Noninvasive assessment of liver fibrosis via spleen stiffness measurement using acoustic radiation force impulse sonoelastography in patients with chronic hepatitis B or C.

Portal hypertension and splenomegaly are common in patients with cirrhosis. However, there is limited previous in vivo research on the correlation between spleen stiffness and stages of liver fibrosis. This study aimed to evaluate the diagnostic value of spleen stiffness measurement (SSM), using acoustic radiation force impulse (ARFI) technology, for liver fibrosis assessment. Eligible patients with chronic hepatitis B or C (n = 163) underwent concurrent liver stiffness measurement (LSM), SSM and percutaneous liver biopsy. Receiver operating characteristic curves estimated the diagnostic performance of SSM, with multiple linear regression models for LSM and SSM determining the significance of explanatory factors. Results indicated significant correlation between LSM and SSM (R(2) = 0.574, P < 0.0001). Using SSM to classify METAVIR fibrosis (METAVIR F) scores, the areas under curves were 0.839 (95% CI: 0.780-0.898) for METAVIR F1 vs F2-4, 0.936 (95% CI: 0.898-0.975) for F1-2 vs F3-4 and 0.932 (95% CI: 0.893-0.971) for F1-3 vs F4, all P < 0.001. Multiple linear regression models identified BMI, spleen stiffness, METAVIR F3 and F4, serum alanine aminotransferase, international normalized ratio of prothrombin time, sodium and platelet count as significant independent explanatory factors for liver stiffness (adjusted R(2) = 0.724, P < 0.001). Male gender, liver stiffness, METAVIR F2, F3 and F4 also significantly and independently explained spleen stiffness (adjusted R(2) = 0.647, P < 0.001). ARFI SSM is potentially useful as a single or adjunct predictor of stages of liver fibrosis.

Early serum HBsAg level as a strong predictor of sustained response to peginterferon alfa-2a in HBeAg-negative chronic hepatitis B.

BACKGROUND: The roles remain unclear of early on-treatment quantitative serum HBsAg and hepatitis B virus (HBV) DNA levels in the prediction of a sustained response (SR) to peginterferon alfa-2a therapy in HBeAg-negative chronic hepatitis B (CHB) patients infected with genotype B or C. AIMS: To determine their roles in HBeAg-negative CHB patients infected with genotype B or C. METHODS: Sixty-one patients were treated with peginterferon alfa-2a for 48 weeks. Serum HBsAg levels were quantified using the Abbott Architect HBsAg QT assay throughout treatment. Multiple regression analyses were performed to identify independent predictors of SR. RESULTS: Nineteen patients (31%) achieved SR with serum HBV DNA levels <312 copies/mL at 24 weeks post-treatment. Serum HBsAg levels at 12 (OR 31.9; 95% CI 4.8-209.6; P = 0.0003) and 24 weeks of therapy (OR 8.8; 95% CI 2.0-38.0; P = 0.0035), and HBV DNA levels at baseline (OR 7.0; 95% CI 1.3-36.2; P = 0.0203), 12 (OR 7.9; 95% CI 1.2-48.4; P = 0.0249) and 24 weeks of therapy (OR 22.3; 95% CI 2.2-224.0; P = 0.0083) were early independent predictors of SR. A serum HBsAg cut-off of 150 IU/mL at week 12 had an AUC, sensitivity, specificity and positive and negative predictive values of 0.75, 63%, 95%, 86% and 85% with respect to predicting SR respectively. CONCLUSIONS: A quantitative serum HBsAg level at 12 weeks of therapy can be used for the early prediction of SR to peginterferon therapy in HBeAg-negative CHB patients infected with genotype B or C.

The role of the brachioradialis H reflex in the management and prognosis of obstetrical brachial plexus palsy.

The H reflex was investigated to determine if it can be useful in the prognosis of obstetrical brachial plexus palsies. The H reflex is an electrically stimulated monosynaptic or oligosynaptic response which can be recorded in peripheral nerves in all muscles of infants up to approximately two years of age. It is essentially the electrophysiologic counterpart of the deep tendon reflex, and its presence indicates intact afferent and efferent axons at the particular spinal segment. Our objectives were to document the Brachioradialis H (Br H) reflex latency and amplitude in normal upper extremities of infants, to evaluate the presence or absence of the Br H reflex in obstetrical palsy neonates and infants between one and seven months of age and to determine if this test was a valid predictor of final clinical outcome. A prospective study of 109 patients was performed to measure the Br H reflex in the affected and the contralateral normal limb. The results from the abnormal limb were compared to the final clinical decision made by nine months for or against surgical intervention. In the normal limbs, a Br H latency of 10.7 +/- 0.8 msec was determined with an amplitude of 1.2 +/- 1.2 mV. The chi 2 analysis in infants from one month to seven months old revealed a strong relationship between an absent Br H reflex and little or no clinical improvement (p < 0.0001), with a sensitivity for predicting poor outcome of 85.7%. The odds ratio (with a 95% confidence interval) of a child with an absent Br H reflex not significantly improving by nine months was 8.4 times higher than if the Br H reflex was present. The false positive rate was 42% however, indicating that a significant number of patients improved clinically, despite having a nonrecordable Br H reflex at age seven months or less. The low false negative rate of 14.3% suggested that in the presence of a Br H reflex, the majority of patients recover. Therefore, the presence of the Br H reflex is a helpful test in the prognostication of good recovery in obstetrical upper plexus palsy patients.

Comparison of Abbott AxSYM, Behring Opus Plus, DPC Immulite and Ortho-Clinical Diagnostics Vitros ECi for measurement of cardiac troponin I.

Myocardial infarction is a common cause of morbidity and mortality in patients with chest pain. The presence of human cardiac troponin I (cTnI) in serum is considered to be a highly specific biochemical marker of acute myocardial infarction. In this study we compare the performances of the Abbott AxSYM, Behring Opus Plus, DPC Immulite and Ortho-Clinical Diagnostics Vitros ECi for the measurement of cTnI. The first two methods use a fluorogenic enzyme-linked immunoassay. whereas the last two use chemiluminescent immunometric assays. All procedures are completely automated. Total percentage coefficients of variation using pooled sera ranged from 5.9 to 6.5% for the AxSYM, 14.4 to 25.6% for the Opus, 6.9 to 9.8% for the Immulite and 4.5 to 5.2% for the Vitros ECi method. The closest correlation between methods, obtained from 120 fresh serum samples, was observed between the Vitros ECi and the Immulite methods, with r=0.99, and the regression line was Immulite cTnI 1.505 (95% confidence interval 1.474-1.536) x Vitros cTnI--0.154 (-0.702 to 0.394). Receiver operating characteristic curves were nearly identical for all assays, and the areas under the curves were 0.972, 0.927, 0.967 and 0.969 for the AxSYM, Opus, Immulite and Vitros ECi methods, respectively. There was a significant difference between the AxSYM and Opus methods (P= 0.036).

DNA polymorphisms at the apolipoprotein A1-CIII loci in Taiwanese: correlation of plasma APOCIII with triglyceride level and body mass index.

BACKGROUND AND PURPOSE: Apolipoprotein (APO) A1-CIII genes are linked within a 2.6-kb region on human chromosome 11. ApoA1 is the main component of high-density lipoprotein (HDL), and apoCIII inhibits lipoprotein lipase activity. Genetic variations in APOA1-CIII may affect the function of apoA1/apoCIII and plasma lipid/lipoprotein levels, and thus, the risk of developing atherosclerosis. This study compared the frequency distributions of genetic variations in APOA1-CIII genes and their influence on plasma lipid concentrations in Taiwanese patients with coronary artery disease (CAD) and in healthy controls. METHODS: Six restriction site variations (RSVs) of the APOA1-CIII gene complex were investigated by DNA amplification using polymerase chain reaction and restriction enzyme digestion in 229 control subjects and 131 CAD patients during the period from 1992 through 1996. The blood lipid profiles of these subjects were also determined. RESULTS: Thirty-seven distinct six-RSV genotypes were observed. Separate comparisons of the frequency distributions of the six genetic variations showed no significant differences between CAD patients and controls subjects, but the combined six-RSV-genotypes showed different frequency distributions between these two groups. Nine of the 37 six-RSV genotypes were found only in the CAD patients and higher frequencies of two of these types were observed in the CAD patients than in healthy controls. The effects of these genetic variations were on high-density lipoprotein cholesterol in women (for MspIB, PstI, SstI and PvuII RSV) and total cholesterol (for PvuII RSV), low-density lipoprotein cholesterol (for XmnI RSV), and apolipoprotein B (for MspI and SstI RSV) levels in men in the control group. Elevated plasma apoCIII concentration was significantly associated with an increased plasma triglyceride level and body mass index in the control group (P < 0.0001). CONCLUSIONS: Analysis of the frequency distribution of six RSVs of the APOA1-CIII gene complex in Taiwanese CAD patients and control subjects showed that the effect of genotype on plasma lipid levels was gender-specific and that the apoCIII level was closely associated with plasma triglyceride level and body mass index.

Quality assurance in clinical laboratories in Taiwan.

BACKGROUND AND PURPOSE: In 1994, the Taiwan National Health Administration assigned the execution of a quality assurance (QA) survey program to the Association of Laboratory Medicine. The purpose of this program was to investigate the quality of clinical laboratory assessments and to promote QA in the fields of clinical microscopy, hematology, chemistry, microbiology, serology, and blood banking. We report the findings of QA surveys conducted in 1998 and the effect of voluntary training on improvement of clinical laboratory testing. METHODS: A total of 1,008 clinical laboratories were included in the program in 1998. Proficiency testing (PT) was performed to evaluate various laboratory tests. Continuing education programs were conducted and experts visited laboratories that sought guidance before the PT was conducted. The full mark was set at a score of 100 for each PT scheme. The criterion for acceptability of PT results was set at a score of 80 or more. RESULTS: The rates of acceptable results were 82.4% (607/736) for hematology, 57.4% (267/465) for blood banking, 69.3% (561/810) for chemistry, and 80.1% (321/401) for microbiology. The rates of acceptable microscopy results were 90.9% (509/560) for urine chemical tests and 84.6% (610/721) for others. The rates of acceptable serology tests were 73.3% (384/524) for hepatitis and 85.6% (441/515) for syphilis. The rates of acceptable performance differed significantly among clinical laboratories with different rankings: clinical laboratories at institutions classified below the level of district hospital showed comparatively poor performance. Laboratories that received guidance showed significant improvement in performance from 1997 to 1998. CONCLUSIONS: A QA program is urgently needed in Taiwan to improve laboratory performance.

The graded effect of hyperhomocysteinemia on the severity and extent of coronary atherosclerosis.

It is not clear to what extent methylenetetrahydrofolate reductase (MTHFR) gene and hyperhomocysteinemia effect the severity and extent of coronary atherosclerosis in Asian populations. We examined the MTHFR genotypes and plasma homocysteine (HCY) concentrations in 192 Taiwanese and investigated their relationship with coronary artery disease (CAD), and the severity and extent of coronary atherosclerosis. The distribution of MTHFR genotypes was similar in 116 CAD patients and 76 non-CAD subjects. Homozygosity was noted in 8% of CAD patients and 13% of non-CAD subjects (P=0.33; 95% CI, 0. 2-1.6). The geometric mean of HCY values was higher in CAD patients (11.10+/-1.51 micromol/l) than in non-CAD subjects (9.21+/-1.55 micromol/l) (P=0.003). HCY levels were higher in patients with multi-vessel disease (P<0.05) or in patients with > or = 90% stenotic lesions (P=0.005), compared with non-CAD subjects. The CAD risks in the top two HCY quartiles (> or = 14.0 and 10.1-13.9 micromol/l) were 4.0 (95% CI, 1.7-9.2) and 3.2 (95% CI, 1.4-7.4) times higher than in the lowest quartile (< or = 7.9 micromol/l) (P=0.001 and 0.007, respectively). Linear regression analysis showed significant correlations between HCY concentrations and the severity and extent of atherosclerosis (P=0.0001 for both). In conclusion, hyperhomocysteinemia appears to have a graded effect on the risk of CAD as well as the severity and extent of coronary atherosclerosis. Our findings do not support the homozygous genotype of MTHFR as a genetic risk factor for CAD in this Taiwanese population. Perhaps a further study including assessment of vitamin status is needed to better clarify the relationship between MTHFR genotypes and CAD.

Newly identified missense mutation reduces lipoprotein lipase activity in Taiwanese patients with hypertriglyceridemia.

Lipoprotein lipase (LPL) plays a crucial role in the regulation of lipoprotein metabolism by hydrolyzing the core triglycerides of circulating chylomicrons and very low-density lipoprotein. Deficiency in this enzyme usually results in disturbances in lipid levels. To understand the molecular defect that leads to a functional deficiency of LPL in patients with hypertriglyceridemia, we looked for mutations of the LPL gene by means of single-strand conformation polymorphism (SSCP) analysis and direct DNA sequencing in 24 patients. A single base C-->G substitution in codon 252 of the LPL gene, encoding a change of a leucine to a valine residue in the mature protein, was found in three women who had hypertriglyceridemia and recurrent pancreatitis. Two of these patients, who were homozygous for the L252V mutation, had variable and occasionally severe hypertriglyceridemia with undetectable or very low LPL activities, respectively. The third woman was heterozygous for this mutation. All three patients had poor post-heparin LPL activity. Site-directed mutagenesis experiments provided in vitro evidence that the mutation of codon 252 was responsible for the loss of LPL activity. In conclusion, we identified a novel LPL mutation that results in decreased LPL activity in Taiwanese patients with hypertriglyceridemia. The assessment of a causative link between the mutation and hyperlipidemia awaits further studies.

Association of apolipoprotein E polymorphism with lipoprotein glomerulopathy. Report of 2 cases with a new genotype and comparison of the relative frequencies of apolipoprotein E isoforms in lipoprotein glomerulopathy and in the general population.

Two cases of lipoprotein glomerulopathy with a new apolipoprotein E (Apo E) genotype, epsilon3/epsilon4, were diagnosed recently. These 2 cases, together with other cases documented in English literature made a total of 6 common isoforms of Apo E encountered in lipoprotein glomerulopathy. Although the calculated allele frequency of epsilon2 is relatively high in cases with lipoprotein glomerulopathy as compared with that in the general population (39.3 vs. 6.4-11.4%), the gradual emergence of Apo E isoforms other than E2/E3 in lipoprotein glomerulopathy implicates that the genetic susceptibility of certain Apo E isoforms may not be a crucial factor. An alteration in the local environment of glomerular capillaries may be more important in the pathogenesis of lipoprotein glomerulopathy.

The histopathological changes in irradiated vs. nonradiated tissue-expanded skin in the porcine model.

This study examined the histological changes following irradiation on nonexpanded and tissue-expanded pigskin. Six Yorkshire pigs received 4860 cGy radiation to one flank with the opposite side serving as the control. A histopathological comparison of tissue expansion in irradiated tissue to nonradiated tissue showed a reduction in the thickness of the dermal and subcutaneous layers, with less prominent rete ridges and a thicker stratum spinosum (p < 0.05). Nonexpanded irradiated tissue showed a reduction of thickness in the dermis and subcutaneous layer, less prominent rete ridges, and a thicker stratum spinosum layer (p < 0.05) when compared with nonradiated tissue. Tissue-expanded irradiated tissue showed no significant differences (p > 0.05) in any of these parameters when compared with nonexpanded irradiated tissue. This study demonstrates that radiation produced a significant change in porcine skin, but tissue expansion did not further alter the histological changes associated with irradiation.

Evaluation of a proprioception pathway in patients with stable and unstable shoulders with somatosensory cortical evoked potentials.

Histologic studies have documented the presence of mechanoreceptors in the glenohumeral ligaments, capsule, and labrum; however, direct evidence of an intact afferent electrical pathway originating in structures in the shoulder is lacking. Because somatosensory cortical evoked potentials are transmitted by way of the dorsal columns of the spinal cord and carry proprioceptive information, this technique can be easily applied to evaluate the potential proprioceptive function of various intraarticular structures for shoulder stability. Patients have somatosensory cortical evoked potentials monitored while undergoing shoulder arthroscopy. The inferior glenohumeral ligament, middle glenohumeral ligament, subscapularis tendon, biceps tendon, supraspinatus rotator cuff capsule, glenoid labrum, and humeral head were evaluated. The intraarticular structures were stimulated with a monopolar electrode probe inserted through the anterior portal, and the evoked potentials were recorded with scalp electrodes. Generated wave forms were recorded and evaluated by measuring the peak-to-peak amplitude and latency. Three groups of patients with shoulder complications were studied: (1) no intraarticular pathologic condition and stable, (2) anterior instability with a Bankart lesion, and (3) anterior instability with a loose capsule. The articular cartilage of the humeral head generated no wave form in any subject. All other intraarticular structures generated consistent wave forms. No statistically significant difference was seen among the three groups when both amplitude and latency for the intraarticular structures were compared.

Evaluation of two homogeneous methods for measuring high-density lipoprotein cholesterol.

We evaluated the performance of two homogeneous assays for quantifying HDL cholesterol (HDL-C) and compared them with the phosphotungstic acid (PTA)/ MgCl2 assay. Both homogeneous HDL-C assays were precise, having a within-run CV of < 1.20% and a between-run CV of < 4.07%. The HDL-C values (y) measured by the two homogeneous methods correlated well with those by the PTA/MgCl2 method (x): y = 1.00x + 64.98 mg/L, r = 0.987, Sy/x = 27.99 mg/L (n = 152) for the polyethylene glycol-modified enzymes/alpha-cyclodextrin sulfate (PEGME) assay (Kyowa), and y = 0.84x + 106.51 mg/L, r = 0.984, Sy/x = 26.10 mg/L (n = 152) for the polyanion-polymer/detergent (PPD) assay (Daiichi). The specificity of the PEGME method seemed better than that of the PPD method, as the PPD method was markedly interfered with by supplemental LDL-C. Addition of 20 g/L triglycerides produced a negative error of approximately 18% in both homogeneous assays. Bilirubin and hemoglobin had little influence on the PEGME method; hemoglobin had little effect on the PPD method. Bilirubin, however, markedly decreased the readings by the PPD method. We found the PEGME assay superior to the PPD assay for routine HDL-C testing, because the PPD assay is relatively inaccurate and not specific.

Comparison of isoproterenol with BRL37344 in activation of beta 3-adrenoceptors to inhibit the uptake of [14C]deoxy-D-glucose and translocation of glucose transporter (GLUT4) to membrane fraction in rat adipocytes.

In an attempt to understand the role of beta 3-adrenoceptors in the regulation of glucose uptake, the effect of isoproterenol was compared with BRL37344 in isolated white adipocytes of the rat using [14C]deoxy-D-glucose as an indicator. In the presence of BRL37344, the specific agonist of beta 3-adrenoceptors, spontaneous uptake of [14C]deoxy-D-glucose (glucose uptake) into adipocytes was markedly attenuated. Similar concentration-dependent inhibition of glucose uptake was also observed in the samples treated with isoproterenol, an agonist for all kinds of beta-adrenoceptors. Action of BRL37344 was blocked by propranolol at concentrations sufficient to abolish the activity of isoproterenol. Pindolol reversed BRL37344-induced inhibition more effectively than propranolol. Moreover, unlike the action of isoproterenol, BRL37344 did not modify the insulin-stimulated glucose uptake. Translocation of glucose transporter (GLUT4) from cytosol to membrane stimulated with insulin was reduced by isoproterenol but not by BRL37344. Combination with the findings that isoproterenol prolonged the time for insulin to reach maximum stimulation of glucose uptake, leads to the conclusion that delay of insulin action by isoproterenol can be considered as one of the mechanisms for this inhibition. The results obtained suggest that BRL37344 decreased the spontaneous uptake of glucose via an activation of beta 3-adrenoceptors while the insulin stimulated glucose uptake was inhibited by isoproterenol but not by BRL37344.

Type I collagen and procollagen fragments in patients with metabolic bone diseases.

The purpose of the present study was to evaluate the serum levels of two new markers, and to compare their clinical usefulness with two conventional markers. Healthy women and patients with aberrant bone metabolism were evaluated for serum or urine levels of different bone markers. We measured serum levels of the pyridinoline cross-linked telopeptide domain of type I collagen (S-ICTP) and carboxy-terminal propeptide of type I procollagen (S-PICP) as markers of bone resorption and formation, respectively. These levels were compared to the concentrations of serum bone gamma-carboxyglutamic acid protein (S-BGP) and total urinary pyridinium cross-links (U-PYD). The control group included 222 premenopausal and postmenopausal women, and the disease groups consisted of 61 individuals with malignancy-associated hypercalcemia, Graves' thyrotoxicosis or primary hyperparathyroidism. Both S-PICP and S-BGP reflected higher bone turnover in postmenopausal than premenopausal women. All patient groups had significantly higher S-ICTP and U-PYD than the controls. Increased S-PICP was seen in malignancy-associated hypercalcemia and Graves' thyrotoxicosis, but not in primary hyperparathyroidism, while higher S-BGP was seen in Graves' thyrotoxicosis and primary hyperparathyroidism, but not in malignancy-associated hypercalcemia. Discrepancy between S-PICP and S-BGP in malignancy-associated hypercalcemia and primary hyperparathyroidism was noted. S-ICTP and U-PYD had higher sensitivity and specificity in discriminating patients from controls. We conclude that S-ICTP is superior to U-PYD as an index of bone resorption in aberrant bone metabolism. S-PICP may also be a useful bone turnover marker but discrepancies between it and S-BGP in malignancy-associated hypercalcemia and primary hyperparathyroidism need further investigation.

Apolipoprotein B 3' hypervariable repeat genotype: association with plasma lipid concentration, coronary artery disease, and other restriction fragment polymorphisms.

Apolipoprotein B gene 3' variable number tandem repeat (VNTR) and related regions were amplified by PCR and analyzed by agarose gel electrophoresis. Eighteen VNTR alleles (VNTR25, 26, 29, 31, 33, 35, 37, 39, 41, 43, 45, 47, 49, 51, 53, 55, 58, 60) and 45 genotypes were observed in 477 Taiwanese subjects. The VNTR35 allele and genotype VNTR35/35 were observed most frequently in this population. The polymorphism information content was 0.62. Some minor alleles, such as VNTR25 and 60, were found only in coronary artery disease (CAD) and stroke patients in our sampling, and no statistically significant difference was observed in VNTR allelic frequency between control and CAD or stroke patients. Significant differences in allelic distribution of some VNTR alleles were observed between our normal Taiwanese population and a Caucasian group studied by others. VNTR43-47 and AluI+ (coding Ala591) restriction fragment length polymorphism (RFLP) as well as VNTR49-60 and EcoRI- (coding Lys4154) RFLP were found to be highly coinherited. No apparent association between the VNTR genotype and plasma lipid concentration was observed; however, for the same genotype, the CAD and stroke patients frequently showed higher lipoprotein(a) and lower HDL cholesterol concentrations than the control group.

Serum lipids and lipoprotein(a) concentrations in Chinese NIDDM patients. Relation to metabolic control.

OBJECTIVE: To compare serum blood lipids and lipoprotein(a) [Lp(a)] levels in Chinese non-insulin-dependent diabetes mellitus (NIDDM) patients and nondiabetic control subjects and also to determine the influence of diabetes control on serum Lp(a) concentration in Chinese individuals. RESEARCH DESIGN AND METHODS: We compared the serum blood lipids and Lp(a) levels in NIDDM patients (n = 100) and age- and sex-matched nondiabetic subjects (n = 100) who participated in a case-control study. Comparisons of Lp(a) concentrations were made between a normal control group, a group of diabetic patients with HbA1c < 8.0%, and a group of diabetic patients with HbA1c of 8% or higher. RESULTS: The diabetic patients had higher total triglyceride, apolipoprotein B (apo B), and apo B-to-apo AI ratios, but lower high-density lipoprotein (HDL) cholesterol and apo AI concentrations than nondiabetic controls (P < 0.001, P < 0.01, P < 0.001, P < 0.05, and P < 0.001, respectively). A similar pattern of distribution of Lp(a) levels according to the degree of metabolic control was seen in patients with NIDDM and nondiabetic controls. No correlation was observed between Lp(a) levels and total cholesterol, low-density lipoprotein cholesterol, HDL cholesterol, apo AI, apo B, and triglyceride levels in all diabetic patients. No difference in the Lp(a) levels was noted between diabetic patients and nondiabetic subjects, even in poorly controlled diabetic patients. CONCLUSIONS: In conclusion, Lp(a) levels are not elevated in diabetic patients, even in poorly controlled metabolic conditions.

A comparison of outpatient and inpatient anterior cruciate ligament reconstruction surgery.

The feasibility of outpatient anterior cruciate ligament (ACL) surgery has not been reported in the literature. We evaluated outpatient ACL surgery by comparing outpatient versus inpatient pain control, narcotic consumption, postoperative complications, recovery time, and cost analysis. Thirty-seven ACL reconstructions were performed in 37 patients over a 16-month period. Twenty-five of the patients had surgery performed as outpatients and 12 as inpatients. One of the outpatients required hospitalization because of excessive nausea and vomiting and another for urinary retention. Only 2 of the 25 outpatients (8%) believed that they should have been hospitalized for pain control. Based on a visual analog scale, pain severity, pain frequency, and pain relief were measured, and no statistically significant difference (P < .05) was noted between the groups, although the data suggested that the inpatients were slightly more comfortable. There were no differences in rehabilitation or in regaining full range of motion of the operated knee. Also, the only postoperative complication in both groups occurred in an inpatient who developed arthrofibrosis. Cost analysis showed that outpatient ACL reconstruction was cost effective. The average inpatient cost was $9,220 (2.4 hospital days) compared with the average outpatient cost of $3,905. This reflected a savings of 58%. These results show that outpatient ACL reconstruction surgery is possible in the appropriate patient without harm to the patient and with a significant cost savings.

The effects of apolipoprotein E polymorphism on the distribution of lipids and lipoproteins in the Chinese population.

The effects of apolipoprotein E (apo E) polymorphism on the distribution of serum levels of total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) were studied in 546 unrelated Chinese in Taiwan. By isoelectric focusing and immunoblotting, three common alleles were demonstrated. The frequencies of the epsilon 2, epsilon 3 and epsilon 4 alleles were 0.076, 0.875 and 0.049, respectively. The relative frequency of the epsilon 3 allele was higher than that in Caucasians, whereas the frequency of epsilon 4 was lower in the Chinese population. Individuals with apo E4/4 phenotype had the highest serum TC and LDL-C concentrations, while the lowest levels were associated with apo E2/2 phenotype. There was a trend for individuals carrying the epsilon 2 allele to have a higher HDL-C level. No relationship between apo E phenotype and TG level was observed in this study. These data indicated that a given apo E allele acted in a relatively similar way in determining individual differences between Chinese and Caucasian populations in serum lipid and lipoprotein.

Reimplantation of a contaminated and devitalized bone fragment after autoclaving in an open fracture.

This case report describes a technique for dealing with open fractures with segmental bone loss and a critical need for restoration of anatomical alignment. In the majority of cases, autogenous bone graft can and should be used successfully. Regardless of the treatment option chosen though, meticulous debridement and sound judgment in regards to wound care and bony stabilization remain the foundation to a successful outcome. Autoclaving a devitalized bone fragment with subsequent reimplantation as described in this case report, although not the procedure of choice, does offer the orthopaedist another option in dealing with the difficult segmental fracture.

The pullout strength and use of tibial interference screws during endoscopic ACL reconstruction surgery.

This article retrospectively reviews the last 89 ACL reconstructions done over the past 24 months by the senior author and also investigates the pullout strength of a 15-mm long interference screw in cadaveric knees. Results revealed that interference screw fixation at the tibial tunnel during endoscopic ACL reconstruction should almost always be possible by ensuring a tibial tunnel with adequate length, taking additional bone on the graft from the proximal tibia, twisting the graft, and possibly using a 15-mm interference screw.