Western Series Research Articles

Tissue proportions and enamel thickness distribution in the early Middle Pleistocene human deciduous molars from Tighenif, Algeria

The present study of three human upper deciduous molars from the early Middle Pleistocene site of Tighenif, Algeria, constitutes the first microtomographic-based endostructural exploration of African fossil teeth likely representative of the Homo heidelbergensis morph. Comparative morphological observations and 2-3D measurements describing subtle tooth organization (crown tissue proportions) and enamel thickness topography (site-specific distribution and global patterning) indicate that their virtual extracted structural signature better fits the modern human, rather than the Neanderthal condition. Accordingly, we predict that the inner structural morphology of the deciduous molars from the Middle Pleistocene western European series better fits the primitive, and not the derived Neanderthal figures.

Compulsive Behaviors in Patients With Parkinson's Disease

Several impulse control disorders (ICDs) may develop in patients with Parkinson's disease (PD). We aimed to identify the frequency and phenomenology of ICDs in our PD population. Among 554 PD patients examined in a 3-year period, we identified 33 patients with ICDs. Disease duration, gender, and age-matched 65 PD patients without ICDs were selected as controls. We noted age-at-onset, duration, and severity of PD, dose and types of dopaminergic treatment, as well as presence of motor complications in both groups. Of 554 patients, 33 (5.9%) had ICDs, of whom, 27 were men (81%), mean age-at onset of PD was 48 and disease duration 8 years. While all patients with ICDs were on dopamine agonist drugs (+/- an adjuvant), all but 2 of controls were on dopamine agonists. Punding was the most frequent behavioral problem (57%), 42% exhibited aggressive hypersexuality, 27% compulsive eating, 24% pathologic shopping, and 21% compulsive medication. Severity of PD, presence of l-Dopa-induced motor complications, l-Dopa equivalent doses of dopamine agonists administered were not statistically different between 2 groups. In this study performed in a tertiary clinic for movement disorders in Turkey, several ICDs occurred in a small group of PD patients, mostly in men with young-onset disease, similar to the previous reported series. However, in contrast to the Western series, the number of gamblers was quite low because gambling is illegal in our country. We did not find any association between ICDs and severity of PD as well as doses of dopaminergic agents.

Intraductal papillary mucinous neoplasm of the pancreas (IPMN): clinico-pathological correlations and surgical indications

BackgroundIntraductal papillary mucinous neoplasms (IPMNs) are increasingly recognized entities, whose management remains sometimes controversial, due to the high rate of benign lesions and on the other side to the good survival after resection of malignant ones.MethodsRetrospective analysis of a prospectively collected Western series of IPMN.ResultsForty cases of IPMN were analysed (1992-2007). Most patients were symptomatic (72.5%); cholangio-MRI had the best diagnostic accuracy both for the tumour nature (83.3%) and for the presence of malignancy (57.1%). ERCP was done in 8 cases (20%), and the results were poor. Thirteen patients were treated by pancreatic resection and 27 were maintained in follow-up. Total pancreatectomy was performed in 46% of the cases; in situ and invasive carcinoma were recognized in 15.4% and 38.4% of the cases, respectively. The mean follow-up was 42 months (range 12-72). One only patients with nodal metastases died 16 months after the operation for disease progression, while 91.6% of the operated patients are disease free. Out of the 27 not resected patients, 2 out of 4 presenting a lesion at high risk for malignancy died, while the remaining are in good conditions and disease free, with a mean follow-up of 31 months.ConclusionTherapeutic indication for IPMNs is mainly based upon radiological evaluation of the risk of malignancy. While the main duct tumours should be resected, preserving whenever possible a portion of the gland, the secondary ducts tumours may be maintained under observation, in absence of radiological elements of suspicion such as size larger than 3 cm, or a wall greater than 3 mm or nodules or papillae in the context of the cyst.

Endoscopic submucosal dissection in patients with early esophageal squamous cell carcinoma: results from a prospective Western series

Although endoscopic submucosal dissection (ESD) is becoming accepted as an established treatment for superficial esophageal squamous cell neoplasia, the majority of data on this endoscopic modality has been provided by Japanese series. To assess the efficacy and safety of ESD for esophageal squamous cell neoplasia in a consecutive series of patients treated in a Western setting. Single-center, prospective observational study. From January 2005 to July 2008, 20 patients with superficial esophageal squamous cell neoplasia were treated by ESD. Rates of en bloc resection, complete resection, and complications were evaluated as short-term outcomes. Overall survival, local or distant recurrence, and postoperative stricture rates were evaluated as long-term outcomes. ESD was performed in 20 patients (mean age 64 years, range 46-81 years; 16 men). The mean size of the lesion was 32 mm (range 15-60 mm); it was 30 mm or larger in 14 patients (70%). The mean time of ESD was 89 minutes (range 58-180 minutes). En bloc resection with resection-free margins was achieved in 18 patients (90%), whereas 2 patients presented with incomplete or indeterminate resection. Two cases (10%) of mediastinal emphysema without overt perforation and 1 case (5%) of post-ESD symptomatic stricture were reported. No local or distant post-ESD recurrence occurred in those with resection-free margins at a median follow-up of 18 months. Small number of patients and limited follow-up. This Western series study confirms that ESD is a potentially curative treatment for superficial esophageal squamous cell neoplasia. Early and late complication rates were comparable to those of Japanese series. ESD should be probably considered as the treatment of choice in all large lesions amenable to endoscopic treatment.

Prevalence of nonpolypoid colorectal neoplasia: An Italian multicenter observational study

The aim of this study was to assess the prevalence of nonpolypoid lesions (NPLs) in Italy and their risk of containing neoplasia or advanced histology. This was a multicenter cross-sectional observational study on consecutive patients undergoing total colonoscopy over a 3-month period in 80 Italian centers. In all, 27,400 total colonoscopies were analyzed. Cancer was diagnosed in 801 patients (2.9 %). A total of 6553 precancerous lesions were detected in 5609 patients. Of these, 4154 patients (74.1 %) had polypoid lesions and 1455 patients (25.9 %) had NPLs. Therefore, the prevalence of NPLs was 5.3 % (95 %CI 5.0 - 5.6). NPLs larger than 10 mm were detected in 254 patients (17.5 %). NPLs were more predominant in the proximal colon (OR 2.92, 95 %CI 2.56 - 3.43; P < 0.0001 vs. polypoid lesions). Neoplastic tissue was diagnosed in 79.0 % and advanced histology (high-grade intraepithelial neoplasia or more) in 20.9 % of resected lesions. The risk of advanced histology was similar for polypoid and nonpolypoid lesions when adjusted for size. Depressed lesions had the highest risk of advanced histology (OR 10.56, 95 %CI 6.02 - 18.55; P < 0.0000 vs. flat-elevated). Age was an independent predictor of both neoplasia and advanced histology ( P = 0.0001). NPLs are relatively common in the Italian population, with a prevalence similar to that in other Western series. NPLs are not more aggressive than polypoid lesions, except for those with depressed morphology.

Low incidence of malignancy in heart-transplant recipients in Taiwan: an update and comparison with kidney-transplant recipients

Malignancy is the leading cause of death among heart-transplant recipients. There is a higher incidence of post-transplant malignancy in heart-transplant recipients than in kidney-transplant recipients. This study sought to assess the incidence of malignancy in heart-transplant recipients in Taiwan. This is a retrospective chart review. From 1987 to 2008, 291 patients who underwent heart transplantation and survived for more than 1 month were enrolled. Seventeen patients (5.8%) developed de novo malignancies including skin cancers (three), post-transplant lymphoproliferative diseases (seven) and solid-organ malignancies (seven). Solid-organ malignancies affected prostate, liver, urinary bladder, kidney, lung, larynx, pancreas and brain in seven patients. Malignancy was responsible for 7% and 13% of all death for heart-transplant recipients who lived for more than 1 year and more than 5 years. The cumulative incidence of 1.03% at 1 year, 4.2% at 5 years and 8.1% at 10 years in our patients was much lower than the incidences reported in the multicentre registry of the International Society for the Heart and Lung Transplantation and in the Western series. The incidence was especially low for skin cancers. Compared with previous reports of kidney-transplant recipients in Taiwan, the incidence of post-transplant malignancy was not significantly increased. The incidence of post-transplant malignancy was low in Chinese heart-transplant recipients compared with heart-transplant recipients in Western countries. It resulted from a relative rarity of skin cancers in the Chinese population.

Clinical outcome of Taiwanese men with clinically localized prostate cancer post-radical prostatectomy: a comparison with other ethnic groups

Background. Prostate cancer incidence varies significantly among different ethnic groups. However, the report concerning the clinical outcome after radical prostatectomy (RP) in the low incidence Asian population is still limited. We aimed to compare the clinical outcome in patient treated with RP among different ethnic groups and to identify significant prognostic factors in Taiwanese patients.Methods. A total of 341 patients with clinical localized prostate cancer undergoing curative RP in three medical centers in Taiwan were included in this study. Ethnic group comparison was performed using the CaPSURE, SEARCH databases from United States (US) and one large European series. The Kaplan–Meier analysis and Cox proportional hazard model were used to identify significant predictors for prostate-specific antigen (PSA) recurrence.Results. Compared to the Caucasian white population in the US and Europe studies, the Taiwanese population have higher age at surgery and higher pre-operative PSA level. With mean and median follow-up of 39.1 months and 31.0 months (range 5–120 months), 127 men (37.2%) had PSA recurrence which was significant higher than the Western series. Significant predictors for PSA recurrence identified in the post-operative overall model were PSA level, pathological Gleason Score, pathological tumor stage and lymph node metastasis.Conclusions. The clinical outcome of Taiwanese male with prostate cancer post-RP appears inferior to the Western country, which is largely due to delay surgery at higher PSA level. Earlier diagnosis and treatment may improve the cancer control of RP.

The urgent need for evaluating recurrent primary sclerosing cholangitis in living donor liver transplantation

In an earlier issue this year, Alabraba and colleagues1 evaluated the risk factors for recurring primary sclerosing cholangitis (PSC); we read with great interest their article entitled “A Re-Evaluation of the Risk Factors for the Recurrence of Primary Sclerosing Cholangitis in Liver Allografts.” Analyzing prospectively collected data for 230 consecutive deceased donor liver transplantation (DDLT) procedures for PSC over a 20-year period with an 83-month follow-up, the authors reported that 54 (24%) of the DDLT recipients presented with recurrent PSC at a median of 4.6 years after transplantation. An analysis of the risk factors indicated that colectomy offered a protective effect against PSC recurrence, whereas the use of grafts recovered under extended donor criteria (EDC) was associated with a higher rate of recurrence. Indeed, although liver transplantation has become an accepted treatment for PSC with liver failure with excellent overall survival, recurrent disease continues to be a threat with a higher rate of retransplantation.2 Identification of the factors affecting recurrence is therefore important. In this context, we were disappointed that some of the recently reported disturbing aspects of living donor liver transplantation (LDLT) are not discussed in the article.1 In contrast to Western countries, liver transplantation from a living donor remains the most realistic option in the Far East. Following the successful results with DDLT reported from the West, LDLT has been applied for PSC with liver failure in Japan. One concern in applying LDLT for PSC has been the unknown effect of a shared genetic disposition in a blood-related recipient and donor pair, which may affect the recurrence of PSC and hence graft survival over the long term. Until recently, however, only sporadic case reports have been published with short follow-up periods, and little information on this aspect has been available. To fill the void, we conducted a retrospective study on the clinical course of PSC after LDLT at our institution. The results of our analysis indicated that PSC not only recurred as in the DDLT series but also recurred at a much higher rate.3 When the analysis was restricted to cases with biologically related live donors, recurrent PSC occurred in 50% of the recipients with a mean time to diagnosis from LDLT of 3.3 years. An observation supporting this finding was reported by another high-volume center.4 Among the 22 patients who survived for more than a year in the series, 13 (59%) presented with PSC recurrence with a mean follow-up period of 2.6 years, 5 of whom died or required retransplantation for graft failure. These preliminary reports have raised considerable concerns, and currently, a nationwide survey, supported by the Ministry of Health, Labor, and Welfare, is ongoing in Japan. The first study by the authors analyzing the risk factors for recurrent PSC in the allograft was published in 2002,5 and since then, LDLT has evolved and spread worldwide, becoming a realistic option in the West and in the East because of the universal organ shortage. Findings regarding the mid-term to long-term outcomes of LDLT for PSC from European or North American series, however, have not been reported despite the rapid accumulation of adult-to-adult LDLT cases. In their analysis, Alabraba and colleagues1 reported that the use of EDC grafts resulted in a 5-fold increase of recurrent PSC, with a 5-year recurrence-free survival of 71% versus 91% for non-EDC grafts. Preliminary studies in LDLT, however, have suggested a further significant impact when a graft donated by a blood-related living donor is used for PSC. In this era of severe graft shortage, the interpretation of these outcomes requires caution, but the implications are nonetheless alarming. Further validation is urgently needed. Currently, however, PSC accounts for less than 3% of all LDLT procedures performed in Japan because of its rarity in comparison with the higher prevalence in Nordic countries and the United States. Studies focusing on the outcomes of LDLT for PSC in a Western series are greatly anticipated. Sumihito Tamura*, Yasuhiko Sugawara*, Noriyo Yamashiki*, Junichi Kaneko*, Norihiro Kokudo*, * Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo Tokyo, Japan.

Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network

The aim of this study was to determine the contemporary prevalence, outcome, and survival after esophagogastric anastomotic leakage (EGAL) following esophagectomy by a regional upper gastrointestinal cancer network and to investigate etiological factors. Two hundred forty consecutive patients underwent esophagectomy over a 10-year period (median age 61 [31-79] years, 147 transthoracic and 93 transhiatal esophagectomy, 105 neoadjuvant chemotherapy, 49 chemoradiotherapy). The primary outcome measures were the development of EGAL and survival. Twenty patients developed EGAL (8.3%, 15 managed conservatively, 5 reoperation). Overall operative mortality was 2% (5 patients in total, 1 after EGAL). Median, 1 and 2-year survival was 22 months, 73% and 50%, in patients after EGAL, compared with 31 months, 80% and 56%, in patients who did not suffer EGAL (P= 0.314). On multivariate analysis, low body mass indices (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.11-0.79, P= 0.016), individual surgeon (HR 1.21, 95% CI 1.02-1.43, P= 0.02), and neoadjuvant chemotherapy (HR 3.28, 95% CI 1.16-9.22, P= 0.024) were significantly associated with the development of EGAL. EGAL following esophagectomy remained common, but associated mortality was less common than reported in earlier Western series and long-term survival was unaffected.

Inflammatory pseudotumours of the liver: A spectrum of presentation and management options

Purpose To review the current management options in inflammatory pseudotumours via analysis of ten cases from this unit the largest experience of this pathology in a Western series. To assess the medical and operative options available for this condition and the varying outcomes and the lessons learned in this unit over the time period. Results Data from the ten cases were analysed and a comprehensive review of the published literature to date has detailed 128 case reports with 215 cases of inflammatory pseudotumour of the liver. Data analysed included patient demographics, diagnostic modalities, details of treatment and eventual outcome. The data was tabulated using an Excel spreadsheet (Microsoft ® Excel 2004 for Mac 2004.Version 11.0). Categorical variables were compared using Pearson's χ 2 test and p values <0.05 were defined as statistically significant. Statistical analysis was performed using SPSS for Windows (Version 9.0, SPSS Inc., Chicago, IL). Conclusion Emphasis is placed on a preferred medical management initially for this tumour with a good prognosis coupled with regular follow up. There may be a need for surgical resection cases where diagnosis is unclear or the patient is not responding to medical treatment with progression of disease or symptoms.

A European case series of endoscopic submucosal dissection for gastric superficial lesions

EMR is an accepted method for resection of superficial lesions in the GI tract. However, because it leads, not unusually, to piecemeal resection, histopathologic interpretation problems and an increased risk of recurrence are noticeable. Endoscopic submucosal dissection (ESD) allows a higher rate of en bloc resection, with low recurrence. Nevertheless, this technique, namely in the upper-GI tract, has rarely been described in Western countries, probably because of the rarity of gastric cancer in most countries. To describe the efficacy and safety of ESD for gastric superficial lesions in a European country. Consecutive case-series report. A tertiary specialized center. Nineteen patients with gastric superficial lesions (15-30 mm), with high-grade (n = 15) or low-grade (n = 4) noninvasive epithelial neoplasias, in the antrum (n = 12), incisura angularis (n = 2), body (n = 3), and cardia (n = 2). ESD with the patient under general anesthesia in the endoscopic room (40-300 minutes) by using an insulated-tip-knife. Complete (R0) and en bloc resection, and complications. ESD was achieved in all cases, with 89% R0 resection and 79% en bloc resection rates observed. Major bleeding was reported in 1 case (5%); there were no cases of perforation. With a median follow-up of 10 months, a single recurrence (5%) was observed. A small series at a single center, with a short median follow-up time. We report the feasibility and effectiveness of gastric ESD in Europe. A further description of a Western series is expected, and guidelines for its dissemination are desirable to define the role of this technique in Western countries.

Occurrence of epilepsy during the first 10 years after traumatic brain injury acquired in childhood up to the age of 18 years in the south western Swedish population-based series

Background: The risk of seizures is increased after a traumatic brain injury (TBI), but the impact and duration of this increased risk is not well characterized in children.Objective: To identify post-traumatic epilepsy (PTE) and post-concussion symptoms 10 years after a TBI during childhood.Research design: The study is a population-based retrospective follow-up study.Procedure: Ten years after brain injury all 165 survivors, who as children (<18 years) in 1987–1991 as residents in the south western Swedish health care region had had a TBI, were invited to participate in a follow-up. A questionnaire regarding medical conditions and medication was filled out by the patients themselves or their parents as was a 21-item questionnaire (PCSQ) regarding post-concussion symptoms. Of the surviving 165 individuals, 109 participated (67%).Results: Eight of 109 developed immediate seizures. During the follow-up period 12/109 had developed active epilepsy. Of these 12, five had had immediate seizures. The incidence of developing PTE within 10 years after a TBI was thus in this series 11%. The relative risk to develop late onset post-traumatic epilepsy (≥1 week after injury) for those who had had immediate seizures was 9.018 (p = 0.0003, 95% CI = 3.69–22.05).Conclusions: TBI is a relatively rare cause of epilepsy in childhood, although immediate seizures are associated with an increased risk of developing post-traumatic epilepsy.

Entirely laparoscopic radical gastrectomy for adenocarcinoma: lymph node yield and resection margins

Laparoscopic assisted distal gastrectomy for adenocarcinoma has been widely reported from Japan and Korea but there are sparse data for Western patients. This study aimed to describe and compare the perioperative outcomes and pathological staging for consecutive patients who underwent laparoscopic or open gastrectomy by a single surgeon in the UK. During the period from April 2005 to May, 2007, patients with gastric adenocarcinoma were selected for open or laparoscopic resection at the discretion of the surgeon. Gastric resections for gastrointestinal stromal tumour (GIST) or benign disease were excluded. Laparoscopic gastrectomy was performed entirely laparoscopically with intracorporeal anastomosis, followed by specimen retrieval via a suprapubic incision. There were 21 men and 8 women, median age 75 years (range 45-88 years), with American Anaesthesiology Association scores of 3 or 4 in 19 patients. Gastrectomy was performed laparoscopically in 18 patients (62%; total gastrectomy, 6 patients) or open in 11 patients (total gastrectomy, 7). Five laparoscopic gastrectomies were converted to open procedures, three patients had re-laparoscopy and one patient had subsequent laparotomy. As compared with open gastrectomy, laparoscopic resection had longer operation time and similar length of hospital stay. There was one postoperative mortality in each group. There was similar lymph node retrieval for laparoscopic or open resection [23 (range 10-44) versus 26 (8-95), respectively; p = 0.40], with inadequate lymphadenectomy (<15 nodes) in two laparoscopic cases and one open case. R1 resection was limited to patients with pT3 disease (laparoscopic, 4; open, 2). Perioperative outcomes were similar for laparoscopic or open gastrectomy. Lymphadenectomy was adequate in 89% of laparoscopic gastrectomies. pT3 tumours were at risk of noncurative resection, as described in large Western series of open gastrectomy.

Differential Late Paleozoic active margin evolution in South-Central Chile (37°S–40°S) – the Lanalhue Fault Zone

The N–S oriented Coastal Cordillera of South Central Chile shows marked lithological contrasts along strike at ∼38°S. Here, the sinistral NW–SE-striking Lanalhue Fault Zone ( nomen novum) juxtaposes Permo-Carboniferous magmatic arc granitoids and associated, frontally accreted metasediments (Eastern Series) in the northeast with a Late Carboniferous to Triassic basal-accretionary forearc wedge complex (Western Series) in the southwest. The fault is interpreted as an initially ductile deformation zone with divergent character, located in the eastern flank of the basally growing, upwarping, and exhuming Western Series. It was later transformed and reactivated as a semiductile to brittle sinistral transform fault. Rb–Sr data and fluid inclusion studies of late-stage fault-related mineralizations revealed Early Permian ages between 280 and 270 Ma for fault activity, with subsequent minor erosion. Regionally, crystallization of arc intrusives and related metamorphism occurred between ∼306 and ∼286 Ma, preceded by early increments of convergence-related deformation. Basal Western Series accretion started at >290 Ma and lasted to ∼250 Ma. North of the Lanalhue fault, Late Paleozoic magmatic arc granitoids are nearly 100 km closer to the present day Andean trench than further south. We hypothesize that this marked difference in paleo-forearc width is due to an Early Permian period of subduction erosion north of 38°S, contrasting with ongoing accretion further south, which kinematically triggered the evolution of the Lanalhue Fault Zone. Permo-Triassic margin segmentation was due to differential forearc accretion and denudation characteristics, and is now expressed in contrasting lithologies and metamorphic signatures in todays Andean forearc region north and south of the Lanalhue Fault Zone.

Morphologic diagnosis of “vascular dementia” — A critical update

Vascular dementia/vascular cognitive impairment (VaD/VCI) is not a single entity, but a large group of conditions characterized by various clinical and morphological findings and variable pathophysiology. Clinical diagnostic criteria show moderate sensitivity (50-70%) and variable specificity (64-98%). Epidemiological studies are hampered by the lack of clear and validated diagnostic criteria, the complexity of brain pathologies, ethnic and geographic variations. In Western clinic-based series VaD/VCI is suggested in 8-15% of cognitively impaired aged subjects, with age-standardized incidence ratios 0.42-2.6 and clinical prevalence at age 70+ of 6-15/1000 person/year. Prevalence in autopsy series ranges from 0.03 to 58% (real mean 8-15% in Western series, 22-35% in Japan). Both prevalence and incidence increase with age. Neuropathology shows multifocal and/or diffuse lesions, ranging from lacunes and microinfarcts, white matter lesions, hippocampal sclerosis to multi-infarct encephalopathy, mixed cortico-subcortical and diffuse post-ischemic lesions. They result from systemic, cardiac, local large and small vessel disease. Pathogenesis is multifactorial and cognitive decline is commonly associated with small ischemic/vascular lesions, often involving subcortical and strategically important brain areas (thalamus, frontobasal, limbic system). Pathophysiology affects neuronal networks involved in cognition, behavior, execution and memory. Vascular lesions often coexist with Alzheimer disease (AD) and other lesions, multiple pathologies greatly increasing the odds of dementia; 25-80% of demented subjects show both AD and cerebrovascular lesions. While both factors by synergistic interaction contribute significantly to the risk of dementia, AD pathology is often less severe in the presence of vascular lesions. Due to the heterogeneity of cerebrovascular pathology and its causative factors, no validated neuropathologic criteria for VaD are currently available, and a large variability across laboratories still exists in morphologic examination procedures and techniques. Harmonization of neuropathologic procedures and evaluation criteria in future prospective clinico-pathologic studies are needed to validate diagnostic criteria for VaD and to clarify the impact of vascular lesions on cognition.

Clinical Outcome of Taiwanese Men With Metastatic Prostate Cancer Compared With Other Ethnic Groups

Prostate cancer incidence varies significantly among different ethnic groups. However, little is known about the survival outcome among groups. We sought to compare the survival outcome in patients with metastatic prostate cancer among different ethnic groups and to identify independent prognostic factors affecting overall survival in Taiwanese patients. From January 1996 to February 2005, 482 men with newly diagnosed metastatic prostate adenocarcinoma were enrolled from five major medical centers in Taiwan. The cohort accounted for about 11.5% of all patients with metastatic disease during the period in Taiwan. The demographics, tumor characteristics, and survival outcome were compared with several published Western and Japanese series. Five series were selected from MEDLINE: the Southwest Oncology Group; Detroit Metropolitan Surveillance, Epidemiology, and End Results Program Registry; American College of Surgeons; National Cancer Registry in Sweden; and Gurma and Nagasaki University Group in Japan. The Taiwanese patients were the oldest among the selected series. The median overall survival of our patients was 38.4 months (95% confidence interval 33 to 45 months), which was longer than that in the Western series (median 25 to 32 months) and similar to those in the Japanese series (median 36 months). In a multivariate analysis with age adjustment, bone pain, Gleason score 8 or greater, and visceral metastases independently predicted a reduced overall survival in our series compared with each favorable strata (hazard ratio 2.22, 1.96, and 1.51, respectively; all P <0.05). Taiwanese men with metastatic prostate cancer might have a better survival compared with Western men.

Clinical characteristics of multiple sclerosis in Lebanon

The epidemiologic, clinical, radiological and laboratory characterization of multiple sclerosis (MS) is very well documented in Caucasian and Japanese populations, but very little is known about MS in the Arab world. Such knowledge is becoming of paramount importance, with the recent advances in therapies, MRI techniques and other diagnostic procedures. We report a cohort of Lebanese MS patients, including details of their clinical and laboratory characteristics. The medical records of 202 patients fulfilling the Mc Donald's diagnostic criteria, and followed in our tertiary care center were reviewed. This cohort is highly representative of the disease in Lebanon where the number of MS patients is estimated to be between 1200 and 1700. The peak age of onset of MS in our cohort was in the third decade with 62.4% of patients developing their first symptoms between 20 and 39 years. The female/male ratio was 1.8/1.0. A positive family history for MS was present in 5% of patients. The most frequent presenting symptoms were brainstem-cerebellar (46.2%) followed by sensory (42.5%), motor (33.9%) and visual (29.6%). Of the total number of patients, 85.1% had relapsing remitting MS at onset, and 7.9% primary progressive MS. Benign MS defined as EDSS<=2.0 after 10 years from onset was present in 20% of patients. The mean time from onset to secondary progressive MS was around 9 years. Visual, brainstem, and somatosensory evoked potentials were abnormal in 65.6%, 27.8%, and 50.7% of patients tested respectively. Cerebrospinal fluid showed pleocytosis in 32.6%, increased IgG synthesis in 45.2%, positive oligoclonal bands in 40%, and elevated protein in 34% of patients tested. Although some of the clinical characteristics of our MS population were different compared to western series, the natural history of the disease was similar.

Deregulation of β‐catenin signal by Helicobacter pylori CagA requires the CagA‐multimerization sequence

Infection with Helicobacter pylori cagA-positive strains causes gastritis and peptic ulceration and is associated with gastric adenocarcinoma. The cagA gene product CagA is delivered into gastric epithelial cells, where it undergoes tyrosine phosphorylation by Src family kinases at the C-terminal EPIYA-repeat region. Tyrosine-phosphorylated CagA specifically binds and activates SHP-2 tyrosine phosphatase, causing cell morphological transformation known as the hummingbird phenotype. CagA also destabilizes the E-cadherin/beta-catenin complex to elicit aberrant activation of the beta-catenin signal that underlies intestinal metaplasia. Here we show that translocalization of membranous beta-catenin and subsequent activation of the beta-catenin signal by CagA requires the EPIYA-repeat region, which is characterized by structural variation between CagA of H. pylori isolated in Western countries (Western CagA) and that of East Asian H. pylori isolates (East Asian CagA), but is independent of CagA tyrosine phosphorylation. Detailed analysis using a series of Western and East Asian CagA mutants revealed that deregulation of beta-catenin requires residues 1009-1086 and residues 908-1012 of ABCCC Western CagA and ABD East Asian CagA, respectively, and is mediated by the 16-amino-acid CagA multimerization sequence that is conserved between the 2 geographically distinct H. pylori CagA species. Our results indicate that aberrant activation of the beta-catenin signal, which promotes precancerous intestinal metaplasia, is an inherent and fundamental CagA activity that is independent of the structural polymorphism of CagA.

Surgical Repair of Sinus of Valsalva Aneurysm in Asian Patients

Sinus of Valsalva aneurysm is a rare cardiac anomaly, and the difference between Asian and Western countries in its occurrence is not well established. This study was designed to investigate the difference between Asian and Western patients. Between September 1988 and February 2006, 83 patients with sinus of Valsalva aneurysm underwent surgical repair in our institute. The aneurysms originated from the right and noncoronary sinus in 74 and 9, respectively, and ruptured into the right ventricle in 52 patients, the right atrium in 30, and the left ventricle in 1. Ventricular septal defect (n = 38), aortic regurgitation (n = 21), and bicuspid aortic valve (n = 4) were the common coexisting anomalies. To compare the differences between Asian and Western patients in sinus of Valsalva aneurysm, 1049 cases (654 Asian patients versus 395 Western) were collected from the literature. Sixty-six patients were followed up for 9.6 +/- 3.8 years. The cardiac function of 15 patients with aortic regurgitation was worse than that of those with no aortic regurgitation (p < 0.05). There was no difference between the direct closure and the patch closure (p > 0.05). Analysis of all collected cases revealed that aneurysm of the sinus of Valsalva in Asian patients compared with Western series is characterized by a higher incidence, more aneurysms originating from the right coronary sinus (85.8% versus 67.9%), more aneurysm rupture into the right ventricle (72.5% versus 60%), a higher incidence of association with ventricular septal defect (52.4% versus 37.5%), and lower incidence of association with bicuspid aortic valve (0.6% versus 7.8%). However, both Asian and Western patient series have similar incidence of combination with aortic regurgitation (33.6% versus 32.7%). Long-term results of ruptured sinus of Valsalva aneurysm are associated with preoperative aortic regurgitation. The difference between Asian and Western patients with ruptured aneurysm of the sinus of Valsalva is significant.

From 2000 Bush–Gore to 2006 Italian elections: voting at fifty-fifty and the contrarian effect

A sociophysical model for opinion dynamics is shown to embody a series of recent western hung national votes all set at the unexpected and very improbable edge of a fifty-fifty score. It started with the Bush–Gore 2000 American presidential election, followed by the 2002 Stoiber–Schroder, then the 2005 Schroder–Merkel German elections, and finally the 2006 Prodi-Berlusconi Italian elections. In each case, the country was facing drastic choices, the running competing parties were advocating very different programs and millions of voters were involved. Moreover, polls were given a substantial margin for the predicted winner. While all these events were perceived as accidental and isolated, our model suggests that indeed they are deterministic and obey to one single universal phenomena associated to the effect of contrarian behavior on the dynamics of opinion forming. The not hung Bush–Kerry 2004 presidential election is shown to belong to the same universal frame. To conclude, the existence of contrarians hints at the repetition of hung elections in the near future.