Antinociceptive potentiation and attenuation of tolerance by intrathecal ß-arrestin 2 small interfering RNA in rats.

BACKGROUND: Tolerance to the analgesic effect of opioids complicates the management of persistent pain states. We tested whether the intrathecal infusion of small interfering RNA (siRNA) against ß-arrestin 2 would reduce tolerance to chronic morphine use and the severity of precipitated morphine withdrawal. METHODS: Intrathecal ß-arrestin 2 (2 µg siRNA per 10 µl per rat) was injected once daily for 3 days. Rats then received a continuous intrathecal infusion of morphine (2 nmol h⁻¹) or saline for 7 days. Daily tail-flick (TF) and intrathecal morphine challenge tests were performed to assess the effect of intrathecal ß-arrestin 2 siRNA on antinociception and tolerance to morphine. Naloxone withdrawal (2 mg kg⁻¹) was performed to assess morphine dependence. RESULTS: In the daily TF test, the antinociception of intrathecal morphine was increased and maintained in rats receiving ß-arrestin 2 siRNA compared with the control group (morphine alone). In the probe response test, rats receiving morphine infusion with ß-arrestin 2 siRNA treatment showed a significant left shift in their dose-response curve, as measured by per cent maximal possible effect (MPE), such that the AD50 was significantly decreased by a factor of 5.6 when compared with that of morphine-infused rats. In the naloxone-induced withdrawal tests, rats receiving ß-arrestin 2 siRNA injection with morphine infusion showed a significant reduction in four of the six signs of withdrawal. CONCLUSIONS: We show here that intrathecal ß-arrestin 2 siRNA in rats enhances analgesia and attenuates naloxone-induced withdrawal symptoms. This may warrant further investigation in the context of long-term use of intrathecal opioids for controlling chronic pain.

Temporal and spatial expression of bone morphogenetic proteins in extracorporeal shock wave-promoted healing of segmental defect.

Extracorporeal shock wave (ESW) is a noninvasive acoustic wave, which has recently been demonstrated to promote bone repair. The actual healing mechanism triggered by ESW has not yet been identified. Bone morphogenetic proteins (BMP) have been implicated as playing an important role in bone development and fracture healing. In this study, we aimed to examine the involvement of BMP-2, BMP-3, BMP-4, and BMP-7 expression in ESW promotion of fracture healing. Rats with a 5-mm segmental femoral defect were given ESW treatment using 500 impulses at 0.16 mJ/mm(2). Femurs and calluses were subjected to immunohistochemistry and RT-PCR assay 1, 2, 4, and 8 weeks after treatment. Histological observation demonstrated that fractured femurs received ESW treatment underwent intensive mesenchymal cell aggregation, hypertrophic chondrogenesis, and endochondral/intramembrane ossification, resulting in the healing of segmental defect. Aggregated mesenchymal cells at the defect, chondrocytes at the hypertrophic cartilage, and osteoblasts adjunct to newly formed woven bone showed intensive proliferating cell nuclear antigen expression. ESW treatment significantly promoted BMP-2, BMP-3, BMP-4, and BMP-7 mRNA expression of callus as determined by RT-PCR, and BMP immunoreactivity appeared throughout the bone regeneration period. Mesenchymal cells and immature chondrocytes showed intensive BMP-2, BMP-3, and BMP-4 immunoreactivity. BMP-7 expression was evident on osteoblasts located at endochondral ossification junction. Our findings suggest that BMP play an important role in signaling ESW-activated cell proliferation and bone regeneration of segmental defect.

Serum levels of matrix metalloproteinase 2 in patients with breast cancer.

Matrix metalloproteinases (MMPs) have been reported to be associated with invasive and metastatic behaviors of human malignant tumors. However, there is still limited knowledge about the role of matrix metalloproteinases-2 (MMP-2) in breast cancer. This study was designed with the aim to elucidate the possible relationship between the preoperative circulating MMP-2 and breast cancer. Fifty-seven consecutive patients with invasive breast cancer undergoing surgery were prospectively included and evaluated. Venous blood samples were collected before the surgery. Sera were obtained by centrifugation, and stored at -70 degrees C until assayed. The control group consisted of 12 patients with benign breast tumor (six with fibrocystic disease and six with fibroadenoma). Serum concentrations of MMP-2 were measured by the quantitative sandwich enzyme immunoassay technique. The data on primary tumor stage, age, estrogen receptor, lymph node status, and TNM staging were reviewed and recorded. The mean value of serum MMP-2 in patients with invasive breast cancer was 694.3+/-140.5 ng/ml and those of control group were 593.3+/-134.0 ng/ml and the difference was significant (P=0.026). Furthermore, there were significantly higher serum levels of MMP-2 in the patients with more advanced primary tumor staging (P=0.005), in the patients with more advanced lymph node status(P=0.011) and in the patients with more advanced TNM staging (P<0.001). In multivariate analysis, TNM staging (P<0.001) appeared as independent factor regarding the significant higher serum levels of MMP-2. Patients with more advanced TNM staging were shown to have higher serum MMP-2 levels. Thus preoperative serum MMP-2 levels might reflect the severity of invasive breast cancer and deserve further evaluation.

Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends.

BACKGROUND: In adenocarcinoma of the colon and rectum, obstruction and perforation may occur either alone or together at the site of the neoplasm or proximally. Both events carry a poor prognosis. This retrospective study sought to determine whether a correlation exists between perforation and obstruction, and between these conditions and different clinicopathological factors in colorectal adenocarcinoma. METHODS: The medical records of 1950 patients with colorectal adenocarcinoma treated in our hospital during a 7-year period were retrospectively analyzed. One hundred patients (5%) were excluded from this study because of a loss of follow-up. Data on clinicopathological factors including age, sex, tumor location, surgical mortality, pathological type, stage, and long-time cancer-free rate were simultaneously analyzed. Patients were grouped as follows: Group 1, complete colonic obstruction without perforation (n = 120). Group 2, complete obstruction with perforation at the site of the cancer (n = 35); Group 3, complete obstruction with perforation proximal to the cancer (n = 13); and Group 4, nonobstructing, nonperforated cancers (n = 1682). RESULTS: When compared with Group 4, Group 1 had a more advanced Dukes' stage, older age, greater incidence of colonic versus rectal cancers, and a poorer cancer-free survival (P < or = .005). Groups 2 and 3 had a greater incidence of colonic versus rectal cancers (P < or = .004), and Group 3 had a greater operative mortality (P < .001). No significant differences were found between Groups 1, 2, and 3. Multivariate analysis revealed that the independent factors favorable to cancer-free survival (> 5-year survival) were female gender (P = .035), well-differentiated pathology (P < .001), uncomplicated cases (P = .004), colon versus rectal location (P < .001), and early stage (P < .001). CONCLUSIONS: The perioperative mortality rate for perforated colorectal cancer at the site of the cancer was 9%; for obstructive colorectal cancer, 5%. Perioperative mortality was much greater for perforations of the colon and rectum occurring proximal to the cancer (31%). Survival was worse (P < .001) for patients with obstruction (33%) or perforation proximal to the cancer (33%). The site of perforation did not appear to impact the 5-year survival, although the numbers are relatively small.

Postoperative choledochoscopy: is routine antibiotic prophylaxis necessary?--A prospective randomized study.

BACKGROUND: Postoperative choledochoscopy-related infection has been reported in the literature. We performed a prospective randomized trial to investigate the value of antibiotic prophylaxis for the prevention of such endoscopy-related infection. METHODS: In a 2-year period from 1990 to 1991, 84 patients with biliary lithiasis were included in the study and randomized. Forty-four patients received antibiotic prophylaxis (1 gm cephalothin intravenously 30 minutes before the procedure and 500 mg cephalexin orally every 6 hours for 3 days afterward). Forty patients in the control group did not receive any antibiotics. RESULTS: There was no significant difference between the groups in age, sex, preprocedure liver function, serum amylase level, white cell count, and duration of the procedure. The results of bacteriologic studies of the bile were also comparable in the two groups. One patient in the control group had transient chill and fever after the procedure. Two patients in the antibiotic group and one patient in the control group had mild abdominal pain. Mild hemobilia was noted in one patient in the antibiotic group. These complications were treated conservatively without any event. No difference was evident in the complications and the success of postoperative choledochoscopy between the two groups. CONCLUSIONS: This prospective randomized study showed that routine antibiotic prophylaxis for postoperative choledochoscopy may be not necessary in selected conditions.

Neuromuscular recovery after parathyroidectomy in primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism today is diagnosed in the asymptomatic phase because of the inclusion of serum calcium in sequential multichannel analysis. The purpose of present study was to test for neuromuscular abnormalities in asymptomatic patients and to test the improvement of neuromuscular performance after parathyroidectomy. METHODS: Nine patients with primary hyperparathyroidism and nine patients with nodular goiter were enrolled in this study. Neuromuscular recovery including muscle power, sensation, and fine motor movement was studied before operation and 1 week and 4 weeks after operation. The muscle power was measured as grip power, palm pinch, lateral pinch, and three-chuck pinch. The sensation was measured as touch sensation and two-point discrimination. The fine motor movement was measured with the Purdue Pegboard Test and the Minnesota Manual Dexterity Test. RESULTS: Four weeks after the operation the patients with hyperparathyroidism had increased their muscle strength and had improved fine motor movement but no change was noted in two-point and touch sensation. When the postoperative muscle recovery was compared, there was a reversible correlation (r = -0.62; p < 0.05) with the preoperative muscle strength and no correlation with the preoperative serum calcium, phosphate, alkaline phosphatase, and intact parathyroid hormone levels. No such improvement was detectable among the control subjects. CONCLUSIONS: Surgery can improve muscle strength and fine motor movement but does not affect sensation in asymptomatic patients.

Smooth muscle tumors of the gastrointestinal tract: analysis of prognostic factors.

BACKGROUND: The survival rates and therapeutic approaches to gastrointestinal leiomyoma and leiomyosarcoma vary widely. This review analyzes the clinical symptoms and signs, the results of the pathologic examination, and the DNA makeup of these tumors and determines the factors that affect the prognosis of patients who have leiomyosarcoma. METHODS: Flow cytometric DNA analysis was performed in 80 patients with gastrointestinal smooth muscle tumors to establish the correlation of DNA ploidy with tumor size and stage and histologic grade. Using univariate and multivariate analyses, we investigated tumor size, histologic grade, association with gastrointestinal bleeding, DNA makeup, operative procedure, age, gender, and tumor necrosis as they affect the long-term survival of 45 patients with leiomyosarcoma. The Kaplan-Meier method was used to determine the survival rates and the log-rank method was used to compare survival rates between the two groups. RESULTS: Between 1986 and 1992, operations were performed on the 80 gastrointestinal smooth muscle tumors--esophageal 1, stomach 32, intestinal 33, colonic 2, and rectal 12. The most common symptoms and signs were gastrointestinal bleeding (43.8%), abdominal mass (37.5%), and abdominal pain (21.3%), and the tumors were classified as leiomyoma 35, low-grade leiomyosarcoma 24, and high-grade leiomyosarcoma 21, according to the cellular atypia and mitotic rate. DNA ploidy correlated with histology grade (r = 0.70, p < 0.01) and tumor size (r = 0.31, p < 0.01) but not with localized or advanced tumors. Only one patient with leiomyoma died of liver metastasis during the follow-up period. In univariate analysis of the 45 patients with leiomyosarcoma, the survival rate was poor in men with tumor sizes greater than 5 cm, incomplete resections, advanced tumors, and high-grade tumors. With multivariate Cox regression analysis only advanced tumors (p < 0.01) and high-grade tumors (p < 0.01) were the independent factors that affected survival. CONCLUSIONS: Leiomyosarcomas usually measure more than 10 cm. In univariate analysis the significant factors affecting the survival rate of patients with leiomyosarcoma are maleness, size greater than 5 cm, inadequate resection, and advanced-stage and high-grade disease. In multivariate Cox regression analysis advanced-stage and high-grade leiomyosarcoma are the only independent factors affecting survival. DNA ploidy correlates with the size and the grade of gastrointestinal smooth muscle tumors but not with tumor stage. DNA ploidy does not affect independently the survival of leiomyosarcoma.

Ductal dilatation and stenting make routine hepatectomy unnecessary for left hepatolithiasis with intrahepatic biliary stricture.

BACKGROUND: Hepatolithiasis with intrahepatic biliary strictures, more common in Southeast Asia than elsewhere, remains a difficult problem to manage. Hepatic resection has recently been advocated as one of the treatment modalities for hepatolithiasis; however, this procedure is not without risk. This study was designed to achieve complete clearance of the stones, eliminate bile stasis, and avoid the potential risks of hepatic resection in the patient with hepatolithiasis and intrahepatic biliary stricture. METHODS: In this prospective clinical trial 13 patients with retained left hepatolithiasis and intrahepatic biliary strictures were included. All the patients met the following criteria: (1) initial surgical procedure for hepatolithiasis, (2) normal gross findings of the left liver, and (3) no obvious clinical evidence of an associated intrahepatic cholangiocarcinoma. After the operation they underwent matured T-tube tract ductal dilatation with percutaneous transhepatic cholangioscopy tube stenting. Choledochoscopic electrohydraulic lithotripsy was used in five patients after dilatation when impacted or large stones were encountered. RESULTS: Complete clearance of the stones was achieved in these 13 patients. One patient had fevers develop after ductal dilatation, and another patient had mild hemobilia after electrohydraulic lithotripsy. Both recovered uneventfully with conservative treatment. These successfully treated patients remain well, with a mean follow-up period of 20 months. CONCLUSIONS: Postoperative matured T-tube tract ductal dilatation and stenting, combined with endoscopic electrohydraulic lithotripsy when indicated, is an effective and safe alternative to hepatic resection for selected left hepatolithiasis with intrahepatic biliary stricture.

An evaluation of the prognostic significance of HLA-DR expression in axillary-node-negative breast cancer.

BACKGROUND: Adjuvant treatment for node-negative breast cancer remains controversial. It is important to pick out the high-risk groups who may benefit from adjuvant systemic therapy and avoid the unnecessary additional therapy for the favorable prognostic groups. METHODS AND MATERIAL: Retrospective study of immunohistochemical staining for HLA-DR on tumor cells from paraffin-embedded tissue specimens of 32 patients with node-negative invasive breast cancer at this hospital from 1986 to 1991 was performed with the aim to investigate its prognostic significance. RESULTS: HLA-DR staining was positive in nine (28%) patients and negative in twenty-three (72%) patients. One (11%) was a recurrence, and no (0%) death occurred in the positive group, compared with nine (39%) recurrences and five (22%) deaths in the negative group. The multivariate analysis failed to show that HLA-DR expression is an independent prognostic factor. However, with univariate analysis, the 5-year disease-free survival rate (87%) of the positive group was significantly better than that (35%) of the negative group (p = 0.04). The 5-year overall survival rate (100%) of the positive group was also better than that (66%) of the negative group, but the difference was not statistically significant. Furthermore, when combination of the HLA-DR expression and estrogen receptor status was used, both the 5-year disease-free and overall survival rate (81% and 100%, respectively) of group A (positive staining for either HLA-DR or estrogen receptor and positive staining for both) were significantly better than those (33% and 58%, respectively) of group B (negative staining for both HLA-DR and estrogen receptor). CONCLUSIONS: We believe HLA-DR expression may be a promising, additive predictive factor to node-negative breast cancer and deserves further investigation based on these preliminary results.

Intraoperative choledochoscopic electrohydraulic lithotripsy for difficulty retrieved impacted common bile duct stones.

BACKGROUND: A difficultly retrieved, impacted distal common bile duct stone is sometimes encountered during supraduodenal common bile duct exploration. Transduodenal sphincteroplasty is usually performed when such stones cannot be retrieved by conventional methods, but not without risk. OBJECTIVES: To achieve clearance of such complicated stones and to avoid the potential risks of transduodenal sphincteroplasty. DESIGN: Prospective clinical trial. SETTING: Medical college-affiliated hospital and tertiary care center. PATIENTS: From July 1991 to April 1993, 10 patients met the following inclusion criteria: (1) an impacted distal common bile duct stone found during supraduodenal common bile duct exploration and (2) failure of conventional methods such as stone forceps, a basket, flushing with normal saline solution, or a Fogarty catheter to retrieve stones via the supraduodenal choledochotomy. Another 10 patients with the same problem, treated with transduodenal sphincteroplasty from February 1989 to May 1991, were used as a comparison group. INTERVENTION: Intraoperative choledochoscopic electrohydraulic lithotripsy was applied with continuous visualization through a choledochoscope. MAIN OUTCOME MEASURES: Effectiveness of stone fragmentation and possible complications. RESULTS: Stones were fragmented and successfully removed by a basket and flushing with normal saline solution. Mild oozing was noted in one patient, but soon stopped spontaneously. The mean operative time of the clinical trial group was significantly shorter (P = .004) than that of the comparison group; the mean postoperative stay was 4 days shorter. The complication rate of the clinical trial group (10%) was lower than that of the comparison group (40%). The 10 successfully treated patients of the clinical trial group remain well, with a mean follow-up of 22 months. CONCLUSION: Intraoperative choledochoscopic electrohydraulic lithotripsy is a safe and effective method for removal of impacted distal common bile duct stones.

Postoperative T-tube cholangiography: is routine antibiotic prophylaxis necessary? A prospective, controlled study.

OBJECTIVE: To determine the value of antibiotic prophylaxis for the prevention of infection following postoperative T-tube cholangiography. DESIGN: A prospective, controlled study. SETTING: A tertiary care center. STUDY PARTICIPANTS: The role of antibiotic prophylaxis during postoperative T-tube cholangiography was prospectively evaluated in 164 patients. INTERVENTION: Sixty-two patients were administered antibiotic prophylaxis treatment (1 g of cephalothin sodium was infused intravenously 30 minutes before the procedure and 500 mg of cephalexin was given orally every 6 hours for 3 days after the procedure). Seventy-one patients were in the control group and did not receive antibiotic therapy. MAIN OUTCOME MEASURES: Complications and adverse reactions following postoperative T-tube cholangiography were recorded and compared between the two groups. RESULTS: There was no significant difference between the groups in regard to age, sex, serum amylase level before T-tube cholangiography, white blood cell count, and liver function. The results of the bacteriologic culture specimens of the bile were also comparable between the groups. One patient who had received antibiotic therapy and one patient in the control group had fever (temperature, > 38 degrees C) and chills after the procedure. Two patients who had received antibiotic therapy and one patient in the control group had mild abdominal pain. These complications were treated conservatively without any event. No significant difference was found in the rates of complications and the success of postoperative T-tube cholangiography between the groups. CONCLUSION: Routine antibiotic prophylaxis for the prevention of infection following postoperative T-tube cholangiography is not necessary under selected conditions.

The comparison of clinical course and results of treatment between gas-forming and non-gas-forming pyogenic liver abscess.

OBJECTIVES: To study and review the clinical manifestations, courses, and results of treatment in 83 cases of verified gas-forming pyogenic liver abscess. DESIGN: Case series. SETTING: Both primary and referral hospital care. PATIENTS: Four hundred twenty-four patients with clinical diagnosis of pyogenic liver abscess were enrolled in the study. Eighty-three patients had gas-forming abscesses and 341 had non-gas-forming abscesses. The clinical manifestations, duration of symptoms, incidence of septic shock, laboratory findings, concurrent diabetes mellitus, cause of abscess, size of abscess, and results of treatment were recorded. MAIN OUTCOME MEASURES: A chi 2 test for qualitative data and Student's test for quantitative data. RESULTS: Duration of symptoms were shorter (mean +/- SD, 5.2 +/- 5.3 vs 7.6 +/- 10 days) (P < .005) and the incidence of septic shock was higher in the gas-forming than in the non-gas-forming group (32.5% vs 11.7%) (P < .01). Laboratory findings revealed high levels of blood glucose, aspartate aminotransferase, alkaline phosphatase, and serum urea nitrogen in the gas-forming group. The size of abscess was usually bigger (> 5 cm) in this group. In the gas-forming group, 71 patients (85.5%) had diabetes mellitus and 65 patients (78.3%) had conditions of cryptogenic origin. Klebsiella pneumoniae was the main bacteria, in blood culture and liver aspirates, especially in gas-forming liver abscess. Medical treatment and/or aspiration carried a high mortality rate (44.4%) in the gas-forming group; also, the overall mortality rate was higher in this group than in the non-gas-forming group (27.7% vs 14.4%) (P < .01). CONCLUSIONS: The gas-forming liver abscess may be a disease of wide spectrum of severity and may run a fulminating course. Strong antibiotics with early adequate drainage are mandatory. Surgery should not be delayed if necessary.

Parathyroidectomy can improve bone mineral density in patients with symptomatic secondary hyperparathyroidism.

HYPOTHESIS: The recovery of osteoporosis or bone mineral density (BMD) after parathyroidectomy and autotransplantation can be improved in patients with symptomatic secondary hyperparathyroidism. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Forty-five patients with symptomatic secondary hyperparathyroidism who underwent total parathyroidectomy and autotransplantation were included. They were divided into an osteoporotic group (n = 20) and a nonosteoporotic group (n = 25) according to preoperative T scores less than -2.5 at either the lumbar spine (L1-L4) or the femoral neck (FN). INTERVENTIONS: Serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were checked before surgery and 1 day, 1 week, and 3 months after surgery. The BMDs of the FN and L1-L4 were measured using dual-energy x-ray absorptiometry before surgery and 6 months after surgery. RESULTS: Patients with osteoporosis were older (mean +/- SD, 50.2 +/- 14.0 years) than those without osteoporosis (42.7 +/- 9.1 years) (P =.04). Except for bone fractures found in 2 women in the osteoporotic group, there were no significant differences between the 2 groups in sex, clinical manifestations, duration of dialysis, weight of removed parathyroid tissue, and types of dialysis. Also, serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were similar in both groups. Both 1 day and 1 week after total parathyroidectomy and autotransplantation, serum levels of calcium and intact parathyroid hormone decreased rapidly and then gradually increased 3 months later; however, serum levels of alkaline phosphatase increased rapidly and then gradually decreased 3 months later. Six months after parathyroidectomy, BMD, T score, and Z score at L1-L4 and the FN increased significantly (P<.001). The increment was much better in the osteoporotic group than in the nonosteoporotic group (P<.001). Also, osteopenia or osteoporosis improved significantly after parathyroidectomy at both L1-L4 and the FN (P<.001 for both). CONCLUSION: Parathyroidectomy and autotransplantation can improve BMD of symptomatic secondary hyperparathyroidism at L1-L4 and the FN.

Serum levels of transforming growth factor beta1 in patients with breast cancer.

HYPOTHESIS: Transforming growth factor beta1 (TGF-beta1) may be related to breast cancer progression. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Sixty consecutive patients with invasive breast cancer undergoing surgery were prospectively included and evaluated. The control group consisted of 14 patients with benign breast tumors (7 with fibrocystic disease and 7 with fibroadenoma). INTERVENTION: Venous blood samples were collected before the surgery. Sera were obtained by centrifugation and stored at -70 degrees C until assayed. Serum concentrations of TGF-beta1 were measured by quantitative sandwich enzyme immunoassay. Data on primary tumor stage, age, estrogen receptor status, lymph node status, distant metastases, and TNM staging (according to the Union Internationale Contre le Cancer) were reviewed and recorded. MAIN OUTCOME MEASURES: Measurements of preoperative serum TGF-beta1 levels in patients with breast cancer. RESULTS: The mean +/- SD value of serum TGF-beta1 in patients with invasive breast cancer was 498.7 +/- 249.7 pg/mL and in the control group was 495.2 +/- 225.5 pg/mL (P =.96). However, there were significantly higher serum levels of TGF-beta1 in patients with more advanced lymph node status (P =.04), more advanced TNM stage (P =.005), and poorer histological grade (P =.02). In multivariate analysis, TNM staging (P =.02) was demonstrated to be the independent factor related to significantly higher serum levels of TGF-beta1. CONCLUSIONS: Patients with more advanced TNM stages were shown to have higher serum TGF-beta1 levels. Thus, serum TGF-beta1 levels may reflect the severity of invasive breast cancer.

The prognostic significance of proliferating cell nuclear antigen in patients with lymph node-positive breast cancer.

OBJECTIVE: To evaluate the prognostic significance of proliferating cell nuclear antigen (PCNA) in patients with lymph node-positive primary breast cancer. DESIGN: A retrospective study. SETTING: A tertiary care hospital. STUDY PARTICIPANTS: A consecutive series of 123 patients with lymph node-positive primary breast cancer. INTERVENTION: The PCNA-labeling index [(PCNA-positive cells/1000 cells) x 100] was quantified in paraffin-embedded tissue specimens from 123 patients with lymph node-positive primary breast cancer by immunohistochemical staining. Other important clinicopathological variables, including estrogen receptor status, histological grade, lymph node status, primary tumor status, ploidy pattern, S-phase fraction, and TNM staging, were also identified and evaluated. MAIN OUTCOME MEASURES: The influence of the PCNA-labeling index on the disease-free survival rate and overall survival rate. RESULTS: The PCNA-labeling index of the tissue specimens tested from 123 patients ranged from 11% to 82%. The PCNA-labeling index was closely related to primary tumor status, histological grade, TNM staging, and S-phase fraction. Between patients with a high PCNA-labeling index (> 35%) and those with a low PCNA-labeling index (< or = 35%), there were significant (P < .01) differences in both 5-year disease-free survival rates (2% vs 85%) and 5-year overall survival rates (2% vs 92%). When the PCNA-labeling index and all the clinicopathologic variables were entered into a multivariate analysis for either disease-free survival or overall survival by the Cox proportional hazards model, the PCNA-labeling index emerged as an independent prognostic factor. CONCLUSION: Based on our results, the PCNA-labeling index potentially is a useful prognostic factor for lymph node-positive primary breast cancer.

Computed tomography and angiography in hepatic tuberculosis mimicking liver tumor.

Tuberculosis is one of the most common and well-documented infectious diseases, with a vast variety of clinical manifestations. A case of isolated hepatic tuberculosis mimicking liver tumor is presented. The patient was a 44-year-old man who had suffered from intermittent epigastralgia for about 2 years. Abdominal computed tomography demonstrated a low density mass with internal calcification over the left lobe of the liver. Celiac angiography showed encasement of the hepatic propia and occlusion of the left hepatic artery. Abnormal tortuous vascular structures were found at the hepatic hilar region. The patient underwent surgical intervention under the impression of left liver tumor. Microscopically, the resected liver tissue specimen revealed tuberculosis.

A study on pruritus after parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: The effective therapy for uremic pruritus remains a clinical challenge, and the factors affecting the pruritus before and after parathyroidectomy have not been defined. STUDY DESIGN: Thirty-seven patients were operated on for secondary hyperparathyroidism. Their ages ranged from 14 to 73 years, and the duration of dialysis from 12 to as long as 168 months. Indications for surgery were skin itch in 22 patients and other reasons in 15 patients. Serum levels of calcium, phosphorus, intact PTH (i-PTH), and alkaline phosphatase were checked at two different intervals-before surgery and 1 week after operation. Immunohistochemical stain of mast cells, antihuman macrophage (CD68), antihuman dendritic reticulum cell (CD35), and i-PTH (IHPTH) were performed on skin specimens. Skin samples were prepared into tissue homogenates and analyzed for concentrations of interleukin-2 (II-2) and tumor necrosis factor-alpha (TNF-alpha). II-2 and TNF-alpha were measured by sandwich enzyme-linked immunosorbent assay. The extent of pruritus was evaluated on a visual analog scale (VAS) ranging from 0 to 10 and a behavior rating scale (BRS) ranging from 0 to 5, at a preoperative stage and 1 week after operation. RESULTS: Serum levels of calcium, phosphorus, the product of calcium and phosphorous (Ca x P), alkaline phosphatase, and i-PTH changed significantly after parathyroidectomy. The VAS decreased from 5.4 +/- 3.2 to 1.8 +/- 1.5 (p < 0.001). Significant improvement of BRS was achieved 1 week after surgery (p < 0.001), and in the followup period. Before surgery, there was no correlation between serum levels of calcium, phosphorus, Ca x P, alkaline phosphatase, i-PTH, number of mast cells, CD68, CD35, and IHPTH, and the scale of itch estimated with either VAS or BRS. The tissue levels of Il-2 and TNF-alpha were not detectable in any of them. We noted that high levels of phosphorus and Ca x P affected the postoperative extent of pruritus. But a linear regression test showed Ca x P was the only factor affecting postoperative itch. CONCLUSIONS: Pruritus in patients with secondary hyperparathyroidism can be reduced by parathyroidectomy. Apparently, high-level Ca x P is the only factor that seems to affect the postoperative extent of pruritus.

Prognostic factors for pyogenic abscess of the liver.

BACKGROUND: Percutaneous drainage and antibiotics for pyogenic abscess are well established therapeutic modalities. However, the mortality rate for hepatic abscess of liver remains high. STUDY DESIGN: Three hundred fifty-two cases of pyogenic hepatic abscesses were studied to evaluate prognostic factors. RESULTS: Using univariate analysis, the following factors were associated with a high mortality rate: patient age, gas-forming abscess, rupture of abscess, bilobe involvement, clinical sepsis, bilirubin (more than 2 mg per dL), blood urea nitrogen (more than 20 mg per dL), serum creatinine (more than 2 mg per dL), aspartate aminotransferase (more than 100 U per L), and albumin (less than 2.5 gm per dL). Using multivariate analysis, the following were independent significant factors in predicting mortality: patient age (more than 60 years), blood urea nitrogen (greater than 20 mg per dL), serum creatinine (greater than 2 mg per dL), total bilirubin (greater than 2 mg per dL), and albumin (less than 2.5 gm per dL). CONCLUSIONS: Systemic effects of hepatic abscess with sepsis and multiple organ failure were significant factors in predicting mortality. Local findings, such as rupture of the abscesses, multiple abscesses, and gas-forming abscesses, were not independent factors. Percutaneous drainage is always considered if the condition of the patient can not be improved with antibiotic therapy. Operative treatment is indicated if the patient is unresponsive to medical treatment and percutaneous drainage or if the patient has complications of biliary tract stone or rupture of the abscess.

Improvement of sexual function in male patients after parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: Clinically, the severity of uremia is known to be inversely proportional to sexual desire and activity in patients with chronic renal failure. We studied sexual function and sex hormones in male patients with symptomatic hyperparathyroidism before and 3 months after parathyroidectomy. STUDY DESIGN: From October 1998 to December 2000, 20 male patients with symptomatic secondary hyperparathyroidism were enrolled in this study. They underwent total parathyridectomy and autotransplantation of 90 mg of tissue to the subcutaneous tissue of the forearm or thigh. They all had regular sexual partners and were sexually active. Preoperatively, hemoglobin, hematocrit, calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), prolactin, testosterone, leutenizing hormone (LH), and follicle stimulation hormone (FSH) were checked routinely. Three months after operation those data were checked again. Sexual function was evaluated with the International Index of Erectile Function (IIEF). Monthly frequency of attempted sexual intercourse, satisfaction of attempted intercourse, and enjoyment of intercourse were individually analyzed preoperatively and 3 months postoperatively. RESULTS: Hemoglobin, hematocrit, testosterone, and LH were noted to have not significantly changed 3 months after surgery. Serum levels of calcium, phosphorus, alkaline phosphatase, FSH, and iPTH were significantly reduced, as were the levels of prolactin. But preoperative and postoperative FSH levels were within normal limits, and 70% of the postoperative alkaline phosphatase levels were above normal. Sexual function increased significantly 3 months after parathyroidectomy, as did monthly frequency of attempted intercourse, satisfaction of attempted intercourse, and enjoyment of intercourse. CONCLUSIONS: Sexual function of male patients with symptomatic hyperparathyroidism can possibly be improved by parathyroidectomy and autotransplantation. Decreases in the levels of prolactin, calcium, phosphorus, and iPTH are also noticed after parathyroidectomy.

Serum level of angiogenin in breast cancer.

OBJECTIVE: Angiogenin (ANG), a potent inducer of neovascularization, is secreted by some types of human tumor cells and appears crucial for their growth. This study was designed with the aim to investigate any correlation between the serum angiogenin and the clinicopathological variables and furthermore evaluate the prognostic value of serum angiogenin in patients with breast cancer. MATERIAL AND METHODS: Sixty-four consecutive patients with invasive breast cancer undergoing surgery were prospectively included and evaluated. Venous blood samples were collected before surgery. Sera were obtained by centrifugation and stored at -70 degrees C until assayed. The control group consisted of 16 patients with benign breast tumor (8 with fibrocystic disease and 8 with fibroadenoma). Serum concentration of angiogenin was measured by the quantitative sandwich enzyme immunoassay technique. The data on primary tumor staging, age, estrogen receptor, lymph node status, distant metastases and TNM staging were reviewed and recorded. RESULTS: The mean value of serum angiogenin in patients with invasive breast cancer was 2123.95 +/- 324.34 pg/ml and that of control group were 2108.16 +/- 398.20 pg/ml (fibrocystic disease) and 2010.27 +/- 318.40 pg/ml (fibroadenoma). The difference was not significant (p = 0.66). Furthermore, with univariate analysis, there were no significant differences in serum angiogenin levels between the subgroups of the above-mentioned clinicopathological variables. CONCLUSION: Serum angiogenin levels did not appear as a meaningful prognostic parameter for invasive breast cancer.