The Hidden Impact of Neonatology Boot Camp: A Qualitative Study

INTRODUCTION

Simulation-based boot camps have been evaluated by fellows as an effective way to learn, to improve self-confidence, and to prepare for new responsibilities. However, existing studies do not explore how boot camps may contribute to other critical aspects of trainee development. Our objective was to use qualitative research methodology to characterize trainees' experiences of boot camp and its impact on their professional development.

METHODS

This study used a phenomenological framework to explore fellows' experience of boot camp. Semistructured phone interviews were conducted with first-year neonatology fellows after attending the Regional Neonatology Boot Camp. Interviews were transcribed and coded for themes. The authors continually evaluated the coding categories in an iterative process until consensus was reached.

RESULTS

Seventy-seven first-year neonatal-perinatal medicine fellows representing 16 fellowship programs participated in the Regional Neonatology Boot Camp in 2016 and 2017. Fifteen fellows from 10 institutions were interviewed before reaching thematic saturation. Five themes were identified: introspection about starting fellowship, learning to lead and communicate, gaining reassurance from the shared experience, understanding the fellow role, and developing future identity as a neonatologist.

CONCLUSIONS

Participation in boot camp enhances fellows' professional identity formation (PIF) by incorporating key aspects of socialization, including role models and mentors, a variety of experiential learning, and opportunities for conscious self-reflection. In designing future boot camp experiences, educators should integrate these elements into the curriculum to support PIF and explicitly state PIF as a learning objective.

[Emergency psychological intervention of acute ammonia leakage event]

Objective: To analyze the situation of emergency psychological intervention in an acute ammonia leakage event, and to provide reference for emergency response. Methods: In August 2020, the emergency treatment of 65 patients admitted by Zhangqiu District People's Hospital Affiliated to Jining Medical College of Shandong Province in June 2019 in the ammonia tank car leakage incident was analyzed, the psychological intervention in emergency after the incident was collected, the anxiety and depression were evaluated by symptom checklist 90 (SCL-90) , and targeted psychological intervention was implemented according to the psychological evaluation results, And analyze the intervention efficiency. Results: Among the 65 patients, there were 52 cases of ammonia stimulation reaction, 11 cases of mild poisoning and 2 cases of moderate poisoning. There were 60 cases of chest tightness and dyspnea, 11 cases of bloody sputum, 58 cases of sore throat, 43 cases of hoarseness, 28 cases of photophobia and tears, 13 cases of blurred vision, 18 cases of nausea and vomiting, and 2 cases of dry and wet rales in the lungs. The scores of somatization, depression, anxiety, hostility, phobia, paranoia and negative coping in patients with mild and moderate poisoning were higher than those in patients with stimulus response (P<0.05) . The effective rate of intervention was 98.7%. Conclusion: Emergency psychological evaluation and intervention in mass public health events are helpful to the treatment of patients.

Corrective steps to enhance ventilation in the delivery room

OBJECTIVE

The clinical impact of ventilation corrective steps for delivery room positive pressure ventilation (PPV) is not well studied. We aimed to characterise the performance and effect of ventilation corrective steps (MRSOPA (Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase and Alternative airway)) during delivery room resuscitation of preterm infants.

DESIGN

Prospective observational study of delivery room PPV using video and respiratory function monitor recordings.

SETTING

Tertiary academic delivery hospital.

PATIENTS

Preterm infants <32 weeks gestation.

MAIN OUTCOME MEASURE

Mean exhaled tidal volume (Vte) of PPV inflations before and after MRSOPA interventions, categorised as inadequate (<4 mL/kg); appropriate (4-8 mL/kg), or excessive (>8 mL/kg). Secondary outcomes were leak (>30%) and obstruction (Vte <1 mL/kg), and infant heart rate.

RESULTS

There were 41 corrective interventions in 30 infants, with a median duration of 15 (IQR 7-29) s. The most frequent intervention was a combination of Mask/Reposition and Suction/Open. Mean Vte was inadequate before 16/41 interventions and became adequate following 6/16. Mean Vte became excessive after 6/41 interventions. Mask leak, present before 13/41 interventions, was unchanged after 4 and resolved after 9. Obstruction was present before five interventions and was subsequently resolved only once. MRSOPA interventions introduced leak in two cases and led to obstruction in one case. The heart rate was <100 beats per minute before 31 interventions and rose to >100 beats per minute after 14/31 of these.

CONCLUSIONS

Ventilation correction interventions improve tidal volume delivery in some cases, but lead to ineffective or excessive tidal volumes in others. Mask leak and obstruction can be induced by MRSOPA manoeuvres.

P2556TXNDC5 is a novel therapeutic target of atrial fibrosis and fibrillation

Background

Atrial fibrillation (AF), one of the most common cardiac arrhythmias, increases the risk of stroke, systemic embolization and cardiovascular mortality. Atrial fibrosis, a hallmark of chronic AF, provides substrates to initiate/propagate fibrillation waves in the atria. There, however, lacks effective and specific therapeutics targeting atrial fibrosis. We have recently identified an endoplasmic reticulum (ER) protein thioredoxin domain containing 5 (TXNDC5) as a critical mediator of cardiac ventricular fibrosis. We hypothesized that TXNDC5 could also play an important role in the pathogenesis of atrial fibrosis and fibrillation.

Purpose

To determine the role of TXNDC5 in atrial fibrosis and fibrillation.

Methods and results

TXNDC5 transcript and protein levels were both significantly upregulated in the atrial tissue from patients with AF. In addition, TXNDC5 mRNA expression levels were positively correlated with those of transcripts encoding transforming growth factor β1 (TGFβ1) and extracellular matrix (ECM) proteins in human atrial tissue. Knockdown of TXNDC5 in human atrial fibroblasts (hAF) attenuated TGFβ1–induced hAF activation, proliferation and ECM protein upregulation, whereas overexpression of TXNDC5 was sufficient to trigger hAF activation, proliferation and ECM protein production. Further experiments revealed that the fibrogenic effects of TXNDC5 were dependent on c-Jun N-terminal kinase (JNK) signaling. Furthermore, using α-MHC-TGFβcys33ser mice, a transgenic mouse model with cardiac-specific overexpression of constitutively active TGFβ, which develop extensive atrial fibrosis and inducible AF, we showed that TXNDC5 was strongly upregulated in the fibrotic atria of α-MHC-TGFβcys33ser mice and specifically enriched in collagen-secreting atrial fibroblasts. Targeted deletion of TXNDC5 (Txndc5−/−) in α-MHC-TGFβcys33ser mice considerably mitigated the extent of atrial fibrosis. In addition, transesophageal atrial burst pacing induced AF in 75% (3 out of 4) α-MHC-TGFβcys33ser mice, whereas knockout of Txndc5 markedly reduced the inducibility of AF (25%, 3 out of 12) in α-MHC-TGFβcys33ser mice (Figure).

TXNDC5 KO Reduces AF Inducibility

Conclusion

The present study revealed that ER protein TXNDC5 augments atrial fibrosis by promoting cardiac fibroblast proliferation and ECM protein production via JNK signaling activation. Targeted deletion of Txndc5 protects against TGFβ induced atrial fibrosis and AF. Targeting TXNDC5, therefore, could be a promising new therapeutic approach to treat or prevent atrial fibrosis and AF.

P5388N-cadherin promotes cardiac regeneration by stabilizing beta-catenin

Background

Although the adult mammalian heart fails to regenerate after injury, it is known that newborn mice within a week have full cardiac regenerative capacity. The molecular determinants underlying the disparate regenerative capacity between neonatal and adult mice, however, remain incompletely understood. Exploiting RNA sequencing in isolated cardiomyocytes from neonatal and adult mouse heart, we identified Cdh2, which encodes the adherence junction protein N-cadherin, as a potential novel mediator of cardiac regeneration. Cdh2 expression levels were much higher in neonatal, compared with adult, cardiomyocytes and showed a strong positive correlation with that of multiple cell cycle genes. N-cadherin has been reported to be essential for embryonic cardiac development; its role in cardiac regeneration, however, remains unknown.

Purpose

To determine the role of Cdh2 (N-cadherin) in cardiac regeneration and to investigate the underlying molecular mechanisms.

Methods

Apical resection in postnatal day 1 mice was used as a cardiac regenerative model. The in vitro gain/loss-of function studies of Cdh2/N-cadherin was performed in postnatal day 1 neonatal mouse cardiomyocytes (P1CM) and human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CM). N-cadherin inhibitor exherin was used to study the effects of N-cadherin in vivo.

Results

Comparing to sham-operated control, Cdh2 was significantly upregulated in mouse cardiac apex and border zone following apical resection, which was accompanied with increased cardiomyocyte proliferation activity. In vitro, knocking down Cdh2 or inhibition of N-cadherin activity with exherin in P1CM significantly reduced the proliferative activity of cardiomyocytes, whereas overexpression of Cdh2 markedly increased the proliferation of P1CM. In addition, forced expression of Cdh2 resulted in significant upregulation of multiple cell cycle genes, including Ccnd1 (Cyclin D1) and Pcna (proliferating cell nuclear antigen), in P1CM. In vivo inhibition of N-cadherin in P1 neonatal mice with exherin following apical resection impaired cardiac regeneration and increased scar formation (Figure). Knocking down CDH2 in human iPSC-CMs significantly reduced the proliferative activity and the expression levels of cell cycle gene CCND1 in iPSC-CMs. Mechanistically, we demonstrated that the pro-mitotic effects of N-cadherin in cardiomyocytes were mediated, at least partially, by stabilizing β-catenin, a pro-mitotic transcription factor, through direct interaction with its cytoplasmic domain and/or inactivation of GSK3β, a critical component of β-catenin destruction complex.

N-Cad blocker impairs heart regeneration

Conclusion

Our study uncovered a previously unrecognized role of Cdh2 (N-cadherin) in cardiomyocyte proliferation and cardiac regeneration. Enhancing cardiac expression or activity of N-cadherin, therefore, could be a potential novel therapeutic approach to promote cardiac regeneration and restore cardiac function in adult heart following injury.

[The role of abnormal mitochondrial fusion and fission in PBDE-47-induced change in mitochondrial mass in PC12 cells]

Objective: To investigate the effect of 2, 2', 4, 4'-tetrabromodiphenyl ether (PBDE-47) on the mitochondrial mass in rat adrenal pheochromocytoma (PC12) cells and the potential mechanisms. Methods: Highly differentiated PC12 cells were divided into control, 1, 10 or 20 μmol/L PBDE-47-treated groups and cultured for 24 h. Transmission electron microscopy was employed to observe the changes in mitochondrial morphology and quantity in PC12 cells. Flow cytometry was used to measure the fluorescence intensity of Nonyl Acridine Orange (NAO) , a fluorescent indicator of mitochondrial membrane cardiolipin, to reflect mitochondria mass. Western blotting was used to determine the expression levels of Mitofusion 1 (Mfn1) and Fission 1 (Fis1) proteins. To further explore the role of abnormal mitochondrial fusion and fission in PBDE-47-induced mitochondrial mass changes, PC12 cells were divided into control group, 5 μmol/L M1 treatment group, 20 μmol/L PBDE-47 treatment group and 5 μmol/L M1+20 μmol/L PBDE-47 combined treatment group and cultured for 24 h, then the fluorescence intensity of NAO and expression levels of Mfn1 and Fis1 proteins were detected. Results: The control group showed numerous mitochondria with normal morphology, while the number of mitochondria decreased after PBDE-47 treatment. Especially, the disappeared cristae, swelling and vacuoles of mitochondria and decreased fluorescence intensity of NAO (P<0.05) were observed in 10 and 20 μmol/L PBDE-47-treated groups. Meanwhile, the expression levels of Mfn1 and Fis1 proteins in the 10 and 20 μmol/L PBDE-47-treated groups were significantly decreased compared with control group (P<0.05) . However, 5 μmol/L M1 co-treatment with 20 μmol/L PBDE-47 significantly increased the levels of Mfn1 and Fis1 proteins and fluorescence intensity of NAO compared with the 20 μmol/L PBDE-47 group (P<0.05) . Conclusion: PBDE-47 can inhibit the mitochondrial fusion and fission process, thus leading to damage of mitochondria mass in PC12 cells.

Steroid-Refractory Autoimmune Myocarditis after Pembrolizumab Therapy: Failure of Equine Anti-Thymocyte Globulin to Prevent Heart Failure

While immune checkpoint inhibitors (ICIs) are improving outcomes for many cancers, they can have severe adverse effects. Though cardiac immune-related adverse effects (irAEs) are rare, they have considerable morbidity and mortality. Prior case studies have demonstrated successful treatment of ICI induced autoimmune myocarditis with a variety of immunosuppressive regimens. This case describes steroid-refractory autoimmune myocarditis after treatment with pembrolizumab. Treatment with equine anti-thymocyte globulin, a regimen previously documented to reverse ICI induced autoimmune myocarditis, temporarily improved clinical status and cardiac biomarkers, however eventually failed to prevent progression to heart failure and cardiovascular death. This case highlights the importance of early stress-dose steroids, identifies troponin as a potential marker of treatment response, and underscores the value of collaboration between oncology and cardiology for optimal management.

In situ forming oxidised hyaluronic acid/adipic acid dihydrazide hydrogel for prevention of epidural fibrosis after laminectomy

Post-operative epidural fibrosis is a biological response after laminectomy that may lead to clinical symptoms, such as radicular pain. An ideal material for prevention of epidural fibrosis should be able to inhibit fibroblast adhesions and reduce formation of scar tissue. An injectable hydrogel would be the material of choice for this purpose, since it could fill an irregular surgical defect completely, gelate in situ and be delivered in a minimally-invasive manner. The objective of this study was to evaluate, in vitro and in vivo, the cytocompatibility and anti-adhesive effect of an oxidised hyaluronic acid/adipic acid dihydrazide (oxi-HA/ADH) hydrogel. Different cell types present in the spine were used to test the cytocompatibility of the hydrogel. The hydrogel extraction medium had no deleterious effects on neural cells (PC-12), but reduced fibroblasts viability (NIH/3T3). Although the hydrogel did not change the release of lactate dehydrogenase from myoblasts (C2C12) and Schwann cells (RSC96), the extraction medium concentration slightly affected the mitochondrial activity of these two cell types. qPCR showed that the hydrogel down-regulated S100a and P4hb expression in NIH/3T3 cells, supporting the hypothesis that the hydrogel might inhibit fibroblast activity. The animal study showed a reduction of scar tissue formation as well as severity of adhesion between scar tissue and the dura mater in a rat laminectomy model. Superficially, the peel-off test showed significantly decreased tenacity. In conclusion, the oxi-HA/ADH hydrogel is a promising injectable and thermosensitive material for prevention of post-operative epidural fibrosis.

Construction of root library by SSH and preliminary analysis of genes responsible for phosphorus deficiency in maize

An elite maize inbred line with high tolerance to low phosphorus, 178, was studied for constructing root library and analyzing some genes closely related to phosphorus (P) deficiency using SSH and Semi-quantitative RT-PCR. As a result, 3648 preliminary clones were obtained for root library under stress of P deficiency. By DNA sequencing of 34 random clones, we obtained 23 unique EST sequences which are involved in functions of root cell structure, tolerance and defense, protein modification and composition, transcription regulation, metabolism, and other unknown aspects. Five representative genes were further analyzed for their expression models. The results suggested that the molecular mechanism to adapt P deficiency in maize, performed by multi-genes with different contributions, is similar to rice, Arabidopsis and soybean. The expression order of 5 low P tolerant genes in maize root was PAP, GCS, TOM, PDI and AIP. And it was considered preliminarily that physiological and biochemical changes were prior to morphologic changes in maize root and the essential tolerance to low P may be determined by extending absorption of P to wide soil range through adaption of root architecture and root secretions, which is the greatest difference between tolerant and sensitive maize varieties under low P stress.

The chondroprotective effects of ferulic acid on hydrogen peroxide-stimulated chondrocytes: inhibition of hydrogen peroxide-induced pro-inflammatory cytokines and metalloproteinase gene expression at the mRNA level

OBJECTIVE

The objective of the study is to evaluate the effect of ferulic acid (FA), an antioxidant from the Chinese herb Dong-Gui [Chinese angelica, Angelica sinensis (Oliv.) Diels], on the regulation of various genes in hydrogen peroxide-stimulated porcine chondrocytes at the mRNA level.

METHODS

The effect of FA and the effective concentration of FA on porcine chondrocytes was evaluated by the lactate dehydrogenase, WST-1, crystal violet assay, and a chemical luminescence assay. Gene expression in hydrogen peroxide-stimulated chondrocytes either pre- or post-treated with FA was evaluated by real-time PCR.

RESULTS

Chondrocytes pre-treated with 40 microM FA decreased the hydrogen peroxide-induced interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), and MMP-1 and partially restored SOX9 gene expression. Post-treatment with 40 microM FA also decreased the expression of MMP-1 and MMP-13.

CONCLUSION

FA decreased the hydrogen peroxide-induced IL-1beta, TNF-alpha, MMP-1 and MMP-13 and increased SOX9 gene expression. These findings suggest that FA may prove to be important in the treatment of osteoarthritis. Further research is needed.

Identification of AF17 as a downstream gene of the beta-catenin/T-cell factor pathway and its involvement in colorectal carcinogenesis

To elucidate the molecular mechanism of colorectal carcinogenesis, we have been attempting to isolate genes involved in the beta-catenin/T-cell factor pathway. In the experiments reported here, analysis by cDNA microarray indicated that AF17, a fusion partner of the MLL gene in acute leukemias with t(11;17)(q23;q21), was transactivated according to accumulation of beta-catenin. Expression of AF17 was significantly enhanced in 8 of the 12 colorectal cancer tissues examined. Introduction of a plasmid designed to express AF17 stimulated growth of NIH3T3 cells, and fluorescence-activated cell sorter analysis indicated that the AF17 regulation of cell-cycle progression was occurring mainly at the G(2)-M transition. Our results suggest that the AF17 gene product is likely to be involved in the beta-catenin-T-cell factor/lymphoid enhancer factor signaling pathway and to function as a growth-promoting, oncogenic protein. These findings should aid development of new strategies for diagnosis, treatment, and prevention of colon cancers and acute leukemias by clarifying the pathogenesis of these conditions.

[Diagnosis of subtypes and lateralization for primary hyperaldosteronism]

OBJECTIVE

To evaluate the value of CT and posture stimulation test (PST) in the differential diagnosis and lateralization of primary hyperaldosteronism(PA).

METHOD

Retrospective study was done based on the clinical data and pathological examinations of 22 patients with PA.

RESULTS

The baseline plasma aldosterone concentration (PAC) of most aldosterone-producing adenomas (APAs) was over 250 pg.ml-1. In the diagnosis of APA, the sensitivity of CT was 75% and the specificity of CT was 100%; the sensitivity and specificity of PST were 87% and 100%, respectively. The examination results of CT and PST had no statistical significant correlativity (P > 0.05) and had bad consistency (P > 0.05), and the diagnostic efficiency of them had no significant difference (P > 0.05).

CONCLUSIONS

The baseline PAC and the result of PST suggest as the best diagnostic index and methods of APA. Both CT and PST have high value in the differential diagnosis. Both CT and PST cannot be substituted for each other.

Double-paddle peroneal tissue transfer for oromandibular reconstruction

The double-paddle peroneal tissue transfer is a useful technique for reconstructing the extensive and complex defect that results after ablative surgery for oral cancer. It can facilitate the design and inset of the skin paddle and avoid the need for a second free flap. The two skin paddles can be based on either two cutaneous perforators of the peroneal vessels or two branches of a single cutaneous perforator. The authors report their experience with double-paddle peroneal tissue flaps (10 fasciocutaneous and five osteocutaneous) in 15 patients. The largest double paddle used was (16 x 9) (15 x 6) cm, and the smallest one was (7 x 5.5) (4.5 x 4) cm. All flaps were used for both intraoral and extraoral defect reconstruction. There was one single skin paddle necrosis caused by erroneous manipulation of the flap 1 week after the operation; however, the skin paddle had survived completely before the manipulation. All other flaps survived completely, with a good to excellent appearance, and no patient had a significant gait disturbance after the operation.

Possibility of large final state interaction phases in light of B --> kpi and pipi data

The newly observed &Bmacr;( 0)-->&Kmacr;( 0)pi(0) mode is quite sizable while pi(-)pi(+) is rather small. Data also hint at pi(-)pi(0) greater, similarpi(-)pi(+). Though consistent with zero, central values of CP violating asymmetries in K-pi(+,0) and &Kmacr;( 0)pi(-) show an interesting pattern. Taking cue from these, we suggest that, besides gamma identical witharg(V(*)(ub)) being large, the rescattering phase delta in Kpi and pipi modes may be greater than 90 degrees. If this is true, not only the above trends can be accounted for, but one would also find pi(0)pi(0) approximately pi(-)pi(+,0), and the CP asymmetry in &Bmacr;( 0) vs B0-->pi(-)pi(+) could be as large as -60%. These results can be tested in a couple of years.

Comparison of the frequency-doubled Q-switched Nd:YAG laser and 35% trichloroacetic acid for the treatment of face lentigines

BACKGROUND

Face lentigines are one of the manifestations of photodamaged skin and often put people in socially embarrassing situations. Several lasers have been used to remove lentigines at vast expense. However, trichloroacetic acid (TCA) is an alternative for treating lentigines that costs much less.

OBJECTIVE

To compare the efficacy of the frequency-doubled Q-Switched Nd:YAG laser (532 nm) and 35% TCA for the treatment of face lentigines.

METHODS

Twenty patients (Fitzpatrick skin Types III-IV) with a total of 37 lentigines on faces were randomly collected; each lentigo was divided into medial and lateral halves. Frequency-doubled Q-switched Nd:YAG laser (532 nm) and 35% TCA were applied to the medial and lateral halves of each lentigo respectively. The efficacy after 1 treatment was compared after 6 months.

RESULTS

The frequency-doubled Q-switched Nd:YAG laser (532 nm) had a better result than that of 35% TCA for the treatment of facial lentigines.

CONCLUSION

In order to get a better result after one treatment, the authors suggest the frequency-doubled Q-switched Nd:YAG laser (532 nm) rather than 35% TCA for treating lentigines even though the cost of frequency-doubled Q-switched Nd:YAG laser (532 nm) is greater than that of 35% TCA for both physician and patient.

A multicenter study on eradication of Helicobacter pylori infection in patients with duodenal ulcer by lansoprazole-antibiotics combined therapy

The aim of this prospective randomized multicenter study was to find out if there is one or several promising regimens containing lansoprazole with various combinations of antibiotics which have a high eradication rate of Helicobacter pylori, few side-effects, good patient compliance, and relative low cost if possible. Two hundred and ninety-seven patients with H. pylori positive duodenal ulcer were enrolled and randomly allocated into one of the five treatment groups: 1) group A: received lansoprazole 30 mg once daily for 2 weeks plus amoxicillin (AM) 500 mg and metronidazole (MZ) 500 mg twice daily for one week in the first week; 2) group B: the AM in group A was replaced by clarithromycin (CM) 250 mg; 3) group C: the MZ in group A was replaced by CM 250 mg; 4) group D: the AM and CM in group C was used for 2 wk; 5) group E: the CM in group D was doubled to 500 mg twice daily. All patients received endoscopies pre- and 4-6 weeks post termination of treatment. H. pylori was detected by culture, histology and rapid urease test (CLO test). 13C-urea breath test was performed if the patients refused the second endoscopy. The E-test was adopted to evaluate the MZ and CM resistance of H. pylori. Totally, 253 patients completed the study. The eradication rate of groups A, B, C, D and E were 75%, 80%, 78%, 92%, and 96%, respectively. The eradication rate of group E was significantly higher than that of groups A, B, or C. There were no significant differences of eradication rates between the groups D and E. Sixty-seven cases (28.8%) were MZ-resistant. The difference of eradication rates between MZ-S and MZ-R patients was significant in group A (85.3% vs. 42.9%) and in the combination of groups A and B (83.8% vs. 59.4%). Good compliance (defined as taking > 90% of medications) was seen in more than 90% of cases in each group. Triple therapy containing lansoprazole 30 mg once daily, AM 500 mg and CM 250 mg twice daily for two weeks is a promising regimen which reaches a high eradication rate, avoids MZ resistance, and has very good patient compliance at an acceptable cost.

Clinical experience with endoscopic stents for treatment of common bile duct stones

Endoscopic removal of common bile duct (CBD) stones after endoscopic sphincterotomy (EST) is now a widely accepted procedure. Surgery is usually recommended when extraction of stones after EST fails. For patients with major medical problems or who are at high surgical risk, however, endoscopic stent placement may help to prevent stone impaction and cholangitis. In this report, we describe the long-term effects and complications of biliary stent use in elderly patients with CBD stones. From August 1995 to June 1998, 19 patients with CBD stones underwent stent placement by duodenoscopy. Three of these patients underwent this procedure for temporary treatment while awaiting surgery or EST. In the remaining 16 patients (6 men and 10 women, mean age 76 +/- 10 years), invasive management carried a high risk of complications. We used a 7F straight stent for the first patient, while the remaining 15 received 7F pigtail stents. During a mean follow-up period of 34 months, two patients were lost to follow-up and two patients had migration of the stents. Three patients had acute cholangitis with stents in situ. Of these, one underwent stent exchange 8 months later, while the CBD stones were cleared either by endoscopy or surgery in the other two patients. Five patients died of nonbiliary diseases during the follow-up period. Our results show that long-term biliary stent placement is an advisable alternative therapeutic modality for high-risk and debilitated patients with CBD stones.

Substituted 3beta-phenylethynyl derivatives of 3alpha-hydroxy-5alpha-pregnan-20-one: remarkably potent neuroactive steroid modulators of gamma-aminobutyric acidA receptors

Neuroactive steroids are positive allosteric modulators of gamma-aminobutyric acidA (GABAA) receptor complexes. Synthetic modification generally does not increase neuroactive steroid potency beyond that of the naturally occurring progesterone metabolite, 3alpha-hydroxy-5alpha-pregnan-20-one (3alpha,5alpha-P). Recently, it has been shown that introduction of appropriately para-substituted phenylethynyl groups at the 3beta-position of 5beta steroids increases receptor potency. The present report presents the synthesis and pharmacological profile of an analogous series of 5alpha steroids. The most striking feature of this series is the further enhancement of in vitro and in vivo potency obtained. In particular, 3beta-(p-acetylphenylethynyl)-3alpha-hydroxy-5alpha-pr egnan-20-one (Co 152791) was 11-, 16- and 49-fold more potent than 3alpha, 5alpha-P in modulating the binding of [35S]TBPS, [3H]flunitrazepam and [3H]muscimol, respectively, in rat brain membranes (Co 152791 IC50 or EC50 = 2-7.5 nM). Similarly, Co 152791 was 3- to 20-fold more potent than 3alpha,5alpha-P as an inhibitor of [35S]TBPS binding in human recombinant receptor combinations containing alpha1, alpha2, alpha3 or alpha5 and beta2gamma2L subunits (Co 152791 IC50 1.4-5.7 nM). Co 152791 displayed low efficacy and 3alpha,5alpha-P had low potency at alpha4/6beta3gamma2L GABAA receptor complexes. Interestingly, Co 152791 demonstrated remarkable potency as a potentiator of GABA-evoked currents in Xenopus oocytes expressing alpha1beta2gamma2L receptors (EC50 0.87 nM), being 184-fold more potent than 3alpha,5alpha-P. High in vitro potency was also reflected in enhanced in vivo activity in that Co 152791 exhibited exceptional anticonvulsant potency, protecting mice from pentylenetetrazol-induced seizures at a approximately 5-fold lower dose than 3alpha,5alpha-P after i.p. administration (Co 152791 ED50 0.6 mg/kg). Moreover, Co 152791 was orally active (ED50 1.1 mg/kg) and exhibited a therapeutic index of 7 relative to rotorod impairment. The remarkable potency of Co 152791 as a positive allosteric modulator of GABAA receptors may be explained by its interaction with an auxiliary binding pocket in the neuroactive steroid binding site. In addition, modification at the 3beta-position probably hinders metabolism of the 3alpha-hydroxy group contributing to the exceptional anticonvulsant potency of this compound relative to other neuroactive steroids.

Fibrolamellar hepatocellular carcinoma--an atypical MR manifestation

We report the imaging findings, specifically magnetic resonance pictures of a non-cirrhotic case of fibrolamellar hepatocellular carcinoma in an older patient (60 years). Computed tomography revealed non-enhanced hypodense central scar without notable intratumoral calcification. MR imaging revealed a mass, which was homogeneously hypointense on T1-weighted images (T1WI) and turned hyperintense on T2-weighted images (T2WI). Stellate central scar was depicted with more hypointensity on T1WI, however, it became markedly hyperintense on T2WI. This manifestation is very different from the typical pattern reported in the literature. In gadolinium enhanced T1WI, the mass other than the central scar got enhanced. Fibronodular hyperplasia and fibrolamellar hepatocellular carcinoma should be differentiated with reference to the clinical and imaging findings. Collagenous central scar was described pathologically within the latter. However, a discrepancy between the pathological and magnetic resonance pattern concerning the central scar which was collagenous and corresponding to hyperintensity on T2WI was found. To our knowledge no similar entity has been described in the literatures so far.

Distinct clinicopathologic characteristics of diffuse- and intestinal-type gastric cancer in Taiwan

The clinicopathologic features of 221 patients with intestinal-type (IT) gastric cancer were compared retrospectively with those of 290 diffuse type (DT). Intestinal type was characterized by an older mean age (65.0 +/- 10.8 years vs. 56.2 +/- 13 years), a higher male-female ratio (2.56 vs. 1.06), predominance of blood group O (46.2% vs. 31.1%), and frequent habitual smoking (50.7% vs. 31.4%) and drinking (28.5% vs. 17.6%) than did DT. In contrast, DT had a higher frequency of positive history of parent or sibling with gastric cancer (9.3% vs. 4.1%) and blood group A (40.3% vs. 27.6%) than did IT. The distinguishing histologic features of DT included more Borrmann type IV (13.1% vs. 1.3%) but less Borrmann type I (1% vs. 7.2%), more frequent involvement of middle third (26.9% vs. 15.9%) and whole stomach (4.1% vs. 0%), and more peritoneal seeding (15.5% vs. 9%), lymph node metastasis (67.2% vs. 51%), and nerve permeation (34.1% vs. 24.4%), but less Helicobacter pylori infection (55.9% vs. 69.2%) when compared with those of IT. There was no difference in depth of tumor invasion, venous permeation, duodenal involvement, and postoperative survival between IT and DT. These distinct clinicopathologic features between IT and DT in Taiwan suggest the presence of a different pathogenic process for these two histologic subtypes of gastric cancer.

Afferent loop syndrome complicated by a duodenal phytobezoar after Billroth-II subtotal gastrectomy

We illustrate a rare late onset (10 yr) complication of gastric surgery with a combination of afferent loop syndrome and a large duodenal bezoar. The patient underwent a subtotal gastrectomy with Billroth II gastrojejunal anastomosis for benign peptic ulcer 10 yr ago. It was not until several days before this presentation that he suffered from epigastralgia and abdominal distension. Leukocytosis and abnormal blood biochemistry were found including amylase, lipase, alkaline phosphatase, total bilirubin, GOT, and GPT in which amylase was markedly elevated to 1188 U/L. Abdominal ultrasound scan and especially CT scan confirmed the diagnosis of a large bezoar in the dilated duodenal afferent loop. To our knowledge, the rare entity in our case is the first reported in the literature.

3 alpha-Hydroxy-3 beta-(phenylethynyl)-5 beta-pregnan-20-ones: synthesis and pharmacological activity of neuroactive steroids with high affinity for GABAA receptors

Neuroactive steroids that allosterically modulate GABAA receptors have potential uses as anticonvulsants, anxiolytics, and sedative-hypnotic agents. Recently, a series of pregnanes substituted with simple alkyl groups at the 3 beta-position were synthesized and found to be active in vitro. The present report describes the synthesis of a series of substituted 3 alpha-hydroxy-3 beta-(phenylethynyl)pregnan-20-ones and their in vitro structure-activity relationship determined by their potency for inhibition of [35S]TBPS binding in rat brain membranes. Appropriate substitution of the phenyl group results in ligands with particularly high affinity for the neuroactive steroid site on GABAA receptors (e.g., 4-acetyl 28, IC50 10 nM). The potency of selected steroids was confirmed electrophysiologically in oocytes expressing cloned human GABAA alpha 1 beta 2 gamma 2L receptors (e.g., compound 28, EC50 6.6 nM). Consistent with their in vitro activity, some of the 3 beta-(phenylethynyl)-substituted steroids displayed anticonvulsant activity in the pentylenetetrazol (PTZ) and maximal electroshock (MES) tests following ip administration in mice. Notably, the 3 beta-[(4-acetylphenyl)ethynyl]-19-nor derivative 36 demonstrated an attractive anticonvulsant profile (PTZ and MES ED50 values of 2.8 and 9.2 mg/kg, respectively). A new pharmacophore for the neuroactive steroid site of GABAA receptors is proposed based upon the high affinity of certain substituted 3 beta-(phenylethynyl) steroids.

Lead poisoning caused by contaminated Cordyceps, a Chinese herbal medicine: two case reports

Two cases of lead poisoning, caused by the Chinese herbal medicine Cordyceps, were reported to the Department of Health in a laboratory-based blood lead surveillance program. Such unusual cases of lead poisoning have not been previously reported. These two patients took Cordyceps herbal medicine for treatment of underlying diseases. Loss of appetite and anemic signs of lead poisoning were manifested in one patient with a blood lead level of 130 microg/dl, while the other patient was asymptomatic with a blood lead level of 46 microg/dl. The lead content in the Cordyceps powder was found to be as high as 20 000 ppm. After cessation of intake in the asymptomatic patient, and cessation of intake and treatment with chelating agents in the symptomatic patient, the blood lead levels returned to normal range. This report raises concerns about lead poisoning from unusual herbal medicine worldwide.

Visual acuity changes throughout adulthood in normal, healthy eyes: seeing beyond 6/6

There are many useful longitudinal and cross-sectional epidemiological studies of how visual acuity (VA) deteriorates with age. However, few studies have evaluated age-related VA changes in normal, healthy eyes. Data from three previous studies that included VA measurements taken with logMAR charts from subjects with normal, healthy eyes were collated and additional data from 42 subjects were added. This provided VA results from 223 subjects (age range 18 to 80 years). Mean logMAR VA improved from -0.13 (Snellen equivalent 6/4.5) in 18- to 24-year-olds to -0.16 (Snellen 6/4(-1)) in 25- to 29-year-olds and then gradually became worse with age to a mean value of -0.02 (Snellen 6/6+1) for subjects over 75 years of age. The inadequacy of 6/6 as a norm value of VA is illustrated. The data show VA levels far superior to the data from the standard references of Pitts (1982) and Weale. (1975, 82) We suggest that this is because we used logMAR charts (providing nontruncated data), the subject's optimal refractive correction (rather than habitual) and strict exclusion criteria ensuring that only subjects with normal, healthy eyes were recruited for the studies.

Ultraviolet-induced lenticular fluorescence: intraocular straylight affecting visual function

Ultraviolet radiation (UVR) excitation of fluorophores within the crystalline lens results in intraocular straylight. These fluorescent emissions are known to increase with age. The visual effect of this increase in fluorescent straylight has not previously been published. In this study, the visual deficit associated with UV-induced lenticular fluorescence was measured for 61 normal subjects between the ages of 21 and 80 yr of age using the Regan visual acuity charts at varying levels of contrast. UVR was shown to decrease low contrast acuity and this loss increased linearly with age.

Anomalous junction of pancreaticobiliary duct with carcinoma of the gallbladder: report of two cases

Anomalous junction of the pancreaticobiliary duct (AJPB) is a rare, congenital anatomic abnormality of the biliary system and is thought to be associated with a high risk of developing carcinoma of the gallbladder. We have had two cases of AJPB-associated gallbladder carcinoma in the past four years. Case 1: a 42-year-old female complaining of right upper quadrant pain was found in an abdominal sonogram to have irregular thickening of the gallbladder wall. Endoscopic retrograde cholangiopancreaticography revealed an abnormally elongated common channel; an abdominal CT scan and celiac angiogram showed a gallbladder tumor with invasion to the liver base. Case 2: a 36-year-old female presented with right upper quadrant pain and a palpable mass. A gallbladder tumor was found in an abdominal sonogram. Intraoperative cholangiography showed an abnormally elongated junction of the pancreaticobiliary duct. In these two cases, adenocarcinoma of the gallbladder was proven by pathology after surgical excision. Since AJPB and bladder carcinoma are both rare, the coexistence of these two diseases indicates that patients with AJPB have a high risk of developing gallbladder carcinoma. It is suggested that patients with AJPB should be closely followed. A prophylactic cholecystectomy may be indicated in some cases because of the high risk of developing gallbladder carcinoma.

Double-blind comparison of omeprazole 20 mg OM and ranitidine 300 mg NOCTE in duodenal ulcer: a Taiwan multi-centre study

Two hundred and twenty-six patients with endoscopically confirmed duodenal ulcers > or = 5 mm in diameter entered a double-blind randomized trial comparing 20 mg omeprazole administered once daily in the morning with 300 mg ranitidine administered once daily at night. The patients were assessed endoscopically and symptomatically after 2 weeks, and those whose ulcers had healed terminated the study. Patients with unhealed ulcers continued treatment for a total of 4 weeks. Omeprazole produced significantly higher healing rates than ranitidine at both 2 weeks (57 vs 28%, P < 0.0001) and 4 weeks (93 vs 80%, P = 0.006). Similarly, significantly higher 'effective healing rates' (defined on the criteria established by the Japanese Society of Digestive Endoscopy) were observed with omeprazole compared with ranitidine at 2 and 4 weeks. After 2 weeks, there were significantly fewer reports of both day-time and night-time epigastric pain by omeprazole-treated patients compared with ranitidine-treated patients (22 vs 44%, P < 0.0001 for day-time pain; 24 vs 35%, P = 0.025 for night-time pain). Both drugs were well-tolerated and no major adverse effects were recorded during either treatment. In conclusion, 20 mg omeprazole administered once daily was superior to 300 mg ranitidine administered once daily for duodenal ulcer healing and symptom relief.

Immunogenicity and protective efficacy of solubilized merozoite-enriched Theileria sergenti immunogens. II: Protection against natural exposure under field conditions

A Theileria sergenti soluble merozoite preparation containing the 29, 34, 35 and 105 KD as the immunodominant polypeptides, was evaluated for efficacy, safety and protectivity in Holstein calves against virulent field tick challenge. The soluble antigens (100 mg/dose) were fortified with either complete or incomplete Freund's adjuvant. Twenty naive calves, aged one month, were subcutaneously inoculated with the preparation and a booster dose was administered 4 weeks later. Twenty additional calves served as controls. Five weeks after the booster dose, vaccinates and uninoculated controls were moved to a pasture, a heavily tick infested area in Cheju-do, Korea. The vaccinates showed negligible change in hematocrit and total RBC count whereas control animals showed significant (p < 0.05) hematological changes and associated anemia. Only 30% of vaccinates required chemotherapy after the experiment was terminated. All control animals required chemotherapy and 25% received blood transfusion. The highest percent parasitized erythrocytes in vaccinated cattle was 0.4% as compared with 3.6% among controls during the month of July. A significant difference (p < 0.05) was observed in the rate of body weight increase. Significant differences were also noted in serum albumin, aspartate aminotransferase, total protein and bilirubin. Significantly more vaccinated cattle maintained normal ranges of hematological and biochemical values as compared with the control group. It is suggested that soluble merozoite T. sergenti antigens may be potential vaccine candidates for developing a genetic vaccine in Korea.

Coaxial photorefractive methods: an optical analysis

We provide a novel geometrical optical analysis of two coaxial photorefractive methods (isotropic and orthogonal). The size of the photorefractive pattern is defined in terms of the critical optical parameters without reference to specific camera parameters. A set of equations is derived that defines the following: a working range where the photorefractive pattern increases linearly with refractive error and pupil size, a dead zone where changes in refractive error do not influence pattern size, and critical values where vignetting by the camera lens becomes important. From this analysis optical parameters can be systematically adjusted to vary a photorefractor's working range. Small discrepancies found between measurements taken with model eyes indicated threshold and blooming effects that require calibration.

Geometrical optical analysis of photorefractive methods

Photorefractive methods allow rapid measures of the refractive and accommodative state of infants and young children whose brief attention and co-operation limit the use of more traditional methods such as retinoscopy and autorefraction. Three methods have been defined: orthogonal, isotropic and eccentric. We provide a common geometrical optical analysis for these three methods where the photorefractive pattern is defined at the plane of focus of the camera. Since this plane is conjugate with the detector plane of the camera then the critical optical parameters can be defined without reference to the design of the camera by simply determining the relative magnification of the projected image of an object photographed at the camera's plane of focus. Specifically the pattern width CF (mm) over a photorefractor's working range can be defined for the isotropic and orthogonal methods as: [formula: see text] and for the eccentric method as: [formula: see text] where: K is a myopic refractive error of the eye (dioptres) (K Less than 0); P the distance of the flash source to the eye (dioptres); L the distance in front of the eye of the camera's plane of focus (dioptres) (L less than 0); GH the pupil diameter (mm); e the eccentricity of the flash source from the camera aperture (mm); M magnification of the image measured relative to the camera plane of focus.

[Clinical analysis of adenocarcinoma of the stomach in patients with duodenal ulcer]

In 332 patients of adenocarcinoma of the stomach and 7095 patients with duodenal ulcer collected in 5-year period, 21 cases were found to have both disease entities. With regard to clinical manifestations, gross morphology, microscopic differentiation and management of adenocarcinoma of the stomach, the patients with duodenal ulcer showed no significant difference from those without duodenal ulcer. The activities of the duodenal ulcers could be in acute active stage or present as chronic scar only. The ulcer history varied from several years to more than 15 years. We concluded that the frequency of adenocarcinoma of the stomach developed in patients with duodenal ulcer is not so rare, presentation of epigastric discomfort or signs of UGI bleeding in patients with duodenal ulcer history not always indicated recurrence of ulcer disease.

[Malignant melanoma metastatic to the stomach: upper G-I endoscopic finding--report of a case]

a 54-year-old male was presented with huge, black, ulcerative and painless tumor of the sole of left foot. Malignant melanoma was proved by biopsy, but patient refused any treatment. He visited our hospital again when bloody vomitus was noted two months later. Chest P-A revealed multiple lung metastases, and marked liver metastasis was also found by abdominal echo. Upper gastrointestinal (UGI) panendoscopy revealed multiple melanotic nodules with ulcerations at the tip, scattering diffusely on the fundus and upper body of the stomach. Metastatic malignant melanoma was proved by endoscopic biopsy. Metastatic tumor of the stomach was rare, and the endoscopic finding of the malignant melanoma with gastric metastasis was more rarer in the literature in Taiwan. So we would like to present the very rare finding of the endoscopy.

Pancreatic vasoactive intestinal polypeptide-secreting tumor: report of a case

A 58-year-old Taiwanese woman was admitted to Mackay Memorial Hospital for evaluation profuse watery diarrhea. She presented with watery diarrhea, hypokalemia, and hypochlorhydria, and had experienced these problems for 2 years prior to admission. A pancreatic tumor with liver metastasis was noted by the ultrasound, abdominal CT scanning, and angiography studies. Surgical exploration disclosed an ill-defined ovoid tumor in the body and tail of the pancreas measuring 8 x 3 x 3 cm. The immunohistochemistry study of the tumor for VIP-immunoreactivity (VIP: vasoactive intestinal polypeptide) was markedly positive, and also stained slightly positive for other peptides, including pancreatic polypeptide (PP), calcitonin, glucagon, and neuron-specific enolase (NSE). Postoperatively, the patient recovered immediately from her symptoms and there has been no evidence of recurrence during the past 8 months of follow-up.

The relationship between nutritional antioxidants and serum lipid peroxides in cancer patients

A new parameter, the ratio of lipid peroxide and vitamins E and C [LPO/(VE + VC)], has been proposed and used to reflect the balance between lipid peroxidation and antioxidation capability of cancer patients and of healthy human controls. The effects of vitamins E, C, and selenium on the serum LPO level in mice bearing Ascites Hepatomas (H22) have also been examined. The results showed that the average of LPO/(VE + VC) ratios in cancer patients (135 cases) was significantly higher than that of the normal controls (222 cases). The authors suggest that this ratio might be used as one of the parameters for early diagnosis and prognosis of diseases (including cancers) caused by free radicals and lipid peroxides. The results also showed that antioxidants - Se(Na2SeO3, 1mg/kg) or vitamin E (5mg/kg) could markedly decrease the level of serum LPO in the tumor-bearing animals. A smaller dose of VE (1mg/kg) and doses of Vc up to 300mg/kg showed no effect on the serum LPO levels when given separately. However, synergistic effects were observed when any 2 out of 3 or three nutrients were given together. Those with three nutrients significantly lowered the serum LPO level. These antioxidants also inhibited the proliferation of tumour cells.

[Cystic sacrococcygeal lesions]

Eleven out of twelve cases of sacrococcygeal cystic lesions, 10 females and 2 males, with ages ranging from 12 to 64 underwent surgical excision with the pathological diagnosis of teratoma in 1, dermoid in 4 and epidermal cyst in 6. Most lesions were multicystic and located in the perirecto-coccygeal region, some are extending into the pelvic cavity. Occult lesions may bulge toward the rectal lumen and thus could be early detected by digital examination or proctoscopy. Early surgery is advocated for fear of malignant change and secondary infection and coccygectomy advised to ensure satisfactory exposure.

Cervical spondylotic myelopathy treated by anterior multilevel decompression and fusion. Follow-up report of 214 cases

From 1974 to 1982, 214 patients were treated for cervical spondylotic myelopathy by anterior multilevel decompression and the Robinson anterior interbody fusion and followed for an average of three years and 11 months. Postoperative results were superior to those obtained previously using posterior decompression. The average patient age was 50.1 years (range, 30-75); there were 187 men and 27 women. Overall, the percent of patients with excellent and good results was 59.3%; with fair results, 29%, no change; 7.9%, and deterioration, 3.8%. Of the 111 patients who had the disease less than one year before treatment, 74% were categorized after surgery as excellent or good. In contrast, only 36% of the 66 patients who had the disease more than two years were rated excellent and good. Myelography is valuable in diagnosing and locating lesions. The average number of discs removed was 3.1 per patient. The number of cases with excellent and good results was the same whether or not union of the graft occurred. Reoperation was required in 12 patients, and a third operation was performed in three patients. Eventually, 93% of the patients were able to lead independent lives.

The natural course of hepatitis B surface antigen-positive chronic active hepatitis in Taiwan

A prospective study on the natural course of hepatitis B surface antigen (HBsAg)-positive chronic active hepatitis (CAH) in 84 patients was conducted at the Taiwan Veterans General Hospital in Taipei. On presentation, 36% of the patients had jaundice and 94% had elevated serum transaminase activity in addition to clinical symptoms. Of the 84 patients with HBsAg-positive CAH, 76 were followed for an average of 46 months, and at the time of the last visit 46% either had evidence of progressive liver disease or had died. Of the 15 deaths, nine were due to complications of liver disease and six were due to primary hepatocellular carcinoma (PHC), alpha-Fetoprotein levels of greater than 400 ng/ml were found only in patients in whom PHC was detected. The course of HBsAg-positive CAH in this predominantly male Asian population was progressive, and deaths occurred either by liver failure, by bleeding esophageal varices, or by progression to PHC.