better, in terms of progression to "well", than those starting with low levels. Amongst subjects starting with low leucocyte vitamin C levels, there was a trend for "vitamin C" subjects to have fared better by 8 weeks than "placebo" subjects. This again occurred despite similar mean initial "severity scores" between the two groups. Amongst subjects diagnosed with respiratory infections there was some tendency for supplemented patients to fare better than unsupplemented patients. Low leucocyte vitamin C levels, on admission, appear to be predictive of poor subsequent prognosis in elderly hospitalised patients. Results from this trial suggest that supplementation with a moderate dose of vitamin C may improve this prognosis and larger trials with greater numbers appear to be merited to confirm or deny this hypothesis.     

Catastrophic familial rhabdomyolysis: compartment syndrome with muscle fiber regeneration

Two reports of patients with rhabdomyolysis are described. Patient 1 was a 4-year-old-girl who had a 48-hour history of pyrexia and a 24-hour history of vomiting, drowsiness, polydipsia oliguria, and back pain. She could not walk easily because of tenderness in the calves. She was treated with furosemide and dopamine. On day 9, she was mobilized with the aid of physiotherapy. After 2 years, she tired easily but could walk normally. Patient 2 was a 3-year-old girl who had a 24-hour history of general malaise, peripheral aches and pain, and increasing drowsiness. She had severe swelling in the calves. Full-leg four compartment fasciotomies were performed on both calves. After patient 2 healed, she was observed to have muscle regeneration, which is very rare.     

Effect of soybean fortification on Ghanaian fermented maize dough aroma

The effect of soy fortification on the development of aroma compounds, dough acidity and growth of the predominant microorganisms were investigated in Ghanaian maize dough fermented spontaneously over a period of 72 h. The fortified maize dough was prepared from a milled mixture of soaked maize grains and pre-soaked, blanched and dehulled soybeans added at 20% replacement level. Extracts of volatiles from the soy-fortified and unfortified dough samples were obtained by Likens–Nickerson simultaneous distillation and extraction method analysed by gas chromatography-mass spectrometry and gas chromatography-olfactometry (gas chromatography-sniffing). Major aroma compound groups identified in the fermented dough samples were carbonyls, alcohols, esters and volatile organic acids. Twenty-nine carbonyls were found in soy-fortified maize dough compared with 21 in the unfortified dough. Although the same alcohols were found in both dough samples, the total concentration of alcohols was slightly different, being less for the soy-fortified sample. Total concentration of esters in soy-fortified dough decreased after 72 h while levels in the unfortified dough increased. Increases in the production of lactic and acetic acids occurred in soy-fortified samples, but the maximum concentrations of acetic acid achieved did not differ significantly between the two types of dough. Twenty-three compounds were perceived to be contributing to the typical aroma of soy-fortified maize dough by the method of gas chromatography-sniffing. These included 12 carbonyls, six alcohols, two esters, two acids and one furan.     

循证医学理念与方法在全科医学教学中的应用及意义

在全科教学中引入循证医学,可以有效提高全科医生临床决策能力,促进全科医学服务模式转变,丰富全科医学内涵。将循证医学理念应用到全科医学教育的途径包括强化全科循证医学师资力量、创新全科循证医学教学方式、将循证医学技能评价与考核引入全科医生考核体系。全科医学教学中引入循证医学教育尚面临诸多问题,需持续改进全科医生循证医学教学手段,科学开展全科医生循证医学教学评估。     

Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.     

No evidence of chikungunya virus and antibodies shortly before the outbreak on Sri Lanka

A massive outbreak of chikungunya disease occurred on Sri Lanka in 2006. Reasons for the explosive nature of the epidemic are being intensively discussed. According to recognised and anecdotal concepts, absence of human population immunity against chikungunya virus (CHIKV) might have supported virus amplification. However, formal proof of concept is lacking. This study determined the prevalence of anti-CHIKV IgG antibodies as well as CHIKV RNA shortly before the outbreak. Two hundred and six human sera were collected from patients with acute febrile illness in 2004/2005. Validated indirect immunofluorescence and real-time RT-PCR assays for dengue as well as CHIKV were employed. Laboratory evidence of dengue virus infection was seen in 67% of patients, indicating virus activity and exposure to Aedes spp. vectors. These vectors are the same as for chikungunya. However, no evidence of acute or previous chikungunya infection could be demonstrated in the same cohort. This study gives formal evidence that the absence of human population immunity correlated with a large chikungunya epidemic. M. Panning and D. Wichmann contributed equally to this work.     

High frequency oscillation in newborn infants with respiratory failure

Objective: To report ventilation strategies, survival and complications in 39 outborn infants treated with high frequency oscillatory ventilation (HFOV).
Methodology Data were collected prospectively between 1 May 1992 and 31 December 1993 on all infants treated with HFOV who had severe respiratory failure despite optimal conventional ventilation.
Results Twenty-eight out of 39 (72%) survived. Of the 15 infants with birthweights <1500g, eight survived. Best survival rates were for infants with pulmonary interstitial emphysema with air leak (4/5) and for infants of birthweight >1500g with hyaline membrane disease (8/8), and meconium aspiration syndrome (7/7). Three infants deteriorated while on HFOV and required extracorporeal membrane oxygenation. Complications were: (i) development of pulmonary interstitial emphysema (1); (ii) recurrence of pneumothorax (3); (iii) hypotension (2); and (iv) bronchopulmonary dysplasia (9). One of the eight infants weighing <1500g who received HFOV in the first week of life developed periventricular haemorrhage.
Conclusion The initial results of HFOV for severe respiratory failure were encouraging although a learning curve was encountered with its introduction.