Association between the Neutrophil-to-lymphocyte Ratio and New-onset Subclinical Macrovascular and Microvascular Diseases in the Chinese Population

OBJECTIVE

The association between neutrophil-to-lymphocyte ratio (NLR) with subclinical macrovascular and microvascular diseases has been less investigated. We sought to examine the association between NLR and new-onset subclinical macrovascular and microvascular abnormalities in the Chinese population.

METHODS

From a community cohort, we included 6,430 adults aged ≥ 40 years without subclinical macrovascular and microvascular diseases at baseline. We measured subclinical macrovascular and microvascular abnormalities separately using the ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and albuminuria.

RESULTS

During a mean follow-up of 4.3 years, 110 participants developed incident abnormal ABI, 746 participants developed incident elevated baPWV, and 503 participants developed incident albuminuria. Poisson regression analysis indicated that NLR was significantly associated with an increased risk of new-onset abnormal ABI, elevated baPWV, and albuminuria. Compared to overweight/obese participants, we found a much stronger association between NLR and subclinical vascular abnormalities in participants with normal weight. Furthermore, we found an interaction between the NLR and body mass index (BMI) on the risk of new-onset abnormal ABI ( P for interaction: 0.01).

CONCLUSION

NLR was associated with subclinical macrovascular and microvascular diseases in the Chinese population. Furthermore, in participants with normal weight, the association between NLR and subclinical vascular abnormalities was much stronger.

Association of Visit-to-Visit Variabilities in Metabolic Factors with Chronic Kidney Disease in Chinese Adults Living in Shanghai

OBJECTIVE

This study aimed to examine the association of visit-to-visit variabilities in metabolic factors with chronic kidney disease (CKD) in Shanghai community residents.

METHODS

We used data from a cohort study of community residents who participated in three examinations in 2008, 2009, and 2013, respectively. Fasting plasma glucose (FPG) level, blood pressure (BP), and lipid levels were determined in 2,109 participants at all three visits, and CKD was evaluated between the second and the third visits. Visit-to-visit variabilities in metabolic factors were described by coefficients of variation (CV) at three visits. A variability score was calculated by adding the numbers of metabolic factors with a high variability defined as the highest quartile of CV. CKD was defined as the estimated glomerular filtration rate < 60 mL/min per 1.73 m ² or urinary albumin-to-creatinine ratio ≥ 30 mg/g.

RESULTS

A total of 200 (9.5%) participants had CKD at the third visit. Compared with the lowest quartile of CV, the highest quartile was associated with a 70% increased risk of CKD for FPG [odds ratio, OR = 1.70; 95% confidence interval ( CI) 1.06-2.72], 62% for systolic BP ( OR = 1.62, 95% CI 1.04-2.50), and 85% for low-density lipoprotein cholesterol ( OR = 1.85, 95% CI 1.23-2.80). Furthermore, the risk of CKD increased significantly with an increasing variability score. Compared with participants with score 0, participants with scores of 1, 2, and 3 were associated with 58% ( OR = 1.58, 95% CI 1.08-2.32), 121% ( OR = 2.21, 95% CI 1.40-3.49), and 548% ( OR = 6.48, 95% CI 3.18-13.21) higher risks of CKD, respectively.

CONCLUSION

The visit-to-visit variabilities in metabolic factors were significantly associated with the risks of CKD in Shanghai community residents.

Inverted U-Shaped Associations between Glycemic Indices and Serum Uric Acid Levels in the General Chinese Population: Findings from the China Cardiometabolic Disease and Cancer Cohort (4C) Study

OBJECTIVE

The relationship between serum uric acid (SUA) levels and glycemic indices, including plasma glucose (FPG), 2-hour postload glucose (2h-PG), and glycated hemoglobin (HbA1c), remains inconclusive. We aimed to explore the associations between glycemic indices and SUA levels in the general Chinese population.

METHODS

The current study was a cross-sectional analysis using the first follow-up survey data from The China Cardiometabolic Disease and Cancer Cohort Study. A total of 105,922 community-dwelling adults aged ≥ 40 years underwent the oral glucose tolerance test and uric acid assessment. The nonlinear relationships between glycemic indices and SUA levels were explored using generalized additive models.

RESULTS

A total of 30,941 men and 62,361 women were eligible for the current analysis. Generalized additive models verified the inverted U-shaped association between glycemic indices and SUA levels, but with different inflection points in men and women. The thresholds for FPG, 2h-PG, and HbA1c for men and women were 6.5/8.0 mmol/L, 11.0/14.0 mmol/L, and 6.1/6.5, respectively (SUA levels increased with increasing glycemic indices before the inflection points and then eventually decreased with further increases in the glycemic indices).

CONCLUSION

An inverted U-shaped association was observed between major glycemic indices and uric acid levels in both sexes, while the inflection points were reached earlier in men than in women.

MiR-424 Inhibits neuronal apoptosis in rats with cerebral infarction through regulating TGF-β1/Smad3 signaling pathway

It has been reported that micro ribonucleic acid (miR)-424 is an important molecule in cerebral ischemia. However, the precise mechanism of action and biological effects of miR-424 remain to be further explored. miR-424 mimic and miR-424 inhibitor were injected via the caudal vein in rats, and the effect of miR-424 expression on brain tissue damage induced by middle cerebral artery occlusion (MCAO) was detected. The miR-424 mimic-induced changes in genomic levels were detected via the gene chip assay, and the signaling pathways regulated by miR-424 and its potential targets were explored combined with target prediction. Then the effect of miR-424 mimic on apoptosis of PC12 cells induced by oxygen-glucose deprivation (OGD) was determined using Annexin V/PI assay. Finally, drosophila mothers against decapentaplegic protein 7 (Smad7) was overexpressed to further verify the mechanism of action of miR-424 mimic. Compared with that in the sham group, the expression of miR-424 in brain tissues significantly declined in the model group. The results of 2,3,5-triphenyltetrazolium chloride (TTC) staining and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay revealed that the miR-424 mimic obviously reduced the cerebral infarction area and apoptosis level of brain tissues, while the miR-424 inhibitor obviously increased the cerebral infarction area and apoptosis level of brain tissues. It was found, using bioinformatics and KEGG enrichment analysis, that differentially expressed genes induced by miR-424 were significantly enriched in the transforming growth factor-β (TGF-β) signaling pathway. According to the results of reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and Western blotting, the miR-424 mimic could evidently lower the expression of Smad7, thus activating the TGF-β1/Smad3 signaling pathway. Overexpression of Smad7 could weaken the protective effect of miR-424 mimic on ischemic-hypoxic cells. Increasing the expression of miR-424 can inhibit Smad7 to activate the TGF-β1/Smad3 signaling pathway, thereby exerting a protective effect against the brain tissue damage induced by MCAO.

Peripheral Artery Disease and Risk of Fibrosis Deterioration in Nonalcoholic Fatty Liver Disease: A Prospective Investigation

OBJECTIVE

Liver fibrosis is an important predictor of mortality in nonalcoholic fatty liver disease (NAFLD). Peripheral artery disease (PAD) and liver fibrosis share many common metabolic dysfunctions. We aimed to explore the association between PAD and risk of fibrosis deterioration in NAFLD patients.

METHODS

The study recruited 1,610 NAFLD patients aged ≥ 40 years from a well-defined community at baseline in 2010 and followed up between August 2014 and May 2015. Fibrosis deterioration was defined as the NAFLD fibrosis score (NFS) status increased to a higher category at the follow-up visit. PAD was defined as an ankle-brachial index of < 0.90 or > 1.40.

RESULTS

During an average of 4.3 years' follow-up, 618 patients progressed to a higher NFS category. PAD was associated with 92% increased risk of fibrosis deterioration [multivariable-adjusted odds ratio ( OR): 1.92, 95% confidence interval ( CI): 1.24, 2.98]. When stratified by baseline NFS status, the OR for progression from low to intermediate or high NFS was 1.74 (95% CI: 1.02, 3.00), and progression from intermediate to high NFS was 2.24 (95% CI: 1.05, 4.80). There was a significant interaction between PAD and insulin resistance (IR) on fibrosis deterioration ( P for interaction = 0.03). As compared with non-PAD and non-IR, the coexistence of PAD and IR was associated with a 3.85-fold (95% CI: 2.06, 7.18) increased risk of fibrosis deterioration.

CONCLUSION

PAD is associated with an increased risk of fibrosis deterioration in NAFLD patients, especially in those with IR. The coexistence of PAD and IR may impose an interactive effect on the risk of fibrosis deterioration.

Ideal Cardiovascular Health is Inversely Associated with Subclinical Atherosclerosis: A Prospective Analysis

OBJECTIVE

Ideal cardiovascular health (CVH) could predict a lower risk of developing cardiovascular diseases. This study was conducted to investigate the association between ideal CVH and subclinical atherosclerosis in a population cohort of Chinese adults aged ⪖ 40 years.

METHODS

This study was designed as a cross-sectional analysis of 8,395 participants who had complete data at baseline and a prospective analysis of 4,879 participants who had complete data at 4.3 years of follow-up. Ideal CVH metrics were defined according to the American Heart Association. Subclinical atherosclerosis was evaluated by plaques in carotid arteries, carotid intima-media thickness (CIMT), brachial-ankle pulse wave velocity (baPWV), and urinary albumin-to-creatinine ratio (UACR).

RESULTS

Both the prevalence and incidence of atherosclerosis measures were found to be decreased with increasing numbers of ideal CVH metrics at baseline (all P values for trend < 0.01). The levels of CIMT and UACR at follow-up showed an inverse and significant association with the numbers of ideal CVH metrics at baseline (both P values for trend < 0.05) but a borderline significant association with baPWV (P for trend = 0.0505). Taking participants with 0-1 ideal metric as reference, we found that participants with 5-6 ideal metrics had significantly lower risks of developing carotid plaques (odds ratio, OR = 0.46; 95% confidence interval, CI 0.27-0.79), increased CIMT (OR = 0.60; 95% CI 0.42-0.84), and increased baPWV (OR = 0.57; 95% CI 0.34-0.97) after full adjustments. A significant interactive effect of age and CVH was detected on CIMT and baPWV progression (both P values for interaction < 0.05).

CONCLUSION

The numbers of ideal CVH metrics showed a significant and inverse association with the risk of developing subclinical atherosclerosis in middle-aged and elderly Chinese adults, whereas its dose-response effect was attenuated in individuals aged ≥ 60 years and partially weakened in male participants.

Association between Coronary Atherosclerotic Plaque Composition and Cardiovascular Disease Risk

OBJECTIVE

The objective of this study is to determine whether coronary atherosclerotic plaque composition is associated with cardiovascular disease (CVD) risk in Chinese adults.

METHODS

We performed a cross-sectional analysis in 549 subjects without previous diagnosis or clinical symptoms of CVD in a community cohort of middle-aged Chinese adults. The participants underwent coronary computed tomography (CT) angiography for the evaluation of the presence and composition of coronary plaques. CVD risk was evaluated by the Framingham risk score (FRS) and the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score.

RESULTS

Among the 549 participants, 267 (48.6%) had no coronary plaques, 201 (36.6%) had noncalcified coronary plaques, and 81 (14.8%) had calcified or mixed coronary plaques. The measures of CVD risk including FRS and ASCVD risk score and the likelihood of having elevated FRS significantly increased across the groups of participants without coronary plaques, with noncalcified coronary plaques, and with calcified or mixed coronary plaques. However, only calcified or mixed coronary plaques were significantly associated with an elevated ASCVD risk score [odds ratio (OR) 2.41; 95% confidence interval (CI) 1.09-5.32] compared with no coronary plaques, whereas no significant association was found for noncalcified coronary plaques and elevated ASCVD risk score (OR 1.25; 95% CI 0.71-2.21) after multivariable adjustment.

CONCLUSION

Calcified or mixed coronary plaques might be more associated with an elevated likelihood of having CVD than noncalcified coronary plaques.

Serum Fetuin-A Levels and Thyroid Function inMiddle-aged and Elderly Chinese

Serum fetuin-A levels are reportedly elevated in hyperthyroidism. However, there are few relevant epidemiologic studies. We conducted a cross-sectional study in Songnan community, China in 2009 to investigate the association between serum fetuin-A concentrations and thyroid function. A total of 2,984 participants aged 40 years and older were analyzed. Multivariable linear regression analysis revealed that serum fetuin-A concentra- tions were positively associated with log (free triiodothyronine) and were inversely associated with log (thyroid peroxidase antibody) after adjustment (both P < 0.05). Compared with the participants in the lowest tertile of free triiodo-thyronine and free thyroxine level, those in the highest tertile had higher fetuin-A concentrations. Additionally, high serum fetuin-A concentrations were related to high thyroid function (odds ratio 1.27, 95% confidence interval 1.01-1.61), after adjustment for conventional risk factors.

Smoking and Its Relation to Metabolic Status among Chinese Adults: Analysis of a Nationwide Survey

OBJECTIVE

To update the estimated prevalence rates of smoking and examine major metabolic diseases associated with smoking status in Chinese adults.

METHODS

Using a complex, multistage, probability sampling design, we recruited a nationally representative sample of 98,658 Chinese adults aged ⋝18 years in 2010. Information on current, former, never, and passive smoking status was obtained using a standard questionnaire. All estimates were weighted to represent the overall Chinese adult population.

RESULTS

The estimated proportion of current smokers was 28.3% for Chinese adults aged ⋝18 years. The corresponding values of former and passive smokers were 5.1% and 21.4%, respectively. Additionally, former smokers were found to have a less favorable metabolic risk profile among all categories of smoking status in both men and women. The prevalence of metabolic diseases such as diabetes and hypertension also increased with a greater number of smoking pack-years in men.

CONCLUSION

The prevalences of current smoking and passive smoking remain high in Chinese adults.

EURO-MUSCULUS/USPRM. Basic scanning protocols for knee

In this protocol, the patient/probe positionings, anatomical drawings and ultrasound images of commonly scanned knee structures are described. This practical guide is prepared (with an international consensus of several expert physiatrists) to serve as a uniform/standard approach especially for beginner sonographers.

EURO-MUSCULUS/USPRM. Basic scanning protocols for hip

In this protocol, the patient/probe positionings, anatomical drawings and ultrasound images of commonly scanned hip structures are described. This practical guide is prepared (with an international consensus of several expert physiatrists) to serve as a uniform/standard approach especially for beginner sonographers.

EURO-MUSCULUS/USPRM. Basic Scanning Protocols for Ankle and foot

In this protocol, the patient/probe positionings, anatomical drawings and ultrasound images of commonly scanned ankle/foot structures are described. This practical guide is prepared (with an international consensus of several expert physiatrists) to serve as a uniform/standard approach especially for beginner sonographers.

EURO-MUSCULUS/USPRM Basic Scanning Protocols for elbow

In this protocol, the patient/probe positionings, anatomical drawings and ultrasound images of commonly scanned elbow structures are described. This practical guide is prepared (with an international consensus of several expert physiatrists) to serve as a uniform/standard approach especially for beginner sonographers.

Corrigendum. Early versus delayed passive range of motion exercise for arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials

Chang KV, Hung CY, Han DS, Chen WS, Wang TG, Chien KL. Early versus delayed passive range of motion exercise for arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials. Am J Sports Med. 2015;43(5):1265-1273. (Original DOI: 10.1177/0363546514544698 )

EURO-MUSCULUS/USPRM Basic Scanning Protocols for shoulder

In this protocol, the patient/probe positionings, anatomical drawings and ultrasound images of commonly scanned shoulder structures are described. This practical guide is prepared (with an international consensus of several expert physiatrists) to serve as a uniform/standard approach especially for beginner sonographers.

Associations of depression with impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes in Chinese adults

AIM

To examine the association between depression and impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes in middle-aged and elderly Chinese people, and whether depression was associated with different treatment regimens or durations of diabetes.

METHODS

A cross-sectional study was performed among 229,047 adults living in the community aged ≥ 40 years from 25 centres in China. The self-reported depression rating scale Patient Health Questionnaire 9 (PHQ-9) was used to diagnose probable and sub-threshold depression. Glucose metabolism status was determined according to World Health Organization 1999 diagnostic criteria.

RESULTS

The numbers of participants with normal glucose regulation, impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes were 120,458, 59,512, 24,826 and 24,251, respectively. The prevalence of sub-threshold depression in the total sample of participants was 4.8% (4.8%, 4.8%, 4.4% and 5.6% from normal glucose regulation to previously diagnosed diabetes, respectively), and the prevalence of probable depression was 1.1% (1.1%, 1.0%, 0.9% and 1.8% from normal glucose regulation to previously diagnosed diabetes, respectively). Compared with participants with normal glucose regulation, those with previously diagnosed diabetes had increased odds of probable depression [odds ratio (OR) = 1.61, 95% confidence interval (CI) 1.39-1.87] and sub-threshold depression (OR = 1.14, 95% CI 1.06-1.24), after adjustment for multiple confounding factors. Newly diagnosed diabetes or impaired glucose regulation was not associated with depression. Among those with previously diagnosed diabetes, insulin treatment was associated with greater odds of depression compared with no treatment or oral anti-diabetic medicine.

CONCLUSION

Previously diagnosed diabetes, but not newly diagnosed diabetes or impaired glucose regulation, was associated with a higher prevalence of depression. Patients receiving insulin were more likely to have depression than those not receiving treatment or being treated with oral anti-diabetic medicine.

Unsteady aerodynamic analysis for offshore floating wind turbines under different wind conditions

A free-vortex wake (FVW) model is developed in this paper to analyse the unsteady aerodynamic performance of offshore floating wind turbines. A time-marching algorithm of third-order accuracy is applied in the FVW model. Owing to the complex floating platform motions, the blade inflow conditions and the positions of initial points of vortex filaments, which are different from the fixed wind turbine, are modified in the implemented model. A three-dimensional rotational effect model and a dynamic stall model are coupled into the FVW model to improve the aerodynamic performance prediction in the unsteady conditions. The effects of floating platform motions in the simulation model are validated by comparison between calculation and experiment for a small-scale rigid test wind turbine coupled with a floating tension leg platform (TLP). The dynamic inflow effect carried by the FVW method itself is confirmed and the results agree well with the experimental data of a pitching transient on another test turbine. Also, the flapping moment at the blade root in yaw on the same test turbine is calculated and compares well with the experimental data. Then, the aerodynamic performance is simulated in a yawed condition of steady wind and in an unyawed condition of turbulent wind, respectively, for a large-scale wind turbine coupled with the floating TLP motions, demonstrating obvious differences in rotor performance and blade loading from the fixed wind turbine. The non-dimensional magnitudes of loading changes due to the floating platform motions decrease from the blade root to the blade tip.

Serum calcium level is associated with brachial-ankle pulse wave velocity in middle-aged and elderly Chinese

OBJECTIVE

To study the relation between serum calcium level and elevated BaPWV in Chinese subjects.

METHODS

The relation between serum calcium level and elevated BaPWV was studied in 9 615 subjects. The mean value of left and right BaPWV was analyzed. BaPWV was defined as high when it was ⋝1752.5 cm/s (the upper quartile) either side.

RESULTS

The BaPWV and its elevated percentage progressively increased across the quartiles of the serum calcium level (P<0.05). The prevalence of elevated BaPWV was significantly higher in subjects of the second, third and highest quartiles than in those of the lowest quartile (26.9%, 28.4%, and 33.2% vs 23.7%, P=0.0116, P=0.0004, and P<0.0001). Logistic regression analysis revealed that the risk of elevated BaPWV was 1.32- fold higher in subjects of the highest quartile than in those of the lowest quartile (OR=1.32, 95% CI: 1.08-1.60).

CONCLUSION

The elevated serum calcium level is related to an elevated BaPWV and a higher risk of arterial stiffness, independent of conventional risk factors, in middle-aged and elderly Chinese subjects.

Association of bisphenol a exposure with circulating sex hormone concentrations in men and postmenopausal women

A total of 1116 middle-aged and elderly men and 1442 postmenopausal women were recruited in this study. Whether bisphenol A exposure was associated with circulating sex hormone concentrations was studied. Univariate analysis revealed that the urinary bisphenol A concentration was negatively correlated with the serum levels of luteinizing hormone (β=-0.061, P<0.0001) and follicle-stimulating hormone (β=-0.086, P<0.0001) in men, and with the serum levels of follicle-stimulating hormone (β=-0.037, P=0.018) and sex hormone-binding globulin (β=-0.043, P=0.006) in women. However, no significant association was observed between the serum levels of urinary bisphenol A and circulating sex hormone after adjustment for the potential confounders.

A novel reactor for making uniform capsules

A novel chemical reactor was designed and developed for the continuous high-rate production of uniform capsules. This reactor helps to control precisely the reaction time between the reacting liquids (anion drops and the cation bath, or vice versa), thereby leading to the formation of uniform capsules with walls of identical thickness. In addition, mild tumbling of the capsules during transit through the reactor ensures that every capsule wall is uniformly thick all around.

A two-step process for controlling the surface smoothness of polyelectrolyte-based microcapsules

Biocompatibility is one of the crucial requirements to be fulfilled when designing devices for immunoisolation of transplanted cells. The quality of the capsule surface (smoothness/roughness) influences the nature of cell overgrowth on it by immunocytes, which eventually may lead to the transplant failure. A microcapsule has been developed based on the polyelectrolyte complexation of the polyanions sodium alginate and cellulose sulphate with the polycation poly(methylene-co-guanidine), which was successfully tested in rodent animal models. Recently, the principles for controlling the surface smoothness of these capsules has been identified. This paper reports on a two-step process used for production of stable capsules with improved surface properties. The methodology involves separating the process of drop shape recovery and precursor capsule formation from the process of membrane formation by applying a two-reactor design. The multi-loop reactors are connected in series, and the process separation is given by the different composition of cation solutions flowing in each reactor. This process enables one to prepare the microcapsule immunoisolation device, which can differ in the extent of surface roughness and, thus, is suitable for studying the effect of surface morphology of the immunoisolation device on cell overgrowth. The effect of this process on the capsule permeability has also been evaluated.

In vitro cellular tropism of human T cell leukemia virus type 2

Human T cell leukemia virus type 1 (HTLV-1) and 2 (HTLV-2) are distinct oncogenic retroviruses that infect several cell types, but display their biologic/pathogenic activity only in T lymphocytes. HTLV-1 is associated with adult T cell leukemia, a malignancy of mature CD4(+) T cells, and a chronic neurological disorder termed HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). HTLV-2 is less pathogenic and has been associated with a few cases of a variant of hairy cell leukemia and neurological disease. Previous studies have indicated that in vivo HTLV-1 has a preferential tropism for CD4(+) T cells, whereas HTLV-2 in vivo tropism is less clear, but appears to favor CD8(+) T cells. The molecular mechanism that determines the cellular tropism of HTLV-1 and HTLV-2 has not been precisely determined. However, one study by our group has provided evidence that HTLV-1-enhanced viral transcription in CD4(+) T cells may be responsible for its tropism. In an effort to understand HTLV-2 tropism we tested the ability of HTLV-2 to infect, replicate in, and transform purified CD4(+) or CD8(+) T cells in cell culture. After cocultures of purified primary human CD4(+) and CD8(+) T cells with an HTLV-2-producer cell line we measured viral transcription by reverse transcription PCR analysis, virus production by p19(gag) ELISA, proviral integration by DNA slot-blot analysis, surface phenotype by FACS analysis, and cellular transformation. We also measured HTLV-2 long terminal repeat-directed transcription in the presence and absence of Tax in purified CD4(+) and CD8(+) T cells, using transient transfection assays. Our data indicate that CD4(+) and CD8(+) T cells are equally susceptible to HTLV-2 infection. We observed no significant difference in viral transcription based on mRNA and virus production in CD4(+) and CD8(+) T cell cocultures. Although LTR transcription was enhanced 12- to 16-fold in the presence of Tax, there was no significant difference in CD4(+) or CD8(+) T cells. Interestingly, we show that HTLV-2 preferentially transforms CD8(+) T cells in culture. Together, our data indicate that, unlike HTLV-1, HTLV-2 cell tropism is not due to inhibition of viral infection and inefficient gene expression in CD4(+) versus CD8(+) T cells, and likely involves unique interactions with viral and CD8(+) T cell-specific proteins.

[The function of T7 promoter as cis-acting elements for polymerase II in eukaryotic cell]

Using the chlorampheniol acetyltransterase gene as reporter, the function of phage T7 promoter in mammalian cells was studied by inhibition of transcription with alpha-amanitin. The experiment proved that the reporter under T7 promoter was transcribed by RNA polymerase II. Competitive electropho retic mobility shift assay (CEMSA) with TATA box, CAAT box, GC box and octamer showed that the TATA box was competitive molecular for synthetic T7 promoter. It is possible that T7 promoter is bound with TF II D transcription factor. The TATA box and octamer were inserted into Pvu II site upstream from the T7 promoter of pT7CAT. Two recombinant plasmids, pT7TATACAT and pT7OCTCAT, were constructed and transfected into CHO cells. CAT-activity test showed that T7 promoter strength was increased by octamer factor, not by TATA box. These results suggested that T7 promoter functions as cis-acting elements of RNA polymerase II transcriptional system in eucaryotic cells.

Lipid hydroperoxide-induced apoptosis in human colonic CaCo-2 cells is associated with an early loss of cellular redox balance

Apoptosis plays a critical role in maintaining homeostasis of the intestinal epithelium. Dietary oxidants like peroxidized lipids could perturb cellular redox status and disrupt mucosal turnover. The objective of this study was to delineate the role of lipid hydroperoxide (LOOH) -induced redox shifts in intestinal apoptosis using the human colonic CaCo-2 cell. We found that subtoxic concentrations of LOOH increased CaCo-2 cell apoptosis. This LOOH-induced apoptosis was associated with a significant decrease in the ratio of reduced glutathione-to-oxidized glutathione (GSH/GSSG), which preceded DNA fragmentation by 12 to 14 h, suggesting a temporal relationship between the two events. Oxidation of GSH with the thiol oxidant diamide caused significant decreases in cellular GSH and GSH/GSSG at 15 min that correlated with the activation of caspase 3 (60 min) and cleavage of PARP (120 min), confirming a temporal link between induction of cellular redox imbalance and initiation of apoptotic cell death. These kinetic studies further reveal that oxidant-mediated early redox change (within 1 h) was a primary inciting event of the apoptotic cascade. Once initiated, the recovery of redox balance did not prevent the progression of CaCo-2 cell apoptosis to its biological end point at 24 h. Collectively, the study shows that subtoxic levels of LOOH disrupt intestinal redox homeostasis, which contributes to apoptosis. These results provide insights into the mechanism of hydroperoxide-induced mucosal turnover that have important implications for understanding oxidant-mediated genesis of gut pathology.

Dysphagia in patients with brainstem stroke: incidence and outcome

OBJECTIVE

This study was conducted to delineate the incidence and outcome of dysphagia among hospitalized patients who were referred for rehabilitation because of brainstem stroke.

DESIGN

We retrospectively reviewed the medical records of 36 patients who were admitted because of brainstem stroke. Information on the patients' clinical features, feeding status, and the results of clinical and videofluoroscopic swallowing examinations were obtained through chart review. Follow-up interviews were conducted via telephone to learn the general medical condition and feeding status of the patients 7-43 mo after hospital discharge.

RESULTS

A total of 81% of the patients had dysphagia at the time of initial clinical swallowing evaluation, which was performed 10-75 days after the onset of stroke. A total of 79% of the dysphagic individuals depended on tube feeding at the initial evaluation; 22% of all individuals could not resume oral intake at discharge. Statistical analyses revealed a significant association between poor outcome and disease involving the medulla, the presence of a wet voice during the initial swallowing test, and a delay or absence of the swallowing reflex. The incidence of aspiration pneumonia was 11%. There was a correlation between the detection of aspiration by modified barium meal videofluoroscopy and the development of aspiration pneumonia. Follow-up interviews showed that 88% of the 27 patients who were contacted had resumed full oral intake 4 mo after the onset of stroke.

CONCLUSIONS

The incidence of dysphagia was relatively high in our study population. The long-term outcome was favorable.

Influencing factors and ambulation outcome in patients with dual disabilities of hemiplegia and amputation

OBJECTIVE

To determine the ambulatory outcome and predictive factors of successful ambulation training in patients with both hemiplegia and lower extremity amputation.

DESIGN

A retrospective study.

SETTING

A rehabilitation center of a university hospital.

PATIENTS

Twenty-three patients with dual disabilities consecutively admitted to the rehabilitation center from 1984 to 1994.

MAIN OUTCOME MEASURES

Ambulatory outcome was measured using physical therapists' and physicians' notes at discharge or the last available clinical visit. Ambulation ability was graded as community and noncommunity ambulation, which included indoor ambulation and nonambulation. Several clinical features were reviewed to assess their association with ambulation outcome.

RESULTS

About two thirds of the 23 patients could be trained to be ambulatory: 10 (43.8%) achieved community ambulation and 5 (21.7%) achieved indoor ambulation. Of the clinical factors, only mental status showed a statistically significant association with good ambulation outcome (p<.05). When odds ratios were considered, several factors, including mild motor involvement, transtibial amputation, amputation before cerebrovascular accident, age younger than 60 years, and the presence of ipsilateral hemiplegia and amputation, showed trends toward association with increased ambulation achievement, although these associations were not statistically significant.

CONCLUSION

Impaired mental status seemed to be the most influential negative predictive factor of achieving community ambulation. If subjects with dual disabilities are properly selected, satisfactory results of ambulation training will be obtained.

Sonographic detection of occult fractures in the foot and ankle

PURPOSE

The purpose of this retrospective study was to determine whether high-resolution sonography can aid in the diagnosis of radiographically occult fractures in the foot and ankle.

METHODS

High-resolution sonography with a 10-MHz linear-array transducer was performed in 268 patients with foot and ankle injuries whose initial plain x-ray films were negative for fracture.

RESULTS

Twenty-four patients had occult fractures demonstrated by sonography. On sonography, the occult fractures appeared as a discontinuity of cortex echogenicity. The fractures were found at the calcaneus (n = 8), metatarsus (n = 6), talus (n = 3), navicular bone (n = 3), cuboid bone (n = 2), cuneiform bone (n = 1), and lateral malleolus (n = 1). Review of the patients' radiographs revealed tiny fractures at the sonographically identified locations in 2 patients. The first 5 patients underwent bone scans, which confirmed the presence of the fractures. The first 11 patients received follow-up sonographic examination 6 weeks after diagnosis; in all 11, an echogenic line over the previous fracture site, presumably representing callus formation, was noted.

CONCLUSIONS

Sonography-a readily available, noninvasive imaging technique-can provide important information about soft tissue injuries and cortical discontinuities in the foot and ankle area. Using this procedure, occult fractures can be identified and delineated, and costly procedures such as MRI can be avoided.

Sonographic evaluation of the posterior cruciate ligament in amputated specimens and normal subjects

The purpose of this study was to define the sonographic appearance and echogenicity of the normal posterior cruciate ligament. We examined the posterior cruciate ligament of five amputated specimens and five normal subjects using a 10 MHz linear array transducer. One K-wire was inserted into the substance of the posterior cruciate ligament of the amputated knee specimens to verify the location of the ligament on the sonogram. Various angles of insonation were used to examine the echogenicity of the posterior cruciate ligament. The results showed that the in situ posterior cruciate ligament appeared as a hypoechoic band relative to the surrounding tissue on sonograms, but it appeared hyperechoic when it was isolated and immersed in a water bath. The specific spatial orientation of the posterior cruciate ligament and anisotropy phenomenon contributed to the hypoechogenicity of the posterior cruciate ligament in situ on sonogram.

Ultrasonographic assessment of posterior heel pain

To investigate the value of ultrasonography in the diagnosis of posterior heel pain, 68 patients with normal plain x-ray findings of the posterior heel underwent ultrasonographic examination with a 10-MHz linear array probe. The findings included Achilles tendinosis (31 patients), retrocalcaneal bursitis (12), superficial Achilles bursitis (7), soft tissue mass (7), Achilles tendon rupture (4), xanthoma (3), tenosynovitis of the flexor hallucis longus tendon (2), and negative findings (2). Sixteen of these patients underwent surgery after ultrasonographic examination. The surgical diagnoses were consistent with the ultrasonographic diagnoses in all cases. With high-resolution ultrasonography, pathologic conditions of the posterior heel can be readily differentiated.

Atomic force microscopy used for the surface characterization of microcapsule immunoisolation devices

The surface morphology of the microcapsule used as a bioartificial pancreas was examined by atomic force microscopy (AFM) under ambient conditions in a liquid environment. The standard contact mode was used for imaging. The capsules exhibited different morphologies and surface roughness depending on the composition of the cation solution: namely, the mole ratio of antigelling and gelling cations [Na+]/[Ca2+]. Surface roughness parameters obtained by AFM measurements provide quantitative information on the surface properties of the capsular membrane. In this respect, AFM can be considered a valuable technique complementary to optical microscopy in providing feedback for capsule optimization.

Treatment of emotionalism with fluoxetine during rehabilitation

Emotionalism (emotional lability) is a common but distressing phenomenon that occurs frequently in individuals suffering cerebral vascular accidents and other brain diseases. Patients with emotionalism sometimes embarrass their families and themselves, becoming socially disabled despite normal physical function. At its worst, emotionalism interferes with rehabilitation programs, delays progress and sometimes makes these programs impossible. This paper reports the effect of fluoxetine in treating three patients with persistent emotionalism (2 cases following cerebrovascular accidents, 1 case following encephalitis). All 3 patients demonstrated dramatic improvement in emotionalism within 6 days of treatment. The severity, frequency and duration of each episode were reduced greatly. The treatment improved the effectiveness of the rehabilitation program, relieved patient and family embarrassment, and enabled patients to resume rapidly their previous lifestyle patterns. All patients reached the functional goals planned prior to the onset of rehabilitation. We conclude that fluoxetine is highly effective in treating the symptoms of emotionalism in all patients, and allows for recovery of both physical and social function.

Ventilatory and mouth occlusion pressure responses to hypercapnia in chronic tetraplegia

OBJECTIVE

To compare the ventilatory response to hypercapnia and the mouth occlusion pressure measured at 0.1 second following inspiration (P0.1) in hypercapnia between chronic tetraplegic and normal subjects.

DESIGN

A case-control study with an uneven sample size for the study of clinical disorders.

SETTING

Patients were recruited from the outpatient clinic of a rehabilitation department.

PARTICIPANTS

Seven normal men and 9 men with tetraplegia who had cervical cord injuries (C5-C8), with a mean injury duration of 9.7 yrs.

INTERVENTIONS

Pulmonary function tests were performed during resting, whereas minute ventilation (VE) and P0.1 were measured during CO2 rebreathing.

RESULTS

The maximal voluntary ventilation (MVV), vital capacity (VC), and maximal respiratory muscle strength in the tetraplegic subjects were significantly less than in the normal subjects. Both the ventilatory and P0.1 responses to hypercapnia were significantly reduced in tetraplegic as compared with normal subjects, but the reductions were eliminated by normalizing with maximal ventilatory performance (MVV or VC) and maximal inspiratory muscle strength (PImax), respectively.

CONCLUSIONS

Chronic tetraplegic persons have diminished ventilatory and P0.1 responses to hypercapnia. Respiratory muscle weakness may be a primary factor contributing to the diminished ventilatory response observed in these patients.

Sonographic detection of a stitch abscess

A 28-year-old man with a ruptured right Achilles tendon underwent primary end-to-end suture immediately after injury. Painful swelling developed 6 months later, and a lump with discharge from a sinus was observed during physical assessment. Sonographic examination with a 10-MHz linear-array transducer demonstrated a hypoechoic mass, 8 x 6 mm, within which were 2 markedly echogenic dots. A stitch abscess was strongly suspected and was confirmed surgically.

Sonography of pigmented villonodular synovitis in the ankle joint

Pigmented villonodular synovitis is a benign proliferative disorder of the synovium that results in villous nodule formation in joints, tendon sheaths, and bursae. We present a case of pigmented villonodular synovitis of the ankle joint that was diagnosed by sonography with color Doppler imaging. The sonograms revealed hypoechoic synovial proliferation, and hypervascularity was visible on color Doppler images. The differential diagnosis of a synovial thickening or mass is also discussed.

New technologies for bioartificial organs

Each year several hundred thousand Americans die because of organ failure. Organ transplantations have achieved remarkable success, but the source of human organs is limited. Only a small portion of patients can benefit annually from this method of treatment. Immunoisolated living cells as bioartificial organs can be transplanted into humans without the need for immunosuppression and its accompanying side effects. Immunoisolation allows cells from nonhuman species to be used, thereby overcoming the limited supply of human cells available for encapsulation, and the capsule can serve as an ideal cage to keep animal viruses from contacting the human host. To achieve this promise, we have incorporated the pore size distribution into a new design of capsule for the immunoisolation of living cells. In this model the capsule wall is thicker and the pores are bigger than in the current systems. The larger pores will allow the immune system to enter the membrane, and the smaller pores inside the membrane will act as the traps to prevent or delay most of the immune system from passing all the way through to the inner volume of the capsule where the living cells reside. Limited animal studies have supported the advantages of this new entrapment model over the current model. Systematic studies to determine optimal capsule design for human transplantation are now feasible.

Permeability assessment of capsules for islet transplantation

Despite considerable progress in the development of immunoisolation devices, the optimal permeability of such devices is not known. This limitation stems partly from deficits in knowledge about which molecules should be allowed to traverse the semipermeable membrane and which molecules should be excluded, and also partly from experimental obstacles that have prevented a systematic study of permeability. To determine the optimal permeability of immunoisolation devices, we have created a series of microcapsules (800 microM diameter) that span a broad range of molecular exclusion limits yet are identical in wall thickness and chemical composition. Capsule permeability was precisely defined by two complementary methods--size exclusion chromatography (SEC) and a newly developed methodology to assess permeability of biologically relevant proteins. The entry of interleukin-1 beta-125I was significantly delayed, but not prevented, when the capsule exclusion limit was decreased from 230 kD to 3.2 kD, as determined by SEC with dextran standards. The influx of IgG was as predicted, based on the viscosity radius R eta of IgG and the capsule exclusion limit defined by SEC. Glucose-stimulated insulin secretion by encapsulated pancreatic islets did not differ as capsule permeability was decreased from a molecular exclusion limit of 230 kD to 120 kD. These studies should assist in the design of immunoisolation devices by defining the permeability optimal for cell function and also should be applicable to any cell type or immunoisolation device.

Purification of polymers used for fabrication of an immunoisolation barrier

A multistep extraction procedure has been tested for purification of natural and semi-synthetic polymers used for fabrication of an immunoisolation barrier for implanting animal cells. This procedure, originally described by Klock et al. for alginates, has been adapted for other gelling polymers to remove pyrogens (endotoxins) and mitogens. Several other steps have also been tested, resulting in a new and simple procedure for polymer purification, giving satisfactory levels of contamination. Endotoxin levels have been quantified by means of chromogenic and gelclot LAL methods. A simple calculation of the endotoxin permissible levels shows that the quality of purified polymers exceeds FDA specifications for implantable polymers.

Interleukin 7 induces TCR gene rearrangement in adult marrow-resident murine precursor T cells

Rearrangement of the T cell antigen receptor genes is a complex, highly regulated process. To gain a better understanding of the extracellular factors involved in the regulation of TCR beta and gamma gene rearrangement in adult murine bone marrow-resident precursor T cells, several cytokines were tested for their ability to induce gene recombination. A selected population of C58/J bone marrow cells (Thy 1(low), CD3, CD8, B220) that is enriched for pre-T cell activity was propagated in vitro in medium supplemented with IL-3 and mast cell growth factor (MGF, also referred to as stem cell factor, Steele factor and c-kit ligand). These cytokines were required for the maintenance of pre-T cell activity in culture, but had no effect on TCR gene expression. Several additional cytokines were added to the culture medium. Of all those tested, only IL-7 induced complete rearrangement of the TCR gamma locus. Complete rearrangement of the TCR beta locus was not induced under any of the culture conditions analysed here. The bone marrow cells cultured in IL-3, MGF and IL-7 did not begin to express mature T cell proteins and maintained their in vivo progenitor potential. Furthermore, IL-7 cultured bone marrow cells were capable of differentiation in vivo into all phenotypic subpopulations of T cells, without an apparent bias toward the gammadelta lineage. The data presented here suggest that TCR gamma gene rearrangement in adult pre-T cells is regulated by IL-7, but that the TCR beta locus requires additional or alternative signals for the induction of complete rearrangement.

Ultrasonographic examination of the posterior tibial tendon

The posterior tibial tendons (PTTs) of 16 patients with PTT dysfunction and 10 age-matched healthy subjects were examined ultrasonographically, using a 10-MHz linear-array transducer. Normal PTTs appeared hyperechoic (more echogenic) and oval, with an average diameter of 7.8 mm x 3.7 mm at the medial malleolar level. Degenerated PTTs appeared hypoechoic (less echogenic) and swollen (9.8 mm x 5.0 mm). Peritendinitis presented as a hypoechoic rim on the longitudinal sonogram (along the long axis of the tendon) and a "target sign" (hyperechoic central structure with a hypoechoic halo) on the transverse sonogram (at the right angle to the long axis of the tendon). Complete rupture of the PTT revealed an empty tibial groove at the level of the medial malleolus on the transverse sonogram and a wavy fibril pattern over the distal end on the longitudinal sonogram. Compared with the operative findings or the results of the magnetic resonance imaging, ultrasonography was sensitive and specific in diagnosing tenosynovitis and complete rupture of the PTT.

Pre-thymic transcription of TCR genes by adult murine bone marrow cells

In the adult mouse, the earliest thymocytes are derived from bone marrow-resident T lymphocyte precursor (pre-T) cells that immigrate to the thymus. There they undergo maturation through a series of developmental steps that include rearrangement and expression of the TCR genes, positive and negative selection, and functional maturation. Although these intrathymic processes have been extensively characterized, little is known about the T cell-specific events that take place in the bone marrow microenvironment. Of particular interest are the events surrounding transcription and rearrangement of the various TCR chains that are required for functional TCR expression. We have previously reported the transcription of incompletely rearranged TCR beta genes in pre-T cell-containing fractions of adult bone marrow. Here we demonstrate that the TCR gamma chain genes are also transcriptionally active in these cells. Like the TCR beta transcripts, TCR gamma transcripts are sterile, originating from unrearranged gamma loci. Interestingly, both RAG-1 and RAG-2 transcripts were also detected in this cell fraction, suggesting that sterile TCR transcription might be dependent upon the presence of a functional recombinase system. However, both C beta and C gamma sterile transcripts could be detected from the same bone marrow cell population isolated from RAG-1 gene deficient mice. Therefore, the expression of TCR genes can initiate at the earliest stages of T cell development, prior to exposure to the thymic microenvironment, and a functional recombinase system is not required for the production of these sterile TCR transcripts.

Clinical experience in rehabilitation of spinal cord injury associated with schizophrenia

OBJECTIVE

To identify the clinical features and rehabilitation outcomes in spinal cord injury (SCI) patients with preexisting schizophrenia.

DESIGN

A retrospective study conducted by reviewing the charts of all patients diagnosed with both SCI and schizophrenia hospitalized from 1987 throughout 1994 in 2 rehabilitation units.

SETTING

Rehabilitation wards of two hospitals in Taiwan.

PATIENTS

Seventeen traumatic SCI patients with schizophrenia, including 7 men and 10 women. Patients without neurological deficits were excluded.

INTERVENTION

All subjects received psychiatric intervention and intensive rehabilitation programs during hospitalization.

MAIN OUTCOME MEASURES

The injury pattern and psychiatric condition were described. Abilities of locomotion, management of activities of daily living, and bladder control were measured.

RESULTS

Fifteen injuries caused by a voluntary fall subsequently resulted in thoracolumbar insult. Ten incomplete paraplegics were able to ambulate with or without a device on discharge. Four subjects had poor bladder control. The outcome of self-care skills was worse in those with high level injury. Psychiatric symptoms were one of the main obstacles during rehabilitation.

CONCLUSION

Voluntary fall that caused thoracolumbar injuries was the main cause of injuries in these patients. Psychiatric symptoms were present in the majority and might hinder the prognosis of treatment. Nevertheless rehabilitation programs were found to benefit subjects after their psychiatric problems were under control.

Transcription of the TCR-beta locus initiates in adult murine bone marrow

Successful expression of the TCR beta-chain gene is a multistep process that involves: 1) initial transcription of multiple, unrearranged gene segments, 2) rearrangement of V, D, and J gene segments to form a complete beta-chain gene, and 3) transcription of the fully rearranged beta gene. All of these events have been shown to occur in the thymus, where the majority of T cell development takes place; however, the extent to which any of these events may occur prethymically has not been established. To examine prethymic TCR-beta gene expression, RNA was isolated from a precursor T cell-enriched population (Thy 1low CD3-) of C58/J mouse bone marrow, and analyzed by reverse transcriptase-PCR. A transcript containing TCR-beta constant (C) region sequences but not variable (V) region sequences was amplified, suggesting that an unrearranged TCR-beta gene locus is transcriptionally active in this bone marrow population. The same product was detected in Thy 1+ CD3- bone marrow cells from nude mice, indicating that the thymic microenvironment is not necessary for initiation of TCR-beta gene transcription. This C beta transcript is not confined to pre-B cells, as it was identified in RNA isolated from Thy 1low CD3- B220- bone marrow cells. Germline V beta transcripts were also detected in RNA from this bone marrow population. Furthermore, Sca-1+ Lin- and Sca-1+ Lin+ bone marrow populations from both C58/J mice and nude mice also expressed the C beta transcript. DNA-PCR analyses with D beta-J beta primer sets revealed that partial rearrangement of the beta locus had occurred in all bone marrow populations analyzed. These data suggest that both transcription and partial rearrangement of the TCR-beta locus can initiate in bone marrow cells of adult mice, before exposure of these cells to the thymus.

Transcription of the TCR-beta locus initiates in adult murine bone marrow

Successful expression of the TCR beta-chain gene is a multistep process that involves: 1) initial transcription of multiple, unrearranged gene segments, 2) rearrangement of V, D, and J gene segments to form a complete beta-chain gene, and 3) transcription of the fully rearranged beta gene. All of these events have been shown to occur in the thymus, where the majority of T cell development takes place; however, the extent to which any of these events may occur prethymically has not been established. To examine prethymic TCR-beta gene expression, RNA was isolated from a precursor T cell-enriched population (Thy 1low CD3-) of C58/J mouse bone marrow, and analyzed by reverse transcriptase-PCR. A transcript containing TCR-beta constant (C) region sequences but not variable (V) region sequences was amplified, suggesting that an unrearranged TCR-beta gene locus is transcriptionally active in this bone marrow population. The same product was detected in Thy 1+ CD3- bone marrow cells from nude mice, indicating that the thymic microenvironment is not necessary for initiation of TCR-beta gene transcription. This C beta transcript is not confined to pre-B cells, as it was identified in RNA isolated from Thy 1low CD3- B220- bone marrow cells. Germline V beta transcripts were also detected in RNA from this bone marrow population. Furthermore, Sca-1+ Lin- and Sca-1+ Lin+ bone marrow populations from both C58/J mice and nude mice also expressed the C beta transcript. DNA-PCR analyses with D beta-J beta primer sets revealed that partial rearrangement of the beta locus had occurred in all bone marrow populations analyzed. These data suggest that both transcription and partial rearrangement of the TCR-beta locus can initiate in bone marrow cells of adult mice, before exposure of these cells to the thymus.

Noninvasive long-term ventilatory support for individuals with spinal muscular atrophy and functional bulbar musculature

Ten individuals with spinal muscular atrophy (SMA) and chronic ventilatory insufficiency were trained in the use of assisted coughing techniques and received intermittent positive pressure ventilation (IPPV) via oral and/or nasal interfaces for a mean of 5.3 (range = 1 to 17) years. During this time they had significantly fewer respiratory complications than before introduction of noninvasive respiratory muscle aids despite the fact that 6 of the 10 went on to require more than 20 hours per day of ventilator use with less than 2 hours of ventilator-free breathing time (VFBT). All except two noninvasive IPPV users had vital capacities (VCs) less than 13% of predicted normal. They could, however, communicate verbally and take nutrition by mouth. All of the patients remained in the community. Five patients were gainfully employed and four were in school. We conclude that noninvasive respiratory muscle aids including noninvasive IPPV and assisted coughing techniques are effective and practical alternatives to tracheostomy for SMA patients with ventilatory failure but functional bulbar musculature.

[Barium-pudding: a new medium for videofluoroscopic examination]

The evaluation of swallowing function is crucial in the management of dysphagic patients. It includes clinical assessment and laboratory tests that consist of fiberoptic endoscopic examination of swallowing (FEES) and videofluoroscopic examination. The "modified barium swallow" has been regarded as the standard procedure of videofluoroscopic examination since its introduction in 1983. The technique enables the entire process of deglutition to be observed with the benefits of safety, easily performance, and information. However, pitfalls developed in patients with pseudobulbar paralysis. Discrepancy always occurs between barium meals and real food and the refusal of swallow and misswallowing to the airway in videofluoroscopic examination sometimes occurs because of the unsatisfactory taste of barium meal. All these things make the procedure impractical and inaccurate. We developed a barium sulfate pudding that is better tasting, similar to real food as a pudding, is adequate to visualise on videofluoroscopic examination, and has the ability to represent the patient's capacity to swallow solid food. We present a case of hypoxic encephalopathy where the patient was considered to be in danger of aspiration when swallowing any consistency of foods. Barium-pudding study showed the patient had the ability to eat solid food with safety. We removed her nasogastric tube following barium-pudding assessment and successfully restored her oral feeding function within 2 weeks. Barium-Pudding is a better medium of videofluoroscopic examination by which to evaluate the swallowing function of solid food than Barium paste in patient, who have disturbed swallowing.

[General introduction to the clinical application of non-invasive respiratory aids]

Intermittent positive pressure ventilation via tracheostomy has been the most common method of providing ventilatory support for patients with respiratory failure since the late 1950s. It is the standard procedure for individuals who suffer from acute respiratory failure, impaired consciousness, and severe restrictive lung disease. However, numerous adverse complications from these invasive techniques have been reported in those who are long-term ventilator users. This paper describes the evolution and current application of non-invasive respiratory aids in both acute and long-term settings. The respiratory function can be aided by applying forces to the body or intermittent pressure to the air ways. The devices are negative pressure body ventilators which act on the body by creating negative pressure around the thorax and abdomen such devices effectively maintain the ventilation of individuals with respiratory failure, but have the shortcomings of bulkiness, high expense, and limitation on the users' activities. The non-invasive positive pressure ventilator applies intermittent pressure directly to the airway by a non-invasive interface; namely mouthpiece, nasal, or face masks. In this way, it can prevent patients from requiring either tracheostomy or endotracheal tube, but is not effective enough to ventilate patients with markedly decreased lung compliance because the high airway resistance provides air leakage from the non-invasive interface. Non-invasive respiratory aids should be the first choice to maintain ventilation for patients with respiratory failure secondary to neuromuscular disorder, because of their benefits of easy application, satisfactory results, fewer complications and early active rehabilitation. Increased understanding of non-invasive respiratory aids should assist in the management of patients with chronic respiratory failure.

[Clinical application of the ice water test in evaluation of neurogenic bladder dysfunction]

Ice water test (IWT) and cystometrography (CMG) were performed on 51 in patients with spinal cord injuries (SCI) to evaluate the sensitivity and specificity of the IWT in detecting detrusor reflex. A three-step grading system as established by Balmaseda et al was applied to determine the presence of detrusor activity on IWT. The test was considered 3+ when the catheter was expelled from the bladder within one minute following instillation of 90 mL of ice water; a 2+ test indicated voiding around the catheter after instillation of 90 mL of ice water; and a 1+ IWT was defined as voiding around the catheter or expelling the catheter after instilling another 210 mL of ice water into the bladder. The results showed that the sensitivity of IWT in detecting the presence of detrusor reflex in patients with neurogenic bladder dysfunction was 96% and the specificity was 79%. Among the four patients having false positive IWT, three of them were diagnosed with poor-compliance bladders. One patient with false negative IWT was found to have severe detrusor-sphincter dyssynergy. There was a significant difference in the strength of detrusor activity among the patients with 3+ IWT, with 2+ IWT, and with 1+ IWT. IWT is a useful technique to predict the existence of detrusor reflex in SCI patients. Its use as a supplement method to cystometrogram could be helpful in the bedside evaluation of patients with neurogenic bladder dysfunction.

Survival of individuals with spinal muscular atrophy on ventilatory support

Six ventilator-assisted individuals (VAIs) with spinal muscular atrophy (SMA) are described. All six survived by using intermittent positive pressure ventilation via an indwelling tracheostomy for a mean of 11.7 +/- 17.7 yr despite frequent episodes of mucus plugging and pneumonia. Four of the VAIs also received all nutrition via indwelling gastrostomy tubes because of severe bulbar muscle weakness. Four VAIs used tracheostomy intermittent positive pressure ventilation with their tracheostomy cuffs deflated and could communicate verbally. Five of the six VAIs remained institutionalized from the onset of ventilatory use. Two SMA VAIs survived for 15 and 4 yr, respectively, despite need for ventilatory support since early infancy. All four SMA VAIs who could communicate remained socially active and one, gainfully employed. We conclude that for patients with advanced SMA markedly prolonged survival is possible with ventilatory assistance despite severe respiratory and bulbar muscle dysfunction.