Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression

Self-expandable metal stents (SEMSs) are effective for malignant esophageal obstruction, but usefulness of SEMSs in extrinsic lesions is yet to be elucidated. This study is aimed at evaluating the clinical usefulness of SEMSs in the extrinsic compression compared with intrinsic. A retrospective review was conducted for 105 patients (intrinsic, 85; extrinsic, 20) with malignant esophageal obstruction who underwent endoscopic SEMSs placement. Technical and clinical success rates were evaluated and clinical outcomes were compared between extrinsic and intrinsic group. Extrinsic group was mostly pulmonary origin. Overall technical and clinical success rate was 100% and 91%, respectively, without immediate complications. Extrinsic and intrinsic group did not differ significantly in clinical success rate. The median stent patency time was 131.3 ± 85.8 days in intrinsic group while that of extrinsic was 54.6 ± 45.1 due to shorter survival after stent insertion. The 4-, 8-, and 12-week patency rates were 90.5%, 78.8%, and 64.9% respectively in intrinsic group, while stents of extrinsic group remained patent until death. Uncovered, fully covered, and double-layered stent were used evenly and the types did not influence patency in both groups. In conclusion, esophageal SEMSs can safely and effectively be used for malignant extrinsic compression as well as intrinsic.

Heterogeneity of mucosal mast cell infiltration in subgroups of patients with esophageal chest pain

BACKGROUND

Although there is growing evidence that an increase in mucosal mast cells (MMCs) in the small and large intestine is associated with visceral hypersensitivity, few studies have evaluated MMCs in humans with esophageal symptoms. The aim of this study was to investigate esophageal MMC distribution in patients with non-cardiac chest pain (NCCP) and to examine the association between the number of gut MMCs and other functional gastrointestinal disorders.

METHODS

Forty-two consecutive NCCP patients and 10 healthy controls completed a questionnaire for bowel symptoms, chest pain intensity score, and psychologic depression. Esophageal, duodenal, and rectal MMCs were identified immunohistochemically and quantified by image analysis.

KEY RESULTS

Numbers of MMCs were significantly higher in NCCP patients vs healthy controls (11.8 ± 5.6 vs 7.6 ± 3.7 MMCs/high-power field, p = 0.026). In comparison of subgroups classified by 24-h impedance-pH monitoring, esophageal MMC counts were highest in the hypersensitive esophagus group (p < 0.01) and were also significantly increased in the functional chest pain group (p < 0.05). A positive correlation between esophageal and duodenal MMC counts was observed in patients with functional dyspepsia (FD; Spearman ρ = 0.604, p = 0.037). In particular, patients with clinical overlap with irritable bowel syndrome showed a strong positive correlation between esophageal and rectal MMC numbers (Spearman ρ = 0.857, p = 0.010).

CONCLUSIONS & INFERENCES

Among NCCP patients, increased MMC infiltration occurs in subgroups with hypersensitive esophagus and functional chest pain. In subpopulations with overlap with FD or irritable bowel syndrome, esophageal MMC counts demonstrated significant positive correlations with duodenal or rectal MMC counts.

Esophageal mucosal mast cell infiltration and changes in segmental smooth muscle contraction in noncardiac chest pain

Mast cells release potent mediators that alter enteric nerve and smooth muscle functions and may contribute to the pathogenesis of functional gastrointestinal disorders. The goal of this study was to determine if mucosal mast cell infiltration was associated with smooth muscle segmental changes in esophageal contraction. All patients with noncardiac chest pain (NCCP) were divided into two groups consisting of patients with non-erosive reflux disease or functional chest pain (FCP) according to the results of ambulatory 24 hours esophageal pH monitoring and high-resolution manometry. Pressure-volume (PV) was calculated by multiplying the length of the esophageal segment, duration of the contraction, and mean pressure over the entire space-time box (P mean). Quantification of mast cells was performed in five consecutive nonoverlapping immunostained sections. Spearman correlation analysis showed that the distal segment PV correlated with the mast cell count in all of the patients combined and in patients with FCP with correlation coefficients of 0.509 and 0.436, respectively (P = 0.004 and P = 0.042). Similar findings were observed for the segmental ratio of distal to proximal smooth muscle PV in all patients and in patients with FCP (correlation coefficients 0.566; P = 0.001 and correlation coefficients 0.525; P = 0.012, respectively). Mucosal mast cell infiltration was associated with distal esophageal contraction as a key pathophysiologic factor of NCCP.

Effect of Cordyceps militaris extract and active constituents on metabolic parameters of obesity induced by high-fat diet in C58BL/6J mice

ETHNOPHARMACOLOGICAL RELEVANCE

Cordyceps species which is well-known as 'winter worm summer grass' has long been used as tonics and stimulants to enhance energy, exhibiting a potential for energy metabolism. Clinical trials have suggested their beneficial effect on lipid metabolic disorders such as hyperlipidemia.

MATERIALS AND METHODS

The effect of Cordyceps militaris on metabolic parameters was investigated using C58BL/6J mice induced by high-fat diet (HFD). The effect was first determined by assessing the body and organ weight. For further investigation, sections of epididymal adipose tissue were stained with hematoxylin and eosin and the size of epididymal adipocyte was measured by Image analysis system. Fat accumulation in frozen liver sections was assessed by the Oil Red O staining and the plasma biochemical parameters were also assessed. Active constituents were characterized using chromatographic and spectroscopic analysis.

RESULTS

The administration of Cordyceps militaris extract (CE) at the dose of 100mg/kg and 300 mg/kg reduced body weight gain and food efficiency ratio induced by HFD. The amount of epididymal fat and size of adipocytes were also decreased by CE treatment. In addition, liver weight and fat deposition in liver were dramatically reduced in CE-treated group. The treatment of CE also showed beneficial effects on plasma parameters related to lipid profiles. Further study for the characterization of active constituents of Cordyceps resulted in the isolation of two new compounds such as cordyrroles A (1) and B (7) together with 12 known compounds including pyrrole alkaloids and nucleotide derivatives. Among the isolated compounds, cordyrrole A significantly inhibited adipocyte differentiation and pancreatic lipase activity, whereas cordyrrole B was more effective at inhibiting pancreatic lipase. Cordycepin, a characteristic compound of Cordyceps militaris, decreased the rate of adipocyte differentiation.

CONCLUSION

Treatment of CE inhibited HFD-induced metabolic disorders, mainly by improvement in metabolic parameters. As active constituents, pyrrole alkaloids and nucleotide derivatives were characterized. These results suggested that Cordyceps militaris might be beneficial for the treatment of metabolic disorders obesity through the combined actions of diverse constituents.

The effects of statins on the clinical outcomes of Clostridium difficile infection in hospitalised patients

BACKGROUND

An association between exposure to statin drugs and favourable treatment outcomes for various types of infections has been established.

AIM

To determine the clinical characteristics and treatment outcomes of Clostridium difficile infection (CDI) among hospitalised patients taking statin drugs.

METHODS

The medical records were reviewed for consecutive in-patients with CDI confirmed by positive toxin assay (A or B), C. difficile culture, or the presence of pseudomembrane on endoscopy. Treatment success was defined as the resolution of diarrhoea within 6 days of therapy. The primary end points were assessed by average symptom recovery time and treatment response (success or failure).

RESULTS

Among 949 patients, the overall response to metronidazole was 91.9%. The baseline characteristics showed some differences between statin users and statin non-users with respect to mean disease severity score. In the multivariate analysis, successful treatment response was significantly associated with the absence of exposure to proton pump inhibitors (PPIs) (OR = 0.690, 95% CI = 0.513-0.929, P = 0.014) and with exposure to statins (OR = 1.449, 95% CI = 1.015-2.070, P = 0.041). Contrary to the treatment response, univariate and multivariate analyses failed to show that exposure to PPIs or statins affected symptom recovery times. Sixty-day CDI recurrence rates for those patients with statin exposure were significantly lower compared with those patients without statin exposure (3% vs. 7.3%, respectively; RR = 0.393, 95% CI = 0.167-0.926, P = 0.033).

CONCLUSION

Prior statin exposure in patients with C. difficile infection is associated with a successful response to treatment.

Elm tree bark extract inhibits HepG2 hepatic cancer cell growth via pro-apoptotic activity

Control of inflammation is widely accepted as an important strategy for cancer chemoprevention. Anti-inflammatory effects of bark extracts of elm tree (BEE) have been amply reported. Therefore, BEE may be a good candidate cancer chemopreventive agent. Considering the high incidence of hepatic cancer and limited therapeutic approaches for treating this disease, it is important to develop liver cancer-specific chemopreventive agents. To evaluate the chemopreventive potential of BEE, we investigated the growth inhibition effect of BEE on the HepG2 human hepatocellular carcinoma cell line. We performed a cell counting kit-8 assay to determine cell viability, and 4,6-diamino-2-phenylindole staining and flow cytometry to measure apoptotic cell death. Finally, the expression levels of pro- and anti-apoptotic proteins were measured. BEE inhibited the growth of HepG2 cells and induced apoptosis in a dose-dependent manner. Pro-apoptotic activity was promoted via the mitochondrial pathway of apoptosis, as demonstrated by the activation of pro-apoptotic proteins Bax, caspase-9, caspase-3, and poly (ADP-ribose) polymerase as well as the down-regulation of the anti-apoptotic protein Bcl-2. These results suggest that BEE may have potential use in hepatic cancer chemoprevention by suppressing cancer cell growth via pro-apoptotic activity.

Efficacy of leukotriene receptor antagonist for erosive esophagitis: a preliminary retrospective comparative study

While diagnostic overlap exists between gastroesophageal reflux disease and eosinophilic esophagitis especially on histological findings, therapeutic approaches for the two disease entities are very different. Recently, anti-inflammatory treatment, in addition to acid suppressants, has been investigated for gastroesophageal reflux disease. This study investigated whether the incidence of endoscopic erosive esophagitis was lower in recipients of long-term leukotriene receptor antagonist (LTRA) treatment. This retrospective comparative study included 207 recipients of an LTRA and an equal number of controls who underwent screening upper endoscopic examination. Twenty-two (10.6%) and 51 (24.6%) cases of erosive esophagitis were detected in the LTRA and control groups, respectively (P < 0.001). A significantly higher incidence of minimal change esophagitis was also found in the controls compared with the LTRA group (14.5% vs. 2.4%, P < 0.001). On multivariate analysis, LTRA treatment was significantly and inversely associated with erosive esophagitis (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.13 to 0.46). Within the LTRA treatment group, an increased risk of erosive esophagitis was strongly associated with the presence of hiatal hernia (OR, 5.89; 95% CI, 2.20-15.73, P < 0.001) and short duration of LTRA treatment (OR, 0.64; 95% CI, 0.37-0.89, P= 0.022). In conclusion, this preliminary retrospective analysis demonstrated that patients who underwent long-term treatment with a LTRA had low incidence of endoscopic minimal change esophagitis.

Basosquamous carcinoma with systemic metastasis in a miniature Pinscher

Basosquamous carcinoma (BSCC) is a rare malignancy, primarily composed of basal cells with foci of squamous differentiation. It is considered to be histologically an intermediate type between basal cell carcinoma and squamous cell carcinoma, and is known to have aggressive behaviors. BSCC occurred in a 17-year-old female minipin with a history of surgical excision for a mammary tumor. The right upper hindlimb was severely enlarged to 8 x 5 cm. Cross-section showed a homogenous white to yellow-white mass compressing the surrounding muscular tissues. The tumor metastasized also to the lungs, heart, abdominal cavity, liver and salivary gland. Microscopically, basaloid cells were crowded into solid nests or lobules separated by well-developed fibrous tissues with occasional keratinizations. Since there was no skin lesions, the tumor is assumed to be originated from the formerly present tumor in mammary gland. To our literature review, this case is the first BSCC with systemic metastasis in a dog.

Histologic diagnosis based on forceps biopsy is not adequate for determining endoscopic treatment of gastric adenomatous lesions

BACKGROUND AND STUDY AIMS

Controversy persists around the treatment of gastric low-grade dysplasia (LGD). The aim of this study was to investigate possible indications for the endoscopic resection of gastric LGD through analysis of the histologic discrepancies between specimens of gastric LGD obtained by forceps biopsy and by endoscopic mucosal resection (EMR), and of their clinicopathologic characteristics.

PATIENTS AND METHODS

The study involved 293 gastric LGD that were histologically proven on the basis of forceps biopsy in Severance Hospital between January 2004 and December 2007. Twenty cases were regularly followed up, and the remaining 273 were resected by EMR. We performed univariate and multivariate analyses of clinical and endoscopic characteristics including lesion size, number of biopsy fragments, and endoscopic appearance, in order to analyze the factors affecting histologic discrepancies.

RESULTS

Of the 273 lesions resected by EMR, 207 (75.8 %) showed concordant histology, whereas for 51 (18.7 %) the histology was upgraded after endoscopic resection. Lesion size, absence of whitish discoloration, and the presence of spontaneous bleeding were found by univariate analysis to be statistically significant factors predicting an upgraded histology after EMR ( P = 0.026, P < 0.001, and P = 0.025, respectively). Multivariate analysis also showed absence of whitish discoloration to be a statistically significant factor influencing histologic discrepancies ( P = 0.001, odds ratio 5.29, 95 % confidence interval 1.95 - 14.37). Perforation and bleeding rates associated with EMR for LGD were 0.7 % and 6.2 %, respectively. Twenty patients who did not undergo EMR were followed up for a mean of 22 months, and 3 were revealed to have adenocarcinoma and 1 high-grade dysplasia on the latest histologic exam.

CONCLUSIONS

We should consider endoscopic resection for gastric LGD that are 2 cm or more in size and do not have whitish discoloration.

Survey of PCDDs and PCDFs in air and soil around various incinerators in Korea, 2003-2007

To investigate the levels of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) pollution in soils and air around incinerators, a total of 574 soil and 48 air samples were collected around 22 incineration facilities in Korea from 2003 to 2007. The concentrations of PCDD/Fs in the flue gases and air ranged from 0.01 to 21.50 ng I-TEQ Sm(-3) and 0.0002 to 9.95 pg I-TEQ Sm(-3), respectively whereas concentrations in soils ranged from n.d. to 153.23 pg I-TEQ g(-1) dw. The average value was 8.14 pg I-TEQ g(-1) dw in soil samples.

The effect of pneumoperitoneum and Trendelenburg position on acute cerebral blood flow-carbon dioxide reactivity under sevoflurane anaesthesia

This study compared cerebral blood flow-carbon dioxide (CBF-CO2) reactivities in the supine and modest Trendelenburg position under pnemoperitoneum during sevoflurane anaesthesia. After induction of anaesthesia in 25 patients, mechanical ventilation was adjusted to increase Paco2 from 4.7 (T1) to 6.0 kPa (T2) in the supine position, and the change in jugular bulb oxygen saturation was measured as an index of CBF. Then, after establishment of pneumoperitoneum and 30 degrees Trendelenburg position, the CO(2) step and measurement of CBF were repeated. The CBF-CO2 reactivity was 7.5 (3.3) %xkPa(-1) (% change in jugular bulb oxygen saturation per unit change in Paco2) in the supine position and 6.8 (2.3) %xkPa(-1) in the 30 degrees Trendelenburg-pneumoperitoneum condition (p = 0.086). We conclude that CBF-CO2 reactivity is unchanged by the modest Trendelenburg position under pneumoperitoneum during sevoflurane anaesthesia.

Caudal midazolam does not affect sevoflurane requirements and recovery in pediatric day-case hernioplasty

BACKGROUND

This prospective, randomized, double-blind study aimed to determine whether caudal midazolam combined with ropivacaine affects anesthetic requirements, recovery profiles, and post-operative analgesia compared with ropivacaine alone in pediatric day-case hernioplasty.

METHODS

Sixty boys (2-5 years old) received caudal injections of 0.2% ropivacaine 1 ml/kg and epinephrine 1 : 200,000 with (RM group) or without (R group) 50 microg/kg of midazolam under sevoflurane anesthesia. The sevoflurane requirement was determined by adjusting to a bispectral index score=50.

RESULTS

Concentrations of end-tidal sevoflurane (ETsevo%) after induction were similar in both groups. After caudal block, ETsevo% before and after surgical stimuli did not show significant intra- or intergroup differences. Recovery characteristics, including post-operative sedations, were similar in both groups. Post-operative pain scores were significantly lower in the RM group than the R group.

CONCLUSIONS

Caudal midazolam (50 microg/kg) added to 2% ropivacaine did not influence sevoflurane requirement or recovery but improved post-operative analgesia compared with ropivacaine alone in pediatric day-case hernioplasty.

Simultaneous monitoring technique for ASE and MPI noises in distributed Raman Amplified Systems

We develop a new technique for simultaneously monitoring the amplified spontaneous emission (ASE) and multi-path interference (MPI) noises in distributed Raman amplified (DRA) systems. This technique utilizes the facts that the degree-of polarization (DOP) of the MPI noise is 1/9, while the ASE noise is unpolarized. The results show that the proposed technique can accurately monitor both of these noises regardless of the bit rates, modulation formats, and optical signal-to-noise ratio (OSNR) levels of the signals.

An evaluation of a six-week intervention designed to facilitate coping with psychological stress

Community dwelling Korean adults (N = 40) coping with the stress of severe mental illness were randomly assigned to a six-week differentiation furthering intervention (experimental) or a directed problem-solving treatment program (control) and administered pre- and posttreatment measures including the Morey Personality Assessment Screener (PAS) and Group Embedded Figures Test (GEFT). As predicted, the experimental group showed greater improvement on 6 out of 10 mental health subscales (PAS) and on the GEFT than the controls. For the entire sample, differentiation gainers showed more improvement on three PAS subscales compared with the no change or loss in differentiation groups. A three-month follow-up showed greater attendance at mental health appointments for the experimental group over controls and for total sample differentiation gainers over nongainers. Implications are discussed of this empirically tested model of a community intervention to facilitate coping with stress and enhancing competence.

Impact of a targeted asthma intervention program on treatment costs in patients with asthma

OBJECTIVE

To evaluate the impact of a targeted asthma intervention on treatment costs, utilization of medical services, number of prescription drugs filled, and trends of medication use from a third-party perspective.

STUDY DESIGN

Longitudinal population-based study.

METHODS

Study asthmatic patients were classified into intermittent and persistent asthma groups according to the Health Plan Employer Data and Information Set (HEDIS) 2000 asthma measurement. The intervention instituted appropriate asthma drug therapy according to National Heart, Lung, and Blood Institute guidelines. A paired t test and analysis of covariance were used to compare treatment costs and the number of prescriptions dispensed in the 9 months before and the 9 months after the intervention.

RESULTS

The study patients (n = 1616) included 566 with intermittent asthma and 1050 with persistent asthma. After the intervention, treatment costs per patient increased significantly by $122 in the intermittent asthma group (P = .001) but decreased significantly by $247 in the persistent asthma group (P < .001). Costs incurred by patients with persistent asthma decreased by $149 for hospitalization (P = .003), $16 for emergency room visits (P < .001), $82 for physician visits (P < .001), and increased by $1 for asthma medications (P = .938). The number of asthma medication prescriptions per patient increased by 0.72 prescriptions in the intermittent asthma group (P < .001), whereas the persistent asthma group had a per patient reduction of 0.99 prescriptions (P < .001).

CONCLUSION

A targeted asthma intervention resulted in decreased hospitalization, emergency room, and physician visit costs in patients with persistent asthma.

Prolonged activation of mitogen-activated protein kinases during NSAID-induced apoptosis in HT-29 colon cancer cells

The mechanisms of the antineoplastic effect of nonsteroidal anti-inflammatory drugs (NSAIDs) still are unknown, but the induction of apoptosis is one of the possible mechanisms. We attempted to demonstrate the role of mitogen-activated protein (MAP) kinases, generally considered to be important mediators of proliferative and apoptotic signals, in NSAID-induced colon cancer cell apoptosis. Apoptosis was detected by demonstration of DNA fragmentation in agarose gel electrophoresis. Cell death was assessed by trypan blue dye exclusion method. MAP kinase activation was assessed by Western blot using phosphospecific antibodies to MAP kinases. Kinase assay using activating transcription factor-2 (ATF-2) fusion protein as a substrate was also performed for measuring p38 MAP kinase activity. For the inhibition of p38 MAP kinase, pyridinylimidazole compound (SB203580) was utilized. Caspase-3 activity was measured using the tetrapeptide fluorogenic substrate Ac-DEVD-AMC. Treatment of HT-29 cells with NSAIDs results in time- and dose-dependent induction of apoptosis, accompanied by sustained activation of all three MAP kinase subfamilies. The SB203580, a p38 MAP kinase inhibitor, reduced indomethacin-induced cell death by 43%, while PD098059, a MAPK/ERK kinase (MEK)1 inhibitor, did not affect cell death. p38 MAP kinase and caspase-3 activation were not significantly interlinked in indomethacin-induced apoptosis. From these results, we conclude that NSAIDs can induce prolonged activation of MAP kinases in colon cancer cells and that, of these, p38 MAP kinase may play a partial but significant role in indomethacin-induced apoptosis.

Clinical and economic impact of adverse drug reactions in hospitalized patients

OBJECTIVE

To identify the classes of drugs that most commonly cause adverse drug reactions (ADRs) and the characteristics of these ADRs and to determine the economic impact of ADRs on patients' length of stay and hospitalization costs.

METHODS

Data on ADRs from patients admitted to a hospital in New Jersey were collected, studied, and analyzed over a five-month period. To determine the economic impact of ADRs, patients who experienced ADRs during hospitalization were matched to controls. Each ADR was rated with regard to its severity, the patients' outcomes were determined, and specific classes of medications were identified as particularly causative of ADRs.

RESULTS

A total of 196 patients experienced ADRs; 131 of these individuals were matched with 1338 patients who did not experience an ADR, based on their diagnosis-related group code. The leading causal drugs according to therapeutic class were antiinfective (17%), cardiovascular (17%), antineoplastic (15%), and analgesics/antiinflammatory agents (15%). The organ systems most often affected were gastrointestinal (24%), dermatologic (19%), and immune systems (15%). The mean length of stay per patient differed significantly between the ADR case group and matched control group (10.6 vs. 6.8 d; p = 0.003), as did the total hospitalization cost ($22775 vs. $17292; p = 0.025).

CONCLUSIONS

Length of hospital stay and total hospitalization costs were significantly higher for patients experiencing ADRs than those who did not experience ADRs. ADR reporting systems in hospitals need to be changed and strengthened to decrease the incidence of avoidable reactions.

Influence of apolipoprotein E genotype on lipid and lipoprotein levels in continuous ambulatory peritoneal dialysis patients

Apolipoprotein (Apo) E has an important role in triglyceride (TG)-rich lipoprotein metabolism, and the genotype of Apo E is associated with premature coronary artery disease. Patients undergoing continuous ambulatory peritoneal dialysis (CAPD) develop various abnormalities of lipid metabolism and are prone to develop accelerated atherosclerosis. To investigate the distribution of Apo E genotype, and to evaluate the influence of Apo E polymorphism on lipid metabolism in CAPD patients, we measured Apo E genotypes, serum lipid, and lipoprotein levels in 54 CAPD patients (M:F = 1:1). The most common genotype of Apo E in the CAPD patients was E 3/3, found in 68.5%. The frequencies of the other genotypes were E 2/3, found in 14.8%, and E 4/3, found in 16.7%. No genotypic differences in Apo E were seen in the patients with regard to the presence of diabetes, the level of parathyroid hormone, or the transport characteristics of the peritoneal membrane. When comparing lipid levels by Apo E genotype, the total cholesterol and TG levels of E 2/3 patients were significantly higher than those of E 3/3 or E 4/3 patients. The differences in high-density or low-density lipoprotein cholesterol levels by Apo E genotype were not significant. In comparing lipoprotein levels by Apo E genotype, the Apo B and lipoprotein (a) levels of E 2/3 patients were significantly lower than those of E 3/3 or E 4/3 patients. In conclusion, the Apo E 3/3 genotype seems to be the most common genotype in CAPD patients, and the Apo E 2/3 genotype appears to be associated with high cholesterol and TG levels. These results demonstrate the need for further prospective studies in these subjects aimed at elucidating the impact of genetic variation at the Apo E locus on the development of atherosclerosis.

The prevalence and associated risk factors of renal artery stenosis in patients undergoing cardiac catheterization

Renal artery stenosis may be a cause of hypertension and a potential contributor to progressive renal insufficiency. However, the prevalence of renal artery disease in a general population is poorly defined. The purposes of this study were to evaluate the prevalence of angiographically-determined renal artery narrowing in a patient population undergoing routine cardiac catheterization, and to identify the risk factors for renal artery stenosis. After left ventriculography, abdominal aortography was performed to screen for the presence of renal artery stenosis. A total of 427 patients (274 males, 153 females) were studied and the mean age was 59 years. Renal artery narrowing was identified in 10.5% of patients. Significant (> or = 50% diameter narrowing) renal artery stenosis was found in 24 patients (5.6%) and insignificant stenosis was found in 21 patients (4.9%). Significant unilateral stenosis was present in 4.2% of patients and bilateral stenosis was present in 1.4%. The stem of the renal artery was a more common site of stenosis in 62.2% of patients than in the ostium (37.8%), but the severity of stenosis was not significantly different according to the site of stenosis. By univariate and multivariate logistic regression analysis, the association of clinical variables with renal artery stenosis was assessed. Multivariable predictors included age, hypertension and peripheral vascular disease (p < 0.05). The variables such as sex, smoking history, hyperlipidemia, renal insufficiency, as well as the presence of obesity, severity of coronary heart disease and D.M., were not associated. In conclusion, the prevalence of angiographically-determined renal artery narrowing in a patient population undergoing cardiac catheterization is 10.5%. Old age, hypertension and evidence of peripheral vascular disease represent the predictors of renal artery stenosis.

Current status of peritoneal dialysis in Korea: efforts to achieve optimal outcome

Since its introduction in 1981, peritoneal dialysis (PD) has become firmly established as an effective mode of renal replacement therapy and serves an increasing patient population in Korea. The latest registry data indicate that about 3700 end-stage renal disease patients are maintained on chronic PD, representing 24.1% of the country's dialysis population. The majority (93.3%) of these patients are on continuous ambulatory peritoneal dialysis (CAPD) using the two-bag disconnect system, while only 3.3% are on automated PD. Under current renal reimbursement policies, most dialysis patients have to pay 20% of dialysis fees. Thus CAPD patients on 4 x 2-L daily exchanges pay about US$200 per month, not including medication and travel costs. Traditionally, most PD centers in Korea have used the "standard" prescription of 4 exchanges of 2 L of solution for most of their patients. A recent survey of 1467 patients who commenced CAPD in 1997 revealed that 84% of these patients were initially prescribed 4 x 2-L exchanges, while 12% were given a daily volume of 6 L. With this standard prescription, the percentages of Korean CAPD patients initially achieving the adequacy target of Kt/V urea > or = 2.0 and standardized creatinine clearance (SCCr) > or = 60 L/week/1.73 m2, were 74.4% and 82.1%, respectively. It is likely that, among current Korean CAPD patients, a much lower percentage will achieve the clearance targets compared to this initial outcome, but the precise data are not available. However, it is not clear whether the levels of small-solute clearance recommended for optimal PD outcomes, and proposed by the NKF-DOQI guidelines, will bring the expected benefits to Korean patients. Overall survival of Korean PD patients appears to be as good as, or even better than, that in most other countries. Recently, a single large PD center reported patient survival of 92.1%, 85.6%, 81.4%, and 67.6% at 1, 2, 3, and 5 years respectively. Other centers also reported similar outcomes. As in other countries, cardiovascular deaths predominate among Korean patients: death was due to cardiac causes in 29%, to vascular causes in 21%, and to infectious causes in 24%. Peritonitis is the most important barrier to prolonged use of CAPD in Korea, and more PD patients transfer to hemodialysis because of peritonitis than in other countries. To further reduce the morbidity and mortality of Korean PD patients, various control measures need to be implemented that can reduce or prevent peritonitis and other infectious complications. Also, to further improve long-term patient outcome, Korean nephrologists need to establish and practice optimal clearance targets in the chronic care of these patients.

Renal osteodystrophy in pre-dialysis patients: ethnic difference?

The purpose of the present study is to investigate whether an ethnic difference exists in the incidence of renal osteodystrophy between Asian and Western countries in end-stage renal disease (ESRD) patients. We evaluated bone histology in 58 pre-dialysis patients (28 male, 30 female; mean age: 47.7 years). All patients had bone biopsies with quantitative histomorphometry and serological parameters such as intact PTH, osteocalcin, total alkaline phosphatase, and basal and deferoxamine-stimulated serum aluminum levels. We observed that 91.4% of all evaluated patients showed renal osteodystrophy before the start of dialytic therapy. Mild osteitis fibrosa were observed in 21 patients (36.2%), severe osteitis fibrosa in 5 patients (8.6%), mixed lesions in 7 patients (12.1%), osteomalacia in 6 patients (10.3%), aplastic bone disease in 14 patients (24.1%), and normal bone in 5 patients (8.6%). Among the bone histomorphometric parameters, fibrosis area rate (%) showed the best correlation with intact PTH, and osteocalcin and osteoid area rate (%) with total alkaline phosphatase. Aluminum-related bone disease was not observed. Among patients with aplastic bone disease, only 14.3% showed aluminum deposition of any significance (5% < stainable bone surface aluminum < 25%). In the diabetic patients, aplastic bone disease was most common, but no case was related to aluminum intoxication. In conclusion, the distribution of renal osteodystrophy in our study was different from that of Western countries in pre-dialysis patients. Our patients tended to have more mild-form osteitis fibrosa and normal findings, and less severe-form osteitis fibrosa and aplastic bone disease. Aluminum-related bone disease was not observed.

Risk factors influencing the decline of residual renal function in continuous ambulatory peritoneal dialysis patients

OBJECTIVE

To assess the nature of the decline in residual renal function (RRF) after the initiation of peritoneal dialysis, and to identify risk factors influencing the preservation of RRF.

DESIGN

A retrospective single-center study.

SETTING

Tertiary medical center.

PATIENTS

Eighty patients who were clinically stable and had been on continuous ambulatory peritoneal dialysis (CAPD) for a minimum of 6 months.

MAIN OUTCOME MEASURES

All subjects had at least three measurements of RRF, which was calculated as the average of creatinine clearance (Ccr) and urea clearance from a 24-hour urine collection. All measurements of RRF were plotted on a logarithmic scale and a linear scale against the duration of CAPD. Covariables used in the correlation analyses were age, sex, the presence of diabetes mellitus, mean blood pressure, mean diastolic blood pressure, hematocrit and Ccr at the start of peritoneal dialysis, peritoneal membrane transport characteristics by peritoneal equilibration test (PET), and the rate of peritonitis.

RESULTS

A significant correlation was found between CAPD duration and RRF decline represented on a logarithmic scale with a correlation coefficient (r) of 0.355 (p < 0.001). In contrast, on a linear scale, the correlation coefficient was only 0.273 (p < 0.01). By linear multiple regression analysis, the only independent risk factor for the decline of RRF was the rate of peritonitis (r = -0.446, p < 0.001).

CONCLUSION

These results suggest that RRF declines exponentially rather than linearly with time, and that the rate of peritonitis is an independent risk factor for the decline of RRF in CAPD patients.

Serum C-reactive protein: a predictor of mortality in continuous ambulatory peritoneal dialysis patients

OBJECTIVE

To evaluate the predictive value of a single baseline serum C-reactive protein (sCRP) as a marker of mortality in continuous ambulatory peritoneal dialysis (CAPD) patients.

DESIGN

A review of prospectively collected data in a 2-year follow-up study.

SETTING

Tertiary medical center.

PATIENTS

The study included 106 patients who were stable and had been on CAPD for a minimum of 3 months.

MAIN OUTCOME MEASURES

Patient survival rate was the main outcome measure of this study. Other outcome measures were technique survival rate, peritonitis rate, and hospitalized days. Covariables used in the survival analysis were age, sex, the presence of cardiovascular disease or diabetes mellitus, sCRP, serum albumin, hematocrit, cholesterol, HDL-cholesterol, malnutrition by subjective global assessment (SGA), weekly Kt/V urea, and weekly standardized creatinine clearance (SCCr).

RESULTS

The 2-year patient survival rate was significantly lower in the increased sCRP group than in the normal sCRP group (66.7% vs 94.1%, p = 0.001), although there was no significant difference in technique failure, peritonitis rate, and hospitalized days between the two groups. By Cox proportional hazards analysis, independent predictors of mortality were: cardiovascular disease (relative risk, RR = 8.96, p < 0.005); increased sCRP level (RR = 1.19, p < 0.05); and high hematocrit (RR = 1.18, p < 0.05).

CONCLUSION

Serum CRP at enrollment is an independent predictor of 2-year patient survival in CAPD patients.

Interleukin-1 beta, -6 and interferon-gamma productions in patients undergoing continuous ambulatory peritoneal dialysis

In order to investigate cytokine productions in patients undergoing continuous ambulatory peritoneal dialysis (CAPD), we studied the production of interleukin (IL)-1 beta, -6 and interferon (IFN)-gamma by cultured peripheral blood mononuclear cells (PBMC) in peritonitis-free CAPD patients. The correlation of cytokine production with plasma parathyroid hormone (PTH) and albumin levels was also evaluated. While the release of IL-1 beta was not markedly different from controls release of IL-6 from 24-hour cultured PBMCs was significantly greater than that of controls, (Mean +/- S.D., IL-6: 2186.8 +/- 1217.9 pg/ml, vs 1516.3 +/- 767.9, p < 0.05). The addition of lipopolysaccharide (LPS, 10 micrograms/ml, significantly stimulated IL-1 beta and -6 production of PBMCs in CAPD patients and controls, compared to an unstimulated condition. The LPS-induced IL-1 beta production was also not markedly different from controls, whereas LPS-induced IL-6 production was significantly higher than controls (IL-6: 13,220.7 +/- 7177.4 vs 7411.4 +/- 1236.9, p < 0.05). However, the percentage increases of IL-6 production stimulated with LPS in CAPD patients were not significantly different from controls (p > 0.05). No difference of baseline IFN-gamma was detected between CAPD patients controls, but phytohemagglutinin (PHA, 10 micrograms/ml)-stimulated IFN-gamma release was significantly higher in CAPD patients than controls (2425.9 +/- 1565.0 pg/ml vs 1364.0 +/- 755.1, p < 0.05). There was no significant correlation between PTH and, IL-1 beta, serum albumin level and LPS-stimulated IL-6 production (r = 0.54, p < 0.05). In conclusion, CAPD seems to partly induce activation of PBMCs with an enhanced release of IL-6 and IFN-gamma, and CAPD patients with higher serum albumin levels tend to show higher IL-6 production in immune response.

Hepatitis G virus infection in hemodialysis and continuous ambulatory peritoneal dialysis patients

To determine the prevalence and clinical relevance of HGV infection in dialysis patients, we performed a cross-sectional study of 61 HD patients and 79 Continuous Ambulatory Peritoneal Dialysis (CAPD) patients. HGV-RNA was identified by reverse-transcription (RT) polymerase chain reaction (PCR) assay with primers from the 5'-untranslated region of the viral genome. The prevalence of HGV infection was similar in HD and CAPD patients (9.8% vs. 12.7%), while that of HCV infection was significantly higher in HD patients compared to CAPD patients (16.4% vs. 1.3%, p < 0.05). The mean age (49.2 +/- 13.4 vs. 46.7 +/- 13.0 years), male to female ratio (2.4:1 vs. 1.3:1), history of transfusion (62.3% vs. 49.4%), history of hepatitis (27.9% vs. 26.6%), mean ALT level during the previous 6 months (22.4 +/- 37.9 vs. 14.0 +/- 7.4 IU/L), and the prevalence of HBsAg (8.2% vs. 6.3%) showed no difference between HD and CAPD patients. In both HD and CAPD patients, the presence of HGV RNA was not related to age, sex, duration of dialysis, history of transfusion, history of hepatitis, or to the presence of HBV or HCV markers. There was no significant difference in the clinical and biochemical data between patients with isolated HGV infection (n = 12) and patients without viremia (n = 106). The clinical feature of patients coinfected with HGV and HBV (n = 2), or HGV and HCV (n = 2) seemed to be similar to those of patients with isolated HBV (n = 8) or HCV (n = 9) infection. In conclusion, the prevalence of HGV infection was not different between HD and CAPD patients, and HGV infections did not seem to be associated with clinically significant hepatitis. The routes of HGV transmission, other than transfusion or contamination during HD procedure, were suspected.

The changing patterns of liver abscess during the past 20 years--a study of 482 cases

The diagnostic and treatment modalities of liver abscess have developed rapidly over the past few years but morbidity and mortality has not been markedly reduced. A total of 482 cases of liver abscess admitted to the Yonsei Medical Center over the past 20 years (Jan. 1971-Dec. 1990) were divided into 261 cases from the 1970s and 221 cases from the 1980s and the clinical and laboratory parameters were analyzed comparatively to determine if the clinical features, therapies and prognosis of liver abscess had changed. The proportion of amebic relative to pyogenic liver abscess decreased. Transbiliary infections increased in pyogenic liver abscess of the 1980s. Clinical signs such as jaundice and hepatomegaly and symptom duration before admission decreased. Abnormal laboratory features including hypoalbuminemia and elevation of alkaline phosphatase decreased and increased, respectively, in the 1980s. Ultrasonically guided percutaneous aspiration was the choice of treatment instead of surgical drainage in the 1980s. Despite diagnostic and therapeutic advances in the management of liver abscess, the prognosis has not improved in the 1980s as compared to the 1970s. This may reflect an increase in the incidence of liver abscess in old aged patients and patients with diabetes mellitus or underlying malignancy in the 1980s.

Differential effect of HTLV infection and HTLV Tax on interleukin 3 expression

To characterize the interactions between human T-cell leukemia virus (HTLV) infection and cellular gene expression, we examined the expression of the lymphokine interleukin 3 (IL-3) in the presence and absence of HTLV infection. IL-3, like granulocyte-macrophage colony-stimulating factor (GM-CSF), is produced by activated but not resting T cells, but although GM-CSF is constitutively expressed in HTLV-infected T cells IL-3 mRNA cannot be detected in either unstimulated or mitogen-stimulated HTLV-infected cells by polymerase chain reaction (PCR) analysis. In contrast, transient co-transfection studies with an IL-3 promoter-CAT reporter gene and an HTLV-II Tax expression construct demonstrate that Tax can transactivate the IL-3 promoter in HTLV-uninfected T cells. To determine whether differences in IL-3 promoter-binding proteins present in HTLV-infected and uninfected T cells account for this discrepancy, DNAase I footprinting of the IL-3 promoter was performed. Although crude nuclear extracts from both cell types protected the IL-3 sequences located between base pairs -168 and -125, the sequences between -125 and -103, which contain the lymphokine consensus sequences CK-1 and CK-2, were protected by extracts from HTLV-infected but not HTLV-uninfected T cells. Deletion of the region containing the CK-1 and CK-2 sequences from an IL-3 promoter CAT construct resulted in a sixfold rise in promoter activity in HTLV-infected but not uninfected T-cell lines, indicating that this region participates in the repression of IL-3 gene expression in HTLV-infected T cells.