A case of cerebellar hypoplasia in a Chinese infant with osteogenesis imperfecta

We report a unique case of unilateral cerebellar hypoplasia in a young Chinese girl with osteogenesis imperfecta type IV. Magnetic resonance imaging showed mild basilar invagination and impression. Although unilateral cerebellar hypoplasia and osteogenesis imperfecta may have been coincidental diagnoses, we propose possible mechanisms for unilateral cerebellar hypoplasia secondary to osteogenesis imperfecta. For example, cerebellar hypoplasia may have been because of vascular disruption or direct compression to the posterior circulation in utero. Foetuses with osteogenesis imperfecta are more susceptible to the above risks compared to the normal foetus because of associated craniocervical anomalies and a poorly ossified skull.

Management of extremity soft tissue sarcoma after unplanned incomplete resection: experience of a regional musculoskeletal tumour centre

This study reviews the presentation and management of extremity soft tissue sarcoma after unplanned incomplete resection in a musculoskeletal tumour centre in Hong Kong. Medical records of 18 patients who were referred to our centre for further management from January 1995 to May 2001 after inadequate tumour excision were reviewed. Fourteen patients had been referred from private clinics and four from public hospitals. At initial presentation, 10 patients had lesions exceeding 5 cm, nine had a tumour deep in the subfascial plane, and eight had tumours that had recently increased in size. Sixteen had no preoperative radiological assessment or biopsy performed before excision. All except two patients needed additional skin and muscle reconstruction in a subsequent re-resection, and 12 required postoperative radiotherapy. Two patients subsequently developed distant metastases, and one patient died of an unrelated cause. No amputations were required, and no major complications arose from second surgery. Physicians' alertness towards the possible malignancy of soft tissue masses in extremities is important to avoid a potentially mutilating second resection. Well-planned re-resection in a specialised tumour centre can achieve satisfactory local control of disease.

Relation of arterial stiffness with gestational age and birth weight

BACKGROUND

The cardiovascular risk of individuals who are born small as a result of prematurity remains controversial. Given the previous findings of stiffer peripheral conduit arteries in growth restricted donor twins in twin-twin transfusion syndrome regardless of gestational age, we hypothesised that among children born preterm, only those with intrauterine growth retardation are predisposed to an increase in cardiovascular risks.

AIM

To compare brachioradial arterial stiffness and systemic blood pressure (BP) among children born preterm and small for gestational age (group 1, n = 15), those born preterm but having birth weight appropriate for gestational age (group 2, n = 36), and those born at term with birth weight appropriate for gestational age (group 3, n = 35).

METHODS

Systemic BP was measured by an automated device (Dinamap), while stiffness of the brachioradial arterial segment was assessed by measuring pulse wave velocity (PWV). The birth weight was adjusted for gestational age and expressed as a z score for analysis.

RESULTS

The 86 children were studied at a mean (SD) age of 8.2 (1.7) years. Subjects from group 1, who were born at 32.3 (2.0) weeks' gestation had a significantly lower z score of birth weight (-2.29 (0.63), p<0.001), compared with those from groups 2 and 3. They had a significantly higher mean blood pressure (p<0.001) and their diastolic blood pressure also tended to be higher (p = 0.07). Likewise, their brachioradial PWV, and hence arterial stiffness, was the highest of the three groups (p<0.001). While subjects from group 2 were similarly born preterm, their PWV was not significantly different from that of group 3 subjects (p = 1.00) and likewise their z score of birth weight did not differ (-0.01 (0.71) v -0.04 (1.1), p = 1.00). Brachioradial PWV correlated significantly with systolic (r = 0.31, p = 0.004), diastolic (r = 0.38, p<0.001), and mean (0.47, p<0.001) BP, and with z score of birth weight (r = -0.43, p<0.001). Multiple linear regression identified mean BP and z score of birth weight as significant determinants of PWV.

CONCLUSION

The findings of the present study support the hypothesis that among children born preterm, only those with intrauterine growth retardation are disadvantaged as a result of increase in systemic arterial stiffness and mean blood pressure.

A case of Langerhans' cell histiocytosis of the lung presenting with haemoptysis

Langerhans' cell histiocytosis of the lung can be part of a multisystem disorder or an isolated disorder. Ninety percent of adult patients with Langerhans' cell histiocytosis of the lung are smokers. This article reports a case of Langerhans' cell histiocytosis presenting with haemoptysis. The diagnostic signs on chest X-ray, high-resolution computed tomography, and histology are highlighted, followed by a short review of the literature.

Coronary normograms and the coronary-aorta index: objective determinants of coronary artery dilatation

This is a prospective study to establish the normal ranges of the proximal left (LCA) and right (RCA) coronary artery diameters in normal children. Echocardiographic measurements of the internal diameters of the LCA, RCA, and the aortic annulus (AoA) were performed on 390 Asians with normal hearts, between the ages of 2 months to 8 years. The maximal diameters of the LCA and RCA in diastole were measured at predetermined sites. The LCA and RCA diameters correlated linearly with age, height, weight, body surface area, as well as the AoA (Pearson's R > 0.8, p <0.005). Regression equations and z-score graphs were constructed. The coronary-aorta index (coronary artery to aortic annulus ratio) falls within a narrow range- LCA/AoA = 0.15 +/- 0.02 (range 0.09-0.21), RCA/AoA = 0.13 +/- 0.02 (range 0.09-0.20). This is independent of age, sex, weight, height, and body surface area. We have established reference ranges for proximal coronary artery diameters in normal children. The regression equations and z-score graphs for the LCA and RCA provide objective determination of coronary size abnormalities. The coronary-aorta index can serve as a quick guide to detect coronary dilatation.

Successful outcome after serial amnioreductions in triplet fetofetal transfusion syndrome

BACKGROUND

Triplet fetofetal transfusion is an extremely rare complication with high perinatal mortality. Its rarity does not allow any prospective randomized study on various interventional methods to be conducted.

CASE

We report one case of triplet fetofetal transfusion syndrome with survival of all three fetuses. Two were donor fetuses, and one was the recipient fetus. Serial amnioreductions were performed at 22, 24, and 26 weeks' gestation to relieve symptomatic polyhydramnios. Premature rupture of membranes occurred at 27 weeks and cesarean delivery was performed. All three babies were discharged home by 4 months of age, and all had normal neurological development when assessed at 6 months of age.

CONCLUSION

The option of serial amnioreduction, with the anticipation and preparation for delivery at around 28 weeks, should be seriously considered when triplet fetofetal transfusion syndrome is encountered.

All that wheezes is not asthma

Asthma is a common disease. Wheezing is not pathognomonic of asthma, however. One must be alert when appropriate asthmatic treatment does not provide adequate control. Other causes of airway obstruction must be considered, especially when stridor is heard. This report describes an elderly patient who had been managed as having asthma but had an endotracheal tumour.

Cost-effectiveness of CT thorax and bronchoscopy in haemoptysis with normal CXR for exclusion of lung cancer

As fibre-optic bronchoscopy and CT thorax become more widely used, patients with haemoptysis who had normal CXR and sputum results are more commonly offered both CT and bronchoscopy to exclude lung cancer. Doctors who are under possible litigation pressure arising from missed diagnoses of lung cancer are often exhaustive in their investigations, even when the haemoptysis has been transient. The present study aims to investigate the number of cancer patients who can be detected with the two investigations, and compare recent similar study results with archive results. We found that despite the use of more efficient investigation tools, the yield is paradoxically much lower and, hence, less cost-effective than that of previous studies. The likely reason is that doctors tend to over-investigate, even for short-term, minimal blood-streaked sputum, which is common among simple bronchitis. In order to be more cost-effective, these investigations should be used more selectively and for high risk patients such as those with prolonged haemoptysis and those who are heavy smokers.

Highly efficient asymmetric epoxidation of alkenes with a D(4)-symmetric chiral dichlororuthenium(IV) porphyrin catalyst

A dichlororuthenium(IV) complex of 5,10,15,20-tetrakis[(1S,4R,5R,8S)-1,2,3,4,5,6,7,8-octahydro-1,2:5,8-dimethanoanthrance-9-yl]porphyrin, [Ru(IV)(D(4)-Por)Cl(2)] (1), was prepared by heating [Ru(II)(D(4)-Por)(CO)(MeOH)] (2) in refluxing CCl(4). Complex 1 is characterized by (1)H NMR (paramagnetically shifted pyrrolic protons at delta(H) = -52.3 ppm), FAB-mass spectroscopies, and magnetic susceptibility measurement (mu(eff) = 3.1 mu(B)). The ruthenium complex exhibits remarkable catalytic activity toward enantioselective alkene epoxidation using 2,6-dichloropyridine N-oxide (Cl(2)pyNO) as terminal oxidant. The Ru(IV)-catalyzed styrene epoxidation is achieved within 2 h (versus 48 h for the 2-catalyzed reaction), and optically active styrene oxide was obtained in 69% ee and 84% yield (875 turnovers). Likewise, substituted styrenes and some conjugated cis-disubstituted alkenes (e.g., cis-beta-methylstyrene, cis-1-phenyl-3-penten-1-yne, 1,2-dihydronaphthalene, and 2,2-dimethylchromenes) are converted effectively to their organic epoxides in 50-80% ee under the Ru(IV)-catalyzed conditions, and more than 850 turnovers of epoxides have been attained. When subjecting 1 to four repetitive uses by recharging the reaction mixture with Cl(2)pyNO and styrene, styrene oxide was obtained in a total of 2190 turnovers and 69% ee. UV-vis and ESI-mass spectral analysis of the final reaction mixture revealed that a ruthenium-carbonyl species could have been formed during the catalytic reaction, leading to the apparent catalyst deactivation. We prepared a heterogeneous chiral ruthenium porphyrin catalyst by immobilizing 1 into sol-gel matrix. The heterogeneous catalyst is highly active toward asymmetric styrene epoxidation producing styrene oxide in 69% ee with up to 10,800 turnovers being achieved. The loss of activity of the Ru/sol-gel catalyst is ascribed to catalyst leaching and/or deactivation. On the basis of Hammett correlation (rho(+) = -1.62, R = 0.99) and product analysis, a dioxoruthenium(VI) porphyrin intermediate is not favored.

Prevention of recurrent central venous stenosis using endovascular irradiation following stent placement in hemodialysis patients

This study was done to evaluate the outcome after brachytherapy (BT) given to prevent restenosis after stent insertion for central venous stenosis in patients with ipsilateral hemodialysis arteriovenous fistulas (AVF). Angioplasty and stenting were performed on 9 primary central venous stenoses in 8 patients with AVF followed by BT, delivering Iridium-192 radiation using an afterloading technique. BT was also administered to three patients with five recurrent stenoses at the stent margins. There was no residual stenosis after angioplasty and stenting. Venographic follow-up (77-644 days, mean 272 days) showed no restenosis in seven primary stenoses. New strictures (45%-100%) developed at the stent margin in six veins (five patients). Angioplasty or stenting was performed for five margin stenoses in three patients, followed by a second BT. Residual stenosis before BT was 0-30%. In our venographic follow-up (140-329 days, mean 215 days), three restenoses occurred (35%-100%). All progressed to complete occlusion on later venographic follow-up irrespective of whether BT was given to the stent margin or not. The mean primary and assisted primary patency of the central veins were 359 days and 639 days, respectively. Endovascular irradiation with a noncentering source does not prolong the patency after angioplasty and stenting of central venous stenosis in hemodialysis patients.

Comparison of treatment response patterns following scaling and root planing in smokers and non-smokers with untreated adult periodontitis

The present study was conducted to compare short-term treatment response patterns following scaling and root planing in smoking and non-smoking Chinese patients with untreated adult periodontitis. Thirteen smokers and twelve periodontally matched non-smokers with untreated advanced adult periodontitis were evaluated prior to and at one, three, and six months after scaling and root planing. Probing depths (PD), probing attachment level (PAL) and gingival height (GH) were assessed at clinically healthy, gingivitis and periodontitis sites. PD and PAL were measured using electronic Florida pocket and disk probes, respectively. Non-smokers consistently showed significant gingival shrinkage in gingivitis sites, whereas smokers had no significant change in GH. In periodontitis sites, both groups exhibited significant decreases in PD (p < 0.001) at one month, and a greater reduction of PD was found in non-smokers than in smokers (p < 0.05), the difference being most notable at three months (2.4 +/- 0.2 mm vs. 1.1 +/- 0.3 mm, p < 0.001). Non-smokers showed a consistent gain of attachment in periodontitis sites from 0.5 +/- 0.2 mm at one month (p < 0.05) to 1.2 +/- 0.3 mm at six months (p < 0.001), whereas no significant gain of attachment was found in smokers until six months (0.5 +/- 0.2 mm; p < 0.05). Overall, the reduction of PD positively correlated with baseline PD in both smokers (p < 0.01) and non-smokers (p < 0.001), but when only the sites with an initial PD > or = 5 mm were considered, such a significant correlation was found only in non-smokers (p < 0.05). A positive correlation was also found between the change in PAL and baseline PD solely in non-smokers (p < 0.05). This study indicates that smokers have different treatment response patterns and healing dynamics compared to non-smokers following scaling and root planing, suggesting that for smoking patients a more intensive treatment regimen is needed for a better treatment outcome and reduced risk for further periodontal disease progression.

BCL10 somatic mutations rarely occur in gastric lymphoma: detection of high frequency of polymorphisms in BCL10 coding region

The BCL10 gene, recently isolated due to its involvement in the t(1;14)(p22;q32) of mucosa-associated lymphoid tissue B cell non-Hodgkin lymphoma (MALToma), was shown to have frequent somatic mutations and short deletions within the coding region in MALToma and a variety of other lymphomas and solid tumors. These observations have been recently questioned. In this study, we examined BCL10 gene mutations by direct sequencing of the entire coding region of the BCL10 gene, amplified from paired normal and tumor genomic DNAs, as well as tumor cDNAs, in 23 cases of primary gastric B cell non-Hodgkin lymphomas, comprising of 6 cases of MALToma and 17 cases of diffuse large cell (DLC) lymphoma. Heterozygosity due to three types of known polymorphisms in codon 5 (17.3%), codon 8 (21.7%), and codon 213 (8.6%) were observed in both normal germline DNA and tumor DNAs and tumor cDNAs in individual cases. In one case (4.3%) G/C heterozygosity in codon 8 in normal germline DNA was reduced to homozygosity (LOH) in tumor DNA and cDNA. Mutations inactivating BCL10 gene product function were not found in any of these cases. Moreover, post-transcriptional alterations were not indicated by abnormalities in BCL10 mRNA sequence in tumor cDNAs in these gastric lymphoma cases. Our results show that somatic mutations in the BCL10 gene rarely occur in gastric lymphoma and indicate that this gene is unlikely to be of pathogenetic significance in the majority of gastric lymphomas.

Pulmonary haemorrhage in a patient with Kikuchi disease

Kikuchi disease is an immunologic disease and most commonly presents with cervical lymphadenopathy. It is usually self-limiting [1]. It is sometimes associated with systemic lupus erythematosus (SLE) [2], and can be associated with many complications including aseptic meningitis, neuropathy, brachial neuritis. It can also be associated with lymphoma, and may sometimes be misdiagnosed as such [3]. The following is the first reported case of Kikuchi disease associated with pulmonary haemorrhage. The patient died and no other cause of the pulmonary haemorrhage could be identified at post mortem.

Pulmonary artery diameters in premature infants: normal ranges

The aim of this study is to establish the norms for pulmonary arterial diameters in the premature infants. One hundred and thirty cross-sectional echocardiograms were performed on 62 premature neonates (23.4 weeks to 36 weeks gestation) in the Neonatal Intensive Care Unit. Except for small atrial septal defects/patent foremen ovale (< or =3 mm) or patent ductus arteriosus (PDA), babies with structural heart defects were excluded. The weight at echocardiography ranges from 470 grams to 2,445 grams, with a mean of 1,157 grams. The diameter of the pulmonary annulus (PA), left pulmonary artery (LPA) and right pulmonary artery (RPA) were measured at peak systole at predetermined sites. Sizes of the atrial septal defect and PDA were also measured, if present. There was no difference in the diameter between the left and right pulmonary arteries (p=0.254, paired t-test) in the same patient. After controlling for weight, the mean diameters of the LPA and RPA were larger in patients with PDA (p=0.002) compared to those without PDA (p=0.002), while their pulmonary annulus were comparable in size (p=0.691). Between the gestational ages of 23 and 36 weeks, the diameter of PA, LPA and RPA correlated linearly with weight (Pearson R = 0.84, 0.82, 0.65 and 0.71, respectively; p<0.0005). Prediction graphs and regression equations are given. These normal ranges can be used for assessment of pulmonary artery diameters in premature neonates.

Echocardiographic features and management of neonatal ductal aneurysm

OBJECTIVES

To determine the case incidence of ductus arterious aneurysm among our neonates, and to report on our experience in the presentation, echocardiographic features, management and outcome of this condition.

METHODS

Retrospective review of cases diagnosed within a 1-year period from 1 July 1998 to 30 June 1999.

RESULTS

Eight cases of neonatal ductus arteriosus aneurysm (DAA) were diagnosed from 1 July 1998 to 30 June 1999. There were 998 new neonatal echocardiograms done during this period, giving us a case incidence of 0.8 per 100 echocardiograms. Only 1 patient was diagnosed antenatally, all others were detected incidentally on echocardiography done for other indications. None had symptoms related directly to the DAA and there was no suggestive mediastinal mass on chest X-ray. Majority were term infants (88%) and there was a predominance of male infants (75%). Three were associated with patent ductus arteriosus (PDA), while in the others, the ductus arteriosus were non-patent at first echocardiography. In the 3 infants whose ductus arteriosus was patent, the PDA was inserted into the pulmonary artery from an unusually superior direction. Close serial echocardiography on some of our patients suggested that resolution of the aneurysm is by thrombosis, manifesting as an echogenic area, followed by regression. In our series, 7 had total resolution, while 1 patient had a persistent echogenic area which became progressively smaller.

CONCLUSIONS

We found ductus arteriosus aneurysms in 0.8% of our neonatal echocardiograms. An unusually superior insertion of PDA into the pulmonary artery is a marker for its presence. Asymptomatic aneurysms resolve spontaneously and should be managed expectantly. Thrombosis plays a part in the resolution of ductal aneurysm.

Surfactant tracheobronchial lavage for the management of a rabbit model of meconium aspiration syndrome

We evaluated the effect of tracheobronchial lavage with diluted surfactant solution (bovine lipid extract surfactant, bLES) in a rabbit model of meconium aspiration. All animals were anaesthetized, tracheotomized and given 3-4 ml/kg of 25% slurry of human meconium into the endotracheal tube and mechanically ventilated for 1 h. The animals were then randomly assigned to surfactant lavage (n = 12) with 15 ml/kg of diluted surfactant at a concentration of 5.4 mg phospholipid/ml administered in aliquots of 2 ml; or simple endotracheal suction (control n = 12) when the oxygenation index (OI) was >/=15. Changes in the arterial blood gases and the histomorphological and radiological appearances of the lungs were recorded. The OI and arterial/alveolar oxygen tension (a/A PO2) of the surfactant lavage group improved significantly at 5 min post-treatment, and these improvements were observed throughout the ensuing 4 h of ventilation. There was significantly more solid content recovered by surfactant lavage compared with the control group (p = 0.0001). Radiologically, the post-treatment air space opacification scores of the lavage group were significantly lower compared with the control (p = 0.002). The post-treatment radiographs of the lavage-treated rabbits were rated by the radiologist, who was blinded to the treatment groups, as much improved in 5 and improved in 4, whereas the control rabbits were rated as much worse in 3 and worse in 4. Histological examination showed the lungs of the lavaged rabbits had significantly more normal airway (p < 0.0001), more fields showing completely normal airspace (p = 0.0001) and less fields showing severe overdistension with meconium (p = 0.0005). We concluded that lavage with diluted surfactant solution effectively washed out the meconium, improved gases exchanges, and improved the histological and radiological appearances in the rabbit model of MAS.

Many-body approach to the dynamics of batch learning

Using the cavity method and diagrammatic methods, we model the dynamics of batch learning of restricted sets of examples, widely applicable to general learning cost functions, and fully taking into account the temporal correlations introduced by the recycling of the examples. The approach is illustrated using the Adaline rule learning teacher-generated or random examples.

Error-correcting codes and image restoration with multiple stages of dynamics

We consider the problems of error-correcting codes and image restoration with multiple stages of dynamics. Information extracted from the former stage can be used selectively to improve the performance of the latter one. Analytic results were derived for the mean-field systems using the cavity method. We find that it has the advantage of being tolerant to uncertainties in hyperparameter estimation, as confirmed by simulations.

Coinfection of multiple strains of Epstein-Barr virus in immunocompetent normal individuals: reassessment of the viral carrier state

This study reassesses the occurrence of Epstein-Barr virus (EBV) diversity and coinfection versus dominance of a single viral strain within immunocompetent normal carriers. Polymerase chain reaction analysis of several different polymorphic loci of the EBV genome was performed on collections of peripheral blood mononuclear cells and multiple lymphoid and epithelial tissues of the same individuals. Autopsy specimens from 15 individuals who died of causes unrelated to EBV infection served as normal viral carriers. Unexpectedly, coinfection of multiple distinct strains of EBV of the same type (usually type 1) and less frequently of both types 1 and 2 was found to be very high within individual viral carriers. These data indicate that coinfection with multiple EBV strains is much more prevalent in normal carriers than previously appreciated, which in turn has direct implications on EBV persistence, host-viral interaction and pathogenesis.