Insulin Pump Use in Children with Type 1 Diabetes: Over a Decade of Disparities

PURPOSE

Racial disparities have been shown in outcomes and treatment of children with type 1 diabetes (T1D). The purpose of this study was to examine temporal trends in insulin pump use among non-Hispanic white (NHW), non-Hispanic black (NHB) and Hispanic children attending a large urban diabetes center. . This study was a retrospective chart review of insulin pump usage by race (NHW/ NHB) in 2005, and race/ethnicity (NHW/NHB/Hispanic) in 2011-2019. Demographic data (age, sex, diabetes duration, SES) and most recent hemoglobin A1c were also abstracted in 2011-2019.

RESULTS

In 2005, NHW children were twice as likely to use an insulin pump as NHB children. From 2011 to 2019, the odds ratio increased to 2.5 for NHW compared to NHB children. The odds of Hispanic children using insulin pumps were also higher than NHB. Insurance status (government versus private), a surrogate for SES, had very little influence on these trends, with NHW children consistently more likely than NHB children to be treated with insulin pumps in 2011, 2013, 2017, 2019 (p < 0.001).

CONCLUSIONS

We have demonstrated that racial disparities in insulin pump use have persisted over the past 15 years, and are not determined by SES. This inequity in diabetes treatment may be playing a role in the poorer glycemic control and higher rates of diabetes complications in NHB children.

PRACTICE IMPLICATIONS

Healthcare providers should be cognizant of racial and ethnic disparities in the treatment of children with T1D. Standardized treatment protocols may reduce unconscious bias in prescribing.

Management of patients with incurable colorectal cancer: a retrospective audit

AIM

Counselling patients and their relatives about non-curative management options in colorectal cancer is difficult because of a paucity of published data. This study aims to determine outcomes in patients unsuitable for curative surgery and the rates of subsequent surgical intervention.

METHOD

This was an analysis of all colorectal cancers managed without curative surgery in a district general hospital from a prospectively maintained cancer registry between 2009 and 2016, as decided by a multidisciplinary team. Primary outcomes were overall survival and secondary outcomes were subsequent intervention rates and impact of tumour stage.

RESULTS

In all, 183 patients out of 976 patients (18.8%) were identified. The median age at diagnosis was 81 years [interquartile range (IQR) 71-87 years]. Overall median survival from diagnosis was 205 days (IQR 60-532 days). One-year mortality was 62.3%. Patients were classified into two groups depending on the reason for a non-curable approach: patient-related (PR) or disease-related (DR). The difference in survival between PR (median 277 days, IQR 70-593) and DR (median 179 days, IQR 51-450) was 98 days (P = 0.023). Twenty-four patients were alive at the end of the study period; 19 out of 91 cases in PR (20.8%) and five out of 92 cases in DR (5.4%). Overall intervention rates were 11.9%, with higher rates in the DR group (P = 0.005). Disease stage was not associated with subsequent surgical intervention between the two groups (P = 0.392).

CONCLUSION

Life expectancy for non-curatively managed patients within our unit was 6.8 months with one in nine patients requiring subsequent surgical admission for palliation. This information may be useful when counselling patients with incurable colorectal malignancy.

Legislations combating counterfeit drugs in Hong Kong

OBJECTIVE

To understand legislation combating counterfeit drugs in Hong Kong.

DESIGN

This study consisted of two parts. In part I, counterfeit drugs–related ordinances and court cases were reviewed. In part II, indepth interviews of the stakeholders were described.

SETTING

Hong Kong.

PARTICIPANTS

All Hong Kong ordinances were screened manually to identify those combating counterfeit drugs. Court cases were searched for each of the identified cases. Then, the relevant judgement justifications were analysed to identify sentencing issues. Indepth interviews with the stakeholders were conducted to understand their perceptions about such legislation.

RESULTS

Trade Marks Ordinance, Patents Ordinance, Trade Descriptions Ordinance, and Pharmacy and Poisons Ordinance were current legislative items combating counterfeit drugs. Sentencing criteria depended on: intention to deceive, quantity of seized drugs, presence of expected therapeutic effect or toxic ingredients, previous criminal records, cooperativeness with Customs officers, honest confessions, pleas of guilty, types of drugs, and precautionary measures to prevent sale of counterfeit drugs. Stakeholders’ perceptions were explored with respect to legislation regarding the scale and significance of the counterfeit drug problem, penalties and deterrents, drug-specific legislation and authority, and inspections and enforcement.

CONCLUSIONS

To plug the loopholes, a specific law with heavy penalties should be adopted. This could be supplemented by non-legal measures like education of judges, lawyers, and the public; publishing the names of offending pharmacies; and emphasising the role of pharmacists to the public.

Single port laparoscopic right colonic resection using a 'vessel-first' approach

AIM

Single port laparoscopic colorectal surgery (SPLC), performed through a single incision of ≤ 3 cm, has been shown to be feasible. This study aimed to assess its safety and efficacy when used as the method of choice for right hemicolectomy.

METHOD

A prospective study was carried out of patients undergoing right hemicolectomy using a single port laparoscopic technique. They were compared with a historical series of patients undergoing right hemicolectomy using a multiport laparoscopic technique. Between December 2009 and September 2010, single port surgery replaced conventional laparoscopic colorectal surgery (LCS) for radical medial to lateral right hemicolectomy performed by a single surgeon. Histology, length of hospital stay, complications, conversions and readmissions were recorded.

RESULTS

Fourteen patients were treated using single port laparoscopic surgery (SPLC): 10 for carcinoma (Dukes A1, B6, C3) and four for Crohn's disease. Twelve patients were treated using multiport laparoscopic colorectal surgery (LCS): eight for carcinoma (Dukes B4, C3, Carcinoid 1), three for Crohn's disease and one for adenoma. The median (interquartile range) operative time for the SPLC group was 120 (90-135) min and for the LCS group was 135 (116-150) min. The median (interquartile range) length of hospital stay was 3.5 (2.0-5.0) days for the SPLC group and for the LCS group was 4.0 (3.8-7.0) days. The median (interquartile range) number of lymph nodes removed for SPLC patients was 14.5 (9.8-19.5) and for the LCS patients was 14.5 (13.0-19.5). There were no conversions, no complications and no readmissions in either group.

CONCLUSION

These data confirm the feasibility of the technique. Furthermore they suggest that it is safe and efficacious.

Knight-field-enabled nuclear spin polarization in single quantum dots

We demonstrate dynamical nuclear-spin polarization in the absence of an external magnetic field by resonant circularly polarized optical excitation of a single electron or hole charged quantum dot. Optical pumping of the electron spin induces an effective inhomogeneous magnetic (Knight) field that determines the direction along which nuclear spins could polarize and enables nuclear-spin cooling by suppressing depolarization induced by nuclear dipole-dipole interactions. Our experiments constitute a first step towards a quantum measurement of the Overhauser field.

Characterization and adsorption properties of eggshells and eggshell membrane

The objective of this work was to study the chemical and physical characterization of eggshell and eggshell membrane particles prepared from the hen eggshell waste. Under the characterization measurements investigated, it was found that the pore structures of the two biomaterials belong to a typical Type II, indicating that they should be basically characteristic of nonporous materials or materials with macropores or open voids. Further, the chemical composition of the resulting eggshell particle was strongly associated with the presence of carbonate minerals from the Fourier transform infrared (FTIR) spectra. In contrast to the resulting eggshell membrane particle, the presence of functional groups of amines and amides was observable because of its chemical composition of fibrous proteins. From the isotherm data of methylene blue at 25 degrees C, the Freundlich model yielded a somewhat better fit than the Langmuir model. The adsorption isotherms revealed the eggshell biosorbents could only uptake the basic dye of less than 1.0mg/g in aqueous medium, which was attributed to their poor pore properties.

Adsorption of ethyl violet dye in aqueous solution by regenerated spent bleaching earth

The adsorption of basic dye (i.e., ethyl violet or basic violet 4) from aqueous solution onto the regenerated spent bleaching earth (RSBE) was carried out by varying the process parameters such as initial concentration, pH, and temperature. As analytical comparisons, activated bleaching earth (ABE) was also used as adsorbent for the adsorption of the basic dye at various initial concentrations. The experimental results showed that the adsorption process can be well described with the pseudo-second-order reaction model and less fitted by the intra-particle diffusion model. The kinetic parameters of both models obtained in the present work are in line with pore properties of the two adsorbents. According to the equilibrium adsorption capacity from the fitting of pseudo-second-order reaction model, it was further found that the both models of Langmuir and Freundlich appeared to fit well the isotherm data. In addition, the thermodynamic parameters were evaluated based on the pseudo-second-order rate constants, showing that the adsorption of ethyl violet onto the RSBE is endothermic in nature.

Cerebral arteriovenous fistulas induced by dural arteriovenous shunts

Dural arteriovenous shunts and pial arteriovenous fistulas are uncommonly associated. Their etiology, pathogenesis, and natural history are still unclear and are likely different. We present three cases of high-flow dural arteriovenous shunts associated with pial arteriovenous fistulas and discuss their pathogenesis, anatomic association, and angioarchitecture. We propose that venous steal effect in the dural sinus secondary to the high-flow dural arteriovenous shunt induced the pial arteriovenous fistulas. Treatment of the high-flow dural arteriovenous shunts and the induced pial arteriovenous fistulas are discussed.

Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly

OBJECTIVE

To evaluate the clinical efficacy and outcomes of percutaneous cholecystostomy as an alternative treatment option for elderly and critically ill patients who have acute cholecystitis.

PATIENTS AND METHODS

The medical records of patients who underwent emergency percutaneous cholecystostomy at the North District Hospital, Hong Kong from September 1999 to July 2002 were reviewed. Indications for the procedure, patient demographics, and other clinical details were recorded.

RESULTS

A total of 25 patients (10 male, 15 female) with a median age of 81 years (range, 39-97 years) presented with acute cholecystitis and underwent percutaneous cholecystostomy with ultrasound guidance. Two patients required emergency cholecystectomy on day 1 after the procedures because of deteriorating conditions. The rest of the patients clinically improved after drainage. There was no major periprocedural complication, and four patients had their catheter accidentally dislodged but did not require re-insertion. There were five in-patient mortalities, although the majority of these deaths were from unrelated illness. Subsequently, only six patients underwent elective cholecystectomy, one open and five laparoscopic. Two patients were offered percutaneous endoscopic cholecystolithotripsy, one defaulted and the other could not tolerate the procedure. Eleven patients declined further intervention due to the high surgical risks, three of these patients developed biliary symptoms, one had acute cholecystitis, and the other two had cholangitis. The rest of patients had no symptoms related to the gallstones. The median follow-up period was 81 weeks (range, 27-162 weeks).

CONCLUSION

Percutaneous cholecystostomy is a viable treatment option for elderly and critically ill patients presenting with acute cholecystitis. It has a high success rate with minimal procedure-related complications. Elective cholecystostomy is the treatment of choice for low-risk patients after the initial acute cholecystitis.

Adsorption kinetics of herbicide paraquat from aqueous solution onto activated bleaching earth

In the present study, the activated bleaching earth was used as adsorbent for the herbicide paraquat adsorption in a batch adsorber. The rate of adsorption has been investigated under the controlled process parameters like agitation speed, initial paraquat concentration, adsorbent dosage and temperature. A batch kinetic model, based on the assumption of a pseudo-second order mechanism, has been tested to predict the rate constant of adsorption, equilibrium adsorption capacity, time of half-adsorption, and equilibrium concentration by the fittings of the experimental data. The results of the kinetic studies show that the adsorption process can be well described with the pseudo-second order equation. Based on the isotherm data obtained from the fittings of the adsorption kinetics, Freundlich model appears to fit the adsorption better than Langmuir model. In addition, the effective diffusion coefficient has also been estimated based on the restrictive diffusion model.

Phase diagram of degenerate exciton systems

Degenerate exciton systems have been produced in quasi-two-dimensional confined areas in semiconductor coupled quantum well structures. We observed contractions of clouds containing tens of thousands of excitons within areas as small as (10 micron)2 near 10 kelvin. The spatial and energy distributions of optically active excitons were determined by measuring photoluminescence as a function of temperature and laser excitation and were used as thermodynamic quantities to construct the phase diagram of the exciton system, which demonstrates the existence of distinct phases. Understanding the formation mechanisms of these degenerate exciton systems can open new opportunities for the realization of Bose-Einstein condensation in the solid state.

Effect of particle size of activated clay on the adsorption of paraquat from aqueous solution

This paper describes the effect of particle size on the process of paraquat adsorption from aqueous solution onto an activated clay surface at 25 degrees C and initial pH 11.0. Measurements of the pore properties of the clay adsorbents with three different particle sizes (0.053-0.074 mm, 0.037-0.053 mm, and <0.037 mm) were carried out. The rates and isotherms of adsorption have been also investigated by batch methods under the controlled conditions. From the experimental results obtained, the adsorption process can be well described with the pseudo-second order model and Freundlich model for adsorption kinetics and adsorption isotherm, respectively. In addition, the effect of the particle size of the clay adsorbent on the adsorption kinetics was found to be of considerable significance; namely, the rate constant (k) of paraquat adsorption by the clay adsorbent decreased with increasing particle size. It was concluded that the pore properties (i.e., surface area and total pore volume) and particle size of the clay adsorbent played a significant role in determining adsorption capacity and adsorption rate, respectively.

Regeneration of bleaching clay waste by chemical activation with chloride salts

Spent bleaching earth (SBE) was regenerated by chemical activation with low cost and low pollution chlorides as activating agents. Under the conditions of activation temperature of 600d egrees C and holding time of 1 h investigated, results show that fresh bleaching earth and regenerated bleaching earth are type IV with hysteresis loops corresponding to type H3 from nitrogen adsorption-desorption isotherms, indicating slit-shaped mesoporous structure. It is also found that the effect of the regeneration treatment studied in the present work on the pore structures and chemical properties of the resulting solids is negligible compared to the fresh bleaching earth. On the other hand, the pore properties of these chemically activated solids are higher than those of the sample regenerated from heat regeneration, but only approximate 45% of surface area are reclaimed. It implies that the carbon residues could be retained within pores and/or clogs the entrance of pores, resulting in a decrease in pore properties.

Sonography of umbilical metastasis (Sister Mary Joseph's nodule): from embryology to imaging

Umbilical metastases are rare occurences. We describe the sonographic features of two cases with an umbilical nodule secondary to metastatic adenocarcinoma. A review of the literature discusses the embryologic and anatomic bases, differential diagnosis, and imaging approach.

Towards Bose-Einstein condensation of excitons in potential traps

An exciton is an electron-hole bound pair in a semiconductor. In the low-density limit, it is a composite Bose quasi-particle, akin to the hydrogen atom. Just as in dilute atomic gases, reducing the temperature or increasing the exciton density increases the occupation numbers of the low-energy states leading to quantum degeneracy and eventually to Bose-Einstein condensation (BEC). Because the exciton mass is small--even smaller than the free electron mass--exciton BEC should occur at temperatures of about 1 K, many orders of magnitude higher than for atoms. However, it is in practice difficult to reach BEC conditions, as the temperature of excitons can considerably exceed that of the semiconductor lattice. The search for exciton BEC has concentrated on long-lived excitons: the exciton lifetime against electron-hole recombination therefore should exceed the characteristic timescale for the cooling of initially hot photo-generated excitons. Until now, all experiments on atom condensation were performed on atomic gases confined in the potential traps. Inspired by these experiments, and using specially designed semiconductor nanostructures, we have collected quasi-two-dimensional excitons in an in-plane potential trap. Our photoluminescence measurements show that the quasi-two-dimensional excitons indeed condense at the bottom of the traps, giving rise to a statistically degenerate Bose gas.

Diagnosis of gastroesophageal varices and portal collateral venous abnormalities by endosonography in cirrhotic patients

BACKGROUND AND STUDY AIMS

The role of endosonography (EUS) in the management of portal hypertension is not well defined. We aimed to study the use of a new generation video-echo endoscope in the diagnosis of gastroesophageal varices (GEV) and extraluminal venous abnormalities in cirrhotic patients.

PATIENTS AND METHODS

Cirrhotic patients were studied by echo endoscopy to assess esophageal varices endoscopically, and gastric varices and extraluminal venous abnormalities sonographically. The results were compared with esophagogastroduodenoscopy (EGD) examination. Dyspeptic patients served as controls.

RESULTS

A total of 52 cirrhotic and 166 dyspeptic patients were studied. EUS identified esophageal varices (EV) endoscopically in 28 patients (53.8 %), which showed a good correlation with EGD findings (r = 0.855, P < 0.001). The red color sign and portal hypertensive gastropathy were diagnosed in six and seven patients, respectively, by both methods. EUS detected gastric varices sonographically in 16 patients (30.8 %), compared with detection in nine patients by EGD. Extraluminal venous abnormalities were detected in 48 cirrhotic patients (92 %) and in only nine dyspeptic patients (5.4 %) (P < 0.001). The size of extraluminal adventitial venous dilatation was significantly correlated with the severity of GEV and cirrhosis (P < 0.001). Perforating veins were identified in all patients with GEV.

CONCLUSION

The new generation video-echo endoscope could be used as a single investigation in assessing both the intraluminal GEV and extraluminal venous abnormalities in cirrhotic patients. It may improve the management of patients with portal hypertension.

Observation of magnetically induced effective-mass enhancement of quasi-2D excitons

We present the first measurements of the dispersion relation of a quasi-2D magnetoexciton. We demonstrate that the magnetoexciton effective mass is determined by the coupling between the center-of-mass motion and internal structure and becomes overwhelmingly larger than the sum of the electron and hole masses in high magnetic fields.

A randomized placebo-controlled trial of a humanized monoclonal antibody to alpha4 integrin in active Crohn's disease

BACKGROUND & AIMS

alpha4 integrins are important mediators of leukocyte migration across vascular endothelium. This pilot placebo-controlled study aimed to assess the safety and efficacy of natalizumab, a recombinant humanized monoclonal antibody to alpha4 integrin, in patients with mild to moderately active Crohn's disease.

METHODS

Thirty patients with active Crohn's disease (Crohn's Disease Activity Index [CDAI] > or =151 and < or =450) received a 3-mg/kg infusion of natalizumab (n = 18) or placebo (n = 12) by double-blind randomization. The study's primary endpoint was change in CDAI at week 2.

RESULTS

At week 2, the CDAI decreased significantly from baseline after infusion of natalizumab (mean 45 points) but not placebo (mean 11 points). Seven (39%) natalizumab-treated patients achieved remission at week 2, compared with 1 (8%) treated with placebo. In contrast, 4 (33%) of the placebo-treated patients required rescue medication by week 2, compared with 2 (11%) natalizumab-treated patients. Significant increases in circulating B and T lymphocytes were detected only after natalizumab administration. The frequency of commonly reported adverse events did not differ significantly between groups.

CONCLUSIONS

A single 3-mg/kg natalizumab infusion was well tolerated by Crohn's disease patients, although the dose used may have been suboptimal. Elevated circulating lymphocyte levels after natalizumab suggest interrupted lymphocyte trafficking. Natalizumab therapy in active Crohn's disease merits further investigation.

Helicobacter pylori infection in Chinese subjects with type 2 diabetes

The relationship between diabetes and Helicobacter pylori (HP) infection is controversial. In this study, we examined the possible relationship between HP infection and type 2 diabetes in Chinese subjects. Sixty-three Chinese type 2 diabetic patients (mean age +/- SD: 49.9 +/- 12.0 years; range: 17-76 years) were recruited irrespective of the duration of diabetes or type of therapy. Twenty-nine (46%) of them had upper gastrointestinal symptoms and the other 34 (54%) did not. Another 55 age- and sex-matched non-diabetic subjects (mean age +/- SD: 45.6 +/- 15.6 years, p=0.098; range 18-79 years) with dyspepsia indicated for upper endoscopy were recruited as a comparison group. Upper endoscopy was performed with antral mucosal biopsy specimens taken for rapid urease test (CLO test). HP infection was considered to be present if the rapid urease test was positive. The rates of HP infection of the diabetic and non-diabetic individuals were 50.8% and 56.4% respectively (p: NS). The rate of HP infection was similar between the 2 groups of diabetic patients with or without gastrointestinal symptoms (42.9% vs. 56.3%, p: NS). Using logistic regression analysis (forward stepwise) with age, sex, glycaemic control, duration of diabetes and upper gastrointestinal symptoms as independent variables to predict the risk of HP infection in diabetic patients, none of the parameters enter into the model. In conclusion, the rate of HP infection in Hong Kong Chinese subjects with type 2 diabetes is around 50%, which is similar to control subjects. No association was found between HP infection, glycaemic status, and duration of diabetes and upper gastrointestinal symptoms in these diabetic subjects.

Long-term ciprofloxacin treatment for the prevention of biliary stent blockage: a prospective randomized study

OBJECTIVE

In vitro experimental and animal studies have shown that quinolones reduce the adherence of bacteria on a polyethylene tube and prevent stent blockage. Our aim was to see whether ciprofloxacin prevents stent blockage in patients with malignant stricture of the biliary tract.

METHODS

Patients with inoperable biliary or pancreatic tumor not involving the bifurcation of the common hepatic duct were recruited. They were randomized to receive either endoscopic stenting alone or stenting with prophylactic treatment of ciprofloxacin (200 mg i.v. before stenting, followed by 250 mg orally twice per day). In each follow-up visit, clinical symptoms of cholangitis were documented and blood samples taken for blood counts, serum levels of bilirubin, and alkaline phosphatase. Stent blockage was defined as clinical symptom(s) of cholangitis with biochemical or radiological evidence of stent dysfunction.

RESULTS

Fifty-eight patients were recruited into the study. Three patients in the stenting group and three in the ciprofloxacin group were excluded after randomization. Eleven patients received stenting alone and five patients receiving ciprofloxacin had previous endoscopic stenting. Thirteen patients (50%) in the ciprofloxacin group and eight patients (31%) in the stenting group died before stent blockage. Ten patients (38%) in each group had stent blockage during the follow-up at 20 wk. The median stent patency was 11.6 wk and 11.9 wk in the ciprofloxacin group and the stenting group, respectively. Kaplan-Meier analysis of stent patency showed no difference between the two groups. Among patients who received endoscopic stenting for the first time, there was a trend favoring ciprofloxacin treatment, but the difference was not significant. The 30-day and 20-wk mortality between the groups were comparable.

CONCLUSION

Long-term use of ciprofloxacin does not prevent blockage of polyethylene biliary stents.

Prediction of oesophagogastric varices in patients with liver cirrhosis

BACKGROUND

All patients with liver cirrhosis are recommended for evaluation of oesophagogastric varices (EGV) regularly. This prospective study was designed to develop a predictive model for EGV in cirrhotic patients.

METHODS

Ninety-two patients were recruited. From all patients studied, the size of palpable spleen, liver chemistry value, platelet count, prothrombin time, diameter of main portal vein and splenic length as assessed by ultrasonography were determined. Upper endoscopy was performed. Oesophageal varices (EV) and gastric varices (GV) were graded (EV, grade 1-4; GV, grade 1-3). In the predictive model, the EGV was classified into two grades (low, grade 1-2 EV or grade 1 GV; high, grade 3-4 EV or grade 2-3 GV).

RESULTS

There were 53 patients with EGV and 39 patients without EGV as determined by endoscopy. Patients with EGV had a significantly higher degree of ascites and hepatic encephalopathy, lower platelet count and longer splenic length than those without EGV. Low platelet count and presence of ascites were the significant independent predictors for high-grade EGV (concordance rate 0.83). The optimal critical value for the platelet count was 150 x 10(9)/L. Of patients without thrombocytopenia and ascites, 37% had low-grade EGV but none had high-grade EGV, whereas 38 and 35% of patients with thrombocytopenia or ascites had low and high-grade EGV, respectively. Therefore, this predictive model for high-grade varices had a positive and negative predictive value of 35 and 100%, respectively.

CONCLUSION

Endoscopic screening for EGV was not necessary until thrombocytopenia or ascites occurred.

Long-term beta-blocker therapy improves autonomic nervous regulation in advanced congestive heart failure: a longitudinal heart rate variability study

BACKGROUND

beta-Blocker therapy is believed to modulate the detrimental effect of overcompensating neurohormonal activation in chronic heart failure. However, clinical doubts remain, particularly the physiologic sympathovagal balance.

METHODS

To respond to clinical concern about worsening autonomic nervous perturbation in beta-blocker therapy of advanced congestive heart failure, 15 consecutive patients were longitudinally studied to elucidate the evolution of cardiac function versus 24-hour heart rate variability (HRV) before and after 1, 3, and 6 to 9 months of atenolol-combined therapy.

RESULTS

Two patients died prematurely within 1 month. All 13 surviving patients showed improvement in New York Heart Association functional class, with decrease in left ventricular end-systolic and end-diastolic dimensions and increase in fraction shortening and ejection fraction by echocardiography after at least 3 months of atenolol use. The retarded therapeutic effect was accompanied by a general rise of total, very low, low-, and high-frequency components (9.0 +/- 0.5, 8.8 +/- 0.5, 6.2 +/- 0.6, and 6.1 +/- 0.5 vs 10.9 +/- 0.3, 10.7 +/- 0.4, 8.6 +/- 0.3, and 7.8 +/- 0.3; all P <.02) of daily HRV. This implied recovery of parasympathetic and baroreceptor function. Return of sympathovagal interaction was further supported by the suppression of Cheyne-Stokes type HRV as detected by Wigner-Ville distribution.

CONCLUSIONS

Long-term beta-blocker therapy for advanced congestive heart failure upwardly regulates the autonomic nervous interaction in synchrony with the evolution of cardiac function performance.

Activation of beta3-adrenoceptors by exogenous dopamine to lower glucose uptake into rat adipocytes

The effect of dopamine hydrochloride on beta3-adrenoceptors was studied in isolated adipocytes of Wistar rats using uptake of [14C]-deoxy-D-glucose (2-DG) as the indicator. Dopamine induced a concentration-dependent decrease of 2-DG uptake into adipocytes in a manner which was not modified by haloperidol at concentrations sufficient to block dopaminergic receptors. Failure of blockade was also observed in samples receiving the pretreatment with a mixture of SCH23390 and domperidone, the dopaminergic antagonists. Absence of dopaminergic receptors in rat white adipocytes was further supported by the findings that dopaminergic agonists did not modify the glucose uptake and the negative response to receptor antibodies in immunoblotting analysis. Pindolol and propranolol reversed this inhibition of dopamine in a concentration-dependent manner. However, this action of dopamine was not affected by prazosin at concentrations sufficient to block alpha-adrenoceptors. Effect of dopamine was reduced in the presence of Rp-cyclic AMPS triethylamine, the membrane-permeable antagonist of cyclic AMP (cAMP), indicating the mediation of cAMP in this inhibition. Direct effect of exogenous dopamine on beta3-adrenoceptors was identified using the antibody for beta3-adrenoceptors that reversed the inhibition of dopamine. These results suggest that dopamine can activate beta3-adrenoceptors to lower glucose uptake into rat white adipocytes which lack dopaminergic receptors.

Stimulatory effect of paeoniflorin on adenosine A-1 receptors to increase the translocation of protein kinase C (PKC) and glucose transporter (GLUT 4) in isolated rat white adipocytes

In an attempt to understand the subcellular signals after activation of adenosine A-1 receptors, paeoniflorin was employed to incubate with rat white adipocytes in vitro. Translocation of protein kinase C (PKC) beta-subtype from cytosol to membrane was enhanced by an incubation with paeoniflorin in a concentration-dependent manner similar to that of porcine insulin. Also, 8-cyclopentyl-1,3-dipropylxanthine (DPCPX) inhibited this action of paeoniflorin in a concentration-related fashion and it markedly attenuated the action of paeoniflorin at a concentrations sufficient to block the action of adenosine. Moreover, chelerythrine inhibited the paeoniflorin-stimulated translocation of PKC in a way similar to that stimulated by porcine insulin. Subcellular inhibition is considered because stimulation of porcine insulin was not modified by DPCPX at concentrations sufficient to block adenosine A-1 receptors. Similar results were also observed in adipocytes regarding the translocation of glucose transporter (GLUT4) from cytosol to membrane. Thus, we found that paeoniflorin can activate adenosine A-1 receptors to increase the translocations of PKC and GLUT4, two major signals for glucose uptake, from cytosol to membrane of the white adipocytes in rats.

Common bile duct stones become smaller after endoscopic biliary stenting

BACKGROUND AND STUDY AIMS

Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones that cannot be extracted at one session. We compared the sizes of the CBD stones after a period of stenting.

PATIENTS AND METHODS

Over a 6-year period, a total of 444 patients with large CBD stones (> 2 cm diameter) or difficult CBD stones were managed in our endoscopy unit, of which 46 were treated by endoscopic stenting. Twenty-eight had second ERCP for stone removal after a median period of 63 days (range 17-1002 days). The largest diameter of the stones and the CBD (after correction of magnification) before and after stenting were compared using the Wilcoxon signed test.

RESULTS

Before stenting the largest diameters of CBD stones were 11-46 mm (mean 24.9 mm) and decreased to 5-46 mm (mean 20.1 mm) after stenting. The difference in stone sizes was statistically significant although the CBD diameter pre- and post-stenting was not significantly different. The reduction in stone sizes was not significantly correlated with the duration of stenting.

CONCLUSION

CBD stones became smaller after stenting. As the difficulty of stone extraction increases with stone size, a period of stenting may make subsequent removal easier for patients with large or difficult CBD stones.

Antihyperglycemic effects of paeoniflorin and 8-debenzoylpaeoniflorin, glucosides from the root of Paeonia lactiflora

Paeoniflorin and 8-debenzoylpaeoniflorin were isolated from the dried root of Paeonia lactiflora Pall. (Ranunculaceae). They produced a significant blood sugar lowering effect in streptozotocin-treated rats and had a maximum effect at 25 min after treatment. This hypoglycemic action was also observed in normoglycemic rats only at 1 mg/kg. The antihyperglycemic activity of 8-debenzoylpaeoniflorin seems lower than that of paeoniflorin. Plasma insulin was not changed in paeoniflorin-treated normoglycemic rats indicating an insulin-independent action. Also, this glucoside reduced the elevation of blood sugar in glucose challenged rats. Increase of glucose utilization by paeoniflorin can thus be considered. There are no previous data showing the hypoglycemic activity of paeoniflorin and/or 8-debenzoylpaeoniflorin in rats.

Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers

OBJECTIVE

To compare endoscopic adrenaline injection alone and adrenaline injection plus heat probe for the treatment of actively bleeding peptic ulcers.

DESIGN

Randomised prospective study of patients admitted with actively bleeding peptic ulcers.

SETTING

One university hospital.

SUBJECTS

276 patients with actively bleeding ulcers detected by endoscopy within 24 hours of admission: 136 patients were randomised to endoscopic adrenaline injection alone and 140 to adrenaline injection plus heat probe treatment.

MAIN OUTCOME MEASURES

Initial endoscopic haemostasis; clinical rebleeding; requirement for operation; requirement for blood transfusion; hospital stay, ulcer healing at four weeks; and mortality in hospital.

RESULTS

Initial haemostasis was achieved in 131/134 patients (98%) who received adrenaline injection alone and 135/136 patients (99%) who received additional heat probe treatment (P = 0.33). Outcome as measured by clinical rebleeding (12 v 5), requirement for emergency operation (14 v 8), blood transfusion (2 v 3 units), hospital stay (4 v 4 days), ulcer healing at four weeks (79.1% v 74%), and in hospital mortality (7 v 8) were not significantly different in the two groups. In the subgroup of patients with spurting haemorrhage 8/27 (29.6%; 14.5% to 50.3%) patients from the adrenaline injection alone group and 2/31 (6.5%; 1.1% to 22.9%) patients from the dual treatment group required operative intervention. The relative risk of this was lower in the dual treatment group (0.17; 0.03 to 0.87). Hospital stay was significantly shorter in the dual treatment group than the adrenaline injection alone group (4 v 6 days, P = 0.01).

CONCLUSION

The addition of heat probe treatment after endoscopic adrenaline injection confers an advantage in ulcers with spurting haemorrhage.

Comparison of isoproterenol with BRL37344 in activation of beta 3-adrenoceptors to inhibit the uptake of [14C]deoxy-D-glucose and translocation of glucose transporter (GLUT4) to membrane fraction in rat adipocytes

In an attempt to understand the role of beta 3-adrenoceptors in the regulation of glucose uptake, the effect of isoproterenol was compared with BRL37344 in isolated white adipocytes of the rat using [14C]deoxy-D-glucose as an indicator. In the presence of BRL37344, the specific agonist of beta 3-adrenoceptors, spontaneous uptake of [14C]deoxy-D-glucose (glucose uptake) into adipocytes was markedly attenuated. Similar concentration-dependent inhibition of glucose uptake was also observed in the samples treated with isoproterenol, an agonist for all kinds of beta-adrenoceptors. Action of BRL37344 was blocked by propranolol at concentrations sufficient to abolish the activity of isoproterenol. Pindolol reversed BRL37344-induced inhibition more effectively than propranolol. Moreover, unlike the action of isoproterenol, BRL37344 did not modify the insulin-stimulated glucose uptake. Translocation of glucose transporter (GLUT4) from cytosol to membrane stimulated with insulin was reduced by isoproterenol but not by BRL37344. Combination with the findings that isoproterenol prolonged the time for insulin to reach maximum stimulation of glucose uptake, leads to the conclusion that delay of insulin action by isoproterenol can be considered as one of the mechanisms for this inhibition. The results obtained suggest that BRL37344 decreased the spontaneous uptake of glucose via an activation of beta 3-adrenoceptors while the insulin stimulated glucose uptake was inhibited by isoproterenol but not by BRL37344.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in laparoscopic cholecystectomy

BACKGROUND

The management of possible common bile duct (CBD) stones in patients scheduled for laparoscopic cholecystectomy remains controversial.

METHODS

Prospective evaluation of 609 patients who underwent laparoscopic cholecystectomy was carried out in relation to the use of selective preoperative ERCP for detection of common duct stones. Preoperative ERCP was performed if there is or has been (1) cholangitis, biliary pancreatitis, or jaundice; (2) abnormal serum liver tests or (3) ultrasonogram showing a dilated CBD or ductal stones.

RESULTS

A total of 139 patients underwent preoperative ERCP, and cannulation of CBD was successful in 133 patients (96%). CBD stones were found in 60 patients (45%) and extracted after sphincterotomy. High prevalence of CBD stones was noted in patients with acute cholangitis and CBD stones on ultrasonogram. There were six endoscopic sphincterotomy-related complications (complication rate, 4.5%): bleeding (2), pancreatitis (3), retroduodenal perforation (1). No patient required surgery as the result of a complication. The prediction of the occurrence of ductal stones was further analyzed using stepwise logistic regression. Acute cholangitis and CBD stones on ultrasonogram were shown to be independent significant risk factors with odds ratios of 8.9 and 13.5, respectively.

CONCLUSIONS

With selective preoperative ERCP, suspected CBD stones can be identified and removed prior to laparoscopic cholecystectomy.

Prospective randomised study of effect of octreotide on rebleeding from oesophageal varices after endoscopic ligation

Up to a third of patients have early rebleeding from oesophageal varices after endoscopic variceal ligation. Octreotide infusion is effective for control of variceal bleeding. We investigated the efficacy of octreotide infusion as an adjunct to endoscopic variceal ligation to prevent early rebleeding from varices. 100 consecutive patients admitted with endoscopically confirmed oesophageal varices and active bleeding or signs of recent haemorrhage were randomly assigned endoscopic variceal ligation alone or octreotide (50 micrograms intravenous bolus injection followed by intravenous infusion at 50 micrograms per h for 5 days) plus endoscopic variceal ligation. Three patients in each group were excluded. Bleeding was controlled in 44 of 47 patients who received variceal ligation alone and in 45 of 47 who received combined treatment (p = 1.0). Recurrent bleeding was documented in 18 (38% [24-52]) patients who received variceal ligation alone and in four (9% [3-21] who received combined treatment (p = 0.0007). The relative risk of rebleeding was lower (0.22 [0.08-0.60]) in the combined therapy group. Ten patients in the variceal ligation group and one in the combined therapy group required balloon tamponade for massive haematesis and haemodynamic instability (p = 0.0039). The in-hospital and 30-day mortality rates were higher in the variceal ligation group than in the combined therapy group (19 vs 9% and 23 vs 11%), but the differences did not reach significance. The relative risks of in-hospital (0.5 [0.04=5.3]) and 30-day (0.45 [0.17-1.2]) mortality were lower in the combined therapy group. Octreotide significantly reduces recurrent bleeding and the need for balloon tamponade in patients with variceal haemorrhage treated by endoscopic variceal ligation.

Survey of public awareness, understanding, and attitudes toward epilepsy in Taiwan

A survey of public awareness and understanding of and attitudes toward epilepsy was made in Taipei City and Chin-San Village, Taiwan in 1992. In a population sample of 2,610 adults, 87% had read or heard about epilepsy, 70% knew someone who had epilepsy, 56% had seen someone having a seizure, 18% would object to having their children associated with persons with epilepsy, 72% would object to having their children marry a person with epilepsy, 31% believed that epileptic persons should not be employed in jobs as other persons are, 7% believed that epilepsy was a form of insanity, 34% did not know the cause of epilepsy, 13% did not know what an epileptic attack was like, and 18% did not know what to recommend if their friends or relatives had epilepsy. Youth, higher education, and upper levels of employment were correlated with answers that were more favorable concerning epilepsy in all survey questions except for the question regarding marriage, for which the reverse was noted. The attitudes toward epilepsy disclosed by this study were more favorable than those detected in a similar survey conducted in Henan Province, China. The comparison suggests that the exposure to Western culture and socioeconomic system in Taiwan might have helped reduce the discrimination against epilepsy.

Antibiotics, biliary sepsis, and bile duct stones

Bacteriologic studies of bile and blood cultures of 579 patients with ductal stones and infected bile revealed that 121 patients (21%) had associated bacteremia. Analysis of bile and stone cultures showed that Escherichia coli, Klebsiella sp, Enterobacter sp, Enterococcus sp, and Streptococcus sp were the most commonly isolated bacteria. Two-thirds of the patients with bacteremia had similar organisms isolated from blood and bile. Pharmacokinetic studies of the hepatic/biliary excretion profiles of ceftazidime, cefoperazone, imipenem, netilmicin, and ciprofloxacin were performed by ERCP and nasobiliary catheter drainage. The bile samples obtained immediately after cannulation from patients with complete biliary obstruction contained low or undetectable levels of the antibiotics administered--the exception being ciprofloxacin, which was present at a concentration of 20% of the serum level. In vitro determination of minimum inhibitory concentration of the aforementioned antibiotics against 199 isolates of biliary pathogens revealed imipenem and ciprofloxacin to have the highest antimicrobial activity. Based on pharmacokinetic studies and in vitro susceptibility findings, we conclude that ciprofloxacin is superior to the other tested antibiotics in prophylaxis and treatment of biliary sepsis.

Antibiotics, biliary sepsis, and bile duct stones

Bacteriologic studies of bile and blood cultures of 579 patients with ductal stones and infected bile revealed that 121 patients (21%) had associated bacteremia. Analysis of bile and stone cultures showed that Escherichia coli, Klebsiella sp, Enterobacter sp, Enterococcus sp, and Streptococcus sp were the most commonly isolated bacteria. Two-thirds of the patients with bacteremia had similar organisms isolated from blood and bile. Pharmacokinetic studies of the hepatic/biliary excretion profiles of ceftazidime, cefoperazone, imipenem, netilmicin, and ciprofloxacin were performed by ERCP and nasobiliary catheter drainage. The bile samples obtained immediately after cannulation from patients with complete biliary obstruction contained low or undetectable levels of the antibiotics administered--the exception being ciprofloxacin, which was present at a concentration of 20% of the serum level. In vitro determination of minimum inhibitory concentration of the aforementioned antibiotics against 199 isolates of biliary pathogens revealed imipenem and ciprofloxacin to have the highest antimicrobial activity. Based on pharmacokinetic studies and in vitro susceptibility findings, we conclude that ciprofloxacin is superior to the other tested antibiotics in prophylaxis and treatment of biliary sepsis.

Octreotide infusion or emergency sclerotherapy for variceal haemorrhage

To compare octreotide with injection sclerotherapy in the treatment of acute variceal haemorrhage, patients admitted with gastrointestinal bleeding and oesophageal varices confirmed by endoscopy were randomised to receive either emergency sclerotherapy with 3% sodium tetradecyl sulphate or octreotide (50 micrograms intravenous bolus plus 50 micrograms per h intravenous infusion for 48 h). At the end of the study period (48 h), the octreotide group also had sclerotherapy to obliterate the varices. 100 patients were recruited. Demographic features including the aetiology of portal hypertension and the Child-Pugh's grading of the two groups were similar. Bleeding was initially controlled in 90% of patients by emergency sclerotherapy and in 84% by octreotide infusion (95% confidence interval 0-19.5, p = 0.55). There were no significant differences between the two groups in early (within 48 h of randomisation) rebleeding (16% vs 14%), blood transfusion (3 units vs 3.5), hospital stay (5 days vs 6 days), or hospital mortality (27% vs 20%). No notable side-effects were associated with octreotide. We conclude that octreotide infusion and emergency sclerotherapy are equally effective in controlling variceal haemorrhage.

Common bile duct stones: a cause of chronic salmonellosis

A chronic carrier state of Salmonella spp is present in 0.15% of the population, and is believed to be related to the presence of a diseased gallbladder. We present a patient with common bile duct (CBD) stones, whose bile cultures repeatedly indicated Salmonella typhi, despite an adequate course of antibiotic treatment. The carrier state was abolished after removal of the CBD stones 4 months later. The chronic carrier state may be related to biofilm formation on the surface of the CBD stones. The removal of the biliary stones, which are the most likely reservoir for Salmonella spp, may be a crucial step in eradication of the carrier state.

Effect of biliary obstruction on the hepatic excretion of imipenem-cilastatin

The biliary excretion of imipenem-cilastatin studied by endoscopic cannulation of the common bile duct in patients with complete obstruction and in a group without obstruction showed that despite a 24-h prophylaxis, the bile obtained from patients with obstruction immediately after cannulation contained neither imipenem nor cilastatin, while there were 2 and 5% of peak concentrations in serum for imipenem and cilastatin, respectively, in the bile from patients without obstruction. Biliary excretion of both compounds increased rapidly after decompression, reaching a maximum of 15% of peak levels in serum within 2 h. Twenty-four hours after drainage, the biliary excretion of the drugs further improved. We conclude that since biliary obstruction impairs excretion of antibiotics, drainage is necessary for the control of sepsis in obstructed cholangitis.

History of epilepsy in Chinese traditional medicine

The first known document on epilepsy in China appeared in The Yellow Emperor's Classic of Internal Medicine, Huang Di Nei Ching, written by a group of physicians around 770-221 B.C. The description of epilepsy in this book and in many others later published was confined to generalized convulsive seizures. No documentation of absence or simple partial seizures was provided. The first classification of epilepsy, probably by Cao Yuan Fang in A.D. 610, listed five types of epilepsy: "Yang Dian," "Yin Dian," "Feng (Wind) Dian," "Shih (Wet) Dian," and "Lao (Labor) Dian." Later, other classifications named seizures after the cry of animals whose cry the "epileptic cry" resembled, or after "visceral organs" believed to be responsible for the seizures. The concept of partial versus generalized seizures, however, was not observed in any of these classifications. The treatment of epilepsy, based on principles of "Yin Yang Wu Xing," consisted of herbs, acupuncture, and massage.

Survey of public awareness, understanding, and attitudes toward epilepsy in Henan province, China

The awareness, understanding, and attitudes toward epilepsy in 1,278 men and women were surveyed in Henan, China in 1988. Results showed that 93% had read or heard about epilepsy; 77% knew someone who had epilepsy; 72% had seen someone who was having a seizure; 57% would object to having their children associate with persons with epilepsy in school or at play; 87% would object to having their children marry a person with epilepsy; 53% believed that epileptic persons should not be employed in jobs as other persons are; 16% believed that epilepsy was a form of insanity; 40% did not know the cause of epilepsy; 10% did not know what an epileptic attack was like; and 17% did not know what to recommend if their friends or relatives had epilepsy. The relationship between the responses and the respondents' age, sex, marital status, number of offspring, level of education, occupation, and residence was analyzed. Education reduced the respondent's prejudice against play and employment, but did not change their objection to marriage and appeared to have reinforced their linking epilepsy with insanity. As compared with the surveys conducted in Western countries, our survey showed that awareness of epilepsy in China was greater, if not the same, but the attitudes toward epilepsy were much more negative.

Epilepsy, myasthenia gravis, and effect of plasmapheresis on antiepileptic drug concentrations

A 28-year-old woman developed complex partial seizures at the age of 17 years and was treated with phenytoin sodium. Five years later she developed myasthenia gravis, and phenytoin was replaced by valproic acid and phenobarbital. She required plasmapheresis (PP). During one course of PP, total and unbound concentrations of valproic acid and phenobarbital were measured in serum sampled before, during, and after PP and in plasma removed by PP. It was determined that the magnitude of loss of valproic acid or phenobarbital by PP was small, and the changes of unbound/total ratio did not reach clinical importance.

Takayasu arteritis presenting as retinal and vertebrobasilar ischemia

A young woman presented with a 4-month history of retinal and vertebrobasilar ischemia. Angiography demonstrated narrowing of major branches of the aortic arch. Intractable, severe retroorbital pain of the right eye developed after a middle cerebral artery stroke. During 4 weeks of aggressive immunosuppressive therapy including IV high dose bolus corticosteroids and pulse cyclophosphamide, her neurologic deficit improved transiently, but her retroorbital pain persisted. She died of staphylococcal sepsis and pneumonia. An autopsy demonstrated thrombotic or fibrous occlusion, with minimal inflammation, of extracranial arteries.

Clinical and electrophysiological responses to dietary challenge in migraineurs

Thirty eight patients with a history of diet-induced migraine were studied with recording of clinical responses, electroencephalography in resting state, in response to photic stimulation, and to hyperventilation and visual evoked potentials. Tests were carried out on an initial baseline day and on a second day, after challenge with chocolate, red wine, cheese, and fasting. Lateralized headache occurred in sixteen subjects (42%), four with scintillating scotomata. Electroencephalograms were abnormal on Day 1 and/or Day 2 in twelve subjects (32%), most abnormalities being non-specific slow waves. In three cases there were paroxysmal features. Electroencephalographic response to hyperventilation was calibrated and was found to be exaggerated in eight subjects (21%) on either Day 1 or Day 2; such response was not related to the occurrence of a headache. Photic simulation showed high frequency driving response (so called "H" response) in all 16 individuals who developed headache but in only 14 out of 22 (64%) who did not (p less than 0.01). Pattern reversal visual evoked responses were normal and failed to show any difference in latency or amplitude between headache responders and non-responders.

Electroencephalography in herpes simplex encephalitis

The EEG in the acute stage of herpes simplex encephalitis (HSE) can show a variety of abnormalities, including uni- or bilateral periodic sharp waves or attenuation of amplitude, focal or generalized slow waves or epileptiform discharges, or electrical seizures. No specific EEG patterns are pathognomonic for HSE, but a focal or lateralized EEG abnormality in the presence of encephalitis is highly suspicious of HSE. In the acute stage, EEG appears to be more sensitive than computerized tomography or radioisotope brain scanning. The EEG findings tend to differ in the course of illness, and the periodic discharges occur only during the acute stage. The EEG findings in either the acute stage or long-term follow-up do not predict the chance of survival or severity of disability, and EEG changes appear to lag behind the clinical changes. EEG results can become normal in both adults and neonates when the acute stage is over.