Prospective randomized comparison of cerebrospinal fluid aspiration and conventional popping methods using 27-gauge spinal needles in patients undergoing spinal anaesthesia.

BACKGROUND: Performing spinal anaesthesia using the conventional popping method with a 27-gauge (27G) spinal needle is technically difficult. In this study, we compared the aspiration and conventional popping method for spinal anaesthesia using 27G Quincke-type needles. METHODS: This prospective, randomized study enrolled 90 patients, aged 19 to 65 years, with American Society of Anesthesiologists physical status I-III, who were undergoing spinal anaesthesia. Patients were randomly assigned to one of two groups using a computer-generated random number table: patients receiving spinal anaesthesia using the aspiration method, in which the needle is advanced with continuous aspiration, or the conventional popping method. The primary outcome measure was the success rate of the first attempt to perform dural puncture. Number of attempts and passages, withdrawal cases, successful attempt time, total procedure time, and actual depth of dural puncture were recorded. RESULTS: Eighty-eight patients were included in the study. In the aspiration group, the success rate of first attempt for dural puncture was 93.3%, compared with 72.1% in the popping group (P = 0.019). Success involving needle withdrawal was recorded in 4 (8.9%) patients in the aspiration group and 13 (30.2%) in the popping group (P = 0.024). In the popping group, the number of attempts was significantly higher (P = 0.044), and total procedure time was significantly longer (P = 0.023). Actual depths of dural puncture were deeper in the popping group than in the aspiration group (P = 0.019). CONCLUSIONS: The aspiration method using a 27G Quincke-type needle offers clinical benefits for dural puncture compared with the conventional popping method for spinal anaesthesia. TRIAL REGISTRATION: Clinical research information service number: KCT0002815, registered 21/Apr/2018. Retrospectively registered.

Physical activity recognition based on rotated acceleration data using quaternion in sedentary behavior: a preliminary study.

This paper suggests a physical activity assessment method based on quaternion. To reduce user inconvenience, we measured the activity using a mobile device which is not put on fixed position. Recognized results were verified with various machine learning algorithms, such as neural network (multilayer perceptron), decision tree (J48), SVM (support vector machine) and naive bayes classifier. All algorithms have shown over 97% accuracy including decision tree (J48), which recognized the activity with 98.35% accuracy. As a result, physical activity assessment method based on rotated acceleration using quaternion can classify sedentary behavior with more accuracy without considering devices' position and orientation.

The relationships of social support, uncertainty, self-efficacy, and commitment to prenatal psychosocial adaptation.

AIMS: To report a study of the relations of prenatal psychosocial adaptation, social support, demographic and obstetric characteristics, uncertainty, information-seeking behaviour, motherhood normalization, self-efficacy, and commitment to pregnancy. BACKGROUND: Prenatal psychosocial assessment is recommended to identify psychosocial risk factors early to prevent psychiatric morbidities of mothers and children. However, knowledge on psychosocial adaptation and its explanatory variables is inconclusive. DESIGN: This study was non-experimental, with a cross-sectional, correlational, prospective design. METHODS: The study investigated Hong Kong Chinese women during late pregnancy. Convenience sampling methods were used, with 550 women recruited from the low-risk clinics of three public hospitals. Data was collected between January-April 2007. A self-reported questionnaire was used, consisting of a number of measurements derived from an integrated framework of the Life Transition Theory and Theory of Uncertainty in Illness. Explanatory variables of psychosocial adaptation were identified using a structural equation modelling programme. RESULTS: The four explanatory variables of the psychosocial adaptation were social support, uncertainty, self-efficacy, and commitment to pregnancy. In the established model, which had good fit indices, greater psychosocial adaptation was associated with higher social support, higher self-efficacy, higher commitment to pregnancy, and lower uncertainty. CONCLUSION: The findings give clinicians and midwives guidance in the aspects to focus on when providing psychosocial assessment in routine prenatal screening. Since there are insufficient reliable screening tools to assist that assessment, midwives should receive adequate training, and effective screening instruments have to be identified. The explanatory role of uncertainty found in this study should encourage inquiries into the relationship between uncertainty and psychosocial adaptation in pregnancy.

Effects of Hydrated Potato Starch on the Quality of Low-fat Ttoekgalbi (Korean Traditional Patty) Packaged in Modified Atmosphere Conditions during Storage.

This study was carried out to investigate the effects of hydrated potato starch on the quality of low-fat ttoekgalbi (Korean traditional patty) packaged in modified atmosphere conditions during storage. The ttoekgalbi was prepared from 53.2% lean beef, 13.9% lean pork, 9.3% pork fat, and 23.6% other ingredients. Two low-fat ttoekgalbi treatments were prepared by substituting pork fat with hydrated potato starch; either by 50% fat replacement (50% FR) or 100% fat replacement (100% FR). Both 50% and 100% FR increased the moisture, crude protein, and decreased fat content, cooking loss, and hardness. For MAP studies, 200 g of ttoekgalbi were placed on the tray and filled with gas composed of 70% O2: 30% CO2 (70% O2-MAP) and 30% CO2: 70% N2 (70% N2-MAP), and were stored at 5°C for 12 d. During the storage time, both 50% and 100% FR showed higher protein deterioration, while no differences were found in CIE a*, CIE L*, lipid oxidation, and bacterial counts in comparison to control. The ttoekgalbi with 70% O2-MAP was more red, lighter in color, and showed higher TBARS values compared with 70% N2-MAP. The meat with 70% N2-MAP showed lower aerobic bacterial counts in control than those with 70% O2-MAP. The lower anaerobic bacterial counts were observed only in 50% FR and 100% FR packed with 70% N2-MAP in comparison with 70% O2-MAP. In conclusion, the fat replacement with hydrated potato starch showed no negative effects on the quality of low fat ttoekgalbi during storage and 70% N2-MAP was better than 70% O2-MAP for low-fat ttoekgalbi packaging.

Neuregulin 3 does not confer risk for schizophrenia and smooth pursuit eye movement abnormality in a Korean population.

Located on chromosome 10q22-q23, the human neuregulin3 (NRG3) is considered to be a strong positional and functional candidate gene for schizophrenia pathogenesis. Several case-control studies examining the association of polymorphisms in NRG3 with schizophrenia and/or related traits such as delusion have been reported recently in cohorts of Han Chinese, Ashkenazi Jews, Australians and white Americans of Western European ancestry. Thus, this study aimed to comprehensively investigate the association of NRG3 genetic variations with the risk of schizophrenia and smooth pursuit eye movement (SPEM) abnormality in a Korean population. Using TaqMan assay, six single-nucleotide polymorphisms (SNPs) in the intronic region of NRG3 were genotyped and two major haplotypes were identified in 435 patients with schizophrenia as cases and 393 unrelated healthy individuals as controls. A total of 113 schizophrenia patients underwent an eye tracking task, and degree of SPEM abnormality was measured using the logarithmic values of the signal/noise (Ln S/N) ratio. Differences in frequency distributions were analyzed using logistic and regression models following various modes of genetic inheritance and controlling for age and sex as covariates. Subsequent analysis revealed that the frequency distributions of NRG3 polymorphisms and haplotypes were similar between schizophrenia patients and healthy controls of Korean ethnicity. Furthermore, no significant differences were observed between the genetic variants tested for SPEM abnormality. By elucidating a lack of association in a Korean population, findings from this study may contribute to the understanding of the genetic etiology focusing on the role of NRG3 in schizophrenia pathogenesis.

The value of dual-time-point 18F-FDG PET/CT for identifying axillary lymph node metastasis in breast cancer patients.

OBJECTIVE: The sensitivity of 18-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) for detecting axillary lymph node (ALN) metastases in breast cancer is reported to be low. Several studies have shown, however, that dual-time-point (18)F-FDG PET imaging provides improved accuracy in the diagnosis of certain primary tumours when compared with single-scan imaging. The purpose of this study was to assess whether the use of dual-time-point (18)F-FDG PET/CT scans could improve the diagnostic accuracy of ALN metastasis in breast cancer. METHOD: The study included 171 breast cancer patients who underwent pre-operative (18)F-FDG PET/CT scans at 2 time-points, the first at 1 h after radiotracer injection and the second 3 h after injection. Where (18)F-FDG uptake was in the ALN perceptibly increased, the maximum standardised uptake values for both time-points (SUVmax1 and SUVmax2) and the retention index (RI) were calculated. Correlation between the PET/CT results and post-operative histological results was assessed. RESULTS: The performance of 1 h and 3 h PET/CT scans was equal, with sensitivity 60.3% and specificity 84.7%, in detecting ALN metastasis. Out of 171 patients, 60 had ALNs with increased (18)F-FDG uptake on 1 h or 3 h images. There was no significant difference in RI between the metastatic ALN-positive group and the node-negative group. The area under the receiver operating characteristic (ROC) curve for SUVmax1 was 0.90 (p<0.001) and 0.87 for SUVmax2 (p<0.001). CONCLUSION: Dual time-point imaging did not improve the overall performance of (18)F-FDG PET/CT in detecting ALN metastasis in breast cancer patients.

A low sintering temperature and electrical performance of nanoparticle copper ink for use in ink-jet printing.

Copper nanoparticles were successfully synthesized from copper chloride with various capping agents. The formation of copper nanoparticles was controlled by varying the species and concentration of the capping agents. The Cu nanoparticles were easily re-dispersed into n-tetradecane, and Cu films were prepared by solution deposition. The thin Cu films form a highly conducting film at low temperature via sintering due to the high surface area to volume ratio. The films were thermally treated at a range of temperatures and then their morphology and resistivity were analyzed. When the Cu films were sintered at 200 degrees C, their electrical resistivity was about 40 microomega. cm.

Significance of incidental focal uptake in prostate on 18-fluoro-2-deoxyglucose positron emission tomography CT images.

To evaluate the clinical significance of incidental focal prostate fluorodeoxyglucose (FDG) uptake, we reviewed 18-F-FDG positron emission tomography (PET)/CT scans from 2003 to 2007 and selected cases with focal FDG uptake in prostate. Cases of known prostate cancer were excluded. The maximum standardised uptake value (SUV(max)), site (central or peripheral) and pattern (discrete or ill-defined) of FDG uptake, calcification (present or absent) and prostate volume (<30 or ≥30 cc) were recorded. The PET/CT findings were correlated with serum prostate-specific antigen (PSA) levels, imaging studies, clinical follow-up and biopsy. Of a total of 5119 cases, 63 (1.2%) demonstrated focal FDG uptake in prostate. Eight cases were lost to follow-up. Among the 55 cases with follow-up, malignancy was confirmed by biopsy in 3 (5.4%). The three malignant cases had SUV(max) values of 3.3, 3.6 and 2.3, and all were noted in the peripheral portion of prostate; two of these cases had a discrete FDG uptake pattern, none had calcification corresponding to the FDG uptake area and one had a prostatic volume greater than 30 cc. The mean SUV(max) of 52 benign cases was 3.2 ± 1.7 and focal FDG uptake was noted in the peripheral portion in 34 (65%), 20 (38%) cases showed a discrete FDG uptake pattern, 35 (67%) were accompanied by calcification and 32 (62%) had a prostatic volume greater than 30 cc. The majority of cases demonstrating focal FDG uptake in prostate were benign and no PET/CT finding could reliably differentiate benign from malignant lesions; however, when discrete focal FDG uptake without coincidental calcification is seen, particularly in the peripheral zone of the prostate, further clinical evaluation is recommended.

Student nurses' experiences and challenges in providing health education in Hong Kong.

Despite a call for increased emphasis on health education within the Hong Kong acute healthcare setting, in reality nurses conduct only minimal health education and do not model good educational practice for students. At the baccalaureate level, nursing education programmes aim to provide students with practical experience of best practice and international standards of care. This study describes the experiences of nursing students in providing health education to in-patients at an obstetric unit in Hong Kong. A qualitative research study using a phenomenological approach was conducted at a major public hospital. Data were collected using participant observation, debriefing notes, students' reflective journals and semi-structured interviews. Four themes emerged from the data: (a) effective knowledge building, (b) being a professional nurse, (c) refining learned skills, and (d) greater cultural awareness. The student experiences were further influenced by the patients' responses, the expectations of both patients and nurses concerning the health educator's role, and the role of the clinical teacher. Study findings highlight the experience of the students in conducting health education, something which has not been adequately examined previously, and demonstrates the benefits of independent clinical learning.

Life after unsuccessful IVF treatment in an assisted reproduction unit: a qualitative analysis of gains through loss among Chinese persons in Hong Kong.

BACKGROUND: Previous studies examining experiences of infertility focused mainly on the aspect of loss but neglected the possible gains realized through surviving the experience of infertility. The success rate of IVF remains relatively low, and we used the strengths perspective to examine adjustment after unsuccessful treatment. This study aims to provide an in-depth description of the gains perceived by Chinese men and women and how they re-constructed their lives after unsuccessful IVF treatment. METHODS: Four couples and another six women who experienced unsuccessful IVF treatment were recruited from an assisted reproduction clinic. Data were collected through in-depth interviews, using a grounded theory constructivist approach. RESULTS: Of the 10 women and 4 men interviewed, 9 remained childless, 3 had adopted a child and 2 had conceived naturally. They reported gains on a personal level, interpersonal level and transpersonal level through surviving the experience of infertility. All, regardless of the eventual outcome, reported at least one form of personal gain: in personality or knowledge gain. Interpersonal gains were perceived in relationships with their spouses, children, parents, friends, colleagues and fellow IVF service users. More than half of them reported spiritual growth and a change in identity through integrating their experiences and offering help to others. CONCLUSION: Despite the small sample size, this study makes a significant contribution by suggesting that while negative feelings provoked by the failure to conceive should be acknowledged, people in this situation should also be enabled to consolidate their negative experiences of IVF constructively, helping them to move on with their lives.

Cement based solidification/stabilization of arsenic-contaminated mine tailings.

Cement was used to solidify/stabilize the abandoned mine tailings contaminated primarily with arsenic (up to 88mg/kg) and lead (up to 35mg/kg). Solidified/stabilized (s/s) forms with a range of cement contents, 5-30wt%, were evaluated to determine the optimal binder content. Unconfined compression strength test (UCS), Korean standard leaching tests, toxicity characteristic leaching procedures (TCLP), and synthetic precipitation leaching procedure (SPLP) were used for physical and chemical characterization of the s/s forms. Addition of 5% cement was enough for the s/s forms to satisfy the UCS requirements (0.35MPa). The addition of 7.5% cement remarkably reduced the leachability of arsenic in tailings. However, that of lead tends to increase slightly with increase of cement content due to its amphoteric nature. The discussions were made for determination of optimal binder content and for results from different evaluation procedures.

Lymph node dissection around the splenic artery and hilum in advanced middle third gastric carcinoma.

AIM: To evaluate the clinicopathological factors influencing lymph node metastasis around the splenic artery and hilum and the effect of spleen-preserved lymphadenectomy in advanced middle third gastric carcinoma. METHODS: We retrospectively studied 131 patients with advanced middle third gastric carcinoma who had received D2 lymphadenectomy and lymph node dissection around the splenic artery and hilum, from 2000 to 2004. Of these patients, 62 simultaneously underwent splenectomy and 69 underwent spleen-preserved lymphadenectomy. RESULTS: The incidences of Nos. 10 and 11 lymph node metastases were 21% and 15%, respectively, in advanced middle third gastric carcinoma. A tumor size larger than 5 cm, metastases of Nos. 1 and 7-9 lymph node were independent risk factors for metastasis of No. 10 and/or No. 11 lymph node. The spleen-preserved group had a slightly better survival rate and a relatively lower rate of postoperative complications than the splenectomy group. No. 10 and/or No. 11 lymph node metastasis was an independent prognostic factor, while splenectomy was not. CONCLUSIONS: It is necessary to remove the lymph nodes around the splenic artery and hilum to achieve radical resection in advanced middle third gastric carcinoma patients with risk factors. Our results demonstrate that spleen-preserved lymphadenectomy is a good option for those patients.

Toxicity of repeated intravenous injection of gene therapeutics for X-CGD in mice.

We made gene therapeutics for X-chronic granulomatous disease (CGD) by transducing murine bone marrow-derived stem cells with MT-gp91 retrovirus and evaluated possible toxicity in mice as a prerequisite for human clinical trials. Male C57BL/6 mice were injected intravenously with gene therapeutics for X-CGD twice at an interval of two weeks at 5 x 10(7) cells/kg and sacrificed 2 weeks after the last administration. Significant changes noted in gene therapeutics for X-CGD-treated animals were an increase in white blood cell counts and a slight decrease in albumin/globulin ratio. The red pulp hyperplasia in the spleen accompanied with an increase in organ weight was considered to result from the accumulation of gene therapeutics for X-CGD, bone marrow-derived stem cells, in the spleen. No anti-gp91 antibody was detected in the sera collected from the animals treated with gene therapeutics for X-CGD. No integration of gp91 DNA from retroviral vector was detected in chromosomal DNA of gonads in animals dosed with the test substance, indicating no potential of genomic integration. In conclusion, the repeated dose of gene therapeutics for X-CGD exerted no toxicity. The splenic red pulp hyperplasia and the increase observed in white blood cell counts and in spleen weights were considered as pharmacological changes induced by the treatment.

Visceral adipose tissue as a predictor for metabolic risk factors in the Korean population.

AIMS: Visceral adipose tissue (VAT) accumulation is closely associated with an increased risk of cardiovascular disease. We have investigated the appropriate VAT cut-off values for predicting metabolic risk factors in the Korean population. METHODS: We assessed 276 men and 540 women aged 17-69 years who were undergoing regular health examinations. Anthropometry, metabolic risk factors and VAT area determined by computed tomography were measured. Receiver-operating characteristic (ROC) analysis was used to define VAT cut-off points for metabolic risk factors. RESULTS: Based on the first quintile of VAT, the odds ratios for having metabolic risk factors increased significantly with each VAT quintile in both men and women. Using ROC analysis, the appropriate VAT cut-offs for metabolic risk factors were 100 cm(2) in men and 70 cm(2) in women. Regression lines indicated that, in men, a VAT of 100 cm(2) corresponded to a waist circumference of 88.1 cm and a body mass index (BMI) of 24.9 kg/m(2); in women, a VAT of 70 cm(2) corresponded to a waist circumference of 84.0 cm and a BMI of 25.1 kg/m(2). CONCLUSION: VAT cut-offs of 100 cm(2) in men and 70 cm(2) in women are useful for defining visceral obesity in Korean subjects. These VAT cut-offs were validated by the ethnic-specific cut-offs for waist circumference and BMI for Korean individuals.

Primary clear cell sarcoma of bone.

Clear cell sarcoma is a rare soft tissue sarcoma of young adults with melanocytic differentiation. It occurs predominantly in the soft tissue of extremities, typically involving tendons and aponeuroses. Primary clear cell sarcoma of bone is extremely rare. We report a case of primary clear cell sarcoma of the right first metatarsal in a 48-year-old woman and provide a literature review of the entity.

Intraocular pressure measurement at the choroid surface: a feasibility study with implications for implantable microsystems.

AIMS: To demonstrate that a sensor, which is inserted through the sclera and placed in intimate contact with the choroid, can reliably detect changes in the intraocular pressure (IOP). METHODS: A manometer was used to control the IOP of three cadaver eyes in steps of 7 mm Hg. A piezoresistive pressure sensor was used to measure the pressure at the choroid through a 2.5 mm diameter hole that was surgically removed from the sclera. Data were collected for two configurations; with the sensor: (i) rigidly attached to a miniature positioning stage, and (ii) sutured to the sclera. RESULTS: Both configurations accurately tracked the manometer pressure from 10 mm Hg to 47 mm Hg. For the fixed sensor cases, the average difference between the pressure measured at the choroid and in the anterior chamber was 0.8 mm Hg for the three eyes. For the sutured sensor case, the average difference was 2.1 mm Hg-although a significant portion of this was attributed to an initial offset. The standard deviations at each pressure level for all of the choroid measurements were under 1.0 mm Hg. CONCLUSIONS: Small changes in IOP can be accurately measured by a sensor in contact with the surface of the choroid, for both a fixed sensor configuration and for a sensor sutured to the sclera. These results are the first step in the realisation of a surgically implantable microsensor to monitor IOP for patients suffering from low tension and other difficult to manage forms of glaucoma.

Fibrosarcoma in bizarre parosteal osteochondromatous proliferation.

Bizarre parosteal osteochondromatous proliferation (BPOP) is a rare benign lesion predominantly involving the small bones of the hands and feet. Malignant transformation in BPOP has not been documented in the English literature. This report presents the coexistence of fibrosarcoma with BPOP in the right distal fibula of an 18-year-old woman.

Validity of PSA, free/total PSA ratio and complexed/total PSA ratio measurements in men with acute urinary retention.

The reliability of serum prostate specific antigen (PSA) measurements in men with acute urinary retention is unclear. Total PSA, free and complexed PSA were measured, and the free/total (f/t) PSA and complexed/total (c/t) PSA ratios calculated, prior to catheterisation and at 48 and 72 h post-catheterisation in 39 men with acute retention. Subsequent histology showed 12 patients had prostate cancer and 27 benign prostatic hypertrophy. Serum free and total PSA fell following catheterisation, while complexed PSA rose during the first 48 h then subsequently fell. The f/t PSA and c/t PSA ratios provided the best discrimination at 48-72 h with 100% sensitivity and 75-82% specificity.Prostate Cancer and Prostatic Diseases (2001) 4, 167-172.

Clinicopathologic and genotypic study of extranodal nasal-type natural killer/T-cell lymphoma and natural killer precursor lymphoma among Koreans.

BACKGROUND: This study aimed to define genotypic profile and to describe the clinicopathologic features of nasal-type natural killer (NK)/T-cell lymphoma of nasal and extranasal origin and NK precursor lymphoma. METHODS: NK/T-cell lymphomas from the upper aerodigestive tract (n = 45), skin (n = 2), gastrointestinal tract (n = 3), and soft tissue (n = 2) and NK precursor neoplasms (n = 3) were studied. Immunophenotype was analyzed by immunohistochemistry and flow cytometry. In situ hybridization with EBER 1/2 RNA probes was performed. T-Cell Receptor (TCR)-gamma gene rearrangement was analyzed by seminested polymerase chain reaction with heteroduplex analysis. Overall survival rate was correlated with clinicopathologic parameters and compared by Wilcoxon test. RESULTS: Clonal TCR-gamma gene rearrangement was detected in 3 of 31 upper aerodigestive and 1 of 2 skin tumors. When immunostained using paraffin embedded tissue, 6 upper aerodigestive lymphomas were negative for CD56 in which 4 cases lacked clonal TCR gene rearrangement. Epstein-Barr virus (EBV) mRNA was detected in 33 upper aerodigestive tumors including 26 of 29 nasal tumors (90%), and 7 of 10 extranasal tumors (70%). There was no histologic, immunophenotypic, or genotypic differences according to the lineage and EBV association in upper aerodigestive lymphomas. Among the patients with upper aerodigestive tumors, overall 1-year survival rate was 41%, and correlated well with the stage (P < 0.05) but not with the size of tumor cells, EBV status, and lineage (P > 0.05). Median survival rate of lymphomas from other sites excluding upper aerodigestive tract was not significantly different from that of upper aerodigestive lymphomas with same stage (P > 0.05). Unlike nasal-type NK/T-cell lymphomas, NK precursor lymphoma involved the bone marrow and lymph nodes at initial presentation or in the course of disease. Tumor cells were positive for TdT in all and myeloid markers in two. TCR gene rearrangement was germ line. CONCLUSIONS: Most upper aerodigestive nasal-type NK/T-cell lymphomas among Koreans are genotypically of NK derivation and few belong to T lineage. Presence or absence of EBV has no significant correlation with the histologic changes and the lineage of these lymphomas.

Pneumocystis carinii pneumonia associated with a rapid reduction of cortisol level in a patient with ectopic ACTH syndrome treated by octreotide and ketoconazole.

A case is herein reported of pneumocystis carinii pneumonia in a 60-year-old female patient with ectopic production of ACTH at a position 2 cm superior to her right clavicle, revealed in an octreotide scan. Her extremely high plasma ACTH and cortisol levels (460 pg/ml and 80 microg/dl, respectively) were markedly decreased with the combined treatment of octreotide (300 microg/d) and ketoconazole (600 mg/d). As her serum cortisol concentration decreased, pneumocystis carinii pneumonia occurred on the third day of treatment. A secondary E. coli infection was superimposed and the patient died of disseminated intravascular coagulation and adult respiratory distress syndrome. This case suggests that primary prophylaxis for pneumocystis carinii infection should be initiated before cortisol lowering therapy, especially when the plasma cortisol concentration is excessively high, and that early adjunctive glucocorticoid therapy can reduce the acute mortality in patients with endogenous Cushing's syndrome and Pneumocystis carinii pneumonia. This case study would also like to point out that plasma ACTH and cortisol levels were decreased effectively by the combination of octreotide and ketoconazole in this instance of ectopic ACTH syndrome.