The safety and cost-analysis of simultaneous versus staged bilateral total knee arthroplasty in a Taiwan population

BACKGROUND

In patients with advanced osteoarthritis (OA) of the bilateral knees, uncertainty remains as to whether simultaneous bilateral total knee arthroplasty (SiTKA) or staged TKA (StTKA) is the treatment of choice. The purpose of this study was to investigate the safety and relative cost of SiTKA versus StTKA in Taiwan patients.

METHODS

Using the Big Data Center of Taipei Veterans General Hospital we retrospectively reviewed all patients who underwent SiTKA or StTKA due to OA or spontaneous osteonecrosis of the knee from January 2011 through December 2016. We assessed length of stay, transfusion rate, early postoperative complications, 30- day and 90-day readmission rate, 1-year reoperation rate, and the indication for reoperation. Furthermore, we analyzed the total cost of the two groups, including reimbursement from the national health insurance (NHI), cost of the procedures, and net income from each case.

RESULTS

A total of 2,016 patients (1,565 SiTKA and 451 StTKA) were included in this study. The two groups had no significant differences in rates of complications, 30-day and 90-day readmission, or 1-year reoperation. The length of stay was on average 5.0 days longer for StTKA (p<0.01). In terms of cost, all categories of medical costs were significantly lower for SiTKA, while the net hospital income was significantly higher for StTKA.

CONCLUSION

SiTKA is a safe and cost-effective surgery. Both SiTKA and StTKA have similar rates of postoperative complications, readmission and reoperation, but SiTKA significantly reduces medical expenses for both the patient and the NHI.

A double-blind comparison of the efficacy and tolerability of telmisartan 40-80 mg vs. losartan 50-100 mg in Taiwanese hypertensive patients

A multicentre, randomised, double-blind, double-dummy, parallel-group, dose-titration study was conducted to determine the efficacy and tolerability of telmisartan 40-80 mg once daily compared with losartan 50-100 mg once daily in 180 Taiwanese patients with mild-to-moderate essential hypertension. After an initial 2-week placebo run-in phase, patients were randomised in a double-blind, double-dummy fashion to receive either telmisartan 40 mg or losartan 50 mg. If blood pressure control (diastolic blood pressure [DBP] <90 mmHg or > or = 10 mmHg reduction in DBP) was achieved after 4 weeks, the dose was maintained for the second 4 weeks of the active treatment phase; if not, the dose was doubled to telmisartan 80 mg or losartan 100 mg, respectively, for the second 4 weeks of double-blind treatment. Telmisartan 40-80 mg (n = 86) was as effective as losartan 50-100 mg (n = 90) in reducing trough seated DBP (11.1 vs. 8.7 mmHg, p = 0.144), and was significantly more effective than losartan in reducing trough seated systolic blood pressure (SBP) (22.1 vs. 16.5 mmHg, p = 0.032) and standing SBP (21.0 vs. 16.3 mmHg, p = 0.033). Significantly fewer patients treated with telmisartan than those treated with losartan required uptitration after 4 weeks' treatment (32.6% vs. 61.5%, p = 0.001). Both telmisartan and losartan were well tolerated.

Cell cycle arrest allows centrin translation but not basal body formation during spermiogenesis inMarsilea

Spermiogenesis in the water fern Marsilea vestita is a rapid process that requires the de novo formation of basal bodies in a cytoplasmic particle known as a blepharoplast. Spermiogenesis is activated by placing dry spores into water and is dependent upon the translation of new proteins from stored mRNAs with little, if any, new transcription. We looked at the necessity of cell division cycles in the gametophyte as a prerequisite for the activation of centrin translation and for the consequent formation of blepharoplasts. Cell cycle arrest was induced by treatments of gametophytes with hydroxyurea, with olomoucine, or after RNAi, employing dsRNA derived from Marsilea cyclin A or cyclin B. In all cases, centrin is translated from stored mRNA at the normal time, approximately 4 hours after imbibition, and it accumulates to maximal levels ∼6 hours after imbibition. In spite of the fact that centrin is translated at essentially normal times and accumulates to nearly normal levels, no blepharoplasts form in the gametophytes where division cycles have been disrupted. These results provide a clear demonstration that the new translation of centrin, by itself, is insufficient for blepharoplast formation, the de novo formation of basal bodies, and the assembly of a motile apparatus.

Extraction of human DNA for PCR from chewed residues of betel quid using a novel "PVP/CTAB" method

Residues of chewed betel quid (BQ) are often found on crime scenes in Taiwan and possibly some of the Southeast Asian countries. Although these residues are important biological evidences relating to the suspects, the forensic analysis of BQ evidence has been hindered by failures in extraction of human DNA for PCR analysis. Therefore, it is a prerequisite for relevant forensic casework to establish a reliable method for extracting DNA from chewed BQ residues. Three conventional methods (salt/chloroform, 5% Chelex-100 resin, and QIAamp) were first tested for extraction of human DNA from 33 mock BQ samples, which had been stored for less than two months, and 50 four-year-old forensic BQ samples. PCR amplifications from the HLA-DQA1&PM and the STR loci were then used to test the quality of the extracted DNA. For the mock samples, three observations were made. First, PCR amplification of DNA extracted by using these conventional methods had low success rate. Second, the addition of extra Taq DNA polymerase could compensate the lost enzyme activities due to putative inhibitors and, thus, increase the yield. Third, using the Centricon-100 column to remove putative inhibitors substantially improved the efficiency of PCR. However, for the four-year-old forensic BQ samples, none of the attempts for PCR were successful. In order to solve the problem in PCR analysis of DNA from old BQ samples, we developed a DNA extraction method based on the use of polyvinyl pyrrolidone (PVP) and cetyltrimethylammonium bromide (CTAB), which bind to two common classes of PCR inhibitors in plants, polyphenols, and polysaccharides, respectively. The result showed that this "PVP/CTAB" method is completely successful for the mock BQ samples, and 92% (46 out of 50) successful for the four-year-old forensic BQ samples. To our best knowledge, this is the first report of a reliable method for the extraction of human DNA for PCR from chewed BQ residues. This method should provide a useful means for forensic identification in countries where betel chewing is common.

Primary structure and developmental expression of zebrafish sodium channel Na(v)1.6 during neurogenesis

A zebrafish sodium channel cDNA encoding a 1949-amino acid polypeptide, Na(v)1.6, was isolated. Two transcripts were detected in zebrafish adult brain but not in cardiac or skeletal muscle. The RNase protection analysis confirmed the neural specificity of zebrafish Na(v)1.6 24 hours postfertilization (hpf) Na(v)1.6 was expressed in the trigeminal ganglion, anterior and posterior lateral line ganglia, rhombomeres, and Rohon-Beard neurons. This preferential localization suggests that Na(v)1.6 plays an important role in tactile sensitivity. The abundance of zebrafish Na(v) 1.6 mRNA in the central and peripheral nervous systems increased markedly between 48 and 72 hpf, during the maturation of the nervous system.

Dietary fat and garlic oil independently regulate hepatic cytochrome p(450) 2B1 and the placental form of glutathione S-transferase expression in rats

The individual and combined effects of dietary fat and garlic oil on two drug-metabolizing enzymes, cytochrome P(450) 2B1 and the placental form of glutathione (GSH) S-transferase (PGST), in rat liver were examined in this study. Rats were fed a low corn oil, high corn oil or high fish oil diet and received various amount of garlic oil (0, 30, 80, 200 mg/kg body) orally three times per week for 6 wk. The fat energy in the low and high fat diets accounted for 11.6 and 45.7% of total energy, respectively. Final body weights did not differ among the three dietary fat groups and were not affected by garlic oil treatment. The fatty acid profile in hepatic phospholipids revealed higher eicosapentaenoic acid [20:5(n-3)] and docosahexaenoic acid [22:6(n-3)] levels in the fish oil-fed group than in the low and high corn oil-fed groups (P < 0.05). In contrast, the corn oil-fed groups had greater hepatic phospholipid arachidonic acid [20:4(n-6)] levels (P < 0.05). Both dietary fat and garlic oil significantly affected hepatic cytochrome 7-pentoxyresorufin O-dealkylase (PROD) activity and GST activity toward ethacrynic acid. Rats fed the high fish oil diet had 85 and 51% higher PROD activity compared with those fed the low or the high corn oil diet, respectively (P < 0.05). The GST activity in the high fish oil and the high corn oil groups was 33 and 18% higher than that in the low corn oil group (P < 0.05), respectively, and the GST activity in rats fed the high fish oil diet was higher than in those fed the high corn oil diet (P < 0.05). Garlic oil dose-dependently increased GST activity. No interaction between dietary fat and garlic oil on PROD or GST activity was noted. Northern and Western blot analysis revealed that dietary fish oil increased both cytochrome P(450) 2B1 and PGST mRNA and protein levels. Cytochrome P(450) 2B1 and PGST mRNA and protein levels were also dose-dependently increased by garlic oil treatment. The effects of garlic oil and dietary fat on P(450) 2B1 and PGST mRNA and protein expression were independent. These results indicate that dietary fat and garlic oil independently modulate P(450) 2B1 and PGST expression at transcriptional and/or post-transcriptional stages.

Analysis of specific adaptation to a domicile habitat: a comparative study of two closely related cockroach species

The German cockroach, Blattella germanica (L.), and the closely related species B. bisignata (Brunner) belong to the germanica species group. They are similar in appearance, life history, reproductive cycle, and courtship behavior. The most significant difference is habitat preferences: B. germanica is a household species and lives in crowded conditions, whereas the feral B. bisignata lives outdoors in a solitary manner. Nevertheless, B. bisignata has recently been found in households. A comparison between the two species has shown that B. germanica displays gregarious behavior and produces an aggregation pheromone, whereas both characters are absent in B. bisignata. Mate preference experiments have revealed that B. germanica females accepted only conspecific males, whereas B. bisignata females mated with males from both species, provided that long distance calling was bypassed. In addition, the high reproductive potential of B. germanica outcompeted the other species: when 10 pairs of B. germanica and of B. bisignata were kept together in crowded conditions during 3 mo, B. bisignata was driven into extinction. It is concluded that the chances of B. bisignata becoming a new household species are remote.

Chimaeric mice with disruption of the gene coding for phosphatidylinositol glycan class A (Pig-a) were defective in embryogenesis and spermatogenesis

Mutations in the gene encoding PIG-A (phosphatidylinositol glycan class A) are found in patients with paroxysmal nocturnal haemoglobinuria (PNH), an acquired haematopoietic stem cell disorder. Individuals with hereditary PIG-A mutations have never been identified, which is also manifested by the difficulties in generating Pig-a knockout (KO) mice. This study investigated the effect of Pig-a mutations on the development of visceral and genital organs in addition to the haematopoietic system by the generation of Pig-a KO chimaeric mice. Of a total of 54 live births out of 1684 blastocysts injected, chimaerism for Pig-a knockout was detected in 29 mice, suggesting the importance of Pig-a in embryogenesis and in live birth. Quantification of the degree of chimaerism in different organs of the surviving chimaeric mice revealed extremely low levels of Pig-a KO cells in the liver and spleen. In contrast, high levels of KO signals were usually detected in the brain, heart, lung and kidney. Haematopoiesis proceeded normally in these chimaeric mice (as measured by 'complete blood cell counting') and the Pig-a KO cells were present at low levels in red blood cells and B lymphocytes but at high levels in T lymphocytes, although these KO cells did not gain any growth advantage. The effect of Pig-a knockout was also prominent in the reproductive system, another organ with high mitotic activity. Breeding the male chimaeras revealed a high rate of infertility and abnormality in the male genital organs, including abnormally shaped testes, epididymis and seminal vesicles. Even in the absence of gross abnormalities of the genital organs, low counts of motile sperm were also discernible. Pig-a KO sperm was detected in these organs; however, no transmission of the KO allele was observed. The results suggest a possible mechanism underlying the non-transmission of the Pig-a KO gene in germlines.

Control of development and motility in the spermatozoids of lower plants

The spermatozoids of lower plants have long been recognized as remarkably complex motile gametes. Spermatozoids differ markedly from the other gametophyte cells that surround or give rise to them. Their differentiation process involves the synthesis and assembly of a complex cytoskeleton and a motile apparatus that can be simple or complex, having as few as two to as many as thousands of ciliary axonemes. An important aspect of spermiogenesis involves the de novo synthesis of basal bodies in a cytoplasmic particle known as the blepharoplast: that is, the cells that produce spermatocytes do not contain centrioles. Thus, these cells provide an ideal system in which to study the formation of basal bodies. The cytoskeletons of spermatozoids from different organisms display a common architecture, with a multilayered structure (MLS) at the anterior end of the cell and a dorsally situated planar ribbon of crosslinked microtubules extending the length of the elongated gamete. The function of the MLS is not known, but it could be involved in cell-body elongation during development and in the control of ciliary motility in the mature gamete, particularly during chemotaxis. The application of modern techniques on these cells can shed light on long-standing problems relating to spermiogenesis and motility.

A human importin-beta family protein, transportin-SR2, interacts with the phosphorylated RS domain of SR proteins

Serine/arginine-rich proteins (SR proteins) are mainly involved in the splicing of precursor mRNA. RS domains are also found in proteins that have influence on other aspects of gene expression. Proteins that contain an RS domain are often located in the speckled domains of the nucleus. Here we show that the RS domain derived from a human papillomavirus E2 transcriptional activator can target a heterologous protein to the nucleus, as it does in many other SR proteins, but insufficient for localization in speckles. By using E2 as a bait in a yeast two-hybrid screen, we identified a human importin-beta family protein that is homologous to yeast Mtr10p and almost identical to human transportin-SR. This transportin-SR2 (TRN-SR2) protein can interact with several cellular SR proteins. More importantly, we demonstrated that TRN-SR2 can directly interact with phosphorylated, but not unphosphorylated, RS domains. Finally, an indirect immunofluoresence study revealed that a transiently expressed TRN-SR2 mutant lacking the N-terminal region becomes localized to the nucleus in a speckled pattern that coincides with the distribution of the SR protein SC35. Thus, our results likely reflect a role of TRN-SR2 in the cellular trafficking of phosphorylated SR proteins.

Deconvolution of local surface response from topography in nanometer profilometry with a dual-scan method

In profilometric measurements, by scanning the sample twice with a fixed vertical offset, one can separate the signal that comes from surface heterogeneity from the topographic signal. Using differential confocal microscopy, a newly developed open-loop nanometer profilometric technique, we demonstrated this dual-scan method on composite samples and obtained 10-nm depth resolution. This technique can also be applied to other profilometric techniques such as atomic force microscopy and scanning tunneling microscopy.

D-serine added to clozapine for the treatment of schizophrenia

OBJECTIVE

D-Serine is a full agonist at the glycine site on the N-methyl-D-aspartate (NMDA) receptor. Previous administration of D-serine to schizophrenic patients taking nonclozapine antipsychotics improved positive, negative, and cognitive symptoms, whereas the partial agonist D-cycloserine improved negative symptoms of patients taking conventional antipsychotics but worsened symptoms in clozapine-treated patients. To study the difference between full and partial agonists at the NMDA receptor glycine site, the clinical effects of adding D-serine to clozapine were assessed.

METHOD

In a 6-week double-blind trial, 20 schizophrenic patients received placebo or D-serine (30 mg/kg per day) in addition to clozapine. Clinical efficacy, side effects, and serum levels of D-serine were determined every other week.

RESULTS

The patients exhibited no improvement with D-serine, nor did their symptoms worsen, as previously reported with D-cycloserine.

CONCLUSIONS

The results suggest either that clozapine may have an agonistic effect on the NMDA system or that clozapine-treated patients do not respond to D-serine.

A novel species of thermoacidophilic archaeon, Sulfolobus yangmingensis sp. nov

A novel microbe was isolated from a geothermal vent in Yang-Ming National Park in northern Taiwan. This spherical microbe with mean cell diameter of 1.1 +/- 0.2 microns is a facultatively chemolithoautotrophic archaeon that grows on elemental sulfur and reduced sulfur compounds. The optimal pH and temperature for growth are 4.0 (pH range 2.0-6.0) and 80 degrees C (temperature range 65-95 degrees C). Its membranes contain the lipids calditoglycerocaldarchaeol and caldarchaeol, which are common to other members of the Sulfolobaceae. Like Sulfolobus acidocaldarius, Sulfolobus shibatae and Sulfolobus solfataricus, the new isolate utilizes sugars and amino acids effectively as sole carbon sources. The G + C content of the genomic DNA was 42 mol%. DNA of the isolate hybridized weakly to the DNA of other Sulfolobus species. Phylogenetic analysis of the 16S rRNA indicated that the new isolate represents a deep branch within the genus Sulfolobus. On the basis of these properties, the new isolate appears to represent a new species of Sulfolobus, for which the name Sulfolobus yangmingensis sp. nov. is proposed. The type strain is strain YM1T.

A 12-amino acid stretch in the hypervariable region of the spike protein S1 subunit is critical for cell fusion activity of mouse hepatitis virus

The spike (S) glycoprotein of mouse hepatitis virus (MHV) plays a major role in the viral pathogenesis. It is often processed into the N-terminal S1 and the C-terminal S2 subunits that were evidently important for binding to cell receptor and inducing cell-cell fusion, respectively. As a consequence of cell-cell fusion, most of the naturally occurring infections of MHV are associated with syncytia formation. So far, only MHV-2 was identified to be fusion-negative. In this study, the S gene of MHV-2 was molecularly cloned, and the nucleotide sequence was determined. The MHV-2 S protein lacks a 12-amino acid stretch in the S1 hypervariable region from amino acid residue 446 to 457 when compared with the fusion-positive strain MHV-JHM. In addition, there are three amino acid substitutions in the S2 subunit, Tyr-1144 to Asp, Glu-1165 to Asp, and Arg-1209 to Lys. The cloned MHV-2 S protein exhibited the fusion-negative property in DBT cells as the intrinsic viral protein. Furthermore, similar to the fusion-positive MHV-JHM strain, proteolytic cleavage activity was detected both in DBT cells infected with the fusion-negative MHV-2 and in the transfected cells that expressed the cloned MHV-2 S protein. Domain swapping experiments demonstrated that the 12-amino acid stretch missing in the MHV-2 S1 subunit, but not the proteolytic cleavage site, was critical for the cell-fusion activity of MHV.

Pyogenic myositis: caused by viridans streptococci in an adult with tetralogy of Fallot

A 34-year-old man came to this Emergency Room because of fever, swelling and pain in the right thigh. Tetralogy of Fallot with bicuspid pulmonary valve was diagnosed after serial examination, and computed tomography of the right thigh revealed pyogenic myositis. Surgical drainage of the right thigh abscess and a further pus culture yielded viridans streptococci. There has been no record in the medical literature of a pyogenic myositis caused by viridans streptococci in an adult tetralogy of Fallot. This is thus the first case reported.

Thrombophilia in patients with hypercholesterolemia

To investigate a possible interrelationship between hypercholesterolemia and the coagulation and fibrinolytic system, the Cardiovascular Disease Risk Factor Two-Township Study in Taiwan was undertaken as a longitudinal prospective study focusing on the evolution of cardiovascular disease risk factors, with an emphasis on hemostatic factors. Hemostatic parameters measured in this study included prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, factor VIIc, factor VIIIc, antithrombin III, and plasminogen. Subjects of both sexes with hypercholesterolemia (> 6.2 mmol/L) also had significant elevations of diastolic blood pressure, plasma glucose, triglycerides, fibrinogen, and factor VIIc and reduced PT and APTT compared with subjects with lower cholesterol. The hypercholesterolemic women additionally had significant elevations of systolic blood pressure and factor VIIc. Levels of the anticoagulant factors, antithrombin III and plasminogen, were also higher in both hypercholesterolemic men and women. In men, only factor VIIIc had no statistically significant elevation. In women, only PT showed no statistical difference. Established coronary risk factors such as fibrinogen and factor VIIc showed remarkable elevations in patients of both sexes. Using Pearson correlation and multiple regression, the most significant parameter related to cholesterol level was factor VIIc. The present results show that hemostatic abnormalities do exist in patients with hypercholesterolemia, and this thrombophilic phenomenon sheds further light on the study of higher cardiovascular mortality in these subjects.

Transcatheter embolization of a coronary arteriovenous fistula with a complex, helical-fibered platinum coil

Transcatheter embolization was successfully performed on a 51-year-old man with a coronary arteriovenous fistula arising from the left circumflex coronary artery and draining into the superior vena cava. The patient presented with typical manifestations of angina pectoris that were first noticed during childhood but had worsened over the past 5 years. A 2 x 20 mm complex, helical-fibered platinum coil was placed in the mid-portion of the fistula and successfully occluded the fistula within 30 minutes. The patient has been free from angina pectoris since the procedure.

Squamous cell carcinoma of the nail bed

Squamous cell carcinoma of the nail bed is a rare disorder. Metastasis is extremely unusual. A case of primary squamous cell carcinoma of the nail bed with metastasis to the regional lymph nodes is reported. The tumor was successfully treated by amputation of the involved finger, block dissection of the regional lymph nodes, postoperative irradiation of the involved axilla, and systemic chemotherapy. Early diagnosis by biopsy, especially in patients with recurrent and persistent disease of the nail bed, is recommended, so that treatment can be instituted early while the tumor is confined to its primary site.

Running Y-V-plasty for burn scar contracture

Seventeen patients with 24 regions received running Y-V-plasties to release burn scar contractures over a 3-year period. The scar band can be completely interrupted and lengthened without the need for undermining and transposition of the skin flaps, circulatory embarrassment of the flaps can be avoided. The wound morbidity was extremely low, and no recurrence of the contracture was noted during follow-up periods. The running Y-V-plasty has unique advantages for the treatment of cord-like or linear burn scar contractures. This approach resulted in shorter hospital stay and allows early mobilization of the involved extremities.

Increased sympathetic nervous system activity in Chinese hypertensive patients with type II diabetes mellitus

To evaluate the coexistence of sympathetic overactivity and hypertension in type 2 diabetic patients, a population-based study was conducted of newly-diagnosed type 2 diabetic patients recruited from a single community located at northern Taiwan. This study included 2877 (male 1382, female 1495) middle-aged ethnic Chinese adults, aged 45-65 years. Of the 1382 males, 67 had newly-diagnosed type 2 diabetes mellitus, whereas 75 of the 1495 females had type 2 diabetes. The data showed that about 39% of diabetic patients had borderline hypertension (mean blood pressure 141/91 mmHg) whereas the average incidence in non-diabetic subjects was 15.5%. The borderline hypertensive diabetic patients had significantly higher heart rates (mean 78.8 vs. 69.3 beats/min; P < 0.001) than control subjects. However, the cardiac index was similar in both control and diabetic subjects (mean 2.48 vs. 2.53 l/min/m2; P > 0.05). Our data show that sympathetic overactivity and increased incidence of hypertension actually existed in these type 2 diabetic patients of Chinese origin.

Reverse digital artery neurovascular cross-finger flap

Soft tissue loss with digital nerve defect in the finger was reconstructed with the reverse digital artery neurovascular cross-finger flap in two cases with favorable results. The flap harvested from the lateral side of the proximal phalanx of the neighboring healthy finger is nourished by a distally based digital artery. The flap contained a segment of digital nerve dorsal branch, which is used to bridge the nerve gap in the wound while the flap is used to reconstruct the soft tissue defect concomitantly. The reverse digital artery neurovascular cross-finger flap seems to be a useful addition to the options for complicated finger damage involving soft tissue loss and nerve defect.

Clinical application of the distally based medial adipofascial flap for soft tissue defects on the lower half of the leg

OBJECTIVE

Reconstruction of soft tissue defects on the lower half of the leg.

DESIGN

The distally based medial adipofascial flap nourished by the lower perforator originating from the posterior tibial artery was harvested, and the pivot point of flap transposition is 9 to 12 cm above the tip of the medial malleolus.

MATERIALS AND METHODS

Twelve cases of open tibial fracture associated with soft tissue defects on the lower half of the leg were reconstructed with this flap. The cases consisted of ten males and two females, and their ages ranged from 16 to 71 (averaging 41 years).

MEASUREMENTS AND MAIN RESULTS

Size of the flap varied from 4 x 7 cm to 5 x 18 cm. Eleven flaps had good perfusion and survived completely. Tip necrosis of the flap occurred in one case. In the early postoperative period, take of the meshed split-thickness skin graft on the flap was not complete. All wounds, however, were resurfaced completely without the need of a second grafting. Discharging sinuses occurred in one case, which was managed by removal of infected bony fragments. All the donor sites were closed primarily, and desquamation of wound edges occurred occasionally.

CONCLUSIONS

The distally based medial adipofascial flap was a reliable and effect local flap for the reconstruction of soft tissue defects on the lower half of the leg.

Salmonellosis and mycotic aneurysm of the aorta. A report of 10 cases

We report a 5 year experience of 10 cases of mycotic aneurysms of the aorta caused by salmonella infection. Of the 10 patients, nine were males and one was female in an age range from 60 to 80 years with a mean of 71 years. The major clinical manifestations were fever, abdominal or back pain, pulsatile abdominal mass and leucocytosis. The diagnosis was based on clinical symptoms and signs and positive blood or tissue cultures. The main confirmatory procedure was computed tomography (CT). Two year survival rate was 20%. Five patients died during hospitalisation, without surgery. Three patients died within 2 months of surgery. The other two patients, treated surgically and by intensive antibiotic therapy, survived. Death resulted usually from recurrent infection and graft leakage. Contrary to previous reports, salmonella mycotic aneurysm is still common in this geographical area and the prognosis is poor.

Tissue distribution of absorbed humic acids

Distribution of humic acids (HA) in rats was studied using radioiodinated HA injected intraperitoneally. Distribution of (125)I was also studied for comparison. The distribution pattern of HA differed greatly from that of (125)I. Except in the thyroid and skin, (125)I was excreted from the body within 24 hours, whereas a large proportion of HA remained in the liver, kidney, skin, thyroid, bone and muscle. The difference in the distribution pattern and organ/serum radioactivity ratio suggests different kinetics for (125)I and (125)I-HA. The distribution pattern of HA correlated very well with the increased prevalences of organ diseases in the blackfoot disease endemic area, as reflected in epidemiologic studies. It is hypothesised that HA-metal complexes are possible etiological factors of diseases such as goitre, hepatoma, bladder cancer, vascular disease and diabetes mellitus, and that free radicals are the common causative factor.

Effect of humic acids on thyroidal function

Humic substances (HS) have been implicated as environmental goitrogens. Increased prevalence of goiter has been recently noticed in the blackfoot disease endemic area on the southwest coast of Taiwan, where well water is rich in HS. This study investigated the in vivo effects of humic acids (HA) on the thyroid gland of rats and mice. Groups of mice and rats were fed regular or moderately iodine deficient (approximately 167 vs 700 micrograms l- per kg) chow and distilled water or HA water (1mg/ml) for 3 or 4 months. Serum T4, T3, reverse T3, and/or TSH were measured by radioimmunoassay. Thyroidal 125I uptake was measured in mice at 2 h after injection of 1 microCi125I ip. Treatment of the rat with HA was associated with a significantly (p < 0.05) reduced serum T4 without a change in other parameters of study. Treatment with low iodine diet was associated with a clear increase in serum T3 and a decrease in serum rT3. Rats treated with both HA and low iodine diet showed a significantly reduced serum T4, increased serum T3 and decreased serum rT3. In mice, treatment with low iodine diet significantly increased thyroidal 125I uptake and additional treatment with HA significantly enhanced the effect of low iodine diet. Treatment with HA did not influence thyroid weight of rats or mice given normal or iodine deficient diets. We conclude that HA per se do not induce goiter, but they may enhance the goitrogenic effect of low iodine.

An easy way to prepare microskin grafts

The conventional technique to produce microskin grafts is a relatively time-consuming procedure. We developed an easy method by using a trimmed circular dermacarrier with the non-grooved side up and driving forward in the meshgraft instrument through six different angles that were 30 degrees apart. The tiny skin particles obtained by this method not only saved operation time but also survived well in the grafted wounds.

Reconstruction of soft tissue defects of the lower leg with the distally based medial adipofascial flap

A distally based medial adipofascial flap, based on the lower perforator originating from the posterior tibial vessels, is described. It has been used successfully to cover tibial bone and/or plate exposure on the lower leg in 5 patients.

Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects

To provide sensation to the reverse digital artery (RDA) flap, both the dorsal branch from the proper digital nerve and the superficial sensory branch from the corresponding radial or ulnar nerve are sectioned at their proximal ends and included with the RDA flap. These are then anastomosed with the distal ends of both radial and ulnar digital nerves at the recipient wound. Three cases of pulp defects reconstructed by this technique achieved very favourable functional and cosmetic results. The RDA flap, innervated through bilateral neurorrhaphy, seems to be an excellent option for one-stage reconstruction of major pulp defects.

Management of windshield facial injuries

Between Jan. 1986 and Dec. 1990, 99 patients with automobile windshield facial injuries were hospitalized in Kaohsiung Medical College hospital. All patients were injured by old type windshields in car accidents. Seventy-three patients (74%) were male and twenty-six (26%) were female. Ages ranged from 6 to 62 years (mean age 31 years). Fifty-seven patients (58%) were car drivers and forty-two (42%) were front seat passengers. All patients had typical multiple U-shaped lacerations on the face. The major injury sites were localized to the upper one third of the face. The wounds were repaired immediately after careful debridement. A total of 21 facial bone fractures were noted. All were open fractures with large, deep avulsion wounds. Displaced and comminuted fractures received reduction and fixation before wound closure. Three patients had cranial bone fracture with no displacement. Brain edema and subarachnoid hemorrhage were found by brain CT scan in two and one patients respectively. They were treated conservatively. In one patient with frontal sinus fracture the glass pieces penetrated into the brain. The foreign bodies were removed from the brain and frontal sinus. Eyeball rupture was found in 16 patients, including two patients in whom both eyes were involved. Eight eyeballs needed immediate evisceration and ten eyeballs received reparation. Blindness occurred in all these patients. Of the 99 patients in this study, 15% sustained additional injury. Most were wounds on the extremities. Because serious injuries can be caused by the old type of windshields, it should be abandoned. Driving with the seat belt fastened is the best way to insure safety.

The subgalea-periosteal turnover flap for reconstruction of scalp defects

Subgalea-periosteal flaps were successfully used in a turnover pattern to reconstruct two scalp defects with exposed calvaria caused by tumor ablation. A copious vascular network of the subgaleal fascia in the base and its attached lateral territories provide adequate blood inflow for the turnover flap. The periosteum is included in the flap to protect the blood supply of the subgaleal component from damage during dissection, and its uniform surface constitutes an ideal bed to receive skin grafts. The tissue is readily available and a large flap can be created in a single surgical step without deformities or sequelae left in the donor area. The subgalea-periosteal turnover flap overlaid with skin graft seems to make reconstruction of the complicated scalp defect much simpler and straightforward.

Tracheal deviation: an unusual complication of platysma myocutaneous flap

Reconstruction of the intraoral defect caused by tongue cancer was done for a patient by using a platysma myocutaneous flap. The relatively short neck, scar contracture, and inactive movement of the involved side of the neck resulted in tracheal deviation, an unusual complication not appearing in previous reports. In order to avoid airway problems during intubation, the surgeon and anesthestist should seriously consider the possibility of this rare complication in patients who have had the platysma myocutaneous flap technique. Careful preoperative evaluation and skillful intubation of the fiberoptic bronchoscope are demanded in cases where next general anesthesia is needed.

Clinical application of adipofascial turn-over flaps for burn wounds

Local adipofascial turn-over flaps overlaid with skin grafts were used successfully to reconstruct nine deep burn wounds following electric injuries or contact burns in seven patients. Durable flap coverage of the exposed tendons, joints or bones can be achieved with a one-stage procedure. Appropriate length-to-width ratio and flap-to-base area ratio, and the tension-free insetting of the flap are essential for flap survival. The non-adherent characteristic of the adiposal component of the flap enables the underlying involved tendons or joints to glide through without adherence, and the rich vascular network in the fascia provides an ideal bed for the skin graft. The adipofascial turn-over flap is a reliable and simple technique for reconstruction of certain deep burn wounds if the surrounding soft tissue is available. The functional and cosmetic results in our series have been rewarding and satisfactory.

Microskin grafting of rabbit skin wounds with Biobrane overlay

Biobrane was used to overlay micrografts and the wound using the microskin grafting technique with an expansion ratio of 10:1 in 16 rabbits. The rabbits were divided randomly into four groups, with four rabbits in each group, for evaluating the wound conditions on days 7, 10, 12 and 14. Histological examination of the removed Biobrane showed a variable degree of entrapment of inflammatory cells within the nylon fabric. Biobrane adhered well to the wounds although many wrinkles containing fluid accumulations were noted on day 7. By 10, 12 and 14 days all the wounds become dry and their Biobrane adhered completely. Histological examination of the grafted wound on day 7 showed active proliferation and spread of micrografts. In the later groups, the neoepidermis increased in thickness and differentiated into skin with a normal texture. On day 10, the wounds were almost completely resurfaced with neoepithelium. The growth of these grafts progressed smoothly as the adherent Biobrane was kept on the wound for 12 or 14 days. In these animal studies, the overlain Biobrane provided favourable conditions for the successful growth of micrografts.

A versatile method for reconstruction of finger defects: reverse digital artery flap

Four types of the reverse digital artery flap--standard, extended, and innervated standard and extended--were developed for 52 finger defects. The arising pattern of the dorsal branch which was included in the innervated flap was studied and classified in cadaver dissections. Topographically, the described "Lai's line" is a useful guide to locate the underlying digital artery. Refinements in flap design and surgical technique resulted in favourable functional and cosmetic results. The average two-point discrimination of the reconstructed fingertip was 6.8 mm and 3.9 mm in the noninnervated and innervated flaps, respectively. This versatile flap is an ideal and reliable option for one-stage reconstruction of various finger defects.

Microskin autograft with pigskin xenograft overlay: a preliminary report of studies on patients

Split-thickness pigskin graft (STPSG) was used to replace allograft skin for microskin grafting in 16 patients, nine of whom were burn patients, five suffered from traumatic defects and two from diabetic ulcers. The expansion ratios used in these patients ranged from 8:1 to 12:1. The STPSG preparation described was found to be safe for clinical application. The autogenous donor skin was excised from the inguinal area, and the donor site was primarily closed. There were no instances of donor site morbidity. The majority of the STPSG overlays adhered to the wound firmly. Histological examination showed that the microskin grafts proliferated actively immediately beneath the STPSG overlay. The time for the wound to be fully resurfaced varied from 13 to 21 days depending on the expansion ratio employed. There were only two episodes of pseudomonas infection and no further grafting was required in any of the patients. In this study the pigskin xenograft was found to provide a suitable environment for the epithelialization of microskin autografts. When allograft is not available, this is an alternative way of ensuring successful microskin grafting.

The distally based posterior tibial arterial adipofascial flap

A distally based posterior tibial artery adipofascial flap with skin graft was used for the reconstruction of soft tissue defects over the Achilles tendon in three cases and over the heel in three cases. Good resurfacing with protective sensation of these wounds was achieved. There was no breakdown of the graft or morbidity of donor sites, which were closed primarily. We believe there were many advantages to this adipofascial flap and that it is an ideal choice for the reconstruction of soft tissue defects in the lower third of the leg and foot, especially over the Achilles tendon.

[Surgical treatment of diffuse scrotal epidermal cysts: case report]

Epidermal cysts are common, benign skin tumors that are found mainly on the face, neck, and trunk. This case was a 53-year-old male bus driver who had suffered from multiple papules on his scrotum for 7 years. This affliction had caused intractable itching and responded poorly to medical treatment. The patient received an excision of these papules (total 32) 3 years ago. According to the pathological reports, these papules were epidermal cysts; unfortunately, these papules recurred within 3 months after the operation and then resulted in itching more severe than before. The patient was again admitted to the hospital ward and received an operation in Oct. 1990. The diseased tissue (14cm x 8cm) was then excised and the defective scrotal skin was covered with a meshed, split-thickness skin graft. The cosmetic result was enhanced by the rugate appearance of the healed meshed graft. The patient was satisfied with both the functional and cosmetic results. The itching sensation on the scrotum improved and there was no recurrence of epidermal cysts within the graft area during the 9 month follow-up period. With this simple and safe operation, the result gave a satisfying improvement in both symptoms and appearance; so this case is offered for reference.

Vasorelaxing effect in rat thoracic aorta caused by denudatin B, isolated from the Chinese herb, magnolia fargesii

Denudatin B is an antiplatelet agent isolated from the flower buds of Magnolia fargesii. We studied the effects of denudatin B on the vasoconstriction of rat thoracic aorta induced by high potassium (K+) solution, norepinephrine (NE) and caffeine, and to elucidate its mode of action. The contraction of rat aorta caused by high K+ (60 mM) and cumulative concentrations of CaCl2 (0.03-3 mM) was inhibited concentration dependently by denudatin B with an IC50 of 21.2 micrograms/ml. NE (3 microM)-induced phasic and tonic contractions of rat aorta were inhibited by pretreatment with denudatin B (10-100 micrograms/ml). The relaxing action of denudatin B persisted in denuded aorta, in Ca2(+)-free and EGTA (2 mM)-containing medium. The vasorelaxing effects were not affected by indomethacin (20 microM), hemoglobin (10 microM) or methylene blue (50 microM) and were not accompanied by PGI2 formation. In quin-2/AM-loaded cultured rat vascular smooth muscle cells, denudatin B (100 micrograms/ml) inhibited the increase of intracellular calcium caused by NE (3 microM) in the presence or absence of extracellular calcium. Denudatin B did not affect the caffeine (10 mM)-induced contraction and the increase in intracellular calcium. Denudatin B (100 micrograms/ml) increased the cGMP, but not the cAMP level in intact and denuded aorta. The 45Ca2+ influx induced in rat aorta by high K+ (60 mM) or NE (3 microM) was markedly inhibited by denudatin B in a concentration-dependent manner. These results indicate that denudatin B relaxed vascular smooth muscle by inhibiting the Ca2+ influx through voltage-gated and receptor-operated Ca2+ channels; its effect to increase cGMP may enhance the vasorelaxation.

Ultradian rhythm of growth hormone secretion and sleep in the adult male rat

The correlation between growth hormone (GH) secretion and the sleep-wakefulness cycle in the adult male rat was studied by serial blood sampling at 10 min intervals. Electroencephalograms (e.e.g.s) recorded continuously during the blood sampling were scored into wakefulness and sleep, and the amount of sleep for every 10 min was plotted against the GH value as assessed by radioimmunoassay. The power spectrum analysis and the least-squares method applied to the time series of GH concentrations in the control rat revealed that the mean (+/- S.E. of the mean) periodicity was 2.93 +/- 0.10 h for the period from 00.00 to 12.00 h in five rats and 2.85 +/- 0.06 h for the period from 12.00 to 24.00 h in eight rats. For the animals in which the e.e.g. was recorded simultaneously with blood samplings from 12.00 to 24.00 h, the cross-correlation analysis performed between the time series of the amount of sleep and the GH value revealed a significant positive correlation at time lags of 0-10 min in six and at time lags of 20-50 min in four out of fourteen rats. The number of animals having a positive correlation at short time lags seemed relatively less, but in most animals, there was observed a definite relationship that each GH peak occurred with a consistent time lag ranging from 40 to 70 min following the onset of sleep cycle. Sleep deprivation performed from 13.00 to 16.00 h during the sampling period from 11.00 to 19.00 h was effective in preventing high-level GH pulses which otherwise should appear during this time of the day. Concurrent measurements of corticosterone concentrations in the sleep-deprivation experiment revealed that peak values of corticosterone secretory episodes were not influenced by sleep deprivation. These findings indicate that the GH secretion in the adult rat is also correlated with the sleep-wakefulness cycle, although somewhat differently from the immature rat.

[A 3-hour period ultradian rhythm of the sleep-wakefulness cycle and growth hormone secretion in the immature rat]

The temporal patterns of the sleep-wakefulness cycle and growth hormone secretion throughout a day in the male and female rat were studied in male and rats at 27 approximately 31 days of age. EEGs were recorded continuously from 27 to 31 days of age, and a time series of the amount of sleep for every 10 min was obtained. Serial blood sampling through an intracardiac cannula at 10-min intervals was performed for each of the 6-h periods beginning at 12:00, 18:00, 00:00 and 06:00 h. By analysis of the power spectrum and the least squares method, the time series was found to have approximately a 3.0-h periodicity in any of the 6-h periods and in either sex. The peak time which was estimated for the time series of GH concentrations was found to occur consistently around 02:00 approximately 03:00, 05:00 approximately 06:00, 08:00 approximately 09:00, 11:00 approximately 12:00, 14:00 approximately 15:00, 17:00 approximately 18:00, 20:00 approximately 21:00 and 23:00 approximately 24:00 h in either the male or the female rat. The time series of the amount of sleep over a 24-h period at 29 days of age revealed an ultradian rhythm with approximately a 3.0-h periodicity, and the peak time was estimated to be the same as that for the GH time series Taking the findings that the GH secretion is related to sleep in the prepubertal rat as described in the accompanying paper (Tsai, 1983), it could be speculated that the rat GH secretory rhythm develops by 30 days of age as a 3.0-h period ultradian rhythm that entrains to the time of day, relating to the rhythm of the sleep-wakefulness cycle.

[The relationship between growth hormone secretion and the sleep-wakefulness cycle in the immature rat]

In order to study the relationship between growth hormone (GH) secretion and the sleep-wakefulness cycle in the rat, 29- to 31-day-old male and female rats were bled serially through an intracardiac cannula at 10-min intervals from 1200 to 1800 h. EEGs recorded continuously during the blood sampling period were scored into wakefulness and sleep, and the amount of sleep for every 10 min was plotted against the GH values as assessed by RIA. The power spectrum analysis and the least squares method applied to the time series of GH concentrations in the control rat revealed that the mean (+/- SE) periodicity was 3.03 +/- 0.17 (n = 11) h for the male and 2.90 +/- 0.13 (n = 11) h for the female. The cross-correlation analysis performed between the time series of the amount of sleep and the GH value revealed a significant positive correlation between GH level and the amount of sleep during the preceding 10 min. Further, the time series of sleep amount had periodicities of 3.22 +/- 0.20 h for the male and 2.96 +/- 0.12 h for the female. Forced-wakefulness imposed on 8 male rats between 1300 and 1500 h was effective in preventing GH secretory bursts, which otherwise should appear during this time of the day. Corticosterone measurement by protein-binding assay revealed that the procedure of forced-wakefulness did not act as the "stress" which has been known to inhibit GH secretion in rats. These findings indicate that GH secretion in the rat is sleep-related as has been proved in humans.

Relationship between the three-hour-period sleep-wakefulness cycle and growth hormone secretion in the immature rat

The temporal pattern of growth hormone (GH) secretion throughout a day and its correlation with the sleep-wakefulness cycle in the 29-31-day-old female rat were studied by serial blood sampling through an intracardiac cannula at 10-min intervals. Electroencephalograms (e.e.g.s) recorded continuously during blood sampling periods were scored into wakefulness and sleep, and the amount of sleep for every 10 min was plotted against the GH value as assessed by radio-immunoassay. B analysis of the power spectrum using the least-squares method, the time series of GH concentration was found to have a periodicity of approximately 3.0 h in any of the 6-h periods sampled, beginning at 12.00, 18.00, 00.00 and 06.00 h, and in either sex. The peak time which was estimated for the time series of GH concentrations was found to occur consistently around 02.00-03.00, 05.00-06.00, 08.00-09.00, 11.00-12.00, 14.00-15.00, 17.00-18.00, 20.00-21.00 and 23.00-24.00 h in either the male or the female rat. The cross-correlation analysis performed between the time series of the amount of sleep and the GH concentration, which were obtained for the 6-h period from 12.00 to 18.00 h, revealed a significant positive correlation between the GH level and the amount of sleep during the preceding 10 min. The time series of the amount of sleep over a 24-h period from the data obtained in the continuous recording of e.e.g.s from 27 to 31 days of age revealed an ultradian rhythm with a periodicity of approximately 3.0 h. These findings indicate that the rat GH secretory rhythm with a 3.0-h periodicity develops by 30 days of age in both sexes, relating to the 3.0-h-period ultradian rhythm of the sleep-wakefulness cycle entrained by the light cycle.

Detailed profile of prolactin secretion in the immature female rat: evidence for the existence of an ultradian rhythm

The detailed profile of prolactin (PRL) secretion in 22-24 and 29-31 days old female rats was investigated by serial blood sampling through an intracardiac cannula at 15-min intervals for each of the 9 or 10-h periods beginning at 09.00 or 10.00 and 22.00 h. By analysis of the power spectrum and the least squares method the time series of PRL concentrations which were measured by RIA were found to have approximately a 3-h period ultradian rhythm in either sampling period of both the 22-24 and 29-31 days old rats. The peak times calculated based on the acrophase estimated through the calculation of periodicity were concentrated around 12.00, 15.00 and 18.00 h for the sampling period 10.00-19.00, and 24.00, 03.00 and 06.00 h for the sampling period 22.00-07.00 h. However, in more than half of the animals at 22-24 days of age, one secretory episode around 12.00 h, and two secretory episodes around 24.00 and 03.00 h had markedly small amplitudes, making the remaining secretory episodes distinct diurnal and nocturnal surges, respectively. In the animals at 29-31 days of age, the amplitudes of the PRL episodes occurring around 12.00 h were markedly small, making the remaining two episodes as diurnal surges, whereas the amplitudes of PRL secretory episodes during the period 22.00-07.00 h were analogous to each other. These findings indicate that the semicircadian rhythm of PRL secretion is established on the basis of PRL secretion with the 3.0-h period ultradian rhythm.

Correlation of growth hormone secretion to sleep in the immature rat

The correlation between growth hormone (GH) secretion and the sleep-wakefulness cycle in the 29-31 day-old male rat was studied by serial blood sampling through an intracardiac cannula at 10 min intervals from 12.00 to 18.00 h. E.e.g.s recorded continuously during the blood sampling period were scored into wakefulness and sleep, and the amount of sleep for every 10 min was plotted against the GH value as assessed by radioimmunoassay. The power spectrum analysis and the least-squares method applied to the time series of GH concentrations in the control rat, revealed that the mean periodicity was 3.12 +/- 0.09 h (mean +/- S.E. of the mean) in fourteen rats examined. For the animals in which the e.e.g. was recorded simultaneously with blood samplings, the cross-correlation analysis performed between the time series of the amount of sleep and the GH value revealed a significant positive correlation between the GH level and the amount of sleep during the preceding 10 min. The time series of the sleep amount and the GH value had mean periodicities of 3.09 +/- 0.17 and 3.05 +/- 0.13 h (mean +/- S.E. of the mean), respectively, in twenty-seven rats examined. 5. Sleep deprivation performed between 13.00 and 15.00 h was effective in preventing GH secretory bursts which otherwise should appear during this time period of the day. 6. Corticosterone measurement by protein-binding assay revealed that the procedure of sleep deprivation did not act as the 'stress' which has been known to inhibit GH secretion in the rat. These findings indicate that GH secretion in the rat is sleep-related, as has been proved in the human.