Successful Treatment of Hepatitis B Virus Infection With Lamivudine After Heart Transplantation

Patients with hepatitis B virus (HBV) infection have a higher morbidity and mortality after heart transplantation (HT). HBV infection is endemic in Taiwan. We studied the effect of lamivudine treatment of HBV infection after HT. From July 1987 to July 2005, 252 patients underwent HT. All recipients and donors underwent routine screening of hepatitis B surface antigen (HBsAg), hepatitis B e antigen, antibody to hepatitis B surface antigen, antibody to hepatitis B core antigen, antibody to hepatitis B e antigen, and an alanine aminotransferase (ALT) level before HT. When ALT was two times greater than the upper limit of normal or serum bilirubin was higher than 3 mg/dL in HBsAg-positive patients, HBV-DNA were checked by a branched DNA assay or polymerase chain reaction. When HVB-DNA was greater than 100,000 copies/mL, lamivudine (100 mg per day) was prescribed indefinitely. There were 14 patients under lamivudine treatment after HT, among whom, none suffered severe adverse reactions from lamivudine. Four patients died: one due to end-stage cirrhosis while awaiting liver transplantation at 14 months after HT. Two died of sudden death at 54 months and 138 months after HT. Another died of diffuse B cell lymphoma at 62 months after HT. All the survivors have normal ALT and undetectable HBV-DNA after lamivudine treatment. But the YMDD mutant was detected in two patients. With successful treatment of HBV infection in HT, it is not necessary to exclude HBV infection patients from HT.

Sparing Immunosuppression in Heart Transplant Recipients With Severe Sepsis

This study described an analysis of severe sepsis among heart transplantation recipients who were treated by sparing all immunosuppressants. Sepsis leading to multiple organ failure (MOF) in heart transplantation has a high mortality. This retrospective study of 190 patients who underwent heart transplantation from 1993 to 2004 included 12 who had severe sepsis with MOF who were treated by sparing all immunosuppressants. Half of them survived after sparing all immunosuppressants with intensive endomyocardial biopsy. Only one case needed pulse therapy for an acute rejection episode. The most common bacterial infectious episodes were caused by methicillin-resistant Staphylococcus aureus (n = 3). All sepsis episodes occurred in the first month after heart transplantation except in one case, which occurred 6 years after heart transplantation. There was a 50% survival rate of heart transplantation recipients who experienced MOF due to severe sepsis and were treated by sparing all immunosuppressants under a program of intensive endomyocardial biopsy.

Simultaneous Heart and Kidney Transplantation for Combined Cardiac and Renal Failure

Simultaneous heart and kidney transplantation (SHKT) is feasible for combined cardiac and renal failure. Herein we reviewed our 10-year experience in SHKT. Six patients underwent SHKT from June 1995 to December 2004. Their ages ranged from 13 to 63 years old with a mean of 45.5 +/- 15.8 years. They were all men except one girl, who was the youngest (aged 13) who suffered from dilated cardiomyopathy with congestive heart failure and chronic renal failure due to systemic lupus erythematosus. Because of aggravating heart failure, she changed from hemodialysis to peritoneal dialysis. Because of intractable heart failure, she underwent SHKT from a 24-year-old female donor. All received hemodialysis before SHKT. The indications for heart transplantation included dilated cardiomyopathy (n = 3), ischemic cardiomyopathy (n = 1), cardiac allograft vasculopathy (n = 1), and cardiac allograft failure (n = 1). The immunosuppressive protocol and rejection surveillance were these employed for heart transplantation. No operative mortality was noted in this study. The 1-year and 5-year survival rates were the same, 83%. The 10-year survival rate was 55%. No cardiac or renal allograft rejection was noted. No renal allograft loss was noted. There were two late mortalities: the one, who underwent redo heart transplantation for coronary artery vasculopathy died of cardiac allograft failure 1 year after SHKT. The other patient died of massive ischemic necrosis of the intestine at 6 years after SHKT. Our experience showed that SHKT had good short- and long-term results without increasing immunosuppressive doses. End-stage failure of either the heart or the kidney did not preclude heart plus kidney transplantation.

Epidural abscess in an obstetric patient with patient-controlled epidural analgesia – a case report

We present the case of a 37-year-old pregnant woman who underwent a cesarean section due to previous cesarean delivery. Spinal anesthesia was performed at the L2-3 intervertebral space with an epidural catheter inserted at L1-2 for postoperative patient-controlled epidural analgesia. When the epidural catheter was removed on day three, an area of redness round the entry point was noted and the patient complained of low back pain, but was discharged from hospital. Later the same day, she felt backache so severe that she was unable to stand up or bend her body. She called for help and was sent to our emergency room. Physicians noted a small amount of discharge from the insertion site, and the body temperature was elevated to 38 degrees C. An anesthesiologist and an infectious disease specialist were consulted, and an epidural abscess was suspected. Urgent magnetic resonance imaging revealed an epidural abscess at L1-2. After five days of unsuccessful treatment with oxacillin, a 28-day course of vancomycin, followed by two months of oral fusidic acid, resulted in complete remission of the epidural abscess. The patient has remained free of neurologic deficit.

Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients

OBJECTIVE

To evaluate potential risk factors and the incidence of bleeding following adenoidectomy or tonsillectomy, with or without adenoidectomy requiring surgical treatment under general anesthesia.

STUDY DESIGN AND SETTING

Retrospective chart review of 15,218 patients who underwent surgery between January 1, 1988, and September 30, 2001, at our institution (St. Anna Hospital, Duisburg).

RESULTS

A total of 229 patients experienced postoperative bleeding (1.5%). Patients of male gender and 70 years of age or older were significantly at risk for post-tonsillectomy hemorrhage. The incidence of bleeding increased with age. Of the bleeding episodes, 76% occurred on the day of surgery; immediate abscess-tonsillectomy was not associated with an increased risk of bleeding.

CONCLUSIONS

Hemorrhage following tonsillectomy and adenoidectomy is rare and predominantly occurs early after surgery. Male patients, 70 years of age or older, infectious mononucleosis, and a history of recurrent tonsillitis were identified as risk factors for post-tonsillectomy hemorrhage. Delayed hemorrhage has the potential to be life-threatening.

The Significance of Hepatic Vein Outflow Volume in Hepatic Outflow Insufficiency of Living Right Liver Graft Evaluated by Doppler Ultrasound

The color Doppler ultrasound has been used to evaluate hepatic vein (HV) outflow insufficiency based on flow velocity and waveforms. In our experience, some cases with flat waveforms are clinically asymptomatic. The parameters of HV flow velocity and waveforms are not always correlated with clinical problems. So, we proposed that total HV flow volume (HVFV) may be a more reliable index. From August 2001 to July 2003, 31 cases among 48 adult-to-adult living related transplants of a right liver graft had one HV anastomosis. HV velocity, waveforms, and HVFV were compared both before and after transplantation. We set the minimal HVFV ratio at 80% based on the original HVFV before graft retrieval. There was no significant difference in HVFV before liver graft retrieval between the 2 groups, but there was a significant change after transplantation. There were no cases of HV insufficiency among group A patients (>80%), whose HVFV ranged from 397 to 1181 mL/min with ratios from 75% to 180% (mean 115%). In group B, there were 4 complicated cases with prolonged severe ascites (<80%) with HVFV ratios from 56% to 76% (mean 66%). Fisher exact test showed a great significance (P < .001). Thus the preliminary criteria of 80% minimal HVFV ratio allows detection of HV insufficiency for further interventional management.

Influence of UNOS status on chance of heart transplantation and posttransplant survival

This study was designed to compare the chance of heart transplantation (HTx) and survival among patients in different UNOS statuses in Taiwan.

METHODS AND RESULTS

From 1996 to 2002, among 203 patients on the heart transplant waiting list, 127 patients had undergone HTx up to December 2002 with 71 dead while waiting, and 5 still alive without transplantation. This study included those 198 patients who had either undergone HTx or who died. At the time of registry, 40 patients were at status IA, 57 at IB, and 101 at II. Nineteen (47.5%) of 40 status IA patients underwent HTx with a mean waiting time of 92 +/- 116 days and median waiting time of 35 days. The 1-month survival was 84%, and 1-year survival was 58%. Seven (64.9%) of 57 status IB patients underwent HTx with a mean waiting time of 85 +/- 100 days and a median waiting time of 40 days. Both 1-month and 1-year survivals were 92%. Seventy-one (70.3%) patients among 101 status II patients underwent HTx. Their mean waiting time was 134 +/- 135 days and median waiting time was 86 days. Their 1-month survival was 95%, and 1-year survival was 85%.

CONCLUSION

Although UNOS status IA patients had a shorter waiting time, their chance to undergo HTx was lower than those in either status IB or status II. The UNOS status IA heart-waiting patients showed lower posttransplant 1-month and 1-year survival rates.

Hepatic venous stenosis in partial liver graft transplantation detected by color Doppler ultrasound before and after radiological interventional management

Hepatic outflow insufficiency remains one of the major complications causing postoperative graft failure especially among partial liver graft transplantations (PLT) including living donor liver transplantation (LDLT), reduced size liver transplantation (RLT), and split liver transplantation (SLT). These procedures are different from the whole liver graft transplantations (OLT), which include multiple vascular anastomoses. Color Doppler ultrasound (CDUS) was used to evaluate the hepatic venous outflow from grafts before and after radiological interventional management and to document treatment effects. From June 1994 to March 2003, our 136 cases of PLTs included 131 LDLTs, two RLTs, and three SLTs. Seven cases (six children and one adult) showed postoperative hepatic vein outflow obstruction and persistent massive ascites, as detected by color Doppler ultrasound (CDUS) and confirmed by interventional angiography. The CDUS showed a monophasic flat waveform with a relatively low hepatic vein average peak velocity (Va) in all cases (mean 11 cm/s). Successful interventional procedures included balloon dilatation in three cases and metallic stent replacement in four cases. CDUS was used with guidance during the procedure to confirm restoration of normal hepatic vein flow with a multiphasic waveform and an objective increase of average flow velocity (high to average 66 cm/s). Ascites disappeared dramatically after the procedure. In conclusion CDUS is the prime modality to diagnose and document a treatment response.

The significance of transarterial embolization for advanced hepatocellular carcinoma in liver transplantation

INTRODUCTION

Transarterial embolization (TAE) is the treatment of choice for advanced HCC to control or even induce tumor shrinkage. The aim of this study was to evaluate the effect of pretransplantation TAE for treatment of advanced HCC.

MATERIAL AND METHODS

From 1996 to 2002, we studied 12 cirrhotic patients with HCC, including six who met and six who exceeded the Milan criteria. All patients had sufficient hepatic function to undergo TAE. Liver transplantations were performed subsequently and they were followed prospectively for a median of 22 months (range = 12 to 53 months).

RESULTS

The explanted livers from the 12 patients who had undergone TAE were noted to have extensive tumor necrosis. The pathological specimens at LT showed downstaging of the HCC, which allowed those six patients to meet the Milan criteria. The overall 1- and 2-year survival rates were 92% and 73%, respectively. The overall 1- and 2-year disease-free survival rates were 92% and 73%, respectively. One death unrelated to liver disease at 2 years after LT was noted in the downgraded group. One patient of the initially eligible group developed lung metastasis at 6 months and died at 12 months after LT.

CONCLUSION

TAE is effective to downstage advanced HCC and reduce the dropout rate on the LT waiting list. Pre-LT TAE may be considered as a better therapeutic strategy for patients with advanced HCC.

Detection of Burkholderia pseudomallei in rice fields with PCR-based technique

Burkholderia pseudomallei Ara- in rice fields was detected using PCR-based techniques with 16S RNA and flagella gene primer sets. The sensitivity of these PCRs was at least 1 CFU/mL of B. pseudomallei Ara- preincubated into Ashdown's medium for 6 h. B. pseudomallei Ara- DNA from watery soil were more detectable than from dry soil. The distribution of this DNA was mainly found at a depth of 300-600 mm under crop-covered fields, but not detected in the location of soil close to the land surface. The results suggest that PCR based on 16S RNA and flagella gene primer sets can be applied to investigate the presence of B. pseudomallei Ara- in contaminated soil of rice fields.

Curcumin inhibited the arylamines N-acetyltransferase activity, gene expression and DNA adduct formation in human lung cancer cells (A549)

It is well known that N-acetyltransferase (NAT) plays an important role in the arylamine metabolism. We analysed the response of A549 human lung cancer cells for N-acetylation of 2-aminofluorene (AF) to curcumin. After curcumin treatment, the NAT activity was examined by HPLC, AF-DNA adduct formation was examined by HPLC, and NAT gene expression by polymerase chain reaction were detected. The NAT activity in the human A549 cells and cytosols was suppressed by curcumin in a dose-dependent manner. The results also demonstrated that gene expression (NAT1 mRNA) in human lung A549 tumor cells was inhibited and decreased by curcumin. After the incubation of human lung A549 tumor cells with AF with or without curcumin co-treatment, the cells were recovered and DNA was prepared and hydrolyzed to nucleotides. The adducted nucleotides were extracted into butanol and analyzation of AF-DNA adducts was done by HPLC. The results also demonstrated that curcumin decreases AF-DNA adduct formation in the human lung A549 tumor cells.

On formation of CaO-Al(2)O(3)-SiO2 glass-ceramics by vitrification of incinerator fly ash

CaO-Al(2)O(3)-SiO(2) system glass ceramics of incinerator fly ash have been prepared by vitrification and then heat-treated in different conditions. The thermal molten process (TMP) was applied to heat treat vitrified samples at high temperatures whereas in the powder sintering process water-quenched vitrified samples were ground into powder and then sintered at high temperatures. Gehlenite was found present as the major phase in all treated samples. Treated samples in general exhibited good leachability characteristics as well as chemical durability, except in the HCl solution. Microstructure and physical properties varied with the treatment condition. Fine and relatively high dense structures with desirable properties were obtained for samples treated by the TMP. For both processes, higher temperature treatments caused crystal growth and thus poor properties were attained. Good physical and mechanical properties achieved at 900-950 degrees C in this study imply the treated samples have attractive potential for engineering applications.

Effects of soil pH, temperature and water content on the growth of Burkholderia pseudomallei

Optimum conditions were determined for the growth of Burkholderia pseudomallei in natural soils or waters. It grows better in paddy soil, crop-covered and fallow field than in fresh and salty water. Although the optimal temperature and pH for the growth were 37 or 42 degrees C, and 6.5 or 7.5 in an environmental-mimicking soil medium, this bacterium can still grow at 4 degrees C, which was suggested to be related with the occurrence of melioidosis in some cold areas. In soil media with water content < 15. B. pseudomallei did not grow until 60 d of incubation, suggesting that water contents of soils in which it dwelled would be one important factor in determining the growth rate.

Digital redesign of anti-wind-up controller for cascaded analog system

The cascaded conventional anti-wind-up (CAW) design method for integral controller is discussed. Then, the prediction-based digital redesign methodology is utilized to find the new pulse amplitude modulated (PAM) digital controller for effective digital control of the analog plant with input saturation constraint. The desired digital controller is determined from existing or pre-designed CAW analog controller. The proposed method provides a novel methodology for indirect digital design of a continuous-time unity output-feedback system with a cascaded analog controller as in the case of PID controllers for industrial control processes with the presence of actuator saturations. It enables us to implement an existing or pre-designed cascaded CAW analog controller via a digital controller effectively.

Ginsenoside Rb1 enhances peripheral nerve regeneration across wide gaps in silicone rubber chambers

Silicone rubber chambers filled with collagen containing ginsenoside Rb1 (GRb1) were used to repair lesioned rat sciatic nerves with 15-mm gaps between stumps. Six weeks after implantation, histology of the nerve regenerated in the chambers filled with GRb1 and collagen contained larger axons than those in the chambers with collagen only. This study showed that the GRb1 could exert a positive influence on nerve regeneration when using silicone rubber tubes.

The cost effectiveness of dual phase 201Tl thyroid scan in detecting thyroid cancer for evaluating thyroid nodules with equivocal fine-needle aspiration results: the preliminary Taiwanese experience

The purposes of this study were to assess the helpfulness of dual phase 201Tl thyroid scan for differentiating malignant from benign thyroid lesions in cases of thyroid nodules with equivocal fine-needle aspiration (FNA) biopsy results. In addition, for thyroid nodules with equivocal FNA biopsy results, we try to make a decision analysis model compared the FNA biopsy alone strategy (strategy A) with decision strategy for the assistance of dual phase 201Tl thyroid scan (strategy B) before diagnostic thyroidectomy as thyroid cancer evaluation strategies for hypothetical cohorts of estimated 17,280-29,160 Taiwanese patients/per year with equivocal FNA biopsy results. Based on the findings of surgical histopathology, dual phase 201Tl thyroid scan sensitivity, specificity, and accuracy were 100%, 90%, and 96%, respectively, in cases of 27 thyroid nodules with equivocal FNA biopsy results. In cost effectiveness analysis, the strategy B showed a cost saving of 16,340,480-27,574,560 US dollars in unnecessary diagnostic thyroidectomy cost. The total cost of strategy B showed a cost saving of 13,932,232-23,520,564 US dollars than that of strategy A. The preliminary data indicate that dual phase 201Tl thyroid scan can save the cost of unnecessary diagnostic thyroidectomy in Taiwanese patients with equivocal FNA biopsy results. In addition, we may provide a noninvasive diagnostic method--dual phase 201Tl thyroid scan, as the first priority for Taiwanese patients with equivocal FNA biopsy before diagnostic thyroidectomy under the coverage of the national health insurance system in Taiwan.