Physician adherence to anaphylaxis guidelines among different age groups in emergency departments: 20-Year observational study

BACKGROUND

Anaphylaxis is an acute and serious allergic reaction. Little is known about physician adherence to anaphylaxis guidelines among patients across different age groups.

OBJECTIVE

To investigate real-world physician adherence to anaphylaxis guidelines among children, adults, and older adults in emergency departments.

METHODS

This study retrospectively analyzed all consecutive patients with anaphylaxis who presented to 2 emergency departments at 2 branches of the largest tertiary hospital in Taiwan, between 2001 and 2020. Patients who met the diagnostic criteria for anaphylaxis were enrolled and grouped by age: children (<18 years), adults (18-64 years), and older adults (≥65 years).

RESULTS

We enrolled 771 patients with anaphylaxis (159 children, 498 adults, and 114 older adults). Intramuscular epinephrine was administered in 294 cases (38.1%). There was a significant age-group difference in the rate of intramuscular epinephrine administration (46.5% in children, 37.3% in adults, and 29.8% in older adults; P trend = .004). When stratified by severity, 14.3% of older adults with moderate reactions received intramuscular epinephrine, whereas 35.2% of adults and 55.3% of children received intramuscular epinephrine (P trend < .001), whereas such difference was not found in patients with severe reactions. Upon discharge from emergency departments, 15.3% received allergist referral (52.2% in children, 6.6% in adults, and 1.8% in older adults; P trend < .001); 12.5% received education on avoidance of triggers (18.9%, 11.4%, and 7.9%; P trend = .01), and 16.1% received education on alarm symptoms (21.4%, 15.1%, and 13.2%; P trend = .05).

CONCLUSION

The real-world physician adherence to anaphylaxis guidelines remains suboptimal in emergency departments, particularly among older adults. Physician continuing education is needed to improve the gap between anaphylaxis guidelines and clinical practice.

The state-of-the-art development of photocatalysts for the degradation of persistent herbicides in wastewater

Herbicides are one of the most recurring pollutants in the aquatic system due to their widespread usage in the agriculture sector for weed control. Semiconductor-based photocatalysts have gained recognition due to their ability to degrade and mineralize pollutants into harmless by-products completely. Lately, many studies have been done to design photocatalysts with efficient separation of photogenerated charge carriers and enhanced light absorption. Photocatalyst engineering through doping with metal and non-metal elements and the formation of heterojunction are proven effective for minimizing the recombination of electron-hole pairs and enlarging the absorption in the visible light region. This review focuses on discussing and evaluating the recent progress in the types of photocatalysts and their performance in the remediation of herbicides in wastewater. The development of innovative hybrid technologies is also highlighted. The limitations and challenges of photocatalysis technology in the present literature have been identified, and future studies are recommended.

941 The Effect of COVID-19 on Orthopaedic Trauma Theatre Efficiency and Surgical Training in the North and East of Scotland Major Trauma Centres – a Year On

Aim

To determine the orthopaedic trauma theatre efficiency in two large major trauma centres (MTCs) in Scotland before and after the outbreak of Coronavirus disease (COVID-19) pandemic.

Method

All trauma patients presented to the North and East of Scotland's MTCs prior to the outbreak of COVID-19 (7th May to 7th June 2019), during the first peak of COVID-19 (7th May to 7th June 2020), after Aerosol Generating Procedures updates (7th November to 7th December 2020) and the ‘new normal’ (7th May to 7th June 2021) were retrospectively reviewed. Training opportunities and theatre time were compared. The Kruskall-Wallis test was used.

Results

There were no significant differences in the length of hospital stay (p=0.117, 0.065) and time from injuries and surgery within groups in both MTCs (p=0.508, 0.384). The pandemic has negatively affected the anaesthetic and surgical preparation time, time between end of procedure and send for next case, and turnover time, with more profound effect on the North of Scotland's MTC. The trainee's involvement as main surgeon had decreased with the outbreak of the pandemic, with the junior trainees being affected most severely in North of Scotland. The time taken for patient to arrive to theatre after sending and total downtime were twice as long in the North of Scotland.

Conclusion

The COVID-19 pandemic has negatively impacted the orthopaedic trauma theatre efficiency and training opportunities. Actions should be taken to improve the turnover time to maximise theatre efficiency while prioritizing training opportunities.

947 COVID19 and Its Impact on the North and East of Scotland Orthopaedic Trainees

Aim

We conducted a trainee survey at the first peak of the pandemic to investigate the impact of COVID-19 on the North of Scotland (NoS) and East of Scotland (EoS) orthopaedic trainees.

Method

An online survey was distributed to all NoS and EoS orthopaedic trainees. All data collection was anonymous.

Results

Across both Scottish deaneries, 28 trainees had responded: 39% from EoS and 61% from NoS. Trainees at all stages of training responded to the survey, with the most responses received from specialist trainees in third year of training (ST3) (25%). In response to the pandemic, 18% of trainees had been redeployed and they were from NoS. Since the reconfiguration of service, 18% of trainees had done &gt;20 operations in a month and they were senior trainees. If COVID-19 outbreak is likely going to reduce operating opportunities for a long period, only 36% of trainees would be open to the idea of making standard surgical specialty training longer whereas 57% of trainees would be open to longer working hours to achieve certification in Trauma and Orthopaedic surgery within 96 months.

Conclusion

The outbreak of COVID-19 has impacted both deaneries orthopaedic training and urgent restoration of surgical training is essential for individual trainees. Changes in working practices necessitated by COVID-19 have known to impact theatre efficiency. Actions should be taken to improve the theatre efficiency while prioritizing training opportunities.

730 Is The Total Hip Arthroplasty For Hip Fracture Comparable With Matched Elective Cohort ? A Prospective Study

Aim

Total hip replacement (THR) has been effective in managing osteoarthritis but its effectiveness in managing neck of femur fracture (#NOF) is debatable due to higher risk of morbidity and mortality. We aimed to review the selection criteria for trauma THR and to compare the functional outcomes and complication profiles of trauma THR cohort with elective THR cohorts.

Method

we prospectively reviewed patients undergoing THR for #NOF with follow-up. The functional outcomes, any further complications-related admissions and death within a year were noted for subsequent analysis. All the patients and data collected were subsequently matched with the elective cohort.

Results

Forty-one matched cases were included in our study. The Modified Harris Hip Score (mHHS) was significantly lower pre-operatively in elective cohort (41.4±14.3 VS 60.3±22.2, P &lt; 0.001) and achieved significantly higher score than trauma cohort 1-year post operatively (88.2±10.9 VS 82.6±12.7, P = 0.029). As for the mHHS Function, the trauma cohort achieved similar value with the pre-operative score post-operatively, and no significant difference was witnessed between the trauma and elective cohort post-operatively (35.1±7.4 VS 37.6±7.7, P = 0.142). mHHS Pain score was significantly higher in trauma cohort pre-operatively (19.8±15.3 VS 12.7±6.3, P = 0.034), but the score was significantly higher than trauma cohort 1-year postoperatively (42.7±4.4 VS 40.7±7.7, P = 0.027). Both cohorts had similar complication rate.

Conclusions

Our study further justified the clinical indication of THR for #NOF. With careful selection, trauma THR can achieve similar HHS function and better pain score. Further randomized controlled trials are warranted to justify our findings.

Orthopaedic assessment unit: a service model for the delivery of orthopaedic trauma care in a major trauma centre during the global pandemic (COVID-19)

INTRODUCTION

We describe a new service model, the Orthopaedic Assessment Unit (OAU), designed to provide care for trauma patients during the COVID-19 pandemic. Patients without COVID-19 symptoms and isolated musculoskeletal injuries were redirected to the OAU.

METHODS

We prospectively reviewed patients throughput during the peak of the global pandemic (7 May 2020 to 7 June 2020) and compared with our historic service provision (7 May 2019 to 7 June 2019). The Mann-Whitney and Fisher Exact tests were used to test the statistical significance of data.

RESULTS

A total of 1,147 patients were seen, with peak attendances between 11am and 2pm; 96% of all referrals were seen within 4h. The majority of patients were seen by orthopaedic registrars (52%) and nurse practitioners (44%). The majority of patients suffered from sprains and strains (39%), followed by fractures (22%) and wounds (20%); 73% of patients were discharged on the same day, 15% given follow up, 8% underwent surgery and 3% were admitted but did not undergo surgery. Our volume of trauma admissions and theatre cases decreased by 22% and 17%, respectively (p=0.058; 0.139). There was a significant reduction of virtual fracture clinic referrals after reconfiguration of services (p<0.001).

CONCLUSIONS

Rapid implementation of a specialist OAU during a pandemic can provide early definitive trauma care while exceeding national waiting time standards. The fall in trauma attendances was lower than anticipated. The retention of orthopaedic staff in the department to staff the unit and maintain a high standard of care is imperative.

Broken guidewire intramedullary: what to do now?

Instrument breakage during orthopaedic procedures is relatively uncommon, but it remains a challenging problem to orthopaedic surgeons. We report a case of a broken guidewire during intramedullary nail fixation of a proximal femur fracture with subtrochanteric extension. We also report a simple yet effective technique for removal of a broken guidewire from the medulla of the proximal femur without causing much iatrogenic trauma.

Docosahexaenoic acid inhibits ethanol/palmitoleic acid-induced necroptosis in AR42J cells

Fatty acid ethyl esters (FAEEs), non-oxidative metabolites of ethanol, are the main causative agents of severe acute pancreatitis resulting from alcohol abuse. Pancreatic acinar cells exposed to ethanol in combination with the fatty acid palmitoleic acid (EtOH/POA) display increased levels of palmitoleic acid ethyl ester and cell death. Oxidative stress and acinar cell necroptosis are implicated in the pathology of severe acute pancreatitis. Docosahexaenoic acid (DHA) serves as a powerful anti-oxidant that reduces pancreatic inflammation and improves the outcomes of patients with acute pancreatitis. We investigated whether treatment of EtOH/POA, as an in vitro model of alcoholic pancreatitis, increases reactive oxygen species (ROS), necroptosis-regulating proteins, and cell death by increasing nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity and intracellular calcium. Also, we investigated whether DHA inhibits EtOH/POA-induced alterations in pancreatic acinar AR42J cells. As a result, EtOH/POA increased intracellular and mitochondrial ROS levels, NADPH oxidase activity, necroptosis-regulating proteins, and cell death, which was inhibited by NADPH oxidase inhibitor apocynin, the Ca²⁺ chelator BAPTA, and DHA. However, DHA did not reduce EtOH/POA-induced increases in Ca²⁺ oscillation or levels in AR42J cells. Furthermore, EtOH/POA induced mitochondrial dysfunction by reducing mitochondrial membrane polarization and hence, adenosine triphosphate (ATP) production. DHA treatment attenuated EtOH/POA-induced mitochondrial dysfunction. In conclusion, DHA inhibits EtOH/POA-induced necroptosis by suppressing NADPH oxidase activity, reducing ROS levels, preventing mitochondrial dysfunction, and inhibiting activation of necroptosis-regulating proteins in AR42J cells.

Inhibitory effect of alpha-lipoic acid on mitochondrial dysfunction and interleukin-8 expression in interleukin-1beta-stimulated ataxia teleangiectasia fibroblasts

Ataxia telangiectasia (A-T) is an inherited neurodegenerative disease caused by mutation in the ataxia telangiectasia mutated (ATM) gene, leading to loss of function in the encoded protein ATM. Because ATM functions to reduce oxidative stress by up-regulating antioxidant enzymes, oxidative stress is a prevalent A-T phenotype and a mediator of the inflammation that drives A-T pathology. Reactive oxygen species (ROS) levels and the expression of pro-inflammatory cytokine interleukin-8 (IL-8) were higher in A-T cells than in normal cells. ROS are related to mitochondrial dysfunction and activation of nuclear factor kappa B (NF-κB) to induce IL-8 expression. Alpha-lipoic acid (α-LA), a naturally occurring thiol compound, shows an antioxidant effect in various cells. This study is aimed to determine if α-LA confers protection against NF-κB activation, IL-8 expression, and mitochondrial dysfunction in A-T cells which are exposed to the inflammatory cytokine IL-1β. A-T fibroblasts were treated with or without α-LA. The levels of intracellular and mitochondrial ROS, mRNA and protein levels of IL-8, mitochondrial membrane potential (MMP), ATP levels, and DNA binding activity of NF-κB were determined. As a result, IL-1β increased NF-κB activation, IL-8 expression, intracellular and mitochondrial ROS levels, but decreased MMP and ATP level in A-T cells. Pretreatment of A-T cells with α-LA inhibited IL-1β-induced activation of NF-κB, IL-8 expression, and mitochondrial dysfunction by reducing ROS levels. In conclusion, supplementation with α-LA may be beneficial for reducing the oxidative stress-induced mitochondrial dysfunction and IL-8 production associated with A-T.

Pancreatitis-associated protein-1 suppresses apoptosis in cerulein-stimulated pancreatic acinar cells in response to nuclear factor-kappa B activation

Pancreatitis is a disease for which there are numerous etiologies but no effective treatments. Although the expression of the pancreatitis-associated protein-1 (PAP-1) serves as a marker for the disease, its biological function is unknown. The present study was carried out to determine if PAP-1 performs a protective role against oxidative stress-induced pancreatic cell death. For this purpose, we used cerulein-stimulated pancreatic acinar AR42J cells as an experimental model of acute pancreatitis. First, we demonstrated that PAP-1 gene expression is increased by cerulein in a dose- and time-dependent manner. In parallel, the level of active nuclear factor kappaB (NF-κB) was found to be increased in cells treated with cerulein. To test whether activation of the oxidant-sensitive transcription factor NF-κB is mediated by nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, the primary source of reactive oxygen species, cerulein-stimulated NADPH oxidase activity was suppressed by using the NADPH oxidase inhibitor diphenyleneiodonium and, separately, by anti-sense oligonucleotides directed against NADPH oxidase subunits p22^phox and p47^phox. We observed that a decrease in NADPH oxidase activity resulted in decreased NF-κB activation and decreased PAP-1 gene expression. To determine whether the cerulein-induced NF-κB activation involves PAP-1 expression, cells were transfected to overexpress the MAD3 double-point IκBα mutant. In response, NF-κB activation and PAP-1 gene expression were decreased. Lastly, we observed that the cerulein-induced reduction in cell viability and increase in apoptosis are reversed by overexpression of PAP-1 in PAP-1-transfected cells. Taken together, these results support the postulate that PAP-1 inhibits cerulein-induced apoptosis in response to NADPH oxidase-mediated NF-κB activation in pancreatic acinar cells.

Lycopene induces apoptosis by inhibiting nuclear translocation of β-catenin in gastric cancer cells

Reactive oxygen species (ROS) promote the development and progression of cancer by their effects on several signaling pathways. Lycopene, a major carotenoid natural product, is known to display antioxidant activity and to induce apoptosis of cancer cells. The aim of the present study was to investigate the mechanism by which lycopene induces apoptosis of the human gastric cancer AGS cells. In the present study, we showed that lycopene reduces the viability of AGS cells by inducing DNA fragmentation and increasing the Bax/Bcl-2 ratio. To determine the mechanistic basis for these effects, studies were conducted to assess the effects of this carotenoid on activation and nuclear translocation of β-catenin, and the expression of β-catenin target genes in AGS cells. The results showed that lycopene reduces the levels of ROS. It also inhibits activation of β-catenin signaling by changing the Wnt/β-catenin multi-protein complex such as a reduction in phosphorylation of glycogen synthase kinase 3β [GSK3β] and an increase in adenomatous polyposis coli [APC] and β-transducin repeats-containing proteins [β-TrCP]). It suppresses nuclear translocation of β-catenin and the expression of the β-catenin target survival genes c-myc and cyclin D1. Lycopene induces apoptosis by reducing ROS levels and suppressing β-catenin-c-myc/cyclin D1 axis. Thus, lycopene induces apoptosis of gastric cancer cells by disrupting nuclear translocation of β-catenin and expression of key cell survival genes.

Multi-centre study on cultural dimensions and perceived attitudes of nurses towards influenza vaccination uptake

This study explored how cultural values affected Health Belief Model (HBM) components and the influenza vaccine uptake among nurses across three Asian populations using a survey conducted in 2017 (N = 3971). The vaccination coverages were 33.5% (Brunei), 35.6% (Hong Kong) and 69.5% (Singapore). Three HBM components (perceived susceptibility, perceived benefits and cues to action) were positively associated with vaccination. A direct negative link and an indirect positive link via HBM were observed between collectivism and vaccination, whereas a negative indirect link via HBM between power distance and vaccination was observed. Cultural values, notably collectivism, advanced HBM to study nurses' vaccination.

Contralateral Approach to Coil Embolization of Proximal A1 Aneurysms Using the Anterior Communicating Artery

BACKGROUND AND PURPOSE

Aneurysms arising from the proximal A1 segment of the anterior cerebral artery are rare, and their distinctive configurations often pose technical challenges during endovascular embolization. Herein, we present 11 patients with proximal A1 aneurysms requiring a contralateral approach (via the anterior communicating artery) to coil embolization.

MATERIALS AND METHODS

From a prospectively collected data repository, we retrieved records of 11 patients consecutively treated for proximal A1 aneurysms between January 2011 and March 2018. In each instance, coil embolization was performed by the contralateral route. Outcomes were analyzed in terms of morphologic features and clinical status.

RESULTS

Aneurysms in all 11 patients were directed posteriorly and were small (<5 mm). A contralateral approach (via the anterior communicating artery) was used after ipsilateral attempts at aneurysm selection failed in each instance, despite using a variety of microcatheters. Single punctures and single guiding catheters sufficed in 9 patients, but 2 patients required dual punctures and 2 guiding catheters. All endovascular treatments ultimately yielded excellent outcomes. Although 1 symptomatic infarct was manifested in the course of ipsilateral treatment, no morbidity or mortality resulted from the contralateral access.

CONCLUSIONS

Due to angio-anatomic constraints, a contralateral strategy for coil embolization of proximal A1 aneurysms is acceptable if ipsilateral access is technically prohibitive and the vessels (contralateral A1 and anterior communicating artery) are amenable to the passage of microdevices.

Effect of thiol antioxidants on lipopolysaccharide-induced cyclooxygenase-2 expression in pulmonary epithelial cells

Cyclooxygenase-2 (COX-2) plays an important role in pulmonary inflammatory response, and its expression is regulated by several transcription factors including nuclear factor kappa-B (NF-κB), activator protein-1 (AP-1), and signal transducer and activator of transcription-3 (STAT-3), which are activated by oxidative stress. Glutathione (GSH) and N-acetyl cysteine (NAC) are thiol antioxidants that scavenge reactive oxygen species (ROS). The present study investigated whether lipopolysaccharide (LPS) induces COX-2 expression through ROS generation and the activation of oxidant-sensitive transcription factors such as NF-κB, AP-1, and STAT-3 in pulmonary epithelial A549 cells. The cells were pretreated with GSH or NAC for 1 hour prior to LPS stimulation. Intracellular ROS levels, DNA-binding activities of NF-κB, AP-1, and STAT-3, and mRNA and protein levels of COX-2 were determined. Our results showed that LPS increased ROS levels that peaked at 2 hours. LPS activated NF-κB, AP-1, and STAT-3 and induced the expression of COX-2 in A549 cells in a time-dependent manner. Pretreatment of thiol antioxidants GSH and NAC reduced ROS levels and attenuated the increase in ROS, the activation of NF-κB, AP-1, and STAT-3, and the expression of COX-2 in LPS-treated A549 cells. In conclusion, GSH and NAC suppress COX-2 expression by reducing ROS levels and inhibiting the activation of NF-κB, AP-1, and STAT-3 in pulmonary epithelial A549 cells exposed to LPS. Pretreatment with thiol antioxidants GSH and NAC may be beneficial for the treatment of pulmonary inflammation associated with oxidative stress.

Persistence of meticillin-resistant Staphylococcus aureus carriage in re-admitted patients

A retrospective cohort study was conducted to investigate the duration and risk factors for persistence of meticillin-resistant Staphylococcus aureus (MRSA) colonization among known carriers who were re-admitted to hospital. MRSA carriage persisted in a high proportion of known carriers up to two years after their last date of discharge, and re-admission screening should be performed for at least this duration. A targeted screening approach should focus on older patients with a history of long inpatient stays, who are at higher risk of persistent carriage. Timely discharge planning is important in reducing the risk of persistent MRSA colonization among known carriers.

Abstract P2-01-36: Ex vivo shear-wave elastography of axillary lymph nodes predicting nodal metastasis in patients with primary breast cancer: A pilot study

Objective: To evaluate the feasibility of shear-wave elastography using breast ultrasonography in identifying metastasis of removed sentinel lymph nodes during the operation for treatment of breast cancer.

Background: Conventional method for identification of sentinel nodal metastasis is time and cost consuming. The optimal method for identification of nodal status is important.

Methods: Excised sentinel lymph nodes during the operation were prospectively examined with the elastography. Metastatic status of lymph nodes was confirmed with permanent histology. Only macrometastasis was regarded as positive. Elastic values measured by the ex vivo elastography and nodal characteristics were analyzed to correlate with nodal metastasis.

Results: A total of 274 lymph nodes harvested from 68 breast cancer patients at Gangnam Severance Hospital from May 2014 to April 2015 were included this study. There was the difference of elastic values between nodes with and without metastasis (mean stiffness, 41.6 kPa and 17.4 kPa, P &lt; 0.001). Mean sizes of metastatic nodes (range 0.36-2.59 cm) were significantly larger than that of non-metastatic nodes (1.0 cm versus 0.75 cm, P &lt; 0.001). Moreover, there was a correlation between the size of metastatic nodes which ranged from 0.7 to 21.5 mm with a median of 7 mm and nodal stiffness (correlation coefficient of mean stiffness, r = 0.431). The area under the receiver operating characteristic curve (AUC) by the mean stiffness was 0.794. The combination of size of nodes, mean stiffness and ratio made AUC of 0.856.

Conclusions: In our study, ex vivo shear-wave elastography of sentinel lymph nodes was a feasible method to predict metastasis. Through the validation study, ex vivo elastography could be helpful to determine metastasis of sentinel lymph nodes during the operation.

Keywords Breast cancer; Elastography; Lymph node metastasis.

Citation Format: Lim JW, Lee HW, Park JT, Ahn SG, Jung J. Ex vivo shear-wave elastography of axillary lymph nodes predicting nodal metastasis in patients with primary breast cancer: A pilot study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-36.

Total hip replacement for neck of femur fracture: Comparing outcomes with matched elective cohort

INTRODUCTION

Current literature suggests that total hip replacement (THR) is superior to hemiarthroplasty (HA) for neck of femur fracture in selected group of patients. The outcomes of THR undertaken for trauma setting remain unclear when comparing with elective THR. We compared the outcomes of THR trauma cohort with best-matched elective cohort.

METHODS

We retrospectively reviewed 102 patients that underwent THR due to trauma from 2011 to 2013. We had access to 90 cases with complete records. Another 90 matched elective cases were obtained from local arthroplasty database. The elective cases were matched for gender, surgical approaches, surgeon's grade, types of implant, patient's age at operation date of ±5 years and operation date of ±60days. Subsequently, the selection criteria were relaxed to patient's age at operation date of ±10 years and operation date of ±60days. Unmatched cases were excluded. Complications and death rate were compared.

RESULTS

The average age for both cohorts was 70 years. The trauma cohort had statistically significant lower BMI and longer hospital stay (p=0.001). The Functional Comorbidity Index (FCI) and Charlson Age Comorbidity Index (CACI) were the same for both cohorts, reflecting an active patient selection for THR in our centre. The trauma cohort had higher surgical complication rate (9% vs 4%), particularly higher dislocation rate (7% vs 1%); and higher medical complication rate (32% vs 6%). These were consistent with the literature. Contrary to literature, the trauma cohort had six dislocations that five of them were done via anterolateral approach. Among the eight trauma cases with surgical complications, six cases were performed by trainees. The cause of surgical complications remains unclear due to the nature of retrospective study. The trauma cohort had higher death rate than the elective cohort (14% vs 4%), with one post-operative cardiac arrest in the trauma cohort. The rest were non-orthopaedic related deaths, ranging between four months to four years.

CONCLUSION

A more robust way of selecting trauma patients for THR is warranted to reduce morbidity and mortality. Follow-up for the trauma cohort is warranted, as the patients are likely to outlive the implants.

Gene regulatory network identification from the yeast cell cycle based on a neuro-fuzzy system

Many studies exist for reconstructing gene regulatory networks (GRNs). In this paper, we propose a method based on an advanced neuro-fuzzy system, for gene regulatory network reconstruction from microarray time-series data. This approach uses a neural network with a weighted fuzzy function to model the relationships between genes. Fuzzy rules, which determine the regulators of genes, are very simplified through this method. Additionally, a regulator selection procedure is proposed, which extracts the exact dynamic relationship between genes, using the information obtained from the weighted fuzzy function. Time-series related features are extracted from the original data to employ the characteristics of temporal data that are useful for accurate GRN reconstruction. The microarray dataset of the yeast cell cycle was used for our study. We measured the mean squared prediction error for the efficiency of the proposed approach and evaluated the accuracy in terms of precision, sensitivity, and F-score. The proposed method outperformed the other existing approaches.

Multi-phased anaerobic baffled reactor treating food waste

This study was conducted to identify the performance of a multi-phased anaerobic baffled reactor (MP-ABR) with food waste (FW) as the substrate for biogas production and thereby to promote an efficient energy recovery and treatment method for the wastes with high organic solid content through phase separation. A four-chambered ABR was operated at an HRT of 30 days with an OLR of 0.5-1.0 g-VS/Ld for a period of 175 days at 35 ± 1°C. Consistent overall removal efficiencies of 85.3% (CODt), 94.5% (CODs), 89.6% (VFA) and 86.4% (VS) were observed throughout the experiment displaying a great potential to treat FW. Biogas generated was 215.57 mL/g-VS removed d. Phase separation was observed and supported by the COD and VFA trends, and an efficient recovery of bioenergy from FW was achieved.

Study of microbial community and biodegradation efficiency for single- and two-phase anaerobic co-digestion of brown water and food waste

The objective of this work was to study the microbial community and reactor performance for the anaerobic co-digestion of brown water and food waste in single- and two-phase continuously stirred tank reactors (CSTRs). Bacterial and archaeal communities were analyzed after 150 days of reactor operation. As compared to single-phase CSTR, methane production in two-phase CSTR was found to be 23% higher. This was likely due to greater extent of solubilization and acidification observed in the latter. These findings could be attributed to the predominance of Firmicutes and greater bacterial diversity in two-phase CSTR, and the lack of Firmicutes in single-phase CSTR. Methanosaeta was predominant in both CSTRs and this correlated to low levels of acetate in their effluent. Insights gained from this study would enhance the understanding of microorganisms involved in co-digestion of brown water and food waste as well as the complex biochemical interactions promoting digester stability and performance.

Blood loss in spinal tumour surgery and surgery for metastatic spinal disease: a meta-analysis

There is currently no consensus about the mean volume of blood lost during spinal tumour surgery and surgery for metastatic spinal disease. We conducted a systematic review of papers published in the English language between 31 January 1992 and 31 January 2012. Only papers that clearly presented blood loss data in spinal surgery for metastatic disease were included. The random effects model was used to obtain the pooled estimate of mean blood loss. We selected 18 papers, including six case series, ten retrospective reviews and two prospective studies. Altogether, there were 760 patients who had undergone spinal tumour surgery and surgery for metastatic spinal disease. The pooled estimate of peri-operative blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic blood loss as high as 5000 ml, which is rare. Aside from two studies that reported large amounts of mean blood loss (> 5500 ml), the resulting funnel plot suggested an absence of publication bias. This was confirmed by Egger's test, which did not show any small-study effects (p = 0.119). However, there was strong evidence of heterogeneity between studies (I(2) = 90%; p < 0.001). Spinal surgery for metastatic disease is associated with significant blood loss and the possibility of catastrophic blood loss. There is a need to establish standardised methods of calculating and reporting this blood loss. Analysis should include assessment by area of the spine, primary pathology and nature of surgery so that the amount of blood loss can be predicted. Consideration should be given to autotransfusion in these patients.

15-deoxy-D12,14-prostaglandin J2 suppresses RANTES expression by inhibiting NADPH oxidase activation in Helicobacter pylori-infected gastric epithelial cells

Peroxisome proliferators-activated receptor-γ (PPAR-γ) is a ligand-activated transcription factor. 15 deoxy-(12,14) prostaglandin J(2) (15d-PGJ(2)) is a potent PPAR-γ ligand and acts as an anti-inflammatory agent via PPAR-γ-dependent and independent mechanisms. Helicobacter pylori (H. pylori) induces gastric inflammation by inducing the activation of oxidant-sensitive transcription factor NF-κB and cytokine expression in gastric epithelial cells. Since 15d-PGJ(2) inhibits NF-κB activation in various cells, it may suppress H. pylori-induced inflammatory signaling and cytokine expression in gastric epithelial cells. The present study aims to determined the effect of 15d-PGJ(2) on the activation of inflammatory mediators Jak/Stat (Janus kinase/signal transducers and activators of transcription) and induction of cytokine RANTES in H. pylori-infected gastric epithelial AGS cells. Since NADPH oxidase is a candidate for the production of reactive oxygen species in H. pylori-infected gastric epithelial cells, we determined the effect of 15d-PGJ(2) on the activation of NADPH oxdase. AGS cells were cultured in the presence of H. pylori treated with or without 15d-PGJ(2). The activations of NADPH oxidase and Jak1/Stat3, the levels of H(2)O(2) and RANTES in the medium, and DNA binding activity of Stat3 were assessed. A Jak/Stat3 specific inhibitor AG490 and an inhibitor of NADPH oxidase diphenyleneiodonium (DPI) were treated to determine the direct involvement of Jak/Stat and NADPH oxidase on the production of H(2)O(2) and RANTES in H. pylori-infected cells. H. pylori induced the production of H(2)O(2) and RANTES as well as the activations of NADPH oxidase and Jak1/Stat3, which were inhibited by the treatment of 15d-PGJ(2). DPI suppressed H. pylori-induced alterations similar to 15d-PGJ(2). However, AG490 had no effect on NADPH oxidase activation, but reduced the level of RANTES in the medium released from H. pylori-infected cells.

CONCLUSION

NADPH oxidase activation is an upstream signaling of Jak1/Stat3 activation and induction of RANTES in H. pylori-infected AGS cells. 15d-PGJ(2), inhibits the activations of NADPH oxidase and Jak1/Stat3 and RANTES expression, suggesting that 15d-PGJ(2) may be beneficial for the treatment of H. pylori-induced gastric inflammation.

Time-resolved MR angiography for detecting and grading ovarian venous reflux: comparison with conventional venography

OBJECTIVE

The purpose of this study was to compare the diagnostic accuracy of time-resolved MR angiography (TR-MRA) with that of conventional venography for the detection and grading of ovarian venous reflux, which aid in the diagnosis of pelvic venous congestion.

METHODS

We performed a retrospective analysis of 19 consecutive patients who underwent TR-MRA and conventional venography. The images were analysed by two radiologists in a randomised "blinded" manner. With the use of conventional venography as a gold standard, the images were reviewed to determine if differences in the detection and grading of ovarian venous reflux were seen between TR-MRA and conventional venography; the sensitivity, specificity and accuracy of TR-MRA compared with that of conventional venography were evaluated. The McNemar test was performed to determine the significance of any differences. Interobserver agreement was analysed using generalised κ statistics.

RESULTS

There was no significant difference between TR-MRA and conventional venography for grading ovarian venous reflux (p>0.05). The sensitivity, specificity and diagnostic accuracy of TR-MRA were found to be 66.7%, 100% and 78.9%, and 75%, 100% and 84.2%, respectively, for the two observers. The weighted κ-values indicated excellent agreement between the two observers for grading ovarian venous reflux on TR-MRA (κ = 0.894).

CONCLUSION

TR-MRA is an accurate method for accessing pelvic venous congestion.

Nitric oxide-induced IL-8 expression is mediated by NF-kappaB and AP-1 in gastric epithelial AGS cells

Inducible nitric oxide synthase (iNOS) and interleukin-8 (IL-8) mediate gastric inflammation. Nitric oxide (NO) produced by iNOS may activate oxidant-sensitive transcription factors. There are the binding sites for NF-kappaB, AP-1, and C/EBP (CCAAT/enhancer binding protein) in the promoter regions of IL-8 gene. The present study aims to investigate whether NO donors, SIN-1 and NOC-18, activate oxidant-sensitive transcription factors NF-kappaB and AP-1 as well as C/EBP to induce IL-8 expression in gastric epithelial AGS cells. Gastric epithelial AGS cells were treated with NO donors, SIN-1 and NOC-18. mRNA expression and protein level of IL-8 in the medium were determined. Nitrite level in the medium and DNA binding activities of NF-kappaB, AP-1, and C/EBP were assessed. NO donors induced the increase in the levels of IL-8 and nitrite in the medium as well as mRNA expression of IL-8 in AGS cells time-dependently. The induction of IL-8 by NO donors was accompanied with the activation of NF-kappaB and AP-1 but not C/EBP in AGS cells.

CONCLUSION

Large amount of NO, which may be produced by iNOS, may induce the activation of NF-kappaB and AP-1 and the expression of IL-8 in gastric epithelial cells.

Beta-carotene inhibits Helicobacter pylori-induced expression of inducible nitric oxide synthase and cyclooxygenase-2 in human gastric epithelial AGS cells

Reactive oxygen species (ROS) play critical roles in Helicobacter pylori (H. pylori)-associated gastric ulceration and carcinogenesis. Inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) are involved in H. pylori-induced gastric diseases. Previously we demonstrated that H. pylori in Korean isolates induced the activation of mitogen-activated protein kinases (MAPK) and oxidant-sensitive transcription factors NF-kappaB and AP-1 which mediates the expression of iNOS and COX-2 in gastric epithelial AGS cells. beta-Carotene shows antioxidant activity and inhibits NF-kappaB-dependent gene expression in various cells. Present study aims to investigate whether beta-carotene inhibits H. pylori-induced expression of iNOS and COX-2 by suppressing the activation of MAPK, NF-kappaB, and AP-1 in gastric epithelial AGS cells. HP99 (H. pylori in Korean isolates) was added to AGS cells at the ratio of bacterium/cell, 300/1. beta-carotene inhibited H. pylori-induced increase in ROS level, the activation of MAPK (p38, the c-Jun NH2-terminal protein kinases, the extracellular signal-regulated kinases), NF-kappaB, and AP-1 and the expression of iNOS and COX-2 in AGS cells.

CONCLUSION

beta-carotene inhibits oxidant-mediated activation of inflammatory signaling and suppresses the expression of iNOS and COX-2 in gastric epithelial AGS cells infected with H. pylori.

Intra-system optical interconnection module directly integrated on a polymeric optical waveguide

A new intra-system optical interconnection module directly integrated on a polymeric optical waveguide is suggested. A polymeric optical waveguide plays a role in the propagation path of optical signals from the transmitter to the receiver and in a platform integrated with various optical/electrical devices such as a vertical cavity surface emitting laser, photodiode, very large scale integrated circuit chips, and electrical connectors. Because the polymeric optical waveguide is simultaneously used as an integrated platform, the fabrication process of the optical interconnection module is very simple, and the proposed process is compatible with the conventional printed circuit board process. The suggested optical interconnection was also successfully demonstrated with a 5-Gb/s data transmission through the module directly integrated on a polymeric optical waveguide.

Chip- and board-level optical interconnections using rigid flexible optical electrical printed circuit boards

A new optical interconnection scheme based on a rigid flexible optical electrical printed circuit board (RFOE-PCB) is suggested. The easily installed RFOE-PCB can be universally applied for both chip- and board-level optical interconnections. This letter describes the detailed fabrication process, optical properties, and heat-resisting property of the RFOE-PCB. The fabricated RFOE-PCB was also successfully demonstrated with a 2.5-Gb/s data transmission through a 45 degrees-ended optical waveguide embedded in the RFOE-PCB.

Enhanced T-ray signal classification using wavelet preprocessing

This study demonstrates the application of one-dimensional discrete wavelet transforms in the classification of T-ray pulsed signals. Fast Fourier transforms (FFTs) are used as a feature extraction tool and a Mahalanobis distance classifier is employed for classification. Soft threshold wavelet shrinkage de-noising is used and plays an important role in de-noising and reconstruction of T-ray pulsed signals. An iterative algorithm is applied to obtain three optimal frequency components and to achieve preferred classification performance.

Prophylactic antibiotics in orthopaedic surgery: guidelines and practice

The national clinical practice guideline has recommended that prophylactic antibiotic be given in orthopaedic surgery involving joint replacements and internal fixation of fractures. The aim of this study is to assess the current antibiotics prophylaxis practice in a state level hospital. One hundred and three patients (68 males, 35 females; mean age 41.6 +/- 22.2 years) undergoing internal fixation for closed fractures and joint replacement surgery were included in this prospective study. The choice of pre and post-operative antibiotics, their dosages and duration of administration were recorded. The pre-operative antibiotics were only deemed to have been given if it was documented in the case notes and in the case of post-operative antibiotics if it was signed on the drug chart. Eighty eight percent were given pre-operative prophylactic antibiotics and 92% were given post-operative antibiotics. For patients undergoing internal fixation of fractures, the most commonly used antibiotic for both pre and post-op is intravenous cefuroxime. For joint replacement surgery, the most commonly used antibiotic is intravenous cefoperazone. The duration or number of doses of post-operative antibiotics was highly variable. It was not stated in 56% of the post-operative instructions. Post-operative antibiotic was ordered for 48 hours or longer in 10%. In conclusion, prophylactic antibiotics appear to be widely practised. The first line antibiotics as recommended by the present guideline were not given in any of the patients. Second generation followed by third generation cephalosporins are the most popular antibiotics, with a trend towards using third generation cephalosporins in arthroplasty patients. Single dose prophylaxis was rarely practised.

Subcutaneous hyalohyphomycosis due to Cephalotheca foveolata in an immunocompetent host

We report the first case of subcutaneous hyalohyphomycosis caused by the genus Cephalotheca, which has not been reported to cause human infection. A 67-year-old immunocompetent farmer presented with a 10-year history of verrucous erythematous plaques on the right foot dorsum, great toe, heel and sole. Histopathology of the lesions revealed chronic granulomatous inflammation with numerous nonpigmented fungal spores in the dermis. Cultures of biopsy specimens on Sabouraud's dextrose agar for 2 weeks developed into yellowish brown, velvety colonies that subsequently turned black after 8 weeks because of the production of black cleistothecia indicating the teleomorph. On the basis of mycological features, scanning electron microscopic morphology and molecular analysis data, a new species of Cephalotheca was identified and designated Cephalotheca foveolata. Because there was no response to the antifungal agents administered, the patient was successfully treated by surgical excision with skin graft.

Sonographic findings of solid and papillary epithelial neoplasm of the pancreas

OBJECTIVE

To evaluate the sonographic findings of solid and papillary epithelial neoplasm of the pancreas, a rare tumor occurring in young women.

METHODS

The sonographic findings of 11 cases of pathologically proven solid and papillary epithelial neoplasm of the pancreas were retrospectively evaluated.

RESULTS

In 6 cases (55%), combined cystic and solid portions of the masses were observed, whereas only solid-looking masses without anechoic cystic portions were seen in 4 cases (36%). One case (9%) had marginal calcification, consequently, the internal architecture was not evaluated by sonography. Internal echoes were seen in 3 of 6 cystic and solid masses. Septa were seen in 3 cases. Among 11 cases of solid and papillary epithelial neoplasm, tumor margins were well defined in 10, and tumor capsules were detected in 9 (echogenic in 7 and hypoechoic in 2). Calcifications were seen in 3 cases (27%).

CONCLUSIONS

The characteristic sonographic findings of solid and papillary epithelial neoplasm were well-encapsulated, cystic, and solid masses, but sometimes the mass was seen as a pure solid-looking mass or had internal septations or calcifications.

NF-kappaB, inducible nitric oxide synthase and apoptosis by Helicobacter pylori infection

Oxygen radicals are considered as an important regulator in the pathogenesis of Helicobacter pylori (H. pylori)-induced gastric ulceration and carcinogenesis. Inflammatory genes including inducible nitric oxide synthase (iNOS) may be regulated by oxidant-sensitive transcription factor, nuclear factor-kappaB (NF-kappaB). iNOS induction has been related to gastric apoptosis. We studied the role of NF-kappaB on iNOS expression and apoptosis in H. pylori-stimulated gastric epithelial AGS cells. AGS cells were treated with antisense oligonucleotide (AS ODN) for NF-kappaB subunit p50, an antioxidant enzyme catalase, an inhibitor of NF-kappaB activation pyrrolidine dithiocarbamate (PDTC), iNOS inhibitors N(G)-nitro-L-arginine-methyl ester (L-NAME) and 2-amino-5,6-dihydro-6-methyl-4H-1,3-thiazine (AMT), a peroxynitrite donor SIN-1, and a nitric oxide donor NOC-18 in the presence or absence of H. pylori. H. pylori induced cytotocixity time- and dose-dependently, which occurred with induction in iNOS expression and nitrite production. SIN-1 and NOC-18 induced dose-dependent cytotoxicity in AGS cells. Catalase, PDTC, L-NAME, and AMT prevented H. pylori-induced cytotoxicity and apoptosis. It was related to their inhibition on iNOS expression and nitrite production. The cells treated with AS ODN had low levels of p50 and NF-kappaB and inhibited H. pylori-induced cytotoxicity, apoptosis, iNOS expression, and nitrite production. In conclusion, NF-kappaB plays a novel role in iNOS expression and apoptosis in H. pylori-infected gastric epithelial cells.

Diagnosis of nut-cracker phenomenon using renal Doppler ultrasound in orthostatic proteinuria

BACKGROUND

We evaluated the efficacy of non-invasive renal Doppler ultrasound (US) to detect the nut-cracker phenomenon (NCP) and we studied the prevalence of NCP in children with orthostatic proteinuria.

METHODS

Among a total 66 cases of orthostatic proteinuria, 39 cases of NCP were found, with 27 cases being detected in a normal control group. Using Doppler US, the anteroposterior (AP) diameter and peak velocity (PV) of the left renal vein (LRV) were measured at the hilar and aortomesenteric portion. We calculated the ratio of AP and PV diameters between the two portions. The parameters were analysed using Student's t-test.

RESULTS

The AP diameters and the ratio in the hilar and narrow portions were all significantly different between the two groups (P<0.01). The PV in the narrow portion and the ratio of PV were significantly different (P<0.01), but the PV in the hilar portion was not statistically different between the two groups (P>0.05). If the diagnostic criteria for NCP was that the ratio of PV was more than 5, then 22 subjects (56.4%) in the orthostatic proteinuria group and none in the control group could be diagnosed as NCP. If, however, the cut-off values for the diagnosis of NCP were set at the mean+/-2 SD of the ratio (PV ratio 3.98 and size ratio 4.16), then the orthostatic proteinuria group showed abnormal AP diameter in 25 (64.1%), peak velocity in 28 (71.8%), and both in 21 patients (53.8%), and the control group showed an abnormal AP diameter in one subject (3.7%).

CONCLUSIONS

NCP may be one of the leading causes of orthostatic proteinuria, and non-invasive renal Doppler US may be a useful diagnostic tool in the screening of NCP. In the future, the diagnostic criteria of NCP must be redefined in children.

Helicobacter pylori-induced expression of interleukin-8 and cyclooxygenase-2 in AGS gastric epithelial cells: mediation by nuclear factor-kappaB

BACKGROUND

Helicobacter pylori infection might activate nuclear factor-kappaB (NF-kappaB), a transcriptional regulator of inducible expression of inflammatory genes, interleukin-8 (IL-8) and cyclooxygenase-2 (COX-2). We studied the role of NF-kappaB on expression of IL-8 and COX-2 in H. pylori-stimulated AGS gastric epithelial cells by using antisense oligonucleotide (AS ODN) for NF-kappaB subunit p50 and an antioxidant, glutathione (GSH) as well as a NF-kappaB inhibitor, pyrrolidine dithiocarbamate (PDTC).

METHODS

AGS cells were treated with p50 AS ODN, GSH or PDTC in the presence of H. pylori. mRNA expression and protein levels for IL-8 and COX-2 were determined by Northern blot analysis and Western blot analysis. Levels of IL-8, 6-keto-prostaglandin F1alpha (6-keto-PGF1alpha) and thromboxane B2 (TXB2) were measured in the medium by enzyme-linked immunosorbent assay. NF-kappaB activation was examined by electrophoretic mobility shift assay.

RESULTS

H. pylori induced a time-dependent expression of mRNA and protein for IL-8 and COX-2 via activation of NF-kappaB and increased the levels of IL-8, 6-keto-PGF1alpha and TXB2, which were inhibited by GSH and PDTC. H. pylori-induced expression of IL-8 and COX-2 was blocked in AGS cells transfected with p50 AS ODN.

CONCLUSION

NF-kappaB may play a novel role in expression of IL-8 and COX-2 in H. pylori-induced gastric inflammation.

Effect of alpha1-acid glycoprotein expressed in cancer cells on malignant characteristics

The alpha1-acid glycoprotein (AAG) is a prototypical serum acute phase reactant in most mammalian species; it is synthesized mainly in liver parenchymal cells. Recently, we found that mRNAs of AAG were expressed in non-hepatic cancer cells, and the expression levels were regulated by the cytokines--IL-1, IL-6, and TNF-alpha. The functional role of AAG in non-hepatic cancer cells has not yet been established. In order to understand the functional role of the AAG expressed in HT-29 cells, the cancer cells were transfected with cloned cDNA for AAG, or exposed to antisense oligodeoxynucleotide (ODN) for AAG. The colony-forming capacity, invasion, and adhesion to laminin of these transformed cancer cells were measured. Overexpression of AAG by transfection, and inhibition of the AAG expression by antisense ODNs were identified by Western blot as well as nested reverse transcriptase-polymerase chain reaction (nested RT-PCR), respectively. Results showed that the overexpression of AAG by transfection reduced colony-forming capacities, invasion, and adhesion to laminin of the cancer cells; on the other hand, the antisense ODN for AAG elevated colony-forming capacities, invasion, and adhesion to laminin of the cancer cells. These results suggest that AAG, expressed in cancer cells inhibited proliferation, invasion, and metastasis of the cancer cells.

Comparison of hydro-US and spiral CT in the staging of gastric cancer

The purpose of this study was to compare the diagnostic accuracy of hydro-ultrasonography (US) and spiral computed tomography (CT) in the staging of gastric cancer. Forty-three patients with gastric cancers confirmed at surgery underwent hydro-US and spiral CT on the same day prospectively. Hydro-US and spiral CT were done after ingestion of water. US and CT images were independently analyzed. After surgery, pathological findings according to TNM classification were compared with US and CT findings. The detection rate for T1 tumors was 75% (12/16), and all T2-T4 tumors were detected (27/27). In the T class, good correlation with pathology occurred in 55.8% of cases for US and 58.1% for CT, and there was no difference in staging accuracy between US and CT (P=.7667). Overstaging occurred in 14% for US and CT. Understaging occurred in 30.2% for US and 27.9% for CT. In the N class, good correlation with pathology occurred in 60.5% for US and 55.8% for CT, and there was no difference in staging accuracy between US and CT (P=.0949). Overstaging occurred in 4.7% for US and 18.6% for CT, and understaging occurred in 34.9% and 25.6%, respectively. The diagnostic accuracy of hydro-US and spiral CT in the staging of gastric cancer was between 55.8% and 60.5%, and there was no significant difference in staging accuracy between hydro-US and spiral CT, except for a tendency to overstaging by CT and understaging by US in the N class (P<.05).

Induction of alpha1-acid glycoprotein mRNA by cytokines and differentiation in human colon carcinoma cell

The mRNA for the alpha1-acid glycoprotein (AAG) was expressed not only in hepatoma cells, but also in non-hepatic cancer cells. The expression of the AAG mRNA in HT-29 human colon carcinoma cells is induced by cytokines, IL-6, IL-1, and TNF-alpha, in a manner characteristic of the acute phase response, and the expression of AAG mRNA was up-regulated in differentiated HT-29 cells.

Prognostic significance of Bcl-2 and p53 expression in advanced laryngeal squamous cell carcinoma

BACKGROUND

Proteins regulating the cell cycle and cell death are frequently abnormally expressed in cancer. Several of these, particularly p53 and Bcl-2, have been widely suggested as possible prognostic markers in diverse human malignancies. Their role in predicting outcome in squamous cell carcinomas of the head and neck is unclear and may depend on the location, stage, and treatment of the tumor.

METHODS

To assess this question specifically for advanced squamous cell carcinoma of the larynx, we studied 69 patients with stage III or IV tumors, all but 6 of whom were treated with surgery plus postoperative irradiation by a single physician. We studied the patients retrospectively to test the association between expression of Bcl-2 and p53, as assessed by immunohistochemistry, with treatment outcome and survival.

RESULTS

Twenty of the 69 patients died from their tumor (poor outcome); the rest were alive and tumor free at the last follow-up or died of unrelated causes without clinical tumor recurrence (good outcome). Fourteen tumors had detectable Bcl-2 expression, including 8 scored as overexpressors. Thirty-nine tumors overexpressed p53. Expression of neither Bcl-2 nor p53 was associated with outcome, overall survival, or disease-free survival. Only tumor stage was significantly associated with outcome and disease-free survival.

CONCLUSION

These data indicate that assessing expression of p53 or Bcl-2 is unlikely to be prognostically useful for surgically treated advanced laryngeal carcinoma.

Nuclear factor-kappaB regulates cyclooxygenase-2 expression and cell proliferation in human gastric cancer cells

Nuclear factor-kappaB (NF-kappaB) is a transcriptional regulator of inducible expression of genes including cyclooxygenase-2 (COX-2), regulating cell proliferation. NF-kappaB is kept silent in the cytoplasm via interaction with the inhibitory protein IkappaBalpha and transmigrated into the nucleus upon activation. However, constitutive NF-kappaB has been found in the nucleus of some cancer cells. We investigated the role of NF-kappaB in COX-2 expression and cell proliferation in human gastric cancer AGS cells. AGS cells were treated with antisense oligodeoxynucleotide (AS ODN) or sense oligodeoxynucleotide (S ODN) for the NF-kappaB subunit p50, or they were transfected with a mutated IkappaBalpha gene (MAD-3 mutant) or a control vector, pcDNA-3. AGS cells were treated with COX-2 inhibitors such as indomethacine and NS-398 or prostaglandin E2. mRNA expression for COX-2, and protein levels for p50, IkappaBalpha, and COX-2 were determined by reverse transcription polymerase chain reaction and Western blot analysis. The NF-kappaB levels were examined by electrophoretic mobility shift assay. Thromboxane B2 (TXB2) and 6-keto-prostaglandin F1alpha (6-keto-PGF1alpha) levels were determined by enzyme-linked immunosorbent assay. Cell proliferation was assessed by viable cell counting, [3H] thymidine incorporation, and colony formation. The nuclear level of p50 decreased in AGS cells treated with AS ODN. The IkappaBa mutant was observed in cells transfected with the mutated IkappaBa gene. NF-kappaB was inhibited in cells treated with AS ODN or transfected with the mutated IkappaBalpha gene, compared with the cells treated with S ODN or transfected with control vector. Cell proliferation, mRNA expression and protein level of COX-2, and production of TXB2 and 6-keto-PGF1alpha were inhibited in cells treated with AS ODN or transfected with the mutated IkappaBalpha gene, which had lower NF-kappaB levels than cells treated with S ODN or transfected with control vector. COX-2 inhibitors suppressed cell proliferation and production of TXB2 and 6-keto-PGF1alpha, in a dose-dependant manner. Prostaglandin E2 prevented the inhibition of proliferation in cells treated with AS ODN or transfected with the mutated IkappaBalpha gene. In conclusion, NF-kappaB mediates COX-2 expression, which may be related to cell proliferation, in human gastric cancer cells.

Suppression of NF-kappaB activation and cytokine production by N-acetylcysteine in pancreatic acinar cells

Reactive oxygen species (ROS), generated by infiltrating neutrophils, are considered as an important regulator in the pathogenesis and development of pancreatitis. A hallmark of the inflammatory response is the induction of cytokine gene expression, which may be regulated by oxidant-sensitive transcription factor, nuclear factor-kappaB (NF-kappaB). Present study aims to investigate whether neutrophils primed by 4beta-phorbol 12beta-myristate 13alpha-acetate (PMA) affect the productions of H(2)O(2) and lipid peroxide (LPO), NF-kappaB activation and cytokine production in pancreatic acinar cells, and whether these alterations were inhibited by N-acetylcysteine (NAC) and superoxide dismutase (SOD). Neutrophils generated ROS by stimulation with PMA, which was inhibited by NAC and SOD. In acinar cells, PMA-primed neutrophils increased the productions of H(2)O(2), LPO, and cytokines both time and dose dependently. PMA-primed neutrophils resulted in the activation of two species of NF-kappaB dimers (a p50/p65 heterodimer and a p50 homodimer) in acinar cells. Both NAC and SOD inhibited neutrophil-induced, oxidant-mediated alterations in acinar cells. In conclusion, ROS, generated by neutrophils, activates NF-kappaB, resulting in upregulation of inflammatory cytokines in acinar cells. Antioxidants such as NAC might be useful antiinflammatory agents by inhibiting oxidant-mediated activation of NF-kappaB and decreasing cytokine production.

Treatment of prostatic abscess: value of transrectal ultrasonographically guided needle aspiration

The purpose of this study was to assess the effectiveness of transrectal ultrasonographically guided needle aspiration in the treatment of prostatic abscess. Fourteen patients with prostatic abscess were evaluated with this technique and treated with sonographically guided needle aspiration. Using this technique, all cases (100%) had one or more hypoechoic areas within the prostate that contained inhomogeneous materials; in 10 patients (71.0%), the lesion showed internal septa or solid portion. The margins of the hypoechoic area were well defined and thick in 11 patients (79.0%) and poorly defined in 3 patients (21.0%). The estimated volume of the prostatic abscess ranged between 2 and 28 ml (mean, 12.0 ml). The presence of a pus collection within the prostate was confirmed by transrectal ultrasonographically guided aspiration in all patients. However, successful treatment of prostatic abscess with transrectal needle aspiration was done in 12 (86.0%) of 14 patients; the treatment failed in 2 (14.0%) of 14 patients. One patient was treated with perineal incision and drainage and the other with transurethral resection. The amount of pus drained ranged between 1 and 39 ml (mean, 12.0 ml). On follow-up transrectal ultrasonographic examination, no remaining abscess pocket was found within the prostate in any of the cases. One year later, the prostatic abscess recurred in one case. In conclusion, transrectal ultrasonographic guidance is useful in the diagnosis of prostatic abscess as well as in the guidance for aspiration and the drainage of such abscesses. Transrectal ultrasonographically guided needle aspiration could be an effective method for treating prostatic abscess.

Experience with percutaneous dilational tracheostomy

Percutaneous dilational tracheostomy (PDT) has gained popularity among critical care specialists in the past 10 years. The initial studies in our specialty resulted in essentially banning the procedure as a dangerous substitute for standard operative tracheostomy. Despite this action, more than 1,100 cases of percutaneous tracheostomy have been reported with details on complications. We reviewed all published data and studied 311 patients of our own. A prospective study was performed in 3 groups of patients: 1) 50 patients scheduled for PDT performed in the operating room by a head and neck surgeon (group 1); 2) 50 patients who underwent standard operative tracheostomy performed by the same surgeon (group 2); and 3) 211 patients who underwent bedside PDT by critical care physicians (group 3). The intraoperative complication rates were 0% in group 1, 2% in group 2, and 4% in group 3; the postoperative complication rates were 13%, 4%, and 12%, respectively. There were 2 deaths in group 3, and none in groups 1 or 2. The statistically significant differences among the groups were the superiority of group I over group 3 in intraoperative complications, as well as the lower postoperative complication rate of the standard tracheostomy group. These results show that PDT can be performed with acceptable morbidity rates in relation to published complication rates of standard tracheostomy, but it has no advantage over standard tracheostomy with respect to postoperative morbidity. When they are performed by a head and neck surgeon, the morbidity associated with both standard and percutaneous tracheostomies can be reduced.

Acetic acid as a sclerosing agent for renal cysts: comparison with ethanol in follow-up results

PURPOSE

To compare follow-up results of sclerotherapy for renal cyst using 50% acetic acid with those using 99% ethanol as sclerosing agents.

METHODS

Eighty-one patients underwent sclerotherapy and 58 patients, 23 males, 35 females, aged 6-76 years, having a total of 60 cysts, were included in this study; the others were lost to follow-up. The renal cysts were diagnosed by sonography, computed tomography (CT), or magnetic resonance imaging (MRI). Sclerotherapy was performed using 50% acetic acid for 32 cysts in 31 patients and 99% ethanol for 28 cysts in 27 patients. Under fluoroscopic guidance, cystic fluid was aspirated as completely as possible. After instillation of a sclerosing agent corresponding to 11.7%-25% (4-100 ml) of the aspirated volume, the patient changed position for 20 min and then the agent was removed. Patients were followed up by sonography for a period of 1-49 months. The volume of the renal cyst after sclerotherapy was compared with that of the renal cyst calculated before sclerotherapy. Medical records were reviewed to analyze complications.

RESULTS

The mean volume after sclerotherapy of the 17 cysts followed for 3-4 months in the acetic acid group was 5.1% of the initial volume, and for the 14 cysts in the ethanol group it was 10.2%. Complete regression during follow-up was shown in 21 cysts (66%) in the acetic acid group; the mean volume of these cysts before the procedure was 245 ml. The mean volume of the nine (32%) completely regressed cysts in the ethanol group was 184 ml. Mild flank pain, which occurred in three patients in each group, was the only complication and resolved the next day.

CONCLUSION

Acetic acid was an effective and safe sclerosing agent for renal cysts, tending to induce faster and more complete regression than ethanol.

Effect of improved nasal breathing on obstructive sleep apnea

OBJECTIVES

The goal was to compare the effect of an improved nasal airway on obstructive sleep apnea (OSA) by use of subjective and objective measures.

METHODS

A prospective study of 50 consecutive patients with nasal airway obstruction and OSA was carried out.

RESULTS

Subjectively, nasal breathing improved in 49 (98%) patients, whereas snoring decreased or disappeared in 17 (34%); the remaining 33 (66%) patients did not notice any significant change in their snoring. Daytime energy levels increased in 39 (78%) patients and remained unchanged or worsened in 11 (22%). In review of the polysomnographic data, the group overall did not have significant changes in respiratory disturbance index (RDI) or lowest oxygen saturation levels (LSaO(2)). Continuous positive airway pressure (CPAP) levels required to correct OSA decreased after nasal surgery (P < 0.01). Patients with mild OSA showed significant worsening in RDI (P < 0.05), whereas LSaO(2) levels were improved in the group with moderate OSA (P < 0.05). In patients with severe OSA neither the RDI levels nor the LSaO(2) changed, but CPAP levels required to alleviate the obstruction after surgery were reduced (P < 0.01).

CONCLUSIONS

Most patients report improvement in nasal and sleep symptoms after correction of nasal airway obstruction. However, nasal surgery alone does not consistently improve OSA when measured objectively. Depending on the severity of OSA, nasal airway reconstruction may contribute to a decrease in CPAP level and improvement in oxygen saturation. Correction of the obstructed nasal airway should certainly be included in the overall treatment plan for OSA.

Early detection and treatment of postoperative pharyngocutaneous fistula

Fever during the early postoperative period traditionally has not been considered an indication of a postoperative wound infection or breakdown. Atelectasis is considered the most likely source for these early fevers. We studied 200 consecutive patients who underwent major head and neck surgery that involved reconstruction with a pharyngeal suture line. Patients were divided into 2 groups: those who had preoperative irradiation and those who did not. All patients had prophylactic antibiotic coverage, and all patients had identical suture material for closure. We showed a high correlation between fever (>101.5 degrees F) that developed in the first 48 hours and eventual fistula formation and wound infection. We also studied length of hospitalization and number of days until decannulation and resumption of oral feedings. Our data indicate that in those patients in whom fistulas developed, early detection led to earlier healing and rehabilitation.

Laparoscopic versus open donor nephrectomy: comparing ureteral complications in the recipients and improving the laparoscopic technique

BACKGROUND

Laparoscopic live donor nephrectomy (LDN) is a recently developed procedure, the performance of which needs to be studied. Given the reported advantages in the donors, this study looks at graft outcome and ureteral complications in recipients of kidneys procured by open donor nephrectomy (ODN) versus LDN.

METHODS

The LDN recipients consisted of 193 patients since 3/27/96. A total of 168 ODN recipients from 1991 to 1998 served as controls. Immunosuppression protocols were similar for both groups.

RESULTS

Two-year graft survival for LDN and ODN was 98% and 96%, respectively. Two-year patient survival for LDN and ODN was 98% and 97%, respectively. The incidence of delayed graft function and mean serum creatinine at 3 and 12 months was similar in both groups. However, the number of ureteral complications that required operative repair was significantly higher for LDN recipients compared to ODN recipients, 7.7% (n=15) vs. 0.6% (n=1) respectively (P=0.03). Ureteral stenting was required in an additional 3.1% (n=6) of LDN and 2.4% (n=4) of ODN (P=NS). There was, however, a learning curve with time. For the first 130 LDN patients, a total of 20 ureteral complications were recorded, whereas only one occurred in the more recent 63 patients (P=0.03).

CONCLUSIONS

The higher ureteral complication rate in LDN recipients has improved over time as technical causes have been identified. We have noted significant improvement in ureteral viability by using the endogastrointestinal anastomosis instrument on the ureter and peri-ureteral tissue. LDN is therefore an excellent alternative to ODN. Identification of hazards unique to this technique is critical before its broader application.

Quantification of lymph nodes in selective neck dissection

OBJECTIVES

Provide reference for surgeon and pathologist regarding expected yield from selective neck dissections. Quantify lymph nodes obtained from cadaver dissection based on current nodal classification and compare with clinical series.

STUDY DESIGN

1. Quantification of lymph nodes at levels I-V harvested from human cadavers and correlation with nodal grouping for supraomohyoid (I-III) and lateral (II-IV) neck dissections. 2. Retrospective review of operative specimens from clinical neck dissections for lymph node quantity.

METHODS

1. Twenty radical neck dissection specimens, harvested from 10 fresh human cadavers without evidence of head and neck cancer, were separated by nodal level for gross and microscopic examination by a pathologist. The quantity of nodes obtained per level for each specimen was tabulated. 2. Charts of patients treated with neck dissection for squamous cell carcinoma were reviewed and tabulated for type of dissection and number of lymph nodes reported.

RESULTS

In the 20 cadaver neck dissections, the average number of lymph nodes removed for levels I-V was 24, with 13 for levels I-III and 19 for levels II-IV. In the clinical review, 98 total neck dissections were included. In the six supraomohyoid dissections, an average of 20 lymph nodes (range, 14-26) were found, with an average of 30 (range, 15-43) in the 11 lateral compartment specimens. In 81 radical or modified radical dissections, an average of 31 nodes (range, 19-63) was reported.

CONCLUSIONS

The number of lymph nodes removed in selective neck dissection should be comparable to that of the corresponding levels in radical neck dissection, provided that strict adherence to surgical boundaries is maintained. Dissection of normal cadavers provides a reference for the surgeon and the pathologist but may under-represent lymph node quantity in the diseased state.