Effect of early dexamethasone on outcomes of COVID-19: A quasi-experimental study using propensity score matching

BACKGROUND

The RECOVERY trial demonstrated that the use of dexamethasone is associated with a 36% lower 28-day mortality in hospitalized patients with COVID-19 on invasive mechanical ventilation. Nevertheless, the optimal timing to start dexamethasone remains uncertain.

METHODS

We conducted a quasi-experimental study at National Taiwan University Hospital (Taipei, Taiwan) using propensity score matching to simulate a randomized controlled trial to receive or not to receive early dexamethasone (6 mg/day) during the first 7 days following the onset of symptoms. Treatment was standard protocol-based, except for the timing to start dexamethasone, which was left to physicians' decision. The primary outcome is 28-day mortality. Secondary outcomes include secondary infection within 60 days and fulfilling the criteria of de-isolation within 20 days.

RESULTS

A total of 377 patients with COVID-19 were enrolled. Early dexamethasone did not decrease 28-day mortality in all patients (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.97-1.10) or in patients who required O2 for severe/critical disease at admission (aOR, 1.05; 95%CI, 0.94-1.18); but is associated with a 24% increase in superinfection in all patients (aOR, 1.24; 95% CI, 1.12-1.37) and a 23% increase in superinfection in patients of O2 for several/critical disease at admission (aOR, 1.23; 95% CI, 1.02-1.47). Moreover, early dexamethasone is associated with a 42% increase in likelihood of delayed clearance of SARS-CoV-2 virus (adjusted hazard ratio, 1.42; 95% CI, 1.01-1.98).

CONCLUSION

An early start of dexamethasone (within 7 days after the onset of symptoms) could be harmful to hospitalized patients with COVID-19.

Nontuberculous mycobacterial infection mimicking gynecologic malignancy in a woman living with HIV

The weakened immune system in people living with HIV (PLWH) can lead to infectious diseases occurring more aggressively and mimicking the clinical manifestations of malignancies. Mycobacterium sherrisii, a slow-growing nontuberculous mycobacterium, may cause opportunistic infections among PLWH. We present a case of a 41-year-old woman who initially presented with fever, vaginal spotting, and a bulky pelvic mass, raising suspicion of uterine malignancy. Following a surgical resection, she was pathologically diagnosed with leiomyoma and endometriosis. However, during an event of needlestick injury, she was unexpectedly found to be HIV-infected and the CD4 count was 157 cells/µL at diagnosis, which prompted a diagnostic work-up for opportunistic infections. The diagnosis of disseminated M. sherrisii infection was confirmed through cultures and special staining of specimens obtained from the pelvic tumor and blood. Subsequently, she was treated with a combination of ethambutol, azithromycin, and levofloxacin. Two months after treatment, abdominal and pelvic computed tomography revealed no evidence of recurrent tumor or abscess formation. Given the frequent association of pelvic masses with gynecologic malignancies in women living with HIV, it can be challenging to differentiate between a cancerous lesion and an infectious process, emphasizing the need for meticulous investigations to minimize the potential for misdiagnosis.

Immunogenicity and safety of heterologous mRNA-1273/MVC-COV1901 vaccination versus homologous mRNA1273 vaccination: A randomized, double-blind controlled study

BACKGROUND/PURPOSE

MVC-COV1901 is a protein vaccine based on the same SARS-CoV-2 strain used in mRNA vaccine mRNA-1273. Data are lacking on immunogenicity and safety of MVC-COV1901 as heterologous boost for people already received one dose of mRNA-1273.

METHODS

This is a randomized, double-blind trial that recruited adults aged 20-70 years who previously received a single dose of mRNA-1273 vaccine and were randomly assigned in a 1:1 ratio to receive a second dose with the homologous vaccine or protein-based MVC-COV1901 8-12 weeks after the first dose. The primary outcome was neutralizing antibody titers in terms of the geometric mean titer (GMT) 14 days after the second dose. Safety was assessed in all participants who received a dose of the study vaccine. The study is registered with ClinicalTrials.gov (NCT05079633).

RESULTS

From September 30 to November 5, 2021, 144 participants were enrolled and randomly assigned to the MVC-COV1901 boost group (n = 72) or the mRNA-1273 boost group (n = 72). The neutralizing antibodies on Day 15 and the anti-SARS-CoV-2 IgG titers on Day 15 and 29 of homologous mRNA-1273 were significantly higher than those of heterologous mRNA-1273/MVC-COV1901. Cellular immune responses were comparable in both groups. However, adverse events were much more frequent after the mRNA-1273 boost than after the MVC-COV1901 boost.

CONCLUSION

Our results show that heterologous boost with MVC-COV1901 yielded an inferior immunogenicity but significantly fewer adverse events, compared with homologous boost with mRNA-1273. In people experienced severe adverse events after prime dose of mRNA-1273, as well as in periods when the supply of mRNA-1273 is limited, MVC-COV1901 could serve as an acceptable alternative heterologous boost.

Risk factors for mortality after linezolid treatment of vancomycin-resistant Enterococcus bloodstream infection

OBJECTIVES

We analyzed the risk factors affecting linezolid treatment outcome in vancomycin-resistant Enterococcus (VRE) bloodstream infection (BSI).

METHODS

We conducted a multicenter observational study of patients who received linezolid 600 mg every 12 hours for VRE BSI. The primary outcome was 28-day mortality. The estimated area under the concentration-time curve and trough concentration were calculated. Multivariable logistic regression was used for the outcome analysis.

RESULTS

A total of 170 patients were included: 114 (67.1%) survived and 56 (32.9%) did not. A total of 26 (18.2%) isolates showed a linezolid minimum inhibitory concentration (MIC) of ≤1 mg/l, 113 (79.0%) of 2 mg/l, and 4 (2.8%) of 4 mg/l. The univariable analysis showed that the linezolid MIC and concentration-time curve/MIC were not associated with mortality (P = 0.95 and P = 0.42, respectively). After adjusting for underlying comorbidity and disease severity, the linezolid dose per body weight (LDBW), body height, and interaction between them were independent risks for mortality. Marginal analysis showed that increasing the LDBW was protective in patients with a body height <160 cm. A trough concentration of >12.2 mg/l was a risk factor for thrombocytopenia.

CONCLUSION

The LDBW and body height were interactively associated with clinical outcomes of linezolid treatment for VRE BSI.

Mitochondrial DNA variants as genetic risk factors for Parkinson disease

BACKGROUND AND PURPOSE

Investigation of the relationship between mitochondrial DNA (mtDNA) variants and Parkinson disease (PD) remains an issue awaiting more supportive evidence. Moreover, an affirming cellular model study is also lacking.

METHODS

The index mtDNA variants and their defining mitochondrial haplogroup were determined in 725 PD patients and 744 non-PD controls. Full-length mtDNA sequences were also conducted in 110 cases harboring various haplogroups. Cybrid cellular models, composed by fusion of mitochondria-depleted rho-zero cells and donor mitochondria, were used for a rotenone-induced PD simulation study.

RESULTS

Multivariate logistic regression analysis revealed that subjects harboring the mitochondrial haplogroup B5 have resistance against PD (odds ratio 0.50, 95% confidence interval 0.32-0.78; P = 0.002). Furthermore, a composite mtDNA variant group consisting of A10398G and G8584A at the coding region was found to have resistance against PD (odds ratio 0.50, 95% confidence interval 0.33-0.78; P = 0.001). In cellular studies, B4 and B5 cybrids were selected according to their higher resistance to rotenone, in comparison with cybrids harboring other haplogroups. The B5 cybrid, containing G8584A/A10398G variants, showed more resistance to rotenone than the B4 cybrid not harboring these variants. This is supported by findings of low reactive oxygen species generation and a low apoptosis rate in the B5 cybrid, whereas a higher expression of autophagy was observed in the B4 cybrid particularly under medium dosage and longer treatment time with rotenone.

CONCLUSIONS

Our studies, offering positive results from clinical investigations and cybrid experiments, provide data supporting the role of variant mtDNA in the risk of PD.

LOUPE-ASSISTED MODIFIED ONE-LAYER VASOVASOSTOMY

Several studies indicate that microsurgical modified one-layer vasovasostomy is comparable to the two-layer anastomosis with respect to patency and pregnancy rates. The objective of this study was to determine the feasibility and result of modified one-layer vasovasostomy under loupe magnification only. Thirty-two patients aged 28 to 64 years (mean 41.3 +/- 6 years) underwent vasovasostomy at CGMH from July 1997 to June 2002, with all operations being a modified on-layer anastomosis created with the aid of a 3 x loupe. The estimated duration of vasectomy ranged from 4 months to 27 years, with a mean of 9.2 +/- 4.8 years. Postoperative semen analysis and pregnancy were examined. Each patient was followed up at 1,4, and 12 weeks postoperatively. The total operation time ranged from 118 to 228 minutes (average 150 +/- 35 minutes). There was no operation-related complication such as hematoma or wound infection. The patency rate was 89% (25/28), and the pregnancy rate at 2 years or more of follow-up was 39% (11/28). The patency and pregnancy rates were similar to those obtained in most studies of microsurgical vasovasostomy. For uncomplicated vasectomy reversal, this simple loupe-assisted modified one-lyer vasovasostomy seems to provide an adequate anastomosis.

HIGH INGUINAL LOUPE-ASSISTED VARICOCELECTOMY FOR SUBFERTILE MEN WITH VARICOCOCELES: TECHNICAL FEASIBILITY, CLINICAL OUTCOMES AND COMPLICATIONS

254 consecutive patients underwent high inguinal loupe-assisted varicocelectomy. All patients had at least a one year history of infertility with abnormal semen parameters and physical examination and/or color Doppler ultrasound proven varicocele. To facilitate the procedure, an x 3.0 loupe was used during spermatic cord dissection near or at level of internal inguinal ring. Semen analysis and physical examination were performed at 3 monthly intervals. No intra-operative complications occurred. The most common post-operative complications were transient scrotal pain and stitch reaction, occurring in 12% and 4% of men, respectively. Only one permanent and two transient hydroceles were observed. Recurrent or persistent varicocele was identified by physical examination and color Doppler in 5 varicocelectomies (1.4%), and by color Doppler only in 6 varicocelectomies (1.7%). Sperm motility increased from 30 +/- 8% to 46 +/- 20%, and sperm concentration. (10(6)/cc) increased from 24 +/- 18 to 41 +/- 28. The one-year pregnancy rate was 37%. High inguinal loupe-assisted varicocelectomy is a safe, simple, and effective treatment for varicocele.

Rejection With Hemodynamic Compromise: Objective Evidence for Efficacy of Photopheresis

BACKGROUND

Photopheresis therapy (photo) has been advocated as a therapy to improve outcome after recalcitrant or severe rejection, but objective evidence of a beneficial effect has been elusive. This study examined the hypothesis that photo provides protection against rejection, rejection with hemodynamic compromise (HC), and death from rejection after cardiac transplantation.

METHODS

Between 1990 and 2003, 36 adult patients (from 343 adult transplant recipients) received at least 3 months of photo (2-day treatment every 3 to 6 weeks for a target of 18 months) after HC rejection (n = 12), recurrent/recalcitrant rejection (n = 20), or as prophylaxis in the presence of anti-donor antibodies (n = 4). Survival and risk factors were examined by analysis using multivariate hazard function modulated renewal function.

RESULTS

Patients selected for photo were at greater risk for rejection (p < 0.0001) and HC rejection (p < 0.0001) than non-photo patients. After 3 months of photo therapy, rejection risk was decreased (p = 0.04). More importantly, the hazard for subsequent HC rejection or rejection death was significantly reduced toward the risk-adjusted level of lower-risk non-photo patients (p = 0.006).

CONCLUSIONS

This study provides objective evidence that photo reduces the risk of subsequent HC rejection and/or death from rejection when initiated for patients with high rejection risk. Photopheresis is recommended as an important therapeutic modality after rejection with hemodynamic compromise, although further studies are needed to define the precise mechanism of the effect and the potential for benefit in other patient sub-sets.

Intractable bladder tamponade due to left internal pudendal and obturator arterial bleeding induced by erection: a superselective arteriography followed by transcatheter arterial embolization

Bladder tamponade is an uncommon clinical symptom among men suffering during sexual intercourse. The authors report on a 46-year-old man for whom this symptom appeared 4-5 years prior to hospitalization. Angiography confirmed the presence of left pudendal and obturator arterial bleeding, and embolotherapy of the internal pudendal and obturator arteries was performed. There was no mortality, or limb loss or sexual potency loss at follow-up.

Patients with thrombotic thrombocytopenic purpura commonly develop metabolic alkalosis during therapeutic plasma exchange

Thrombotic thrombocytopenic purpura (TTP) and myasthenia gravis (MG) are category I indications for therapeutic plasma exchange (TPE). This study was based on the hypothesis that the development of metabolic alkalosis during TPE is more common in TTP than in MG, based on our previous observations. In order to test it, we compared the levels of bicarbonate and potassium in both groups of patients undergoing plasmapheresis. Fifteen patients with TTP (190 procedures) and ten MG patients seen concurrently were studied. While baseline bicarbonate levels were similar among all patients, the post-procedure bicarbonate levels in TTP patients were mostly elevated with a mean +/- SD of 29.4 +/- 3.5 mEq/L, as opposed to decreased or unchanged in MG patients 26.3 +/- 3.1 mEq/L (mean +/- SD) (P = 1.4 x 10(-8)). Furthermore, alkalosis in the TTP group persisted throughout subsequent daily treatments. There was also a significant decrease between pre- and post-TPE potassium levels in TTP patients (P = 3 x 10(-21)) by paired Student's t test. Additionally, samples with levels <3.3 mEq/L were alkalotic 75% of the time. In the MG group, however, potassium was normal in 85% and 83% of the pre- and post-TPE samples, respectively. Consequently, the hypokalemia was significantly more marked in the TTP group (P = 0.0008). These data confirm that plasmapheresis commonly induces metabolic alkalosis in TTP patients, probably due to high citrate in fresh frozen plasma, the frequency of treatments, and perhaps decreased renal clearance due to disease involvement of the kidneys.

Improvement of practice performance in urological surgery via clinical pathway implementation

The purpose of this study was to compare performance measurements to evaluate the effects of clinical pathway implementation on improving practice performances in urology. Since April 1997, a total of 18 clinical pathways have been created in the urology department. Of these clinical pathways, six were implemented for endoscopic surgery, and four and eight were for minor and major surgery, respectively. Eight prominent performance measurements, which were identified as representative indicators of the practice performances, were selected in endoscopic surgery, five in minor surgery, and 11 in major surgery. Between April 1997 and March 1999, 2,883 consecutive patients, who underwent endoscopic surgery, minor surgery, and major surgery, were evaluated herein. The treatment results for patients in the first and second years of clinical pathway implementation were compared to those from the year preceding the implementation. In endoscopic surgery, five of the eight performance measurements improved significantly in the first year of implementation. Notably, three of the five improved performances continued to improve in the second year. Similarly, in minor surgery, four of the five performance measurements improved significantly following 2 years. Finally, in major urological surgery, six of the 11 performance measurements also improved significantly after 1 year; four of which continued to improve during the second year. Therefore, we conclude that patient care, which is based on the implementation of clinical pathways, can improve practice performances and facilitate medical care.

ASSESS-3: a randomised, double-blind, flexible-dose clinical trial of the efficacy and safety of oral sildenafil in the treatment of men with erectile dysfunction in Taiwan

The efficacy and safety of sildenafil were evaluated in a randomised, double-blind, placebo-controlled, flexible-dose study in Taiwanese men aged 26 to 80 y with erectile dysfunction (ED) of broad-spectrum aetiology and more than 6 months' duration. A total of 236 patients were randomised at six medical centres in Taiwan to receive either sildenafil (50 mg initially increased if necessary to 100 mg or decreased to 25 mg depending on efficacy and toleration) (n=119) or matching placebo (n=117) taken on an 'as needed' basis 1 h prior to anticipated sexual activity for a period of 12 weeks. At the end of 12 weeks, the primary efficacy variables relating to the achievement and maintenance of erections sufficient for sexual intercourse, and the secondary efficacy variables, which included: (1) the five separate domains of sexual functioning of the IIEF (International Index of Erectile Function) scale, (2) the percentage of successful intercourse attempts; and (3) a global assessment of erections, were all statistically significantly improved by sildenafil in comparison with placebo (P<0.0001). Treatment-related adverse events occurred in 43.7% of patients receiving sildenafil and 18.8% receiving placebo. The most common adverse events with sildenafil were flushing, dizziness and headache (25.2, 6.7 and 5.9% of patients, respectively), and most were mild in nature. The efficacy and safety of sildenafil in the population of Taiwanese men appears similar to that reported in other studies in western populations.

Use of sildenafil citrate in treatment of Taiwanese men with erectile dysfunction: a single center experience

BACKGROUND

We evaluated the efficacy and safety of sildenafil citrate in the treatment of Taiwanese men with erectile dysfunction in the post-marketing era.

METHODS

From March 24, 1999 to September 30, 1999, we evaluated the efficacy and safety of Sildenafil in patients with erectile dysfunction. We used questions 3 and 4 of the International Index of Erectile Function (IIEF) as objective efficacy end-points. The patients used a home medication diary to record the subjective efficacy and side effects of sildenafil and their satisfaction with this drug as well as that of their sexual partners.

RESULTS

There were 415 patients with erectile dysfunction in our survey. Their ages ranged from 29 to 85 years old with a mean of 60 years. Of these, 212 patients (51.1%) returned their home medication diaries. The satisfaction rate of these patients was 81.6% and the satisfaction rate of their sexual partners was 71.2%. About 71% of these patients achieved more than 60% rigidity. The most common side effect was facial flushing (45.8%), followed by dizziness (13.7%), visual disturbances (10.8%), headache (8%), nasal congestion (8%) and dyspepsia (4.7%).

CONCLUSION

Sildenafil citrate is an effective oral medication for the treatment of erectile dysfunction in Taiwanese men. Our study noted more facial flushing and visual disturbances than other studies. These side effects were transient and well tolerated by most of the patients.

Improvement of health outcomes after continued implementation of a clinical pathway for radical nephrectomy

The clinical pathway is an important tool for outcome management. We evaluated the overall effects of the continued implementation of a clinical pathway for radical nephrectomy on the length of hospital stay, admission charges, and the quality of medical care. The data obtained from the second-year implementation (group 3) of the clinical pathway were compared with the data from the first-year implementation (group 2) and the year preceding implementation (group 1). Thirty-seven consecutive patients with renal cell carcinoma underwent radical nephrectomy in group 1, 47 in group 2, and 55 in group 3; all were enrolled in this study. The length of hospital stay, average admission charges, and 8 quality indicators were measured in these patients. We also evaluated the variances in the implementation of the clinical pathway. The mean length of stay decreased by 14.0% (P = 0.0048) in group 2, and by 15.8% (P= 0.0014) in group 3, when compared to group 1. The total admission charges significantly decreased by 19.0% (P = 0.001) in group 2, and by 27.9% (P < 0.0001) in group 3, compared to the charges for group 1. A continued decrease in charges for operation and anesthesia, laboratory, pharmacy, and others were found 2 years after implementation of the clinical pathway. Among the 8 quality indicators, 2 were continuously improved in the second-year implementation of the clinical pathway, 2 were improved significantly in the second-year implementation only, and 4 showed no significant change at all. Variances from the clinical pathway decreased significantly after continued implementation. Continued implementation of the clinical pathway for radical nephrectomy can improve a physician's practice continuously by decreasing the length of hospital stay, admission charges, and variances, and by improving quality. However, the improved results after implementation of the clinical pathway should be maintained carefully to assure good health care.

Reciprocal regulation of nitric oxide and glutamate in the nucleus tractus solitarii of rats

Nitric oxide (NO) and glutamate are both important mediators of the central cardiovascular regulation in the nucleus tractus solitarii. Our previous studies revealed that the central cardiovascular effects of NO in the nucleus tractus solitarii could be inhibited by glutamate receptor blockade. On the other hand, nitric oxide synthase (NOS) inhibitor attenuated the cardiovascular effects of glutamate. Thus, NO and glutamatergic systems appear to interact in central cardiovascular regulation. The present study examined whether NO and glutamate may affect each other's release/production in the nucleus tractus solitarii. A microdialysis probe was implanted into the nucleus tractus solitarii of male Sprague-Dawley rats, and the changes in the extracellular levels of glutamate and NO were determined by high performance liquid chromatography coupled with electrochemical detection and an NO analyzer, respectively. The results showed that NO solution elicited >10 fold increases in the extracellular level of glutamate, which returned to normal 60 min after the end of NO perfusion. The NO donor N-acetyl-penicillamine (SNAP) had an effect similar to NO solution. Furthermore, the glutamate level was reduced to 61% of basal value by perfusion with the NOS inhibitor, N(G)-monomethyl-L-arginine (L-NMMA). When glutamate receptor agonist N-methyl-D-aspartic acid (NMDA) or alpha-amino-3-hydroxy-5-methylixoxazole-4-propionic acid (AMPA) was administered into the nucleus tractus solitarii, the extracellular NO level was increased by 70-100%, whereas glutamate receptor antagonists (MK-801 hydrogen maleate and 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX)) did not alter the basal levels of NO. These results suggest that NO and glutamate may enhance each other's release/production in the nucleus tractus solitarii. This reciprocal regulation of NO and glutamate may be important in central cardiovascular control in the nucleus tractus solitarii.

Improvement of medical care quality after implementation of a clinical path monitoring program for transurethral prostatectomy patients

OBJECTIVES

The purpose of this study was to determine the effect on quality of care through the implementation of a clinical path for patients receiving transurethral prostatectomy.

METHODS

We selected ten quality indicators with important clinical relevance as representative elements of the clinical path. These quality indicators were monitored during the entire hospitalization period of 100 consecutive patients who received transurethral prostatectomy. Monitoring data obtained from these patients were compared to data from 100 patients who received transurethral prostatectomy prior to implementation of the clinical path. Data was assessed to determine the relationship between quality indicators and management processes.

RESULTS

Implementation of the clinical path for transurethral prostatectomy significantly decreased the percent of patients with incomplete preoperative tests on admission day, the duration of intravenous antibiotics administration, the percent of patients who required acute pain management postoperatively, the percent of patients who received postoperative bladder irrigation with normal saline and the percent of patients who had their Foley catheter removed after postoperative day 2. Three of the quality indicators had a significant relationship with management processes and may have directly affected the total admission charges.

CONCLUSIONS

To evaluate the effect of the transurethral prostatectomy clinical path implementation on the quality of medical care, we compared ten quality indicators before and after implementation of this path. We concluded that implementation of the clinical path resulted in a statistically significant improvement in the quality of medical care.

Identification of immune-related protein kinases from mosquitoes (Aedes aegypti)

Protein kinases are known to be involved in signal transduction for numerous physiological events. However, little is known about the roles of protein kinases in insect immunity. A fragment around 150 bp was amplified by polymerase chain reaction using cDNA templates from bacterial inoculated mosquitoes and primers corresponding to the conserved domain of protein kinases. Based on sequence analysis, 11 groups of protein kinases were characterized including 3 nonreceptor tyrosine kinases, 3 receptor tyrosine kinases, 3 serine/threonine kinases, and 2 novel protein kinases. The most abundant kinase obtained in this study reveals a high degree of similarity to human cholinesterase-related cell division controller (CHED) protein kinase. The expression of this mosquito CHED-like kinase is not detectable in normal female mosquitoes, but induced only after bacterial inoculation and trauma. A mosquito protein kinase was demonstrated to share homology with a plant Tousled gene, but has not yet been characterized in the animal system. In addition, analysis of the sequences of several protein kinases cloned from mosquitoes suggests that they might be involved in the regulation of cellular or humoral immunity.

Adrenal ganglioneuroma: report of five cases

Adrenal ganglioneuromas are rare tumors originating from the neural crest tissue of the sympathetic nervous system. The clinical presentation of most patients is asymptomatic, and most of these tumors are hormone silent. Usually the tumor is detected incidentally by abdominal imaging studies for unrelated reasons. Herein, we review our cases of adrenal ganglioneuroma over the past 20 years. All patients diagnosed with primary adrenal ganglioneuroma between 1979 and 1999 were reviewed. There were 5 cases of pathologically confirmed adrenal ganglioneuroma. All patients underwent surgical excision of the adrenal tumors. The mean age of the 5 patients (3 women and 2 men) was 27 years (range, 11 to 45 years). The average diameter of the tumor was 8.2 cm (range, 6 to 10 cm). The mean follow-up period was 33.6 months (range, 3 to 92 months). One case involved mesenteric lymph nodes. This patient had persistent hypertension following the operation, but no evidence of tumor recurrence was noted over the 7-year follow-up period. The prognosis was excellent after surgical excision in our series. Awareness of this rare entity may add to the differential diagnoses of adrenal masses preoperatively.

Leiomyoma of the epididymis: case report

Herein, we report on a rare case of leiomyoma of the epididymis. The case we present involved a 55-year-old patient who had had a painless left scrotal mass for 20 years. The mass was round and elastic and measured about 2 x 2 x 2 cm. We recognized the mass as a benign tumor by scrotal ultrasonography and performed an organ salvage operation for this patient. The final pathologic diagnosis of the mass was leiomyoma. Our report includes a detailed description of the ultrasonographic characteristics of this disease as well as a review of the literature. In general, sharp acoustic shadows with central hypoechoic lesions in heterogenous parenchyma are the distinctive characteristics of leiomyoma of the epididymis. We also discuss the possibility of a testis salvage operation for this type of disease. We conclude that the ultrasonographic characteristics can serve as an important guide for the surgeon to consider an organ salvage operation in cases of a painless scrotal mass.

Use of a medical decision support system to improve the preoperative diagnosis of prostate cancer with pelvic lymph node metastases

BACKGROUND

We evaluated the effects of a medical decision support system on the preoperative diagnosis of prostate cancer with pelvic lymph node metastases.

METHODS

The preoperative accuracy of staging prostate cancer with pelvic lymph node metastasis by the prostate cancer expert system (PCES) for 43 patients was compared to the accuracy of staging performed by 2 urological attending physicians and 5 residents, to test the validity of the PCES. The effect of PCES consultation on physicians' staging for prostate cancer with pelvic lymph node involvement was evaluated.

RESULTS

In the diagnosis of prostate cancer with pelvic lymph node metastasis, PCES was significantly more accurate than the two attending physicians alone (p = 0.042; p = 0.008). All the urological residents' diagnoses were significantly less accurate than those of the PCES. After PCES consultation, all the urological residents increased diagnostic specificity significantly. Most residents usually used PCES for consultation only after the attending physician or department asked for the results.

CONCLUSION

Owing to an increased ability for preoperative diagnosis of prostate cancer with pelvic lymph node metastasis, as supported by the PCES, some unnecessary pelvic lymphadenectomies may be avoided.

The implementation of clinical paths for six common urological procedures, and an analysis of variances

OBJECTIVE

To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths.

PATIENTS AND METHODS

The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation.

RESULTS

The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0. 01), but the mortality and readmission rate did not increase.

CONCLUSIONS

The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.

Evaluation of a decision-support system for preoperative staging of prostate cancer

The usefulness and effectiveness of a decision-support system for preoperative staging of prostate cancers (PCES) were evaluated. The study population consisted of 43 consecutive patients with the preoperative diagnosis of prostate cancer who underwent surgical operation. Results obtained using the PCES were compared with staging by four urology attending physicians and five urology residents. The effect of PCES consultation on the physicians' staging of prostate cancer was also evaluated. To confirm the usefulness of the clinical findings of prostate-specific antigen, prostate-specific antigen density, prostate volume, and abnormal Gleason score in the PCES, their receiver operating characteristic (ROC) curves for diagnosis of advanced prostate cancer were plotted. The values of the areas under the curves were 0.772, 0.800, 0.531, and 0.752. The stage of prostate cancer was correctly determined by the PCES for 38 of the 43 patients, yielding 88.4% preoperative diagnostic accuracy. The PCES was significantly more accurate than two of the attending physicians and all residents. PCES consultation improved the residents' staging accuracy to approximately that of the attending physicians. The effect of PCES consultation on the residents' staging was significantly (p < 0.001) greater than the effect on the physicians' staging. The PCES may be useful in the preoperative staging of prostate cancers, especially during residency. The system's accuracy in determining the stage of advanced prostate cancer may make it possible to avoid unneccesary surgical operations.

Does the use of clinical paths improve the efficiency and quality of care under the case payment system for inguinal herniorrhaphy or transurethral prostatectomy?

BACKGROUND

We evaluated the effects of implementing clinical paths for both inguinal herniorrhaphy (IH) and transurethral prostatectomy (TURP) on the efficiency and quality of medical care under the case payment system.

METHODS

Patients undergoing IH or TURP were treated using the guidelines for clinical paths under the case payment system (CPUCP). The results of treatment after implementation of CPUCP were compared with results for patients treated before implementation of CPUCP. We also compared results using eight quality indicators both before and after implementation of CPUCP.

RESULTS

The post-CPUCP length of hospital stay decreased significantly in patients who underwent either IH (p < 0.001) or TURP (p = 0.008). The post-CPUCP total admission charges decreased (p = 0.001) by 7.5% in the IH group alone. Two quality indicators in the IH group and three quality indicators in the TURP group were significantly improved after implementation of CPUCP. The percentage of patients who completed treatment without deviation as recommended by the guidelines for CPUCP was about 60% in the IH group and about 70% in the TURP group.

CONCLUSION

The results of this study indicate that the implementation of clinical paths under the case payment system for patients undergoing inguinal herniorrhaphy or transurethral prostatectomy can improve the efficiency and quality of medical care.

Effects of implementation of 18 clinical pathways on costs and quality of care among patients undergoing urological surgery

PURPOSE

We evaluated the effects on the costs and quality of care of implementation of 18 clinical pathways for urological operations.

MATERIALS AND METHODS

From April 1997 to March 1998 patients undergoing 1 of 18 urological operations were treated according to clinical pathways. The outcomes in terms of length of hospital stay and admission charges of these patients were compared with those of patients treated between April 1996 and March 1997 before clinical pathways were implemented. We also selected 7 clinically relevant quality indicators to assess the quality of care before and after clinical pathway implementation.

RESULTS

Of the 1,784 patients undergoing urological surgery from April 1997 to March 1998, 1,382 (77.5%) were treated according to 1 of the 18 clinical pathways. Before implementation 1,279 of 1,615 patients (79.2%) underwent these procedures. The length of hospital stay decreased from 5.5 to 4.9 days (p < 0.01) and the average hospital admission charges decreased by 12.9% (p < 0.01) after implementation. Five of the quality indicators, including the rate of surgical complications, were significantly improved after pathway implementation. The hospitalization rate was not affected (1.3 before versus 0.8% after implementation, p = 0.18). Variations from the clinical pathways occurred in 543 cases (39.3%) and affected the length of hospital stay only (11.6%) or the admission charge only (12.9%) more often than both (7.8%, p < 0.01) or neither (7.0%, p < 0.01). The most common variances in these patients were patient related (30.8%).

CONCLUSIONS

Implementation of multiple clinical pathways in a urology department can improve urological practice by decreasing the length of hospital stay, admission charges and rate of surgical complications, and by improving the quality of care.

Glucocorticoids inhibit serum depletion-induced apoptosis in T lymphocytes expressing Bcl-2

Depletion of growth factors and glucocorticoids are known to induce apoptosis and inhibit growth in T lymphocytes. We have examined the effect of Bcl-2 expression on the cellular response to growth factor depletion in the presence or absence of glucocorticoids. Cell growth was determined by cell counting and viability was quantitated by dye exclusion. Apoptosis was evaluated by flow cytometry, analysis of DNA integrity, and enzymatic determination of caspase-3-like activity. Serum depletion and glucocorticoid administration inhibited cell growth and stimulated apoptosis in Bcl-2 negative cells. Cotreatment with both stimuli had additive effects on apoptosis but not on inhibition of cell growth. Bcl-2 expression abrogated the repressive effect of glucocorticoids on apoptosis but not on cell growth. In contrast, neither apoptosis nor growth inhibition induced by serum depletion of cells was blocked by Bcl-2 expression. However, glucocorticoid treatment of Bcl-2-overexpressing cells protected them from apoptosis induced by serum depletion. Glucocorticoid protection of Bcl-2-overexpressing cells from serum depletion-induced apoptosis was mimicked by other inducers of apoptosis, which act to inhibit protein synthesis. These data suggest that Bcl-2 expression can switch the effect of glucocorticoids from proapoptotic to antiapoptotic when lymphocytes expressing Bcl-2 are exposed to other apoptotic stimuli.

Squamous cell carcinoma of the bladder: a ten-year retrospective study

BACKGROUND

There is a limited amount of information available on treatment efficacy and optimal management of squamous cell carcinoma of bladder. The goal of this study was to assess the long-term outcome of patients with squamous cell carcinoma of the bladder treated using different modalities.

MATERIALS AND METHODS

Retrospective analysis of the medical records of 22 patients with squamous cell carcinoma of the bladder treated at Chang Gung Memorial Hospital from 1986 though 1996 was performed. The follow-up period ranged from 12 months to 111 months.

RESULTS

The treatment modalities included transurethral resection in 7 patients, radical cystectomy with urinary diversion in 6 patients, preoperative radiation followed by total cystectomy in 8 patients, and partial cystectomy in one patient. The overall 5-year survival rate was 9%. Only 6 patients (27.3%) in this series were alive two years after diagnosis. Treatment using a combination of modalities including preoperative radiation followed by total cystectomy resulted in a 5-year survival rate of 12.5% in 8 patients. Total cystectomy alone in 6 patients resulted in a 5-year survival rate of 0%. However, the difference in survival rates between these 2 treatment groups was not statistically significant.

CONCLUSION

Our results suggest that no definite significance concerning the role of preoperative radiation followed by total cystectomy could be drawn. The results were probably because most of our patients had locally advanced bladder cancer. Another consideration is the small sample size, which may have affected the significance. Although, cystectomy did not improve the 5-year survival rate of patients in this series, it improved the 2-year survival rate.

Electroacupuncture decreases c-fos expression in the spinal cord induced by noxious stimulation of the rat bladder

PURPOSE

The present study investigated the effects of noxious stimulation of the lower urinary tract on neuronal fos protein expression in the spinal micturition center of rats and also examined the effects of electroacupuncture (EA) on fos expression induced by noxious stimulation of the lower urinary tract.

MATERIALS AND METHODS

Experiments were conducted on 21 female Sprague-Dawley rats divided into four groups. Group 1 rats (n = 5) served as normal controls. Group 2 rats (n = 5) received EA at the Sanyinjiao acupoint. Group 3 animals (n = 6) were catheterized through the urethra and instilled with 1% acetic acid, and group 4 (n = 5) animals received EA 1 hour before 1% acetic acid instillation. All animals underwent arterial perfusion, laminectomy, and spinal cord removal. Spinal cords were sectioned and processed for immunohistochemical staining for fos protein.

RESULTS

No fos protein was detected in any spinal neurons in normal control animals, and either none or few (0 to 4 cells/section) fos-immunoreactive (fos-IR) cells were seen in animals treated with EA. Noxious stimulation of the lower urinary tract with 1% acetic acid drastically increased the number of fos-IR neurons (30 to 127 cells/L6 section, mean 76.17+/-13.98; 28 to 77, cells/S1 section, mean 59+/-8.30; 7 to 35 cells/S2 section, mean 19.83+/-4.10). However, EA administered 1 hour before 1% acetic acid instillation significantly decreased the number of fos-IR neurons resulting from chemical irritation (0 to 50 cells/L6 section, mean 19.8+/-9.33; 0 to 47 cells/S1 section, mean 13.2+/-9.12; 0 to 37 cells/S2 section, mean 13.6+/-7.31).

CONCLUSIONS

Our study demonstrates that bladder instillation with 1% acetic acid induces fos protein expression in the spinal micturition center of the rat and that electroacupuncture can reduce this expression. These results suggest a link between electroacupuncture and reduction in spinal neuronal cell activity.

Blood supply of esophageal stumps

BACKGROUND/AIMS

The purpose of the study was to determine the blood supply of stumps of mobilized esophagus.

METHODOLOGY

Esophageal stumps of five groups of rabbits were studied. The esophageal stumps were dyed via intravenous injection of trypan blue, and were analyzed by color image processing.

RESULTS

The dyed length of the esophageal stump was 7.15+/-0.5 cm in the stomach-connecting group; 4.6+/-0.69 cm in the stomach-connecting with myotomy group; 6.1+/-0.88 cm in the distal stomach-connecting group; 3.0+/-0.47 cm in the neck-connecting group; and, 2.1+/-0.2 cm in the neck-connecting with myotomy group. There was a significant difference in the dyed length between the stomach-connecting and neck-connecting groups (p=0.000), and between the stomach-connecting and stomach-connecting with myotomy groups (p=0.026), but there was no significant difference between the neck-connecting and neck-connecting with myotomy (p=0.094), or the stomach-connecting and distal stomach-connecting groups (p=0.053).

CONCLUSIONS

Stumps of the mobilized esophagus in rabbits, with or without myotomy, exhibit differences in dyed length, depending on the diameter, wall thickness and location of the blood supply in the esophagus.

The early effect of pelvic floor muscle exercise after transurethral prostatectomy

PURPOSE

We evaluate the early effect of pelvic floor muscle exercise on the frequency of urination, terminal dribbling, urinary incontinence and satisfaction with life in patients after transurethral prostatectomy.

MATERIALS AND METHODS

From February to October 1996, 50 patients who had undergone transurethral prostatectomy were selected for study. The first 25 men served as a control group and the next 25 were the experimental group. Pelvic floor muscle exercise was started after removal of the Foley catheter postoperatively in the experimental group. The patients were evaluated before pelvic floor muscle exercise and weekly at our outpatient department after discharge from the hospital. Results for the later 25 patients treated with the pelvic floor muscle exercise program were compared to those of the prior 25 patients.

RESULTS

There was a statistically significant difference (p <0.05) in the strength of pelvic floor muscle contractions at 4 weeks, length of between void interval (p <0.01), terminal dribbling at week 4 (p <0.05) and urinary incontinence at weeks 3 and 4 between the 2 groups after pelvic floor muscle exercise. During this study no complication or mortality occurred and there were no cases of hospitalization for either group. After pelvic floor muscle exercise patients in the experimental group had better satisfaction with life than the control group (p <0.01).

CONCLUSIONS

We conclude that pelvic floor muscle exercise seems to help reduce symptoms within the first 4 weeks after transurethral prostatectomy, and provides better psychological and social quality of life.

Ethambutol-induced pulmonary infiltrates with fever and skin rash: a case report

A 55-year-old man presented with the suspicion of pulmonary tuberculosis. He was treated with isoniazid, ethambutol, rifampicin and pyrazinamide. However, he developed high fever, skin rash and pulmonary infiltrates following 10 days of treatment. The above-mentioned conditions subsided promptly after stopping ethambutol therapy and reappeared after rechallenge, marking ethambutol as the offender. To present knowledge, this is the second case of an ethambutol-induced hypersensitivity lung reaction reported in English literature.

Improvements in the efficiency of care after implementing a clinical-care pathway for transurethral prostatectomy

OBJECTIVE

To investigate the efficiency of care, length of hospital stay and admission charges after implementing a clinical-care pathway for transurethral prostatectomy (TURP).

PATIENTS AND METHODS

Changes in the length of hospital stay and admission charges were identified by comparing a series of 100 patients undergoing TURP and treated after implementing a clinical-care pathway with 100 patients treated by the same physicians before implementation.

RESULTS

After implementing the care pathway, the mean length of hospital stay and admission charges were significantly lower (P < 0.01). The shorter length of stay was caused by a significant reduction (P < 0.05) in patient-related psychological/social delay after implementation. The number of laboratory tests and use of pharmacological agents were also significantly lower (P < 0.001) after implementation, with the decreases in these last variables significantly greater (P < 0.001) among junior physicians.

CONCLUSIONS

The advantages of the TURP clinical-care pathway were the shorter hospital stay, arising from reduced patient-related psychological or social delay, and reduced admission charges consequent on the decreased use of laboratory tests and drugs, particularly for patients treated by junior physicians. These results suggest that physicians are likely to modify their management methods to improve efficiency when a clinical path is implemented.

Progress toward preparation of universal donor red cells

Coupling of an inert polymer to the surface of red cells was examined as a potential means of covering blood group antigens and producing cells that could serve as universal donor cells for transfusion. Effective blockade of red cell antigens was achieved with N-hydroxysuccinimide-activated esters of polyethylene glycol. It was possible to block all antigens tested, but lower concentrations of reactants were required to block peptide-defined antigens than carbohydrate-defined antigens. Red cells remained intact after modification but were significantly damaged. Our results demonstrate the feasibility of antigenic blockade of red cells, but there is a need to reduce damage during coupling reactions to produce viable red cells.

Carboxylate ions are strong allosteric ligands for the HisB10 sites of the R-state insulin hexamer

The insulin hexamer is an allosteric protein which displays positive and negative cooperativity and half-site reactivity that is modulated by strong homotropic and heterotropic ligand binding interactions at two different loci. These loci consist of phenolic pockets situated on the dimer-dimer interfaces of T-R and R-R subunit pairs and of anion sites comprising the HisB10 metal ion sites of the R3 units of the T3R3 and R6 states. In this study, we show that suitably tailored organic carboxylates are strong allosteric effectors with relatively high affinities for the R-state HisB10 metal sites. Methods of quantifying the relative affinities of ligands for these sites in both Co(II)- and Zn(II)-substituted insulin hexamers are presented. These analyses show that, in addition to the electron density on the ion, the carboxylate affinity is influenced by polar, nonpolar, and hydrophobic interactions between substituents on the carboxylate and the amphipathic protein surface of the narrow tunnel which controls ligand access to the metal ion. Since the binding of anions to the HisB10 site makes a critically important contribution to the stability of the T3R3 and R6 forms of the insulin hexamer, the design of high-affinity ligands with a carboxylate donor for coordination to the metal ion provides an opportunity for constructing insulin formulations with improved pharmaceutical properties.

The Assignment of Absolute and Relative Depth in Constructing a 3-D Mental Model from Viewed Orthographic Displays

Constructing the 3-D mental structure from viewed 2-D orthographic displays may require establishing both the relative depth relation (RD) between adjacent areas in the orthographic displays and the exact magnitude of absolute depth (AD) for a given area. We examined the processes of depth assignment involved in 3-D model construction by asking subjects to mentally imagine the 3-D object portrayed by a pair of orthographic projections, and then choose among four alternative isometrics the one that matched the imagined 3-D model. One alternative corresponded to the previously shown orthographic views (ie, target). The other alternatives were distractors that differed from the target in terms of RD, AD, or both.

Results from four experiments show that (a) when subjects mistook a distractor for target, they were more likely to misidentify the distractor sharing the same RD with target but with different AD, than to misidentify the distractor sharing the same AD but with different RD; (b) subjects could shorten their solution time by 40% without greatly compromising their performances when times available for imagining 3-D models were reduced in proportion to those consumed in a self-pacing condition. The implications of these results are discussed in terms of a model in which an observer may try to decide the relative depth prior to figuring out the exact absolute depth, although it is necessary to consider both aspects of depth assignment in the construction of 3-D mental models.

mRNA and protein expression of nitric oxide synthase and adrenoceptor alpha 1 in young and old rat penile tissues

OBJECTIVE

To investigate alterations of neuronal structure and the mRNA expression of nitric oxide synthase (NOS) and adrenoceptor alpha 1 in young and old rat penile tissues, and assess the importance of these factors in erectile dysfunction (ED) associated with ageing.

MATERIALS AND METHODS

NOS was determined in the pelvic ganglia of 32 rats using nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase staining. Adrenergic neurons were identified by histofluorescence staining. The gene expression for NOS and for adrenoceptor alpha 1 was investigated in corporal tissue by differential reverse transcriptase-polymerase chain reaction (RT-PCR) using specific oligonucleotide primers. b-actin was used as an internal standard in each tube to quantify the baseline gene expression.

RESULTS

The following changes occurred in old rats: (i) an increase of lipofuscin and a decrease in both bNOS-containing neurons and fluorescent adrenergic neurons in the pelvic ganglia; (ii) significantly less expression of NOS mRNA than in young rat penile tissues; and (iii) no significant alteration in adrenoreceptor alpha 1 mRNA expression.

CONCLUSIONS

The fewer adrenergic and NOS-containing neurons and neurotransmitters in pelvic ganglia from old rats may explain the enhanced penile smooth muscle tone previously reported in older impotent men. Furthermore, lower mRNA expression of NOS may be associated with structural and functional changes associated with ageing penile tissue.

Use of the transurethral prostatectomy clinical path to monitor health outcomes

PURPOSE

We evaluated the effect on cost and medical care quality of use of the transurethral prostatectomy clinical path.

MATERIALS AND METHODS

Results in 100 patients treated when the transurethral prostatectomy clinical path was used were compared to those of 100 treated by the same physicians before implementation of this path.

RESULTS

After implementation of the transurethral prostatectomy clinical path the length of hospital stay was significantly decreased from 5.9 to 5.0 days (p < 0.01) and Foley catheterization time was significantly decreased from 3.13 to 2.84 days (p < 0.01). Antibiotics were routinely used from the day before surgery to the day of hospital discharge as required by patient conditions. Therefore, a shorter hospital stay will significantly decrease the use of antibiotics. After implementation of the clinical path the average admission charges were decreased significantly by 17% (p < 0.01). Although some results from use of this path will not significantly affect costs, they will reflect some quality improvement. The effect of clinical path implementation on length of hospital stay between patients treated by junior and senior attending physicians was not significant. However, there was a statistically significant difference (p < 0.01) between results obtained by junior and senior attending physicians regarding average admission charges.

CONCLUSIONS

Implementation of the transurethral prostatectomy clinical path can improve health care outcome by decreasing length of stay and admission charges, and improving quality of medical care, particularly for patients treated by junior attending physicians.

[The loss-grief reaction and coping behavior of a mother whose child died of a brain tumor]

This is a study on the loss-grief reaction and coping behavior of a mother whose child died of brain tumor. The researcher used field methods to collect data and analyze observations of mother-nurse interaction. The results showed that this mother had self-blame depression, and guilt feelings and affected the whole family. With the help of nurses and various supportive resources the mother was finally able to go through the grieving process smoothly.

The patterns of dental caries of preschool children in Kaohsiung City Taiwan

In order to understand caries patterns, we investigated the severity of caries and the distribution of decayed teeth in 1,654 preschool children aged 3-6 years old in Kaohsiung, Taiwan. The results of our investigation were as follows: the lower second molars had the highest percentage of caries followed by the upper central incisors in the deciduous teeth. The distribution of decayed surfaces in the upper dentition indicated that the occlusal surface of molars, the labial surface of canines, and the mesial and labial surfaces of incisors had relatively high percentages of caries in all age groups. In the 3 year-old children, labial caries on the four upper anterior teeth and no caries in the lower anterior teeth is basically similar to baby bottle tooth decay. Most caries remained in the enamel at this stage. Dentin caries and pulp involved caries became more complex and multiple surfaces were involved in both 5 and 6 year-old children. We therefore suggest that 6, 18, and 30 month-old babies, at the time of vaccination, should have an oral examination as well, and the prevention program for baby bottle tooth decay plus oral hygiene instructions should also be given to the parents. Dentists, pediatricians, gynecologists, and family doctors should all participate in the prevention program against baby bottle tooth decay. For 3 year-old children who already have caries, increasing the filling rate for them should be a very important thing to do for pedodontic specialists and general dental practitioners alike.

The use of alprostadil sterile powder in a home self-injection study of Asian men with erectile dysfunction

This study evaluated the individual optimal dose of alprostadil in the office setting that could be used as the basis for effective home self-injection therapy. The study included 150 Asian men with erectile dysfunction (ED). The mean age of study participants was 48.3 years (range, 21 to 74 years), and the mean duration of ED was 3.6 years. The most common cause of ED was venogenic (24%), psychogenic (21%), arteriogenic (13%), neurogenic (0.7%), or a combination of these (41%). An optimal response was seen in 72% of patients (n = 108) in the office and 96% of patients (n = 100) at home. The mean +/- SD office dose of alprostadil was 19.4 +/- 12.8 micrograms versus 18.0 +/- 12.2 micrograms at home. More than half of the patients (57% in an office setting and 53% at home) achieved an optimal response at a dose between 5 and 15 micrograms. By the 20-micrograms dose, 82% of patients had achieved an optimal dose at home compared with 70% of patients in the office. An optimal response was seen at the same dose in the office and home in 75% of patients; the dose at home decreased from the office dose for 16% of the patients and increased for 9%. There were 24 patients who experienced adverse events: penile pain after injection (18 patients), cold sweating (2 patients), pediculosis (1 patient), broken leg (1 patient), ankle pain (1 patient), and prolonged erection (1 patient). One patient discontinued the study because of penile pain. Alprostadil sterile powder offered safe and effective treatment of ED for home self-injection therapy. Once an optimal dose response had been established in the physician's office, further home adjustments were needed in 25% of patients. Penile pain, usually mild, was the most common, possibly related adverse effect reported.

Effects of a medical expert system on differential diagnosis of renal masses: a prospective study

A medical expert system, RMDS, was used to prospectively evaluate patients undergoing nephrectomy for suspected renal masses. The effects of a medical expert system on differential diagnosis of renal masses were investigated. After RMDS consultation, three chief residents and one junior attending physician changed their preoperative diagnosis and significantly increased their diagnostic accuracy. The results indicate that the medical expert system may have an useful role in preoperative diagnosis of renal masses.

Ligand binding to wild-type and E-B13Q mutant insulins: a three-state allosteric model system showing half-site reactivity

By using ultra-violet and visible absorbance in conjunction with high field 1H-nuclear magnetic resonance spectroscopy, the insulin hexamer has been shown to undergo two allosteric transitions in solution involving three allosteric states (T6<-->T3 R3<-->R6). A simple mathematical model consisting of four variables has been derived that quantitatively describes the complex homotropic and heterotropic interactions that modulate these allosteric transitions. The mutation of one residue, Glu-B13 to Gln, results in an unexpected change in the T3R3 to R6 equilibrium by a factor of 10(7).

Effects of fluoride on dental pulp of young rabbits

Fluoride has been adopting as an anticariogenic agent for many years. Many histologic experiments with the effect of fluoride were made on dental hard tissue, but little is known about its effect on dental pulp. We made histopathological tests on dental pulp of rabbits during administration of fluoride. In this study, 24 young New Zealand rabbits aged 7 days were used. The experimental group (N = 20) was given two intraperitoneal injections of sodium fluoride that contained approximately 7 mg F/kg body mass. The control group (N = 4) was injected with an equivalent volume of normal saline. At the thirteenth day after the final injection, the mandibles were collected and processed according to routine histologic methods. Selected sections were stained with hematoxylin and eosin stain. The mandibular incisor pulp was microscopically examined. The following results were obtained. In the experimental group, histopathologic alterations were observed in the pulp, with loss of palisading of the odontoblastic layer. Slightly elongated swollen odontoblasts were found which showed hydropic alterations. Dilatation and hyperemia of blood vessels were also noted. This dose affected deciduous root resorption and changes in secretory ameloblasts; and also appeared to disturb the dental pulp. The present observations of initial reactions in the pulp following intraperitoneal injection of fluoride are considered suitable as a basis for detailed discussion of histopathologic implications.

[The comparison of shear bond strength of orthodontic brackets to bovine enamel pretreated by different conditions of Nd-YAG laser]

Laser beams can cause the enamel surface roughly which is similar to the effect of the traditional acid-etching technique. We wanted to study the possibility of the application of the laser on enamel etching. In this study we treated the enamel with different energy levels for orthodontic bracket placement and measuring the shear bond strength. 104 bovine teeth were polished by 600 # grit sandpaper, then cut, embedded, set and divided into 13 groups. The control group was not treated. 12 different energy levels (10pps 50, 70, 85, 100mJ; 15pps 83.3mJ; 20pps 50, 87.5, 100, 150mJ; 30pps 50, 86.7, 100mJ) were treated on the enamel. The orthodontic brackets were placed on 8 specimens of each group with orthodontic resin (Ormco). Then, the specimens were put in 37 degrees C water bath for 24 hours. 7 specimens of the control group of brackets fell off after water bath. The shear forces of the other 97 specimens were measured by the Instron at a crosshead speed of 0.5 mm/min. The shear strength of the only one specimen of the control group was 0.1MPa. The results for the range of shear strength of the laser group were 2.66-5.53MPa. The shear strength increased proportionately to the energy density. Because the mean shear strength of the laser group were significantly high, we can refer the practical application in orthodontic clinic. The laser beam only affected the area coated with Chinese ink, so the treated area is controllable. The fracture surface of the laser-etched was smooth.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pheochromocytoma nuclear pattern analysis by flow cytometry]

Flow cytometric nuclear DNA analyses were performed on paraffin-embedded tissue samples taken from 39 patients with pheochromocytoma treated between 1981 and 1992. The Hedley technique was used for measurement of nuclear DNA contents. Only 30 cases out of the 39 tumors were available for the determination of DNA ploidy analyses. Ten cases (33.3%) showed a diploidy pattern, 8-cases (27%) showed an aneuploidy pattern and 12 cases (40%) revealed a tetraploidy pattern. Four cases of malignant pheochromocytoma with regional or distal metastasis had been noted during a mean follow-up period of 4.75 years. All these four cases showed tetraploidy nuclear pattern with vascular invasion on pathological examination, which was statistically significant (p < 0.001) in differentiation between benign and malignant pheochromocytoma. About one third of patients with tetraploidy appeared to have malignant tendencies and this was statistically significant (p < 0.05). None of the patients with either diploidy or aneuploidy pattern had disease progression. The location of the tumor (adrenal vs. extra-adrenal) and 24 hours urine total vanillylmandelic acid (VMA) amounts were not significantly different from the diploid, aneuploid or tetraploid groups. These results suggested that nuclear DNA ploidy pattern is an important independent, and useful prognostic factor for patients with pheochromocytoma.

[A radiographic survey of root resorption in pulpless primary teeth]

The goal of this article is to survey the relation between root resorption types and sex, age, pulpless source, tooth position of pulpless primary central incisors. Healthy children with pulpless primary maxillary central incisors were systematically selected from the Kaohsiung Medical College Hospital Pedodontic Department. After a complete recording of age (3-6y/o), Sex (male, female), pulpless source (caries, trauma), and tooth position (#51, #61), the bisecting angle technique was used to take periapical X-ray film of pulpless primary maxillary central incisors. A total of 112 pulpless primary central incisors was collected and classified into 5 types: Type I--mild resorption Type II--end-cutting resorption Type III--semi-circumferential resorption Type IV--circumferential resorption Type V--irregular resorption 15 teeth (13.4%) were classified as type I, 27 teeth (24.1%) classified as type II, 35 teeth (31.2%) as type III, 30 teeth (26.8%) as type IV, and 5 teeth (4.5%) classified as type V. Chi-square analysis between root resorption types and sex, age, pulpless source, tooth position were performed, and two results were noted: (1) There are no relation between root resorption types and sex, age, tooth position. (2) There is a close relation between root resorption type and pulpless source. The pulpless teeth caused by caries tend to be resorbed as type III and type IV; on the other hand, the pulpless teeth caused by a traumatic source tend to behave like type I and type II.