Association of Cognitive Performance with Frailty in Older Individuals with Cognitive Complaints

OBJECTIVES

Frailty is a risk factor for poor cognitive performance in older adults. However, few studies have evaluated the association of cognitive performance with frailty in a low- to middle-income country (LMIC). This study aimed to investigate an association between cognitive performance and frailty in older adults with memory complaints in Brazil. Secondarily, we aim to assess an association of cognitive performance with gait speed and grip strength.

DESIGN

Cross-sectional study.

SETTING

Outpatient service from a LMIC.

PARTICIPANTS

Older adults with memory complaints reported by the participants, their proxies, or their physicians.

MEASUREMENTS

Frailty was evaluated using the Cardiovascular Health Study criteria. A neuropsychological battery evaluated memory, attention, language, visuospatial function, executive function. Linear regression analysis with adjustment for age, sex, and education was used. We also evaluated the interaction of education with frailty, grip strength, and gait speed.

RESULTS

Prefrailty was associated with poor performance in the memory domain, as well as slower gait speed was associated with worse performance in memory, attention, language, and executive function. Frailty and grip strength were not associated with cognitive performance. Interactions of education with gait speed were significant for global performance, as well as for attention and visuospatial ability.

CONCLUSION

In elderly patients with memory complaints, prefrailty was associated with poor memory performance. Slowness was associated with poorer performance in some cognitive domains, mainly in participants with low education.

[Construction of artificial neural network model for predicting the efficacy of first-line FOLFOX chemotherapy for metastatic colorectal cancer]

Objective: To explore and establish an artificial neural network (ANN) model for predicting the efficacy of first-line FOLFOX chemotherapy for metastatic colorectal cancer. Methods: A set of FOLFOX chemotherapy data from a group of patients with metastatic colorectal cancer (mCRC) (GSE104645) was downloaded from the GEO database as a training set. According to the FOLFOX protocol, the efficacy was divided into two groups: the chemo-sensitive group (including complete response and partial response) and the chemo-resistant group (including stable disease and progressive disease), including 31 cases in the sensitive group and 23 in the resistant group. Then, chip data (accessible number: GSE69657) from Fujian Medical University Union Hospital were chosen as a test set. A total of 30 patients were enrolled in the study, including 13 in the sensitive group and 17 in the resistant group. The batch effect correction was performed on the expression values of the two sets of matrices using the R 3.5.1 software Combat package. The gene expression difference of sensitive and resistant group in GSE104645 was analyzed by the GEO2R platform. P<0.05 and the absolute value of log(2)FC>0.33 (FC abbreviation of fold change) were used as the threshold value to screen the drug resistance and sensitive genes of the FOLFOX regimen. An ANN was constructed using the multi-layer perceptron (MLP) to perform the FOLFOX regimen on the GSE104645 dataset. The GSE69657 expression matrix and clinical efficacy parameters were then used for retrospective verification. Receiver operating characteristic(ROC) curves were used to evaluate the test results and predictive power. Results: A total of 2, 076 differentially expressed genes in GSE104645 were selected, of which 822 genes were up-regulated and 1, 254 genes were down-regulated in the chemo-resistance group. The down-regulated genes were sensitive genes. GO analysis of the biological processes in which the differentially expressed genes were involved, revealed that they were mainly involved in the regulation of substance metabolism. A total of 39 genes were included in the final model construction. This was a neural network model with two hidden layers. The accuracy of predicting training samples and test samples was 75.7% and 76.5%, respectively, and the area under the ROC curve was 0.875. The chip data set of our department (GSE69657) was set as the test set, and the area under the ROC curve was 0.778. Conclusions: In this study, an artificial neural network model is successfully constructed to predict the efficacy of first-line FOLFOX regimen for metastatic colorectal cancer based on the microarray, and an independent external verification is also conducted. The model has good stability and well prediction efficiency. Besides, the results of this study suggest that the gene functions related to oxaliplatin resistance are mainly enriched in the regulation process of substance metabolism.

[Establishment of clinical features and prognostic scoring model in early-stage hepatitis B-related acute-on-chronic liver failure]

Objective: To explore the clinical characteristics and establish a corresponding prognostic scoring model in patients with early-stage clinical features of hepatitis B-induced acute-on-chronic liver failure (HBV-ACLF). Methods: Clinical characteristics of 725 cases with hepatitis B-related acute-on-chronic hepatic dysfunction (HBV-ACHD) were retrospectively analyzed using Chinese group on the study of severe hepatitis B (COSSH). The independent risk factors associated with 90-day prognosis to establish a prognostic scoring model was analyzed by multivariate Cox regression, and was validated by 500 internal and 390 external HBV-ACHD patients. Results: Among 725 cases with HBV-ACHD, 76.8% were male, 96.8% had cirrhosis base,66.5% had complications of ascites, 4.1% had coagulation failure in respect to organ failure, and 9.2% had 90-day mortality rate. Multivariate Cox regression analysis showed that TBil, WBC and ALP were the best predictors of 90-day mortality rate in HBV-ACHD patients. The established scoring model was COSS-HACHADs = 0.75 × ln(WBC) + 0.57 × ln(TBil)-0.94 × ln(ALP) +10. The area under the receiver operating characteristic curve (AUROC) of subjects was significantly higher than MELD, MELD-Na, CTP and CLIF-C ADs(P < 0.05). An analysis of 500 and 390 cases of internal random selection group and external group had similar verified results. Conclusion: HBV-ACHD patients are a group of people with decompensated cirrhosis combined with small number of organ failure, and the 90-day mortality rate is 9.2%. COSSH-ACHDs have a higher predictive effect on HBV-ACHD patients' 90-day prognosis, and thus provide evidence-based medicine for early clinical diagnosis and treatment.

[Solitary fibrous tumor/hemangiopericytoma of central nervous system: a clinicopathologic analysis of 71 cases]

Objective: As solitary fibrous tumor (SFT) and hemangiopericytoma (HPC) share the same molecular genetics features, the 2016 WHO classification of central nervous system (CNS) tumors had created the combined term SFT/HPC and assigns three grades. This study aims to investigate the clinicopathologic characteristics, diagnosis, differential diagnosis and prognosis of CNS SFT/HPC. Methods: Seventy-one cases of CNS SFT and HPC were retrospectively reclassified and studied. Histopathological, immunohistochemical and imaging features were analyzed. The follow-up data were analyzed. Results: There were 37 male and 34 female patients. The median age was 48 years (range, 3-77 years). Twelve cases (17%) were WHO grade Ⅰ, 26 (37%) were WHO grade Ⅱ and 33 (46%) were WHO grade Ⅲ. Microscopically the tumor could show traditional SFT phenotype, HPC phenotype or mixed phenotype. Immunochemically, 97%(69/71) were positive for STAT6, with 96%(66/69)showing diffuse strong staining. Approximately 90% were diffusely positive for bcl-2, CD99 and vimentin. The expression rate of CD34 decreased with increasing tumor grade, and the mean expression rate was 78%. SSTR2a was variably expressed in 10% (7/71) of cases including one case showing strong cytoplasmic staining. A few cases expressed EMA, CD57 and S-100 focally. The Ki-67 index ranged from 1% to 50%. Thirty four patients were followed up for 8-130 months; 12 patients(35%)had recurrences, and two (6%) had liver metastases. Conclusions: CNS SFT/HPC is relatively uncommon. There was significant morphological overlap or transition between different grades. STAT6 is a specific marker for the diagnosis of this tumor. Surgical resection is the preferred treatment. WHO grade Ⅱ and Ⅲ SFT/HPC show rates of local recurrence and systemic metastasis, with liver being the most common site of extracranial metastasis.

Association of cyclin D1 and survivin expression with sensitivity to radiotherapy in patients with nasopharyngeal carcinoma

The association between cyclin D1 and survivin protein expressions with radiotherapy sensitivity in patients with nasopharyngeal carcinoma was investigated. Biopsy specimens of 72 patients with nasopharyngeal carcinoma were collected before the initiation of radiotherapy (49 cases were in the radiation-sensitive group and 23 cases were in the radiation-insensitive group). Conventional hematoxylin and eosin staining was used for tissue typing. The immunohistochemical SP method was used to detect cyclin D1 and survivin protein expression levels. The IBM SPSS Statistics 20 statistical software was applied for conducting the chi-squared test and the Spearman correlation analysis. In the 72 cases, the high expression rates of cyclin D1 were 28.6% (14/49) and 69.6% (16/23) in the radiotherapy-sensitive group and in the radiotherapy-insensitive group, respectively, and the differences between groups were statistically significant (P<0.05). The high expression rates of survivin were 34.7% (17/49) and 73.9% (17/23) in the radiotherapy-sensitive group and in the radiotherapy-insensitive group, respectively, which differed significantly (P<0.05). The protein expressions of cyclin D1 and survivin were positively correlated (Spearman's r=0.353, P<0.05). Cyclin D1 and survivin expression levels were negatively correlated with the radiosensitivity of nasopharyngeal carcinoma. Cyclin D1 and survivin may be used as molecular markers to predict the sensitivity of radiotherapy.

Exploring the FDA adverse event reporting system to generate hypotheses for monitoring of disease characteristics

The US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) is a database for postmarketing drug safety monitoring and influences changes in FDA safety guidance documents such as drug labels. The number of cases in the FAERS has rapidly increased with the improvement of submission methods and data standards and thus has become an important resource for regulatory science. Although the FAERS has been predominantly used for safety signal detection, this study explored its utility for disease characteristics.

An early decrease in serum HBeAg titre is a strong predictor of virological response to entecavir in HBeAg-positive patients

Quantification of HBeAg levels has been found to be useful in monitoring and predicting the outcomes of interferon and lamivudine treatment in HBeAg-positive patients. The aim of this study was to determine whether quantification of HBeAg at baseline and on treatment could predict which patients would achieve HBeAg seroconversion after 96 weeks of entecavir therapy. Sixty-five HBeAg-positive naïve chronic hepatitis B patients who were treated with entecavir at a dose of 0.5 mg once daily for 96 weeks were evaluated. Serum HBV DNA levels were assessed at baseline, week 24, 48 and 96; serum HBeAg levels were assessed at baseline, week 12, 24, 48, 72 and 96. Serum HBeAg levels were associated with a higher likelihood of HBeAg seroconversion to entecavir at weeks 96 than serum HBV DNA levels both at baseline and on treatment (at baseline: OR = 9.932, P = 0.003 vs. OR = 5.045, P = 0.036; on treatment: OR = 112.5, P < 0.0001 vs. OR = 47.782, P < 0.0001). A maintained reduction in HBeAg > 65% of pretreatment HBeAg values after 24 weeks of entecavir therapy is the strongest predictor for HBeAg seroconversion at week 96 (OR = 70.578, P < 0.0001). Quantification of HBeAg at the start and early during therapy showed a higher predictive value than that of HBV DNA for HBeAg seroconversion by entecavir. A significant decrease in serum HBeAg levels at week 24 may be a useful on-treatment measurement in the early phase for predicting HBeAg seroconversion and identifying patients who will most likely benefit from finite entecavir treatment.

Assessing sources of inconsistencies in genotypes and their effects on genome-wide association studies with HapMap samples

The discordance in results of independent genome-wide association studies (GWAS) indicates the potential for Type I and Type II errors. We assessed the repeatibility of current Affymetrix technologies that support GWAS. Reasonable reproducibility was observed for both raw intensity and the genotypes/copy number variants. We also assessed consistencies between different SNP arrays and between genotype calling algorithms. We observed that the inconsistency in genotypes was generally small at the specimen level. To further examine whether the differences from genotyping and genotype calling are possible sources of variation in GWAS results, an association analysis was applied to compare the associated SNPs. We observed that the inconsistency in genotypes not only propagated to the association analysis, but was amplified in the associated SNPs. Our studies show that inconsistencies between SNP arrays and between genotype calling algorithms are potential sources for the lack of reproducibility in GWAS results.

[Effect of very early kangaroo care on extrauterine temperature adaptation in newborn infants with hypothermia problems]

Increased morbidity and mortality has been associated with neonates admitted with body temperatures below 36 degrees C. We employed an experimental design in a randomized control trial to compare the effectiveness of using early kangaroo care (KC) for extrauterine temperature adaptation against that of using radiant warmers. Trial subjects included 78 consecutive cesarean newborn infants with hypothermia problems. The KC group received skin-to-skin contact with their mothers in the post-operative room, while infants in the control group received routine care under radiant warmers. The mean temperature of the KC group was slightly higher than that of the control group (36.29 degrees C vs. 36.22 degrees C, p = .044). After four hours, 97.43% of KC group infants had reached normal body temperatures, compared with 82.05% in the radiant warmer group. Results demonstrate the positive effects of KC for extrauterine temperature adaptation in hypothermia infants. In the course of evidence-based practice, KC could be incorporated into the standard care regimen in order to improve hypothermia care.

Association of Single Nucleotide Polymorphisms of the Insulin Gene with Chicken Early Growth and Fat Deposition

Growth rate, body composition, and fat deposition are important traits in chickens. Insulin plays important roles in hepatic cells, muscle cells, and adipose tissue cells. The purpose of the present study was to analyze association of the insulin (INS) gene with chicken growth and body composition traits. Using a F2 design resource population constructed with the crossing of Chinese native Xinghua chickens and White Recessive Rock chickens, the association of 4 single nucleotide polymorphisms (SNP; A+428G, C+1549T, T+3737C, and A+3971G) of INS gene with 13 growth and body composition traits was studied. The T+3737C genotypes were significantly associated with small intestine length (P = 0.0002), and the A+3971G genotypes were significantly associated with early growth (hatch weight and BW at 28 d of age) (P < 0.0001), breast angle (P = 0.0002), and small intestine length (P < 0.0001). None of the 4 SNP was significantly associated with abdominal fat pad weight (P > 0.05). The haplotypes based on the 4 SNP were also significantly associated with early growth (hatch weight and BW at 28 d of age; P < 0.0001) and breast angle (P < 0.0001) but not with small intestine length (P = 0.0505). These results suggested that variation of the insulin gene was significantly associated with chicken early growth but not with fat deposition. In addition, the data from the present study supported the inference that both the one-SNP-at-a-time and the haplotype-based approaches have their own advantages and disadvantages when association analysis of one SNP and haplotypes with chicken complex traits was conducted.

Reduction of subretinal fluid after preoperative immobilization of the eyes with rhegmatogenous retinal detachment

BACKGROUND

Bullous retinal detachment may be difficult to handle with higher operative complications. Preoperative immobilization of the eyes might reduce subretinal fluid and facilitate surgical procedures. Factors influencing subretinal fluid absorption were analyzed.

METHODS

Twenty-eight eyes with primary rhegmatogenous retinal detachment with preoperative binocular patching and complete bed rest for at least 12 hours were enrolled. Ultrasonography was performed before and after immobilization to estimate the reduction in subretinal fluid.

RESULTS

The amount of reduction diverged in cases with an average of a 17.1% decrease in the maximal height of detachment. Retinal detachments in patients with smaller breaks and without vitreal traction or chronicity showed more significant reduction of subretinal fluid than did those patients with larger breaks and with vitreal traction or chronicity. On the other hand, break shape, height of retinal detachment, age, and gender had no obvious effect on subretinal fluid change.

CONCLUSIONS

Preoperative immobilization of the eyes reduces the subretinal fluid in selected cases, which can decrease operative complications. Break size, vitreal traction, and chronicity are important factors affecting the absorption of subretinal fluid.

Reversal of mivacurium chloride: edrophonium of spontaneous recovery in microscopic laryngeal surgery

BACKGROUND

A double-blind, randomized study was designed to compare the recovery manner of mivacurium infusion with or without edrophonium reversal in microscopic laryngeal surgery. Neuromuscular blockade was quantified using the train-of-four stimuli to the ulnar nerve and quantification of the ratio of the fourth twitch to the first twitch.

METHODS

With the approval of the Human Studies Committee of the Taipei Veterans General Hospital and patient informed consent, 40 healthy (ASA I or II) patients with age from 24 to 54 years, undergoing microscopic laryngeal surgery were randomly selected for study. Mivacurium chloride 0.2 mg/kg was given intravenously, and then it was given in continuous infusion to maintain muscle relaxation at 90% twitch block during the procedure. At the end of operation, mivacurium infusion was terminated. In a double-blind manner, group I patients (n = 20) received intravenous edrophonium 1 mg/kg and atropine 0.01 mg/kg for reversal when T1 was at 10% recovery whereas patients in Group II (n = 20) received placebo in the same manner. Mean infusion rate, recovery index (RI50, time from T1 25% to T1 50%; RI75, time from T1 25% to T1 75%), extubation time, and discharge time between groups were compared. Nausea, vomiting, and dysrhythmias were also documented until the patient was discharged from hospital.

RESULTS

The demographic data between two groups were similar. The recovery index (RI75) for group I was shorter than that of placebo group (5.3 +/- 2.19 min vs. 7.3 +/- 0.9 min) and the difference was statistically significant (P = 0.017). There were no statistically significant differences in mean infusion rate, incidence of nausea and vomiting, and discharge time from the POR. The incidence of tachycardia or arrhythmia in group I was significantly greater than that in group placebo.

CONCLUSIONS

Mivacurium, a short-acting nondepolarizing agent, is a suitable muscle relaxant for patients receiving microscopic laryngeal surgery. Recovery time with the use of edrophonium as reversal agent was shorter than with placebo, but extubation and discharge time did not differ in two groups. The time which could be saved by the use of edrophonium for reversal of mivacurium to hasten the maximal recovery appears to be less than a few minutes. Therefore, clinically, the value of routine use of edrophonium to obtain a faster recovery does not outweigh its demerits of cost and risk and is not worthy of recommendation.

Hormonal markers and hepatitis B virus-related hepatocellular carcinoma risk: a nested case-control study among men

BACKGROUND

The incidence of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) is higher in men than in women. We examined whether endogenous sex hormone levels or hormone-related factors might affect the risk of HCC in men.

METHODS

Baseline blood samples were collected from 4841 male Taiwanese HBV carriers without diagnosed HCC from 1988 through 1992. Plasma testosterone and estradiol levels and genetic polymorphisms in the hormone-related factors cytochrome P450c17 alpha (CYP17, A1 versus A2 alleles), steroid 5 alpha-reductase type II (SRD5A2, valine [V] versus leucine [L] alleles), and androgen receptor (AR, number of CAG repeats) were assayed among 119 case patients who were diagnosed with HCC during 12 years of follow-up and 238 control subjects. All statistical tests were two-sided.

RESULTS

The risk of HCC increased with increasing concentrations of testosterone (odds ratio [OR](highest versus lowest tertile) = 2.97; 95% confidence interval [CI] = 1.54 to 5.70; P(trend) <.001) and with increasing number of the V allele of the SRD5A2 V89L polymorphism (OR(VV versus LL genotype) = 2.47; 95% CI = 1.21 to 5.03; P(trend) =.011). Fewer AR gene CAG repeats (<23 repeats) were associated with a 1.64-fold (95% CI = 1.00 to 2.68) increased risk of HCC. Although the CYP17 genotype alone did not increase the risk of HCC, there was evidence of a gene-gene interaction, because the CYP17 A1 allele statistically significantly increased the risk of HCC in the presence of fewer AR gene CAG repeats (OR = 2.51; 95% CI = 1.06 to 5.94). We found a similar interaction between the SRD5A2 VV genotype and fewer AR gene CAG repeats (OR = 5.58; 95% CI = 1.86 to 16.71). Body mass index (BMI) modified the association of HCC with testosterone and SRD5A2 genotype; in men with low BMI, multivariate-adjusted ORs for the highest tertile of testosterone versus the lowest and the SRD5A2 VV genotype versus the LL genotype were 7.63 (95% CI = 2.13 to 27.27) and 8.64 (95% CI = 2.75 to 27.14), respectively. No clear associations were found between estradiol or testosterone-to-estradiol ratio and HCC.

CONCLUSIONS

Pathways involving androgen signaling may affect the risk of HBV-related HCC among men.

Intralesional injection for hepatic metastasis from cervical carcinoma. A report of two cases

BACKGROUND

The treatment of isolated hepatic metastasis from carcinoma of the uterine cervix has yet to be established. We tested the efficacy of percutaneous injection of ethanol and acetic acid as a curative-intent treatment modality for this rare event.

CASES

Under real-time sonographic guidance, two patients with a solitary hepatic metastasis from carcinoma of the cervix were treated with 99.5% percutaneous ethanol injection (one patient) and 50% percutaneous acetic acid injection (the other patient). The treatment was repeated weekly if laboratory data permitted and aspiration cytology interpreted on site showed tumor cells. Cytology after complete treatment showed no residual tumor cells in either case. Both patients had no evidence of disease during follow-up for 12 and 24 months, respectively.

CONCLUSION

Treatment was successful in two patients with isolated hepatic metastatic lesions from carcinoma of the cervix who received percutaneous injection of 99.5% ethanol or 50% acetic acid.

Anesthetic management of parturients with Eisenmenger's syndrome--report of two cases

Pregnancy is badly tolerated in patients with Eisenmenger's syndrome; maternal mortality with coherent fetal morbidity is high. Even with the advancement of both obstetric and anesthetic managements, the maternal mortality still exceeds 25%. Once conception occurs in patients of Eisenmenger's syndrome with severe pulmonary hypertension, interruption of pregnancy is still the best manipulation to be recommended. We report two cases of parturients with Eisenmenger's syndrome, who underwent termination of pregnancy. In this report, the obstetric and anesthetic management of this kind of parturients with Eisenmenger's syndrome has been thoroughly discussed.

Critical assessment of microarray data analysis: the 2001 challenge

We initiated the Critical Assessment of Microarray Data Analysis (CAMDA) conference to stimulate and evaluate the development of advanced data analysis techniques for microarrays. A standard data set has been released for this data analysis challenge. The goal of this challenge is to assess the performance of different analytical methods and at the same time to determine how such methods should be evaluated. We hope this effort will catalyze the discussion of microarray data analysis among the research community of biologists, statisticians, mathematicians, and computer scientists.

AVAILABILITY

http://camda.duke.edu.

Overexpression of manganese superoxide dismutase suppresses tumor formation by modulation of activator protein-1 signaling in a multistage skin carcinogenesis model

Manganese superoxide dismutase (MnSOD) is a nuclear encoded primary antioxidant enzyme localized in mitochondria. Because expression of MnSOD plays a major role in maintaining cellular redox status and reactive oxygen species are known to play a role in signal transduction and carcinogenesis, we investigated the role of MnSOD in the development of cancer using a two-stage [7,12-dimethylbenz(a)-anthracene plus 12-O-tetradecanoylphorbol-13-acetate (TPA)] skin carcinogenesis model. Female transgenic mice expressing the human MnSOD gene in the skin and their nontransgenic counterparts were used in this study. Pathological examination demonstrated significant reduction of papilloma formation in transgenic mice. Quantitative analysis of 4-hydroxy-2-nonenal-modified proteins showed greater accumulation of oxidative damage products in nontransgenic compared with transgenic mice, and this oxidative damage was demonstrated to be present in both mitochondria and nucleus. TPA increased activator protein-1 (AP-1) binding activity within 6 h in nontransgenic mice, but increased AP-1 binding activity was delayed in the transgenic mice. Electrophoretic mobility shift assay, transcription of the target genes, and Western analysis studies indicated that the increased AP-1 binding activity was attributable to induction of the Jun but not the Fos protein families. Overexpression of MnSOD selectively inhibited the TPA-induced activation of protein kinase Cepsilon and prevented subsequent activation of c-Jun NH(2)-terminal kinase in response to TPA. Overall, these results indicate that MnSOD regulates both cellular redox status and selectively modulates PKCepsilon signaling, thereby delaying AP-1 activation and inhibiting tumor promotion, resulting in reduction of tumors in MnSOD transgenic mice.

Overexpression of MnSOD protects murine fibrosarcoma cells (FSa-II) from apoptosis and promotes a differentiation program upon treatment with 5-azacytidine: involvement of MAPK and NFkappaB pathways

Stable transfection of neomycin and human manganese superoxide dismutase (MnSOD2) expression plasmids into a murine fibrosarcoma cell line (FSa-II) was previously done in our laboratory. Treatment with 10 microM 5-azacytidine induced apoptosis in the control cell line (NEO), whereas the MnSOD-overexpressing cell line (SOD-H) demonstrated differentiated-appearing morphology. The levels of the myogenic transcription factor, MyoD, and the muscle-specific marker, alpha-actin, were increased over time with 5-azacytidine treatment in the SOD-H cell line. Nuclear transcription factor NFkappaB was activated in the SOD-H cell line, whereas inhibition of NFkappaB activation reduced the levels of MyoD and alpha-actin. Members of mitogen-activated protein kinase pathway and the Raf1/MEK/ERK cascade were shown to play a positive role in this event. Overexpression of MnSOD not only can protect cells from the toxic effects of 5-azacytidine, but can also promote the fibrosarcoma cells to enter a differentiation program.

Repeated attacks of venous air embolism during craniotomy--a case report

Venous air embolism (VAE) is not uncommon during craniotomy, but repeated attacks of VAE during a single surgical procedure is rarely seen. We report a successful intraoperative management of repeated attacks of air embolism in a patient who sustained craniotomy for intracranial hemorrhage (ICH) in prone position. A 70-year-old male suffering from hemorrhage in the right cerebellar hemisphere with impending brainstem herniation was scheduled for craniotomy. He had history of hypertension but it was not well controlled with medical treatment. Emergent craniotomy for removal of blood clot resulting from ICH was performed. During the operation, sudden decrease of end-tidal CO2 (EtCO2) level, fall of blood pressure and increase of central venous pressure (CVP) were noted. Since air bubbles were retrieved from CVP catheter venous air embolism was highly suspected. With prompt diagnosis and proper management, we successfully improved the patient's hemodynamic status and he was discharged without any sequelae. Early detection together with aggressive treatment is the only way in the management of intraoperative venous air embolism.

Androgen-receptor gene CAG repeats, plasma testosterone levels, and risk of hepatitis B-related hepatocellular carcinoma

BACKGROUND

Worldwide, hepatocellular carcinoma (HCC) is more prevalent in men than in women, suggesting that sex hormones and/or X-chromosome-linked genes may be involved in hepatocarcinogenesis. We investigated the association of a trinucleotide (CAG) repeat in the androgen receptor (AR) gene (located on the X chromosome) termed "AR-CAG repeats," levels of plasma testosterone, and the risk of HCC in Taiwanese men. Chronic hepatitis B virus (HBV) infection, which is associated with risk of HCC, is hyperendemic in Taiwan.

METHODS

We compared the number of AR-CAG repeats in 285 HBV carriers with HCC and in 349 HBV carriers without HCC. We also conducted a nested case--control study on participants in a cohort study. Blood was collected prospectively from 110 case patients and 239 control subjects and was used to determine the number of AR-CAG repeats and plasma testosterone level. All statistical tests were two-sided.

RESULTS

The overall odds ratio (OR) for HCC was 1.72 (95% confidence interval [CI] = 1.03--2.89) for HBV carriers with 20 or fewer AR-CAG repeats compared with those with more than 24 repeats. This association was observed only in patients with late-onset HCC (OR = 2.37; 95% CI = 1.28--4.38). In the nested case-control study, HBV carriers in the highest tertile of testosterone levels had a statistically significantly increased risk of HCC (OR = 2.06; 95% CI = 1.14--3.70) compared with those in the lowest tertile. Elevated testosterone was more strongly associated with early-onset (OR = 4.67; 95% CI = 1.41--15.38) than late-onset disease. HBV carriers with 20 or fewer AR-CAG repeats and higher testosterone levels had a fourfold increase in HCC risk compared with those with more than 24 repeats and testosterone levels in the lowest tertile.

CONCLUSIONS

Higher levels of androgen signaling, reflected by higher testosterone levels and 20 or fewer AR-CAG repeats, may be associated with an increased risk of HBV-related HCC in men.

Low molecular weight heparin in hemodialysis patients with a bleeding tendency

Efficacy and safety of a low-molecular-weight heparin (LMWH) were studied in 33 stable maintenance hemodialysis patients who had a bleeding tendency on unfractionated heparin. The optimal dose of LMWH for each patient was titrated before the study; the mean total LMWH dosage was 1,152 +/- 574 IU. No major bleeding or clot formation was noted in a total of 2,470 hemodialysis sessions during 6 months of LMWH administration. The mean value of plasma anti-factor Xa (anti-Xa) activity increased from 0.05 +/- 0.03 IU/ml before dialysis to 0.34 +/- 0.28 IU/ml after 2 h of dialysis and returned to 0.15 +/- 0.09 IU/ml after 4 h of dialysis; the mean activated partial thromboplastin time was 26.1 +/- 4.4 s before dialysis, 30.7 +/- 9.5 s (an 18% increase) after 2 h of dialysis, and 26.2 +/- 4.4 s after 4 h of dialysis. No significant change in serum antithrombin levels was noted throughout the whole study period. We conclude that a low dosage of LMWH is safe and effective in hemodialysis patients who have a risk of bleeding with unfractionated heparin. Serum anti-Xa activity is better than activated partial thromboplastin time and antithrombin in assessing the optimal dose of LMWH. A plasma anti-Xa activity of 0.37 IU/ml after 2 h of hemodialysis may represent an optimal dosage of LMWH for most patients.

Role of N-acetyltransferase polymorphisms in hepatitis B related hepatocellular carcinoma: impact of smoking on risk

BACKGROUND

Persistent infection with hepatitis B virus (HBV) causes chronic phasic necroinflammation and regenerative proliferation in the liver. The sustained hepatocellular proliferation may render chronic HBV carriers more susceptible to the effects of environmental carcinogens. Aromatic amines are potential hepatocarcinogens in humans. N-acetyltransferase (NAT) is involved in the metabolic activation and detoxification of these compounds.

AIMS

To investigate if genetic polymorphisms in N-acetylation are related to hepatocellular carcinoma (HCC) among chronic HBV carriers.

METHODS

Genotyping of NAT1 and NAT2 was performed using polymerase chain reaction-restriction fragment length polymorphism on peripheral leucocyte DNA from 151 incident cases of HCC and 211 controls. All subjects were male, and were chronic HBV surface antigen carriers.

RESULTS

A significant association between NAT2 genetic polymorphism and HCC was observed among chronic HBV carriers who were smokers but not among those who were non-smokers. For smoking HBV carriers, the odds ratios of developing HCC for those heterozygous and homozygous for the NAT2*4 functional allele compared with those without any copies of the functional allele (reference group) were 2.67 (95% confidence interval 1.15-6.22) and 2.58 (95% confidence interval 1.04-6.43), respectively. The interaction between cigarette smoking and the presence of the NAT2*4 allele just failed to reach statistical significance (p=0.06). No association between NAT1 genotype and HCC was evident overall or within the smoking stratified subgroups.

CONCLUSIONS

Our results suggest that NAT2 activity may be particularly critical in smoking related hepatocarcinogenesis among chronic HBV carriers. Our data also indirectly support a role for tobacco smoke derived aromatic amines in the aetiology of HCC.

Corneal endothelial damage after neodymium:YAG laser iridotomy

BACKGROUND AND OBJECTIVE

This study examined the long-term effect of neodynium:YAG (Nd:YAG) laser iridotomy on the corneal endothelium.

PATIENTS AND METHODS

A prospective study was designed. Patients with narrow and occludable angles or fellow eye of acute angle closure glaucoma attack were treated with Nd:YAG laser iridotomy. For one year, 31 eyes of 21 patients underwent complete follow-up. Corneal endothelial specular microscopy was performed before and after laser iridotomy at 1, 3, 6, and 12 months.

RESULTS

The decrease of endothelial cell density after YAG laser iridotomy was statistically significant at 1 month (P = 0.036), 6 months (P = 0.004), and 12 months (P = 0.000), respectively. The decrease was not statistically significant at 3 months (P = 0.467). Linear regression analysis indicated no statistical correlation between the percentage change in endothelial cell density and the total energy used during the treatment (1 month: P=0.08, 3 months: P= 0.3, 6 months: P=0.9, 12 months: P=0.2).

CONCLUSION

This study demonstrated significant endothelial cell loss in the 1-year follow-up. The result suggested that Nd:YAG laser iridotomy may pose a long-term hazard to the corneal endothelium.

Familial risk of hepatocellular carcinoma among chronic hepatitis B carriers and their relatives

BACKGROUND

Familial predisposition as a risk factor for hepatocellular carcinoma (HCC) in hepatitis B virus (HBV) carriers has not been thoroughly explored.

METHODS

The HCC risk associated with having parents and/or siblings with HCC was evaluated by use of a cohort study of 4808 male HBV carriers. A case-control family study was also conducted on data from first-degree relatives of 553 HBV carriers who had newly diagnosed HCC (case subjects) and 4684 HBV carriers without HCC (control subjects).

RESULTS

In the cohort study, HBV carriers with a family history of HCC had a multivariate-adjusted rate ratio for HCC of 2.41 (95% confidence interval [CI] = 1.47-3.95) compared with HBV carriers without a family history of HCC. For carriers with two or more affected relatives, the ratio increased to 5.55 (95% CI = 2.02-15.26). Cumulative HCC risk by age 70 years was 235.6 per 1000 (95% CI = 95. 3-375.9 per 1000) for HBV carriers with family history compared with 88.9 per 1000 (95% CI = 67.9-109.9 per 1000) for those without. In the case-control family study, first-degree relatives of case subjects were more likely to have HCC (age-sex-adjusted odds ratio [OR] = 2.57; 95% CI = 2.03-3.25) than first-degree relatives of control subjects. The excess risk of HCC among relatives was particularly evident in siblings (sisters-age-adjusted OR = 4.55 [95% CI = 2.22-9.31]; brothers-age-adjusted OR = 3.73 [95% CI = 2. 64-5.27]), but it was also observed in parents. The cumulative risk of HCC to age 80 years was 83.0 per 1000 among relatives of case subjects and 42.0 per 1000 among relatives of control subjects. Among relatives of case subjects, the cumulative risk of HCC was greater if the case subjects were diagnosed before age 50 years (two-sided P =.047). Liver cirrhosis was 2.29 (95% CI = 1.68-3.11) times more frequent in relatives of case subjects than in relatives of control subjects.

CONCLUSIONS

First-degree relatives of patients with HBV-related HCC appear to be at increased risk of HCC and should be considered in the formulation of HCC-screening programs.

Detection of iatrogenic cardiac tamponade by transesophageal echocardiography during vena cava filter procedure

PURPOSE

To present a patient who developed cardiac tamponade during insertion of an inferior vena cava (IVC) filter. Intraoperative transesophageal echocardiography (TEE) was used as a means to diagnose the cardiac tamponade and to facilitate guiding of pericardiocentesis.

CLINICAL FEATURES

A 45-yr-old man with protein S deficiency complicated by repeated attacks of deep vein thrombosis and pulmonary thromboembolism was scheduled for insertion of an IVC filter. He had history of chronic renal insufficiency, heart failure, and cerebral infarction with mild left hemiparesis. Current medication included diltiazem (30 mg, I tab tid ), prednisolone (5 mg, 2 tabs qd ), and warfarin (2.5 mg daily). Preoperative transthoracic echocardiography demonstrated bilateral pleural effusions, moderate mitral regurgitation and tricuspid regurgitation, left atrial appendage thrombus and severe generalized hypokinesia of left ventricle. Nuclear medicine examination by (99)Tc showed ejection fractions of left ventricle and right ventricle as 20% and 22%, respectively. Under the impression of protein S deficiency with multiple attacks of thromboembolism and failure of anticoagulant therapy, he was arranged for the procedure of vena caval filter insertion. Unfortunately, iatrogenic cardiac tamponade occurred during the course of the procedure with rapid hemodynamic deterioration. Because of the expedient of routine monitoring of cardiac condition with TEE, a prompt diagnosis was made. We successfully improved the patient's hemodynamic status after transthoracic echo-guided pericardiocentesis.

CONCLUSION

Intraoperative TEE is recommended to be used routinely in patients undergoing vena cava filter procedures. The availability of echocardiographic monitoring in the operation room allows the confirmation of the diagnosis and facilitation pericardiocentesis.

Increased immunoreactive labeling of the spinal N-methyl-D-aspartate R1 receptors after dorsal root ganglionectomy in the rats

The N-methyl-D-aspartate (NMDA) receptor plays an important role in the development of the autotomy after dorsal root ganglionectomy (DRGn). In this study, we further investigated the expression of the NMDAR1 in the spinal cord of the rats after right DRGn by immunohistochemical analyses. Computerized densitometric analysis of the NMDAR1 immunoreactivity was done and the integrated optical density (IOD) of the superficial laminae of the dorsal horn of the spinal cord was measured. The immunoreactive labeling of the NMDAR1 was increased in the cervical spinal cord ipsilateral to the DRGn from day 5 to 14 after DRGn. The ratio of the right/left IOD of the rats receiving DRGn was significantly higher than the rats in the sham-operated group and the control group (P<0.05). The expression of the NMDAR1 increased gradually to reach the peak at day 7 after DRGn (mean right/left IOD ratio=1.52), then decreased thereafter. The increased expression of the NMDAR1 at day 7 was suppressed by MK-801 (NMDA receptor antagonist) administered immediately after DRGn, but not by normal saline or 1,2,3,4-tetrahydro-6-nitro-2, 3-dioxo-benzo[f] quinoxaline-7-sulfonamide (NBQX, non-NMDA receptor antagonist). The results indicated that the expression of the NMDAR1 in the superficial laminae of the dorsal horn of the spinal cord was increased after DRGn and the time course was compatible with the onset and development of the autotomy induced by DRGn.

A pollen-specific and desiccation-associated transcript in Lilium longiflorum during development and stress

A cDNA clone encoding a desiccation-induced protein (LLA23) has been isolated from the mature pollen of a Lilium longiflorum cDNA library. Sequence analysis revealed significant similarity between the predicted LLA23 polypeptide, particularly at the C-terminal half of the sequence and a group of water-deficit/ripening-induced proteins. The expression of LLA23 gene is pollen-specific and the transcript accumulates only at the later stage of pollen maturation prior to anthesis. Premature drying of developing pollen confirmed that the accumulation of LLA23 transcripts was associated with desiccation. The LLA23 proteins decreased their levels when pollen/pollen tubes grew in the germination buffer. Treatments of pollen with abscisic acid (ABA) and polyethylene glycol (PEG)-8000 during germination greatly retarded the disappearance of LLA23 proteins and mRNAs. The LLA23 transcripts decreased their levels in pollen tubes grown both in vitro and in vivo, but the disappearance of LLA23 transcripts in tube cells grown in vivo was slower than those grown in vitro. In situ localization using anti-chicken immunoglobulin G conjugated with gold particles confirmed that LLA23 was located in the cytoplasm of pollen grains. The protective function of the desiccation-related proteins in the cytoplasm of pollen grains is proposed.

Effect of milrinone on postbypass pulmonary hypertension in children after tetralogy of Fallot repair

BACKGROUND

Postbypass pulmonary hypertension in surgical correction of tetralogy of Fallot (TOF) is a risk for right ventricular failure. Effective management remains a major challenge. Milrinone is a new drug with a unique mechanism of "inodilation", which offers both inotropic and vasodilatory effects. We attempted to determine if application of milrinone could improve cardiopulmonary dysfunction in children after TOF repair.

METHODS

We studied 10 children with postbypass pulmonary hypertension after TOF repair within six months. Heart rate, systolic pulmonary arterial pressure (PAP), systolic arterial blood pressure (SBP), pulmonary capillary wedge pressure and PAP/SBP ratio were recorded. Standard cardiopulmonary bypass (CPB) was performed. After CPB, if PAP/SBP was more than 0.5, pulmonary hypertension was suspected and milrinone was administered with a loading dose of 20 micrograms/kg followed by continuous infusion of 0.2 microgram/kg/minute. Hemodynamics were compared before and after administration of milrinone to evaluate its effect.

RESULTS

significant reduction in PAP/SBP ratio within 15 minutes was found after administration of milrinone. The effect persisted for 24 hours during continuous infusion of milrinone. No remarkable adverse effect was noted in the study.

CONCLUSIONS

We conclude that milrinone is effective in the management of pulmonary hypertension following CPB in children who underwent TOF repair.

Mergers and acquisitions. Frequently asked questions and answers

This article is structured in a question/answer format based on interviews with Dr. Carolyn Hope Smeltzer and Salima Manji Lin of PricewaterhouseCoopers, Chicago, and Chuck Thomas of Hinshaw & Culbertson, Rockford. The questions come from CEO's, healthcare executives, and nurse executives at hospitals that are contemplating mergers or that have both succeeded and failed to merge their institutions. The experts share their knowledge.

Factors affecting the outcome of surgical treatment of acromegaly

PURPOSE

To assess the results of and factors associated with the outcome of surgery for acromegaly.

METHODS

We retrospectively examined the medical records of acromegalic patients who underwent trans-sphenoidal adenomectomy at our hospital during the period of January 1991 through August 1997. Preoperative evaluations included measurement of basal serum growth hormone (GH), insulin-like growth factor-I (IGF-I), prolactin (PRL), GH response to oral glucose, and GH and PRL response to bromocriptine, as well as pituitary magnetic resonance (MR) imaging. Postoperative evaluations included measurement of basal serum GH and IGF-I concentrations, and pituitary MR imaging.

RESULTS

Thirty patients (14 men) with a mean age of 38 years were included. The mean follow-up period was 50 months (range, 15-90 mo). Ten of the 30 patients (33%) had early postoperative (1 mo after surgery) GH levels of less than 5 ng/mL. Twenty patients (67%) had final postoperative (last follow-up, 15-90 mo after surgery) GH levels of less than 5 ng/mL. Preoperative GH levels were positively correlated with early postoperative GH levels (r = 0.458, p = 0.011) and final postoperative GH levels (r = 0.479, p = 0.007). Early postoperative GH levels were also positively correlated with final postoperative GH levels (r = 0.595, p = 0.001). Tumor grade and stage were not significantly correlated with early or final postoperative GH levels. Thirteen of 21 patients (62%) who had postoperative MR imaging follow-up had residual tumor. There was no surgical mortality.

CONCLUSIONS

These results highlight that acromegaly is not easily treated with surgery alone. The preoperative GH level was associated with the surgical outcome.

Cytologic changes in hepatocellular carcinoma after percutaneous acetic acid injection. Correlation with helical computed tomography findings

OBJECTIVE

To illustrate the cytologic features of hepatocellular carcinoma (HCC) after percutaneous acetic acid injection (PAI) and to correlate the cytologic findings with helical computed tomography (CT) findings.

STUDY DESIGN

The study included 30 patients with 37 HCC who had undergone PAI. Baseline cytomorphology of HCC was evaluated by needle aspiration in all cases. PAI under ultrasound guidance was done every three to seven days. Upon completion of PAI, fine needle aspiration cytology was performed and followed by helical CT within two weeks. The degeneration of HCC after PAI was classified into two grades. Grade 1 showed incomplete degeneration (99% of nuclear area); grade 2 showed complete degeneration or severe degeneration with cell debris or amorphous material only. The specimens were stained with Riu's method (Romanowsky system).

RESULTS

The cytologic changes after PAI included decreased cell number, reduced cellular aggregation, degeneration of cytoplasm and nucleus, and eosinophilic or basophilic background in all tumors. In all the 37 tumors without enhancement on helical CT, grade 2 degeneration was detected.

CONCLUSION

Our results reveal that grade 2 degeneration alone, demonstrated cytologically, could indicate almost complete necrosis of HCC after PAI, probably implying no need for booster PAI.

Endotoxemia augments neurogenic plasma exudation in guinea pig lungs

BACKGROUND

Lipopolysaccharide (LPS) is closely associated with the development of infection-induced deleterious pulmonary reactions. In this study, we investigated the enhancement effects of LPS on tachykinin-mediated plasma exudation in the lungs of guinea pigs. The role of oxidants was also explored.

METHODS

Intravenous LPS (100 mu kg-1) or its vehicle was administered 0 to 3 hours prior to bilateral electrical or sham stimulation of the cervical vagus nerves in animals anesthetized with urethane and artificially ventilated. Plasma exudation into the lungs was assessed by measurement of extravasated 125I-albumin which had been intravenously administered before stimulation.

RESULTS

The plasma exudation in the lungs increased after bilateral cervical vagal stimulation. LPS alone did not induce significant plasma exudation. The vagally-mediated plasma exudation was enhanced by LPS with the peak effect 1 hour after LPS administration. LPS also enhanced exogenous substance P (10(-8) mol kg-1, i.v.)-induced plasma exudation. The vagally-induced plasma exudation was abolished by a specific neurokinin-1 (NK-1) receptor antagonist, L-732,138. The LPS-induced enhancement response was also attenuated by L-732,138. The vagally-induced plasma exudation was not affected by superoxide dismutase (SOD, 5000 U kg-1, i.p.) pretreatment. However, SOD significantly inhibited the LPS-enhanced neurogenic plasma leakage. The LPS-induced enhancement was not completely abolished by either L-732,138 or SOD pretreatment alone, but by a combination of both.

CONCLUSION

LPS augments neurogenic plasma exudation partly through NK-1 receptors to increase vascular permeability and partly via the generation of oxidative metabolites. Tachykinins released from nerve endings may contribute to endotoxin-related pulmonary inflammatory responses.

CPP antagonizes hypoxia-induced changes in dopamine metabolism in the striatum of newborn rat

Treatment with 3-(2-carboxypiperazin-4-yl)-propyl-1-phosphonic acid (CPP), a potent and competitive N-methyl-D-aspartate antagonist, is able to reduce the hypoxia-induced increase in striatal dopamine level by 26% even after the hypoxic insult has occurred. The hypoxia-induced decrease of the striatal 3,4-dihydroxyphenylacetic acid level can also be reversed by CPP. This study demonstrates that CPP can antagonize the hypoxia-induced changes in the dopamine metabolism in the striatum of the newborn rat.

Surgical outcome of combined phacoemulsification and trabeculectomy

BACKGROUND

A retrospective study was undertaken to evaluate the results of phacoemulsification, intraocular lens implantation, and trabeculectomy in patients with cataracts coexisting with glaucoma.

METHODS

This study consisted of 20 eyes from 19 patients. Fifteen eyes had chronic angle-closure glaucoma and 5 eyes had primary open-angle glaucoma. All cases were followed for a minimum of 6 months (range, 6 to 16 months). The mean preoperative intraocular pressure (IOP) was 17.3 +/- 4.5 mmHg. The mean preoperative visual acuity was 0.05 +/- 0.19. The mean number of preoperative antiglaucoma medications per patient was 2.3.

RESULTS

Postoperatively, all patients except for one no longer required antiglaucoma medication. The mean IOP was 10.7 +/- 3.7 mmHg one month postoperatively and 13.7 +/- 4.3 mmHg at the final follow-up visit. Vision improved in 80% of the patients and remained unchanged in 20%. The failure to achieve improvement was due to advanced optic atrophy. The mean level of surgically induced astigmatism at the final visit was 0.98 +/- 0.91 diopters as calculated by vector analysis. Various extents of fibrin exudate was found in 10 eyes (50%). The most serious postoperative complication, occurring in one eye (5%), was temporary hypotony with moderate choroidal effusion, which later resolved spontaneously.

CONCLUSION

Combined phacoemulsification and trabeculectomy is an effective and safe approach for obtaining good visual rehabilitation and glaucoma control.

Comparison of recovery characteristics of sevoflurane and halothane for outpatient surgery in infants

BACKGROUND

Sevoflurane, a newly approved potent inhaled anesthetic in Taiwan, provides rapid emergence from anesthesia in adults and children. Clinically, it is difficult to accurately assess the rate of recovery from anesthesia in infants. This study was designed to compare the emergence characteristics of halothane with those of sevoflurane having recourse to a respiratory agent monitor in infants undergoing outpatient surgery.

METHODS

Forty infants of ASA class I, scheduled for day-case urologic surgery were studied. Patients were randomly allocated to two groups of 20. Sevoflurane or halothane was used as the inhaled anesthetic. Toward the end of surgery, sevoflurane or halothane was turned off. The concentrations of exhaled sevoflurane or halothane were read every minute after its discontinuation until extubation. The decay curve of the exhaled concentration of either agent was recorded minute by minute for 10 minutes. The time intervals from discontinuation of the inhalation agent to spontaneous movement and tracheal extubation were recorded. Untoward side-effects during emergence were also compared.

RESULTS

Sevoflurane was eliminated faster than halothane. Based on the decay curves of the exhaled concentrations of the two agents, the time constant for halothane was 2.59 minutes and that for sevoflurane was only 1.43 minutes. The time from discontinuation of agent to extubation was also shorter for sevoflurane. Postoperative restlessness or agitation occurred more frequently in infants who received sevoflurane, although the difference was of no statistical significance.

CONCLUSIONS

Sevoflurane is superior to halothane for rapid elimination in infant outpatient surgery as gauged by observation of end-tidal concentration elimination curves recorded with a respiratory agent monitor. No other postoperative side-effect was evident in sevoflurane anesthesia.

Predictability of surgical results of herniated disc-induced cervical myelopathy based on spinal cord motor conduction study

A motor evoked potential (MEP) study with percutaneous magnetic stimulation over the motor cortices and an F-wave study in peripheral nerves were performed to measure spinal cord motor conduction velocity (SCMCV) in 25 patients with herniated disc-induced cervical myelopathy (HDICM). Grading of motor function and assessment of SCMCV were performed before and 2 years after microsurgical discectomy. The results show that functional motor improvement accompanied by an increase in SCMCV occurred in grade I patients with mild neurological impairment after surgery, whereas no definite change was seen in grade II and grade III patients with moderate and severely neurological impairment. This finding suggests that measurement of SCMCV by MEP study with a noninvasive method may provide an objective and quantitative method to assessment of the functional integrity of the spinal motor pathway and that the results of such studies may serve as a predictor in evaluation of surgical outcome in patients with HDICM.

Regression of orthotopic brain tumors by cytokine-assisted tumor vaccines primed in the brain

This study investigated the therapeutic effects of a rat glioma cell line, C6, that was engineered to secrete mouse GM-CSF (mGM-CSF) on intracerebral (i.c.) brain tumors. Significant antitumor immunity was induced in rats when the live or irradiated mGM-CSF-secreting tumor vaccine was implanted i.c. The antitumor activity was effective on small tumors and, to a lesser extent, on large tumors or tumors existing in vivo for a longer duration. Immunohistochemical analysis revealed cellular infiltrates (granulocytes, macrophages, and CD4+ and CD8+ T cells) at both the vaccine site and the tumor site, indicating that immune responses were similarly activated when tumor vaccine was inoculated in the brain, as at the subcutis. Additional studies demonstrated that the therapeutic effects of tumor vaccines on the large tumors or the long-existing tumors were enhanced by strategies such as increasing the dosage of tumor vaccines, using combined vaccines consisting of mGM-CSF and human interleukin-2, or combining tumor vaccine with herpes simplex virus thymidine kinase/ganciclovir treatment. All of the modified strategies yielded synergistic therapeutic effects on the large tumor burdens. The data presented herein suggest that cytokine gene therapy is highly promising for the treatment of i.c. gliomas.

Etiology of sporadic acute viral hepatitis in Taiwan: the role of hepatitis C virus, hepatitis E virus and GB virus-C/hepatitis G virus in an endemic area of hepatitis A and B

The etiology of sporadic acute hepatitis was studied in 334 consecutive patients from Taiwan (237 men and 97 women, aged 16-81 years), with emphasis on the role of hepatitis C virus (HCV), hepatitis E virus (HEV), and GB virus-C/hepatitis G virus (GBV-C/HGV) in acute non-A, non-B (NANB) hepatitis and in HBsAg carriers with superimposed acute hepatitis. According to the conventional diagnostic criteria, there were 12 cases (3.6%) of acute hepatitis A, 17 cases (5.1%) of acute hepatitis B, 128 cases (38.3%) of acute NANB hepatitis, and 177 cases (53.0%) of acute hepatitis in HBsAg carriers (those who were HBsAg positive but IgM anti-HBc negative). Among 128 cases of acute NANB hepatitis, 70 (54.7%) had acute hepatitis C (HCV RNA positive), 5 (3.9%) had acute hepatitis E (IgM anti-HEV positive), and the other 53 (41.4%) were presumably acute hepatitis non-A-E. The prevalence of acute hepatitis A, B, E, and non-A-E showed no significant sex difference, whereas acute hepatitis C was significantly more prevalent in females. The prevalence of acute hepatitis A and B decreased and that of acute hepatitis C increased significantly with increasing age. In contrast, acute hepatitis E and non-A-E showed no significant age predominance. Of 177 HBsAg carriers with acute hepatitis, 64 (36.1%) demonstrated non-B hepatotropic virus superinfection, with HCV being the most common (60.9%), followed by hepatitis D, E, and A viruses, and the other 55 (31.1%) and 58 (32.8%) were presumed to have acute exacerbation of chronic hepatitis B or superimposed acute hepatitis non-A-E, respectively. Serum GBV-C/HGV RNA was detected in 3-4% of acute hepatitis non-A-E cases, suggesting its limited role in these cases.

Percutaneous ethanol injection therapy in 47 cirrhotic patients with hepatocellular carcinoma 5 cm or less: a long-term result

To elucidate the long-term results of percutaneous ethanol injection (PEI) for hepatocellular carcinoma (HCC), 47 cirrhotic patients with HCC < or = 5 cm after PEI were analysed. Thirty-two of the patients were male. The age range was 37-68 years. Thirty-nine patients were seropositive either for hepatitis B surface antigen or antihepatitis C virus antibody. There were a total of 61 tumours, including solitary tumours in 35 patients, double tumours in 10 and triple tumours in two. The size of the main tumour was < or = 3 cm in 29 patients and more than 3 cm in 18 patients. Seventeen, 27 and three patients were in Child's class A, B and C respectively; 5-10 ml 95% ethanol was injected into the tumour every three to seven days until the echogenicity of the tumour changed to a hyperechoic or heterogeneous one. A booster PEI was given in 34 (56%) lesions with viable tumour, which was detected by dynamic computed tomography. The one, two, three and four-year survival rates were 85%, 75%, 61% and 39% respectively for all patients. Good liver reserve significantly improved the survival rate (p < 0.01, Child's class A and B vs Child's class C). The one, two, three and four-year recurrence rates were 24%, 55%, 69% and 79% for all patients. HCC recurred more frequently in patients with multiple tumours (p < 0.02).

Effects of chlorides on emissions of toxic compounds in waste incineration: study on partitioning characteristics of heavy metal

Chlorides derived from plastics and food residue content in MSW will affect the formation and partitioning of metal chlorides in the incineration discharges. Our study investigated the effects of waste-derived chlorides on the partitioning of heavy metals in a single-metal combustion system. The results indicate that the heavy metal partitioning behaviors are mainly affected by the presence of chloride, alkaline metals (i.e., Na, K) and moisture in the wastes. The configuration of the metal partitioning is determined by the availability of chlorine, hydrogen, and alkaline metals, or the extent to which the elements may divide from their compounds at a given combustion temperature. The effects of chlorides, including PVC, C2Cl4, FeCl3, NaCl and KCl, were also discussed.

Long-term beneficial effect of interferon therapy in patients with chronic hepatitis B virus infection

To examine the long-term effect of interferon (IFN) therapy in patients with chronic hepatitis B virus (HBV) infection, particularly on survival and hepatocellular carcinoma (HCC) prevention, 101 male patients with chronic hepatitis B in a randomized controlled trial were followed up for 1.1 to 11.5 years after the end of therapy. Of the 101 patients, 34 patients received a placebo (control), and 67 patients were treated with IFN (31 patients were treated with IFN alone and 36 patients were treated with IFN after prednisolone priming). Follow-up studies included clinical, biochemical, and virological aspects and HCC screening every 3 to 6 months. Twenty-eight (42%) of the 67 IFN-treated patients and 8 (24%) of the 34 untreated patients seroconverted by the end of the trial. During follow-up, 22 (56%) of the 39 patients who did not seroconvert in the treated group and 5 (19%) of the 26 patients who did not seroconvert in the control group showed a delayed sustained response (P <.005). The cumulative incidence of sustained response was highest in the steroid priming group (P =.049 vs. the IFN-alone group; P =.028 vs. the control group). HCC was detected in 1 (1.5%) of the 67 treated patients and 4 (12%) of the 34 untreated patients (P =.043). The interval between entry and HCC detection was 3.5 to 8.2 years. The cumulative incidence of HCC development was significantly higher in the control group than in the treated group (P =.013). In contrast, the cumulative survival rate was higher in the treated group than the control group (P =. 018). Multivariate analysis showed that IFN therapy, preexisting cirrhosis, and the patient's age at entry are significant independent factors for both survival and HCC development. The results suggest that IFN has long-term beneficial effects in terms of HBV clearance, reduction of HCC, and prolonging survival.

Catecholaminergic mechanisms-mediated hypothermia induced by magnolol in rats

Intraperitoneal administration of magnolol (25-100 mg/kg) produced a dose-related fall in rats' colonic temperature. The magnolol-induced hypothermia was attenuated by pretreatment with intracerebroventricular 6-hydroxydopamine (200 microg/rat). The L-DOPA (200 mg/kg, i.p.) plus benserazide (50 mg/kg, i.p.)-induced hyperthermia was attenuated by magnolol. On the other hand, the alpha-methyltyrosine (100 mg/kg, i.p.)-induced hypothermia was potentiated by magnolol. Furthermore, magnolol (50 mg/kg, i.p.) decreased the dopamine and norepinephrine release in the hypothalamus, but did not change the concentrations for their metabolites (3,4-dihydroxyphenylacetic acid and homovanillic acid). The data suggest that magnolol decreases colonic temperature by reducing catecholaminergic activity in rat hypothalamus.

Thyrotropin-secreting pituitary adenoma

Thyrotropin (TSH)-secreting pituitary adenoma (TSPA) is a rare cause of hyperthyroidism and detailed reports of this entity in Taiwan are uncommon. We report a patient with TSPA with symptoms of hyperthyroidism and describe the presentation, endocrine and histologic findings, and treatment. The patient, a 42-year-old man, presented with a 2-year history of weight loss, palpitation, anxiety, and bad temper. He had increased basal serum thyroxine (T4, 18.3 micrograms/dL) and triiodothyronine (T3, 250 ng/dL) concentrations. The TSH concentration was normal (4.6 microIU/mL) and showed impaired response to stimulation by TSH-releasing hormone. Tests for antithyroid antibodies were negative. Thyroid scintigraphy showed mild thyroid enlargement. The thyroid uptake of radioactive iodine (131I) was high at 2 hours (34%) and 24 hours (63%) after 131I administration. Other serum hormone concentrations were within normal limits. Magnetic resonance imaging of the brain showed a microadenoma in the pituitary region. Octreotide and bromocriptine tests showed 78.4% and 58.3% inhibition of TSH, respectively. The patient underwent trans-sphenoidal pituitary tumor excision, and the symptoms of hyperthyroidism subsided after surgery. Six months after the operation, there was no evidence of recurrence of the tumor or symptoms of hyperthyroidism. Hormonal supplements were also not necessary. In conclusion, TSPA is a rare cause of hyperthyroidism. However, in patients with symptoms of hyperthyroidism and increased basal serum T1 and T3 concentrations, but normal or even elevated serum TSH concentrations, TSPA should be considered in the differential diagnosis.

Low-dose dopamine infusion in cirrhosis with refractory ascites

To investigate the effect of dopamine on the renal blood flow, five cirrhotic patients with refractory ascites but no hepatorenal syndrome were allocated to this study. Low-dose dopamine infusion at a rate of 2 micrograms/kg/min was undertaken at least for 24 hours. Effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) were measured by computerised nuclear scanning before and after dopamine infusion. The results revealed no difference in the changes of blood urea nitrogen, creatinine, creatinine clearance, blood pressure, pulse rate, serum sodium, serum aldosterone and GFR despite insignificant increases in urine output and urinary sodium excretion after dopamine infusion. However, ERBF values before and after dopamine infusion were 288-311, 208-267, 418-442, 246-270 and 262-396 ml/min in these five patients respectively and showed significant increase (p < 0.01). Our study revealed that low-dose dopamine infusion could increase ERPF in cirrhotic patients with refractory ascites.

Substantia nigra lesion suppresses the antagonistic effects of N-methyl-D-aspartate receptor antagonist (MK-801) on the autotomy in the rat

Rats received right dorsal root ganglionectomy (DRGn) to induce autotomy, and were treated with MK-801 and/or left substantia nigra (SN) lesion after DRGn. The behavior was quantified using an autotomy grading scale. All the rats in the control groups manifested autotomy from 4 to 19 days after DRGn and attained the highest autotomy score. The group treated with MK-801 immediately after DRGn showed suppression of the development of autotomy. The groups receiving left SN lesion with 6-hydroxydopamine immediately, 2, or 4 days after DRGn showed similar patterns of autotomy as the control groups. However, when combined with the administration of MK-801 immediately after DRGn, SN lesion done immediately or 2 days after DRGn suppressed the antagonistic effect of MK-801 (P < 0.01). When the SN lesion was delayed by 4 days, the suppression effect disappeared. These data suggest that the action of the NMDA receptor antagonist on the autotomy within 4 days after DRGn depend on the integrity of the dopaminergic system.

The neuromuscular effects of mivacurium in adults with priming technique during nitrous oxide-fentanyl anesthesia: a randomized comparative study with succinylcholine

BACKGROUND

We investigated the neuromuscular effects of equipotent dose (3 x ED90) of mivacurium either given as a single bolus or under the influence of priming technique, comparing with that of succinylcholine in adults undergoing elective surgery during nitrous oxide-narcotic anesthesia.

METHODS

Sixty ASA class I patients of either sex with age between 16 to 49 years were randomly assigned to 3 groups for a trial of mivacurium under nitrous oxide-narcotic anesthesia. Group I (non-priming group, n = 20) received mivacurium 0.25 mg/kg straight as a single intubating dose; Group II (priming group, n = 20) received an intubating dose of 0.225 mg/kg mivacurium which was preceded by 0.025 mg/kg 3 min earlier; and Group III received an intubating bolus of succinylcholine 1 mg/kg. Thenar electromyogram response to supramaximal train-of-four stimulation of the ulnar nerve at 12-s intervals was used to determine neuromuscular blockade. Blood pressure and heart rate were recorded before and at 1-min interval for 3 min after injection of drugs. Data were presented as mean +/- standard deviation. P value < 0.05 was considered statistically significant.

RESULTS

The onset time of mivacurium was accelerated by priming procedure in comparison with the nonpriming technique (2.0 min vs. 2.7 min), but it was much slower than that of succinylcholine (0.8 min). The priming procedure did not influence the duration of action or recovery. Side effects of mivacurium, such as cutaneous flushing and hypotension, were minimal at this dose in our patients.

CONCLUSIONS

Priming technique (with 10% of the total dose as the priming dose, and 3 min as the priming interval) can hasten the onset of mivacurium in adults during nitrous oxide-narcotic anesthesia without influencing the duration of action and recovery time.

Neonatal intracardiac rhabdomyomatosis: a case report

Intracardiac tumors are rare in neonates. Most of these lesions are rhabdomyomas and they occur almost exclusively during infancy. Rhabdomyomas are commonly associated with tuberous sclerosis and often involve the brain, kidneys and pancreas; they are frequently multiple and originate most commonly from the ventricular septum. Surgical intervention is indicated for rhabdomyoma with either mechanical cardiac obstruction or dysrhythmias resulting in symptoms or sudden death. A newborn with diffuse rhabdomyomatosis over the right atrium, right ventricle and left ventricle of the heart complicated with congestive heart failure and intractable supraventricular tachycardia is reported herein. No tuberous sclerosis or other organ involvement was noted. The tumor was resected.