Neurotrauma research in Taiwan

Because of the rapid industrial and economic growth, Taiwan and other developing countries have faced an enormous increase in the number of motorcycles, which has subsequently caused a rapid increase of the motorcycle-related traumatic brain injuries (TBI). In order to tackle this serious problem, stepwise approaches for TBI were implemented in Taiwan from 1991 to 2007. Step 1 was to do a nationwide TBI registry in order to identify the risk factors and determinants. We found that the major cause of TBI in Taiwan was motorcycle-related injury, and very few motorcyclists wore a helmet. Step 2 was to launch the implementation of the helmet use law on June 1, 1997. A rapid decline of TBI hospitalizations and deaths was demonstrated soon thereafter. Step 3 was to enroll into international collaborations with the Global Spine and Head Injury Prevention Project (Global SHIP Project) groups for TBI. The comparative results thus obtained could be used to develop prevention strategies for developing countries. Step 4 was to implement clinical researches for TBI, which included a Propofol study, hyperbaric oxygen therapy (HBOT), brain parenchymal oxygen (PbtO2) monitoring, etc. Step 5 was to develop guidelines for the management of severe TBI in Taiwan. Through a 2-year period of review, discussion, and integration, a 9-chapter guideline was published in June 2007. In summary, our experience and process for management of TBI in Taiwan can be used as a reference for other developing countries.

Remote metastatic cervical carcinoma to kidneys mimicking bilateral renal abscesses

A 53-year-old woman presented bilateral renal masses, which were interpreted as abscesses with a computed tomography scan 9 years after primary surgery for cervical carcinoma. Subsequent biopsies under ultrasound guidance revealed metastatic adenocarcinoma of kidneys originating from the cervical carcinoma. Clinical detection of renal involvement from cervical cancer is extremely rare. There were only seven cases reported in the literature, and three cases were interpreted as abscesses initially. In comparison with these cases, the time between renal metastases and initial detection of cervical carcinoma is the longest in our case.

Molecular cloning and expression analysis of rainbow trout (Oncorhynchus mykiss) CCAAT/enhancer binding protein genes and their responses to induction by GH in vitro and in vivo

CCAAT/enhancer-binding proteins (C/EBPs) are transcription factors consisting of six isoforms and play diverse physiological roles in vertebrates. In rainbow trout (Oncorhynchus mykiss), in addition to the reported C/EBPbeta1, we have isolated cDNA of four other isoforms, C/EBPalpha, C/EBPbeta2, C/EBPdelta1, C/EBPdelta2, from the liver. Comparison of the deduced amino acid sequence of rainbow trout C/EBPs with those of other vertebrates revealed that C/EBP isoforms are highly conserved. The profiles of tissue-specific expression of individual C/EBP isoform mRNA, determined by quantitative real-time (RT)-PCR showed distinct patterns. Furthermore, injection of bovine GH into yearling rainbow trout resulted in a significant increase of mRNA levels of C/EBPbeta1, C/EBPbeta2, and C/EBPdelta2 but not C/EBPalpha and C/EBPdelta1 in the liver. GH-dependent increase of mRNA levels of C/EBPbeta1, C/EBPbeta2, C/EBPdelta2, and IGF-II were also confirmed by treating rainbow trout hepatoma cells expressing a goldfish GH receptor with bGH. Together with our previous findings, the results presented in this paper strengthen our previous hypothesis that GH may regulate the expression of the IGF-II gene via mediating the expression of C/EBPbeta1, C/EBPbeta2, and C/EBPdelta2 mRNA.

Associations between VHL genotype and clinical phenotype in familial von Hippel-Lindau disease

BACKGROUND

Von Hippel-Lindau (VHL) disease is an autosomal dominant hereditary disorder associated with tumours and cysts in the central nervous system (CNS) and other visceral organs. Germline mutations in the VHL gene on chromosome 3p25-26 are considered the cause of this disease.

MATERIALS AND METHODS

We studied six patients with VHL disease and their relatives. Loss of heterozygosity (LOH) was determined by five flanking microsatellite polymorphic markers in the VHL locus. Multiplex ligation-dependent probe amplification (MLPA) and quantitative real-time polymerase chain reaction (qPCR) amplification were used to detect the genomic deletions. Single-strand conformation polymorphism (SSCP) analysis was applied to test for sequence variations.

RESULTS

Three germline deletions in the VHL gene (142.9, 53.3 and 3.3 kb) were found by MLPA. These deletions were defined clearly by qPCR analyses. The142.9 kb germline deletion was significantly associated with patients with CNS haemangioblastomas (P < 0.01 by Fisher's exact test), and one missense mutation (Gln209Arg) was detected from a patient with a pancreatic cyst in the same family. LOH was also detected from a patient with bilateral renal cell carcinomas.

CONCLUSION

Diverse genetic conditions are associated with the clinical manifestations of VHL disease. Genomic deletions that can be detected by MLPA or qPCR are major causes for this syndrome. Missense mutations and LOH accompanying the disease lead to complex clinical symptoms and genotypic determination can facilitate a clinical diagnosis because of their strong association.

Tumor volume is a better prognostic factor than greatest tumor diameter in stage Ia non-small cell lung cancer

OBJECTIVE

The objective was to determine whether tumor volume, calculated by multiplying 3-dimensional diameters recorded from surgical specimens, could represent tumor size more precisely than the currently used greatest tumor diameter (T status) as a prognostic factor in early-stage non-small cell lung cancer (NSCLC).

METHODS

From 1991 to 2001, a total of 236 stage Ia NSCLC patients underwent curative resection in our institution. Their clinicopathological factors were retrospectively reviewed. The cases were grouped according to stereographic tumor size. Group 1 included tumor volumes less than 0.5236 (1(3) x pi/6) cm3, Group 2 included tumor volumes between 0.5236 - 4.1888 (2(3) x pi/6) cm3, while Group 3 included tumor volumes between 4.188 - 14.1372 (3(3) x pi/6) cm3. Overall survival and disease-free interval analyses were performed with the Kaplan-Meier method and multivariable Cox's proportional hazard model. Tumor volume and other clinico-pathological factors were included for analysis.

RESULTS

Median follow-up was 55.5 months. The overall 5- and 10-year survival rates were 78 % and 71 %, and the 5- and 10-year disease-free intervals were 68 % and 64 %, respectively. The overall survival ( P = 0.0075) and disease-free interval ( P = 0.0025) showed significant differences between tumor volume groups. Smoking history, presence of symptoms and the number of resected lymph nodes were also significantly related to overall survival and disease-free interval.

CONCLUSION

The products of 3-D diameters (tumor volume) more precisely evaluated tumor size as well as survival of patients with stage Ia NSCLC.

Salmonellae and campylobacters in household and stray dogs in northern Taiwan

Rectal swabs were collected from 437 household and 491 stray dogs in northern Taiwan from May 2003 to June 2005 to investigate the prevalence and antimicrobial susceptibilities of salmonellae and campylobacters. The results revealed that 2.1% of household dogs and 6.3% of stray dogs were positive for salmonellae, with Salmonella Duesseldorf being the most dominant serotype in both. Additionally, 2.7% of the household dogs and 23.8% of the stray dogs were positive for campylobacters. Campylobacter jejuni was the most prevalent species (86.8%), followed by C. upsaliensis (9.3%) and C. coli (3.9%). Both salmonella and campylobacter isolation rates from the stray dogs were significantly higher than those from the household dogs (p < 0.01). The susceptibility of 33 C. jejuni isolates to eight antimicrobials was studied by the E-test. A high rate of resistance was observed to azithromycin (93.9%), clindamycin (87.9%), erythromycin (81.8%), tetracycline (78.8%), chloramphenicol (69.7%), nalidixic acid (51.5%), gentamicin (33.3%), and ciprofloxacin (18.2%). The susceptibility of 40 Salmonella isolates to 15 antimicrobials was also studied by the disc-diffusion method. All the Salmonella isolates were susceptible to ciprofloxacin and ceftriaxone. Resistance was observed most frequently to tetracycline (77.5%), chloramphenicol (52.5%), and ampicillin (50%).

Degradation of di-butyl-phthalate by soil bacteria

Twelve Gram-positive phthalate ester degraders were isolated from soil. Using Biolog GP2 plates, eight of them were identified as belonging to the Corynebacterium-Mycobacterium-Nocardia group, while the remaining four were unidentifiable. When cultured in the presence of di-butyl-phthalate (DBP) in basal salts solution, five of these isolates accomplished more than 90% of DBP degradation within 48 h (fast group), three were placed in the medium group, and the remaining four were placed in the slow group which caused less than 30% of DBP degradation within the same period of time. A 420 bp DNA fragment was amplified from six isolates and none of them fell within the slow group. When compared with the large subunit of phthalate dioxygenase gene (phtA) of Arthrobacter keyseri, 83% and 91% similarities were evident in the nucleotide and amino acid sequences, respectively. However, no correlation between cell surface hydrophobicity and phthalate degradation ability was evident. Six surfactants (Brij 30, Brij 35, Tergitoltype NP-10, Triton N-101, Triton X-100 and SDS) were tested for their abilities to increase degradation rate. When added at the critical micellar concentration (CMC), they all displayed strong growth inhibition against the three bacteria tested, with Brij 30 been the least toxic to isolates G2 and G11, and Brij 35 had the least inhibitory effect for G1. When half the CMC of Brij 30 was incorporated into the basal salts, the inhibitory effect on DBP degradation remained. Soil helped to minimize surfactant toxicity of surfactant and increase the degradation potential of some of the test bacteria. When DBP-amended soil had been aged for three months, decreases in bioavailability were observed but the effect varied tremendously between different organisms. For isolates G1, G2, G5, G7 and G17 the aging effects were almost non-exist. The present study indicates that selection of a suitable degrader may minimize the undesired effect of aging on bioremediation process.

Idiopathic syringomyelia: case report and review of the literature

Syringomyelia is an uncommon disease that is caused most often by type I Chiari malformation, which develops in the hindbrain, and less frequently by other factors which are not limited to the hindbrain, including trauma, infection, or scoliosis. Idiopathic syringomyelia is rare. We present in this article a patient with idiopathic syringomyelia characterized by hypoesthesia and progressive weakness in the left lower limb. Decompression was attempted by means of laminectomy and a syringoarachnoid shunt. Motor, sensory, and bladder functions were monitored by the change in Japanese Orthopedic Association scores, which increased from 10 points preoperatively to 14 points 30 days postoperatively. This case demonstrates the effectiveness of surgical decompression in a patient with remarkable neurological deficit.

Biosynthesis and purification of a hydrophobic peptide from transmembrane domains of G-protein-coupled CB2 receptor

A major challenge for the structural study of the seven-transmembrane G-protein-coupled receptors is to obtain a sufficient amount of purified protein at the milligram level, which is required for either nuclear magnetic resonance (NMR) spectroscopy or X-ray crystallography. In order to develop a high-yield and cost-effective method, and also to obtain preliminary structural information for the computer modeling of the three-dimensional receptor structural model, a highly hydrophobic peptide from human cannabinoid subtype 2 receptor CB2(65-101), was chosen to develop high-yield membrane protein expression and purification methods. The peptide included the second transmembrane helix with the associated loop regions of the CB2 receptor. It was over-expressed in Escherichia coli, with a modified TrpDelta LE1413 (TrpLE) leading fusion sequence and a nine-histidine tag, and was then separated and purified from the tag in a preparative scale. An experimental protocol for the chemical cleavage of membrane protein fragment was developed using cyanogen bromide to remove the TrpLE tag from the hydrophobic fusion protein. In addition, protein uniformly labeled with isotopic 15N was obtained by expression in 15N-enriched minimum media. The developed and optimized preparation scheme of expression, cleavage, and purification provided a sufficient amount of peptide for NMR structure analysis and other biophysical studies that will be reported elsewhere. The process of fusion protein cleavage following purification was monitored by high-performance liquid chromatography (HPLC) and mass spectrometry (MS), and the final sample was validated by MS and circular dichroism experiments.

Rhabdomyolysis in 119 students after repetitive exercise

Exercise induced rhabdomyolysis is well known, but has rarely been reported in high school students. This is the report of 119 cases in high school students who exercised vigorously (120 push ups in five minutes) in cold weather. Most of them developed muscle pain and dark urine within two to four days of the exercise.

Block-dependent sedation during epidural anaesthesia is associated with delayed brainstem conduction

BACKGROUND

Neuraxial anaesthesia produces a sedative and anaesthetic-sparing effect. Recent evidence suggests that spinal cord anaesthesia modifies reticulo-thalamo-cortical arousal by decreasing afferent sensory transmission. We hypothesized that epidural anaesthesia produces sensory deafferentation-dependent sedation that is associated with impairment of brainstem transmission. We used brainstem auditory evoked potentials (BAEP) to evaluate reticular function in 11 volunteers.

METHODS

Epidural anaesthesia was induced with 2-chloroprocaine 2%. Haemodynamic and respiratory responses, sensory block level, sedation depth and BAEP were assessed throughout induction and resolution of epidural anaesthesia. Sedation was evaluated using verbal rating score (VRS), observer's assessment alertness/sedation (OAA/S) score, and bispectral index score (BIS). Prediction probability (PK) was used to associate sensory block with sedation, as well as BIS with other sedation measures. Spearman's rank order correlation was used to associate block level and sedation with the absolute and interpeak BAEP latencies.

RESULTS

Sensory block level significantly predicted VRS (PK=0.747), OAA/S score (PK=0.748) and BIS. BIS predicted VRS and OAA/S score (PK=0.728). The latency of wave III of BAEP significantly correlated with sedation level (rho=0.335, P<0.01) and sensory block (rho=0.394, P<0.01). The other BAEP parameters did not change during epidural anaesthesia. Haemodynamic and respiratory responses remained stable throughout the study.

CONCLUSIONS

Sedation during epidural anaesthesia depends on sensory block level and is associated with detectable block-dependent alterations in the brainstem auditory evoked responses. Sensory deafferentation may reduce CNS alertness through mechanisms related to brainstem neural activity.

A prospective study of nocturia and the quality of life of elderly patients with obstructive sleep apnea or sleep onset insomnia

OBJECTIVE

To prospectively evaluate the relationship between obstructive sleep apnea syndrome (OSAS), nocturia and quality of life in elderly patients free of the urologic and medical conditions that lead to increased nocturia.

METHODS

Prospective study of nocturia in men 65 years and older with isolated OSAS or sleep onset insomnia. After a 7-day nocturia evaluation and nocturnal polysomnography, Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI), Quality of Life (SF-36) were administered.

RESULTS

OSAS patients with frequent nocturia had significantly greater body mass index (BMI), greater apnea-hypopnea index (AHI), lower lowest oxygen saturation and lower SF-36 subscale scores. Treatment with nasal continuous positive airway pressure (CPAP) for OSAS and behavioral techniques for insomnia improved ESS and BDI scores for all three groups. SF-36 subscale scores improved more in subjects with multiple nocturia. AHI and BMI explain 38% of the variance for nocturia.

CONCLUSION

Nasal CPAP reduces OSA and nocturia and improves quality of life of elderly patients.

Consumer acceptance of fresh-cut iceberg lettuce treated with 2% hydrogen peroxide and mild heat

An antibacterial treatment consisting of 2% hydrogen peroxide at 50 degrees C for 60 s was evaluated for its effects on the sensory quality of fresh-cut iceberg lettuce. Treated lettuce was packaged in polyethylene film by a protocol used in the fresh-cut produce industry and then stored along with untreated controls for 3, 10, and 15 days at 5 degrees C. Gas chromatographic analysis confirmed that the desired initial volume (approximately 6 liters) and oxygen gas content (approximately 10%) were maintained during storage. Consumers from the local community who were the primary shoppers for their households and who purchased and ate lettuce regularly evaluated the appearance, color, aroma, flavor, and texture of the lettuce and their overall liking of the lettuce. Forty consumers were recruited to evaluate processing replication 1 on 26 April, and another 40 were chosen to evaluate processing replication 2 on 3 May. Because replication differences were observed in instrumental color measurements and in mean sensory ratings, replications were not pooled for the two test dates. Lettuce purchased for processing replication 2 was considerably greener than that used in replication 1. Overall, the antibacterial treatment was more effective than the control treatment in maintaining sensory quality over 15 days of storage, provided that the lettuce was initially intensely green. Three-fourths of the participants indicated that they would be willing to buy precut packaged lettuce that had already been treated at the packinghouse or processing plant with an antibacterial solution, and of these participants, 62.5% indicated that they would be willing to pay 5 to 10 cents more per bag.

Dehydroepiandrosterone sulfate (DHEAS) suppresses P2X purinoceptor-coupled responses in PC12 cells

Some steroids rapidly alter neuronal excitability through interaction with neurotransmitter-gated ion channels in addition to their well-known genomic effects via intracellular steroid receptors. Such effects were found in GABA receptor, nicotinic receptors, yet not investigated in P2X purinoceptors. In this study, the effects of dehydroepiandrosterone sulfate on the P2 purinoceptor was investigated. Results show that dehydroepiandrosterone sulfate acutely inhibits P2X purinoceptor functions in PC12 cells. Dehydroepiandrosterone sulfate suppressed ATP-induced cytosolic free calcium concentration ([Ca(2+)](i)) rise, cytosolic free sodium concentration ([Na(+)](i)) rise, and dopamine secretion in the presence of external calcium, but had no effect on ATP-induced [Ca(2+)](i) rise in the absence of external calcium or on UTP-induced [Ca(2+)](i) rise in the absence or presence of external calcium. Our data show that dehydroepiandrosterone sulfate exerted its effect on P2X, but not on the P2Y purinoceptors found in PC12 cells. Estradiol and estrone have similar effects on P2X purinoceptor, but dehydroepiandrosterone and progesterone do not.

Inadvertent hypothermia causes pulseless electrical activity in a patient during cervical spine surgery--a case report

Recent studies have shown that hypothermia triples the incidence of major cardiac events. We present a happening in which a 71-year-old patient developed pulseless electrical activity (PEA) while he was undergoing cervical laminectomy for spinal stenosis in the sitting position. Thromboembolism or venous air embolism and acute myocardial infarction were respectively excluded by transesophageal echocardiography and cardiac enzymes analysis to be the causes of the cardiac event. The abnormal finding that stood out was low nasopharyngeal temperature (31 degrees C) during the procedure, which was thought to contribute to the development of the PEA episode.

Glutamine metabolism in sepsis and infection

Severe infection causes marked derangements in the flow of glutamine among organs, and these changes are accompanied by significant alterations in regional cell membrane transport and intracellular glutamine metabolism. Skeletal muscle, the major repository of glutamine, exhibits a twofold increase in glutamine release during infection, which is associated with a significant increase in endogenous glutamine biosynthesis. Despite an increase in glutamine synthetase activity in skeletal muscle, the intracellular glutamine pool becomes depleted, indicating that release rates exceed rates of synthesis. Simultaneously, the circulating pool of glutamine does not increase, indicating accelerated uptake by other organs. The liver appears to be the major organ of glutamine uptake in severe infection; studies in endotoxemic rodents have shown net hepatic glutamine uptake to increase by as much as 8- to 10-fold. This increase is due partially to increases in liver blood flow, but also to a three- to fourfold increase in hepatocyte System N activity in the liver. Cytokines and glucocorticoids mediate the increased uptake of glutamine by the liver in septic states as well as other compounds. Sepsis does not appear to induce an increase in System N gene expression, indicating that the increase in hepatic glutamine transport observed during severe infection is probably regulated at the protein level. The bowel displays a decrease in glutamine utilization during sepsis, a response that may be related to the decrease in circulating insulin-like growth factor-1 (IGF-1) levels that is characteristic of sepsis. Recent studies suggest that IGF-1 has a direct effect on stimulating glutamine transport across the gut lumen and thus may represent a therapeutic avenue for improving gut nutrition during severe infection. The cells of the immune system (lymphocytes, macrophages) are also major glutamine consumers during inflammatory states in which cell proliferation is increased. Under these conditions, glutamine availability can become rate limiting for key cell functions, such as phagocytosis and antibody production.

Destruction of Escherichia coli O157:H7 and Salmonella enteritidis in cow manure composting

Application of cow manure and composted manure in agricultural practice could potentially cause contamination of foodstuffs with pathogenic bacteria such as Salmonella Enteritidis and Escherichia coli O157:H7. In this study, rifampicin-resistant (RifR) E. coli O157:H7 and Salmonella Enteritidis at a level of 7 log CFU/g of raw compost feed were used to determine the effect of a bench-scale composting system on their survival. RifR E. coli O157:H7 was not detected after 72 h of composting at 45 degrees C, and RifR Salmonella Enteritidis was not detected after 48 h. The use of selective media for enrichment failed to recover in the composting samples held at 45 degrees C for 96 h. However, the pathogens showed no change in bacterial numbers when the composting system was held at room temperature. Thus, properly composted manure can be safely used in food crop production while minimizing the likelihood of microbial contamination.

Combined conventional and jet ventilation in airway management in tracheal tumor

Tumors on the carina are uncommon, and their anesthetic management can present a considerable challenge. The principle anesthetic consideration is ventilation and oxygenation in the face of an open airway. A 60-year-old man patient suffered a carinal tumor, which occupied 70% of the both main bronchi and bled spontaneously while coughing. Surgical resection and reconstruction were done. The carinal surgical approach was a right posterolateral thoracotomy, and the patient was placed in the left decubitus position. Because we could not insert the jet catheter past the mass, high frequency jet ventilation to ventilate the dependent lung could not be applied. Our choice was differential lung ventilation with a combination of conventional and high frequency jet ventilation modes to preserve oxygenation during tumor excision and tracheal reconstruction. An episode of desaturation was successfully treated during removal of tumor. The postoperative course was uneventful. The patient was sent to the intensive care unit after surgery and discharged on the 11th day. He received further combined chemotherapy and radiotherapy during his next admission. Fiberoptic examination on the 5 months later no evidence of recurrence. In summary, we described our airway management on carinal tumor excision, especially the tumor was so large that dependent lung jet ventilation could not employ.

Hemodynamic responses of thiopental and propofol in different-aged patients during endotracheal intubation

BACKGROUND

Thiopental and propofol are 2 popularly used anesthetic induction agents that have different pharmacological and pharmacokinetic actions. It is not clear how the hemodynamic responses differ in different-aged patients using these 2 drugs for anesthetic induction. The aim of this study was to investigate the hemodynamic responses to propofol and thiopental of different-aged patients during endotracheal intubation.

METHODS

Sixty patients, 20 to 83 years old, were included in this study. Patients were randomly divided into 6 groups according to age and different inductive anesthetics. Non-invasive blood pressure (NIBP) monitoring was performed every minute before anesthesia, during anesthetic induction with 5 mg.kg-1 thiopental or 2 mg.kg-1 propofol intravenously, and after intubation.

RESULTS

Propofol induction produced a smaller mean arterial pressure increase immediately after intubation than did thiopental induction in adult and elderly groups (101.0 +/- 18.5 and 104.0 +/- 21.1 mmHg in the propofol groups vs. 138.3 +/- 17.1 and 138.9 +/- 16.1 mmHg in the thiopental groups at 1 minute after intubation, p < 0.001 and p = 0.001, respectively). Differences in heart rate between propofol and thiopental groups were found in young and adult groups (85.1 +/- 9.2 and 81.7 +/- 10.9 in the propofol groups vs. 94.5 +/- 9.9 and 95.0 +/- 14.0 beats per minute in the thiopental groups at 1 minute after intubation, p = 0.041 and p = 0.029, respectively).

CONCLUSION

Propofol induction produced more stable hemodynamics after intubation in adult and elderly patients than did thiopental induction. Therefore, it is safer to use propofol for induction and intubation in adult and elderly patients.

Pneumopericardium after bronchoscopic carbon dioxide laser surgery--a case report

A female baby sustained pneumopericardium after bronchoscopic CO2 laser surgery for tracheal stenosis. Perioperative pneumopericardium though rare is a life-threatening condition in babies. The symptoms are usually not specific such as hypotension, bradycardia, muffled heart sound, cardiovascular collapse, etc. The causes and clinical findings of pneumopericardium were reviewed, as are the radiographic features so as to differentiate the condition from pneumomediastinum. Early recognition of pneumopericardium is important, because emergent pericardiocentesis may be required if there is clinical evidence of cardiac tamponade.

Anterior mediastinal tumour identified by intraoperative transesophageal echocardiography

PURPOSE

To report a child with anterior mediastinal tumour misdiagnosed as pericardial effusion who had been sent to the operating theatre for drainage. After induction of general anesthesia she developed cardio-respiratory collapse. The diagnosis was made with the aid of transesophageal echocardiography (TEE).

CLINICAL FEATURES

A 14-yr-old girl suffered from cough and intermittent fever for one month before admission. Four days before admission, she became orthopneic and was admitted to the intensive care unit. Precordial echocardiography showed an anterior and posterior echolucent space between the pericardium and epicardium that was thought to be a pericardial effusion. She was sent to the operating room for emergency drainage. After induction of general anesthesia, breath sounds were not heard on the left side of the chest. The patient developed increasing hypoxemia and hypotension despite cardiocentesis. A TEE determined that an anterior mediastinal mass was the cause of her hypoxemia and hypotension. The tumour was debulked and the patient made an uneventful postoperative recovery.

CONCLUSION

In this case, the correct diagnosis of an anterior mediastinal mass was made with TEE. The place of TEE may be indicated in patients with unexplained hypoxemia and hypotension.

Interleukin-10-induced T cell unresponsiveness can be reversed by dendritic cell stimulation

The secretion of immunosuppressive factors like interleukin-10 (IL-10), either by tumor cells or by tumor-infiltrating leukocytes, has been recognized as one of the mechanisms involved in tumor immunological escape and a serious obstacle for successful immunotherapy. Therefore, any therapeutic attempts aimed at inducing antitumor immunity in tumor-bearing hosts must overcome this immunosuppressive state. This study aimed to determine whether dendritic cell (DC) immunization, a promising approach to induce antitumor immunity, could break IL-10-induced anergic state in CD4+ T cells, essential cells in generating tumor-specific immunity. We found that the ability of DC to reverse IL-10-induced anergic state in human CD4+ T cells is dependent on the IL-10 concentration that T cells have been exposed to and the degree of DC maturation. The efficacy of mature DC in reversing T cell anergy can be mimicked by higher cell numbers of immature DC. In addition, activated T cells induced by DC stimulation are sensitive to IL-10 treatment. Collectively, our results suggest the use of mature DC and the necessity of antagonizing the action of tumor-derived IL-10 in immunotherapy of cancer with DC immunization.

T cell receptor binding kinetics and special role of Valpha in T cell development and activation

The kinetics of the interaction between T cell receptor (TCR) and major histocompatibility complex (MHC) has an important role in determining thymocyte-positive and -negative selection in the thymus, as well as in T cell activation. The alpha chain of the TCR is the major player in determining how the TCR fits onto the MHC ligand, and thus has a major role in determining whether a T cell develops as class I or class II restricted. In this article, we summarize recent data from our laboratory and others on the role of polymorphism in the Valpha combining site in determining MHC class restriction, and on kinetic parameters in thymocyte selection.

Anesthesia of CO2 laser surgery in a patient with Hunter syndrome: case report

Hunter syndrome (mucopolysaccharidosis, type II; MPS II) is one of a heterogeneous group of recessively inherited mucopolysaccharide storage diseases. Patients with mucopolysaccharidosis show progressive involvement and derangement of many organs, especially upper airway anomalies, which are the major cause of perioperative death. In recent years, a CO2 laser is often applied to upper airway lesions. A 16-year-old patient suffering from Hunter syndrome was scheduled for CO2 laser surgery because of sleep apnea and respiratory stridor. Otolaryngological examination revealed bulging of the bilateral false cord with stenosis of the glottis. We adopted sevoflurane mask induction and high-frequency jet ventilation to overcome the perioperative airway problems. The anesthetic course was uneventful, and the patient was discharged 2 days after the operation.

Respiratory management after self-extubation

BACKGROUND AND PURPOSE

Self-extubation is a potentially life-threatening event, but may also provide an opportunity to wean patients who should have been extubated earlier. The purpose of this study was to determine the risk factors for re-intubation after self-extubation.

METHODS

The medical charts of 69 self-extubated patients treated in Shin Kong Hospital, Taipei, from September 1996 through August 1998 were reviewed. Demographic data, ventilator settings before self-extubation, arterial blood gas values, and the type of respiratory management used after self-extubation were examined to determine their association with re-intubation.

RESULTS

Of the 69 self-extubated patients, 38 fared well without further ventilatory support after self-extubation. Four factors were associated with extubation outcome: 1) mean pre-extubation FiO2 (fraction of inspired oxygen), which was significantly higher in the re-intubated group (RI) than in the not re-intubated group (NRI) (0.48 vs 0.33, p = 0.002)--all self-extubated patients receiving an FiO2 of more than 0.40 were re-intubated; 2) PaO2/FiO2 (ratio of arterial oxygen tension to inspired oxygen concentration), which was lower in the RI group than in the NRI group (259.4 vs 346.4, p = 0.005); 3) requirement for assist/control ventilatory mode--patients needing this type of ventilatory support had a greater likelihood of reintubation than those requiring partial ventilatory support (odds ratio [OR], 3.790; confidence interval [CI], 1.055-13.621; p = 0.041); and 4) female sex (OR 0.188; CI 0.048-0.732; p = 0.016).

CONCLUSIONS

About half of self-extubated patients may not require re-intubation. Pre-extubation FiO2, PaO2/FiO2, and ventilator mode, as well as gender, may be useful in determining the likelihood that a self-extubated patient will require re-intubation.