What happens after no contralateral exploration in total extraperitoneal (TEP) herniorrhaphy of clinical unilateral inguinal hernias?

BACKGROUND: While performing unilateral TEP herniorrhaphy, controversy still exists about whether to do contralateral exploration or not. Routine contralateral exploration has been proposed to prevent metachronous contralateral hernias by the repair of incidental contralateral occult hernias. Some surgeons have even proposed to do prophylactic bilateral TEP herniorrhaphy for unilateral hernia patients. To evaluate the appropriateness of not doing contralateral exploration in unilateral TEP herniorrhaphy, we reviewed our experiences under our practice of no contralateral exploration and we also reviewed other published literature. METHODS: A total of 305 patients who underwent 313 TEP herniorrhaphies for inguinal hernias by a single surgeon during August 2012-July 2016 at Chia-Yi Christian Hospital were enrolled in this retrospective study. Demographic, perioperative and follow-up data were obtained for analysis and review. RESULTS: Of the 305 patients, 261 patients had unilateral TEP herniorrhaphy and 44 patients had bilateral TEP herniorrhaphy. The mean operation time for the unilateral TEP herniorrhaphy group was 59.8 min, and for the bilateral TEP herniorrhaphy group it was 85.2 min (p < 0.001). Seven of 261 (2.7%) patients had metachronous contralateral hernia after unilateral TEP herniorrhaphy. There were no statistically significant differences in any of the outcome variables when comparing the sequential and simultaneous primary bilateral TEP herniorrhaphies. CONCLUSIONS: Without routine contralateral exploration, the incidence of metachronous contralateral hernia was 2.7% (7/261) in unilateral hernia patients. This is acceptable as metachronous hernia also occurred in 3.2% of patients with negative contralateral exploration according to our literature review. Sequential and simultaneous bilateral primary TEP herniorrhaphy outcomes were similar. We conclude that no exploration for the other groin is a justified decision for unilateral inguinal hernia patients.

Trismus, xerostomia and nutrition status in nasopharyngeal carcinoma survivors treated with radiation.

The aims of the study were to: (1) examine levels of trismus, xerostomia and nutritional status; (2) compare levels of trismus, xerostomia and nutritional status in patients with nasopharyngeal carcinoma (NPC) receiving different types of radiation modalities; and (3) identify factors related to NPC survivors' risk status for malnutrition and existing malnutrition. A cross-sectional study with consecutive sampling was conducted. NPC survivors were recruited from otolaryngology/oncology outpatient clinics in a medical centre in Northern Taiwan. Study measures included (1) Mandibular Function Impairment Questionnaire, (2) Xerostomia Questionnaire, (3) Mini Nutrition Assessment, (4) Hospital Anxiety and Depression Scale - Depression subscale, and (5) Symptom Severity Scale. A total of 110 subjects were recruited. Those receiving intensity-modulated radiation therapy had less trismus and xerostomia than patients receiving two-dimensional radiation therapy. Patients with female gender, advanced stage, completion of treatments within 1 year, higher levels of depression, more severe trismus and higher symptom severity tended to have malnutrition or were at risk of malnutrition. Trismus and xerostomia are long-term problems in some NPC survivors and may contribute to malnutrition. To better manage a patient's trismus and xerostomia and to enhance nutritional status, clinicians should develop a patient-specific care programme based on careful assessment and targeted measures to improve oral function and insure adequate nutritional intake.

Laparoscopic Roux-en-Y gastric bypass in a morbidly obese patient with renal transplant: a case report.

Renal transplant is the only curative treatment for end-stage renal disease. As diabetes and obesity are the major causes of graft failure and post-transplant complication, it is important to manage obesity in patients with renal transplant. Herein, we report a case of a morbidly obese renal-transplant patient with poorly controlled diabetes who received bariatric surgery. A 34-year-old obese Taiwanese man with type 2 diabetes had end-stage renal disease that had progressed since 2008, when he had commenced hemodialysis (January 2008) and had a renal transplant (July 2008). Because of persistent obesity and poorly controlled diabetes, he received LRYGB at Chiayi Christian hospital on 18 August 2010. In the month that followed, he lost 10 kg. His serum creatinine decreased to 1.11 mg/dL (1.4 mg/dL, preoperative) and his hemoglobin A1c decreased to 8.5% (10.4%, preoperative). These results indicate that, in obese renal transplant patients, LRYGB may be employed to treat obesity, control diabetes and stabilize or improve the renal function.

Observation of a near-threshold enhancement in the e+e- -->Lambda+_(c)Lambda-_(c) cross section using initial-state radiation.

We report a measurement of the exclusive e+ e- -->Lambda+_(c)Lambda-_(c) cross section as a function of center-of-mass energy near the Lambda+_(c)Lambda-_(c) threshold. A clear peak with a significance of 8.2sigma is observed in the Lambda+_(c)Lambda-_(c) invariant mass distribution just above threshold. With an assumption of a resonance origin for the observed peak, a mass and width of M=[4634 (+8)_(-7)(stat)(+5)_(-8)(syst)] MeV/c(2) and Gamma_(tot)=[92 (+40)_(-24)(stat)(+10)_(-21)(syst)] MeV are determined. The analysis is based on a study of events with initial-state-radiation photons in a data sample collected with the Belle detector at the Upsilon(4S) resonance and nearby continuum with an integrated luminosity of 695 fb(-1) at the KEKB asymmetric-energy e+ e- collider.

Observation of the psi(4415)-->DD2*(2460) decay using initial-state radiation.

We report measurements of the exclusive cross section for e(+)e(-)-->D(0)D(-)pi(+) over the center-of-mass energy range 4.0 GeV to 5.0 GeV with initial-state radiation and the first observation of the decay psi(4415)-->D(0)D(-)pi(+). From a study of the resonant substructure in psi(4415) decay we conclude that the psi(4415)-->D(0)D(-)pi(+) decay is dominated by psi(4415)-->DD(2)(*)(2460). We obtain B(psi(4415)-->D(0)D(-)pi(nonresonant)(+))/B(psi(4415)-->DD(2)(*)(2460)-->D(0)D(-)pi(+))<0.22 at 90% C.L. The analysis is based on a data sample collected with the Belle detector with an integrated luminosity of 673 fb(-1).

Evaluation of transforming growth factor and vascular endothelial growth factor polymorphisms in Taiwan Chinese patients with pterygium.

PURPOSE: Pterygium is an invasive and highly vascularized growth, thought to arise from activated and proliferating limbal epithelial stem cells. Epidemiologic studies have found the increase of active angiogenic and epithelial growth factors in pterygia, and implicated that these molecules could be involved directly or indirectly in the pathogenesis of pterygia as causative factors. The aim of this study was to investigate the association of polymorphisms of transforming growth factor (TGF) and vascular endothelial growth factor (VEGF) with pterygium. METHODS: A total of 133 pterygium patients and 105 volunteers without pterygium were enrolled in this study. Polymerase chain reaction based restriction fragment length polymorphism analysis was used to resolve the TGF-Beta1-509 and VEGF-460 genotypes. RESULTS: There was no significant difference in the allele frequency or genotype of TGF-Beta1-509 or VEGF-460 between total pterygium and the control group. No interaction between TGF-Beta1-509 and VEGF-460 was found either. CONCLUSIONS: These results indicate that TGF-Beta1-509 and VEGF-460 polymorphisms were not highly associated with the pathology of pterygium. However, it may still be worthwhile to continue to search for angiogenic gene polymorphisms in order to predict the development of pterygium.

Observation of two resonant structures in e+ e- -->pi+ pi- psi(2S) via initial-state radiation at Belle.

The cross section for e+ e- --> pi+ pi- psi(2S) between threshold and sqrt[s]=5.5 GeV is measured using 673 fb(-1) of data on and off the Upsilon(4S) resonance collected with the Belle detector at KEKB. Two resonant structures are observed in the pi+ pi- psi(2S) invariant-mass distribution, one at 4361 +/- 9 +/- 9 MeV/c2 with a width of 74 +/- 15 +/- 10 MeV/c2, and another at 4664 +/- 11 +/- 5 MeV/c2 with a width of 48 +/- 15 +/- 3 MeV/c2, if the mass spectrum is parametrized with the coherent sum of two Breit-Wigner functions. These values do not match those of any of the known charmonium states.

Treatment of malignant bone tumours by extracorporeally irradiated autograft-prosthetic composite arthroplasty.

Autogenous bone graft which has been either autoclaved or irradiated is commonly used in oriental countries as an alternative to allograft. We started to use the technique of extracorporeal irradiation of the resected specimen and reimplantation (ECIR) in 1991. There was, however, a high incidence of fracture of the irradiated bone and loss of articular cartilage. In an attempt to reduce these complications, we combined the irradiated autograft with a conventional arthroplasty. Between 1995 and 1998, 14 patients underwent limb salvage by this method. Seven had an osteosarcoma, two bony metastases, three a chondrosarcoma, one a malignant fibrous histiocytoma, and one a leiomyosarcoma. Ten tumours were located in the proximal femur, two in the proximal humerus, and two in the distal femur. One patient who had a solitary metastasis in the proximal part of the left femur died from lung metastases 13 months after operation. The remaining 13 patients were alive and without evidence of local recurrence or distant metastases at a mean follow-up of 43 months (28 to 72). Postoperative palsy of the sciatic nerve occurred in one patient, but no complications such as wound infection, fracture, or nonunion were seen. All host-irradiated bone junctions healed uneventfully within eight months. Using the Enneking functional evaluation system, the mean postoperative score for all 14 patients was 80% (57 to 93). The use of irradiated autograft prosthesis composites reduces the complications of ECIR and gives good functional results. It may be a good alternative in limb-salvage surgery, especially in countries where it is difficult to obtain allografts.

The developments of mass urinary screening in Taiwan.

A program of mass urinary screening of elementary and junior high school students has been in operation since August 1990 in Taiwan Province. This program is done once a semester, i.e., twice a year. In the first 3 years, the total number of elementary and junior high school students to be examined in each semester was approx. 2.7 millions. From August 1993, the total number increased to 3.1 millions because the senior high and senior vocational school students were added. The procedures can roughly be divided into five parts: The first part is first urinary screening. The second part is the second urinary screening. The third part is so called the third examination namely serological examination. Life guidance is introduced in the fourth part. The last part is the follow-up system. All the procedures and details will be discussed later.

Assembly and release of human immunodeficiency virus type 1 Gag proteins containing tandem repeats of the matrix protein coding sequences in the matrix domain.

We have constructed human immunodeficiency virus (HIV) gag mutants by increasing the matrix protein (MA) sequences via tandemly repeated duplication of the central 107-MA codons. Instead of a total of 132 amino acid residues for the wild-type MA, the resultant mutants designated as MA2, MA3, and MA4 contained a total of 242, 352, and 462 codons in the MA domains, respectively. Analysis indicated that the addition of 110 or 220 amino acid residues to the MA did not significantly affect the assembly, release, and processing of particles; however, particle production was markedly reduced when another copy of 110 residues was added to the MA. Subcellular fractionation analysis suggested that the MA tandem repeat mutations enhanced the Gag membrane affinity, in a manner which correlated with the copy number of MA sequences. The effects of enhanced membrane affinity were substantially reduced when sequences downstream of the capsid (CA) domain were deleted. Sucrose density gradient fractionation analysis showed that particles produced by the large insertion mutants possessed wild-type (wt) HIV particle density. Truncation of sequences downstream of the nucleocapsid (NC) domains of the mutants did not influence the budding of particles. In contrast, particle budding was severely impaired when sequences downstream of the CA domain were truncated. Particle densities for the large Gag proteins, which were truncated at the C-terminus of CA, were about 1.12-1.14 g/ml lower than that for wt. Our results suggest that the HIV MA domain could adopt insertions of large protein sequences, and strongly support the proposal that the NC and p2 domains play a crucial role in the process of correct Gag protein packing.

Analysis of a human immunodeficiency virus type 1 gag mutant with an engineered 110-amino-acid insertion in the matrix protein domain.

A human immunodeficiency virus (HIV) matrix (MA) protein mutant was constructed by duplication of 107 codons of the HIV-1 MA domain. This MA protein duplication mutant (MAII) still could assemble and process particles, had a wild-type (wt) HIV particle density, and possessed reverse transcriptase activity of about 80% of the wild type virus level. The incorporation of HIV Env and viral RNA genome was not greatly affected. The MAII was noninfectious or poorly infectious, however, when pseudotyped with an amphotropic murine leukemia virus envelope protein or with the HIV envelope protein. Although the MAII mutant displayed an immunofluorescence staining pattern similar to that of the wild type virus, subcellular fractionation studies indicated that the membrane association of MAII Gag precursors was unstable under high-salt conditions. Electron microscopic studies showed that the mutant had a decreased density of particle cores compared with that of the wild type virus, suggesting an altered arrangement of the packed proteins. As this insertion in the MA gene caused no major effects on virus assembly implies that the HIV-1 gag has the potential to adapt large insertions of extra coding sequences without loss of the ability to direct particle assembly and release.

Assembly and processing of human immunodeficiency virus Gag mutants containing a partial replacement of the matrix domain by the viral protease domain.

We constructed human immunodeficiency virus (HIV) mutants by replacing the matrix domain with sequences encoding the viral protease or p6* and protease. The chimeras retaining matrix myristylation and processing signals underwent efficient autoprocessing with severely defective particle budding. The budding defects of the chimeras were rescued by suppressing the chimera protease activity either through addition of an HIV protease inhibitor or through inactivating the chimera protease via a substitution mutation of the catalytic aspartic acid residue. This resulted in the release of chimeric virus-like particles with the density of a wild-type retrovirus particle. In addition, the assembly-competent but processing-defective chimeras produced proteolytically processed particles with significant reverse transcriptase activity when a downstream native pol gene was present. These results suggest that HIV has the potential to adapt heterologous sequences in place of the matrix sequence without major effects on virus-like particle budding. In addition, the positions of the protease and substrate accessibility may contribute significantly toward avoiding a premature Gag or Gag-Pol process, which leads to severe defects in both particle budding and incorporation.

Central retinal vein occlusion due to hyperviscosity syndrome.

A 57-year-old man with no previous medical history entered the emergency department with 2 days of painless vision loss in the left eye. The patient was diagnosed with central retinal vein occlusion (CRVO) and admitted for treatment. Further work-up revealed that the cause of his CRVO was a hyperviscosity syndrome secondary to multiple myeloma. The patient received two rounds of plasmapheresis with slight recovery of vision and was discharged 28 days later.

Product development of AG-331 lyophilized powder for injection.

AG-331, a water-soluble glucuronate salt of a potential anticancer drug, was synthesized using a technology described as "Protein Structure-based Drug Design." A lyophilized product containing 44.4% (w/w) of AG-331, 55.6% (w/w) of mannitol and trace of water was developed for parenteral delivery of AG-331. The pre-lyophilized solution, which contains 2.0% (w/v) of AG-331 and 2.5% (w/v) mannitol can be aseptically filtered through commonly used 0.2-micron filters without significant AG-331 loss. The filter of choice was made of PTFE (polytetrafluoroethylene) membrane. The lyophilized product is stable under accelerated conditions for at least 6 months. The product can be sterilized with gamma-irradiation. The AG-331 reconstituted solution in 5% Dextrose Injection, USP is stable in PVC infusion bags for at least 2 days at 5 degrees C and 30 degrees C.

The Fusarium solani-induced expression of a pea gene family encoding high cysteine content proteins.

Two pea genes, pI39 and pI230, which are specifically induced by two forma specials of Fusarium solani, encode closely related proteins with predicted molecular masses (Mr) of 8.2 and 8 kDa, respectively. Both proteins contain a signal sequence and are cleaved to mature proteins of Mr 5 kDa as indicated by an in vitro translation system. The mature proteins contain about 17% cysteine residues and have the potential to form four disulfide bonds. The two proteins share extensive homology in their signal sequences but much less homology as mature proteins. The cysteine residues of the mature proteins are highly conserved, suggesting functional importance. Southern hybridization suggests these genes belong to a multigene family. The relative accumulations of mRNA levels indicate that the two genes are expressed somewhat differentially. In both the compatible (susceptible) and incompatible reactions between F. solani and pea tissue, pI39 mRNA accumulates more slowly than pI230 mRNA and accumulates to relatively high levels after 24 hr of inoculation. The increase in accumulation of pI230 mRNA occurs within 6 hr and thus correlates with an initial suppression of the growth of both the compatible and incompatible pathogen, which is cytologically observable at 6 hr. pI39 and pI230 belong to a distinct class of pathogenesis-related proteins characterized previously, which are associated with and thus may contribute to nonhost resistance in plants.

Cloning and characterization of a disease resistance response gene in pea inducible by Fusarium solani.

Disease resistance response genes (DRRG) of peas are expressed as the tissue is expressing race-specific or nonhost resistance. A pea genomic clone DRRG49-c encompassing one DRRG structural gene, the expression of which is correlated with the expression of disease resistance, was sequenced and characterized. The 2.3-kb genomic segment sequenced encompassed 986 bp 5' to the major transcriptional initiation site, a 474-bp open-reading frame interrupted by one 88-bp AT-rich intron and an additional 574-bp segment 3' from the stop codon. Southern blot analysis indicated that the DRRG structural gene is one of a multigenic family, and an estimated five copies exist within the pea genome. Primer extension analysis of the 5' terminus of the corresponding RNA suggested the presence of one major transcript with possibly two minor transcripts. The major transcript, located 65 bp from the translational initiation site, was expressed when challenged with Fusarium solani f. sp. phaseoli but not with water. The structural gene sequence corresponding to the genomic clone DRRG49-c is not identical with the structural gene of the cDNA clone DRRG49-a used as a probe for northern blot analysis, and thus, a possibility remains that it is not expressed in peas; however, the DRRG49-c promoter was able to express the chloramphenicol acetyltransferase reporter gene in tobacco protoplasts. Western blot analysis using antiserum prepared from a beta-galactosidase-DRRG49-a fusion protein identified the DRRG49 gene product as a major protein accumulating during the host-pathogen interactions.

Drug permeation across the skin: effect of penetrant hydrophilicity.

The hydrophilicity of progesterone, a lipophilic steroid itself, was progressively increased by incorporating one or more hydroxy substituents at different positions on the steroidal skeleton. Effects of these hydrophilic substituents on the permeation of progesterone across the intact skin and stripped skin of the hairless mouse were studied using a hydrodynamically well-calibrated in vitro skin permeation system. The steady-state rate of permeation across the intact skin and stripped skin was found to be approximately proportional to the solubility of drugs in the stratum corneum or in the viable skin, respectively. Furthermore, the solubility of progesterone and its hydroxyl derivatives in the stratum corneum was noted to decrease gradually as the hydrophilicity of the penetrant increased. This finding was similar to that of a previously reported study of drug permeation across the lipophilic silicone membrane. However, the solubility of these progestins in the viable skin was observed to be dependent not only on the penetrant hydrophilicity but also on the position of the OH group on the penetrant molecule. The diffusivity of progesterone and its hydroxyl derivatives across the stratum corneum and viable skin was almost independent of the hydrophilicity of the drugs.