Eplerenone improves hyperglycemia and sympathetic excitation in chronic renocardiac syndrome in rats

We aimed to assess the efficacy of eplerenone, a steroidal mineralocorticoid receptor antagonist known to reduce blood pressure and mitigate cardiovascular disease (CVD) progression, in retarding the progression of chronic kidney disease (CKD) and CVD in a rat model of type 4 cardiorenal syndrome (CRS). We grouped rats into four experimental categories: sham surgery, sham treatment with eplerenone, nephrectomy without eplerenone (Nx), and nephrectomy with eplerenone (Nx + EP). For the Nx + EP group, rats received five-sixths nephrectomy, inducing CKD and CVD conditions such as renal hypertension and hyperglycemia, and were then treated with eplerenone (100 mg/kg/day, orally) over 4 weeks after an initial 4-week observation period. Heart rate, blood pressure, blood sugar levels, and sympathetic nerve excitation were monitored biweekly. In addition, assessments of renal and cardiac tissues, including evaluation of renal tubulointerstitial injury, glomerular injury, and cardiomyocyte hypertrophy, were conducted at week 8. Eplerenone administration mitigated CKD and CVD progression in the Nx + EP group, evident by improved blood pressure (217.3 ± 5.4 versus 175.3 ± 5.6), blood sugar (121.8 ± 1.3 versus 145.6 ± 6.0) level, reduced sympathetic nerve excitation, and cardiomyocyte hypertrophy compared to the Nx group. However, renal tubulointerstitial injury, glomerular injury, and cardiovascular dysfunction, which were increased in rats with type 4 CRS, did not show significant changes with eplerenone treatment. Our study demonstrated that eplerenone treatment did not exacerbate type 4 CRS but improved blood pressure, blood sugar levels, sympathetic nerve excitation, and cardiomyocyte hypertrophy in this model.

Extended X-ray absorption fine structure of dynamically-compressed copper up to 1 terapascal

Large laser facilities have recently enabled material characterization at the pressures of Earth and Super-Earth cores. However, the temperature of the compressed materials has been largely unknown, or solely relied on models and simulations, due to lack of diagnostics under these challenging conditions. Here, we report on temperature, density, pressure, and local structure of copper determined from extended x-ray absorption fine structure and velocimetry up to 1 Terapascal. These results nearly double the highest pressure at which extended x-ray absorption fine structure has been reported in any material. In this work, the copper temperature is unexpectedly found to be much higher than predicted when adjacent to diamond layer(s), demonstrating the important influence of the sample environment on the thermal state of materials; this effect may introduce additional temperature uncertainties in some previous experiments using diamond and provides new guidance for future experimental design.

Reentrance of interface superconductivity in a high-Tc cuprate heterostructure

Increasing the carrier density in a Mott insulator by chemical doping gives rise to a generic superconducting dome in high temperature superconductors. An intriguing question is whether a second superconducting dome may exist at higher dopings. Here we heavily overdope La2-xSrxCuO4 (0.45 ≤ x ≤ 1.0) and discover an unprecedented reentrance of interface superconductivity in La2-xSrxCuO4 /La2CuO4 heterostructures. As x increases, the superconductivity is weakened and completely fades away at x = 0.8; but it revives at higher doping and fully recovers at x = 1.0. This is shown to be correlated with the suppression of the interfacial charge transfer around x = 0.8 and the weak-to-strong localization crossover in the La2-xSrxCuO4 layer. We further construct a theoretical model to account for the sophisticated relation between charge localization and interfacial charge transfer. Our work advances both the search for and control of new superconducting heterostructures.

A Randomized Standard-of-Care Controlled Trial of Xenogeneic Platelet-Rich Plasma Lotion to Reduce Acute Radiation Dermatitis in Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

Breast cancer patients experience acute radiation dermatitis (ARD) during radiation therapy (RT). The Multinational Association for Supportive Cancer Care published clinical practice guidelines for the prevention and treatment of ARD in 2013, and mild bathing at the irradiated site is the standard health education. This study examined the prophylactic effect of the newly developed xenogeneic platelet-rich plasma (PRP) lotion on acute radiation dermatitis (ARD) for breast cancer patients.

MATERIALS/METHODS

Ductal carcinoma in situ and early-stage breast cancers were enrolled after breast conserving surgery. Hypo-fractionated whole breast irradiation (42.5 Gy in 16 fractions) followed by tumor bed boost (10 Gy in 5 fractions) was used. Patients were randomly assigned to the Standard of Care (SOC) group (n = 48) or the PRP lotion group (n = 52). In both groups, patients were educated with standard health education on topical skin care. In the PRP lotion group, patients were instructed to apply the provided lotion twice a day, starting from the first day of RT: the first application within 1 hour after the daily RT session, the second at bedtime, and continue during the weekends. Patients were instructed not to apply the lotion within 6 hours before daily RT. We recorded the following skin reaction every week during RT and two weeks after RT: ARD was graded following the RTOG definition by two radiation oncologists; Dermatology Life Quality Index (DLQI) and Visual Analogue Scale for Pain (VAS Pain) were subjectively scored by patients to present patient-reported outcomes. The statistical software was used for all statistical analyses.

RESULTS

The patient characteristics in both groups were balanced except for a higher body mass index in the PRP lotion group. One patient did not complete RT in the SOC group due to pain intolerance. The severity of ARD grading in both groups is shown in Table. In comparison to the SOC group, the PRP lotion group demonstrated significantly reduced and delayed progression of ARD (p<0.01) and VAS Pain (p<0.01) during the whole RT course and two weeks after RT. The DLQI significantly improved at the 2nd week (p = 0.003), 3rd week (p = 0.01), 4th week (p<0.001), and the two weeks post-RT (p<0.001) period; however, this was not observed during the 1st week (p = 0.68). Similarly, the DLQI value progressively worsened two weeks after RT in the SOC group but not in the PRP lotion group.

CONCLUSION

This is the first study to use xenogeneic PRP lotion to prevent ARD clinically. The outcome of this study validated the prophylactic effects of xenogeneic PRP lotion on ARD, subsequently leading to an improved quality of life across the RT course.

Paricalcitol improved cardiac hypertrophy and fibrosis through upregulation of fibroblast growth factor-23 and downregulation of transforming growth factor-beta in a rat model of isoproterenol-induced cardiomyopathy

Acute cardiomyopathy is a significant global health concern and one of the leading causes of death in developed countries. Prior studies have shown an association between acute cardiomyopathy and low vitamin D levels. Although paricalcitol, a vitamin D receptor (VDR) activator, has demonstrated clinical benefits in patients with advanced kidney disease, its effect on cardiac remodeling in cardiomyopathy is unknown. This study aimed to investigate the relative effects of paricalcitol on cardiomyopathy in rats. Wistar-Kyoto rats were administered vehicle (sham control group) or isoproterenol to induce cardiomyopathy. Rats administered isoproterenol were subsequently treated with paricalcitol (experimental group) or vehicle (isoproterenol group). Picrosirius red and immunofluorescence staining were used to analyze cardiac fibrosis and hypertrophy. Immunohistochemistry staining was used to confirm the molecular mechanisms involved in isoproterenol-induced cardiomyopathy in rats. Injection of paricalcitol could reduce collagen and transforming growth factor-beta 1 (TGF-β1) levels while activating fibroblast growth factor receptor 1 (FGFR1) and fibroblast growth factor-23 (FGF23) without the help of Klotho, thereby reducing myocardial hypertrophy and fibrosis. As a VDR activator, paricalcitol reduces isoproterenol-induced cardiac fibrosis and hypertrophy by reducing the expression of TGF-β1 and enhancing the expression of VDR, FGFR1, and FGF23.

[A multicenter study on childhood Hodgkin lymphoma treated with HL-2013 regimen in China]

Objective: To evaluate the efficacy of the Hodgkin lymphoma (HL)-2013 regimen in the treatment of children with HL, and to investigate the prognostic factors of childhood HL. Methods: Clinical data of 145 children (aged ≤18 years) with newly diagnosed HL, treated with HL-2013 regimen in 8 tertiary referral centers for childhood cancer from August 2011 to April 2021 were analyzed retrospectively. All the diagnosis were confirmed by histopathological morphology and immunohistochemical examination. The clinical characteristics and treatment outcomes were summarized, and the patients were divided into different groups according to clinical characteristics. Kaplan-Meier method was used for survival analysis, and the comparison of survival rates between groups was performed with Log-rank test. Results: Of the 145 cases, there were 115 males and 30 females, the age at diagnosis was 7.9 (5.8, 10.6) years. Cervical lymph node enlargement (114 cases, 78.6%) was the common symptom of the disease, and 57 patients (39.3%) were accompanied by large masses. The most common pathological classification was mixed cell type (93 cases, 64.1%). According to the Ann Arbor staging system, there were 9 cases of stage Ⅰ, 62 cases of stage Ⅱ, 45 cases of stage Ⅲ, 29 cases of stage Ⅳ. According to the risk stratification: there were 14 cases of low-risk group, 76 cases of medium-risk group and 55 cases of high-risk group. Of all patients, 68 cases (46.9%) achieved an early complete remission (CR) after 2 courses of chemotherapy, and the CR rate was 93.8% (136/145) after first-line treatment. Disease recurrence or progression occurred in 22 cases (15.2%). Of all patients, 125 cases survived, 6 cases died and 14 cases were lost to follow-up. Among the survived cases, 123 cases were continuously at CR state,and the follow-up time was 55 (40, 76) months. The 5-year overall survival (OS) and event free survival (EFS) rates were (95.3±1.9)% and (84.2±3.0)% for the entire group, respectively. 5-year OS and EFS rates for patients with stage Ⅲ-Ⅳ were both lower than those for patients with stage Ⅰ-Ⅱ (χ²=6.28 and 7.58, both P<0.05), the 5-year OS and EFS rates for patients in high-risk group were both lower than those for patients in low-risk and medium-risk group (χ²=10.93, 7.79, both P<0.05). The 5-year OS rates for the patient with early CR and without early CR were 100.0% and (90.9±3.6)% (χ²=5.77, P=0.016). EFS rates for the patient with early CR (68 cases) and without early CR (77 cases) were (93.8±3.0)% and (75.8±5.0)% (χ²=8.78, P=0.003). Conclusions: HL-2013 regimen is significantly effective in the treatment of pediatric HL. However, the patients in high-risk group and those without early CR are prone to disease recurrence or progression. Stage Ⅲ-Ⅳ and without early CR were associated with worse prognosis.

Performance of the EuroSCORE II Model in Predicting Short-Term Mortality of General Cardiac Surgery: A Single-Center Study in Taiwan

BACKGROUND

The latest European System for Cardiac Operative Risk Evaluation (EuroSCORE) II is a well-accepted risk evaluation system for mortality in cardiac surgery in Europe.

OBJECTIVES

To determine the performance of this new model in Taiwanese patients.

METHODS

Between January 2012 and December 2014, 657 patients underwent cardiac surgery at our institution. The EuroSCORE II scores of all patients were determined preoperatively. The short-term surgical outcomes of 30-day and in-hospital mortality were evaluated to assess the performance of the EuroSCORE II.

RESULTS

Of the 657 patients [192 women (29.22%); age 63.5 ± 12.68 years], the 30-day mortality rate was 5.48%, and the in-hospital mortality rate was 9.28%. The discrimination power of this new model was good in all populations, regardless of 30-day mortality or in-hospital mortality. Good accuracy was also noted in different procedures related to coronary artery bypass grafting, and good calibration was noted for cardiac procedures (p value > 0.05). When predicting surgical death within 30 days, the EuroSCORE II overestimated the risk (observed to expected: 0.79), but in-hospital mortality was underestimated (observed to expected: 1.33). The predictive ability [area under the curve (AUC) of the receiver operating characteristic (ROC) curve] and calibration of the EuroSCORE II for 30-day mortality (0.792) and in-hospital mortality (0.825) suggested that in-hospital mortality is a better endpoint for the EuroSCORE II.

CONCLUSIONS

The new EuroSCORE II model performed well in predicting short-term outcomes among patients undergoing general cardiac surgeries. For short-term outcomes, in-hospital mortality was better than 30-day mortality as an indicator of surgical results, suggesting that it may be a better endpoint for the EuroSCORE II.

It is Time to Replace Large Drains with Small Ones After Fixation of Rib Fractures: A Prospective Observational Study

Introduction

Large-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS.

Methods

Overall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared.

Results

All patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171–10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109–4.888, P = 0.027).

Conclusion

After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.

Glut5 Knockdown in the Nucleus Tractus Solitarii Alleviates Fructose-Induced Hypertension in Rats

BACKGROUND

Several studies have suggested mechanisms whereby excessive fructose intake increases blood pressure (BP). Glucose transporter 5 (GLUT5) is a fructose transporter expressed on enterocytes, and its involvement in the nucleus tractus solitarius (NTS)-modulated increase in BP following fructose intake remains unclear.

OBJECTIVES

Herein, we investigated whether NTS Glut5 knockdown (KD) can alleviate fructose-induced hypertension in rat models.

METHODS

Male Wistar-Kyoto rats (6-8 weeks old; average weight: 230 g) were randomly assigned into 4 groups [control (Con), fructose (Fru), fructose + scrambled (Fru + S), and Fru +  KD]. The Con group rats had ad libitum access to regular water, and the other 3 groups were provided 10% fructose water ad libitum for 4 weeks (2 weeks before lentiviral transfection in the Fru + S and Fru + KD groups). Glut5 short hairpin RNA was delivered into the NTS of rats using a lentivirus system. Fructose-induced hypertension was assessed via the tail-cuff technique, a noninvasive blood pressure measurement approach. GLUT5-associated and other insulin signaling pathways in the NTS of rats were assessed using immunofluorescence and immunoblotting analyses. We evaluated between-group differences using the Mann-Whitney U test or Kruskal-Wallis 1-way ANOVA.

RESULTS

Compared with the Fru + S group, the Fru + KD group had reduced sympathetic nerve hyperactivity (48.8 ± 3.2 bursts/min; P < 0.05), improved central insulin signaling, upregulated protein kinase B (AKT; 3.0-fold) and neuronal NO synthase (nNOS; 2.78-fold) expression, and lowered BP (17 ± 1 mmHg, P < 0.05). Moreover, Glut5 KD restored signaling dependent on adenosine 5'-monophosphate-activated protein kinase and reduced fructose-induced oxidative stress 2.0-fold, and thus decreased NAD(P)H oxidase in p67-phox 1.9-fold within the NTS.

CONCLUSIONS

Fructose-induced reactive oxygen species generates in the NTS of rats through GLUT5 and receptor for advanced glycation end products signaling, thus impairing the AKT-nNOS-NO signaling pathway and ultimately causing hypertension.

Endovascular management of aorto-iliac occlusive disease (Leriche syndrome)

BACKGROUND

Bypass grafting is the standard of care for chronic aorto-iliac occlusive disease (AIOD, aka Leriche Syndrome) but is associated with mortality rates of up to 25% if surgical re-intervention is necessary. Despite a recent shift towards an endovascular-first strategy for TransAtlantic InterSociety Consensus II ("TASC II") C and D lesions, reports from Leriche Syndrome are still limited.

PATIENTS AND METHODS

15 high-risk patients (11 male, 4 female), mean age of 60.6 years, with chronic aorto-iliac occlusive disease were retrospectively reviewed. Retrograde approaches via the bilateral femoral arteries for aortic occlusion less than 4 cm in length and/or antegrade fashion from the brachial artery for juxtarenal type lesions were made. For the latter, thrombolysis prior to angioplasty was also performed. Intraluminal or if necessary, subintimal angioplasty was performed with deployment of either bare metal stents or stentgrafts in a kissing-stent fashion.

RESULTS

A total of 28 iliac arteries and 14 occluded abdominal aorta were treated with 100% technical success, of which 25% success were achieved by using subintimal technique. Two minor complications occurred, including vascular rupture and distal emboli in one patient apiece, which were successfully managed via endovascular fashion. There were no complications of renal artery emboli. Primary and secondary patency rates at 1, 3 and 5 years were 92.3% and 100%; 83.9% and 100%; and 83.9% and 100%, respectively.

CONCLUSION

Endovascular therapy for chronic aorto-iliac occlusion has a high technical success rate, with good short- and mid-term primary and secondary patency rates and may provide a valid alternative to surgery for high-risk patients.

A Rare Case of Douche Injury Sustained during Water Recreation Activities: More Protection will Mean less Injury

Douche injury is a rare consequence of water recreation activities; it can manifest as vaginal laceration or even haemoperitoneum. Such severe trauma can cause massive bleeding and hypovolaemic shock; therefore, it is potentially life threatening. Herein, we present the case of a patient who had vaginal laceration and haemoperitoneum due to water recreation activities; surgery was performed to stop the bleeding. We suggest wearing a rubber or neoprene wetsuit during water recreation activities to prevent such potentially lethal injury.

The use of a Colapinto TIPS Needle under cone-beam computed tomography guidance for true lumen re-entry in subintimal recanalization of chronic iliac artery occlusion

BACKGROUND

To report the technique and clinical outcome of subintimal re-entry in chronic iliac artery occlusion by using a Colapinto transjugular intrahepatic portosystemic shunt (TIPS) needle under rotational angiography (cone-beam computed tomography; CT) imaging guidance.

METHODS

Patients with chronic iliac artery occlusion with earlier failed attempts at conventional percutaneous recanalization during the past 5 years were enrolled in our study. In these patients, an ipsilateral femoral access route was routinely utilized in a retrograde fashion. A Colapinto TIPS Needle was used to aid the true lumen re-entry after failed conventional intraluminal or subintimal guidewire and catheter-based techniques. The puncture was directed under rotational angiography cone-beam CT guidance to re-enter the abdominal aorta. Bare metallic stents 8-10 mm in diameter were deployed in the common iliac artery, and followed by balloon dilation.

RESULTS

Ten patients (9 male; median age, 75 years) were included in our investigation. The average occlusion length was 10.2 cm (range, 4-15 cm). According to the Trans-Atlantic Inter-Society Consensus (TASC) II classification, there were five patients each with Class B and D lesions. Successful re-entry was achieved in all patients without procedure-related complications. The ankle-brachial index (ABI) values increased from 0.38-0.79 to 0.75-1.28 after the procedure. Imaging follow-up (> 6 months) was available in six patients with patency of all stented iliac artery. Thereafter, no complaints of recurrent clinical symptoms occurred during the follow-up period.

CONCLUSION

The use of Colapinto TIPS needle, especially under cone-beam CT image guidance, appears to be safe and effective to re-enter the true lumen in a subintimal angioplasty for a difficult chronic total iliac occlusion.

[Comparison of clinical outcomes of patients with non-small cell lung cancer harboring different types of epidermal growth factor receptor sensitive mutations after first-line EGFR-TKI treatment]

OBJECTIVE

To analyze whether there are differences in the efficacy and clinical outcomes to first-line tyrosine kinase inhibitors (TKI) therapy in Chinese patients with metastatic non-small-cell lung cancer (NSCLC) harboring different subtypes of epidermal growth factor receptor (EGFR) mutations.

METHODS

A retrospective analysis was made on the clinical data of stage ⅢB or Ⅳ NSCLC patients who were diagnosed by histology and received EGFR mutation test, in order to confirm if there is any difference between the therapeutic effects of TKIs as first-line therapy and the prognosis.

RESULTS

A total of 165 patients harboring EGFR exon 19 deletion (19del, n=71), exon 21 L858R mutation (L858R, n=80) or uncommon sensitive mutation (n=14) were treated with EGFR-TKIs for first-line treatment. The comparison among different groups of common types of sensitive mutations revealed that the objective response rate (ORR) of group 19del and group L858R were 57.8% and 45.0%, respectively (P=0.113). The disease control rate (DCR) was 93.0% and 93.8%, respectively (P=0.158). However, the ORR and DCR of uncommon sensitive mutation were 35.7% and 78.6%, which were significantly lower than that of the group 19del (P=0.035) and group L858R (P=0.020). The median progression-free survival (PFS) of group 19del, group L858R and uncommon sensitive mutation were 14.0 months, 7.8 months and 5.1 months, respectively (P=0.001). The median PFS of the group 19del was significantly longer than that of the group L858R (P=0.009). The median overall survival (OS) of these three groups had significant difference (22.8, 15.2 and 10.0 months) (P=0.048). But those of group 19del and group L858R were similar (P=0.152). The multivariate analysis indicated that ECOG-PS (P=0.030), cigarette smoking (P=0.013) and EGFR mutation types (P=0.034) are independent prognostic factors of OS.

CONCLUSIONS

For Chinese NSCLC patients with different types of sensitive mutation, there are differences between their efficacy and prognosis of EGFR-TKIs as first-line treatment. The PFS of group 19del is obviously longer than that of other types of sensitive mutations, but have no significant differences in OS. The PFS and OS of patients with common types of sensitive mutation are better than those with uncommon sensitive mutation.

Left Atrial Expansion Index Predicts Left Ventricular Filling Pressure and Adverse Events in Acute Heart Failure With Severe Left Ventricular Dysfunction

BACKGROUND

The power of left atrial (LA) parameters for predicting left ventricular (LV) filling pressure and adverse events in acute heart failure (HF) with severe LV dysfunction, either sinus rhythm or atrial fibrillation (AF), is not fully understood.

METHODS AND RESULTS

Echocardiography was performed in 141 patients with acute decompensated congestive HF and LV ejection fraction <35%, including 42 with permanent AF. The LA expansion index was calculated as (Volmax - Volmin) × 100%/Volmin, where Volmax was defined as maximal and Volmin as minimal LA volume. Of 141 patients, invasive LV filling pressures within 12 hours of LA expansion index measurement were available in 109. The end points were 3-year frequencies of HF hospitalization and all-cause mortality. Over a median follow-up of 3.1 years, 74 participants (52.5%) reached the end points (sinus vs AF group: 48.5% vs 61.9%, respectively; P = .047). Multivariate analysis revealed that adverse events of both groups were only independently associated with age and LA expansion index. Rates of adverse events were proportional to LA expansion index. There was a good logarithmic relationship between LA expansion index and LV filling pressure, regardless of presence or absence of AF.

CONCLUSIONS

LV filling pressure can be estimated well by LA expansion index, with or without AF. The LA expansion index predicts adverse events in HF patients with severe systolic dysfunction. (ClinicalTrials.gov number: NCT01307722).

Clonal evolution in hematological malignancies and therapeutic implications

The ability of cancer to evolve and adapt is a principal challenge to therapy in general and to the paradigm of targeted therapy in particular. This ability is fueled by the co-existence of multiple, genetically heterogeneous subpopulations within the cancer cell population. Increasing evidence has supported the idea that these subpopulations are selected in a Darwinian fashion, by which the genetic landscape of the tumor is continuously reshaped. Massively parallel sequencing has enabled a recent surge in our ability to study this process, adding to previous efforts using cytogenetic methods and targeted sequencing. Altogether, these studies reveal the complex evolutionary trajectories occurring across individual hematological malignancies. They also suggest that while clonal evolution may contribute to resistance to therapy, treatment may also hasten the evolutionary process. New insights into this process challenge us to understand the impact of treatment on clonal evolution and inspire the development of novel prognostic and therapeutic strategies.

Pneumonia caused by Aeromonas species in Taiwan, 2004-2011

We investigated the clinical characteristics of patients with pneumonia caused by Aeromonas species. Patients with pneumonia caused by Aeromonas species during the period 2004 to 2011 were identified from a computerized database of a regional hospital in southern Taiwan. The medical records of these patients were retrospectively reviewed. Of the 84 patients with pneumonia due to Aeromonas species, possible Aeromonas pneumonia was diagnosed in 58 patients, probable Aeromonas pneumonia was diagnosed in 18 patients, and pneumonia due to Aeromonas was conclusively diagnosed in 8 patients. Most of the cases of Aeromonas pneumonia developed in men and in patients of advanced age. A. hydrophila (n = 50, 59.5 %) was the most common pathogen, followed by A. caviae (n = 24, 28.6 %), A. veronii biovar sobria (n = 7, 8.3 %), and A. veronii biovar veronii (n = 3, 3.6 %). Cancer (n = 37, 44.0 %) was the most common underlying disease, followed by diabetes mellitus (n = 27, 32.1 %). Drowning-associated pneumonia developed in 6 (7.1 %) patients. Of 47 patients who were admitted to the intensive care ward, 42 patients developed acute respiratory failure and 24 of those patients died. The overall in-hospital mortality rate was significantly associated with liver cirrhosis, cancer, initial presentation of shock, and usage of mechanical ventilation. In conclusion, Aeromonas species should be considered as one of the causative pathogens of severe pneumonia, especially in immunocompromised patients, and should be recognized as a cause of drowning-associated pneumonia. Cirrhosis, cancer, and shock as the initial presenting symptom are associated with poor outcome.

Treatment strategies for acute coronary syndrome with severe mitral regurgitation and their effects on short- and long-term prognosis

Mitral regurgitation (MR) of even mild severity affects the prognosis of patients with acute coronary syndrome (ACS). The present study retrospectively analyzed 1,142 patients with ACS and MR of varying severity. Of the 95 patients with severe MR, 57 (60%) underwent primary percutaneous coronary intervention only and 38 (40%) underwent coronary artery bypass grafting (CABG) and mitral valve replacement (MVR). The severity of MR was significantly associated with the risk of heart failure but not with in-hospital or long-term mortality. In patients with severe MR, in-hospital mortality was no greater in those treated with CABG and MVR than in those treated with percutaneous coronary intervention alone. However, the incidence of long-term hard events (heart failure and all-cause mortality) was lower in those who had received the combined treatment. Multivariate analysis showed that, compared to percutaneous coronary intervention alone, CABG combined with MVR at the acute phase of ACS resulted in a significantly improved prognosis (odds ratio 0.172, 95% confidence interval 0.046 to 0.649, p = 0.009), even after adjusting for age, left ventricular filling pressure, and ejection fraction. In conclusion, the severity of MR in patients with ACS is associated with long-term heart failure events. Even at the acute phase of ACS, CABG combined with MVR results in an acceptable in-hospital mortality rate. The combined strategy also reduced the long-term hard events.

Left atrial expansion index for predicting atrial fibrillation and in-hospital mortality after coronary artery bypass graft surgery

BACKGROUND

Atrial fibrillation (AF), a common complication after coronary artery bypass graft surgery (CABG), is associated with prolonged hospital stay. This prospective study assessed the accuracy of left atrial parameters and additional preoperative characteristics for predicting post-CABG AF and in-hospital mortality.

METHODS

A total of 197 patients without hemodynamic-significant valvular problems, who received isolated CABG, were enrolled. Echocardiography was performed before CABG.

RESULTS

Compared with patients without post-CABG AF, those with post-CABG AF were older (71 vs 64 years, p<0.0001), had a higher incidence of CABG during index hospitalization of acute myocardial infarction and preoperative respiratory failure requiring ventilator support, lower left ventricular ejection fraction (0.41 vs 0.48, p<0.0001), lower left atrial expansion index (52.2% vs 93.3%, p<0.0001), and higher left ventricular filling pressure (24.2 vs 19.1 mm Hg, p<0.0001). Multivariate analysis of preoperative variables showed that independent predictors of AF included age (odds ratio [OR], 1.064; 95% confidence interval [CI], 1.022 to 1.107 per 1-year increase; p 0.002), maximal indexed left atrial volume (OR, 1.026; 95% CI, 1.002 to 1.051 per 1 mL/m2 increase; p 0.037) and left atrial expansion index (OR, 0.981; 95% CI, 0.962 to 0.998 per 1% increase; p 0.029). The left atrial expansion index was also significantly associated with in-hospital mortality (OR, 0.982; 95% CI, 0.951 to 0.996 per 1% increase; p 0.042). Incidence of post-CABG AF in patients with left atrial expansion index less than 120% progressively increased as left atrial expansion index decreased.

CONCLUSIONS

Left atrial expansion index independently predicts post-CABG AF and in-hospital mortality.

STUDIES ON NATURAL IMMUNITY TO PNEUMOCOCCUS TYPE III : IV. OBSERVATIONS ON A NON-TYPE SPECIFIC HUMORAL FACTOR INVOLVED IN RESISTANCE TO PNEUMOCOCCUS TYPE III

Since there is no evidence for the occurrence of type specific antibody in the normal rabbit and since, as we have shown, the Pneumococcus Type III whether avirulent or virulent is not removed from the blood stream or destroyed when the capsule is intact, the following factors which have been revealed in the course of our work appear to represent certain essential components, if not the complete mechanism, upon which the natural immunity of the rabbit against this organism depends. (a) The elevation of the body temperature after intravenous infection to 41°C. or thereabouts and its maintenance for varying periods. (b) The ability of the phagocytic cells, both fixed and mobile, to attack any cocci which have become vulnerable through the deterioration of capsular integrity. (c) The adjuvant effect of an antibody, reacting with the somatic C carbohydrate, which enhances the phagocytosis of such organisms as no longer possess a completely intact envelope. Conversely, the varying degrees of virulence for rabbits observed among Pneumococcus Type III strains are based upon: (a) differences in the ability of the organisms to multiply at the elevated temperatures encountered in the infected host. Strains markedly susceptible to the harmful influence of this factor fail to induce a generalized fatal infection. Not all "thermo-resistant" strains are highly virulent, however, and these may contrast sharply with regard to (b) size of the capsule and the ease with which it is impaired or completely lost. The capsules must be maintained intact for a sufficient time until multiplication of the organisms can proceed to such a degree that death of the host results. Avirulent strains even when capable of growth at 41°C. appear to be unable to satisfy this requirement. The differences in virulence of various strains apparently conditioned by these factors are not limited solely to the case of the rabbit, since for at least two strains similar differences in virulence have been shown to exist when the intravenous route of infection is employed in mice.

STUDIES ON NATURAL IMMUNITY TO PNEUMOCOCCUS TYPE III : II. CERTAIN DISTINGUISHING PROPERTIES OF TWO STRAINS OF PNEUMOCOCCUS TYPE III VARYING IN THEIR VIRULENCE FOR RABBITS, AND THE REAPPEARANCE OF THESE PROPERTIES FOLLOWING R-->S RECONVERSION OF THEIR RESPECTIVE ROUGH DERIVATIVES

The results which have been presented show that under the conditions of artificial cultivation at 37°C. definite differences exist between two smooth strains of Pneumococcus Type III both of which are highly virulent for mice by the intraperitoneal route, but which may be sharply distinguished in their virulence for rabbits. These differences consist in the size of the fully developed intact capsule and the interval of time required for its loss. The somewhat smaller capsule of the avirulent strain, well formed and easily demonstrable during the early period of growth, diminishes quickly, while the large capsule of the strain virulent for rabbits is retained for a considerably longer period. Closely correlated with the time at which this reduction of capsule occurs is the appearance of changes in the surface properties of the bacteria which are revealed by a shifting of the range of acid agglutination, susceptibility to clumping in anti-R serum and ingestion by normal adult human polymorphonuclear leucocytes and serum. Since it has been shown that these alterations as growth continues, result in a loss of characteristics which distinguish the strictly type specific, fully capsulated pneumococcus and ultimately lead to a state temporarily approximating that of the completely avirulent R form, and since under the experimental conditions they are inaugurated sooner, advance more rapidly and are more complete in the rabbit avirulent organism, we believe that they may partly account for difference in rabbit virulence of the two strains. In the following paper an attempt has therefore been made to correlate this behavior in vitro with the events attendant upon inoculation into the animal body. The studies of Clark and Ruehl (16), Henrici (17), Bayne-Jones and Adolph (18) and others have demonstrated a marked increase in the size of the bacterial cell associated with the early phases of growth. These authors have dealt chiefly with noncapsulated rod forms and even Clark and Ruehl who included cultures of various cocci do not make reference to variations in capsule size. Recently Seastone (19) has called attention to the large volume occupied by young capsulated streptococci. Similarly we have found that increase and decrease of Pneumococcus Type III volume appears to be due largely to the formation of capsule in young cultures and its subsequent loss as the organisms age. Because of the relatively great proportion of capsule in comparison with soma, a greater disparity exists between the volume of young and old pneumococci than that found by those who have studied bacteria lacking this structure. Of interest in connection with our observations are those of Preisz (20) on the nature of the capsules of virulent anthrax bacilli and strains attenuated by cultivation at 42.5°C. The latter produced soft, rapidly dissolving capsules while such structures in the former were characteristically firm and were retained by the bacilli for longer periods. This worker also noted in confirmation of the earlier work of others, that the capsules of B. anthracis are lost during the course of growth in serum media and in the subcutaneous tissues of the susceptible mouse. We have demonstrated that the R variants derived under the same conditions from the two smooth strains of Pneumococcus Type III reveal certain characteristics by which they may be distinguished from each other in respect to cell and colony morphology, growth in broth, as well as growth at 41°C. (cf. Paper I). By employing the method of Griffith, these two R variants have been induced to revert to the S form. Following the injection into mice of the various possible combinations of living R variant and the killed S organisms of either rabbit virulent or avirulent strain, as well as very large numbers of the R variant alone, S forms emerged which in their various attributes, notably that of virulence for rabbits, resembled the original smooth strain from which the particular R variant involved was dissociated. The function of the smooth killed organisms in the process of transformation appeared to be only that of a stimulus toward reversion to the S. They apparently play no rôle in determining the virulence or the growth properties of the resulting S form. These observations indicate that the factors involved in virulence are conditioned by stable physiological properties peculiar to the individual strain and that although temporarily inactive during the R state, they are again resumed unaltered upon the transition to the S form. They serve also to reemphasize the fact, apparent from several studies but perhaps not sufficiently realized, that the R variants of the pneumococcus, even though obtained under the same conditions from the same type but from different strains, may vary definitely in their various attributes. Finally, they strongly suggest that the degree of virulence of a given strain of a bacterial species may be determined not only by its ability to multiply in the environment of the host and to synthesize certain substances of definite chemical and antigenic properties, but also by the capacity to elaborate these in greater or lesser degree and under the conditions of parasitism within the animal body to maintain them in contact with the soma of the cell in such state that they afford an efficient barrier to the defensive mechanisms of the host.

STUDIES ON NATURAL IMMUNITY TO PNEUMOCOCCUS TYPE III : III. CORRELATION OF THE BEHAVIOR IN VIVO OF PNEUMOCOCCI TYPE III VARYING IN THEIR VIRULENCE FOR RABBITS WITH CERTAIN DIFFERENCES OBSERVED IN VITRO

AMONG THE EXPERIMENTAL FINDINGS REPORTED IN THIS PAPER TO WHICH WE WISH TO GIVE PARTICULAR EMPHASIS ARE THE FOLLOWING: 1. The results which follow the intravenous injection into rabbits of two strains of Pneumococcus Type III of different degrees of virulence vary with the state of the capsule. Thus when this structure is completely developed both remain in the blood. A culture of either strain begins to become susceptible to the blood-clearing mechanism contemporaneously with the onset of capsular degeneration and the initiation of other concomitant changes at the surface of the organism (cf Paper II), which occur much earlier with the less virulent strain. 2. When, in either case, removal from the blood stream occurs, this is effected by the phagocytic cells of the body. There is no suggestion that a new or unknown mechanism is involved. The greatest share of the burden is borne by the fixed phagocytic cells of the liver and spleen, and to a less extent by those of the lung and bone marrow. Nevertheless, it has been demonstrated that the polymorphonuclear leucocytes may also participate. 3. Phagocytosis by the leucocytes of the normal animal either in intro or in vivo has been observed only at such a time as the capsule has become impaired. Ingestion of the organisms by the fixed tissue cells appears also to be effective only under the same condition and is accordingly observed with much younger cultures of the less virulent strain. 4. Following their removal from the blood and their accumulation within the fixed phagocytes of the organs, destruction of most of the cocci proceeds within 2 to 4 hours. Both strains are destroyed provided they are in the state favorable to phagocytic attack. 5. Evidence has been presented which indicates that just as in vitro, so in a local area of inflammation within the body, aging with attendant capsular loss and increasing susceptibility to phagocytosis may take place. 6. With organisms from either strain a variable period of lag follows their injection into the blood stream, even when they are introduced in a state of active multiplication and complete encapsulation. 7. Differences in virulence for rabbits of two strains of Pneumococcus Type III do not imply that this animal possesses a defensive mechanism which is absent in other species, since it has been possible to demonstrate similar differences when the organisms are injected intravenously into mice. This fact indicates that the factors determining the degree of virulence of these strains are to be sought in the organisms themselves, rather than in the kind of host.

AN IMMUNOLOGICAL STUDY OF THE A SUBSTANCE OR ACETYL POLYSACCHARIDE OF PNEUMOCOCCUS TYPE I

1. The A carbohydrate isolated from Type I pneumococcus by Pappenheimer and Enders, on the basis of elementary analysis, the presence of the acetyl group and its immunological properties, appears to be identical with the acetyl polysaccharide described by Avery and Goebel. 2. The A carbohydrate possesses a greater anti-opsonic action than either the deacetylated substance obtained by boiling in alkali or the soluble specific substance of Type I pneumococcus prepared according to the procedure of Heidelberger, Goebel and Avery. The opsonic titre of normal human serum is practically eliminated upon the addition of the A carbohydrate—an effect not observed with equivalent amounts of either the deacetylated material or the specific soluble substance. In immune serum, the A carbohydrate brings about a quantitatively greater reduction in opsonic activity than its derivatives, but it has not been possible to demonstrate complete inhibition of phagocytic action by the method of absorption of antibody. 3. In a system of normal human serum and leucocytes capable of destroying Type I pneumococcus, the bactericidal effect maybe entirely removed upon the addition of the A carbohydrate. It proved impossible to inactivate the bactericidal action with the deacetylated substance in equivalent proportions. In this system, the A carbohydrate was about 64 times more effective as an antibactericidal agent than the deacetylated compound. Essentially similar results were obtained in a study of the antibactericidal properties of the A carbohydrate and the deacetylated derivative in the presence of anti-Type I pneumococcus rabbit serum added to a mixture of exudative leucocytes and the defibrinated blood of the rabbit. 4. The mouse-protective titre of anti-Type I pneumococcus rabbit serum is lowered to a greater degree after absorption with the A carbohydrate than it is by similar treatment with the deacetylated compound. Absorption with the A carbohydrate does not, however, completely remove the protective antibody. 5. As Avery and Goebel have shown in the case of the acetyl polysaccharide, so the A carbohydrate, when administered in very small quantities, protects mice against an otherwise fatal dose of Type I pneumococcus. Active immunity in mice has been obtained with as little as 0.00005 mg. of the A carbohydrate administered in a single dose. Doses larger than 0.005 mg. confer no protection on these animals. Deacetylization of the A carbohydrate after boiling in N/10 sodium hydroxide destroys its protective capacity while similar treatment in N/50 alkali does not completely remove its immunizing property. Active immunity may arise within 3 days following a single injection of the A substance. It appears to be at its height from 6 to 25 days thereafter, and is retrogressive by the 49th day following vaccination. Injection of the A carbohydrate into immunized mice immediately before infection deletes the state of resistance. 6. The immunity actively induced as a result of injection of the A carbohydrate may be passively transferred to normal mice with the serum of vaccinated animals. 7. Since the evidence obtained in the course of this study indicates that the A carbohydrate of Type I pneumococcus and the acetyl polysaccharide of Avery and Goebel represent the same chemical substance, it is suggested that the designation "A carbohydrate" or "A substance" be relinquished in favor of the more exactly descriptive term "acetyl polysaccharide."

Redox regulation of matrix metalloproteinase gene family in small cell lung cancer cells

It has been implicated that reactive oxygen species (ROS) play important roles in modulating tumor progression. However, the mechanisms by which redox-regulated tumor progression are largely unknown. We previously demonstrated that reduced intracellular redox conditions could be achieved in stably transfected small cell lung cancer cells with gamma-glutamylcysteine synthetase (gamma-GCSh) cDNA which encodes a rate-limiting enzyme in the biosynthesis of glutathione (GSH), a major physiological redox regulator. In the present study, using DNA microarray analyses, we compared the expression profiles between the gamma-GCSh-transfected cells and their nontransfected counterpart. We observed downregulation of several matrix metalloproteinases (MMPs), i.e., MMPI and MMP3, and MMP10 in the transfected cells. Dot blot and Northern blot hybridizations confirmed that, among the 18 MMP gene family members and four tissue inhibitors of matrix metalloprotein family (TIMP) analyzed, the expression levels of these three MMPs were consistently reduced. Transiently increased gamma-GCSh expression using tetracycline-inducible gamma-GCSh adenoviral expression system also showed down-regulation of MMP3 and MMP10, but not MMP1. Our results demonstrated that redox regulation of MMP1, MMP3 and MMP10 expression depend upon different modes of redox manipulation. These results bear implication that antioxidant modulation of antitumor progression may be contributed at least in part by the downregulation of a subset of metrix metalloproteins.

Molecular analysis of HLA-DRB1 allelic associations with systemic lupus erythematous and lupus nephritis in Taiwan

To evaluate the association of human leukocyte antigen (HLA)–DRB1 alleles with systemic lupus erythematosus (SLE) and lupus nephritis (LN) in the Taiwanese population, and to investigate the possible association of HLA-DRB1 alleles with disease severity in LN. HLA-DRB1 alleles were studied in 105 SLE patients (82 patients with LN, 23 patients without LN) and 855 healthy controls by polymerase chain reaction and sequence-based typing assays. The frequency of the HLA class II alleles DRB1*0301 (Odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.31–3.10, Pc = 0.02) and DRB1*1501 (OR = 2.06, 95% CI = 1.36–3.13, Pc = 0.01) were both increased in SLE patients, compared to healthy controls. The frequency of DRB1*1202 was significantly lower in LN patients than in SLE patients without nephritis (OR = 0.23, 95% CI = 0.09–0.57, Pc = 0.01). No specific allele was significantly associated with an increased or decreased risk for severity of LN in this sample. In Taiwanese people, the DRB1*0301 and DRB1*1501 alleles are significant risk factors for SLE, while the DRB1*1202 allele is protective for LN.

Acinar cell carcinomas with exophytic growth and intraductal pancreatic duct invasion: peculiar multislice computed tomographic picture

On an ultrasound and multislice computed tomography (MSCT), a 76-year-old woman was found to have a huge mass lesion in the pancreatic head. MSCT showed 8.4 cm well-enhancing exophytic tumor of the pancreatic head which also protruded into the duodenum. A tongue-like protrusion into the main pancreatic duct was depicted. Laboratory data showed elevated carbohydrate antigen 19-9. Whipple's operation was performed. The pathological diagnosis was acinar cell carcinoma (ACC) originating in the pancreatic head and directly invading through the duodenal wall and the main pancreatic duct, without any lymph node involvement. A peculiar ACC with good enhancement, exophytic picture and tongue-like protrusion into the main pancreatic duct on MSCT is presented.

Polymorphism of the growth hormone gene and its association with growth traits in Boer goat bucks

In the present study, the polymorphism of growth hormone (GH) gene was analyzed as a genetic marker candidate for growth traits in Boer goat bucks. Two single nucleotide polymorphisms (SNPs) - A781G (Ser/Gly35) and A1575G (Leu147), were identified by GH gene sequencing and PCR-RFLP (polymerase chain reaction-restriction fragment length polymorphism) analysis. AA genotype resulted in a significant decrease in birth chest girth (P=0.03) and weaning weight (P=0.014) comparing to AB genotype, while CC genotype contributed to weaning height (P=0.04) greater than CD genotype. When in combination, AACD genotype was undesired for lower scores in a series of growth traits including body weight, length, height, and chest girth at birth and weaning, as well as the pre-weaning daily gain and body weight at age of 11 months. These results indicate that new molecular markers associated with caprine growth traits can be used in MAS (marker-assisted selection) in Boer goat bucks.

Arginine deprivation as a targeted therapy for cancer

Certain cancers may be auxotrophic for a particular amino acid, and amino acid deprivation is one method to treat these tumors. Arginine deprivation is a novel approach to target tumors which lack argininosuccinate synthetase (ASS) expression. ASS is a key enzyme which converts citrulline to arginine. Tumors which usually do not express ASS include melanoma, hepatocellular carcinoma, some mesotheliomas and some renal cell cancers. Arginine can be degraded by several enzymes including arginine deiminase (ADI). Although ADI is a microbial enzyme from mycoplasma, it has high affinity to arginine and catalyzes arginine to citrulline and ammonia. Citrulline can be recycled back to arginine in normal cells which express ASS, whereas ASS(-) tumor cells cannot. A pegylated form of ADI (ADI-PEG20) has been formulated and has shown in vitro and in vivo activity against melanoma and hepatocellular carcinoma. ADI-PEG20 induces apoptosis in melanoma cell lines. However, arginine deprivation can also induce ASS expression in certain melanoma cell lines which can lead to in vitro drug resistance. Phase I and II clinical trials with ADI-PEG20 have been conducted in patients with melanoma and hepatocellular carcinoma, and antitumor activity has been demonstrated in both cancers. This article reviews our laboratory and clinical experience as well as that from others with ADI-PEG20 as an antineoplastic agent. Future direction in utilizing this agent is also discussed.

High-dose versus low-dose esomeprazole-based triple therapy for Helicobacter pylori infection

BACKGROUND

This prospective, randomized, controlled study was conducted to compare the efficacies of high-dose and low-dose esomeprazole-based triple therapies for Helicobacter pylori eradication in Taiwan.

MATERIALS AND METHODS

From January 2004 to June 2006, 240 H. pylori-infected patients were randomly assigned to undergo high-dose (40 mg b.d.) or low-dose (40 mg o.d.) esomeprazole combined with clarithromycin (500 mg b.d.) and amoxicillin (1 g b.d.) for one week. Follow-up endoscopy was performed at eight weeks after the end of treatment to evaluate the response to therapy.

RESULTS

Intention-to-treat analysis demonstrated no differences between eradication rates of high-dose and low-dose groups (92% vs. 90%, respectively, P > 0.05). Per-protocol analysis yielded comparable results (95% vs. 93%). Both groups exhibited similar frequencies of adverse events (13% vs. 11%) and drug compliance (96% vs. 93%). Multivariate analysis indicated that only good compliance (odds ratio: 10.3, 95% CI, 3.0-35.7) was an independent predictor of treatment success.

CONCLUSIONS

This work demonstrates that low-dose esomeprazole-based triple therapy yields a similar eradication rate as high-dose esomeprazole-based therapy in Taiwan. Since the cost of the low-dose regime is lower than that of the high-dose regime, low-dose esomeprazole-based triple therapy can reasonably be recommended for the first-line eradication of H. pylori for Taiwanese and probably most Asians.

Quantitative monitoring by polymerase colony assay of known mutations resistant to ABL kinase inhibitors

Resistance to molecularly targeted chemotherapy, and the development of novel agents that are active against resistant forms of target proteins create the need for a sensitive and quantitative assay to monitor drug-resistant mutations in patients to guide treatment and assess response. Here, we describe an application of the polymerase colony (polony) method to identify and quantify known point mutations in the BCR-ABL oncogene in patients with chronic myelogenous leukemia who evolve resistance to ABL kinase inhibitors. The assay can detect mutations with a sensitivity of 10(-4), quantify the burden of drug-resistant cells, and simultaneously monitor the dynamics of several coexisting mutations. As a proof of concept, we analysed blood samples from three patients undergoing therapy with ABL kinase inhibitors and found that the patients' response to therapy correlated with our molecular monitoring. We were also able to detect mutations emerging in patients long before clinical relapse. Therefore, the polony assay could be applied to a larger patient sample to assess the utility of early mutation detection in patient-specific treatment decisions. Finally, this methodology could be a valuable research tool to shed light on the natural behavior of mutations pre-existing kinase inhibitors therapy and either disappearing over time or slowly taking over.

Aggressive management of acute myocardial infarction: successful outcome in an older patient with cardiogenic shock

A 71-year-old man was referred to our emergency department presenting with acute inferior and right ventricular myocardial infarction with cardiogenic shock. He developed ventricular fibrillation 80 minutes after arrival. Immediate defibrillation, mechanical ventilatory support with oxygenation, and inotropic agents were instituted. Despite restoration of sinus rhythm, his hypotension persisted. He promptly received intra-aortic balloon pump (IABP) counterpulsation and cardiac catheterisation. Coronary angiography revealed a subtotal occlusion of the left anterior descending coronary artery and complete occlusion of the right coronary artery. Since the right coronary artery was considered to be the infarct-related coronary artery, percutaneous coronary intervention (PCI) was carried out to the right coronary artery only. The patient was extubated and IABP was removed on the second and third admission day, respectively. He was discharged from the hospital eight days later. A second PCI to the left anterior descending coronary artery was performed successfully three weeks later. This case illustrates that in patients with acute myocardial infarction and cardiogenic shock, prompt application of IABP and PCI of the infarct-related coronary artery may be beneficial in reducing the catastrophic morbidity and mortality, especially in older patients.

The development of a VR-based treatment planning system for oncology

In this study, an oncology treatment planning system was developed by integrating the techniques of computer graphics, virtual reality (VR) and three dimensional (3D) image reconstruction. The virtual treatment room was constructed according to the real space, and the 3D data of patient's body was reconstructed from computer tomography (CT) slices in order to provide the 3D clinical information to compare with the therapy in real world. In addition, the virtual multi-leaf collimator (MLC) was constructed to simulate and visualize both the radiation and irradiation fields. All objects in the system had been scaled down according to the true size. The system can be expected to save the preparation time and can be used for teaching and training prior to a real therapy.

Randomized comparison of two rescue therapies for Helicobacter pylori infection

BACKGROUND

Bismuth salts are not available worldwide. It remains unknown whether clarithromycin can replace bismuth salts as an adjuvant agent in the rescue regimens for Helicobacter pylori infection. We therefore designed the prospective study to compare the efficacies of two rescue therapies for H. pylori infection after standard triple therapies.

PATIENTS AND METHODS

Ninety-three patients who failed H. pylori eradication using proton pump inhibitor plus clarithromycin and amoxicillin were randomly assigned to undergo rescue therapy with esomeprazole, clarithromycin, tetracycline and metronidazole (ECTM group, n = 46) or esomeprazole, bismuth subcitrate, tetracycline and metronidazole (EBTM group, n = 47). Follow-up endoscopy was performed at 8 weeks after the end of treatment to assess the treatment response.

RESULTS

Intention-to-treat analysis demonstrated both groups had similar eradication rates (ECTM 74% vs. EBTM 77%; P = 0.76) and drug compliance (ECTM 94% vs. EBTM 96%; P = 0.68). However, the frequency of adverse events in the ECTM group was higher than that in EBTM group (ECTM 57% vs. EBTM 36%, P = 0.05). In the EBTM group, eradication rate of metronidazole-resistant strains was lower than that of metronidazole-susceptible strains (67%[8/12] vs. 100%[9/9], P = 0.05). However, eradication rates were similar between metronidazole-susceptible and metronidazole-resistant strains in ECTM group (69%[9/13] vs. 70%[7/10], P = 1.00).

CONCLUSIONS

The new ECTM second-line therapy can achieve similar eradication rate as standard EBTM therapy. It may be very useful in countries where bismuth salts are not available.

Ten-year experience with living related donated splenic transplantation for the treatment of hemophilia A

AIM

Six cases of hemophilia A treated with living related donated splenic transplantation (LRDST) were performed over 10 years.

METHODS

We reviewed the six consecutive cases of LRDST from 1992 to 2002. Three patients received whole spleen allografts and the other three, partial spleen allografts. All allografts were transplanted to the extraperitoneal space in the right iliac fossa by an end-to-end anastomosis between the splenic artery and the internal iliac artery and an end-to-side anastomosis between the splenic vein and the external (or common) iliac vein. After the operation, a combined regimen with cyclosporine, azathioprine, anti-lymphocyte globulin, OKT3, was administered to suppress the immune reaction.

RESULTS

The functional period of the allografts varied between 30 days to 4 years. Patient factor-VIII (F-VIII) levels rose from less than 5% before operation to 15% to 56% postoperatively. One patient died from central nervous system complications. Another lost his graft because exogenous F-VIII was not supplemented in timely fashion at the onset of rejection. And the third could no longer afford the expensive immunosuppressive drugs at 2 years after the operation and eventually lost the spleen. The remaining three patients presently have regained self-support, among whom one has survived for 4 years.

CONCLUSION

Though the sample pool is relatively small, our clinical observations tend to confirm LRDST as a feasible, effective treatment for hemophilia A.

Aim, design and methods of the ‘reasons for not intensifying antihypertensive treatment’ (RIAT): an international registry in essential hypertension

Failure of physicians to adhere to hypertension guidelines may partly account for the failure to achieve blood pressure (BP) goals in clinical practice. The aim of this trial is a comprehensive description of the approach of physicians in the management of high BP among primary care patients. It will primarily assess what are the Reasons for not Intensifying an Antihypertensive Treatment (RIAT), when predefined individual BP goals are not achieved. Open intervention survey was conducted in 17 countries in Latin America, Eastern Europe, Africa and Asia in family practices, government and private clinics. The registry is based on a three-step epidemiological design. Step one shall identify guidelines and recommendations taken as reference in each country for the management of hypertension. Step two will assess the variance between individual targets defined by physicians in their practice compared to guidelines and recommendations. Step three is a prospective registry where physicians collect patient data at baseline; determine individual target BP values. Several follow-up visits are proposed to monitor achievement of these targets. Step three of RIAT aims at providing responses to several key objectives. Recruitment is under way aiming at enrolling 33,000 patients. To identify, what is the BP targeted according to the risk factor profile and what are the reasons for not modifying an antihypertensive treatment when BP goals are not reached, and to analyse the type of antihypertensive drugs prescribed according to compelling indications and to assess the percentage of patients reaching target figures.

Adrenocorticotropin-producing pulmonary tumorlets with lymph node metastasis

A case of pulmonary tumorlets with ectopic adrenocorticotropin (ACTH) production and lymph node metastasis in a bronchiectatic patient is reported. A 65-year-old man underwent right lower lobe lobectomy because of a sudden attack of cough and hemoptysis. Histological study revealed multiple discrete uniform small nests of tumor cells surrounding dilated bronchioles. Tumor nests were also found in the hilar lymph node. Immunohistochemically, the proliferating cells were confirmed to be neuroendocrine in origin with ectopic ACTH production, despite being clinically silent. The findings in the present case suggest that the clinical behavior of pulmonary tumorlets may be like a carcinoid, and need to be treated as tumor-like lesions. Ectopic hormonal production in the present case suggests pulmonary tumorlets should be considered in the differential diagnosis of Cushing's syndrome.

Anti-leukemic immunity against U937 cells in uremic patients

To examine anti-tumor immunity in uremic patients undergoing regular hemodialysis, we designed this study using in vitro mononuclear cell (MNC) cultures, with human leukemic U937 cells as the target. MNC were collected and cultured from uremic subjects and age- and gender-matched healthy controls. Conditioned media from the cultures (MNC-CM) were collected after stimulation with various concentrations of phytohemagglutinin (PHA). The proliferation-inhibiting and differentiation-inducing activities of the PHA-MNC-CM on U937 cells were evaluated. The growth inhibition activity of uremic patients' PHA-MNC-CM was lower than that of controls. The differentiation-inducing effects were evaluated by morphological scoring, superoxide production, and monocyte-associated antigen expression (CD14 and CD68). All three parameters demonstrated that the differentiation-inducing effect of MNC-CM increased with increasing doses of PHA. These effects, however, were significantly less in uremic patients compared to controls at higher doses of PHA. The levels of TNF-alpha and IFN-gamma in PHA-MNC-CM increased in a PHA dose-dependent manner and were much higher in the controls. We conclude that the capacity of MNC from uremic hemodialysis patients to produce anti-leukemic immunity is significantly lower than that of healthy controls.

Association between serum inflammatory cytokines and disease activity in juvenile idiopathic arthritis

Circulating interleukin-1beta (IL-1beta), IL-6, tumour necrosis factor-alpha (TNF-alpha), osteocalcin, and conventional parameters of inflammation were examined serially in 14 children with juvenile idiopathic arthritis (JIA) to determine any correlation with the disease activity. Serum IL-1beta was undetectable in all JIA patients. Serum IL-6, white blood cell counts, platelet counts, erythrocyte sedimentation rate and C-reactive protein levels were significantly elevated in the active phase of JIA, whereas hemoglobin levels were significantly lower. Osteocalcin levels were decreased and TNF-alpha increased in active JIA status, but these differences showed no statistical significance. We concluded that inflammatory cytokines play an important role in JIA. Monitoring IL-6 in children with JIA is useful in determining disease activity and response to therapy. These findings confirm earlier reports.

Can short-term administration of dexamethasone abrogate radiation-induced acute cytokine gene response in lung and modify subsequent molecular responses?

PURPOSE

To investigate the effects of short-term administration of dexamethasone (DEX) on radiation-induced responses in the mouse lung, focusing on expression of pro-inflammatory cytokine and related genes.

METHODS AND MATERIALS

At indicated times after thoracic irradiation and/or drug treatment, mRNA expression levels of cytokines (mTNF-alpha, mIL-1 alpha, mIL-1 beta, mIL-2, mIL-3, mIL-4, mIL-5, mIL-6, mIFN-gamma) and related genes in the lungs of C3H/HeN mice were measured by RNase protection assay.

RESULTS

Radiation-induced pro-inflammatory cytokine mRNA expression levels in lung peak at 6 h after thoracic irradiation. DEX (5 mg/kg) suppresses both basal cytokine mRNA levels and this early response when given immediately after irradiation. However, by 24 h, in mice treated with DEX alone or DEX plus radiation, there was a strong rebound effect that lasted up to 3 days. Modification of the early radiation-induced response by DEX did not change the second wave of cytokine gene expression in the lung that occurs at 1 to 2 weeks, suggesting that early cytokine gene induction might not determine subsequent molecular events. A single dose of DEX attenuated, but did not completely suppress, increases in cytokine mRNA levels induced by lipopolysaccharide (2.5 mg/kg) treatment, but, unlike with radiation, no significant rebound effect was seen. Five days of dexamethasone treatment in the pneumonitic phase also inhibited pro-inflammatory cytokine gene expression and, again, there was a rebound effect after withdrawal of the drug.

CONCLUSIONS

Our findings suggest that short-term use of dexamethasone can temporarily suppress radiation-induced pro-inflammatory cytokine gene expression, but there may be a rebound after drug withdrawal and the drug does little to change the essence and course of the pneumonitic process.

The presence of three isoflavonoid compounds in Psoralea corylifolia

The optimization of a high-performance liquid chromatographic method to determine three isoflavonoids (daidzein, genistein, and biochanin A) in the fruit of Psoralea corylifolia is developed and validated. Dried psoralea fruit powder is extracted with aqueous methanol followed by the hydrolysis of the analytes' conjugated glycosides with hydrochloric acid. The HPLC assay is performed on a reverse-phase C18 column with gradient elution using acetonitrile and 10% acetic acid as the mobile phase at a flow rate of 0.8 mL/min. Flavone is used as the internal standard and the substances are detected at 260 nm. Calibrations are linear (correlation coefficient > or = 0.995) for all three analytes. The limits of detection are 0.01 microg/mL for daidzein and genistein and 0.1 microg/mL for biochanin A. The overall intra- and interassay precision range from 2.5% to 4.9% and from 0.5% to 4.7%, respectively. The method proved to be sensitive, specific, accurate, and precise for the determination of daidzein, genistein, and biochanin A in Psoralea corylifolia.