Showing papers in "National Medical Journal of China in 2000"

Alcohol drinking and cigarette smoking: a "partner" for gastric ulceration.

Abstract: Alcohol consumption and cigarette smoking are two etiologic factors that have a close relationship with peptic ulcer diseases. Chronic active gastritis is reportedly associated with chronic alcohol ingestion. Nonetheless, the inflammatory changes are likely to be related to concurrent Helicobacter pylori infection that is common among alcoholics. Moreover, chronic alcoholism is also correlated with the presence of gastric metaplasia. Both clinically and experimentally, alcohol had been shown to affect the mucosal barrier and histology. These ulcerogenic effects play a crucial role in altering gastric mucosal defense mechanisms. Cigarette smoking is coupled with the initiation and prolongation of gastric ulcers. Epidemiologic data show that cigarette smoking increases both the incidence and relapse rate of peptic ulcer diseases and also delays ulcer healing in humans. Retrospective studies also indicate that cigarette smoking is a key factor in inducing ulcer diseases rather than a linked behavior. The general detrimental effects of cigarette smoking in the gastric mucosa include reduction of circulating epidermal growth factor, increase in tissue free radical production and the presence of free radicals in smoke, together with reduction of mucosal constitutive nitric oxide synthase activity. Furthermore, the alteration of normal gastric mucosal blood flow and angiogenesis and the suppression of cell proliferation contribute largely to the delay in ulcer healing in cigarette smokers. Concurrent consumption of alcohol and cigarette smoking significantly increases the risk of gastric ulcers. In animal experiments, cigarette smoking potentiated ethanol-induced gastric mucosal damage. The reduction of mucus secretion, increase in leukotriene B4 level, increased activities of inducible nitric oxide synthase, xanthine oxidase and myeloperoxidase, and the expression of adhesion molecules in the gastric mucosa accompanied such potentiating effects. Substances other than nicotine in cigarette smoke may also contribute to the above effects.

Population-based study on prevalence and risk factors of age-related cataracts in Peitou, Taiwan.

Abstract: Background Age-related cataracts are the main cause of blindness throughout the world. Nonetheless, population-based data on the epidemiology of age-related cataracts among Taiwanese populations are not readily available. This study was conducted to estimate the prevalence of age-related cataracts and to determine the relationships of age, gender, blood pressure, diabetes and smoking to the risks of age-related cataracts in an urban Taiwanese population. Methods The study was part of a population-based survey of eye diseases among residents aged 50 years or older in Peitou Precinct, Taipei, Taiwan. Of the 2,700 eligible persons, 2,038 (75.5%) underwent a standard evaluation protocol including dilated slit-lamp examination, a questionnaire of medical and ophthalmic histories and blood pressure measurement. Results Among the participants, 1,040 were diagnosed with age-related cataracts. The prevalence was 51.0% (95% confidence interval, 48.9%-53.2%). Nuclear opacity was the most prevalent type (718/1,040; 35.2%) of cataracts, followed by posterior subcapsular opacity (311/1,040; 15.3%) and cortical opacity (163/1,040; 7.8%). An increased risk of age-related cataracts was associated with female gender (p = 0.002). When a single type of lens opacity was considered, diabetes was significantly associated with a posterior subcapsular cataract (p = 0.022). Overall, older women with diabetes and relatively lower diastolic blood pressure were more likely to have age-related cataracts. Conclusions The study provided the first prevalence data on age-related cataracts in an urban Taiwanese population and highlighted the relationships of age, gender, blood pressure and diabetes to the frequency and type of age-related cataracts. The results can assist in the design and implementation of intervention programs to reduce the prevalence of age-related cataracts.

Vaginal fluid creatinine, human chorionic gonadotropin and alpha-fetoprotein levels for detecting premature rupture of membranes.

Abstract: BACKGROUND Diagnosis of premature rupture of membranes (PROM) is difficult in equivocal cases. The concentrations of human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP) and creatinine are high in amniotic fluid. The purpose of this study was to determine the usefulness of vaginal fluid hCG, AFP and creatinine measurements in the detection of PROM. METHODS About 3 ml of normal saline was used to irrigate the posterior vaginal fornix and was collected for the measurement of hCG, AFP and creatinine. The control group included 10 normal pregnant women in the third trimester (> 28 weeks of gestational age). Levels of hCG, AFP and creatinine were compared with those of 10 women with confirmed PROM. RESULTS The median levels of vaginal fluid hCG of normal pregnant women and pregnant women with confirmed PROM were 35.0 mIU/ml and 478.0 mIU/ml (p = 0.0046), respectively. For AFP, the corresponding values were 0.80 ng/ml and 54.24 ng/ml (p < 0.0001), respectively, and for creatinine, the values were 0.05 mg/dl and 0.95 mg/dl (p < 0.0001), respectively. All three markers were significantly higher in the experimental group than in the control group. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for hCG were 80%, 70%, 72.7%, 77.8% and 75%, respectively. For AFP, these values were 90%, 100%, 100%, 90.9%, and 95.0%, respectively, and for creatinine, they were 90%, 100%, 100%, 90.9%, and 95%, respectively. The diagnostic value of AFP or creatinine level in vaginal washing may be better than that of hCG, though the difference was not statistically significant, probably due to the limited case number. CONCLUSIONS Creatinine in vaginal fluid washings is a useful marker for PROM. It was less expensive and easier to measure than hCG and AFP, and appears to be more accurate than hCG.

Surgical repair of postinfarction ventricular septal defect.

Abstract: Background Rupture of the interventricular septum complicates 1% to 2% of all acute myocardial infarction patients and its natural course is ominous. The purpose of this study is to present our experience with surgical ventricular septal defect (VSD) repair and examine the possible risk factors and explanations for surgical mortality. Methods Fourteen patients underwent repair of postinfarction VSD from 1996 to 1998 at the Taipei Veterans General Hospital. Thirteen patients were in New York Heart Association (NYHA) Functional Class IV and one was in Functional Class III. Eleven patients were in cardiogenic shock with intra-aortic balloon pumps (IABPs) prior to surgery. The operative techniques for VSD repair range from extensive infarctectomy with reconstruction of the septum and the right and left ventricular free walls using single or double patches, to minimal or no infarctectomy with closure of the VSD by excluding the infarcted muscle from the left ventricular cavity and leaving the right ventricle intact. Results Overall surgical mortality occurred in four patients. All deaths occurred in patients with cardiogenic shock, two with anterior VSD and two with posterior VSD. Three late survivors had limited exercise tolerance with NYHA Functional Class II to III. Left ventricular function was moderately impaired in most patients with a mean nuclear scan ejection fraction of 0.32. However, all patients were elderly and adapted to their residual symptoms without significant life-style changes. Conclusions The surgical mortality for treating patients with postinfarction VSD has decreased with improvements in surgical technique. Rapid diagnosis, appropriate preoperative management and delicate surgical repair improve the overall results and help to attain long-term survival.

Review of pre-eclampsia in Taiwan: a multi-institutional study.

Abstract: BACKGROUND Because the reported frequency of pre-eclampsia in Taiwan varies significantly, the aims of this study were to measure the current incidence of pre-eclampsia and its correlated morbidity and mortality for both mothers and fetuses in Taiwan. METHODS We retrospectively studied all reported cases of pre-eclampsia and eclampsia from January 1, 1993 to December 31, 1997 in the 14 tertiary medical centers and regional hospitals in Taiwan. Recruiting criteria were pregnancy-induced hypertension (systolic blood pressure > or = 140 mmHg or diastolic blood pressure > or = 90 mmHg) with proteinuria (> or = 300 mg of urinary protein per 24 hours) and independent part edema. RESULTS There were 4,193 patients with pre-eclampsia and eclampsia for a frequency of 2.03% of 206,551 deliveries during the study period. Of these, 58.9% of patients were classified as having mild pre-eclampsia while 38.4% had severe pre-eclampsia. Advanced maternal age (> 35 years) (odds ratio [OR] = 4.56; 95% confidence interval [CI] = 4.23-4.90; p < 0.001), primiparity (OR = 1.71; 95% CI = 1.61-1.82; p = 0.02) and twin pregnancy (OR = 1.92; 95% CI = 1.64-2.25; p = 0.01) were significant risk factors for developing pre-eclampsia. However, multivariate analysis showed that only advanced maternal age was a significant risk factor for pre-eclampsia (OR = 3.21; 95% CI = 2.95-3.50; p < 0.001). In contrast to mild pre-eclampsia, severe pre-eclampsia resulted in significantly worse outcomes for both mothers and fetuses. Complications in patients with severe pre-eclampsia included placental abruption, acute renal failure, pulmonary edema, postpartum hemorrhage, pleural effusion, preterm labor, intrauterine growth retardation, stillbirth, neonatal mortality and low birth weight infants, all of which occurred significantly more frequently than in patients with mild pre-eclampsia (p < 0.001). CONCLUSIONS Pre-eclampsia remains a big challenge in modern obstetrics in Taiwan. Early diagnosis and management of patients with pre-eclampsia to prevent progression would significantly improve outcomes for mothers and fetuses.

Changes in cytokine (IL-8, IL-6 and TNF-alpha) levels in the amniotic fluid and maternal serum in patients with premature rupture of the membranes.

Abstract: PURPOSE To study the changes in interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-alpha) levels in patients with premature rupture of the membranes (PROM). METHODS A total of 46 normal term pregnant women served as controls and 46 women with PROM were enrolled for study. Maternal serum and amniotic fluid IL-6, IL-8 and TNF-alpha levels were determined by enzyme-linked immunosorbent assay and a sensitive radioimmunoassay, respectively. RESULTS The maternal serum IL-6 and IL-8 levels and amniotic fluid IL-6, IL-8 and TNF-alpha levels were higher than those of controls, and the differences were significant between the two groups (p < 0.05). Although the levels of TNF-alpha in maternal serum were higher than that of controls, the difference was not significant. There were significant relationships between the levels of IL-6, IL-8 and TNF-alpha and the duration of PROM. The longer the duration of PROM, the higher the levels of maternal serum and amniotic fluid IL-6, IL-8 and TNF-alpha were. There were 12 cases of clinical chorioamnionitis, and the levels of IL-6, IL-8 and TNF-alpha in the maternal and amniotic fluid were higher than that of those without chorioamnionitis (p < 0.05). CONCLUSION Determining cytokines (IL-6, IL-8 and TNF-alpha) is a valuable clinical method for identifying chorioamnionitis in patients with PROM.

A preliminary report of two cases of human hand allograft

Abstract: Objective To study the feasibility of reconstruction of amputation by hand allograft in human being. Methods Two male recipients with traumatic right wrist amputation for 2 years, were matched respectively to two ABO- and Rh-compatible, HLA- half mpatible brain-dead donors. Direct crossmatch was performed to confirm the absence of prior sensitization to alloantigens. After amputation the donor's arm was irrigated with UW organ preservation solution at 4 degrees, and transported in a box with ice. One of the two donor arms was randomly selected and irradiated by 8 gy x-ray before transplantation. The transplantation involved radial and ulnar bone fixation, anastomoses of radial and ulnar artery, sutures of median and ulnar and radial nerves, joining of tendons except flexors digitorum superficialis, and skin closure. After surgery the patients were given wide-spectrum antibiotics, anticoagulation and antispasm agents, and immunosuppressants, which included antithymocyte globins, FK506, mycophenolic acid, prednisone systematically and fluocinolone acetonide ointment locally. Clinical observations included vital signs and circulation of the hands. Immune state was monitored by assaying C-reactive protein, Igs and PRA in the blood. Skin biopsy was done to exclude the dermal rejection. After the surgery the patients received psychotherapy and hand rehabilitation. Results The circulation of the transplanted hands was similar to that of replanted ones. One of the patients developed hyperglycaemia, which required insulin administration. The skin healed naturally. The nerve regeneration were found more rapid by Tinel's sign. At 7 weeks erythema papulatum occurred on the skin, which was cured by withdrawing of fluocinolone acetonide ointment and application of calamine lotion. At 4 months the function of grafted hands recovered well, which could hold a drinking cup. The nerves had grown to the end of fingers and electromyograph showed regenerative action potentials of thenal muscles. Skin biopsy confirmed no rejection. Conclusion Ideal histocompatability and combined usage of currently available immunosupressants can prevent hyperacute and accelerating rejection of human hand allograft. The tissues heal and the early function recover similarly to those in autologous replantation.

Endoscopic endonasal transsphenoidal surgery for pituitary tumors.

Abstract: BACKGROUND: The traditional transsphenoidal approach for pituitary surgery can be performed via transnasal, transseptal, or sublabial routes through unilateral or bilateral nostrils. It requires wide mucosal and septal dissection and postoperative nasal packing. Endoscopic surgery has been widely used because it allows excellent visualization with minimal invasion. Recently, it has also been applied to pituitary surgery. METHODS: From January, 1997 to February, 1999, 40 patients with pituitary adenomas underwent the transsphenoidal approach using a rigid endoscope via one nostril. Among the 40 cases, 18 were prolactinomas, seven were growth hormone-secreting adenomas and 15 were nonfunctional adenomas. RESULTS: After surgery, complete resolution or improvement of symptoms and restoration of normal hormone levels were achieved in 16 patients with prolactinomas, five with growth hormone-secreting adenomas and 12 with nonfunctional macroadenomas. One patient with a recurrent microprolactinoma needed a second operation to remove the cavernous portion of the tumor. Another male patient with a macroprolactinoma who experienced galactorrhea and gynecomastia showed improvement of clinical symptoms after the operation. Two patients with residual growth hormone-secreting macroadenomas in the cavernous sinus needed Sandostatin treatment. Three patients with nonfunctional macroadenomas underwent nearly total resection leaving residual tumor in the cavernous sinus, which then required adjuvant radiotherapy. No complications related to this approach were encountered in the patients during the follow-up period. CONCLUSIONS: Endonasal transsphenoidal endoscopic surgery can be employed for treating pituitary tumors without septal or sublabial complications. Postoperative suffering was reduced and hospitalization was shortened by this mini-invasive procedure. This surgical procedure can be used for both microadenomas and macroadenomas.

Clinical, virologic and pathologic significance of elevated serum gamma-glutamyl transpeptidase in patients with chronic hepatitis C.

Abstract: Background Elevated serum gamma-glutamyl transpeptidase (GGT) is often seen in patients with chronic hepatitis C virus (HCV) infection and is associated with a poor response to interferon treatment. The pathogenesis of these phenomena is unclear. Therefore, we assessed the prevalence of elevated serum GGT in Chinese patients with chronic hepatitis C and evaluated the clinical, biochemical, virologic and histologic features of this phenomenon. Methods One hundred and twelve patients with biopsy-proven chronic hepatitis C were enrolled. Patients who were habitual alcohol drinkers, alcoholics or had diabetes mellitus were excluded. Results Forty-three (38.4%) of 112 patients had elevated serum GGT (> 60 U/l). Patients with elevated serum GGT had significantly higher serum levels of alanine and aspartate aminotransferases, alkaline phosphatase and total bilirubin, significantly higher histologic scores of liver lobular necro-inflammation and fibrosis when compared to patients with normal serum GGT. Elevated serum GGT was not correlated to serum HCV RNA titer or HCV genotype. Multivariate logistic regression analysis showed that a histologic fibrotic score > or = 2 was the only significantly independent predictor associated with elevated serum GGT. Fifty-seven of 112 patients completed a six-month course of interferon treatment. Patients with elevated serum GGT had a significantly lower sustained response rate to interferon when compared to patients with normal serum GGT (8% vs 30%, p = 0.042). Conclusions Elevated serum GGT in chronic hepatitis C patients was frequently associated with more severe hepatic fibrosis or cirrhosis and may, in part, account for poor response to interferon therapy.

Establishment of an animal model of hepatic encephalopathy.

Abstract: BACKGROUND Hepatic encephalopathy is a neuropsychiatric syndrome associated with acute liver failure, chronic parenchymal liver disease or portal systemic anastomosis. The spectrum of symptoms may vary from subtle mental changes to a disrupted circadian rhythm to hepatic coma. In order to investigate the possible pathogenetic mediators and the use of potential new therapies, the aim of our study was to create a reliable animal model for research on hepatic encephalopathy. METHODS Forty male Sprague-Dawley rats were used. Fulminant hepatic failure was induced by intraperitoneal injection of thioacetamide (TAA, 350 mg/kg) for three consecutive days (n = 30). Rats treated with normal saline served as controls (n = 10). The clinical stage of hepatic encephalopathy in TAA-treated rats was graded according to neurobehavioral testing. Spontaneous motor activities of rats were calculated using the Opto-Varimex animal activity meter. We also investigated the relationships between the neurobehavioral score and the motor activity count. RESULTS Compared with normal, saline-treated rats, those receiving consecutive injections of TAA had apparently lower neurobehavioral scores (p < 0.001) accompanied by significantly blunted motor activities (p < 0.001). A significant correlation was demonstrated between the neurobehavioral score and total movements in rats with encephalopathy (r = 0.71, p < 0.001). In addition, the neurobehavioral score also correlated well with ambulatory movements (r = 0.73, p < 0.001) and vertical movements (r = 0.45, p < 0.05). CONCLUSIONS The rat model is acceptable for the study of hepatic encephalopathy, as established in this study. This experimental model can be used to explore the pathogenesis and management of hepatic encephalopathy.

Evaluation of absorbed radiation dose to working staff during cardiac catheterization procedures.

Abstract: BACKGROUND Cardiac catheterization has been used frequently for the evaluation and treatment of patients with heart diseases. The working staff, particularly cardiologists who perform these procedures, have the highest potential risk of receiving high radiation doses due to close contact with patients. The purpose of this study was to measure and evaluate the accumulated radiation dosage of the cardiologists while they were performing clinical procedures in the cardiac catheterization laboratory. The working environment of the catheterization laboratory was also monitored for radiation. METHODS Thermoluminescent dosimeters (TLDs) with very high sensitivity were employed for dose evaluations. They were taped to various parts of the body of the cardiologists during catheterization procedures. For environmental monitoring, TLDs were also distributed at several sites of the catheterization rooms for a period of 2 to 4 weeks. RESULTS The study showed that the left wrist of the cardiologists received the highest radiation dose (338 microsieverts [microSv]/procedure) and the left lens received the second highest dose (149 microSv/procedure) during the procedures. The dose to the knees was unexpectedly high (92 microSv/procedure), partly due to radiation leakage from the lead curtain shielding under the patient couch. On average, the effective radiation dose per year was 37 mSv/y for a cardiologist who performs 10 catheterization procedures per week. Compare this to the occupational exposure limit of 50 mSv/y. The estimated accumulated equivalent dose to the lens was 152 mSv/y, which exceeded the regulatory limit for occupational exposure. CONCLUSIONS Using proper lead shielding and increasing the distance from the radiation source are good strategies for reducing the radiation dose in medical staff. The work area outside the catheterization room was considered safe because the radiation level was essentially equivalent to the background radiation level.

Clinicopathologic analysis of renal and extrarenal angiomyolipomas: report of 44 cases.

Abstract: BACKGROUND Angiomyolipoma (AML) is a rare soft tissue tumor involving the kidneys, liver and other visceral organs. It is composed of smooth muscle cells, adipocytes and small- to medium-sized hyalinized vessels. The purpose of this study was to investigate the characteristic clinicopathologic manifestations of AML in different tissues. METHODS We collected 37 renal, four hepatic, one lymph node, one subcutaneous and one uterine cervical AML to analyze the clinical, histologic, histochemical and immunohistochemical variations of AML in different tissues. RESULTS Clinically, renal and hepatic AML were associated with tuberous sclerosis complex and predominate in women. There were several prominent pathologic differences between renal and extrarenal AML. First, none of the tumors were encapsulated except for the subcutaneous AML, which had a pseudocapsule. Secondly, the smooth muscle cells were usually epithelioid shaped in hepatic AML and occasionally in renal AML, but not in subcutaneous or uterine AML. Furthermore, hepatic AML characteristically showed extramedullary hematopoiesis and eosinophilic hyaline granules. Finally, only the tumor cells of renal, lymph node and hepatic AML had periodic acid-Schiff (PAS), PAS-D (after diastase digestion) positive granules and monoclonal mouse anti-human melanosome clone (HMB-45) immunoreactivity. CONCLUSIONS By combining the clinical, histologic, histochemical and immunohistochemical features, some discrepancies between the renal and extrarenal AML were observed, such as female predominance, association with tuberous sclerosis complex, morphology of the smooth muscle cells, presence of PAS, PAS-D positive granules and HMB-45 immunoreactivity in tumor cells. Extramedullary hematopoiesis and hyaline globules are unique to hepatic AMLs. These specific pathologic manifestations not only implicate the histogenesis of AML from different organs, but also assist in making a correct diagnosis.

Surgical treatment of full thickness rotator cuff tear in patients younger than 40 years.

Abstract: BACKGROUND Full thickness tear of the rotator cuff is a well-known entity in the middle-aged and elderly population and the results of surgical repair are well documented. Rotator cuff tear in patients under the age of 40 years is unusual and the cause and treatment are not well established. The present study reports 12 young patients with full thickness tear of the rotator cuff treated surgically. METHODS Open anteroinferior acromioplasty and cuff repairs were performed on every patient after failure of nonsurgical treatment. The average follow-up was 59.5 months (range, 36-100 months). RESULTS The average patient age at the time of surgery was 30.2 years (range, 17-39 years). Symptoms included pain and dysfunction in all patients and weakness in eight patients. The duration of symptoms before surgery ranged from 6 to 60 months (average, 22.8 months). Ten patients were able to return to their preinjury status within an average of 4.5 months (range, 3-9 months) after surgery. Three athletes were able to return to previous levels of competition. Nine patients had excellent functional results with regard to pain, motion, strength, function and satisfaction. Eleven patients were satisfied with the operation and had significant pain reduction compared with their preoperative status. CONCLUSIONS An acute traumatic event was the etiology of the rotator cuff tears in this study. The results of surgical treatment in this younger group of patients were satisfactory and were comparable to the outcomes reported for surgical treatment of rotator cuff tears in older patients and athletes.

Randomized, double-blind comparison of irbesartan and enalapril for treatment of mild to moderate hypertension.

Abstract: Background Irbesartan is a newly developed angiotensin II receptor antagonist. Its antihypertensive efficacy and safety in Taiwanese patients with mild to moderate hypertension remains to be determined. Methods This was a multicenter, double-blind, randomized, parallel group study. One hundred and sixteen patients from three centers were enrolled. After a placebo lead-in period of 14 days, 55 patients (24-75 years-of-age) who had a mean seated diastolic blood pressure of 95 to 110 mmHg were randomized to once-daily treatment with irbesartan 150 mg or enalapril 10 mg. Doses were doubled at week 4 if trough seated diastolic blood pressure was 90 mmHg or more. Trough blood pressure was measured at zero, two, four and eight weeks of treatment. Results Both treatments lowered blood pressure with no significant difference in efficacy between treatment groups. Irbesartan 150 mg to 300 mg provided reductions in trough seated systolic and diastolic blood pressures at week 8 of -16.5 mmHg and -7.2 mmHg, respectively, with 36% of patients having a favorable response. Similarly, enalapril 10 mg to 20 mg reduced systolic and diastolic blood pressure by -10.6 mmHg and -5.0 mmHg, respectively, with a response rate of 43%. Headache, malaise and dizziness were the major adverse reactions observed in both groups. The incidence of drug-related cough was significantly higher with enalapril (18%) than with irbesartan (0%). Conclusions Irbesartan 150 mg to 300 mg once daily was as effective in lowering blood pressure as enalapril 10 mg to 20 mg once daily. Both irbesartan and enalapril were well tolerated, while there was a significantly lower incidence of cough with irbesartan compared with enalapril.

Chronic myeloid leukemia initially presenting with spontaneous mediastinal hematoma and hemothorax

Abstract: Spontaneous mediastinal hematoma is rarely seen in hematologic malignancy. We report a case of chronic myeloid leukemia initially presenting with spontaneous hematoma and hemothorax. In addition to a detailed history, computerized tomography of the chest is important in analyzing whether an anterior mediastinal mass lesion is present. Magnetic resonance imaging is helpful in confirming the nature of a mediastinal hematoma. Trauma, vascular disease and coagulopathy should first be ruled out when making a diagnosis of spontaneous bleeding in the thorax. In our patient, the mediastinal hematoma regressed spontaneously after three months. Leukemia should be considered in the differential diagnosis of spontaneous mediastinal hematoma. In leukemia patients with spontaneous mediastinal hematoma, supportive observation and close follow-up may be better than surgery, unless massive hemorrhage or active bleeding in the thorax is suspected.

Statistics in ophthalmic research: two eyes, one eye or the mean?

Abstract: Background Ophthalmic data, while different among individuals, are usually similar between fellow eyes of the same individual. This study was designed to illustrate alternative approaches to account for the correlation between fellow eyes. This is important for making inferences using data from both eyes. Methods With the use of a real data set from a population-based study, we described the distribution of intraocular pressure (IOP) by estimating the mean and standard deviation (SD) and evaluated the potential risk factors of higher IOP based on the regression method. The units of observation studied were of both eyes, right eye only, left eye only, the eyes with higher IOP and the mean value of both eyes. Furthermore, the generalized estimating equation (GEE) method was used to account for the correlation between fellow eyes in the regression analysis. Results and inferences from the different approaches were compared. Results The analysis included all the eyes, providing the largest sample size and unbiased estimates of the mean and SDs. There were some discrepancies among different approaches in the regression analysis. The GEE method simultaneously evaluated the effects of both eyes, and increased precision and enhanced inferences. Conclusions Inconsistent results among different ophthalmic studies result from variations in not only study design and courses but also statistical methods. Making the best use of appropriate statistical techniques, which account for between eye correlation, provides valid statistical inferences.

Associations between lipoprotein lipase gene polymorphisms and insulin resistance in coronary heart disease.

Abstract: BACKGROUND Lipoprotein lipase (LPL) is a crucial enzyme in plasma lipoprotein metabolism. Variants of the LPL gene (Pvu II and Hind III polymorphisms) may increase the risk of developing coronary heart disease (CHD) but their effect on insulin resistance remains unknown. The present study was conducted to examine whether DNA variations of the LPL gene were related to insulin resistance, carbohydrate and lipid risk factors for CHD in nondiabetic individuals. METHODS Pvu II and Hind III allele status of the LPL gene and fasting plasma glucose, insulin and lipid values were determined in nondiabetic men with angiographically documented CHD (n = 102) and in a control group (n = 145). Plasma glucose and insulin responses to a 75-g oral glucose tolerance test and insulin resistance as measured by an insulin suppression test were also carried out in 46 (45%) of the patients with CHD and in 73 (50%) of the control individuals. RESULTS The allele frequencies of LPL Pvu II and Hind III were not significantly different between the CHD patients and the controls. No association was found between Pvu II status and blood pressure, fasting plasma glucose, insulin, lipid levels or insulin resistance in patients with CHD. Nevertheless, compared with individuals with the Hind III H2H2 allele, CHD patients carrying the H1 allele (H1H1 + H1H2) were more insulin resistant, as indicated by higher steady state plasma glucose concentrations (253 +/- 87 vs 200 +/- 74 mg/dl, p = 0.032). CONCLUSIONS We suggest that the LPL gene Hind III allele might be associated with insulin resistance in nondiabetic men with CHD. However, further studies with larger populations of both sexes will be required to confirm this finding.

[Preventing neural tube defects with periconceptional folic acid supplementation: a population-based intervention program in the China].

Abstract: OBJECTIVES To evaluate the effectiveness of periconceptional use of 400 microgram folic acid only on the prevention of neural tube defects (NTDs) METHOD As part of a public health campaign in areas of high (North) and low (South) NTDs prevalence in the China during 1993 and 1995, 130 142 pill takers and 117 689 non-pill takers were recruited Women were asked to begin taking a pill containing only 400 microgram of folic acid daily from the time of their premarital examination until the end of the first trimester of pregnancy The outcomes of these pregnancies were ascertained through 1996 RESULTS We identified 102 NTDs among offspring of pill takers and 173 NTDs among offspring of non-pill takers The NTDs rate in offspring of non-pill takers was 48 per thousand (16/3 318) and 10 per thousand (28/28 625) in the south; while the rate in pill takers was 10 per thousand (13/13 012) in the north and 06 per thousand in the south The greatest reduction in risk occurred among the fetuses or infants of a subgroup of women in the northern region with periconceptional use who took pills more than 80 percent of the time (reduction in risk, 85 percent as compared with the fetuses or infants of women who registered before their last menstrual period and who took no folic acid; 95 percent confidence interval, 62 to 94 percent) In the southern region the reduction in risk among the fetuses or infants of women with periconceptional use of folic acid was also significant (reduction in risk, 41 percent; 95% confidence interval, 3 to 64 percent) CONCLUSION Periconceptional intake of supplements containing only 400 microgram folic acid can reduce the risk for NTDs in areas of high and low NTDs prevalence

Effects of four methods of sperm preparation on motion characteristics and nitric oxide concentration in laboratory-prepared oligospermia.

Abstract: BACKGROUND To compare four different spermatozoa preparation methods in semen samples with respect to recovery rate, percent motility, path and progressive velocity, and nitric oxide (NO) production before and after centrifugation. METHODS Each of 36 semen specimens was diluted to 1 x 10(6)/ml and divided into four 1-ml aliquots for sperm processing using four methods: swim-up, two (Percoll II) and three (Percoll III) layer Percoll (Pharmacia Biotech AB, Uppsala, Sweden) gradients and albumin columns. The motile sperm recovery rate, percent motility and motion parameters were measured for each semen specimen (n = 36) before and after processing using the four methods. NO was measured with the use of a chemiluminescence method before and after centrifugation (n = 17). RESULTS The sperm recovery rate was higher using both Percoll gradients than with the other two methods (Percoll II, 68 +/- 20.5%, Percoll III, 75.3 +/- 22.2% vs swim-up, 25.8 +/- 9.9% and albumin, 33.1 +/- 20.7%). The results were similar for total motile cells (Percoll II, 3.55 +/- 1.72 x 10(6)/ml, Percoll III, 4.25 +/- 1.29 x 10(6)/ml vs swim-up, 1.19 +/- 0.71 x 10(6)/ml and albumin, 1.89 +/- 1.36 x 10(6)/ml). Both Percoll methods and the albumin method produced a statistically significant improvement over the swim-up method in motility. The albumin column method resulted in the least path and progressive velocities (51.3 +/- 15.4 microns/s and 46.2 +/- 16.5 microns/s, respectively). NO produced during sperm processing did not differ significantly among the four processing methods (swim-up, 4,531 +/- 1,626 nM, Percoll II, 5,119 +/- 3,969 nM, Percoll III, 6,060 +/- 5,512 nM, albumin 4,838 +/- 2,462 nM). CONCLUSIONS Our data suggest that Percoll methods are superior to swim-up and albumin columns for sperm preparation, yielding good sperm recovery, motility and motion characteristics. The trend toward lower NO levels among samples prepared using albumin columns did not reach statistical significance.

Cardiac manifestations of fatal enterovirus infection during the 1998 outbreak in Taiwan.

Abstract: BACKGROUND: An outbreak of hand-foot-and-mouth disease caused by enterovirus infection occurred in Taiwan in 1998 and more than 70 infants and children with fulminant courses died. We compared the cardiac manifestations of fatal cases with patients who survived the enterovirus infection. METHODS: A total 187 patients with enterovirus infection were treated at Taichung Veterans General Hospital between April and June 1998. Enterovirus infection was diagnosed by history, clinical features, polymerase chain reaction study and/or viral culture. Cardiac examinations including complete physical examinations, electrocardiography and echocardiography were performed on seven cases (group I) with or without central nervous system (CNS) involvement, 30 patients with CNS involvement (group II), and 150 patients without CNS involvement (group III). RESULTS: There were no significant differences in sex distribution, days of fever, heart rate, systemic blood pressure or time from the onset of symptoms to hospital admission among the three groups. All group I patients had features of acute congestive heart failure, pulmonary edema and neurologic signs except one who presented with right-sided heart failure and neurologic signs. The echocardiographic findings of group I were a lower fractional shortening, lower ejection fraction, and more severe and higher incidence of mitral regurgitation (p < 0.01) than in groups II and III, but there were no significant differences in end-systolic wall stress, left ventricular end-diastolic internal dimension and incidence of pericardial effusion among the three groups. CONCLUSIONS: We conclude that seven infants and children (group I) died due to either severe cardiomyopathy or encephalopathy. The possible pathogenesis of enterovirus infection leading to death is reviewed and analyzed.

Mah-jong epilepsy: a new reflex epilepsy.

Abstract: Background Flickering light and color patterns, reading, language, movement, decision making, eating, tapping and touching, hot water immersion and auditory stimulation can induce seizures in some patients. This is known as "reflex epilepsy". The mechanism of reflex epilepsy is not clear. Recently, we cared for 12 patients (11 men and 1 woman, age 41-74 years; mean age = 63.1 years) whose seizures were induced by playing mah-jong, with mean age at seizure onset of 48.7 years. Nine of the 12 patients had seizures exclusively while playing mah-jong. Methods We retrospectively reviewed the medical records of 12 epileptic patients who visited our neurologic clinic from 1987 to 1999, with the chief complaint of mah-jong induced seizures. All patients underwent examinations including electroencephalography, brain computed tomography or magnetic resonance imaging, analysis of clinical manifestation of seizures, family history and past medical history. All were given anticonvulsant therapy for preventing seizures. Results Clinically, 10 patients had generalized tonic-clonic seizures and two patients had partial seizures with secondary generalization. Interictally, normal results on EEG were found in six patients, three had focal temporal spikes, and three had intermittent slow activity in the frontotemporal regions. Neuroimaging studies of the brain were normal in seven patients, two had lacunar infarctions, one had generalized atrophy and one had focal left parietal lesions of an unclear nature. Only one patient had a family history of epilepsy. All 12 patients received anticonvulsant therapy, and of these, nine had good epilepsy control. Conclusions "Mah-jong epilepsy," a new reflex epilepsy, is probably related to thinking and decision making while playing mah-jong. The easy control of seizures induced by mah-jong suggests a benign nature. In addition to anticonvulsant therapy, avoiding playing mah-jong may be essential in preventing seizures.

Effect of milrinone on postbypass pulmonary hypertension in children after tetralogy of Fallot repair.

Abstract: Background Postbypass pulmonary hypertension in surgical correction of tetralogy of Fallot (TOF) is a risk for right ventricular failure. Effective management remains a major challenge. Milrinone is a new drug with a unique mechanism of "inodilation", which offers both inotropic and vasodilatory effects. We attempted to determine if application of milrinone could improve cardiopulmonary dysfunction in children after TOF repair. Methods We studied 10 children with postbypass pulmonary hypertension after TOF repair within six months. Heart rate, systolic pulmonary arterial pressure (PAP), systolic arterial blood pressure (SBP), pulmonary capillary wedge pressure and PAP/SBP ratio were recorded. Standard cardiopulmonary bypass (CPB) was performed. After CPB, if PAP/SBP was more than 0.5, pulmonary hypertension was suspected and milrinone was administered with a loading dose of 20 micrograms/kg followed by continuous infusion of 0.2 microgram/kg/minute. Hemodynamics were compared before and after administration of milrinone to evaluate its effect. Results significant reduction in PAP/SBP ratio within 15 minutes was found after administration of milrinone. The effect persisted for 24 hours during continuous infusion of milrinone. No remarkable adverse effect was noted in the study. Conclusions We conclude that milrinone is effective in the management of pulmonary hypertension following CPB in children who underwent TOF repair.

Ectopic lacrimal gland cyst of the orbit.

Abstract: Lacrimal duct cysts are not common. It is extremely rare when a lacrimal duct cyst and an ectopic lacrimal gland develop in the orbital cavity. A unique case of an ectopic lacrimal gland cyst of the orbit is presented. A 33-year-old man had a palpable mass above the inferior medial orbital rim for nearly two years. An ocular examination was normal except for a movable, firm mass found in the anterior nasal inferior orbit of the right eye. An echogram revealed a homogeneous, hypoechoic cystic mass. Computed tomography of the orbit showed a well-encapsulated lesion in the lower orbit of the right eye near the inferior rectus muscle, without bony erosion. A tense, thin-walled, clear fluid-filled cyst measuring 15 x 12 x 13 mm in size was completely enucleated without rupture by anterior orbitotomy. Pathologic examination disclosed a small nest of normal gland tissue surrounded by a cystic lesion lined with two layers of lacrimal duct epithelium cells. No recurrent signs were noticed during a 12-month period of follow-up.

Repeated episodes of spontaneous intracystic hemorrhage of hepatic cysts mimicking malignancy.

Abstract: Repeated episodes of spontaneous intracystic hemorrhage in the liver are very rare. We present the case of a patient with spontaneous intracystic hemorrhage mimicking hepatic malignancy, following an episode of spontaneous hemorrhage of a cyst in the left lobe of the liver. Sonography revealed a heterogenous mass with amorphous material in one episode and a cystic mass with internal papillary projections and septations in the other. The patient experienced acute abdominal pain in the first episode and remained asymptomatic during the two-year follow-up period. With an accurate diagnosis, spontaneous hemorrhage of a hepatic cyst may follow a benign course and be treated conservatively.

Klebsiella pneumoniae renal abscess.

Abstract: Background The clinical characteristics of renal abscess caused by Klebsiella pneumoniae have not been previously reported in case-series studies. The purpose of this study is to demonstrate the clinical characteristics of K pneumoniae renal abscess for early diagnosis and to identify the clinical risk factors associating with poor prognosis. Methods We retrospectively reviewed the medical records of 24 patients with K pneumoniae renal abscess, from April, 1982 through February, 1998. The clinical presentations, including the demographic characteristics, predisposing disorders, initial signs and symptoms, laboratory test results, diagnostic radiology studies, therapeutic modalities and risk factors associated with mortality were studied. Results The mean age was 58.7 years and the male to female ratio was 10:14. The most common predisposing factors were diabetes mellitus (58%), urolithiasis (25%) and immunosuppression (17%). Fever, chills and flank pain were the most common symptoms and signs, whereas pyuria, elevation of leukocyte count, glucose, blood urea nitrogen and creatinine were the common laboratory features. The distinct complications of K pneumoniae renal abscess were bacteremia in 13 (54%), emphysematous pyelonephritis in five (21%), and metastatic septic infection in three (12.5%). The cure rate was 52% (11/21) in patients treated with a combination of antibiotics and percutaneous drainage; however, six (35%) patients who survived required another surgical procedure for complete recovery. The overall mortality rate was 25%. The clinical factors of elderly age (>65 years) at presentation, lethargy, elevation of serum blood urea nitrogen and pulmonary complications were associated with poor prognoses. Conclusions Focusing on the early diagnosis of K pneumoniae renal abscess and recognition of the prognostic factors for a poor prognosis, we highlight the specific clinical characteristics that include elderly age, lethargy, impairment of renal function, metastatic septic lesions and pulmonary complications. All patients with K pneumoniae renal abscesses should receive empiric antibiotics and percutaneous drainage or aspiration, and surgical intervention as necessary for patients with intractable disease.

Problem-based, small-group tutorial learning in clinical neurology for second-year medical students.

Abstract: Background Problem-based learning (PBL) in small-group tutorials has been a trend in medical education Chinese students are known to be reserved and passive; thus, they may not be adaptable to PBL Neuroanatomy, important to clinical neurology, is difficult to learn We incorporated clinical neurology with PBL, complementary to the traditional neuroanatomy curriculum, to evaluate the feasibility of PBL for Chinese students in Taiwan Methods Forty-two second-year medical students and seven tutors participated in the clinical neurology PBL small-group tutorials Twelve case reports were discussed weekly beginning in February, 1999 Each case was designed to meet the progressive curriculum of the neuroanatomy course The tutors evaluated the students by the degree of their preparation, participation, key-point comprehension and interaction All tutors and students filled out questionnaires at the end of each session Results The majority of the students and tutors agreed that the case materials were clearly written Ninety percent of the students agreed that the case materials matched the traditional content of neuroanatomy Eighty-five percent of students and 71% of tutors were satisfied and found the class rewarding Ninety-one percent of students and 74% of tutors were in favor of PBL being continued Conclusions This preliminary PBL, small-group tutorial learning in clinical neurology showed satisfactory results and was, indeed, complementary to a traditional neuroanatomy course The students, as early as during the second year of their medical school education, were able to learn through the PBL More integration of basic and clinical sciences by PBL may be considered in future curricula designs

Catheter-induced coronary spasm--a view of mechanical factors and experience with selective left coronary arteriography.

Abstract: BACKGROUND Coronary spasm during cardiac catheterization is not unusual. The mechanism of spasm remains uncertain, but is considered to be multifactorial. Many researchers believe that coronary spasm that develops during catheterization is partly spontaneous and partly catheter-induced. Because catheter-induced spasm results from mechanical irritation, we tried to find the iatrogenic factors that predispose patients to coronary spasm during coronary angiography. METHODS Retrospectively, we reviewed the records of 7,295 patients who underwent coronary angiography at our hospital from June, 1983 to November, 1997; coronary spasm was documented in 30 patients, who became the study group. We randomly selected 41 patients who had normal coronary arteries as the normal control group. After reviewing cine films of coronary angiography, we compared these two groups for several parameters. These parameters included the length and diameter of the left main coronary artery (LMC), the angle between the LMC and the aorta, the angle between the catheter tip and the LMC, whether the catheter tip came into contact with the vascular wall and whether there was vessel wall bulging, catheter size and catheter/LMC ratio. This angiographic data and the demographic features, including age, sex, history of hypertension, diabetes mellitus, smoking, previous myocardial infarction, family history of coronary artery disease, cholesterol and triglyceride levels and chest pain character (exertional or rest pain) were compared between the study patient group and the control group. RESULTS The results disclosed that larger catheter size (7.1 +/- 0.6 mm vs 6.4 +/- 0.7 mm, p < 0.001), smaller LMC diameter (4.2 +/- 0.9 mm vs 4.9 +/- 1.0 mm, p = 0.004), larger catheter/LMC ratio (0.07 +/- 0.05 vs 0.05 +/- 0.03, p = 0.022), catheter contact with the vessel wall (27/30 vs 20/41, p < 0.001) and vessel bulging (18/30 vs 5/41, p < 0.001) were related to catheter-induced coronary spasm. We found that the catheter tip coming into contact with the vessel wall, vessel wall bulging and catheter/LMC ratio (odds ratio 8.92 x 10(14)) were statistically significant factors predisposing patients to catheter-induced coronary spasm. CONCLUSIONS Multiple factors contribute to coronary spasm. Of those, mechanical or iatrogenic factors might predispose patients to spasm during coronary catheterization. These facts deserve our attention, because iatrogenically induced spasms may be avoided by meticulously selecting catheters and manipulating them gently.

Coexistence of epilepsy, myasthenia gravis and psoriasis vulgaris.

Abstract: We report the case of a 36-year-old Chinese man with a history of complex partial seizure of temporal lobe origin since the age of 12 years, superimposed by myasthenia gravis since the age of 27 years and psoriasis vulgaris since the age of 29 years. With an eight-year follow-up, the above three diseases remained without complete remission. Anticonvulsant therapy (phenytoin and trimethadione) caused drug-induced myasthenia gravis, which should gradually disappear after discontinuing the drugs. However, the myasthenic symptoms and serum acetylcholine receptor antibody persisted following the discontinuation of phenytoin in our patient. Myasthenia gravis and psoriasis are both autoimmune diseases and correlate with specific human histocompatibility antigens. This suggests a close connection between these two diseases. The coexistence of epilepsy, myasthenia gravis and psoriasis vulgaris has not been previously reported, and to the best of our knowledge, our patient is the first reported case. The relationship among these three diseases requires further investigation.

[Association of HLA-DRB1 allele and the susceptibility to alveolar echinococcosis in the west of China].

Abstract: OBJECTIVE: To investigat the association of HLA-DRB1 alleles and the susceptibility to alveolar echinococcosis (AE) METHODS: Thirty-five patients with AE in the high prevalence areas in the west of China were investigated for HLA-DRB1 gene by PCR/SSP technique The results were compared with 104 normal healthy peoples RESULTS: Frequency of HLA-DRB1 * 040x was 26% in patient group, which was significantly higher than in control group (962%), with a relative risk (RR) of 445 (chi(2) = 1367, P < 001), and with an etiological fraction of 020 Frequency of HLA-DRB1 * 0701 allele was decreased in patient group (patient 286%, control 1394%; chi(2) = 667, P < 005), with preventable fraction of 030 While the frequencies of other DRB1 alleles were not significantly different CONCLUSION: Susceptibility to AE is strongly associated with the HLA-DRB1 * 040x allele The high prevalence of human AE in this region was associated with genetic factor HLA-DRB1 * 0701 geners resistant to Echinococcus multilocularis metacestode infection

[Association between genetic polymorphism of dopamine transporter gene and susceptibility to Parkinson's disease].

Abstract: OBJECTIVE To explore the association between genetic polymorphism of dopamine transporter (DAT) gene and susceptibility to Parkinson's disease (PD). METHODS The polymorphism of DAT 3' VNTR was analyzed in 171 PD patients and 180 unrelated healthy controls with amplification fragment length polymorphism (Amp-FLP). RESULTS Five alleles of the DAT 3' VNTR were detected, consisting of 7, 8, 9, 10 and 11 copies of the 40 bp repeated sequence. The 10-copy allele was the most common one in both patients and controls. There were significant differences in both allelic and genotypic distributions of the DAT 3' VNTR between the patient and control groups (P = 0.016, P = 0.03, respectively; Fisher's exact test). The frequency of the 11-copy allele was significantly higher in patients (4.4%) than in controls (1.1%), with an odds ratio of 4.08 (95% confidence interval 1.25 approximately 14.7, P = 0.008). CONCLUSION DAT 3' VNTR 11-copy allele is a genetic factor susceptible to PD in the population tested.