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Aim: Patients who undergo continuous ambulatory peritoneal dialysis (CAPD) frequently need second surgical procedures (SSP) for various reasons. After 18 years of practice and observation, we analysed the records of these patients and tried to determine what complications occurred most often and how to deal with them. Patients and methods: We retrospectively reviewed the medical records of patients receiving CAPD treatment in the past 18 years at our hospital. The impact of the most serious complications to the CAPD modality was presented by the technique survival rate. We also classified the SSP and analysed the indications for SSP. Results: All 206 SSP could be classified into 12 types of procedures. More than half of the procedures (51.9 per cent) were catheter removal, followed by debridement (14.1 per cent) and herniorrhaphy (10.2 per cent). There were 18 indications for SSP. The most common indication was peritonitis (21.4 per cent). The 3-year technique survival was only 23.2 per cent in 82 patients whose catheters were removed because of serious complications. Conclusions: During our long-term follow up of CAPD patients, more than one-third (36 per cent) needed SSP. Catheter removal forced by peritonitis still remains a major problem for patients and care providers. Technique survival was very low once a serious complication occurred.

Significant heterogenity of stage IB (sixth edition of the TNM staging system) nonsmall cell lung cancer (NSCLC) has been identified, and further subclassification according to tumour size has been proposed. The aim of this study is to evaluate the prognostic factors in patients with resected stage IB NSCLC3 cm. From January 1980 to December 2000, 525 patients underwent surgical resection for stage IB NSCLC3 cm at Taipei Veterans General Hospital, Taipei, Taiwan. The clinicopathological characteristics of these patients were retrospectively reviewed. The 5- and 10-yr overall survival rates were 44.9% and 27.3%, respectively. Age (p0.001), tumour size (p = 0.002), extent of pulmonary resection (p = 0.002), histological type (p = 0.005) and number of mediastinal lymph nodes dissected/sampled (p = 0.004) were significant predictors for overall survival in multivariate analysis. Patients with tumour size7 cm, or5 to ≤ 7 cm, had a worse survival than those with tumour size3 to ≤ 5 cm. However, visceral pleural invasion did not influence overall survival. Stage IB NSCLC with a diameter3 cm may be subclassified according to tumour size regardless of visceral pleural invasion.

Background: The goal of this study was to investigate the prognostic factors and patterns of recurrence in patients with resected non-small cell lung cancer (NSCLC) ≤ 1 cm in diameter. Methods: We conducted a retrospective review of the clinicopathological characteristics of 71 patients with NSCLC ≤ 1 cm in diameter in Taipei Veterans General Hospital between 1982 and 2007. Overall survival and its predictors were analyzed. Results: Median follow-up time of the 71 patients was 33.3 months. Complete resection was performed in 68 patients (95.8%) with stage I disease. The 5- and 10-year overall survival rates of patients who underwent complete resections were 81.7% and 44.9%, respectively. There was tumor recurrence in 6 (8.8%) of these 68 patients. Five (9.3%) of 54 patients who underwent standard resection experienced tumor recurrence, but only 1 (7.1%) of 14 patients who received sublobar resection had recurrent disease. The difference was not statistically significant (p = 0.569). Multivariate analysis revealed that sublobar resection (hazard ratio, 5.00; 95% confidence interval, 1.28–20.00; p = 0.020) was a significant predictor for worse overall survival. Conclusion: Survival in patients with NSCLC ≤ 1 cm in diameter is satisfactory. Sublobar resection, performed in patients unfit for standard resection, is a poor prognostic factor for overall survival. [J Chin Med Assoc 2010;73(6):308–313]

Eyes with threshold retinopathy of prematurity (ROP) often show dilation of the existing tunica vasculosa lentis (TVL), which is a prognostic factor in ROP screening and treatment, but can be frequently misdiagnosed as true iris neovascularization (NV). Besides, candidemia in preterm infants can aggravate the severity of ROP, possibly to the threshold stage requiring laser treatment. A case of prolonged candidemia without ophthalmic infection in an extremely-low-birth-weight (ELBW) (birth weight: 800 g), pre-term (gestation: 26 weeks) infant with persistent TVL and severe ROP are reported. The threshold ROP was successfully treated with argon laser therapy. Candidemia without eye infection in this case was associated with early use of a systemic antifungal drug. To our knowledge, no similar cases have been reported in the literature.

Objective Distant metastasis after surgical resection is the most frequent cause of death in patients with nonsmall cell lung cancer (NSCLC). This study aimed to investigate the patterns of distant metastasis and the prognostic factors of postrecurrence survival in patients with resected stage I NSCLC with distant metastases. Methods The clinicopathological characteristics of 166 patients with distant metastases after complete resection of stage I NSCLC at Taipei Veterans General Hospital between 1980 and 2000 were retrospectively reviewed. The patients were divided into two groups according to patterns of distant metastasis (single or multiple organ metastases). Predictors of postrecurrence survival were analysed. Results The patterns of distant metastasis included single organ metastasis in 106 (63.9%) and multiple organ metastases in 60 (36.1%) patients. The 1- and 2-year postrecurrence survival rates for those with single organ metastasis were 30.2% and 15.1%, respectively. The most common site of single organ metastasis was bone (32.1%), followed by the brain (29.2%). Multivariate analysis revealed that disease-free interval >16 months (HR 0.534; 95% CI 0.288 to 0.990; p¼0.046) and treatment for distant metastasis (including re-operation, chemotherapy and/or radiotherapy) (HR 0.245; 95% CI 0.089 to 0.673; p¼0.006) were significant predictors of better postrecurrence survival in resected stage I NSCLC with single organ metastasis. Conclusions A longer disease-free interval is a favourable prognostic predictor for postrecurrence survival in resected stage I NSCLC with single organ metastasis. Treatment for distant metastasis significantly prolongs postrecurrence survival.

Objectives. The purpose of this study was to establish the minimal detectable change (MDC) and clinically important differences (CIDs) of the physical domains of the Stroke Impact Scale (SIS) and to assess the proportions of patients’ change scores exceeding the MDC and CIDs after stroke rehabilitation. Methods. Seventy-four patients received 1 of 3 treatments for 3 weeks and underwent clinical assessment before and after treatment. The MDC was calculated from the standard error of measurement to indicate a real change with 95% confidence for individual patients (MDC95). Anchor-based and distribution-based approaches were adopted to triangulate the ranges of minimal CIDs. The percentage of patients exceeding MDC95 and minimal CIDs were also calculated. Results. The MDC95 of the strength, activities of daily living/instrumental activities of daily living, mobility, and hand function subscales were 24.0, 17.3, 15.1, and 25.9, respectively. The respective minimal CIDs for these 4 subscales were 9.2, 5.9, 4.5, and 17.8 points, respectively, and the MDC95 and CID proportions were 14% to 43%, 16% to 49%, 10% to 50%, and 23% to 64%, respectively. Conclusions . The change score of an individual patient has to reach 24.0, 17.3, 15.1, and 25.9 on the 4 subscales to indicate a true change. The mean change scores of a stroke group on the 4 subscales should reach 9.2, 5.9, 4.5, and 17.8 points to be regarded as clinically important changes. Future research with larger sample sizes is warranted to validate these estimates.

Metastasis is the most common cause of disease failure and mortality for non-small cell lung cancer (NSCLC) after surgical resection. Snail and TWIST1 are epithelial-mesenchymal transition (EMT) regulators which induce metastasis. Intratumoral hypoxia followed by stabilisation of hypoxia-inducible factor 1alpha (HIF-1alpha) promotes metastasis through regulation of certain EMT regulators. The aim of this study was to evaluate the prognostic value of HIF-1alpha, TWIST1 and Snail expression in patients with resectable NSCLC.A retrospective analysis of 87 patients with resectable NSCLC from Taipei Veterans General Hospital between 2003 and 2004 was performed using immunohistochemistry to analyse HIF-1alpha, TWIST1 and Snail expression. The association between HIF-1alpha, TWIST1 and Snail expression and patients' overall and recurrence-free survivals was investigated.Overexpression of HIF-1alpha, TWIST1 or Snail was shown in 32.2%, 36.8% and 55.2% of primary tumours, respectively. Overexpression of HIF-1alpha, TWIST1 or Snail in primary NSCLCs was associated with a shorter overall survival (p = 0.005, p = 0.026, p = 0.009, respectively), and overexpression of HIF-1alpha was associated with a shorter recurrence-free survival (p = 0.016). We categorised the patients into four groups according to the positivity of HIF-1alpha/TWIST1/Snail to investigate the accumulated effects of these markers on survival. Co-expression of more than two markers was an independent prognostic indicator for both recurrence-free survival and overall survival (p = 0.004 and p0.001, respectively, by multivariate Cox proportional hazards model).Co-expression of more than two markers from HIF-1alpha, TWIST1 and Snail is a significant prognostic predictor in patients with NSCLC.

Resection is the best treatment for patients with stage I non-small cell lung cancer (NSCLC). Patterns of disease recurrence after complete resection in stage I NSCLC have not been well demonstrated. The aim of this study was to evaluate the prognostic predictors of post-recurrence survival in patients with resected stage I NSCLC with local recurrence.The clinicopathological characteristics of 123 patients with local recurrence after complete resection of stage I NSCLC in Taipei Veterans General Hospital between 1980 and 2000 were retrospectively reviewed. Post-recurrence survival and their predictors were analysed.The patterns of local recurrence included local only in 74 (60.2%) and both local and distant in 49 (39.8%) patients. The 1 and 2 year post-recurrence survival rates for the 74 patients with local only recurrence were 48.7% and 17.6%, respectively. Tumour size (p = 0.033) and treatment for initial recurrence (p0.001) were significant predictors for post-recurrence survival in 74 patients with local only recurrence in univariate analyses. The hazard of death was greater in patients with larger tumour size. Treatment for initial recurrence (p = 0.001) was still a significant prognostic indicator in multivariate analyses. Patients who underwent reoperation after local recurrence survived longer than those who received chemotherapy and/or radiotherapy and those that received no treatment.Treatment for initial recurrence is a prognostic predictor for post-recurrence survival in resected stage I NSCLC with local recurrence. Complete surgical resection should be considered in selected candidates with resectable local recurrent disease.

Background. Trials of constraint-induced movement therapy (CIT) to improve upper extremity function after stroke have usually not included an actively treated control group. Objective. This study compared a modified CIT intervention with a dose-matched control intervention that included restraint of the less affected hand and assessed for differences in motor and functional performance and health-related quality of life. Methods. This 2-group randomized controlled trial, using pretreatment and posttreatment measures, enrolled 32 patients within 6 to 40 months after onset of a first stroke (mean age, 55.7 years). They received either CIT (restraint of the less affected limb combined with intensive training of the affected limb for 2 hours daily 5 days per week for 3 weeks and restraint of the less affected hand for 5 hours outside of the rehabilitation training) or a conventional intervention with hand restraint for the same duration. Outcome measures were the Fugl-Meyer Assessment, Functional Independence Measure, Motor Activity Log, Nottingham Extended Activities of Daily Living Scale, and Stroke Impact Scale. Results. Compared with the control group, the CIT group exhibited significantly better performance in motor function, level of functional independence, mobility of extended activities during daily life, and health-related quality of life after treatment. Conclusions. The robust effects of this form of CIT were demonstrated in various aspects of outcome, including motor function, basic and extended functional ability, and quality of life.

Cholecystolithiasis is a common disease, making cholecystectomy a commonly performed surgical procedure. The gross appearance of gallstones differs from case to case. To classify gallstones on the basis of their structure, we randomly collected gallstones from 100 (64 of them women) of 3,289 patients who underwent cholecystectomy at our hospital. The stones were grossly classified into five major types: pure-cholesterol stones, combination stones, mixed stones, black stones, and calcium bilirubinate stones. We then used thin-section petrographic microscopic study (TSPMS) to inspect each stone under a polarizing microscope. Final classification of the stone depended on TSPMS findings. Of the 100 patients, 35 had pure-cholesterol stones, 12 had combination stones, 17 had mixed stones, 25 had black stones, and 8 had calcium bilirubinate stones; the stones from 3 patients could not be classified on TSPMS. Accurate structural classification of gallstones could be made by gross inspection with confirmation by TSPMS, a useful method of classifying gallstones.

To the Editor: In their assessment of the usefulness of combined positron-emission tomography and computed tomography (PET–CT) in the preoperative staging of lung cancer, Fischer et al. (July 2 issue)1 provide no information on the interval between baseline staging and thoracotomy, nor on the use of neoadjuvant therapy. A prolonged delay between PET–CT and surgery may negate the diagnostic value of PET–CT and may be due to coexisting conditions that would themselves have a negative effect on survival. Although the PET–CT scans in the study were read by an experienced radiologist and a nuclear medicine specialist, it is unclear who interpreted the diagnostic CT scans and whether the final tumor–node–metastasis (TNM) stage was determined by the same investigators in all patients or whether the stage was decided locally. These factors are important for assessing the influence of observer bias on the study results.

Background Breast cancer is a heterogeneous disease in terms of transcriptional aberrations; moreover, microarray gene expression profiles had defined 5 molecular subtypes based on certain intrinsic genes. This study aimed to evaluate the prediction consistency of breast cancer molecular subtypes from 3 distinct intrinsic gene sets (Sørlie 500, Hu 306 and PAM50) as well as clinical presentations of each molecualr subtype in Han Chinese population. Methods In all, 169 breast cancer samples (44 from Taiwan and 125 from China) of Han Chinese population were gathered, and the gene expression features corresponding to 3 distinct intrinsic gene sets (Sørlie 500, Hu 306 and PAM50) were retrieved for molecular subtype prediction. Results For Sørlie 500 and Hu 306 intrinsic gene set, mean-centring of genes and distance-weighted discrimination (DWD) remarkably reduced the number of unclassified cases. Regarding pairwise agreement, the highest predictive consistency was found between Hu 306 and PAM50. In all, 150 and 126 samples were assigned into identical subtypes by both Hu 306 and PAM50 genes, under mean-centring and DWD. Luminal B tended to show a higher nuclear grade and have more HER2 over-expression status than luminal A did. No basal-like breast tumours were ER positive, and most HER2-enriched breast tumours showed HER2 over-expression, whereas, only two-thirds of ER negativity/HER2 over-expression tumros were predicted as HER2-enriched molecular subtype. For 44 Taiwanese breast cancers with survival data, a better prognosis of luminal A than luminal B subtype in ER-postive breast cancers and a better prognosis of basal-like than HER2-enriched subtype in ER-negative breast cancers was observed. Conclusions We suggest that the intrinsic signature Hu 306 or PAM50 be used for breast cancers in the Han Chinese population during molecular subtyping. For the prognostic value and decision making based on intrinsic subtypes, further prospective study with longer survival data is needed.

Lin K-C, Chung H-Y, Wu C-Y, Liu H-L, Hsieh Y-W, Chen I-H, Chen C-L, Chuang L-L, Liu J-S, Wai Y-Y: Constraint-induced therapy versus control intervention in patients with stroke: a functional magnetic resonance imaging study. Am J Phys Med Rehabil 2010;89:177‐185. Objective: This study compared the effects of a distributed form of constraint-induced therapy with control intervention in motor recovery and brain reorganization after stroke. Design: A two-group randomized controlled trial with pretreatment and posttreatment measures was conducted. Thirteen patients with stroke were randomly assigned to the distributed form of constraint-induced therapy (n 5) or the control intervention group (n 8). Outcome measures included the Fugl-Meyer Assessment, the Motor Activity Log, and functional magnetic resonance imaging examination. The number of activation voxels and laterality index were determined from the functional magnetic resonance imaging data for the study of brain reorganization. Results: The distributed form of constraint-induced therapy group exhibited significantly greater improvements in the Fugl-Meyer Assessment and Motor Activity Log than the control intervention group. The functional magnetic resonance imaging data showed that distributed form of constraintinduced therapy significantly increased activation in the contralesional hemisphere during movement of the affected and unaffected hand. The control intervention group showed a decrease in primary sensorimotor cortex activation of the ipsilesional hemisphere during movement of the affected hand. Conclusions: The preliminary findings indicate that brain adaptation may be modulated by specific rehabilitation practices, although generalization of the functional magnetic resonance imaging findings is limited by sample size. Further research is needed to identify the specific neural correlates of the behavioral gains achieved after rehabilitation therapies.

Background and Purpose— This study investigated and compared the responsiveness and validity of the Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), and the Wolf Motor Function Test (WMFT) for patients after stroke rehabilitation. Methods— A total of 57 patients with stroke received 1 of 3 rehabilitation treatments for 3 weeks. At pretreatment and posttreatment, the 3 outcome measures, as well as the Functional Independence Measure (FIM) as the external criterion, were administered. The standardized response mean (SRM) and the Wilcoxon signed rank test were used to examine the responsiveness. Construct validity and predictive validity were examined by the Spearman correlation coefficient (ρ). Results— The responsiveness of the FMA, ARAT, and WMFT functional ability scores was large (SRM=0.95–1.42), whereas the WMFT performance time score was small (SRM=0.38). The responsiveness of the FMA was significantly larger than those of the ARAT and the WMFT-TIME, but not the WMFT functional ability scores. With respect to construct validity, correlations between the FMA and other measures were relatively high (ρ=0.42–0.76). The FMA and the WMFT performance time scores at pretreatment had moderate predictive validity with the FIM scores at posttreatment (ρ=0.42–0.47). In addition, the ARAT and the WMFT functional ability scores revealed a low predictive validity with the FIM (ρ=0.17–0.26). Conclusions— The results support the FMA and the WMFT-FAS are suitable to detect changes over time for patients after stroke rehabilitation. While simultaneously considering the responsiveness and validity attributes, the FMA may be a relatively sound measure of motor function for stroke patients based on our results. Further research based on a larger sample is needed to replicate the findings.

Carcinosarcoma of the esophagus is a rare malignant neoplasm. It often presents as a large intraluminal polypoid tumor with early onset of symptoms resulting in prompt diagnosis. We present here the first case of a carcinosarcoma of the esophagus that had a basaloid squamous cell carcinoma component in addition to the osteosarcoma and without a transitional zone. A 57-year-old man was diagnosed with a polypoid tumor in middle third of the esophagus causing dysphagia. Local recurrence and solitary pulmonary metastasis occurred 16 and 30 months after initial excision of the tumor, respectively. Prompt and aggressive surgical resection is mandatory for carcinosarcoma of the esophagus.

Experience collected from 5200 cases of laparoscopic cholecystectomy (LC) and 29 patients (6 ours, 23 referred) with major common bile duct (CBD) injury during LC in our institute between December 1990 and July 2004 was reported to demonstrate that the system approach we applied in performing LC prevents CBD injury and enhances surgical performance. Each case of CBD injury was meticulously analyzed to identify causative factors. We developed preventive strategies focusing on 4 dimensions: patient, environment, procedure, and operator. Surgical performance was then evaluated to demonstrate improvements. Incidence of CBD injury was calculated for early and latter halves of the series to compare 5 parameters of surgical performance: patient selection, operation time, indwelling drainage tube, surgeon, and conversion rate. Results of accident analysis demonstrated that CBD injury followed definite mechanisms; several warning signs appearing before and during injury were identified and classified. According to these results, we designed strategies to prevent injury, including: setting up patient-selection program, controlling surgical environment, developing error-proof procedures, and constructing training programs. Incidence of CBD injury in the whole series was 0.12% (6/5200), 0.27% in early half (6/2224), and zero (0/2967) in latter half. Attending doctors had significantly shorter operation times in latter period for both elective and emergent LC. Rate of using drainage tubes for elective surgery by attending doctors was significantly decreased in latter period. Operation time for elective surgery by residents was similar in both early and latter periods. However, residents in latter period had longer operation times (around 23 min long, P

To the Editors: In a recent article printed in the European Respiratory Journal , Infante et al. 1 validated a stepwise approach including oral antibiotics, follow-up computed tomography and computed tomography-guided biopsy for the differential diagnosis and management of focal pulmonary ground-glass opacities (GGOs). Although a retrospective study, their work provides critical information on discrimination and management of focal GGOs. However, some of the results in the article did not fully support their conclusions. One of the major conclusions in the study by Infante et al. 1 was that the stepwise approach increased the diagnostic specificity and reduced time to definitive diagnosis. They recommended response to antibiotic trial as the first management step. After a course of oral antibiotics, five (12.5%) patients with inflammatory lesions were ruled out. However, six patients in their study were evaluated with lesions retrospectively visible in earlier computed tomography scans and oral antibiotics were not given. Since the patients …