Tzu Chi Medical Journal

Intravesical Botulinum Toxin Injection for Overactive Bladder—What We Can Learn From Previous Clinical Trials

Hann-Chorng Kuo — 2009-12-01

Abstract: Intravesical botulinum toxin A (BoNT-A) injection is effective in treating overactive bladder (OAB) and detrusor overactivity (DO)-induced incontinence refractory to antimuscarinic treatment. In the past 5 years, there have been several clinical trials using BoNT-A targeting OAB and idiopathic DO (IDO), and the therapeutic results are promising. Recent investigations have shown that urothelial dysfunction and abnormality of sensory receptor expression or transmitter release in the suburothelial nerves might contribute to OAB refractory to antimuscarinics. Intravesical BoNT-A treatment to inhibit abnormal receptor expression or transmitter release in the sensory nerve terminals in the suburothelial space has shown to have a good therapeutic effect on OAB. Intradetrusor or suburothelial BoNT-A injections, with small or large doses of BoNT-A in the bladder body or bladder base, can achieve satisfactory results. However, BoNT-A impairs detrusor contractility and causes a large postvoid residual (PVR) urine volume after injection in some patients. This adverse effect induces acute urinary retention and it is difficult to empty the bladder in the early postoperative period. Urinary tract infections can occur in patients with a large PVR. Although adverse effects may not influence the therapeutic outcome, they might prohibit wide application of BoNT-A in the treatment of refractory OAB. Patients with a high risk of a large PVR or urinary retention should be taught clean intermittent catheterization. Analysis of patient characteristics and urodynamic variables has shown that patients who are elderly, have low detrusor contractility at baseline, and have chronic medical diseases are at risk of adverse effects. Therefore, careful adjustment of the dose, appropriate injection site and correct patient selection is mandatory to achieve satisfactory results with intravesical BoNT-A therapy.

Implications of Circadian Rhythms on Metabolic Disorders

Shu-Chuan Yang, Kun-Ruey Shieh — 2009-12-01

Abstract: A vital role of circadian rhythms is to enable an organism to predict or adapt to environmental oscillations, including internal and external cues. These physiological and behavioral circadian rhythmicities are exhibited by all mammals and are generated by intracellular levels of circadian oscillators, which are composed of transcriptional/translational feedback loops involving a set of circadian-clock genes. These circadian-clock genes play important roles in regulating not only circadian rhythms but also energy homeostasis and metabolism. Increasing evidence shows that mutations or knockouts of circadian-clock genes or disruptions of the circadian rhythm initiate metabolic disorders. Similarly, high-nutrient diets influence the expression levels of circadian-clock genes in the liver. Changes in the cellular redox potential affect the activity of circadian-clock gene transcription factors and the expressions and functions of circadian-clock genes, which regulate energy metabolism. The characterizations of circadian-clock genes have potential therapeutic relevance with respect to the pathogenesis and treatment of obesity-related metabolic diseases including type 2 diabetes and metabolic syndrome.

Obesity and Perimenopausal Symptoms in Mid-life Women in Southern Taiwan

Hsiang-Chu Pai, Ming-Yung Lee, Sheuan Lee — 2009-12-01

Abstract: Objective: Body mass index (BMI) has been found to be associated with perimenopausal symptoms. This study focused on the relationship between overall perimenopausal symptoms and obesity in Taiwanese women living in rural communities. Materials and Methods: This study was cross-sectional and descriptive, and the subjects included 56 climacteric women from a rural community in southern Taiwan. Data were collected using the Perceived Perimenopausal Disturbances Scale and face-to-face interviews, and obesity was assessed by anthropometric measurements (height, weight, and waist circumference). Results: The current analysis included 56 women 40–60 years of age (mean age = 47.11 years). Twenty-five percent of the women were obese (BMI ≥ 27 kg/m2) and 39.3% presented with central obesity (waist circumference ≥ 80 cm). Based on the subscale for perimenopausal symptoms, we found that for postmenopausal women, a higher BMI and waist circumference were associated with more frequent urinary complaints and reproductive system symptoms. Conclusion: Participants reported more frequent urinary problems when they were postmenopausal, and these problems were associated with a higher BMI. The findings suggest that clinical practitioners should consider developing strategies to reduce BMI in mid-life women.

High-sensitivity C-reactive Protein and Other Factors as Outcome Predictors in Acute Decompensated Heart Failure

Chih-Wei Chen, Yen-Hsien Lee, Hung-Mei Chen, Ying-Lung Lin — 2009-12-01

Abstract: Objective: Patients with acute decompensated heart failure (ADHF) have high mortality and rehospitalization rates. Although circulating levels of high-sensitivity C-reactive protein (hs-CRP) are an accurate prognostic factor in chronic heart failure, no data are available to indicate whether hs-CRP can predict outcomes in patients with ADHF. Materials and Methods: We prospectively evaluated serum hs-CRP levels, patient characteristics, laboratory data, medications and management during hospitalization and two end points (inhospital mortality and 6-month readmission rate for heart failure) in 80 patients who presented with ADHF. Results: No correlation was found between initial hs-CRP at admission and the two end points. The result was the same for all patients after excluding those in whom infection was a predisposing factor for ADHF. Cardiogenic shock significantly predicted inhospital mortality (odds ratio [OR] = 15.76; 95% confidence interval [CI] = 1.8–180.06; p = 0.026). A high serum peak creatinine level (OR = 1.39; 95% CI = 0.98–1.98; p = 0.064) and ischemic heart disease as the etiology of heart failure ((OR = 2.48; 95% CI = 0.93–6.58; p = 0.068) could predict 6-month readmission with borderline significance. Conclusion: Hs-CRP may have no value as a predictor of the outcomes of inhospital mortality and 6-month readmission for heart failure in ADHF. Many clinical factors such as cardiogenic shock were found to be associated with inhospital mortality, and high serum peak creatinine levels and ischemic heart disease as the etiology of heart failure were found to be associated with 6-month readmission. Therefore, early detection of these high-risk groups to predict inhospital outcomes is possible.

Different Effects of Volatile Anesthetics on Cardiovascular Neural Regulation of the Autonomic Nervous System in the Streptozotocin-induced Diabetic Rat

2009-12-01

Abstract: Objective: Inhalation anesthetics increase heart rate (HR) in vivo in both animals and humans but decrease heart rate in isolated hearts. Clinical studies indicate that insulin-dependent diabetes mellitus is associated with alterations in autonomic nervous system control of cardiovascular function. The specific aim of this study was to elucidate the effects of different inhalation anesthetics on cardiovascular autonomic function in diabetic rats. Materials and Methods: We measured blood pressure variability (BPV) in streptozotocin (STZ, 60 mg/kg, i.p.)-induced diabetic Sprague-Dawley rats and vehicle control groups exposed to different inhalation anesthetics (halothane, desflurane and sevoflurane) and BPV was recorded until the recovery stage. Frequency-domain analysis of telemetric systemic arterial pressure and pulse-pulse interval were applied to quantify the parameters of BPV. High frequency power (HF) was regarded as cardiac vagal modulation. Low frequency power of BPV (BLF) was referred to as vascular sympathetic modulation. Normalized low-frequency power (LF%) of the spectrogram of the RR interval was regarded as cardiac sympathetic modulation. Results: STZ-induced diabetes was associated with a significant reduction of HR but not consistently with a higher HF among these volatile anesthetics. BLF was significantly decreased at one minimum alveolar concentration (MAC) of desflurane when compared with halothane and sevoflurane in the STZ-induced diabetic group. We found an early recovery of the BLF to awake stage baseline values 30 minutes post-anesthesia for sevoflurane, although it was not significant when compared with the other two anesthetics. However, the LF% significantly recovered to 80% of awake baseline values with desflurane and sevoflurane when compared with halothane 30 minutes post-anesthesia. Conclusion: The components of sympathetic regulation (BLF and LF%) may be an early sign of hemodynamic recovery to the awake stage during anesthesia in STZ-induced diabetic rats. Our results provide an indication for clinical anesthetic choice in diabetes patients receiving anesthesia.

Effectiveness of Workflow Change for Improving the Timing of Prophylactic Antibiotics

Sung-Ching Pan, Hsiang-Chi Kung, Jou-Wei Lin, Szu-Min Hsieh, Shan-Chwen Chang — 2009-12-01

Abstract: Objective: Prophylactic antibiotics are effective in reducing surgical site infection, especially if administered with appropriate timing. However, the timing of administration in clinical practice is usually suboptimal. This study evaluated the effect of changing workflow to improve the timing and documentation of antibiotic administration. Materials and Methods: In a 682-bed regional teaching hospital, the personnel in charge of prophylactic antibiotic administration were changed from ward nurses to operating room nurses and the time of antibiotic administration was recorded on the surgical nursing record starting on April 1, 2006. The effect of workflow change was measured by improvement in the timing of antibiotic administration after the intervention. Patient records were identified by a search of the hospital coding database. A case was defined by a principal or secondary procedure code for six types of surgeries: total hip replacement, total knee replacement, herniorrhaphy, thyroidectomy, hemorrhoidectomy and abdominal hysterectomy. Patients receiving therapeutic antibiotics because of documented preoperative infections were excluded from the study. Appropriate timing was defined as prophylactic antibiotics administered within 2 hours before incision. Patient outcome was assessed by the incidence of surgical site infections. Results: During the study period from May 1 to October 31, 2006, 178 patients were enrolled in the study. These patients were compared with 160 patients who had surgery before the intervention period (May 1 to October 31, 2005). A statistically significant improvement in the appropriate timing of administering prophylactic antibiotics was noted between the two periods (41.8% to 78.9%; OR = 5.199; p < 0.001; 95% CI = 3.213–8.413). The number of patients without documentation of timing of prophylaxis decreased significantly from 49.4% to 3.4% (OR = 0.036; p < 0.001; 95% CI = 0.015–0.087). Conclusion: The workflow change had a significant effect on improving the timing and documentation of prophylactic antibiotic administration.

Hemodynamics of the Internal Jugular Vein: An Ultrasonographic Study

Shinn-Kuang Lin, Yeu-Jhy Chang, Fu-Yi Yang — 2009-12-01

Abstract: Objective: To establish a simple classification of internal jugular venous flow using ultrasonography. Materials and Methods: We retrospectively analyzed the sonographic findings of 1600 consecutive patients who were referred to the neurosono-graphic laboratory. Abnormal jugular venous flow was classified into five groups: (A) markedly decreased flow velocity; (B) stasis and/or thrombus formation; (C) reversed flow; (D) increased turbulent flow; and (E) pulsa-tile turbulent flow. Groups A to C were categorized as slow flow groups and groups D and E as high flow groups. Results: Abnormal jugular venous flow was found in 182 (11%) patients. A slow flow pattern (73%) comprised the majority of abnormalities. Eightynine percent of patients in the slow flow groups had abnormalities in the left internal jugular vein (IJV) and 92% of those in the high flow groups had abnormalities in the bilateral IJV. Incompetence of the jugular valve was the most common cause of slow flow in the IJV. Most of the increased turbulent flow was found in patients with hyperthyroidism and in pregnant women. Arteriovenous malformation and carotid-cavernous fistula were the causes of pulsatile turbulent jugular venous flow. Associated clinical symptoms occurred in only two (1.5%) patients (with a concomitant left IJV and left subclavian vein thrombosis) in the slow flow groups, and in 34 (68%) patients in the high flow groups. Conclusion: Most of the abnormally decreased jugular venous flow occurred on the left side. Decreased venous flow or even thrombosis of one side of the IJV was usually asymptomatic. Increased jugular flow was associated with a physiological hyperemic state in cerebral hemodynamics. Increased awareness and angiographic studies are indicated in patients with pulsatile turbulent jugular venous flow because of a high correlation with intracranial arteriovenous shunting.

Blunt Abdominal Injury With Isolated Gallbladder Hematoma

Hsing-Lin Lin, Jiun-Nong Lin, Wei-Che Lee, Chao-Wen Chen, Liang-Chi Kuo — 2009-12-01

Abstract: Blunt abdominal contusion is common in children, but isolated injury with gallbladder hematoma is rarely observed. Examining children can be difficult because they may not cooperate or understand procedures, and therefore, radiography is helpful for diagnosis. However, there are still limitations in applying radiographic examinations in diagnosing intra-abdominal injuries, especially in children with peritoneal signs or an unstable hemodynamic status. In these circumstances, invasive intervention with laparoscopy should be applied for further evaluation. We report here a 6-year-old girl with blunt abdominal trauma in whom hepatobiliary injury was noted on computed tomography and magnetic resonance imaging. Because the patient was unconscious, had unstable vital signs, and the radiographic study was ambiguous, peritonitis could not be excluded. A laparoscopy was then performed and isolated gallbladder hematoma was diagnosed. The patient was discharged after laparoscopic intervention and orthopedic fixation.

Recurrent Nasopharyngeal Carcinoma Presenting as a Positron Emission Tomography False-negative Scan

Chien Shih, Jenq-Yuh Ko, Cheng-Ping Wang, Lai-Lei Ting, Jong-Kai Hsiao — 2009-12-01

Abstract: Positron emission tomography (PET) is valuable for detecting locoregional recurrences of nasopharyngeal carcinoma (NPC) with a high sensitivity and fair specificity. A negative PET result is generally thought to confidently exclude the presence of a tumor. However, a false-negative PET scan is more dangerous than false-positive results because an undiscovered recurrent tumor may eventually lead to the patient's death without proper treatment. In this report, we describe a false-negative PET scan in a NPC patient with a recurrent tumor in the left cavernous sinus, presenting as a new onset of left 6th cranial nerve palsy 1 year after irradiation. The first magnetic resonance imaging (MRI) and PET scan failed to disclose any abnormalities. The second MRI performed 3 months after the first scans demonstrated a new abnormal lesion in the left cavernous sinus, which had resolved in the following MRI after re-irradiation. Therefore, clinical observation with suggestive symptoms is still important, even with negative imaging results. Close follow-up with a series of imaging studies must be performed when indicated.

Genital Tuberculosis With Presentation of Spontaneous Abortion in a Patient With Miliary Tuberculosis

Chih-Wei Hsu, Sheng-Chuan Hu, Yung-Hsiang Hsu, Song-Wei Liu — 2009-12-01

Abstract: Tuberculosis (TB) is a major public health concern worldwide. In Taiwan, the annual mortality rate for TB is 3.4 per 100,000 people (783 deaths in 2007). TB primarily affects the lungs, but approximately one third of patients also demonstrate involvement of extrapulmonary areas such as the meninges, bones and genitourinary tract. Female genital TB is rarely seen in developed countries. The occurrence of genital TB is only 0.01% in Taiwan. We present here a rare case of miliary TB accompanied by endometrial spread with no known immunodeficiency.

Late-onset Methemoglobinemia Induced by Metobromuron/metolachlor

Bang-Gee Hsu, Han-Yu Huang — 2009-12-01

Abstract: The herbicide, Galex, containing 25% of metolachlor and 25% of metobromuron dissolved in 46.7% emulsifiable concentrate was widely used for the control of grasses and broad-leaf weeds in the 1990s and continues to be used today. Metobromuron, a substitute urea herbicide, may cause methemoglobinemia in humans, but very few studies are available about the harmful effects on humans. We report here a case where a 47-year-old man developed severe methemoglobinemia 10 hours after ingestion of 1000 mL of Galex. Acute hypoxic respiratory failure with coma occurred suddenly. After ventilator support was instituted, intravenous methylene blue (1%, 2 mg/kg) was administrated immediately. A second dose of methylene blue was given because of a persistent high level of methemoglobin 2 hours later. The patient was weaned from the ventilator on day 4. However, hemolytic anemia, possibly due to the administration of methylene blue, occurred and persisted to day 11. This resolved gradually only after multiple blood transfusions. Ingestion of a large volume of herbicide containing metobromuron, a substituted urea herbicide, can induce late-onset methemoglobinemia in humans and, while rare, may be fatal if not observed for a sufficient time in the emergency department. Death is possible following the ingestion of this herbicide when adequate diagnoses and treatment are not instituted. Methylene blue is useful in reversing methemoglobinemia, but the side effects such as hemolytic anemia should be monitored, especially at doses exceeding 4 mg/kg or in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Clinicians should consider the relevant history of G6PD deficiency before using methylene blue to decrease the risk of unnecessary hemolytic anemia. Methemoglobinemia in patients with G6PD deficiency is best treated with blood transfusions.

Transdiscal Cement Leakage During Vertebroplasty

Wen-Chin Hsu, Ting-Chen Lee — 2009-12-01

Abstract: Bone cement leakage is a major cause of surgical complications during percutaneous vertebroplasty. A 78-year-old woman experienced transdiscal cement leakage during vertebroplasty for painful compression fractures of thoracic vertebrae 9 and 10 (T9 and T10). During surgery, bone cement leaked from T9 to T10, passing through the right anterior intervertebral disc space. We have had no prior experience with this complication and, to our knowledge, there are no similar cases in the literature. Nevertheless, the patient's back pain was relieved to a considerable degree. Related imaging findings and possible reasons for leakage are discussed.

AIDS-related Kaposi's Sarcoma of the Nasopharynx

Miao-Chun Yang, Yung-Hsiang Hsu, Dai-Wei Liu, Yu-Fu Chou — 2009-12-01

Abstract: Kaposi's sarcoma (KS) is an acquired immunodeficiency syndrome (AIDS)-related malignancy and may present in the head and neck as an initial sign of AIDS. However, it is rare in the nasopharynx. We report a 28-year-old man who complained of postnasal drip and occasional bloody saliva for 2 months. A purple-red bulging nasopharyngeal tumor was found on examination; a biopsy specimen proved that it was KS with positive human herpes virus type 8 (HHV-8) staining in the tumor cell nuclei. AIDS was diagnosed when enzyme immunoassay and Western blot were positive for serum human immunodeficiency virus. Antiviral therapy was given to treat AIDS, and low-dose radiation was given to treat nasopharyngeal KS with a complete response.

Perioperative Stroke Following General Surgery

Chia-Chun Huang, Jimmy Ong, Chia-Ling Lee, Tsung-Ying Chen — 2009-12-01

Abstract: Perioperative stroke is rare; however, patients undergoing cardiovascular surgery are considered to be at high risk for perioperative stroke. Here, we outline a case where perioperative stroke occurred following total hip replacement surgery. The risk factors and possible causes of the stroke in this patient are discussed. In addition, we reiterate the appropriate management approaches needed to prevent perioperative stroke. Briefly, the importance of precise preoperative evaluation and of proper intraoperative and postoperative management should not be overlooked. Finally, it is important to realize that decreasing perioperative strokes and the disabilities associated with them will lower the financial burden on families and the community.

Rare Type of Deep Neck Infection: Two Cases of Descending Necrotizing Mediastinitis

Shih-Ming Huang, Ren-Chieh Wu — 2009-12-01

Abstract: Descending necrotizing mediastinitis is a relatively uncommon complication of deep neck infections. Patients often have some type of immuno-compromised condition. Computed tomography is very helpful for early diagnosis. Poor prognosis is due to delays in diagnosis or inappropriate surgical drainage. We present two cases of descending necrotizing mediastinitis that was successfully treated because of early diagnosis and adequate surgical intervention.

Mirtazapine and Bupropion Combined Treatment in Treatment-resistant Depression

Chien-Han Lai — 2009-12-01

Abstract: Treatment-resistant depression is a difficult problem in clinical practice. Evidence for the efficacy of newer antidepressants, such as duloxetine and bupropion, is not yet well established. We present a case of treatment-resistant depression with full recovery where a combination of mirtazapine and bupropion was used after a failed response to combined mirtazapine and duloxetine treatment.

Coexisting Innominate Vein Compression Syndrome and May-Thurner Syndrome

Sheng-Heng Tsai, I-Chen Tsai, Chung-Chi Wang, Clayton Chi-Chang Chen — 2009-12-01

Abstract: Innominate vein compression syndrome and May-Thurner syndrome (also called iliac vein compression syndrome) are venous compression syndromes caused by normal anatomic structures. Here, we present a case in which these two conditions were found in the same patient using multidetector row computed tomography. This case is significant for two reasons: (1) it is, to the best of our knowledge, the first case study in the literature to report coexisting innominate vein compression syndrome and May-Thurner syndrome; and (2) it shows that multidetector row computed tomography has powerful diagnostic ability for venous diseases.

Pelvic Actinomycosis

Yung-Hsiang Hsu — 2009-12-01