Implementation difficulties and solutions for a smart-clothes assisted home nursing care program for older adults with dementia or recovering from hip fracture

BACKGROUND

Wearable devices have the advantage of always being with individuals, enabling easy detection of their movements. Smart clothing can provide feedback to family caregivers of older adults with disabilities who require in-home care.

METHODS

This study describes the process of setting up a smart technology-assisted (STA) home-nursing care program, the difficulties encountered, and strategies applied to improve the program. The STA program utilized a smart-vest, designed specifically for older persons with dementia or recovering from hip-fracture surgery. The smart-vest facilitated nurses' and family caregivers' detection of a care receiver's movements via a remote-monitoring system. Movements included getting up at night, time spent in the bathroom, duration of daytime immobility, leaving the house, and daily activity. Twelve caregivers of older adults and their care receiver participated; care receivers included persons recovering from hip fracture (n = 5) and persons living with dementia (n = 7). Data about installation of the individual STA in-home systems, monitoring, and technical difficulties encountered were obtained from researchers' reports. Qualitative data about the caregivers' and care receivers' use of the system were obtained from homecare nurses' reports, which were explored with thematic analysis.

RESULTS

Compiled reports from the research team identified three areas of difficulty with the system: incompatibility with the home environment, which caused extra hours of manpower and added to the cost of set-up and maintenance; interruptions in data transmissions, due to system malfunctions; and inaccuracies in data transmissions, due to sensors on the smart-vest. These difficulties contributed to frustration experienced by caregivers and care receivers.

CONCLUSIONS

The difficulties encountered impeded implementation of the STA home nursing care. Each of these difficulties had their own unique problems and strategies to resolve them. Our findings can provide a reference for future implementation of similar smart-home systems, which could facilitate ease-of-use for family caregivers.

Trajectories of social support are associated with health outcomes and depressive symptoms among older Taiwanese adults with diabetes following hip-fracture surgery

OBJECTIVE

This study examined trajectories of social support and their relationships with health outcomes over 2 years post hip-fracture surgery for older adults with diabetes mellitus (DM).

METHODS

This was a secondary analysis of data derived from a clinical trial, which included 158 hip fractured older adults with DM who had completed the Medical Outcomes Study Social Support Survey at 1-, 12-, 18-, and 24-months following hospital discharge. Health outcomes for self-care, physical and nutritional status, mental health, and depression were assessed at 3-month intervals up to 24-months after hospital discharge. Trajectories of social support were derived with latent class analysis while hierarchical linear models were employed to assess the associations of social-support trajectory with health outcomes.

RESULTS

Four social-support trajectories were derived for persons with DM following hip-fracture surgery: poor and declining (n = 18, 11.4%), moderate and stable (n = 29, 18.4%), high but declining (n = 34, 21.5%), and high and stable (n = 77, 48.7%). Relative to those in the poor and declining group, participants in the high and stable trajectory group performed better in Activities of Daily Living and quadriceps muscle power, had better mental Health-Related Quality of Life and nutritional status, and had fewer depressive symptoms. These differences persisted over the 2 years following hospital discharge.

CONCLUSIONS

These results suggest social support for persons with DM should be continually assessed following hip-fracture surgery.

Better nutrition trajectory improves recovery following a hip fracture surgery for older persons with diabetes mellitus

BACKGROUND

Influences of nutritional status on hip fractured persons with diabetes mellitus (DM) following surgery have not been reported.

AIMS

To explore the trajectory groups of nutritional status and their influences on post-operative recovery for older persons with hip fracture and DM.

METHODS

A total of 169 patients with DM and hip fracture from a clinical trial were included in this analysis. Mini Nutritional Assessment was used to assess the nutritional status of the participants. Outcome variables included self-care ability, muscle strength, depressive symptoms, health related quality of life, and cognitive function, which were collected before discharge and 1-, 3-, 6-, 12-, 18-, and 24-months following hospital discharge.

RESULTS

Among hip fractured older persons with DM, within two years following surgery there were three nutritional trajectory groups: malnourished (28.3%), at-risk of malnutrition (41.9%) and well-nourished (29.8%). A decline in nutritional status, especially for the malnourished group, was seen in the second year. A better nutritional trajectory was associated with better recovery outcomes, including self-care ability, health related quality of life, cognitive function and less depressive symptoms.

DISCUSSION

Close to 30% of hip fractured persons with DM were considered to have a malnourished trajectory over 2 years following surgery. A poor nutritional trajectory was associated with poor mental health and physical recovery.

CONCLUSIONS

Continuous nutrition assessment during the first 2 years following hip fracture surgery for older persons with DM is important. Development and implementation of interventions targeting the malnourished trajectory group are suggested.

Effects of dietary crude protein concentration on animal performance and nitrogen utilisation efficiency at different stages of lactation in Holstein-Friesian dairy cows

Nitrogen (N) excretion from livestock production systems is of significant environmental concern; however, few studies have investigated the effect of dietary CP concentration on N utilisation efficiency at different stages of lactation, and the interaction between dietary CP levels and stages of lactation on N utilisation. Holstein-Friesian dairy cows (12 primiparous and 12 multiparous) used in the present study were selected from a larger group of cows involved in a whole-lactation study designed to examine the effect of dietary CP concentration on milk production and N excretion rates at different stages of lactation. The total diet CP concentrations evaluated were 114 (low CP), 144 (medium CP) and 173 (high CP) g/kg DM, with diets containing (g/kg DM) 550 concentrates, 270 grass silage and 180 maize silage. During early (70-80 days), mid- (150-160 days) and late (230-240 days) lactation, the same 24 animals were transferred from the main cow house to metabolism units for measurements of feed intake, milk production and faeces and urine outputs. Diet had no effect on BW, body condition score, or milk fat, protein or lactose concentration, but DM intake, milk yield and digestibilities of DM, energy and N increased with increasing diet CP concentration. The effect of diet on milk yield was largely due to differences between the low and medium CP diets. Increasing dietary CP concentration significantly increased urine N/N intake and urine N/manure N, and decreased faecal N/N intake, milk N/N intake and manure N/N intake. Although increasing dietary CP level significantly increased urine N/milk yield and manure N/milk yield, differences in these two variables between low and medium CP diets were not significant. There was no significant interaction between CP level and stage of lactation on any N utilisation variable, indicating that the effects of CP concentration on these variables were similar between stages of lactation. These results demonstrated that a decrease in dietary CP concentration from high (173 g/kg DM) to medium level (144 g/kg DM) may be appropriate for Holstein-Friesian dairy cow to maintain milk production efficiency, whilst reducing both urine N and manure N as a proportion of N intake or milk production.

[Effect of underdilated stent on the occurrence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation]

Objective: To evaluate whether underdilated stent could reduce the occurrence of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation. Methods: A total of 197 patients with decompensated liver cirrhosis, who had underwent TIPS creation at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, were analyzed retrospectively, including 110 males and 87 females with age 25-79 (54±11) years old. Uncovered and covered stents with 8 mm diameter were implanted in all subjects, and then dilated by balloon catheters with 6 mm or 8 mm diameter. The patients were divided into two groups, including underdilated group (6 mm, n=105) and control group (8 mm, n=92).Kaplan-Meier curves were used to illustrate cumulative rate of HE, and the differences were assessed with the log-rank test. Multivariate analyses with a Cox regression model were conducted to explore the risk factors for HE. Results: During a median follow-up period of 29 (12-54) months, 16 (15.2%) patients developed HE in the underdilated group and 27 (29.3%) patients in the control group. There was a significant difference in the cumulative rate of HE (P=0.014), but no statistical differences were found in terms of variceal rebleeding, shunt dysfunction and survival between the two groups (P=0.608, P=0.659, P=0.968). In multivariated analysis, group assignment (underdilated vs. control, HR=0.291, 95%CI 0.125-0.674, P=0.004) was identified as an independent risk factor for HE after TIPS creation. Conclusion: Underdilated TIPS could reduced the risk of HE compared with completely dilated TIPS, with comparable risk of variceal rebleeding, shunt dysfunction and mortality. And it is worthy of applying this technique to a large sample of patients in clinical practice.

Smart clothes-assisted home-nursing care program for family caregivers of older persons with dementia and hip fracture: a mixed-methods study

Background

The purpose of this preliminary study was to explore whether a smart clothes-assisted home-nursing care program could benefit family caregivers and their care recipients.

Methods

Family caregivers in charge of a care recipient’s living situation participated in this convergent parallel, mixed methods study. We recruited older persons with dementia (n = 7) and those discharged following hip-fracture surgery (n = 6) from neurological clinics and surgical wards of a medical center, respectively, along with their family caregivers: three spouses, eight sons, one daughter, and one daughter-in-law. Care recipients were asked to wear a smart vest at least 4 days/week for 6 months, which contained a coin-size monitor hidden in an inner pocket. Sensors installed in bedrooms and living areas received signals from the smart clothing, which were transmitted to a mobile phone app of homecare nurses, who provided caregivers with transmitted information regarding activities, emergency situations and suggestions for caregiving activities. Outcomes included changes from baseline in caregivers’ preparedness and depressive symptoms collected at 1- and 3-months, which were analyzed with Friedman’s non-parametric test of repeated measures with post-hoc analysis. Transcripts of face-to-face semi-structured interview data about caregivers’ experiences were analyzed to identify descriptive, interpretative, and pattern codes.

Results

Preparedness did not change from baseline at either 1- or 3-months for family caregivers of persons with dementia. However, depressive symptoms decreased significantly at 1-month and 3-months compared with baseline, but not between 1-months and 3-months. Analysis of the interview data revealed the smart clothes program increased family caregivers’ knowledge of the care recipient’s situation and condition, informed healthcare providers of the care recipient’s physical health and cognitive status, helped homecare nurses provide timely interventions, balanced the care recipient’s exercise and safety, motivated recipients to exercise, helped family caregivers balance work and caregiving, and provided guidance for caregiving activities.

Conclusions

Experiences with the smart clothes-assisted home-nursing care program directly benefited family caregivers, which provided indirect benefits to the care recipients due to the timely interventions and caregiving guidance from homecare nurses. These benefits suggest a smart-clothes-assisted program might be beneficial for all family caregivers.

Skin Ultrastructure and the Changes of HIF-2α, H-FABP Expression in the Myocardium of Electric Shock Death Rats

Abstract

Objective To observe the skin ultrastructure change of electric shock death rats and to test the expression changes of hypoxia-inducible factor-2α （HIF-2α） and heart type-fatty acid-binding protein （H-FABP） of myocardial cells, in order to provide basis for forensic identification of electric shock death. Methods The electric shock model of rats was established. The 72 rats were randomly divided into control group, electric shock death group and postmortem electric shock group. Each group was divided into three subgroups, immediate （0 min）, 30 min and 60 min after death. The skin changes of rats were observed by HE staining, the changes of skin ultrastructure were observed by scanning electron microscopy, and the expression of HIF-2α and H-FABP in rats myocardium was tested by immunohistochemical staining. Results The skin in the electric shock death group and postmortem electric shock group had no significant difference through the naked eye or by HE staining. Under the scanning electron microscope, a large number of cellular debris, cells with unclear boundaries, withered cracks, circular or elliptical holes scattered on the cell surface and irregular edges were observed. A large number of spherical foreign body particles were observed. Compared with the control group, the expression of HIF-2α in all electric shock death subgroups increased, reaching the peak immediately after death. In the postmortem electric shock group, HIF-2α expression only increased immediately after death, but was lower than that of electric shock death group （P<0.05）. Compared with the control group, the expression of H-FABP in all subgroups of electric shock death group and postmortem electric shock group significantly decreased. The expression of H-FABP in all subgroups of electric shock death group was lower than that of the postmortem electric shock group （P<0.05）. Conclusion Electric shock can increase HIF-2α expression and decrease H-FABP expression in the myocardium, which may be of forensic significance for the determination of electric shock death and identification of antemortem and postmortem electric shock.

Resuming Normal Life as a Family Caregiver During Drip-Like Recovery of Older Persons With Cognitive Impairment Recovering From Hip Surgery: A Grounded Theory

PURPOSE

This study was undertaken to develop a theoretical framework explaining family caregiving processes for older persons with cognitive impairment recovering from hip fracture surgery.

DESIGN AND METHODS

In this grounded theory study, data were collected in audio-recorded face-to-face interviews with 21 family caregivers. Among these caregivers, 14 cared for hip-fractured persons with cognitive impairment, and seven cared for those without cognitive impairment. Caregivers were interviewed five times after patients' discharge: at 1 week and at 1, 3, 6, and 12 months. Data were analyzed by constant comparative analysis.

FINDINGS

The core category explaining the family caregiving process for hip-fractured persons with cognitive impairment was "resuming normal life during drip-like recovery." This category captures the slowness of the recovery process, as slow as dripping water. During the early postoperative period, caregivers attempted to gain control of the postoperative situation, using various maintenance and improvement strategies to deal with the chaos in individuals and the family and to protect hip-fractured persons with cognitive impairment from further harm. The goal of recovery was to get back to their original life.

CONCLUSIONS

Family caregivers of hip-fractured older persons with cognitive impairment needed to deal with more complex chaotic situations, exerted more efforts to administer safety measures, and required more time to achieve a stable life pattern.

CLINICAL RELEVANCE

Since postoperative recovery was perceived as extremely slow, family caregivers of hip-fractured older persons with cognitive impairment should be patient regarding recovery and be informed before hospital discharge of different strategies to resume normal life during postoperative recovery.

Effects of a diabetes-specific care model for hip fractured older patients with diabetes: A randomized controlled trial

OBJECTIVES

To examine the effects of a diabetes-specific care model for hip fractured elderly with diabetes mellitus (DM).

METHODS

A randomized controlled trial was implemented in a 3000-bed medical center in northern Taiwan. Older adults (age ≥ 60) with DM who had hip-fracture surgery (N = 176) were recruited and randomly assigned to diabetes-specific care (n = 88) and usual care (n = 88). Usual care entailed one or two in-hospital rehabilitation sessions. Diabetes-specific care comprised an interdisciplinary care (including geriatric consultation, discharge planning, and in-home rehabilitation) and diabetes-specific care (including dietary and diabetes education, blood pressure control, dyslipidemia management, a glycemic treatment regimen, and rehabilitation exercises). Outcomes including heart rate variability; rehabilitation outcomes; activities of daily living and instrumental activities of daily living were assessed before discharge and 1, 3, 6, 12, 18, 24 months afterwards.

RESULTS

Patients who received diabetes-specific care had significantly higher hip-flexion range of motion (b = 5.24, p < .01), peak-force quadriceps strength of the affected limb (b = 2.13, p < .05), higher total heart rate variability in terms of the time-domain parameter for the mean squared difference between two adjacent normal R-R intervals (b = 11.35, p < .05), and frequency-domain parameters, such as low frequency (b = 42.17, p < .05), and the high frequency-to-low frequency ratio (b = 0.11, p < .01).

CONCLUSIONS

Our diabetes-specific care model enhanced hip-flexion range of motion, peak quadriceps strength of the affected limb, and overall heart rate variability, indicating dynamic responses to environmental changes during the 24 months following hospital discharge, above and beyond the effects of usual care.

Diabetic neuropathies influence recovery from hip-fracture surgery in older persons with diabetes

BACKGROUND/OBJECTIVES

To explore the impact of diabetic peripheral neuropathy (DPN) on the recovery of older persons with diabetes mellitus (DM) after hip-fracture surgery.

DESIGN, SETTING, PARTICIPANTS

Secondary data for this study came from a clinical trial on the effectiveness of a DM-specific care model for 176 older persons (age ≥ 60) with DM over 2 years following hip-fracture surgery at a medical center in Taiwan. In the original trial, the experimental group (n = 88) received DM-specific care comprising diabetes care plus subacute care, and the control group (n = 88) received only usual care.

MEASUREMENTS

DPN was assessed using the Michigan Neuropathy Screening Instrument. Outcomes of self-care ability in activities of daily living (ADL), health-related quality of life (HRQoL), and depressive symptoms were assessed 1, 3, 6, 12, 18, 24 months following hospital discharge using the Chinese Barthel Index and Chinese-version instrumental ADL (IADL) scale; the SF-36 Taiwan version; and the Chinese-version Geriatric Depression Scale, short form, respectively.

RESULTS

After controlling for covariates, participants with DPN had 8.38 fewer points in ADL performance, 0.49 fewer points in IADL performance, and 2.33 fewer points in the physical component summary (PCS) of HRQoL than participants without DPN at 3 months following discharge. During the first year following discharge, the rate of improvement increased less for PCS (β = -0.45, p < 0.05), but more for the mental component summary (β = 0.49, p < 0.05) for those with DPN than for those without. During the second year, the rate of decline in physical function-related HRQoL increased slightly more for those with DPN than for those without (β = 0.03, p < 0.05).

CONCLUSION

DPN adversely affected ADL performance, IADL performance, and physical function-related health outcomes for older persons recovering from hip-fracture surgery. These results suggest that older patients with DM recovering from hip-fracture surgery should be assessed and managed for DPN.

Estimation on Formation Time of Thrombus

OBJECTIVES

To observe the changes of the formation time of venous thrombus in rats, and to provide new ideas and methods for the estimation on thrombus formation time of the forensic cases died from thrombosis.

METHODS

Totally 80 rats were randomly divided into 10 groups （0 h, 3 h, 6 h, 12 h, 1 d, 3 d, 1 week, 2 weeks, 3 weeks and 4 weeks after operation）. A vein thrombosis model was established by the "narrow" method. The processes of thrombosis, organization, recanalization and the features of change on hemosiderin and calcium salt were observed by HE stain, Perls stain and Von Kossa stain. The expression changes of CD61, α-SMA and CD34 were observed by immunohistochemical staining technique.

RESULTS

Platelets adhered to the exposed blood vessel intima 3 h after operation, and platelet trabeculae were formed by the repeated accumulation of platelets 1 d after operation. The thrombus organization formed through the fibroblasts from vessel wall that grew into the interior of the thrombus 3 d after operation. Endothelial cells covered the surface of thrombus and then the new blood vessels were reformed, and the vessels were reconstructed. The expression of CD61 upregulated at the stages of the thrombus formation （3 h） and thrombus reformation （4 weeks）, and reached the peak 1 d after thrombus formation. The release of hemosiderin and the initial expression of α-SMA were detected 3 d later. Calcium deposit and expression of CD34 were observed 1 week later.

CONCLUSIONS

The hemosiderin, calcium salt, CD61, α-SMA and CD34 show time-dependent changing characteristics, which is expected to provide a reference for the estimation on thrombus formation time of the forensic cases died from thrombosis.

The influence of mulberry leaf flavonoids and Candida tropicalis on antioxidant function and gastrointestinal development of preweaning calves challenged with Escherichia coli O141:K99

This study investigated the effects of mulberry (Morus alba L.) leaf flavonoids and Candida tropicalis on the growth, gastrointestinal development, enzyme activity of gastrointestinal digesta, and blood antioxidant function of dairy calves challenged with Escherichia coli O141:K99. A total of 15 Holstein preweaning bull calves (age = 28 d; body weight = 51 ± 3.9 kg, mean ± standard deviation) were randomly divided into 3 homogeneous groups with no supplementation (control, CON), Candida tropicalis added at 1 g/calf per day (CT), and mulberry leaf flavonoids added at 3 g/calf per day (MLF). The feed efficiency was greater in calves fed MLF than in CON either before or after the E. coli challenge test. The fecal score increased after E. coli challenge, but it was greater in the CON group than in the CT treatment and in the MLF group at d 1, 2, and 3 after the E. coli challenge. Calves fed the CT diet showed decreased blood β-hydroxybutyrate concentrations compared with those on the CON and MLF diets before the E. coli challenge. Dietary supplementation with CT resulted in lower blood superoxide dismutase activity than the CON after E. coli challenge. The calves fed CT and MLF showed much lower blood glutathione peroxidase activity than the CON group after being challenged with E. coli. The tunica mucosa of the duodenum was lower in CT and MLF than in CON. The lactase activity of the jejunal digesta was greater in MLF than in CON and CT. In summary, MLF and CT supplementation might effectively improve antioxidant function and reduce the incidence of oxidative stress after challenge with E. coli in 28-d-old preweaning calves, and this effect may be partially explained by the relative decreases in blood superoxide dismutase and glutathione peroxidase as well as fecal score.

Family caregivers' mental health is associated with postoperative recovery of elderly patients with hip fracture: a sample in Taiwan

OBJECTIVE

This study investigated the relationship between family caregivers' mental health and postoperative recovery for elderly patients with hip fracture in Taiwan.

METHODS

This study is a secondary analysis of data from a randomized controlled trial with 12-month follow-up on 276 family caregiver-patient dyads. Categories of caregiver mental-health trajectory groups were identified by latent-class finite-mixture modeling. Differences in these groups were explored using the generalized estimating equation approach for effects on patients' postoperative recovery, including pain intensity, range of motion, maximum muscle strength, recovery of self-care ability, mobility, re-hospitalization, and health-related quality of life.

RESULTS

The patterns of family caregivers' mental health best fit a three-group trajectory model (poor, moderate, and good). Compared to patients with caregivers in the "poor" mental health group, patients with caregivers in the "good" group had better trajectories in physical functional recovery, including mobility, muscle strength, hip flexion and extension, and ankle extension. These patients were also less likely to be hospitalized, experienced less pain, and had better physical and mental health. Patients with caregivers in the "moderate" group likewise performed better than those in the "poor" group.

CONCLUSION

During the first year following discharge, postoperative recovery of patients after hip fracture was associated with their family caregivers' mental health. When a family caregiver's mental health was "poor," the patient recovering after hip-fracture surgery was more likely to recover poorly. These results suggest that health care providers could consider family caregivers' mental well-being while estimating recovery times and health outcomes of patients following hip fracture.

Strong tendency of homeotropic alignment and anisotropic lithium ion conductivity of sulfonate functionalized zwitterionic imidazolium ionic liquid crystals

Here, we report the first attempt to investigate the liquid crystal (LC) behavior of SO3(-) functionalized imidazolium zwitterionic (SO3(-)ImZI) salts, which display homeotropic alignment on a glass slide without the aid of any aligning approach. Doping lithium salt to ImZI salts lowers the melting temperatures and raises the clearing temperatures substantially to form room temperature ImZILCs. Excellent anisotropic lithium ion conductivity is achieved; which is strengthened by their tendency for homeotropic alignment.

Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture: a randomised controlled trial

BACKGROUND

Elderly patients with hip fracture have been found to benefit from subacute care interventions that usually comprise usual care with added geriatric intervention, early rehabilitation, and supported discharge. However, no studies were found on the effects of combining subacute care and health-maintenance interventions on health outcomes for elders with hip fracture.

OBJECTIVES

To compare the effects of an interdisciplinary comprehensive care programme with those of subacute care and usual care programmes on health-related quality of life (HRQoL) for elderly patients with hip fracture.

DESIGN

Randomised controlled trial.

SETTINGS

A 3000-bed medical centre in northern Taiwan.

PARTICIPANTS

Patients with hip fracture (N=299) were randomised into three groups: subacute care (n=101), comprehensive care (n=99), and usual care (n=99).

METHODS

Subacute care included geriatric consultation, continuous rehabilitation, and discharge planning. Comprehensive care consisted of subacute care plus health-maintenance interventions to manage depressive symptoms, manage malnutrition, and prevent falls. Usual care included only 1-2 in-hospital rehabilitation sessions, discharge planning without environmental assessment, no geriatric consultation, and no in-home rehabilitation. HRQoL was measured using the Medical Outcomes Study Short-Form 36 Taiwan version at 1, 3, 6, and 12 months after discharge.

RESULTS

Participants in the comprehensive care group improved more in physical function, role physical, general health and mental health than those in the usual care group. The subacute care group had greater improvement in physical function, role physical, vitality, and social function than the usual care group. The intervention effects for both comprehensive and subacute care increased over time, specifically from 6 months after hip fracture onward, and reached a maximum at 12 months following discharge.

CONCLUSIONS

Both comprehensive care and subacute care programmes may improve health outcomes of elders with hip fracture. Our results may provide a reference for health care providers in countries using similar programmes with Chinese/Taiwanese immigrant populations.

Cancer cell proliferation is inhibited by specific modulation frequencies

Background:

There is clinical evidence that very low and safe levels of amplitude-modulated electromagnetic fields administered via an intrabuccal spoon-shaped probe may elicit therapeutic responses in patients with cancer. However, there is no known mechanism explaining the anti-proliferative effect of very low intensity electromagnetic fields.

Methods:

To understand the mechanism of this novel approach, hepatocellular carcinoma (HCC) cells were exposed to 27.12 MHz radiofrequency electromagnetic fields using in vitro exposure systems designed to replicate in vivo conditions. Cancer cells were exposed to tumour-specific modulation frequencies, previously identified by biofeedback methods in patients with a diagnosis of cancer. Control modulation frequencies consisted of randomly chosen modulation frequencies within the same 100 Hz–21 kHz range as cancer-specific frequencies.

Results:

The growth of HCC and breast cancer cells was significantly decreased by HCC-specific and breast cancer-specific modulation frequencies, respectively. However, the same frequencies did not affect proliferation of nonmalignant hepatocytes or breast epithelial cells. Inhibition of HCC cell proliferation was associated with downregulation of XCL2 and PLP2. Furthermore, HCC-specific modulation frequencies disrupted the mitotic spindle.

Conclusion:

These findings uncover a novel mechanism controlling the growth of cancer cells at specific modulation frequencies without affecting normal tissues, which may have broad implications in oncology.

Interdisciplinary intervention for hip fracture in older Taiwanese: benefits last for 1 year

BACKGROUND

Little is known about the effects of interventions for elderly patients with hip fracture in Asian countries, particularly beyond the short term.

METHODS

Outcomes (service utilization, clinical outcomes, self-care ability, and depressive symptoms) were assessed at 1, 3, 6, and 12 months after discharge. Self-care ability (ability to perform activities of daily living [ADLs]), was measured by the Chinese Barthel Index. Depressive symptoms were measured by the Chinese Geriatric Depression Scale, short form.

RESULTS

The experimental group (n = 80) had a significantly better ADL trajectory than the control group (n = 82) during the 1st year after discharge (p =.002). More participants in the experimental group than in the control group recovered their previous walking ability both at 6 months (81% vs 58%, respectively) and 12 months (84% vs 66%, respectively) after discharge. Overall, the odds ratio for the experimental group recovering their previous walking ability was 2.72 (p <.001) compared to the control group. The experimental group had significantly fewer depressive symptoms than the control group during the 1st year following discharge (p =.004).

CONCLUSION

An interdisciplinary intervention for hip fracture with a discharge support component benefited elderly persons with hip fracture by improving both self-care ability and walking ability, and by decreasing depressive symptoms during the 1st year after hospital discharge.

The efficacy and economic benefits of Supercox®, a live anticoccidial vaccine in a commercial trial in broiler chickens in China

The efficacy and economic benefits of Supercox, a live anticoccidial vaccine were examined and compared with an anticoccidial drug in a trial in broiler chickens under modern commercial conditions in China. In total, 40,660 chickens were used in the present study, half of which were vaccinated with the Supercox vaccine comprising a precocious line of Eimeria tenella and non-attenuated lines of Eimeria maxima and Eimeria acervulina, and the other half were medicated with Diclazuril delivered as feed additive at the dosage of 1mg/kg of feed. The vaccine was administered orally to 7-day-old chickens. No clinical diseases were diagnosed in any of the vaccinated birds. However, clinical coccidiosis occurred in a large proportion of medicated control birds and these chickens had to be treated with anticoccidial drugs (Diclazuril and Toltrazuril). Comparison of production performance between vaccinated birds and medicated control birds revealed that the vaccine Supercox performed better than anticoccidial drugs in terms of mortalities, costs and overall economic benefits (profits). These findings demonstrated that the use of the Supercox vaccine could control clinical coccidiosis in broilers and achieve production performance superior to that using anticoccidial drugs, particularly where drug resistance might result in failure to control clinical diseases.

Changes in immunological and hematological parameters of female residents exposed to volatile organic compounds in the city of Kaohsiung, Taiwan

The objective of this study was to assess the effects, if any, of volatile organic compounds (VOCs) in the ambient air of Kaohsiung, Taiwan, on certain hematological and immunological parameters of 153 female study participants. The major source of VOCs was vehicle emissions. The participants were selected from three areas, each area at a different distance from a freeway. Results indicated that total concentrations of VOCs and a subgroup of 25 VOCs (VOC25) ranged from 250 to 335 ppb and 89 to 113 ppb, respectively. The distribution of VOC concentrations did not correlate with distance from the freeway. The participants living in the area with higher VOC concentrations had significantly higher abnormalities of white blood cells (WBC) and hemoglobin (Hb). In addition, IgG and IgA counts were significantly lower for the participants in the area with higher VOCs than for participants in the area with lower VOCs. This finding indicates that VOCs in ambient air may suppress immunological variables.

Alcohol metabolism of local Chinese in Hong Kong: a statistical determination on the effects of various physiological factors

A study was designed to examine the elimination rate of alcohol from the body of the local Chinese after consumption of different types of alcoholic drinks. The breath alcohol of 184 healthy volunteers was determined and converted into blood alcohol levels after they finished drinking. Information on the type and volume of alcoholic drinks consumed, age group, sex, drinking habit, and drinking on empty stomach or with/after meal was recorded for each participant. The results show that the elimination rate of an individual can be explained in terms of physiological variables including sex and drinking habit. The determined elimination rates allow forensic toxicologists to back calculate the blood alcohol concentration (BAC) of the drivers at the time of accident in drunk driving cases. The elimination rates of blood alcohol at 95% prediction intervals for male and female are in the range of 9.5-23.8 mg/100 ml/h and 11.1-37.1 mg/100 ml/h, respectively.

A pilot investigation of the short-term effects of an interdisciplinary intervention program on elderly patients with hip fracture in Taiwan

OBJECTIVES

To evaluate an interdisciplinary intervention program for older people with hip fracture in Taiwan.

DESIGN

Randomized experimental design.

SETTING

A 3,800-bed medical center in northern Taiwan.

PARTICIPANTS

Elderly patients with hip fracture (N=137) were randomly assigned to an experimental (n=68) or control (n=69) group.

INTERVENTION

An interdisciplinary program of geriatric consultation, continuous rehabilitation, and discharge planning.

MEASUREMENTS

Demographic and outcome variables were measured. Outcome variables included service utilization, clinical outcomes, self-care abilities, health-related quality-of-life (HRQOL) outcomes, and depressive symptoms.

RESULTS

Subjects in the experimental group improved significantly more than those in the control group in the following outcomes: ratio of hip flexion 1 month after discharge (P=.02), recovery of previous walking ability at 1 month (P=.04) and 3 months (P=.001) after discharge, and activities of daily living at 1 month (P=.01) and 2 months (P=.001) after discharge. Three months after discharge, the experimental group showed significant improvement in peak force of the fractured limb's quadriceps (P=.04) and the following health outcomes: bodily pain (P=.03), vitality (P<.001), mental health (P=.02), physical function (P<.001), and role physical (P=.006). They also had fewer depressive symptoms (P=.008) 3 months after discharge.

CONCLUSION

This intervention program may benefit older people with hip fractures in Taiwan by improving their clinical outcomes, self-care abilities, and HRQOL and by decreasing depressive symptoms within 3 months after discharge.

Widmark factors for local Chinese in Hong Kong

The Widmark formula has been widely adopted in forensic applications to drink driving cases for the last 70 years. It is known that the amount of alcohol consumed and the body weight of the drinkers are important information for the estimation of blood alcohol concentration (BAC). However, the direct application of the Widmark factors derived from Caucasian to the calculation of BAC for the Chinese population often encounters serious challenges. Owing to this inherent weakness, a thorough analysis to determine the theoretical Widmark factors for the Chinese population, r(0) at the start of drinking and the practical factors, r(peak), at peak BAC was conducted. In the present study, other factors such as gender, stomach condition and other physiological conditions are taken into account. The determined theoretical Widmark factors, r(0,) for local Chinese male and female are 0.68 and 0.59 (with BAC in the units of weight/volume), respectively, demonstrating the applicability of the Widmark formula to the Chinese population. The practical factors at peak BAC, r(peak), were also determined to serve the forensic purpose of refuting the "hip-flask" defence in drink driving cases. Findings show that gender and stomach condition are the key factors that could statistically explain the variability of both r(0) and r(peak).

Combined bronchoalveolar lavage and polymerase chain reaction in the diagnosis of pulmonary tuberculosis in smear-negative patients

SETTING

The polymerase chain reaction (PCR) may be sensitive and specific for the diagnosis of tuberculosis, but most reports are of studies conducted in well-controlled laboratories. A study to evaluate the clinical value of bronchoalveolar lavage (BAL) combined with PCR was necessary.

OBJECTIVE

One hundred and thirty one patients were recruited into the study from March 1994 to February 1997.

DESIGN

Patients with a positive acid-fast stain on sputum smear were recruited into group A as positive controls, patients with lung cancer and a negative acid-fast stain on sputum smear were put into group B as negative controls, and patients who had clinical symptoms of pulmonary TB without sputum or with negative smear results were the investigating group. PCR was performed on the sputum samples from group A and B patients and on the BAL fluid from those in group C.

RESULTS

The sensitivity of PCR was 96% in group A, and the specificity was 100% in group B. The sensitivity of PCR in the BAL fluid from the group C patients was 36% and the specificity was 96%; the positive predictive value was 94% and the negative predictive value was 45%.

CONCLUSION

BAL plus PCR is useful in the rapid diagnosis of pulmonary TB in non-productive or smear-negative patients.

Interconversion of a monomer and two coordination polymers of a copper(II)-reduced Schiff base ligand-1,10-phenanthroline complex based on hydrogen- and coordinative-bonding

Two compounds, [Cu(3)(Sbal)(2)(phen)(H(2)O)(2)](ClO(4))(2)-3H(2)O (1) and [Cu(H(2)Sbal)(2)(phen)](ClO(4))(2) (2), were isolated in successive steps from the reaction mixture containing Cu(ClO(4))(2)-6H(2)O, 1,10-phenanthroline, N-(2-hydroxybenzyl)-beta-alanine (H(2)Sbal), and LiOH in the ratio of 1:1:1:1. When the ratio of the base was doubled, the neutral monomer [Cu(Sbal)(phen)]-2H(2)O (3) was obtained. The cation in 1 exists as a one-dimensional polymer in the solid state, while weak O--H...O hydrogen bonds in the cation of 2 generate Delta Lambda Delta Lambda. type one-dimensional spiral chains. Addition of HClO(4) to 3 furnished 1 and 2, and this mixture can be converted back to 3 by the addition of a base. This conversion of a monomer to two 1-D polymers was found to be reversible. Crystal data for 1: triclinic space group P one macro, a = 12.0353(5) A, b = 12.2848(5) A, c = 15.3185(6) A, alpha = 84.993(1) degrees, beta = 89.411(1) degrees, gamma = 67.414(1) degrees, V = 2082.5(2) A(3), Z = 2, rho(calcd) = 1.668 g cm(-3). Crystal data for 2: tetragonal space group P4(1)/a, a = 10.8095(1) A, c = 59.0159(4) A, V = 6895.7(1) A(3), Z = 8, rho(calcd) = 1.605 g cm(-3). Crystal data for 3: monoclinic space group Pn, a = 10.6344(3) A, b = 5.3953(1) A, c = 18.1983(1) A, V = 1029.26(4) A(3), Z = 2, rho(calcd) = 1.526 g cm(-3). When Cu(NO(3))(2) was used in the place of Cu(ClO(4))(2), [Cu(2)(Sbal)(phen)(3)](NO(3))(2)-2.5H(2)O (4) was the only isolable product for the 1:1:1:1 ratio, and 3 was the only isolable product for the 1:1:1:2 ratio. Crystal data for 4: triclinic space group P one macro, a = 10.8063(8) A, b = 13.919(1) A, c = 16.564(1) A, alpha = 88.957(2) degrees, beta = 71.008(1) degrees, gamma = 69.829(2) degrees, V = 2198.9(3) A(3), Z = 2, rho(calcd) = 1.556 g cm(-3). Variable temperature magnetic measurements showed that the polymeric structure in 1 behaves, magnetically, as a strongly coupled micro-phenoxo dimer (2J = -390 cm(-1)) plus an isolated monomer.

p14(ARF) modulates the cytolytic effect of ONYX-015 in mesothelioma cells with wild-type p53

ONYX-015 has been reported to kill selectively tumor cells lacking functional p53. Genetic alterations of INK4a/ARF locus, which is a predominant event in malignant pleural mesothelioma, may result in loss of p14(ARF) and subsequent disruption of p53 pathway in cancer cells. In the present study, ONYX-015 was able to kill three mesothelioma cell lines (H28, H513, and 211H) with wild-type p53 but lacking p14(ARF). In contrast, MS-1 mesothelioma cells, which expressed both p53 and p14(ARF), were resistant to ONYX-015. Introducing p14(ARF) gene into the H28 cell, a mesothelioma cell without p14(ARF) expression, significantly increased the resistance of this cell line to the cytolytic effect of ONYX-015. Our results suggest that human mesotheliomas with wild-type p53 yet lacking p14(ARF) are potential candidates for ONYX-015 therapy.

CD exciton chirality method for determination of the absolute configuration of beta-hydroxy-alpha-amino acid derivatives

The absolute configuration of beta-hydroxy-alpha-amino acids was studied by CD exciton chirality method using 7-diethylaminocoumarin-3-carboxylate as a red-shifted chromophore. The CD spectra of bischromophoric derivatives of (S)-serine and (2S,3R)-threonine methyl esters (2 and 7) were compared with those of acyclic vic-aminoalcohols and diols (3--6 and 8--9). This study indicates that the polar carboxylate group of beta-hydroxy-alpha-amino acids makes them a unique subclass of vic-aminoalcohols. By combining the data of CD and NMR coupling constants, we are able to correlate their preferred conformer B and positive CD to the corresponding absolute configuration.

Identification of a Drosophila vitamin K-dependent gamma-glutamyl carboxylase

Using reduced vitamin K, oxygen, and carbon dioxide, gamma-glutamyl carboxylase post-translationally modifies certain glutamates by adding carbon dioxide to the gamma position of those amino acids. In vertebrates, the modification of glutamate residues of target proteins is facilitated by an interaction between a propeptide present on target proteins and the gamma-glutamyl carboxylase. Previously, the gastropod Conus was the only known invertebrate with a demonstrated vitamin K-dependent carboxylase. We report here the discovery of a gamma-glutamyl carboxylase in Drosophila. This Drosophila enzyme is remarkably similar in amino acid sequence to the known mammalian carboxylases; it has 33% sequence identity and 45% sequence similarity to human gamma-glutamyl carboxylase. The Drosophila carboxylase is vitamin K-dependent, and it has a K(m) toward a model pentapeptide substrate, FLEEL, of about 4 mm. However, unlike the human gamma-glutamyl carboxylase, it is not stimulated by human blood coagulation factor IX propeptides. We found the mRNA for Drosophila gamma-glutamyl carboxylase in virtually every embryonic and adult stage that we investigated, with the highest concentration evident in the adult head.

Adenovirus-mediated p14(ARF) gene transfer in human mesothelioma cells

BACKGROUND

The p14(ARF) protein encoded by the INK4a/ARF locus promotes degradation of the MDM2 protein and thus prevents the MDM2-mediated inhibition of p53. Homozygous deletion of the INK4a/ARF locus is common in human mesothelioma and may result in the loss of p14(ARF) and the inactivation of p53. We designed this study to evaluate the biologic and potential therapeutic roles of p14(ARF) expression in mesothelioma cells.

METHODS AND RESULTS

We constructed Adp14, an adenoviral vector carrying human p14(ARF) complementary DNA, and used it to transfect human mesothelioma cell lines H28, H513, H2052, and MSTO-211H. Overexpression of p14(ARF) led to increased amounts of p53 and the p21(WAF) proteins and dephosphorylation of the retinoblastoma protein. The growth rate of mesothelioma cells was inhibited markedly by infection with Adp14 compared with mock infection or infection with a control adenovirus vector, AdCtrl. Overexpression of p14(ARF) induced G(1)-phase cell cycle arrest and apoptotic cell death. Cytotoxicity assays showed that Adp14 had a statistically significantly (P =.002) greater effect on colon cancer (HCT116) cell lines containing two copies of the wild-type p53 gene than on p53-null cells, suggesting that functional p53 is a critical determinant of p14(ARF)-mediated cytotoxicity.

CONCLUSIONS

The transfection of p14(ARF) into mesothelioma cells led to the overexpression of p14(ARF), which resulted in G(1)-phase arrest and apoptotic cell death. These results suggest that this gene therapy-based approach may be of use in the treatment of mesothelioma.

Increased absolute number but not proportion of gamma/delta T-lymphocytes in the bronchoalveolar lavage fluid of patients with active pulmonary tuberculosis

SETTING

The proportions and absolute cell count of gamma/delta T-lymphocytes in the peripheral blood of patients with pulmonary tuberculosis (PTB) remains controversial. Since PTB is an infections airway disease, bronchoalveolar T-lymphocytes should be a better indicator of local immune T-cell reaction after TB infection than peripheral blood T-lymphocytes.

OBJECTIVE

To quantitate the absolute cell count and proportions of gamma/delta T-lymphocytes in the bronchoalveolar lavage fluid (BALF) of patients with active PTB.

DESIGN

Bronchoalveolar lavage (BAL) and analysis of lymphocytes in the BALF was performed in 25 patients with active PTB and 16 normal controls. All of the patients were negative for HIV infection and none was immunocompromised. BALF and blood were prepared for cell differential count and flow cytometry analysis using monoclonal antibodies CD3, CD4, CD8, CD25, HLA-DR and gamma/delta as well as alpha/beta T-lymphocyte receptors.

RESULTS

The number of cells per volume of recovered BALF was significantly higher in the patients with active PTB than in normal controls. BALF from active PTB patients also showed increased percentage of lymphocytes and neutrophils. The absolute number of total lymphocytes, CD3+ lymphocytes and CD3+ gamma/delta T-lymphocytes were significantly higher in the BALF, but not in the blood, of patients with TB, however, the proportions of CD3+ gamma/delta T-lymphocytes in BALF of patients with TB was comparable to that of normal controls. gamma/delta T-lymphocytes in the BALF rarely expressed CD4, CD25, and HLA-DR in both groups.

CONCLUSION

These results suggest that gamma/delta T-lymphocytes are not the major subpopulation of CD3+ lymphocytes in the BALF that react to mycobacterial infection in the patients with clinically established active TB.

ONYX-015 works synergistically with chemotherapy in lung cancer cell lines and primary cultures freshly made from lung cancer patients

p53 mutations and loss of heterozygosity (LOH) have been detected in >50% of lung cancers. Wild-type p53 can prevent replication of damaged DNA and promote apoptosis of cells with abnormal DNA. A human adenovirus, ONYX-015, which has a deletion in the E1B region, has shown tumor-specific cytolytic effect in tumor cells with nonfunctional p53 and antitumor efficacy that can be augmented by chemotherapeutic agents. A recent report from an independent group, however, indicates that wild-type p53 is necessary for the infection of this replicating virus, and it is in direct contradiction to previous observations of the ONYX group. In this study, we carried out cytopathic effect (CPE) assays using ONYX-015 on five human lung cancer cell lines with known p53 status. Two of these cell lines, NCI-H522 and NCI-H1703, have mutations and LOH in their p53 gene. Both lines were lysed in a dose-dependent manner and showed 100% cytolysis at a multiplicity of infection of 0.1. Two additional cell lines, NCI-H2347 and NCI-H838, both of which have wild-type p53 gene, showed near complete lysis at a multiplicity of infection of 1. We demonstrate here that the lung cancer cells with nonfunctional p53 are at least 10 times more sensitive to ONYX-015 cytolysis than the lung cancer cells with wild-type p53. In addition, standard chemotherapeutic agents (paclitaxol and cisplatin) showed a synergistic effect when combined with ONYX-015, and this effect was p53 mutant dependent. Furthermore, we tested the cytolytic effect of ONYX-015 on a panel (n = 7) of primary first-passage cultures made from freshly resected lung cancers. ONYX-015 lysed primary lung cancer cells in six of seven (86 %) primary cultures. Two of four primary cultures treated with chemotherapeutic agents had a synergistic effect with ONYX-015. Our data indicate that wild-type p53 is not required for the infection of this replicating virus, and also we demonstrate that ONYX-015 is effective alone and works synergistically with chemotherapeutic agents in lung cancer cell lines and primary cultures. This study suggests that ONYX-015 may be effective, especially in combination with conventional chemotherapy, in the treatment of patients with lung cancer.

Pulmonary mechanics in patients with prolonged mechanical ventilation requiring tracheostomy

This study was performed to assess the changes in pulmonary mechanics before and after tracheostomy in patients with prolonged mechanical ventilation and to detect pre-tracheostomy physiologic factors that predict the outcome of weaning from mechanical ventilation. Pulmonary mechanics were recorded before and after tracheostomy in 20 patients. Work of breathing, mean airway resistance and pressure/time product showed no significant differences after tracheostomy. Peak inspiratory pressure was significantly reduced (pre 33.4 +/- 11.8 vs post 28.6 +/- 9.2 mmHg). There was no difference in age or duration of mechanical ventilation between two different groups according to the outcome (weaned and not-weaned). Pre-tracheostomy intrinsic positive end expiratory pressure (PEEPi) was significantly lower in the weaned group (1.1 +/- 1.6 vs 2.7 +/- 1.4 mmHg). A significant difference was also found in pre-tracheostomy compliance (Cstatic) (47.3 +/- 36.9 vs 28.8 +/- 16.5 ml/cmH2O). We concluded that tracheostomy changed pulmonary mechanics very little except for a fall in peak inspiratory pressure. Patients who had better underlying lung mechanics (higher Cstatic and lower PEEPi) had better chances of weaning from mechanical ventilation after tracheostomy.

Comparison of indoor allergens, allergic scores, and demographic data in Taiwanese adults with asthma or allergic rhinitis, or both

We examined the relationships between exposure to different indoor allergens and demographic factors in 515 adult Taiwanese patients with allergic diseases such as asthma and rhinitis. Patients who had positive screening results on an immunoglobulin E (IgE) test were recruited from the outpatient clinics of Chang Gung Memorial Hospital. Patients were divided into the following three groups: asthma (n = 332), combined asthma and allergic rhinitis (n = 165), and allergic rhinitis (n = 18). Serum samples were analyzed for IgE by enzyme-linked immunosorbent assay. Significantly elevated titer of dust mite-specific IgE were found in all three groups, with markedly higher levels in the combined asthma and allergic rhinitis group (p < 0.05). Allergen scores were significantly related to the demographic variables of older age (> or = 65 years), female gender, and spring season, with significantly lower scores (p < 0.05). No significant difference in allergen scores was found among cigarette smoking subjects and subjects from residential areas. Multiple linear regression analysis revealed significant allergic contributors to be, in order of importance, age, gender, and atopic disease category. We conclude that mite allergen exposure is the most significant factor associated with asthma and/or allergic rhinitis in Taiwan. Younger subjects and males had a higher rate of asthma and/or allergic rhinitis.

The effects of two different cisplatin-based chemotherapy regimens on advanced non-small cell lung cancer

BACKGROUND

Many different cisplatin-based regimens have been used on advanced non-small cell lung cancer (NSCLC) in previous studies but there have been few such references in Taiwan. In this study, we evaluated the efficacy and toxicity of two different regimens including 5-Fluorouracil, Leucovorin, Etoposide and cisPlatin (FLEP) and cisPlatin, Etoposide and Mitomycin (PEM) in the treatment of patients with advanced NSCLC.

METHODS

We retrospectively analyzed the records of 44 patients with NSCLC who met the selection criteria from February 1995 through April 1998. All of them were confirmed, using histologic tests, that they were in advanced stages, i.e. stage IIIB or IV. Twenty-two patients received FLEP and 22 patients received PEM.

RESULTS

Three patients with FLEP therapy and 3 patients with PEM therapy had partial response. No patient had complete response. The response rate was 13.6% in both groups, respectively. The median survival was 160 +/- 30 (median + SD) days for patients with FLEP therapy and 263 +/- 104 days for patients with PEM therapy. The factors that were associated with longer survival in all patients included response (Stable Disease vs Disease Progression p = 0.004, Partial Response vs Disease Progression p = 0.047) and regimen of chemotherapy (PEM vs FLEP p = 0.008). The major clinically significant toxicity was myelosupression.

CONCLUSION

The responses to regimens, FLEP and PEM, were low in our study groups that might be due to the low dose of cisplatin and etoposide in our regimens. The patients with response to chemotherapy and PEM therapy had longer median survival than those who underwent FLEP therapy.

Tuberculin purified protein derivative up-regulates the telomerase activity of peripheral blood mononuclear cells from patients with pulmonary tuberculosis

Telomerase activity was detectable in cells of tuberculous pleural effusions at high percentage. To investigate the possible role of telomerase in the immune function, we examined the proliferating state and the expression of telomerase activity in peripheral blood mononuclear cells (PBMC) from 13 patients with pulmonary tuberculosis (TB) and 13 healthy volunteers in response to tuberculin purified protein derivative (PPD) challenge. Exposure of cells to phytohemagglutinin (PHA) significantly promoted PBMC proliferation during a 6 day-period in both TB patient and healthy volunteer groups. PPD treatment also significantly promoted PBMC proliferation during a 6 day-period in TB patient group, but had no significant effect in healthy volunteer group. During the same period, telomerase activity was detected in every PHA- and PPD-treated samples of the TB patient group. However, the telomerase activity was not detected in PPD-treated samples from healthy donors and all the untreated samples. Our results indicate that the telomerase activity in PBMC could be induced by PPD stimulation in TB patients. Telomerase activity may thus play a permissive role in cell division and clonal expansion of the immune cells in response to TB.

Percutaneous cholangiofiberscopic endoluminal forceps biopsy of intrabile duct diseases

BACKGROUND/AIMS

The aim of the present study was to determine the usefulness and sensitivity of percutaneous cholangiofiberscopic guided forceps biopsy in patients suspected of intrabile duct diseases. This study also emphasized the use of a video monitor system in which the field of view is magnified; thus, even a small lesion can easily be detected. Furthermore, coordination of both the operator and assistant is easier because both can observe the image together on the video monitor.

METHODOLOGY

Percutaneous cholangio-fiberscopic forceps biopsy was performed in 27 patients (14 men, 13 women, aged 37-81 years with a mean age of 61 years). A mature T-tube tract was used as an access for cholangioscopy in 17 cases while the remaining 10 patients underwent percutaneous transhepatic biliary drainage and gradual tract dilatation from 7-French to 16-French. A flexible fiberoptic choledoscope was gently inserted into a mature tract and once an abnormal mucosal lesion was identified, a forceps biopsy was inserted into a working channel of the scope, and 3-5 specimens were taken for histological examination.

RESULTS

A histological diagnosis was obtained in 24 cases of the 27 patients (sensitivity 89%) and included cholangiocarcinoma (n=8), papillomatosis (n=3), ampullary adenoma (n=1), ampullary adenocarcinoma (n=1), hepatoma with intrabile duct invasion (n=1), and chronic inflammation (n=10). Post-procedural bleeding was noted in 1 patient.

CONCLUSIONS

Percutaneous cholangiofiberscopic-guided forceps biopsy is a safe and easy to perform procedure. It yielded a high sensitivity rate for definitive diagnosis of very small or early intrabile duct lesions; thus, a curative therapeutic modality can be appropriately applied. The use of a video monitor system, which magnified the field of view without distorting the quality of the image, plays a crucial role in this technique. Mucin substance is commonly seen in cholangiocarcinoma. The association between bile duct stones and neoplasm needs further evaluation.

Oxygen, arterial blood gases and ventilation are unchanged during dialysis in patients receiving pressure support ventilation

This study was undertaken to observe whether dialysis-induced alveolar hypoventilation and arterial hypoxaemia occur during bicarbonate haemodialysis in patients receiving partial mechanical support with pressure support ventilation. Nineteen patients admitted to the medical intensive care unit requiring mechanical ventilation and haemodialysis were enrolled. Arterial blood gas, white blood cell (WBC) count, minute ventilation, respiratory rate, breathing pattern and blood pressure were measured according to the following time schedule: pre-dialysis (time 0), and at 15, 30, 60, 120, 180, 240 min thereafter. Results showed that, with the use of cuprammonium dialyser, the WBC count dropped immediately and reached the nadir 15 min after haemodialysis. Thereafter, it recovered and overshot the pre-dialysis values until the end of dialysis. The bicarbonate dialysate indeed resulted in rapid and significant metabolic alkalosis. However, no decrease of PaO2 occurred throughout haemodialysis. The tidal volume, minute ventilation and breathing pattern remained stable during haemodialysis. We conclude that neither dialysis-induced alveolar hypoventilation nor arterial hypoxaemia developed during bicarbonate dialysis in patients mechanically ventilated with the pressure support ventilation.

Telomerase activity in pleural effusions: diagnostic significance

PURPOSE

To determine the diagnostic value of pleural fluid telomerase activity in distinguishing a malignant from a nonmalignant pleurol effusion in a cohort of patients undergoing thoracentesis.

PATIENTS AND METHODS

Using a polymerase chain reaction (PCR)-based assay, telomerase activity was examined in the pleural fluid cells obtained from 144 consecutive, unselected patients. According to the final diagnosis achieved, these patients were classified into three groups: group I consisted of 70 malignant pleural effusions diagnosed by either fluid cytology or pleural biopsy, group II consisted of 52 nonmalignant pleural effusions, and another 22 samples were categorized to be suspicious malignant pleural effusions (group III) due to inconclusive results in effusion cytology and percutaneous pleural biopsy, but were strongly suspicious in clinical settings.

RESULTS

The presence of telomerase activity was observed in 64 of 70 samples in group I (91.4%), three of 52 samples in group II (5.8%), and 20 of 22 samples in group III. All three nonmalignant, telomerase-positive pleural effusion samples in group II were obtained from patients with tuberculosis. As a diagnostic criterion for malignant pleural effusion in group I and group II patients, positive telomerase activity had a sensitivity of 91.4%, a specificity of 94.2%, and a positive and negative predictive value of 0.96 and 0.89, respectively.

CONCLUSION

Our results indicate that the detection of telomerase activity may be a useful adjunct to cytopathologic methods in the diagnosis of malignant pleural effusions.

Respiratory drive and pulmonary mechanics during haemodialysis with ultrafiltration in ventilated patients

The improvements of respiratory drive and pulmonary mechanics which follow haemodialysis with ultrafiltration in mechanically ventilated renal failure patients seem predictable but have not been studied before. In this study, 14 renal failure patients with stable haemodynamics mechanically ventilated with pressure support ventilation (PSV) were enrolled. Respiratory drive (represented as P0.1), pulmonary mechanics, breathing pattern, arterial blood gas and haemodynamics were measured according to the time schedule: pre-dialysis (Time 0), and at 60, 120, 180, 240 minutes thereafter. Following the removal of excess lung water during haemodialysis, auto-PEEP and patient's work of breathing (WOBp) decreased gradually. P0.1 lessened progressively along with the improvement in pulmonary mechanics. The changes in auto-PEEP and WOBp correlated closely to the pre- and post-dialysis decline of P0.1 (delta P0.1). There was a negative, moderately significant correlation between the amount of fluid ultrafiltrated during dialysis (delta UF) and the delta P0.1 (R = -0.54). The breathing pattern remained stable during dialysis. No hypoventilation or hypoxaemia occurred despite the development of metabolic alkalosis induced by bicarbonate dialysate. We have shown that respiratory drive decreases gradually during bicarbonate haemodialysis. The improvements of pulmonary mechanics, rather than the rapid alkalization of body fluids, responds to the decrease of P0.1 in renal failure patients ventilated with PSV.

Concurrent 5-fluorouracil, leucovorin, etoposide, cisplatin and radiotherapy for locally advanced non-small cell lung cancer

BACKGROUND

The prognosis of Stage III unresectable non-small cell lung cancer may be improved by concurrent chemoradiotherapy. In this study, we attempted to evaluate the feasibility, tolerance, efficacy and toxicities of the combination of thoracic radiation and chemotherapy with a novel regimen that included 5-fluorouracil, leucovorin, etoposide and cisplatin (the FLEP regimen) in the treatment of this group of patients.

PATIENTS AND METHODS

From July 1995 to September 1996, 20 untreated patients with locally advanced non-small cell lung cancer were enrolled in the study. Radiation at a dose of 44 Gy was initially delivered in daily fractions of 2 Gy 5 days a week to the tumor and mediastinum, followed by a boost to the tumor (20 to 26 Gy according to patients tolerance). Concurrently with thoracic irradiation, patients were treated with chemotherapy consisting of cisplatin at the dose of 60 mg/m2/d for 1 day, etoposide at the dose of 60 mg/m2/d for 2 days, and 5-FU 500 mg/m2/d plus leucovorin 50 mg/d infusion for 48 hours. Cycles of chemotherapy were repeated every 3 weeks for a maximum of 3 cycles.

RESULTS

Seventeen of 20 patients were assessable. The overall response rate was 70.6% (95% confidence interval = 49-92%). No complete response was achieved. The median response duration for all responding patients is not yet estimable, with a range of 3.5 to 15.5+ months. Eleven patients remain progression-free for 4 to 15 months. The median survival for the entire group is not estimable. The major toxicity was esophagitis. Other grade 3 or 4 toxicities were not frequently observed.

CONCLUSION

Combined-modality therapy with FLEP regimen and radiation is a promising treatment with a high response rate and acceptable toxicity for locally advanced non-small cell lung cancer.

Elastance of the pleural space: a predictor for the outcome of pleurodesis in patients with malignant pleural effusion

BACKGROUND

In patients who have malignant pleural effusion, it is difficult to diagnose trapped lung before thoracoscopy, thoracostomy, and drainage of the effusion. Predicting the outcome of pleurodesis in patients who have malignant pleural effusion without trapped lung is also difficult.

OBJECTIVE

To investigate the factors that may be useful in diagnosing trapped lung and predicting the outcome of pleurodesis.

DESIGN

Prospective cohort study.

SETTING

University medical center.

PATIENTS

65 patients with symptomatic malignant pleural effusion.

INTERVENTION

A chest tube was inserted for drainage of the effusion, and pleurodesis was done using bleomycin as the sclerosant.

MEASUREMENTS

The pH and glucose levels of the effusion and the elastance of the pleural space (defined as the decline in pleural fluid pressure in cm H2O after removal of 500 mL of effusion) were measured. The outcome of pleurodesis was evaluated 1 month after the chest tube was removed.

RESULTS

Patients with an elastance of 19 cm H2O or more had a higher incidence of trapped lung (11 of 14 patients) than did those with an elastance less than 19 cm H2O (3 of 51 patients) (P < 0.001). None of the 14 patients with an elastance of 19 cm H2O or more and none of the 14 patients with a trapped lung had successful pleurodesis. Forty-two of 43 patients with an elastance less than 19 cm H2O who did not have a trapped lung had successful pleurodesis. Elastance seemed to be the best predictor for trapped lung and outcome of pleurodesis, although outcome was also correlated with pH and glucose levels of the effusion. Low-dose bleomycin (30 mg) is as effective as the usual dose of bleomycin (60 mg) for pleurodesis.

CONCLUSION

In patients with symptomatic malignant pleural effusion, measurement of the elastance of the pleural space is a simple and effective method for the diagnosis of trapped lung and prediction of the outcome of chemical pleurodesis with bleomycin.

[Community-based integrated home care model for the demented patients and their families]

The purposes of this research project were to establish an integrated home care model and understand the influence of an integrated home care model on demented elders and their families. The changes in cognitive function and self-care ability of demented elders were also explored longitudinally. The disciplines involved in the integrated home care model included doctors, home care nurses and social workers. The integrated home care model was developed according to the functions and roles of different disciplines in their actual working process. Services provided included home nursing care, telephone consultation and a support group. Home care nurses played the role of case manager in this model. Twenty-five families participated in this study. Among them, 22 received home care service, and 20 of them participated in a caregiver support group. The cognitive function of the demented elders did not significantly decrease over the 6-month period. Among their self-care ability, grooming and eating dependency were found significantly increased during this period. Overall, 81% families reported that home nursing care services could help them to develop care skills, care knowledge and provided emotional support. However, the caregiver burden did not significantly decrease after the home nursing care services. Seventy percent of caregivers reported that telephone consultation could support them emotionally and provided them with information concerning care. Over half of the caregivers reported that in getting related information and receiving emotional support was helpful. This integrated model developed from this research project can be adapted and used in networking home care agencies, the community and health care resources. The small and convenient sample was one of the limitations of this study. The insignificance of some of the findings might be due to the short time period (6 months) and some effects of the model might appear later than 6 months. For further research, larger and random samples and a longer period of follow-up with more health disciplines involved were suggested.

Differential effects of nasal continuous positive airway pressure on reversible or fixed upper and lower airway obstruction

Our study was to assess whether there were differential effects of nasal continuous positive airway pressure (nCPAP) on different kinds of obstruction in either upper or lower airways in patients with chronic obstructive pulmonary disease (COPD). nCPAP (6 cmH2O for ten minutes) was applied to 7 patients with reversible extrathoracic upper airway obstruction (RUAO) and 3 patients with fixed extrathoracic upper airway obstruction (FUAO). Eighteen stable asthmatics, receiving methacholine challenge to induce a more than 20% reduction in FEV1, were randomly investigated for the effect of nCPAP or sham pressure on reversible lower airway obstruction. Nine stable COPD patients were enrolled to study the effect on irreversible lower airway obstruction. Maximal expiratory and inspiratory flow volume curves and dyspnoea scores were obtained before and after immediate withdrawal of nCPAP. In the RUAO group, nCPAP significantly improved stridor and dyspnoea scores, decreased the ratio of FEF50/FIF50 from 2.05 +/- 0.25 to 1.42 +/- 0.16, and increased peak inspiratory flow (PIF) as well as forced inspiratory vital capacity by 26 +/- 8% and 9 +/- 4%, respectively. In expiratory phase, there was no significant change in pulmonary functions. In asthmatics, nCPAP significantly reversed methacholine-induced bronchoconstriction increasing forced vital capacity by 10 +/- 3%, FEV1 by 15 +/- 4% and PIF by 32 +/- 11%. nCPAP significantly increased the response to bronchodilators. The improvement in airflow rate persisted for at least 5 min after nCPAP withdrawal and was highly correlated with the response to bronchodilators. There was no significant effect of nCPAP on airflow rate in COPD patients. Subjective dyspnoea score changes paralleled the pulmonary function improvement. We conclude that there are differential effects of nCPAP on airflow rates in patients with different nature of airway obstruction. Patients with airway obstruction caused by structural changes may not benefit from the use of nCPAP in improving airflow rates.

Dimercaptosuccinic acid renal scan in children with urinary tract infection

The hospital records of 247 children less than 16 years old, who had had UTI and received dimercaptosuccinic acid (DMSA) renal scans during the period October 1991 to October 1993, were reviewed. Abnormal DMSA renal scans were found in 207 kidneys (207/494, 41.9%) and in 163 cases (163/247, 66%). The appearance of an abnormal DMSA renal scan is correlated with fever and vesicoureteral reflux, but not with age or sex. Because the prevalence of upper UTI in children is high, DMSA renal scan is undoubtedly a valuable tool for pediatricians as a guide in giving appropriate antibiotic therapy and to prevent further renal damage.