Risks to pedestrians in traffic systems with unfamiliar driving rules: a virtual reality approach

In this study, a virtual-reality (VR) pedestrian simulation method was used to evaluate the risks to pedestrians crossing streets in a traffic system with driving rules that were unfamiliar to them. Pedestrians from mainland China (which has a right-side driving (RD) system) and Hong Kong (which has a left-side driving (LD) system) were studied. Significant differences were observed between pedestrians from the different locations in terms of the direction in which the pedestrians habitually first looked before crossing. When exposed to an unfamiliar driving rule (i.e., traffic coming from an inconsistent direction in terms of participants' habitual driving system), the odds of participants from mainland China making an error in their looking behavior were 2.93 times those when exposed to a familiar driving rule. Road markings and traffic sound did not improve these participants' looking behavior. The results also show a negative correlation between inattentive looking behavior and time to collision (significant at the 1% level), as these errors lead to a shorter time to collision and increased the risk to pedestrians. The results of this study confirmed the risks for pedestrians traveling to places with unfamiliar driving rules and confirmed the existence of habitual looking behavior, and therefore provide evidence of the need for future studies to improve this problem. These may help decision makers take the risks of pedestrians from different driving rules into consideration in future traffic policymaking or traffic-facility improvements. The use of a VR simulation-based approach in this study provided a safe and controllable way to trial interventions and potential improvements without risking injury to participants, and thus may also be used for similar future studies.

Effect of Pulsed Magnetic Stimulation on Sexual Function in Couples With Female Stress Urinary Incontinence Partners

We prospectively evaluated the effects of pulsed magnetic stimulation (PMS) on sexual function of couples with stress urinary incontinence (SUI) partners. Female SUI subjects received 16 or 32 biweekly PMS sessions, depending on treatment response. Prior to, immediately after, and at 6-months posttreatment, couples completed the Golombok Rust Inventory of Sexual Satisfaction (GRISS) questionnaire. Fifty-three (80.3%) of 66 couples completed reassessments. Based on the overall GRISS score, there were significant improvements in sexual function in both female subjects (M_diff -5.05, SE 1.34, p = 0.001) and their partners (M_diff -3.42, SE 1.24, p = 0.026). Our findings suggest that PMS improved sexual function of SUI patients and their partners.

Responsiveness of the Golombok Rust Inventory of Sexual Satisfaction in couples with incontinent partners

OBJECTIVE

In order for a measure to reliably evaluate treatment efficacy, it is important that the measure used has adequate responsiveness. However, the responsiveness of the Golombok Rust Inventory of Sexual Satisfaction (GRISS) questionnaire, a highly recommended questionnaire by the International Consultation of Incontinence to assess sexual function in patients with incontinence, has not been established. To enable the use of GRISS to measure change in sexual function following incontinence treatment, we evaluated the short- and long-term responsiveness of the GRISS in couples with female stress urinary incontinence partners.

STUDY DESIGN

Forty-eight couples with female stress urinary incontinence partners were included in the study. The GRISS, a 28-item multidimensional measure, comprises two sets of questionnaires to assess sexual function in both male and female partners. Responsiveness was investigated using data from our recent randomized controlled trials evaluating efficacy of pulsed magnetic stimulation for treatment of female patients with stress urinary incontinence. Effect size index and standardized response mean were used to measure responsiveness of the English and Chinese versions of GRISS.

RESULTS

For short-term responsiveness, the overall female and male GRISS scores had effect sizes and standardized response means ranging from 0.60 to 0.83 and 0.44 to 0.78 respectively. For long-term responsiveness, the overall female and male GRISS scores had effect sizes and standardized response means ranging from 0.59 to 0.77 and 0.48 to 0.79 respectively.

CONCLUSION

In conclusion, the English and Chinese versions of GRISS had adequate responsiveness for use in couples with incontinent partners. The GRISS can be a useful measure to detect change in sexual function of couples following treatment of females with stress urinary incontinence.

Superior Dislocation of the Patella Treated by Closed Reduction: A Rare Case Report and Review of the Literature

Superior dislocation of the patella is a rare condition. We report a 70-year-old gentleman with his patella lower pole osteophyte interlocked with the anterior femoral condyles after hyperextension. The patella was reduced successfully with proper reduction technique under sedation. The active range of movement ranged from full extension to 120-degree flexion a few minutes after reduction. He walked unaided afterwards. There was no knee problem in two years of follow-up. On reviewing the literature, only 20 cases were reported till year 2007 worldwide and 19 cases could be treated by closed reduction with or without sedation.

The Impact of Stress Urinary Incontinence on Individual Components of Quality of Life in Malaysian Women

OBJECTIVE

To assess the impact of stress urinary incontinence (SUI) on individual components of quality of life (QoL) using both condition-specific and generic questionnaires, and to compare the results of the 2 instruments with a control group.

METHODS

Women with or without SUI aged ≥21 years old were recruited. Subjects completed the International Consultation of Incontinence-Urinary Incontinence Short Form (ICIQ-UI-SF), International Consultation of Incontinence-Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), and EQ-5D questionnaires.

RESULTS

A total of 120 women with SUI and 145 controls participated. The ICIQ-LUTSqol total score (mean ± standard deviation) was significantly higher in the SUI group (38.96 ± 10.28) compared with the control group (20.78 ± 2.73) (P <.001). When adjusted for significant confounders, the SUI group continued to have significantly poorer QoL compared with the control group (P <.001). The negative effect of SUI on "physical activities" and "jobs" were the 2 most frequently reported and burdensome components of the ICIQ-LUTSqol, with approximately 50% of women with SUI affected "moderately" or "a lot." When measured using the EQ-5D questionnaire, there were significantly higher percentages of patients with SUI who had problems with usual activities, pain or discomfort, and anxiety or depression (P <.05).

CONCLUSION

Women suffering from SUI have significantly poorer QoL compared with continent women when measured using both condition-specific and generic QoL measures. Clinicians should pay closer attention to the impact of SUI on individual components of QoL, particularly limitations on physical activities and jobs, which were the 2 most impairing and frequently reported components of QoL.

ACE gene sequence and nucleotide variants in IgA nephropathy

INTRODUCTION

Association studies with single nucleotide polymorphisms (SNPs) have been contradictory. Haplotypes may be more helpful. With gene sequencing, all SNPs can be found for construction of haplotypes.

METHODS

The ACE gene was sequenced in four healthy Chinese subjects and 20 patients with IgA nephropathy (IgAN) to observe if differences exist among SNPs and haplotypes. 20 patients on angiotensin 1-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ATRA) therapy were then compared with another 20 patients not treated with ACEI /ATRA to determine their renal outcome in response to ACEI/ATRA therapy and whether their genetic profile of ACE gene could play a role in determining their outcome to ACEI /ATRA therapy and progression to end-stage renal failure (ESRF).

RESULTS

IgAN patients had 53 variants, of which 17 were unique, whereas normal subjects had 38 variants, of which two were unique (p less than 0.005). No unique variant was a significant risk factor for IgAN. Significant genotype and allele frequency differences in five variants were observed between IgAN patients with renal impairment and those with ESRF (p less than 0.02).

CONCLUSION

Our data suggests that at least in the ACE gene, haplotyping SNPs within a single gene seems to have no added advantage over genotyping the individual component SNPs. The D allele and haplotype 3 confer an adverse prognosis, while the I allele and haplotype 5 appear to be renoprotective. The data suggests that genotypes of the ACE gene are linked to certain haplotypes, which could influence IgAN patients' response to ACEI/ATRA therapy.

Factors affecting mortality in Hong Kong patients with upper limb necrotising fasciitis

OBJECTIVE

To identify predictive factors for mortality of patients with upper limb necrotising fasciitis.

DESIGN

Retrospective study.

SETTING

Six hospitals in Hong Kong.

PATIENTS

Clinical records of 29 patients treated in the hospitals were traced and analysed.

MAIN OUTCOME MEASURES

Possible predictive factors for mortality as evaluated by application of Fisher's test.

RESULTS

Overall mortality was 28%. Digital infections conferred a lower mortality, but progressive necrosis necessitated amputation. Vibrio vulnificus was the commonest organism identified in association with marine injury and in patients with cirrhosis. Prognostic indicators with decreasing significance include deranged renal and liver function, thrombocytopaenia, proximal involvement (elbow or above) initially, and presence of hypotension upon admission.

CONCLUSION

With a P value of less than 0.05, deranged renal and liver function, thrombocytopaenia, initial proximal involvement, and hypotension on admission were predictors of mortality in necrotising fasciitis affecting the upper limbs. The ALERTS (Abnormal Liver function, Extent of infection, Renal impairment, Thrombocytopenia, and Shock) score with a cutoff of 3 appeared to predict mortality.

Experience sharing on the implementation of telehealth system in Hong Kong

With the growth of the ageing population in Hong Kong, healthcare professionals believe that there will be a great demand of healthcare service at the community level. In 2000, the first prototype of telehealth system was developed, tested and validated by the School of Nursing, The Hong Kong Polytechnic University. With the advancement of information technology and inexpensive video- conference facility, an inter-clinic patient-centered healthcare information system has been evolved and used by a number of satellite clinics since 2003. In order to foster the importance of personal healthcare education at the community level, different versions of the telehealth system were designed and developed for school children and teenagers. Now the research team is focusing on the development of the pocket PC's version. Experience on the deployment of such technology-intensive system in healthcare was discussed in this paper.

ATRA therapy restores normal renal function and renal reserve and prevents renal failure

This article presents clinical data which suggest that the current dosage of losartan 50 to 100 mg/day may not be the optimum in many cases, especially if used as monotherapy in the treatment of proteinuria and we may have to increase to 200 mg/day. However, about 30% of patients cannot take angiotensin-converting enzyme inhibitor (ACEI) because of the side effect of cough. To potentiate the anti-proteinuric effect of losartan, especially for patients who do not adhere to a low salt diet, a 12.5-mg dose of hydro-chlorothiazide may further decrease proteinuria. The main message of this article is that we would have to, in many instances, increase the dose of losartan to a minimum of 100 mg/day or 100 mg twice a day for some patients for optimal therapy. The second message is to monitor the creatinine clearance test (CCT) and to start therapy when CCT is reduced and not wait for serum creatinine to rise to abnormal levels (renal impairment) before starting therapy. The first group involves half a dozen patients with hypertension but no proteinuria. Therapy with losartan is shown to improve the renal function. This data suggest that losartan, apart from its use in reduction of proteinuria, can be used in patients with mild renal impairment without proteinuria to reverse the mild renal impairment and preserve renal function. The second group deals with 3 patients with low creatinine clearance. After a followup period of an average of 3 years, they all developed renal impairment. In another 6 patients, the data suggest that we should perhaps treat patients with low CCT as soon as possible and with dose ranging from 100 to 200 mg/day if necessary, to derive maximum beneficial effect. The third group highlights 5 patients with high CCT due to glomerular hyperfiltration. With time, the high CCT decreases and renal impairment sets in. The data suggest that patients with high CCT should be treated early to prevent renal impairment. The fourth group illustrates 6 patients where their proteinuria was markedly reduced with the increase of losartan from 100 mg/day to 200 mg/day, suggesting that losartan 200 mg/day is probably the optimum dose. In conclusion, apart from its traditional usage in reduction of proteinuria to retard progression to renal failure, the data suggest that losartan is also indicated in patients with renal impairment in the absence of proteinuria; patients with low CCT, patients with high CCT and patients who do not respond to a dosage of 100 mg/day should have the dosage increased to 100 mg twice daily to increase efficacy of losartan. It is hoped that with these new and earlier indications as well as increased dosage of losartan starting with 100 mg, whenever possible, and increasing to 200 mg/day, if there is no response, we can prevent more patients from developing renal failure. Based on these observations, further randomised controlled trials should be designed to address these issues.

ACE gene polymorphism and disease progression of IgA nephropathy in Asians in Singapore

The deletion polymorphism of the angiotensin-converting enzyme (ACE) gene has been considered as a risk factor for IgA nephropathy and for its progression to end-stage renal failure. However, results from various studies are conflicting. We had genotyped the ACE gene in 100 patients with IgA nephropathy, 32 of whom were in end-stage renal failure and in 90 normal adult subjects. All DD cases were subjected to confirmation with a second PCR, performed with the insert-specific forward primer. Similar genotype frequencies were obtained for the 90 normal control subjects (II: 47%, ID: 44%, DD: 9%); for the 68 patients not in end-stage renal failure (ESRF) (II: 47%, ID: 46%, DD: 7%) and for the 32 patients with ESRF (II: 53%, ID: 38%, DD: 9%). The genotype frequencies in all 3 series are in Hardy-Weinberg equilibrium. These results suggest that ACE gene polymorphism is not a risk factor for IgA nephropathy and is not a predictor for its progression. Definitive proof of association between ACE gene polymorphism and progression in IgA nephropathy will require a prospective study, controlled for important risk factors, with adequate patient numbers and facility for confirming DD genotypes.

SDS-PAGE is underutilized as a tool for investigating renal patients

SDS-PAGE is an excellent single test for investigating proteinuria. It can provide much useful information on the underlying renal problem. Yet the literature hardly report a SDS-PAGE result in the management of renal patients. To examine how closely SDS-PAGE results may reflect biopsy findings, we investigated 11 patients scheduled for renal biopsy. Urine samples were taken at the same time for SDS-PAGE analysis using the PhastSystem (Pharmacia, Sweden). Comparing biopsy findings and SDS-PAGE results, the data show consistency in the revelation of tubular dysfunction and/or glomerular damage in all 11 patients. We concluded that the SDS-PAGE test is underutilized and suggest that its role for the management of renal patients be fully explored particularly in its potential for reducing the need for renal biopsy in certain patient groups.

Proteinuria: clinical signficance and basis for therapy

Proteinuria is the hallmark of renal disease and proteinuria exceeding 1 gm a day in patients with renal disease augers a poorer prognosis. Proteinuria has been shown to be tubulotoxic and directly contributes to renal deterioration. Patients with non-selective proteinuria are more likely to have progressive renal disease. Diabetic patients with persistent microhaematuria have about 20 times the risk of developing diabetic nephropathy. In essential hypertension, the onset of de novo proteinuria after years of adequate BP control is a marker of subsequent decline in renal function. In glomerulonephritis, more severe proteinuria is associated with faster rate of progression. Even though the initial phase of proteinuria in patients with glomerulonephritis is usually of immunological origin, in the vast majority of patients with established disease, the latter progressive phase of proteinuric glomerulopathy is the result of glomerular hyperfiltration which shifts glomerular non-selective pores to larger dimensions resulting in excessive leakage of protein in the urine. Endothelial injury resulting from glomerular hyperfiltration causes increase in local generation of Angiotensin II in the kidney as part of the hemodynamic response. ACE inhibitors and angiotensin II receptor antagonists (ATRA) can improve glomerular pore-selectivity by remodelling the glomerular basement membrane. In addition, these agents also have beneficial effects by decreasing TGF-beta production therapy decreasing mesangial cell proliferation, hence ameliorating disease progression in patients with diabetic nephropathy and IgA nephropathy. A number of recent clinical trials have shown that ACEI and ATRA therapy can retard the progression of renal deterioration in patients with NIDDM and those with IgA nephropathy and even restore normal renal function in those with mild renal impairment. Treatment and control of proteinuria in patients with renal disease should be regarded as important as treatment of hypertension as it can prevent renal failure.

ACEI/ATRA therapy decreases proteinuria by improving glomerular permselectivity in IgA nephritis

BACKGROUND

It has been postulated that angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ATRA) may decrease proteinuria in patients with glomerulonephritis by its action on the glomerular basement membrane. We therefore studied the relationship between the response of patients with IgA nephritis (IgAN) to ACEI/ATRA therapy by decreasing proteinuria and its effect on the selectivity index (SI) in these patients.

METHODS

Forty-one patients with biopsy-proven IgAN entered a control trial, with 21 in the treatment group and 20 in the control group. The entry criteria included proteinuria of 1 g or more and/or renal impairment. Patients in the treatment group received ACEI/ATRA or both with three monthly increases in dosage. In the control group, hypertension was treated with atenolol, hydrallazine, or methyldopa. The following tests were performed at three monthly intervals: serum creatinine, total urinary protein, SI, sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and low molecular weight (LMW) proteinuria.

RESULTS

After a mean duration of therapy of 13 +/- 5 months, in the treatment group, there was no significant change in serum creatinine, proteinuria, or SI, but in the control group, serum creatinine deteriorated from 1.8 +/- 0.8 to 2.3 +/- 1.1 mg/dL (P < 0.05). Among the 21 patients in the treatment group, 10 responded to ACEI/ATRA therapy determined as a decrease in proteinuria by 30% (responders), and the other 11 did not respond (nonresponders). Among the responders, SI improved from a mean of 0.26 +/- 0.07 to 0.18 +/- 0. 07 (P < 0.001), indicating a tendency toward selective proteinuria. This was associated with an improvement in serum creatinine from mean 1.7 +/- 0.6 to 1.5 +/- 0.6 mg/dL (P < 0.02) and a decrease in proteinuria from a mean of 2.3 +/- 1.1 to 0.7 +/- 0.5 g/day (P < 0. 001). After treatment, proteinuria in the treatment group (1.8 +/- 1. 6 g/day) was significantly less than in the control group (2.9 +/- 1. 8 g/day, P < 0.05). The post-treatment SI in the responder group (0. 18 +/- 0.07) was better than that of the nonresponder group (0.33 +/- 0.11, P < 0.002). Eight out of 21 patients in the treatment group who had documented renal impairment had improved renal function compared with two in the control group (chi2 = 4.4, P < 0. 05). Of the eight patients in the treatment group who improved their renal function, three normalized their renal function compared with one from the control group.

CONCLUSION

Our data suggest that ACEI/ATRA therapy may be beneficial in patients with IgAN with renal impairment and nonselective proteinuria, as such patients may respond to therapy with improvement in protein selectivity, decrease in proteinuria, and improvement in renal function. ACEI/ATRA therapy probably modifies pore size distribution by reducing the radius of large unselective pores, causing the shunt pathway to become less pronounced, resulting in less leakage of protein into the urine.

High tumoral maspin expression is associated with improved survival of patients with oral squamous cell carcinoma

Maspin, a member of the serpin family of protease inhibitors, is known to have tumor-suppressor functions. However, the association between its expression level and survival has not been demonstrated in human cancer. Using the immunohistochemical technique to examine the expression levels of maspin in 44 cases of oral squamous cell carcinoma (SCC), we found that 66% of the cases expressed low to intermediate levels of maspin and 34% of the cases expressed high levels of maspin. We further examined maspin protein expression in a series of six SCC cell lines from the head and neck, and found that all but one expressed low or no maspin protein. We also compared the clinicopathological features of the oral SCC cases with the maspin expression level, and found that high maspin expression was associated with the absence of lymph node metastasis. More importantly, we showed that higher maspin expression was significantly associated with better rates of overall survival, suggesting that high maspin expression may be a favorable prognostic marker for oral SCC.

High tumoral maspin expression is associated with improved survival of patients with oral squamous cell carcinoma

Maspin, a member of the serpin family of protease inhibitors, is known to have tumor-suppressor functions. However, the association between its expression level and survival has not been demonstrated in human cancer. Using the immunohistochemical technique to examine the expression levels of maspin in 44 cases of oral squamous cell carcinoma (SCC), we found that 66% of the cases expressed low to intermediate levels of maspin and 34% of the cases expressed high levels of maspin. We further examined maspin protein expression in a series of six SCC cell lines from the head and neck, and found that all but one expressed low or no maspin protein. We also compared the clinicopathological features of the oral SCC cases with the maspin expression level, and found that high maspin expression was associated with the absence of lymph node metastasis. More importantly, we showed that higher maspin expression was significantly associated with better rates of overall survival, suggesting that high maspin expression may be a favorable prognostic marker for oral SCC.

Proteinuria and angiotensin converting enzyme (ACE) gene polymorphism

INTRODUCTION

Although proteinuria is traditionally regarded as the result of glomerular damage, recent evidence suggests that proteinuria can directly cause renal damage through lysosomal injury, growth factor induced tubular fibrosis and transcriptase genes which trigger vasoactive and inflammatory renal damage. The renin angiotensin system which releases angiotensin, a most powerful vasoconstrictor and mediator of mesangial cell proliferation and matrix expansion, has been associated with progressive renal injury. This paper reviews the role of angiotensin converting enzyme (ACE) gene polymorphisms in the genesis of progressive renal failure, as well as their role in the response of proteinuria to ACE inhibitor (ACEI) or angiotensin receptor antagonist (ATRA) therapy.

METHODOLOGY

The deletion/insertion polymorphism of the ACE gene has 3 genotypes DD, ID and II. Reported studies on the association of ACE gene polymorphisms with patients with IgA nephritis and progressive renal failure, including their response to ACEI or ATRA therapy, were reviewed.

RESULTS

Individuals with the DD genotypes have a higher risk of declining renal function with progressive IgA nephritis and more rapid deterioration to renal failure. Therapy with ACEI and or ATRA may be beneficial in patients with IgA nephritis with renal impairment and non-selective proteinuria as such patients may respond to therapy with improvement in protein selectivity, decrease in proteinuria and improvement in renal function.

CONCLUSION

ACE genotypes appear to predict antiproteinuric response to ACEI therapy. ACEI/ATRA therapy probably modifies pore size distribution by reducing the radius of large non-selective pores, causing the shunt pathway to become less pronounced resulting in less leakage of protein into the urine.

Combination of EGFR, HER-2/neu, and HER-3 is a stronger predictor for the outcome of oral squamous cell carcinoma than any individual family members

In a series of 111 patients with squamous cell carcinoma (SCC), we used immunohistochemistry to examine the expression levels of four epidermal growth factor receptor (EGFR) family members (EGFR, HER-2/neu, HER-3, and HER-4). Expression of the EGFR members was not significantly associated with tumor size. However, their expressions (except for HER-4) were significantly associated with the presence of lymph node metastasis, and all of them were significantly associated with distant metastasis. We further examined the association between the expression levels of the EGFR members and the survival rates in 47 oral SCC patients whose detailed clinical follow-ups were available. The expression of all EGFR members was significantly associated with shortened patient survival, and the association was strongest for HER-2/neu. Furthermore, the combination of HER-2, HER-3, and EGFR but not HER-4 significantly improved the predicting power. The expression level of HER-2/neu was significantly correlated with that of EGFR or HER-3. Similar coexpression patterns were also observed in three oral SCC cell lines studied, but not in four other head and neck SCC cell lines. Taken together, these results indicated that expression levels of EGFR, HER-2/ neu, and HER-3 may help predict the outcome of patients with oral SCC.

The changing pattern of glomerulonephritis in Singapore over the past two decades

This study reviews the pattern of glomerulonephritis (GN) in Singapore over the past 2 decades. In the earlier decade the pattern was typical of most Asian countries with mesangial proliferative GN (Mes GN) (56%) as the most common form of primary GN including the nephrotic syndrome (40%). In the 2nd decade the pattern undergoes a change. Though Mes GN is the commonest primary GN (42%), the commonest form of nephrotic syndrome is now minimal change disease (30%) with Mes GN decreasing to 25% among all primary nephrotic syndromes. Both minimal change and focal global sclerosis account for 50% of steroid/cyclophosphamide responsive GN today. Membranous GN though still uncommon, has increased from 3% (1st decade) to 6% (2nd decade) (p < 0.01). IgA nephritis is still the commonest primary GN occurring in Singapore (42% of all primary GN in the 1st decade and 45% in the 2nd decade). The present pattern of GN in Singapore, though, still predominantly Asian with the preponderance of mesangial proliferative GN with a relatively low incidence of membranous GN contrasts with the pattern in the West where membranous GN is the commonest form of primary GN. Even the incidence of FSGS has not increased as in the West where there is a rising incidence. The underlying basis for most GN in Singapore as in other Asian countries and elsewhere is antigen-driven: infective antigen as well as food or other allergens.

Basic science of HER-2/neu: a review

The HER-2/neu (also known as c-erbB-2) oncogene is the second member of the epidermal growth factor receptor family. It is overexpressed in many different types of human cancers, including breast, ovarian, lung, gastric, and oral cancers. Overexpression of HER-2/neu in breast cancer has been associated with poor overall survival and has been shown preclinically to enhance malignancy and the metastatic phenotypes. Although discrepancies exist between different studies, HER-2/ neu overexpression seems to induce chemoresistance in certain experimental conditions. Many studies have convincingly shown that repression of HER-2/neu suppresses the malignant phenotypes of HER-2/neu-overexpressing cancer cells. These findings strongly suggest that HER-2/neu may serve as an excellent target for developing anticancer agents specific for HER-2/neu-overexpressing cancer cells. HER-2/neu-encoded p185 protein is a receptor tyrosine kinase that can be associated with multiple signal transduction pathways. However, it is not yet clear how a specific signal pathway may correspond to a specific biological response. This report reviews basic information on signal transduction of HER-2/neu receptor tyrosine kinase and summarizes our approaches to targeting HER-2/neu-overexpressing cancer cells. The HER-2/neu promoter was targeted using cationic liposomes or an adenovirus vector to deliver the adenovirus-5 EIA gene products and a nontransformed mutant of the SV40 large T antigen into the tumor-bearing mice. This resulted in suppression of the tumor growth and prolongation of survival. For repressing the function of HER-2/neu we used emodin, a tyrosine kinase inhibitor. This agent can inhibit the tyrosine kinase activity of HER-2/neu and preferentially block the growth of the HER-2/neu-overexpressing human breast cancer cells in tissue culture as well as in nude mice.

Tyrosine kinase inhibitor emodin suppresses growth of HER-2/neu-overexpressing breast cancer cells in athymic mice and sensitizes these cells to the inhibitory effect of paclitaxel

Overexpression of the HER-2/neu proto-oncogene, which encodes the tyrosine kinase receptor p185neu, has been observed in tumors from breast cancer patients. We demonstrated previously that emodin, a tyrosine kinase inhibitor, suppresses tyrosine kinase activity in HER-2/neu-overexpressing breast cancer cells and preferentially represses transformation phenotypes of these cells in vitro. In the present study, we examined whether emodin can inhibit the growth of HER-2/neu-overexpressing tumors in mice and whether emodin can sensitize these tumors to paclitaxel, a commonly used chemotherapeutic agent for breast cancer patients. We found that emodin significantly inhibited tumor growth and prolonged survival in mice bearing HER-2/neu-overexpressing human breast cancer cells. Furthermore, the combination of emodin and paclitaxel synergistically inhibited the anchorage-dependent and -independent growth of HER-2/neu-overexpressing breast cancer cells in vitro and synergistically inhibited tumor growth and prolonged survival in athymic mice bearing s.c. xenografts of human tumor cells expressing high levels of p185neu. Both immunohistochemical staining and Western blot analysis showed that emodin decreases tyrosine phosphorylation of HER-2/neu in tumor tissue. Taken together, our results suggest that the tyrosine kinase activity of HER-2/neu is required for tumor growth and chemoresistance and that tyrosine kinase inhibitors such as emodin can inhibit the growth of HER-2/neu-overexpressing tumors in mice and also sensitize these tumors to paclitaxel. The results may have important implications in chemotherapy for HER-2/neu-overexpressing breast tumors.

Assessment of myocardial viability by dobutamine echocardiography, positron emission tomography and thallium-201 SPECT: correlation with histopathology in explanted hearts

OBJECTIVES

We examined the relationship among viability assessment by dobutamine echocardiography (DE), positron emission tomography (PET) and thallium-201 single-photon emission computed tomography (TI-SPECT) to the degree of fibrosis.

BACKGROUND

DE, PET and TI-SPECT have been shown to be sensitive in identifying viability of asynergic myocardium. However, PET and TI-SPECT indicated viability in a significant percentage of segments without dobutamine response or functional improvement after revascularization.

METHODS

Twelve patients with coronary artery disease and severely reduced left ventricular function (EF 14.5+/-5.2%) were studied with DE prior to cardiac transplantation: 5 had additional PET and 7 had TI-SPECT studies. Results of the three techniques were compared to histologic findings of the explanted hearts.

RESULTS

Segments with >75% viable myocytes by histology were determined to be viable in 78%, 89% and 87% by DE, PET and TI-SPECT; those with 50-75% viable myocytes in 71%, 50% and 87%, respectively. Segments with 25-50% viable myocytes showed response to dobutamine in only 15%, but were viable in 60% by PET and 82% by TI-SPECT. Segments with <25% viable myocytes responded to dobutamine in 19%; however, PET and TI-SPECT demonstrated viability in 33% and 38%, respectively. Discrepant segments without dobutamine response but viability by PET and SPECT had significantly more viable myocytes by pathology than did those classified in agreement to be nonviable but had significantly less viable myocytes than those classified in agreement to be viable (p < .001).

CONCLUSIONS

These findings suggest that contractile reserve as evidenced by a positive dobutamine response requires at least 50% viable myocytes in a given segment whereas scintigraphic methods also identify segments with less viable myocytes. Thus, the methods may provide complementary information: Nuclear techniques appear to be highly sensitive for the detection of myocardial viability, and negative tests make it highly unlikely that a significant number of viable myocytes are present in a given segment. Conversely, dobutamine echo may be particularly useful for predicting recovery of systolic function after revascularization.

Tyrosine kinase inhibitors, emodin and its derivative repress HER-2/neu-induced cellular transformation and metastasis-associated properties

We have previously shown that emodin suppresses tyrosine kinase activity of HER-2/neu-encoded p185neu receptor tyrosine kinase. In this study, we examine the relationship between the chemical structure and the activity of emodin and nine derivatives, and identified that one methyl, one hydroxy, and one carbonyl functional groups are critical for the biological activities of emodin. We also found that one of the derivatives 10-(4-acetamidobenzylidene)-9-anthrone (DK-V-47) is more effective than emodin in repressing the tyrosine phosphorylation of p185neu and in inhibiting the proliferation and transformation of HER-2/neu-overexpressing human breast cancer cells. Using mutation-activated HER-2/neu transformed 3T3 cells, we also investigated whether emodin and DK-V-47 can inhibit malignant transformation induced solely by the HER-2/neu oncogene. We found that DK-V-47 is more potent than emodin in suppressing transformation phenotypes of activated HER-2/neu transformed 3T3 cells including anchorage-dependent and -independent growth, metastasis-associated properties. These results clearly indicate that the inhibition of p185neu tyrosine kinase by both emodin and DK-V-47 is capable of suppressing the HER-2/neu associated transformed phenotypes including the ability to induce metastatic potential. Our results also support the chemotherapeutic implications of the use of either emodin or DK-V-47 to target HER-2/neu-overexpressing cancer cells.

Pattern of proteinuria in tubular injury and glomerular hyperfiltration

Proteinuria is one of the bad prognostic indices in renal disease. This study compares the pattern of protein excretion in 10 patients with IgA nephropathy (IgAN), 10 patients with chronic glomerulonephritis approaching end-stage renal failure (ESRF) who still had proteinuria and 10 other patients with diabetic nephropathy (DN) with proteinuria but normal renal function. The pattern of proteinuria was analysed by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE), isoelectric focusing (IEF) and assayed for orosomucoid, alpha-1-microglobulin, retinol-binding protein, lysozyme, beta-2-microglobulin and N-acetyl-beta-D-glucosaminidase activity. Our data showed much similarity in the pattern of proteinuria between the DN and ESRF groups but significant differences with the IgAN group. The pattern of proteinuria in the IgAN group reflects glomerulonephritis whereas the similar pattern between the ESRF and DN groups may reflect hyperfiltration as well as tubular injury.

Incompleteness of statutory notification of bacterial gastro-intestinal infection

A study was made of all potentially statutorily notifiable bacterial infections diagnosed in faecal samples submitted from symptomatic patients to a single microbiology laboratory during a six-month period. Salmonella spp, Campylobacter spp or Shigella spp were isolated from 167 patients and 51% of these were formally notified (54% of general practice patients and 47% of hospital patients). Forty-seven percent of cases of food-poisoning (Salmonella spp. and Campylobacter spp) were notified as were 70% of cases of shigella infections. Notification was made on average 9.4d after sending a specimen to the laboratory. A questionnaire used to ascertain the reasons for non-notification in 80 of 85 cases elicited replies in respect of 78 patients. Four patients infected with Salmonella spp or Campylobacter spp were said not to have been suffering from food-poisoning. A variety of reasons was given for failing to notify the others, the most common were forgetfulness, not receiving the result of the specimen, or believing someone else had made the notification.

Strong correlation between c-erbB-2 overexpression and overall survival of patients with oral squamous cell carcinoma

Overexpression of c-erbB-2 (also known as HER-2/neu) has been found in many human cancers, including head and neck squamous cell carcinoma (SCC). We therefore examined expression of the oncoprotein in oral SCC primary tumor samples and compared its relationship with clinical stages and survival rate. Out of 80 cases of oral SCC, high expression level (++ or +++) of c-erbB-2 was found in 41 cases. Of the 80 cases with follow-up information, 39 were further investigated for the correlation of expression level of c-erbB-2 and survival rate. Overexpression of the oncoprotein was significantly correlated with shorter overall survival, and the patients with low and no expression of c-erbB-2 had much higher survival rates. Overexpression of c-erbB-2 was also significantly correlated with nodal stage and metastasis. We found that high expression level of c-erbB-2 was frequently detected in oral cancer cell lines but not in the other head and neck SCC cell lines. Thus, we conclude that overexpression of c-erbB-2 is a frequent event in oral SCC and is correlated with poor survival and may be used as a poor prognostic factor.

Effects of dobutamine stimulation on myocardial blood flow, glucose metabolism, and wall motion in normal and dysfunctional myocardium

BACKGROUND

This investigation examines the effects of inotropic stimulation on myocardial blood flow (MBF) and glucose metabolism (MRGlc) in dysfunctional myocardium through the use of positron emission tomography (PET).

METHODS AND RESULTS

Nineteen patients with chronic coronary artery disease and 12 normal volunteers were studied with 13N-ammonia, 18F-deoxyglucose, and PET and with two-dimensional echocardiography at baseline and during intravenous dobutamine (5 to 10 micrograms/kg per minute). At rest, MBF in mismatch regions (n = 10) averaged 0.53 +/- 0.19 mL/g per minute and increased by 41.4 +/- 46.6% (P = .01) during dobutamine, whereas in match regions (n = 16) MBF was 0.28 +/- 0.09 mL/g per minute at rest without an increase during dobutamine (26.4 +/- 47.3%; NS). Myocardium with normal rest MBF was classified as normal remote (normal wall motion, n = 8) or abnormal remote (abnormal wall motion, n = 11). Dobutamine raised MBF similarly in normal subjects and in normal remote regions (by 82 +/- 85% and 84 +/- 42%, P < .01) but by only 33 +/- 34% in abnormal remote regions. MRGlc declined by 49 +/- 28% (P < .005) with dobutamine in the normal subjects, remained unchanged in normal and abnormal remote regions of the patients, but increased in mismatch and match regions (by 49 +/- 74% and 46 +/- 77%; P < .05). Wall motion improved with dobutamine only in mismatch and abnormal remote regions but not in match regions.

CONCLUSIONS

Blood flow-metabolism mismatch patterns are not consistently associated with a fixed downregulation of MBF; the increased contractile work in response to dobutamine stimulation is associated with an increase in MBF and a greater reliance on glucose utilization, possibly reflecting acute ischemia or alterations in substrate selection by chronically dysfunctional myocardium. Importantly, functionally impaired though normally perfused myocardium frequently exists in chronic coronary artery disease patients and may represent repetitively stunned or, more likely, remodeled left ventricular myocardium.

Case report: lysosomal glycogen storage disease with normal acid maltase: an unusual form of hypertrophic cardiomyopathy with rapidly progressive heart failure

A 14-year-old boy with mild mental retardation, myopathy, and nonobstructive hypertrophic cardiomyopathy (HCM) with clinical and histopathologic features consistent with lysosomal glycogen storage disease with normal acid maltase is described. The case illustrates the aggressive nature of the cardiomyopathy of this syndrome. This condition is associated with malignant ventricular arrhythmias, relentlessly progressive ventricular dilatation, dysfunction, and sudden death. It is important to recognize this unusual and malignant form of HCM to precipitate low early diagnosis by muscle biopsy. Patients with this condition would be excellent candidates for life-saving heart transplant as the myopathy and mental retardation are mild and nonprogressive. The underlying biochemical defect and mode of inheritance of this syndrome are unclear. However, a significant proportion are genetically related and thus, relatives may benefit from family screening.

Transesophageal echocardiography in the detection of inferior vena cava and cardiac metastasis in hepatocellular carcinoma

Antemortem diagnosis of inferior vena cava (IVC) and cardiac metastasis of hepatocellular carcinoma (HCC) is difficult but important before consideration of curative resection. There are only a few cases of cardiac metastasis of HCC which have been diagnosed antemortem by echocardiography. Accordingly, 18 consecutive patients with HCC who were potential candidates for curative resection were studied by transthoracic (TTE) and transesophageal echocardiography (TEE). One (6%) and two (11%) patients had cardiac and IVC metastasis of HCC, respectively, which was detected by two-dimensional TTE. In contrast, by using TEE, four patients (22%) showed tumor invasion of the IVC, of whom two (11%) had tumor mass extending into the right atrium (RA). There was no significant difference in age, serum level of alpha-fetoprotein, and percentage of right liver lobar involvement between those with and without cardiac metastasis. Patients without cardiac metastasis detected on TTE or TEE had significantly longer mean duration of survival (5.0 +/- 2.1 vs. 2.1 +/- 1.0 months; p < 0.05). In summary, TEE may be more useful than TTE in the detection of cardiac metastasis of HCC, which occurred in 22% of patients whose primary tumor was considered to be surgically resectable in our series. This can be safely performed in patients with HCC and can provide optimal visualization of the IVC and RA. The high prevalence of subclinical cardiac metastasis in HCC mandates the use of TEE in all patients with HCC prior to surgical intervention.

Parvovirus B19 outbreak on an adult ward

In November and December 1992, an outbreak of parvovirus B19 infection occurred among patients and staff on an adult mixed surgical ward at a large hospital in London. Three patients and 15 staff members were serologically confirmed as acute cases. The attack rate among susceptible members of staff was 47%. In those infected, arthralgia (80%) and rash (67%) were the most common symptoms. Of six susceptible in-patients on the ward, three became infected. One of the in-patients who had carcinoma of the mouth was viraemic for more than 10 days with marrow suppression resulting in the postponement of chemotherapy until intravenous immunoglobulin was given and he was no longer viraemic. Control measures taken included closure of the ward to new admissions, transfer of only immune staff to the ward, and restriction of the ward nursing staff to working only on that ward. Although no specific exposure was conclusively identified as a risk factor, there was a suggestion of an increased risk of acquiring parvovirus B19 infection among those staff who did not adopt strict hand washing procedures after each physical contact with a patient (RR = 2.33; P = 0.07). Knowledge of parvovirus B19 among interviewed health care workers was poor: only 42% reported knowing about parvovirus B19 and only 38% could name a patient category at risk of a severe outcome following infection. This is the first report of a nosocomial outbreak affecting an adult ward and of possible transmission of parvovirus B19 infection from staff to in-patients. Hospital control of infection teams should include parvovirus B19 in their outbreak containment plans.

Isoelectric focusing and selectivity index in IgA nephrotic syndrome

Proteinuria in 13 patients with IgA nephritis with nephrotic syndrome (IgANS) was analysed by isoelectric focusing (IEF) and compared with 12 patients with minimal change nephrotic syndrome (MCNS) (n = 8) or focal global sclerosis nephrotic syndrome (FGS) (n = 4) to determine the pattern of proteinuria on IEF and to assess the value of IEF and protein selectivity index (SI) as predictors of response to therapy with predisolone or cyclophosphamide. Steroid/cyclophosphamide responsive patients with IgANS had SC:UA (cationic serum albumin with anionic urine albumin) or SA:UC (anionic serum albumin with cationic urine albumin) IEF patterns and steroid/cyclophosphamide unresponsive patients with IgANS had an SC:UC (cationic serum albumin with cationic urine albumin) IEF pattern. The majority of patients with MCNS or FGS who had an SA:UC IEF pattern were steroid responsive. SI was a better predictor of steroid/cyclophosphamide responsiveness in patients with IgANS (r = 0.78, p < 0.002 compared to IEF, r = 0.64, p < 0.02).

Differential oxygen sensitivities in G6PDH activities of cultured keloid and normal skin dermis single cells

Cell cultures of excised keloids and biopsied normal skin were established from patients of the Plastic Surgery Department of Singapore General Hospital and their single cells quantitated for glucose-6-phosphate dehydrogenase (G6PDH) activity using microspectrophometry. G6PDH has been cited as a transformation-linked discriminant. Analysis of variance shows no difference in overall activity between skin and keloid cells, but under oxygen saturation conditions, keloid G6PDH activity was significantly higher than skin G6PDH activity, although they were almost identical under nitrogen saturation conditions. Differential oxygen sensitivity in G6PDH activities between malignant and non-malignant cells have been reported, but its occurrence between keloid and normal skin cells is novel, especially as the keloid is regarded as a benign tumor with a zero carcinogenicity rate.

Effects of triple therapy in IgA nephritis: a follow-up study 5 years later

This study is a 5-year post trial assessment of patients with IgA nephritis who entered a 3-year prospective controlled trial of cyclophosphamide, dipyridamole (D) and low-dose warfarin (W). Patients entered the trial from 1979 to 1981 and the trial ended in 1984 with those in the treatment group having more stable renal function and less proteinuria compared to the control group. Present reassessment of the patients in 1989 showed no difference in the renal function between those in the treatment group (n = 27) and the control group (n = 21). 6 patients in the treatment group and 7 in the control group were in ESRF. At the conclusion of the trial in 1984, among the 27 patients in the original treatment group, 13 patients elected to continue with D + W while the other 14 patients chose to cease therapy and therefore served as the new control group. 5 years later, renal function in the new treatment group (n = 13) was significantly stable compared to the new control group (n = 14), (serum creatinine 1.4 +/- 0.7 versus 4.4 +/- 3.2 mg/dl, p less than 0.01). Furthermore, all the 6 patients with ESRF in the original treatment group of 27 patients were from the new control group (n = 14) where treatment with D + W had been ceased. None of the patients still on D + W are in ESRF.

Pattern of proteinuria in IgA nephritis by SDS-PAGE: clinical significance

Of sixty patients with IgA nephritis, none had CRF at first examination, 13 developed CRF with creatinine above 1.6 mg/dl within 6 years. Among these patients who had analysis of proteinuria by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE), 31 patients had middle molecular weight (MMW) proteinuria alone (pattern 1), 10 had MMW and Low MW (LMW) or tubular proteinuria (pattern 2), 10 had high MW (HMW) and MMW proteinuria (Pattern 3) and 9 had HMW, MMW and LMW proteinuria (Pattern 4). At the end of a follow up period of 6 years (1983-1989) patients with mixed proteinuria had a higher incidence of chronic renal failure (CRF), 11/29 (38%) compared to those with pattern 1 proteinuria, 2/31 (6%) (chi 2 = 8.7, p less than 0.005). Based on the glomerular selectivity index (GSI), 19 patients had nonselective proteinuria but they did not have a higher incidence of CRF. By the selectivity index (SI), 18 patients had nonselective proteinuria and they showed a significantly higher incidence of CRF. Compared to the 41 patients who did not have LMW proteinuria, 19 patients with LMW proteinuria had more severe proteinuria. After a follow-up period of 6 years, patients with LMW proteinuria had a higher incidence of CRF (10% versus 47%, p less than 0.001). The presence of LMW proteinuria indicates a less favourable outcome and the pattern of proteinuria as assessed by the SDS-PAGE appears to be a better prognostic index in IgA nephritis than the SI and the GSI.

Measurement of sulphur gases in ambient air

A gas chromatograph with a flame photometric detector is set up for the direct analysis of COS, H2S, CS2, SO2, CH3SH, C2H5SH in ambient air.Logarithmic transformation is used to counterbalance the non-linear nature of the detector response for the individual sulphur gases. A quality assurance procedure is described to compensate any variation of response during field measurement. The use of Tedlar bags for sampling COS, CS2, CH3SH, C2H5SH is acceptable despite the general conception that sulphur gases are unstable in Tedlar bags.

The simultaneous determination of active ingredients in cough-cold mixtures by isocratic reversed-phase ion-pair high-performance liquid chromatography

A simple, rapid and accurate method for the simultaneous determination of active ingredients in cough-cold mixtures using isocratic reversed-phase ion-pair high-performance liquid chromatography has been developed. It involves the use of an octadecylsilane column as the stationary phase with methanol, water, tetrahydrofuran, phosphoric acid mixtures as mobile phase including sodium dioctylsulphosuccinate as the ion-pair agent. The pH of the mobile phase was adjusted to 4.6 by means of phosphoric acid and ammonium hydroxide solutions. The proposed method involves the simple dilution of the samples with the mobile phase and the addition of metoclopramide hydrochloride as the internal standard. The active ingredients under investigation were chlorpheniramine, codeine, diphenhydramine, ephedrine, ethylmorphine, phenylephrine, phenylpropanolamine and pholcodine, which exist as various combinations in cough-cold mixtures. The optimum composition of the mobile phase and the optimum flow rate were determined and are reported. The method was applied to the determination of active ingredients in seven commercially available cough-cold mixtures.

Protein selectivity: a prognostic index in IgA nephritis

Among 98 patients with IgA nephritis who had protein selectivity studies performed, 54% had nonselective proteinuria and the remaining 46% had selective proteinuria. Patients with nonselective proteinuria had a higher incidence of glomerulosclerosis. At the end of a 4-year follow-up period, patients with nonselective proteinuria had lower creatinine clearance, higher incidence of hypertension and chronic renal failure when compared to patients with selective proteinuria. Six out of eleven patients (55%) in the study who had the nephrotic syndrome had selective proteinuria. Among these 6 patients, 1 had spontaneous remission and 5 responded to steroid or cyclophosphamide therapy. The remaining 5 patients with nonselective proteinuria did not respond to therapy. In the patients who had selectivity studies repeated, the data showed that the selectivity index (SI) can fluctuate depending on the clinical course of the patients. SI can therefore be used to monitor the progress of patients on long-term follow-up. Protein selectivity appears to be a useful prognostic index in IgA nephritis. For patients with the nephrotic syndrome it may serve as a guide to therapy.

Hypertension in IgA nephropathy

Among 151 patients with IgA nephritis, 18/151 (12%) had hypertension at presentation and 50/151 (33%) were hypertensive after an interval of 65 +/- 40 (Mean +/- SD) months. Hypertensive patients (n = 50) had a higher incidence of glomerulosclerosis, medial hypertrophy of blood vessels, tubular atrophy, poorly selective proteinuria and extension of immunodeposits to peripheral capillary walls compared to normotensive patients (n = 101). Chronic renal failure occurred more commonly among hypertensives compared to normotensive patients (42%) versus 14%. However, the time taken for patients to reach renal impairment or end stage renal failure was not significantly different. The cumulative renal survival for the hypertensive group was 78% after 8 years compared to 91% in the normotensive group (p less than 0.05). In the second part of the study, patients who were hypertensive at presentation (n = 18) were compared with those who developed hypertension on follow up (n = 32). Apart from a shorter duration of follow up for patients with hypertension and a higher incidence of glomerulosclerosis, there were no significant differences in their clinical presentation, laboratory indices or other histological parameters. The incidence of chronic renal failure and the time taken to reach end stage renal failure were not different. Uncontrolled hypertension was an important cause for rapid deterioration to end stage renal failure within 3 years, compared to 8 years when hypertension was controlled.