Supraclavicular lymph node metastases in cervical cancer

PURPOSE OF INVESTIGATION

To evaluate the outcome and prognostic factors of patients with supraclavicular lymph node (SCLN) involvement at primary diagnosis.

METHODS

We reviewed the medical records of cervical cancer patients primarily treated at Chang Gung Memorial Hospital between 1987 and 2005. Thirty-three patients with histologically confirmed SCLN metastasis at primary diagnosis were eligible for analysis. Clinical and pathological features were analyzed for association with outcome.

RESULTS

The 3- and 5-year survival rates of patients with SCLN metastasis were 16.5% and 16.5%, respectively. Multivariate analysis showed the serum level of squamous cell carcinoma antigen (SCC-Ag) < 15 ng/ml at initial diagnosis (p = 0.021) and staging/restaging including [18F] fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) (p = 0.006) to be associated with a better prognosis.

CONCLUSION

Primary SCLN metastasis in cervical cancer is not incurable. The benefit from PET findings might help in selecting appropriate patients for curative primary and/or salvage treatment.

Pain relief by applying transcutaneous electrical nerve stimulation (TENS) on acupuncture points during the first stage of labor: a randomized double-blind placebo-controlled trial

Transcutaneous electrical nerve stimulation (TENS) is one of the non-pharmacological means of pain relief for labor and delivery. We aimed to investigate the efficacy and safety of TENS on specific acupuncture points for reducing pain in the first stage of labor. In this double-blind, placebo-controlled trial, we randomly assigned healthy full-term parturients in active phase of first-stage labor to either TENS on four acupuncture points (Hegu [Li 4] and Sanyinjiao [Sp 6]) (n=52) or the TENS placebo (n=53). Visual analogue scale (VAS) was used to assess pain before and 30 and 60 min after treatment. The primary outcome was the rate of VAS score decrease 3 in each group. A questionnaire was given at 24h post-partum to evaluate the satisfaction of pain relieving method and the willingness to have the same treatment again. Mode of delivery and neonatal effect were measured as secondary outcome. One hundred women were eligible for analysis. TENS group experienced VAS score reduction 3 significantly more common than the TENS placebo group (31/50 [62%] vs 7/50 [14%], P<0.001). Willingness of using the same analgesic method for a future childbirth was also significantly different (TENS: 48/50 [96%] vs TENS placebo: 33/50 [66%], P<0.001). Operative delivery was increased in the TENS group (12/50 [24%] vs 4/50 [8%], P=0.05), but the neonatal outcomes were not different. The application of TENS on specific acupuncture points could be a non-invasive adjunct for pain relief in the first stage of labor.

Abundance-Based Similarity Indices and Their Estimation When There Are Unseen Species in Samples

A wide variety of similarity indices for comparing two assemblages based on species incidence (i.e., presence/absence) data have been proposed in the literature. These indices are generally based on three simple incidence counts: the number of species shared by two assemblages and the number of species unique to each of them. We provide a new probabilistic derivation for any incidence-based index that is symmetric (i.e., the index is not affected by the identity ordering of the two assemblages) and homogeneous (i.e., the index is unchanged if all counts are multiplied by a constant). The probabilistic approach is further extended to formulate abundance-based indices. Thus any symmetric and homogeneous incidence index can be easily modified to an abundance-type version. Applying the Laplace approximation formulas, we propose estimators that adjust for the effect of unseen shared species on our abundance-based indices. Simulation results show that the adjusted estimators significantly reduce the biases of the corresponding unadjusted ones when a substantial fraction of species is missing from samples. Data on successional vegetation in six tropical forests are used for illustration. Advantages and disadvantages of some commonly applied indices are briefly discussed.

Analgesic Use in Intubated Patients during Acute Resuscitation

BACKGROUND

Pain relief can often be overlooked during a busy trauma resuscitation, especially in patients who are intubated. We sought to investigate qualitative and quantitative aspects of analgesic use in intubated patients during the acute phase of resuscitation.

METHODS

We evaluated a retrospective cohort of consecutive adult patients who were intubated during the acute trauma resuscitation (first 6 hours) from January 2001 to May 2002 at a Level I trauma center in the United States. Patient demographics, injuries, vital signs, medications, trauma bay procedures, and disposition status were analyzed. Analgesia was recorded as the type of analgesic, route of administration, elapsed time to receive the first analgesic, total dosage, and time intervals between two successive doses. Fisher's exact test, chi test, and ANOVA were used to analyze data.

RESULTS

A total of 120 patients were included. Sixty-one (51%) patients received analgesia during their stay in the emergency department. Using logistic regression analysis, patients who more likely to receive analgesia were those who did not require immediate surgical operation and were transferred to the intensive care unit (odds ratio [OR]=3.91; 95% CI=1.75-8.76) and those who were admitted during the hours of 8 am to 6 pm (OR=3.17; CI=1.40-7.16). Among those patients receiving analgesia, 30 (25%) patients received analgesia within 30 minutes upon arrival. The mean time of receiving the first analgesia dose was 57 minutes. The average morphine equivalent dose given to the patients was 15.7 mg. The most frequently given single dose was 100 mug of intravenous fentanyl. Most of the analgesics (37%) were given between 30 to 60 minutes apart.

CONCLUSION

Our findings suggest that patients who are intubated during the acute resuscitation probably receive inadequate analgesia. The inadequacy appears to be in the timing and repetition of administration, rather than the dose. Patients who were transferred early to the intensive care unit were more likely to receive analgesics.

Modeling Animals' Behavioral Response by Markov Chain Models for Capture-Recapture Experiments

A bivariate Markov chain approach that includes both enduring (long-term) and ephemeral (short-term) behavioral effects in models for capture-recapture experiments is proposed. The capture history of each animal is modeled as a Markov chain with a bivariate state space with states determined by the capture status (capture/noncapture) and marking status (marked/unmarked). In this framework, a conditional-likelihood method is used to estimate the population size and the transition probabilities. The classical behavioral model that assumes only an enduring behavioral effect is included as a special case of the bivariate Markovian model. Another special case that assumes only an ephemeral behavioral effect reduces to a univariate Markov chain based on capture/noncapture status. The model with the ephemeral behavioral effect is extended to incorporate time effects; in this model, in contrast to extensions of the classical behavioral model, all parameters are identifiable. A data set is analyzed to illustrate the use of the Markovian models in interpreting animals' behavioral response. Simulation results are reported to examine the performance of the estimators.

Acute cardiovascular collapse after pericardial drainage in a patient with aortic dissection

Proximal aortic dissection is frequently associated with cardiac tamponade. The treatment sometimes is difficult. We present a 69-year-old female patient who after repeated episodes of syncope received an open drainage of pericardial effusion that ended in a fatal outcome. She was also known to have mural thrombi in the aorta. However, preanesthetic trransesophageal echocardiography revealed besides pericardial effusion, also dilatation of aortic root which compressed both atria. She developed sudden cardiovascular collapse following drainage of pericardial effusion to which she succumbed in spite of vigorous resuscitation. We suggest that the patients with cardiac tamponade complicated by aortic dissection must receive direct aortic repair together with intraoperative pericardial drainage. Selective or single pericardiocentesis should better be avoided.

A comparison study of realtime fatality rates: severe acute respiratory syndrome in Hong Kong, Singapore, Taiwan, Toronto and Beijing, China

  In an outbreak of a completely new infectious disease like severe acute respiratory syndrome (SARS), estimation of the fatality rate over the course of the epidemic is of clinical and epidemiological importance. In contrast with the constant case fatality rate, a new measure, termed the 'realtime' fatality rate, is proposed for monitoring the new emerging epidemic at a population level. A competing risk model implemented via a counting process is used to estimate the realtime fatality rate in an epidemic of SARS. It can capture and reflect the time-varying nature of the fatality rate over the course of the outbreak in a timely and accurate manner. More importantly, it can provide information on the efficacy of a certain treatment and management policy for the disease. The method has been applied to the SARS data from the regions affected, namely Hong Kong, Singapore, Toronto, Taiwan and Beijing. The magnitudes and patterns of the estimated fatalities are virtually the same except in Beijing, which has a lower rate. It is speculated that the effect is linked to the different treatment protocols that were used. The standard estimate of the case fatality rate that was used by the World Health Organization has been shown to be unable to provide useful information to monitor the time-varying fatalities that are caused by the epidemic.

Abdominal Compartment Syndrome Secondary to Ovarian Mucinous Cystadenoma

BACKGROUND

Abdominal compartment syndrome secondary to a very large benign ovarian tumor has been rarely reported in gynecology. With the increase of intraabdominal pressure in abdominal compartment syndrome, all major organ systems are adversely affected, causing a potentially fatal condition.

CASE

A 43-year-old woman presenting with a tensely distended abdomen developed hypotension, difficulty in ventilation, and anuria. An ovarian tumor complicated by abdominal compartment syndrome was diagnosed, along with hemodynamic decompensation. Prompt resuscitation with immediate surgical removal of the tumor reversed the life-threatening situation.

CONCLUSION

Timely aggressive resuscitation, prompt surgical decompression, and intensive perioperative hemodynamic management are required for patients with ovarian mucinous cystadenoma complicated by abdominal compartment syndrome.

EST analysis of mouse retina and RPE/choroid cDNA libraries

PURPOSE

cDNA libraries from the mouse retina have recently been reported, but no well characterized library from the retinal pigment epithelium (RPE) or choroid of the mouse has yet appeared in the literature. To complement these libraries and to provide the first mouse RPE/choroid library, we used freshly dissected tissue from adult C57BL/6J mice to construct new retina and RPE/choroid libraries.

METHODS

Eyes from 100 six to eight week old C57BL/6J mice were dissected in groups of 10. The whole retina and RPE/choroid were isolated individually and then homogenized before RNA isolation. Over 5000 clones each were sequenced from the unamplified and un-normalized retina and RPE/choroid libraries. All sequences were analyzed using GRIST (GRouping and Identification of Sequence Tags), a bioinformatics program for gene identification and clustering.

RESULTS

The RPE/choroid library contained 3145 clusters with 76% of the clusters representing single clones. Nearly 87% of the clusters corresponded to named genes in GenBank, and 8% of the RPE clusters remain unidentified. The retina library contained 3190 clusters of which 78% represented only one clone. Approximately 85% of the clusters matched sequences in GenBank, and 9% of the clusters remain unidentified. The clones most abundant in each library were all well-known sequences and both libraries contained a number of tissue specific or tissue-enhanced genes.

CONCLUSIONS

These new libraries should provide a valuable resource for gene discovery and cDNAs for expression analysis and functional studies.

Hepatic encephalopathy and cerebral blood flow improved by liver dialysis treatment

Eight acute liver failure patients, all in grade IV hepatic encephalopathy, were administered liver dialysis treatment with the Hemo Therapies Unit (Hemo Therapies Inc, San Diego, CA, USA). The patients were evaluated to determine whether the Glasgow Coma Scale score and cerebral blood flow improved with treatment. After the initial treatment, consciousness levels as measured by the Glasgow Coma Scale improved from a pre-treatment median of 5 (range 3 to 6) to a post-treatment median of 7 (range 5 to 9) (p=0.0005 by paired Wilcoxon test); mean blood flow velocity in the middle cerebral arteries as shown by transcranial Doppler sonography increased from a median of 37.85 cm/sec (range 20.3 to 114.0) to 57.90 (32.5 to 135.0) post-treatment (p=0.022); however, there was no significant change in the pulsatility index from a median of 1.18 (range 0.61 to 1.71) to 0.85 (range 0.70 to approximately 1.79) post-treatment (p=0.13). The 8 patients received 2 to 7 (median 5.5) times of daily 6-h liver dialysis treatments. Following the completion of all liver dialysis treatments, hepatic coma was fully resolved in 4 of 8 patients (50%) Three of 8 patients (37.5%) survived to hospital discharge, whereas 5 patients did not survive due to irreversible liver function and associated complications. In conclusion, liver dialysis treatment could improve hepatic encephalopathy, but the prognosis still depended on the underlying diseases.

Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation

OBJECTIVES

We conducted this study to determine the result of prolonged cardiopulmonary resuscitation (CPR) with extracorporeal membrane oxygenation (ECMO) and the predictive factors for hospital discharge and ECMO weaning.

BACKGROUND

Prolonged CPR carries considerable associated mortality and morbidity. As yet, ECMO for prolonged CPR has no definite results. Only small groups of patients and no detailed analysis have been reported.

METHODS

Candidates for ECMO resuscitation were patients in cardiac arrest receiving CPR >10 min without return of spontaneous circulation and no absolute contraindication. Venoarterial ECMO was set up during CPR. We reviewed the data of 57 prolonged CPR patients who received ECMO during CPR over a six-year period.

RESULTS

The mean duration of CPR was 47.6 +/- 13.4 min and that of ECMO was 96.1 +/- 87.9 h. The rate of weaning was 66.7%, and the survival rate was 31.6%. Multiple-organ failure was the major reason for mortality, despite successful weaning. Among survivors, long-term follow-up revealed 88.9% survival, and only 5.6% had a severe neurologic deficit. The results indicate that a shorter CPR duration, postcardiotomy arrest, myocardial indicators, a hepatic indicator, and lactic acid are significantly correlated with both weaning and survival, whereas late damage (level on the third or seventh day of reperfusion) rather than initial damage (level on the first day) was more predictive of the results.

CONCLUSIONS

Prolonged CPR rescue by ECMO provides an acceptable survival rate and outcome in survivors. Our results of the selected cases encourage further investigations of the wider application of ECMO in CPR.

Estimating the number of species in a stochastic abundance model

Consider a stochastic abundance model in which the species arrive in the sample according to independent Poisson processes, where the abundance parameters of the processes follow a gamma distribution. We propose a new estimator of the number of species for this model. The estimator takes the form of the number of duplicated species (i.e., species represented by two or more individuals) divided by an estimated duplication fraction. The duplication fraction is estimated from all frequencies including singleton information. The new estimator is closely related to the sample coverage estimator presented by Chao and Lee (1992, Journal of the American Statistical Association 87, 210-217). We illustrate the procedure using the Malayan butterfly data discussed by Fisher, Corbet, and Williams (1943, Journal of Animal Ecology 12, 42-58) and a 1989 Christmas Bird Count dataset collected in Florida, U.S.A. Simulation studies show that this estimator compares well with maximum likelihood estimators (i.e., empirical Bayes estimators from the Bayesian viewpoint) for which an iterative numerical procedure is needed and may be infeasible.

Does nifedipine prevent the tachysystole associated with misoprostol induction?

OBJECTIVE

To determine the efficacy of oral nifedipine as prophylaxis against uterine tachysystole associated with misoprostol induction of labor.

METHODS

A total of 116 patients undergoing induction with term, singleton pregnancies were enrolled. All patients received 50 microg misoprostol intravaginally every 4 h. Patients were randomly assigned also to receive nifedipine 10 mg orally every 4 h, or no prophylaxis. The primary outcome variable was the incidence of 12 or more contractions in any 20-min interval.

RESULTS

Data on 106 patients were available for analysis. There were 55 subjects in the misoprostol-nifedipine group and 51 controls. Nifedipine did not diminish the incidence of tachysystole when added to misoprostol (42% vs. 45% without nifedipine; p = 0.7).

CONCLUSION

Prophylactic oral nifedipine was not shown to decrease the uterine tachysystole associated with vaginal misoprostol induction at a 50-microg dose.

Negligible changes in piglet serum clinical indicators or organ weights due to dietary single-cell long-chain polyunsaturated oils

Single-cell oils are currently included in human infant formula as sources of the long-chain polyunsaturates (LCP) docosahexaenoic acid (DHA) and arachidonic acid (AA) in many countries, but have not yet been approved for use in the USA. We prepared four bovine-milk-based formulas with AA/DHA=0, 34/17, 68/34 and 170/85 (mg per 100 kcal formula) provided by two commercial single-cell oils. These levels correspond approximately to 0, 1, 2 and 5 times the concentrations used in infant formulas and, due to greater consumption of formula per unit body weight, resulted in daily consumption of approximately 0, 3, 6 and 16 times those anticipated for human infants. All other dietary fat (47% of calories) was provided by a vegetable oil blend used in commercial human infant formulas. Domestic piglets were allowed to nurse with the sow for 24 h after parturition, then removed to individual cages and maintained on one of the four diets. At 30 days of age the piglets were sacrificed, and serum collected and organs weighed. With litters treated as a blocked variable, no significant differences among groups were found by analysis of variance for the following serum assays: alkaline phosphatase, alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN), creatinine, albumin, glucose, cholesterol, triglycerides, and total protein. No significant differences were found for hematocrit or body weight. No significant differences were found among groups for weights of liver, brain, heart, lung, spleen, kidneys or lung, analyzed as absolute weight and as a fraction of body weight. Hematoxylin/eosin liver sections examined by light microscopy showed no abnormalities as evaluated by an independent pathologist. DHA content in liver and heart and AA content in heart showed significant dose-related accumulation (P<0.05) and confirmed enhanced tissue accretion of DHA and AA from both oils. We conclude that single-cell oils in formula consumed for 1 month in amounts up to 16-fold greater than proposed for human infants in the USA did not result in clinical chemistry or histopathologic indications of toxic effects in neonatal pigs.

A comparative thrombogenicity study of heparin soaked fluoro-passivated polyester and ePTFE patches in sheep

OBJECTIVES

to compare heparin soaked fluoro-passivated gelatine sealed polyester and expanded polytetrafluoroethylene (ePTFE) patches in a sheep model of acute platelet accumulation following patch angioplasty.

MATERIALS AND METHODS

heparin soaked patches were placed in the carotid arteries of 9 sheep and autologous (111)Indium labelled platelets were infused. The patches were explanted two hours after the injection of labelled platelets. Median specimen radioactivity was calculated as a ratio of radioactivity in explanted and in 4 ml of blood. Explanted patches were also investigated by scanning electron microscopy (SEM).

RESULTS

platelet accumulation was significantly greater on ePTFE patches. For both materials platelet accumulation was greater at the distal end compared to the proximal (p<0.05). SEM demonstrated more platelets as well as thicker thrombus layer on ePTFE-patches.

CONCLUSION

in sheep carotid arteries, a fluoropassivated gelatine sealed polyester patch appears to result in less platelet accumulation when compared to ePTFE.