Longitudinal association of prepubertal urinary phthalate metabolite concentrations with pubertal progression among a cohort of boys

BACKGROUND

Epidemiological studies have reported associations of anti-androgenic phthalate metabolite concentrations with later onset of male puberty, but few have assessed associations with progression.

OBJECTIVES

We examined the association of prepubertal urinary phthalate metabolite concentrations with trajectories of pubertal progression among Russian boys.

METHODS

At enrollment (ages 8-9 years), medical history, dietary, and demographic information were collected. At entry and annually to age 19 years, physical examinations including testicular volume (TV) were performed and spot urines collected. Each boy's prepubertal urine samples were pooled, and 15 phthalate metabolites were quantified by isotope dilution LC-MS/MS at Moscow State University. Metabolites of anti-androgenic parent phthalates were included: butylbenzyl (BBzP), di-n-butyl (DnBP), diisobutyl (DiBP), di(2-ethylhexyl) (DEHP) and diisononyl (DiNP) phthalates. We calculated the molar sums of DEHP, DiNP, and all AAP metabolites. We used group-based trajectory models (GBTMs) to identify subgroups of boys who followed similar pubertal trajectories from ages 8-19 years based on annual TV. We used multinomial and ordinal regression models to evaluate whether prepubertal log-transformed phthalate metabolite concentrations were associated with slower or faster pubertal progression trajectories, adjusting for covariates.

RESULTS

304 boys contributed a total of 752 prepubertal urine samples (median 2, range: 1-6) for creation of individual pools. The median length of follow-up was 10.0 years; 79% of boys were followed beyond age 15. We identified three pubertal progression groups: slower (34%), moderate (43%), and faster (23%) progression. A standard deviation increase in urinary log-monobenzyl phthalate (MBzP) concentrations was associated with higher adjusted odds of being in the slow versus faster pubertal progression trajectory (aOR 1.47, 95% CI 1.06-2.04). None of the other phthalate metabolites were associated with pubertal progression.

CONCLUSIONS

On average, boys with higher concentrations of prepubertal urinary MBzP had a slower tempo of pubertal progression, perhaps attributable to the disruption of androgen-dependent biological pathways.

Breathers in lattices with alternating strain-hardening and strain-softening interactions

This work focuses on the study of time-periodic solutions, including breathers, in a nonlinear lattice consisting of elements whose contacts alternate between strain hardening and strain softening. The existence, stability, and bifurcation structure of such solutions, as well as the system dynamics in the presence of damping and driving, are studied systematically. It is found that the linear resonant peaks in the system bend toward the frequency gap in the presence of nonlinearity. The time-periodic solutions that lie within the frequency gap compare well to Hamiltonian breathers if the damping and driving are small. In the Hamiltonian limit of the problem, we use a multiple scale analysis to derive a nonlinear Schrödinger equation to construct both acoustic and optical breathers. The latter compare very well with the numerically obtained breathers in the Hamiltonian limit.

Systematic review on the prevalence of nonalcoholic fatty liver disease in South Korea

AIMS

We aimed to conduct a systematic review and a meta-analysis to estimate NAFLD prevalence and its change in Korea.

METHODS

We searched the literature involving NAFLD prevalence in Korea in PubMed, RISS, and KMBASE from inception to June 2017. Studies with subjects with certain disorders, population limitations, or subjects who consume alcohol were excluded. Analysis was stratified by publication year, age, gender, severity, body mass index (BMI), and diagnostic technique. Random-effects models were used to provide point estimates (95% confidence interval) of prevalence with subgroup analysis to account for heterogeneity.

RESULTS

A total of 61 studies (837,897 participants) were included. The overall NAFLD prevalence in Korea was 30.3% (men: 41.1%, women: 20.3%), with a slight increase from 29.0% to 31.0% over an approximately 10-year period. BMI significantly affected NAFLD prevalence (≤ or > 25 kg/m², 12.3% vs. 41.7%, p < 0.001), while women were significantly affected by aging (< or ≥ 50 years, 17.0% vs. 25.8%, p < 0.01). The prevalence of steatosis by severity was 22.6% for mild, 9.8% for moderate to severe and 2.2% for nonalcoholic steatohepatitis (NASH), with different patterns by gender.

CONCLUSION

The current study is the first systematic analysis on NAFLD prevalence in Korea and found a change in NAFLD prevalence during the recent decade.

Shorter Symptoms Onset to Emergency Department Presentation Time Predicts Failure of Needle Aspiration in Primary Spontaneous Pneumothorax

Objective

To evaluate factors in predicting the failure of needle aspiration in primary spontaneous pneumothorax, in particular the interval between symptom onset and emergency department presentation.

Methods

This is a retrospective cohort study carried out from January 2010 to October 2012 in two public hospitals in Hong Kong. All consecutive adult patients aged 18 or more who attended the emergency departments in the study period with the diagnosis of primary spontaneous pneumothorax, where needle aspiration was performed as the primary treatment were recruited. Age, smoking status, previous pneumothorax, symptom interval, size of pneumothorax and aspirated gas volume were included in the analysis. The outcome was successful or failed needle aspiration. Logistic regression was used to identify independent predictors of failed needle aspiration.

Results

A total of 196 patients were included. Overall, 105 patients (53.6%) were treated successfully with no recurrence upon discharge. Among those failure patient, 30 patients (15.3%) failed as evidence by the chest X-ray taken immediately after the procedure while 61 patients (31.1%) failed upon subsequent chest X-ray. Multivariate logistic regression showed factors independently associated with failure of needle aspiration included size of pneumothorax (apex to cupola distance) (odds ratio [OR]=1.022, 95% confidence interval [CI]=1.009-1.039, p=0.001) and symptoms onset to emergency department presentation time (OR=0.987, 95% CI=0.976-0.999, p=0.028).

Conclusions

Large pneumothorax and shorter symptoms onset to emergency department presentation time were associated with higher failure rate of needle aspiration for primary spontaneous pneumothorax. (Hong Kong j.emerg. med. 2014;21:16-22)

Effect of Immigration Status on Outcomes in Pediatric Kidney Transplant Recipients

Kidney transplantation is the optimal treatment for children with end-stage renal disease. For children with undocumented immigration status, access to kidney transplantation is limited, and data on transplant outcomes in this population are scarce. The goal of the present retrospective single-center study was to compare outcomes after kidney transplantation in undocumented children with those of US citizen children. Undocumented residency status was identified in 48 (17%) of 289 children who received a kidney transplant between 1998 and 2010. In undocumented recipients, graft survival at 1 and 5 years posttransplantation was similar, and mean estimated glomerular filtration rate at 1 year was higher than that in recipients who were citizens. The risk of allograft failure was lower in undocumented recipients relative to that in citizens at 5 years posttransplantation, after adjustment for patient age, donor age, donor type, and HLA mismatch (p < 0.04). In contrast, nearly one in five undocumented recipients who reached 21 years of age lost their graft, primarily because they were unable to pay for immunosuppressive medications once their state-funded insurance had ended. These findings support the ongoing need for immigration policies for the undocumented that facilitate access to work-permits and employment-related insurance for this disadvantaged group.

Prediction of en-route complications during interfacility transport by outcome predictive scores in ED

OBJECTIVE

The objective was to determine the accuracy of the outcome predictive scores (Modified Early Warning Score [MEWS]; Hypotension, Low Oxygen Saturation, Low Temperature, Abnormal ECG, Loss of Independence [HOTEL] score; and Simple Clinical Score [SCS]) in predicting en-route complications during interfacility transport (IFT) in emergency department.

DESIGN

This was a retrospective cohort study.

METHODS

All IFT cases by ambulances with either nurse-led or physician-led escort, occurring between 1 January 2011 and 31 December 2012, were included. Obstetric and pediatric cases (age < 18 years) were excluded. The condition of patients was quantified by using the predictive scores (MEWS, HOTEL, and SCS) at triage station and on ambulance departure. The accuracy of predictive scores was compared by the receiver operating characteristic (ROC) curves.

RESULTS

A total of 659 cases were included. Seventeen cases had en-route complications (2.6%). The complication rate in physician-escorted transport (2.2%) was similar to that in nurse-escorted transport (2.6%). None of the 57 intubated cases had en-route complications. The area under the ROC curve for MEWS was 0.662 (triage) and 0.479 (departure). The accuracy of MEWS at triage was better than that at departure (P = .049). The area under the ROC curve for HOTEL was 0.613 (triage) and 0.597 (departure), and that for SCS was 0.6 (triage) and 0.568 (departure). In general, the predictive scores at triage were better than those on departure.

CONCLUSION

None of the scores had good accuracy in prediction of en-route complications during IFT. MEWS at triage was among the best one already but was not ideal.

An investigation of intracellular glycosylation activities in CHO cells: effects of nucleotide sugar precursor feeding

Controlling glycosylation of recombinant proteins produced by CHO cells is highly desired as it can be directed towards maintaining or increasing product quality. To further our understanding of the different factors influencing glycosylation, a glycosylation sub-array of 79 genes and a capillary electrophoresis method which simultaneously analyzes 12 nucleotides and 7 nucleotide sugars; were used to generate intracellular N-glycosylation profiles. Specifically, the effects of nucleotide sugar precursor feeding on intracellular glycosylation activities were analyzed in CHO cells producing recombinant human interferon-gamma (IFN-gamma). Galactose (+/-uridine), glucosamine (+/-uridine), and N-acetylmannosamine (ManNAc) (+/-cytidine) feeding resulted in 12%, 28%, and 32% increase in IFN-gamma sialylation as compared to the untreated control cultures. This could be directly attributed to increases in nucleotide sugar substrates, UDP-Hex ( approximately 20-fold), UDP-HexNAc (6- to 15-fold) and CMP-sialic acid (30- to 120-fold), respectively. Up-regulation of B4gal and St3gal could also have enhanced glycan addition onto the proteins, leading to more complete glycosylation (sialylation). Combined feeding of glucosamine + uridine and ManNAc + cytidine increased UDP-HexNAc and CMP-sialic acid by another two- to fourfold as compared to feeding sugar precursors alone. However, it did not lead to a synergistic increase in IFN-gamma sialylation. Other factors such as glycosyltransferase or glycan substrate levels could have become limiting. In addition, uridine feeding increased the levels of uridine- and cytidine-activated nucleotide sugars simultaneously, which could imply that uridine is one of the limiting substrates for nucleotide sugar synthesis in the study. Hence, the characterization of intracellular glycosylation activities has increased our understanding of how nucleotide sugar precursor feeding influence glycosylation of recombinant proteins produced in CHO cells. It has also led to the optimization of more effective strategies for manipulating glycan quality.

Incidence of neonatal chlamydial conjunctivitis and its association with nasopharyngeal colonisation in a Hong Kong hospital, assessed by polymerase chain reaction

OBJECTIVES

Using polymerase chain reactions, this study aimed to evaluate the incidence of neonatal chlamydial conjunctivitis in our region of Hong Kong and explore any association between such conjunctivitis and nasopharyngeal colonisation with Chlamydia trachomatis.

DESIGN

Prospective epidemiological study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Consecutive patients with neonatal conjunctivitis presenting to our hospital were recruited from May 2004 to April 2005 inclusive. Both eyes were investigated separately for Chlamydia trachomatis by polymerase chain reaction, direct immunofluorescent assay, and cell culture by two assigned ophthalmologists. Neonates diagnosed to have ocular Chlamydia trachomatis infection were subjected to additional nasopharyngeal investigations. Complete sets of ocular and nasopharyngeal investigations were also undertaken 1 week after oral erythromycin treatment to confirm complete eradication of Chlamydia trachomatis.

RESULTS

Of 192 patients with neonatal conjunctivitis, 24 were diagnosed to have chlamydial conjunctivitis. Fifteen of them had nasopharyngeal colonisation with Chlamydia trachomatis. Among the 20 neonatal chlamydial conjunctivitis patients that completed the follow-up study, one suffered treatment failure. None had clinically diagnosed systemic Chlamydia trachomatis infection 3 months after oral erythromycin.

CONCLUSIONS

The incidence of neonatal chlamydial conjunctivitis in our region of Hong Kong was 4 in 1000 live births, of whom 63% had nasopharyngeal presence of Chlamydia trachomatis. Owing to the high rate of nasopharyngeal isolation and possibility of treatment failure, post-treatment ocular and nasopharyngeal polymerase chain reaction testing for Chlamydia trachomatis may be considered to confirm complete eradication.

Comparison of inhibitory effects of oxygen radicals and calf serum protein on surfactant activity

The effects of the reactive oxygen species (ROS) superoxide anion (O2*-) and hydroxyl radical (*OH) on the surface tension lowering properties of bovine lipid extract surfactant (BLES) were compared to the effects of calf serum protein (CSP) in a captive bubble surfactometer (CBS). O2*- was generated from xanthine/xanthine oxidase (X/XO), and *OH was generated by the Fenton reaction. ROS were demonstrated by electron spin resonance (ESR) using 5,5-dimethyl-1-pyrroline-N-oxide (DMPO) as the spin trap. Lipid peroxidation was measured using the thiobarbituric acid method. *OH had broad inhibitory effects on surface tension parameters, including adsorption, minimum surface tension, percentage film area change and film compressibility. O2*- showed inhibitory effects on adsorption, film area change and film compressibility but had no significant effect on minimum surface tension. Both O2*- and *OH treatment were associated with a large 'squeezeout' plateau around 20-25 mN/m in the surface tension-area relation, indicating poor film organization during the compression phase. At the concentrations used, ROS were associated with lipid peroxidation of BLES, which also demonstrated radical scavenging properties. Calf serum protein produced inhibitory effects on adsorption, minimum surface tension and percentage film area change that were quantitatively similar to those produced by *OH. The effects on film compression were significantly greater and qualitatively different from those seen with either O2*- or *OH. We conclude that the inhibition of BLES surface activity by ROS and inhibitory proteins can be distinguished in the captive bubble surfactometer and, particularly, by changes in the film compressibility modulus.

Breast cancer risk in women with abnormal cytology in nipple aspirates of breast fluid

BACKGROUND

We previously showed that women with abnormal cytology in breast fluid obtained by nipple aspiration had an increased relative risk (RR) of breast cancer compared with women from whom fluid was not obtained and with women whose fluid had normal cytology. This study extends the follow-up in the original study group (n = 4046) and presents the first follow-up for a second group of women (n = 3627).

METHODS

We collected nipple aspirate fluid from women in the San Francisco Bay Area during the period from 1972 through 1991, classified the women according to the most severe epithelial cytology observed in fluid specimens, and determined breast cancer incidence through March 1999. We estimated RRs for breast cancer using Cox regressions, adjusting for age and year of study entry. All statistical tests were two-sided.

RESULTS

For women in the first and second study groups, the median years of follow-up were 21 years and 9 years, respectively, and breast cancer incidences were 7.8% (285 cases in the 3633 women for whom breast cancer status could be determined) and 3.5% (115 of 3271), respectively. Compared with women from whom no fluid was obtained, whose incidences of breast cancer were 4.7% (39 of 825) and 3.3% (65 of 1950) for those in group 1 and group 2, respectively, incidences and adjusted RRs were 8.1% (34 of 422), with RR = 1.4 (95% confidence interval [CI] = 0.9 to 2.3), and 0% (0 of 31), respectively, for those with unsatisfactory aspirate specimens and 8.2% (148 of 1816), with RR = 1.6 (95% CI = 1.1 to 2.3), and 3.1% (25 of 811), with RR = 1.2 (95% CI = 0.8 to 2.0), respectively, for those with normal cytology in aspirates. Compared with women from whom no fluid was obtained, incidences and adjusted RRs for women in group 1 with epithelial hyperplasia and atypical hyperplasia in aspirates were 10.8% (52 of 483), with RR = 2.4 (95% CI = 1.6 to 3.7), and 13.8% (12 of 87), with RR = 2.8 (95% CI = 1.5 to 5.5), respectively, while those for women in group 2 were 5.5% (25 of 457) and 0% (0 of 22), respectively, with a combined RR = 2.0 (95% CI = 1.3 to 3.3).

CONCLUSION

The results obtained with the newly followed women independently confirmed previous findings that women with abnormal cytology in nipple aspirates of breast fluid have an increased risk of breast cancer.

Inhibition of nitric oxide synthesis increases apoptotic cardiomyocyte death and myocardial angiotensin-converting enzyme gene expression in ischemia/reperfusion-injured myocardium of rats

Cardiomyocyte apoptosis is an important pathogenic mechanism in myocardial ischemia/reperfusion (I/R) injury. It has been shown that nitric oxide (NO) and the renin-angiotensin system (RAS) are closely related, and both systems regulate apoptotic cell death. However, the effects of NO modulation on myocardial apoptotic cell death and changes in the RAS in the I/R-injured myocardium have not been studied. Female Sprague-Dawley rats were randomized into three groups: NO synthesis inhibitor, N(G)-nitro-L-arginine-methyl ester (L-NAME, 10mg/kg); NO precursor, L-arginine (540mg/kg); and vehicle. The rats were then subjected to 45 min coronary occlusion followed by 4 h reperfusion. The TdT-mediated in situ nick and labeling (TUNEL) indices were 39.9%+/-0.8% at the border and 30.9%+/-1.2% at the center of the I/R area in the vehicle group. L-NAME administration significantly increased these TUNEL-positive cells to 45.3%+/-1.9% and 37.9%+/-1.3%, respectively (P < 0.05 each). L-arginine administration reduced the TUNEL index at the border zone with marginal significance (P = 0.08 vs vehicle group). I/R injury significantly reduced the angiotensin-converting enzyme (ACE) mRNA expression in the left (ventricular) free wall of vehicle group rats. However, ACE mRNA expression was 1.9 times greater in the L-NAME group than that in the vehicle group (P < 0.05). This study showed that the inhibition of NO synthesis increased apoptotic cardiomyocyte death and local ACE mRNA expression in the I/R-injured myocardium. Our observations indicate that NO, ACE, and apoptotic cardiomyocyte death are related to each other during I/R injury.

Vitamin C prevents radiation-induced endothelium-dependent vasomotor dysfunction and de-endothelialization by inhibiting oxidative damage in the rat

1. The present study was undertaken to determine whether endothelial function or morphology was altered in aortic rings of rats after irradiation, to investigate the mechanism of radiation effects on the endothelium and to examine the effect of vitamin C treatment against radiation-induced damage of the endothelium. 2. Female Sprague-Dawley rats were randomized into four groups (control, radiation, radiation + vitamin C, radiation + vitamin C + NG-nitro-L-arginine methyl ester (L-NAME); n = 10 for each group and n = 7 for the control group) and were irradiated with 10 Gy of 137Cs as a radiation source. Segments of the thoracic aorta were obtained and isometric tension, levels of 8-hydroxydeoxyguanosine (OH-dG) and immunohistochemical staining were measured. 3. Irradiation significantly impaired the acetylcholine-induced vasodilation of aortic segments, an effect that could be prevented by pretreatment with vitamin C (500 mg/kg per day). This beneficial effect of vitamin C was abolished by the addition of L-NAME (100 microg/kg per day), an inhibitor of nitric oxide (NO) synthesis. Irradiation significantly increased the level of OH-dG in the aorta (1.02 +/- 0.27 vs 2.61 +/- 0.78 OH-dG/105 deoxyguanosine (dG) for control and irradiated tissues, respectively; P < 0.01), an increase that was prevented by vitamin C treatment (1.59 +/- 0.23 OH-dG/105 dG; P < 0.01). Irradiation caused significant de-endothelialization (von Willebrand factor (vWF) staining was 93 +/- 7 vs 100% in irradiated and control tissues, respectively; P < 0.05) and this was prevented by vitamin C treatment (vWF staining 98 +/- 3%; P < 0.05). 4. Radiation caused endothelial damage and impaired NO production through oxidative injury, resulting in a selective impairment of endothelial-dependent vasodilation that could be prevented by vitamin C, partly through anti-oxidant mechanisms.

Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts

BACKGROUND

There is concern that a hypercoagulable status is caused after coronary artery bypass grafting without cardiopulmonary bypass (off-pump coronary artery bypass grafting, or OPCAB) and may potentially endanger the patency of the anastomosis. The aims of this study were: (1) to compare 1-year graft patency after OPCAB with that of conventional coronary artery bypass grafting (CABG) and that of on-pump beating CABG; and (2) to demonstrate any differences in patency of various conduits among the three groups.

METHODS

We analyzed the results of 122 consecutive OPCAB cases (group 1) compared with those of 65 consecutive conventional CABG cases (group II) and those of 19 consecutive on-pump beating CABG cases (group III). In group I, coronary angiography (CAG) was performed immediately postoperatively and 1 year after surgery. In groups II and III, CAG was performed 1 year after surgery. Graft patency was graded as grade A (excellent), grade B (fair), or grade O (occluded).

RESULTS

The average number of distal anastomoses in groups I, II, and III were 3.1 +/- 1.1, 3.7 +/- 0.9, and 3.6 +/- 0.9, respectively. In group I, postoperative CAG was performed in 92% of patients (112/122) before discharge. The patency rate (grade A + B) was 96.4% (162/168) for arterial grafts, and 85.6% (160/187) for saphenous vein grafts (SVG). One-year follow-up CAG was performed in 74% of patients (90/122). The patency rate was 97.8% (132/135) for arterial grafts and 67.9% (106/156) for SVG. In group II, 1-year follow-up CAG was performed in 65% of patients (42/65). The patency rate (grade A + B) was 93.5% (43/46) for arterial grafts and 88.3% (98/111) for SVG. In group III, 1-year follow-up CAG was performed in 89% of patients (17/19). The patency rate (grade A + B) was 100% (19/19) for arterial grafts and 86.8% (33/38) for SVG.

CONCLUSIONS

Our results demonstrate that the patency rate ot SVG after OPCAB was significantly lower than that of arterial grafts in the early postoperative CAG (p < 0.001), and was also significantly lower than those of SVG of group II (p < 0.001) and group III (p < 0.01) in the postoperative 1-year CAG, although there was no significant difference in 1-year patency of arterial grafts among the three groups. Our data suggest that a specific perioperative anticoagulant therapy may be advisable in patients undergoing OPCAB with SVG.

Müllerian inhibiting substance inhibits testosterone synthesis in adult rats

Müllerian inhibiting substance (MIS) is a gonadal hormone that causes regression of the Müllerian ducts during male sexual differentiation. Postnatally, MIS inhibits the proliferation and differentiation of immature Leydig cells, and transgenic mice that overexpress MIS have decreased serum testosterone concentrations. To elucidate the effects of MIS on androgen regulation in the postnatal testis, we examined testosterone synthesis in adult Sprague-Dawley rats following intratesticular and intraperitoneal injections of MIS. Intratesticular MIS injection achieved high local concentrations of MIS (574.0 +/- 60.0 ng/mL) at 4 hours, with a corresponding decline in serum testosterone concentrations to 0.7 +/- 0.1 ng/mL, compared to 1.1 +/- 0.2 ng/mL with intraperitoneal MIS and 1.6 +/- 0.1 ng/mL with intratesticular vehicle (IT-Veh) (P < .001). Intratesticular administration of MIS (IT-MIS) resulted in much higher serum and testicular interstitial fluid MIS concentrations than the intraperitoneal route. To directly examine the testosterone production rate in MIS-treated animals, we isolated Leydig cells from MIS and vehicle-injected testes. Primary Leydig cells exposed to MIS had a lower testosterone production rate and decreased expression of p450c17 (hydroxylase/lyase) and luteinizing hormone (LH) receptor mRNAs than that of vehicle-injected controls or the noninjected contralateral testis. In conclusion, intratesticular administration of MIS caused a decline in serum testosterone concentrations by decreasing the rate of testosterone biosynthesis, confirming that MIS can regulate adult Leydig cell androgen production. The ability of MIS to down-regulate mRNA expression of the p450c17 and LH receptor genes suggests that this effect is mediated transcriptionally. These data indicate that, in addition to its role in embryonic differentiation of the male reproductive tract, MIS has a regulatory function in the postnatal testis. We conclude that one such function is for MIS to directly inhibit adult Leydig cell steroidogenesis.

Psychometric characteristics of the Barthel activities of daily living index in stroke patients

BACKGROUND AND PURPOSE

Although the Barthel activities of daily living (ADL) index (BI) is widely used to measure disability in Taiwan, the usage of the BI has not been scientifically justified. This study examined the reliability, validity, and responsiveness of the BI in a cohort of stroke patients who were followed for half a year after stroke.

METHODS

One hundred and twenty-one patients were assessed using the BI at 14, 30, 90, and 180 days after stroke (DAS). Reliability of the BI was determined by estimation of inter-rater agreement and internal consistency. Validity of the BI was determined by examining convergent construct validity and predictive validity. Responsiveness was determined using effect size and t-statistics calculations.

RESULTS

There was moderate to excellent agreement between raters for individual items (kappa value range, 0.53-0.94) and total score (ICC = 0.94). An excellent internal consistency was found within the BI at four DAS points (alpha value range, 0.89-0.92). The BI scores closely correlated with scores of the Fugl-Meyer motor assessment (measuring impairment) and the Berg balance scale (measuring balance) (Pearson's r > or = 0.78, p < 0.0001). The Frenchay activities index (measuring instrumental ADL) at 180 DAS showed moderate correlation with the BI scores obtained at 14, 30, and 90 DAS (Pearson's r > or = 0.59, p < 0.0001). The effect size d, standardized response mean, t-statistics, and p-values showed that the BI was moderately to highly responsive at each stage of stroke recovery except the late stage (90-180 DAS).

CONCLUSION

This study has demonstrated that the BI is a useful instrument with high inter-rater reliability, internal consistency, convergent and predictive validity, and adequate responsiveness in assessing ADL functions in stroke patients in Taiwan.

Developmentally distinct MYB genes encode functionally equivalent proteins in Arabidopsis

The duplication and divergence of developmental control genes is thought to have driven morphological diversification during the evolution of multicellular organisms. To examine the molecular basis of this process, we analyzed the functional relationship between two paralogous MYB transcription factor genes, WEREWOLF (WER) and GLABROUS1 (GL1), in Arabidopsis. The WER and GL1 genes specify distinct cell types and exhibit non-overlapping expression patterns during Arabidopsis development. Nevertheless, reciprocal complementation experiments with a series of gene fusions showed that WER and GL1 encode functionally equivalent proteins, and their unique roles in plant development are entirely due to differences in their cis-regulatory sequences. Similar experiments with a distantly related MYB gene (MYB2) showed that its product cannot functionally substitute for WER or GL1. Furthermore, an analysis of the WER and GL1 proteins shows that conserved sequences correspond to specific functional domains. These results provide new insights into the evolution of the MYB gene family in Arabidopsis, and, more generally, they demonstrate that novel developmental gene function may arise solely by the modification of cis-regulatory sequences.

Reproducibility of an automatic quantitation of regional myocardial wall motion and systolic thickening on gated 99mTc-sestamibi myocardial SPECT

We investigated the reproducibility of an automatic quantitative algorithm for measuring regional myocardial wall motion and systolic thickening.

METHODS

99mTc-sestamibi gated myocardial SPECT with dipyridamole stress was performed twice consecutively on 31 patients with known or suspected coronary artery disease, with the patients in the same position for each scan. With AutoQUANT software, segmental wall motion and systolic thickening were quantified automatically and expressed in millimeters and percentage increase, respectively, for 20 segments. Afterward, the correlation and agreement between repeated measurements were investigated, and the influences of wall location, perfusion grade, and partitioning of the myocardium on reproducibility were evaluated by ANOVA and t testing.

RESULTS

High correlations (r = 0.95 for wall motion and 0.88 for systolic thickening) and good agreements (weighted kappa = 0.81 and 0.71, respectively) were obtained from repeated measurements on consecutive gated SPECT. Changes in wall location and perfusion grade did not cause significant differences between repeated measurements (P > 0.05 in ANOVA and t testing), but a change in partitioning did. On Bland-Altman analysis, 2 SDs for repeated wall motion and for systolic thickening were 2.0 mm and 20%, respectively.

CONCLUSION

The automatic quantitative algorithm for myocardial SPECT provided by AutoQUANT software has good reproducibility under diverse conditions. A change of motion > 2.0 mm or a change of systolic thickening > 20% can be regarded as significant during a follow-up study using this software.

Dietary fat and breast cancer

One of the most often studied associations in epidemiology is dietary fat and breast cancer risk. That migrants from low-risk countries increase their risk on immigrating to higher-risk countries suggests that some modifiable lifestyle or environmental factor is responsible for the development of breast cancer. Although early international correlational studies and experimental animals studies support dietary fat as a risk factor for breast cancer, more recent data from case-control studies and cohort studies have been equivocal, thus the analytical data do not support a strong positive association. The conflicting results from analytic studies may be due to methodologic issues associated with study design, dietary assessment tools, measurement error, improper statistical analyses, and a lack of heterogeneity in fat intake among the study population. Moreover, current dietary questionnaires may be inadequate in capturing true dietary intakes or capturing the risk with exposure during earlier periods of a woman's life. Although two large clinical trials investigating the fat/breast cancer relationships issue are underway, researchers are generally skeptical at their ability to detect an independent association between fat and breast cancer risk. Further epidemiologic studies using current methodology may not prove to be fruitful in generating definitive answers to shed light on this controversial issue. In addition, rather than concentrating on dietary fat, researchers should focus on diets that are not only low in saturated fat, but also high in fruit and vegetable consumption. Researchers should take advantage of advances in molecular and genetic technology for a different perspective in examining the issue. For example, markers of susceptibility to breast cancer that can detect women at higher risk for breast cancer may be helpful in clarifying the role of dietary fat. More comprehensive and multiple approaches to studying dietary factors and breast cancer are recommended.

Effect of hypercholesterolemia on macrophage infiltration after balloon injury to rabbit iliac artery

Both hypercholesterolemia and vascular injury have been reported to induce macrophage infiltration, but their combined effect and the mechanism by which hypercholesterolemia enhances the infiltration remain to be clarified in vivo. To evaluate the effect of hypercholesterolemia on macrophage infiltration after vascular injury, the iliac arteries of hypercholesterolemic (HC) and normocholesterolemic (NC) rabbits were examined 2h, 1 day, 3 days, 7 days, and 14 days after balloon injury using immunohistochemical staining for macrophages, intercellular adhesion molecule (ICAM)-1, and vascular cell adhesion molecule (VCAM)-1. Nuclear factor kappa-B (NF-kappaB) activation was also evaluated in fresh frozen iliac arteries using the electrophoretic mobility shift assay method. The fundamental difference between HC and NC was the amount of macrophage infiltration seen in HC from 7 days after balloon injury. Two out of 4 HC iliac arteries on the 7th day, and 3 out of 4 HC iliac arteries on the 14th day were positively stained with ICAM-1 in regenerated endothelium and neointima, whereas there were no positively stained NC iliac arteries. Neither HC nor NC tissues showed positive staining with VCAM-1. NF-kappaB was activated in HC 7 and 14 days after balloon injury, but not in NC. In conclusion, in vivo hypercholesterolemia induces macrophage infiltration after balloon injury and it is mediated by increased NF-kappaB activation promoting ICAM-1 expression.

The value of contrast echocardiography in the diagnosis of patent ductus arteriosus with Eisenmenger's syndrome

When patent ductus arteriosus (PDA) is complicated by pulmonary hypertension resulting in a right-to-left shunt, an erroneous diagnosis of primary pulmonary hypertension may be made, even after echocardiographic examination. Among the 8 patients referred to our echocardiography laboratory with the diagnosis of primary pulmonary hypertension between June 1994 and November 1999, 2 patients were found to have PDA with Eisenmenger's syndrome. Patent ductus arteriosus with Eisenmenger's syndrome can be diagnosed by the opacification of the abdominal aorta without opacification of the left-sided chambers during contrast echocardiography.

Differentiation between reversible and irreversible restrictive left ventricular filling patterns with the use of mitral annulus velocity

A restrictive left ventricular filling pattern is generally recognized as an ominous prognostic sign in patients with congestive heart failure. Recently, this filling pattern has been further categorized into reversible and irreversible groups according to the changes in the mitral inflow pattern after preload reduction; furthermore, the prognosis is reported to be different for the two groups. Forty-two patients with a restrictive left ventricular filling pattern who could adequately perform Valsalva's maneuver were studied. Baseline peak early (E) and late (A) mitral inflow velocities, E/A ratio, deceleration time of E velocity, peak early (E') and late (A') diastolic mitral annulus velocities, and E'/A' ratio were obtained. During Valsalva's maneuver, the E/A ratio reversed (<1) in fifteen patients (15/42, 36%). These patients were categorized as belonging to the reversible group. Among the baseline mitral inflow and mitral annulus velocity parameters, A' > 0.05 m/s best discriminated between the reversible and irreversible restrictive left ventricular filling patterns, with a sensitivity of 80% and a specificity of 85%.

Anti-inflammatory and neuroprotective effects of magnolol in chemical hypoxia in rat cultured cortical cells in hypoglycemic media

Our previous studies demonstrated that magnolol protects neurons against chemical hypoxia by KCN in cortical neuron-astrocyte mixed cultures (14). In the present study, we examined whether the neuroprotective effect of magnolol involve modulating inflammatory mediators, prostaglandin E2 (PGE2) and nitric oxide (NO), induced by KCN (hypoxia) or KCN plus lipopolysaccharide (LPS). In glucose-absent (hypoglycemia) media, KCN or KCN plus LPS induced increases in lactate dehydrogenase (LDH) activity by 32% and 34%, and PGE2 production by 12% and 32%, respectively. Both LDH and PGE2 increases were suppressed by 100 microM magnolol. In addition, although KCN or LPS alone did not increase NO generation, KCN plus LPS increased NO generation. This increase was reduced by 100 microM magnolol or 10 microM L-NAME, but the LDH increase and PGE2 production were not reduced by L-NAME. These findings suggest that the protective effects of magnolol against brain damage by KCN or KCN plus LPS in hypoglycemic media may involve inhibition of PGE2 production, but inhibition of NO generation may not be important.

Evidence that tyrosine phosphorylation regulates N-cadherin turnover during retinal development

N-cadherin, a member of the cadherin family of calcium-dependent cell adhesion molecules, mediates adhesive and signaling interactions between cells during development. N-Cadherin undergoes dynamic spatiotemporal changes in expression which correlate with morphogenetic movements of cells during organogenesis and histogenesis. We have previously shown that N-cadherin expression during development is regulated by several mechanisms, including mRNA expression, cytokine modulation, and proteolytically mediated turnover, yielding the NCAD90 protein. The present study was directed at determining the extent to which N-cadherin in primary embryonic cells is the target of endogenous kinases and phosphatases, as well as the effects of modulation of these enzymes on NCAD90 expression. The results of phosphoamino acid analyses, peptide mapping, and measurements of N-cadherin and NCAD90 expression in embryonic tissues indicate that N-cadherin is indeed the target of endogenous kinase and phosphatase action, and that modulation of different classes of these enzymes can result in either stimulation or inhibition of NCAD90 production. These results provide a mechanistic explanation for observations that cadherin function is downregulated following expression of exogenously introduced viral tyrosine kinases and provide a function for the tyrosine phosphatases recently found in association with cadherins. The results indicate that N-cadherin expression during retinal development is possibly regulated in part by modulation of its phosphorylation state, the balance of which may determine whether N-cadherin remains stably expressed or is targeted for proteolytically mediated turnover to produce NCAD90.

A probability prediction rule for malignant cervical lymphadenopathy using sonography

BACKGROUND

Our purpose was to weigh various sonographic parameters as predicting malignant cervical lymphadenopathy and build a reliable prediction rule.

METHODS

One hundred and eighty-nine cervical lymph node lesions from 125 consecutive patients were used for building the prediction model. Sonographic variables, including 15 morphologic features of B-mode, 5 vascular parameters of color Doppler mode, along with age and sex, were analyzed with multivariate logistic regression to evaluate the joint effect of a set of independent variables. A prediction rule for malignant lymphadenopathy was established, and prospective validation was assessed on a new group consisting of 100 lymph nodes from another 60 consecutive patients.

RESULTS

The association of heterogeneous content, long transverse diameter, pathologic vascular pattern, high vascular density, and older age provided the most robust prediction value. Scoring scale was designed as 1x (age) + 2x (vascularity index) + 3x (short axis) + 4x (vascular pattern) + 4x (internal echo) according to the parameter estimates of multivariate logistic regression analysis. Cut-off value of score >==10 as malignancy resulted in 89.2% sensitivity and 85.2% specificity. Prospective validation also showed satisfactory results (sensitivity, 82.9%; specificity, 86.2%).

CONCLUSIONS

By measuring only 4 sonographic parameters and age, this prediction rule could provide the physician a nonconfusing and reliable probability reference for managing cervical lymphadenopathy.

Limited incremental diagnostic values of attenuation-noncorrected gating and ungated attenuation correction to rest/stress myocardial perfusion SPECT in patients with an intermediate likelihood of coronary artery disease

Either gated myocardial perfusion SPECT or attenuation-corrected SPECT can be used to improve specificity in the diagnosis of coronary artery disease (CAD). We investigated whether attenuation-noncorrected gating and ungated attenuation correction could improve the diagnostic performance of rest/stress perfusion SPECT in patients having an intermediate pretest likelihood of CAD.

METHODS

Sixty-eight patients (29 men, 39 women; mean age, 59 +/- 12 y) with coronary artery stenosis > or =70% (1 vessel, n = 13; 2 vessels, n = 18; 3 vessels, n = 8; normal, n = 29) underwent rest attenuation-corrected 201TI SPECT and dipyridamole stress gated attenuation-corrected 99mTc-methoxyisobutyl isonitrile SPECT with an ADAC vertex camera. Three physicians graded the post-test likelihood of CAD for each arterial territory using a 5-point scale (1, normal; 2, possibly normal; 3, equivocal; 4, possibly abnormal; 5, abnormal). The sensitivity, specificity, and areas under receiver-operating-characteristic curves were compared for each operator by 3 methods: attenuation-noncorrected rest/stress SPECT, gated poststress SPECT plus attenuation-noncorrected rest/stress SPECT, and attenuation-corrected rest/stress SPECT plus gated poststress SPECT plus attenuation-noncorrected rest/stress SPECT.

RESULTS

When higher than grade 3 was used as the criterion for CAD, no differences in sensitivity and specificity were found among the 3 methods for each operator. Areas under receiver-operating-characteristic curves for the diagnosis of CAD and stenosis revealed no differences for each modality (P > 0.05 for each comparison).

CONCLUSION

In patients with an intermediate risk of CAD, viewing attenuation-noncorrected gated poststress SPECT and ungated attenuation-corrected rest/stress SPECT images did not improve the diagnostic performance for CAD and stenosis.

Analysis of mitochondrial DNA deletions in four chambers of failing human heart: hemodynamic stress, age, and disease are important factors

Mitochondrial DNA (mtDNA) mutations are not only responsible for organ dysfunction due to inefficient energy production but also indicators of metabolic and functional stresses in the organ. To analyze the significance of deletion mutation in human myocardium, we screened the presence of two common deletions (7.4 kb from 8637-16084 nt, 5.0 kb from 8470-13477 nt) in four chambers using long-PCR, and using serial-dilution PCR, measured the amount of deleted mtDNA in normal heart (NL) of brain-dead victims of road accidents (n = 9, age = 10-59) and failing hearts (CHF) of patients who underwent heart transplantation (n = 24, age = 17-63). Frequency of both deletions was higher in ventricles (Vt) than in atria (At) (Vt:At = 25/33:12/33 for 7.4 kb, 19/33:6/33 for 5 kb) (p < 0.05), whereas it was the same in the right and left chambers. In ventricles, both deletions were more frequent among older persons (> 35 yrs) than in younger persons (< or = 35 yrs) (older:younger = 16/20:9/13 for 7.4 kb, 15/20:4/13 for 5 kb) (p < 0.05). In ventricles of failing heart, the 5-kb deletion was more frequent than in those of normal heart (CHF:NL = 17/24:2/9) (p < 0.05), whereas the 7.4-kb deletion was frequent both in failing and normal hearts (CHF:NL = 19/24:6/9). The association of mutation with aging or disease process observed in ventricles was not found in the atria. Although the amount of mutant mtDNA in the left ventricle tended to increase according to a disease process, it was small, at most 1.56% or 0.012% of total mtDNA for a 7.4- or 5-kb deletion, respectively. No deletion was found, however, in lymphocytes from any patient who underwent transplantation. In conclusion, deletion mutation of mtDNA is frequently, but in a small amount, found in the ventricle of older failing heart than in the atrium of younger normal heart. This suggests that hemodynamic stress, age, and disease are factors to induce mtDNA mutation that represents the indicator of stresses on the heart and might turn into a contributor of progressive heart failure under extreme conditions.

Apoptosis and regulation of Bax and Bcl-X proteins during human neonatal vascular remodeling

To verify that apoptosis is one of the possible mechanisms of neonatal vascular remodeling during the transition from fetal to neonatal circulation, we assayed for apoptosis and evaluated the expression of apoptosis-regulatory proteins in umbilical vessel versus ascending aorta, ductus arteriosus (DA) versus adjacent pulmonary artery and aorta, or aorta versus its branching arteries. Twenty-two umbilical cords (UCs), 6 DAs with adjacent aortas and pulmonary arteries, and 4 aortic arches with their branching great arteries were obtained from neonates. Smooth muscle cell (SMC) apoptosis in umbilical vessels was identified in all UCs. The expressions of Bax and Bcl-X were stronger in umbilical artery than in the neonatal aorta, but Bcl-2 was weak in both arteries in immunohistochemistry. In the immunoblot analysis of UCs, the expression of the proapoptotic short isoform of Bcl-X was stronger than in other tissue, and caspase-3 was selectively activated, whereas it was not in the other components of the cardiovascular system. In contrast, the expression patterns of the FasAg and Fas ligand were similar in umbilical artery and aorta. Regulation of Bcl-2 family proteins was also observed in other vascular sites at which SMCs undergo apoptosis on hemodynamic changes during birth, such as the DA and the branching points of the great arteries from the aortic arch. Apoptosis is involved in the regression of human umbilical vessels and the DA and in the remodeling of the branching great arteries during the neonatal period, when Bcl-2 family proteins are likely to play a key role.

Effects of methacholine and uridine 5'-triphosphate on tracheal mucus rheology in mice

We compared the action of methacholine (MCh) and uridine 5'-triphosphate (UTP) with and without pretreatment with the chloride channel blocker 4,4'-diisothiocyano-2,2'-stilbenedisulfonate (DIDS) on the transepithelial potential difference (PD), the mucus collection rate (MCR), and tracheal mucus rheology using anesthetized C57BL/6 mice. The cystic fibrosis transmembrane conductance regulator (CFTR) blocker 5-nitro-2-(3-phenylpropylamino)benzoate (NPPB) was also used as a pretreatment for MCh. After collecting baseline mucus for 1.5 h, mucus secretion was stimulated by instilling 5 microl of 10(-2) M MCh or UTP around the upper trachea. There was a significant increase in PD after MCh or UTP stimulation (-21.3+/-2.0 mV MCh versus -14.1+/-1.6 mV control; -25.4+/-2.5 mV UTP versus -19.2+/-1.9 mV control). When UTP administration was preceded by DIDS, PD shifted from -15.2+/-2.9 to -12.0+/-2.2 mV. When MCh was preceded by DIDS or by NPPB, there was no change in PD. There was a significant decrease in mucus rigidity index, logG*, with MCh (2.54+/-0.09 versus 2.99+/-0.14 for control), similar to that previously reported in other species. With UTP, 14 of 16 mice responded in terms of PD becoming more negative, and of these, there was a significant difference in logG* after UTP administration (2.29 +/-0.10 versus 2.57+/-0.10 for control), whereas there was no change in logG* with DIDS administration before UTP. When DIDS administration preceded MCh, there was a diminished but still significant decrease in logG* from control, whereas there was no change in logG* when NPPB was preadministered. The control mucus collection rate was 0.19+/-0.09 mg/h, whereas after MCh stimulation, it increased to 2.83+/-0.78 mg/h. No significant difference was measured in the MCR after either UTP or DIDS+UTP stimulation. DIDS+MCh and NPPB+MCh both resulted in significant increases in MCR, but of a much smaller magnitude than that for MCh alone. We conclude that hypersecretion owing to UTP in C57BL/6 mice is less vigorous than with MCh, reflecting the limited population of Ca(2+)-dependent Cl(-) channels stimulated by UTP P(2) receptors. The action of MCh on tracheal mucus secretion in mice appears to involve both CFTR- and non-CFTR-dependent chloride channels.

Synergistic effect of angiotensin-converting enzyme and angiotensinogen gene on cardiac hypertrophy

AIMS

There are controversies concerning the association of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism with left ventricular hypertrophy (LVH), and the unclear association between angiotensinogen (ATG) M235T polymorphism and LVH. We investigated both the separate and interactive effects of these two genes on LVH in patients (N=396) with cardiovascular disease and normal healthy volunteers (N=133).

RESULTS

Frequency of DD genotype of ACE gene was significantly (P<0.05) higher in patients with LVH than patients without LVH or normal controls. Frequency of IT genotype of ATG gene in patients with LVH was significantly (P<0.01) greater than that in normal controls or marginally (P=0.1) higher than that in patients without LVH. These findings were also observed in normotensive patients and normal controls after excluding hypertensive patients. Only in patient group, the frequency of DD genotype in the highest quartile of LVMI was significantly greater than that in the lowest quartile (P<0.05). The higher tendency of TT genotype in the highest quartile patients compared with that in the lowest, did not reach statistical significance. In combined genotype analysis, there was a remarkable difference in LVMI between the two extreme double homozygotes only in patient group (156+/-25 versus 109+/-25 g/m2 for TT+DD versus MM+II) (P<0.01). In ANCOVA, the interaction term composed of ACE and ATG genotype was a significant independent variable for LVMI only in the male patient group (P<0.01).

CONCLUSION

The D-allele of ACE and T-allele of ATG gene exert a synergistic effect on cardiac hypertrophy in male patients with cardiovascular diseases, but not in normal healthy population.

Alternative therapies used by women with breast cancer in four ethnic populations

BACKGROUND

Interest in alternative therapies is growing rapidly in the United States. We studied the types and prevalence of conventional and alternative therapies used by women in four ethnic groups (Latino, white, black, and Chinese) diagnosed with breast cancer from 1990 through 1992 in San Francisco, CA, and explored factors influencing the choices of their therapies.

METHODS

Subjects (n = 379) completed a 30-minute telephone interview in their preferred language. Logistic regression models assessed factors associated with the use of alternative therapies after a diagnosis of breast cancer.

RESULTS

About one half of the women used at least one type of alternative therapy, and about one third used two types; most therapies were used for a duration of less than 6 months. Both the alternative therapies used and factors influencing the choice of therapy varied by ethnicity. Blacks most often used spiritual healing (36%), Chinese most often used herbal remedies (22%), and Latino women most often used dietary therapies (30%) and spiritual healing (26%). Among whites, 35% used dietary methods and 21% used physical methods, such as massage and acupuncture. In general, women who had a higher educational level or income, were of younger age, had private insurance, and exercised or attended support groups were more likely to use alternative therapies. About half of the women using alternative therapies reported discussing this use with their physicians. More than 90% of the subjects found the therapies helpful and would recommend them to their friends.

CONCLUSIONS

Given the high prevalence of alternative therapies used in San Francisco by the four ethnic groups and the relatively poor communication between patients and doctors, physicians who treat patients with breast cancer should initiate dialogues on this topic to better understand patients' choices with regard to treatment options.

Postoperative intramuscular dextromethorphan injection provides pain relief and decreases opioid requirement after modified radical mastectomy

BACKGROUND

Narcotics are still the therapeutic mainstay for postoperative pain relief. However, many unwanted side effects are accompanied. NMDA antagonists have been demonstrated to produce analgesic and antihyperalgesic effects, moreover, to possess potentiated effect of narcotics on postoperative pain management.

AIMS

To examine whether postoperative dextromethorphan (DM), an antitussive and also an NMDA antagonist, intramuscular injection (I.M.) reduced pain and analgesic requirement after modified radical mastectomy (MRM).

METHODS

Sixty-one patients scheduled for MRM were included and randomly allocated into two groups. For the control group (n=31), patients received chlorpheniramine maleate (CPM, 20 mg) I.M., while in the DM group (n = 30), 40 mg DM containing 20 mg CPM (I.M.) was given at the end of surgery. Meperidine (1 mg/kg, I.M.) was prescribed for postoperative pain relief, if ask. The time to first meperidine injection, total meperidine consumption, worst pain score, bed-rest time, and meperidine-related side effects were recorded for 48 hours postoperation.

RESULTS

A longer time to first meperidine injection (20.3 +/- 1.4 vs 1.5 +/- 0.2 hr, p < 0.001) and lower meperidine consumption (10.7 +/- 4.0 vs 70.7 +/- 8.9 mg, p < 0.001) were observed in the DM group than the control group. The average bed rest time was significantly shorter in the DM group than in the control group (18.9 +/- 1.5 vs 23.4 +/- 1.6 hr, p < 0.001). The number of patients who required meperidine injection (6 vs 27, p < 0.005) and meperidine-related side effects were significantly lower in the DM group than in the control group (1 vs 7, p < 0.025). No difference was noted in worst VAS pain score between the DM and the study groups.

CONCLUSION

Postoperative DM I.M. injection provided an analgesic effect and reduced meperidine requirement after MRM.

Pre-incisional epidural ketamine, morphine and bupivacaine combined with epidural and general anaesthesia provides pre-emptive analgesia for upper abdominal surgery

BACKGROUND

Previous studies have shown that N-methyl-D-asparate (NMDA) receptor antagonists provide a pre-emptive analgesic effect in humans. This study investigated the benefits of pre-emptive analgesia for upper abdominal surgery, using pre-incisional epidural ketamine + morphine + bupivacaine (K+M+B) treatment for achieving postoperative pain relief.

METHODS

Sixty ASA 1-2 patients scheduled for upper abdominal surgery were allocated to three groups in a randomized, single-blinded study. Patients in the control group (I) received general anaesthesia followed by an infusion of normal saline. Group II and III patients received general anaesthesia with a continuous epidural infusion of 2% lidocaine. Thirty minutes after the incision in groups I and II, an epidural pain control regimen was administered using ketamine (10 mg) and morphine (1 mg) in 10 ml of 0.085% bupivacaine (K+M+B). Group III patients also received K+M+B, but it was administered 10 min after the 2% lidocaine injection and 30 min before skin incision. All patients received an epidural pain control regimen (q12 h) for 3 days after their first injection. Patient-controlled analgesia (PCA) with morphine was used to control subsequent postoperative pain. During the 3-day period following surgery, duration to PCA trigger (h), morphine consumption (mg), pain intensity at rest and when coughing/moving, and analgesic-related adverse effects were recorded. The VAS scale (0-10) was used to assess pain intensity.

RESULTS

Median times to first PCA trigger were 1.2 (0.5-2.0) h, 3.0 (0.7-4.2) h, and 4.0 (2.5-7.5) h for groups I, II, and III, respectively. Both the incident and resting pain scores were consistently lower for group III patients than groups I and II. The number of PCA triggers (all attempts/successful triggers) during the day following surgery were 14.0 (3-30)/8.0 (3-24) times, 10.0 (3-23)/6.0 (2-20) times, and 7.0 (3-12)/4.5 (1-10) times for groups I, II, and III. Total morphine consumption for the 3-day observation period was 12.5 (3-42) mg, 10.5 (2-29) mg, and 6.0 (1-20) for groups I, II, and III, respectively.

CONCLUSION

Pre-incisional epidural K+M+B treatment combined with continuous epidural anaesthesia and general anaesthesia provides an ideal pre-emptive analgesic therapy, exhibiting better postoperative pain relief than general anaesthesia and post-incisional K+M+B treatment.

Transient prolonged stunning induced by dipyridamole and shown on 1- and 24-hour poststress 99mTc-MIBI gated SPECT

We investigated whether poststress gated SPECT, which was believed to show resting wall motion, revealed stunning induced by dipyridamole stress.

METHODS

In 62 patients with coronary artery disease (n = 57) or chest pain (n = 5), dipyridamole stress gated 99mTc-hexakis-2-methoxyisobutyl isonitrile (MIBI) SPECT and rest 201Tl SPECT were performed on the first day; 24-h delayed 201Tl SPECT and rest gated 99mTc-MIBI SPECT were performed on the second day. Stress and rest gated 99mTc-MIBI SPECT was performed 1 h after injection. The myocardium was divided into 17 segments, and perfusion was scored on a 4-point scoring system (scores, 0-3 for normal to defect); wall motion during first-day poststress gated and second-day rest gated SPECT was also scored on another 4-point scale (scores, 0-3 for normal to dyskinesia).

RESULTS

Thirty-one of 62 patients showed wall motion abnormality that was worse after stress than during resting. Three hundred eight (29%) of the total 1054 segments showed wall motion abnormality on poststress gated SPECT. In 198 of these segments, wall motion abnormality was the same on poststress and rest gated SPECT, and 106 segments showed wall motion that was worse on 1-h poststress than on rest gated SPECT. Perfusion was normal either during rest (n = 113) or after a 24-h delay (n = 18) in 131 segments with the poststress wall motion abnormality. Of these 131 segments, 69 showed the same wall motion abnormality between poststress and resting periods (persistent stunning). However, in 40 segments, abnormal wall motion on 1-h poststress gated SPECT normalized on rest gated SPECT (transient prolonged stunning). The other 20 segments showed improvement of wall motion during rest compared with the poststress period but still showed abnormal wall motion during the resting period (between transient prolonged stunning and persistent stunning). Stress perfusion decrease was more severe in transient prolonged stunning than in persistent stunning. Poststress wall motion abnormality was more severe in persistent stunning.

CONCLUSION

Using gated 99mTc-MIBI SPECT, stunned myocardium was found on 1-h poststress SPECT compared with normal resting wall motion found on rest gated SPECT on the next day. We conclude that some myocardial walls did not show true resting wall motion on 1-h poststress gated SPECT; hence, caution is necessary when using wall motion on 1-h poststress gated SPECT to assess resting wall motion.

Preincisional dextromethorphan decreases postoperative pain and opioid requirement after modified radical mastectomy

PURPOSE

To examine whether preincisional dextromethorphan (DM) improved analgesia after modified radical mastectomy (MRM).

METHODS

Sixty patients (ASA I-II) scheduled for MRM were included and randomly allocated into two groups. Patients in the treatment group (DM) received 40 mg DM and 20 mg chlorpheniramine maleate (CPM) i.m., and those in the control group received 20 mg CPM i.m. alone 30 min before skin incision. Meperidine, 1 mg x kg(-1) i.m., was given for postoperative pain relief as required. The time to first meperidine injection, total meperidine consumption, worst pain score, bed-rest time, and side effects were recorded every 24 hr for 48 hr after surgery by a resident anesthesiologist on a double-blind basis.

RESULTS

A longer time to first meperidine injection (19.2 +/- 1.6 vs 1.5 +/- 0.23 hr, P < 0.001) and lower meperidine consumption (0[10] vs 75[50] mg, median [interquartile range], P < 0.001) were observed in the DM group than in the control group. The bed-rest time was shorter in the DM than in the control group (18.0[4] vs 23.0[19] hr, P < 0.001). No difference was noted in worst VAS pain score. Meperidine-related side effects (nausea, vomiting, pruritus, dizziness, headache) were more frequent in the control (10/30) than in the DM group (3/30, P < 0.05). The number of patients who required meperidine injection for pain relief was lower in the DM (7/30) than in the control group (25/30, P < 0.005). No DM- or CPM-associated side effects were observed.

CONCLUSION

Preincisional IM. DM treatment decreased postoperative pain and opioid requirement after MRM surgery.

WEREWOLF, a MYB-related protein in Arabidopsis, is a position-dependent regulator of epidermal cell patterning

The formation of the root epidermis of Arabidopsis provides a simple and elegant model for the analysis of cell patterning. A novel gene, WEREWOLF (WER), is described here that is required for position-dependent patterning of the epidermal cell types. The WER gene encodes a MYB-type protein and is preferentially expressed within cells destined to adopt the non-hair fate. Furthermore, WER is shown to regulate the position-dependent expression of the GLABRA2 homeobox gene, to interact with a bHLH protein, and to act in opposition to the CAPRICE MYB. These results suggest a simple model to explain the specification of the two root epidermal cell types, and they provide insight into the molecular mechanisms used to control cell patterning.

Multimodality therapy in advanced paranasal sinus carcinoma: superior long-term results

PURPOSE

This study was conducted to determine the efficacy of multimodality treatment for stage III and IV, locoregionally advanced paranasal sinus carcinoma.

PATIENTS AND METHODS

A subgroup analysis of 19 consecutive patients with stage III or IV paranasal sinus carcinoma treated with multimodality therapy from head and neck cancer protocols between 1984 and 1996 were analyzed for outcome. Sixteen patients received induction chemotherapy consisting of three cycles of cisplatin and 5-fluorouracil, followed by traditional resection (14 patients) or surgical debulking (two patients). Surgery was followed by concomitant chemoradiotherapy with hydroxyurea and 5-fluorouracil in a week-on, week-off sequence in 15 patients. One patient received standard radiation therapy. An additional three patients were treated with a sequence of surgical resection followed by concomitant chemoradiotherapy. The median total dose to the primary tumor was 60 Gy (range, 45-74 Gy).

RESULTS

The overall survival at 5 and 10 years by lifetable analysis was 72.7% and 53.9%, respectively, and the disease-free survival at both 5 and 10 years was 66.6%. Local control was 76.1% at both 5 and 10 years. In the subgroup of patients treated with induction chemotherapy, 87% (14/16) achieved a clinical response. A complete response was confirmed at the time of surgery in five patients, whereas 11 patients had residual disease in the surgical specimen. Regional and distant failures were unusual (one patient each), with a 10-year regional control rate of 93% and a distant control rate of 95.5%. Serious, nonreversible long-term complications included two cases of unilateral blindness, one cataract, and one case of ototoxicity.

DISCUSSION

An excellent long-term outcome with respect to local control, overall survival, and disease-free survival is achieved in locoregionally advanced paranasal sinus cancer treated with induction chemotherapy, surgery, and concomitant chemoradiotherapy. The 15 patients treated with this regimen had 10-year overall survival, disease-free survival, and local control rates of 56%, 73%, and 79%, respectively. These results are encouraging and are superior to the 40% survival achieved with surgery and radiation therapy. Further investigation of this regimen is warranted.

Variant angina is not associated with angiotensin I converting enzyme gene polymorphism but rather with smoking

BACKGROUND

Angiotensin converting enzyme (ACE) perhaps plays roles in regulating coronary vasomotor tone by producing angiotensin II and degrading bradykinin.

OBJECTIVES

We sought to investigate the role of ACE gene polymorphism in the pathogenesis of variant angina and to compare it with that of other clinical risk factors for male patients with variant angina and age-matched and sex-matched control subjects.

METHODS

We studied 78 male patients with variant angina who exhibited spontaneous or provoked coronary spasms during coronary angiography and compared prevalences of ACE gene genotype (deletion D and insertion I) and other risk factors between this group of patients with variant angina and age-matched and sex-matched control subjects whose angiograms were normal and in whom the ergonovine test did not cause spasms (n = 80).

RESULTS

Smokers were more prevalent in the group of patients with variant angina (P < 0.05). Genotype and allele prevalences of the group of patients with variant angina (0.14, 0.53 and 0.33 for DD, DI and II and 0.41 and 0.59 for D and I, respectively) were no different from those of the control group (0.16, 0.49 and 0.35 for DD, DI and II and 0.40 and 0.60 for D and I). Multiple logistic regression analysis showed that smoking was a significant risk factor for variant angina (odds ratio 2.61, 95% confidence interval 1.03-6.66) whereas ACE genotype was not.

CONCLUSIONS

Variant angina is associated with an environmental factor, such as smoking, rather than a genetic factor, such as ACE gene polymorphism.

Müllerian-inhibiting substance type II receptor expression and function in purified rat Leydig cells

Müllerian-inhibiting substance (MIS), a gonadal hormone in the transforming growth factor-beta superfamily, induces Müllerian duct involution during male sexual differentiation. Mice with null mutations of the MIS ligand or receptor develop Leydig cell hyperplasia and neoplasia in addition to retained Müllerian ducts, whereas MIS-overexpressing transgenic mice have decreased testosterone concentrations and Leydig cell numbers. We hypothesized that MIS directly modulates Leydig cell proliferation and differentiated function in the maturing testis. Therefore, highly purified rat Leydig and Sertoli cells were isolated to examine cell-specific expression, binding, and function of the MIS type II receptor. These studies revealed that this receptor is expressed abundantly in progenitor (21-day) and immature (35-day) Leydig cells as well as in Sertoli cells. Prepubertal progenitor Leydig cells exhibit high affinity (Kd = 15 nM), saturable binding of MIS. No binding, however, is detected with either peripubertal immature Leydig cells or Sertoli cells at either age. Moreover, progenitor, but not immature Leydig cells, respond to MIS by decreasing DNA synthesis. These data demonstrate that functional MIS type II receptors are expressed in progenitor Leydig cells and support the hypothesis that MIS has a direct role in the regulation of postnatal testicular development.

Effects of dextran on tracheal mucociliary velocity in dogs in vivo

We have previously shown that dextran (molecular weight 4kDa) is a potential mucolytic agent, reducing the viscoelasticity and spinnability of cystic fibrosis (CF) sputum and improving its mucociliary clearability during in vitro testing. We wished to see whether low molecular weight (LMW) dextran had similar effects on mucus rheology when administered by aerosol to living dogs, and whether the administration of dextran increased the rate of mucociliary clearance. Healthy mongrel dogs were anesthetized with pentobarbital and intubated. After a 30-min Ringer aerosol delivery during spontaneous breathing, tracheal mucociliary velocity (TMV by charcoal marker particle transport) was measured under bronchoscopic control, and mucus for viscoelasticity analysis (magnetic rheometer) was collected by the endotracheal tube method. Then LMW dextran in Ringer vehicle was delivered by aerosol via the endotracheal tube, followed by the same procedures. We performed eight experiments in eight dogs, involving 30 min administrations of dextran aerosol; all dogs received inhalations of 20 mg/ml, 65 mg/ml, and 200 mg/ml dextran. Compared with Ringer control, TMV increased to 145% of control (P=0.0417) at 65 mg/ml dextran. Mucus viscoelasticity (G*) significantly decreased to 19% of control (P=0.0426) at 65 mg/ml. This in vivo study supports our previous in vitro testing, that LMW dextran decreases the mucus viscoelasticity and increases the rate of mucociliary clearance. We estimate the dosage received by aerosol at 65 mg/ml to be within the effective concentration range studied in vitro, i.e. 10-15 mg/ml final concentration. The results are consistent with the proposed mechanism that the saccharide moieties in LMW dextran compete for hydrogen bonding sites with other mucous glycoproteins. These new hydrogen bonds are structurally and rheologically ineffective, thus reducing the overall cross-link density, and making the mucus more easily cleared by ciliary and cough mechanisms.

Sulfuric acid aerosol induces changes in alveolar surface tension in the guinea pig but not in the rat

The purpose of this study was to investigate the effects of an acid aerosol, at high concentration, on the surface properties of the extracellular fluid lining the airways and alveolae. Guinea pigs and rats were exposed to 43 mg/m3 and 94 mg/m3 of sulfuric acid aerosol mass median aerodynamic diameter (MMAD) 0.9 micron or water aerosol (control), respectively, for 4 hours in an exposure chamber. Surfactant material was extracted from bronchoalveolar lavage fluid (BAL) by centrifugation, and phospholipid, protein, and cell concentrations measured. The extract was reconstituted to 300 micrograms/mL of phospholipid, and its surface properties assessed with a captive bubble surfactometer. The minimum surface tension for the acid-exposed guinea pig BAL was 12.1 +/- 8.48 (mean +/- SD) mN/m, which was significantly higher than the control group, 2.0 +/- 0.43 (mean +/- SD) or the acid-exposed rats, 1.29 +/- 0.11 (mean +/- SD). The change in film area obtained by compressing the film from equilibrium surface tension (25 mN/m) to its minimum value (gamma min) was 62.9 +/- 13.83 (mean +/- SD)% for acid-exposed guinea pigs, compared to 16.3 +/- 5.77 (mean +/- SD)% for the control guinea pigs. The most sensitive index of surfactant inhibition was found to be the maximum film compressibility (Cmax) of the compression isotherm. This index was 119 times greater for the acid-exposed guinea pigs compared to control animals. These abnormalities were associated with an elevation of total protein (0.95 +/- 0.33 [mean +/- SD] mg/mL compared to 0.13 +/- 0.03 [mean +/- SD] mg/mL in controls) and polymorphonuclear leucocytes in the BAL. There was no change in total phospholipids. By contrast BAL retrieved from rats exposed to approximately twice the concentration of acid aerosol showed no cellular nor biochemical abnormalities and its surface tension properties were normal. We conclude that the abnormalities of surfactant activity in the acid-exposed guinea pigs result from the cellular and humoral responses of acute lung injury rather than a direct effect of acid.

Expression of nuclear retinoid receptors in normal, premalignant and malignant gastric tissues determined by in situ hybridization

Retinoids exhibit multiple functions through interaction with nuclear retinoid receptors and have growth-suppressive activity on gastric cancer cells. To better understand the roles of nuclear retinoid receptors during gastric carcinogenesis, we have used in situ hybridization to investigate expression of retinoic acid receptors (RARs) and retinoid x receptors (RXRs) in premalignant and malignant formalin-fixed paraffin-embedded gastric tissues. Histological sections of eight normal, 17 distal normal and nine gastric cancer tissues were hybridized with non-radioactive RNA probes for subtypes of RAR and RXR. Expression of RAR alpha, RAR beta, RAR gamma, RXR alpha and RXR beta was found in most cell types in gastric mucosa tissues from normal individuals as well as in distal normal tissues from cancer patients. Expression of RAR alpha and RAR beta were found in three and seven cancer tissues, respectively, and levels of RXR alpha mRNA were significantly decreased in poorly differentiated cancer tissues. Among the five investigated nuclear retinoid receptors, only expression of RAR alpha mRNA was significantly decreased in intestinal metaplasia, dysplasia and cancer tissues when compared to adjacent normal tissues. In conclusion, normal gastric mucosa expressed both RARs and RXRs, which supports the physiological role of retinoic acid on normal gastric mucosa. The decrease in RAR alpha expression in premalignant and malignant gastric tissues suggests a significant role of RAR alpha during gastric carcinogenesis.

Diagnostic utility of Müllerian inhibiting substance determination in patients with primary and recurrent granulosa cell tumors

OBJECTIVES

In this study we evaluated changes in serum Müllerian inhibiting substance (MIS) concentration in a large number of patients with granulosa cell tumors (GCT) to determine whether MIS is elevated at the time of presentation and whether MIS is an index of successful surgical resection and management of recurrences.

METHODS

We retrospectively reviewed MIS levels from 17 subjects prior to tumor resection and studied serial MIS samples from 56 subjects following initial tumor resection. Clinical follow-up information was available for 36 of those with postoperative MIS values. Serum MIS was measured by an ELISA. MIS values were compared to a combination of normative values previously established in our laboratory and from more recently obtained samples from older pre- and postmenopausal women, using this assay.

RESULTS

Serum MIS was elevated pre-operatively in 6 of 8 (75%) subjects with juvenile GCTs and in 7 of 9 (78%) of those with adult GCTs relative to age-matched controls (76% for both types combined). Post-operative clinical correlation was available for 36 patients. There was no clinical recurrence in 21 subjects with normal or undetectable postoperative values, and incompletely resectable tumor or recurrence was identified in 6 of 15 patients with elevated postoperative values.

CONCLUSIONS

The results of this study demonstrate that postoperative serum MIS concentrations may be used to evaluate the completeness of tumor removal following initial surgery and that serial MIS determinations may allow the detection of recurrences.

Phosphorylation of CREB in axon-induced Schwann cell proliferation

Axonal contact regulates Schwann cell (SC) proliferation during development. However, the intracellular signal transduction pathways involved in the axon-induced proliferation of SC have not been described. We have previously shown that SC proliferation induced by axolemma-enriched fractions (AEF) is accompanied by increased expression of cyclic AMP-responsive element binding protein, CREB. We now report the AEF and dorsal root ganglion neuritic-induced signal transduction pathway(s) which regulate the phosphorylation of CREB that correlate with the SC proliferative response. The phosphorylated form of CREB was significantly increased after 16 hr of axonal stimulation, continued to increase for 48 hr, and subsequently decreased as monitored by immunocytochemistry and Western blot analysis. Treatment with protein kinase A (PKA) inhibitor, H89, completely abolished both the CREB activation and SC proliferation. In contrast, treatment with protein kinase C (PKC) inhibitor (bisindolylmaleimide) inhibited AEF-induced SC proliferation, but did not immediately affect CREB phosphorylation. These data are consistent with the view that PKA and PKC pathways are essential for AEF-induced SC proliferation. Since PKC can influence SC proliferation without initially affecting CREB phosphorylation, PKC may regulate SC proliferation at pathways distal to the immediate CREB activation.