International Clinics Research Articles

P-215 Prospective validation of the EMBRYOAID software for AI-based evaluation of embryos on the 5th day after fertilization during the in vitro procedure - multi-centre study

Abstract Study question Is AI-based evaluation of embryos as effective in achieving pregnancy as the standard assessment performed by an experienced embryologist? Summary answer AI-based assessment of blastocysts may result in comparable pregnancy rates as the standard assessment performed by an experienced embryologist. What is known already Standard clinical practice in the IVF procedure includes morphological assessment of blastocysts based on visual evaluation following Gardner scale. However, this subjective grading process is susceptible to variability dependent on the professionals’ experience and knowledge, leading to potential inconsistencies in selecting embryos for transfer. Recently, there has been a suggestion that artificial intelligence (AI) algorithms could enhance the predictability of treatment outcomes and many AI-based software applications have been introduced to the procedure in many IVF centers. Nevertheless, there are very few prospective evaluations of the real-life implementation of the novel technologies. Study design, size, duration It is an ongoing, randomized, prospective, multicenter, international study performed in four investigation centers since November 2023. The duration of the study is scheduled for one year. Participants/materials, setting, methods The first stage of the evaluation comprises a randomized selection of a patient meeting the inclusion criteria to one of the groups: test or control group. The next step includes a selection of the embryo for implantation. For the control group, the experienced embryologist performs the standard selection of embryos as per normal clinical practice following the Gardner scale. For the study group, the embryologist selects the embryo for transfer indicated by the EMBRYOAID application. Main results and the role of chance Currently, there have been 149 patients recruited in the study and 160 cycles with 638 embryos have been entered in the EMBRYOAID software for AI-based evaluation. Test group of 80 patients comprises 87 cycles with 346 embryos. Preliminary results of the prospective study conducted in real-life settings show encouraging outcomes in relation to the idea that AI-supported embryo evaluation may be as effective in regards to obtaining pregnancy as a standard clinical assessment performed by experienced professionals. Nevertheless, the sample size is not yet sufficient to achieve statistical significance. Therefore, further data gathering will be conducted and the study hypothesis will be furthermore examined. Limitations, reasons for caution The sample size is still insufficient to reach statistical significance and the study shows the preliminary results which will be further verified on a larger patient group. Wider implications of the findings Results of a prospective, randomized trial conducted in several international clinics may enhance the trend to introduce more objective, bias-free AI-based tools into the embryology labs. Trial registration number EMBRYO National Center for Research and Development nr POIR.01.01.01-00-1631/20-00; ERC Consolidator Grant TUgbOAT no 772346

1169-P: Pediatric Type 1 Diabetes (T1D) Care Approaches Compared across International Clinics with Mean HbA1c <7% and ≥7%

1169-P: Pediatric Type 1 Diabetes (T1D) Care Approaches Compared across International Clinics with Mean HbA1c <7% and ≥7%

BS O08 The burden of bariatric health tourism on publicly funded health services in the UK

Abstract Background Bariatric surgery is a safe and effective treatment for obesity and it's associated co-morbidities. Limited access to surgery in the NHS and a combination of cheaper costs and aggressive advertising by international clinics has led to a surge in people seeking surgery abroad. There is a perception that an indeterminate volume of bariatric health tourism has resulted in increased rate of serious complications in UK. This study aimed to objectively quantify this perceived burden by describing the presentation, management and outcomes of bariatric emergencies in cases undertaken abroad and comparing them to emergency cases originating in the UK. Methods This was a retrospective review of all consecutive non-elective attendances and admissions between January 2018 and April 2023. The setting was a regional bariatric and metabolic surgery centre with a dedicated bariatric on-call service serving Greater Manchester and the North-West of England. Patient demographics, data on index procedures, diagnostic and therapeutic interventions as well as length of hospital and ITU stay was collected. Changes in trends in patients undergoing their index procedure abroad (bariatric health tourist BHT group) were explored and compared to those undergoing surgery in the UK (UK group). Results 373 non-elective episodes were included; 28% related to index procedures abroad. The proportion of admissions related to BHT was 35.5% (17/48), 21% (10/48), 16.5% (9/54), 17% (6/35) and 36.5% (47/128) in years 1 to 5 respectively. BHT patients presented were most likely to present with sleeve complications (33% vs UK 20%) whilst UK patients were most likely to present with band-related problems (46% vs BHT 20%). BHT patients underwent 124 fluoroscopies, 115 CT-scans and 60% required surgical interventions. BHT patients accounted for 37% of total bed days (1610/4311) and had longer median ITU stays (8 v 3 days). Conclusions The total number of emergency episodes related to bariatric surgery undertaken abroad increased eight-fold in the last 12 months compared to the preceding year, and was higher than the total number of episodes in the preceding 4 years. This reflects the ongoing challenges with patient access to publicly funded and affordable bariatric surgery in the UK. Complications arising in this patient group result in longer stays and greater resource burden compared to those patients who have undergone surgery in the UK. This trend has enormous resource implications for service design and an urgent response is needed.

Keratoconus International Consortium (KIC)- advancing keratoconus research

Clinical relevanceThe Keratoconus International Consortium (KIC) will allow better understanding of keratoconus.BackgroundKeratoconus is a disorder characterised by corneal elevation and thinning, leading to reduced vision. The current gaps in understanding of this disease will be discussed and the need for a multi-pronged and multi-centre engagement to enhance our understanding of keratoconus will be highlighted.DesignKIC has been established to address the gaps in our understanding of keratoconus with the aim of collecting baseline as well as longitudinal data on several fields.ParticipantsKeratoconus and control (no corneal condition) subjects from different sites globally will be recruited in the study.MethodsKIC collects data using an online, secure database, which enables standardised data collection at member sites. Data fields collected include medical history, clinical features, quality of life and economic burden questionnaires and possible genetic sample collection from patients of different ethnicities across different geographical locations.ResultsThere are currently 40 Australian and international clinics or hospital departments who have joined the KIC. Baseline data has so far been collected on 1130 keratoconus patients and indicates a median age of 29.70 years with 61% being male. A total of 15.3% report a positive family history of keratoconus and 57.7% self-report a history of frequent eye rubbing.ConclusionThe strength of this consortium is its international, collaborative design and use of a common data collection tool. Inclusion and analyses of cross-sectional and longitudinal data will help answer many questions that remain in keratoconus, including factors affecting progression and treatment outcomes.

The Healthcare Needs of International Clients in China: A Qualitative Study

BackgroundDue to globalization, an increasing number of international visitors comes to China. The needs of their medical care are understudied, which can cause low patient satisfaction and lead to poor clinical outcomes for the clients. To meet those international clients’ medical care needs, hospitals in China are seeking strategies to improve services.PurposeThe aim of this study was to explore international clients’ medical care experiences in China, and their perceptions of the quality of these international healthcare services.Patients and MethodsIn May 2020, focus group interviews with 24 clients and four healthcare professionals were conducted in the international clinic at Sir Run Run Shaw Hospital (SRRSH). In the client group, 24 representatives of international clients from nine countries were invited and divided into three groups to discuss healthcare needs of international clients who seek healthcare in China. Four healthcare providers, including two nurses and two physicians who usually serve in the international clinic, were also interviewed. Data were analyzed using hybrid inductive/deductive thematic analysis.ResultsSix major healthcare needs of international clients were identified, namely: needs for privacy and confidentiality; effective communication; multicultural sensitive care; pleasant environments; qualified care and procedures; and respect. International healthcare is a complex process for both international clients and healthcare professionals.ConclusionThe government and institutional administrators around the world should construct the policies and protocols and integrate cultural competence, communication skills, and privacy and confidentiality protection into health professionals training program to ensure the quality services in the international clinics.

Assessment of Quality of Life (QoL) in Systemic Lupus Erythematosus Patients at a Tertiary Care Hospital in Egypt.

The objective of this study was to explore the quality of life among Egyptian SLE patients and to assess its relationships with demographic and clinical features. One hundred sixty-four SLE patients were recruited for this study. Demographic information; clinical parameters; disease activity, as evaluated by the systemic lupus erythematosus Disease Activity Index; and organ damage, as assessed by the systemic lupus international Collaborative Clinics/American College of Rheumatology Damage Index, were reported. Quality of life was assessed with a quality of life questionnaire specifically designed for patients with systemic lupus erythematosus; the questions are grouped in the following six domains: physical function, sociooccupational activities, symptoms, treatment, mood, and self-image. Higher values indicate poorer quality of life. Of the 164 Egyptian SLE patients who completed the survey, 142 (86.6%) were women. The mean age of the participants was 31± 8 years, the mean systemic lupus erythematosus disease activity index score was 17 ± 11, the mean systemic lupus international collaborative clinics/ American College of Rheumatology Damage Index score was 0.9 ± 1.2, and the mean quality of life score was 18.23± 6.89. Strong correlations were found between the total quality of life score and the scores for each domain of the questionnaire separately and disease activity, neurological manifestations, renal manifestations and musculoskeletal manifestations (p<0.0001); moreover, there was a significant positive correlation between the Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index score and the total quality of life score (p=0.005). Poor quality of life among Egyptian SLE patients and disease activity are strongly related to impaired lifestyles in these patients.

Long-Term Intellectual and Fine Motor Outcomes in Spina Bifida Are Related to Myelomeningocele Repair and Shunt Intervention History.

Lifespan outcomes of simultaneous versus sequential myelomeningocele repair and shunt placement or effects of repeated shunt revisions on specific domains of IQ or fine motor dexterity are largely unknown. The current study addressed these gaps in a large cohort of children and adults with spina bifida myelomeningocele (SBM). Participants between 7 and 44 years of age with SBM and shunted hydrocephalus were recruited from international clinics at two time points. Each participant completed a standardized neuropsychological evaluation that included estimates of IQ and fine motor dexterity. Simultaneous versus sequential surgical repair and number of shunt revisions were examined in relation to long-term IQ and fine motor scores. Simultaneous myelomeningocele repair and shunting were associated with more frequent shunt revisions, as well as to lower Full Scale and verbal IQ scores, controlling for number of shunt revisions. More shunt revisions across study time points were associated with higher nonverbal IQ (NVIQ) scores. No effects were observed on fine motor dexterity. Findings indicate generally greater influence of surgery type over shunt revision history on outcomes in well-managed hydrocephalus. Findings supported apparent, domain-specific benefits of sequential compared to simultaneous surgery across the lifespan in SBM. Higher NVIQ scores with greater number of additional shunt revisions across surgery type supported positive outcomes with effective surgical management for hydrocephalus.

New Technologies in the Diagnostics and Treatment of Brain Deseases: from Neurosciences to the Multidisciplinary Clinical Practice and Maintaining of Mental Health

Over the past years, the prevalence of brain diseases and, consequently, their social significance and economic burden for society has been steadily increasing throughout the world. Brain diseases are a heterogeneous group of diseases that unite a number of disorders that are within the competence of both neurology and psychiatry, often concurrent or comorbid with each other. Z. P. Soloviev Research and Clinical Center for Neuropsychiatry is a leading medical organization in Moscow, which performs a full treatment cycle, studies the data and has postgraduate training programs in this field of medicine. It is conducting a number of relevant research programs; some in collaboration with international clinics. This study deals with the following programs: fundamental aspects of depression and stress-reactivity, suicidal and self-damaging behavior, usage of biofeedback and gravity therapy in rehabilitation and training programs for medical workers in successful communication.

\u201cEnsure that you are well aware of the risks you are taking\u2026\u201d: actions and activities medical tourists\u2019 informal caregivers can undertake to protect their health and safety

BackgroundWhen seeking care at international hospitals and clinics, medical tourists are often accompanied by family members, friends, or other caregivers. Such caregiver-companions assume a variety of roles and responsibilities and typically offer physical assistance, provide emotional support, and aid in decision-making and record keeping as medical tourists navigate unfamiliar environments. While traveling abroad, medical tourists’ caregiver-companions can find themselves confronted with challenging communication barriers, financial pressures, emotional strain, and unsafe environments.MethodsTo better understand what actions and activities medical tourists’ informal caregivers can undertake to protect their health and safety, 20 interviews were conducted with Canadians who had experienced accompanying a medical tourist to an international health care facility for surgery. Interview transcripts were subsequently used to identify inductive and deductive themes central to the advice research participants offered to prospective caregiver-companions.ResultsAdvice offered to future caregiver-companions spanned the following actions and activities to protect health and safety: become an informed health care consumer; assess and avoid exposure to identifiable risks; anticipate the care needs of medical tourists and thereby attempt to guard against caregiver burden; become familiar with important logistics related to travel and anticipated recovery timelines; and take practical measures to protect one’s own health.ConclusionGiven that a key feature of public health is to use research findings to develop interventions and policies intended to promote health and reduce risks to individuals and populations, the paper draws upon major points of advice offered by study participants to take the first steps toward the development of an informational intervention designed specifically for the health and safety needs of medical tourists’ caregiver companions. While additional research is required to finalize the content and form of such an intervention, this study provides insight into what practical advice former caregiver-companions state should be shared with individuals considering assuming these roles and responsibilities in the future. In addition, this research draws attention to the importance of ensuring that such an intervention is web-based and readily accessible by prospective caregiver-companions.

Tackling variability: A multicenter study to provide a gold‐standard network approach for frontotemporal dementia

Biomarkers represent a critical research area in neurodegeneration disease as they can contribute to studying potential disease-modifying agents, fostering timely therapeutic interventions, and alleviating associated financial costs. Functional connectivity (FC) analysis represents a promising approach to identify early biomarkers in specific diseases. Yet, virtually no study has tested whether potential FC biomarkers prove to be reliable and reproducible across different centers. As such, their implementation remains uncertain due to multiple sources of variability across studies: the numerous international centers capable conducting FC research vary in their scanning equipment and their samples' socio-cultural background, and, more troublingly still, no gold-standard method exists to analyze FC. In this unprecedented study, we aim to address both issues by performing the first multicenter FC research in the behavioral-variant frontotemporal dementia (bvFTD), and by assessing multiple FC approaches to propose a gold-standard method for analysis. We enrolled 52 bvFTD patients and 60 controls from three international clinics (with different fMRI recording parameters), and three additional neurological patient groups. To evaluate FC, we focused on seed analysis, inter-regional connectivity, and several graph-theory approaches. Only graph-theory analysis, based on weighted-matrices, yielded consistent differences between bvFTD and controls across centers. Also, graph metrics robustly discriminated bvFTD from the other neurological conditions. The consistency of our findings across heterogeneous contexts highlights graph-theory as a potential gold-standard approach for brain network analysis in bvFTD. Hum Brain Mapp 38:3804-3822, 2017. © 2017 Wiley Periodicals, Inc.

PYCR2 Mutations cause a lethal syndrome of microcephaly and failure to thrive.

A study was undertaken to characterize the clinical features of the newly described hypomyelinating leukodystrophy type 10 with microcephaly. This is an autosomal recessive disorder mapped to chromosome 1q42.12 due to mutations in the PYCR2 gene, encoding an enzyme involved in proline synthesis in mitochondria. From several international clinics, 11 consanguineous families were identified with PYCR2 mutations by whole exome or targeted sequencing, with detailed clinical and radiological phenotyping. Selective mutations from patients were tested for effect on protein function. The characteristic clinical presentation of patients with PYCR2 mutations included failure to thrive, microcephaly, craniofacial dysmorphism, progressive psychomotor disability, hyperkinetic movements, and axial hypotonia with variable appendicular spasticity. Patients did not survive beyond the first decade of life. Brain magnetic resonance imaging showed global brain atrophy and white matter T2 hyperintensities. Routine serum metabolic profiles were unremarkable. Both nonsense and missense mutations were identified, which impaired protein multimerization. PYCR2-related syndrome represents a clinically recognizable condition in which PYCR2 mutations lead to protein dysfunction, not detectable on routine biochemical assessments. Mutations predict a poor outcome, probably as a result of impaired mitochondrial function. Ann Neurol 2016;80:59-70.

Borderline ovarian tumors: the issues of chemotherapy and prognosis

The paper discusses the results of studies conducted in international clinics and the authors’ data on approaches to treating borderline ovarian tumors. It analyzes and comparatively assesses groups of patients who have received chemotherapy and those who have not. The authors mainly state the view that chemotherapy for borderline ovarian tumors affects their prognosis in no way, but makes it even worse in a number of investigations. They also give the data of their observations, which show that attitudes towards chemotherapy for borderline ovarian tumors change in different decades. If in the 1980s chemotherapy was a mandatory treatment stage, it is nowadays prescribed only in exceptional cases in the author’s clinic. Different predictors, such as microinvasion, the micropapillary pattern of borderline tumors, invasive implants, their impact on the probability of recurrences and survival are being investigated. Whether chemotherapy against unfavorable factors, such as invasive implants, may be used is considered. There is evidence that conservative and ultraconservative surgeries for borderline ovarian tumors may be performed. Ultraconservative operations that can spare ovarian tissue as much as possible demonstrate the best pregnancy and labor outcomes as compared with conservative surgical approaches. Thus, this paper considers whether it is expedient to use chemotherapy in patients with borderline ovarian tumors. It also discusses scientists’ views and the authors’ data on neoadjuvant and adjuvant treatments, predictors in borderline ovarian tumors, and survival rates in different international clinics.

Genetic variants conferring susceptibility to Alzheimer’s disease in the general population; do they also predispose to dementia in Down’s syndrome

BackgroundDown’s syndrome (DS) is caused by either complete or partial triplication of chromosome 21, affecting approximately 1/1000 live births, and it is widely accepted that individuals with DS are more likely to develop dementia of Alzheimer’s disease (DAD) compared with the general population. Recent collaborative genome-wide association studies of large case control data sets of individuals with and without Alzhemier’s disease (AD) have revealed new risk variants for dementia, as well as confirming previously identified risk variants. In this study, nine AD-derived SNPs, near or within the CR1 (rs3818361), BIN1 (rs744373), CD2AP (rs9349407), EPHA1 (rs11767557), CLU (rs1532278), MS4A6A/4A (rs610932), PICALM (rs561655), ABCA7 (rs3764650) and CD33 (rs3865444) genes were genotyped in 295 individuals with DS.ResultsThere were no significant associations between these nine GWAS-derived SNPs and DAD in British Caucasian individuals with DS. Interestingly the CR1 rs3818361 variant appeared to be associated with mortality in our cohort, particularly in the subjects without dementia. To our knowledge, this is the first time that this variant has been implicated as a determinant of mortality and the finding warrants further investigation in other cohorts with DS.ConclusionsThis study shows negative associations of nine AD-derived SNPs with DAD in DS. This may be due to the modest size of our cohort, which may indicate that our study is insufficiently powered to pick up such associations. We cannot conclusively exclude a role for these SNPs in DAD in DS. Clearly, efforts to investigate genetic variants with small effects on disease risk require a much larger cohort of individuals with DS. In fact, we hypothesize that a sample size of 4465 individuals with DS would be needed to determine the role in DAD in DS of the nine AD-derived SNPs investigated in this study. We therefore recommend that all national and international clinics with access to individuals with DS should contribute DNA samples to form DS consortia.

Nutrition education tools used in phenylketonuria: clinician, parent and patient perspectives from three international surveys

Three international surveys were developed aiming to identify the current nutrition educational tools used in the management of phenylketonuria (PKU) and the perceived effectiveness of these tools by clinicians, parents and patients. The first two surveys were distributed through the Metabolic Dietitians ListServe (pno-metabl@listserv.cc.emory.edu), and the third survey was distributed by international clinics and the National PKU Alliance website (www.npkua.org). A total of 888 responses (S1, n=88; S2, n=81; S3, n=719) were collected from all three surveys. The surveys represent participants from 17 countries, in Europe; North America (USA and Canada); Mexico; Argentina; Turkey; Australia; and Africa (Tunisia). A consistent decline in 'parents as role models' as an educational tool was observed starting at age 10years. Patients responded they feel their families are the most effective form of education, whereas handouts were selected as the least effective educational tool by patients. Parents responded they feel the most effective educational tool is one-on-one counselling. Patients and parents show a desirable trend in wanting to attend group clinic, even in centres where this type of educational tool is not offered. There was a discrepancy between clinicians and patient views regarding the perceived effectiveness of the nutrition education tools. Future research is needed surrounding the impact nutrition education may have on improved dietary compliance in patients with PKU.

Key Elements for the Improvement of Healthcare Services for Foreigners in Korea: A Delphi Study

Purpose: This study was performed to identify the key elements for the improvement of healthcare services for foreigners in Korea. Method: Delphi technique was used for this study. As the members of an expert panel for this study, 32 healthcare professionals, who were physicians, nurses, administrators, and care coordinators, with at least 6 months of experiences in international clinics and healthcare services in five metropolitan areas in Korea participated. Data collections were conducted three times from August to October, 2009. The priority and the importance were analyzed using descriptive statistics in SPSS Win 15.0. Result: The key element selected most frequently by the experts was the 'Healthcare providers' abilities for foreign languages' followed by 'Guidelines for facing medical accidences and disputes', 'Information and guide for healthcare services written in English', 'Informed consent preventing medical disputes', 'System of healthcare service fees for foreigners'. Conclusions: The key elements for the improvement of healthcare services for foreigners in Korea were mostly the requirements for effective communication with the foreign clients and the systemic support. The key elements identified in this study can be applied usefully for the development of strategies to improve the quality of healthcare services for foreigners.

224 THE EFFECT OF TREATMENT WITH VARIOUS DOSES OF A SYNTHETIC GONADOTROPIN-RELEASING HORMONE ON INDUCTION OF OVULATION IN LLAMAS

Llamas require a copulation stimulus to elicit an LH surge that subsequently leads to induced ovulation. Gonadotropin-releasing hormone has been used to induce ovulation in llamas; however, results have been variable because of the different analogues and doses in previous studies (Bravo PW et al. 1992 Biol. Reprod. 47, 884-888; Ratto M et al. 2006 Anim. Reprod. Sci. 91, 299-306). Additionally, the effect of different doses and types of GnRH analogues on CL formation and function has not been described in detail. The purpose of the present study was to conduct a dose response trial to examine the effect of a synthetic analogue of GnRH, gonadorelin acetate (Ovalyse®, Pfizer, Santiago, Chile) on ovulation and CL formation in llamas. Nonpregnant and nonlactating adult llamas (range 4-8 years) weighing 90 to 130 kg were examined once daily by transrectal ultrasonography using a B mode scanner with a 7.5-MHz linear-array transducer (Aloka® SSD 500, International Clinics, Santiago, Chile). Llamas with a follicle ≥8 mm in diameter that had grown for 3 consecutive days were assigned randomly to be given an i.m. administration of gonadorelin at a dose of 1) 50 μg (n = 5); 2) 25 μg (n = 8); 3) 12.5 μg (n = 9); 4) 6.25 μg (n = 8), or 5) i.m. administration of 0.5 mL of PBS as a negative control group (n = 5). Llamas were examined by ultrasonography every 12 h from treatment (Day 0) to ovulation and thereafter on Day 8 to determine CL formation. Ovulation was defined as the sudden disappearance of a large follicle ≥8 mm that was detected during the previous examination and was confirmed by subsequent CL formation on Day 8. Ovulation rate was analyzed by chi-square analysis. Follicle diameter (at the time of treatment), interval from treatment to ovulation, and CL diameter on Day 8 were analyzed using one-way ANOVA. Mean ± SD diameter of preovulatory follicle did not differ (P = 0.4) among groups (11 ± 1.6, 10.6 ± 1.5, 11.5 ± 1.9, 11.7 ± 1.9, and 9.8 ± 2.9 mm for 50, 25, 12.5, and 6.25 μg of gonadorelin and 0.5 mL PBS, respectively). The proportions of ovulated llamas did not differ (P = 0.1) among GnRH-treated groups (100, 62.5, 77.7, and 62.5% for 50, 25, 12.5, and 6.25 μg of gonadorelin, respectively) but they did differ (P &lt; 0.01) from the control group (0%). Also, the interval from treatment to ovulation in those ovulated females ranged from 36 to 48 h and it did not differ (P = 0.6) among groups. Corpus luteum diameter on Day 8 (12.2 ± 1.8, 10.2 ± 1.1, 11.7 ± 2.2, and 11.3 ± 1.8 for 50, 25, 12.5, and 6.25 μg of gonadorelin, respectively) did not differ (P = 0.3) among groups. In conclusion, the minimal dose of gonadorelin used in this study (1/8 dose) was as equally effective as the highest dose to induce ovulation in llamas without compromising CL formation. The study was supported by Proyecto FONDECYT 11080141, Convenio de Desempeño en Investigacion (2007 DGI-CDA-04), Universidad Catolica de Temuco, and College of Graduate Studies, Faculty of Veterinary Sciences, Universidad Austral de Chile.

Is melamine contamination an issue in Canada?

A Chinese family immigrated to Canada in early 2008. One week after their arrival, the parents brought their nine-month-old son to the emergency department because of fever and unexplained crying. He refused solids, drank small amounts of a commercial iron-fortified formula and had few episodes of vomiting without diarrhea. His parents noticed that his urine was darker than normal with a strong smell, without macroscopic hematuria. On physical examination, the infant was feverish but not toxic, and crying with slight pallor. He was not clinically dehydrated, and his blood pressure was 90/60 mmHg. The physician elicited suprapubic and left flank pain on palpation and questioned the possibility of a urinary tract infection. The laboratory test results revealed a white blood cell count of 9.0×109/L and a hemoglobin level of 95 g/L, and urinalysis revealed pyuria and microscopic hematuria. The child also had hypercalciuria. The urine culture obtained by catheterization confirmed an Escherichia coli infection; his blood culture was negative. The abdominal ultrasound revealed a left hydronephrosis, and a plain radiograph of the abdomen confirmed the presence of a radiopaque renal stone at the pelviureteric junction. The parents were concerned and asked whether their son’s disease could be related to the outbreak of kidney disease stemming from melamine-contaminated milk in China. LEARNING POINTS In late 2008, the United States Food and Drug Administration and the World Health Organization reported an outbreak of renal stones and/or acute renal failure occurring in very young children in China, which was associated with the consumption of powdered milk products contaminated with melamine, and that led to a few deaths. Public interest rose when other dairy products, such as frozen yogurts, chocolate cookies and toffee candies, made in China and exported to other areas such as Australia, Europe, the United States and Canada, were found to contain melamine. Infant formula manufactured in China is not approved for sale in Canada. Health Canada also confirmed with the four major manufacturers of infant formula sold in Canada that they do not use any milk ingredients that come from China . In light of this public health priority and to obtain national epidemiological data, the Public Health Agency of Canada commissioned the Canadian Paediatric Surveillance Program (CPSP), in October 2008, to conduct an emergency survey to assess whether any presentations of renal stones and/or acute renal failure in Canadian children may have been caused by a melamine outbreak. The CPSP survey was issued within 10 days to 2475 actively practicing paediatricians and paediatric subspecialists. The response rate was 47%. Fortunately, no cases of melamine-associated renal diseases were reported. Of the 1153 respondents, 12 cases of renal stones were reported and one of these also had acute renal failure, all presenting in the previous 12 months. The main causes identified so far are urinary tract infections, hydronephrosis and hypercalciuria. Interestingly, nearly 10% of respondents mentioned that parental concerns were voiced to them, especially from those who worked in international adoption clinics. Parents of the clinical vignette were reassured that their son’s renal stone and urinary tract infection were not related to melamine contamination, because his renal stone was radiopaque in the presence of hypercalciuria, and he did not have any exposure to powdered milk and other milk products from China. A list of products with melamine levels higher than interim standards is accessible at . The CPSP emergency-response preparedness exemplifies the excellent added value of investing in a national network of active surveillance, well connected with front-line paediatricians and public health officials.

STRATEGIES FOR IMPROVING THE PREDICTION OF PSYCHOSIS

Introduction: Over the last fifteen years, valid and reliable criteria have been developed for identifying individuals at ‘ultra-high risk’ (UHR) of imminent onset of psychotic disorder. A number of randomized controlled trials (RCTs) have been conducted in the UHR population. These trials have demonstrated that psychotic disorder can at least be delayed in this population. However, it remains unclear what the most effective type, timing and duration of treatment is for this population is. There is evidence that benign treatments may be sufficient as a first step in the UHR population. Recent research also indicates a reduction in rate of transition to psychotic disorder in the UHR population. Together, these data suggests that a staged approach to treatment, starting with more benign interventions and progressing to more intensive treatments in the case of poor response or deterioration, may be appropriate for the UHR population. Another factor that has been a challenge in UHR intervent ion studies has been to recruit a sufficient number of participants to provide statistical power to address research questions. Methods: This background has provided the impetus for a new multisite RCT being developed in the UHR population. The RCT has a two-stage design. Stage 1 consists of participants being randomized to one of two conditions: cognitive-behavioural case management (CBCM) + placebo or CBCM + eico sapentanoic acid (EPA). Treatment will continue for 3 months. Participants who fail to respond to treatment in Stage 1 will be randomized at Stage 2 to either CBCM + low dose atypical anti-psychotic medication (quetiapine) or CBCM + placebo. Treatment will continue for 6 months. The study will be conducted across 9 international UHR clinics.

Cross-border dental care: 'dental tourism' and patient mobility

Patient mobility is increasing. 'Dental tourism' is driven by numerous factors. These factors include the high cost of local care, delays in obtaining access to local dentists, competent care at many international clinics, inexpensive air travel, and the Internet's capacity to link 'customers' to 'sellers' of health-related services. Though dental tourism will benefit some patients, increased patient mobility comes with numerous risks. Lack of access to affordable and timely local care plays a significant role in prompting patients to cross borders and receive dental care outside their local communities.

Ideas and anomalies in the evolution of modern oxygen therapy.

Ideas and anomalies in the evolution of modern oxygen therapy.