Acupuncture versus topiramate in chronic migraine prophylaxis: a randomized clinical trial.

BACKGROUND: The aim of this study was to investigate the efficacy and tolerability of acupuncture compared with topiramate treatment in chronic migraine (CM) prophylaxis. METHODS: A total of 66 consecutive and prospective CM patients were randomly divided into two treatment arms: 1) acupuncture group: acupuncture administered in 24 sessions over 12 weeks (n = 33); and 2) topiramate group: a 4-week titration, initiated at 25 mg/day and increased by 25 mg/day weekly to a maximum of 100 mg/day followed by an 8-week maintenance period (n = 33). RESULTS: A significantly larger decrease in the mean monthly number of moderate/severe headache days (primary end point) from 20.2 ± 1.5 days to 9.8 ± 2.8 days was observed in the acupuncture group compared with 19.8 ± 1.7 days to 12.0 ± 4.1 days in the topiramate group (p < .01) Significant differences favoring acupuncture were also observed for all secondary efficacy variables. These significant differences still existed when we focused on those patients who were overusing acute medication. Adverse events occurred in 6% of acupuncture group and 66% of topiramate group. CONCLUSION: We suggest that acupuncture could be considered a treatment option for CM patients willing to undergo this prophylactic treatment, even for those patients with medication overuse.

Application of the mixed venous blood concentration equation in desflurane anesthesia.

BACKGROUND: We have previously proposed an equation derived from Fick's law and Lin's concept of effective blood concentration (EBC) to calculate the mixed venous blood concentration (MVBC) of isoflurane. Desflurane has a lower blood/air partition coefficient than isoflurane and, as such, promotes a faster induction and recovery from anesthesia. In this study, we investigated the application of the MVBC equation to predict the MVBC of desflurane. METHODS: We maintained anesthesia with a fixed inspired concentration (CI) of desflurane (10%) during cardiac anesthesia in 11 patients. In order to measure the real concentrations of desflurane in mixed venous blood, pulmonary arterial blood samples were collected at different time points via a Swan-Ganz catheter for gas chromatographic-mass spectrometric determination. The relationship between the calculated concentrations and the actual blood sample concentrations of desflurane in mixed venous blood was investigated. Lin's EBC method was also used and the results were compared with those of MVBC. RESULTS: The calculations from our derived MVBC equation and the actual blood concentrations showed a similar kinetic pattern; the concentration levels were approximately the same and correlated well (r = 0.89) during anesthesia. However, the EBC method failed to accurately estimate the actual blood concentrations. CONCLUSIONS: The results demonstrate that our equation, but not the EBC method, may be useful for estimating pulmonary blood concentrations of desflurane. The clinical significance and the importance of the method merit further investigation.

Application of MVBC equation to predict mixed venous blood concentrations of sevoflurane in cardiac anaesthesia.

We have proposed an equation for estimating the real-time mixed venous blood concentration (MVBC) of isoflurane in cardiac anaesthesia. However, information related to the application of our method to sevoflurane is lacking. We studied 12 patients undergoing cardiac surgery and anaesthetised with sevoflurane. At different time points, pulmonary arterial blood samples were collected for gas chromatography-mass spectrometry (GC-MS) to determine the real mixed venous concentrations of sevoflurane. The inspired and expired concentrations of sevoflurane, measured by a gas monitor, were used for the MVBC calculations. Using Bland-Altman analyses, we found that the calculated MVBCs accurately represent the actual concentrations of sevoflurane in pulmonary arterial blood, as shown by a near-zero percentage bias with a 0.14% precision between the two concentrations. The results demonstrated that our equation could be a useful method for estimating the pulmonary blood concentration of sevoflurane.

A novel method for determining the blood/gas partition coefficients of inhalation anesthetics to calculate the percentage of loss at different temperatures.

The loss by blood/gas (lambda) partition of inhalation anesthetics can be estimated by an equation for the percentage of loss. However, because lambdas of inhalation anesthetics at different temperatures have not been fully determined so far, the percentage of loss at varying temperature in various headspace volumes cannot be estimated. Therefore, a novel method was developed for the determination of inhalation anesthetic lambda, in this study. The method was precise, with a relative standard deviation of less than 5%. The average of lambda from seven distinct blood samples at 4 degrees C, 25 degrees C, and 37 degrees C were determined as 6.68, 2.04, and 1.32 of isoflurane; 3.47, 1.10, and 0.65 of sevoflurane; and 2.31, 0.75, and 0.46 of desflurane, respectively. In addition, increasing temperature was found to decrease lambda profoundly by a secondary order mechanism. Using the obtained value of lambda, the percentage of loss of isoflurane, sevoflurane, and desflurane were then predicted using a 5-mL vacuum tube as a collecting container for an example. In conclusion, a novel method was developed here for lambda determination, and lambdas of isoflurane, sevoflurane, and desflurane at various temperatures were given for estimating the loss resulting from liquid/gas partitioning.

Reasons for current practices in managing Barrett's esophagus.

We evaluated the reasons for current practices in managing Barrett's esophagus. Using a questionnaire, we assessed the practices and beliefs of 162 Californian gastroenterologists in managing Barrett's esophagus, using descriptive statistics as well as multivariate logistic regression. Out of the 103 respondents, 87% screened for Barrett's esophagus in patients with > 12 months of reflux symptoms, but only 72% believed that screening would improve survival, and 48% believed it to be cost-effective. In total, 98% surveyed patients with long-segment Barrett's esophagus at least biennially (76% thought this would improve survival and 49% believed it to be cost-effective) and 82% surveyed short-segment Barrett's esophagus at least biennially (57% thought this would improve survival and 30% believed it to be cost-effective). Finally, 44% surveyed microscopic intestinal metaplasia at least biennially (26% thought this would improve survival and 11% believed it to be cost-effective). In total, 18% performed endoscopic ablation, whereas 3% referred patients with low-grade dysplasia and 85% referred patients with high-grade dysplasia for esophagectomy. Finally, 81% treated asymptomatic Barrett's esophagus patients with proton pump inhibitors, but only 56% believed that this would reduce the risk of cancer. Logistic regression showed that the only independent factor predictive of surveillance practices was belief in efficacy. Practice patterns tend to be more aggressive than those recommended by recent guidelines and those reported by previous surveys. Medico-legal considerations affect practice substantially.

Simultaneous determination of fluorinated inhalation anesthetics in blood by gas chromatography-mass spectrometry combined with a headspace autosampler.

Although the fluorinated inhalation anesthetics, including desflurane, sevoflurane, isoflurane, enflurane, and halothane are commonly used, fatal cases resulting from their abuse or misuse have been reported. To date, gas chromatography (GC) equipped with different kinds of detectors has been utilized to analyze inhalation anesthetics. However, none of them can detect desflurane reliably or analyze all five common anesthetics simultaneously. The purpose of the present work is to further modify the previously developed headspace (HS) GC-MS method for blood isoflurane determination to analyze and distinguish five common clinical inhalation anesthetics, simultaneously. The modified HS-GC-MS method adopts a 60 m x 0.25 mm I.D., 0.25 microm film thickness DB-5 capillary column along with an adequate GC temperature program, which gives the five inhalation anesthetics, including isoflurane and its isomer, enflurane, a high resolution. The method also takes both the volatility and the influence of the top space on the obtained concentration into consideration and therefore keeps the sample loss acceptable even for analyzing the highly volatile desflurane. Within a certain concentration range of the calibration standard (about 20-300 microg/ml), this method shows a good linearity with correlation coefficients greater than 0.999. In addition, both within- and between-run precision and accuracy results meet the validation requirements as well as the tested results of practical blood samples of desflurane. In summary, this is a reliable analytical method to simultaneously determine the concentration of five common inhalation anesthetics in blood. Such a method is very practical for both clinical and occupational monitoring, as well as for analytical toxicology.

Infective endocarditis with neurologic complications: 10-year experience.

The impact of neurologic complications on clinical outcomes in infective endocarditis was assessed. Medical records of patients with infective endocarditis from January 1, 1987 through September 30,1998 were analyzed. Patients were divided into two groups: one with neurological complications and the other without. The outcomes of the two groups were compared using Fisher's exact test. Fifty-eight patients fulfilled the definite Duke criteria. There were 46 men and 12 women, ranging from 3 to 71 years of age with a mean of 40.6 years. Pathogens of infective endocarditis were documented by blood culture in 55 (94.8%) of 58 patients as follows: 52 with gram-positive cocci, two with gram-negative bacilli, and one with fungus. All 58 patients had initially received antimicrobial agents. Eight (13.8%) of the 58 patients had received surgical valvular replacement because of medical treatment failure. Overall, 16 (27.6%) of 58 patients died. Neurologic complications were either the chief complaint or one of the major presenting symptoms in 16 (27.6%) of the 58 patients. Patients with neurologic complications had a higher mortality rate (50% vs 20.9%, p = 0.025) than those without neurologic complications. The adjusted risk ratio for neurologic complications for a fatal event was 3.51 (95% CI = 1.1-11.18, p = 0.03). Neurologic complications pose a significant problem in infective endocarditis. To reduce mortality, we recommend that more attention be paid to the treatment and prevention of the neurologic complications of infective endocarditis.

Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation.

BACKGROUND/AIMS: In cirrhotic patients, spontaneous bacterial peritonitis (SBP) may be difficult to distinguish from secondary peritonitis with occult intestinal perforation; Runyon's criteria (based on ascitic fluid glucose, protein and lactate dehydrogenase levels) are sensitive but not specific. Ascitic fluid carcinoembryonic antigen (CEA) and alkaline phosphatase (AP) are potential markers for secondary peritonitis. METHODS: Ascitic fluid CEA and AP levels were prospectively compared among three subject groups--cirrhotic patients with sterile ascites, cirrhotic patients with SBP, and patients (cirrhotic and non-cirrhotic) with perforation-related secondary peritonitis. RESULTS: The secondary peritonitis group (n = 38 including 11 cirrhotic patients) had significantly higher mean CEA and AP levels than the SBP (n = 34) and sterile ascites patients (n = 63). Of secondary peritonitis patients, 92% fulfilled predetermined criteria (either CEA >5 ng/ml or AP >240 units/l) versus only 12% of SBP patients; sensitivity was 92% and specificity 88% for differentiating secondary peritonitis from SBP. Runyon's criteria had a sensitivity of 97% and specificity of 56%. Stratification of secondary peritonitis patients by the presence or absence of cirrhosis did not alter our results. CONCLUSIONS: Ascitic fluid CEA or AP elevations appear to be sensitive and specific markers for perforation-related secondary peritonitis in cirrhotic as well as non-cirrhotic patients.

Fall characteristics, functional mobility and bone mineral density as risk factors of hip fracture in the community-dwelling ambulatory elderly.

Hip fracture is the most serious consequence of osteoporosis, frequently occurring in the elderly; however, no research has been performed to identify the fall characteristics, functional mobility and bone mineral density (BMD) concurrently as risk factors. We investigated the risk factors of hip fractures using a multifactorial approach for a further preventive strategy. This age- and sex-matched case-control study was conducted in a community-based general hospital. A total of 252 consecutive community-dwelling ambulatory elderly, aged between 65 and 85 years, were studied: 127 patients (faller with hip fracture) and 125 controls (faller without hip fracture). Body mass index (BMI), predisposing medical conditions, fall characteristics, functional mobility and BMD of the hip were evaluated by direct interview and clinical examination. In the final model of multivariate regression analysis, risk factors for hip fracture were direct hip impact (adjusted odds ratio (OR), 4.9; 95% confidence interval (CI), 2.7-8.8), previous stroke (adjusted OR, 2.9; 95% CI, 1.3-6.3), sideways fall (adjusted OR, 2.5; 95% CI, 1.6-3.9), functional mobility (a decrease of 1 SD; adjusted OR, 2.0; 95% CI, 1.1-3.5), BMI (a decrease of 1 SD; adjusted OR, 1.8; 95% CI, 1.1-2.8) and femoral neck BMD (a decrease of 1 SD; adjusted OR, 1.7; 95% CI, 1.0-2.8). The effect of risk factors remained the same in different analysis sets, and adding or removing femoral neck BMD did not change other risk factors, though BMD was significantly correlated with functional mobility and BMI. Importantly, both sideways fall and direct hip impact are independent predictors of hip fracture. From these results, we suggest a preventive strategy of hip fracture in the elderly: besides the maintenance of BMD, keeping an appropriate body weight and maintaining a physically active lifestyle might be crucial.

Dietary habits and right-sided colonic diverticulosis.

PURPOSE: In Asian populations, there is a high prevalence of right-sided colonic diverticulosis, the cause of which is uncertain. It is suspected that dietary habits may interact with a congenital predilection to cause this condition. To evaluate the relationship between long-term dietary habits and the prevalence of right-sided diverticulosis in the general population, we performed a retrospective case-control study. METHODS: We reviewed the records of 3,105 screening colonoscopies performed on healthy, asymptomatic adults. All cases of right-sided diverticulosis were selected, and a similar number of gender-matched and age-matched controls with negative colonoscopies were randomly sampled from the same cohort. All case and control subjects were interviewed by a single-blinded nurse to establish their dietary habits during the past decade, in addition to other demographic characteristics. Based on consumption frequency, they were assigned to one of three diet classes for each of three food categories of interest: meat, vegetable, and fruit products. Staple foods such as rice were not included. Odds ratios were then calculated using multivariate conditional logistic regression and tests for trend were performed. RESULTS: A total of 86 cases of right-sided diverticulosis were included, whereas 106 controls were randomly selected. There was a marked association between meat consumption frequency and right-sided diverticulosis, with a trend P value of <0.01 and an odds ratio of 24.81 between the most and least frequent consumers of meat products. CONCLUSIONS: The prevalence of right-sided diverticulosis is strongly positively associated with past meat consumption frequency. There is no association with vegetable or fruit consumption frequency, laxative use, supplemental fiber intake, smoking, or family history.

Reliable gas chromatographic-mass spectrometric method combined with a headspace autosampler for isoflurane determination in blood.

Isoflurane is a nonflammable, liquid, volatile inhalation anesthetic administered by vaporizing. Although it is now commonly used, fatal cases resulting from its abuse or misuse have been reported. A combined system of a gas chromatograph-mass spectrometer and a headspace autosampler is therefore proposed for the detection of blood isoflurane. This analytic method showed sharp and well separated peaks, and revealed a good linear relationship (r=0.9994) with a function of y = 7.3768x - 0.0222 at concentrations between 18.7 and 299.2 microg/ml. The limits of detection and quantitation of this method were 1.2 and 4.7 microg/ml, respectively. The within- and between-run precision for spiked samples, assessed by the coefficient of variations, ranged from 1.7 to 10.0% and from 4.1 to 12.8%, respectively. The within- and between-run accuracy, assessed by errors from theoretical values, were 2.2-7.8% and 2.4-9.6%, respectively. In addition, practical sample analysis showed a good applicability, with a within-run precision rate of 5.6 to 7.7% and a between-run precision rate of 5.2-10.6%. In summary, the present work presents a valid alternative for blood isoflurane analysis.

An outbreak of Salmonella infection after a Chinese year-end party in central Taiwan.

An outbreak of food poisoning caused by Salmonella O7 serogroup C1 and O8 serogroup C2, occurred in Taichung City after a Chinese year-end buffet party with 127 attendees including employees, relatives and guests of the Psychiatry Department of Changhua Christian Hospital (CCH). Among the 114 attendees interviewed, 96 (84.2%) reported developing symptoms within 120 h after the dinner on February 4, 1999. The time of onset ranged from 2 h to 101 h after the dinner with an average of 20 +/- 16 h. The median and mode incubation periods were 17 h and 16 h, respectively. Salmonella C1 and C2 serogroups were isolated from the stool samples of 45 attendees. Based on the results of interview questionnaire, the most likely contaminated food was eel kabayaki (OR = 4.8, 95% CI:1.6-14.9, p < 0.01) followed by baked mussels (OR = 4.04, 95% CI:1.3-12.1, p = 0.01). However, this result could not be confirmed by food sample investigation due to the lack of leftover food. Possible techniques for the prevention of food-borne disease transmission, enhancement of communication about foodborne disease outbreaks within the health reporting system, and the reduction of response time during an outbreak of infection are required.

Evaluation of the quality of surgical gloves among four different manufactures.

A randomized trial was conducted to evaluate the quality of four different brands of surgical gloves in terms of the perforation rate, ventilation, fitness, allergic reaction, elasticity, thickness, powder, and satisfaction. Gloves of four different manufactures which were used by various medical centres were distributed to participants according to a computer-generated randomization table. A structured questionnaire was self-administered by volunteers immediately after the surgical procedure to gather the information from participants, including the demographic data, allergy history, length of use, and variables of quality measures. Two brands, A and D, were significantly inferior to the best manufacture among the four, B, in terms of the ventilation, elasticity, and thickness, odds ratios ranging from 6 to 24, p < 0.05. For the amount of corn starch powder and satisfaction, all three other brands were inferior to brand B, odds ratios ranging from 6 to 44, p < 0.05. Gloves worn longer than 2 hours had a slightly higher perforation rate post procedures (11.5% vs. 2.1%, p = 0.048). The rate of latex allergic reaction was not significantly different between surgeons (8.3%) and the others (6.7%). No difference of the allergic reaction rate was found between subjects with allergy history (7.7%) and those without the history (7.5%). The quality of surgical gloves differs from brand to brand. The government and institutions should take the responsibility of monitoring the quality of surgical gloves in order to provide a safer and more comfortable environment for the surgical personnel and patients.

Induction of immune responses to HIV-1 by canarypox virus (ALVAC) HIV-1 and gp120 SF-2 recombinant vaccines in uninfected volunteers. NIAID AIDS Vaccine Evaluation Group.

OBJECTIVE: To determine the ability of live attenuated canarypox virus expressing HIV antigens to induce CD8+ cytotoxic T-cell responses and to prime for neutralizing antibody responses to boosting with purified recombinant gp120 subunit vaccine. DESIGN: A prospective, double-blind, randomized, immunogenicity and safety study was conducted in healthy adults at low risk for acquiring HIV infection and who were seronegative for HIV. METHODS: CD8+ cytotoxic T-cells directed against Env or Gag expressing target cells were measured after live recombinant canarypox-HIV-1 vaccine priming (vaccine given at days 0, 7, 14 and 21). Neutralizing antibodies were measured after subunit boosting (vaccine given at days 28 and 84). RESULTS: CD8+ CTL were induced in 64% of volunteers by the live recombinant canarypox-HIV-1 vaccine. All volunteers who received two doses of subunit vaccine after live recombinant canarypox priming developed neutralizing antibodies directed against laboratory strains of HIV-1 and seven out of eight volunteers tested developed neutralizing antibodies to the primary isolate, BZ167, but to none of eight other primary isolates. Unprimed controls had low or absent neutralizing antibodies after two doses of subunit vaccine. CONCLUSIONS: The live canarypox vector was safe, stimulated cytotoxic T-cells and primed for a vigorous neutralizing antibody response upon boosting with subunit gp120 vaccine. This vaccine combination should be evaluated further for inducing protection against HIV infection.