Hyperbaric Oxygen Therapy Adjuvant Chemotherapy and Radiotherapy through Inhibiting Stemness in Glioblastoma

Glioblastoma multiforme (GBM) is the most common and deadliest primary brain tumor in adults. Despite the advances in GBM treatment, outcomes remain poor, with a 2-year survival rate of less than 5%. Hyperbaric oxygen (HBO) therapy is an intermittent, high-concentration, short-term oxygen therapy used to increase cellular oxygen content. In this study, we evaluated the effects of HBO therapy, alone or combined with other treatment modalities, on GBM in vitro and in vivo. In the in vitro analysis, we used a 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay to assess the effects of HBO therapy alone, a colony formation assay to analyze the effects of HBO therapy combined with radiotherapy and with temozolomide (TMZ), and a neurosphere assay to assess GBM stemness. In the in vivo analysis, we used immunohistochemical staining and in vivo bioluminescence imaging to assess GBM stemness and the therapeutic effect of HBO therapy alone or combined with TMZ or radiotherapy, respectively. HBO therapy did not affect GBM cell viability, but it did reduce the analyzed tumors' ability to form cancer stem cells. In addition, HBO therapy increased GBM sensitivity to TMZ and radiotherapy both in vitro and in vivo. HBO therapy did not enhance tumor growth and exhibited adjuvant effects to chemotherapy and radiotherapy through inhibiting GBM stemness. In conclusion, HBO therapy shows promise as an adjuvant treatment for GBM by reducing cancer stem cell formation and enhancing sensitivity to chemotherapy and radiotherapy.

The relationship of leukoaraiosis and the clinical severity of vascular Parkinsonism

Vascular Parkinsonism (VP) is referred to as secondary Parkinsonian syndrome. It occurs with lacunar state or sub-cortical white matter micro-angiopathy and is highly associated with vascular risk factors and leukoaraiosis, also known as cerebral white matter lesions (WML). This study aimed to assess the prevalence of different vascular risk factors and WML in patients with VP, and their impact on clinical features. Sixty-two consecutive VP patients (70.2 ± 9.2 years) were evaluated for clinical severity using the Unified Parkinson's Disease Rating Scale (UPDRS). WML was assessed and scored on fluid-attenuated inversion recovery T2-weighted (FLAIR) magnetic resonance imaging (MRI). Cerebro-vascular risk factors, WML severity, and the UPDRS for clinical disability were analyzed statistically. There were no associations between WML score and age, sex, hypertension, diabetes, previous stroke, cardiac disease, cigarette smoking, or serum levels of cholesterol and triglyceride. The WML score positively correlated with UPDRS part I (p = 0.035) and part III (p = 0.041) scores. After adjustments for age, gender, stroke history, and use of levodopa, the WML score was associated with the UPDRS total (p = 0.020), part I (p = 0.012), part II (p = 0.039), and part III (p = 0.019) scores. The severity of WML is not associated with conventional vascular risk factors in VP patients but is significantly correlated with the UPDRS total and all sub-scores, which suggests that disruption of the cortico-sub-cortical circuits may lead to impaired mentation, behavior and mood, activities of daily living, and motor performance in these patients.

Risk factors of hyperammonemia in patients with epilepsy under valproic acid therapy

Hyperammonemia has been reported to be associated with patients who receive valproic acid (VPA) therapy. This study aimed to determine the risk factors for hyperammonemia in patients with epilepsy treated with VPA. One hundred and fifty-eight adult patients with epilepsy aged older than 17 years who received VPA therapy were enrolled into this study. Blood samples were taken during the interictal state and analyzed for the blood level of ammonia. Statistical analysis was conducted between different groups of patients. The results showed that the frequency of hyperammonemia associated with VPA therapy was 27.8% (ammonia level >93 µg/dL), and 5.1% of the patients had severe hyperammonemia (ammonia level >150 µg/dL). The blood ammonia level was significantly correlated with the dosage of VPA and the plasma concentration of VPA. An increase of 1 mg in the dosage of VPA increased the risk of hyperammonemia by 0.1%. In addition, combination treatment with liver enzyme inducing antiepileptic drugs (AEDs) and antipsychotic drugs increased the risk of hyperammonemia. In conclusion, the use of VPA in adult patients with epilepsy was associated with a dose-dependent increase in blood concentrations of ammonia. Combination treatment with liver enzyme-inducing AEDs and antipsychotic drugs increased the risk of VPA-induced hyperammonemia. Most of the patients with VPA-induced hyperammonemia were asymptomatic; however, if patients taking VPA present with symptoms such as nausea, fatigue, somnolence, ataxia, and consciousness disturbance, the blood ammonia level should be measured.

Association between MIF gene polymorphisms and carotid artery atherosclerosis

Atherosclerosis is a chronic inflammatory disorder. Macrophage migration inhibitory factor (MIF) is a potent cytokine that plays an important role in the regulation of immune responses. Polymorphisms including five- to eight-repeat CATT variants ((CATT)(5-8)) and G-173C in the promoter region of the MIF gene are associated with altered levels of MIF gene transcription. The purpose of the study is to investigate the relationship between promoter polymorphisms of the MIF gene and the severity of carotid artery atherosclerosis (CAA). The severity of CAA was assessed in 593 individuals with a history of ischemic stroke by using sonographic examination, and the MIF promoter polymorphisms of these individuals were genotyped. The carriage of (CATT)7 (compared to genotypes composed of (CATT)5, (CATT)6, or both), carriage of C allele (compared to GG), and carriage of the haplotype (CATT)7-C (compared to genotypes composed of (CATT)5-G, (CATT)6-G, or both) were significantly associated with an increase in the severity of CAA. We conclude that polymorphisms in the MIF gene promoter are associated with CAA severity in ischemic stroke patients. These genetic variants may serve as markers for individual susceptibility to CAA.

Sleep quality and daytime sleepiness in patients with epilepsy

PURPOSE

Poor sleep quality and excessive daytime sleepiness (EDS) are common complaints of patients with epilepsy (PWE). This study aimed to evaluate possible predisposing factors for EDS and subjective sleep quality in PWE.

METHODS

One hundred and seventeen PWE were enrolled and 30 healthy volunteers were recruited as controls. EDS was evaluated by the Epworth Sleepiness Scale (ESS) while the Pittsburg Sleep Quality Index (PSQI) was designed to evaluate overall sleep quality. Clinical baseline data and possible risk factors for sleep disturbances were included in the statistical analysis.

RESULTS

Twenty percent of PWE (23/117) and 7% of healthy controls (2/30) had excessive daytime sleepiness (p = 0.007). PWE had significantly higher PSQI total scores (6.5 ± 3.8 vs. 3.7 ± 2.9), sleep latency (1.2 ± 0.8 vs. 0.6 ± 0.7) and sleep efficiency (0.8 ± 1.0 vs. 0.0 ± 0.2) scores than the controls (all p < 0.001). A significantly higher prevalence of poor sleep quality was found in the partial seizure, non-seizure-free, and polytherapy groups (all p < 0.05). Multivariate analysis showed that poor seizure control was the strongest independent risk factor for poor sleep quality (OR = 2.43, 95% CI = 1.15-5.15, p = 0.02).

CONCLUSION

EDS and poor sleep quality are common in PWE and are closely related to partial epilepsy, poor seizure control, and polytherapy. These relationships must be addressed in order to provide the best management of sleep disturbance in such patients.

Star fruit intoxication in a patient with moderate renal insufficiency presents as a posterior reversible encephalopathy syndrome

PURPOSE

Star fruit has been reported to contain neurotoxins that often cause severe neurological complications in patients with uremia or severe chronic renal insufficiency. However, the occurrence of neurotoxicity in patients with mild or moderate renal insufficiency has rarely been mentioned.

CASE REPORT

A 67-year-old woman who had diabetes mellitus and moderate renal insufficiency presented with acute onset of hiccups and nausea two hours after ingestion of one fresh star fruit. She further presented with progressively incoherent speech, echolalia and bizarre behavior. On the next day, her consciousness level declined to deep coma and she experienced two seizures. Brain magnetic resonance imaging examinations revealed a focal cerebral lesion over the left occipital area. The clinical symptoms recovered and the brain lesion reversed after emergency hemodialysis.

CONCLUSION

The clinicians should be aware that star fruit intoxication must be considered when patients with a chronic renal disease, even mild or moderate chronic renal insufficiency, present with unexplained neurological or psychiatric symptoms. Emergency hemodialysis or other replacement therapies may be required for the management of acute star fruit intoxication.

Episodic pain syndrome restricted cheiro-oral region associated with pontine lesion

Other than from the thalamus and sensory cortex, episodic pain is an extremely rare neurological manifestation in the central compartment. This study reports a middle-aged man who experienced an acute onset of episodic oscillatory burning pain restricted to the cheiro-oral region, who was found to have a singular infarct at the left tegmental pons. A close relationship between his pain attack and an elevation of arterial blood pressure was clearly observed. Blood adenohypophyseal hormones and electroencephalogram did not reveal an abnormality in the ictus. Neuroimaging and clinical studies did not support involvement of the thalamus, periaqueductal gray matter, hypothalamus or regional structure. Therefore, episodic pain may be an isolated manifestation with a pontine lesion. A relapsing expansion of focal cerebral oedema with fluid retention may have corresponded to the oscillation of his sensory deficit. This accumulating, devastating calamity by a repetitive and paroxysmal offense after a blood-brain barrier breakdown should be cautiously reviewed.

Association of plasma homocysteine concentration with cerebral white matter hyperintensity on magnetic resonance images in stroke patients

BACKGROUND

Homocysteine (Hcy) has been recognized as a risk factor for atherosclerosis. White matter hyperintensity (WMH) on MRI has been regarded as a hallmark for cerebral small vascular disease. The study is to investigate the relationship between plasma Hcy level and WMH on a hospital-based cohort of Taiwanese stroke patients.

METHODS AND RESULTS

A total of 352 consecutive stroke patients (64.7+/-11.2 years) were included. Severity of WMH was semi-quantitatively evaluated with a scoring system. The top WMH score tertile was defined as severe white matter change (sv-WMH). Associations between Hcy tertile levels and sv-WMH were examined, adjusting for demographics and atherosclerosis risk factors. Subjects in the top Hcy tertile (>10.25 micromol/L) had higher WMH scores and prevalence of sv-WMH than those in the middle and in the bottom tertile. The adjusted odds ratio of having sv-WMH was 2.04 (95% confidence interval 1.20-3.47, p=0.008) for the top Hcy level tertile than for the lower two tertiles combined.

CONCLUSION

Hcy is a risk factor for cerebral white matter lesion in stroke patients. Even mild hyperhomocysteinemia can significantly increase severity of cerebral microangiopathy.

The relation between plasma homocysteine level and cardiovascular risk factors in cerebral ischemia

PURPOSE

Hyperhomocysteinemia (HHcy) is associated with a higher risk of cerebral ischemia and other vascular thrombosis. Homocysteine is greatly influenced by a broad spectrum of physiological and pathological conditions but the confounding factor for HHcy is unknown in our population, especially in normocreatininemic individuals. It is our aim in this study to elucidate the relation between homocysteine and cardiovascular risk factors, and also describe the distribution of plasma homocysteine level in cerebral ischemia patients with normal serum creatinine level.

METHODS

A retrospective study was conducted to understand the frequency of HHcy in cerebral ischemia patients, and the confounding cardiovascular risk factors in HHcy. Patients were classified into two groups by their plasma homocysteine levels; group I patients were those whose level was > or = 12 microM/L whereas group II < 12 microM/L.

RESULTS

A total of 218 patients were enrolled. Their plasma homocysteine level ranged from 3.57 to 46.37 microM/L (mean: 10.01 +/- 5.03 microM/L). Group I included 45 patients whereas group II 173 patients. The frequency of hypertension, diabetes mellitus and cardiac disease, as well as age, aminotransferases, total cholesterol, triglyceride, albumin, hematocrit, hemoglobin and leucocyte count did not differ between group I and II patients, except serum creatinine level was higher in group I patients (p < 0.01). Serum creatinine level correlated directly to and was an independent predictor for the plasma homocysteine level.

CONCLUSIONS

HHcy is common in our cerebral ischemia patients. Since renal function is a determinant for HHcy even in normocreatininemic patients, as a cardiovascular risk factor which detriments the renal function, it should be regularly monitored as HHcy is amenable for treatment.

Vigabatrin-attributable visual field defects in patients with intractable partial epilepsy

INTRODUCTION

Vigabatrin (VGB) is implicated to cause visual field defects. We estimated the prevalence, described the characteristics and investigated the risk factors of VGB-attributable visual field defects.

METHODS

Patients with intractable partial epilepsy under VGB add-on treatment received static perimetric examinations. Visual field charts were reviewed and interpreted using a three-grade system. Clinical features and therapeutic courses were analyzed for possible risk factors.

RESULTS

Visual field defects in at least one eye were detected in 27 (79%) of 34 patients. In the subgroup of 27 patients with both eyes reliably tested, 16 (59%) had bilateral defect, among whom seven were severely involved and showed nasally dominant, crescent or concentric defect. Five patients had unilateral visual field defects. Four out of the 27 affected patients reported blurred vision. No statistically significant differences were noted between patients with and without visual field defects in terms of gender, age, duration or etiology of the epilepsy, and duration, maximum daily dose, or cumulative dose of VGB.

CONCLUSIONS

There was a high prevalence of VGB-attributable visual field defects. No risk factors could be identified. Routine initial and regular follow-up of visual field examination, especially that focusing within a range of central fixation to 60 degrees, should be performed in patients on VGB.

Ictal paralysis with tonic eye gazing mimicking a pontine infarction

PURPOSE

Concomitant positive and negative motor phenomena in a single seizure have not been reported before.

METHOD

We used an extensive history review, neurological examination, EEG, MRI and SPECT study to demonstrate a rare combination of motor presentations as an ictal phenomenon.

RESULT

A 64-year-old male was brought to the emergency room with dizziness, progressive drowsiness and left hemiparesis. A spontaneous eye deviation to the left side with nystagmus was observed. A right pontine lesion was tentatively diagnosed. However, a focal motor seizure of the patient's left face and limbs occurred 3.5h later. A brain MRI revealed a high signal in the right amygdala, hippocampus and thalamus, instead of the pons. An EEG showed periodic epileptic discharges in the right posterior temporal parietal region. Regional hyperperfusion was found by brain SPECT. The level of consciousness improved dramatically after adequate phenytoin treatment.

CONCLUSION

A posterior temporal-parietal seizure can present with a prolonged ictal paralysis, a positive ocular nystagmoid deviation and an altered level of consciousness. The EEG is essential for a correct diagnosis, especially with a negative or an unexplainable MRI study. The SPECT has an additional role for the differential diagnosis.

Detection and quantification of glucuro- and sulfoconjugated metabolites in human urine following oral administration of xenobiotic 19-norsteroids

Recently, the endogenous origin of nandrolone (19-nortestosterone) and other 19-norsteroids has been a focus of research in the field of drug testing in sport. In the present study, we investigated metabolites conjugated to a glucuronic acid and to a sulfuric acid in urine following administration of four xenobiotic 19-norsteroids. Adult male volunteers administered a single oral dose (10 mg) of each of four 19-norsteroids. Urinary samples collected from 0 to 120 h were subjected to methanolysis and beta-glucuronidase hydrolysis and were derivatized by N-methyl-N-trimethylsilyltrifluoroacetamide (MSTFA) before gas chromatography-mass spectrometry analysis. We confirmed that 19-norandrosterone (19-NA) and 19-noretiocholanolone (19-NE) were present in both glucuronide (g) and sulfate (s) conjugates and 19-norepiandrosterone (19-NEA) was excreted exclusively as a sulfate fraction in urine of all 19-norsteroids tested. The overall levels of the three metabolites can be ranked as follows: 19-NA(g+s)>19-NE(g+s)>19-NEA(s). The concentration profiles of these three metabolites in urine peaked between 2 to 12h post-administration and declined thereafter until approximately 72-96 h. 19-NA was most prominent throughout the first 24 h post-administration, except for a case in which an inverse relationship was found after 6h post-administration of nandrolone. Furthermore, we found that sulfate conjugates were present in both 19-NA and 19-NE metabolites in urine of all 19-norsteroids tested. The averaged total amounts of metabolites (i.e. 19-NA(s+g)+19-NE(s+g)+19-NEA(s)) excreted in urine were 38.6, 42.9, 48.3 and 21.6% for nandrolone, 19-nor-4-androsten-3,17-dione, 19-nor-4-androsten-3beta,17beta-diol and 19-nor-5-androstene-3beta,17beta-diol, respectively. Results from the excretion studies demonstrate significance of sulfate-conjugated metabolites on interpretation of misuse of the 19-norsteroids.

Magnetic resonance imaging and single-photon emission computed tomography changes in hypoglycemia-induced chorea

We present two case studies, one of generalized chorea and one of hemichorea, both after severe hypoglycemia episodes. Both cases showed hyperperfusion in their SPECT scans. The MRI and SPECT findings serve as clues regarding the role of basal ganglion dysfunction associated with chorea.

Spontaneous intracranial hypotension in a patient with reversible pachymeningeal enhancement and brain descent

A 56-year-old woman presented with severe orthostatic headache in association with nausea and vomiting. Lumbar puncture for the patient revealed significantly low cerebrospinal fluid pressure (CSF) and the clinical diagnosis of intracranial hypotension syndrome was made. An initial gadolinium-enhanced brain magnetic resonance imaging (MRI) disclosed diffuse meningeal enhancement as well as brain sagging. No definite CSF leakage was found using radionuclide cisternography. Her headaches abated with proper usage of analgesics, strict bed rest, and intravenous hydration. Follow-up neuroimaging studies showed partially resolved meningeal enhancement 2 months after treatment and complete resolution 6 months after treatment. The temporal changes found on MRI suggest that the pachymeningeal enhancement is reversible in patients with spontaneous intracranial hypotension. Moreover, proliferation of meninges is likely to be responsible for this type of delayed resolution phenomenon.

Immunohistochemical analysis of epidermal growth factor receptor family members in stage I non-small cell lung cancer

BACKGROUND

To elucidate the relationship between the expression of epidermal growth factor receptor family members (ErbB-1, neu/ErbB-2, ErbB-3, and ErbB-4) and tumor recurrence.

METHODS

We used immunohistochemistry to examine the expression of four epidermal growth factor receptor family members in 73 patients with stage I non-small cell lung cancer.

RESULTS

Using Cox univariate analysis, we determined that angiolymphatic tumor emboli and non-well-differentiated tumor cells were two significant conventional pathologic predictors of tumor recurrence, and that ErbB-1 and ErbB-3 were also significant predictors. Co-expression of ErbB-1+, -3+, or expression of three or more epidermal growth factor receptor family members had a significant effect on lung cancer recurrence. A stepwise multivariate Cox proportional hazards regression analysis provided a predictive model for tumor recurrence.

CONCLUSIONS

The present study shows that in patients with a non-well-differentiated tumor, overexpression of ErbB-3 is a useful marker for predicting tumor recurrence. The present study also confirmed that ErbB-1 expression increased in proportion to the loss of tumor differentiation. The correlation between ErbB-3 and distant metastasis was good.

Phase I and pharmacokinetic study of a stable, polyethylene-glycolated liposomal doxorubicin in patients with solid tumors: the relation between pharmacokinetic property and toxicity

BACKGROUND

Compared with free drug, sterically stabilized liposomal drug has prolonged circulation time and, thereby, higher tumor selectivity and antitumor activity. The stability in plasma is an important consideration in the formulation of clinically useful liposomal drug. A Phase I study of a stable liposomal doxorubicin with polyethylene glycol (PEG) coating and phospholipid component of distearoyl phosphatidylcholine (DSPC) was performed to characterize its pharmacokinetic properties, toxicity profile, and maximal tolerated dose.

METHODS

The starting dose was 30 mg/m(2) every 3 weeks with an increment of 10 mg/m(2) for each level. A cohort of at least three patients was entered for each level. Dose escalation stopped when more than one-third of patients had dose limiting toxicity (DLT), which was equal to or more than Grade 3 nonhematologic toxicity. Blood was sampled immediately before and at 5 minutes, 2 hours, 4 hours, 10 hours, 24 hours, 48 hours, 72 hours, and 168 hours after the completion of PEGylated liposomal doxorubicin (PLD) infusion. Plasma level of doxorubicin was determined with fluorometry, and the pharmacokinetic properties were analyzed.

RESULTS

Twenty-six patients were entered, and 101 courses were studied. This DSPC PLD had a steady-state distribution volume (Vss) of 2.4 +/- 0.9 liters (mean +/- standard deviation), a clearance of 0.027 +/- 0.010 liters per hour, and a beta half-life of 65.0 +/- 17.8 per hour. These characteristics were dose independent, and the Vss and clearance were smaller than those of a well characterized PLD comprised of hydrogenated soybean phosphatidylcholine (HSPC). At the dose level of 50 mg/m(2), its plasma area under the concentration time curve was approximately twice that of HSPC PLD. Attenuation of acute toxicity, such as nausea, emesis, and alopecia, was noted in all dose levels. However, stomatitis was common from the dose level of 30 mg/m(2), and its incidence and severity increased with dosage and became dose limiting at 50 mg/m(2). A dose of 45 mg/m(2) every 3 weeks was then given in eight patients, and the side effects were acceptable. This dose was recommended for Phase II clinical trials. Fourteen of 17 patients with a dose level > or = 40 mg/m(2) were evaluable for response, but none achieved partial remission.

CONCLUSIONS

This DSPC PLD had the characteristics of second-generation liposomal drug pharmacokinetically and toxicologically. The incidence of severe stomatitis was higher than that of HSPC PLD, corresponding to the difference in pharmacokinetics. Only limited antitumor activity was observed, although defining its therapeutic application will need further Phase II studies. Further prolongation of plasma stability of PLD may not be clinically beneficial considering the increased stomatitis and the reduced achievable dose intensity.

Redoing reconstruction of the esophagus using remnants of the ileo-left colon aided by microvascular anastomosis

Theoretically, the jejunum, fasciocutaneous or myocutaneous flap is recommended as an esophageal substitute in redoing reconstruction of the esophagus after a second incidence of corrosive injury. However, other esophageal substitutes should also be considered. We present a case of a 42-year-old woman who underwent esophageal reconstruction using an ileocolon graft for corrosive esophageal stricture ten years before. The patient ingested caustic drain cleaner again and underwent resection of the ileocolon graft secondary to corrosive necrosis. Two and a half months after the second incidence of corrosive injury, reconstruction of the esophagus was again performed using a graft of remnant ileo-left colon aided by microvascular anastomosis. The patient was able to swallow a regular diet after the procedure. Remnant ileo-left colon is a good alternative esophageal substitute in cases of repeated corrosive injury.

Surgery for lung abscess in immunocompetent and immunocompromised children

PURPOSE

The aim of this study was to evaluate the surgical management results of lung abscess in immunocompetent and immunocompromised children.

METHODS

Surgery was performed on 30 children with lung abscess or necrotizing pneumonia refractory to medical treatment in a 12-year period. Of them, 23 were immunocompetent, and 7 were immunocompromised. Pulmonary resection was performed including unilateral lung in 28, bilateral in 2, and 2 lobes in 6. Concomitant decortication was performed in 18 (78.2%) immunocompetent patients.

RESULTS

Increased incidence of surgery for lung abscess was caused mainly by drug-resistant and fungal infection. Surgery was performed commonly for bacterial lung abscess on patients less than 5 years old and fungal lung abscess on adolescence. A multiple small abscess was the predominant type of abscess in immunocompetent patients, whereas 2-lobe involvement tended to occur in immunocompromised patients. Fungal lung abscess tended to occur on left lung and in female patients. Left lower lobe was involved most commonly in both groups of patients in which majority need lobectomy. Immunocompromised patients required a more extensive pulmonary resection. There were 3 postoperative complications (morbidity of 10.2%) with no postoperative mortality. Length of postoperative hospital stay ranged from 6 to 85 days with average of 18.4 days.

CONCLUSIONS

The incidence and pattern of lung abscess that required surgery between immunocompetent and immunocompromised children were different. A more aggressive, extensive surgical procedure is preferable for immunocompromised patients, and the surgical results were comparatively excellent to immunocompetent patients. However, the prognosis of immunocompromised children depends on their underlying disease process.

Intrathoracic muscle flap transposition in the treatment of fibrocavernous tuberculosis

BACKGROUND AND OBJECTIVE

Conventionally, pulmonary resection with thoracoplasty is used to treat fibrocavernous complication of pulmonary tuberculosis. This operation is usually bloody, time-consuming with complicated postoperative course. To prevent massive blood loss and preserved pulmonary function, a more simplified operative procedure, cavernostomy combined intrathoracic muscle flap transposition was used and the outcome was evaluated in this study.

DESIGN

Retrospective review.

METHODOLOGY

Between December 1989 and June 1996, a total of ten patients with fibrocavernous pulmonary tuberculosis were managed using cavernostomy combined with intrathoracic muscle flap transposition. Five of them had concomitant aspergilloma within the cavity while three had multiple drug resistant pulmonary tuberculosis. The muscle flap was used to plombage the cavity and reinforce the closure of bronchopleural fistula after cavernostomy.

RESULTS

Six postoperative complications occurred in five patients, including reformation of cavity (2), bronchopleurocutaneous fistulae (3), and postoperative bleeding (1). The success or failure of intrathoracic muscle flap transposition on patients with fibrocavernous tuberculosis was significantly correlated with the size of the cavity (194.0+/-11.2 vs. 283.0+/-44.6 cm(3), P=0.016) and the number of bronchopleural fistulae (1.6+/-0.4 vs. 4.0+/-0.4, P=0.008). There was no operative death and in long term follow-up, there was no recurrence of hemoptysis or deterioration of pulmonary function in the successful group of patients.

CONCLUSIONS

Cavernostomy combined with intrathoracic muscle flap transposition can be used to treat well-selected fibrocavernous pulmonary tuberculosis patients, except on patients with large size cavity, multiple bronchopleural fistulae or multiple drug resistance tuberculosis.

Pegylated liposomal doxorubicin in treating a case of advanced hepatocellular carcinoma with severe hepatic dysfunction and pharmacokinetic study

BACKGROUND

There is lack of effective and safe chemotherapy for advanced hepatocellular carcinoma. Polyethylene glycol-coated (pegylated) liposomal doxorubicin (PLD) has long circulation time and enhanced drug accumulation in the tumor tissues. It has significant activity in Kaposi's sarcoma, breast and ovarian cancers and the acute adverse effects of free drug are reduced.

PATIENTS AND METHODS

A patient with advanced hepatocellular carcinoma was treated with PLD and a pharmacokinetic study was performed. Initial serum total and direct bilirubin were 3.6 and 6.8 folds of upper normal, respectively, and an indocyanine green clearance test at 15 minutes was 26.3% (normal < 15%).

RESULTS

Compared to cases with normal liver function, increased volume of distribution of doxorubicin correlated with a large amount of ascites (P < 0.05). The clearance of drug was unexpectedly higher than in cases with normal liver function (P < 0.05). According to the pharmacokinetic studies, the disposition of PLD in this case has not been retarded even in the presence of severe liver dysfunction. Only minimal toxicities including grade 2 stomatitis and moderate leukopenia were observed. The tumor had a partial remission and the patient survived nine months after PLD treatment.

CONCLUSION

PLD could serve as a safe and effective treatment for hepatocellular carcinoma even in the presence of impaired liver function. Its role in treating advanced hepatocellular carcinoma is worthy of further study.

Direct comparison of liposomal doxorubicin with or without polyethylene glycol coating in C-26 tumor-bearing mice: is surface coating with polyethylene glycol beneficial?

Sterically stabilized liposome is characterized by a surface coating of polyethylene glycol (PEG) or other polymers that can reduce opsonization of the liposome by plasma proteins. It has a higher plasma area under the concentration-time curve (AUC), which is believed to correlate with better therapeutic efficacy. However, the presence of large molecules on the liposomal surface may reduce the interactions of liposomes with cells and hinder entry of liposomes into the tumor tissue. Using a stable liposomal system composed of distearoyl phosphatidylcholine/cholesterol, we examined the effect of PEG (Mr 2000) on the pharmacokinetics and on the efficacy of liposomal doxorubicin with C-26 syngeneic tumor model in BALB/c mice. The plasma AUC of liposomal doxorubicin with 6 mol-% PEG-modified distearoyl phosphatidylethanolamine (PEG-DSPE) was approximately twice that of liposomal doxorubicin without PEG at various dosages, regardless of whether the mice were tumor-bearing. Paradoxically, the group of mice treated with liposomal doxorubicin without PEG had higher tumor doxorubicin concentrations. The 72-h tumor AUC was 1.44 times that of liposomal doxorubicin with 6% PEG-DSPE. The tumor-accumulation efficiency (AUC(Tumor)/AUC(Plasma)) of liposomal doxorubicin without PEG was 0.87, and this was more than twice that of the liposomal doxorubicin with 6% PEG-DSPE (0.31). At a dose of 10 mg/kg, although both liposomal groups were better than the free drug group in terms of clinically relevant parameters, including toxicity, tumor shrinkage, and survival, there was no difference between the two liposomal drug groups. In this stable liposome system, surface coating with PEG offered no benefit for liposomal doxorubicin in the C-26 tumor model. To enhance the therapeutic index of liposomal doxorubicin, simply increasing plasma AUC by surface coating with PEG may not be satisfactory.

Sterically stabilized anti-idiotype immunoliposomes improve the therapeutic efficacy of doxorubicin in a murine B-cell lymphoma model

A liposome containing diverse synthetic lipid derivatives of polyethylene glycol (PEG) results in smaller distribution volume and longer circulation time in blood and, thus, may improve drug targeting. The characteristics and therapeutic efficacy of immunoliposomes with similar liposomal formulation have never been studied in lymphoma models. We have developed immunoliposomes conjugated with S5A8 monoclonal antibody, an anti-idiotype antibody to 38C13 murine B-cell lymphoma, and loaded them with doxorubicin using an ammonium sulfate gradient. Purified antibodies were covalently coupled to the termini of PEG on the surface of small unilamellar liposomes. Cell binding and internalization ability of these immunoliposomes were estimated by a fluorescence assay using a pH-sensitive fluorescent dye (HPTS). The in vitro cytotoxicity of doxorubicin encapsulated in immunoliposomes was greater for idiotype-positive 38C13 cells than for the idiotype-negative variant of this cell line. In syngeneic C3H/HeN mice, doxorubicin encapsulated in immunoliposomes exhibited a long circulation time and was more effective at prolonging survival of mice bearing 38C13 tumor than non-targeted liposomal doxorubicin or free doxorubicin plus empty immunoliposomes. Our results demonstrate the superiority of targeted therapy with these immunoliposomes and its potential in lymphoma treatment.

Giant intraluminal fibrovascular polyp of the esophagus

Giant polyps of the esophagus are relatively rare. Without previous history, the diagnosis of the disease is difficult to be made by esophagography and esophagoscopy. A case of giant intraluminal fibrovascular polyp (13x4x3.5 cm) of the esophagus is presented. The polyp was retrieved from the esophagus by a Foley's catheter and resected via the oral route.

Surgical results of 40 patients with malignant tracheobronchial lesions

The objective of this study was to evaluate the results of tracheobronchoplastyperformed on a variety of malignant diseases which involved the tracheobronchus. Between July 1988 and March 1996 tracheobronchial surgery was performed on 40 patients who had a variety of malignant diseases. The primary diseases were bronchogenic carcinoma (n=26), tracheobronchial tumour (n=5), thyroid cancer (n=6), and oesophageal cancer (n=3). Operative procedures that were performed on the tracheobronchus were sleeve lobectomy (n=22) or bilobectomies (n=5), sleeve pneumonectomy (n=3), sleeve resection of trachea (n=7) and bronchus (n=3). There was one postoperative death with a mortality rate of 2.5%. However, there were no significant postoperative complications apart from the one postoperative death; one patient developed a bronchopleural fistula and empyema. In lung cancer patients, the 2 year survival rate was 47.3%, and one (3.8%) local tumour recurrence. Four of five patients who had tracheobronchial tumours were alive and free from disease during 2-6 year follow-up period. One patient who had malignant fibrous histiocytoma died of brain metastasis 6 months after the operation. Among six patients whose thyroid cancer involved the trachea, one patient survived for 7 years, the other five patients were still alive and free from disease 2-5 years after the operation. Of the three patients whose oesophageal carcinoma involved the tracheobronchus, there was one operative death and the others died of tumour recurrence 1 and 2 years, respectively. We suggest that tracheobronchoplasty is a safe procedure with low morbidity and mortality rates in carefully selected patients with malignant diseases.

Surgical results of 29 patients with benign tracheobronchial lesions

This study was carried out in order to evaluate the surgical results of benign tracheobronchial diseases. Between July 1988 and March 1996, tracheobronchial surgery was performed on 29 patients with a variety of benign diseases. The primary diseases were post intubation or post tracheostomy tracheal stenosis (n = 12), tuberculous stenosis (n = 7), congenital tracheal stenosis with or without vascular ring (n = 4), tracheobronchial tumour (n = 2), oesophageal tumour (n = 1), and miscellaneous conditions (n = 3). Thirty-one operative procedures included sleeve lobectomy (n = 7), sleeve resection of trachea (n = 17) and bronchus (n = 2), and plastic surgery of trachea (n = 4) and bronchus (n = 1). There was one operative death, which put the mortality rate at 3.4%. There were five postoperative complications in this series (17.2%), including anastomotic disruption of trachea (n = 1), bilateral vocal cord palsy (n = 1), prolonged endotracheal intubation (n = 1) and overgrowth of granulation (n = 2). The complication of anastomotic disruption of trachea was treated by insertion of a tracheal T-tube, and the granulation was treated by bronchoscopic excision. We suggest that tracheobronchoplasty is a safe procedure in carefully selected patients with benign diseases.

Surgical results of 23 patients with tracheobronchial injuries

The objective of this study was to evaluate the surgical results of tracheobronchial injuries. Between July 1988 and March 1996, tracheobronchial surgery was performed on 23 injured patients. According to the aetiology, the injuries were categorized as blunt injury (n = 13), cutting or penetrating injury (n = 5), and corrosive injury (n = 5). Blunt injuries included three complete laryngotracheal disruptions, one tracheal laceration, and eight bronchial ruptures. Cutting or penetration injuries included four laryngotracheal ruptures and one tracheal cutting wound. Corrosive injuries included one tracheal necrosis, one tracheal stenosis and three esophagorespiratory fistulae. Operative procedures that were performed on the tracheobronchus included tracheoplasty (n = 12), bronchoplasty (n = 7), sleeve resection of the trachea (n = 2) and bronchus (n = 2). Two hospital deaths were encountered, with a mortality rate of 8.7%. One patient with caustic injury died of bronchopleural fistula and empyema. The other patient died with multiple injuries from multiple organ failure which was unrelated to the bronchoplasty. One postoperative complication was restenosis of the trachea in a caustic injured patient, which was treated by a T-tube insertion. In conclusion, tracheobronchoplasty is an effective life-saving emergency procedure for the patients with tracheobronchial injuries.

Surgical treatment of pediatric lung abscess

Eight pediatric patients with lung abscesses underwent surgical intervention in our hospital during a 7-year period. All the abscesses were associated with severe sepsis or complicated by a bronchopleural fistula that did not respond to medical treatment and tube thoracostomy. Seven patients required unilateral thoracotomies, and one patient with bilateral lesions required simultaneous bilateral thoracotomies. One tension pneumatocele required a preceding pneumonostomy. All patients underwent decortication and at least one additional surgical procedure consisting of: lung debridement plus bronchial closure (n = 4); lobectomy (n = 2); bisegmentectomy (n = 3); and/or segmentectomy (n = 1). There were no operative deaths, but two patients had persistent air leakage that was treated by bronchial closure. The average hospital stay was 22 days (postoperative 10.1 days). All the patients recovered completely. For many pediatric lung abscesses that do not respond to medical treatment and simple drainage procedures, surgical intervention is indicated and can shorten the hospital stay.

Results of surgical treatment of 107 patients with complications of pulmonary tuberculosis

The objective of this study was to evaluate the results of surgical intervention performed on 107 patients with pulmonary tuberculosis complications. Between September 1988 and December 1995, 107 patients underwent a total of 126 operations for major complications of pulmonary tuberculosis. One hundred and twenty-six operations consisted of lobectomies only or plus other lung resections performed in 55 cases, pneumonectomies in 20 cases, segmentectomies in 18 cases, wedge resections in two cases, tracheobronchoplasties in four cases, decortications in two cases, cavernostomies with concomitant muscle transpositions in seven cases, thoracoplasties reserved for the previously failed operations or to be a supplement for pulmonary resections in 18 cases. The operative mortality rate was of 1.8%, and the major complication rate was of 16.8%. Twenty-eight (26.1%) patients with tuberculosis bacilli in sputum before operation have converted except one diabetic patient. In conclusion, surgery is indicated in pulmonary tuberculosis complications that are life-threatening or unresponsive to chemotherapy. Pulmonary resection is the procedure of choice for most cases that require surgery.

Functional evaluation of esophageal substitutes

BACKGROUND

The function of esophageal Substitutes is not comparable to the normal esophagus.

METHODS

To clarify the difference between esophageal substitutes and the normal esophagus, radionuclide scintigraphy and clinical assessment were used as study methods. The study was conducted in groups of substernal colon (n = 9), substernal ileocolon (n = 6), posterior mediastinal colon (n = 6) and posterior mediastinal gastric tube (n = 14). The control group consisted of normal volunteers (n = 8).

RESULTS

Patients with substernal ileocolon did not experience nocturnal regurgitation, which occurred often in other groups. All esophageal substitutes had a decreased clearance ability compared to the normal esophagus. Among these substitutes, the posterior mediastinal gastric tube had the shortest swallowing time, while the substernal ileocolon had the longest. The substernal colon had a significantly prolonged transit time. Among these study groups, neither differences of clearance ability nor those of alimentary reflux reached statistical significance.

CONCLUSIONS

From the view point of food transit, it is suggested that a posterior mediastinal gastric tube or posterior mediastinal colon is the first choice of esophageal substitute.

Transneuronal WGA-HRP: can it demonstrate development of ocular dominance patches and effects of monocular deprivation?

We have attempted to use intraocular injections of wheat germ agglutinin-horseradish peroxidase (WGA-HRP) to label ocular dominance patches in developing layer 4 of cat visual cortex. The cortices of animals killed at 49 days or later showed normal ocular dominance patches similar to those seen in [3H]proline material. Animals killed at 42 days showed some patches, but also showed unsegregated regions. Animals killed younger were difficult to stain and did not have patches. We also examined the ability of the WGA-HRP technique to demonstrate the effects of monocular deprivation (MD). MD for the first 3 months of life produced expansion of the afferents from the nondeprived eye and retraction of the patches from the deprived eye. One week of MD at about 5 weeks of age produced an expansion of the patches innervated by the nondeprived eye, but did not obviously affect the patches innervated by the deprived eye. We conclude that WGA-HRP is useful for examining the effects of long-term MD on ocular dominance patches but not for following the development of segregation. Its advantages over the [3H]proline technique are that it does not require a delay of many weeks before the sections can be examined and is much less expensive.

The development of MK-801, kainate, AMPA, and muscimol binding sites in cat visual cortex

Previous work using homogenate binding has shown that the development of (+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]-cyclohepten-5,10imin e maleate (MK-801) binding in cat visual cortex increases from 21 days to 42 days, the height of the plastic period, and decreases in adulthood. We have studied the generality of this finding by examining the development of NMDA binding sites in several brain regions and by examining the development of other binding sites in the visual cortex. After confirming the original finding, we extended it by showing that the sensitivity of MK-801 binding sites to glutamate and glycine decreases when the cat becomes an adult. We then examined the regional specificity of MK-801 binding. Retinal binding did not change significantly with age. Binding in both visual cortex and hippocampus increased significantly from 7 days to 42 days regardless of whether binding was measured per milligram wet weight or per milligram protein. The decline from 42 days to adulthood was less dramatic in the hippocampus than in the visual cortex and was statistically significant only when binding was measured per milligram protein. Saturation analyses also showed a difference in the two structures. Bmax in the visual cortex, but not in the hippocampus, decreased from 42 days to adulthood. To determine whether these developmental changes were specific to MK-801 binding sites, we compared the age-dependent binding of MK-801, kainate, alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), and muscimol. Like MK-801, kainate binding increased from 7 days to 42 days and decreased from 42 days to adulthood. AMPA and muscimol binding showed a similar increase in binding from 7 days to 42 days but did not decrease significantly from 42 days to adulthood. Displacement experiments suggest that AMPA and kainate bind to separate sites. The 42-day peak in NMDA and kainate binding suggests that their associated receptors may have a role in determining the plastic period of visual cortex.

Bronchial rupture caused by blunt chest injury

We have surgically treated six patients with bronchial rupture caused by blunt chest injury in the past 5 years. All injuries resulted from traffic accidents, except in one patient who was hit by a crane. Clinical manifestations included chest pain (n = 6), subcutaneous emphysema (n = 4), and dyspnea (n = 6). Roentgenographic findings were tension (n = 3) or nontension (n = 3) pneumothorax, subcutaneous emphysema (n = 4), pneumomediastinum (n = 3), deep cervical emphysema (n = 5), and delayed collapse of the affected lung (n = 3). Three patients had associated injuries: right clavicle and rib fractures in the first; right humeral, scapular, and multiple rib fractures and left sternoclavicular joint dislocation in the second; and left clavicle fracture in the third. These six patients all underwent immediate tube thoracostomy and then bronchoplasty. Bronchoplasty was performed within 3 days in four patients and on days 16 and 30, respectively, in the other two patients. The affected lung demonstrated full expansion in all patients immediately after bronchoplasty. Follow-up bronchoscopy showed good patency of all bronchi.

Origins of sympathetic innervation to the mesenteric vein vessel in cats

Physiological and histochemical studies have clearly demonstrated the control and innervation of the sympathetic nerve on the splanchnic veins. However, the origins of postganglionic fibers remain to be determined. In this study, we used the retrograde transport of horseradish peroxidase (HRP) technique to trace the origins of postganglionic neurons in pre- and paravertebral sympathetic ganglia that innervate the mesenteric vein. A segment (6-8 mm) of mesenteric vein close to the duodeno-jejunal junction was isolated. HRP was applied externally on the vein segment to allow uptake into the nerve endings. In 10 cats, there was a total of 9275 HRP-labeled neurons in the pre- and paravertebral ganglia. The neuron distribution (mean +/- S.E.M.) was as follows: 452 +/- 77 (49%) in the superior mesenteric ganglion (SMG), 248 +/- 62 (27%) in the right celiac ganglion (RCG), 111 +/- 23 (12%) in the left celiac ganglion (LCG) and 58 +/- 16 (6%) in the splanchnic ganglia. Although the appearance of HRP neurons in the paravertebral ganglia (T10-L3) was relatively sparse, there were still significant numbers in L1 (26 +/- 13, 3%), T13 (15 +/- 5, 2%) and other ganglia. The results indicate that more than 90% of the presynaptic sympathetic neurons innervating the mesenteric vein make their synaptic connections in the prevertebral ganglia, mostly SMG and then RCG as well as LCG. Postsynaptic neurons arising directly from the paravertebral ganglia (mostly L1 and T13) constitute to about 6% of the total.

Lightning injury: report of a case

Lightning injury can cause severe damage to many systems and often results in a high mortality. We report a case of sustained lightning injury in which a 54-year-old woman presented with heart failure, pulmonary edema and consciousness disturbance. The patient was found unconscious, lying face down on the ground of a trash dump on the day of a thunderstorm. No deformities were seen in the extremities, but scattered third degree burns (less than 1%) were found on her neck where her necklace had been. Ventilator and inotropic agents with an adequate fluid supply were used. A Swan-Ganz catheter was inserted for monitoring. The patient was discharged two weeks later with an uneventful clinical course, except for mild neurologic sequelae (amnesia, disorientation).

Biotransformation of territrems by S9 fraction from rat liver

Male Wistar rats were pretreated with phenobarbital, 3-methyl-cholanthrene, or polychlorinated biphenyl. The S9 fraction was isolated from their livers. An amount of 40-microliters territrem (TRA, B, or C) (1 mg/ml methanol) was added to 5-ml reaction mixtures containing S9 (8 mg protein), NADP sodium salt (20 mumol), glucose-6-phosphate monosodium salt (25 mumol), MgCl2 (40 mumol), KCl (165 mumol), and sodium phosphate buffer, 0.1 M, pH 7.4, after preincubation for 5 min. Further incubation was carried out for 30 min by shaking (100 ocillations/min). The reaction was stopped by adding 2 ml acetone. The acetone was then removed by evaporation in a hood at room temperature. The residue was lyophilized and extracted with 2 ml methanol 3 times. When TRB was a substrate, at least four blue fluorescent products, designated as MB1, MB2, MB3, and MB4, were found in the methanol extract by TLC under view of long-wave UV light. MB2 was the major product. When TRA or TRC was a substrate, two products, MA1 (the major product) and MA2 from TRA, and one product, MC from TRC, were, respectively, detected in the methanol extract. The formation of the products was dependent on the presence of S9, NADP, glucose-6-phosphate, and territrem. The reaction was enhanced by pretreatment of rats with phenobarbital. It was demonstrated that MB2 and MA1 are hydroxylated products of the methyl group at the C4 position of TRB and TRA. MB4 was identified as TRC. MC was shown to be identical to MB1, which was the hydroxylated product at the methyl group of C4 position of TRC.(ABSTRACT TRUNCATED AT 250 WORDS)

Thyrotropin modulates receptor-mediated processing of the atrial natriuretic peptide receptor in cultured thyroid cells

In a prior study of atrial natriuretic peptide (ANP) binding to cultured thyroid cells, we reported that at 4 C, more than 95% of bound ANP is recovered on cell membranes, with negligible ANP internalization observed. Since ANP binding was inhibited by TSH, we have further studied TSH effects on postbinding ANP processing to determine whether this phenomenon reflects enhanced endocytosis of the ANP-receptor complex. An ANP chase study was initiated by binding [125I] ANP to thyroid cells at 4 C for 2 h, followed by incubation at 37 C. ANP processing was then traced by following 125I activity at various time intervals in three fractions: cell surface membranes, incubation medium, and inside the cells. Radioactivity released into medium represented processed ANP rather than ANP dissociated from surface membranes, since prebound [125I]ANP could not be competitively dissociated by a high concentration of ANP (1 mumol/L) at 37 C. Chase study results showed that prebound ANP quickly disappeared from cell membranes down to 34% by 30 min. Internalized ANP peaked at 10 min, with 21% of initial prebound ANP found inside the cells. At the same time, radioactivity recovered in incubation medium sharply increased between 10-30 min from 8% to 52%. Preincubation of cells with chloroquine (which blocks degradation of the ANP-receptor complex by inhibiting lysosomal hydrolase) caused a 146% increase in internalized [125I]ANP by 30 min (39% compared to 15% control), while medium radioactivity decreased from 52% to 16%, suggesting that processing of the receptor complex is mediated via lysosomal enzymes. In chase studies employing cells pretreated with chloroquine, TSH stimulated the internalization rate of ANP-receptor complex. By 30 min, TSH significantly reduced the membrane-bound ANP, and the decrease was inversely correlated to the increase in internalized radioactivity. In the absence of ANP ligand, TSH also modulated receptor translocation, resulting in decreased receptor number on surface membrane. However, TSH did not affect ANP degradation on the basis of analysis by immunoprecipitation and high performance liquid chromatography. Taken together, these data suggest that TSH downregulates ANP receptor on thyroid cell surface membranes, and that an ANP degradative pathway exists which is not mediated through receptor binding.

Iodothyronines: oxidative deiodination by hemoglobin and inhibition of lipid peroxidation

Purified rat hemoglobin catalyzes the oxidative degradation of iodothyronines to form iodide and an iodine-containing intermediate that reacts with protein. Hemoglobin also catalyzes peroxidation of linoleic acid. These observations are consistent with the reported intrinsic peroxidase activity of hemoglobin and other heme-proteins. However, incubations containing both linoleic acid and an iodothyronine produced a surprising result: deiodination was stimulated rather than competitively inhibited. In contrast, linoleic-acid peroxidation was inhibited by iodothyronines. Thus, low levels of iodothyronines (2.6 X 10(-7) M) are effective inhibitors of linoleic-acid peroxidation. Thyroxine and reverse T3 were found to be more effective in this antioxidant activity than vitamin E, glutathione, ascorbic acid and DTT. Since linoleic-acid peroxidation proceeds by a propagating free-radical mechanism, we have concluded that iodothyronines can effectively terminate the free-radical chain reaction to become oxidatively deiodinated. Consistent with this antioxidant mechanism, reverse T3 is effective in preserving red cell membranes as measured by the inhibition of erythrocyte hemolysis.

Relationships between tibial rotary torque and knee flexion/extension after tendon transplant surgery

The hamstring muscles play an important role in decelerating and checking tibial rotation before excessive stresses are applied to knee support structures. The purpose of this study was to determine the relationships between standard flexion/extension rehabilitative techniques and tibial rotary torque among subjects who had received pes anserinus transfers at least 1 year prior. Postsurgical and healthy contralateral limbs of 15 males were tested for maximum, isokinetic knee flexion/extension and internal/external tibial rotation. An adjustable chair and stabilizing boot were used to minimize extraneous hip, thigh and subtalar movements. Product-moment correlation coefficients were computed to determine the relationships between muscle forces generated during tibial rotation and knee flexion/extension. Relatively small relationships were found between rotation and flexion. Tibial rotation and flexion were more highly correlated in the nonsurgical than in the surgical limbs. The results also revealed that peak torque was generated within the first 5-10 degrees of motion for tibial rotation and within the first 20-30 degrees of motion for knee flexion and extension. The data indicate that measures of maximal knee flexor torque cannot be used to predict the rotational capabilities of the same muscle group and that separate measurement and rehabilitative techniques are necessary. Further analyses of postsurgical knees revealed force deficits among knee flexors and extensors when compared to nonsurgical counterparts. The findings suggest long-term sensitivity of the quadriceps to immobility.