Fasting plasma glucose in screening for diabetes in the Taiwanese population

OBJECTIVE

To reveal the relationship between fasting and 2-h postload plasma glucose and to examine the appropriate fasting glucose cutoff as the primary screening test for diabetes.

RESEARCH DESIGN AND METHODS

We recruited 5,303 subjects from preventive services of the National Cheng Kung University Hospital. Exclusion criteria were age <20 years, pregnancy, known diabetes, and a history of recent surgery, trauma, or illness. All subjects received the 75-g oral glucose tolerance test. The relationship between fasting and 2-h glucose was examined. Sensitivities, specificities, efficiency, and predictive values were assessed at different cutoffs of fasting glucose for prediction of diabetes.

RESULTS

The best fit model for the relationship between fasting and 2-h glucose was fasting glucose = 4.914-0.060 x (2-h glucose) + 0.0144 x (2-h glucose)2. From this model, the fasting glucose was 6.0 mmol/l when 2-h glucose was 11.1 mmol/l. A fasting glucose with 6.25 mmol/l gave the same diabetes prevalence as the World Health Organization 2-h glucose criterion. When 7.8 mmol/l was the fasting glucose cutoff, the sensitivity was 28.5%. Lowering the cutoff from 7.8 to 7.0 mmol/l increased the sensitivity by 11.2% and slightly reduced the specificity and positive predictive value. If the cutoffs were 6.25 and 6.0 mmol/l, the sensitivity increased and the specificity and the positive predictive value decreased accordingly.

CONCLUSIONS

Our results suggest that fasting glucose as a screening criterion for diabetes could be revised downward to 7.0 mmol/l, because the slight reduction of positive predictive value was more than balanced by an apparent increase of sensitivity and insignificant change of specificity.

Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment

OBJECTIVE

To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery.

SUMMARY BACKGROUND DATA

Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications.

METHODS

The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey.

RESULTS

Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit.

CONCLUSIONS

Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.

Cost, performance, and reliability simulator for optical transceiver modules

The program couple combines simulators for optical performance, mechanical reliability, and production cost under a graphical-user interface to design, simulate, and evaluate micro-optomechanical structures. The thermal simulator predicts the package temperature distribution on the basis of the materials and the geometry as well as on heat sources, sinks, and boundary conditions. The thermal distribution is input to the mechanical simulator, which calculates the stresses or strains and displacements caused by differential thermal expansion. The optical simulator predicts the impact on the optical efficiency and the cross talk of mechanical and optical parameter variations such as solder heights, misalignments, and wavelength distributions. The cost simulator represents the manufacturing process flow and calculates the final cost and the cost sensitivity on basis of the cost and the yield of each process step. By means of balancing detector and coupling yield, cosimulation from optical to cost domains determines the optimum detector size to produce the lowest-cost transceiver module.

Local treatment of abdominal wound reduces tumor implantation

BACKGROUND AND OBJECTIVES

Pneumoperitoneum increases the trocar-site tumor implantation rate using a human colon cancer cell line in a hamster model. The purpose of this study was to determine whether local treatment of trocar sites with potential tumoricidal agents can inhibit tumor implantation after pneumoperitoneum.

METHODS

GW-39 human colon cancer cells (0.5 ml of 2.5% v/v; 8.0 x 10(5) cells) were injected throughout the abdomen of 133 Golden Syrian hamsters through a midline incision. The animals were randomized to receive either untreated 5-mm trocars in each abdominal quadrant (group I control, n = 49), trocars dipped in 10% povidone-iodine (group II, n = 53), or trocars coated with 1% silver sulfadiazine (group III, n = 51). The midline wounds were also coated with the respective agents before closing. Pneumoperitoneum was then maintained at 10 mmHg for 10 min, after which the trocar wounds were closed. In group II, the trocar sites were treated with a coat of povidone-iodine after the trocars were withdrawn and before closing. Gross and microscopic tumor implants were analyzed at 7 weeks postoperatively.

RESULTS

The rate of tumor cell implantation at trocar sites was reduced from 93% (172/184) in the control group to 75% (126/168) and 78% (141/180) in groups II and III, respectively (P < 0.0001). Fewer palpable tumors were detected in groups II and III (40% and 23%, respectively) than in the control group (72%, P < 0.0001). Mean tumor mass in group III (0.4+/-0.1 g), but not in group II (1.0+/-0.2 g), was significantly less than that in the control group (1.3+/-0.1 g, P < 0.01). Overall tumor involvement of the larger midline wound was similar for all groups (I = 80%, II = 79%, III = 71%). However, palpable tumors were identified more frequently in group I (67%) than in groups II and III (43%, P < 0.05; 22%, P < 0.01, respectively).

CONCLUSION

Pretreatment of abdominal wounds with povidone-iodine or silver sulfadiazine can reduce tumor implantation after pneumoperitoneum in a hamster model.

Excision of trocar sites reduces tumor implantation in an animal model

PURPOSE

The purpose of this study was to determine the effect of excising abdominal trocar wound sites after pneumoperitoneum on the rate of trocar site tumor implantation in a hamster model. This would help determine whether tumor cells seed trocar sites during or after pneumoperitoneum.

METHODS

A total of 0.5 ml of GW-39 human colon cancer cell suspension at 2.5 percent v/v (8 x 10(5) cells) was injected into the abdomens of 77 hamsters through a midline incision. Animals were subjected to ten minutes of pneumoperitoneum, after placement of four abdominal trocars, and then randomly assigned to undergo either simple suture closure or 4-mm radius trocar wound site excision at the end of the procedure. Gross and microscopic tumor implants were documented seven weeks later.

RESULTS

There were three and four deaths in simple suture closure and wound site excision groups, respectively. Of the remaining 35 hamsters in each group, tumor cells implanted at 89 and 78 percent of trocar sites, respectively (P < 0.03). There was no significant difference between the two groups in tumor implantation at midline laparotomy sites. Wound site excision also resulted in fewer palpable tumors (44 vs. 61 percent; P < 0.01) and a lower tumor implantation rate (49 vs. 74 percent; P < 0.05) at all four concurrent sites compared with simple suture closure.

CONCLUSIONS

Excision of laparoscopic abdominal trocar wound sites can significantly, but not completely, reduce tumor implantation rate compared with simple wound closure.

Production and systemic absorption of toxic byproducts of tissue combustion during laparoscopic cholecystectomy

Among the potential hazards of laparoscopic surgery using electrocautery is the release of chemical by-products of incomplete tissue combustion into the pneumoperitoneum with subsequent transperitoneal absorption into the bloodstream and/or release into the operating room. The purpose of this study of patients undergoing laparoscopic cholecystectomy (LC) was twofold: (1) to assess the relationship between intraperitoneal concentration of carbon monoxide (CO) and blood levels of carboxyhemoglobin (COHb) and methemoglobin (MetHb), and (2) to assess the surgeon's inhalation of CO resulting from ambient smoke exposure. During LC with monopolar electrocautery, 21 patients were evaluated intraoperatively for intraperitoneal [CO] by sampling gas from a trocar, whereas arterial [COHb) and [MetHb] were determined perioperatively. The surgeon's venous blood was drawn pre- and postoperatively to assay [COHb] and [MetHb]. Patients completed visual analogue questionnaires 6 hours and 24 hours postoperatively to assess for adverse symptoms. Mean (+/- SEM) patient age and weight were 45 +/- 3 years and 84 +/- 4 kg, respectively. Mean duration of the operation was 69 +/- 5 minutes, and electrocautery was used for 3.0 +/- 0.3 minutes. Intraperitoneal [CO] rose to peak levels of 209 +/- 19 ppm at 50 minutes, whereas systemic [COHb] and [MetHb] were unchanged. The surgeon's systemic [COHb] and [MetHb] did not increase postoperatively. Nausea, abdominal pain, and fatigue scores decreased significantly between 6 and 24 hours postoperatively; however, there were no correlations between these symptoms and peak intraperitoneal [CO]. Although LC using electrocautery increases intraperitoneal [CO] to "hazardous" levels, systemic [COHb] and [MetHb] are not elevated by generation of intraperitoneal smoke. The surgeon's exposure to CO by the evacuation of smoke through laparoscopic ports is negligible. Production of smoke during LC using monopolar electrocautery, therefore, does not appear to pose a threat to either the patient or the surgeon.

Choroidal involvement in Wegener's granulomatosis: a case report

Wegener's granulomatosis is a necrotizing, granulomatous vasculitis. It usually causes sinusitis, pneumonitis and glomerulonephritis. The common ocular manifestations include conjunctivitis, scleritis, peripheral keratitis and orbital inflammation. We report the case of a 50-year-old woman with Wegener's granulomatosis and very severe ocular complications who underwent bilateral enucleation. The pathologic findings of the eyeballs revealed granulomatous necrotizing scleritis, perivasculitis and granulomatous choroiditis. The last, as far as we know, has not yet been reported.

Endoscopic axillary lymph node dissection: an experimental study in human cadavers

BACKGROUND

The role of axillary lymph node dissection in the staging of patients with breast carcinoma is currently under evaluation. As a result of recent advances in minimally invasive techniques, an endoscopic approach to axillary lymph node dissection may be an attractive alternative to lymphadenectomy performed via a standard "open" axillary incision. The purpose of the present study was to evaluate the technical feasibility and safety of such an approach in human cadavers.

STUDY DESIGN

Twelve axillary dissections (right in seven, left in five) were performed in seven cadavers. A 2.5-cm incision was made along the lateral chest wall 12 cm inferior to the apex of the axilla. The subcutaneous axillary space was expanded with a balloon dissector, and exposure was maintained with a prototype external lift device. Endoscopic dissection was performed with three or four 5-mm ports inserted into this space. Histologic analysis was performed to document the number of lymph nodes removed.

RESULTS

The mean dissection time for endoscopic axillary lymphadenectomy was 56.7+/-19 minutes (range, 30-90 minutes). Structures visualized endoscopically included the axillary vein (12 of 12 patients), the long thoracic nerve (12 of 12 patients), the thoracodorsal nerve (10 of 12 patients), and the intercostobrachial nerve (11 of 12 patients). An average of 9.9+/-7.2 lymph nodes (range, 2-22 nodes) was removed from each axilla. Open exploration of the axilla after the endoscopic dissection confirmed no injuries to any neurovascular structures. Residual lymph nodes were removed from the axilla in 7 of 12 dissections (58%; average, 4.2+/-4.0 nodes per specimen).

CONCLUSIONS

These results suggest that endoscopic axillary dissection is feasible with currently available technology. Clinical trials in patients with breast carcinoma may be warranted to evaluate this technique further.

Identification of genes expressed in human CD34(+) hematopoietic stem/progenitor cells by expressed sequence tags and efficient full-length cDNA cloning

Hematopoietic stem/progenitor cells (HSPCs) possess the potentials of self-renewal, proliferation, and differentiation toward different lineages of blood cells. These cells not only play a primordial role in hematopoietic development but also have important clinical application. Characterization of the gene expression profile in CD34(+) HSPCs may lead to a better understanding of the regulation of normal and pathological hematopoiesis. In the present work, genes expressed in human umbilical cord blood CD34(+) cells were catalogued by partially sequencing a large amount of cDNA clones [or expressed sequence tags (ESTs)] and analyzing these sequences with the tools of bioinformatics. Among 9,866 ESTs thus obtained, 4,697 (47.6%) showed identity to known genes in the GenBank database, 2, 603 (26.4%) matched to the ESTs previously deposited in a public domain database, 1,415 (14.3%) were previously undescribed ESTs, and the remaining 1,151 (11.7%) were mitochondrial DNA, ribosomal RNA, or repetitive (Alu or L1) sequences. Integration of ESTs of known genes generated a profile including 855 genes that could be divided into different categories according to their functions. Some (8.2%) of the genes in this profile were considered related to early hematopoiesis. The possible function of ESTs corresponding to so far unknown genes were approached by means of homology and functional motif searches. Moreover, attempts were made to generate libraries enriched for full-length cDNAs, to better explore the genes in HSPCs. Nearly 60% of the cDNA clones of mRNA under 2 kb in our libraries had 5' ends upstream of the first ATG codon of the ORF. With this satisfactory result, we have developed an efficient working system that allowed fast sequencing of 32 full-length cDNAs, 16 of them being mapped to the chromosomes with radiation hybrid panels. This work may lay a basis for the further research on the molecular network of hematopoietic regulation.

A population-based study of the prevalence and associated factors of diabetes mellitus in southern Taiwan

Diabetes mellitus is one of the major health care problems in Taiwan, since the mortality rate has increased from 7.91 per 100,000 in 1980 to 35.1 per 100,000 in 1996. To determine the prevalence of diabetes in southern Taiwan and to investigate possible associated factors, a stratified systematic cluster sampling of 1638 subjects (780 men and 858 women) aged > or =20 years living in Tainan city was investigated with a standard 75-g oral glucose tolerance test. The crude prevalence of diabetes in Tainan was 9.0% (10.3% men and 7.9% women) and the age-adjusted prevalence was 9.2% (10.4% men and 8.1% women). The crude prevalence of IGT was 14.0% (13.8% men and 14.1% women), and the age-adjusted prevalence was 15.5% (15.0% men and 15.9% women). The prevalence of diabetes by using the revised new diagnostic criteria was 7.5%. The prevalence of diabetes and IGT increased significantly with age for both genders, although the rises in prevalence of IGT in women was less consistent. Diabetic and IGT subjects were older and had higher levels of BMI, triglyceride, systolic and diastolic blood pressure, and higher prevalence of obesity, hypertension, and dyslipidemia but indulged in less physical activity than non-diabetic subjects. The significant factors associated with the newly diagnosed diabetes were age, family history of DM, BMI, systolic blood pressure, physical activity, and serum triglyceride levels.

Incidence of neoplastic polyps in the ileal pouch of patients with familial adenomatous polyposis after restorative proctocolectomy

PURPOSE

Although adenomatous polyps and even adenocarcinomas have been found in the terminal ileum of patients with familial adenomatous polyposis, the prevalence of neoplastic changes in the pouches of patients who have undergone restorative proctocolectomy is unknown. The objective of this study was to determine the frequency of pelvic pouch neoplasia in familial adenomatous polyposis patients after restorative proctocolectomy.

METHODS

Patients in a polyposis registry who had undergone restorative proctocolectomy were recruited. Demographic, surgical, pathologic, and endoscopic data were obtained from patient records. Video pouchoscopy was done after two enemas and representative biopsies were taken.

RESULTS

Of 102 eligible patients, 26 (17 males and 9 females) participated. Median age at ileal pouch-anal anastomosis was 31 (range, 12-58) years. Median follow-up period was 66 (11-156) months. Adenomas were found in the pouch of 11 (42 percent) patients, in the terminal ileum above the pouch in 1 patient, and in the anal canal of 4 patients. Among patients with pouch polyps, three patients had one lesion, three patients had two lesions, and five patients had more than ten lesions. The incidence of polyps increased steadily with time from restorative proctocolectomy. There was no relation between the incidence of pouch polyposis and the severity of colonic or duodenal disease.

CONCLUSIONS

Proctocolectomy and ileal pouch-anal anastomosis is associated with a significant risk of pouch neoplasia in familial adenomatous polyposis patients. The severity of pouch adenomas was not related either to the severity of colonic or duodenal disease. The pelvic pouches of all patients with familial adenomatous polyposis who have undergone restorative proctocolectomy should be examined periodically.

The evolution and maturation of laparoscopic cholecystectomy in an academic practice

BACKGROUND

The technique of laparoscopic cholecystectomy (LC) has evolved since its adoption in the late 1980s. We sought to document these changes and assess whether patient outcomes were influenced during this maturational process.

STUDY DESIGN

A prospective data base was used to record the outcomes of all LCs performed in an academic surgeon's practice. Trends over time among 1,165 consecutive patients were assessed by comparing the first 100 LCs (group I), the middle 100 LCs (group II), and the most recent 100 LCs (group III).

RESULTS

During a 93-month period with 1,165 patients undergoing LC, 25 procedures (2.1%) were converted to open cholecystectomy. Perioperative complications occurred in 31 patients (3%): grade I in 9 (0.8%), grade II in 16 (1.4%), grade III in 5 (0.4%), and grade IV (death) in 1 (0.1%). Length of hospital stay and convalescence were 1.1 +/- 0.1 and 9.5 +/- 0.5 days, respectively. Nineteen patients (2%) were readmitted early after operation and 10 (1%) developed long-term complications (port-site hernia or retained stone). In group III, cholangiography was largely replaced by intraoperative ultrasonography for ductal evaluation. Operating room time decreased, while the rates of conversion, morbidity, and readmission remained the same. Patients had higher ASA classifications in the latter two groups, whereas operative charges were greater in Group III than in Groups I and II. These trends occurred even though most procedures are currently performed by residents, and fewer LCs are being done.

CONCLUSIONS

Laparoscopic cholecystectomy has matured into a more efficient operation, yet remains safe with low morbidity when performed by residents at an academic institution.

[Morphological evidence for thymocytes apoptosis outside the thymus]

In vitro thymus explants culture designed in this paper can mimic the thymic microenvironment as it were in vivo. Theoretically, thymus explants are cut off free from blood stream. So if some developing or developed thymocytes had the inclination to migrate into the periphery, they would only be accumulated in the blood vessels within thymus explants. After 3-day's culture, under transmission electron microscope we observed the migrating thymocytes accumulated in the blood vessels of C57BL/6 mice thymus explants, and these thymocytes were occurring apoptosis at different stage. To our knowledge, this findings offers the first morphological evidence that thymocytes do not necessarily die inside the thymus in situ, and that having acquired the death signals thymocytes can migrate into the blood stream and die quickly outside the thymus. But this is not to say that we deny the intrathymic death hypothesis. On the contrary, we found the number of thymocytes occurring in situ apoptosis on the surfaces of stromal cells is far more than that of migrating into the blood vessels. So, our proposal is that there are two sites for thymocytes apoptosis, some die inside the thymus and the others die outside the thymus.

Relationship between glycosylated hemoglobin, blood pressure, serum lipid profiles and body fat distribution in healthy Chinese

Obesity-related metabolic disorders have not been adequately addressed due to a failure to distinguish the importance of general obesity or body fat distribution in relation to atherosclerotic risk factors, especially in the less obese populations. To assess the relationship between general obesity (reflected by BMI, total body fat percentage and total adiposity), body fat distribution (reflected by WHR, default regions and ROIs of DEXA) and atherosclerotic risk factors in the Chinese population, a total of 872 healthy subjects (477 male and 395 female) were enrolled in the study. The results indicated that the android pattern of fat distribution, independent of general obesity, was positively correlated with blood pressure, atherogenic indices, fasting and OGTT 2-h plasma glucose, glycosylated hemoglobin (HbA1c), serum concentration of cholesterol, triglyceride, LDL cholesterol and negatively correlated with HDL cholesterol in both genders. The gender differences in patterns of body fat distribution and atherosclerotic risk factors remained significant after adjustments were made for age, BMI and total adiposity, although diminished after further adjustments for body fat distribution. In conclusion, body fat distribution, rather than general obesity, is more correlated with obesity-related atherosclerotic risk factors and sex-associated differences. ROIs measured by DEXA may be a useful method to evaluate sex-associated changes in body fat distribution and atherosclerotic risk factors in the healthy Chinese population.

Laparoscopic hepatic lobectomy in the porcine model

BACKGROUND

To date, there have been only a few anecdotal reports of laparoscopic hepatectomy, most of which are limited to wedge resections. The aim of this study was to assess the feasibility of laparoscopic hepatic lobectomy in a porcine model.

METHODS

Eight pigs were anesthetized before placement of an abdominal wall lift device and five laparoscopic ports. With the porta hepatis clamped, the left lateral hepatic lobe was divided with an ultrasonic dissector. Small vessels and ducts were clipped, larger vascular structures were transected with staplers, and surface hemorrhage was controlled with an argon beam coagulator. Serum liver enzymes (LFTs) and blood counts were drawn pre- and postoperatively. All animals were killed after 1 week.

RESULTS

Mean +/- SEM operating and clamp times were 131 +/- 8 and 39 +/- 2 min, respectively. There were four intraoperative complications in three animals (three lacerations of the hepatic vein and one tear of the splenic capsule), all of which were controlled at surgery. Mean blood loss was 189 +/- 52 ml, and the mass of the resected specimen was 139 +/- 11 g. There were no postoperative complications or deaths. White blood cell count, hematocrit, and LFTs did not change postoperatively, except for aspartate aminotransferase (AST), which was elevated transiently. There were no bile leaks or intraabdominal abscesses.

CONCLUSIONS

Laparoscopic left hepatic lobectomy was technically feasible in the porcine model using an abdominal wall lift device for exposure. Clinical trials are needed to assess its feasibility and limitations before laparoscopic hepatic lobectomy is deemed safe for human use.

Film-forming polymer-granulated excipients as the matrix materials for controlled release dosage forms

Lactose and dibasic calcium phosphate (DCP) were granulated with various concentrations of film-forming polymers by a stepwise spraying method to prepare a directly compressible matrix excipient. The film-forming polymeric latex of Eudragit RS-30D, Eudragit RL-30D, and Surelease (ethylcellulose) were used in this study as the source of the granulating materials. Better flowability and compressibility were observed for all the granulated particles than the polymer-free granules. Most tablets prepared from the polymer-granulated particles exhibited satisfactory friability of less than 1% except for those prepared from lactose particles granulated with low concentrations of ethylcellulose and from plain lactose granules. Change in tensile strength and tablet thickness were in good agreement with the plasticity of the granulating polymer. Polymer-granulated lactose and DCP provided for controlled release of captopril from matrix tablets. This investigation suggests that conventional excipients can be modified by a simple granulating procedure to provide better physical properties for being used as a matrix material.

Effects of pneumoperitoneum on tumor implantation with decreasing tumor inoculum

INTRODUCTION

The aim of this study was to determine the effect of pneumoperitoneum on the rate of trocar-site implantation with decreasing inoculum of cancer cells.

METHODS

A total of 0.5 ml of GW-39 human colon cancer cell suspensions at 1 percent (approximately 3.2 x 10(5) cells) and at 0.5 percent (approximately 1.6 x 10(5) cells; v/v) were injected into the abdomen of hamsters through a midline incision. Animals in each group were randomized to receive either pneumoperitoneum (1 percent = 33; 0.5 percent = 43) or not (1 percent = 32; 0.5 percent = 39). Gross and microscopic tumor implants were documented seven weeks later at four trocar sites.

RESULTS

In the 1 percent group, pneumoperitoneum significantly increased trocar-site tumor implants from 50 to 71 percent (P < 0.001). Pneumoperitoneum also resulted in the following: 1) more frequent involvement of all four concurrent sites (38 vs. 10 percent; P < 0.02); 2) more frequent palpable tumors (13 vs. 5 percent; P < 0.01); 3) larger tumor mass (2.1 +/- 0.6 g vs. 0.2 +/- 0.1 g; P < 0.02). In the 0.5 percent group, pneumoperitoneum did not significantly increase trocar-site tumor implants, and it did not result in a larger tumor mass. The percent increase in trocar-site implants owing to pneumoperitoneum was influenced by the amount of tumor inoculum (21 percent in the 1 percent group; 10 percent in the 0.5 percent group). The mass of palpable tumor implants after pneumoperitoneum decreased with decreased inoculum: 1 percent = 2.1 +/- 0.6 g; 0.5 percent = 0.3 +/- 0.1 g (P < 0.0001).

CONCLUSIONS

Pneumoperitoneum significantly increased both tumor implantation rate and mass when approximately 3.2 x 10(5) colon cancer cells were injected into the peritoneal cavity. These effects of pneumoperitoneum diminished with one-half as many tumor cells injected in the peritoneal cavity.

Modification of physical characteristics of microcrystalline cellulose by codrying with beta-cyclodextrins

In an attempt to modify the physical properties of microcrystalline cellulose (MCC), the slurry form of this material was codried with beta-cyclodextrin (beta-CD). MCC slurry was blended with beta-CD at concentrations of 10%-50% w/w as a dried mass relative to MCC. The mixtures were then granulated with water and codried at 60 degrees C for 12 h or until a constant weight was reached. Codried granules were pulverized, and the fraction between 61 and 150 microns in size was reserved. The powder and tableting properties of the codried products were compared to those of various grades of MCC and the corresponding components and physical mixtures. The results showed that the products of MCC codried with beta-CD significantly improved the flowability of MCC powder. It is probable that the improved flowability was due to the more rounded shape of particles formed with this codried process, which was confirmed by SEM photographs. Moreover, the compactibility and disintegration properties of tablets produced from the codried products were even better than those using MCC alone, physical mixtures, or various grades of MCC. MCC in a slurry form was more efficient than the existing MCC products in achieving these results, which is postulated to be due to the greater amount of water required and the higher solubility of beta-CD in water promoting the interaction between beta-CD and MCC during granulation. In conclusion, MCC codried with beta-CD provides a useful excipient for direct compression.

The utility of intracorporeal ultrasonography for screening of the bile duct during laparoscopic cholecystectomy

Different strategies and imaging modalities have been used to detect common bile duct (CBD) stones during laparoscopic cholecystectomy. We prospectively compared fluoroscopic intraoperative cholangiography (FIOC) and laparoscopic intracorporcal ultrasonography (LICU) in patients undergoing laparoscopic cholecystcctomy for this purpose. In a consecutive series of 607 laparoscopic cholecystectomics, FIOC was used in the first 407 patients, whereas LICU was preferentially applied to the subsequent 200 patients. When LICU documented CBD stones, the duct was flushed with saline solution after intravenous administration of glucagon, and stone persistence or absence was confirmed by FIOC and/or repeat LICU. In the FIOC group, 10 patients were converted to open cholecystectomy and 16 patients did not undergo FIOC. Among the remaining 381 patients, FIOC was successful in 370 (97%). In the LICU group, two patients were converted and LICU was not performed in 26 patients. In the remaining 172 patients, the cystic duct (CBD) junction and the CBD were visualized in all cases (P <0.05 vs. FIOC). The mean (+/- SEM) times required to complete FIOC and LICU were 15. 1 +/- 0.4 minutes and 5.3 +/- 0.2 minutes, respectively (P <0.0001). Choledocholithiasis was detected in 25 patients (7%) undergoing FIOC and in 22 patients (13%) undergoing LICU (P <0.05). In the LICU group, the mean sizes of the stones cleared by ampullary dilatation and flushing (17 of 22, 77%) and those requiring more invasive methods (5 of 22, 23%) were 1.6 +/- 0.2 mm and 2.7 +/- 0.3 mm, respectively (P <0.01). Sludge seen in the CBD by LICU in 10 patients (6%), which disappeared with flushing in all cases. LICU is accurate, safe, and permits more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. LICU may be overly sensitive in detecting small stones and sludge, which are of questionable significance. Stones 2 mm or less can usually be cleared by flushing, whereas larger ones often require invasive techniques for removal.

APC genotype, polyp number, and surgical options in familial adenomatous polyposis

OBJECTIVE

This study was performed to examine the relation between phenotypic expression in patients with familial adenomatous polyposis (FAP) and the site of mutations in the APC (adenomatous polyposis coli) gene. The ability of APC mutations to predict surgical outcome was also investigated.

SUMMARY BACKGROUND DATA

Germline mutations in the APC gene cause FAP and can now be identified by direct mutational analysis. Such an analysis can identify affected persons for close surveillance and spare unaffected persons. Phenotypic expression varies within and among FAP kindreds, but certain mutations have been associated with severe disease. Patients with severe polyposis are frequently offered total proctocolectomy rather than colectomy and ileorectal anastomosis out of concern for increased rectal cancer risk. Mutation analysis may offer a more rational basis for these decisions.

METHODS

The postsurgical courses of 58 patients from 19 FAP kindreds with identified APC gene mutations were reviewed. APC gene mutations were identified by analysis of leukocyte DNA using single-strand conformational analysis and DNA sequencing. FAP severity was defined according to the number of polyps in the colon at the time of resection (< 1000, mild; > 1000, severe). Operations included subtotal colectomy with ileorectal anastomosis (IRA), total proctocolectomy with ileal pouch/anal anastomosis, total proctocolectomy with end ileostomy, and partial colectomy (PC).

RESULTS

Eight different APC mutations were identified. Mutations at codons 1309 and 1328 in exon 15G were associated with a uniformly severe polyposis phenotype. For other mutations, the phenotype was more variable. Patients with APC mutations at codons 1309 and 1328 more commonly underwent proctectomy. Among the 43 patients who initially underwent either IRA or PC, the rectum was later removed in 8. Seven of these patients had a mutation at codon 1309 or 1328. With one exception, all patients with mutations outside the 1309 or 1328 site who initially had IRA have retained their rectum.

CONCLUSIONS

Our data support an association between severe polyposis phenotype and mutations at APC gene codons 1309 and 1328. For patients with these mutations, the prognosis for retaining the rectum is poor.

Production and systemic absorption of toxic byproducts of tissue combustion during laparoscopic surgery

BACKGROUND

Among the potential hazards of laparoscopic surgery using electrocautery is the intraperitoneal release and subsequent absorption of byproducts of tissue combustion. In a porcine model of laparoscopic surgery with smoke production, our aims were to assess (1) the relationship between levels of intraperitoneal carbon monoxide (CO) and systemic carboxyhemoglobin (COHb) and methemoglobin (MetHb), and (2) intraperitoneal concentrations of other noxious gases, including hydrogen cyanide (HCN), acrylonitrile (Acr), and benzene (Bzn).

METHODS

Seven pigs underwent laparoscopic resection of three hepatic wedges using monopolar electrocautery in a CO2 pneumoperitoneum. Sequential arterial samples were drawn to measure [COHb] and [MetHb] perioperatively, while gaseous intraabdominal [CO], [HCN], [Acr], and [Bzn] were assayed intraoperatively.

RESULTS

The mean +/- SEM duration of operation was 90 +/- 2 min, and electrocautery was used for 68 +/- 4 min. Intraabdominal [CO] rose from 0 to 814 +/- 200 ppm (p < 0.01) while [COHb] increased from 2.9 +/- 0.1% to 3.5 +/- 0.1% (p < 0.001). Systemic [MetHb] remained unchanged intra- and postoperatively, ranging from 0.3 to 0.7%. Intraperitoneal [HCN] rose from 0 to 5.7 +/- 0.7 ppm (p < 0.001). [Acr], however, did not change significantly from preoperative values, ranging from 0 to 1.6 +/- 1. 0 ppm, and [Bzn] was undetectable.

CONCLUSIONS

Laparoscopic tissue combustion increases intraabdominal [CO] to "hazardous" levels leading to minimal, yet significant, elevations of [COHb]. Systemic [MetHb] and intraabdominal [HCN], [Acr], and [Bzn] are not elevated to toxic levels. Production of intraperitoneal smoke during laparoscopic electrosurgery therefore may not pose a significant threat to the patient.

Experimental development of an endoscopic approach to neck exploration and parathyroidectomy

BACKGROUND

Recent advances in minimally invasive surgical technology have the potential to lead to new applications outside body cavities. The purpose of the present study was to develop techniques for obtaining endoscopic exposure and access to the pretracheal space in the neck with the goal of performing neck exploration and parathyroidectomy and to evaluate the safety and efficacy of such an approach experimentally.

METHODS

The technique for endoscopic neck exploration was developed in eight adult mongrel dogs and was further evaluated in a survival dog model and in human cadavers. The pretracheal space was accessed by a 2.5 cm midline incision in the lower neck. This space was expanded with a balloon dissector, and exposure was maintained with an external lift device. A 5 or 10/12 mm midline port and two to four lateral 5 mm cervical ports were placed, and dissection was carried out with pediatric endoscopic instruments and an ultrasonic coagulator. Excised parathyroid tissue was verified histologically.

RESULTS

Two-gland parathyroidectomy was successfully completed in five of six dogs; inadequate exposure led to a failed procedure in one animal. Mean operative time was 130 +/- 6 minutes, and there were no operative complications. Serum calcium levels did not change significantly after operation (p = not significant). At autopsy, approximately 20 ml of clear sterile fluid was present in the pretracheal space of every dog. In five human cadavers mean dissection time for attempted four-gland parathyroidectomy was 69 +/- 38 minutes (range, 45 to 135 minutes). Four of four parathyroids were identified and removed in two patients, three of three parathyroids in one patient, three of four parathyroids in one patient, and two of four parathyroids in one patient.

CONCLUSIONS

Parathyroidectomy may be performed safely and reliably in an animal model with minimally invasive techniques that can be applied to parathyroid dissection in human cadavers. These results suggest that an endoscopic approach to neck exploration and parathyroidectomy is potentially feasible and may warrant further study in clinical trials.

Laparoscopic-assisted ileocolic resections in patients with Crohn's disease: are abscesses, phlegmons, or recurrent disease contraindications?

BACKGROUND

Because of the inflammatory nature of Crohn's disease, ileocolic resections are often difficult to perform, especially if an abscess, phlegmon, or recurrent disease at a previous ileocolic anastomosis is present. Our goal was to determine whether the above factors are contraindications to a successful laparoscopic-assisted ileocolic resection.

METHODS

Between 1992 and 1996, 46 laparoscopic-assisted ileocolic resections were attempted. Fourteen patients had an abscess or phlegmon treated with bowel rest before operation (group I), 10 patients had recurrent Crohn's disease at the previous ileocolic anastomosis (group II), and 22 patients had no previous operation and no phlegmon or abscess associated with their disease (group III). These groups were compared with each other and with 70 consecutive open ileocolic resections for Crohn's disease during the same time period (group IV).

RESULTS

Operative blood loss and time were greater in group IV than in groups I, II, and III (245 versus 151, 131, and 195 ml, respectively, and 202 versus 152, 144, and 139 minutes, respectively). Conversion to open procedure occurred in 5 patients (group I, 1 [7%]; group II, 2 [20%]; group III, 2 [9%]). Morbidity was highest in group IV (21% versus 0%, 10%, and 10%, respectively). Only one patient died (group IV, 1%). Length of hospital stay was longest in group IV (7.9 versus 4.8, 3.9, and 4.5 days, respectively).

CONCLUSIONS

The laparoscopic-assisted approach to Crohn's disease is feasible and safe with good outcomes. Co-morbid preoperative findings such as abscess, phlegmon, or recurrent disease at the previous ileocolic anastomosis are not contraindications to a successful laparoscopic-assisted ileocolic resection in select patients.

Implantation of colon cancer at trocar sites is increased by low pressure pneumoperitoneum

BACKGROUND

The purpose of this study was to determine the effect of pneumoperitoneum on the implantation of tumor at trocar sites.

METHODS

GW-39 human colon cancer cell suspension (0.5 ml of 2.5% v/v) was injected into the peritoneal cavity of golden Syrian hamsters through a 1 cm midline incision. Four 5 mm trocars were inserted through the anterior abdominal wall, and the midline incision was then closed. The animals were randomized to receive pneumoperitoneum (n = 62) or no pneumoperitoneum (n = 60) for 10 minutes. Tumor implantations at trocar sites and midline wound incisions were documented grossly and histologically 8 weeks later.

RESULTS

Tumor was identified in 86% (49 of 57) of control animals and 95% (52 of 55) of the experimental group (p = 0.20). Implants increased with pneumoperitoneum at the midline incision from 44% to 71% (p < 0.01) and at trocar sites from 41% to 64% (p < 0.00001).

CONCLUSIONS

Pneumoperitoneum significantly increased tumor implantation at trocar sites and midline incisions.

Respiratory-related facial nerve activity in response to activation of the rostral ventrolateral medulla in the cat

The effects of electrical and chemical activation of the rostral ventrolateral medulla (rVLM) on respiratory-related facial nerve activity were investigated in decerebrated, paralyzed, vagotomized and ventilated cats. The animal was maintained at normocapnia and hypercapnia in hyperoxia. Phrenic and facial nerve activities were simultaneously recorded. Excitation of the rVLM either by electrical current (12.5 to 50 microA, 80 Hz and 0.5 ms pulse duration) or glutamate microinjection (50 mM, 20 to 200 nl) inhibited both phrenic and facial nerve discharges. Although inhibition of the rVLM upon both nerves was attenuated by hypercapnia, this inhibition remained significant during hypercapnia. These results suggest that the rVLM may be involved in the modulation of upper airway patency by controlling respiratory-related facial nerve activity.

Age and sex effects on HbA1c. A study in a healthy Chinese population

OBJECTIVE

To evaluate whether glycohemoglobin levels increase with age in both sexes and to determine the effect of BMI on this increment.

RESEARCH DESIGN AND METHODS

A cross-sectional survey of 4,580 healthy Chinese men and women, aged 20-85 years, was performed. All subjects who did not have identifiable diseases and who were not on medication known to influence glucose tolerance were recruited from participants at the preventive services of the National Cheng-Kung University Hospital. As an indicator of plasma glucose levels, glycohemoglobin was measured. The subjects were classified according to their age and BMI for both men and women, and any relationships with glycohemoglobin levels were evaluated.

RESULTS

In all the BMI groups divided into quartiles, glycohemoglobin levels increased with age. The largest elevation of glycohemoglobin was observed in the 45- to 54-year-old age-group, except in men with a BMI between the lowest and highest quartiles. The group with a BMI above the highest quartile had a higher glycohemoglobin than the group with a BMI below the lowest quartile in men aged < 54 years and women aged 35-64 years. Men had higher average glycohemoglobin levels than women < 55 years of age.

CONCLUSIONS

The age factor itself may cause an elevation in glycohemoglobin independent of other age-related factors in Chinese men and women, and there is a sex difference with a lower average glycohemoglobin level in women before menopause. Furthermore, BMI, but not a family predisposition to diabetes or leisure-time physical activity, affects this age-dependent increase in glycohemoglobin levels.

Primary orbital hemangiopericytoma: a case report

A case of primary orbital hemangiopericytoma is reported in a 31-year-old female presenting with progressive proptosis of the left eye and deteriorating diplopia over a period of 2 years. Orbital computed tomography revealed a superiorly located well-circumscribed extraconal mass. A 32x57x16 mm soft mass that appeared grossly encapsulated was removed intact via anterior orbitotomy. Histopathological examination disclosed it to be a hemangiopericytoma. The clinical importance is its potentially malignant behavior, with a high local recurrence rate in case of incomplete excision. Literature was reviewed.

Measurement of polyethylene wear in cementless total hip arthroplasty

We made a clinical study of polyethylene wear in 240 hips of 187 patients having primary total hip arthroplasties from 1989 to 1990, using uncemented Osteonics components, with a head size of 26 mm. We excluded cups with anteversion of over 20 degrees and measured linear wear by a new method using a digitiser and special software of our design. Follow-up was from two to five years (mean 4.3). The mean age at operation was 50.3 years, with more men than women (1.4:1). The mean linear wear per year was 0.15 mm; this did not increase with the longevity of the prosthesis (p = 0.54). In 59 hips showing evidence of osteolysis, the mean linear wear rate was significantly higher at 0.23 mm/year (p <0.001). The mean linear wear rate also correlated significantly with age at the time of operation (p = 0.008), but we found no significant correlations with body-weight, gender, aetiology of the disease, thickness of polyethylene, or cup position. Our new method of measurement is time-saving and reproducible. The results confirm the greater rate of linear wear of polyethylene in patients showing osteolysis and in those who are younger.

Technique for performing direct lymphangiography in pigs

RATIONALE AND OBJECTIVES

The authors developed a porcine model for direct lymphangiography to be used as a reference for lymph node harvesting.

METHODS

A pilot animal was studied first to develop the protocol, which was used successfully in 24 pigs. An indicator dye was first injected into each foot to make the lymphatic vessels visible. Then, ethiodized poppy seed oil was injected directly through cutdowns in both groins. Radiographs were obtained before and after lymph node harvesting.

RESULTS

Images were of diagnostic quality in all animals. The pilot animal developed transient respiratory distress, which was thought to be due to the oil-based contrast material. The amount injected was reduced by half, and no episodes occurred thereafter in the study group. There were no other immediate or delayed complications.

CONCLUSION

Direct lymphangiography is safe, easy, and reliable in a porcine model.

Early experience with laparoscopic abdominoperineal resection

BACKGROUND

Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center.

METHODS

A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient).

RESULTS

The procedure was converted to open procedure in four patients (19%). The mean (+/-SEM) operative time and blood loss for completed and converted LAPR were 239 +/- 11 min and 424 +/- 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% +/- 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1-44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates.

CONCLUSION

Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients.

Laparoscopic pancreaticoduodenectomy in the porcine model

BACKGROUND

Minimally invasive techniques offer theoretical advantages for treating resectable periampullary neoplasms. Laparoscopic pancreaticoduodenectomy (LPD) was first reported in 1992 and has been performed clinically despite lack of animal data to support the operation. The purpose of this study was to develop LPD in an acute porcine model and to assess safety and efficacy before considering clinical trials.

METHODS

LPD was initiated in six domestic pigs under general anesthesia. Once pneumoperitoneum was created, five 10-mm access ports were placed (one central and two in each flank). After cholecystectomy, the duodenum was mobilized and the proximal jejunum was divided distal to the ligament of Treitz. The neck of the pancreas was separated from the superior mesenteric vein, and the midstomach was divided by a stapler. Pancreaticojejunostomy (PJ), choledochojejunostomy (CDJ), and gastrojejunostomy (GJ) were performed using interrupted sutures. The animals were immediately sacrificed and the operative site was examined.

RESULTS

LPD was aborted in three animals due to complications: intestinal perforation with fecal contamination (one) and prolonged resection time >/= 2.5 h (two). LPD was completed in three animals (operative time ranged from 5.0 to 7.5 h, blood loss < 200 cc); however, at sacrifice one PJ and two CDJs had small posterior leaks. The efferent loop of the GJ was narrowed by the staple line in one pig. All animals had extensive ecchymosis of the jejunal serosa due to excessive manipulation.

CONCLUSION

Despite a significant number of anastomotic leaks in the immediate postoperative period, laparoscopic pancreaticoduodenectomy is feasible in a porcine model. Further studies and technical development are necessary before laparoscopic pancreatic resection can be performed on a more widespread basis.

Comparison of dietary self-efficacy and behavior among American-born and foreign-born Chinese adolescents residing in New York City and Chinese adolescents in Guangzhou, China

OBJECTIVE

The purpose of this study was to compare the differences of dietary self-efficacy and behavior among US-born, foreign-born Chinese-American, and native Chinese students.

METHODS

The total number of subjects participated in the study was 239 from New York and Guangzhou, China. The research instrument was composed of demographic information, dietary behavior, and self-efficacy of dietary behavior.

RESULTS

Results indicated that native Chinese students had the lowest scores in total fat, saturated fat, and cholesterol intake followed by foreign-born and US-born Chinese-American students in that order. Native Chinese students also had the highest scores in complex carbohydrate and fiber intake as well as dietary self-efficacy followed by foreign-born and US-born Chinese-American students. In addition, self-efficacy was positively correlated with dietary behavior, and the age of immigration of foreign-born Chinese-American students was positively correlated with the scores of dietary behavior and self-efficacy of dietary behavior.

CONCLUSION

The results of this study indicated that environmental and cultural influences are important factors affecting dietary behavior and self-efficacy of dietary behavior among these students.

Surgical therapy for Crohn's disease of the colon and rectum

Crohn's disease remains incurable by either medical or surgical treatment. Both physician and surgeon must work together with the common objective of restoring health by eliminating or alleviating the complications of Crohn's disease. From the surgeon's viewpoint, operation is performed for complications of the disease or for failure of medical management. Although aggressive surgical excision of affected bowel rids the patient of disease for a period of time, the beneficial effects of operation have to be considered in the context that disease recurrence is always a possibility and that reoperation for such complications may be necessary. The aim of the surgeon is to deal with the current problem as simply as possible and to maintain a long-term, strategic view of the disease process with the understanding that what is done today may affect the patient for life.

The influence of surgical technique on clinical outcome of laparoscopic Nissen fundoplication

BACKGROUND

During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided, the crura reapproximated, or the wrap sutured to the crus.

METHODS

Since first performing LNF, we have consistently utilized a <2.5-cm wrap performed over a >50 Fr dilator. Other technical details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF, two were converted to open operation (2%). In the remaining 103 patients with >/=3-month follow-up (mean 17 months), the initial 46 (group 1; 45%, mean age +/- SEM = 47 +/- 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients (65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the subsequent 57 LNFs (group 2; 55%, 47 +/- 2 years), all patients underwent SGV division, posterior crural closure, and suture of the wrap to the crus.

RESULTS

Clinical outcome at >/=3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and 13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of these technical variables were significantly related to the improved outcome in group II.

CONCLUSION

Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure of the crura, and fixation of the wrap to the crus during LNF.

Factors associated with orthostatic hypotension in the Chinese population in Taiwan

Factors associated with orthostatic hypotension are heterogeneous, and some of the factors are interrelated and interdependent, which may confound their relationships to orthostatic hypotension. To investigate the factors that were most likely related to orthostatic hypotension, a study of community-dwelling persons (419 men and 309 women) was conducted. Blood pressures and heart rates were measured after the subjects had been recumbent for 5 min and upright for 1 min. A total of 119 persons (16.3%) experienced orthostatic hypotension. Univariate analysis showed that orthostatic hypotension was associated with the following variables: hypertension, diabetes mellitus, cerebrovascular disease, proteinuria, abnormal renal function, or medications use. Those patients with orthostatic hypotension were older in age and had a higher body mass index, seated blood pressure, plasma creatinine, hemoglobin A1c, fasting and 2-h postload glucose levels than those without orthostatic hypotension. Multivariate analysis revealed that diabetes mellitus, hypertension, and age were independently associated factors for orthostatic hypotension. The higher the level of plasma hemoglobin A1c (%) elevation, the higher the likelihood of orthostatic hypotension manifestation. Clinically, elderly persons or patients with hypertension or diabetes mellitus should receive regular monitoring of supine and upright blood pressure in order to detect orthostatic hypotension and prevent its complications.

Fluorine intake of a Tibetan population

Measurements of food consumption of randomly selected families and fluorine levels in food and beverages were used to calculate the fluorine intake of Tibetan people living in nomadic or semi-nomadic areas of the region and regularly consuming brick tea both as a beverage and in food. The fluorine intake of these groups (children 5.49-7.62 mg day; adults 10.43-14.48 mg/day) was much higher than that of members of a Han population living in the region (children 1.44 mg/day; adults 2.54 mg/day). The amounts of fluorine consumed by the Tibetan inhabitants are at least twice the WHO suggested limit (2 mg/day). Tea plants are rich in fluorine, and the highest levels are found in older leaves which are used to make brick tea. We conclude that brick tea is the major source of fluorine intake by the Tibetan population studied.

Primary nonkeratinized epithelial (conjunctival) orbital cyst: a case report

We report a 24-year-old male patient with the chief complaint of a slowly progressive tumor-growth over the supero-nasal quadrant of his left orbit over the previous 3 years. Physical examination disclosed negative systemic abnormality except ocular finding. Ophthalmological check-up revealed a firm mass palpable over the medial portion of left upper eyelid. CT scan was performed and revealed a well-defined cystic mass without involvement of adjacent bony structure. Finally, he underwent superior orbitotomy and the specimen was sent for histopathological studies. Histological sections showed a cystic structure lined with nonkeratinized squamous epithelium in which some goblet cells were present. This is the first case report of primary conjunctival orbital cyst in Taiwan, also, we believe, the first case in Asia.

Pouch polyposis after ileal pouch-anal anastomosis for familial adenomatous polyposis: report of a case

PURPOSE

A case of a patient with familial adenomatous polyposis (FAP) is reported, in whom adenomas developed in an ileal pelvic pouch six years after it was made. This case is reported to serve as a warning that restorative proctocolectomy, a relatively recent addition to surgical options for FAP, does not remove the risk of metachronous intestinal neoplasia; it merely defers it.

METHODS

Case of a patient with pouch polyposis was reviewed, and patient was prospectively studied after three months of sulindac therapy.

RESULTS

Polyps not removed at first examination became much less prominent. Literature review reveals only one study of adenomas in pelvic pouches, with 7 cases of 38.

CONCLUSION

Proctocolectomy and ileal pouch-anal anastomosis does not cure FAP, and multiple polyps can occur in the ileal pouch.

Clarification of the mechanical behaviour of spinal motion segments through a three-dimensional poroelastic mixed finite element model

The purpose of this study is to clarify the mechanical behaviour of spinal motion segments through a proper numerical model. The model constructed can give correct information and provide medical fields with valuable guidance in solving clinical problems occurring in the spine. A three-dimensional poroelastic finite element model of spinal motion segments is constructed and a mixed formulation is introduced. The geometry of the model is automatically formed from a series of CT-scanning images. Vertebral column, intervertebral joint, facet joints and ligaments are all included in the model. The contact surface of facet joints is considered as the inclined boundary. Such inclination is imposed when the contact surface is under compression. Ligaments surrounding the vertebral body and the intervertebral disc are put into the model when they are under tension. Iteration is implemented in the computing process to meet such boundary characteristics of facet joints and ligaments. Prediction of the mechanical behaviour in the segment under long term creep loading, is demonstrated using the current algorithm. Results show that the model and corresponding numerical procedures developed here can simulate the mechanical behaviour of the spinal motion segments properly.

Community-based study on the relationship between physical activity and hypertension

In order to investigate the prevalence and risk factors for hypertension, and the association between reported physical activity and newly-diagnosed hypertension in Taiwan, 1,103 subjects randomly sampled from 6,725 residents, aged over 20 years from Nanhwa Township, Tainan County, Taiwan, were examined. Questionnaire interviews as well as blood pressure and anthropometric measurements were completed for 479 participants (adjusted response rate, 71.1%) in 1994. The prevalence of hypertension age-sex-standardized to the population of Taiwan in 1992 was 17.8% for adults aged over 20 years and 33.3% for those aged over 40 according to the Fifth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (systolic > or = 140 and/or diastolic > or = 90 mmHg), and 11.3% and 22.0%, according to the World Health Organization (systolic > or = 160 and/or diastolic > or = 95 mmHg). Education level, socioeconomic status, history of heart disease and diabetes, family history of hypertension, body mass index, waist-to-hip ratio and physical activity level were all correlated with newly-diagnosed hypertension prevalence after adjustment for age and sex. In a multiple logistic regression model, physical activity, especially low sports activity, was an independent risk factor for hypertension after adjustment for age, sex, body mass index, waist-to-hip ratio and family history of hypertension.

Mei-S332, a Drosophila protein required for sister-chromatid cohesion, can localize to meiotic centromere regions

Mutations in the Drosophila mei-S332 gene cause premature separation of the sister chromatids in late anaphase of meiosis I. Therefore, the mei-S332 protein was postulated to hold the centromere regions of sister chromatids together until anaphase II. The mei-S332 gene encodes a novel 44 kDa protein. Mutations in mei-S332 that differentially affect function in males or females map to distinct domains of the protein. A fusion of mei-S332 to the green fluorescent protein (GFP) is fully functional and localizes specifically to the centromere region of meiotic chromosomes. When sister chromatids separate at anaphase II, mei-S332-GFP disappears from the chromosomes, suggesting that the destruction or release of this protein is required for sister-chromatid separation.

Transformation of cadmium-binding complexes during cadmium sequestration in fission yeast

Fission yeast responded to environmental cadmium by producing a family of small Cd-binding peptides, phytochelatins (PCn). A low molecular weight (LMW) complex essentially composed of PC2, and PC3 was produced and then disappeared gradually in 24 hrs after Cd treatment, which served as a transient form for a temporary but quick relief of Cd in the cytosoL It had been reported that the LMW complex was further transported into the vacuole by an ABC-type protein (HMT1), and a higher molecular weight (HMW) complex was formed in the vacuole. Results from gel filtration chromatography and HPLC analysis showed that the transformation of the LMW to the HMW complex was accompanied with a rearrangement of its PCn component. Besides, the molecular conformation of the HMW complex changed from a relaxed form in the early stage to a more condensed conformation during cell aging. And the transformation of the LMW into the HMW complex by the addition of sulfide in the test tube was demonstrated.

Treatment of Hirschsprung's disease in the adult. Report of five cases

PURPOSE

Between 1983 and 1991, five adult patients were diagnosed and treated for Hirschsprung's disease. Mean age was 37 (range, 13-45) years. Three patients had classic Hirschsprung's disease, and two had findings consistent with short segment disease. Each patient had a history of disabling, lifelong constipation.

METHODS

Diagnosis was established with the aid of barium enema study, anorectal manometry, and tissue biopsy.

RESULTS

Three patients with classic disease underwent resection of diseased bowel, rectal mucosectomy, and anastomosis between the ganglion-containing bowel and anus. All three patients had excellent functional improvement in the perioperative period. Two patients with findings consistent with short segment Hirschsprung's disease were treated by anorectal myectomy. Neither patient obtained lasting relief.

Genotype distribution of hepatitis C virus infection in Taiwan

To investigate the prevalence of genotype distribution of hepatitis C virus (HCV) infection in Taiwan, genotypes were identified in 122 (36 anti-HCV-positive blood donors, 44 anti-HCV-positive aborigines, 28 hemodialysis patients, and 14 patients with chronic liver diseases) of 280 subjects, using polymerase chain reaction by Okamoto's type-specific primer method. Type II was the dominant (66.7%) type among anti-HCV-positive blood donors, followed by type III and type IV with the same percentages (16.7%), while none of type I was detected. The prevalence of genotype distribution were 75.0%, 81.1%, and 64.3% for type II, 4.6%, 17.9%, and 21.4% for type III, 13.6%, 0%, and 7.1% for type IV, for the aborigines, hemodialysis, and chronic liver diseases groups, respectively. Four subjects revealed mixed infections by two different genotypes: two cases of II and III; and each one case of II and IV, and III and IV. Diverse genotype distributions in two hemodialysis groups disclose the existence of obvious regional differences even within a region. The results reveal the highest prevalence of type II as in Japan. However, there is a higher prevalence rate of type IV than in Japan.

N-linked glycosylation is not required for Na+/glucose symport activity in LLC-PK1 cells

The role of N-linked glycosylation in Na+/glucose symporter function was investigated using LLC-PK1 cell cultures. Tunicamycin treatment did not inhibit Na(+)-dependent glucose transport or phlorizin binding activity assayed in intact LLC-PK1 cells. However apical membrane vesicles derived from tunicamycin-treated cells had no detectable Na(+)-dependent glucose transport activity but retained unchanged phlorizin binding to the symporter. These observations suggest that N-linked glycosylation is not required for transport function or insertion in the membrane in intact cells but may play a role in maintaining symporter transport activity in isolated membranes.

[The diagnosis and surgical treatment of cholelithiasis of the caudal lobe of the liver]

From June 1983 to Feb. 1993, a total of 528 patients with hepatobiliary stones were surgically treated by hepatoenterostomy with a basin-typed plasty at the stump of hilar bile duct. Among them there were 220 cases suffering from cholelithiasis in the caudal lobe, with an average age of 39.1 years. Preoperative sonography, PTC, ERCP, and CT all failed to find stones in this particular location. In the 220 cases, simple caudal lobe stones accounted for 14.5%, caudal lobe stones with bile duct abnormality accounted for 46.8%, and stones with stricture of the duct for 46.4%. Surgical treatment included bile duct dilatation, cholangiotomy, and cholangioplasty and direct chilangiotomy in the caudal lobe.

Enzymic cleavage as a probe of the molecular structures of mammalian equilibrative nucleoside transporters

We have used enzymic cleavage by trypsin in conjunction with glycosidase digestion to probe the transmembrane topologies and molecular structures of mammalian equilibrative, nitrobenzylthioinosine (NBMPR)-sensitive, nucleoside transport systems. Transporters from four species (human, pig, guinea pig, and rat) and three tissues (erythrocyte, liver, and lung), which differ from each other in size and in their sensitivity to inhibition by the vasodilator dipyridamole, were investigated. Broadly equivalent sites of [3H]NBMPR photolabeling, carbohydrate attachment, and trypsin cleavage were observed for all systems. Results from these experiments demonstrate that molecular weight differences between rat transporters and those from two other species (human and guinea pig) are due largely to oligosaccharide heterogeneity and that the low dipyridamole sensitivity of rat nucleoside transporters is probably a consequence of relatively minor differences in molecular structure. In marked contrast, carbohydrate removal increases the molecular weight difference between the pig erythrocyte transporter and, for example, that in human erythrocytes. This polypeptide difference is limited largely, if not completely, to one tryptic fragment of the protein. In the case of the human erythrocyte transporter, the site of N-linked glycosylation has been located very close to one end of the protein, and the site of NBMPR photolabeling to within 16 kDa of that site. Trypsin cleavage occurs endofacially. Our results provide evidence of substantial structural conservation among mammalian NBMPR-sensitive nucleoside transporters.

Changing seroepidemiology of hepatitis A virus infection between two regions in Taiwan differing in socioeconomic status

In Taiwan, hepatitis A virus (HAV) infection is hyperendemic, and prior to the late 1970s more than 85% of the population was infected by 15 years of age. In this study, the prevalence of HAV infection in two regions of Taiwan with differing standards of living is evaluated. Serum antibody to HAV (anti-HAV) was determined by enzyme immunoassay. A total of 4,218 subjects under the age of 16 years were enrolled. The first group of 1,581 subjects were residents of the prosperous western plain region where the socioeconomic status and living environment have improved greatly in the past 20 years; the second group of 2,637 subjects were aborigines inhabiting the eastern and central mountain regions where improvement in the standard of living lags far behind the western region. All serum samples were collected in 1991 except for 1,100 samples collected in 1989 from elementary and junior middle school students in Tainan city. The prevalence of HAV infection was 11.9% for the western region and 81.0% for the eastern and central regions. In the eastern and central regions, 80% of the subjects had been infected with HAV before the age of six years, in contrast to 0% in the western region. By the age of 13 years, only 6% of the subjects were infected in the western region; however 97% had been infected in the eastern and central regions. Among children under the age of 10 years, only 10.6% (10/94) of the IgM-anti-HAV positive cases had clinical symptoms. These findings indicate that HAV infection has a close relationship with socioeconomic status and environmental sanitation.

Comparison of hepatitis C virus strains obtained from hemodialysis patients

To understand what genotypes of hepatitis C virus (HCV) exist in Taiwan, we chose the non-structure 5 (NS5) region of the HCV genome for the target area of reverse transcription-polymerase chain reaction (RT-PCR) to detect HCV RNA from sera of hemodialysis patients. Of 39 serum samples which were positive for the HCV antibody among 87 samples from hemodialysis patients, 12 (antibody against HCV core protein, OD > 2) were examined by the RT-PCR. The plasmid pUC19 was used to clone HCV cDNAs in the NS5 region (401 bp) derived from 11 serum samples which were positive for HCV RNA. Sequence analyses of individual clone of these 11 amplified cDNA fragments were performed. Dr. Cha's classification (16) suggested that two genotypes of HCV were found in these serum samples; type II (2/18.2%) and type III (9/81.8%). Our study indicates also that NS5 is an adequate target region to differentiate HCV strains derived from different patients in the same hospital. The analysis of the amplified cDNA in the NS5 region of the HCV genome will therefore provide suitable information to perform a molecular epidemiological study on the transmission routes of this important virus infection.