INTRODUCTIONPaediatric laparoscopic choledochal cyst excision has increasingly gained acceptance as an alternative to open excision. Laparoscopic excision is feasible and safe in the short term, but long-term outcomes are not as well established. KK Women's and Children's Hospital started performing laparoscopic choledochal cyst excision in children since 2007. In this paper, we report our experience with the laparoscopic approach, and the early and mid-term outcomes in comparison with the conventional open approach.

MATERIALS AND METHODSThirty-five consecutive cases by a single surgeon between May 2006 and April 2012 were retrospectively reviewed. Patient characteristics and surgical outcomes were analysed.

RESULTSThere were 13 laparoscopic and 22 open cases. Baseline patient characteristics were similar. Operative time was longer in the laparoscopic group. Three cases in the laparoscopic group were converted to open in our early experience. There were no differences in time to feeds or length of hospitalisation. One laparoscopic case developed minor bile leak that resolved on conservative management. There were no complications in the laparoscopic group on median follow-up of 35 months. In the open group, there was 1 case of pancreatitis, cholangitis, and hypertrophic scarring respectively. There were 3 cases of suspected adhesive colic that resolved without surgery.

CONCLUSIONLaparoscopic choledochal cyst excision enjoys excellent early and mid-term outcomes compared to open excision, even in centres with smaller patient volume. It should be the approach of choice where technical expertise is available.

Child, Preschool ; Choledochal Cyst ; surgery ; Digestive System Surgical Procedures ; methods ; Female ; Hospitals, Pediatric ; Humans ; Laparoscopy ; Male ; Retrospective Studies ; Tertiary Care Centers ; Time Factors ; Treatment Outcome

The article probes into the approach to the interns' capability of clinical thinking and analyzing and solving problems by disscussing causes of gastrointestinal hemorrhage. Correct clinical thinking always comes from solid basis and clinical theory and knowledge, careful history taking, meticulous physical examination, rigorous logical thinking and constant summing up experiences and lessons. As a teacher, we should help interns develop clinical thinking ability during their whole peroid of medical education.Besides, theory should be combined with practice to prevent and correct vicious clinical thinking

INTRODUCTIONParenteral nutrition (PN) is an important supportive therapy. However, it is expensive and associated with significant complications. Our aim is to describe the patients given PN in 2006, to compare with the 2001 cohort and determine if PN had been prescribed for the appropriate indications.

MATERIALS AND METHODSA retrospective cohort study of adult patients receiving PN between January and December 2006 was undertaken in a single institution. Appropriateness of indications for PN was based on the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines 2002.

RESULTSOne hundred and eighty-two patients received 194 courses (102 males, 92 females) of PN. Median age was 62 years (range, 16 to 100). Eighty-two percent were surgical patients and 18% were medical patients. Median PN duration was 9 days (range, 2 to 115). Common indications were surgeons' anticipation of non-functioning gut postoperatively [47 (24.2%) courses], postoperative complications [33 (17.0%) courses] and postoperative ileus [31 (16.1%) courses]. Indications for PN met A.S.P.E.N. guidelines in 93.3% of cases compared to 78.3% in 2001. In 1.5% of cases, we were unable to determine if the indications met the guidelines. Ten courses did not meet the guidelines; 3 had PN for <7 days preoperatively, 6 had PN because the managing team thought the patients were critically ill and 1 was given PN for refusal to eat because of depression.

CONCLUSIONSince 2001, there has been an increase in the proportion of PN given for appropriate indications. However, physician education with respect to the benefit of PN for preoperative and critically ill patients with functioning guts needs reinforcing.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Critical Care ; methods ; Female ; Hospitalization ; Humans ; Inappropriate Prescribing ; prevention & control ; statistics & numerical data ; Male ; Middle Aged ; Parenteral Nutrition ; utilization ; Retrospective Studies ; Young Adult

Objective To assess the liver histopathological characteristics of chronic hepatitis B (CHB) patients with alanine aminotransferase(ALT)lower than 2 times the upper limit of normal (ULN) through liver biopsy, and try to provide subjective evidence for clinical anti-viral treatment.Methods From October 2005 to August 2010, patients accepted liver biopsy in department of infectious disease, Sichuan provincial people's hospital were enrolled. The criteria for liver biopsy was as follow, (1) HBsAg-positive for more than 6 months, (2) HBeAg-positive patients with HBV DNA ≥103 copies/ml or HBeAg-negative patients with HBV DNA≥ 104copies/ml, (3) ALT was lower than 2 times ULN for more than 6 months,and without any hepatic protectants, (4) never accepted any antiviral treatment before, including IFN or nucleoside analogues, (5) willing to accept liver biopsy. Before liver biopsy, routine blood test, prothrombin time, liver function test, hepatitis B antigen and antibody test, HBV DNA quantification were examined. The biopsy position was located under routine ultrasound, liver biopsy were performed to assess the grading of inflammation and necrosis and the degree of fibrosis. The correlation between all the factors and liver inflammation and fibrosis were analyzed. Results Totally 383 cases (240 males and 143 females) met the diagnostic criteria, aged from 16 to 59 years old and the mean age was 28.0 years old. Cases of liver inflammation in G0, G1, G2, G3andG4 grade was 2 cases (0.5％), 165 cases (43.1％), 191 cases (49.9％), 25 cases (6.5 ％ ) and 0 cases (0 ％ ) respectively, cases≥G2 grade accounted 56.4 ％ of total. Meanwhile,stage of fibrosis in S0, S1, S2, S3 and S4 was 103 cases (26.9％), 265 cases (69. 2％), 13 cases (3.4％), 2 cases (0.5％) and 0 cases (0％) respectively, percentage of liver fibrosis in S2stage and over was only 3.9％. The occurrence of serious liver inflammation was associated with age, ALT levels, HBV DNA levels and HBeAg status (P＜0.05). There was no obvious association between HBV DNA level and liver fibrosis (P＞0.05). Conclusions There were obvious liver inflammation and different degree of liver fibrosis in CHB patients with alanine aminotransferase(ALT)lower than 2 times ULN. The degree of liver injury assessed by liver biopsys is recommended as an evaluation for the necessary of anti-viral therapy.

INTRODUCTIONOrthodeoxia is a rare clinical syndrome characterised by dyspnoea and arterial deoxygenation that accompanies a change from a supine to erect position.

CLINICAL PICTUREWe describe an unusual case of "paradoxical orthodeoxia" in a 70-year-old man with a thoracic aortic aneurysm: arterial desaturation when supine that improved when erect.

TREATMENT AND OUTCOMENon-invasive imaging revealed compression of the left pulmonary artery by the aneurysm (thoracic computed tomography) and patent foramen ovale (transesophageal echocardiography). Nuclear studies show decreased relative left lung perfusion attributable to the former, and right-to-left atrial shunt attributable to the latter. The degree of right-to-left shunt increases in the supine position: nuclear pulmonary shunt study shows shunt extent of 21% when supine versus 10% erect.

CONCLUSIONA physioanatomical explanation is proposed.

Aged ; Aortic Aneurysm, Thoracic ; epidemiology ; Dyspnea ; etiology ; Echocardiography, Transesophageal ; Female ; Heart Septal Defects, Atrial ; epidemiology ; Humans ; Oxygen ; blood ; Posture ; physiology ; Supine Position ; physiology

INTRODUCTIONSingapore is the first Asian country to establish a nationwide breast screening programme, but our breast cancer screening uptake lags behind the Western countries. This survey focused on the subject of screening mammography, to assess the reasons for non-attendance and explore ways to improve our screening uptake.

MATERIALS AND METHODSFemales ≥21 years old were approached at primary healthcare clinics to participate in this survey, which questioned their knowledge, perception and expectations of breast screening.

RESULTSThere were 1011 respondents. Of the 740 respondents ≥40 years old, 332 respondents (45.5%) went for regular mammogram screening. Women who had lower household incomes [<$2000 (OR 0.49; 95% CI, 0.28 to 0.85); $2000 to $3999 (OR 0.59; 95% CI, 0.36 to 0.97)], did not know anyone with breast cancer (OR 0.62; 95% CI, 0.42 to 0.92), did not perform breast self-examination (OR 0.42; 95% CI, 0.28 to 0.62), had lower knowledge scores (OR 0.34; 95% CI 0.22 to 0.51), did not attend other health screening (OR 0.14; 95% CI, 0.05 to 0.41), and perceived mammography as embarrassing (OR 0.55; 95% CI, 0.31 to 0.96), were less likely to attend mammographic screening. Many did not know that screening is for the asymptomatic (51.2%), or the age to start screening (46.3%). Most respondents preferred to have their mammograms in the polyclinics (62.2%) and their screening reminders to be through short messaging service (SMS) (46.0%).

CONCLUSIONOur results show the current influences on Singapore women's screening practices, and also revealed that their understanding of mammogram screening is limited despite a high level of breast cancer awareness.

Adult ; Aged ; Aged, 80 and over ; Breast Neoplasms ; diagnosis ; diagnostic imaging ; Breast Self-Examination ; Early Detection of Cancer ; Female ; Health Knowledge, Attitudes, Practice ; Humans ; Mammography ; Middle Aged ; Patient Acceptance of Health Care ; Singapore ; Surveys and Questionnaires ; Young Adult

Objective To investigate the safty and accuracy ot estimating the living donor's graft volume with IQQA liver imaging evaluation system.Methods Between June 2007 and July 2010,123living liver donors were enrolled to undergo 16-slice CT scanning,then graft volume was estimated by both IQQA and manu-traced multi-slice spiral computed tomography (MSCT) approach.The graft volume and time consuming between IQQA and manu-traced MSCT were compared. Pearson Correlation test was uesd to verify the correlation between the estimated graft volume estimated each method and actual graft weight detected in operation.Linear correlation analysis was done.Results The mean graft volume by IQQA and manu-traced MSCT was (856.76 ± 162.18) and (870.64 ±172.54) cm3 respectively preoperation.Paired t-test showed there was no statistically significant difference between IQQA and MSCT methods (P＞0.05).It took mean ( 16.9 ± 1.4) min to calculatethe graft volume by IQQA and (39.3 ± 2.1 ) min by manu-traced MSCT,respectively (P＜0.05).The real graft volume was (632.59 ± 13 1.73) cm3.Pearson correlation test showed the graft volume calculated by either IQQA or MSCT method had a significantly positive correlation with the real graft weight (MSCT r =0.921,IQQA r =0.896,P＜0.01 ).Graft weight could be expressed in the equation:Actual graft weight =- 150.303 + 1.025 × IQQA value or =- 94.397 + 0.955 × MSCT value.Conclusion IQQA system has same accuracy with MSCT method in predicting the graft volume but consuming less time.IQQA system promotes the recognition of clinician on liver three dimensional anatomic structure.

Objective To explore the association of mild cognitive impairment (MCI) with obesity level in middle and elderly population. Methods A total of 19181 subjects aged 50-85 years were collected in this study from the first and second recruitment phase of the Guangzhou Biobank Cohort Study. The subjects received face-to-face interviews to collect the detailed information on their sociodemographic background, occupational exposures, living environment, lifestyle, family and personal disease histories, and had physical examinations and tests including 12-lead ECG, chest radiograph, and pulmonary function testing. Each subject was screened for a range of fasting biochemical parameters. The cognitive ability was tested with 10-words delayed memory test. The associations between cognition function and anthropometric indices of obesity, including body mass index, waist-to-hip ratio (WHR) and waistline, were evaluated. Results Apart from fast glucose and hypertension in subjects with normal cognition function and abnormal cognition function, some lifestyle and such physiological and biochemical factors as age, education, smoking status, and drinking status were significantly different in both gender (P＜0.05). WHR was the independent risk factor of MCI in both gender (P＜0.05). Logistic regression indicated that high WHR was a risk of MCI in both gender; the greater the WHR, the poorer memory the middle and elderly population; the OR and 95％ CI was 1.57 (1.42-1.72) in female and 1.22(1.05-1.41) in male. Conclusion Centripetal obesity is associated with MCI. WHR is a sensitive indicator influencing the cognitive function in women.

INTRODUCTIONIntrathecal baclofen (ITB) therapy is a proven, effective treatment for disabling cortical spasticity. We describe the first local series of five patients with acquired brain injury (ABI) who received ITB and were followed up for 63.8 months.

METHODSA retrospective review of medical and rehabilitation records of patients who received ITB therapy was carried out. Data studied included baseline demographic and injury variables, implantation data, spasticity and function, ITB dosage over time and complications.

RESULTSFrom 2006 to 2010, a total of five patients received ITB therapy via implanted pumps about 39.4 months after ABI. Four out of five patients experienced significant reductions in their lower limb spasticity scores and improvements in global function and dependency. One patient had minor adverse events associated with baclofen-related sedation. The mean ITB dose at one year was 182.7 ± 65.6 mcg/day.

CONCLUSIONOur preliminary study showed encouraging long-term outcomes and safety for ITB therapy after ABI-related intractable spasticity. Individual ITB responses over time were variable, with gender differences. The outcomes experienced by our centre were comparable to those in the general ABI population, supporting the efficacy of ITB therapy for chronic disabling spasticity.

Baclofen ; administration & dosage ; Brain Injuries ; complications ; drug therapy ; Dose-Response Relationship, Drug ; Female ; Follow-Up Studies ; Humans ; Infusion Pumps, Implantable ; Injections, Spinal ; Male ; Muscle Relaxants, Central ; administration & dosage ; Muscle Spasticity ; diagnosis ; drug therapy ; etiology ; Retrospective Studies ; Severity of Illness Index ; Singapore ; epidemiology ; Tertiary Care Centers ; Treatment Outcome

Introduction: Multitude studies have shown perception is an integral factor associated with smoking, However, no such tool was available in Malay language. In this study, we established a Bahasa Malaysia version of PTSQ (BM-PTSQ) and tested the validity and reliability among secondary school adolescents. Methods: The English version of PTSQ originally consists of 12 items. It was translated into Bahasa Malaysia and back-translated again into English to check for consistency. After face validity (face-to-face query) was determined among 20 secondary school adolescents, only 10 items were included in the survey. Construct validity was established from 407 school adolescents through random selection in the same locality. More than 60% of the respondents were female, a majority (67.3%) were schooling in rural areas. Then, the reliability of the questionnaire was determined with Cronbach's alpha. Results: EFA has grouped PTSQ into two components, they are associated with either knowledge or attitude towards smoking. The variance and Cronbach's alpha for the first and second component were 38.24% and 0.861 (7 items) and 21.62% and 0.661 (3 items) respectively. Conclusion The PTSQ showed good validity and reliability for measurement of perception in smoking among school adolescents in Malaysia, thus this is a viable measurement tool. More importantly this study shows an urgent need to improve the smoking education among adolescents in Malaysia.