[Clinical efficacy of stent-assisted coil embolization for recurrent intracranial bifurcation aneurysms]

Objective: To evaluate the safety and efficacy of stent-assisted coil embolization in patients with recurrent intracranial bifurcation aneurysms,after initial simple coiling or microsurgical clipping. Methods: Clinical data of 20 patients with recurrent intracranial bifurcation aneurysms who initially underwent simple coiling or surgical clipping and subsequently re-treated by stent-assisted coiling embolization at the Radiology Intervention Department of Huashan Hospital between March 2009 and November 2019 were collected and analyzed retrospectively.There were 9 males and 11 females,with a median age of 55.5 years (range:33 to 71 years),including 17 aneurysms initially treated with simple coiling and 3 treated with surgical clipping.All cases were re-treated with stent-assisted coiling,15 using a single stent and 5 employing two stents in a Y-configuration.Peri-and post-operative complications and outcomes were evaluated.Mann-Whitney U tests were performed to compare the follow-up duration between initial treatment and re-treatment.Student's t tests were used to compare the parent artery angles before re-treatment, after re-treatment and at the last follow-up. The parent artery angle was defined using the proximal main trunk and the stented branch. Results: Immediate complete occlusion (Raymond Ⅰ) was achieved in 18 aneurysms (90.0%) while 2 aneurysms (10.0%) had a residual neck (Raymond Ⅱ).The median follow-up time(M(Q_R)) was 8.5(16.3)months,which had no significantly different from the initial treatment follow-up duration (15.5(27.0)months)(U=157.7,P=0.25). During the follow-up period,2 aneurysms (10.0%) with immediate post-operative residual necks recanalized again,including 1 aneurysm re-treated with the Y-configuration stent.Symptomatic thromboembolic complications occurred in 6 patients,including 4 re-treated with the Y-configuration stent.No peri-operative hemorrhagic complications occurred,along with no operation-related permanent disability or death. The parent artery angle increased significantly from pre-operative(90.1±21.1)°to post-operative and the last follow-up ((115.4±28.9)° and (132.6±26.8)°);t=5.14,P<0.01;t=7.78,P<0.01). Conclusion: For recurrent intracranial bifurcation aneurysms after initial surgical clipping or simple coiling,stent assisted coil embolization is proved to be safe and can decrease recurrence rate.

Molecular characterization and functional analysis of sheep thyroid transcription factor-1

Thyroid transcription factor-1 (TTF-1), a member of the Nkx2 family of homeodomain-containing proteins, is involved in binding to and in activating the promoters of several important genes in the thyroid, lungs, and brain, and in regulating expression of these tissue-specific genes. We investigated potential roles of sheep (Ovis aries) TTF-1 in regulating cell fate and organ morphogenesis and in controlling puberty and reproductive capability of females. We amplified and cloned the sheep TTF-1 full-length DNA for the first time, analyzed its functional domains and regions, predicted molecular structure of its homeodomain and DNA-binding sites, and examined its expression in pituitary, brain, thyroid gland, ovary, and hypothalamus. We found that sheep TTF-1 has a high degree of homologous identity with that of other mammals, and it has several important domains including domain N, DNA-binding domain, domain C, TN-domain, domain I, and NK2-SD. The DNA-binding domain of sheep TTF-1 has 10 potential DNA-binding sites and is a novel mammalian homeodomain that shows considerable sequence homology with the corresponding rat homeodomain. Several functional regions in sheep TTF-1 share high sequence identity with rat TTF-1, indicating that these regions may have the same activity as in the rat. Expression of TTF-1 in several specific tissues implies that sheep TTF-1 in involved in sheep sexual development and reproductive capability. These results suggest a role of sheep TTF-1 in enhancing sheep reproduction performance and we propose it as a candidate gene for selection.

Do-not-resuscitate decision: the attitudes of medical and non-medical students

OBJECTIVES

To study the attitudes of both medical and non-medical students towards the do-not-resuscitate (DNR) decision in a university in Hong Kong, and the factors affecting their attitudes.

METHODS

A questionnaire-based survey conducted in the campus of a university in Hong Kong. Preferences and priorities of participants on cardiopulmonary resuscitation in various situations and case scenarios, experience of death and dying, prior knowledge of DNR and basic demographic data were evaluated.

RESULTS

A total of 766 students participated in the study. There were statistically significant differences in their DNR decisions in various situations between medical and non-medical students, clinical and preclinical students, and between students who had previously experienced death and dying and those who had not. A prior knowledge of DNR significantly affected DNR decision, although 66.4% of non-medical students and 18.7% of medical students had never heard of DNR. 74% of participants from both medical and non-medical fields considered the patient's own wish as the most important factor that the healthcare team should consider when making DNR decisions. Family wishes might not be decisive on the choice of DNR.

CONCLUSIONS

Students in medical and non-medical fields held different views on DNR. A majority of participants considered the patient's own wish as most important in DNR decisions. Family wishes were considered less important than the patient's own wishes.

Ruptured renal microaneurysms complicated with a retroperitoneal abscess for a patient with systemic lupus erythematosus

Renal artery aneurysm is extremely rare among patients with systemic lupus erythematosus.(SLE). Herein, we report on a 22-year-old male lupus patient who presented with acute abdominal pain, anemia and subsequent hypertension. Abdominal computed tomography revealed a peri-renal hematoma over the right kidney. A renal angiography revealed bilateral renal microaneurysms. The patient subsequently developed a right-side retroperitoneal abscess 4 weeks after hematoma formation and received an emergent laparotomy with drainage. Subsequent culture ofthe abscess-derived fluid revealed the presence of Proteus mirabilis and Escherichia coli. Following appropriate antipyretic and immunosuppressive drugs therapy, the patient recovered successfully. To the best of our knowledge, this is the first report of SLE associated with a retro-peritoneal abscess probably secondary to a ruptured renal microaneurysm.

Autologous peripheral blood stem cell transplantation for patients with malignancies: the Tri-Service General Hospital experience

BACKGROUND

High-dose chemotherapy/radiotherapy followed by autologous peripheral blood stem cells transplantation (APBSCT) can be used to treat chemosensitive malignant diseases. We retrospectively studied the APBSCT treatment efficacy and safety of patients at Tri-Service General Hospital (TSGH).

METHODS

From January 1994 to March 2000, 11 patients were treated with high doses of chemotherapy/radiotherapy followed by APBSCT. Nine patients were male and 2 were female. The median age was 26 years, with a range of 21 to 51. There were 7 acute myeloid leukemia (AML), 3 non-Hodgkin's lymphoma (NHL) and 1 ovarian cancer. All patients received both chemotherapy and granulocyte-colony stimulating factor to mobilize hematopoietic stem cells, and the most commonly used conditioning regimen was combined chemotherapy with Busulfan and Cyclophosphamide.

RESULTS

The median numbers of infused mononuclear and CD34+ cells were 3.19 x 10(8)/kg and 9.2 x 10(6)/kg, respectively. Nine of the 11 patients engrafted successfully, but 2 patients with AML failed to engraft. The median times of WBC recovery (ANC > or = 500/uL) and platelet recovery (> or = 20 x 10(3)/uL) were 13 and 16 days, respectively. Four patients with AML survived after APBSCT and two of them were alive and disease-free for 36 and 51 months, respectively. One patient with AML and 3 patients with NHL died of relapse, and one patient with ovarian cancer was alive but with disease at 50 months.

CONCLUSIONS

For patients with AML, APBSCT may be an alternative, safe and useful treatment modality. Further strategies for reducing relapse in lymphoma patients merit further investigation.

New chiral catalysts for reduction of ketones

The condensation of o-(diphenylphosphino)benzaldehyde and various chiral diamine gives a series of diimino-diphosphine tetradentate ligands, which are reduced with excess NaBH4 in refluxing ethanol to afford the corresponding diaminodiphosphine ligands in good yield. The reactivity of these ligands toward trans-RuCl2(DMSO)4 and [Rh(COD)Cl]2 had been investigated and a number of chiral Ru(II) and Rh(I) complexes with the PNNP-type ligands were synthesized and characterized by microanalysis and IR, NMR spectroscopic methods. The chiral Ru(II) and Rh(I) complexes have proved to be excellent catalyst precursors for the asymmetric transfer hydrogenation of aromatic ketones, leading to optically active alcohols in up to 97% ee.

Syntheses and spectroscopic and structural characterization of molybdenum(VI) citrato monomeric raceme and dimer, K4[MoO3(cit)].2H2O and K4[(MoO2)2O(Hcit)2].4H2O

Investigation of the aqueous coordination chemistry for citrate and molybdenum(VI) resulted in the isolation of molybdenum(VI) citrato monomeric raceme and dimer K4[MoO3(cit)].2H2O (1) and K4[(MoO2)2O(Hcit)2].4H2O (2) (H4cit = citric acid). Complex 1 can serve as the first structurally characterized monomeric citrato molybdate and may represent an early mobilized precursor in the biosynthesis of FeMo-co (FeMo-cofactor). The two complexes have been characterized by elemental analyses and IR and NMR spectroscopies. The IR and NMR spectra are consistent with a monomeric species or a monooxo-bridged dinuclear structure, as revealed by a single crystal X-ray diffraction study. Compound 1 is monoclinic space group P2(1)/c with a = 7.225(1) A, b = 9.151(2) A, c = 22.727(2) A, beta = 94.93(1) degrees, V = 1497.1(7) A3, and Z = 4. Full-matrix least-squares refinement resulted in residuals of R = 0.027 and Rw = 0.032. The molybdenum atom forms an octahedral coordination with three oxo groups and one tridentate citrate, in which the latter is coordinated through the alkoxy and vicinal carboxyl and much more weakly by one of the two terminal groups [2.411(3) A]. Compound 2 is triclinic space group P1 with a = 8.2728(8) A, b = 8.9514(8) A, c = 10.0605(9) A, alpha = 101.673(8) degrees, beta = 100.672(7) degrees, gamma = 112.938(7) degrees, V = 642.5(3) A3, and Z = 1. Full-matrix least-squares refinement resulted in residuals of R = 0.033 and Rw = 0.039. The complex anion contains a linear (O2Mo)O(MoO2) core with the bridging oxo group lying at the center of inversion symmetry (Mo-Ob-Mo, 180 degrees). Each citrate ligand is three-coordinated to one molybdenum atom through the deprotonated hydroxy, alpha-carboxyl, and one beta-carboxyl group, making each metal atom six-coordinate.

Acquired hemophilia A: report of two cases

Two patients who presented with active bleeding and were diagnosed with acquired hemophilia A (AHA) are reported herein. One was a 27-year-old woman who experienced spontaneous oozing from an episiotomy wound six days after her second normal delivery. Bleeding became progressively worse, despite treatment with primary sutures and curettage of the uterus at a local hospital. She underwent emergency exploratory laparotomy because of intra-abdominal bleeding, during which perforations of the uterus were discovered. Unremitting bleeding from the surgical wound occurred after surgery. The patient was finally diagnosed with AHA when Factor VIII (FVIII) inhibitor (titer, 19 Bethesda units (BU)/ml) was detected in her plasma. She died of refractory hemorrhaging, despite intensive treatment with Factor IX concentrate infusion and cyclophosphamide therapy. The second patient was a 22-year-old man who sustained spontaneous and recurrent intramuscular hemorrhage in the right thigh for one month. Laboratory studies including complete blood count, biochemical evaluation, coagulation screening and immunologic assays were all within normal limits, except for a prolonged activated partial thromboplastin time. Idiopathic AHA was diagnosed after the detection of plasma FVIII inhibitor with a concentration of 5.9 BU/ml. The patient's coagulopathy was successfully managed with plasma exchange and subsequent treatment with oral prednisolone and cyclophosphamide.

Acceleration of skin graft healing by growth factors

A special local burn wound treatment, using a healing promotion factor, attempted to achieve earlier wound closure. Clinically it is not difficult to harvest autologous human platelet-derived wound healing factor (HPDWHF) from burn patients. Another study has proved that porcine pituitary extract (PPE) could be one of the supplements for growing human keratinocytes in vitro (Wang HJ, Chen TM, Tung YM et al. Burns 1995). Initially, using the ELISA immunoassay, we detected titres of platelet-derived growth factor heterodimer AB (PDGF-AB) and epidermal growth factor (EGF) in HPDWHF and PPE. After elevating a 6 X 9 cm2 flap on the backs of Sprague-Dawley (SD) rats 1 ml of heterologous HPDWHF and PPE were sprayed topically on the wound and followed by grafting six pieces of 1 cm2 autologous full-thickness skin. The flap wound was then closed with a piece of large-pore Biobrane interposed between the skin graft wound and the flap. On postgraft day 7, the wound was reopened to measure the area of the full-thickness skin graft (FTSG) using micrographic paper; the results are reported as the percentage of graft expansion beyond the original size. In the cytokine study, we found that the concentrations of PDGF-AB dimer in HPDWHF and PPE were 5222 +/- 102 and 375 +/- 12 pg/ml (both values are reported after a 1:10 dilution) (n = 3), whereas the EGF concentration was 245 +/- 9 pg/ml, and undetectable in undiluted PPE (n = 3), thereby proving that the PDGF-AB and EGF fibres in the HPDWHF were significantly higher than in the PPE Both the HPDWHF (n = 6, with each animal grafted with six skin graft samples) and PPE (n = 7) demonstrated significant accelerations of FTSG growth, with 14.41 +/- 1.08 per cent and 13.16 +/- 3.25 per cent increases in the FTSG size when compared to the sham control group 1.39 +/- 3.26 per cent (n = 5) (P < 0.05). Comparisons between the treatment groups showed no evidence to indicate that the HPDWHF is superior to the PPE in accelerating FTSG growth (P > 0.05). This supports the hypothesis that PDGF appears to transduce its signal through wound macrophages and may trigger the induction of positive autocrine feedback loops and synthesis of endogenous wound PDGF and other growth factors, thereby enhancing the cascade of tissue repair (Pierce GF, Mustoe TA, Altrock B et al. 1991; J Cell Biochem 1991; 45: 319-326), and the effect that PDGF-AB on wound healing is not dose dependent (Mustoe TA, Cutler NR, Allman RM et al. Arch Surg 1994; 129: 213-219). In future studies we expect to show that autologous HPDWHF and heterologous PPE will promote skin graft wound healing in burn patients since they contain a high concentration of PDGF-AB.

Microsurgical replantation of avulsed scalps

Four cases of extensive scalp avulsion were successfully replanted in this reported series. All patients were female, with the youngest 3 years of age. All replanted scalps survived, with some marginal necrosis due to tissue destruction. Postoperative venous congestion of the involved ear in one patient was managed with anticoagulant therapy. Another patient underwent severe congestion of the whole replanted scalp and was treated with thin skin-graft shaving in the parietal area. In the follow-up period, all patients obtained hair growth in the scalp with light touch sensation.

Radioimmunodetection of prostatic cancer: in vivo use of antibody against r-seminoprotein for diagnosis of prostatic cancer

Forty patients (25 cases of prostatic cancer and 15 cases of benign prostatic hyperplasia) were examined with radioimmunodetection (RAID) using antibody against r-Seminoprotein (r-Sm). The images of malignant tumor sites were revealed from the scan of single photon emission computerized tomography with the tracing of dual radionuclide and computer digital subtraction technique. Of the 25 patients with prostatic cancer tested, twenty-four were demonstrated in RAID with a positive rate of 96%. The ratio of taking in nuclide radioactivity between the tumor tissue and normal tissue (T/N) was 6.9 and the best showing time was the 96th hr from injection of radioactive antibody against r-Sm. The minimum diameter of the tumor detected in RAID was 0.5 cm. All of the 8 cases of metastatic prostatic cancer in pelvic or bone location were detected, with a rate of 100%. Of the 15 cases of benign prostatic hyperplasia, only one showed mild positive result. B-ultrasonography and CT showed a positive detective rate of 72.7% and 65%, respectively. Our results have indicated that RAID using 131I-labeled antibody against r-Sm possesses more advantages in specificity, because RAID not only defines the involved sites, but also shows the sites of the original tumors, and the metastatic location as well as the relationship between them.

Analysis of cellular DNA content using flow cytometry in skin squamous cell carcinoma and its relationship to clinical behaviors

Our report includes a technique using the flow cytometer to analyze the cellular DNA content of paraffin-embedded histological material from tumors. This technique allows for the retrospective study of tumors from patients whose clinical outcome is already known. We have applied this process to study skin squamous cell carcinomas (SCCs). We reviewed and studied 34 patients positive for SCCs, With or without lymph node or distant metastasis. All received radical treatment from December 1982 to December 1988. The DNA distribution pattern of SCCs in relation to the clinical stage and the histological grade was evaluated. Our findings indicated that patients with diploid tumors had a better prognosis than those with aneuploid tumors. The DNA distribution pattern correlates well with the clinical stage and is a better determinant than histological grading or clinical behaviors.

[Versatility of rectus abdominis muscle or myocutaneous flap--report of seven cases]

The rectus abdominis muscle, due to its strategic location in the abdomen with its dual blood supply and wide arc of transposition, is ideally suited to repair defects over the chest, abdomen, groin and perineum. The muscle is generally based on the superior epigastric artery, deep inferior epigastric artery and their associated capillary communications. From September 1989 to September 1990, at Taichung Veterans General Hospital, seven cases were presented utilizing unilateral rectus abdominis muscle or myocutaneous flap for local or free tissue transfer. The recipient areas included abdomen, groin, perineum, lower leg and a penis reconstruction. Of all flaps that survived, one developed minor skin necrosis causing urethral orifice stricture and urethrocutaneous fistula that later required repair. All cases achieved the surgical goals. There was no donor site infection, nor abdominal wall herniation but persisted wound pain in 2 cases was noted during the follow-up period. All patients resumed daily activity without limitation about six weeks postoperatively. The large skin territory with abundant soft tissue offers versatile flap design. The dissection is simple, speedy and straight foreward. The deep inferior epigastric vessels are long and their calibers are suitable for vascular anastomosis. Usually, the donor sites are primary closed. We recommend this flap as one to be considered in reconstruction planning and as a donor material for free tissue transfer.

[Transfusion-induced severe allergic reaction--report of one case]

Recently, improved cross-matching techniques have reduced the frequency of adverse reactions of blood transfusion less the 2%, but allergic reactions (non-hemolytic) occur in about 3% of patients receiving properly typed and crossmatched blood. Allergic reactions to blood or drugs administered during anesthesia represent an unpredictable and occasionally life-threatening event. When a severe allergic reaction develops, an aggressive and prompt treatment, including intravenous epinephrine, is necessary to minimize morbidity and mortality. We experienced a case of intraoperative shock due to blood transfusion. The case manifested with hypotension, tachycardia, cutaneous rash and bronchospasm during blood transfusion and then the aggressive treatment was given to resume normal vital signs. The rest of anesthesia and surgery as well as the recovery was uneventful and the patient was discharged on the 18th postoperative day.