Case report: life-threatening haematochezia from a jejunal leiomyoma

Leiomyoma is a common benign intestinal tumour. Melaena is not rare in this tumour. Recently, rectal haematochezia has been considered as one of the very rare manifestations of leiomyoma. We report a case of jejunal leiomyoma showing life-threatening rectal bleeding. This 76-year-old man was admitted to hospital because of continuous rectal bleeding for 2 days. Haemorrhagic shock occurred and transfusion of 27 units of packed red blood cells failed to correct the shock. Emergent superior mesenteric angiography revealed a distal jejunal tumour showing evidence of active oozing. Segmental intestinal resection was performed to remove this jejunal tumour. Final pathological examination disclosed a jejunal leiomyoma with a ruptured artery responsible for the life-threatening bleeding. The patient recovered after tumour resection. Our presenting case was probably the second case of jejunal leiomyoma showing haematochezia. The diagnostic priority is discussed.

Bacterial meningitis and lumbar epidural hematoma due to lumbar acupunctures: a case report

A 48-year-old female expressed signs of meningeal irritation after having received several lumbar acupunctures within one week for back pain. Bacterial meningitis was diagnosed from cerebrospinal fluid examinations. Magnetic resonance image (MRI) of spine at admission demonstrated a fusiform lesion with characters of subacute hematoma in the epidural space of the first and second lumbar level. She received antibiotics treatment only and recovered from her central nervous system infection completely. The epidural lesion disappeared spontaneously in the MRI follow up three weeks later. We report the diagnosis and follow-up of epidural hematoma of the lumbar spine by MRI which aided the medical physician to treat meningitis attentively.

Surgical treatment and its long-term result for caustic-induced prepyloric obstruction

OBJECTIVE

To present our long-term results of the treatment of caustic-induced prepyloric obstruction, and to set out guidelines for the management of such patients.

DESIGN

Retrospective study.

SETTING

General hospital (medical centre), Taiwan.

SUBJECTS

30 patients (8 male and 22 female, mean age 34 years, range 13-62) who developed prepyloric obstruction out of 271 treated for caustic injuries of the upper gastrointestinal tract.

INTERVENTIONS

Gastrojejunostomy (n = 24), antrectomy and Billroth I reconstruction (n = 4), and antrectomy and Billroth II reconstruction (n = 2). Four patients required second operations: oesophageal reconstruction for stricture (n = 3), and gastrojejunostomy for restenosis of Billroth I anastomosis (n = 1).

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

No patient died postoperatively, and there were three complications--wound infection, internal bleeding, and stenosis of the Billroth I anastomosis. 21 patients were able to enjoy their normal diet postoperatively, 5 required periodic dilatation of oesophageal strictures, and 4 required further operations.

CONCLUSIONS

Gastrojejunostomy gives good long term results as long as there is no oesophageal stricturing, and morbidity and mortality are low. The long term outcome is dependent on the degree of oesophageal involvement.

Rapid spongiform degeneration of the cerebrum and cerebellum in Creutzfeldt-Jakob encephalitis: serial MR findings

We report the cerebral MR imaging findings in a patient with pathologically proved Creutzfeldt-Jakob disease in whom predominant gray and white matter degeneration was seen within 1 year of symptom onset. The initial MR signal abnormalities in the basal ganglia were subtle. A follow-up MR examination revealed diffuse cerebral and cerebellar atrophy and demyelination.

Value of ultrasonically guided needle biopsy of pleural masses: an under-utilized technique

Thirty-six patients with pleural masses underwent ultrasonically guided needle biopsy (UGNB), including ultrasonically guided aspiration biopsy (UGAB) in all 36 patients and ultrasonically guided cutting biopsy (UGCB) in 13 patients. Using UGAB alone, the diagnostic rate for pleural masses was 64% (23/36); carcinomatous pleural masses were more easily diagnosed than non-carcinomatous pleural masses (87% vs 23%, p < 0.01). If both UGAB and UGCB were used, the diagnostic rate was 89% (32/36); thus, selective UGCB was valuable in improving the diagnostic rate of non-carcinomatous pleural masses (from 23% to 69%). In patients with pleural effusions (n = 19), 11 underwent cytologic examinations of the pleural effusion (3 also undergoing pleural biopsy) without conclusive diagnosis; however, the diagnosis was made from pleural masses by UGAB (n = 7) or UGCB (n = 4). In patients without pleural effusions (n = 17), 12 had only pleural masses (3 also having multiple peripheral pulmonary nodules and 4 having mediastinal tumors) and could not be diagnosed by conventional bronchoscopic and sputum examinations. However, the diagnosis was rapidly confirmed by UGAB (n = 5) or UGCB (n = 3) from the pleural masses in 8 patients. We conclude that UGNB is a useful and valuable diagnostic tool, not only detecting the pleural masses hidden by pleural effusions but also for rapidly diagnosing the pleural masses.

Optic atrophy and cerebral infarcts caused by methanol intoxication: MRI

We present the MRI findings of cerebral and optic pathway damage in the acute and subacute stages of methanol intoxication. In the acute stage, CT and MRI showed bilateral haemorrhagic necrosis of the corpus striatum and infarcts in the anterior and middle cerebral arterial territories. MRI in the subacute stage demonstrated atrophy of the optic chiasm and prechiasmatic optic nerves in addition to the cerebral infarcts. The patient survived, with total blindness.

Hyperbaric oxygen in the treatment of diabetic foot infection

BACKGROUND

Although hyperbaric oxygen therapy to treat diabetic foot lesions has been approved for insurance reimbursement in Taiwan, its clinical application has not yet been well accepted. This study evaluated multiple healing predictive factors in patients with diabetic foot infections to determine the usefulness of adjunctive hyperbaric oxygen in the treatment of such patients.

METHODS

From March 1995 to May 1996, we treated 31 diabetic patients presenting with infected foot lesions with a regimen of adequate metabolic control, frequent wound debridement and hyperbaric oxygen therapy. Age, gender, leukocyte count, total lymphocyte count, hemoglobin, erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), glycosylated hemoglobin Alc (HbAlc), albumin, ankle-brachial index, types of bacterial cultures and number of debridements were compared between successful and failed treatments. Independent t-test and Fisher's exact test were used to identify the prognostic factors associated with outcome of treatment.

RESULTS

The mean age of the patients was 63.0 +/- 9.7 years (range 43 to 81). The mean number of hyperbaric oxygen therapies was 35.3 +/- 21.8 treatments (range 5 to 83). Of the 31 patients, 6 received below knee amputation, and 25 had their foot preserved or achieved a lower level of amputation. Elevated leukocyte count and low ankle-brachial index were significantly related to poor outcome.

CONCLUSIONS

In the treatment of diabetic foot infection, adjunctive hyperbaric oxygen therapy seems to be a useful tool to enhance wound healing provided that there are preserved circulation and controlled infection.

Plasmid virulence gene expression induced by short-chain fatty acids in Salmonella dublin: identification of rpoS-dependent and rpo-S-independent mechanisms

The Salmonella plasmid virulence spvABCD genes are growth phase regulated and require RpoS for maximal expression in stationary phase. We identified a growth phase-independent expression of spv which is mediated by short-chain fatty acids. During this fatty acid-mediated expression of spv, RpoS is required for induction only during exponential phase. In stationary phase, an rpoS-independent mechanism is responsible for expression of spv.

Clinical assessment of the bacterial load of Helicobacter pylori on gastric mucosa by a new multi-scaled rapid urease test

The present study tests the efficacy of the multi-scaled urease test (MUT) in detecting Helicobacter pylori infection and determines whether the MUT can predict the bacterial density on histology. A total of 111 sets of gastric specimens were obtained from patients with dyspepsia but without recent bleeding. Two biopsies were taken as closely as possible in each set. One sample was used for the MUT (Hp fast; GI Supply, Camp Hill, PA, USA), while the other was used to determine the histological density of H. pylori by modified Giemsa stain (grade 0-5). The results of MUT were interpreted as negative if the colour was yellow or bright green (reaction score 0) and positive if the colour was green, light blue, or blue (reaction score 1, 2 and 3, respectively). The reaction scores of MUT were recorded sequentially at 15 and 30 min and 1, 4 and 24 h. On the basis of histological confirmation, MUT had a sensitivity of 89.6%, a specificity of 88.2%, a positive predictive value of 94.5% and a negative predictive value of 78.9%. Focusing on specimens with the presence of bacteria under histology, 77 specimens were divided into five subgroups by grades of density of H. pylori (HPD1-5). The reaction scores had become sequentially elevated from 30 min through to 24 h in each subgroup. For subgroups HPD4 and 5, the positive rates of MUT were 70.6 and 66.6%, respectively, as early as 30 min and progressed to 100% within 4 h. In contrast, the positive rate for the HPD1 subgroup was 16.6% at 4 h and increased to only 62.5% at 24 h. In subgroups HPD 2 and 3, the positive rates were less than 30% at 30 min, but became more than 66.6% at 4 h and were 100% at 24 h. The early (i.e. mean value of reaction scores before 4 h) and late (24 h) mean reaction scores disclosed two elevated trends as the density of H. pylori increased (early: 0.2, 0.7, 0.8, 1.5, 1.2; late: 1.4, 2.3, 2.6, 3.0, 3.0; P < 0.05). In conclusion, MUT is a reliable method for the diagnosis of H. pylori infection. It can also indirectly predict the density of H. pylori on histology.

Implications of Helicobacter pylori serological titer for the histological severity of antral gastritis

BACKGROUND AND STUDY AIMS

We attempted to determine whether the serological titer of anti-Helicobacter pylori (HP) immunoglobulin (IgG) would be capable of predicting the presence of ulcer, or would correlate with the histological grading of gastritis in patients with dyspepsia.

PATIENTS AND METHODS

One hundred eighty-three dyspeptic patients were prospectively included in the study after panendoscopy. Each patient underwent blood sampling for anti-HP IgG titer, and antral biopsy for both a rapid urease test (CLO) and histology. The severity of antral gastritis was semi-quantitated for acute and chronic inflammation scores (range 0-3).

RESULTS

The HP findings were positive in 157 patients (85.5%), and their histological inflammation scores and serological titer were higher than those of HP-negative patients (P < 0.05). Based on the endoscopic findings, these 157 patients were classified into ulcer (n = 109) and non-ulcer dyspepsia (n = 48) subgroups. The mean chronic inflammation score in the ulcer subgroup was higher than that in the non-ulcer dyspepsia subgroup (1.77 vs. 1.28, P < 0.001). However, on the basis of only the titer itself, there was no cut-off value for serological titer to predict the presence or absence of ulcer in HP-infected patients. As the scores for either acute or chronic inflammation increased, the mean serological titer rose (acute inflammation score 0-3: 0.63, 0.78, 0.93, 1.39; chronic inflammation score 0-3: 0.18, 0.56, 0.88, 0.91).

CONCLUSIONS

The titer of HP serology does not provide a method for predicting the presence of ulcer in patients with HP infection, but may indirectly offer evidence of the severity of histological changes.

CD69 to CD3 ratio of peripheral blood mononuclear cells as a marker to monitor systemic lupus erythematosus disease activity

CD69 is an early T cell activation marker. In order to investigate whether the disease activity of systemic lupus erythematosus (SLE) is correlated with T cell hyperactivity as well as B cell hyperactivity, we measured the CD69 to CD3 ratio (CD69/CD3) of peripheral blood mononuclear cells (PBMCs) from 42 SLE patients and 18 healthy controls. To assess B cell activation, we measured the levels of anti-dsDNA, complement C3 and C4. Disease activity was assessed with the SLE disease activity index (SLEDAI) score. The mean value (+/- standard deviation) of CD69/CD3 for SLE patients (3.34 +/- 0.486) and healthy controls (0.92 +/- 0.015) were significantly different (P < 0.05). CD69/CD3, anti-dsDNA, C3 and C4 were all significantly correlated with SLEDAI (r = 0.50, 0.51, -0.68, -0.31, respectively, P < 0.05). CD69/CD3 could explain 25.4% of the variance in SLEDAI, and 6.7% of the variance that was independent of anti-dsDNA, C3 and C4. In patients with SLEDAI scores which were discordant with anti-dsDNA, C3 and C4 values, CD69/ CD3 still showed high correlation with SLEDAI. We conclude that CD69/CD3, which detects T cell activation is correlated with SLEDAI scores. Thus, T cell activation contributes part of the disease activity independent of B cell activity. This marker can complement in the estimation of disease activity when levels of anti-dsDNA, C3 and C4 fail to show good correlation.

[The present status of psychiatric consultation in Chang Gung Memorial Hospital, Keelung: a report of clinical characteristics]

One hundred and sixty three inpatients (84 males and 79 females) were referred for psychiatric consultation through the year of 1994. The referal rate (0.71%) was considerably low when compared with the rates (0.72-2.05%) reported by other hospitals in Taiwan. Most of the referrals were the patients of internal medicine (64.78%), especially the nephrology department. And the most common psychiatric diagnoses were organic mental syndrome. The primary reason of referals was suicidal attempt (evaluation of suicidal risk) (33.14%). In a general hospital, psychoactive substance use disorders and induced mental disorders tended to be an most usual task of psychiatric consultation. The rate of execution of suggested medication was 72.68%. Most psychotic patients and nearly overall suicidal patients had higher rate of execution of pharmacotherapy. The rate of follow-up compliance was 39.58%. The development of consultation-liaison psychiatry is in the initial stage in our hospital. The results of our study could provide reference in clinical practice and stimulate further investigation.

Mesial temporal dysembryoplastic neuroepithelial tumor mimicking oligodendroglioma: a case report and review of the literature

Dysembryoplastic neuroepithelial tumor (DNT) is an uncommon congenital tumor occurring in children. We report a 12-year-old boy who had a focal motor seizure involving his left face 6 months prior to admission. Preoperative computed tomography of the brain demonstrated a focal calcified tumor measuring 2.5 cm in diameter in the right temporal lobe. Initial pathological diagnosis was oligodendroglioma, and postoperative radiotherapy with a total dose of 5000 cGy in 28 fractions over 5&1/2 weeks was given. At follow-up 8 months later, neither clinical nor radiological recurrence was found. Because of the benign clinical course, a review of the surgical specimen was made, which led to the diagnosis of DNT. It is important to distinguish DNT from other tumors that have a worse prognosis. Correct diagnosis may prevent unnecessary radiotherapy or chemotherapy. The pathologic and radiologic diagnostic criteria of DNT are discussed, with a review of the literature.

Posterior bow and vanishing line signs in diagnosis of burst fractures of the spine on plain radiographs

It is not uncommon to misdiagnose a burst fracture as a wedge compression fracture initially on plain film, resulting in a late progressive deformity and neurologic damage. The purpose of this study was to analyze the sensitivity, specificity and positive predictive value of plain radiographs in the diagnosis of thoracic and lumbar burst fractures using the posterior bow (PB) and vanishing line (VL) signs. Seven independent examiners, comprising three chief orthopedic residents, two radiologic third-year residents and two emergency attending physicians (orthopedists), randomly reviewed 26 sets of admission anteroposterior and lateral thoracolumbar spine radiographs taken in association with back injuries. They were asked to decide whether patients had a burst or a wedge compression fracture. All patients had computed tomography (CT) scans for diagnostic confirmation. The overall initial sensitivity using discriminant analysis in the diagnosis of burst fractures was 80%. This increased to 90% after the examiners were requested to use the PB and VL signs. The specificity decreased slightly from 75% to 71%, while the positive predictive value remained at 88%. Overdiagnosis of wedge compression fractures as burst fractures occurred, especially when the quality of the films was not ideal. We conclude that, with careful reading, the PB and VL signs help in identifying burst fractures on the initial plain film evaluation.

A clinical study of 130 patients with biliary tract cancers and periampullary tumors

A retrospective review of 130 patients with peripheral-type cholangiocarcinomas (PTCC), hilar-type cholangiocarcinomas (HTCC), extrahepatic cholangiocarcinomas (EHCC), gallbladder cancers (GBCA), and periampullary cancers (PACA), seen at National Cheng Kung University Hospital and Tainan Municipal Hospital from June 1987 to July 1993 was performed. There were 47 (36%) HTCC, 32 (25%) PACA, 24 (19%) PTCC, 17 (13%) GBCA, and 10 (8%) EHCC patients. The distribution is completely different from that reported in western countries. These cancers mainly occur in elderly patients. HTCC and GBCA were predominantly noted in female patients. Biliary cancers in Taiwan were not related to liver fluke infestation, inflammatory bowel disease or hepatitis B virus infection. However, a close association with biliary lithiasis was found. The incidence of gallstones was 67, 39, 20, 29 and 19% for PTCC, HTCC, EHCC, GBCA and PACA, respectively. The most common presentation for PTCC and GBCA was abdominal pain, or jaundice for HTCC, EHCC and PACA. These symptoms correlate well with the location of the tumors. Among serum tumor markers, the elevation of CA19-9 was most frequent, occurring in 86% of the patients while CA125 and CEA occurred in 47% and 30% of the patients, respectively. During the course of disease, infection developed in 61% of the patients and was the main cause of death in 25%. Biliary tract infection and sepsis were the two leading manifestations and occurred in 49% and 32% of the patients, respectively. Overall survival was poor except in patients whose tumor could be completely resected.

Measurement of skin entrance exposure with a dose-area-product meter at chest radiography

Skin entrance exposure measurements obtained with a dose-area-product meter and thermoluminescent dosimeters were compared at posteroanterior and lateral chest radiography in 52 adult male patients. In a linear regression analysis of data collected in both views, values of 1.23 +/- 0.02 and 1.26 +/- 0.01 (r = .98 and .99) were found for the ratios of thermoluminescent-dosimeter and dose-are-product exposures, respectively. Skin entrance exposures from 16 mR (4.13 microC/kg) to 150 mR (38.7 microC/kg) in the posteroanterior view and 24 mR (6.19 microC/kg) to 475 mR (123 microC/kg) in the lateral view were found. Dose-area-product meters offer a rapid and accurate means to measure skin entrance exposure when the radiography field size is known.

The practice of Chinese medicine in Taiwan

This paper examines the practice of Chinese medicine in Taiwan. Using a national sample survey of Chinese medicine physicians, supplemented by another national survey of Chinese medicine hospitals and government records, the authors study the education and training background of Chinese medicine physicians, their mode of practice, their productivity measured by patient visits, and the practice characteristics of Chinese medicine hospitals. Moreover, the authors investigate the relationship between the resource input, the public health insurance contract, and the number of patient visits Chinese medicine physicians provided. Results of this study are used to make several recommendations on the appropriate way of integrating the practice of Chinese medicine into the modern health care system. Many of these recommendations may also be applicable to other countries that are contemplating integrating traditional or alternative medicine into their health care systems.

Daily exercise and gender influence arterial baroreflex regulation of heart rate and nerve activity

The influence of daily spontaneous running (DSR) and gender on the arterial baroreflex regulation of heart rate (HR) and lumbar sympathetic nerve activity (LSNA) was examined in 13 male [7 sedentary (SED) and 6 DSR] and 12 female (6 SED and 6 DSR) Sprague-Dawley rats. After 8-9 wk of DSR or SED control, all animals were chronically instrumented with right femoral venous and left carotid arterial catheters and electrodes around the lumbar sympathetic trunk. DSR resulted in an increase in heart weight-to-body weight ratio (P = 0.001) in male and female rats and resting bradycardia in male rats (P = 0.001). Arterial baroreflex function was examined by ramp increases (1.25 +/- 0.07 mmHg/s) and decreases (1.47 mmHg/s) in arterial pressure. DSR attenuated the arterial baroreflex regulation of LSNA in a similar manner in female and male rats. DSR reduced the range (32 and 29% for female and male rats, respectively), maximum (26 and 21% for female and male rats, respectively), and maximum gain (Gmax; 46 and 17% for female and male rats, respectively). In contrast, there was a gender influence on the arterial baroreflex regulation of HR. For example, SED female rats had a higher Gmax (40%) than SED male rats. Furthermore, DSR altered the arterial baroreflex regulation of HR differently in male and female rats. DSR female rats had a reduced Gmax (38%), range (25%), and maximum (12%), whereas DSR male rats had a reduced maximum (17%) and minimum (23%). These results demonstrate that DSR attenuated the arterial baroreflex regulation of LSNA in a similar manner in female and male rats. In contrast, DSR altered the arterial baroreflex regulation of HR differently in female and male rats.

Expression of Salmonella typhimurium rpoS and rpoS-dependent genes in the intracellular environment of eukaryotic cells

Adaptation to the intracellular environment of host cells is crucial for the pathogenesis of Salmonella infections. The alternative sigma factor RpoS is a global regulator of gene expression during starvation and stress conditions and is required for virulence in Salmonella spp. We have used lacZ reporter fusions to rpoS and rpoS-dependent genes to study rpoS regulation after entry of Salmonella typhimurium into macrophages and epithelial cells. The results demonstrate that expression of an rpoS::lacZ translational fusion increases rapidly in S. typhimurium after phagocytosis. Activity of RpoS also increases after bacterial entry into both macrophages and epithelial cells, as demonstrated by the induction of the rpoS-regulated genes katE and spvB. A control rpoS-independent promoter for neomycin resistance does not show significant induction after cell entry. These results demonstrate that the regulatory system mediated by RpoS in S. typhimurium is activated by the intracellular environment of eukaryotic cells.

Recruitment of the tinman homolog Nkx-2.5 by serum response factor activates cardiac alpha-actin gene transcription

We recently showed that the cardiogenic homeodomain factor Nkx-2.5 served as a positive acting accessory factor for serum response factor (SRF) and that together they provided strong transcriptional activation of the cardiac alpha-actin promoter, depending upon intact serum response elements (SREs) (C. Y. Chen, J. Croissant, M. Majesky, S. Topouz, T. McQuinn, M. J. Frankovsky, and R. J. Schwartz, Dev. Genet. 19:119-130, 1996). As shown here, Nkx-2.5 and SRF collaborated to activate the endogenous murine cardiac alpha-actin gene in 10T1/2 fibroblasts by a mechanism in which SRF recruited Nkx-2.5 to the alpha-actin promoter. Activation of a truncated promoter consisting of the proximal alpha-actin SRE1 occurred even when Nkx-2.5 DNA-binding activity was blocked by a point mutation in the third helix of its homeodomain. Investigation of protein-protein interactions showed that Nkx-2.5 was bound to SRF in the absence of DNA in soluble protein complexes retrieved from cardiac myocyte nuclei but could also be detected in coassociated binding complexes on the proximal SRE1. Recruitment of Nkx-2.5 to an SRE depended upon SRF DNA-binding activity and was blocked by the dominant negative SRFpm1 mutant, which allowed for dimerization of SRF monomers but prevented DNA binding. Interactive regions shared by Nkx-2.5 and SRF were mapped to N-terminal/helix I and helix II/helix III regions of the Nkx-2.5 homeodomain and to the N-terminal extension of the MADS box. Our study suggests that physical association between Nkx-2.5 and SRF is one way that cardiac specified genes are activated in cardiac cell lineages.

Microbial corrosion of aluminum alloy

Several microbes were isolated from the contaminated fuel-oil in Taiwan and the microbial corrosion of aluminum alloy A356-T6 was tested by MIL-STD-810E test method. Penicillium sp. AM-F5 and Cladosporium resinac ATCC 22712 had significant adsorption and pitting on the surface of aluminum alloy, Pseudomonas acruginosa AM-B5 had weak adsorption and some precipitation in the bottom, and Candida sp. AM-Y1 had the less adsorption and few cavities formation on the surface. pH of the aqueous phase decreased 0.3 to 0.7 unit for 4 months of incubation. The corrosion of aluminum alloy was very significant in the cultures of Penicillium sp. AM-F2, Penicillium sp. AM-F5 and C. resinac ATCC 22712. The major metabolites in the aqueous phase with the inoculation of C. resinac were citric acid and oxalic acid, while succinic acid and fumaric acid were the minors.

Pericerebral fluid collection: differentiation of enlarged subarachnoid spaces from subdural collections with color Doppler US

PURPOSE

To determine if the cerebral cortical vain sign seen on magnetic resonance (MR) images can be used with color Doppler ultrasound (US) to differentiate enlarged subarachnoid space from subdural collection.

MATERIALS AND METHODS

Eighteen infants with pericerebral fluid collection were prospectively examined with color Doppler US and MR imaging. Patients were classified into two groups: group A, with positive cortical vein sign (visualization of color-coded cortical veins that cross fluid collections at cerebral convexities); and group B, without the sign.

RESULTS

Positive cortical vein sign was seen at US in 12 patients (group A): nine with benign enlargement of subarachnoid spaces, two with brain atrophy, and one with meningococcal meningitis. The veins were displaced and embedded within the echogenic pia-arachnoid that surrounds the brain or were trapped in the subarachnoid spaces between the neo-membrane and cortical surface (group B, negative cortical vein sign) in four patients with meningitis, two victims of child abuse, and one patient with leukemia. Findings from subsequent MR imaging confirmed the color Doppler US findings.

CONCLUSION

Color Doppler US depiction of the cortical vain sign appears to be as effective as MR imaging in differentiating enlargement of the subarachnoid fluid space from subdural effusion.

Paradox of accessory pathway block after radiofrequency ablation in patients with the Wolff-Parkinson-White syndrome

Although pacing technique has demonstrated that the most common site of conduction block in a manifest accessory pathway (AP) was between the AP and the ventricle, most of the block sites have been found to be between the atrium and AP after successful radiofrequency ablation. Furthermore, the block site in a concealed AP after successful radiofrequency catheter ablation has not been reported in the literature, and comparisons between a manifest and concealed AP have not been performed. This study included 219 consecutive patients undergoing successful radiofrequency catheter ablation of a single AP. AP potential was recorded at the successful target site in 76 of 92 (82.6%) patients with manifest APs, and in 99 of 127 (77.9%) patients with concealed APs. All the left-sided APs (including left posteroseptal APs) were ablated by a ventricular approach, and right-sided APs (including anteromidseptal and right posteroseptal APs) were ablated by an atrial approach. The site of conduction block was determined by analyzing and comparing the local electrograms recorded before and after radiofrequency ablation at successful ablation sites. Conduction block of manifest APs was between the atrial-AP (A-AP) in 69 patients (75%) and between the AP-ventricle (AP-V) interface in 7 patients (7.6%), whereas the conduction block of concealed APs occurred between the AP-V in 90 patients (70.9%) and between the A-AP interface in 9 patients (7.1%). Neither the preablation electrogram nor electrophysiologic characteristics of APs predicted the site of conduction block. Furthermore, neither the location of the APs nor the position of the ablation catheter affected the block site. It was concluded that the most common site of conduction block during successful radiofrequency catheter ablation of a manifest and concealed AP was between the A-AP and AP-V interface, respectively, and the impedance mismatch theory explained only part of the findings.

Calcium-dependent immediate-early gene induction in lymphocytes is negatively regulated by p21Ha-ras

The induction of immediate-early (IE) response genes, such as egr-1, c-fos, and c-jun, occurs rapidly after the activation of T lymphocytes. The process of activation involves calcium mobilization, activation of protein kinase C (PKC), and phosphorylation of tyrosine kinases. p21(ras), a guanine nucleotide binding factor, mediates T-cell signal transduction through PKC-dependent and PKC-independent pathways. The involvement of p21(ras) in the regulation of calcium-dependent signals has been suggested through analysis of its role in the activation of NF-AT. We have investigated the inductions of the IE genes in response to calcium signals in Jurkat cells (in the presence of activated p21(ras)) and their correlated consequences. The expression of activated p21(ras) negatively regulated the induction of IE genes by calcium ionophore. This inhibition of calcium-activated IE gene induction was reversed by treatment with cyclosporin A, suggesting the involvement of calcineurin in this regulation. A later result of inhibition of this activation pathway by p21(ras) was down-regulation of the activity of the transcription factor AP-1 and subsequent coordinate reductions in IL-2 gene expression and protein production. These results suggest that p2l(ras) is an essential mediator in generating not only positive but also negative modulatory mechanisms controlling the competence of T cells in response to inductive stimulations.