Timing of antibiotics in septic patients: a prospective cohort study

OBJECTIVES

To evaluate the effect of timing and appropriateness of antibiotics administration on mortality in patients diagnosed with sepsis according to the Sepsis-3 definition.

METHODS

This prospective cohort study was conducted in patients diagnosed with sepsis according to the Sepsis-3 definition at the emergency department of Korea University Ansan Hospital from January 2016 to January 2019. The time to antibiotics was defined as the time in hours from emergency department arrival to the first antibiotic administration. Cox proportional hazards regression analysis was used to estimate the association between time to antibiotics and 7-, 14- and 28-day mortality.

RESULTS

Of 482 patients enrolled onto this study, 203 (42.1%) of 482 and 312 (64.7%) of 482 were diagnosed with septic shock and high-grade infection respectively. The median time to receipt of antibiotic therapy was 115 minutes. Antibiotics were administered within 3 and 6 hours in 340 (70.4%) of 482 and 450 (93.2%) of 482 patients respectively. Initial appropriate empirical antibiotics were administered in 375 (77.8%) of 482 patients. The time to and appropriateness of the initial antibiotics were not associated with 7-, 14- and 28-day mortality in multivariate analysis. The Sequential Organ Failure Assessment (SOFA) score (adjusted hazard ratio (aHR) 1.229, 95% confidence interval (CI) 1.093-1.381, p 0.001) and initial lactate levels (aHR 1.128, 95% CI 1.034-1.230, p 0.007), Charlson comorbidity index (aHR 1.115, 95% CI 1.027-1.210, p 0.014), 2-hour lactate level (aHR 1.115, 95% CI 1.027-1.210, p 0.009) and SOFA score (aHR 1.077, 95% CI 1.013-1.144, p 0.018) affected 7-, 14- and 28-day mortality respectively. Subgroup analysis with septic shock, bacteraemia and high-grade infection did not affect mortality rates.

CONCLUSIONS

Time to receipt of antibiotics may not affect the prognosis of patients with sepsis if a rapid and well-trained resuscitation is combined with appropriate antibiotic administration within a reasonable time.

Central Serous Chorioretinopathy in Two Families

Purpose and Methods.

The reported occurrence of central serous chorioretinopathy (CSCR) in families is rare. We report two families (five patients) who have been diagnosed with CSCR. The diagnosis of CSCR was made on clinical and fluorescein angiographic findings.

Results

Three members of the first family and two members of the second family had CSCR. Affected individuals were all males.

Conclusions

CSCR has been associated with psychological and emotional stress and the occurrence of CSCR in families may be due to similar inherited psychological and physiological characteristics and responses that predispose these families to the development of CSCR.

Measurement of levels of fractional exhaled nitric oxide in patients with pulmonary tuberculosis

SETTING

The role of fractional exhaled nitric oxide (FeNO) in the diagnosis and treatment of pulmonary tuberculosis (PTB) is uncertain.

OBJECTIVE

To examine the value of FeNO as a biomarker for PTB.

DESIGN

Baseline FeNO levels were compared in 69 PTB patients and 118 healthy controls. The correlation between baseline FeNO levels and clinical variables of tuberculosis were studied. FeNO levels were checked twice in the PTB group, at diagnosis and after 2 months of anti-tuberculosis medication, and factors affecting changes in FeNO levels after treatment were analysed.

RESULTS

FeNO levels were not significantly different in the PTB group and controls (mean ± standard deviation 27.7 ± 17.6 parts per billion [ppb] vs. 27.0 ± 10.8 ppb, P = 0.531). In a multivariate regression analysis, no variable was shown to affect FeNO levels at diagnosis. FeNO levels did not significantly change after 2 months of treatment (26.8 ± 18.3 ppb vs. 24.0 ± 10.7 ppb, P = 0.257). Only PTB with a high FeNO level (>25 ppb) was related to a decline in FeNO levels after 2 months of treatment.

CONCLUSION

FeNO levels do not appear to be affected in PTB patients.

The effect of low-volatile organic compounds, water-based paint on aggravation of allergic disease in schoolchildren

Whether indoor painting aggravates preexisting allergic diseases remains unclear. We aimed to evaluate the impact of new classroom painting on aggravation of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) in children. Studied school was previously painted with conventional water-based paint 20 years ago and had natural ventilation system. We identified a total of 172 children aged 10-12 years with allergic diseases in 17 classrooms, which were allocated to newly painted rooms with low-volatile organic compounds (VOC), water-based paint, or existing rooms. After painting, there was no intervention or internal airflow to influence indoor air environment in both classrooms. We prospectively assessed the symptom severity and serious events of allergic diseases between both classrooms at baseline and after one and eight weeks after painting. At one and eight weeks, there were no significant changes in the Childhood Asthma Control Test scores, the fractional nitric oxide levels, lung function in asthmatic children in either classroom. There were also no significant changes in the severity score of AR or AD, or serious events in all allergic diseases. These findings suggest classroom painting with this new paint at the levels encountered in this study might not be a major aggravating factor for school-aged children with allergic diseases.

Comparison of Inner Ear Contrast Enhancement among Patients with Unilateral Inner Ear Symptoms in MR Images Obtained 10 Minutes and 4 Hours after Gadolinium Injection

BACKGROUND AND PURPOSE

Recently 4-hour delayed-enhanced 3D-FLAIR MR imaging has been used in pathophysiologic analysis of the inner ear in many auditory diseases, including sudden sensorineural hearing loss, but comparison among different time points is not clear in patients with unilateral inner ear symptoms. We compared the signal-intensity ratios of the inner ears in patients with unilateral inner ear symptoms on 10-minute delayed-enhanced and 4-hour delayed-enhanced 3D-FLAIR MR images after IV gadolinium injection.

MATERIALS AND METHODS

The 10-minute delayed-enhanced and 4-hour delayed-enhanced 3D-FLAIR MR images were retrospectively analyzed. Signal-intensity ratios between the cerebellum and inner ear structures, such as the cochleae, vestibules, and vestibulocochlear nerve were assessed. Multiple comparisons were performed.

RESULTS

Signal-intensity ratios of the affected cochleae, vestibules, and vestibulocochlear nerve were higher than those of unaffected sides in both 10-minute delayed-enhanced and 4-hour delayed-enhanced images. At the affected side, signal-intensity ratios of the vestibulocochlear nerve were higher in patients with nonsudden sensorineural hearing loss than in those with sudden sensorineural hearing loss on both 10-minute delayed-enhanced and 4-hour delayed-enhanced images. The signal-intensity ratios of some affected inner ear structures were higher than those of the unaffected sides in a group of 30 patients with sudden sensorineural hearing loss and 20 patients with nonsudden sensorineural hearing loss on 10-minute delayed-enhanced and 4-hour delayed-enhanced images.

CONCLUSIONS

Signal-intensity ratios of the inner ear show statistically significant increases in many diseases, especially neuritis, in 10-minute delayed-enhanced and 4-hour delayed-enhanced images. The 4-hour delayed-enhanced images may be superior in neural inflammatory-dominant conditions, while 10-minute delayed-enhanced images may be superior in neural noninflammatory-dominant conditions.

Clinical characteristics predicting early clinical failure after 72 h of antibiotic treatment in women with community-onset acute pyelonephritis: a prospective multicentre study

In patients with community-onset acute pyelonephritis (CO-APN), assessing the risk factors for poor clinical response after 72 h of antibiotic treatment (early clinical failure) is important. The objectives of this study were to define those risk factors, and to assess whether early clinical failure influences mortality and treatment outcomes. We prospectively collected the clinical and microbiological data of women with CO-APN in South Korea from March 2010 to February 2012. The numbers of cases in the early clinical success and early clinical failure groups were 840 (79.1%) and 222 (20.9%), respectively. Final clinical failure and mortality were higher in the early clinical failure group than in the early clinical success group (14.9% vs 2.3%, p <0.001; 6.8% vs 0.1%, p 0.001, respectively). In a multiple logistic regression model, the risk factors for early clinical failure among the total 1062 patients were diabetes mellitus (OR 1.5; 95% CI 1.1-2.1), chronic liver diseases (OR 3.3; 95% CI 1.6-6.7), malignancy (OR 2.2; 95% CI 1.1-4.4), Pitt score ≥2 (OR 2.5; 95% CI 1.6-3.8), presence of azotaemia (OR 1.8; 95% CI 1.2-2.7), white blood cell count ≥20 000/mm(3) (OR 2.5; 95% CI 1.6-4.0), serum C-reactive protein level ≥20 mg/dL (OR 1.7; 95% CI 1.2-2.4), and history of antibiotic usage within the previous year (OR 1.5; 95% CI 1.1-2.2). Analysing the subgroup of 743 patients with CO-APN due to Enterobacteriaceae, fluoroquinolone resistance of the uropathogen was another factor associated with early clinical failure (OR 1.7; 95% CI 1.1-2.5). Simple variables of underlying diseases, previous antibiotic usage and initial laboratory test outcomes can be used to decide on the direction of treatment in CO-APN.

Clinical characteristics of community-acquired acute pyelonephritis caused by ESBL-producing pathogens in South Korea

OBJECTIVES

The aim of this study was to determine the risk factors and clinical characteristics of community-acquired acute pyelonephritis (CA-APN) caused by extended-spectrum β-lactamase (ESBL)-producing organisms.

METHODS

From March 2010 to February 2011, patients with CA-APN were recruited in 11 hospitals in South Korea. Clinical and microbiological data were collected prospectively, and the ESBLs and multilocus sequence types of the ESBL-producing Escherichia coli were characterized. Comparison between CA-APN caused by ESBL-producing Enterobacteriaceae and those by non-ESBL-producing organisms was performed.

RESULTS

A total of 566 patients were recruited. Enterobacteriaceae were detected in 526 patients. Forty-six isolates (46/526, 8.7 %) were positive for ESBLs. Clinical and microbiological failure did not differ between the two groups, despite there being fewer patients with ESBL-positive isolates provided with appropriate antibiotics initially (19.6 vs. 93.8 %, p < 0.001). However, the duration of hospitalization was longer in the ESBL group (10.5 vs. 7.0 days, p = 0.012). In a logistic regression model, Charlson score ≥1 point [odds ratio (OR) 3.4, 95 % confidence interval (CI) 1.6-7.0, p = 0.001], antibiotics usage during the previous year (OR 3.1, 95 % CI 1.4-7.2, p = 0.008), and urinary catheterization during the previous month (OR 4.4, 95 % CI 1.1-17.6, p = 0.035) were associated with the risks of CA-APN by ESBL producers. CTX-M-15 (48 %) and CTX-M-14 (38 %) were the most common ESBLs. ST131 was the most common clone (7/24, 29.1 %), which was more frequently resistant to cefepime, fosfomycin, and temocillin.

CONCLUSIONS

The risk factors for CA-APN by ESBL producers were Charlson score ≥1 point, antibiotics usage during the previous year, and urinary catheterization during the previous month.

Roles of ultrasonography and computed tomography in the surgical management of cervical lymph node metastases in papillary thyroid carcinoma

AIMS

Adequate evaluation and surgical management of cervical lymph node metastasis is very important in papillary thyroid carcinoma (PTC). The aim of this study was to evaluate the impact of preoperative ultrasonography (US) and computed tomography (CT) on the surgical management of cervical lymph node metastases in PTC.

METHODS

Medical records and imaging findings were retrospectively analyzed for 252 patients with PTC who underwent thyroidectomy with neck dissection.

RESULTS

The sensitivity of both imaging techniques was lower in the central neck (US 23%, CT 41%) than in the lateral neck (US 70%, CT 82%). The specificities of US and CT were 97% and 90% in the central neck, and 84% and 64% in the lateral neck, respectively. Our surgical plans for therapeutic neck dissection were based on imaging findings in 59% of patients who underwent lateral compartment neck dissection and in 32.1% of patients who underwent central compartment neck dissection, respectively.

CONCLUSIONS

The roles of preoperative US and CT in surgical planning for central compartment neck dissection in PTC are limited because of their low sensitivity in the central neck, but US and CT may be useful in cases with non-palpable lateral neck nodes.

Clarithromycin and amikacin vs. clarithromycin and moxifloxacin for the treatment of post-acupuncture cutaneous infections due to Mycobacterium abscessus: a prospective observational study

An outbreak of post-acupuncture cutaneous infections due to Mycobacterium abscessus occurred in Ansan, Korea, from November 2007 through to May 2008. During this time a prospective, observational, non-randomized study was conducted involving 52 patients that were diagnosed with cutaneous M. abscessus infection. We compared the clinical response between patients treated with clarithromycin plus amikacin regimen and those treated with clarithromycin plus moxifloxacin regimens with regard to time to resolution of the cutaneous lesions. Among the 52 study patients, 33 were treated with clarithromycin plus amikacin, and 19 were treated with clarithromycin plus moxifloxacin. The baseline characteristics for the treatment groups were not significantly different, except for initial surgical excision (n = 27 vs. 6, respectively, p = 0.001). The median time (weeks) to resolution of the lesions in the clarithromycin plus moxifloxacin-treated subjects was significantly shorter than that in the clarithromycin plus amikacin-treated subjects (17 ± 1.1 vs. 20 ± 0.9, respectively, p = 0.017). With adjustments for age, location of lesions, prior incision and drainage, and excision during medical therapy, clarithromycin plus moxifloxacin-treated subjects were more likely to have resolved lesions (hazard ratio, 0.387; 95% confidence interval, 0.165-0.907; p = 0.029). The frequency of drug-related adverse events in the two treatment groups was not significantly different (n = 18 vs. 14, respectively; p = 0.240). The most common adverse event was gastrointestinal discomfort. The results of our study showed that the combination regimen of clarithromycin and moxifloxacin resulted in a better clinical response than a regimen of clarithromycin plus amikacin when used for treatment of cutaneous M. abscessus infection.

Differential immune-related gene expression in two genetically disparate chicken lines during infection by Eimeria maxima

Two M5.1 and M15.2 B complex congenic lines of Fayoumi chickens were evaluated for body weight loss and faecal oocyst counts as parameters of avian coccidiosis. M5.1 chickens exhibited resistance to E. maxima compared with M15.2. To correlate the differential responses of the M5.1 and M15.2 lines to E. maxima infection with cellular immune responses, the expression levels of mRNAs encoding 14 immune-related molecules were measured by quantitative RT-PCR in intestinal intraepithelial lymphocytes (IELs) and splenocytes at 0, 3, 4, and 5 days following parasite infection. Intestinal IELs from M5.1 chickens expressed higher levels of transcripts encoding interferon gamma (IFNG), interleukin-lbeta (1L1B), IL6, IL8, IL12, IL15, IL17A, inducible nitric oxide synthase (iNOS), and lipopolysaccharide-induced tumour necrosis a factor (LITAF), and lower levels of mRNAs for IFNA, IL10, IL17D, NK-lysin (NKL), and tumour necrosis factor superfamily 15 (TNFSF15) at 3 days post infection, compared with the M15.2 line. In the spleen, E. maxima infection was associated with higher expression levels of IFNA, and IL15 and lower levels of IL6, IL17D, and IL12 in M5.1 compared to M15.2 birds. Using an intestinal IEL cDNA microarray, the differential dynamics of gene expression in the gut of M5.1 and M15.2 chickens following experimental coccidiosis were evident. In particular, the genes encoding lymphotactin and parathymosin were expressed at significantly higher levels in M5.1 compared with M15.2 line chickens. In conclusion, genetic determinants within the chicken major histocompatibility complex (MHC) B complex influence resistance to E. maxima infection by controlling the local and systemic expression of immune-related cytokine and chemokine genes.

Immune-related gene expression in two B-complex disparate genetically inbred Fayoumi chicken lines following Eimeria maxima infection

To investigate the influence of genetic differences in the MHC on susceptibility to avian coccidiosis, M5.1 and M15.2 B-haplotype-disparate Fayoumi chickens were orally infected with live Eimeria maxima oocysts, and BW gain, fecal oocyst production, and expression of 14 immune-related genes were determined as parameters of protective immunity. Weight loss was reduced and fecal parasite numbers were lower in birds of the M5.1 line compared with M15.2 line birds. Intestinal intraepithelial lymphocytes from M5.1 chickens expressed greater levels of transcripts encoding interferon-gamma (IFN-gamma), interleukin-1beta (IL-1beta), IL-6, IL-8, IL-12, IL-15, IL-17A, inducible nitric oxide synthase, and lipopolysaccharide-induced tumor necrosis factor-alpha factor and lower levels of mRNA for IFN-alpha, IL-10, IL-17D, NK-lysin, and tumor necrosis factor superfamily 15 compared with the M15.2 line. In the spleen, E. maxima infection was associated with greater expression levels of IFN-gamma, IL-15, and IL-8 and lower levels of IL-6, IL-17D, and IL-12 in M5.1 vs. M15.2 birds. These results suggest that genetic determinants within the chicken MHC influence resistance to E. maxima infection by controlling the local and systemic expression of immune-related cytokine and chemokine genes.

Influence of Pediococcus-Based Probiotic on Coccidiosis in Broiler Chickens

Coccidiosis is the major parasitic disease of poultry and is caused by the apicomplexan parasites Eimeria. Drugs and live vaccines are the 2 main control measures of the disease; however, due to increasing concerns with prophylactic drug use and the high cost of vaccines, alternative control methods are needed. Recent evidence that various dietary and live microbial supplements can influence host immunity against enteric diseases prompted us to investigate the role of a Pediococcus-based probiotic on coccidiosis in broiler chickens. In the present study, we examined BW gains, oocyst shedding, and antibody responses of broilers fed the commercial probiotic MitoGrow. Day-old chicks were fed either a regular broiler diet or 1 of 2 probiotic diets supplemented with 0.1% (MG 0.1) or 0.2% MitoGrow. Chicks were orally challenged with 5,000 or 10,000 sporulated oocysts of Eimeria acervulina or with 5,000 Eimeria tenella oocysts on d 10 or 12 of age, respectively. In E. acervulina-infected birds, the MG 0.1 group improved (P < 0.05) weight gain as compared with the other 2 groups and reduced (P < 0.05) oocyst shedding in birds infected with 5,000 E. acervulina oocysts. In E. tenella-infected birds, Eimeria-specific antibody levels were higher (P < 0.05) in the Mito-Grow-fed groups, especially in the MG 0.1 birds, compared with the regular diet group, although their oocyst shedding and weight gains were not clearly improved. These results demonstrate that this Pediococcus acidilactici-based probiotic effectively enhances the resistance of birds and partially protects against the negative growth effects associated with coccidiosis, particularly when supplemented at 0.1% MitoGrow of the diet.

Progesterone-dependent release of transforming growth factor-beta1 from epithelial cells enhances the endometrial decidualization by turning on the Smad signalling in stromal cells

Endometrial decidualization results from the differentiation of stromal cells in an ovarian steroid-sensitive manner. Human endometrial tissues obtained from fertile women at various stages of the menstrual cycle were subjected to immunohistochemistry to localize the components of the transforming growth factor-beta (TGF-beta) system. TGF-beta receptor-I and -II expression was higher in stromal cells than in epithelial cells during the secretory phase while no such variation was observed during the proliferative phase. The expression of phosphorylated Smad3 (pSmad2/3), an activated form of a component of the TGF-beta signalling pathway, and translocation of pSmad2/3 from the cytoplasm to the nucleus were more pronounced in secretory endometrium. In coculture of human endometrial epithelial with stromal cells, each isolated from the proliferative endometrium, administration of progesterone stimulated decidualization as well as TGF-beta signalling activation in stromal cells. Progesterone also significantly elevated the concentration of TGF-beta1 in the coculture medium. Careful manipulation of the coculture, i.e. selective addition and omission of the cellular components, showed that this progesterone-induced increase in secretion of TGF-beta1 come mainly from epithelial cells. Moreover, administration of TGF-beta1 (10 ng/ml) directly to cultured stromal cells enhanced the expression of prolactin as well as pSamd2/3 even without progesterone. Taken together, our present data support the notion that progesterone induces stromal decidualization indirectly, i.e. by enhancing the expression and secretion of TGF-beta1 from epithelial cells. The secreted, epithelial-derived TGF-beta1 then acts on adjacent stromal cells, at least in part, to turn on Smad signalling that could lead to stromal decidualization.

Transfer of 137Cs to rice plants from various paddy soils contaminated under flooded conditions at different growth stages

Soil blocks from 18 paddy fields around three Korean nuclear power plant sites were put into lysimeters. Greenhouse experiments were carried out to investigate the (137)Cs transfer from these paddy soils to rice plants for its deposition at different growth stages. A solution of (137)Cs was applied to the flooded lysimeters at 2-3 different stages. The applied (137)Cs was mixed with the topsoil only at the pre-transplanting application. The transfer was quantified with a transfer factor based on the unit-area deposition (TF(a), m(2)kg(-1)-dry). The TF(a) in the pre-transplanting application showed a remarkable variation with the soils. However, the differences in the mean values among the study sites were not statistically significant. The straw TF(a) was 2-3 times higher than the corresponding seed value. The early-tillering stage and booting stage applications resulted in a higher transfer than the pre-transplanting application by factors of, on an average, 2 and 16 for the straws, and 3 and 25 for the hulled seeds, respectively. The (137)Cs transfer was found to correlate negatively with the soil pH and positively with the organic matter content. Based on the present results, the representative (137)Cs TF(a) values for the rice are proposed for use in the whole of Korea for the deposition at three different growth stages.

Solid and papillary epithelial neoplasm of the pancreas with peritoneal metastasis and its recurrence: a case report

Solid and papillary epithelial neoplasm of the pancreas is a low-grade malignant tumor, generally occurring as a slowly growing upper abdominal mass in a young female. With complete excision, the prognosis is good. Malignant behavior with metastasis does occur, but the incidence is very low. We report a young woman who had this neoplasm in the pancreatic tail with peritoneal seeding and its recurrence.

Biodegradation of toluene by a lab-scale biofilter inoculated with Pseudomonas putida DK-1

The biodegradation of toluene by biofiltration inoculated with Pseudomonas putida DK-1 was investigated with variation of the several environmental parameters, such as temperature, bed length, gas flow rate and optimal humidity zone. The optimal temperature range to treat toluene gas was found to be 32-35 degrees C. Increasing the gas flow rate showed an inverse effect on the elimination capacity and the removal efficiency. The optimal gas flow rate was obtained at 65 ml min(-1) from the relation between the removal efficiency and the elimination capacity. The biodegradation rate of the toluene with respect to the bed lengths (3, 6, 9, 12 and 15 cm) increased up to 80 h but was then independent of the bed lengths after 80 h except for the 3 cm bed length. The elimination capacity was improved by about 70% compared with that reported in other literature and was also in agreement with theoretical models.

Relationship between sonographic and pathologic findings in epidermal inclusion cysts

PURPOSE

We evaluated the sonographic findings in epidermal inclusion cysts and related them to the pathologic findings.

METHODS

We retrospectively reviewed the sonograms and pathology specimens of 24 patients with pathologically proven epidermal inclusion cysts. We evaluated the lesions for shape, size, internal echogenicity, posterior sound enhancement, and presence of color Doppler signals. We classified the masses into 5 sonographic types according to their internal echogenicity. The relationship between the sonographic types and the pathologic findings was examined.

RESULTS

The masses were ovoid or spherical in 17 cases (71%), lobulated in 5 (21%), and tubular in 2 (8%). The longest diameter ranged from 1 to 6 cm (mean, 3.1 cm). Twenty-three cases (96%) were associated with posterior sound enhancement. Color Doppler signals were absent in 20 cases, but some vascularity was noted in 4 ruptured epidermal cysts, in areas of granulation tissue. The most common sonographic type was a hypoechoic lesion with scattered echogenic reflectors (10 cases). Sonographic findings were related to the lamellation of keratin debris and the granulation tissue secondary to rupture. Most cases with a lobulated configuration (4 of 5) or color Doppler signals (4 of 4) were ruptured cysts.

CONCLUSIONS

Epidermal inclusion cysts most often appeared sonographically as a hypoechoic mass containing variable echogenic foci without color Doppler signals. Ruptured epidermal cysts, however, may have lobulated contours and show color Doppler signals, mimicking a solid mass.

Potential predictors of asymptomatic ischemic heart disease in patients with vasculogenic erectile dysfunction

OBJECTIVES

To prospectively define the potential predictors of asymptomatic ischemic heart disease in patients with vasculogenic erectile dysfunction using a simple and practical method. Most patients with vasculogenic erectile dysfunction are known to have at least one significant cardiovascular risk factor.

METHODS

After baseline evaluations, patients with erectile dysfunction of presumed vascular origin, who were older than 45 years and with no history of ischemic heart disease, were enrolled in the study. According to the results of repeated pharmacologic erection tests, we divided patients into responders and nonresponders. The cardiologic evaluations consisted of a comprehensive history taking, the assessment of cardiovascular risk factors, a physical examination, and an exercise treadmill test.

RESULTS

A total of 97 patients completed the study. Fifteen (32.6%) of 46 responders and 25 (49.0%) of 51 nonresponders, respectively, had two or more cardiovascular risk factors (P = 0.101). Ischemic ST-segment changes on the exercise treadmill test were only observed in 8 nonresponders (15.7%) (P = 0.006). All these patients were older than 55 years, and seven had two or more cardiovascular risk factors, including hypertension.

CONCLUSIONS

On the basis of these preliminary data, we suggest that cardiovascular evaluations may prove beneficial before prescribing sildenafil to patients with vasculogenic erectile dysfunction who are nonresponders to the pharmacologic erection test, are older than 55 years, and have two or more risk factors, including hypertension.

Localization of matrix metalloproteinases on endometrial cancer cell invasion in vitro

OBJECTIVES

In this study, we have established an in vitro three-dimensional (3D) coculture, where normal endometrial stromal cells and endometrial cancer cells were cocultured under defined hormonal conditions, to investigate the potential paracrine effects on synthesis and secretion of matrix metalloproteinases (MMPs) and, thus, cancer invasion.

METHODS

Endometrial stromal cells were obtained by biopsy, cultured in the presence of 100 nM estrogen for 3 days, and then mixed with extracellular matrix (ECM) composed of collagen I and matrigel in a 4:1 ratio. After 3 more days in culture, a 3D coculture was established with HEC-1A cells, an endometrial adenocarcinoma cell line, grown on top of the mixture under various ovarian steroids (no steroid, 100 nM beta-estradiol (E2), or 1.0 microM progesterone (P4)) for 10 days. The expression and localization of MMP-2, MMP-9, and integrin beta 3 subunit were visualized by immunocytochemistry and analyzed by reverse transcription polymerase chain reaction (RT-PCR). The extent of cancer invasion was quantified by Boyden's chamber assay.

RESULTS

Integrin beta 3 subunit was localized along the cell surface of HEC-1A cell under all three hormonal conditions. MMP-2 was located in the cytoplasm of stromal cells and on the surface of HEC-1A cells. Synthesis and secretion of stromal MMP-2 were increased in the presence of ovarian steroids. In contrast, expression of stromal MMP-9 was suppressed in the presence of ovarian steroids. No MMPs were synthesized in HEC-1A cells. Invasion assay revealed that HEC-1A cells achieved high tumoral invasiveness in the presence of beta-estradiol.

CONCLUSIONS

These findings suggest that stromal cell-derived MMP-2 is translocated to the surface of HEC-1A cells. Integrin beta 3 subunit might contribute, in part, to providing a binding site for MMP-2. Thus, HEC-1A cells invade by recruiting MMP-2 secreted by stromal cells, which is greatly enhanced in the presence of beta-estradiol. The 3D coculture provides an excellent experimental system in which single parameters can be isolated from a complex in vivo system in the process of endometrial cancer invasion.

Group IIA secretory phospholipase A(2) stimulates inducible nitric oxide synthase expression via ERK and NF-kappaB in macrophages

The mammalian group IIA secretory phospholipase A(2) (sPLA(2)) is believed to play an important role in inflammation and cell injury. The present study underlines the importance of group IIA sPLA(2) in the regulation of iNOS. Treatment of cells with sPLA(2) induced protein expression and mRNA accumulation of iNOS in a dose-dependent manner. The pretreatment of cells with rho-BPB or SCA, selective sPLA(2) inhibitors, inhibited sPLA(2)-induced iNOS expression. sPLA(2) stimulated the simultaneous activation of two classes of mitogen-activated protein kinases ERK and JNK, but did not stimulate p38 MAPK. PD98059, a selective MEK inhibitor, inhibited sPLA(2)-induced nitrite production and iNOS expression as well as ERK phosphorylation. In addition, pretreatment of rho-BPB or SCA also resulted in inhibition of sPLA(2)-induced ERK phosphorylation. The sPLA(2) signaling mechanisms involving the activation of transcription factor NF-kappaB were studied in the same cells. That stimulation of cells with sPLA(2) caused NF-kappaB activation in a time-dependent manner was shown by the detection of NF-kappaB-specific DNA-protein binding and by IkappaBalpha degradation. sPLA(2)-induced NF-kappaB activation was prevented in the presence of rho-BPB. Furthermore, the NF-kappaB inhibitor PDTC suppressed sPLA(2)-induced nitrite production and iNOS expression as well as IkappaBalpha degradation. The results strongly suggest that group IIA sPLA(2) induces iNOS in macrophages and that this induction occurs through ERK and NF-kappaB.

Roentgenographic assessment of acromial morphology using supraspinatus outlet radiographs

PURPOSE

The purpose of this study was to offer objective and standardized criteria for classifying acromial morphology.

TYPE OF STUDY

Blinded study.

METHODS

Two of the authors independently classified 106 supraspinatus outlet radiographs (SOR), obtained from 100 skeletally mature patients with impingement syndrome of the shoulder, using both Bigliani's and Park's standardized criteria. The same authors classified the 106 SOR again using the same criteria 2 weeks later. In addition, 2 orthopaedic residents independently classified the same SOR on the basis of the Bigliani and Park criteria in the same manner.

RESULTS

The rate of agreement was 66.0% (70 of 106) on the basis of Bigliani's criteria and 95.3% (101 of 106) on the basis of Park's criteria. The interobserver reliability coefficient of the 2 authors the first time was 0.448 (poor) and 0.914 (good to excellent). Their mean intraobserver reliability coefficient was 0.834 (good to excellent) and 0.87 (good to excellent) each. For the 2 orthopaedic residents, the rate of agreement was 58.5% (62 of 106) on the basis of Bigliani's criteria and 86.8% (92 of 106) on the basis of Park's criteria, and the interobserver reliability coefficient the first time was 0.28 (poor) and 0.77 (good to excellent) each. The mean intraobserver reliability coefficient was 0.738 (fair) and 0.844 (good to excellent) each.

CONCLUSIONS

In conclusion, regarding the classification for acromial morphology, Park's standardized criteria were far more objective, reliable, and reproducible rather than Bigliani's criteria through naked eye observations, especially for distinguishing the type II and type III acromion.

A comparative pharmacodynamic study of IY-81149 versus omeprazole in patients with gastroesophageal reflux disease

OBJECTIVE

To evaluate and compare the pharmacodynamic effects of IY-81149 and omeprazole on gastric pH in patients with gastroesophageal reflux disease.

METHODS

Sixty male and female volunteers with gastroesophageal reflux disease were enrolled in a double-blind, two-way, crossover, dose-ranging study. Subjects were randomized into three groups, with each group comparing the effect of one of three doses of IY-81149 (5, 10, or 20 mg) with 20 mg omeprazole. IY-81149 and omeprazole were administered once daily for 5 days. Continuous 24-hour pH measurements were performed before the first dose (baseline) and after the fifth dose in both periods. Gastric acid suppression was evaluated on the basis of the following parameters: AUC(0-24), median pH in a 24-hour interval (pHmedian), and the percent time in a 24-hour interval in which the gastric pH was greater than 4 (tpH > 4). The truncated AUC parameters AUC(0-8), AUC(8-16), and AUC(16-24) were also calculated. The effects of IY-81149 and omeprazole on gastric pH were compared by use of analyses of covariance. The dose-response relationship for IY-81149 was also evaluated.

RESULTS

There were no statistically significant differences between 5 mg IY-81149 and 20 mg omeprazole in terms of AUC(0-24), pHmedian, tpH, 4, AUC(0-8), and AUC(8-16). IY-81149, at 10 mg, produced a significantly greater gastric acid suppression than omeprazole on the basis of the values of AUC(0-24), pHmedian, tpH > 4, AUC(8-16), and AUC(16-24). Administration of 20 mg IY-81149 produced a significantly greater gastric acid suppression on the basis of all parameters. All doses of IY-81149 were more effective than omeprazole during 16 to 24 hours after the dose was administered.

CONCLUSIONS

Administration of 10 and 20 mg IY-81149 produced a statistically significantly greater and prolonged suppression of gastric pH than 20 mg omeprazole.

Outcome of sulcus fixation of dislocated posterior chamber intraocular lenses using temporary externalization of the haptics

OBJECTIVE

This study evaluated the visual outcome and complications of repositioning and sulcus fixation of a dislocated posterior chamber intraocular lens (PC IOL) using a technique in which the haptics of the IOL are temporarily externalized for suture placement.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Seventy-eight patients with a dislocated PC IOL.

INTERVENTION

All patients underwent surgery to fixate the PC IOL using this technique.

MAIN OUTCOME MEASURES

Patients were evaluated for visual acuity, refractive error, and surgical complications associated with the procedure.

RESULTS

The average visual acuity before surgery was 20/205 (range, 20/20 to light perception), with a median refractive error of -1.00 diopters (D; range, -7.25-+15.00 D). After surgery, the average visual acuity improved to 20/72 (range, 20/20 to no light perception), with a median refractive error of -0.75 D (range, -5.50-+3.50 D). Patients were observed for a median of 15.5 months (range, 6-57 months). Twenty patients had postoperative cystoid macular edema (26%), 7 patients had an epiretinal membrane (ERM) (9%), and 5 patients had a retinal detachment (6%). Eight patients (10%) experienced iris capture of the sutured IOL, and in three patients (4%) the PC IOL dislocated again after surgery.

CONCLUSIONS

This technique is an effective method for securing a dislocated PC IOL.

MR imaging of medullary streaks in osteosclerosis: a case report

We present a case of medullary sclerosis of the appendicular skeleton in a patient with chronic renal insufficiency for whom MR imaging findings were characteristic. T1- and T2-weighted MR images showed multiple vertical lines (medullary streaks) of low signal intensity in the metaphyses and diaphyses of the distal femur and proximal tibia.

Pars plana vitrectomy without scleral buckle for pseudophakic retinal detachments

OBJECTIVE

To report the anatomic and visual results of primary pars plana vitrectomy (PPV) without scleral buckling to repair primary rhegmatogenous retinal detachments in pseudophakic eyes.

DESIGN

Nonrandomized, prospective, comparative clinical trial.

PARTICIPANTS

Two hundred eighty-three consecutive patients (294 eyes) with pseudophakia, peripheral retinal tears, and new rhegmatogenous retinal detachments were treated according to the surgery protocol.

INTERVENTION

Patients underwent PPV with fluid-gas exchange and endolaser to repair the retinal detachment. Two hundred sixty-four patients (275 eyes) were followed from 6 months to 6 years and 8 months with an average follow-up of 19 months.

MAIN OUTCOME MEASURES

Reattachment of the retina and visual outcome were compared to previously published studies.

RESULTS

Of 97 eyes with a macula-attached rhegmatogenous retinal detachment, 88 eyes (91%) were reattached with a single operation, and of the 178 eyes with a macula-detached retinal detachment, 153 (86%) eyes were reattached with a single operation. In 241 (88%) of 275 eyes, the retina was reattached with a single operation, and in 265 (96%) of 275 eyes, the retina was ultimately reattached with subsequent operations. The median initial visual acuity was 20/300, and the median final visual acuity was 20/40. The rate of reattachment with one operation was similar for eyes with an anterior chamber intraocular lens (91%) and for eyes with a posterior chamber intraocular lens (88%). Refractive error measurements obtained in 81 eyes were essentially unchanged. The mean change in refractive error was -0.15 diopter. Seventeen eyes (6%) developed macular puckers requiring surgery, 46 eyes (17%) developed cystoid macular edema, and 6 eyes (2%) developed full-thickness macular holes.

CONCLUSION

Primary PPV with fluid-gas exchange and laser is a safe, effective method to repair primary pseudophakic retinal detachments. The anatomic reattachment rate and the visual acuity obtained with this technique appear to be at least as good as those reported in the literature for scleral buckling, PPV with scleral buckling, and pneumatic retinopexy.

Macular hole surgery with internal-limiting membrane peeling and intravitreous air

OBJECTIVE

To examine the results of macular hole surgery using pars plana vitrectomy, internal-limiting membrane peeling, and intravitreous air in a series of consecutive patients.

DESIGN

A retrospective, interventional, noncomparative case series.

PATIENTS

Fifty consecutive patients (58 eyes) with full-thickness macular holes.

INTERVENTION

All eyes underwent a pars plana vitrectomy with internal-limiting membrane peeling and intravitreous air, and patients were asked to position face-down for only 4 days.

MAIN OUTCOME MEASURES

Status of macular holes, visual acuity, and associated findings and complications.

RESULTS

All patients had postsurgical follow-up of 6 months or greater. Eight eyes (14%) presented with stage-2 macular holes, 48 eyes (83%) with stage-3 macular holes, and 2 eyes (3%) with stage-4 macular holes. Only 26 eyes (45%) had a macular epiretinal membrane seen before surgery. Fifty-three (91 %) of the 58 macular holes were closed with 1 operation, and 55 (95%) had closure of the macular holes with subsequent operations. Five (9%) of 58 eyes had an initial visual acuity of 20/50 or better, and 31 eyes (53%) had a final visual acuity of 20/50 or better. Of the 45 eyes with symptoms of less than 6 months' duration, 44 (98%) had macular holes that were closed with 1 operation and 27 (60%) had a final visual acuity of 20/50 or better. Of the 13 eyes with symptoms of 6 months' duration or longer, 9 (69%) had macular holes that were closed with 1 operation and 4 (31 %) had a final visual acuity of 20/50 or better. Complications attributed to the operation included retinal tears, retinal detachments, postoperative macular puckers, and macular light toxicity.

CONCLUSIONS

The anatomic and visual results in this series are good. The current technique is similar to that of conventional macular hole surgery except for the use of intravitreous air, internal-limiting membrane peeling in all eyes, and only 4 days of postoperative positioning. This study would suggest that peeling of the internal-limiting membrane is an important adjuvant for successful closure of macular holes.

The effect of mitomycin-C on the healing process in rabbit extraocular muscle surgery

BACKGROUND AND OBJECTIVE

One of the most serious complications following extraocular muscle surgery is formation of postoperative adhesions that may result in restrictive ocular motility dysfunction. The effect of mitomycin-C (MMC) on postoperative wound healing in extraocular muscle surgery was investigated.

MATERIALS AND METHODS

Sixteen albino rabbits (24 eyes) were used and anesthetized with ketamine and xylazine. These rabbits were divided into 3 groups; (1) control group (balanced salt solution (BSS) exposure for 5 minutes), (2) Group 1 (0.5 mg/ml MMC exposure for 1 minute) and (3) Group 2 (0.5 mg/ml MMC exposure for 5 minutes). After 3 mm recession of superior rectus muscle, MMC or BSS was applied using Weck-Cel sponge (Solan, Jacksonville, FL). The reduction of fibroblast and collagen fiber proliferation were evaluated histopathologically with light microscope at 1, 2, 4 and 8 weeks after operation. We also evaluated the amount of basic fibroblast growth factor (bFGF) by immunohistochemical study at the same time.

RESULTS

Histopathologically, there was a more significant reduction of fibroblast and collagen fiber proliferation in Group 1 and 2 than the control group. Immunohistochemically, Group 1 and 2 showed lesser expression of bFGF than the control group. But, there was no difference between Group 1 and 2.

CONCLUSIONS

Topical intraoperative application of mitomycin C in extraocular muscle surgery may reduce postoperative adhesions.

The use of internal limiting membrane maculorrhexis in treatment of idiopathic macular holes

The purpose of this study was to assess surgical results of internal limiting membrane (ILM) maculorrhexis in macular hole surgery. This study is a part of continuing prospective clinical trial of our team of researchers. Thirteen eyes of 13 patients with idiopathic macular hole underwent vitrectomy with the removal of posterior cortical vitreous, peeling of the macular ILM, and intraocular gas tamponade, followed by postoperative face-down positioning. The excised specimens were evaluated with transmission electron microscopy. Complete closure of the hole was observed in all 13 eyes (100% anatomic success rate). Visual improvement of 2 or more lines on ETDRS visual acuity chart was achieved in 11 (85%) of the 13 eyes. Six (54.5%) eyes attained visual acuity of 20/50 or better. Electron microscopy showed ILM in the removed specimens. ILM maculorrhexis is a promising new surgical approach to close idiopathic macular holes but requires further investigation and long-term evaluation.

Phakic patients with cystoid macular edema, retinal periphlebitis, and vitreous inflammation

OBJECTIVE

To characterize a group of phakic patients with idiopathic intermediate uveitis as defined by vitritis, cystoid macular edema, and retinal periphlebitis.

DESIGN

Cross-sectional study.

PARTICIPANTS

Nineteen phakic patients (35 eyes) with vitreous inflammation, cystoid macular edema, and/or retinal periphlebitis of unknown cause.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Best-corrected final visual acuities, standardized clinical examinations, photographic and fluorescein angiographic evaluations, and class I and II HLA analysis on all 19 patients.

RESULTS

Fifteen of the 19 patients were women. The mean age was 38 years, the mean follow-up was 104 months, and the mean duration of symptoms was 154 months. All 35 affected eyes had significant vitritis; 21 eyes (60%) had cystoid macular edema, 21 eyes (60%) had retinal periphlebitis. The median initial visual acuity was 20/30. The median final visual acuity was 20/20 with 32 (91%) of 35 eyes having 20/40 or better visual acuity at the final visit. No patient developed "snow-banks" or evidence of systemic disease, including multiple sclerosis or sarcoidosis, during the follow-up period. There were no statistically significant HLA associations in these patients compared with controls from another study from Iowa, but the Iowa phakic patients with cystoid macular edema did differ from the Iowa patients with pars-planitis at loci HLA-B8, HLA-B51, and HLA-DR2.

CONCLUSIONS

We describe a disease entity of idiopathic intermediate uveitis that affects primarily young to middle-aged women and usually causes bilateral vitritis, cystoid macular edema, and retinal periphlebitis. Most patients retained good vision over a prolonged follow-up period. Multiple sequential examinations and HLA associations suggest that these conditions are distinct from other syndromes of intermediate uveitis, particularly parsplanitis.

Acute posterior multifocal placoid pigment epitheliopathy with corneal stromal infiltrates

PURPOSE

To report the association of perilimbal corneal stromal infiltrates with acute posterior multifocal placoid pigment epitheliopathy.

METHOD

Case report.

RESULTS

A 29-year-old woman with bilateral fundus lesions typical of acute posterior multifocal placoid pigment epitheliopathy presented with peripheral corneal stromal infiltrates that resolved with fundus lesions.

CONCLUSION

Corneal stromal infiltrates may be associated with characteristic fundus lesions of acute posterior multifocal placoid pigment epitheliopathy.

Grid laser photocoagulation for macular edema in bilateral juxtafoveal telangiectasis

OBJECTIVE

The purpose of the study is to report the efficacy of laser photocoagulation treatment for macular edema in bilateral juxtafoveal telangiectasis (BJT).

DESIGN

The study design was a retrospective, clinical study.

PARTICIPANTS

The authors observed 14 patients with BJT, studying the visual acuities and retinal changes of treated and untreated eyes.

MAIN OUTCOME MEASURES

Visual acuity, presence of macular edema, and associated retinal findings were measured.

RESULTS

Of 28 eyes, 10 (8 patients) received 15 laser photocoagulation treatments for macular edema. Neither treated nor untreated eyes had visual improvement of two or more lines. After treatment, five eyes (50%) had increased retinal vascular distortion develop, three (30%) had new draining retinal venules, five (50%) had intraretinal fibrovascular tissues, and four (40%) had retinal and preretinal hemorrhages develop.

CONCLUSIONS

Grid laser photocoagulation therapy for macular edema in patients with BJT appears to neither improve nor stabilize long-term visual acuity. In addition, treatment is associated with retinal pigment epithelial changes, increased postoperative retinal vascular distortion, postoperative vascularized retinal scars, and postoperative retinal hemorrhages. These changes, however, do not appear to cause a further loss of vision.

Subacute sclerosing panencephalitis manifesting as viral retinitis: clinical and histopathologic findings

PURPOSE AND METHODS

To describe the clinical and histopathologic features of a patient with viral retinitis secondary to subacute sclerosing panencephalitis.

RESULTS

The patient was a human immunodeficiency virus-negative intravenous drug abuser with an acute retinitis that later progressed to encephalitis despite aggressive treatment for possible viral, protozoal, bacterial, and rickettsial infections. The patient had many of the characteristic findings of subacute sclerosing panencephalitis, including a history of measles in early childhood, myoclonus, periodic complexes on electroencephalographic testing, persistently elevated serum and cerebrospinal fluid antimeasles immunoglobulin G (IgG) titers, and a cerebrospinal fluid oligoclonal IgG gammopathy. Ultrastructural examination demonstrated numerous filamentous microtubular intranuclear viral inclusions in the nuclear layers of the retina consistent with the measles virus. This case is unusual in that our patient developed subacute sclerosing panencephalitis later in life and because there was an 8-year period between presumed viral infections in the two eyes.

CONCLUSIONS

An acute retinitis in an intravenous drug abuser is not always caused by human immunodeficiency virus-related infections; not all viral retinitis responds to therapy; and mortality as well as the usual morbidity may be associated with viral retinitis. One might consider the diagnosis of subacute sclerosing panencephalitis in a young person with an acute retinitis with little or no vitreal inflammation and lack of response to anticytomegalovirus and antitoxoplasmosis therapy.

Ring retinal pigment epithelial window defect of the macula in central serous chorioretinopathy

PURPOSE

Central serous chorioretinopathy is usually a benign disorder, in which resolution of serous subretinal fluid and return to a visual acuity of 20/40 or better is the normal outcome. In unusual cases of central serous chorioretinopathy, chronic subretinal fluid can lead to permanent retinal pigment epithelial depigmentation. In this report, we describe a ring-like (bull's eye) pattern of retinal pigment epithelial atrophy associated with central serous chorioretinopathy.

METHODS

We examined eight patients (nine eyes) with central serous chorioretinopathy in whom retinal pigment epithelial window defects encircling the fovea developed.

RESULTS

The average duration of symptoms before recognition of a circular window defect was 6 years. Visual acuity at the time of documentation of the ring-like window defect was 20/40 or worse in seven of nine (77%) eyes. Although laser photocoagulation treatment was performed in six of the nine eyes, vision improved two or more lines in only one eye (17%).

CONCLUSION

Chronic central serous chorioretinopathy can cause a ring-like (bull's eye) pattern of retinal pigment epithelial window defects encircling the fovea. This pattern of retinal pigment epithelial window defect when seen in patients with central serous chorioretinopathy may indicate that a patient has a more severe form of central serous chorioretinopathy.

Transrectal color Doppler ultrasonography for postejaculation hematuria

A case involving an adult man with postejaculation hematuria (PEH) is described. We used transrectal color Doppler ultrasonography to evaluate periprostatic or intraprostatic vascular anomalies. We confirmed a vascular anomaly by angiography and embolized it. Periprostatic vascular anomaly may be a cause of PEH, and color Doppler ultrasonography is helpful for the initial studies of this entity.

Effect of diclofenac sodium (Voltaren) on hypoxia-induced corneal edema in humans

We evaluated the effect of diclofenac sodium (Voltaren) drops on patients with hypoxia-induced corneal edema. Thirty age- and sex-matched subjects were randomly assigned to one of three groups. Members of each group received masked solutions of either Voltaren, Voltaren vehicle, or a non-preserved lubricant (Cellufresh) every 6 hours for 24 hours and then hourly for 2 hours immediately prior to inducing corneal edema in the experimental eye. Bilateral ultrasonic pachymetry was performed prior to applying a thick contact lens and light patch on the experimental eye of all subjects for 3 hours. The fellow eye served as the control. Following lens removal, bilateral corneal thickness was measured every 30 minutes. The percentage change in corneal swelling for each subject and group was calculated. The findings were also normalized to the control eye to minimize diurnal and individual variability. The results were plotted both as percentage change from hour 0 and percentage change normalized to the control eye. Corneal swelling ranged from 9-11% in all 3 groups, with recovery at 2-3 hours. No significant difference was found among the three groups (P > 0.05, ANOVA). There was a slight trend toward reduced thickness in the Cellufresh group, but this was not statistically significant. Voltaren does not appear to have an effect on the hypoxia-induced corneal edema associated with the production of arachidonic acid pathway metabolites.