Clinical characteristics of neutropenic patients under antithyroid drug: Twelve-year experience in a medical center

BACKGROUND

Thionamide-induced agranulocytosis (TiA) is a rare adverse event with a reported incidence of approximately 0.1% to 1.75%. Prompt recognition of TiA is critical to reduce the mortality rate. However, the differential diagnosis between cases of TiA and non-TiA neutropenia can be challenging due to the potential simultaneous involvement of other causes of neutropenia, such as concomitant chemotherapy, liver dysfunction, or infection. The aim of the present study was to investigate the possible factors associated with the development of TiA.

METHODS

This was a retrospective cohort study of patients treated with antithyroid drugs (ATDs) in Taipei Veterans General Hospital, Taipei, Taiwan, from 2006 to 2018. Patients who developed a neutropenic event during treatment with ATDs were identified from their medical records. The diagnosis of TiA was based on the following: (1) development of neutropenia during treatment or within 7 days after previous exposure to the same ATDs; (2) complete resolution of neutropenia within 1 month after discontinuation of the culprit drug with an absolute neutrophil count (ANC) >1500/μL; and (3) exclusion of other causes of neutropenia. The incidence and risk factors of TiA were analyzed and compared with those of non-TiA neutropenia.

RESULTS

Among 6644 patients treated with ATDs, 66 (mean age: 53 ± 15 years; 16.2% men) developed a neutropenic event and 20 were diagnosed with TiA (incidence: 0.3%). In the univariate analysis, compared with non-TiA neutropenia, TiA was associated with a lower Charlson Comorbidity Index, shorter treatment duration, lower cumulative ATD dosage, higher ATD dosage, higher ANC, and higher levels of free T4 at the time of the neutropenic event. In the multivariate logistic regression analysis, after adjusting for age, gender and the time to neutropenia, the cumulative ATD dose to neutropenia and ATD dosage at the time of the neutropenic event, Charlson Comorbidity Index, free T4 levels (odds ratio [OR], 4.44; 95% CI, 1.48-13.25), and ANC (OR, 1.00; 95% CI, 1.00-1.01) remained independently associated with TiA.

CONCLUSION

Patients with TiA were more likely to have higher levels of free T4 and ANC at the time of the neutropenic event vs those with non-TiA neutropenia.

The fibrosis-4 score is associated with long-term mortality in different phenotypes of acute heart failure

BACKGROUND

Fibrosis-4 score (FIB4) was a non-invasive surrogate to estimate the amount of liver scarring in chronic hepatitis. Considering the presence of increased central venous pressure and congestive hepatopathy in patients with decompensated heart failure, we therefore investigated the prognostic values of FIB4 in acute heart failure (AHF) patients.

METHOD

Patients hospitalised primarily for HF were drawn from an intramural registry. FIB4 was calculated according to age, aspartate aminotransferase, alanine aminotransferase and platelet count. All-cause mortality up to 5 years after discharge was obtained by linking to the national death registry.

RESULTS

Among a total of 1854 participants, 940 patients died during a mean follow-up of 28.3 ± 21.8 months. FIB4 score was related to mortality and the composite of cardiovascular death or HF rehospitalisation, independent of age, sex, left ventricular ejection fraction, left atrial dimension, sodium and haemoglobin levels, estimated glomerular filtration rate, comorbidities, and medications [hazard ratio and 95% confidence interval of mortality: 1.009 (1.002-1.015), and the composite of cardiovascular death or HF hospitalisation: 1.020 (1.010-1.031)]. The prognostic value of FIB4 was predominantly in the subjects with heart failure and preserved or mildly reduced ejection fraction (HFpEF and HFmrEF), or coronary artery disease (CAD) than the counterparts [interaction p-value <0.001, and 0.004, respectively].

CONCLUSIONS

FIB4 was an independent predictor of survival in AHF patients, irrespective of the phenotypes of HF. The higher predictive value of mortality of FIB4 was observed in the subjects with HFpEF, HFmrEF or CAD.

Tissue inhibitor of metalloproteinase (TIMP)-1 predicts negative remodeling and recovery of ejection fraction in acute heart failure with reduced ejection fraction

Background

Heart failure with recovered ejection fraction (HFrecEF) is a recently identified phenotype of heart failure, which had lower rates of mortality, heart failure hospitalization, ventricular assist device placement, and heart transplantation compared to heart failure with reduced ejection fraction (HFrEF). Several predictors of HFrecEF had been proposed such as female gender, lower HF duration, nonischemic cause, no left bundle branch block (LBBB), lower EF, and lower N-terminal pro-brain natriuretic peptide (NT-proBNP) in the previous studies. Tissue inhibitors of metalloproteinase-1 (TIMP-1) was a biomarker that regulated the activity of metalloproteinases (MMPs). TIMP-1 was up-regulated during HF and was associated with ventricular remodeling and poor prognosis. However, the predictive value of TIMP-1 and MMP-9 in recovery of EF was yet to be investigated.

Purpose

The present study aimed at investigating the predictive value of TIMP-1 and MMP-9 of recovery of EF.

Methods

Subjects with acute decompensated heart failure and reduced left ventricular ejection fraction were eligible for this study. HFrEF was defined as EF &lt;40% and HFrecEF was defined as follow-up EF ≥40% and ≥10% improvement from baseline EF. The biomarkers including NT-proBNP, plasma MMP-9 and serum TIMP-1 were measured in all enrolled subjects at admission. The receiver operating characteristic (ROC) curves and Youden index were used to select the model variables and cutoff values. Binary logistic regression analysis assessed the association between the biomarkers and recovery ejection fraction.

Results

Among a total of 91 AHF with reduced ejection fraction subjects (70.1±16.2 years, baseline EF 28.9±7.6%), 19 (20.8%) HFrecEF and 72 (79.2%) persistent HFrEF were found at 6 months. TIMP-1 and NT-proBNP were significantly higher in persistent HFrEF compared to HFrecEF. MMP-9 was similar between these two phenotypes of HF. The area under the ROC curve for recovery of ejection fraction of TIMP-1, MMP-9 and NT-proBNP were 0.69, 0.52, and 0.65, respectively. The optimal cutoff value of TIMP-1 according to Youden index was 200.68 ng/ml. In binary logistic regression analysis, TIMP-1 was negatively correlated with recovered ejection fraction as continuous variables [per 1-SD=8.96 ng/ml, odds ratio and 95% confidence interval: 0.99 (0.98–1.00)] and categorical variables [cutoff value 200.68 ng/ml, odds ratio and 95% confidence interval: 0.16 (0.05–0.54)] after adjusting age, gender, EF, acute myocardial infarction, LBBB and NT-proBNP.

Conclusions

In AHF subjects with HFrEF, TIMP-1 was negatively correlated to the recovery of EF and could be a potential biomarker for the prediction of the recovery of EF.

Funding Acknowledgement

Type of funding sources: None.

Age of First Oral Health Examination and Dental Treatment Needs of Medicaid-Enrolled Children

INTRODUCTION

Early childhood caries (ECC), despite being preventable, remains the most prevalent disease of childhood, particularly in children between the ages of 2 and 5 y. The association between the type of health care provider completing initial oral health examinations and subsequent dental caries in children under 6 y of age is unclear.

OBJECTIVE

The objective of the current study is to longitudinally assess the association between age at first oral health examination and provider type at first oral health examination on dental treatment for children under 6 y of age.

METHODS

Deidentified administrative claims data were used from the IBM Marketscan Multi-State Medicaid Database (n = 2.41 million Medicaid-enrolled children younger than 6 y in 13 states from 2012 to 2017). A Kaplan-Meier survival analysis was used to examine the association between age at first oral health examination and provider type with first treatment of dental caries at follow-up.

RESULTS

The adjusted hazard ratio (HR) of dental caries for children whose first oral health examination at 4 y of age is 5.425 times higher than for children whose first oral health examination was before 1 y of age (95% confidence interval [CI], 5.371-5.479). The adjusted HR of dental caries for children seen by pediatric dentists (HR = 1.215; 95% CI, 1.207-1.223) and physicians (HR = 2.618; 95% CI, 2.601-2.635) was higher than those seen by a general dentist.

CONCLUSIONS

Findings from this study highlight the importance of children having their first oral health examination no later than 12 mo of age in accordance with existing guidelines and referrals from physicians to prevent the need for invasive treatment.

KNOWLEDGE OF TRANSFER STATEMENT

Results of this study emphasize the need for a child's first oral health examination to be completed no later than 12 mo of age to prevent dental caries. Reinforcement and referrals by physicians based on this recommendation facilitate early establishment of a dental home in young children.

P5006Metformin reduces the risk of hospitalization for heart failure in type 2 diabetes patients: a retrospective cohort analysis

Background

A beneficial effect of metformin on heart failure requires confirmation.

Purpose

To investigate whether metformin might affect the risk of heart failure hospitalization in type 2 diabetes patients.

Methods

Patients with new-onset type 2 diabetes during 1999–2005 were enrolled from the reimbursement database of Taiwan's National Health Insurance and followed until December 31, 2011. Analyses were conducted in a propensity score (PS) matched-pair cohort (42,367 ever users and 42,367 never users) and hazard ratios were estimated by Cox's hazard regression analysis incorporated with the inverse probability of treatment weighting using the PS.

Results

A total of 1,592 never users and 987 ever users were hospitalized for heart failure for the first time during follow-up, with a respective incidence of 843.34 and 499.18 per 100,000 person-years. The overall hazard ratio was 0.588 (95% confidence interval: 0.543–0.637), and the hazard ratios for the first (<29.13 months), second (29.13–61.63 months), and third (>61.63 months) tertiles of cumulative duration were 1.018 (0.914–1.135), 0.575 (0.511–0.647), and 0.340 (0.297–0.390), respectively. Sensitivity analyses conducted in an unmatched cohort before and after excluding patients who received an irregular refill of metformin or who were treated with incretin-based therapies during follow-up consistently supported such a protective effect of metformin on heart failure.

Conclusion

Metformin use is associated with a lower risk of hospitalization for heart failure.

Acknowledgement/Funding

The study was partly supported by the Ministry of Science and Technology (MOST 107-2221-E-002-129-MY3) of Taiwan.

Attitudes and potential barriers towards hepatitis C treatment in patients with and without HIV coinfection

This study aimed to assess attitudes and potential barriers towards treatment in patients with hepatitis C virus (HCV) infection, comparing those with and without HIV coinfection. A cross-sectional survey of 82 HCV-infected adults with and without HIV was conducted in greater Los Angeles between November 2013 and July 2015. Overall, there were 53 (64.6%) with HIV coinfection, 20 (25.0%) with self-reported cirrhosis, and 22 (26.8%) with a history of prior HCV treatment. Of all, 93.2% wanted HCV treatment, but 45.9% were unwilling/unable to spend anything out of pocket, 29.4% were waiting for new therapies, and 23.5% were recommended to defer HCV treatment. HIV/HCV-coinfected patients were more likely to want treatment within one year (90.2% versus 68.2%, p = 0.02), more willing to join a clinical trial (74.5% versus 8.0%, p < 0.01), more willing to take medications twice daily (86.3% versus 61.5%, p = 0.01), and more likely to prefer hepatitis C treatment by an infectious diseases/HIV physician (36.7% versus 4.0%, p < 0.01). Of all, 77.1% of coinfected patients were willing to change antiretroviral therapy if necessary to treat HCV, but only 48.0% of patients were willing to take a medication if it had not been studied in HIV-positive patients. Treatment preferences differ between HIV/HCV-coinfected and HCV-monoinfected patients. Despite a strong willingness among the study cohort to start HCV treatment, other factors such as cost, access to medications, and provider reluctance may be delaying treatment initiation.

Neuroprotective Effects of Intranasal IGF-1 against Neonatal Lipopolysaccharide-Induced Neurobehavioral Deficits and Neuronal Inflammation in the Substantia Nigra and Locus Coeruleus of Juvenile Rats

Neonatal lipopolysaccharide (LPS) exposure-induced brain inflammation resulted in motor dysfunction and brain dopaminergic neuronal injury, and increased the risks of neurodegenerative disorders in adult rats. Our previous studies showed that intranasal administration of insulin-like growth factor-1 (IGF-1) protects against LPS-induced white matter injury in the developing rat brain. To further examine whether IGF-1 protects against LPS-induced brain neuronal injury and neurobehavioral dysfunction, recombinant human IGF-1 (rhIGF-1) at a dose of 50 µg/pup was administered intranasally 1 h following intracerebral injection of LPS (1 mg/kg) in postnatal day 5 (P5) Sprague-Dawley rat pups. Neurobehavioral tests were carried out from P7 to P21, and brain neuronal injury was examined at P21. Our results showed that LPS exposure resulted in disturbances of motor behaviors in juvenile rats. Moreover, LPS exposure caused injury to central catecholaminergic neurons, as indicated by a reduction of tyrosine hydroxylase (TH) immunoreactivity in the substantia nigra (SN), ventral tegmental area (VTA) and olfactory bulb (OB), and brain noradrenergic neurons, as indicated by a reduction of TH immunoreactivity in the locus coeruleus (LC) of the P21 rat brain. The LPS-induced reduction of TH+ cells was observed at a greater degree in the SN and LC of the P21 rat brain. Intranasal rhIGF-1 treatment attenuated LPS-induced central catecholaminergic neuronal injury and motor behavioral disturbances, including locomotion, beam walking test and gait analysis. Intranasal rhIGF-1 administration also attenuated LPS-induced elevation of IL-1β levels and numbers of activated microglia, and cyclooxygenase-2+ cells, which were double labeled with TH+ cells in the SN, VTA, OB and LC of the P21 rat brain. These results suggest that IGF-1 may provide protection against neonatal LPS exposure-induced central catecholaminergic neuronal injury and motor behavioral disturbances, and that the protective effects are associated with the inhibition of microglia activation and the reduction of neuronal oxidative stress by the suppression of the neuronal cyclooxygenase-2 expression.

Electro-optically spectrum tailorable intracavity optical parametric oscillator

We report a unique, pulsed intracavity optical parametric oscillator (IOPO) whose output spectrum is electro-optically (EO) tailorable based on an aperiodically poled lithium niobate (APPLN) working simultaneously as an optical parametric gain medium and an active gain spectrum filter in the system. We have successfully obtained from the IOPO the emission of single to multiple narrow-line signal spectral peaks in a near-infrared (1531 nm) band simply by electro-optic control. The power spectral density of the EO tailored signal can be enhanced by up to 10 times over the original (nontailored) signal.

Tunable, pulsed multiline intracavity optical parametric oscillator using two-dimensional MgO: periodically poled lithium niobate-aperiodically poled lithium niobate

We report a tunable, pulsed multiline intracavity optical parametric oscillator (IOPO) realized in an Nd:YVO4 laser using a two-dimensionally domain engineered MgO:LiNbO3 as simultaneously an electro-optic Bragg Q switch and a multichannel optical parametric downconverter. The MgO:LiNbO3 was periodically and aperiodically poled along the crystallographic y and x axes, respectively, to simultaneously satisfy the phase-matching conditions required by the two quasi-phase-matching devices. When Q switched by 1 kHz, 300 V pulses, three signal lines at 1518, 1526, and 1534 nm were simultaneously generated, each with a peak power of ∼1  kW from the IOPO at 8.3 W diode power at 50°C. Spectral tuning of the three-line IOPO with temperature was demonstrated.

Limits on spin-independent couplings of WIMP dark matter with a p-type point-contact germanium detector

We report new limits on a spin-independent weakly interacting massive particle (WIMP)-nucleon interaction cross section using 39.5 kg days of data taken with a p-type point-contact germanium detector of 840 g fiducial mass at the Kuo-Sheng Reactor Neutrino Laboratory. Crucial to this study is the understanding of the selection procedures and, in particular, the bulk-surface events differentiation at the sub-keV range. The signal-retaining and background-rejecting efficiencies were measured with calibration gamma sources and a novel n-type point-contact germanium detector. Part of the parameter space in the cross section versus WIMP-mass implied by various experiments is probed and excluded.

Decrease of postprandial endothelial dysfunction by spice mix added to high-fat hamburger meat in men with Type 2 diabetes mellitus

AIMS

Consumption of a high-fat diet has been demonstrated to promote endothelial dysfunction, possibly through an increase in lipid peroxidation and decrease in serum nitric oxide. The present study was designed to investigate whether consumption of a hamburger cooked with a polyphenol-rich spice mixture will reduce postprandial lipid oxidation and endothelial dysfunction in men with Type 2 diabetes.

METHODS

Twenty-two subjects consumed burgers cooked with salt only (control burger) or with salt and spice mix (spice burger) in randomized order. The postprandial concentration of urinary malondialdehyde and nitrate/nitrite as well as the peripheral arterial tonometry score were determined.

RESULTS

Eighteen subjects completed the study. Postprandial serum glucose, insulin and triglyceride concentrations were similar in all subjects after control burger or spice burger consumption. Urine malondialdehyde excretion in mmol/g creatinine was reduced by 31% (P < 0.001) after consuming the spice burger compared with the control burger. Two hours after consumption of the burgers, the peripheral arterial tonometry score was significantly different between control burger consumption (-9.7 ± 21.5%) and spice burger consumption (+18.0 ± 42.4%) (P = 0.025). Mean urinary nitrate/nitrite concentrations in urine collected during the 6 h after consumption of the control burger was 9.09 ± 5.7 mmol/g creatinine, but 12.37 ± 7.00 mmol/g creatinine after the spice burger (P = 0.053).

CONCLUSION

Adding a spice mix to hamburger meat prior to cooking resulted in a reduction in urinary malondialdehyde, an increase in urinary nitrate/nitrite and improvement of postprandial endothelial dysfunction in men with Type 2 diabetes. Therefore, cooking a hamburger with a polyphenol-rich spice mixture may lead to potential cardiovascular benefits in patients with Type 2 diabetes mellitus.

Electro-optically tunable, multi-wavelength optical parametric generators in aperiodically poled lithium niobates

We report on the design and demonstration of electro-optically tunable, multi-wavelength optical parametric generators (OPGs) based on aperiodically poled lithium niobate (APPLN) crystals. Two methods have been proposed to significantly enhance the electro-optic (EO) tunability of an APPLN OPG constructed by the aperiodic optical superlattice (AOS) technique. This is done by engineering the APPLN domain structure either in the crystal fabrication or in the crystal design process to increase the length or block-number difference of the two opposite-polarity domains used in the structure. Several orders of magnitude enhancement on the EO tuning rate of the APPLN OPGs constructed by the proposed techniques for simultaneous multiple signal wavelength generation over a conventional one has been demonstrated in a near infrared band (1500-1600 nm).

Furano-1,2-naphthoquinone inhibits EGFR signaling associated with G2/M cell cycle arrest and apoptosis in A549 cells

Furano-1,2-naphthoquinone (FNQ), prepared from 2-hydroxy-1,4-naphthoquinone and chloroacetaldehyde in an efficient one-pot reaction, exhibits an anti-carcinogenic effect. FNQ exerted anti-proliferative activity with the G(2)/M cell cycle arrest and apoptosis in A549 cells. FNQ-induced G(2)/M arrest was correlated with a marked decrease in the expression levels of cyclin A and cyclin B, and their activating partner cyclin-dependent kinases (Cdk) 1 and 2 with concomitant induction of p53, p21, and p27. FNQ-induced apoptosis was accompanied with Bax up-regulation and the down-regulation of Bcl-2, X-linked inhibitor of apoptosis (XIAP), and survivin, resulting in cytochrome c release and sequential activation of caspase-9 and caspase-3. Western blot analysis revealed that FNQ suppressed EGFR phosphorylation and JAK2, STAT3, and STAT5 activation, but increased in activation of p38 MAPK and c-Jun NH2-terminal kinase (JNK) stress signal. The combined treatment of FNQ with AG1478 (a specific EGFR inhibitor) significantly enhanced the G(2)/M arrest and apoptosis, and also led to up-regulation in Bax, p53, p21, p27, release of mitochondrial cytochrome c, and down-regulation of Bcl-2, XIAP, survivin, cyclin A, cyclin B, Cdk1, and Cdk2 in A549 cells. These findings suggest that FNQ-mediated cytotoxicity of A549 cell related with the G(2)/M cell cycle arrest and apoptosis via inactivation of EGFR-mediated signaling pathway.

Parental diabetes in Taiwanese diabetic women with and without previous gestational diabetes

Background Gestational diabetes mellitus (GDM) is reported to be associated with maternal but not paternal diabetes. This study examined the relative contribution of maternal and paternal diabetes among type 2 diabetic women with and without a GDM history. Materials and methods A total of 48 502 type 2 diabetic women from a national sample were interviewed by telephone. Among them, 510 reported a GDM history. Parental diabetes was compared between patients with and without a GDM history considering the confounding effects of age, body mass index, smoking, hypertension, duration of diabetes and insulin use. Results Patients with a GDM history were younger in age, had younger age of onset, longer duration of diabetes, slightly lower body mass index, higher prevalence of insulin use and lower prevalence of hypertension, but smoking rates were similar. The percentages of parental diabetes of nil, mother only, father only and both father and mother for those without a GDM history were 76.2, 15.2, 5.8 and 2.8%, respectively; and were 47.8, 26.8, 17.5 and 7.9%, respectively, for those with a GDM history (P < 0.001). The adjusted odds ratios for patients with versus without a GDM history for parental diabetes of nil, mother only, father only, and both father and mother were 1.000, 1.210 (0.948-1.544), 1.783 (1.341-2.371) and 2.094 (1.440-3.045), respectively. Conclusions Although maternal diabetes is more commonly seen, the disproportionately higher paternal diabetes in patients with a GDM history suggests an important role for paternal diabetes on the development of GDM into type 2 diabetes mellitus.

Effect of parental hypertension and/or parental diabetes on hypertension in Taiwanese diabetic patients

BACKGROUND

Both type 2 diabetes mellitus (T2DM) and hypertension aggregate in families. It is a common thought that diabetic patients with parental diabetes and/or parental hypertension are more likely to develop hypertension. This study evaluated the separate and joint effects of parental hypertension and parental diabetes on the prevalence of hypertension in patients with T2DM.

MATERIALS AND METHODS

A total of 89 956 patients from a national cohort were interviewed by telephone. Information about age, sex, onset age of diabetes, body height, body weight, systolic (SBP) and diastolic blood pressure (DBP), smoking, hypertension, and paternal and maternal history of diabetes and hypertension were obtained. Hypertension was defined in two ways: (1) a positive history; or (2) a positive history or a reported SBP > or = 140 mmHg and/or DBP > or = 90 mmHg in patients without a hypertension history.

RESULTS

While analysed separately in logistic models, both parental diabetes and parental hypertension were positively associated with hypertension. However, when both were analysed together, only parental hypertension was positively associated with hypertension, with paternal and maternal hypertension exerting a similar effect of an approximately 2.5-fold higher risk. While considering the effect of parental hypertension, both paternal and maternal diabetes was significantly associated with a lower risk of hypertension with odds ratios of approximately 0.8. Parental hypertension was also significantly associated with increased SBP and DBP; and parental diabetes with lower values in multiple linear regression.

CONCLUSIONS

Parental hypertension is strongly associated with hypertension. However, parental diabetes may be protective if the effect of parental hypertension is considered.

Angiotensin-converting enzyme gene polymorphism and stroke in type 2 diabetic patients in Taiwan

BACKGROUND

The effect of traditional risk factors on the association between angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and stroke was rarely studied previously. We investigated such effect in Taiwanese type 2 diabetic patients.

MATERIALS AND METHODS

A total of 872 (422 men and 450 women) patients aged 63.5 (SD: 11.6) years were recruited. Among them, 92 cases (48 men and 44 women) had stroke. Polymerase chain reaction was used to classify the genotypes as II, ID and DD. Analyses were performed in separate sexes.

RESULTS

The adjusted odds ratios for stroke for ID vs. II and DD vs. II were 0.837 (0.413-1.697) and 1.778 (0.596-5.300), respectively, for men; but were 1.700 (0.824-3.505) and 3.706 (1.375-9.985), respectively, for women. In models assuming recessive (DD vs. II + ID), dominant (DD + ID vs. II) and additive (II = 0, ID = 1 and DD = 2) transmission, none of the odds ratios was significant for men; but were all significant for women: 2.784 (1.137-6.818), 1.996 (1.006-3.962) and 1.877 (1.155-3.050), respectively. In models using patients without risk factors (hypertension, obesity, smoking or dyslipidaemia ) as a referent group and comparing them to patients with the risk factor and with ID/II, and with DD genotypes, all models (except for smoking) favoured an increasing trend of risk with patients having the risk factor and DD genotype at the highest risk in women. Similar trends for hypertension and dyslipidaemia were also observed in men.

CONCLUSION

Traditional risk factors play an important role in the association between the ACE genotypes and stroke. Patients with DD genotype and having traditional risk factors are at the highest risk.

Idiopathic syringomyelia: case report and review of the literature

Syringomyelia is an uncommon disease that is caused most often by type I Chiari malformation, which develops in the hindbrain, and less frequently by other factors which are not limited to the hindbrain, including trauma, infection, or scoliosis. Idiopathic syringomyelia is rare. We present in this article a patient with idiopathic syringomyelia characterized by hypoesthesia and progressive weakness in the left lower limb. Decompression was attempted by means of laminectomy and a syringoarachnoid shunt. Motor, sensory, and bladder functions were monitored by the change in Japanese Orthopedic Association scores, which increased from 10 points preoperatively to 14 points 30 days postoperatively. This case demonstrates the effectiveness of surgical decompression in a patient with remarkable neurological deficit.

The prevalence of TT virus and GB virus C/hepatitis G virus infection in individuals with raised liver enzymes but without HBV or HCV infection in Taiwan

The prevalence of TT virus (TTV) and GB virus-C/hepatitis G virus (GBV-C/HGV) infection and the association with raised liver function tests in 546 Taiwanese with negative HBsAg, anti-HCV and HCV RNA was elucidated. They were tested for serum alanine aminotransferase (ALT), GBV-C/HGV RNA, anti-envelope protein 2 antibody (anti-E2) and TTV DNA. Direct sequencing and phylogenetic analyses were performed on 58 isolates for TTV genotype determination. The prevalence of TTV DNA, GBV-C/HGV RNA, anti-E2 and over all GBV-C/HGV exposure was 24.9, 3.4, 8.2 and 11.1%, respectively. Using uni- and multi-variate analyses, male gender and TTV viremia were associated significantly with raised ALT values. Sixty-nine percent of TTV isolates were deduced to be TTV genotype 1 and they had significantly lower mean age than genotype non-1 isolates. In the population, raised ALT may be related to male gender and be attributable to TTV infection but not to GBV-C/HGV among individuals with no evidence of current HBV and HCV infection. TTV genotype 1 is the most prevalent genotype and associated with younger age.

Real-time PCR for rapid genotyping of angiotensin-converting enzyme insertion/deletion polymorphism

OBJECTIVE

To develop a real-time PCR technique for detection of the insertion/deletion (I/D) polymorphism of angiotensin-converting enzyme (ACE) gene.

DESIGN AND METHODS

Three primers were designed for performing real-time PCR in the presence of SYBR Green I as flurochrome followed by melting curve analysis. Forty human genomic DNA that have been genotyped by two-rounds of conventional PCR were used for evaluation of this technique.

RESULTS

Melting curve analysis indicated the melting peak at 73.9 degrees C and 76.2 degrees C corresponding to the presence of I and D alleles, respectively. Comparable genotyping results were obtained by both conventional and real-time PCR. Besides, the mistyping of ID allele individuals by the first run of conventional PCR were accurately genotyped by single-tube real time PCR.

CONCLUSIONS

The real-time PCR method presented in this study provides a rapid and sensitive way for genotyping of ACE gene that may be suitable for large-scale clinical and epidemiologic study.

Enhanced effect of in-situ generated ammonium salts aerosols on the removal of NOx from simulated flue gas

The combined removal of sulfur dioxide (SO2, up to 3,000 ppm) and nitrogen oxides (NO and NO2, up to 1,200 ppm) has been investigated in a bench-scale pulsed-corona enhanced wet electrostatic precipitator (wESP) with the optional injection of ammonia and/or ozone. The reaction of ammonia with SO2 produces submicron aerosols under certain conditions. Experiments have shown the feasibility of combined SO2 and NOx removal from simulated flue gases by the action of these in-situ generated aerosols. The mechanisms for NOx removal include oxidation of NO to NO2 and subsequent absorption of NO2 into the water wall of the wESP. The results have shown that injecting NH3 (NH3/NOx molar ratio 1) resulted in NOx removal of approximately 13% in a simulated combustion flue gas. Injecting 200 ppm ozone (no ammonia) increased NO conversion to 35% by oxidation, but total NOx removal increased to only 17%. Without the formation of ammonium salts aerosols (e.g., without SO2 in the gas), co-injection of ammonia and ozone increased NO conversion to 60% and NOx removal to 40%. However, high NOx removals were measured in simulated flue gas that contained NH3, SO2, and ozone. The total NOx removal efficiency was 79% when the ammonium salts aerosols were formed in the presence of 2400 ppm SO2, 312 ppm O3, and 2,900 ppm NH3. The energy efficiency of collection improved by approximately 250% for SO2 removal and more than 4700% for NOx removal under these conditions. It was determined that the ammonium salts aerosols produced from the reaction of ammonia and sulfur dioxide substantially enhanced total NOx removal.

Induction of disabled-2 gene during megakaryocyte differentiation of k562 cells

Megakaryocyte differentiation is often accompanied by the changes of gene expression pattern. Here we reported that the expression of DAB2, a putative adaptor protein in cell signaling, was induced at the protein and mRNA levels upon 12-O-tetradecanoylphorbol-13-acetate-mediated megakaryocyte differentiation of human chronic myeloid leukemic K562 cells. On the other hand, the differentiation agents DMSO and retinoic acid had no effect on DAB2 expression. Analysis of promoter activity with the human DAB2 luciferase reporter constructs suggested that the regulation is partially at the transcriptional level. The responsive sequences located within an 80-bp DAB2 promoter region. To determine the involvement of MEK1-p42/p44 MAPK pathway in mediating DAB2 gene expression, we have performed the following experiments and found that (i) there was sustained activation of p42/p44 MAPK, but not p38 MAPK, upon K562 cells differentiation; (ii) application of MEK1 inhibitor U0126 reduced the expression of DAB2 protein, mRNA and promoter activity, as well as cell differentiation; (iii) constitutively active MEK1 increased DAB2 promoter activity; and (iv) dominant negative ERK2 abolished constitutively active MEK1-induced DAB2 promoter activity. Taken together, our results indicate that DAB2 gene is induced upon megakaryocyte differentiation by the MEK1-p42/p44 MAPK pathway and may define a new role of DAB2 in hematopoietic cell differentiation.

Incidence of transitional cell carcinoma and arsenic in drinking water: a follow-up study of 8,102 residents in an arseniasis-endemic area in northeastern Taiwan

A significant association between ingested arsenic and bladder cancer has been reported in an arseniasis-endemic area in southwestern Taiwan, where many households share only a few wells in their villages. In another arseniasis-endemic area in northeastern Taiwan, each household has its own well for obtaining drinking water. In 1991-1994, the authors examined risk of transitional cell carcinoma (TCC) in relation to ingested arsenic in a cohort of 8,102 residents in northeastern Taiwan. Estimation of each study subject's individual exposure to inorganic arsenic was based on the arsenic concentration in his or her own well water, which was determined by hydride generation combined with atomic absorption spectrometry. Information on duration of consumption of the well water was obtained through standardized questionnaire interviews. The occurrence of urinary tract cancers was ascertained by follow-up interview and by data linkage with community hospital records, the national death certification profile, and the cancer registry profile. Cox proportional hazards regression analysis was used to estimate multivariate-adjusted relative risks and 95% confidence intervals. There was a significantly increased incidence of urinary cancers for the study cohort compared with the general population in Taiwan (standardized incidence ratio = 2.05; 95% confidence interval (CI): 1.22, 3.24). A significant dose-response relation between risk of cancers of the urinary organs, especially TCC, and indices of arsenic exposure was observed after adjustment for age, sex, and cigarette smoking. The multivariate-adjusted relative risks of developing TCC were 1.9, 8.2, and 15.3 for arsenic concentrations of 10.1-50.0, 50.1-100, and >100 microg/liter, respectively, compared with the referent level of < or =10.0 microg/liter.

Unexpected cytokines in serum of malignant melanoma patients during sequential biochemotherapy

Biochemotherapy, which combines traditional chemotherapy with immune modulating biologicals, produces an unexpectedly high response rate (>50%) in advanced melanoma patients. We hypothesize that immunological mechanism(s) are responsible for the increased response rate, and particularly that macrophage activation is involved in tumor reduction. Patients were randomized to receive chemotherapy, composed of cisplatin, vinblastine, and dacarbazine (CVD), or biochemotherapy, which is CVD followed by interleukin (IL)-2 and IFN-alpha2b (CVD-BIO). Laboratory analysis was performed on sera from 41 patients from each arm. Measurements of macrophage activation (neopterin), nitric oxide production (nitrite), and tumor necrosis factor-alpha (TNF-alpha), IL-1alpha, IL-1beta, IFN-gamma, IL-6, IL-10, and soluble IL-2 receptor (sIL-2R) were performed. Six of the nine biological responses (nitrite, neopterin, IFN-gamma, IL-6, soluble IL-2R, and IL-10) significantly (P < 0.0002) increased in the CVD-BIO patients but not in the CVD patients. The increased IL-6 (P = 0.04) and IL-10 (P = 0.05) correlated with patient response, but only when the minor responders were included in the analysis. Evidence of macrophage activation was found in CVD-BIO patients and not in those receiving CVD alone. In addition, an unusual cytokine elaboration composed of IL-6, IFN-gamma, IL-10, nitrite, neopterin, and sIL-2R, but not the expected TNF-alpha and IL-1, was detected. A trend of higher increase in IL-6 and IL-10 in patients having clinical response was found, suggesting an incomplete Th2 pattern of cytokine elaboration. These data show that macrophage activation does not appear to be critical in the response to CVD-BIO, but that IL-10 and IL-6 induced by the BIO component of the CVD-BIO were associated with tumor regression, and that their biology should be pursued further in the analysis of mechanism(s) of response.

The incidence of type 2 diabetes mellitus in Taiwan

Currently, diabetes mellitus is the fifth leading cause of death in Taiwan. The trends of diabetes mortality is increasing steadily. Epidemiologic studies also showed increasing prevalence of diabetes mellitus over the past few decades. The incidence of diabetes mellitus in Taiwan has only been studied in recent 10 years. The areas that have been included as study areas for diabetes incidence are Kin-Chen (Kinmen), Chu-Dung, Pu-Tzu, Pu-Li and Pu-Tai. The reported incidence rates ranged from 1.0 to 4.0% per year for people with varying degrees of baseline plasma glucose levels not reaching the diagnosis of diabetes mellitus according to the criteria of the World Health Organization. Age, baseline glucose level, and obesity are important predictors for the development of diabetes mellitus. In the Pu-Tai study, which was aimed at following a group of people who had been living in the hyperendemic villages of blackfoot disease and had been exposed to arsenic from drinking artesian well water, the incidence of diabetes mellitus was calculated to be 27.4 per 1000 person years. The incidence of diabetes mellitus in these arseniasis-hyperendemic villages correlated with age, body mass index and cumulative arsenic exposure.

Long-term arsenic exposure and incidence of non-insulin-dependent diabetes mellitus: a cohort study in arseniasis-hyperendemic villages in Taiwan

Diabetes prevalence in arseniasis-hyperendemic villages in Taiwan has been reported to be significantly higher than in the general population. The aim of this cohort study was to further evaluate the association between ingested inorganic arsenic and the incidence of non-insulin-dependent diabetes mellitus in these villages. A total of 446 nondiabetic residents in these villages were followed biannually by oral glucose tolerance test. Diabetes is defined as a fasting plasma glucose level > or = 7.8 mmol/L and/or a 2-hr post-load glucose level > or = 11.1 mmol/L. During the follow-up period of 1499.5 person-years, 41 cases developed diabetes, showing an overall incidence of 27.4/1,000 person-years. The incidence of diabetes correlated with age, body mass index, and cumulative arsenic exposure. The multivariate-adjusted relative risks were 1.6, 2.3, and 2.1 for age > or = 55 versus < 55 years, a body mass index ¿Greater/Equal to] 25 versus < 25 kg/m(2), and a cumulative arsenic exposure > or = 17 versus < 17 mg/L-years, respectively. The incidence density ratios (95% confidence intervals) between the hyperendemic villages and the two nonendemic control townships were 3.6 (3.5-3.6), 2.3 (1.1-4.9), 4.3 (2.4-7.7), and 5.5 (2.2-13.5), respectively, for the age groups of 35-44, 45-54, 55-64, and 65-74 years. The findings are consistent with our previous cross-sectional observation that ingested inorganic arsenic is diabetogenic in human beings.

Magnetic resonance imaging of convection in laser-polarized xenon

We demonstrate nuclear magnetic resonance (NMR) imaging of the flow and diffusion of laser-polarized xenon (129Xe) gas undergoing convection above evaporating laser-polarized liquid xenon. The large xenon NMR signal provided by the laser-polarization technique allows more rapid imaging than one can achieve with thermally polarized gas-liquid systems, permitting shorter time-scale events such as rapid gas flow and gas-liquid dynamics to be observed. Two-dimensional velocity-encoded imaging shows convective gas flow above the evaporating liquid xenon, and also permits the measurement of enhanced gas diffusion near regions of large velocity variation.

A system for low field imaging of laser-polarized noble gas

We describe a device for performing MRI with laser-polarized noble gas at low magnetic fields (<50 G). The system is robust, portable, inexpensive, and provides gas-phase imaging resolution comparable to that of high field clinical instruments. At 20.6 G, we have imaged laser-polarized (3)He (Larmor frequency of 67 kHz) in both sealed glass cells and excised rat lungs, using approximately 0.1 G/cm gradients to achieve approximately 1 mm(2) resolution. In addition, we measured (3)He T(2)(*) times greater than 100 ms in excised rat lungs, which is roughly 20 times longer than typical values observed at high ( approximately 2 T) fields. We include a discussion of the practical considerations for working at low magnetic fields and conclude with evidence of radiation damping in this system.

Single-shot diffusion measurement in laser-polarized Gas

A single-shot pulsed gradient stimulated echo sequence is introduced to address the challenges of diffusion measurements of laser polarized 3He and 129Xe gas. Laser polarization enhances the NMR sensitivity of these noble gases by >10(3), but creates an unstable, nonthermal polarization that is not readily renewable. A new method is presented which permits parallel acquisition of the several measurements required to determine a diffusive attenuation curve. The NMR characterization of a sample's diffusion behavior can be accomplished in a single measurement, using only a single polarization step. As a demonstration, the diffusion coefficient of a sample of laser-polarized 129Xe gas is measured via this method.

Construction and implementation of NMR quantum logic gates for two spin systems

The implementation of small prototype quantum computers has been studied through ensemble quantum computing via NMR measurements. In such laboratory studies it is convenient to have access to a wide array of logic gates. Here a systematic approach to reduce the logic gate to an NMR pulse sequence is introduced. This approach views the truth table for a quantum logic operation as a permutation matrix that corresponds to a propagator for an NMR transition. This propagator is then used as the starting point for the derivation of a pulse sequence. Pulse sequences for all the permutations of a four level system are reported along with implementations of representative examples on a two spin-1/2 system, 13C-labeled chloroform.

Accrual strategies for phase I trials with delayed patient outcome

Phase I dose-finding trials typically are conducted using adaptive rules that select dose levels for successive patient cohorts based on the outcomes of patients treated previously in the trial. When patient outcome cannot be observed immediately after treatment, the problem arises of how to deal with new patients while waiting to observe the current patient cohort's outcomes. We consider two alternative approaches to this problem in the context of a phase I trial conducted using the continual reassessment method. With the first approach, a patient requiring treatment before the next cohort opens is treated off protocol with standard therapy, and otherwise waits until the next cohort opens. The second approach treats each patient immediately upon arrival at the dose recommended based on currently available data. We compare these two approaches by simulation under varying dose--toxicity curves, accrual rates, cohort sizes and early stopping rules. We evaluate patient waiting time, trial duration, number of patients treated off protocol and the probabilities of toxicity and of selecting the correct dose. We also study three strategies for assigning patients to trials when two or more phase I trials may be ongoing simultaneously. Based on our results, we provide practical guidelines for deciding among these approaches and strategies in a given clinical setting.

Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sentinel lymph node status in 612 stage I or II melanoma patients

PURPOSE

To compare the effect of pathologic sentinel lymph node (SLN) status with that of other known prognostic factors on recurrence and survival in patients with stage I or II cutaneous melanoma.

PATIENTS AND METHODS

We reviewed the records of 612 patients with primary cutaneous melanoma who underwent lymphatic mapping and SLN biopsy between January 1991 and May 1995 to determine the effects of tumor thickness, ulceration, Clark level, location, sex, and SLN pathologic status on disease-free and disease-specific survival.

RESULTS

In the 580 patients in whom lymphatic mapping and SLN biopsy were successful, the SLN was positive by conventional histology in 85 patients (15%) but negative in 495 patients (85%). SLN status was the most significant prognostic factor with respect to disease-free and disease-specific survival by univariate and multiple covariate analyses. Although tumor thickness and ulceration influenced survival in SLN-negative patients, they provided no additional prognostic information in SLN-positive patients.

CONCLUSION

Lymphatic mapping and SLN biopsy is highly accurate in staging nodal basins at risk for regional metastases in primary melanoma patients and identifies those who may benefit from earlier lymphadenectomy. Furthermore, pathologic status of the SLN in these patients with clinically negative nodes is the most important prognostic factor for recurrence. The information from SLN biopsy is particularly helpful in establishing stratification criteria for future adjuvant trials.

Low serum carotene level and increased risk of ischemic heart disease related to long-term arsenic exposure

To elucidate the association between arsenic-related ischemic heart disease (ISHD) and serum antioxidant micronutrient level, residents aged 30 or older living in arseniasis-hyperendemic villages in Taiwan were recruited in a community-based health survey. A structured questionnaire was used to obtain a history of long-term exposure to arsenic through consuming artesian well water and fasting serum samples were also collected at the recruitment. A total of 74 patients affected with ISHD, who were diagnosed through both electrocardiography and Rose questionnaire interview, and 193 age-sex-matched healthy controls were selected for the examination of serum levels of micronutrients by high performance liquid chromatography (HPLC). There was a significant biological gradient between the risk of ISHD and the duration of consuming high-arsenic artesian well water. A significant reverse dose-response relationship with arsenic-related ISHD was observed for serum level of alpha- and beta-carotene, but not for serum levels of retinol, lycopene and alpha-tocopherol. Multivariate analysis showed a synergistic interaction on arsenic-related ISHD between duration of consuming artesian well water and low serum carotene level. An increased risk of arsenic-related ISHD was also associated with hypertension and elevated body mass index, but not with serum lipid profile, cigarette smoking and alcohol drinking. The findings seem to suggest that arsenic-related ISHD has a pathogenic mechanism which is at least partially different from that of ISHD unrelated to long-term exposure to arsenic.

Pulsed-field-gradient measurements of time-dependent gas diffusion

Pulsed-field-gradient NMR techniques are demonstrated for measurements of time-dependent gas diffusion. The standard PGSE technique and variants, applied to a free gas mixture of thermally polarized xenon and O2, are found to provide a reproducible measure of the xenon diffusion coefficient (5.71 x 10(-6) m2 s-1 for 1 atm of pure xenon), in excellent agreement with previous, non-NMR measurements. The utility of pulsed-field-gradient NMR techniques is demonstrated by the first measurement of time-dependent (i.e., restricted) gas diffusion inside a porous medium (a random pack of glass beads), with results that agree well with theory. Two modified NMR pulse sequences derived from the PGSE technique (named the Pulsed Gradient Echo, or PGE, and the Pulsed Gradient Multiple Spin Echo, or PGMSE) are also applied to measurements of time dependent diffusion of laser polarized xenon gas, with results in good agreement with previous measurements on thermally polarized gas. The PGMSE technique is found to be superior to the PGE method, and to standard PGSE techniques and variants, for efficiently measuring laser polarized noble gas diffusion over a wide range of diffusion times.

Low-field MRI of laser polarized noble gas

NMR images of laser polarized 3He gas were obtained at 21 G using a simple, homebuilt instrument. At such low fields magnetic resonance imaging (MRI) of thermally polarized samples (e.g., water) is not practical. Low-field noble gas MRI has novel scientific, engineering, and medical applications. Examples include portable systems for diagnosis of lung disease, as well as imaging of voids in porous media and within metallic systems.

Improved sentinel lymph node localization in patients with primary melanoma with the use of radiolabeled colloid

BACKGROUND

The purpose of this study was to determine whether the sentinel lymph node (SLN) localization technique, which uses blue dye and 99mTc-labeled sulfur colloid, provides advantages over blue dye alone in the management of patients with stages I and II cutaneous melanoma.

METHODS

The records of 626 consecutive patients with melanoma who underwent lymphatic mapping and SLN biopsy between 1991 and 1997 at the M.D. Anderson Cancer Center were reviewed. Lymphatic mapping was performed with isosulfan blue dye alone (n = 252) or in combination with 99mTc-labeled sulfur colloid accompanied by a hand-held gamma probe (n = 374). SLNs were defined as those that stained blue or demonstrated increased focal radiotracer uptake.

RESULTS

SLN identification rates improved from 87% (dye alone) to 99% (dye and colloid) (P < .0001) with the combined technique in all anatomic sites examined. The mean number of SLNs harvested from each basin was significantly greater in the patients mapped with dye and colloid (1.74 vs 1.31; P < .0001). Occult metastatic disease was identified in 17.5% of all patients and did not significantly differ between groups. In 92% of patients who had at least one positive SLN and were mapped with both agents, lymphatic metastases were identified in the SLN that contained the greatest radiotracer uptake.

CONCLUSIONS

SLN identification is enhanced by the addition of radiolabeled sulfur colloid and intraoperative use of the hand-held gamma probe and may identify SLNs missed by the blue dye alone. These data support the combined use of radiolabeled sulfur colloid and blue dye in lymphatic mapping procedures to improve the nodal staging of stages I and II melanoma.

NMR of laser-polarized 129Xe in blood foam

Laser-polarized 129Xe dissolved in a foam preparation of fresh human blood was investigated. The NMR signal of 129Xe dissolved in blood was enhanced by creating a foam in which the dissolved 129Xe exchanged with a large reservoir of gaseous laser-polarized 129Xe. The dissolved 129Xe T1 in this system was found to be significantly shorter in oxygenated blood than in deoxygenated blood. The T1 of 129Xe dissolved in oxygenated blood foam was found to be approximately 21 (+/-5) s, and in deoxygenated blood foam to be greater than 40 s. To understand the oxygenation trend, T1 measurements were also made on plasma and hemoglobin foam preparations. The measurement technique using a foam gas-liquid exchange interface may also be useful for studying foam coarsening and other liquid physical properties.

Lipid profile and peripheral vascular disease in arseniasis-hyperendemic villages in Taiwan

To examine whether lipid abnormalities contributed to the endemic peripheral vascular disease (PVD) in villages where arseniasis was hyperendemic in Taiwan, the authors studied 533 adults with Doppler ultrasound and lipid profiles including total cholesterol, triglyceride, high- and low-density lipoprotein cholesterol, apolipoprotein AI, and apolipoprotein B. Among them, 63 had PVD based on an ankle-brachial index < 0.90. Long-term arsenic exposure indices including cumulative arsenic exposure in mg/L-years, duration of drinking artesian well water in years, and duration of living in arseniasis-hyperendemic villages in years were calculated from detailed history obtained through standardized interviews based on a structured questionnaire and arsenic concentration in well water. Possible confounders including age, sex, body mass index, cigarette smoking, and disease status of diabetes mellitus and hypertension were considered in the analyses. None of the lipid profiles differed significantly between the presence and absence of PVD. The odds ratios for PVD did not differ among different quintiles of lipid profiles with the lowest quintile as the referent. However, a significant dose-response relation was found for the long-term arsenic exposure indices. The multivariate-adjusted odds ratios for cumulative arsenic exposure of 0.1 approximately 19.9 and > or = 20 mg/L-years were 2.77 and 4.68, respectively, compared with the unexposed. These results suggest that the PVD in arseniasis-hyperendemic villages is correlated with ingested inorganic arsenic and not with the lipid profiles.

Determinants of tissue delivery for 129Xe magnetic resonance in humans

Magnetic resonance imaging using laser-polarized 129Xe is a new technique first demonstrated by Albert et. al. (Nature 370, 1994) who obtained a 129Xe image of an excised mouse lung. This paper describes the factors influencing the accumulation of inhaled, polarized 129Xe in human tissue. The resulting model predicts the 129Xe magnetization in different tissues as a function of the time from the start of inhalation, the tissue perfusion rate and partition coefficient for xenon, and the relevant T1 decay times. The relaxation times of 129Xe in biological tissues are not yet known precisely. Substitution of estimated values for these parameters results in an expected signal-to-noise ratio (SNR) from polarized 129Xe MR in the brain of approximately 2% of the equivalent SNR from proton MR.

Color-Doppler Ultrasound-assisted endoscopic neurosurgery for intracerebral hemorrhage

BACKGROUND

Over the past few years, the use of endoscopy in neurosurgery has gradually gained importance. In this study we described the performance of Color Doppler Ultrasound (CDU)-guided endoscopic neurosurgery in ten patients with intracerebral hemorrhage. The completeness of hematoma evacuation was also evaluated.

METHODS

CDU, resectoscope, cutting loops, biopsy forcep, and the irrigation and suction device were the main instruments used in treating intracerebral hematoma. The CDU probe was utilized to locate the exact position of the hematoma and to provide direct visual control of the operation. The cutting loops and biopsy forcep were applied to morcellate and fragment the hematoma. Next, the fragmented hematoma was aspirated by a suction and irrigation device. CDU was then re-used to verify the completeness of hematoma resection and hemostasis as well as evaluate the position of midline shifting.

RESULTS

The completeness of hematoma evacuation in our patient series was over 90% in three patients, over 50% in five patients, and less than 50% in two patients. One patient showed signs of rebleeding two days post-operatively and underwent conventional craniotomy.

CONCLUSIONS

This endoscopic neurosurgical procedure caused less trauma around and along the route to the hematoma, and inflicted less damage to healthy brain tissue. Sonography, especially CDU, is quite helpful in the localization of hematoma and evaluation of intra- or post-operative bleeding. The operation time was also significantly shortened as compared to conventional craniotomy, thereby reducing the risk of operation.

Dose-response relationship between peripheral vascular disease and ingested inorganic arsenic among residents in blackfoot disease endemic villages in Taiwan

The purpose of this study was to examine the correlation between previous arsenic exposure and peripheral vascular disease after stopping consumption of high-arsenic artesian well water for more than two decades in blackfoot disease endemic villages in Taiwan. A total of 582 adults (263 men and 319 women, aged 52.6 +/- 10.6 years) living in these villages underwent Doppler ultrasound measurement of systolic pressures on bilateral ankle (posterior tibial and dorsal pedal) and brachial arteries and estimation for long-term arsenic exposure. The diagnosis of peripheral vascular disease was based on an ankle-brachial index (the ratio between ankle and brachial systolic pressures) <0.90 on either side. Three indices of arsenic exposure were estimated: (1) duration of living in blackfoot disease endemic villages; (2) duration of artesian well water consumption; and (3) cumulative arsenic exposure in mg/l-years based on the detailed history of residential addresses and artesian well water consumption and the arsenic concentration in artesian well water. Multiple logistic regression analysis was used to assess the association between peripheral vascular disease and arsenic exposure. A dose-response relation was observed between the prevalence of peripheral vascular disease and the long-term arsenic exposure. The odds ratios (95% confidence intervals) after adjustment for age, sex, body mass index, cigarette smoking, serum cholesterol and triglyceride levels, diabetes mellitus and hypertension were 2.77 (0.84-9.14), and 4.28 (1.26-14.54) for those who had cumulative arsenic exposure of 0.1-19.9 and > or = 20.0 mg/l-years, respectively, compared with those who were not exposed. This study suggests a close relation between long-term arsenic exposure and peripheral vascular disease in blackfoot disease endemic villages in Taiwan after stopping consumption of artesian well water.

Body composition and its relationship with physical activity and anthropometric factors in Chinese adults

To evaluate the relationship of body composition with physical activity and other anthropometric factors, a group of 437 healthy Chinese men and women were recruited. Body composition was measured using the bioelectric impedance technique. Levels of physical activity (LPA) were classified as light, moderate and heavy. Anthropometric factors evaluated included body mass index (BMI), ponderal index (PI), waist-to-hip ratio (WHR), triceps skinfold thickness (TSF), mid-arm circumference, mid-forearm circumference, arm muscle circumference (AMC) and arm muscle area (AMA). Sex was found to be highly associated with body composition, with females having a higher percentage of body fat and males having a higher percentage of body lean mass. This gender difference was independent of age, physical activity or other anthropometric factors. An increased level of physical activity was associated with higher body lean mass and lower body fat. Sex, LPA, TSF, PI and WHR were all entered into the regression equations to estimate body composition. Sex and physical activity have an independent effect on body composition and the commonly used estimators for adiposity and fat distribution such as BMI, PI, TSF and WHR are closely correlated with body composition.

Changes in pulmonary mechanics and gas exchange after thoracentesis on patients with inversion of a hemidiaphragm secondary to large pleural effusion

The present study was designed to test whether there was a significant improvement in pulmonary function and arterial blood oxygenation after therapeutic thoracentesis on patients with inversion of a hemidiaphragm due to pleural effusion. In 21 patients with inversion of a hemidiaphragm because of a pleural effusion, we studied the changes in pulmonary mechanics and gas exchange that occurred in 24 h after removal of 600 to 2,700 mL of fluid by thoracentesis. There was a small but significant increase in the forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) (p < 0.001). The alveolar-arterial oxygen gradient (P[A-a]O2) and partial pressure of arterial oxygen (PaO2) showed a significant increase (p < 0.001), but there was no change in partial pressure of arterial carbon dioxide (PaCO2). In the present study, all patients with a large pleural effusion had inversion of a hemidiaphragm documented by chest sonography, and that was an important factor to observe significant improvement in pulmonary mechanics and gas exchange.

A case of spindle cell sarcomatous change of hepatic ducts manifesting as obstructive jaundice

Spindle cell carcinoma is a rare tumor commonly occurring in the upper aerodigestive tract. We report a 62-year-old male with spindle cell sarcomatous change located at the hepatic hilum, resulting in obstructive jaundice. The patient died after an extended resective operation. The rare disease and its histogenesis is discussed.

Fibrolamellar variant of hepatocellular carcinoma--report of a Chinese patient

Fibrolamellar hepatocellular carcinoma is rare. By chance, a Chinese woman detected a mass in the right upper quadrant of the abdomen. Ultrasonography, computed tomography and magnetic resonance imaging revealed a solid tumor with a central fibrous scar locating at the posterior inferior subsegment of the right hepatic lobe. The tumor was successfully resected and histopathological examination revealed a fibrolamellar hepatocellular carcinoma. Our case shows that fibrolamellar hepatocellular carcinoma may also occur in Chinese as well as in Japanese and Westerners.

Prior epidural injection of 10 ml normal saline reduces the incidence of inadvertant venous puncture in epidural catheterization

BACKGROUND

Anesthetically, epidural neural blockade is widely used in the fields of surgery and obstetrics as well as in diagnosis and management of acute and chronic pain. However, inadvertent epidural venous puncture might be a serious problem, or even life-threatening particularly when drug is erronaneously injected and prompt diagnosis is not made correct and treatment is not instituted. Although many anesthesiologists suggested that injection of fluid into the epidural space before catheter insertion could prevent an epidural venous puncture, some others did not agree to it. This study aimed a assess the effect of injection of different volumes of saline into the epidural space before catheter insertion on the incidence of epidural venous puncture.

METHODS

Three hundred ASA I or II patients receiving Extracorporeal Shock Wave Lithotripsy (ESWL) were randomly divided into three groups: group A (no saline), group B (5 ml of saline) and group C (10 ml of saline). After the injection of different volume of saline into the epidural space, an epidural catheter was inserted into the epidural space via a Touhy needle. The incidence of epidural venous puncture in each group was compared.

RESULTS

The incidence of epidural venous puncture in group A and B was 14% and 11%, respectively. However, the incidence in group C (1%) was significantly lower than the other two groups.

CONCLUSIONS

Our results suggest that injection of 10 ml saline into the epidural space before catheter insertion could significantly diminish the incidence of epidural venous puncture.

Abnormal peripheral microcirculation in seemingly normal subjects living in blackfoot-disease-hyperendemic villages in Taiwan

Blackfoot disease (BFD) is an endemic peripheral arterial disease confined to the southwestern coast of Taiwan. The cause of the disease has been ascribed to the high-arsenic artesian well water. The purpose of this study was to examine the possible association between the long-term exposure to artesian well water and the change in microvascular circulation in the absence of peripheral arterial insufficiency. A total of 45 men living in the BFD-hyperendemic villages and another 51 age- sex- body-mass index-matched men who lived in nonendemic villages nearby were recruited into this study. All subjects were free from peripheral vascular disease (resting ankle-brachial index > 1.00), clinical claudication, cigarette smoking, diabetes mellitus, hypertension, ischemic heart disease, cerebral infarction and obesity. Laser Doppler flowmetry was used to measure the peripheral microcirculation on the big toes both at 36 degrees C (basal perfusion, Pb) and after a hyperthermic test at 42 degrees C (Ph). The time required to reach Ph (T), and the average rate (R) of increase from Pb to Ph measured by (Ph-Pb)/T were also calculated. Results showed that those living in the BFD-hyperendemic area had a lower Pb [32.8 +/- 6.0 perfusion units (PU) vs. 67.0 +/- 4.3 PU, p < 0.001], a lower Ph (193.2 +/- 13.6 vs. 231.1 +/- 6.3 PU, p < 0.005), a longer T (3.04 +/- 0.19 vs. 1.31 +/- 0.08 min, p < 0.001) and a slower rate of increase from Pb to Ph (48.0 +/- 4.8 vs. 76.2 +/- 5.4 PU/min, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)