The effective dose assessment of C-arm CT in hepatic arterial embolisation therapy.

OBJECTIVE: To assess the effective dose of the liver C-arm computed tomography (CT) scan during hepatic arterial embolisation surgery with clinical dose-area product (DAP) data from Taiwan. METHODS: The experiment used two kinds of phantoms: RANDO® Man and RANDO Woman (The Phantom Laboratory, Salem, NY), embedded with thermoluminescent dosemeters at locations according to the International Commission on Radiological Protection 103 report. The conversion factors of DAP to effective doses for males and females, respectively, were obtained. The clinical DAP data of liver C-arm CT scan during hepatic arterial embolisation surgery were collected in a hospital in Taiwan. RESULTS: There were 125 liver transarterial embolisation therapy cases, including 94 males and 31 females, from February 2009 to June 2010. C-arm CT was used 38 times for males and 17 times for females. The corresponding average and standard deviation of clinical DAP were 61.0±6.6 Gy cm(2) and 52.2±8.3 Gy cm(2), respectively. CONCLUSION: The DAP of RANDO Man and RANDO Woman phantoms simply scanned by C-arm CT are much lower than that of patients. After consideration of the clinical DAP of patients, the effective doses of a liver C-arm CT scan recommended for males and females in Taiwan are 11.5±2.3 mSv and 11.3±3.0 mSv, respectively. ADVANCES IN KNOWLEDGE: The conversion factors of DAP to effective doses for males and females are 0.19±0.03 mSv Gy(-1) cm(-2) and 0.22±0.05 mSv Gy(-1) cm(-2). Only if the actual DAP value of a patient scan is multiplied by the conversion factor can the correct effective dose be determined.

WITHDRAWN: NaS1 sulfate transporter is linked to hyposulfatemia and longevity.

This article has been withdrawn at the request of the editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Negative regulation of the Wnt-beta-catenin pathway by the transcriptional repressor HBP1.

In certain cancers, constitutive Wnt signaling results from mutation in one or more pathway components. The result is the accumulation and nuclear localization of beta-catenin, which interacts with the lymphoid enhancer factor-1 (LEF)/T-cell factor (TCF) family of HMG-box transcription factors, which activate important growth regulatory genes, including cyclin D1 and c-myc. As exemplified by APC and axin, the negative regulation of beta-catenin is important for tumor suppression. Another potential mode of negative regulation is transcriptional repression of cyclin D1 and other Wnt target genes. In mammals, the transcriptional repressors in the Wnt pathway are not well defined. We have previously identified HBP1 as an HMG-box repressor and a cell cycle inhibitor. Here, we show that HBP1 is a repressor of the cyclin D1 gene and inhibits the Wnt signaling pathway. The inhibition of Wnt signaling and growth requires a common domain of HBP1. The apparent mechanism is an inhibition of TCF/LEF DNA binding through a physical interaction with HBP1. These data suggest that the suppression of Wnt signaling by HBP1 may be a mechanism to prevent inappropriate proliferation.

Patient-controlled analgesia with morphine plus lysine acetyl salicylate.

UNLABELLED: Using a patient-controlled analgesia (PCA) delivery system, we evaluated the clinical advantages and disadvantages of morphine PCA compared with morphine plus lysine acetyl salicylate (LAS), a soluble aspirin. After major orthopedic surgery, 50 adult patients were enrolled in a prospective, randomized, and double-blinded study. When a patient in the recovery room complained of pain, an initial dose of morphine or the morphine/LAS mixture was titrated to achieve analgesia of visual analog score < or = 3 in 30 min. An equivalent volume PCA dose of either morphine 1 mg/mL or morphine 0.5 mg + LAS 90 mg/mL was used with a lockout interval of 10 min. Pain score, patient satisfaction, vital signs, and adverse effects were observed for 48 h. Adequate analgesia (visual analog scale score < or = 3) was achieved with either drug. Morphine consumption in the morphine/LAS group was significantly less than in morphine group (13.9 vs 18.4 mg in 24 h and 24.3 vs 32.4 mg in 48 h). Significantly more sedation was evident with the morphine group (P < 0.05). We conclude that injectable LAS can be used as an effective and safe adjuvant to morphine for PCA. This combination reduces dose requirements of morphine and hence some of its adverse effects. IMPLICATIONS: Injectable aspirin could be used as an effective and safe adjuvant to morphine for patient-controlled analgesia. This combination reduces the dose requirement of morphine and therefore some of the morphine-related untoward effects.

Insufficiency fracture of acetabulum: a case report.

Most stress fractures of the hip joint occur on the femoral side. A review of the English literature showed that only eight cases of stress fracture of the acetabulum had been reported. Another insufficiency fracture of the acetabulum in an osteoporotic bone is reported.

Glomus tumors of the upper extremity: experience with twelve cases.

BACKGROUND: The glomus tumor is an uncommon tumor of the hand, which presents with much pain. It is a benign neoplasm composed of a glomus body, which is located in the dermis. Glomus tumors present a classic clinical picture of pain, sensitivity to cold and local tenderness over the lesion. METHODS: Twelve patients underwent surgical removal for glomus tumors of the upper extremity from 1983 to 1992. There were three males and nine females; their average age was 37 years (25 to 60 years). The clinical manifestations were pain and local tenderness in 12 patients, and cold intolerance in 6 patients. RESULTS: There was a difference in gender in the anatomical site of the tumor. In three male patients, only one tumor was found in the digit. In female patients, all nine tumors were located in the digits. The average tumor size was 0.6 cm in diameter. After follow-up of 4.5 years (average), no recurrence, no residual pain or cold intolerance was noted. CONCLUSIONS: The treatment of glomus tumor consisted of local excision or curettage, with or without reconstruction of the nail bed. Recurrence is not a problem after complete removal of the tumor tissue. Permanent nail deformity is still a problem. Efforts to prevent this sequelae are worth trying.

Treatment of femoral fracture with nonunion.

Thirty-four patients with femoral nonunion were managed by autogenous and/or allogenous bone graft alone, or internal fixation (including DCP or intramedullary nail) combined with bone graft, or external fixation in Taichung Veterans General hospital. Adequate follow-up study was obtained in 32 patients; two patients were unable to be contacted for follow-up. All 32 patients had received one or more operations. All but four patients showed clinical and radiological union, with an overall union rate 87.5%. Twenty-five patients (89.3%) returned to work, but half of these patients changed jobs. All twenty-eight patients with solid unions could walk, but eleven patients (39.3%) had a slight limp. Twenty-two patients (78.6%) could squat, and all patients could straighten their knees. Fourteen patients (50%) complained of occasional soreness over the operated area. In our limited experience, most femoral nonunions result from (1) inappropriate selection and usage of internal fixator, (2) severe stripping of soft tissue around the fracture site, or inappropriate usage of cerclage wire, and (3) infection. Treatment must depend on the causes and types of nonunion. In this study, a high union rate and good functional recovery were achieved with interlocking nails with or without autogenous bone graft. Plating would extend the time for union to take place, and even resulted in refracture of the plate by contact with the medial cortex when there was no medial buttress. In general, detailed planning before operation, skilled surgical techniques and aseptic procedures are essential in the prevention and treatment of nonunion.

Two to five year follow-up of Harris-Galante cementless total hip arthroplasty.

One hundred and forty-nine hips (125 patients) underwent cementless Harris-Galante primary total hip arthroplasty from September 1987 to June 1990 at the Taichung Veterans General Hospital. Seventy hips (61 patients) have been followed up for at least 2 years (range, 26-55 months, mean 36 months). The primary diagnoses included osteoarthritis (42.9%) and avascular necrosis (57.1%). All the hips were evaluated using Harris hip score and Mayo Clinic hip score. The average Harris hip score was 36.5 points (23-73) preoperatively, and 95 points (80-100) postoperatively. When evaluated by the Harris hip score, 94.3% were excellent, and 5.7% had good results; and 90% were excellent, 10% had good results when evaluated by Mayo Clinic hip score. No fair or poor results were noted by either evaluating system. Fifty-seven femoral components (81.4%) appeared to have stable bone ingrowth fixation, ten components (14.3%) had stable fibrous ingrowth, and three (4.3%) were unstable. Fifty-five hips (78.6%) showed radiolucent lines around the femoral component in follow-up roentgenogram; most were at the non-porous, fiber-mesh part. It seemed that there was no correlation between these radiolucent lines and clinical outcome, according to this short-term study.

Pigmented villonodular synovitis.

Seventy-three patients, 28 males and 45 females, diagnosed with pigmented villonodular synovitis (PVNS) between 1982 and 1990 were followed for an average of 42.2 months (range, 21 to 108 months). Fifty-five cases occurred in the tendon sheath and eighteen in synovial joint. Ages ranged from 5 to 77 years, with an average of 38.9 years. The clinical presentations included chronic tumescence, serosanguinous arthrocentesis and painful limitation of range of motion. Plain roentgenography usually demonstrated soft tissue swelling with varying density, bony erosion or joint space narrowing. Arthrography and magnetic resonance imaging both gave specific pictures, with good diagnostic rates. The therapeutic regimen consisted of marginal excision for tendon sheath lesions and total synovectomy for intraarticular lesions. Extensive synovectomy with prosthesis replacement yielded good functional results in elderly patients with PVNS and cartilage destruction. Recurrence rate averaged 26% and was higher among knee joint lesions (33%), possibly because of inaccessibility of the popliteal fossa and inadequate excision of the lesion. Differences in the mitotic index between recurrence and non-recurrence groups had no statistical significance. This phenomenon may well serve against "tumor origin" as the etiology of this disease.

[Treatment of proximal humeral tumor: a case report].

In management of malignancy of the proximal humerus, amputation or a complete flail limb both give poor functional results. The limb-salvage procedure with joint reconstruction preserves function in the elbow and hand, thereby improving the quality of remaining life for patient. Prosthetic humeral replacement may avert amputation and preserve a functional arm, but neither segmental modular proximal humeral prosthesis nor custom-made prosthesis is readily available here. Combining the Neer II shoulder prosthesis and Kuntscher's nail with acrylic cement can replace the proximal humerus with an adjustable length of stem within the humeral shaft. A piece of mesh is incorporated into the prosthesis, placed around the neck of the Neer II shoulder prosthesis, and sutured to the rotator cuff to prevent subluxation of the humeral head and preserve some function of the rotator cuff. The above prosthetic humeral replacement has been applied to one patient with a primary osteosarcoma. It preserved the function of the elbow and hand well. One year post-operatively, there was no dislocation or subluxation. Details of procedures used are given.

[Primary amyloidoma of the spine].

Amyloidosis involving the musculoskeletal system is an uncommon occurrence. The primary form is rare and only six cases involving the spine have been reported in the literature. The following case is believed to be the first reported in Taiwan. A 65-year-old male was admitted due to chronic nonspecific pain in the lower back with progressive paralysis of the lower limbs. Amyloidoma involving both thoracic and lumbar spine, never reported in the literature, was proved by histologic and histochemical studies. Serial radiographic examinations were also presented. Anterior decompression of the thoracic spine with iliac crest strut bone graft and Kaneda device fixation achieved good functional results. The symptoms and signs of spinal amyloidoma are nonspecific and difficult to diagnose; hence a correct diagnosis requires the surgeon to be extremely suspicious. A special histochemical stain is essential for this purpose. Because of the rarity, we report this case with review of the literature.

[Second hip fracture].

During the period from 1982-1990, a total of 1644 patients were admitted to our hospital with proximal femoral fractures. Trochanteric fractures were encountered in 54 per cent of the cases (887/1644) with a mean age of 68 years. Cervical fractures were encountered in 46 per cent of the cases (757/1644) with a mean age of 62 years. We found 28 patients who had been readmitted with a second hip fracture in this retrospective study, including twenty three males and five females. Two of these second hip fractures occurred on the same side as the initial fracture and twenty six occurred on the opposite side. The time interval between the first and the second hip fracture was shorter in males than that in females (1.7 years V.S. 2.7 years) and the interval also was shorter in those with a previous trochanteric fracture as compared to those with a previous cervical fracture (1.5 years V.S. 2.6 years). It appeared that a hip fracture reduced the risk of a subsequent hip fracture on the same side, and almost all second hip fractures were located on the opposite side of the patient (93 per cent). A possible reason for this "protective mechanism" is increased strength of the bone due to callus formation. A significant symmetry (trochanteric-trochanteric or cervical-cervical) was found between the first and the second hip fractures (69 per cent). We believe the symmetrical fracture pattern is due to senile osteoporosis, a kind of ongoing systemic weakening of the skeletal system among the elderly.

[Tardy ulnar palsy treated by anterior subcutaneous transposition].

Twenty cases of tardy ulnar palsy were treated by anterior subcutaneous transposition in the past 6 years at the Veterans General Hospital-Taichung. These cases were followed up for at least 9 months after operation. Mean duration of follow up was 39.5 months. Age distribution was from 40y/o to 72y/o, mean age was 54.5y/o. Duration of symptoms was from 2 months to 72 months, mean was 20.3 months. Eight cases were attributed to the idiopathic type. 16 cases (80%) improved after operation. Four factors were analyzed to evaluate their status as a prognostic guide: age, duration of syndrome, severity before operation and precipitating factors. Only severity before operation correlated with prognosis, but good recovery can be achieved in severe cases. Anterior subcutaneous transposition is a good method for treating tardy ulnar palsy.