Three-dimensional bone CT reconstruction anatomy of the vidian canal.

OBJECTIVES: To examine the anatomical features of the anterior opening of the vidian canal using three-dimensional (3D) computed tomography (CT) images of the bone. METHODS: We reviewed 62 patients who had undergone bilateral vidian neurectomies. One hundred and twenty-four vidian canals and their surrounding anatomies were analyzed. 3D images were reconstructed using algorithms and compared with conventional two-dimensional (2D) CT images. RESULTS: A bony prominence that overlaid the vidian canal along the sphenoid sinus floor was found in 60 (48.39 %) canals. Pneumatization of the pterygoid process was observed in 45 sides (36.29%). No significant discrepancy was found in detecting these variances between the 2D and the 3D images. The presence of a surgically favorable gap between the palatine and the sphenoid bone was seen in 25 sides (20.16%) without significant association with pterygoid process pneumatization or vidian canal protrusion. This gap was not identified on the 2D CT scans. CONCLUSION: 3D CT reconstruction images of bone provide superior delineation of the gap between the palatine and the sphenoid bone, which is a critical variation for vidian neurectomy. This useful method may contribute to better prediction and guidance of the surgical approach to the vidian canal and pterygopalatine fossa.

The Angio-Seal arterial closure device for early ambulation after elective percutaneous coronary intervention in patients receiving low-dose enoxaparin.

This study evaluated the efficacy and safety of use of the Angio-Seal vascular closure device deployment for early ambulation (2 h) after elective percutaneous coronary intervention in 143 consecutive patients receiving either intravenous low-dose enoxaparin (0.5 mg/kg) or unfractionated heparin (UFH). The initial success rate of Angio-Seal(trade mark) deployment was 98.6%, with no significant difference between the UFH group (98.9%) and the enoxaparin group (98.0%). In-hospital and clinic outcomes were evaluated in the 141 patients with successful Angio-Seal deployment. During hospitalization, there were no deaths, myocardial infarction, urgent target vessel revascularization or bleeding events in either group; three patients in the UFH group and none in the enoxaparin group had minor vascular complications (differences not significant). In clinic follow-up, two patients in the UFH group and none in the enoxaparin group had major vascular complications (differences not significant). Routine use of the Angio-Seal(trade mark) for early ambulation in patients receiving intravenous low-dose enoxaparin compared with UFH provides promising efficacy and safety for daily practice.

Time-dependent benefit of initial thrombosuction on myocardial reperfusion in primary percutaneous coronary intervention.

BACKGROUND: In ST-segment elevation acute myocardial infarction (STEMI), dislodgement of thrombus within the culprit artery during primary percutaneous coronary intervention (PCI) may cause distal embolisation and impaired myocardial reperfusion. Clinical results of thromboembolic protection strategies have been controversial. We conducted this study to investigate whether the benefit of thrombus removal is time dependent. METHODS: Seventy-four STEMI patients within 12 h from onset were randomised to receive either primary PCI with initial thrombosuction (IT) or standard strategy. Results were analysed in subgroups according to the onset-to-lab time intervals (subgroup 1: 0-240 min, subgroup 2: 241-480 min and subgroup 3: 481-720 min). RESULTS: The primary end-points were improvements in thrombolysis in myocardial infarction flow (DeltaTIMI) and myocardial blush grade (DeltaMBG) postprocedure. Better DeltaTIMI (2.2 +/- 1.1 vs. 1.5 +/- 1.3, p = 0.014) and DeltaMBG (2.3 +/- 1.1 vs. 1.0 +/- 1.5, p < 0.001) were observed in IT patients, compared with standard PCI patients. In onset-to-lab time subgroup analysis, the difference between IT and standard PCI is significant only in subgroup 2 (DeltaTIMI 2.6 +/- 1.0 vs. 1.3 +/- 1.2, p = 0.007; DeltaMBG 2.6 +/- 0.9 vs. 1.0 +/- 1.1, p = 0.010), but not in the other two subgroups. CONCLUSIONS: This prospective randomised study shows that primary PCI with IT may improve epicardial flow and myocardial reperfusion in patients with STEMI, and this benefit is the most significant in patients treated within 4-8 h after symptom onset.

Significance of serum hepatocyte growth factor levels in patients with hepatocellular carcinoma undergoing hepatic resection.

BACKGROUND: Hepatocyte growth factor (HGF) is a potent hepatocyte mitogen and may stimulate the proliferation and invasiveness of human hepatocellular carcinoma (HCC) cells through the c-met receptor. This study evaluates the significance of serum HGF levels in patients undergoing HCC resection. STUDY DESIGN: The peripheral and portal sera and HCC and non-tumorous tissues of 40 HCC patients, with tumor TNM stage I (n=12), II (n=17), and III (n=11) diseases, who underwent hepatic resection were prospectively collected. Serum HGF levels were determined by enzyme-linked immunosorbent assay. The c-met protein expressions were examined by immunohistochemistry. Median follow-up time was 69 months. RESULTS: The prehepatectomy portal HGF levels (median, 622pg/mL) were significantly higher than peripheral HGF levels (564pg/mL) (P=0.026). The posthepatectomy portal HGF levels (699pg/mL) were significantly higher than prehepatectomy portal HGF levels (P<0.001). C-met expression was detected in 87.5% HCC and in 85.0% non-tumorous liver tissues. By Cox multivariate analysis, posthepatectomy portal HGF level >699pg/mL (P<0.001), multiple tumors (P=0.042), and TNM stages II (P=0.019) and III (P=0.009) were independent factors related with survival. Patients with a posthepatectomy portal HCG level >699pg/mL and with a positive c-met expression in HCC tissue have the worst survival. CONCLUSIONS: In HCC patients, high peripheral and portal HGF serum levels related with poor prognosis after hepatic resection. Hepatocyte growth factor and c-met receptor can be targets of future HCC postoperative treatment.

Clinicopathological significance of survivin expression in patients with hepatocellular carcinoma.

AIMS: Survivin, a newly discovered member of the inhibitor of apoptosis protein family, is suggested to be involved in liver carcinogenesis. The aim was to investigate the clinical significance of survivin expression in resected hepatocellular carcinoma (HCC) and paired adjacent non-tumour tissue. METHODS AND RESULTS: Immunohistochemistry, reverse transcriptase-polymerase chain reaction and Western blots were used to examine survivin mRNA and protein levels in 94 specimens of HCC tissues at different TNM stages and the data were correlated with the clinicopathological profiles. Patients were categorized into those with high tumour survivin protein levels (T-N >or= -1) and those with low levels (T-N < -1). Follow-up data were collected prospectively. mRNA levels of survivin and its splice variants in tumour tissue were significantly higher than in paired non-tumour tissue. However, survivin protein levels in paired non-tumour tissue were significantly higher than in tumour tissue from all three TNM stages. Additionally, high tumour survivin protein levels (T-N >or= -1) correlated with a better prognosis and low levels (T-N < -1) with a worse survival rate. CONCLUSIONS: High cytoplasmic survivin protein levels in HCC tissues seem to be an indicator of better prognosis in HCC patients after resection.

The impact of lesion length on angiographic restenosis after vertebral artery origin stenting.

OBJECTIVE: To evaluate the effect of lesion length on in-stent restenosis (ISR) of vertebral artery (VA) origin stenting. METHODS: We retrospectively analyzed the medical and radiological records of patients receiving VA origin stenting from March 1999 to June 2005. They were subdivided according to lesion length. ISR was defined as >50% diameter narrowing in stent. RESULTS: Eighty symptomatic patients (64 male, mean age 72 years) with 90 lesions treated with balloon expandable tubular coronary stents were enrolled. There were 34 patients with 38 short lesions (length5 mm, <10 mm, group 2) and 9 patients with 10 long lesions (length>or=10 mm, group 3). Eighty seven bare-metal stents and 3 drug-eluting stents were implanted. Repeat angiography was done in 40 lesions (44%) at 11.7+/-9.6 months. The ISR rate in group 1, 2, 3 is 21%, 29%, and 50% (p=0.486). Multivariable Cox regression analysis showed lesion length was the only significant independent predictor of ISR (hazard ratio: 1.19, p=0.039). CONCLUSION: ISR of VA origin stenting is common. Lesion length is an important predictor of ISR in VA origin stenting.

Differentiation of ovarian mucinous carcinoma and metastatic colorectal adenocarcinoma by immunostaining with beta-catenin.

AIMS: To investigate whether localization of beta-catenin is helpful in differentiating primary ovarian mucinous carcinoma and colorectal adenocarcinoma metastatic to the ovary. Extra-ovarian cancers which metastasize to the ovaries, especially from colorectal adenocarcinoma, frequently mimic primary ovarian carcinomas, particularly endometrioid and mucinous types. Distinguishing primary ovarian carcinoma from metastatic colorectal carcinoma is important for both therapeutic and prognostic reasons. Even after thorough histological examination, metastatic colorectal adenocarcinomas are still often mistaken for primary ovarian adenocarcinomas. Although some tumour makers have been advocated and are helpful in most cases, sometimes the distinction between primary mucinous carcinoma and metastatic colorectal carcinoma remains a problem. Activation of Wnt signalling through mutations of APC or beta-catenin is a key event in the development of colorectal cancer. These mutations lead to nuclear localization of beta-catenin, which can be demonstrated immunohistochemically. METHODS AND RESULTS: Formalin-fixed paraffin-embedded specimens from 43 primary ovarian mucinous carcinomas and 23 metastatic colorectal adenocarcinomas were included in this study. Sections were immunostained with antibodies to beta-catenin, cytokeratin (CK)7, CK20 and carcinoembryonic antigen (CEA). Nuclear localization of beta-catenin was found in 83% (19/23) of metastatic colorectal cancers and 9% (4/43) of ovarian mucinous carcinomas. Ovarian mucinous carcinomas were usually positive for CK7 (34/43, 79%). For comparison, 40 non-mucinous carcinomas of the ovary and 42 metastatic adenocarcinomas from other organs were also immunostained with antibodies against beta-catenin. Although nuclear localization of beta-catenin was occasionally seen in non-mucinous carcinoma of the ovary and metastatic adenocarcinoma from other organs, such tumours were usually distinguishable by their clinicopathological picture and rarely raised diagnostic problems. CONCLUSIONS: Immunostaining of beta-catenin is a useful marker for differentiating between ovarian mucinous carcinoma and metastatic colorectal adenocarcinoma.

Alterations of myocardial ultrasonic tissue characterization by coronary angioplasty in patients with chronic stable coronary artery disease.

We conducted a study to delineate the alterations in the cyclic changes of myocardial ultrasonic integrated backscatter (IBS) in patients receiving angioplasty for chronic coronary artery disease. Ultrasonic tissue characterization (UTC) and dobutamine stress echocardiography were performed in 43 patients before and 24 h after angioplasty, as well as before the follow-up angiography 3 months later. For segments being normokinetic with ischemic burden, the blunted amplitude and increased nadir deviation of IBS cyclic modulation recovered soon after angioplasty. For dyssynergic segments with contractile reserve, the angioplasty rebuilt the amplitude before the wall motion recovered, but corrected the nadir deviation tardily. In both circumstances, the coronary restenosis abolished the initial restoration. Those nonviable segments persistently revealed large deviations and small weighted amplitudes irrelevant to coronary lesions. The progress of myocardial ischemia, the development of wall motion dyssynergy and, then, the loss of viability, show different patterns of alterations in UTC after alleviating coronary obstructions.

Accuracy of biphasic response, sustained improvement and worsening during dobutamine echocardiography in predicting recovery of resting myocardial dysfunction after revascularization: comparison with thallium-201 SPECT.

To evaluate the accuracy of various types of wall motion response during dobutamine echocardiography (DE) in predicting functional recovery after revascularization, we studied 30 patients with stable coronary disease and left ventricular dysfunction by simultaneous DE and (201)Tl reinjection SPECT. Among 480 segments (16 segments/patient), 199 had abnormal wall motion at baseline and 167 were revascularized. The predictive value for recovery of function was 72% for a biphasic response, 61% for sustained improvement, 77% for worsening, and 27% for no change (p < 0.01 vs. each). Biphasic response had a sensitivity of 40% and specificity of 85%. Combining biphasic, sustained improvement and worsening responses, the sensitivity, specificity and accuracy were 76%, 65% and 71%, respectively. For (201)Tl SPECT, they were 90%, 65% and 78%, respectively. Thus, a biphasic response alone is of low sensitivity. Combination of biphasic, sustained improvement and worsening responses gives an accuracy rate comparable to that of (201)Tl reinjection SPECT in assessing functional recovery.

Aortic stenting on a type B aortic dissection with visceral and limb ischemia.

Aortic dissection complicated with limb and visceral ischemia is a clinical dilemma since surgical intervention carries high risk of morbidity and mortality. The management is further complicated when renal perfusion is impaired and thus associated with severe renovascular hypertension. As catheterization techniques advanced over the past decade, percutaneous endovascular intervention provides a less invasive alternative for management of such cases. We report a case of chronic Stanford type B aortic dissection complicated with visceral and limb ischemia presenting with marked renovascular hypertension, which was successfully treated with percutaneous endovascular aortic stenting.

Serum matrix metalloproteinase-9 level associated with stromal reaction in patients with gastric cancer.

BACKGROUND: Matrix metalloproteinase 9 (MMP-9) plays an important role in cancer invasion and metastasis. The relationship between serum MMP-9 levels and clinicopathological factors in gastric cancer patients is not clear. MATERIALS AND METHODS: Preoperative serum was obtained from 170 patients who had undergone gastrectomy for gastric cancer at the Veterans General Hospital-Taipei. The serum MMP-9 level was measured using a sandwich enzyme-linked immunoassay by monoclonal antibodies. RESULTS: The median serum MMP-9 level was 368.6 ng/mL (range: 43.9-1871.3 ng/mL). Univariate analysis showed that stromal reaction and Lauren's histological classification were two factors related to serum MMP-9 levels (p = 0.014 and p = 0.030 respectively). Multivariate analysis revealed that stromal reaction was the only factor independently (odds ratio: 1.695) associated with MMP-9 levels. Patients with a serum MMP-9 level < 368.5 ng/mL had a tendency towards better survival rate (5-year survival rate: 64.4%) than those with > 368.5 ng/mL (58.5%), but this tendency did not reach statistical significance (p = 0.512). CONCLUSION: These data suggests that serum MMP-9 levels are associated with stromal reaction in gastric cancer.

Serum interleukin-10 but not interleukin-6 is related to clinical outcome in patients with resectable hepatocellular carcinoma.

OBJECTIVE: To evaluate the clinical significance of preoperative serum levels of interleukin-10 (IL-10) and interleukin-6 (IL-6) in patients with resectable hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: IL-10 is an immunosuppressive factor and IL-6 is a multifunctional cytokine that plays a role in host defense mechanisms. Both have been reported to be related to the disease prognosis in some human solid tumors. Their role in human HCC has not been investigated. METHODS: Preoperative serum samples of 67 patients with HCC who underwent potentially curative resection and 27 normal healthy donors were assayed. Levels of IL-10 and IL-6 were determined by enzyme-linked immunosorbent assay. The clinical significance of serum IL-10 and IL-6 was evaluated and compared with conventional clinicopathologic factors. RESULTS: Levels of IL-10 and IL-6 were significantly higher in patients with HCC than in healthy subjects. There was no correlation between IL-10 and IL-6 levels. Tumor resection resulted in a decrease in IL-10 and IL-6 levels. On univariate analysis, patients with high IL-10 levels had a worse disease-free survival, but IL-6 levels had no correlation with the disease-free survival. Multivariate analysis identified IL-10 levels as a predictor of postresectional outcome, in addition to the well-established clinical risk factors. CONCLUSIONS: In patients with HCC, the preoperative serum IL-10 level is related to the clinical outcome. IL-10 may play an important role in the progression of HCC.

Constrictive pericarditis in patients with tuberculous pericarditis.

Constrictive pericarditis is a complication of tuberculous pericarditis that necessitates surgical intervention. In this study, we sought to identify echocardiographic features that could predict the development of constrictive pericarditis from acute or subacute pericarditis. From January 1988 through May 1998, all patients with a discharge diagnosis of tuberculous pericarditis were enrolled in the study, and their clinical features, laboratory findings, sonographic images, treatments, and outcomes were analyzed. Tuberculous pericarditis was demonstrated on the basis of positive Mycobacterium tuberculosis cultures from pericardial fluid or tissue in 11 patients; pericardial biopsy specimens demonstrating caseating granulomas in seven; and bacteriologic or histologic evidence of active extra-pericardial tuberculosis in conjunction with major pericardial effusion in four. Seventeen patients had effusive tuberculous pericarditis and five had constrictive tuberculous pericarditis as the initial diagnosis. The echocardiographic findings of effusive pericarditis were classified as shaggy-type effusion (n = 8) and non-shaggy-type effusion (9). Shaggy effusion was defined as the presence of multiple fibrin strands or a mass-like exudate coating the pericardium and bridging the pericardial effusion. Non-shaggy effusion was characterized by an anechoic pericardial space with or without a thickened pericardium, but no shaggy exudative coating. The mean duration between the onset of symptoms and diagnosis was longer in patients with shaggy-type effusion (39.6 +/- 8.7 vs 21.0 +/- 13.9 days, p < 0.05). Prednisolone (20-30 mg/d) was used in addition to antituberculous chemotherapy in 11 of the 17 patients with effusive pericarditis. Two of 11 patients (18%) who received steroid therapy, and five of the six patients (83%) who did not, developed constrictive pericarditis in the following year. Therefore, we concluded that adjuvant therapy with steroids significantly decreased the risk of constrictive pericarditis in patients with non-shaggy, but not shaggy, effusion.

Alterations in ultrasonic backscatter during intra-aortic balloon counterpulsation support in patients with acute myocardial infarction.

Alterations of ultrasonic backscatter parameters have been evident in humans with myocardial infarction or ischemia. The backscatter variability could be restored in ischemic or stunned myocardium after reperfusion. The aims of this study were to determinate changes in regional myocardial ultrasonic backscatter during intra-aortic balloon counterpulsation (IABP) support in patients with acute myocardial infarction (AMI), and to evaluate whether backscatter imaging could be a functional guide of IABP support. A total of 9 patients with AMI were investigated during IABP support with a two-dimensional (2-D) ultrasonic backscatter imaging approach for parasternal short-axis view. Coronary angiography was performed in 6 of the 9 patients. A total of 21 vessel territories were studied in different modes of IABP support: 1:1, 1:2 and standby. Restoration of cyclic variation of backscatter after IABP support was demonstrated in 10 vessel territories. Failure of restoration of cyclic variation of backscatter after IABP support was noted in 6 vessel territories with severe coronary lesions (total or nearly total occlusion) or scar tissue. No changes of the ultrasonic backscatter were found in nonischemic vessel territories with patent coronary arteries or TIMI III coronary flow. In addition, the wall motion score did not change significantly with different IABP support. These results suggest that IABP could restore the cyclic variation of backscatter in ischemic myocardium. Myocardial anisotropy may play an influential role in the alterations of ultrasonic backscatter. We propose that ultrasonic backscatter could be a noninvasively functional guide of IABP use in patients with AMI.

Relationship between hormone receptor concentration and tumor shrinkage in uterine myoma after treatment with a GnRHa.

BACKGROUND: Uterine myomas are benign tumors of the uterus, occurring in up to 25% of women of reproductive age. We examined the possible causes for different degrees of volume reduction in patients with uterine myomas who received gonadotropin-releasing hormone agonist (GnRHa) treatment by investigating the hormone receptors at the end of GnRHa treatment. METHODS: This trial was designed as a prospective study of five premenopausal women presenting with symptomatic uterine myoma. All patients were treated with a subcutaneous injection of goserelin depot 3.6 mg every four weeks for 16 weeks. Clinical examinations, hormonal evaluation and ultrasound determinations were performed before, during and after treatment. At the end of the treatment period, all patients underwent myomectomy. The concentrations of the unbound progesterone receptors and estrogen receptors were evaluated. RESULTS: The volume of the uterine myoma decreased by 21% to 65%. The percentage of decrease in volume of treated uterine myomas was found to negatively correlate with the concentration of unbound progesterone receptors (r2 = 0.92, p = 0.008). This percentage was not significantly correlated with the concentration of unbound estrogen receptors (r2 = 0.02, p = 0.84). CONCLUSIONS: The limited data available suggested that the volume decrease of uterine myomas in GnRHa-treated patients is partly dependent on the concentrations of unbound sex-hormone receptors in the uterine myomas.

Effects of ozone on ovalbumin sensitization in guinea pigs.

The effects of ozone on allergen sensitization is still controversial. This study is aimed to clarify the effect of ozone on airway hypersensitivity to ovalbumin (OVA) in guinea pigs, by exposing them to ozone (3 ppm 2 hours daily) and OVA (1 gm/dL 10 min weekly) for two weeks. OVA specific IgG and airway hypersensitivity to methacholine were determined after the sensitization. The results demonstrated that there was a synergistic effect of ozone on OVA-induced IgG antibody production. OVA specific IgG was 0.51 +/- 0.1 U/mL and 0.46 +/- 0.1 U/mL using OVA and ozone alone respectively, which increased to 1.09 +/- 0.4 U/mL when both OVA and ozone were given simultaneously. Ozone exposure was able to cause airway hypersensitivity. The provocation dose of methacholine causing a 100% increase of airway resistance (PD 100 airway resistance) was 0.54 +/- 0.19 mg/mL and 1.17 +/- 0.30 mg/mL using OVA and ozone exposure alone, which had decreased to 0.49 +/- 0.18 mg/mL when both OVA and ozone were given simultaneously. There were macrophages around the peribronchial tissue in all guinea pigs except in the control. The macrophages in the group of OVA with ozone (24.2 +/- 7.2 cells/HPF) were significantly more than those in the OVA group (18.0 +/- 4.2 cells/HPF) and the ozone group (14.5 +/- 6.2 cells/HPF). When OVA-presensitized guinea pigs were exposed to ozone immediately or daily for two weeks, a restrictive type of lung function impairment with similar airway hypersensitivity post ozone exposure was observed. In conclusion, guinea pigs exposed to ozone in conjunction with aeroallergen may not only facilitate the damage of the airway but also enhance antibody production to the aeroallergen. The ozone-induced airway inflammation might have a contributing effect on OVA induced airway hypersensitivity in guinea pigs.

Streptococcus adjacens endocarditis in a patient with nephrotic syndrome.

Streptococcus adjacens has never previously been reported as an etiologic organism of infective endocarditis in Taiwan. We describe a case of severe native valve endocarditis caused by S. adjacens, involving the mitral valve, the aortic valve, and the left atrium, in a 29-year-old woman with nephrotic syndrome on steroid therapy. Blood cultures yielded gram-positive cocci that grew poorly on blood agar but strongly on chocolate agar. Despite aggressive antibiotic treatment, the patients continued to have high fever and progressive congestive heart failure, which necessitated surgical intervention. Symptoms were alleviated after surgery; teicoplanin was continued for 4 weeks and the patient remained symptom-free at the 6 month follow up. To our knowledge, this is the first reported case of bacterial endocarditis involving the left atrium without preexisting myxoma.

Class I and class II major histocompatibility complex antigens expression on human hepatocytes and hepatoma cells: an approach with high sensitivity and specificity.

The expression of gene products of the major histocompatibility complex (MHC) on the cell surface is known to play an important role in immunological responses. While some studies have reported the presence of MHC antigens on hepatocytes, information about specific, sensitive hepatocyte MHC antigen expression in various liver diseases is minimal. To investigate the expression of class I and class II MHC antigens on hepatocellular carcinoma (HCC) specimens, two-color flow cytometry was used to demonstrate MHC antigen expression on non-malignant and malignant hepatocytes using the hepatocyte-specific monoclonal antibody (MAb) 9B2 for selective gating and either MHC-specific W6/32 (class I) or Q5/13 (class II) MAb for MHC antigen detection. Non-malignant liver tissues demonstrated variable MHC antigen expression. Malignant hepatocytes isolated from resected HCC specimens as well as non-tumorous hepatocytes from these HCC specimens also disclosed various degrees of MHC antigen expression. Although we were not able to demonstrate a clear correlation between clinical outcome and MHC antigen expression in HCC, we conclude that the expression of MHC antigens on human hepatocytes and hepatoma cells can be accurately detected by flow cytometry using hepatocyte-specific MAb for selective gating and MHC-specific MAbs. Of note, two cases of non-malignant fetal liver tissues indicated that >95% of fetal hepatocytes expressed class I MHC antigens and <25% of fetal hepatocytes expressed class II MHC antigens. These findings may lead to further investigations into the progression of HCC cells or into the possible mechanisms of the hepatocellular carcinogenesis.