A Randomized Trial Comparing Quality of Life After Low-Dose Rate or High-Dose Rate Prostate Brachytherapy Boost With Pelvic External Beam Radiation Therapy

PURPOSE

To compare health-related quality of life (QoL) in urinary, bowel, and sexual domains after combined external beam radiation therapy (EBRT) and either low-dose rate (LDR) or high-dose rate (HDR) prostate brachytherapy (BT).

METHODS AND MATERIALS

Eligible men with intermediate or high-risk prostate cancer treated with combined pelvic EBRT and BT were randomly assigned to either HDR (15 Gy) or LDR (110 Gy) boost. International Prostate Symptom Score, Index of Erectile Function, and Expanded Prostate Cancer Composite were collected at baseline, 1, 3, 6, and 12 months, every 6 months to 3 years and then annually along with prostate-specific antigen/testosterone. Fisher's exact test compared categorical variables and the Mann-Whitney U test Expanded Prostate Cancer Index Composite (EPIC) domain scores.

RESULTS

From January 2014 to December 2019, a random number generator assigned 195 men: 108 to HDR and 87 to LDR. Median age was 71 years. Risk group was high in 57% and unfavorable intermediate in 43%. Androgen deprivation (used in 74%) began with 3 months neoadjuvant and continued for median 12 months. Baseline EPIC scores were similar for the LDR/HDR cohorts: 89 and 88 respectively for Genito-urinary; 92 and 93 for Gastro-intestinal. EPIC urinary scores decreased at 1 month for HDR but recovered promptly to a steady state by 6 months. LDR scores reached a nadir at 3 months with slow recovery to 18 months, after which urinary QoL was similar for HDR and LDR. Bowel QOL scores fell in both cohorts reaching respective nadirs at 12 months. HDR patients recovered close to baseline and maintained higher scores than LDR patients to 5 years. The decline for LDR patients remained more than the minimum clinically important difference out to 5 years.

CONCLUSIONS

The patient experience for combined EBRT and prostate BT is improved with HDR BT. Urinary QoL improves over time to be equivalent between the 2 modalities after 18 months, but LDR patients report lasting bowel symptoms.

Immunometabolic features of natural killer cells are associated with infection outcomes in critical illness

Immunosuppression increases the risk of nosocomial infection in patients with chronic critical illness. This exploratory study aimed to determine the immunometabolic signature associated with nosocomial infection during chronic critical illness. We prospectively recruited patients who were admitted to the respiratory care center and who had received mechanical ventilator support for more than 10 days in the intensive care unit. The study subjects were followed for the occurrence of nosocomial infection until 6 weeks after admission, hospital discharge, or death. The cytokine levels in the plasma samples were measured. Single-cell immunometabolic regulome profiling by mass cytometry, which analyzed 16 metabolic regulators in 21 immune subsets, was performed to identify immunometabolic features associated with the risk of nosocomial infection. During the study period, 37 patients were enrolled, and 16 patients (43.2%) developed nosocomial infection. Unsupervised immunologic clustering using multidimensional scaling and logistic regression analyses revealed that expression of nuclear respiratory factor 1 (NRF1) and carnitine palmitoyltransferase 1a (CPT1a), key regulators of mitochondrial biogenesis and fatty acid transport, respectively, in natural killer (NK) cells was significantly associated with nosocomial infection. Downregulated NRF1 and upregulated CPT1a were found in all subsets of NK cells from patients who developed a nosocomial infection. The risk of nosocomial infection is significantly correlated with the predictive score developed by selecting NK cell-specific features using an elastic net algorithm. Findings were further examined in an independent cohort of COVID-19-infected patients, and the results confirm that COVID-19-related mortality is significantly associated with mitochondria biogenesis and fatty acid oxidation pathways in NK cells. In conclusion, this study uncovers that NK cell-specific immunometabolic features are significantly associated with the occurrence and fatal outcomes of infection in critically ill population, and provides mechanistic insights into NK cell-specific immunity against microbial invasion in critical illness.

End-Expiratory Lung Volumes During Spontaneous Breathing Trials in Tracheostomized Subjects on Prolonged Mechanical Ventilation

BACKGROUND

The role of end-expiratory lung volume (EELV) during a spontaneous breathing trial (SBT) in patients who were tracheostomized and on prolonged mechanical ventilation is unclear. This study aimed to assess EELV during a 60-min SBT and its correlation with weaning success.

METHODS

Enrolled subjects admitted to a weaning unit were measured for EELV and relevant parameters before and after the SBT.

RESULTS

Of the 44 enrolled subjects, 29 (66%) were successfully liberated, defined as not needing mechanical ventilation for 5 d. The success group had fewer subjects with chronic kidney disease (41% vs 73%, P = .044), stronger mean ± SD maximum inspiratory pressure (41.6 ± 10.4 vs 34.1 ± 7.1 cm H₂O; P = .02) and mean ± SD maximum expiratory pressure (46.9 ± 11.7 vs 35.3 ± 16.9 cm H₂O; P = .01) versus the failure group. Toward the end of the SBT, the success group had a significant increase in the mean ± SD EELV (before vs after: 1,278 ± 744 vs 1,493 ± 867 mL; P = .040) and a decrease in the mean ± SD rapid shallow breathing index (83.8 ± 39.4 vs 66.3 ± 29.4; P = .02), whereas there were no significant changes in these 2 parameters in the failure group. The Cox regression analysis showed that, at the beginning of SBT, a greater difference between EELV with a PEEP of 0 cm H₂O and with a PEEP of 5 cm H₂O was significantly correlated to a higher likelihood of weaning success. Toward the end of the SBT, a greater EELV level at a PEEP of 0 cm H₂O was also correlated with weaning success. Also, the greater difference of EELV at a PEEP of 0 cm H₂O between the beginning and the end of the SBT was also correlated with a shorter duration to weaning success.

CONCLUSIONS

The change in EELV during a 60-min SBT may be of prognostic value for liberation from prolonged mechanical ventilation in patients who had a tracheostomy. Our findings suggest a model to understand the underlying mechanism of failure of liberation from mechanical ventilation in these patients.

Biological Aging and Periodontal Disease: Analysis of NHANES (2001-2002)

INTRODUCTION

Periodontitis is a chronic inflammatory disease caused by multiple potential contributing factors such as bacterial biofilm infection of the tissues surrounding the teeth and environmental determinants and a dysregulated host response for modifying and resolving the inflammation. Because periodontal disease is a major public health concern with substantial increases in the prevalence and severity in aging populations, previous studies of periodontitis tended to approach the disease as an age-associated outcome across the life span. However, few investigations have considered that, as a chronic noncommunicable disease, periodontitis may not simply be a disease that increases with age but may contribute to more rapid biologic aging.

OBJECTIVES

Increasing population data supports the potential disconnect between chronological aging and biologic aging, which would contribute to the heterogeneity of aging phenotypes within chronologic ages across populations. Thus, our aim was to test whether periodontal disease affects biological aging across the life span.

METHODS

The prevalence of periodontitis in the adult US population is a portion of the assessment of the National Health and Nutrition Examination Survey (NHANES), which has been ongoing since 1971 through 2-y cycles sampling populations across the country. We used NHANES 2001-2002 to test the hypothesis that the presence/severity of periodontal disease as an exposure variable would negatively affect telomere length, a measure of biological aging, and that this relationship is modified by factors that also affect the progression of periodontitis, such as sex, race/ethnicity, and smoking.

RESULTS

The data demonstrated a significant impact of periodontitis on decreasing telomere lengths across the life span. These differences were modulated by age, sex, race/ethnicity, and smoking within the population.

CONCLUSION

The findings lay the groundwork for future studies documenting broader effects on biological aging parameters as well as potential intervention strategies for periodontitis in driving unhealthy aging processes.

KNOWLEDGE TRANSFER STATEMENT

Periodontitis is a chronic inflammatory disease and dysregulated host response. Shortening of telomeres is a reflection of biologic aging. Decreased telomere lengths with periodontitis are seemingly related to chronic infection and persistent local and systemic inflammation. These findings suggest that periodontitis is not simply a disease of aging but may also transmit chronic systemic signals that could affect more rapid biological aging. Clinicians can use this outcome to recognize the role of periodontitis in driving unhealthy aging processes in patients.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

A metaphyseal fracture rat model for mechanistic studies of osteoporotic bone healing

Most osteoporotic fractures occur at metaphyseal regions of long bones. The present study proposed a clinically relevant animal model that satisfied: i) induction of osteoporosis, ii) unilateral complete osteotomy at metaphysis, iii) internal fixation. 6 months old female Sprague-Dawley rats (n = 64) were randomly divided into the ovariectomised-metaphyseal osteotomy (OVX, n = 32) and metaphyseal osteotomy (SHAM, n = 32) groups. The metaphyseal-osteotomy model was created with a plate-fixation of the osteotomy and assessed by X-ray, micro-computed tomography, histomorphometry and mechanical testing at weeks 1, 3 and 6. X-ray results showed complete healing of metaphyseal osteotomy at week 6. Histology showed 3 stages of metaphyseal healing. Stage 1 was characterised by fibrous tissue, consisting of disorganised orientation of collagen fibres, and infiltration of immune cells. At stage 2, a transitional zone consisting of maturing fibrous tissue and differentiating mesenchymal cells with early trabecular bone formation and disorganised woven bone were observed. During stage 3, cortical bone ends unified and woven bone underwent transformation to lamellar bone. OVX group healing was significantly delayed when compared to SHAM samples. The study demonstrated that healing of osteoporotic osteotomy at the metaphyseal region was delayed in terms of radiography, histomorphometry and mechanical strength. These quantitative evaluations, along with histological features, may provide key references for future studies. The animal model may provide additional clinical relevance as most osteoporotic fracture in humans occurs at metaphyseal regions.

γ-Synuclein Expression Is a Malignant Index in Oral Squamous Cell Carcinoma

Dysregulation of γ-synuclein (SNCG) has been reported in many cancers; however, its role in cancer development is still controversial. Here, we examined the potential involvement of DNA methylation in regulating SNCG and its role in oral squamous cell carcinoma (OSCC). We used 8 OSCC cell lines to investigate SNCG methylation and expression. SNCG methylation was examination by methylation-specific polymerase chain reaction and bisulfate sequencing. Cells showing a high degree of SNCG methylation were treated with 5-aza (methylation inhibitor), and changes in their methylation and expression profiles were analyzed. Functional effects of SNCG in OSCC were examined by its overexpression and knockdown. Additionally, methylation and expression of SNCG in OSCC tissues were investigated and correlated with clinicopathologic features. All OSCC cells showed detectable SNCG expression at the mRNA and protein levels. Methylation-specific polymerase chain reaction and bisulfate sequencing revealed high SNCG expression in SCC25 cells with the unmethylated allele, and their 15 CpG islands were unmethylated. The methylated allele was detected only in OEC-M1 cells exhibiting low SNCG expression, and their CpG islands were partially methylated. 5-aza treatment in OEC-M1 cells attenuated methylation and restored SNCG expression. SNCG overexpression increased colony forming, migration, and invasion abilities in OEC-M1 cells. Silencing SNCG in SCC25 cells suppressed these behaviors. All 25 tumor-adjacent normal tissues were negative for SNCG immunostaining. SNCG upregulation was frequently observed in dysplastic and OSCC tissues. Positive SNCG expression was found in 45% (37 of 82) OSCC tissues. Positive SNCG expression in OSCC significantly correlated with cancer staging and lymph node metastasis. However, SNCG methylation did not correlate with its expression and clinicopathologic variables in OSCC tissues. DNA methylation may participate in regulating SNCG expression in some OSCC cells. SNCG upregulation could be involved in OSCC progression.

Discriminating neural representations of physical and social pains: how multivariate statistics challenge the "shared representation" theory of pain

Overlapping functional magnetic resonance imaging (fMRI) activity elicited by physical pain and social rejection has posited a common neural representation between the two experiences. However, Woo and colleagues (Nat Commun 5: 5380, 2014) recently used multivariate statistics to challenge the "shared representation" theory of pain. This study has implications in the way results from fMRI studies are interpreted and has the potential of broadening our understanding of different pain states and future development of personalized medicine.

Note: Vector network analyzer-ferromagnetic resonance spectrometer using high Q-factor cavity

A ferromagnetic resonance (FMR) spectrometer whose main components consist of an X-band resonator and a vector network analyzer (VNA) was developed. This spectrometer takes advantage of a high Q-factor (9600) cavity and state-of-the-art VNA. Accordingly, field modulation lock-in technique for signal to noise ratio (SNR) enhancement is no longer necessary, and FMR absorption can therefore be extracted directly. Its derivative for the ascertainment of full width at half maximum height of FMR peak can be found by taking the differentiation of original data. This system was characterized with different thicknesses of permalloy (Py) films and its multilayer, and found that the SNR of 5 nm Py on glass was better than 50, and did not have significant reduction even at low microwave excitation power (-20 dBm), and at low Q-factor (3000). The FMR other than X-band can also be examined in the same manner by using a suitable band cavity within the frequency range of VNA.

An acoustic rectifier

The detection of acoustic signals is of relevance for a range of practical applications, for example in medical diagnostics. However, whereas rectification of electric current and other energy forms such as thermal flux has been demonstrated, acoustic rectification has not yet been achieved. Here, on the basis of the earlier theoretical proposal of an 'acoustic diode', we present the first experimental demonstration of a rectified energy flux of acoustic waves. A one-dimensional acoustic rectifier is fabricated by coupling a superlattice with a layer of ultrasound contrast agent microbubble suspension. A significant rectifying effect is observed within two frequency bands at locations that agree well with theoretical predictions. Following optimization of the concentration of the microbubble suspension, rectifying ratios can be as high as ~10(4). This realization of an acoustic rectifier should have substantial practical significance, for example in the focusing of ultrasound in medical applications.

Autophagy is increased in prostate cancer cells overexpressing acid ceramidase and enhances resistance to C6 ceramide

Acid ceramidase (AC) overexpression has been observed in prostate cancer cell lines and primary tumors, and contributes to resistance to chemotherapy and radiation. The consequence of AC overexpression is the ability to convert ceramide, which is often produced as a proapoptotic response to stress, to sphingosine, which can then be converted to the prosurvival molecule sphingosine-1-phosphate. In addition to their ability to metabolize ceramide produced in response to stress, we show here that prostate cancer cell lines overexpressing AC also have increased lysosomal density and increased levels of autophagy. Furthermore, pretreatment with 3-methyladenine restores sensitivity of these cells to treatment with C(6) ceramide. We also observed increased expression of the lysosomal stabilizing protein KIF5B and increased sensitivity to the lysosomotropic agent LCL385. Thus, we conclude that AC overexpression increases autophagy in prostate cancer cells, and that increased autophagy enhances resistance to ceramide.

Angiotensin-converting enzyme gene polymorphism and stroke in type 2 diabetic patients in Taiwan

BACKGROUND

The effect of traditional risk factors on the association between angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and stroke was rarely studied previously. We investigated such effect in Taiwanese type 2 diabetic patients.

MATERIALS AND METHODS

A total of 872 (422 men and 450 women) patients aged 63.5 (SD: 11.6) years were recruited. Among them, 92 cases (48 men and 44 women) had stroke. Polymerase chain reaction was used to classify the genotypes as II, ID and DD. Analyses were performed in separate sexes.

RESULTS

The adjusted odds ratios for stroke for ID vs. II and DD vs. II were 0.837 (0.413-1.697) and 1.778 (0.596-5.300), respectively, for men; but were 1.700 (0.824-3.505) and 3.706 (1.375-9.985), respectively, for women. In models assuming recessive (DD vs. II + ID), dominant (DD + ID vs. II) and additive (II = 0, ID = 1 and DD = 2) transmission, none of the odds ratios was significant for men; but were all significant for women: 2.784 (1.137-6.818), 1.996 (1.006-3.962) and 1.877 (1.155-3.050), respectively. In models using patients without risk factors (hypertension, obesity, smoking or dyslipidaemia ) as a referent group and comparing them to patients with the risk factor and with ID/II, and with DD genotypes, all models (except for smoking) favoured an increasing trend of risk with patients having the risk factor and DD genotype at the highest risk in women. Similar trends for hypertension and dyslipidaemia were also observed in men.

CONCLUSION

Traditional risk factors play an important role in the association between the ACE genotypes and stroke. Patients with DD genotype and having traditional risk factors are at the highest risk.

Concurrent chemoradiotherapy with twice weekly paclitaxel and cisplatin followed by esophagectomy for locally advanced esophageal cancer

BACKGROUND

To test the feasibility of incorporating a twice-weekly paclitaxel (Taxol) and cisplatin regimen into concurrent chemoradiotherapy (CCRT), followed by surgery, for patients with locally advanced esophageal cancer.

PATIENTS AND METHODS

Patients with operable T3N0-1M0 or T1-3N1M0 esophageal cancer were enrolled. The CCRT regimen included paclitaxel (35 mg/m2 1 h on days 1 and 4/week), cisplatin (15 mg/m2 1 h on days 2 and 5/week), and radiotherapy (2 Gy on days 1-5/week). When the accumulated radiation dose reached 40 Gy, the feasibility of esophagectomy was evaluated in all patients. In patients for whom esophagectomy was not feasible, CCRT was continued to a dose of 60 Gy.

RESULTS

The majority of 97 patients enrolled had squamous cell carcinoma on histology (95%) and T3N1 disease by endoscopic ultrasonographic staging (90%). All patients received CCRT to 40 Gy. Sixty-one patients underwent surgery, and 26 patients continued definitive CCRT to 60 Gy. The intention-to-treat pathological complete response rate was 25% [24/97, 95% confidence interval (CI) 16-33]. At a median follow-up of 25.3 months, the median progression-free and overall survival was 15.6 and 28.8 months, respectively. The most common grade 3/4 toxic effects were leukopenia (30%), thrombocytopenia (10%), and diarrhea (15%).

CONCLUSIONS

CCRT with a twice-weekly paclitaxel and cisplatin regimen followed by esophagectomy is an active treatment of locally advanced esophageal cancer.

Zebularine: a new drug for epigenetic therapy

Regulatory genes are often hypermethylated at their promoter 5' regions and silenced in cancer. Epigenetic therapy with DNA methylation inhibitors have been shown to result in the demethylation and reactivation of these genes. Zebularine is a recently discovered mechanism-based inhibitor of DNA methylation, and has received much attention for its potential in clinical use. Further studies exploring the effectiveness of zebularine in a variety of settings could allow the development of novel therapies for cancer.

Spectrofluorometric analysis of length-dependent conformational changes in cardiac troponin C

Length modulation of cardiac muscle is manifested in the Frank-Starling relation of the heart. Recently, it has been shown that length-dependent changes in SH reactivity of cardiac troponin C (cTnC) occurred in association with cross-bridge attachment and Ca2+. However, the presence of two SH groups (Cys-35 and Cys-84) in the regulatory region of cTnC complicates efforts to detect conformational changes. In this study skinned porcine cardiac fibers were reacted with 7-diethylamino-3-[4'maleimidylphenyl]-4-methylcoumarin (CPM). Alkaline urea gel electrophoresis, along with protein elution, was used to isolate filament bound cTnC. Analysis of fluorescence measurement showed that there is a Ca(2+)-increased fluorescence for CPM-labeled cTnC in long fibers (sarcomere length = 2.2 approximately 2.5 microm) but not in short fibers (sarcomere length = 1.6 approximately 1.8 microm). In addition, the labeled cTnC was measured for the fluorescence decrease over time by adding a non-fluorescence energy acceptor, 4-dimethylaminophenylazophenyl-4'maleimide (DABMI), in the presence and absence of Ca2+. Fluorescence quenching by DABMI is not affected by Ca2+ in long fibers but it is significantly increased in short fibers. However, the fibers maintained in the relaxed state with 5 mM MgATP and 1 mM Vanadate showed no length effect on the CPM-labeled cTnC in terms of the Ca(2+)-mediated changes in fluorescence spectrum and in fluorescence quenching by DABMI. All together, our results suggest that the relative reactivities of Cys-35 and Cys-84 vary with sarcomere length.

The effect of vertebral rotation of the lumbar spine on dual energy X-ray absorptiometry measurements: observational study

OBJECTIVE

To estimate how axial rotation of lumbar vertebrae quantitatively affects bone mineral density, as measured by dual energy X-ray absorptiometry in the anteroposterior plane.

DESIGN

Observational study.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Cadaver lumbar vertebrae (L2 to L4) were removed from four adults.

MAIN OUTCOME MEASURES

Using dual energy X-ray absorptiometry, the bone mineral content, bone area, and bone mineral density were measured in the neutral position and with vertebral axial rotation in increments of 7.5 degrees, up to a maximum of 45 degrees.

RESULTS

Correlation analysis showed a significant positive correlation between the degree of rotation and measured bone area, a significant negative correlation between degree of rotation and bone mineral density measurements, but no significant correlation between degree of rotation and measured bone mineral content. The measured bone area increased approximately 24% and the bone mineral density decreased approximately 19% when the vertebrae were rotated by 45 degrees.

CONCLUSIONS

These results suggest that for patients with rotational deformity of the spine, such as scoliosis, measurements of lumbar spine bone mineral content by dual energy X-ray absorptiometry is not affected, while bone mineral density measurements are not reliable.

MR imaging of children's knees

The spectrum of paediatric knee disorders ranges from developmental and growth disorders, traumatic derangement, inflammation, infection, and diffuse marrow disorder to neoplasm. We present in this pictorial review the MR imaging findings used to characterize these various diseases affecting the knee region of children and adolescents.

Examining prognostic factors and patterns of failure in nasopharyngeal carcinoma following concomitant radiotherapy and chemotherapy: impact on future clinical trials

PURPOSE

Concomitant chemotherapy and radiotherapy (CCRT), followed by adjuvant chemotherapy, has improved the outcome of nasopharyngeal carcinoma (NPC). However, the prognosis and patterns of failure after this combined-modality treatment are not yet clear. In this report, the prognostic factors and failure patterns we observed with CCRT may shed new light in the design of future trials.

METHODS AND PATIENTS

One hundred forty-nine (149) patients with newly diagnosed and histologically proven NPC were prospectively treated with CCRT followed by adjuvant chemotherapy between April 1990 and December 1997. One hundred and thirty-three (89.3%) patients had MRI of head and neck for primary evaluation before treatment. Radiotherapy was delivered either at 2 Gy per fraction per day up to 70 Gy or 1.2 Gy per fraction, 2 fractions per day, up to 74.4 Gy. Chemotherapy consisted of cisplatin and 5-fluorouracil. According to the AJCC 1997 staging system, 32 patients were in Stage II, 53 in Stage III, and 64 in Stage IV (M0).

RESULTS

Univariate analysis revealed that WHO (World Health Organization) Type II histology, T4 classification, and parapharyngeal extension were poor prognostic factors for locoregional control. Multivariate analysis revealed that T4 disease was the most important adverse factor that affects locoregional control, the risk ratio being 5.965 (p = 0.02). Univariate analysis for distant metastasis revealed that T4 and N3 classifications, serum LDH level > 410 U/L (normal range, 180-460), parapharyngeal extension, and infiltration of the clivus were significantly associated with poor prognosis. Multivariate analysis, however, revealed that T4 classification and N3 category were the only two factors that predicted distant metastasis; the risk ratios were 3.994 (p = 0.02) and 3.390 (p = 0.01), respectively. Therefore, based on the risk factor analysis, we were able to identify low-, intermediate-, and high-risk patients. Low-risk patients were those without the risk factors mentioned above. They consisted of Stage II patients with T2aN0, T1N1, and T2aN1 categories and of Stage III patients with T1N2 and T2aN2 categories. Their risk of recurrence is low (4%). Intermediate-risk patients were those with at least one univariate risk factor. They are Stage II patients with T2bN0 and T2bN1 categories and Stage III patients with T2bN2 and T3N0-2 categories. The risk of recurrence is modest (18%). High-risk patients have risk factors by multivariate analysis. They are stage T4 or N3 patients. Their risk of recurrence is high (36%).

CONCLUSION

Low-risk patients have an excellent outcome. Future trials should focus on reducing treatment-associated toxicities and complications and reevaluate the benefit of sequential adjuvant chemotherapy. The recurrence in treatment of intermediate-risk patients is modest; CCRT and adjuvant chemotherapy may be the best standard for them. Patients with T4 and N3 disease have poorer prognosis. Hyperfractionated radiotherapy may be considered for the T4 patients. Future study in these high-risk patients should also address the problem of distant spread of the disease.

Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases

BACKGROUND

The natural history of congenital muscular torticollis and the outcome of different treatment modalities have been poorly investigated, and the results of treatment have varied considerably.

METHODS

The main objective of this prospective study was to evaluate the outcomes of 821 consecutive patients with congenital muscular torticollis who were first seen when they were less than one year old, were treated with a standardized program of manual stretching, and were followed for a mean of 4.5 years. Before treatment, the patients were classified into one of three clinical groups: (1) palpable sternomastoid tumor, (2) muscular torticollis (thickening and tightness of the sternocleidomastoid muscle), and (3) postural torticollis (torticollis but no tightness or tumor).

RESULTS

Of the 821 patients, 452 (55%) had a sternomastoid tumor; 276 (34%), muscular torticollis; and ninety-three (11%), postural torticollis. Multivariate analysis of the outcomes showed that (1) the duration of treatment was significantly associated with the clinical group (p < 0.0001), a passive rotation deficit of the neck (p < 0.0001), involvement of the right side (p < 0.0001), difficulties with the birth (p < 0.009), and age at presentation (p < 0.0001); (2) the overall final assessment score was associated with the rotation deficit (p = 0.02), age at presentation (p = 0.014), and duration of treatment (p < 0.0001); and (3) subsequent surgical treatment was required by 8% (thirty-four) of the 452 patients in the sternomastoid tumor group compared with 3% (eight) of the 276 patients in the muscular torticollis group and 0% (none) of the ninety-three patients in the postural torticollis group.

CONCLUSIONS

This large prospective study demonstrated that controlled manual stretching is safe and effective in the treatment of congenital muscular torticollis when a patient is seen before the age of one year. The most important factors that predict the outcome of manual stretching are the clinical group, the initial deficit in rotation of the neck, and the age of the patient at presentation. Surgical treatment is indicated when a patient has undergone at least six months of controlled manual stretching and has residual head tilt, deficits of passive rotation and lateral bending of the neck of >15 degrees, a tight muscular band or tumor, and a poor outcome according to our special assessment chart.

Comparison of intensity modulated radiation therapy (IMRT) treatment techniques for nasopharyngeal carcinoma

We studied target volume coverage and normal tissue sparing of serial tomotherapy intensity modulated radiation therapy (IMRT) and fixed-field IMRT for nasopharyngeal carcinoma (NPC), as compared with those of conventional beam arrangements. Twelve patients with NPC (T2-4N1-3M0) at Mallinckrodt Institute of Radiology underwent computed tomography simulation. Images were then transferred to a virtual simulation workstation computer for target contouring. Target gross tumor volumes (GTV) were primary nasopharyngeal tumor (GTV(NP)) with a prescription of 70 Gy, grossly enlarged cervical nodes (GTV(LN)) with a prescription of 70 Gy, and the uninvolved cervical lymphatics [designated as the clinical tumor volume (CTV)] with a prescription of 60 Gy. Critical organs, including the parotid gland, spinal cord, brain stem, mandible, and pituitary gland, were also delineated. Conventional beam arrangements were designed following the guidelines of Intergroup (SWOG, RTOG, ECOG) NPC Study 0099 in which the dose was prescribed to the central axis and the target volumes were aimed to receive the prescribed dose +/- 10%. Similar dosimetric criteria were used to assess the target volume coverage capability of IMRT. Serial tomotherapy IMRT was planned using a 0.86-cm wide multivane collimator, while a dynamic multileaf collimator system with five equally spaced fixed gantry angles was designated for fixed-beam IMRT. The fractional volume of each critical organ that received a certain predefined threshold dose was obtained from dose-volume histograms of each organ in either the three-dimensional or IMRT treatment planning computer systems. Statistical analysis (paired t-test) was used to examine statistical significance. We found that serial tomotherapy achieved similar target volume coverage as conventional techniques (97.8 +/- 2.3% vs. 98.9 +/- 1.3%). The static-field IMRT technique (five equally spaced fields) was inferior, with 92.1 +/- 8.6% fractional GTV(NP) receiving 70 Gy +/- 10% dose (P < 0.05). However, GTV(LN) coverage of 70 Gy was significantly better with both IMRT techniques (96.1 +/- 3.2%, 87.7 +/- 10.6%, and 42.2 +/- 21% for tomotherapy, fixed-field IMRT, and conventional therapy, respectively). CTV coverage of 60 Gy was also significantly better with the IMRT techniques. Parotid gland sparing was quantified by evaluating the fractional volume of parotid gland receiving more than 30 Gy; 66.6 +/- 15%, 48.3 +/- 4%, and 93 +/- 10% of the parotid volume received more than 30 Gy using tomotherapy, fixed-field IMRT, and conventional therapy, respectively (P < 0.05). Fixed-field IMRT technique had the best parotid-sparing effect despite less desirable target coverage. The pituitary gland, mandible, spinal cord, and brain stem were also better spared by both IMRT techniques. These encouraging dosimetric results substantiate the theoretical advantage of inverse-planning IMRT in the management of NPC. We showed that target coverage of the primary tumor was maintained and nodal coverage was improved, as compared with conventional beam arrangements. The ability of IMRT to spare the parotid glands is exciting, and a prospective clinical study is currently underway at our institution to address the optimal parotid dose-volume needs to be spared to prevent xerostomia and to improve the quality of life in patients with NPC.

Nanoindentation study of interfaces between calcium phosphate and bone in an animal spinal fusion model

Intertransverse process spinal fusion is a common surgical procedure for the treatment of spinal disorders. In the present study, a porous hydroxyapatite (HA)/beta-tricalcium phosphate (beta-TCP) ceramic was tested as graft material using a rabbit lumbar transverse process (L5-L6) fusion model. The porous ceramic blocks were implanted onto the dorsal decorticated surface of the lumbar transverse processes. The specimens were harvested at the seventh week after implantation. Histomorphological observation revealed that the integration of HA/beta-TCP with the host bone of the transverse process occurred by both cancellous bone formation and cartilage formation. Scanning electron microscopy-wavelength dispersive X-ray spectrometry examinations showed significant differences in calcium, phosphorus, and sulfur contents in the newly formed tissues and the porous HA/TCP implants. Nanoindentations were used to evaluate the intrinsic mechanical properties of the implants and the newly formed tissues. The Young's moduli of the newly formed cartilage, new cancellous bone, and HA/TCP, were 0.66 +/- 0.02 GPa, 2.36 +/- 0.50 GPa, and 10.2 +/- 1.21 GPa, respectively. Nanoindentation results revealed degradation of the porous ceramics and incomplete calcification of the new cancellous bone at the seventh week after implantation. Nanoindentation appeared to be a useful technique for assessing the mechanical status of spinal fusion in animal models.

Snapping during manual stretching in congenital muscular torticollis

Manual stretching frequently is used in the treatment of congenital muscular torticollis in infants. During manipulation, it is not uncommon for the sternocleidomastoid muscle to snap or suddenly give way. The main objective of this study was to evaluate the predisposing causes and clinical significance of such snapping. Four hundred fifty-five patients younger than 1 year of age with congenital muscular torticollis treated with a standardized gentle manual stretching program during a 13-year period were studied. Using prospective standardized assessment parameters, the pretreatment, treatment, and followup results of a group of 41 patients with snapping detected during treatment were compared with the results of a group of 404 patients without snapping during treatment. The group with snapping was associated with a more severe sternomastoid tumor, higher incidence of hip dysplasia, earlier clinical presentation, and shorter duration of treatment. With a mean followup of 3.5 years, the group with snapping was not different from the group that had no snapping in the final assessment score and percentage requiring surgery. From this study, unintentional snapping during the gentle manipulation treatment of congenital muscular torticollis has clinical and ultrasonographic evidence of partial or complete rupture of the sternocleidomastoid muscle. No long-term deleterious effect on the outcome was observed after the snapping.

Osteopenia in adolescent idiopathic scoliosis: a histomorphometric study

STUDY DESIGN

Bone biopsies from iliac crest and spinous process of adolescent idiopathic scoliosis patients were obtained intraoperatively for histology and histomorphometric analysis.

OBJECTIVES

To study the histologic features of cancellous bone and to correlate the histomorphometric variables with preoperative bone mineral density in patients with adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Low bone mineral density has been reported in adolescent idiopathic scoliosis. However, there is limited information about the histopathologic changes.

METHODS

Undecalcified and decalcified bone specimens from iliac crest and spinous process of adolescent idiopathic scoliosis patients obtained intraoperatively were stained with Goldner and hematoxylin & eosin stain, respectively. Results were correlated with bone mineral density of the lumbar spine (L2-L4) and proximal femur measured before surgery.

RESULTS

Bone histology showed significant less osteocyte count in the trabecular bone characterized with smooth and continuous borders in patients with adolescent idiopathic scoliosis. Histomorphometry confirmed the lower static parameters. The results correlated well with the decreased bone mineral density.

CONCLUSION

Bone biopsy study suggested disturbance of bone turnover in patients with adolescent idiopathic scoliosis. The abnormal metabolism might contribute to the low bone mineral density and play an important role in the etiology and pathogenesis of adolescent idiopathic scoliosis.

Significance of non-level walking on transtibial prosthesis fitting with particular reference to the effects of anterior-posterior alignment

Despite the fact that non-level walking is known to be important for prosthesis fitting, its clinical significance has not been investigated. In this study, the acceptable prosthesis alignment ranges of six subjects with transtibial amputation on level and non-level walking were determined and compared. With the aid of a recently developed alignment jig, prosthesis fitting was performed for each subject with varied anterior-posterior (AP) alignments. Conventional assessments and the subjects' comment were used to determine whether the alignment was acceptable or not. The results showed that the acceptable alignment range for non-level walking consistently fell within and was significantly smaller than that for level walking with p<0.05. It was evident that non-level walking is important for better approximation of optimum alignment and should be included in routine prosthesis fitting.

Epidemiological features of supracondylar fractures of the humerus in Chinese children

We studied 450 children with a supracondylar fracture of the humerus in the period 1991 to 1995, and were able to collect full management details in 403 of them (253 boys and 150 girls). The median age at presentation was 6 years (6.6 years in boys, and 5 years in girls), with the nondominant humerus 1.5 times more commonly injured. Fifteen percent of children presented more than 1 day after the injury. Garland type III fractures constituted 45% of cases, type I 30%, and type II 24%, with flexion type fractures present only in 1% of the children. A nerve injury was associated with the fracture in 19 cases. Although the radial pulse was not palpable at presentation in nine patients, only one child had diminished distal circulation requiring exploration. Concomitant fractures were present in 14 patients. Elbow hyperextension was greater than in a comparable group of noninjured children. Open reduction was necessary in 20% of these children, most being managed by manipulation under anaesthesia, at times associated with percutaneous Kirschner wiring. The hospital stay was 2 days or less in two-thirds of the patients, with more than 90% discharged home within 1 week of admission. In conclusion, many Chinese patients attend hospital later than their Western counterparts, and the rate of flexion-type injuries is low.

Acute elbow trauma in children: spectrum of injury revealed by MR imaging not apparent on radiographs

OBJECTIVE

The objective of this study is to evaluate the frequency and significance of unrecognized bone or soft-tissue injury in pediatric patients with elbow trauma assessed with radiographs alone.

SUBJECTS AND METHODS

Fifty children (32 boys and 18 girls; mean age, 7.3 years; age range, 2-12 years) with acute elbow trauma were examined with radiography and MR imaging. Radiographs were categorized into those showing normal findings, an effusion, an equivocal fracture, or an unequivocal fracture. MR examinations were assessed for an effusion, fracture, transphyseal fracture extension, physeal injury, bone bruising, and ligament or muscle injury. Average clinical follow-up was 1.6 years (range, 6-28 months) after injury.

RESULTS

Radiographs showed normal findings in seven children (14%), an effusion only in 17 children (34%), and an unequivocal or equivocal fracture in 26 children (52%). MR imaging showed an effusion in 48 children (96%); unequivocal fracture in 37 children (74%), including transphyseal fracture in seven children (14%) and other physeal injury in three children (6%); bone bruising in 45 children (90%); ligament injury in six children (14%); and muscle injury in 19 children (38%). A less severe spectrum of injury occurred in children with normal findings on radiographs than in those with an effusion or fracture seen on radiography. Follow-up radiographs did not help in the detection of radiographically occult fractures. MR findings had no appreciable effect on patient treatment and no value in predicting duration of convalescence or clinical outcome at an average of 1.6 years after injury.

CONCLUSION

In children with elbow trauma, MR imaging reveals a broad spectrum of bone and soft-tissue injury beyond that recognizable radiographically. However, the additional information afforded by MR imaging has little bearing on treatment or clinical outcome.

Deferoxamine-induced bone dysplasia in the distal femur and patella of pediatric patients and young adults: MR imaging appearance

OBJECTIVE

We investigated the MR imaging appearance of deferoxamine-induced bone dysplasia in the distal femur and patella in patients with thalassemia major.

MATERIALS AND METHODS

Thirty-five patients with homozygous ss-thalassemia major who were undergoing regular transfusions and chelation therapy underwent coronal T1-weighted MR imaging of the femur, including the femoral head and the distal femoral epiphysis. Additional coronal fat-saturated dual-echo and sagittal T1-weighted images of the distal femur and patella were obtained in 11 patients who were suspected of having distal femoral lesions on the basis of the coronal T1-weighted images of the entire femur.

RESULTS

No dysplastic change was detected in the proximal femur on coronal T1-weighted images. In 22 distal femurs of 11 patients, the following abnormalities were detected on MR imaging: blurred physeal-metaphyseal junction (n = 22), distal metaphyseal areas of hyperintensity (n = 21), physeal widening (n = 18), metadiaphyseal lesions (n = 11), epiphyseal lesions (n = 10), and patellar lesions (n = 2). Physeal widening and distal metaphyseal hyperintense areas were all more pronounced peripherally. Of the 21 distal metaphyseal hyperintensities, lateral abnormalities were larger than medial abnormalities in 16. Of the 18 distal femurs in which physeal widening was detected, the lateral widening was more marked than the medial widening in 12. Patients with MR imaging evidence of bone dysplasia have a significantly (p = 0.003) greater height reduction than patients without such evidence of bone dysplasia.

CONCLUSION

Deferoxamine-induced bone dysplasia in the distal femur and patella is represented by a spectrum of morphologic changes in the epiphysis, physis, metaphysis, and metadiaphysis on MR imaging.

Long-term survival of nasopharyngeal carcinoma following concomitant radiotherapy and chemotherapy

PURPOSE

The purpose of this study is to demonstrate long-term survival of nasopharyngeal carcinoma treated with concomitant chemotherapy and radiotherapy (CCRT) followed by adjuvant chemotherapy.

METHODS AND PATIENTS

One hundred and seven patients with Stage III and IV (American Joint Committee on Cancer, AJCC, 1988) nasopharyngeal carcinoma (NPC) were treated with concomitant chemotherapy and radiotherapy (CCRT) followed by adjuvant chemotherapy between April 1990 and December 1997 in Koo Foundation Sun Yat-Sen Cancer Center, Taipei. The dose of radiation was 70 Gray (Gy) given in 35 fractions, 5 fractions per week. Two courses of chemotherapy, consisting of cisplatin and 5-fluorouracil, were delivered simultaneously with radiotherapy in Weeks 1 and 6 and two additional monthly courses were given after radiotherapy. According to the AJCC 1997 staging system, 32 patients had Stage II disease, 44 had Stage III, and 31 had Stage IV disease.

RESULTS

With median follow-up of 44 months, the 5-year overall survival rate in all 107 patients was 84.1%, disease-free survival rate was 74.4%, and locoregional control rate was 89.8%. The 3-year overall survival for Stage II was 100%, for Stage III it was 92.8%, and for Stage IV, 69. 4% (p = 0.0002). The 3-year disease-free survival for Stage II was 96.9%, for Stage III it was 87.7%, and for Stage IV it was 51.9% (p = 0.0001).

CONCLUSION

CCRT and adjuvant chemotherapy is effective in Taiwanese patients with advanced NPC. The prognosis of AJCC 1997 Stage II and III disease is excellent, but, for Stage IV (M0), it is relatively poor. Future strategies of therapy should focus on high-risk AJCC 1997 Stage IV (M0) cohort.

Locoregional recurrence in patients with one to three positive axillary nodes after mastectomy without adjuvant radiotherapy

PURPOSE

To retrospectively assess the risk of locoregional recurrence (LRR) and analyze the prognostic factors of this pattern of failure in patients with breast cancer and one to three positive axillary lymph nodes treated with modified radical mastectomy (MRM) without adjuvant radiotherapy.

METHODS

From April 1991 through December 1997, 649 patients received a diagnosis of invasive breast cancer, and 545 were treated with MRM. Eighty-one of these patients who were found to have one to three positive axillary nodes and had a minimum follow-up of 2 years were included in this study. None of the 81 patients received adjuvant radiation therapy after mastectomy; 43 patients received adjuvant chemotherapy; and 60 patients received adjuvant hormone therapy. The median duration of follow-up was 39 months.

RESULTS

Thirteen patients had LRR during follow-up, all within 2 years after mastectomy. The 3-year LRR rate was 14%. The 3-year rates of distant metastasis for patients with and without LRR were 48% and 14% (p = 0.03), respectively. The 3-year survival rates for patients with and without LRR were 73% and 87% (p = 0.01), respectively. In univariate analysis, age (p = 0.01), estrogen receptor (ER) status (p = 0.02), and the addition of hormone therapy (p < 0.001) were significant risk factors for LRR; in multivariate analysis, negative ER status (p = 0.02) was the only statistically significant risk factor. The 3-year LRR rates for ER-negative patients and those with positive or unknown ER status were 31% and 11%, respectively.

CONCLUSIONS

LRR after mastectomy is a substantial clinical problem, despite the use of adjuvant chemotherapy and/or hormone therapy. Further randomized trials of postmastectomy radiotherapy for patients with one to three positive axillary nodes and specific risk factors are urgently needed to determine its potential benefit in locoregional control and survival, especially for young and ER-negative patients.

Correlation of ultrasonographic imaging of congenital muscular torticollis with clinical assessment in infants

Congenital muscular torticollis (CMT) is a common problem affecting infants and children. There is a general lack of standard clinical classification or objective assessment methods. Ultrasonographic imaging of the sternomastoid muscle (SCM) has been carried out in a consecutive series of 436 infants less than 1 y old presenting with CMT over a 5-y period. All patients were classified into three clinical groups: postural torticollis, muscular torticollis and sternomastoid tumor. The severity of the torticollis was also expressed into four subgroups according to the degree of deficits in passive rotation of the neck. The ultrasonographic image of the affected SCM included the echogenicity, texture, motility, softness and the transverse and longitudinal extent of the involvement. The disturbance in the quantitative measurement of the transverse diameter of the lower and upper third of the SCM and the ratio of the measurement to the normal side was recorded. The qualitative and quantitative changes in the SCM image were found to correlate significantly with the clinical typing and severity of rotational deficits of the neck. Ultrasonographic imaging has important potential clinical application in helping the diagnosis, prognostication and monitoring of progress of CMT longitudinally.

Roles of the AX(4)GKS and arginine-rich motifs of hepatitis C virus RNA helicase in ATP- and viral RNA-binding activity

The nonstructural protein 3 (NS3) of hepatitis C virus (HCV) possesses protease, nucleoside triphosphatase, and helicase activities. Although the enzymatic activities have been extensively studied, the ATP- and RNA-binding domains of the NS3 helicase are not well-characterized. In this study, NS3 proteins with point mutations in the conserved helicase motifs were expressed in Escherichia coli, purified, and analyzed for their effects on ATP binding, RNA binding, ATP hydrolysis, and RNA unwinding. UV cross-linking experiments indicate that the lysine residue in the AX(4)GKS motif is directly involved in ATP binding, whereas the NS3(GR1490DT) mutant in which the arginine-rich motif (1486-QRRGRTGR-1493) was changed to QRRDTTGR bound ATP as well as the wild type. The binding activity of HCV NS3 helicase to the viral RNA was drastically reduced with the mutation at Arg1488 (R1488A) and was also affected by the K1236E substitution in the AX(4)GKS motif and the R1490A and GR1490DT mutations in the arginine-rich motif. Previously, Arg1490 was suggested, based on the crystal structure of an NS3-deoxyuridine octamer complex, to directly interact with the gamma-phosphate group of ATP. Nevertheless, our functional analysis demonstrated the critical roles of Arg1490 in binding to the viral RNA, ATP hydrolysis, and RNA unwinding, but not in ATP binding.

Unique features of breast cancer in Taiwan

Between April 1990 and December 1997, 811 consecutive patients with 830 newly diagnosed breast cancers having their primary treatments in our institution were included in this study. Sixty three percent of breast cancer patients were premenopausal. The early-onset breast cancer (age < or = 40) composed 29.3% of all patients. The five-year survival rate of all patients was 80.4% (95% confidence interval [CI], 76.2-84.6%). The five-year overall survival rate for stage 0 was 95.7% (95% CI, 87.3-100%), stage I, 93.9% (95% CI, 88.9-98.9%), stage II, 88.5% (95% CI, 82.0-95.1%), stage III, 65.0% (95% CI, 54.0-75.9%), and stage IV, 18.5% (95% CI, 3.4-33.7%). Multivariate analysis of primary operable breast cancer revealed that axillary lymph node involvement, high nuclear grade and early-onset breast cancer (age < or = 40) were poor prognostic factors. The early-onset breast cancer had a more aggressive clinical behavior than that of the older age group, their five-year disease-free survival rates for stage I, stage II and stage III diseases being only 64.7%, 66.5%, and 43.3%, respectively. In these patients the only meaningful prognostic factor was extensive axillary lymph node metastasis (> or = 10). In summary, breast cancer patients in Taiwan tend to be younger than their counterpart in western countries. The early-onset breast cancer had poorer prognostic features for all stages comparing to the older age group. Standard pathologic factors are not good predictors of their outcome. For these patients new biologic markers need to be sought to distinguish between high and low risk and the treatment strategy for them should be guided by the aggressive characteristics of the disease.

Generalized low areal and volumetric bone mineral density in adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) may be associated with generalized low bone mineral status. The bone mineral density (BMD) of 75 girls of 12-14 years of age and diagnosed as having AIS were compared with 94 age-matched female control subjects. Areal BMD (aBMD) of the lumbar spine (L2-L4) and the bilateral proximal femur were measured using-energy X-ray absorptiometry (DEXA), and volumetric BMD (vBMD) of the nondominant distal radius and bilateral distal tibias was measured with peripheral quantitative computer tomography (pQCT). Relevant anthropometric parameters and the severity of the spinal deformity (Cobb's angle) also were evaluated and correlated with the BMD measurements. Results revealed the presence of a generalized lower bone mineral status in AIS patients. Detailed analysis showed that the aBMD and vBMD measured at the bilateral lower extremities were significantly lower in AIS patients when compared with the same in the normal controls. The most significant effect was seen in the trabecular BMD (tBMD) of the distal tibias. Of all the AIS girls, 38% of the aBMD and 36% of the vBMD were below -1 SD of the normal. BMD was found to correlate better with "years since menarche" (YSM) than with chronological age. When the BMD was evaluated for the 3 YSM groups, aBMD of the proximal femur and tBMD of distal tibias were found to be significantly lower in the AIS patients. Neither the aBMD nor the vBMD of AIS patients was found to be associated with the severity of spinal deformity. In addition, anthropometric measurements showed significantly longer arm span and lower extremities in the AIS girls. We concluded that the AIS girls had generalized lower aBMDs and vBMDs.

The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases

BACKGROUND/PURPOSE

The main objectives of this study were to define the clinical patterns and characteristics of congenital muscular torticollis (CMT) presented in the first year of life and to study the outcome of different treatment methods.

METHODS

This is a prospective study of all CMT patients seen in 1 center over a 12-year period with uniform recording system, assessment methods, and treatment protocol.

RESULTS

From a total of 1,086 CMT infants, 3 clinical subgroups of sternomastoid tumor (SMT; 42.7%), muscular torticollis (MT; 30.6%), and postural torticollis (POST; 22.1%) were identified. The SMT group was found to present earlier within the first 3 months and was associated with higher incidence of breech presentation (19.5%), difficult labor (56%), and hip dysplasia (6.81%). Severity of limitation of passive neck rotation range (ROTGp) was found to correlate significantly with the presence of SMT, bigger tumor size, hip dysplasia, degree of head tilt, and craniofacial asymmetry.

CONCLUSIONS

A total of 24.5% of the patients with initial deficits of passive rotation of less than 10 degrees showed excellent and good outcome with active home positioning and stimulation program. The remaining cases with rotation deficits of over 10 degrees and treated with manual stretching program showed an overall excellent to good results in 91.1% with 5.1% requiring subsequent surgical treatment. The most important prognostic factors for the necessity of surgical treatment were the clinical subgroup, the ROTGp, and the age at presentation (P < .001).

The role of the Arabidopsis ELD1 gene in cell development and photomorphogenesis in darkness

Because cell growth and differentiation are regulated by complex interactions among different signaling pathways, a growth defect affects subsequent differentiation. We report on a growth-defective mutant of Arabidopsis, called eld1 (elongation defective 1). Cell elongation was impaired in every organ examined. Later characteristics of the eld1 phenotype include defective vascular tissue differentiation, the inability to grow in soil, ectopic deposition of suberin around twisted vascular bundles, the de-etiolation phenotype, and continuation of shoot development and flowering in the dark. The dwarf phenotype of eld1 could not be rescued by treatment with exogenous growth regulators. Because defective cell elongation is the earliest and most universal feature detected in eld1 mutants, control of or activity in cell elongation may be the primary function of the ELD1 gene. The impaired cell growth results in pleiotropic effects on cell proliferation and differentiation, and the retardation in hypocotyl elongation enables growth and development in darkness.

Longitudinal changes in trunkal balance after selective fusion of King II curves in adolescent idiopathic scoliosis

STUDY DESIGN

A retrospective study was performed on the longitudinal changes of the trunkal balance in King II curves treated with selective posterior fusion of the thoracic curve.

OBJECTIVES

To determine the effect of selective fusion on the coronal and sagittal plane balance in King II adolescent idiopathic scoliosis by analyzing the changes in shoulder level, pelvic tilt, trunk shift, centering of fusion mass, changes in the T11-L1 sagittal angle, and behavior of the unfused lumbar curve and its correlation with the end level of fusion.

SUMMARY OF BACKGROUND DATA

It has been shown that selective fusion of the thoracic curve in a King II curve is associated with good results and arrest of lumbar curve progression in selected cases. Detailed quantitative analysis of the longitudinal changes and correlation between various clinical and radiologic parameters was not readily available in the literature.

METHODS

This study investigated 24 patients with King II adolescent idiopathic scoliosis treated with Harrington rod and segmental spinous processes wiring in a 10-year period with follow-up periods of 3 to 8 years. Clinical and radiologic parameters were analyzed longitudinally during the preoperative and immediate postoperative period, then at 6 months, 1 year, 3 years, and final follow-up assessment.

RESULTS

Progressive improvement in the trunk shift to within 2 cm of the center sacral line together with progressive leveling and stabilization of the shoulder and pelvic tilt was noted during the first year after surgery. Gradual movement of the Harrington rod toward the center sacral line assuming a "straight rod sign" with a rod to center line distance of less than 1 cm was found in 90% of the cases. Improvement of the sagittal alignment with no significant residual junctional kyphosis also was found. The unfused lumbar curve improved in both the coronal and sagittal plane and did not show any further progression. Patients whose lower end level of fusion was at T12 had a better percentage of lumbar curve correction than those that ended at L1.

CONCLUSIONS

Selective thoracic fusion for King II idiopathic scoliosis curve can achieve acceptable coronal and sagittal plane balance of the spine. The rod to centersacral line distance is a helpful parameter in assessing the results and prognosis of surgically treated patients.

Local radiotherapy with or without transcatheter arterial chemoembolization for patients with unresectable hepatocellular carcinoma

PURPOSE

To evaluate the treatment outcome, patterns of failure, and prognostic factors for patients with unresectable hepatocellular carcinoma (HCC) treated with local radiotherapy alone or as an adjunct to transcatheter arterial chemoembolization (TACE).

METHODS AND MATERIALS

From March 1994 to December 1997, 25 patients with unresectable HCC underwent local radiotherapy to a portion of the liver. Twenty-three patients were classified as having cirrhosis in Child-Pugh class A and 2 in class B. Mean diameter of the treated hepatic tumor was 10.3 cm. Mean dose of radiation was 46.9 +/- 5.9 Gy in a daily fraction of 1.8-2 Gy. Sixteen patients were also treated with Lipiodol and chemotherapeutic agents mixed with Ivalon or Gelfoam particles for chemoembolization, either before and/or after radiotherapy. Percutaneous ethanol injection therapy (PEIT) was given to one patient. All patients were monitored for treatment-related toxicity and for survival and patterns of failure.

RESULTS

In a median follow-up period of 23 months, 11 patients were alive and 14 dead. The median survival duration from treatment was 19.2 months with a 2-year survival of 41%. Only 3 of 25 patients had local progression of the treated hepatic tumor. The recurrences were seen within the liver or extrahepatic. The 2-year local, regional, and extrahepatic progression-free survival rates were 78%, 46%, and 39%, respectively. The local control ranked the highest. Patients with Okuda Stage I disease had significantly longer survival than those with Stage II and III (p = 0.02). Patients with T4 disease (p = 0.02) or treated with radiotherapy alone (p = 0.003) had significantly shorter survival. T4 disease (p = 0.03) and pretreatment alpha-fetoprotein level of more than 200 ng/ml (p = 0. 03) were associated with significantly worse regional progression-free survival. A significant difference was observed in both regional progression-free survival (p = 0.0001) and extrahepatic progression-free survival (p = 0.005) between patients with and without portal vein thrombosis before treatment. The presence of satellite nodules had a significantly worse impact on regional progression-free survival (p = 0.04) and extrahepatic progression-free survival (p = 0.03). Patients with hepatic tumor more than 6 cm in diameter or portal vein thrombosis tended to have shorter survival. Radiation-induced liver disease (RILD) and gastrointestinal bleeding were the most common treatment-related toxicities.

CONCLUSION

Radiotherapy is effective in the treatment of patients with unresectable HCC. Its effect appeared to be more prominent within the site to which radiation was given. The combination of TACE and radiation was associated with better control of HCC than radiation given alone, probably due to the selection of patients with favorable prognosis for the combined treatment. A dose-volume model should be established in the next phase of research in the treatment of unresectable HCC.

Concomitant radiotherapy and chemotherapy for early-stage nasopharyngeal carcinoma

PURPOSE

Early-stage nasopharyngeal carcinoma (NPC) continues to carry a failure rate of 15% to 30% when treated with radiotherapy alone; the benefit of concomitant radiotherapy and chemotherapy (CCRT) in early-stage NPC is unclear. The purpose of this report is to describe our efforts to improve treatment outcome in early-stage NPC after CCRT.

PATIENTS AND METHODS

Of 189 newly diagnosed NPC patients without evidence of distant metastases who were treated in our institution between 1990 and 1997, 44 presented with early-stage (stage I and II) disease according to the American Joint Committee on Cancer (AJCC) 1997 NPC staging system. Twelve of these patients were treated with radiotherapy alone and 32 with CCRT. Each patient's head and neck area was evaluated by magnetic resonance imaging or computed tomography. Radiotherapy was administered at 2 Gy per fraction per day, Monday through Friday, for 35 fractions for a total dose of 70 Gy. Chemotherapy consisting of cis-diamine-dichloroplatinum and fluorouracil was delivered simultaneously with radiotherapy in weeks 1 and 6 and sequentially for two monthly cycles after radiotherapy.

RESULTS

Patients who were treated with radiotherapy alone primarily had stage I disease, whereas none of those who were treated with CCRT had stage I disease (11 of 12 patients v none of 32 patients; P =.001). The locoregional control rate at 3 years for the radiotherapy group was 91.7% (median follow-up period, 34 months) and was 100% for the CCRT group (median follow-up period, 44 months) (P =.10). The 3-year disease-free survival rate in the radiotherapy group was 91.7% and was 96.9% in the CCRT group (P =.66).

CONCLUSION

Our results reveal excellent prognosis of AJCC 1997 stage II NPC treated with CCRT. Stage II patients with a greater tumor burden treated with CCRT showed an equal disease-free survival, compared with stage I patients treated with radiotherapy alone. A prospective randomized trial is underway to confirm the role of CCRT in stage II NPC.

Aggressive thoracic actinomycosis complicated by vertebral osteomyelitis and epidural abscess leading to spinal cord compression

STUDY DESIGN

Report of a successfully diagnosed and treated case of spinal cord compression due to epidural actinomycosis.

OBJECTIVE

To illustrate that proper use of imaging strategy can greatly facilitate diagnosis and management of this rare condition.

SUMMARY OF BACKGROUND DATA

Spinal actinomycosis causing epidural abscess and significant spinal cord compression is an uncommon condition. Although diagnosis is difficult, favorable results are widely reported when specific therapy is instituted.

METHODS

A 32-year-old Chinese man had extensive dorsal thoracic soft tissue swelling and lower limb weakness. Collapse of the T5 vertebral body was found on plain radiographs with mediastinal infiltrates on chest radiograph. It took magnetic resonance imaging (MRI) to fully delineate the epidural abscess and dorsal muscular abscesses, which were not depicted by computed tomographic (CT) scan. Diagnosis was made by examination of CT-guided aspirate and tissue recovered during surgery by a microbiologist. The patient received high-dose intravenous penicillin and prompt spinal decompression once diagnosis of actinomycosis was confirmed.

RESULTS

The dorsal muscular abscesses and upper thoracic epidural abscess resolved rapidly after intravenous antibiotics and surgical drainage. This was well documented by follow-up MRI and the full recovery of motor power and lower limb sensation in the patient.

CONCLUSIONS

High clinical suspicion and proper use of imaging data led to timely diagnosis of this rare case of mediastinal, epidural, and intramuscular thoracic actinomycosis. Specific antibiotic therapy and timely, well-targeted surgical intervention greatly improve the outcome of this condition.

An international comparison of childhood injuries in Hong Kong

OBJECTIVES

This study describes 7813 childhood injuries in Shatin, Hong Kong. Supplementary analyses include developmental specificity of external causes and comparison with international childhood injury data.

METHODS

Children aged 0-15 attending the accident and emergency (A&E) department of the Prince of Wales Hospital in Hong Kong were recruited for the study. Attendance records of participants from the A&E department were analyzed. Details concerning the injury, including the International Classification of Diseases, ninth revision, external cause of injury (E code), nature of injury (N code), abbreviated injury scale, and injury severity scale constitute core measurements, along with participants' age, gender, and respective A&E procedural data.

RESULTS

Males (65.7%) and fall related injuries (44.2%) predominate, while contusion (34.6%) is the prevailing nature of injury. Two age external cause dimensions are derived from a correspondence analysis. Children 0-1 years old are associated with falls, poisoning, scalds, and machinery related injury. Adolescents aged 12-15 are associated with motor related injury, animal related injury, and cuts/piercings. In comparison with international data, unintentional child injuries in Hong Kong comprised more falls but fewer poisonings and burns.

CONCLUSION

A large proportion of falls, along with low proportion of poisonings and burns, are characteristics of childhood injury profile in Hong Kong. From the results of age external cause correspondence analysis, prevention strategies for different external cause should be developmentally specific.

A new alignment jig for quantification and prescription of three-dimensional alignment for the patellar-tendon-bearing trans-tibial prosthesis

Clinically, it is hard to achieve and reproduce prosthesis alignment at will during daily prosthesis fitting. A new alignment jig was designed and developed to facilitate quantification and prescription of prosthesis alignment for patellar-tendon-bearing (PTB) trans-tibial prostheses. The alignment jig provided instantaneous readings of the three-dimensional orientation and position of the socket relative to the prosthetic foot in standardised units. The inter- and intra-tester errors of the alignment jig in measuring prosthesis alignment were evaluated and demonstrated to have good reliability. The alignment jig was recommended to be used clinically after the conventional dynamic alignment procedure to document the prosthesis alignment. Further application of the alignment jig for systematic evaluation of the effects of prosthesis alignment on gait for trans-tibial amputees is suggested.

A pilot study of three-dimensional conformal radiotherapy in unresectable hepatocellular carcinoma

BACKGROUND

The purpose of this study was to determine the potential role of three-dimensional (3-D) conformal radiotherapy (RT) in treatment of unresectable hepatocellular carcinoma (HCC).

METHODS

Thirteen patients were included in this study, which was conducted between 1993 and 1996. Nine patients (group A) were treated with 3-D conformal RT alone because of main portal vein thrombosis, inferior vena cava thrombosis, obstructive jaundice and failure of previous transcatheter arterial chemoembolization (TACE) to control the disease. The remaining four patients (group B) were treated with a combination of TACE and 3-D conformal RT.

RESULTS

The greatest dimension of the main tumour in the whole group of patients ranged from 6 to 25 cm (median 15 cm). The radiation dose ranged from 40 to 60 Gy. The tumour response was evaluated by computed tomography scans of the liver 6-8 weeks after completion of radiotherapy. Partial response was observed in 58% of the patients (seven of 12) and minimal response in another 25% of patients (three of 12). One patient could not be evaluated because of the development of hepatic failure 1 month after completion of RT. All patients in group B lived for more than 1 year (range 16-40 months). In group A, one patient who had a large tumour (11 x 10 x 21 cm) with portal vein thrombosis was converted to become resectable after 45 Gy of radiation. The resection specimen revealed no residual cancer cells. This patient is alive longer than 15 months after treatment without the evidence of disease.

CONCLUSIONS

Our experience indicates that HCC is more radiosensitive than it was traditionally expected. Three-dimensional reconstruction of tumour and surrounding organs helps to avoid excessive exposure of the liver and adjacent organs to RT and makes it a safer treatment modality for unresectable HCC. Our preliminary data show promise and are worthy of further study to explore the potential role of radiotherapy in the treatment strategy for HCC at various stages of involvement.

Incidence of complicated healing and osteoradionecrosis following tooth extraction in patients receiving radiotherapy for treatment of nasopharyngeal carcinoma

A group of 43 patients requiring tooth extraction after radiotherapy for nasopharyngeal carcinoma (NPC) was studied retrospectively to determine the incidence of post-extraction complications. It was found that because of the method used in the delivery of radiation, extraction of maxillary posterior teeth resulted in the greatest risk of complications (28.9 per cent), including a 10.5 per cent risk of osteoradionecrosis (ORN). Based on the findings, a protocol was established for the dental care of such patients. It was concluded that when extraction of maxillary posterior teeth was necessary, prophylactic antibiotics were not sufficient to prevent the complication of delayed healing. The risk of ORN was 10.5 per cent within the field of maximal radiation dose. Hyperbaric oxygen may be the better choice of preventive measures. However, in view of the low risk of ORN, wholesale prescription of hyperbaric oxygen therapy may not be indicated. An additional patient who had tooth extraction two weeks prior to radiotherapy was included to show that if adequate time for wound healing was not allowed, ORN could develop.

Bone mineralization at the callotasis site after completion of lengthening

We studied the course of bone mineralization of regenerate bone after callotasis lengthening. Twenty-three patients (eight boys) (mean age at operation 11.5 years, range 4-17 years; leg length discrepancy [LLD] at surgery ranging from 4 to 13 cm) underwent dual-energy X-ray absorptiometry (DEXA) scanning weekly during the distraction phase, at 2 week intervals until removal of the fixator, and at the time of their out-patient visits thereafter, for a mean of 794 +/- 420 days after removal of the apparatus. At removal of the fixator, the bone mineral content (BMC) of the regenerate was nearly 70% of the normal contralateral limb. With time, this value gradually increased, and tended to reach normal values, with no significant difference between femur and tibia. With time, the BMC of the regenerate tends to return to the value of the normal contralateral limb. Probably, once the limb length discrepancy has been equalized, the mechanical stimuli imparted through weight-bearing to the lengthened limb are of the same magnitude bilaterally. In this instance, then, the newly formed bone, responding to these physical stimuli, would normalize its mineral content, confirming that bone remodeling continues well after lengthening is terminated. Mineralization of the regenerate after completion of the lengthening process reaches values significantly greater than at removal of the fixator, with an increase of >50% of the prelengthening values, regardless of the underlying pathology. The final value of this increased BMC is not significantly different than in the normal contralateral unoperated limb. At least part of the increase in bone mineralization following callotasis lengthening is due to the normal process of growth and development.