Pulmonary mucormycosis: the first case with preoperative diagnosis and successful surgical treatment in Taiwan

Pulmonarycosis is a rare disease, which refers to an infection by fungi belonging to the order Mucorales. This organism usually invades the skin, nose mouth, paranasal sinus, gastrointestinal tract, lung, brain, eyes and so forth. It usually occurs in patients with diabetes mellitus, hematological malignancy or other immunocompromised states. Until recently, this disease was rarely diagnosed before death. We report a case of pulmonary mucormycosis in a woman with poorly controlled diabetes mellitus. This is the first case in Taiwan of pulmonary mucormycosis diagnosed preoperatively and treated successfully by lobectomy only. Persistent pulmonary lesions resistant to antibiotic treatment in high risk patients should arouse the suspicion of mucormycosis. Prompt bronchoscopic examination, open lung biopsy and transthoracic pulmonary aspiration cytology and biopsy should be done. Surgical resection of localized lesions remains the treatment of choice.

Jejunal leiomyosarcoma detected by Tc-99m sulfur colloid gastrointestinal bleeding scan

Jejunal leiomyosarcoma was initially detected in a patient by a gastrointestinal bleeding scan with Tc-99m sulfur colloid (SC). The scan showed increased blood flow and delayed persistent accumulation of radiotracer in the tumor. The Tc-99m SC gastrointestinal bleeding scan provided useful information to help determine the differential diagnosis of gastrointestinal tumor with bleeding.

Striatonigral degeneration: clinical, MRI, and pathologic correlation

We report a patient with striatonigral degeneration in whom T2-weighted MRI imaging revealed low signal and atrophy in the putamen. Neuropathologic studies confirmed putaminal atrophy and iron deposition in the MRI low signal regions.

Negative correlation between the change in bone mineral density and serum osteocalcin in patients with hyperthyroidism

To assess the changes in bone mineral density and osteoblastic activity in patients with hyperthyroidism and to investigate the relationship between those changes, we measured bone mineral density and serum osteocalcin in 109 patients with Graves' disease, comprising 75 untreated patients and 34 patients under treatment, and 200 normal controls. The degree of change in bone mineral density was quantified with Z transformation, in which we used means and SDs of bone mineral densities obtained in the process of age- and sex-matched 1:1 pairing developed by ourselves. Bone mineral density was low in female patients with hyperthyroidism in the spine, femur neck, trochanter, and Ward's triangle, but was not low in male patients. Serum osteocalcin was elevated in patients with untreated Graves' disease and correlated negatively with the Z values of bone mineral densities of the spine, femur neck, and trochanter. In conclusion, indices of osteoblastic activity were elevated in patients with hyperthyroidism, probably secondary to a thyroid hormone-induced increase in bone resorption which resulted in reduced bone mineral density. Quantification of the change in bone mineral density by using the parameters derived in the process of age- and sex-matched pairing seems to be an efficient method for statistical analyses.

Localization of In-111 antimyosin Fab and 99mTc-pyrophosphate in reperfusion myocardial infarction model

The myocardial uptake of In-111 antimyosin Fab and Tc-99m pyrophosphate was studied in dogs undergoing coronary artery occlusion for 90 minutes followed by reperfusion. The regional myocardial blood flow was determined by injecting Sc-46 labeled microsphere and was related to the relative concentrations of In-111 antimyosin and Tc-99m pyrophosphate. There was an inverse linear correlation between In-111 antimyosin Fab localization and the regional blood flow in both the subendocardial (r = 0.81) and subepicardial myocardium (r = -0.80). The greatest uptake of antimyosin was observed in areas of severe blood flow reduction (0-10% of normal). On the other hand, there was no correlation between the Tc-99m pyrophosphate uptake and the degree of blood flow reduction. Maximal subendocardial localization of Tc-99m degree of blood flow reduction. Maximal subendocardial localization of Tc-99m pyrophosphate was observed in areas where the blood flow was reduced to 31-50% of the normal. In the case of the subepicardium, the greatest uptake was localized to areas of 0 to 10% of the normal flow. In addition, there was significant myocardial uptake in regions where the blood flow was minimally reduced (greater than 81%). This study suggests that In-111 antimyosin Fab is a specific and quantitative tool in the evaluation of myocardial necrosis.

Changes in the properties of the thyrotropin receptor antibody in patients with Graves' disease after radioiodine treatment

We investigated the effect of a single dose of 131I upon thyrotropin receptor antibodies (TRAb) in 21 patients with Graves' disease. The thyrotropin receptor antibodies were assessed by parallel measurements of thyrotropin binding inhibitor immunoglobulin (TBII), thyroid stimulating antibody (TSAb) and thyroid stimulation blocking antibody (TSBAb) in serum by radoreceptor assay, stimulation of adenlate cyclase and inhibition of TSH-stimulated adenylate cyclase activation in FRTL-5 cells, respectively. Prior to radioiodine treatment, TBII was detected in all 21 patients and TSAb in 19 patients. After radioiodine treatment, TBII activities did not change during the 12-months observation period, but in eight patients TSAb activities gradually decreased and were undetectable at the end of the 12-month observation period. Persistence of TSAb was not associated with the clinical outcome. Eight patients developed hypothyroidism within one year after radioiodine treatment. Three of the hypothyroid patients developed TSBAb, and the appearance of TSBAb coincided with the development of hypothyroidism. These results suggest that TSBAb might develop after radioiodine treatment in a minority of patients with Graves' disease and that the appearance of TSBAb, in addition to radiation-induced thyroid destruction, might be involved in the development of hypothyroidism following radioiodine treatment.

[Oral tramadol for extracorporeal shock wave lithotripsy]

Two hundred patients undergoing shock wave lithotripsy for renal calculi with the improved version of Dornier HM3 lithotripter system were randomly divided into group A and group B with 100 patients in each. Patients in group A were orally given tramadol 100 mg and lorazepam 1 mg and those in group B flunitrazepam 1 mg was given. Those in group A, who did not need supplemental medication during ESWL were subdivided in group A while those who needed an adjuvant of 100 micrograms intravenous fentanyl were subdivided in group A2. Like group A, those in group B, who did not need supplemental drug and those who needed 100 micrograms intravenous fentanyl were respectively subcategorized into groups B1 and B2. Drugs were given with 15 mL water 30 min prior to ESWL. Pre-operatively, an intravenous line and monitoring system which included noninvasive blood pressure and pulse oximeter were established. The entire course was divided into 5 stages i.e. stage I (prior to oral medication), stage II (10 min after medication), stage III (10 min following ESWL), stage IV (5 min following 100 micrograms intravenous fentanyl) and stage V (10 min after ESWL). The mean blood pressure, heart rate and SpO2, pain scale, sedation scale and side effects were recorded in various stages. The results showed that in group A 68 patients passed the ESWL smoothly (A1) and 32 patients needed supplemental fentanyl (A2). In group B 70 patients successfully underwent the ESWL (B1) while 30 patients needed supplemental fentanyl (B2). Ther were no significant changes in both groups in various stages regarding heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in the properties of the thyrotropin receptor antibody in patients with Graves' disease after radioiodine treatment

We investigated the effect of a single dose of 131I upon thyrotropin receptor antibodies (TRAb) in 21 patients with Graves' disease. The thyrotropin receptor antibodies were assessed by parallel measurements of thyrotropin binding inhibitor immunoglobulin (TBII), thyroid stimulating antibody (TSAb), and thyroid stimulation blocking antibody (TSBAb) in serum by radioreceptor assay, stimulation of adenylate cyclase and inhibition of TSH-stimulated adenylate cyclase activation in FRTL-5 cells, respectively. Prior to radioiodine treatment TBII was detected in all 21 patients and TSAB in 19 patients. After radioiodine treatment TBII activities did not change during 12 months observation period, but in eight patients TSAb activities gradually decreased and were undetectable at the end of a 12 month observation period. Persistence of TSAb was not associated with clinical outcome. Eight patients developed hypothyroidism within 1 year after radioiodine treatment. Three of the hypothyroid patients developed TSBAb, and the appearance of TSBAb coincided with the development of hypothyroidism. These results suggest that TSBAb might develop after radioiodine treatment in a minority of patients with Graves' disease, and that the appearance of TSBAb, in addition to radiation induced thyroid destruction, might be involved in the development of hypothyroidism following radioiodine treatment.

Surgical management of congenital coronary artery fistula

Over a period of 6 years, 8 patients underwent surgical treatment at our hospital for congenital coronary artery fistula (CAF). The ages of the patients ranged from 4 months to 50 years (mean 22.7 years). Continuous heart murmurs could be heard in all patients, except one. The diagnosis was made by retrograde aortography and/or selective coronary arteriography. Only one patients had associated cardiac disease. All the drainage sites of the CAF were on the right side of the heart (right atrium, right ventricle, pulmonary artery). Two patients had both right and left CAFs. Symptoms due to "coronary steal" by a coronary artery fistula were demonstrated by a nuclear medicine study in one of our patients. Four patients were operated on with the aid of cardiopulmonary bypass. The other 4 patients were treated with suture ligation directly. There was no surgical mortality or morbidity, and the longterm results have been good. Since surgical correction is safe and effective, it would appear desirable for all patients with CAF be operated on. However, surgical intervention is controversial in asymptomatic patients.

[Continuous thoracic epidural fentanyl in postoperative pain control--a comparison of two different dosages]

We evaluate the postoperative pain relief using continuous epidural fentanyl infusion in two different dosages for thoracic and upper abdominal surgeries. A total of 21 ASA class III patients were studied. A thoracic epidural catheter was placed before surgery but pain control was begun when the patients became fully awake and complained of pain in the recovery room. Patients were divided into group A (n = 9) and group B (n = 12). Those in group A were given fentanyl 1.5 micrograms/kg in saline solution as initial dose followed by continuous infusion at a rate of 1 microgram/kg/h for 23 hours. In group B the initial dose and the maintenance dose were respectively 1.0 microgram/kg and 0.5 micrograms/kg/h. Following the initial dose, the intensity of pain was assessed hourly for a total of 24 hours using a visual analogue pain scale with scores from 0 to 10. In group A, the pain scale fell from the baseline level of 7.7 +/- 2.6 to 2.3 +/- 2.0 at the first hour while in group B it fell from 8.9 +/- 1.4 to 4.3 +/- 2.1. The pain scores following continuous infusion in groups A and B were respectively 1.3 +/- 1.5 and 2.9 +/- 1.7. Although the analgesic effect appeared to be better in group A, pain relief was satisfactory in both groups (p less than 0.01). Regarding respiratory depression, there was a greater degree of rise in PaCO2 in group A and some of the patients even had a PaCO2 value above 50 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

Transatrial membranotomy for Budd-Chiari syndrome

In a 7-year period, transatrial membranotomy was performed in 11 patients with membranous obstruction of the inferior vena cava. There were 5 men and 6 women, ranging in age from 23 to 53 years. Clinical symptoms included jaundice in 4 patients, hepatomegaly in 4, leg edema or varicose veins in 10, and venous collaterals over the abdominal and chest wall in all 11 patients. Transatrial membranotomy was performed through a median sternotomy in all patients. When inferior vena cava venography revealed that the obstruction was accompanied by long segmental thrombosis, additional dilation was performed with a Hegar dilator. There was no surgical mortality. Early operative complications included pulmonary embolism in 2 patients and bleeding requiring reoperation in 1. In a mean follow-up period of 30.6 months (range, 2 to 88 months), 9 patients had no symptoms, transient pericardial constriction developed in 1 patient and resolved 1 month later, and restenosis of the inferior vena cava developed in another patient 1 year after the first operation. This latter patient received a second transatrial membranotomy followed by percutaneous balloon angioplasty of the inferior vena cava, with a satisfactory result at 8 months follow-up. We conclude that transatrial membranotomy is an effective and safe procedure for patients with membranous obstruction of the inferior vena cava.

[Chondrosarcoma of the rib--a case report]

Chondrosarcoma is second in frequency only to osteogenic sarcoma as a malignant tumor of bone, and constitutes 17 to 22% of all bone tumors. However, chondrosarcoma is the most common malignant tumor of the sternum or rib. The natural history of chest wall chondrosarcoma is one of slow growth and local recurrence. Wide excision is the main treatment, but usually plastic surgery is needed for chest wall reconstruction. A 29-year-old male patient visited to local clinic due to URI symptoms (eg: cough, rhinorrhea). Routine chest X-ray examination showed a huge tumor within L't chest cavity and chondrosarcoma was proved via tissue biopsy. P't underwent surgery for total removal of the tumor and corresponding rib (3rd rib) and the chest wall defect was repaired with bovine pericardium. So far, after follow-up and treatment for 4 months, there is no evidence of recurrence.

Job and life satisfaction among rural physicians. Results of a survey

Results of a survey of approximately half of Minnesota's rural physicians show that these physicians appear to be well-satisfied with their jobs (average rating of 2.5 on a five-point scale with 2 = very satisfied and 3 = moderately satisfied). In aggregate, areas of greatest job satisfaction are the diversity of patients physicians see, physicians' contact with others, and their ability to derive personal gratification from patient care. Salary/income was not a source of dissatisfaction. Areas of least satisfaction are physicians' opportunities for promotion, their ability to remain knowledgeable, and their role in making organizational and administrative decisions. Rural Minnesota physicians feel least work stress about their feelings of clinical competence/interpersonal relations at work and anxieties about the future. Areas of greatest stress focus on time pressures and realities of medical practice, i.e., being reimbursed by third-party payers and meeting the need for certainty when medical knowledge only allows for approximation. These physicians are reasonably happy with their lives in general (5.4 on a seven-point scale with 7 = delighted, 1 = terrible). In aggregate, areas of lowest life satisfaction are physicians' social relations, leisure activities, and finances. Examination of subgroups shows that women are statistically less satisfied with their living situations; younger physicians are less satisfied with their work, their living situations, and their leisure activities; physicians who spend more than 10 hours per week on administrative duties are less satisfied with their living and social situations; and physicians who see more than 100 patients per week are less satisfied with their social relations.

Acute mitral regurgitation secondary to blunt chest trauma: report of a case

A 24-year-old male patient who sustained blunt trauma to the chest resulting in a flail chest, myocardial contusion and injury to mitral valve is reported. An emergency surgical correction of the mitral lesion was performed. A high index of suspicion, prompt diagnosis and aggressive intervention of such injuries can lead to successful repair of such a potentially fatal cardiac trauma.

Muscle glycogen storage postexercise: effect of mode of carbohydrate administration

The primary purpose of this study was to determine whether gastric emptying limits the rate of muscle glycogen storage during the initial 4 h after exercise when a carbohydrate supplement is provided. A secondary purpose was to determine whether liquid (L) and solid (S) carbohydrate (CHO) feedings result in different rates of muscle glycogen storage after exercise. Eight subjects cycled for 2 h on three separate occasions to deplete their muscle glycogen stores. After each exercise bout they received 3 g CHO/kg body wt in L (50% glucose polymer) or S (rice/banana cake) form or by intravenous infusion (I; 20% sterile glucose). The L and S supplements were divided into two equal doses and administered immediately after and 120 min after exercise, whereas the I supplement was administered continuously during the first 235 min of the 240-min recovery period. Blood samples were drawn from an antecubital vein before exercise, during exercise, and throughout recovery. Muscle biopsies were taken from the vastus lateralis immediately after and 120 and 240 min after exercise. Blood glucose and insulin declined during exercise and increased significantly above preexercise levels during recovery in all treatments. The increase in blood glucose during the I treatment, however, was three times greater than during the L or S treatments. The average insulin response of the L treatment (61.7 +/- 4.9 microU/ml) was significantly greater than that of the S treatment (47.5 +/- 4.2 microU/ml) but not that of the I (55.3 +/- 4.5 microU/ml) treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Quasi-static electric-field-enhanced degenerate four-wave mixing in a nematic liquid-crystal film

Degenerate four-wave mixing can be induced or enhanced dramatically when two weak overlapping laser beams are incident upon a nematic liquid-crystal film that is biased by a quasi-static electric field. This phenomenon is shown to be the result of the critical behavior at the Freedericksz transition. The experimental results show that the diffracted intensity is proportional to the third power of the laser intensity, as expected for a four-wave mixing process, despite the strength of the electric-field bias voltage above threshold.

Use of a total wash-out method in an open heart operation

Pathological cold agglutinins may induce hemolysis in patients who need hypothermic cardiopulmonary bypass and blood transfusion. A simple technique, termed the total wash-out method, was used in a patient with high thermal amplitude, moderate-titer cold agglutinin before hypothermic cardiopulmonary bypass. The patient's cold agglutinin titer decreased abruptly after operation. None of the preoperative hemolysis phenomena were found during her 6 months of follow-up.

Insensitivity of tensile failure properties of human bridging veins to strain rate: implications in biomechanics of subdural hematoma

The effects of strain rate on tensile failure properties of human parasagittal bridging veins were studied in eight unembalmed cadavers. While bathed in physiological saline at 37 degrees C, the intact vessel was stretched axially by a servo-controlled hydraulic testing machine at either a low strain rate of 0.1-2.5 s-1 or a high rate of 100-250 s-1. The mean ultimate stretch ratios for low and high strain rates, respectively, were 1.51 +/- 0.24 (S.D. n = 29) and 1.55 +/- 0.15 (n = 34), and the ultimate stresses were 3.24 +/- 1.65 (n = 17) and 3.42 +/- 1.38 MPa (n = 20). Neither difference between strain rates was significant (p greater than 0.45). Thus, our results do not support the hypothesis that sensitivity of the ultimate strain of bridging veins to strain rate explains the acceleration tolerance data for subdural hematoma in primates [Gennarelli, R. A. and Thibault, L. E. (1982) Biomechanics of acute subdural hematoma. J. Trauma 22, 680-686].

Muscle glycogen storage after different amounts of carbohydrate ingestion

The purpose of this study was to determine whether the rate of muscle glycogen storage could be enhanced during the initial 4-h period postexercise by substantially increasing the amount of the carbohydrate consumed. Eight subjects cycled for 2 h on three separate occasions to deplete their muscle glycogen stores. Immediately and 2 h after exercise they consumed either 0 (P), 1.5 (L), or 3.0 g glucose/kg body wt (H) from a 50% glucose polymer solution. Blood samples were drawn from an antecubital vein before exercise, during exercise, and throughout recovery. Muscle biopsies were taken from the vastus lateralis immediately, 2 h, and 4 h after exercise. Blood glucose and insulin declined significantly during exercise in each of the three treatments. They remained below the preexercise concentrations during recovery in the P treatment but increased significantly above the preexercise concentrations during the L and H treatments. By the end of the 4 h-recovery period, blood glucose and insulin were still significantly above the preexercise concentrations in both treatments. Muscle glycogen storage was significantly increased above the basal rate (P, 0.5 mumol.g wet wt-1.h-1) after ingestion of either glucose polymer supplement. The rates of muscle glycogen storage, however, were not different between the L and H treatments during the first 2 h (L, 5.2 +/- 0.9 vs. H, 5.8 +/- 0.7 mumol.g wet wt-1.h-1) or the second 2 h of recovery (L, 4.0 +/- 0.9 vs. H, 4.5 +/- 0.6 mumol.g wet wt-1. h-1).(ABSTRACT TRUNCATED AT 250 WORDS)

Computerized quality control of radioimmunoassay in Korea

Automated data processing and quality control of radioimmunoassays offer not only increased speed but also a more thorough and statistically rigorous analysis of results. An external quality assessment scheme for serum thyroxine, triiodothyronine and thyroid stimulating hormone (TSH) assays was performed in five nuclear medicine laboratories in Korea to compare with the assay performances of the World Health Organization Radioimmunoassay Program. The required radioimmunoassay kits were supplied through the International Atomic Energy Agency (IAEA). We have determined the weighted root mean squared error, and variance ratio as the indices of standard curve and also the average batch coefficient of variation (ABCV) as the parameters of response error relationship curve and precision profile. There was a good fit for the triiodothyronine assay, but 3 of 5 laboratories showed possible bad fit in the T4 and TSH assay systems. The ABCV was less than 5 percent for the T3 and T4 assay system, however for the TSH system, only 1 laboratory showed the ABCV value of less than 5 percent. We have also calculated the within batch variation (drift) and between laboratory variations.

Duration of occupancy of opiate receptors by naltrexone

To determine the duration of blockade of mu-opiate receptors by naltrexone, we measured the binding of [11C]carfentanil in the brain of five normal volunteers with a positron radiation detection system before and 1, 48, 72, 120, and 168 hr after naltrexone administration. The half-time of blockade by naltrexone in the brain ranged from 72 to 108 hr which is greater than the fast plasma clearance components (4-12 hr) of naltrexone or its metabolite, beta-naltrexol, but corresponds well to the half-time of the terminal phase of plasma naltrexone clearance (96 hr). These results are consistent with the duration of the pharmacologic effects of naltrexone in response to heroin administration and indicate that 50 mg/day of oral naltrexone results in plasma levels in excess of that needed to saturate opiate receptors. This is the first example of the use of a simple dual-detector system with positron-emitting radioactive drugs to provide information regarding the duration of action of the drug on its specific receptor site. The plasma clearance half-time of a drug may not give an accurate reflection of the duration of action of the drug on a specific neuroreceptor site. Direct measurement of drug effects on recognition sites greatly extend current studies of pharmacokinetics.

Supplemental insulin delivery from an implanted reservoir activated by external compression

An implant made of insulin in palmitic acid provides a basal dose sufficient to reduce hyperglycemia for 42 +/- 12 days in rats with induced diabetes. For preprandial dose supplements another arrangement is required. In this study a device consisting of a reservoir is assembled by attaching a 1 cm diameter foam ring to a 5 mm diameter piece of the same material. A 6 mg piece of compressed insulin is inserted into a cut between the ring and the attachment, along with 2 mg tetracycline to hinder microbial growth. The assembly is then enclosed between two membranes and an annular external wall. The top membrane is pierced once, and the device is tested by implantation under the abdominal skin of diabetic rats. Serous fluid will enter the interior through the orifice and leach the solid insulin that does not leak out. Daily sidewise compression over the skinfold of the unanesthetized animal indicated that the insulin supply lasted for 24 +/- 4 days. The blood glucose was consistently maintained at 3.4 +/- 1.1 mmol/L for 6-8 hr each day. After depletion the device can be refilled percutaneously by injecting insulin suspended in phosphate-buffered saline.