Imaging findings of spontaneous spinal epidural hematoma

The imaging studies of 12 patients with spontaneous spinal epidural hematomas (SSEHs) who were treated from 1987 to 1995 at Chang Gung Memorial Hospital were retrospectively analyzed. The advantages and disadvantages of myelography, computed tomographic myelography (CTM) and magnetic resonance imaging (MRI) in diagnosing SSEH were evaluated. We found that in subacute and chronic stages of SSEH, MRI was the diagnostic choice because of its pathognomonic magnetic resonance signal changes. However, in the first 24 hours of SSEH, the MRI signal changes of hematomas were confused with those of epidural metastatic tumors or abscesses. In this situation, enhancement was not an absolute sign to rule out hematomas, because gadolinium enhancement of a hematoma did occur in one of our patients. CTM was helpful in this stage because a hyperdense epidural mass was always noted. In conclusion, we found that MRI offers a noninvasive and specific diagnosis of SSEH, though it has some pitfalls in the first 24 hours of SSEH. CTM with sagittal reformations also provides a specific diagnosis, especially when a hyperdense mass is seen. By combining these diagnostic imaging modalities and clinical manifestations, an early diagnosis of SSEH is possible.

Childhood-onset autosomal-dominant limb-girdle muscular dystrophy with cardiac conduction block

We report childhood-onset autosomal-dominant limb-girdle muscular dystrophy (LGMD) in a Chinese family with complete atrioventricular conduction block in the adult members. Six patients, including 5 men and 1 woman with an age of onset from 3 to 7 years, were affected. The grandfather had exercise intolerance since childhood and complete heart block with pace-maker placement at age 52. Three siblings had proximal muscle weakness and/or wasting since age 5 and heart block in their 40s. Two grandsons at the ages 7 and 3 showed exercise intolerance, and proximal muscle weakness and wasting. Sinus bradycardia was present in the elder grandson. Muscle enzymes were elevated in 3, particularly in childhood. Muscle biopsies from the proband showed myopathic changes with fatty degeneration, whorled fibers, and rimmed vacuoles. In adult patients, muscle magnetic resonance imaging scans disclosed atrophic changes and fatty degeneration in the gluteal, quadriceps, adductors, hamstrings, gastrocnemius, and soleus muscles, while in child probands the early atrophic changes were seen in the gluteal and hamstrings muscles. We conclude that this distinct family is characterized by childhood-onset autosomal-dominant LGMD with heart block and that prevention of sudden death in these patients is important.

HLA-DMA and DMB genotyping in patients with rheumatoid arthritis

OBJECTIVE

To investigate the relation of HLA-DMA and DMB alleles to the development of rheumatoid arthritis (RA).

METHODS

We studied HLA-DMA and DMB alleles in 153 patients with RA and 138 healthy controls using the amplification created restriction site method and digestion with restriction enzymes.

RESULTS

There was no significant difference in frequencies of HLA-DMA and DMB alleles between patients with RA and controls. The HLA-DMA and DMB alleles were not related to extraarticular involvement, seropositivity for rheumatoid factor, or bone erosion. There was also no significant difference in frequencies of HLA-DMA and DMB alleles among DR4-positive and DR4-negative patients and controls.

CONCLUSION

HLA-DMA and DMB do not appear to be associated with the pathogenesis of RA.

CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation

PURPOSE

The purpose of our study was to devise a CT grading scheme for blunt pancreatic injuries (BPIs) and to apply it to predict the presence or absence of ductal disruption.

METHOD

We retrospectively reviewed CT scans of 22 patients with proven BPIs. We graded these injuries on CT (A, BI, BII, CI, and CII) based on the (a) presence or absence of pancreatic lacerations, (b) site of lacerations, and (c) depth of lacerations. CT grading was correlated with surgical findings for glandular and ductal injuries.

RESULTS

Main pancreatic ducts were intact in 2 patients with normal CT scans and in all grade A injuries (n = 10). Distal pancreatic ducts were disrupted in all grade B injuries (BI, n = 1; BII, n = 4). Of five grade C injuries, three CII injuries had disruption of proximal pancreatic duct, one CII injury had disruption of minor duct, and one CI injury had an intact ductal system.

CONCLUSION

CT grading of BPIs was useful in predicting ductal integrity or disruption. Ductal disruption was likely present if the pancreas appeared to have a transection or deep laceration on CT scans. It was accurate in grade A and B injuries. Overestimation could occur in grade CI and CII injuries.

CT features of genitourinary tuberculosis

The genitourinary system is the most common site of extrapulmonary tuberculous infection. The diagnosis is difficult and often delayed. In this essay, we illustrate the CT features of the kidneys, ureters, bladder, prostate gland, and seminal vesicles caused by tuberculosis.

Evidence for linkage of a candidate chromosome 1 region to human systemic lupus erythematosus

Genetic susceptibility confers significant risk for systemic lupus erythematosus (SLE). The MHC region and other polymorphic loci have been associated with SLE. Because more compelling evidence for an involvement of a genetic locus includes linkage, we tested a candidate region homologous to a murine SLE susceptibility region in 52 SLE-affected sibpairs from three ethnic groups. We analyzed seven microsatellite markers from the human chromosome 1q31-q42 region corresponding to the telomeric end of mouse chromosome 1, the region where specific manifestations of murine lupus, including glomerulonephritis and IgG antichromatin, have been mapped. Comparing the mean allele sharing in affected sibpairs of each of these seven markers to their expected values of 0.50, only the five markers located at 1q41-q42 showed evidence for linkage (P = 0.0005-0.08). Serum levels of IgG antichromatin also showed evidence for linkage to two of these five markers (P = 0.04), suggesting that this phenotype is conserved between mice and humans. Compared to the expected random distribution, the trend of increased sharing of haplotypes was observed in affected sibpairs from three ethnic groups (P < 0.01). We concluded that this candidate 1q41-q42 region probably contains a susceptibility gene(s) that confers risk for SLE in multiple ethnic groups.

Small isolated paraspinal arteriovenous fistula

We report a case of a small, isolated paraspinal arteriovenous fistula (AVF) that arose in an adult without obvious trauma. The fistula, despite its extraspinal location and small size, caused hypertension of the intrathecal venous system and produced symptoms that were similar to those of spinal dural AVF. Detecting such a small lesion is difficult, but contrast-enhanced MR imaging can prove helpful in this regard.

Epidermal growth factor enhances transcription of human arachidonate 12-lipoxygenase in A431 cells

Epidermal growth factor (EGF), determined by immunoprecipitation and Western blot analysis, increased both enzyme activity and protein level of 12-lipoxygenase in the solubilized microsomes of human epidermoid carcinoma A431 cells, respectively. The EGF-induced expression of 12-lipoxygenase mRNA was inhibited by transcription inhibitors such as actinomycin D and 5,6-dichlorobenzimidazole riboside. Promoters of different lengths for human 12-lipoxygenase gene were used to prepare the luciferase fusion vectors. These construct plasmids were transiently transfected into A431 cells, and the induction of luciferase expression by EGF was examined. A 4- to 6-fold increase in luciferase reporter activity stimulated by EGF for 18 h treatment was observed in plasmids with the 5'-flanking region length of -951 bp and that of -224 bp upstream from translation starting site. The time-dependent induction of luciferase activity by EGF paralleled the EGF-induced enzyme activity and expression of 12-lipoxygenase protein. Taken together, the results of this study indicate that EGF enhanced the transcription of the human 12-lipoxygenase gene, resulting in an increase in the amount and activity of 12-lipoxygenase.

Differential infectivity of two Autographa californica nucleopolyhedrovirus mutants on three permissive cell lines is the result of lef-7 deletion

We isolated two Autographa californica nucleopolyhedrovirus (AcMNPV) mutants that have infectivity similar to that of wild-type (wt) AcMNPV in TN368 cells, but reduced budded virus and polyhedral inclusion body production in IPLB-SF-21 and SE1c cells. Restriction endonuclease analysis and sequence analysis indicated that 3.2-kb (77.0-79.4 m.u.) and 4.4-kb (76.7-80.1 m.u.) regions, the location of four major open reading frames (ORFs), pk2, ORF-247, lef-7, and chitinase, were deleted in mutant T295 and T297, respectively. Phenotypes of recombinant viruses vdel-AG, in which all four ORFs were deleted, and vlef7-AG, in which only lef-7 was deleted, were identical to the mutants. The phenotypes of recombinant viruses with deletions of the other ORFs were indistinguishable from wt AcMNPV. This demonstrated that the deletion of lef-7 was responsible for the mutant phenotypes. Viral DNA synthesis in both mutant- and vlef7-AG-infected SF-21 and SE1c cells was reduced to less than 10% of that of wt AcMNPV-infected cells. In TN368 cells, DNA synthesis in mutant- and vlef7-AG-infected cells was delayed relative to wt-infected cells. Although lef-7 is not essential for AcMNPV infection in TN368 cells, it is expressed in TN368, SF-21, and SE1c cells in a similar manner.

The TNF2 allele does not contribute towards susceptibility to systemic lupus erythematosus

The uncommon allele (TNF2) of a polymorphism in the promoter region of the tumor necrosis factor-alpha (TNF-alpha) gene has been reported to be increased in Caucasian systemic lupus erythematosus (SLE) patients (associated with HLA-DR3). To investigate whether TNF2 contributes towards susceptibility to Chinese SLE patients (not associated with HLA-DR3), 100 patients with SLE and 107 controls were studied. The frequency of TNF2 allele in controls was 0.140. There was a strong association between TNF2 allele and HLA-DR3 (P < 10(-8)) in controls. The frequency of TNF2 allele in SLE patients was 0.15. There was no difference in frequencies of TNF2 allele between patients and controls. This finding strongly suggests that TNF2 does not play a direct role in the susceptibility of SLE.

Seroepidemiology of Hantaan virus infection in Taiwan

In order to investigate the infection rate of Hantaan virus in Taiwan, a total of 6,536 human serum samples were collected from residents, selected by stratified random sampling, from 19 townships covering four different ethnic groups: Aborigines, Fukien Taiwanese, Hakka Taiwanese, and Mainland Chinese. Serum samples were screened for Hantaan virus antibodies by indirect immunofluorescence. The prototype Hantaan virus (76/118)-infected Vero E6 cells were used as the viral antigen for the antibody detection. Among 6,536 human serum samples, 403 (6.2%) samples had Hantaan virus antibodies. The seropositive rates for males and females were 6.1% and 6.2%, respectively. A higher seropositive rate was found among Aborigines on the Orchid Islets (11.5%) and Fukien Taiwanese on the Penghu Islets (11.6%), while the lowest rate was observed among Hakka Taiwanese in the south of Taiwan (2.5%). In comparing with different ethnic groups, the highest prevalence was found among Fukien Taiwanese (8.1%) and the lowest among Mainland Chinese (4.9%). Among the different geographical areas, the highest positive rate was found in western Taiwan (7.1%) and the lowest in southern Taiwan (5.4%). Hantaan virus antibodies were also detected in 22 of 548 (4.0%) rat serum samples. The highest seropositive rate was found in rat sera collected from the Orchid Islets (21.4%). None of the rat sera collected from Hsinchu, Miaoli, Changhua, Nantu, Yunlin, Chiayi, Tainan, and Penghu Counties were positive. Hantaan virus antibodies were found in rats: Rattus rattus (20%), Bandicota indica (9.0%), Rattus norvegicus (8.3%), Bandicota nemorivaga (6.3%), Rattus losea (4.2%), and Apodemus agrarius (1.6%). Hantaan virus antibodies were not detected in rat sera collected from species of Rattus coxinga, Rattus culturatus, Mus musculus, Mus caroli, Suncus murinus, and Apodemus semotus. The results show that the Hantaan or Hantaan-related virus exists and is distributed widely in both human and rats in Taiwan.

Risk factors of sudden infant death in Chinese babies

The influence of social and biologic factors on sudden infant death was studied in a large Chinese population. Data from all birth certificates in Taiwan from 1988 to 1992 were merged with death certificate data for postneonatal deaths from sudden infant death syndrome and suffocation. The Cox's proportional hazard model was used to compute multivariate adjusted relative risk estimates and 95% confidence intervals. Age difference of parents of more than 10 years was associated with a relative risk (RR) of 1.8 (multivariate adjusted, 95% confidence interval (CI) 1.3-2.3). Better than elementary education for the father was protective (adjusted RR 0.8, 95% CI 0.7-1.0, p < 0.05), and college education of the mother elevated the risk (adjusted RR 1.2, 95% CI 1.0-1.4, p < 0.05). Infants born second to fourth had an adjusted RR of 1.7 (95% CI 1.5-1.9), and infants born fifth or higher had a RR of 2.3 (95% CI 1.5-3.4). The multivariate adjusted RR for low birth weight and prematurity were 2.3 (95% CI 1.9-2.8) and 1.2 (95% CI 1.0-1.5), respectively. Data from this 5-year cohort in Taiwan emphasize biologic and social variables as important risk factors of sudden infant death in Chinese babies.

Papillary cystic tumor of the pancreas in children

Papillary cystic tumor of the pancreas, so-called Frantz tumor, is a very rare tumor in children. Only 157 cases had been reported since 1959. The clinical manifestations of this disease are usually a slowly growing abdominal mass with or without abdominal pain. It occurs predominantly in young females, and its pathogenesis is still unknown. Surgical resection is usually curative, and its prognosis is excellent. Four adolescent girls with acute or chronic abdominal pain were found to have papillary cystic tumor of the pancreas at our hospital in the past 4 years. They all have a variable clinical presentation. Papillary cystic tumor of the pancreas should therefore be considered one of the differential diagnoses of abdominal pain or abdominal mass in adolescent girls.

Identification and purification of a hemoglobin-binding outer membrane protein from Neisseria gonorrhoeae

The majority of in vitro-grown Neisseria gonorrhoeae strains were unable to use hemoglobin as the sole source of iron for growth (Hgb-), but a minor population was able to do so (Hgb+). The ability of Hgb+ gonococci to utilize hemoglobin as the iron source was associated with the expression of an iron-repressible 89-kDa hemoglobin-binding protein in the outer membrane. The N-terminal amino acid sequence of this protein revealed amino acids, from positions 2 to 16, identical to those of HpuB, an 85 kDa iron-regulated hemoglobin-haptoglobin utilization outer membrane protein of Neisseria meningitidis. Isogenic mutants constructed by allelic replacement with a meningococcal hpu::mini-Tn3erm construct no longer expressed the 89-kDa protein. Mutants could not utilize hemoglobin to support growth but still grew on heme. Thus, the gonococcal HpuB homolog is a functional hemoglobin receptor and is essential for growth with hemoglobin.

Idiopathic hypereosinophilic syndrome with eosinophilic myositis, peripheral neuropathy and central nervous system involvement

Idiopathic hypereosinophilic syndrome (HES) is a rare disorder marked by a sustained overproduction of eosinophils and a predilection for damage to multiple organ systems. Its neurologic involvement ranges from the central to the peripheral nervous system, and can be associated with eosinophilic myositis. We report a 68-year-old woman who had eosinophilia, eosinophilic dermatitis and eosinophilic pneumonia. She also suffered from numbness and weakness of the lower limbs. Because of long-lasting (> 6 mo) eosinophilia (> 1.5 x 10(9)/L) in the peripheral blood and the fact that no other underlying causes of eosinophilia and neurologic involvement could be identified, a diagnosis of idiopathic hypereosinophilic syndrome was made. The muscle biopsy showed infiltration of inflammatory cells, including a few eosinophils (Liu's stain). Magnetic resonance images, motor evoked potentials, somatosensory evoked potentials and nerve conduction velocities also showed abnormalities in the central and peripheral nervous systems. The pathogenesis and treatments of HES are discussed in this report.

Role of interferon regulatory factor-1 in the induction of biliary glycoprotein (cell CAM-1) by interferon-gamma

Biliary glycoprotein (BGP), also known as C-CAM-1, has been shown to be down-regulated in colon and prostate tumors. Previously, we demonstrated that BGP mRNA is up-regulated by interferon-gamma (IFN-gamma) in colon cancer cell lines (Takahashi, H., Okai, Y., Paxton, R. J., Hefta, L. J. F., and Shively, J. E. (1993) Cancer Res. 53, 1612-1619). We now show that the BGP promoter contains an interferon-sensitive response element (ISRE) that is specifically protected in in vivo footprints. Interferon regulatory factor-1 (IRF-1) was identified as the ISRE-binding factor by electrophoretic mobility shift assays. The induction of IRF-1 mRNA by IFN-gamma in HT-29 cells reaches a maximum at 6 h and is superinduced by cycloheximide. Four mRNA species for BGP are induced by IFN-gamma, the major band of which is inhibited by cycloheximide. Transfection of HT-29 cells with an IRF-1 expression plasmid (pAct-1) transactivates a BGP promoter reporter gene containing wild-type (but not mutant) ISRE. Electrophoretic mobility shift assay analysis of a second footprint reveals the binding of Sp1, an Sp1-like protein, and upstream stimulatory factor. The Sp1-like complex was also induced by IFN-gamma treatment of HT-29 cells and may be a second point of transcriptional control for the BGP gene.

Gender differences in postneonatal infant mortality in Taiwan

Numerous studies have indicated that gender discrimination influencing child survival is widespread in Asia. Therefore, we have investigated gender and cause-specific postneonatal mortality in Taiwan. Mortality data derived from death certificates and demographic statistics in Taiwan between 1981 and 1990 were analyzed. Postneonatal mortality decreased from 9.4 per 1000 live births to 5.5 per 1000 live births for males, and from 8.3 to 5.0 for females. The trends for cause-specific mortality for male and female infants were similar during the study period. The male-to-female ratio of overall death rates was 1.11. It was slightly higher in cities and lower in rural areas, and lowest in the least developed eastern region of Taiwan. Mortality from congenital diseases had the lowest male-to-female ratio, specifically in the North, the cities and areas of indigenous people. Infectious disease mortality showed low male-to-female ratios in the rural areas and in the eastern region. The place of death from infectious diseases as a measure for the use of sophisticated medical care showed that more female than male deaths occurred at home in the rural areas, cities, and central regions. It was concluded that a high level of socio-economic development created conditions of gender equality, whereas in situations of low socio-economic development males were favoured. The tendency to discriminate according to gender is very subtle in Taiwan, much less so than in other regions of Asia, including Thailand and India.

Aflatoxin exposure and risk of hepatocellular carcinoma in Taiwan

To investigate the carcinogenic effect of environmental aflatoxin exposure, 56 cases of hepatocellular carcinoma (HCC) diagnosed between 1991 and 1995 were identified and individually matched by age, sex, residence and date of recruitment to 220 healthy controls from the same large cohort in Taiwan. Blood samples were analyzed for hepatitis B and C viral markers and for aflatoxin-albumin adducts; urine was tested for aflatoxin metabolites. We obtained information about sociodemographic characteristics, habitual alcohol drinking, cigarette smoking and diet in a structured interview. Hepatitis B virus surface antigen (HBsAg) carriers had a significantly increased risk for HCC. After adjustment for HBsAg serostatus, the matched odds ratio (ORm) was significantly elevated for subjects with high levels of urinary aflatoxin metabolites. When stratified into tertiles, a dose-response relationship with HCC was observed. The ORm for detectable aflatoxin-albumin adducts was not significant after adjustment for HBsAg serostatus. HBsAg-seropositive subjects with high aflatoxin exposure had a higher risk than subjects with high aflatoxin exposure only or HBsAg seropositivity only. In male HBsAg-seropositive subjects, adjusted ORs were 2.8 (95% confidence interval [CI] = 0.9-9.1) for detectable compared with non-detectable aflatoxin-albumin adducts and 5.5 (CI = 1.3-23.4) for high compared with low urinary aflatoxin metabolite levels. Our results suggest that environmental aflatoxin exposure may enhance the hepatic carcinogenic potential of hepatitis B virus. A large-scale study will be needed to evaluate the effect of aflatoxin exposure on HBsAg non-carriers.

Decreased bone mineral density in premenopausal patients with systemic lupus erythematosus

To study bone mineral density (BMD) in premenopausal adult female patients with systemic lupus erythematosus (SLE) and its relation with clinical parameters, 56 SLE patients (mean age 31 years, mean disease duration 6.3 years) and 15 normal controls were studied. BMD at the lumbar vertebrae (L2-L4) was measured by dual energy X-ray absorptiometry (DEXA). Classification of BMD was made according to the WHO criteria in 1994. Correlation between BMD and clinical parameters was calculated. It was found BMD in the SLE patients (0.942 +/- 0.136 g/cm2) was lower than in the control group (1.055 +/- 0.080 g/cm2) (P < 0.01). According to the WHO criteria, 17 patients (30%) had normal BMD, 22 patients (40%) had osteopenia and 17 patients (30%) had osteoporosis. BMD was inversely correlated with disease duration in SLE patients (p < 0.005). The minimal disease duration for a female SLE patient to develop osteopenia was 3.5 years. In conclusion, SLE patients have lower lumbar BMD than normal controls. SLE patients with longer disease duration have lower BMD. In order to achieve early prevention of osteoporosis, we suggest that female SLE patients with disease duration for more than 3.5 years should take a BMD examination.

Elevated aflatoxin exposure and increased risk of hepatocellular carcinoma

To elucidate the importance of aflatoxin in the etiology of hepatocellular carcinoma (HCC), a community-based cohort study combined with molecular dosimetry of aflatoxin exposure was performed in the Penghu Islets where the HCC mortality rate is highest in Taiwan. A total of 6,487 residents aged 30 to 65 years were recruited in the two-stage screening survey and underwent regular follow-up examination. Among 33 newly diagnosed HCC cases, 31 (94%) were chronic hepatitis B surface antigen (HBsAg) carriers and 3 (9%) were positive for antibodies against hepatitis C virus (HCV). Among 20 HCC patients and 86 matched healthy controls whose serum samples were tested for aflatoxin B1 (AFB1)-albumin adducts by competitive enzyme-linked immunosorbant assay (ELISA), 13 (65%) HCC patients and 32 (37%) matched controls were seropositive, showing a statistically significant multivariate-adjusted odds ratio of 5.5 with a 95% confidence interval of 1.2 to 24.5. The results imply the elevated risk of HCC among Penghu residents may be attributable to their heavy exposure to aflatoxins and high HBsAg carrier rate.

Aflatoxin exposure and risk of hepatocellular carcinoma in Taiwan

To investigate the carcinogenic effect of environmental aflatoxin exposure, 56 cases of hepatocellular carcinoma (HCC) diagnosed between 1991 and 1995 were identified and individually matched by age, sex, residence and date of recruitment to 220 healthy controls from the same large cohort in Taiwan. Blood samples were analyzed for hepatitis B and C viral markers and for aflatoxin-albumin adducts; urine was tested for aflatoxin metabolites. We obtained information about sociodemographic characteristics, habitual alcohol drinking, cigarette smoking and diet in a structured interview. Hepatitis B virus surface antigen (HBsAg) carriers had a significantly increased risk for HCC. After adjustment for HBsAg serostatus, the matched odds ratio (ORm) was significantly elevated for subjects with high levels of urinary aflatoxin metabolites. When stratified into tertiles, a dose-response relationship with HCC was observed. The ORm for detectable aflatoxin-albumin adducts was not significant after adjustment for HBsAg serostatus. HBsAg-seropositive subjects with high aflatoxin exposure had a higher risk than subjects with high aflatoxin exposure only or HBsAg seropositivity only. In male HBsAg-seropositive subjects, adjusted ORs were 2.8 (95% confidence interval [CI] = 0.9-9.1) for detectable compared with non-detectable aflatoxin-albumin adducts and 5.5 (CI = 1.3-23.4) for high compared with low urinary aflatoxin metabolite levels. Our results suggest that environmental aflatoxin exposure may enhance the hepatic carcinogenic potential of hepatitis B virus. A large-scale study will be needed to evaluate the effect of aflatoxin exposure on HBsAg non-carriers.

Serial MRI studies in pathologically verified Balò's concentric sclerosis

We report serial MRI studies in a patient with Balò's concentric sclerosis, who presented with a progressive weakness in the right limbs of 10 day duration. Serial MR images revealed several concentric lesions characterized by layer by layer of demyelinated and myelinated appearance and multiple plaques in the white matter. Pathological study of a biopsy of a concentric lesion (which was performed to rule out neoplasm) further confirmed this diagnosis. These MR findings resolved in correspondence with clinical improvement. The patient was almost completely normal 1 year later. In conclusion, in this case, we found that MRI could show the striking feature reminiscent of the histopathologic findings of Balò's concentric sclerosis and played an important role in antemortem diagnosis of this rare demyelinating disease.

Body size and risk of pre- and post-menopausal breast cancer in Taiwan

The incidence of breast cancer is increasing rapidly in Taiwan but is still low compared with western countries. The impact of body size factors in western countries inspired us to have a case-control study. A matched case-control study was done on 122 pairs of incident cases of female breast cancer and community controls. Body height and weight were collected from a questionnaire interview and used to derive the body mass index (kg/m2). Demographic and reproductive characteristics were collected and controlled as potential confounders. Conditional multiple logistic regression analysis was used to estimate the multivariate-adjusted odds ratios for each risk factor regarding body size. After adjustment for age, schooling years, age at menarche and parity; body weight and height were positively related to postmenopausal breast cancer but not significantly related to the risk of premenopausal breast cancer. The odds ratios for body mass index were less prominent. Women with a higher breast stem cell mass resulting from better adolescent nutrition had a higher risk for breast cancer; and postmenopausal obesity may increase the breast cancer risk through the increased conversion of adrenal androstenedione to estrogen in adipose tissue after menopause.

Concomitant fracture of the coracoid and acromion after direct shoulder trauma

Fractures of the acromial process or coracoid process of the scapula are rare. We present a combined fracture of the coracoid and acromion after direct trauma to the shoulder. An anteroposterior radiography with the central x-ray beam angled 25 degrees cephalad or an axillary lateral radiograph may be needed to detect these fractures.