Clinical and radiological septic joint analysis of spontaneous sternoclavicular joint infections: achieving the best outcomes-a systems engineering approach

OBJECTIVES

Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining.

METHODS

An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes.

RESULTS

A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis.

CONCLUSIONS

This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

Multidisciplinary Teams for the Management of Infective Endocarditis: A Systematic Review and Meta-analysis

Background

The management of infective endocarditis (IE) is complex owing to a high burden of morbidity and mortality. Recent guidelines recommend dedicated multidisciplinary teams (MDTs) for the management of IE. The aim of this systematic review and meta-analysis was to evaluate and summarize the effect of MDT management on patient outcomes.

Methods

A systematic review was performed and, where feasible, results were meta-analyzed; otherwise, results were summarized narratively. Data extraction and quality assessment were performed in duplicate. Restricted maximum likelihood random effects models were used to calculate unadjusted risk ratios and 95% CIs.

Results

Screening of 2343 studies based on title and abstract yielded 60 full-text reviews; 18 studies were summarized narratively, of which 15 were included in a meta-analysis of short-term mortality. Meta-analysis resulted in a risk ratio of 0.61 (95% CI, .47-.78; I2 = 62%) for mortality in favor of a dedicated MDT as compared with usual care. Length of stay was variable, with 55% (10/18) of studies reporting an increased length of stay. Most studies (16/18, 88.9%) reported a decreased time to surgery and an increased rate of surgery (13/18, 73%). No studies reported on patient-reported outcomes.

Conclusions

This is the first systematic review and meta-analysis to assess the impact of MDT management on IE. The sum of evidence demonstrated a significant association between MDTs and improved short-term mortality. Further research is needed to evaluate benefits of virtual MDT care, cost-effectiveness, and the impact on patient-reported outcomes and long-term mortality.

The Limit of Detection Matters: The Case for Benchmarking Severe Acute Respiratory Syndrome Coronavirus 2 Testing

BACKGROUND

Resolving the coronavirus disease 2019 (COVID-19) pandemic requires diagnostic testing to determine which individuals are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The current gold standard is to perform reverse-transcription polymerase chain reaction (PCR) on nasopharyngeal samples. Best-in-class assays demonstrate a limit of detection (LoD) of approximately 100 copies of viral RNA per milliliter of transport media. However, LoDs of currently approved assays vary over 10,000-fold. Assays with higher LoDs will miss infected patients. However, the relative clinical sensitivity of these assays remains unknown.

METHODS

Here we model the clinical sensitivities of assays based on their LoD. Cycle threshold (Ct) values were obtained from 4700 first-time positive patients using the Abbott RealTime SARS-CoV-2 Emergency Use Authorization test. We derived viral loads from Ct based on PCR principles and empiric analysis. A sliding scale relationship for predicting clinical sensitivity was developed from analysis of viral load distribution relative to assay LoD.

RESULTS

Ct values were reliably repeatable over short time testing windows, providing support for use as a tool to estimate viral load. Viral load was found to be relatively evenly distributed across log10 bins of incremental viral load. Based on these data, each 10-fold increase in LoD is expected to lower assay sensitivity by approximately 13%.

CONCLUSIONS

The assay LoD meaningfully impacts clinical performance of SARS-CoV-2 tests. The highest LoDs on the market will miss a majority of infected patients. Assays should therefore be benchmarked against a universal standard to allow cross-comparison of SARS-CoV-2 detection methods.

Case Report: Refractory Cryptosporidiosis after CAR T-Cell Therapy for Lymphoma

Cryptosporidial diarrhea is uncommon in immunocompetent individuals, more often seen in severely immunocompromised patients. Severe refractory cases have been described in patients with HIV/AIDS before the advent of modern antiretroviral therapy due to an inability to mount an adequate cellular immune response. We describe an 85-year-old patient post-chimeric antigen receptor T-cell therapy relapsed lymphoma who developed refractory Cryptosporidium spp. diarrhea in the setting of persistent CD4+ cytopenia. Despite receiving multiple antiparasitic agents, including failure of a prolonged course of nitazoxanide, the patient experienced persistent symptoms for 9 months with repeatedly positivity stool Cryptosporidium spp. direct fluorescent antibody (DFA) test. We highlight this case of refractory Cryptosporidium spp. and the importance of recognizing the pathogen in a non-HIV-infected immunosuppressed host.

Intravenous cephalosporin versus non-cephalosporin-based prophylaxis to prevent surgical site infections in colorectal surgery patients: A systematic review and meta-analysis

Background

Surgical site infection (SSI) is common in colorectal surgery patients and associated with morbidity and mortality. Guidelines recommend preoperative intravenous antimicrobial prophylaxis with aerobic and anaerobic coverage to reduce SSI risk. Cephalosporin based prophylaxis (CBP) regimens are recommended as first-line prophylaxis, and non-cephalosporin based are recommended as alternative prophylaxis (AP). We evaluate the efficacy of CBP versus AP in preventing surgical site infections in colorectal surgery patients.

Methods

A systematic review and meta-analysis was conducted of studies published between 2005 and 2020 in MEDLINE and Web of Science. Studies were excluded if intravenous antimicrobial prophylaxis was not administered, or if oral and intravenous prophylaxis were routinely co-administered. Heterogeneity was reported using the Q-statistic and I²-statistic. Publication bias was evaluated using a funnel plot and Egger test for small study effects. Statistical significance was defined as a two-sided p < 0.05.

Results

11 studies met inclusion criteria. AP was not associated with increased SSI risk at 30 days compared to CBP (OR 1.01, 95% CI 0.91, 1.13; OR < 1 favors AP). There was no effect size variability in subgroup analysis comparing higher-to lower-quality studies (I² = 99%, P = 0.17). Subgroup analysis by publication year approached a significant difference in effect size between studies published prior to 2014 and later than 2014 (I² = 99%, P = 0.06).

Conclusions

Meta-analysis of 11 studies of SSI risk in adult colorectal surgery patients suggest that SSI risk is similar for patients receiving CBP or AP, subgroup analysis of studies published since 2014 suggest increased SSI risk with AP compared to CBP.

•

Meta-Analysis found that surgical site infection risk is similar for patients receiving intravenous cephalosporin based or alternative prophylaxis.

•

Subgroup analysis of studies published since 2014 suggest increased surgical site infection risk with alternative prophylaxis compared to cephalosporin based prophylaxis.

•

RCT’s are needed to evaluate trends in SSI risk in cephalosporin-based prophylaxis compared to alternative prophylaxis.

The Limit of Detection Matters: The Case for Benchmarking Severe Acute Respiratory Syndrome Coronavirus 2 Testing

Background

Resolving the coronavirus disease 2019 (COVID-19) pandemic requires diagnostic testing to determine which individuals are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The current gold standard is to perform reverse-transcription polymerase chain reaction (PCR) on nasopharyngeal samples. Best-in-class assays demonstrate a limit of detection (LoD) of approximately 100 copies of viral RNA per milliliter of transport media. However, LoDs of currently approved assays vary over 10,000-fold. Assays with higher LoDs will miss infected patients. However, the relative clinical sensitivity of these assays remains unknown.

Methods

Here we model the clinical sensitivities of assays based on their LoD. Cycle threshold (Ct) values were obtained from 4700 first-time positive patients using the Abbott RealTime SARS-CoV-2 Emergency Use Authorization test. We derived viral loads from Ct based on PCR principles and empiric analysis. A sliding scale relationship for predicting clinical sensitivity was developed from analysis of viral load distribution relative to assay LoD.

Results

Ct values were reliably repeatable over short time testing windows, providing support for use as a tool to estimate viral load. Viral load was found to be relatively evenly distributed across log₁₀ bins of incremental viral load. Based on these data, each 10-fold increase in LoD is expected to lower assay sensitivity by approximately 13%.

Conclusions

The assay LoD meaningfully impacts clinical performance of SARS-CoV-2 tests. The highest LoDs on the market will miss a majority of infected patients. Assays should therefore be benchmarked against a universal standard to allow cross-comparison of SARS-CoV-2 detection methods.

Risk of QT Interval Prolongation Associated With Use of Hydroxychloroquine With or Without Concomitant Azithromycin Among Hospitalized Patients Testing Positive for Coronavirus Disease 2019 (COVID-19)

IMPORTANCE

Administration of hydroxychloroquine with or without azithromycin for the treatment of coronavirus disease 2019 (COVID-19)-associated pneumonia carries increased risk of corrected QT (QTc) prolongation and cardiac arrhythmias.

OBJECTIVE

To characterize the risk and degree of QT prolongation in patients with COVID-19 in association with their use of hydroxychloroquine with or without concomitant azithromycin.

DESIGN, SETTING, AND PARTICIPANTS

This was a cohort study performed at an academic tertiary care center in Boston, Massachusetts, of patients hospitalized with at least 1 positive COVID-19 nasopharyngeal polymerase chain reaction test result and clinical findings consistent with pneumonia who received at least 1 day of hydroxychloroquine from March 1, 2020, through April 7, 2020.

MAIN OUTCOMES AND MEASURES

Change in QT interval after receiving hydroxychloroquine with or without azithromycin; occurrence of other potential adverse drug events.

RESULTS

Among 90 patients given hydroxychloroquine, 53 received concomitant azithromycin; 44 (48.9%) were female, and the mean (SD) body mass index was 31.5 (6.6). Hypertension (in 48 patients [53.3%]) and diabetes mellitus (in 26 patients [28.9%]) were the most common comorbid conditions. The overall median (interquartile range) baseline QTc was 455 (430-474) milliseconds (hydroxychloroquine, 473 [454-487] milliseconds vs hydroxychloroquine and azithromycin, 442 [427-461] milliseconds; P < .001). Those receiving concomitant azithromycin had a greater median (interquartile range) change in QT interval (23 [10-40] milliseconds) compared with those receiving hydroxychloroquine alone (5.5 [-15.5 to 34.25] milliseconds; P = .03). Seven patients (19%) who received hydroxychloroquine monotherapy developed prolonged QTc of 500 milliseconds or more, and 3 patients (8%) had a change in QTc of 60 milliseconds or more. Of those who received concomitant azithromycin, 11 of 53 (21%) had prolonged QTc of 500 milliseconds or more and 7 of 53 (13 %) had a change in QTc of 60 milliseconds or more. The likelihood of prolonged QTc was greater in those who received concomitant loop diuretics (adjusted odds ratio, 3.38 [95% CI, 1.03-11.08]) or had a baseline QTc of 450 milliseconds or more (adjusted odds ratio, 7.11 [95% CI, 1.75-28.87]). Ten patients had hydroxychloroquine discontinued early because of potential adverse drug events, including intractable nausea, hypoglycemia, and 1 case of torsades de pointes.

CONCLUSIONS AND RELEVANCE

In this cohort study, patients who received hydroxychloroquine for the treatment of pneumonia associated with COVID-19 were at high risk of QTc prolongation, and concurrent treatment with azithromycin was associated with greater changes in QTc. Clinicians should carefully weigh risks and benefits if considering hydroxychloroquine and azithromycin, with close monitoring of QTc and concomitant medication usage.

SARS-CoV2 Testing: The Limit of Detection Matters

Resolving the COVID-19 pandemic requires diagnostic testing to determine which individuals are infected and which are not. The current gold standard is to perform RT-PCR on nasopharyngeal samples. Best-in-class assays demonstrate a limit of detection (LoD) of ~100 copies of viral RNA per milliliter of transport media. However, LoDs of currently approved assays vary over 10,000-fold. Assays with higher LoDs will miss more infected patients, resulting in more false negatives. However, the false-negative rate for a given LoD remains unknown. Here we address this question using over 27,500 test results for patients from across our healthcare network tested using the Abbott RealTime SARS-CoV-2 EUA. These results suggest that each 10-fold increase in LoD is expected to increase the false negative rate by 13%, missing an additional one in eight infected patients. The highest LoDs on the market will miss a majority of infected patients, with false negative rates as high as 70%. These results suggest that choice of assay has meaningful clinical and epidemiological consequences. The limit of detection matters.

Measuring Force-Induced Dissociation Kinetics of Protein Complexes Using Single-Molecule Atomic Force Microscopy

Proteins respond to mechanical force by undergoing conformational changes and altering the kinetics of their interactions. However, the biophysical relationship between mechanical force and the lifetime of protein complexes is not completely understood. In this chapter, we provide a step-by-step tutorial on characterizing the force-dependent regulation of protein interactions using in vitro and in vivo single-molecule force clamp measurements with an atomic force microscope (AFM). While we focus on the force-induced dissociation of E-cadherins, a critical cell-cell adhesion protein, the approaches described here can be readily adapted to study other protein complexes. We begin this chapter by providing a brief overview of theoretical models that describe force-dependent kinetics of biomolecular interactions. Next, we present step-by-step methods for measuring the response of single receptor-ligand bonds to tensile force in vitro. Finally, we describe methods for quantifying the mechanical response of single protein complexes on the surface of living cells. We describe general protocols for conducting such measurements, including sample preparation, AFM force clamp measurements, and data analysis. We also highlight critical limitations in current technologies and discuss solutions to these challenges.

The association between Internet addiction and psychiatric disorder: a review of the literature

Internet addiction is a newly emergent disorder. It has been found to be associated with a variety of psychiatric disorders. Information about such coexisting psychiatric disorders is essential to understand the mechanism of Internet addiction. In this review, we have recruited articles mentioning coexisting psychiatric disorders of Internet addiction from the PubMed database as at November 3, 2009. We describe the updated results for such disorders of Internet addiction, which include substance use disorder, attention-deficit hyperactivity disorder, depression, hostility, and social anxiety disorder. We also provide discussion for possible mechanisms accounting for the coexistence of psychiatric disorders and Internet addiction. The review might suggest that combined psychiatric disorders mentioned above should be evaluated and treated to prevent their deteriorating effect on the prognosis of Internet addiction. On the other hand, Internet addiction should be paid more attention to when treating people with these coexisting psychiatric disorders of Internet addiction. Additionally, we also suggest future necessary research directions that could provide further important information for the understanding of this issue.

Abundantly expressed hepatic genes and their differential expression in liver of prelaying and laying geese

Geese have a short egg-laying period and a low egg production rate. To induce and maintain egg laying, genes related to generating hepatic lipid for yolk deposition should be adequately expressed. Liver mRNA from 6 laying geese was extracted and used for construction of a full-length enriched cDNA library. About 2,400 clones containing gene sequences were determined and National Center for Biotechnology Information Gallus gallus Gene Index databases were used to compare and analyze these sequences. Ten highly expressed genes were selected to determine the differential expression between laying and prelay goose liver. Tissue distribution data showed that very low density apolipoprotein II, liver type fatty acid binding protein, vitellogenin I, and vitellogenin II transcripts were specifically expressed in the liver of laying geese. Ovoinhibitor, preproalbumin, alpha-2-hs-glycoprotein, and vitamin D binding protein mRNA were highly expressed in the liver and to a lesser extent in other tissues. Ovotransferrin mRNA was expressed in liver, ovary, oviduct, shell gland, brain, and adipose tissues. The concentration of transthyretin mRNA was high in the liver and brain. The mRNA concentrations of liver type fatty acid binding protein, alpha-2-hs-glycoprotein, and transthyretin in the livers of laying and prelay geese were not different. The concentrations of hepatic ovotransferrin, ovoinhibitor, preproalbumin, very low density apolipoprotein II, vitellogenin I, vitellogenin II, and vitamin D binding protein mRNA were higher in the liver of laying geese than in prelay geese, suggesting that these genes may be involved in laying function or lipid metabolism related to egg formation.

Case report: herpes simplex encephalitis in cancer patients

The manifestation of herpes simplex encephalitis in patients can often be interpreted as a possible brain tumor. In order to make a definite diagnosis, subsequent invasive testing is frequently required. In addition to other routine diagnostic measures, particular symptoms, especially those indicating that a patient is immunocompromised, should be considered as possible evidence indicating presence of this central nervous system (CNS) viral infection.

The differential expression of hepatic genes between prelaying and laying geese

Suppression subtractive hybridization was used to detect differential expression of genes in the livers of laying and prelaying geese. Liver tissues from prelaying and laying geese were dissected for mRNA extraction. The cDNA, reverse transcribed from liver mRNA of prelaying geese, was subtracted from the cDNA generated from the laying geese (forward subtraction). Five hundred seventy-six clones with possible differentially expressed gene fragments were observed by forward subtraction hybridization. After differential screening using the reverse and forward subtraction cDNA, 164 clones were subjected to gene sequence determination and further analysis. Using Northern analysis, 5 known and 8 unknown genes were shown to be highly expressed in the livers of laying geese compared with prelaying geese. Vitellogenin I, apoVLDL-II, ethanolamine kinase, G-protein gamma-5 subunit, and leucyl-tRNA synthase were highly expressed in the livers of laying geese compared with that from the prelaying geese (P<0.05). The expression of these known genes suggests that their function in the liver of laying geese is primarily involved in lipid and lipoprotein metabolism. Several of these differentially expressed genes were found to be responsive to estrogen stimulation, confirming the involvement of these genes in the egg-laying function of the goose.

The Expression of Pituitary Gland Genes in Laying Geese

The purpose of this study was to detect differential expression of genes in the pituitary gland in laying geese by suppression subtractive hybridization (SSH). Pituitary glands from prelaying and laying geese were dissected for mRNA extraction. The cDNA from pituitary glands of prelaying geese was subtracted from the cDNA from the pituitary glands of laying geese (forward subtraction); the reverse subtraction was also performed. We screened 384 clones with possible differentially expressed gene fragments by differential screening. Sixty-five clones from the differential screening results were subjected to gene sequencing and further analysis. We found that at least 19 genes were highly expressed in the pituitary glands of laying geese compared with prelaying geese. Among these, 6 genes (including 4 novel genes) were confirmed by virtual Northern analysis. We found that prolactin and visinin-like protein were highly expressed in the pituitary glands of laying geese compared with prelaying geese (P < 0.05). Further investigation is needed to demonstrate specific functions of the novel genes discovered in the current study.

Cloning and expression of the genes associated with lipid metabolism in Tsaiya ducks

Sterol regulatory element binding protein 1 (SREBP1) drives the expression of several lipogenic genes, whereas SREBP2 dictates the expression of every gene involved in cholesterolgenesis in mammals. In the current study, we cloned the cDNA fragments for SREBP1, SREBP2, fatty acid synthase (FAS), 3-hydroxy-3-methylglutaryl-CoA reductase (HMG-CoA reductase), and very low density apolipoprotein-II (apoVLDL-II), the genes associated with lipid metabolism. Fifteen ducks immediately before the first egg was laid (18 wk old) and 15 ducks from the same population at an egg production rate of 80% were killed. Total RNA was extracted from liver and used to amplify the targeted genes by reverse transcription-PCR and screening of a cDNA library. The sequence data showed that Tsaiya duck SREBP1, SREBP2, FAS, and HMG-CoA reductase were highly homologous to that of chicken. Tsaiya duck SREBP1 mRNA was expressed in adipose tissue, cardiac muscle, skeletal muscle, liver, and ovary. The SREBP2 mRNA concentration was highest in liver and ovary. Concentrations of FAS and HMG-CoA reductase mRNA were high in liver and lower in other tissues. The apoVLDL-II mRNA was specifically expressed in the liver. The differences between mRNA concentrations of SREBP1, SREBP2, and FAS in the livers of laying and prelay ducks were not significant. However, the concentrations of hepatic HMG-CoA reductase and apoVLDL-II mRNA were higher in the laying ducks than in prelay ducks. Therefore, laying may affect particular aspects of lipid metabolism, especially biochemical pathways that involved apoVLDL-II and HMG-CoA reductase.

Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan

OBJECTIVES

The aims of the present study were to examine health characteristics and healthcare utilization in relation to people with intellectual disability (ID) having psychiatric disorders in Taiwan.

METHODS

A cross-sectional study was employed; study subjects were recruited from the National Disability Registration Database. Taiwan, stratified by administrative geographical area for the study. Statistical analysis of 1026 carers for people with ID was made to examine the health status and healthcare utilization of individuals with ID having psychiatric disorders.

RESULTS

Approximately 12.1% of people with ID had psychiatric disorders. These individuals were more likely to be poorer in health condition and consuming more medical services (in the outpatient, inpatient and emergency care areas), than those individuals without psychiatric disorders. These individuals with psychiatric disorders were also taking medicines regularly at a far greater percentage than did those without psychiatric disorders.

CONCLUSIONS

Given the high prevalence of psychiatric disorders among individuals with ID, the healthcare system should take further steps to develop an appropriate health status monitoring system and community-based and easily accessible mental health services for them.

An exploratory study into health care policy for persons with intellectual disabilities in Taiwan

BACKGROUND

Although Taiwan has already had a higher quality of health care compared with other countries, there still is a need to review the quality and effectiveness of services provided. The lack of health care policy for persons with disabilities is a reflection of health care provision in Taiwan. Health care provision problems will limit persons with disabilities in their access to the health care system. The purpose of the present study was to examine the general beliefs about the current health care policies for persons with intellectual disabilities (ID) in Taiwan.

METHODS

Data were obtained from two sources, namely government policies analysis and interviews with representatives for key stakeholders in the field of ID.

RESULTS

The results illustrate that health care service problems for persons with ID include: how to enforce the discovery system and early intervention service, disability evaluation system, National Health Insurance medical payment and medical care resource development are still confining their quality of care. Furthermore, the links between social welfare, education and health care have been lost because the different roles and perspectives of people in these fields are fundamentally at odds with one another. Health care professionals have become less reform-minded as a consequence of the conditions of their work. Consequently, a complete and coordinated health care policy for persons with ID has become unattainable in society. The present paper draws on evidence from research and policies to explore the problems and potential of service development for persons with ID, and to identify review and action points for managing its implementation.

Factors attributing to the psychological recovery from the 1999 Taiwan earthquake among junior high school students: a focus group interview study

The aim of this study was to evaluate the factors contributing to the psychological recovery from the 1999 Taiwan earthquake from the perspective of adolescents in Chungliao. A total of 22 junior high school students who had significant decrease of Impact of Event Scale (IES) scores in the follow-up period of 9 months were recruited to participate in one of three focus groups. By applying the method of focus group interviewing, adolescents' attributions of factors relating to the improvements of psychological reactions were collected. All interviews were tape-recorded and the transcripts were approached by content analysis. Four major factors contributing to psychological recovery from the earthquake are clustered: (1) self-healing effect as time passed away; (2) assistance from people of the non-afflicted areas; (3) being engaged in interests in leisure time; and (4) other important events happening after the earthquake. Several factors contributed to the psychological recovery of adolescents from the experience of the earthquake. The results of this study can serve as the basis of further treatment strategies for the adolescent refugees from major disasters.

Three-dimensional ultrasonic images of normal fetus

BACKGROUND

The purpose of this study was to assess the usefulness and feasibility of 3-dimensional (3D) ultrasound for routine fetal observation.

METHODS

Eighty-five normal pregnancies with gestational ages of 20-36 weeks were studied. A conventional ultrasound scanner with a specially designed operation unit, frame memory, and 3D probe was the apparatus used in this study. The unit has a circuit board consisting of digital integrated circuit chips designed to make calculations of volume ray tracings for volume rendering in real time. For each fetus, scanning was performed with different levels of opacity in the equation for volume rendering. In areas where there was an inadequate amniotic fluid pocket to perform an adequate examination, the pregnant woman was asked to push the fetus to the opposite side by gently pressing on her abdomen.

RESULTS

Face, limbs, and fingers which are difficult to visualize on conventional ultrasonography could be seen clearly. Extremely satisfactory images were obtained at between 24 and 34 weeks of gestation that produced sonographic pictures easily recognized even by laypersons. Beyond 34 weeks of gestation due to the relative decrease in the size of amniotic fluid pockets, and before 24 weeks of gestation due to frequent fetal movement, the soft tissue of fetuses is thin and its acoustic impedance is virtually the same as that of water, so surface-rendered images are less satisfactory. In addition, the anterior wall placenta, multiple pregnancies, and oligohydramnios made viewing even more difficult.

CONCLUSION

Between 24 and 34 weeks of gestation, 3D ultrasound is a feasible and useful procedure for routine antenatal examination.

Classification for endoscopic treatment of mullerian anomalies with an obstructive cervix

STUDY OBJECTIVE

To describe our classification according to severity of developmental mullerian anomalies with obstructed cervix.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

Ten women with developmental mullerian anomalies with obstructed cervix.

INTERVENTION

Patients with didelphic uterus with a rudimentary nonfunctional horn and hypoplastic cervix (type 1) underwent hemihysterectomy or diagnostic endoscopy. Those with agenesis of cervix with normal uterus (type 2) had uterovaginal canalization or neocervix with full-thickness skin graft. Women with identical didelphic uteri and hypoplastic cervix (type 3) underwent uterovaginal canalization with or without endometrial ablation or hemihysterectomy. Patients with didelphic uterus with a rudimentary horn and hypoplastic cervix (type 4) had laparoscopic hemihysterectomy. Those with agenesis of the vagina and cervix but with functional endometrium (type 5) had laparoscopic-assisted full-thickness skin graft.

MEASUREMENTS AND MAIN RESULTS

Average duration of surgery was 60 to 210 minutes. There were no intraoperative complications. Patients with type 1 anomaly are continuing infertility treatment. All three patients in type 2 continue to have regular menses without dysmenorrhea. In those with type 3 conditions, hemihysterectomy was performed in one woman and uterovaginal canalization was performed on the hypoplastic cervix in another. After the neocervix was created, endometrial ablation was performed. No evidence of cervical obstruction or hematometra was found in either patient. The patient with type 4 anomaly continues to have regular menstrual periods without dysmenorrhea. Women with type 5 disorder had good healing of vaginal skin grafts.

CONCLUSION

This classification helps identify mullerian anomalies in relation to obstructive cervix. It is useful in categorizing the disorders and determines management strategies and prognosis.

Extraperitoneal approach to laparoscopic Burch colposuspension

STUDY OBJECTIVE

To evaluate 3-year outcomes of extraperitoneal laparoscopic colposuspension in treating genuine stress incontinence.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

One hundred sixty women with genuine stress incontinence with bladder neck hypermobility.

INTERVENTION

Extraperitoneal space was created with CO2 through a 10-mm midline port 2 cm above the pubic hairline. A pair of sutures was inserted at the level of midurethral and urethrovesical junction, fixing them to Cooper's ligament on each side with proper tension.

MEASUREMENTS AND MAIN RESULTS

Of 160 women, 10 were lost to follow-up. On follow-up questionnaire sent to 150 patients, 148 (98.7%) were pleased with the results of surgery. Stress incontinence was cured in 136 women (90.7%) after a minimum of 3 years' follow-up.

CONCLUSION

Cure rates for extraperitoneal colposuspension were similar to those reported for traditional laparoscopic or laparotomy Burch procedures; however, this is a more direct method to expose the space of Retzius, thus eliminating the need to open and close peritoneum.

Microlaparoscopically assisted vaginal hysterectomy. A preliminary report

OBJECTIVE

To evaluate the clinical possibility of using a microlaparoscope in laparoscopically assisted vaginal hysterectomy.

STUDY DESIGN

Twenty-five women with different indications for hysterectomy and a uterine size < 14 weeks' gestation underwent laparoscopically assisted vaginal hysterectomy using a microlaparoscope and 2-mm instruments.

RESULTS

Microlaparoscopic procedures included coagulation and separation of infundibulopelvic or uteroovarian round ligaments, vesico-uterine-visceral peritoneal fold dissection, and anterior and posterior colpotomy. The mean operative time, blood loss and length of hospital stay were 84.40 +/- 16.85 minutes, 262.00 +/- 112.99 mL and 3.08 +/- 0.64 days, respectively. No patients developed serious complications, but there were two minor ones.

CONCLUSION

Microlaparoscopy appears to be an efficacious alternative treatment option in well-selected patients undergoing laparoscopically assisted vaginal hysterectomy.

The thermal environment of arboreal pools and its effects on the metabolism of the arboreal, oophagous tadpoles of a Taiwanese tree frog, Chirixalus eiffingeri (Anura: Rhacophoridae)

We have studied seasonal and diurnal fluctuations of water temperature in bamboo stumps and the effect of temperature on the energy metabolism of arboreal, oophagous tadpoles of Chirixalus eiffingeri. We collected tadpoles (Gosner stage 28-29) in February and August from Chitou, Taiwan and acclimated them to 12 and 22 degrees C. Using a closed system, we measured tadpole oxygen consumption (V.O(2)) at 12, 17 and 22 degrees C. The water temperature was lowest in February (11-13 degrees C), increased rapidly during March and April and was highest from May to August (20-24 degrees C). Diel fluctuations in the temperature of the pools of water in bamboo stumps mirrored fluctuations in air temperature. Tadpoles collected in February and August exhibited metabolic compensation in that tadpoles acclimated at 12 degrees C had significantly higher V.O(2) than those acclimated at 22 degrees C. There are at least two possible explanations for the presence of metabolic compensation in C. eiffingeri tadpoles. Firstly, the larval period of C. eiffingeri ranges from 40 to 78 days, a tadpole could experience relatively large fluctuations in body temperature (up to 10 degrees C) during the development. As a result, C. eiffingeri tadpoles most likely evolved metabolic compensation to maintain activity levels under different thermal environments. Secondly, because arboreal pools are small, thermally unstratified, aquatic microhabitats, tadpoles are unable to behaviorally select preferred temperatures. As a result, metabolic compensation allows tadpoles to regulate their physiological functions.

Laparoscopic diagnosis and management of Fitz-Hugh-Curtis syndrome: report of three cases

Perihepatic adhesions between the liver capsule and the diaphragm or the anterior peritoneal surface characterizes Fitz-Hugh-Curtis syndrome (FHCS). FHCS is an extrapelvic manifestation of pelvic inflammatory disease and usually refractory to medical treatment and surgical intervention. With the increased incidence of pelvic inflammatory disease, chronic pelvic pain and sequalae of the process are becoming more common. Herein, we report 3 patients with pelvic inflammatory disease in whom medical treatment failed initially and FHCS was diagnosed via laparoscopy. Laparoscopic lysis of pelvic and perihepatic adhesions, irrigation of the abdomino-pelvic cavity, and antibiotics treatment after surgery successfully relieved these patients' symptoms. FHCS is not a new syndrome but most gynecologists might neglect this condition. Laparoscopy is a less invasive procedure than exploratory laparotomy. We recommend laparoscopy in patients with lower abdominal and right upper quadrant discomfort when other organic disease has been ruled out and medical treatment has failed to relieve symptoms.

A multidimensional assessment of insights in schizophrenic patients

This study aims to construct a multidimensional instrument in assessing insight of schizophrenic patients and further to examine its relationships with other factors such as psychiatric symptoms, demographic characteristics, and course of illness. An instrument (the Schedule for assessment of Insight in Psychosis, SIP) with a 4-point rating scale was constructed to assess the insight of schizophrenic patients in five dimensions. One hundred schizophrenic patients were recruited for the study and all of them received a semi-structured interview using the SIP. Their demographic variables, length of illness and severity of psychotic symptoms were analyzed for insight. The reliability and validity of the SIP were satisfactory. Significant factors related to insight were psychotic symptoms, including both positive and negative symptoms. This study showed insight was affected by a multitude of factors, and it could be assessed quantitatively in various dimensions.

Concomitant closure of patent canal of Nuck during laparoscopic surgery: case report

Indirect inguinal hernia is neglected by many female patients. When women undergo laparoscopy for infertility work-up or other gynaecological conditions, the hernia appears pressurized by the pneumoperitoneum. A large opening on the peritoneum followed by the patent canal of Nuck-as seen in the patient in this case report-is accompanied by a bulge above the labia major. This situation was treated with simple ligation of the canal of Nuck from the internal inguinal ring, and the vulvar bulging mass quickly disappeared, even while under pneumoperitoneal pressure. Laparoscopic hernia repair is currently performed with a mesh prosthesis to cover the defect; however, in female patients it seems unnecessary to use such an invasive method designed largely for males. According to our experience, the concomitant simple closure method for female indirect inguinal hernia is a quick and simple procedure, and deals with the problem during the same laparoscopy. In addition, disappearance of the bulging mass under the pneumoperitoneum offers a useful diagnostic test to secure hernia management.

Uterovaginal canalization and endometrial ablation of the obstructed uterine horn with hypoplastic cervix in the didelphic uterus

Maldevelopment of the mullerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix. Two women with this anomaly experienced symptoms including recurrent lower abdominal pain off and on of 1 to 2 years' duration. Magnetic resonance imaging revealed a double uterus with right hematometrium both patients. After hysteroscopic identification of hypoplasia of right uterine cervix, laparoscopic resection of the hematosalpinx, followed by uterovaginal canalization and prophylactic endometrial ablation of the right uterus was successfully performed by resectoscope. Normal menstruation ensued during follow-up of 18 and 24 months, respectively. Our experience suggests that uterovaginal canalization with prophylactic endometrial ablation may be an efficacious alternative to hysterectomy for management of didelphic uterus with a hypoplastic cervix. (J Am Assoc Gynecol Laparosc 8(1):151-153, 2001)

Laparoscopic closure of patent canal of Nuck for female indirect inguinal hernia

STUDY OBJECTIVE

To determine the efficacy of concomitant laparoscopic closure of the patent canal of Nuck in treatment of indirect inguinal hernias in women.

DESIGN

Prospective clinical trial (Canadian Task Force classification II-2).

SETTING

University-associated tertiary care referral center.

PATIENTS

Six women scheduled for laparoscopy for gynecologic indications. Intervention. Concomitant simple closure of the patent canal of Nuck from the peritoneal cavity during laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Inguinal hernias were repaired in all six patients, with no recurrence.

CONCLUSION

l Laparoscopic closure of the patent canal of Nuck is an easy, safe, and effective treatment of indirect inguinal hernias in women. (J Am Assoc Gynecol Laparosc 8(1):143-146, 2001)

A new portal for gynecologic laparoscopy

We used the middle upper abdomen as a primary port insertion as an alternative portal for laparoscopy and multiport operative pelviscopy in 188 women who were at high risk for subumbilical adhesions because of previous abdominal surgeries or history of gynecologic cancer. Primary cannula insertion was in the middle upper abdomen between xyphoid process and umbilicus (Lee-Huang point). This was the single entry site for the Veress needle and primary laparoscopy port. In 184 (98.4%) of 188 women surgery was performed without complications. No procedure was converted to laparotomy due to visceral or vascular injuries. Two omentum injuries from primary port insertion were repaired with bipolar electrocoagulation; a colon injury was repaired with laparoscopic sutures. In our experience, this laparoscopic port is effective in women who have had abdominal surgery or gynecologic malignancy. (J Am Assoc Gynecol Laparosc 8(1):147-150, 2001)

Laparoscopic-assisted vaginal myomectomy

STUDY OBJECTIVE

To evaluate the safety and efficacy of combined laparoscopic and vaginal approach in dealing with uterine myomas.

DESIGN

Retrospective case study (Canadian Task Force classification II-2).

SETTING

Tertiary care major teaching hospital.

PATIENTS

Thirty-one women with symptomatic fundal and/or posterior wall uterine myomas.

INTERVENTION

Laparoscopic-assisted vaginal myomectomy performed by one of the authors from July 1996 to December 1998.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SD operating time, blood loss, and length of hospital stay were 79.19+/-18.31 minutes, 150.00+/- 103.28 ml, and 3.10+/-0.75 days, respectively. No patients developed serious complications, and only two minor complications occurred.

CONCLUSION

After laparoscopic inspection and location of uterine myomas, dealing with posterior and fundal uterine myomas by the vaginal route makes hemostasis and uterine repair easier than by purely laparoscopic approach.

Highly functionalized Bicyclo[2.2.2]octenone-fused [60]fullerenes from masked o-benzoquinones and C(60)

[reaction: see text] The Diels-Alder reactions of masked o-benzoquinones (MOBs) with [60]fullerene, affording novel and highly functionalized bicyclo[2.2. 2]octenone-fused [60]fullerene derivatives, are described.

Radical laparoscopic surgery for carcinoma of the cervical stump

Traditionally, most women with cervical stump cancer underwent radiation therapy, as radical surgery was considered difficult. Given our success performing laparoscopic-assisted radical vaginal hysterectomy, we modified that technique to treat two women with carcinoma of the cervical stump. At follow-up of 14 and 17 months, respectively, both patients were free of recurrence.

Laparoscopic extraperitoneal sacrospinous suspension for vaginal vault prolapse

BACKGROUND

A new laparoscopic sacrospinous suspension procedure is described for the correction of vaginal vault prolapse using an extraperitoneal approach. This is the first report in the literature of the extraperitoneal approach.

METHODS

We reviewed 12 women who had been treated in our hospital using this technique because of vaginal vault prolapse. These women had undergone hysterectomies (10 abdominal; 2 vaginal) between 5 and 22 years previously (mean, 12 years). After pre-laparoscopic preparation, a 10-mm trocar with a 10-mm zero-degree telescope was placed into the Retzius space. Using a direct air-distended method with a 20 mmHg insufflation pressure, Retzius and para-rectal spaces were created. The sacrospinous ligament could be easily identified and confirmed. A permanent suture was then inserted from the sacrospinous ligament to the vaginal vault to ensure that there was no space in between.

RESULTS

This procedure was followed for all 12 patients. There were no major complications during surgery. Eleven women had no recurrence of vaginal vault prolapse during a follow-up period of 1 to 3 years (mean, 2.2 years). One patient developed recurrent vaginal vault prolapse; however, she subsequently underwent a successful colposacropexy by laparoscopy 23 months after the initial surgery.

CONCLUSION

We modified the traditional sacrospinous fixation laparoscopically, following principles to restore the correct anatomic position of the vault. Laparoscopic extraperitoneal sacrospinous suspension can eliminate the procedure of opening and closing the peritoneum and avoid interference with the intestine during surgery. It can be used as an alternative to traditional genital suspension surgeries.

Comparison the efficacy of laparosonic coagulating shears and electrosurgery in laparoscopically assisted vaginal hysterectomy: preliminary results

OBJECTIVE

To compare the safety and effectiveness of laparosonic coagulating shears (LCS) and electrosurgery for use in laparoscopically assisted vaginal hysterectomy (LAVH).

STUDY DESIGN

In this prospective study, patients undergoing LAVH performed by one of the authors from October 1997 to January 1998 were assigned at random to the electrosurgery group (n = 20) or the LCS group (n = 20). Procedures performed with LCS or electrosurgery included coagulation and separation of infundibulopelvic or utero-ovarian round ligaments, vesico-uterine-visceral peritoneal fold dissection, and anterior and posterior colpotomy. Outcome measures were operative time, blood loss, decrease in hemoglobin values, and length of hospitalization.

RESULTS

The mean operative time (90+/-22.9 min versus 80.3+/-17.1 min, P = 0.391), blood loss (308+/-167 ml versus 250+/-104 ml, P = 0.11), and hemoglobin decrease (1.57+/-0.769 mg/dl versus 1.36+/-0.886 mg/dl, P = 0.55) were slightly greater in the LCS group than in the electrosurgery group, although these differences were not statistically significant. The length of hospital stay was similar in the two groups (5 days). No patients developed serious complications related to electrosurgery or LCS.

CONCLUSION

Our findings indicate that LCS is as safe and effective as electrosurgery, and may offer an alternative option for patients undergoing LAVH.

A huge 6.2 kilogram uterine myoma coinciding with omental leiomyosarcoma: case report

Surgery for massive abdominal tumors is both interesting and challenging. We present a case involving a multiple uterine myoma weighing 6.2 Kg which coincided with omental leiomyosarcoma. To our knowledge, this is the first report of this type of condition in the English literature. A 44-year-old nulliparous woman had suffered from abdominal pain for a long time. A huge abdominal mass was palpated on physical examination. Computed tomography scanning revealed a huge pelvic-abdominal mass with the possibility of small bowel loops invaded by the mass. A 6-cm omental mass was incidentally found during the subsequent hysterectomy procedure. Perforation of the urinary bladder occurred during the dissection of adhesion. Resection of the omental mass, wide wedge resection of the invaded small bowel, primary repair of the bladder, and hysterectomy were performed. The final pathologic diagnosis was uterine leiomyomata with omental leiomyosarcoma. The patient returned home on postoperative day 14 and was well at the 18-month follow-up examination. The challenge of these tumors lies in their proper diagnosis and surgical management. More case reports and follow-up studies are needed to confirm the efficacy of their management.

Endoscopic management of injured bowel using the automatic stapler

Bowel injury is a rare but potentially fatal complication of laparoscopy if it is unrecognized at the time of the procedure. Once a bowel injury is identified, it must be repaired by either laparoscopy or laparotomy. The Endo GIA 30 stapler is effective for achieving large-vessel hemostasis and facilitating laparoscopic procedures, and is reported safe for laparoscopic hysterectomy. It was used successfully in two women to repair extensive bowel injuries.

Laparoscopic hemi-hysterectomy in treatment of a didelphic uterus with a hypoplastic cervix and obstructed hemivagina

Maldevelopment of the Müllerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix and obstructed hemivagina. We report a patient with this anomaly who was treated by laparoscopic hemi-hysterectomy and hysteroscopic resection of hemivagina. A 17 year old patient who had complained of vaginal pus-like discharge on and off for 1 year was diagnosed by MRI to have a double uterus with obstructed right hemivagina and ipsilateral renal agenesis. After hysteroscopic identification of hypoplasia of the right uterine cervix, laparoscopic resection of the right uterus and right Fallopian tube and hysteroscopically assisted resection of the vaginal septa were performed successfully. From our experience, combined laparoscopy and hysteroscopy may be an efficacious alternative in the management and diagnosis of Müllerian anomalies.

Vaginoscopy using hysteroscope for diagnosis of vaginal bleeding during childhood: case report

Vaginal bleeding is an uncommon and alarming symptom for children, and serious underlying causes should be excluded. Though vaginal bleeding during childhood was mostly associated with precocious puberty, the physician should keep in mind that local vaginal lesions such infectious vaginitis, vaginal trauma, and vaginal foreign bodies frequently present vaginal bleeding. A 10-year-old girl who denied any traumatic injuries or sexual abuse presented with profuse vaginal bleeding. She had normal development milestones and had no signs of thelarche or adrenarche. Her hymen was intact and the basal measurements of sex hormones including tyrotropic hormone and thyroxine were all within reference ranges. Finally, a laceration of the vaginal wall was found by vaginoscopy using a hysteroscope under general anesthesia and treated using gauze packing. We must emphasize the importance of vaginoscopy and examination under anesthesia in a child with vaginal bleeding to exclude local vaginal lesions. In addition, vaginoscopy using a hysteroscope makes the examination efficient and cost effective.

Laparoscopic management of an ectopic pregnancy in a previous Caesarean section scar

A case of laparoscopic management of an ectopic pregnancy in a previous Caesarean section scar is reported. A 30 year old woman was admitted to our hospital for profuse vaginal bleeding 2 weeks after an abortion had been performed. A urine pregnancy test was positive. Abdominal ultrasound revealed a well-encapsulated bulging mass over the lower anterior uterine wall measuring 7x5 cm. Hysteroscopy revealed retained gestational tissue in the lower corpus despite a normal uterine cavity. An incision was made over the most prominent area of the mass by operative laparoscopy. Dark reddish tissue suggestive of the products of conception was removed using grasping forceps. One-layer of continuous endoscopic sutures along the affected uterine wall was made with 1-0 Prolene. Laparoscopy enabled the successful treatment of an unruptured ectopic pregnancy in a previous Caesarean scar and made it possible to preserve the patient's reproductive capability.

Laparoscopically assisted full thickness skin graft for reconstruction in congenital agenesis of vagina and uterine cervix

In patients with agenesis of the vagina and cervix but with a functional endometrium, the traditional treatment is hysterectomy with construction of a neovagina. We report successful treatment by laparoscopically assisted full thickness skin graft for reconstruction in a patient with congenital agenesis of the vagina and uterine cervix concomitant with haematometra and ovarian endometrioma in a 12 year old girl. Postoperatively, the vaginal skin graft healed well, and menstruation first appeared 4 weeks later. In our opinion, a combined laparoscopic and vaginal procedure with full thickness skin graft is an efficacious alternative in managing such genital defects.

Apoptosis may be either suppressed or enhanced with strategic combinations of antineoplastic drugs or anti-IgM

A variety of drugs have been used to treat B-lymphocyte neoplasms, including both cell cycle-specific (CCS) and non-cell-cycle-specific drugs. Although the therapy for such cancers is complex and can include both types of drugs, the efficacy of these drugs in inducing cell death remains unclear. In this paper we have concentrated on specific CCS drugs and have examined their ability to induce programmed cell death (apoptosis) in Burkitt's lymphoma cell lines derived from patients. The CCS drugs chosen were hydroxyurea and aphidicolin (active in late G1, early S phase), the topoisomerase poisons camptothecin and etoposide (S, early G2 phase) and vincristine and Taxol (late G2, M phase). These choices allow comparison of two drugs with differing modes of action for each of the various phases of the cell cycle. Our results indicate that the variation in apoptosis between drugs that act at the same phase of the cell cycle is negligible. Both S/G2 and G2/M blockers are very potent at inducing apoptosis whereas G1/S blockers are ineffective in the induction of apoptosis. In addition, marked kinetic variations in the rate of apoptosis induction were observed, etoposide and camptothecin being more rapid in their action than the other agents. The order of effectiveness in inducing apoptosis on a kinetic basis was S/G2 agents >> G2/M agents >> G1/S agents. In this study we have also found that growth inhibition was induced by all the CCS agents chosen and by anti-IgM in various Burkitt's lymphoma lines. Furthermore c-myc was down-regulated under similar conditions. Since apoptosis was only selectively induced by some of the CCS agents, it implies c-myc expression is associated with growth regulation and c-myc down-regulation is an insufficient condition for the induction of apoptosis. In addition, cotreatments using the CCS and other agents revealed the following: Cotreatment using two CCS drugs which act at the same stage in the cell cycle showed either no change or only additivity to the effects seen with either agent alone. However, cotreatment with CCS drugs showed that an inhibitory effect is found between G1/S and G2/M drugs or S/G2 and G2/M drugs. No effect was found between G1/S and S/G2 drugs. Anti-IgM, which by itself was capable of inducing apoptosis, was observed to augment apoptosis induced by very low concentrations of G2/M-acting drugs but it has little effect on G1/S or the S/G2 drugs. The inhibitory effect of anti-CD40 or TNF-alpha on anti-IgM-induced apoptosis did not carry over to an effect on apoptosis induction by the CCS agents. Thus specific combinations of agents may lead to either enhancement, inhibition, or no interactive effect on apoptosis.

Water balance, growth, development, and survival of arboreal frog eggs (Chirixalus eiffingeri, Rhacophoridae): importance of egg distribution in bamboo stumps

We studied the effects of substrate moisture and flooding on the arboreal eggs of Chirixalus eiffingeri and determined the possible causes of egg mortality. Eggs appear highly permeable to water vapor, losing 16.24% and 38.38% of initial egg mass in 2 h at 90% and 45% relative humidity, respectively. Eggs that experienced positive water uptake developed faster, hatched earlier with larger hatchlings, and had greater hatching success than eggs that experienced negligible or negative water uptake. The hatching success of eggs that were submerged in water in bamboo stumps was significantly lower than that of eggs that were incubated on the water surface and was significantly correlated with the water PO2. In some bamboo stumps, we observed chironomid and tipulid larvae preying on submerged eggs. A dilution of water collected from bamboo stumps did not increase the hatching success of eggs. The water PO2 of bamboo stumps in the field was 67.4+/-18.8 mmHg, and the degree of hypoxia of water in each bamboo stump was correlated with the turbidity. Our findings demonstrated that the vertical distribution of C. eiffingeri eggs on walls of bamboo stumps significantly influenced the growth, development, and survival of embryos. Eggs deposited too far from the water may become desiccated, while eggs deposited too close to the water may become submerged and die of hypoxia or predation by insect larvae.

Extraperitoneoscopic colposuspension using CO2 distension method

PURPOSE

To validate our experience in extraperitoneoscopic colposuspension for genuine stress incontinence.

MATERIALS AND METHODS

Between March 1995 and July 1996, 48 women who had genuine stress incontinence underwent extraperitoneoscopic colposuspension in our institute. After standard laparascopic surgery preparation, a 10 mm puncture site was made midline just in the cm above the pubic hair line, and the extraperitoneal space was developed with the higher pressure of insufflating CO2. A pair of sutures was inserted at the level of the midurethral and unrethrovesical junction with Cooper's ligament.

RESULTS

All of these patients underwent the same procedures. The average blood loss was less than 50 ml, with a range from 10 to 200 ml. The operative time was from 20 to 90 min, with a mean time of 32 min. There was one bladder injury, 2 cases of voiding difficulties and 2 of detrussor instability in our series and the overall complication rate was 10.4%. So far, 45 of the 48 patients are satisfied with the surgery.

CONCLUSIONS

Laparoscopic Burch colposuspension is a practicable surgical procedure for managing stress incontinence. Extraperitoneal space was created easily with the higher pressure of insufflating CO2. An extraperitoneoscopic approach can reduce the necessity of laparscopic suturing. Moreover, it avoids violating the peritonel cavity and reduces the potential risk of postoperative adhesion formation and the discomfort resulting from pneumoperitonium. Thus, extraperitoneal colposuspension affords an alternative to laparoscopic or abdominal retropubic colposuspension in well-selected patients.

Minimal access surgery in children: the use of laparoscopy for management of pediatric ovarian teratoma: a case report

This article presents a case of left ovarian teratoma in a young child. Prompt diagnosis was made using real-time ultrasound, computed tomography (CT) and laparoscopy. The latter was used for performing tumor enucleation. We recommend that laparoscopy precede laparotomy and be done more routinely in the young patient.

Anti-IgM-induced growth inhibition and apoptosis are independent of ornithine decarboxylase in Ramos cells

Ornithine decarboxylase (ODC) is a key enzyme involved in polyamine production and is thought to regulate growth and apoptosis in multiple cell systems. A potential link between ODC and growth may involve the action of an oncogene c-myc which is thought to transcriptionally regulate ODC. We have examined the involvement of ODC in anti-IgM-induced growth inhibition and apoptosis in Burkitt's lymphoma cells. Inhibitors of ODC such as difluoromethylornithine (DFMO) completely blocked ODC activity, resulting in growth inhibition but not apoptosis. Addition of putrescine, the product of ODC enzymatic action, to Ramos cells had only a minor effect on growth, did not cause apoptosis, did not augment or block anti-IgM-mediated growth inhibition and apoptosis, but did reverse DFMO-mediated growth inhibition. Anti-IgM treatment of Ramos cells, which markedly decreased c-myc mRNA and protein, caused a paradoxical increase in ODC mRNA level as well as ODC enzymatic activity and increased cellular levels of putrescine. DFMO and putrescine did not alter c-myc mRNA levels directly, nor did they have any affects on anti-IgM-mediated down-regulation of c-myc mRNA. TNF-alpha, which inhibited anti-IgM-mediated apoptosis, did not inhibit either anti-IgM or DFMO-mediated inhibition of growth. These agents were without effect on ODC activity itself or on the anti-IgM-mediated increase in ODC activity. From these studies we conclude that ODC inhibition affects growth but is unrelated to the induction of apoptosis. Both anti-IgM-mediated inhibition of growth and induction of apoptosis are independent of ODC. Thus two distinct pathways for growth regulation are present: one in which ODC and polyamines are important and the other cell surface receptor-mediated (sIg) which is independent of ODC and polyamines.

Severe granulocytopenia secondary to chlorpromazine despite concurrent lithium treatment: a case report

Severe chlorpromazine-induced granulocytopenia where the white-cell count decreases to below 1,000/mm3 rarely occurs and lithium is known to cause leucocytosis. The use of lithium in the prevention of granulocytopenia induced by drugs is still controversial. This report describes a patient with bipolar disorder suffering from severe granulocytopenia and severe respiratory infection after receiving chlorpromazine 50 to 150 mg per day along with long term lithium therapy. Bone-marrow aspiration and biopsy revealed inhibited maturation of myeloid series in the promyelocyte stage. The findings were consistent with a drug-induced effect. White-cell count return to normal after the discontinuation of chlorpromazine. It was proved in this case that combined lithium therapy had no effect in preventing agranulocytosis induced by chlorpromazine.

The psychiatric manifestation of Creutzfeldt-Jakob disease

Creutzfeldt-Jakob disease (CJD) is considered to be very rare in the population, and the psychiatric manifestation of the disease even rarer with only one report in the past few years in Taiwan. To clarify whether the psychiatric manifestation of CJD is really rare or whether it is neglected in Taiwan, the authors reviewed the discharge notes of patients who had been admitted to a neurological unit in the past 15 years and conducted a chart review of the patients of CJD supported by the clinical courses, EEG finding and brain biopsies. An inquiry was made by telephoning their families to follow up their condition after discharge. Five of the 8 cases with CJD had psychiatric symptoms including changes of mood, thought, behavior and perception during their course of illness. Four cases had been sent to the psychiatric unit and received treatment under several kinds of psychiatric diagnoses. Two patients had been admitted to the psychiatric unit and one had received electroconvulsive treatment. Two of the patients had been suspected to be the victims of neuroleptic malignant syndrome. It is likely that it is psychiatrists who will meet CJD patients first in the early stages of disease. CJD should be kept in mind and EEGs with detailed neurological checkups should be completed, if the cognitive functions of the patients with unusual neurological symptoms deteriorate quickly and their psychiatric symptoms fail to respond to any treatment.