99Tcm-dimercaptosuccinic acid renal scintigraphy for detection of renal cortical defects in acute pyelonephritis: posterior 180 degrees SPECT versus planar image and 360 degrees SPECT

To evaluate the usefulness of the posterior 180 degrees acquisition technique for renal defects in acute pyelonephritis (APN), a prospective study was conducted using planar imaging, 360 degrees and posterior 180 degrees renal single photon emission computed tomography (SPECT) with 99Tcm-dimercaptosuccinic acid. Sixty subjects with the suspicion of APN were included. The kidneys were divided into three zones: each was graded as positive, equivocal or negative for renal defects. To evaluate inter-observer variation, each study was read in a double-blind fashion by two nuclear physicians. Renal defects were found in 24 patients (31 kidneys and 47 zones) with posterior 180 degrees SPECT, 23 patients (29 kidneys and 44 zones) with 360 degrees SPECT (McNemar's test, P = 0.375 for zones) and 15 patients (16 kidneys and 24 zones) with planar image (P = 0.001 for zones, vs 180 degrees and 360 degrees SPECT). The proportion of positive agreement for posterior 180 degrees and 360 degrees SPECT between readers for the presence of renal defects was 0.81 and 0.62, respectively, whereas the proportion of negative agreement was 0.92 and 0.87, respectively. Both posterior 180 degrees and 360 degrees SPECTs significantly detected more renal defects than planar imaging. The detectability of renal defects in APN by posterior 180 degrees renal SPECT was equal to 360 degrees SPECT but inter-observer agreement was better.

Dexamethasone for preventing nausea and vomiting associated with epidural morphine: a dose-ranging study

We conducted a dose-ranging study of dexamethasone for preventing nausea and vomiting within the first 24 h after the administration of epidural morphine. Two hundred twenty-five women (n = 45 in each of the five groups) undergoing simple abdominal total hysterectomy under epidural anesthesia were enrolled in this randomized, double-blind, placebo-controlled study. When the incision closure was completed, patients received IV dexamethasone, 10 mg, 5 mg, or 2.5 mg; IV droperidol 1.25 mg; or saline 2 mL. All patients received epidural morphine 3 mg for postoperative analgesia. We found that patients who received dexamethasone 5 mg or 10 mg or droperidol 1.25 mg were significantly different from those who received saline alone in the following variables: the total incidence of nausea and vomiting, the incidence of more than four vomiting episodes, the number of patients requiring rescue antiemetics, the total number of patients with no vomiting and/or no antiemetic medication (P < 0.05 to P < 0.01). The differences among dexamethasone 10 mg and 5 mg and droperidol 1.25 mg were not significant. Dexamethasone 2.5 mg was ineffective. In conclusion, because dexamethasone 5 mg was as effective as 10 mg as an antiemetic, we recommend the smaller dose for preventing nausea and vomiting associated with epidural morphine.

IMPLICATIONS

We conducted a dose-ranging study of dexamethasone for preventing nausea and vomiting within the first 24 h after the administration of epidural morphine. We found that dexamethasone 5 mg was as effective as 10 mg. We recommend the smaller dose for this purpose.

Dexamethasone prophylaxis of nausea and vomiting after epidural morphine for post-Cesarean analgesia

PURPOSE

To determine the minimum effective dose of dexamethasone in preventing nausea and vomiting associated with epidural morphine for post-Cesarean analgesia.

METHOD

One hundred and eighty parturients (n=45 in each of four groups) requiring epidural morphine for post-Cesarean analgesia were enrolled in this randomized, double-blinded, placebo-controlled study. At the end of surgery, parturients received either dexamethasone, at doses of 10 mg, 5 mg, 2.5 mg, or saline i.v.. Three milligrams epidural morphine were given to all parturients for postoperative analgesia. The incidence of PONV and side effects were estimated for 24 hr after delivery by blinded, trained nurse anesthetists.

RESULTS

Parturients who received dexamethasone, either 10 mg or 5 mg were different from those who received saline alone in the following parameters: the total incidence of nausea and vomiting, incidence of > 4 vomiting episodes, number the of parturients requiring rescue antiemetics, and the total number of parturients with no vomiting and/or no antiemetic medication (P < 0.05 to P < 0.01). The differences between dexamethasone 10 mg and 5 mg were not significant. Dexamethasone 2.5 mg was partially effective.

CONCLUSION

Dexamethasone, 5 mg i.v., is suggested as the minimum effective dose in preventing nausea and vomiting associated with epidural morphine for post-Cesarean analgesia.

Sauropus androgynus-constrictive obliterative bronchitis/bronchiolitis--histopathological study of pneumonectomy and biopsy specimens with emphasis on the inflammatory process and disease progression

AIMS

The histopathology of the Sauropus androgynus (SA)-constrictive bronchiolitis obliterans (BO) is still controversial. A recent report using pneumonectomy specimens showed that the major histopathology was obliterative arteriopathy with segmental necrosis of small bronchi instead of constrictive BO as previously described.

METHODS AND RESULTS

We analysed semiquantitatively and immunohistochemically the histopathology of one pneumonectomy and four biopsies specimens of SA-associated lung disease. We found a significant number of constrictive and obliterative bronchioles 1 mm or less in diameter and segmental inflammatory destruction with complete luminal obliteration of the bronchi less than 3 mm in diameter in the pneumonectomy specimen (37% and 25%, respectively). Fibromuscular intimal sclerosis of the bronchial arteries was identified in 15% of the bronchi 4 mm or less in diameter. The inflammation in these airways was composed predominantly of T-lymphocytes, macrophages, mast cells and eosinophils. They were present throughout the evolutionary stages of the bronchiolitis ranging from early oedematous to the late fibrotic obliterative stage. Double immunohistochemical stains revealed negative proliferative cell nuclear antigen for most of the T-lymphocytes and macrophages but positive for fibroblasts.

CONCLUSIONS

A more accurate histopathological designation of the SA-associated lung disease should be constrictive obliterative bronchitis/bronchiolitis, with the participation of T-lymphocytes, macrophages, mast cells, eosinophils and fibroblasts in its morphogenesis. The persistent accumulation of inflammatory cells was mediated predominantly by continued recruitment to the site of injury from the bloodstream, resulting eventually in the irreversible fibrosis of the bronchioles and the bronchi less than 3 mm in diameter. Obliterative arteriopathy is suspected of being only an indirect contributing factor.

Physicians' knowledge and attitudes toward the use of analgesics for cancer pain management: a survey of two medical centers in Taiwan

The purposes of this study were to examine the attitudes of physicians regarding the optimal use of analgesics for cancer pain management (CPM), to evaluate their knowledge and attitudes toward opioid prescribing, and to comprehend their perceptions of the barriers to optimal CPM. A survey was conducted on 356 physicians with cancer patient care responsibilities practicing in two medical centers in Taiwan. A total of 204 (57%) physicians responded, including internists (28%), surgeons (27%), oncologists (11%), anesthesiologists (10%), and other specialties (24%). The majority of physicians displayed significantly inadequate knowledge and negative attitudes toward the optimal use of analgesics and opioid prescribing. Multivariate analyses showed that the following six categories of physicians would be inclined to have inadequate knowledge of opioid prescribing: 1) those with perception of good medical school training in CPM, 2) those with perception of poor residency or fellowship training in CPM, 3) those with a medical specialty in surgery, medicine, or oncology (vs. anesthesiology), 4) those with limited clinical experience in cancer patient care (number of patients less than 30), 5) those with a limited aim of pain relief, and 6) those with an underestimation of analgesic effect. Additionally, physicians with inadequate knowledge of opioid prescribing and with hesitation to intervene earlier with maximal dose of analgesia would be inclined to have reluctant attitudes toward opioid prescribing. The most important barriers to optimal CPM identified by physicians themselves were physician-related problems, such as inadequate guidance from a pain specialist, inadequate knowledge of CPM, and inadequate pain assessment. The results of this study suggest that active analgesic education programs are urgently needed in Taiwan.

Risk factors for presentation with bleeding in patients with Helicobacter pylori-related peptic ulcer diseases

At present, there is no study that simultaneously addresses the apparent differences between bacterial and host factors in patients with bleeding and nonbleeding Helicobacter pylori-related ulcer diseases. Therefore, we designed this prospective study to evaluate whether there are identifiable differences between the two groups of patients whose H. pylori-related peptic ulcer diseases present with bleeding or dyspepsia. From July 1996 to November 1996, consecutive patients presenting with upper gastrointestinal bleeding or dyspepsia were enrolled if H. pylori-related ulcer diseases were confirmed. Fifteen clinical, endoscopic, histologic, and serologic factors were tested for association with ulcer bleeding by a logistic regression analysis. In the study period, bleeding occurred in 39 out of 119 patients with H. pylori-related peptic ulcer diseases. Multivariate analysis showed that ingestion of nonsteroidal antiinflammatory drugs (NSAIDs; p = 0.0156; odds ratio = 5:4), ulcer size > or = 1 cm (p = 0.0033; odds ratio = 4:2), and low bacterial density (p = 0.0030; odds ratio = 4:1) were independent factors associated with the risk of bleeding. There were no associations between ulcer bleeding and age, sex, smoking, alcohol consumption, the histologic grade of gastritis, location and number of ulcers, and the cytotoxin-associated gene (CagA) status of H. pylori strain. Therefore, we concluded that H. pylori-related ulcer patients who use NSAIDs or have large ulcers are more likely to present with upper gastrointestinal bleeding; that the CagA-bearing strains are not associated with the development of bleeding complication in patients with peptic ulcer diseases; and that the exact reason concerning the association between low bacterial density and ulcer bleeding merits further investigation.

The cause of slowed forearm median conduction velocity in carpal tunnel syndrome

OBJECTIVES

Attempting to answer a debate concerning the etiopathogenesis of the decreased forearm median motor conduction velocity (FMMCV), we tried to use proximal stimulation at the wrist, elbow, mid-arm and axillary regions to determine segmental median motor conduction velocity (MMCV). We also correlated the FMMCV with median motor distal latency (MMDL) and compound muscle action potential (CMAP) amplitudes of the abductor pollicis brevis (APB) muscle in order to assess whether the conduction block of large myelinating fibers or retrograde axonal atrophy was the major cause of the decreased FMMCV.

BACKGROUND

The cause of the decreased FMMCV resulting from either the conduction block of the large myelinating fibers at the wrist or distal compression with retrograde axonal atrophy remains an unresolved issue at the moment. Animal models have supported the hypothesis that the retrograde axonal atrophy might also occur in humans. Other authors believe the standard FMMCV is calculated by subtracting the distal latency which may not represent an exact assessment of FMMCV but rather the velocity of small fibers that persist through the carpal tunnel.

SUBJECTS AND METHODS

Patients with the clinical symptoms and signs of carpal tunnel syndrome (CTS) confirmed using standard electrodiagnosis were included. The patients were arbitrarily divided into two groups based on the FMMCV, one with reduced FMMCV (n = 20, FMMCV < 50 m/s) and the other with normal FMMCV (n = 35, FMMCV> or =50 m/s). Age-matched volunteers served as controls. We explored motor conduction proximally at wrist, elbow, mid-arm and axillary stimulation, and recorded at the APB muscles. Based on the latency differences, we calculated the FMMCV, distal arm MMCV (DAMMCV) and proximal arm MMCV (PAMMCV), and compared the conduction velocity (CV) differences of DAMMCV-FMMCV, PAMMCV-FMMCV and PAMMCV-DAMMCV in the two patient groups and the control. Furthermore, we correlated FMMCV with MMDL and CMAP amplitudes of APB muscle because MMDL and CMAP amplitudes might reflect the integrity of the large myelinating fibers.

RESULTS

CMAP amplitudes of APB muscle at wrist stimulation and MMDL were not correlated with FMMCV in either of the two patient groups; however, the CMAP amplitude was markedly decreased and MMDL was significantly prolonged when compared with normal controls. The significant increase of CV gradient of DAMMCV-FMMCV and PAMMCV-FMMCV without an equal increase of CV gradient of PAMMCV-DAMMCV only occurred in the reduced FMMCV patient group, suggesting that the conduction block is not the primary cause. The CV gradient of DAMMCV-FMMCV and PAMMCV-DAMMCV did not show any significant difference between patients with the normal FMMCV and the control group.

CONCLUSION

The retrograde axonal atrophy, not selective damage of the large fibers at the wrist, was the direct cause of the decreased FMMCV.

Impact of Helicobacter pylori eradication on the development of MALT, gland atrophy and intestinal metaplasia of the antrum

BACKGROUND

Chronic Helicobacter pylori infection leads to the development of mucosa-associated lymphoid tissue (MALT), gland atrophy, intestinal metaplasia, and in certain individuals, gastric lymphoma and adenocarcinoma. We conducted a prospective study to determine the effect of H pylori eradication on the development of MALT, gland atrophy and intestinal metaplasia.

METHODS

From July 1995 to October 1996, 63 consecutive patients with H pylori-associated peptic ulcer disease were enrolled in a bacterial eradication trial. The grade of MALT and the degree of gastritis of the antrum were assessed using Wotherspoon's scale and the Sydney system before treatment, and at eight weeks and one year after H pylori eradication therapy.

RESULTS

During the study period, 43 patients received complete follow-up. In the patient group with eradication failure (n = 22), MALT score was significantly decreased at the end of the eighth week (p < 0.05) but returned to the initial level by one year of follow-up. There were no changes in the scores for inflammation, neutrophil activity, gland atrophy or intestinal metaplasia at the end of the eighth week and at one year following H pylori eradication therapy. In contrast, there was a marked reduction in the MALT, inflammation, and activity scores at eight weeks (p < 0.01, < 0.05 and < 0.05, respectively) and one year after treatment (p < 0.05, < 0.001 and < 0.001, respectively) in the patient group with successful eradication (n = 21). However, no significant changes in gland atrophy and intestinal metaplasia were observed during the follow-up period.

CONCLUSIONS

Eradication of H pylori leads to regression of MALT in the stomach, but the degrees of gland atrophy and intestinal metaplasia remain unchanged, even after one-year of follow-up.

A 15-minute [13C]-urea breath test for the diagnosis of Helicobacter pylori infection in patients with non-ulcer dyspepsia

BACKGROUND

Non-ulcer dyspepsia (NUD) accounts for the majority of dyspeptic patients and studies on the epidemiology of Helicobacter pylori infection in NUD depend on a non-invasive and rapid diagnostic test. This study was performed to determine the sensitivity and specificity of a 15-min simplified protocol of the [13C]-urea breath test ([13C]-UBT) for the diagnosis of H. pylori infection in patients with NUD.

METHODS

One hundred and thirty-six patients with a clinical and endoscopic diagnosis of NUD were included. The [13C]-UBT was modified from the European standard protocol. The baseline breath sample was collected 5 min after the patient took a test meal and the 13CO2 was collected 15 min after the patient drank 100 mg [13C]-urea. The gold standard used for comparison was either a positive culture or positive histology + positive rapid urease test sampled on upper gastrointestinal endoscopy.

RESULTS

The prevalence of H. pylori infection in NUD by the gold standard was 59.6%, whereas that calculated by the [13C]-UBT was 60.3%. The sensitivity and specificity of [13C]-UBT was 93.8 and 89.1% compared with the gold standard. The shortened collection time and simplification of the procedure may have led to a decline in specificity.

CONCLUSION

The 15-min [13C]-UBT is a rapid but less specific protocol for detecting the presence of H. pylori infection in patients with NUD.

Impact of bacterial eradication on the cell proliferation and p53 protein accumulation in Helicobacter pylori-associated gastritis

BACKGROUND

This study investigates the cell proliferation and the expression of p53 protein in Helicobacter pylori (H. pylori)-associated gastritis and assesses the effect of bacterial eradication on these epithelial factors.

MATERIAL AND METHODS

Seventy-nine patients with H. pylori-associated gastritis were randomized into the control group (n = 38) and anti-H. pylori group (n = 41). Each patient received endoscopic examinations with gastric biopsy before and 8 weeks after the treatment. The specimens from gastric antrum were immunostained for monoclonal antibodies against the proliferating cell nuclear antigen (PCNA) and p53 protein.

RESULTS

In the control group, the total labeling index (L.I.) of PCNA and the positive index (P.I.) of p53 in the whole foveolar epithelium were unchanged after treatment. In the anti-H. pylori group, 35 of 41 cases (85.3%) achieved eradication of H. pylori. Amongst the H. pylori-eradicated cases, the total L.I. of PCNA in the whole foveolar epithelium did not meaningfully alter after H. pylori elimination (p > 0.05). However, a significant reduction of L.I. was observed in the middle compartments of the gastric pits (before vs. after treatment: 14.0 vs. 7.3, p < 0.05). With regard to the p53 expression, the P.I.s were significantly decreased in the whole foveolar epithelium (before vs. after treatment: 0.57 vs. 0.17, p < 0.05) and in each compartment of the gastric pits (before vs. after treatment: [upper compartment]: 0.34 vs. 0.15, p < 0.05; [middle compartment]: 0.67 vs. 0.23, p < 0.05; [lower compartment]: 0.71 vs. 0.20, p < 0.05) after eradication of H. pylori.

CONCLUSIONS

Bacterial eradication reverses the hyperproliferating status of the foveolar epithelium in patients with H. pylori gastritis and leads to a decrease in p53 accumulation in the epithelial cells.

Validation of the Brief Pain Inventory in a Taiwanese population

Assessment of pain in cancer patients is very important to all health care professionals. This paper describes the development of a Taiwanese version of the Brief Pain Inventory (BPI-T) and discusses its psychometric properties in Taiwan. The BPI-T was developed from the original BPI using back-translation and committee review. A total of 534 cytologically or pathologically diagnosed cancer patients in three medical centers in Taiwan were interviewed between July 1992 and October 1997. The intraclass correlation coefficient for the test-retest reliability was 0.79 for the pain severity scale and 0.81 for the pain interference scale. The explained variance for the within-scale factor analyses was larger than 60% in both scales. The coefficient alpha for the internal reliability was 0.81 for the severity scale and 0.89 for the interference scale. Confirmatory factor analysis of the BPI-T clearly identified the same two scales (severity and interference scales) in the 299 adult patients (age between 20-64) with high education (education years > 9) or patients at an early stage of disease. However, in the 235 nonadult patients with distant metastasis or low education patients with distant metastasis, the "most severe pain" item loaded more to the interference scale than the severity scale. Convergent validity of the pain severity was demonstrated by significant correlations with stage of disease (National Cancer Institute's Surveillance, Epidemiology, and End Results Program [SEER]), performance status (Eastern Cooperative Oncology Group [ECOG]), and pain interference. In conclusion, interviewer-administered BPI-T was a reliable instrument for cancer pain severity and its interference in Taiwan. Additionally, it was a valid instrument on adult cancer patients with high education or patients at an early stage of disease.

Recurrent inverted papilloma: diagnosis with pharmacokinetic dynamic gadolinium-enhanced MR imaging

BACKGROUND AND PURPOSE

Dynamic gadolinium-enhanced MR imaging has been used successfully to identify post-treatment recurrence or postoperative changes in rectal and cervical carcinoma. Our purpose was to evaluate the usefulness of dynamic gadolinium-enhanced MR imaging for distinguishing recurrent inverted papilloma (IP) from postoperative changes.

METHODS

Fifteen patients with 20 pathologically proved lesions (recurrent IP, 12; fibrosis or granulation tissue, eight) were enrolled in the study. Three observers, blinded to pathologic results, independently evaluated conventional MR images, including T1-weighted (unenhanced and postcontrast), proton-density-weighted, and T2-weighted spin-echo images. Results then were determined by consensus. Dynamic images were obtained using fast spin-echo sequences at 5, 30, 60, 90, 120, 150, 180, and 300 seconds after the injection of gadolinium-diethylene-triamine penta-acetic acid. Time-signal intensity curves of suspected lesions were analyzed by a pharmacokinetic model. The calculated amplitude and tissue distribution time were used to characterize tissue, and their values were displayed as a color-coded overlay.

RESULTS

T2-weighted images yielded a sensitivity of 67%, a specificity of 75%, and an accuracy of 70% in the diagnosis of recurrent IP. Contrast-enhanced T1-weighted images yielded a sensitivity of 75%, a specificity of 50%, and an accuracy of 65%. Pharmacokinetic analysis showed that recurrent IP had faster (distribution time, 41 versus 88 seconds) and higher (amplitude, 2.4 versus 1.2 arbitrary units) enhancement than did fibrosis or granulation tissue. A cut-off of 65 seconds for distribution time and 1.6 units for amplitude yielded a sensitivity of 100% and a specificity of 100% for diagnosing recurrent IP.

CONCLUSION

Dynamic MR imaging can differentiate accurately recurrent IP from postoperative changes and seems to be a valuable diagnostic tool.

Does cholecystectomy after endoscopic sphincterotomy prevent the recurrence of biliary complications?

BACKGROUND

The intact gallbladder after endoscopic sphincterotomy is thought to be a potential risk factor for recurrent biliary complications. The aim of this non-randomized prospective study was to investigate whether cholecystectomy soon after endoscopic sphincterotomy could prevent the recurrence of biliary complications.

METHODS

From January 1991 to October 1995, 140 patients with intact gallbladder underwent endoscopic sphincterotomy for clearance of stones in the bile duct. Of the 140 patients, 46 underwent elective cholecystectomy soon after sphincterotomy (group A) and 94 did not (group B). All 140 patients had quantitative cholescintigraphy after normalization of liver function and were followed on a regular basis with liver biochemistry, sonography, and/or computed tomography. Endoscopic retrograde cholangiography was also performed if a recurrent biliary problem was suspected.

RESULTS

After a median 43 months (range 23 to 80) of follow-up, 5 patients in group A developed bile duct stones whereas 12 patients in group B had recurrent stones; 4 patients in group A versus 6 patients in group B had recurrent biliary symptoms. One patient in group A and 5 patients in group B with recurrent biliary stones were without symptoms. In group B, the age, gender, diameter of the bile duct, preexisting cholelithiasis, abnormal filling of the gallbladder on quantitative cholescintigraphy, and presence of juxtapapillary diverticulum were not found to be the significant factors affecting the recurrence of biliary symptoms or stones. Endoscopic removal of recurrent biliary stones was successful in all patients. Three patients in group B underwent cholecystectomy after abatement of symptoms.

CONCLUSION

Elective cholecystectomy after endoscopic sphincterotomy does not reduce the incidence of recurrent biliary complications.

Oral drug of choice in carpal tunnel syndrome

BACKGROUND

Conservative treatment of mild to moderate carpal tunnel syndrome (CTS) is variable.

OBJECTIVE

To evaluate the effectiveness of commonly used oral medications such as diuretics, nonsteroid anti-inflammatory drugs (NSAIDs), and steroids in the treatment of CTS.

METHODS

Prospective, randomized, double-blind and placebo-controlled study of patients with clinical symptoms and signs of CTS, confirmed by standard electrodiagnosis. Baseline assessments included a standardized symptom questionnaire, rating five categories of symptoms (pain, numbness, paresthesia, weakness/clumsiness, and nocturnal awakening) on a scale from 0 (no symptoms) to 10 (severe). The total score in each of the five categories was termed the global symptom score (GSS). After baseline assessment, patients were randomized to the following treatment arms: 1) 4 weeks of placebo (n = 16); 2) 4 weeks of diuretic (trichlormethiazide, 2 mg daily; n = 16); 3) 4 weeks of NSAID-slow release (SR) (tenoxicam-SR, 20 mg daily; n = 18); and 4) 2 weeks of prednisolone, 20 mg daily, followed by another 2-week dosage of 10 mg daily (n = 23). Results of follow-up assessments in the second and the fourth weeks were identical to baseline scores. The changes in GSS were analyzed to determine the statistical difference.

RESULTS

No significant reduction from baseline GSS was seen at second, and fourth weeks in the placebo, NSAID-SR, and diuretic groups. However, the mean score at 4 weeks in the steroid group decreased significantly from a baseline of 27.9 +/- 6.9 to 10 +/- 7.4.

CONCLUSION

For patients with mild to moderate CTS who opt for conservative treatment, corticosteroids are of greater benefit.

The prevalence and severity of cancer pain: a study of newly-diagnosed cancer patients in Taiwan

Cancer pain is a relatively neglected public health issue in Taiwan. To characterize the nature of this problem, interviews were conducted on newly diagnosed cancer patients admitted to the Tri-Service General Hospital during a period of 18 months. Data were collected on the prevalence and severity of cancer pain, its treatment, and impact on patients in the week before the interview. Correlates of prevalence and severity of cancer pain were also examined. The final analysis included 296 patients who had no history of recent surgery. Most of the patients (69%) were interviewed within 14 days of their definitive diagnosis of cancer. Thirty-eight percent (N = 113) of the patients had cancer-related pain. Of these 113 patients, 65% had "significant worst pain" (worst pain level at or above five on a ten-point scale) and 31% had "significant average pain" (average pain level at or above five most of the time); 69% received no pain medication at all or inadequate medication (not "by the ladder"), and 23% had pain medication that was not administered at a fixed interval (not "by the clock"). Multivariate analyses showed that cancer pain was more prevalent in non-Mainlanders, those with a lower level of insurance, those with a history of excellent pain tolerance, those with poor Eastern Cooperative Oncology Group (ECOG) performance status, and those with distant metastases. Patients who were at greater risk of "significant worst pain" were those with regional or distant metastases, those in whom an inadequate analgesic medication had been prescribed (not "by the ladder"), and those who had received an appropriate analgesic medication but no fixed schedule dosing ("by the ladder" but not "by the clock"). Patients who were at greater risk of "significant average pain" were those not undergoing any resection of the tumor lesion and those who received an appropriate drug but no fixed schedule dosing ("by the ladder" but not "by the clock").

Expression of inducible nitric oxide synthase and apoptosis in human lupus nephritis

To understand the expression of inducible nitric oxide synthase (iNOS) and its possible association with apoptosis in human lupus nephritis, 48 renal tissue samples from patients with lupus nephritis were investigated immunohistochemically and by the terminal-deoxynucleotidyl-transferase-mediated dUTP nick end labeling method for the detection of iNOS and apoptosis, respectively. Modulation of apoptosis by p53 and Bcl-2 was also evaluated. This study showed immunohistochemical evidence of iNOS expression, predominantly in the glomerular and tubulointerstitial cells of class-IV lupus nephritis. The frequency of iNOS+ glomeruli was significantly correlated with that of apoptosis+ glomeruli, and the frequency of the latter was also significantly correlated with that of the glomeruli showing p53 overexpression. Bcl-2 was predominantly expressed in the cellular and fibrocellular crescents. This study suggests that induction of iNOS, and thus nitric oxide production, plays a role in the occurrence of apoptosis in the glomeruli of lupus nephritis; and the occurrence of apoptosis might in part be modulated by p53 and Bcl-2-related pathways. The expression of Bcl-2 in predominantly cellular and fibrocellular crescents suggests that Bcl-2 may participate in persistent proliferation of the crescentic cells.

Correlation of serum immunoglobulin G Helicobacter pylori antibody titers with histologic and endoscopic findings in patients with dyspepsia

Serum immunoglobulin G (IgG) antibody tests are used extensively. We attempted to find out whether the titers of anti-Helicobacter pylori IgG antibody correlated with the degree of macroscopic gastrointestinal damage, the severity of antral gastritis, and the density of antral H. pylori colonization in symptomatic patients. Peripyloric antral biopsy specimens were obtained from 50 consecutive patients with dyspepsia undergoing upper gastrointestinal endoscopy. The macroscopic gastrointestinal damage and the histologic grades of antral gastritis were scored by a modified Lanza scale and Sydney system, respectively. In addition, the densities of antral H. pylori colonization were graded semiquantitatively. Serum IgG antibodies to H. pylori were measured by enzyme-linked immunosorbent assay. Thirty-six (M/F = 29/7) of the 50 patients had H. pylori infection documented by histologic examination or rapid urease test or both. Among the subjects, the IgG antibody titers to H. pylori correlated significantly with the grades of antral polymorphonuclear cell infiltration (p = 0.002) and antral bacterial density (p = 0.01) but not with endoscopic scores, the grades of mononuclear cell infiltration, mucosal atrophy, or intestinal metaplasia (p > 0.05). In addition, endoscopic scores also were found to be significantly correlated with antral bacterial density (p = 0.049) and the grade of polymorphonuclear cell infiltration (p = 0.012). We therefore conclude that high titers of IgG antibody to H. pylori in patients with dyspepsia indicate dense H. pylori colonization and severe antral polymorphonuclear cell infiltration. However, it cannot replace endoscopic examination to evaluate the degree of macroscopic gastrointestinal damage.

Cardiovascular effects of nitric oxide and N-methyl-D-aspartate receptors in the nucleus tractus solitarii of rats

Nitric oxide (NO) is an endogenously synthesized effector molecule that acts as a neurotransmitter with novel properties in both the central and peripheral nervous systems. We previously reported that NO was involved in central cardiovascular regulation and modulated the baroreflex in the nucleus tractus solitarii (NTS) of rats. The aim of the present study was to determine whether NO and excitatory amino acids reciprocally release each other in the NTS. In normotensive Sprague-Dawley rats, intra-NTS microinjection of L-arginine (1 to 100 nmol/60 nL) produced a dose-dependent decrease in blood pressure and heart rate. Microinjection of excitatory amino acids L-glutamate and NMDA also produced depressor and bradycardic effects. These effects of L-glutamate or NMDA were blocked by prior administration of NO synthase inhibitor N(G)-methyl-L-arginine or N(G)-nitro-L-arginine methyl ester. Similarly, prior administration of N-methyl-D-aspartate (NMDA) receptor antagonist MK-801 and non-NMDA receptor antagonist 6,7-dinitroquinoxaline-2,3-dione significantly attenuated the depressor and bradycardic effect of L-arginine. These results demonstrated a reciprocal attenuation of NO synthase inhibitor and NMDA receptor antagonist on NMDA and L-arginine responses, respectively, in the NTS and suggest that NO and NMDA receptors may interact in central cardiovascular regulation.

Patient barriers to cancer pain management: from the viewpoint of the cancer patients receiving analgesics in a teaching hospital of Taiwan

BACKGROUND

The purpose of this study was to investigate the barriers to receiving analgesics for cancer pain in Taiwanese patients.

METHODS

The sample consisted of 128 hospitalized patients. All of the subjects were receiving analgesics. Three questionnaires entitled "Barriers Questionnaire-Taiwan Form (BQT)", "Brief Pain Inventory Short Form", and "Pain Management Index (PMI)" were used in this study. Data were analyzed using Student's t-test and Pearson correlation.

RESULTS

The results showed that most of BQT subscales including disease progression, time interval, tolerance, injection, addiction, fatalism and side effects were approaching toward the moderate or high end of the scale. 42.1% (n = 54) of the patients had negative PMI scores indicating that they were using less than adequate analgesics for pain. There was a significant difference between those who had adequate medication and those who did not, in terms of disease progression score and the total BQT score.

CONCLUSIONS

Overall the result revealed that pain management in these cancer patients was inadequate. Misconceptions on the part of patients still exist. Educational intervention could be an effective means for overcoming such barriers in Taiwanese patients who received analgesics for cancer pain.

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

BACKGROUND

Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients.

AIMS

To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence.

METHODS

One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient.

RESULTS

During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the differences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy.

CONCLUSION

Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.

The relation between thickened aortic valve and coronary artery disease

BACKGROUND

The relationship between the site of aortic valve thickening and ipsilateral coronary artery stenosis has not been reported previously. This study was undertaken to test the hypothesis that left-sided coronary cusp thickening may be associated with a left-sided coronary artery stenosis, and also as would be in the right-sided relationship.

METHODS

Two-dimensional echocardiography and cardiac catheterization were used to evaluate 420 consecutive patients. One hundred and six patients who had echocardiographic evidence of a single aortic valve thickening were studied to determine whether there was a relation between the coronary artery stenosis and the aortic valve thickening at the same side. Thickened aortic valve was defined as an aortic valve thickness to aortic wall thickness ratio > or = 1.0. Coronary artery disease (CAD) was defined as a > 50% luminal diameter narrowing of the left main coronary artery or a > 70% luminal diameter narrowing of the coronary artery other than the left main coronary artery.

RESULTS

Patients with a thickened aortic valve had a greater incidence of CAD (89/132, 67.4%) than those without (141/288, 49.0%) (p < 0.05). In patients with thickened aortic valves, the incidence of CAD was 45.5% in the fifth decade, 60% in the sixth decade, 69.6% in the seventh decade and 74.1% in the eighth decade. Progressive increase of the incidence of CAD was not found in patients without a thickened aortic valve. In the 106 cases with a single aortic valve thickening, 30 patients (28.3%) had a left coronary cusp thickening; 12 of them (40%) had a left-sided coronary artery stenosis, 3 patients (10%) had right coronary artery stenosis and 7 patients (23.3%) had no coronary artery stenosis. In the 34 patients with right coronary cusp thickening, the stenosis occurred at the left coronary artery in 13 patients (38.2%), at the right coronary artery in 3 patients (8.8%) and with normal coronary artery in 5 patients (14.7%). This finding did not support the relationship between thickened aortic valve and coronary artery disease at the same side (chi 2 = 0.06, p = 0.96).

CONCLUSIONS

There was a significantly greater incidence of CAD in patients with a thickened aortic valve than in those without. The incidence of CAD in patients with thickened aortic valves increased with age. There was no direct relationship observed between the site of aortic valve thickening and ipsilateral coronary artery stenosis.

Implications of serum basic fibroblast growth factor levels in chronic liver diseases and hepatocellular carcinoma

Angiogenesis occurs in response to tissue damage, and is of vital importance for tumor growth and metastasis. Basic fibroblast growth factor (bFGF), a well-known angiogenic factor, has been suggested to be a useful diagnostic marker in certain hypervascular tumors. However, the relevance of its detection has not been well evaluated in patients with hepatocellular carcinoma (HCC) and benign chronic liver diseases. In the current study, immunoassay of bFGF was performed on serum samples from 39 patients with HCC, 21 with liver cirrhosis, 22 with chronic hepatitis and 40 normal subjects. The serum bFGF level was significantly increased in patients with liver cirrhosis and HCC when compared with those with chronic hepatitis or normal subjects (all p-values < 0.001). However, no difference was observed between the groups with liver cirrhosis and HCC (p > 0.05). If we set 9.6 pg/ml (mean + 3 standard deviations of bFGF in the control group) as the upper limit of normal serum level of bFGF, elevated bFGF concentrations were noted in 9.1%, 42.9% and 51.3% of patients with chronic hepatitis, liver cirrhosis and HCC respectively. In non-cancer patients, the coexistence of acute illness (p = 0.000) was an independent factor related to the elevation of serum bFGF. On the other hand, a multivariate analysis demonstrated that both advanced stage of cancer (p = 0.026) and coexistence of acute illness (p = 0.000) influence the serum level of bFGF in patients with HCC. We conclude that serum bFGF levels are significantly higher in patients with HCC and are positively correlated with advanced tumor stage. Nevertheless, elevation of serum bFGF may also be observed in a significant number of patients with liver cirrhosis. Therefore, measurement of serum bFGF alone cannot be satisfactory as a tumor marker for diagnosis of HCC. In addition, it is important to point out that coexistence of acute illness may be a crucial confounding factor in the diagnosis or monitoring of any cancer by the estimation of serum bFGF.

Association of Sauropus androgynus and bronchiolitis obliterans syndrome: a hospital-based case-control study

In late April 1995, an outbreak of a poorly defined respiratory illness related to the ingestion of leaves of Sauropus androgynus was observed in southern Taiwan. To further evaluate the association between S. androgynus and bronchiolitis obliterans syndrome, a hospital-based case-control study was conducted with one case group and three different control groups at Veterans General Hospital-Kaohsiung between April and September 1995. A total of 54 cases (50 females, 4 males), 54 age- and sex-matched neighborhood controls, 54 matched routine physical check-up controls, and 54 matched self-referred patron controls (who had ingested S. androgynus yet without obstructive physiology) were interviewed for clinical symptoms, history of S. androgynus consumption, and potential confounding factors. All 54 cases (100%) ingested S. androgynus compared with only five (9%) neighborhood controls (matched odds ratio (OR) incalculable, p < 0.001) and two (4%) physical check-up controls (matched OR incalculable, p < 0.001). In the univariate analysis of 54 cases and 54 self-referred patron controls, factors associated with an increased risk of bronchiolitis obliterans syndrome were methods of food preparation (uncooked juice vs. stir fried or boiled dishes, matched OR 10.3 (95% confidence interval (CI) 1.3-84.4)); preparer of the S. androgynus-containing food (vendor only vs. patient only or patient plus vendor, matched OR 2.8 (95% CI 1.1-7.1)); total S. androgynus consumption quantity (> 4,500 vs. 413-2,063 g, matched OR 10.0 (95% CI 1.9-53.0)); duration of consumption (> 45 vs. 6-24 days, matched OR 2.1 (95% CI 1.2-3.8)); and midterm interruption (< 2 vs. 2-5 days per week, matched OR 2.6 (95% CI 1.1-6.1)). Additionally, multiple conditional logistic regression analysis of cases and self-referred patron controls revealed that a larger total amount of S. androgynus consumption, preparation of S. androgynus food without cooking, and ingesting S. androgynus food prepared by a vendor were the significant risk factors associated with bronchiolitis obliterans syndrome.

Expression of glomerular antioxidant enzymes in human glomerulonephritis

Increased oxidative stress can be correlated with glomerular injury. By immunohistochemical studies, we found expression of glomerular antioxidant enzymes (AOEs), including CuZn-superoxide dismutase (SOD), Mn-SOD, and catalase, in a wide variety of glomerular diseases. The distribution of the AOEs was either localized the in mesangial region or along the luminal surface or epithelial surface of the glomerular capillary wall. There was no significant difference of glomerular AOE expression among minimal change disease (MCD), IgM nephropathy (IgM N), focal segmental glomerulosclerosis, and membranous glomerulonephritis (MGN). However, when compared with MCD, IgM N and MGN, the glomerulus of lupus nephritis and IgA nephropathy expressed a significantly higher positive rate of AOEs (p = 0.04-0.002). The expression of AOEs had a trend to be associated with increased proliferative cell nuclear antigen-positive cells in the glomerulus of diffuse proliferative lupus nephritis (p = 0.056). No association was found between infiltrating leukocytes and AOE expression in all the disease groups. The glomerulus in kidneys with renal cell carcinoma expressed a significantly higher positive rate of AOEs and therefore could not be regarded as a normal control group. In summary, the immunohistochemical evidence of glomerular AOE expression in this study provides supporting evidence of oxidative stress in a wide variety of glomerular diseases.

When to discharge patients with bleeding peptic ulcers: a prospective study of residual risk of rebleeding

BACKGROUND

From January 1993 to December 1994, we conducted a prospective study to investigate the evolutionary change of rebleeding risk in bleeding peptic ulcers. To obviate possible confounding factors that would influence decision making for discharge of patients, subjects with coexistent acute illnesses, systemic bleeding disorders, alcoholism, and use of nonsteroidal anti-inflammatory drugs were excluded.

METHODS

Emergency endoscopies were performed in patients with hematemesis or a melena within 24 hours of admission. Ulcer lesions were divided into six categories according to endoscopic findings. The residual risks of rebleeding of each type of ulcers were calculated for 10 days, and the critical point of acceptable rebleeding risk after discharge was set at 3%.

RESULTS

Three hundred ninety-two patients with bleeding peptic ulcers completed the study. The ulcers, characterized by clean bases, red or black spots, adherent clots, nonbleeding visible vessels without local therapy, nonbleeding visible vessels with local therapy, and bleeding visible vessels with local therapy took 0, 3, 3, 4, 4, and 3 days, respectively, to decrease rebleeding risk to below the critical point. All episodes of fatal rebleeding (n = 4) occurred within 24 hours after admission.

CONCLUSIONS

Patients with clean-based ulcers can be discharged in the first day of admission. The optimal duration required for hospitalization of patients with ulcers characterized by nonbleeding visible vessels at initial endoscopy is 4 days. The remaining patients with ulcers marked by other bleeding stigmata may be discharged after a 3-day observation.

Cancer patients' knowledge of their diagnoses

The most frequently discussed ethical issue on the subject of cancer is whether patients should be told their diagnosis. Cancer patients' knowledge of their diagnosis and the relationship between patient characteristics and that knowledge were evaluated in a cross-sectional study. From July 1992 to December 1993 at Tri-Service General Hospital, Taipei, a total of 964 patients with cytologically- or pathologically-proven cancer were studied. Of those studied, 359 patients (37.2%) knew their diagnosis. The proportion of patients who believed that they had a benign tumor was 25.1%; 12.6% believed they had nonneoplastic disease (inflammation or other chronic disease); 7.5% believed they had precancerous changes; and 17.6% knew nothing about their diagnosis. Multivariate analyses showed that patients with the following characteristics were inclined to know their diagnosis: younger age (20-59 yr), higher levels of education (> 9 yr) with relatives of a high socioeconomic status, cancer of a genital organ, cancer requiring disfiguring treatment (osteosarcoma, leukemia), cancer in obvious sites (head and neck), cancer of more than one type (multiple primary lesions), cancer of good prognosis (excluding lung, liver, gall bladder or pancreatic cancers), aggressive anticancer treatment and longer duration of pathologic proof (> 14 d). The results showed that concealing the diagnosis from cancer patients is still very common in Taiwan. Patient's sociodemographic background and disease-related factors were the most important patient characteristics related to their knowledge of the diagnosis.

Outbreak of bronchiolitis obliterans associated with consumption of Sauropus androgynus in Taiwan

BACKGROUND

In August, 1995, there was an outbreak in Taiwan of rapidly progressive respiratory distress associated with consumption of uncooked Sauropus androgynus, a vegetable with a claimed yet unconfirmed effect on weight control. We report on 23 patients with strikingly similar clinical presentations.

METHODS

A structured questionnaire for clinical manifestations was completed. Radiographic findings, pulmonary physiological changes, immunological and microbiological studies, and pathological examination were evaluated.

FINDINGS

All patients were young and middle-aged women (mean age 39 years [range 21-52]). They took uncooked S androgynus juice, generally mixed with guava or pineapple juice, for a mean duration of 10 weeks. Progressive dyspnoea and persistent cough were the main symptoms on presentation. Pulmonary function testing uniformly revealed moderate to severe airflow obstruction with mean forced expiratory volume in 1 s (FEV1) of 0.66 L (26% of predicted). No bronchodilator response was observed. Room-air arterial blood gas analysis showed hypoxaemia (mean PaO2 9.6 [SD 1.6] kPa). Chest radiographs were essentially normal. High-resolution computed tomography showed bilateral bronchiectasis and patchy low attenuation of lung parenchyma with mosaic perfusion. Ventilation-perfusion scintigraphic findings were compatible with obstructive lung disease. Histopathology of open lung biopsy specimens in four patients confirmed the presence of bronchiolitis obliterans. Immunohistochemical stains of the open lung biopsy specimens showed predominance of T cells over B cells. Immunofluorescent stains for IgG, IgM, IgA, C1q, C3, and C4 were negative. Serum concentrations of tumour necrosis factor alpha were higher than those of normal controls. Clinical response to prednisolone was limited.

INTERPRETATION

We describe an unusual association between bronchiolitis obliterans and ingestion of the vegetable S androgynus. T-cell mediated immunity may be involved in the pathogenesis.

CYFRA 21-1 enzyme-linked immunosorbent assay. Evaluation as a tumor marker in non-small cell lung cancer

BACKGROUND

The CYFRA 21-1, a newly developed sandwich enzyme-linked immunosorbent assay (ELISA), was used to measure soluble cytokeratin 19 fragment in serum that is expressed in simple epithelium and its malignant counterpart. The present study was designed to investigate whether CYFRA 21-1 is a sensitive and specific tumor marker for non-small cell lung cancer.

METHODS

CYFRA 21-1 assay, using two specific monoclonal antibodies (KS 19.1 and BM 19.21) for cytokeratin 19, was measured in 312 serum samples, including 164 lung cancer, 118 benign pulmonary disease, and 30 healthy individuals. The sensitivity of CYFRA 21-1 was also compared with two other markers, carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC), in 164 patients with lung cancer.

RESULTS

The median value of healthy individuals was 1.3 ng/mL (95th percentile 1.8). In patients with benign pulmonary diseases, the median was 1.5 ng/mL (95th percentile 2.9). There is no significant difference between sexes, smoking habit, and the subgroups of benign pulmonary disease, such as tuberculosis, pneumonia, or COPD. Using the cutoff value of 3.3 ng/mL, defined at 95% specificity for benign lung disease, the sensitivities of CYFRA 21-1 for squamous cell carcinoma (n=74), adenocarcinoma (n=54), undifferentiated large cell carcinoma (n=11), and small cell lung cancer (n=25) were 62%, 39%, 36%, and 20%, respectively. Despite the cell types, the sensitivities of CYFRA 21-1 in non-small cell lung cancer (NSCLC, n=169) were 51% (CEA 42%, SCC 20%). The sensitivity of CEA was significantly higher in patients with adenocarcinoma (58%) than other markers; while in patients with squamous cell carcinoma, CYFRA 21-1 assay has the highest sensitivity. The median level of CYFRA 21-1 in squamous cell carcinoma is significantly higher than that of other cell types (Mann-Whitney test, p<0.001). The serum level and sensitivity of CYFRA 21-1 were well correlated with staging and tumor size in squamous cell carcinoma. The CYFRA 21-1 values were measured for monitoring progression of disease in 20 patients with squamous cell carcinoma. There is significant difference in paired observation of CYFRA 21-1 level in patients with progressive disease (Wilcoxon signed-rank test, p<0.05), but no difference was observed in patients with stabilized disease (p>0.1).

CONCLUSION

For patients with NSCLC, especially in squamous cell carcinoma, CYFRA 21-1 is not only a sensitive and specific tumor marker, but also may be a useful adjunctive marker for disease monitoring.

Cardiovascular effects of nitric oxide in the brain stem nuclei of rats

Nitric oxide, synthesized from the semiessential amino acid L-arginine by nitric oxide synthase, is a remarkable regulatory molecule and plays an important role in physiological functions. However, the physiological role of nitric oxide in cardiovascular regulation by the central nervous system is not well understood. In this study we investigated the cardiovascular effects of nitric oxide in the lateral ventricle, nucleus tractus solitarii, area postrema, and rostral ventrolateral medulla in urethane-anesthetized male Sprague-Dawley rats. Microinjection of NG-monomethyl-L-arginine, a nitric oxide synthase inhibitor, into the cerebral ventricle of rats elicited a dose-dependent increase in blood pressure and heart rate. This suggests that nitric oxide may be involved in central cardiovascular regulation. Unilateral microinjection (60 nL) of L-arginine (1 to 100 nmol) into the nucleus tractus solitarii and rostral ventrolateral medulla produced prominent dose-related depressor and bradycardic effects and reduced renal sympathetic nerve activity. However, L-arginine had no significant cardiovascular effects in the area postrema. In addition, 4 to 6 hours after intravenous injection of bacterial endotoxin-lipopolysaccharide (10 mg/kg), there was a time-related potentiation of the L-arginine-induced depressor and bradycardic effects in the nucleus tractus solitarii. These results indicate that nitric oxide is involved in central cardiovascular regulation. The depressor effect of nitric oxide in the nucleus tractus solitarii and rostral ventrolateral medulla may be through inhibition of renal sympathetic nerve activity.

Twice-per-day fractionated high versus continuous low dose rate intracavitary therapy in the radical treatment of cervical cancer: a nonrandomized comparison of treatment results

PURPOSE

To compare the efficacy of two twice-per-day fractionated high dose rate (HDR) brachytherapies with a historical control group treated with low dose rate (LDR) brachytherapy for cervical cancer patients.

METHODS AND MATERIALS

From 1985 to 1988, 92 patients with cancer of the cervic were treated by remote-controlled, HDR brachytherapy, six fractions of 7 Gy per fraction (42 Gy) at point A (HDR-6). Fifty-seven patients were treated with four fractions of 8 Gy per fraction (32 Gy) at point A (HDR-4). A twice-per-day program was used for all HDR patients by two split courses. As a historical control, treatment results of 259 patients treated with LDR brachytherapy (40 Gy in two split courses) were compared with those of the two HDR regimens. All patients received whole pelvic external irradiation, 36-45 Gy (mostly 40 Gy) before brachytherapy.

RESULTS

Five-year local control rates were not significantly different for the three groups (HDR-6 = 82.0%, HDR-4 = 85.5%, and LDR = 89.5%, respectively). Five-year survival rates were also comparable (67.7%, 77.9%, and 74.1%, respectively). However, late complications were lower in HDR-4 than HDR-6 (11.0% vs. 25.6%).

CONCLUSIONS

Both 5-year local control and survival rates were comparable among the three groups. However, HDR-4, which was more biologically equivalent to our LDR regimen, showed fewer complications compared to HDR-6. In addition, our twice-per-day schedule shortened the hospital stay.

Attenuated cardiovascular response to adenosine in the brain stem nuclei of spontaneously hypertensive rats

We previously reported that adenosine has significant depressor effects in the nucleus tractus solitarii and area postrema of the rat. The purpose of this study was to determine whether the spontaneously hypertensive rat (SHR) has abnormalities in medullary sensitivity to adenosine. Male SHR and Wistar-Kyoto (WKY) rats (aged 12 to 15 weeks) were anesthetized with urethane, and blood pressure was monitored intraarterially. Stereotaxic microinjection (60 nL) of adenosine was made into the nucleus tractus solitarii and the area postrema and was confirmed histologically. Dose-related decreases in mean blood pressure and heart rate occurred in both strains tested, and this effect was completely abolished by 1,3-dipropyl- 8-p-sulfophenylxanthine (0.92 nmol), a potent adenosine receptor antagonist. However, there were significant differences between SHR and WKY rats in the magnitude of blood pressure and heart rate depression. A similar pattern of response was found in the area postrema. Thus, adenosine is a potent depressor agent in the nucleus tractus solitarii and area postrema of rats, and adenosine has significantly fewer depressor effects in SHR. These data suggest that alterations in purinergic mechanisms of central cardiovascular control exist in the SHR model.

Cardiovascular effects of angiotensin III in brainstem nuclei of normotensive and hypertensive rats

The cardiovascular role of angiotensin III (ANG III) in the central nervous system is unclear. In this study, we investigated the hemodynamic effects of microinjection of ANG III and compared them with those of angiotensin II (ANG II) into the cerebral ventricle (i.c.v.), the area postrema (AP) and the nucleus tractus solitarii (NTS) of urethane-anesthetized rats. Male Sprague-Dawley rats [normal, renovascular hypertensive (2-kidney, 1-clip) and sham-operated groups] were used in this study. A dose-dependent pressor and bradycardic effect of ANG II and ANG III was observed after i.c.v. injection. When low doses of ANG II or ANG III were microinjected into both NTS and AP, a dose-dependent depressor and bradycardic effect were observed. The maximal depressor effect was observed at 9.6 pmol. When we increased the doses of ANG II or ANG III into the NTS, a pressor and tachycardic effect were observed. A significant difference of the cardiovascular effects of ANG III were noticed between renovascular hypertensive rats and sham-operated rats. The sympathetic nerve activity was inhibited by both pressor and depressor effects. The cardiovascular actions of both ANG II and ANG III were partially or completely abolished after pretreatment of their selective antagonists. These results indicate that the pressor effect of i.c.v. angiotensin are not mediated by activations of angiotensin receptors in the NTS or in the AP.

Prognostic factors in 43 cases of osteosarcoma

Osteosarcoma is the most common primary bone malignancy. The purpose of this study was to investigate the prognostic factors in the overall and disease-free survival rates by using univariate methods and Cox's multivariate regression model. Patients from Tri-Service General Hospital and Chang Gung Memorial Hospital in Kaohsiung with pathologically proven high-grade osteosarcoma were recruited for this study. There were 29 (67.4%) men and 14 (32.6%) women with a mean age of 17.8 years (range 8 to 35 years). Twenty-five cases (58.1%) were stage IIB, and 18 cases (41.9%) were stage III. The overall five-year survival rate was 15% for these 43 cases. Additionally, the disease-free survival rate was 20% at five years for the 25 stage IIB cases. Univariate and multivariate analyses showed that male gender, stage III disease, surgery only, radiotherapy only, chemotherapy only, no treatment and proximal extremity location were the unfavorable factors associated with death in these 43 cases; while male gender, radiotherapy only, chemotherapy only, no treatment and an elevated serum alkaline phosphatase level were the unfavorable factors associated with recurrence for stage IIB cases.

Risk factors of lung cancer by histological category in Taiwan

The relationship between various risk factors and lung cancer by different histological types was evaluated in a case-control study. A total of 72 adenocarcinoma patients and 59 squamous/small cell lung cancer patients, 262 hospital controls and 262 neighborhood controls were interviewed. Multiple conditional logistic regression analyses revealed that occupational exposures to asbestos and working as a cook were significant risk factors associated with adenocarcinoma of the lung. An inverse association between incense burning and the adenocarcinoma was noted. The squamous and small cell carcinomas of the lung were significantly associated with cigarette smoking, passive smoking exposure from friends at entertainment activities, the use of coal as cooking fuel, history of prior tuberculosis and chronic bronchitis, and occupational exposures to asbestos.

[Risk factors of lung cancer]

The relationship between various risk factors and lung cancer was evaluated in a case-control study. One hundred and forty-one cancer patients newly cytologically or pathologically diagnosed from May 1990 to July 1991 at Tri-Service General Hospital (TSGH) were recruited as cases. Two control groups were also studied: 282 hospital controls two-to-one matched with cases on sex, age, hospital of admission and insurance status were selected from the TSGH Ophthalmologic Department, and 282 neighborhood controls two-to-one matched on sex, age, and residence were randomly selected from eligible neighbors. A comparison of interview data between cases and hospital controls based on multiple conditional logistic regression revealed that cigarette smoking, keeping doves as pet, occupational exposure to cotton dust and working as a cook were risk factors for lung cancer. An inverse association between incense burning and lung cancer was noted. The comparison between cases and neighborhood controls showed lung cancer was significantly associated with cigarette smoking, keeping doves, prior chronic bronchitis, occupational exposure to cotton dust, asbestos and radiation, low frequency of burning incense, and low intake of vitamin A derived from vegetables and fruits. There was no association between lung cancer and working as a cook when cases were compared with neighborhood controls.

[A clinical study on 268 patients with cervical carcinoma]

Cancer is the leading cause of death in Taiwan with cervical carcinoma having the highest incidence rate (29.65 per 100,000) of all cancers among women. In the present study, we collected 268 consecutive cases of cervical carcinoma, seen in Tri-Service General Hospital from January 1983 to December 1984. The evaluation included a review of the case data including demographic features, symptoms, stage of cancer, reproductive history, pathology, and survival time (product limit method for survival). Results showed that in situ cervical carcinoma was diagnosed in 31 (11.5%) patients with a mean age of 47.7 years. Two hundred and thirty-seven patients (88.5%) with a mean age of 55.6 years were noted to have invasive carcinoma, showing stage I 22.4%, stage II 46.6%, stage III 10.1% and stage IV 9.3%. The ratio of invasive carcinoma to carcinoma in situ was 7.7:1. Ninety-two percent of patients were symptomatic on admission with vaginal bleeding (78%), vaginal discharge (16%) and abdominal pain (16%) being the most common, and the majority of these patients were symptomatic before cervical carcinoma was pathologically proved. Survival analysis showed five-year survival rates of 100%, 84.6%, 63.2%, 54.1% and 13.2% for stages O, I, II, III and IV, respectively. Low cervical carcinoma survival rates seemed clearly related to progression of the disease the presence of more extensive disease. The average age at the time of diagnosis was older and the clinical stage of disease was more advanced when compared with most developed countries.(ABSTRACT TRUNCATED AT 250 WORDS)

Chondrosarcoma of bone: a statistical analysis of prognostic factors

From 1980 to 1988, 30 cases of chondrosarcoma of the bone were treated surgically. Twenty-seven cases were followed from 6 months to 8.7 years (mean, 3.2 years). In all cases, a clinicopathological review was performed and the significance of prognostic factors were analyzed. The five-year survival of total patients was 88%. The survival was related to adequacy of treatment and histologic grade of the tumor. The five-year survival of adequately treated patients was 100%, but in inadequately treated patients it was 68%. At 8.7 years, 100% of the patients with grade-1 or grade-2 tumors survived, compared to 50% of the six-month survival rate in patients with the grade-3 tumors. None of the grade-1 or grade-2 chondrosarcomas metastasized, while 75% of grade-3 chondrosarcomas metastasized. The incidence of local recurrence was influenced by adequacy of treatment. At the final follow-up, the recurrence rate in the adequately treated group was 7%, while in the inadequately treated group it was 57%.

[The study of cancer pain and its correlates]

From August 1989 to December 1990, we collected 1523 cases of malignancy at Tri-service General Hospital (TSGH), and 470 cases (30.9%) of these malignancy had pain complaint. Moreover, we found that 68.1% (79/116 cases) of malignancy with bony metastasis had pain complaint. These informations were obtained from medical records. By counting the site of these 1523 cases, the leading sites in sequence were lung (207 cases), stomach (164 cases), cervix uteri (132 cases), breast (117 cases) and colon (91 cases). Regarding the incidence of cancer pain among these malignancy, bone cancer had the highest incidence (75.0%), followed by tongue (66.7%), brain (65.7%), liver (62.3%) and pancreas (60.0%). There was no difference of the incidence of cancer pain between male and female. The incidences of cancer pain in different age groups were different; the young patients had higher incidence than elderly patients. The analgesics for cancer pain used most frequently by physicians at TSGH were nonsteroid anti-inflammatory drugs and meperidine. Although the therapeutic management of cancer pain has been advancedly developed, we found that the treatments of cancer pain by physicians at TSGH were not aggressive enough. Therefore, promotion of the concept in advanced pain control and techniques is our important task in the near future.

Interrelation between alpha 2-adrenoreceptor system and neuropeptide Y in rat nucleus tractus solitarii

In several systems, alpha 2-adrenoreceptor agonists and neuropeptide Y (NPY) potentiate one another. We reported recently that NPY is a potent depressor agent in the nucleus tractus solitarii (NTS). The purpose of this study is to investigate the possible modulation of the agonist effect by NPY in this site. Microinjection (60nl) of NPY, anti-NPY antiserum, the alpha 2 agonist alpha-methylnorepinephrine (alpha-MNE), clonidine, and the alpha 2 antagonists idazoxan and yohimbine were made into the NTS. Administration of idazoxan (0.2 nmol) prior to the injection of NPY (2.3 pmol) attenuated the potent depressor and bradycardic effect of NPY. There was a similar attenuation of yohimbine's effect. Similarly, prior administration of the anti-NPY antiserum attenuated the depressor effect of the central antihypertensive agents, alpha-MNE and clonidine, whereas inactivated antiserum or control normal rabbit serum were not able to attenuate these effects. Even a subdepressor dose of NPY (47 fmol) could potentiate the effect of alpha-MNE. These results demonstrate a reciprocal potentiation of NPY and alpha 2 agonists in the brainstem, and suggest that NPY and catecholamines interact in central cardiovascular regulation.

Malignant melanoma: a clinicopathologic study of 22 cases

To provide updated clinicopathologic information on malignant melanoma, we studied 22 cases of malignant melanoma registered at Tri-Service General Hospital, Taiwan from 1983 to 1988. About 60% (13/22) of the patients had a tumor thickness of more than 2.5 mm and 45% (10/22) of the patients of over 4 mm. No patient had a thin melanoma (tumor thickness less than 0.76mm) when first diagnosed. Forty-four percent of the patients, which was twice as many as those (22%) in a previous study done at the same hospital, were classified as stage III. Eleven patients (50%) had acral lentiginous melanoma, the most common type of malignant melanoma in Orientals as previously reported. The cumulative survival rate was 59% and 39% at 3 years and 5 years respectively. The age primary sites, clinical stage and tumor thickness were retrospectively evaluated. Due to the small sample size, the accuracy of the statistical analysis of survival is questionable. An extensive island-wide multicenter epidemiologic study is mandatory to clarify this issue.

[Small cell lung cancer: survival analysis of 96 cases]

Existing records of 96 patients with small cell lung cancer (SCLC) at TSGH from 1983 to 1987 were analyzed to determine the relationship of survival rate and prognostic factors including age, sex stage, symptomatic history, liver metastasis, bone metastasis, albumin level, hemoglobin value, and choice of treatment. For the SCLC patients the median survival time (MST) is only 7.2 month, the 1-year survival rate is 25.1%, and the 2-year survival rate is 5.1%. The prognosis for patients with liver or bone metastasis was poor. Sixteen prognostic variables were evaluated in a Cox proportional hazard regression model analysis to assess their prognostic value. It is suggested that improving survival rate for patients with SCLS can be obtained by using selective combined therapy.