Pulmonary structural maturation and pulmonary artery remodeling after reversible fetal ovine tracheal occlusion in diaphragmatic hernia

PURPOSE

Congenital diaphragmatic hernia (CDH) is associated with thickened pulmonary arteries (PA) contributing to pulmonary hypertension. In the current study, the effects of antenatal glucocorticoids and reversible tracheal occlusion (TO) on PA structure were assessed in a hypoplastic lung model.

METHODS

A left-sided CDH was created in fetal lambs at 80 days gestation, TO at 108 days, and release of the occlusion (TR) at 129 days. All were given 1 dose of maternal glucocorticoids at 135 days. At 136 days (term, 145 days), the fetus was delivered by cesarian section. CDH (n = 7), CDH + TO (n = 6), CDH + TO + TR (n = 6), and unoperated twin controls (n = 16) were compared. Outcome measurements were (1) lung growth, represented by lung weight to body weight ratio (LW/BW), (2) lung structural maturation, which is inversely proportional to mean terminal bronchiole density (MTBD), (3) PA medial and adventitial areas (square micrometers), (4) lung capillary load, which is the ratio of vessel surface area (SA) to tissue SA ratio.

RESULTS

CDH lungs were hypoplastic with a low LW/BW and high MTBD. The small PAs (<75 microm) of CDH had an increased medial area, indicating increased muscle mass and an increased adventitial area. CDH + TO +/- TR increased LW/BW and achieved normal structural lung maturity with a low MTBD. Only CDH + TO thinned the PA medial area closer to control values. The adventitial area remained thick in CDH +/- TO +/- TR when compared with controls. All 4 groups had similar capillary load.

CONCLUSIONS

TO may be especially important for PA remodeling in the latter part of gestation, because TR 1 week before delivery prevents thinning of the small PAs in CDH. The shaping achieved by TO in terms of lung growth, structural maturity, and pulmonary artery medial area thinning may prove beneficial in lessening the severity of the associated pulmonary hypertension in CDH.

Mice deficient in methylenetetrahydrofolate reductase exhibit hyperhomocysteinemia and decreased methylation capacity, with neuropathology and aortic lipid deposition

Hyperhomocysteinemia, a risk factor for cardiovascular disease, is caused by nutritional and/or genetic disruptions in homocysteine metabolism. The most common genetic cause of hyperhomocysteinemia is the 677C-->T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene. This variant, with mild enzymatic deficiency, is associated with an increased risk for neural tube defects and pregnancy complications and with a decreased risk for colon cancer and leukemia. Although many studies have reported that this variant is also a risk factor for vascular disease, this area of investigation is still controversial. Severe MTHFR deficiency results in homocystinuria, an inborn error of metabolism with neurological and vascular complications. To investigate the in vivo pathogenetic mechanisms of MTHFR deficiency, we generated mice with a knockout of MTHFR: Plasma total homocysteine levels in heterozygous and homozygous knockout mice are 1.6- and 10-fold higher than those in wild-type littermates, respectively. Both heterozygous and homozygous knockouts have either significantly decreased S-adenosylmethionine levels or significantly increased S-adenosylhomocysteine levels, or both, with global DNA hypomethylation. The heterozygous knockout mice appear normal, whereas the homozygotes are smaller and show developmental retardation with cerebellar pathology. Abnormal lipid deposition in the proximal portion of the aorta was observed in older heterozygotes and homozygotes, alluding to an atherogenic effect of hyperhomocysteinemia in these mice.

Surgical treatment of pancreatic vasoactive intestinal polypeptide-secreting tumor: a case report

A 68-year-old woman presented with secretory watery diarrhea causing hypokalimia, hypoalbuminemia and dehydration for 5 years. Subsequent investigations including abdominal ultrasonography and computed tomography scanning revealed a mass measuring 7 x 6 cm in the pancreatic tail. The diagnosis of pancreatic VIPomas was suspected on the basis of clinical symptoms. The patient underwent distal pancreatectomy and splenectomy after resuscitation of electrolyte imbalance, dehydration and malnutrition. The pathological examination with histoimmunochemical stain confirmed the diagnosis. Postoperative course is uneventful and the patient does not have symptoms any longer during the follow-up period.

Color Doppler ultrasound in breast carcinomas: relationship with hormone receptors, DNA ploidy, S-phase fraction, and histopathology

Data on 368 patients with breast carcinomas measuring < or = 5 cm were analyzed to study the relationship between the prognostic factors and the flow indices measured by color Doppler ultrasound (US). Vascularity was detected by color Doppler US in 348 (94.6%) of the 368 breast tumors. Tumors without vascularity were significantly (p = 0.0001) smaller than the tumors with vascularity. There was a correlation between Vmax and tumor size. Postmenopausal women had greater values of RI, PI, and V(max). Tumors larger than 2 cm had significantly greater RI, V(max) and number of vessels as compared with the tumors smaller than 2 cm. RI was significantly greater in the nondiploid tumors than in the diploid tumors. RI > or = 0.7 was significantly associated with nondiploid carcinomas and SPF > or = 7%. Tumor size and Vmax significantly predicted axillary lymph node metastases.

Nerve fibers and histopathology of endometriosis-harboring peritoneum

STUDY OBJECTIVE

To evaluate the presence of nerve fibers and histopathology of normal peritoneum and endometriosis-harboring peritoneum.

DESIGN

Prospective, nonrandomized study (Canadian Task Force classification II-1).

SETTING

University hospital.

MATERIALS

Peritoneal specimen from 40 women with laparoscopic findings of endometriosis (24 confirmed histopathologically, group H, 16 diagnosed by laparoscopy, group L) and from 9 women with no endometriosis (controls).

INTERVENTION

Histopathologic examination of peritoneal specimens with nerve fibers identified by immunocytochemistry staining with an antibody to neurofilament.

MEASUREMENTS AND MAIN RESULTS

No differences in mean nerve score were seen among the three groups. Degrees of lymphocytic infiltration and mesothelial hyperplasia were higher in group H than in the other two groups (p <0.01 and <0.05, respectively). The degree of lymphocytic infiltration was significantly higher in group L than in the control group (p <0.05). There were no differences in all measurements between women in group H who experienced chronic pelvic pain and those who did not.

CONCLUSION

The presence of nerve fibers in peritoneum is not related to endometriosis. Endometriosis-harboring peritoneum contains more lymphocytic infiltration than normal peritoneum. (J Am Assoc Gynecol Laparosc 8(1):95-98, 2001)

Comparison of ischemic patterns in myocardial bridge and syndrome X: evaluation by dobutamine stress echocardiography and stress thallium-201 SPECT

BACKGROUND AND PURPOSE

Ischemic patterns in patients with syndrome X are thought to differ from those in patients with myocardial bridge, because the mechanisms of coronary flow reduction in these two diseases are different. The aim of this study was to compare the ischemic patterns in patients with syndrome X and those with myocardial bridge through the use of dobutamine stress echocardiography (DSE) and stress thallium-201 single-photon emission computed tomography (SPECT).

METHODS

Twenty-six patients with typical angina and stress-induced ST-segment depression were enrolled. All patients underwent coronary angiography, DSE, and stress thallium-201 SPECT within 7 days after enrollment.

RESULTS

Of the 26 patients enrolled, 10 had myocardial bridge of the left anterior descending artery and 16 had syndrome X. Among patients with myocardial bridge, myocardial dyssynergy was found by DSE in five patients and reversible or fixed thallium-201 perfusion defects were found in four. Seven patients with myocardial bridge had reverse redistribution patterns on thallium-201 scintigraphy. In the 16 patients with syndrome X, myocardial dyssynergy was found by DSE in only one patient (p = 0.018 vs myocardial bridge group) and reversible or fixed thallium-201 perfusion defects were found in nine (p > 0.05 vs myocardial bridge group). Four patients with syndrome X had reverse redistribution patterns on thallium-201 scintigraphy. The resting left ventricular end-diastolic pressure was higher in patients with myocardial bridge than in those with syndrome X (17 +/- 4 vs 12 +/- 5 mm Hg, p = 0.02).

CONCLUSIONS

The most common ischemic patterns in patients with syndrome X were chest pain and stress-induced ST-segment depression, followed by myocardial perfusion defects. Dobutamine-induced dyssynergy was rare. Left ventricular end-diastolic pressure elevation and dobutamine-induced wall motion abnormalities were more common in patients with myocardial bridge than in those with syndrome X.

Assessment of the myocardial changes in heart transplant recipients without evident acute myocardial rejection by integrated backscatter: comparison with simultaneous dobutamine stress echocardiography and (201)thallium spect

Cardiomyocyte hypertrophy and interstitial fibrin deposition develop in cardiac allografts and contribute to the functional changes of transplanted hearts. We hypothesized that integrated backscatter (IBS) can detect these myocardial changes. A total of 32 heart transplant recipients with either no or mild acute rejection (International Society of Heart and Lung Transplantation grade IA) were enrolled in this study. IBS data of myocardium were collected immediately before simultaneous dobutamine stress echocardiography (DSE) and (201)thallium imaging. Coronary angiography and endomyocardial biopsy were also performed. Coronary angiography showed diffuse narrowing in 1 patient who also had abnormal results of IBS, DSE, and thallium results. In the other 31 patients with patent coronary arteries, there were 3 patients (10%) with abnormal DSE results, 19 patients (61%) with abnormal IBS patterns, and 16 patients (52%) with reversible thallium perfusion defects. Of the patients, 44% had cardiomyocyte hypertrophy and 56% interstitial fibrin deposition. There were significant differences in the prevalence of (201)thallium perfusion defects and serum cyclosporine levels between patients with and without abnormal IBS patterns. Pathologic changes were also associated with abnormal IBS patterns (p = 0.01). However, there was no association between abnormal IBS and DSE results. By multiple logistic regression analysis, the abnormal IBS patterns were associated inversely with serum cyclosporine level (p = 0.028). In conclusion, abnormal IBS patterns are associated significantly with perfusion heterogeneity and pathologic changes in heart transplant recipients without evident acute myocardial rejection. There is no association between abnormal IBS patterns and dobutamine-induced dyssynergy in these patients. IBS provides a noninvasive approach for detection of myocardial changes in transplanted hearts without evident acute rejection.

Surgery for chronic obstructive pancreatitis: comparison of end-to-side pancreaticojejunostomy with pancreaticoduodenectomy

BACKGROUND/AIMS

Chronic obstructive pancreatitis usually manifests with intractable pain and recurrent episodes of chronic pancreatic inflammation. The side-to-side pancreaticojejunostomy is used for those patients with a large pancreatic duct. But for the patients with small pancreatic duct, the optimal surgical procedure needs to be evaluated. A prospective study was designed to compare the different results between distal pancreatectomy plus end-to-side pancreaticojejunostomy and pancreaticoduodenectomy.

METHODOLOGY

The patients were chosen prospectively and randomly to undergo either a distal pancreatectomy plus end-to-side pancreaticojejunostomy or pancreaticoduodenectomy in the last 3 years. Eighteen patients with chronic obstructive pancreatitis were randomly divided into two groups. Ten patients (group A) underwent distal pancreatectomy plus end-to-side and ductal to mucosal pancreaticojejunostomy, and the other 8 patients (group B) underwent pancreaticoduodenectomy were compared.

RESULTS

The operative time was significantly shorter and operative blood loss was less in group A. The postoperative follow-up of patients in group A had better outcome with increased body weight and no steatorrhea or diabetes mellitus, and all of them had complete pain relief.

CONCLUSIONS

We concluded that distal pancreatectomy with end-to-side pancreaticojejunostomy provided a better surgical treatment for the patients with chronic obstructive pancreatitis and small pancreatic duct.

Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma

BACKGROUND

Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management.

METHODS

During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material.

RESULTS

The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable.

CONCLUSION

With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.

Distension of urinary bladder induces exaggerated coronary constriction in smokers with early atherosclerosis

Distension of the urinary bladder causes an increase in efferent sympathetic activity, which can precipitate myocardial ischemia. Smoking has been shown to modulate activities of afferent nerves from the distended urinary bladder and to impair endothelial function in response to sympathetic activation. To assess the effect of bladder distension on coronary dynamics in smokers, we measured epicardial and microvascular responses in 24 patients with early atherosclerosis (< 50% diameter stenosis). Patients were classified into habitual smokers (group 1, n = 14) and nonsmokers (group 2, n = 10). Habitual smokers were randomized into two subgroups on the basis of the use of doxazosin, as follows: subgroup 1A (n = 7), without administration of doxazosin before catheterization; subgroup 1B (n = 7), with dosing doxazosin. In response to bladder distension (mean intravesical pressure 21.5 mmHg), bladder distension significantly decreased coronary diameter at the stenotic segments, coronary blood flow, and increased coronary resistance compared with baseline values, in subgroup 1A patients. In subgroup 1B patients during bladder distension, coronary diameter, coronary blood flow, and coronary resistance did not show significant changes compared with baseline values. There were significant differences of coronary diameter at the stenotic segments, coronary blood flow, and of changes of coronary vascular resistance between subgroup 1A and group 2 during bladder distension, despite similar changes in rate-pressure product. The present study showed that urinary bladder distension caused an abnormal vasomotor response of epicardial vasoconstriction and a concomitant increased coronary resistance, which leads to reduction in coronary blood flow in patients with early atherosclerosis. Smoking may further impair the response, implying that smoking has exaggerated response to sympathetic stimulation of conduit and resistance vessels. The abnormal response was abolished by pretreated administration of doxazosin, suggesting that the involved mechanisms are related to alpha(1)-adrenoceptors.

A Piscirickettsia salmonis-like bacterium associated with mortality of white seabass Atractoscion nobilis

Mortality among hatchery-reared juvenile white seabass Atractoscion nobilis in southern California, USA, was associated with infections by a Piscirickettsia salmonis-like organism (WSPSLO). Infected fish had no consistent external signs other than pale gills, lethargy and impaired swimming behavior. Internally, the kidney and spleen were enlarged, and some fish had livers with multiple pale foci. Smears from infected kidney, liver, and spleen stained with Wright-Giemsa had intracytoplasmic coccoid organisms, often in pairs, that ranged in size from 0.5 to 1.0 microm. Microscopic lesions included multifocal hepatic, renal, and splenic necrosis, and intralesional macrophages often contained the WSPSLO. The bacterium was isolated from infected fish on cell lines of salmonid (CHSE-214) and white seabass (WSBK) origin. The WSPSLO induced plaque formation and destroyed the cell monolayers within 10 to 14 d incubation at temperatures of 15 and 20 degrees C. The bacterium retained infectivity for cell lines up to 14 d at 4 and 13 degrees C, up to 7 d at 20 degrees C, but it was inactivated at 37 and 56 degrees C within 24 and 1 h, respectively. Freezing at -20 degrees C reduced infectivity by 100-fold. Dehydration and resuspension in distilled water completely inactivated the bacterium. In contrast, the WSPSLO retained nearly all of its infectivity for CHSE-214 cells following a 72 h period in seawater at 20 degrees C. Polyclonal rabbit antibodies made to the WSPSLO reacted specifically in indirect fluorescent antibody tests (IFAT) with the bacterium in cell cultures and smears from infected fish tissues. Tissue smears from infected salmon or CHSE-214 cells with P. salmonis reacted weakly with the anti-WSPSLO serum. Conversely, polyclonal anti-P. salmonis serum produced a weakly positive reaction with the WSPSLO from infected CHSE-214 cells. The WSPSLO as propagated in CHSE-214 cells was highly virulent for juvenile coho salmon Oncorhynchus kisutch, inducing 80% mortality within 10 d of intraperitoneal injection of 10(2.5)-50% tissue culture infectious doses per fish. We conclude that the bacterium from white seabass possesses antigenic differences from P. salmonis yet possesses virulence for salmon equal to known strains of P. salmonis.

Surgery for adult polycystic liver disease

Adult polycystic liver disease, commonly associated with polycystic kidney disease, can result in massive hepatomegaly and debilitating symptoms. Surgical intervention for symptomatic polycystic liver disease, such as cyst fenestration or liver resection has been associated with significant morbidity and inconsistent long-term palliation. However, selected patients with severe symptoms benefit from liver resection and extensive fenestration with acceptable morbidity and mortality. Total hepatectomy and orthotopic liver transplantation may be considered for patients with severe adult polycystic liver disease.

Factors determining operative mortality of grade V blunt hepatic trauma

BACKGROUND

Despite recent advances in the management of severe hepatic injuries, the operative mortality rate of grade V hepatic injuries still ranges from 67% to 80%. Grade V hepatic injuries involving the retrohepatic cava or main hepatic veins are almost always lethal, especially those from blunt trauma. The purpose of this study is to understand the risk factors determining operative mortality in grade V blunt hepatic trauma, and to try to improve the surgical management of these injuries.

METHODS

A retrospective study was conducted at a medical center that offers services including primary, secondary, and tertiary care. Forty-four patients with grade V blunt hepatic injuries were treated during a 6-year period from January 1, 1991, to December 31, 1996. The operative mortality was compared by a multivariate analysis.

RESULTS

Forty-four patients with grade V blunt hepatic injuries were identified. Seven patients had only parenchymal injuries, and the others had vascular and associated parenchymal injuries. Venorrhaphy was used in 37 patients; 29 were treated using a nonshunting approach, and 8 with an atriocaval shunt. The overall mortality rate was 68% (30 of 44), and liver-related mortality was 50% (22 of 44). Univariate analysis revealed that the significant variables affecting operative mortality were initial systolic blood pressure, initial base deficit, the Glasgow Coma Scale, injury type, number of resected segments, and total intraoperative blood loss. Based on forward stepping logistic regression analysis, patients with an initial base deficit of -6 mmol/L or less (relative risk = 17.3), and a total intraoperative blood loss of 5,000 mL or more (relative risk = 23.5) would, significantly, encounter a worsening prognosis.

CONCLUSIONS

Initial base deficit and total intraoperative blood loss were the significant factors that determined operative mortality after grade V blunt hepatic trauma. We suggest that prompt resuscitation and expeditious and appropriate surgical management, to control operative blood loss, is the only way to reduce operative mortality in patients with grade V blunt hepatic trauma.

Dedifferentiation of human hepatocellular carcinoma up-regulates telomerase and Ki-67 expression

HYPOTHESIS

Dedifferentiation of human hepatocellular carcinoma (HCC) may influence telomerase activation and Ki-67 expression.

DESIGN

Laboratory study using human HCC specimens.

SETTING

University hospital.

PATIENTS

Twelve patients with HCC with specific morphologic patterns (nodule-in-nodule [n = 4] or confluent multinodular [n = 8] type) and histological heterogeneity and who had undergone curative hepatectomy were studied. Of these, 8 patients had 2 different histological grades of HCC cells distributed at various nodules but within the same tumor; 3 patients, 3 different histological grades; and 1 patient, all 4 different histological grades.

INTERVENTION

Tissue samples were retrieved from each nodule of the tumor and not mixed with one another. A total of 42 cancerous tissues from different distinctive nodules of the 12 patients were taken for telomerase and Ki-67 study, and corresponding noncancerous counterparts (n = 12) served as healthy control samples. Telomerase activity was assayed by the telomerase repeat amplification protocol. Expression of messenger RNA (mRNA) by the human telomerase catalytic subunit human telomerase reverse transcriptase (hTERT) was determined using reverse transcription polymerase chain reaction. The relative telomerase activity and hTERT mRNA in each tissue sample was quantified using densitometry and expressed as a percentage of the standardized HeLa cell line. Immunostaining with anti-Ki-67 antibody was used to detect Ki-67 and was expressed as Ki-67 labeling index.

MAIN OUTCOME MEASURES

Telomerase activity, hTERT mRNA, and Ki-67 labeling index stratified by different histological gradings in each patient was analyzed. The correlations between telomerase activity and hTERT mRNA and between telomerase activity and expression of Ki-67 were plotted.

RESULTS

Telomerase activity increased from more to less differentiated foci of HCC cells in each case (generalized linear model, P<.001). Mean +/- SD expression of hTERT mRNA in 43 cancerous tissue samples, even those 4 with negative telomerase activity, was distinguishable from that of the noncancerous controls (0.84 + 0.23 vs 0.41 + 0.11; t test, P =.008). Telomerase activity was correlated to hTERT mRNA expression (Pearson correlation, r(2) = 0.56; P<.001). The Ki-67 labeling index increased from more to less differentiated foci of HCC in each case (generalized linear model, P<.001). Expression of Ki-67 correlated with telomerase activity within differently graded areas within individual tumors (Pearson correlation, r(2) = 0.38; P<. 001).

CONCLUSION

Using the model of human HCC with histological heterogeneity, we determined that dedifferentiation of human HCC induces telomerase activation and Ki-67 expression.

Female sex hormones modulate the function of LPS-treated macrophages

PROBLEM

To study the effects of estradiol (E2) or progesterone on macrophage function in the presence of lipopolysaccharide (LPS).

METHOD OF STUDY

Male rat peritoneal macrophages were treated in vitro with 0.1 microg/mL of LPS and E2 or progesterone.

RESULTS

At 10(-2) ng/mL, E2 significantly (P < 0.05; n = 6) enhanced tumor necrosis factor (TNF) release by LPS-treated macrophages. TNF release was significantly (P < 0.05; n = 6) inhibited by 10(2) ng/mL or 10(3) ng/mL of E2 and by progesterone at less than 10(-3) ng/mL or greater than 10(-1) ng/mL. E2 (10(-4) and 10 ng/mL) and progesterone (10(-6)-10(-4) ng/mL and 10(2) ng/mL) each significantly (P < 0.05, n = 8) enhanced H2O2 release by LPS-treated macrophages. E2 ( < 10(-2) and > 10 ng/mL) and progesterone (10(-7)-10(4) ng/mL) each significantly inhibited (P< 0.05; n = 6) NO2- release by LPS-treated macrophages.

CONCLUSIONS

Exposure to LPS tended to diminish the effects of E2 and to enhance the effects of progesterone on the parameters determined here. Such LPS-associated alterations in the dose-response profile of macrophages to female sex hormones may contribute to gender-related differences in the immune response under normal and pathological conditions.

Hepatectomy for hepatitis B-, hepatitis C-, and dual hepatitis B- and C-related hepatocellular carcinoma in Taiwan

To evaluate the surgical results of patients with hepatitis B-, hepatitis C- and dual hepatitis B- and C-related hepatocellular carcinoma (HCC), we reviewed the clinical records 252 patients (196 men and 56 women) with complete profiles of hepatitis B and hepatitis C infection who had hepatectomies to treat HCC from March, 1992, to August, 1998. The patients were divided into four groups, 30 patients (11.9%) without either hepatitis B surface antigen or anti-hepatitis C antibody (N-HCC group), 133 patients (52.8%) with hepatitis B infection only (B-HCC group), 66 patients (26.2%) with hepatitis C infection only (C-HCC group), and 23 patients (9.1%) with dual hepatitis B and C infection (BC-HCC group). Compared with the patients in the other groups, the patients in the C-HCC group were older and had more severe cirrhotic change of the liver. The surgical complication rates and hospital mortalities in the C-HCC and BC-HCC groups were 30.3% and 12.1% and 30.4% and 17.4%, respectively, which were higher than those in the N-HCC (13.3%, 3.3%) and B-HCC (15.8%, 3.8%) groups. The mean disease-free survivals for the N-HCC, B-HCC, C-HCC, and BC-HCC groups were 31.4, 25.4, 38.9 and 13.8 months, respectively, with the difference between the four groups being significant (P < 0.05). However, the mean overall survival times, 38.3 months for the N-HCC group, 37.2 months for the B-HCC group, 52.1 months for the C-HCC group, and 32.7 months for the BC-HCC group, were not significantly different (P = 0.146). In conclusion, surgical treatments for HCC related to hepatitis C or dual hepatitis B and C infection were associated with a higher surgical complication rate and hospital mortality. Hepatocellular carcinoma related to dual hepatitis B and C infection recurred earlier after hepatectomy, but the overall survival of the four groups was not significantly different.

Assessment of the coronary artery disease and systolic dysfunction in hypertensive patients with the dobutamine-atropine stress echocardiography: effect of the left ventricular hypertrophy

This study was performed to evaluate whether left ventricular hypertrophy (LVH) can influence the diagnostic accuracy of coronary artery disease (CAD) using the dobutamine stress echocardiography (DSE) in hypertensive patients. In addition to the detection of CAD, the relationship between systolic dysfunction and the quantitation wall motion scoring system of DSE was studied also. DSE was performed in 101 patients. There were 45 (45%) patients with a history of acute myocardial infarction. Twenty-eight patients (28%) had electrocardiographic LVH and 59 patients (58%) had echocardiographic LVH. A total of 74 patients (73%) had angiographically documented CAD defined as > or = 50% diameter stenosis. For the 56 patients without history of myocardial infarction, the diagnostic sensitivity, specificity, and accuracy in detecting CAD were not influenced by LVH defined by either electrocardiography or echocardiography. For the total patients, the diagnostic sensitivity, specificity, and accuracy in detecting multivessel disease were also not influenced by LVH defined by either method. The resting global wall motion score was correlated well with the left ventricular ejection fraction in patients with and without LVH (r = -0.70, p < 0.001 vs. r = -0.70, p < 0.001). When using the resting wall motion score of 24 as a cutoff value, the diagnostic sensitivity, specificity, and accuracy of systolic dysfunction (defined by left ventricular ejection fraction <40%) were 79, 86 and 85%, respectively. In conclusion, the diagnostic accuracy of CAD using the DSE was not affected by LVH in hypertensive patients. In addition to detection of coronary artery disease, the resting wall motion score of DSE was able to detect systolic dysfunction in patients with and without LVH.

Blunt hepatic injury: minimal intervention is the policy of treatment

BACKGROUND

Many publications recommend nonoperative treatment for stable blunt hepatic injury patients. Unstable hemodynamic status is the only indication for surgery. When operation is indicated, controversies exist regarding which operative procedure will be more beneficial to the patients. The purposes of this study are to compare the results of operative and nonoperative management of patients with blunt hepatic injuries and to identify the optimal surgical approach when surgery is indicated.

METHODS

Different prospective protocols of treating adult blunt hepatic injuries were conducted. From 1992 to 1993 (group I), urgent surgery would be performed in the presence of hemoperitoneum. The policy shifted to aggressive nonoperative approach between 1996 and 1997 (group II). The patients from each period were divided into three subgroups. Group A included the patients who received nonoperative treatment in either period. Group B consisted of the patients who received surgery in the first period and nonoperative management in the second period. Group C included the patients who were operated on in either group. Comparisons were made between matched groups.

RESULTS

Groups IA and IIA patients had minor injuries and could be successfully treated nonoperatively. The results of groups IB and IIB were similar concerning hospital stay, morbidity, and mortality. Transfusion requirements of group IIB patients were significantly higher (2.2 vs. 1.1 units,p = 0.01) than those of group IB. However, 25 (58%) celiotomies of group IB patients were nontherapeutic. When surgery was indicated, group IC patients had significantly higher liver-related mortality (14 of 49 vs. 3 of 55, p = 0.002). Anatomic resection was performed more frequently in that period.

CONCLUSION

Nonoperative treatment significantly decreased the rate of nontherapeutic laparotomy but carried the risks of higher transfusion requirements and delaying operation. When surgery was indicated, the policy of minimal intervention positively affected the patients' outcomes. The goal of surgery should be hemorrhage control rather than resection of the injured liver tissues.

A randomized crossover evaluation of antianginal efficacy and safety of nitrolingual-spray and nitroglycerin tablet form in coronary artery disease patients

Twenty-eight coronary artery disease patients with more than 50% stenosis in at least one major coronary artery completed this randomized crossover clinical trial for the comparison of efficacy and safety of Nitrolingual-Spray and nitroglycerin (NTG) tablets. Exercise time was lengthened to 399.1 s (spray) or 408.5 s (tablets), compared to a baseline of 387.3 s. Ischemic burden decreased to about -4.0 mm with both forms, compared to -7.5 mm at baseline (ANOVA: p = 0.003). The ischemic time improved to 137.2 s (spray) or 152.9 s (tablets), compared to 253.4 s at baseline (ANOVA: p = 0. 005). Patients taking tablets experienced more episodes of hypotension and/or headache compared to patients taking the spray. Nitrolingual-Spray is as effective and safe as NTG tablets for the treatment of symptomatic coronary heart disease.

Integrated backscatter for quantification and risk stratification of blood stagnation in left atrial appendages of patients with rheumatic mitral stenosis

This study was designed to quantify the blood stagnation in left atrial appendages (LAA) of patients with rheumatic mitral stenosis, and to stratify the risk of spontaneous echo contrast (SEC) for thrombus formation. A total of 45 patients were enrolled in this study. Thirty of the 45 patients had rheumatic mitral stenosis. All the above patients were evaluated for LAA contractility by transesophageal echocardiography. Acoustic density of the stagnant blood was assessed using the integrated backscatter (IBS) mode. Multivariate linear regression analysis showed that the significant independent variables determining relative IBS in LAA were the mitral valve area (p = 0.02) and the atrial fibrillation rhythm (p = 0.0003). In patients with mitral stenosis, the IBS in LAA correlated well with the presence of thrombus (p = 0.004) and SEC (p = 0.002). Using the relative IBS in LAA with 6.8 dB as the cutoff value, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy of SEC formation in LAA was 83, 86, 95, 60 and 83%, respectively. Using the relative IBS in LAA with 10.0 dB as the cutoff value, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy of SEC with thrombus formation in LAA was 80, 80, 67, 89 and 80%, respectively. In conclusion, the blood stasis in LAA can be objectively quantified using IBS. Utilizing different cutoff values, the acoustic densitometry in LAA enables identification of stagnant blood which represents a risk for the development of either SEC only or SEC with thrombus formation.

Biliary hamartomas associated with biliary stones presenting as multiple microabscesses: case report

A 63-year-old men suffered from fever, jaundice, and right upper quadrant pain for 1 week. Biliary stones with biliary tract infection were diagnosed. He was treated with parenteral antibiotics. However, abdominal ultrasonography showed multiple hyperechoic lesions in both lobes, and infiltrating hepatocellular carcinoma was suspected initially. Numerous hypervascular nodular-enhancing lesions were revealed by computed tomography. Magnetic resonance imaging further disclosed numerous tiny cystic lesions with peripheral enhancement. Exploratory laparotomy was performed for biliary calculi and probable underlying malignancy. Cholecystectomy, choledocholithotomy, and liver wedge biopsy were done. The pathology revealed bile duct hamartomas with microabscess formation. The past literature about biliary hamartomas is reviewed.

Clinicopathologic factors influencing long-term survival after resection for hepatocellular carcinoma

BACKGROUND

The purpose of this study is to investigate the clinicopathologic factors that influence a survival longer than 5 years with no recurrence in patients after resection for hepatocellular carcinoma (HCC).

METHODS

Between January 1992 and December 1994, 64 patients with complete viral markers study underwent curative hepatic resection for HCC. Four patients who died of surgical morbidity (hospital mortality, 6.3%) were excluded from this study. Among the 60 patients who survived, 10 patients (16.7%) survived over 5 years without recurrence. The clinicopathologic features and surgical procedures of the patients with long-term survival (> or = 5 years) without recurrence (n = 10) were compared with those of less than 5 years survival or with tumor recurrence (n = 50). The median follow-up was 64.8 months, ranging from 61.1 to 76.7 months.

RESULTS

Six of the 10 patients were men with an age ranging from 35 to 75 years (mean, 57.6 +/- 9.7). Using univariate analysis, long-term survival without recurrence was significantly associated with a lower amount of perioperative blood transfusion (less than 7 units, p = 0.036) and an existence of tumor capsule (p = 0.031). But in multivariate analysis, only the presence of tumor capsule was statistically significant.

CONCLUSIONS

Long-term survival without recurrence was related to a lower amount of perioperative blood transfusion, and an existence of tumor capsule in univariate analysis. But in multivariate analysis, only the existence of tumor capsule plays a significant role.

Increase in resting levels of superoxide anion in the whole blood of uremic patients on chronic hemodialysis

Recently, we developed a new method to measure the resting level of superoxide anion in whole blood using an ultrasensitive chemiluminescence analyzer and lucigenin amplification. The advantage of this method is that the assay system can be performed in the absence of leukocyte isolation and stimulant administration. In this study, we applied this method to measure the blood resting levels of superoxide anion in 104 uremic patients on chronic hemodialysis (CHD) and 98 sex- and age-matched healthy controls to clarify the influence of HD on blood levels of superoxide anion. Simultaneously, the plasma levels of copper, zinc superoxide dismutase (Cu,Zn-SOD), glutathion peroxidase (GPX), myeloperoxidase (MPO) and lactoferrin (Lacto-F) were measured. The results showed that the basal blood levels of superoxide anion, Cu,Zn-SOD, and MPO in CHD patients were significantly greater than those of healthy controls. However, there was no difference in the basal plasma levels of Lacto-F and GPX between CHD patients and healthy controls. One session of HD further increased the blood levels of superoxide anion, MPO, Lacto-F and Cu,Zn-SOD but not GPX. These results suggest that the blood levels of superoxide anion are higher in CHD patients and further increase after one session of HD. This mechanism should be studied further.