Intracranial mesenchymal tumor with multiple extracranial metastases: A case report and literature review.

This study presents a rare case of an older woman with an intracranial mesenchymal tumor in the right frontal and parietal lobes. Despite prompt surgical intervention, her condition rapidly deteriorated because of tumor dissemination, leading to her demise. We highlight the tumor's marked invasiveness and heterogeneity, coupled with a propensity for distant systemic metastasis, which negatively impacted the patient's prognosis. This particular clinical behavior had not been previously reported, making this a novel observation. Thus, through a comprehensive review of relevant literature, we aim to provide valuable insights for further understanding, diagnosing, and treating such tumors.

Interactive Game-Based Platform System for Assessing and Improving Posture Control in the Elderly.

Inadequate response to balance perturbations lead to posture instability in the elderly. The fall risks are increased by a reduced capacity to control the center of pressure (COP) displacement within the safety limit of the supporting base. This study developed an interactive evaluation and training platform. The system incorporated a computerized program with instantaneous force plate evaluation. Ten young subjects underwent a baseline evaluation and twenty-nine community-dwelling elderly received pre- and post-intervention testing. The ability to reach the stability limit was assessed by measuring the maximum voluntary excursion of the COP in anterior-posterior and medial-lateral directions. Functional mobility tests including Berg Balance Scale, Timed-Up-and-Go and functional reach were used as functional outcomes. The experimental group (n = 15) received a 40 min intervention three times a week for six weeks. The interactive game-based training focused on multi-directional weight shifting by tracing a COPcontrolled target to challenge an individual's stability limit. The control group (n = 14) maintained daily activities as usual. The young group revealed a superior COP displacement through active ankle control than the elderly, especially in the anterior-posterior direction. The experimental group improved their COP displacement control more in the medial-lateral direction due to the predominant side-to-side gameplay movement. The functional outcome measures were also significantly improved after training. Using the COPcontrolled game-based program, the stability limit was challenged to facilitate dynamic posture control by an incremental increase in self-initiated perturbations. The platform system could assist in transferring the immediate training effects into daily functional mobility in the elderly.

Microvascular reactivity using laser Doppler measurement in type 2 diabetes with subclinical atherosclerosis.

Microangiopathy should be noted in diabetes with subclinical vascular diseases. Little is known about whether various surrogate markers of systemic arterial trees exacerbate simultaneously in preclinical atherosclerosis. To clarify the association of skin microvascular reactivity with arterial stiffness is essential to elucidating early atherosclerotic changes. The post-occlusive reactive hyperemia of skin microcirculation was evaluated in 27 control and 65 type 2 diabetic subjects, including 31 microalbuminuria (MAU) and 34 normoalbuminuria (NAU) patients. The laser Doppler skin perfusion signals were transformed into three frequency intervals for the investigation of endothelial, neurogenic, and myogenic effects on basal and reactive flow motion changes. The analysis of spectral intensity and distribution provided insight into potential significance of microvascular regulation in subclinical atherosclerotic diseases. Systemic arterial stiffness was studied by the brachial ankle pulse wave velocity (baPWV). Following occlusive ischemia, the percent change of endothelial flow motion was lower in MAU than in NAU and control groups. The MAU group revealed a relative increase in myogenic activity and a decrease in endothelial activity in normalized spectra. The baPWV showed more significant associations with reactive endothelial change (r = - 0.48, P < 0.01) and normalized myogenic value (r = - 0.37, P < 0.05) than diabetes duration and HbA1c. By multivariate regression analysis, only endothelial vasomotor changes independently contributed to the decreased baPWV (OR 3.47, 95% CI 1.63-7.42, P < 0.05). Impaired microcirculatory control is associated with increased arterial stiffness in preclinical atherosclerosis. To identify the early manifestations is necessary for at-risk patients to prevent from further vascular damage.

Functional Assessment of 3D-Printed Multifunction Assistive Hand Device for Chronic Stroke Patients.

Patients with chronic stroke often have difficulty opening their hands and performing grasping movements. Several passive hand orthoses for assisting hand rehabilitation have been developed and demonstrated to be clinically effective. However, current devices have several limitations, such as supporting only a single grasping motion and using an abnormal grasping posture. Therefore, this study developed a three-dimensional (3D)-printed multifunctional hand device (3DP-MFHD) to solve these problems and evaluated the feasibility of using the device during home rehabilitation. Six participants were enrolled, and each of them was provided with the 3DP-MFHD. In addition to a task-oriented training course, the participants were asked to train at home for 4 weeks for at least 5 days per week and 40 min per day. The results revealed that hand grip force increased by 36.1%, lateral pinch force increased by 17.6%, and the Action Research Arm Test score increased by 54.1%. The 3DP-MFHD is a promising means to facilitate hand rehabilitation and improve hand strength and function in patients with chronic stroke. The 3DP-MFHD can be used as part of home rehabilitation.

A Novel Anastomosis Technique for Laparoscopic Pancreaticoduodenectomy: Case Series of Our Center's Experience.

Background: Laparoscopic pancreaticoduodenectomy has developed rapidly in recent years. Postoperative pancreatic fistula is still the most dangerous complication of laparoscopic pancreaticoduodenectomy. Baumgart pancreaticojejunostomy is considered one of the safest anastomosis procedures, with low rates of pancreatic fistula. We modified Blumgart pancreaticojejunostomy and applied the modified procedure during laparoscopic pancreaticoduodenectomy. The modified procedure entailed a longitudinal U-shaped suture through the pancreas for anastomosis of the pancreatic duct and the jejunal mucosa. Methods: We prospectively collected and retrospectively analyzed the data of 120 patients who underwent laparoscopic pancreaticoduodenectomy from January 2016. The total operative time, time for complete pancreaticojejunostomy, postoperative pancreatic fistula rate, postoperative delayed gastric emptying, postoperative bleeding, postoperative length of hospital stays, and mortality within 90 days after surgery were analyzed. An analysis of laparoscopic pancreaticojejunostomy compared with open pancreaticojejunostomy is also reported. Results: In the laparoscopic pancreaticojejunostomy group, the average total operative time, the average time for complete pancreaticojejunostomy, and the average intraoperative blood loss were 271 min, 35.3 min, and 184 ml, respectively. The total postoperative clinically relevant pancreatic fistula rate was 9.2% (Grade B and C fistulas). The incidence rates of postoperative delayed gastric emptying and postoperative biliary fistula were ~2.5 and 1.7%, respectively. The postoperative bleeding rate was 0.83%, and the average postoperative indwelling time of the abdominal drainage tube was 7.3 days. The postoperative length of hospital stay was 10.8 days, and the mortality rate within 90 days after surgery was 0.83%. The rates of clinically relevant postoperative clinically relevant pancreatic fistula are comparable between laparoscopic and open surgery, there were no other severe postoperative complications in either group. The mean postoperative length of hospital stay was significantly shorter in the laparoscopic pancreaticojejunostomy group. Conclusion: The modified laparoscopic-adapted Blumgart anastomosis simplifies and facilitates the creation of the pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy. The rates of clinically relevant postoperative pancreatic fistula are comparable with those obtained by open surgery, and length of stay are shoter.

Biomechanical Evaluation and Strength Test of 3D-Printed Foot Orthoses.

Foot orthoses (FOs) are commonly used as interventions for individuals with flatfoot. Advances in technologies such as three-dimensional (3D) scanning and 3D printing have facilitated the fabrication of custom FOs. However, few studies have been conducted on the mechanical properties and biomechanical effects of 3D-printed FOs. The purposes of this study were to evaluate the mechanical properties of 3D-printed FOs and determine their biomechanical effects in individuals with flexible flatfoot. During mechanical testing, a total of 18 FO samples with three orientations (0°, 45°, and 90°) were fabricated and tested. The maximum compressive load and stiffness were calculated. During a motion capture experiment, 12 individuals with flatfoot were enrolled, and the 3D-printed FOs were used as interventions. Kinematic and kinetic data were collected during walking by using an optical motion capture system. A one-way analysis of variance was performed to compare the mechanical parameters among the three build orientations. A paired t-test was conducted to compare the biomechanical variables under two conditions: walking in standard shoes (Shoe) and walking in shoes embedded with FOs (Shoe+FO). The results indicated that the 45° build orientation produced the strongest FOs. In addition, the maximum ankle evertor and external rotator moments under the Shoe+FO condition were significantly reduced by 35% and 16%, respectively, but the maximum ankle plantar flexor moments increased by 3%, compared with the Shoe condition. No significant difference in ground reaction force was observed between the two conditions. This study demonstrated that 3D-printed FOs could alter the ankle joint moments during gait.

Biomechanical Evaluation of Three-Dimensional Printed Dynamic Hand Device for Patients With Chronic Stroke.

Provision of adequate task-oriented training can be difficult for stroke survivors with limited hand movement. The current passive devices are mainly intended for gross grasp and release training. Additional assistive devices are required to improve functional opposition. This paper investigated the functional recovery of chronic stroke patients after using a three-dimensional (3D) printed dynamic hand device (3D-DHD) as an adjunct to conducting a task-oriented approach (TOA). Ten participants were randomly assigned to either the 3D-DHD group (n = 5) or the control group (n = 5). The TOA was used for the 3D-DHD group by using the 3D-DHD twice a week for four weeks, followed by a two-week home program. Only the TOA was used for the control group. The outcome measures, including the box and blocks test (BBT) of manual dexterity and prehensile strength, were conducted at baseline and at follow-up at four and six weeks later. The 3D-DHD group exhibited significantly superior improvements to the control group in the BBT and the palmar pinch force test. Both the groups had significant within-group improvements in the BBT and in all strength measures compared with baseline measurements. The use of 3D-DHD could position stroke-affected hands in coordinated functional opposition and had the potential to facilitate manual dexterity and advanced prehensile movement.

Segmental zoster abdominal paresis mimicking an abdominal hernia: A case report and literature review.

RATIONALE: Herpes zoster infection typically involves the posterior root ganglia and most of the symptoms are sensory. Motor involvement can occur in the same distribution but is relatively uncommon. Segmental zoster paresis is a rare motor complication of Herpes zoster, mimicking an abdominal hernia, but it needs no surgery different from the real abdominal wall hernia. PATIENT CONCERNS: We present a case of a 58-year-old man with an abdominal protrusion and characteristical herpes zoster rash. DIAGNOSES: Initially, the surgeon regarded it as an abdominal hernia, while ultrasonography excluded the abdominal wall defect, and then the dermatologist diagnosed it as segmental herpes zoster abdominal paralysis. INTERVENTIONS: He received a treatment with oral acyclovir, mecobalamin, and vitamin B1. OUTCOMES: The abdominal wall bulge disappeared after 2 months, avoiding unnecessary surgery. LESSONS: Segmental zoster abdominal paresis, mimicking an abdominal hernia needs no surgery.

Large Aggressive Angiomyxoma of the Liver: A Case Report and Brief Review of the Literature.

Aggressive angiomyxoma (AAM) is an uncommon mesenchymal myxoid tumor that almost solely involves the soft tissues of the perineum and pelvis. An AAM originating from the liver is extremely rare. Herein, we present a case of a 45-year-old female with a large mass in the left lateral lobe of the liver. She underwent a left lateral lobe hepatectomy. The histopathology of the resected specimen showed features that were characteristic of AAM. Immunohistochemical analysis of the neoplastic cells showed reactions to antibodies against CD34, smooth muscle actin (SMA), and Ki67 (2%) and showed no reactions to antibodies against Estrogen receptor (ER), C-keratin (CK), and Desmin. The patient was subsequently diagnosed with a primary AAM of the liver. This is the largest AAM of the liver that has been reported. We hereby report these findings and review the current literature.

Isolated pancreatic tuberculosis with elevated CA 19-9 levels masquerading as a malignancy: A rare case report and literature review.

RATIONALE: Primary pancreatic tuberculosis is extremely rare, it presents with non-specific clinical symptoms and imaging features; it may be falsely identified as a malignancy of the pancreas. PATIENT CONCERNS: A 41-year-old male with no history of tuberculosis presented to our hospital with a 2-week history of jaundice. DIAGNOSES: Abdominal computed tomography (CT) showed a heterogeneous irregular hypodense mass in the head of the pancreas causing dilatation of the common bile duct (CBD), and it was enhanced after infusion of contrast material. Serum cancer antigen (CA) 19-9 was 124 U/mL (normal: 0-40 U/mL). He was preoperatively diagnosed as having a pancreatic carcinoma. INTERVENTIONS: A Whipple procedure (pancreaticoduodenectomy) was performed. The pancreatic tuberculosis was confirmed based on the postoperative histopathologic specimens and acid-fast stain of the drainage. Then isoniazid, rifampicin, and ethambutol were given for 6 months. OUTCOMES: The patient recovered very well. There was no evidence of tuberculosis recurrence, and the patient remained free of symptoms during the follow-up examination 1 year after surgery. LESSONS: Pancreatic tuberculosis should be considered when the mass is located on the head of the pancreas even with elevated serum CA19-9 levels.

Primary clear cell adenocarcinoma of the pancreas: a case report and literature update.

Primary clear cell carcinoma of pancreas is extremely rare. We present a case of a 64-year-old male with a mass in the distal body and tail of the pancreas. He underwent a distal pancreatectomy. The histopathology of tumor cells showed features with abundant clear cytoplasm and prominent cell boundaries. Immunohistochemical analysis of neoplastic cells showed reactions to antibodies against cytokeratin-7 and showed no reactions to antibodies against hepatocyte nuclear factor-1ß, carbonic anhydrase 9, synaptophysin, and chromogranin A. The patient was subsequently diagnosed with a primary clear cell carcinoma of the pancreas. This is the first time we have encountered it. We report this rare case and update the current literature of this tumor.

High-Dose Static and Dynamic Intensity-Modulated Radiotherapy Combined with Chemotherapy for Patients with Locally Advanced Nasopharyngeal Carcinoma Improves Survival and Reduces Brainstem Toxicity.

BACKGROUND Intensity-modulated radiotherapy (IMRT) is the standard treatment for patients with nasopharyngeal cancer (NPC). However, the dose-volume criteria for adjacent anatomically normal organs at risk (OARs) remain controversial. The aim of this study was to evaluate the effects of higher than conventional doses of static and dynamic IMRT on the locoregional control of NPC, patient survival, and brainstem radiation toxicity. MATERIAL AND METHODS Patients (n=186) with stage III and stage IVa NPC underwent high-dose static and dynamic IMRT treatment (68-76.96 Gy) with or without chemotherapy for 34-57 days. Overall survival (OS), the presence of distant metastases, and brainstem toxicity were assessed. One-year, three-year, and five-year follow-up was performed. RESULTS High-dose IMRT alone or in combination with chemotherapy resulted in a 100% objective response rate and significantly improved OS rates, with one-year, three-year, and five-year OS rates of 94.1%, 89.8%, and 88.2%, respectively. The local recurrence rate (17.6%), and distant metastasis to the lung, liver, and bone (17.2%), and mortality (n=22) were reduced. Chemotherapy was the only factor that was significantly correlated with patient survival. Brainstem toxicity was reduced in patients treated with static IMRT (0.07%) and dynamic IMRT (0.08%). There were 26 additional factors that were not found to significantly affect brainstem toxicity. CONCLUSIONS High-dose static or dynamic IMRT combined with chemotherapy improved survival and reduces distal metastasis with a very low occurrence of brainstem toxicity in patients with locally advanced NPC. These findings might provide therapeutic guidance for clinicians when planning optimal dose-volume IMRT parameters.

New insight into the fouling behavior of hydrophobic and hydrophilic polypropylene membranes in integrated membrane bioreactors.

To investigate the effect of hydrophobic and hydrophilic polypropylene hollow fiber membranes (PPHFMs) applied in membrane bioreactors (MBR), the fouling behaviors of membrane surfaces and pores have been tested. The structural and morphological features on the membrane surface were characterized using attenuated total reflection-Fourier transform infrared spectroscopy, field emission scanning electron microscopy, atomic force microscope, energy dispersive X-ray spectroscopy and laser granularity distribution analysis. The results showed that significantly more polysaccharide, protein and inorganic ingredients were accumulated in the original membrane compared to the hydrophilic membrane. Furthermore, it was found that the pore size influenced the particle distribution and accumulation, such that smaller pore size membranes tended to contain fewer pollutants and a narrow size distribution. Under a constant flux of 11.5 L/m2 h, the transmembrane pressure (TMP) varied narrowly between 38 and 53 KPa. Alongside this, a relatively hydrophilic membrane (PP-g-AA) showed the characteristics of lower TMP in comparison to hydrophobic membranes (PP). Indeed, the flux recovery was 30% higher than those of the original PPHFM. This investigation broadens our understanding of membrane modifying and fouling behavior in integrated MBRs.

Microcirculatory vasomotor changes are associated with severity of peripheral neuropathy in patients with type 2 diabetes.

Systemic microvascular complications are related to the presence of diabetic neuropathy. This study investigated the associations of blood flow oscillations with peripheral neuropathy in 25 controls and 3 diabetic groups including clinical (24), subclinical (27) and without neuropathy (26). Laser Doppler skin perfusion was transformed into three low-frequency subintervals corresponding to endothelial, neurogenic and myogenic vasomotor controls. The average vasomotion was significantly reduced in clinical neuropathy group and characterized by endothelial and neural but not smooth muscle-related changes. The normalized spectrums revealed a relative increase of myogenic and decrease of neurogenic activity in subclinical neuropathy group. The myogenic component showed a statistically inverse correlation with postural fall in systolic blood pressure (r = -0.32, p < 0.01). The diabetic patients with decreased low-frequency vasomotor responses were associated with increased odds ratio of peripheral neuropathy [odds ratio = 3.51 (95% confidence interval = 1.19-10.31), p = 0.02]. This study elucidated possible interaction between impaired microvascular flow motion and diabetic peripheral neuropathy. The vasomotor changes of skin microcirculation could be detected even in the absence of overt cardiovascular dysfunction.

Prevalence of maternal group B streptococcus colonization and vertical transmission in low-risk women in a single institute.

BACKGROUND: Intrapartum administration of antibiotics lowers the risk of neonatal group B streptococcus (GBS) infection based on recommended guidelines (a risk-based approach and a culture-based screening approach). However, many pregnant women do not undergo culture-based screening, nor treatment with prophylactic antibiotics after a GBS risk-based approach. Therefore, the value of GBS detection in asymptomatic low-risk pregnant women is controversial. METHODS: A cohort study of 354 asymptomatic pregnant women at more than 37 weeks' gestation who were planning to undergo vaginal delivery, and 118 neonates (107 paired samples of both mother and newborn), was conducted to evaluate the GBS colonization rate of these pregnant women and the subsequent vertical transmission rate, using a culture method. RESULTS: The positive rate for GBS culture was 6.2% (22/354). Among 107 paired samples, six maternal samples and one neonatal sample were positive for GBS culture, with an estimated vertical transmission rate of 16.7% (1/6). CONCLUSION: Although the positive rate of GBS culture was lower in asymptomatic low-risk pregnant women, the possibility of vertical transmission might be high. This finding is worthy of further investigation.

Biomechanical analysis of foot with different foot arch heights: a finite element analysis.

Clinically, different foot arch heights are associated with different tissue injuries to the foot. To investigate the possible factors contributing to the difference in foot arch heights, previous studies have mostly measured foot pressure in either low-arched or high-arched feet. However, little information exists on stress variation inside the foot with different arch heights. Therefore, this study aimed to implement the finite element (FE) method to analyse the influence of different foot arches. This study established a 3D foot FE model using software ANSYS 11.0. After validating the FE model, this study created low-arched, high-arched and normal-arched foot FE models. The FE analysis found that both the stress and strain on the plantar fascia and metatarsal were higher in the high-arched foot, whereas the stress and strain on the calcaneous, navicular and cuboid were higher in low-arched foot. Additionally, forefoot pressure was increased with an increase in arch height.

Impaired microvascular flow motion in subclinical diabetic feet with sudomotor dysfunction.

Impaired cutaneous blood flow and sweating dysfunction might be among the earliest manifestations of diabetic autonomic neuropathy. This study assessed the pathophysiological basis underlying skin vasomotion changes and their relation with progressive sudomotor dysfunction and other autonomic and somatic measures in subclinical diabetic feet. Laser Doppler skin perfusion was assessed on 68 diabetic and 25 control subjects. The low-frequency vasomotion was transformed into three frequency intervals 0.0095-0.021, 0.021-0.052 and 0.052-0.145 Hz, respectively, for the investigation of endothelial, neurogenic and myogenic effects on microcirculatory alterations. The diabetic patients were categorized into three groups by increasing severity of sudomotor dysfunction: SSR+ (sympathetic skin response present; 27 patients), SSR- (SSR absent; 23 patients) and at-risk (SSR absent and of preulcerative cracked skin; 18 patients). All diabetic patients underwent nerve conduction and cardiovascular autonomic studies. The total spectral and endothelial activity was significantly decreased only in the at-risk group. The SSR- group had lower neurogenic vasomotion than the SSR+ group (p<0.05). Although no statistical difference was noted between any group in absolute myogenic spectrum, the SSR- group had higher normalized myogenic activity than the SSR+ group (p<0.01). The larger drop in orthostatic pressure was paralleled by a reduction in the myogenic amplitude (r=-0.33, p<0.01). These results suggested that early impairment of low-frequency flow motion correlated closely with the presence of sudomotor dysfunction of subclinical feet mainly in neurogenic and endothelial components. Impaired systemic vascular tone as manifested by orthostatic hypotension was proportional to the degree of myogenic dysregulation in diabetic patients.

Production of reactive oxygen species and induction of signaling pathways for the ACO gene expressions in tomato plants triggered by the volatile organic compound ether.

Diethyl ether (ether), a volatile organic compound, is widely used as an industrial solvent and easily released to the environment. Acute exposure of tomato plants to high concentrations of ether caused young leaves to curl. Histochemical analyses revealed that superoxide anion (•O(2-) and hydrogen peroxide were formed sequentially by ether, and that (•O(2-) was the major ROS produced in response to ether exposure. We observed cell death by microscopic inspection of Evans blue-stained samples, following fumigation with ether for 6 h. The ethylene biosynthetic gene, 1-aminocyclopropane-1-carboxylic acid oxidase (ACO), was induced as early as 15-30 min after ether fumigation and could be activated at ether concentration as low as 1 µL/L. Induction of ACO gene expression occurred simultaneously with ROS accumulation and coincided with the occurrence of cell death. Simultaneous treatment of tomato plants with mechanical wounding and ether induced differential expression of the ACO gene family. Ether strongly induced ACO4 and moderately induced ACO1, whereas mechanical wounding strongly induced ACO1 and slightly induced ACO4. Induction of the ACO gene family by ether occurred via different signaling pathways. While the ACO1 gene was induced via protein phosphorylation, the ACO4 gene was induced through protein dephosphorylation. Induction of ACO1 and ACO4 might be through MPK1, MPK2, MPK3, and PP2Ac1. These results suggest that the cellular responses of tomato plants to ether are different from the plant responses to ozone, and that tomato plants respond to different air pollutants through different perceptions and downstream signaling pathways.

Improving preventive foot care for diabetic patients participating in group education.

BACKGROUND: Diabetic foot care has yet to be enhanced in a universal health-care system in which specialized podiatric medical services are unavailable. This baseline assessment surveyed diabetic patients attending group education to improve current foot-care practices. METHODS: Of 302 diabetic patients receiving usual outpatient care, 155 received group patient education on general diabetes-related information, which included foot care and an annual checkup by a diabetes association during the previous 2 years, and 147 did not. Patient foot-care behaviors, physician practice patterns, and patient self-perceived foot risk as cross-checked with the neurologic and vascular assessments were investigated by conducting retrospective medical record reviews and structured interviews. RESULTS: More than half of the patients in both groups reported inappropriate self-care behaviors (eg, walking barefoot and heating or soaking their feet). The percentages of patients receiving documented examinations and referrals for foot problems were low in both groups and were not significantly different. Among at-risk patients, 56% of the diabetes association group but only 30% of the non-diabetes association group perceived themselves to be at risk for future foot problems (P<.01). CONCLUSIONS: Many diabetic patients were not offered adequate foot-specific information during group lectures, even those with high-risk foot problems. To improve this, combining caregiver and patient education in foot-care practices is important, and systems of networked multidisciplinary professionals are believed to be needed, particularly in delivering customized interventions to at-risk patients based on the initial evaluation.

An enzyme-linked immunometric assay for cortisol based on idiotype-anti-idiotype reactions.

Cortisol levels in body fluids are useful for monitoring the function of the pituitary-adrenal axis. Here, we established an "enzyme-linked immunometric assay" (a noncompetitive-type ELISA) for cortisol based on idiotype-anti-idiotype reactions. Six different anti-idiotype monoclonal antibodies that recognized the variable regions of a newly established anti-cortisol antibody were generated using hybridoma technology; these were two beta-type and four alpha-type anti-idiotype antibodies, recognizing the paratope and framework regions, respectively. An immunometric assay was established using a combination of a selected alpha-type and a selected beta-type antibody. The analyte (cortisol) was captured by an excess amount of anti-cortisol antibody immobilized on microplates, and the unoccupied paratope was saturated with the beta-type antibody. Hapten-occupied anti-cortisol antibody, with less steric hindrance, was then selectively bound by the alpha-type antibody, labeled with biotin. The amount of biotin residue on the microplates was colorimetrically monitored using a peroxidase-labeled streptavidin. This assay had an approximately threefold higher sensitivity (detection limit: 90 pg = 248 fmol cortisol) than a competitive ELISA using the same anti-cortisol antibody, as well as a practical specificity for providing reasonable determination of normal urinary cortisol levels.