Physiopathology of this condition is clear. Early findings following radiotherapy show mucosal hyperemia and acute tissue edema. In the later stage, obliterating endarteritis and fibrosis impair rectal compliance and tissue oxygenation. All these alterations affect anastomotic healing. The aim of this study was to evaluate radiotherapy as a risk factor for the anastomotic leakage. It is important to decide which cases we should perform the defunctioning stoma to avoid an urgent operation. Previous studies have shown that the risk for anastomotic leakage is reduced by the use of defunctioning stoma. Others do not embrace this theory. Calculating complications related to stoma itself and the necessity of another operation, the surgeon should chose these cases with prudence.
In this study, the authors tried to exclude patients with other known risk factors to have the possibility of a more accurate evaluation as much as they could. For this purpose, the authors grouped and compared patients depending on surgical procedure they had (AR or LAR) to minimize the influence of this factor in conclusions as well (Tables 2 and 3). In the previous studies, no advantage of defunctioning stoma on anastomotic leakage was found, hence it BMS354825 is not considered in this study.
Anastomotic leakage associated to neoadjuvant therapy varies in different studies up to 10%–20%. Replacement of cobalt therapy with IMRT through LINAC has diminished lateral effects of radiotherapy, like toxicity and extensive fibrosis. This promises better surgical approach and results. In this study, the significant difference was not found regarding to the anastomotic leakage among the patients treated with preoperative radiotherapy and those who did not had a preoperative radiotherapy (Table 3). This means that preoperative IMRT may not be considered for a defunctioning stoma, unless there are concomitant risk factors. Otherwise, conventional radiotherapy through cobalt will increase the risk of anastomotic leakage (Table 3). Also, it is considered that radiotherapy through cobalt predisposes to an extensive fibrosis of the treated area, which for sure is unpleasant to the operatory surgeon. Counting the toxicity of the procedure itself as well, it might be considered the defunctioning stoma after resecting the tumor, especially when performing a LAR (Table 3).
Conflict of interest statement
Supracondylar humerus fracture is one of the most common types of fracture in children, of which the Gartland type-I closed fracture, no obvious displacement with intact anterior and posterior periosteum, can be treated well by manual reduction and plaster external fixation. While the Gartland type-II and type-III closed fractures have a significant displacement leading to a very difficult and complicated clinical procedure. At present, the common clinical therapies for Gartland type-II and type-III fractures include manual reduction, external plaster fixation, open reduction and internal fixation and closed reduction combined with internal Kirschner wire fixation, and so on. The recurrence rate of fracture displacement after operation was high due to the small plane contact areas of broken ends from Gartland type-II and type-III supracondylar humerus fracture, the swelling of soft tissue subsides after fractures reduction, and incoordination of children of hyperactivity in therapy of immobilization.
In recent years, clinical academics have basically reached a consensus on the operation method for Gartland type-II and type-III supracondylar humerus fracture. Closed reduction and percutaneous Kirschner wire fixation has been considered as the preferred treatment, which avoid a great trauma caused by open reduction and internal fixation and also the displacement of fracture ends caused by external plaster fixation. However, the operation timing of closed reduction and percutaneous Kirschner wire fixation for Gartland type-II and type-III supracondylar humerus fracture in children has not yet reached an agreement. In the following study, we compared the effect between emergency treatment and selective closed reduction combined with percutaneous Kirschner wire fixation for Gartland type-II and type-III supracondylar humerus fracture.
The analgesic effect of acupuncture has been suggested to be associated with gate control and/or neurohormonal mechanisms . Stimulation of acupuncture points by low-frequency current has been shown to induce analgesia in human and animal experiments. Insertion of acupuncture needles leads to release of endogenous opioids, which have been known to improve pain control by stimulating pain receptors [6,7]. In addition, acupuncture has been thought to augment the order Clozapine N-oxide by regulating immune modulation [8,9]. The acupuncture point LI4 (Hegu) is considered to be the most important point to apply acupuncture for every type of pain. In addition to LI4, the acupuncture point ST25 (Thianshu) has been reported to be effective in regulating bowel movements , while Ren12 (Zhongwan) is claimed to inhibit gastric motility .
Materials and Methods
Statistical analysis of data was performed using the statistical software package program PASW Statistics for Windows (version 16.0; SPSS Inc., Chicago, IL, USA). Chi-square test was used for comparisons of the ratios. A t test for the independent samples and paired samples was used for comparing the averages.
A total of 20 volunteers were included in the study; 14 (70%) were male and six (30%) were female volunteers. The average age of participants was 29.6±6.08 years. The ages of the volunteers ranged from 19 years to 38 years. The number of patients receiving colchicine treatment was 13 (65%) and the remaining seven (35%) were not taking colchicine. The number of those admitted to the emergency department with complaints of abdominal pain was 13 (65%) and the number of those with abdominal pain and nausea was 7 (35%).
The average of Pain Scale Scores was 8.45±0.75 before the treatment and 2.10±0.85 after the treatment. VPS scores reduced in all of the patients. The reduction of VPS scores was statistically significant (p=0.001; Table 1).
We found a statistically significant reduction in VPS scores post-treatment when compared with pretreatment values. To our knowledge, there is no study evaluating the effectiveness of acupuncture in the treatment of FMF attacks in the literature. However, there are studies suggesting that acupuncture treatment plays a regulatory role in functional bowel disease by increasing parasympathetic activity in the gastrointestinal tract [12,13]. Complaints related to FMF are similar to those of inflammatory bowel syndrome (IBS). The promising results of the studies on acupuncture treatment in IBS, syndromes of which are similar to FMF, support our results [14,15]. In a study conducted with 11 IBS patients, acupuncture applied to the LI11, ST36, ST25, Ren3, and LI4 acupuncture points found that complaints of patients decreased significantly at the end of 12 sessions .
Although it is widely accepted that it is very difficult to achieve functional improvement of the visual system at the end of its complete development—age 10/12 years at the latest—a traditional Chinese medicine (TCM) approach was used to treat a teenage (14-year old) girl with reduced visual acuity. As she suffered from a congenital depigmentation of the retina, her visual acuity of 20/40 in both eyes (BE) was considered to be the highest visual acuity possible. Traditional techniques had not provided any significant benefit. It was, therefore, decided to apply unconventional TCM techniques .
The American Academy of Ophthalmology  has quite recently (2012) carried out a survey of the pathology and, in the framework of the “Preferred Practice Patterns,” proposed “optical correction, patching, pharmacological penalization, optical penalization, Bangerter filters, surgery to remove the causes of amblyopia, acupuncture, and vision therapy” for the treatment of amblyopia.
The abovementioned document reports the use of acupuncture for amblyopia treatment in two clinical trials: The first study found acupuncture over a 15-week period to be as effective as occlusion for 88 children aged 7–12 years who had anisometropic amblyopia . In this randomized controlled trial, children had 20/40–20/125 BCVA and no strabismus. The second study examined the effect of adding acupuncture to refractive correction for 83 children aged 3–7 years who had untreated anisometropic amblyopia (20/40–20/200) . At 15 weeks, there was a greater improvement in visual acuity using refractive correction with acupuncture compared with refractive correction alone. In both studies, the acupuncture technique consisted of five acupuncture needles placed and manipulated for 15 minutes 5 times/wk for 15 weeks. In both the above studies, the selected acupoints, needle insertion, manipulation of the needles, and application protocol are indicated.
This work was supported by the Vermont Experimental Program for Stimulating Competitive Research (EPSCoR) Award number NSF EPS Grant # 1101317. The authors acknowledge the Vermont Advanced Computing Core which is supported by NASA (NNX 06AC88G), at the University of Vermont for providing High Performance Computing resources that have contributed to the research results reported within this paper. We acknowledge the World Climate Research Programme\’s Working Group on Coupled Modelling, which is responsible for CMIP, and we thank the climate modeling groups (listed in Table A-1 of this paper) for producing and making available their model output. For CMIP, the U.S. Department of Energy\’s Program for Climate Model Diagnosis and Intercomparison provides coordinating support and led development of software infrastructure in partnership with the Global Organization for Earth System Science Portals. The authors are indebted to two anonymous reviewers for their constructive and thorough reviews.
Water use by deep-rooted forests is in some cases higher than shallow-rooted agricultural crops or pasture (Zhang et al., 2001). Prior to European settlement, the Atlantic Forest region of Brazil was predominantly covered by rainforest occupying an area of approximately 150Mha distributed across large latitude and climatic ranges (Ribeiro et al., 2009). By the late 1900s, however, clearing for agriculture and population growth left only about 11–16% coverage of this native forest (Instituto National de Pesquisas Espaciais, 2011; Ribeiro et al., 2009). During the past four decades, plantation forestry has expanded rapidly in parts of this region mainly by replacing pasture. Eucalypt plantations in Brazil now occupy more than 5.1Mha with a significant portion in this Kinase Inhibitor Library (ABRAF, 2012). This plantation expansion has largely occurred on the plateau part of the landscape away from streams, while rainforest covers areas closest to the streams (gullies). These large-scale changes in vegetation may have affected stream flows, but these effects have not been widely quantified. Despite the mean annual precipitation of around 1200mm, stream flow is intermittent and low water availability during the dry season probably limits plantation growth (Stape et al., 2008).
Plantation management, particularly harvesting, and the proportional area of and water use by the native forest, could affect stream flow. However, the potential effect of harvesting the native forest has not been measured in this landscape. Such an experiment was not possible as harvesting of streamside native forest is prohibited by the Brazilian forest code (Presidência da República, Lei N° 12.651, 2012), in which it is referred to as the area of permanent preservation (APP).
Generally, stream flow is affected by precipitation amount, distribution and intensity, soil water holding capacity and soil hydraulic conductivity, vegetation interception and water use, and terrain topography. Water use by vegetation depends on plant water demand and actual uptake, which in-turn depends on factors including rooting density and depth, available soil water and climate. The hydrological effects of native forest fragmentation are poorly understood, especially in the tropics in relation to horizontal interactions between land units of vegetation, topography and soils (Giambelluca, 2002). Previous studies in Espírito Santo State of the Atlantic Forest region have quantified many of the aspects of the hydrological cycle in one dimension (plot scale) at plantation and native forest sites, in which water balance simulations generally matched observations (Soares and Almeida, 2001; Almeida and Soares, 2003; Almeida et al., 2007, 2010). A similar capability has become available in two dimensions (e.g. hillslope) using the HYDRUS model (Smethurst et al., 2013), which enabled extension of water balance simulations at the same site to the headwater catchment scale and thereby take into account both vegetation types, i.e. Eucalyptus plantation and native forest. Our objectives here were to (1) determine if the HYDRUS model could be used to adequately simulate the hydrology of a headwater catchment in the Atlantic Forest region of Brazil used for plantation forestry with native forest in the APP, and if so (2) use it to understand the potential impacts of harvesting of one or both vegetation types on ground water and stream flow. Our hypothesis was that a quantitative analysis using the HYDRUS model would demonstrate that water use by the native forest APP could prevent an increase in stream flow after harvesting up-slope eucalypt plantations.
Virtually all the up-to-date high-end digital displays can manipulate true-color images; however, this has never been the case 15 or more years ago. However, there is still a need to deal with devices and setups with a limited – sometimes very limited – color display capabilities that each pixel can only be switched to one of a small set of colors. Here are some examples of such devices and setups that may still be in use on a wide scale:
The oldest method to address this issue is half-toning that has been invented and deployed in the pre-digital era to display gray-scale analog photographs on old fashioned printed press produced via monochrome (i.e. black and white) printing. Half-toning prints a dot with a black area proportional to the darkness of the gray level of each point in the image; i.e. spatial Zalcitabine Supplier is traded for color resolution.
With the emergence of the digital age, more involved variants of half-toning have been developed to utilize the capabilities of monitors and digital graphic cards that can display multiple gray levels beyond the binary ones (Floyd and Steinberg, 1976). New variants of image dithering for colored images then emerged with the prevalence of color monitors and graphics cards with wider storage. Earlier such variants worked on each color dimension independently (Gentile et al., 1990), and then more sophisticated algorithms have been devised to simultaneously acquire the palette and perform the image digitization so that the loss of image quality in the digitized image is minimal (Kollias and Anastassion, 1991; Flohr and T., 1993; Ketterer et al., 1998; Cheng et al., 2009). The algorithm that provides the best results in this regard is commonly known as scolorq (for Spatial Color Quantization) (Ketterer et al., 1998); however, it is also the most mathematically sophisticated and computationally demanding one, because it is not a mere dithering algorithm but is actually an intricate solution of a combinatorial cost minimization problem.
On the other hand, Fig. 9 depicts our much simpler solution to this problem that is based on the direct application of our general dithering scheme presented in Section 3 of this paper.
The input digital image is assumed to be a true-color image in the RGB space which is the most common color space used for the representation of digital images on electronic displays. However, the Euclidean distance between two different points (i.e. colors) in the RGB space does not correspond to the difference in the human perception of these two colors (Hunt, 1998). So, the first module M1 in our system converts the input image from the RGB color space to the CIE-Lab color space where the Euclidean distance between two different color vectors does correspond to the perceived visual difference of these two colors (Hunt, 1998).
Module M2 then applies the LBG vector clustering algorithm (Linde et al., 1980; Gray, 1984; Gray and Neuhoff, 1998) to the population of the CIE-Lab color vectors of the pixels in the output image from M1 in order to infer the optimal palette of a given size L⩾2 .
The CIE-Lab color vector of each pixel in the image is then dithered via our Soft VQ with inverse power-function distributions detailed in Section 3 above. So, given a power m⩾2, the module M3 stochastically attributes each CIE-Lab color vector to one of the palette colors ;1⩽i⩽L with probabilities calculated according to Eqs. (8) and (9).
Module M4 converts the output of M3 from the CIE-Lab color space back into the RGB color space as the output of our system. The output of M4 is then a digital image encoded with a limited palette that are compliant with digital image displays with any ⩾log2(L) .
Fig. 10 shows an illustrative example on the performance of our solution for encoding true-color images with a limited palette through Soft VQ with inverse power-function distributions. The upper left corner of the figure shows the input original true-color photographic image.
The pattern of correlations (Table 4) revealed that b1, b2, b3, and b7 generally have stronger relationships with the chapter independence scores than with the frequency scores. This finding made intuitive sense because the FUNDES independence dimension measures the extent to which assistance in daily life is needed based on the perspectives of parents/proxies. Children with more problems in body functions would be expected to need more assistance from others. Assistance provided to the child might be affected by parents\’ perspectives on what activities are most important for their children to participate in, and the parents\’ level of experience in providing strategies to promote their children\’s participation.
In the correlation patterns between the d and e chapter scores, the e1 (Product and technology) scores had higher correlations with the d independence scores than with the frequency scores, while e4 (Attitudes of others) had higher correlations with the frequency scores than with the independence ones. Children with less independence were associated with greater impairment in body functions and might face more barriers associated with the adequacy of assistive technology and physical products. By contrast, children with greater frequency restrictions tended to have more problems associated with the negative attitudes of others (e4), which might decrease children\’s opportunities to attend activities. This suggests that participation frequency might be more related to social support, including the acceptability and accommodability of the environment, while independence might be more related to physical support, including the availability, accessibility, and affordability of the environment.
Drug-induced gingival overgrowth and fibrosis occurs as a side effect of systemic medication of immunosuppressant cyclosporine A (CsA). CsA-induced gingival overgrowth characterizes fibrosis via the increased accumulation of fibroblasts, collagen, and other extracellular matrix components, such as plasminogen activator inhibitor-1, lysyl oxidase (LOX), cystatin C, heat shock protein 47, and transglutaminase-2. The upregulation of the buy dihydroergotamine growth factor may contribute to the pathogenesis of CsA-induced gingival overgrowth. In addition, gingival inflammation is a contributing factor to the development of CsA-induced overgrowth, and chlorhexidine was reported to ameliorate gingival overgrowth via an anti-inflammatory mechanism in an established rat model. However, the pathologic mechanisms of CsA-induced gingival overgrowth still need to be further clarified.
Epithelial–mesenchymal transition (EMT) is characterized by the loss of proteins associated with the epithelial phenotype and by the increased expression of proteins associated with a mesenchymal and migratory cell phenotype. EMT occurs in drug-induced gingival overgrowth. Snail, a member of the Snail family of zinc finger transcription factors, is one of the master regulators that promote EMT. Overexpression of Snail is found in various fibrotic diseases, including liver fibrosis and renal fibrosis. However, it is unclear whether Snail is involved in the pathogenesis of CsA-induced gingival overgrowth.
In this study, the effect of CsA on normal human gingival fibroblasts (HGFs) was used to elucidate the possible role of Snail in the pathogenesis of CsA-induced gingival overgrowth. Quantitative real-time reverse transcription–polymerase chain reaction (qRT-PCR) and western blot were used to determine the effects of CsA on the expression of Snail in cultured HGFs in vitro. In addition, the cell proliferation rate in CsA-treated HGFs with Snail lentiviral-mediated short hairpin RNA interference (shRNAi) knockdown was evaluated by tetrazolium bromide reduction assay.
To examine the effect of CsA on Snail expression in vitro, HGFs were treated with CsA, and the levels of transcript and protein were measured by qRT-PCR and western blot analyses. As shown in Figure 1, CsA increased the Snail transcript in HGFs in a dose-dependent manner (p < 0.05). In addition, CsA upregulated Snail protein expression in a dose-dependent manner (p < 0.05; Figure 2A). From the AlphaImager 2000, the levels of Snail protein increased about 1.6-, 3.4-, 3.1-, and 3.0-fold after exposure to 100 ng/mL, 200 ng/mL, 500 ng/mL, and 1000 ng/mL CsA, respectively (Figure 2B).
His medical history did not reveal any chronic diseases nor infections in the past. The pupils on both eyes were round and reactive to light, ocular motility was free and OCT-scans of the macula showed normal findings. The intraocular pressure was 27 mmHg (right eye) and 19 mmHg (left eye). Examination at the slit lamp showed no relevant pathology of the left eye. Examination of the right eye of the patient, however, revealed a yellowish iris mass covering the iridocorneal angle from the 5 o\’clock to the 6 o\’clock position (Figs. 1 and 2). This finding was accompanied by a strong vascularization of the iris, by TG-101348 and fibrin in the anterior chamber and by a mild hyposphagma. Because there was an acute eye irritation and the symptoms developed fast during one week, a nevus or neurofibroma could be excluded as a differential diagnose.
The tumor\’s infiltration of the iris was revealed by sonographic examination (UBM, Fig. 3). This infiltration was limited to the iris, there was no infiltration of the vitreous body. Because the lesion was suspicious for a xanthogranuloma, granulomatous disorders like tuberculosis, sarcoidosis, granulomatosis with polyangiitis and syphilis were considered as differential diagnoses. Medical laboratory tests (for, e.g., activity of levels of angiotensin converting enzyme and concentrations of soluble interleukine-2 receptor), Venereal Disease Research Laboratory (VDRL) test and Treponema-pallidum-hemagglutination-assay (TPHA), ear-nose-throat and radiological examinations (chest X-ray and computertomography) did not reveal any acute or chronic disease. Strikingly, blood analysis revealed a polyglobulia. Due to this finding, the patient was presented to the hemato-oncologists with suspect of polycythemia vera lateron.
The patient was treated with topical and systemic prednisolone (inflanefran forte drops every hour, prednisolone 100 mg) and Cosopt S drops (twice a day). The consistent application of this therapy gradually led to recovery of visual acuity within four days (visual acuity on the right eye 20/25). The iris vascularization began to decrease, the iris tumor however persisted. Oral prednisolone (100 mg daily, with a reduction by 10 mg a week) and topical prednisolone drops (every hour) were prescribed to the patient. In the follow-up medical examination after one week, the iris tumor had significantly decreased. Supported by this finding, the patient was instructed to taper off prednisolone and to attend a follow-up examination after four weeks. One month later, the iris tumor had completely disappeared and visual acuity had fully recovered (Figs. 4 and 5). This finding remained stable and without recurrence in further follow-up examinations (up to now five months after initial presentation).
Besides the juvenile xanthogranuloma, there are also other histiocytoses which may show ocular manifestations: The Erdheim-Chester disease (ECD) is affecting primarily long bones of adults in middle age and the Langerhans cell histiocytosis, which is characterized by bone marrow affection and involvement of other organs in younger children. Patients with Erdheim-Chester disease may develop lipogranulomatous masses in the orbita, which can lead to exophthalmus, ophthalmoplegia or even blindness due to optic atrophy. In patients with Langerhans cell histiocytosis, cases with lytic lesions within the orbital wall and large soft-tissue masses in the orbita leading to proptosis have been described. An intraocular tumor due to a histiocytic disease may indicate an intraocular manifestation of the juvenile xanthogranuloma.
The first pediatric case of a juvenile xanthogranuloma with intraocular involvement was published by Blank et al., in 1949. They compared histological findings of skin lesions with the lesion in the eye. The ocular symptoms include unilateral atraumatic hyphaema, iritis, decreased visual acuity and secondary glaucoma due to the obstruction of the iridocorneal angle by the iris tumor. Nowadays, fine needle aspiration cytology from the lesion or the aqueous may lead to the diagnosis of the juvenile xanthogranuloma, but in most cases, the diagnosis “intraocular juvenile xanthogranuloma” is based on the clinical picture alone. Zimmerman et al. (1965) postulated five criteria each of which may indicate a possible intraocular manifestation of the juvenile xanthogranuloma: 1) spontaneous hyphaema, 2) a red eye with signs of uveitis, 3) congenital or acquired heterochromia iridis, 4) iris tumor and 5) unilateral glaucoma. Our patient had a unilateral red eye, an iris tumor and he complained of glare and a decreased visual acuity. The intraocular pressure was moderately increased to 27 mmHg (19 mmHg in the other eye) which required topical medication. Clinically the yellowish tumor covered the iridocorneal angle of the right eye from the 5 o\’clock to the 6 o\’clock position. There were no further lesions neither in the eyes nor in the skin of our fifty-year-old patient.
The timely recognition of dementia is the prerequisite for adequate information, treatment, and care. Nevertheless, dementia is known to be considerably underdiagnosed; even in high-income countries with advanced medical care systems about 50% to 80% of people with dementia (PWD) are not formally diagnosed [1,2]. There are approaches to improve the recognition of dementia, such as the proactive “dementia case finding scheme” that was initiated by the government of the United Kingdom  or the “Annual Wellness Visit” for Medicare enrollees in the United States which includes the detection of any cognitive impairment . However, the best practice for the identification of dementia in primary care has not yet been established. Previous studies showed that the use of structured screening instruments improves the identification of cognitive impairment in primary care and that the screening for dementia increases diagnosis rates [5–7]. Nevertheless, routine screening is controversially discussed and not recommended in respective dementia guidelines because there is still a lack of evidence that patients benefit from it 69 8 [8–12]. Arguments against routine screening include the risk of receiving a false-positive diagnosis of dementia after a positive screening outcome; the cause of anxiety or depression among positively screened subjects; unnecessary examinations and treatments; the diversion of resources that would better be used to care for real dementia cases; or the danger that older patients will avoid visiting their general practitioner (GP) because they fear to be diagnosed with dementia [13–16]. Therefore, routine screening of asymptomatic patients is not seen as the favorable solution to improve the recognition of patients with dementia in primary care. It has been suggested that the case-finding of dementia should focus on patients presenting with cognitive complaints [14,15].
Subjective memory impairment (SMI) may represent the first symptomatic manifestation of Alzheimer\’s disease and SMI and related worries have been identified as risk factors for the incidence of dementia in people without objective cognitive impairment [17–19]. However, the diagnostic value of self-reported cognitive impairment for prevalent dementia seems to be limited for several reasons: SMI is associated with depression [20–22]; cognitively healthy older persons frequently complain about memory impairment [23,24]; and PWD are often not aware of their memory problems [25,26].
Mitchell  conducted a meta-analysis of the diagnostic value of subjective memory complaints for manifest dementia in community samples with a low prevalence of dementia and found a positive predictive value (PPV) of 19% and a negative predictive value (NPV) of 94%. Mitchell concludes that the absence of subjective memory complaints may be a reasonable method of excluding dementia and could be incorporated into short screening programs in settings with low prevalence of dementia. However, to our knowledge this assumption has not yet been validated in clinical settings. This study aims to determine whether self-reported SMI or SMI-related worries could be used as a valid criteria to decide if an elderly primary care patient should be screened for dementia.
Our analyses showed that the sensitivity of SMI was just 54%. This means that 46% of the primary care patients screened positive for dementia did not report SMI before the screening. Thus almost half of the patients with cognitive impairment would have been overlooked if the presence of SMI would have been the precondition for performing the structured cognitive test. In addition, both the PPV (19%) and the UI+ (0.10; interpreted as “poor” rule-in-accuracy) of SMI were very low. Mitchell  reported similar results with a meta-analytic pooled sensitivity of 43%, a PPV of 19%, and an UI+ of 0.08 and concluded that “subjective memory complaints should not be relied on for case-finding”. These findings are in line with the results of previous studies that showed that people with dementia are often not aware of their memory problems [25,26].
Material and methods
CYP1A2 is a metabolic enzyme for theophylline, tizanidine, and caffeine. In several cases, Bakumondo-to was co-administrated with theophylline for airway inflammation and chronic Cy3.5 hydrazide treatment. Saruwatari et al. (2004) reported that Bakumondo-to tended to inhibit the CYP1A2 activity after 7days in an in vivo human study. In our study, it was observed that Bakumondo-to significantly inhibited CYP1A2 activity, but its protein expression was not changed compared with that of the control. It suggested that the inhibition of CYP1A2 activities by Bakumondo-to is independent of protein expression. Taking our and Saruwatari’s study data into account, Bakumondo-to may change the affinity of CYP1A2. Chang reported that Ginseng root extract, one of the components of Bakumondo-to, inhibited CYP1A2 activity (Chang et al., 2002). However, the inhibitory components and mechanisms are still unknown and need to be clarified.
CYP2C is approximately 25% of P450 in human liver microsomes (Imaoka et al., 1996). It is reported that CYP2C is the key enzyme for the metabolism of zafirlukast, montelukast, omeprazole, and phenytoin (Dekhuijzen and Koopmans, 2002; Karonen et al., 2012). Zafirlukast or montelukast, a leukotriene receptor antagonist, is used for the treatment of asthma and allergic rhinitis. Bakumondo-to is co-administrated with zafirlukast or montelukast in several cases. Therefore, we also examined the effect of Bakumondo-to on CYP2C. The activities were increased by 158%, and the density of CYP2C bands were increased by 288% compared with that of the control groups. The data suggest that the increased activities depend on the induced protein expression. Only 4days of treatment caused CYP2C induction. If Bakumondo-to is administered for long periods in clinical situations caution should be taken to prevent drug-herbal interactions via CYP2C.
Logistic analysis has shown that age and the count of inhalation device are significant factors that lead to diminished inhalation technique, even when the type of inhalation device is taken into account (Table 3). Although it apomorphine has been previously reported that the type of the inhalation device, in addition to age, causes a difference in the performance of the inhalation technique, this divergence seems to be attributable to individual patients or to differences in the method of evaluation. In the current study, patients of a variety of ages were recruited without bias to determine the effects of age as primary endpoints. However, in regard to the inhalation device, the secondary endpoint, various inhalation devices including the aforementioned three devices used by many patients are currently available, and the prominent effects of age on inhalation devices could be detected, but it was also possible that the influences of inhalation devices were hardly detected. On the other hand, the count of inhalation device is the significant factor of inhalation technique independent from age. In order to prevent the confusions, we should choose same device for same patient as possible. Thus, it is presumed that confirmation of inhalation technique is important for elderly patients, regardless of the type of inhalation device. In recent years, inhalation devices with simplified operation have become available, and it is expected that the development of inhalation devices associated with fewer operational errors will be further promoted according to advances in pharmaceutical technology.
Table 4 shows the results of comparison between the two groups of patients, i.e., the elderly group (≥66.5 years of age) and the non-elderly group (<66.5 years of age), in regard to the frequencies of specific problems. Similar to the NRS scores, the number of patients who reported some problems on their subjective assessment was significantly greater in the non-elderly group, whereas those with problems were more frequent in the elderly group on the objective assessment of medical professionals, showing a divergence. Thus, these results highlighted the lack of awareness of problems among elderly patients. Medical professionals\’ objective assessment revealed that patients who had problems in inhalation technique were predominant particularly in the elderly group. In contrast, patients\’ subjective assessment showed that there were more patients who had difficulty continuing medication in the non-elderly group. In general, older age in patients is reported to be associated with low adherence to treatment because of decreased cognitive and physical function. On the other hand, Transcribed spacer has been reported that elderly patients have higher respect for medical professionals and are more likely to visit a hospital regularly, and therefore medical professionals play an important role in the patients\’ acceptance of treatment. The results of this study also suggest that tolerance to continuation of medication, i.e., motivation for treatment, remained undiminished. The decrease in resistance to continuation of treatment might also be derived from the fact that elderly patients are more likely to be unemployed and thus have fewer temporal restrictions than non-elderly patients. There are some limitations in this study. (1) Medical professionals\’ assessment was not based on a checklist, and therefore the rating scale might have varied among different raters. However, the variance among individual raters is presumed to be great enough to affect the relationship between age, the primary endpoint, and the technique or knowledge of inhalation. (2) The present study was not complete survey, and therefore there is potential for bias that the participants are likely to be health-conscious patients. Despite those health conscious patients, increasing age spoils their light recognition for inhalation therapy. (3) Because the present study is a questionnaire survey, we could not capture the detailed patients information, such as activities of daily living (ADL) and complications. However, in the present study, patients were not eligible if it was difficult for them to respond to the questionnaire because of decreased cognitive function. Therefore, patients who have extremely low ADL were not included in the present study. Generally, the ADL associates with the age of patient. In the present study, we considered that the influence of ADL on inhalation therapy was included in the influence of age.
In this study, the most common reported associated extra pancreatic finding was dilated CBD and intra hepatic biliary radical, which was seen in 6 patients (42%); this is seen in 75% of patients with head masses. John et al. stated that ductal dilatation occurs in 58% of patients with pancreatic neoplasm and ductal dilatation proximal to the obstructing tumors was detected in approximately 88% of pancreatic head tumors.
Liver metastases were detected by multi slice CT in 7 patients (50%). This comes in agreement with Murfitt who stated that Phos-tag Acrylamide to the liver occurred in approximately 17–55% of the patients.
Chest distant metastatic finding was a common association with pancreatic neoplasm in the current study. This was reported in 28.5% of the patients. Osteolytic bony lesion was found in 7%. This comes in agreement with the statement of Kloppel who stated that metastasis to lung, pleura and bone is only seen in advanced tumor stages.
In our study, 5 cases were resectable out of 14 cases (35%). Near to this is the study of Grenacher and KlauB which stated that only 20% of all patients believed to have a surgically resectable disease.
Resection is aborted in one case out of 6 cases (about 16% of the suspected resectable cases) due to unsuspected peritoneal deposits, whereas Zamboni et al. decided that resection was aborted in 11% of their suspected resectable cases.
Darren et al. stated that False-negative results almost often occur because of the unsuspected liver surface metastases, peritoneal deposits, or unsuspected vascular invasion.
Frate et al. stated that MSCT has an accuracy rate for staging of pancreatic adenocarcinoma of virtually 100%. In our study the overall accuracy of tumor staging by MSCT was 84%. Whereas Zamboni et al. stated that the accuracies ranged from 85% to 95%, Scaglione et al. decided that the accuracy of MSCT in staging of pancreatic cancer is as high as 93%.
In our study insulinoma appeared as well defined small lesion which enhanced more intensely than the normal pancreatic parenchyma in all phases. This coincides with McLean study which stated that insulinomas are typically hyper attenuating on at least one phase of contrast enhancement typically on the late arterial [25s] or pancreatic phase [35–40s] of imaging but occasionally in the portal venous phase.
In our study there were two cases of pathologically confirmed pancreatic mucinous cystadenoma. Both patients were female and in relatively younger age group (53 and 57years). Aslam and Yee stated that a mucinous cystic neoplasm occurs predominantly in women.
One case was diagnosed by MDCT as serous cystadenoma. This was a 54year old male. This is in contrast to Dewhurst et al. who stated that about 80% occur in women who are more than 60years old. This is possibly attributed to small number of cases enrolled in our study.
One case of pancreatic metastasis was from renal cell carcinoma. Paspulati stated that the common primary tumors that metastasize to the pancreas are from lung, breast, kidney, and melanoma. Mechó et al. stated that pancreatic metastases are uncommon, representing 4.5% of pancreatic tumors.
Conflict of interest
Chronic pelvic pain (CPP) is a significant health problem in women particularly during childbearing age and may account for 10% of outpatient gynecologic visits. Etiology of chronic pelvic pain includes irritable bowel syndrome, endometriosis, adenomyosis, pelvic congestion syndrome, atypical menstrual pain, urologic disorders, and psychosocial issues.
Pelvic congestion syndrome occurs mostly because of ovarian vein reflux, but can also occur because of the obstruction of ovarian vein outflow resulting in reversed flow.
Ovarian vein reflux (OVR) is found and PCS is diagnosed most frequently in multiparous women. During pregnancy, ovarian vein flow may increase up to 60 times. This increase in blood flow causes ovarian vein dilatation and may result in venous valve incompetence. PCS is likely caused by the incompetence of the venous valves of the ovarian and pelvic veins, which results in OVR leading to ovarian and pelvic vein dilatation and stasis. Therefore incompetence, venous reflux, and dilatation of the ovarian veins lead to the development of pelvic varicosities and congestion, which are known causes of pelvic pain and the most likely etiology of PCS.