Association of HLA with Vogt-Koyanagi-Harada syndrome in Koreans

PURPOSE

To study the distribution of human leukocyte antigen HLA-A/B antigens and HLA-DR/-DQ/-DP alleles and to investigate the immunogenetic background of Korean patients with Vogt-Koyanagi-Harada (VKH) syndrome and clinical course with different types of HLA.

METHODS

Human leukocyte antigen typings were performed in 18 Korean patients with VKH syndrome and in 128 healthy control subjects. HLA-A/B loci serologic typing was performed according to the standard microlymphocytotoxicity technique. DNA was extracted through the salting out method, and HLA-DR phenotyping and HLA-DR4, HLA-DQ, and HLA-DP subtyping were performed with the polymerase chain reaction-sequence specific oligonucleotide probe (PCR-SSOP) method.

RESULTS

Among HLA-A/B antigens typed by the standard microlymphocytotoxicity method, the frequencies of HLA-A31 (RR = 6.1, P<1x10(-2)) and HLA-B55 (RR = 15.8, P<.05) were significantly increased in the patient group compared with the control group. Among HLA-DR/-DQ/-DP alleles subtyped by DNA methods, the frequencies of HLA-DRB1*04 (RR = 45.1, P<1x10(-7)) and HLA-DRB1*07 (RR = 3.2, P<.05) were significantly increased. However, significant decreases in HLA-DRB1*08 (RR = .1, P<.05), HLA-DRB1*13 (RR = .1, P<.05), and HLA-DRB1*14 (RR = .1, P<.05) frequencies were observed. The result of HLA-DR, HLA-DQ, and HLA-DP subtyping showed the significant increase in DRB1*0405 (RR = 45.1, P<1x10(-7)), DQA1*0302 (RR = 12.0, P<1x10(-4)), DQB1*0303 (RR = 5.0, P<1x10(-2)), DQB1*0401 (RR = 18.9, P<1x 10-6), and DPB1*0501 (RR = 3.8, P<.05). However, significant decreases in DQA1*0101 (RR = .1, P< .05), DQA10102 (RR = .1, P<1x10(-2)), DQA1*0103 (RR = .1, P<.05), DQA1*0501 (RR = .1, P<1x10(-2)), DQB1*0301 (RR = .1, P<.05), DQB1*0601 (RR = .1, P<.05), DPB1*0201 (RR = .3, P<.05), and DPB1*0401 (RR = .1, P<.05) frequencies were also observed. In patients with DRB1*0405 itself or HLA-DRB1*0405-DQA1*0302-DQB1*0401 haplotype, a reduction in visual acuity and ocular complications was common.

CONCLUSIONS

These results suggest that HLA-DRB1*0405 itself or HLA-DRB1*0405-DQA1*0302-DQB1*0401 haplotype is greatly increased and may play the most important role in the development and the clinical course of VKH syndrome in Korean patients.

Decreased expression of mac25 mRNA in uterine leiomyomata compared with adjacent myometrium

PROBLEM

The pathogenesis of uterine leiomyomata is still unclear. Recently it has been suggested that mac25 plays a tumor-suppressive role in various tumors. The aims of this study were to evaluate a possible involvement of mac25 in the growth of leiomyoma and in the mechanism of a gonadotropin-releasing hormone agonist (GnRHa) inducing shrinkage of leiomyoma.

METHODS OF STUDY

Mac25 mRNA transcript was measured by Northern blot in total RNA extracted from the paired specimens of leiomyoma and adjacent myometrium from untreated patients (n = 25) and from leiomyoma specimens from GnRHa-pretreated patients (n = 10).

RESULTS

Mac25 mRNA expression was significantly lower in large leiomyoma (more than 150 cm3 in volume) than in adjacent myometrium and small leiomyoma (less than 120 cm3 in volume) from untreated patients. There was no difference in this expression between the proliferative and secretory phases of the menstrual cycle. Leiomyoma from GnRHa-pretreated patients had mac25 gene expression levels similar to myometrium and small leiomyoma from untreated patients.

CONCLUSIONS

Mac25 may be involved in the growth of uterine leiomyoma and the action of GnRHa may, in part, be mediated by mac25.

Outcome of men with ischemic cardiomyopathy, asymptomatic nonsustained ventricular tachycardia, and negative electrophysiologic studies

The natural history of patients with ischemic cardiomyopathy, asymptomatic nonsustained ventricular tachycardia, and negative electrophysiologic studies was assessed in a retrospective analysis of 55 consecutive patients. The results suggest that the prognosis for arrhythmic death in these patients is not necessarily benign.

Cosmic ray hits in the central nervous system at solar maximum

It has been suggested that a manned mission to Mars be launched at solar maximum rather than at solar minimum to minimize the radiation exposure to galactic cosmic rays. It is true that the number of hits from highly ionizing particles to critical regions in the brain will be less at solar maximum, and it is of interest to estimate how much less. We present here calculations for several sites within the brain from iron ions (z = 26) and from particles with charge, z, greater than or equal to 15. The same shielding configurations and sites in the brain used in an earlier paper for solar minimum are employed so that direct comparison of results between the two solar activity conditions can be made. A simple pressure-vessel wall and an equipment room onboard a spacecraft are chosen as shielding examples. In the equipment room, typical results for the thalamus are that the probability of any particles with 7 greater than or equal to 15 and from 2.3 percent to 1.3 percent for iron ions. The extra shielding provided in the equipment room makes little difference in these numbers. We conclude that this decrease in hit frequency (less than a factor of two) does not provide a compelling reason to avoid solar minimum for a manned mission to Mars. This conclusion could be revised, however, if a very small number of hits is found to cause critical malfunction within the brain.

Sequence analysis and tissue specific expression of human HOXA7

A 3071-bp fragment containing the human HOXA7 gene was sequenced. It contained two exons, one intron, and two polyadenylation signals (AATAAA) at positions 1844 and 2923. The exon encoded 230 aa residues, while the hexapeptide, homeodomain, and C-terminal acidic domains were detected. When the total sequences were compared with those of murine Hoxa-7, the 5' untranslated region (UTR), exon I, intron, exon II, and 3' UTR exhibited 99, 92, 65, 85, and 72% homology, respectively. Through Northern analysis, about a 1.9-kb transcript was detected in the fetal kidney. Minor transcripts of 1.5 and 1.1-kb were also detected in the fetal liver as well as in the kidney. In the case of adult tissues, most of the tissues tested (lung, liver, skeletal muscle, kidney, pancreas, and placenta), except brain tissue, expressed a 5.3 kb transcript with various intensities. Our results here suggested that not only Abd-B type Hox genes, but the ones in paralogous groups I-VIII could generate multiple transcripts. The characterization of these tissue-specific and stage-specific alternative transcripts would help to understand the regulatory function of the HOXA7 gene during development, and possibly the pathology of human disease caused by Hox genes.

Matrix metalloproteinases of human NK cells

We have previously reported that MMP-2 and MMP-9 are present in rat A-NK cells, and have recently documented that additional MMPs are present in rodent A-NK cells. To our knowledge only proMMP-9 has previously been reported for human NK and A-NK cells. Herein, we report for the first time the presence of MMP-2 and MT1-MMP in human NK cells. The importance of these enzymes for the migration of A-NK cells into tumor metastases is of great potential relevance. MMPs may be rate limiting in A-NK cells, following their adoptive transfer, to traverse basement membrane and accumulate within established cancer metastases, a likely pre-requisite to their cytolytic function. Human NK cells express and produce MMP-2, MMP-9, MT1-MMP and the inhibitor TIMP-1. Moreover, human A-NK cells degrade the extracellular matrix equivalent (Matrigel) in a seemingly IL-2 dependent manner. It is therefore likely that A-NK cell MMPs play crucial roles in contributing to A-NK cell localisation and positioning the cells in vivo to allow for triggering their cytolytic potential.

C677T mutation of the methylenetetrahydrofolate reductase gene among the Korean infants in Seoul city

The missense mutation, C677T (Ala--->Val), in the methylenetetrahydrofolate reductase (MTHFR) gene, is related to hyperhomocysteinemia and is regarded as a risk factor for coronary artery disease and neural tube defects. The prevalence of this mutation was reported to differ among various ethnic groups, but there are few reports concerning Asian populations. We have investigated the frequencies of C677T mutation in 124 Korean infants (residents in Seoul city, Korea) and 115 Japanese adults (residents in Kobe city, Japan), and compared them with the reported data from other ethnic groups. The frequencies of the three genotypes in Koreans were as follows: C/C (wild homozygosity) 0.27, C/T (heterozygosity) 0.66, T/T (mutated homozygosity) 0.07, while those in Japanese were as follows: C/C 0.44, C/T 0.40, T/T 0.16. There was a marked difference in the genotype frequencies between the two populations (chi-square = 16.67, P = 0.0002), even though they are closely related in genetic background. The high C/T genotype frequency led to significant deviation from Hardy-Weinberg equilibrium (chi-square = 17.35, P = 0.00003). Deviation from Hardy-Weinberg equilibrium has not been found in any other ethnic groups. The high frequency of C/T genotype may offer Koreans a selective advantage.

Pharmacokinetics and organ distribution of cyclosporin A incorporated in liposomes and mixed micelles

The commercially available intravenous dosage form of cyclosporin A (C-CsA) contains a solubilizing agent, polyoxyethylated castor oil, which has been reported to be toxic. To replace the toxic solubilizing agent present in C-CsA, liposomal and mixed micellar preparations were made to solubilize CsA by the proliposome method and characterized. Furthermore, pharmacokinetics and organ distributions of these preparations were evaluated in comparison to C-CsA, which is micellar. The mean size of liposomal preparation (L-CsA) composed of DPPC/PA (molar ratio 3/1) and CsA was 43.6 nm and that of mixed micellar preparation (M-CsA) composed of DMPC/DSPE-PEG (molar ratio 95/5) and CsA was 6.5 nm. The solubilization of CsA was 2-fold greater in mixed micellar solution than in liposomes (0.06 vs 0.03 mg of CsA/mg of lipid). L-CsA, M-CsA and C-CsA were intravenously administered into rats via the femoral vein to analyze pharmacokinetics and organ distribution of CsA. M-CsA was not significantly different from C-CsA in every pharmacokinetic parameter studied. However, L-CsA resulted in 30% decrease in AUC and 55% increase in Cl(t) compared with C-CsA (P<0. 05), without any significant differences in MRT, V(dss) and t(1/2). In addition, the distributions of M-CsA and L-CsA in different organs were not significantly different from those of C-CsA (0.05), except for a 51% decrease of M-CsA in the spleen at 4 h and a 33% increase of L-CsA in the liver at 4 h (P<0.05). These findings demonstrate that the liposomal preparation composed of DPPC/PA and CsA shows slightly different pharmacokinetics and organ distribution patterns from C-CsA, whereas the mixed micellar preparation composed of DMPC/DSPE-PEG and CsA exhibits similar patterns to C-CsA, as expected. Furthermore, these results suggest that those mixed micellar and liposomal preparations can replace C-CsA containing the toxic solubilizing agent, thus providing useful alternative dosage forms for intravenous administration of CsA.

Factors relating to readmission of term and near-term neonates in the first two weeks of life. Early Discharge Survey Group of the Health Professional Advisory Board of the Greater New York Chapter of the March of Dimes

AIMS

A multisite study of term and near term infants readmitted in the first two weeks of life to 9 New York City area hospitals in 1995 was conducted to evaluate factors related to readmission, including length of newborn stay.

RESULTS

Of the 30,884 infants born at the 9 study hospitals 391 newborns were readmitted. The major admission diagnoses were infection, 40.7%, hyperbilirubinemia, 39.1%, and feeding and/or gastrointestinal problems, 10.5%. In the first week, 65.1% of readmissions were for hyperbilirubinemia and 19.1% were for infection or suspected sepsis. In the second week, 67.8% of readmissions were for infection and 7.6% were for hyperbilirubinemia. Hyperbilirubinemia was the most frequent diagnosis for White and Asian infants, while infection was most frequent for African-American and Hispanic infants. Age at readmission was younger and the interval from discharge was shorter for infants with hyperbilirubinemia. Abnormalities which should have precluded early discharge included feeding difficulties, cyanotic congenital heart defects, hemolytic disease of the newborn, early jaundice or early high bilirubin levels.

CONCLUSION

Attention to identification of infants at risk and programs such as lactation counseling and universal screening for bilirubin (with appropriate interpretation) prior to discharge could have reduced the necessity for readmission regardless of the newborn length of stay.

Electrocardiographic predictors of successful ablation of tachycardia or bigeminy arising in the right ventricular outflow tract

Among various electrocardiographic variables, the QRS duration in V2 was found to be the best discriminator of outcome in patients undergoing radiofrequency catheter ablation of the right ventricular outflow tract tachycardia and/or bigeminy. If the QRS duration is <160 ms in lead V2, the probability of successful ablation is lower than if the QRS duration is longer.

Encapsulation of ethanol by spray drying technique: effects of sodium lauryl sulfate

Microcapsules composed of ethanol, water and dextrin as a water-soluble polymer can be used to encapsulate poorly water-soluble drugs by spray drying technique. For the encapsulation of a high dose of poorly water-soluble drugs, large amounts of ethanol and consequently large quantities of dextrin are needed for the dissolution of drug and the encapsulation of ethanol, respectively. In order to increase the ethanol content with the decreased amount of dextrin, sodium lauryl sulfate (SLS) was employed in the preparation of microcapsules without drug by a spray drying method. Phase diagrams were prepared to determine the region of microcapsule formation with a three-component system of ethanol, dextrin and water. The homogeneous phase indicated in the phase diagram was used to prepare the alcoholic microcapsules since this phase was not separated rapidly and not too viscous to be spray-dried. Interestingly, SLS at concentrations below 2% remarkably increased both the ethanol content and the encapsulation efficiency of ethanol. The maximum ethanol content and encapsulation efficiency were observed with 0.5-1% of SLS (35.4 and 67.6%, respectively). Furthermore, the increase by SLS was more pronounced at the low dextrin/water ratios than at the high dextrin/water ratios. In particular, the ethanol content and the encapsulation efficiency with the dextrin/ethanol/water ratio of 0.4/1/1, which had relatively small amounts of dextrin, were about ten times higher in the presence of SLS than those without SLS. In conclusion, this study shows that small amounts of SLS can increase the ethanol content and the encapsulation efficiency of ethanol, and allow the reduction in the amount of dextrin required to encapsulate ethanol in the preparation of microcapsules. These findings suggest that the use of SLS may permit the effective encapsulation of high dose of water-insoluble drug into microcapsules.

Association of oligohydramnios in women with preterm premature rupture of membranes with an inflammatory response in fetal, amniotic, and maternal compartments

OBJECTIVE

This study was undertaken to examine whether oligohydramnios in women with preterm premature rupture of membranes is associated with evidence of fetal, amniotic, and maternal inflammatory responses.

STUDY DESIGN

Amniotic fluid index was measured before the performance of amniocentesis in patients with preterm premature rupture of membranes. Fifty-nine patients who were delivered of preterm neonates (gestational age </=35 weeks) within 3 days of amniocentesis were included in this study. Amniotic fluid was cultured for aerobic and anaerobic bacteria and for genital mycoplasmas. The intensity of the inflammatory response was evaluated by the following: presence of clinical and histologic chorioamnionitis; amniotic fluid concentrations of interleukin 6, interleukin 1beta, and tumor necrosis factor alpha; amniotic fluid white blood cell count; and interleukin 6 concentrations in umbilical cord plasma at birth. Proinflammatory cytokines were measured with specific and sensitive immunoassays.

RESULTS

Thirty-two percent (19/59) of patients had an amniotic fluid index </=5 cm. Patients with an amniotic fluid index </=5 cm had significantly higher rates of positive amniotic fluid culture results and clinical and histologic chorioamnionitis; higher median amniotic fluid concentrations of interleukin 6, interleukin 1beta, and tumor necrosis factor alpha; and higher median cord plasma concentrations of interleukin 6 than did those with an amniotic fluid index >5 cm (positive amniotic fluid culture result, 79% [15/19] vs 30% [12/40]; clinical chorioamnionitis, 37% [7/19] vs 5% [2/40]; histologic chorioamnionitis, 100% [17/17] vs 69% [24/35]; median amniotic fluid interleukin 6 concentration, 13.5 ng/mL; range, 0.2-142.2 ng/mL vs 3.0 ng/mL and 0.001-115.2 ng/mL; median amniotic fluid interleukin 1beta concentration, 348.0 pg/mL; range, 0.7->80, 000 pg/mL vs 36.6 pg/mL and 0-2075 pg/mL; median amniotic fluid tumor necrosis factor alpha concentration, 132.0 pg/mL; range, 0-1600 pg/mL vs 11.2 pg/mL and 0-1305 pg/mL; median cord plasma interleukin 6 concentration, 49.7 pg/mL; range, 4.4-7400 pg/mL vs 9. 1 pg/mL and 0-5211 pg/mL; P <.05 for each). There was no significant difference between the 2 groups of patients in the mean umbilical artery pH at birth.

CONCLUSION

Oligohydramnios in women with preterm premature rupture of membranes is associated with an inflammatory response in the fetal, amniotic, and maternal compartments.

Effects of beta-adrenergic blocking therapy on left ventricular diastolic relaxation properties in patients with dilated cardiomyopathy

BACKGROUND

The hemodynamic mechanism for the improvement in left ventricle (LV) end-diastolic pressure in cardiomyopathy patients treated with beta-adrenergic blocking agents is controversial. We hypothesized that the salutary effect of this kind of therapy on LV end-diastolic pressure would be indicative of an improvement in late, passive diastolic relaxation properties.

METHODS AND RESULTS

We studied 14 cardiomyopathy patients in normal sinus rhythm with no arteriographic evidence of coronary artery disease and an LV ejection fraction of </=40% by radionuclide angiography both before and after 6 months of metoprolol therapy with simultaneous micromanometry and biplane cineventriculography. Four comparable patients who were not treated with metoprolol were studied in a similar fashion and served as control subjects. In those receiving metoprolol, LV end-diastolic pressure decreased (P=0.001). The isovolumic relaxation index, tau(ln), shortened (P=0.03). In a similar fashion, the LV chamber stiffness constant, kappa, decreased (P=0.02), LV volume elastance improved (P=0.04), and the myocardial stiffness constant, kappa(e), decreased (P=0.02). A multiple regression analysis revealed that the decrease in LV end-diastolic pressure was indicative of significant improvements in tau(ln) and kappa(e) with the relationship: LV end-diastolic pressure=-4.73+0.27 tau(ln)+0.54 kappa(e) (r=0.81, P<0.0001). These LV diastolic relaxation properties did not change or worsened in the control cardiomyopathy patients.

CONCLUSIONS

We conclude that the decrease in LV end-diastolic pressure in cardiomyopathy patients treated with metoprolol is an indicator of improvement in LV diastolic properties resulting from more complete myocardial relaxation.

Epidemiological study on Korean gallstone disease: a nationwide cooperative study

To clarify the epidemiological characteristics of gallstone disease in Korea and to evaluate the chronological changes in gallstone disease, the authors performed this first prospective nationwide cooperative study. The subjects were 1263 gallstone patients who were admitted at 19 hospitals in Korea from February to July 1997. Questionnaires were recorded on 1263 patients and gallstones were harvested from 1133 patients. The proportion of patients with gallbladder (GB), common bile duct (CBD), and intrahepatic duct (IHD) stones among total gallstone patients was 64.0%, 21.9%, and 14.1%, respectively. GB stones were categorized as cholesterol (58.1%), black pigment (25.2%), and brown pigment (12.1%) stones. CBD stones were classified as brown pigment (76.1%), cholesterol (18.4%), and black pigment (3.5%) stones. IHD stones were classified as brown pigment (61.4%) and mixed (35.6%) stones. Intrahepatic mixed stones had mean cholesterol and bilirubin contents of 63.4 +/- 20.8% and 23.1 +/- 9.9%, respectively. In contrast, IHD brown pigment stones had mean cholesterol and bilirubin contents of 35.1 +/- 20.5% and 39.6 +/- 17.4%, respectively. Our study showed that the type and composition of gallstones in Korea was somewhat different compared with those in the West. This study also demonstrated that there have been chronological changes in the type and composition of gallstones when compared with previous domestic data. Another nationwide cooperative study may be needed to elucidate and confirm the changing pattern of gallstone disease.

Endoscopic hemostasis in sphincterotomy-induced hemorrhage: its efficacy and safety

BACKGROUND AND STUDY AIMS

Hemorrhage is induced in approximately 0.5-12% of endoscopic biliary sphincterotomy (ES) procedures. We prospectively investigated the risk factors for ES-induced hemorrhage and evaluated the safety as well as the effectiveness of endoscopic hemostasis.

PATIENTS AND METHODS

The study included 1304 patients who underwent ES between July 1996 and June 1998. Epinephrine spray was used initially for hemostatic treatment. If bleeding persisted, an epinephrine injection was given consecutively. In patients with exposed vessels, epinephrine injection followed by alcohol injection was given.

RESULTS

ES-induced hemorrhage occurred in 136 (10.4%) patients. The type of sphincterotome used (needle-knife sphincterotome, P=0.025) and the cutting speed (the so-called "zipper" cut, P = 0.049) were revealed as significant variables with regard to the occurrence of bleeding. Mild, moderate, and severe bleeding were noted in 108 (79.4%), 22 (16.2%), and six (4.4%) patients, respectively. Once bleeding occurred, patients with an associated ampullary lesion (impacted stone or cancer) or with coagulopathy were more likely to bleed profusely. Initial hemostasis was achieved in all patients. However, rebleeding occurred in eight patients who were initially classified as having moderate or severe bleeding. Finally, ES-induced hemorrhage was successfully controlled in all patients after 1-3 treatment sessions (mean 1.1 sessions). The difference in the incidence of complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant.

CONCLUSIONS

ES-induced hemorrhage occurred in 10% of the patients studied. The use of needle-knife sphincterotomy and the cutting speed were independent risk factors for the occurrence of bleeding. Once bleeding occurred, its severity was affected by an associated ampullary lesion (impacted stone or cancer) or coagulopathy. Endoscopic hemostasis with epinephrine and/or alcohol was effective and safe in ES-induced hemorrhage.

Clinical and histopathological characteristics of basal cell carcinoma in Korean patients

Seventy-eight Korean patients with basal cell carcinoma (BCC) between 1984 and 1998 were retrospectively examined at Ewha Womans University Tongdaemun Hospital, Seoul, Korea. We analyzed the annual incidence, age and sex distribution, site of the lesions, clinical appearance, including the proportion of clinically pigmented tumors, modalities of treatment, incidence of recurrence and metastasis of the tumors, the histopathological patterns, and whether solar elastosis, microscopic pigmentation, or adamantinoid feature were associated. The male-to-female ratio was 0.902, and the average age of the patients at first examination was 58.2 years. Eighty percent of the tumors occurred on the head and neck, most commonly on the nose (26.9%), followed by the cheek, eyelid, and upper lip. Ulcerated nodules were the most common clinical presentation. Clinically, 55% of the tumors were pigmented. Six tumors recurred; none metastasized. Surgical excision was the most common modality of treatment. The most frequent histopathological pattern was the solid type (60.3%), followed by the superficial (11.5%) and fibrosing (9.0%) types. The occurrence of the superficial type was significantly associated with truncal lesions (p < 0.001). Solar elastosis was present in 62.1% of the tumors on the head and neck, compared with 8.3% in those of the trunk and limbs (p < 0.001), indicating the significance of sun exposure in the pathogenesis of BCC on exposed areas. Microscopic pigmentation was seen in 69.2% of the tumors. The focal adamantinoid feature was found in 14.1%, which is much higher than the previously reported incidence.

The role of endoscopic fenestration procedures for cerebral arachnoid cysts

Recently, endoscopic procedures have been recommended as the first surgical option for cerebral arachnoid cyst (AC). The author reports seven ACs treated endoscopically and discuss the role of endoscopic fenestration. The age of the patients ranged from two to 62 years. Three ACs were located in the posterior cranial fossa, two in the suprasellar area, one in the middle cranial fossa, and one in the convexity. All cases were examined by cine magnetic resonance (MR) flow study. The patient's symptoms included headache, vomiting, dizziness, problems in balance, visual disturbance, and seizure. The author performed a cysto-cisternostomy or cysto-ventriculostomy via a single burr hole. The follow-up periods ranged from six to 18 months. There was no mortality or morbidity except one case of intracisternal bleeding during endoscopic procedure. Symptoms were relieved in all seven patients. Follow-up imaging studies revealed a decrease in the size or disappearance of the cysts. The results support that the minimal fenestration procedure as possibly as preserving the internal environment is valuable for the management of ACs.

Effect of electrode polarity on the energy required for transthoracic atrial defibrillation

Two hundred patients with atrial fibrillation underwent transthoracic cardioversion using adhesive electrodes positioned at the apex and right infraclavicular area, and the apex electrode was randomly selected to serve as the cathode or anode. The mean defibrillation energy requirement with the cathodal configuration was significantly lower than with the anodal configuration.

A new strategy for the application of CA19-9 in the differentiation of pancreaticobiliary cancer: analysis using a receiver operating characteristic curve

OBJECTIVE

Clinicians might be misled in interpreting an elevated CA19-9 when differentiating pancreaticobiliary cancer from benign clinical conditions such as acute cholangitis or cholestasis, because in these conditions, the concentration of CA19-9 may also be elevated. The aims of our study were to calculate new individual cutoff values for CA19-9 according to clinical situations using a receiver operating characteristic (ROC) curve and to define a new strategy for interpreting CA19-9 in pancreaticobiliary cancer.

METHODS

One hundred sixty patients with pancreatic diseases (cancer 90, benign disease 70), 322 patients with biliary tract diseases (biliary cancer 152, benign disease 170), and 20,035 asymptomatic controls were enrolled in the present study. An ROC curve was described by plotting the sensitivity on the y-axis against 1-specificity on the x-axis for each of several cutoff values.

RESULTS

The area under the ROC curve was significantly greater for pancreatic cancer than for biliary cancer (p < 0.05). For patients with pancreatic cancer, CA19-9 proved to be useful. At a cutoff value of 37 U/ml, sensitivity and specificity were 76.7% and 87.1%, respectively. For patients with biliary cancer, CA19-9 was not helpful. However, when patients with biliary disease were divided into two groups according to the presence of cholangitis or cholestasis, CA19-9 proved to be more useful for the group without cholangitis or cholestasis than for the group with cholangitis or cholestasis (p < 0.05). In the former group, the sensitivity and specificity of CA19-9 were 77.6% and 83%, respectively, at the cutoff value of 37 U/ml. For the latter group, the sensitivity and specificity of CA19-9 were 74% and 41.5% respectively, whereas the specificity reached 87% at 300 U/ml. CA19-9 in diagnosing pancreatic cancer was useful regardless of accompanying acute pancreatitis or cholestasis. The serum concentration of CA19-9 in asymptomatic individuals was 9.42 +/- 9.95 U/ml. Only 1 of 157 patients with a concentration of CA19-9 above 37 U/ml was found to have gallbladder cancer. The positive and negative predictive values were 0.65% and 0.78%, respectively.

CONCLUSIONS

The use of CA19-9 for the differentiation of pancreaticobiliary cancer should be applied individually, depending on the clinical situation.

Choledochal cyst associated the with anomalous union of pancreaticobiliary duct (AUPBD) has a more grave clinical course than choledochal cyst alone

OBJECTIVE

Since choledochal cyst is frequently associated with the anomalous union of pancreaticobiliary duct (AUPBD), AUPBD has been regarded to be the etiologic factor of choledochal cyst. However, the clinical significance of AUPBD an patients with choledochal cyst has not been clearly defined. Therefore, to clarify the significance of AUPBD in choledochal cyst patients, we compared the clinical features of patients with choledochal cyst according to the presence or absence of AUPBD.

METHODS

Among 52 cases which were diagnosed as choledochal cyst out of 5,037 ERCP referrals between August 1990 and December 1996, we selected 44 cases, in which the pancreaticobiliary junction was clearly visualized on cholangio-pancreaticography. These cases were divided into AUPBD-present group (n = 28) and AUPBD-absent group (n = 16). Clinical features were compared between the two groups. Furthermore, in AUPBD-present group, clinical data were also analyzed according to Kimura's classification of AUPBD.

RESULTS

In our study, AUPBD was associated with choledochal cyst in 28 (64%) cases. AUPBD was found only in type I and IV according to Todani's classification of choledochal cyst. There were no significant differences between the AUPBD-present group and the AUPBD-absent group in the incidence of gallstone disease, while the incidence of acute inflammation was 93% (26/28) in the AUPBD-absent group (p < 0.01). Carcinoma developed only in the AUOBD-present group (9/28, 32%) (p < 0.05). Pancreatic disorders (i.e. pancreatic stone, pancreatitis or pancreatic cancer) occurred in 12 of 28 cases in the AUPBD-present group (43%), while only in 1 of 16 cases in the AUPBD-absent group (6%) (p < 0.05).

CONCLUSION

AUPBD associated with choledochal cyst may have implications not only as a possible etiologic factor but also as an important factor that may affect the clinical course, surgical planning and prognosis. In cases with choledochal cyst, we should make an effort to evaluate the presence of AUPBD.

Development of dried liposomes containing beta-galactosidase for the digestion of lactose in milk

The hydrolyzed-lactose milk for lactase-deficient subjects has a sweeter taste than whole milk, and some subjects dislike its taste. In order to cope with this shortcoming, we examined whether beta-galactosidase, which hydrolyzes lactose, added to the whole milk in the form of dried liposomes, would be able to digest lactose in milk following the lysis of liposomes in the presence of bile salts. Dried liposomes containing beta-galactosidase were prepared in the presence of trehalose by the dehydration-rehydration vesicle method to overcome the instability of the conventional liposome suspension. The stability of liposomal membranes was evaluated by measuring the activity of entrapped beta-galactosidase under various storage conditions. By treating liposomes with trehalose, which was found to prevent the fusion of liposomes and the leakage of entrapped drug, the entrapping efficiency increased up to fourfold. Over 95% of dried liposomes which had been stored at 17 degrees C for 60 days were reconstituted to liposomes upon rehydration process. From the stability study, dried liposomes were found to retain 87% of beta-galactosidase activity at 17 degrees C after 60 days and to be more stable than the multilamellar vesicle suspension prepared without trehalose. The lysis study showed that dried liposomes were hardly lyzed in the simulated gastric fluid with pepsin, but lyzed immediately more than 90% in 0.01 M deoxycholic acid. Lactose hydrolysis in the presence of deoxycholic acid after the addition of dried liposome-entrapped beta-galactosidase to whole milk was proportional to the quantity of entrapped beta-galactosidase and the amount of dried liposomes added. These results demonstrate that beta-galactosidase entrapped in liposome is stable and reconstituted mostly upon rehydration, and can digest lactose in milk after the efficient lysis of liposomes in the presence of bile salts. This study implies that beta-galactosidase entrapped in liposome may be applied to whole milk for lactase-deficient subjects.

Target temperatures of 48 degrees C versus 60 degrees C during slow pathway ablation: a randomized comparison

INTRODUCTION

The relationship between temperature at the electrode-tissue interface and the loss of AV and ventriculoatrial (VA) conduction is not established, and the optimal target temperature for the slow pathway approach to radiofrequency ablation of AV nodal reentrant tachycardia (AVNRT) is unknown. Therefore, the purpose of this study was to compare target temperatures of 48 degrees C and 60 degrees C during the slow pathway approach to ablation of AVNRT.

METHODS AND RESULTS

The study included 138 patients undergoing ablation for AVNRT. Patients undergoing slow pathway ablation using closed-loop temperature monitoring were randomly assigned to a target temperature of either 48 degrees C or 60 degrees C. The primary success rates were 76% in the patients assigned to 48 degrees C and 100% in the patients assigned to 60 degrees C (P < 0.01). The ablation procedure duration (33 +/- 31 min vs 26 +/- 28 min; P = 0.2), fluoroscopic time (25 +/- 15 min vs 24 +/- 16 min; P = 0.5), and mean number of applications (9.3 +/- 6.5 vs 7.8 +/- 8.1; P = 0.3) were similar in patients assigned to 48 degrees and 60 degrees C, respectively. The mean temperature (46.1 degrees +/- 24.8 degrees C vs 48.7 +/- 3.2 degrees C; P < 0.01), the temperature associated with junctional ectopy (48.1 degrees +/- 2.0 degrees C vs 53.5 degrees +/- 3.5 degrees C, P < 0.0001), and the frequency of VA block during junctional ectopy (24.6% vs 37.2%; P < 0.0001) were less in the patients assigned to 48 degrees C compared to 60 degrees C. The frequency of transient or permanent AV block was similar in each group (2.8% vs 3.6%; P = 0.2). In the 60 degrees C group, only 12% of applications achieved an electrode temperature of 60 degrees C. During follow-up of 9.9 +/- 4.2 months, there was one recurrence of AVNRT in the 48 degrees C group and none in the 60 degrees C group.

CONCLUSIONS

Compared to 48 degrees C, a target temperature of 60 degrees C during radiofrequency slow pathway ablation is associated with a higher primary success rate and a higher incidence of VA block during junctional ectopy induced by the radiofrequency energy. AV block is not more common with the higher target temperature, but only if VA conduction is aggressively monitored during applications of radiofrequency energy.