Nasopharyngeal carcinoma: the role of the dentist in assessment, early diagnosis and care before and after cancer therapy

Nasopharyngeal carcinoma (NPC) may present first to the dental profession as facial pain, neck masses, difficulty in speech and swallowing, ear, nose and throat symptoms, or as symptoms of temporomandibular disorders (TMD). Recognition of the signs and symptoms are essential in order to lead to the correct diagnosis, and to avoid inappropriate intervention that may further delay diagnosis and initiation of treatment of the cancer. Differentiation between NPC and TMD may be facilitated by specific questioning of other symptoms that are not frequently associated with TMD such as neck masses, nasal obstruction, recent unilateral hearing deficit and epistaxis. The general dentist can become involved at three stages of a patient's experience with NPC: Stage 1, recognition of signs and symptoms; Stage 2, pre-treatment dental assessment; and Stage 3, post-treatment support. This paper is intended to: (1) alert the general dentist of the signs and symptoms associated with NPC, such that timely and appropriate treatment may ensue; (2) provide a basic outline for assessment, preparation, palliation and continuing care of a patient diagnosed with NPC; and (3) underline the significant role of the general dentist in achieving an optimal quality of life for these patients

Development of a laparoscopic approach to neurolytic celiac plexus block in a porcine model

BACKGROUND

Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control in cases of inoperable pancreatic cancer. This study was undertaken to evaluate the feasibility of a laparoscopic approach to NCPB in an experimental animal model.

METHODS

The laparoscopic technique for NCPB was developed in an acute study of six domestic swine followed by a chronic study of nine domestic swine that were monitored 3-21 days after surgery for adverse neurologic, gastrointestinal, or other sequelae. Using a four-port laparoscopic technique, the esophageal hiatus was dissected to expose the aorta at the level of the diaphragmatic crura. Under combined endoscopic and laparoscopic ultrasound (LUS) guidance, 5 ml of sclerosant dye (95% ethanol mixed with India ink) was injected into either side of the para-aortic soft tissue via a percutaneously placed 18-gauge spinal needle. After the animals were killed, the aorta and periaortic tissue were harvested from each animal for gross and histologic analysis.

RESULTS

Under LUS guidance, sclerosant was injected successfully into the para-aortic soft tissue in all animals. There were no intraoperative complications in the acute animal group. Placement of sclerosant injection was successful in all nine chronic cases. Two pigs in the chronic study group died in the immediate postoperative period secondary to pneumothorax. No adverse neurologic, gastrointestinal, or other sequelae were observed in the remaining seven animals at 3-21 days postoperatively. After the animals were killed, we found no injuries to the aorta or esophagus, and histologic analysis demonstrated good placement of dye-labeled sclerosant with no compromise of aortic structural integrity.

CONCLUSION

A laparoscopic approach to the aortic hiatus and NCPB is feasible. Further studies are warranted to evaluate this approach in patients who undergo staging laparoscopy for pancreatic cancer and are found to have unresectable disease.

Consumer health information websites in Taiwan

Developers of consumer health information (CHI) websites and pages in Taiwan have included: 1) individuals; 2) general hospitals; 3) disease-oriented associations; 4) government health administrative agencies; and 5) commercial corporations. General hospitals have developed the largest number of sites, but the quality of these sites differs widely. The unprecedented impact of health-oriented websites on medical care and the health of the public in general necessitates the establishment of credible instruments for the evaluation and rating of the quality of such websites and pages. In this paper, we describe the current status of CHI websites and pages in Taiwan. Suggestions for improving the content of CHI websites and pages are also proposed.

Hypertension in elderly persons: its prevalence and associated cardiovascular risk factors in Tainan City, southern Taiwan

BACKGROUND

Hypertension was the eighth leading cause of death in Taiwan in 1996, and the prevalence of hypertension has increased recently. The purpose of the study was to assess the prevalence of hypertension and its associated cardiovascular risk factors in elderly persons in Tainan City, southern Taiwan.

METHODS

The study was a cross-sectional, population-based study. We used the stratified cluster sampling method to enroll subjects aged 65 years and above, 1435 persons in total, into our study. Questionnaire interview, body weight, body height, and blood pressure measurement were completed for 876 participants (response rate of 70.2%) at each subject's home by home visit.

RESULTS

Hypertension was defined according to the criteria of the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The crude prevalence of hypertension was 60.4% (men 59.1%, women 61.9%); previously diagnosed hypertension was 31.1% (men 29.4%, women 33.1%); and newly diagnosed hypertension was 29.3% (men 29.7%, women 28.8%). The hypertensive group had a higher body mass index (BMI) than the normotensive group. There were no lifestyle differences such as smoking, drinking, eating a vegetarian diet, reading health information, and undergoing a health examination in the past year between the hypertensive and normotensive groups. However, the hypertensive group had a higher prevalence of regular exercise than did the normal blood pressure group on univariate analysis. Only BMI and family history of hypertension had a significantly positive association with hypertension on multiple logistic regression analysis.

CONCLUSIONS

The crude prevalence of hypertension was 60.4% in elderly persons in Tainan City. Subjects who had family history of hypertension and higher BMI had a higher risk of hypertension, so they should be screened for high blood pressure regularly.

Linkage of a gene for familial hypobetalipoproteinemia to chromosome 3p21.1-22

Familial hypobetalipoproteinemia (FHBL) is an apparently autosomal dominant disorder of lipid metabolism characterized by less than fifth percentile age- and sex-specific levels of apolipoprotein beta (apobeta) and low-density lipoprotein-cholesterol. In a minority of cases, FHBL is due to truncation-producing mutations in the apobeta gene on chromosome 2p23-24. Previously, we reported on a four-generation FHBL kindred in which we had ruled out linkage of the trait to the apobeta gene. To locate other loci containing genes for low apobeta levels in the kindred, a genomewide search was conducted. Regions on 3p21.1-22 with two-point LOD scores >1.5 were identified. Additional markers were typed in the region of these signals. Two-point LOD scores in the region of D3S2407 increased to 3.35 at O = 0. GENEHUNTER confirmed this finding with an nonparametric multipoint LOD score of 7.5 (P=.0004). Additional model-free analyses were conducted with the square root of the apobeta level as the phenotype. Results from the Loki and SOLAR programs further confirmed linkage of FHBL to 3p21.1-22. Weaker linkage to a region near D19S916 was also indicated by Loki and SOLAR. Thus, a heretofore unidentified genetic susceptibility locus for FHBL may reside on chromosome 3.

Cardiac and pulmonary vagal neurons receive excitatory chemoreceptor input

The effects of hypercapnia and hypocapnia on the activities of the cardiac and pulmonary vagal single fibers were examined in the decerebrated, unanesthetized, paralyzed, and vagotomized cats. The animals breathed 100% O2. Fractional end tidal CO2 concentration was raised to 9% by adding CO2 into the O2 inlet. Average discharge rate of efferent cardiac vagal units (n=10) increased from 1.0+/-0.3 to 2.2+/-0.3 Hz. Hypocapnia apnea was produced by hyperventilation. Activities of cardiac vagal units tested (n = 4) showed dramatic decrease (0.1+/-0.0 Hz). Mean arterial blood pressure did not change significantly under these conditions. In contrast, only instantaneous firing rate during inspiration was significantly increased for efferent pulmonary vagal units (n = 11) during hypercapnia. The activities of the 3 pulmonary vagal units tested with hypocapnia decreased significantly. We concluded that cardiac and pulmonary vagal neurons were excited by chemoreceptor input.

Chlamydia pneumoniae infection in community-acquired pneumonia in Taiwan

Chlamydia pneumoniae is a common cause of pneumonia worldwide. This study examined the role of C. pneumoniae in 229 patients with community-acquired pneumonia. The ages of the patients ranged from 2 to 95 years. Sera were assayed for IgM and IgG antibodies with microimmunofluorescence (MIF). An IgM titer equal to or greater than 1:20 and IgG titer equal to or greater than 1:64 were considered positive. The prevalence of positive IgG among all of the patients was 75.1% (172/229). The seroprevalence was 81.8% (9/11) for patients in the 11- to 20-year-old group, 63.6% (14/22) in the 31- to 40-year-old group and 88.1% (52/59) in the 71- to 80-year-old group. All patients had a negative result for IgM antibody. Twenty-five of the patients had an IgG titer equal to or greater than 1:512, indicating the presence of current infection or reinfection. Age older than 60 years (vs. < or = 60 years) was a risk factor for C. pneumoniae seropositivity in patients with community-acquired pneumonia (p < 0.001). Males had a significantly higher seroprevalence of C. pneumoniae infection (p = 0.1010). Patients older than 60 years were more likely to have C. pneumoniae infection (p = 0.1107). In this series, C. pneumoniae infection accounted for 10.9% (25/229) of community-acquired pneumonia. The most common clinical manifestations included fever (92%), productive cough (52%), white blood cell more than 10,000/mm3 (56%), and bilateral pulmonary infiltrate (60%).

Community-acquired methicillin-resistant Staphylococcus aureus endocarditis with septic embolism of popliteal artery: a case report

A 20-year-old man presented with a 14-day course of fever. Physical examination showed petechiae of the conjunctivae, Janeway lesions on both hands, a grade III/VI systolic murmur over the apex, pulseless dorsal pedal artery and posterior tibial artery of the right leg, and a pale right foot. Femoral arteriogram of the right leg revealed total occlusion of the popliteal artery with collateral circulation of the posterior tibial artery. Transthoracic echocardiogram showed trace mitral regurgitation. Embolectomy of the right popliteal artery was done, and penicillin and gentamicin treatment was administered. However, postoperative fever developed intermittently. Transesophageal echocardiogram disclosed vegetation over the anterior leaflet of the mitral valve. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from all three cultures of blood drawn at admission and from the septic embolus during operation. He had neither evidence of underlying heart disease, nor history of intravenous drug abuse or hospitalization. Exploratory cardiotomy with removal of vegetation on the mitral valve was performed followed by a 4-week treatment with intravenous vancomycin. After discharge, he was well at 2-year follow-up.

Epimeric separation of L-ascorbic acid and D-isoascorbic acid by capillary zone electrophoresis

Capillary zone electrophoresis (CZE) was used for separation of L-ascorbic acid (L-AA) and D-isoascorbic acid (D-IAA) in a model system. The effects of borate buffer concentration (0.05-0.25 M) and pH (pH 7.5-9.0) on migration time, resolution (Rs), and theoretical plates (N) were investigated. The migration times of L-AA and D-IAA increased with the increasing pH of carrier electrolyte (0.2 borate buffer), and the resolutions (Rs) of L-AA and D-IAA were calculated to be 12.98 at pH 9.0. Concentrations of borate buffer (pH 9.0) increased the Rs values of L-AA and D-IAA, and buffer concentrations >0.1 M were found to be effective for separation of L-AA and D-IAA. Methanol in the carrier electrolyte was also influential in improving the separation of L-AA and D-IAA, which increased with the increasing concentrations (0-10%) of methanol. The optimal separation conditions for L-AA and D-IAA were as follows: carrier electrolyte, 0.2 M borate buffer (pH 9.0); applied voltage, 25 kV, with an uncoated fused silica capillary, 75 microm (i.d.) x 57 cm.

The mitotic centromeric protein MEI-S332 and its role in sister-chromatid cohesion

Faithful segregation of sister chromatids during cell division requires properly regulated cohesion between the sister centromeres. The sister chromatids are attached along their lengths, but particularly tightly in the centromeric regions. Therefore specific cohesion proteins may be needed at the centromere. Here we show that Drosophila MEI-S332 protein localizes to mitotic metaphase centromeres. Both overexpression and mutation of MEI-S332 increase the number of apoptotic cells. In mei-S332 mutants the ratio of metaphase to anaphase figures is lower than wild type, but it is higher if MEI-S332 is overexpressed. In chromosomal squashes centromeric attachments appear weaker in mei-S332 mutants than wild type and tighter when MEI-S332 is overexpressed. These results are consistent with MEI-S332 contributing to centromeric sister-chromatid cohesion in a dose-dependent manner. MEI-S332 is the first member identified of a predicted class of centromeric proteins that maintain centromeric cohesion.

Discriminating glucose tolerance status by regions of interest of dual-energy X-ray absorptiometry. Clinical implications of body fat distribution

OBJECTIVE

To determine whether measuring body fat distribution by dual-energy X-ray absorptiometry (DEXA) can be used to discriminate glucose tolerance status.

RESEARCH DESIGN AND METHODS

Using a 75-g oral glucose tolerance test, a total of 1,015 Chinese subjects (559 men and 456 women) were categorized as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT), or diabetes. Blood pressure and lipid profiles of these subjects were measured. Waist-to-hip ratio (WHR) and DEXA were used to evaluate the varying patterns of body fat distribution among the groups.

RESULTS

Body fat distribution, as reflected by WHR and the centrality index, showed significant partial correlation coefficients with glycosylated hemoglobin, blood pressure, and lipid profiles in all subjects. After adjusting for age and BMI, there were significant differences among the three glycemic groups for all the cardiovascular risk factors except for total cholesterol level. The diabetic group had a significantly higher WHR and centrality index, but lower femoral fat percentage than the NGT and IGT groups. The diabetic group also showed higher abdominal fat percentage than the NGT group. Moreover, the IGT group had a higher centrality index than the NGT group. However, no significant differences were found in the percentage of lean tissue mass among the three groups. Using multiple stepwise logistic regression models, the centrality index remained a significant factor for discriminating different glucose tolerance status independent of the percentage total body fat.

CONCLUSIONS

Central obesity has shown significant correlation with cardiovascular risk factors among the three different glycemic groups. Centrality index measured by DEXA appears to be the better predictor of glucose intolerance, compared with WHR, abdominal fat, and general obesity (reflected by percentage total body fat or BMI) in a large cohort of the Chinese population.

Corticotropin releasing factor and substance P mediate the nucleus amygdaloideus centralis-nucleus ventromedialis-nucleus dorsomedialis pressor system

Prolonged emotional stress is an important factor in the development of neurogenic hypertension, but its mechanism is still unclear. The purpose of the present study is to analyze the possible neural basis of hypertension induced by prolonged emotional stress. In the brain many nuclei are involved in emotional reaction, stress or defense response; among them the nucleus amygdaloideus centralis (AC) is the most important one which widely connects with other nuclei controlling emotion and stress, such as nucleus ventromedialis (NVM), nucleus dorsomedialis (NDM), nucleus paraventricularis (NPV) etc. These nuclei contain corticotropin releasing factor (CRF)- and substance P (SP)-immunoreactive cell bodies, nerve terminals and corresponding receptors. Our previous and present studies showed that microinjection of CRF or SP into these nuclei induced pressor responses. These data imply that excitation of the AC can activate many nuclei controlling emotion and stress via CRF and SP, and excessive activities of these nuclei may be the neural basis of hypertension induced by prolonged emotional stress. The present study revealed that (1) the AC pressor response to glutamate (Glu) could be reduced by preinjection of CRF antagonist (alpha-Helical CRF[9-41] or SP antagonist ([D-Pro(2), D-Phe(7), D-Trp(9)]-substance P) into bilateral NVM, (2) the NVM pressor response to Glu were decreased by pretreatment of the NDM with CRF- or SP-antagonist, (3) the AC-, NVM- or NDM-pressor responses were all attenuated by preinjection of CRF- or SP-antagonist into bilateral NPV or rostral ventrolateral medulla (RVL). The results indicate that excitation of the AC can indirectly activate the NPV and RVL to evoke pressor response via the NVM-NDM, CRF and SP are transmitters in each connection of this pathway; this is one component of the mechanism underlying the AC pressor response. Taken together with the findings of our previous studies, it provides neurophysiological basis for the above-mentioned implications.

Postural hypotension and postural dizziness in patients with non-insulin-dependent diabetes

BACKGROUND

Postural hypotension with a decline of 20 mm Hg or more in systolic blood pressure on standing is considered a potentially dangerous hypotensive response. Postural dizziness is often strongly associated with postural hypotension. However, there is conflicting evidence, and previous studies have been confined to the elderly, not specifically to patients with diabetes. Thus, we evaluated the association between postural hypotension and postural dizziness, and determined the factors most likely related to postural hypotension in patients with diabetes.

METHODS

The subjects were 204 consecutive noninsulin-dependent patients with diabetes and 408 age- and sex-matched control subjects. Postural hypotension was defined as a decline of 20 mm Hg or more in systolic blood pressure 1 minute after standing. Postural dizziness was any feelings of dizziness, lightheadedness, or faintness that occurred while standing during the examination.

RESULTS

The prevalence of postural hypotension and postural dizziness in patients with diabetes was higher than in control subjects. Those patients with both diabetes and postural hypotension were older and had higher supine systolic blood pressures and higher plasma glycosylated hemoglobin and fasting glucose levels. They had higher prevalence of postural dizziness, hypertension, and cerebrovascular disease, and lower standing systolic blood pressures than those without postural hypotension. They also were more often being treated with antihypertensive agents. Only 32.8% of patients with diabetes with postural hypotension suffered from postural dizziness. Postural dizziness, hypertension, cerebrovascular disease, and plasma glycosylated hemoglobin levels were independently associated with postural hypotension in patients with diabetes.

CONCLUSIONS

Postural dizziness, glycemic control, hypertension, and cerebrovascular disease were important determinants of postural hypotension in patients with diabetes. Postural hypotension was associated with postural dizziness, but it cannot be determined clinically just from the presence of postural dizziness because the sensitivity for diagnosis of postural hypotension is low.

Hepatitis B vaccination in high-risk infants: 10-year follow-up

The long-term efficacy of hepatitis B vaccination among high-risk infants was determined in 805 vaccine responders, immunized at birth in Taiwan during 1981-1984 and followed to age 10 years, via life table survival and Cox multivariate analyses. At 10 years, cumulative persistence of antibody to hepatitis B surface antigen (anti-HBs) was 85%, and cumulative incidence of hepatitis B virus (HBV) infection was 15%. Three children became carriers. Twelve-month anti-HBs titer was the strongest predictor of efficacy. The higher the initial titer, the lower the risk of anti-HBs loss (relative risk [RR], 0.26 for titer of 100-999 mIU/mL; RR, 0.08 for titer >1000 mIU/mL; P<.001) and HBV infection (RR, 0.55 and 0.27; P<.05). Maternal hepatitis B e antigen positivity but not hepatitis B immunoglobulin dose or gender predicted greater antibody persistence to age 10 years. Because the level of antibody persistence remained high and few became carriers, booster revaccination within 10 years seems unnecessary.

Sodium hyaluronate carboxymethylcellulose-based bioresorbable membrane (Seprafilm)--does it affect tumor implantation at abdominal wound sites?

PURPOSE

This study examines the effects of a sodium hyaluronate-based bioresorbable membrane (Seprafilm) on tumor implantation at surgical wound and laparoscopic trocar sites.

METHODS

GW-39, an established human colon cancer line carried in immunocompetent golden Syrian hamsters was used as the experimental model. Under general anesthesia, a 2-cm midline incision was made to allow placement of four 5-mm abdominal trocars. Hamsters were then randomly assigned to preSeprafilm, postSeprafilm, and control (no Seprafilm) groups. In the preSeprafilm group 0.5 ml of a 5 percent (vol/vol) suspension of the GW-39 tumor cells (approximately 1.675 x 10(6) cells) was injected into the abdomen of each hamster via midline incision. Trocars were removed, the wounds were closed, and 1 cm2 of Seprafilm was placed on the peritoneal surface of each trocar site. In the postSeprafilm group the membrane was placed at each site before injection of tumor cells. The control group did not receive Seprafilm. The animals were killed after seven weeks, and the abdominal wound sites were excised. Sites without gross tumor underwent histologic evaluation.

RESULTS

One hundred thirty-two animals were randomly assigned to the three groups. The preSeprafilm group had an 87 percent tumor implantation rate. The postSeprafilm group had a 90 percent tumor implantation rate. The control group had an 88 percent tumor implantation rate. Chi squared analysis demonstrated that these total tumor implant rates and mean tumor mass were similar at all wound sites and between groups. No toxicity was observed in any of the experimental groups.

CONCLUSIONS

Sodium hyaluronate-based bioresorbable membrane (Seprafilm) does not influence GW-39 human colon cancer implantation at abdominal wound sites in this hamster model.

Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair

BACKGROUND

Unlike sliding hiatal hernias, paraesophageal hiatal hernias (PEH) present a risk of catastrophic complications and should be repaired. To assess laparoscopic repair of PEH, we prospectively evaluated the outcome of 38 consecutive patients with type II (20 patients) or III (18 patients) PEH treated laparoscopically.

METHODS

With the use of 5 or 6 ports, laparoscopic PEH reduction and repair was attempted. One patient (3%) was converted to an open procedure. In the first 12 patients, the hiatus was closed using varying techniques including the placement of prothestic mesh in 6 patients, and the hernia sac was not routinely excised. In the next 25 patients, the hernia sac always was excised and the hiatus routinely sutured posteriorly to the esophagus. Twenty-nine patients also underwent either a Nissen (n = 27) or Toupet (n = 2) fundoplication, which is now performed routinely. Sutured anterior gastropexy was performed selectively in 10 of the first 20 patients, then routinely, using T-fasteners in the last 17 patients. Barium swallow studies were performed on all patients at 3 to 5 months postoperatively.

RESULTS

Mean +/- standard error of the mean (SEM) age was 67 +/- 2 year (range, 39-92 years; 11 men, 27 women), and the American Society of Anesthesia (ASA) score was 2.5 +/- 0.1. The operating time was 195 +/- 10 min: 244 +/- 15 min in the first 12 patients and 170 +/- 11 min in the last 25 patients (p < 0.001). There were three (8%) intraoperation complications, which were treated without sequelae, and four (11%) grade II postoperation morbidities. Median discharge was 3 days, and return to full activity was 14 days. Two patients (5%) died of cardiovascular disease after discharge. Barium swallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathoracic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but only 1 patient (4%) required medication for these symptoms.

CONCLUSIONS

Laparoscopic PEH repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. Rapid recovery is achieved with acceptable morbidity and early outcome. Barium x-rays revealed hiatal abnormalities in a significant fraction of patients, many of whom were asymptomatic. Longer follow-up will be required to determine the ideal strategy for management of these patients.

[Quantification of female teenagers' competence of sexual cognition]

Compiling a questionnaire of sexual cognition for surveying 224 female teenagers (11 to 14 years old), the results showed that they were deficient in the knowledge of sexual physiology, mortality and law. And also, the deficiency had a high co-relationship with the age of surveyed female teenagers. It suggested that this questionnaire be valuable in the quantification of sexual cognition.

Randomized comparison of laparoscopic and open lymphadenectomy in pigs

OBJECTIVE

To compare the efficacy of open and laparoscopic lymphadenectomy and validate an objective model of lymph node retrieval using lymphangiography in pigs.

METHODS

Twenty-five pigs weighing 54-75 lbs were randomly assigned by side to open or laparoscopic pelvic and paraaortic lymphadenectomy. Lymph node yield, quantified by a masked pathologist, operative time, complications, blood loss, and other variables were recorded. Lymphangiography was done, and radiographs were taken before and after lymph node harvesting. Statistical analysis used McNemar test for nominal data and paired Student t test or Wilcoxon signed-rank test for continuous variables.

RESULTS

Lymph node yields were a mean of 11.5 with a standard deviation of 2.8 for open and 15.3 +/- 3.4 nodes for laparoscopic lymphadenectomy (P = .009). Mean operating time was 26.5 +/- 5.3 minutes for open versus 54.9 +/- 23.7 minutes for laparoscopy (P < .01). Mean blood loss was higher for laparoscopic cases, 35 mL for open versus 58 mL for laparoscopic lymphadenectomy (P = .048). The four major complications were evenly distributed between the two procedures. Lymphangiography was successful in 24 of 25 pigs. A total of 243 lymph nodes were identified with equal distribution by side. Lymphangiographic data correlated well with number of lymph nodes retrieved.

CONCLUSION

In this randomized trial, laparoscopic lymphadenectomy was at least as effective as open lymphadenectomy, although operating time and blood loss were greater. Lymphangiography was a reliable, objective mode for documentation and assurance of lymph node recovery.

Sympathetic hyperactivity in Wistar rats with insulin-resistance

In an attempt to know the effect of sustained hyperinsulinemia on sympathetic function, plasma norepinephrine (NE) and glucose levels were measured in Wistar rats with insulin resistance. Both the basal plasma glucose and the plasma NE levels in insulin-resistant rats were markedly higher than that obtained in normal or streptozotocin (STZ)-induced diabetic rats. Treatment with guanethidine and prazosin reversed these sympathetic hyperactive responses in insulin-resistant rats. Moreover, increase of plasma insulin in rats receiving an intraperitoneal glucose challenge test confirmed the mediation of endogenous insulin in this sympathetic hyperactivity. These results suggest an increase of sympathetic activity in insulin-resistant state that may be related to the hypertension-prone associated with diabetes mellitus in clinics.

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.