[Sulphasalazine in patients with rheumatoid arthritis in China: a cross-sectional study]

OBJECTIVE

To investigate the medication status of rheumatoid arthritis (RA) patients and to analyze the clinical use of sulphasalazine (SSZ) and the adverse effect.

METHODS

A total of 1 096 outpatients and inpatients diagnosed with RA were investigated in 21 hospitals all over China from July 2009 to December 2010, including gender, age of onset, clinical manifestations, as well as the clinical characteristics and medication status of 160 RA patients who received SSZ therapy.

RESULTS

In the group of 160 patients who received SSZ, the male-to-female ratio was 1:7, The average age at onset was (46.1±15.0) years, while the average course was (9.9±7.8) years. The average dose of sulphasalazine was (1.87±0.52) g/d for a mean duration of (26.3± 14.6) months. Only 17% (27/160) of the patients received SSZ monotherapy. Methotrexate (63.1%), leflunomide (36.2%) and hydroxychloroquine (18.1%) were most commonly used combination drugs. And 36.2% (58/160) of the patients used the two-drug combination of methotrexate plus sulphasalazine .In this group, 41.9% (67/160) once used SSZ but withdrew for adverse events and other reasons, while 17.5% (28/160) withdrew for adverse events, of which the most common were gastrointestinal (8.8%), skin (3.8%) and liver toxicity (3.1%).

CONCLUSION

Sulphaszlazine is not a common choice in the RA therapeutics in China, and the average dose of SSZ is lower than the standard dose of 2 to 3 g/d . The adverse events of SSZ are common; however, there are few severe adverse events or threat to life,SSZ is relatively safe in clinical practice.

[Survey of tumor necrosis factor inhibitors application in patients with rheumatoid arthritis in China]

OBJECTIVE

To investigate the current status of tumor necrosis factor (TNF) inhibitors application in rheumatoid arthritis (RA) patients in China and to analyze the related factors.

METHODS

A retrospective survey was conducted in 21 hospitals from different parts of China. The patients with RA were randomly enrolled. Data of their social backgrounds, clinical conditions, usage and adverse effects of TNF inhibitors were collected. The costs of TNF inhibitors and the indirect costs of the disease were calculated. A multivariate Logistic regression analysis was performed to analyze the factors related to TNF inhibitors application.

RESULTS

In the study, 1 095 RA patients from July 2009 to November 2010 were enrolled, of whom 112 had received TNF inhibitors, representing 10.2% of the total patients. The patients who received etanercept and infliximab were 7.4% (86/1 095) of the patients and 2.4% (26/1 095), respectively. There were 0.5% of the patients (5/1 095) who had received both of the TNF inhibitors. The patients who had accepted etanercept and treatment duration for less than 3 months and 3-6 months accounted for 38.5% and 25.0% respectively, while those treated with Infliximab were 38.1%. Their health assessment questionnaire (HAQ) scores were 1.1, 0.5 and 0.1, corresponding to treatment duration of infliximab for less than 3, 3-6 and 6-9 months and those were 1.3, 1.0, 0.3 corresponding to treatment duration of etanercept, respectively. Infliximab costs were RMB 24 525.0, 69 300.0 and 96 800.0 Yuan and etanercept costs were RMB 7 394.8, 9 158.6, 54 910.9 Yuan, respectively. Indirect costs for RA patients who accepted infliximab for less than 3, 3-6 and 6-9 months were RMB 365.6, 0 and 158.9 Yuan and those who accepted etanercept were RMB 2 158.4, 288.5 and 180.1 Yuan, respectively. Allergy and infection were the main side-effects of etanercept and both happened in 3.5% of all the patients. Liver damage happened in 2.3% of all the patients, while allergy and infection happened in 6.5% of all the patients who accepted infliximab. Logistic regression analysis showed that patients with higher education experience increased the odds of entering the TNF inhibitors group (OR: 1.292, 95%CI: 1.132-1.473, P=0.000).

CONCLUSION

About one-tenth of RA patients in China have accepted TNF inhibitors. Higher education experience is the key factor for using TNF inhibitors.

HIV-1 reactivation in HIV-latently infected dendritic cells by oral microorganisms and LPS

Dendritic cells are critical components of the host defense system that play pivotal role in linking innate immunity to adaptive immune responses. In the role of interfacing with pathogens through the action of surface pattern-recognition receptors, dendritic cells are a potential target for retroviral infection and latency. Dendritic cells are a long-lived reservoir of latent virus in HIV (human immunodeficiency virus)-infected patients. It is hypothesized that HIV-latently infected dendritic cells would be stimulated by oral bacteria leading to reactivation of HIV. In our HIV-latently infected dendritic cell models, of both promoter activation and HIV production, significant differences were observed among the bacterial species in their ability to stimulate HIV reactivation. The experimental data support the hypothesis that oral bacteria related to periodontal infections could trigger latently infected dendritic cells in gingival tissues and contribute to HIV recrudescence and undermining anti-retroviral therapy.

[The role of promoter CpG islands methylation of leptin gene in osteoarthritis]

OBJECTIVE

To investigate the effects of 5-Aza-CdR (methylation transferase inhibitor)on the expression levels of leptin gene in chondrocytes and methylation states of leptin promoter region between osteoarthritis (OA) group and control.

METHODS

The chondrocytes in osteoarthritis group were treated with 5-Aza-CdR with different doses and time-points, and the expression level of leptin was detected by real-time polymerase chain reaction for picking up the optimum dose and time-point. Next, the chondrocytes in 5 osteoarthritis patients and 5 control patients (amputation due to severe trauma) were treated with 5-Aza-CdR. Lastly, leptin mRNA expression levels in the four groups osteoarthritis and control chondrocytes treated with/without 5-Aza-CdR were measured by real-time PCR and the methylation state of promoter region (-280 - +79) was detected by epitope quantitative DNA methylation analysis.

RESULTS

(1) After treating the chondrocytes in OA groups with 10 µmol/L 5-Aza-CdR for 72 h, the mRNA expression levels of leptin were increased significantly. (2) The mRNA expression levels of leptin were significantly different among the four groups (P < 0.05), and the chondrocytes in osteoarthritis groups treated with 5-Aza-CdR showed a marked induction of leptin mRNA expression. (3) Analysis of quantitative methylation data using an unsupervised hierarchical clustering algorithm, showed that methylation patterns of leptin promoter was different between control and osteoarthritis chondrocyte treated with/without 5-Aza-CdR.

CONCLUSION

Demethylation of leptin promoter might up-regulate leptin gene expression level and it might contribute to osteoarthritis.

Supernatants from oral epithelial cells and gingival fibroblasts modulate human immunodeficiency virus type 1 promoter activation induced by periodontopathogens in monocytes/macrophages

Bacterial and host cell products during coinfections of Human Immunodeficiency Virus type 1-positive (HIV-1(+)) patients regulate HIV-1 recrudescence in latently infected cells (e.g. T cells, monocytes/macrophages), impacting highly active antiretroviral therapy (HAART) failure and progression of acquired immunodeficiency syndrome. A high frequency of oral opportunistic infections (e.g. periodontitis) in HIV-1(+) patients has been demonstrated; however, their potential to impact HIV-1 exacerbation is unclear. We sought to determine the ability of supernatants derived from oral epithelial cells (OKF4) and human gingival fibroblasts (Gin-4) challenged with periodontal pathogens, to modulate the HIV-1 promoter activation in monocytes/macrophages. BF24 monocytes/macrophages transfected with the HIV-1 promoter driving the expression of chloramphenicol acetyltransferase (CAT) were stimulated with Porphyromonas gingivalis, Fusobacterium nucleatum, or Treponema denticola in the presence of supernatants from OKF4 or Gin4 cells either unstimulated or previously pulsed with bacteria. CAT levels were determined by enzyme-linked immunosorbent assay and cytokine production was evaluated by Luminex beadlyte assays. OKF4 and Gin4 supernatants enhanced HIV-1 promoter activation particularly related to F. nucleatum challenge. An additive effect was observed in HIV-1 promoter activation when monocytes/macrophages were simultaneously stimulated with gingival cell supernatants and bacterial extracts. OKF4 cells produced higher levels of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukins -6 and -8 in response to F. nucleatum and P. gingivalis. Preincubation of OKF4 supernatants with anti-GM-CSF reduced the additive effect in periodontopathogen-induced HIV-1 promoter activation. These results suggest that soluble mediators produced by gingival resident cells in response to periodontopathogens could contribute to HIV-1 promoter activation in monocytes/macrophages, albeit this effect is most notable following direct stimulation of the cells with oral gram-negative bacteria.

Oral bacteria induce a differential activation of human immunodeficiency virus-1 promoter in T cells, macrophages and dendritic cells

INTRODUCTION

The human immunodeficiency virus (HIV) can integrate into T cells, macrophages and dendritic cells resulting in a latent infection. Reports have also demonstrated that various microbial and host cell factors can trigger HIV reactivation leading to HIV recrudescence, potentially undermining highly active antiretroviral therapies.

METHODS

This study evaluated the capacity of oral bacteria associated with chronic periodontal infections to stimulate HIV promoter activation in various cell models of HIV latency.

RESULTS

T cells (1G5) challenged with oral bacteria demonstrated a dose-response of HIV promoter activation with a subset of the bacteria, as well as kinetics that were generally similar irrespective of the stimuli. Direct bacterial challenge of the T cells resulted in increased activation of approximately 1.5- to 7-fold over controls. Challenge of macrophages (BF24) indicated different kinetics for individual bacteria and resulted in consistent increases in promoter activation of five fold to six fold over basal levels for all bacteria except Streptococcus mutans. Dendritic cells showed increases in HIV reactivation of 7- to 34-fold specific for individual species of bacteria.

CONCLUSION

These results suggested that oral bacteria have the capability to reactivate HIV from latently infected cells, showing a relationship of mature dendritic cells > immature dendritic cells > macrophages > or = T cells. Expression of various pattern recognition receptors on these various cell types may provide insight into the primary receptors/signaling pathways used for reactivation by the bacteria.

[Efficacy and safety of infliximab in patients with rheumatoid arthritis]

OBJECTIVE

To investigate the efficacy and safety of Infliximab (IFX) plus methotrexate (MTX) combination therapy in patients with rheumatoid arthritis (RA).

METHODS

Prospectively observe refractory RA patients who were treated with combination therapy of MTX and IFX. IFX was infused at the dosage of 3 mg/kg, in week 0, 2, 6, and then every 8 weeks. During treatment, clinical variables, disease activity and adverse effects were evaluated.

RESULTS

After treatment, 69.8%, 52.4%, 29.5% and 7.2% RA patients achieved ACR20, ACR50, ACR70 and ACR90 respectively. There were significant statistical differences in the changes of swollen joint counts, tender joint counts, VAS scale, patient' s global assessment, and physician's global assessment before and after therapy.

CONCLUSION

Infliximab plus MTX achieved significant efficacy and safety in refractory RA patients.

Oral infectious diseases: a potential risk factor for HIV virus recrudescence?

As the highly active antiretroviral therapy (HAART) has transitioned human immunodeficiency virus (HIV) infection into a 'chronic disease' management strategy, there is growing evidence that infection with non-HIV pathogens in HIV+ patients may have important public health implications in undermining HAART success and acquired immunodeficiency syndrome progression. Several bacterial and host cell products during infections with non-HIV pathogens have shown the capacity to regulate HIV replication in latently infected cells. A high prevalence of oral infections caused by bacteria, viruses and fungi has been described in HIV+ patients, including periodontal disease. The oral cavity appears to be a site of HIV pathogenesis and potential reservoir for the disease as HIV RNA and DNA forms are present in saliva as well as in gingival crevicular fluid, and oral epithelial cells are susceptible to either cell free or cell-associated HIV infection. The clinical and biological bases of potential associations between chronic oral inflammatory disorders, such as periodontal disease, and exacerbation of HIV viraemia have received little attention. This review attempts to evaluate the current understanding of HIV reactivation as a result of co-infection and/or inflammation induced by non-HIV pathogens in HIV-infected patients, and presents a hypothetic model about the potential role of periodontitis as a global oral infection that potentially contributes to HIV recrudescence.

Improved Real-Time Puff-by-Puff GC-MS System for Whole Smoke Analysis

An automated puff-by-puff mainstream smoke (MSS) system is developed to monitor real-time whole smoke in mainstream cigarette smoke using gas chromatography (GC)-mass spectrometry (MS). The whole-smoke analysis is based on automated sample collection and injection into the GC-MS system. The important feature of this system is the real-time rapid analysis that is simple, sensitive, precise, flexible, and exhibits low carryover of volatile and semivolatile smoke constituents. The system is equipped with an automated sampling and switching valve and a smoking machine. The key improvements of the system, as compared with current and alternative methodologies, include minimizing variations caused by operator sampling techniques, the real-time analysis of MSS, the detection of flavorants in MSS from a single puff of cigarette smoke, the ability to analyze numerous smoke constituents from either whole smoke or the gas phase of a single puff, the ability to monitor a few selected smoke constituents in whole smoke using multiple puffs, and its good feasibility compared with solvent extraction and impinger trapping procedures for volatile organic compounds in MSS. System configuration and sampling methodologies are described. Sensitivity, flexibility, precision, feasibility, carryover, and applications of the system are discussed.

[Immunological characteristics of 1291 cases of severe acute respiratory syndrome in Beijing]

OBJECTIVE

To investigate the immunological characteristics of the cases of severe acute respiratory syndrome (SARS) in Beijing City.

METHODS

Clinical data of 1291 patients with SARS from March to July 2003 in Beijing City were retrospectively analyzed.

RESULTS

In patients with SARS, the absolute numbers of white blood cells, lymphocytes and CD(3), CD(4) and CD(8) lymphocyte subsets decreased during the early period of the disease, being manifested in 56.91%, 88.26%, 47.96%, 45.56% and 41.10% of the patients, respectively. During the first 3 days the median numbers of CD(3), CD(4) and CD(8) were 425 x 10(6)/L, 223 x 10(6)/L, 170 x 10(6)/L, respectively, being the lowest values in the course of the disease. During the second week the corresponding numbers were 536 x 10(6)/L, 267 x 10(6)/L, 224 x 10(6)/L, respectively; they returned to normal by the fourth week (P < 0.05), showing a trend of gradual increase during the disease progression. Comparison of different time points of the same cases also showed that CD(3), CD(4) and CD(8) were lowest in the first 1 - 3 days. The median number of CD(3) was higher (954 x 10(6)/L) during week 3, and there was no significant difference among other 3 weeks (P > 0.05). In the early period of the disease the CRP increased but ESR, C(3) and C(4) were still in normal ranges.

CONCLUSIONS

In the early period of SARS, the WBC, lymphocytes, CD(3), CD(4) and CD(8) lymphocyte subsets decreased remarkably, and they tended to increase as the disease progressed. Simultaneous decreases in CD(3), CD(4) and CD(8) during the first week is a characteristic immunological change, which may facilitate the early diagnosis of SARS.

Determination of tobacco alkaloids by gas chromatography with nitrogen-phosphorus detection

An improved method, gas chromatography (GC) with nitrogen-phosphorus detection (NPD), has been used for determination of alkaloids in green and cured tobacco. Tobacco alkaloids of interest included nicotine, nornicotine, myosmine, anabasine, and anatabine. Tobacco samples were treated with a small quantity of aqueous ammonia solution to "loosen" tobacco tissue and to adjust pH, then extracted with solvent. The composition of the extraction solvent solution affected recoveries of the alkaloids, particularly nornicotine, and also contributed to other phenomena such as carry-over in the injection liner and "quenching" of the nitrogen-phosphorus detector. Use of a packed injection liner (e.g. with Carbowax-KOH on Chromosorb) to reduce carry-over was studied. Quenching of the nitrogen-phosphorus detector was eliminated by reducing the injection volume (i.e. increasing the split ratio), by use of a packed injection liner, and by reducing the amount of pretreatment with aqueous ammonia. A narrow bore capillary column (i.e. 0.18 mm id) was used to improve sensitivity and resolution and to increase the speed of GC analysis. An internal standard, 2,4'-dipyridyl, was used for quantitative measurement of these tobacco alkaloids.

[Genescan analysis of the loss of heterozygosity on the long arm of chromosome 6 in non-small cell lung cancer]

To investigate if there are microsatellite loci in the long arm of chromosome 6 that have close relationship with non-small cell lung cancer, Multiple PCR approach was used to analyze the 36 loci in the long arm of chromosome 6. The PCR products were analyzed in PAGE and then the electrophoresis maps were analyzed with Genescan and Genotyper. There is different LOH frequency in different loci. The total frequency of LOH in 41 lung cancers was 78%(32/41), with the highest frequency of LOH was detected on the locus D6S302(75%). There are 14 loci which have LOH frequency more than 20% and the loci are mainly located in 2 regions: 6q16.3-q21 [6 loci D6S458 (21.43%), D6S1694 (26.92%), D6S1717 (35.71%), D6S1565 (40%), D6S302 (75%), D6S1706 (36.36%) and 6q26-q27 (5 loci D6S1550 (38.46%), D6S264 (20%), D6S1585 (25%), D6S446 (33.33%), D6S281 (30.77%)], There may be tumor suppressor genes located in the two regions, which have a close relationship with non-small cell lung cancer.

Optimization of headspace sampling using solid-phase microextraction for volatile components in tobacco

Solid-phase microextraction (SPME) was evaluated as a tool for headspace sampling of tobacco samples. Several experimental parameters (e.g. sampling temperature, pH, moisture, and the type of SPME fibers) were optimized to improve sampling efficiency in two aspects; maximum adsorption and selective adsorption of volatile components onto SPME fibers. The effect of these parameters was often dominated by the physical and chemical nature (e.g. volatility, polarity) of target compounds, thus, SPME sampling conditions can be adjusted to favor a selected group of compounds, such as organic acids in tobacco.

Neonatal lupus erythematosus in association with anti-RNP antibody: a case report

Neonatal lupus erythematosus (NLE) is a syndrome with the manifestation of dermatological, cardiac, hepatic, or hematological abnormalities. Thrombocytopenia has been documented infrequently in association with congenital heart block or lupus dermatitis in NLE. However, isolated neonatal thrombocytopenia may be the only manifestation of NLE. The strong association with maternal anti-SSA/Ro antibodies suggests a role for these antibodies in the pathogenesis of NLE. There are some data to suggest that anti-SSB/La and, rarely, anti-RNP antibodies play an important pathological role in some cases of NLE. The manifestation of anti-RNP-positive NLE was somewhat atypical. We report a case of anti-RNP-positive NLE with the manifestation of thrombocytopenia. Anti-SSA/Ro antibodies, which were negative based on the use of immunodiffusion, did exhibit low titer when later tested by enzyme-linked immunoadsorbent assay (ELISA).

Primary spinal epidural non-Hodgkin's lymphoma in a child

Non-Hodgkin's lymphoma usually involves the central nervous system by metastatic disease. Primary spinal epidural non-Hodgkin's lymphoma (PSENL) is a relatively rare cause of spinal cord compression. It mainly occurs in adults past the 4th or 5th decades. This entity is even rarer in children. The proper treatment modalities are controversial in adults with PSENL. Radiotherapy is the main strategy after surgery; the role of chemotherapy is uncertain. Therapeutic experience in childhood PSENL is extremely limited. We report a 10-year-old boy presenting with backache and bilateral lower leg weakness after minor trauma. Small non-cleaved cell non-Hodgkin's lymphoma of the epidural space was proven after subtotal tumor removal. Other investigations including computed tomography of the chest and abdomen, bone scan, gallium scan, bone marrow aspiration, and cerebrospinal fluid study were all negative for occult disease. The patient received combined therapy with irradiation and chemotherapy after surgery. Esophageal stricture resulting from radiotherapy developed during treatment and colon interposition was performed. He has remained disease free 42 months after the diagnosis with normal functional status.

Isolated fetal and neonatal ascites: report of two cases

Neonatal ascites is an uncommon problem that may be caused by a number of etiologies including diseases of genitourinary system and gastrointestinal system, cardiac disease, hepatic disease, systemic infection such as TORCH or parvovirus, chylous, ovarian cause, inborn error of metabolism and idiopathic. We reported two cases of neonatal ascites, one was caused by cytomegalovirus and no obvious causes could be detected in the second one. The ascites were diagnosed by prenatal ultrasound at the gestational age of 25 weeks and 37 weeks respectively and were resolved spontaneously after birth. One-year follow-up of both cases revealed normal growth and development. No recurrent ascites could be detected by abdominal sonography except for evidence of mild hepatomegaly that was noted in case 1. Thus, isolated fetal and neonatal ascites without other concomitant abnormalities were diagnosed, a separate entity from non-immune hydrops fetalis with excellent prognosis.

Pancreatitis with gallbladder ascariasis in a child: case report

A 10-year-old girl was admitted for abdominal pain for 1 week. Morning vomiting with 5 Ascaris and diarrhea with Ascaris were found. Radiograph of the abdomen disclosed no significant abnormality. Abdominal sonogram revealed a normal biliary tree; but mildly enlarged pancreatic thickness, and thickened gallbladder wall. Within the thickened gallbladder wall a linear echogenic structure with worm-like movement suspected of being Ascaris was found. We report this case because pediatric pancreatitis and a gallbladder wall thickened with worm-movement have rarely been reported. Urgent treatment and surgery are required for the very ill child with a tensely distended abdomen or signs of peritoneal irritation. Early diagnosis is very important to prevent further complications. We emphasize the role of sonography in the diagnosis of this case and the prevention of progressive deterioration.

Clinical features and outcome of appendicitis in children younger than three years of age

BACKGROUND

Acute appendicitis is the most common surgically amenable cause of acute abdominal pain in children. We analyzed our past experience of appendectomies in children and present the clinical characteristics of appendicitis in children younger than 3 years of age. A better understanding of appendicitis in early childhood would allow us to achieve an earlier diagnosis.

METHODS

A group of 475 children from 4 months to 15 years of age who underwent appendectomy for appendicitis was studied over a 5-year period from July 1994 to June 1999. Excluding cases with negative pathological findings (n = 34), they were divided into 2 age groups: group I (< or = 3 years old) and group II (> 3 years old). Medical records were reviewed and comparisons between clinical findings, laboratory data, pathology findings, and complications were made.

RESULTS

Of 441 cases enrolled in our study, 24 (5.4%) were 3 years of age or younger. Of all children older than 3 years of age, 32 (7.1%) had negative pathological findings compared to children younger than 3 years of age (7.7%). The duration of symptoms prior to diagnosis in group I was 3.6 days compared to group II at 2.0 days. Children from group I frequently showed a higher incidence of fever (90% vs. 53.4%), abdominal distention (50% vs. 9.8%), perforation (50% vs. 40.1%), and missed first impression (29% vs. 2.4%) than those from group II. Children of group I also had a higher complication rate (41.7% vs. 11.5%).

CONCLUSIONS

In early childhood the symptoms and signs of appendicitis usually are nonspecific. There is a longer duration before diagnosis, more instances of fever and abdominal distention, less right lower quadrant pain, less local tenderness and rebounding pain, and no obturator sign. Close observation and on-going evaluation of patients are essential.

Bezoars in children: report of four cases

We reviewed the histories of four children (2 boys and 2 girls, aged 6 mo to 10 yr) with surgically proven bezoars, treated from 1991 to 1998. Two had gastric bezoars and two had intestinal bezoars. All four patients presented with gastrointestinal symptoms and none had undergone previous surgery. Three had a history of abnormal ingestion, including one who ate a pickled fruit from the Boraginaceae (locally known as Po-pu-tsu) plant for 1 year. Plain radiographs revealed intestinal obstruction in all four patients. Abdominal sonography disclosed a hyperechoic band-like lesion and acoustic shadow in both cases of gastric bezoar, and these bezoars were subsequently confirmed by gastric endoscopy. Lower gastrointestinal studies showed obstruction considered most likely to be due to bezoar in one case, while computed tomography (CT) revealed a characteristic small bowel mottled gas pattern in another. Surgical treatment relieved obstruction in all four patients. Bezoar should be suspected in patients with intestinal obstruction who have a history of ingestion of unusual substances. The findings of this report suggest that sonography and endoscopy are useful in the diagnosis of gastric bezoar, while CT is useful in the detection of intestinal bezoar.

Flexible bronchoscopic diagnosis of airway injuries after intubation in children

BACKGROUND

Airway intubation injuries occur frequently but are often neglected because of spontaneous regression. Although most airway injuries that result from intubation resolve without sequelae, severe complications can develop even when initial symptoms of upper airway obstruction are absent. This retrospective study assessed the clinical features, flexible bronchoscopic findings, and clinical outcomes in children with airway intubation injuries.

METHODS

From February 1998 to February 1999, 90 children underwent flexible bronchoscopic examination in our hospital. Fifteen of these patients (6 girls, 9 boys; age range, 1 mo to 5 yr; mean, 21.1 +/- 24.4 mo) were noted to have intubation injuries.

RESULTS

The average time for symptoms to emerge after extubation was 1.8 days (range, 0-14 days). The airway intubation injuries diagnosed by flexible bronchoscopy were subglottic stenosis in seven patients, vocal cord granulation in four, supraglottic granulation in two, subglottic web in two, bronchial granulation in two, glottic stenosis in one, and tracheal stenosis in one; two cases were discovered incidentally during postoperative follow-up. Four patients had undergone repeated intubation and eventually required tracheostomy.

CONCLUSIONS

The results of this study indicate that flexible bronchoscopy is a simple, safe, and useful technique for the diagnosis and follow-up of airway intubation injury. It should be performed on all patients who have symptoms of upper airway obstruction after extubation as well as those who have undergone long-term or emergency intubation.

Infantile hypertrophic pyloric stenosis in a 5-month-old baby: case report

Hypertrophic pyloric stenosis is commonly seen in infants 2 to 4 weeks old. We report a case of pyloric stenosis diagnosed in a boy 5 months and 11 days old suffering from the sudden onset of vomiting. Gastric volvulus was initially diagnosed at another hospital. Abdominal ultrasonography at first using an Acuson 5-MHz transducer revealed a negative diagnosis. However, a tubular pyloric mass measuring 5.5 mm in thickness, 15 mm in the transverse diameter, and 2.0 cm in length was detected by a 7-MHz transducer immediately after the infant vomited. On physical examination, no abdominal mass was palpable. This suggested that this might have been a case of hypertrophic pyloric stenosis which was missed until the infant was older than 5 months. We believe this is the oldest reported case of infantile hypertrophic pyloric stenosis in Taiwan.

Hemorrhagic disease in a newborn due to inadequate vitamin K prophylaxis: case report

Vitamin K prophylaxis for all neonates has been recommended to prevent hemorrhagic disease of the newborn (HDN), but it is still an uncommon practice in most developing countries throughout the world. In the United States and Canada, where vitamin K injections continue to be recommended in the newborn period, HDN is not a major concern. The risk factors for HDN include inadequate vitamin K prophylaxis, exclusively breast-fed infants, diarrhea, and alternative causes of vitamin K deficiency, such as liver disease and cystic fibrosis. We present an exclusively breast-fed 3-week-old infant with diarrhea for 2 days who died from intracranial hemorrhage related to HDN despite having received a single intramuscular injection of 0.2 mg of vitamin K at birth. Hemorrhage in the infant from vitamin K deficiency should be a concern for pediatricians and obstetricians. We emphasize the importance of administering an adequate dosage of vitamin K for prevention of HDN, particularly in an exclusively breast-fed infant.

Unexpected delivery before arrival at hospital: an observation of 18 cases

BACKGROUND

We identify and discuss risk factors related to prolonged hospitalization, as compared with the average hospital stay (5.1 days) of normal delivery neonates throughout the last 10 years, associated with babies delivered unexpectedly in southern Taiwan.

METHODS

This is a retrospective case series study; those babies delivered unexpectedly, including both pre-term and term infants, were pooled out from normal-birth babies, and their laboratory data and clinical histories were reviewed and discussed.

RESULTS

There was a total of 18 babies delivered unexpectedly during the past 10 years. Out of these 18 babies, there was only 1 mortality. The mean gestational age was 38 weeks; the mean birth body weight was 3097 g, and the average hospital stay was 6.2 days. Possible clinical factors related to prolonged hospitalization include the following: hypothermia, hypoglycemia, hyperkalemia, polycythemia, and a relatively high ratio of positive findings of chest X-ray study.

CONCLUSION

The best way to reduce prolonged hospitalization caused by unexpected delivery is by prevention, or if this is not possible, by increasing the knowledge and effectiveness of handling intrapartum accidents. Hypothermia, hypoglycemia, hyperkalemia, polycythemia, and positive chest radiological results were the most common reasons for prolonged hospital stays in unexpectedly delivered neonates. However, due to the limited cases in our study, a larger group study is still needed in the future for more precise statistical information.

Profiles of inflammatory cytokines in bronchoalveolar lavage fluid from premature infants with respiratory distress disease

In view of cytokine's effects in promoting or inhibiting inflammation, the objective of this study was to explore the characteristics of the proinflammatory cytokine, interleukin-8 (IL-8), and the inhibitory cytokine, interleukin-10 (IL-10), in the bronchoalveolar lavage (BAL) fluid of premature infants suffering from respiratory distress disease. Eighteen premature neonates with respiratory distress disease with gestational age (GA) ranging from 24 to 37 weeks were recruited for study. BAL fluids were collected following endotracheal intubation during an episode of hypoxemia or dyspnea. A series of BAL samples were obtained on day 1, 2, 4 and 7 after intubation for measuring IL-8 and IL-10 levels. The results indicate that premature infants with GA ranging from 24 to 32 weeks had a higher level of IL-8 (p = 0.029), but not level of IL-10 (p = 0.109), in the BAL obtained during the first intubation compared to premature infants with GA ranging from 33 to 37 weeks. The administration of exogenous surfactant did not influence the profiles of IL-8 and IL-10, as compared to those in-patients without treatment. Levels of IL-8 were correlated with IL-10 levels (r = 0.613, p = 0.007) in BAL fluid samples obtained on the day of intubation. The level of IL-8, but not IL-10, was significantly correlated with the duration of intubation. IL-8 and IL-10 levels in BAL fluid samples collected on the day of intubation were correlated with the development of chronic lung disease (CLD). The results suggest that extreme prematurity tends to have increased IL-8 and IL-10 levels in BAL fluid compared to premature infants with older GA, and that these increased levels are associated with the development of CLD.

Toxic megacolon in Salmonella colitis: report of two cases

Toxic megacolon is a complication that usually presents in inflammatory bowel disease such as ulcerative colitis or Crohn's disease. It also occurs in typhoid fever, acute bacillary dysentery, amebic colitis, ischemic colitis, pseudomembranous colitis and severe salmonellosis. This report describes the occurrence of toxic megacolon in two young children with Salmonella colitis manifesting as abdominal distension, diarrhea and fever. The clinical course of these two cases suggests that toxic megacolon is a severe complication of salmonellosis in children, irrespective of the use of antibiotics. In the light of its paucity in children and severity, accurate diagnosis and appropriate intensive medical-surgical management is essential.

Usefulness of pediatric flexible bronchoscopy in the early diagnosis and postoperation evaluation of vascular rings: report of three cases

Vascular rings are a diagnostic and therapeutic challenge for pediatricians. Many diagnostic modalities contribute to the detection of these rare congenital vascular anomalies. The role of flexible bronchoscopy is still being debated. We present 3 cases to emphasize the usefulness of pediatric flexible bronchoscopy (PFB) in the early diagnosis and postoperative evaluation of vascular rings. In patient 1, PFB was performed before conventional techniques were available. A right aortic arch with a retroesophageal aortic diverticulum and mirror-image branching was later confirmed. In patients 2 and 3, pulmonary artery slings could not be detected clearly by imaging studies before PFB was performed. PFB was arranged again postoperatively for these 2 patients, because of difficulty weaning patient 2 from ventilator support and persistent respiratory distress in patient 3. In conclusion, we expect that more vascular rings will be diagnosed using PFB. This instrument is also useful in making a decision for surgery, and for detecting associated tracheobronchial anomalies preoperatively, assuring appropriate correction intraoperatively, and monitoring the condition of vascular rings postoperatively.

Noonan syndrome presented with cystic hygroma and chylothorax: case report

A cystic hygroma was found in a full-term (39 week-old) male newborn delivered by cesarian section. Polyhydramnios was diagnosed by sonography at 21 weeks of gestation. Clinical manifestations at birth, such as respiratory distress, tachypnea and chylothorax were successfully relieved by the insertion of chest tube and medical therapy. Other conditions, which included mild hydronephrosis of left kidney, thickening of aortic and pulmonary valves with mild mitral and tricuspid valves regurgitation, subsided within six months. The cystic hygroma regressed to a webbed neck. In general, the features and clinical manifestations of the present case resembled the criteria of Noonan syndrome including various congenital heart defects; webbed neck; chest deformity; a characteristic facial appearance comprising of a broad forehead, ocular hypertelorism, antimongoloid slant of palpebral fissures, low set ears; and bilateral undescended testis etc., suggested by Noonan and other subsequent authors. The outcome of this infant was satisfactory following medical and surgical therapy (chest tube, orchiopexy) and a special dietary regimen.

Enhancement of electrolaryngeal speech by adaptive filtering

Artificial larynges provide a means of verbal communication for people who have either lost or are otherwise unable to use their larynges. Although they enable adequate communication, the resulting speech has an unnatural quality and is significantly less intelligible than normal speech. One of the major problems with the widely used Transcutaneous Artificial Larynx (TAL) is the presence of a steady background noise caused by the leakage of acoustic energy from the TAL, its interface with the neck, and the surrounding neck tissue. The severity of the problem varies from speaker to speaker, partly depending upon the characteristics of the individual's neck tissue. The present study tests the hypothesis that TAL speech is enhanced in quality (as assessed through listener preference judgments) and intelligibility by removal of the inherent, directly radiated background signal. In particular, the focus is on the improvement of speech over the telephone or through some other electronic communication medium. A novel adaptive filtering architecture was designed and implemented to remove the background noise. Perceptual tests were conducted to assess speech, from two individuals with a laryngectomy and two normal speakers using the Servox TAL, before and after processing by the adaptive filter. A spectral analysis of the adaptively filtered TAL speech revealed a significant reduction in the amount of background source radiation yet preserved the acoustic characteristics of the vocal output. Results from the perceptual tests indicate a clear preference for the processed speech. In general, there was no significant improvement or degradation in intelligibility. However, the processing did improve the intelligibility of word-initial non-nasal consonants.

Congenital bilateral cystic neuroblastoma with liver metastases and massive intracystic haemorrhage

A case of bilateral cystic neuroblastoma with liver metastases in a newborn is reported. CT showed a 10 cm right suprarenal multicystic mass and numerous hepatic cystic masses with intracystic fluid-fluid levels. Multiple smaller cystic lesions were also present in the left adrenal gland. To our knowledge, the CT findings of neonatal bilateral cystic neuroblastoma with liver metastasis and massive acute intracystic haemorrhage has not been previously documented.

Immunohistochemical localization of cytochrome P450 enzymes 2C and 4A in the normal rat brain

OBJECTIVE

To localize cytochrome P450 enzymes 4A and 2C in central nervous cells of normal male rats.

METHODS

Eight drug/alcohol untreated normal male rats (150-200 g of body weight) were treated by the optimized perfusion technique, then brain tissues were postfixed, paraffin-embedded and cut into series sections, which were labeled by the improved strept-avidin-biotin complex DAB-nickel enhancer (SABC-DAB-Ni) immunohistochemistry and hematoxylin & eosin (H & E) stain techniques.

RESULTS

The immunohistochemical results indicated that P450 2C-11 enzyme was localized in diverse numbers of neurons as well as some neuroglial cells, with focal or defuse distribution in many brain regions such as cerebrum, thalamus, olfactory bulb, hypothalamus, brain-stem, hippocampus, cerebellum, interpositus nucleus, caudate-putamen, and globus pallidus. In contrast, no positive findings of P450 4A-2, 3 and 8 enzymes were obtained in the same animals. With high magnification, 2C-11 protein was able to be roughly observed on the endoplasmic reticulum of the rat neurons.

CONCLUSIONS

P450 2C-11 protein, rather than P450 4A-2, 3 and 8, may be a candidate of brain P450 enzymes in the normal male rats.

Spleen rupture in infectious mononucleosis: report of one case

Spleen rupture has been a rare but feared complication in patients with infectious mononucleosis. There have been many cases reported during the last decade. However, it has rarely been mentioned among the young infant group. Here, we present a case of an infant, two months of age, who suffered from spleen rupture due to infectious mononucleosis, and was latter cured by himself under conservative treatment.

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS): a case report

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is a rare congenital disorder characterized by a massively enlarged urinary bladder without mechanical outlet obstruction and microcolon, as well as a hypoperistaltic bowel with normal ganglion cell distribution. We report one such case to discuss the findings of antenatal ultrasound and the radiologic and pathologic features of this condition.

Systemic sclerosis with pulmonary involvement and right ventricular failure in a child

We report a very rare case of systemic sclerosis in a 6-year-old girl. She presented with diffuse scleroderma, Raynaud's phenomenon, pulmonary interstitial fibrosis, pulmonary hypertension, and right ventricular failure. The diagnosis was confirmed by skin manifestations, high resolution computed tomography, cardiac catheterization, and anti-nuclear antibodies. Nifedipine, prednisolone, digoxin, and furosemide were given. There was remission of the right ventricular failure and dyspnea, and the skin showed partial improvement. The patient remained asymptomatic for a year. The symptoms of respiratory and right heart failure developed again after an episode of lower respiratory tract infection and she eventually died. We discuss the clinical manifestations, treatment, and outcome.

Histopathology of the liver in pediatric patients following transplantation

Recognition of rejection and other hepatic complications by needle biopsy plays a significant role in the management of liver allograft recipients. In this report, 22 pediatric patients (below 18 years old) were selected from the 37 liver transplants. Seven of the 22 cases have an uneventful posttransplant course. The most common cause of allograft injury in these patients appeared to be acute cellular rejection. It occurred in 7 (31.8%) of the 22 cases and was the primary process in 8 of the 25 episodes of liver dysfunction. Other etiologies, such as opportunistic viral infection (3 cases), biliary obstruction (2 cases), preservation injury (1 case), and vascular obstruction (1 case) were less common. Acute graft rejection causing liver dysfunction was associated with a mixed portal inflammation, destruction of the interlobular bile ducts, and varied degree of venous endotheliitis, followed by centrilobular hepatocyte necrosis. Chronic rejection was not seen in our pediatric cases. Cold ischemic injury causing transient graft dysfunction as seen in one of our patients demonstrated focal, limited areas of hepatocyte necrosis, mild centrilobular hepatocyte ballooning, and cholestasis without evidence of bile duct damage. More severe ischemic injury resulted from vascular complication causing diffuse hepatocyte necrosis was seen in one patient with hepatic vein thrombosis. The histologic patterns observed were not pathognomic; however, liver biopsies were helpful in suggesting the probable cause of liver dysfunction and in predicting subsequent allograft recovery when used in conjunction with clinical information, radiologic, and other laboratory tests.

Primary Burkitt's lymphoma of the liver: report of a case with long-term survival after surgical resection and combination chemotherapy

PURPOSE

A case of primary Burkitt's cell lymphoma of the liver is reported.

PATIENT

A 14-year-old Chinese boy presented with a 10-day history of postprandial epigastric pain and weight loss.

RESULTS

Preoperative imaging studies revealed a large solid mass confined to the right lobe of the liver; there was no evidence of involvement of other sites. There was serological and immunohistochemical evidence of asymptomatic hepatitis B virus infection. Complete removal of the mass was achieved by right hepatic lobectomy. Histological examination revealed a small noncleaved cell lymphoma of Burkitt's type that immunostained positively for B-cell markers. The patient remains well, with no evidence of disease > 8 years after surgical resection and combination chemotherapy.

CONCLUSIONS

Only five cases (two children and three adults) of primary small noncleaved cell lymphoma of the liver have been reported. We believe this is the second reported case of childhood hepatic lymphoma with long-term disease-free survival. Further work is needed to elucidate the relationship between hepatitis B virus infection and the development of a primary small noncleaved lymphoma of the liver.

Necrotizing enterocolitis in newborn: nine years' experience

BACKGROUND

Necrotizing enterocolitis (NEC) is the most significant acquired gastrointestinal (GI) emergency in the neonatal intensive care unit.

METHODS

We sought to gain a clinical perspective on NEC by reviewing the records of NEC patients over a 9-year period. The case histories of 22 infants with NEC treated from September 1, 1986 to September 1, 1995 were reviewed.

RESULTS

Mean gestational age was 32 weeks and mean birth weight was 1774 grams. Eighteen percent were full term babies and 82% were premature. Average age at the onset of NEC was 11 days. The most common clinical manifestations were abdominal distension (100%), gastric retention (64%), unstable vital signs (59%) and Guaiac-positive vomitus or stool (36%). Sixteen cases (73%) were classified as stage III NEC, which has the highest mortality and/or morbidity.

CONCLUSION

Early identification and management are critical to improve the outcome of NEC.

Caution with use of cimetidine in tolazoline induced upper gastrointestinal bleeding

A 2-day-old newborn was treated with tolazoline for persistent pulmonary hypertension due to meconium aspiration syndrome. Hypoxemia improved during continuous tolazoline infusion, but gastrointestinal bleeding occurred. After treatment with cimetidine, there was a rapid deterioration with decreased oxygen saturation and arterial PO2 values. Tolazoline induces a dilatation of the pulmonary vascular system by stimulating H2 receptors. Cimetidine, an H2 blocker, may partially abolish the effect of tolazoline. However, given the clinically significant result to the interaction between tolazoline and cimetidine we report, the use of cimetidine in tolazoline induced upper gastrointestinal hemorrhage should deserve more attention.

Gastric perforation in the neonate: clinical analysis of 12 cases

Gastric perforation is a rare abdominal catastrophe which associated with high mortality in newborn infants. From June 1978 to July 1991, twelve cases of neonatal gastric perforation presented at Chang Gung Memorial Hospital. Male to female ratio was 9:3. The most common presenting signs were abdominal distension (100%), feeding intolerance (92%), respiratory distress (67%) and poor activity (58%). All cases had significant symptoms between two and five days of age. All of the abdominal plain film showed pneumoperitonium. The most common site of perforation was the great curvature of the stomach (83%). Among the 10 pathological reports available, 8 cases had ischemic change and 2 cases had hemorrhage and inflammatory cell infiltration. There was a high mortality rate of 58% in this series. Male, hyponatremia (serum sodium < 130 meq/l) and metabolic acidosis (pH < 7.3) were poor prognostic factors. This report suggests that early diagnosis and early management before clinical deterioration of the metabolic status may improve prognosis for neonatal gastric perforation patients.

The McKusick-Kaufman hydrometrocolpos-polydactyly syndrome--a case report

Hydrometrocolpos is a rare congenital anomaly and serious life threatening condition in the newborn infant due to its long-term compression sequelae and associated congenital anomalies. Prenatal diagnosis of hydrometrocolpos by sonogram allows appropriate management during the prenatal and neonatal period. The combination of hydrometrocolpos and polydactyly is the cardinal hallmark feature of McKusick-Kaufman Syndrome. We present a case of congenital hydrometrocolpos due to vaginal atresia combined with polydactyly of both feet, mild atrial septum defect, bilateral hydronephrosis, fetal ascites and polyhydramnios. Pathogenesis and treatment of hydrometrocolpos and its associated congenital anomalies are discussed.

Congenital cutaneous candidiasis--report of two cases

Candida infection contracted in utero and manifested at birth is a rare event. Two newborn infants are presented with generalized maculopapular rashes at birth. The eruption soon became vesicles or pustules; no other manifestations were found. Candida albicans was isolated from the skin lesion. After topical antifungal application, the lesions became fine and desquamated in the recuperative period. No complication was noted during the course. The diagnosis of congenital cutaneous candidiasis relies on its clinical course and positive culture result of the skin lesion. No systemic antifungal therapy is recommended except for the high risk infants.

Primary hyperparathyroidism in children: report of a case and a brief review of the literature

A case of primary hyperparathyroidism in an 11-year-old boy who presented with bowlegs is reported and the literature is reviewed. From the literature, it appears that the pathologic findings, clinical manifestations and sex distribution of primary hyperparathyroidism is different in adults than in children and young infants. In adults, primary hyperparathyroidism is commonly caused by adenoma and is often found unexpectedly on a biochemical screen of the serum. Elderly women are most at risk. Renal stones or other renal complications are more frequently seen in adults than in children. Neonatal hyperparathyroidism is often genetically transmitted and is fatal unless recognized and treated early. The characteristic pathologic change is chief cell hyperplasia of the parathyroid glands. On the other hand, adenoma is the most common pathologic finding in older children. No case of childhood parathyroid carcinoma was found in our review of the literature. In children, primary hyperparathyroidism is more frequent in boys than in girls and osseous lesions are more common than in adults. Prognosis is good if the disease is recognized early and appropriate surgical treatment is received.

[Adult onset Still's disease: review of 50 cases and evaluation of diagnostic criteria]

On the basis of clinical and laboratory data of 50 patients with adult onset Still's disease (AOSD), we strictly examined 4 diagnostic criteria adopted by different authors: criteria of Calabro, ARA, Medsger and Liu Gui-xin. Our result shows that Calabro's criteria has the best specificity (100%) and a higher diagnosis index (0.90) among the 4 criteria. Liu's criteria provides the best sensitivity (98%), but a lower specificity (86.9%) with a misdiagnosis rate of 14%. The rate of missed diagnosis with the ARA criteria is 35.7%. According to the present study, we recommend Liu's criteria for preliminary screen diagnosis, while Calabro's criteria for confirmation and differential diagnosis. Of special interest is that serum ferritin (SF) determination showed significantly higher level in 20 patients with AOSD (average 1194.5mg/L) than that in 19 patients with other rheumatic diseases (average 94mg/L, P < 0.001). AOSD patients with active disease have higher SF levels than patients with inactive disease (average 2742.9mg/L & 291.25mg/L, P < 0.001). So this test might be useful in diagnosis in AOSD and assessment of disease activity.

Oat bran, rye bran, and soybean hull increase goblet cell volume density in the small intestine of the golden hamster. A histochemical and stereologic light-microscopic study

Small-intestinal morphology, particularly the amount of goblet cells, was studied in Syrian golden hamsters fed either a low-fibre (0.5% fibre) diet or the same diet supplemented with oat bran, rye bran, or soybean hull (12% fibre) during 6 weeks. All fibre diets increased the density of goblet cell volume to epithelial volume and to villus volume in the ileum and to some extent in the jejunum and also the number of goblet cells related to surface traces of villi both in the proximal and distal small intestine. The weight of the small intestine and the circumference and the volume of the intestinal wall in the ileum were greater in the rye bran diet group as compared with all the other groups, suggesting hyperplasia. These results suggest that oat bran, rye bran, and soybean hull supplementation might result in higher goblet cell secretory activity in both the proximal and distal small intestine of hamsters. The various fibre sources influenced the small-intestinal wall differently.

Trisomy 18 (Edwards syndrome): report of two cases

Edwards syndrome is the second most common autosomal trisomy syndrome, resulting from an extra chromosome in chromosome 18. Recently we encountered two cases with the following representative features: intrauterine growth retardation, polyhydramnios, low-set ears, micrognathia and clenched hands. Both cases were female newborns and had an abnormal karyotype 47, XX, 18.

Unusual short rib-polydactyly syndrome

We present a case of lethal short rib-polydactyly syndrome (SRPS) that cannot be categorized into the existing classification. A nosologic discussion is presented. To our knowledge, situs inversus totalis, as in our case, has not been described before in any SRPS.

Quantification of the sulphomucin-producing cell population of the colonic mucosa during protracted stress in rats

The sulphomucins contained in goblet cells of the descending colon of 55 Sprague-Dawley rats were histochemically labelled by High Iron Diamine (HID) and quantified in an image analyzer (Cortex controller). After transportation to the stress laboratory, 25 rats were compelled to swim for two consecutive hours/day either only once (5 rats), for one week (5 rats), two weeks (5 rats), four weeks (5 rats) or eight weeks (5 rats). 25 additional rats were only transported to the stress laboratory (i.e. "sham-handled" control), either once (5 rats), for one week (5 rats), two weeks (5 rats), four weeks (5 rats) or eight weeks (5 rats). The remaining 5 rats were "untransported", resting control rats (i.e. day zero). The results were expressed in percent of HID-staining/total mucosa analyzed. When various time intervals were compared with those of day zero (i.e. horizontal study), it was found that one day swimming rats had a significantly lower percentage (p less than 0.001) of HID stained material. The fluctuations at other time intervals were non-significant. On the other hand, for transported rats, a significant increase (p less than 0.001) in the percentage of HID positive areas was found for rats swimming for eight weeks. When compared to day one, the percentage of HID positive areas increased from day one to one-eight weeks, the differences being significant (p less than 0.001) at four and (p less than 0.01) eight weeks. Similar results were found for transported rats.(ABSTRACT TRUNCATED AT 250 WORDS)