A Precision Medicine Navigator Can Mitigate Inequities Associated with Utilization of Genomic Tests in Black Men with Prostate Cancer

PURPOSE/OBJECTIVE(S)

Black men with prostate cancer in the United States experience disproportionately worse clinical outcomes compared to other racial groups. Identifying more reliable prognosticators to address these inequities has thus been the subject of considerable research scrutiny. However, prognostic genomic tools and genomic biorepositories suffer from an even greater lack of racial diversity. Strategies to mitigate these amplifying developments in inequities are desperately needed. We hypothesized that the presence of a precision medicine navigator (PMN) may mitigate inequities with standard of care (SOC) genomic test utilization among Black men with prostate cancer.

MATERIALS/METHODS

We retrospectively reviewed prostate cancer consults within one healthcare system from 11/2/2021 to 1/2/2022. We compared the frequency of patients who received SOC Decipher or Tempus genomic testing in the 7 months prior to the PMN start (pre-PMN) to the 7 months afterward (post-PMN). Chi square analysis was used to compare subgroups. Binary logistic regression was used to calculate the odds of receiving genomic testing.

RESULTS

The sample included 693 patients, 44.9% (311/693) pre-PMN and 55.1% (382/693) post-PMN, with a median age of 68 in both groups. Pre- and post-PMN racial distributions were similar with 60.1% and 60.2% White, 35.1% and 34% Black, 3.2% and 3.7% Asian/Pacific Islander, and 1.3% and 2.1% Latino, respectively. Pre- and post-PMN NCCN risk category distribution was 15.2% and 10.4% low risk, 46.8% and 49.9% intermediate risk, and 38.1% and 39.7% high risk, respectively. Pre- and post-PMN groups had 14.5% and 17% distant metastases, 77.2% and 76.9% localized disease, 10.3% and 10% prior prostatectomy, 47% and 51% income below sample median, 51% and 52% with Medicare/Medicaid, and 47% and 48% seen at community hospitals, respectively. There were no statistically significant differences for these variables pre- and post-PMN. However, from pre- to post-PMN, the proportion of Black patients receiving genomic testing increased from 19% to 58%. Black patients seen post-PMN were six times more likely to receive testing (p<0.001). Significant increases in SOC genomic testing post-PMN also occurred among lower median income patients, patients with Medicare/Medicaid, and community hospital patients.

CONCLUSION

The presence of a PMN may improve disparate rates of Black patients receiving SOC genomic tests for prostate cancer compared to other racial groups and may alleviate genomic testing inequities among other demographics.

Comparison between Percutaneous Screw Fixation and Plate Fixation via Sinus Tarsi Approach for Calcaneal Fractures: An 8-10-Year Follow-up Study

Objective

To assess the long‐term outcomes after percutaneous reduction (PR) and screw fixation versus plate fixation via the sinus tarsi approach (STA) for displaced intra‐articular calcaneal fractures (DIACF).

Methods

This retrospective study included a total of 150 patients (June 2008–August 2011), comprising 85 men and 65 women (mean age, 38.4 years), who were assigned to the PR group or the STA group. The inclusion criteria were DIACF (>2 mm) including Sanders type II and III, closed fracture, unilateral fracture, no history of smoking or no smoking during hospitalization and 3 months after surgery, and follow‐up time not less than 8 years. The exclusion criteria were clear surgical contraindications (severe cardiovascular and cerebrovascular diseases), local or systemic infection symptoms, diagnosis with diabetes or lower extremity vascular disease, and Sanders type IV or open fractures. Outcomes were assessed by means of the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scores, radiographic images, and postoperative complications.

Results

The mean follow‐up period was 8.7 years (range, 8.0–10.0 years). The AOFAS scores in the PR group during the follow‐up period were 54.2 ± 5.1, 85.8 ± 4.0, 88.1 ± 3.8, 87.9 ± 3.6, 87.8 ± 3.9, 86.9 ± 3.9, respectively, and in the STA group were 55.0 ± 5.6, 84.5 ± 5.2, 87.1 ± 3.8, 86.9 ± 3.8, 87.7 ± 3.3, and 87.6 ± 2.8, respectively. There was no significant difference in AOFAS scores, Bohler's angle, Gissane's angle, calcaneal length, and height between the two groups (P > 0.05). The good to excellent rate of the PR group (80.8%) was less than that of the STA group (91.7%) (P = 0.055). For Sanders III fractures, the good to excellent rate of the PR group (33.3%) was less than that of the STA group (76.9%) (P = 0.029). For calcaneal width recovery, the STA group performed better than the PR group (P < 0.05). The incidence of postoperative complications in the PR group (12.8%) was lower than that in the STA group (27.8%) (P = 0.026), of which the incidence of wound complications was 3.8% in the PR group and 13.9% in the STA group (P = 0.041). In addition, there was no significant difference in other postoperative complications such as sural nerve injury, peroneus longus and brevis muscle injury, calcaneal valgus symptoms, lateral impingement symptoms, and subtalar arthritis (P > 0.05).

Conclusion

From the 8–10‐year follow‐up results of PR and STA as surgical procedures for the treatment of DIACF, it was found that there was no significant difference in the overall efficacy between them. STA was found to be superior to the PR in terms of the recovery of calcaneal width, providing more stable fixation for Sanders III fractures. PR was found to be more effective in reducing wound complications.

Acute acromioclavicular joint dislocation treated with tightrope : Mini-open versus percutaneous stabilization

The purpose of this study was to compare prospecti- vely the radiographic and clinical results of patients treated with tightrope through either mini-open or percutaneous stabilization for acute AC joint injuries. Eighty patients were included in this study and were randomly divided into two groups. Group A included 40 injuries treated with mini-open repair. Group B consisted of 40 injuries treated with percutaneous stabilization. Demographic and clinical data were comparable between the two groups before surgery (P>0.05). Peri-operative data, complications and clinical outcomes between the two groups were compared. The average follow-up time of Group A, was 26.5±4.3 months and Group B, was 25.2±5.6 months (P>0.05). The mean operative time was 63.2±9.6 minutes and 45.6±7.1 minutes, and the mean incision length was 6.0±1.5 cm and 4.0±0.8 cm, respectively. The operative time and incision length were significantly longer in Group A (both P<0.05). However, the radiological assessment revealed no significant difference in the coracoclavicular (CC) distance between the two groups (P>0.05). The rate of loss of reduction in the Group A was similar to that in Group B (6/40 vs. 5/40, P>0.05). Both methods were efficient methods for acute AC joint dislocation. However, percutaneous fixation had the advantages of a shorter surgical time and smaller incision length.

Enantioselective [2 + 2] cycloaddition of N-allenamides with cyclic N-sulfonylketimines: access to polysubstituted azetidines bearing quaternary stereocenters

A Ni(ClO₄)₂-catalyzed enantioselective [2 + 2] cycloaddition of N-allenamides with cyclic N-sulfonylketimines was developed, which regioselectively occurred at the proximal C Created by potrace 1.16, written by Peter Selinger 2001-2019 ]]> C bonds of the N-allenamides.

A Ni(ClO₄)₂-catalyzed enantioselective [2 + 2] cycloaddition of N-allenamides with cyclic N-sulfonylketimines was developed, which regioselectively occurred at the proximal CC bonds of the N-allenamides. Broad substrate scope of N-allenamides and cyclic N-sulfonylketimines was observed. A range of fused polysubstituted azetidines bearing quaternary stereocenters were afforded in good yields and with excellent enantioselectivities (up to 99%).

[Endobutton and cortical screw fixation for the treatment of distal tibiofibular syndesmosis separated]

OBJECTIVE

To analyze the treatment effect of Endobutton plate cable system for the treatment of the distal tibiofibular syndesmosis injury.

METHODS

Total 38 patients with tibiofibular syndesmosis separation treated by surgical operation from October 2011 to October 2013 were analyzed retrospectively. According to internal fixation, 38 cases were divided into two groups involving group A (cortical screw fixation) and group B (Endobutton plate cable system fixation). In group A, there were 26 patients including 16 males and 10 females with an average age of (37.90±4.67) years old ranging from 19 to 63 years old; 14 cases were on the left and 12 on the right;involving 8 cases of Weber-Denis type B, 18 cases of Weber-Denis type C; according to Lauge-Hanson typing, 9 cases of supination external rotation (SER), 10 cases of pronation abduction (PAB), 7 cases of pronation external rotation (PER). In group B, there were 12 cases including 7 males and 5 females, with an average age of (38.70±6.03) years old ranging from 20 to 55 years old;6 cases were on the left and 6 cases on the right;involving 4 cases of Weber-Denis type B and 8 cases of Weber-Denis; involving 7 cases of PER, 3 cases of SER, 2 cases of PAB. The operative time, intraoperative blood loss, surgery cost, hospital stay time, the wound healing, pain score at 1 month after operation, and the load time were recorded and evaluated. According to reviewing of X rays regulary, the healing of fracture were assessed, the function outcomes of ankle was evaluated according to the Ankle Hind Foot Scale of American Orthopaedic Foot and Ankle Society.

RESULTS

All patients were followed up for 8 to 18 months with an average of 13.5 months. There were no statistical significance in intraoperative blood loss, hospital stay time, average load time and postoperative pain score at 1 month after operation between two groups (P>0.05). Duration of operation, the operative time were significantly shorter in cortical screw group;however, the average cost of hospitalization was significantly higher in Endobutton group. No significant differences were found between two groups in outcome of radiographic measurement. The X rays of 36 patients showed well healing of fracture, normal mortise and no distal tibiofibular syndesmosis separation. AOFAS score at the final follow up in group A was (87.50±8.67) scores, 18 cases got excellent result, 4 cases were good, and 4 cases were fair. AOFAS score at the final follow up in group B was (86.23±7.42) scores, 7 cases obtained excellent result, 4 cases were good and 1 case was fair; AOFAS score between two groups were no significant difference (P>0.05).

CONCLUSIONS

Endobutton plate cable system is a dynamic capital equipment in treating the tibiofibular syndesmosis separation, it has a similar outcome compared with the screw, but without screw fractured and do not regular remove after operation. The patients could take the functional exercises earlier.

Comparison of reconstruction plate screw fixation and percutaneous cannulated screw fixation in treatment of Tile B1 type pubic symphysis diastasis: a finite element analysis and 10-year clinical experience

Objective

The objective of this study is to compare the biomechanical properties and clinical outcomes of Tile B1 type pubic symphysis diastasis (PSD) treated by percutaneous cannulated screw fixation (PCSF) and reconstruction plate screw fixation (RPSF).

Materials and Methods

Finite element analysis (FEA) was used to compare the biomechanical properties between PCSF and RPSF. CT scan data of one PSD patient were used for three-dimensional reconstructions. After a validated pelvic finite element model was established, both PCSF and RPSF were simulated, and a vertical downward load of 600 N was loaded. The distance of pubic symphysis and stress were tested. Then, 51 Tile type B1 PSD patients (24 in the PCSF group; 27 in the RPSF group) were reviewed. Intra-operative blood loss, operative time, and the length of the skin scar were recorded. The distance of pubic symphysis was measured, and complications of infection, implant failure, and revision surgery were recorded. The Majeed scoring system was also evaluated.

Results

The maximum displacement of the pubic symphysis was 0.408 and 0.643 mm in the RPSF and PCSF models, respectively. The maximum stress of the plate in RPSF was 1846 MPa and that of the cannulated screw in PCSF was 30.92 MPa. All 51 patients received follow-up at least 18 months post-surgery (range 18–54 months). Intra-operative blood loss, operative time, and the length of the skin scar in the PCSF group were significantly different than those in the RPSF group. No significant differences were found in wound infection, implant failure, rate of revision surgery, distance of pubic symphysis, and Majeed score.

Conclusion

PCSF can provide comparable biomechanical properties to RPSF in the treatment of Tile B1 type PSD. Meanwhile, PCSF and RPSF have similar clinical and radiographic outcomes. Furthermore, PCSF also has the advantages of being minimally invasive, has less blood loss, and has shorter operative time and skin scar.

COL1A1 gene -1997G/T polymorphism and risk of osteoporosis in postmenopausal women: a meta-analysis

Studies investigating the association between the COL1A1 gene -1997G/T polymorphism and the risk of osteoporosis in postmenopausal women have reported conflicting results. We performed a meta-analysis based on the evidence currently available from the literature to make a more precise estimation of this relationship. We conducted searches of the published literature in the PubMed and Embase databases up to September 2014. We estimated the pooled odds ratios with their 95% confidence intervals to assess the associations using fixed- or random-effect models. Publication bias was investigated by Begg's funnel plot. Meta-analysis was performed using the STATA package version 12.0. No significant association was found between the -1997G/T polymorphism in the COL1A1 gene and osteoporosis risk in the total population analysis (TT vs GG: OR = 1.28, 95%CI = 0.76-2.17; TT vs GT: OR = 1.04, 95%CI = 0.60-1.78; dominant model: OR = 0.84, 95%CI = 0.50-1.40; recessive model: OR = 1.18, 95%CI = 0.84- 1.66). In a subgroup analysis by nationality, the results also showed that no significant associations between the COL1A1 gene -1997G/T polymorphism and osteoporosis risk existed in either Caucasian or Asian populations. No evidence of publication bias was found. In conclusion, the COL1A1 gene -1997G/T polymorphism might not be a risk factor for osteoporosis in postmenopausal women. Further large and well-designed studies are needed to confirm these conclusions.

A study on knowledge and attitude toward brain death and organ retrieval among health care professionals in Korea

PURPOSE

The practice of retrieving vital organs from brain-dead donors is legally and medically accepted in Korea, but health care professionals' beliefs and opinions regarding these matters have not been sufficiently explored. The purpose of this study was to evaluate the knowledge and attitudes of health care professionals to the concepts of brain death and organ retrieval.

METHODS

Data were collected using a 41-item questionnaire during a week in June 2011. Sixty-one doctors and 109 nurses from five hospitals with more than 2000 beds in Seoul, Korea, participated in the survey. The data was analyzed using SPSS version 17.0 (SPSS Inc. Chicago, Illinois, USA).

RESULTS

There were statistically significant differences in the scores on knowledge according to marital status (P = .001) education level (P = .019), whether the participants were informed about organ donation from a brain-dead donor (P = .002), and the participant's experience managing potential brain-dead patients (P = .037). There were statistically significant differences in the scores on the attitude according to gender (P < .001), age (P < .001), marital status (P < .001), education level (P = .003), job position (P < .001), and the participant's experience referring brain-dead patients to the hospital-based organ procurement organization (P = .001). Significantly, attitude's positively correlated with knowledge about brain-dead organ donation (P < .001).

CONCLUSION

Compared with previous studies, the knowledge and attitudes of health care professionals' regarding brain death and organ retrieval were not improved. There are passive attitudes to brain death and organ retrieval. More research must be performed to promote knowledge and understanding toward brain death and organ retrieval among health care professionals.

[Biomechanical comparison of Evans procedure and Chrisman-Snook technique for the treatment of II degree lateral collateral ligament of ankle joint]

OBJECTIVE

To measure the stability of Evans procedure and Chrisman-Snook technique in the treatment of II degree lateral collateral ligament of ankle joint, and provide basis for treatment and prognosis.

METHODS

From July 2008 to June 2009,18 frozen corpes were collected, including 10 males and 8 females, with an average age of fresh 39.3 +/- 11.2 years. The frozen corpes were randomly divided into three group, including normal controls(group A), Evans procedure (group B) and Chrisman-Snook technique ( group C), 6 specimens in each group. Anterior talofibular ligament and calcaneofibular ligament were cut off to cause II degree lateral collateral ligament in group B and C. Evans procedure or Chrisman-Snook technique were applied to restore lateral collateral ligament, and measure biomechnics. The displacement of tibiotalar joint and subtalar joint were observed.

RESULTS

(1) The lateral stress results of tibiotalar joint showed the displacement by Evans procedure (group B) was greater than other groups (P < 0.0001). There were no significant differences between group A and C (P > 0.05). (2) The lateral stress results of subtalar joint showed the displacement by Evans procedure (group B) was greater than other groups (P< 0.0001). There were no significant differences between group A and C (P > 0.05).

CONCLUSION

Ankle instability is caused by ankle joint lateral collateral ligament injury. Chrisman-Snook technique is better than Evans procedure in stability on the early stage of ankle joint restoration, and conform to principle of biomechanics.

Overexpression of beta-catenin is responsible for the development of portal hypertension during liver cirrhosis

beta-catenin functions as both a structural protein and a transcriptional activator. In this study, we examined the expression of beta-catenin in human cirrhotic livers, and administered adenoviruses carrying the beta-catenin or DeltaTCF4 genes to cirrhotic rats to investigate the role of beta-catenin in the development of liver cirrhosis development. beta-catenin expression was associated with liver cirrhosis development in cirrhotic human and rat liver. beta-catenin adenovirus was capable of accelerating cirrhosis progress but this progression was unaffected by administration of DeltaTCF4 adenovirus. beta-catenin was mainly located in the intercellular regions between liver cells and was highly concentrated in the hepatic sinusoid wall, where alpha-smooth muscle actin (SMA) was also mainly distributed. The binding of beta-catenin to alpha-SMA was also increased in cirrhotic liver. Portal vein blood pressure was significantly increased in the group administered beta-catenin adenovirus, but not in that receiving DeltaTCF4 adenovirus. These results suggest that high concentrations of beta-catenin at the hepatic intercellular membrane and the hepatic sinusoid wall contribute to hepatic hyperpiesia in liver cirrhosis patients. beta-catenin functions as a structural molecule, but not as a signaling molecule, during liver cirrhosis development.

Decision-Related Factors and Attitudes Toward Donation in Living Related Liver Transplantation: Ten-Year Experience

INTRODUCTION

Living related liver transplantation (LRLT) has been performed since 1994 in Korea; more than 600 donors have contributed to our successful LRLT program for 10 years. Although the decision to donate is difficult and the donors need a formal psychosocial assessment, no system has been available to us for the assessment. This survey was performed as a presurveillance for the development of a psychosocial assessment protocol.

METHODS

A survey questionnaire included 31 questions on general and medical characteristics, factors, and processes related to the decision for donation. Donors of partial livers at least 6 months ago during the period from December 1994 to August 2003 and whose address could be confirmed by telephone were enrolled in the study.

RESULTS

A questionnaire was sent by mail to 441 contactable donors of whom 209 (47.4%) responded. Male-to-female ratio was 2:1 and mean age was 32.8 years (range: 16 to 60 years). The number of spousal donors was 120 (57.4%) and 164 (78.5%) donors were employed at the time of donation. Protestants, Buddhists, and Catholics were 29.2%, 19.1%, and 14.8%, respectively. Parents were the most common recipients (33.0%), followed by siblings (17.2%), extended family members (17.2%), and children (15.8%); one hundred eighty nine (90.4%) donors had decided by themselves, the major reason for donation in 192 (91.9%) donors was "to save the lives of family members and relatives." The first person who suggested donation was the donor (64.1%), followed by family members (23.9%) or the attending physicians (8.6%). Although 70.8% of donors answered that they were not hesitant to donate at the time of decision, 44.5% were uneasy at the possibility of being unable to sustain a normal life after donation, at their lack of knowledge on organ donation, and about the pain and fear of surgery. Family members and relatives (53.3%), medical personnel (46.7%), and previous donors (35.4%) were the preferable counselors compared to transplantation institutions and clergymen. The large majority (80.8%) of donors would encourage others to donate.

CONCLUSIONS

Although the decision to donate was made by the donors themselves in most cases and they appeared firm and determined about their decision, a significant number of donors felt uneasy about possible complications of organ donation and effects on their lives after donation. A precise and formal psychosocial assessment protocol is needed to support and secure their decision before and after donation.

Nucleotide sequences of genome segments S6, S7 and S10 of Dendrolimus punctatus cypovirus 1

The nucleotide sequences of genome segments S6, S7 and S10 of Dendrolimus punctatus cypovirus 1 Hunan I (DpCPV-HN(I)) and DpCPV-HN(I)-Se(3) (DpCPV-HN(I) passed three times in Spodoptera exigua) were determined. Segment S10 was 944 nucleotides in length and encoded a polyhedrin of 248 amino acids (28,439 Da). Only two nucleotide mutations were found between DpCPV-HN(I) S10 and DpCPV-HN(I)-Se3 S10, and the deduced amino acid sequences of the polyhedrin proteins were identical. Segment S7, 1 501 nucleotides, encoded a protein of 448 amino acids ( approximately 50 kDa; p50). Thirty-one nucleotide mutations were found between DpCPV-HN(I) S7 and DpCPV-HN(I)-Se3 S7, but these resulted in only four amino acid changes. DpCPV-HN(I) S6 encoded a protein of 561 amino acids (63,688 Da; p64). The amino acid sequence of p64, had a high leucine content (10%), and contained a leucine zipper motif and one ATP/GTP-binding site motif.

Experimental infection of mice with tightly coiled spiral bacteria ("Candidatus Helicobacter suis") originating from the pig stomach

Mice (n=34) were inoculated orally with a gastric homogenate from a pig infected with tightly coiled spiral bacteria (TCSB). In mice killed in pairs at 16 intervals up to 108 weeks post-inoculation (pi), TCSB were invariably found, mainly in the mucosal surface, gastric pits, intercellular spaces, cytoplasm of surface epithelial cells, and lumina of gastric glands. Histopathologically, infiltration of lymphocytes and plasma cells was seen from 8 weeks pi onwards, gradually increasing as infection progressed. From 64 weeks pi onwards, the formation of large follicles was observed in the lamina propria and submucosa, together with severe necrosis of surface epithelial cells. Glandular epithelial cells in the fundic mucosa were markedly dysplastic and intruded through the basement membrane into the submucosal layer. Common antigenicity between TCSB and Helicobacter pylori was demonstrated by Western blotting, ELISA, and immunohistochemistry. The sequence of the 16S rDNA fragment of 374 bp showed 100% homology with the 16S rRNA gene of "Candidatus Helicobacter suis". Experimental infection of the gastric mucosa of mice with TCSB was closely associated with chronic gastritis and dysplastic lesions.

Genomic sequence analyses of segments 1 to 6 of Dendrolimus punctatus cytoplasmic polyhedrosis virus

The complete nucleotide sequences of genomic segments S1 to S6 from Dendrolimus punctatus cypovirus 1 (DpCPV-1) have been determined. Each segment of S1 to S6 possess a single open reading frame. Conserved motifs 5' (AGUAA) and 3'(GUUAGCC) were found at the ends of each segment. Comparison of the proteins of DpCPV with those of other members in the family Reoviridae lead us to suggest that S1, S3, S4 and S6 encode the viral structural protein VP1, VP2, VP3 and VP4, respectively. S5 encoded viral non-structural protein p100 and S2 encodes an RNA-dependent RNA polymerase (RdRp). Motif analysis shows that VP3 is similar to the methyltransferase of Methanosarcina mazei Goe1, VP4 has motifs for leucine zipper and ATP/GTP-binding sites, and p100 is remarkably similar to foot-and-mouth disease virus 2A protease (FMDV 2Apro). Phylogenetic analysis of RdRps from nine viruses of the family Reoviridae indicates that DpCPV is a type 1 cypovirus, more related to Bombyx mori cypovirus (BmCPV) than to other cypovirus species. DpCPV is more related to Rice ragged stunt virus (RRSV) than to other members of different genera of the family Reoviridae, which seems to confirm the previous hypothesis that plant reoviruses originated from insect reoviruses.

Molecular characterization of segments 7-10 of Dendrolimus punctatus cytoplasmic polyhedrosis virus provides the complete genome

The nucleotide sequences of genomic segments S7-S10 from Dendrolimus punctatus cypovirus strain Hunan (DpCPV-Hn) have been determined. This provides the complete genome sequences of DpCPV-Hn. Each segment of S7-S10 possess a single segment each. Homology searches showed that the nucleotide sequences and the deduced amino acid sequences of DpCPV S7-10 had high level of identities with those of Bombyx mori cypovirus (BmCPV) S7-10, respectively. While the amino acid sequences of the proteins encoded by DpCPV S7 and S8 have low identities with those of the proteins encoded by type 14 Lymantria dispar cypovirus S7 and S8, respectively. DpCPV S7 encodes viral structural protein VP5, S8 and S9 encode viral non-structural proteins, and S10 encodes polyhedrin gene, according to the function of the genome segments of BmCPV. There are glutamic-acid-rich and proline-rich domains in the central region of DpCPV S8 encoded protein. A nuclear localization signal was found in the protein encoded by DpCPV S9. Phylogenetic analysis of RNA-dependent RNA polymerases from nine viruses of the family Reoviridae and polyhedrin from eight viruses of the genus Cypovirus indicate that DpCPV is a type 1 cypovirus, more closely related to BmCPV than to other cypovirus species. These results also support the classification of CPV groups based on the electrophoretic migration of genomic dsRNA.

Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome

BACKGROUND

Intra-abdominal hypertension has been recognized as a source of morbidity and mortality in the traumatized patient following laparotomy. Multiple organ dysfunction attributable to intra-abdominal hypertension has been called the abdominal compartment syndrome. The epidemiology and characteristics of these processes remain poorly defined.

METHODS

Intra-abdominal pressure was measured prospectively in all patients admitted to a trauma intensive care unit over 9 months. Data were gathered on all patients with intra-abdominal hypertension.

RESULTS

Some 706 patients were evaluated. Fifteen (2 per cent) of 706 patients had intra-abdominal hypertension. Six of the 15 patients with intra-abdominal hypertension had abdominal compartment syndrome. Half of the patients with abdominal compartment syndrome died, as did two of the remaining nine patients with intra-abdominal hypertension. Patients with abdominal compartment syndrome had a mean intra-abdominal pressure of 42 mmHg compared with 26 mmHg in patients with intra-abdominal hypertension only (P < 0.05).

CONCLUSION

The incidence of intra-abdominal hypertension and abdominal compartment syndrome was 2 and 1 per cent respectively. Intra-abdominal hypertension did not necessarily lead to abdominal compartment syndrome, and often resolved without clinical sequelae. Abdominal compartment syndrome did not occur in the absence of earlier laparotomy. Abdominal compartment syndrome was associated with a marked increase in intra-abdominal pressure (above 40 mmHg).

Benzodiazepine discontinuation difficulties in panic disorder: conceptual model and outcome for cognitive-behavior therapy

There is consistent support for the efficacy of cognitive-behavior therapy (CBT) to aid the successful discontinuation of benzodiazepine (BZ) medication in patients with panic disorder, and help these individuals maintain treatment gains while off medication. In this article, we provide a conceptual model for BZ discontinuation difficulties in patients with panic disorder. Outcome studies are reviewed, and are placed in the context of other evidence for the efficacy of CBT in patients with this disorder.

Dietary hematein ameliorates fatty streak lesions in the rabbit by the possible mechanism of reducing VCAM-1 and MCP-1 expression

Hematein is a compound isolated from Caesalpinia sappan that has been used in oriental medicine as both an analgesic and an anti-inflammatory agent. In this study, we examined the anti-atherogenic potential of hematein using cholesterol-fed New Zealand White (NZW) rabbits. NZW rabbits were divided into a hematein-supplemented (0.05% in diet) group (n=6), a probucol-supplemented (0.25% in diet) group (n=6), and a control group (n=6). After 8 weeks of treatments, the extent of the atherosclerotic lesions was significantly reduced in the hematein-supplemented group and the probucol-supplemented group without changing plasma lipoprotein levels. Hematein and probucol prevented the up-regulation of the vascular cell adhesion molecule-1 (VCAM-1) expression on the descending aorta induced by cholesterol diet. In culture, hematein also significantly inhibited the secretion of soluble VCAM-1 and of monocyte chemotactic protein-1 (MCP-1) respectively induced by tumor necrotic factor alpha (TNF-alpha) and mildly oxidized low density lipoprotein in human umbilical vein endothelial cell (HUVEC) culture. Also, hematein inhibited monocyte adhesion to endothelial cell and the activation of NF-kappaB in HUVECs stimulated with TNF-alpha. The results of the present study suggest that the anti-atherogenic effect of hematein is not related to control of the plasma lipid profile but probably related to the inhibition of VCAM-1 and MCP-1 expression resulting in an amelioration of lesion development in the rabbit.

Ketanserin attenuates the behavioural effects of corticosterone: implications for 5-HT(2A) receptor regulation

The effects of chronic corticosterone treatment on sexual behaviour and wet-dog shakes were investigated in both female and male rats. The serotonergic type 2A (5-HT(2A)) receptor antagonist ketanserin was administered to test the hypothesis that the behavioural effects of corticosterone were mediated by increased 5-HT(2A) receptor activity. Rats were randomly assigned to one of four chronic treatment groups: control, ketanserin alone, corticosterone alone, or ketanserin and corticosterone. Ketanserin attenuated the corticosterone-induced changes in both sexual behaviour and wet-dog shakes. Ketanserin alone had no effect on these behaviours. Results suggest that increased 5-HT(2A) receptor activity mediates the effects of corticosterone on sexual behaviour and wet-dog shakes.

Therapeutic effect of hyaluronic acid on experimental osteoarthrosis of ovine temporomandibular joint

A symptomatic relief by hyaluronic acid (HA, MW: 3.5 x 10(6)), which is synthesized by Streptococcus spp, was investigated in experimental ovine osteoarthrosis. Bilateral osteoarthrosis (OA) of the temporo-mandibular joints (TMJs) was induced by perforating discs and by scrapping subchondral condylar surface. HA was intra-articularly injected into the left joints of 6 sheep on 7, 10, 14, 17 and 21 days after the operation and physiological saline as the control was injected into the contralateral (right) joints on the same day. Three sheep were killed at I month post-operation (MPO) and the remaining three sheep were killed at 3 MPO. Various responses such as proliferation of fibrous tissue, denudation, erosion, osteophyte formation, subcortical cyst formation and ankylosis were observed radiographically and histopathologically. The treatment of HA ameliorated the degenerative changes and lowered the osteoarthrotic score in the left joints at I MPO (9.96 vs 5.81) and 3 MPO (10.86 vs 5.29) compared to the right joints. These results indicate that a repeated intra-articular injection of HA inhibits the progression of OA in ovine TMJs by inducing the development of articular cartilage and by reducing the proliferation of fibrotic tissue.

Evaluating blunt abdominal trauma with sonography: a cost analysis

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan-Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan-Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the abdomen: 0 US, 466 CT, and 176 DPL (see table) [table: see text]. This compares to 801 procedures on the 1,033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant (P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 (P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

Review article: current therapeutic options for radiation proctopathy

Radiation proctopathy is a common unfortunate complication following radiation therapy of pelvic malignancies. Symptoms of chronic radiation proctopathy include haematochezia, urgency, constipation, tenesmus, diarrhoea and rectal pain. Currently, a wide variety of pharmacological options, endoscopic cautery techniques and surgical procedures have been proposed for the treatment of chronic radiation proctopathy. Although these have been proposed primarily as treatment for rectal bleeding, the control of other symptoms has been noted with some of these agents. Pharmacological options include 5-aminosalicylic acid preparations, coticosteroid enemas, sucralfate (oral, enemas), formalin, short chain fatty acid enemas, oestrogen/progesterone, hyperbaric oxygen, antioxidants, sodium pentosan polysulphate and misoprostol rectal suppositories. Of these, sucralfate and formalin therapy appear to be effective for bleeding control. Misoprostol rectal suppositories and oral sucralfate may be useful in the prevention of acute and chronic symptoms of radiation proctopathy. Endoscopic cautery techniques have included the use of Nd:YAG laser and argon laser for coagulation of bleeding neovascular telangiectasias. Argon plasma coagulation offers a safe non-contact method of delivering haemostasis which has proven to be particularly useful in targeting difficult to reach lesions tangentially. Surgery is generally reserved for severe refractory cases involving ongoing haemorrhage, obstruction, stricture formation, fistulas and perforation. Given that formal randomized placebo-controlled studies are lacking for most treatments, the management of these patients is often challenging and unclear. Hence, there is a need for more research and education on radiation proctopathy.

Sex-related differences in the tolerance of Oriental fruit moth (Grapholita molesta) to organophosphate insecticides

In vivo toxicity assays have shown that organophosphate insecticides are less toxic to male than to female Oriental fruit moths Grapholita molesta. While male moths have higher levels of acetylcholinesterase and general esterase activities, female moth acetylcholinesterase enzymes are less sensitive to aromatic and aliphatic organophosphates than male enzymes. Elevated esterase and acetylcholinesterase activities in male moths explain their greater tolerance to aromatic and aliphatic organophosphates. Male and female acetylcholinesterase enzymes are equally tolerant to heteroaromatic organophosphates, the most widely used of this class of insecticides in G molesta control. This observation, in contrast to the greater sensitivity of male acetylcholinesterases to aromatic and aliphatic organophosphates, shows the potential for the evolution of insensitive target sites in male moths, which would increase male G molesta tolerance to these insecticides. Significant sex-linked differences in insecticide tolerance have not been reported previously in lepidopterans. The practical implications of the observed differences in tolerance in male and female G molesta question the practice of using pheromone traps to monitor populations of these moths in orchards.

Cognitive-behavior therapy for discontinuation of SSRI treatment of panic disorder: a case series

In this report we describe the outcome of eight outpatients with panic disorder and agoraphobia who discontinued their treatment with a selective serotonin reuptake inhibitor (SSRI) in the context of a structured, group program of cognitive-behavior therapy. All patients successfully discontinued their SSRI medication while demonstrating clinical improvement. These results were maintained at 3-month follow-up. This case series suggests that manualized CBT for discontinuation of benzodiazepine treatment for panic disorder may be successfully applied to SSRI discontinuation as well.

Mycophenolate mofetil reduces renal cortical inducible nitric oxide synthase mRNA expression and diminishes glomerulosclerosis in MRL/lpr mice

Overexpression of inducible nitric oxide synthase (iNOS) has been implicated in the pathogenesis of lupus glomerulonephritis. Mycophenolate mofetil (MMF), a novel immunosuppressive agent, is currently used in organ transplantation and under evaluation for treatment of autoimmune disorders. Mycophenolic acid, the active metabolite of MMF, has been shown to suppress cytokine-induced nitric oxide production in vitro. The aim of this study was to evaluate the effect of MMF on the expression of renal cortical iNOS mRNA and protection against glomerulonephritis in MRL/lpr mice. Three-month-old MRL/lpr mice (n = 6) displaying clinical symptoms of glomerulonephritis were treated for 3 months with MMF (90 mg/kg/day) dissolved in a vehicle. Controls were age- and sex-matched mice (n = 6) that received the vehicle alone. By reverse-transcription competitive polymerase chain reaction, we found that the renal cortical iNOS/beta-actin mRNA ratio was reduced by 30.8% (P <.05) in MMF-treated mice. Furthermore, MMF significantly reduced urinary nitrite production and degree of glomerulosclerosis. The glomerular volume was reduced by 17.5% (P <.001). Proteinuria was also significantly reduced in the MMF-treated group. However, by electrophoretic mobility shift assay, the nuclear binding of nuclear factor-kappaB (NF-kappaB) was not affected by MMF treatment. We conclude that in addition to its immunosuppressive action, MMF may reduce renal cortical iNOS mRNA expression and diminish glomerulosclerosis in MRL/lpr mice independent of modulation of the NF-kappaB pathway.

Inhibition of cytokine-induced vascular cell adhesion molecule-1 expression; possible mechanism for anti-atherogenic effect of Agastache rugosa

Adhesion molecules such as vascular cell adhesion molecule-1 (VCAM-1) play an important role during the early stages of atherogenesis. Agastache rugosa has an anti-atherogenic effect in low density lipoprotein receptor -/- mice. Moreover, A. rugosa reduced macrophage infiltration and VCAM-1 expression has been localized in aortic endothelium that overlies early foam cell lesions. This study ascertained that tilianin (100 microM), a major component of A. rugosa, inhibits the tumor necrotic factor-alpha (TNF-alpha)-induced expression of VCAM-1 by 74% in cultured human umbilical vein endothelial cells (HUVECs). Also, tilianin (100 microM) reduced TNF-alpha-induced activation of nuclear factor-kappaB in HUVECs.

Hematein inhibits tumor necrotic factor-alpha-induced vascular cell adhesion molecule-1 and NF-kappaB-dependent gene expression in human vascular endothelial cells

Monocyte adhesion to the endothelium via adhesion molecules is one of the earliest events in atherogenesis. It has been suggested that vascular cell adhesion molecule-1 (VCAM-1) plays a very important role in the recruitment of monocytes in atherosclerosis. The aim of our study was to evaluate whether hematein can influence the expression of VCAM-1 and the transcription of nuclear factor-kappaB (NF-kappaB)-dependent genes. Immunohistochemistry revealed that mouse aortic artery endothelial cells express VCAM-1 after feeding a high cholesterol diet for 8 weeks. Hematein dose dependently suppressed TNF-alpha-induced VCAM-1 in both surface (30.8%) and soluble protein (65%) production in HUVECs. The transcription level of VCAM-1 was measured by Northern blot analysis, and decreased VCAM-1 protein expression was associated with a reduction of VCAM-1 mRNA expression. Transient transfection study of NF-kappaB promoter construct and electrophoretic mobility shift assay suggested that hematein inhibited both NF-kappaB-dependent gene expression and NF-kappaB activation induced by TNF-alpha. Our results suggest that the down-regulation of VCAM-1 expression by hematein may in part be due to the inhibition of NF-kappaB-dependent gene expression.

A new surgical treatment of keloid: keloid core excision

Keloids and hypertrophic scars result from excessive collagen deposition, the cause of which is not yet known. Unlike hypertrophic scars, keloids frequently persist at the site of injury, often recur after excision and always overgrow the boundaries of the original wound. There have been many trials to control keloids, but most of them have been unsuccessful. The authors propose a new surgical technique to treat keloids and name it keloid core extirpation. They excise the inner fibrous core from the keloid and cover the defect with a keloid rind flap, which is arterialized by the subcapsular vascular plexus. The authors treated 24 keloids of the ear, trunk, face, and genitalia with keloid core excision. Four cases of partial rind flap congestion or necrosis occurred. Those patients who healed primarily after surgery showed no evidence of keloid recurrence as long as they were followed. The authors have found the keloid core extirpation technique to be excellent in preventing keloid recurrence, with no adjuvant therapy after surgery.

Pike. A nuclear gtpase that enhances PI3kinase activity and is regulated by protein 4.1N

While cytoplasmic PI3Kinase (PI3K) is well characterized, regulation of nuclear PI3K has been obscure. A novel protein, PIKE (PI3Kinase Enhancer), interacts with nuclear PI3K to stimulate its lipid kinase activity. PIKE encodes a 753 amino acid nuclear GTPase. Dominant-negative PIKE prevents the NGF enhancement of PI3K and upregulation of cyclin D1. NGF treatment also leads to PIKE interactions with 4.1N, which has translocated to the nucleus, fitting with the initial identification of PIKE based on its binding 4.1N in a yeast two-hybrid screen. Overexpression of 4.1N abolishes PIKE effects on PI3K. Activation of nuclear PI3K by PIKE is inhibited by the NGF-stimulated 4.1N translocation to the nucleus. Thus, PIKE physiologically modulates the activation by NGF of nuclear PI3K.

The calcineurin-binding protein cain is a negative regulator of synaptic vesicle endocytosis

During neurotransmitter release, exocytosed neurotransmitter vesicles are recycled by endocytosis, which involves the assembly of a complex of endocytic proteins. Assembly of endocytic proteins into a functional complex depends on their dephosphorylation by calcineurin, a calcium-sensitive protein phosphatase and the inhibitory target of immunosuppressive drugs cyclosporin A and FK506. Cain is a recently identified protein inhibitor of calcineurin. We now provide evidence that cain is a component of the endocytic protein complex. The proline-rich region of cain forms a stable association with the SH3 domain of amphiphysin 1. Using a transferrin uptake assay, we found that overexpression of cain in HEK293 cells blocks endocytosis as potently as expression of a dominant negative dynamin 1 construct. The use of other calcineurin inhibitors such as cyclosporin A and FK506 also blocks endocytosis. Since binding of cain to amphiphysin 1 does not affect amphiphysin's interaction with other endocytic proteins, our results suggest that cain negatively regulates synaptic vesicle endocytosis by inhibiting calcineurin activity, rather than sterically interfering with the assembly of the endocytic protein complex.

Histomorphologic changes of hair follicles in human expanded scalp

To obtain information about changes that occur in hair follicles when tissue expansion is performed on the scalp, punch biopsy samples were taken from normal scalp (stage I) and the top of the expander immediately before removal (stage II) and 12 weeks after the second operation (expander removal and flap transposition, stage III) in 10 consecutive patients. We compared histologic and quantitative changes of hair follicles in transverse sections of the expanded scalp and long-term changes with those in normal controls using three specimens from each patient. Both the proportion of terminal hair to vellus hair and the proportion of anagen hair to telogen hair were significantly increased during stages II and III (p < 0.05). Perifollicular inflammation and fibrosis were observed during stage II but disappeared during stage III. All these findings imply that tissue expansion at the hair-bearing scalp made the telogen period short, possibly because of active epidermal mitosis.

Dual-plane lipoplasty for the superficial and deep layers

Two embryologically and histologically distinct layers of the subcutaneous adipose tissue were treated individually by different modalities. The authors performed ultrasound-assisted lipoplasty at the superficial layer and traditional suction-assisted lipectomy in the deep subcutaneous tissue. The ultrasound procedure allowed tissue-specific destruction of the superficial layer supported by dense fibrous networks without disrupting them. Skin retractions caused by this procedure could diminish the necessity of surgical dermolipectomy such as an abdominoplasty in moderately deformed cases. On the other hand, the traditional liposuction was performed to remove the excessive deep fat contained in the loose fibrous network in a limited area. Although the advancement of ultrasound devices and regimens has now reduced their operating times significantly, the ultrasonic lipoplasty was slower than traditional liposuction at the beginning of our procedure. In the abdominal wall, the procedure was performed only in a confined area, because the skin retractions made over the locally managed areas created a circumferential tightness around the trunk, using the nontreated area as a bridge. Confinement on the managed area prevented unnecessary blood loss and tissue destruction. It was less a matter of fat volume to remove in the superficial layer; rather, a precise application to the exact target area was required to get a more natural result. Dual-plane lipoplasty was performed for 2 years in 35 patients, mostly for the abdomen. No serious complication such as seromas or skin loss was observed in our series of patients.

The calcineurin-dynamin 1 complex as a calcium sensor for synaptic vesicle endocytosis

Exocytosis of synaptic vesicles is calcium-dependent, with synaptotagmin serving as the calcium sensor. Endocytosis of synaptic vesicles has also been postulated as a calcium-dependent process; however, an endocytic calcium sensor has not been found. We now report a physical association between the calcium-dependent phosphatase calcineurin and dynamin 1, a component of the synaptic endocytic machinery. The calcineurin-dynamin 1 interaction is calcium-dependent, with an EC(50) for calcium in the range of 0.1-0. 4 microM. Disruption of the calcineurin-dynamin 1 interaction inhibits clathrin-mediated endocytosis. Thus, the calcium-dependent formation of the calcineurin-dynamin 1 complex, delivered to the other endocytic coat proteins, provides a calcium-sensing mechanism that facilitates endocytosis.

Corticosterone regulation of 5-HT2A receptor-mediated behaviors: attenuation by melatonin

The effects of chronic corticosterone treatment on sexual behavior and on wet-dog shakes (WDS), a serotonergic type 2A (5-HT2A) receptor-mediated behavior, were explored in the male rat. In addition, the effects of acute melatonin treatment, both alone and in combination with corticosterone, were investigated. Chronic injections of corticosterone resulted in an overall decrease in consummatory measures of sexual behavior, and an increase in WDS. Furthermore, although an acute injection of melatonin alone had no effect on any recorded behavior, it attenuated the effects of corticosterone on sexual behavior and WDS. The data suggest that in the context of 5-HT2A receptor-mediated behaviors, melatonin has possible implications as a 5-HT2A antagonist.

Hereditary defects in fibrinolysis associated with thrombosis

The plasminogen-plasmin system involves proteolytic enzymes which are primarily responsible for the degradation of fibrin deposits in blood vessels. Through intricate interactions between the various components and inhibitors, a balance is maintained between profibrinolysis and impaired fibrinolytic activity. Several hereditary defects have been described affecting functional plasminogen concentrations, plasminogen activator levels, and plasminogen activator inhibitor activity. These defects have been implicated as risk factors for thrombosis based on a multitude of case reports associating impaired fibrinolysis with thrombosis. However, under close scrutiny, the role of decreased fibrinolysis as an etiologic factor in thrombosis has not been firmly established. Rather, dysfibrinolysis may manifest itself through an accentuation of an underlying thrombophilic state such as recurrent thrombotic episodes. Further evaluation of impaired fibrinolytic activity in conjunction with an underlying thrombophilic condition is warranted.

Multiplane face lift with the subperiosteal dissection for orientals

A subperiosteal face lift rejuvenates the midface and periorbital region by restoring facial muscle tone. Since 1993, the authors have performed this procedure on Oriental patients who have their own distinct facial contours: the brachycephalic cranium and a prominent zygoma and mandibular angle. Although it was thought that these protuberances might disturb the subperiosteal procedure, especially in the anterior midface, the procedure could be performed easily by adopting the ancillary upper buccovestibular and subciliary incisions; the authors found that the protuberances actually act as fulcrums to keep up the lifting vectors reliably. For older patients, the procedure was combined with a deep subcutaneous dissection. A simple lift of the periosteum would not improve a severe nasolabial fold deformity and prominent wrinkles adequately because of "lag-lifting" of the superficial layer. It was concluded that the multiplane face lift, consisting of the subperiosteal and the deep subcutaneous approaches, achieves a natural-appearing rejuvenation of the Oriental aging face.

Spontaneous rupture of the urinary bladder in the alcoholic patient

A case of a young man with an acute abdominal condition and hematuria is presented. BUN and SCr levels were markedly elevated. Retrograde cystography revealed intraperitoneal extravasation of contrast material. At exploration, a large intraperitoneal bladder perforation was noted and repaired in two layers. Recovery was uneventful. The presentation, diagnosis, and treatment of spontaneous rupture of the urinary bladder are discussed.

The engagement of beta1 integrins on promonocytic cells promotes phosphorylation of Syk and formation of a protein complex containing Lyn and beta1 integrin

The protein-tyrosine kinase Syk participates in signal transduction pathways downstream from multiple immune recognition receptors. Recent evidence indicates that Syk is also functionally coupled to cell surface integrins, which mediate interactions between the actin cytoskeleton and extracellular matrix proteins. The interactions of undifferentiated, promonocytic HL60 or U937 cells with fibronectin or anti-beta1 integrin antibodies leads to an apparent activation and tyrosine phosphorylation of Syk that is independent of tight cellular adhesion and spreading. In response to fibronectin or anti-beta1 integrin antibodies, beta1 integrins become associated with a complex of proteins that include the Lyn protein tyrosine kinase and endogenous kinase substrates of 29 and 75-80 kDa. Lyn becomes transiently activated following integrin engagement and co-localizes with the actin cytoskeleton. These studies suggest a major role for Lyn in coupling beta1 integrins to the activation of Syk.

Current Clinical Practice: Current Management of Thrombotic Thrombocytopenic Purpura

Historically, the mortality rate of thrombotic thrombocytopenic purpura (TTP) approached 100%. However, by the 1980's, new therapy was instituted with a vast improvement in survival to 90%. The exact pathogenesis of TTP remains elusive. Yet, despite incomplete understanding of the pathophysiology, outcome has improved due to increased awareness of the symptomatology leading to earlier diagnosis and better supportive care, in addition to effective therapy with plasma exchange. TTP represents a disease in which prompt diagnosis and treatment can lead to a critical difference in clinical outcome.

Effect of onychomycosis on quality of life

BACKGROUND

Onychomycosis impairs normal nail functions, causes considerable pain, interferes with daily activities, and has negative psychosocial effects.

OBJECTIVE

Our purpose was to determine patients' perception of onychomycosis on the quality of life.

METHODS

A total of 258 patients with confirmed onychomycosis were surveyed by telephone at three centers. Responses to a standardized quality-of-life questionnaire were analyzed for patient demographics, physical and functional impact, psychosocial impact, and economic impact.

RESULTS

Highest positive responses were nail-trimming problems (76%), embarrassment (74%), pain (48%), nail pressure (40%), and discomfort wearing shoes (38%). Ability to pick up small objects was impaired in 41% of subjects with fingernail involvement. More than 58 onychomycosis-related sick days and 468 medical visits (1.8 per subject) were reported during a 6-month period.

CONCLUSION

Onychomycosis has significant social, psychologic, health, and occupational effects. Relevance of quality-of-life issues to overall health, earning potential, and social functioning should prompt reconsideration of the value of aggressive treatment of and financial coverage for onychomycosis.

Portal vein gas, a changing clinical entity. Report of 7 patients and review of the literature

OBJECTIVE

To assess the clinical significance of portal vein gas (PVG) demonstrated by computed tomography (CT).

DESIGN

Review of medical records.

SETTING

Three network-affiliated hospitals providing both primary community-based and tertiary services.

METHODS

Review of diagnosis, clinical circumstances, and significance of PVG in 7 patients detected by CT during a 3-year period in 3 affiliated hospitals.

RESULTS

Four of 7 patients underwent laparotomy; 1 patient refused surgery. Two patients were treated with intravenous antibiotics only and had uneventful clinical courses. Of the 3 patients who died, 1 refused and 2 underwent laparotomy.

CONCLUSIONS

This series indicates that more sensitive imaging and more widespread use of endoscopic retrograde cholangiopancreatography, colonoscopy, and liver transplantation have changed the clinical presentation of PVG; PVG may be found in various clinical settings that do not mandate laparotomy; and the significance of PVG must be derived from the clinical context of the individual patient.

Poor pre-dialysis glycaemic control is a predictor of mortality in type II diabetic patients on maintenance haemodialysis

BACKGROUND

In type II diabetic patients, a better glycaemic control has been reported to slow down the progression of nephropathy. The effect of pre-dialysis glycaemic control on the long term prognosis in type II diabetics on haemodialysis is still uncertain. The purpose of this study is to evaluate the effect of glycaemic control before starting maintenance haemodialysis on the clinical outcome in type II diabetic haemodialysis patients.

METHODS

One hundred and thirty-seven type II diabetics receiving regular haemodialysis in a single university hospital were enrolled. The patients were classified as either good or poor glycaemic control group according to their glycaemic control within 6 months before starting haemodialysis. Serum albumin, haematocrit, cholesterol, triglyceride, residual renal function, diabetic complications, and patient survival were analysed in both groups.

RESULTS

There was no significant difference in age, gender, predialysis albumin level, cholesterol level, triglyceride level, and residual renal function between the two groups. The 1-year (94.5% vs 80.0%), 3-year (82.9% vs 58.1%), and 5-year (75.8% vs 21.8%) cumulative survival rates were lower in the poor glycaemic control group than in the good glycaemic control group (P < 0.001). The poor glycaemic control group also had more cardiovascular morbidity during the period of dialysis (P < 0.001). The increase in cardiovascular complications also accounted for the increased mortality during the course of haemodialysis.

CONCLUSIONS

We conclude that poor glycaemic control before starting dialysis is a strong predictor of cardiovascular morbidity and survival for type II diabetics on haemodialysis. These results imply that better glycaemic control before dialysis might be important in improving the long-term prognosis in type II diabetics on haemodialysis.