Catamenial hemoptysis from tracheobronchial endometriosis: reappraisal of diagnostic value of bronchoscopy and bronchial brush cytology

OBJECTIVES

To analyze the clinical data of four patients with a diagnosis of tracheobronchial endometriosis, and to reappraise the diagnostic value of bronchoscopy and bronchial brush cytology in these patients.

METHODS

We conducted a retrospective study of four patients with documented tracheobronchial endometriosis treated at National Taiwan University Hospital from 1994 to 1998. The complete histories, diagnostic time interval, results of physical examinations, laboratory data, bronchoscopic findings, cytologic results, chest radiographs, and chest CT of these patients were analyzed.

RESULTS

These patients tend to be younger and nonmultiparous as compared to other patients with thoracic endometriosis. Bronchoscopic examination performed within 1 day or 2 days of menses disclosed multiple purplish-red submucosal patches bilaterally that bled easily when touched. Cytologic evaluation of the brushing specimens demonstrated clusters of small cuboid cells consistent with an endometrial origin. Follow-up bronchoscopic examination in the middle of the menstrual cycle showed disappearance of the previous tracheobronchial lesions. The mean diagnostic interval was 3.25 months. All four patients were successfully treated with danazol therapy.

CONCLUSIONS

Tracheobronchial endometriosis consists of a special subgroup of patients with thoracic endometriosis. Proper timing of bronchoscopic examination plays an important diagnostic role in these patients. Cytologic features as well as cyclic changes in bronchoscopic findings are sufficient to warrant the diagnosis. The results of treatment with danazol in these patients seemed favorable.

Crystallization and preliminary crystallographic studies of bar-headed goose fluoromethaemoglobin with inositol hexaphosphate

Bar-headed goose fluoromethaemoglobin (fluoromet-Hb) complexed with inositol hexaphosphate (IHP) has been crystallized using PEG 6000 as precipitant. The crystal belongs to space group P2(1), with unit-cell parameters a = 59.8, b = 72.0, c = 79.8 A, beta = 102.1 degrees, and diffracts to 2.5 A resolution. To prove the presence of IHP, the structure was determined by the molecular-replacement method. IHP was observed at the entrance to the central cavity between the N and C termini of two beta subunits.

Detection of a novel quiescence-dependent protein kinase

We have identified a cell quiescence-specific 33-kDa cytoplasmic protein kinase (p33(QIK), Quiescence-Induced Kinase) based on induction of p33(QIK)-specific kinase activity of cells growth-arrested in the quiescent phase and deactivation upon entry into the cell cycle. Blockage of macromolecular synthesis prevents p33(QIK) from deactivation, indicating a requirement of newly synthesized regulators for deactivation of p33(QIK) during G(0)/G(1) transition. Stress shock induces additional increases of p33(QIK) activity in a quiescence-dependent manner that correlates with induction of apoptosis. Using a specific antibody to Krs1/Mst2 protein, we found that p33(QIK) is related to p63(Krs1) and is distinguishable from a 36-kDa protein kinase, which is induced through proteolytic modification of activated p63(Krs1) in proliferating cells undergoing apoptosis. p33(QIK) is constantly expressed in quiescent, proliferating, and apoptotic quiescent cells. Regulation of p33(QIK) activity involves protein phosphorylation/dephosphorylation in a proteolysis-independent manner. Regulation of p33(QIK) and related p63(Krs1) and p36 appears to involve distinct pathways in quiescent and proliferating cells, respectively. Our results illustrate the relevance of p33(QIK) activity for cell quiescence that may provide a new insight into signaling pathways regulated in cells during quiescence and quiescence-related apoptosis.

Clinical spectrum of acute respiratory distress syndrome in a tertiary referral hospital: etiology, severity, clinical course, and hospital outcome

BACKGROUND AND PURPOSE

The clinical picture of patients with acute respiratory distress syndrome (ARDS) in Taiwan has seldom been reported, although new definitions of ARDS have been introduced over the past years. The purpose of this study was to investigate the clinical characteristics, modalities of management, and outcomes in patients with ARDS treated in a tertiary referral hospital.

METHODS

Case records were selected through a computerized search of diagnosis codified at discharge during the period from January 1995 to June 1997. Patients who met the criteria of the American-European Consensus Conference definition of ARDS were included and their medical records were retrospectively reviewed.

RESULTS

A total of 145 patients (91 men, 54 women; mean age, 58 years) who fulfilled the criteria for ARDS were identified. Malignancy (n = 53) and diabetes mellitus (n = 23) were the most common co-morbid conditions. Pneumonia (n = 90), including community-acquired pneumonia in 45 (31%) patients, was the most common risk factor. The lung injury score at the time of ARDS diagnosis was 2.89 +/- 0.40 (mean +/- standard error, SE). The worst value of PaO2/FIO2 was 86.8 +/- 3.8 mm Hg (mean +/- SE). Among the 145 patients, 130 (90%) received mechanical ventilation and 118 (81%) were treated in the intensive care unit. In-hospital mortality was 87%. Seventy (48%) patients received intensive treatment for ARDS, among whom 52 (74%) died; the most common causes of death were multiple organ failure (54%) and respiratory failure (23%).

CONCLUSIONS

The mortality in patients with ARDS was high in this tertiary referral institution. Our findings suggest that aggressive ventilatory, pharmacologic, and supportive therapy may be important to achieve a higher survival rate.

Bacteriology of infected cavitating lung tumor

Differentiation between in situ infection and simple tumor necrosis in cavitating lung tumors by means of imaging studies is difficult. In this study, we prospectively investigated the role of ultrasound (US)-guided transthoracic aspiration for bacteriologic examination of infected cavitating lung tumors, and the influence of the culture results on the treatment of patients. Twenty-two patients (18 men and four women) with cavitating lung tumors treated from January 1996 to October 1998 were included. All patients underwent US-guided transthoracic aspiration for bacterial, fungal, and mycobacterial cultures. Microorganisms were isolated from six of seven febrile patients and one of 15 nonfebrile patients. A total of nine pathogens were isolated from seven patients: Klebsiella pneumoniae (n = 3); Haemophilus influenzae (n = 2); Enterococcus faecium (n = 1); Bifidobacterium (n = 1); Shewanella putrefaciens (n = 1); and Mycobacterium tuberculosis (n = 1). Two pathogens were isolated from the aspirate cultures in two patients, while the others had monomicrobial infection. The six febrile patients who had positive lung aspirate cultures were treated with empiric antimicrobial agents before the culture results were available, and the culture results led to adjustment of the antibiotic regimen in five of these. The clinical conditions of the six patients with infected cavitating lung tumors improved after the initiation of individualized antimicrobial treatment. Pneumothorax occurred in one patient, and was the sole procedure-related complication. In conclusion, US-guided transthoracic aspiration is helpful for differentiating infected cavitating lung tumors from simple tumor necrosis. Infection in cavitating lung tumors is common among febrile patients, and the culture results can guide modification of the antimicrobial therapy.

Oxidative stress disrupts glucocorticoid hormone-dependent transcription of the amiloride-sensitive epithelial sodium channel alpha-subunit in lung epithelial cells through ERK-dependent and thioredoxin-sensitive pathways

The amiloride-sensitive epithelial Na(+) channel (ENaC) plays a critical role in the maintenance of alveolar fluid balance. It is generally accepted that reactive oxygen and nitrogen species can inhibit ENaC activity and aggravate acute lung injury; however, the molecular mechanism for free radical-mediated ENaC inhibition is unclear. Previously, we showed that the expression of the alpha-subunit of ENaC, alpha-ENaC, which is indispensable for ENaC activity, is repressed by Ras activation in salivary epithelial cells. Here, we investigated whether exogenous H(2)O(2) modulates alpha-ENaC gene expression in lung epithelial cells through a similar molecular mechanism. Utilizing transient transfection reporter assays and site-directed mutagenesis analyses, we found that the glucocorticoid response element (GRE), located at -1334 to -1306 base pairs of the alpha-ENaC 5'-flanking region, is the major enhancer for the stimulated alpha-ENaC expression in A549 lung epithelial cells. We further demonstrate that the presence of an intact GRE is necessary and sufficient for oxidants to repress alpha-ENaC expression. Consistent with our hypothesis, exogenous H(2)O(2)-mediated repression of alpha-ENaC GRE activity is partially blocked by either a specific inhibitor for extracellular signal-regulated kinase (ERK) pathway activation, U0126, or dominant negative ERK, suggesting that, in part, activated ERK may mediate the repressive effects of H(2)O(2) on alpha-ENaC expression. In addition, overexpression of thioredoxin restored glucocorticoid receptor action on the alpha-ENaC GRE in the presence of exogenous H(2)O(2). Taken together, we hypothesize that oxidative stress impairs Na(+) transport activity by inhibiting dexamethasone-dependent alpha-ENaC GRE activation via both ERK-dependent and thioredoxin-sensitive pathways. These results suggest a putative mechanism whereby cellular redox potentials modulate the glucocorticoid receptor/dexamethasone effect on alpha-ENaC expression in lung and other tight epithelia.

Hypohidrotic ectodermal dysplasia

Hypohidrotic ectodermal dysplasia was first described by Thurnam in 1848. It is a rare, X-linked, recessive disorder characterized by anhidrosis or hypohidrosis, hypotrichosis, dental hypoplasia and characteristic facial features. Herein, we report a typical case of hypohidrotic ectodermal dysplasia. A 20-year-old male presented with the above symptoms at birth. When a family history was taken, it was discovered that his uncle (mother's brother) had the same characteristic facial features and hypotrichosis.

Chronic myeloid leukemia initially presenting with spontaneous mediastinal hematoma and hemothorax

Spontaneous mediastinal hematoma is rarely seen in hematologic malignancy. We report a case of chronic myeloid leukemia initially presenting with spontaneous hematoma and hemothorax. In addition to a detailed history, computerized tomography of the chest is important in analyzing whether an anterior mediastinal mass lesion is present. Magnetic resonance imaging is helpful in confirming the nature of a mediastinal hematoma. Trauma, vascular disease and coagulopathy should first be ruled out when making a diagnosis of spontaneous bleeding in the thorax. In our patient, the mediastinal hematoma regressed spontaneously after three months. Leukemia should be considered in the differential diagnosis of spontaneous mediastinal hematoma. In leukemia patients with spontaneous mediastinal hematoma, supportive observation and close follow-up may be better than surgery, unless massive hemorrhage or active bleeding in the thorax is suspected.

Ischemic stroke in a teenage girl with primary antiphospholipid antibody syndrome

The diagnosis of stroke in children and young adults can be difficult, and the causes of ischemic stroke often remains unexplained even after extensive evaluation. We present a 13-year-old girl who had two ischemic strokes within a period of 3 weeks. A carotid duplex study and magnetic resonance angiography confirmed total occlusion of the left internal carotid artery. Serum immunologic examination revealed a high titer of immunoglobulin G anticardiolipin antibody (45.7 GPL U/mL; normal range, 0-16.2 GPL U/mL). The patient received long-term anticoagulation treatment with warfarin 5 to 7.5 mg per day, and international normalized ratios were maintained between 2.4 and 4.0. She recovered completely 5 weeks after the first stroke and has been well during the 6 months of follow-up after the onset. This is the first reported case of childhood ischemic stroke secondary to primary antiphospholipid antibody syndrome in Taiwan. This case emphasizes the importance of evaluating antiphospholipid antibody levels in patients with unexplained ischemic strokes.

Lack of evidence of association of p21WAF1/CIP1 polymorphism with lung cancer susceptibility and prognosis in Taiwan

An association between the Arg allele of the p21WAF1/CIP1 codon 31 polymorphism and lung cancer has been reported. However, the genotype distribution of the p21 codon 31 polymorphism, as well as the association of this polymorphism with lung cancer risk and prognosis, remain undefined in the Taiwanese population. Therefore, we investigated the genotype distribution of the p21 codon 31 polymorphism in 155 lung cancer patients and 189 non-cancer controls. The genotype frequencies in the Taiwanese non-cancer controls were 0.51 (Ser) and 0.49 (Arg). Chi2 analysis indicated significant differences in Taiwanese genotype distribution of p21 from those reported for Swedes (P=0.001), Caucasians (P=0.001), Indians (P=0.001), and African-Americans (P=0.001). However, our data did not demonstrate an association of the Arg allele of the p21 polymorphism with lung cancer risk in Taiwan. Lung cancer patients with Ser/Arg and Arg/Arg genotypes were at a nonsignificant 1.15-fold increased risk of lung cancer when compared to individuals with the Ser/Ser genotype (95%CI, 0.70-1.86). In addition, although p21 is a downstream target of p53, we found no significant correlation of the p21 polymorphism with the p53 polymorphism and p53 gene mutation in lung cancer patients. We further investigated the association of the p21 polymorphism with prognosis in 154 lung cancer patients. Patients with the Ser/Ser genotype tended to have a poorer prognosis than those with the Ser/Arg and Arg/Arg genotypes (P=0.097, by the log rank test). Our data suggest that the p21 codon 31 polymorphism may not play a significant role in cancer susceptibility and the prognosis of lung cancer patients in Taiwan.

Clinicopathologic analysis of malignant melanoma in Taiwan

BACKGROUND

Malignant melanoma is the leading cause of death among skin cancers in western countries. However, the incidence, histologic subtypes, and tumor behaviors are quite different in Asians and people of color.

OBJECTIVE

Our purpose was to define the tumor behaviors and possible prognostic predictors of melanomas based on a Taiwanese patient population.

METHODS

From the 65 patients diagnosed with melanoma at Veterans General Hospital, Taichung, we analyzed mean age at onset, gender, histologic subtypes, tumor thickness, level of invasion, primary tumor locations, and metastatic sites. Univariate analysis and multivariate analyses for survival, according to clinical and histologic tumor behaviors, were performed by means of Cox proportional hazard model. Survival curves were plotted by Kaplan-Meier method.

RESULTS

Fifty-one cutaneous melanomas were identified and analyzed by both clinical behaviors and histology. Acral lentiginous melanoma was the most common type (54.9%), followed by nodular melanoma (29.4%), superficial spreading melanoma, and lentigo maligna melanoma. Univariate analysis for overall survival of melanoma revealed that age at onset older than 55 years, male gender, ulceration of tumor, and thicker tumor have the tendency to poorer prognosis, but without significant differences. The advanced stages (III and IV) and histologic subtypes other than acral lentiginous melanoma predicted a poorer survival with significant differences. Multivariate analysis demonstrated advanced stages, and histologic subtypes were the independent risk factors for poor prognosis.

CONCLUSION

We proposed that histologic subtypes other than acral lentiginous melanoma and advanced stages have a poorer prognosis with significant differences.

Pulmonary cryptococcosis: manifestations in the era of acquired immunodeficiency syndrome

To examine the clinical manifestations, treatment, and outcome of pulmonary cryptococcosis, we reviewed the medical records of all patients treated for Cryptococcus neoformans infection at our hospital from January 1988 through September 1998. Sixty-three patients were included in the analysis, 10 (16%) of whom had acquired immunodeficiency syndrome (AIDS). Thirty-four of the 53 non-AIDS patients, including 19 men and 15 women had pulmonary cryptococcosis, including 31 with isolated pulmonary cryptococcosis and three with disseminated disease. Of the 10 AIDS patients, seven presented with disseminated cryptococcosis (including one patient with lung involvement) and one had isolated cryptococcal lung disease. The age (mean +/- SD) of the 34 non-AIDS patients with pulmonary cryptococcosis was 52.1 +/- 15.2 years (range, 19-75 yr). Cough was the most common symptom (58%). Diabetes mellitus (12%) and malignancy (12%) were two major underlying diseases. Nodules and masses were the predominant manifestations of pulmonary cryptococcosis in non-AIDS patients (79%). The most frequently used diagnostic modality for pulmonary cryptococcosis was biopsy with/without aspiration under ultrasound guidance (56%). Antifungal therapy (20/34) was the most common treatment for non-AIDS patients, followed by surgical resections with antifungal therapy (9), surgical resections alone (3), and no treatment (2). Antifungal therapy and/or resection yielded excellent outcomes (total recovery, 27; improvement, 4). Of the 18 patients who underwent lumbar puncture, only two had positive cerebrospinal fluid (CSF) cultures for C. neoformans, both had symptoms and signs of increased intracranial pressure. There was no clinical evidence of meningitis in the other 32 patients. Our findings indicate that pulmonary cryptococcosis in non-AIDS patients tends to be a more localized and benign process than in AIDS patients. Ultrasound-guided lung biopsy or aspiration is an effective tool for diagnosis. CSF examination may not be mandatory as an initial routine procedure for pulmonary cryptococcosis in non-AIDS patients.

[Localization of SC35 in the nucleolus and nucleoplasm of the root meristematic cells of Vicia faba]

SC35 is a non-snRNP spliceosome component purified from mammalian cells by Fu and Maniatis in 1990. In vitro splicing assays showed that SC35 plays a key role in splicing site selection and ATP-dependent pre-spliceosome assembly. In the mammalian nucleus, SC35 has been localized to distinct and dynamic nuclear domains: immunofluorescence observations revealed the presence of SC35 in speckles distributed in various regions throughout the nucleoplasm, which, as identified with immunoelectron microscopy, correspond to the interchromatin granules (IGs) and perichromatin fibrils (PFs). However, there has been no report regarding the presence and distribution pattern of SC35 in higher plant nuclei. Engage in such studies will surely contribute to our understanding of RNA processing and the spatial organization or structure basis of this process in higher plant. In this article, we studied the distribution pattern of SC35 in the nucleus of the root meristematic cells of Vicia faba by immunoelectron microscopy. After immunolabeling with anti-SC35 mAb and protein A-colloidal gold, IGs and PFs in the nucleoplasm and dense fibrillar component (DFC) of the nucleolus were heavily labeled with gold particles, while only a few of the gold particles were found in fibrillar centers (FC) and nucleolar vacuoles (NV) of the nucleolus and the central domains of the condensed chromatin. Densities of gold particles in the areas of DFC and the area of IGs plus PFs were 65.89/microns 2 and 36.28/microns 2 respectively, much higher than that of the central domain of condensed chromatin and that of FC plus NV, which were only 5.90/microns 2 and 6.26/microns 2 respectively. This indicates that DFC of the nucleolus and the area of IGs plus PFs of the nucleoplasm are enriched with SC35 or SC35-like protein. The distribution pattern of SC35 or SC35-like protein in the nucleoplasm of Vicia faba is similar to that of the mammalian nuclei. To the authors' knowledge, it is a new finding that SC35 or SC35-like protein exists in the nucleolus.

Predictors of depression among Chinese family caregivers of Alzheimer patients

From April 1996 to January 1997, 74 Alzheimer disease (AD) patients and their caregivers were recruited for participation in a comprehensive assessment at the Veterans General Hospital-Taipei, a 2,198-bed tertiary care teaching hospital in Taipei, Taiwan. Diagnosis of AD was made according to criteria of the Diagnostic and Statistical Manual of Mental Disorders-III-R (DSM-III-R). All AD patients were tested with the Chinese version of Cognitive Abilities Screening Instrument (CASI). Their primary caregivers rated the patients using the Revised Memory and Behavior Problems Checklist (RMBPC), the short version of Geriatric Depression Scale (GDS-S), and obtained information about coping strategies using the Carer's Stress scale. The three subscale scores for memory-related problems, depression, and disruptive behavior were obtained from the RMBPC. Scores for three subscales for management of situations, meaning, and distress were obtained from the coping strategies' assessment. Depression was defined as a GDS-S score > or = 5. Among the 74 AD patients, 38 were men and 36 women. Their ages ranged from 47 to 90 years, with a mean age of 72.2 years (SD, 9.0). The CASI scores ranged from 1 to 88 (mean, 45.2; SD, 22.9). Thirty-three caregivers were men and 41 were women. Their age ranged from 20 to 85 years, with a mean age of 53.5 years (SD, 16.9). Twenty-six of the 74 caregivers (35.1%) were classified as depressed. The GDS-S scores of caregivers were correlated positively with the frequency of the use of a management of distress coping strategy and the frequency of the patients' disruptive behavior and were correlated negatively with the educational years of the caregivers.

Poorer prognosis in young patients with gastric cancer?

BACKGROUND/AIMS

Although the relationship between prognosis and age of patients with gastric cancer is controversial, a poorer prognosis in young patients has been suggested by most investigators. To further examine the hypothesis, a retrospective study was undertaken to analyze a large series of patients with gastric cancer in Taiwan.

METHODOLOGY

A total of 1,642 consecutive patients diagnosed with gastric cancer and receiving further management at one medical center from 1988 to 1993 were reviewed. The gender, TNM tumor stage, rate of curative resection and survival of the patients were compared in the young age group (< or = 39 years) and the old age group (> 39 years). Survival was estimated with the product-limit method and difference in survival was tested by the log-rank test. Multivariate analysis was done by the Cox proportional hazard model.

RESULTS

Among the 1,642 patients, 61 patients were in the young age group and 1,581 patients were in the old age group. There was no significant difference for the 2 groups of patients in the distribution of TNM stage (stage I: 20%; II: 8%; III: 13%; IV: 59% vs. 19%, 11%, 25% and 45% respectively, in the old age group, p = 0.098) and rate of curative resection (38% vs 51% in the old age group, p = 0.059). The overall 5-year survival showed no significant difference between the 2 groups (25% vs. 29% in the old). Subgroup analyses showed that survival after curative resection and survival without curative treatment (including palliative resection and no resection) also had no difference in the 2 groups. Multivariate analysis also showed that age was not an independent factor.

CONCLUSIONS

Although most reports suggested a dismal prognosis in young patients with gastric cancer, based on our findings, young patients (< or = 39 years) do not have a worse prognosis than older patients.

[Comparisons of home care utilization between insured and not-insured patients]

In the Andersen-Newman model, utilization of medical services behavior affected by the three factors of need, enabling, and predisposing. Many studies on medical services behavior adapting this model obtained the same results. Our study aimed to describe the difference of insured and non-insured patients using home care, to examine the factors that explain the long-term utilization of home care by using Andersen-Newman model, and to survey the expenditure on home care. Our study collected 486 cases by questionnaires through home interview from various home care units from Sep. 1 to Dec. 31 1994. The response rate was 68.1%. Chi-square and multiple regression tests from SAS computer program performed data analysis. Our results showed there was a significant difference in four months' utilization between insured and non-insured patients (2.38/month vs 1.72/month, p < 0.01). However, if the utilization number per month was less than two, no significance between the two groups was found. Regarding utilization behavior in home care, there were some differences among the need, enabling, and predisposing factors. Our findings demonstrated young patients, patients with chronic illness, and the Fukienese with families involving for care were willing to pay for home care despite the fact that they did not have full support from the family. The determining factors affecting long-term utilization of home care were the Fukienese, patients owning an independent house, patients with health insurance, and patients who lived in mid- or east-Taiwan. In addition, patients with an elevated number of utilizations per month and poor daily activity used home care. All dependent variables could explain 62.38% of variance. The results proposed to the authorities concerned, health institutions and medical professionals for reference in developing home care program.

Revised memory and behavior problems checklist in Taiwanese patients with Alzheimer's disease

The Revised Memory and Behavior Problems Checklist (RMBPC) is a 24-item caregiver report that measures observable behavioral and memory problems in dementia patients and their caregivers' reaction to these problems. The purpose of the present study was to evaluate the applicability of the RMBPC for use in Taiwanese patients with Alzheimer's disease (AD). The subjects included 76 AD patients (39 men and 37 women, mean age 72.3) and their caregivers (34 men and 42 women, mean age 53.5) who participated in a comprehensive assessment at the Veterans General Hospital-Taipei. The Chinese version of the Cognitive Abilities Screening Instrument was administered to the patients. Their caregivers rated the RMBPC and the short version of the Geriatric Depression Score (GDS). To assess the test-retest reliability, 30 caregivers rated a second RMBPC 3 days after the first evaluation. The mean score for the frequency rating on the RMBPC was 32.63 (SD = 12.44, range = 5-61) and the mean reaction score was 10.96 (SD = 11.53). The reaction score was significantly correlated with the GDS score (r = .363, p = .001). The Cronbach's alpha coefficients for frequency and reaction scores were .816 and .895 respectively. The test-retest reliabilities of total frequency and reaction scores were significantly correlated; overall correlations were .89 for frequency (p < .001) and .74 for reaction (p < .001). These findings suggest that the RMBPC be recommended as a reliable tool to assess behavioral and memory disturbance in Taiwanese AD patients.

Small cell lung carcinoma associated with paraneoplastic limbic encephalitis

Limbic encephalitis is an unusual presentation of paraneoplastic syndrome. We report a case of small cell lung carcinoma associated with limbic encephalitis. A 67-year-old man presented with convulsions, memory impairment, and neuropsychiatric disturbances as initial symptoms. Subsequently, small cell lung carcinoma was diagnosed by bronchoscopic biopsy. The cerebrospinal fluid studies, electroencephalography, and magnetic resonance imaging findings had distinctive features compatible with paraneoplastic limbic encephalitis. The neuropsychiatric symptoms improved significantly after six cycles of systemic chemotherapy and adjuvant radiotherapy, resulting in partial remission of the tumor. A follow-up computed tomography scan of the head showed no evidence of intracranial metastasis 7 months after the diagnosis of cancer. Limbic encephalitis may be an initial manifestation of lung cancer. Greater awareness for diagnosis and early treatment of the primary tumor offers the best chance for improvement in patients with lung cancer presenting with limbic encephalitis.

The caregiving burden scale among Chinese caregivers of Alzheimer patients

From April 1996 to January 1997, a total of 76 Alzheimer's disease (AD) patients and their caregivers were recruited for participation in a comprehensive assessment at the Veterans General Hospital-Taipei, a 2,198-bed tertiary-care teaching hospital in Taipei, Taiwan. The AD patients responded to the Chinese version of the Cognitive Abilities Screening Instrument. Primary caregivers rated the patients using the Symptom Check List-90 (SLC-90) and the Revised Memory and Behavior Problems Checklist and then rated themselves with the caregiving burden scale (CBS), coping strategies scale and the short version of the Geriatric Depression Score (GDS-S). The internal consistency of the CBS, as assessed by Cronbach's alpha, was 0.849. The correlations between the CBS, SCL-90 and GDS-S ranged from 0.435 to 0.698. The CBS scores increased with disease progression and were higher among spouse caregivers than adult children caregivers. Multiple-regression analysis revealed that caregivers with higher CBS scores were more likely to have lower education levels and to use the meaning subscales of coping strategies, and that these caregivers' patients had greater disruptive behavior and were older (R2 = 0.727, p = 0. 001). The current study establishes the reliability and validity of the Chinese version of the CBS for assessment of Chinese caregivers of AD patients.

Levodopa may improve orthostatic tremor: case report and trial of treatment

Primary orthostatic tremor is a regular fast lower limb tremor causing unsteadiness on standing. Treatment is generally unsatisfactory. A patient with primary orthostatic tremor who 9 years later developed levodopa responsive idiopathic Parkinson's disease is described. The patient exhibited the classic features of primary orthostatic tremor with relief of the tremor by walking or sitting while treated with levodopa. However, in the "off" state, when the benefits of levodopa disappeared, this orthostatic tremor was continuous and severely compromised the patient's gait. On the basis of this finding eight patients with primary orthostatic tremor were treated with levodopa. Five patients experienced benefit and elected to remain on long term treatment. This study is the first trial of therapy in primary orthostatic tremor and suggests that levodopa can lead to good symptomatic relief in this potentially disabling condition.

Impairment of EEG desynchronisation before and during movement and its relation to bradykinesia in Parkinson's disease

OBJECTIVE

It has been suggested that the basal ganglia act to release cortical elements from idling (alpha) rhythms so that they may become coherent in the gamma range, thereby binding together those distributed activities necessary for the effective selection and execution of a motor act. This hypothesis was tested in 10 patients with idiopathic Parkinson's disease.

METHODS

Surface EEG was recorded during self paced squeezing of the hand and elbow flexion performed separately, simultaneously, or sequentially. Recordings were made after overnight withdrawal of medication and, again, 1 hour after levodopa. The medication related improvement in EEG desynchronisation (in the 7.5-12.5 Hz band) over the 1 second before movement and during movement were separately correlated with the improvement in movement time for each electrode site. Correlation coefficients (r) > 0.632 were considered significant (p<0.05).

RESULTS

Improvement in premovement desynchronisation correlated with reduction in bradykinesia over the contralateral sensorimotor cortex and supplementary motor area in flexion and squeeze, respectively. However, when both movements were combined either simultaneously or sequentially, this correlation shifted anteriorly, to areas overlying prefrontal cortex. Improvement in EEG desynchronisation during movement only correlated with reduction in bradykinesia in two tasks. Correlation was seen over the supplementary motor area during flexion, and central prefrontal and ipsilateral premotor areas during simultaneous flex and squeeze.

CONCLUSIONS

The results are consistent with the idea that the basal ganglia liberate frontal cortex from idling rhythms, and that this effect is focused and specific in so far as it changes with the demands of the task. In particular, the effective selection and execution of more complex tasks is associated with changes over the prefrontal cortex.

Self-organizing tree-growing network for the classification of protein sequences

The self-organizing tree algorithm (SOTA) was recently introduced to construct phylogenetic trees from biological sequences, based on the principles of Kohonen's self-organizing maps and on Fritzke's growing cell structures. SOTA is designed in such a way that the generation of new nodes can be stopped when the sequences assigned to a node are already above a certain similarity threshold. In this way a phylogenetic tree resolved at a high taxonomic level can be obtained. This capability is especially useful to classify sets of diversified sequences. SOTA was originally designed to analyze pre-aligned sequences. It is now adapted to be able to analyze patterns associated to the frequency of residues along a sequence, such as protein dipeptide composition and other n-gram compositions. In this work we show that the algorithm applied to these data is able to not only successfully construct phylogenetic trees of protein families, such as cytochrome c, triosephophate isomerase, and hemoglobin alpha chains, but also classify very diversified sequence data sets, such as a mixture of interleukins and their receptors.