[Epidemiological and Etiologic characteristics of Meningococcal meningitis in Xinjiang Uygur Autonomous Region,1960-2019]

Objective: To understand the epidemiological and etiologic characteristics of meningococcal meningitis in Xinjiang Uygur Autonomous Region (Xinjiang). Methods: The epidemiological data about the meningococcal meningitis cases in Xinjiang from 1960 to 2019 were collected from the China information system for disease control and prevention and the Center for Disease Control and Prevention of Xinjiang. The epidemiological characteristics were analyzed. Clinical specimens from suspected cases were cultured and tested by real-time PCR method. A survey on the carriage rate of Neisseria meningitides (Nm) in the healthy population was performed. The serogroups of isolates were determined by serum-agglutination and PCR methods. Multi-locus sequence typing was used for subtyping the isolates. Results: The incidence rates of meningococcal meningitis in Xinjiang from 1960 to 2019 were 0.02/100 000-81.32/100 000, with the mortality as 1.05%-20.78%. The five districts with the most cases were Kashi prefecture, Aksu prefecture, Urumqi city, Changji Hui autonomous prefecture, and Hotan prefecture. Before 1990, serogroup A (81.82%) was the commonest group for cases and contacts. After 1990, 14.00% of the cases were caused by serogroups B, C, W, and Y. There was no predominant serogroup for contacts with serogroups B, C, W, Y, and C accounting for 23.28%, 18.53%, 15.52%, 9.91% and 7.33% respectively. The general Nm carriage rate was 15.50%, with the population of 16 - 20 years age group having the highest rate (25.53%). Serogroups B (52.11%), W (20.66%), C (12.21%), and Y (9.39%) occupied 52.11%, 20.66%, 12.21% and 9.39% respectively. The commonest clonal lineages of Nm isolates were ST-4821, ST-175, and ST-5 clonal complexes, while the ST-5 and ST-4821 clonal complexes were the major ones for invasive strains. Conclusions: There appeared regional differences in the incidence rates of Xinjiang meningococcal meningitis, and the carriage rate of Nm was high. The serogroups have been changing. It is necessary to strengthen the prevention and control of meningococcal meningitis to prevent any potential outbreak.

KLF13 loss-of-function variation contributes to familial congenital heart defects

OBJECTIVE

Congenital heart defect (CHD) represents the most common form of human developmental abnormality and contributes to substantial morbidity, mortality, and socioeconomic burden worldwide. Accumulating evidence underscores the strong genetic basis of CHD. Nevertheless, CHD is of pronounced genetic heterogeneity, and the genetic determinants underlying CHD in most patients are still unclear. This study was mainly sought to identify the causative gene for CHD in a consanguineous Chinese family.

PATIENTS AND METHODS

Whole-exosome sequencing and bioinformatics analyses were performed in a Chinese family with CHD (double-outlet right ventricle and ventricular septal defect), which was transmitted in an autosomal dominant pattern. A total of 312 unrelated healthy individuals were then genotyped for the identified genetic variation. The functional effect of the identified variation was characterized by utilizing a Dual-Luciferase reporter assay system.

RESULTS

A novel heterozygous variation, NM_015995.3: c.370G>T; p.(Glu124*), was identified in the KLF13 gene, which encodes Kruppel-like factor 13 key to proper heart development. Genetic analysis of the pedigree unveiled that the variation co-segregated with CHD, with complete penetrance. The variation was absent from 624 control chromosomes. The biological analysis revealed that the Glu124*-mutant KLF13 protein failed to transactivate its cardiac target genes ACTC1 and ANP. Furthermore, the variation disrupted the synergistic transactivation between KLF13 and GATA4, as well as GATA6, two other genes that have been recognized to cause CHD.

CONCLUSIONS

These findings firstly indicate that genetically defective KLF13 predisposes to familial CHD, implying potential implications for genetic counseling and an improved prophylactic strategy in a subset of CHD patients.

Locomotor transition: how squid jet from water to air

The amazing multi-modal locomotion of flying squid helps to achieve fast-speed migration and predator-escape behavior. Observation of flying squid has been rarely reported in recent years, since it is challenging to clearly record the flying squid's aquatic-aerial locomotion in a marine environment. The existing reports of squid-flying events are rare and merely record the in-air motion. Therefore, the water-air locomotor transition of flying squid is still unknown. This paper proposes the idea of using CFD to simulate the process of the flying squid (Sthenoteuthis oualaniensis (S. oualaniensis)) launching from water into air. The results for the first time reveal the flow field information of squid in launching phase and show the kinematic parameters of flying squid in quantification. Both a trailing jet and pinch-off vortex rings are formed to generate launching thrust, and the formation number L _ω /D _ω is 5.22, demonstrating that the jet strategy is to produce greater time-averaged thrust rather than higher propulsion efficiency. The results also indicate that the maximum flying speed negatively correlates with the launch angle, indicating that a lower launch angle could result in a larger flying speed for the flying squid to escape. These findings explore the multi-modal locomotion of flying squid from a new perspective, helping to explain the trade-off strategy of water-to-air transition, and further enhance the performance of aquatic-aerial vehicles.

Using Meglumine Diatrizoate to improve the accuracy of diagnosis of cracked teeth on Cone-beam CT images

AIM

To explore in a laboratory setting the feasibility of using Meglumine Diatrizoate (MD) to improve the accuracy of diagnosis of cracked teeth on cone-beam CT (CBCT) images.

METHODOLOGY

Twenty-four teeth were cracked artificially by soaking them cyclically in liquid nitrogen and hot water. The number and position of crack lines were evaluated with a dental operating microscope and used as the gold standard. The artificially cracked teeth were then examined using routine scanning (RS) and enhanced scanning (ES) modes, respectively. For the ES mode, MD was painted on the surface of the crack lines, and then, CBCT scanning with the same parameters was performed after 10 min. A radiological graduate student and an experienced radiologist evaluated the presence or absence of crack lines, respectively. The differences between the RS and ES modes were determined and assessed using McNemar's test. Inter-examiner agreement and intra-examiner agreement were assessed using kappa analysis.

RESULTS

Fifty-seven crack lines were found in the 24 cracked teeth. In the RS mode, the accuracy of detection of crack lines was 23% (radiological graduate student) and 32% (experienced radiologist), whereas in the ES mode, the accuracy was 61% (radiological graduate student) and 65% (experienced radiologist). The inter-examiner agreement was 0.693 in RS mode and 0.849 in ES mode. The intra-examiner agreement was 0.872 and 0.949 for the radiological graduate student in RS and ES mode respectively; and one for the experienced radiologist both in RS and ES mode.

CONCLUSIONS

Compared with routine scanning mode, more crack lines could be detected in enhanced scanning mode using Meglumine Diatrizoate as a contrast medium. MD could be a potential contrast medium to improve the accuracy of detection of crack lines on CBCT images.

[A cross-sectional study of seroepidemiology of viral hepatitis among Uighurs in Shufu of Xinjiang]

Objective: To explore the status of seroepidemiology on hepatitis A, B and C among students and residents aged equal or greater than 18 years in south Xinjiang, and to provide scientific evidence for prevention and control of viral hepatitis. Methods: Uyghur students in four towns and villages were selected by cluster random sampling from Feb to May, 2015, and Uyghur residents aged 18 to 69 years were selected by stratified cluster sampling from May to September, 2016. 4 507 middle and primary Uygur students and 4 833 Uyghur resides equal or greater than 18 years attended this survey. Self-designed questionnaire was used to collect the demographic information. And Elisa test was adopted to detect HAV-IgG, HBsAg, HBsAb and HCV-IgG. Chi-square test was used to calculate the difference on antibody positive rate of three types of hepatitis among the participants. Results: The overall HAV-IgG positive rate was 99.45% (9 289/9 340). The positive rates were 99.70% (4 006/4 018) in male and 99.27% (5 283/5 322) in female (χ(2)=7.95, P=0.005). The HAV-IgG positive rate among people aged 10 to 14 years was the highest (99.91%, 2 233/2 235), and the difference between the age specific HAV-IgG positive rates was statistical significant (χ(2)=38.21, P<0.001). The overall HBsAg positive rate was 4.11% (384 cases), with 4.55% (183 cases) for male and 3.78% (201 cases) for female. The HBsAg positive rate among participants 19 to 24 years old was the highest (9.46%, 21/222) and the differences between the age specific HBsAg was statistically significant (χ(2)=116.22, P<0.001). The HBsAb positive rate was 35.03% (3 272 cases), with 35.59% (1 430 cases) for male and 34.61% (1 842 cases) for female, and the HBsAb positive rate among participants aged 15 to 18 years was the highest, which was 69.12% (696/1 007). The differences between the age specific HBsAb rates appeared statistically significant (χ(2)=671.80, P<0.001). The overall HCV-IgG positive rate was 0.65%(61 cases). The HCV-IgG positive rate in female was 0.86% (46 cases) and 0.37% (15 cases) in male (χ(2)=8.51, P=0.004).The HCV-IgG positive rate among participants aged over 70 years was the highest (3.78%,9/238) , and the difference between the age specific HCV-IgG positive rates had statistic significance (χ(2)=70.30, P<0.001). The HAV-IgG positive rate in hepatitis A vaccinees (100%, 876/876) was higher than that among the non-vaccinees (99.40%, 8 413/8 464) (χ(2)=4.26, P=0.039). The HBsAb positive rate in hepatitis B vaccinees was 39.32% (1 816/4 619) which was higher than that among the non-vaccinees (30.84%, 1 456/4 721) (χ(2)=73.68, P<0.001). Conclusion: The positive rate of overall HAV-IgG was high, male and participants aged between 10 to 14 had higher probability to be infected. But the infection rates of hepatitis B and C were low, with the low vaccination rate and the poor protective effectiveness of hepatitis B.

[Prevalence of hypertension and risk factors in Uygur population in Kashgar area of Xinjiang Uygur Autonomous Region]

Objective: To investigate the prevalence of hypertension and risk factors in Uygur adults in Kashgar of Xinjiang. Methods: A total of 4 748 Uygur adults aged ≥18 years selected through cluster random sampling in Shufu county of Kashgar prefecture were surveyed by means of questionnaire survey, physical examination and laboratory test. The prevalence, awareness, treatment and control rate of hypertension of different groups were calculated and risk factors of hypertension was analyzed by using non-conditional logistic regression model. Results: The overall prevalence of hypertension was 15.73% (age-adjusted prevalence was 13.75%). The prevalence rates of hypertension in men and women were 16.36% (age-adjusted prevalence was 12.96%), 15.39% (age-adjusted prevalence was 14.34%), respectively. The rates of awareness, treatment and control of hypertension were 59.57%, 52.74%, 21.29%, respectively. The prevalence of hypertension increased with age. Compared with age group 18-34 years, the age groups 55-64, ≥65 years had higher risk of hypertension and the OR values were 10.53, 20.96 for men and 16.27, 33.20 for women. The overweight (OR=1.47 for men, OR=1.82 for women, P<0.05) and obesity (OR=1.88 for men, OR=2.66 for women, P<0.05) also increased the risk of hypertension. The groups with family history of hypertension (OR=3.85 for men, OR=2.34 for women, P<0.05) also had higher risk of hypertension. Hypertriglyceridemia was positively correlated with the prevalence of hypertension in men (OR=1.62, 95%CI: 1.09-2.41). Conclusions: The prevalence of hypertension in Uygur adults in Kashgar area of Xinjiang was at relatively low level. The related risk factors were age, overweight, obesity, family history and hypertriglyceridemia in men and the risk factors were similar in women except hypertriglyceridemia.

[Prevalence of diabetes mellitus and associated risk factors in Uygur population in Kashgar area of Xinjiang Uygur Autonomous Region]

Objective: To investigate the epidemiologic characteristics of diabetes mellitus (DM) in Uygur residents in Kashgar of Xinjiang. Methods: The survey was conducted among the Uygur residents aged ≥18 years selected through stratified cluster sampling in Kashgar by means of questionnaire survey, physical examination and basic laboratory test. The prevalence of different groups were calculated and risk factors of DM was analyzed by logistic vegression model. Results: A total of 4 608 adults were surveyed. The prevalence of DM was 11.31% (standardized prevalence: 10.59%) and the prevalence was 13.65% (standardized prevalence: 12.34%) in males and 10.04% (standardized prevalence: 9.83%) in females. The prevalence increased with age. The prevalence of DM was higher than the prevalence of impaired fasting glucose (IFG) in people aged >60 years, especially in females. The rates of awareness, treatment and control of DM were 28.02%, 21.31% and 5.57%, respectively. Multivariate logistic regression analysis indicated that people aged 45-55, 55-65 and >65 years had higher risk of DM and the odds ratio were 2.08 (95%CI: 1.24-3.48), 2.73 (95%CI: 1.63-4.56) and 3.90 (95%CI: 2.24-6.78) for men and 2.63 (95% CI: 1.71-4.02), 3.14 (95%CI: 2.00-4.94) and 5.56 (95%CI: 3.47-8.92) for woman, respectively. Family history of DM (OR=2.88 for men, 95% CI: 1.45-5.72; OR=2.52 for women, 95% CI: 1.49-4.26) and BMI≥28.0 kg/m(2) (OR=1.77 for men, 95% CI: 1.19-2.64, OR=1.80 for women, 95% CI: 1.30-2.50) were also risk factors for DM. Conclusion: The prevalence of DM was high in Uygur residents in Kashgar, but the rate of awareness, treatment and control of DM were low. It is necessary to improve the detection rate of DM and conduct targeted prevention and control of DM.

The comparative, long-term effect of the Salter osteotomy and Pemberton acetabuloplasty on pelvic height, scoliosis and functional outcome

AIMS

This study compared the long-term results following Salter osteotomy and Pemberton acetabuloplasty in children with developmental dysplasia of the hip (DDH). We assessed if there was a greater increase in pelvic height following the Salter osteotomy, and if this had a continued effect on pelvic tilt, lumbar curvature or functional outcomes.

PATIENTS AND METHODS

We reviewed 42 children at more than ten years post-operatively following a unilateral Salter osteotomy or Pemberton acetabuloplasty. We measured the increase in pelvic height and the iliac crest tilt and sacral tilt at the most recent review and at an earlier review point in the first decade of follow-up. We measured the lumbar Cobb angle and the Short Form-36 (SF-36) and Harris hip scores were collected at the most recent review.

RESULTS

During the first decade of follow-up, there was a greater increase in pelvic height in the children who had a Salter osteotomy (Salter, 10.1%; Pemberton, 4.3%, p < 0.001). The difference in the increase in pelvic height was insignificant at the most recent review (Salter, 4.4%; Pemberton, 3.1%, p = 0.249). There was no significant difference between the two groups for the lumbar Cobb angle, (Salter, 3.1°; Pemberton, 3.3°, p = 0.906). A coronal lumbar curve was seen in 41 children (97%), 30 of these had a compensatory curve. Sacral tilt was the radiographic parameter for pelvic imbalance that correlated most with the lumbar Cobb angle (Pearson correlation co-efficient 0.59). The Harris hip score and SF-36 were good and showed no differences between the two groups.

CONCLUSION

In the long-term, we found no difference in the functional results or pelvic imbalance between Salter osteotomy and Pemberton acetabuloplasty in the management of children with DDH. Cite this article: Bone Joint J 2016;98-B:1145-50.

Mid-infrared photodetectors operating over an extended wavelength range up to 90 K

We report a wavelength threshold extension, from the designed value of 3.1 to 8.9 μm, in a p-type heterostructure photodetector. This is associated with the use of a graded barrier and barrier offset, and arises from hole-hole interactions in the detector absorber. Experiments show that using long-pass filters to tune the energies of incident photons gives rise to changes in the intensity of the response. This demonstrates an alternative approach to achieving tuning of the photodetector response without the need to adjust the characteristic energy that is determined by the band structure.

Serum nerve growth factor level indicates therapeutic efficacy of 125I seed implantation in advanced pancreatic adenocarcinoma

OBJECTIVE

To evaluate serum nerve growth factor (NGF) as a marker in predicting effectiveness of 125I seed implantation in advanced pancreatic carcinoma.

PATIENTS AND METHODS

A total of 45 patients (30 males/15 females with mean age of 52.07±8.43 years) diagnosed with advanced pancreatic adenocarcinoma (PCa) between January 2011 to May 2014 were enrolled as PCa group in this study. Tumors were categorized as at least stage III with unresectionable condition by the TNM standard. The average tumour shortest diameter was 37.54±13.84 mm (18.50-71.20 mm). NGF level in serum before 125I seed implantation and in tumor tissue resected during surgery was measured by ELISA. After treatment, CT Scan was used to serially monitor the diameters of the tumour monthly for 6-month follow-up. RECIST was applied to evaluate the efficacy. Predictive value of serum and tumour derived NGF was evaluated based on ROC curve chart.

RESULTS

We found that the serum NGF level was significantly increased in PCa patients (775.60 ± 250.97 pg/ml) compared to the healthy control group (35.03 ± 25.36 pg/ml), after age and gender adjustment. In the PCa group, the serum NGF level positively correlated with that from loci tumor tissue (r=0.487). The serum NGF level was compared between the effective group (537.42 ± 122.61 pg/ml) and noneffective group (883.17 ± 217.79 pg/ml), and significant difference was detected (p<0.0001). Patients with lower serum NGF level had good response to the 125I seeds implantation. Taking cut-off at 649.59 pg/ml, 85.70% specificity and 90.30% sensitivity were achieved by ROC. Area under the Curve of serum NGF was 0.945, standard deviation was 0.032, 95% confidence interval was 0.882-1.000.

CONCLUSIONS

The level of serum NGF could be a referential index to predict the therapeutic efficacy of 125I seed implantation treatments in advanced pancreatic adenocarcinoma.

IFI27, a novel epidermal growth factor-stabilized protein, is functionally involved in proliferation and cell cycling of human epidermal keratinocytes

OBJECTIVES

IFI27 is highly expressed in psoriatic lesions but its function has not been known. The present study aimed to explore its role in proliferation of epidermal keratinocytes.

MATERIALS AND METHODS

IFI27 knockdown and over-expression in keratinocytes were used to compare their proliferation, by MTT assay, apoptosis (by annexin V binding) and cell cycle progression by flow cytometry. Formation of cyclin A/CDK1 complex was examined by a co-immunoprecipitaion method. Anti-proliferation effects of IFI27 were also examined in vivo by topical application of IFI27 siRNA on imiquimod-induced psoriatic lesions, in a mouse model.

RESULTS

Epidermal growth factor was demonstrated to increase IFI27 expression by prolonging half-life of IFI27 protein. The IFI27 knockdown in keratinocytes reduced the proliferation rate, but had no effect on apoptosis nor on apoptosis-related genes. Interestingly, IFI27 knockdown resulted in S-phase arrest that was found to be associated with increased Tyr15 phosphorylation of CDK1, reduced CDC25B and reduced formation of cyclin A/CDK1 complex. In addition, IFI27 knockdown was also shown to activate p53 by Ser15 phosphorylation and increase p21 expression. Topical application of IFI27 siRNA on imiquimod-induced psoriatic lesion in a mouse model reduced epidermal thickness, formation of rete ridges and PCNA expression.

CONCLUSIONS

Our study demonstrates for the first time, that cell function of IFI27 is involved in proliferation of skin keratinocytes both in vitro and in vivo. It suggests that IFI27 might be a suitable target for development of a novel anti-psoriasis therapy.

CFD based investigation on the impact acceleration when a gannet impacts with water during plunge diving

Plunge diving is the most commonly used feeding method of a gannet, which can make the gannet transit from air to water rapidly and successfully. A large impact acceleration can be generated due to the air-to-water transition. However, the impact acceleration experienced by the gannet during plunge diving has not been studied. In this paper, this issue is investigated by using the CFD method. The effect of the dropping height and the water-entry inclination angle on the impact acceleration is considered. The results reveal that the impact acceleration along the longitudinal body axis increases with either of the two parameters. The peak time decreases with the dropping height. A quadratic relation is found between the peak impact acceleration and the initial water-entry velocity. According to the computation, when the dropping height is 30 m (most of gannets plunge from about this height), the peak impact acceleration can reach about 23 times the gravitational acceleration, which will exert a considerable force on the gannet body. Furthermore, the pressure distribution of different water-entry inclination angles indicates that the large pressure asymmetry caused by a small oblique angle may lead to a large impact acceleration in the direction perpendicular to the longitudinal body axis and cause damage to the neck of the gannet, which partly explains the reason why a gannet performing a high plunge diving in nature enters water with a large oblique angle from the perspective of impact mechanics. The investigation on the plunge-diving behavior in this paper will inspire and promote the development of a biomimetic amphibious robot that transits from air to water with the plunge-diving mode.

Hydrodynamic investigation of a self-propelled robotic fish based on a force-feedback control method

We implement a mackerel (Scomber scombrus) body-shaped robot, programmed to display the three most typical body/caudal fin undulatory kinematics (i.e. anguilliform, carangiform and thunniform), in order to biomimetically investigate hydrodynamic issues not easily tackled experimentally with live fish. The robotic mackerel, mounted on a servo towing system and initially at rest, can determine its self-propelled speed by measuring the external force acting upon it and allowing for the simultaneous measurement of power, flow field and self-propelled speed. Experimental results showed that the robotic swimmer with thunniform kinematics achieved a faster final swimming speed (St = 0.424) relative to those with carangiform (St = 0.43) and anguilliform kinematics (St = 0.55). The thrust efficiency, estimated from a digital particle image velocimetry (DPIV) flow field, showed that the robotic swimmer with thunniform kinematics is more efficient (47.3%) than those with carangiform (31.4%) and anguilliform kinematics (26.6%). Furthermore, the DPIV measurements illustrate that the large-scale characteristics of the flow pattern generated by the robotic swimmer with both anguilliform and carangiform kinematics were wedge-like, double-row wake structures. Additionally, a typical single-row reverse Karman vortex was produced by the robotic swimmer using thunniform kinematics. Finally, we discuss this novel force-feedback-controlled experimental method, and review the relative self-propelled hydrodynamic results of the robot when utilizing the three types of undulatory kinematics.

Utility of PDL progenitors for in vivo tissue regeneration: a report of 3 cases

OBJECTIVE

Periodontal disease is an inflammatory disorder with widespread morbidities involving both oral and systemic health. The primary goal of periodontal treatment is the regeneration of the lost or diseased periodontium. In this study, we retrospectively examined feasibility and safety of reconstructing the periodontal intrabony defects with autologous periodontal ligament progenitor (PDLP) implantation in three patients.

MATERIALS AND METHODS

In this retrospective pilot study, we treated 16 teeth with at least one deep intrabony defect of probing depth (PD) > OR = 6 mm with PDLP transplantation and evaluated clinical outcome measures in terms of probing depth, gingival recession and attachment gain for a duration of 32-72 months. Furthermore, we compare PDLPs with standard PDL stem cells (PDLSCs) and confirmed that PDLPs possessed progenitor characters.

RESULTS

Clinical examination indicated that transplantationof PDLPs may provide therapeutic benefit for the periodontal defects. All treated patients showed no adverse effects during the entire course of follow up. We also found that PDLPs were analogous to PDLSCs in terms of high proliferation, expression of mesenchymal surface molecules, multipotent differentiation, and in vivo tissue regain. However, PDLPs failed to express scleraxis, a marker of tendon, as seen in PDLSCs.

CONCLUSIONS

This study demonstrated clinical and experimental evidences supporting a potential efficacy and safety of utilizing autologous PDL cells in the treatment of human periodontitis.

MINILAPAROTOMY RADICAL RETROPUBICPROSTATECTOMY FOR PROSTATE CANCER

Radical prostatectomy is still the gold standard for treating patients with clinically localized cancer. A total of 33 consecutive patients underwent minilaparotomy radical prostatectomy by a single surgeon. The minilaparotomy radical retropubic prostatectomy was performed via an eight-centimeter lower midline incision and a Book Walter retractor for surgical assistance. Mean patient age was 65 years (range 47 to 74). Tumor stages were observed as 12.1% of total for T1c, 21.2% for T2a, 45.5% for T2b, 6% for T3a and 15.2% for T3b. Satisfactory continence was achieved in 80% of the patients. 85% of patients revealed a prostate-specific antigen at a serum concentration of less than 0.2 ng/ml. Minilaparotomy radical retropubic prostatectomy compares favorably with standard radical retropubic prostatectomy.

Kidney Ultrasound Is Useful Tool in Posttransplant Follow-Up

OBJECTIVES

Renal sonography has been an important imaging tool in surveys of kidney diseases. We reviewed our experience in the finding and management of asymptomatic patients who underwent renal transplantation.

METHODS

We performed baseline graft and native kidney sonography after renal transplantation, as well as annually even if the patient was asymptomatic. At the end of 2004, a total of 326 transplant cases had been annually surveyed. If the findings were positive, they were compared with previous data to determine the need for further examinations and management.

RESULTS

The native kidneys of 105 patients were abnormal. Cysts were detected in 71 cases, 23 of which were bilateral. Stones were found in 15 cases. Polycystic kidney disease was identified in 5. The findings in these 91 patients were the same as before. Moderate hydronephrosis was observed in 14 cases. Nine had native ureteral cancer and underwent nephroureterectomy. Ureteral stricture was found in the other 5 patients. Forty-five grafts were abnormal. Thirty-one showed hydronephrosis and 2 underwent ureteral reimplantation. Asymptomatic stones were found in 2. A new single renal cyst was found in 2 cases; and multiple cysts in one other. Elevated RI on color Doppler was discovered in 12 patients, 4 of whom lost their grafts this year. Serum creatinine values of 6.9 and 2.2 mg/dL were observed in 2 patients.

CONCLUSIONS

Renal sonography screening is useful not only for the graft but also for the native kidney. Hydronephrosis is an important finding. The high possibility of urothelial malignancy should be expected, requiring further examination and sequential follow-up. Elevated RI is a clue to predict graft outcome; rapid deterioration was observed within months.

A 3D Graphical Representation of RNA Secondary Structures

In this paper, we proposed a 3-D graphical representation of RNA secondary structures. Based on this representation, we outline an approach by constructing a 3-component vector whose components are the normalized leading eigenvalues of the L/L matrices associated with RNA secondary structure. The examination of similarities/dissimilarities among the secondary structure at the 3'-terminus of different viruses illustrates the utility of the approach.

Retina-specific cis-elements and binding nuclear proteins of carp rhodopsin gene

The upstream cis-elements controlling the retina-specific expression of carp rhodopsin gene were fully characterized in vivo. Transgenic studies demonstrated that both carp neural retina leucine zipper response-like element (cNRE, within nucleotides (nt) -63 to -75) and carp-specific element (CSE, nt -46 to -52) were crucial to reporter gene expression in medaka retinae. The retina-specific expression rates of embryos injected with nt -1 to -641 and longer fragments were much higher than those of embryos injected with nt -1 to -138 and shorter fragments, indicating that an enhancer is located in the nt -138 to -641 region. Retinal extracts and the probe BAT-1 (nt -90 to -120) formed two DNA-protein complexes, B1 and B2. Retinal extracts and the probes cNRE and CSE formed the complexes N1 and C1, respectively. The protein factors in B1 and C1 were mammal-like cone-rod homeobox proteins.

One-stage correction of neglected developmental dysplasia of the hip by open reduction and pemberton osteotomy

BACKGROUND AND PURPOSE

Pemberton osteotomy is commonly used for correction of hip-dysplasia. Its application in treating hip dislocation is rarely reported. The purpose of this study was to determine the efficacy of one-stage open reduction and Pemberton osteotomy of neglected developmental dysplasia of the hip (DDH).

METHODS

We retrospectively reviewed the clinical and radiographic results of one-stage total correction in 75 patients with neglected DDH (86 hips) from 1984 through 1996. Sixty-nine patients (77 hips) aged 13 to 76 months (mean, 21.5 mo) underwent open reduction, Pemberton osteotomy, and hip spica for 8 weeks. Seven patients (9 hips) aged 29 to 73 months (mean, 46.6 mo) underwent additional femoral shortening (another hip in one bilaterally involved patient underwent only open reduction and Pemberton osteotomy).

RESULTS

Acetabular index improved markedly from 40.4 degrees (range, 25-60 degrees) preoperatively to 16.2 degrees (range, 0-30 degrees) postoperatively. Complications included redislocation in four patients (4 hips) and avascular necrosis in three patients (3 hips). Reoperation was performed in four patients (4 hips). All patients were followed up for at least 3 years. By Severin's classification, all operated hips had excellent (18) or good (68) final radiographic results. The functional results, evaluated by McKay's criteria, were also excellent (52 patients/60 hips) and good (23 patients/26 hips).

CONCLUSIONS

Neglected DDH was safely and effectively treated by open reduction, Pemberton osteotomy, and optional femoral shortening with limited complications.

Improvement of health outcomes after continued implementation of a clinical pathway for radical nephrectomy

The clinical pathway is an important tool for outcome management. We evaluated the overall effects of the continued implementation of a clinical pathway for radical nephrectomy on the length of hospital stay, admission charges, and the quality of medical care. The data obtained from the second-year implementation (group 3) of the clinical pathway were compared with the data from the first-year implementation (group 2) and the year preceding implementation (group 1). Thirty-seven consecutive patients with renal cell carcinoma underwent radical nephrectomy in group 1, 47 in group 2, and 55 in group 3; all were enrolled in this study. The length of hospital stay, average admission charges, and 8 quality indicators were measured in these patients. We also evaluated the variances in the implementation of the clinical pathway. The mean length of stay decreased by 14.0% (P = 0.0048) in group 2, and by 15.8% (P= 0.0014) in group 3, when compared to group 1. The total admission charges significantly decreased by 19.0% (P = 0.001) in group 2, and by 27.9% (P < 0.0001) in group 3, compared to the charges for group 1. A continued decrease in charges for operation and anesthesia, laboratory, pharmacy, and others were found 2 years after implementation of the clinical pathway. Among the 8 quality indicators, 2 were continuously improved in the second-year implementation of the clinical pathway, 2 were improved significantly in the second-year implementation only, and 4 showed no significant change at all. Variances from the clinical pathway decreased significantly after continued implementation. Continued implementation of the clinical pathway for radical nephrectomy can improve a physician's practice continuously by decreasing the length of hospital stay, admission charges, and variances, and by improving quality. However, the improved results after implementation of the clinical pathway should be maintained carefully to assure good health care.

Prolonged and enhanced suppression of thymidylate synthase by weekly 24-h infusion of high-dose 5-fluorouracil

We have recently demonstrated that HDFL (high-dose 5-FU 2600 mg m-2 week-1 and leucovorin 500 mg m-2 week-1, weekly 24-h infusion) is highly active in the treatment of gastric cancer. To further clarify the possible mechanism underlying the improved activity of HDFL compared with conventional 5-FU regimens, we conducted in vitro studies examining the effect of these regimens on the differential regulation of thymidylate synthase (TS) in NCI-N87, a human gastric cancer cell line. The expected serum concentrations of 5-FU are 100-200 mM (lasting for less than 30 min) and 5-10 mM (lasting for 24 h) for the conventional 5-FU regimens (bolus injection or short intravenous infusion of 5-FU 370-500 mg m-2) and the HDFL regimens, respectively. Western blot analysis revealed that 24-h exposure of NCI-N87 to 2.5-10.0 mM of 5-FU resulted in a dose-dependent depletion of free TS, lasting for more than 24 h. In contrast, 30-min exposure of NCI-N87 to 200 mM of 5-FU resulted in a less than 12-h depletion of free TS. Moreover, 24-h exposure to 5-FU resulted in a higher S-phase blockade and enhanced cytotoxicity. In both modes of 5-FU treatment, the initial rapid depletion of free TS was accompanied by a rapid increment of a higher-molecular-weight TS molecule, suggesting that rapid formation of the ternary complex was the key mechanism of 5-FU action during this period. Northern blot analysis showed that the steady-state mRNA of TS was not affected by either of the schedules. We conclude that 24-h exposure of gastric cancer cells to low concentration of 5-FU resulted in better suppression of free TS, a higher degree of S-phase blockade, and enhanced cytotoxicity compared to 30-min exposure to high concentration of 5-FU. These in vitro results may help explain the improved clinical efficacy of HDFL regimens compared to conventional 5-FU regimens.

Improvement of medical care quality after implementation of a clinical path monitoring program for transurethral prostatectomy patients

OBJECTIVES

The purpose of this study was to determine the effect on quality of care through the implementation of a clinical path for patients receiving transurethral prostatectomy.

METHODS

We selected ten quality indicators with important clinical relevance as representative elements of the clinical path. These quality indicators were monitored during the entire hospitalization period of 100 consecutive patients who received transurethral prostatectomy. Monitoring data obtained from these patients were compared to data from 100 patients who received transurethral prostatectomy prior to implementation of the clinical path. Data was assessed to determine the relationship between quality indicators and management processes.

RESULTS

Implementation of the clinical path for transurethral prostatectomy significantly decreased the percent of patients with incomplete preoperative tests on admission day, the duration of intravenous antibiotics administration, the percent of patients who required acute pain management postoperatively, the percent of patients who received postoperative bladder irrigation with normal saline and the percent of patients who had their Foley catheter removed after postoperative day 2. Three of the quality indicators had a significant relationship with management processes and may have directly affected the total admission charges.

CONCLUSIONS

To evaluate the effect of the transurethral prostatectomy clinical path implementation on the quality of medical care, we compared ten quality indicators before and after implementation of this path. We concluded that implementation of the clinical path resulted in a statistically significant improvement in the quality of medical care.

The follow-up on the training course of pediatric advanced life support

Two parts are included in this article. First, to improve the training course in pediatric advanced life support (PALS), we held a 2-day PALS training course on March 28 and 29, 1999. A pretest, posttest, and survey questionnaire were given to each participant. Of the 143 participating in the 2-day PALS course, 137 completed the study. The mean pretest score was 70.2 (SD = 11.5) and the mean posttest score was 86.9 (SD = 9.1). There was significant improvement noted after the 2-day PALS training course (p < 0.001). The 2-day PALS training course resulted in greater improvement in scores compared with the previous 1-day PALS training course in some certain groups of participants. The number of participants complaining that they were too rushed to get the best learning result declined from 71 of 106 (66.3%) taking the 1-day training course to 43 of 137 (31.4%) taking the 2-day training course. Second, a same written test was given to the 129 participants who had finished a 1-day PALS training course one year previously to evaluate the participants' retention of knowledge after 1 year. Of 82 responders who took the 1-year follow up test, 75 were from the medical center. The score of the follow-up test for these 75 participants showed a significant decline when compared with the posttest, except for those receiving another training course of advanced life support during the follow-up year. We conclude that the 2-day PALS training course is better than the 1-day PALS training course. Those who participate in the pediatric critical or emergent care had better receive the 2-day PALS training course. The participants receiving the 1-day PALS training showed a significant decline in their knowledge after 1 year, and they should reinforce their knowledge in the following years.

Nosocomial infection in a neonatal intensive care unit--from a viewpoint of national health insurance

In order to survey both the epidemiology of nosocomial infection in our neonatal intensive care unit (NICU) and the changing face of nosocomial infection after the introduction of National Health Insurance (NHI) in Taiwan, we retrospectively reviewed the nosocomial infections which occurred in our NICU from March 1, 1991, to February 28, 1999. We also compared the nosocomial infections from the viewpoint of NHI. The mean rate of nosocomial infections in our NICU during these 8 years was 13.6%, and it had significantly increased after the NHI plan was implemented (from 7.9% to 19.0%). The most common type of nosocomial infection was blood stream infection (53.8%, 120 of 223 infections). Coagulase-negative Staphylococci and fungi were the two most common pathogens of nosocomial blood stream infection in our NICU, accounting for 28.1% and 24.2% of the infections, respectively. The survival rate of very low birth weight (VLBW) infants increased from 76.3% to 78.4% after the implementation of NHI. However, the nosocomial infection rate of the VLBW infants had markedly increased from 22.6% to 41.9%. The total number of hospitalization days of the patients with nosocomial infection was significantly greater than that of those without nosocomial infections (p < 0.05), and the patients with the lower birth weights had longer hospital stays. The risk factors for nosocomial infection including invasive procedures, multiple and empirical antibiotics, and extremely low birth weight premature infants, remained the same, but the prevalence of nosocomial infection in the neonatal intensive care unit has changed markedly since the NHI plan began. Further investigation to determine strategies for preventing nosocomial infection in very low birth weight infants is warranted.

Individualized developmental care in the newborn intensive care unit

With recent advances on newborn intensive care, the survival rate of very low birth weight preterm infants has been improved. The consequently new morbidities such as learning disabilities, behavioral problems, lower mean IQ and motor clumsiness have become more frequent. Neonatal individualized developmental care seeks to read the behavior of premature infants, and pace our procedures and caregiving according to individual infant's cues. Studies have shown that with implementation of developmental care, the time spent on ventilator and hospitalization was decreased, and infants started oral feeding earlier. The short and long-term neurobehavioral outcomes were improved. Developmental care focuses not only on changing the environment to provide a calming and soothing environment for the infants and family, but also provides a chance for all the staff members to read the behavior of the infants, think and reflect before doing something to the infants.

Expression of p16(INK4A) induces dominant suppression of glioblastoma growth in situ through necrosis and cell cycle arrest

Tumor suppressor genes may represent an important new therapeutic modality in the treatment of human glioblastoma (GBM). p16(INK4A) is a tumor suppressor gene with mutation and/or deletion found in many human tumors, including glioblastomas, melanoma, and leukemias. RT-2 rat GBM cell line was used to investigate if the p16 gene induces dominant suppression of glioblastoma growth. Close to 100% of tumor cells were infected by high titer pCL retrovirus encoding the full-length human p16 cDNA at 5 m.o.i. Infected cells showed a 98% reduction in colony forming assay and a 60% reduction in growth curves in vitro compared to vector control. Exogenous overexpression of p16 induced hypophosphorylation of Rb protein by Western blot analysis. Intracranial injection of p16-infected tumor cells into syngeneic rats resulted in a 95% reduction in tumor volume compared to the controls. Intratumoral injection of p16 retrovirus resulted in tumor necrosis and prominent human p16 transgene expressions. Proliferation marker PCNA was not detected in these human p16-expressed RT-2 tumor cells, suggesting the cells were unable to enter into S phase after p16 expression. In addition, direct repeat intracranial injections of p16 retrovirus prolonged animal survival 3.2-fold compared to the controls (48.4 +/- 13.4 vs 15.0 +/- 2.1 days, p < 0.001). Two out of ten rats were found with dormant tumors at day 60 after p16 retrovirus injection. These results showed that p16 is effective in inhibiting GBM growth in situ. The mechanisms of tumor growth reduction and necrosis in vivo might be due to G1 arrest triggered by p16 expression.

Leiomyoma of the epididymis: case report

Herein, we report on a rare case of leiomyoma of the epididymis. The case we present involved a 55-year-old patient who had had a painless left scrotal mass for 20 years. The mass was round and elastic and measured about 2 x 2 x 2 cm. We recognized the mass as a benign tumor by scrotal ultrasonography and performed an organ salvage operation for this patient. The final pathologic diagnosis of the mass was leiomyoma. Our report includes a detailed description of the ultrasonographic characteristics of this disease as well as a review of the literature. In general, sharp acoustic shadows with central hypoechoic lesions in heterogenous parenchyma are the distinctive characteristics of leiomyoma of the epididymis. We also discuss the possibility of a testis salvage operation for this type of disease. We conclude that the ultrasonographic characteristics can serve as an important guide for the surgeon to consider an organ salvage operation in cases of a painless scrotal mass.

[The electrostatic protection of the medical devices & equipments]

This paper describes the harms of the static electricity to medical devices & equipments and its protection.

The effect of breast- and bottle-feeding on oxygen saturation and body temperature in preterm infants

From July 1997 to June 1998, 25 preterm infants (birth weight < 1800 g) were included in a prospective study to compare the clinical effects of breast- and bottle-feeding. Oxygen saturation, heart rate, respiratory rate, and body temperature were recorded every minute for 20 minutes during feeding periods. Eighty pairs of breast- and bottle-feeding sessions were observed at the chronological age of 9.3 +/- 4.3 (range = 2.1-25.3) weeks. Oxygen saturation and body temperature of the preterm infants were significantly higher when they were directly breastfed. There were 2 episodes of apnea (breath pause more than 20 seconds) and 20 episodes of oxygen desaturation (PaO2 < 90%) during bottle-feeding and none during breastfeeding. We conclude that breastfeeding is a more physiological feeding method for the preterm infant and bottle-feeding may be more stressful.

Use of a medical decision support system to improve the preoperative diagnosis of prostate cancer with pelvic lymph node metastases

BACKGROUND

We evaluated the effects of a medical decision support system on the preoperative diagnosis of prostate cancer with pelvic lymph node metastases.

METHODS

The preoperative accuracy of staging prostate cancer with pelvic lymph node metastasis by the prostate cancer expert system (PCES) for 43 patients was compared to the accuracy of staging performed by 2 urological attending physicians and 5 residents, to test the validity of the PCES. The effect of PCES consultation on physicians' staging for prostate cancer with pelvic lymph node involvement was evaluated.

RESULTS

In the diagnosis of prostate cancer with pelvic lymph node metastasis, PCES was significantly more accurate than the two attending physicians alone (p = 0.042; p = 0.008). All the urological residents' diagnoses were significantly less accurate than those of the PCES. After PCES consultation, all the urological residents increased diagnostic specificity significantly. Most residents usually used PCES for consultation only after the attending physician or department asked for the results.

CONCLUSION

Owing to an increased ability for preoperative diagnosis of prostate cancer with pelvic lymph node metastasis, as supported by the PCES, some unnecessary pelvic lymphadenectomies may be avoided.

The implementation of clinical paths for six common urological procedures, and an analysis of variances

OBJECTIVE

To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths.

PATIENTS AND METHODS

The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation.

RESULTS

The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0. 01), but the mortality and readmission rate did not increase.

CONCLUSIONS

The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.

Evaluation of a decision-support system for preoperative staging of prostate cancer

The usefulness and effectiveness of a decision-support system for preoperative staging of prostate cancers (PCES) were evaluated. The study population consisted of 43 consecutive patients with the preoperative diagnosis of prostate cancer who underwent surgical operation. Results obtained using the PCES were compared with staging by four urology attending physicians and five urology residents. The effect of PCES consultation on the physicians' staging of prostate cancer was also evaluated. To confirm the usefulness of the clinical findings of prostate-specific antigen, prostate-specific antigen density, prostate volume, and abnormal Gleason score in the PCES, their receiver operating characteristic (ROC) curves for diagnosis of advanced prostate cancer were plotted. The values of the areas under the curves were 0.772, 0.800, 0.531, and 0.752. The stage of prostate cancer was correctly determined by the PCES for 38 of the 43 patients, yielding 88.4% preoperative diagnostic accuracy. The PCES was significantly more accurate than two of the attending physicians and all residents. PCES consultation improved the residents' staging accuracy to approximately that of the attending physicians. The effect of PCES consultation on the residents' staging was significantly (p < 0.001) greater than the effect on the physicians' staging. The PCES may be useful in the preoperative staging of prostate cancers, especially during residency. The system's accuracy in determining the stage of advanced prostate cancer may make it possible to avoid unneccesary surgical operations.

Does the use of clinical paths improve the efficiency and quality of care under the case payment system for inguinal herniorrhaphy or transurethral prostatectomy?

BACKGROUND

We evaluated the effects of implementing clinical paths for both inguinal herniorrhaphy (IH) and transurethral prostatectomy (TURP) on the efficiency and quality of medical care under the case payment system.

METHODS

Patients undergoing IH or TURP were treated using the guidelines for clinical paths under the case payment system (CPUCP). The results of treatment after implementation of CPUCP were compared with results for patients treated before implementation of CPUCP. We also compared results using eight quality indicators both before and after implementation of CPUCP.

RESULTS

The post-CPUCP length of hospital stay decreased significantly in patients who underwent either IH (p < 0.001) or TURP (p = 0.008). The post-CPUCP total admission charges decreased (p = 0.001) by 7.5% in the IH group alone. Two quality indicators in the IH group and three quality indicators in the TURP group were significantly improved after implementation of CPUCP. The percentage of patients who completed treatment without deviation as recommended by the guidelines for CPUCP was about 60% in the IH group and about 70% in the TURP group.

CONCLUSION

The results of this study indicate that the implementation of clinical paths under the case payment system for patients undergoing inguinal herniorrhaphy or transurethral prostatectomy can improve the efficiency and quality of medical care.

Effects of implementation of 18 clinical pathways on costs and quality of care among patients undergoing urological surgery

PURPOSE

We evaluated the effects on the costs and quality of care of implementation of 18 clinical pathways for urological operations.

MATERIALS AND METHODS

From April 1997 to March 1998 patients undergoing 1 of 18 urological operations were treated according to clinical pathways. The outcomes in terms of length of hospital stay and admission charges of these patients were compared with those of patients treated between April 1996 and March 1997 before clinical pathways were implemented. We also selected 7 clinically relevant quality indicators to assess the quality of care before and after clinical pathway implementation.

RESULTS

Of the 1,784 patients undergoing urological surgery from April 1997 to March 1998, 1,382 (77.5%) were treated according to 1 of the 18 clinical pathways. Before implementation 1,279 of 1,615 patients (79.2%) underwent these procedures. The length of hospital stay decreased from 5.5 to 4.9 days (p < 0.01) and the average hospital admission charges decreased by 12.9% (p < 0.01) after implementation. Five of the quality indicators, including the rate of surgical complications, were significantly improved after pathway implementation. The hospitalization rate was not affected (1.3 before versus 0.8% after implementation, p = 0.18). Variations from the clinical pathways occurred in 543 cases (39.3%) and affected the length of hospital stay only (11.6%) or the admission charge only (12.9%) more often than both (7.8%, p < 0.01) or neither (7.0%, p < 0.01). The most common variances in these patients were patient related (30.8%).

CONCLUSIONS

Implementation of multiple clinical pathways in a urology department can improve urological practice by decreasing the length of hospital stay, admission charges and rate of surgical complications, and by improving the quality of care.

Infants of twin pregnancies with one twin demise in the uterus: a retrospective study

Many papers have reported that twin pregnancies with one twin demise in the uterus can cause complications in the surviving twin. We retrospectively reviewed charts from 1988 to 1997 at our hospital and found 17 of 302 twin deliveries with one twin intrauterine fetal death. The incidence of intrauterine death of a single twin was 5.7%. Six of the surviving twin (35.3%) had renal function impairment. One died due to acute renal failure. The other five patients recovered normal serum creatinine level. Five patients (29.4%) had abnormal brain imaging findings. One had multicystic encephalomalacia and microcephaly. Three of the five patients were complicated with cerebral palsy. After dividing the patients into complicated (n = 8, 47.1%) and non-complicated (n = 9, 52.9%) groups, we found that the patients with complication had lower Apgar score at 5 minutes and those with monochorionic diamniotic placenta had higher incidences of complication (62.5% vs 12.5%). We conclude that twin pregnancies with one fetal demise in the uterus do result in a higher incidence of complication in the surviving twin, especially if placentation type is monochorionic diamniotic. In managing the surviving twin of the monozygous twin pregnancies with one fetal demise in the uterus, we must be careful to monitor these patients. If complication was suspected, we should arrange the brain and kidney ultrasonography and manage these patients appropriately to decrease the complication risk.

Squamous cell carcinoma of the bladder: a ten-year retrospective study

BACKGROUND

There is a limited amount of information available on treatment efficacy and optimal management of squamous cell carcinoma of bladder. The goal of this study was to assess the long-term outcome of patients with squamous cell carcinoma of the bladder treated using different modalities.

MATERIALS AND METHODS

Retrospective analysis of the medical records of 22 patients with squamous cell carcinoma of the bladder treated at Chang Gung Memorial Hospital from 1986 though 1996 was performed. The follow-up period ranged from 12 months to 111 months.

RESULTS

The treatment modalities included transurethral resection in 7 patients, radical cystectomy with urinary diversion in 6 patients, preoperative radiation followed by total cystectomy in 8 patients, and partial cystectomy in one patient. The overall 5-year survival rate was 9%. Only 6 patients (27.3%) in this series were alive two years after diagnosis. Treatment using a combination of modalities including preoperative radiation followed by total cystectomy resulted in a 5-year survival rate of 12.5% in 8 patients. Total cystectomy alone in 6 patients resulted in a 5-year survival rate of 0%. However, the difference in survival rates between these 2 treatment groups was not statistically significant.

CONCLUSION

Our results suggest that no definite significance concerning the role of preoperative radiation followed by total cystectomy could be drawn. The results were probably because most of our patients had locally advanced bladder cancer. Another consideration is the small sample size, which may have affected the significance. Although, cystectomy did not improve the 5-year survival rate of patients in this series, it improved the 2-year survival rate.

The early effect of pelvic floor muscle exercise after transurethral prostatectomy

PURPOSE

We evaluate the early effect of pelvic floor muscle exercise on the frequency of urination, terminal dribbling, urinary incontinence and satisfaction with life in patients after transurethral prostatectomy.

MATERIALS AND METHODS

From February to October 1996, 50 patients who had undergone transurethral prostatectomy were selected for study. The first 25 men served as a control group and the next 25 were the experimental group. Pelvic floor muscle exercise was started after removal of the Foley catheter postoperatively in the experimental group. The patients were evaluated before pelvic floor muscle exercise and weekly at our outpatient department after discharge from the hospital. Results for the later 25 patients treated with the pelvic floor muscle exercise program were compared to those of the prior 25 patients.

RESULTS

There was a statistically significant difference (p <0.05) in the strength of pelvic floor muscle contractions at 4 weeks, length of between void interval (p <0.01), terminal dribbling at week 4 (p <0.05) and urinary incontinence at weeks 3 and 4 between the 2 groups after pelvic floor muscle exercise. During this study no complication or mortality occurred and there were no cases of hospitalization for either group. After pelvic floor muscle exercise patients in the experimental group had better satisfaction with life than the control group (p <0.01).

CONCLUSIONS

We conclude that pelvic floor muscle exercise seems to help reduce symptoms within the first 4 weeks after transurethral prostatectomy, and provides better psychological and social quality of life.

Improvements in the efficiency of care after implementing a clinical-care pathway for transurethral prostatectomy

OBJECTIVE

To investigate the efficiency of care, length of hospital stay and admission charges after implementing a clinical-care pathway for transurethral prostatectomy (TURP).

PATIENTS AND METHODS

Changes in the length of hospital stay and admission charges were identified by comparing a series of 100 patients undergoing TURP and treated after implementing a clinical-care pathway with 100 patients treated by the same physicians before implementation.

RESULTS

After implementing the care pathway, the mean length of hospital stay and admission charges were significantly lower (P < 0.01). The shorter length of stay was caused by a significant reduction (P < 0.05) in patient-related psychological/social delay after implementation. The number of laboratory tests and use of pharmacological agents were also significantly lower (P < 0.001) after implementation, with the decreases in these last variables significantly greater (P < 0.001) among junior physicians.

CONCLUSIONS

The advantages of the TURP clinical-care pathway were the shorter hospital stay, arising from reduced patient-related psychological or social delay, and reduced admission charges consequent on the decreased use of laboratory tests and drugs, particularly for patients treated by junior physicians. These results suggest that physicians are likely to modify their management methods to improve efficiency when a clinical path is implemented.

[Identification of Staphylococcus epidermidis by desferrioxamine susceptibility and trehalose fermentation tests]

The importance of coagulase-negative staphylococci, especially Staphylococcus epidermidis in clinical and nosocomial infection are recognized increasingly in recent years. A rapid and accurate identification of S. epidermidis is therefore important and necessary. A new test, susceptibility to desferrioxamine, coupled with trehalose fermentation has been recommended for the identification of this organism. However, the medium and method used are different from what has been recommended by the NCCLS. To investigate the feasibility of using the desferrioxamine susceptibility test in conjunction with the routinely used disc agar diffusion test, we employed 111 staphylococcal strains (including 51 S. epidermidis isolates, 15 S. hominis and 45 other coagulase-negative staphylococci) as test organisms, and followed the procedures recommended by the NCCLS in which Mueller-Hinton agar and standard inoculum were used. Results indicated that all strains of S. epidermidis and S. hominis were susceptible to 1 mg desferrioxamine (the diameter of the inhibition zone were 28-37 mm). The minimum inhibitory concentrations of desferrioxamine to S. epidermidis and S. hominis isolates were determined to be 125 micrograms/ml. Further differentiation of S. hominis and S. epidermidis can be made by their ability to ferment trehalose, the former could while the latter could not. We conclude that the desferrioxamine susceptibility test of coagulase-negative staphylococci can be used in conjunction with the routine disc agar diffusion method. S. epidermidis can be identified rapidly and accurately by its susceptibility to 1 mg desferrioxamine and inability to ferment trehalose.

Simultaneous determination of amoxycillin and clavulanic acid in pharmaceutical products by HPLC with beta-cyclodextrin stationary phase

A simple, rapid and accurate method for simultaneous determination of amoxycillin and clavulanic acid using HPLC with beta-cyclodextrin stationary phase was developed. It involves the use of tetraethylammonium acetate (TEAA) as an additive reagent, methanol-buffer solution (pH 4.5) (35:65; v/v) as the mobile phase, detection at 225 mm and chromatogram within 12 min. Linearity and precision of the internal standard method have been obtained. Recoveries ranged from 99.25 to 105.63% for amoxycillin in the synthetic mixture. For clavulanic acid it was from 99.50 to 101.64%. This method is convenient and reproducible for analyses of these two components in different dosage forms.

Diversity of DNA sequences among Vibrio cholerae O1 and non-O1 isolates detected by whole-cell repetitive element sequence-based polymerase chain reaction

Vibrio cholerae strains isolated from patient, food and environmental sources in Taiwan and reference V. cholerae strains were examined by repetitive element sequence-based PCR (rep-PCR). Specimens from broth cultures were used directly in the PCR mixture with three different primers. The PCR fingerprinting profiles of toxigenic 01 isolates were not only homogeneous with primers from enterobacterial repetitive intergenic consensus (ERIC) sequences, but also allowed the differentiation from non-toxigenic O1 and non-O1 strains. Toxigenic 01 strains were further differentiated into El Tor and classical biotypes with primers designed from ERIC-related sequences of V. cholerae. Primers from the other V. cholerae repetitive DNA sequences, VCR, separated toxigenic El Tor strains into six groups and a unique pattern was also obtained in 16 isolates from imported cases of cholera and imported seafood. The results indicated that rep-PCR can be used to identify and differentiate different toxigenic 01, non-toxigenic 01 and non-O1 V. cholerae isolates.

Retained vaginal gauze with unusual complication: a case report

We report a case of a postpartum retained vaginal gauze which migrated to the bladder and presented as a bladder stone. The patient had received numerous clinical evaluations for her chronic abdominal pain, of all which failed to detect or indicate the presence of retained gauze. Retained surgical gauze is a preventable problem but continues to occur periodically. Prevention remains the key to this problem. The gauze packed within the vagina either after transvaginal surgery or delivery should be cared for as in other parts of the body. Though extremely rare, retained surgical gauze should be considered in the differential diagnosis in postpartum patients with chronic abdominal pain, irritable bladder symptoms or pelvic abscess.

Susceptibility of Pseudomonas aeruginosa of various pyocin types to the newly synthesized ampicillin derivative, N-(6,7-difluoroquinolonyl)ampicillin

Six hundred and thirty-two isolates of Pseudomonas aeruginosa of 17 pyocin types were collected in 1993 in Taiwan. Types 1, 10, 3, 35 and 12 were the most common pyocin types identified in Taiwan with isolation frequencies of 47.3%, 24.4%, 7.6%, 3.6% and 2.2%, respectively. Several pyocin subtypes were determined. All pyocin types (one isolate of each tested) were resistant to ampicillin and nalidixic acid, but sensitive to fluoroquinolone antibiotics, such as norfloxacin and enoxacin, indicating that cross-resistance to quinolone antibiotics of nalidixic acid and fluoroquinolone derivatives has not developed. A new ampicillin derivative of 6,7-difluoroquinolonic acid, N-(6,7-difluoroquinolonyl)-ampicillin (AU-1), was synthesized by coupling ampicillin with 6,7-difluoroquinolonic acid (FP-3). Compound AU-1 was much more active than either ampicillin or FP-3 alone against all pyocin types of P. aeruginosa and induced filamentation in most growing cells.

Diagnosis of prostate cancer: comparison of serum prostate specific antigen, digital rectal examination and transrectal ultrasonography

BACKGROUND

While prostate specific antigen (PSA) is useful as a tumor marker for monitoring patients with prostate cancer after definitive therapy, limitations have been noted when it is used for early detection of prostate cancer.

METHODS

We reviewed the charts of 121 patients who had undergone prostate needle biopsies, documented digital rectal examination (DRE) and serum PSA determination before biopsy from January 1993 to October 1994. Indications for biopsy included abnormal DRE. PSA level greater than 4.0 ng/ml or abnormal lesions on transrectal ultrasonography (TRUS).

RESULTS

Seventeen patients (14%) had stage A carcinoma with normal DRE and PSA levels from 0.1 to 34.9 ng/ml (mean 9.0 ng/ml). Four patients (3%) had stage B carcinoma with an average PSA level of 32.3 ng/ml and less than one lobe indurated on DRE. Six patients (5%) had stage C carcinoma and had an average PSA level of 48.5 ng/ml and less than one lobe indurated on DRE. Ninety-four (78%) patients had stage D carcinoma with an average PSA level of 120 ng/ml and more than one lobe indurated on DRE. While hypoechoic sectors were more than twice as likely as isoechoic sectors of the prostate to contain malignancy on biopsy, nearly 20% of cancers were found in isoechoic sectors.

CONCLUSION

Serum PSA is the most accurate of the three diagnostic tests evaluated. The addition of DRE or TRUS improves the detection rate of prostate cancer over PSA alone.

Use of the transurethral prostatectomy clinical path to monitor health outcomes

PURPOSE

We evaluated the effect on cost and medical care quality of use of the transurethral prostatectomy clinical path.

MATERIALS AND METHODS

Results in 100 patients treated when the transurethral prostatectomy clinical path was used were compared to those of 100 treated by the same physicians before implementation of this path.

RESULTS

After implementation of the transurethral prostatectomy clinical path the length of hospital stay was significantly decreased from 5.9 to 5.0 days (p < 0.01) and Foley catheterization time was significantly decreased from 3.13 to 2.84 days (p < 0.01). Antibiotics were routinely used from the day before surgery to the day of hospital discharge as required by patient conditions. Therefore, a shorter hospital stay will significantly decrease the use of antibiotics. After implementation of the clinical path the average admission charges were decreased significantly by 17% (p < 0.01). Although some results from use of this path will not significantly affect costs, they will reflect some quality improvement. The effect of clinical path implementation on length of hospital stay between patients treated by junior and senior attending physicians was not significant. However, there was a statistically significant difference (p < 0.01) between results obtained by junior and senior attending physicians regarding average admission charges.

CONCLUSIONS

Implementation of the transurethral prostatectomy clinical path can improve health care outcome by decreasing length of stay and admission charges, and improving quality of medical care, particularly for patients treated by junior attending physicians.

Effects of 4-aminopyridine on saxitoxin intoxication

Effects of 4-aminopyridine (4-AP) on neurotoxicity induced by saxitoxin (STX) are investigated in this study. In vitro, twitch tension evoked by nerve stimulation was depressed by STX (1.35 nM) in rat phrenic nerve-diaphragm preparations, and this inhibition was antagonized by 4-AP (0.1 mM). In addition, 4-AP (0.1 mM) restored the firing of membrane action potentials that were suppressed or even abolished by 0.334 nM STX in frog sartorius muscles. In vivo studies showed that 4-AP (0.3 mg/kg, iv) significantly reversed the respiratory rate, tidal volume, and blood pressure to normal values in anesthetized STX-toxicosis rats. Furthermore, 4-AP (0.75-6 mg/kg, ip) not only prolonged the survival time but also decreased the mortality of mice (71-43%) at a normally lethal dose (30 micrograms/kg, ip) of STX. The results suggest that 4-AP may be useful as an antidote for STX intoxication.

Cytotoxic effects of anthrax lethal toxin on macrophage-like cell line J774A.1

The cytotoxic effects of anthrax lethal toxin purified from an avirulent strain were examined on mouse macrophage-like J774A.1 cells. Cell death induced by high concentration of purified lethal toxin had the characteristics of necrosis. At lower concentrations, the toxin caused no morphological change and most of the cells were viable. Interestingly, apoptotic cells were observed when the cells were preincubated with a serine/threonine phosphatase inhibitor, calyculin A, and then exposed to a toxin concentration of 0.1 microg/ml. This is the first report that lethal toxin of the anthrax bacillus can induce both necrosis and apoptosis and that protein phosphatases are implicated in the regulation of bacterial toxin-induced apoptosis.