Replication of association of IL1 gene complex members with ankylosing spondylitis in Taiwanese Chinese

OBJECTIVE

To test the association of interleukin 1 (IL1) gene family members with ankylosing spondylitis (AS), previously reported in Europid subjects, in an ethnically remote population.

METHODS

200 Taiwanese Chinese AS patients and 200 ethnically matched healthy controls were genotyped for five single nucleotide polymorphisms (SNPs) and the IL1RN.VNTR, markers previously associated with AS. Allele, genotype, and haplotype frequencies were compared between cases and controls.

RESULTS

Association of alleles and genotypes of the markers IL1F10.3, IL1RN.4, and IL1RN.VNTR was observed with AS (p<0.05). Haplotypes of pairs of these markers and of the markers IL1RN.6/1 and IL1RN.6/2 were also significantly associated with AS. The strongest associations observed were with the marker IL1RN.4, and with the two-marker haplotype IL1RN.4-IL1RN.VNTR (both p = 0.004). Strong linkage disequilibrium was observed between all marker pairs except those involving IL1B-511 (D' 0.4 to 0.9, p<0.01).

CONCLUSIONS

The IL1 gene cluster is associated with AS in Taiwanese Chinese. This finding provides strong statistical support that the previously observed association of this gene cluster with AS is a true positive finding. These authors contributed equally to the study.

The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves' hyperthyroidism

OBJECTIVE

The study aims to evaluate the efficacy of combination therapy with propylthiouracil (PTU) and cholestyramine in the treatment of Graves' hyperthyroidism.

BACKGROUND

Thyroxine (T4) is metabolized mainly in the liver by conjugation to glucuronides and sulphates that enter the enterohepatic circulation. Thyrotoxic patients have an abnormal increase in thyroid hormone in their enterohepatic circulation. Previous studies on combination therapy with methimazole and cholestyramine for Graves' hyperthyroidism have shown it to be an effective adjunctive treatment. In this study, we examined the efficacy of combination therapy with PTU and cholestyramine in the treatment of Graves' hyperthyroidism.

METHODS

Thirty patients with newly diagnosed Graves' hyperthyroidism were randomly divided into two groups: group I (n = 15) received PTU 100 mg twice a day, propranolol 40 mg twice a day and cholestyramine 4 g twice a day for 4 weeks; group II (n = 15) received PTU 100 mg twice a day and propranolol 40 mg twice a day for 4 weeks. The therapeutic efficacy was determined by serum total triiodothyronine (TT3), free thyroxine (FT4) and TRAb levels at baseline, and at the end of 2 and 4 weeks during the study period.

RESULTS

There was no significant difference in baseline thyroid function parameters. At the end of 2 and 4 weeks of the study period, serum TT3 and FT4 levels of group I were significantly lower than those of group II. No significant differences in the TRAb level were found between the two groups.

CONCLUSION

Cholestyramine contributed to a more rapid and complete decline in thyroid hormone levels in patients with Graves' hyperthyroidism. It was thus proved to be an effective and well-tolerated adjunctive therapy.

Study of undifferentiated spondyloarthropathy among first-degree relatives of ankylosing spondylitis probands

OBJECTIVE

To estimate in a Chinese population the prevalence of undifferentiated spondyloarthropathy (USpA) among first-degree relatives (FDRs) of ankylosing spondylitis (AS) probands, and to compare the clinical features of familial USpA with those of sporadic USpA.

METHODS

The FDRs of two separate cohorts of consecutive AS probands were evaluated for the prevalence of USpA, using the Modified New York criteria and the European Spondylitis Study Group criteria for AS and SpA, respectively. Sporadic USpA and FDRs of non-SpA rheumatic patient probands served as separate controls.

RESULTS

Among the 301 FDRs of 102 AS probands, 7.0% were USpA. This was 1000 times higher than the 147 FDRs of 40 non-SpA probands (P = 0.00230). Within the AS families, USpA was less male-dominated than AS (33.3 vs 72.5%) (P = 0.006). The only feature distinguishing familial from sporadic USpA was that the percentages of HLA B27 were 100 and 50%, respectively (P<0.001).

CONCLUSION

USpA and AS coexist in the same Chinese families, both being predisposed by HLA B27. In these families, a female gender favours the development of USpA rather than AS. A significant subset of sporadic USpA (HLA B27-negative group) has a different genetic predisposition compared with familial USpA.

Correlations between white blood cell count and metabolic syndrome in middle-age Taiwanese

Metabolic syndrome was first proposed in 1988 and has been recognized as a powerful predictor for cardiovascular disease and diabetes. At the same time, white blood cell count (WBCC) was proposed to have significant correlation with metabolic syndrome (MS). In this study, we attempted to investigate the relationship between WBCC and components of metabolic syndrome in subjects in Taiwan with normal WBCC, no significant medical disease, and no medications known to affect the components of MS. We enrolled 1185 subjects with age > or = 40 years in 1997. These subjects participated in the annual health examination of the MJ Life Clinic. Subjects with abnormal WBCC (> 10x 10(9) cells/l), history of diabetes, hypertension or hyperlipidemia, or taking medications for these diseases or medications known to affect components of MS, were excluded. Because the menstrual cycle has an effect on the components of MS, we divided the subjects into three groups: male (M group, n = 576), old female (OF group, aged > or = 50 years, n = 307), and young female (YF group: aged < 50 years, n = 302). Each group was further divided into four quartiles according to WBCC (WBCC1 to WBCC4, from the lowest to highest WBCC). The body mass index (BMI) of YF was significantly lower than both M and OF. The diastolic blood pressure (DBP) and triglycerides (TG) were higher in M than YF. High-density lipoprotein cholesterol (HDLC) was lower in M compared to both YF and OF. When evaluating the metabolic components in different quartiles of WBCC in M, only WBCC1 had lower BMI and TG than WBCC4 after adjustment for age and BMI. For OF, the results were similar, the BMI of both WBCC1 and WBCC2 was lower than WBCC3 and TG of WBCC1 was lower than WBCC4. Finally, in YF, none of the BMI, blood pressure, FPG, HDLC, or TG was different in the four WBCC quartiles. The results of multiple regression between the WBCC and components of MS after adjustment for age and BMI were also evaluated. Significant correlations could only be noted in WBCC with BMI and TG in M and OF. In conclusion, in subjects with normal WBCC and no history of significant medical diseases, BMI and TG are significantly related to the levels of WBCC and are the two earliest components of MS to be noted, especially in males and post-menopausal females.

Evaluation of the dose rate distribution for an air-type 60Co irradiation facility

The dose rate distributions in the 29,000-Ci 60Co irradiation facility in National Tsing Hua University were investigated by measurements and calculations. The dose rate measurements were performed using radiochromic dye films and an Exradin A2 ion chamber mounted on a PC-controlled motorised vertical translation stage. The calculations were made by using the three-dimensional point kernel code QAD-CGGP with detailed source composition and geometry modelling. The scattered gamma rays from the walls of the irradiation cell were also evaluated by using the Monte Carlo code MCNP.

Absolute instabilities in a high-order-mode gyrotron traveling-wave amplifier

The absolute instability is a subject of considerable physics interest as well as a major source of self-oscillations in the gyrotron traveling-wave amplifier (gyro-TWT). We present a theoretical study of the absolute instabilities in a TE01 mode, fundamental cyclotron harmonic gyro-TWT with distributed wall losses. In this high-order-mode circuit, absolute instabilities arise in a variety of ways, including overdrive of the operating mode, fundamental cyclotron harmonic interactions with lower-order modes, and second cyclotron harmonic interaction with a higher-order mode. The distributed losses, on the other hand, provide an effective means for their stabilization. The combined configuration thus allows a rich display of absolute instability behavior together with the demonstration of its control. We begin with a study of the field profiles of absolute instabilities, which exhibit a range of characteristics depending in large measure upon the sign and magnitude of the synchronous value of the propagation constant. These profiles in turn explain the sensitivity of oscillation thresholds to the beam and circuit parameters. A general recipe for oscillation stabilization has resulted from these studies and its significance to the current TE01 -mode, 94-GHz gyro-TWT experiment at UC Davis is discussed.

Psoriatic patients with arthropathy show significant expression of free HLA class I heavy chains on circulating monocytes: a potential role in the pathogenesis of psoriatic arthropathy

BACKGROUND

Surface free heavy chains on monocytes were recently implicated in playing a role in the pathogenesis of several forms of arthritis.

OBJECTIVES

To determine the expression of surface free heavy chains (recognized by monoclonal antibody HC10) on peripheral blood mononuclear cells of psoriatic patients with or without arthropathy.

METHODS

Twenty-eight psoriatic patients from the dermatology outpatient clinic were included in this study. Blood samples were collected during outpatient visits and clinical characteristics of the patients were documented. Quantitative analyses of circulating mononuclear cells were performed using flow cytometry.

RESULTS

Circulating monocytes showed higher expression of HC10 compared with circulating lymphocytes (P < 0.05). Psoriatic patients with arthropathy showed elevated expression of HC10 on peripheral blood monocytes compared with those without arthropathy (P < 0.05). Among the arthropathic group, those without the human leucocyte antigen (HLA)-B27 allele showed even higher expression of HC10 on circulating monocytes compared with those possessing HLA-B27 (P < 0.05). The polyarthropathic subgroup showed the highest HC10 expression, but the level of expression was not high enough to be of statistical significance compared with other arthropathic subgroups. No correlation was found between psoriatic skin involvement and the expression of HC10 on circulating monocytes.

CONCLUSIONS

The presence of free heavy chains on circulating monocytes is closely associated with psoriatic arthropathy, while the expression of free heavy chains on circulating monocytes has no significant influence on psoriatic skin lesions.

Development and validation of an HPLC method for AG331 bulk drug substance and lyophilized powder for injection

AG331 is a water soluble glucuronate salt of a novel antitumor compound synthesized by protein structure based drug design. A lyophilized powder for injection was developed for clinical studies. During HPLC assay development, AG331 showed an inherent tailing problem due to an amino group in the structure. An optimized reverse-phase gradient HPLC method was developed to minimize the tailing and separate AG331 from its synthetic intermediates (I-1, I-2, I-3, I-4, I-5, I-6, I-8), other impurities and degradation compounds. The method was shown to be linear, precise, accurate, rugged and stability-indicating.

HLA-B60 and B61 are strongly associated with ankylosing spondylitis in HLA-B27-negative Taiwan Chinese patients

OBJECTIVES

Carriage of HLA-B60 has been shown to increase the risk of ankylosing spondylitis (AS) in B27-positive Caucasian patients, but the association in B27-negative cases is less certain. This study assessed HLA class I gene associations in Chinese HLA-B27-negative AS patients.

METHODS

Forty-one Chinese HLA-B27-negative AS patients fulfilling the modified New York diagnostic criteria for AS were recruited, and 11 383 HLA-B27-negative blood donors were used for comparison. HLA-A and -B typing was done with the microlymphocytotoxicity assay.

RESULTS

Among the B27-negative AS patients, 21 were male and 20 were female. Of HLA-B alleles, only B60 and B61 significantly increased susceptibility to AS in HLA-B27-negative patients (P<0.001).

CONCLUSIONS

In Taiwan Chinese, carriage of B60 is increased in HLA-B27-negative AS patients. The association between B61 and HLA-B27-negative AS patients has not been reported previously. Whether the gene involved is HLA-B60 or B61 or another gene in linkage disequilibrium with these genes is unknown.

Distinct regulation of genes by bFGF and VEGF-A in endothelial cells

A finely tuned balance of angiogenic inhibitors and inducers controls the activity of angiogenesis characterized by proliferation, migration and differentiation of endothelial cells. Among many angiogenic factors, basic fibroblast growth factor (bFGF) was first identified to be angiogenic whereas vascular endothelial growth factor A (VEGF-A) is an endothelial cell specific mitogen. In addition to being a specific mitogen, VEGF-A is also known as a vascular permeability factor. The majority of growth factors transduce their mitogenic signals from cell surface to nucleus where gene expression occurs. Whether these ligands utilize a distinct or a common molecular pathway to exert their biological effects on human endothelial cells remains elusive. We thus studied the expression profile of 884 human genes under the influence of either bFGF or VEGF-A alone in the context of human endothelial cells. A total of ninety-four genes were differentially regulated by more than two folds. The expression patterns of 32 genes are similar between the treatment of either factor alone whereas those of the remaining 62 genes are only regulated by one but not the other factor. Their function in the control of angiogenesis will be discussed and apoptotic signaling in the regulation of angiogenesis is also implicated.

Bloodletting acupuncture of the engorged vein around Bl-40 (Wei-Chung) for acute lumbar sprain

Bloodletting acupuncture is one of the most classic methods of acupuncture therapy, and is still popularly used to treat acute lumbar sprain in the oriental world. However, most physicians in the western world are not familiar with bloodletting acupuncture, though they may know ordinary acupuncture well. Furthermore based on the literature reviewed, there have been few studies which have investigated the effect of bloodletting acupuncture upon acute lumbar sprain. In this study, we tried to determine if bloodletting acupuncture is effective for acute lumbar sprain. In total, twelve patients were enrolled for analysis. Five patients were treated with ordinary acupuncture upon the contralateral SI-3 (Hou-Hsi) point alone. Seven patients were first treated with bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 (Wei-Chung), and then followed by ordinary acupuncture upon the contralateral SI-3. It was demonstrated that bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 followed by ordinary acupuncture upon the contralateral SI-3 had more pain relief than ordinary acupuncture upon the contralateral SI-3 alone (83 +/- 23% vs. 44 +/- 28%) (P < 0.01). And bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 decreased pain by 56 +/- 23%, similar to that of ordinary acupuncture upon the contralateral SI-3 alone (44 +/- 28%). These findings suggest that bloodletting acupuncture to the engorged vein around the ipisilateral Bl-40 (Wei-Chung) has a substantial contribution for treatment of acute lumbar sprain.

A 588-gene microarray analysis of the peripheral blood mononuclear cells of spondyloarthropathy patients

OBJECTIVES

To identify genes which are more highly expressed in the peripheral blood mononuclear cells (PBMC) of patients with spondyloarthropathy (SpA), rheumatoid arthritis (RA) and psoriatic arthritis (PsA), in comparison to normal subjects.

METHODS

A 588-gene microarray was used as a screening tool to select a panel of such genes from PBMC of these subjects and of normal subjects. Results were then validated by reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

The following genes were more highly expressed in arthritis patients than in normal subjects: macrophage differentiation marker MNDA (myeloid nuclear differentiation antigen), MRP8 and MRP14 (migratory inhibitory factor-related proteins); signalling molecules JAK3 (janus kinase 3) and MAP kinase p38 (mitogen-activated protein kinase); receptors TNFR2/p75, C-C-chemokine receptor type 1 (CCR1), C-X-C-chemokine receptor type 4 (CXCR4) and integrin beta1; and the cytokines/chemokines interleukin (IL) 1beta and IL-8. Expression of CXCR4 was unexpectedly high among all arthritis subjects. Using RT-PCR, ELISA and immunohistology, expression of stromal cell-derived factor 1 (SDF-1) was demonstrated in arthritis joints.

CONCLUSIONS

The CXCR4/SDF-1 is a potential pro-inflammatory axis for RA, PsA and SpA.

Systemic lupus erythematosus complicated by recurrent spontaneous pneumothorax--a case report

Despite frequent pleuro-pulmonary involvement, spontaneous pneumothorax is rare in patients with systemic lupus erythematosus (SLE). Here, we report a 17-year-old female patient with SLE, complicated by multiple organs involvement. She initially presented with interstitial pneumonitis and pulmonary hemorrhage, followed by spontaneous pneumothorax and CNS involvement. The patient was treated with immunosuppressive agents, including steroid and cyclophosphamide pulse therapies. Spontaneous pneumothorax happened to her once again at a different location during treatment. After aggressive therapy, the disease activity of SLE gradually diminished, and pneumothorax had not recurred during the further follow-up. Therefore, the pneumothorax may occur in SLE patients with high disease activity.

Factors affecting the recovery of Legionella pneumophila serogroup 1 from cooling tower water systems

A total of 20 water samples collected from the cooling towers at 20 different sites were analyzed under various conditions for the presence of Legionella pneumophila serogroup 1. A comparative assessment was performed to evaluate methods of sample collection (spray drops, beneath water at 20- to 40-cm depth, and water outlet), concentration (filtration and centrifugation), acid buffer treatment (no treatment, treatment for 3, 5, and 15 min), and CO2 incubation or candle jar incubation. The reduction in viable colonies and false negative rate were compared for the different factors. No quantitative differences in isolation of L. pneumophila serogroup 1 was found among samples collected from water at a depth of 20 to 40 cm, from water outlet, and from spray drops. Treatment in an acid buffer for 15 min significantly reduced the recovery rate, with a reduction in bacterial counts of about 40%, compared with a 3-min (12%) or a 5-min (25%) treatment. Acid buffer treatment for 3 or 5 min reduced the overgrowth of commensal flora. This treatment improved the selectivity but not the sensitivity for L. pneumophila serogroup 1. Colonies on plates incubated at 37 degrees C in a candle jar with a humidified atmosphere grew better than those incubated at 35 degrees C with 5% CO2. These results demonstrate that methods of sample collection, concentration, and incubation, but not collection site, can affect the isolation rate for L. pneumophila serogroup 1.

Selective inhibition of COX-2 improves early survival in murine endotoxemia but not in bacterial peritonitis

Prostaglandins of the E series are believed to act as important mediators of several pathophysiological events that occur in sepsis. Studies were performed to evaluate the effect of cyclooxygenase (COX)-2-specific inhibition on the outcome in murine endotoxemia and cecal ligation and puncture (CLP). We observed a significant time-dependent upregulation of PGE(2) production in both blood and lung homogenates of mice administered lipopolysaccharide intraperitoneally, which was nearly completely suppressed by the administration of the COX-2 inhibitor NS-398. Treatment with NS-398 significantly improved early but not late survival in lipopolysaccharide-challenged mice. On the contrary, elevated PGE(2) levels were found in bronchoalveolar lavage fluid but not in plasma of mice subjected to CLP (21 gauge). Pretreatment with NS-398 failed to significantly improve survival in CLP mice. No significant differences were noted in plasma or lung homogenate proinflammatory cytokine levels or lung neutrophil sequestration between the NS-398-treated and control groups. These results demonstrate that selective COX-2 inhibition confers early but not long-term benefits without affecting the expression of proinflammatory cytokines or the development of lung inflammation.

Tumor necrosis factor promoter polymorphisms in patients with rheumatoid arthritis in Taiwan

OBJECTIVE

To investigate the association of tumor necrosis factor (TNF) promoter polymorphisms with rheumatoid arthritis (RA) in Taiwan.

METHODS

TNF promoter polymorphisms at positions -238, -244, -308, -376, -857, and -863 were determined in 97 patients with RA and 97 healthy controls using the PCR-RFLP method.

RESULTS

The phenotypic frequency of TNF-308A was significantly lower in patients with RA than in healthy controls. This finding can only be found in HLA-DR4 negative patients, not in DR4 positive RA patients and controls. The TNF promoter polymorphisms at positions -238, -244, -308, -376, -857, and -863 were not related to the clinical manifestations of RA patients.

CONCLUSION

TNF-308A itself or a neighboring gene may be a protective factor for the development of RA in the HLA-DR4 negative population in Taiwan. TNF promoter polymorphisms were not associated with the clinical manifestations of patients with RA in Taiwan.

Disseminated vaccine strain varicella as the acquired immunodeficiency syndrome-defining illness in a previously undiagnosed child

The Food and Drug Administration licensed a live-virus varicella vaccine (Varivax; Merck & Co Inc, West Point, PA) in March 1995. Prelicensure adverse events were minimal; however, since licensure and increased vaccine use, rare previously undetected risks have arisen. Presented here is the clinical course of a previously undiagnosed, human immunodeficiency virus-infected boy who developed dissemination of the vaccine strain of varicella zoster after immunization. chickenpox, human immunodeficiency virus, pneumonia, encephalopathy, varicella vaccine, adverse events, dissemination.

Coexistence of tuberculous constrictive pericarditis and right atrial tuberculoma: a case report

Tuberculous constrictive pericarditis is a rare condition with a high mortality rate. The coexistence of constrictive pericarditis and intracardiac tuberculoma has not previously been reported. We report the case of a 65-year-old man presenting with left-side pleural effusion and signs of systemic venous congestion for 2 months. Echocardiography and computerized tomography showed a thickened pericardium and a mass in the right atrium. Pericardiectomy and excision of the right atrial mass were performed. Pathologic examination of the pericardium and the right atrial mass both revealed chronic granulomatous inflammation with acid-fast bacilli and confirmed the diagnosis of tuberculous constrictive pericarditis and right atrial tuberculoma. This case reminds us of the possibility of this type of rare combination of tuberculous constrictive pericarditis and intracardiac right atrial tuberculoma, and the need for complete imaging studies when such cases are encountered.

Surface characteristics of Bacillus cereus and its adhesion to stainless steel

The ability of a Bacillus cereus strain, isolated from spoiled milk, to adhere to the surface of stainless steel chips was evaluated during its growth in diluted tryptic soy broth (DTSB). The number of cells that adhered to the surface increased markedly as the culture reached the end of the log phase and entered stationary phase, and continued to increase with further incubation. The surface properties of cells from the log, stationary, and late stationary phases were measured by hydrophobic interaction chromatography (HIC) and electrostatic interaction chromatography (ESIC). It was found that surface hydrophobicity of B. cereus vegetative cells from the late stationary phase was the highest followed by those from the stationary phase and the log phase cultures. While the vegetative cells prepared from stationary phase and log phase cultures, respectively, had the highest and the lowest surface charges. Adhesion of B. cereus vegetative cells to stainless steel was positively correlated with the cell surface hydrophobicity (R = 0.979). Surface hydrophobicity and surface positive charge noted on the spores harvested from diluted tryptic soy agar (DTSA) and Mn2+-tryptone glucose extract agar were higher than those harvested from the sucrose or lactose-added DTSA. A wide variation in the surface charge values was noted on the surface of various spores prepared from cultures grown on the four different media tested, while their ability to adhere to stainless steel chips in phosphate buffered saline (PBS) showed no significant difference (p > 0.05). Similarly, the number of spores or vegetative cells adhering to stainless steel suspended in PBS, milk or diluted milk (1000 x) did not differ significantly (p > 0.05).

HLA-DQA1 genotyping in patients with rheumatoid arthritis in Taiwan

To investigate the role of HLA-DQA1 genotypes and their interaction with HLA-DRB1 in the pathogenesis of rheumatoid arthritis (RA) in Taiwan, HLA-DQA1 was determined in 71 patients with RA and 108 healthy controls by SSP-PCR method. HLA-DRB1 and HLA-DQA1 were simultaneously detected in 55 RA patients and 101 healthy controls. PCR/SSOP method was used to determine the HLA-DRB1 genotypes, and the subtypes of HLA-DR4 were determined by cloning and sequencing. The phenotypic frequency of HLA-DQA1*0301 was significantly lower in RA than in controls, and, in contrast, the HLA-DQA1*0302 and DQA1*0303 were significantly higher in RA than in controls. The associations of DQA1*0301, *0302, and *0303 with RA were independent of DR4 and DRB1*0405. Moreover, the interactions between HLA-DR4 and HLA-DQA1*0302 or DQA1*0303 could enhance the development of RA. We also found that the prevalence of bone erosion and seropositivity of rheumatoid factor (RF) were significantly higher in HLA-DQA1*0303 positive RA patients than in healthy controls. HLA-DQA1*0302 and DQA1*0303 are the risk factors for susceptibility to RA, while HLA-DQA1*0301 is a protective factor. A synergistic effect for the susceptibility to RA can be found between HLA-DR4 and HLA-DQA1*0302 or DQA1*0303. We also found that the HLA-DQA1*0303 was related to bone erosion and seropositivity of RF in RA patients.

Familial Mediterranean fever in a Taiwanese patient

Familial Mediterranean fever is a rare disease characterized by cyclic attacks of fever, serositis and strong family background. Here we report a 22-year-old man who suffered from recurrent fever accompanied by chest and abdominal pain for more than 10 years. The attack frequency was about once per 2-3 weeks. Although he consulted many clinics and even received appendectomy at the age of 15, no definite diagnosis was given. During the admission, many laboratory examinations failed to show any abnormality except mild leukocytosis and elevated C-reaction protein. Image studies including chest X ray and abdominal CT scan showed negative result but, interestingly, Gallium-67 scan showed a hot spot in right lower chest and right lower abdomen. After prophylaxis with colchicine 1.0 mg per day, he has enjoyed more than 2 years without the above symptoms.

Chemokine-dependent neutrophil recruitment in a murine model of Legionella pneumonia: potential role of neutrophils as immunoregulatory cells

The roles of CXC chemokine-mediated host responses were examined with an A/J mouse model of Legionella pneumophila pneumonia. After intratracheal inoculation of 10(6) CFU of L. pneumophila, the bacterial numbers in the lungs increased 10-fold by day 2; this increase was accompanied by the massive accumulation of neutrophils. Reverse transcription-PCR data demonstrated the up-regulation of CXC chemokines, such as keratinocyte-derived chemokine, macrophage inflammatory protein 2 (MIP-2), and lipopolysaccharide-induced CXC chemokine (LIX). Consistent with these data, increased levels of KC, MIP-2, and LIX proteins were observed in the lungs and peaked at days 1, 2, and 2, respectively. Although the administration of anti-KC or anti-MIP-2 antibody resulted in an approximately 20% decrease in neutrophil recruitment on day 2, no increase in mortality was observed. In contrast, the blockade of CXC chemokine receptor 2 (CXCR2), a receptor for CXC chemokines, including KC and MIP-2, strikingly enhanced mortality; this effect coincided with a 67% decrease in neutrophil recruitment. Interestingly, anti-CXCR2 antibody did not affect bacterial burden by day 2, even in the presence of a lethal challenge of bacteria. Moreover, a significant decrease in interleukin-12 (IL-12) levels, in contrast to the increases in KC, MIP-2, and LIX levels, was demonstrated for CXCR2-blocked mice. These data indicated that CXCR2-mediated neutrophil accumulation may play a crucial role in host defense against L. pneumophila pneumonia in mice. The increase in lethality without a change in early bacterial clearance suggested that neutrophils may exert their protective effect not through direct killing but through more immunomodulatory actions in L. pneumophila pneumonia. We speculate that a decrease in the levels of the protective cytokine IL-12 may explain, at least in part, the high mortality in the setting of reduced neutrophil recruitment.

Ultrasound evaluation of plantar fasciitis

OBJECTIVE

To investigate the sonographic features of plantar fasciitis (PF).

METHODS

High-resolution ultrasound was used to measure the thickness and echogenicity of the proximal plantar fascia and associated heel pad thickness for 102 consecutive patients with PF (unilateral: 81, bilateral: 21) and 33 control subjects.

RESULTS

The mean thickness of the plantar fascia was greater on the symptomatic side for patients with bilateral and unilateral PF than on the asymptomatic side for patients with unilateral PF, and also control subjects (5.47+/-1.09, 5.61+/-1.19, 3.83+/-0.72, 3.19+/-0.43 mm, respectively, p<0.001). A substantial difference in thickness between the asymptomatic side of patients with unilateral PF and control subjects was also noted (p=0.001). The heel pad thickness was not show different between control subjects and patients with PF. The incidence of hypoechoic fascia was 68.3% (84/123). Other findings among the patients from our test group included intratendinous calcification (two cases), the presence of perifascial fluid (one case), atrophic heel pads (one case), and the partial rupture of plantar fascia (one case).

CONCLUSION

Increased thickness and hypoechoic plantar fascia are consistent sonographic findings in patients exhibiting PF. These objective measurements can provide sufficient information for the physician to confirm an initial diagnosis of PF and assess individual treatment regimens.

Blood pressure and left ventricular hypertrophy in patients on different peritoneal dialysis regimens

OBJECTIVE

To examine the relation between the results of ambulatory 24-hour blood pressure monitoring (ABPM) and left ventricular mass index (LVMI), then to find the independent determinant for left ventricular hypertrophy (LVH) in peritoneal dialysis (PD) patients. Finally, to evaluate the differences in the clinical and cardiovascular characteristics between patients on continuous ambulatory PD (CAPD) and continuous cyclic PD (CCPD).

DESIGN

An open, nonrandomized, cross-sectional study.

SETTING

Divisions of nephrology and cardiology in a medical center.

PATIENTS

Thirty-two uremic patients on maintenance PD therapy (22 patients on CAPD, and 10 on CCPD) without anatomical heart disease or history of receiving long-term hemodialysis.

INTERVENTIONS

Home blood pressure (BP) and office BP were measured using the Korotkoff sound technique by sphygmomanometer. ABPM was employed for continuous measurement of BP. Echocardiography was performed for measurement of cardiac parameters and calculation of LVMI.

MAIN OUTCOME MEASURES

Multivariate logistic regression analysis was performed for independent determinant of LVH in PD patients. The differences in clinical and cardiovascular characteristics between CAPD and CCPD patients were compared.

RESULTS

Simple regression analysis showed positive correlations between LVMI and the duration of hypertension, ambulatory nighttime BP/BP load/BP load > 30%, serum phosphate, calcium-phosphate product, ultrafiltration (UF) volume, and percentage of UF volume during the nighttime. A negative correlation was noted between LVMI and dipping. In multiple regression analysis, the duration of hypertension was the only variable linked to LVMI. In multivariate logistic regression analysis, only ambulatory nighttime systolic BP load > 30% had an independent association with LVH. There were correlations between office/home BP and ambulatory 24-hour BP. In addition, CCPD patients had higher LVMI, UF volume during the nighttime, and percentage of UF volume during the nighttime than those of CAPD patients.

CONCLUSIONS

In this study, ambulatory nighttime systolic BP load > 30% had an independent association with LVH. Office and home BP measurements were correlated with ABPM in PD patients. The result that CCPD patients had a higher LVMI than CAPD patients may be due to a relative volume overload during the daytime in CCPD patients.

Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection

OBJECTIVE

To investigate the efficacy of ultrasound-guided steroid injection for the treatment of proximal plantar fasciitis and to evaluate mechanical properties of the heel pad after steroid injection.

DESIGN

Proximal plantar fascia and heel pad were assessed with a 10-MHz linear array ultrasound transducer. Pain intensity was quantified with a tenderness threshold (TT) and visual analog scale (VAS). The transducer was incorporated into a specially designed device to measure mechanical properties of the heel pad. Evaluations were performed before injection and at 2 weeks and 3 months after injection.

SETTING

An outpatient clinic of a tertiary care center.

PATIENTS

Fourteen consecutive patients with unilateral proximal plantar fasciitis.

INTERVENTION

Ultrasound-guided injection of 7 mg betamethasone and 0.5 mL of 1% lidocaine into the inflamed proximal plantar fascia.

MAIN OUTCOME MEASURES

VAS, TT, heel pad and plantar fascia thickness, and echogenicity of the proximal plantar fascia on sonogram were assessed. Mechanical properties included unloaded heel pad thickness, compressibility index, and energy dissipation ratio.

RESULTS

Both VAS score +/- standard deviation (SD; 5.43 +/- 2.03, 1.39 +/- 2.19, 0.57 +/- 1.40 at the 3 measurements, respectively) and TT +/- SD (5.05 +/- 1.42, 9.34 +/- 1.84, 9.93 +/- 1.98 kg/cm2 at the 3 measurements, respectively) improved significantly (p < .001) after steroid injection. The mean thickness of the plantar fascia was greater in the symptomatic side than in the asymptomatic side before treatment (0.58 +/- 0.13 cm vs 0.40 +/- 0.11 cm, p < .001). The thickness had decreased significantly 3 months after injection (0.46 +/- 0.12 cm at 2 weeks, 0.42 +/- 0.10 cm at 3 months, p < .001). The hypoechogenicity at the proximal plantar fascia disappeared after steroid injection (p < .001). Mechanical properties of the heel pad did not change 3 months after steroid injection (p > .05).

CONCLUSION

Ultrasound offers an objective measurement of the therapeutic effect on proximal plantar fasciitis. Accurate steroid injection under ultrasound guidance can effectively treat proximal plantar fasciitis without significant deterioration of the mechanical properties of the heel pads.

Sick sinus syndrome in a patient with single coronary artery anomaly

Single coronary artery anomaly is very rare. The reported manifestations include angina pectoris and congestive heart failure. Here we describe a case of single coronary artery anomaly presenting as sick sinus syndrome, which has no literature precedence. A 47-year-old woman had complained of intermittent dizziness for years. A Holter electrocardiogram showed sinus bradycardia and junctional or ventricular rhythm with a maximal ventricular pause of up to 3.2 seconds. Electrophysiologic study revealed prolonged corrected sinus nodal recovery time. Coronary angiography showed that the left anterior descending artery had a long course with a side branch originating from the proximal part and coursing anteriorly to the territory of the proximal portion of the right coronary artery. The sinus node is usually supplied by the sinoatrial branch via the right coronary artery. Aortography showed that the right coronary artery ostium was absent. A permanent pacemaker was implanted and the patient was discharged in good condition. The present case suggests that coronary artery anomaly may lead to compromised blood supply to the sinus node, and hence sick sinus syndrome.

CXC chemokine receptor CXCR2 is essential for protective innate host response in murine Pseudomonas aeruginosa pneumonia

Pulmonary infection due to Pseudomonas aeruginosa has emerged as a leading cause of mortality. A vigorous host response is required to effectively clear the organisms from the lungs. This host defense is dependent on the recruitment and activation of neutrophils and macrophages. A family of chemotactic cytokines (chemokines) has been shown to participate in this protective response. In this study, we assessed the role of the ELR(+) (glutamic acid-leucine-arginine motif positive) CXC chemokines and their CXC chemokine receptor (CXCR2) in lung antibacterial host defense. The intratracheal administration of Pseudomonas to mice resulted in the time-dependent influx of neutrophils to the lung, peaking at 12 to 24 h after inoculation. The influx of neutrophils was associated with a similar time-dependent expression of the ELR(+) CXC chemokines, KC, macrophage inflammatory protein 2 (MIP-2), and lipopolysaccharide-induced CXC chemokine (LIX). Selective neutralization of MIP-2 or KC resulted in modest changes in neutrophil influx but no change in bacterial clearance or survival. However, neutralization of CXCR2 resulted in a striking increase in mortality, which was associated with a marked decrease in neutrophil recruitment and bacterial clearance. Conversely, the site-specific transgenic expression of KC resulted in enhanced clearance of bacteria after Pseudomonas challenge. This study indicates that ELR(+) CXC chemokines are critical mediators of neutrophil-mediated host defense in Pseudomonas pneumonia.

Effect of atrial fibrillation on pulmonary venous flow patterns assessed by Doppler transesophageal echocardiography

STUDY OBJECTIVES

To investigate the effect of atrial fibrillation (AF) on pulmonary venous flow (PVF) patterns in a cohort with nonrheumatic AF.

DESIGN AND SETTINGS

A prospective and controlled study undertaken at a tertiary referral medical center.

PATIENTS AND MEASUREMENTS

The echocardiographic parameters of left superior PVF as assessed by Doppler transesophageal echocardiography in 40 patients with chronic AF (group 1) were compared to those of 33 volunteers with sinus rhythm (group 2) and well-matched baseline characteristics.

RESULTS

: All group 1 patients presented with single systolic forward flow (SFF) patterns. In contrast, single and double SFF patterns were found equally in group 2. With regard to reverse flow (RF), most group 1 patients (33 of 40) had an early systolic RF and none had atrial RF; however, most group 2 subjects (29 of 33) had an atrial RF. Some of the group 1 patients (17%) had a late systolic RF in the absence of significant mitral regurgitation. In group 1, the SFF appeared later and disappeared earlier than in group 2. The mean systolic peak velocity and time-velocity integral (TVI) of the SFF were significantly lower in group 1 compared to group 2. The diastolic peak velocity and TVI were not significantly different between groups.

CONCLUSIONS

: Our data indicate that AF independently and significantly affects the PVF and leads to characteristic flow patterns different from sinus rhythm. The presence of AF reduces SFF in addition to the absence of atrial RF. These changes in the flow patterns should be taken into account while interpreting the implications of PVF in the presence of AF.

Characterization of the inhibition of DNA synthesis in proliferating mink lung epithelial cells by insulin-like growth factor binding protein-3

Insulin-like growth factor binding protein-3 (IGFBP-3) can inhibit cell growth by directly interacting with cells, as well as by forming complexes with IGF-I and IGF-II that prevent their growth-promoting activity. The present study examines the mechanism of inhibition of DNA synthesis by IGFBP-3 in CCL64 mink lung epithelial cells. DNA synthesis was measured by the incorporation of 5-bromo-2'-deoxyuridine, using an immunocolorimetric assay. Recombinant human IGFBP-3 (rh[N109D,N172D]IGFBP-3) inhibited DNA synthesis in proliferating and quiescent CCL64 cells. Inhibition was abolished by co-incubation of IGFBP-3 with a 20% molar excess of Leu(60)-IGF-I, a biologically inactive IGF-I analogue that binds to IGFBP-3 but not to IGF-I receptors. DNA synthesis was not inhibited by incubation with a preformed 1:1 molar complex of Leu(60)-IGF-I and IGFBP-3, indicating that only free IGFBP-3 inhibits CCL64 DNA synthesis. Inhibition by IGFBP-3 is not due to the formation of biologically inactive complexes with free IGF, since endogenous IGFs could not be detected in CCL64 conditioned media; any IGFs that might have been present could only have existed in inactive complexes, since endogenous IGFBPs were present in excess; and biologically active IGFs were not displaced from endogenous IGFBP complexes by Leu(60)-IGF-I. After incubation with CCL64 cells, (125)I-IGFBP-3 was covalently cross-linked to a major thick similar400-kDa complex. This complex co-migrated with a complex formed after incubation with (125)I-labeled transforming growth factor-beta (TGF-beta) that has been designated the type V TGF-beta receptor. (125)I-IGFBP-3 binding to the thick similar400-kDa receptor was inhibited by co-incubation with unlabeled IGF-I or Leu(60)-IGF-I. The ability of Leu(60)-IGF-I to decrease both the inhibition of DNA synthesis by IGFBP-3 and IGFBP-3 binding to the thick similar400-kDa receptor is consistent with the hypothesis that the thick similar400-kDa IGFBP-3 receptor mediates the inhibition of CCL64 DNA synthesis by IGFBP-3.

Cytokines as targets of immunotherapy in bacterial pneumonia

The generation of a vigorous inflammatory response is essential for the rapid clearance of microbes from the alveolar space. The magnitude of the inflammatory response is tightly controlled by host-derived cytokines, which mediate lung inflammation by serving as leukocyte chemoattractants, leukocyte activating factors, or afferent signals in the induction or regulation of other effector molecules. In this article the role of specific cytokines in lung innate immunity will be reviewed. Future directions regarding the use of specific forms of immunotherapy, including compartmentalized cytokine delivery with gene therapy as adjuvant therapy in the treatment of pneumonia, will be explored.

G-33A mutation in the promoter region of thrombomodulin gene and its association with coronary artery disease and plasma soluble thrombomodulin levels

Thrombomodulin is an endothelial glycoprotein that decreases thrombin activity and activates protein C. A recent study has shown that G-33A promoter mutation of the thrombomodulin gene occurs particularly in Asians. In this study, we analyzed the distribution of G-33A mutation in the promoter region of the thrombomodulin gene in the Chinese population and determined whether the mutation might be a risk for coronary artery disease (CAD). In addition, the influence of this mutation on plasma soluble thrombomodulin levels in patients with CAD was also examined. We studied 320 consecutive patients (mean age 63 years; 73% men) with CAD and 200 age- and sex-matched control subjects. Screening for thrombomodulin G-33A promoter mutation was conducted using polymerase chain reaction, single-strand conformation polymorphism, and direct deoxyribonucleic acid sequencing. The frequency of the G-33A mutation (GA+AA genotypes) was significantly higher in the CAD group (23.8% vs 15.5%, odds ratio [OR] 1.70, p = 0.031). Multiple logistic regression analysis showed that the mutation was an independent risk factor (OR 1.81, p = 0.016) for CAD, as was hypertension (OR 1.44, p = 0.040), diabetes mellitus (OR 2.50, p <0.001), and smoking (OR 2.15, p <0.001). In CAD patients with GG genotype, the soluble thrombomodulin level increased with the extent of CAD (36 +/- 15 vs 47 +/- 18 vs 55 +/- 36 ng/ml in 1-, 2-, or 3-vessel CAD, p <0.001). However, in CAD patients with G-33A mutation, there was no difference between the levels of soluble thrombomodulin (39 +/- 17 vs 37 +/- 15 vs 42 +/- 18 ng/ml, p = NS) in 1-, 2-, or 3-vessel CAD. Our observations suggest that there is a significant association of the G-33A mutation in thrombomodulin gene with CAD, and this mutation may influence the soluble thrombomodulin levels in patients with CAD.

Correlation of homocytsteine levels with the extent of coronary atherosclerosis in patients with low cardiovascular risk profiles

Elevation of homocysteine is now known as an independent risk factor for vascular diseases. However, influences of homocysteine to the extent of coronary atherosclerosis in patients with different coronary risk profiles have not been studied. In this study, we used angiographic "diffuse score" and "clinical vessel score" to evaluate the extent of coronary atherosclerosis, and examined the correlation between levels of serum total homocysteine and angiographic scores among patients with high- and low-risk profiles. Seventy consecutive patients (58 men and 12 women, mean age 50 years) undergoing selective coronary angiography for the first time were recruited for this study. Patients were divided into high-risk (risk factor > or =3, n = 35) and low-risk (risk factor <3, n = 35) groups. Linear regression analysis revealed that levels of serum homocysteine were only significantly correlated with diffuse (r = 0.217, p = 0.007) and clinical vessel (r = 0.078, p = 0.037) scores in low-risk patients. These correlations could not be observed in diffuse (r = 0.070, p = 0.319) and clinical vessel (r = -0.001, p = 0.970) scores in the high-risk group. In conclusion, levels of homocysteine correlated with the extent of coronary atherosclerosis only among patients with low cardiovascular risk profiles.

CXC chemokine receptor-2 ligands are necessary components of neutrophil-mediated host defense in invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis is a devastating complication of immunosuppression, which occurs in association with neutrophil dysfunction or deficiency. ELR+ CXC chemokines are a subfamily of chemokines that play a critical role in neutrophil chemotaxis and activation both in vitro and in vivo. We hypothesized that interaction of these ligands with CXC chemokine receptor-2 (CXCR2), their sole murine receptor, is a major component of neutrophil-dependent pulmonary host defense against Aspergillus fumigatus. In immunocompetent animals, neutrophils were recruited to the lung in response to intratracheally administered A. fumigatus conidia. In a model of transient in vivo depletion of neutrophils, animals developed invasive pulmonary aspergillosis, associated with delayed influx of neutrophils into the lung. In both normal and neutrophil-depleted animals, the ELR+ CXC chemokines MIP-2 and KC were induced in response to intratracheal administration of conidia. Ab-mediated neutralization of the common ELR+ CXC chemokine receptor, CXCR2, resulted in development of invasive disease indistinguishable from the disease in neutrophil-depleted animals, while control animals were highly resistant to the development of infection. CXCR2 neutralization was associated with reduced lung neutrophil influx and resulted in a marked increase in mortality compared with controls. In contrast, animals with constitutive lung-specific transgenic expression of KC were resistant to the organism, with reduced mortality and lower lung burden of fungus. We conclude that CXCR2 ligands are essential mediators of host defense against A. fumigatus, and may be important targets in devising future therapeutic strategies in this disease.

The mechanical properties of the heel pad in unilateral plantar heel pain syndrome

Plantar heel pain syndrome has been attributed to entrapment neuropathy, plantar fasciitis, calcaneal spurs, and stress fractures of the calcaneus. Although deteriorated mechanical properties of the heel pads may play an important role in the pathogenesis of heel pain syndrome, this has received little notice. In this study, a specially designed compression relaxation device with a push-pull scale and a 10-MHz linear array transducer was used to determine thickness of the heel pad under different loading conditions. Twenty consecutive patients aged 29 to 77 years with unilateral plantar heel pain syndrome were enrolled. Thickness of heel pad bilaterally was measured when the heel pad was compressed by serial increments of 0.5 kg to a maximum of 3 kg and then relaxed sequentially. The load-displacement curve during a loading-unloading cycle was plotted, and the compressibility index and energy dissipation ratio of the heel pad were calculated accordingly. Phase I displacement of the heel pad (from 0 to 1 kg load) on the painless side was greater than that on the painful side (P < 0.01), but there was no statistically significant difference between painless and painful sides in thickness of unloaded heel pads, compressibility index, or energy dissipation ratio (P > 0.05). In conclusion, the affected heel pad in plantar heel pain syndrome was stiffer under light pressure than the heel pad on the painless side. The changed nature of chambered adipose tissue in a painful heel pad may be responsible for its increased stiffness under light pressure.

HLA-DMA and HLA-DMB genotyping in patients with systemic lupus erythematosus

OBJECTIVE. To investigate the relation of HLA-DMA and DMB alleles to the development of systemic lupus erythematosus (SLE).

METHODS

We studied HLA-DMA and DMB alleles in 108 patients with SLE and 138 healthy controls using the amplification created restriction site method.

RESULTS

The phenotypic frequency of HLA-DMA*0104 was significantly higher in patients with SLE than in healthy controls. The HLA-DMA and DMB alleles were not related to clinical manifestations and various laboratory tests in patients with SLE.

CONCLUSION

HLA-DMA*0104 may be associated with the susceptibility of SLE.

Pulmonary artery leiomyosarcoma

Pulmonary artery leiomyosarcoma is a rare but highly lethal disease, and can be mistaken for pulmonary thromboembolism. We report a case of pulmonary artery leiomyosarcoma managed with surgical resection, chemotherapy, and radiotherapy. A 57-year-old woman was admitted with complaints of aggravated dyspnea. She was initially treated with oxygen therapy and heparinization for a suspected pulmonary embolism. Echocardiography revealed a dilated right atrium and ventricle and severe tricuspid regurgitation, with an estimated systolic right ventricular pressure of 95 mm Hg; a shadow of a mass in the main pulmonary artery was also noted. Right ventriculography revealed a filling defect, and to-and-fro motion of the mass in the main pulmonary artery. The left pulmonary artery was almost totally occluded by the mass. The patient's condition improved dramatically after palliative excision of the mass and patch reconstruction of the outflow tract of the right ventricle with a bicuspid xenograft. Pathologic examination of the mass revealed leiomyosarcoma. Chemotherapy and radiotherapy were subsequently administered and follow-up imaging studies 3 months postoperatively revealed no recurrence of the tumor. The patient remains well, more than 1 year after treatment. This report emphasises that pulmonary artery sarcoma should be considered in the differential diagnosis in cases of suspected pulmonary thromboembolism.

Prognostic determinants of infective endocarditis in the 1990s

The clinical profiles of infective endocarditis (IE) might have changed in recent years, owing to the advent of transesophageal echocardiography, the introduction of new diagnostic criteria, and the increased frequency of intravenous drug abuse. In this retrospective study, we sought to identify factors affecting the in-hospital outcome of IE patients in a single tertiary referral center in the 1990s (1990-1997). Eighty-eight episodes of IE in 80 consecutive patients admitted from January 1990 through June 1997 were evaluated. Clinical variables that were significantly associated with in-hospital mortality in univariate analyses were entered into a multiple logistic regression model. A total of 22 patients (25%) died. Fatal episodes were significantly more likely than non-fatal episodes to involve older patients (> or = 50 years), use of coumadin, short interval between symptom onset and hospitalization (< 15 days), noncardiac shock, and complications of the heart, central nervous system, and kidneys. White blood cell counts and C-reactive protein concentrations were also significantly higher in fatal than in non-fatal episodes of IE. Multivariate analysis showed that in-hospital mortality was associated with noncardiac shock, neurological complications, cardiac complications, and older age (> or = 50 years). Compared with previous reports, our findings suggest that the clinical profiles of IE have undergone some changes in the 1990s. The most important prognostic predictors of in-hospital mortality in patients with IE were noncardiac shock and neurologic complications.

HLA-DMA and HLA-DMB genotyping in patients with rheumatic diseases

To investigate the correlation of HLA-DMA and DMB alleles to some rheumatic diseases, HLA-DMA and DMB genes were detected in 11 patients with juvenile rheumatoid arthritis (JRA), 22 patients with psoriatic arthritis, 26 patients with Behcet's disease, 62 patients with ankylosing spondylitis (AS), and 138 unrelated healthy controls. There was no significant difference in phenotypic frequencies of HLA-DMA and DMB alleles between controls and patients with these rheumatic diseases. HLA-DMA and DMB genes are not related to the susceptibility of JRA, psoriatic arthritis, Behcet's disease, and AS.

Prognostic significance of elevated hemostatic markers in patients with acute myocardial infarction

OBJECTIVES

The purpose of this study was to determine whether the elevated levels of hemostatic markers in the early phase of myocardial infarction may serve as risk factors for subsequent cardiac mortality.

BACKGROUND

Increased plasma hemostatic markers were noted in acute myocardial infarction, indicating that the blood coagulation system is highly activated in those patients. However, there are few clinical data concerning the association between the elevated hemostatic markers and survival in patients with myocardial infarction.

METHODS

Blood samples were obtained from 64 patients (mean age 67 +/- 11 years; 49 male) with acute myocardial infarction within 12 h after the onset of symptoms and before the initiation of any antithrombotic treatment. We measured plasma concentrations of fibrinopeptide A (FPA), prothrombin fragment 1+2 (F1+2) and thrombin-antithrombin complex (TAT) using the enzyme-linked immunosorbent assay method, and examined the associations between the level of these markers and survival with Cox proportional hazards models.

RESULTS

The follow-up time was 27 +/- 17 months, and 19 patients died of cardiac causes during the follow-up. Univariate survival analysis identified Killip class IV (hazard ratio 4.86; 95% confidence interval [CI] 1.55-15.19), left ventricular ejection fraction (hazard ratio 0.94; 95% CI 0.90-0.99), FPA (hazard ratio 1.54; 95% CI 1.13-2.10), F1+2 (hazard ratio 2.03; 95% CI 1.17-3.53) and TAT (hazard ratio 1.88; 95% CI 1.27-2.79) as significant factors associated with cardiac mortality. In multivariate analyses, only FPA level (hazard ratio 1.84; 95% CI 1.03-3.30) and left ventricular ejection fraction (hazard ratio 0.93; 95% CI 0.88-0.98) were independent predictors of cardiac mortality.

CONCLUSIONS

Elevated FPA in the early phase of myocardial infarction identifies patients with increased risk for subsequent cardiac death. This association appears to be independent of residual left ventricular function after infarction.

Prognostic value of Doppler-derived mitral deceleration time in postinfarction patients with left ventricular ejection fractions of 35% or more

Short Doppler-derived mitral deceleration time of early filling has been proved to be an independent predictor of poor prognosis in patients with left ventricular dysfunction. However, the prognostic value of Doppler-derived mitral deceleration time in postinfarction patients without overt left ventricular dysfunction is poorly understood. A total of 27 survivors of acute myocardial infarction with left ventricular ejection fractions of 35% or more, as determined by radionuclide ventriculography, were prospectively studied. Doppler study was performed 5 to 7 days after the index infarction. The patients were divided into two groups. Group A included 10 patients whose mitral deceleration time was 125 msec or less and group B consisted of 17 patients whose mitral deceleration time was 125 msec or more. The two groups were similar in terms of age and gender distribution and there were no statistically significant differences in coronary risk factors, peak creatine kinase concentration, location of infarction, Killip classification, thrombolytic therapy, left ventricular ejection fraction, or medications. After a mean follow-up period of 30 months, the rate of congestive heart failure (New York Heart Association, NYHA, class II or above) was significantly higher in group A (5/10) than in group B (1/17) (p < 0.01). These results suggest that a short mitral deceleration time could be a useful early predictor of the potential development of future congestive heart failure in postinfarction patients with left ventricular ejection fractions of 35% or more.

Identification of Enterobacteriaceae bacteria by direct matrix-assisted laser desorptiom/ionization mass spectrometric analysis of whole cells

Several members of Enterobacteriaceas were analyzed by matrix-assisted laser desorption ionization (MALDI) time-of-flight mass spectrometry (TOFMS). Characteristic mass spectral peaks and patterns were observed in the mass range of 2 to 20 kDa. The mass peaks reported to be reproducibly observed by previous researchers, which were claimed to serve as species/strain-specific biomarkers, are consistently observed in our current study. Despite the high degree of similarity found in the MALDI mass spectra within the enteric bacteria, minor yet notable differences existed to allow their differentiation. Five spectral peaks at m/z 4364, 5380, 6384, 6856, and 9540, generated reproducibly for each genus studied here, are assigned as family-specific biomarkers for the Family Enterobacteriaceae. The mass peaks at m/z 7324, 7724, 9136, and 9253 are assigned as genus-specific biomarkers for Salmonella. Some unique biomarkers characterizing the species and strains of E. coli are also presented.

Decreased left atrial appendage function is an important predictor of elevated left ventricular filling pressure in patients with congestive heart failure

OBJECTIVE

The aim of this study was to investigate whether left atrial (LA) appendage function, as indicated by LA appendage blood flow velocities and its ejection fraction, could identify elevated left ventricular filling pressure in patients with chronic congestive heart failure.

METHODS

Using transesophageal echocardiography, adequate pulsed Doppler LA appendage active emptying and filling velocities could be recorded in 25 consecutive patients (16 men and 9 women, aged 57+/-10 years) with chronic congestive heart failure (symptom duration > or =1 year). LA appendage ejection fraction calculated as (LA appendage maximal area)-(LA appendage minimal area)/(LA appendage maximal area) x 100 was also determined in these patients. Left ventricular end-diastolic pressure was recorded during cardiac catheterization performed within 24 h of echocardiographic study.

RESULTS

Left ventricular end-diastolic pressure was 2 to 47 mm Hg. There were close negative correlations of LA appendage emptying velocity (r=-0.508; P<0.01), filling velocity (r=-0.429; P<0.05) and LA appendage ejection fraction (r=-0.523; P<0.005) with left ventricular end-diastolic pressure. LA appendage active emptying velocity <30 cm/s predicted left ventricular end-diastolic pressure >25 mm Hg with a sensitivity of 72.7%, a specificity of 92.9% and a positive and negative predictive value of 88.9 and 81.3%.

CONCLUSIONS

The findings suggest that measurement of LA appendage blood flow velocities and contractile function by transesophageal echocardiography can be used to predict elevated left ventricular filling pressure in patients with congestive heart failure.

Liquid ventilation in an infant with pulmonary alveolar proteinosis

Partial liquid ventilation (PLV) has been applied in various pulmonary diseases. We describe the use of partial liquid ventilation as a lavage method following normal saline (NS) lavage in an infant with pulmonary alveolar proteinosis (PAP) and severe hypoxemia. A 6 weeks old 3.4 kg former 36 weeks gestation boy on supplemental oxygen was transferred to our NICU with persistent tachypnea, dry cough, and increasing oxygen requirements. A lingular open lung biopsy revealed PAP. He developed progressive respiratory failure requiring ventilatory support, necessitating conventional NS lavage, followed by lung lavage with perflubron (LiquiVent; Alliance Pharmaceutical Corp. and Hoechst Marion Roussel) while on venovenous extracorporeal life support (ECLS). Lung lavage with NS and perflubron yielded minimal cloudy effluent. Gas exchange and pulmonary function deteriorated following NS lavage and attempts to discontinue ECLS were poorly tolerated. In contrast, tidal volume, PaO2, and pulmonary compliance increased after PLV, while the (A-a) D(O2) decreased to a point where ECLS was no longer required. Once perflubron was added repeatedly to the ventilator circuit to correct for evaporation over the 4 days of PLV. Cardiovascular status remained stable for several days; however, eventually he required reinitiation of ECLS and more mechanical ventilatory support with each trial off ECLS. He was maintained on high pressures and FiO2 without any possibility to wean him from mechanical ventilation. Life support was withdrawn 1 month after admission. The survival from PAP in infants remains dismal, even with total lung NS lavage. While both NS and perflubron lavage in this patient were not effective in removing the proteinaceous alveolar debris, PLV following NS lavage was associated with an improvement in gas exchange and lung compliance.

Genetic analysis of interleukin-10 promoter region in patients with systemic lupus erythematosus in Taiwan

Overproduction of interleukin-10 (IL-10) may play an important role in the development of systemic lupus erythematosus (SLE) or lupus nephritis. There is also a polymorphic dinucleotide repeat in the human IL-10 promoter region (IL-10PR). Our aim was to study whether or not the IL-10PR alleles contributed to the susceptibility to SLE or lupus nephritis. One hundred SLE patients and 103 healthy controls were studied for IL-10PR by PCR and electrophoretic analysis. The distribution of IL-10PR alleles, genotypes and the sum of both alleles (SBA) from different groups or subgroups were analyzed. SLE patients showed no difference in the distribution of IL-10PR alleles, genotypes and SBA, as compared to healthy controls. Lupus nephritis patients (N = 49) also showed no difference in IL-10PR alleles, genotypes and SBA, as compared to SLE patients without nephritis (N = 51). Of 49 lupus nephritis patients, ten developed end-stage renal disease (ESRD) and four of them were found to suffer from rapid progressive renal failure (RPRF). Patients with RPRF presented much smaller SBA than other ESRD patients (p = 0.005). Lupus nephritis patients carrying small SBA (< 18) suffered from a higher prevalence of RPRF than lupus nephritis patients without small SBA (50% V.S. 0%, p < 0.001, relative risk 82). Our data provide the first evidence of a strong association between IL-10PR and severe progression of lupus nephritis in human patients. In the future, a prospective genetic analysis of IL-10PR for patients with lupus nephritis is recommended. It might be helpful for physicians to identify the lupus nephritis subgroup with a high risk of developing RPRF early, because this might lead to a better therapy and prognosis for these patients.

Use of fluorescein labelled antibody and fluorescence activated cell sorter for rapid identification of Mycobacterium species

A fluorescein labelled antibody (Ab)/Fluorescence Activated Cell Sorter (FACS)-based assay was developed for detection of a wide range of mycobacterial species directly from bacterial culture and sputum specimens. The whole process could be completed within 3 hours and had a high specificity and sensitivity for cultured bacteria. The method was also shown to be applicable for direct identification from clinical specimens. This study showed that pretesting of clinical specimens for mycobacteria to the genus level with an antibody to Mycobacterium species offers the routine clinical laboratory a single convenient test for the detection of tuberculous and nontuberculous mycobacteria. Depending on the availability of species-specific antibody, the identification of Mycobacterium to the species level can be achieved.

Treatment of emotionalism with fluoxetine during rehabilitation

Emotionalism (emotional lability) is a common but distressing phenomenon that occurs frequently in individuals suffering cerebral vascular accidents and other brain diseases. Patients with emotionalism sometimes embarrass their families and themselves, becoming socially disabled despite normal physical function. At its worst, emotionalism interferes with rehabilitation programs, delays progress and sometimes makes these programs impossible. This paper reports the effect of fluoxetine in treating three patients with persistent emotionalism (2 cases following cerebrovascular accidents, 1 case following encephalitis). All 3 patients demonstrated dramatic improvement in emotionalism within 6 days of treatment. The severity, frequency and duration of each episode were reduced greatly. The treatment improved the effectiveness of the rehabilitation program, relieved patient and family embarrassment, and enabled patients to resume rapidly their previous lifestyle patterns. All patients reached the functional goals planned prior to the onset of rehabilitation. We conclude that fluoxetine is highly effective in treating the symptoms of emotionalism in all patients, and allows for recovery of both physical and social function.