Use of azathioprine for graft-vs-host disease is the major risk for development of secondary malignancies after haematopoietic stem cell transplantation: a nationwide population-based study.

BACKGROUND: As more patients are treated by haematopoietic stem cell transplantation (HSCT), development of secondary malignancy (SM) becomes an increasingly common issue in long-term survivors. METHODS: We conducted a nationwide population-based study of the Taiwanese population to analyse patients who received HSCT between January 1997 and December 2010. Standardised incidence ratios (SIRs) were used to compare the risk of SM in HSCT patients and the general population. Multivariate analysis was performed to identify independent predictors of SM. RESULTS: Patients receiving HSCT had a significantly greater risk of developing SM (SIR 2.00; 95% confidence interval (CI) 1.45-2.69; P<0.001). Specifically, the incidence increased for cancers of the oral cavity (SIR 14.18) and oesophagus (SIR 14.75) after allogeneic HSCT. Multivariate analysis revealed an increased SIR for cancer in patients who received the immunosuppressant azathioprine. The risk of SM also increased with greater cumulative doses of azathioprine. CONCLUSIONS: This study demonstrates an increased incidence of SM in Taiwanese patients who received allogeneic HSCT, especially for cancers of the oral cavity and oesophagus. This finding is different from results in populations of Western countries. Physicians should be cautious about azathioprine use for graft-vs-host disease after HSCT.

Long-term risk of tuberculosis in haematopoietic stem cell transplant recipients: a 10-year nationwide study.

BACKGROUND: Tuberculosis (TB) is a serious problem for patients undergoing haematopoietic stem cell transplantation (HSCT) in TB-endemic areas; however, data on these patients are limited. METHODS: We obtained data on 2040 HSCT recipients from the Registry of Catastrophic Illness in Taiwan from 1997 to 2006. We also obtained data on age-, sex- and enrolment date-matched controls from the Longitudinal Health Insurance Database. The cumulative incidence of active TB in HSCT recipients and controls and risk factors for TB were analysed. RESULTS: Among 2040 HSCT recipients identified, 39 (1.9%) had newly diagnosed TB. The incidence rate was 688 per 100 000 person-years. The 10-year cumulative TB incidence was respectively 3.52% and 0.38% in HSCT recipients and controls (P < 0.001). HSCT was an independent risk factor for TB compared with matched controls. Among post-HSCT patients, independent risk factors for TB included age ⩾18 years and allogeneic recipients with graft-versus-host disease (GVHD). Post-HSCT patients with subsequent TB had a higher mortality rate than those without TB (P < 0.001). CONCLUSION: HSCT is associated with an increased risk of TB in endemic regions. Older age and development of chronic GVHD are independent predictors of late onset active TB in HSCT recipients.

Increased stroke risk in Bell's palsy patients without steroid treatment.

BACKGROUND AND PURPOSE: To investigate the risk of stroke development following a diagnosis of Bell's palsy in a nationwide follow-up study. METHODS AND MATERIALS: Information on Bell's palsy and other factors relevant for stroke was obtained for 433218 eligible subjects without previous stroke who had ambulatory visit in 2004. Of those, 897 patients with Bell's palsy were identified. Over a median 2.9 years of follow-up, 4581 incident strokes were identified. We estimated hazard ratios (HR) and 95% confidence intervals [CI] with Cox proportional hazard models adjusting for age, sex, co-morbidities, and important risk factors. Standardized incidence ratio of stroke amongst patients with Bell's palsy was analyzed. RESULTS: Compared with non-Bell's palsy patients, patients with Bell's palsy had a 2.02-times (95% CI, 1.42-2.86) higher risk of stroke. The adjusted HR of developing stroke for patients with Bell's palsy treated with and without systemic steroid were 1.67 (95% CI, 0.69-4) and 2.10 (95%, 1.40-3.07), respectively. CONCLUSIONS: Patients with Bell's palsy carry a higher risk of stroke than the general population. Our data suggest that these patients might benefit from a more intensive stroke prevention therapy and regular follow-up after initial diagnosis.

Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis.

Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0-5mm (mean 2.3mm). The intraoperative mouth opening was 12-20mm (mean 16 mm) after submucous release, and 32-42 mm (mean 35.5mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8-9 cm in length and 2-2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18-38 mm (mean 28.2mm) after a mean of 21 months' follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.

Cadmium availability from granulated and bulk-blended phosphate-potassium fertilizers.

Recent field experiments have shown that high chloride (Cl) in irrigation waters can increase soil cadmium (Cd) uptake by crops because of the formation of soluble ion-pair complexes of Cd with Cl in soil solution. The present study was aimed at testing a hypothesis that KCl in granulated PK fertilizers may enhance Cd uptake by crops from Cd-containing P fertilizers because of close contact between Cd and Cl in the same granules. Less effect would be expected if the same granular PK fertilizers were bulk-blended because of separation of Cd and Cl in different granules. A single superphosphate (SSP) containing 32 mg Cd kg(-1) was granulated by the compaction process with KCl at a P to K ratio = 1:1. Granular KCl was also bulk-blended with granular SSP or Cd-free monocalcium phosphate (MCP) at the same P to K ratio. An acid Ultisol (pH 5.2) was treated with PK fertilizers at 400 mg kg(-1) each for P and K. Upland rice (Oryza sativa L.) and soybean [Glycine max (L.) Merr.] were grown to maturity, and signalgrass (Brachiaria decumbens Stapf.) was cut four times during the study. The results showed that the agronomic effectiveness in increasing crop yield was the same with SSP and MCP whether granulated or bulk-blended with KCl. Concentrations of Cd in plant tissue samples of all crops were much lower for MCP than for SSP. In all the plant tissue samples, except grain samples of upland rice, Cd concentrations obtained with granulated (SSP + KCl) were significantly higher than that with bulk-blended (SSP) + (KCl).

Photodissociation of ethylene sulfide at 193 nm: a photofragment translational spectroscopy study with VUV synchrotron radiation and ab initio calculations.

Photodissociation of ethylene sulfide at 193 nm has been studied using photofragment translational spectroscopy and ab initio theoretical calculations. Tunable synchrotron radiation was used as a universal but selective probe of the reaction products to reveal new aspects of the photodissociation dynamics. The channel giving S + C2H4 was found to be dominated by production of ground-state sulfur atoms (S(3P):S(1D) = 1.44:1), mostly through a spin-forbidden process. The results also suggest the presence of a channel giving S(3P) in conjunction with triplet ethylene C2H4 (3B(1u)) and allow insight into the energy of the latter species near its equilibrium geometry, in which the two methylene groups occupy perpendicular planes. In addition, a channel leading to the production of H2S with C2H2 also has been observed. Our experimental results are supported and elaborated by theoretical calculations.

Mechanical properties of heel pads reconstructed with flaps.

We compared the mechanical properties of normal and reconstructed heel pads in seven patients. Four had latissimus dorsi flaps and one each an anterior thigh flap, a local dorsalis pedis flap and a sural arterial flap. The thickness of the heel pad was measured under serial incremental loads of 0.5 kg to a maximum of 3 kg and then relaxed sequentially. The load-displacement curve of the heel pad during a loading-unloading cycle was plotted and from this the unloaded heel-pad thickness (UHPT), compressibility index (CI), elastic modulus (Ep), and energy dissipation ratio (EDR) were calculated. The EDR was significantly increased in the reconstructed heels (53.7 +/- 18% v 23.4 +/- 6.5%, p = 0.003) indicating that in them more energy is dissipated as heat. Insufficient functional capacity in the reconstructed heel pad can lead to the development of shock-induced discomfort and ulceration.

Surgical treatment of pathologic fracture of the femur.

A retrospective study of the surgical treatment of 32 metastatic lesions of the femur in 30 patients at the Kaohsiung Medical College Hospital was performed from 1987 to 1994. There were 16 women and 14 men with an average age of 61 years. A surgical technique combining internal fixation or prosthesis and methylmethacrylate cement was used in all cases. Adequate pain relief was achieved in thirty-one cases (97 %). Of the entire group, 20 cases (62%) remained ambulatory, 10 cases (31%) were confined to a wheelchair, only two cases had implant failure and one suffered from infection.

No association of dopamine D2 receptor molecular variant Cys311 and schizophrenia in Chinese patients.

A serine-to-cysteine mutation of dopamine D2 receptor at codon 311 (Cys311) was found to have higher frequency in schizophrenic patients than in normal controls in Japanese by Arinami et al. [1994: Lancet 343: 703-704]. The Cys311 allele was found to be associated with patients with younger age-of-onset, positive family history, and more positive symptoms. To investigate the possible involvement of Cys311 in schizophrenia in the Chinese population, 114 unrelated Taiwanese Chinese schizophrenic patients with positive family history and 88 normal controls were genotyped for Cys311. Four patients and 5 normal controls were heterozygotes of Ser311/Cys311; no homozygotes of Cys311 were identified in either group. The allele frequencies of Cys311 in Chinese schizophrenic patients and normal controls were 2% and 3%, respectively. No significant difference was detected between the two groups. Our results do not support the argument that the Cys311 allele of DRD2 poses a genetic risk for certain types of schizophrenia in Chinese populations.

A fixational method of tendon transfer in foot surgery.

Tendon transfer has been used for correcting foot deformities and improving foot function in paralytic and spastic foot problems. The traditional fixational method by Cole's pull-out button often induces pressure sores which make the button sink and loosens the transferred tendon, leading to poor surgical results. By using a metal eye cover and pull-out wire instead of button and suture material, the transferred tendon can be firmly fixed. Moreover, the concavity of the metal eye cover is suitable for the arch of the foot that provides a large contact surface & even pressure distribution to prevent the most common complications of the pull-out button method, the pressure sore.

Immunoglobulin and T-cell receptor gene rearrangements in acute lymphoblastic leukemia--a higher incidence of double rearrangements in patients with myeloid antigen expression.

Among 160 patients who were diagnosed as having acute lymphoblastic leukemia (ALL) by French American British (FAB) criteria, 32 patients (20%) expressed myeloid-associated antigens on leukemic blasts (My+ALL). Correlation of immunophenotype with rearrangement of immunoglobulin (Ig) heavy chain and T-cell receptor (TCR) beta chain genes was performed on 73 of these patients (21 were My+ALL). Rearrangements of both Ig and TCR genes (double rearrangements) were detected in 24 patients, including three (19%) of 16 T-lineage ALL. 17 (33%) of 52 B-lineage ALL, and four of five ALL expressing both B and T-cell surface markers. Also a higher incidence of double rearrangements in My+ALL was found as compared with My-ALL (43% vs 29%). This difference was more evident when only B-lineage ALL was considered (50% in My+ patients vs 24% in My- patients). However the difference is not statistically significant yet possibly due to the small number of patients in the study. Further studies on more patients are needed to confirm this. In My-B-lineage ALL, rearrangements of TCR beta chain gene were restricted to certain subgroups (Groups III & IV) of patients who expressed CD10 surface antigens but lacked cytoplasmic Ig. In My+ B-lineage ALL, rearrangements of TCR beta chain gene could be found in various subgroups studied (Groups II through V). Cross-lineage gene rearrangement in My+ALL may involve mechanisms different from those in My-ALL.

Chromosomal characteristics of Ph-positive chronic myelogenous leukemia in transformation. A study of 23 Chinese patients in Taiwan.

Cytogenetic study was performed in the past 3 years on 23 Chinese patients with Philadelphia chromosome (Ph) positive chronic myelogenous leukemia (CML) in transformation; seven were in accelerated phase and 16 in acute blast crisis. Chromosomal abnormalities in addition to Ph were found in three (43%) of the patients at accelerated phase and 14 (88%) of the patients at blast crisis. The common nonrandom chromosomal aberrations were double Ph, trisomy 8, trisomy 19, and trisomy 21, which occurred in 47%, 41%, 35%, and 29%, respectively, of the total patients with extra chromosomal abnormalities. Isochromosome for the long arm of chromosome 17 was found in only one patient. In patients with blast crisis, the type of blast cell was characterized through morphologic, cytochemical, and immunocytochemical studies. Eleven cases were classified as myeloid and five as lymphoid transformation. Trisomy 8, 19, and 21 were detected only in patients with myeloid blast crisis. This study also revealed a high incidence of trisomy 21 and a low incidence of i(17q) in Chinese patients with transformation of CML.