Outcomes of abdominal false lumen embolization for chronic aortic dissection after prior proximal repair with stent-graft

BACKGROUND

Persistent false lumen (FL) perfusion with aneurysmal formation is common after thoracic endovascular aortic repair (TEVAR) for typical extended aortic dissection and is associated with poor outcomes. Endovascular FL embolization (FLE) has recently been tried for treatment of postdissection aortic aneurysm (PDAA). However, most reports address thoracic rather than abdominal FLE. In this study, we present the results of abdominal FLE in patients with residual patent abdominal FL following stent-graft repair for aortic dissection.

METHODS

Between 2015 and 2019, 24 patients (mean age: 56.7 ± 11.8 years, range: 40-84 years, 18 male) received endovascular abdominal FLE using vascular plugs, coils, or candy plugs as the main surgery (5 patients) or auxiliary procedure (19 patients) after earlier stent-graft repair for aortic dissection (Type A: 9, Type B: 15). The medical records were reviewed and aortic remodeling was examined comparing the preembolization computed tomography (CT) and the most recent CT before reintervention.

RESULTS

Technical success was achieved without any intraoperative complications, early morbidity, or mortality. Median follow-up was 34.4 months (range: 12-71). Regarding thoracic FL, 15 patients exhibited complete thrombosis before the procedure and did not change status thereafter except for 1 patient with distal stent-graft-induced new entry. In the other 9 patients, 6 exhibited increased thrombosis. With regard to the abdominal aorta, increased FL thrombosis only occurred in 8 patients with 3 (12.5%) achieving complete thrombosis. The maximal thoracic aortic diameter did not change (1.4 ± 5.6 mm) statistically, but the abdominal diameter increased significantly (4.3 ± 3.7 mm, p < 0.005).

CONCLUSION

From our results, abdominal FLE is a safe procedure. However, covering all the re-entry tears is complex and the possibility of complete FL thrombosis is low. The abdominal aortic diameter appears to become enlarged in these patients. Continuous follow-up is necessary after FLE.

[Opportunities and prospects for sports medicine in China]

Over the past decades, Chinese sports medicine has made remarkable progress, successfully establishing its status as a discipline and embracing unprecedented development opportunities. In the foreseeable future, "sports for health promotion", in addition to already fast development of "sports injury treatment" and "sports rehabilitation", will become the third vital advancing directions of sports medicine in China. The popularization and application of exercise prescription will become an effective and reliable approach to fulfill sports for health promotion. "Function first, early rehabilitation, return to sports" is the principle of treatment and discipline tenet that will lead the sports injury treatment and rehabilitation to achieve great breakthrough in many fields of sports medicine. With the opportunities and challenges, how to consistently identify and follow the right development path in line with our national circumstances requires the determination, perseverance, courage and wisdom of all Chinese sports medicine practitioners.

A Systematic Review and Meta-Analysis of Extracorporeal Membrane Oxygenation in Patients with Burns

BACKGROUND

Severely burned patients are at high risk for cardiopulmonary failure. Promising studies have stimulated interest in using extracorporeal membrane oxygenation as a potential therapy for burn patients with refractory cardiac and/or respiratory failure. However, the findings from previous studies vary.

METHODS

In this study, the authors conducted a systematic review and meta-analysis using standardized mortality ratios to elucidate the benefits associated with the use of extracorporeal membrane oxygenation in patients with burn and/or inhalation injuries. A literature search was performed, and clinical outcomes in the selected studies were compared.

RESULTS

The meta-analysis found that the observed mortality was significantly higher than the predicted mortality in patients receiving extracorporeal membrane oxygenation (standardized mortality ratio, 2.07; 95 percent CI, 1.04 to 4.14). However, the subgroup of burn patients with inhalation injuries had lower mortality rates compared to their predicted mortality rates (standardized mortality ratio, 0.95; 95 percent CI, 0.52 to 1.73). Other subgroup analyses reported no benefits from extracorporeal membrane oxygenation; however, these results were not statistically significant. Interestingly, the pooled standardized mortality ratio values decreased as the selected patients' revised Baux scores increased (R = -0.92), indicating that the potential benefits from the treatment increased as the severity of patients with burns increased.

CONCLUSIONS

The authors' meta-analysis revealed that burn patients receiving extracorporeal membrane oxygenation treatment were at a higher risk of death. However, select patients, including those with inhalation injuries and those with revised Baux scores over 90, would benefit from the treatment. The authors suggest that burn patients with inhalation injuries or with revised Baux scores exceeding 90 should be considered for the treatment and early transfer to an extracorporeal membrane oxygenation center.

Mid-Term Outcome of Infected Abdominal Aortic Stent Graft Dismantlement with Reconstruction of Bilateral Axillofemoral Bypass

Background: Abdominal aortic stent graft infection (AAGI) is a severe complication. The optimal management of AAGI remains unclear. This study provides updated results of bilateral axillofemoral bypasses (AFBs) for patients with AAGI. Patients and Methods: In total, 31 patients (25 men; mean age, 67.1 years) with AAGI treated using AFB between January 2006 and April 2020 were included. Overall, the mean follow-up duration was 24 months (range, 1-72). In the 23 patients who survived the post-operative period, the mean follow-up duration was 32 months (range, 12-72). Results: Thirty-day and in-hospital mortality rates was 16% and 26%, respectively. The 12-month primary and secondary patency rates for the AFB graft were both 91%. In total, seven (30%) patients received re-interventions such as thrombectomy and balloon angioplasty. No amputation was required during follow-up. Culture results were positive in 87% of pre-operative cultures and 84% of intra-operative cultures. Staphylococcus aureus was the most prevalent pathogen, with four cases of methicillin-resistant Staphylococcus aureus and one each of vancomycin-resistant enterococci, carbapenem-resistant Klebsiella pneumoniae, and carbapenem-resistant Enterobacteriaceae. In-hospital mortality rate was 57% in patients with drug-resistant pathogens. Conclusions: Reconstruction with bilateral AFB and stent graft removal in patients with AAGI is a feasible treatment modality and provided an acceptable patency rate and low amputation rate. Additional studies investigating long-term results and the optimal treatment of AAGI are required.

Genomic Signature of Mismatch Repair Deficiency in Areca Nut-Related Oral Cancer

Areca nut (AN) chewing contributes to an increase of oral squamous cell carcinoma (OSCC) cases in South and Southeast Asia; however, genomic events underlying the carcinogenesis process of AN-related OSCC remain unclear. Here, we comprehensively describe the genomic and transcriptome alterations of 113 Chinese OSCC patients (89 AN related and 24 AN negative) by whole-exome sequencing and RNA sequencing, and we compared the genomic differences between AN-related and AN-negative samples by integrating sequencing data of 325 OSCC patients from The Cancer Genome Atlas database and 50 from a published Taiwanese study. We identified 11 significantly mutated genes for OSCC, including 4 novel ones (ATG2A, WEE1, DST, and TSC2), of which WEE1 and ATG2A mutated with significantly higher rates in AN-related samples (P = 0.04 and P = 0.003, respectively). Mutational signature analysis revealed that AN-related OSCCs were specially characterized by the genomic signature of mismatch repair deficiency (dMMR), which could also predict the prognosis status of AN-related OSCC. In addition, an elevated PD-L1 expression was also observed in both AN-related patients (P = 3.71 × 10^-11) and those with a high dMMR level (P = 1.99 × 10^-4). Further differential expression analysis and in vitro experiments confirmed the role of dMMR in the development of OSCC induced by AN exposure. Taken together, this study first revealed the molecular profiles and highlighted the role of dMMR in AN-related OSCC among the Chinese population and identified that AN-related OSCC may represent a potential cohort for effective anti-PD-1/L1 immunotherapy.

Endovascular and Hybrid Revascularization for Complicated Aorto-Iliac Occlusive Disease: Short-Term Results in Single Institute Experience

Background

Treatment for extensive aortoiliac occlusive disease (AIOD) includes endovascular interventions, hybrid procedures and surgical reconstruction. This study evaluated the short-term outcomes of endovascular and hybrid procedures in patients with Trans-Atlantic Inter-Society Consensus II (TASC-II) D AIOD lesions.

Materials and Methods

From January 2013 to June 2015, 41 patients with TASC-II D AIOD lesions who underwent revascularization at our institute were retrospectively included. Nineteen underwent endovascular procedures and 22 underwent hybrid procedures with a postoperative surveillance program for at least 1 year. Patient demographics and short-term outcomes were analyzed.

Results

The procedural success rate in all patients was 100%. The accumulative postoperative complication rate was 20.2%, and the major complication was acute kidney injury (14.6%). The time of freedom from target lesion revascularization was 18.9 months. The primary patency rates in the endovascular group were 89.5% and 84.2% at 1 and 2 years, respectively, compared to 95.5% at 1 and 2 years in the hybrid group; however, the difference was not significant (p = 0.234). The secondary patency rates were 94.7% and 93% at 1 and 2 years, respectively, in the endovascular group, and 95.5% and 94% at 1 and 2 years, respectively, in the hybrid group; however, the differences was not significant (p = 0.916).

Conclusions

Our study revealed that endovascular and hybrid procedures are favorable treatment choices for patients with TASC-II D AIOD lesions. In patients with multilevel steno-occlusive lesions, hybrid procedures improved distal runoff flow and reduced the complexity of endovascular procedures.

Blunt Abdominal Trauma with Left Kidney Dropped into Lower Retroperitoneal Cavity: A Case Report and Literature Review

Blunt abdominal injury with kidney laceration is not unusually seen in high-energy traffic accident. It can present with no symptoms and yet lead to fatal complications. High-grade lacerations of kidney (American Association for the Surgery of Trauma [AAST] grade IV to V) will show up with contrast extravasation and disrupted kidney/pelvicalyceal system morphology in computed tomography (CT). However, it is rare to see kidney dislocation from retroperitoneal space because of the presence of the Gerota's fascia. We present a case of a 16-year-old boy suffering from traffic accident with blunt truncal/abdominal injury. The contrast CT of abdomen revealed that his left kidney was dislocated from the original retroperitoneal space and sagged to the lower retroperitoneal cavity. We performed emergency left nephrectomy. He recovered well and there was no complication noted after the surgical intervention. We also review the literature of kidney laceration regarding diagnosis and treatment. (Hong Kong j.emerg.med. 2016;24:176-179)

Systemic therapies for recurrent or metastatic nasopharyngeal carcinoma: a systematic review

BACKGROUND

The majority of published studies in recurrent or metastatic nasopharyngeal carcinoma (RM-NPC) are single-arm trials. Reliable modelling of progression-free survival (PFS) and overall survival (OS) outcomes, therefore, is difficult. This study aim to analyse existent literature to estimate the relative efficacy of available systemic regimens in RM-NPC, as well as provide estimates of aggregate OS and PFS.

METHODS

We conducted a systematic search of MEDLINE, EMBASE and the Cochrane Library to March 2015. Clinical trials (in English only) investigating cytotoxic and molecularly targeted agents in adult patients with RM-NPC were included. All relevant studies were assessed for quality using Downs and Blacks (DB) checklist (maximum quality score of 27). Aggregate data analysis and Student's t-test were performed for all identified studies (model A). For studies that published analysable Kaplan-Meier curves, survival data were extracted and marginal proportional hazards models were constructed (model B).

RESULTS

A total of 56 studies were identified and included in model A, 26 of which had analysable Kaplan-Meier curves and were included in model B. The 26 studies in model B had significantly higher mean DB scores than the remaining 30 (17.3 vs 13.7, P=0.002). For patients receiving first line chemotherapy, the estimated median OS was 15.7 months by model A (95% CI, 12.3-19.1), and 19.3 months by model B (95% CI, 17.6-21.1). For patients undergoing second line or higher therapies (2nd+), the estimated median OS was 11.5 months by model A (95% CI 10.1-12.9), and 12.5 months by model B (95% CI 11.9-13.4). PFS estimates for patients undergoing first-line chemotherapy by model A was 7.6 months (95% CI, 6.2-9.0), and 8.0 months by model B (95% CI, 7.6-8.8). For patients undergoing therapy in the 2nd+ setting, the estimated PFS by model A was 5.4 months (95% CI, 3.8-7.0), and 5.2 months by model B (95% CI, 4.7-5.6).

CONCLUSIONS

We present the first aggregate estimates of OS and PFS for RM-NPC patients receiving first and second-line or higher treatment settings, which could inform the design of future clinical trials in this disease setting.

Extracorporeal membrane oxygenation support may be a lifesaving modality in patients with burn and severe acute respiratory distress syndrome: Experience of Formosa Water Park dust explosion disaster in Taiwan

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been reported to improve outcomes in patients with refractory respiratory failure. These successful experiences have stimulated interest in using ECMO as a potential therapy for patients with acute pulmonary failure resulting from burn and inhalation lung injury. Current literature has supported the use of ECMO in critically-ill, pediatric burn patients. On the other hand, it is controversial to apply ECMO in adult burn patients, and the evidence is limited by the shortcomings of small sample size. We share our successful experience of ECMO treatment in the casualties of the Formosa Water Park Dust Explosion Disaster.

METHODS

We investigated the data from the dust explosion event, which happened on June 27, 2015, in New Taipei, Taiwan. The medical records of five patients with severe acute respiratory distress syndrome receiving ECMO were evaluated.

RESULTS

The mean study subject age was 21.8 years, with a mean total body surface area burned of 82.9%. The average time to ECMO setup was 48.6 days. Survivors and non-survivors averaged four days and 77.7 days, respectively. The overall mortality rate was 40%. Three survivors were discharged without any ECMO-related complications or pulmonary sequelae after one year of follow up.

CONCLUSIONS

ECMO may be a lifesaving modality for burn patients with severe lung injury who are nonresponsive to maximal medical management, especially for young patients with early ECMO intervention.

A systematic review of immune-related adverse event reporting in clinical trials of immune checkpoint inhibitors

BACKGROUND

There are limited data about the quality of immune-related adverse event (irAE) reporting in immune checkpoint inhibitor (ICI) clinical trial publications.

METHODS

A systematic search of citations from Medline, EMBASE and Cochrane databases identified prospective clinical trials involving ICIs in advanced solid tumors from 2003 to 2013. A 21-point quality score (QS) was adapted from the CONSORT harms extension statement. Linear regression was used to identify factors associated with quality reporting.

RESULTS

After a review of 2628 articles, 50 trial reports were included, with ICIs as either monotherapy (54%) or part of a combination regimen (46%). The mean QS was 11.21 points (range 3.50-17.50 points). The median grade 3/4 AE rate reported was 21% (range 0%-66%) and 29/50 (58%) trials concluded that irAEs were tolerable. Multivariate regression analysis revealed that year of publication (within last 5 years, P = 0.01) and journal impact factor >15 (P = 0.004) were associated with higher QS. Complete reporting of specific characteristics of irAEs including onset, management and reversibility were reported by 14%, 8% and 6% of studies, respectively. The incidence of grade 3/4 adverse events was higher for inhibitors against CTLA-4 compared with other immune checkpoints (P < 0.001).

CONCLUSIONS

The reporting of irAEs is suboptimal. A standardized reporting method of irAEs that accounts for tolerability, management and reversibility is needed and would enable a more precise evaluation of the therapeutic risk benefit ratio of ICIs.

Appropriate liver resection type for patients with the American joint committee on cancer classification T1 and T2 hepatocellular carcinoma

SYNOPSIS

Major liver resection prevents intrahepatic tumor recurrence in T2 hepatocellular carcinoma patients with microvascular invasion or daughter nodules.

BACKGROUND AND OBJECTIVES

There is no consensus on whether major or minor hepatectomy is better for hepatocellular carcinoma (HCC) patients. We investigated the outcomes of liver resection type in resectable HCC patients.

METHODS

Two hundred sixty-three HCC patients with Child-Pugh class A liver function who underwent curative hepatectomy were enrolled. Among them, 186 patients had pathologic stage T1 HCC and 77 had stage T2 HCC. Patients were also classed according to the type of resection (major or minor). Clinicopathologic characteristics and outcomes were compared.

RESULTS

Patients with T1 HCC who underwent major resection had a higher rate of blood transfusion than those who underwent minor resection (P < 0.001). The disease-free survival rate of T2 patients who underwent major resection was better than that of patients who underwent minor resection (P = 0.004). The overall survival rates of T1 and T2 HCC patients did not differ significantly between those with major or minor resection.

CONCLUSIONS

Major liver resection is recommended for T2 HCC patients with adequate remnant liver function because it results in a better disease-free survival rate than does minor resection in these patients. Minor liver resection is suggested for T1 HCC patients, except for those with a tumor sitting close to vessels, because it is associated with a low incidence of blood transfusion and a good survival rate.

Radiofrequency ablation after transarterial embolization as therapy for patients with unresectable hepatocellular carcinoma

PURPOSE

To evaluate the usefulness of transcatheter arterial embolization (TAE) followed by radiofrequency ablation (RFA) as combined treatment for unresectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Thirty-six consecutive patients (cirrhosis, Child-Pugh class A or B) with solitary or oligonodular HCC were treated (41 lesions; mean size, 58.9 mm; range, 30-120 mm). RFA was performed after one TAE treatment. Local efficacy was evaluated with multiphasic computed tomography (CT) performed an average of two months after RFA and once during later follow-up.

RESULTS

The mean follow-up period was 16 months (range, 2-45 months). Technical success (namely, complete tumor devascularization during the arterial phase) was achieved for 59% of lesions at the first CT evaluation and for 46% at the second evaluation. Among prognostic factors included in the analysis, only lesion diameter (< 50 mm versus > or = 50 mm) was statistically significant in terms of predicting local success (Fisher's exact test: 85% versus 43% at first CT, p<0.01; 70% versus 36% during follow-up, p=0.05). There were no major periprocedural complications. Kaplan-Meier analysis showed survival rates of 84% at 12 months and 57% at 24 months.

CONCLUSIONS

Combined therapy--TAE then RFA--for unresectable HCC lesions in patients with cirrhosis produces a relatively high complete local response rate compared with TAE or RFA alone. Our results, considered with those from other case series, may help design prospective, randomized clinical trials to test combination therapy versus single-modality therapy in terms of risks and benefits.

Current and strain-induced spin polarization in InGaN/GaN superlattices

The lateral current-induced spin polarization in InGaN/GaN superlattices (SLs) without an applied magnetic field is reported. The fact that the sign of the nonequilibrium spin changes as the current reverses and is opposite for the two edges provides a clear signature for the spin Hall effect. In addition, it is discovered that the spin Hall effect can be strongly manipulated by the internal strains. A theoretical work has also been developed to understand the observed strain-induced spin polarization. Our result paves an alternative way for the generation of spin polarized current.

Intrapericardial isolation of the inferior vena cava through a transdiaphragmatic pericardial window for tumor resection without sternotomy or thoracotomy

AIMS

The prognosis for patients with advanced tumors invading the inferior vena cava (IVC) is dismal and surgical treatments for these tumors are challenging. A surgical approach that avoids sternotomy and thoracotomy for tumors invading the IVC even to the level of the hepatocaval junction would be extremely helpful.

METHODS

The intrapericardial IVC was isolated via a transdiaphragmatic pericardial window using a transabdominal approach. Hepatectomy was then applied via an anterior approach until the IVC was seen. Total hepatic vascular exclusion was achieved by clamping the portal triad, intrapericardial IVC and infrahepatic IVC. We removed the primary tumor, the liver portion involved and the tumor thrombi, with segmental resection of the IVC. Vascular continuity was reestablished using a 20-mm-diameter polytetrafluoroethylene graft.

RESULTS

Four patients with tumors invading the IVC were treated with this method. All underwent gross en-bloc tumor resections and all survived.

CONCLUSION

This method for the resection of IVC tumors could avoid emboli dislodging from the tumor thrombi, prevent the complications of sternotomy, cardiopulmonary bypass and shorten operative times.

Comparison of clinical staging systems in predicting survival of hepatocellular carcinoma patients receiving major or minor hepatectomy

AIM

To compare the utility of seven commonly used staging systems in the prediction of survival among patients with hepatocellular carcinoma (HCC) undergoing major or minor hepatectomy.

METHODS

All patients were classified by the Okuda, the TNM, the CLIP, the BCLC, the CUPI, the JIS and the MELD classifications to estimate the probabilities of survival. Survival curves were calculated using the Kaplan-Meier method and were examined using log-rank testing. The overall predictive power for patient survival with each staging system was evaluated using linear trend chi(2) tests and from the area under the receiver operating characteristic (ROC) curve.

RESULTS

In our patient cohort, the log-rank test and the linear trend chi(2) test of the CLIP and JIS systems gave better results than did the other staging systems. The discriminatory ability of the CLIP and JIS staging for death, evaluated by ROC curve areas, was also better. In the subgroups of major hepatectomy patients with a non-cirrhotic liver or minor hepatectomy patients with a cirrhotic liver, the CLIP and JIS systems showed similar better performances in these three tests. The discriminatory ability of the CLIP system was the best in major hepatectomy patients with a non-cirrhotic liver while JIS score discriminated best in minor hepatectomy patients with a cirrhotic liver.

CONCLUSION

Among the seven staging systems, the CLIP and JIS systems perform better than do the others. While the CLIP system should be considered to stage major hepatectomy patients, the JIS system could be chosen to stage minor hepatectomy patients.

An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases

AIM

The aim of the present study was to report our experience of totally implantable central venous access devices (TICVAD) implantation using two techniques and attempt to define the better technique.

MATERIALS AND METHODS

From January 1998 to September 2003, 1131 patients were reviewed and divided into two groups with implantation by cephalic vein cut-down (group A) done by general surgeons and subclavian vein puncture with the Seldinger technique (group B) done by vascular surgeons. The operative time, early and late complications of these two groups were compared. Data were analysed by Student's t-test.

RESULTS

The average of operative time was 43 min in group A (35-70 min) and 40 min in group B (35-60 min) (P>0.05). No post-operative pneumothorax, hemothorax and fragmentation occurred in group A; the incidence of peri-operative complication was higher in group B. The overall and early complications of group A were significantly lower than that of group B (P<0.0001).

CONCLUSION

This retrospective study showed that the cephalic vein cut-down approach for TICVAD placement avoided the risks of pneumothorax, hemothorax and catheter fragmentation.

Prediction of the risk of hepatic failure in patients with portal vein invasion hepatoma after hepatic resection

AIM

Hepatic failure can develop after curative hepatectomy in patients with a hepatocellular carcinoma (HCC) invading the portal vein, because of cirrhosis and excessive tissue loss. This study aimed to identify the risk factors for hepatic failure in such patients.

METHOD

Forty patients with an HCC invading the portal vein underwent curative hepatectomy from January 1995 to June 2003. Eight patients developed hepatic failure and died within 3 months. Possible risk factors for this were analysed using univariate and multivariate regression. These included the liver function index, surgical blood loss, tumour pattern, portal hypertension, estimated residual liver volume measured by computed tomography (ERLV(CT)) and estimated residual liver volume using the indocyanine green (ICG) retention rate at 15 min (ERLV(ICG15)).

RESULTS

The ERLV(CT) smaller than the ERLV(ICG15) and presence of portal hypertension were independent risk factors for post-hepatectomy hepatic failure.

CONCLUSION

Having portal vein invasion HCC with portal hypertension or an ERLV(CT) less than an ERLV(ICG15) are significant predictors of post-hepatectomy hepatic failure. These factors are important considerations for patients with portal vein invasion HCC who could undergo curative hepatic resection.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interpretation of skull radiographs for facial fractures by medical staff working in UK emergency departments: a pilot study

OBJECTIVES

This was a pilot study to determine the ability of hospital doctors (1) to assess the technical quality of occipitomental (OM) radiographs and (2) to identify facial fractures.

METHOD

Twenty-two doctors from four UK Accident and Emergency (A&E) departments participated in a two part study: Part A was a postal questionnaire containing questions on demographic data, educational background, selection criteria, assessing radiographs and radiation protection; and Part B was a clinical viewing session to interpret 20 randomized OM radiographs divided into four groups; technically good and poor without fractures, and technically good and poor with fractures.

RESULTS

Study participants ranged from junior house officers to senior consultants. There was considerable variation in educational background and radiographic interpretation instruction at undergraduate and postgraduate level. OM radiographs constituted 10% of all skull radiographs examined per week, yet only 40% of the doctors felt confident when assessing technical quality. The majority of participants had only a limited knowledge of radiation protection legislation. During the viewing session, only 50% of the participants correctly identified those radiographs with fractures and those with technique errors. There was no significant difference between house officers and other grades of staff. A higher level of seniority did not equate with greater interpretative ability. Subjective confidence in assessing film quality did not correlate with the actual film viewing.

CONCLUSION

Only half of the A&E doctors taking part in the study were able to correctly assess film quality and identify facial fractures on OM radiographs. If the pilot sample is representative, then the findings are of considerable concern.

The effect of surgical stress on insulin sensitivity, glucose effectiveness and acute insulin response to glucose load

Hyperglycemia after stress is a very common clinical phenomenon. It is generally hypothesized that the underlying cause is a neuroendocrine-mediated deterioration in glucose metabolism. However, the detailed roles of insulin sensitivity, glucose effectiveness and acute insulin response to glucose load in response to stress have not been well established. Hernioplasty was used as a minor stress model for studying stress-induced hyperglycemia. Eleven healthy young men were enrolled voluntarily in this study. Their mean age was 22.0 +/- 0.9 yr and BMI 23.3 +/- 0.6 kg/m2. Frequently sampled i.v. glucose tolerance tests were performed one day before and one day after the surgery. Insulin sensitivity (SI), glucose effectiveness (EG) and area under acute insulin response (AIR) were calculated from "minimal model" algorithms. We also measured fasting concentrations of human GH, ACTH and F on the days of the test. Compared to the pre-operation data, levels of ACTH and F did not change significantly after the surgery. Only GH levels were marginally significant. On the other hand, the SI (0.75 +/- 0.1, 0.52 +/- 0.9 x 10(-5) min(-1)/pmol, p = 0.04), EG (0.023 +/- 0.03, 0.016 +/- 0.003 min(-1), p = 0.01) and AIR (6738.5 +/- 1111.6, 5130.0 +/- 1047.2 pmol, p = 0.005) were all significantly decreased after surgery. The percentages of decrease were 16.3 +/- 15.5, 32.1 +/- 10.3 and 17.8 +/- 10.3%, respectively. Finally, only the changes of EG positively correlate with the changes of ACTH before and after surgery. No significant changes were noted among other stress hormones and the changes of SI, EG and AIR. In conclusion, hernioplasty results in reduced SI, EG and AIR. Among them, although not statistically significant, the EG showed the most distinct decrease after the surgery, which has not been found in previous literature.

Thiamine deficiency and unexplained encephalopathy in hemodialysis and peritoneal dialysis patients

Patients with end-stage renal disease undergoing regular dialysis are prone to encephalopathy, but the cause is often unclear. Dialysis patients are at risk for thiamine deficiency, which may mimic many uremic complications, including encephalopathy. To determine whether unexplained encephalopathy in regular dialysis patients is associated with thiamine deficiency, we conducted a prospective study that enrolled 30 consecutive dialysis patients with altered mental status admitted to a referred hospital during a 1-year period. A complete history, physical and neurological examinations, laboratory investigations, and computed tomographic scans or magnetic resonance imaging of the brain were obtained for each subject. In 10 of the 30 patients, diagnoses remained obscure after the initial workup. Manifestations included confusion, chorea, acute visual loss, rapidly progressive dementia, myoclonus, convulsions, and coma. Intravenous thiamine was administered to these 10 patients. All 10 patients had thiamine deficiency confirmed by a marked response to thiamine supplementation and/or a low serum thiamine concentration (35.3 +/- 6.0 nmol/L; normal, >50 nmol/L). Nine patients recovered, but one patient failed to respond because of delayed treatment. We conclude that in regular dialysis patients, unexplained encephalopathy can be mainly attributed to thiamine deficiency. This condition is fatal if unrecognized and can be successfully treated with prompt thiamine replacement.

Optical emissions in a sonoluminescing bubble

We study how the mechanism of spontaneous decay of atoms (or molecules) in a sonoluminescing bubble (SLB) can be affected by the high density and high temperature environment resulting from the rapid collapse of the gas bubble immediately prior to light emission. We present a detailed study of the density of states of photons in multiple-layered spheres, which mimic various stages of a SLB. In particular, we found that the spontaneous decay rate could be strongly enhanced in the presence of a thin plasma shell inside the bubble, which was predicted recently in numerical hydrodynamic simulations of a SLB.

Human peritoneal mesothelial cells produce nitric oxide: induction by cytokines

OBJECTIVE

To investigate the induction of nitric oxide synthase type II (iNOS) in human peritoneal mesothelial cells (HPMC) using cytokines and bacterial lipopolysaccharide (LPS).

DESIGN

Confluent monolayers of HPMC were exposed to cytokines [tumor necrosis factor alpha (TNFalpha), interleukin-1 beta (IL-1beta), interferon gamma (IFNgamma)] or LPS, individually or in various double and triple combinations, for 24-72 hours. Concentrations of nitrate and nitrite in the media were quantified using the Griess reaction and used as indirect indices of nitric oxide (NO) production. The expression of iNOS was assessed using reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blot.

RESULTS

Neither single cytokines nor LPS was able to induce iNOS mRNA or NO production. Both double combinations of TNFalpha + IFNgamma and IL-1beta + IFNgamma were able to induce iNOS mRNA expression, but only TNFalpha + IFNgamma induced significant NO production. The triple combination of TNFalpha + IFNgamma + IL-1beta induced even more NO production than TNFalpha + IFNgamma. There was no constitutive NO synthase type III (eNOS) expression in HPMC.

CONCLUSIONS

Certain combinations of cytokines could stimulate cultured HPMC to produce NO, and HPMC might be a source of intraperitoneal NO production during peritonitis.

The effect of electroacupuncture on shoulder subluxation for stroke patients

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

Mycotic aneurysm of the abdominal aorta in a patient undergoing hemodialysis: an unusual complication of Staphylococcus aureus bacteremia

When Staphylococcus aureus is repeatedly positive in blood cultures even under effective antibiotics therapy (vancomycin, teicoplanin, or rifampin), computed tomography scan and sonography should be performed early to exclude mycotic aneurysm of the deeply seated arteries, especially in patients with abdominal aortic calcification. Before 1990, the most common causative organism of suprarenal aortic mycotic aneurysm was Salmonella; since 1990, it has been gram-positive cocci (i.e., Streptococcus and Staphylococcus) rather than gram-negative bacilli (i.e., Salmonella), possibly because of the more invasive procedures performed in clinical settings, but this hypothesis needs further investigation.

Significance of nitrogen removal mass in uremic patients on different modalities of dialysis therapy

BACKGROUND AND PURPOSE

While most nephrologists use Kt/V values for dialysis prescriptions, some researchers are beginning to view the role of solute removal mass as an indicator of adequate dialysis. This study, using nitrogen as a surrogate for solute removal, probed whether solute removal mass can be used as the target of adequate dialysis. Mathematical formulas for easy bedside calculation of nitrogen removal mass were used to avoid the problems associated with direct measurement.

METHODS

The weekly removal mass of urea nitrogen (M) and the urea generation rate (G) of 32 conventional hemodialysis (HD) and 21 continuous ambulatory peritoneal dialysis (CAPD) patients were calculated. All the patients were anuric, clinically stable, and under adequate dialysis pursuant to either the criterion of the urea index, Kt/V, or clinical requirements.

RESULTS

The difference in MHD (MHD = 41.9 +/- 9.5 g/week, MCAPD = 38.8 +/- 11.9 g/week) and G (GHD = 3.90 +/- 1.02 mg/min, GCAPD = 3.85 +/- 1.21 mg/min) between the two groups was statistically insignificant (p = 0.119 and p = 0.868, respectively). When protein nitrogen leaking through the peritoneal membrane was considered and added to MCAPD, nitrogen removal in CAPD patients (M'CAPD = 42.3 +/- 13.0 g/week) approached that in HD patients (p = 0.886). There was no correlation between dialysis dosage and urea removal mass in either the CAPD or HD groups.

CONCLUSIONS

Urea nitrogen removal mass is similar to the protein catabolic rate (PCR) in stable patients. It is meaningful in dialysis evaluation only when it is used simultaneously with blood urea nitrogen measurement. However, because M changes at the inception of dialysis, it more significant than PCR in the evaluation of unstable patients.

Is serum transferrin receptor a sensitive marker of iron repletion in patients with iron-deficiency anemia and hemodialysis patients?

BACKGROUND

Serum transferrin receptor (sTfR) concentration has been recognized as a reliable laboratory indicator of iron deficiency in recent years. But its response to iron supplementation has not been investigated.

METHODS

We evaluated the sTfR concentrations in 15 patients diagnosed with iron-deficiency anemia, in 30 patients receiving maintenance hemodialysis (HD) with iron repletion and in 31 healthy controls. The serial changes of sTfR concentration and their correlation with serum ferritin in patients with iron deficiency under iron repletion were also examined in three patients.

RESULTS

In patients with iron-deficiency anemia, the sTfR concentration was 5.6 +/- 2.4 mg/ml, significantly higher than that in the control group (1.8 +/- 0.4 mg/ml) and patients receiving maintenance HD with iron repletion (1.7 +/- 0.5 mg/ml). The three patients with iron-deficiency anemia who received eight to 16 weeks of iron supplementation showed steady and significant decreases in sTfR concentration and significant increases in serum ferritin and transferrin saturation. However, the decreases in sTfR concentration did not occur immediately, as did the increases in serum ferritin and transferrin saturation, following iron repletion. There was a four-week delayed response in the decrease of sTfR concentrations as measured against serum ferritin and transferrin saturation.

CONCLUSIONS

sTfR concentration may not be as effective as an early index of iron repletion compared with serum ferritin and transferrin saturation.

Erythropoietin hyporesponsiveness: from iron deficiency to iron overload

Iron deficiency is the most frequently encountered cause of suboptimal response to recombinant human erythropoietin (rHuEPO). Carefully assessing iron status is of paramount importance in chronic renal failure patients prior to or during rHuEPO therapy. Because there is great need for iron in the EPO-stimulated erythroid progenitors, it is essential that serum ferritin and transferrin saturation levels should be maintained over 300 microg/liter and 30%, respectively. Investigators have shown that oral iron is unlikely to keep pace with the iron demand for an optimal rHuEPO response in uremics. Therefore, patients with iron deficiency will always require intravenous iron therapy. The early and prompt iron supplementation can lead to reductions in rHuEPO dose and hence cost. After the iron deficiency has been corrected or excluded, we must remember all of the possible causes of hyporesponsiveness in every rHuEPO-treated patient. As dose requirements vary, it is not clear which dose of rHuEPO causes this hyporesponsiveness. However, if the patient with iron repletion does not respond well after the induction period, the major causes blunting the response to rHuEPO should be investigated. Most factors are reversible and remediable, except resistant anemia associated with hemoglobinopathy or bone marrow fibrosis, which requires a further increase in the rHuEPO dose. By means of early detection and correction of the possible causes, the goal of increasing therapeutic efficacy can be achieved. Iron overload may lead to an enhanced risk for infection, cardiovascular complication, and cancer. Over-treatment with iron should be avoided in dialysis patients, despite the fact that the safe upper limit of serum ferritin to avoid iron overload is not clearly defined. On the other hand, functional iron deficiency may develop even when serum ferritin levels are increased. Controversy remains as to whether intravenous iron therapy can overcome this form of hyporesponsiveness in iron-overloaded patients. Moreover, a treatment option of iron supplementation is not warranted in these patients, as the potential hazards of iron overload will be worsened. We demonstrated that the mean hematocrit significantly increased from 25.1+/-0.9% to 31+/-1.2% after eight weeks of intravenous ascorbate therapy (300 mg three times a week) in 12 hemodialysis patients with serum ferritin levels of more than 500 microg/liter. The enhanced erythropoiesis paralleled with a rise in transferrin saturation (27.8+/-2.5% vs. 44.8+/-9.5%, P < 0.05) and reductions in erythrocyte zinc protoporphyrin (130+/-32 vs. 72+/-19 micromol/mol heme, P < 0.05) and monthly rHuEPO dose (24.2+/-4.5 vs. 16.8+/-3.4 x 10(3) units, P < 0.05) at the end of study. It is speculated that ascorbate supplementation not only facilitates the iron release from storage sites and its delivery to hematopoietic tissues, but also increases iron utilization in erythroid cells. Our study provides a more complete understanding of the pathogenesis of iron overload-related anemia and the development of an adjuvant therapy, intravenous ascorbic acid, to the existing treatments.

Prosthetic reconstruction in the cleft lip and palate patient with an extracoronal resilient attachment retained removable partial overdenture: case report

There are still some difficulties in prosthetic reconstruction of cleft lip and palate patients with conventional prostheses or implant retained prostheses. The most common difficulties are insufficient alveolar bone quality and quantity, inadequate soft tissue, and abutment teeth. The patient we report on was a 23-year-old man with a clinical diagnosis of right incomplete cleft lip and palate combined with midface dysplasia. The maxillary six anterior teeth were reconstructed. The maxillary right central incisor and canine were used as abutments for an extracoronal resilient attachment (ERA) retained removable partial overdenture. The STERN ERA SYSTEM is a hinged resilient attachment with an ideal stress breaking characteristic, a good retentive function, and easy chairside replacement. The 2-year follow-up examination revealed an adequate esthetic appearance with good retention and stability of the prosthesis. A removable partial overdenture using the teeth adjacent to the cleft area as abutments with an adequate attachment design is an alternative method for prosthetic reconstruction of cleft lip and palate deformity.

Assessing recurrent fall risk of community-dwelling, frail older veterans using specific tests of mobility and the physical performance test of function

BACKGROUND

The purpose of this prospective cohort study was to determine if older individuals at risk for recurrent falls are best identified by mobility or functional assessments.

METHODS

Eighty-four community-dwelling, frail male veterans, mean age of 75.5 years (SD=7.33), participated. The history of recurrent falls was determined by self or proxy report in a clinical interview. Mobility assessments included the Modified Gait Abnormality Rating Scale (GARS-M), stride length, and walking velocity; functional performance was determined using the Physical Performance Test (PPT). The clinical usefulness of the measures was described by determining the sensitivity and specificity of each measure using the history of recurrent falls as a standard.

RESULT

Stepwise logistic regression analysis of the data indicated that the GARS-M (p < .01) and the PPT (p < .01) were the most important predictors of recurrent fall risk. The sensitivity and specificity of the measures used were: GARS-M, 62.3% and 87.1%; PPT, 79.3% and 71.0%; walking speed, 71.7% and 74.2%; and stride length, 63.2% and 77.4%. Together the GARS-M and PPT demonstrated the highest sensitivity of 90.6% and the highest specificity of 87. 1% based on a subject testing positive on at least one test.

CONCLUSION

Used independently and in combination, the GARS-M and the PPT were clinically useful measures in screening for older individuals at risk for recurrent falls.

Thyroid dysfunction and nodular goiter in hemodialysis and peritoneal dialysis patients

OBJECTIVE

To investigate the prevalence of nodular goiter and thyroid dysfunction in uremic patients undergoing hemodialysis (HD) and peritoneal dialysis.

DESIGN

Cross-sectional study.

SETTING

Single dialysis unit and outpatient clinic.

PATIENTS

The study included 221 patients [143 HD and 78 continuous ambulatory peritoneal dialysis (CAPD) patients] along with 135 consecutively selected outpatients as controls.

MAIN OUTCOME MEASURES

Ultrasonography was used to detect patients' thyroid function and nodular goiter.

RESULTS

Nodular goiter was detected in 54.8% of the uremic patients and in 21.5% of the controls. Uremic patients had higher prevalence of thyroid dysfunction, which included reduced serum concentration of total T3, total T4, and free T4, and increased serum level of TSH. Hypothyroidism was also observed more frequently in uremic patients than in the control group (5.4% vs 0.7%, p < 0.05). Nodular goiter was more frequently found in females than in males (63.5% vs 48%, p < 0.05). Moreover, the prevalence of nodular goiter increased with age (p < 0.02) in uremic patients. Hemodialysis patients had a higher frequency of reduced total T3 level (46.9% vs 29.5%, p < 0.02). However, CAPD patients had lower T4 levels (6.23+/-1.82 microg/dL vs 7.15+/-1.99 microg/dL, p < 0.05).

CONCLUSION

Because of the high incidence of hypothyroidism and nodular goiter in uremic patients, screening of thyroid function and goiter detection with ultrasound should be considered in evaluation of end-stage renal disease patients.

Focal segmental glomerulosclerosis after poststreptococcal glomerulonephritis in the elderly: a case report

Acute poststreptococcal glomerulonephritis (PSGN) is quite rare in the elderly population. It is very difficult to recognize because the initial symptoms are similar to those of more common diseases of this age group. Compared with younger patients, elderly patients with PSGN tend to have a high incidence of renal function impairment and anuria or prolonged oliguria. Recovery from acute PSGN in the elderly is less predictable than in children and younger adults, especially when associated with severe impairment of renal function. We present the case of an elderly patient with PSGN, who had a skin infection of the face and anuria on admission. Percutaneous left renal biopsy was performed in the initial hospitalization period and in the recovery phase of the disease. Renal function recovered within two months. However, increased urinary white blood cell sediments with normal serum creatinine concentrations persisted in the successive three years of follow-up. Renal biopsy was repeated and showed evidence of focal segmental glomerulosclerosis.

Recovering colors in an image with chromatic illuminant

Colors in a scene change under different illuminants. By adopting models that are used to describe human color constancy, the maximum-spectral-value method is proposed to estimate the illuminant from the maximum distribution of reflected lights in an image. From the experimental results, the proposed method recovers colors well with different illuminants.

Linkage analysis of families with autosomal dominant polycystic kidney disease by KG8-CA marker

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common genetic diseases of human. Traditionally, ADPKD is diagnosed by ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI) of kidneys for the presence of renal cysts. Individuals who carry the defective gene but have not yet developed cysts in kidney may not be diagnosed. Genetic analysis reveals it to be caused mostly by a single-gene disorder of a genetic locus, designated PKD1. Recently, the genetic locus involving PKD1 has been identified on chromosome 16p13.3, and has been cloned and completely sequenced.

METHODS

A pair of primers, KG8-CA, located between D16S84 and D16S125, was selected and synthesized for the polymerase chain reaction (PCR) to identify individuals who may carry the defective locus. The sequence of KG8-CA primers, was 5'-CTCCCAGGGTGGAGGAAGGTG-3' and 5'-GCAGGCACAGCCAGCTCCGAG-3'. PCR products were analyzed in denaturing condition, using gel containing 8% acrylamide and 7M urea. Autoradiography was carried out to interpret the results.

RESULTS

Four Chinese families with history of ADPKD showed different DNA patterns in individuals with ADPKD and in normal individuals. Among the members in four families with history of ADPKD, every individual shared a common DNA band, suggesting that this band was derived from normal PKD1 allele. On the other hand, individuals diagnosed to have ADPKD showed one or two additional DNA bands which migrated differently from the common DNA band and should therefore be derived from defective ADPKD allele. Previous studies have shown that the ADPKD allele is highly polymorphic, as was evident in these family studies.

CONCLUSIONS

Among the members from these four families, some were clinically normal and had DNA pattern that was typical to patients with ADPKD. These individuals might carry the defective PKD1 allele but have not yet developed the ADPKD symptoms. Therefore, the method described in this study has diagnostic values for pre-symptomatic individuals as well as for patients already diagnosed with ADPKD.