Penile curvature associated with scleroderma

We present 2 cases of Peyronie's disease in patients with scleroderma. This association is uncommon, and our patients' symptoms and disease course differed from that typical for Peyronie's disease. We suggest a more conservative approach when treating patients whose penile curvature is associated with a systemic disease such as scleroderma.

Interventional radiologic procedures in liver transplantation

Postoperative biliary and vascular complications contribute significantly to morbidity and mortality in liver transplantation. Interventional radiologists are an integral part of the multidisciplinary team necessary for optimizing the management of these complications. During a 15-year period, 39 cadaveric and 25 living related liver transplantations were performed at the Chang Gung Memorial hospital, Taiwan. Of 64 liver transplant recipients, 9 (3 adult and 6 pediatric) underwent 13 interventional radiological procedures for the treatment of biliary sludge-casts (n = 2), bile duct occlusion or stenosis (n = 2), hepatic veins thrombosis (n = 1), hepatic veins stenosis (n = 1), portal vein stenosis with splenorenal shunting (n = 1), biloma (n = 1), and infected fluid collection or ascites (n = 4). Antegrade or retrograde interventional approach was used to successfully treat all biliary complications, and all percutaneous drainage procedures were effective in the control of intra-abdominal fluid collections. Portal vein stenosis was treated by balloon dilatation, and the associated splenorenal shunt was closed by metallic coil embolization via transhepatic catheterization of the portal vein. Hepatic vein stenosis was effectively treated by balloon dilatation and expandable metallic stent deployment via transfemoral and jugular venous approaches, respectively. Hepatic vein thrombosis was only partially lysed by transvenous streptokinase administration, and surgical thrombectomy was needed to achieve complete recanalization. The total success rate of the interventional procedures was 92 % with no procedure-related complications. The overall survival rate in this series is 89 %, and all patients who underwent living related liver transplantation maintain to date a 100 % survival rate. We can conclude that interventional radiological procedures are very useful for managing biliary and vascular complications after liver transplantation. These techniques provide a cure in most situations, thus obviating the need for further surgical intervention or re-transplantation.

[Process analysis of cognitive-behavioral group psychotherapy for patients with panic disorder]

The study explores the verbal interaction relationship between therapists and members, and the interaction model of this group. Six subjects were chosen by convenience sampling from the psychiatric OPD of a medical center in the Taichung area. Subjects with informed consent participated in a 12-week course of closed group psychotherapy. All data was tape-recorded and the Hill Interaction Matrix (HIM) scale was applied for simultaneous triangulation, in order to analyze the group's dynamic development of cognitive-behavioral psychotherapy for patients with panic disorder. The results indicated that the interactive relationship between therapists and members fluctuated during the group process. Development of the group process can be subdivided into three stages: initial stage-adaptive and familiar, middle stage-explorative, and terminal stage-productive. The amount of verbal interaction was greatest in the third quadrant. In the group interaction model, the therapist tended to explore the members' problems most. Providing support was the second most frequent. Meanwhile, members also tended to discuss personal problems. It was revealed that the verbal interaction of the therapists and members were the same. The content style of this group session is member-centered, and work style is pre-worked. The results showed that the group sessions did have great therapeutic value for members.

Assessment of donor fatty livers for liver transplantation

AIM

The effect of fatty liver on graft survival, especially with reference to macrovesicular and microvesicular steatosis, is still uncertain. This preliminarily study was designed to create a noninvasive method for the quantification of the hepatic fat content in vivo and to establish provisional criteria for the assessment of fatty donor livers before liver transplantation among transplant surgeons, radiologists, and pathologists.

METHODS AND MATERIALS

Different degrees of rat fatty liver model were established by feeding rats a diet deficient in choline and methionine for different periods of time. Computed tomography (CT) with test tubes containing variable percentages of fat equivalent substance were used to assess the severity of fatty change of the rat liver. This was then correlated with the histological classification, level of hepatic enzymes, and graft survival.

RESULTS

Linear correlation between the fat volume fraction added to the test tubes and CT density were found. The process of producing a fatty liver via diet alteration peaked at week 3. At this time hepatic enzymes, radiological fat content, and posttransplantation survival were worse (P=0.013), compared with other time points. Radiological assessment of fatty liver correlated well with survival and serum glutamic oxaloacetic transaminase and glutamic pyruvate transaminase levels.

CONCLUSION

Severe microvesicular steatosis does not influence recipient survival, however, macrovesicular steatosis affects graft survival. Caliber CT is a practical and simple method that allows an accurate noninvasive quantitative assessment of hepatic fatty infiltration. It has potential to be a useful parameter for the assessment of donor livers for clinical liver transplantation.

The clinical use of small-dose tetracaine spinal anesthesia for transurethral prostatectomy

In a double-blinded study, we compared conventional dose tetracaine (8 mg), small-dose tetracaine (4 mg) with added fentanyl and epinephrine, and small-dose tetracaine (4 mg) with added fentanyl subarachnoid anesthesia. Forty-five patients scheduled for transurethral resection of prostate (TURP) under subarachnoid anesthesia were randomly assigned to Group 1 (8 mg hyperbaric tetracaine), Group 2 (4 mg hyperbaric tetracaine, 10 microg fen-tanyl, and 0.2 mg epinephrine), and Group 3 (4 mg hyperbaric tetracaine, 10 microg fentanyl, and 0.2 mL saline). Evaluations were performed after spinal anesthesia. Subarachnoid block was successful in all patients except one in Group 1, who required general anesthesia by mask. The median peak sensory levels 10 min after the induction of spinal anesthesia in Group 1 was T8, which was significantly higher than Group 2 and Group 3 (P < 0.05). The time of sensory and motor recovery in Group 3 was less than in Groups 1 and 2 (P < 0.05). Hypotension was observed in four patients in Group 1 and none in Groups 2 and 3. We conclude that small-dose 4-mg hyperbaric tetracaine plus 10 microg fentanyl might provide adequate anesthesia and fewer side effects for TURP when compared with the conventional (8 mg) dose.

IMPLICATIONS

Small-dose hyperbaric tetracaine (4 mg with 10 microg fentanyl added) may provide adequate anesthesia and fewer side effects for transurethral resection of the prostate.

Biliary complications in living related liver transplantation

BACKGROUND

Biliary tract reconstruction has long been considered the Achilles' heel of liver transplantation as biliary complications can increase morbidity and mortality especially in partial liver graft transplantation.

METHODS

Thirty-four living related liver transplants were performed at Chang Gung Memorial Hospital in Kaohsiung for 33 children and 1 adolescent during a 5.5-year period. All potential donors underwent a detailed preoperative imaging study of the vascular and biliary anatomy, including three-dimensional helical computed tomographic cholangiography (n = 20), magnetic resonance cholangiography (n = 14), and intra-operative cholangiography (n = 31) before graft retrieval. All hepatic artery anastomoses were performed in the standard microsurgery fashion and their patency was confirmed intra-operatively using Doppler ultrasound.

RESULTS

The biliary complication rate was 8.8% (3/34), including multiple intrahepatic biliary stenosis of unknown origin (n = 1), bile leakage from the Roux-en-Y loop (n = 1), and a missed biliary radicle (n = 1) which were treated via interventional radiological and surgical procedures. The overall graft and patient survival rates were 100%.

CONCLUSION

The biliary complication rate in this series was low compared to those of other experienced centers. Complete study of the variations of intrahepatic duct ramification pre-and-intra-operatively provided adequate information on the appropriate transection plane. Furthermore, intra-operative Doppler ultrasound verification of vessel patency helps prevent vascular complications, which has been identified as a cause of biliary complications.

Biomechanical effects of progressive anterior cervical decompression

STUDY DESIGN

A repeated-measures in vitro flexibility test was performed.

OBJECTIVES

To determine the biomechanical functions of tissues resected during anterior cervical decompression of various extents.

SUMMARY OF BACKGROUND DATA

The biomechanical consequences of discectomy have been studied in vitro, and uncovertebral joint removal has been modeled numerically. No studies have assessed the relative biomechanical contributions of different anterior column structures.

METHODS

In seven human cadaver C4-T1 specimens, 20 motion segments were studied. After each destructive step, including discectomy, unilateral uncinate process removal, bilateral uncinate process removal, and posterior longitudinal ligament transection, torques were applied to four-level specimens while the angular motion was measured at each level.

RESULTS

Angular range of motion and neutral zone increased by variable but statistically significant amounts after each progressive resection, most notably in flexion and extension. Each resection step caused progressively larger shifts (up to 23 mm) in the location of the axis of rotation. Uncovertebral joint resection caused the most significant changes in the observed angular coupling.

CONCLUSIONS

Anterior cervical decompression significantly increases the instability and alters the kinematics of cervical motion segments. Each structure resected contributes to normal stability and kinematics, so as many structures as possible should be left intact during anterior decompression without fusion. Because flexion and extension were the modes of motion that increased most significantly after decompression, the primary function of a grafting technique or fixation device should be to limit these motions.

Reversible hypertensive retinopathy in a child with bilateral pheochromocytoma after tumor resection

Pheochromocytoma is very rare in children. We report a case of bilateral pheochromocytoma in a 12-year-old boy who had blurred vision due to hypertensive retinopathy. Abdominal ultrasound and computed tomography revealed bilateral suprarenal tumors. Resection of the bilateral tumors along with right total and left subtotal adrenalectomy were performed. Blood pressure and visual acuity returned to normal after surgery.

Comparison of in vitro growth-inhibitory activity of carboplatin and cisplatin on leukemic cells and hematopoietic progenitors: the myelosuppressive activity of carboplatin may be greater than its antileukemic effect

BACKGROUND

Carboplatin [cis-diammine(cyclobutane-1, 1-dicarboxylato)platinum(II)] has been shown to be an active agent for acute myeloid leukemia. This second-generation platinum drug has less nephrotoxicity and ototoxicity but more myelotoxicity than does the first-generation platinum drug cisplatin. The study was designed to elucidate whether their myelosuppressive activities equal their antileukemic effects.

METHODS

Cisplatin and carboplatin were used to treat four leukemic cell lines (CEM, HL60, K562 and U937), blast cells from 10 leukemic patients and hematopoietic progenitors from five umbilical cord blood samples.

RESULTS

The mean IC50 of leukemic cell lines was 0.4 and 6.2 microg/ml, the mean IC50 of patients' leukemic blasts was 2.0 and 22.4 microg/ml and the mean IC50 of hematopoietic progenitors (BFU-E, CFU-E and CFU-GM) was 1.8 and 1.7 microg/ml for cisplatin and carboplatin, respectively.

CONCLUSIONS

Carboplatin required a 10 times higher drug concentration than cisplatin to induce a similar degree of growth inhibition on leukemic cells. However, the hematopoietic progenitors responded equally to cisplatin and carboplatin at the same drug concentration. The results suggest that the myelosuppressive activity of carboplatin is greater than its antileukemic effect.

A quasi-experimental study on a quality circle program in a Taiwanese hospital

OBJECTIVE

To explore the impact of quality circles on job satisfaction, absenteeism, and turnover among hospital nurses in Taiwan.

DESIGN

A quasi-experimental research design.

SETTING

In November 1995, a study was initiated to establish quality circles in a 500-bed community hospital in Taiwan. After the administrative process and a pilot study, three of the experimental units began implementing the quality circle program in January 1997. For the comparison group, three non-quality circle medical-surgical units were selected from another building.

STUDY PARTICIPANTS

All registered nurses on the three selected units who met the criteria of having worked full-time on those units for > or = 6 months were included in the study. There were 53 full-time registered nurses (49 female, four male) who met the criteria and 100% participated. There were no significant differences between the quality circle group and the non-quality circle group in terms of sex, age, and number of years of working experience, education or marital status.

INTERVENTIONS

After obtaining administrative approval and support, the pilot study began with 3-month quality circle courses and 3-month quality circle process training for the experimental group nurses. Each circle has been meeting for 1 hour each week to identify problems, barriers, and solutions for effective implementation since 1997.

MAIN OUTCOME MEASURES

(i) Demographic data questionnaire; (ii) Stamps and Piedmont's Index of Work Satisfaction; (iii) hospital records for absenteeism and turnover data.

RESULTS

The data reveal that nurses of the three quality circle units felt more satisfied (P < 0.01) than did nurses from the three non-participating units. In the non-participating group, 36% had considered leaving the units, compared to 10% of nurses from the quality circle group. The turnover rate was significantly higher for the non-participating group (40%) than for the quality circle group (13%).

CONCLUSION

This quality circle program in a Taiwanese hospital significantly improved satisfaction, reduced absenteeism, and lowered turnover of nurses. The findings support other studies reported in the literature.

Bezoars in children: report of four cases

We reviewed the histories of four children (2 boys and 2 girls, aged 6 mo to 10 yr) with surgically proven bezoars, treated from 1991 to 1998. Two had gastric bezoars and two had intestinal bezoars. All four patients presented with gastrointestinal symptoms and none had undergone previous surgery. Three had a history of abnormal ingestion, including one who ate a pickled fruit from the Boraginaceae (locally known as Po-pu-tsu) plant for 1 year. Plain radiographs revealed intestinal obstruction in all four patients. Abdominal sonography disclosed a hyperechoic band-like lesion and acoustic shadow in both cases of gastric bezoar, and these bezoars were subsequently confirmed by gastric endoscopy. Lower gastrointestinal studies showed obstruction considered most likely to be due to bezoar in one case, while computed tomography (CT) revealed a characteristic small bowel mottled gas pattern in another. Surgical treatment relieved obstruction in all four patients. Bezoar should be suspected in patients with intestinal obstruction who have a history of ingestion of unusual substances. The findings of this report suggest that sonography and endoscopy are useful in the diagnosis of gastric bezoar, while CT is useful in the detection of intestinal bezoar.

Vaccination against gonadotropin-releasing hormone (GnRH) using toxin receptor-binding domain-conjugated GnRH repeats

A method for the preparation of an immunogen containing multiple copies of a self-peptide in linear alignment was designed in order to overcome the difficulty of inducing an immune response to poorly immunogenic peptide antigens. DNA fragments encoding multiple repeats of the self-peptide were generated by a new technique, termed template-repeated polymerase chain reaction (TR-PCR), which could be subcloned into an expression vector for production of peptide repeats as an immunogen. This approach was tested by constructing fusion proteins containing the receptor-binding domain of Pseudomonas exotoxin A and multiple copies of the 10-residue sequence of the peptide hormone gonadotropin-releasing hormone (GnRH). Immunization of female rabbits with the immunogen that contained the exotoxin receptor-binding domain and 12 copies of GnRH (PEIa-GnRH12) resulted in the generation of high-titer antibodies specific for GnRH. Although at equal molar basis of the GnRH moiety, the immunogen that contained single copy of GnRH (PEIa-GnRH1) induced low-titer anti-GnRH antibodies. These observations suggest that the presence of multiple peptide repeats is a key factor in eliciting an immune response. In addition, anti-GnRH antibodies effectively neutralized GnRH activity in vivo, as demonstrated by the degeneration of the ovaries in the injected rabbits. Because anti-GnRH antibody could be functionally analogous to GnRH antagonist, which has been used to treat patients with ovarian cancer, vaccination of PEIa-GnRH12 presents a potential therapeutic application for the treatment of GnRH-sensitive ovarian cancer.

Treatment of complicated hepatolithiasis with intrahepatic biliary stricture by ductal dilatation and stenting: long-term results

A group of 190 cases of hepatolithiasis with postoperative residual stones located proximal to the stricture sites were managed with the aim of complete clearance of stones and relief of bile stasis to decrease the potential risk of recurrence. All procedures were performed through a T-tube track with gradual dilatation and stent placement through the stricture sites, creating a channel that allows cholangioscopy and electrohydraulic lithotripsy. Complete clearance of intrahepatic duct (IHD) stones was achieved in 88.4% of cases. Multiple sharply angulated IHD strictures in right-sided hepatolithiasis constituted a major cause of failure. Recurrent stone formation and repeated cholangitis, subsequent drainage, and liver resection are associated with high mortality rates particularly if there is late development of a cholangiocarcinoma. We concluded that postoperative ductal dilatation and stenting through the T-tube track combined with endoscopic electrohydraulic lithotripsy is effective and safe for managing complicated hepatolithiasis. Persistent irreversible aneurysmal dilatation of IHD and atrophic change of the affected hepatic lobe at follow-up were ominous signs of recurrence and cholangiocarcinoma development. Early drainage with stone extraction combined with surgical intervention can prevent subsequent morbidity and mortality.

Development of DNA delivery system using Pseudomonas exotoxin A and a DNA binding region of human DNA topoisomerase I

Gene therapy is defined as the delivery of a functional gene for expression in somatic tissues with the intent to cure a disease. Thus, highly efficient gene transfer is essential for gene therapy. Receptor-mediated gene delivery can offer high efficiency in gene transfer, but several technical difficulties need to be solved. In this study, we first examined the DNA binding regions of the human DNA topoisomerase I (Topo I), using agarose gel mobility shift assay, in order to identify sites of noncovalent binding of human DNA Topo I to plasmid DNA. We identified four DNA binding regions in human DNA Topo I. They resided in aa 51-200, 271-375, 422-596, and 651-696 of the human DNA Topo I. We then used one of the four regions as a DNA binding protein fragment in the construction of a DNA delivery vehicle. Based on the known functional property of each Pseudomonas exotoxin A (PE) domain and human DNA Topo I, we fused the receptor binding and membrane translocation domains of PE with a highly positively charged DNA binding region of the N-terminal 198 amino acid residues of human DNA Topo I. The resulting recombinant protein was examined for DNA binding in vitro and transfer efficiency in cultured cells. The results show that this DNA delivery protein is a general DNA delivery vehicle without DNA sequence, topology, and cell-type specificity. The DNA delivery protein could be used to target genes of interest into cells for genetic and biochemical studies. Therefore, this technique can potentially be applied to cancer gene therapy.

Effects of the chitin synthesis inhibitor buprofezin on survival and development of immatures of Chrysoperla rufilabris (Neuroptera: Chrysopidae)

Effects of buprofezin (Applaud), a chitin synthesis inhibitor, on survival and development of eggs, three instars, and pupae of Chrysoperla rufilabris (Burmeister) were determined in the laboratory. Buprofezin at three tested concentrations (100, 500, and 1,000 mg [AI]/liter) did not affect the viability and development of eggs when the eggs were treated, or third instars and pupae when those stages were treated. Although the degree of effects by buprofezin on larvae varied with instar, buprofezin at the higher concentrations (500 and 1,000 mg [AI]/liter) reduced survival rates 17-47% and prolonged the overall development from first instars to adult emergence by 2 or 3 d when first instars were treated, indicating that the first instar is the most vulnerable stage. When second instars were treated, the survival of C. rufilabris from second instars to pupae was not significantly affected. However, the developmental time from second instar to adult emergence was longer in the treatments with the highest concentration (1,000 mg [AI]/liter) than that with the lowest concentration (100 mg [AI]/liter). The compatibility of buprofezin with natural enemies in integrated pest management programs is discussed.

The clinical presentation of uppermost cervical disc protrusion

OBJECT

The purpose of this study is to clarify the clinical presentation of the C2-C3 cervical herniation disc.

SUMMARY OF BACKGROUND DATA

Uppermost cervical disc protrusion is an uncommon condition. The pattern of large central fragments of nucleus impinging on the highest cervical disc region is often poorly localized according to its clinical presentation.

METHODS

Eight patients treated with anterior cervical discectomy with fusion for C2-C3 disc herniation participated in a detailed clinical and radiologic review to determine early detection and clarify potential hazards. Each patient's neurologic function was tested and recorded successively by a team of physicians and qualified physiotherapists.

RESULTS

Reviewing the symptomatology, most patients presented ascending radicular symptoms secondary to trivial trauma, characterized by suboccipital pain, loss of hand dexterity, and paresthesia over face and unilateral lateral arm. Six (75%) patients had remarkable improvement postoperatively in neurologic function, except for some residual sensory embarrassment in at least 6 months follow-up.

CONCLUSIONS

Clinical neurologic examination provides a less precise anatomic basis, to point to a particular upper cervical disc protrusion. Nonspecific neck and shoulder pain, a variety of cervical radiculopathy, and myelopathy may present. However, this rare spondylotic pattern is usually characterized by impairment of motor and sensory function more in the upper extremities than lower extremities and mostly starting following trauma. Radiculopathy generally outweighs the cord sign. Cruciate paralysis associated with vague diffuse and patch regions of hypesthesia over perioral distribution may help to localize this upper cervical lesion. The present study demonstrates that early detection and adequate anterior decompression may provide excellent outcome.

Correlation of homocytsteine levels with the extent of coronary atherosclerosis in patients with low cardiovascular risk profiles

Elevation of homocysteine is now known as an independent risk factor for vascular diseases. However, influences of homocysteine to the extent of coronary atherosclerosis in patients with different coronary risk profiles have not been studied. In this study, we used angiographic "diffuse score" and "clinical vessel score" to evaluate the extent of coronary atherosclerosis, and examined the correlation between levels of serum total homocysteine and angiographic scores among patients with high- and low-risk profiles. Seventy consecutive patients (58 men and 12 women, mean age 50 years) undergoing selective coronary angiography for the first time were recruited for this study. Patients were divided into high-risk (risk factor > or =3, n = 35) and low-risk (risk factor <3, n = 35) groups. Linear regression analysis revealed that levels of serum homocysteine were only significantly correlated with diffuse (r = 0.217, p = 0.007) and clinical vessel (r = 0.078, p = 0.037) scores in low-risk patients. These correlations could not be observed in diffuse (r = 0.070, p = 0.319) and clinical vessel (r = -0.001, p = 0.970) scores in the high-risk group. In conclusion, levels of homocysteine correlated with the extent of coronary atherosclerosis only among patients with low cardiovascular risk profiles.