Improving the diagnosis related grouping model's ability to explain length of stay of elderly medical inpatients by incorporating function-linked variables

INTRODUCTION

This study first aimed to determine the adequacy of the Diagnosis Related Grouping (DRG) model's ability to explain (1) the variance in the actual length of stay (LOS) of elderly medical inpatients and (2) the LOS difference in the same cohort between the departments of Geriatric Medicine (GRM) and General Medicine (GM). We then looked at how these explanatory abilities of the DRG changed when patients' function-linked variables (ignored by DRG) were incorporated into the model.

MATERIALS AND METHODS

Basic demographic data of a consecutively hospitalised cohort of elderly medical inpatients from GRM and GM, as well as their actual LOS, discharge DRG codes [with their corresponding trimmed average length of stay (ALOS)] and selected function-linked variables (including premorbid functional status, change in functional profile during hospitalisation and number of therapists seen) were recorded. Beginning with ALOS, function-linked variables that were significantly associated with LOS were then added into two multiple liner regression models so as to quantify how the functional dimension improved the DRGs' abilities to explain LOS variances and interdepartmental LOS differences. Forward selection procedure was employed to determine the final models. For the interdepartmental analysis, the study sample was restricted to patients who shared common DRG codes.

RESULTS

114 GRM and 118 GM patients were studied. Trimmed ALOS alone explained 8% of the actual LOS variance. With the addition of function-linked variables, the adjusted R2 of the final model increased to 28%. Due to common code restrictions, the data of 79 GRM and 78 GM patients were available for the analysis of interdepartmental LOS differences. At the unadjusted stage, the median stay of GRM patients was 4.3 days longer than GM's and with adjustments made for the DRGs, this difference was reduced to 3.9 days. Additionally adjusting for the patients' functional features diminished the interdepartmental LOS discrepancy even further, to 2.1 days.

CONCLUSION

This study demonstrates that for elderly medical inpatients, the incorporation of patients' functional status significantly improves the DRG model's ability to predict the patients' actual LOS as well as to explain interdepartmental LOS differences between GRM and GM.

Pseudobasophilia as an erroneous white blood cell differential count with a discrepancy between automated cell counters: report of two cases

We report two cases that showed erroneous white blood cell differential counts by automated cell counters. Each case showed an interesting discrepancy of differential count between cell counters, and marked pseudobasophilia was observed by one of the two counters. The first patient was a 44-year-old female who suffered from multiple myeloma for more than one and a half years. Increased myeloma cells (43%) in peripheral blood were counted as basophils by the ADVIA 120, and as monocytes by SE-9000, respectively. The second patient was a 72-year-old female diagnosed as having chronic myelomonocytic leukemia. Dysgranulopoietic neutrophils (50%) and monocytes (31%) were increased in the peripheral blood. Dysgranulopoietic neutrophils were counted as basophils by STKS. In contrast, about half of the increased monocytes were counted as neutrophils by the ADVIA 120. These interesting findings highlight the importance of microscopic examination of the blood film in routine laboratory practice, and automated cell counters, especially for the hematologic patients, cannot completely substitute for it. These results also imply that at least some subpopulations with different membrane or cytoplasmic properties may exist even in the similarly classified cells.

Tailoring the field and indication of adjuvant pelvic radiation for patients with FIGO stage Ib lymph nodes-negative cervical carcinoma following radical surgery based on the GOG score--a pilot study

INTRODUCTION

The traditional indications for adjuvant pelvic radiotherapy (RT) for International Federation of Obstetrics and Gynecology (FIGO) stage Ib1 lymph nodes-negative cervix carcinoma following radical surgery based on histopathological factors, such as deep stromal invasion and lymphovascular space invasion (LVSI), were often inconsistently applied. The perceived risk of relapse was subjectively determined. This pilot study attempts to determine if the treatment outcome will be affected when the indication for RT is based on the Gynecologic Oncology Group (GOG) Risk Score (RS) and the field of adjuvant RT is tailored to the RS.

MATERIALS AND METHODS

From 1997 to 1999, 55 patients with FIGO stage Ib1 lymph nodes-negative cervical carcinoma limited to the cervix were prescribed RT following radical surgery, based on their RS, as follows: RS <40, RT is omitted; RS >40 to <120, modified (smaller) field RT; and RS >120, standard field pelvic RT. Their incidence and site of recurrence were compared with a similar cohort of 40 patients who were treated prior to 1997.

RESULTS

Prior to 1997, of the 40 patients, 10 patients were given standard field RT. There were 2 (5%) recurrent diseases. The mean duration of follow-up was 61.6 months (range, 1 to 103 months). The RS of 23 of the 30 patients who were not given RT were available. The mean RS was 22 with 5 patients having a score of >40. From 1997 onwards, of the 55 patients, 28 (51%) did not require RT, 13 (23%) were treated with modified (smaller) field RT and 14 (26%) were given standard field RT. There were 2 (3.6%) cases of relapse. The mean duration of follow-up was 36.4 months (range, 5 to 60 months). All patients with a RS of <40 did not suffer any relapse. Their survival outcomes were better when compared to patients who did not have any RT in the GOG Study.

CONCLUSIONS

The results of this study indicated that postoperative adjuvant RT given to patients with a high GOG RS of >120, significantly improved their 5-year recurrence rate and disease-free survival, as compared with the similar group of patients who were without adjuvant therapy in the GOG study. Patients with a GOG risk-score of <40 may be safely spared from adjuvant pelvic RT. The current treatment protocol did not compromise the outcome in patients, compared with the use of a less precise treatment protocol in the past.

Bisphosphonates induce apoptosis of stromal tumor cells in giant cell tumor of bone

Giant cell tumour of bone (GCT) is an aggressive primary neoplasm that results in the production of osteolytic lesions. Stromal cells, which form the main neoplastic component of this tumor, regulate the formation of osleoclast-like giant cells that are ultimately responsible for bone destruction. Bisphosphonates prevent bone resorption by inhibiting osteoclast activity and promoting osteoclast apoptosis, and they have been known to induce apoptosis of primary neoplastic cells such as those in breast and prostate cancers. We hypothesized that in bisphosphonates may induce apoptosis not only in osteoclast-like giant cells but also in neoplastic stromal cells of GCT both in vitro and in vivo. Twelve patients with GCT were treated with weekly injections of pamidronate for a period of 6 weeks prior to surgery. GCT specimens were collected at the time of biopsy and during definitive surgery. TUNEL assay was used to evaluate apoptotic DNA fragmentation in cells. In addition, twelve GCT primary cultures from these patients were treated with zoledronate, pamidronate, or alendronate for 48 hours at different doses (3, 30, or 150 microM) and subjected to apoptosis assay by flow cytometry following fluorescent Annexin-V labeling. The results showed that pamidronate significantly induced apoptosis in both osteoclast-like giant cells and stromal tumor cells, in vivo. All three bisphosphonates caused substantial apoptosis of stromal tumor cells in cultures. Zoledronate was the most potent reagent, resulting in an average cell death of 27.41% at 150 microM, followed by pamidronate (22.23%) and alendronate (15.3%). Our observations suggest that these drugs may be considered as potential adjuvants in the treatment of GCT.

Alendronate regulates cell invasion and MMP-2 secretion in human osteosarcoma cell lines

BACKGROUND

Osteosarcoma is the most common malignant bone tumor of childhood. Significant proportions of these patients eventually develop pulmonary metastases and succumb to their disease even after conventional multi-agent chemotherapy and surgical excision. Matrix metalloproteinase (MMP)-2 induced degradation of blood vessel basement membranes is an important pre-requisite for tumor invasion and metastasis. Bisphosphonates (BPs) have been known to inhibit tumor growth and metastasis in some tumors such as breast cancer, renal cell carcinoma, and prostate cancer, and may do so through inhibition of MMP secretion. We, therefore, tested the effect of BPs on tumor cell invasion, MMP-2 secretion, and apoptosis of osteosarcoma cell lines.

PROCEDURE

Two osteosarcoma cell lines (SaOS-2, U(2)OS) were treated with alendronate (50, 100, and 150 microM) for 24 and 48 hr. Matrigel invasion assay was used to investigate the invasive potential of osteosarcoma cell lines before and after alendronate treatment. Real-time quantitative RT-PCR was used to determine the mRNA level of MMP-2 with and without alendronate treatment. Enzyme-linked immunosorbent assay (ELISA) was used to quantify the cytokine level of MMP-2 secreted in the condition medium. BP-induced cell apoptosis was evaluated by fluorescent flow cytometric analysis.

RESULTS AND CONCLUSIONS

The results showed that alendronate inhibited cell invasion of both osteosarcoma cell lines in a dose-dependent manner. Alendronate reduced the mRNA level and cellular level of MMP-2 in both cell lines in a time and dose-dependent manner. Alendronate also induced significant apoptosis in both cell lines. Our finding suggests that alendronate downregulates MMP-2 secretion and induces apoptosis in osteosarcoma cells, which may both contribute to the reduction of invasive potential of the tumor cells.

Expression of preosteoblast markers and Cbfa-1 and Osterix gene transcripts in stromal tumour cells of giant cell tumour of bone

In giant cell tumour of bone (GCT), mononuclear stromal cells, which represent the neoplastic component of this lesion, regulate the formation of multinucleated osteoclast-like giant cells which are the characteristic hallmark of this tumour. However, the origin of stromal tumour cells has not yet been clearly defined. In this study, we evaluated several osteoblast markers including collagen type I, bone sialoprotein (BSP), osteonectin and osteocalcin in GCT using immunohistochemical techniques. Amongst the 13 GCT specimens and 7 GCT stromal cell (GCTSC) cultures studied, majority of the GCTSC synthesized type I collagen, BSP and osteonectin proteins but did not produce the differentiated osteoblast marker, osteocalcin. We further examined the regulation of several important osteogenic genes such as Cbfa-1, osterix and osteocalcin, and regulation of ALP activity in GCTSC in culture by bone morphogenetic protein 2 (BMP-2). Real-time PCR analysis indicated that Cbfa-1, osterix and osteocalcin mRNA were present in primary cultures of GCTSC. The addition of BMP-2 upregulated Cbfa-1 and osterix gene expression within 12 h and the enhancement was still observed at 24 h. ALP activity was minimal in untreated GCTSC in cultures. The number of ALP-positive GCTSC was significantly increased following treatment with BMP-2 or combinations with beta-glycerophosphate and ascorbic acid. In contrast, BMP enhancement of osterix mRNA level and ALP activity was also seen in SaOS2 osteoblast-like cells, but not in the primary culture of normal human skin fibroblasts. In summary, our data suggest that GCT stromal tumour cells may have an osteoblastic lineage and retain the ability to differentiate into osteoblasts.

Computed tomography of fibrous dysplasia

OBJECTIVE

Fibrous dysplasia (FD) is an uncommon, but important lesion affecting the jaws. The aim of this study was to reveal its presentation on computed tomography (CT) in a consecutive series of cases.

METHODS

The files of the Department of Oral and Maxillofacial Surgery of Hong Kong University between 1989 and 2000 were reviewed for cases of FD.

RESULTS

Of the ten cases investigated by CT, two were rejected because of extensive biopsy or surgery before the CT investigation. Seven of the remaining eight cases were Chinese and one was Indian. The mandible and maxilla were equally affected. The cortex was generally intact, except when adjacent to the teeth in the maxilla. The margins were generally poorly-defined, but well-defined on at least some sections of each maxillary case. Five cases were extensive, affecting or nearly affecting the whole hemi-mandible or hemi-maxilla to the midline. All cases displayed expansion, which was fusiform in the mandible and an enlargement of the normal contour in the maxilla. The maxillary antrum was completely obturated in three maxillary cases; one displayed a rounded dome-shaped lesion more suggestive of a benign neoplasm. The orbital floor was displaced in three cases; one of those cases presented with proptosis. All maxillary cases extended back to the pterygoid process, but did not displace it. The "bone windows" of eight cases generally displayed a "ground-glass" pattern; one also displayed cyst-like radiolucencies. The soft tissue window, which depicts mineralized tissue as "white", showed that five cases were completely mineralized.

CONCLUSION

CT can be used to determine the extent, specific dimensions and radiodensity of FD.

Computed tomography of odontogenic myxoma

AIM

The aim of this study was to determine the computed tomography (CT) presentation of odontogenic myxoma (OM) in a Chinese population and to compare them with those observed on the accompanying conventional radiographs (CR).

MATERIALS AND METHODS

The files of the Department of Oral and Maxillofacial Surgery of the University of Hong Kong between 1989 and 2000 were reviewed for myxoma cases.

RESULTS

Ten cases of OM were found of which eight had been investigated by CT. The formatted hard copy was found in seven cases, four in the maxilla and three in the mandible. Most of the OMs had a round shape but one was fusiform. CT was more likely to display a cortex and its perforation. All OMs had perforated cortices on CT with soft tissue appearing outside the bony contour in two cases. Contrast enhancement was apparent in six cases. Both CR and CT displayed septae, but the latter method revealed that most septae were situated at the periphery, presenting as "sunray" type spicules in one case. Tooth displacement and root resorption were more reliably observed on CR.

CONCLUSION

The likelihood of perforation and pattern of septa of OM is better displayed by CT. CR should also allow a better assessment of the degree of definition of the lesion's margins with adjacent normal bone. Therefore, both CT and CR should be used in an investigation of an OM.

Protein 4.1 deficiency and deletion of chromosome 20q are associated with acquired elliptocytosis in myelodysplastic syndrome

We report a case of myelodysplastic syndrome (MDS), associated with prominent elliptocytosis. A 66-year-old male presented with peripheral pancytopenia, and was diagnosed with MDS [refractory anaemia (RA)]. Apart from marked elliptocytosis, dyshaematopoietic features were not evident in his peripheral blood or hypercellular bone marrow. After 18 months, he had progressed to RA with excess blasts in transformation. Analysis of red blood cell membrane proteins by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) showed a reduced quantity of protein 4.1 (30% of control). Deletion of chromosome 20q was identified by conventional cytogenetic analysis and fluorescence in situ hybridization. Marked elliptocytosis, persistent for more than 17 months, decreased strikingly after chemotherapy with idarubicin and Ara-C. These findings suggest that acquired elliptocytosis occurred as an unusual morphological feature of MDS, associated with abnormalities of protein 4.1 and chromosome 20q.

SEM/EDS evaluation of porcelain adherence to gold-coated cast titanium

The adhesion between titanium and dental porcelain is related to the diffusion of oxygen to the reaction layer formed on cast-titanium surfaces during porcelain firing. The diffusion of oxygen could be suppressed by coating the titanium surface with a thin gold layer. This study characterized the effects of gold coating on titanium-ceramic adhesion. ASTM grade II CP titanium was cast into a MgO-based investment (Selevest CB, Selec). The specimen surfaces were air abraded with 110-microm Al(2)O(3) particles. Gold coating was applied on titanium surfaces by three methods: gold-paste (Deck Gold NF, Degussa-Ney) coating and firing at 800 degrees C for three times, single gold-paste coating and firing followed by sputter coating (40 mA, 500 s), and sputter coating (40 mA, 1000 s). Surfaces only air abraded with Al(2)O(3) particles were used as controls. An ultra-low-fusing dental porcelain (Vita Titankeramik, Vident) was fused on titanium surfaces. Specimen surfaces were characterized by SEM/EDS and XRD. The titanium-ceramic adhesion was evaluated by a biaxial flexure test (N = 8), and area fraction of adherent porcelain (AFAP) was determined by EDS. Numerical results were statistically analyzed by one-way ANOVA and the Student-Newman-Keuls test at alpha = 0.05. SEM fractography showed a substantial amount of porcelains remaining on the gold-sputter-coated titanium surfaces. A new Au(2)Ti phase was found on gold-coated titanium surface after the firing. Significantly higher (p <.05) AFAP values were determined for the gold-sputter-coated specimens compared to the others. No significant differences were found among the other groups and the control. Results suggested that gold coatings used in this study are not effective barriers to completely protect titanium from oxidation during the porcelain firing, and porcelain adherence to cast titanium can be improved by gold-sputter coating used in the present study.

Low intensity pulsed ultrasound stimulates osteogenic activity of human periosteal cells

The effect of low intensity pulsed ultrasound on human periosteal cells was investigated. Normal human periosteum was obtained to culture the periosteal cells. After characterization, cultures of periosteal cells at Days 2 and 4 were treated with ultrasound for 5, 10, and 20 minutes respectively. Assessments were done to assess total number of viable cells, cell proliferation, alkaline phosphatase activity, osteocalcin secretion, vascular endothelial growth factor expression, and calcium nodule formation. With the cells not treated with ultrasound as the control, the results showed that ultrasound did not affect the total number of viable cells. It stimulated cell proliferation at the early phase of cell culture. The activity of alkaline phosphatase was increased significantly in the culture at Day 4. A similar effect was seen with osteocalcin secretion and the responses were dose-dependent. The vascular endothelial growth factor secretion increased in Day 2 and Day 4 cultures with the dose-dependent effect. Formation of calcium nodules was significantly higher with ultrasound treatment. We think that low intensity pulsed ultrasound stimulated periosteal cell proliferation and differentiation toward osteogenic lineage. The dose-dependent effect on osteogenic activities may modify the existing treatment regimen. Ultrasound treatment should be started from the beginning of fracture healing.

The effect of hyaluronan on osteoblast proliferation and differentiation in rat calvarial-derived cell cultures

Hyaluronan (or hyaluronic acid, HA) is an essential component of extracellular matrices. It interacts with other macromolecules and plays a predominant role in tissue morphogenesis, cell migration, differentiation, and adhesion. The cell signaling functions of HA are mediated through the CD-44 receptor and are dependent upon the molecular weight of the polymer. We hypothesized that an HA of appropriate molecular weight alone in optimal concentration may induce osteoblast differentiation and bone formation. Enzyme-digested calvarial-derived mesenchymal cells from 2-day-old newborn rats were cultured with the addition of HA of three different molecular weights (2300, 900, and 60 kDa). We added, 0.5, 1.0, and 2.0 mg/mL HA for each molecular weight to the medium at the first plating of cells. After 7 to 20 days in culture, cell proliferation and differentiation were evaluated by measuring thymidine incorporation, alkaline phosphatase activity, and osteocalcin gene expression. The effects of HA on bone formation were examined by using Alizarin red staining for mineralization. The results showed that low molecular weight HA (60 kDa) significantly stimulated cell growth, increased osteocalcin mRNA expression in a dose-dependent manner, but showed no apparent effects on alkaline phosphatase activity and bone mineralization. On the other hand, high-weight HA (900 and 2,300 kDa) significantly increased all the parameters examined, particularly alkaline phosphatase activity, in a dose-dependent manner and stimulated cell mineralization to 126% and 119% of the controls, respectively, in the 1.0 mg/mL dose. Our findings suggest that HA has a molecular weight-specific and dose-specific mode of action that may enhance the osteogenic and osteoinductive properties of bone graft materials and substitutes due to its stimulatory effects on osteoblasts.

FIGO stage 1B2 cervical carcinoma--the KK Women's and Children's Hospital experience

INTRODUCTION

The objectives of this review were to document the surgico-pathological characteristics of surgically resected FIGO stage 1B2 cervical carcinoma and to review our overall experience with this disease.

MATERIALS AND METHODS

This is a retrospective review of 35 patients diagnosed and treated from September 1990 to November 2001.

RESULTS

The median age was 42 years and the mean tumour diameter was 5.1 cm. Majority were squamous cell carcinomas (65.7%), 28.6% were adenocarcinomas and 5.7% were adeno-squamous carcinomas. The primary treatment comprised radical surgery in 77.1%, radiotherapy in 20% and neoadjuvant chemotherapy followed by radical surgery and adjuvant radiotherapy in 2.9%. Significant surgico-pathological features noted were deep stromal invasion (66.7%), lympho-vascular space invasion (55.6%), parametrial involvement (22.2%), positive margins (3.7%) and pelvic node metastases (33.3%). Postoperative radiation was given to 92.6% of the patients who underwent primary surgery, of whom 29% received concurrent chemotherapy. Radiation toxicity was mild with no grade 3 or 4 toxicity documented. For the patients who had surgery, the recurRence rate was 14.8% (11.1% pelvic and 3.7% distant) and the survival rate was 88.9%. For those who had primary radiation, the rate of persistent disease was 28.6%, the distant recurrence rate was 28.6% and the survival rate was 57.1%.

CONCLUSION

FIGO stage 1B2 cervical carcinomas are associated with significant rates of adverse surgico-pathological features. The ideal primary treatment is yet to be established and should be determined by prospective randomised trials.

Expression of VEGF and MMP-9 in giant cell tumor of bone and other osteolytic lesions

This study aims to investigate the expression of vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9) in giant cell tumor of bone (GCT) and other osteolytic lesions in bone. By using semi-quantitative RT-PCR, we showed that three major isoforms of VEGF (121, 165 and 189) were expressed in GCTs, with isoform 121 being the most abundant. The expression levels of VEGF and MMP-9 mRNA were significantly higher in advanced GCTs (stage II/III) than in stage I GCTs. We further elucidated the cellular localization of VEGF and MMP-9 gene transcripts in GCT and other osteolytic lesions using an in situ hybridization assay. The results showed that stromal tumor cells and osteoclast-like giant cells of GCT, fibrous stromal cells in anuerysmal bone cysts and fibrous dysplasia, and Langerhans-type giant cells as well as histocytes in eosinophillic granuloma, were all strongly positive for VEGF and MMP-9 mRNA expression. In a prospective study, we performed VEGF and MMP-9 immuno-staining on paraffin sections of pathological tissues harvested from 48 patients (14 GCT, 10 anuerysmal bone cysts, 10 eosinophillic granuloma, 4 fibrous dysplasia, 2 simple bone cyst, 2 osteomyelitis and 6 patients with fractured femoral head as control). The results showed that the differences in VEGF and MMP-9 expression between Stage I and other advanced Stages (II, III and recurrent) were highly significant (p<0.001), with advanced stages showing a higher mean expression. The difference between recurrent and Stage II and III lesions, was also statistically significant (p=0.03 for VEGF, and p=0.01 for MMP-9 expression), with recurrent lesions showing a higher mean expression of both VEGF and MMP-9. In conclusion, VEGF and MMP-9 expression in osteolytic lesions of bone co-relates well with the extent of bone destruction and local recurrence. Their expression may therefore provide some prognostic indication of the possible aggressive behavior of the underlying pathology.

Effect of long-term administration of rebamipide on Helicobacter pylori infection in mice

BACKGROUND

It has been suggested that chronic, persistent, uncontrolled inflammations in the stomach could provide the basic step for the beginning of carcinogenesis. One of the potential clinical applications of rebamipide is the inhibition of the immunoinflammatory response in gastric mucosa imposed by Helicobacter pylori.

AIM

To determine the implications of long-term rebamipide treatment in H. pylori infection, we studied the underlying moleculo-pathological changes in gastric lesions in mice infected with H. pylori (SS1 strain), following this treatment.

METHODS

C57BL/6 mice were sacrificed 24 and 50 weeks after H. pylori infection, respectively. Colonization rates of H. pylori, degree of gastric inflammation and other pathological changes including atrophic gastritis and metaplasia, serum levels of IL-1beta, TNF-alpha, IFN-gamma and IL-10, mRNA transcripts of various mouse cytokines and chemokines, and NF-kappaB binding activities, and finally the presence of gastric adenocarcinoma were compared between an H. pylori infected group (HP), and an H. pylori infected group administered with long-term rebamipide-containing pellet diets (HPR).

RESULTS

Serum levels of IL-1beta, IFN-gamma and TNF-alpha, the gastric mucosal expression of ICAM-1, HCAM and MMP, and transcriptional regulation of NF-kappaB-DNA binding were all significantly decreased in the HPR group compared with the HP group. An RNase protection assay showed, in the rebamipide administered group, significantly decreased mRNA levels of apoptosis-related genes such as caspase-8, FasL, Fas, TRAIL and various cytokines genes such as IFN-gamma, RANTES, TNF-alpha, TNFR p75, IL-1beta. In the experiment designed to provoke gastric cancer through MNU treatment with H. pylori infection, the incidence of gastric carcinoma was not different in either group. However, long-term administration of rebamipide showed the advantage of decreasing precancerous lesions like chronic atrophic gastritis and showed molecular evidence of attenuation of proliferation.

CONCLUSION

The long-term administration of rebamipide should be considered in the treatment of H. pylori since it demonstrated molecular and biological advantages like a lessening of gastric inflammation and a possible chemopreventive effect.

Oral testosterone undecanoate (Andriol) supplement therapy improves the quality of life for men with testosterone deficiency

In a single-blind, placebo-controlled study, the effects of a 3-month oral administration of 160 mg/day testosterone undecanoate (Andriol) on the quality of life of men with testosterone deficiency were evaluated. The subjects included ten men with primary hypogonadism and 29 with andropause with sexual dysfunction as the most common problem. The changes in subjective symptoms were evaluated by the PNUH QoL scoring system and the St. Louis University Questionnaire for androgen deficiency in aging males (ADAM). Digital rectal examination (DRE) was performed and serum testosterone, prostate-specific antigen (PSA) and liver profile were monitored. Testosterone undecanoate treatment (n = 33) significantly improved sexual dysfunction and symptom scores of metabolic, cardiopulmonary, musculoskeletal and gastrointestinal functions compared to baseline and to placebo (n = 6). ADAM score also significantly improved after 3 months of treatment. Serum testosterone was significantly increased compared to pretreatment levels only in the testosterone undecanoate group. In the placebo group, no significant changes compared to baseline were found for testosterone levels and QoL questionnaires. No abnormal findings were detected on DRE or laboratory findings in either group. Adverse events, such as gastrointestinal problems and fatigue, were mild and self-limiting. It is concluded that androgen supplement therapy with oral testosterone undecanoate (Andriol) restores the quality of life through improvement of general body functions in men with testosterone deficiency.

Change of complement system predicts the outcome of patients with severe thermal injury

To establish the clinical relevance of the changes in the complement system in patients with thermal injury, we studied 20 patients who had third-degree burns on more than 60% of total body surface area. Their levels of the C3, C4, soluble C5b-9, and functional hemolytic activities of total (CH50) and alternative (AH50) complement pathways were sequentially measured for 2 weeks after thermal injury. All patients showed low C3 levels initially but increased C3 levels in the following days. The increasing trend of C3 levels was prominent in survivors but transient and diminished in nonsurvivors. The change of levels of C3, CH50, and AH50 was closely associated with one another, and their chronological trends related to the survival of patients (P =.0060,.0064 and.0066, respectively). The recovery of C3, AH50, and CH50 to normal or supranormal level during the early treatment period relates to the survival of patients with thermal injury. The failure of recovery of the complement system indicates a poor prognosis for patients and the monitoring of complement system might be beneficial in the care of patients with thermal injury.

Attitudes towards psychotherapy with older people among trainee clinical psychologists

Therapists have been described as reluctant to work with older people. A legacy of pessimism towards psychotherapy with this group has been traced back to Freud's assertions that older people are no longer educable. It remains unclear to what extent these views continue to influence today's therapists. This study explores the attitudes of trainee clinical psychologists towards psychotherapy with this age group. A cross-sectional postal survey design was used and the data were analyzed using content analysis. Three hundred and seventy-one trainees responded, representing 38% of the total population of trainees in the UK. The majority of the trainees thought that work with older people provided the opportunity to apply psychological knowledge and skills, although therapists needed to respond differently when working with an older person. Factors to take into account included cognitive decline and physical health problems. The trainees described a number of rewards and challenges associated with working with older people. The responses suggest that although a significant minority of trainees continue to hold some negative stereotypes about therapeutic work with older people, positive attitudes are also clearly evident. Further research to explore the attitudes of other healthcare professionals is recommended and the implications for training and supervision are examined.

Immortalization with telomerase of the Nestin-positive cells of the human pancreas

Cells expressing the neuronal stem cell marker Nestin are present in the human pancreas but the biological role of these cells has yet to be resolved. We report here the establishment with the catalytic subunit of human telomerase (hTERT) of a line of normal human cells representing this cell type. Primary human cells derived from the ducts of the pancreas were transduced with an hTERT cDNA. The infected cells became positive for telomerase, failed to senesce, and were still proliferating after more than 150 doublings. The immortalized cells were positive for the expression of Nestin (at both the mRNA and protein levels) and were found to be free of cancer-associated changes: diploid and expressing wild type p16(INK4a), p53, and K-Ras. An established line of normal human cells representing this cell type should be of great value to help define the biological properties of this novel cell type.

In vitro activity of beta-lactams in combination with other antimicrobial agents against resistant strains of Pseudomonas aeruginosa

Using the chequerboard titration method, the activity in combination of beta-lactams, fluoroquinolones and aminoglycosides was investigated against 24 Pseudomonas aeruginosa isolates resistant to these antibiotics. Synergy was detected with one or more antimicrobial combinations against 15 of 24 (63%) isolates and partial synergy was detected with one or more combinations against all 24 isolates. No antagonism was seen with any combination. Ceftazidime and cefepime with aztreonam, amikacin and isepamicin showed synergy or partial synergy against 12-20 (50-80%) isolates. Imipenem and meropenem with amikacin and isepamicin showed synergy or partial synergy against eight to 12 (33-50%) isolates. The results of this study indicate that against P. aeruginosa, synergy may occur between beta-lactams, fluoroquinolones and aminoglycosides although the strains are resistant to the individual antibiotics.

Treatment of phenolic wastewater using agricultural wastes as an adsorbent in a sequencing batch reactor

The objective of this study is to investigate the potential of the activated rice husk to be used as an alternative adsorbent to powdered activated carbon (PAC) in the simultaneous adsorption and biodegradation processes under sequencing batch reactor (SBR) operation to treat synthetic wastewater containing phenol, p-methylphenol, p-ethylphenol and p-isopropylphenol. The rice husk (PRH) was activated by pyrolysis at 600 degrees C for 5 hours in a nitrogen atmosphere. Using the Langmuir model, the limiting adsorption capacities of PRH for the phenols were found to vary from 0.015-0.05 of those of PAC. The SBR reactors with and without adsorbent addition were operated with fill, react, settle, draw and idle periods in the ratio of 4:6:1:0.76:0.25 for a cycle time of 12 hours. For phenolic wastewater containing, 1,200 mg/L phenol, 1,200 mg/L p-methylphenol, 800 mg/L p-ethylphenol and 660 mg/L p-isopropylphenol, it was found that the biodegradation process alone was unable to produce effluent of quality which would satisfy the discharge standards of COD < or = 100 mg/L and phenol concentration < or = 1 mg/L. The addition of PAC in the ratio of PAC/phenolic compound at 0.095 g/g for phenol, 0.119 g/g for p-methylpheol, 0.179 g/g for p-ethylphenol and 0.220 g/g for p-isopropylphenol, can improve the effluent quality to satisfy the discharge standards. Equivalent treatment performance was achieved with the use of PRH at dosages of 2-3 times higher than those of PAC for all the phenolic wastewater studied. The increased adsorption capacity of PRH shown in the treatment indicates bioregeneration of the adsorbed surface during the treatment process.

Effect of virological response on post-treatment durability of lamivudine-induced HBeAg seroconversion

Lamivudine-induced HBeAg seroconversion may not be durable in Korean patients with hepatitis B virus (HBV) infection. It is unknown whether virological response during lamivudine treatment affects the post-treatment outcome. We retrospectively analysed 124 consecutive HBeAg-positive chronic hepatitis B (CHB) patients treated with lamivudine. Lamivudine was given at a dose of 100 mg per day. HBV DNA levels in sera obtained before and during therapy were measured by the Digene Hybrid Capture II assay and Digene Ultrasensitive Hybrid Capture II assay, respectively. HBeAg seroconversion was achieved in 42 of the 124 patients (33.8%) treated with lamivudine. Mean duration of treatment in HBeAg seroconverters was 12.86 +/- 4.44 months. During the follow-up period, the cumulative relapse rates at 3 months and 6 months post-treatment in 42 patients with HBeAg seroconversion were 40.5% and 57.4%, respectively. Among 31 seroconverted patients whose sera were available at the second month of treatment, HBV DNA remained at > 4.7 x 103 genomes/mL in 15 patients and decreased to < 4.7 x 103 genomes/mL in the remaining 16 patients. HBV DNA levels at the second month of treatment was not related with relapse after discontinuation of treatment (66.7% vs. 43.8%, P= 0.2). At the time of HBeAg seroconversion, HBV DNA remained at > 4.7 x 103 genomes/mL in five patients and decreased to < 4.7 x 103 genomes/mL in the remaining 37 patients. Relapse rates were increased in patients who remained at > 4.7 x 103 genomes/mL compared with patients with HBV DNA levels < 4.7 x 103 genomes/mL (100% vs. 51.4%, P < 0.001). Thus, monitoring of serum HBV DNA at the time of HBeAg seroconversion may be helpful for predicting relapse in patients with lamivudine-induced HBeAg seroconversion.

Conditional loss of TGF-beta signalling leads to increased susceptibility to gastrointestinal carcinogenesis in mice

BACKGROUND

Downregulation of TGF-beta receptors is implicated in colon cancer development. Inactivation of either of the two transmembrane serine/threonine kinases, TGF-beta1 types I/II receptors, is now implicated in carcinogenesis, especially gastrointestinal carcinogenesis.

METHODS

We generated transgenic mice, called pS2-dnRII or ITF-dnRII, of which the dominant negative mutant of the TGF-beta type II receptor was expressed under the control of tissue-specific promoters, the pS2 promoter for stomach and ITF for intestine. They were either infected with H.pylori (ATCC 43504 strain, CagA+ and VacA+) or administered with azoxymethane to determine the significance of loss of TGF-beta signalling in gastrointestinal carcinogenesis.

RESULTS

Gastric adenocarcinoma developed in pS2-dnRII mice, whereas only chronic active gastritis was noted in wild-type littermates after 36 weeks of H.pylori infection. Mice lacking in TGF-beta signalling specifically in the stomach showed a significantly higher proliferation cell nuclear antigen-labelling index when infected with H.pylori than wild-type littermates (P < 0.01). Development of colonic aberrant crypt foci was provoked in mice by intraperitoneal injections of azoxymethane, and ITF-dnRII mice showed significantly higher incidences of ACF and colon cancers than wild-type littermates.

CONCLUSIONS

Maintaining normal TGF-beta signalling in the gastrointestinal tract seems to be important either for preventing abnormal mucosal proliferation, or for suppressing or retarding carcinogenesis.

Odontogenic myxomas in the Hong Kong Chinese: clinico-radiological presentation and systematic review

AIM

The aim of this study was to determine the clinical and radiological presentation on plain films of central odontogenic myxomas (OM) in the Hong Kong Chinese and compare them to other reported series by a systematic review (SR).

METHODS

The study had two elements, that of a complete series of all OMs presenting at a major Chinese maxillofacial surgical unit and a SR. The files of the Department of Oral and Maxillofacial Surgery of the University of Hong Kong between 1989 and 2000 were reviewed for OM cases. The relevant literature was identified by electronic databases, review of citation lists and handsearching of key journals. The principal selection criterion was that the study should represent a complete collection of cases.

RESULTS

The SR revealed that only a quarter of the reports provided any quantitative radiological details. Just under half of the included reports provided the relative period prevalence of OMs compared to other odontogenic tumours, but these reports almost completely excluded consideration not only of the radiology but also specific clinical details. Furthermore, they did not report of recurrence data, an important feature of the OM. Most of the most recent reports were concerned with relative period prevalence. The relative period prevalence and 'number of OMs per hospital per year' of studies separated by two or more decades in Hong Kong and Nigeria indicate an increase in the number of lesions diagnosed as OMs. The 10 Hong Kong cases were broadly consistent with the predilections for females and the mandible of other reports. The mean age at first presentation in the present report is 36.9, older than the other reports. Most lesions are large, affecting both posterior and anterior quadrants. They appear to be larger than those in many other reports. Two of the OMs are accompanied by histories of recent rapid growth. Tooth displacement and root resorption are more frequently observed in OMs in the present study. Although all OMs in the present study are still being followed up after surgery, none have recurred.

CONCLUSION

Although the presentation of larger lesions in the older Chinese could in part be explained by attitudes rooted in traditional medicine in spite of the widespread availability of modern medical care in Hong Kong, there is a history of recent rapid growth in at least two cases. An emphasis by recent reports on the OMs' relative period prevalence of concurrent odontogenic lesions, has omitted recording the radiology and the specific clinical details usually required for diagnosis.,

Polymorphism of the angiotensin-converting enzyme gene in patients with cerebral infarction in Koreans

The relationship between cerebrovascular disease and an insertion/deletion (I/D) polymorphism in the angiotensin-converting enzyme (ACE) gene is still being debated. The frequency of the DD genotype of the ACE gene was significantly higher in subjects with than those without cerebral infarction in Japan. The aim of the present study was to assess the relationship between ACE gene polymorphism and the development of cerebral infarction in a population from Korea. We examined its possible role as a risk factor in patients with cerebral infarction. The association between ACE gene polymorphism and cerebral infarction was examined in 106 patients with cerebral infarction and 498 controls without cerebral infarction. Frequencies of the genotypes and alleles of the ACE gene were investigated. The ACE genotype was analyzed by the polymerase chain reaction (PCR). The frequency of D allele was 37.7% in patients and 39.1% in controls (chi2 = 0.128, p = 0.720). The frequencies of the genotypes of the ACE gene were II: 39.6%, ID: 45.3%, and DD: 15.1% in patients, and II: 37.1%, ID: 47.6%, and DD: 15.3% in controls (chi2 = 0.127, p = 0.721). There was no significant difference in the frequency of the DD genotype of the ACE gene, and we did not find any association between ACE polymorphism and cerebral infarction. These results indicate that ACE polymorphism is not a risk factor for the development of cerebral infarction in a Korean population.