Addition of adipose tissue-derived mesenchymal stem cells improves empagliflozin therapy for alleviating hyperglycemia--induced neuropathy

BACKGROUND

We examined the impact of adipose-derived mesenchymal stem cell (ADMSC)-facilitated empagliflozin (EMPA) therapy for alleviating hyperglycemic induced neuropathy [i.e., diabetic neuropathy (DN)].

METHODS

Study constituted N2a cell culture and rats to be classified into groups 1 (sham-operated-control)/2 (DN)/3 (DN + empagliflozin/20 mg/kg/daily orally for 6 weeks since post-day-7 DN induction)/4 (DN + ADMSCs/1.2 × 106 cells by vein transfusion at time intervals of 1/3/5 weeks after DN induction)/5 (DN + empagliflozin + ADMSCs) and sacrificed by day-42 after DN induction.

RESULTS

In vitro results showed that, compared to N2a cells, the cellular levels of senescence/DNA-damage and protein expressions of oxidative-stress (OS), apoptotic, autophagic and inflammatory biomarkers were significantly higher in N2a + glucose (25 mM) but were significantly reversed in N2a + glucose + ADMSCs, whereas the cellular levels of mitochondrial cytochrome C and protein levels of anti-oxidants displayed an opposite pattern of OS (all P<0.001). The above-mentioned parameters (i.e., OS/apoptosis/fibrosis/autophagy/DNA-damage) were lowest in N2a cells, highest in N2a + glucose and significantly higher in N2a + glucose + EMPA (50 μM) than in N2a + glucose + EMPA (150 μM) (all P<0.001). By days 7/14/21/28/35/42 after DN induction, the values of thermal paw-withdrawal-latency (TPWL)/mechanical-paw-withdrawal-threshold were highest in group 1 and significantly progressively increased from groups 2/4/3/5 (all P<0.0001). The cellular levels of unmyelinated C- and myelinated A-δ fibers, and protein levels of OS/apoptotic/DNA-damaged/fibrotic/autophagic/inflammatory/pain-facilitated/voltage-gated sodium channel biomarkers in L4-L5 levels of dorsal-root-ganglia exhibited an contradictory manner of TPWL among the groups (all P<0.0001).

CONCLUSIONS

Combination of EMPA and ADMSC therapy was superior to either alone for improving outcomes of DN.

Synergic Effect of Early Administration of Probiotics and Adipose-Derived Mesenchymal Stem Cells on Alleviating Inflammation-Induced Chronic Neuropathic Pain in Rodents

This study investigated the hypothesis that probiotics enhanced the therapeutic effect of adipose-derived mesenchymal stem cells (ADMSCs) on alleviating neuropathic pain (NP) due to chronic constriction injury (CCI) mainly through regulating the microbiota in rats. SD rats (n = 50) were categorized into group 1 (sham-control), group 2 (NP), group 3 (NP + probiotics (i.e., 1.5 billion C.F.U./day/rat, orally 3 h after NP procedure, followed by QOD 30 times)), group 4 (NP + ADMSCs (3.0 × 105 cells) 3 h after CCI procedure, followed by QOD six times (i.e., seven times in total, i.e., mimic a clinical setting of drug use) and group 5 (NP + probiotics + ADMSCs (3.0 × 105 cells)) and euthanized by day 60 after NP induction. By day 28 after NP induction, flow-cytometric analysis showed circulating levels of early (AN-V+/PI−) and late (AN-V+/PI+) apoptotic, and three inflammatory (CD11b-c+, Ly6G+ and MPO+) cells were lowest in group 1 and significantly progressively reduced in groups 2 to 5 (all p < 0.0001). By days 7, 14, 21, 28, and 60 after CCI, the thresholds of thermal paw withdrawal latency (PWL) and mechanical paw withdrawal threshold (PWT) were highest in group 1 and significantly progressively increased in groups 2 to 5 (all p < 0.0001). Numbers of pain-connived cells (Nav1.8+/peripherin+, p-ERK+/peripherin+, p-p38+/peripherin+ and p-p38+/NF200+) and protein expressions of inflammatory (p-NF-κB, IL-1ß, TNF-α and MMP-9), apoptotic (cleaved-caspase-3, cleaved-PARP), oxidative-stress (NOX-1, NOX-2), DNA-damaged (γ-H2AX) and MAPK-family (p-P38, p-JNK, p-ERK1/2) biomarkers as well as the protein levels of Nav.1.3, Nav.1.8, and Nav.1.9 in L4-L5 in dorsal root ganglia displayed an opposite pattern of mechanical PWT among the groups (all p < 0.0001). In conclusion, combined probiotic and ADMSC therapy was superior to merely one for alleviating CCI-induced NP mainly through suppressing inflammation and oxidative stress.

[The distribution of peripheral anterior synechiae in patients with primary angle-closure glaucoma]

Objective: To describe the distribution and characteristics of peripheral anterior synechiae (PAS) in patients with primary angle-closure glaucoma (PACG). Methods: Retrospective case study. A total of 285 PACG patients (406 eyes) diagnosed in the Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University from January 2017 to August 2019 were included. They were 102 males and 183 females, with a median age of 67 years old (range, 21 to 95 years old). The PAS range was detected by gonioscopy examination, and the frequency distribution of PAS at 12 clock points was counted by clockwise. The PAS distribution at the middle point of PAS with continuous distribution and ≤6 clock points was assessed. Results: In all cases, PAS of the right eye was concentrated at 11:00 to 4:00 regions [range, 62.0% (129/208) to 78.8% (164/208)]. PAS of the left eye was concentrated at 7:00 to 1:00 regions [range, 50.0% (99/198) to 75.8% (150/198)]. When the PAS range of the atrial angle was ≤6 clock regions, it was mainly at 12:00 to 3:00 [range, 58.3% (74/127) to 67.7% (86/127)] in the right eye and at 10:00 to 12:00 [range, 54.8% (68/124) to 66.1% (82/124)] in the left eye. Among 121 cases (242 eyes) with both eyes involved, the PAS region was at 11:00 to 5:00 [range, 52.1% (63/121) to 79.3% (96/121)] in the right eye and at 8:00 to 1:00 [range, 50.4% (61/121) to 76.9% (93/121)] in the left eye. When the PAS range of the atrial angle was ≤6 clock regions, it was mainly at 12:00 to 4:00 [range, 53.2% (41/77) to 71.4% (55/77)] in the right eye and at 10:00 to 12:00 [range, 50.6% (39/77) to 64.9% (50/77)] in the left eye. In all cases, there were 171 cases of right eyes and 175 cases of left eyes with continuous angle PAS. The central PAS clock position of the right eye was mainly at 11:00 to 3:00 [range, 15.2% (26/171) to 24.0% (41/171)], and that of the left eye was mainly at 8:00 to 12:00 [range, 15.4% (27/175) to 20.6% (36/175)]. Among cases with both eyes involved, there were 98 cases of right eyes and 104 cases of left eyes with continuous angle PAS. The clock distribution of the middle position of the right eye angle PAS was concentrated at 11:00 to 3:00 [range, 17.3% (17/98) to 26.5% (26/98)], and that of the left eye was concentrated at 8:00 to 12:00 [range, 13.5% (14/104) to 20.2% (21/104)]. Conclusions: The PAS of PACG patients is mainly located in the upper and nasal sides, and the closer to the temporal side, the smaller the PAS frequency, showing a gradual downward trend. The PAS distribution of binocular angles is of obvious mirror symmetry. (Chin J Ophthalmol, 2021, 57: 666-671).

[The 484th case:asthma, limb numbness, diplopia, headache]

A 47-year-old female who had a history of asthma and sinusitis in the past was admitted to hospital with limbs numbness and pain for ten days. The symptoms were aggravated for eight hours. On admission, significant peripheral eosinophilia was noted. Paranasal sinusitis and transient bronchiolitis were found by CT scan.Electromyogram demonstrated multiple mononeuropathy. Eosinophilia was indicated by bone marrow biopsy. The diagnosis of eosinophilic granulomatous polyangiitis(EGPA) was determined. The patient got better after applying glucocorticoid and cyclophosphamide.Later she developed abdominal pain and partial oculomotor nerve palsy, while her condition improved after continued immunosuppression and anticoagulant therapy. She was hospitalized for the third time because of headache. Subarachnoid hemorrhage was diagnosed after lumber puncture and cranial MRI+MRA+MRV and other examinations. She was relieved after conservative treatment. Subarachnoid hemorrhage with EGPA is rare. This case may improve physicians' understanding of EGPA complicated with subarachnoid hemorrhage.

Adipose-derived mesenchymal stem cell-derived exosomes markedly protected the brain against sepsis syndrome induced injury in rat

This study tested the hypothesis that sepsis syndrome [SS-induced by cecal-ligation and puncture (CLP)]-induced systemic inflammation and brain damage in rats were effectively suppressed by allogenic adipose-derived mesenchymal stem cell-derived exosome (AMSC^EXO). SD rats (n = 72) were divided into group 1 [sham-control (SC)], group 2 (SS only) and group 3 (SS + AMSC^EXO) and equally euthanized at 6/24/48/72 h after SS induction, respectively. By 6/16/24/72 h, flow cytometric analyses demonstrated the numbers of inflammatory cells (Ly6G+/CD11^b/c+), immune (CD3+/CD4+ cells/CD3+/CD8+ cells) and early (AN-V+/PI-)/late (AN-V+/PI+) apoptotic cells in circulation were significantly increased in group 2 than in groups 1 and 3, and significantly increased in group 3 than in group 1, whereas the number of T-reg+ cells was significantly progressively increased from groups 1 to 3 (all P < 0.0001). At 6/16/24/72 h, the numbers of (CD3+/CD4+ cells/CD3+/CD8+ cells/T-reg+ cells) in spleen exhibited an identical pattern of circulation among the three groups (all P < 0.0001). ELISA showed inflammatory mediators (IL-6/TNF-α) in circulating/cerebrospinal fluid at 6/24/72 h displayed an identical trend as the immune cells among the three groups (all P < 0.0001). Microscopic findings demonstrated that the cellular expressions of inflammatory (F4/80+//MMP-9+//CD14+//GFPA+) and brain-damaged (AQP4+/γ-H2AX+) biomarkers at 24/72 h exhibited an identical pattern of immune cells among the three groups (all P < 0.0001). The protein expressions of inflammatory (IL-1β/MMP-9/TNF-α/NF-κB/TLR2/TLR-4/MyD88/HMGB1), apoptotic (cleaved-caspase3/PARP/mitochondrial-Bax) and oxidative-stress (NOX-1/NOX-2/oxidized protein) biomarkers displayed an identical pattern as the immune cells among the three groups (all P < 0.0001). In conclusion, SS elicited vigorously inflammatory reaction not only in circulation but also in spleen/brain, resulting in serious brain damage.

The Correlation between Severity of Neurological Impairment and Left Ventricular Function in Patients after Acute Ischemic Stroke

Despite left ventricular (LV) dysfunction increases the risk of incidental acute ischemic stroke (AIS), the association between LV function and severity of neurological deficits after AIS remains unclear. Between November 2015 and October 1017, a total of 99 AIS patients were prospectively enrolled and categorized into two groups based on National Institute of Health Stroke Scale (NIHSS). The AIS patients with NIHSS <6 were allocated into Group 1 (n = 50) and those with NIHSS ≥6 were into Group 2 (n = 49). Echocardiography was performed within 5 days after AIS to assess chamber size, left ventricular ejection fraction (LVEF) and valvular regurgitation. Besides, two inflammatory biomarkers, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), were evaluated on admission. The results showed Group 2 had significantly higher value of NLR and PLR (all p-values < 0.01) but lower LVEF (p = 0.001) and frequency of mitral regurgitation (p = 0.021) than Group 1. The NIHSS and modified Rankin scale were significantly negatively correlated with LVEF, whereas both were significantly positively correlated with NLR and PLR (all p-values < 0.02). Multivariate analysis showed LVEF <65%, aging and inflammation were significantly associated with NIHSS ≥6 (all p-values < 0.01). In conclusion, the AIS patients with NIHSS ≥6 had lower LVEF but more clinically dominant mitral regurgitation and higher NLR and PLR compared to those with NIHSS <6.

Intra-carotid arterial transfusion of autologous circulatory derived CD34+ cells for old ischemic stroke patients - a phase I clinical trial to evaluate safety and tolerability

This phase I clinical trial tested the hypothesis that circulatory CD34+ cell therapy might be safe for old ischemic stroke (IS) (defined as IS>6 months) patients and also to evaluate the neurological function after the therapy. Nine old IS patients (with mean IS interval: 8.6 ± 6.4 years) were consecutively enrolled and received intra-carotid artery transfusion of circulatory-derived autologous CD34+ cells (3.0×10⁷ cells/patient) into the ipsilateral brain infarct area at catheterization room by Catheter Looping Technique, after subcutaneous G-CSF injection (5 μg/kg twice a day for 4 days). The results showed that procedural safety was 100% with all patients uneventfully discharged. The circulating number of EPCs and angiogenesis (i.e., by Matrigel assay) were significantly higher at post than at prior to G-CSF treatment (all P<0.001). Time courses (0/5/10/30 minutes) of blood samplings from right-internal jugular vein exhibited significantly increased in levels of SDF-1α and EPCs numbers in time points of 5/10/30 minutes than in the baseline (0 minute) (all P<0.05). Barthel index was increased (defined as ≥5 scores) in 44.4% (4/9) and CASI score was notably improved (all P<0.01) at 6-month follow-up after the cell therapy as compared to the baseline. No recurrent IS or any tumorigenesis was found in these patients with a mean follow-up time interval of 16.5 ± 6.2 months. All of these patients remain survive and are followed up at outpatient department. In conclusion, CD34+ cell therapy is safe and might offer some benefit to old IS patients.

[A multicenter, large-sample, randomized clinical trial on improving the median survival time of advanced non-small cell lung cancer by combination of Ginseng Rg3 and chemotherapy]

Objective: To observe the efficacy of the combination of chemotherapy and Ginseng Rg3 on advanced non-small cell lung cancer(NSCLC). Methods: In the multi-center, large-sample, randomized, double blind trial, 414 patients with Ⅲ-Ⅳ NSCLC were enrolled.199 were in the experimental group and 215 the control group. The patients in the experimental group were treated with the standard first-line chemotherapy combined with Ginseng Rg3. The patients in the control group were treated with the same chemotherapy combined with placebo. Median overall survival (OS), Karnofsky performance scale (KPS), Traditional Chinese Medicine (TCM) symptoms score and side effects of two groups were observed as main indexes. Results: The median OS were 12.03 months in the experimental group, which was significantly better than that in the control group (8.46 months, P<0.05). Hemoglobin and white blood cells were decreased after the first and second cycle of treatment in both groups. Both adverse events were significantly milder in the treatment group (P<0.05). In addition, after two courses of treatment, the KPS of patients was 78.95±9.14 in the experimental group and 76.77±9.15 in the control group, while the TCM symptoms score was 2.45±1.73 in the experimental group and 2.92±2.06 in the control group, with significant difference (P<0.05). Conclusions: Combination of TCM with Western medicine such as chemotherapy could prolong the survival of patients with advanced NSCLC. The combined therapy improved patients' symptoms and reduced chemotherapy induced myelosuppression.

Melatonin attenuated brain death tissue extract-induced cardiac damage by suppressing DAMP signaling

We tested the hypothesis that melatonin prevents brain death (BD) tissue extract (BDEX)-induced cardiac damage by suppressing inflammatory damage-associated molecular pattern (DAMP) signaling in rats. Six hours after BD induction, levels of a DAMP component (HMGB1) and inflammatory markers (TLR-2, TLR-4, MYD88, IκB, NF-κB, IL-1β, IFN-γ, TNF-α and IL-6) were higher in brain tissue from BD animals than controls. Levels of HMGB1 and inflammatory markers were higher in BDEX-treated H9C2 cardiac myoblasts than in cells treated with healthy brain tissue extract. These increases were attenuated by melatonin but re-induced with luzindole (all P < 0.001). Additional male rats (n = 30) were divided into groups 1 (negative control), 2 (healthy brain tissue extract implanted in the left ventricular myocardium [LVM]), 3 (BDEX-LVM), 4 (BDEX-LVM + melatonin), and 5 (BDEX-LVM + melatonin + luzindole). Collagen deposition/fibrosis and LVM levels of MTR2, HMGB1, inflammatory markers, oxidative stress, apoptosis, mitochondrial damage and DNA damage were highest in group 3, lowest in groups 1 and 2, and higher in group 5 than in group 4. Heart function and LVM levels of MTR1 and anti-inflammatory, mitochondrial-integrity and anti-oxidative markers exhibited a pattern opposite that of the inflammatory markers in the five groups (all P < 0.0001). These results indicate melatonin inhibits BDEX-induced cardiac damage by suppressing the DAMP inflammatory axis.

Amitriptyline and Sexual Function: A Systematic Review Updated for Sexual Health Practice

Amitriptyline is an old drug but is still prevalently used as the first-line treatment for a variety of common diseases. Surprisingly, knowledge of sexual risks with amitriptyline comes from only one clinical trial and several case reports from three decades ago. In the current study, a systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) related to amitriptyline and sexual dysfunction (SD) was performed. The frequency, gender-difference, types, disease-specificity and time course of SD, and the relationship between SD and nonsexual adversity were studied. A total of 14 publications, including 8 qualified randomized clinical trials, were eligible. The frequency of SD in overall, male and female patients was 5.7, 11.9 and 1.7%, respectively. SD was six-fold higher in men than women. The frequency of SD was 6.9% in depressive patients compared with 0.8% in non-depressive patients ( p = .008), and gradually decreased at 8 weeks after treatment ( p = .02). Amitriptyline impacted arousal and libido more than orgasm and ejaculation in male patients but mainly libido in female patients. SD was significantly correlated with insomnia linearly whereas somnolence and nausea dually. Therefore, amitriptyline-associated SD mainly occurs in depressive and male patients, disturbs each phase of the sexual response cycle in men but mainly libido in women, gradually decreases under long-term treatment, and can be predicted by the co-existence of insomnia, somnolence or nausea during treatment. Clinicians should caution and tailor the gender and disease vulnerability of amitriptyline in their practice.

Topiramate-associated sexual dysfunction: A systematic review

INTRODUCTION

Sexual pharmacotoxicity renders patients with epilepsy at a risk for sexual dysfunction (SD). This study is aimed to analyze the relationship between sexual function and topiramate to avoid topiramate-associated SD.

METHODS

A systematic review following the PRISMA guidelines was performed to elucidate any SD occurrence in patients receiving topiramate.

RESULTS

A total of 17 publications were reviewed. Based on limited polytherapy observational studies, the frequency of self-reported topiramate-associated SD, libido disorder, and orgasmic disorder in patients with polytherapy was 9.0%, 9.0%, and 2.6%, respectively (grade C evidence). Female patients mainly had anorgasmia, whereas male patients principally had erectile dysfunction. The daily dose of topiramate in patients with SD was within the recommended dose. Sexual adversity usually occurred from 4weeks after topiramate use but favorably subsided without eventful complications after topiramate substitution or dose reduction in all patients.

CONCLUSIONS

Topiramate can elicit different patterns of SD, especially anorgasmia in women and erectile dysfunction in men, even with a therapeutic dose. Detailed drug education and careful monitoring are necessary to maximize sexual health, especially in persons undergoing polytherapy and with other risks for SD. Moreover, a rapid response, such as substitution or reduction of the dose, is suggested when SD occurs during its use.

EPO-cyclosporine combination therapy reduced brain infarct area in rat after acute ischemic stroke: role of innate immune-inflammatory response, micro-RNAs and MAPK family signaling pathway

This study tested the hypothesis that erythropoietin (EPO) and cyclosporine (CsA) could effectively reduce brain infarct area (BIA) in rat after acute ischemic stroke (AIS) through regulating inflammation, oxidative stress, MAPK family signaling and microRNA (miR-223/miR-30a/miR-383). Adult male Sprague-Dawley rats (n = 48) were equally divided into group 1 (sham control), group 2 (AIS), group 3 [AIS+EPO (5,000 IU/kg at 0.5/24/48 h, subcutaneous)] and group 4 [AIS+CsA (20.0 mg/kg at 0.5/24/48 h, intra-peritoneal)]. By 72 h, histopathology showed that BIA was largest in group 2 and smallest in group 1, and significantly larger in group 4 than group 3 (all P<0.0001). The three microRNAs expressed were higher in group 2 than in the other three groups (all P<0.04); between these three latter groups there were no significant differences. The protein expressions of MAPK family [phosphorylated (p)-ERK1/2, p-p38/p-JNK], inflammatory (iNOS/MMP-9/TNF-α/NF-κB/IL-12/MIP-1α/CD14/CD68/Ly6g), apoptotic (caspase-3/PARP/mitochondrial-Bax), oxidative-stress (NOX-1/NOX-2/oxidized protein) and mitochondrial-damaged (cytosolic cytochrome-C) biomarkers exhibited an identical pattern to BIA findings (all P<0.0001). The cellular expressions of brain edema (AQP4+), inflammation (CD11+/glial-fibrillary-acid protein+), and cellular damage (TUNEL assay/positive Periodic acid-Schiff stain) biomarkers exhibited an identical pattern, whereas the cellular-integrity markers (neuN+/MAP2+/doublecorin+) exhibited an opposite pattern to BIA (all P value <0.001). EPO-CsA therapy markedly reduced BIA mainly by suppressing the innate immune response to inflammation, oxidative stress, microRNAs (miR-223/miR-30a/miR-383) and MAPK family signaling.

Cheiro-pedal syndrome: A revisit of etiology, localization and outcome

OBJECTIVE

Cheiro-pedal syndrome (CPS) is an incomplete sensory disorder confined to hand and foot and is generally considered a benign entity. However, knowledge comes from case report or case series only. The aim of this study is to clarify the etiology, localization and outcome of CPS.

PATIENT AND METHOD

A total of 21 CPS patients from our database and another 9 patients from literature were reviewed. CPS was classified into 4 types, namely unilateral and ipsilateral (Type I), bilateral (Type II), incomplete bilateral (Type III), and crossed (Type IV).

RESULTS

They were 20 men and 10 women; including 20 Type I patients, 9 Type II patients, 1 Type III patients, and 0 Type IV patient. Vascular disorders, non-vascular cervical disorder and polyneuropathy were the responsible causes in 18 patients, 7 patients, and 2 patients, respectively. Etiology was unknown in another 3 patients. Lesions were located at brain parenchyma in 16 patients, and cervical cord above C5 level in 9 patients. Disable motoroparesis occurred between 4days to 2 months in two-third of deteriorated patients. In three patients, their lesions were detected only on recurrence or exacerbation of CPS 4 months to 2 years later. Recovery, residual deficit and deterioration ensued in 44%, 28% and 28% patients, respectively. A 33.3% of brain involvement patients and 100.0% of spinal involvement patients terminated to residual deficit or deterioration. The sensitivity and specificity of prediction for deterioration was 77.8% and 100%, respectively, by type II or III CPS.

CONCLUSION

CPS is actually not a benign neurological disorder but a sensory alarm sign. A thorough examination of brain parenchyma and cervical spinal cord is urgent for identifying any treatable or preventable pathological lesions to reduce harmful consequence, especially in case of type II or III CPS.

Baseline Vulnerability and Inpatient Frailty Status in Relation to Adverse Outcomes in a Surgical Cohort

This study aimed to derive measures of baseline vulnerability and inpatient frailty in elderly surgical patients and to study their association with adverse post-operative outcomes. Data from comprehensive geriatric assessment of 208 general surgical and orthopaedic patients aged 70 and over admitted to four acute hospitals in Queensland, Australia, were analysed to derive a baseline and inpatient Frailty Index (FI). The association of these indices with adverse outcomes was examined in logistic regression. The mean (SD) baseline FI was 0.19 (0.09) compared to 0.26 (0.12) on admission, with a predominant increase in domains related to functional status. Both baseline and inpatient FI were significant predictors of one year mortality, inpatient delirium, and a composite adverse outcome, after adjusting for age, sex and acuity of surgery. In summary, detecting baseline frailty pre-hospitalisation may be useful to trigger the implementation of supportive and preventative measures in hospital.

Association of TLR2 and TLR4 non-missense single nucleotide polymorphisms with type 2 diabetes risk in a southern Chinese population: a case-control study

Toll-like receptors (TLRs), the triggers of the innate and adaptive immune responses, are involved in the pathogenesis of type 2 diabetes mellitus (T2DM). Several studies have investigated the effects of genetic polymorphisms in TLR4 and TLR2, but they have yielded limited results. We investigated whether non-missense genetic polymorphisms in the regulatory regions of TLR4 and TLR2 were related to T2DM in a southern Chinese population. Single nucleotide polymorphisms (SNPs) in TLR4 (rs1927911, rs11536889, rs1927907, rs1927906, rs1927914, rs7873784, and rs2149356) and TLR2 (rs1898830, rs3804099, rs4696480, and rs3804100) were genotyped in 552 T2DM and 552 unrelated age- and gender-matched controls by SNaPShot Multiplex assay. Genotypes GG (OR = 0.09, 95%CI = 0.01- 0.83, P = 0.03) and CG (OR = 0.08, 95%CI = 0.01-0.74, P = 0.03) of the 3'-untranslated region (UTR) SNP rs7873784 in TLR4, and genotype AG (OR = 0.67, 95%CI = 0.46-0.97, P = 0.04) and allele G (OR = 0.88, 95%CI = 0.79-0.97, P = 0.01) of the intron SNP rs1898830 in TLR2 were identified as protective against the development of T2DM in southern Chinese people. In contrast, a meta-analysis of rs1927911 and rs1927914 showed no association. Haplotypes AGTT (OR = 0.34, 95%CI = 0.15-0.77, P = 0.01) and AATT (OR = 1.20, 95%CI = 1.01- 1.44, P = 0.05) in TLR2 were significantly associated with susceptibility to T2DM. Our results suggest that the effects of non-missense polymorphisms located in the regulatory regions of TLR4 and TLR2 should not be neglected in T2DM association analysis.

An exploration of life insurance among the elderly in Taiwan

The burgeoning of the life insurance industry in Taiwan cannot be attributed solely to a rise in incomes, but also to increasing urbanization and industrialization, aggressive marketing strategies introduced by U.S. life insurance companies, and important changes in values that make it increasingly acceptable to own life insurance. The growing use of life insurance can be considered part of a transition from informal, familial care of the elderly to formal market mechanisms to protect the financial security of loved ones, including a widowed spouse, and as one component of the pattern of intergenerational relations. We use data from the 1991-92 Telephone Followup to the 1989 Survey of Health and Living Status of the Elderly in Taiwan to explore the extent to which familial resources and socioeconomic/demographic characteristics influence the propensity of elderly persons to own life insurance. We also consider motivations for and against the ownership of insurance, and if insurance is currently held, the relationship of the beneficiary to the respondent. We conclude with suggestions for additional data that can help resolve a number of issues raised in this exploratory study.

Levels of circulating neopterin in patients with severe carotid artery stenosis undergoing carotid stenting

AIMS

The association between an elevated serum neopterin level and the development of coronary artery complex lesions has been extensively assessed; however, the correlation between the serum neopterin level and the development of carotid artery stenosis has seldom been reported. This study tested whether this biomarker is increased in patients with severe carotid artery stenosis(≥70%) undergoing carotid artery(CA) stenting and investigated independent predictors of an increased circulating neopterin level.

METHODS

Fifty patients with severe CA stenosis(CAS) undergoing CA stenting were consecutively enrolled in this study from January 2009 through December 2011. The serum neopterin levels of age- and gender-matched acute ischemic stroke(AIS) patients(n=120) and control subjects(CS)(n=33) were also measured. A blood sample was prospectively collected from each patient in the catheterization room.

RESULTS

The serum levels of neopterin were significantly higher in the CAS patients than in the AIS patients or CS and significantly higher in the AIS patients than in the CS(all p＜0.001). An analysis of the variables of 170 patients(CAS＋AIS) demonstrated that age, a previous history of stroke and severe CAS were significantly correlated with an increased serum level of neopterin(all p＜0.005). A multivariate binary logistic regression analysis of the severe CAS patients(n=50) demonstrated that age and the creatinine level were independent predictors of a high neopterin level(neopterin level ≥16.52 ng/dL, i.e., according to the median value of neopterin)(all p＜0.05).

CONCLUSIONS

The circulating neopterin levels are significantly higher in patients with severe CAS than in those with AIS. The presence of CAS, age and the creatinine level were significantly correlated with an increased serum neopterin level.

Association between MIF gene polymorphisms and carotid artery atherosclerosis

Atherosclerosis is a chronic inflammatory disorder. Macrophage migration inhibitory factor (MIF) is a potent cytokine that plays an important role in the regulation of immune responses. Polymorphisms including five- to eight-repeat CATT variants ((CATT)(5-8)) and G-173C in the promoter region of the MIF gene are associated with altered levels of MIF gene transcription. The purpose of the study is to investigate the relationship between promoter polymorphisms of the MIF gene and the severity of carotid artery atherosclerosis (CAA). The severity of CAA was assessed in 593 individuals with a history of ischemic stroke by using sonographic examination, and the MIF promoter polymorphisms of these individuals were genotyped. The carriage of (CATT)7 (compared to genotypes composed of (CATT)5, (CATT)6, or both), carriage of C allele (compared to GG), and carriage of the haplotype (CATT)7-C (compared to genotypes composed of (CATT)5-G, (CATT)6-G, or both) were significantly associated with an increase in the severity of CAA. We conclude that polymorphisms in the MIF gene promoter are associated with CAA severity in ischemic stroke patients. These genetic variants may serve as markers for individual susceptibility to CAA.

Co-morbidities in psoriasis: a hospital-based case-control study

BACKGROUND

Recent researches show that psoriasis is frequently associated with systemic co-morbidities.

OBJECTIVES

This study aimed to identify possible associated co-morbidities in psoriatic patients stratified by age and sex.

METHODS

In this retrospective hospital-based case-control study, patients diagnosed as psoriasis at the Kaohsiung Veterans General Hospital in Taiwan between January 2008 and December 2009 were enrolled as cases and classified into severe and mild based on their use of systemic therapy. The controls were the patients without psoriasis matched the cases in 1 : 1 ratio with same birth year, sex and calendar date. Odds ratios (ORs) and 95% confidence intervals (CIs) from the conditional logistic regression method were used to assess the risk of co-morbidities between psoriatic and non-psoriatic patients.

RESULTS

A total of 447 cases and 447 matched controls, with mean age of 51.3 ± 18.3 years and male-to-female ratio of 2.17 : 1 were enrolled. The ratio of mild-to-severe was 3.5 : 1. Compared with non-psoriatic patients, psoriatic patients had significantly higher OR of hypertension (1.85), diabetes mellitus (2.88) and obesity (1.66). Among those aged ≥51 years old, there was significant risk in male psoriatic patients with ischaemic and hypertensive heart disease (IHHD) (OR = 2.167) after eliminating female IHHD psoriatic patients (OR = 0.125). Psoriasis was significantly negatively associated with cancers (OR = 0.267). Psoriasis patients often had the usual drinking habit (OR = 2.23) and seldom had an occasional drinking habit (OR = 0.25).

CONCLUSIONS

Psoriasis is strongly associated with hypertension, diabetes mellitus and obesity. The association between psoriasis and IHHD, stroke, cancers, smoking and alcohol habits warrant more investigation.

Urbanization, non-familial work, education, and fertility in Taiwan

Abstract It is well known, that there is a relationship between the level of development of a society and its level offertility.(1) However, it is not clear which of the complex ofvariables associated with development are primarily associated with the reduction of fertility. Urbanization, female labour force participation and education are three of the variables most commonly cited as bearing a causal relationship to fertility. Urbanization implies a change of environment of a substantial portion of the population which may result in a change in the value placed on large families. This is particularly true when urban mortality is lower than rural, so that more children survive.(2) However, it has also been argued that urbanization results in a change in family structure from the extended to the nuclear family with a concomitant reduction in the value placed on having many children.(3) Additional changes in family patterns which are sometimes said to explain fertility reduction due to urbanization are increases in the proportion of women never marrying and increases in the age at marriage.

Serum level and prognostic value of neopterin in patients after ischemic stroke

BACKGROUND

We hypothesized that serum level of neopterin is significantly predictive of prognostic outcome in patients after acute ischemic stroke (IS).

METHODS

Between November 2008 and May 2010, serum levels of neopterin were prospectively collected at 48 h after acute IS in 157 patients.

RESULTS

Serum neopterin levels were substantially higher in patients with severe neurological impairment [National institutes of Health Stroke Scale (NIHSS) score ≥12] than in those with NIHSS <12 (p<0.008). Furthermore, Spearman's test showed a strongly positive correlation between neopterin level and NIHSS (p=0.003). Multiple logistic regression analysis demonstrated that serum neopterin level was strongly and independently predictive of NIHSS ≥12 (p=0.002) at 48 h after acute IS and 90-day major adverse clinical outcome (defined as NIHSS≥12, recurrent stroke or death) (p=0.003).

CONCLUSION

Serum level of neopterin was notably increased after acute IS. This biomarker was strongly and independently predictive of 90-day unfavorable clinical outcome in patients after acute IS.

Montreal cognitive assessment in assessing clinical severity and white matter hyperintensity in Alzheimer's disease with normal control comparison

PURPOSE

Use Taiwanese version of the Montreal Cognitive Assessment (MoCA) in evaluating patients in different stages of Alzheimer's disease (AD) and correlate with white matter change.

METHODS

Ninety-seven normal controls (NC), 52 very-mild AD (clinical dementia rating [CDR] = 0.5), 48 mild AD (CDR = 1) and 38 moderate AD (CDR = 2) patients were enrolled for the MoCA, Mini- Mental State Examination (MMSE) and the Cognitive Assessment Screening Instrument (CASI). White matter hyperintensities (WMHs) on brain MRI were visually rated and classified as deep or periventricular WMHs.

RESULTS

In NC group, education (β = 0.326) but not age (β = -0.183, p = 0.069), was significantly related to MoCA score. However, while we added two points to the AD patients with less than 6 years education, the effects of education disappeared as compared with those of 7 years of education. For all educational levels, the cutoff value of MoCA for very-mild AD was 22/23 (sensitivity = 82.7%, specificity = 87.6%). No significant differences were found in the areas under the curves that differentiated NC from the patients with AD for MoCA and MMSE (differences = 0.008, p = 0.490), or for MoCA and CASI (differences = 0.023, p = 0.082). Total WMHs, frontal deep and periventricular WMHs were inversely correlated with the attention and delayed-recall subdomain.

CONCLUSION

The MoCA is a good clinical tool for screening very-mild stage AD if the educational effects are carefully considered. The correlation between the executive subdomains with the frontal WMHs also makes it a useful tool for detecting subtle WMHs.

Link between lipoprotein-associated phospholipase A2 gene expression of peripheral-blood mononuclear cells and prognostic outcome after acute ischemic stroke

AIM

To evaluate the potential of the lipoprotein-associated phospholipase A(2) (Lp-PLA(2) level as a biomarker in the prediction of prognostic outcome in patients with acute ischemic stroke (IS).

METHODS

From October 2008 to March 2010, 130 patients with acute IS were prospectively enrolled in the study and their medical records were reviewed. A blood sample was collected from each patient 48 hours after acute IS, as well as from 20 healthy volunteers as controls. Messenger-RNA (mRNA) expression of Lp-PLA(2) of peripheral-blood mononuclear cells (PBMNCs) relative to that of β actin was measured using quantitative reverse transcription polymerase chain reaction (RT-PCR).

RESULTS

Patients with acute IS exhibited significantly higher Lp-PLA(2) mRNA expression of PBMNCs than the control group (p <0.0001). Lp-PLA(2) mRNA expression of PBMNCs in patients with a major adverse clinical outcome (MACO) (defined as recurrent stroke or death) within 90 days was significantly higher than in patients without MACO (p=0.006). Furthermore, elevated Lp-PLA(2) mRNA expression was strongly associated with old age, diabetes mellitus, a positive history of significant coronary arterial disease and significant stenosis of the extra-cranial carotid arteries (all p <0.04), and positively correlated with the body mass index, leukocyte count, and serum levels of total cholesterol and low-density lipoprotein cholesterol. Multivariate analysis revealed that Lp-PLA(2) mRNA expression of PBMNCs was a significant independent predictor of MACO within 90 days (p= 0.011).

CONCLUSION

Elevated Lp-PLA(2) mRNA expression of PBMNCs seems to be a potential biomarker for predicting an unfavorable outcome in patients with acute IS.

Comparison of acute versus convalescent stage high-sensitivity C-Reactive protein level in predicting clinical outcome after acute ischemic stroke and impact of erythropoietin

Background and Aim

Currently, no data on the optimal time point after acute ischemic stroke (IS) at which high-sensitivity C-reactive protein (hs-CRP) level is most predictive of unfavorable outcome. We tested the hypothesis that hs-CRP levels during both acute (48 h after IS) and convalescent (21 days after IS) phases are equally important in predicting 90-day clinical outcome after acute IS. We further evaluated the impact of erythropoietin (EPO), an anti-inflammatory agent, on level of hs-CRP after acute IS.

Methods

Totally 160 patients were prospectively randomized to receive either EPO therapy (group 1, n = 80) (5,000 IU each time, subcutaneously) at 48 h and 72 h after acute IS, or placebo (group 2, n = 80). Serum level of hs-CRP was determined using ELISA at 48 h and on day 21 after IS and once in 60 healthy volunteers.

Results

Serum level of hs-CRP was substantially higher in all patients with IS than in healthy controls at 48 h and day 21 after IS (all p < 0.001). Levels of hs-CRP did not differ between group 1 and 2 at 48 h and day 21 after IS (all p > 0.5). Multivariate analysis showed that hs-CRP levels (at 48 h and day 21) were independently predictive of 90-day major adverse neurological event (MANE) (defined as recurrent stroke, NIHSS≥8, or death) (all p < 0.03), whereas EPO therapy was independently predictive of reduced 90-day MANE (all p < 0.02).

Conclusion

EPO therapy which was independently predictive of freedom from 90-day MANE did not alter the crucial role of hs-CRP levels measured at 48 h and 21-day in predicting unfavorable clinical outcome after IS.

The medicolegal issue of tissue plasminogen activator in ischemic stroke: a review of judiciary decrees in Taiwan

PURPOSE

Tissue plasminogen activator (tPA) was approved by the Food and Drug Administration for ischemic stroke treatment since 1996 at the United States of America and also 2002 at Taiwan. Since after it is strongly advertised for a promising benefit to early thrombolysis that is further echoed by a recommendation in clinical guidelines from multiple medical associations in worldwide. Because of an overwhelming data of positive benefit collected in the evidence-based medicine database, legal dispute subsequently occurs when tPA is failed to be administrated in appropriate time.

METHODS

In order to elucidate the legal viewpoint for tPA used in ischemic stroke, a review of the domestic judiciary decrees regarding this issue was conducted. Cases in Taiwan were executed from the open access database of the Judicial Yuan, Taiwan. The background, legal dispute and judgment of each case were analyzed.

RESULTS

Till August, 2010, there were 6 cases in Taiwan. All cases occurred after 2003. The causes of disputes were a loss of chance for thrombolysis due to a delay of diagnosis (4 cases, 67%) and a failure of thrombolytic treatment after a diagnosis of ischemic stroke (2 cases, 23%). All cases were presented to non-neurologists at initial. Five cases expired or terminated into vegetation before litigation.

CONCLUSION

A failure of early diagnosis or treatment after a diagnosis of ischemic stroke are important for medicolegal dispute in tPA usage, which is expected to become prevalent in Taiwan in future. A fatal or poor outcome may be a triggering factor for litigation. Therefore, an improvement of the knowledge and practice to increase early diagnosis of ischemic stroke is the key factor for reducing medicolegal issue regarding tPA use in ischemic stroke. This is particularly true for non-neurologist physicians.

Isolated numbness of the tip of the tongue in hemispheric stroke

Although the somatosensory afferent of the tip of the tongue runs proximal and parallel along the spinothalamocortical and trigeminothalamocortical pathway up to the sensory cortex, central involvement has been rarely described in cases of nongustatory sensory disturbance at the tip of the tongue. In a hypertensive woman who experienced an acute onset of an isolated numbness at the tip of her tongue, recent small infarctions were found at the postcentral gyrus of the right parietal lobe. Thus, central involvement should not be neglected in the case of sensory disturbance at the tip of tongue.

Effect of erythropoietin on level of circulating endothelial progenitor cells and outcome in patients after acute ischemic stroke

INTRODUCTION

Erythropoietin (EPO) enhances the circulating level of endothelial progenitor cells (EPCs), which has been reported to be associated with prognostic outcome in ischemic stroke (IS) patients. The aim of this study was to evaluate the time course of circulating EPC level and the impact of EPO therapy on EPC level and clinical outcome in patients after acute IS.

METHODS

In total, 167 patients were prospectively randomized to receive either EPO therapy (group 1) (5,000 IU each time, subcutaneously) at 48 h and 72 h after acute IS, or serve as placebo (group 2). The circulating level of EPCs (double-stained markers: CD31/CD34 (E1), CD62E/CD34 (E2) and KDR/CD34 (E3)) was determined using flow cytometry at 48 h and on days 7 and 21 after IS. EPC level was also evaluated once in 60 healthy volunteers.

RESULTS

Circulating EPC (E1 to E3) level at 48 h after IS was remarkably higher in patients than in control subjects (P < 0.02). At 48 h and on Day 7 after IS, EPC (E1 to E3) level did not differ between groups 1 and 2 (all P > 0.1). However, by Day 21, EPC (E1 to E3) level was significantly higher in group 1 than in group 2 (all P < 0.03). Additionally, 90-day recurrent stroke rate was notably lower in group 1 compared with group 2 (P = 0.022). Multivariate analysis demonstrated that EPO therapy (95% confidence interval (CI), 0.153 to 0.730; P = 0.006) and EPC (E3) (95% CI, 0.341 to 0.997; P = 0.049) levels were significantly and independently predictive of a reduced 90-day major adverse neurological event (MANE) (defined as recurrent stroke, National Institutes of Health Stroke scale ≥8, or death).

CONCLUSIONS

EPO therapy significantly improved circulating EPC level and 90-day MANE.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN96340690.

Symptomatic noncompressive motoromyelopathy presents as early manifestation in ankylosing spondylitis

Ankylosing spondylitis (AS) is an autoimmune spondyloarthropathy involving principally the sacroiliac joint and axial skeleton. Spinal cord involvement is an infrequent and late complication. It mostly results from compressive myelopathy due to skeletal osteopathy and usually presents with radiculomyelopathic sensory and motor deficits. To report three patients who suffered a progressive paraparesis/tetraparesis compatible with motor myelopathy without typical skeletal symptom. Myelopathy of unknown origin was initially interpreted in these patients. Radiography did not show typical change at sacroiliac joint or vertebrate. Spinal magnetic resonance image revealed cord atrophy at cervical and thoracic segment. A positivity of B27 antigen was found afterward. Their spondyloarthropathic symptoms developed within six months later with radiographic sacroiliitis. Seropositive AS with noncompressive myelopathy was finally established. Patients showed a reverse of motor impairment when their pain was well undercontrolled. Motor myelopathy may be neglected or underestimated in AS, in especially when typical skeletal symptom is absent or minimal. It may progress surreptitiously to harm spinal function or superimpose to crippling disability in compressive spinal cord injury. Therefore, a careful evaluation and monitor of spinal cord function is important for AS patient despite spinal deformity is not observed.

Comparison of carotid artery stenting performance between cardiologists and neuroradiologists: one medical center's experience

PURPOSE

To report the experience of carotid artery angioplasty with stenting (CAS) by cardiologists (CV) and neuroradiologists (NR) in an area with less incidence of extracranial artery stenosis.

METHODS

From 1999 to 2008, 210 patients with 231 stents were collected by claim records from the administrative office and reviewed by one independent neurologist. Outcome measures were peri-procedural adverse events (AE), restenosis and recurrent ipsilateral stroke (RS) rate, categorized into treatment groups by either CV or NR.

RESULTS

The average age was 69.0 years and 82.9 % of the patients were men. 63.8% of the patients with 62.8% stents were treated by CV and the remaining 36.2% of patients with 37.2% stents were done by NR. Symptomatic CAS was evident in 70.1% of the CV cases and 83.0% in NR treated patients (P = 0.017). The peri-procedural AE rate was 31.6%; 35.9% in CV group and 24.4% in the NR group (P = 0.071). RS rate was 4.8% in 663.3 days; 4.1% in 920.8 days in the CV group and 5.8% in 354.2 days in the NR group (P = 0.865). The restenosis rate was 10.9% in 630.5 days; 5.4% in the CV group in 224.8 days and 20.6% in the NR group in 817.8 days (P = 0.007).

CONCLUSIONS

The restenosis and recurrent stroke rates after carotid artery stenting in Taiwan appears to be consistent with other published and well organized trials. Measures to minimize peri-procedural AR rates are definitely warranted.

Postoperative parkinsonism and lupus anticoagulant: A model of autoantibody-mediated neurotoxicity in stress

PRIMARY OBJECTIVE

Nigrostriatal hypodopaminergism is the fundamental basis in parkinsonism. It may arise secondarily from a variety of disorders but is rarely mentioned shortly after surgery.

METHODS AND PROCEDURES

To report the clinical course of five patients who had had symptomatic parkinsonism developed shortly after surgery (lumbar laminectomy, prostatectomy and cholestectomy). Appropriate investigations were done to elucidate their pathogenesis.

MAIN OUTCOMES AND RESULTS

There was no remarkable finding of their anesthetic agents, duration of surgery, type of surgery, medical conditions or preoperative screening test. Extensive investigations did not reveal consistent abnormality. However, an abnormal presence of lupus anticoagulant was detected in four patients; primary antiphospholipid antibody syndrome was fulfilled in two of them. The lupus anticoagulant restored to the reference range in another two patients later. Catastrophic antiphospholipid antibody syndrome was not seen. Initially, their parkinsonian symptoms rapidly progressed but slowed down after six months.

CONCLUSION

Lupus anticoagulant possesses neurotoxic property and has been found in cases of movement disorder involving with the central dopaminergism. Surgery, a form of traumatic stress, has been reported to bring on lupus anticoagulant and catastrophic antiphospholipid antibody syndrome. These relationships remind a generation or an enhancement of pathognomic autoantibody vulnerable for dopaminergic toxicity, such as lupus anticoagulant or other antiphospholipid antibody.

Cheirobuccopedal syndrome

OBJECTIVES

Restricted sensory syndrome provides an excellent chance for the understanding of neuroanatomic correlation. The trigeminal nerve has been shown to convey buccal sensory impulse to central compartment. However, the pathway between cortex and the trigeminal sensory nucleus remains largely unknown.

METHOD

A patient presented with cheirobuccopedal syndrome, or objective sensory impairment confined to the left intraoral cheek, hand and foot, was reported.

RESULTS

Decrease in pinprick pain and fine touch sensation was detected at the left intraoral cheek, hand and foot. A recent infarction was disclosed at the left paramedian pons. The foregoing hypalgesia and hypesthesia recovered within one month after onset.

DISCUSSION

The trigeminobuccal sensory tracts are deemed to run in parallel with other spinothalamic and trigeminothalamic tracts within the brainstem. The rarity of buccal sensory deficit upon brainstem damage may be due to dispersion of the trigeminobuccal sensory tracts on their way of ascending, or their relatively high tolerance to different insults.

Serotonin transporter gene promoter polymorphism is associated with body mass index and obesity in non-elderly stroke patients

BACKGROUND

The serotonergic system is involved in the complex behavioral and physiological process in maintaining energy balance. Genetic factors regulating serotonergic function may have links with the development of obesity.

AIM

To investigate whether the 5-HTTLPR polymorphism of the serotonin transporter gene is associated with body mass index (BMI) and obesity in stroke patients.

SUBJECTS AND METHODS

The study included 376 patients (65.3+/-11.3 yr; male, 61.7%) with stroke. Associations between the 5-HTTLPR and BMI and obesity (BMI > or = 25 kg/m2) were examined in all subjects. In order to test age-dependent effects of the genetic variant, the association was also examined in the non-elderly subgroup (<65 yr) and the elderly subgroup (> or =65 yr) respectively.

RESULTS

For non-elderly subjects, the SS genotype was independently associated with increased BMI level (beta=1.84, p=0.037) and obesity (odds ratio 4.17, 95% CI 1.25-14.0, p=0.021) when the LL genotype was used as the reference. The association was not found for all patients or in the elderly subgroup. The LS genotype was not different from the LL genotype in BMI level or risk of obesity, either for all subjects or with regard to the non-elderly and elderly subgroups.

CONCLUSIONS

The SS genotype of 5-HTTLPR is an independent determinant of increased BMI level and obesity in non-elderly stroke patients but not in elderly patients. An age-dependent modification for the effect of the 5-HTTLPR on development of obesity is considered.

Uncoupling of protein C and antithrombin III activity in cerebral ischemia patients associated with cutis marmorata

PURPOSE

Cutis marmorata is a cutaneous livedoid disorder which can be differentiated from livedo reticularis in both clinical and pathological presentations. Unlike Sneddon syndrome, a detailed immunocoagulation profile has not yet been delineated for cutis marmorata in patients with cerebral ischemia.

METHODS

To analyze the immunocoagulation profile in cutis marmorata patients associated with cerebral ischemia (CMCI) in a series of 135 cerebral ischemia patients.

RESULTS

A total of 32 patients were found to have cutis marmorata. The blood protein C activity, protein S activity, antithrombin III activity, platelet count, fibrinogen and frequency of abnormal antiphospholipid antibody level were similar among 32 CMCI patients, 103 cerebral ischemia patients without cutis marmorata, and 35 healthy subjects. However, uncoupling of protein C and anti-thrombin III was observed in CMCI patients. Serum antinuclear antibody and Venereal Disease Research Laboratory were not detected in these patients.

CONCLUSION

Cutis marmorata is not uncommon in our ischemic stroke patient population, and is characterized by uncoupling of protein C and antithrombin III with altered thrombin hemostasis. Our findings raise the need for a careful cutaneous examination in patients with ischemic stroke. Abnormal immunocoagulating profile should alert physicians to the risk for cerebral ischemia even in the absence of other cardiovascular risk factors.

Cheirobuccal sensory syndrome

Two patients presented with sensory impairments confined to their right intraoral cheek and right first three fingers. An objective decrease of pinprick pain was detected at these sites. Neuroimaging illustrated recent infarcts in the contralateral ventral thalamus of both patients. The intraoral and cheiral sensory impairments resolved within two months after onset. We coined the term "cheirobuccal sensory syndrome" to describe these cases. The clinical significance and pathogenesis of this peculiar syndrome are discussed.

The relation between plasma homocysteine level and cardiovascular risk factors in cerebral ischemia

PURPOSE

Hyperhomocysteinemia (HHcy) is associated with a higher risk of cerebral ischemia and other vascular thrombosis. Homocysteine is greatly influenced by a broad spectrum of physiological and pathological conditions but the confounding factor for HHcy is unknown in our population, especially in normocreatininemic individuals. It is our aim in this study to elucidate the relation between homocysteine and cardiovascular risk factors, and also describe the distribution of plasma homocysteine level in cerebral ischemia patients with normal serum creatinine level.

METHODS

A retrospective study was conducted to understand the frequency of HHcy in cerebral ischemia patients, and the confounding cardiovascular risk factors in HHcy. Patients were classified into two groups by their plasma homocysteine levels; group I patients were those whose level was > or = 12 microM/L whereas group II < 12 microM/L.

RESULTS

A total of 218 patients were enrolled. Their plasma homocysteine level ranged from 3.57 to 46.37 microM/L (mean: 10.01 +/- 5.03 microM/L). Group I included 45 patients whereas group II 173 patients. The frequency of hypertension, diabetes mellitus and cardiac disease, as well as age, aminotransferases, total cholesterol, triglyceride, albumin, hematocrit, hemoglobin and leucocyte count did not differ between group I and II patients, except serum creatinine level was higher in group I patients (p < 0.01). Serum creatinine level correlated directly to and was an independent predictor for the plasma homocysteine level.

CONCLUSIONS

HHcy is common in our cerebral ischemia patients. Since renal function is a determinant for HHcy even in normocreatininemic patients, as a cardiovascular risk factor which detriments the renal function, it should be regularly monitored as HHcy is amenable for treatment.

Delayed hypokalemic paralysis following a convulsion due to alcohol abstinence

We encountered three patients with hypokalemic paralysis following a convulsion in the early stages of alcohol abstinence. The transtubular potassium gradient was less than 2.0, suggesting intracellular potassium shift. Hypokalaemic paralysis may result from retention of intracellular cationic potassium bound by anionic phosphorylated compounds, precipitated by an acceleration of the (Na+)-(K+) pump in alcohol withdrawal and convulsions. These findings warn of the lethal hypokalemia that may occur after convulsions, particularly soon after alcohol abstinence associated with moderate withdrawal symptoms.

Role of parents and peers in influencing the smoking status of high school students in Taiwan

OBJECTIVES

To assess parental influence on smoking behaviour by high school students in an Asian culture and to compare the relative importance of parental and peer influence.

METHODS

A 5% nationally representative sample, including 44 976 high school students in 10th to 12th grade (aged 15-18 years) in Taiwan, were surveyed in 1995. Each completed a long self administered questionnaire. Parental influence was measured by examining both parental behaviour (smoking status) and attitudes (perceived "tender loving care" (TLC) by adolescents). Changes in smoking status were used to determine peer influence, defined as the increase in the likelihood of smoking from grade 10 to 12 in a steady state environment. Odds ratios (ORs) were calculated for parental and peer influence, using logistic regression.

RESULTS

Adolescents of smoking parents with low TLC had the highest smoking rates and those of non-smoking parents with high TLC had the lowest. The difference was more than twofold in boys and more than fourfold in girls. When either parental smoking status or TLC alone was considered, parental influence was similar to peer influence in boys, but larger than peer influence in girls. However, when smoking status and TLC were considered jointly, it became larger than peer influence for both groups (OR 2.8 v 1.8 for boys and OR 3.9 v 1.3 for girls).

CONCLUSION

When parental influence is taken as parental behaviour and attitude together, it plays a more important role than peer influence in smoking among high school students in Taiwan. This study, characterising such relationships among Asian populations for the first time, implies that future prevention programmes should direct more efforts toward the parental smoking and parent-child relationships, and not aim exclusively at adolescents in schools.

HLA-B60 and B61 are strongly associated with ankylosing spondylitis in HLA-B27-negative Taiwan Chinese patients

OBJECTIVES

Carriage of HLA-B60 has been shown to increase the risk of ankylosing spondylitis (AS) in B27-positive Caucasian patients, but the association in B27-negative cases is less certain. This study assessed HLA class I gene associations in Chinese HLA-B27-negative AS patients.

METHODS

Forty-one Chinese HLA-B27-negative AS patients fulfilling the modified New York diagnostic criteria for AS were recruited, and 11 383 HLA-B27-negative blood donors were used for comparison. HLA-A and -B typing was done with the microlymphocytotoxicity assay.

RESULTS

Among the B27-negative AS patients, 21 were male and 20 were female. Of HLA-B alleles, only B60 and B61 significantly increased susceptibility to AS in HLA-B27-negative patients (P<0.001).

CONCLUSIONS

In Taiwan Chinese, carriage of B60 is increased in HLA-B27-negative AS patients. The association between B61 and HLA-B27-negative AS patients has not been reported previously. Whether the gene involved is HLA-B60 or B61 or another gene in linkage disequilibrium with these genes is unknown.

Outcome Analysis for Stage IE and IIE Thyroid Lymphoma

Previous reports have revealed modest results in the management of thyroid lymphoma with radiotherapy alone. This retrospective report evaluates the outcome of patients treated for thyroid lymphoma with radiotherapy alone and with combined modality therapy (chemotherapy and radiotherapy) at a single institution. Twenty-seven patients with stages IE and IIE non-Hodgkin's lymphoma of the thyroid gland were treated between 1960 and 1998 at Barnes-Jewish Hospital, of which 14 patients were stage IE and 13 patients were stage IIE. The median age at diagnosis was 67 years, and there were 21 females and 6 males evaluated. The median follow-up time was 38 months (range: 3-279 months). All patients had histologically proven non-Hodgkin's lymphoma, of which 22 patients (81%) were intermediate grade. Treatment consisted of radiotherapy alone in 19 patients and a combined modality therapy in 8 patients. The median radiation dose to the thyroid bed was 44 Gy, and most patients received a doxorubicin-containing regimen administered prior to radiotherapy. Patient, tumor, and treatment-related characteristics were evaluated using Cox regression analysis. Local-regional tumor control, disease-free survival (DFS), and overall survival (OS) were calculated using the Kaplan-Meier method. Four patients had local relapse in this series, with a crude local tumor control rate of 85%. No factor was determined to be significant for local tumor control. The actuarial 5-year DFS and OS for the entire cohort were 57%, and 56%, respectively. In terms of DFS, both age and stage were statistically significant. The 5-year actuarial DFS for patients less than age 65 years was 83% versus 37% for those more than this age (p = 0.024). Furthermore, the 5-year actuarial DFS for patients with stage I and II disease was 69% and 45%, respectively (p = 0.022). In multivariate analysis, age continued to be significant for DFS (p = 0.049). Overall survival analysis revealed age, local tumor control, and stage to be significant in univariate analysis. Multivariate analysis was further carried out using Cox proportional hazard model, and it revealed age (p = 0.006) and local tumor control (p = 0.007) to be significant. Primary thyroid gland lymphomas have a favorable outcome with appropriate therapy, but prognosis depends on both clinical stage and age at presentation. Because of the risk of both local-regional and distant failure, combined modality approaches that use chemotherapy with radiotherapy are warranted for intermediate- and high grade thyroid lymphoma.

Impact of complementary mistletoe extract treatment on quality of life in breast, ovarian and non-small cell lung cancer patients. A prospective randomized controlled clinical trial

Standardized aqueous mistletoe extracts have been applied to cancer patients for several decades as complementary medicine. A multicentric, randomized, open, prospective clinical trial was conducted in three oncological centers in the People's Republic of China in Bejing, Shenyang and Tianjin. Following the guidelines of "Good Clinical Practice" (GCP) this study was performed to get information on efficacy safety and side-effects of the standardized mistletoe extract (sME). Two hundred and thirty-three patients with breast (n=68), ovarian (n=71) and non-small cell lung cancer (NSCLC; n=94) were enrolled into this study. Two hundred and twenty-four patients fulfilled the requirements for final analysis (n=115 treated with sME HELIXOR A; n=109 comprising the control group being treated with the approved immunomodulating phytopharmacon Lentinan). All patients were provided with standard tumor-destructive treatment schedules and complementarily treated with sME or Lentinan during chemotherapy according to treatment protocol. Biometrically, the patients of the control and sME treatment group were comparable regarding distribution, clinical classification (WHO) and treatment protocols. Analysis was performed according to the "Intention to treat principle". Quality of life (QoL) was significantly (p<0.05) improved for patients who were complementarily treated with sME, as determined by the questionnaires FLIC (Functional Living Index-Cancer), TCM (Traditional Chinese Medicine Index) and the KPI (Karnofsky Performance Index) in comparison to the control group. Additionally, the occurrence of adverse events (AEs) was less frequent in the sME than in the control group (total number of AEs 52 versus 90 and number of serious AEs 5 versus 10 in study and control group, most of them due to chemotherapy). Only one serious AE was allocated to complementary treatment in each group (1 angioedema in sME group). All other side-effects of the sME (7 harmless local inflammatory reactions at subcutaneous injection site, 4 cases with fever) were self-limiting and did not demand therapeutic intervention. This study showed that complementary treatment with sME can beneficially reduce the side-effects of chemotherapy in cancer patients and thus improve quality of life.

Low-dose (550 cGy), single-exposure total body irradiation and cyclophosphamide: consistent, durable engraftment of related-donor peripheral blood stem cells with low treatment-related mortality and fatal organ toxicity

On the basis of observations of dog models and from earlier studies with humans, we hypothesized that a low-dose (550 cGy) TBI-based conditioning regimen would result in sustained engraftment of HLA-matched sibling peripheral blood stem cells (PBSC) with low treatment-related mortality (TRM) and low serious organ toxicity if the TBI was given as a single dose and at a high dose rate. The regimen included 550 cGy TBI administered as a single dose at 30 cGy/min and cyclophosphamide. Cyclosporine was given as GVHD prophylaxis. Twenty-seven good-risk (acute leukemia in first remission and chronic-phase chronic myelogenous leukemia) and 53 poor-risk (other) patients were accrued. Complete donor engraftment occurred in 93% to 100% of evaluable patients at each scheduled assessment and was durable through 4 years. Mixed chimerism (50% to 98% donor) was observed in 9 patients (11%). Without further intervention, all patients had complete donor engraftment on subsequent assessments. Graft failure did not occur. TRM through at least 2 years was 7% in the good-risk and 19% in the poor-risk diagnostic groups. Grade 4 (fatal) organ toxicity occurred in only 2 patients (2.5%). Other causes of TRM included infection and GVHD. Median follow-up for the surviving patients was 1234 days (range, 780-1632 days). Current status includes 39 patients (49%) alive and in complete remission, 2 alive in relapse, and 39 dead. Relapse occurred in 15% of the good-risk group and 45% of the poor-risk group. The Kaplan-Meier estimates of 3-year disease-free and overall survival of the good-risk group were 77% and 85%, respectively, and of the poor-risk group were 34% and 36%, respectively. Low-dose (550 cGy), single-exposure TBI given at a high dose rate with cyclophosphamide resulted in consistent durable engraftment of HLA-matched sibling PBSC with a low risk of fatal organ toxicity and TRM.

Low incidence of transplantation-related acute complications in patients with chronic myeloid leukemia undergoing allogeneic stem cell transplantation with a low-dose (550 cGy) total body irradiation conditioning regimen

Although allogeneic transplantation is a curative therapy for chronic myeloid leukemia (CML), treatment-related mortality is still a major cause of posttransplantation mortality, especially for patients older than 40 years. We investigated, in a phase II trial, the role of a low-dose (550 cGy) high-dose rate (35 cGy/min) single-exposure total body irradiation (TBI) conditioning regimen for allogeneic peripheral blood stem cell (PBSC) transplantation in patients with CML. Between June 1997 and August 2000, 30 adult patients with CML underwent cytokine-mobilized allogeneic PBSC transplantation from HLA-matched siblings following administration of cyclophosphamide (60 mg/kg per day intravenously on days -2 and -1) and single-dose TBI (550 cGy delivered at 30 cGy/min on day 0). Cyclosporine A alone was administered for prophylaxis against graft-versus-host disease (GVHD). Median patient age was 47 years (range, 21-63 years), with 23 patients (77%) older than 40 years. The preparative regimen was well tolerated. Grade 4 toxicities and oral mucositis were not observed. Graft failure did not occur. Severe acute GVHD was observed in 5 patients (17%). The median follow-up was 23 months (range, 6-39 months). Cytogenetic or hematologic relapse was detected in 3 patients (10%), 2 of whom subsequently entered remission following a taper of immunosuppression. Nonrelapse mortality occurred in 5 patients (17%), and the Kaplan-Meier estimate of survival at 2 years was 83% (95% confidence interval, 70%-97%). In summary, this low-dose TBI-based preparative regimen resulted in uniform donor engraftment, with markedly reduced organ toxicity and nonrelapse mortality, in this relatively older cohort of patients with CML.

Effects of Tamm-Horsfall protein and albumin on the inhibition of free radicals

INTRODUCTION

Oxalate in urine can cause tubular cellular damage by the production of free radicals. Then, cell death and cellular debris may promote the retention of calcium oxalate crystals and finally the formation of stones. The two most abundant urinary proteins, Tamm-Horsfall protein (THP) and albumin, were tested for the effects of antioxidants.

MATERIALS AND METHODS

By using xanthine-xanthine oxidase reaction, purified THP and albumin were tested for the inhibitory effect. OD(295) was used as a spectrophotometric method to measure the production of uric acid during the reaction.

RESULTS AND CONCLUSIONS

Both proteins can inhibit the reaction of xanthine oxidase on xanthine, although the effect was decreased after enzymatic deglycosylation of sialic acid. Albumin has an IC(50) of 10.7 nM in native condition and 11.9 nM after deglycosylation, whereas THP has 69.6 nM in native condition and 102.0 nM in deglycosylated condition. The data indicates that THP and albumin have an antioxidant effect. Sialic acid in THP has partly an inhibitory effect and is associated with calcium oxalate formation. Studies have indicated that further investigation of the role of free radicals in the formation of urolithiasis and of sialic acid in protein function is needed.

Effects of Tamm-Horsfall protein and albumin on calcium oxalate crystallization and importance of sialic acids

BACKGROUND

Tamm-Horsfall protein and human serum albumin are common urinary proteins that show uncertain inhibitory action on the crystallization of calcium oxalate monohydrate.

MATERIALS AND METHODS

Batch experiments on crystal nucleation, growth, and aggregation were performed using purified Tamm-Horsfall protein and albumin before and after enzymatic removal of sialic acids from the proteins.

RESULTS

At a concentration of 100 nM, both Tamm-Horsfall protein and albumin promoted the time of crystal nucleation by 18.4% and 8.9%, respectively, relative to the control. However, both of the proteins exerted an inhibitory effect on crystal growth, with the IC(50) being 7.27 nM for Tamm-Horsfall protein and 37.5 nM for albumin. The inhibition of crystal aggregation was 81.82% by Tamm-Horsfall protein 100 nM but only 54.55% at 50 nM after enzymatic removal of the sialic acid. Instead of increasing the inhibition, the effect was changed to promotion after an increase in the concentration of Tamm-Horsfall protein to more than 500 nM for native protein and to more than 100 nM for the enzymatic digest. Albumin showed little change after enzymatic treatment and maintained a maximal inhibitory effect of 72.73% on crystal aggregation when the concentration reached to 100 nM.

CONCLUSION

Because the promotion of nucleation could lessen the subsequent saturation of a calcium oxalate solution, it is concluded that Tamm-Horsfall protein and albumin show an overall effect of inhibition on crystallization in vitro. The inhibitory effect of Tamm-Horsfall protein is partly related to sialic acid.

Pharmacokinetic study of all-trans-retinoyl-beta-D-glucuronide in Sprague-Dawley rats after single and multiple intravenous administration(s)

All-trans-retinoyl-beta-D-glucuronide (RAG) is an endogenous active metabolite of all-trans-retinoic acid (ATRA). In the present study, the pharmacokinetics of RAG was examined after the administration of a single intravenous does (5, 10, or 15 micromol/kg) and of multiple daily intravenous doses (5 micromol/kg) to rats for 8 days. The plasma concentrations of RAG and ATRA were measured by a reverse-phase HPLC method. A rapid distribution phase of approximately 1 h was observed in all of the rats after single or multiple doses. Thereafter, RAG was eliminated through a first-order process, in accord with a typical two-compartment first order pharmacokinetic profile. After single intravenous doses, the AUC of RAG increased proportionally with the dose and the clearance remained unchanged within the tested doses. There was no statistical significant difference in distribution rate constants from central compartment to peripheral compartment (K(12)) and from peripheral compartment to central compartment (K(21)) between different doses. However, as the dose increased from 5 micromol/kg to 10 micromol/kg, the volume of distribution at the steady state (V(ss)) and the volume of peripheral compartment (V(p)) decreased significantly (p < 0.05) from 1.290 +/- 0.269, 0.928 +/- 0.232. L/kg to 0.961 +/- 0.149, 0.647 +/- 0.107 L/kg, respectively. V(ss) and V(p) at a dose of 15 micromol/kg (0.924 +/- 0.187, 0.698 +/- 0.165 L/kg) were not significantly different from that at 10 micromol/kg. Thus, RAG might saturate the tissue-binding sites at higher doses. ATRA was detected as a metabolite of RAG at low levels (usually < 0.05 microM) only in the first 2 h after intravenous administration. RAG clearly was not extensively hydrolyzed to ATRA in our study. After multiple daily intravenous administration of RAG, the clearance (Cl) and the elimination rate constant (K(10)) remained unchanged (p > 0.05), indicating that long-term daily administration of RAG did not induce its accelerated metabolism. However, K(12), V(p), and V(ss) declined significantly (p < 0.05) from 1.67 +/- 0.54 h(-1), 0.928 +/- 0.232 L/kg, and 1.290 +/- 0.269 L/kg to 0.96 +/- 0.48 h(-1), 0.494 +/- 0.147 L/kg, and 0.818 +/- 0.187 L/kg, respectively. Therefore, long-term daily dosing of RAG seemed to decrease its distribution profile. Although the AUC of RAG did not change significantly after multiple dosing, the AUC of ATRA after RAG dosing significantly declined (p < 0.05) from 0.032 +/- 0.019 microM x h to 0.010 +/- 0.006 microM x h. The decline in the AUC of ATRA might reflect an increase in its uptake by tissue and/or in its metabolism. Because enhanced clearance is not associated with RAG after multiple administrations, RAG could be considered as an alternate to ATRA in appropriate clinical applications.

[Studies of the integration and expression of exogenes in transgenic rice obtained via particle bombardment transformation]

Various integration events from simple to complex have been found in transgenic elite rice varieties, which were co-transformed with bar and cecropin B gene by particle bombardment after system studies of the structure and expression of the transgene. It was displayed that there were one to seven insertion loci and one to ten copies of transgene in different transformants. No absolute correlation was found between the numbers of transgene copies and the gene expression. Different level expression of transgenes with similar insertion mode was also discovered. The expression cassette integrity and transcription frequency of selectable bar gene were more than non-selectable cecropin B gene, whereas gene silence in plants integrated with intact bar gene was found and higher expression level of cecropin B gene with 0.6 kb fragments degraded in terminator was deduced.

Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications

OBJECTIVE

The placement of percutaneous endoscopic gastrostomy (PEG) tubes is within the realm of the head and neck surgeon because most are proficient in the use of rigid and flexible esophagoscopes. The ability to provide comprehensive care for the patient with head and neck cancer provides further incentive for the head and neck surgeon to adopt this technique. Although it is a technically simple procedure, the surgeon must be aware of the range of complications that can occur with PEG. We review our experience with PEG focusing on the complications as well as strategies for the prevention and management of these complications.

METHODS

A retrospective review of the records of patients who underwent PEG at Stanford University by the Head and Neck Surgery Service between July 1992 and December 1998 was conducted. A total of 103 patients were identified, of which 84 (82%) were patients with head and neck cancers. Complications associated with PEG were identified. All PEGs were performed using the pull technique.

RESULTS

There was no mortality associated with the procedure. Minor complications occurred in 11 cases (10.7%). These included cellulitis (4), ileus (3), tube extrusion (1), clogged lumen (1), and peristomal leakage (2). The only major complication was a single case of PEG site metastasis.

CONCLUSION

The review of our experience with PEG tube placement revealed a low complication rate. Safe PEG placement was achieved by transillumination of the abdominal wall and confirmation by ballottement. In addition, appropriate patient selection, use of perioperative antibiotics, as well as meticulous post-procedure care contributed to the low rate of complications. For the patients with head and neck cancer, a barrier should be placed between the tumor and the instrumentation at the time of tube placement.

Immediate and long-term outcomes of stent implantation for unprotected left main coronary artery disease

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18+/-3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.