Guideline-Adherent Hypertension in Children and Adolescents: A Multi-Institutional Database Analysis from Taiwan

BACKGROUND/AIMS

Childhood-onset hypertension is associated with cardiovascular morbidity and adult mortality. This study aimed to assess guideline-adherent hypertension among Taiwanese youth and the agreement on hypertension between the 2017 American Academy of Pediatrics guidelines and the 2004 Fourth Report.

METHODS

In this cross-sectional study, we collected outpatient blood pressure (OBP) measurements obtained during routine care visits from a large healthcare delivery system between 2009 and 2018 to evaluate the rate of guideline-adherent hypertension and assess patient-related factors of pediatric hypertension.

RESULTS

In total, 12,469 children and adolescents who underwent three separate ≥3 OBP measurements over 33,369 person-years with a total of 95,608 BP measurements in an outpatient setting were analyzed. According to the 2017 American Academy of Pediatrics (AAP) guidelines, the rate of pediatric hypertension in the study setting, which included participants aged 1 to 17 years, ranged from 0.78 to 5.95 per 1000 persons. Although there was perfect agreement between the thresholds of the two guidelines for defining hypertension in the age groups of 1-7, 8-12, and 13-17 years (all κ statistic ≥ 0.85), the use of the AAP threshold classified more adolescents as having hypertension. Children and adolescents with hypertension often had complex chronic diseases and required substantial healthcare services in outpatient, emergency, and inpatient settings.

CONCLUSIONS

The present study provides evidence of guideline-adherent pediatric hypertension and highlights the importance of regularly monitoring blood pressure to identify and manage hypertension in children and adolescents. Further research is required to determine the impact of new thresholds on the detection of target organ damage at a pediatric age.

Cardiovascular diseases morbidity and mortality among children, adolescents and young adults with dialysis therapy

Background

The age-specific burden of cardiovascular disease (CVD) and mortality in pediatric and young adult patients with end-stage kidney disease (ESKD) remains unclear. We aimed to examine the prevalence and incidence of CVD and all-cause mortality in children and adolescents compared with adults with dialysis in Taiwan.

Methods

This retrospective observational cohort study comprised 3,910 patients with more than 2 time point receipts of dialysis therapy in a year, including 156 aged <12 years (children), 250 aged 13-20 years (adolescents), 1,036 aged 21-30 years (young adults) and 2,468 aged 31-40 years (adults) in a large healthcare delivery system in Taiwan (2003-2017). Age groups were classified by the date of first receipt of dialysis therapy. The outcomes include the composite of CVD events and any cause of death. Death-censored Cox proportional hazard models were used to evaluate the composite outcome risk of CVD in the four age groups.

Results

Among patients receiving dialysis treatment, the risk of composite CVD events [HR, 1.63 (1.22-2.19)] and mortality [HR, 1.76 (1.38-2.25)] was greater in children than the dialysis initiated in older patients. Non-atherosclerotic CVD was more prevalent, especially in younger patients, within the first 6 months after the initiation of dialysis. After 6 months of initial dialysis, the risk of atherosclerotic CVD was higher in adults than those for adolescents and children. The magnitude of CVD risk in adolescents who initiated dialysis therapy was higher in females [HR, 2.08 (1.50-2.88)] than in males [HR, 0.75 (0.52-1.10)].

Conclusion

Younger patients undergoing chronic dialysis with a higher risk of CVD events than older patients are associated with a faster onset of non-atherosclerotic CVD and a higher risk of both CVD- and non-CVD-related mortality.

Kidney Function Trajectory within Six Months after Acute Kidney Injury Inpatient Care and Subsequent Adverse Kidney Outcomes: A Retrospective Cohort Study

Timing and extent of kidney function recovery after an acute kidney injury (AKI) episode are associated with chronic kidney disease onset and progression. This study aimed to categorize AKI recovery patterns within 6 months after index hospital discharge and associate them with kidney outcomes. This was a retrospective cohort study of 234,867 patients, hospitalized between 2010 and 2017, and classified as AKI or no AKI. Kidney function recovery from pre-hospitalization baseline within 1.5× serum creatinine (SCr) were evaluated at 3 and 6 months after hospital discharge and categorized as persistent non-recovery (PNR: SCr not recovered at 3 and 6 months), non-recovery (NR: SCr not recovered at 6 months), and recovery (SCr recovered at 6 months). A composite of incident chronic kidney disease, kidney replacement therapy, and estimated glomerular filtration rate reduction >30% from baseline and <15 mL/min/1.73 m2 was evaluated. Of 14,673 AKI surviving patients, 10.18% had PNR and 14.33% showed NR. Compared with no AKI, PNR and NR of AKI were associated with an increased risk of composite adverse outcomes (adjusted subdistribution hazard ratio (SHR) 4.55; 95% CI, 4.05−5.11; SHR, 3.54; 95% CI, 3.18−3.94, respectively). Patients with NR showed a greater risk of adverse outcomes than those with non-rapid recovery at 3 months after hospital discharge. The AKI recovery pattern within 6 months following inpatient care revealed an increasing continuum of risk of long-term adverse kidney outcomes. Risk stratification and a kidney function monitoring plan at discharge are needed to improve post-AKI care.

Trajectory of low-density lipoprotein cholesterol in patients with chronic kidney disease and its association with cardiovascular disease

Background

The role of longitudinal temporal trends in LDL-C in cardiovascular disease (CVD) in patients with chronic kidney disease (CKD) and diabetes is unclear. This study categorized the long-term LDL-C trajectory and determined its association with the incidence of atherosclerotic CVD in patients with CKD according to diabetes status and estimated glomerular filtration rate (eGFR).

Methods

The risk of atherosclerotic CVD was estimated in 137,127 Taiwanese patients with CKD using six LDL-C trajectory classes determined by the latent class mixed model as optimal, near optimal, above optimal, borderline, sustained high, and declined high over 5 years.

Results

The risk of CVD was higher in the sustained high LDL-C [>160 mg/dL over time; adjusted hazard ratio (aHR) = 1.68, 95% CI = 1.45–1.94], declined high LDL-C (>160 to <100 mg/dL; aHR = 1.23, 95% CI = 1.11–1.38), and borderline LDL-C (approximately 140 mg/dL over time; aHR = 1.16, 95% CI = 1.07–1.26) groups than in the optimal LDL-C group (<100 mg/dL over time). There was no such association in patients with an eGFR <15 mL/min/1.73 m². Persistent diabetes was associated with a 1.15–2.47-fold increase in CVD in patients with high LDL-C (>120 mg/dL).

Conclusion

The LDL-C trajectory pattern was associated with the phenotype of CVD risk. The degree of risk varied according to eGFR and diabetes status. A stable low LDL-C over time was potentially beneficial for prevention of CVD. Intensive lipid management and periodic assessment of LDL-C is essential to reduce the risk of CVD in patients with CKD and diabetes.

Continuity and Completeness of Electronic Health Record Data for Patients Treated With Oral Hypoglycemic Agents: Findings From Healthcare Delivery Systems in Taiwan

Objective: To evaluate the continuity and completeness of electronic health record (EHR) data, and the concordance of select clinical outcomes and baseline comorbidities between EHR and linked claims data, from three healthcare delivery systems in Taiwan.

Methods: We identified oral hypoglycemic agent (OHA) users from the Integrated Medical Database of National Taiwan University Hospital (NTUH-iMD), which was linked to the National Health Insurance Research Database (NHIRD), from June 2011 to December 2016. A secondary evaluation involved two additional EHR databases. We created consecutive 90-day periods before and after the first recorded OHA prescription and defined patients as having continuous EHR data if there was at least one encounter or prescription in a 90-day interval. EHR data completeness was measured by dividing the number of encounters in the NTUH-iMD by the number of encounters in the NHIRD. We assessed the concordance between EHR and claims data on three clinical outcomes (cardiovascular events, nephropathy-related events, and heart failure admission). We used individual comorbidities that comprised the Charlson comorbidity index to examine the concordance of select baseline comorbidities between EHRs and claims.

Results: We identified 39,268 OHA users in the NTUH-iMD. Thirty-one percent (n = 12,296) of these users contributed to the analysis that examined data continuity during the 6-month baseline and 24-month follow-up period; 31% (n = 3,845) of the 12,296 users had continuous data during this 30-month period and EHR data completeness was 52%. The concordance of major cardiovascular events, nephropathy-related events, and heart failure admission was moderate, with the NTU-iMD capturing 49–55% of the outcome events recorded in the NHIRD. The concordance of comorbidities was considerably different between the NTUH-iMD and NHIRD, with an absolute standardized difference >0.1 for most comorbidities examined. Across the three EHR databases studied, 29–55% of the OHA users had continuous records during the 6-month baseline and 24-month follow-up period.

Conclusion: EHR data continuity and data completeness may be suboptimal. A thorough evaluation of data continuity and completeness is recommended before conducting clinical and translational research using EHR data in Taiwan.

Changing trends in dialysis modalities utilization and mortality in children, adolescents and young adults with acute kidney injury, 2010-2017

The aim of the study was to assess trends in the relative use of dialysis modalities in the hospital-based pediatric cohort and to determine risk factors associated with in-hospital morality among pediatric patients receiving dialysis for acute kidney injury (AKI). Patients aged < 20 years who received dialysis between 2010 and 2017 were identified from electronic health records databases of a Taiwan's healthcare delivery system. The annual uses of intermittent hemodialysis (HD), continuous and automated peritoneal dialysis (PD) and continuous kidney replacement therapy (CKRT) were assessed using Cochran-Armitage Tests for trend. Among patients who received their first dialysis as inpatients for AKI, a multivariate logistic regression model was employed to assess mortality risks associated with dialysis modalities, patient demographics, complexity of baseline chronic disease, and healthcare service use during their hospital stays. Kidney dialysis was performed 37.9 per patient per year over the study period. Intermittent hemodialysis (HD) (73.3%) was the most frequently used dialysis modality. In the inpatient setting, the relative annual use of CKRT increased over the study period, while HD use concomitantly declined (P < 0.0001). The overall in-hospital mortality rate after dialysis for AKI was 33.6%, which remained steady over time (P = 0.2411). Patients aged < 2 years [adjusted odds ratio: (aOR) 3.36; 95% confidence interval (CI) 1.34-8.93] and greater vasoactive regimen use (aOR: 17.1; 95% CI: 5.3-55.21) were significantly associated with dialysis-related mortality. Overall treatment modality used for dialysis in pediatric patients increased slowly in the study period, and HD and CRKT modality uses largely evolved in the inpatient setting. Younger ages and use of more vasoactive medication regimens were independently associated with increased early mortality in patients on AKI-dialysis.

The association between denture self-satisfaction rates and OHRQoL - a follow-up study

Backgroud

The objectives of this study were to try to identify the key dimension in satisfaction from the combination of satisfaction clusters, and its effect on the change of OHRQoL(Oral Health-related Quality of Life) of elderly denture users.

Methods

This follow-up study was conducted in subjects aged 65 years and over. All participants (n = 2128) completed questionnaires before and approximately 6 months after receiving complete denture. Information obtained by questionnaire included demographic characteristics, patients’ self-satisfaction rate and OHRQoL. The 6 satisfaction dimensions (including speaking, stability, esthetic, chewing, doctor and general dimensions) were classified as 5 cluster groups, which is the group of not at all satisfied in all dimensions (NAS); only satisfied with doctor and general dimensions(SDG); moderate satisfaction group(MS); quite satisfied group(QS); the highly satisfied group(HS) by an analysis of PCA (Principle component analysis) and CA (cluster analysis). Multiple linear regression was adapted to estimate the association between satisfaction and the responsiveness of OHIP-7T (Oral Health Impact Profile).

Results

When compared to the cluster “NAS”, the greatest improvement of OHRQoL after treatment was found in the group “HS” (β = 7.31(6.26–8.36), followed by group “QS” (β = 4.71(3.54–5.87)), group “MS” (β = 4.33(2.92–5.74)) and group “SDG” (β = 3.25(2.10–4.41)). An increasing trend was detected in patient-rating satisfaction and OHRQoL. The satisfaction cluster group is an important factor of OHRQoL after adjusting for other confounders.

Conclusion

Psychological-related aspects is the greatest impacting dimension on OHRQoL among denture wearers in Taiwan elderly. Better communication from the dental professional team with denture patients would improve their OHRQoL.

Safety and tolerability of transcranial magnetic and direct current stimulation in children: Prospective single center evidence from 3.5 million stimulations

BACKGROUND

Non-invasive brain stimulation is being increasingly used to interrogate neurophysiology and modulate brain function. Despite the high scientific and therapeutic potential of non-invasive brain stimulation, experience in the developing brain has been limited.

OBJECTIVE

To determine the safety and tolerability of non-invasive neurostimulation in children across diverse modalities of stimulation and pediatric populations.

METHODS

A non-invasive brain stimulation program was established in 2008 at our pediatric, academic institution. Multi-disciplinary neurophysiological studies included single- and paired-pulse Transcranial Magnetic Stimulation (TMS) methods. Motor mapping employed robotic TMS. Interventional trials included repetitive TMS (rTMS) and transcranial direct current stimulation (tDCS). Standardized safety and tolerability measures were completed prospectively by all participants.

RESULTS

Over 10 years, 384 children underwent brain stimulation (median 13 years, range 0.8-18.0). Populations included typical development (n = 118), perinatal stroke/cerebral palsy (n = 101), mild traumatic brain injury (n = 121) neuropsychiatric disorders (n = 37), and other (n = 7). No serious adverse events occurred. Drop-outs were rare (<1%). No seizures were reported despite >100 participants having brain injuries and/or epilepsy. Tolerability between single and paired-pulse TMS (542340 stimulations) and rTMS (3.0 million stimulations) was comparable and favourable. TMS-related headache was more common in perinatal stroke (40%) than healthy participants (13%) but was mild and self-limiting. Tolerability improved over time with side-effect frequency decreasing by >50%. Robotic TMS motor mapping was well-tolerated though neck pain was more common than with manual TMS (33% vs 3%). Across 612 tDCS sessions including 92 children, tolerability was favourable with mild itching/tingling reported in 37%.

CONCLUSIONS

Standard non-invasive brain stimulation paradigms are safe and well-tolerated in children and should be considered minimal risk. Advancement of applications in the developing brain are warranted. A new and improved pediatric NIBS safety and tolerability form is included.

Continuity of care and multiple chronic conditions impact frequent use of outpatient services

This study investigated the association between care continuity and chronic conditions in relation to highly frequent use of outpatient service in order to find constructive suggestions to bring efficient, high-quality care for patients with multiple chronic conditions. The National Health Insurance database was used and 333,294 patients were identified from 2007 to 2009. The continuity of care index indicates the dispersion of a patient's ambulatory visits among providers. Multivariate logistic regression was used to estimate adjusted odds ratios with 95 percent confidence intervals. Continuity of care index was significantly associated with age, sex, urbanization level, socioeconomic status, emergency department visits, hospitalization, psychological disorders, chronic diseases, and catastrophic illness card; those with low continuity of care index were likely to use outpatient care highly frequently. Improving continuity of care is fundamental, and the best way is to advance the practice of family medicine for primary care.

Assessing a conceptual model with both oral health and health related quality of life in community-dwelling elders

PURPOSE

The objective of this study was to test a hypothesized conceptual model for both the clinical and non-clinical status of oral health and health related quality of life (OHRQoL & HRQoL) among community-dwelling elders.

MATERIALS AND METHODS

Study participants (n = 517), who were recruited as part of a Taiwanese elderly community survey, were collected via dental examinations and questionnaires. We collected measures of clinical variables, self-reported symptom status, OHRQoL, nutritional status and HRQoL. The 517 participants were randomly assigned to one of two samples, to provide one training sample for estimation and one testing sample for validation. The path analysis with all observed variables was conducted based on the proposed theoretical model delineating pathways.

RESULTS

All of the direct pathways hypothesized by the model were significant. Functional status (OHRQoL measured by OHIP-14T) mediated clinical occlusion, and symptom status mediated nutritional status (MNA) and HRQoL (WHOQOL-BREF). The model accounted for 29% of the variance in HRQoL and demonstrated a good fit with the data.

CONCLUSIONS

This conceptual model suggests that OHRQoL, as an important mediator, links clinical conditions, symptom status, nutritional status, and overall HRQoL. Therefore, when therapeutic efforts are made to improve the outcomes for patients with oral diseases, not only can the OHRQoL be enhanced, but also the HRQoL can be improved as a result.

Incidence, clinical characteristics, and associated diseases in patients with immune thrombocytopenia: A nationwide population-based study in Taiwan

INTRODUCTION

Immune thrombocytopenia (ITP) is an immune-mediated disease; it has been reported to be associated with several diseases. The data on ITP in patients with hepatitis B, tuberculosis, or thyroid diseases are relatively scarce. In addition, these diseases are not rare in Taiwan, together with hepatitis C and Helicobacter pylori which are also related to ITP.

METHODS AND MATERIALS

We identified 1223 ITP patients and characterized these patients between 2000 and 2013 from the National Health Insurance Research Database. The adult ITP patients were matched with non-ITP patients.

RESULTS

The overall incidence of ITP was 2.59/100,000 person-years. The frequencies of hepatitis B and C in adult ITP patients were much higher than those indicated in previous studies. The frequencies of non-traumatic intracerebral hemorrhage and gastrointestinal bleeding during hospitalization among ITP patients were low. The diseases associated with increased risks of ITP included hepatitis B (OR = 18.70, 95% CI = 9.71-36.03), hepatitis C (OR = 54.43, 95% CI = 15.94-185.88), hepatitis B and hepatitis C (OR = 7.02, 95% CI = 1.47-33.56), tuberculosis (OR = 5.37, 95% CI = 2.72-10.61), Helicobacter pylori infection (OR = 5.93, 95% CI = 3.16-11.10), hyperthyroidism (OR = 3.43, 95% CI = 2.09-5.64), hypothyroidism (OR = 6.70, 95% CI = 2.35-19.13), and simple and unspecified goiter (OR = 2.68, 95% CI = 1.43-5.03).

CONCLUSIONS

Surveying for the diseases which are frequent and related to increased risks of ITP among patients with newly diagnosed ITP should be considered.

Periodontal surgery improves oral health-related quality of life in chronic periodontitis patients in Asian population

The effect of periodontal surgery on patients' quality of life was investigated. Sixty patients received regenerative surgery or resective osseous surgery. Oral health-related quality of life and health-related quality of life instruments were used to assess the participants' quality of life before surgery and 4 weeks after surgery. Periodontal surgery can improve patients' quality of life by alleviating the physical pain and psychological discomfort. The scores were lower (more favorable) in the regenerative surgery group, and the functional limitations of the regenerative surgery group improved substantially compared with those of the resective osseous surgery group (P = 0.0421). The patients' oral health-related quality of life scores improved significantly after periodontal surgery. Clinicians can take advantage of the positive functional oral health-related quality of life impacts of regenerative surgery.

The Responsiveness of Patients' Quality of Life to Dental Caries Treatment-A Prospective Study

The objective of this study was to determine the responsiveness of oral health-related quality of life (OHRQoL) (oral health impact profile [OHIP] and oral impact on daily performance [OIDP]) and health-related quality of life (HRQoL) (World Health Organization quality of life scale, brief [WHOQOL-BREF]) in dental caries restoration treatment. The study also aimed to assess the influence of treatment on the responsiveness of patients' quality of life (QoL). A total of 126 patients (aged 16-40 years) received dental caries restoration treatment with a 2-week follow-up and pre- and posttreatment interviews by questionnaire. Patients were assessed for their perceptions of OHRQoL and HRQoL by using the OHIP, OIDP, and WHOQOL-BREF measures. The responsiveness of all outcome measurements was assessed by effect size (ES). Stepwise multiple regression analysis was used to examine the association with the responsiveness of all outcome measurements. Significant differences were found between OIDP (ES = 0.39), OHIP (ES = 0.54), and WHOQOL-BREF (ES = 0.13) with regard to pretreatment and posttreatment (p-values: <0.0001, <0.0001, and 0.0120, respectively). Sex and dental caries status at baseline were significantly associated with responsiveness by all measurements. This study suggests that dental caries treatment moderately improves OHRQoL, but is less related to HRQoL. Furthermore, the number of dental caries and restoration are important factors affecting the improvement of patients' perceived OHRQoL.

Improved carrier injection in GaN-based VCSEL via AlGaN/GaN multiple quantum barrier electron blocking layer

In this report, the improved lasing performance of the III-nitride based vertical-cavity surface-emitting laser (VCSEL) has been demonstrated by replacing the bulk AlGaN electron blocking layer (EBL) in the conventional VCSEL structure with an AlGaN/GaN multiple quantum barrier (MQB) EBL. The output power can be enhanced up to three times from 0.3 mW to 0.9 mW. In addition, the threshold current density of the fabricated device with the MQB-EBL was reduced from 12 kA/cm2 (9.5 mA) to 10.6 kA/cm2 (8.5 mA) compared with the use of the bulk AlGaN EBL. Theoretical calculation results suggest that the improved carrier injection efficiency can be mainly attributed to the partial release of the strain and the effect of quantum interference by using the MQB structure, hence increasing the effective barrier height of the conduction band.

Maternal citrulline supplementation prevents prenatal dexamethasone-induced programmed hypertension

Glucocorticoids are administered to premature infants to accelerate pulmonary maturation. In experimental model, prenatal dexamethasone (DEX) results in reduced nephron number and adulthood hypertension. Asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase (NOS), can cause oxidative stress and is involved in the development of hypertension. L-citrulline can be converted to l-arginine (the substrate for NOS) in the body. Thus we intended to determine if maternal L-citrulline therapy can prevent prenatal DEX-induced programmed hypertension by restoration ADMA/nitric oxide (NO) balance, alterations of renin-angiotensin system (RAS) and sodium transporters, and epigenetic regulation by histone deacetylases (HDACs). Male offspring were assigned to four groups: control, pregnancy rats received intraperitoneal DEX (0.2 mg/kg body weight) daily on gestational days 15 and 16 (DEX), pregnancy rats received 0.25% L-citrulline in drinking water during the entire pregnancy and lactation period (CIT), and DEX + CIT. We found DEX group developed hypertension at 16 weeks of age, which was prevented by maternal L-citrulline therapy. Prenatal DEX exposure increased plasma ADMA concentrations and reduced renal NO production. However, L-citrulline reduced plasma ADMA level and increased renal level of NO in DEX + CIT group. Next, prenatal DEX-induced programmed hypertension is related to increased mRNA expression of angiotensin and angiotensin II type 1 receptor, and class I HDACs in the kidney. Prenatal DEX exposure increased renal protein abundance of Na(+)/Cl(-) cotransporter (NCC), which was prevented by L-citrulline therapy. The beneficial effects of L-citrulline therapy include restoration of ADMA/NO balance and alteration of NCC, to prevent the prenatal DEX-induced programmed hypertension.

Distance dependence of energy transfer from InGaN quantum wells to graphene oxide

We report the distance-dependent energy transfer from an InGaN quantum well to graphene oxide (GO) by time-resolved photoluminescence (PL). A pronounced shortening of the PL decay time in the InGaN quantum well was observed when interacting with GO. The nature of the energy-transfer process has been analyzed, and we find the energy-transfer efficiency depends on the 1/d² separation distance, which is dominated by the layer-to-layer dipole coupling.

Optical coupling from InGaAs subcell to InGaP subcell in InGaP/InGaAs/Ge multi-junction solar cells

Spatially-resolved electroluminescence (EL) images in the triple-junction InGaP/InGaAs/Ge solar cell have been investigated to demonstrate the subcell coupling effect. Upon irradiating the infrared light with an energy below bandgap of the active layer in the top subcell, but above that in the middle subcell, the EL of the top subcell quenches. By analysis of EL intensity as a function of irradiation level, it is found that the coupled p-n junction structure and the photovoltaic effect are responsible for the observed EL quenching. With optical coupling and photoswitching effects in the multi-junction diode, a concept of infrared image sensors is proposed.

The association of responsiveness in oral and general health-related quality of life with patients' satisfaction of new complete dentures

PURPOSE

The objective was to determine the responsiveness properties of the Oral Health Impact Profile (OHIP) short-forms and 36-item Short-Form (SF-36) in complete denture treatment, and further to evaluate the association between patients' satisfaction and improvements in oral and general health-related quality of life (OHRQoL and HRQoL) after fitting of new, complete dentures.

METHODS

Study data were obtained from the 'Dentures for the Elders through Public Funding' study conducted in Kaohsiung County. A total of 224 subjects received denture treatments with 6-month follow-up and pre-/post-treatment interviews by questionnaire. The OHIP and SF-36 were used to measure OHRQoL and HRQoL. In addition, specific questions investigating seven aspects of patients' satisfaction were used to measure the patients' perceptions of complete denture success. The responsiveness of all outcome measures and their dimensions were assessed by effect size (ES). Multivariable analysis was used to examine the association between patients' satisfaction and OHIP/SF-36 while adjusting for demographic characteristics.

RESULTS

There were improvements with regard to the 'physical pain' (ES = 0.19) and 'psychological discomfort' (ES = 0.42) dimensions of the Taiwanese short-form OHIP (OHIP-14T) after new complete denture treatment, but only improvement in the 'general health' (ES = 0.17) dimension in the SF-36 measure. Patients satisfied with 'comfort' and 'ease of cleaning' of their new dentures were significantly associated with the improvement of the OHIP-49 and OHIP-14T.

CONCLUSIONS

This study suggests that denture treatments are associated with improvements of OHRQoL, but not in HRQoL. Furthermore, patients' satisfaction was significantly associated with responsiveness of OHRQoL but less significantly associated with responsiveness of HRQoL.

Acute disseminated encephalomyelitis that meets modified McDonald criteria for dissemination in space is associated with a high probability of conversion to multiple sclerosis in Taiwanese patients

BACKGROUND

Patients with acute disseminated encephalomyelitis (ADEM) may relapse and some may ultimately convert to multiple sclerosis (MS); however, no criteria that can predict MS conversion are available to date. Our aim was to describe the clinical and magnetic resonance imaging (MRI) features of patients with an initial ADEM attack and evaluate which MRI criteria can predict conversion to MS.

METHODS

We retrospectively reviewed the records of 36 patients diagnosed with ADEM. We determined clinical signs/symptoms, examined the cerebrospinal fluid (CSF), and performed brain MRI scans and compared the findings between patients who did and did not convert to MS.

RESULTS

Clinical signs/symptoms, and CSF analysis show no significant difference between the two groups. The rate of conversion to MS from ADEM in Taiwanese patients is low (11%) after a mean follow-up period of 28.36 months. Modified McDonald criteria were fulfilled in 19/36 patients: 21% (4/19) of those patients developed MS according to Poser criteria subsequently. Of the other patients (17/36) who did not fulfill these criteria, none converted to MS. (log rank test; P=0.027).

CONCLUSIONS

It is difficult to predict from initial clinical presentations to address which patients with ADEM will convert to MS. Patients with ADEM whose brain MRI findings met the modified McDonald criteria may have clinically isolated syndrome because they have a significantly higher probability of conversion to MS. In contrast, patients whose brain MRI findings did not meeting these criteria may be considered as having classic ADEM because they have a lower probability of conversion to MS.

Energy transfer from InGaN quantum wells to Au nanoclusters via optical waveguiding

We present the first observation of resonance energy transfer from InGaN quantum wells to Au nanoclusters via optical waveguiding. Steady-state and time-resolved photoluminescence measurements provide conclusive evidence of resonance energy transfer and obtain an optimum transfer efficiency of ~72%. A set of rate equations is successfully used to model the kinetics of resonance energy transfer.

Light extraction efficiency enhancement of GaN-based light emitting diodes on n-GaN layer using a SiO2 photonic quasi-crystal overgrowth

In this paper, GaN-based LEDs with a SiO2 photonic quasi-crystal (PQC) pattern on an n-GaN layer by nano-imprint lithography (NIL) are fabricated and investigated. At a driving current of 20 mA on Transistor Outline (TO)-can package, the better light output power of LED III (d = 1.2 microm) was enhanced by a factor of 1.20. After 1000 h life test (55 degrees C/50 mA) condition, Normalized output power of LED with a SiO2 PQC pattern (LED III (d = 1.2 microm)) on an n-GaN layer only decreased by 5%. This results offer promising potential to enhance the light output power of commercial light-emitting devices using the technique of nano-imprint lithography.

Oblique electron-beam evaporation of distinctive indium-tin-oxide nanorods for enhanced light extraction from InGaN/GaN light emitting diodes

This paper presents a novel and mass-producible technique to fabricate indium-tin-oxide (ITO) nanorods which serve as an omnidirectional transparent conductive layer (TCL) for InGaN/GaN light emitting diodes (LEDs). The characteristic nanorods, prepared by oblique electron-beam evaporation in a nitrogen ambient, demonstrate high optical transmittance (T>90%) for the wavelength range of 450nm to 900nm. The light output power of a packaged InGaN/GaN LED with the incorporated nanorod layer is increased by 35.1% at an injection current of 350mA, compared to that of a conventional LED. Calculations based on a finite difference time domain (FDTD) method suggest that the extraction enhancement factor can be further improved by increasing the thickness of the nanorod layer, indicating great potential to enhance the luminous intensity of solid-state lighting devices using ITO nanorod structures.

Broadband and omnidirectional antireflection employing disordered GaN nanopillars

Disordered GaN nanopillars of three different heights: 300, 550, and 720 nm are fabricated, and demonstrate broad angular and spectral antireflective characteristics, up to an incident angle of 60? and for the wavelength range of lambda=300-1800 nm. An algorithm based on a rigorous coupled-wave analysis (RCWA) method is developed to investigate the correlations between the reflective characteristics and the structural properties of the nanopillars. The broadband and omnidirectional antireflection arises mainly from the refractive-index gradient provided by nanopillars. Calculations show excellent agreement with the measured reflectivities for both s- and p- polarizations.

Comparing factors affecting commencement and cessation of betel quid chewing behavior in Taiwanese adults

BACKGROUND

Betel quid is the fourth most common used substance in the world after tobacco, alcohol and caffeine. Although factors related to betel quid chewing or cessation of behaviors were reported previously, few studies simultaneously compared both behaviors in the same population. In addition, it is essential to consider time-to-event concept, since the chance of developing or stopping habit may vary over time. The purpose of this study was to compare the risk factors for commencement and cessation of betel quid chewing behaviors in a time-to-event setting.

METHODS

A stratified multi-stage cluster sampling with selection probabilities proportional to size (PPS) was designed for Taiwanese adults with aged 18 years old and above. Kaplan-Meier estimates and Cox proportional hazard regression models were used to compare and calculate the hazard rate ratios for related factors to commencement or cessation of chewing habits.

RESULTS

In Taiwan, men had a higher betel quid chewing rate (M: 20.9%, W: 1.2%), but woman chewers had a lower cessation rate (M: 27.5%, W: 12.7%). The hazard rate ratio (HRR) of having chewing habit changed from 4.22 (men vs women) univariately to 1.38 multivariablely, which indicated gender differences were confounded by other factors. In multivariable analysis, the risk factors of gender, education and ethnicity were significantly associated with both starting and cessation of betel quid chewing behavior. The factors of occupation, cigarette smoking and alcohol drinking were only associated with starting habit.

CONCLUSION

Commencement or cessation of chewing behavior involves a scenario of time, hence it is preferable to use a time-to-event approach for the comparison. The cessation rates of betel quid chewing were decreasingly associated with the daily consumption of betel quid. Hence, reducing of daily amount in betel quid cessation program may be associated with future stopping habit.

Enhanced light output from a nitride-based power chip of green light-emitting diodes with nano-rough surface using nanoimprint lithography

Enhanced light extraction from a GaN-based power chip (PC) of green light-emitting diodes (LEDs) with a rough p-GaN surface using nanoimprint lithography is presented. At a driving current of 350 mA and with a chip size of 1 mm × 1 mm packaged on transistor outline (TO)-cans, the light output power of the green PC LEDs with nano-rough p-GaN surface is enhanced by 48% when compared with the same device without a rough p-GaN surface. In addition, by examining the radiation patterns, the green PC LED with nano-rough p-GaN surface shows stronger light extraction with a wider view angle. These results offer promising potential to enhance the light output powers of commercial light-emitting devices by using the technique of nanoimprint lithography under suitable nanopattern design.

Optically modulated internal strain in InGaN quantum dots grown on SiN(x) nano masks

Optically modulated internal strain has been observed in InGaN quantum dots (QDs) deposited on SiN(x) nano masks. The modulated internal strain can induce a number of intriguing effects, including the change of refractive index and the redshift of InGaN A(1)(LO) phonon. The underlying mechanism can be well accounted for in terms of the variation of internal strain through the converse piezoelectric effect arising from the screening of the internal electric field due to spatial separation of photoexcited electrons and holes. Our results point out a convenient way for the fine tuning of physical properties in nitride-based semiconductor nanostructures, which is very important for high quality optoelectronic devices.

Tunable slow light device using quantum dot semiconductor laser

This investigation experimentally demonstrates a tunable slow light device using a quantum dot (QD) semiconductor laser. The QD semiconductor laser at 1.3 mum fabricated on a GaAs substrate is grown by molecular beam epitaxy. Tunable slow light can be achieved by adjusting the bias current and wavelength detuning. The slow light device operated under probe signal from 5 to 10 GHz is presented. Moreover, we also demonstrate that the tunable slow light device can be used in a subcarrier multiplexed system.

Dynamic characteristics of long-wavelength quantum dot vertical-cavity surface-emitting lasers with light injection

This investigation experimentally demonstrates the dynamic characteristics of quantum dot vertical-cavity surface-emitting lasers (QD VCSEL) without and with light injection. The QD VCSEL is fully doped structure on GaAs substrate and operates in the 1.3 mum optical communication wavelength. The eye diagram, frequency response, and intermodulation distortion are presented. We also demonstrate that the frequency response enhancement by light injection technique allows us to improve the performance of subcarrier multiplexed system.

InGaN self-assembled quantum dots grown by metal-organic chemical vapour deposition with growth interruption

Self-assembled InGaN quantum dots (QDs) were grown by metal-organic chemical vapour deposition with growth interruption at low V/III ratio and low growth temperature on sapphire substrates. The effects of the interruption time on the morphological and optical properties of InGaN QDs were studied. The results show that the growth interruption can modify the dimension and distribution of InGaN QDs, and cause the QD emission wavelength to blue shift with increasing interruption time. A density of InGaN QDs of about 4.5 × 10(10) cm(-2) with an average lateral size of 11.5 nm and an average height of 1.6 nm can be obtained by using a growth interruption time of 60 s.

Computer-identified nuclear localization signal in exon 1A of the transporter DMT1 is essentially ineffective in nuclear targeting

Divalent metal transporter 1 (DMT1; also called DCT1, Nramp2, or SLC11A2) has multiple isoforms that localize differently in many cell types. DMT1 +IRE species (encoded by mRNA with an iron-responsive element) are limited to the plasma membrane and cytosolic vesicles. In neural cells, -IRE isoforms of DMT1 (encoded by mRNA lacking an IRE) localize to the nucleus, plasma membrane, and cytosolic vesicles. In considering nuclear compartmentalization of -IRE isoforms, we hypothesized that the newly identified exon 1A in the N-terminus of this transporter might contain a nuclear localization signal. DNA constructs starting with exon 1A and ending with exons encoding alternative isoforms were made and transiently transfected into HEK293T and PC12 cells as well as rat sympathetic neurons. None of the constructs appeared in the nucleus despite the presence of exon 1A. Antibody specific for exon 1A was also used in both immunostaining and Western blots to investigate localization of exon 1A expressed both endogenously and ectopically in cells. Again, nuclear localization of DMT1 containing exon 1A was not observed. Our data suggest that exon 1A is neither sufficient nor necessary for DMT1 to appear in the nucleus.

Epidemiological and genetic studies of myotonic dystrophy type 1 in Taiwan

To investigate the prevalence and genetic characteristics of myotonic dystrophy type 1 (DM1) in Taiwan, DM-suspected patients and their families identified during the period of 1990-2001 had their clinical records reevaluated and the CTG repeat sizes at the DM1 locus examined. A total of 96 subjects belonging to 26 families were identified as DM1 patients, which gave a minimal disease prevalence of 0.46/100,000 inhabitants. Clinical anticipation was frequently observed in affected families, even in some parent-child pairs with transmission contraction of the CTG repeat size. The inverse correlation between age at onset and CTG repeat length was significant only in patients with small expansions. In addition, a DM1 carrier with a childhood-onset son was found to have CTG length heterogeneity in the range of 40-50, indicating that premutation alleles could be unstable during gametogenesis as well as in somatic tissues. Our data demonstrated that DM1 is a rare disease in Taiwan and showed that transmission contraction of repeat size is more likely to occur in alleles with large repeats.

A defect in the Kv channel-interacting protein 2 (KChIP2) gene leads to a complete loss of I(to) and confers susceptibility to ventricular tachycardia

KChIP2, a gene encoding three auxiliary subunits of Kv4.2 and Kv4.3, is preferentially expressed in the adult heart, and its expression is downregulated in cardiac hypertrophy. Mice deficient for KChIP2 exhibit normal cardiac structure and function but display a prolonged elevation in the ST segment on the electrocardiogram. The KChIP2(-/-) mice are highly susceptible to the induction of cardiac arrhythmias. Single-cell analysis revealed a substrate for arrhythmogenesis, including a complete absence of transient outward potassium current, I(to), and a marked increase in action potential duration. These studies demonstrate that a defect in KChIP2 is sufficient to confer a marked genetic susceptibility to arrhythmias, establishing a novel genetic pathway for ventricular tachycardia via a loss of the transmural gradient of I(to).

The surgical results of the pubovaginal sling procedure using polypropylene mesh for stress urinary incontinence

OBJECTIVE

To investigate the surgical results after a pubovaginal sling procedure using polypropylene mesh in women with stress urinary incontinence (SUI).

PATIENTS AND METHODS

Sixty-four women with different types of SUI underwent a pubovaginal sling procedure, using polypropylene mesh. The sling was placed at the level of the proximal half of the urethra and tied with adequate tension, but not obstructing the bladder outlet. A video-urodynamic study and transrectal ultrasonography were undertaken before and after surgery. The surgical results were assessed and the urodynamic changes compared at different stages.

RESULTS

At a median follow-up of 24 months, 52 patients (81%) were completely continent, 10 (16%) had an improvement but with mild SUI, and two had persistent SUI requiring a second sling procedure. The treatment result was considered satisfactory by 55 patients (86%). The video-urodynamic study showed no significant change in voiding pressure, cystometric capacity and residual urine volume after surgery. The bladder neck opening time was increased at 7 days and the maximum flow rate increased at 3 months after surgery. Transrectal ultrasonography showed that all the polypropylene mesh slings were located beneath the bladder neck and proximal urethra, with no notable granuloma formation around the sling.

CONCLUSION

The pubovaginal sling procedure is effective in treating female SUI, using polypropylene mesh as the sling material. The video-urodynamic results showed that a pubovaginal sling of polypropylene mesh causes no bladder outlet obstruction when the correct surgical technique is used.

Myasthenia gravis and Waldenström's macroglobulinemia: a case report and review of the literature

An elderly man with ocular type myasthenia gravis (MG) was found to have monoclonal gammopathy (IgM). Waldenström's macroglobulinemia (WM) was proven later. This is the second case report of MG associated with WM. However, this case is unique due to the presence of anti-acetylcholine receptor (anti-AChR) antibody (IgG). MG is considered to be an autoimmune disease and WM an immunoproliferative disorder. The association of MG and WM is not clear.

Sonographic evaluation of anatomic results after the pubovaginal sling procedure for stress urinary incontinence

OBJECTIVE

To investigate the anatomic changes after the pubovaginal sling procedure in women with stress urinary incontinence by transrectal sonography

METHODS

This study enrolled 56 women with varying types of stress urinary incontinence who were treated with the pubovaginal sling procedure using self-fashioned polypropylene mesh. The suburethral sling was fixed without tension and was placed at the position between the bladder neck and the proximal urethra. The patients were investigated preoperatively and postoperatively by transrectal sonography of the bladder and urethra.

RESULTS

At a median follow-up of 24 months (range, 6-39 months), 48 patients (85.7%) were cured, 6 (10.7%) had improved, and 2 (3.6%) had treatment failures. Transrectal sonography revealed a well-suspended bladder neck and proximal urethra in all patients who were cured. As measured by changes of the axis of the pubovesical ligament, the position of the bladder neck was elevated by a mean of 29.6 +/- 21.5 degrees in the resting condition and 47.4 +/- 27.7 degrees in the straining condition. An incompetent bladder neck and proximal urethra were noted in 8 patients who had stress urinary incontinence after surgery. The incidence of opening of the bladder neck was 84.6% in 13 patients with de novo urgency or urge incontinence, whereas only 2 (4.7%) of 43 patients who did not have postoperative urgency had opening of the neck (P = .000).

CONCLUSION

Transrectal sonography provides useful information about anatomic changes after the pubovaginal sling procedure. Bladder neck incompetence after surgery was closely related to postoperative urgency or urge incontinence.

Anatomical and functional results of pubovaginal sling procedure using polypropylene mesh for the treatment of stress urinary incontinence

PURPOSE

The anatomical and functional results of pubovaginal sling procedure using polypropylene mesh were investigated.

MATERIALS AND METHODS

A total of 50 women with stress urinary incontinence, including 26 with type 2, 7 with mixed type 2/3 and 17 with type 3 disease, underwent the pubovaginal sling procedure using polypropylene mesh. A self-fashioned 2 cm. polypropylene mesh sling was used in all cases. The slings were fixed without tension at each side of the bladder neck. The sling was further suspended to elevate the bladder neck in patients with type 2 disease and those with a hypermobile bladder base, while it was placed without further tension in those with type 3 disease and those with a nonmobile bladder base. After the operation video urodynamics and transrectal sonography were done to evaluate functional and anatomical results.

RESULTS

At a median followup of 24 months 42 women were cured, 6 had improvement and treatment had failed in 2. Although the maximum flow rate increased, no changes were noted in detrusor pressure, post-void residual urine or cystometric capacity at month 3. Transrectal sonography revealed that mean sling width plus or minus standard deviation had decreased to 13.5 +/- 3.3 mm. at 3 months. The endopelvic fascia was thicker in women with type 2 than in those with types 2/3 or 3 disease (mean 5.3 +/- 1.5 versus 3.5 +/- 1.3 mm., p = 0.001). The position of bladder neck on video urodynamics was elevated a mean of 2.01 +/- 2.01 and 3.07 +/- 2.07 cm. compared to baseline elevation during resting and straining, respectively (p = 0). No hypermobility was noted while the patients coughed and no kinking of the urethra was observed while they performed the Valsalva maneuver. Detrusor instability resolved in 6 of 8 women (75%) and new onset detrusor instability was noted in 7 (14%). In 2 women with persistent stress urinary incontinence a repeat sling procedure was necessary to treat type 3 disease and cure incontinence. The overall success rate was 96%. One patient with sling erosion into the vaginal wall was treated with simple revision.

CONCLUSIONS

Fixation of a polypropylene mesh sling at the bladder neck and adequate suspension may effectively achieve a hammock effect without creating bladder outlet obstruction in patients with types 2 and 2/3 stress urinary incontinence. The anatomical and functional results of this study show that a well suspended bladder neck did not create bladder outlet obstruction after a pubovaginal sling procedure using polypropylene mesh.

Urodynamic results of intravesical heparin therapy for women with frequency urgency syndrome and interstitial cystitis

BACKGROUND AND PURPOSE

Although intravesical heparin instillation is effective in relieving symptoms in patients with frequency urgency syndrome and interstitial cystitis (IC), its efficacy has not been evaluated by urodynamic study. We used urodynamic studies to evaluate the efficacy of heparin instillation in patients with frequency urgency syndrome and IC.

METHODS

Forty women (mean age, 59.6 yr) with severe frequency, urgency, and suprapubic pain at full bladder were enrolled in this study. Patients underwent videourodynamic study with the potassium chloride (KCl) test. All patients had a positive KCl test and were treated with intravesical heparin 25,000 units twice a week for 3 months. Results of urodynamic study and voiding symptom changes assessed by the International Prostate Symptom Score at the end of treatment were compared with baseline data.

RESULTS

Twenty-nine patients had symptom score improvement of more than 50%, and eight had symptom score improvement of less than 50% but improved nocturia. Significant improvement in symptom score (9.0 +/- 4.0 vs 19.5 +/- 4.6, p < 0.001) and nocturia (2.3 +/- 1.1 vs 5.7 +/- 2.0, p < 0.001) were noted after treatment. Urodynamic study at the end of treatment revealed significant improvements in the first sensation of filling (146 +/- 55.4 vs 96 +/- 46.4 mL, p = 0.001) and cystometric capacity (304 +/- 84.8 vs 262 +/- 89.8 mL, p = 0.002). Posttreatment KCl test was negative in 20 patients, improved in 13, and unchanged in seven. Among the 10 patients with cystoscopically proven IC, eight had symptomatic improvement and four had a negative KCl test after treatment.

CONCLUSIONS

IC and frequency urgency syndrome may be caused by increased urothelial permeability. The results of this study show that intravesical heparin can relieve bladder symptoms in a significant proportion of patients, and this may be associated with the restoration of mucosal integrity.

Long-term results of surgical treatment for female stress urinary incontinence

OBJECTIVE

To compare the long-term success rates of bladder neck suspension (BNS) and pubovaginal sling procedure in different types of female stress urinary incontinence (SUI) in order to identify appropriate treatment strategies for SUI.

METHODS

A total of 157 women who received anti-incontinence surgery were followed-up for a mean period of 58.1 +/- 33.9 months. The surgical outcome was analyzed and was compared among the different types of SUI and among BNS and pubovaginal sling procedures.

RESULTS

SUI was classified as type I in 16 patients, type II in 111 patients, and type III in 34 patients. Surgical procedures included Gittes BNS (n = 62), Raz BNS (n = 53), and pubovaginal sling procedure (n = 42). The total success rate was 77.1%, including a 38.2% cure rate and a 38.9% significantly improved rate. Analysis of the results revealed that type III SUI had the lowest success rate (67.6%), while the pubovaginal sling procedure had the best success (93.9%) and cure rates (54.8%). The success rates of BNS were significantly lower than that of pubovaginal sling in type III SUI, less favorable in type II SUI, but remained high in type I SUI. 75% of patients with treatment failure had recurrence within the fist postoperative year.

CONCLUSIONS

In this series of patients, the long-term cure rates of anti-incontinence surgeries are not satisfactory. BNS procedures had satisfactory results only in type I SUI while the pubovaginal sling procedure had better results in both types II and III SUI. The pubovaginal sling procedure might have better long-term results in the treatment of all types of SUI.

Comparison of video urodynamic results after the pubovaginal sling procedure using rectus fascia and polypropylene mesh for stress urinary incontinence

PURPOSE

Video urodynamic changes were compared after the pubovaginal sling procedure using rectus fascia or polypropylene mesh in women with stress urinary incontinence.

MATERIALS AND METHODS

A total of 50 women with various types of stress urinary incontinence were treated with the pubovaginal sling procedure using randomly abdominal rectus fascia in 24 or polypropylene mesh in 26. The sling was placed at the level of the bladder neck and tied with sufficient tension to prevent urinary leakage without obstructing the bladder outlet. Video urodynamics were performed preoperatively, and 7 to 14 days and 3 to 6 months postoperatively in all cases. Surgical results and urodynamic changes after the pubovaginal sling procedure were compared in the 2 groups. Long-term results were evaluated at a mean followup of 2 years.

RESULTS

Complete continence was achieved in 23 patients (95.8%) in the rectus fascia group and 26 (100%) in the polypropylene mesh group, including 1 initial failure with reoperation, at a median followup of 24 and 23 months, respectively. The subjective success rate was 91.6% for rectus fascia and 92.3% for polypropylene mesh. The main cause of dissatisfaction was persistent urge incontinence and dysuria in 2 cases each. In each group video urodynamics revealed a mild but nonsignificant decrease in maximum urinary flow and a significant increase in bladder neck opening time at 7 to 14 days versus baseline. However, these parameters returned to baseline within 3 to 6 months postoperatively. Voiding pressure, cystometric capacity and post-void residual urine also showed no significant change in either group after the pubovaginal sling procedure. Patients treated with a polypropylene mesh sling had a shorter operative time and hospital stay, a higher spontaneous voiding rate after catheter removal and a lower incidence of wound pain after surgery. One patient treated with polypropylene mesh had sling margin extrusion. The incidence of new onset detrusor instability and persistent dysuria was similar in the 2 groups. Transrectal sonography of the sling showed that it was located beneath the bladder neck and proximal urethra in all patients in each group.

CONCLUSIONS

The results of this study show that the pubovaginal sling procedure using rectus fascia or polypropylene mesh as the sling material had similar effectiveness for treating female stress incontinence but the polypropylene group had more rapid recovery. Postoperatively video urodynamics demonstrated that the pubovaginal sling using either sling material did not cause bladder outlet obstruction with proper surgical technique.

A pregnancy following PGD for X-linked dominant [correction of X-linked autosomal dominant] incontinentia pigmenti (Bloch-Sulzberger syndrome): case report

Incontinentia Pigmenti (Bloch-Sulzberger syndrome) is a rare multisystem, ectodermal disorder associated with dermatological, dental and ocular features, and in <10% of cases, severe neurological deficit. Pedigree review suggests X-linked dominance with lethality in affected males. Presentation in female carriers is variable. Following genetic counselling, a mildly affected female carrier diagnosed in infancy with a de novo mutation was referred for preimplantation sexing, unusually selecting for male gender, with an acceptance of either normality or early miscarriage in an affected male. Following standard in-vitro fertilization and embryo biopsy, fluorescence in situ hybridization (FISH) unambiguously identified two male and two female embryos. A single 8-cell, grade 4 male embryo was replaced. A positive pregnancy test was reported 2 weeks after embryo transfer, although ultrasonography failed to demonstrate a viable pregnancy. Post abortive fetal tissue karyotyping diagnosed a male fetus with trisomy 16. This is an unusual report of preimplantation genetic diagnosis (PGD) being used for selection of males in an X-linked autosomal dominant disorder and demonstrates the value of PGD where amniocentesis or chorion villus sampling followed by abortion is not acceptable to the patient. This case also demonstrates the importance of follow-up prenatal diagnosis.

Pathophysiology of lower urinary tract symptoms in aged men without bladder outlet obstruction

OBJECTIVE

To assess the pathophysiology of lower urinary tract symptoms (LUTS) in aged men without bladder outlet obstruction in a videourodynamic study.

METHODS

In a videourodynamic study of 324 consecutive men with moderate to severe LUTS suggestive for bladder outlet obstruction, 112 were found to be urodynamically nonobstructed. International prostatic symptom score (IPSS), uroflowmetry and transrectal sonography of the prostate were assessed before videourodynamic study. The pressure flow expression and the obstructive parameters were compared between the 212 obstructed and 112 nonobstructed men.

RESULTS

Of the 112 nonobstructed men investigated, 25 had a normal bladder and urethral trace (22.3%), 5 had detrusor instability (4.5%), 17 had a hypersensitive bladder and a normal urethra (15.2%), 3 had detrusor underactivity and a normal urethra (2.7%), while 61 were found to have a poorly relaxed external sphincter and low detrusor contractility (54.5%). Most of the patients in the normal and hypersensitive groups had normal voiding pressure and high flow (NPHF) tracings, whereas men with detrusor underactivity or a poorly relaxed external sphincter had normal voiding pressure and low flow (NPLF) tracings. Only the maximal flow rate and voided volume were significantly higher in patients with NPHF than in patients with NPLF tracings. However, both groups showed a significantly lower IPSS, less residual urine, and a smaller transition zone index than the obstructive group. After medical treatment, 78 patients (69.6%) had satisfactorily improved, 31 patients (27.6%) remained stationary, while 3 (2.7%) worsened.

CONCLUSION

Nonobstructed men with LUTS have various pathophysiologies other than benign prostatic obstruction. In this study 54.5% of these patients had poorly relaxed external sphincter on videourodynamic study. Identification of the underlying pathology can not only prevent unnecessary prostate surgery but can also enable proper medical treatment to be selected.

Comparative study of therapeutic effect of dibenyline, finasteride, and combination drugs for symptomatic benign prostatic hyperplasia

OBJECTIVES

A prospective study was conducted in a community hospital in order to evaluate the therapeutic effect of dibenyline, finasteride, and a combination of the two drugs for symptomatic benign prostatic hyperplasia (BPH).

METHODS

190 men suffering from severe prostatism entered this study. They were assessed by IPSS symptom score, digital rectal examination, transrectal sonography of the prostate, uroflowmetry and residual urine. The patients were randomly selected for medical treatment with dibenyline 10 mg b.i.d. (n = 71), finasteride 5 mg q.d. (n = 54), and a combination (n = 65). Clinical assessments were carried out before treatment and 3 and 6 months after starting treatment. Patients who could not complete the treatment and those with prostatic cancer were excluded from the final statistics. The quality of life after 6 months of treatment and side effects were also assessed.

RESULTS

A total of 172 patients completed the treatment course and 153 patients completed the periodic clinical assessments. Improvement in IPSS was noted in all 3 groups of patients both at 3 and 6 months. The prostatic volume was found to decrease in the finasteride group and the combination group at 6 months by 24.3 and 10.5%, respectively. Maximal flow rate (Qmax) was significantly improved in the dibenyline and combination groups but not in the finasteride group at 3 months. At 6 months a significant increase in Qmax was noted in all groups with a mean increase of 1.4-1.8 ml/s. The quality of life after treatment was satisfactory in 71.9% of the dibenyline group, 70.4% of the finasteride group and 83.1% of the combination group. Side effects were higher in the dibenyline than the finasteride or combination group. The dropout rate was higher in the dibenyline group (15.5%) than in the finasteride (7.5%) and combination (4.6%) groups. After 6 months of treatment, some of the patients discontinued medication and symptom relapse was noted in 92.6% of the dibenyline group, 57.6% of the finasteride group, and 71% of the combination group.

CONCLUSIONS

Medical treatment is effective in treating symptomatic BPH. Combination dibenyline and finasteride provides a weak synergistic clinical effect without additive side effects.