Trends of pre-treatment drug resistance in antiretroviral-naïve people with HIV-1 in the era of second-generation integrase strand-transfer inhibitors in Taiwan

BACKGROUND

Monitoring the trends of pre-treatment drug resistance (PDR) and resistance-associated mutations (RAMs) among antiretroviral-naïve people with HIV (PWH) is important for the implementation of HIV treatment and control programmes. We analysed the trends of HIV-1 PDR after the introduction of second-generation integrase strand-transfer inhibitors (INSTIs) in 2016 in Taiwan, when single-tablet regimens of non-nucleoside reverse-transcriptase inhibitor (NNRTI-) and INSTI-based antiretroviral therapy became the preferred treatments.

MATERIALS AND METHODS

In this multicentre study, we included newly diagnosed, antiretroviral-naïve PWH who underwent tests for RAMs between 2016 and 2022. Pre-treatment genotypic resistance testing was performed, along with HIV-1 subtyping and determinations of plasma HIV RNA load and CD4 lymphocyte counts. RAMs were analysed using the Stanford University HIV Drug Resistance Database and only RAMs conferring at least low-level resistance were included.

RESULTS

From 2016 to 2022, pre-treatment blood samples from 3001 newly diagnosed PWH, which constituted 24.3% of newly diagnosed PWH in Taiwan during the study period, were tested. Of the PWH with analysable gene sequences, the HIV-1 PDR prevalence to NNRTIs, nucleoside reverse-transcriptase inhibitors (NRTIs), first- and second-generation INSTIs and PIs was 10.0%, 2.1%, 2.5%, 0.6% and 0.4%, respectively. While the trends of PDR remained stable for NRTIs, INSTIs and PIs, there was a significantly increasing trend of PDR to NNRTIs from 6.0% in 2016% to 13.1% in 2022 (P = 0.001).

CONCLUSIONS

After the introduction of second-generation INSTIs in Taiwan, the trends of HIV-1 PDR to NRTIs and INSTIs remained low. Furthermore, there was no significant decrease of the prevalence of PDR toward NNRTIs between 2016 and 2022.

Comparable clinical outcomes with same-day versus rapid initiation of antiretroviral therapy in Taiwan

OBJECTIVES

WHO has recommended same-day antiretroviral therapy (SDART) initiation since 2017; however, higher attrition rates were noted in developing countries.

METHODS

We included newly diagnosed people with HIV (PWH) from 2018 to 2022 at 18 hospitals around Taiwan. SDART initiation was defined as starting ART on the same day of HIV diagnosis and rapid initiation as starting ART within 14 days of diagnosis. A composite unfavorable outcome was defined as death after 30 days of diagnosis, loss to follow-up (LTFU), or virologic failure or rebound at 12 months.

RESULTS

At 12 months, PWH on SDART initiation and those on rapid ART initiation showed similar rates of engagement in care with plasma HIV-1 RNA <50 copies/mL (87.5% vs 87.7%) and composite unfavorable outcome (7.7% vs 7.7%). PWH aged >30 years were less likely to have LTFU (aHR 0.44, 95% CI 0.28-0.70). PWH aged >30 years (aHR 0.59, 95% CI 0.41-0.85) and gay, bisexual, and men who have sex with men (GBMSM) (aHR 0.50, 95% CI 0.32-0.79) were less likely to have composite unfavorable outcomes.

CONCLUSIONS

SDART and rapid ART initiation resulted in comparable clinical outcomes and viral suppression rates. PWH aged >30 years and GBMSM were less likely to have unfavorable outcomes.

Discovery of New Isotopes ^{160}Os and ^{156}W: Revealing Enhanced Stability of the N=82 Shell Closure on the Neutron-Deficient Side

Using the fusion-evaporation reaction ^{106}Cd(^{58}Ni,4n)^{160}Os and the gas-filled recoil separator SHANS, two new isotopes _{76}^{160}Os and _{74}^{156}W have been identified. The α decay of ^{160}Os, measured with an α-particle energy of 7080(26) keV and a half-life of 201_{-37}^{+58}  μs, is assigned to originate from the ground state. The daughter nucleus ^{156}W is a β^{+} emitter with a half-life of 291_{-61}^{+86}  ms. The newly measured α-decay data allow us to derive α-decay reduced widths (δ^{2}) for the N=84 isotones up to osmium (Z=76), which are found to decrease with increasing atomic number above Z=68. The reduction of δ^{2} is interpreted as evidence for the strengthening of the N=82 shell closure toward the proton drip line, supported by the increase of the neutron-shell gaps predicted in theoretical models.

Risky sexual practices and hepatitis C viremia among HIV-positive men who have sex with men in Taiwan

BACKGROUND

Understanding the risk behaviors associated with sexually-transmitted hepatitis C virus (HCV) infection among men who have sex with men (MSM) may inform the public health policies and interventions aiming to achieve HCV microelimination.

METHODS

HIV-positive MSM who had one of the following conditions were enrolled to undergo face-to-face questionnaire interviews to collect information on their sexual practices in the past 12 months: (1) elevation of aminotransferases in the past 6 months; (2) acquisition of sexually transmitted infections in the past 6 months; and (3) previous HCV infections. Plasma HCV RNA were tested at enrolment and every 3 months during follow-up. Baseline characteristics and risky behaviors were compared to identify factors associated with HCV viremia between HCV-viremic MSM and HCV-aviremic MSM in multivariate analysis.

RESULTS

Among 781 MSM with a median age of 36 years, 57 (7.3%) had HCV viremia and 724 (92.7%) no HCV viremia during follow-up. A high proportion (38.9%) of the participants reported having used recreational drugs in the past 12 months, with 34.4% of them having slamming, but only 4.8% reported having shared their injection equipment. In multivariate analysis, use of recreational drugs (adjusted odds ratio [aOR], 2.14; 95% CI, 1.16-3.96), having participated in group sex (aOR, 2.35; 95% CI 1.24-4.40) and having had condomless receptive anal intercourse (aOR, 1.97; 95% CI 1.07-3.62) were significantly associated with HCV viremia.

CONCLUSION

Among high-risk HIV-positive MSM, use of recreational drugs and risky sexual contacts were associated with HCV viremia, suggesting the mucosal contacts as the major route of HCV transmission.

Recently acquired hepatitis C virus infection among people living with human immunodeficiency virus at a university hospital in Taiwan

BACKGROUND

Little is known about the engagement in hepatitis C virus (HCV) care and completion of HCV treatment in people living with human immunodeficiency virus (HIV) (PLWH) who have HCV coinfection in the Asia-Pacific region. Examining the HCV care cascade can identify barriers to the completion of HCV treatment and facilitate achievement of HCV micro-elimination in PLWH.

AIM

To investigate the care cascade of incident HCV infections among PLWH in Taiwan.

METHODS

PLWH with incident HCV infections, defined as HCV seroconversion, were retrospectively identified by sequential anti-HCV testing of all archived blood samples at National Taiwan University Hospital between 2011 and 2018. All PLWH with incident HCV infections were followed until December 31, 2019. The care cascade of HCV examined included all incident HCV-infected patients, the percentages of anti-HCV antibodies detected by HIV-treating physicians in clinical care, plasma HCV RNA load tested, HCV RNA positivity diagnosed, referral to treatment assessment made, anti-HCV treatment initiated, and sustained virologic response achieved. Those who had HCV seroconversion during the interferon (IFN) era (2011–2016) and the direct-acting antiviral (DAA) era (2017–2018) were analyzed separately. The duration of HCV viremia—from the date of seroconversion to viral clearance by treatments or until the end of observation—and the incidence of sexually transmitted infections (STIs) during the HCV viremic period were estimated.

RESULTS

During the study period, 287 of 3495 (8.2%) PLWH (92.3% being men who have sex with men) who were HCV-seronegative at baseline developed HCV seroconversion by retrospective testing of all archived blood samples. Of the 287 incident HCV infections, 277 (96.5%) had anti-HCV antibodies detected by HIV-treating physicians, 270 (94.1%) had plasma HCV RNA determined and 251 (87.5%) tested positive for HCV RNA. Of those with HCV viremia, 226 (78.7%) were referred to treatment assessment, 215 (74.9%) initiated anti-HCV treatment, and 202 (70.4%) achieved viral clearance. Compared with that in the IFN era, the median interval from HCV seroconversion by retrospective testing to detection of HCV seropositivity by HIV-treating physicians was significantly shorter in the DAA era {179 d [interquartile range (IQR) 87-434] vs 92 d (IQR 57-173); P < 0.001}. The incidence rate of STIs in the DAA vs the IFN era was 50.5 per 100 person-years of follow-up (PYFU) and 38.5 per 100 PYFU, respectively, with an incidence rate ratio of 1.31 (95% confidence interval 0.96-1.77), while the duration of HCV viremia was 380 d (IQR 274-554) and 735 d (IQR 391-1447) (P < 0.001), respectively.

CONCLUSION

While anti-HCV therapies are effective in achieving viral clearance, our study suggests more efforts are needed to expedite the linkage of PLWH diagnosed with incident HCV infections to HCV treatment.

New α-Emitting Isotope ^{214}U and Abnormal Enhancement of α-Particle Clustering in Lightest Uranium Isotopes

A new α-emitting isotope ^{214}U, produced by the fusion-evaporation reaction ^{182}W(^{36}Ar,4n)^{214}U, was identified by employing the gas-filled recoil separator SHANS and the recoil-α correlation technique. More precise α-decay properties of even-even nuclei ^{216,218}U were also measured in the reactions of ^{40}Ar, ^{40}Ca beams with ^{180,182,184}W targets. By combining the experimental data, improved α-decay reduced widths δ^{2} for the even-even Po-Pu nuclei in the vicinity of the magic neutron number N=126 are deduced. Their systematic trends are discussed in terms of the N_{p}N_{n} scheme in order to study the influence of proton-neutron interaction on α decay in this region of nuclei. It is strikingly found that the reduced widths of ^{214,216}U are significantly enhanced by a factor of two as compared with the N_{p}N_{n} systematics for the 84≤Z≤90 and N<126 even-even nuclei. The abnormal enhancement is interpreted by the strong monopole interaction between the valence protons and neutrons occupying the π1f_{7/2} and ν1f_{5/2} spin-orbit partner orbits, which is supported by the large-scale shell model calculation.

Molecular diagnosis and therapy for cutaneous leishmaniasis of a returned traveler from Mexico

Leishmaniasis is prevalent in Southern Europe, the Middle East, India, Africa, and Central and South America. Cutaneous leishmaniasis may spontaneously heal over time without treatment; however, risk of visceral dissemination and the impact of cosmetic defect are important concerns. We report a Case of cutaneous leishmaniasis in a patient who ever traveled to Mexico before the onset of a deteriorating wound around the swollen left eyebrow. A diagnosis of infection with Leishmania mexicana was made based on histopathological examination and molecular identification. Systemic treatment with liposomal amphotericin B and ketoconazole were administered with gradual healing of the lesion. Also, this traveler case implicates that the spread of endemic parasitic diseases may be a concealed risk on the public health for Taiwan underlying globalization.

Short-Lived α-Emitting Isotope ^{222}Np and the Stability of the N=126 Magic Shell

A new, very short-lived neutron-deficient isotope ^{222}Np was produced in the complete-fusion reaction ^{187}Re(^{40}Ar,5n)^{222}Np, and observed at the gas-filled recoil separator SHANS. The new isotope ^{222}Np was identified by employing a recoil-α correlation measurement, and six α-decay chains were established for it. The decay properties of ^{222}Np with E_{α}=10016(33)  keV and T_{1/2}=380_{-110}^{+260}  ns were determined experimentally. The α-decay systematics of Np isotopes is improved by adding the new data for ^{222}Np, which validates the N=126 shell effect in Np isotopes. The evolution of the N=126 shell closure is discussed in the neutron-deficient nuclei up to Np within the framework of α-decay reduced width.

Trends of recent hepatitis C virus infection among HIV-positive men who have sex with men in Taiwan, 2011-2018

BACKGROUND

Increasing trends of HCV infection have been reported among HIV-positive men who have sex with men (MSM) in Europe, Australia and North America. The trends of recently acquired HCV infection among HIV-positive MSM are less clear in Asia-pacific region.

METHODS

All HIV-positive patients seeking care at a university hospital in Taiwan tested for anti-HCV IgG at least once annually to estimate the incidence of HCV seroconversion during 2011-2018. HCV genotyping and sequencing were performed and multivariate logistic regression analysis was conducted to identify the factors associated with HCV seroconversion among MSM.

FINDINGS

During the study period, 3495 HCV-seronegative patients (86·4% MSM) were included and 294 (8·4%) with recent HCV infection were identified, in whom 281 (95·6%) were MSM, during a total of 16,361·86 person-years of follow-up (PYFU), giving an overall incidence rate of 17·97 per 1000 PYFU, which increased from 14·28 per 1000 PYFU in 2011 to 25·38 per 1000 PYFU in 2018 (p<0·001). HCV seroconversion among MSM was associated with aspartate aminotransferase ≥37 U/L (adjusted odds ratio [AOR] 7·50, 95% CI 4·17-13·50), alanine aminotransferase ≥41 U/L (AOR 7·47, 95% CI 4·11-13·58), and syphilis acquisition (AOR 2·88, 95% CI 1·67-4·97). Among the 277 (94·2%) with HCV viremia, genotype 2a (n = 116) was the leading genotype, followed by 1b (n = 85), 6a (n = 34), and 1a (n = 21). Genotypes 3a and 6a increased from 0% and 5·2%, respectively, in 2011-2014 to 4·1% and 17·1% in 2015-2018. Phylogenetic analysis revealed increased clusters in genotypes 2a, 3a and 6a from 2011-2014 to 2015-2018.

INTERPRETATION

An expanding HCV epidemic among HIV-positive MSM is occurring in Taiwan. Improving access to HCV testing and early linkage to treatment are needed to curb the expanding HCV epidemic.

FUNDING

This research was supported by a grant from National Taiwan University Hospital, Taipei, Taiwan (NTUH.106-003347 to Hsin-Yun Sun).

HCV reinfections after viral clearance among HIV-positive patients with recent HCV infection in Taiwan

BACKGROUND

Higher rates of hepatitis C virus (HCV) reinfection after viral clearance have been well described among HIV-positive men who have sex with men (MSM) in Europe. The epidemiology of HCV reinfection, however, has rarely been investigated among HIV-positive patients in Asia-Pacific region.

METHODS

We retrospectively identified HIV-positive patients with recent HCV infection who had cleared their primary infection, either spontaneously or via treatment, between January 2011 and May 2018. All included patients were observed until 31 March 2019. HCV reinfection was defined as recurrent HCV viraemia after achieving viral clearance with anti-HCV treatment or after spontaneous clearance.

RESULTS

During the study period, 219 HIV-positive patients (90.4% MSM) were diagnosed with recent HCV infection. Viral clearance with successful treatment was achieved in 108 patients (49.3%) and spontaneous clearance occurred in 20 (9.1%); of them, 18 (14.1%) acquired HCV reinfections, resulting in an incidence rate of 8.2 per 100 person-years of follow-up (95% CI 5.2-13.1). With the adjusted Cox proportional hazards model, we found a higher reinfection risk in patients with syphilis (adjusted hazard ratio 10.3, 95% CI 1.4-77.8, P = .023) compared to those without syphilis. HCV RNA testing, if performed only following syphilis and elevated aminotransferases, might miss 44.4% and 33.3% of HCV reinfections, respectively.

CONCLUSIONS

Similar to the findings in Europe, we observed a high incidence of HCV reinfection among HIV-positive Taiwanese with recent HCV infection, which was significantly associated with syphilis. To identify HCV reinfections, annual HCV RNA testing should be instituted instead of testing driven by symptoms, syphilis or elevated aminotransferases.

New Isotope ^{220}Np: Probing the Robustness of the N=126 Shell Closure in Neptunium

A new short-lived neutron-deficient isotope ^{220}Np was synthesized in the fusion-evaporation reaction ^{185}Re(^{40}Ar,5n)^{220}Np at the gas-filled recoil separator SHANS. Based on the measurement of the correlated α-decay chains, the decay properties of ^{220}Np with E_{α}=10040(18)  keV and T_{1/2}=25_{-7}^{+14}  μs were determined, which are in good agreement with theoretical predictions. From the new experimental results coupled with the recently reported α-decay data of ^{219,223}Np, the α-decay systematics for Np isotopes around N=126 was established, which allows us for the first time to test the robustness of the N=126 shell closure in Z=93 Np isotopes. The results also indicate that, in the region of nuclei with Z≥83, the proton drip line has been reached for all odd-Z isotopes up to Np.

[Analysis on brucellosis epidemiological characteristics in Hainan province]

Objective: To understand the epidemiological characteristics of brucellosis in Hainan province. Methods: Automatic microbial identification system of Vitek 2 compact was used for the preliminary identification of 16 brucellosis cases in Hainan province from 2012 to 2017, and further confirmation was performed with traditional biological typing methods. The epidemiological and clinical characteristics of the patients were analyzed in combination with the results of serological and etiological tests for raised livestock. Results: Vitek 2 compact detection results showed that 12 strains were Brucella (B.) melitensis and 4 strains were Ochrobactrum anthropi. Traditional biological typing methods showed that 11 strains were B. melitensis biovar 3 and 5 strains were B. suis biovar 3. Sixteen cases were found in Dongfang, Lingao, Haikou, Wanning, Ledong and Ding'an with 1 case in 2012, 2 cases in 2013, 4 cases in 2014, 1 case in 2015, 2 cases in 2016 and 6 cases in 2017 respectively. At the same time, 745 sheep serum samples from the epidemic area (Dongfang) were collected for Brucella serum antibody detection, in which 47 were positive (6.3%). And B. melitensis biovar 3 was isolated from samples collected from sick sheep in Dongfang. Conclusions: Vitek 2 compact is an simple and convenient method for Brucella identification, but it cannot replace traditional biological typing methods yet. The major epidemic strains of Brucella in Hainan were B. melitensis biovar 3 and B. suis biovar 3. The epidemic of brucellosis in Dongfang in 2017 indicated that brucellosis had spread from animal to human in Hainan, and it is very important to strengthen the prevention and control of brucellosis in Hainan.

[Tympanum meningioma: one case report]

Clinical presatation: right ear tinnitus, hearing loss, headache for 1 year with intermittent vertigo for 9 months. Specialized examination: right ear tympanum hyperemia and edema, right ear severe conduction deafness, left ear mild hearing loss. The average threshold: right ear 65 dB, the left ear 35 dB. Imaging examination: CT showed the soft tissue density mass in the right ear tympanum, part of the ear bone obscurity, superior wall of the tympanic cavity attenuation, tympanic sinus entry is not expanding. Imaging diagnosis: chronic otitis media with cholesteatoma formation. Postoperative diagnosis: meningioma.

Psychometric comparisons of three measures for assessing motor functions in preschoolers with intellectual disabilities

BACKGROUND

Deficit in motor performance is common in children with intellectual disabilities (ID). A motor function measure with sound psychometric properties is indispensable for clinical and research use. The purpose of this study was to compare the psychometric properties of three commonly used clinical measures for assessing motor function in preschoolers with ID: the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition, the Movement Assessment Battery for Children-Second Edition and the Peabody Developmental Motor Scale-Second Edition (PDMS-2).

METHOD

One hundred and ninety-one children aged 3-6 years with ID were evaluated with the three measures at three time points: two baseline measurements with a 1-week interval before the intervention, and a follow-up measurement after 6 months of paediatric rehabilitation programme. One hundred and forty-one participants completed all of the assessments. The distribution (ceiling and floor effects) and reliability (internal consistency and test-retest reliability) of each measure were examined. Concurrent validity, predictive validity, and responsiveness were examined as well.

RESULTS

All measures, except for the PDMS-2, had significant floor effects or ceiling effects at one or more time points. The three measures had good internal consistency (Cronbach α ≥ 0.86) and test-retest reliability (intraclass correlation coefficient ≥ 0.96). The Spearman ρ correlation coefficient for each pair of the three measures was ≥ 0.80, indicating high concurrent validity. The predictive validity of the three measures was satisfactory (Spearman ρ ≥ 0.52). The responsiveness of the three measures was moderate (0.47 ≤ effect size ≤ 0.74). The minimal detectable changes of the three measures were satisfactory.

CONCLUSIONS

All three measures showed sufficient reliability, validity and responsiveness in preschoolers with ID, but the PDMS-2 is recommended for its superior psychometric properties.

Do the effects of APOE-ε4 on cognitive function and decline depend upon vitamin status? MacArthur Studies of Successful Aging

OBJECTIVES

To investigate whether gene nutrient interactions influence the risk of cognitive dysfunction among older persons.

DESIGN

We performed a cross-sectional and longitudinal study of 499 adults aged 70-79 years from the Mac Arthur Study of Successful Aging to determine the effect of apolipoprotein E (APOE) in conjunction with plasma levels of homocysteine and of the related B vitamins on multiple domains of cognitive function and cognitive decline.

RESULTS

The APOE-ε4 allele, high homocysteine, low folate, and low vitamin B6 levels were each associated with worse baseline cognitive function, and all but B6 and B12 were associated with seven year cognitive decline. There was no interaction between APOE-ε4, and homocysteine, folate, B6, or B12 in predicting baseline cognitive function (p-values: 0.12-0.94) or longitudinal decline (p-values: 0.52-0.91). Of five cognitive subtests, there was a significant interaction between the ε4 allele, low B6, and decline in correct naming response items (p=0.04).

CONCLUSION

B vitamin status does not influence the risk of overall cognitive dysfunction in ε4 allele affected older adults.

A cost effective simulator for education of ultrasound image interpretation and probe manipulation

Ultrasonography is the lowest cost no risk medical imaging technique. However, reading an ultrasonographic (US) image as well as performing a good US probe positioning remain difficult tasks. Education in this domain is today performed on patients, thus limiting it to the most common cases. In this paper, we present a cost effective simulator that allows US image practice and realistic probe manipulation from CT data. More precisely, we tackle the issue of providing a realistic interface for the probe manipulation with a basic haptic feedback.

Topoisomerase 2α plays a pivotal role in the tumor biology of stage IV thymic neoplasia

BACKGROUND

Microsatellite studies in histologic types B3 and C thymic neoplasia detected gains on chromosome 17q, which contains the Her-2/neu and its juxtaposed topoisomerase 2alpha (T2alpha) genes. The study aimed to evaluate their impact on tumor biology and survival of advanced thymic neoplasia patients.

METHODS

From 1991 to 2005, 36 consecutive stage IV thymic carcinoma patients were treated, 18 men and 18 women, aged 11 to 84 years. There were 22 thymic carcinoma, 13 type B3, and 1 type B2 thymoma. Patients received treatment consisting of surgical resection, combination chemotherapy with the CAP (cyclophosphamide, Adriamycin, cisplatin) regimen, or radiation therapy potentiated by high-dose weekly 5-fluorouracil infusion. Permutations of these 3 treatment modalities were prescribed as necessary.

RESULTS

T2alpha gene amplification was detected in 4 of 14 thymic carcinoma and 1 of 15 type B3 thymoma. Three thymic carcinoma patients had Her-2/neu coamplification and these 3 patients had rapidly growing tumor and extensive disease at initial diagnosis. CAP was prescribed in 28 patients and 20 patients responded (response rate, 71.4%, 95% confidence interval [CI]: 52.8% to 85%); all responders overexpressed (> or = 10% nuclei positive) the T2alpha protein, whereas 4 nonresponders had very low expression. T2alpha overexpression predicts CAP response, and its absence predicts resistance (P = .001). Overall survival was significantly prolonged if the tumor was resectable (P = .001), of type B3 histology (P = .0039), and had no Her-2 gene amplification (P = .0081).

CONCLUSION

T2alpha and Her-2/neu genes play a pivotal role in the tumor biology, CAP response, and survival of advanced thymic neoplasia patients.

Correlation of Drug-Testing Results - Immunoassay versus Gas Chromatography-Mass Spectrometry

The need for and prevalence of workplace drug-testing programs mandate the development of an effective and efficient two-step test strategy. Successful implementation of the two-step test strategy relies on the establishment of a reasonable correlation between the preliminary and the confirmatory test data and the selection of an appropriate cutoff for each test step. Correlations of test data derived form these two test steps were most commonly studied qualitatively by comparing the positive/negative test result concluded by these two test steps; however, when instrument-based immunoassays (IA) are used in the preliminary test step, the resulting "semiquantitative" and "apparent" concentration of the targeted analyte can be quantitatively correlated to the analyte concentration as determined by gas chromatography-mass spectrometry (GC-MS). Specimens selected for quantitative correlation studies should be clinical specimens with the distributions of metabolites similar to that present in test specimens; if the resulting correlation data are to be used for selecting appropriate/corresponding cutoffs for these two test steps, the concentrations of the targeted analyte in these specimens should also be within a narrow range centering on the proposed GC-MS cutoff concentration. Among the very significant number of reports correlating IA and GC-MS test data, cannabis and urine are the most common drug category and test specimen studied. The degree of correlation between IA and the GC-MS test data varies with the IA reagent manufacturers, and even with manufacture dates/lots of those supplied by the same manufacturer. The most important factors underlying the observed degree of correlation are undoubtedly the cross-reacting characteristics of the antibody and the metabolite distribution pattern of the drug of concern. Over time, specificities of IA reagents have been optimized so that the two-step test strategy can be most effectively and efficiently applied using the cutoffs mandated by workplace drug-testing programs. The nature of correlation and the selection of appropriate/corresponding cutoffs between IA and GC-MS test data derived from alternate biological matrices are yet to be fully understood and established.

The effects of weight reduction on the rehabilitation of patients with knee osteoarthritis and obesity

OBJECTIVE

To evaluate the effect of weight reduction on the rehabilitation of patients with knee osteoarthritis and obesity.

METHODS

A total of 126 patients with bilateral knee osteoarthritis and obesity were classified into 3 groups by their stages of osteoarthritis. Each group was divided into subgroups a, b, and c. The subjects in subgroup a received weight reduction treatment, those in subgroup b received weight reduction and electrotherapy modalities, and those in subgroup c received electrotherapy modalities to relieve pain.

RESULTS

Pain reduction, weight reduction, ambulation speed, and changes of Lequesne's index were greater in patients in subgroups a and b than in subgroup c after treatment. Although the last pain scores in subgroup b were less than those in subgroup a, as measured by a visual analog scale (VAS), there was no significant difference between their functional status. Significant pain relief (VAS < 2) and an acceptable functional status (Lequesne's index < 7) were indicated when weight reduction was more than 15% and 12%, respectively, of the initial body weight of the individual.

CONCLUSION

Weight reduction was found to be a practical adjuvant treatment in the rehabilitation of patients with knee osteoarthritis.

Analyses and applications of single scan dose profiles in computed tomography

Comprehensive analyses and measurements of computed tomography (CT) single-scan dose profiles were performed for several scanners and operating conditions. Measurements were made using two types of thermoluminescent dosimeters, LiF:Mg,Cu,P and CaSO4:Dy, and two CT dosimetry phantoms, head and body. Analyses of CT single-scan dose profiles were made in terms of a Gaussian function for primary radiation and a Lorentzian function for scattered radiation. This function was used to investigate several common descriptions of the CT dose, including the computed tomography dose index (CTDI) and the multiple scan average dose. The relative percentage of scatter versus primary radiation to the contribution of CTDI at the central and peripheral locations was determined and analyzed. The correlation between CTDI of thermoluminescent dosimeter measurements and pencil-shaped ionization chamber measurements was determined. A method for estimating organ dose from CT was developed and compared to organ-dose estimates from Monte Carlo simulations.

Gemcitabine and cisplatin in a multimodality treatment for locally advanced non-small cell lung cancer

The role of new cytotoxic agents like gemcitabine has not yet been proven in the neoadjuvant settings. We designed a phase II study to test the feasibility of using gemcitabine and cisplatin before local treatment for stage III non-small cell lung cancer patients. Patients received three cycles of induction chemotherapy of gemcitabine (1000 mg m(-2), days 1, 8, 15) and cisplatin (90 mg m(-2), day 15) every 4 weeks before evaluation for operability. Operable patients underwent radical resection. Inoperable patients and patients who had incomplete resection received concurrent chemoradiotherapy with daily low dose cisplatin. All patients who did not progress after local treatment received three more cycles of adjuvant chemotherapy of gemcitabine and cisplatin. Fifty-two patients received induction treatment. Two patients had complete response and 31 patients had partial response (response rate 63.5%) after induction chemotherapy. Thirty-six patients (69%) were operable. Eighteen patients (35%) had their tumours completely resected. Two patients had pathological complete response. Median overall survival was 19.1 months, projected 1-year survival was 66% and 2-year survival was 34%. Three cycles of gemcitabine and cisplatin is effective and can be used as induction treatment before surgery for locally advanced non-small cell lung cancer patients.

Predicting long-term care institution utilization among post-rehabilitation stroke patients in Taiwan: a medical centre-based study

PURPOSE

Early identification of predictive factors relevant to the utilization of long-term care institution for stroke patients is important and thus investigated in this study on stroke patients receiving rehabilitation therapy.

METHODS

This prospective follow-up investigation carried out during patients' clinical visits, at homes or long-term care institutions, was conducted at least 6 months after stroke on 151 stroke survivors. Functional ability was evaluated with the functional independence measure (FIM) instrument at discharge of the inpatient rehabilitation programme. Balance status was measured using the seven item balance scale of the Fugl-Meyer sensorimotor assessment (FMSA). Major medical, rehabilitative and sociodemographic factors were also examined during hospitalization period as independent variables.

RESULTS

Of all the patients surveyed, 23 (15.2%) had been living in long-term care institutions. Univariate statistical analysis indicated that the significant factors related to long-term care institution utilization included recurrence of attack, bilateral involvement, impaired orientation, and functional and balance status at discharge.

CONCLUSIONS

Basing on the significant predictors identified, analysis using the logistic regression model correctly classified three quarters of the subjects as long-term care institution residents. The strongest predictors of long-term care institution utilization for stroke patients following rehabilitation therapy were: bilaterally affected, impaired orientation and poor standing ability at discharge.

Assessing the accuracy of a food frequency questionnaire for estimating usual intake of phytoestrogens

The primary objective of this study was to assess the accuracy of a modified Block food frequency questionnaire (FFQ) with respect to its ability to assess usual dietary intakes of daidzein and genistein. Participants were a convenience sample of 51 Japanese and 18 Caucasian women. All interviews were conducted between February 1997 and October 1997. At each of the four study visits, participants provided a 24-hour urine specimen and a 48-hour dietary recall. At the first visit, participants also completed an interviewer-administered modified Block FFQ. The daidzein and genistein intakes estimated using the FFQ were moderately correlated with the mean estimates of daidzein and genistein intake calculated from four 48-hour dietary recalls (correlation for daidzein = 0.49-0.58 and correlation for genistein = 0.45-0.54) and estimates of urinary concentrations of these compounds calculated from four collections (correlations for daidzein and genistein = 0.49 and 0.30, respectively). The accuracy of the modified Block FFQ for assessment of usual daidzein and genistein intakes is supported by this study. These results support the use of this instrument in epidemiological studies as an easy and low-cost method to assess the usual dietary daidzein or genistein intake.

Diversity of SHV and TEM beta-lactamases in Klebsiella pneumoniae: gene evolution in Northern Taiwan and two novel beta-lactamases, SHV-25 and SHV-26

A total of 113 blood culture isolates of Klebsiella pneumoniae from 10 hospitals in northern Taiwan were studied for SHV and TEM beta-lactamase production. bla(SHV) was amplified from all isolates by PCR. TEM-type resistance, was found in 32 of the isolates and was of the TEM-1 type in all isolates. SHV-1, -2, -5, -11, and -12 and two novel enzymes were identified. These novel enzymes were designated SHV-25 and SHV-26 and had pIs of 7.5 and 7.6, respectively. Amino acid differences in comparison to the amino acid sequence of bla(SHV-1) were found at positions T18A (ThrACC-->AlaGCC), L35Q (LeuCTA-->GluCAA), and M129V (MetATG-->ValGTG) for SHV-25 and at position A187T (AlaGCC-->ThrACC) for SHV-26. The results of substrate profiles and MIC determinations showed that the novel enzymes did not hydrolyze extended-spectrum cephalosporins, rendering the isolates susceptible to these agents. Inhibition profiles revealed that the 50% inhibitory concentration for SHV-26 was higher than those for SHV-1 and SHV-25, resulting in an intermediate resistance to amoxicillin-clavulanic acid. Forty-nine ribotypes were identified, suggesting that major clonal spread had not occurred in any of the hospitals. According to the amino acid sequence, SHV beta-lactamases in Taiwan may basically be derived through stepwise mutation from SHV-1 or SHV-11 and further subdivided by four routes. The stepwise mutations initiated from SHV-1 or SHV-11 to SHV-2, SHV-5, and SHV-12 comprise the evolutionary change responsible for extended-spectrum beta-lactamase (ESBL) production in Taiwan. The stepwise mutations that lead to a non-ESBL (SHV-25) and the beta-lactamase (SHV-26) with reduced susceptibility to clavulanic acid are possibly derived from SHV-11 and SHV-1, respectively. The results suggest a stepwise evolution of SHV beta-lactamases in Taiwan.

Room-temperature ultraviolet nanowire nanolasers

Room-temperature ultraviolet lasing in semiconductor nanowire arrays has been demonstrated. The self-organized, <0001> oriented zinc oxide nanowires grown on sapphire substrates were synthesized with a simple vapor transport and condensation process. These wide band-gap semiconductor nanowires form natural laser cavities with diameters varying from 20 to 150 nanometers and lengths up to 10 micrometers. Under optical excitation, surface-emitting lasing action was observed at 385 nanometers, with an emission linewidth less than 0.3 nanometer. The chemical flexibility and the one-dimensionality of the nanowires make them ideal miniaturized laser light sources. These short-wavelength nanolasers could have myriad applications, including optical computing, information storage, and microanalysis.

[Phylogenetic relationships among Viperidae, Crotalinae based on mitochondrial 12S rRNA sequence variations]

This paper analyzed the phylogenetic relationships and classification of pit vipers (Viperidae, Crotalinae) based on mitochondrial 12S rRNA gene sequence variations. We have sequenced mtDNA 12S rRNA gene about 370 bp fragment from Gloydius saxatilis Emelianov, Gloydius shedaoensis Zhao, Gloydius ussurriensis (Emelianov), Trimeresurus stejnegeri Schmidt and Deinagkistrodon acutus, Gloydius brevicaudus (Stejneger) from two different localities, respectively. Combined with the sequence of Dinodon semicarinatus from GenBank, we have constructed two molecular phylogenetic trees using both Maximum-parsimony analysis and Neighbor-joining. Our results support the following conclusions: (1) Deinagkistrodon is a valid genus; (2) we also discussed the origin of Gloydius shedaoensis and showed it is a subspecies of Gloydius saxatilis; (3) Gloydius brevicaudsu and Gloydius ussurriensis are classified two species.

Patient-controlled analgesia with tramadol versus tramadol plus lysine acetyl salicylate

By using a patient-controlled analgesia (PCA) delivery system, we compared the clinical advantages and disadvantages of PCA with tramadol and PCA with a mixture of tramadol plus lysine acetyl salicylate (a soluble aspirin). Fifty adult patients who had undergone major orthopedic surgeries were enrolled into a prospective, randomized, and double-blinded study. The general anesthesia was performed in a standard manner. At the beginning of wound closure, an equal volume dose of either tramadol 2.5 mg/kg (Group 1) or tramadol 1.25 mg/kg + lysine acetyl salicylate 12.5 mg/kg mixture (Group 2) was administered slowly IV. These solutions were continued postoperatively for IV PCA. Pain control, patient satisfaction, vital signs, and adverse effects were assessed for 48 h. Visual Analog Scale </=3 could be achieved with either group. Total tramadol consumption was significantly less in Group 2 than in Group 1 (614 +/- 259 mg vs 923 +/- 354 mg) (P: < 0.05). Patients in Group 2 were more alert (P: < 0.05). Blood loss from the surgical drain was similar, 865 +/- 275 mL (Group 1) vs 702 +/- 345 mL (Group 2). We conclude that aspirin can be used as an effective and safe adjuvant to tramadol for PCA after orthopedic surgery.

IMPLICATIONS

Injectable aspirin can be used as an effective and safe adjuvant to tramadol for patient-controlled analgesia (PCA) in orthopedic patients. The tramadol requirement is therefore reduced. This combination supports the concept that drugs other than opioids can be used for PCA.

Production and characterization of monoclonal antibodies to serine proteinase allergens in Penicillium and Aspergillus species

BACKGROUND

Alkaline and/or vacuolar serine proteinases are major allergens in prevalent airborne Penicillium and Aspergillus species.

OBJECTIVE

The object of this study is to generate and characterize monoclonal antibodies against these serine proteinase allergens.

METHODS

BALB/c mice were immunized individually with the Penicillium citrinum culture medium or the crude extract and culture medium preparations of Aspergillus fumigatus. Hybridoma cells that secrete monoclonal antibodies against serine proteinase allergens were selected by immunoblotting. Antigens in three different Penicillium (P. citrinum, P. notatum and P. oxalicum) and two different Aspergillus species (A. fumigatus, and A. flavus) recognized by these monoclonal antibodies were analysed by sodium dodecyl sulphate and two-dimensional polyacrylamide gel electrophoresis immunoblotting and N-terminal amino acid sequence analysis.

RESULTS

Four (PCM8, PCM10, PCM16 and PCM39) and one (FUM20) monoclonal antibodies against serine proteinase allergens were generated after fusion of NS-1 cells with spleen cells obtained from BALB/c mice immunized with antigens from P. citrinum and A. fumigatus, respectively. Immunoblotting results showed that PCM8 reacted with an alkaline serine proteinase allergen in P. citrinum and P. notatum. PCM10 and PCM39 reacted with the alkaline serine proteinase in two Penicillium (P. citrinum, P. notatum) and two Aspergillus species (A. fumigatus, and A. flavus) tested. PCM16 reacted with the alkaline serine proteinase allergen in P. citrinum, A. fumigatus and A. flavus but not with that in P. notatum. MoAb FUM20 reacted with the alkaline serine proteinase allergen in two Aspergillus species (A. fumigatus and A. flavus) but not with that in two different Penicillium species (P. citrinum, P. notatum) tested. Among these five monoclonal antibodies generated, only PCM39 and FUM20 can react with the vacuolar serine proteinase allergen in P. notatum, P. oxalicum and in A. fumigatus. The 35 kDa P. citrinum component that reacted with FUM20 has an N-terminal amino acid sequence of DSPSVEKNAP.

CONCLUSION

Five monoclonal antibodies against different epitopes of the serine proteinase major allergens in prevalent Penicillium and Aspergillus species were generated in the present study. Antibodies obtained may be useful in the characterization and standardization of serine proteinase allergens in crude fungal extracts.

Intraoperative loading attenuates nausea and vomiting of tramadol patient-controlled analgesia

PURPOSE

To evaluate the adverse effect profile of tramadol by patient-controlled analgesia (PCA) with administration of the loading dose either intraoperatively or postoperatively.

METHODS

Sixty adult patients scheduled for elective abdominal surgery were enrolled into this prospective, randomized, double blind study. The patients were anesthetized in a similar manner. At the beginning of wound closure, the patients were randomly allocated to receive 5 mg x kg(-1) tramadol (Group 1) or normal saline (Group 2). In the post-anesthesia care unit (PACU), when patients in either group complained of pain, 30 mg x ml(-1) tramadol i.v. were given every three minutes until visual analogue scale (VAS) 3, followed by tramadol PCA with bolus dose of 30 mg and five minute lockout interval. Pain control and adverse effect assessments were done in the PACU and every six hours for 48 hr post drug by an independent observer.

RESULTS

The loading dose was 290 +/- 45 mg in Group 1 and 315 +/- 148 mg in Group 2. In PACU, more nausea/vomiting both in terms of incidence (13/30, 43% vs 2/30, 6.6%, P < 0.05) and severity (nausea/vomiting score 2.5 +/- 2.0 vs 0.2 +/- 0.6, P < 0.05) was observed in patients with postoperative loading than in those with intraoperative loading of tramadol.

CONCLUSION

Administering the loading dose of tramadol during surgery decreases the nausea/vomiting associated with high dose of tramadol and improves the quality of tramadol PCA in the relief of postoperative pain.

The effect of electroacupuncture on shoulder subluxation for stroke patients

In this study, we evaluated the effect of electroacupuncture on shoulder subluxation for stroke patients. Twenty hemiplegic patients with shoulder subluxation were randomly and equally divided into two groups. The subjects in the control group received conventional therapy, and the subjects in the study group were treated with electroacupuncture and conventional therapy for four weeks. The visual analog scale (VAS) for shoulder pain, motor function status, anthropometry, and X-ray assessment were used to evaluate the status of shoulder subluxation before and after treatment. The results indicated that the pain scores decreased in the study groups significantly more than those in the control group. The degrees of shoulder reduction, including the measurement of anthropometry and X-ray assessment in the study group, were more than those of the control group. However, the motor function status showed no significant difference between two groups. It is concluded that electroacupuncture can be an effective adjuvant management in the treatment of shoulder subluxation for stroke patients.

Prognosis and recurrent patterns in bronchioloalveolar carcinoma

STUDY OBJECTIVE

Bronchioloalveolar carcinoma (BAC) is an uncommon pulmonary neoplasm with various radiologic and clinical presentations. In this article, we analyze the initial radiologic findings, TNM stagings, surgical types, and radiologic features of recurrence, and correlate them with patient survival.

DESIGN

A retrospective review of 93 patients who underwent resection for BAC from February 1989 to May 1999.

PATIENTS

There were a total of 153 patients with BAC diagnosed during this period. Among them, 60 patients (39.2%) had diffuse disease and received medical therapy only, and the remaining 93 patients (60.8%), who had localized disease, underwent surgical resection. Patients who received surgical resection were enrolled in this study.

MEASUREMENTS

Data regarding demographics, presentation symptoms, initial radiologic features, surgical type, tumor staging, recurrence status, radiologic patterns of recurrence, and survival were obtained from all patients.

RESULTS

Female patients were significantly younger than male patients. Patients who were female, nonsmoking, undergoing curative surgery, lobectomy, or bilobectomy, and with early tumor staging and no nodal involvement had a better prognosis. Patients with a right lung tumor had a longer survival than those with a left lung tumor, with borderline significance. Among those who suffered from recurrent diseases, a second resection yielded a better survival. Multivariate analysis showed curative surgery, initial surgical type, recurrence status, radiologic patterns of recurrence, and duration from surgical resection to recurrence all had a significant impact on survival.

CONCLUSIONS

Those patients with localized, early-stage BAC who underwent curative surgery had a better survival. Patients with localized recurrence after the initial surgery warranted a second resection. Those with a diffuse radiologic pattern of recurrence and/or early recurrence had a worse prognosis.

Is total knee replacement more painful than total hip replacement?

BACKGROUND

During its use in pain management the patient-controlled analgesia (PCA) devices are capable of registering the course of treatment at patient request, the condition of drug delivery and total amount of drug being given. The patients could determine the need of medication to their own satisfaction while forced treatment by the bias of the health care personnel is avoided and the safety of patients is further warranted. In pain relief with this device, the number of requests for analgesia and the dose of analgesic used can be easily measured. Therefore, it is more objective to compare the pain intensity among different types of operation when PCA device is used. Using PCA morphine consumption as a parameter, we attempted to elucidate the difference of intensity of pain associated with total hip and total knee replacements by comparing their morphine requirement.

METHODS

In this prospective cohort study, 50 patients who underwent either total hip replacement (THR, n = 24) or total knee replacement (TKR, n = 26) were enrolled. After recovery from general anesthesia when the patients first complained intense pain in the recovery room, morphine was given intravenously in titration with a calculated loading dose in 30 min to achieve an acceptable analgesia (VAS < or = 3) followed by morphine PCA at 1 mg bolus with a lockout interval of 6 min. The patients were then followed for 48 h. During and at the end of the course the data relevant to pain score, total dose, demand, delivery, and adverse effects were recorded for assessment.

RESULTS

With the use of PCA, the pain scores were similar in both surgical groups in the 48 h observation. Total consumption of morphine in THR was 13.2 +/- 8.1 mg as against 19.7 +/- 5.7 mg in TKR in postoperative day 1 and 25.2 +/- 12.7 mg as against 34.1 +/- 13.9 mg in postoperative day 2 (P < 0.05, t-test). Demand/delivery ratio was not statistically significant between the 2 groups at 24 and 48 h (t-test). Minor adverse effects were seen in both groups but the differences were not significant.

CONCLUSIONS

Using PCA morphine consumption as parameter, we can distinguish the magnitude of pain intensity between 2 major orthopedic surgeries. The deeper and more extensive operation would in total hip replacement does not mean that it is a more painful procedure than total knee replacement. Several speculations are proposed.

Transplant of cultured autologous pure melanocytes after laser-abrasion for the treatment of segmental vitiligo

Segmental vitiligo is a special type of vitiligo with unilateral distribution of lesions and has a stable course. Clinically, many patients with segmental vitiligo have unsatisfactory responses to topical corticosteroid or UV phototherapy. We have developed a technique for the isolation of melanocytes from a small specimen of normally pigmented skin obtained via a suction blister. The melanocytes can be proliferated in culture and then replanted onto laser-abrased vitiliginous areas. We used this procedure to treat 25 patients with segmental vitiligo that were refractory to medical therapy. The repigmented portion of the total treated area amounted to 95-100% in 21 patients and 65 to 94% in 4 patients. The response rate to treatment was 100% in this study. No scarring or other side-effects developed. The results of this study demonstrate that this method is a valuable tool for the treatment of patients with segmental vitiligo.

Factors influencing functional independence outcome in stroke patients after rehabilitation

The purpose of this study was to identify predictive variables relevant to functional independence outcomes for stroke patients following rehabilitation therapy. We prospectively studied 150 stroke patients consecutively admitted to the inpatient rehabilitation department of a university hospital from January 1 to December 31, 1997. Functional ability was assessed with the Functional Independence Measure (FIM) instrument on admission, on discharge of inpatient rehabilitation program, and at the 6 months follow-up visit after discharge. Severity of stroke was determined by using the Canadian Neurological Scale (CNS) on admission. In addition, major medical and sociodemographic factors were documented during hospitalization as independent variables. Of the 142 subjects surveyed, 23 (16.2%) stroke patients achieved functional independence at home when re-visited. Univariate test and multiple logistic regression analyses indicated that the significant factors affecting functional independence included age of onset, occupation, prior heart problems, the presence of medical complications, bilateral hemiplegia, and the functional ability (FIM score) and the severity of stroke (CNS score) on admission. The results of this study suggest that the admission CNS and FIM scores are useful in the prediction of functional independence outcome for stroke survivors following rehabilitation therapy.

Efficiency and effectiveness of stroke rehabilitation after first stroke

PURPOSE

To investigate predictive variables of rehabilitation efficiency and achievement of rehabilitation potential following stroke rehabilitation.

METHODS

We prospectively studied 110 first-stroke patients consecutively admitted to the inpatient rehabilitation department of our university hospital from 1 January to 31 December 1997. Functional recovery was measured as improvement in the ability to perform the Functional Independence Measure (FIM) instrument. Major medical (side of paralysis, stroke etiology, risk factors, Brunnstrom motor recovery stage, etc.), rehabilitative (initial FIM subscore, interval from stroke onset to rehabilitation commencement, rehabilitation stay, etc.), and demographic (age, years of education, occupation, marital and living status, care-giver, etc.) variables were examined.

RESULTS

The mean FIM score was 57.7 +/- 24.5 at admission and 77.3 +/- 26.3 at discharge. The mean rehabilitation efficiency (0.7 +/- 0.7) and effectiveness (30.6 +/- 24.0%) of stroke rehabilitation were determined. Rehabilitation efficiency and rehabilitation effectiveness were significantly predicted by length of stay and arm motor recovery stage, and by age and arm motor recovery stage, respectively. The variance explained only 21% of the rehabilitation efficiency and 24% of the achievement of rehabilitation potential.

CONCLUSIONS

The results of this study suggest that the large proportion of the unexplained variance in rehabilitation efficiency and effectiveness is due to nonmedical factors influencing the selection of patients for rehabilitation.

Perceptual differences between stroke patients with cerebral infarction and intracerebral hemorrhage

OBJECTIVE

To assess perceptual performances of patients with intracerebral hemorrhage (ICH) compared with those of ischemic patients early after stroke and to analyze the psychometric properties of three perceptual tests used in the study.

DESIGN

Cross-sectional study.

SETTING

A rehabilitation unit at a teaching hospital.

PATIENTS

Twenty-two stroke patients with ICH and 22 demographically matched stroke patients with infarction.

MAIN OUTCOME MEASURES

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Rivermead Perceptual Assessment Battery (RPAB), and Motor-Free Visual Perception Test (MVPT).

RESULTS

Stroke patients with ICH had significantly more severe deficits on a task of thinking operations than did patients with infarction. A significant lateralized effect of stroke existed in the ICH group, with patients with right-hemisphere strokes scoring lower than patients with left-hemisphere strokes on the figure-ground discrimination subtest of the RPAB. A considerable overlap among the three instruments was found. Yet, the observed correlations between supposedly similar subtests from the tests proved to be moderate, indicating that to a certain extent these test measures tap different perceptual processes. Four factors were generated from a joint LOTCA-RPAB-MVPT factor analysis. They assessed different facets of perceptual functioning, including higher-level and lower-level perceptual skills, part/whole conceptual integration, and color perception. This factor pattern accounted for 75.5% of the variance.

CONCLUSIONS

Higher-level perceptual functions tend to be relatively susceptible to ICH stroke pathology early in the course of the disease. This information has important clinical implications in the early treatment planning for the stroke patients with ICH, such that specific compensatory strategies for these deficiencies should be devised to facilitate a successful rehabilitation. Knowledge regarding the influences of specific deficits on the performance of daily activities may also be useful to the patients' family.

Resectional treatment for thyroid cancer with tracheal invasion: a long-term follow-up study

HYPOTHESIS

Transmural invasion of the trachea by well-differentiated thyroid carcinomas is a locally advanced disease condition. It frequently causes deaths owing to airway obstruction. We hypothesized that resection of the invaded trachea followed by primary anastomosis provides the opportunity for cure.

DESIGN

A retrospective review study of medical records.

SETTING

The surgical department of a tertiary referral center.

PATIENTS

Eight patients with well-differentiated thyroid carcinomas, complicated with tracheal invasion resulting in bleeding and airway obstruction, operated on by tracheal resection and immediate anastomosis, were included.

INTERVENTIONS

All patients received total thyroidectomy and neck lymph node dissection as well as segmental tracheal resection followed by primary reconstruction. Postoperative radioactive sodium iodine I 131 treatment and suppression therapy with thyroxine were applied to all of them.

MAIN OUTCOME MEASURE

Postoperative follow-up of serum levels of human thyroglobulin and abnormal radioactive iodine 131I from whole body scan.

RESULTS

Seven patients are alive. Of these patients, 5 had no evidence of disease: (3 had no evidence of cancer for more than 10 years' follow-up), 2 had regional lymph node metastasis, and 1 had lung metastases. The remaining patient had anastomotic site recurrence with airway obstruction and needed tracheostomy to relieve stridor. She was lost to follow-up 39 months after undergoing the initial operation.

CONCLUSIONS

Patients with mucosal invasion of the trachea by well-differentiated thyroid carcinomas should be treated by surgical resection followed by primary reconstruction when technically feasible. This facilitates postoperative care, and it is possible to achieve long-term survival with improvement of the quality of life and possible cures.

Squamous cell carcinoma of the right upper lung congenital tracheal bronchus

Tracheal bronchus, directly arising from the abnormal tracheal wall, is a rare congenital anomaly of the airway. Lung cancer developing in a tracheal bronchus is even more rare. A 68-year-old man had a mass shadow over the right upper lung on chest radiography. Bronchoscopy revealed an abnormally displaced bronchus stemming from the right side of the tracheal wall, 2 cm above the carina. Arising from this tracheal bronchus was a tumor, a biopsy of which showed squamous cell carcinoma. During surgery, a bronchus arising from the right lateral wall of the trachea and supplying the apical segment of the right upper lobe was found. There was a tumor occluding the lumen of the tracheal bronchus, causing distal obstructive pneumonitis. The patient underwent right upper lobectomy with closure of the tracheal bronchus and radical lymph node dissection. The subsequent pathologic examination of the specimen revealed squamous cell carcinoma with surrounding pneumonitis. Bronchogenic cancers developing in a tracheal bronchus are rarely reported in the English language literature. Surgical resection appears to be the treatment of choice.

Complementary DNA cloning and immunologic characterization of a new Penicillium citrinum allergen (Pen c 3)

BACKGROUND

Penicillium citrinum has been identified as the most prevalent airborne Penicillium species in the Taipei area. It is important to understand the allergenic composition of this ubiquitous fungal species.

OBJECTIVE

The complementary DNA (cDNA) clone of an allergen from P citrinum was isolated and expressed in Escherichia coli as a fusion protein. mAbs were prepared with the recombinant protein as antigen. The corresponding natural allergen in the fungal extracts was identified with the mAbs.

METHODS

A Uni-Zap XR P citrinum cDNA library was screened with sera from asthmatic patients. An IgE-binding cDNA clone was isolated and expressed as a glutathione-S-transferase fusion protein. The frequency of IgE binding to the expressed protein was analyzed by immunoblotting. Spleen cells from BALB/c mice immunized with the recombinant protein were fused with NS-1 cells for mAb generation.

RESULTS

A P citrinum cDNA library was screened with a mixture of serum samples from 4 asthmatic patients. An IgE-binding cDNA clone was obtained and designated as PCE2. PCE2 has a 694-bp insert that contains a 167 amino acids open reading frame. The deduced amino acid sequence of the encoded protein has 82.6% (138 amino acids) identity with an Aspergillus fumigatus peroxisomal membrane protein allergen (Asp f 3). PCE2 was expressed in E coli as a fusion protein and designated as Pen c 3. Sera from 13 (46%) of the 28 Penicillium-sensitized asthmatic patients demonstrated IgE binding to Pen c 3. In addition, 11 of the 13 Pen c 3-positive serum samples have IgE immunoblot reactivity to recombinant Asp f 3. The presence of IgE cross-reactivity between Pen c 3 and Asp f 3 was also detected by immunoblot inhibition. Four of the 6 mAbs generated against Pen c 3 cross-react with Asp f 3. The presence of the corresponding 18-k natural allergens in the crude extracts of P citrinum and A fumigatus were detected by immunoblot with use of the mAbs and sera from asthmatic patients.

CONCLUSION

Results obtained suggest that the peroxisomal membrane protein (Pen c 3) is an important allergen of P citrinum. PCE2 is a full-length cDNA clone encoding this allergen. In addition, the mAbs generated may be useful in standardizing the diagnostic allergenic extracts.

Clinical significance of serum soluble interleukin 2 receptor-alpha in esophageal squamous cell carcinoma

Although the serum level of soluble interleukin-2 receptor alpha (sIL-2Ralpha) has been shown to correlate with progression and prognosis of several cancers, data to support its clinical significance to esophageal squamous cell carcinoma (ESCC) are limited. This study was conducted to assess the prognostic value and source of sIL-2Ralpha in patients with ESCC. From January 1986 to June 1997, 125 patients with histopathologically confirmed ESCC were enrolled for study. Ninety-three patients underwent en bloc esophagectomy, and 32 patients with unresectable tumor underwent palliative surgery. Four (4.3%; 4 of 93) patients died of surgical complications. Serum levels of sIL-2Ralpha were measured by ELISA. Expression of IL-2Ralpha, IL-2Rbeta, and IL-2Rgamma in the pathological section was determined, respectively, by immunohistochemistry (IHC) and in situ hybridization (ISH). Compared with the healthy control group (1020 +/-476 pg/ml, n = 103), ESCC patients tended to have significantly higher serum sIL-2Ralpha concentrations (1424 +/- 798 pg/ml, n = 121). The sIL-2Ralpha level was correlated with age, Tumor-Node-Metastasis classification, tumor stage, reading score of the IHC staining, and survival but not with the pathological grade or lymphovascular invasion. Prognosis was worse for patients with high sIL-2Ralpha levels (> or =1500 pg/ml) than for those with low serum sIL-2Ralpha levels (< 1500 pg/ml; P = 0.0209). It can be used as an independent prognostic factor of ESCC. In the pathological sections, expression of IL-2Ralpha, IL-2Rbeta, and IL-2Rgamma was detected in 17 (18.1%), 83 (89.2%), and 83 (89.2%) cases, respectively, by IHC, and the message of IL-2Ralpha was identified in tumor cells by ISH in 30.1% (28 of 93) of the cases. Serum concentrations of sIL-2Ralpha are frequently elevated in ESCC patients and are correlated with disease progression and survival. These data indicate that, in addition to activated T cells, cancer cells could be an important source of sIL-2Ralpha in ESCC patients.

Anatomic basis of safe percutaneous subclavian venous catheterization

BACKGROUND

The technique of percutaneous catheterization of the subclavian vein by the infraclavicular approach is dependent on the location of the subclavian vein in relation to the clavicle. The purpose of this study was to analyze the anatomic relationship between these two structures and how it is influenced by changes in shoulder positioning.

METHODS

Dissections of the infraclavicular region were performed in seven fresh cadavers and linear measurements made to determine the extent of overlap between the vein and the clavicle in different shoulder positions.

RESULTS

When the shoulder was in neutral position, the subclavian vein was overlapped by the medial third or more of the clavicle and this segment of bone was able to serve as a landmark for the vein. However, shoulder elevation displaced the clavicle cephalad and reduced the degree of overlap. Mild shoulder retraction increased the area of contact between the vein and the undersurface of the clavicle, whereas protraction lifted the clavicle off the vein.

CONCLUSION

Infraclavicular subclavian venipuncture should be performed with shoulders in a neutral position and also in slight retraction. An appreciation of the anatomic relationship between the clavicle and the subclavian vein is the key to successful execution of this technique.

The effects of tramadol versus fentanyl in attenuating hemodynamic response following tracheal intubation

BACKGROUND

Tramadol is a novel central acting analgesic. It has been used as a complement to general anesthesia and an effective agent for postoperative analgesia. However, the influence of tramadol on the hemodynamic response following laryngoscopy and tracheal intubation is less known.

METHODS

Forty patients of both sexes, 16-50 year old, ASA physical status I or II, scheduled for elective surgery were randomly divided into equal groups in this prospective, double blind study. After obtaining the baseline data, the patient was given 3 micrograms/kg fentanyl (Group F) or 3 mg/kg tramadol (Group T). Then induction of anesthesia in a uniform and standardized manner was carried out by an anesthesiologist who was blind to the medication. The hemodynamic parameters were measured and recorded immediately after induction but prior to laryngoscopy, 3, 6, and 9 min after intubation, and before incision. We also observed any unusual effect in the postoperative care unit. Chi-square test, Student's t-test and paired t-test were used for statistical comparison. A P less than 0.05 was considered statistically significant.

RESULTS

All patients had a successful induction and intubation. Differences in baseline values were not significant, nor were the differences in the values following induction. After laryngoscopy and intubation, heart rate increased significantly above the baseline level in both groups. The increase of heart rate was significantly more at 6 and 9 min (P < 0.05) and lasted longer in the tramadol group. After intubation, systolic, mean and diastolic arterial pressure (SAP, MAP, DAP) increased significantly above baseline in both groups too, except for DAP in fentanyl group. At 6 and 9 min, the MAP and DAP were significantly higher in tramadol than in fentanyl group (P < 0.05). Six patients in tramadol group had mild pain on injection of tramadol.

CONCLUSIONS

When administered right before thiopental induction, 3 mg/kg tramadol did not display a better attenuation against the increase of hemodynamic profiles than did 3 micrograms/kg fentanyl following tracheal intubation.

Comparison of patient-controlled analgesia (PCA) with tramadol or morphine

PURPOSE

To compared the clinical efficacy of tramadol and morphine using a patient-controlled analgesia (PCA) delivery system.

METHODS

In a prospective, randomized, double blind study, we evaluated 80 adult patients scheduled for elective hip or knee arthroplasty with general inhalational anesthesia. When patients complained of pain in the recovery room, patients were randomized to receive either tramadol or morphine by titration in 30 min to achieve analgesia (VAS < or =4). Equivalent volumes containing either 30 mg x ml(-1) tramadol or 1 mg x ml(-1) morphine were used for PCA with a lockout interval of 10 min. The patients were followed six-hourly for 48 hr for VAS, satisfaction rate, analgesic dose, and side effects.

RESULTS

Patients obtained adequate analgesia with either drug. More patients had very good satisfaction scores in the morphine group in the recovery room (43% vs. 23%, P<0.05) and at 24 hr (40% vs. 20%, P<0.05) than those in the tramadol group. More nausea was evident in the tramadol group (48% vs. 11% in recovery room and 28% vs. 12% in 24 hr, P<0.05) than in the morphine group. Vomiting was also more (28% vs. 5% in recovery room, 15% vs. 3% in 24 hr, P<0.05). Morphine produced more sleepiness (45% vs. 23% in recovery room, P<0.05 and 35% vs. 15% in 24 hr, P<0.05).

CONCLUSION

Tramadol PCA can provide effective analgesia following major orthopedic surgery provided sufficiently high doses are given for loading and by patient demand. However, the incidence of nausea/vomiting is also higher causing decreased satisfaction.

Patient-controlled analgesia with morphine plus lysine acetyl salicylate

Using a patient-controlled analgesia (PCA) delivery system, we evaluated the clinical advantages and disadvantages of morphine PCA compared with morphine plus lysine acetyl salicylate (LAS), a soluble aspirin. After major orthopedic surgery, 50 adult patients were enrolled in a prospective, randomized, and double-blinded study. When a patient in the recovery room complained of pain, an initial dose of morphine or the morphine/LAS mixture was titrated to achieve analgesia of visual analog score < or = 3 in 30 min. An equivalent volume PCA dose of either morphine 1 mg/mL or morphine 0.5 mg + LAS 90 mg/mL was used with a lockout interval of 10 min. Pain score, patient satisfaction, vital signs, and adverse effects were observed for 48 h. Adequate analgesia (visual analog scale score < or = 3) was achieved with either drug. Morphine consumption in the morphine/LAS group was significantly less than in morphine group (13.9 vs 18.4 mg in 24 h and 24.3 vs 32.4 mg in 48 h). Significantly more sedation was evident with the morphine group (P < 0.05). We conclude that injectable LAS can be used as an effective and safe adjuvant to morphine for PCA. This combination reduces dose requirements of morphine and hence some of its adverse effects.

IMPLICATIONS

Injectable aspirin could be used as an effective and safe adjuvant to morphine for patient-controlled analgesia. This combination reduces the dose requirement of morphine and therefore some of the morphine-related untoward effects.

Detection of Epstein-Barr virus in esophageal squamous cell carcinoma in Taiwan

OBJECTIVE

Recently, an association between viral infection and the development of esophageal carcinoma has been reported, particularly the human papilloma virus (HPV) and Esptein-Bar virus (EBV). However, geographic variation in carcinogenesis is realized. In this study, we investigate the viral carcinogenesis and the biologic effect of viral infection on esophageal squamous cell carcinoma (ESCC) in Taiwan.

METHODS

To determine the association of viral infection (EBV and HPV) with ESCC, we applied polymerase chain reaction (PCR), immunohistochemistry, and in situ hybridization (ISH) to examine 119 surgical specimens from different sites of esophagus in 31 ESCC patients. Additionally, an immunoperoxidase method was used to detect EBV latent membrane protein-1 (LMP-1), p53, CD45RO (UCHL-1), Fas ligand (Fas L), and RNA ISH with oligonucleotide sequences was used to detected interleukin-6 (IL-6) mRNA.

RESULTS

By PCR, EBV DNA was detected in 11 cases (35.5%). Expression of EBERs in ESCC was further confirmed with ISH. Nonetheless, no LMP-1 expression was detected. On the other hand, human papillomavirus (HPV) was identified in only one case (3.2%) of ESCC. Furthermore, HPV was located by ISH in the distant normal region rather than in tumor cells. In EBV-positive cases, accumulation of p53 protein was detected in 10 lesions (91%); CD45RO+ lymphocytes together with expressions of FasL and IL-6 were respectively identified in 100%, 63.6%, and 54.5% of 11 EBV-positive lesions. Interestingly, in the EBV-negative cases (n = 20), p53 protein was detected in 40% of lesions; CD45RO 30%; FasL 50%, and IL-6 10%.

CONCLUSIONS

In this study, no correlation was found between the presence of EBV in ESCC and the patients' age, sex, as well as survival. Although our results indicate that EBV could be associated with ESCC, the clinical role of EBV in ESCC remains to be determined.

A review of mandibular fractures in a craniomaxillofacial trauma centre

This report is a retrospective review of 74 cases of mandibular fractures managed in a craniomaxillofacial trauma centre between January 1994 and May 1998. Demographic data revealed that 85% of the patient population were male, with a mean age of 27.5 years. The commonest causes of injury were motor vehicle accidents (48.6%), followed by assault (16.2%) and accidental falls (17.6%). In 25 patients (33.8%) the fractures were single. Of these, fractures of the condylar region were the most common (8 patients). The remaining patients sustained fractures in two or more anatomic sites. There were other associated facial fractures in 45.9% of patients. Trauma to other systems was present in 37.8%, with orthopaedic and neurosurgical injuries being the most common. Surgical management in the form of open reduction and internal fixation was carried out in 61 patients (82.4%). Maxillo-mandibular fixation was used as an adjunct to maintain occlusion and bony reduction in unstable and comminuted fractures (15 patients, 20.3%), and as the primary mode of treatment in patients with stable, undisplaced fractures, particularly condylar fractures, in which the pretraumatic occlusal relationship was not disrupted (9 patients, 12.2%). A successful outcome was defined as a stable and healed fracture, with restoration of functional occlusion, facial symmetry and facial aesthetics. Complications observed included temporomandibular joint dysfunction (10.8%), malocclusion (9.5%), infection (8.1%), implant exposure (5.4%), and non-union or delayed union (4.1%).

Acute jaundice in pregnancy: acute fatty liver or acute viral hepatitis?

In this case, the difficulty in differential diagnosis between acute viral hepatitis and acute fatty liver of pregnancy was analyzed. These 2 conditions often raise controversal question regarding the decision making on emergency anesthesia for cesarean section to avert complications and optimize management. The dilemma in which an anesthesiologist is put is whether to promise the anesthesia straightaway in the face of a demonstrable acute jaundice in pregnancy to advise a postponement of surgery until a turn for the better. In this embarrassing situation, the authors suggest that a postpronement of surgery is rational to observe the development during which both the mother and the fetus should be closely monitored. Once the necessity of a cesarean section outweighs the benefit of transitional conservative treatment, it should be performed immediately.