Treatment guidelines for isolated dissection of the superior mesenteric artery based on follow-up CT findings

OBJECTIVES

The treatment guidelines for isolated superior mesenteric artery dissection (SMAD) are not well established. The purpose of this study was to report a single-centre series of SMAD and propose treatment guidelines.

MATERIALS AND METHODS

Between November 2004 and December 2009, 30 patients were diagnosed with SMAD. We retrospectively reviewed their medical records.

RESULTS

The subjects included 26 men and four women, with a mean age of 55.1 years. The chief complaint was abdominal pain in 17 patients, whereas 13 patients were asymptomatic. The mean follow-up was 38.3 months. The radiographic findings included intimal flap with a false lumen in 20 patients and intramural haematoma in 10 patients. The treatments included observation in 18 patients, anticoagulation in five patients, stenting in six patients and surgery in one patient. During follow-up (mean 15.6 months), there was no change in the computed tomography scans of seven patients, improvement was observed in four patients and complete resolution was observed in four patients. All patients, including the symptomatic patients, remained asymptomatic during follow-up.

CONCLUSIONS

Most patients with SMAD can be successfully managed with conservative treatment. Surgical treatment or percutaneous intervention can be reserved for patients with severe mesenteric ischaemia and those for whom the initial conservative treatment fails.

Reproducibility and agreement in evaluating retinal nerve fibre layer thickness between Stratus and Spectralis OCT

PURPOSE

To evaluate intra-device reproducibility of retinal nerve fibre layer (RNFL) measurements obtained using Stratus and Spectralis optical coherence tomography, and to analyze inter-device correlation and agreement for these measurements.

DESIGN

Prospective observational study.

METHODS

A total of 30 normal individuals participated in the study. One eye of each participant was scanned three times during one session by the same operator using Spectralis and Stratus. Intra-class correlation coefficients (ICCs), correlation coefficients (R), and Bland-Altman plots (BAPs) were used to assess reproducibility, correlation, and agreement between the two devices, respectively.

RESULTS

A significant difference in mean RNFL thickness was seen between Stratus and Spectralis (106.2 ± 6.9 μm vs 100.0 ± 7.3 μm, P = 0.0001). ICCs of RNFL thickness measurements ranged from 0.69 (clock hour 2; 95% confidence interval (95% CI): 0.54, 0.85) to 0.91 (inferior quadrant; 95% CI: 0.86, 0.96) for Stratus and were higher for Spectralis, ranging from 0.87 (temporal-superior sector; 95% CI: 0.79, 0.94) to 0.96 (global and nasal-inferior sector; 95% CI: 0.94, 0.99). Rs of RNFL thickness measurements between the two instruments ranged from 0.61 (temporal quadrant) to 0.87 (superior quadrant). BAPs demonstrated a systematic difference in RNFL values between the two devices, with Spectralis producing thinner RNFL values than Stratus.

CONCLUSIONS

Spectralis demonstrated higher ICCs and thinner RNFL measurements than Stratus. Although the inter-device correlation was good, differences in RNFL measurements obtained by the two devices indicate that these measurements would not be interchangeable in clinical evaluations.

Benefits of drug eluting stents versus bare metal stents in ST-elevation myocardial infarction: a contemporary review

The efficacy of drug-eluting stents (DES) in reducing the rates of in-stent restenosis after percutaneous coronary intervention (PCI) compared to bare metal stents (BMS) in stable coronary artery disease has been well demonstrated. Thus, the Food and Drug Administration has approved the utilization of DES for stable coronary disease. However, there is still much debate surrounding the implantation of DES for patients with ST-segment elevation myocardial infarction (STEMI) given safety concerns about the possibility of increased rates of stent thrombosis with DES. The review of the current body of evidence comparing DES with BMS is consistent with results from previous trials in stable coronary disease and reveals lower rates of revascularization with DES in STEMI patients. The ultimate decision regarding the appropriate stent during PCI needs to be individualized as patients' compliance with dual antiplatelet therapy is critical. The data suggest that PCI with DES in STEMI patients who adhere to long-term dual antiplatelet therapy is safe and effective. Randomized trials with longer-term follow-up are necessary to better elucidate the safety and efficacy of DES versus BMS in patients with STEMI.

Risk of Stroke in Patients Hospitalized for Isolated Vertigo

Background and Purpose—

Vertigo is a common presenting symptom in ambulatory care settings, and stroke is its leading and most challenging concern. This study aimed to determine the risk of stroke in vertigo patients in a 4-year follow-up after hospitalization for acute isolated vertigo.

Methods—

The study cohorts consisted of all patients hospitalized with a principal diagnosis of vertigo (n=3021), whereas patients hospitalized for an appendectomy in 2004 (n=3021) comprised the control group and surrogate for the general population. Cox proportional hazard model was performed as a means of comparing the 4-year stroke-free survival rate between the 2 cohorts after adjusting for possible confounding and risk factors. Among vertigo patients, there was further stratification for risk factors to identify the group at high risk for stroke.

Results—

Of the 243 stroke patients, 185 (6.1%) were from the study cohort and 58 (1.9%) were from the control group. Comparing the 2 groups, patients with vertigo symptoms had a 3.01-times (95% CI, 2.20–4.11; P <0.001) higher risk for stroke after adjusting for patient characteristics, comorbidities, geographic region, urbanization level of residence, and socioeconomic status. Vertigo patients with ≥3 risk factors had a 5.51-fold higher risk for stroke (95% CI, 3.10–9.79; P <0.001) than those without risk factors.

Conclusions—

Vertigo patients are at higher risk for stroke than the general population. They should have a comprehensive neurological examination, vascular risk factors survey, and regular follow-up for several years after hospital discharge after treatment of isolated vertigo.

Attributes of response in depressed patients switched to treatment with duloxetine

BACKGROUND

This study was designed to assess clinical and functional outcomes associated with switching to duloxetine treatment in patients with major depressive disorder (MDD) experiencing emotional and painful physical symptoms in their current episode.

METHODS

In this 8-week, multinational, multicentre, single-arm, open-label clinical trial, 242 MDD patients were switched to duloxetine 60 mg/day after selective serotonin reuptake inhibitor (SSRI) or serotonin and norepinephrine reuptake inhibitor (SNRI) treatment. The primary analysis compared mean change from baseline in Brief Pain Inventory-Modified Short Form (BPI-SF) interference score between initial responders [≥ 50% reduction from baseline on the 17-item Hamilton Depression Rating Scale (HAMD(17)) Maier subscale] and initial non-responders after 4 weeks. Initial responders continued with duloxetine 60 mg/day. Initial non-responders received duloxetine 120 mg/day for the remaining 4 weeks. Depression, pain, anxiety and functional outcomes were also compared after 8 weeks.

RESULTS

BPI-SF interference decreased from baseline in initial responders (n = 108) and initial non-responders (n = 85) after 4 weeks of duloxetine treatment, with greater reductions in initial responders [BPI-SF mean difference in reduction: 1.01 (95% CI 0.42-1.61); p < 0.001]. Reductions in pain interference favouring initial responders were also apparent after 8 weeks [0.68 (95% CI: 0.03-1.33); p = 0.042]. Depression, pain, anxiety and function improved over 8 weeks across patient groups.

CONCLUSIONS

Elements of core mood and pain are important residual symptoms following poor treatment response in MDD. Early improvement in these symptoms after switching to duloxetine indicated an increased chance of functional recovery.

Formation of Ge quantum dots array in layer-cake technique for advanced photovoltaics

We report a simple and manageable growth method for placing dense three-dimensional Ge quantum dot (QD) arrays in a uniform or a graded size distribution, based on thermally oxidizing stacked poly-SiGe in a layer-cake technique. The QD size and spatial density in each stack can be modulated by conditions of the Ge content in poly-Si(1-x)Ge(x), oxidation, and the underlay buffer layer. Size-dependent internal structure, strain, and photoluminescence properties of Ge QDs are systematically investigated. Optimization of the processing conditions could be carried out for producing dense Ge QD arrays to maximize photovoltaic efficiency.

Reflexology: an update of a systematic review of randomised clinical trials

Reflexology is a popular form of complementary and alternative medicine (CAM). The aim of this update is to critically evaluate the evidence for or against the effectiveness of reflexology in patients with any type of medical condition. Six electronic databases were searched to identify all relevant randomised clinical trials (RCTs). Their methodological quality was assessed independently by the two reviewers using the Jadad score. Overall, 23 studies met all inclusion criteria. They related to a wide range of medical conditions. The methodological quality of the RCTs was often poor. Nine high quality RCTs generated negative findings; and five generated positive findings. Eight RCTs suggested that reflexology is effective for the following conditions: diabetes, premenstrual syndrome, cancer patients, multiple sclerosis, symptomatic idiopathic detrusor over-activity and dementia yet important caveats remain. It is concluded that the best clinical evidence does not demonstrate convincingly reflexology to be an effective treatment for any medical condition.

Brain-derived neurotrophic factor gene polymorphisms and mirtazapine responses in Koreans with major depression

Brain-derived neurotrophic factor (BDNF) is a candidate molecule for influencing the clinical response to antidepressant treatment. The aims of this study were to determine the relationship between the Val66Met polymorphism in the BDNF gene and the response to mirtazapine in 243 Korean subjects with major depressive disorder (MDD). The reduction in the Hamilton Depression score over the 8-week treatment period was not influenced by BDNF V66M genotypes. A marginal effect of genotype on somatic anxiety score was observed at baseline (P = 0.047 in the dominant model). However, genotype-time interaction had no effect on somatic anxiety score after the 8-week a treatment period. Plasma BDNF levels tended to increase during mirtazapine treatment, although without statistical significance (P = 0.055). After 8 weeks of mirtazapine treatment, plasma BDNF levels were higher in Met allele homozygotes (1499.7 ± 370.6 ng/mL) than in Val allele carriers (649.7 ± 158.5 ng/mL, P = 0.049). Our results do not support the hypothesis that the Val66Met promoter polymorphism in the BDNF gene influences the therapeutic response to mirtazapine in Korean MDD patients. However, our data indicate that this polymorphism results in increased plasma BDNF after mirtazapine treatment.

The concentration of antibiotic in fresh-frozen bone graft

We investigated the antibiotic concentration in fresh-frozen femoral head allografts harvested from two groups of living donors. Ten samples were collected from patients with osteoarthritis of the hip and ten from those with a fracture of the neck of the femur scheduled for primary arthroplasty. Cefazolin (1 g) was administered as a pre-operative prophylactic antibiotic. After storage at -80 degrees C for two weeks the pattern of release of cefazolin from morsellised femoral heads was evaluated by an in vitro broth elution assay using high-performance liquid chromatography. The bioactivity of the bone was further determined with an agar disc diffusion and standardised tube dilution bioassay. The results indicated that the fresh-frozen femoral heads contained cefazolin. The morsellised bone released cefazolin for up to four days. The concentration of cefazolin was significantly higher in the heads from patients with osteoarthritis of the hip than in those with a fracture.Also, in bioassays the bone showed inhibitory effects against bacteria.We concluded that allografts of morsellised bone from the femoral head harvested from patients undergoing arthroplasty of the hip contained cefazolin, which had been administered pre-operatively and they exhibited inhibitory effects against bacteria in vitro.

Widespread expression of prostate apoptosis response-4 in nasopharyngeal carcinoma

BACKGROUND

Prostate apoptosis response-4 (Par-4) augments apoptosis in various tumors, either during apoptotic insult or by ectopic overexpression. However, investigation of Par-4 expression in nasopharyngeal carcinoma (NPC) is lacking.

METHODS

Specimens from patients with NPC, hypopharyngeal carcinoma (HPC), or oral cavity cancer were examined for Par-4 expression using immunohistochemistry. NPC cell proliferation and apoptosis were analyzed using immunohistochemical staining for Ki67, B-cell lymphoma 2 (Bcl-2), and in situ terminal deoxyribonucleotidyl transferase (TdT)-mediated biotin-16-dUTP nick end-labeling (TUNEL) assay, respectively.

RESULTS

Par-4 was ubiquitously expressed in NPC biopsies (96.2%, 25/26) and was significantly higher than in HPC (47.6%, 50/105, p < .0001) and oral cavity cancers (38.7%, 12/31, p < .0001). Remarkably, apoptosis of NPC cells was absent and Par-4 expression was associated with obvious expression of Bcl-2 and Ki67 in all patients tested with NPC.

CONCLUSIONS

Immunohistochemistry results showed widespread expression of Par-4 in NPC and revealed sustainable proliferation of NPC cells regardless of Par-4 expression.

Buccal mucosa carcinoma: surgical margin less than 3 mm, not 5 mm, predicts locoregional recurrence

Background

Most treatment failure of buccal mucosal cancer post surgery is locoregional recurrence. We tried to figure out how close the surgical margin being unsafe and needed further adjuvant treatment.

Methods

Between August 2000 and June 2008, a total of 110 patients with buccal mucosa carcinoma (25 with stage I, 31 with stage II, 11 with stage III, and 43 with Stage IV classified according to the American Joint Committee on Cancer 6^th edition) were treated with surgery alone (n = 32), surgery plus postoperative radiotherapy (n = 38) or surgery plus adjuvant concurrent chemoradiotherapy (n = 40).

Main outcome measures: The primary endpoint was locoregional disease control.

Results

The median follow-up time at analysis was 25 months (range, 4-104 months). The 3-year locoregional control rates were significantly different when a 3-mm surgical margin (≤3 versus >3 mm, 71% versus 95%, p = 0.04) but not a 5-mm margin (75% versus 92%, p = 0.22) was used as the cut-off level. We also found a quantitative correlation between surgical margin and locoregional failure (hazard ratio, 2.16; 95% confidence interval, 1.14 - 4.11; p = 0.019). Multivariate analysis identified pN classification and surgical margin as independent factors affecting disease-free survival and locoregional control.

Conclusions

Narrow surgical margin ≤3 mm, but not 5 mm, is associated with high risk for locoregional recurrence of buccal mucosa carcinoma. More aggressive treatment after surgery is suggested.

Avian influenza monitoring in migrating birds in Taiwan during 1998-2007

Avian influenza virus (AIV) monitoring in migratory birds has been performed in Taiwan since 1998. From 1998 to 2007, 29,287 samples were collected from wild ducks, shorebirds, and other wild birds in the four wetlands around Taiwan and at two outside islets, Penghu and Kinmen. Virus isolation was performed for all collected samples by inoculating chicken embryos. The AIV in the allantoic fluid was identified using hemagglutination and reverse transcription PCR. The AIV prevalence from those samples was 0.81% (237/29,287). The peak prevalence reached 1.06% (186/17,493) from September to December, during which time migrating ducks came from the North. The prevalence from January to April was 0.51%. However, no virus was isolated from May to August. The partial HA genes of 28 H4 AIVs were sequenced and analyzed. The phylogenetic tree showed that a correlation existed between the isolation years and the evolutional distances. The pathogenicity of the isolated H5 and H7 AIVs was determined by intravenous pathogenicity index (IVPI) testing in specific-pathogen-free chickens and by HA cleavage sequencing. Using the IVPI test and the HA cleavage sequences, all of the H5 or H7 AIVs isolated were determined to be low pathogenicity AIVs.

Evaluation of difference in the neurotoxicity produced by dermal application of chlorpyrifos on the neonatal and adult mice

Dermal exposure to organophosphate pesticide is important because of its popular use. This study planned to compare the changes in serum acetylcholinesterase, paraoxonase and neuronal density of hippocampus and iso-cortex between two age groups of Swiss albino mice (18-day-old and 150-day-old) after dermal application of (1/2) LD50 of chlorpyrifos for 14 days. Statistically significant reduction was observed in serum acetylcholinesterase (Mann-Whitney test, p<0.05) and neuronal density (Independent samples t-test, p<0.05) in exposed groups compared to the control. The reduction in serum AChE and neuronal density was more pronounced in exposed adult mice than in exposed neonatal mice. The paraoxonase level was insignificant in control neonatal mice, whereas it was 890-fold more in exposed neonatal mice. Upregulated paraoxonase levels may be extrapolated to produce relatively lower reduction of cholinesterase and neuronal density in neonatal mice.

Clinical application of tumor volume in advanced nasopharyngeal carcinoma to predict outcome

BACKGROUND

Current staging systems have limited ability to adjust optimal therapy in advanced nasopharyngeal carcinoma (NPC). This study aimed to delineate the correlation between tumor volume, treatment outcome and chemotherapy cycles in advanced NPC.

METHODS

A retrospective review of 110 patients with stage III-IV NPC was performed. All patients were treated first with neoadjuvant chemotherapy, then concurrent chemoradiation, and followed by adjuvant chemotherapy as being the definitive therapy. Gross tumor volume of primary tumor plus retropharyngeal nodes (GTVprn) was calculated to be an index of treatment outcome.

RESULTS

GTVprn had a close relationship with survival and recurrence in advanced NPC. Large GTVprn (> or =13 ml) was associated with a significantly poorer local control, lower distant metastasis-free rate, and poorer survival. In patients with GTVprn > or =13 ml, overall survival was better after > or =4 cycles of chemotherapy than after less than 4 cycles.

CONCLUSIONS

The incorporation of GTVprn can provide more information to adjust treatment strategy.

Influence of human allogenic bone marrow and cord blood-derived mesenchymal stem cell secreting trophic factors on ATP (adenosine-5'-triphosphate)/ADP (adenosine-5'-diphosphate) ratio and insulin secretory function of isolated human islets from cadaveric donor

Successful islet transplantation (ITx) is not only dependent on the number of islets, but also their quality, including viability, metabolic activity, and function. Islet quality decreases during cultivation after the isolation procedure. To overcome this obstacle, we established the practice of islet and mesenchymal stem cells (MSCs) coculture. This coculture condition improved the ATP (adenosine-5'-triphosphate)/ADP (adenosine-5'-diphosphate) ratio and insulin secretory function in vitro. It is believed that the enhancement of islet quality in islet-MSCs cocultures may be caused by the secretion of active agents by MSCs. Herein we have shown that interleukin-6 (IL-6), vascular endothelial growth factor-A (VEGF-A), hepatocyte growth factor (HGF), and transforming growth factor-beta (TGF-beta) were significantly increased as measured by enzyme-linked immunosorbent assay (ELISA) in MSCs-cultured medium, factors that have been shown to improve the survival, function, and angiogenesis/revascularization of islets. These results indicated that the quality of human islets was enhanced by trophic molecules secreted by MSCs, which influence the intracellular islet ATP content and insulin secretory function.

SOX2 modulates alternative splicing in transitional cell carcinoma

Aberrant alternative splicing of key cellular regulators may play a pivotal role in cancer development. To investigate the potential influence of altered alternative splicing on the development of transitional cell carcinoma (TCC), splicing activity in the TCC cell lines TSGH8301 and BFTC905 was examined using the SV40-immortalized uroepithelial cell line SV-HUC-1 as a reference. Our results indicate a significant alteration in splice site selection in the TCC cell lines. By gene expression profiling and subsequent validation, we discovered that sex-determining region Y-box protein 2 (SOX2) is specifically upregulated in BFTC905. Furthermore, ectopic expression of SOX2 modulates alternative splicing of the splicing reporter in vivo. More significantly, using an in vitro pull-down assay, it was found that SOX2 exhibits RNA-binding capability. Our observations suggest that SOX2 modulates alternative splicing by functioning as a splicing factor.

Endoscopic treatment of difficult bile duct stones by using a double-lumen basket for laser lithotripsy--a case series

Laser lithotripsy is an effective and safe method for difficult common bile duct (CBD) stones. However, radiolucent laser fibers make accurate fragmentation difficult and require continuous visual control or an accessory for effective targeting. The newly developed double-lumen basket may promote effective laser lithotripsy after stone capture. We performed laser lithotripsy using a double-lumen basket in 14 patients with CBD stones refractive to conventional endoscopic treatment, and evaluated the feasibility and efficacy of this procedure. Stones were successfully fragmented in 13 of 14 patients, and 13 patients eventually became stone-free. Mechanical lithotripsy was applied in two patients with biliary strictures. Minor complications were noted in three patients, including transient hemobilia in one patient. For a selected group of patients with difficult CBD stones, laser lithotripsy using a double-lumen basket appears to be an effective and safe method. However, continuous development of basket protocols to increase the success rate of lithotripsy is needed.

Extracorporeal shockwave for hip necrosis in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) frequently received corticosteroid therapy, resulting in osteonecrosis of the femoral head (ONFH). Prior studies demonstrated the effectiveness of extracorporeal shockwave treatment (ESWT) for ONFH.. This study evaluated the effectiveness of ESWT for ONFH in patients with SLE. We studied 39 patients, including 15 patients with SLE (26 hips) and 24 controls (29 hips). To each affected hip we applied ESWT (6000 impulses at 28 kV in a single session). Patients were ambulated with partial weight bearing for 4-6 weeks. The primary endpoint was the need for hip replacement. The secondary endpoints were improvement in hip pain and function and image changes on X-ray and MRI. Patients received total hip replacement in 12% of patients with SLE and in 14% of controls (P = 0.802). There was no statistically significant difference in pain scores (0.86 vs. 0.89; P = 0.467) and function scores (89% vs. 91%; P = 0.194) between patients with SLE and controls. SLE response to ESWT for ONFH is comparable with ONFH in patients without SLE.

Transdermal fentanyl for pain caused by radiotherapy in head and neck cancer patients treated in an outpatient setting: a multicenter trial in Taiwan

OBJECTIVE

This study evaluated the efficacy and safety of transdermal fentanyl in the outpatient treatment of head and neck cancer patients with pain caused by radiotherapy.

METHODS

Patients with a visual analogue scale score >or=4 were invited to participate in the study. The following variables were collected: visual analogue scale, the Brief Pain Inventory, concomitant pain medications and adverse effects. A total of 163 head and neck cancer patients were enrolled (148 males and 15 females; median age, 53 years; age range, 21-72 years). Seventy-two (44%) patients had a visual analogue scale score >6 at enrollment, despite the use of non-steroidal anti-inflammatory drugs or weak opioids. Ninety-four (57.7%) patients received concurrent chemotherapy.

RESULTS

A total of 88 patients completed the study, whereas 55 underwent a drop-out by side effects. The most frequently reported adverse events were vomiting (23.9%) and nausea (16.6%). Treatment with transdermal fentanyl resulted in a significant decrease in visual analogue scale and Brief Pain Inventory scores that persisted during treatment. In the overall efficacy evaluation, the pain-alleviating effect, the easiness of application and the overall impression of transdermal fentanyl were rated as good by 54.5%, 65.9% and 59.1% of the completers, respectively. Effects of transdermal fentanyl were rated as good by 64.8% of the investigators.

CONCLUSIONS

Our data provide evidence that transdermal fentanyl is effective and relatively easy to use for outpatient treatment of pain control in head and neck cancer patients following radiotherapy in selected patients. Reduction of side effects and effective pain management need to be paramount in the management of head and neck cancer patients undergoing radiotherapy.