Klotho Overexpression Is Frequently Associated With Upstream Rearrangements in Fusion-Negative Phosphaturic Mesenchymal Tumors of Bone and Sinonasal Tract

Phosphaturic mesenchymal tumors (PMT) are uncommon neoplasms that cause hypophosphatemia/osteomalacia mainly by secreting fibroblast growth factor 23. We previously identified FN1::FGFR1/FGF1 fusions in nearly half of the PMTs and frequent KL (Klotho or α-Klotho) overexpression in only those with no known fusion. Here, we studied a larger cohort of PMTs for KL expression and alterations. By FN1 break-apart fluorescence in situ hybridization (FISH) and reappraisal of previous RNA sequencing data, 6 tumors previously considered "fusion-negative" (defined by negative results of FISH for FN1::FGFR1 fusion and FGF1 break-apart and/or of RNA sequencing) were reclassified as fusion-positive PMTs, including 1 containing a novel FN1::ZACN fusion. The final cohort of fusion-negative PMTs included 33 tumors from 32 patients, which occurred in the bone (n = 18), soft tissue (n = 10), sinonasal tract (n = 4), and brain (n = 1). In combination with previous work, RNA sequencing, RNA in situ hybridization, and immunohistochemistry showed largely concordant results and demonstrated KL/α-Klotho overexpression in 17 of the 28 fusion-negative and none of the 10 fusion-positive PMTs studied. Prompted by a patient in this cohort harboring germline KL upstream translocation with systemic α-Klotho overexpression and multifocal PMTs, FISH was performed and revealed KL rearrangement in 16 of the 33 fusion-negative PMTs (one also with amplification), including 14 of the 17 cases with KL/α-Klotho overexpression and none of the 11 KL/α-Klotho-low fusion-negative and 11 fusion-positive cases studied. Whole genomic sequencing confirmed translocation and inversion in 2 FISH-positive cases involving the KL upstream region, warranting further investigation into the mechanism whereby these rearrangements may lead to KL upregulation. Methylated DNA immunoprecipitation and sequencing suggested no major role of promoter methylation in KL regulation in PMT. Interestingly, KL-high/-rearranged cases seemed to form a clinicopathologically homogeneous group, showing a predilection for skeletal/sinonasal locations and typically matrix-poor, cellular solitary fibrous tumor-like morphology. Importantly, FGFR1 signaling pathways were upregulated in fusion-negative PMTs regardless of the KL status compared with non-PMT mesenchymal tumors by gene set enrichment analysis, perhaps justifying FGFR1 inhibition in treating this subset of PMTs.

Prognosis of medication-related osteonecrosis of the jaws in cancer patients using antiresorptive agent zoledronic acid

BACKGROUND/PURPOSE

Anti-resorptive agents are commonly used in cancer patients with bone metastasis or multiple myeloma (MM). An adverse event termed medication-related osteonecrosis of the jaws (MRONJ) was discovered in patients using these agents but relatively little attention has been paid to its prognosis. Our aims were to find out the treatment outcomes and prognostic indicators of MRONJ in cancer patients who received zoledronic acid as antiresorptive therapy.

METHODS

We retrospectively surveyed a cohort of 133 cancer patients who received zoledronic acid. A total of 150 MRONJ lesions were included for investigation. Cumulative complete response rate after treatment was calculated with the Kaplan-Meier method, and significance was examined with the log-rank tests. Cox regression was used for univariate and multivariate analyses of prognostic factors.

RESULTS

The cumulative complete response rate of all patients at 24 months was 53.2%, and those of patients with MM, breast cancer and prostate cancer were 27.8%, 60.7% and 68.0%, respectively. Having MM was identified as an independent prognostic factor in a multivariate analysis with adjusted hazard ratios of 0.28 (95% confidence interval, 0.09-0.83).

CONCLUSION

For cancer patients with ONJ related to zoledronic acid, patients with MM endure a worse treatment outcome.

Prognosis of medication-related osteonecrosis of the jaws in metastatic prostate cancer patients

OBJECTIVES

The aim of this study was to find out the prognosis of medication-related osteonecrosis of the jaws (MRONJ) in prostate cancer patients who received two different types of antiresorptive agents for bone metastasis.

MATERIALS AND METHODS

We retrospectively surveyed a cohort of 95 metastatic prostate cancer patients with 122 MRONJ lesions treated in a single medical center. Treatment outcomes and prognostic factors were investigated. The cumulative complete response rate was calculated with the Kaplan-Meier method, and significance was examined with the log-rank and Breslow tests. Cox regression was used for the univariate and multivariate analyses of prognostic factors.

RESULTS

The cumulative complete response rate of all patients at 12 months was 37.8%, and that of patients treated with zoledronic acid and denosumab was 22.9% and 70.5%, respectively. Denosumab, pretreatment C-terminal telopeptide of collagen I (CTX) level > 150 pg/ml, and anemia were identified as independent prognostic factors in a multivariate analysis with adjusted hazard ratios of 3.18 (95% confidence interval [CI], 1.24-8.11), 3.24 (95% CI, 1.39-7.53), and 0.42 (95% CI, 0.19-0.93), respectively.

CONCLUSION

A higher pretreatment level of CTX, using denosumab as the antiresorptive agent and without anemia, indicates a better treatment outcome of MRONJ in prostate cancer patients.

Status of endocrinology and metabolism specialists in Taiwan

BACKGROUND

The literature emphasizes the importance of matching the demand and supply of endocrinology and metabolism (EM) specialists. This study analyzed the current status of EM specialists in Taiwan. The gender effects on the workplace of EM specialists were also evaluated.

METHODS

The number of internal medicine (IM) specialists was obtained from the websites of the Ministry of Health and Welfare. Data about EM specialists were retrieved from the database of the Endocrine Society of the Republic of China (ESROC; Taiwan). Differences in age distribution and workplace levels or locations between female and male EM specialists were analyzed.

RESULTS

Since 1988, 809 physicians were certified as EM specialists. The average age of 739 EM specialists (509 male, 230 female) who remained as active members of the ESROC was 49.9 ± 11.1 years. The age distribution (p < 0.001) and workplace location (p = 0.043) were significantly different between male and female EM specialists. Divided by decades, the ratio of female-to-male EM specialists revealed an increasing tendency (p < 0.001). The percentage of EM specialists among IM specialists, certified 2 years previously, declined from 14.0% in 2017 to 7.9% and 8.3% in 2018 and 2019, respectively.

CONCLUSION

The female-to-male ratio of EM specialists increased gradually. Compared to males, female EM specialists were relatively younger, and more of them had clinical practice in northern Taiwan. The percentage of IM specialists becoming EM specialists declined in the last 2 years. The equilibrium between the supply and demand of EM specialists deserves further investigation.

Immediate knowledge improvement and long-term teaching confidence after general medicine faculty training program

BACKGROUND/PURPOSE

This study analyzed the effects of the General Medicine Faculty Training Program (GMFTP), which was implemented in 2009. The training program includes a 7-hour basic training (BT) to introduce ways of teaching and assessing the 6 core competencies identified by the Accreditation Council for Graduate Medical Education, and a 40-hour clinical training program.

METHODS

Physicians from different hospitals attended the GMFTPs. Since 2010, we have been using quick tests to assess trainees' familiarity of core competencies. Knowledge improvement (KI) was defined as the difference between post-BT and pre-BT test scores. Since 2013, we have been annually mailing questionnaires to assess trainees' teaching confidence (TC) of core competencies. We analyzed the correlations between trainees' characteristics, KIs, and TCs.

RESULTS

Between year 2009 and 2017, a total of 319 attending physicians (257 male, 62 female), with a mean age of 39.1 ± 6.2 years, completed the GMFTPs. Significant KI (32.6-55.4) was noted. There were no correlations between trainees' characteristics and KIs. The mean TCs for the 6 core competences were all above 4.0 (based on a 5-point Likert scale). TCs were positively correlated with age during GMFTP training, age when responding to the questionnaire, and duration between training and the last time responding to the questionnaire. TC showed no correlation with sex, hospitals, departments, or KI.

CONCLUSION

Knowledge of teaching core competencies improved immediately after BT, but KIs did not correlate with TCs in long-term follow-up. After the training program, physicians' teaching confidence increased over time.

Thyrotropin receptor antibodies and a genetic hint in antithyroid drug-induced adverse drug reactions

BACKGROUND

Antithyroid drugs (ATDs) are known to cause various adverse drug reactions (ADRs) that can lead to treatment complexity and unpredictable risks. With the aim of ensuring safer drug use, we assessed whether thyrotropin receptor antibody (TRAb) titers are associated with ATD-induced cutaneous reactions and/or hepatotoxicity, and examined potential genetic predisposition factors.

METHODS

We compared TRAb titers of 37 Graves' disease (GD) patients who had experienced carbimazole/methimazole-induced cutaneous reactions and/or hepatotoxicity with those of 40 normal individuals, or 78 GD patients without the aforementioned ATD-induced ADRs. We performed a genome-wide association study and/or human leukocyte antigen genotyping on GD patients [first stage (chart reviews): 24 cases with ADRs and 423 controls; second stage (actively recruited): 45 cases with ADRs and 137 controls].

RESULTS

For patients with Graves' hyperthyroidism, individuals with higher TRAb titers showed a predisposition to carbimazole/methimazole-induced cutaneous reactions and/or hepatotoxicity, with an estimated odds ratio of 5.19 (cut-off value: 64%). Potential associations with the rs144542704 and rs61893841 on chromosomes 17 and 11, respectively, warrant further genetic association analysis.

CONCLUSION

Our findings support the use of carbimazole/methimazole in patients with low TRAb titers to ensure safer drug use. The identified genetic associations warrant further research.

Moxifloxacin Improves Treatment Outcomes in Patients with Ofloxacin-Resistant Multidrug-Resistant Tuberculosis

It is unclear whether the use of moxifloxacin (MFX), a newer synthetic fluoroquinolone, results in better outcomes in patients with ofloxacin (OFX)-resistant multidrug-resistant tuberculosis (MDR-TB). During the period from April 2006 to December 2013, a total of 2,511 patients with culture-confirmed tuberculosis (TB) were treated at a TB referral hospital in southern Taiwan. Of the 2,511 patients, 325 (12.9%) had MDR-TB, and of those 325 patients, 81 (24.9%) had OFX-resistant MDR-TB and were included in the study. Among the 81 patients with OFX-resistant MDR-TB, 50 (61.7%) were successfully treated and 31 (38.3%) had unfavorable outcomes, including treatment failure (n = 25; 30.9%), loss to follow-up (n = 2; 2.5%), and death (n = 4; 4.9%). Patients treated with MFX had a significantly higher rate of treatment success (77.3% versus 43.2%; odds ratio [OR] = 4.46, 95% confidence interval [CI] = 1.710 to 11.646, P = 0.002) than patients not treated with MFX, especially among those infected with MFX-susceptible isolates (40.7%) or isolates with low-level resistance to MFX (28.4%). Multivariate logistic regression analysis showed that treatment with MFX (adjusted odds ratio = 6.54, 95% CI = 1.44 to 29.59, P = 0.015) was the only independent factor associated with treatment success. Mutation at codon 94 in the gyrA gene was the most frequent mutation (68.0%) associated with high-level MFX resistance. Multivariate Cox proportional hazards regression analysis showed that treatment with MFX was also an independent factor associated with early culture conversion (hazard ratio = 3.12, 95% CI = 1.48 to 6.54, P = 0.003). Our results show that a significant proportion of OFX-resistant MDR-TB isolates were susceptible or had low-level resistance to MFX, indicating that patients with OFX-resistant MDR-TB benefit from treatment with MFX.

Thyroid fine-needle aspiration biopsy and thyroid cancer diagnosis: a nationwide population-based study

BACKGROUND

Thyroid cancer is the most common endocrine gland malignancy and fine-needle aspiration biopsy is widely used for thyroid nodule evaluation. Repeated aspiration biopsies are needed due to plausible false-negative results. This study aimed to investigate the overall relationship between aspiration biopsy and thyroid cancer diagnosis, and to explore factors related to shorter diagnostic time.

METHODS

This nationwide retrospective cohort study retrieved data from the Longitudinal Health Insurance Database in Taiwan. Subjects without known thyroid malignancies and who received the first thyroid aspiration biopsy after 2004 were followed-up from 2004 to 2009 (n = 7700). Chi-square test, Kaplan-Meier survival analysis, and Cox proportional hazards model were used for data analysis.

RESULTS

Of 7700 newly-aspirated patients, 276 eventually developed thyroid cancer (malignancy rate 3.6%). Among the 276 patients with thyroid cancer, 61.6% underwent only one aspiration biopsy and 81.2% were found within the first year after the initial aspiration. Cox proportional hazards model revealed that aspiration frequency (HR 1.07, 95% CI 1.06-1.08), ultrasound frequency (HR 1.02, 95% CI 1.01-1.03), older age, male sex, and aspiration biopsies arranged by surgery, endocrinology or otolaryngology subspecialties were all associated with shorter time to thyroid cancer diagnosis.

CONCLUSIONS

About 17.4% of thyroid cancer cases received more than two aspiration biopsies and 18.8% were diagnosed one year after the first biopsy. Regular follow-up with repeated aspiration or ultrasound may be required for patients with clinically significant thyroid nodules.

Performance Assessment of the BluePoint MycoID Plus Kit for Identification of Mycobacterium tuberculosis, Including Rifampin- and Isoniazid-resistant Isolates, and Nontuberculous Mycobacteria

The performance of the BluePoint MycoID plus kit (Bio Concept Corporation, Taichung, Taiwan), which was designed to simultaneously detect Mycobacterium tuberculosis (MTB), rifampin- and isoniazid-resistant MTB, and nontuberculous mycobacteria (NTM) was first evaluated with 950 consecutive positive cultures in Mycobacterium Growth Indicator Tube (MGIT) system (BACTEC, MGIT 960 system, Becton-Dickinson, Sparks) from clinical respiratory specimens. The discrepant results between kit and culture-based identification were finally assessed by 16S rRNA gene sequencing and clinical diagnosis. The accuracy rate of this kit for identification of all Mycobacterium species was 96.3% (905/940). For MTB identification, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the kit were 99.7%, 99.3%, 99.0% and 99.8%, respectively. For rifampicin-resistant MTB identification, the sensitivity, specificity, PPV, and NPV of the kit were 100.0%, 99.4%, 91.3%, and 100.0%, respectively, while the corresponding values of isoniazid-resistant MTB identification were 82.6%, 99.4%, 95.0%, and 97.6%, respectively. In identifying specific NTM species, the kit correctly identified 99.3% of M. abscessus (147/148) complex, 100% of M. fortuitum (32/32), M. gordonae (38/38), M. avium (39/39), M. intracellulare (90/90), M. kansasii (36/36), and M. avium complex species other than M. avium and M. intracellulare (94/94). In conclusions, the diagnostic value of the BluePoint MycoID plus kit was superior to culture method for recoveries and identification of NTM to species level. In addition, the diagnostic accuracy of BluePoint MycoID plus kit in MTB identification was similar to conventional culture method with high accuracy rate of rifampicin-resistant M. tuberculosis identification.

Ovarian cancer-related hypophosphatemic osteomalacia--a case report

CONTEXT

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused primarily by benign mesenchymal tumors. It has been associated with malignancies in rare cases. High serum levels of fibroblast growth factor (FGF) 23 reported in a group of patients with ovarian cancer had normal serum phosphate levels. There had been no ovarian cancer-related hypophosphatemic osteomalacia in a search of the literature.

OBJECTIVE

We investigated a 57-year-old woman with progressive low back pain.

DESIGN AND INTERVENTION

Clinical, biochemical, and radiological assessments were performed. The patient's serum phosphate and FGF23 levels were evaluated at baseline and after treatment for ovarian cancer.

RESULTS

The patient presented with progressive low back pain and weight loss during the previous 6 months. Imaging studies revealed low bone mineral density and multiple suspicious spinal metastatic lesions. Laboratory examination showed hypophosphatemia, hyperphosphaturia, normocalcemia, an elevated serum alkaline phosphatase level, and an elevated serum FGF23 level. Because TIO was suspected, a tumor survey was performed, and ovarian carcinoma with multiple metastasis was detected. After surgery and chemotherapy treatments for ovarian cancer, the serum phosphate and FGF23 levels returned to normal, and the low back pain improved.

CONCLUSIONS

To our knowledge, this is the first case of ovarian cancer-related hypophosphatemic osteomalacia reported in the literature. TIO should be considered in patients with ovarian cancer presenting with weakness, bone pain, and fractures. Investigation of TIO is appropriate when these patients present hypophosphatemia.

The risk of osteonecrosis of the jaws in Taiwanese osteoporotic patients treated with oral alendronate or raloxifene

BACKGROUND

This study aimed to explore the possible association between osteonecrosis of the jaws (ONJ) and oral alendronate or raloxifene used for osteoporosis and to estimate its absolute and attributable risks in the Taiwanese population.

METHODS

Using an electronic medical records system and manual confirmation of ONJ, we identified patients who began taking alendronate or raloxifene for osteoporosis and developed ONJ between January 2000 and April 2012.

RESULTS

The incidence of ONJ associated with oral alendronate for the management of osteoporosis began after 1 year of drug exposure and progressively increased with longer durations of therapy, specifically from 0.23% to 0.92% as the duration of treatment went from 2 years to 10 years. The overall frequency of ONJ related to oral alendronate over a 12-year period was 0.55%. The incidence rate of ONJ attributed to alendronate exposure was 283 per 100 000 persons per year. On multivariate Cox proportional analysis, adjusting for the potential confounders, alendronate remains an independent predictor for ONJ occurrence [hazard ratio 7.42 (1.02-54.09)] compared with raloxifene. Advanced age, drug duration, and coexisting diabetes and rheumatoid arthritis are contributing factors to the development of oral alendronate-related ONJ.

CONCLUSION

We provided the evidence to support the association of ONJ with oral alendronate used in the treatment or prevention of osteoporosis.

Clinical characteristics of patients with congenital long QT syndrome and bigenic mutations

BACKGROUND

Congenital long QT syndrome (LQTS) is an ion channelopathy associated with genetic mutations. It is well known that most LQTS patients (91%) have a single mutation. The purpose of this study was to investigate the clinical characteristics of congenital LQTS patients with bigenic mutations in Taiwan, China.

METHODS

Congenital LQTS patients were recruited consecutively at Taiwan University Hospital in Taiwan from 2003 to 2009. The diagnosis of LQTS was defined by an LQTS Schwartz score greater than 4. Mutation screening in KCNQ1, KCNH2, KCNE1, and SCN5A was performed using direct sequencing.

RESULTS

Three of 16 LQTS patients (18.7%) were identified with bigenic mutations. One patient had missense mutations in KCNQ1 and KCNH2, the second in KCNQ1 and KCNE1, and the third in KCNH2 and SCN5A. The mean age at onset of LQTS for patients with bigenic mutations was (17 ± 3) years, and all of these patients were female. Two of them experienced seizure and one presented with syncope, although one of them had a family history of syncope. The mean QTc interval was (515 ± 17) ms, similar to those with single mutation or SNPs ((536 ± 74) ms, P = 0.63). Compared to those LQTS patients with single mutation or SNPs, a significantly higher percentage of LQTS patients with bigenic mutations presented with seizure and were younger at onset of the first index event (P = 0.03 and 0.001, respectively), but lower percentage of them presented with sudden cardiac death (P = 0.03).

CONCLUSIONS

Although the percentage of bigenic mutations in LQTS is less than 10% in Caucasian populations, we identified 3 of 16 LQTS patients (18.7%, 95% confidence interval: 0.04-0.46) with bigenic mutations in Taiwan. However, the severity of their clinical presentations was not higher than those patients with single mutation or SNPs.

Atypical femoral fractures shortly after osteonecrosis of the jaw in a postmenopausal woman taking alendronate for osteoporosis

CONTEXT

Bisphosphonates effectively increase bone mineral density and reduce fracture risk in patients with osteoporosis, but there are concerns about osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFFs) in the long-term users. So far both complications have not been reported as occurring simultaneously in an osteoporotic individual on oral alendronate.

OBJECTIVE

The aim of this study was to report a postmenopausal woman presenting with concomitant ONJ and AFF on oral alendronate treatment. SUBJECT, MEASURES, AND RESULT: The patient was a 63-year-old woman with a history of rheumatoid arthritis for 30 years and diabetes for 3 years. Spinal compression fractures at levels L3 and L4 were documented, and she took alendronate 70 mg weekly for 7 years. She is the first case whose dental periapical imaging and pelvic radiography documented her ONJ and AFF, which developed subsequently within 6 months.

CONCLUSIONS

This case report supports the association of both ONJ and AFF with long-term oral bisphosphonate therapy.

Brugada-type electrocardiogram in the Taiwanese population--is it a risk factor for sudden death?

BACKGROUND/PURPOSE

People receive electrocardiogram (ECG) examination for various reasons in a hospital setting. An important clinical practice issue may be that cardiologists need to be consulted for Brugada-type ECGs identified through routine screening. We investigated the prevalence and prognosis of patients with Brugada-type ECG in a hospital-based population in an attempt to improve the management of these patients.

METHODS

In 20,562 patients seeking medical care for non-cardiovascular reasons, 74,955 ECGs were performed from December 1999 to February 2001. The diagnostic criteria for Brugada-like ECG from the European Society of Cardiology were used. International Statistical Classification of Diseases codes and city residents' records were documented to indicate the reasons for visiting clinics or hospitalization and mortality outcome. Medical records were reviewed and telephone interviews were conducted.

RESULTS

Twenty-six (0.13%) of the 20,562 patients were confirmed to have Brugada-type ECGs. None of these patients had ever experienced syncope, near syncope or sudden cardiac death. After 57.1 ± 15.8 months of follow-up, there were four deaths out of the 26 patients with Brugada-type ECG (15.4%, 95% CI: 1.53-2.9%) compared with 2899 of those without (14.1%, 95% CI: 13.6-14.5%; p=0.89, log-rank test). Neither sudden cardiac death (p=0.61) nor hospitalized death (p=0.55) was different between patients with and without Brugada-type ECG.

CONCLUSION

Patients with Brugada-type ECGs are not rare in a hospital-based population. The presence of Brugada-type ECGs in patients without syncope or sudden cardiac death was not associated with hospitalized mortality.

Linkage of Graves' disease to the human leucocyte antigen region in the Chinese-Han population in Taiwan

OBJECTIVE

To investigate whether markers in the candidate chromosome regions, including the human leucocyte antigen (HLA) region, are linked to Graves' disease (GD).

DESIGN

A familial linkage study with a candidate region approach.

PATIENTS

A total of 536 individuals in 122 multiplex Chinese-Han families with a GD proband and at least one other affected sibling, resulting in 270 affected sib-pairs. Subjects with a family history of noniatrogenic hypothyroidism or Hashimoto's thyroiditis were excluded.

MEASUREMENTS

We genotyped eight short tandem repeat polymorphism (STRP) markers in a 13.7 cM region covering the HLA region on chromosome 6p21 and 26 STRPs in four other candidate regions previously reported in the literature.

RESULTS

Multipoint nonparametric linkage (NPL) analysis showed significant linkage to the HLA region [the marker UniSTS:239159, nonparametric log of odds (LOD) score 3.44, P = 0.00003; NPL Z-score 4.1, P = 0.00002] from 270 affected sib-pairs. The 1-LOD support interval comprised the whole HLA region (ca. 4 Mb). By contrast, the maximal NPL Z-scores of the markers of the other candidate regions (2q33, 5q31, 7q22 and 14q31) previously reported were all less than 1.0.

CONCLUSIONS

Our results provide strong support for linkage of GD to the HLA region. Further dissection of this region to identify the candidate gene for GD is warranted in our population.

Identification of three novel mutations in the GATA3 gene responsible for familial hypoparathyroidism and deafness in the Chinese population

BACKGROUND

Familial hypoparathyroidism may be caused by mutations of several genes. The CaSR and GATA3 genes are the two candidates most commonly responsible for this condition.

OBJECTIVES

We collected five unrelated families with familial hypoparathyroidism and examined their CaSR and GATA3 genes.

METHODS

Blood samples from these five families and 50 ethnically matched unrelated controls were acquired. Biochemistry screening and formal audiogram were performed to evaluate the affected individuals. All the exons and exon-intron boundaries of the GATA3 and CaSR genes were sequenced.

RESULTS

We identified three novel mutations in the GATA3 gene responsible for familial hypoparathyroidism and deafness: 1) a frameshift deletion occurring in codon 160 (478delG) was hypothesized to disrupt dual zinc fingers as well as one transactivating domain; 2) a donor splice site mutation at exon 4/intron 4 boundary (IVS4 + 2 T to GCTTACTTCCC) was predicted to lead to truncated GATA3 proteins that lack both N- and C-terminal zinc-containing fingers; and 3) a missense mutation R353S was predicted to disrupt the helical turn and thus changed the angle between the C-terminal zinc finger and the adjacent C-terminal tail. Except for a previously described polymorphism, G990R, we did not find any genetic variants in the CaSR gene.

CONCLUSIONS

This is the first article presenting mutations of the GATA3 gene responsible for familial hypoparathyroidism and deafness in the Chinese population. Our results expand the spectrum of mutations and report the first splice donor site mutation of the GATA3 gene. In contrast, we do not find causal sequence variants of the CaSR gene from our collection of familial hypoparathyroidism.

Dysphagia as a manifestation of thyrotoxicosis: report of three cases and literature review

Myopathy is frequently associated with thyrotoxicosis. Skeletal muscles are predominantly involved in thyrotoxic myopathy, but dysphagia is extremely rare. We report three cases of thyrotoxicosis with dysphagia and review of the literature of the past 30 years. Most of these patients had antecedent muscle weakness before the onset of dysphagia although some suffered from a sudden onset of bulbar palsy. Either a myopathic or neuropathic pattern was found on electromyography. The incidence of oropharyngeal dysphagia was higher than that of esophageal motility dysfunction. Aspiration pneumonia occurred more accompanied by oropharyngeal dysphagia. The swallowing disorder could be resolved completely within 3 weeks after treatment for thyrotoxicosis. In light of these clinical experiences, early intensive treatment that includes antithyroid agent, beta-blocker, and Lugol solution may be necessary.

Surgical treatment of parastomal hernia complicating sigmoid colostomies

PURPOSE

Parastomal hernia is a common late complication of colostomy. Surgical approach to the repair of parastomal hernia is controversial. Results of surgical treatment are disappointing. The aim of this study was to assess the outcome of surgical treatment of parastomal hernia.

METHOD

This article reports a retrospective review of those patients who had undergone a surgical treatment of parastomal hernia complicating sigmoid colostomy. The indications, surgical procedures, complications, and outcome were carefully studied.

RESULTS

There were 43 surgical treatments of parastomal hernia. Sixteen underwent simple local repair; 25 stomas were relocated, and 2 were locally repaired with mesh. Overall recurrence was 18 of 40 (45 percent). Recurrences for fascial repair and stoma relocation were 6 of 13 (46 percent) and 10 of 25 (40 percent), respectively. Stoma relocation could be accomplished without formal laparotomy in 19 of 25 cases. Incisional hernia occurred in only 2 of these 25 relocations.

CONCLUSION

Fascial repair alone can be performed for symptomatic small hernias because of its advantage of minimal morbidity. Stoma relocation without formal laparotomy can be advocated for larger hernias. A combination of local resite together with mesh reinforcement may be the alternative for further improvement of results.

Properties of the poly(vinyl alcohol)/chitosan blend and its effect on the culture of fibroblast in vitro

In this work, the properties of poly(vinyl alcohol) (PVA) and PVA/chitosan blended membranes were investigated by scanning electron microscopy (SEM), differential scanning calorimetry (DSC) and electron spectroscopy for chemical analysis (ESCA). The SEM photographs show the PVA/chitosan blended membrane undergoes dramatic changes on the surface and bulk structure during the membrane formation. The DSC analysis shows that PVA and chitosan are not very compatible in the PVA/chitosan blended membrane, whereas the combination of two polymer chains of constitutionally different features is revealed. In addition, the surface of the PVA/chitosan blended membrane is enriched with nitrogen atoms at the ESCA analysis. These reflect the PVA membrane can be modified by blending with chitosan that in turn may affect the biocompatibility of the blended membrane. Therefore, adhesion and growth of fibroblasts on the PVA as well as PVA/chitosan blended membranes were investigated. Cell morphologies on the membranes were examined by SEM and cell viability was studied using MTT assay. It was observed that the PVA/chitosan blended membrane was more favorable for the cell culture than the pure PVA membrane. Cells cultured on the PVA/chitosan blended membrane had good spreading, cytoplasm webbing and flattening and were more compacting than on the pure PVA membrane. Consequently, the PVA/chitosan blended membrane may spatially mediate cellular response that can promote cell attachment and growth, indicating the PVA/chitosan blended membrane should be useful as a biomaterial for cell culture.

Audit of laparoscopic cholecystectomy in a single center

A continuous audit is required to ensure laparoscopic cholecystectomy (LC) is performed safely in the surgical community in general. A retrospective review of all LC done in a single center was performed. A total of 1,244 LC were attempted. The conversion rate was 12.4%, the complication rate 3.5%, and the bile duct injury rate 0.4%. Forty percent of bile duct injury occurred after conversion. A decreasing trend of complication rate was seen in the early part of the series, then the rate steadied at about 2.5-3%. A higher threshold of conversion may not increase the bile duct injury rate. However, good laparoscopic technique and adequate experience are prerequisites to safe LC.

A home made rapid urease test in the diagnosis of Helicobacter pylori infection

AIM OF STUDY

To determine whether a homemade rapid urease test (RUT) (1 mL of 10% urea broth in distilled water plus one drop of 1% phenol red as indicator, cost/test USD0.19) was reliable when compared to histology in the diagnosis of HP infection.

METHOD

Prospective consecutive sampling of patients who underwent outpatient oesophagogastroduodenoscopy and antral biopsies from October 1996 to January 1997. RUT and histology examinations were done on all specimens. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the RUT were calculated accordingly.

RESULTS

Amongst our 140 patients, the sensitivity, specificity, positive and negative predictive values and accuracy of RUT were 94%, 99%, 99%, 95% and 96% respectively. Seventy-seven percent of the positive RUTs can be detected within 1 hour.

CONCLUSION

Our homemade RUT is an inexpensive test with good sensitivity and specificity for HP infection.

The investigation and management of thyroid nodules--a retrospective review of 183 cases

The management of the patient with a thyroid nodule remains a clinical challenge because of its risk of malignancy. This is a retrospective audit of 183 patients undergoing thyroidectomy for thyroid nodules at the Queen Elizabeth Hospital, Hong Kong, in 1994. The history, physical examination and investigations done were charted and analysed against the final histopathology of the specimens. Age, sex, symptom duration and nodularity were not associated with malignancy statistically, whereas a nodule hard in consistency was shown to be associated with malignancy (P < 0.05). The sensitivity and specificity of ultrasonography, radionuclide scan and fine-needle aspiration cytology (FNAC) were 71% and 57%, 50% and 43%, and 93% and 60%, respectively. Hence, history and physical examination are unreliable for detecting malignant thyroid nodules and FNAC is mandatory. FNAC is superior to ultrasonography or radionuclide scan for evaluating thyroid nodules and should be used as the initial investigation.

Comparison of serum protein removal in haemodialysis therapy by partly protein-permeable haemodialysers

Partly protein-permeable haemodialysers were evaluated during haemodialysis therapy for removal of serum low-molecular-mass proteins (10,000-76,000) in patients with chronic renal failure. The six haemodialyser membranes used were cuproammonium rayon (CL-S12W), cellulose acetate (Duo-Flux HP and FF-22), ethylene-vinyl alcohol copolymer (KF-101-15), polyacrylonitrile (H12-2400S) and polymethyl methacrylate (BK2.0H). The analysis was carried out by gel permeation chromatography, sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) and two-dimensional gel electrophoresis (2-DE). The removal of ten serum proteins per haemodialysis therapy was also carried out by the immunodiffusion method. The protein removal in each haemodialyser is qualitatively comparable to that obtained by SDS-PAGE and 2-DE. beta 2-Microglobulin in the haemodialysate obtained with BK2.0H was removed to a lesser extent than that from the other haemodialysers, which seems to be the reason for its adsorption in the BK2.0H haemodialyser, which contains a polymethyl methacrylate membrane. The amount of serum protein excretion during haemodiafiltration treatment using the partly protein-permeable haemodialysers decreased in the order KF-101-15C greater than BK2.0H greater than CL-S12W greater than Duo-Flux HP greater than FF-22 greater than H12-2400S.

The 14-MeV neutron activation analysis of Chinese medicines for protein, phosphorus, potassium and magnesium contents (II)

Elementary form of nitrogen (protein), phosphorus, potassium and magnesium contained in 180 different kinds of Chinese medicines are analyzed by means of 14-MeV neutron activation technique. The percent contents of these elements in the Chinese medicines range from 0 to 34.41% (average: 11.73%) for protein, from 0.03 to 37.42% (average: 1.72%) for phosphorus, from 0.12 to 33.22% (average: 2.94%) for potassium and 0.03 to 5.62% (average: 0.43%) for magnesium. Comparison of the present results with the previous measurements for another 66 kinds of Chinese medicines is made.

The 14-MeV neutron activation analysis of Chinese medicines for protein, phosphorus, potassium and magnesium contents

Elementary form of nitrogen (protein), phosphorus, potassium and magnesium contained in sixty-six different kinds of Chinese medicines were analyzed by means of 14-MeV neutron activation technique. The % contents of these elements in Chinese medicines range from 4.1 to 38.6% (average: 12.7%) for protein, 0.1 to 10.5% (average: 1.3%) for phosphorus, 1.6 to 13.8% (average 4.5%) for potassium and 0.1 to 2.5% (average: 0.5%) for magnesium. The procedure proves to be quite precise and potentially quite accurate, while only requiring about 20 minutes per sample. The methods of determining the elements are described.