Low Frequency of MKRN3 Mutations in Central Precocious Puberty Among Korean Girls

Mutations of MKRN3, the gene encoding makorin RING-finger protein 3, lead to central precocious puberty (CPP). The aim of this study was to investigate mutations of the MKRN3 gene in Korean girls with CPP. Two hundred-sixty Korean girls with idiopathic CPP were included. Auxological and endocrine parameters were measured, and the entire MKRN3 gene was directly sequenced. MKRN3 gene analysis revealed one novel nonsense mutation (p.Gln281 *) and 6 missense variants (p.Ile100Phe, p.Gly196Val, p.Ile204Thr, p.Gln226Pro, p.Lys233Asn, and p.Ser396Arg). The novel nonsense mutation (p.Gln281 *) was a heterozygous C>T nucleotide change (c.841C>T) predicted to result in a truncated protein due to a premature stop codon in the MKRN3 gene. The nonsense mutation (p.Gln281 *) was only identified in one of the girls and her younger brother. Compared to previous reports on MKRN3 mutations in familial and sporadic cases of CPP, the present study reveals a relatively low number of MKRN 3 mutations in Korean girls with CPP. Larger samples of children with CPP and MKRN3 mutations are necessary in order to clarify whether the clinical course of puberty may differ as compared to idiopathic CPP.

Association of interleukin-10 promoter region polymorphisms with risk factors of Atherosclerosis

Atherosclerosis is considered as an inflammatory disease, and carotid artery intima-media thickness (IMT) and carotid plaque are generally used as intermediated phenotype of atherosclerosis. The aim of this study was to investigate whether carotid IMT and plaque are associated with promoter region polymorphisms of interleukin 10 (IL-10) gene. We recruited 135 subjects from a rural area of south-eastern part of South Korea. Three polymorphisms in the promoter region of IL-10 (-1082 A/G, -819 T/C and -592 A/C) were genotyped by pyrosequencing. Carotid IMT was measured at common carotid arteries, and carotid bulbs and cardiovascular risk factors such as cholesterol, blood pressure, uric acid and homocysteine were measured using blood samples. Subjects with the minor allele (C) of -819 T/C or the minor allele (C) of -592 A/C showed lower values in carotid IMT than those with major allele homozygote of each polymorphism (P = 0.018 and P = 0.031, respectively). Subjects with carotid plaque were significantly older and showed higher values in carotid IMT, uric acid and homocysteine than those without plaque (P < 0.01, respectively). In conclusion, the promoter region polymorphisms of IL-10 gene associate with carotid IMT and plaque. Further studies with larger samples are needed to provide stronger evidence to justify anti-atheromatous properties of IL-10.

A comparison of the BURP and conventional and modified jaw thrust manoeuvres for orotracheal intubation using the Clarus Video System

We evaluated the effects of three airway manipulation manoeuvres: (a) conventional (single-handed chin lift); (b) backward, upward and right-sided pressure (BURP) manoeuvre; and (c) modified jaw thrust manoeuvre (two-handed aided by an assistant) on laryngeal view and intubation time using the Clarus Video System in 215 patients undergoing general anaesthesia with orotracheal intubation. In the first part of this study, the laryngeal view was recorded as a modified Cormack-Lehane grade with each manoeuvre. In the second part, intubation was performed using the assigned airway manipulation. The primary outcome was the time to intubation, and the secondary outcomes were the modified Cormack-Lehane grade, the number of attempts and the overall success rate. There were significant differences in modified Cormack-Lehane grade between the three airway manipulations (p < 0.0001). Post-hoc analysis indicated that the modified jaw thrust improved the laryngeal view compared with the conventional (p < 0.0001) and the BURP manoeuvres (p < 0.0001). The BURP worsened the laryngeal view compared with the conventional manoeuvre (p = 0.0132). The time to intubation in the modified jaw thrust group was shorter than with the conventional manoeuvre (p = 0.0004) and the BURP group (p < 0.0001). We conclude that the modified jaw thrust is the most effective manoeuvre at improving the laryngeal view and shortening intubation time with the Clarus Video System.

The clinical characteristics of gastroesophageal reflux disease in patients with laryngeal symptoms who are referred to gastroenterology

The prevalence of gastroesophageal reflux disease (GERD) has increased recently in Asia-Pacific countries. However, little is known about its prevalence and clinical characteristics in GERD patients with atypical symptoms in Asia. The aim of this study was to investigate the clinical characteristics of GERD in patients who had laryngeal symptoms in Korea. Data were gathered retrospectively from patients who presented with atypical symptoms, such as throat discomfort, globus pharyngeus, hoarseness, and chronic cough. They underwent a 24-hour ambulatory intraesophageal pH monitoring and filled in a validated reflux questionnaire. Overall, 128 patients (36 men and 92 women) with laryngeal symptoms were included. Of these 128, 43 patients (34%) had erosive esophagitis or pathological reflux from 24-hour ambulatory pH monitoring, and 24 (19%) had a positive Bernstein test or positive symptom index from 24-hour pH monitoring. Sixty-one patients (48%) had no evidence of reflux esophagitis on upper endoscopy and pathological acid reflux on 24-hour pH monitoring. Fifty-six patients (44%) had weekly heartburn or regurgitation. Typical symptoms and dyspepsia were significantly more common in patients with GERD who had laryngeal symptoms than non-GERD. Fifty-two percent of patients had laryngeal symptoms that were associated with GERD. The presence of typical reflux symptoms and dyspepsia are risk factors for GERD in patients who present with laryngeal symptoms.

Biochemical analysis of Hyphantria cunea NPV attachment to Spodoptera frugiperda 21 cells

Binding characteristics of Hyphantria cunea nuclear polyhedrosis virus (HcNPV) to Spodoptera frugiperda 21 (Sf21) cells was determined. The cells displayed an affinity of 0.9 x 10(10) M(-1) with about 8900 binding sites per cell. The biochemical nature of HcNPV-binding sites on the cell surface was also partially elucidated. There were 45 to 49% reductions in HcNPV binding following the pretreatment of cells with three proteases, suggesting the involvement of a cellular protein component in virus binding. Tunicamycin, which inhibits N-linked glycosylation and the expression of some membrane proteins on the cell surface, reduced virus binding suggesting a role for glycoprotein(s) in binding. Treatment of cells with wheat germ agglutinin or neuraminidase did not measurably reduce virus binding, indicating that oligosaccharides containing N-acetylglucosamine or sialic acid are not directly involved in HcNPV attachment. The negative effect of methylamine on HcNPV binding seems to be due to the fact that HcNPV entry via an endocytic pathway is blocked by the increased pH of the endosome. Data on energy inhibitors (sodium azide and dinitrophenol) indicates that HcNPV attachment to Sf21 cells may be closely linked to viral entry via receptor-mediated endocytosis. These findings suggest that the binding site moiety has a glycoprotein component, but that direct involvement of oligosacccharides containing N-acetylglucosamine or sialic acid residues in binding is unlikely, and that HcNPV attachment to Sf21 cells might be via receptor-mediated endocytosis.

Which score system can best predict recipient outcomes after living donor liver transplantation?

INTRODUCTION

Many scoring systems have been suggested to predict the outcomes of deceased donor liver transplantations. The aims of this study were to compare the Model for End-Stage Liver Disease (MELD) score with respect to other scores among patients who underwent living donor liver transplantation (LDLT) seeking to evaluate the best system to correlate with postoperative outcomes after LDLT.

METHODS

We analyzed retrospectively data from 202 adult patients who underwent LDLT from January 2008 to July 2010. We calculated preoperative MELD, MELD-sodium, MELD to serum sodium ratio (MESO), integrated MELD, United Kingdom MELD, Child-Turcotte-Pugh, Acute Physiology and Chronic Health evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) scores in all patients. We analyzed the correlation of each score with postoperative laboratory results, as well as survival at 1, 3, 6 and 12 months after LDLT.

RESULTS

There was significant positive correlation between all scores and peak total bilirubin during the first 7 days after LDLT. The MELD score showed the greatest correlation with peak total bilirubin (r=0.745). APACHE II and SOFA scores at 6 months and 1 year after LDLT and MESO score at 1 year after LDLT showed acceptable discrimination performance {area under the receiver operating characteristic curves (AUC)>0.7, while other scoring systems showed poor discrimination. However, the AUCs of each score were not significantly different from the MELD score AUC.

CONCLUSION

The MELD score most correlated with total bilirubin after LDLT, while the APACHE II and SOFA scores seemed to correlate with mortality after LDLT.

Comparison of bolus transit patterns identified by esophageal impedance to barium esophagram in patients with dysphagia

Bolus transit through the esophagus has not been validated by videoesophagram in patients with dysphagia and changes in impedance with abnormal barium transit have not been described in those patients. The aim of this study was to compare esophageal impedance findings with barium esophagram measurements in patients with dysphagia. The consecutive patients with dysphagia underwent conventional multichannel esophageal impedance manometry, after which a barium videoesophagram was performed simultaneously with multichannel esophageal impedance manometry using a mean of three swallows of barium. Esophageal emptying patterns shown in the esophagogram were classified by the degree of intraesophageal stasis and presence of intraesophageal reflux. Bolus transit patterns in impedance were classified as complete and incomplete transit. Sixteen patients (M : F = 8 : 8, mean age, 47 years) were enrolled. Their manometric diagnosis were normal (n= 6), ineffective esophageal motility (n= 1), diffuse esophageal spasm (DES; n= 2), and achalasia (n= 7). Sixty-three swallows were analyzed. According to impedance analysis, 21/22 swallows with normal barium emptying showed complete transit (96%) and 31/32 swallows with severe stasis showed incomplete transit (97%). Nine swallows with mild stasis showed either complete or incomplete transit patterns in impedance. Swallows with mild barium stasis and complete transit in impedance were observed in patients who had received treatment (two patients with achalasia with history of esophageal balloonplasty and a patient with DES after nifedipine administration). Impedance reflected severe stasis with retrograde barium movement and described typical bolus transit patterns in patients with achalasia and DES. In conclusion, impedance-barium esophagram concordance is high for swallows with normal esophageal emptying and for severe barium stasis in patients with dysphagia.

The role of small intestinal bacterial overgrowth in postgastrectomy patients

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is expected in postgastrectomy patients; however, its role has not been clarified. This study was to estimate the prevalence of SIBO and investigate the clinical role of SIBO in postgastrectomy patients.

METHODS

This prospective study involved 76 patients who underwent gastrectomy for early gastric cancer with no evidence of recurrence. An H(2)-CH(4) breath test with oral glucose challenge test was performed to diagnose SIBO and dumping syndrome. Sigstad dumping questionnaires, serum glucose, hematocrit and pulse rate were simultaneously monitored for every 30 min for 3 hours.

KEY RESULTS

There were significant differences in SIBO between the postgastrectomy patients and controls (77.6%vs 6.7%, P < 0.01). Abdominal fullness or borborygmus during oral glucose load were more common in SIBO-positive than in negative patients (50.8%vs 17.6%, P = 0.03), and were the independent factors for predicting SIBO in postgastrectomy patients (P = 0.02). The prevalences of dumping syndrome and hypoglycemia after oral glucose were 35 (46.1%) and 19 (25.0%), and were not different between both groups. However, the plasma glucose was significantly lower in SIBO-positive than in SIBO-negative patients at 120 and 150 min after oral glucose load (P < 0.05). No significant differences were observed in pulse rate and hematocrit in both groups.

CONCLUSIONS & INFERENCES

SIBO is common among postgastrectomy patients. It appears to be associated with postprandial intestinal symptoms and might aggravate late hypoglycemia. SIBO could be a new therapeutic target for managing intestinal symptoms in postgastrectomy patients.

The role of small intestinal bacterial overgrowth in postgastrectomy patients

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is expected in postgastrectomy patients; however, its role has not been clarified. This study was to estimate the prevalence of SIBO and investigate the clinical role of SIBO in postgastrectomy patients.

METHODS

This prospective study involved 76 patients who underwent gastrectomy for early gastric cancer with no evidence of recurrence. An H(2)-CH(4) breath test with oral glucose challenge test was performed to diagnose SIBO and dumping syndrome. Sigstad dumping questionnaires, serum glucose, hematocrit and pulse rate were simultaneously monitored for every 30 min for 3 hours.

KEY RESULTS

There were significant differences in SIBO between the postgastrectomy patients and controls (77.6%vs 6.7%, P < 0.01). Abdominal fullness or borborygmus during oral glucose load were more common in SIBO-positive than in negative patients (50.8%vs 17.6%, P = 0.03), and were the independent factors for predicting SIBO in postgastrectomy patients (P = 0.02). The prevalences of dumping syndrome and hypoglycemia after oral glucose were 35 (46.1%) and 19 (25.0%), and were not different between both groups. However, the plasma glucose was significantly lower in SIBO-positive than in SIBO-negative patients at 120 and 150 min after oral glucose load (P < 0.05). No significant differences were observed in pulse rate and hematocrit in both groups.

CONCLUSIONS & INFERENCES

SIBO is common among postgastrectomy patients. It appears to be associated with postprandial intestinal symptoms and might aggravate late hypoglycemia. SIBO could be a new therapeutic target for managing intestinal symptoms in postgastrectomy patients.

Increased incidence of colorectal malignancies in renal transplant recipients: a case control study

This study was to evaluate the frequency of colorectal neoplasia in renal transplant recipients and to investigate the association with Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infection. We compared the frequency of colorectal neoplasia among renal transplant recipients with that of the healthy subjects. Specimens of colorectal neoplasia were examined for EBV and CMV using in situ hybridization and immunohistochemistry, respectively. Of 796 renal transplantation cohorts, 315 were enrolled. The frequency of colorectal neoplasia among the patients was 22.9%. Compared with the healthy subjects, the odds ratio (OR) for advanced adenoma was 3.32 (95% CI, 1.81-6.10). The frequency of cancer among the patients was 1.9% (OR, 12.0; 95% CI, 1.45-99.7). A long interval between transplantation and colonoscopy was a significant factor in the development of advanced colorectal neoplasia. EBV positivity was detected in 30.6% of colorectal neoplasia specimens from renal transplant recipients, which was higher than that for the controls (p = 0.002). CMV was not detected in any lesions of patients or controls. In conclusion, renal transplant recipients have a significantly increased risk of advanced colorectal neoplasia. EBV was more frequently found in specimens of advanced colorectal neoplasm obtained from the renal transplant recipients.

Ethanol fermentation of crude acid hydrolyzate of cellulose using high-level yeast inocula

High-level yeast inocula was investigated as a means of overcoming the toxicity problem in ethanol fermentation of acid hydrolyzate of wood cellulose. When the inoculum level exceeded 10(8) initial cells/mL, 50% of the yeast cells survived the initial cell death period during which furfural and HMF were depleted. The fermentation thus proceeded to completion by virtue of cell regrowth. The specific ethanol productivity in batch fermentation on the basis of viable cells was comparable to that of pure glucose fermentation. Continuous fermentation with cell recycle was superior to batch fermentation in that there was no overall cell decline and the ethanol yield was substantially higher. The maximum ethanol productivity in continuous fermentation was 4.9 g/L h and it occurred at a dilution rate of 0.24 hr(-1).

The prevalence of and risk factors for erosive oesophagitis and non-erosive reflux disease: a nationwide multicentre prospective study in Korea

BACKGROUND

Prospective nationwide multicentre studies that have evaluated endoscopic findings and reflux symptoms using a well-designed questionnaire are very rare.

AIM

To compare the prevalence rates of and risk factors for erosive oesophagitis and non-erosive reflux disease (NERD) in the Korean population.

METHODS

A gastroscopic examination was performed on 25 536 subjects who visited 40 Healthcare Centers for a health check-up. A gastro-oesophageal reflux questionnaire and multivariate analysis were used to determine the risk factors for erosive oesophagitis and NERD.

RESULTS

2019 (8%) and 996 subjects (4%) had erosive oesophagitis and non-erosive reflux disease, respectively; only 58% of subjects with erosive oesophagitis had reflux symptoms. Multivariate analysis showed that the risk factors for erosive oesophagitis and NERD differed, i.e. those of erosive oesophagitis were male, a Helicobacter pylori eradication history, alcohol, body mass index > or =25 and hiatal hernia. In contrast, the risk factors for NERD were female, age <40 and > or =60 vs. 40-59 years, body mass index <23 and a monthly income <$1000, glucose > or =126 mg/dL, smoking, a stooping posture at work and antibiotic usage.

CONCLUSIONS

The prevalence rates of erosive oesophagitis and NERD were 8% and 4%, respectively, in Korean health check-up subjects. The risk factors for erosive oesophagitis and NERD were found to differ, which indicates that their underlying pathogeneses are distinct.

Successful endoscopic hemoclipping of an esophageal perforation

We describe a case of esophageal perforation that resulted from a fishbone. A 71-year-old man had had a fishbone impacted in the lower esophagus for 2 days. At presentation, the bone was dislodged at endoscopy; one round opening in a deep ulceration was detected when the fishbone was removed. The perforation was closed by endoscopic hemoclipping, after the removal of the fishbone. A thoracic computed tomography revealed air around the esophagus, aorta and bronchus and the presence of a pleural effusion. These findings suggested mediastinal emphysema and mediastinitis due to the esophageal perforation after the removal of the fishbone. Esophagography revealed a focal esophageal defect and linear contrast leakage at the distal esophagus. The mediastinal emphysema and pleural effusion successfully resolved after the endoscopic hemoclip application and conservative management of the perforation.

Serotonin transporter gene polymorphism and irritable bowel syndrome

Polymorphisms in the promoter region of the serotonin reuptake transporter (SERT) gene may underlie the disturbance in gut function in patients with irritable bowel syndrome (IBS). Association studies of SERT polymorphisms and IBS have shown diverse results among different countries, which might be due to racial and subject composition differences. The aim of this study was to assess the potential association between SERT polymorphisms and IBS in Koreans. A total of 190 IBS patients, who met the Rome II criteria, and 437 healthy controls were subjected to genotyping. SERT polymorphisms differed in the IBS and control groups (P = 0.014). The SERT deletion/deletion genotype occurred with greater frequency in the diarrhoea-predominant IBS group than in the controls. A strong genotypic association was observed between the SERT deletion/deletion genotype and diarrhoea-predominant IBS (P = 0.012). None of the clinical symptoms analysed was significantly associated with the SERT genotypes. The frequency of the SERT insertion/insertion genotype was much lower than that of the other two genotypes. A significant association was observed between the SERT polymorphism and IBS, especially diarrhoea-predominant IBS, suggesting that the SERT gene is a potential candidate gene involved in IBS in Korea.

Endoscopic hemoclipping using a transparent cap in technically difficult cases

BACKGROUND AND STUDY AIMS

Technical difficulties have been experienced in endoscopic hemoclipping on the posterior wall of the body of the stomach because the angle of approach is tangential. It has been suggested that the use of a transparent cap on the tip of the endoscope could help to solve this problem. The purpose of this study was to examine the efficacy of endoscopic hemoclipping using a transparent cap over the tip of the endoscope.

PATIENTS AND METHODS

A total of 74 patients with a bleeding peptic ulcer or stigmata of recent hemorrhage underwent endoscopic hemoclipping. Technical difficulty in hemoclipping was experienced in 18 patients and the transparent cap was used in these cases. We therefore conducted a nonrandomized prospective study to compare bleeding control with the hemoclip with and without the aid of a transparent cap.

RESULTS

There were no statistically significant differences between the patients treated with the cap and those treated without the cap with regard to the initial hemostasis rate (94.4 % vs. 91.1 %), the rebleeding rate (11.7 % vs. 11.8 %), or the permanent hemostasis rate (94.4 % vs. 96.4 %).

CONCLUSIONS

Although there was no statistically significant difference between patients treated with or without a transparent cap, hemoclipping with the aid of the cap made it possible to clip a lesion too tangential to be clipped without it. However, this study did not compare conventional hemoclipping with hemoclipping using a cap because the cap was only used in cases in which conventional clipping had failed.

Two cases of steakhouse syndrome associated with nutcracker esophagus

The most common type of esophageal food-related foreign body is the meat bolus, which is frequently associated with underlying esophageal stenosis. Herein, we report two cases of meat bolus impaction associated with nutcracker esophagus. In the first case, the 63-year-old male patient had chest discomfort and swallowing difficulty after ingestion of butcher's meat. In the second case, the 55-year-old male patient had complained of swallowing difficulty after ingestion of chicken. In both cases, no pathologic findings were observed endoscopically after removal of the esophageal meat bolus. We performed esophageal manometry, which showed very high amplitudes of esophageal pressure in the mid- and distal esophagus. These findings were consistent with nutcracker esophagus. These cases show that esophageal motility disorder may be the cause of esophageal foreign body impaction, and esophageal manometry should be performed for evaluation of the cause of foreign body, especially in an endoscopically normal patient.

Risk factors for epistaxis during nasotracheal intubation

We performed a study to confirm which risk factors are significantly associated with epistaxis during nasotracheal intubation. One hundred patients who underwent nasotracheal intubation were included. Risk factors for epistaxis were analysed using the multiple logistic regression analysis with stepwise variable selection method. Epistaxis was most likely to occur if transit of the tube through the nasal passage was difficult (P=0.0001, odds ratio 625, 95% confidence interval 3.14-14.26). On the other hand, age and gender, obesity, smoking, tube size, repeated attempts of intubation, and intubation performed with the aid of Magillforceps were not significantly related with risk of epistaxis. The presence of nasal anatomical abnormalities also did not correlate significantly with epistaxis. Strategies to ensure smooth transit of the tube through the nasal passageways are essential to reduce the incidence of epistaxis.

Effect of rebamipide in treatment of Helicobacter pylori-associated duodenal ulcer: attenuation of chemokine expression and nitrosative damage

Production of cytokines along with increased activity of nitric oxide synthase has been implicated as one of the contributing mechanisms of Helicobacter pylori-mediated gastroduodenal diseases. We aimed to evaluate the effect of rebamipide in treating Helicobacter pylori-associated duodenal ulcers in terms of cytokine production and nitrosative damage of the gastric mucosa. In patients with duodenal ulcers, rebamipide or placebo were given randomly after eradication. Mucosal cytokine production was measured by enzyme linked immunoassay, and nitrotyrosine immunoexpression was measured by immunohistochemistry. The inflammatory activity and degree of neutrophil infiltration were graded accordingly. The mucosal production of RANTES, interleukin-8, and TNF-alpha showed a significant decrease after eradication in patients with rebamipide after-treatment. The nitrotyrosine immunoreactivity of gastric epithelium was significantly decreased in the rebamipide group. Rebamipide treatment after eradication resulted in a significant reduction in chemokine production along with nitrotyrosine immunoexpression in Helicobacter pylori-associated duodenal ulcers.

Efficacy of low-dose clarithromycin triple therapy and tinidazole-containing triple therapy for Helicobacter pylori eradication

BACKGROUND

Proton pump inhibitor-based triple therapies are recommended as the first-line treatment for Helicobacter pylori eradication.

AIM

To evaluate the efficacies of low-dose clarithromycin triple therapy and tinidazole-containing triple therapy in a metronidazole resistance prevalent area and to compare the efficacies with standard triple therapy.

METHODS

In a randomized, multicentre, prospective study, a total of 352 patients with duodenal ulcer or non-ulcer dyspepsia were randomly divided into three groups according to the administered regimen: OAC250 group (omeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 250 mg), OAC500 group (omeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg) and OTC group (omeprazole, 20 mg, tinidazole, 500 mg, and clarithromycin, 500 mg). The three groups received each regimen twice daily for 7 days. Upper gastrointestinal endoscopy was performed before and 4 weeks after treatment. H. pylori status was determined by rapid urease test and 13C urea breath test.

RESULTS

The eradication rates in the OAC250, OAC500 and OTC groups were 76.2%, 65.7% and 64.8% (95% confidence interval: 67.9-84.4%, 56.7-74.8% and 55.7-73.9%), respectively, by intention-to-treat analysis (P=0.149) and 92.8%, 87.2% and 84.1% (95% confidence interval: 84.4-97.3%, 77.9-93.8% and 73.9-91.2%), respectively, by per protocol analysis (P=0.088). All regimens were well tolerated and compliance was excellent.

CONCLUSIONS

Both low-dose clarithromycin triple therapy and tinidazole-containing triple therapy are effective and safe regimens for H. pylori eradication.

The flow rate of the elastomeric balloon infusor is influenced by the internal pressure of the infusor

The purpose of this study was to evaluate the flow rate of elastomeric balloon infusor composed of rubber or silicone materials. Two models were studied: the Baxter Twoday Infusor and Advance Silicone Infusor. Each infusion device has a preset flow rate of 2 mL/hr. Fifteen units of each device were filled with 100 mL of normal saline. The flow rate was measured gravimetically using an electronic balance. The internal pressure of the balloon infusor was measured with a Digital pressure meter via the pressure transducer. The monitored internal pressure of the two kinds of infusor was not maintained uniformly during the entire delivery period, which was divided into 3 phases: the phase of decreasing, maintained, and increasing pressure during the delivery of drug. Both devices initially infused at a relatively high rate, followed by a somewhat steady flow rate. The flow rate distinctly increased in the small residual volume. The flow rate of the balloon infusor used in this study was not sustained uniformly during the entire delivery period and was in proportion to the internal pressure of the infusor regardless of the materials.

Nurses' assessment of postoperative pain: can it be an alternative to patients' self-reports?

This study was designed to evaluate whether the nurses' assessment of postoperative pain can be an alternative to patients' self-reporting. We examined 187 patients receiving postoperative intravenous patient-controlled analgesia. The nurses assessed the patients' pain with three pain indices (therapeutic efficacy, pain intensity, and facial pain expression) 8 hr after operation. The patients recorded their resting and movement pain using 100-mm visual analog scales immediately following the nurses' assessment. There was an acceptable correlation between overall pain measurement assessed by patients and that assessed by nurses (canonical correlation coefficient=0.72, p=0.0001). The resting pain was more reliably reflected than the movement pain in overall measurement assessed both by nurses and by patients. Among the three pain indices assessed by nurses, the pain intensity most reliably reflected the patients' self-reports. The pain intensity assessed with a simple verbal descriptor scale therefore is believed to be an effective alternative to the patients' self-reports of postoperative pain at rest. However, it mirrored the patients' self-reports during movement less reliably. Therapeutic efficacy and facial pain expression indices were not effective alternatives to patients' self-reporting.

Seroepidemiological study of Helicobacter pylori infection in asymptomatic people in South Korea

BACKGROUND

Helicobacter pylori infection occurs throughout the world and causes gastroduodenal diseases in all age groups. The prevalence of H. pylori infection varies between countries and races. The aim of this study was to evaluate the seroprevalence of H. pylori infection in asymptomatic healthy people in South Korea.

METHODS

From March 1998 to October 1998, 5732 asymptomatic subjects who responded to the self-assessment questionnaires from 54 hospitals in South Korea were enrolled in this study. The serum levels of antibodies for H. pylori immunoglobulinG were measured by using an ELISA test.

RESULTS

The overall seroprevalence of H. pylori infection was 46.6% and there was no statistical difference between males (47.2%) and females (45.9%). In adults, a significant difference was observed between genders. According to the geographic areas, the high prevalent provinces were Kangwon (53.4%), Cheju (52.9%) and Cholla province (50.6%); Seoul (41.9%) was the lowest prevalent area. The seroprevalence increased with age and was highest when patients were aged in their 40s (78.5%). The characteristic feature of our study was that the infection rate was steeply increased in three age groups (10-12 year olds, 16-19 year olds and those aged in their 20s). In Seoul, there was no difference in the prevalence rate among the districts studied.

CONCLUSIONS

This nation-wide seroprevalence of H. pylori infection in South Korea was 46.6%, which showed the transition from a developing country to a developed country. More studies on the epidemiological factors and the route of transmission of H. pylori infection should be warranted.

Successful treatment of massive lower gastrointestinal bleeding caused by mixed infection of cytomegalovirus and mucormycosis in a renal transplant recipient

We describe a case of lower gastrointestinal bleeding due to mixed infection of cytomegalovirus (CMV) and mucormycosis in a renal transplant recipient. A 33-year-old male received renal transplantation and his clinical course was uneventful. On the 18th postoperative day, acute rejection was developed and this was treated with high-dose methylprednisolone and OKT3. During antirejection treatment, sudden onset massive hematochezia was developed. Emergency colonofibroscopy revealed multiple colonic ulcers and pathologic findings were consistent with mucormycosis and CMV infection. The patient was successfully treated with amphotericin B (1.0-1.5 mg/kg) and ganciclovir (62.5-125 mg/day) for 5 weeks. To our knowledge, this is the first report showing coexistence of mucormycosis and CMV in the colon ulcer base. This finding suggests that CMV infection may trigger fungal infection in the pathogenesis of colonic ulcer.

Optimal production and in vitro activity of recombinant endostatin from stably transformed Drosophila melanogaster S2 cells

Recombinant plasmids containing a complementary deoxyribonucleic acid coding mouse endostatin were transfected and stably expressed in Drosophila melanogaster Schneider 2 (S2) cells. Stably transformed polyclonal cell populations expressing recombinant endostatin were isolated after 4 wk of selection with hygromycin B. Recombinant endostatin expressed in the stably transformed S2 cells under the influence of the Drosophila BiP protein signal sequence was secreted into the medium. Recombinant endostatin was also purified to homogeneity using a simple one-step Ni2+ affinity fractionation method. Purified recombinant endostatin inhibited endothelial cell proliferation in a dose-dependent manner. The concentration at maximum inhibition for recombinant endostatin was approximately 1.8 microg/ml. The stably transformed S2 cells produced 18 mg recombinant endostatin/L 7 d after induction with 5 microM CdCl2. Sodium butyrate supplementation (2.5 mM) increased recombinant endostatin production by 17%. These findings demonstrate optimal production and in vitro activity of recombinant endostatin from stably transformed D. melanogaster S2 cells.

The clinical significance of upper gastrointestinal endoscopy in gastrointestinal vasculitis related to scrub typhus

BACKGROUND AND STUDY AIMS

Scrub typhus is an acute febrile illness caused by Rickettsia tsutsugamushi-induced vasculitis, which is common in Asia and the Pacific islands and is sometimes encountered in Western countries because of increased travel and economic changes spurred by world globalization. Skin rash and eschar are typical physical findings on the trunk and extremities, but endoscopic mucosal changes have not been described in the gastrointestinal tract until now. We aimed to describe different endoscopic characteristics of the gastrointestinal manifestation of scrub typhus, to ascertain the necessity for endoscopy, and to determine correlations between the degrees of endoscopic lesion and clinical severity, including cutaneous manifestation.

PATIENTS AND METHODS

Between January 1993 and October 1998, out of 256 scrub typhus patients, we applied esophagogastroduodenoscopy to 58 patients who complained of gastrointestinal symptoms but had no past history of these symptoms. We categorized clinical severity into four grades according to the degree of six clinical indicators of systemic complications, and endoscopic findings were graded from I to IV (I, normal, nonspecific hyperemia; II, distinct hyperemia, petechiae, purpura; II, superficial hemorrhage, erosion; IV, ulcer, active bleeding).

RESULTS

Endoscopic findings of scrub typhus were characterized by petechiae, superficial hemorrhage, erosion, ulcers, and vascular bleeding (grade I, 14 patients; grade II, 11 patients; grade III, 16 patients; grade IV, 17 patients). In 83.3% of patients there was multiple occurrence of lesions without any predilection sites. Clinical severity was graded (grade I, 7 patients; grade II, 23 patients; grade III, 22 patients; grade IV, 6 patients). There was a correlation between clinical severity and endoscopic findings (P < 0.01). The grade of lesion was high in patients with cutaneous lesions (r(s) 0.359, P < 0.01). In two cases of gastric vascular bleeding, complete hemostasis was achieved by endoscopic hemoclipping.

CONCLUSIONS

The major endoscopic features that can develop in scrub typhus are superficial mucosal hemorrhage, multiple erosions and ulcers without any predilection sites, and unusual vascular bleeding. The endoscopic features are related to cutaneous lesions and severity of the disease. Endoscopy is useful for diagnosis and management of gastrointestinal vasculitis related to scrub typhus.

Insulin reverses bupivacaine-induced cardiac depression in dogs

We tested the hypothesis that an insulin infusion would effectively treat bupivacaine-induced cardiac depression in dogs. In 24 mongrel dogs anesthetized with pentobarbital (5 mgkg(-1)h(-1), IV), 0.5% bupivacaine was administrated at a rate of 0.5 mgkg(-1)min(-1) until the mixed venous oxygen saturation decreased to 60% or less. The bupivacaine infusion induced a decrease in mean arterial pressure, cardiac output, and heart rate. The dogs were randomly assigned to one of four groups after the end of bupivacaine infusion. The Control (C, n = 6) and Glucose (G, n = 6) groups received an IV infusion of normal saline (2 mL/kg) and glucose (2 mL/kg of 50% dextrose in water) for 15 min, respectively. The Insulin-Glucose (IG, n = 6) group received an IV bolus of regular insulin (1 U/kg), plus a glucose infusion (2 mL/kg of 50% dextrose in water) for 15 min. The Insulin-Glucose-Potassium (IGK, n = 6) group received the same dose of insulin and glucose as the IG group, plus potassium (1-3 mEqkg(-1)h(-1)). Mean arterial pressure, cardiac output, heart rate, and mixed venous oxygen saturation recovered toward baseline level more rapidly in the IG and IGK groups than in the C group (within 5 min versus more than 20 min). These results suggest that the infusion of insulin and glucose might reverse bupivacaine-induced cardiac depression in dogs.

IMPLICATIONS

We found that insulin and glucose rapidly reversed hemodynamic abnormality in dogs with bupivacaine-induced cardiac depression. This study implies a possible clinical application of insulin treatment for bupivacaine-induced cardiac depression.

Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery

BACKGROUND AND OBJECTIVES

Epidural injection has been known to enhance spinal anesthesia in combined spinal and epidural (CSE) anesthesia. Saline and local anesthetics have been reported to have a volume effect, elevating sensory level when supplementing a volume into the epidural space. We evaluated the effects of epidural injection when using the CSE technique for cesarean delivery.

METHODS

Sixty-six parturients were allocated randomly into group C (control, n = 21), S (saline, n = 21), or B (bupivacaine, n = 24): epidural injections of 10 mL saline and 0.25% bupivacaine were given in groups S and B, respectively, 10 minutes after they received 8 mg of 0.5% hyperbaric bupivacaine intrathecally, and no injection was given in group C. The sensory level at 10 minutes, the maximal level and the time to reach it, and degree of motor block and muscle relaxation were compared. We also investigated intraoperative side effects and postoperative findings in the postanesthesia care unit.

RESULTS

Epidural injection raised the sensory level significantly in groups S and B, but the maximal height of sensory block and degree of muscle relaxation did not differ among the groups. Fewer patients complained of intraoperative pain in group B than in the other groups (P <.001).

CONCLUSIONS

We could not achieve satisfactory surgical analgesia with 8 mg of hyperbaric bupivacaine injected into the subarachnoid space using the needle-through-needle technique in cesarean deliveries. An epidural saline injection elevated the sensory level, which did not improve the spinal block, whereas an epidural injection of 10 mL of 0.25% bupivacaine enhanced the spinal block and sustained the block postoperatively.

Development of the lip and palate in staged human embryos and early fetuses

Cleft lip and palate are the most common congenital malformations in humans. Using 43 staged human embryos and early fetuses ranging from the 4th to 12th week of development, we investigated the development of the lip and palate in order to provide the basic developmental concepts required for managing these anomalies. The lower lip appeared as bilateral mandibular arches at Carnegie stage 11, and these were completely merged at stage 15. The components of the upper lip, medial nasal prominence and maxillary process, appeared at stage 16, and completely merged at stage 20. The median palatine process appeared at stage 16, and the lateral palatine process, at stage 17. The palatine processes and the nasal septum started to fuse abruptly at stage 23, and from external observation seemed to be fused at the 9th week. However, complete fusion did not take place until the 12th week of development. The tongue was prominent at stage 16, showed differentiation of the muscular tissue at stage 21, and was located superior to the lateral palatine process before stage 23. These results may be used in understanding the different mechanisms present in the formation of various congenital anomalies in this region.

Comparison of combined spinal epidural anesthesia and epidural anesthesia for cesarean section

BACKGROUND

Epidural anesthesia (EA) is popular for cesarean section, but has some drawbacks such as incomplete block, inadequate muscle relaxation and delayed onset. Combined spinal epidural anesthesia (CSEA) has gained increasing interest as it combines the reliability of a spinal block and the flexibility of an epidural block. We investigated the efficacy of CSEA that combines the main spinal and the supporting epidural anesthesia, comparing with pH-adjusted EA, for cesarean section.

METHODS

Sixty-four pregnant women at full term were divided into two groups. Patients in the CSEA group (n=32) were given 1.5-1.6 ml of 0.5% hyperbaric bupivacaine intrathecally, followed by 10 ml of 0.25% plain bupivacaine through the epidural catheter 10 min later. Patients in the EA group (n=32) received 20-25 ml of 2% lidocaine which was already mixed with 0.1 ml of 0.1% epinephrine, 100 g of fentanyl and 1.5 ml of 8.4% sodium bicarbonate. The quality and side effects of surgical anesthesia, neonatal state, and postoperative course were compared between the two groups.

RESULTS

In the EA group, 22% (7 cases) complained of intraoperative pain but none in the CSEA group (P=0.011). Muscle relaxation and motor block were much better in the CSEA group (P<0.001 and P=0.011 each). Significantly more women in the EA group had shivering (P=0.001). They also had more nausea and vomiting but the differences were not significant. Not only the time to T4 block (9.7 vs. 18.3 min, mean, P<0.001) but also the stay in the postanesthesia care unit, recovery of sensory and motor block and start of postoperative pain were all significantly shorter in the CSEA group. No one in either group had postdural puncture headache (PDPH).

CONCLUSION

We can conclude that, when combining the main spinal and the supporting epidural anesthesia, CSEA has greater efficacy and fewer side effects than the pH-adjusted EA in cesarean sections.

Management of foreign bodies in the gastrointestinal tract: an analysis of 104 cases in children

BACKGROUND AND STUDY AIMS

Ingested foreign bodies may be managed by endoscopy, observation, or surgery. The aim of the study was to investigate the methods of removal of foreign bodies according to type and location, success rates, and complications.

PATIENTS AND METHODS

The charts of 104 children who had ingested foreign bodies were retrospectively reviewed.

RESULTS

Of the patients, 80 (76.9%) were managed endoscopically. The overall success rate for endoscopic management was 98.8%. There were no complications during endoscopic interventions. In 23 cases the foreign bodies spontaneously passed through the gastrointestinal tract (22.1%). Surgical removal of a foreign body was done in only one case (0.96%). The majority of the foreign bodies which were located in the upper gastrointestinal tract could be removed endoscopically regardless of the nature of the material. Foreign bodies in the small and large intestine tended to pass through spontaneously without complications.

CONCLUSIONS

It appears that the endoscopic approach is the preferable method for the extraction of upper gastrointestinal foreign bodies in child patients because of its high success rate, and that foreign bodies in the small and large intestine tend to be passed spontaneously without complications.

Clinical validation of the Helikit: a 13C urea breath test used for the diagnosis of Helicobacter pylori infection

OBJECTIVE

To assess the clinical performance of the Helikit, a 13C urea breath test, in the diagnosis of Helicobacter pylori infection.

METHODS

A total of 205 participants were assessed in Canada and Korea for H. pylori infection status by endoscopy, or a combination of IgG ELISA and CLO test, as well as by the Helikit. The Helikit contains 75 mg of 13C urea as well as citric acid, flavor enhancers and stabilizers in a single plastic cup. The powder is dissolved in 75 mL of water for oral administration. No extra mixing or dilution steps are required.

RESULTS

Using the biopsy-derived data as the gold standard the Helikit displayed a clinical sensitivity of 93.5% (95% confidence interval 88.5 to 98.5%) and a clinical specificity of 97.3% (94.3 to 100%). An overall diagnostic efficiency of 95.6% (92.8 to 98.4%) was obtained. No statistically significant difference in the performance characteristics was found between Korea and Canada. No significant adverse events were noted.

CONCLUSIONS

The Helikit offers an easy, safe and accurate approach to the diagnosis of H. pylori infection.

Concentrating Autographa californica nuclear polyhedrosis virus and recombinant alkaline phosphatase from insect cells using a temperature-sensitive hydrogel

Recombinant alkaline phosphatase expressed in insect cells was concentrated by a factor of one and half times at a separation efficiency of 54.2% using hydrogel ultrafiltration. Enzyme concentration was confirmed by SDS-PAGE as well as by spectrophotometric measurement. Wild and recombinant Autographa californica nuclear polyhedrosis viruses (AcNPV) were concentrated 1.4 and 1.6 times of the feed solution at 48.5 and 60.0% separation efficiency, respectively. Hydrogel ultrafiltration appears to be an attractive alternative for the concentration of AcNPV and recombinant proteins from insect cells.

Activation of multiple effector pathways of immune system by the antineoplastic immunostimulator acidic polysaccharide ginsan isolated from Panax ginseng

In the present study an acidic polysaccharide ginsan, with a molecular weight of 150,000, devoid of lectin properties, was purified from Panax ginseng C.A. Meyer (Araliaceae). Ginsan induced the proliferation of T cells and B cells. Spleen cells became cytotoxic to a wide range of tumor cells without major histocompatibility complex-restriction after 4 or 5 days culture in vitro with ginsan. For the generation of these ginsan-activated killer (AK) cells adherent macrophages and CD4+ cells were needed as accessory cells. The generation of ginsan-AK cells was blocked in the presence of anti-IL-2, anti-IFN gamma, anti-IL-1 or anti-TNF alpha antibodies, showing the importance of these cytokines in the process. The surface phenotypes of the 4 day-cultured ginsan-AK cells was Thy1+, AsGM1+, CD8+, which is distinct from rIL-2 induced lymphokine activated killer (LAK) cells that were CD8. The ginsan also activated macrophages to produce reactive nitrogen intermediates and become tumoricidal. It also exhibited significant in vivo antitumor activity against B16 melanoma cells lines, and in the benzo(a)pyrene-induced autochthonous lung tumor model, at much lower doses than the maximum tolerate doses. Indeed, no mice died, which injected with ginsan at 1g/kg body weight intraperitoneally. In conclusion, 'ginsan' could potentially be an ideal nontoxic antineoplastic immunostimulator by activating multiple effector arms of the immune system.

[Effects on hemolysis of the manually operated portable cardiopulmonary bypass system]

We studied the effects on hemolysis of our manually operated, portable cardiopulmonary bypass system with two self-inflatable reservoir-pumps in parallel by using bovine blood. The blood shed from both the jugular vein and the carotid artery, immediately after slaughter, was divided into three plastic containers, one for the control, one for manual circulation, and the other for conventional circulation with a roller-pump. Small bore catheters were intentionally placed into the inflow and outflow routes of both circulation systems to simulate clinical situations. Free hemoglobin and potassium in plasma were measured every 30 min during the experimental circulation for 120 min. The free hemoglobin in plasma increased gradually under manual circulation, but this increase was statistically insignificant when compared with the variances of those in the conventional circulation and the control blood groups. The values of the potassium in the plasma showed no differences among the three blood groups. Our manually operated, portable cardiopulmonary bypass system will be a valuable adjunct for emergency medicine.

Production of human alkaline phosphatase, a secreted, glycosylated protein, from a baculovirus expression system and the attachment-dependent cell line Trichoplusia ni BTI-Tn 5B1-4 using a split-flow, air-lift bioreactor

A split-flow, air-lift bioreactor for the cultivation of insect cells to produce recombinant protein is described. It can be used advantageously with attached cell systems. This bioreactor incorporates two sections: a rise and a downcomer. Trichoplusia ni BTI-Tn 5B1-4 cells are grown on a support material of glass beads or microcarriers placed in the downcomer. This cell line is more productive than other commonly used insect cell lines, but it has the disadvantage of being difficult to use at large volumes since it is not easily adaptable to suspension culture. Adequate oxygen demand is supplied by sparging without direct exposure of cells to air bubbles. Nutrients are supplied convectively to the attached cells on support material as the fluid flows through the downcomer. The split-flow, air-lift bioreactor appears to be suitable for insect cell culture and is potentially scalable. It can provide a high surface-to-volume ratio and can be operated in batch or continuous mode. A lab-scale prototype bioreactor has been constructed and tested for the production of a secreted, glycosylated recombinant protein (human alkaline phosphatase) or seAP using an Autographa californica multiple nuclear polyhedrosis virus (AcMNPV) vector. With a ratio of riser cross-sectional area to downcomer cross-sectional area of 1, an aspect ratio of 4.4, an air-flow rate of 54 mL/min in the riser, and a bed of 2400 3-min nonporous glass beads, 10.7 micrograms/mL of seAP was produced using an MOI (multiplicity of infection or the ratio of plaque-forming units to cells) of 10.(ABSTRACT TRUNCATED AT 250 WORDS)

Degenerative changes after meniscectomy and meniscal regeneration

In an experimental study on rabbit knees, regeneration of the medial meniscus occurred following 9 out of 10 meniscectomies, compared with only 1 out of 10 lateral menisci. Degenerative changes in the articular cartilage were seen in 8 of 9 knees where the lateral cartilage failed to regenerate, but in only 2 of 9 with a regenerated medial cartilage. The rate of regeneration is lower after lateral meniscectomy and this may partially explain the occurrence of more severe degenerative changes after this operation.