Prognostic implication of residual inflammatory risk according to disease status in patients treated with percutaneous coronary intervention

Background

Compared with stable angina, acute myocardial infarction (AMI) phenotype is related with the elevated inflammatory activity. However, time-dependent change of inflammatory level and its prognostic implication has not been fully understood according to the disease entity.

Methods

We enrolled total 4,263 patients who underwent percutaneous coronary intervention (PCI) with serial measurement of high-sensitivity C-reactive protein (hsCRP) at on-admission and 1-month post-PCI. The risks of MACE (a composite of death, MI or stroke), and major bleeding were evaluated up to 4 years after procedure.

Results

Compared with the non-AMI group (n=1,887), the AMI group (n=2,376) showed the significant decrease of hs-CRP during 1 month (∇0.5 vs. ∇0.1 mg/L; P<0.001). However, 1-month hs-CRP value still was higher in the AMI group than in the non-AMI group (median: 1.0 vs. 0.9 mg/L; P=0.001). During 1-month follow-up, high vs. low inflammatory risk (upper vs. lower tertile of hs-CRP) was significantly associated with increased rate of MACE in the AMI group (HR: 7.66; 95% CI: 2.29–25.59; P<0.001), but not in the non-AMI group (HR: 0.74; 95% CI: 0.12–4.40; P=0.736). From 1-month to 4-years, patients with high inflammatory risk showed the greater rate of MACE compared to those with low inflammatory risk, in both the AMI (HR: 2.40; 95% CI: 1.73–3.45; P<0.001) and non-AMI (HR: 2.67; 95% CI: 1.80–3.94; P<0.001) groups.

Conclusion

In PCI-treated patients, patients presented with AMI showed the greater values of inflammatory activity and its prognostic implication during the early phase, but combined inflammatory risk appeared similar across the disease entity during the late phase. This result may support that clinical benefit of post-PCI anti-inflammatory treatment would be constant regardless of the disease entity during the stabilized phase.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous coronary intervention in patients with peripheral artery disease and adverse cardiovascular adverse event and bleeding

Background

Peripheral artery disease (PAD) increase the risk of comorbidity and mortality in coronary artery disease (CAD).

Objectives

We evaluate influence of PAD on prognosis in patients undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed all consecutive patients included in our dedicated local registry for PCI between January 2011 and December 2016. Presence of PAD was defined by decreased ankle-brachial index (<0.9). Major adverse cardiovascular event (MACE) was defined as a composite of cardiovascular death, non-fatal myocardial infarct, revascularization, and ischemic stroke. Major bleeding was defined as Bleeding Academic Research Consortium 3 or 5.

Results

Among the 4,747 patients who underwent the PCI, 12.9% (n=610) of PAD were identified. Old age (>60 years), renal dysfunction, reduced ejection fraction, and presence of PAD were predictors with both MACE and major bleeding event. Among them, presence of PAD was an independent risk factor of MACE and major bleeding (MACE, HR 8.26, 95% CI 2.33- 29.41, p=0.036; major bleeding, HR 3.11, 95% CI 1.10–10.63, p=0.040, respectively). The MACE and major bleeding rate at 5-year was significantly increased in patients with PAD (MACE, 30.0% vs. 15.8%, log rank test p<0.001; major bleeding, 6.7 vs. 3.6%, log rank test p=0.003, respectively) (Figure).

Conclusion

Presence of PAD was strongly associated with higher rate of long-term MACE and major bleeding. These findings could have a clinical relevance in requiring individualized pharmacologic strategies to reduce the burden of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Impact of active and stable cancer on survival in patients undergoing percutaneous coronary intervention

Background

With advances in treatment of ischemic heart disease and cancer treatment, use of percutaneous coronary intervention (PCI) in cancer survivors and patients with active cancer (AC) is expanding.

Objectives

The purpose of this study was to determine the impact of cancer on survival and major cardiovascular events (MACE) in a long-term, single-center cohort of patients treated with PCI.

Methods

Patients treated with PCI between January 2010 and December 2017 were grouped as follows: controls (patients without cancer), stable cancer (SC), and AC. AC was included patients with cancer diagnosed within the past 6 months, patients who had cancer-related therapy within the past 6 months, active metastatic disease, or active recurrence of the cancer. The primary endpoints were 5-year survival and a secondary endpoint was 5-year MACE.

Results

A total of 6,743 patients (age 66±12 years, 68.4% men) treated with PCI were included: 6,404 (95.0%) controls, 245 (3.6%) SC, and 94 (1.4%) AC. Predominant malignancies were gastrointestinal (37.4%), lung (22.7%), and genitourinary cancer (14.7%). No differences were observed between patients with AC, SC and controls regarding 5-year MACE (total MACE, 33.2% vs. 28.1% vs. 17.5%, p=0.072; cardiac death, 13.6% vs. 9.1% vs. 6.7%, p=0.066; non-fatal myocardial infarction, 2.9% vs. 7.5% vs. 7.8%, p=0.820; revascularization, 17.9% vs. 17.6% vs. 11.6%, p=0.794, respectively). Patients with AC and SC had reduced 5-year survival compared with controls (62.0% vs. 81.5% vs. 89.8%, p<0.001) (Figure). AC was associated with a 1.76 (95% CI 1.22 to 2.54, p=0.002) fold increased risk of all-cause 5-year mortality in multivariable adjusted models.

Conclusions

Cumulative incidence of 5-year survival was discriminated by concurrent status of cancer following PCI. Individualized decision making is needed in the routine practice of PCI regarding concurrent cancer-specific treatment and prognosis.

Funding Acknowledgement

Type of funding sources: None.

P1416 Clinical importance of consecutive transthoracic echocardiography in the patients with hypertrophic cardiomyopathy

Funding Acknowledgements

nothing

OnBehalf

nothing

Background

prediction of outcomes Hypertrophic cardiomyopathy (HCM) have been robustly analyzed with echocardiography. However, there is limited data of serial follow-up (FU) transthoracic echocardiography (TTE) to predict outcomes in patients with HCM.

Objectives

This study aim is to discover clinical predictors associated with consecutive TTE follow-up in patients with HCM.

Methods

From 2010 to 2016, 162 patients with HCM were enrolled retrospectively. Concentric LVH and others systolic disease related to wall thickness were excluded. Index TTE (baseline) was measured when firstly admitted in our hospital. FU TTE was analyzed at the end of follow-up, defined as the last recorded value in patients who did not develop events or the last recorded value before events developed.

Results

The average of FU TTE and clinical FU period was 3.7 ± 2.0 years. Clinical outcomes were defined as stroke, syncope, heart failure, arrhythmia and death. Interestingly, only baseline TR V max was a predictor for clinical outcome whereas the others echo parameters were not associated with events (Table 1). KM curve showed the TR Vmax ≥2.5m/s was also significant (log rank = 0.008, Fig 1.)

Conclusions Our study showed short-term FU TTE did not bring clinician with clinical benefits in the aspect of prediction for events. Only baseline TR V max was good correlation with cardiovascular outcomes and even in the survival analysis.

Serial TTE and changed values Total N = 162 index TTE (baseline) FU TTE Change of FU per year event no event p-value event no event p-value event no event p-value IVDd, mm 14 ± 4 15 ± 5 0.500 15 ± 5 14 ± 5 0.758 0.23 ± 0.51 -0.07 ± 1.27 0.200 LVIDd, mm 47 ± 5 48 ± 6 0.256 47 ± 7 48 ± 6 0.560 -0.22 ± 2.79 0.10 ± 2.27 0.444 LVEF, % 62 ± 5 61 ± 7 0.379 61 ± 6 61 ± 10 0.927 -0.43 ± 3.10 -0.04 ± 4.94 0.620 LAVI 43 ± 9 43 ± 8 0.879 57 ± 27 58 ± 23 0.849 0.53 ± 14.5 3.11 ± 7.2 0.134 EA ratio 0.9 ± 0.6 0.9 ± 0.6 0.782 1.0 ± 0.8 0.9 ± 0.6 0.595 -0.02 ± 0.76 0.003 ± 0.027 0.594 DT,ms 196 ± 58 201 ± 62 0.603 203 ± 91 217 ± 89 0.370 17 ± 57 5 ± 40 0.154 septal e` 4.4 ± 2.1 4.2 ± 1.6 0.585 4.4 ± 1.6 4.6 ± 1.7 0.438 0.24 ± 0.91 0.05 ± 0.65 0.190 E of e` 17 ± 11 17 ± 23 0.993 15 ± 9 15 ± 6 0.726 -0.48 ± 4.42 -1.66 ± 22.78 0.728 TR velocity 2.6 ± 0.5 2.4 ± 0.4 0.012 2.7 ± 0.6 2.6 ± 0.4 0.604 0.05 ± 0.30 0.04 ± 0.18 0.905 Max wall thickness 17 ± 3 18 ± 3 0.137 17 ± 4 17 ± 3 0.888 -0.01 ± 2.19 -0.18 ± 1.14 0.522

Abstract P1416 Figure. TR Vmax and CV outcomes in the KM curve

P3637Relationship between serial measurements of NT-proBNP and cardiovascular events in patients with acute coronary syndrome

Background

Increased level of natriuretic peptides has been known as an important predictors of adverse cardiovascular (CV) outcomes in patients with acute coronary syndrome (ACS). We sought to evaluate clinical implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) measured at initial and follow-up periods.

Methods

Serial NT-proBNP levels (on-admission and one-month post-PCI) were measured in ACS patients undergoing PCI (n=2,290). High NT-proBNP levels were determined according to the predefined age-specific criteria. Patients were stratified into 4 groups according to NT-proBNP levels (on-admission & one-month): (1) normal-normal group (n=1234, 53.9%); (2) high–normal group (n=257, 11.2%); (3) normal-high group (n=376, 16.4%); and (4) high-high group (n=423, 18.5%). Clinical events were defined as all-cause death and MACE (a composite of CV death, non-fatal MI, and ischemic stroke).

Results

With a median follow-up of 35.9 (IQR: 16.8, 54.5) months, all-cause death and MACE were occurred in 4.1% and 7.2%, respectively. NT-proBNP on-admission vs. at one-month did not differ significantly (median 391.6 [IQR: 143.9, 1402.3] vs. median 619.1 [IQR 240.1, 1616.1]; p=0.622), but the prevalence of high NT-proBNP was increased over time (25.3% to 34.9%; p<0.001). The rates of all-cause death and MACE significantly increased only in the high-high group compared with other groups (log-rank test, all p values <0.001, Figure). After adjustment, the high-high group remained significantly risky in terms with the occurrence of all-cause death (HR, 2.99; 95% CI, 1.65 to 5.41; p<0.001) and MACE (HR, 1.96; 95% CI, 1.28 to 3.01; p=0.002).

Figure 1

Conclusion

Serial measurements of NT-proBNP at on-admission and follow-up can help to stratify the risks of all-cause death and adverse CV events following PCI in ACS patients. About two-fifths of patients having high NT-proBNP level during hospitalization can be classified into the low-risk group for all-cause death and adverse CV events.

Acknowledgement/Funding

None

Use of the Extended Sinus Tarsi Approach for Treatment of Displaced Intra-articular Calcaneal Fractures Compared with the Extended Lateral Approach

Category:

Trauma

Introduction/Purpose:

We compared the radiographic results and clinical outcomes of patients with displaced, intra-articular calcaneal fractures treated via the extended sinus tarsi approach (ESTA) and the extended lateral approach (ELA).

Methods:

We retrospectively studied the utility of the ELA (46 patients, 52 feet) and the ESTA (56 patients, 64 feet) in patients operated upon between January 2009 and September 2014. We evaluated pre- and post-operative X-rays and computed tomography (CT) data. Pain, patient-reported functional outcomes, patient satisfaction, and postoperative complications, were investigated at the three year follow-up.

Results:

Neither the postoperative nor three year follow-up Böhler angles, nor the calcaneal width, differed significantly between the two groups (both p > 0.05). The maximum step-off of the posterior facet on the three month CT follow-up of the ESTA was significantly less than that of the ELA (p < 0.05). We found no significant between-group differences in terms of postoperative translation (p = 0.232) or angulation of the sustentacular fragment (p = 0.132), three year follow-up mean visual analog scale pain score at rest (p = 0.641) or during weight-bearing (p = 0.525), Foot Function Index (FFI) (p = 0.712), and self-reported satisfaction (p = 0.823). The ELA experienced significantly more wound complications (p = 0.039) and nonunions (p = 0.014) than the ESTA.

Conclusion:

Compared with the ELA, the ESTA afforded comparable radiological results and clinical outcomes, associated with a reduced operative time and fewer wound complications and nonunions. We suggest that the ESTA is an efficient surgical option when treating displaced, intra-articular calcaneal fractures.

The Value of Axial Loading 3D CT as a Substitute for Full Weightbearing 3D CT

Category:

Other

Introduction/Purpose:

Full weightbearing(WB) three dimensional computed tomography(3D CT) is an excellent imaging tool. However, due to its high cost, it is only used in a few hospitals. We evaluated the usefulness and cost-effectiveness of axial loading(AL) 3D CT by comparing bony alignments with standing radiographs, and assessed reproducibility according to the degree of AL.

Methods:

Eighty patients(156 feet), who underwent standing radiographs and 3D CT with an AL device from January 2016 to May 2017, were investigated. According to the degree of AL(AL force×100/body weight), the patients were randomly assigned to three groups: Group A(30-50%; n=21, 40 feet), Group B(50-70%; n=32, 63 feet), and Group C(70-100%; n=27, 53 feet). The following angles were measured three times by two orthopedists: hallux valgus(HVA), 1st-2nd intermetatarsal(IMA1-2), and talo-navicular coverage(TNCA), calcaneal pitch(CPA), talo-1st metatarsal(T1MA), and talo-calcaneal angle(TCA). Agreements between the two imaging methods were analyzed and compared according to the degree of axial loading in each group.

Results:

Intra- and interobserver reliability was excellent (>0.75). In Group A(30-50% AL), all of the angles except HVA and IMA1-2 differed (p<.05). In Group B(50-70%), TNCA (p= .023), T1MA (p= .017), and TCA (p=.035) differed. In Group C(70-100%), none of the angles differed between the two imaging methods (p> .05). Higher agreement between the two imaging methods was realized when 70% or more(>70%) AL was applied.

Conclusion:

AL 3D CT with >70% axial load has full WB effects and can be substituted for expensive full WB 3D CT.

The Efficacy of Different Ropivacaine Concentrations (0.5%, 0.6% vs 0.75%) for Regional Nerve Block in Lower Extremity

Category:

Basic Sciences/Biologics

Introduction/Purpose:

There have only been a few studies on optimal concentrations, doses, and volume of injection material in the regional nerve block for lower extremity operations. The purpose of this study was to evaluate the efficacy of different concentrations of ropivacaine with respect to anesthetic time, intraoperative, postoperative pain, and patient’s satisfaction.

Methods:

A total of 339 patients underwent lower extremity surgery under ultrasound-guided nerve block (combined femoral and sciatic nerve block) at a single institution between March 2016 and February 2017 and were randomly assigned to three groups: Group A (0.5% 42 ml), B (0.6%, 30 ml), and C (0.75%, 30 ml). The interval between nerve block procedure and onset of the complete anesthetic effect (complete anesthetic time) was investigated. The degrees of intraoperative pain (during the first 10 minutes of the surgical procedure), and postoperative pain (6, 12 hours after operation) were evaluated using a visual analog scale (VAS) score. Patient’s satisfaction (0~10) was investigated 12 hours after the operation. To evaluate the efficacy in accordance with the concentration under the same dose and same volume, group A and B were compared with group C respectively.

Results:

There were 108, 118, and 113, in groups A, B, and C, respectively. The complete anesthetic times were 78.5, 76.4, and 58.6 minutes, respectively. The intraoperative VAS scores were 2.04, 0.62, and 0.24; and the postoperative VAS scores (6hours / 12hours) were 2.41 / 4.08, 0.26 / 1.24, and 0.38 / 1/53. The patient’s satisfactory scores were 8.53, 9.38, and 9.4 respectively. Compared with group C, group A showed significantly longer complete anesthetic time (p<0.05) and higher intra, postoperative VAS scores (all p<.05). Group B showed longer complete anesthetic time (p<0.05), but no significant difference of intra, postoperative VAS scores (all p>.05). Patient’s satisfactory scores in both group A and B were similar to group C(p>.05, p>.05). There were no adverse reactions in all groups.

Conclusion:

Ropivacaine 0.6% as well as 0.75% are safe and effective anesthetics under the same volume (30 ml) for regional nerve block of the lower extremity. However, taking into account of the longer complete anesthetic time, the operation start time must be adjusted.

Dorsal Suspension for Morton’s Neuroma

Category:

Midfoot/Forefoot

Introduction/Purpose:

We performed a dorsal suspension of neuroma using the dorsal transverse ligament for the treatment of Morton’s neuroma. The purpose of this study was to investigate and compare the functional outcomes and complications of dorsal suspension with those of neurectomy.

Methods:

We conducted a retrospective study of thirty-eight (40 feet, 40 neuromas) and thirty-six (36 feet, 36 neuromas) patients who underwent dorsal suspension and neurectomy, respectively. At twenty-four month follow-up, the visual analog scale was used to evaluate pain, and the Foot and Ankle Ability Measure (FAAM) was used to investigate patient-reported function of activities of daily living and sports. Satisfaction analysis was performed using the Coughlin scale, and postoperative complications were also evaluated.

Results:

Both groups reported significant pain relief, and there were no significant differences between the groups with respect to postoperative pain (dorsal suspension group, mean, 12.0; neurectomy group, mean, 25.8; p = .99). The postoperative FAAM outcomes showed no significant between-group differences in activities of daily living (dorsal suspension group, mean, 89.5, neurectomy group, mean, 77.2; p = .22) or sports subscales (dorsal suspension group, mean, 85.5; neurectomy group, mean, 69.4; p = .97). Satisfaction analysis showed ‘excellent’ and ‘good’ results in the dorsal suspension and neurectomy groups (95% and 77.7%, respectively). Complications reported in the dorsal suspension and neurectomy groups were numbness (5% vs 61.1%, respectively, p < .05) and paresthesia (5% vs 33.3%, respectively, p < .05).

Conclusion:

Compared with neurectomy, dorsal suspension provided comparable pain relief and improvement in terms of functional outcomes, as measured by the FAAM. With its lower rate of complication and high satisfaction, dorsal suspension can be another operative option for the treatment of Morton’s neuroma.

Extraforaminal approach of biportal endoscopic spinal surgery: a new endoscopic technique for transforaminal decompression and discectomy

This study was performed to describe the extraforaminal approach of biportal endoscopic spinal surgery (BESS) as a new endoscopic technique for transforaminal decompression and discectomy and to demonstrate the clinical outcomes of this new procedure for the first time. Twenty-one patients (27 segments) who underwent the extraforaminal approach of BESS between March 2015 and April 2016 were enrolled according to the inclusion and exclusion criteria. The operative time (minutes/level) and complications after the procedure were recorded. The visual analog scale (VAS) score was checked to assess the degree of radicular leg pain preoperatively and at the time of the last follow-up. The modified Macnab criteria were used to examine the clinical outcomes at the time of the last follow-up. The mean duration of the follow-up period was 14.8 months (minimum duration 12 months). The mean operative time was 96.7 minutes for one level. The mean VAS score for radicular leg pain dropped from a preoperative score of 7.5 ± 0.9 to a final follow-up score of 2.5 ± 1.2 (p < 0.001). The final outcome according to the modified Macnab criteria was excellent in 5 patients (23.8%), good in 12 (57.2%), fair in 4 (19.0%), and poor in 0. Therefore, excellent or good results (a satisfied outcome) were obtained in 80.9% of the patients. Complications were limited to one dural tear (4.8%). The authors found that the extraforaminal approach of BESS was a feasible and advantageous endoscopic technique for the treatment of foraminal lesions, including stenosis and disc herniation. They suggest that this technique represents a useful, alternative, minimally invasive method that can be used to treat lumbar foraminal stenosis and disc herniation.

Adherence to ketoacids/essential amino acids-supplemented low protein diets and new indications for patients with chronic kidney disease

BACKGROUND

Low protein diets (LPD) have long been prescribed to chronic kidney disease patients with the goals of improving metabolic abnormalities and postpone the start of maintenance dialysis.

METHODS

We reviewed the recent literature addressing low protein diets supplemented with ketoacids/essential aminoacids prescribed during chronic kidney disease and their effects on metabolic, nutritional and renal parameters since 2013.

RESULTS

We show new information on how to improve adherence to these diets, on metabolic improvement and delay of the dialysis needs, and preliminary data in chronic kidney disease associated pregnancy. In addition, data on incremental dialysis have been reviewed, as well as potential strategies to reverse protein energy wasting in patients undergoing maintenance dialysis.

CONCLUSION

These recent data help to better identify the use of low protein diets supplemented with ketoacids/essential aminoacids during chronic kidney disease.

Whole Body Vibration Reduces Inflammatory Bone Loss in a Lipopolysaccharide Murine Model

Whole body vibration (WBV) stimulation has a beneficial effect on the recovery of osteoporotic bone. We aimed to investigate the immediate effect of WBV on lipopolysaccharide (LPS)-mediated inflammatory bone loss by varying the exposure timing. Balb/C mice were divided into the following groups: control, LPS (L), and LPS with vibration (LV). The L and LV groups received LPS (5 mg/kg) by 2 intraperitoneal injections on days 0 and 4. The LV group was exposed to WBV (0.4 g, 45 Hz) either during LPS treatment (LV1) or after cessation of LPS injection (LV2) and then continued WBV treatment for 10 min/d for 3 d. Evaluation based on micro-computed tomography was performed 7 d after the first injection, when the L group showed a significant decrease in bone volume (-25.8%) and bone mineral density (-33.5%) compared with the control group. The LV2 group recovered bone volume (35%) and bone mineral density (19.9%) compared with the L group, whereas the LV1 group showed no improvement. This vibratory signal showed a suppressive effect on the LPS-mediated induction of inflammatory cytokines such as IL-1β or TNF-α in human mesenchymal stem cells in vitro. These findings suggest that immediate exposure to WBV after the conclusion of LPS treatment efficiently reduces trabecular bone loss, but WBV might be less effective during the course of treatment with inflammatory factor.

HbA1c variability is associated with microalbuminuria development in type 2 diabetes: a 7-year prospective cohort study

AIMS/HYPOTHESIS

HbA(1c) variability has been shown to be an independent risk factor for nephropathy in patients with type 1 diabetes. In this study, we aimed to explore the association between HbA(1c) variability and microalbuminuria development in patients with type 2 diabetes. We also intended to test the applicability of serially measured HbA(1c) over 2 years for this risk assessment.

METHODS

Between 2003 and 2005, we recruited 821 middle-aged normoalbuminuric individuals with type 2 diabetes and followed them through to the end of 2010. The average follow-up time was 6.2 years. We defined microalbuminuria as a urine albumin to creatinine ratio of 30 mg/g (3.4 mg/mmol) or higher. HbA(1c) variability was calculated by the SD of serially measured HbA(1c). The Cox proportional hazards model was used to evaluate the association between HbA(1c) SD quartile and development of microalbuminuria.

RESULTS

The incidence of microalbuminuria for the overall population was 58.4, 58.6, 60.8 and 91.9 per 1,000 person-years for Q1- to Q4-adjusted HbA(1c) SD, respectively (p for trend = 0.042). Compared with patients in Q1, those in Q4 were about 37% more likely to develop microalbuminuria. The HR derived from a series of 2 year HbA(1c) measurements was similar to that from data collection for longer than 4 years.

CONCLUSIONS/INTERPRETATION

In addition to mean HbA(1c) values, HbA(1c) variability, even measured as early as 2 years, is independently associated with the development of microalbuminuria in patients with type 2 diabetes.

Human mesenchymal stromal cells are mechanosensitive to vibration stimuli

Low-magnitude high-frequency (LMHF) vibrations have the ability to stimulate bone formation and reduce bone loss. However, the anabolic mechanisms that are mediated by vibration in human bone cells at the cellular level remain unclear. We hypothesized that human mesenchymal stromal cells (hMSCs) display direct osteoblastic responses to LMHF vibration signals. Daily exposure to vibrations increased the proliferation of hMSCs, with the highest efficiency occurring at a peak acceleration of 0.3 g and vibrations at 30 to 40 Hz. Specifically, these conditions promoted osteoblast differentiation through an increase in alkaline phosphatase activity and in vitro matrix mineralization. The effect of vibration on the expression of osteogenesis-related factors differed depending on culture method. hMSCs that underwent vibration in a monolayer culture did not exhibit any changes in the expressions of these genes, while cells in three-dimensional culture showed increased expression of type I collagen, osteoprotegerin, or VEGF, and VEGF induction appeared in 2 different hMSC lines. These results are among the first to demonstrate a dose-response effect upon LMHF stimulation, thereby demonstrating that hMSCs are mechanosensitive to LMHF vibration signals such that they could facilitate the osteogenic process.

Immunohistochemical changes of adenomyosis after heat therapy: comparison of radiofrequency myolysis and endoablation

PURPOSE

To check the pathologic changes of focal adenomyosis after heat therapy using radiofrequency and to evaluate which approach--endometrial ablation or direct heat therapy--is better for adenomyosis. To evaluate whether the timing of the procedure and the menstrual cycle are related to pathologic outcomes after heat therapy.

METHODS

This study included nine women who underwent total hysterectomy for adenomyosis (diameter, > or = 6 cm). Six fresh uteri were excised in the midline and subjected to radiofrequency heat therapy at the center of the adenomyomas (direct heat therapy) and three uteri were subjected to endometrial ablation. Thereafter, 1 cm(3) myometrial tissue was obtained at 1 cm, 2 cm, and 3 cm away from the endometrium. Tissue sections were stained with hematoxylin and eosin. Immunohistochemical analysis using antibodies against cytokerain-19 (CK-19), actin, and estrogen receptor/progesterone receptor (ER/PR) was performed to evaluate CK-19 (endometrial epithelium marker), actin (myometrial marker) and ER/PR (checking the state of the menstrual cycle), respectively.

RESULTS

After endometrial ablation, cauterized tissues were not noted 2 cm away from the endometrium. All tissues between the endometruim and center of adenomyosis were cauterized after direct heat therapy. During the uterine proliferative phase, unlike the secretory phase, subendometrial layers were cauterized 10 min after direct cauterization.

CONCLUSION

Direct heat therapy is more effective than endometrial ablation in adenomyosis, and heat is conducted effectively when the patients are in the proliferative phase.

Osteogenic responses of human mesenchymal stromal cells to static stretch

Molecular signals driving the regenerative process in distraction osteogenesis (DO) involve a complex system of cellular behavior triggered by mechanical strain. However, it remains unclear how mesenchymal stromal cells (MSCs) adapt to osteogenic demands during DO. We hypothesized that human MSCs (hMSCs) modulate early osteogenic metabolism during exposure to static stretch. The proliferation of hMSCs was increased by static stretch, which, in turn, suppressed TGF-β1-mediated decreases in cell proliferation. The amount of stretching force applied had little effect on osteoblast differentiation of hMSCs induced by dexamethasone treatment. However, this strain induced sustained production of nitric oxide and vascular endothelial growth factor (VEGF), which are critical factors in angiogenesis, from differentiated hMSCs. Mechanical stretch involved ERK and p38 mitogen-activated protein kinase pathways, the selective inhibitors of which decreased static-stretch-induced VEGF production. These findings provide evidence that hMSCs act to facilitate early osteogenic metabolism during exposure to static stretch.

Cigarette smoking and proteinuria in Taiwanese men with Type 2 diabetes mellitus

AIMS

Cigarette smoking is a well-known risk factor associated with diabetic nephropathy. The objective of this study was to further investigate the dose-response effect of tobacco exposure on proteinuria in males with Type 2 diabetes.

METHODS

Five hundred and nine males with Type 2 diabetes were selected from a cohort participating in a glucose control study in Taiwan. Pack-years of cigarette smoking were calculated to define tobacco exposure. Proteinuria was identified if albumin-to-creatinine ratio was > or = 30 mg/g in at least two of three consecutive urine tests. Logistic regression and trend tests were used to delineate the association between smoking status and proteinuria.

RESULTS

Compared with non-smokers, those who had smoked 15-30 or more than 30 pack-years were respectively 2.78 (95% CI 1.34-5.76, P < 0.01) and 3.20 (95% CI 1.74-5.86, P < 0.001) times more likely to develop proteinuria. The dose-response effect of tobacco exposure on the development of proteinuria is highly significant in all subjects (P = 0.001) and in subgroups with relatively short duration of diabetes mellitus (P < 0.001), good blood pressure control (P = 0.001) and those of young age (P = 0.007).

CONCLUSIONS

The current study shows a clear dose-response effect of cigarette smoking on development of proteinuria in male Type 2 diabetic patients. These findings reinforce the urgent need to encourage diabetic patients to stop smoking regardless of age, duration of diabetes mellitus or status of blood pressure control.

Sewage sludge reduction and system optimization in a catalytic ozonation process

The main objective of this study was to suggest a feasible, effective process for the reduction of sewage sludge using ozone oxidation catalysed by metal ion. A series of lab-scale experiments was conducted to select a suitable catalyst and its proper dose to achieve optimum sludge reduction. Using a central composite design under response surface methodology (RSM), system optimization with respect to sludge reduction and cost-effectiveness was performed by varying the independent parameters: dosages of ozone and ions. Five metal ions, Mn2+, Fe2+, Zn2+, CU2+, and Al3+1, were tested, and the manganese ion showed the highest sludge reduction, as measured by a decrease in total suspended solids. The ozone/Mn combination achieved approximately twice as much sludge reduction as the ozonation alone. Furthermore, the Mn dose of 10 mg/g-TS (total solids) resulted in the highest sludge reduction efficiency among the different doses, which ranged from 0 to 20 mg-Mn/g-TS. The predicted efficiency of sewage sludge reduction using the RSM was found to agree well with the experimental results, and the statistical analyses predicted optimum ranges for the doses of ozone and Mn ions, taking into account the overall cost for sewage sludge treatment.

IL-17 stimulates the proliferation and differentiation of human mesenchymal stem cells: implications for bone remodeling

Interleukin-17 (IL-17) is a cytokine secreted primarily by T(H)-17 cells. Although IL-17 is primarily associated with the induction of tissue inflammation, the other biological roles of IL-17, including non-immune functions, have yet to be thoroughly explored. Here, we report that T-cell-produced IL-17 can induce proliferation of human bone marrow-derived mesenchymal stem cells (hMSCs) in a manner dependent on the generation of reactive oxygen species (ROS). Rac1 GTPase and NADPH oxidase 1 (Nox1) are activated by IL-17 to produce ROS, which in turn stimulates hMSC proliferation. The activation of the MEK-ERK pathway is also crucial for IL-17-dependent hMSC proliferation. TRAF6 and Act1 are required to activate Nox 1 and to phosphorylate MEK on IL-17 stimulation. Interestingly, IL-17 not only accelerates the proliferation of hMSCs, but also induces their migration, motility, and osteoblastic differentiation. Furthermore, IL-17 induces the expression of M-CSF and receptor activator of NF-kappaB ligand (RANKL) on hMSCs, thereby supporting osteoclastogenesis both in vivo and in vitro. On the basis of these results, we suggest that IL-17 can function as a signal to induce extensive bone turnover by regulating hMSC recruitment, proliferation, motility, and differentiation.

Enhanced bio-energy recovery in a two-stage hydrogen/methane fermentation process

A two-stage hydrogen/methane fermentation process has emerged as a feasible engineering system to recover bio-energy from wastewater. Hydrogen-producing bacteria (HPB) generate hydrogen from readily available carbohydrates, and organic acids produced during the hydrogen fermentation step can be degraded to generate methane in the following step. Three strong acids, HCl, H(2)SO(4), and HNO(3), were tested to determine the appropriate pre-treatment method for enhanced hydrogen production. The hydrogen production rates of 230, 290, and 20 L/kg(-glucose)/day was observed for the sludge treated with HCl, H(2)SO(4), and HNO(3), respectively, indicating that the acid pre-treatment using either HCl or H(2)SO(4) resulted in a significant increase in hydrogen production. The fluorescent in situ hybridization method indicated that the acid pre-treatment selectively enriched HPB including Clostridium sp. of cluster I from inoculum sludge. After hydrogen fermentation was terminated, the sludge was introduced to a methane fermentation reactor. This experiment showed methane production rates of 100, 30, and 13 L/kg(-glucose)/day for the sludge pre-treated with HCl, H(2)SO(4), and HNO(3), respectively, implying that both sulfate and nitrate inhibited the activity of methane-producing bacteria. Consequently, the acid pre-treatment might be a feasible option to enhance biogas recovery in the two-stage fermentation process, and HCl was selected as the optimal strong acid for the enrichment of HPB and the continuous production of methane.

Characteristics of felodipine-located poly(ε-caprolactone) microspheres

Felodipine-loaded poly (epsilon-caprolactone) (PCL) microspheres were prepared by two methods, the conventional emulsion solvent evapouration method and the quenching method. The aim of this work was to investigate the effects of process parameters such as emulsion type, drug loading, molecular-weight of the polymer, types of emulsion stabilizer and dispersed phase solvents, as well as preparation methods. The results show that, when conventional emulsion solvent evapouration method was used, the o/w-method produced smaller mean size and higher encapsulation efficiency compared with the o/o-method. The encapsulation efficiencies increased with an increase in the molecular weight and a decrease in crystallinity of PCL. The size of microspheres varied with the type of emulsion stabilizer used, smaller microspheres with PVA and narrow size distribution with Pol 237. The water solubility of the dispersed phase solvent was one of the critical factors in controlling the encapsulation efficiency and microsphere mean size. When water-soluble solvents such as acetonitrile and ethyl formate were used, the encapsulation efficiencies decreased due to higher evapouration rate. When quenching methods were used, in contrast to the conventional emulsion solvent evapouration method, very narrowly size-distributed but bigger microspheres were obtained.

Controlled delivery of a hydrophilic drug from a biodegradable microsphere system by supercritical anti-solvent precipitation technique

The purpose of this study was to prepare microspheres loaded with hydrophilic drug, bupivacaine HCl using poly(D,L-lactic-co-glycolic acid) (PLGA) and poly(L-lactic acid) (PLLA). Microspheres were prepared with varying the PLGA/PLLA ratio with two different levels of bupivacaine HCl (5 and 10%) using a supercritical anti-solvent (SAS) technique. Microspheres ranging from 4-10 microm in geometric mean diameter could be prepared, with high loading efficiency. Powder X-ray diffraction (PXRD) revealed that bupivacaine HCl retained its crystalline state within the polymer and was present as a dispersion within the polymer phase after SAS processing. The release of bupivacaine HCl from biodegradable polymer microspheres was rapid up to 4 h, thereafter bupivacaine HCl was continuously and slowly released for at least 7 days according to the PLGA/PLLA ratio and the molecular weight of PLLA.

Quality and effect of single dose versus split dose of polyethylene glycol bowel preparation for early-morning colonoscopy

BACKGROUND AND STUDY AIMS

The conventional procedure of ingestion of an entire dose of polyethylene glycol solution on the day before early-morning colonoscopy may result in poor bowel preparation. The aim of this study was to evaluate the efficacy and effect of a split-dose ingestion of polyethylene glycol for early-morning colonoscopy.

METHODS

A total of 303 age- and sex-matched consecutive individuals presenting for medical check-ups were randomly assigned to receive either 4 L of polyethylene glycol solution with a soft diet on the day before colonoscopy (n = 152; group A), or 3 L of polyethylene glycol solution with a soft diet on the preceding day and then 1 L of the solution on the day of colonoscopy (n = 151; group B). The quality of bowel preparation was evaluated using the Ottawa scale, and the time to cecal intubation and the technical difficulty during the procedure were also recorded.

RESULTS

There was no difference in compliance between group A (single-dose) and group B (split-dose). The quality of bowel preparation was better in group B compared with group A. When the participants were categorized according to compliance (good compliance, 116 in group A, 119 in group B; poor compliance, 36 in group A, 32 in group B), the quality of the bowel preparation had a higher score in the good compliance compared with the poor compliance group, and in group B this difference was usually significant.

CONCLUSIONS

Split-dose bowel preparation with polyethylene glycol solution provided a better quality preparation than the conventional method for patients undergoing early-morning colonoscopy.

Motion analysis based on a multi-segment foot model in normal walking

The foot, an exceedingly complicated system, is essential to move the body forward and to keep dynamic stability during gait. In most previous studies on gait analysis, the foot has been defined as a single rigid segment, which results in many problems to understand the foot motion in detail. The purpose of this study is to develop a multi-segment foot model that can help analyze biomechanics of the foot during gait. A 9-segment foot model with 8 major joints was developed in this study. In addition, it was applied to the 3D motion analysis to determine the kinematics and the kinetics of the foot in the normal walking. Understanding the detailed foot motions by the present multi-segment foot model would be very useful to diagnose patients with various foot diseases.

Endothelin-1 regulates parathyroid hormone expression of human parathyroid cells

OBJECTIVE

Parathyroid cells synthesize and release endothelin-1 (ET-1). ET-1 displays an in vitro inhibitory effect on basal parathyroid hormone (PTH) secretion and also counteracts PTH hypersecretion stimulated by low calcium. Such effects are further demonstrated in vivo, independent of the changes in calcitonin. We propose that ET-1 may regulate the pathogenesis of uremic hyperparathyroidism. However, this was not directly demonstrated in human parathyroid glands.

DESIGN

Hyperplastic parathyroid glands are obtained from the surgical operation for uremic hyperparathyroidism. Cells are isolated by enzyme digestion and treated with ET-1, and are assessed for PTH mRNA expression. PTH in the plasma and the medium is measured by a newly developed method to detect the whole PTH (1-84).

PATIENTS

Uremic patients with severe secondary hyperparathyroidism and ultrasonography-proved hypertrophy of parathyroid glands received elective surgical approaches under general anesthesia. The resected glands were immediately taken to the laboratory for fresh isolation.

MEASUREMENTS

Following ET-1 treatment, PTH mRNA expression is evaluated by RT-PCR method. ET-1 is detected with radioimmunoassay kit and PTH is measured by a new commercially available Duo PTH kit.

RESULTS

ET-1 exhibited a dose-dependent inhibitory effect (from 10(-12) - 10(-7) M) on PTH mRNA expression of parathyroid cells, either in the basal or in the low-calcium-stimulated states. Release of PTH into the medium is also gradually inhibited by the increase in ET-1 concentrations.

CONCLUSIONS

Our results demonstrate that ET-1 attenuates PTH mRNA expression in freshly isolated human parathyroid cells, and PTH release is also decreased. This result is consistent with our previously reported in vitro and in vivo experiments.

The prescriptions frequencies and patterns of Chinese herbal medicine for allergic rhinitis in Taiwan

BACKGROUND

The evaluation of Chinese herbal medicines (CHM) to allergic rhinitis (AR) by large-scale pharmaco-epidemiological study is not ease found, although CHM had been reported to have potential effect for AR in some clinical trials.

AIMS OF THE STUDY

To explore the frequency and pattern of CHM prescriptions on AR, we have the study by analysing the population-based CHM database in Taiwan.

METHODS

The way for this study was linked and processed the complete traditional Chinese medicine database for Taiwanese recorded in the year 2002. The diagnosis of AR was extracted with the only single ICD-9 Code of 477 to calculate the frequency and pattern of prescriptions. Association rule was applied to analyse co-prescription of CHM for patients with AR.

RESULTS

In the year 2002, among the 22 520 776 valid beneficiaries of the National Health Insurance, Taiwan, 914 612 subjects (3.8% of the total valid beneficiaries) have diagnosed AR. There were 35.6% of AR patients been treated by CHM. The peak age of AR patients treated by CHM was at the first decade (0-10). For the AR patients, the most common Chinese herbal formula prescription was Shin-yi-qing-fei-tang, or Angelica dahurica (Bai-zhi) for the single Chinese herb. While for the combination treatments the most common prescription was the two formulae, Xiao-qing-long-tang and Shin-yi-san.

CONCLUSIONS

Because of the high utilization rate of the CHM treatment for AR, a large-scale randomized trial warrants further research for its efficacy and safety.

Decreased B cells and IgA-secreting B cells partially explain the high prevalence of IgA deficiency in dialysis patients

AIMS

We previously reported 2 hemodialysis (HD) patients with recurrent infections and selective immunoglobulin A deficiency (IgAD). We further demonstrated that serum IgA levels were lower and the prevalence of IgAD was higher in uremic patients. The exact mechanisms of IgAD in uremic patients largely remained unclear. In some patients, it was caused by anti-IgA antibody neutralization and subsequent destruction. We performed the present study to survey if there is any defect in IgA production.

MATERIALS AND METHODS

288 patients were initially included for examination of serum immunoglobulins. 16 normal persons, 16 dialysis patients without IgAD, and 12 dialysis patients with IgAD were enrolled after the initial examination. Blood was drawn into heparinized tubes. WBC counts and lymphocyte percentage were examined by a CBC counter. Lymphocytes were separated by the Ficoll-Paque method. Flow cytometry was utilized to isolate the B cell and IgA-secreting B cell after staining with CD 19 phycoerythrin and FITC-conjugated rabbit anti-human IgA antibody.

RESULTS

There is no significant difference between WBC counts or total lymphocyte counts of these 3 groups. However, we found a lower percentage of total lymphocyte counts in dialysis patients, either with or without IgAD. The total B cell numbers were lower in dialysis patients with IgAD. In addition, there were fewer IgA-secreting B cells in dialysis patients with IgAD.

CONCLUSION

Decreased B cell and IgA-secreting B cell counts are seen in uremic patients with IgAD. This, in turn, indicates that there might be a defect of IgA production in some patients, rather than IgA destruction by anti-IgA antibodies as seen in some other patients. Further study is needed to investigate the mechanisms of decreased B cells and IgA-secreting B cells.

Neuropeptide Y immunoreactivity and corticotropin-releasing hormone mRNA level are increased in the hypothalamus of mouse bearing a human oral squamous cell carcinoma

We examined gene expression of corticotropin-releasing hormone and neuropeptide Y level in the hypothalamic paraventricular nucleus of mouse bearing a human oral squamous cell carcinoma. A cell line derived from a human oral squamous cell carcinoma was inoculated into the lower dorsal area of nude mice. Body weight, tumor size and daily food intake were recorded every morning. Mice were sacrificed for corticotropin-releasing hormone mRNA in situ hybridization and neuropeptide Y immunohistochemistry, when the tumor ratio reached to 11-13% of real body weight. The results were compared with the age-matching non-tumor controls injected with saline instead of carcinoma cell. Body weight gain was significantly reduced in tumor bearing mice, however, no compensatory hyperphagia was found, i.e. daily food intake of the tumor mice did not differ from the non-tumor mice. Both neuropeptide Y immunoreactivity and corticotropin-releasing hormone mRNA level were significantly increased in the hypothalamic paraventricular nucleus of tumor mice. These results suggest that a human oral squamous cell carcinoma may induce anorexia, at least partly, via increasing the hypothalamic expression of corticotropin-releasing hormone in the tumor subjects. Additionally, neuropeptide Y-induced feeding appears to be inhibited in this tumor anorexia model, and this may correlate with increased expression of corticotropin-releasing hormone.

Acquired syngnathia

We report two cases of acquired syngnathia, in case 1 probably as a result of a fibrotic tubed pedicle and in case 2 from myositis ossificans. The treatment plan for syngnathia must include not only operation but also a rehabilitation programme (particularly muscle training)

Concomitant reconstruction of mandibular basal and alveolar bone with a free fibular flap

Repair of long-span mandibular defects with a free fibular flap is now a routine procedure. However, the bone height of the neo-mandible after reconstruction with a fibular flap is about half that of the dentulous mandible. When a fibular graft is placed only at the inferior border of the mandible, the resulting vertical discrepancy between the graft segment and the occlusal plane can adversely affect implant mechanics or denture stability and retention. To overcome these problems, we developed a technique for two-strut type mandibular reconstruction. A vascularized fibular segment is used to reconstruct the inferior basal portion of the neo-mandible, while a non-vascularized residual fibular segment is used to simulate the superior alveolar portion. We used this technique in 22 patients. Graft survival, graft resorption, and the ability to place implants were assessed as compared with those after the conventional one-strut type technique. The fibular segment grafted to the alveolar region was removed in one patient with intraoral wound dehiscence and in two with postoperative infection. All vascularized fibular flaps were successful. The resorption rate was 13.6+/-7.2% for non-vascularized segments and 3.0+/-3.7% for vascularized segments. Dental implants were placed in five of our 22 patients. The crown:fixture length ratio was improved to 1:1.7, as compared with a ratio of 1:1.21 with use of a conventional fibular flap. We conclude that our technique is very easy and safe and provides substantially improved lower-lip and cheek support and implant-prosthetic mechanics than conventional procedures for the repair of long-span mandibular defects.

Clinical analysis of extranodal non-Hodgkin's lymphoma in the sinonasal tract

We investigated the clinical analysis of non-Hodgkin's lymphoma (NHL) of the sinonasal tract, including the survival rate and treatment outcome. Fifty patients who had previously received a diagnosis of extranodal NHL of the sinonasal cavity from May 1992 to April 2001 were included. We reviewed the patients' clinical characteristics and the survival rates, retrospectively. Of 50 patients, 49 were classified as having extranodal NK/T cell lymphoma and only one patient as having diffuse large B cell (DLBC) lymphoma according to the new WHO classification. Even though higher mortality rates were observed in patients receiving chemotherapy alone than in those receiving chemotherapy and radiation therapy in the advanced stage, the combination treatment of chemotherapy and radiation therapy failed to demonstrate a significantly higher survival rate.

Chitosan microparticle preparation for controlled drug release by response surface methodology

The objectives were to investigate the effects of formulation variables on the release of drug and to optimize the formulation of chitosan microparticles loaded with drug for controlled release using response surface methodology. Chitosan microparticles were prepared by dropping a chitosan solution into sodium tripolyphosphate (TPP) through ionic cross-linking. The release behaviour of felodipine as a model drug was affected by preparation variables. A central composite design was used to evaluate and optimize the effect of preparation variables, chitosan concentration (X1), the pH of the TPP solution (X2) and cross-linking time (X3) on the cumulative per cent drug release (Y) in 24 h. Chitosan concentration and cross-linking time affected negatively the release of felodipine, while the pH of the TPP did so positively and was the highest influential factor. The optimum rate of drug release, 100% in 24 h, was achieved at 1.8% chitosan concentration, a pH 8.7 for the TPP solution and 9.7 min cross-linking time.

Characteristics of granular sludge in a single upflow sludge blanket reactor treating high levels of nitrate and simple organic compounds

Simultaneous denitrification and methanogenesis were accomplished in a single upflow sludge blanket (USB) reactor. More than 99% and 95% of nitrate and chemical oxygen demand (COD) removal rates were obtained at a loading of 600 mg NO3-N/L x d and 3,300 mg COD/L x d, respectively. The specific denitrification rate (SDR) increased as COD/NO3-N ratios decreased. Maximum SDR with acetate could reach 1.05 g NO3-N/gVSS x d. Significant sludge flotation was observed at the top of the reactor due to the change of microbial composition and the formation of hollow granules. Granules became fluffy and buoyant due to the growth of denitrifiers. Microscopic examination showed that granules exhibited layered structure and they were mainly composed of Methanosarcina sp., Pseudomonas sp., and rod-shaped bacteria.

Vanilloid receptor VR1-positive afferents are distributed differently at different levels of the rat lumbar spinal cord

The vanilloid receptor VR1 renders a group of primary afferents that express it sensitive to noxious heat and capsaicin, and is thus an important marker for nociceptors. We use double immunofluorescence and confocal microscopy to show that the density of VR1-positive fibers and boutons in the dorsal horn increases progressively from spinal segments L4 to L6 and that the colocalization of VR1 with the neuropeptide substance P (SP) in lamina I and along the lateral collateral path, where the majority of visceral afferents terminate, is negligible at L4, but substantial at L6. We conclude that VR1 is expressed by visceral afferents to the lower lumbar spinal cord in the rat, which also express SP.

Trends in prescribing proton pump inhibitors in Taiwan: 1997 - 2000

OBJECTIVE

The prescribing of proton pump inhibitors (PPIs) had increased greatly in recent years worldwide. Aim of our study was to analyze the utilization patterns of PPIs within the National Health Insurance program in Taiwan from 1997 - 2000.

MATERIAL AND METHOD

The systemic sampling data-sets from the National Health Insurance Research Database served as data sources. Units of measurement for PPIs were numbers of prescription items and defined daily doses (DDDs). To estimate the proportion of the population treated daily with PPIs, numbers of DDDs per 1,000 inhabitants per day were calculated. In order to realize the role of PPIs in treating Helicobacter pylori-related disorders, we also analyzed various combined prescriptions of PPIs with amoxicillin, clarithromycin, metronidazole, tetracycline and bismuth.

RESULTS

In the study period, PPI prescriptions increased nearly 2-fold at the outpatient sector and more than 3-fold at the inpatient sector. Men received more PPI prescriptions, as a whole, than women. Most PPIs were prescribed at the outpatient sector: 93.9% in 1997, 92.3% in 1998, 90.4% in 1999 and 87.3% in 2000. The numbers of DDDs per 1,000 inhabitants per day for all kinds of PPIs were 0.59, 0.78, 1.07, and 1.13 from 1997 - 2000, respectively. While the percentage of monotherapy increased from 63.6% in 1997 to 75.5% in 2000, the combination therapies did not experience a rapid and sustained growth. Among the combination therapies, PPI + amoxicillin + metronidazole and PPI + amoxicillin were popular in 1997 and 1998, but triple therapy with PPI + amoxicillin + clarithromycin predominated in 1999 and 2000.

CONCLUSIONS

Despite increasing use, prescribing volumes of PPIs in Taiwan were far fewer than those in other developed countries. Treatment of Helicobacter pylori-related disorders in Taiwan followed universal standard.

Preparation and release characteristics of polymer-coated and blended alginate microspheres

To prevent a rapid drug release from alginate microspheres in simulated intestinal media, alginate microspheres were coated or blended with polymers. Three polymers were selected and evaluated such as HPMC, Eudragit RS 30D and chitosan, as both coating materials and additive polymers for controlling the drug release. This study focused on the release characteristics of polymer-coated and blended alginate microspheres, varying the type of polymer and its concentration. The alginate microspheres were prepared by dropping the mixture of drug and sodium alginate into CaCl(2) solution using a spray-gun. Polymer-coated microspheres were prepared by adding alginate microspheres into polymer solution with mild stirring. Polymer-blended microspheres were prepared by dropping the mixture of drug, sodium alginate and additive polymer with plasticizer into CaCl(2) solution. In vitro release test was carried out to investigate the release profiles in 500 ml of phosphate buffered saline (PBS, pH 7.4). As the amount of polymer in sodium alginate or coating solution increase, the drug release generally decreased. HPMC-blended microspheres swelled but withstood the disintegration, showing an ideal linear release profiles. Chitosan-coated microspheres showed smooth and round surface and extended the release of drug. In comparison with chitosan-coated microspheres, HPMC-blended alginate microspheres can be easily made and used for controlled drug delivery systems due to convenient process and controlled drug release.

A case of mitochondrial trifunctional protein deficiency diagnosed by acylcarnitine profile and DNA analysis in a dried blood spot of a 4-day-old boy

We report a Korean case, consistent with a biochemical diagnosis of trifunctional protein (TFP) deficiency, in which molecular diagnosis revealed a novel mutation in the alpha-subunit of TFP and the rare combination of two intergenic region (C/C and G/G) polymorphisms.

Preparation and characterization of chitosan microparticles intended for controlled drug delivery

Chitosan microparticles were prepared with tripolyphosphate (TPP) by ionic crosslinking. The particle sizes of TPP-chitosan microparticles were in range from 500 to 710 microm and encapsulation efficiencies of drug were more than 90%. The morphologies of TPP-chitosan microparticles were examined with scanning electron microscopy. As pH of TPP solution decreased and molecular weight (MW) of chitosan increased, microparticles had more spherical shape and smooth surface. Release behaviors of felodipine as a model drug were affected by various preparation processes. Chitosan microparticles prepared with lower pH or higher concentration of TPP solution resulted in slower felodipine release from microparticles. With decreasing MW and concentration of chitosan solution, release behavior was increased. The release of drug from TPP-chitosan microparticles decreased when cross-linking time increased. These results indicate that TPP-chitosan microparticles may become a potential delivery system to control the release of drug.

Preparation and characterization of drug-loaded polymethacrylate microspheres by an emulsion solvent evaporation method

Microspheres containing the anti-hypertension drug, felodipine, were prepared by the emulsion solvent evaporation method (o/o) using acrylate methacrylate copolymers, Eudragit RL PO and Eudragit RS PO, as wall materials. In order to increase the encapsulation efficiency, a mixed solvent system comprising 1:1 proportions of acetonitrile and dichloromethane was used as a dispersed phase. The morphology of the microspheres was evaluated using a scanning electron microscope, which showed a spherical shape with smooth surface. The mean sphere diameter was between 9.5-13.2 microm and the microencapsulation efficiencies ranged from 51.4-80.4%. The release profiles and encapsulation efficiencies depended strongly on the structure of the polymers used as wall materials. The release rate of the Eudragit RS PO microspheres was much lower than that of Eudragit RL PO microspheres. Whereas Eudragit RL PO microspheres followed the Higuchi rule, Eudragit RS PO microspheres exhibited a triphasic release profile. It is concluded that drug release rate can be controlled by choice of polymer type.

Preparation of alginate beads for floating drug delivery system: effects of CO(2) gas-forming agents

Floating beads were prepared from a sodium alginate solution containing CaCO(3) or NaHCO(3) as gas-forming agents. The solution was dropped to 1% CaCl(2) solution containing 10% acetic acid for CO(2) gas and gel formation. The effects of gas-forming agents on bead size and floating properties were investigated. As gas-forming agents increased, the size and floating properties increased. Bead porosity and volume average pore size, as well as the surface and cross-sectional morphology of the beads were examined with Mercury porosimetry and Scanning Electron Microscopy. NaHCO(3) significantly increased porosity and pore diameter than CaCO(3). Incorporation of CaCO(3) into alginate solution resulted in smoother beads than those produced with NaHCO(3). Gel strength analysis indicated that bead strength decreased with increasing gas-forming agent from 9 to 4 N. Beads incorporating CaCO(3) exhibited significantly increased gel strength over control and NaHCO(3)-containing samples. Release characteristics of riboflavin as a model drug were studied in vitro. Release rate of riboflavin increased proportionally with addition of NaHCO(3). However, increasing weight ratios of CaCO(3) did not appreciably accelerate drug release. The results of these studies indicate that CaCO(3) is superior to NaHCO(3) as a gas forming agent in alginate bead preparations. The enhanced buoyancy and sustained release properties of CaCO(3)-containing beads make them an excellent candidate for floating drug dosage systems (FDDS).

Evaluation of acupuncture effect to chronic myofascial pain syndrome in the cervical and upper back regions by the concept of Meridians

Myofascial pain syndrome (MPS) in the cervical and upper back regions is a common medical problem. The involved muscles include trapezius, multifidi, splenius cervicis, levator scapulae, supraspinatus or infraspinatus. Acupuncture is a well-known method for relief of chronic pain. In this study, we evaluated the effect of acupuncture in MPS and its durability by using the concept of meridians. Twenty-nine patients with chronic MPS in the upper back and cervical regions received acupuncture 2 times per week for 3 weeks. According to the pathways of the meridians, we chose acupuncture points by the pain regions located in which parts of meridian passing (i.e. "Where the meridian passes, where to treat the disease."). We evaluated the intensity of pain by visual analog scales (VAS) and active range of motion (ROM) of neck before and after therapy. After receiving acupuncture for 3 weeks, VAS of pain fell significantly from 9.0+/-1.0 to 4.9+/-2.5 and active ROM of neck significantly increased from 35.8+/-10.2 degrees to 61.3+/-9.4 degrees (p<0.05). The onset of symptom relief was gradual and duration of symptom relief after a course of acupuncture was average 5.3+/-1.2 days. In conclusion, acupuncture is a somewhat effective method for pain relief of patients with chronic MPS in the cervical and upper back regions. However, the effect of acupuncture with the concept of meridians on MPS is insidious and the duration of the relief is not long enough.

Edema due to protein-losing enteropathy--a disorder rarely considered by nephrologists

In the differential diagnosis, protein-losing enteropathy (PLE) is a rarely considered explanation of edema. Three such cases are reported in this article. Clinical presentations varied from severe generalized anasarca and respiratory distress to mild pitting edema on the pretibial surface. Hypoalbuminemia (< 35 g/l) was another common finding in addition to edema. The patients were carefully examined to exclude other causes of hypoalbuminemia. Two patients experienced diarrhea. Endoscopic studies (plus biopsies) for any mucosal lesion in the stomach and colon were also performed. PLE was confirmed by the positive radionuclide scanning results after infusing intravenous 99mTc human serum albumin (USA). Investigation for the etiologies showed intestinal lymphangiectasia in 1 patient, Menetrier's disease in another, and no recognizable cause in the third. The severe anasarca of the patient with intestinal lymphangiectasia didn't respond to corticosteroids and albumin supplement plus large doses of furosemide. She died of overwhelming pulmonary infection despite the use of powerful antibiotics (ceftriaxone and amikacin). We planned to treat the Menetrier's disease patient with somatostatin to decrease the exocrine activities of the intestinal tract. The patient with presumable idiopathic PLE had the least severe edema and was not treated with any medication. In addition to the above patients, another 3 patients with hypoalbuminemia and edema were also noted to have positive HSA scan results. However, 2 of these patients had systemic lupus erythromatosus and the third pulmonary tuberculosis and biopsy-proven membranous nephropathy. Treatment of their underlying diseases showed satisfactory remission of edema.

A giant pyogenic granuloma in the nasal cavity caused by nasal packing

Pyogenic granuloma is a benign, rapidly growing hemorrhagic lesion of unknown origin. This disorder, however, is obscure to many rhinologists, because the nose is a relatively rare location for the lesion. In the practice of otorhinolaryngology, nasal packing is a very common procedure for nasal bleeding and postoperative hemostasis. However, few pyogenic granulomas occurring from nasal packing have been reported in the literature. A 56-year-old man underwent nasal packing with vaseline gauze because of nasal bleeding. Two months later, a dark brown nasal tumor was found in his nasal cavity. He underwent endoscopic endonasal removal of the tumor. The pathology result showed a pyogenic granuloma. This is the third case recorded in the literature of a confirmed pyogenic granuloma occuring as a complication of nasal packing. This uncommon lesion should be considered in the differential diagnosis of a rapidly growing hemorrhagic lesion within the nasal fossa.

Leukopenia and thrombocytopenia in hemodialysis patients with hepatitis B or C virus infection and non-hemodialysis patients with hepatitis cirrhosis

AIMS

To investigate the relation of leukopenia and thrombocytopenia in hemodialysis (HD) patients with hepatitis C virus (HCV) infection.

MATERIALS AND METHODS

The study included 86 HD patients with hepatitis B surface antigen-negative and hepatitis C antibody-negative, 28 HD patients with hepatitis C antibody-positive, 22 HD patients with hepatitis B surface antigen-positive, 78 non-HD patients with hepatitis B-induced liver cirrhosis and 38 non-hemodialysis patients with hepatitis C-induced liver cirrhosis. The following parameters were checked: anti-HCV, hepatitis B surface antigen, hemoglobin, hematocrit, white blood cells, platelets, calcium, phosphate, iron, ferritin, albumin, globulin, aspartate transaminase (AST), alanine transaminase (ALT) and C-reactive protein. The history of blood transfusions, medications, erythropoietin doses and adequate dialysis (KTNV) for 6 consecutive months was also recorded from charts.

RESULTS

The HD patients with positive serum anti-HCV and non-HD patients with hepatitis B- or C-induced liver cirrhosis had higher prevalences of leukopenia (39.3%, 43.6% and 50% vs. 15.1%; p < 0.001) and thrombocytopenia (67.9%, 89.7% and 81.6% vs. 34.9%: p < 0.001) than HD patients with serum anti-HCV(-)HbsAg(-). The WBC (4,432 +/- 1,394, 4,792 +/- 2,263 and 4,624 2,446 vs. 5,590 +/- 1,500/mm3; p < 0.001) and platelet counts (140 +/- 45, 80 +/- 50 and 89 +/- 65 vs. 186 +/- 62 x 10(3)/mm3; p < 0.001) of HD patients with positive serum anti-HCV and non-HD patients with hepatitis B- or C-induced cirrhosis were also lower than HD patients without anti-HCV antibody. The liver cirrhosis patients had more thrombocytopenia than the HD patients with anti-HCV(+). The WBC and platelet counts did not vary between HD patients with HbsAg(+) and HD patients with anti-HCV(-)HBsAg(-). The durations of HD, hepatitis and liver cirrhosis were not related to the leukopenia or thrombocytopenia (p > 0.05).

CONCLUSIONS

HCV infection associated with leukopenia and/or thrombocytopenia in HD patients is as common as in non-HD patients with liver cirrhosis. This may be due to the direct effect of hemopoiesis rather than the hyperspleenism of liver cirrhosis patients. There is a need for further prospective investigation to ascertain the clinical significance of leukopenia and thrombocytopenia in HD patients with anti-HCV(+). The prevalence of leukopenia and thrombocytopenia was higher in HD patients with hepatitis C than in HD patients with hepatitis B and HD patient without hepatitis.

Hepatitis C viral genotype influences the clinical outcome of patients with acute posttransfusion hepatitis C

Most patients with an acute infection of hepatitis C virus (HCV) will develop chronic hepatitis, and only about 15-20% of the cases will resolve spontaneously. The mechanism for the different outcomes in patients with acute HCV infection remains unclear. HCV genotype has been recognized as an important factor affecting the clinical course and outcome of chronic hepatitis C patients. In order to evaluate the role of HCV genotype in the clinical course and outcome of acute posttransfusion hepatitis C, 67 patients with acute posttransfusion hepatitis C from a prospective study of posttransfusion non-A, non-B hepatitis were enrolled. Thirty-nine patients (58.2%) were HCV genotype 1b. Among the 67 patients with acute posttransfusion hepatitis C, 53 (79.1%) progressed to chronic hepatitis. Significantly more patients with genotype 1b than non-1b genotypes developed chronic hepatitis (89.7% vs. 64.3%; P = 0.019). There was no significant difference in gender, mean age, amount of transfused blood, hepatitis symptoms, jaundice, incubation period, peak serum alanine transaminase, or serum HCV RNA titer between patients with HCV genotype 1b and non-1b infections. Patients who developed chronic hepatitis had a significantly greater incidence of genotype 1b infection (66.0% vs. 28.6%; P = 0.013) and a longer incubation period (7.3 weeks vs. 5.4 weeks; P = 0.052) than patients whose infection was resolved. Patients with a genotype 1b infection that resolved itself spontaneously all had an incubation period of less than 6 weeks. Multivariate logistic regression analysis revealed that genotype 1b and an incubation period > or = 6 weeks were significant predictive factors for the development of chronic hepatitis. Therefore, the HCV genotype can influence the outcome of patients with acute HCV infection.

Hepatitis C virus infection: an overview

Hepatitis C virus is an RNA virus belonging to the Flaviviridae family. The diagnosis of hepatitis C virus infection was based on the detection of serum antibody to hepatitis C virus (anti-HCV) using immunoassay or recombinant immunoblot assay, or the direct detection of serum hepatitis C virus RNA using polymerase chain reaction. The anti-HCV positive rate in the general population or healthy blood donors is 0.5% to 4% worldwide. Parenteral transmission was the major route of hepatitis C virus infection. High-risk groups for hepatitis C virus infection included recipients of blood transfusion of which the blood donors were not screened for anti-HCV, intravenous drug abusers, hemophiliacs, and patients who have received hemodialysis. More than 80% of patients with hepatitis C virus infection progressed into chronicity, 20% to 30% of patients with chronic hepatitis C progressed to cirrhosis after 10 to 20 years of follow-up, and some developed hepatocellular carcinoma. Hepatitis C virus was the most common cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma in Western countries and in Japan, where hepatitis B virus is not endemic. Interferon therapy at a dosage of 3 MU and subcutaneous injection 3 times per week for 6 months normalized serum transaminase in 50% of patients with chronic hepatitis C at the end of treatment. However, the relapse rate was high and only 20% to 25% of patients sustained response 1 year after discontinuing therapy. Prolonged interferon therapy up to 12 to 18 months has been suggested to improve interferon efficacy by decreasing the relapse rate and thus increasing the sustained response rate. New interferon preparation such as consensus interferon and long-acting pegylated-interferon has recently shown better treatment response than the traditional interferon regimen. The combined regimen of interferon and ribavirin was shown to have better efficacy than interferon alone in treating patients with chronic hepatitis C.