Patient and health care system characteristics are associated with delayed treatment of tuberculosis cases in Taiwan

Background

The decline of the incidence rate of tuberculosis in Taiwan has been partly attributed to the launch of the directly observed therapy short course (DOTS) program in 2006, followed by the DOTS-Plus in 2007. However, with the phasing out of the specialized tuberculosis care system and the declining incidence, clinical workers in Taiwan might become less familiar with the presentation of tuberculosis. Complementing the patient-pathway analysis with health system delay estimates, the objective of this study is twofold: to estimate the alignment between patient care initiation and the availability of prompt diagnostic and treatment services, and to identify the risk factors of delayed tuberculosis treatment.

Methods

The study population included all Taiwanese patients with incident tuberculosis in 2013. We (1) identified 11,507 incident tuberculosis patients from the 2013 National TB Registry, and (2) linked 10,932 Taiwanese from the registry to the 2012–2013 National Health Insurance Research Database. We assessed patient’s care-seeking pathways and associated the determinants of health system delay in a Cox model.

Results

The overall health system delay was 46 days. We found that 20.5 and 3.5% of 10,932 tuberculosis patients were diagnosed and treated respectively at the initial visit to seek care for TB-related symptoms. Risk factors related to the prolonged health system delay included female gender (adjusted HR = 0.921, 95% CI: 0.884, 0.960), age > =65 years (adjusted HR = 0.720, 95% CI: 0.692, 0.750), non-severe (chest X-ray without cavities) (adjusted HR =0.721, 95% CI 0.683–0.760), chronic respiratory diseases (adjusted HR = 0.544, 95% CI: 0.522, 0.566), living in long-term care facilities (adjusted HR = 0.580, 95% CI: 0.525,0.640), an initial visit at a primary care clinic (adjusted HR = 0.588, 95% CI: 0.565, 0.612), and living in southern Taiwan (adjusted HR = 0.887, 95% CI: 0.798, 0.987).

Conclusions

The low access to TB diagnostic and treatment services at the initial visit and the prolonged health system delay indicate inefficiency in the health care system. Strengthening training of physicians at public hospitals and health workers at nursing homes might improve the efficiency and timeliness of tuberculosis diagnosis and treatment in Taiwan.

Long-term urinary tract effect of ileal conduit after radical cystectomy compared with bladder preservation: a nationwide, population-based cohort study with propensity score-matching analysis

OBJECTIVE

Ileal conduit urinary diversion (ICUD) is the most common procedure after radical cystectomy. Although complications have been reported, few patients with ICUD and bladder preservation controls have been available for long-term follow-up. This study compared the long-term effect of structural changes after cystectomy with ICUD to that in bladder preservation controls.

DESIGN

A retrospective nationwide cohort study.

SETTING

Data retrieved from the Taiwan National Health Insurance Research Database.

PARTICIPANTS

The National Health Insurance database was explored for patients diagnosed with bladder cancer between 1997 and 2006. Only cancer-free patients without chemotherapy and other types of urinary diversion who lived for >5 years were included in the analysis.

OUTCOME MEASURES

Patient characteristics, comorbidity and postoperative urinary tract disease were statistically analysed and compared. Cox proportional hazards model was used to evaluate the incidence rates of outcomes after adjustment for covariates. Propensity scores analysis was used to balance the clinical parameters between groups. The primary outcomes were postoperative new-onset urinary tract disease such as urinary tract infection (UTI), UTI with septicaemia and chronic kidney disease (CKD), or calculus of kidney and ureter.

RESULTS

There were 11 185 patients included in our cohort, among which 703 (6.3%) and 10 482 (93.7%) patients received ICUD and bladder preservation procedure, respectively. Compared with patients who only underwent a bladder preservation procedure, those who had undergone ICUD after cystectomy were independently associated with postoperative de novo urinary tract disease. Propensity score analysis (1:4) was also performed. ICUD contributed to significantly higher new-onset UTI, UTI with sepsis and CKD (HR=1.30, 3.16, 1.35, respectively) compared with bladder preservation procedure after adjustment for age, gender and comorbidities.

CONCLUSION

ICUD after radical cystectomy was associated with a higher incidence of UTI, UTI with septicaemia and CKD during long-term follow-up than the incidences following a bladder preservation procedure.

Outcomes of neonatal jaundice in Taiwan

OBJECTIVE

To investigate the burden of clinically significant neonatal jaundice (SNJ) in Taiwan, 2000-2010.

STUDY DESIGN

The nationwide, population-based health insurance database in Taiwan was used to investigate the incidence, kernicterus rate and mortality rates of SNJ cohort born between 2000 and 2010.

RESULTS

From 2000 to 2010, up to 242 546 patients admitted with neonatal jaundice (NJ) were identified. The incidence of SNJ was 5.9% in 2000 and increased to 13.7% in 2010 (P<0.001). The mortality rate significantly decreased from 0.51% in 2000 to 0.26% in 2010 (P<0.001) and the average incidence of kernicterus was 0.86 per 100 000 live births, indicating dramatically decreased rates compared with earlier rates in Taiwan.

CONCLUSIONS

In spite of the increased incidence rates, the rates of mortality and kernicterus in patients with NJ significantly declined in Taiwan. The public health prevention programme, clinicians' awareness and effective management might contribute to the reduction of these acute severe sequelae.

Effect of mechanistic target of rapamycin inhibitors on postrenal transplantation malignancy: A nationwide cohort study

BACKGROUND

Post-transplantation malignancy influenced graft survival and overall survival in the patients receiving renal transplantation. Immunosuppressants influenced the immune surveillance, but whether immunosuppressive agents have impact for incidence of post-transplantation malignancy is still elusive in Taiwan.

METHOD

We conducted a nationwide population-based study. Patients who did not have malignancy history and received kidney transplantation between 2000 and 2010 were enrolled. Specific immunosuppressive users are defined as sustained use (more than 12 months) after renal transplantation. The primary outcome is the development of cancer after kidney transplantation. A Cox proportional hazards model was used to determine the risk of cancer development.

RESULT

Among 4438 recipients, 559 of them were diagnosed with malignancy after 1 year of transplantation. A total of 742 of recipients were as user of mechanistic target of rapamycin (mTOR) inhibitors. The mTOR users had higher rate of receiving pulse therapy. The hazard ratios (HR) for mTOR inhibitor users with exposure more than 5 years for overall malignancy and urothelial malignancy were 0.68 (95% CI: 0.48-0.95, P = 0.02) and 0.60 (95% CI: 0.36-0.99, P = 0.02), respectively. For the overall mortality and reentry of dialysis, the probability of both groups was similar (overall mortality: P = 0.53; reentry of dialysis: P = 0.77).

CONCLUSION

Among the recipients of renal transplantation in Taiwan, mTOR inhibitors with exposure more than 5 years provided a protective role in reducing the risk of overall neoplasm and urothelial malignancy. The probability of reentry of dialysis and overall mortality was similar between the mTORi users and nonusers.

Dietary quality linkage to overall competence at school and emotional disturbance in representative Taiwanese young adolescents: dependence on gender, parental characteristics and personal behaviors

BACKGROUND

Child school performance during puberty may be at increased risk through emotional disturbance. It is hypothesized that this may be mitigated by dietary quality.

METHODS

In a nationally representative sample (Nutrition and Health Survey in Taiwan, NAHSIT), 1371 Taiwanese aged 11-16 years, overall competence at school, (OCS) and emotional status have been assessed by teachers with the SAED (Scale for Assessing Emotional Disturbance). Parents provided family socio-demographics and students completed a behavioral and dietary questionnaire (Youth Healthy Eating Index - Taiwan, YHEI-TW). Associations between emotional disturbance (ED), OCS and dietary quality (YHEI-TW) were assessed in multiple linear regression models with adjustments for covariates including parental characteristics, personal behaviors, body fatness and puberty.

RESULTS

Boys or girls with ED had a less favorable OCS (p < 0.001), minimally dependent on YHEI-TW. On multivariable analysis there was a more positive association between OCS and YHEI-TW among boys (β = 0.05, p < 0.01) and girls (β = 0.07, p < 0.001). Poor dietary quality was associated with ED, especially in girls (β =  - 0.06, p < 0.001). Additionally, parental characteristics, body fatness, and personal behaviors are associated with OCS. Puberty is associated with ED and may be indirectly linked to OCS.

CONCLUSIONS

Unsatisfactory food intake is associated with the link between emotional disturbance and impaired school performance, as assessed by OCS, especially among girls. For both genders, socio-economic and behavioral factors including parenteral income, reading, screen viewing and smoking are modulators of this association. Puberty was a modifying factor in girls. Dietary quality is a relevant factor for health (ED) as well as education (OCS) during early adolescence.

Spatial Analysis of Ambient PM2.5 Exposure and Bladder Cancer Mortality in Taiwan

Fine particulate matter (PM_2.5) is an air pollutant that is receiving intense regulatory attention in Taiwan. In previous studies, the effect of air pollution on bladder cancer has been explored. This study was conducted to elucidate the effect of atmospheric PM_2.5 and other local risk factors on bladder cancer mortality based on available 13-year mortality data. Geographically weighted regression (GWR) was applied to estimate and interpret the spatial variability of the relationships between bladder cancer mortality and ambient PM_2.5 concentrations, and other variables were covariates used to adjust for the effect of PM_2.5. After applying a GWR model, the concentration of ambient PM_2.5 showed a positive correlation with bladder cancer mortality in males in northern Taiwan and females in most of the townships in Taiwan. This is the first time PM_2.5 has been identified as a risk factor for bladder cancer based on the statistical evidence provided by GWR analysis.

Increased Risk of Respiratory Mortality Associated with the High-Tech Manufacturing Industry: A 26-Year Study

Global high-tech manufacturers are mainly located in newly industrialized countries, raising concerns about adverse health consequences from industrial pollution for people living nearby. We investigated the ecological association between respiratory mortality and the development of Taiwan's high-tech manufacturing, taking into account industrialization and socioeconomic development, for 19 cities and counties-6 in the science park group and 13 in the control group-from 1982 to 2007. We applied a linear mixed-effects model to analyze how science park development over time is associated with age-adjusted and sex-specific mortality rates for asthma and chronic obstructive pulmonary disease (COPD). Asthma and female COPD mortality rates decreased in both groups, but they decreased 9%-16% slower in the science park group. Male COPD mortality rates increased in both groups, but the rate increased 10% faster in the science park group. Science park development over time was a significant predictor of death from asthma (p ≤ 0.0001) and COPD (p = 0.0212). The long-term development of clustered high-tech manufacturing may negatively affect nearby populations, constraining health advantages that were anticipated, given overall progress in living standards, knowledge, and health services. National governments should incorporate the long-term health effects on local populations into environmental impact assessments.

Spatial Clustering and Local Risk Factors of Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) mortality has been steadily increasing in Taiwan since 2009. In order to understand where the hotspot areas are and what the local risk factors are, we integrated an ecological and a case-control study. We used a two-stage approach to identify hotspots and explore the possible risk factors for developing COPD. The first stage used the annual township COPD mortality from 2000 to 2012 and applied the retrospective space-time scan statistic to calculate the local relative risks in each township. In the second stage, we conducted a case-control study, recruiting 200 patients from one local hospital within the one identified hotspot area located in southern Taiwan. Logistic regression was applied for analyzing the personal risk factors of COPD. The univariate analyses showed that higher percentages of aborigines, patients with tuberculosis (TB) history, and those with smoking history had COPD (p < 0.05). After controlling for demographic variables, aboriginal status (adjusted odds ratios (AORs): 3.01, 95% CI: 1.52-5.93) and smoking history (AORs: 2.64, 95% CI: 1.46-4.76) were still the two significant risk factors. This two-stage approach might be beneficial to examine and cross-validate the findings from an aggregate to an individual scale, and can be easily extended to other chronic diseases.

Addressing health disparities in chronic kidney disease

According to the official health statistics, Taiwan has the highest prevalence of end stage renal disease (ESRD) in the world. Each year, around 60,000 ESRD patients in Taiwan consume 6% of the national insurance budget for dialysis treatment. The prevalence of chronic kidney disease (CKD) has been climbing during 2008–2012. However, the spatial disparities and clustering of CKD at the public health level have rarely been discussed. The aims of this study are to explore the possible population level risk factors and identify any clusters of CKD, using the national health insurance database. The results show that the ESRD prevalence in females is higher than that in males. ESRD medical expenditure constitutes 87% of total CKD medical expenditure. Pre-CKD and pre-ESRD disease management might slow the progression from CKD to ESRD. After applying ordinary least-squares regression, the percentages of high education status and the elderly in the townships are positively correlated with CKD prevalence. Geographically weighted regression and Local Moran’s I are used for identifying the clusters in southern Taiwan. The findings can be important evidence for earlier and targeted community interventions and reducing the health disparities of CKD.

Dietary quality of elders and children is interdependent in Taiwanese communities: a NAHSIT mapping study

Dietary quality may exhibit intergenerational associations in Taiwanese communities. Nutrition and Health Surveys in Taiwan (NAHSIT) for children and elders (1999-2002) were mapped for coincident locality and ethnicity with Geo-Gadget. Communities were characterized ecologically. Dietary quality was assessed by the Youth Healthy Eating Index-Taiwan (YHEI-TW) for children and Overall Dietary Index-Revised (ODI-R) for elders. Hierarchical regression analysis was used. Elderly ODI-R was linked with the overall child YHEI-TW (p < .001). When ODI-R increased 1 unit, the child YHEI-TW improved 0.232 and 0.134 YHEI-TW units with men and women, respectively. Dietary quality of community elders is related to that of children.

Geographic disparity in chronic obstructive pulmonary disease (COPD) mortality rates among the Taiwan population

Chronic obstructive pulmonary disease (COPD) causes a high disease burden among the elderly worldwide. In Taiwan, the long-term temporal trend of COPD mortality is declining, but the geographical disparity of the disease is not yet known. Nationwide COPD age-adjusted mortality at the township level during 1999-2007 is used for elucidating the geographical distribution of the disease. With an ordinary least squares (OLS) model and geographically weighted regression (GWR), the ecologic risk factors such as smoking rate, area deprivation index, tuberculosis exposure, percentage of aborigines, density of health care facilities, air pollution and altitude are all considered in both models to evaluate their effects on mortality. Global and local Moran's I are used for examining their spatial autocorrelation and identifying clusters. During the study period, the COPD age-adjusted mortality rates in males declined from 26.83 to 19.67 per 100,000 population, and those in females declined from 8.98 to 5.70 per 100,000 population. Overall, males' COPD mortality rate was around three times higher than females'. In the results of GWR, the median coefficients of smoking rate, the percentage of aborigines, PM10 and the altitude are positively correlated with COPD mortality in males and females. The median value of density of health care facilities is negatively correlated with COPD mortality. The overall adjusted R-squares are about 20% higher in the GWR model than in the OLS model. The local Moran's I of the GWR's residuals reflected the consistent high-high cluster in southern Taiwan. The findings indicate that geographical disparities in COPD mortality exist. Future epidemiological investigation is required to understand the specific risk factors within the clustering areas.

Leisure time physical activities and dietary quality of the general and indigenous Taiwanese populations are associated with fat distribution and sarcopenia

Indigenous peoples are at greater risk of obesity-related health problems for various reasons. These have been explored in the adulthood (>=19 yrs) section of the nationally-representative Nutrition and Health Survey in Taiwan (NAHSIT) for 2005-2008 in Indigenous mountain-dwelling (IndT) (n=226) and general (mainly Han Chinese) (GenT) (n=1486) Taiwanese. Physical activity, BMI, fat distribution (waist circum-ference (WC) and triceps skinfold (TSF)) and mid arm muscle circumference (MAMC) have been com-pared. Leisure-time physical activities (LTPA) were assigned metabolic equivalents (METs). Comparisons were made by ethnicity-locality. Indigenous men and women were 3.81 and 5.47 times more obese (WHO criteria BMI>=30 kg/m2) than the GenT, respectively. Some 55% of the IndT and 34% of the GenT reported no LTPA. All LTPA types were less evident in the IndT. Multivaiable adjusted ORs (95% CIs) against inactivity as referent were, for sarcopenic MAMC, in Indigenes with MVI-LTPA 0.13 (0.03-0.67) and in the GenT 0.61 (0.37-1.01); in the GenT with LTPA for BMI >=30 kg/m2 and obese TSF, they were 0.53 (0.31-0.91) and 0.77 (0.60-0.98), respectively. Without dietary quality adjustment, the sarcopenia risk in GenT with LTPA was significant (OR=0.60, 95% CI: 0.37-0.97). Having adjusted for dietary quality, the significance disappeared. Less sarcopenia was found with ambulation in the GenT (OR=2.07, 95% CI: 1.26-3.43). More over-fatness in an IndT than GenT is associated with less LTPA. LTPA reduces sarcope-nic risk irrespective of ethnicity, is partly dependent on diet, and reduces obesity indices in the GenT.

Outpatient physical therapy utilization for children and adolescents with intellectual disabilities in Taiwan: a population-based nationwide study

This study analyzed the utilization and utilization determinants of outpatient physical therapy (PT) among children and adolescents with intellectual disabilities (ID) in Taiwan. A cross-sectional study was conducted to analyze 2007 national health insurance (NHI) claim data from 35,802 eighteen-year-old and younger persons with intellectual disabilities. A total of 3944 (11.02%) claimants received outpatient physical therapy. Variables that affected PT utilization included age, residence urbanization level, ID level, copayment status and major co-morbidity. The average annual PT visit frequency was 25.4 ± 33.0; pre-school children, claimants suffering from catastrophic disease and ID co-occurring with cerebral palsy had a higher mean cost per visit. Age, ID level, copayment status and co-morbidity were factors that influenced expenditure. Pre-school children, males, individuals who resided in the lowest urbanization areas and individuals with a catastrophic disease tended to use hospital services. The point prevalence of epilepsy and cerebral palsy were 12.10% and 19.80%, respectively. Despite the NHI program and government regulations to provide special services, the use of physical therapy for children and adolescents with intellectual disabilities was low, and the utilization decreased as the subjects aged.

Trends in the use of psychotropic drugs in people with intellectual disability in Taiwan: a nationwide outpatient service study, 1997-2007

This study aims to examine trends in outpatient psychotropic drug use among people with intellectual disabilities in Taiwan. The NHI outpatient medication records between January 1, 1997 and December 31, 2007 for people with intellectual disabilities were analyzed to observe the percent change, prevalence and prescription trends in psychotropic drugs. The overall prevalence of psychotropic medication increased from 17.82% to 23.22% during the study period. Results from stepwise logistic analysis demonstrated that females, the elderly, and individuals suffering from catastrophic disease were more prone to receive psychotropic drugs and that those with mild intellectual disability were less likely to receive psychotropic drugs. The percentage change in prescription rates of antipsychotics, hypnotics/sedatives, and antidepressants were 85.30%, 127.25%, and 167.50%, respectively, and the trends were statistically significant (p<0.05). Taiwan's NHI program and off-label use of psychotropic drugs might have attributed to this trend.

Spatio-temporal analysis on enterovirus cases through integrated surveillance in Taiwan

Background

Severe epidemics of enterovirus have occurred frequently in Malaysia, Singapore, Taiwan, Cambodia, and China, involving cases of pulmonary edema, hemorrhage and encephalitis, and an effective vaccine has not been available. The specific aim of this study was to understand the epidemiological characteristics of mild and severe enterovirus cases through integrated surveillance data.

Methods

All enterovirus cases in Taiwan over almost ten years from three main databases, including national notifiable diseases surveillance, sentinel physician surveillance and laboratory surveillance programs from July 1, 1999 to December 31, 2008 were analyzed. The Pearson’s correlation coefficient was applied for measuring the consistency of the trends in the cases between different surveillance systems. Cross correlation analysis in a time series model was applied for examining the capability to predict severe enterovirus infections. Poisson temporal, spatial and space-time scan statistics were used for identifying the most likely clusters of severe enterovirus outbreaks. The directional distribution method with two standard deviations of ellipse was applied to measure the size and the movement of the epidemic.

Results

The secular trend showed that the number of severe EV cases peaked in 2008, and the number of mild EV cases was significantly correlated with that of severe ones occurring in the same week [r = 0.553, p < 0.01]. These severe EV cases showed significantly higher association with the weekly positive isolation rates of EV-71 than the mild cases [severe: 0.498, p < 0.01 vs. mild: 0.278, p < 0.01]. In a time series model, the increase of mild EV cases was the significant predictor for the occurrence of severe EV cases. The directional distribution showed that both the mild and severe EV cases spread extensively during the peak. Before the detected spatio-temporal clusters in June 2008, the mild cases had begun to rise since May 2008, and the outbreak spread from south to north.

Conclusions

Local public health professionals can monitor the temporal and spatial trends plus spatio-temporal clusters and isolation rate of EV-71 in mild and severe EV cases in a community when virus transmission is high, to provide early warning signals and to prevent subsequent severe epidemics.

Use of GIS Mapping as a Public Health Tool-From Cholera to Cancer

The field of medical geographic information systems (Medical GIS) has become extremely useful in understanding the bigger picture of public health. The discipline holds a substantial capacity to understand not only differences, but also similarities in population health all over the world. The main goal of marrying the disciplines of medical geography, public health and informatics is to understand how countless health issues impact populations, and the trends by which these populations are affected. From the 1990s to today, this practical approach has become a valued and progressive system in analyzing medical and epidemiological phenomena ranging from cholera to cancer. The instruments supporting this field include geographic information systems (GIS), disease surveillance, big data, and analytical approaches like the Geographical Analysis Machine (GAM), Dynamic Continuous Area Space Time Analysis (DYCAST), cellular automata, agent-based modeling, spatial statistics and self-organizing maps. The positive effects on disease mapping have proven to be tremendous as these instruments continue to have a great impact on the mission to improve worldwide health care. While traditional uses of GIS in public health are static and lacking real-time components, implementing a space-time animation in these instruments will be monumental as technology and data continue to grow.

Bidirectionality and gender differences in emotional disturbance associations with obesity among Taiwanese schoolchildren

Childhood obesity is associated with psychological problems, but little is known about its association with emotional disturbance (ED) in the educational setting, especially by gender. In the population representative Elementary School Children's Nutrition and Health Survey in Taiwan 2001-2002 of children aged 6-13 (n=2283), we have considered whether ED is associated with obesity by gender. Schoolchildren were assessed with the modified scale for assessing emotional disturbance questionnaires. For some subscales, boys and girls had ED associations with obesity which were bidirectional. With normal weight as referent and relevant adjustments, the significant ED subscales predictable by obesity were relationship problems (RP) in boys (odds ratio, OR=1.89 with 95% CI: 1.08-3.30) and inappropriate behavior (IB) in girls (OR=2.88: 95% CI: 1.47-5.61). Conversely, with 'no-specific-ED' as referent, obesity was predictable by fully-adjusted specific-EDs in the same subscales, namely RP in boys (OR=1.88 with 95% CI: 1.13-3.13) and IB in girls (OR=3.03: 95% CI: 1.57-5.85). Child obesity prevalence showed no trend with school grade from 1 to 6, but for aggregate ED and most of its subscales the prevalence increased with grade (P for trend <0.01). Thus, there is some dissociation of obesity and ED as judged by their trend presence with school grade. Where obesity and ED occurred together (for inability-to-learn and unhappiness or depression), there were upward trends with grade (P<0.01). There are probably some selected bidirectional pathogenicities for obesity-ED associations with different expression in boys and girls and during elementary education. This provides some policy direction while mechanisms and causality require elucidation.

Healthcare utilization and expenditure analysis between individuals with intellectual disabilities and the general population in Taiwan: a population-based nationwide child and adolescent study

This study examines differences in outpatient-visit frequency and medical expenditures between (1) children and adolescents in Taiwan with intellectual disabilities and (2) children and adolescents in Taiwan's general population. A cross-sectional study was conducted to analyze data from 2007 provided by Taiwan's National Health Insurance program. A total of 236,045 beneficiaries younger than 19 years made use of outpatient services; among them, 35,802 had a principal diagnosis of mental retardation (intellectual disability). The average number of ambulatory visits was 14.9 ± 12.4, which is much higher than in the United States and other developed countries. The mean number of annual visits of the individuals with intellectual disabilities was significantly higher than that of the general population in Taiwan (20.1 ± 20.0 vs. 14.0 ± 12.2); age, gender, urbanization level of residential area, and copayment status affected outpatient visit frequency. The mean annual outpatient costs were NTD6371.3 ± NTD11989.1 for the general population and NTD19724.9 ± NTD40469.9 for those with intellectual disabilities (US $1 equals approximately NTD30). Age, gender, urbanization level of residential area, and copayment status were the determinants that accounted for this difference in cost. Children and adolescents with intellectual disabilities had higher use rates of rehabilitative and psychiatric services than the general population. We conclude that individuals with intellectual disabilities had higher demands than the general population for healthcare services, especially for rehabilitative and psychiatric services.

Abstract B71: Does hormone replacement therapy or mammography screening affect breast cancer incidence rates in Taiwan? A nationwide cohort study

Background: Breast cancer incidence in Taiwan is continuous rising to the leading cancer incidence rate in women according to cancer registry. We hypothesize hormone replacement therapy (HRT) or mammography screening affect the breast cancer incidence.

Objectives: 1) To determine whether a similar decline of HRT use and breast incidence occurred in Taiwan. 2) To compare frequency and dose of use HRT with breast cancer incidence. 3) To compare change of mammography rates in different age groups and period of time with breast cancer incidence and mortality.

Methods: Breast cancer incidence in most industry countries declines as HRT use drops. This study analyzed national health insurance data from 2000-2008. Women aged above 40 years who was diagnosis postmenopausal or osteopenic were extracted from database for analysis. This research looked at information from prescriptions for HRT, mammography rates and breast cancer incidence and mortality rates. Approximately 82,478 postmenopausal or osteopenic women were included in this analysis. Odd ratios were derived from nested case control estimation to compare with HRT use, total dose and total duration of HRT. Mammography rates in different age groups and different period of year were compared by using national health insurance data.

Results: We found that a reduced frequency of use of HRT was reflected in the decrease in dispensed HRT prescriptions after 2002 announced be the Women Health Initiative (WHI) in Taiwan. The largest drop in use of HRT occurred between 2002 and 2003 and continuous drop is noted during our study period. Compared with never users, estrogen and progestin users were with higher risk of breast cancer (OR: 1.58, 95% CI 1.16-2.14, p&lt;0.003) and higher among current users of estrogen only (OR: 1.48, 95% CI 1.13-1.93, p&lt;0.004). The HRT use, total dose of HRT and duration of HRT all showed dose-response effects (OR: 2.42 for HRT use more than 30 times; OR: 3.59 for total use of HRT for more than 3 years; OR: 3.18 for duration of use HRT). They are all statistical significant (p&lt;0.001). Compared with mammography rates with different period of time, the study found that nearly 40% rise in breast cancer rates coincided with the 50% increase in mammography rates between 2000 and 2008. The breast cancer incidence increased following by mammography rates inclined, particular in aged 40 to 59 years group during 2001 to 2005 and 2006 to 2010. Breast cancer incidence rates began to increase dramatically in 2006 to 2010 among women aged 40-49 years. Compared with total mortality to incidence ratio [1-(M/I)] (proxy site-specific cancer survival), the survival ratio increased from 74.7% (2000) to 81.3% (2008).

Conclusion: The breast cancer risk was elevated with the use of combined HRT. In Taiwan, breast cancer incidence rates continuous increase among aged 40-59 years, which is likely explained by the promotion of mammography for government breast cancer screening programs from 2003. Mortality to incidence ratio in Taiwan did show some improvement, but still limit. Some argue that the plasticizers - DEHA, DBP, BBP, DEHP, DOP - as estrogen-like substances is the cause which was discovered widely used for food packaging and illegally add into food drink in Taiwan food industry may disturb the endocrine system. Further long-term surveillance studies of time trend and spatial patterns between breast cancer incidence rate and screening rates can help reconcile the potential population-level association of these two factors.

Citation Format: Eng-Mei Tsai, Po-Huang Chiang, Yen-Chen Chang. Does hormone replacement therapy or mammography screening affect breast cancer incidence rates in Taiwan? A nationwide cohort study. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr B71.

Comparison of outpatient services between elderly people with intellectual disabilities and the general elderly population in Taiwan

This study aims to analyze the ambulatory visit frequency and medical expenditures of the general elderly population versus the elderly with intellectual disabilities in Taiwan, while examining the effects of age, gender, urbanization and copayment status on ambulatory utilization. A cross-sectional study was conducted to analyze data from 103,183 national health insurance claimants aged 65 or older. A total of 1469 had a principal diagnosis of mental retardation (intellectual disability) and claimed medical outpatient services in 2007. The average number of ambulatory visits was 30.1 ± 23.1, which is much higher than in the United States and other developed countries, and the mean annual visits of the elderly with intellectual disabilities was significantly higher than the general population in Taiwan (35.2 ± 28.7 vs. 30.0 ± 23.1). Age and copayment status affected outpatient visit frequency. The mean medical expenditure per visit and the mean annual outpatient cost were 1146.5 ± 4497.7 NT$ and 34,533.7 ± 115,891.7 NT$, respectively. Male beneficiaries tended to have higher average annual medical expenses and mean medical expenses per visit than female beneficiaries. The three most frequent principal diagnoses at ambulatory visits were circulatory system diseases, musculoskeletal system and connective tissue diseases and digestive system diseases. We conclude that the elderly with intellectual disabilities had higher demand than the general population for healthcare services, and the NHI program lowers the barrier to care for populations with special needs.

High risk of renal failure in stage 3B chronic kidney disease is under-recognized in standard medical screening

BACKGROUND

The objective of this study was to determine the risk of renal failure in patients with under-recognized chronic kidney disease (CKD) in the self-pay standard medical screening program of health management centers.

METHODS

The abbreviated Modification of Diet in Renal Disease equation was used to calculate the estimated glomerular filtration rate (eGFR) of study subjects. Study subjects with eGFR less than 60 mL/min/1.73m(2) but with normal results of routine assessment, including serum creatinine, blood urea nitrogen, urinalysis and kidney ultrasound, were defined as having under-recognized CKD. Episodes of renal failure requiring dialysis within 2 years in subjects with stage 3 to stage 5 CKD were evaluated.

RESULTS

A total of 15,817 subjects were recruited and 28.4% of subjects were identified by routine assessments as having a kidney problem. The prevalences of CKD 3A, 3B, 4 and 5 were 8.3%, 1.9%, 0.3% and 0.2%, respectively. All subjects with stages 4 and 5 CKD had abnormal serum creatinine levels, but 48.7% of 1,507 subjects with stage 3 CKD (stage 3A, n = 713; stage 3B, n = 21) had normal routine assessments. Subjects with under-recognized stage 3B CKD had the highest risk (20%) of developing renal failure compared to subjects with stages 3-5 CKD and abnormal results of routine assessments.

CONCLUSION

Identifying subjects with CKD stage 3 by the eGFR equation, especially in stage 3B, is advantageous in detecting the risk of renal failure over the routine clinical assessment that is currently carried out by health management institutions in Taiwan.

The impact of matching vaccine strains and post-SARS public health efforts on reducing influenza-associated mortality among the elderly

Public health administrators do not have effective models to predict excess influenza-associated mortality and monitor viral changes associated with it. This study evaluated the effect of matching/mismatching vaccine strains, type/subtype pattern changes in Taiwan's influenza viruses, and the impact of post-SARS (severe acute respiratory syndrome) public health efforts on excess influenza-associated mortalities among the elderly. A negative binomial model was developed to estimate Taiwan's monthly influenza-associated mortality among the elderly. We calculated three winter and annual excess influenza-associated mortalities [pneumonia and influenza (P&I), respiratory and circulatory, and all-cause] from the 1999-2000 through the 2006-2007 influenza seasons. Obtaining influenza virus sequences from the months/years in which death from P&I was excessive, we investigated molecular variation in vaccine-mismatched influenza viruses by comparing hemagglutinin 1 (HA1) of the circulating and vaccine strains. We found that the higher the isolation rate of A (H3N2) and vaccine-mismatched influenza viruses, the greater the monthly P&I mortality. However, this significant positive association became negative for higher matching of A (H3N2) and public health efforts with post-SARS effect. Mean excess P&I mortality for winters was significantly higher before 2003 than after that year [mean +/- S.D.: 1.44+/-1.35 vs. 0.35+/-1.13, p = 0.04]. Further analysis revealed that vaccine-matched circulating influenza A viruses were significantly associated with lower excess P&I mortality during post-SARS winters (i.e., 2005-2007) than during pre-SARS winters [0.03+/-0.06 vs. 1.57+/-1.27, p = 0.01]. Stratification of these vaccine-matching and post-SARS effect showed substantial trends toward lower elderly excess P&I mortalities in winters with either mismatching vaccines during the post-SARS period or matching vaccines during the pre-SARS period. Importantly, all three excess mortalities were at their highest in May, 2003, when inter-hospital nosocomial infections were peaking. Furthermore, vaccine-mismatched H3N2 viruses circulating in the years with high excess P&I mortality exhibited both a lower amino acid identity percentage of HA1 between vaccine and circulating strains and a higher numbers of variations at epitope B. Our model can help future decision makers to estimate excess P&I mortality effectively, select and test virus strains for antigenic variation, and evaluate public health strategy effectiveness.

M(1)-like muscarinic acetylcholine receptors regulate fast-spiking interneuron excitability in rat dentate gyrus

Cholinergic transmission through muscarinic acetylcholine receptors (mAChRs) plays a key role in cortical oscillations. Although fast-spiking (FS), parvalbumin-expressing basket cells (BCs) are proposed to be the cellular substrates of gamma oscillations, previous studies reported that FS nonpyramidal cells in neocortical areas are unresponsive to cholinergic modulation. Dentate gyrus (DG) is an independent gamma oscillator in the hippocampal formation. However, in contrast to other cortical regions, the direct impact of mAChR activation on FS BC excitability in this area has not been investigated. Here, we show that bath-applied muscarine or carbachol, two mAChR agonists, depolarize DG BCs in the acute brain slices, leading to action potential firing in the theta-gamma bands in the presence of blockers of ionotropic glutamate and gamma-aminobutyric acid type A receptors at physiological temperatures. The depolarizing action persists in the presence of tetrodotoxin, a voltage-gated Na(+) channel blocker. In voltage-clamp recordings, muscarine markedly reduces background K(+) currents. These effects are mimicked by oxotremorine methiodide, an mAChR-specific agonist, and largely reversed by atropine, a non-selective mAChR antagonist, or pirenzepine, an M(1) receptor antagonist, but not by gallamine, an M(2/4) receptor antagonist. Interestingly, in contrast to M(1)-receptor-mediated depolarization, M(2) receptor activation by the specific agonist arecaidine but-2-ynyl ester tosylate down-regulates GABA release at BC axons-the effect is occluded by gallamine, an M(2) receptor antagonist. Overall, muscarinic activation results in a net increase in phasic inhibitory output to the target cells. Thus, cholinergic activation through M(1)-like receptor enhances BC activity and promotes the generation of nested theta and gamma rhythms, thereby enhancing hippocampal function and associated performance.

Abstract A23: PSA testing and prostate cancer mortality in an Asian population: Linking prevalence of elevated PSA and mortality rate

Background: In Asian populations, prostate cancer mortality (PCM) has been increasing with the increasing use of PSA testing.

Objectives: 1) To establish prevalence of elevated PSA at different cutpoints in Taiwan and to assess the predictive relationship of PSA with PCM. 2) To compare PCM between those with PSA tested and not tested from a cohort study.

Methods: Among the cohort, 231,937, who received standard medical screening examination between 1994 and 2006 at a private screening clinic, 46,951 subjects, aged at least 50 years old, had PSA test results. Age and education were adjusted to those of Taiwan to arrive at national PSA prevalence. PCM was compared between the PSA untested (38,596) and PSA tested group (24,176), with the latter including those with a self-reported history of prostate cancer (1,675).

Results: National prevalence of PSA was 8.8% (threshold at 4) and 1.9% (threshold at 10). With national mortality rate at 30.1/100,000, the chance of dying in ten years was 3.4%, 15.8% or 27.9% among those above threshold at 4, 10, or 15, respectively, yielding false positives rates, with mortality as the outcome, 96.4%, 84.2% or 72.1%, and false negative rates, 12%, 33% or 50%, respectively. Having PSA tested, when compared with not tested, was not associated with decreased mortality from prostate cancer, even though PSA tested group, a higher educational class, had significantly decreased mortality from all cause. Increasing PSA levels were associated with increasing HRs.

Conclusion: PSA value above standard threshold of 4 is common in this Asian population (one out of 11 for age 50 and older), but only one in 29 tested positive was expected to die from prostate cancer within the next 10 years. This 10-year probability increased when threshold was 10 (1/6) but was still low. The high false positive rate of PSA (97%) and the harm associated with intervention among Asians should be communicated to the elderly patients, in view of the particularly low mortality rate of this cancer.

Citation Information: Cancer Prev Res 2010;3(1 Suppl):A23.

Abstract B135: Mortality risks and life-shortening effect of hepatitis C virus infection: A prospective cohort study of 487,369 adults in Taiwan

Background: There has been emerging knowledge on the serious burden of diseases attributable to Hepatitis C carriers (HCV). However, the extent of the life time risk of HCV, when independently assessed, is as yet fully understood, particularly regarding associated risk factors that are amenable to reductions.

Objectives: We assessed the mortality risks and life-shortening effect of HCV, along with its associated risk factors, based on following up a large healthy cohort in Taiwan.

Methods: The cohort, consisting of 487,369 subjects, participated in a standardized medical screening program since 1994. Based on the hepatitis carrier status (either HBV or HCV or both), three sub-cohorts were created. As of 2007, 16,920 deaths were identified, including 1,383 liver cancer and 631 cirrhosis, with average follow up of 8.5 years. Hazard ratio (RR) was calculated using Cox proportionate hazard model. National prevalence was arrived at by standardizing age and educational status, a surrogate for socioeconomic status (SES) to those in Taiwan. Glomerular Filtration Rate (GFR) was calculated by MDRD equation.

Results: National Prevalence for HCV: 3.6% above age 20, and 6.6% above age 40 (male 6.0% and female 7.3%) increased with age and with lower SES. Rates of diabetes, hypertension, obesity, and HDL among HCV+ participants were significantly higher, but total cholesterol and triglycerides were lower. They had 35% more chronic kidney disease (CKD), with 54% more proteinuria and 13% more reduced GFR (13%). Cohort mortality results: HCV+ male participants had 7.37 years shorter than the total cohort at age 20, compared to 3.36 years for HBV+. In contrast to one out of 7 deaths (13.7%) in the total cohort was liver related, one out of two in the HCV+ sub-cohort. With HR for all-cause being 2.42, 58.7% of the deaths were HCV-related, larger than HBV counterparts (36.7%). The number of HCV related cirrhosis was 1/4 (28%) that of HCC, and HCV related risk, 10.74, was slightly smaller than that for HCC, 14.56. Nearly one out of 10 HCV+ coexisted with HBV (8.9%), and the risk became synergistic, with 2/3 of them dying from liver-related causes. Kidney cancer (5.46), diabetes (2.31), and stroke (1.91) were also significantly increased. In the order of ranking All Cause mortality risks among HCV+ subjects, diabetes (4.5), proteinuria (4.1), smoking (3.5), obesity (3.3), drinking (3.2) and hypertension (2.9) were all significantly increased.

Conclusion: The life expectancy of HCV+ carriers was shortened by 7.37–8.45 years. While the main effect was liver cancer and cirrhosis, HCV also involved kidney damage, producing proteinuria and reduced GFR, and led to an increased mortality from diabetes and stroke. The ranking order of reducible HCV risks were diabetes, CKD including proteinuria, smoking, obesity, drinking and hypertension.

Citation Information: Cancer Prev Res 2010;3(1 Suppl):B135.

Spatiotemporal analysis of air pollution and asthma patient visits in Taipei, Taiwan

Background

Buffer analyses have shown that air pollution is associated with an increased incidence of asthma, but little is known about how air pollutants affect health outside a defined buffer. The aim of this study was to better understand how air pollutants affect asthma patient visits in a metropolitan area. The study used an integrated spatial and temporal approach that included the Kriging method and the Generalized Additive Model (GAM).

Results

We analyzed daily outpatient and emergency visit data from the Taiwan Bureau of National Health Insurance and air pollution data from the Taiwan Environmental Protection Administration during 2000–2002. In general, children (aged 0–15 years) had the highest number of total asthma visits. Seasonal changes of PM₁₀, NO₂, O₃ and SO₂ were evident. However, SO₂ showed a positive correlation with the dew point (r = 0.17, p < 0.01) and temperature (r = 0.22, p < 0.01). Among the four pollutants studied, the elevation of NO₂ concentration had the highest impact on asthma outpatient visits on the day that a 10% increase of concentration caused the asthma outpatient visit rate to increase by 0.30% (95% CI: 0.16%~0.45%) in the four pollutant model. For emergency visits, the elevation of PM₁₀ concentration, which occurred two days before the visits, had the most significant influence on this type of patient visit with an increase of 0.14% (95% CI: 0.01%~0.28%) in the four pollutants model. The impact on the emergency visit rate was non-significant two days following exposure to the other three air pollutants.

Conclusion

This preliminary study demonstrates the feasibility of an integrated spatial and temporal approach to assess the impact of air pollution on asthma patient visits. The results of this study provide a better understanding of the correlation of air pollution with asthma patient visits and demonstrate that NO₂ and PM₁₀ might have a positive impact on outpatient and emergency settings respectively. Future research is required to validate robust spatiotemporal patterns and trends.

The development of bladder tumors and contralateral upper urinary tract tumors after primary transitional cell carcinoma of the upper urinary tract

BACKGROUND

Contralateral, metachronous upper urinary tract (UUT) tumors after primary transitional cell carcinoma (TCC) of the UUT are reported rarely, and to the authors' knowledge the risk factors have not been determined to date. In addition, few reports have described the characteristics of recurrent bladder tumors and contralateral UUT tumors and any relation between theses tumor types.

METHODS

Statistical analysis of data from 223 patients with documented primary UUT-TCC was undertaken. After excluding bilateral involvement and distant metastases, 12 variables were analyzed by multivariate analysis in 189 patients to determine the risk factors for recurrent urothelial tumors.

RESULTS

The incidence rates of recurrent bladder tumors and contralateral UUT tumors were 31.2% and 5.8%, respectively. Multiplicity was determined as a risk factor for recurrent bladder tumors. Renal insufficiency, uremia, and concurrent bladder tumors significantly predisposed patients to develop contralateral UUT tumors after primary UUT-TCC. The time intervals and stage distributions differed significantly between recurrent bladder tumors and contralateral UTT tumors. Patients who had recurrent bladder tumors had earlier stage tumors and had a shorter time to recur compared with patients who had contralateral, metachronous UUT tumors.

CONCLUSIONS

For patients with primary UUT-TCC, regular follow-up by cystoscopy is necessary to detect recurrent bladder tumors. Intravenous urography or retrograde pyelography should be performed for patients who have a high risk of developing contralateral UUT tumors.

Tracking the assembly pathway of human immunodeficiency virus type 1 Gag deletion mutants by immunogold labeling

The Pr55gag gene product of human immunodeficiency virus type 1 (HIV-1) is sufficient to direct the formation of retrovirus-like particles (RVLPs). Recent biochemical evidence has indicated the presence of Gag intermediates in the cytoplasm; however, the Gag assembly process into RVLPs remains incompletely defined. The authors present here the subcellular localization of Gag mutant proteins in BSC40 and Jurkat cells by immunoelectron microscopy (IEM). The full Gag/Pol and Gag precursors, a C-terminal deletion mutant lacking a portion of nucleocapsid (NC), and all p6Gag gave rise to similar levels of RVLPs at the cell surface. A C-terminal deletion of all NC and p6Gag abrogated particle formation, whereas p24 was found in patches at the cell surface. Deletion of matrix (MA) sequences from Gag resulted in intracellular particles, and myristylation was not required for particle formation in the context of the MA deletion. Matrix expression was enhanced with Gag/Pol or Env coexpression as determined by semiquantitative IEM. p24 protein was targeted at vacuolar and mitochondrial membranes, but not at Golgi cisternae. In addition, aggregations of Gag intermediates and RVLPs in the cytoplasm, rough endoplasmic reticulum, cisternae, and mitochondria were noted. These results provide defined in situ evidence that HIV-1 particle assembly occurs in the cytosol in addition to budding at most intracellular membranes.

Retroperitoneal laparoscopic nephrectomy in the treatment of incontinence from ectopic ureter with renal hypoplasia in the child--a case report

Unilateral single vaginal ectopic ureteral opening with ipsilateral hypoplastic kidney is a rare disease. It is classically presented with continuous urinary incontinence, but a normal voiding pattern after successful toilet training. The kidneys associated with this condition are usually nonfunctional and nephrectomy is the treatment of choice to cure the incontinence. We present a 7-year old girl with such a problem successfully treated by retroperitoneal laparoscopy. The patient resumed her normal unrestricted activity level on postoperative day 3. She was free of symptoms related to the operation during a 6-year follow-up period. It is suggested from this case that despite the reduced working space in children, retroperitoneal laparoscopic nephrectomy in the treatment of small kidney with complications is a feasible procedure.

Adenosine-stimulated intracellular calcium increase in cultured human uterine myocyte

The effect of adenosine on intracellular free calcium concentration ([Ca2+]i) was studied in human uterine myocyte. Adenosine 10(-6) M elicited a rapid followed by a maintained increase in [Ca2+]i in Fluo-3-loaded myocytes. Compared with basal [Ca2+]i level, adenosine induced a 2.6-fold increase in the absence of extracellular calcium, and a 2.4-fold increase in the presence of extracellular calcium. There was no significant difference between the two groups in the initial response. After depletion of intracellular calcium stores by repetitive caffeine (10 mM) applications, adenosine could not induce increase in [Ca2+]i. The initial rise could be induced in the absence of extracellular calcium, whereas the maintained phase after 120 s of adenosine application was dependent on the presence of extracellular calcium. The maintained phase response was 1.39- and 0.90-fold compared with basal [Ca2+]i level in the presence and absence of extracellular calcium respectively. There was significant (p < 0.01) maintenance of [Ca2+]i in the presence of extracellular calcium, which appeared to be associated with calcium influx. The data suggest that in human uterine myocytes, adenosine stimulates release of Ca2+ from intracellular stores and influx of extracellular Ca2+ through Ca2+ entry pathway.

Orthotopic bladder substitution in women using the ileal neobladder

Before 1990, orthotopic bladder substitution was limited to men and urethrectomy was routinely performed in women--making orthotopic reconstruction impossible. Following studies on pelvic exenteration for transitional cell bladder cancer patients, and after anatomic studies of the female urethra, the first report on orthotopic bladder substitution was published in 1994. Here, we present our ileal neobladder technique, which was applied for the treatment of bladder cancer in three women, and sigmoid colon cancer with vesical metastasis in one woman. This surgical procedure preserves the urethral sphincter, the endopelvic fascia, and the pubourethral ligaments. The innervation of the sphincter is also maintained. A 45-cm segment is isolated from the distal ileum and arranged in a W-shaped configuration. An anastomosis between the ileal bladder and the urethra is made and an antireflux ureteroileal implantation is created. Postoperatively, all patients reported daytime continence. The average urinary flow rate was 13.5 +/- 2.1 mL/sec 3 months after surgery. The reservoir had low pressure and high capacity. There was no reflux or deterioration of renal function. In properly selected female patients undergoing radical cystectomy, an ileal neobladder is now an option.

Intravesical mitoxantrone in superficial bladder cancer

Twenty-five patients with Ta-T1 transitional cell carcinoma of the bladder were treated by transurethral resection (TUR) followed by intravesical chemoprophylaxis with mitoxantrone (10 mg diluted in 50 ml normal saline) administered weekly for 6 weeks. After a mean follow-up of 12 months, 76% of patients in the whole group, 69% in the newly diagnosed patients and 89% in the group of previously relapsed patients remained relapse free. These rates compare favorably with the other prophylactic agents available. Therapy was well tolerated in most patients, with only two patients reporting grade 3 local toxicity. We conclude that mitoxantrone is an effective and safe agent for intravesical chemotherapy.

Molecular cloning and nuclear localization of a histone deacetylase homologue in Plasmodium falciparum

Reversible acetylation of core histones plays an important role in transcriptional regulation, cell cycle progression and developmental events. The acetylation state of histones is controlled by a dynamic equilibrium between activities of histone acetylase and deacetylase enzymes. Histone deacetylase (HDAC) was recently suggested to be the target of a fungus-derived antiprotozoal agent exhibiting structural similarity to known HDAC inhibitors. We have initiated a study of HDAC of human malaria parasite, Plasmodium falciparum, to evaluate its potential as the target for novel antimalarials and its role in parasite development. We have isolated HDAC1 gene from the P. falciparum genomic and cDNA libraries. The nucleotide sequence contains no intervening sequence and its open reading frame (ORF) codes for a protein of 449 amino acid residues. We have named the protein, PfHDAC1, as the sequence shows significant homology to yeast, human and other eukaryotic HDACs. Northern blot analysis of the total RNA from different asexual and sexual stages of the parasite reveals the presence of single mRNA transcript, which is predominantly expressed in mature asexual blood stages and in gametocytes. Antiserum raised against a carboxyl terminal peptide immunoprecipitated an in vitro translated P. falciparum HDAC gene product and recognized an approximately 50 kDa protein in the Triton X-100 insoluble fraction of parasites. Immunoelectron microscopy analysis showed majority of the protein localized in the nucleus of P. falciparum. To our knowledge, this is the first HDAC gene isolated from the malaria parasite.

Hysteroscopic resection of vaginal septum in an adolescent virgin with obstructed hemivagina

This article reports on one patient with a double uterus, unilateral vaginal obstruction, with hemi-haematocolpos and ipsilateral renal agenesis. Early accurate diagnosis followed by the excision of the obstructing vaginal septum offers complete relief of symptoms, while preserving reproductive capacity. Unlike conventional excision of vaginal septum, we used resectoscope excision with cutting electrode under continuous pure distilled water irrigation. The postoperative course was uneventful, and haematocolpos and severe dysmenorrhoea disappeared. The resected vaginal area revealed re-epithelialization by hysteroscope follow-up one year after resection. With advancements in resectoscopic operation, evaluation and treatment of vaginal disorders in babies and virgins is very feasible.

The experiences of rectosigmoid pouch as a continent urinary diversion after radical cystectomy

Thirty-five patients receiving cystectomy underwent rectosigmoid pouch. The technique of ureteral submucous implantation was described. The follow-up results were analyzed. The relationship of postoperative voiding frequency and preoperative anal closure pressure was assessed. The day and night time continence rate is 97% (34/35). There were no hydronephrosis, no ureterocolonic stricture or reflux. The complications are not unique to rectosigmoid pouch and not high when compared with other forms of urinary diversion. When the preoperative anal closure pressure reaches nearly 100 cmH2O a postoperative outcome with good quality of life will be predicted. With the advantages of high continence rate and simplicity of performance the rectosigmoid pouch will become one of the alternative forms of continent urinary diversion. For obtaining the favorable results a patient with normal renal function, good hepatic function and anal closure pressure more than 50 cmH2O is required.

Pilot study of transurethral needle ablation (TUNA) in treatment of nonbacterial prostatitis

Transurethral needle ablation (TUNA) was performed on seven patients with chronic nonbacterial prostatitis who failed to respond to conventional treatments administered for more than half a year. The TUNA procedure heated the prostate to a temperature ranging from 90 degrees to 100 degrees C while the urethral temperature was maintained below 43 degrees C by a protective sheath and irrigation. After treatment, four patients showed complete resolution of symptoms and three a partial improvement. All patients had a decrease in the leukocyte count in expressed prostatic secretions (EPS) 1 month after treatment. Recurrence of abnormal inflammatory cells in the EPS was noted in two patients at 3 months after treatment. The subjective improvement has been maintained during the subsequent follow-up. From these results, TUNA is considered to be an effective, safe, and easy treatment for most patients with nonbacterial prostatitis.

Nerve-sparing radical cystoprostatectomy: 3-year experience

From June 1993 through January 1996, ten men underwent nerve-sparing radical cystoprostatectomy for carcinoma of the bladder. We describe a modification of surgical technique in which the puboprostatic ligaments are left intact and dissection of neurovascular bundle is performed immediately after the ligation of dorsal vein complex. Rigiscan was performed in 7 patients and 4 patients had good rigidity. Color duplex sonography revealed 8 of 10 patients had peak systolic velocity over 30 cm/sec after the injection of prostaglandin E1. Maintenance of sexual function was stated by seven (70%) patients. These is no positive surgical margin. We conclude that the nerve-sparing modifications are possible to preserve potency in most men undergoing radical cystoprostatectomy and do not compromise cancer control.

Transurethral needle ablation of the prostate (TUNA) in the treatment of chronic urinary retention

The transurethral needle ablation (TUNA) of the prostate was performed in 8 patients in chronic urinary retention, all of whom were a poor surgical risk. A special catheter device was used to deliver low-level radiofrequency energy to heat tissue within the prostate to 100 degrees C. After treatment, uroflowmetry, symptom score and quality of life score were evaluated. Tolerance of the procedure with topical anesthesia was satisfactory. Of the 8 patients, 6 (75%) resumed voiding within a mean time of 9.2 days (range 1-21). The mean maximal flow rate was 9.8 +/- 3.2 ml/s (range 5.9-14). Failure to void was associated with a decompensated detrusor function. We conclude that TUNA is effective for patients with urinary retention due to benign prostatic hyperplasia. It seems particularly suitable for treating elderly patients with a high surgical risk.

Effects of adenyl purines in human uterine arteries and uterine myometrium

This in vitro study was undertaken to investigate the effects of adenyl purines in human uterine myometrium and uterine arteries. Segments of uterine myometrium and uterine arteries obtained at hysterectomy were isolated and mounted in tissue chambers. The muscle activity was recorded by polygraph. Adenyl purines agonists, such as adenosine, N-[(R)-1-methyl-2 phenylethyl]-adenosine (R-PIA) and 5-N-ethylcarboxamide adenosine (NECA) produced concentration-dependent contraction in human uterine myometrium. The potency order was NECA = R-PIA > adenosine. Adenosine A1 receptor antagonist: 1, 3-dipropyl-8-cyclopentylxanthine (DPCPX) blocked the effect of adenosine in human uterine myometrium. Otherwise, adenyl purines induced dose-dependent relaxation in human uterine artery precontracted by phenylephrine (PE, 10(-5)M). The potency gradient was NECA > R-PIA > adenosine; the results indicate adenyl purine induces uterine myometrium contraction via A1 receptor. However, adenosine causes uterine artery relaxation by A2 receptor.

Adenosine modulation of neurotransmission in human uterine arteries

The relaxing effects of adenosine, N-[(R)-1-methyl-2 phenylethyl]-adenosine (R-PIA) and 5-N-ethylcarboxamide adenosine (NECA) were investigated in human uterine arteries precontracted by phenylephrine in vitro. Adenosine, R-PIA and NECA relaxed isolated uterine arteries with intact endothelium, the potency order was NECA > R-PIA > adenosine. When tested on vessels devoid of their endothelium, the relaxing effect of adenosine was the same. These results suggest the vasodilatation effect on human uterine arteries is endothelium-independent, and might be via the A2 receptor (by pharmacological classification). By administering adenosine to human uterine arterial cell culture, single cell intracellular calcium change was also determined by laser cytometry. Decreased intracellular calcium was observed after administration of adenosine 10(-6) M and 2 x 10(-6) M. We concluded from the results that adenosine acts on human uterine artery cell by A2 receptor, independently of the endothelium, and decreases the intracellular calcium concentration, thus causing uterine artery relaxation.

Recent experience of penile fracture (1989-1993)

Penile fracture is an uncommon injury in the genitourinary organ which occurs following a blunt injury on the rigid penis. Penile fracture with urethral injury is even rarer. A total of 11 new patients with penile fracture were treated at our institution from 1989 to 1993. All of these injuries occurred during sexual intercourse and received immediate surgical repair to preserve the sexual function. Only one patient with complete transection of the urethra received end-to-end anastomosis of the urethra. Unfortunately, he suffered from urethral-cutaneous fistula ten days later. Suprapubic urinary diversion was performed in 3 patients with partial urethral tearing, and they enjoyed satisfactory outcomes during the limited follow-up. Immediate surgical repair of tunica albuginea is recommended for preserving penile function. If associated with partial urethral tear, suprapubic urinary diversion is sufficient to treat urethral lesions.

Adenosine modulation of neurotransmission in penile erection

1. Adenosine inhibited the noradrenaline-induced contraction of rabbit corpus cavernosum in a dose-dependent manner. The effect of adenosine was greater in intact corpus cavernosa than in endothelium-denuded preparations. This finding indicates that the relaxing effect of adenosine is partially endothelium-dependent and involved in the release of endothelium-derived relaxing factors. 2. Adenosine and its analogues relaxed the noradrenaline-induced contractile response as well as inhibited the transmural nerve induced contraction with the potency order: NECA > R-PIA > adenosine. These data indicate that adenosine can modulate both the non-adrenergic non-cholinergic and adrenergic neurotransmission. DMPX, an adenosine antagonist selective for the A2 receptors, abolished the electrically elicited relaxation. However, CGS 21680, selective for A2a receptor, had no effect on relaxation. Therefore, adenosine receptors involved in the modulation of neurotransmission in rabbit corpus cavernosum appear to be A2b subtype. 3. Adenosine also induced an increase in human cavernosal arterial velocity and resistive index measured by colour duplex sonography. The combination of adenosine and 10 micrograms prostaglandin E1 was more effective in resistive index and erection grade than 20 micrograms prostaglandin E1 alone. Our results suggest that adenosine seems to be an important neuromodulator for penile erection and can be an effective and alternative combination in the treatment of impotence.

The role of trazodone in the treatment of erectile dysfunction

The effects of trazodone on the nocturnal penile erection were demonstrated in 14 impotent patients by Rigiscan recordings. Trazodone significantly increased the total erectile time, per cent of sleep with erection and maximum rigidity, while it had no effect on increment of tumescence size. Trazodone (150 mg to 200 mg) was administered to 35 clearly organic impotent patients in a 5-week single-blind design. Patients were evaluated by questionnaire. The study showed an improvement in 68.6 per cent of the patients receiving trazodone versus 11.4 per cent receiving placebo. In vitro, trazodone could relax rabbit corporeal smooth muscle contractions induced by exogenous norepinephrine and inhibit contractions elicited by transmural electrical stimulation of adrenergic nerve endings. The effects of trazodone on penile erection may be due to a peripheral alpha adrenoceptor antagonism and central unknown mechanism. We conclude that trazodone may prove an effective treatment for impotent patients.

The altered expression of cytokeratin polypeptides in carcinomas of human bladder

After extraction in high salt buffers and Triton X-100, cytokeratin polypeptides could be isolated from normal epithelium and transitional cell carcinoma of the human bladder in the southwestern coast of Taiwan. The polypeptides were solubilized via lysis buffer, separated by two-dimensional gel electrophoresis, and identified by immunoblot. Five cases of normal epithelium expressed cytokeratin No. 5 (58 kd), 7 (54 kd), 18 (45 kd) and one case further expressed cytokeratin No. 19 (40 kd) in addition to the above cytokeratins. Combined patterns of cytokeratin polypeptides were observed among various Grades of transitional cell carcinoma of bladder. Comparing the patterns between the normal epithelium and the transitional cell carcinoma of bladder, 88% (14/16) of carcinomas expressed cytokeratin No. 8 (52.5 kd) and 63% (10/16) expressed No. 17 (46 kd), which were not seen in the normal epithelium. Some other cytokeratin polypeptides particular to carcinomas were No. 4 (59 kd), No. 10 (56.5 kd), No. 13 (54 kd) and No. 14 (50 kd) and were only present in less than 50% (ranging from 31-56%) of the examined specimens. Thus cytokeratin No. 8 and 17 could be helpful markers for diagnosis of bladder carcinoma.

Adenosine stimulates human sperm motility via A2 receptors

The effects of adenosine and its analogues on human sperm motility were studied using a transmembrane migration method. Specific binding sites for adenosine in human sperm were also investigated. Adenosine and 5'-N-ethylcarboxamidoadenosine (NECA) stimulated human sperm motility with similar efficacies and the maximal amplitudes of motility increases were both about 70%. 3,7-Dimethyl-1-propargylxanthine (DMPX), a potent A2 antagonist, competitively antagonized NECA-induced motility stimulation. Successively higher concentrations of DMPX shifted the dose-response curve of NECA to the right in a nearly parallel fashion. Dipyridamole, an inhibitor of adenosine uptake, does not reduce the ability of adenosine to stimulate human sperm motility. In radioligand-binding studies, adenosine A1 selective analogues, cyclopentyl-1,3-dipropylxanthine and 1-methyl-2-phenylethyl adenosine, have little competitive effect on [3H]NECA binding in human sperm membrane. These results provide evidence that adenosine enhances human sperm motility via adenosine A2 receptors on the surface of sperm membranes.

Transitional cell carcinoma of the renal pelvis and ureter in Taiwan. DNA analysis by flow cytometry

BACKGROUND

The incidence of upper urinary tract tumors is relatively high in southern Taiwan. DNA analysis by means of flow cytometry is not well investigated with regard to tumors of the upper urinary tract and the differences in DNA ploidy between transitional cell carcinomas in endemic and nonendemic areas.

METHODS

A retrospective nuclear DNA ploidy analysis by flow cytometry comprised 41 formaldehyde solution-fixed, paraffin-embedded tissue specimens of transitional cell carcinoma of the renal pelvis and ureter. The preparation of nuclear suspensions from paraffin-embedded tissue blocks and staining were modified by means of the techniques of Hedley and Vindeløv.

RESULTS

There was no statistical correlation between DNA ploidy, histologic grade, and pathologic stage, however, 82% of the DNA nondiploid tumors showed tumor progression. In contrast, only 46% of the DNA diploid tumors revealed tumor progression. Among Grade 2 tumors, 85% of the DNA nondiploid tumors showed postoperative tumor progression, whereas only 31% of the DNA diploid tumors showed tumor progression. Seventy-nine percent of the nondiploid patterns were present in patients native to the Pa Chang Valley, where the so-called "blackfoot disease" and urothelium tumor are endemic, whereas only 22% appeared in patients living in other areas.

CONCLUSIONS

DNA flow cytometry can identify a group of patients with poor outcome unpredictable by pathologic examination, and is an important tool in research into the pathogenesis of cancer.