A real-time prediction model for post-irradiation malignant cervical lymph nodes.

OBJECTIVE: To establish a real-time predictive scoring model based on sonographic characteristics for identifying malignant cervical lymph nodes (LNs) in cancer patients after neck irradiation. METHODS: One-hundred forty-four irradiation-treated patients underwent ultrasonography and ultrasound-guided fine-needle aspirations (USgFNAs), and the resultant data were used to construct a real-time and computerised predictive scoring model. This scoring system was further compared with our previously proposed prediction model. RESULTS: A predictive scoring model, 1.35 × (L axis) + 2.03 × (S axis) + 2.27 × (margin) + 1.48 × (echogenic hilum) + 3.7, was generated by stepwise multivariate logistic regression analysis. Neck LNs were considered to be malignant when the score was ≥ 7, corresponding to a sensitivity of 85.5%, specificity of 79.4%, positive predictive value (PPV) of 82.3%, negative predictive value (NPV) of 83.1%, and overall accuracy of 82.6%. When this new model and the original model were compared, the areas under the receiver operating characteristic curve (c-statistic) were 0.89 and 0.81, respectively (P < .05). CONCLUSIONS: A real-time sonographic predictive scoring model was constructed to provide prompt and reliable guidance for USgFNA biopsies to manage cervical LNs after neck irradiation.

Prognostic impact of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in nasopharyngeal carcinoma: A retrospective study of 180 Taiwanese patients.

OBJECTIVES: Nasopharyngeal cancer (NPC) is an endemic disease in Taiwan. Prognostic factors the anatomical TNM stage are important for its prognostic stratification. An elevated neutrophil-to-lymphocyte ratio (NLR) has been reported to be associated with poor prognosis in various solid tumours. In this study, we analysed the prognostic impact of the NLR in NPC in Taiwan. DESIGN: Single-institution retrospective study. SETTING: Medical centre. PARTICIPANTS: One hundred and eighty patients with NPC treated at the Far Eastern Memorial Hospital, Taiwan, from January 2007 to December 2013. MAIN OUTCOME MEASURES: The association between the clinical or haematological presentations and the prognosis. RESULTS: The majority of the 180 patients included in this study were men (80%) and were <65 years old (91.7%). A neck mass (55.6%) was the most common clinical presentation, followed by nasal (39.4%) and aural (30.6%) symptoms. In addition, the majority (75.4%) of patients had advanced stage (III and IV) disease. Patients with a high NLR (≧3.6) had significantly lower progression-free survival, overall survival and disease-specific survival rates. The association between high NLR and poor prognosis was more pronounced in patients with advanced disease than in those with early-stage NPC. The results of a multivariate analysis revealed that advanced age, clinical symptoms including headache, diplopia and facial numbness, advanced disease stage, and high NLR were independent prognostic factors. CONCLUSION: A high NLR is an independent poor prognostic factor of NPC in Taiwan.

Effects of comorbidity and medication use on the haemodynamic status during office-based laryngeal procedures: A prospective cohort study.

OBJECTIVE: Office-based laryngeal procedures (OBLPs) are emerging as effective alternative modalities for vocal disorders. This study systematically investigates the haemodynamic status of patients, specifically focusing on the potential effects of underlying comorbidity and medication use. DESIGN: Prospective cohort study. SETTING: Tertiary referral centre. PARTICIPANTS: We prospectively recruited 214 consecutive patients who received OBLPs during January-December 2015. All procedures were performed under local anaesthesia without sedation, in an upright (sitting) position. MAIN OUTCOME MEASURES: We measured heart rate (HR), systolic and diastolic blood pressure, and oxygen saturations at baseline (before procedure), immediately after local anaesthesia to the pharynx and larynx, immediately after completing of procedure, and 20 minutes after the procedure. RESULTS: Systolic, diastolic blood pressures and HR all significantly increased after local anaesthesia, and gradually decreased after the procedure (P<.01). Oxygen concentration remained unchanged. Patients with comorbidity and those receiving vasoactive medications showed significantly higher perioperative blood pressures than the other patients (P<.05), but the trend remained similar. Prominent hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg) was noted in 17 patients, more commonly in patients with older age, higher baseline blood pressures and receiving vasoactive medications. Only 2% of patients with normal baseline measurements developed prominent hypertension perioperatively. Tachycardia (HR≥100 bpm) developed in 22 patients, more frequently in patients with higher baseline HRs, and perceiving greater discomforts. CONCLUSION: This study revealed that routine haemodynamic monitoring may not be necessary for all the OBLPs, but should be considered for older patients, those with higher baseline blood pressure or HR, sensitive patients who might be more susceptible to perioperative discomfort, and those receiving vasoactive medications.

Isolated adult Langerhans' cell histiocytosis in cervical lymph nodes: should it be treated?

OBJECTIVE: We report an extremely rare case of Langerhans' cell histiocytosis involving isolated cervical lymph nodes, and we discuss the diagnosis and treatment of this infrequent disease. METHOD: We present a case report and literature review concerning this disease entity. RESULTS: A 54-year-old man presented with persistent, multiple, left neck masses. Histopathological study of lymph node specimens showed proliferation of Langerhans' cells coupled with eosinophilic and neutrophilic microabscesses. Positive immunohistochemical staining for Cluster of Differentiation 1a (CD1a) in Langerhans' cells confirmed the diagnosis. No other abnormalities were noted on a series of image studies. The patient was managed with 'watchful waiting' without subsequent therapy. The neck lesions regressed gradually over time, and the patient did well over a two-year follow-up period. CONCLUSION: The clinical presentation of Langerhans' cell histiocytosis is highly variable, and the choice of treatment depends on the involved organs. Definitive diagnosis depends on identification of characteristic immunohistochemical or ultrastructural features of the biopsy specimen. Watchful waiting may be an effective management strategy in cases of adult isolated lymph node Langerhans' cell histiocytosis, due to its possible spontaneous regression.

Migration of ventriculoperitoneal shunt into the stomach, presenting with gastric bleeding.

We present an extremely rare complication after ventriculoperitoneal shunting. The peritoneal tube migrated into the stomach 8 months after the operation and patient presented with gastric bleeding.

Modulation of catecholamine release by endogenous adenosine in the rat adrenal medulla.

Adenosine was shown to inhibit norepinephrine (NE) release from sympathetic nerve endings. The purpose of this study was to examine whether endogenous adenosine restrains NE and epinephrine release from the adrenal medulla. The effects of an adenosine receptor antagonist, 1,3-dipropyl-8-(p-sulfophenyl) xanthine (DPSPX), on epinephrine and NE release induced by intravenous administration of insulin in conscious rats were examined. Plasma catecholamines were measured by HPLC with an electrochemical detector. DPSPX significantly increased plasma catecholamine in both control rats and rats treated with insulin. The effect of DPSPX on plasma catecholamine was significantly greater in rats treated with insulin. Additional experiments were performed in adrenalectomized rats to investigate the contribution of the adrenal medulla to the effect of DPSPX on plasma catecholamine. The effect of DPSPX and insulin on epinephrine in adrenalectomized rats was significantly reduced compared with that of the controls. Finally, we tested whether endogenous adenosine restrains catecholamine secretion partially through inhibiting the renin-angiotensin system. The effect of DPSPX on plasma catecholamine in rats pretreated with captopril (an angiotensin-converting enzyme inhibitor) was reduced. These results demonstrate that under basal physiological conditions, endogenous adenosine tonically inhibits catecholamine secretion from the adrenal medulla, and this effect is augmented when the sympathetic system is stimulated. The effect of endogenous adenosine on catecholamine secretion from the adrenal medulla is achieved partially through the inhibitory effect of adenosine on the renin-angiotensin system.

Epstein-Barr virus-associated hemophagocytic syndrome masquerading as lymphoma: a case report.

Virus-associated hemophagocytic syndrome (VAHS) is a non-neoplastic, generalized histiocytic proliferation with prominent hemophagocytosis associated with a systemic viral infection. Although Epstein-Barr virus (EBV) is one candidate virus for this association, thorough serologic and molecular biologic studies to determine the presence of the viral infection have been lacking in many reports. Whereas elevated liver function tests are common findings in patients with VAHS, exudative ascites and abdominal lymphadenopathy are rare. We describe a case of EBV-AHS masquerading as lymphoma in which treatment with intravenous immunoglobulins was associated with complete clinical remission at 2 years and 6 months after the onset. Regardless of the exact mechanism responsible for ascites formation in VAHS, this case adds support to the possible involvement of EBV in patients with abdominal lymphadenopathy and ascites.

Acute disseminated encephalomyelitis in autoimmune hemolytic anemia.

A 16-year-old female with chronic autoimmune hemolytic anemia is presented. She was diagnosed with acute disseminated encephalomyelitis by clinical findings and magnetic resonance imaging (MRI), and the condition occurred after a systemic infection with Cryptococcus neoformans. Intravenous immunoglobulin therapy remarkably improved the patient's neurologic deficit and resolved abnormalities evidenced on MRI. To our knowledge, this report is the first of a pediatric patient with autoimmune hemolytic anemia complicated by acute disseminated encephalomyelitis that developed after an apparently successful treatment of cryptococcal meningitis.

Suspected nasopharyngeal carcinoma in three workers with long-term exposure to sulphuric acid vapour.

Sulphuric acid vapour has been suspected of being an industrial carcinogen. In this study, a cluster is presented of three patients with nasopharyngeal carcinoma (NPC) who worked in the same building of a telecommunications conveyance station in southern Taiwan with long term exposure to sulphuric acid vapour concentrations as high as 0.18 mg/m3. All three workers were diagnosed with NPC within a 5 month period between September 1992, and March 1993. Compared with 19 other healthy workers from the same building, these three workers with NPC had worked significantly longer in this building than had the others (mean (SD) (years): 12.7 (0.6) v 7.4 (4.4); p = 0.01). With an in situ nucleic acid hybridisation and immunostaining method for colocalised Epstein-Barr virus (EBV) and secretory component (SC) protein among biopsy specimens of these three patients with NPCs, it was found that some tumour cells did not contain EBV and SC protein staining signals. These results indicate that EBV infection is not the only risk factor for NPC and long term exposure to relatively low concentrations of sulphuric acid vapour may be associated with the development of NPC.

Effect of non-steroidal anti-inflammatory drugs on gastric and duodenal prostaglandin concentrations in patients with Helicobacter pylori infection.

BACKGROUND/AIMS: Both Helicobacter pylori and non-steroidal anti-inflammatory drugs are reported to affect gastroduodenal prostaglandin synthesis. However, their influence on gastric mucosal prostaglandins remains unclear. The aim of this study was to investigate the influence of nonsteroidal anti-inflammatory drugs on mucosal prostaglandin synthesis in patients with Helicobacter pylori infection. METHODOLOGY: We enrolled 87 Helicobacter pylori-infected patients in this study (gastric ulcer: 33, duodenal ulcer: 41, and non-ulcer dyspepsia: 13). Of them, 27 patients received non-steroidal anti-inflammatory drugs. Endoscopy was performed and biospy specimens from gastric body, antrum and duodenal bulb were assessed for Helicobacter pylori and prostaglandin concentration. RESULTS: A significantly lower mucosal prostaglandin E2 level at gastric body (142.2 +/- 28.1 ng/mg vs. 222.0 +/- 12.4 ng/mg, mean +/- SEM) and antrum (131.3 +/- 26.4 ng/mg vs. 226.0 +/- 19.0 ng/mg) was noted in Helicobacter pylori-infected gastric ulcer patients with non-steroidal anti-inflammatory drugs ingestion than in that of patients without non-steroidal anti-inflammatory drugs ingestion (p < 0.05). Using a multivariate analysis, we found that non-steroidal anti-inflammatory drug was an independent variable affecting gastric and duodenal mucosal prostaglandin E2 synthesis in patients with Helicobacter pylori-infected gastric ulcer. CONCLUSIONS: Non-steroidal anti-inflammatory drugs decrease gastroduodenal mucosal prostaglandin E2 synthesis in gastric ulcer patients with Helicobacter pylori infection.

Identification of a novel mouse p53 target gene DDA3.

We have identified a novel p53 regulated gene designated DDA3 through differential mRNA display on IW32 erythroleukemia cells containing a temperature sensitive p53 allele, tsp53val-135. DDA3 mRNA induction could be observed in all sublines expressing tsp53val-135 cultured at permissive temperature as well as in NIH3T3 cells undergoing DNA damage. Upregulation of DDA3 could be detected within 2 h after down-shifting the temperature to 32.5 degrees C; upon shifting back to 38.5 degrees C, DDA3 mRNA rapidly degraded with a half-life of less than 2 h. Actinomycin D, but not cycloheximide, inhibited the p53 dependent DDA3 induction, suggesting that the activation is through transcriptional regulation and does not require de novo protein synthesis. DDA3 was expressed in multiple mouse tissues including brain, spleen, lung, kidney and testis. Full-length DDA3 cDNA was cloned and it contained an open reading frame predicted to encode a proline rich protein of 329 amino acids. Overexpression of DDA3 in H1299 lung carcinoma cells suppressed colony formation. These results suggest that DDA3 is a p53-regulated gene that might participate in the p53-mediated growth suppression.

Diagnosis of the congenital urethral anomalies of male child by voiding cystourethrography.

Congenital urethral anomalies in boys are rare. This report concerns seven children with congenital urethral anomalies other than hypospadias from March 1995 to February 1998. Seven cases of congenital urethral anomalies were diagnosed by voiding cystourethrography (VCUG) from 1246 examinations of boys over a period of three years. There were four posterior urethral values, one anterior urethral valve, one anterior urethral diverticulum, and one megalourethra. Five of them had vesicoureteral reflux (VUR). Two cases of posterior urethral valve had renal failure in spite of surgery. Three cases exhibited renal cystic dysplasia. The clinical presentation and imaging findings are presented. Conventional fluoroscopically monitored VCUG is the principal examination used for bladder and urethra study in children. Therefore, in boys presenting the signs and symptoms related to voiding disturbance, VCUG is used to detect not only VUR but also anomalies in the bladder and urethra. In conclusion, VCUG is safe and essential for diagnosis of congenital urethral anomalies.

Cardiovascular effects of nitric oxide and adenosine in the nucleus tractus solitarii of rats.

It has been shown that nitric oxide (NO) is synthesized in the central nervous system as well as in vascular endothelial cells. We recently reported that NO was involved in central cardiovascular regulation, modulated the baroreflex, and was involved in a reciprocal release with excitatory amino acids in the nucleus tractus solitarii (NTS) of rats. We also reported previously that adenosine increased the release of glutamate in the NTS. The purpose of the present study was to investigate the possible interaction of NO and adenosine in the NTS. Male Sprague-Dawley rats were anesthetized with urethane, and blood pressure was monitored intra-arterially. Unilateral microinjection of L-arginine (3.3 nmol/60 nL) into the NTS produced decreases in blood pressure and heart rate. Microinjection of adenosine (2.3 nmol/60 nL) also produced depressive and bradycardic effects. These cardiovascular effects were attenuated by prior administration of the specific adenosine receptor antagonist DPSPX (0.92 nmol). Similarly, prior administration of NO synthase inhibitor NG-monomethyl-L-arginine or NG-nitro-L-arginine methyl ester significantly attenuated the depressive and bradycardic effects of adenosine. These results demonstrate a reciprocal attenuation of adenosine receptor antagonist and NO synthase inhibitor on L-arginine and adenosine responses, respectively, in the NTS and implicate an interaction between NO and adenosine in central cardiovascular regulation.

Predictive factors for rebleeding in patients with peptic ulcer bleeding after multipolar electrocoagulation: a retrospective analysis.

The role of endoscopic therapy for peptic ulcer bleeding is well-documented. Nevertheless, rebleeding occurs in 10% to 30% of patients, and such patients are at high risk for death without early retreatment or definitive surgery. The aim of our study was to predict which patients would rebleed within 1 month after successful multipolar electrocoagulation of 100 patients with active peptic ulcer bleeding (spurting, oozing, or nonbleeding visible vessel). We had achieved initial hemostasis in 97 patients and carried out univariate and multivariate analyses to predict which patients would rebleed. Rebleeding occurred within 1 month in 17 (17.5%) patients. we correlated 20 clinical and endoscopic factors with rebleeding episodes. With univariate analysis, blood transfusion of 500 ml or more at entry (p < 0.0001) and use of cimetidine (p = 0.01) were statistically significant for rebleeding. With multivariate analysis, use of omeprazole was an independent factor for preventing rebleeding (odds ratio, 7.68; 95% confidence interval, 1.642-35.929). We suggest that omeprazole may help to prevent rebleeding in patients who have had hemostasis with multipolar electrocoagulation.

A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy.

BACKGROUND: A blood clot in a peptic ulcer is unstable in a low pH environment. The use of omeprazole may prevent rebleeding by elevating intragastric pH in patients with bleeding peptic ulcer after hemostasis has been achieved. OBJECTIVES: To assess the influence of using omeprazole and cimetidine on 24-hour intragastric pH and to determine their ability to prevent rebleeding after having achieved initial hemostasis in patients with active bleeding or nonbleeding visible vessels. METHODS: One hundred patients with bleeding peptic ulcers who had obtained initial hemostasis were enrolled in this randomized comparative trial. In the cimetidine group (n = 50), a 300-mg intravenous bolus of cimetidine was given, followed by a 1200-mg continuous infusion daily for 3 days. Thereafter, 400 mg of cimetidine was given orally twice daily for 2 months. In the omeprazole group (n = 50), a 40-mg intravenous bolus of omeprazole was given, followed by 160 mg of continuous infusion daily for 3 days. Thereafter, 20 mg of omeprazole was given orally once daily for 2 months. A pH meter was inserted in each patient's fundus under fluoroscopic guidance after the intravenous bolus of cimetidine or omeprazole had been administered. RESULTS: The stigmata of recent hemorrhage before endoscopic therapy in the omeprazole and cimetidine groups were, respectively, spurting (9 vs 12), oozing (4 vs 9), and nonbleeding visible vessel (37 vs 29) (P > .05). The duration of intragastric pH higher than 6.0 was longer in the omeprazole group (mean [+/- SD], 84.4% +/- 22.9%) than that of the cimetidine group (mean [+/- SD], 53.5% +/- 32.3%) (P < .001). Rebleeding occurred in 2 patients (4%) in the omeprazole group and in 12 patients (24%) in the cimetidine group by day 14 after enrollment (P = .004). There was a tendency for patients in the omeprazole group to require less blood transfusion (median, 0 mL; range, 0-2500 mL) than those in the cimetidine group (median, 0 mL; range, 0-5000 mL) (P = .08). The hospital stay and number of operations and mortality rate were similar between both groups. CONCLUSIONS: The use of omeprazole is more effective than cimetidine in increasing intragastric pH and reducing rebleeding episodes in patients with bleeding peptic ulcers after successful endoscopic therapy. This suggests that omeprazole should be used routinely after successful endoscopic therapy.