The association between tooth loss and coronary heart disease in men and women

OBJECTIVES

This paper evaluates the relation of tooth loss to incidence of coronary heart disease in two large cohort studies.

METHODS

Participants included 41,407 men and 58,974 women free of any cardiovascular diseases at baseline. We recorded 1,654 incident coronary heart disease events (562 fatal events) among men during 12 years of follow-up and 544 events (158 fatal events) among women during 6 years of follow-up.

RESULTS

After controlling for important cardiovascular risk factors, compared to men with 25-32 teeth at baseline, men with 0-10 teeth had a significantly higher risk of coronary heart disease (relative risk [RR]= 1.36; 95 percent confidence interval [CI]=1.11, 1.67). The relative risk increased to 1.79 (95% CI=1.34, 2.40) when limited to fatal events. Women with 0-10 teeth were also at increased risk of coronary heart disease compared to women with 25-32 teeth (RR=1.64; 95% CI=1.31, 2.05). The association was similar for fatal events (RR= 1.65; 95% CI=1.11, 2.46). The association between number of teeth and incidence of coronary heart disease was similar between men with and without a history of periodontal disease, and there was no significant association between tooth loss during follow-up and coronary heart disease.

CONCLUSIONS

This study showed a significant association between number of teeth at baseline and risk of coronary heart disease and the mechanisms to explain this association should be further clarified.

Fruit and Vegetable Intake and Risk of Major Chronic Disease

BACKGROUND

Studies of fruit and vegetable consumption in relation to overall health are limited. We evaluated the relationship between fruit and vegetable intake and the incidence of cardiovascular disease and cancer and of deaths from other causes in two prospective cohorts.

METHODS

A total of 71 910 female participants in the Nurses' Health study and 37,725 male participants in the Health Professionals' Follow-up Study who were free of major chronic disease completed baseline semiquantitative food-frequency questionnaires in 1984 and 1986, respectively. Dietary information was updated in 1986, 1990, and 1994 for women and in 1990 and 1994 for men. Participants were followed up for incidence of cardiovascular disease, cancer, or death through May 1998 (women) and January 1998 (men). Multivariable-adjusted relative risks were calculated with Cox proportional hazards analysis.

RESULTS

We ascertained 9329 events (1964 cardiovascular, 6584 cancer, and 781 other deaths) in women and 4957 events (1670 cardiovascular diseases, 2500 cancers, and 787 other deaths) in men during follow-up. For men and women combined, participants in the highest quintile of total fruit and vegetable intake had a relative risk for major chronic disease of 0.95 (95% confidence interval [CI] = 0.89 to 1.01) times that of those in the lowest. Total fruit and vegetable intake was inversely associated with risk of cardiovascular disease but not with overall cancer incidence, with relative risk for an increment of five servings daily of 0.88 (95% CI = 0.81 to 0.95) for cardiovascular disease and 1.00 (95% CI = 0.95 to 1.05) for cancer. Of the food groups analyzed, green leafy vegetable intake showed the strongest inverse association with major chronic disease and cardiovascular disease. For an increment of one serving per day of green leafy vegetables, relative risks were 0.95 (95% CI = 0.92 to 0.99) for major chronic disease and 0.89 (95% CI = 0.83 to 0.96) for cardiovascular disease.

CONCLUSIONS

Increased fruit and vegetable consumption was associated with a modest although not statistically significant reduction in the development of major chronic disease. The benefits appeared to be primarily for cardiovascular disease and not for cancer.

Association between diet and esophageal cancer in Taiwan

BACKGROUND

Several studies have reported the importance of dietary factors in the development of esophageal cancer. The purpose of the present study was to evaluate the effects of several common dietary factors on the risk of squamous cell carcinoma of the esophagus in a Taiwanese population.

METHODS

The association between diet and esophageal cancer was examined in 284 male patients and 480 male controls, who were recruited during 6 year period.

RESULTS

Consumption of preserved and overheated foods was found to be associated with increased risk of esophageal cancer, whereas intake of fresh fruits, vegetables, and tea was inversely associated with this risk. Men who consumed fermented bean products, salted food and preserved/pickled vegetables more than once a week after age 40 years had a 3.4-fold risk (95% confidence interval (CI): 1.9-6.2), 2.3-fold risk (95%CI: 1.2-4.2), and 2.5-fold risk (95%CI: 1.3-4.5), respectively, compared to men eating these items less than once a week. It was further found that these preserved foods were more strongly associated with esophageal cancer among men who consumed fruit less than once per day than those who consumed fruits one or more times per day.

CONCLUSIONS

These results suggest that a high intake of preserved foods and overheated drinks might increase the risk of esophageal cancer, and intake of fruit, vegetables, and tea might be negatively associated with risk of esophageal cancer. The results also suggest that diet is an important factor in the development of esophageal cancer in Taiwan.

Indirect Traumatic Optic Neuropathy Complicated With Periorbital Facial Bone Fracture

This study evaluated the outcome for 45 consecutive, nonrandomized patients whose indirect type traumatic optic neuropathy and periorbital facial bone fracture were treated at the Chang Gung Memorial Hospital in Kaohsiung between June of 1996 and June of 2001. There were a total of 48 eye injuries in 45 patients (3 patients sustained bilateral eye injuries). Data related to megadose steroid treatment, timing of open reduction and internal fixation for periorbital facial fractures, and pretreatment and post-treatment of visual acuities were collected from the medical records. Measurements of visual improvement in terms of degree and percentage were calculated after the visual acuities were converted into the log of the minimum angle of resolution units. Visual acuities were significantly improved according to mechanism of injury, gender, or associated periorbital skin laceration wound. However, no light perception for eight patients at initial presentation and gradually deteriorating vision in four injured eyes of three patients were identified as poor prognostic factors. Therefore, repeated visual measurements are recommended to detect any gradually deteriorating vision, which although uncommon, has a poor prognosis. No significantly improved vision was found after treatment with megadose steroids. However, if improvement in vision did occur, treatment with megadose steroids resulted in a much greater visual improvement in terms of degree (p = 0.001) and percentage (p = 0.02). Thus treatment with megadose steroid is recommended. No significant differences were found in the visual improvement between those who received and those who did not receive periorbital open reduction and internal fixation operations, and between those who received early repair within 48 hours and those who received late repair after more than 48 hours. However, it seems medicolegally prudent to delay the procedure because some patients may experience gradually deteriorating vision, which has a poor prognosis, and because postoperative visual loss after facial fracture repair did happen.

The Association Between Fruit and Vegetable Consumption and Peripheral Arterial Disease

BACKGROUND

High fruit and vegetable consumption has been associated with a lower risk of cardiovascular diseases, but few studies have focused on peripheral arterial disease. In this study, we evaluated the association of consumption of fruits and vegetables with peripheral arterial disease.

METHODS

In a cohort of 44,059 men initially free of cardiovascular disease and diabetes, we documented 295 cases of peripheral arterial disease during a 12-year follow-up. Fruit and vegetable consumption was assessed by food frequency questionnaire.

RESULTS

In the age-adjusted model, men in the highest quintile had a relative risk of 0.55 (95% confidence interval = 0.38-0.80) for overall fruit and vegetable intake, 0.52 (0.36-0.77) for fruit intake, and 0.54 (0.36-0.81) for vegetable intake, compared with those in the lowest quintile of intake. However, the associations were greatly weakened after adjustment for smoking and other traditional cardiovascular disease risk factors. Comparing men in the highest quintile versus the lowest quintile, relative risks and 95% confidence intervals were 0.95 (0.62-1.44) for overall fruit and vegetable intake, 0.97 (0.64-1.48) for fruit intake, and 0.76 (0.50-1.17) for vegetable intake.

CONCLUSIONS

We did not find evidence that fruit and vegetable consumption protects against peripheral arterial disease, although a modest benefit cannot be excluded.

Tooth loss and dietary intake

BACKGROUND

Several studies have reported that impaired dentition status is associated with poor nutritional intake. However, most of these studies are cross-sectional and thus are unable to clarify the temporal sequence.

METHODS

We assessed the longitudinal relation between tooth loss and changes in consumption of fruits and vegetables and of nutrients important for general health among 31,813 eligible male health professionals.

RESULTS

Subjects who lost five or more teeth had a significantly smaller reduction in consumption of dietary cholesterol and vitamin B12, greater reduction in consumption of polyunsaturated fat and smaller increase in consumption of dietary fiber and whole fruit than did subjects who had lost no teeth. Men who had lost teeth also were more likely to stop eating apples, pears and raw carrots.

CONCLUSIONS

The results support the temporal association between tooth loss and detrimental changes in dietary intakes, which could contribute to increased risk of developing chronic diseases.

PRACTICE IMPLICATIONS

Dietary evaluation and recommendations can be incorporated into dental visits to provide a greater benefit to patients.

Synergistic effect of multiple indoor allergen sources on atopic symptoms in primary school children

Accumulating data show that the complex modern indoor environment contributes to increasing prevalence of atopic diseases. However, the dose-response relationship between allergic symptoms and complexity of indoor environmental allergen sources (IEAS) has not been clearly evaluated before. Therefore, we designed this study to investigate the overall effect of multiple IEAS on appearance of asthma (AS), allergic rhinitis (AR), and eczema (EC) symptoms in 1472 primary school children. Among various IEAS analyzed, only stuffed toys, cockroaches, and mold patches fit the model of 'more IEAS, higher odds ratio (OR) of association'. The association of IEAS and AR increased stepwise as more IEAS appeared in the environment (1.71, 2.47, to 2.86). In AS and EC, the association was significant only when all three IEAS were present (1.42, 1.98, to 4.11 in AS; 1.40, 1.76, to 2.95 in EC). These results showed that different IEAS had a synergistic effect on their association with atopic symptoms and also suggest that there is a dose-response relationship between kinds of IEAS and risk of appearance of atopic diseases.

Lifestyle and Psychosocial Factors Associated with Chronic Periodontitis in Taiwanese Adults

BACKGROUND

The development of chronic periodontitis (CP) is a multifactorial process and variation in severity cannot be explained by just a few risk factors. The aims of this study were: 1) to explore the lifestyle and psychosocial factors of CP patients and 2) to estimate the proportion of total CP cases attributable to one or more risk factors considered.

METHODS

A case-control study of 250 cases of CP patients and 250 controls were matched by age (within 3 years) and gender. Complete dental examinations were performed based on the clinical criteria for CP for both groups. Structured questionnaires were conducted to collect lifestyle and psychosocial factors. Multivariate logistic regression was applied to assess the association between risk factors and chronic periodontitis.

RESULTS

Conditional multivariable logistic regression analysis showed that toothbrushing frequency (odds ratio [OR]: 5.77, if rarely; OR: 3.50, if once a day), mental illness (OR: 5.32, if Chinese Health Questionnaire scores were > or = 6), and smoking (OR: 3.93, if pack years smoked was > 21) are significantly and independently associated with chronic periodontitis. In addition, all these variables reflected a dose-response effect (P trend = <0.001, 0.004, and 0.005, respectively).

CONCLUSIONS

For Taiwanese adults, 36.10% of CP cases were presumably attributable to toothbrushing frequency, mental illness, and smoking. These three factors should be the first priorities in establishing a preventive program to improve the periodontal health status.

Oral health and peripheral arterial disease

BACKGROUND

Many studies have reported the association between poor oral health and coronary heart disease or stroke, but few of them evaluated peripheral arterial disease (PAD). Hence, in this study we examined the associations between oral health and PAD.

METHODS AND RESULTS

In the prospective study of 45,136 eligible male health professionals free of cardiovascular diseases at baseline, we identified 342 cases of PAD during a 12-year follow-up period. We evaluated the association between different measures of oral diseases and the occurrence of PAD. Baseline number of teeth was not related to the risk of PAD, but cumulative incident tooth loss was significantly associated with elevated risk of subsequent occurrence of PAD. The relative risk for history of periodontal disease was 1.41 (95% CI, 1.12 to 1.77) and for any tooth loss during the follow-up period was 1.39 (95% CI, 1.07 to 1.82), controlling for traditional risk factors of cardiovascular disease. Among men with a history of periodontal diseases, the relative risk of tooth loss increased to 1.88 (95% CI, 1.27 to 2.77), whereas no association was found between tooth loss and PAD among those without periodontal diseases (RR, 0.92; 95% CI, 0.61 to 1.38). We further explored the potential induction period of tooth loss and found that tooth loss in the previous 2 to 6 years was most strongly associated with PAD.

CONCLUSIONS

We found that incident tooth loss was significantly associated with PAD, especially among men with periodontal diseases. The results support a potential oral infection-inflammation pathway.

Periodontal disease, tooth loss, and incidence of ischemic stroke

BACKGROUND AND PURPOSE

Periodontal and other infections have been suggested as potential risk factors for stroke. This study evaluates periodontal disease and tooth loss as risk factors for ischemic stroke.

METHODS

The study population consisted of 41 380 men who were free of cardiovascular disease and diabetes at baseline. Periodontal disease history was assessed by mailed validated questionnaires. During 12 years of follow-up, stroke incidence was assessed and subclassified by use of medical history, medical records, and imaging reports. Hazard ratios (HRs) were adjusted for age, amount smoked, obesity, alcohol, exercise, family history of cardiovascular disease, multivitamin use, vitamin E use, profession, baseline reported hypertension, and hypercholesterolemia. Sex and socioeconomic status were inherently controlled for by restriction. Confounding variables were updated in the analyses for each 2-year follow-up interval.

RESULTS

We documented 349 ischemic stroke cases during the follow-up period. Men who had < or =24 teeth at baseline were at a higher risk of stroke compared to men with > or =25 teeth (HR=1.57; 95% CI, 1.24 to 1.98). There was little evidence of an increased risk with recent tooth loss during follow-up. A modest association was seen between baseline periodontal disease history and ischemic stroke (HR=1.33; 95% CI, 1.03 to 1.70). Addition of dietary factors to the model changed the HR only slightly.

CONCLUSIONS

Our results suggest that periodontal disease and fewer teeth may be associated with increased risk of ischemic stroke.

Meta-analysis of the effect of scaling and root planing, surgical treatment and antibiotic therapies on periodontal probing depth and attachment loss

OBJECTIVE

This paper reports a meta-analysis of studies that have investigated the effect of scaling and root planing on periodontal probing depth and attachment loss.

MATERIAL AND METHODS

The criteria used for inclusion of studies were as follows: root planing and scaling alone was one of the primary treatment arms; patients or quadrants of each patient were randomly assigned to study groups; 80% of patients enrolled were included in first year follow-up examinations; periodontal probing depth and attachment loss were reported in mm; the sample size of each study and substudy was reported. Sample size was used to weight the relative contribution of each study since standard errors were not reported by many studies and sample size is highly correlated with standard error and therefore statistically able to explain a substantial portion of the standard error on studies that use similar measures.

RESULTS

The meta-analysis results show that periodontal probing depth and gain of attachment level do not improve significantly following root planing and scaling for patients with shallow initial periodontal probing depths. However, there was about a 1-mm reduction for medium initial periodontal probing depths and a 2-mm reduction for deep initial periodontal probing depths. Similarly, there was about a 0.50-mm gain in attachment for medium initial periodontal probing depth measurements and slightly more than a l-mm gain in attachment for deep initial periodontal probing depth measurements. Surgical therapy for patients with deep initial probing depths showed better results than scaling and root planing in reducing probing depths. When patients were followed up over 3 years or more, these differences were reduced to less than 0.4 mm. Antibiotic therapy showed similar results to scaling and root planing. However, a consistent improvement in periodontal probing depth and gain of attachment is demonstrated when local antibiotic therapy is combined with root planing and scaling.

Nutrition as a mediator in the relation between oral and systemic disease: associations between specific measures of adult oral health and nutrition outcomes

Recent associations between oral health and systemic disease have led to renewed interest in the mouth and its contribution to health outcomes. Many pathways for this relationship have been postulated, among them the potential mediating role of nutrition. The link between various nutrients and systemic disease has been established, but relatively little work has been done in relating oral conditions with nutrition. We searched MEDLINE, from 1966 to July, 2001, to identify articles relating specific oral measures to nutrition outcomes. We included original articles written in English with a sample size greater than 30 that used objective oral health measures. We reviewed a total of 56 articles. Only a small proportion of these studies were methodologically sound. Although many studies were small and cross-sectional, the literature suggests that tooth loss affects dietary quality and nutrient intake in a manner that may increase the risk for several systemic diseases. The impact of tooth loss on diet may be only partially compensated for by prostheses. To date, there is little information relating periodontal disease and oral pain and nutrition. A few studies suggest poorer nutrition among individuals with xerostomia and altered taste. Further, impaired dentition may contribute to weight change, depending on age and other population characteristics. There is a paucity of well-designed studies addressing oral health and nutrition. Before we can acquire a better understanding of how nutrition and oral health interrelate, however, more studies will be required to confirm these associations-preferably longitudinal studies with larger sample sizes and better control of important confounders.

Multiple unfolding intermediates of human placental alkaline phosphatase in equilibrium urea denaturation

Alkaline phosphatase is an enzyme with a typical alpha/beta hydrolase fold. The conformational stability of the human placental alkaline phosphatase was examined with the chemical denaturant urea. The red shifts of fluorescence spectra show a complex unfolding process involving multiple equilibrium intermediates indicating differential stability of the subdomains of the enzyme. None of these unfolding intermediates were observed in the presence of 83 mM NaCl, indicating the importance of ionic interactions in the stabilization of the unfolding intermediates. Guanidinium chloride, on the other hand, could stabilize one of the unfolding intermediates, which is not a salt effect. Some of the unfolding intermediates were also observed in circular dichroism spectroscopy, which clearly indicates steady loss of helical structure during unfolding, but very little change was observed for the beta strand content until the late stage of the unfolding process. The enzyme does not lose its phosphate-binding ability after substantial tertiary structure changes, suggesting that the substrate-binding region is more resistant to chemical denaturant than the other structural domains. Global analysis of the fluorescence spectral change demonstrated the following folding-unfolding process of the enzyme: N <--> I(1) <--> I(2) <--> I(3) <--> I(4) <--> I(5) <--> D. These discrete intermediates are stable at urea concentrations of 2.6, 4.1, 4.7, 5.5, 6.6, and 7.7 M, respectively. These intermediates are further characterized by acrylamide and/or potassium iodide quenching of the intrinsic fluorescence of the enzyme and by the hydrophobic probes, 1-anilinonaphthalene-8-sulfonic acid and 4,4'-dianilino-1,1'-binaphthyl-5,5'-disulfonic acid. The stepwise unfolding process was interpreted by the folding energy landscape in terms of the unique structure of the enzyme. The rigid central beta-strand domain is surrounded by the peripheral alpha-helical and coil structures, which are marginally stable toward a chemical denaturant.

Differentiation of the slow-binding mechanism for magnesium ion activation and zinc ion inhibition of human placental alkaline phosphatase

The binding mechanism of Mg(2+) at the M3 site of human placental alkaline phosphatase was found to be a slow-binding process with a low binding affinity (K(Mg(app.)) = 3.32 mM). Quenching of the intrinsic fluorescence of the Mg(2+)-free and Mg(2+)-containing enzymes by acrylamide showed almost identical dynamic quenching constant (K(sv) = 4.44 +/- 0.09 M(-1)), indicating that there is no gross conformational difference between the M3-free and the M3-Mg(2+) enzymes. However, Zn(2+) was found to have a high affinity with the M3 site (K(Zn(app.)) = 0.11 mM) and was observed as a time-dependent inhibitor of the enzyme. The dependence of the observed transition rate from higher activity to lower activity (k(obs)) at different zinc concentrations resulted in a hyperbolic curve suggesting that zinc ion induces a slow conformational change of the enzyme, which locks the enzyme in a conformation (M3'-Zn) having an extremely high affinity for the Zn(2+) (K*(Zn(app.)) = 0.33 microM). The conformation of the M3'-Zn enzyme, however, is unfavorable for the catalysis by the enzyme. Both Mg(2+) activation and Zn(2+) inhibition of the enzyme are reversible processes. Structural information indicates that the M3 site, which is octahedrally coordinated to Mg(2+), has been converted to a distorted tetrahedral coordination when zinc ion substitutes for magnesium ion at the M3 site. This conformation of the enzyme has a small dynamic quenching constant for acrylamide (K(sv) = 3.86 +/- 0.04 M(-1)), suggesting a conformational change. Both Mg(2+) and phosphate prevent the enzyme from reaching this inactive structure. GTP plays an important role in reactivating the Zn-inhibited enzyme activity. We propose that, under physiological conditions, magnesium ion may play an important modulatory role in the cell for protecting the enzyme by retaining a favorable geometry of the active site needed for catalysis.

Slow binding of metal ions to pigeon liver malic enzyme: a general case

Pigeon liver malic enzyme was inhibited by lutetium ion through a slow-binding process, which resulted in a concave down tracing of the enzyme activity assay. The fast initial rates were independent of lutetium ion concentration, while the slow steady-state rates decreased with increasing Lu(3+) concentration. The observed rate constant for the transition from initial rate to steady-state rate, k(obs), exhibited saturation kinetics as a function of Lu(3+) concentration, suggesting the involvement of an isomerization process between two enzyme forms (R-form and T-form). The binding affinity of Lu(3+) to the R-form is weaker (K(d,Lu) = 14 microM) than that of Mn(2+) (K(m,Mn) = 1.89 microM); however, Lu(3+) has much tighter binding affinity with the T-form ( = 0.83 microM). Lu(3+) was shown to be a competitive inhibitor with respect to Mn(2+), which suggests that Lu(3+) and Mn(2+) are competing for the same metal binding site of the enzyme. These observations are in accordance with the available crystal structure information, which shows a distorted active site region of the Lu(3+)-containing enzyme. Other divalent cations, i.e., Fe(2+), Cu(2+), or Zn(2+), also act as time-dependent slow inhibitors for malic enzyme. The dynamic quenching constants of the intrinsic fluorescence for the metal-free and Lu(3+)-containing enzymes are quite different, indicating the conformational differences between the two enzyme forms. The secondary structure of these two enzyme forms, on the other hand, was not changed. The above results indicated that replacement of the catalytically essential Mn(2+) by other metal ions leads to a slow conformational change of the enzyme and consequently alters the geometry of the active site. The transformed enzyme conformation, however, is unfavorable for catalysis. Both the chemical nature of the metal ion and its correct coordination in the active site are essential for catalysis.

Potent and competitive inhibition of malic enzymes by lanthanide ions

The catalytic activity of malic enzyme (ME), a member of a new class of oxidative decarboxylases, requires the presence of divalent cations (Mn(2+), Mg(2+), and others). The crystal structure at 2.9 A resolution of human mitochondrial NAD(+)-dependent malic enzyme in a ternary complex with NAD(+) and the lanthanide ion Lu(3+), which has similar radius as Mn(2+), reveals a new conformation of the enzyme. The active site in this ternary complex is in an open form, while the organization of the tetramer of the enzyme actually resembles that with a closed active site. The Lu(3+) ion is bound to the enzyme at the same site as Mn(2+). Kinetic studies showed that Lu(3+) is a potent inhibitor of both the human NAD(P)(+)-dependent ME and the NADP(+)-dependent ME from pigeon liver, and is competitive with respect to the divalent cation, consistent with the structural information.

Reverse micelles as life-mimicking systems

In this review, we attempt to demonstrate that reverse micelles are simple artificial systems that mimic many life systems from cell division to the creation of an enzyme catalytic mechanism. For a membranous enzyme like placental alkaline phosphatase, the kinetic properties observed in reverse micelles might represent those found under physiological conditions. The reverse micellar system, consisting of a positively charged surfactant, mimics a detoxification enzyme glutathione transferase. We propose a novel island-in-oil-lake reverse micellar model for the glutathione transferase that can account for almost all the catalytic properties of this enzyme. Reverse micelles may provide an excellent model system in investigating the reaction mechanism of other detoxification enzymes.

Successful initial treatment with weekly etoposide, epirubicin, cisplatin, 5-fluorouracil and leucovorin chemotherapy in advanced gastric cancer patients with disseminated intravascular coagulation

BACKGROUND

Acute disseminated intravascular coagulation (DIC) is a rare but severe complication of gastric adenocarcinoma. Conventional treatments, such as fresh frozen plasma, platelet replacement and heparin injections, are disappointing. The only way to correct this fatal condition is to control the underlying cancer promptly by effective chemotherapy. Here the successful initial control of acute DIC in gastric cancer patients with weekly EEPFL chemotherapy is reported.

METHODS

Advanced gastric cancer patients complicated with acute DIC were eligible. Patients were treated with weekly EEPFL therapy (etoposide 40, epirubicin 10, cisplatin 25, 5-fluorouracil 2200 and leucovorin 120 mg/m2 ). Response, survival and toxicity were evaluated.

RESULTS

From April 1997 to April 1999, six patients were included in this study. All patients received EEPFL chemotherapy. Clinical and laboratory evidence of acute DIC stabilized quickly after starting chemotherapy. Four patients showed a partial response, one stable disease and one progressive disease. The toxicity was mild and well tolerated. Median survival was 28 weeks (12, 14, 26, 30, 30 and 32 weeks). All patients suffered from a relapse of DIC after initial successful control and died within 30 days of clinical and laboratory evidence of acute DIC relapse.

CONCLUSION

EEPFL therapy is an effective chemotherapy regimen for patients with advanced gastric cancer associated with acute DIC. The prognosis is poor if the DIC relapses after the initial successful control.

Proximal arterioportal shunting associated with hepatocellular carcinoma: features revealed by dynamic helical CT

OBJECTIVE

This study investigated the findings revealed by dynamic helical CT of proximal arterioportal shunting associated with hepatocellular carcinoma. We also evaluated the diagnostic capability of this imaging technique to reveal the mass in patients with hepatocellular carcinoma.

CONCLUSION

On dynamic helical CT, proximal arterioportal shunting altered liver perfusion and tumor enhancement. Heterogeneous enhancement of liver parenchyma and decreased enhancement of hepatomas diminished diagnostic capability on the arterial dominant phase image. However, with the addition of imaging in the arterial portal phase, lesion conspicuity improved.

Klebsiella pneumoniae panophthalmitis: a possible complication of endoscopic variceal injection sclerotherapy

Complication of endoscopic variceal injection sclerotherapy for esophageal variceal hemorrhage is not unusual. However, sclerotherapy complicated panophthalmitis was never reported before. We report such an unusual complication and discuss its possible mechanism and treatment.

Radiotherapy in the treatment of duodenal bleeding due to hepatocellular carcinoma invasion

Haemorrhage from an hepatocellular carcinoma (HCC) directly invading the gastrointestinal (GI) tract is uncommon. A 58-year-old man was admitted with upper gastrointestinal (UGI) bleeding and panendoscopy on examination revealed a large duodenal ulcerative bleeding mass. The mass was eventually diagnosed as HCC by pathological examination. The bleeding failed to respond to conventional management of haemostasis, but resolved with an external beam of radiotherapy with a total dose of 6000 cGy over a 5 week period. This unusual presentation of UGI bleeding, due to HCC invading the duodenum and treated by radiotherapy, has not been previously reported.

Biphasic denaturation of human placental alkaline phosphatase in guanidinium chloride

Human placental alkaline phosphatase is a membrane-anchored dimeric protein. Unfolding of the enzyme by guanidinium chloride (GdmCl) caused a decrease of the fluorescence intensity and a large red-shifting of the protein fluorescence maximum wavelength from 332 to 346 nm. The fluorescence changes were completely reversible upon dilution. GdmCl induced a clear biphasic fluorescence spectrum change, suggesting that a three-state unfolding mechanism with an intermediate state was involved in the denaturation process. The half unfolding GdmCl concentrations, [GdmCl]0.5, corresponding to the two phases were 1.45 M and 2.50 M, respectively. NaCl did not cause the same effect as GdmCl, indicating that the GdmCl-induced biphasic denaturation is not a salt effect. The decrease in fluorescence intensity was monophasic, corresponding to the first phase of the denaturation process with [GdmCl]0.5 = 1.37 M and reached a minimum at 1.5 M GdmCl, where the enzyme remained completely active. The enzymatic activity lost started at 2.0 M GdmCl and was monophasic but coincided with the second-phase denaturation with [GdmCl]0.5 = 2.46 M. Inorganic phosphate provides substantial protection of the enzyme against GdmCl inactivation. Determining the molecular weight by sucrose-density gradient ultracentrifugation revealed that the enzyme gradually dissociates in both phases. Complete dissociation occurred at [GdmCl] > 3 M. The dissociated monomers reassociated to dimers after dilution of the GdmCl concentration. Refolding kinetics for the first-phase denaturation is first-order but not second-order. The biphasic phenomenon thereby was a mixed dissociation-denaturation process. A completely folded monomer never existed during the GdmCl denaturation. The biphasic denaturation curve thereby clearly demonstrates an enzymatically fully active intermediate state, which could represent an active-site structure intact and other structure domains partially melted intermediate state.

Solvent kinetic isotope effects of human placental alkaline phosphatase in reverse micelles

Human placental alkaline phosphatase was embedded in a reverse micellar system prepared by dissolving the surfactant sodium bis(2-ethylhexyl) sulphosuccinate (Aerosol-OT) in 2,2, 4-trimethylpentane. This microemulsion system provides a convenient instrumental tool to study the possible kinetic properties of the membranous enzyme in an immobilized form. The pL (pH/p2H) dependence of hydrolysis of 4-nitrophenyl phosphate has been examined over a pL range of 8.5-12.5 in both aqueous and reverse micellar systems. Profiles of log V versus pL were Ha-bell shaped in the acidic region but reached a plateau in the basic region in which two pKa values of 9.01-9.71 and 9.86-10.48, respectively, were observed in reverse micelles. However, only one pKa value of 9.78-10.27 in aqueous solution was detected. Profiles of log V/K versus pL were bell-shaped in the acidic region. However, they were wave-shaped in the basic region in which a residue of pKa 9.10-9.44 in aqueous solution and 8.07-8.78 in reverse micelles must be dehydronated for the reaction to reach an optimum. The V/K value shifted to a lower value upon dehydronation of a pKa value of 9.80-10.62 in aqueous solution and 11.23-12.17 in reverse micelles. Solvent kinetic isotope effects were measured at three pL values. At pL 9.5, the observed isotope effect was a product of equilibrium isotope effect and a kinetic isotope effect; at pL 10.4, the log V/K value was identical in water and deuterium. The deuterium kinetic isotope effect on V/K was 1.14 in an aqueous solution and 1.16 in reverse micelles. At pL 11.0 at which the log V values reached a plateau in either solvent system, the deuterium kinetic isotope effect on V was 2.08 in an aqueous solution and 0.62 in reverse micelles. Results from a proton inventory experiment suggested that a hydron transfer step is involved in the transition state of the catalytic reaction. The isotopic fractionation factor (pi) for deuterium for the transition state (piT) increased when the pH of the solution was raised. At pL 11.0, the piT was 1.07 in reverse micelles, which corresponds to the inverse-isotope effect of the reaction in this solvent system. Normal viscosity effects on kcat and kcat/Km were observed in aqueous solution, corresponding to a diffusional controlled physical step as the rate-limiting step. We propose that the rate-limiting step of the hydrolytic reaction changes from phosphate releasing in aqueous solution to a covalent phosphorylation or dephosphorylation step in reverse micelles.