Prediction of bleeding diathesis in patients undergoing cardiopulmonary bypass during cardiac surgery: viscoelastic measures versus routine coagulation test

BACKGROUND

Severe hemorrhagic tendency often complicates cardiopulmonary bypass (CPB) in cardiac surgery. In this study, we compared the effectiveness of thromboelastography (TEG), Sonoclot (SCT), and routine coagulation test (RCT) in the prediction of coagulation defects.

METHODS

Forty-three patients undergoing cardiac surgery with CPB were included. Blood for RCT, TEG, and SCT profiles was sampled before systemic heparinization and after protamine administration. Clinically significant bleeding was defined as chest tube drainage in excess of 100 ml/h for 3 consecutive hours or 300 ml/h in 1 h. All coagulation parameters obtained before and after CPB were compared. The sensitivity, specificity, accuracy, false positive, and false negative rate were also calculated and compared.

RESULTS

All coagulation tests were within normal range except higher partial thromboplastin time. Variables which were significantly different from those before CPB included platelet count, fibrinogen level, prothrombin time, and thrombin time in RCT, alpha angle and maximum amplitude in TEG, and R2 and peak time in SCT. In the TEG tracing, all variables had high sensitivity, specificity, and accuracy (average 85.4%, 83%, and 83.5% respectively) and low false positive and negative rate (12.5% and 5% respectively). Although SCT had high sensitivity (76.3%) and low false negative rate (6.5%), its specificity and accuracy were all under 50%.

CONCLUSIONS

Our data demonstrated that the TEG monitoring is a useful tool for detecting post-CPB bleeding diathesis and can provide much predictive information. RCT and SCT are of limited value because of higher rate of unreliable results.

Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison

OBJECTIVE

To investigate the occurrence of referred pain (ReP) elicited by palpation (Pal-ReP) or by needle injection (Inj-ReP) of myofascial trigger point (MTrP), and to assess the correlated factors, including the pain intensity of an active MTrP and the occurrence of local twitch response (LTR).

DESIGN

Correlational study.

PATIENTS

Ninety-five patients who were treated with MTrP injections.

INTERVENTION

MTrP injections.

MAIN OUTCOME MEASURE

Pain intensity of MTrP and occurrence of Pal-ReP, Inj-ReP, and LTR.

RESULTS

Both Pal-ReP and Inj-ReP were elicited in 53.9% of MTrPs, Inj-ReP, but not Pal-ReP, was elicited in 33.7% of MTrPs. Both Pal-ReP and Inj-ReP were unobtainable in 12.3% of MTrPs. The occurrence of ReP was significantly correlated to the pain intensity of active MTrP and the occurrence of LTR.

CONCLUSION

ReP could be elicited more frequently by needling than by palpation. The frequency of occurrence in ReP mainly depends on pain intensity of an active MTrP.

1-alpha-Hydroxyvitamin D3 treatment decreases bone turnover and modulates calcium-regulating hormones in early postmenopausal women

50 Japanese women within 10 years after menopause (mean age 52.5 years) were studied to determine the effects of 0.75 microgram of 1-alpha-hydroxyvitamin D3 [1-alpha-(OH)D3] with calcium (150 mg/day) (treated group: N = 25) and calcium only (control group: N = 25) for 12 months on bone mass and metabolism. Their L2-4 BMD measurements were 1.5 SD below the mean value of Japanese young, normal women. L2-4 BMDs increased significantly in the treated group (+2.1%; p < 0.01), but decreased significantly in controls (-2.1%; p < 0.01). Although serum calcium and creatinine remained unchanged in both groups, phosphorus levels increased significantly in the treated group (p < 0.01). Urinary calcium/creatinine (Cr) increased in both groups. Urinary pyridinoline/Cr and deoxypyridinoline/Cr decreased significantly in the treated group (p < 0.05), but not in the control group. Serum osteocalcin levels remained unchanged in both groups. Intact parathyroid hormone levels decreased significantly (p < 0.05) and calcitonin levels significantly increased in the treated group (p < 0.05), but these changes were not observed in the control group. These data clearly demonstrate that 0.75 microgram of 1-alpha-(OH)D3 maintained bone mass by reducing bone resorption by modulation of calcium-regulating hormones. Temporarily increased urinary calcium excretion was observed in control group, but did not appear to be effective in modulating bone turnover.

Optimal surgical strategy for potentially curable serosa-involved gastric carcinoma with intraperitoneal free cancer cells

BACKGROUND

Radical gastrectomy with systematic lymphadenectomy (RG) remains controversial in the treatment of gastric carcinoma. On the other hand, the prognosis of gastric carcinoma, in the presence of intraperitoneal free cancer cells, is poor. The optimal surgical strategy for serosa-involved gastric carcinoma with intraperitoneal free cancer cells remains undefined.

STUDY DESIGN

A prospective study of intraperitoneal cytologic washing was conducted on 134 patients with potentially curable serosa-involved gastric carcinoma who underwent RG. During the same period, 28 patients with resectable tumors who received palliative simple gastrectomies because of the presence of gross incurable conditions (eg, multiple hepatic metastases, peritoneal carcinomatosis, or extra-abdominal metastasis) were used as controls.

RESULTS

Intraperitoneal free cancer cells were found in 26 patients (19.4 percent). Compared with the remaining 108 patients without free cancer cells, there were no significant differences in the clinicopathologic characteristics and pathologic stages. No patients died after palliative resection, but five patients died after RG. The patients with free intraperitoneal free cancer cells had a poorer long-term prognosis after RG than those without free cancer cells (p < 0.0001). The prognosis for such patients was similar to the prognosis of those who underwent palliative resection.

CONCLUSIONS

A peritoneal washing cytologic examination is mandatory before resection for potentially curable serosa-involved gastric carcinoma. When free cancer cells appear in the washing fluid, the cancer is incurable. Simply gastrectomy without additional lymphadenectomy is the optimal strategy for treatment.

Effect of 1 alpha-hydroxyvitamin D3 on loss of bone mineral density immediately after artificial menopause

To evaluate the effects of 1 alpha-hydroxyvitamin D3 (1 alpha(OH)D3), a series of clinical trials, preventive and therapeutic, were performed in an open label manner in women immediately after oophorectomy. The series included a total of 121 oophorectomized subjects, whose lumbar bone mineral density (L2-4BMD) was followed by the use of dual energy X-ray absorptiometry. (1) Preventive trial: 61 women who had undergone premenopausal bilateral oophorectomy, were divided into 3 groups (Group C: control; Group L: 0.25 micrograms 1 alpha (OH)D3/day; Group H: 0.50-0.75 micrograms 1 alpha (OH)D3/day). The changes in BMD and chemical indices were followed up for one year. (2) Therapeutic trial: the trial included 60 premenopausally oophorectomized subjects having L2-4BMD lower than the normal control level minus 1SD which has been reported in age-matched normal Japanese women. These subjects were divided into 3 groups and treated in the same way as in the preventive trial. In the preventive trial, L2-4BMD decreased by 8.2%, 6.5% and 4.5% in groups C, L and H, respectively, at 12 months of treatment, whereas in the therapeutic trial, L2-4BMD decreased by 3.6%, 3.2% and 0.8% in the groups C, L and H, respectively, at 12 months of treatment. In conclusion, 1 alpha(OH)D3 was found to be effective both to prevent the bone loss subsequent to bilateral oophorectomy and improve low bone mass after oophorectomy.

Mutational analysis of BRCA1 gene in ovarian and breast-ovarian cancer families in Japan

We analyzed the alteration of BRCA1 in DNA obtained from 83 individuals of 13 Japanese site-specific ovarian cancer families and 6 breast-ovarian cancer families. Six germline mutations were detected in 7 families, which consisted of 4 breast-ovarian cancer and 3 site-specific ovarian cancer families, by single-strand conformation polymorphism analysis, followed by direct sequence determination. The mutations included three frameshifts, two nonsense mutations, and one missense mutation causing loss of a zinc-binding motif. The frequency of loss of heterozygosity at the microsatellite markers on the BRCA1 gene was 57% (8 of 14 cases) in site-specific ovarian cancer families, and 100% (6 of 6 cases) in breast-ovarian cancer families. All tumors of the patients carrying a mutation of BRCA1 showed deletion of wild-type alleles, implicating BRCA1 as a tumor suppressor gene. These results suggest that germline mutations of the BRCA1 gene play an important role in the carcinogenesis of breast and/or ovarian cancer in a majority of breast-ovarian cancer families and in some site-specific ovarian cancer families.

Can we monitor socioeconomic inequalities in health? A survey of U.S. health departments' data collection and reporting practices

OBJECTIVE

To evaluate the potential for and obstacles to routine monitoring of socioeconomic inequalities in health using U.S. vital statistics and disease registry data, the authors surveyed current data collection and reporting practices for specific socioeconomic variables.

METHODS

In 1996 the authors mailed a self-administered survey to all of the 55 health department vital statistics offices reporting data to the National Center for Health Statistics (NCHS) to determine what kinds of socioeconomic data they collected on birth and death certificates and in cancer, AIDS, and tuberculosis (TB) registries and what kinds of socioeconomic data were routinely reported in health department publications.

RESULTS

Health departments routinely obtained data on occupation on death certificates and in most cancer registries. They collected data on educational level for both birth and death certificates. None of the databases collected information on income, and few obtained data on employment status, health insurance carrier, or receipt of public assistance. When socioeconomic data were collected, they were usually not included in published reports (except for mothers educational level in birth certificate data). Obstacles cited to collecting and reporting socioeconomic data included lack of resources and concerns about the confidentiality and accuracy of data. All databases, however, included residential addresses, suggesting records could be geocoded and linked to Census-based socioeconomic data.

CONCLUSIONS

U.S. state and Federal vital statistics and disease registries should routinely collect and publish socioeconomic data to improve efforts to monitor trends in and reduce social inequalities in health.

Serum N-terminal osteocalcin is a good indicator for estimating responders to hormone replacement therapy in postmenopausal women

To estimate the response to hormone replacement therapy (HRT) by bone metabolic markers, 36 patients with postmenopausal osteoporosis or osteopenia were studied to assess the correlation between percent baseline changes in lumbar bone mineral density (BMD) after 12 months and those in various bone metabolic markers after 3, 6, and 12 months of HRT. All the patients were treated with 0.625 mg of conjugated estrogen and 2.5 mg of medroxyprogesterone per day and continued for 12 months. BMD was significantly increased up to 4.19 +/- 0.87% after 6 months and 4.93 +/- 1.27% after 12 months of HRT (p = 0.0001 by analysis of variance). In accordance with this, changes in the levels of osteocalcin (p = 0.041), alkaline phosphatase (p = 0.0001), N-terminal osteocalcin (p = 0.0001), urinary excretion of pyridinoline/Cr (p = 0.0001), and deoxypyridinoline/Cr (p = 0.0001) were significantly decreased, respectively. Among these bone metabolic markers, only the change in the serum N-terminal osteocalcin at 3 months (r = 0.557, p = 0.0022), at 6 months (r = 0.470, p = 0.0184), and at 12 months (r = 0.545, p = 0.0061) significantly correlated with the change in BMD 12 months after HRT. The elution profiles of immunoreactive osteocalcin-related molecules in serum fractionated by reverse-phase high performance liquid chromatography revealed that the N-terminal fragment as well as the intact osteocalcin molecule decreased after 3 months of HRT. These results demonstrate that N-terminal osteocalcin is a suitable predictor for estimating good responders to HRT in postmenopausal women.

Inhibitors of the polymerase chain reaction in Papanicolaou stain. Removal with a simple destaining procedure

OBJECTIVE

To identify inhibitors of the polymerase chain reaction (PCR) within Papanicolaou stain and to develop a method of removal.

STUDY DESIGN

PCR was performed on cellular digests of archival, Papanicolaou-stained cervical smears and unstained cervical smears using primers to the human beta-globin gene to determine if Papanicolaou stain inhibited the reaction. Next, in order to identify the specific reagents responsible for inhibition, components of the Papanicolaou stain were added to PCRs performed on purified human genomic DNA. Finally, PCR was performed on cellular digests of cervical smears that had been destained using 1% HCl to determine if the inhibitors of PCR were removed.

RESULTS

Cellular digests from Papanicolaou-stained cervical smears did not yield products from PCR, whereas cellular digests from unstained cervical smears always yielded PCR products. Analysis of individual Papanicolaou stain reagents revealed inhibition of PCR by hematoxylin and aluminum sulfate. These inhibitors could be removed from Papanicolaou-stained cervical smears by destaining the slides with 1% HCl.

CONCLUSION

The hematoxylin and aluminum sulfate within Papanicolaou stain inhibit PCR but can be removed from Papanicolaou-stained cytologic specimens using a simple destaining procedure.

Self-Assembled Smectic Phases in Rod-Coil Block Copolymers

Rod-coil block copolymers are self-assembling polymers that combine the physics of orientational ordering of rodlike polymers and the microphase separation of coil-coil block copolymers. Several new solid-state morphologies were observed in a series of anionically synthesized model poly(hexyl isocyanate-b-styrene) rod-coil diblock copolymers examined by transmission electron microscopy and selected-area electron diffraction. The rod-coils formed smectic C-like and O-like morphologies with domain sizes ranging from tens of nanometers to almost 1 micrometer. Both structural and orientational changes were found for increasing rod volume fractions. In addition, some morphologies exhibited spontaneous long-range orientational order over many tens of micrometers.

Amino acid polymorphism and rare electrophoretic variants of G6PD from natural populations of Drosophila melanogaster

Identifying the amino acid changes responsible for electrophoretic variants is essential to understanding the significance of allozyme polymorphism in adaptation. The amino acid mutations responsible for the common G6PD allozyme polymorphisms in Drosophila melanogaster have been recently described. This study characterizes the amino acid changes associated with 11 rare electrophoretic G6PD variants. The 11 rare electrophoretic variants result from six independent amino acid mutations. The in vivo function of the rare variants was determined in an earlier study and most variants fell into one of two function classes. It is shown here that the function of the rare variants reflects the state of the Pro/Leu mutation responsible for the A/B allozyme polymorphism in each variant. Two mutations destabilize quaternary structure resulting in shifts from tetrameric dimeric alleles, and one of these also results in a variant with in vivo function intermediate to A and B. That mutation is an aspartic-acid-to-asparagine change that is two residues away from the Pro/Leu polymorphism responsible for the A/B dimertetramer quaternary shift. Structure-function relationships based on studies of human G6PD deficiency-associated mutations predict that these last two amino acid changes fall within the protein domain responsible for NADP binding.

Overexpression of p53 is not a feature of ovarian granulosa cell tumors

The p53 tumor suppressor gene has been extensively studied in various human tumors including epithelial ovarian cancers. However, little is known about the expression of this gene in ovarian granulosa cell tumors, the most common histologic type of sex cord-stromal tumors. We investigated whether overexpression of the p53 gene product occurs in this specific ovarian tumor. Nineteen patients with ovarian granulosa cell tumors were recruited in this study. Immunohistochemical staining for the p53 protein with monoclonal antibody PAb 1801 was performed in the paraffin-embedded tissue of each case to screen for p53 overexpression. Among the 19 ovarian granulosa cell tumors, there was only one well-differentiated tumor found to have nuclear immunoreactivity in a small fraction of tumor cells. Polymerase chain reaction--single-stranded conformation polymorphism was used to study the tumor showing focal p53 positivity, but no mobility shift was noted from exon 4 through exon 9 of the p53 gene. On the basis of this observation, we propose that alteration of the p53 tumor suppressor gene is not a common finding in ovarian granulosa cell tumors.

Complete structures of three rice sucrose synthase isogenes and differential regulation of their expressions

By cloning and sequencing cDNA and genomic DNA and transcription initiation site mapping, the total structures including at least 1 kb of putative regulatory sequences upstream of the transcription initiation sites of three genes encoding rice sucrose synthase isoprotomers were either newly established or amended. The third type of SS gene, RSus3, has not been found in other plants. The structures of the three genes and the gene products were compared and their evolutionary sequence was proposed. Specific probes for the three SS mRNA's were developed and used for analyzing their steady state levels at different organs and under some physiological stress conditions. It appears that RSus2 is a house-keeping gene, RSus3 is highly specific to the grain, and the expression of RSus1 shows a tendency to complement that of RSus3. A possible cause of the presence of the third rice SS gene was discussed. We also reported a novel method to synthesize single-stranded DNA for S1 mapping of a transcription initiation site associated with extended secondary structures.

Oesophageal squamous cell carcinoma after gastrectomy for benign ulcer disease

Of 684 patients treated for squamous cell carcinoma of the oesophagus in 1982-1993, 19 (2.8%) had previously undergone partial gastrectomy for benign ulcer disease. The average interval between gastrectomy and diagnosis of oesophageal carcinoma was 14 years. In six of the 19 (31.6%) cases the carcinoma was in the lower thoracic oesophagus, an incidence not significantly higher than the 25% in the total series. The oesophageal resectability rates were 52.6% in the gastrectomized patients and 44.4% in the total series (intergroup difference not significant). Of the ten gastrectomized patients who underwent oesophageal resection, only one had oesophagitis at the oesophagogastric junction, without significant histologic characteristics. The relationship between oesophageal squamous cell carcinoma and previous gastrectomy for benign ulcer disease may be incidental.

Use of recombinant Epstein-Barr virus early antigen for detection of antibody in patients with nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is one of the most common cancers in southern China and Taiwan. Serological studies revealed the close-relationship between NPC and Epstein-Barr virus (EBV). Elevated serum and saliva levels of anti-EBV antibodies are detected in patients with NPC. Therefore, Development Center for Biotechnology prepared the EBV-early antigen (EA-D) by recombinant DNA technique for screening the serum and throat washing samples from patients with head and neck cancers.

METHODS

The BMRF1 gene for EBV early antigen (EA-D) was placed into the plasmid pDB18, then transformed into an Escherichia coli strain containing the lambda cI857 temperature-sensitive repressor. Heat treatment of the transformant, at exponential growth phase, inactivated the cI protein and induced an over-expression of the EA-D protein. Next, the EA-D was purified by chromatography and characterized as a protein of molecular weight 47 kDa, by sodium dodecyl sulfate-polyacry lamide gel electrophoresis (SDS-PAGE) and Western blot analysis using monoclonal anti-EA antibody and sera from patients with nasopharyngeal carcinoma (NPC). Enzyme-linked immunosorbent assay (ELISA) with the purified EA-D antigen was used to screen 129 serum and throat washing (TW) samples from patients with head and neck tumors, 24 from patients with a nonmalignant disease and 44 from normal donors.

RESULTS

Experimental results indicated significantly higher positive rates of EA-D IgA (69%) and EA-D IgG (91%) in NPC sera than in the sera of patients with other head and neck tumors and normal controls. TW samples from patients with NPC also showed a higher positive rate (34%) than the other groups (7-20%).

CONCLUSIONS

Results in this study demonstrate that the bacterially expressed EA-D antigen could be recognized by sera from patients with NPC and monoclonal anti-EA antibody. Thus, it has potential use in ELISA for screening EBV-related diseases such as NPC.

Rapid diagnosis of beta-thalassaemia by mutagenically separated polymerase chain reaction (MS-PCR) and its application to prenatal diagnosis

We have developed a rapid and simple PCR-based method which is modified from the mutagenically separated polymerase chain reaction (MS-PCR) to detect the molecular defects of beta-thalassaemia. We can use this technique to amplify normal and mutant alleles of the beta-globin gene in the same reaction tube, using different-sized allele-specific primers. This mutagenesis separates the amplification reactions of alleles performed in the same tube. Subsequent gel electrophoresis shows at least one of the two allelic products at the same locus or at least two of the several allelic products at different loci. Therefore, in addition to simple handling, MS-PCR provides a within-assay quality control for the exclusion of false negative results. The five most common mutations of beta-thalassaemia and haemoglobin E which occur in the Taiwanese population were tested, and 14 prenatal samples were checked with accurate results. This method is simple, rapid and accurate, and can be used routinely in prenatal diagnosis. The principle used here can also be applied to other genetic diseases.

Intradural metastasis to the cauda equina from carcinoma of the anus

STUDY DESIGN

This is a report of a man with carcinoma of the anus and intradural metastasis to the cauda equina.

OBJECTIVE

To perform a laminectomy with tumor removal for relief of pain.

SUMMARY OF BACKGROUND DATA

Only 25 cases of intradural spinal metastasis have been reported in the English literature. This is the first report of a metastatic case, moving from the carcinoma of the anus to the cauda equina.

METHODS

Magnetic resonance imaging showed an ill-defined mass, with central necrosis, to the cauda equina. The possibility of intradural metastasis to the cauda equina was indicated by unique pain symptoms.

RESULTS

The patient's back pain subsided after total laminectomy of L3-L5 with subtotal removal of the tumor. The residual tumor became smaller with postoperative radiation.

CONCLUSION

Magnetic resonance imaging is a good diagnostic choice in this situation. The cause of the metastasis was unclear, but it was presumed to have occurred through the perineural lymphatic ducts. Laminectomy with tumor removal is feasible for relieving pain and demonstrating pathology.

Basal tail skin temperature elevation and augmented response to calcitonin gene-related peptide in ovariectomized rats

Hyper-release of calcitonin gene-related peptide (CGRP) plays a direct and pivotal role in the induction of menopausal hot flushes (HFs), in which a drastic increase in skin temperature occurs. However, it is not possible to investigate whether CGRP induces skin temperature increase and whether skin temperature response to CGRP changes and contributes to the occurrence of HFs in postmenopausal women who are in oestrogen deficiency. By using rats' tail skin temperature (TST), a good marker to evaluate skin temperature regulation, we examined the effects of CGRP and calcitonin (3, 10 and 30 micrograms/kg, i.v.) on TST in female rats and further investigated the TST change induced by CGRP (10 micrograms/kg, i.v.) in ovariectomized (OVX) rats compared with that in sham-operated (Sham) rats. We found that CGRP, but not calcitonin, induced a TST increase in a dose-dependent manner and that the TST change induced by CGRP (0.6 +/- 0.2 degrees C for OVX rats vs 0.3 +/- 0.1 degree C for Sham rats, P < 0.05) and also the basal TST (26.0 +/- 0.2 degrees C for OVX rats vs 25.5 +/- 0.1 degree C for Sham rats) were significantly greater in OVX rats (P < 0.05). Furthermore, treatment with oestradiol (30 micrograms/kg, s.c.) for 8 days partially inhibited the augmented TST response to CGRP in OVX rats and almost completely inhibited (P < 0.05) the basal TST elevation, with the concomitant recovery of the serum oestradiol level to that in Sham rats. These results suggest that the augmented skin temperature response to CGRP and the elevation of basal skin temperature that are found in OVX rats, animals which are oestradiol deficient, may also occur in menopausal women and contribute to their HFs.

Rapid detection of hemoglobin variants by mutagenically separated polymerase chain reaction (MS-PCR)

The detection of molecular defects of hemoglobin variants using mutagenically separated polymerase chain reaction (MS-PCR) was applied in this study. Using different lengths of allele-specific mutagenic primers, normal and mutant alleles of hemoglobin genes were amplified in the same reaction tube. Subsequent gel electrophoresis showed at least one of the two allelic products at the same loci or at least two of the several allelic products at different loci. We employed MS-PCR to test the following hemoglobin variants: Hb Constant Spring (Hb CS), Hb E, Hb G-Taichung, Hb J-Meinung, and Hb Kaohsiung. The results were the same as those obtained by amplified created reaction sites (ACRS) or direct sequencing. We conclude that the MS-PCR provides a rapid and simple alternative to other techniques for mutation detection in hemoglobin variants. Moreover, the principle can be extended to other genetic diseases.