Campylobacter jejuni lipopolysaccharides in Guillain-Barré syndrome: molecular mimicry and host susceptibility

OBJECTIVE

This study was designed to determine if the presence of specific ganglioside-like moieties in Campylobacter lipopolysaccharides (LPSs) is related to the development of Guillain-Barré syndrome (GBS), and to discover how frequently such moieties, including GM1, are present in these LPSs.

METHODS

We studied Campylobacter isolates and sera from seven patients with GBS (five acute motor axonal neuropathy, one acute inflammatory demyelinating polyneuropathy, and one Fisher's syndrome), and compared them with similar specimens from patients with Campylobacter enteritis alone.

RESULTS

All GBS patients had antiganglioside antibodies. Anti-GM1 and anti-GD1a titers were significantly elevated in post-Campylobacter GBS, both axonal and demyelinating, compared with normal control subjects or those with uncomplicated Campylobacter diarrhea. Campylobacter isolated from patients with GBS and with enteritis alone had similar ganglioside-like moieties.

CONCLUSIONS

These results indicate that patients who develop GBS respond differently to the ganglioside-like epitopes on Campylobacter than do non-GBS diarrhea patients. Our findings support a role for host susceptibility as a determinant for the outcome following Campylobacter infection. These findings have important implications for the development of vaccines against Campylobacter jejuni.

Fractal characterization of chromatin appearance for diagnosis in breast cytology

This study explores the use of fractal analysis in the numerical description of chromatin appearance in breast cytology. Images of nuclei from fine-needle aspiration biopsies of the breast are characterized in terms of their Minkowski and spectral fractal dimensions, for 19 patients with benign epithelial cell lesions and 22 with invasive ductal carcinomas. Chromatin appearance in breast epithelial cell nuclear images is demonstrated to be fractal, suggesting that the three-dimensional chromatin structure in these cells also has fractal properties. A statistically significant difference between the mean spectral dimensions of the benign and malignant cases is demonstrated. The two fractal dimensions are very weakly correlated. A statistically significant difference between the benign and malignant cases in lacunarity, a fractal property characterizing the size of holes or gaps in a texture, is found over a wide range of scales. These differences are particularly pronounced at the smallest and largest scales, corresponding respectively to fine-scale texture, indicating whether chromatin is clumped or fine, and to large-scale structures like nucleoli. Logistic regression and artificial neural network classification models are developed to classify unknown cases on the basis of fractal measures of chromatin texture. Using leave-one-out cross-validation, the best logistic regression classifier correctly diagnoses 95.1 per cent of the cases. The best neural network model can correctly classify all of the cases, but it is unclear whether this is due to overtraining. Fractal dimensions and lacunarity are useful tools for the quantitative characterization of chromatin appearance, and can potentially be incorporated into image analysis devices to assure the quality and reproducibility of diagnosis by breast fine-needle aspiration biopsy.

A parametric fitting algorithm for segmentation of cell images

This paper presents a parametric fitting algorithm for segmentation of cervical and breast cell images from cytology smears. A parametric elliptical model for cells is introduced and the parameters adjusted to fit the cell shapes while minimizing a cost function. Segmentation results of noisy human cervical cell and textured breast cell images demonstrate that the proposed parametric fitting algorithm is very successful in segmentation of images of both nonoverlapped and overlapped elliptically shaped cells.

Hepatic resection for bilobar multicentric hepatocellular carcinoma: is it justified?

BACKGROUND

Hepatic resection for multiple hepatocellular carcinomas (HCCs) involving both lobes of the liver is rarely recommended because of high operative risks and low radicality. Thus the justification of hepatic resection for bilobar multicentric HCC remains undefined.

METHODS

Two hundred eleven patients with HCC, who underwent curative hepatic resection, were studied retrospectively. The patients were divided into two groups. Group A consisted of 39 patients with bilobar (both sides of Cantlie's line) multicentric HCCs. Group B consisted of 172 patients with HCC with solitary or unilobar lesions. The backgrounds and resectional results of patients in groups A and B were compared.

RESULTS

Patients in group A usually required multiple separate liver resections and a longer operative time. However, the operative blood loss, amount of blood transfused, and operative morbidity and mortality rates were not significantly different. Patients in group A showed higher incidences of associated satellite nodules, microscopic vascular invasion, and a lack of capsules. The 6-year disease-free and actuarial survival rates of patients in groups A and B were 30.5% and 41.8% (p = 0.17) and 42.9% and 51.4% (p = 0.12), respectively. For patients in group A the presence of satellite nodules in any resected tumor was the only independent unfavorable feature that influenced the actuarial survival rate after multivariate analysis.

CONCLUSIONS

Liver resection is justified for bilobar multicentric HCCs in selected patients, if the tumors can be totally resected. Postoperative adjuvant therapies should be considered when satellite nodules are present in any resected tumor.

A prospective clinical and electrophysiologic survey of acute flaccid paralysis in Chinese children

We studied 29 children admitted to Beijing Children's Hospital (BCH) with acute flaccid paralysis between June 1991 and June 1993. Twenty-seven patients had Guillain-Barré syndrome--7 with acute inflammatory demyelinating polyneuropathy and 20 with acute motor axonal neuropathy (AMAN). Two had poliomyelitis. The most common cause of acute flaccid paralysis at BCH is the AMAN pattern of GBS.

Klebsiella pneumoniae meningitis: analysis on clinical features of thirty-two adult patients

BACKGROUND

To assess the clinical features and therapeutic outcomes of adult Klebsiella pneumoniae (KP) meningitis.

METHODS

Thirty-two adult patients with KP meningitis were included in this study. Their clinical features, the outcomes with the third generation cephalosporin (moxalactam, cefotaxime, ceftazidime) treatment and prognostic factors were analyzed.

RESULTS

These patients' diseases were predominantly community-acquired. Males outnumbered females (3:1). Diabetes mellitus (DM) was the most common underlying disease, followed by other debilitating diseases such as liver cirrhosis, neoplasm and end-stage renal disease (ESRD). Patients with spontaneous meningitis had a more fulminant course with a higher prevalence of bacteremia, shock and death (66%). Metastatic septic abscess was frequent (19%). Among the 21 patients who received initial appropriate antimicrobial therapy (IAAT), 2 took cefotaxime and 1 died; 13 took moxalactam of whom 5 died; and 6 took ceftazidime of whom 3 died. All of the other 11 patients who did not receive IAAT died.

CONCLUSIONS

The clinical features of KP meningitis are various and indistinguishable from other form of bacteria meningitis. Most of the patients with KP meningitis are associated with underlying medical problems, such as diabetes mellitus and liver cirrhosis. Many factors, including septic shock, bacteremia, high cerebrospinal fluid lactate concentration, and IAAT, might influence the prognosis. In spite of a high mortality rate, however, IAAT is mandatory to improve the overall survival rate.

Reproducibility and accuracy of interactive segmentation procedures for image analysis in cytology

The segmentation of nuclear images is a crucial step in the development of procedures using image analysis for the cytological diagnosis of cancer. The purpose of this study is to evaluate the reproducibility and accuracy of several interactive segmentation methods which can be used in this context. Four methods were studied: a thresholding-based method enabling selection of intensity histogram contrast and brightness, manual tracing with a stylus, and arc- and ellipse-fitting routines. Features of nuclear size and shape were derived from nuclei segmented on repeated occasions by several individuals. Variance component models provided a statistical framework for evaluating the intraobserver and interobserver variability of these measurements in terms of their intraclass correlation coefficients. Of the methods tested, the arc-fitting segmentation method gave the most reproducible results, and thresholding the least. Reproducibility was generally very high both between individuals and for repeated segmentations by a single individual. Accuracies of area measurements for the various methods, as determined with respect to point counting, paralleled the reproducibilities of the methods. Sample size requirements were observed to be more dependent on the biological variability of the tissue sampled than on the particular segmentation method or on the number of individuals performing segmentation.

Neuroimages of Japanese encephalitis: report of three patients

The cranial computed tomography (CT) and magnetic resonance image (MRI) studies of three Japanese encephalitis (JE) patients, 24 to 37 years of age, are reported. The initial findings of CT study were limited but initial MRI studies revealed multiple lesions involving the brainstem, basal ganglia and bilateral thalami. Follow-up MRI studies showed small residual lesions only. The result shows that MRI can delineate and detect brain lesions better than CT in patients in the acute stage of JE. The locations of lesions in MRI study are noteworthy and have a good correlation with pathologic anatomic distribution. Therefore, MRI study is helpful in early diagnosis of JE.

Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report

A case of pneumocephalus and respiratory depression after dural puncture during lumbar epidural analgesia is reported. The loss of resistance to air technique was employed to identify the epidural space. Severe respiratory depression and stuporous consciousness developed one hour after a bolus of 2 mg morphine was given epidurally at the end of operation. With computerized tomographic brain scanning and continuous observation of clinical course, the neurologic symptoms were thought to be a mixed complication of pneumocephalus and possible intrathecal morphine overdose. We suggest that in order to avoid iatrogenic pneumocephalus by inadvertent dural puncture in the attempt to identify the epidural space the use of the loss of resistance to normal saline technique or the hanging-drop technique is more reliable than the loss of resistance to air technique. A small test dose prior to a full dose is given and should not be omitted to further confirm the proper placement of the epidural catheter during epidural analgesia.

Ovarian metastasis from cervical carcinoma

OBJECTIVE

To study the prognosis and metastatic route of cervical carcinoma with ovarian metastasis.

METHOD

From 1980 to 1993, 10 of the 1507 patients with cervical carcinoma operated and who had ovarian metastasis were analyzed.

RESULTS

Six patients had squamous cell carcinomas and 4 patients had adenocarcinomas. Their mean age was 45 years. Six of 9 patients undergoing pelvic lymphadenectomy had nodal metastasis. One patient did not have nodal dissection in the treatment course. Five of 10 patients had involvement of corpus: 3 were accompanied with nodal metastasis, 1 was not and 1 other was unknown. None of our cases survived more than 5 years. Their mean survival time was 20.8 months for squamous cell carcinomas and 29 months for adenocarcinomas.

CONCLUSIONS

(1) Ovarian metastasis is histologically one of the ominous signs of cervical carcinomas regardless of stage. The prognosis of patients with ovarian metastasis from cervical squamous cell carcinoma from our data is not different from those from cervical adenocarcinoma. (2) Lymphatic spread and transtubal implantation are possible pathways of cervical cancer metastasizing to ovary, and involvement of the corpus may potentiate this mechanism.

An iterative algorithm for cell segmentation using short-time Fourier transform

In this paper, an iterative cell image segmentation algorithm using short-time Fourier transform magnitude vectors as class features is presented. The cluster centroids of the magnitude vectors are obtained by the K-means clustering method and used as representative class features. The initial image segmentation classifies only those image pixels whose surrounding closely matches a class centroid. The subsequent procedure iteratively classifies the remaining image pixels by combining their spatial distance from the regions already segmented and the similarities between their corresponding magnitude vectors and the cluster centroids. Experimental results of the proposed algorithm for segmenting real cell images are provided.

Survey on the distribution of Vibrionaceae at the seaport areas in Taiwan, 1991-1994

A monthly survey on the distribution of human-pathogenic Vibrionaceae of the seawater from five principal harbors in Taiwan was conducted by National Quarantine Service from July, 1991 to February, 1994. Of the total 1,167 Vibrionaceae isolates, strains of Vibrio alginolyticus (449 strains) were the most frequently isolated, followed by Vibrio parahaemolyticus (262) , Aeromonas hydrophila (153), Vibrio cholerae non-O1 (86), and Vibrio vulnificus (67). None of Vibrio cholerae O1 was isolated. The pH, salinity, and water temperature in this study ranged from 5.8 to 8.6, 0.1 to 4.2% , and 15 to 34 degrees C, respectively. It is concluded that the family Vibrionaceae exists autochthonously around the coastal waters in Taiwan.

[The thermoregulatory threshold during surgery with propofol-nitrous oxide anaesthesia]

BACKGROUND

Thermoregulatory responses are thought to be drastically suppressed by general anesthesia. In previous studies, it was shown that halothane, isoflurane and fentanyl-N2O combination decrease the threshold of vasoconstriction in general anesthesia. Propofol is a recently introduced intravenous anesthetic. The thermoregulatory threshold of its administration during surgery has not been quantified.

MATERIALS

Fourteen unpremedicated ASA class I patients were anesthetized with N2O (67%) and propofol (2 mg/kg in bolus followed by 6 mg/kg/h infusion) during elective surgery of free flap. Patients were randomly assigned either to receive additional warming (n = 5) or standard (n = 9) management. Significant vasoconstriction was prospectively defined as the temperature gradient between forearm surface and finger-tip surface is > or = 4 degrees C, and the thermoregulatory threshold was defined as the esophageal temperature (core temperature) at a point where the skin temperature gradient between two tested zones exceeds 4 degrees C.

RESULTS

Vasoconstriction did not occur in patients who received additional warming and they remained in nearly normothermia. The average minimum core temperature was 36.3 +/- 0.4 degrees C. In patients who underwent standard management the core temperature ranged from 32.8 to 34.6 degrees C (33.6 +/- 0.7 degrees C), signifying significant vasoconstriction.

CONCLUSIONS

General anesthesia with propofol/N2O during surgery drastically inhibits thermoregulatory vasoconstriction. This effect should also be noted during long-term use of propofol (e.g. ICU-sedation).

[Cardiac arrhythmia after lung cancer surgery--an analysis of 140 pneumonectomy cases]

Among 808 surgically resected lung cancer cases at Shanghai Chest Hospital during the period of January 1991 to December 1992, 140 of them (17.3%) underwent pneumonectomy (47 right, 93 left). In the 140 cases: 124 male, 16 female; aged 27-74 yrs, pre-operative abnormal EKG was found in 38 cases. Postoperatively, arrhythmia occurred in 76 cases, with an incidence of 54.3%. Of the 76 arrhythmias, atrial fibrillation was seen in 7 patients, atrial premature beats in 2, supraventricular tachycardia in 1 and sinus tachycardia in 66. The results indicate that cardiac arrhythmia is a common complication after pneumonectomy for lung cancer surgery. The major causes of arrhythmia were incisional pain, hypovolemia due to blood loss and respiratory insufficiency due to anoxia. The perioperative measures to prevent arrhythmia were discussed.

Intractable hiccup due to multiple sclerosis: MR imaging of medullary plaque

We describe a 31-year-old man with clinically definite multiple sclerosis who presented with intractable hiccup for one month prior to admission. The responsible lesion was confirmed by magnetic resonance imaging to be a plaque in the ventral paramedian portion of the medulla oblongata.

Unilateral cheiro-oral syndrome in a patient with bilateral subdural hematomas

We report a 49-year-old man with acute intermittent perioral and distal hand sensory dysfunction on the left side (cheiro-oral syndrome). The responsible lesion was confirmed by magnetic resonance imaging to be bilateral subdural hematomas with the larger side compressing the middle and lower thirds of the right postcentral gyrus. We emphasize that subdural hematoma should be considered in the differential diagnosis of cheiro-oral syndrome.

[Evaluation of MRI of knee by arthroscopy]

Between August 1989 and April 1993, 61 patients (68 knees) suspected of having intraarticular knee pathology underwent magnetic resonance imaging (MRI) before arthroscopy. In order to evaluate the diagnostic value of the MRI of knee joints, a retrospective study was undertaken. The analysis of the correlation between the arthroscopic findings and the results of MRI indicated the high sensitivity and specificity of MRI in diagnosing disorders of the knee joint. Also the characteristics of MRI of knee and the affecting factors have been discussed in this paper.

The clinical correlates of high-titer IgG anti-GM1 antibodies

Serum IgG anti-GM1 antibodies have been reported to occur in a variety of disorders, including Guillain-Barré syndrome and chronic polyneuropathies. Of over 5,000 serums tested in our laboratory, high titers of selective IgG anti-GM1 antibodies (> 1:1,000) and without binding to sulfatide were found in 35 patients. Clinical correlation revealed that almost all patients had axonal, motor neuropathies. One subgroup was comprised of individuals with an acute motor neuropathy, described either as an acute axonal Guillain-Barré-like syndrome that was occasionally associated with a prodrome of Campylobacter jejuni enteritis or as Chinese paralysis syndrome. A second group of patients had chronic asymmetric lower motor neuron (LMN) syndromes with no conduction block or other evidence of demyelination. The presence of selective high-titer IgG anti-GM1 antibody reactivity in serum is uncommon but when present is strongly associated with acute axonal motor neuropathies or chronic asymmetric LMN syndromes.

[Comparison of intravenous alfentanil, fentanyl and epidural lidocaine for extracorporeal shock wave lithotripsy]

Due to the development of newer generation of lithotriptor, the anesthesia for extracorporeal shock wave lithotripsy (ESWL) was variable recently. To compare opioid analgesia with epidural lidocaine for their efficacy in pain control, hemodynamic changes, side effects and patient acceptance during ESWL, sixty unpremedicated patients undergoing elective ESWL for upper urinary calculi with second generation Dornier MFL 5000 nonimmersion lithotriptor were randomly assigned equally into one of the following managements: Group E: 1% epidural lidocaine with 1:200000 epinephrine; Group A: 15 micrograms/kg alfentanil initially and 7 micrograms/kg on demand intravenously; Group F: 4 micrograms/kg fentanyl initially and 2 micrograms/kg on demand intravenously. Significant hypotension and bradycardia occurred in Gp.E as compared to baseline value (p < 0.05). Early respiratory depression was observed in both Gp. A and Gp. F, but Gp. A showed significantly shorter period (2 to 5 minutes) as compared to Gp.F (2 to 15 minutes). Under the insufflation of oxygen by nasal cannula, mean PaCO2 increased maximally to 50 mmHg, but no arterial oxygen desaturation (< 90%) was noted in Gp.A and Gp.F. The incidence of post-ESWL nausea was higher in Gp.F (p < 0.05), shivering and delayed recovery time were the main disturbing problems in Gp.E (p < 0.01). Although five-point verbal pain scale was significantly higher in Gp.A and Gp.F (at 30 to 45 minutes during ESWL) as compared to Gp.E, acceptance among patients was high throughout the course. We conclude that different anesthetic plans should be determined on different lithotriptors settings and patient's physical condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Babinski-Nageotte syndrome: a case report

A 68-year-old man developed a sudden onset of the left Wallenberg's syndrome with additional left hypoglossal nerve palsy and contralateral hemiparesis sparing the face. The clinical constellation, known as Babinski-Nageotte syndrome, is regarded as a combination of the medial and lateral medullary syndrome. Magnetic resonance imaging showed potential of in vivo confirmation of the underlying vascular insult, which clearly demonstrated an infarct area in the left half of the medulla oblongata.

Ankle arthrodesis

As a fused ankle provides a painless ankle joint with limited functional disability, ankle arthrodesis is still the treatment of choice for most disabling ankle arthritis. From January 1987 to December 1990, 45 cases of ankle arthrodesis were performed, including 27 male and 18 female patients, aged from 18 to 70 years with an average of 41.9 years. The causes leading to arthrodesis included 19 cases of post-traumatic arthritis, 3 rheumatoid arthritis, 7 osteoarthritis, 9 ankle infections (4 pyogenic and 5 tuberculosis), 4 ankle deformities, 2 avascular necrosis of the talus and 1 cases of Charcot joint. The methods included modified Blair's ankle arthrodesis (34 cases), compression arthrodesis (7 cases) either by Hoffman external fixation or triangular compression device, and intra articular arthrodesis by staple fixation (4 cases). The follow up period ranged from 17 Ms to 52 Ms with an average of 28.6 Ms. There were 2 cases who ultimately required amputation due to uncontrollable infection, and 2 cases of nonunion and one of them received refusion. There were 11 cases of delayed union (union time more than 6 Ms). The average union time was 5.6 Ms, ranging from 2 Ms to 10 Ms. Excluding the cases of amputation and nonunion, all patients had improvement in the ankle functional scale evaluation and 85.3% of the patients were satisfied with their present condition. The modified Blair's method of ankle arthrodesis has proven to be an effective method for treating ankle arthritis no matter what the cause. However, for cases of infection, compression arthrodesis with an external fixational device is superior.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical study on super-long-term survival over 15 years of postoperative patients with lung cancer]

A total of 1478 patients with lung cancer were operated upon at the Shanghai Chest Hospital from 1958 to 1973. The resectability was 88.6%. Up to May 1989, 128 patients with a super-long-term survival, from 15 to 31 years (md = 18.8 years) after resection, had complete data for analysis. Seventy one (55.5%) patients are still alive. The 15-year survival rate was 8.7%. After 15 years of postoperative survival, only the death rate of smoking group (BI = 538) was significantly higher than that of non-smoking group in eleven statistic items (chi 2 = 4.45, P < 0.05). This suggests that smoking exerts a negative influence on super-long-term survival by reducing the immune function and inducing senile chronic pulmonary-cardiovascular diseases in the host. The importance of radical resection and healthy psychological status of the host for super-long-term survival is discussed.

Acute motor axonal neuropathy: a frequent cause of acute flaccid paralysis in China

In northern China, annual epidemics of acute-onset flaccid paralysis diagnosed clinically as Guillain-Barré syndrome have been recognized for at least 20 years. On the basis of an historical analysis of more than 3,200 patients, distinctive features include most cases occurring during the summer months among children and young adults, most of whom reside in rural areas. Of 90 patients with acute flaccid paralysis, 88 had a distinctive pattern that shares clinical and cerebrospinal fluid findings with demyelinating Guillain-Barré syndrome, but that differs from Guillain-Barré syndrome physiologically and pathologically. The clinical course is marked by rapidly progressive ascending tetraparesis, often with respiratory failure, but without fever, systemic illness, or sensory involvement. Cerebrospinal fluid is acellular, and elevations of protein content occur in the second or third week of illness. Electrodiagnostic studies show normal motor distal latencies and limb conduction velocities, but reduced compound muscle action potential amplitudes. Sensory nerve action potentials and, when elicitable, F waves are within the range of normal. Recovery is usually good. Autopsy studies have shown Wallerian-like degeneration of motor fibers. These studies establish that this is a distinctive syndrome, distinguishable from poliomyelitis and demyelinating Guillain-Barré syndrome.

Can daily dietary arginine supplement affect the function and subpopulation of lymphocytes in patients with advanced gastric cancer?

Since arginine can stimulate lymphocyte proliferation in the healthy human, its effect on lymphocyte proliferation in vitro was studied in 7 patients with far advanced gastric cancer. These patients with normal nourishment were ambulatory and could consume a regular diet. A daily dietary supplement of 30 g arginine for 7 days did not alter the total lymphocyte counts or the T/B cell ratio in the peripheral blood. Enhancement of lymphocyte proliferation in response to mitogen stimulation was not observed. Furthermore, an in vitro study on the effect of arginine on phytohemagglutinin-stimulated lymphocyte proliferation showed that lymphocytes from gastric cancer patients had poorer responses than those obtained from normal subjects, despite the supplement in the culture medium with normal serum, patient serum, or fetal bovine serum. Arginine ingestion did not impair liver function and had no detectable side effects except transient nausea in 1 patient. These results indicate that dietary arginine supplement appears safe but does not stimulate lymphocyte function in far advanced gastric cancer patients. The suppressed immune function in gastric cancer patients may be the result of their intrinsic lymphocyte defect.