[Pharmacological study on Tianxiong (tuber of Aconitum carmichaeli Debx.), a Chinese drug for reinforcing the kidney yang retail in Hong Kong market]

OBJECTIVE

To explore the pharmacodynamic mechanism of Tianxiong (Aconitum carmichaeli) in tonifying the kidney and supporting Yang, so as to provide evidences for further development of new drugs treating Yang-eficiency of the kidney.

METHOD

Observing parameters such as visceral index, survival time of low-temperature swimming for hydrocortisone-induced Yang-deficiency model mouse and testis-removed kidney-deficiency model rat.

RESULT

The decoction of processed Tianxiong could strengthen the antifatigual ability and prolong the survival time of low-temperature swimming for mice, and promote immunization in rats.

CONCLUSION

Tianxiong is able to reinforce the kidney Yang, which reconforms the conclusion of "replenishing the fire of vital gate and the Qi of kidney" recorded in Chinese historical literature and proved by overseas clinical practice.

Activation of coagulation and fibrinolysis during dengue virus infection

Dengue virus infection can induce mild dengue fever (DF) or severe dengue hemorrhagic fever and dengue shock syndrome (DHF/DSS) in human. The pathogenesis of hemorrhage in dengue virus infection is not fully understood. Since hemostasis depends on the balance between coagulation and fibrinolysis, alternation of some coagulation parameters (platelet count and activated partial thromoboplastin time, APTT) as well as fibrinolytic parameters (tissue plasminogen activator, tPA and plasminogen activator inhibitor-1, PAI-1) were compared in 8 DHF/DSS and 17 DF patients. Patients showed thrombocytopenia, APTT prolongation, and tPA increase in the acute stage of disease, indicating activation of coagulation and fibrinolysis. The activation of coagulation and fibrinolysis in DHF/DSS patients was much more severe than DF patients. In the convalescent stage, a rise of PAI-1 level and platelet count with concomitant decline of tPA level and APTT returned to normal in both DHF/DSS and DF patients. Therefore, the activation of coagulation and fibrinolysis during the acute stage of dengue virus infection is offset by the increase of platelet and PAI-1 during convalescent stage. Taken together, these results suggest that the degree of coagulation and fibrinolysis activation induced by dengue virus infection is associated with the disease severity.

Using the prevalence of an elevated serum alanine aminotransferase level for identifying communities with a high prevalence of hepatitis C virus infection

BACKGROUND

Antibody to hepatitis C virus (anti-HCV) is a widely accepted method for the diagnosis of HCV infection. However, it is too expensive to use in large-scale health surveys.

OBJECTIVE

To investigate the use of the serum alanine aminotransferase (ALT) level to predict the prevalence of HCV infection.

PATIENTS AND METHODS

A sample of 6095 residents aged 35 years old or older in a small township of southern Taiwan, Republic of China, were examined in a community health survey. These persons were walk-ins to the government-sponsored stations after an intensive health promotion for this survey. Blood samples were obtained and analyzed for serum ALT levels. The presence of hepatitis B surface antigen and anti-HCV were determined by enzyme immunoassay methods.

RESULTS

The overall prevalences of hepatitis B surface antigens(+), anti-HCV(+), and elevated ALT levels were 11.8%, 15.0%, and 7.5%, respectively. Among the 13 villages in this community, the prevalence of hepatitis B surface antigen(+) ranged from 6.8% to 17.3%, anti-HCV(+) ranged from 7.2% to 37.6%, and an elevated ALT level ranged from 5.8% to 16.5%. A strong positive correlation was found between the prevalence of an elevated ALT level and anti-HCV(+) (r= 0.91, Spearman rank correlation; P<.001). However, nearly 0 correlation (r= -0.05, P=.87) was obtained between the prevalence of an elevated serum ALT level and hepatitis B surface antigen(+).

CONCLUSION

The prevalence of an elevated serum ALT level in a community is a strong indicator of its prevalence of anti-HCV(+), even in areas where there is a similar prevalence of hepatitis B virus infection. This result is useful for economically identifying hyperendemic communities with HCV infection.

Differences in 99mTc-HMPAO brain SPET perfusion imaging between Tourette's syndrome and chronic tic disorder in children

Early differential diagnosis between Tourette's syndrome and chronic tic disorder is difficult but important because both the outcome and the treatment of these two childhood-onset diseases are distinct. We assessed the sensitivity and specificity of brain single-photon emission tomography (SPET) perfusion imaging in distinguishing the two diseases, and characterized their different cerebral perfusion patterns. Twenty-seven children with Tourette's syndrome and 11 with chronic tic disorder (mean age 9.5 and 8.6 years, respectively) underwent brain SPET with technetium-99m hexamethylpropylene amine oxime (HMPAO). Visual interpretation and semiquantitative analysis of SPET images were performed. On visual interpretation, 22 of 27 (82%) of the Tourette's syndrome group had lesions characterized by decreased perfusion. The left hemisphere was more frequently involved. None of the children with chronic tic disorder had a visible abnormality. Semi-quantitative analysis showed that, compared with children with chronic tic disorder, children with Tourette's syndrome had significantly lower perfusion in the left lateral temporal area and asymmetric perfusion in the dorsolateral frontal, lateral and medial temporal areas. In conclusion, using the visual approach, brain SPET perfusion imaging is sensitive and specific in differentiating Tourette's syndrome and chronic tic disorder. The perfusion difference between the two groups, demonstrated by semi-quantitative analysis, may be related more to the co-morbidity in Tourette's syndrome than to tics per se.

Generation of IgM anti-platelet autoantibody in dengue patients

Dengue virus infection causes a wide range of diseases from dengue fever to life-threatening dengue hemorrhagic fever and dengue shock syndrome (DHF/DSS). The mechanisms involved in DHF/DSS pathogenesis remain unclear. Patient sera collected from an outbreak in southern Taiwan from November 1998 to January 1999 were studied. The presence of antibodies which cross-reacted with platelets could be detected in patient sera, and the isotype of these autoantibodies was IgM. The anti-platelet IgM levels were higher in DHF/DSS than in dengue fever patient sera in disease acute phase. These autoantibodies were still detectable in convalescent stage (1-3 weeks after acute phase) and even eight to nine months after illness. The platelet binding activity was not observed in other virus-infected patient sera tested. Further investigation showed that dengue patient sera caused platelet lysis in the presence of complement. The platelet cytotoxicity induced by DHF/DSS patient sera was higher than that by dengue fever sera. Dengue patient sera also inhibited platelet aggregation which, however, appeared to be not related to DHF/DSS development.

Reappraisal of the role of NM23-H1 in colorectal cancers

BACKGROUND AND OBJECTIVES

A number of evidence indicate that downregulation of the nm23-H1 gene may be relevant to metastatic progression of many kinds of human cancer. However, its role in colorectal cancers remains controversial. To address the issue, this study was performed to investigate the clinical relevance of nm23-H1 in patients with colorectal cancers.

METHODS

Immunohistochemical expression of nm23-H1 protein product (NM23-H1) was studied in a total of 146 colorectal cancer patients and compared for its prognostic value at a mean follow-up of 54 months.

RESULTS

There was no apparent correlation between NM23-H1 expression and clinicopathological indicators, including Dukes category, lymphatic metastasis, distant metastasis, histological grading, and tumor location (P < 0.1, respectively). In addition, determination of NM23-H1 expression status did not provide independent prognostic information compared with conventional pathological staging.

CONCLUSIONS

The results indicate that nm23-H1 gene does not play an important part in the progression of colorectal carcinogenesis.

The determinants of safe sex behaviors of junior college students with sexual experience

The purpose of this study was to explore the safe sex behavior and related factors of junior college students with sexual experience in southern Taiwan. This study used a cross-sectional design, in which data from a sample of 187 junior college students with sexual experience were collected by an anonymous and self-administered questionnaire. For a conceptual framework, the study used constructs from the PRECEDE (Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation) model. Two predisposing factors (AIDS-prevention self-efficacy, AIDS related knowledge), one enabling factor (school resources in AIDS prevention), one reinforcing factor (perception of peers' AIDS prevention behavior), demographic characteristics (gender, parents' educational level), substance use (cigarette and alcohol use) and sexual history (age of first sexual intercourse, number of sexual partners) were examined for their ability to influence safe sex behavior of junior college students with sexual experience. The results showed that gender, fathers' educational level, age of first sexual intercourse, number of sexual partners, cigarette use and alcohol use were significant factors for difference in safe sex behavior. AIDS prevention self-efficacy, AIDS-related knowledge, and perception of peers' AIDS prevention behavior were all positively related to safe sex behavior. AIDS prevention self-efficacy, fathers' educational level accounted for 49.8% of the variance in safe sex behavior.

Prevalence study of thyroid dysfunction in the elderly of Taiwan

The present study was aimed at investigating the prevalence of thyroid dysfunction in the elderly, aged 65 years or older, in a community of southern Taiwan. By using the records of the local household registry, a sampling frame for the elderly population was constructed, and a sample of 1,400 subjects was drawn by simple random sampling. After the exclusion of nonresponse subjects, 917 subjects aged between 65 and 88 years (mean 71.9) were included in our survey. The serum thyrotropin levels of these participants were measured by monoclonal antibodies TSH immunoradiometric assays. A normal range, 0.45-4.65 microU/ml, was determined from the middle 95% of the TSH distribution of 140 'disease-free' subjects. By reference to the normal range, 23 (2.51%) participants had high (> 4.65 microU/ml), and 41 (4.47%) had low (< 0.46 microU/ml) TSH levels. The overall prevalence of thyroid dysfunction in the sample was 6.98%. Of the 23 participants with high TSH levels, 8 (34.8%) had low free T4 values (< 1.21 ng/dl), so-called overt hypothyroidism, and of the 41 participants with low TSH levels, only 1 (2.4%) had high T3 values, so-called T3 thyrotoxicosis. Antithyroid antibodies were found in 56.5% of those with high TSH levels but only 12.2% of those with low TSH levels (odds ratio = 8.53, 95% confidence limits = 2.55-28.50, p < 0.001). This result indicates that autoimmune disease is still the major cause of hypothyroidism in aged people. However, the prevalence of subclinical hyperthyroidism is higher than that of subclinical hypothyroidism and it might relate to nonautoimmune factors.

Influence of nucleotide polymorphisms in the CCR2 gene and the CCR5 promoter on the expression of cell surface CCR5 and CXCR4

Polymorphisms in the CCR2 gene (CCR2-64I) and the CCR5 promoter (pCCR5-59029G) have been correlated with slower HIV-1 disease progression. How these polymorphisms influence the rate of AIDS progression has remained unclear. We have therefore investigated whether these nucleotide polymorphisms will reduce the expression levels of surface CCR5 and CXCR4, and thus lead to slower AIDS progression. For this, a cohort of Chinese volunteers in Taiwan was subjected to the determination of CCR2 and pCCR5 genotypes followed by analysis of the surface CCR5 and CXCR4 expression on five cell types derived from peripheral blood mononuclear cells by flow cytometry. Several significant associations were detected between genotypes and expression levels of the proteins. The most important finding was that an increased number of CD4(+) cells expressing CCR5 correlated with pCCR5-59029A homozygosity without the interference of both the CCR2-64 and the CCR5 delta 32 (deleted 32 bp) mutations (P: = 0.0453), which is consistent with the previous data on the association of the genotype to AIDS progression. Since different genetic polymorphisms co-exist in human beings, the rate of AIDS progression as well as the risk of rheumatoid arthritis may be governed by the interplay of the array of nucleotide changes and their affected proteins.

Percutaneous epididymal sperm aspiration versus microsurgical epididymal sperm aspiration for irreparable obstructive azoospermia--experience with 100 cases

PURPOSE

This study investigated the sperm retrieval success rates, fertilization rates, pregnancy rates, and complications of percutaneous epididymal sperm aspiration (PESA) and microsurgical epididymal sperm aspiration (MESA) in cases of irreparable obstructive azoospermia.

METHODS

During a period of 36 months, 100 men with irreparable obstructive azoospermia underwent 109 cycles of sperm retrieval procedures and intracytoplasmic sperm injection (ICSI). We routinely performed PESA first in each retrieval cycle; MESA and/or testicular sperm extraction (TESE) were performed if PESA failed. The sperm retrieval success rates, mean fertilization rates, and pregnancy rates of PESA and MESA were evaluated.

RESULTS

PESA was performed in all 109 retrieval cycles with a successful sperm retrieval rate of 61%. When PESA failed to retrieve a sufficient number of viable sperm, MESA was subsequently performed with a sperm retrieval rate of 93%. Three cases, which had failed retrieval with both the PESA and MESA procedures, received TESE successfully. The rates of fertilization and pregnancy were 56% and 39% in the 66 PESA-ICSI cycles, respectively, and 47% and 45% in the 40 MESA-ICSI cycles. No significant differences were found in fertilization rates or pregnancy rates among the various sperm retrieval methods and obstruction etiologies. The overall mean fertilization rate and pregnancy rate were 51% and 41%, respectively.

CONCLUSION

Both PESA and MESA can be used successfully to obtain sufficient sperm for ICSI. PESA cannot replace MESA in some cases as some epididymal pathologies prevent its success. The results of this study indicate that PESA should be the treatment of choice for patients with ductal obstruction distal to the epididymis, owing to its higher initial success rate. In contrast, patients with irreparable epididymal obstruction might achieve better success rates with MESA.

Carbon urea breath test is not as accurate as endoscopy to detect Helicobacter pylori after gastrectomy

BACKGROUND

This study was conducted to determine (1) whether Helicobacter pylori infection decreases in conjunction with time elapsed after gastrectomy and (2) the diagnostic efficacy of (13)C urea breath test (UBT) for H pylori in patients after gastrectomy.

METHODS

From January 1997 to June 1998, 86 patients who had undergone gastrectomy and 180 patients with dyspepsia without gastrectomy were enrolled. A UBT for the analysis of excess (13)CO(2)/(12)CO(2) ratio (ECR) was obtained for each patient. Each patient also underwent endoscopy to obtain gastric biopsies for histology and H pylori culture. The presence of H pylori by either histology or culture served as the standard to test the efficacy of UBT. The 86 patients with a prior gastrectomy were categorized into 3 subgroups (I, less than 1 year; II, 1 to 3 years; III, greater than 3 years), according to the interval between surgery and UBT. The initial H pylori status of these 86 patients was determined by histologic evaluation of the resected stomach.

RESULTS

At trial initiation, the postgastrectomy group had a lower H pylori infection rate (52.3%) as compared with the dyspeptic control group (80%). The initial H pylori status among subgroups I, II, and III was similar. There was a trend for the presence of H pylori in the stomach to decrease with increasing time elapsed after surgery (I to III: 68.8%, 48.3%, 36%, respectively; p < 0.05). The maximum UBT sensitivity and specificity achieved were 82.2% and 87.8% in the gastrectomy group and 97.2% and 96.3% in the dyspeptic group, with cutoff points of 2.5 and 4.0, respectively.

CONCLUSION

The prevalence of H pylori diminishes with time elapsed after gastrectomy. UBT for detection of H pylori is more effective in patients without prior gastrectomy than in patients who have undergone gastrectomy and is less effective than endoscopy for patients who have had a gastrectomy.

Incisional hernia after laparotomy: prospective randomized comparison between early-absorbable and late-absorbable suture materials

Incisional hernia is a serious postoperative complication of laparotomy. Selecting an appropriate suture material may lessen such morbidity. This study undertook a prospective, randomized comparison of early-absorbable polyglactin 910 suture versus late-absorbable polydioxanone loop suture for fascial closure after abdominal surgery. A series of 340 consecutive patients undergoing elective laparotomy were randomized to have fascial closure with either polyglactin 910 suture or polydioxanone loop suture between October 1993 and August 1996. A 2-year follow-up revealed that 23 patients had died, and the overall mortality rate was 6.8% (23/340). Ten (10/340, 2.9%) patients, including seven with polyglactin 910 suture and three with polydioxanone loop suture, developed incisional hernias. The early postoperative evaluation revealed an incidence of wound infection of 4.1% (14/340). The development of incisional hernia was not secondary to postoperative wound infection in this study. Among these 340 patients, 192 had malignant diseases and 148 had nonmalignant ones. Fascial closure with polyglactin 910 suture was associated with more incisional hernias than that with polydioxanone loop suture, with marginal significance for patients in the malignant group (4.7% versus 0%, p = 0.07) but not in the nonmalignant group (2.6% versus 4.2%, p = 0.67). In conclusion, abdominal closure with a late-absorbable polydioxanone loop suture may be beneficial to patients with a malignant disease for preventing incisional hernia.

Prognostic value of vascular endothelial growth factor expression in colorectal cancer patients

Solid tumours require neovascularisation for growth and metastasis. Vascular endothelial growth factor (VEGF) has been shown to be an important regulator of tumour angiogenesis. To examine the relevance of VEGF in the neoplastic transformation of human colon, we analysed protein expression in a total 30 polyps and 145 colorectal carcinomas by immunohistochemistry. All adenoma specimens, regardless of histological differentiation, and normal colonic mucosa did not express VEGF. Amongst 90 patients with non-metastatic colorectal cancer, VEGF expression was observed in 43 (48%) cases, whilst 29 of the 55 patients (53%) with metastases expressed the angiogenic factor. Both the proportion and intensity of VEGF expression were positively associated with the progression of colon carcinogenesis. Tumours with the highest VEGF expression tended to correlate with patients' survival, although VEGF expression did not emerge as an independent risk factor in a multivariate analysis. After exclusion of the patients with distant metastases, both univariate and multivariate analysis did not indicate any prognostic value for the tissues with the highest VEGF expression. Our results suggest that VEGF may play a role in the progression of colon cancer, although evaluation of this angiogenic phenotype did not provide additional prognostic information compared with that obtained from Dukes' staging of the tumours.

Neurocognitive attention and behavior outcome of school-age children with a history of febrile convulsions: a population study

PURPOSE

A prospective population-based case-control study was performed to ascertain whether febrile convulsion (FC) in early childhood is associated with neurocognitive attention deficits in school age.

METHODS

A total of 103 children, confirmed to have FC by age 3 years from a population survey of 4,340 live-birth newborns in Tainan City, Taiwan, was followed up until at least age 6 years. An achievement test, behavioral ratings, and computerized neurocognitive battery assessing various subcomponents of attention were given to 87 FC children (FC group) and 87 randomly selected population-matched control (CC group).

RESULTS

Compared with the CC group, the FC group did not have scholastic performance or behavioral outcome disadvantage. Overall FC group performance was distinguished by significantly higher scores in the achievement test and fewer missing errors (p < 0.005) and commission errors (p < 0. 05), less variability in reaction time (p < 0.005), and a nonsignificant trend of impulsivity. Attention performance of the FC and CC groups were comparable. Within the FC group, age at onset, complex FC, recurrence of FC, development of unprovoked seizures, or prior use of phenobarbital had no adverse effects on neurocognitive attention outcome.

CONCLUSIONS

This population study suggests that FC in early childhood does not have adverse effects on behavior, scholastic performance, and neurocognitive attention. On the contrary, the FC group demonstrated significantly better control of distractibility and attention at school age.

The use of the motion analysis system for evaluation of loss of movement in the finger

We have used the motion analysis system to measure loss of finger movement after injury. The motion analysis system can provide information about the dynamic angular changes of each finger joint and the fingertip motion area for the injured finger. The latter can be used to calculate the percentage of fingertip motion area preserved. A stiff finger may show limited fingertip motion area with the finger joints tending to flex and extend together.

Novel image analysis of corpus cavernous tissue in impotent men

OBJECTIVES

To objectively evaluate the contents of corpus cavernous tissue in impotent men using an automated novel image analysis system.

METHODS

Thirty-three impotent men and 2 normal potent men (controls) underwent corpus cavernous biopsies. The procedures were performed using a Biopty gun under local anesthesia. The obtained specimens were stained with Masson's trichome technique, and the collagen fiber contents were evaluated by a computerized morphometric analysis method. In addition, we estimated the intraobserver and interobserver reliability of this automated image analysis system.

RESULTS

No major complication was noted during or after the biopsies. Of the 33 impotent patients, 3 were diagnosed as having psychogenic, 11 as having arteriogenic, 13 as having venogenic, 1 as having neurogenic, and 5 as having idiopathic impotence. The collagen fiber percentages in the 35 men were as follows: normal potent: 48.2% +/- 1.4%, psychogenic 55.2% +/- 11.6%, arteriogenic 73.2% +/- 4.4%, venogenic 66.5% +/- 4.2%, neurogenic 76.9%, and idiopathic 77.4% +/- 4.2%. Significant differences were found between the normal potent and arteriogenic groups (P <0.05) and between the normal potent and idiopathic groups (P <0.05). Patients older than 60 years had a higher collagen fiber content (70.4% +/- 3.7%) than those younger than 50 years old (58.6% +/- 5.2%). The interobserver and intraobserver variances were both negligible for this automated image analysis system. This method significantly reduced the amount of variation introduced by the intra-rater reliability of a technician compared with the manual method.

CONCLUSIONS

The present automated image analysis system is believed to be a reliable, accurate quantitative measurement tool for studies of penile tissue. Cavernous biopsy is a rapid, safe, and representative modality to study penile disease. An increase in cavernous collagen fibers (or corporal fibrosis) is considered an important factor in impaired erectile function.

Levothyroxine suppression of thyroglobulin in patients with differentiated thyroid carcinoma

For patients with differentiated thyroid carcinoma, the appropriate degree of TSH suppression by levothyroxine (L-T4) is still unknown. To find the target level of TSH suppression, we analyzed the relationship between the degree of TSH suppression determined by third generation assay and thyroglobulin (Tg) response during the titration of the dosage of L-T4. Ninety-two patients with differentiated thyroid carcinoma (19 males and 73 females; age, 40.5+/-13.5, mean +/- SD) were included. All of the recruited patients had near-total thyroidectomy, 30-150 mCi 131I thyroid ablation, and negative Tg autoantibodies. They were classified into 3 groups. Group A was composed of 25 patients with local or distant relapse. Group B was composed of 12 patients without clinically detectable relapse, but Tg levels either above 2 ng/mL under L-T4 suppression or above 3 ng/mL off L-T4 therapy. Group C included 55 patients who had no active disease and Tg levels below 2 and 3 ng/mL during and off L-T4 suppression, respectively. Serum TSH and Tg were measured simultaneously at the end of 8-12 weeks of a certain dose of L-T4 therapy during dosage titration and also after withdrawal of L-T4 for 4-6 weeks for the total body scan. Wilcoxon signed ranks test was used to compare paired samples of Tg, and Spearman rank correlation was used to determine the correlation of relative changes in TSH to changes in Tg calculated by individual. The results showed that 1) Tg levels were significantly higher during the period off L-T4 therapy than on L-T4, therapy in all 3 groups (P < 0.01); 2) during L-T4, therapy, within the same treatment course, mean Tg levels were higher when TSH levels were normal than when TSH levels were suppressed, statistically significant in group A (P = 0.001), nonsignificant in group B (P = 0.09), and nonsignificant in group C (P = 0.30); and 3) when TSH was suppressed below normal, there was no correlation between the relative changes in TSH and Tg by individual in all 3 groups (P > 0.05). The data suggest a stratified postoperative thyroid hormone management of patients with differentiated thyroid carcinoma. TSH should be lowered to below normal in patients with active disease. If patients are clinically disease free with Tg levels below 2 ng/mL, TSH can be kept within the normal range. For the most controversial group B patients, it is recommended that the TSH be suppressed and be closely followed up.

Antioxidant administration inhibits exercise-induced thymocyte apoptosis in rats

PURPOSE

The purpose of this study was to investigate the effect of antioxidant on exercise-induced apoptosis in rat thymocytes.

METHODS

After exercise at 13.8 m x min(-1) for 60-90 min x d(-1) on a motor-driven drum exerciser for 2 consecutive days, rat thymocyte apoptosis was monitored by the feature of DNA fragmentation. To study the effect of antioxidant, rats were administered with butylated hydroxyanisole (BHA) for 7 d before exercise.

RESULTS

Exercise could induce thymocyte DNA fragmentation as detected on electrophoretic gel and by cell death detection ELISA kit. Further studies indicated that pretreatment with antioxidant BHA to rats resulted in a blockage of exercise-induced DNA fragmentation. The concentrations of glutathione (GSH) were not significantly changed in rat thymocytes after exercise with or without BHA treatment.

CONCLUSION

These results suggest that reactive oxygen species may play a role in thymocyte apoptosis induced by exercise. However, changes in GSH levels were not observed in this exercise model.

Neurologic complications in children with enterovirus 71 infection

BACKGROUND

Enterovirus 71 infection causes hand-foot-and-mouth disease in young children, which is characterized by several days of fever and vomiting, ulcerative lesions in the oral mucosa, and vesicles on the backs of the hands and feet. The initial illness resolves but is sometimes followed by aseptic meningitis, encephalomyelitis, or even acute flaccid paralysis similar to paralytic poliomyelitis.

METHODS

We describe the neurologic complications associated with the enterovirus 71 epidemic that occurred in Taiwan in 1998. At three major hospitals we identified 41 children with culture-confirmed enterovirus 71 infection and acute neurologic manifestations. Magnetic resonance imaging (MRI) was performed in 4 patients with acute flaccid paralysis and 24 with rhombencephalitis.

RESULTS

The mean age of the patients was 2.5 years (range, 3 months to 8.2 years). Twenty-eight patients had hand-foot-and-mouth disease (68 percent), and 6 had herpangina (15 percent). The other seven patients had no skin or mucosal lesions. Three neurologic syndromes were identified: aseptic meningitis (in 3 patients); brain-stem encephalitis, or rhombencephalitis (in 37); and acute flaccid paralysis (in 4), which followed rhombencephalitis in 3 patients. In 20 patients with rhombencephalitis, the syndrome was characterized by myoclonic jerks and tremor, ataxia, or both (grade I disease). Ten patients had myoclonus and cranial-nerve involvement (grade II disease). In seven patients the brain-stem infection produced transient myoclonus followed by the rapid onset of respiratory distress, cyanosis, poor peripheral perfusion, shock, coma, loss of the doll's eye reflex, and apnea (grade III disease); five of these patients died within 12 hours after admission. In 17 of the 24 patients with rhombencephalitis who underwent MRI, T2-weighted scans showed high-intensity lesions in the brain stem, most commonly in the pontine tegmentum. At follow-up, two of the patients with acute flaccid paralysis had residual limb weakness, and five of the patients with rhombencephalitis had persistent neurologic deficits, including myoclonus (in one child), cranial-nerve deficits (in two), and ventilator-dependent apnea (in two).

CONCLUSIONS

In the 1998 enterovirus 71 epidemic in Taiwan, the chief neurologic complication was rhombencephalitis, which had a fatality rate of 14 percent. The most common initial symptoms were myoclonic jerks, and MRI usually showed evidence of brainstem involvement.

AO fixateur interne in treating burst fractures of the thoracolumbar spine

BACKGROUND

A burst fracture of the thoracolumbar junction is an unstable spinal fracture, which is caused by high-energy trauma. There are many methods of treatment, both surgical and nonsurgical, in dealing with spinal burst fractures. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) Fixateur Interne (FI) system was introduced in 1985 for posterior spine surgery with a transpedicular screw system.

METHODS

From April, 1989, through December, 1994, we encountered 42 patients with 42 acute burst fractures of the spine; 26 were male and 16 were female, with an average age of 41.2 years. One fracture occurred on T11, seven on T12, 16 on L1, 11 on L2, one on L3, four on L4 and two on L5. According to the Denis classification, there were eight type A, 23 type B, five type C, three type D and three type E fractures. All of these patients received posterior reduction without decompression, posterior short segmental fixation with AO FI instrumentation and posterior fusion.

RESULTS

After follow-up for an average of 66.1 months, all fractures were found to have united with residual back pain in only six patients; five patients, including one with nonunion, had back pain without the necessity of medication, and the other one had occasional back pain that was well controlled by medication. The immediate postoperative Cobb's angle improved by an average of 14.2 degrees, and there was an average loss of 3.3 degrees at final follow-up. All patients were neurologically intact at final follow-up except two patients, who were Frankel D. Seven patients had complications during follow-up; one experienced nonunion; four experienced screw breakage, one had screw pullout, and the other experienced breakage of the connecting rod.

CONCLUSIONS

From our retrospective study, the outcome of burst fracture of the spine treated with AO FI instrumentation system was satisfactory.

Measurement of the urinary lactate:creatinine ratio for the early identification of newborn infants at risk for hypoxic-ischemic encephalopathy

BACKGROUND

Newborn infants with perinatal asphyxia are prone to the development of hypoxic-ischemic encephalopathy. There are no reliable methods for identifying infants at risk for this disorder.

METHODS

We measured the ratio of lactate to creatinine in urine by proton nuclear magnetic resonance spectroscopy within 6 hours and again 48 to 72 hours after birth in 58 normal infants and 40 infants with asphyxia. The results were correlated with the subsequent presence or absence of hypoxic-ischemic encephalopathy.

RESULTS

Hypoxic-ischemic encephalopathy did not develop in any of the normal newborns but did develop in 16 of the 40 newborns with asphyxia. Within six hours after birth, the mean (+/-SD) ratio of urinary lactate to creatinine was 16.75+/-27.38 in the infants who subsequently had hypoxic-ischemic encephalopathy, as compared with 0.09+/-0.02 in the normal infants (P<0.001) and 0.19+/-0.12 in the infants with asphyxia in whom hypoxic-ischemic encephalopathy did not develop (P<0.001). A ratio of 0.64 or higher within six hours after birth had a sensitivity of 94 percent and a specificity of 100 percent for predicting the development of hypoxic-ischemic encephalopathy. The sensitivity and specificity of measurements obtained 48 to 72 hours after birth were much lower. The mean ratio of urinary lactate to creatinine was significantly higher in the infants who had adverse outcomes at one year (25.36+/-32.02) than in the infants with favorable outcomes (0.63+/-1.50) (P<0.001).

CONCLUSIONS

Measurement of the urinary lactate: creatinine ratio soon after birth may help identify infants at high risk for hypoxic-ischemic encephalopathy.

Risk factors for a first febrile convulsion in children: a population study in southern Taiwan

PURPOSE

To identify risk factors for a first febrile convulsion among 3-year-old children by a matched case-control population study.

METHODS

All 11,714 neonatal survivors born in Tainan City between October 1989 and September 1991 were enrolled. At age 3, 10,460 children were available for telephone survey for febrile convulsions, and were confirmed by home visit interviews. Those without history of seizure were randomly matched to each febrile convulsion case by age, gender, and residence district.

RESULTS

Two hundred fifty six children had febrile convulsions, and 218 of them and their matched controls were available for analysis. The febrile convulsion cases had significantly more febrile episodes (four or more) per year (33.0 vs. 22.5%; p = 0.021), and cases had a higher percentage of developmental delay (3.7 vs. 0.4%; p = 0.046) and a higher percentage of febrile convulsions in their siblings (12 vs. 0.4%; p = 0.011) than controls. The other sociodemographic, environmental, and biologic variables showed no differences between cases and controls. Step-wise logistic regression showed a highly significant independent association between febrile convulsions and history of febrile convulsions in the siblings, and a moderate one between febrile convulsions and the number of febrile episodes per year.

CONCLUSIONS

The presence of febrile convulsions in the siblings and the number of fever episodes per year were the independent and significant predictors of febrile convulsion for an individual case in our population-based sample.