Incidence of oral anticoagulant interruption among stroke patients with atrial fibrillation and subsequent stroke

BACKGROUND AND PURPOSE

We analyzed the incidence and causes of oral anticoagulant (OAC) cessation and subsequent stroke after OAC withdrawal in a cohort of Korean stroke patients with atrial fibrillation.

METHODS

The Korean Atrial Fibrillation Evaluation Registry in Ischemic Stroke patients (K-ATTENTION) is a multicenter cohort study, merging stroke registries from 11 tertiary centers in Korea. The number of OAC interruption episodes and the reasons were reviewed from hospital records. Stroke after OAC withdrawal was defined when a patient experienced ischaemic stroke within 31 days after OAC withdrawal. Clinical variables were compared between patients who experienced stroke recurrence during OAC interruption and those who did not experience recurrence.

RESULTS

Among 3213 stroke patients with atrial fibrillation, a total of 329 episodes of OAC interruption were detected in 229 patients after index stroke (mean age 72.9 ± 8.3 years, 113 female patients). The most frequent reason for OAC withdrawal was poor compliance [103 episodes (31.3%)] followed by extracranial bleeding [96 episodes (29.2%)]. Stroke after OAC withdrawal was noted in 13 patients. Mean age, vascular risk factor profile and mean CHA₂ DS₂ -VASc score were not significantly different between patients with and without recurrent stroke.

CONCLUSIONS

A considerable number of stroke patients with atrial fibrillation experienced temporary interruption of OAC after index stroke, which was associated with stroke recurrence of 4.0 cases per 100 interruption episodes.

Magnitude of Mycobacterium tuberculosis transmission among household and non-household contacts of TB patients

<sec id="st1"> <title>SETTING</title> The household and non-household contacts of patients with tuberculosis (TB) face varying degrees of risk of infection by Mycobacterium tuberculosis. </sec> <sec id="st2"> <title>OBJECTIVE</title> To quantify new infection and to determine the risk factors associated with new infection among named contacts in San Francisco, CA, USA. </sec> <sec id="st3"> <title>DESIGN</title> We performed a cohort study in patients with culture-positive pulmonary TB. We analyzed patient, contact, environmental and bacterial characteristics. </sec> <sec id="st4"> <title>RESULTS</title> Of the 2422 contacts named by 256 patients, 149 (6.2%) had new infection due to recent transmission from 79 (30.9%) patients. Of the 149 new infections, 87 (58.4%) occurred among household contacts and 62 (41.6%) among non-household contacts. Numerous acid-fast bacilli in sputum (odds ratio [OR] 2.64, 95%CI 1.32-5.25) and contacts being named by more than one patient (OR 2.90, 95%CI 1.23-6.85) were associated with new infection among household contacts. Being older than 50 years (OR 1.93, 95%CI 1.09-3.41) and an Asian/Pacific Islander (OR 3.09, 95%CI 1.50-6.37) were associated with new infection among non-household contacts. </sec> <sec id="st5"> <title>CONCLUSIONS</title> Fewer than one third of patients caused new infection to his/her contacts. A substantial proportion of transmission resulting in new infection occurred outside of the household. The risk factors for infection among household and non-household contacts are different and should be considered when prioritizing control interventions. </sec>.

Association between time to treatment and functional outcomes according to the Diffusion-Weighted Imaging Alberta Stroke Program Early Computed Tomography Score in endovascular stroke therapy

BACKGROUND AND PURPOSE

The rate at which the chance of a good outcome of endovascular stroke therapy (EVT) decays with time when eligible patients are selected by baseline diffusion-weighted magnetic resonance imaging (DWI-MRI) and whether ischaemic core size affects this rate remain to be investigated.

METHODS

This study analyses a prospective multicentre registry of stroke patients treated with EVT based on pretreatment DWI-MRI that was categorized into three groups: small [Diffusion-Weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS)] (8-10), moderate (5-7) and large (<5) cores. The main outcome was a good outcome at 90 days (modified Rankin Scale 0-2). The interaction between onset-to-groin puncture time (OTP) and DWI-ASPECTS categories regarding functional outcomes was investigated.

RESULTS

Ultimately, 985 patients (age 69 ± 11 years; male 55%) were analysed. Potential interaction effects between the DWI-ASPECTS categories and OTP on a good outcome at 90 days were observed (P_interaction  = 0.06). Every 60-min delay in OTP was associated with a 16% reduced likelihood of a good outcome at 90 days amongst patients with large cores, although no associations were observed amongst patients with small to moderate cores. Interestingly, the adjusted rates of a good outcome at 90 days steeply declined between 65 and 213 min of OTP and then remained smooth throughout 24 h of OTP (P_nonlinearity  = 0.15).

CONCLUSIONS

Our study showed that the probability of a good outcome after EVT nonlinearly decreased, with a steeper decline at earlier OTP than at later OTP. Discrepant effects of OTP on functional outcomes by baseline DWI-ASPECTS categories were observed. Thus, different strategies for EVT based on time and ischaemic core size are warranted.

Testosterone effects on pain and brain activation patterns

BACKGROUND

This study investigated whether pain and pain-related unpleasantness ratings were altered by blood testosterone levels. We also investigated whether activation of brain regions that represent pain intensity [primary somatosensory cortex (S1)] and pain-related unpleasantness [perigenual ACC (pACC) and orbitofrontal cortex (OFC)] were affected by blood testosterone levels.

METHODS

Twenty-six healthy men were recruited. Blood testosterone levels were measured before fMRI scanning. The participants were classified into two groups (high vs. low testosterone) according to their blood testosterone level (each group n = 13). The middle finger was immersed in a 50°C water bath (50°C, 30 s, five times) to induce identical noxious stimulation in all participants.

RESULTS

The low testosterone group showed statistically significantly higher pain (P = 0.047), unpleasantness (P = 0.047), anxiety (P = 0.015), and fear ratings (P = 0.01) than the high testosterone group. Fear rating increased as pain rating rose and as testosterone level decreased (P < 0.001). When participants received noxious stimulation, the pACC and OFC were more highly activated in the low testosterone group compared to the high testosterone group. Activation of S1, a region related to pain intensity, did not differ between both groups.

CONCLUSION

Compared to the high testosterone group, the low testosterone group had significant activation in the pACC and OFC, regions that represent pain-related unpleasantness, but not in S1 that represents pain intensity, leading to higher pain ratings. These findings emphasize the importance of considering the effects of testosterone levels when treating patients.

Reduced sensitivity of the QuantiFERON(®) test in diabetic patients with smear-negative tuberculosis

SETTING

Immunosuppressive conditions have been associated with low sensitivity of interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST) for the diagnosis of tuberculosis (TB). However, no systematic analysis of patient and bacterial characteristics has been performed before.

OBJECTIVE

To determine the sensitivity and the risk factors for false-negative QuantiFERON(®)-TB (QFT) assay and TST in TB patients.

DESIGN

We performed a retrospective analysis of data collected in a community-based study of TB in San Francisco, CA, USA. We included 300 TB patients who underwent QFT and TST.

RESULTS

The risk factors for false-negative QFT were human immunodeficiency virus infection and the use of QuantiFERON(®)-TB Gold. In patients with sputum smear-negative TB, diabetes mellitus (DM) was associated with false-negative QFT (OR 2.85, 95%CI 1.02-7.97, P = 0.045). TST sensitivity was higher than QFT sensitivity in DM patients (OR 9.46, 95%CI 2.53-35.3).

CONCLUSIONS

In San Francisco, QFT sensitivity was lower than that of TST, especially in patients with DM. Stratified analysis by sputum smear results showed that this association was specific to smear-negative TB. In contrast, TST was not affected by the presence of DM.

Step-down vs. step-up noxious stimulation: differential effects on pain perception and patterns of brain activation

BACKGROUND

We hypothesize that pain and brain responses are affected by changes in the presentation sequence of noxious stimuli that are, overall, identical in intensity and duration.

METHODS

During functional magnetic resonance imaging (fMRI) scanning, 21 participants experienced three patterns of noxious stimulation: Up-type (step-up noxious stimulation, 15 s), Down-type (step-down noxious stimulation, 15 s), and Down-up-type (decreasing and increasing pattern of noxious stimulation, 15 s). The total intensity and duration of the three noxious stimulation patterns were identical, but the stimulation sequences were different.

RESULTS

Pain and unpleasantness ratings in the Down- and Down-up-type noxious stimulations were lower than in the Up-type noxious stimulation. The left prefrontal cortex [(PFC, BA (Brodmann area) 10, (-45, 50, 1)] was more highly activated in the Down- and Down-up-type noxious stimulations than in the Up-type noxious stimulation. The S1, S2, insula, bilateral PFC (BA 46), and midcingulate cortex were more highly activated in the Up-type noxious stimulation than in the Down-type noxious stimulation. PFC BA 10 was located at an inferior level compared to the bilateral PFC BA 46 (Z axis = 1 for BA 10, compared to 22 and 25 for the right and left BA 46, respectively). When cortisol level was increased, the left hippocampal cortex, along with the left parahippocampal cortex, was greatly activated for the Up-type noxious stimulation.

CONCLUSION

When pain cannot be avoided in clinical practice, noxious stimuli should be applied to patients in a step-down pattern that delivers the most intense pain first and the least intense pain last.

Brain mechanisms of pain relief by transcutaneous electrical nerve stimulation: A functional magnetic resonance imaging study

BACKGROUND

Although the exact mechanism of TENS pain relief is unknown, it is believed that TENS impulses interrupt nociceptive signals at the dorsal horn of the spinal cord.

AIMS

To evaluate the hypotheses that during pain caused by noxious stimuli, brain responses, temporal summation and brain functional connectivity are modulated by TENS, and that mechanisms of pain relief by TENS differ between men and women.

METHODS

During fMRI scanning, the same noxious stimuli were delivered to each participant in pain-only and pain+TENS conditions. In the pain-only condition, noxious stimuli were presented without TENS. In the pain+TENS condition, participants received noxious stimuli and TENS concurrently. Participants were initially presented with TENS at an intensity that was just below that causing discomfort. TENS intensity was presented in a step-wise fashion to prevent temporal summation from repetitive noxious stimuli.

RESULTS

Pain and unpleasantness ratings were significantly higher in the pain-only than the pain+TENS condition. With non-painful TENS, primary and secondary somatosensory and parietal cortices were activated, and temporal summation from repetitive noxious stimuli was prevented. Periaqueductal gray (PAG) and lateral prefrontal cortex functional connectivity was increased by TENS, and modulated by testosterone and cortisol. Women reported greater pain during TENS than men, and showed greater activation in the temporoparietal junction cortex and increased PAG functional connectivity with the orbitofrontal cortex.

CONCLUSION

TENS led to pain reduction, probably due to activation of the descending pain-inhibitory pathway, indicating that this TENS method may be applied in clinical practice.

Modulation of pain sensation by stress-related testosterone and cortisol

Stress increases cortisol and decreases testosterone. It is not known whether pain is affected by stress-related testosterone. Therefore, we investigated whether stress can affect pain perception by decreasing testosterone and increasing cortisol. Pain thresholds, pain and anxiety ratings and salivary testosterone and cortisol levels were measured in 46 healthy men during resting and stressful conditions. Pain was induced by electrical stimulation. Stress was induced by having participants perform a medical test. Stress significantly increased anxiety ratings and salivary cortisol levels, but decreased salivary testosterone levels. Stress also increased pain ratings and decreased pain thresholds. During stress, cortisol levels were negatively correlated with pain thresholds and testosterone levels were positively correlated with pain thresholds. Results indicated that testosterone can decrease and cortisol can increase pain induced by electrical stimulation, suggesting that acute clinical pain may be relieved by controlling stress and managing consequent stress-related testosterone and cortisol.

Paradoxical response in HIV-negative patients with pleural tuberculosis: a retrospective multicentre study

OBJECTIVE

To evaluate the incidence, clinical characteristics and predicting factors for the development of paradoxical response in human immunodeficiency virus negative patients with isolated pleural tuberculosis (TB).

DESIGN

A multicentre, retrospective cohort study including 458 patients who were diagnosed and treated with isolated pleural TB between March 2005 and February 2010.

RESULTS

Paradoxical response developed in 72 patients (16%) with isolated pleural TB. The mean time to development of paradoxical response was 8.8 ± 6.4 weeks after initiation of anti-tuberculosis treatment. The main presentation of paradoxical response was aggravation of pre-existing pleural effusion in 58 patients (81%). However, the majority of the patients who developed paradoxical response had no associated symptoms (n = 49, 68%). In multiple logistic regression analysis, development of paradoxical response was independently associated with the proportion of eosinophils (adjusted OR 1.293, 95%CI 1.077-1.553) and protein concentrations (adjusted OR 0.590, 95%CI 0.397-0.878) in the pleural fluid at the time of diagnosis.

CONCLUSION

Paradoxical response developed in 16% of the patients approximately 2 months after initiation of anti-tuberculosis treatment, presenting with aggravation of pre-existing pleural effusion. Development of paradoxical response was associated with the proportion of eosinophils and protein concentrations in the pleural fluid at the time of diagnosis.

Clinical characteristics and outcomes of H1N1-associated pneumonia among adults in South Korea

BACKGROUND

Pneumonia has been reported to be the most life-threatening complication of influenza virus infection.

OBJECTIVE

to describe clinical characteristics and determine risk factors for death among patients with H1N1-associated pneumonia.

DESIGN

A retrospective cohort study included all adult patients diagnosed and treated with H1N1-associated pneumonia in 14 participating institutions between 1 May 2009 and 28 February 2010 in South Korea. Clinical outcomes were summarised and predictors for death evaluated through univariate and multivariate analysis.

RESULTS

A total of 269 adult patients with H1N1-associated pneumonia were diagnosed and treated. Hospital visits or admissions peaked in November 2009, coinciding with the peak in the 2009 H1N1 epidemic in South Korea. The patients' median age was 48 years; 143 were male. Most (n = 266, 98.9%) were admitted for treatment: 97 (36.1%) required intensive care and 28 (10.4%) needed mechanical ventilation. Despite the use of antiviral and antibacterial agents, 19 patients (7.1%) died. Risk factors predictive of death included presence of malignancy (aOR 12.0, 95%CI 2.8-51.5), and pneumonia severity index (PSI) score (aOR 1.03, 95%CI 1.01-1.04).

CONCLUSION

Deaths among adult patients with H1N1-associated pneumonia were not rare. Clinicians should be aware of the possibility of a poor prognosis among H1N1-associated pneumonia patients with underlying malignancy or high PSI score.

Risk and cost of anthracycline-induced cardiotoxicity among breast cancer patients in the United States

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Background: Onset of anthracycline-induced cardiotoxicity is well documented. However, information regarding the time of onset varies depending on literature. The purpose of this study was to compare the risk of cardiotoxicity among three cohort groups: anthracycline-containing-chemotherapy (ACC), no-anthracycline-containing-chemotherapy (NACC), and no-chemotherapy (control) groups. Methods: A retrospective cohort study was designed using commercial managed care claims database. Adult subjects (≥18) diagnosed with breast cancer, between January 1, 2002 to December 31, 2005, (index-period) were followed for 24 months. Subjects with a previous cardiotoxic events (CE), breast cancer diagnosis, or anthracycline-use 12-months prior to index date were excluded. Index date was the first chemotherapy claim date for ACC and NACC and non-chemotherapy medication claim date for controls. Cohorts were matched by index date and year of birth. CE was defined based on ICD-9-CM and Healthcare Common Procedure Coding System codes. Risk of CE was evaluated using a logistic model with and without adjusting for confounders. Results: 21,106 subjects were classified as ACC (n = 3,428), NACC (n = 7,125), and controls (n = 10,553). NACC cohort was significantly (p < 0.01) older (mean age: 62 years ±12.5) compared to ACC (53±9.7) or control cohorts (59±12.5). ACC cohort had a higher (p < 0.01) average degree of comorbidity, (1.8±0.8) compared to NACC (1.6±0.9) or control (1.3±0.8) as measured by Charlson comorbidity-index. Higher rates of CE were found within the ACC group compared to NACC and controls as early as month 3 post index-date and remained consistent over 24 months. At month 12 post index-date, 14% (n = 485) of ACC and 5% (n = 381) of NACC had CE compared to 3% (n = 310) of controls. After adjusting for all baseline differences, the odds ratio of CE compared to controls was 3.98 (95% CI: 3.27–4.85), and 1.31 (95% CI: 1.11–1.54) for ACC and NACC cohorts, respectively. The total mean costs were $59,287, $20,528, and $11,600, among ACC, NACC, and control cohorts respectively. Conclusions: Compared to NACC and controls, ACC cohorts had significantly higher risk of cardiotoxic events and seen as early as month 3 post treatment initiation.

[Table: see text]

Effects of cocaine place conditioning, chronic escalating-dose "binge" pattern cocaine administration and acute withdrawal on orexin/hypocretin and preprodynorphin gene expressions in lateral hypothalamus of Fischer and Sprague-Dawley rats

Recent evidence suggests an important role for hypothalamic orexins/hypocretins in modulation of drug reward and addiction-like behaviors in rodents. Our recent study has shown that the aversive state of arousal during acute morphine withdrawal is associated with increased orexin gene expression in lateral hypothalamus (LH) of Fischer 344 (F344) inbred rats, with no change in the expression of preprodynorphin (ppDyn), a gene co-expressed with LH orexin. Therefore, we determined whether orexin and ppDyn mRNA levels in LH or medial hypothalamus (including perifornical and dorsomedial areas) of F344 or Sprague-Dawley (SD) outbred rats, are altered following: 1) cocaine (10 mg/kg, i.p.) conditioned place preference (CPP); 2) chronic (14 days) cocaine exposure using both "binge" pattern administration in steady-dose (45 mg/kg/day) and escalating-dose (45-90 mg/kg/day) regimens; and 3) acute (1 day) and chronic (14 days) withdrawal from cocaine with opioid receptor antagonist naloxone treatment (1 mg/kg). We found that orexin mRNA levels were decreased after cocaine place conditioning in the LH of SD rats. A decreased LH orexin mRNA level was also observed after chronic escalating-dose cocaine (but not CPP pattern regimen without conditioning, or steady-dose regimen) in both strains. In F344 rats only, acute withdrawal from chronic escalating-dose cocaine administration resulted in increases in both LH orexin and ppDyn mRNA levels, which were unaltered by naloxone or after chronic withdrawal. Our results suggest that (1) alteration of LH orexin gene expression is region-specific after cocaine place conditioning in SD rats and dose-dependent after chronic exposure in both strains; and (2) increased LH orexin and ppDyn gene expressions in F344 rats may contribute to negative affective states in cocaine withdrawal.

Use of silicone stents for the management of post-tuberculosis tracheobronchial stenosis

The role of bronchoscopic management in post-tuberculosis tracheobronchial stenosis is not well defined. To investigate the role of bronchoscopic intervention, including silicone stenting, in the management of post-tuberculosis tracheobronchial stenosis, the current retrospective study was conducted at a tertiary referral hospital. Under rigid bronchoscopy, 80 patients underwent ballooning, neodymium-yttrium aluminium garnet laser resection and/or bougienation as first-line methods of airway dilatation between January 2000 and December 2003 inclusive, and were followed for a median of 41 months. Silicone stents were required in 75 out of 80 (94%) patients to maintain airway patency. Bronchoscopic intervention provided immediate symptomatic relief and improved lung function in 88% of the patients. After airway stabilisation, stents were removed successfully in 49 out of 75 (65%) patients at a median of 14 months post-insertion. Three patients out of 75 (4%) eventually underwent surgical management. Acute complications included: excessive bleeding (n = 1); pneumothorax (n = 5); and pneumomediastinum without mortality (n = 2). Stent-related late complications, such as migration (51%), granuloma formation (49%), mucostasis (19%) and re-stenosis (40%), were controllable during a median follow-up of 41 months. In conclusion, bronchoscopic intervention, including silicone stenting, could be a useful and safe method for treating post-tuberculosis tracheobronchial stenosis.

Onychomycosis in a premature infant caused by Candida tropicalis

We report a case of onychomycosis caused by Candida tropicalis in a 107-day-old infant.

Porous polyethylene implant for orbital wall reconstruction

Short-term and intermediate-term results from clinical use of high-density porous polyethylene implants for reconstructive orbital surgery have been encouraging. This article presents an intermediate-term result from one institution with a comprehensive comparative analysis of other available alloplastic materials. A patient survey of 32 cases of orbital reconstruction using porous polyethylene sheet implants was performed, with a mean follow-up period of 32 months (range 15 to 67). All cases were trauma-related injuries. The result was compared with that of published reports of other alloplastic materials with specific emphasis on complication rates. Complication rate following the use of porous polyethylene sheet implants was 6%. This finding was consistent with those of other reports on porous polyethylene sheet implants. A consistent, satisfactory surgical outcome and low complication rate were observed. In the authors' review, the porous polyethylene implants compared favorably in a comparative analysis of other alloplastic materials.

Effect of ethanol on spontaneous phasic contractions of cat gastric smooth muscle

BACKGROUND

Ethanol is generally believed to inhibit extracellular Ca2+ influx, thereby inhibiting gastric muscle contraction. Recently, we observed that verapamil inhibited only the amplitude of spontaneous phasic contractions, whereas ethanol inhibited both amplitude and frequency. In our objective to investigate the mechanism of ethanol's inhibition of gastric motility, the involvement of various protein kinases in ethanol-inhibited spontaneous phasic contractions of the stomach muscle strips was tested.

METHODS

Circular muscle strips (2.0 x 0.2 cm) were prepared from the corpus of cat stomach in order to measure isometric contraction in a chamber filled with Krebs-Ringer solution (pH 7.4, temperature 36 degrees C) bubbled with 5% CO2 in O2.

RESULTS

Spontaneous phasic contraction was not affected by various receptor antagonists (I microM atropine, 1 microM hexamethonium, 1 microM phentolamine and 1 microM propranolol) or 1 microM tetrodotoxin. EGTA and verapamil dose-dependently inhibited only the amplitude of spontaneous phasic contractions and not the frequency. Ethanol dose-dependently inhibited both the amplitude and frequency of phasic contractions. The amplitude and frequency of spontaneous phasic contractions were significantly inhibited by protein kinase C and tyrosine kinase inhibitors. However, neither protein kinase C activator nor various phosphatase inhibitors blocked the inhibitory effect of ethanol.

CONCLUSIONS

Ethanol appears to inhibit spontaneous phasic contractions by a mechanism other than the inhibition of protein kinase C or tyrosine kinase or the inhibition of extracellular Ca2+ influx.

Expression of cutaneous lymphocyte-associated antigen and TIA-1 by lymphocytes in pityriasis lichenoides et varioliformis acuta and lymphomatoid papulosis: immunohistochemical study

BACKGROUND

Pityriasis lichenoides et varioliformis acuta (PLEVA) and lymphomatoid papulosis (LyP) are benign self-healing cutaneous eruptions that may be clinically and histologically similar. The purposes of this study were to evaluate immunohistological characteristics of PLEVA and LyP and to investigate whether Epstein-Barr virus (EBV) may be present in PLEVA and LyP.

METHODS

We performed an immunohistochemical staining in 12 cases of PLEVA and 8 cases of LyP using nine antibodies for CD3, CD4, CD8, CD30, CD45RO, CD56, CD79, cutaneous lymphocyte-associated antigen (CLA), and TIA-1. In situ hybridization was performed using fluorescein-conjugated oligonucleotide probes for EBV early regions (EBER).

RESULTS

In PLEVA, immunohistochemical studies revealed that infiltrated lymphocytes consisted of mainly CD3-positive (5+), CD8-positive (4+ to 5+), CLA-positive (4+ to 5+) T cells and partly CD79 positive (+ to 2+) B cells. CD4-positive T cells were less than 25%. In LyP, immunohistochemical studies revealed that infiltrated lymphocytes consisted of partly CD3-positive (5+), CD8-positive (2+ to 3+), CLA-positive (3+ to 4+) T cells and partly CD79-positive (2+ to 3+) B cells. CD4-positive T cells were less than 10%. CD8 and CLA were more strongly expressed in PLEVA than in LyP. CD30 was strongly expressed in LyP but not expressed in PLEVA. CD79 was more expressed in LyP than in PLEVA. TIA-1 was not expressed in any cases. In situ hybridization using antisense EBER probe showed negative reaction in all cases.

CONCLUSIONS

Immunohistochemical stains for CD8, CD30, CD79 and CLA may be valuable tools in the differential diagnosis between PLEVA and LyP. TIA-1 was negative in LyP, which means cytotoxic cells may not be implicated in the pathogenesis of LyP. It was a contradictory result to the previous results. The absence of EBV in PLEVA and LyP suggests that this virus may not be operative in the pathogenesis of these diseases. These results suggest that LyP and PLEVA are separate disorders, thus accounting for their variable prognosis.

Clinicohistopathologic comparison of adult type and juvenile type xanthogranulomas in Korea

Xanthogranuloma (XG) is an uncommon benign disorder characterized by solitary or multiple yellow-red papulonodules on the skin, and occasionally, in other organs. It is predominantly a disease of infancy or early childhood, although adults may rarely be affected. To compare the clinicohistopathological featues of juvenile-type xanthogranulomas UXGs) and adult-type xanthogranulomas (AXGs) (>14 years) in Korea, 30 cases of JXGs and 15 cases of AXGs were compared clinically and histopathologically. Except for the fact AXGs were more often solitary and larger and showed neither other associated systemic diseases nor spontaneous regression, the clinical features such as color, mean number, or site of the lesions in AXGs were not statistically different from JXGs. Histologically, AXCs were not significantly different in amounts of foamy cells, giant cells including Touton cells, and inflammatory cells, although subcutaneous involvement was seen only in the two infant cases. In conclusion, in contrast to AXGs, JXGs need special attention to accompanying systemic diseases and do not need excisional procedures, considering their frequent spontaneous regression.

The involvement of phospholipase A(2) in ethanol-induced gastric muscle contraction

To understand the underlying mechanism of ethanol in tonic contraction, the effect of ethanol on phospholipase A(2) and phospholipase C activities and the effects of phospholipase inhibitors on ethanol-induced contraction of cat gastric smooth muscle were tested. Circular muscle strips (2.0 x 0.2 cm) obtained from the fundus of cat stomach were used to measure isometric contraction. Ethanol elicited tonic contraction and activated phospholipase A(2) activity in a dose-dependent manner. Phospholipase A(2) inhibitors, manoalide (0.1--10 microM) and oleyloxyethyl phosphorylcholine (1--10 microM), significantly inhibited ethanol-induced contraction. Furthermore, 342 mM ethanol-induced contraction was significantly inhibited by cyclooxygenase inhibitors, ibuprofen (10--100 microM) and indomethacin (10--100 microM), but not by lipoxygenase inhibitors. On the other hand, phospholipase C inhibitors had no effect on ethanol-induced contraction, indicating that phospholipase C is not involved in ethanol-induced contraction. It is suggested from the above results that ethanol-induced contraction in cat gastric smooth muscle is, in part, mediated by phospholipase A(2) and cyclooxygenase pathways.

Involvement of cyclic GMP in nitric-oxide-induced gastric relaxation Comparison of the actions of cyclic GMP and cyclic AMP

BACKGROUND

Smooth muscle relaxation induced by various agents that increase the cellular levels of cyclic nucleotides (cAMP and cGMP) is accompanied by a decrease in intracellular Ca2+ concentration. However, little is known about the differences between the inhibitory effects of cAMP and cGMP on the contraction of smooth muscle.

OBJECTIVE

To compare the effects and underlying mechanisms of cAMP and cGMP on the inhibition of gastric smooth muscle contraction, cyclic nucleotide promoting agents, as well as cell membrane permeable cyclic nucleotides were used.

METHODS

Isometric contraction was measured from circular muscle strips prepared from the fundus of cat stomach in a cylinder-shaped chamber filled with Krebs-Ringer solution (pH 7.4, temperature 36 degrees C) bubbled with 5% CO2 in O2. The level of inositol phosphates (IPs) was measured.

RESULTS

Forskolin and sodium nitroprusside significantly inhibited acetylcholine (ACh)-induced gastric smooth muscle contraction and increased the cellular levels of cAMP and cGMP, respectively. Direct application of 8-Br-cAMP and 8-Br-cGMP also significantly inhibited ACh-induced contraction. Both verapamil and TMB-8 inhibited ACh-induced contraction. The combined inhibitory effect of verapamil and TMB-8 was significantly greater than the effect of either one, separately. Forskolin or sodium nitroprusside similarly augmented the effect of verapamil. However, the inhibitory effect of TMB-8 was augmented only by 8-Br-cGMP or sodium nitroprusside but not by 8-BrcAMP or forskolin. Forskolin and 8-Br-cAMP significantly inhibited the formation of inositol phosphates stimulated by ACh.

CONCLUSIONS

cAMP inhibits the contraction mechanism associated with intracellular Ca2+ mobilization as well as extracellular Ca2+ influx, while cGMP inhibits contraction by inhibiting the mechanism associated with extracellular Ca2+ influx.

Computed tomographic characteristics of chronic subdural hematomas

Although medical history and physical examination should lead to diagnosis of chronic subdural hematomas, 40% of these patients are likely to be misdiagnosed because many of these symptoms occur in other disease processes, such as transient ischemic attacks, stroke, dementia, and tumors. Computed tomography remains one of the most useful tools in the evaluation of these patients because of its rapidity, cost, availability, and pathologic sensitivity.

Orthopedic problems in Lesch-Nyhan syndrome

Lesch-Nyhan syndrome is an X-linked disorder of purine metabolism. The orthopedic problems and results of treatment of nine Lesch-Nyhan patients are reviewed. Associated orthopedic problems included hip subluxation or dislocation (nine of 18 hips), fractures (three), autoamputation, infections (three), minor scoliosis, and contractures. Lesch-Nyhan patients can safely undergo orthopedic procedures and the results of surgery are satisfactory and similar to those of patients with spastic cerebral palsy. All of the seven operated-on hips maintained good reduction at 6-year mean follow-up. With adequate cast technique, fractures and hip subluxation/dislocation may be treated successfully. The treating orthopedist should be aware of the increased incidence of heterotopic ossification in this population, as well as the potential for serious complications such as hardware failure or femur fracture, if appropriate immobilization is not used.

Hepatic involvement in hypereosinophilia: sonographic findings

Hypereosinophilic syndrome may cause eosinophil-related tissue damage to various organs. The purpose of this paper is to describe sonographic findings in 13 patients with hypereosinophilia in whom the liver was involved. The diagnosis in these 13 patients was based on liver biopsy in seven patients with bone marrow biopsy in six patients. Eight patients had hypereosinophilic syndrome and five patients had clonorchiasis. All 13 patients had mild to marked hepatomegaly. Seven of 13 patients showed multiple round or oval hypoechoic (n = 6) or variably echogenic (n = 1) lesions measuring 1 to 2 cm with poorly defined margins in both lobes of the liver. Four patients had one or two hypoechoic lesions 3 to 4 cm in size, with geographic pattern and poorly defined margins. Two patients showed diffuse hepatomegaly with increased parenchymal echogenicity. The number of lesions and the extent of diffuse lesions seem to be proportional to the degree of eosinophilia. Hypereosinophilia may produce multiple small focal hepatic lesions or diffuse segmental or lobar echogenic lesions simulating primary or metastatic tumor of the liver.

Potential decreased morbidity of interstitial brachytherapy for gynecologic malignancies using laparoscopy: A pilot study

OBJECTIVES

This pilot study was designed to prospectively assess whether the addition of laparoscopy at the time of interstitial brachytherapy is safe, provides verification and/or guidance of needle placement, and results in a reduction of treatment-related morbidity.

METHODS

Between 7/93 and 2/97 15 consecutive eligible patients were entered into this study. All patients received external pelvic radiation to a dose range between 45 and 61.20 Gy using 1.8-Gy fractions. In each patient the minimum prescribed dose for the brachytherapy portion was 20 Gy. Minimum cumulative doses to sites of gross disease ranged from 71.8 to 115.3 Gy. A Syed-Neblett afterloading perineal template was used in all the procedures. Laparoscopy using established guidelines was performed during placement of interstitial needles. During template placement, verification of interstitial needles on laparoscopy and any subsequent changes or needle rearrangement were noted.

RESULTS

No acute radiation toxicity greater than Grade 2 was noted during the external beam portion of treatment, and no perioperative complications were encountered. These needles were withdrawn under laparoscopic guidance to just below the peritoneal reflection, avoiding proximity to the bowel and improving tumor coverage. Median follow-up time was 26 months. No late radiation morbidity greater than Grade 2 nor any laparoscopic-related complications were noted. To date, one patient has died of disease; six are alive with disease; and eight are alive free of disease with a mean disease-free survival of 17.3 months.

CONCLUSION

Laparoscopy at the time of interstitial brachytherapy appears to be safe. No radiation toxicity greater than Grade 2 has developed. No perioperative complications were seen with the addition of laparoscopy. The addition of laparoscopy to the placement of transperineal interstitial implants impacted needle arrangement and/or loading of sources in 50% of patients.

Medpor Motility Coupling Post: a rabbit model

PURPOSE

To verify if a Medpor porous polyethylene orbital implant (PPOI) (Porex Surgical, Atlanta, GA, U.S.A.), once vascularized, will tolerate a partially exposed titanium screw on its anterior surface.

METHODS

Ten New Zealand white rabbits were enucleated and given Medpor PPOIs. Eight weeks postoperatively, Medpor Motility Coupling Posts (MCPs) (Porex Surgical) were placed into the orbital implants. Clinical tissue tolerance and histologic response to the new device were noted.

RESULTS

The titanium screws were well tolerated by the animals. No case of post-operative infection, conjunctival inflammation, conjunctival erosion, MCP dislocation, or PPOI fragmentation was noted. A fibrous tissue growth over the titanium head was noted in all screws with a head height of 2.5 mm. The fibrous tissue overgrowth was not observed in screws with a head height of 4 mm or more.

CONCLUSION

During the 6-month observation period, all implanted Medpor MCPs demonstrated favorable tissue tolerance and stable interfaces between the MCP and the conjunctiva and between the MCP and the PPOI.

Porous polyethylene channel implants: a modified porous polyethylene sheet implant designed for repairs of large and complex orbital wall fractures

PURPOSE

To evaluate the effectiveness of a modified porous polyethylene implant in orbital fracture repair. A porous polyethylene channel implant (PPCI) has internal channels that accept mini- or microplates from conventional plating systems, facilitating fixation to bone in the reconstruction of large, complex orbital fractures.

METHODS

The authors used 29 PPCIs to repair 25 orbits. Seventeen cases involved repair of an acute (less than two weeks after injury) fracture of one or more orbital walls. Eight cases represented delayed reconstruction of orbital walls for late enophthalmos or for residual defects after previous operations.

RESULTS

A PPCI provides a stable platform for orbital soft tissue. Excellent results were obtained in all patients with acute orbital fractures, whereas good or excellent corrections of enophthalmos and hypoglobus were achieved in all patients who underwent late repair. There were no instances of orbital infection, implant exposure or migration, worsening diplopia, visual loss, or loss of structural support during 31 months of follow-up.

CONCLUSIONS

A PPCI allows controlled placement of a porous polyethylene sheet with secure fixation to stable bone. The implant design allows it to be cantilevered from the orbital rim to serve as a stable platform when fractures are too large to support the implant in the posterior orbit. PPCIs are ideally suited for reconstruction of defects resulting from displacement of orbital walls and for repair of posterior floor fractures, medial wall fractures, and combined floor and medial wall defects.

Trabeculectomy with intraoperative 5-fluorouracil

BACKGROUND AND OBJECTIVE

To investigate the outcome and complication rates of trabeculectomy following the combined use of intraoperative, topical 5-fluorouracil (5-FU) and low-dose, postoperative subconjunctival 5-FU injections.

PATIENTS AND METHODS

Forty-one eyes of 41 patients with advanced, medically uncontrolled glaucoma underwent trabeculectomy with intraoperative episcleral application of 5-FU (50 mg/ml for 5 minutes). A variable number of subconjunctival 5-FU injections were administered postoperatively at the discretion of the operating surgeon.

RESULTS

Six-, 12-, and 15-month life-table success rates (5 mm Hg < or = intraocular pressure [IOP < or = 21 mm Hg) were 100%, 97%, and 83%, respectively. Mean postoperative IOP was 12.1 +/- 4.3 mm Hg. An average of 2.2 +/- 1.6 (range 0 to 7) supplemental subconjunctival 5-FU injections were administered postoperatively. Corneal epithelial erosions developed in 7 (17%) of the eyes. Five of 7 patients who underwent subsequent surgical procedures maintained successful control of IOP at an average of 11.0 +/- 4.8 (range 5 to 16) months after the secondary surgery.

CONCLUSION

Trabeculectomy with intraoperative 5-FU is effective in controlling IOP while possibly minimizing the need for frequent postoperative injections and the occurrence of corneal epitheliopathy.

The role and results of bone grafting in revision total knee replacement

Failure in total knee replacement requiring revision surgery is often accompanied by significant bone loss and soft tissue asymmetry. When embarking on these complex reconstructions, careful preoperative planning is necessary to ensure that these deficiencies will be corrected by surgical technique and implant selection. This article discusses various techniques and results of bone grafting in revision total knee arthroplasty.

Porous polyethylene sheet implant with a barrier surface: a rabbit study

Soft tissue adhesion to the porous polyethylene sheet implant (PPSI) raises the concern of postoperative extraocular motility disturbance after orbital blowout fracture repairs using PPSI. A PPSI with a barrier surface (PPSI-B) has been developed to reduce adhesion between soft tissue and the implant. Six PPSI-B and six conventional PPSI were implanted under the scalps of three New Zealand white rabbits. The implants were harvested at 2-, 4-, and 20-week intervals. Clinical and histologic comparisons were made between PPSI-B and PPSI with regard to adhesion at the soft tissue-implant interface. Clinically, PPSI-B demonstrated less adhesion between soft tissue and implant compared with the conventional PPSI. Both types of implants demonstrated a complete fibrovascular ingrowth by 2 weeks. Because PPSI-B causes less adhesion at the soft tissue-implant interface, consideration should be given to the use of PPSI-B in repairs of orbital blowout fractures in which extraocular muscle is exposed to the implant surface.

Use of botulinum A toxin in patients at risk of wound complications following eyelid reconstruction

Our purpose was to determine the efficacy of botulinum A toxin (BOTOX) in promoting wound immobilization and preventing wound dehiscence in patients at risk of wound-healing complications following eyelid reconstruction. In 11 patients at risk of postoperative wound complications, we injected BOTOX into the periocular musculature in addition to standard suture tarsorrhaphy. Each patient experienced excellent wound immobilization and wound healing. There were no complications. Adjuvant use of BOTOX, in conjunction with suture tarsorrhaphy, immobilizes the eyelids and promotes wound healing in patients at risk of wound complications following eyelid reconstruction.

Specific sequences of fibronectin activate the protein kinase C signal transduction pathway in invasive bladder cancer

The mechanism of human bladder cancer cell invasion is not clear, but it appears that extracellular matrix components, such as fibronectin, may be involved. To investigate the role of fibronectin in tumor cell invasion and progression, we used an in vitro invasion assay to define the motility stimulating fragment of fibronectin for invasive human bladder cancer T24 cells. Using a modified Boyden chamber assay and purified fragments of fibronectin, we demonstrated that both the 120 kDa chymotrypsin generated fragment of fibronectin (containing the cell attachment RGD motif and additional sequences towards the carboxyl-terminal heparin binding domain), as well as the trypsin generated 60 kDa fragment of fibronectin (containing the carboxyl-terminal heparin binding domain and additional sequences towards the cell attachment RGD motif), were able to stimulate the migration of invasive human bladder cancer T24 cells. Control fragments containing only the amino-terminal gelatin binding region of fibronectin did not stimulate the motility of the human bladder cancer T24 cells. To determine the molecular mechanism in which these fragments may stimulate the migration of the T24 cells, we assayed for intracellular signal transduction pathway protein kinase C (PKC). We demonstrated that both the 120 kDa and the 60 kDa fragments were able to stimulate the activation of protein kinase C. Non-motility stimulating fragments of fibronectin were not able to activate protein kinase C. We conclude that the PKC signal transduction pathway may be involved in matrix mediated motility, and suggest that the inhibition of such pathway(s) may alter the malignant phenotype of human bladder cancer.

Bacillus Calmette-Guérin interacts with the carboxyl-terminal heparin binding domain of fibronectin: implications for BCG-mediated antitumor activity

Intravesical bacillus Calmette-Guérin (BCG) has been shown to be an effective treatment for superficial transitional cell carcinoma of the bladder. The mechanisms by which BCG achieves this effect remain unclear. Reports have attributed an important role to fibronectin both in the initial attachment of BCG to bladder surfaces and in the limitation of tumor cell motility. In the present study, using limited protease cathepsin B degradation followed by Western blot analyses with antibodies to various domains of the fibronectin molecule, we showed that BCG appears to bind to fibronectin near the carboxyl terminal and adjacent to the heparin binding domain. Furthermore a 51-chromium release assay with human bladder cancer cell line T24 as target cells and lymphokine activated killer (LAK) cells as effector cells showed that fibronectin was needed for tumor cytotoxicity by the LAK cells. By using antibodies and peptides to various domains of the fibronectin molecule, the heparin binding domain, but not the cell binding domain, carboxyl terminal region, or the amino terminal region of the fibronectin molecule, was identified as essential to tumor cell lysis by the LAK cells. Flow cytometric analysis showed that both peripheral blood lymphocytes and the LAK cells express fibronectin receptors VLA-3, VLA-4 and VLA-5 on their surfaces. However, the numbers of receptors are not significantly different in the two cell populations. We conclude that, by binding near the carboxyl terminal region and adjacent to the heparin-binding domain of the fibronectin molecule, BCG may protect this region of the molecule from tumor proteases, and may thus allow the antitumor activity of the host immune cells to take place.

Neural-vascular relationships in central retina of macaque monkeys (Macaca fascicularis)

The relationship of the vasculature to the neuronal layers was studied in whole-mounts and in sections of macaque retinas. Like other central nervous structures, primate retinas have local variations in vascularity that reflect local variations in metabolism, rather than simply tissue thickness or volume. A special feature of the retina is a dense vascular plexus in the nerve fiber layer, which is unmyelinated and hence must generate a substantial metabolic demand for ion pumping. Much of the retinal vasculature is laminated and located at specific layer boundaries. Throughout the central retina, two planes of capillaries bracket the inner nuclear layer to form a sclerad capillary network. In some regions, especially near the fovea, a second, more vitread network brackets the ganglion cell layer with another pair of capillary planes. Wherever the nerve fiber layer is thick, the vitread network becomes less planar and is multilayered. When surrounded by nerve fibers, capillaries tend to orient parallel to the fibers; when adjacent to ganglion cell bodies, the capillaries are less systematically oriented. At the border between the nerve fiber layer and the ganglion cell layer, rows of ganglion cells often interdigitate with nerve fiber bundles, resulting in local perturbations of capillary orientation. The volume of the sclerad capillary network is relatively constant at different locations, but the volume of the vitread network increases dramatically where the nerve fiber layer is thick. As a result, the vascularity of the retina is greatest in the peripapillary region near the optic disk, even though the total thickness of the peripapillary retina is comparable to the retinal thickness near the foveal crest. As many as 60-70% of the photons passing through the retina in the peripapillary region will encounter one or more capillaries before reaching a photoreceptor. Median capillary diameter increases with retinal depth from 4.5-4.7 microns in the nerve fiber layer to 5.0 microns at the sclerad border of the inner nuclear layer. Capillary diameter in the nerve fiber layer also increases near the optic disk.