Nighttime Outdoor Artificial Light and Risk of Age-Related Macular Degeneration

Importance

Light pollution's impact on human health is increasingly recognized, but its link to exudative age-related macular degeneration (EAMD) remains unclear.

Objective

To investigate the association between exposure to outdoor artificial light at night (OALAN) and the risk of incident EAMD.

Design, Setting, and Participants

In this nationwide population-based case-control study, all individuals 50 years or older with newly diagnosed EAMD between January 1, 2010, and December 31, 2011, were identified with reference to the Korean National Health Insurance Service registration program database for rare and intractable diseases. Birth year- and sex-matched controls (with no EAMD diagnosis until 2020) were selected at a 1:30 ratio. Data were acquired from May 1 to December 31, 2021, and analyzed from June 1 to November 30, 2022.

Exposures

Mean levels of OALAN at participants' residential addresses during 2008 and 2009 were estimated using time-varying satellite data for a composite view of persistent nighttime illumination at an approximate scale of 1 km2.

Main Outcomes and Measures

The hazard ratios (HRs) and 95% CIs of the association between residential OALAN and risk of incident EAMD were determined based on maximum likelihood estimation after adjusting for sociodemographic characteristics, comorbidities, and area-level risk factors (ie, nighttime traffic noise and particulate matter of aerodynamic diameter ≤10 μm in each participant's administrative district of residence).

Results

A total of 126 418 participants were included in the analysis (mean [SD] age, 66.0 [7.9] years; 78 244 men [61.9%]). Of these, 4078 were patients with newly diagnosed EAMD and 122 340 were EAMD-free matched controls. In fully adjusted models, an IQR (55.8 nW/cm2/sr) increase in OALAN level was associated with an HR of 1.67 (95% CI, 1.56-1.78) for incident EAMD. The exposure-response curve demonstrated a nonlinear, concave upward slope becoming more pronounced at higher levels of light exposure (ie, at approximately 110 nW/cm2/sr). In a subgroup analysis, an IQR increase in OALAN was associated with increased risk of incident EAMD in urban areas (HR, 1.46 [95% CI, 1.33-1.61]) but not in rural areas (HR, 1.01 [95% CI, 0.84-1.22]).

Conclusions and Relevance

In this nationwide population-based case-control study, higher levels of residential OALAN were associated with an increased risk of incident EAMD. Future studies with more detailed information on exposure, individual adaptive behaviors, and potential mediators are warranted.

Low-dose aspirin in the primary prevention of cardiovascular diseases: A retrospective, propensity score matched study

BACKGROUND AND AIMS

Although the guidelines have been revised recently, the effect of aspirin for the primary prevention of cardiovascular disease (CVD) is still controversial. Thus, we aimed to evaluate the effect of aspirin on primary prevention in the real world.

METHODS

Among the 4,266,268 participants without a history of CVD or previous prescription of aspirin and other antiplatelet agents who were screened between 2002 and 2008, 268,963 persons who were prescribed low-dose aspirin (≤100 mg/day) over 90 days in 2002-2008 and 1,075,852 persons who did not receive aspirin were selected after propensity score matching. A Cox proportional-hazards model was used to evaluate the effect of low-dose aspirin on the development of CVD and bleeding episodes.

RESULTS

Aspirin showed a protective effect on total CVD events (hazard ratio (HR); 0.737, 95% confidence interval; 0.729-0.745). The protective effect of aspirin on total CVD events was significant in men, women and even in young participants (<65 years). Aspirin had a protective effect in participants with diabetes or hypertension against all subcategories of CVD. The HR of bleeding risk was 1.4-1.5 in aspirin group.

CONCLUSIONS

Low-dose aspirin generally showed a protective effect against CVD regardless of age, sex, and underlying comorbidities in the real world. Though, the effect of aspirin was evident at a young age, the risk of bleeding was also high (1.4-1.5 times), and thus, careful prescription is required.

Comparison of dominant and nondominant C3 deposition in primary glomerulonephritis

BACKGROUND

Alternative complement pathway dysregulation plays a key role in glomerulonephritis (GN) and is associated with C3 deposition. Herein, we examined pathological and clinical differences between cases of primary GN with C3-dominant (C3D-GN) and nondominant (C3ND-GN) deposition.

METHODS

We extracted primary GN data from the Korean GlomeruloNEphritis sTudy (KoGNET). C3D-GN was defined as C3 staining two grades greater than C1q, C4, and immunoglobulin via immunofluorescence analysis. To overcome a large difference in the number of patients between the C3D-GN and C3ND-GN groups (31 vs. 9,689), permutation testing was used for analysis.

RESULTS

The C3D-GN group exhibited higher serum creatinine (p ≤ 0.001), a greater prevalence of estimated glomerular filtration rate of &lt;60 mL/min/1.72 m2 (p ≤ 0.001), higher (but not significantly so) C-reactive protein level, and lower serum C3 level (p ≤ 0.001). Serum albumin, urine protein/creatinine ratio, number of patients who progressed to end-stage renal disease, and all-cause mortality were comparable between groups. Interstitial fibrosis and mesangial cellularity were greater in the C3D-GN group (p = 0.04 and p = 0.01, respectively) than in the C3ND-GN group. C3 deposition was dominant in the former group (p &lt; 0.001), in parallel with increased subendothelial deposition (p ≤ 0.001).

CONCLUSION

Greater progression of renal injury and higher mortality occurred in patients with C3D-GN than with C3ND-GN, along with pathologic differences in interstitial and mesangial changes.

Shift to a Younger Age and Regional Differences in Inflammatory Bowel Disease in Korea: Using Healthcare Administrative Data

BACKGROUND

Research using healthcare administrative data with a validated algorithm can reveal the real-world data of rare diseases.

AIMS

We investigated an accurate algorithm for detecting incident cases of inflammatory bowel disease (IBD) from healthcare data and analyzed the nationwide population-based epidemiological features in Korea.

METHODS

Healthcare data from Songpa-Kangdong districts in Seoul were extracted from the National Health Insurance Service and analyzed to identify the best algorithm reflecting the cohort data. The most accurate criterion was applied to the entire database for further analysis.

RESULTS

With the selected working criteria, 37,555 incident cases of IBD (Crohn's Disease [CD], 13,130; ulcerative colitis [UC], 24,425) were identified from 2005 to 2016. The male-to-female ratio was 2.5:1 for CD and 1.4:1 for UC. Over 12 years, the annual standardized incidence rate (SIR) per 100,000 people increased from 1.6 to 2.7 and 3.8 to 4.3 for CD and UC, respectively. The peak age at diagnosis of UC shifted from 55-59 years to 20-24 years, whereas that of CD shifted from 19 to 17 years. The SIR of CD was higher in metropolitan areas than in non-metropolitan areas.

CONCLUSIONS

This nationwide population-based epidemiologic study of Korean IBD revealed a gradual increase in the incidence rates and a notable shift toward younger age at diagnosis. Males were predominant in both CD and UC. There was an urban-rural difference in the SIR of CD.

Spatial autocorrelation may bias the risk estimation: An application of eigenvector spatial filtering on the risk of air pollutant on asthma

Air pollutants are major risk factors for respiratory diseases, particularly asthma, socially and spatially correlated. Many existing environment-asthma-related studies, however, have evaluated the impact of crude trends at the largest district level, which accounts only for temporal effects and may produce biased results with spatial autocorrelation. This study aimed to investigate how the spatial autocorrelation affects the air pollution effect estimations (sulfur dioxide [SO₂], nitrogen dioxide [NO₂], carbon monoxide [CO], and particulate matter [PM₁₀]) on daily asthma emergency department (ED) visits in two metropolitan areas in Korea (Seoul Metropolitan Area [SMA] and Busan Metropolitan City, Ulsan Metropolitan City, Gyeongsangnamdo [BUG]). We applied eigenvector spatial filter (ESF) to the spatio-temporal model to remove spatial autocorrelation and distributed lag nonlinear model (DLNM) to explore nonlinear patterns between air pollutant concentration and lagged days on the three models including aggregated model (a temporal model), spatial model without ESF, and spatial model with ESF (both are spatio-temporal models). The effect of SO₂ was not statistically significant for asthma ED visits in the aggregated model for SMA (cumulative relative risks [CRR] = 0.99, confidence intervals [CI]: 0.93-1.05), while the effect was statistically significant in the spatial model with ESF (CRR = 1.10, CI: 1.08-1.12). NO₂ and CO were positively correlated to asthma ED visits in the spatial model without ESF (CRR = 0.84, CI: 0.81-0.86; 0.91, 0.89-0.94, respectively), but the spatial model with ESF showed significant risks (CRR = 1.21, CI: 1.18-1.24; 1.13, 1.11-1.16). Moreover, the spatial model with ESF successfully removed spatial autocorrelation (P-values for Moran's I 0.83-0.98) and demonstrated the highest model fit (McFadden's pseudo R² 0.42-0.43 for SMA and 0.26-0.27 for BUG) among the three models. Our findings demonstrate how ESF can be introduced into spatial correlation to remove bias and construct more reliable models.

Transoesophageal echocardiographic evaluation of central venous catheter positioning using Peres' formula or a radiological landmark-based approach: a prospective randomized single-centre study

BACKGROUND

The lower superior vena cava (SVC), near its junction with the right atrium (RA), is considered the ideal location for the central venous catheter tip to ensure proper function and prevent injuries. We determined catheter insertion depth with a new formula using the sternoclavicular joint and the carina as radiological landmarks, with a 1.5 cm safety margin. The accuracy of tip positioning with the radiological landmark-based technique (R) and Peres' formula (P) was compared using transoesophageal echocardiography.

METHODS

Real-time ultrasound-guided central venous catheter insertion was done through the right internal jugular or subclavian vein. Patients were randomly assigned to either the P group (n=93) or the R group (n=95). Optimal catheter tip position was considered to be within 2 cm above and 1 cm below the RA-SVC junction. Catheter tip position, abutment, angle to the vascular wall, and flow stream were evaluated on a bicaval view.

RESULTS

The distance from the skin insertion point to the RA-SVC junction and determined depth of catheter insertion were more strongly correlated in the R group [17.4 (1.2) and 16.7 (1.5) cm; r=0.821, P<0.001] than in the P group [17.3 (1.2) and 16.4 (1.1) cm; r=0.517, P<0.001], with z=3.96 (P<0.001). More tips were correctly positioned in the R group than in the P group (74 vs 93%, P=0.001). Abutment, tip angle to the lateral wall >40°, and disrupted flow stream were comparable.

CONCLUSIONS

Catheter tip position was more accurate with a radiological landmark-based technique than with Peres' formula.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registry of Korea: https://cris.nih.go.kr/cris/index.jsp KCT0001937.

Racial disparities in prostate cancer outcome among prostate-specific antigen screening eligible populations in the United States

Background

In 2012, the United States Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA) screening, despite evidence that Black men are at a higher risk of prostate cancer-specific mortality (PCSM). We evaluated whether Black men of potentially screening-eligible age (55-69 years) are at a disproportionally high risk of poor outcomes.

Patients and methods

The SEER database was used to study 390 259 men diagnosed with prostate cancer in the United States between 2004 and 2011. Multivariable logistic regression modeled the association between Black race and stage of presentation, while Fine-Gray competing risks regression modeled the association between Black race and PCSM, both as a function of screening eligibility (age 55-69 years versus not).

Results

Black men were more likely to present with metastatic disease (adjusted odds ratio [AOR] 1.65; 1.58-1.72; P < 0.001) and were at a higher risk of PCSM (adjusted hazard ratio [AHR] 1.36; 1.27-1.46; P < 0.001) compared to non-Black men. There were significant interactions between race and PSA-screening eligibility such that Black patients experienced more disproportionate rates of metastatic disease (AOR 1.76; 1.65-1.87 versus 1.55; 1.47-1.65; Pinteraction < 0.001) and PCSM (AHR 1.53; 1.37-1.70 versus 1.25; 1.14-1.37; Pinteraction = 0.01) in the potentially PSA-screening eligible group than in the group not eligible for screening.

Conclusions

Racial disparities in prostate cancer outcome among Black men are significantly worse in PSA-screening eligible populations. These results raise the possibility that Black men could be disproportionately impacted by recommendations to end PSA screening in the United States and suggest that Black race should be included in the updated USPSTF PSA screening guidelines.

Medical androgen deprivation therapy and increased non-cancer mortality in non-metastatic prostate cancer patients aged ≥66 years

PURPOSE

To examine the potential relationship between androgen deprivation therapy and other-cause mortality (OCM) in patients with prostate cancer treated with medical primary-androgen deprivation therapy, prostatectomy, or radiation.

METHODS

A total of 137,524 patients with non-metastatic PCa treated between 1995 and 2009 within the Surveillance Epidemiology and End Results Medicare-linked database were included. Cox-regression analysis tested the association of ADT with OCM. A 40-item comorbidity score was used for adjustment.

RESULTS

Overall, 9.3% of patients harbored stage III-IV disease, and 57.7% of patients received ADT. The mean duration of ADT exposure was 22.9 months (median: 9.1; IQR: 2.8-31.5). Mean and median follow-up were 66.9, and 60.4 months, respectively. At 10 years, overall-OCM rate was 36.5%; it was 30.6% in patients treated without ADT vs. 40.1% in patients treated with ADT (p < 0.001). In multivariable-analysis, ADT was associated with an increased risk of OCM (Hazard-ratio [HR]: 1.11, 95% Confidence-interval [95% CI]: 1.08-1.13). Patients with no comorbidity (10-year OCM excess risk: 9%) were more subject to harm from ADT than patients with high comorbidity (10-year OCM excess risk: 4.7%).

CONCLUSIONS

In patients with PCa, treatment with medical ADT may increase the risk of mortality due to causes other than PCa. Whether this is a simple association or a cause-effect relationship is unknown and warrants further study in prospective studies.

Perioperative outcomes and hospital reimbursement by type of radical prostatectomy: results from a privately insured patient population

BACKGROUND

With the increasing use of robotic surgery in the United States, the comparative effectiveness and differences in reimbursement of minimally invasive radical prostatectomy (MIRP) and open prostatectomy (ORP) in privately insured patients are unknown. Therefore, we sought to assess the differences in perioperative outcomes and hospital reimbursement in a privately insured patient population who were surgically treated for prostate cancer.

METHODS

Using a large private insurance database, we identified 17,610 prostate cancer patients who underwent either MIRP or ORP from 2003 to 2010. The primary outcomes were length of stay (LOS), perioperative complications, 90-day readmissions rates and hospital reimbursement. Multivariable regression analyses were used to evaluate for differences in primary outcomes across surgical approaches.

RESULTS

Overall, 8981 (51.0%) and 8629 (49.0%) surgically treated prostate cancer patients underwent MIRP and ORP, respectively. The proportion of patients undergoing MIRP markedly rose from 11.9% in 2003 to 72.5% in 2010 (P<0.001 for trend). Relative to ORP, MIRP was associated with a shorter median LOS (1.0 day vs 3.0 days; P<0.001) and lower adjusted odds ratio of perioperative complications (OR: 0.82; P<0.001). However, the 90-day readmission rates of MIRP and ORP were similar (OR: 0.99; P=0.76). MIRP provided higher adjusted mean hospital reimbursement compared with ORP (US $19,292 vs. US $17,347; P<0.001).

CONCLUSIONS

Among privately insured patients diagnosed with prostate cancer, robotic surgery rapidly disseminated with over 70% of patients undergoing MIRP by 2009-2010. Although MIRP was associated with shorter LOS and modestly better perioperative outcomes, hospitals received higher reimbursement for MIRP compared with ORP.

The effect of age at diagnosis on prostate cancer mortality: a grade-for-grade and stage-for-stage analysis

OBJECTIVE

To evaluate the effect of advancing age on cancer-specific mortality (CSM) after radical prostatectomy (RP).

MATERIALS AND METHODS

Overall, 205,551 patients with PCa diagnosed between 1988 and 2009 within the Surveillance Epidemiology and End Results (SEER) database were included in the study. Patients were stratified according to age at diagnosis: ≤ 50, 51-60, 61-70, and ≥ 71 years. The 15-year cumulative incidence CSM rates were computed. Competing-risks regression models were performed to test the effect of age on CSM in the entire cohort, and for each grade (Gleason score 2-4, 5-7, and 8-10) and stage (pT2, pT3a, and pT3b) sub-cohorts.

RESULTS

Advancing age was associated with higher 15-year CSM rates (2.3 vs. 3.4 vs. 4.6 vs. 6.3% for patients aged ≤ 50 vs. 51-60 vs. 61-70 vs. ≥ 71 years, respectively; P < 0.001). In multivariable analyses, age at diagnosis was a significant predictor of CSM. This relationship was also observed in sub-analyses focusing on patients with Gleason score 5-7, and/or pT2 disease (all P ≤ 0.05). Conversely, age failed to reach the independent predictor status in men with Gleason score 2-4, 8-10, pT3a, and/or pT3b disease.

CONCLUSIONS

Advancing age increases the risk of CSM. However, when considering patients affected by more aggressive disease, age was not significantly associated with higher risk of dying from PCa. In high-risk patients, tumor characteristics rather than age should be considered when making treatment decisions.

Continuous neuronal ensemble control of simulated arm reaching by a human with tetraplegia

Functional electrical stimulation (FES), the coordinated electrical activation of multiple muscles, has been used to restore arm and hand function in people with paralysis. User interfaces for such systems typically derive commands from mechanically unrelated parts of the body with retained volitional control, and are unnatural and unable to simultaneously command the various joints of the arm. Neural interface systems, based on spiking intracortical signals recorded from the arm area of motor cortex, have shown the ability to control computer cursors, robotic arms and individual muscles in intact non-human primates. Such neural interface systems may thus offer a more natural source of commands for restoring dexterous movements via FES. However, the ability to use decoded neural signals to control the complex mechanical dynamics of a reanimated human limb, rather than the kinematics of a computer mouse, has not been demonstrated. This study demonstrates the ability of an individual with long-standing tetraplegia to use cortical neuron recordings to command the real-time movements of a simulated dynamic arm. This virtual arm replicates the dynamics associated with arm mass and muscle contractile properties, as well as those of an FES feedback controller that converts user commands into the required muscle activation patterns. An individual with long-standing tetraplegia was thus able to control a virtual, two-joint, dynamic arm in real time using commands derived from an existing human intracortical interface technology. These results show the feasibility of combining such an intracortical interface with existing FES systems to provide a high-performance, natural system for restoring arm and hand function in individuals with extensive paralysis.

Predictors of idiopathic thrombocytopenic purpura in pregnant women presenting with thrombocytopenia

OBJECTIVE

Idiopathic thrombocytopenic purpura (ITP) and gestational thrombocytopenia (GT) are common causes of thrombocytopenia during pregnancy. Despite an ever-increasing experience with these disorders, differentiation between the two entities still remains a diagnostic challenge. The current study attempted to identify the antenatal predictors of ITP for pregnant women.

METHODS

Between January 1999 and June 2005, a total of 58 pregnant women with a presumptive diagnosis of either ITP or GT were recruited for the study. All of them had platelet counts of less than 100 x 10(9)/L. The predictors of ITP were evaluated by comparison between the two disorders.

RESULTS

The detection of thrombocytopenia prior to 28 weeks of gestation and platelet counts <50 x 10(9)/L at its diagnosis remained independently predictive of ITP (P<0.001 and P=0.004, respectively). The combined analysis of these two factors provided a 96.0% sensitivity and a specificity of 75.8%.

CONCLUSION

The onset time of thrombocytopenia and platelet count at its presentation remain the strongest predictors of ITP for pregnant women. The combination model using these factors may be useful for the early prediction of ITP.

Supportive management of pregnancy-associated aplastic anemia

OBJECTIVE

To examine maternal and fetal outcomes of pregnancy-associated aplastic anemia treated with supportive care.

METHODS

From January 1995 to December 2004, 14 women newly diagnosed as having pregnancy-associated aplastic anemia were recruited for the study.

RESULTS

Diagnosis was made during the second or third trimester for 11 (78%) of the 14 patients, and 3 of the 8 severe cases of aplastic anemia were diagnosed at initial presentation. All patients had conservative management with transfusions but no specific immunologic or hormonal therapy during pregnancy. Of the 12 women eligible for follow-up, 1 achieved complete remission and 8 achieved partial remission after delivery. The pregnancies progressed uneventfully in most cases.

CONCLUSIONS

This study demonstrated favorable maternal and neonatal outcomes with transfusion support alone for pregnancy-associated aplastic anemia.

Effects of polyhemoglobin-antioxidant enzyme complex on ischemia-reperfusion in kidney

INTRODUCTION

The kidney suffers ischemia-reperfusion (I/R) injury during transplantation. The purpose of the present study was to investigate the therapeutic effect of artificials cells on renal I/R injury through biochemical assays and histological examination.

METHODS

We prepared artificial cells using cross-linked hemoglobin (Hb), superoxide dismutase (SOD), and catalase. Normal male Sprague-Dawley rats were divided into 6 groups: the sham-operated control group, the group treated with polyHb,and the group treated with polyHb-SOD-catalase (PSC) (per groups were subjected to ischemia for 1 hour or 2 hours). After reperfusion for 4 hours, kidney and blood samples were obtained.

RESULTS

The levels of SOD and catalase in the PSC group were 15 and 50 times higher than those of the control group, respectively. In the polyHb group, the levels of blood urea nitrogen (BUN), serum creatinine, renal hydrogen peroxide, and renal malondialdehyde were increased. However, their levels were significantly decreased by PSC administration. Renal SOD activity did not show any significant changes in the polyHb group, but renal catalase activity was decreased by polyHb treatment in comparison with the control group. The activities of renal SOD and catalase were increased using PSC treatment. In the histological findings, the PSC group showed no evidence of acute tubular necrosis in proximal convoluted tubules; their microvilli and cytoplasmic microorganelles were relatively well preserved.

CONCLUSIONS

These results show that PSC effectively reduces renal damage via diminished oxygen free radical-mediated injury after I/R.

Effect of artificial cells on hepatic function after ischemia–reperfusion injury in liver

BACKGROUND

The liver suffers from ischemia/reperfusion injury during transplantation. Reactive oxygen species generated by xanthine oxidase during reperfusion of the ischemic liver may be partially responsible for the hepatic injury. Oxygen free radicals are removed by antioxidant enzymes such as superoxide dismutase (SOD), catalase, and glutathione peroxidase. Using glutaraldehyde and lysine we constructed crosslinked hemoglobin, containing SOD and catalase, and assessed its ability to protect against ischemia/reperfusion injury during transplantation.

METHODS

In contrast to the sham-operated control groups, blood was exchanged using crosslinked hemoglobin (polyHb) a PolyHb-SOD-catalase (PSC) group. After ischemia/reperfusion injury, several parameters of hepatic damage and oxygen free radicals were measured as well as microscopic examination.

RESULTS

Alanine aminotransferase, aspartate aminotransferase, superoxide production, hydrogen peroxide, and malondialdehyde levels were higher among the PolyHb group than sham-operated controls. The PolyHb group revealed a few apoptotic bodies, some acute inflammatory infiltrates in the sinusoids, nuclear fragmentations, cell shrinkage, and chromatin clumping with formation of apoptotic bodies in the apoptotic cells under microscopic examination. Alanine aminotransferase, aspartate aminotransferase, superoxide production, and hydrogen peroxide levels were lower in the PSC than the PolyHb group. Hepatic structures were well preserved in the PSC group.

CONCLUSIONS

Reactive oxygen species contribute to hepatic dysfunction with morphologic changes. PSC is effective to reduce hepatic damage by lowering oxygen free radical-mediated injury after ischemia/reperfusion in the liver.

Ultrastructural evaluation of the protective effect of nitroglycerin in preservation-reperfusion injury of rat lungs

AIM OF STUDY

Nitric oxide (NO) has been reported as a favorable protective supplement in donor lung preservation, but related ultrastructural studies are rare in the literature. This study was performed to assess the ultrastructural changes and to evaluate the protective effect of NO as donor nitroglycerin (NTG) treatment of ischemia-reperfusion injury in rat lungs.

MATERIALS AND METHODS

Fifteen Sprague-Dawley rats weighing 300 to 350 g were used in this study. The NTG group (n = 5) used intravenous administration followed by mixture in the University of Wisconsin (UW) solution. For the non-NTG group (n = 5), we injected the same amount of normal saline intravenously followed by admixture in the UW solution. The heart-lung blocks were removed, weighed, and kept in UW solution for 24 hours at 10 degrees C. Reperfusion using human blood diluted in Krebs-Hensleit solution was done for 60 minutes. For the control group (n = 5), we injected the same amount of normal saline intravenously, and removed the lungs with no preservation and reperfusion procedures.

RESULTS

The non-NTG group showed multiple patchy areas of alveolar collapse with marked swelling and destruction of type I epithelial cells, loss of type II cell surfactant granules, endothelial swelling and papillary projection, interstitial edema, and alveolar macrophages with active phagocytosis of the destroyed materials. The NTG group showed similar ultrastructural changes, but in a lesser severity compared with the non-NTG group.

CONCLUSION

Administration of the NTG reduced the ischemia-reperfusion injury in the rat donor lungs. Ultrastructural examination was an effective tool to evaluate the protective effect of NTG in ischemia-reperfusion procedures of donor lungs.

Elective vs. conservative management of ovarian tumors in pregnancy

OBJECTIVES

To determine optimal management of the ovarian tumors in pregnancy.

METHODS

This study included 89 cases of the ovarian tumor in pregnancy that required surgery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001. Among 89 cases, 36 and 53 were emergency and elective surgery, respectively. Student's t-test and the chi(2)-test were used for statistical analysis and a P-value of <0.05 was considered statistically significant.

RESULTS

The most common size of torsion of ovarian tumors during pregnancy was 6-10 cm and the incidence was the most frequent during the first trimester of pregnancy. The incidence of preterm delivery (<37 weeks) was higher in emergency surgery, but there was no difference in the gestational age at delivery, also no difference in the birth weight or the method of delivery.

CONCLUSIONS

Although surgery for ovarian tumors in pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with that after elective surgery. We propose that conservative management would be used in optimal management of pregnant women with ovarian tumors.

Expression of insulin-like growth factor-II and insulin-like growth factor binding protein-1 in the placental basal plate from pre-eclamptic pregnancies

OBJECTIVES

To determine whether expressions of insulin-like growth factor-II (IGF-II) and insulin-like growth factor binding protein-1 (IGFBP-1) are altered in pre-eclamptic placenta and to elucidate the possible relationship between their expressions and a mechanism for inadequate trophoblast invasion in pre-eclampsia.

METHODS

Placental tissues were obtained at cesarean delivery from five normotensive, nine mild pre-eclamptic and five severe pre-eclamptic women at 33-39 completed weeks of gestation. After total ribonucleic acid was extracted, reverse transcriptase-polymerase chain reaction was performed to determine IGF-II and IGFBP-1 mRNA expression. Product bands were quantitated by scanning densitometry and results were expressed as ratio of cytokines/beta-actin. Western blot analysis was also done to determine IGF-II and IGFBP-1 protein expression. Statistical analysis was determined by Kruskal-Wallis analysis of variance with the Scheffe multiple post-hoc test.

RESULTS

The IGF-II mRNA levels of mild and severe pre-eclamptic placenta were significantly lower than that of uncomplicated placenta (P<0.005, P<0.001, respectively), with the level of severe pre-eclamptic placenta being significantly lower than that of mild pre-eclamptic placenta (P<0.05). As for the IGF-II protein expression, a significant decrease was found among the three groups (P<0.001), correlating with the IGF-II mRNA results. However, the mean IGFBP-1 mRNA levels of mild and severe pre-eclamptic placenta were significantly higher than that of uncomplicated placenta (P<0.05, P<0.005, respectively), with the level of severe pre-eclamptic placenta being significantly raised compared with that of mild pre-eclamptic placenta (P<0.05). Finally, a significant increase of IGFBP-1 protein expression was noted among the three groups (P<0.001), correlating with the IGFBP-1 mRNA results.

CONCLUSIONS

This study suggests that IGF-II and IGFBP-1 might be associated with the impaired trophoblastic invasion that may lead to pathogenesis of pre-eclampsia.

Vestibular schwannoma with malignant transformation: a case report

We describe a rare case of malignant transformation in a vestibular schwannoma in a 33-yr-old woman. She presented herself with headache, tinnitus, and hearing loss and underwent posterior fossa explorations three times during the short period of 3 months. The clinicopathological features of the original tumor were typical of benign vestibular schwannoma. Despite a complete microsurgical excision, two months later, the tumor recurred locally with a rapid increase in size causing a progressive worsening of neurological symptoms. A diagnosis of malignant schwannoma was made for the recurrent tumor on the basis of the microscopic findings of high cellularity, moderate pleomorphism, and the presence of mitotic cells. Repeat magnetic resonance imaging performed a month after the second surgery unexpectedly showed definite tumor enlargement. She remained clinically stable following the third debulking of the tumor and adjuvant radiotherapy. We propose that this recurrent tumor represent malignant transformation from a benign vestibular schwannoma which was an unusual occurrence in a patient without neurofibromatosis.

Ether fraction of methanol extracts of Gastrodia elata, a traditional medicinal herb, protects against kainic acid-induced neuronal damage in the mouse hippocampus

Gastrodia elata (GE) has been used traditionally for the treatment of convulsive diseases such as epilepsy in oriental countries including South Korea and still occupies an important place in traditional medicine in Asia. We studied the anticonvulsive effect and protective effect of the ether fraction of methanol extracts (EFME) of GE against hippocampal neuronal damage after kainic acid administration in mice. Mice were treated with the EFME of GE (200 or 500 mg/kg per day, p.o.) for 14 days before kainic acid injection (45 mg/kg, i.p.). The EFME of GE (at the dose of 500 mg/kg) delayed the onset time of neurobehavioral change (P<0.01) and reduced the severity of convulsions (P<0.05) and hippocampal neuronal damage in the CA1 (P<0.01) and CA3 (P<0.05) regions. Our results show that The EFME of GE has anticonvulsive effect and putative neuroprotective effect against excitotoxicity induced by kainic acid.

Evaluation of the petrifilm plate method for the enumeration of aerobic microorganisms and coliforms in retailed meat samples

This study was designed to compare the effectiveness and applicability of the Petrifilm plate method with the Association of Official Analytical Chemists' (AOAC) standard aerobic count method and violet red bile agar method for meat products. The comparison was carried out using 303 meat samples collected from various retailers: 110 pork samples, 87 chicken samples, and 107 beef samples. In the comparison of the correlation coefficient (R) between the conventional method and the Petrifilm plate method by a linear regression analysis, the correlation coefficient in total microorganisms was 0.99, 0.95, and 0.94 in pork, beef, and chicken samples, respectively. The correlation coefficient in coliform count was 0.83, 0.96, and 0.81 in pork, beef, and chicken samples, respectively. Based on the high correlation in the total microorganism count, it might be possible to replace the conventional methods with the Petrifilm plate method. For coliform counts, the Petrifilm plate method also showed a generally high correlation coefficient, except for pork samples, which are more subject to contamination. The Petrifilm plate method was simpler and less time-consuming in sample preparation and, in procedures, faster than the conventional method. These results suggested that the 3M Petrifilm plate method could replace the conventional methods in the analysis of microorganism contamination measurement in meat products.

Health literacy and shared decision making for prostate cancer patients with low socioeconomic status

Quality of life (QOL) considerations are important in the treatment decision making process for prostate cancer patients. Although patient involvement in the treatment decision process has been encouraged, low health literacy can limit patient understanding of the complex information about treatments and their probable QOL outcomes and is a barrier to patient participation in the decision-making process. The objectives of the study were to evaluate (i) knowledge, level of satisfaction, and treatment preferences and intentions of men newly diagnosed with prostate cancer after participation in a CD-ROM shared decision making program; and (ii) the relationship between prostate cancer knowledge and health literacy. Thirty newly diagnosed prostate cancer patients from two Veteran's Administration (VA) hospitals in Chicago completed a demographic questionnaire and participated in an interactive CD-ROM shared decision making program. Subsequently, knowledge of prostate cancer, satisfaction with the information in the computer CD-ROM program, treatment preferences, and likelihood of following treatment preferences were assessed using interviewer-administered questionnaires. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). The Pearson correlation test was used to assess the relationship between health literacy and prostate cancer knowledge. The chi2 test and the Fischer exact test were used to evaluate relationships between patient demographics and other variables. More than three-quarters of the patients rated the information in the CD-ROM as "very satisfactory" (highest possible rating). Two-thirds of the patients (21 of 30) selected a treatment after participation in the CD-ROM program and 90.5% of these patients stated that they were very or somewhat likely to adhere to their selection. However, prostate cancer knowledge was variable, with one-third of the patients scoring 69.9% or lower. Participants' health literacy was equivalent to a 7th-8th grade reading level (mean = 57.1+/-10.9), and more than one-third of participants (36.7%) had lower than 9th grade literacy levels. Participants' prostate cancer knowledge was correlated with health literacy (Pearson correlation rhor = 0.65, rhop = 0.0001). Patients were satisfied with the interactive shared decision making CD-ROM program, and two-thirds of patients were able to select a preferred treatment based on the information presented in the program that they intended to follow. However, prostate cancer knowledge scores varied among participants after participation in the CD-ROM program, raising doubts that patients were adequately informed to make appropriate choices regarding their treatment. Lower prostate cancer knowledge scores corresponded to lower literacy scores, indicating that low literacy may have hindered patient understanding of the shared decision making program. The development of shared decision making tools should include collaborative efforts with the target population to improve the success of shared decision making programs among patients with low health literacy.

Melatonin reduces X-ray irradiation-induced oxidative damages in cultured human skin fibroblasts

Melatonin is a hormone with multiple functions in humans, produced by the pineal gland and stimulated by beta-adrenergic receptors. Melatonin has been shown to have radioprotection properties, but there has been little progress toward identifying the specific mechanisms of its action. To clarify the role of melatonin as a radioprotective compound, in response to X-ray irradiation, we investigated the effects of X-ray irradiation and melatonin on cytotoxicity, lipid peroxidation and alteration of the cell cycle in cultured skin fibroblast. An 8 Gy dose of X radiation resulted in cell death in 63% of irradiated cells, i.e. the cell viability was 37%. The damage was associated with lipid peroxidation of the cell membrane, as shown by the accumulation of malondialdehyde (MDA). By pre-incubation with melatonin (10(-5) M), a significant preventive effect was noted on the increase in the absolute number of surviving cells (up to 68% of cells were survived), and the levels of MDA were markedly decreased. These findings suggest a close correlation between an increase of lipid peroxidation and a rate of cell death. Morphological changes associated with apoptotic cell death were demonstrated by TEM. DNA flow-cytometry analysis revealed that X radiation increased pre-G1 apoptotic population by 7.6% compared to a very low level (1.3%) of non-irradiated cells. However, in the presence of melatonin, this apoptotic population decreased up to 4.5% at 10(-5) M. The p53 and p21 protein levels of skin fibroblasts increased 4 h after 8 Gy irradiation, but melatonin pretreatment did not change those levels. This study suggests that melatonin pretreatment inhibits radiation-induced apoptosis, and melatonin exerts its radioprotective effect by inhibition of lipid peroxidation and without any involvement of the p53/p21 pathway.

Risk and protective factors related to native Hawaiian adolescent alcohol use

The present study examined protective and risk factors in the prediction of alcohol use for Hawaiian and non-Hawaiian (i.e. Caucasian, Japanese, Filipino, 'other') adolescents. Comparable rates of approximately 25% were found for both the Hawaiian and non-Hawaiian samples regarding sometimes drinking too much alcohol. However, Hawaiians reported a statistically significantly higher rate (3.7%) of taking 'a drink in the morning to steady my nerves or to get rid of a hangover' than non-Hawaiians (1.3%). The reason for this is unknown but might indicate a higher rate of dependent alcohol use. The overall results supported the traditional model of protective and risk factors predicting alcohol use (R(2) > 15.0%), with relatively few differences found between the two ethnic groups. Further research is needed in assessing possibly unique cultural variables such as Hawaiian acculturation.

Spectral analysis of fetal heart rate variability as a predictor of intrapartum fetal distress

OBJECTIVE

To evaluate the usefulness of power spectral analysis on fetal heart rate variability as a new diagnostic method of fetal distress.

STUDY DESIGN

Among 76 pregnant women who underwent computerized electronic fetal monitoring and cord blood gas analysis, we divided them into three groups: normal fetus group (36); presumed distress group (26); and acidemic distress group (14). In order to perform linear analysis on the raw data of the fetal heart rate, after resampling, we performed Fourier transformation and investigated power distributions among very low frequency (VLF), low frequency (LF), high frequency (HF) bands, and autonomic balance (LF/HF).

RESULTS

The results of the spectral analysis showed that in normal fetus group, the difference in the distribution of power spectrums of VLF, LF and HF was significantly higher than in presumed distress group and acidemic distress group. In fetal distress, the LF and VLF value (< or = 0.0023, > or = 0.0437) were good predictors (sensitivity 97.5%, 75.0% and specificity 86.1%, 94.4%). The LF value (< or = 0.0013) was a good predictor in fetal acidemia (sensitivity 97.5% and specificity 86.1%).

CONCLUSIONS

A computerized spectral analysis of fetal heart rate variation is a good predictor of fetal distress, which is made automatically and objectively.

Equivalencies regarding the measurement and constructs of self-esteem and major life events in an Asian/Pacific islander sample

Construct, scalar, and functional measurement equivalencies of the Rosenberg Self-Esteem Scale (RSES) and Major Life Events checklist (MLE) and the constructs assessed were investigated across groups differentiated on Hawaiian/part-Hawaiian and non-Hawaiian (e.g., Caucasian, Filipino, Hispanic, Japanese, and mixed/2 or more) ethnicity and gender. Initial results from maximum likelihood factoring with promax rotation showed that RSES negatively worded Item 5 loaded with the positively worded Items 1, 2, 4, 6, and 7 on 1 of 2 factors for Hawaiian/part-Hawaiian female participants. Similarly, negatively worded Item 8 and the same positively worded items comprised 1 of 2 factors for non-Hawaiian male participants. For the other 2 Ethnicity x Gender groups, factors were respectively comprised of the 5 positively and 5 negatively worded RSES items. Construct equivalence or simple (2-factor) structure underlying the RSES was indicated across the 4 groups after Items 5 and 8 were excluded from a subsequent factoring procedure. Simple structure showed that Factor 1 comprised the positively worded Items 1, 2, 4, 6, and 7, and the remaining negatively worded Items 3, 9, and 10 loaded on Factor 2. Scalar equivalence of the self-esteem and major life events measures was supported by the statistical nonsignificance of the Major Life Events x Ethnicity x Gender interaction effect in multiple regression models. The consistency in the absolute size and direction of the intercorrelations between overall self-esteem, self-esteem Factors 1 and 2, and major life events variables indicated the functional equivalence of respective measures and constructs assessed. Measurement equivalency findings concerning the RSES and MLE, the constructs measured, and their utility versus caution against their use in multiethnic studies were discussed.

Central role of the adipocyte in the metabolic syndrome

Insulin resistance is associated with a plethora of chronic illnesses, including Type 2 diabetes, dyslipidemia, clotting dysfunction, and colon cancer. The relationship between obesity and insulin resistance is well established, and an increase in obesity in Western countries is implicated in increased incidence of diabetes and other diseases. Central, or visceral, adiposity has been particularly associated with insulin resistance; however, the mechanisms responsible for this association are unclear. Our laboratory has been studying the physiological mechanisms relating visceral adiposity and insulin resistance. Moderate fat feeding of the dog yields a model reminiscent of the metabolic syndrome, including visceral adiposity, hyperinsulinemia, and insulin resistance. We propose that insulin resistance of the liver derives from a relative increase in the delivery of free fatty acids (FFA) from the omental fat depot to the liver (via the portal vein). Increased delivery results from 1) more stored lipids in omental depot, 2) severe insulin resistance of the central fat depot, and 3) possible regulation of visceral lipolysis by the central nervous system. The significance of portal FFA delivery results from the importance of FFA in the control of liver glucose production. Insulin regulates liver glucose output primarily via control of adipocyte lipolysis. Thus, because FFA regulate the liver, it is expected that visceral adiposity will enhance delivery of FFA to the liver and make the liver relatively insulin resistant. It is of interest how the intact organism compensates for insulin resistance secondary to visceral fat deposition. While part of the compensation is enhanced B-cell sensitivity to glucose, an equally important component is reduced liver insulin clearance, which allows for a greater fraction of B-cell insulin secretion to bypass liver degradation, to enter the systemic circulation, and to result in hyperinsulinemic compensation. The signal(s) resulting in B-cell up-regulation and reduced liver insulin clearance with visceral adiposity is (are) unknown, but it appears that the glucagon-like peptide (GLP-1) hormone plays an important role. The integrated response of the organism to central adiposity is complex, involving several organs and tissue beds. An investigation into the integrated response may help to explain the features of the metabolic syndrome.

Longitudinal compensation for fat-induced insulin resistance includes reduced insulin clearance and enhanced beta-cell response

Central adiposity is highly correlated with insulin resistance, which is an important risk factor for type 2 diabetes and other chronic diseases. However, in normal individuals, central adiposity can be tolerated for many years without development of impaired glucose tolerance or diabetes. Here we examine longitudinally the mechanisms by which glucose tolerance can be maintained in the face of substantial insulin resistance. Normal dogs were fed a diet enriched with moderate amounts of fat (2 g x kg(-1) x day(-1)), similar to that seen in modern "cafeteria" diets, and the time course of metabolic changes in these animals was examined over 12 weeks. Trunk adiposity as assessed by magnetic resonance imaging increased from 12 to 19%, but body weight remained unchanged. Insulin sensitivity (SI) as determined by frequently sampled intravenous glucose tolerance tests was measured over a 12-week period. SI decreased 35% by week 1 and remained impaired for the entire 12 weeks. Intravenous glucose tolerance was reduced transiently for 1 week, recovered to baseline, and then again began to decline after 8 weeks. First-phase insulin response began to increase after week 2, peaked by week 6 (190% of basal), and then declined. The increase in insulin response was due partially to enhanced beta-cell function (22%) but due also to an approximately 50% reduction in insulin clearance. This compensation by insulin clearance was also confirmed with insulin clamps performed in fat-fed versus control dogs. The present study confirms the ability of the normal individual to compensate for fat-induced insulin resistance by enhanced insulin response, such that the product of insulin sensitivity x secretion is little changed. However, the compensation is due as much to reduced insulin clearance as increased beta-cell sensitivity to glucose. Reduced hepatic extraction of insulin may be the first line of defense providing a higher proportion of secreted insulin to the periphery and sparing the beta-cells during compensation for the insulin-resistant state.

Chronic peritoneal inflammation by cyanate in rats

OBJECTIVE

During peritoneal dialysis, the peritoneum is exposed to waste products, including urea. Urea forms cyanate spontaneously at body temperature and pH, and cyanate carbamylates amino acids, peptides, and proteins. Cyanate may contribute to peritoneal injury with morphological changes in the peritoneum. To test this hypothesis, we injected cyanate into rats.

METHODS

Experiments were performed in two groups of 7 rats each. In the cyanate group, each rat received 1 mL of 1.5 micromol/L potassium cyanate dissolved in 40 mmol/L sodium bicarbonate solution intraperitoneally each experiment day. In the control group, each rat received 1 mL of 1.5 micromol/L potassium bicarbonate instead of potassium cyanate. The rats in both groups were anesthetized and killed at the 85th day after the first injection. After formalin fixation, tissue samples from abdominal walls and livers were sliced, embedded in a standard manner, and stained with hematoxylin and eosin.

RESULTS

Parietal peritoneum from rats in the cyanate group showed a mild increase in the number of fibroblasts, with collagen deposits, infiltration by mononuclear cells, vascular congestion, round-shaped transformation of mesothelial cells, widening of submesothelial spaces, and abundant denudation of mesothelial cells. The visceral peritoneum from rats in the cyanate group showed collagen deposits with fibroblastic proliferation.

CONCLUSIONS

Cyanate can induce chronic inflammation in the peritoneum, and exposure of the peritoneum to cyanate may contribute to peritoneal injury in patients being treated with peritoneal dialysis.

Protective effect of topiramate against hippocampal neuronal damage after global ischemia in the gerbils

The purpose of this study was to examine whether topiramate would reduce neuronal damage after transient global ischemia in the gerbils because topiramate blocks voltage sensitive sodium channels and non-N-methyl-D-aspartate receptors and enhances gamma-aminobutyric acid-mediated inhibitory transmission. Both common carotid arteries were occluded for 3 min with microaneurysmal clips. The gerbils were treated with topiramate (50, 100, or 200 mg/kg, i.p.) immediately after ischemia. Neuronal cell damage in the hippocampal CA1 region was evaluated quantitatively 7 days after ischemia. Topiramate at the dose of 50 mg/kg failed to reduce hippocampal neuronal damage. However, topiramate when administered at the dose of 100 or 200 mg/kg significantly reduced hippocampal neuronal damage in dose-dependent manner (P<0.001 and P<0.0005, respectively). These results suggest that topiramate has a neuroprotective effect against neuronal damage following global ischemia in the gerbils.

Survey of the cross-cultural content of U.S. psychiatry residency training programs

To establish the extent of cross-cultural content contained in the 224 psychiatric residency training programs, the Directors of Residency Training were surveyed by mail. Thirty-seven percent (N = 83) of Directors responded; 92% (N = 76) had cross-cultural content, 99% (N = 82) had opportunities to work with minority patients, and 77% (N = 64) had supervision by some minority faculty. Responding programs reported a need for teaching videotapes (85%, N = 71), cross-cultural references (78%, N = 65), academic psychiatrists familiar with different cultural groups (76%, N = 63), and cross-cultural supervision (75%, N = 62).

Psychometric properties of the state-trait anxiety inventory for Asian/Pacific-islander adolescents

Anxiety disorders are said to be universal across all cultures and recent reviews have found relatively high prevalence rates across different countries. However, the experience and interpretation of anxiety are strongly influenced by cultural factors. Demonstrating cross-cultural equivalence of measures of anxiety is essential to assure that comparisons between cultures will result in meaningful interpretations. Despite the State-Trait Anxiety Inventory being the most researched of anxiety measures from a cross-cultural basis, there is a lack of empirical studies on the psychometric properties of the STAI with adolescent Asian/Pacific Islanders. The present study examined the STAI using a large sample of ethnically diverse high school students in Hawaii. In general, a four-factor model (State-Anxiety Absent, State-Anxiety Present, Trait-Anxiety Absent, and Trait-Anxiety Present) provided the best fit based on a series of confirmatory factor analyses. Indicators of internal consistency supported the reliability of the factors and subscales, and the inter-factor correlations reflected positively on the concurrent validity of the different STAI factor and subscale measures. This study suggested cautious use and interpretation of one particular item (Trait Item 14 = I try to avoid facing a crisis or difficulty ), and cautious application of the STAI to Filipino adolescents (particularly Filipino males). Domains for further research are discussed.

Earlier prediction of anastomotic insufficiency after thoracic esophagectomy by intramucosal pH

OBJECTIVES

To assess the value of using intramucosal pH (pHi) measurements to evaluate the viability of the gastric tube after thoracic esophagectomy, and to determine whether these measurements may be used for early prediction of anastomotic insufficiency.

DESIGN

Prospective, observational study.

SETTING

University hospital in Japan.

PATIENTS

Thirty-nine patients who had undergone thoracic esophagectomy as a treatment for esophageal cancer.

INTERVENTIONS

The blood flow within the gastric tube was measured using a laser Doppler flowmeter during surgery. Periodic measurement of the pHi within the gastric tube (gastric pHi) began during surgery and continued until the second postoperative day. In 30 patients, the pHi within the rectum (rectal pHi) was measured simultaneously with the gastric pHi. The patients were divided into two groups: those patients who experienced anastomotic insufficiency constituted the leakage(+) group (n = 13); those patients who did not experience these complications were designated the leakage(-) group (n = 26).

MEASUREMENTS AND MAIN RESULTS

The gastric pHi values correlated significantly with simultaneous measurements of the blood flow at the anastomotic site (p < .01). The postoperative gastric pHi values increased gradually in the leakage(-) group but stopped increasing after surgery in the leakage(+) group. The rectal pHi values increased gradually after surgery in both groups. Furthermore, there was a significant difference between the two groups when their gastric pHi values were subtracted from their rectal pHi values from the morning of the first postoperative day until the morning of the second postoperative day (p < .05).

CONCLUSIONS

The gastric pHi values well reflected the viability of the gastric tube, especially when combined with the rectal pHi values. By measuring pHi, we can more accurately predict the risk of anastomotic insufficiency earlier after surgery and therefore give those patients who need it additional care to improve the viability of the gastric tube.

QOL and outcomes research in prostate cancer patients with low socioeconomic status

The VA Cancer of the Prostate Outcomes Study (VA CaPOS) is collecting quality-of-life (QOL) information from prostate cancer patients, spouses, and physicians at six VA medical centers. Currently, 601 men with prostate cancer are included in the study, most of whom are of low socioeconomic status and over half of whom are African-American. Quality-of-life responses were most favorable for newly diagnosed patients, intermediate for those with stable metastatic disease, and poorest for those with progressive metastatic disease. Patients could not provide reliable estimates of their own preferences for future QOL states but responded reliably to questions phrased as a comparison of the preferences of two hypothetical patients. High out-of-pocket costs for hormonal therapies, lack of health insurance, and a belief that the non-VA system offered poorer services were the most common reasons for patient transferral to the VA system. Satisfaction with medical care was generally high. While African-American patients were more likely to have advanced prostate cancer at diagnosis, after adjustment for differences in health literacy, race was no longer a significant predictor of advanced disease. The VA CaPOS provides useful information on health status and patient satisfaction of VA prostate cancer patients. Long-term evaluations are needed to detect clinically meaningful QOL information as the disease progresses.

Recognition of Pneumocystis carinii antigen on its surface by immunohistochemistry and immunoelectron microscopy

The aim of this study was to detect the surface antigens in different stages of experimental induced Pneumocystis carinii in Sprague-Dawley rats. Immunohistochemical staining with monoclonal (900, 902 and 904) and polyclonal (SP-D) antibodies demonstrated that the P. carinii organisms were mostly in the alveolar lumina. The binding sites of the monoclonal (900, 902 and 904) and polyclonal (SP-D) antibodies developed against P. carinii were examined at the ultrastructural level by using a post-embedding immunogold labeling. The gold particles were observed evenly on the surface of precyst and cyst stages of the P. carinii. In the trophozoite stage, scattered gold particles were seen on the pellicles and tubular expansions. The monoclonal antibodies reacted mainly with pellicles of P. carinii, whereas SP-D labeled pellicles, intracystic bodies, cytoplasms of alveolar macrophages, free floating surfactant material in the alveolar spaces, and adjacent type II epithelial cells. In the immunogold labeling, basically no significant differences were found in the precyst, cyst, and ruptured cyst stages. These results indicate that the gold particles were observed adhering to every stage of P. carinii, mostly concentrated on the pellicles, and more concentrated in the precyst or cyst stage than trophozoite stage which may be due to an increase in antigen accumulation during development from the trophozoite to the cyst.

A new diagnostic approach to biliary atresia with emphasis on the ultrasonographic triangular cord sign: comparison of ultrasonography, hepatobiliary scintigraphy, and liver needle biopsy in the evaluation of infantile cholestasis

BACKGROUND/PURPOSE

The authors evaluated prospectively the utility of ultrasonography, Tc-99m-DISIDA hepatobiliary scintigraphy, and liver needle biopsy in differentiating biliary atresia (BA) from intrahepatic cholestasis in 73 consecutive infants who had cholestasis.

METHODS

Sixty three ultrasonographic examinations of 61 infants with 7.0-MHz transducer were carried out, focusing on the fibrous tissue at the porta hepatis. The authors defined the triangular cord (TC) as visualization of a triangular or tubular shaped echogenic density just cranial to the portal vein bifurcation on a transverse or longitudinal scan.

RESULTS

Although 17 of 20 ultrasonographic examinations from infants who had BA denoted TC, 43 ultrasonographic examinations from infants with either neonatal hepatitis (NH) or other causes of cholestasis denoted no TC, showing a diagnostic accuracy of 95% with 85% sensitivity and 100% specificity. Investigation with Tc-99m-DISIDA hepatobiliary scintigraphy showed that 24 of 25 infants who had BA had no gut excretion, and 16 of 46 infants who had either NH or other causes of cholestasis had gut excretion, showing a diagnostic accuracy of 56% with 96% sensitivity and 35% specificity. Therefore, gut excretion of tracer excluded BA, but no gut excretion of tracer needed further investigations as liver needle biopsy. Forty-four liver needle biopsies were carried out in 19 infants who had BA and 24 infants who had either NH or other causes of cholestasis. Although 18 of 20 biopsy findings in infants who had BA were correctly interpreted as having BA, 23 of 24 biopsy results in infants who had either NH or other causes of cholestasis were correctly diagnosed, showing a diagnostic accuracy of 93% with 90% sensitivity and 96% specificity.

CONCLUSIONS

Since the introduction of ultrasonographic TC sign in the diagnosis of BA by our institution, we have found that it seemed to be a simple, time-saving, highly reliable, and non-invasive tool in the diagnosis of BA from other causes of cholestasis. The authors propose a new diagnostic strategy in the evaluation of infantile cholestasis with emphasis on ultrasonographic TC sign as first priority of investigations. When the TC is visualized, prompt exploratory laparotomy is mandatory without further investigations. When the TC is not visualized, hepatobiliary scintigraphy is the next step. Excretion of tracer into the small bowel actually rules out BA. Liver needle biopsy is reserved only for the infants with no excretion of tracer. The authors believe that a correct decision regarding the need for surgery can be made in almost all cases with infantile cholestasis by this multidisciplinary approach.

Bone mineral density of the spine using dual energy X-ray absorptiometry in patients with non-insulin-dependent diabetes mellitus

To evaluate the influence of non-insulin-dependent diabetes mellitus (NIDDM) on bone mineral density (BMD), we measured BMD in 185 female patients with NIDDM using dual energy X-ray absorptiometry (DEXA). BMD was measured in lumbar vertebrae (L2-4). BMD is slightly higher in the diabetic patients compared with control subjects and bone loss related to menopause starts before the onset of menopause. The BMD of postmenopausal women showed a definite decrease with aging and there was abrupt bone loss after 55 years of age (p < 0.05). In relation to the duration of diabetes, the decrease of BMD for 15 years was 10.0%. BMD was negatively correlated with age, years since menopause (YSM), and disease duration (r = -0.584, r = -0.470, r = -0.186). These results suggest that age, YSM, and the duration of disease appear to be the risk factors for decreased BMD in the diabetic patients.

Electron microscopic study of the liver with biliary atresia and neonatal hepatitis

Eleven cases of biliary atresia (BA) and eight of neonatal hepatitis (NH) were studied, using transmission electron microscopy, to document their different ultrastructural characteristics and to elucidate the possible pathogenesis of biliary atresia. Among 30 consecutive liver biopsies obtained from 19 infants with BA or NH, 21 specimens composed (13 BA, 8 NH) were examined ultrastructurally. The electron microscopic features of NH (patients' age range, 35 to 60 days) were (1) giant hepatocytic transformation with scattered areas of dilated endoplasmic reticulum, indicative of intracytoplasmic degeneration, (2) frequent cytoplasmic biliary necrosis, and (3) relatively intact microvilli in most bile canaliculi, which contained some hepatocytic cytoplasmic fragments. These features strongly suggest that the main pathological process in NH is hepatocellular injury rather than bile duct damage. In contrast, all cases with BA (age range, 27 to 130 days) demonstrated (1) marked hepatocellular cholestasis associated with many lysosomes and myelin figures, (2) marked loss of bile canalicular microvilli, (3) degenerated bile ductular cells containing bile pigments, and (4) periductal inflammatory fibrosis. These features suggest that the main pathological process in BA involves the biliary system. A few viral inclusions were observed in two cases with BA, which suggests that viral infection is a potential cause. In two BA cases (aged 40 and 43 days at the time of first biopsy), the ultrastructural findings essentially were the same as those of NH, and follow-up biopsy specimens (at 48 and 94 days) showed findings consistent with BA. Such results support Landing's hypothesis that BA and NH are different manifestations of a single pathological process.

A new finite-state vector quantizer with optimized state space and derailment-free operation

A new finite-state vector quantization (FSVQ) algorithm is developed based on state space optimization and the derailment prevention requirement. The proposed derailment-free FSVQ (DF-FSVQ) achieves good performance through (i) state space reduction, which allows a practical implementation of high-order FSVQ, and (ii) derailment free state transitions. Experimental results show that our approach outperforms other known FSVQ schemes in terms of performance, system complexity, and processing speed, especially at low bit rate image coding.