Low Breast Conserving Surgery (BCS) rates in public hospitals in Malaysia: The effect of stage and ethnicity.

INTRODUCTION: Breast-conserving surgery (BCS) with radiation therapy is the procedure of choice for early-stage breast cancer. Survival and locoregional recurrence is non-inferior to mastectomy, with superior cosmetic and psycho-social outcomes. Differing health systems have demonstrated a wide variation in the rate of BCS. Little is known about the rate of BCS and factors influencing its practice in middle resource countries. This study aims to examine the BCS rates in Malaysia and to identify factors influencing its uptake. METHODOLOGY: This is a multi-centre, cross-sectional study involving the University of Malaya Medical Centre (UMMC), Queen Elizabeth II Hospital (QEH), and Tengku Ampuan Rahimah Hospital (TARH). Patients diagnosed with invasive breast cancer from January 2014 to December 2015 were included, excluding stromal cancers and lymphomas. Univariate and multivariate analyses identified factors influencing BCS. RESULTS: A total of 1005 patients were diagnosed with breast cancer in the allocated time frame. Excluding incomplete records and those who did not have surgery, 730 patients were analysed. Overall BCS rate was 32.9%. The BCS rate was highest at QEH (54.1%), followed by UMMC (29.5%), and TARH (17.4%). 16.9% had BCS after neoadjuvant therapy. Factors influencing BCS uptake included age, ethnic group, breast-surgeon led services, AJCC Stage, tumour size, HER-2 expression, and tumour grade. CONCLUSIONS: The rate of BCS in Malaysia is low. A wide variation of rate exists among the studied hospitals. Younger age, earlier AJCC stage, and the presence of a Breast sub-specialist surgeon, would make it more likely that the patient has her breast conserved.

Idiopathic Internal Thoracic Artery (ITA) Pseudoaneurysm treated with Endovascular Embolization.

A 44-year-old female was diagnosed with an ITA pseudoaneurysm in the right supraclavicular fossa. She was successfully treated with endovascular embolization. The challenges of diagnosis and treatment are discussed.

Cerebral hemodynamics and baroreflex sensitivity after carotid artery stenting.

OBJECTIVES: The long-term hemodynamic effects of carotid angioplasty and stenting (CAS) are unclear. We performed a longitudinal study to investigate the variations in cerebral hemodynamics in patients undergoing CAS. MATERIALS AND METHODS: We performed prospective evaluation of 63 symptomatic male patients (19 patients had transient ischemic attack and 44 had minor stroke; mean age: 77.3 ± 6.3 years [range: 51-86]). The mean blood flow velocities (MBFV) and pulsatility index (PI) of the middle cerebral arteries (MCA) on both sides were evaluated using transcranial color-coded Doppler (TCCD) ultrasonography. Cardiac autonomic activities were evaluated by measuring baroreflex sensitivity (BRS). All parameters were measured at baseline prior to CAS and at 1, 3, 6, and 12 months after CAS. RESULTS: The preoperative MBFV and PI of the ipsilateral MCA were significantly lower than those of the contralateral side. However, after CAS, MBFV in the ipsilateral MCA increased significantly until 2 weeks after stenting, after which the MBFV gradually decreased and remained stable for 1 year after CAS. Further, we observed a nonsignificant increase in MBFV in the contralateral MCA after CAS. In contrast to the MBFV, the BRS values decreased significantly 1 month after stenting and returned to baseline levels 6 months after CAS. CONCLUSIONS: Patients with CAS showed improved global cerebral hemodynamic status. However, the BRS did not normalize initially, and baseline value was achieved at 6 months after stenting.

Surface modification of PCL-TCP scaffolds improve interfacial mechanical interlock and enhance early bone formation: an in vitro and in vivo characterization.

Pretreatment of polycaprolactone-20% tricalcium phosphate (PCL-TCP) scaffolds under alkaline conditions can be utilized to alter surface characteristics for enhanced early bone formation. PCL-TCP scaffolds were treated with sodium hydroxide (NaOH) at various time intervals (group A: untreated, group B: 3M NaOH for 48 h, and group C: 3M NaOH for 96 h). In vitro results showed a greater degree of physical changes in the NaOH-treated scaffolds (B and C) than the untreated group (A). Clearly, the NaOH-treated scaffolds showed an increased surface roughness than the untreated ones. A significantly large number of "channel-like" pits and greater average pit sizes were detected in groups B (14.51 +/- 10.9 microm) and C (20.27 +/- 14.3 microm); and absent in group A. In addition, treated scaffolds had a significant reduction of the water contact angle (40.9-58.2%). Favorably, the pore dimensions and scaffold rod thickness remained unchanged throughout the experiment. When implanted in the calvaria of rabbits, NaOH-treated scaffolds reported greater early matrix deposition and bone formation from scanning electron images and Micro-computed tomography analyses. In conclusion, pretreatment of PCL-TCP scaffolds with NaOH increases the wettability and surface area for initial matrix deposition and early bone ingrowth.

Noninvasive assessment of spontaneous baroreflex sensitivity and heart rate variability in patients with carotid stenosis.

BACKGROUND: Previous limited observations have suggested that atherosclerosis may affect the distensibility of the carotid sinus and then impair the baroreflex sensitivity (BRS). No studies have been done to compare the BRS and heart rate variability (HRV) in patients with carotid stenosis and normal controls. METHODS: A convenience-consecutive sample of 118 patients with transient ischemic attack or minor stroke 3 months to 1 year before (mean 6 months) who met the study criteria were referred to the neurovascular laboratory of the study hospital. Forty-three age-matched healthy adults were recruited as the normal controls. The inclusion criteria for participation were (1) no diabetes mellitus, (2) no history, symptoms or ECG signs of coronary artery disease or myocardial infarction, and (3) presence of carotid stenosis greater than or equal to 50%. The diagnosis of carotid stenosis was made using color-coded duplex ultrasound with published criteria. We categorized the patients into two groups: group 1 had moderate stenosis (50-75%) and group 2 had high-grade stenosis (75-99%). Instantaneous systolic blood pressure (SBP) and heart rate of all participants were assessed noninvasively using servo-controlled infrared finger plethysmography. The fluctuation in SBP as well as the interpulse interval (IPI) was divided into three components at specific frequency ranges by fast Fourier transform as high frequency (HF; 0.15-0.4 Hz), low frequency (LF; 0.04-0.15 Hz) and very low frequency (VLF; 0.004-0.04 Hz). The BRS was expressed as (1) transfer function with its magnitude in the HF and LF ranges, (2) BRS index alpha, and (3) regression coefficient by sequence analysis. The HRV was expressed as total power and power in the three frequency ranges (HF, LF and VLF). RESULTS: The final analysis included 99 patients (mean age 72 +/- 6 years, 79 male) and 43 healthy controls (mean age 68 +/- 7 years, 30 male). Forty-three patients were classified as group 1 (stenosis 50-75%) and 56 as group 2 (stenosis 75-99%). There was no significant difference in the IPI between patients and controls (p value = 0.8637). We observed a significant decrease in all three HRV components (VLF, LF and HF) in the patients; however, there were no differences between the two patient groups with various degrees of stenosis. All the indices of BRS, including the magnitude of SBP-IPI transfer function at LF and HF, the computed BRS index alpha and the regression coefficient of sequence analysis, revealed similar results. Patients exhibited a significant reduction in the BRS (p < 0.001) compared with controls, and no difference was found between the two groups of patients. CONCLUSIONS: Our study linked significant carotid stenosis to two important autonomic markers (BRS and HRV) that may have prognostic value for patients with cardiovascular events. Further prospective studies are needed to explore whether or not the decreased BRS and HRV can be predictors for poor cardiovascular prognosis, or even for shortened life span in general, in patients with significant carotid stenosis.

The influence of age on weight-bearing joint reposition sense of the knee.

Knee joint-position sensitivity has been shown to decline with increasing age, with much of the research reported in the literature investigating this age effect in non-weight-bearing (NWB) conditions. However, little data is available in the more functional position of weight-bearing conditions. The objective of this study was to identify the influence of age on the accuracy and nature of knee joint-position sense (JPS) in both full weight-bearing (FWB) and partial weight-bearing (PWB) conditions and to determine the effect of lower-extremity dominance on knee JPS. Sixty healthy subjects from three age groups (young: 20-35 years old, middle-aged: 40-55 years, and older: 60-75 years) were assessed. Tests were conducted on both the right and left legs to examine the ability of subjects to correctly reproduce knee angles in an active criterion-active repositioning paradigm. Knee angles were measured in degrees using an electromagnetic tracking device, Polhemus 3Space Fastrak, that detected positions of sensors placed on the test limb. Errors in FWB knee joint repositioning did not increase with age, but significant age-related increases in knee joint-repositioning error were found in PWB. It was found that elderly subjects tended to overshoot the criterion angle more often than subjects from the young and middle-aged groups. Subjects in all three age groups performed better in FWB than in PWB. Differences between the stance-dominant (STD) and skill-dominant (SKD) legs did not reach significance. Results demonstrated that for, normal pain-free individuals, there is no age-related decline in knee JPS in FWB, although an age effect does exist in PWB. This outcome challenges the current view that a generalised decline in knee joint proprioception occurs with age. In addition, lower-limb dominance is not a factor in acuity of knee JPS.

MR perfusion studies of brain for patients with unilateral carotid stenosis or occlusion: evaluation of maps of "time to peak" and "percentage of baseline at peak".

Maps of "time to peak" (TTP) and "percentage of baseline at peak" (PBP) were compared with maps of conventional brain perfusion parameters, namely, mean transit time (MTT) and relative cerebral blood volume (rCBV). We performed MR perfusion studies in 11 patients. All of them had occlusion or high-grade stenosis of the unilateral carotid artery. Three areas of old infarct, 4 areas of new infarct, and 10 areas of brain without infarct were evaluated specifically. In all these cases, the TTP maps appeared similar to the MTT maps. They showed increases, normal values, or decreases at the same time in all areas evaluated. Most areas of abnormally decreased CBV had increased signal in PBP maps. In conclusion, the TTP map provided the same qualitative information as MTT. PBP seemed correlated inversely to CBV and was less sensitive in demonstrating abnormality.

Spectral analysis of arterial blood pressure and cerebral blood flow velocity during supine rest and orthostasis.

This study evaluates the effect of orthostasis on the low frequency (LF, 0.04 to 0.15 Hz) fluctuations in the blood flow velocity of the middle cerebral artery (MCAFV) in relation to its arterial blood pressure (ABP) equivalent to further define and quantify this relationship in cerebrovascular regulation. Spectral analysis was performed on 22 healthy subjects during supine rest and head-up tilt. The power in the LF range can be used to quantify the LF fluctuations, and four types of LF power data could be obtained for each individual: LF power of supine MCAFV, LF power of supine ABP, LF power of tilt MCAFV, and LF power of tilt ABP. By comparing LF power of MCAFV with LF power of ABP, two power ratios could be generated to describe the flow-pressure relationship during supine rest and head-up tilt, respectively, supine power ratio (LF power of supine MCAFV/ LF power of supine ABP) and tilt power ratio (LF power of tilt MCAFV/ LF power of tilt ABP). In addition, an index for dynamic autoregulation in response to orthostasis can be calculated from these two power ratios (tilt power ratio/supine power ratio). The authors found that this index was dependent on the extent of orthostatic MCAFV changes, and the dependency could be mathematically expressed (r = 0.61, P = .0001), suggesting its involvement in cerebrovascular regulation. Moreover, these data further support the previous observation that the LF fluctuations of MCAFV might result from modulation of its ABP equivalent, and the modulation effect could be quantified as the power ratio (LF power of MCAFV/ LF power of ABP). These observations could be an important step toward further insight into cerebrovascular regulation, which warrants more research in the future.

Transcranial Doppler monitoring with head-upright tilting in patients with syncope.

BACKGROUND: The aim of our study was to evaluate the effects of orthostatic stress produced by the head-upright tilt test on human cerebral hemodynamics by transcranial Doppler sonography. METHODS: We studied 60 subjects who were divided into two groups; one of normal controls (n = 43) and one of patients suffering from syncope (n = 17). A 30-minute head-upright tilt test was conducted on all subjects, and heart rate and blood pressure were monitored by surface electrocardiography and cuff sphygmomanometry, respectively. Cerebral blood flow velocity and cerebral vasoreactivity were continuously monitored using transcranial Doppler sonography. RESULTS: The maximal decreases in mean blood pressure of controls and patients with syncope were 2.6 +/- 7.8% and 0.5 +/- 7.9% of baseline, respectively. The maximal decreases in mean blood flow velocity in the middle cerebral artery between the two groups reached 19.6 +/- 6.2% and 30.7 +/- 14.1% of baseline, respectively (p < 0.05). The increases in pulsatility index between the two groups were 15.4 +/- 14.3% and 16.9 +/- 21.1% of baseline, respectively. CONCLUSION: The responses of cerebral blood flow to upright tilting differed significantly between normal controls and patients with syncope, implying that the latter may suffer an impairment of cerebral autoregulation. Further studies are needed to ascertain what clinical implications this finding might have.

A double-blind, placebo-controlled study of tacrine in Chinese patients with Alzheimer's disease.

The purpose of the study was to evaluate the efficacy and safety of tacrine over 30 weeks in Chinese patients with probable Alzheimer's disease (AD). A total of 100 patients with mild to moderate AD were recruited and randomly assigned to active or placebo treatment. The active group received 30 mg/day of tacrine for the first 6 weeks, 60 mg/day for the next 6 weeks, 90 mg/day for 6 more weeks and then 120 mg/day for the remaining 12 weeks. Safety evaluations included biweekly determinations of alanine aminotransferase (ALT). The primary outcome measures were Cognitive Abilities Screening Instrument (CASI), Clinical Global Impression of Change (CGIC) by investigator and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Secondary outcome measures were Mini-mental State Examination (MMSE), Alzheimer's Deficit Scale (ADS) and CGIC by caregivers. Sixty-eight patients were included in an intent-to-treat analysis (48 active and 20 placebo); 56 patients had evaluable data at week 30 (36 active and 20 placebo). The results of the complete case analysis revealed a significant improvement in the CASI and MMSE scores of the active group in the 18th week (90 mg/day) and the 30th week (120 mg/day) (p < 0.01). In the intent-to-treat analysis, significant improvement of the active group was noted on CASI at week 30 (p = 0.05), but there was no significant difference in the measures of IQCODE, CGIC and ADS. The primary reasons for withdrawal of tacrine-treated patients (39 patients, 52%) were asymptomatic ALT elevation, anorexia and nausea/vomiting. These patients all recovered from the adverse events on discontinuation of treatment. Tacrine produced a statistically significant improvement in the CASI and MMSE in Chinese patients with mild to moderate AD using a lower dose than in western people.

Transfer function analysis of cerebral hemodynamics in patients with carotid stenosis.

This study evaluates the validity of the transfer function analysis of spontaneous fluctuations of arterial blood pressure (ABP) and blood flow velocity of the middle cerebral artery (MCAFV) as a simple, convenient method to assess human cerebral autoregulation in patients with carotid stenosis. Eighty-three consecutive patients with various degrees of carotid stenosis and 37 healthy controls were enrolled. The carotid stenosis was graded based on the diagnostic criteria of duplex ultrasound. Instantaneous bilateral MCAFV and ABP of all participants were assessed noninvasively using transcranial Doppler sonography and the servocontrolled infrared finger plethysmography, respectively. Spectral analyses of ABP and MCAFV were performed by fast Fourier transform. The fluctuations in ABP as well as in MCAFV were diffracted into three components at specific frequency ranges designated as high-frequency (HF; 0.15 to 0.4 Hz), low-frequency (LF; 0.04 to 0.15 Hz), and very low-frequency (VLF; 0.016 to 0.04 Hz). Cross-spectral analysis was applied to quantify the coherence, transfer phase, and magnitude in individual HF, LF, and VLF components. Transcranial Doppler CO2 vasomotor reactivity was measured with 5% CO2 inhalation. The LF phase angle (r=-0.53, P<0.001); magnitude of VLF (r=-0.29, P=0.002), LF (r=-0.35, P<0.001), and HF (r=-0.47, P<0.001); and CO2 vasomotor reactivity (r=-0.66, P<0.001) were negatively correlated with the severity of stenosis. Patients with unilateral high-grade (greater than 90% stenosis) carotid stenosis demonstrated significant reduction in LF phase angle (P<0.001) and HF magnitude (P=0.018) on the ipsilateral side of the affected vessel compared with their contralateral side. The study also revealed a high sensitivity, specificity, and accuracy using LF phase angle and HF magnitude to detect a high-grade carotid stenosis. A strong correlation existed between the LF phase angle and the CO2 vasomotor reactivity test (r=0.62, P<0.001), and the correlation between the HF magnitude and the CO2 vasomotor reactivity (r=0.44, P<0.001) was statistically significant as well. We conclude that transfer function analysis of spontaneous fluctuations of MCAFV and ABP could be used to identify hemodynamically significant high-grade carotid stenosis with impaired cerebral autoregulation or vasomotor reserve.

Frequency domain analysis of cerebral blood flow velocity and its correlation with arterial blood pressure.

We applied frequency domain analysis to detect and quantify spontaneous fluctuations in the blood flow velocity of the middle cerebral artery (MCAFV). Instantaneous MCAFV of normal volunteers was detected using transcranial Doppler sonography. Spectral and transfer function analyses of MCAFV and arterial blood pressure (ABP) were performed by fast Fourier transform. We found the fluctuations in MCAFV, like ABP, could be diffracted into three components at specific frequency ranges, designated as high-frequency (HF, 0.15 to 0.4 Hz), low-frequency (LF, 0.04 to 0.15 Hz), and very low-frequency (VLF, 0.016 to 0.04 Hz) components. The HF and LF components of MCAFV exhibited high coherence with those of ABP, indicating great similarity of MCAFV and ABP fluctuations within the two frequency ranges. However, it was not the case for the VLF component. Transfer function analysis revealed that the ABP-MCAFV phase angle was frequency-dependent in the LF range (r = -0.79, P < 0.001) but not in the HF range. The time delay between LF fluctuations of ABP and those of MCAFV was evaluated as 2.1 seconds. We conclude that in addition to traditional B-wave equivalents, there are at least two different mechanisms for MCAFV fluctuations: the HF and LF fluctuations of MCAFV are basically secondary to those of ABP, and cerebral autoregulation may operate efficiently in LF rather than HF range. Frequency domain analysis offers an opportunity to explore the nature and underlying mechanism of dynamic regulation in cerebral circulation.

Comparison of risk factors for lacunar infarcts and other stroke subtypes.

BACKGROUND: Lacunar infarction (LI) is an ischemic stroke subtype with unique clinical, radiological and pathological features. Its relation to other stroke subtypes is unclear. To better understand the underlying pathological process of LI, we compared the risk factors of LI with those of other stroke subtypes. METHODS: During the study period (from January 1, 1990 to December 31, 1991), 240 consecutive patients with first-ever strokes admitted to the stroke unit of our hospital were enrolled to the study and were classified into one of the four stroke subtypes (52 with LI, 80 atherothrombotic infarcts, 38 cardiogenic embolism and 70 brain hemorrhage) based on their computed tomography (CT) and clinical features using the guideline developed by the National Institute of Neurological Disorders. Eighty outpatients of similar age who had either low back pain or cervical spondylosis were recruited from the clinics of Neurology to serve as non-stroke controls. Data collected included demographics, lifestyle, and other vascular risk factors. Detailed physical and neurological examination, blood biochemistry and Doppler ultrasound on cervical vessels were performed. RESULTS: Our investigations revealed that LI is a common stroke subtype accounting for 21% of all first-ever strokes in our hospital. Like ischemic stroke patients, those with LI were much more likely to have hypertension, diabetes, heart disease and carotid disease when compared with non-stroke controls. Patients with brain hemorrhage had less history of diabetes and lower levels of cholesterol than LI patients. CONCLUSIONS: LI patients seemed to share more risk factors with ischemic stroke patients than with brain hemorrhage patients. These shared risk factors suggest a possibly similar underlying pathological process between ischemic strokes and LI patients. Careful screening for those risk factors should be part of the mandatory clinical management for the prevention of LI.

Transorbital color Doppler flow imaging of the carotid siphon and major arteries at the base of the brain.

PURPOSE: To describe and evaluate an application of sonography, transorbital color Doppler flow imaging of the carotid siphon and major intracranial arteries, and to compare it with transtemporal color Doppler flow imaging. METHODS: The carotid siphon and major arteries at the base of the brain of 50 healthy volunteers were screened using the transorbital color Doppler flow sonography. These arteries were also studied by a transtemporal approach for comparison. In 5 volunteers, MR images in special inclination planes were obtained and compared with the transorbital color-coded Doppler flow images. RESULTS: The B-mode image of the orbit and intracranial anatomic structures, in addition to the color-coded flow images, provided an unambiguous identification of the carotid siphon and major intracranial arteries. The failure rate was lower when using the transorbital approach than when using the transtemporal approach in identifying the anterior cerebral artery (17% versus 32%). Color Doppler flow imaging using the transtemporal approach was better for the middle cerebral artery, whereas color Doppler flow imaging using the transorbital approach was better for the anterior cerebral artery (contralateral). The Doppler incident angles using the transorbital approach were better for the carotid siphon and anterior cerebral artery (contralateral). CONCLUSION: Transorbital color Doppler flow imaging, when used in conjunction with the transtemporal examination, can add information concerning the major arteries at the base of the brain.

Synthesis and structure-activity studies of N,N'-diarylguanidine derivatives. N-(1-naphthyl)-N'-(3-ethylphenyl)-N'-methylguanidine: a new, selective noncompetitive NMDA receptor antagonist.

Diarylguanidines, acting as NMDA receptor ion channel site ligands, represent a new class of potential neuroprotective drugs. Several diarylguanidines structurally related to N,N'-di-o-tolylguanidine (DTG), a known selective sigma receptor ligand, were synthesized and evaluated in in vitro radioligand displacement assays, with rat or guinea pig brain membrane homogenates, using the NMDA receptor ion channel site specific radioligand [3H]-(+)-5(S)-methyl-10(R),11-dihydro-5H-dibenzo[a,d]cyclohepten-5 ,10- imine (MK-801, 3), and the sigma receptor-specific radioligand [3H]-di-o-tolylguanidine (DTG, 5). This paper presents the structure-activity relationships leading to novel tri- and tetrasubstituted guanidines, which exhibit high selectivity for NMDA receptor ion channel sites and weak or negligible affinity for sigma receptors. The in vitro binding results from symmetrically substituted diphenylguanidines indicated that compounds having ortho or meta substituents (with respect to the position of the guanidine nitrogen) on the phenyl rings showed greater affinity for the NMDA receptor ion channel site compared with para-substituted derivatives. Among the group of ring substituents studied for symmetrical diarylguanidines, an isopropyl group was preferred at the ortho position and an ethyl group was preferred at the meta position. Several unsymmetrical guanidines containing a naphthalene ring on one nitrogen atom and an ortho- or a meta-substituted phenyl ring on the second nitrogen atom, e.g., N-1-naphthyl-N'-(3-ethylphenyl)guanidine (36), showed a 3-5-fold increase in affinity for the NMDA receptor ion channel site and no change in sigma receptor affinity compared to the respective symmetrical counterparts. Additional small substituents on the guanidine nitrogen atoms bearing the aryl rings resulted in tri- and tetrasubstituted guanidine derivatives which retained affinity for NMDA receptor ion channel sites but exhibited a significant reduction in their affinities for sigma receptors. For example, N-1-naphthyl-N'-(3-ethylphenyl)-N'-methylguanidine (40) showed high affinity for the NMDA receptor ion channel site (IC50 = 36 nM vs [3H]-3) and low affinity for sigma receptors (IC50 = 2540 nM vs [3H]-5). Selectivity for the NMDA receptor ion channel sites over sigma receptors appears to be dependent upon the structure of the additional substituents on the guanidine nitrogen atoms bearing the aryl groups. Methyl and ethyl substituents are most preferred in the tri- and tetrasubstituted diarylguanidines. The trisubstituted guanidine, N-1-naphthyl-N'-(3-ethylphenyl)-N'-methylguanidine (40) and its close analogues showed good in vivo neuroprotection and are potential neuroprotective drug candidates for the treatment of stroke and other neurodegenerative disorders.

[Clinical investigation by transcranial Doppler sonography of the effect of norepinephrine on cerebral arterial blood velocity of normotensive males].

Transcranial Doppler (TCD) sonography is a new, non-invasive method for evaluation of the hemodynamics of cerebral circulation. Using a 2-MHz probe, the intracranial middle, posterior, vertebral and basilar arteries can be isolated easily to obtain parameters of systolic, diastolic, mean velocities and pulsatility index (PI). Changes of blood velocities and PI can assist evaluation of the condition of intracranial arterial spasm, dilatation and cerebral vascular resistance. The purpose of this study is to evaluate the hemodynamic effect of norepinephrine (NE) on cerebral circulation. Eighteen normotensive male healthy volunteers (mean age 42 years) were studied with TCD before and during NE infusion (13-16 micrograms/min). Results showed that systolic, diastolic and mean arterial pressure were increased significantly during NE infusion. Blood velocities of middle, posterior, vertebral and basilar arteries also increased markedly. Increased cerebral vascular resistance with elevation of PI was also noted in all of the persons studied. These findings provide evidence that NE infusion induces intracerebral vasospasm.

The serial hemostasis-related changes in patients with cerebral infarction: comparison between progressing and non-progressing stroke.

Serial determinations of beta-thromboglobulin (BTG), platelet factor 4 (PF4), fibrinopeptide A (FPA), antithrombin III (ATIII), protein C (PC), fibrin (ogen) degradation product (FDP), FDP D-dimer, activated partial thromboplastin time (APTT), prothrombin time (PT), and euglobulin lysis time (ELT) were performed in 18 patients with non-progressing stroke and 14 patients with progressing stroke in order to predict the development of progressing stroke. Increasing levels of BTG, PF4 and FDP with frequent fluctuation were noted in both kinds of stroke. Fluctuation of FPA levels was also noted but was less pronounced. PC levels were found to be slightly decreased with fluctuation but the mean was still in the lower normal limit. BTG, PF4 and PC all elevated at the time of deterioration of physical condition in patients with progressing stroke, whereas FPA had no definite change at that time. From our study, we conclude that both platelet activation and coagulation process do occur in both kinds of stroke. But the latter plays a minor role in the formation of thrombosis. The hemostasis change, especially concerning the thrombosis formation, probably plays a role in the development of progressing stroke, but we cannot predict their development even by the detections of the newly known molecular substances appearing in various steps of the hemostatic mechanism. Development of new tests for understanding the whole dynamic change of the thrombosis process is necessary for accurate prediction of the progressing stroke in the future.

Prevalence of stroke in Taiwan.

We investigated the prevalence of stroke in Taiwan in an epidemiologic study of stroke, diabetes, and cardiovascular disease that used a two-phase survey design. The study population was drawn by cluster sampling and consisted of both urban and rural communities from four regions of Taiwan. There were 8,705 people 36 years of age or older interviewed during the period of October 1 to December 31, 1986, and 143 cases of completed stroke were later identified by a neurologist. The point prevalence rate for people aged 36 or older in our study was 1,642/100,000 population (95% confidence interval 1,389-1,942/100,000). Prevalence rates differed significantly among the four study regions and between urban and rural communities; prevalence was greater in northern Taiwan and in urban communities. Percentages of the major types of stroke in 143 stroke survivors were as follows: cerebral infarction 67.1% (96 cases), cerebral hemorrhage 14.0% (20 cases), subarachnoid hemorrhage 4.2% (six cases), and unclassified 14.7% (21 cases). Of the stroke survivors, 67.1% were independent in activities of daily living, and 75.5% were independent in ambulation. Hypertension, heart disease, diabetes mellitus, and a family history of stroke were significantly more common in stroke survivors than in strokefree individuals.

Functional voiding disorders in women.

From July 1986 to Dec 1987, 78 women complaining of frequency, urgency, dysuria and suprapubic discomfort were evaluated at our clinic. Their ages ranged from 20 to 68 (mean age: 38.2). The patients who were noted to have evidence of pyuria, neurological or gynecological abnormalities were excluded from the study. Urodynamic examinations including uroflowmetry, cystometry (CMG), urethral pressure profiles (UPP) and electromyography (EMG) of the external urethral sphincter were performed. The results revealed low flow rates in 56 patients (71.8%), non-relaxation of the external sphincter during voiding in 55 patients (70.5%), unstable bladder in 6 patients (7.7%) and a high maximal urethral closure pressure (MUCP) (greater than 80 cmH2O) in 44 patients (56.4%). The average volume of the cystometric capacity (250 +/- 86 ml) was decreased. The association between the low flow rate, non-relaxation of the external sphincter and a high MUCP was statistically significant. Urethral hypersensitivity has been recognized as being the major cause of these symptoms.