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Background: Patients with frog-leg squatting have restricted internal rotation and adduction of the affected hips during sitting or squatting. In the surgical literature, the cause generally has been presumed to arise from and be pathognomonic for gluteal muscle contracture. However, we have encountered patients with frog-leg squatting but without gluteal muscle contracture.Questions/purposes: We therefore raised the following questions: What are the imaging features of patients with frog-leg squatting? Do conditions other than gluteal muscle contracture manifest frog-leg squatting?Patients and Methods: We retrospectively reviewed the MR images of 67 patients presenting with frog-leg squatting from April 1998 to July 2010. There were four females and 63 males; their mean age was 22.2 years (range, 4-50 years). During MRI readout, we observed aberrant axes of some femoral necks and obtained additional CT to measure femoral torsion angles in 59 of the 67 patients.Results: MR images of 27 (40%) patients had signs of gluteal muscle contracture. Twenty-two (33%) patients (40 femora) had aberrant femoral torsion, including diminished anteversion (range, 6°-0°; average, 3.9°) in 11 femora of eight patients and femoral retroversion (range, < 0° to -31°, average, -7.5°) in 29 femora of 17 patients. The remaining 18 (27%) patients did not have gluteal muscle contracture or aberrant femoral torsion. The observation of aberrant femoral torsion was not anticipated before imaging studies.Conclusions: In addition to gluteal muscle contracture, aberrant femoral torsion can be a cause of frog-leg squatting.Level Of Evidence: Level II, diagnostic study. See the guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), is an established treatment for heart failure (HF) with reduced left ventricular ejection fraction. It has not been rigorously compared with angiotensin-converting enzyme inhibitors in children. PANORAMA-HF (Prospective Trial to Assess the Angiotensin Receptor Blocker Neprilysin Inhibitor LCZ696 Versus Angiotensin-Converting Enzyme Inhibitor for the Medical Treatment of Pediatric HF) is a randomized, double-blind trial that evaluated the pharmacokinetics and pharmacodynamics (PK/PD), safety, and efficacy of sacubitril/valsartan versus enalapril in children 1 month to <18 years of age with HF attributable to systemic left ventricular systolic dysfunction (LVSD)., Methods: Children with HF attributable to LVSD were randomized to sacubitril/valsartan versus enalapril to assess the efficacy and safety of sacubitril/valsartan at 52 weeks of follow-up. The primary end point of the study was to determine whether sacubitril/valsartan was superior to enalapril for the treatment of pediatric patients with HF attributable to systemic LVSD, assessed using a primary global rank end point consisting of ranking patients from worst to best on the basis of clinical events such as death, listing for urgent heart transplant, mechanical life support requirement, worsening HF, New York Heart Association (NYHA)/Ross class, Patient Global Impression of Severity (PGIS), and Pediatric Quality of Life Inventory physical functioning domain. The change from baseline to 52 weeks in NT-proBNP (N-terminal pro-B-type natriuretic peptide) was an exploratory end point., Results: A total of 375 children (mean age, 8.1±5.6 years; 52% female) were randomized to sacubitril/valsartan (n=187) or enalapril (n=188). At week 52, no significant difference was observed between the 2 treatment arms in the global rank end point (Mann-Whitney probability, 0.52 [95% CI, 0.47-0.58]; Mann-Whitney odds, 0.91 [95% CI, 0.72-1.14]; P =0.42). At week 52, clinically meaningful reductions were observed in both treatment arms in NYHA/Ross, PGIS, Patient Global Impression of Change, and NT-proBNP, without significant differences between groups. Adverse events were similar between treatment arms (incidence: sacubitril/valsartan, 88.8%; enalapril, 87.8%), and the safety profile of sacubitril/valsartan was acceptable in children., Conclusions: In this study, sacubitril/valsartan did not show superiority over enalapril in the treatment of children with HF attributable to systemic LVSD using the prespecified global rank end point. However, both treatment arms showed clinically meaningful improvements over 52 weeks., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02678312.

Objective: To compare the image quality of short-tau inversion recovery (STIR) and the STIR-slice encoding for metal artifact correction (SEMAC) sequence for postsurgery spine magnetic resonance imaging (MRI)., Methods: Twenty-nine patients with metallic spinal implants who underwent spinal 1.5 T MRI with STIR and STIR-SEMAC sequences between July 2016 and November 2020 were retrospectively enrolled. Qualitative assessments were performed using 5-point scales; higher scores indicated better image quality. For screw metal artifact analysis, scores were obtained for artifacts on vertebral bodies and neural foramina, screw artifact widths, and bone marrow signal intensities. For patient-based analysis, scores were obtained for imaging quality and fat suppression quality, signal intensity, and cerebrospinal fluid noise. A paired t test was performed for statistical analyses., Results: We analyzed 163 screws in 29 patients. In the screw metal artifact analysis, the vertebral body and neural foramen scores were significantly higher for the STIR-SEMAC images than for the STIR (all P < 0.001). The artifact width in the STIR-SEMAC images (9.8 ± 3.4 mm) was significantly smaller than that in the STIR images (16.0 ± 4.7 mm, P < 0.001). In patient-based analysis, the fat suppression and imaging quality scores were significantly higher for the STIR-SEMAC images than for the STIR images (all P < 0.001). The cerebrospinal fluid signal intensity, noise, and signal-to-noise ratios were significantly higher for the STIR images (all P < 0.005)., Conclusions: Short-tau inversion recovery-SEMAC sequences provide good metallic artifact reduction and fat suppression for postsurgery spine 1.5 T MRI., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We aimed to identify the sound pressure distribution along the external auditory canal after radical mastoidectomy with meatoplasty by combining real ear measurements and measurements obtained using a finite-element model., Study Design: Case series with chart review., Setting: Tertiary care university hospital., Patients: We evaluated 16 patients who had undergone radical mastoidectomy with meatoplasty in one ear and had intact nonoperated contralateral ears, which served as the control group., Intervention Diagnostic: Real ear measurements testing at specific frequencies were performed postoperatively., Main Outcome Measure: Sound pressure gains were measured at five different depths along the external auditory canal, and a validated finite-element model was used to simulate the sound pressure distributions along the external auditory canals of the operated and nonoperated ears., Results: The average peak resonant frequency near the tympanic membrane in operated ears was significantly lesser than that in nonoperated ears (2434.4 ± 616.4 versus 2935.9 ± 602.2 Hz; Wilcoxon signed-rank test, p < 0.05). The average peak resonant amplitude near the tympanic membrane showed no significant intergroup difference (paired-sample t test, p > 0.05). The peak resonant frequencies at different depths of the external auditory canal varied in the nonoperated ears (Kruskal-Wallis rank-sum test, 2880.9 ± 581.7 Hz, p = 0.02) but did not differ significantly in the operated ears (Kruskal-Wallis rank-sum test, 2464.4 ± 670.3 Hz, p = 0.75). In the finite-element model, the peak resonant frequencies along the depth of the external auditory canal varied in the normal ear and were homogeneous in the operated ear., Conclusion: Radical mastoidectomy with meatoplasty altered the sound distribution in the external auditory canal. Our finite-element model successfully simulated the postoperative sound distribution in the external auditory canal and will facilitate development of wearable equipment for these patients., Competing Interests: The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors have no other funding financial relationships or conflicts of interest to disclose., (Copyright © 2022, Otology & Neurotology, Inc.)

Background: Variable penetrance and late-onset phenotypes are key challenges for classifying causal as well as incidental findings in inherited cardiac conditions. Allele frequencies of variants in ancestry-specific populations, along with clinical variant analysis and interpretation, are critical to determine their true significance., Methods: Here, we carefully reviewed and classified variants in genes associated with inherited cardiac conditions based on a population whole-genome sequencing cohort of 4810 Singaporeans representing Southeast Asian ancestries., Results: Eighty-nine (1.85%) individuals carried either pathogenic or likely pathogenic variants across 25 genes. Forty-six (51.7%) had variants in causal genes for familial hyperlipidemia, but there were also recurrent variants in SCN5A and MYBPC3 , causal genes for inherited arrhythmia and cardiomyopathy, which, despite previous reports, we determined to lack criteria for pathogenicity., Conclusions: Our findings highlight the incidence of disease-related variants in inherited cardiac conditions and emphasize the value of large-scale sequencing in specific ancestries. Follow-up detailed phenotyping and analysis of pedigrees are crucial because assigning pathogenicity will significantly affect clinical management for individuals and their family members.

Introduction: Blunt chest trauma (BCT) accounts for up to 65% of polytrauma patients. In patients with 0 to 2 rib fractures, treatment interventions are typically limited to oral analgesics and breathing exercises. Patients suffering from BCT experience symptoms of severe pain, poor sleep, and inability to perform simple daily life activities for an extended period of time thereafter. In this trial, we aim to investigate the efficacy of acupuncture as a functional and reliable treatment option for blunt chest trauma patients., Methods: The study is designed as a double-blind randomized control trial. We will include 72 patients divided into 2 groups; the acupuncture group (Acu) and placebo group (Con). The acupuncture group will receive true acupuncture using a uniquely designed press tack needle. The control group will receive placebo acupuncture treatment through the use of a similarly designed press tack needle without the needle element. The acupoints selected for both groups are GB 34, GB 36, LI 4, LU 7, ST 36, and TH 5. Both groups will receive 1 treatment only following the initial visit to the medical facility and upon diagnosis of BCT. Patient outcome measurements include: Numerical Rating Scale, Face Rating Scale, respiratory function flowmeter, Verran Snyder-Halpern sleep scale, and the total amount of allopathic medication used. Follow-up time will be scheduled at 4 days, 2 weeks, and lastly 3 months., Expected Outcome: The results of this study can potentially provide a simple and cost-effective analgesic solution to blunt chest trauma patients. This novel study design can serve as supporting evidence for future double-blind studies within the field of acupuncture., Other Information: The study will be conducted in the thoracic surgical department and acupuncture department in China Medical University Hospital, Taichung, Taiwan. The study will be conducted on blunt chest trauma patients and is anticipated to have minimum risk of adverse events. Enrollment of the patients and data collection will start from March 2020. Study completion time is expected in March 2022., Protocol Registration: (CMUH109-REC1-002), (NCT04318496)., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Background: Non-pulmonary vein (NPV) trigger has been reported as an important predictor of recurrence post-atrial fibrillation ablation. Elimination of NPV triggers can reduce the recurrence of postablation atrial fibrillation. Deep learning was applied to preablation pulmonary vein computed tomography geometric slices to create a prediction model for NPV triggers in patients with paroxysmal atrial fibrillation., Methods: We retrospectively analyzed 521 patients with paroxysmal atrial fibrillation who underwent catheter ablation of paroxysmal atrial fibrillation. Among them, pulmonary vein computed tomography geometric slices from 358 patients with nonrecurrent atrial fibrillation (1-3 mm interspace per slice, 20-200 slices for each patient, ranging from the upper border of the left atrium to the bottom of the heart, for a total of 23 683 images of slices) were used in the deep learning process, the ResNet34 of the neural network, to create the prediction model of the NPV trigger. There were 298 (83.2%) patients with only pulmonary vein triggers and 60 (16.8%) patients with NPV triggers±pulmonary vein triggers. The patients were randomly assigned to either training, validation, or test groups, and their data were allocated according to those sets. The image datasets were split into training (n=17 340), validation (n=3491), and testing (n=2852) groups, which had completely independent sets of patients., Results: The accuracy of prediction in each pulmonary vein computed tomography image for NPV trigger was up to 82.4±2.0%. The sensitivity and specificity were 64.3±5.4% and 88.4±1.9%, respectively. For each patient, the accuracy of prediction for a NPV trigger was 88.6±2.3%. The sensitivity and specificity were 75.0±5.8% and 95.7±1.8%, respectively. The area under the curve for each image and patient were 0.82±0.01 and 0.88±0.07, respectively., Conclusions: The deep learning model using preablation pulmonary vein computed tomography can be applied to predict the trigger origins in patients with paroxysmal atrial fibrillation receiving catheter ablation. The application of this model may identify patients with a high risk of NPV trigger before ablation.

Lung cancer is a common malignancy worldwide, and risk factors include bronchitis, asthma, tuberculosis, smoking, and air pollution. These are also risk factors for spontaneous pneumothorax, a benign disease. We hypothesized that patients who experience a spontaneous pneumothorax have a greater risk to develop lung cancer, and designed a study to determine if this is so.We used the population-based Taiwan Health Insurance Research Database to perform a retrospective cohort study. The database includes more than 99% of the population of Taiwan. We established a 27,405-person pneumothorax cohort and a 109,620 person comparison cohort with data from 2000 to 2009 to evaluate the relationship between spontaneous pneumothorax and lung cancer.Multivariable analysis showed that patients who have had a spontaneous pneumothorax have a greater relative risk to develop lung cancer. The overall hazard ratio was 2.09 (95% confidence interval 1.69-2.58) adjusted by age, gender, hypertension, diabetes mellitus, and chronic lung diseases such as chronic obstructive pulmonary disease, tuberculosis, asthma, bronchitis, and emphysema. A dose effect was present; a high frequency of spontaneous pneumothorax was associated with a greater relative risk to develop lung cancer. If the spontaneous pneumothorax frequency was greater than 2 times per year, the hazard ratio was 34.09 (95% confidence interval 22.74-51.10)Patients with spontaneous pneumothorax have an increased relative risk to develop lung cancer, especially among patients 35 to 49 years of age. The more frequent the occurrence of spontaneous pneumothorax, the greater the relative risk of lung cancer. If the spontaneous pneumothorax frequency was greater than 2 times per year, the increase in risk of lung cancer was more than 30-fold.

Background: Team collaboration is an important factor that affects the performance of the operating room (OR). Therefore, the ability of OR nurses to adapt to and manage interpersonal conflict incidents properly is very important., Purpose: The aims of this study were to investigate the interpersonal conflict management capabilities of OR nursing staffs and to find the relationships among the demographics of OR nurses and the following: work-related variables, interpersonal conflict management style, and target of interpersonal conflict., Methods: This study investigated 201 OR nurses who had worked for more than 6 months at the target hospitals, which were located in the three counties of Changhua, Yunlin, and Chiayi. The questionnaire that was used to collect data included three components: a demographic and work-related variables survey, interpersonal conflict management factor analysis scale, and interpersonal conflict parties and frequency scale. Data were analyzed using independent t test, analysis of variance, Scheffe's test, and Pearson's correlation coefficient., Results: The main findings were as follows: (a) Integration and arbitration were the major interpersonal conflict management strategies adopted by the participants; (b) medical doctor, OR nurses, and anesthetists were the primary targets of conflict for the participants; (c) the factors of educational background, job position, experience in other departments, seniority, attending courses in conflict management, and level of hospital significantly affected the strategies that participants used to manage interpersonal conflict; and (d) license level, experience in other departments, seniority, and inclination toward serving in the OR were each found to relate significantly to the target of interpersonal conflict and the frequency of interpersonal conflict incidents., Conclusions/implications for Practice: The main implications of this study are as follows: (a) The environment for communication in the OR should be made more friendly to encourage junior OR nurses to adopt constructive interpersonal conflict management strategies; (b) prior experience in other departments should be one of the most important factors of consideration when recruiting new nurses for the OR; and, ((c) hospitals should provide more interpersonal conflict management training courses to support the capability of OR nursing staffs in terms of adopting cooperativeness strategies and coping effectively with all types of interpersonal conflicts.)

Background: Unlike adult patients, the utility of cardiopulmonary exercise testing (CPET) in children as a prognostic tool is unclear. We sought to examine the associations of CPET with outcomes in children with dilated cardiomyopathy (DCM)., Methods: This was a single-center, retrospective review of children with DCM who underwent CPET. The primary endpoint for this study was a time-dependent composite outcome of hospitalization for management of decompensated heart failure, initiation of mechanical circulatory support, heart transplant, or death., Results: We examined 52 children with DCM who underwent CPET at median age 12.6 years (interquartile range [IQR], 9.9-14.6 years). At first CPET, the median peak heart rate was 80% (IQR, 70-88%) of predicted, median peak oxygen consumption 62% (IQR, 45-77%) of predicted, and median minute ventilation/carbon dioxide production slope 34.9 (IQR, 27.9-39.4). Eighteen (35%) patients reached the composite outcome during follow-up. Univariable factors associated with the composite outcome included: lower peak heart rate predicted, lower blood pressure response, lower peak oxygen consumption predicted, and higher minute ventilation/carbon dioxide production slope. The association between exercise performance and composite outcome was linear; thus, no reliable cutoff point could be identified. Serial CPET had been performed in 30 patients; clinically, those with deterioration of exercise capacity had poorer outcomes., Conclusions: Cardiopulmonary exercise testing is feasible in children with DCM and is useful to predict outcomes. The finding of lower exercise capacity and lower blood pressure response should prompt closer follow-up. In those with serial testing, a decline in exercise capacity may be a marker of clinical deterioration.

Although there are 3 hospice care programs for terminal cancer patients in Taiwan, the medical utilization and expenses for these patients by programs have not been well-explored. The aim of this study was to examine the medical utilization and expenses of terminal cancer patients under different programs of hospice care in the last 90, 30, and 14 days of life.This was a retrospective observational study by secondary data analysis. By using the National Health Insurance claim database and Hospice Shared Care Databases. We identified cancer descents from these databases and classified them into nonhospice care and hospice care groups based on different combination of hospice care received. We then analyzed medical utilization including inpatient care, outpatient care, emergency room visits, and medical expenses by patient groups in the last 90, 30, and 14 days of life.Among 118,376 cancer descents, 46.9% ever received hospice care. Patients had ever received hospice care had significantly lower average medical utilization and expenses in their last 90, 30, and 14 days of life (all P < 0.001) compared to nonhospice care group. Each hospice care group had significantly less medical utilization and expenses in the last 90, 30, and 14 days of life (all P < 0.01).Different kinds of hospice care program have different effects on medical care utilization reduction and cost-saving at different stage of the end of life of terminal cancer patients.

Do-Not-Resuscitate (DNR) and hospice care are not only applied to cancer patients but also to patients with noncancer progressive illness. However, the trends of DNR consent and hospice utilization are not well explored for noncancer patients. This study aimed to explore the trends of DNR consent and hospice care utilization among noncancer decedents in a tertiary hospital in Taiwan. We analyzed the Death and Hospice Palliative Care Database from the Taipei Veterans General Hospital in Taiwan. The Death and Hospice Palliative Care Database contains information including patient sex, major diagnosis, admission date, date of death, age at death, department at discharge, status of DNR consent, and status of hospice care of patients who died in the Taipei Veterans General Hospital. Data on patients aged 20 years old or more who died of major terminal noncancer diseases, including brain diseases, amyotrophic lateral sclerosis, dementia, chronic obstructive pulmonary disease (COPD) and other lung diseases, heart failure, chronic liver diseases and cirrhosis, and renal failure between 2010 and 2014 were extracted for analysis. A total of 1416 patients aged 20 years or more died of major noncancer diseases in Taipei Veterans General Hospital during the study period. The most common diagnosis was brain diseases, amyotrophic lateral sclerosis, and dementias (n = 510, 36%) followed by chronic obstructive pulmonary disease and other lung diseases (n = 322, 22.7%). Among these noncancer decedents, 1045 (73.8%) had DNR consents, while 134 (9.5%) received hospice care. Patients diagnosed with renal failure had the highest percentage of DNR consent (80%), followed by chronic liver diseases and cirrhosis (77.7%). Patients diagnosed with chronic liver diseases and cirrhosis had the highest percentage of hospice utilization (17.4%), followed by renal failure (15.8%). The percentages of DNR consent and hospice utilization were significantly different across different disease diagnosis, hospitalization department, and year of death. There were increased trends of DNR consent in patients with major noncancer diagnoses, and increased hospice care utilization in patients diagnosed with lung diseases and renal failure from 2010 to 2014. However, the hospice care utilization could be improved. Further study to evaluate factors associated hospice care to improve the utilization is suggested., Competing Interests: The authors have no conflicts of interest to declare.

Sepsis is a common condition in the emergency department that is associated with high mortality. Red blood cell distribution width (RDW) has been used as a simple prognosis predictor for patients with community-acquired pneumonia, gram-negative bacteremia, and severe sepsis or septic shock. To evaluate the performance of RDW to predict in-hospital mortality among septic patients, we conducted a hospital-based retrospective cohort study in an emergency department of a tertiary teaching hospital. RDW was compared with other commonly used clinical prediction scores (Systemic Inflammatory Response Syndrome (SIRS), Mortality in Emergency Department Sepsis (MEDS) and the Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 years of age and older (CURB65)). Of 6973 consecutive adult patients with a clinical diagnosis of sepsis and 2 sets of blood culture ordered by physicians, 477 (6.8%) died. The mortality group had higher RDW levels than the survival group (15.7% vs 13.8%). After dividing RDW into quartiles, the patients in the highest RDW quartile (RDW >15.6%; mortality, 16.7%) had more than twice the risk of in-hospital mortality compared with patients in the second highest quartile (RDW >14% and <15.6%; mortality, 7.3%), whereas the mortality rate in the lowest RDW quartile (<13.1%) was only 1.6%. The area under the receiver operating characteristic curve of RDW to predict mortality was 0.75 (95% confidence interval, 0.72-0.77), which is significantly higher than the areas under the curve of clinical prediction rules (SIRS, MEDS, and CURB65). After integrating RDW into these scores, all scores performed better in predicting mortality (0.73, 0.72, and 0.77, for SIRS, MEDS, and CURB65, respectively). RDW could be an independent predictor of mortality among septic patients. Clinicians could classify the septic patients into different risk groups according to RDW quartiles. For more accurate mortality prediction, RDW could be a potential parameter to be incorporated into clinical prediction rules., Competing Interests: The authors have no conflicts of interest to disclose.

Few studies have reported on readmissions among cancer patients receiving inpatient palliative care (IPC). This study investigated readmissions in cancer patients after their first discharge from IPC in Taiwan from 2002 to 2010.This study was a secondary data analysis using information from the National Health Insurance Database in Taiwan from 2002 to 2010. We included subjects ≥20 years old diagnosed with malignant neoplasms who were listed in the registry of catastrophic illness. Patients diagnosed with cancer before January 1, 2002 or who had ever been admitted to an inpatient hospice palliative care unit before the study period were excluded. Readmission was defined as hospital readmission at least once after discharge from first admission to IPC until mortality or the end of the study period.A total of 42,022 patients who met the inclusion criteria were identified. The majority of these patients were male (60.4%). The mean age of cancer diagnosis was 64.0 ± 14.4 years for men and 64.5 ± 14.7 years for women. The mean age at first hospice ward admission was 65.2 ± 14.2 years for men and 65.9 ± 14.9 years for women. During their first admission to IPC, 59.2% patients died, and the median stay of first IPC admission was 8.0 days. Among those discharged alive from their first admission to IPC, 64.9% were readmitted, and 19.4% of these patients were readmitted on the same day of discharge. From first IPC discharge until mortality, 54.8% of patients were readmitted once, 23.9% were readmitted twice, 9.9% were readmitted 3 times, and 11.5% were readmitted 4 or more times. Being male, having a higher insurance premium level, having a longer length of stay during first IPC admission, being admitted to a teaching hospital, or being admitted to a tertiary hospital increased the adjusted hazard ratio for readmission.We found that terminal cancer patients in Taiwan received relatively late referrals for first admission to IPC and experienced a high rate of readmission after first discharge from IPC. Policies to improve hospice palliative care referrals and decrease readmissions should be considered.

Background: It is unclear whether the myocardium undergoes accelerated fibrotic remodeling in children after heart transplantation (HTx)., Methods: In this prospective study, cardiac magnetic resonance (CMR) studies in 17 patients 1.3 years (median, range 0.03-12.6 years) after HTx (mean age, 9.8 ± 6.2 years; 8 girls) were compared to CMR studies in 9 healthy controls (mean age, 12.4 ± 2.4 years; 4 girls). T1 measurements were performed at a midventricular short axis slice before (ie, native T1 times) and after the application of 0.2 mmol/kg gadopentetate dimeglumine in the interventricular septum, left ventricular (LV) free wall and encompassing the entire LV myocardium. The tissue-blood partition coefficient (TBPC), reflecting the degree of diffuse myocardial fibrosis, was calculated as a function of the ratio of T1 change of myocardium compared to blood. Native T1 times and TBPC were correlated with echocardiographic parameters of diastolic function., Results: Native T1 times were significantly higher in HTx patients compared to controls in all regions assessed (LV free wall 973 ± 42 vs 923 ± 12 ms; P < 0.005; interventricular septum 1003 ± 31 vs 974 ± 21 ms, P < 0.05; entire LV myocardium 987 ± 33 vs 951 ± 16 ms; P < 0.005) and correlated with LV E/e' as an echocardiographic marker of diastolic dysfunction (r = 0.54, P < 0.05). The TBPC was elevated in the LV free wall (0.45 ± 0.06 vs 0.40 ± 0.03, P < 0.005) and the entire LV myocardium (0.47 ± 0.06 vs 0.43 ± 0.03, P < 0.05)., Conclusions: Evidence of diffuse myocardial fibrosis and is already present in children after HTx. It appears to be associated with diastolic dysfunction.

The optimal timing of percutaneous cholecystostomy for severe acute cholecystitis is unclear. The aim of this study was to investigate the timing of percutaneous cholecystostomy and its relationship to clinical outcomes in patients with inoperable acute severe cholecystitis.From 2008 to 2010, 209 consecutive patients who were admitted to our hospital due to acute cholecystitis and were treated by percutaneous cholecystostomy were retrospectively reviewed. The time periods from symptom onset to when percutaneous cholecystostomy was performed and when patients were discharged were recorded.In the 209 patients, the median time period between symptom onset and percutaneous cholecystostomy was 23 hours (range, 3-95 hours). The early intervention group (≤24 hours, n = 109) had a significantly lower procedure-related bleeding rate (0.0% vs 5.0%, P = 0.018) and shorter hospital stay (15.8 ± 12.9 vs 21.0 ± 17.5 days) as compared with the late intervention group (>24 hours, n = 100). Delayed percutaneous cholecystostomy was a significant independent factor for a longer hospital stay (odds ratio 3.03, P = 0.001).In inoperable patients with acute severe cholecystitis, early percutaneous cholecystostomy reduced hospital stay and procedure-related bleeding without increasing the mortality rate.

The bowenoid transformation of seborrheic keratosis (SK) has rarely been reported. The purpose of this study is to identify their diagnostic immunohistochemical features and association with human papillomavirus (HPV) infection. Skin biopsy specimens of the phenomenon were retrieved from 2001 to 2010. Benign SK, Bowen disease, bowenoid papulosis, and squamous cell carcinoma were included as controls. All specimens were stained for hematoxylin and eosin, Ki-67, p21, p16, p53, and cyclin D1. Polymerase chain reaction-amplified HPV DNA was analyzed. Seventeen cases of SK with bowenoid transformation were identified. The immunohistochemical pattern of bowenoid transformation was similar to that of Bowen disease and bowenoid papulosis. The malignant cells exhibited increased expressions of p16, p21, and ki-67 and a decreased expression of cyclin D1 (P < 0.01). HPV DNA was detected in 5 cases of bowenoid transformation. In conclusion, a portion of the cases of SK with bowenoid transformation were associated with HPV infection. Selective immunohistochemical stains were helpful in the diagnosis of malignant change in these cases.

Objectives: 1) To review the radiologic and audiologic data of 656 children with sensorineural hearing impairment who underwent 3-dimensional magnetic resonance imaging (MRI) in our cochlear implant (CI) center to understand the incidence of cochlear nerve deficiency (CND); and 2) to compare postimplant auditory and speech intelligibility outcomes in implantees with cochlear nerve (CN) aplasia, CN hypoplasia, and normal CN., Study Design: A retrospective cohort study., Setting: A tertiary medical center., Patients: A total of 656 patients (aged 0-18 yr; mean, 4.5 ± 4.3 yr) who underwent MRI in our center during May 2000 to December 2012., Main Outcome Measures: The radiologic/audiologic data were reviewed. The postimplant outcomes of 13 implantees with CND (7 aplasia and 6 hypoplasia) were compared with 50 non-CND implantees using the Categories of Auditory Performance (CAP) and the Speech Intelligibility Rating (SIR) scales., Results: Upon MRI, 139 patients (21.2%) exhibited CND. Bilateral CN aplasia occurred in 4.3% of the patients with severe-to-profound deafness (588 cases) and in one-fifth of patients with CND. The aplasia group showed significantly worse postimplant CAP (p = 0.002) and SIR (p = 0.009) scores than the non-CND group. No significant difference was noted between the hypoplasia group and the non-CND group., Conclusion: Although the audiologic and radiologic results may be incompatible, the majority of patients with CND may be well delineated preoperatively using MRI. The type of CND (aplasia/hypoplasia) may affect CI outcomes. Patients implanted on the side with CN hypoplasia are more likely to exhibit favorable results compared with patients implanted on the side with CN aplasia.

The remarkable success of trastuzumab and other newly developed anti-HER2 (human epidermal growth factor receptor 2) therapies in breast, gastric, or gastroesophageal junction cancer patients has supported us to investigate the HER2 status and its possible therapeutic implication in mucinous epithelial ovarian cancer (EOC). However, there is currently no standardization of HER2 scoring criteria in mucinous EOC. In this study, we aimed to compare both the assay performance characteristics of the 2007 and the 2013 American Society for Clinical Oncology and College of American Pathologists scoring methods. Forty-nine tissue microarray samples of mucinous EOC from Asian women were analyzed by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) tests using the 2007 and the 2013 criteria, respectively. The overall concordance between IHC and FISH by the 2007 criteria was 97.92 % (kappa = 0.921), and that by the 2013 criteria was 100% (kappa = 1.000). The percentage of Her2 FISH-amplified cases showed an increasing trend significantly through their corresponding HER2 IHC ordinals by the 2007 and the 2013 criteria, respectively (P < 0.001, P < 0.001). After excluding equivocal cases, the specificity (100%) and positive predictive value (100%) were unchanged under either the 2007 or the 2013 criteria. The sensitivity (100%), negative predictive value (NPV) (100%), and accuracy (100%) of HER2 IHC were higher under the 2013 criteria than those (sensitivity 87.5%, NPV 97.6%, and accuracy 97.9%) under the 2007 criteria. Of the total 49 cases, the number (n = 4) of HER2 IHC equivocal results under the 2013 criteria was 4-fold higher than that (n = 1) under the 2007 criteria (8.16% vs 2.04%). Conclusively, if first tested by IHC, the 2013 criteria caused more equivocal HER2 IHC cases to be referred to Her2 FISH testing than the 2007 criteria. That decreased the false-negative rate of HER2 status and increased the detection rates of HER2 positivity in mucinous EOC.

Objectives: The purpose of this study was to objectively evaluate the position and migration of the cochlear implant receiver and ball electrode using 3-dimensional (3D) rendering of computed tomography., Study Design: Retrospective case review., Setting: Tertiary referral center., Patients: Thirty-one patients were treated for profound sensorineural hearing loss with cochlear implant. The operative methods were divided into 2 groups: an inverted J-shaped incision with bony tie-down suture, and a minimally invasive incision without tie-down suture., Intervention(s): When the receiver and ball electrode were detected in 3D imaging, the zygomatic process-receiver angle (ZRA), ear canal to receiver distance (ERD), and ear canal to ball electrode distance (EBD) were measured., Main Outcome Measure(s): Comparison and statistical analysis of postoperative angle and distances., Results: The mean ZRA, EBD, and ERD values were 139.1 degrees, 20.7 mm, and 36.0 mm, respectively. The mean ZRA in patients with an inverted J-shaped incision was significantly wider than for those with a minimally invasive incision (151.2 versus 136.9, p = 0.002). In 10 patients who received postoperative computed tomography 2 times, ZRA increased from 138.6 to 144.4 degrees (p < 0.001) and ERD decreased from 37.0 to 34.9 mm (p = 0.001)., Conclusion: 3D computed tomography is a useful tool for localization and migration of the receiver and ball electrode. Micro downward movements of the receiver were found in both bony tie-down and non-tie-down suture groups.

Purpose of Review: This article reviews recent clinical applications of ultrasound imaging in laryngeal examinations and new developments in imaging techniques for laryngeal tissue characterization., Recent Findings: The B-mode image has become a popular tool for identifying masses, lesions, and nodules at the vocal folds, and combining the B-scan with Doppler imaging makes it possible to also evaluate their functionality. The B-mode image has been used to diagnose lesions and paralysis in vocal folds in children, and to evaluate nerve function by visualizing the structure of the larynx and the movement of the bilateral vocal folds. Ultrasound Nakagami imaging based on the statistics of backscattered signals is a new parametric imaging method that complements the conventional B-scan for tissue characterization. Nakagami imaging is a functional ultrasound imaging tool for visualizing the relative concentrations of collagen and elastic fibers, which are key factors influencing the biomechanical properties of the vocal folds., Summary: Future clinical applications could combine conventional B-mode and Nakagami images to allow physicians to simultaneously evaluate the morphology and scatterer properties of laryngeal tissues.

Introduction: Methamphetamine (MAMP) use is highly associated with psychiatric disorders with 12-13% of MAMP-dependent patients experiencing psychotic symptoms. Substance abuse and dependence may primarily involve the mesolimbic pathway and dopaminergic brain structures. It follows that dopaminergic genes, particularly COMT (encoding catechol-O-methyltransferase) and its val158met polymorphism (rs4680), are natural candidates for susceptibility loci to addiction. We have previously found an association with rs4680 and MAMP addiction., Methods: We present additional genotyping of rs165599 in 423 cases and 502 controls of a Taiwanese MAMP user sample. We carried out an in-silico evaluation of rs165599 for a possible impact on microRNA binding or UTR stability. We also carried out a review of transcript sequences across the COMT 3'UTR., Results: Genotype counts were (cases/controls): AA 94/110, AG 198/210 and GG 93/109. There were no significant allele or genotype differences between cases and controls for rs165599. However, a haplotype main effect was detected using both rs4680 and rs165599 using the χ²-test in UNPHASED. The global P-value was P=0.0044 with the effect appearing to derive from one haplotype that is underrepresented in cases: A/G for rs4680/rs165599 (haplotype P=0.001). rs165599 is a single nucleotide polymorphism located in the COMT 3' untranslated region (UTR), a noncoding transcript region subject to posttranscriptional down-regulation by mechanisms such as microRNA binding. A review of transcript sequences across the COMT 3'UTR found evidence to suggest antisense interference of COMT from the 3'UTR of the neighbouring 'Armadillo repeat gene deleted in velocardiofacial syndrome' gene.

Rationale: Parasympathetic regulation of heart rate is mediated by acetylcholine binding to G protein-coupled muscarinic M2 receptors, which activate heterotrimeric G(i/o) proteins to promote G protein-coupled inwardly rectifying K(+) (GIRK) channel activation. Regulator of G protein signaling (RGS) proteins, which function to inactivate G proteins, are indispensable for normal parasympathetic control of the heart. However, it is unclear which of the more than 20 known RGS proteins function to negatively regulate and thereby ensure normal parasympathetic control of the heart., Objective: To examine the specific contribution of RGS6 as an essential regulator of parasympathetic signaling in heart., Methods and Results: We developed RGS6 knockout mice to determine the functional impact of loss of RGS6 on parasympathetic regulation of cardiac automaticity. RGS6 exhibited a uniquely robust expression in the heart, particularly in sinoatrial and atrioventricular nodal regions. Loss of RGS6 provoked dramatically exaggerated bradycardia in response to carbachol in mice and isolated perfused hearts and significantly enhanced the effect of carbachol on inhibition of spontaneous action potential firing in sinoatrial node cells. Consistent with a role of RGS6 in G protein inactivation, RGS6-deficient atrial myocytes exhibited a significant reduction in the time course of acetylcholine-activated potassium current (I(K)(ACh)) activation and deactivation, as well as the extent of I(K)(ACh) desensitization., Conclusions: RGS6 is a previously unrecognized, but essential, regulator of parasympathetic activation in heart, functioning to prevent parasympathetic override and severe bradycardia. These effects likely result from actions of RGS6 as a negative regulator of G protein activation of GIRK channels.

A 39-year-old female presented with abdominal distension. A right adnexal mass was found on physical examination, which was shown to be cystic on ultrasound. An exploratory laparotomy revealed a right ovarian mass, which was removed and a staging procedure was performed. Histologically, the mass was a borderline ovarian tumor with stromal microinvasion and hemangiomatous mural nodules.

Background: Most operating room (OR) scheduling is done by scheduling personnel based on experience or heuristics. Such often results in excessive overtime for medical personnel and poor resource-use efficiencies., Purpose: This study was designed to employ an integrated OR scheduling performance evaluation model (IOSPEM), which integrates quantitative and qualitative multiple objectives, to the improvement of OR scheduling quality., Methods: The fuzzy Delphi method was used to obtain the weight values of time factor, cost factor, and risk factor. The fuzzy set theory was applied to transform qualitative risk measures into quantitative values. The desirability function was utilized to integrate time, cost, and risk factors to develop the IOSPEM. The simulated annealing algorithm was used to develop the scheduling system and test proposed model performance., Results: The proposed IOSPEM successfully integrated the quantitative and qualitative indices into a sole quantitative index. Experiment results show that the IOSPEM incorporating the simulated annealing algorithm is able to obtain the most efficient OR schedule and is helpful in reducing costs and fatigue risks., Conclusions and Implications for Practice: Operating room scheduling will be made more objective and efficient if OR scheduling personnel can simultaneously consider the cost, fatigue risk, and other factors in scheduling. Cost of each OR room should be considered to set appropriate cost coefficients in practical application of the IOSPEM. It is also suggested that other indices (e.g., OR overtime costs and OR nurse fatigue risks) also be considered in the proposed model so as to better reflect the actual scheduling environment. The procedure and methods implemented in this study may be used as the basis for further developing more effective and efficient OR scheduling systems.

Angioimmunoblastic T-cell lymphoma is a nodal peripheral T-cell lymphoma considered to be derived from CD4 follicular helper T cells. It is characterized by the proliferation of arborizing vessels, hyperplastic follicular dendritic cells, and a polymorphous lymphoid infiltrate including large B immunoblasts, which could be polyclonal, oligoclonal, or monoclonal. The polymerase chain reaction-based clonality study of lymphoproliferations is increasingly popular in the diagnostic workup. With the commercially available Biomed-2 protocols, lymphoproliferations with amplicons in the expected size ranges are considered clonal, whereas clonal products outside the expected ranges are extremely rare. We presented the case of a 60-year-old male patient with angioimmunoblastic T-cell lymphoma, in which the neoplastic T cells expressed CD8, bcl-6, and programmed death-1. Furthermore, there was a proliferation of large B cells in this tumor. The results of T-cell receptor gene rearrangement study using the Biomed-2 protocols showed clonal rearrangement with amplicons falling within the expected size ranges. Interestingly, the size of the amplicons detected by the Biomed-2 immunoglobulin heavy chain gene (IgH) rearrangement using FR2/JH primers was around 240 bp, slightly smaller than the expected size ranges. Through cloning, sequencing, and BLAST searches, we confirmed that the FR2/JH amplicon was derived from the IgH rearrangement with a deletion of a short segment. Our case illustrates that polymerase chain reaction amplicons outside the expected size ranges may still be clonal products.

Background: Understanding the interactive relationships between demographics and work-related variables, job stress, job stress coping strategies, and job satisfaction for operating room (OR) nurses is important., Purpose: The purpose of this study was to determine the stressors, the stress coping strategies, and the job satisfaction of nursing staff who worked in the OR and to evaluate influence of demographic characteristics on job stress, stress coping strategies, and job satisfaction., Methods: A cross-sectional research design was used to collect data. Participants included 121 nurses with more than 6 months of work experience at seven hospitals in Yunlin and Chiayi Counties. Data were collected from March through May 2008. One hundred twelve questionnaires were returned, giving a response rate of 92.56%. The questionnaire included four parts designed to gather data on demographics and work-related information, job stress, stress coping strategies, and job satisfaction., Results: Major findings of this study were as follows: (a) stress level and frequency perception of OR nurses were significantly related to the type of hospital; (b) the most intense stressor perceived by OR nurses was patient safety; (c) the stressor most frequently perceived by OR nurses was administrative feedback; (d) although all job stressors were positively related to destructive stress coping strategies, professional status, patient safety, and OR environment were also positively related to constructive stress coping strategies; (e) factors including work rewards, OR environment, and administrative management of job satisfaction were inversely related to destructive stress coping strategies; and (f) factors including work rewards, OR environment, and administrative management of job satisfaction were inversely related to all job stressors., Conclusions/implications for Practice: Major suggestions of this study include the following: (a) hospitals should ensure set standard operating procedures for the OR, strengthen the designed-in security of the OR working environment, and provide adequate safety protection equipment to safeguard OR staff and patients; (b) the OR department should increase the quantity and the quality of stress relief courses; (c) the OR department should improve the OR environment and the administrative management skills; and (d) the OR department should offer self-esteem-related training programs to assist OR nursing staff to adopt constructive stress coping strategies.

Somnambulism consists of variously complex behaviors that may result in harm to self or to others. Many different medications have been reported to induce somnambulism, and a few of them are newer antidepressants. A 40-year-old woman with history of major depression who experienced new onset somnambulism for successive 3 nights, whereas the antidepressant mirtazapine was increased from 30 to 45 mg/d. The notable and complex sleepwalking symptoms terminated dramatically on the first night after withdrawal of mirtazapine. There is clearly a cause-and-effect relationship between the treatment of higher-dosage mirtazapine and development of somnambulism. It might be related to the different affinities to 5-hydroxytryptamine 2 (5-HT(2)) and H(1) receptors at different dosages of mirtazapine, which explain the patient experiencing sleepwalking episodes exclusively at higher doses of mirtazapine. Clinical physicians should be aware of this adverse effect and taper or discontinue the regimen if sleepwalking develops.

Objective: To evaluate the effects of an anterior leaflet ankle-foot orthosis (AFO) on postural stability in stroke patients with hemiplegia., Design: Twenty-one stroke patients with hemiplegia resulting from new-onset stroke and ten normal subjects were included in this study. The SMART balance master system was used to assess the postural stability by measuring the ankle strategy, maximal stability, and velocity of center-of-gravity (COG) movement under the following six conditions: (1) eyes open and fixed support (EOFS), (2) eyes closed and fixed support (ECFS), (3) sway-referenced vision and fixed support (SVFS), (4) eyes open and sway-referenced support (EOSS), (5) eyes closed and sway-referenced support (ECSS), and (6) sway-referenced vision and support (SVSS). Each patient was tested with and without an anterior AFO as compared with normal subjects., Results: When wearing an anterior AFO, patients used ankle strategy more than hip strategy to maintain postural stability in all the six sensory conditions (P < 0.05). An anterior AFO also provided stroke patients with better maximal stability under relatively challenging conditions such as SVFS, EOSS, and ECSS (P < 0.05), but the effect was not apparent in the conditions without external perturbation (EOFS and ECFS) and the most difficult condition (SVSS). The velocity of COG movement was lowered when wearing an anterior AFO in stroke patients, and significant differences existed in the EOFS, ECFS, ECSS, and SVSS conditions (P < 0.05)., Conclusions: In the early stage of recovery, the use of an anterior AFO may assist stroke patients with hemiplegia to improve their postural stability.

Background: Paralysis of the marginal mandibular branch of the facial nerve is frequently seen in patients with oromandibular reconstructions or facial palsy. However, deformities caused by overpulling of the depressor muscles of the contralateral lower lip without being antagonized by the diseased counterpart is often quite conspicuous. Depressor myectomy of the contralateral lower lip therefore provides a method for correcting the dynamic deformity., Methods: Seventy-six patients with paralysis of the marginal mandibular branch of the facial nerve were treated with either surgical depressor myectomy of the lower lip (25 patients), depressor myectomy with subsequent botulinum toxin injection (eight patients), or only chemical depressor myectomy with botulinum toxin injections (43 patients)., Results: Good to fair results were always achieved, with near balance of the lower lip during mouth opening and in facial expressions. Surgical myectomy may still result in recurrence in eight patients (24 percent), which will necessitate further treatment with botulinum toxin injections., Conclusions: Using myectomy for paralysis of the marginal mandibular branch of the facial nerve can be an effective treatment for this significant deformity. Chemical myectomy with botulinum toxin injection is a safe and convenient mode of treatment; however, the disadvantage is that it needs repeated injections and costs more.

Background and Purpose: Multi-detector computed tomographic (MDCT) angiography is a recently developed imaging technique that can study small vessels such as medullary arteries and veins. The purpose of this study was to evaluate MDCT angiography in diagnosing SDAVF., Methods: Eight patients with initial magnetic resonance imaging (MRI) and clinical findings suggestive of spinal dural arteriovenous fistula (SDAVF) and 8 control subjects underwent MDCT angiography. Both MDCT angiography and catheter angiography were performed within 5 days in patients with SDAVFs. The results of MDCT angiography in patients with SDAVFs were compared with those of catheter angiography., Results: MDCT angiography detected engorged perimedullary draining veins and correctly localized the fistula of the SDAVFs, and correlated well with catheter angiography. Fistula was at the thoracic level in 7 patients, and sacral level in 1 patient. MDCT angiography did not visualize the engorged perimedullary venous plexus in the control group., Conclusions: MDCT angiography correlated well with catheter angiography in diagnosing SDAVFs. It might play a role in shortening the length of the catheter angiography in diagnosing this disease.

Several open-label studies or case reports have suggested the effectiveness of clozapine or topiramate in the treatment of resistant rapid-cycling bipolar patients, but none of these publications report the long-term effectiveness of these two agents in combination. The authors present a 38-year-old woman with a 22-year history of rapid-cycling bipolar I disorder who failed to respond satisfactorily to various somatic therapies, including combination therapy for complex regimens and a course of bilateral electroconvulsive therapy, but finally responded well to a combination treatment of clozapine and topiramate. Such a combination therapy led the patient to a complete remission for more than 3 years without inducing side effects such as weight gain, hyperglycemia, type II diabetes mellitus, or hyperlipidemia. In addition, she had a weight loss of 12 kg over the past 3 years. This case suggests that the combination treatment of clozapine and topiramate can be safe and effective in some resistant rapid-cycling bipolar patients.

In this study, we investigated the interaction between lipopolysaccharide (LPS) and lead (Pb) and the involvement of tumor necrosis factor-alpha (TNF-alpha) and oxidative stress in Pb-plus-LPS (Pb/LPS)-induced liver damage in rats. Serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), TNF-alpha, nitric oxide (NO), and lipid peroxidation (LPO) were determined in rats treated with Pb and/or LPS. Pb ranging from 0 to 15 mg/kg dose dependently increased AST, ALT, NO, or LPO in LPS-treated rats. Pretreatment with iNOS inhibitor 1400W reduced NO, LPO, TNF-alpha, AST, and ALT in Pb/LPS-treated rats. Thus, Pb increased LPS-induced liver damage, which might be associated with increased NO-initiated oxidative stress and TNF-alpha in rats.

Objectives: Substance use disorders are familial, and genetic factors explain a substantial degree of their familial aggregation. This study employs an association approach to examine the genetic underpinning of methamphetamine (MAMP) use and MAMP-induced psychosis., Methods: A total of 416 MAMP abusers from a hospital and a detention center in Taipei were interviewed with the Diagnostic Interview for Genetic Study and the Family Interview for Genetic Study. Genetic polymorphisms of D2-like dopamine receptor genes, DRD2 TaqI A, DRD3 Ser-9-Gly, and DRD4 exon III variable number of tandem repeats, were compared between: (a) MAMP users as a whole and 435 normal controls, and (b) those 154 individuals with MAMP-induced psychosis and the 252 MAMP users with no psychosis., Results: None of the three markers we studied were associated with predisposition to psychosis among the MAMP abusers. The MAMP abusers had a higher (P=0.011) prevalence of the seven-repeat allele of DRD4 than normal controls., Conclusions: Chance fluctuations in the frequency of rare alleles and ascertainment differences in the case and control samples cannot be ruled out. Therefore, further studies of the seven-repeat allele in MAMP abusers and controls should be performed before an association can be established.

Objective: To identify risk factors for cancer recurrence in patients with stage IB, IIA, and IIB cervical carcinoma after abdominal radical hysterectomy with pelvic lymph node dissection and postoperative pelvic irradiation., Methods: One hundred and eighty-seven patients with cervical carcinoma stage IB (n = 63), IIA (n = 43), and IIB (n = 81) disease who received abdominal radical hysterectomy with pelvic lymph node dissection and postoperative pelvic irradiation were followed-up for 2-10 years. The histologic type, grade, lymphovascular tumor emboli, tumor size, invasion sites, deep cervical stromal invasion, and pelvic lymph node metastases were assessed for correlation with cancer recurrence., Results: Recurrence occurred in 45 cases (24%), of whom 40 had died of the disease at the 5-year follow-up period. Univariate proportional hazards analysis revealed that the significant risk factors were adenocarcinoma, bulky tumor size (4 cm or greater), lymphovascular tumor emboli, deep cervical stromal invasion, and lymph node metastases, especially iliac nodal metastases and bilateral nodal metastases. Multivariate proportional hazards analysis showed that bulky tumor size (hazard ratio 2.34), tumor emboli (hazard ratio 2.74) and iliac nodal metastases (hazard ratio 5.31) remained significant risk factors. In contrast, no deaths occurred in the other 142 cases who did not have recurrence., Conclusion: This retrospective study suggests that stage IB, IIA, and IIB cervical carcinoma cases with the above-mentioned pathologic factors are at higher risk of recurrence after abdominal radical hysterectomy with pelvic lymph node dissection and postoperative pelvic irradiation.

The influence of timing of FK 506 (Tacrolimus) administration on renal function and recovery from renal warm ischemia was studied in Sprague-Dawley rats. Animals were administered FK 506 and subjected to 60 min of renal warm ischemia by temporary occlusion of the renal artery and vein. No significant differences in serum creatinine levels among rats subjected to renal ischemia, FK 506, or FK 506 vehicle (methanol and 5% dextrose in water) were demonstrated. In contrast, FK 506 administration (4 mg/kg intraperitoneally) in combination with renal warm ischemia resulted in significant deterioration of renal function with peaking of serum creatinine on day 2. The timing of FK 506 administration relative to renal ischemia did not significantly affect serum creatinine levels. Rats that received FK 506 either 24 hr pre-ischemia, 4 hr pre-ischemia, 4 hr post-ischemia, or 24 hr post-ischemia all showed similar serum creatinine levels on day 2 (3.85 +/- 0.9, 4.7 +/- 0.5, 3.8 +/- 0.9, and 5.1 +/- 0.6 mg/dl, respectively, p = NS). In all animals, serum creatinine returned to baseline values by day 10. Histopathologic examination of kidneys revealed tubular atrophy and dilatation with tubular calcifications at the corticomedullary junction in FK 506 treated animals with or without ischemia. Our data suggest the timing of FK 506 administration in rats subjected to renal warm ischemia does not influence the extent of renal injury with an equally deleterious effect seen when administered within a 24 hr period of an ischemic event. Changes in kidney morphology, however, were seen in all FK 506 treated rats, with or without a period of warm ischemia.

Background: Cryptococcal infection is opportunistic and occurs most commonly in immunocompromised patients. Meningitis is the most frequent manifestation and causes marked morbidity and mortality. Other sites are less common. We report a case of vaginal cryptococcal infection., Case: A 72-year-old patient who had undergone resection of the colon for cancer 9 years earlier was noted to have a suspicious lesion on the right vaginal wall after an abnormal Papanicolaou test. Biopsy of the lesion showed findings compatible with cryptococcal infection. Serial examinations revealed no evidence of systemic infection or immunocompromised condition. Empirical treatment was tried with fluconazole. Follow-up colposcopy showed almost complete disappearance of the vaginal lesion, and histologic section and culture of the tissue failed to reveal cryptococcus., Conclusion: Cryptococcal infection is rare, especially in a patient with no evidence of an immunocompromised condition. The preliminary result of fluconazole treatment was satisfactory. However, further follow-up and evaluation are needed to confirm the effectiveness of fluconazole in our patient.

Balloon coarctation angioplasty (BCA) was performed in seven consecutive patients (five boys and two girls) 18 months to 18 years old (mean 9.5) with isolated discrete unoperated coarctation of the aorta. A No. 8F or 9F catheter was chosen with balloon lengths of 30 or 40 mm and maximum inflation diameters 1 mm less than the smallest measured aortic diameter determined 1 cm proximal to the coarctation site. A 10 sec inflation-deflation cycle of 6 to 8 atmospheres (90 to 120 psi) was performed. The peak systolic pressure gradient (PSG) before BCA ranged from 35 to 70 mm Hg (mean 58), and immediately after BCA it decreased to 0 to 20 mm Hg (mean 7). One to two year follow-up (mean 14 months) of the seven patients revealed a PSG range of 10 to 30 mm Hg (mean 19). Repeat angiography was performed immediately proximal to the coarctation site. Three patients (43%) had evidence of aneurysm formation at or immediately distal to the balloon dilatation site. One patient had coarctation restenosis. While initial results with BCA for unoperated coarctation were encouraging, current data raise serious concerns about its long-term safety and efficacy.

Radiographic findings include supraacetabular bone erosions, subchondral acetabular cysts, soft tissue masses with or without radiolucent inclusions representing nitrogen gas, joint space narrowing, and abnormal hip configuration. Associated tears of the acetabular labrum were confirmed by arthrography in two patients. Computed tomography and magnetic resonance imaging afforded improved delineation of soft tissue ganglia and their relationship to the acetabular bone, labrum, and hip joint. We report our experience with seven patients in whom various imaging examinations clearly documented the presence of soft tissue cystic lesions adjacent to the acetabulum; in six of the seven patients, significant clinical manifestations were evident in the affected hip. Such cysts, whether designated synovial or ganglionic in type, appear to be a frequently overlooked yet important cause of hip symptomatology.