Endoscopic saphenous vein harvest decreases leg wound complication in coronary artery bypass grafting patients

BACKGROUND

Coronary artery bypass grafting (CABG) is the most common procedure performed in adult cardiovascular surgery. The most frequently used conduit is the greater saphenous vein. Using traditional methods, the complication rate of the leg is relatively high (up to 24%). To decrease the complication rate, we used the Endo-Path to harvest the greater saphenous vein.

METHODS AND RESULTS

From May 1997 through March 1999, a total of 135 patients received the CABG operation. We excluded the patients who died immediately postoperatively or had concomitant surgical procedures. Sixty patients received the endoscopic saphenous vein harvest procedure (group A), while another 59 patients (group B) did not. No important differences were noted between the two groups in respect to the number of distal anastomoses, length of harvested vein, total surgical time, and length of ICU stay. However, the leg wound complication rate decreased from 20.3% to 5.0% (p < 0.001).

CONCLUSIONS

Although the long-term patency rate needs time to be proven, the endoscopic greater saphenous vein harvest method is an attractive and effective method.

Double-lumen aortic arch with anomalous left pulmonary artery origin from the main pulmonary artery--bilateral persistent fifth aortic arch--a case report

Both double-lumen aortic arch (i.e., persistent fifth arch) and anomalous origin of the left pulmonary artery from the ascending aorta (failure of the development of the sixth arch) are rare diseases. They are frequently associated with cardiovascular anomalies. However, the co-occurrence of these two diseases has not been previously reported. We report such a case in a female baby with facial anomalies similar to conotruncal anomaly face syndrome.

Staphylococcus capitis bacteremia of very low birth weight premature infants at neonatal intensive care units: clinical significance and antimicrobial susceptibility

Coagulase-negative staphylococci (CNS) are frequently isolated from blood cultures in critically ill neonates. However, Staphylococcus capitis is rarely reported as a pathogen in human beings. From January, 1995 to December, 1997 at a tertiary care neonatal intensive care unit (NICU), a total of 147 (62%) CNS isolates were detected from 236 positive blood cultures, including 27 isolates of S. capitis. Among the S. capitis bacteremia, 17 isolates were judged to be infections as opposed to 10 of the noninfection cultures. The occurrence of S. capitis infection was correlated with long hospital stay (52 +/- 17.6 days vs. 28 +/- 18.5 days, p=0.003) and total parenteral nutrition administration (46 +/- 17.4 days vs. 22 +/- 19.1 days, p=0.006). Apnea, bradycardia, temperature instability and poor activity were the predominant clinical features. Among the 17 episodes of bacteremia, one patient had complicated septic meningitis. There is no statistical significance between S. capitis infection and the duration of a central venous catheter placement (37 +/- 17.5 days vs. 26 +/- 19.5 days, p=0.165). No catheter related infection was proven. Removal of a percutaneous central venous catheter routinely in patients with S. capitis bacteremia is not recommended. All the patients survived after antibiotic treatment. The prevalence rate of multiple resistant S. capitis was 94%. All isolates were resistant to oxacillin, erythromycin and clindamycin but susceptible to ampicillin/sulbactam, vancomycin and teicoplanin. Empiric therapy for S. capitis infection in NICU with ampicillin/sulbactam is therefore recommended. It is important to detect S. capitis which has a high degree of antibiotic resistance in order to treat the patient correctly. S. capitis should be included as etiology and the possibility of nosocomial outbreak in very low birth weight (VLBW) premature infants at NICU.

High rates of antimicrobial resistance among clinical isolates of nontyphoidal Salmonella in Taiwan

To assess trends in antimicrobial-resistant Salmonella infections from 1989 to 1996 in southern Taiwan, the minimum inhibitory concentrations (MICs) of 14 antibiotics or antibiotic combinations were determined by the agar dilution method for 297 clinical isolates of nontyphoidal Salmonella. The rates of resistance to ampicillin, chloramphenicol, and tetracycline were 65, 67, and 78%, respectively. Resistance to trimethoprim-sulfamethoxazole (TMP-SMX) increased from 25% in 1989-1992 to 35% in 1993-1996 (P=0.057). For new quinolones and extended-spectrum cephalosporins, no resistant strains were encountered. Multiple resistance to more than five antimicrobial drugs doubled from 10.6% in 1989-1992 to 19.7% in 1993-1996. Multiply resistant salmonellae were isolated more commonly from blood samples than from feces (30% vs. 14%, P<0.05). In Taiwan, ampicillin, chloramphenicol, and even TMP-SMX are no longer the drugs of choice for treatment of serious nontyphoidal Salmonella infections. Extended-spectrum cephalosporins are now the preferred drugs in Taiwan for treatment of invasive Salmonella infections in children.

Fatal coxsackievirus B infection in early infancy characterized by fulminant hepatitis

OBJECTIVES

to clarify the major features of fatal coxsackievirus B infection characterized by fulminant hepatitis in early infancy.

METHODS

clinical manifestations and laboratory investigations concerning five consecutive young infants with overwhelming coxsackievirus B fulminant hepatitis between 1994 and 1997 were retrospectively reviewed. Aetiological diagnosis was made by viral cultures and confirmed by a neutralization test with a type-specific antiserum.

RESULTS

all five had a deteriorating clinical course of severe hepatitis complicated by disseminated intravascular coagulopathy (DIC). Coxsackievirus B1 infection was established in four patients and coxsackievirus B3 in one. The pathological findings of the two cases illustrated extensive hepatocellular necrosis. Fulminant hepatitis can occur as a leading presentation of disseminated coxsackievirus B infections and dominant the clinical features in neonates and young infants.

CONCLUSIONS

the liver was the target organ of fatal coxsackievirus B infection in our patients. Hepatic involvement progressed rapidly to jaundice and coagulopathy, and was considered to be indicative of poor prognosis. Coxsackievirus B hepatitis may be serious in early infancy.

Group B streptococcal infections in children: the changing spectrum of infections in infants

During a 9-year period from January 1988 to December 1996, 36 patients less than 18 years of age with Lancefield group B streptococcal infections were seen in the National Cheng Kung University Hospital. Among 33 infants with invasive group B streptococcal infections, 3 (9%) were early onset disease (EOD), 27 (82%) late onset disease (LOD) and 3 (9%) onset beyond the third month of life. All cases of EOD were detected during the first day of life and 2 of them were premature births. In the infants with LOD, a high incidence of meningitis occurred (78%). The most common clinical presentation in group B streptococcal infections was fever (81%), followed by irritable crying (42%) and poor feeding (39%). Seizure was noted in 57% of meningitis cases. Obstetric and neonatal risk factors were compared between EOD and LOD, with prematurity and low birth weight significantly (P=0.01) more common among infants with EOD compared with LOD. Of the strains tested, the sensitivity to penicillin, ampicillin and erythromycin were 83%, 74%, and 75%, respectively. All strains were resistant to tetracycline and gentamicin. There were 2 case fatalities (6%) and 6 (17%) had major neurologic sequelae. These data provide that the vast majority of EOD are recognized on the first day of life and prematurity is an important risk factor. In comparison to the previous report in Taiwan, a changing spectrum of GBS infections in infants occurs during the study period. The observed incidence of EOD is decreased and meningitis is still predominantly in LOD. It is suggested early recognition and aggressive therapy have resulted in a much lower mortality rate than previously reported.

Absence of an analgesic effect of qigong "external qi" in rats

The analgesic effect of "external Qi" emitted from the Qigong practitioner was investigated in rats. In behavioral experiments, the rat's tail-flick and head-movement threshold measurements were used to determine if the "external Qi" had analgesic effect. The results were negative. In electrophysiological study, the "external Qi" shows no significant changes in the pain-related evoked cortical potentials to tooth-pulp stimulation. Thus the results of this study are different from those reported by other investigators. It is proposed that this research be repeated and extended.

Effect of infection brain edema on NMDA receptor binding in rat brain in vivo

The purpose of this study was to determine the effect of infection brain edema (IBE) in the rat model induced by injecting pertussis bacilli (PB) into the left carotid artery. The specific binding of N-methyl-D-aspartate (NMDA) receptor with [3H] MK-801 was measured in the neuronal membrane of cerebral cortex. The Scatchard plots were performed. The Bmax values were 0.623 +/- 0.082 and 0.606 +/- 0.087 pmol/mg protein in the group that received normal saline (NS) and PB respectively (P < 0.05). The Kd values were 43.1 +/- 4.2 and 30.5 +/- 3.0 nM in the groups NS and PB respectively. The results indicated that the affinity of NMDA receptor was significantly higher in the group PB than group NS, whereas the total number of NMDA receptors had not changed in the IBE model. The increase of affinity of NMDA receptor can be blockaded by MK-801 pretreatment in vivo.

The role of microvascular permeability in the mechanism for stunned myocardium in rats

The microvascular permeability of stunned myocardium in rats in vivo was studied with FITC-labeled albumin (FITC-BSA). It was found that 15 and 20 min of myocardial ischemia followed by 1 hr of reperfusion resulted in myocardial stunning. The concentrations of FITC-BSA in myocardial tissue were 240.6 +/- 7.8 (IS15) and 267.4 +/- 7.9 (IS20) micrograms/g myocardium in ischemic groups, respectively, which were significantly higher than those in the control group (166.0 +/- 7.9 micrograms/g myocardium; P < 0.01). In stunned groups, the concentrations were 224.8 +/- 11.8 (MS15) and 241.7 +/- 6.0 (MS20) micrograms/g myocardium, decreased from those in ischemic groups but still higher than those in control group by 35.4 and 45.6%, respectively. The more significant the concentration of FITC-BSA, the more serious the myocardial stunning. Electron microscopy revealed no significant vascular injury. The results suggest that the increase in microvascular permeability resulting from transient ischemia is functional and is involved in the pathogenesis of stunned myocardium.

Aluminum utensils contribute to aluminum accumulation in patients with renal disease

Presently, aluminum utensils are widely used in the world, especially in the developing countries. However, whether aluminum leaching from such utensils contributes to aluminum accumulation or causes any damage in patients with renal disease remains unknown. We designed a prospective study to evaluate this problem. After excluding patients who were not examined at follow-up or who poorly complied during the study period, the opened randomized study consisted of 42 patients with chronic renal insufficiency (creatinine clearance <60 mL/min and >10 mL/min). All patients had not taken any aluminum-containing agents for 3 months, but used aluminum kitchen utensils for more than 1 year. Twelve patients comprised the control group; the other 30 patients comprised the study group. The aluminum kitchen utensils used by the study group patients were replaced with stainless steel utensils for 3 months, but those used by the control group were not. After 3 months, the decrements of serum aluminum (5.5 +/- 4.6 microg/L v 2.1 +/- 3.5 microg/L; P = 0.012) and daily urine aluminum excretion (14.3 +/- 15.2 microg/d v 2.1 +/- 5.6 microg/d; P = 0.005) in the study group patients were greater than those in the control group patients. The increments of transferrin saturation of the study group patients (1.8% +/- 9.5% v -3.7% +/- 9.5%; P = 0.052) were greater than those of the control group patients. In addition, the increments of iron (r = 0.368, P = 0.035) and transferrin saturation (r = 0.345, P = 0.049) positively correlated with the decrements of daily aluminum excretion in all patients. The study group patients with greater decrements of serum aluminum (>5.5 microg/L) had greater serum iron levels (90.2 +/- 27.7 microg/dL v 71.9 +/- 27.8 microg/dL; P = 0.047) and transferrin saturation (30.5% +/- 11.0% v 23.0% +/- 9.5%; P = 0.046) than those with less decrements of serum aluminum (<5.5 microg/L) after the study. Our study demonstrates that aluminum kitchen utensils may be the important aluminum exposure source for patients with chronic renal insufficiency who are not taking aluminum-containing agents, and hints that the long-term exposure of aluminum leaching from aluminum utensils probably affects iron levels in patients with chronic renal insufficiency. Further studies are clearly needed to confirm this observation.

Myocarditis with complete atrioventricular block associated with herpes simplex virus infection: report of one case

Myocarditis with complete atrioventricular block is a very unusual complication of the herpex simplex infection. We report a 10-year-old boy infected very likely by the herpes simplex virus and who presented with high fever, erythema multiforme, complete atrioventricular block, and Adams-Stokes seizures. Emergent temporary pacemaker was performed for bradycardia. A sixteen-fold rise in herpes simplex antibody titer by a complement fixation method occurred within two weeks. Normal cardiac rhythm recovered 11 days later with a sequela of complete right bundle branch block after 2 years follow-up.

Streptococcal toxic shock syndrome complicating varicella in children

The most common complication in children with varicella is cutaneous superimposed infection with pyogenic bacteria. Group A beta-hemolytic streptococci, which are known to cause life-threatening infections in both previously healthy children and those with underlying diseases, are the most frequently associated pathogens. A newly recognized disease, called streptococcal toxic shock syndrome, is associated with severe morbidity and mortality. We report a 3-year-old boy with a diagnosis of this syndrome who presented with increasing fever, vomiting, and lethargy 7 days after the development of a classic varicella skin lesion. In spite of aggressive fluid supply, administration of inotropic agents, and cardiopulmonary resuscitation, a rapidly deteriorating clinical course led to death 4 hours after hospitalization. This is the first report of this association in Taiwan. Pediatricians evaluating children with varicella must be mindful of the potential for Group A beta-hemolytic streptococcal infection.

Bezoar manifested with digestive and biliary obstruction

BACKGROUND/AIMS

Gastrointestinal obstructions caused by bezoars are uncommon but are encountered with increasing frequency in general surgery.

METHODOLOGY

We made a retrospective review of 30 cases treated in the National Cheng Kung University hospital between July 1988 and December 1994.

RESULTS

Fourteen patients had either prior gastric surgery (9) or peptic ulcer disease (5) and were categorized as group I. The remaining 16 patients without above conditions were categorized as group II; and seven of them had history of ingestion of Pho Pu Zi (Cordia dichotoma Frost. f.), three had food bolus ingestion, two had diverticulum, two had adhesion and the remaining two had no significant features. Two patients, who received endoscopic removal of gastric bezoar and subsequently developed bowel obstruction, needed operation. Sixteen of 30 who underwent operation within 24 hours after arrival, recuperated uneventfully and most were discharged within a week. Eleven patients who received operation after 24 hours resulted in prolonged hospitalization in 9 and death in two. Re-operation was performed in one case for the recurrence of obstruction by the residual bezoar.

CONCLUSION

Dietary factors (Pho Pu Zi or bolus ingestion), and gastrointestinal (GI) anatomical lesion (diverticulum or adhesion) are the profound etiologies for formation of bezoars in cases without previous gastric surgery. On the other hand, gastric factors (previous ulcer surgery or peptic ulcer) play a major role even after ingestion of nonspecific high fiber diet. Early diagnosis, surgical intervention without delay and thorough exploration of the entire GI tract are essential for good postoperative results.

Effect of sodium glycyrrhetinate on chemical peritonitis in rats

AIM

To study the anti-inflammatory mechanisms of sodium glycyrrhetinate (SG).

METHODS

Rat chemical peritonitis was used. The protein content and prostaglandin E2 (PGE2) content in exudate were measured by Folin-phenol assay and RIA, respectively. SOD activity in neutrophils (Neu) was determined by pyrogallol-NBT colorimetry. cAMP content in Neu was detected by competitive protein binding assay.

RESULTS

In peritonitis caused by histamine, SG 10-20 mg.kg-1 i.m. reduced exudate volume and Neu counts, and 5-20 mg.kg-1 i.m. lowered the protein content in exudate. In peritonitis induced by carrageenan, SG 20 mg.kg-1 i.m. reduced exudate volume, Neu counts, protein content and PGE2 content in exudate, increased SOD activity in Neu, but did not affect beta-glucuronidase release from Neu. In peritonitis induced by arachidonic acid, SG 20 mg.kg-1 i.m. reduced Neu counts, protein content, and PGE2 content in exudate, and attenuated the reduction of cAMP level in Neu.

CONCLUSION

SG exerts its anti-inflammatory action by lowering permeability of capillaries in inflammatory site, inhibiting Neu emigration and PGE2 biosynthesis, and scavenging oxygen free radicals.

Thrombolytic therapy for mitral valve thrombosis

A 44-year-old man with a St. Jude mitral valve was admitted because of progressive pulmonary edema. He was diagnosed with prosthetic heart valve thrombosis (PHVT) based on the findings of "muffled" prosthetic valve clicks. Doppler echocardiographic evidence of severe mitral stenosis and transesophageal echocardiographic evidence of limited mitral valve motility. Because the patient hesitated to undergo our recommended surgical treatment, he was immediately treated with intravenous recombinant tissue plasminogen activator (100 mg over 3 h) followed by heparinization. Two hours after the thrombolytic therapy, the prosthetic valve clicks became clearly audible and his congestive symptoms were dramatically improved. Follow-up echocardiography no longer-showed significant mitral valve obstruction. A transient cerebral ischemic attack occurred at the end of thrombolytic therapy but there were no neurologic sequalae. The patient, on warfarin therapy, was well at follow-up 8 months after discharge. Surgical intervention has long been the standard therapy for patients with PHVT. Our case experience suggests that thrombolytic therapy may be considered as an effective alternative to surgical intervention for selected patients with PHVT. In this report, we also review the current literature regarding the indications, effectiveness and safety of thrombolytic therapy in PHVT.

Surgical experience with Salmonella-infected aneurysms of the abdominal aorta

Five patients, aged between 64 and 75 years with Salmonella-infected abdominal aortic aneurysms were surgically treated between 1993 and 1995 at the National Cheng Kung University Hospital. Cultures of aneurysmal wall tissue and blood yielded Salmonella enteritidis Group B in three patients and Salmonella choleraesuis in the remaining two. All patients presented with fever and abdominal or back pain. Pulsatile masses were noted in only two patients. Infrarenal abdominal infected aneurysms were demonstrated by computed tomography and aortography in each patient. The five patients underwent aneurysmal resection with in situ graft reconstruction from 1 to 20 days after the diagnosis was made. The graft was wrapped with an omental pedicle. Duodenal repair was performed in one patient due to an aortoduodenal fistula found during surgery. He died 19 days after surgery because of duodenal leakage and uncontrolled sepsis. Four patients survived and remained well 11 to 34 months (mean, 25 mo) after surgery. Postoperatively, only one patient developed adhesion ileus and required enterolysis. Parenteral antimicrobial therapy was continued in all patients after surgery for 2 to 4 weeks; only one patient had an additional 4 months of oral antibiotics. Although the number of patients was small, the survival rate was high, at 80%. Our experience suggests that Salmonella-infected aneurysms of the abdominal aorta can be successfully treated by resection of the aneurysm with extensive debridement followed by in situ graft interposition with omentum wrapping. Once diagnosed, the patients should be scheduled for surgery as soon as possible. Antibiotics should be continued parenterally for at least 2 to 4 weeks postoperatively. While long-term suppressive antibiotic therapy is usually recommended, it might not be essential with our surgical approach.

Cantrell's syndrome in an infant

Cantrell's syndrome is a rare combination of congenital midline thoracoabdominal defects and congenital heart disease. surgical repair can correct many of the anomalies. We report a neonate who presented with a short sternum, defective upper abdominal muscle, ectopic umbilicus, anterior diaphragmatic defect, ventricular septal defect and an intra-abdominal left ventricular diverticulum. Initially, the infant was treated with digoxin and diuretics for 5 months. Due to poor control of heart failure, one-stage surgical correction was performed with patch repair of the ventricular septal defect, ligation of left ventricular diverticulum and closure of the defects of the diaphragm and upper abdominal wall.

Papillary cystic tumor of the pancreas in children

Papillary cystic tumor of the pancreas, so-called Frantz tumor, is a very rare tumor in children. Only 157 cases had been reported since 1959. The clinical manifestations of this disease are usually a slowly growing abdominal mass with or without abdominal pain. It occurs predominantly in young females, and its pathogenesis is still unknown. Surgical resection is usually curative, and its prognosis is excellent. Four adolescent girls with acute or chronic abdominal pain were found to have papillary cystic tumor of the pancreas at our hospital in the past 4 years. They all have a variable clinical presentation. Papillary cystic tumor of the pancreas should therefore be considered one of the differential diagnoses of abdominal pain or abdominal mass in adolescent girls.

Role of endothelial cell mitosis in transendothelial transport of low density lipoprotein in hypercholesterolemic and normal rabbits

BACKGROUND

Atherosclerosis is characterized by focal areas of lipid accumulation and intimal smooth muscle cell proliferation in large arteries. It has been suggested that the permeability of arterial endothelium to lipid is an important factor in the initiation and progression of atherosclerosis. The mechanism by which macromolecules such as low density lipoprotein (LDL) enter the arterial wall, however, is still not completely understood. Our previous studies have demonstrated that there is close association of endothelial cell turnover with transendothelial macromolecular transport in normal rat aorta. Because hypercholesterolemia has been well documented as one of the major risk factors for atherosclerosis, we explore the relationship between endothelial cell mitosis and transendothelial transport of LDL in hypercholesterolemic rabbits.

METHODS

The present study is designed to perform on thoracic aortae from 30 male New Zealand white rabbits fed with either 1% cholesterol-enriched diet (HC group; n = 15) or normal diet (NC group; n = 15). The concentrations of serum cholesterol and triglycerides from two groups were measured by enzymatic procedures using commercial kits. The aortae of hypercholesterolemic and normocholesterolemic rabbits underwent perfusion-fixation 10 min following the intravenous injection of low density lipoprotein conjugated with Lucifer yellow (LY-LDL) for fluorescence microscopy. En face preparations of the thoracic aortae stained with hematoxylin allowed the identification of ECs in mitosis. The relationship between LY-LDL leakage and endothelial cell mitosis was determined.

RESULTS

Although endothelial cell mitosis is infrequent (NC: 0.0022 +/- 0.0007%; HC: 0.0004 +/- 0.0001%) in the thoracic aorta of New Zealand white rabbits, 68.2 +/- 8.4% (NC) or 74.3 +/- 9.0% (HC) of dividing cells in the M phase were associated with LYLDL leakage. These dividing cells accounted for 65.0 +/- 9.2% (NC) or 64.4 +/- 11.3% (HC) of all LY-LDL leaky spots.

CONCLUSIONS

Thus, this study not only confirmed the close association of EC mitosis with macromolecular permeability in normal group, but also demonstrated that the same relationship existed in hypercholesterolemic rabbits. These observations lend support to the theory that transiently open junctions surrounding the endothelial cells undergoing cell turnover provide pathways through which LDL enters the subendothelial space, resulting in lipid accumulation and atherosclerosis.

Incidence of post-transfusion hepatitis in Taiwan before and after introduction of anti-HCV testing

The effectiveness of second-generation anti-hepatitis C virus antibody (anti-HCV) screening of blood donations for the prevention of non-A, non-B post-transfusion hepatitis (NANB PTH) was assessed. A prospective study of 192 transfusion recipients was performed to compare the incidence of NANB PTH after the introduction of the second-generation anti-HCV test with the incidence before its introduction. We used a polymerase chain reaction to detect HCV-RNA and HBV-DNA in the sera of patients with NANB PTH. The incidence of acute post-transfusion hepatitis C was 11% (8 of 71) before the screening for anti-HCV as compared with 2.5% (3 of 121) after the screening (p < 0.05). Viremia was detected within the first five weeks of infection in 10 patients with acute post-transfusion hepatitis C. However, there was no significant difference in the incidence of non-A, non-B, non-C (NANBNC) PTH before screening (3 of 71, 4.2%) compared with after screening (3 of 121, 2.5%). Usually, NANBNC PTH was not clinically important. Anti-HCV screening of blood donors significantly reduces the incidence of post-transfusion hepatitis C, but not the incidence of NANBNC PTH.

Chronic elemental mercury intoxication: neuropsychological follow-up case study

In initial and follow-up investigations of neuropsychological function in a patient with elemental mercury intoxication, his scores were compared with those of a group of normal control subjects matched for sex, age and education. Each subject received a comprehensive neuropsychological examination including a personality inventory. On the initial examination the results indicated that the patient had a significant depression of performance intellectual functioning, impairments of attention, non-verbal short-term memory and visual judgement of angles and directions, psychomotor retardation and personality changes including depression, anxiety, desire to be alone, lack of interest and sensitivity to physical problems. Such an impairment picture is compatible with the previous observations of individuals with chronic exposure to elemental, organic or inorganic mercury. The follow-up study was undertaken about 1.5 years later. The results show that the patient's cognitive and personality functions were fully recovered. Our findings thus suggest a reversibility of impaired neuropsychological function in persons with elemental mercury poisoning if a prompt removal from the toxic environment is accomplished, together with proper medical treatment.

Hepatitis C virus RNA in peripheral blood mononuclear cells: comparing acute and chronic hepatitis C virus infection

Hepatitis C virus (HCV) can infect peripheral blood mononuclear cells (PBMC) of patients with chronic HCV infection. No data are available on PBMC testing for HCV RNA in acute hepatitis C. This study investigated the presence of HCV RNA in PBMC of patients with acute posttransfusion hepatitis C, compared with those with chronic HCV infection. Nested polymerase chain reaction (PCR) was applied to detect HCV RNA in 111 and 48 paired samples of serum and PBMC of 11 patients with acute posttransfusion hepatitis C and 48 patients with chronic HCV infection, respectively. In patients with acute posttransfusion hepatitis C, HCV RNA was detected in 17 of 29 (59%) and 67 of 82 (82%) serum samples collected during the incubation period and acute phase, respectively. Meanwhile, of the 48 patients with chronic HCV infection, 41 had serum HCV RNA (85%). HCV RNA was not detected in PBMC samples from incubation period or from acute-phase hepatitis, although it was detected in 12 of the 48 PBMC samples of chronically infected patients (25%) P < .005). Of the 12 PBMC specimens positive for positive-stranded HCV RNA, 6 were also positive for negative-stranded HCV RNA. Among patients with chronic HCV infection, HCV infection of PBMC was not related to age, sex, blood transfusion, serum alanine transaminase (ALT) levels, or serum virus titers. In conclusion, HCV infection of PBMC rarely exists in patients with acute hepatitis C. As HCV infection persists, the incidence of HCV infection of PBMC becomes higher.

Upper airway obstruction caused by vascular anomalies in children

Vascular ring or sling is one of the important etiologies for congenital upper airway obstruction in children. Between July 1988 and July 1995, a total of 92 children with stridor were initially evaluated by an esophagogram and two-dimensional echocardiogram. Seven children (7.7%) with variable types of vascular anomalies were diagnosed including pulmonary artery sling (2 cases), double aortic arch (1 case), right arch with left aberrant subclavian artery and ligamentum ductus (1 case), double aortic arch with one atretic arch (2 cases), and innominate artery compression of the trachea (1 case). The age at diagnosis ranged from 18 days to 3 years old. Only one patient was associated with an intracardiac anomaly. Five of the 7 patients were diagnosed as having laryngomalacia previously. Six patients had esophageal indentation on their esophagograms. Besides external airway compression, three patients also had intrinsic tracheal stenosis. Six patients received surgery because of severe respiratory distress. The patients' symptoms improved after surgery, but a premature baby died after a second operation for intrinsic tracheal stenosis at the age of 8 months.

One-stage repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries by a handmade trifurcated valved conduit

An 18-year-old girl with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (MAPCAs) was reported. Her left-side pulmonary artery was absent, and the blood flow to the left lung was derived from two MAPCAs. One-stage correction, including the left-side thoracotomy and followed by the median sternotomy, was performed. A handmade trifurcated valved conduit was used to connect the right ventricle and the distal pulmonary arteries. The patient was doing well 3 years after the operation.

In vitro enhancement of antibody responses by T delta cells expressing IgD receptors

Previous in vivo studies have shown that murine T cells induced to express receptors specific for IgD (IgD-R) have humoral immunoaugmenting properties with respect to both primary and secondary antibody responses to various antigens. Such murine IgD-R+ T cells (T delta cells) belong to the CD4+ T cell population in contrast with human T delta cells which also include CD8+ cells. The purpose of these studies was to develop an in vitro assay system to examine the mechanism by which T delta cells facilitate enhanced antibody responses. Our studies demonstrate that B cell responses to both soluble and particulate antigens can, indeed, be enhanced in vitro by coculture with T cells previously induced to express IgD-R. This in vitro effect requires cognate interaction between T and B cells and is dependent on the presence of adherent cells or IL-1. T cell priming with antigen, while not a prerequisite, was found to result in more effective T delta-B cell interactions compared with naive T delta cells. Finally, evidence was obtained in support of an adhesion-mediated T delta-B cell interaction since the immunoaugmenting properties of T cells expressing IgD-R are completely blocked by the addition of very low doses of monomeric IgD to the cultures.

The value of Tc-99m MIBI SPECT during isosorbide dinitrate infusion in assessment of viable myocardium in patients with myocardial infarction

Tc-99m MIBI myocardial SPECT has shown promise for evaluation of coronary artery disease. But its role in predicting myocardial viability is still under investigation. The purpose of this study was to evaluate the value of Tc-99m MIBI myocardial SPECT during isosorbide dinitrate (ISDN) infusion in the assessment of myocardial viability. Thirty-seven patients with previous myocardial infarction (the infarct age ranged from < or = 30 days to 900 days) were studied, of them 13 patients had Tc-99m MIBI studies before and after coronary artery bypass grafting (CABG). The results showed that out of 134 segments with hypoperfusion at resting SPECT, 56 segments (41.8%) had an increase in Tc-99m MIBI uptake during ISDN infusion. Among them, 17 segments (30.4%) were normalized, 6 segments (10.7%) were significantly improved and 33 segments (58.9%) were improved. The degree of improvement in perfusion was related to the age of the myocardial infarction. In 13 patients with CABG, of 31 segments with improvement in perfusion post CABG, 25 segments (80.6%) showed perfusion improvement during ISDN infusion, and of 28 segments with improved wall motion post CABG, 23 segments (82.1%) showed improvement in perfusion during ISDN infusion. Tc-99m MIBI SPECT during ISDN infusion may therefore be a useful approach for assessing myocardial viability.

Modified Senning procedures for simple transposition of the great arteries

From December 1990 to July 1994, 10 infants with simple transposition of the great arteries (TGA) underwent the Senning procedure at National Cheng Kung University Medical College. Their ages ranged from 1 to 8 months (mean, 4.8 +/- 2 months), and their body weight ranged from 3.5 to 7.5 kg (mean, 5.7 +/- 1.2 kg). Four infants were treated with the conventional method by covering the sinoatrial (SA) node with the anterior right atrial flap (group 1). The other six patients had modified procedures, having the suture line across the caval vein, caudal to the SA node (group 2). Three of the group 1 patients experienced junctional rhythm temporarily, another had SA node dysfunction for 1 week postoperatively. In group 2, all patients were in sinus rhythm except one, who returned to sinus rhythm on the second postoperative day. There was one (10%) surgical mortality, a patient in group 1, and one (10%) late mortality, in group 2. The clinical follow-up interval was 6 to 46 months (mean, 28.8 mo). All survivors were in sinus rhythm, and echocardiographic studies demonstrated no difference between the two groups as to conduit obstruction or degree of tricuspid valve regurgitation. In conclusion, in situations that require atrial switch for the correction of TGA, a suture line across the caval vein, caudal to the SA node, may be a useful modification to prevent arrhythmias.

Tetralogy of Fallot with an additional muscular inlet type ventricular septal defect--repair with split patch technique

An 8-year-old girl with tetralogy of Fallot (TF) and double ventricular septal defects (VSDs) was reported. The additional VSD was a muscular inlet type. A split patch technique was used to cover both VSDs during the total correction. Follow-up echocardiogram demonstrated no residual shunt nor significant tricuspid valve regurgitation. The patient is doing well 2 years after operation.

Schwann cell properties: 3. C-fos expression, bFGF production, phagocytosis and proliferation during Wallerian degeneration

The role of Schwann cells (SC) during Wallerian degeneration has been controversial. The consensus opinion is that monocytes/macrophages are mainly responsible for myelin removal although SC were shown to phagocytose myelin in vitro and in vivo. In the present study, we correlate proto-oncogene expression with phenotypic changes in SC during Wallerian degeneration using immunohistochemistry and electron microscopy. The proliferative cells are labeled with proliferative cell nuclear antigen (PCNA), and macrophages are labeled with ED1 macrophage marker. We demonstrate c-fos expression in SC at the onset of axon disintegration 12 hours post-axotomy followed by expression of ED1, basic fibroblast growth factor (bFGF) and PCNA after 1 day. The myelin sheath fragments at the nodal region and forms ellipsoids. Schwann cells move to internodes and undergo nuclear and cytoplasmic hypertrophy; they phagocytose myelin ellipsoids with thick vimentin-rich processes and undergo mitosis. Resident macrophages express c-fos and phagocytose myelin debris sequestered into endoneurium by SC after 3 days, but they do not enter the tube until the fifth day. We believe that SC are induced by signals from injured axons to express c-fos which activates downstream genes that lead to the acquisition of phagocytic and proliferative activities. Myelin debris processed by SC may act as an inducer and a chemoattractant for resident macrophages. Cytokines produced by macrophages may stimulate SC proliferation and production of neurotrophic factors.

Effect of injury on the bi-affinity alpha 1-adrenoreceptor binding in rat brain in vivo

Focal freezing lesions in rats cause a widespread decrease of cortical glucose utilization in the lesioned hemisphere, probably as a reflection of depressed cortical activity. The noradrenergic neurotransmitter system was implicated in these alterations when it was demonstrated that prazosin, a specific norepinephrine (NE) antagonist at alpha 1-adrenergic receptors, prevented their development. In normal rat brain, specific binding of [125I]HEAT [(+/-)2-(3-[125I]iodo-4-hydroxyphenyl)-ethyl-aminomethyl-tetralone], another selective alpha 1-adrenoreceptor ligand, was demonstrated in vivo at sites consistent with the alpha 1A- and alpha 1B-adrenoreceptor subtypes. In the present study, the effect of a freezing lesion on specific binding of [125I]HEAT in rat brain in vivo was determined three days after traumatization when cortical glucose use suggested the greatest degree of functional depression. The steady-state volumes of distribution of [125I]HEAT three days after injury were significantly increased in all the cortical areas of the lesioned hemisphere, but not in the subcortical structures. Injury did not modify the binding affinities for HEAT. However, a statistically significant increase in the number of low-affinity binding sites for this ligand was demonstrated in all cortical areas of the lesioned hemisphere, but not in subcortical structures. The traumatization did not modify Bmax estimates for the high-affinity binding of HEAT. The results support the hypothesis that changes in the noradrenergic system are of functional importance in brain injury and that at least some effects of injury are mediated by alpha 1B-adrenergic receptors.

Cardiac responses activated by nicotine in canine ganglial plexus between aorta and pulmonary artery

In order to study the location and function of nicotine-sensitive neurons of cardiac ganglial plexuses, microdissections of collections of fat pads were carried out, and nicotine (100 micrograms) was injected into the ganglial plexus between aorta and pulmonary artery (A-PGP) in 30 anesthetized open-chest dogs. There were numerous ganglia or neurons in A-PGP. Either positive or negative inotropic and chronotropic responses were elicited following injections of nicotine into A-PGP. Control injections of 0.1 ml saline into A-PGP and injections of nicotine (100 or 200 micrograms) into right marginal ganglial plexus did not elicit any cardiac responses. After acute decentralization, nicotine (100 micrograms) was again injected into the same locus of A-PGP. Some positive and negative responses could still be induced, but their frequencies were reduced. These suggest that nicotine can directly activate the efferent parasympathetic and sympathetic neurons and indirectly activate them by stimulating the afferent neurons existing on the surface of dog heart.

Variation in mitochondrial DNA and population structure of the Taipei treefrog Rhacophorus taipeianus in Taiwan

Mitochondrial DNA (mtDNA) from 40 samples of the Taipei treefrog Rhacophorus taipeianus collected from seven populations in Taiwan were sequenced to document the DNA sequence variation in anuran mtDNA and to elucidate the phylogeographic population structure in the Taipei treefrog. Sequences of 722-764 bases in length, including a 108-bp segment of the cytochrome b gene and a 614-656-bp D-loop segment, were obtained by direct sequencing using polymerase chain reaction (PCR). The variation in length was due to a 40-bp region that tandemly repeated four to five times in the D-loop region. The first repeat is the most conserved one among the five repeats because there are no variable sites in this repeat. Besides the 40-bp length variation, 28 positions in the 764-bp sequences are variable and distributed evenly in the cytochrome b gene fragment and D-loop region. Variation in the D-loop of the Taipei treefrog is comparable to those of other vertebrates. Two well-differentiated lineages (northern and central) differing by mean sequence divergence of 1.7% are identified and concordant with their geographic distributions. The two lineages are inferred to have split from a common ancestral population in the early Pleistocene. However, the interpopulation divergence of the northern lineage (< 0.33%) is apparently lower than that of the central lineage (1.11%), implying that the two lineages evolved independently and had different demographic histories after divergence. This study reveals that anuran D-loop has potential as a genetic marker in phylogenetic and population genetic analyses of anurans.

Chronic elemental mercury intoxication: clinical and field studies in lampsocket manufacturers

Four workers chronically exposed to elemental mental mercury in a lampsocket manufacturing factory were studied. The clinical manifestations were severe in one, mild in another, and suspicious in the remaining two. Correlation between severity of clinical features and increased urinary mercury concentrations was found. The time weighted average mercury concentrations were 0.945 mg/m3 and 0.709 mg/m3 for two workers in one room and 0.225 mg/m3 in the other. After stopping exposure, the workers recovered spontaneously or with D-penicillamine treatment within six months. It is concluded that recovery from chronic elemental mercury intoxication may be complete when patients are removed early from the exposure environment. The hazard of mercury intoxication in recycling of waste substances is emphasised.

Systemic atrioventricular valve replacement in an infant with corrected transposition of the great arteries

An eight-month-old male infant with corrected transposition of the great arteries and severe systemic atrioventricular valve regurgitation due to "Ebstein-like anomaly" is reported. Through a midline sternotomy and transeptal approach, a 20 mm Medtronic Hall aortic mechanical valve was reversely implanted into the systemic atrioventricular valve. Anti-platelet drugs (acetylsalicylic acid and dipyridamole) were prescribed for prevention of thromboembolism. The patient is doing well three years after operation.

Left vocal cord palsy: an unusual presentation of a mycotic aneurysm of the aorta caused by Salmonella cholerasuis

A 67-year-old man was admitted to hospital because of fever, productive cough and a concomitant hoarseness. A para-aortic lesion was found on chest X-ray, and bronchoscopy revealed a left vocal cord palsy. Due to rapid enlargement of the lesion, angiography was performed, which revealed a pseudoaneurysm at the descending aorta. Operation disclosed an infected aneurysm with rupture, and tissue culture yielded Salmonella cholerasuis. The findings of a mycotic aneurysm and hoarseness due to compression of the left recurrent laryngeal nerve is a rare and serious combination caused by salmonella, previously unreported in the medical literature.

Importance of transcapillary insulin transport to dynamics of insulin action after intravenous glucose

Insulin action in vivo is determined by both transendothelial insulin transport (TET) across the capillary and subsequent insulin binding and postreceptor events. To examine TET under non-steady-state conditions, we performed intravenous glucose tolerance tests (IVGTT; 0.3 g/kg; n = 7) on conscious dogs. At basal, insulin in lymph was only 53 +/- 7% of plasma insulin (P < 0.001), whereas lymph glucose exceeded plasma levels (109 +/- 4 vs. 104 +/- 4 mg/dl, respectively; P < 0.02). On injection, dynamics of glucose in plasma and lymph were similar, suggesting rapid equilibration of glucose between compartments. In contrast, insulin appearance in lymph was delayed relative to plasma (5.1 +/- 1.3 vs. 2 +/- 0 min), peaked later (21 +/- 2 vs. 8 +/- 2 min), attained peak value of only 52 +/- 6% of plasma insulin (range, 35-76%), and remained lower than plasma insulin throughout the IVGTT (P < 0.05 or better). Minimal model-derived insulin sensitivity (SI) averaged 3.55 +/- 0.75 x 10(-4) min-1/(microU/ml). There was a strong linear relationship between lymph insulin and its effect on glucose disappearance [X(t), r = 0.95 +/- 0.01]. Determination of the relative contributions of TET and post-TET insulin-sensitive processes to overall SI revealed that cellular sensitivity to interstitial insulin dominated (r2 = 0.55), but was not the exclusive determinant of, overall SI, as insulin transport was also important (r2 = 0.21). TET is a previously unrecognized contributor to SI in vivo.

Reperfusion arrhythmias in acute myocardial infarction

In 27 patients with acute myocardial infarction (MI) and their infarct-related coronary artery being completely occluded who received thrombolytic therapy or percutaneous transluminal coronary angioplasty, reperfusion was confirmed by immediate coronary angiography in 24. Reperfusion arrhythmias (RA) occurred in 19 (79.2%) of the patients, including ventricular arrhythmias in 13 (54.2%). Ventricular fibrillation and sustained ventricular tachycardia developed in 2 (8.4%) and accelerated idioventricular rhythm in 5 (20.8%), the latter was a reliable indicator of coronary recanalization. Transient sinus bradycardia or AV block occurred in 10 (66.7%) of the 15 patients with inferoposterior MI. The occurrence of RA was not related to the duration of ischemia; ventricular RA was also not related to the location of MI and the occurrence and severity of ischemic arrhythmias before reperfusion.

Persistent truncus arteriosus associated with interrupted aortic arch: report of two cases

Two neonates with a combination of truncus arteriosus and interruption of the aortic arch, so-called type A4 of the Van Praagh classification, are reported. Both presented as tachypnea, poor appetite and increasing cyanosis during the first week of life. The combination of these defects significantly increases the surgical risk. Di-George syndrome was noted in one patient, who presented with hypocalcemia and T cell dysfunction. Autopsy confirmed this diagnosis.

[The natural history of sick sinus syndrome]

Ninety one cases of sick sinus syndrome (SSS) have been traced clinically for an average term of 5 years and 4 months. The result shows that the natural history of SSS is relatively long, no one of these cases died of arrhythmia during the investigation, and pacemaker is the first choice for patients with apparent severe symptoms.

Shone's anomaly: report of one case

A two-month-old female infant presented with intractable congestive heart failure and cyanosis, present since the neonatal period. The echocardiogram and angiogram showed a parachute mitral valve, aortic and subaortic stenosis, perimembranous type ventricular septal defect, mild aortic coarctation and patent ductus arteriosus. Unfortunately, the patient expired two days after surgical angioplasty for coarctation of the aorta. The autopsy proved a typical case of Shone's anomaly.

[Quantitative assessment of the effect of nitroglycerin on left ventricular function with two-dimensional echocardiography in patients with myocardial infarction]

The effect of sublingual and intravenous nitroglycerin (SLNTG and IVNTG) on left ventricular global and segmental systolic function was quantitatively assessed with two-dimensional echocardiography (2DE) in 28 cases of myocardial infarction (MI), including a group without heart failure of 13 and another group with heart failure of 15. The results showed that after SLNTG and IVNTG the left ventricular end-diastolic and end-systolic volumes were significantly decreased in both groups (P < 0.05-0.001), the left ventricular global systolic function was improved particularly in MI patients with heart failure during IVNTG. The wall motion in the normal and/or hypokinetic segments was enhanced after both SLNTG and IVNTG. It was shown that nitroglycerin could strengthen the left ventricular global systolic function in patients with MI.

[Osteogenesis imperfecta: report of two cases]

Osteogenesis imperfecta (OI) is a heterogenous group of inherited conditions arising from a variety of biochemical and morphological collagen defects. We report 2 cases with a clinical diagnosis of OI. The first case was classified as Silence type IIA. He was delivered at 38 weeks' gestation with severe bowing of long bones, blue sclera and craniotabes at birth. Radiographs showed severe generalized osteoporosis, broad and crumpled long bones, beading ribs and poorly mineralized skull. Histological examination of the long bones revealed the trabecula of the calcified cartilage with an abnormally thin layer of osteoid & the bony trabeculae were thin and basophilic. The second case was classified as Sillence type III. She was delivered at 39 weeks' gestation. Short, bowed lower extremities but normal color of sclerae were noted after birth. Radiographs revealed L't femoral fracture and callus formation of R't 8th rib. She survives till now with gradual deformity of long bone and growth retardation. Because of the poor prognosis of Sillence type II and type III, there is no doubt that accurate genetic counseling and prenatal diagnosis will become important in the management of the disease.

Blood levels of platelet-activating factor in endotoxin-sensitive and endotoxin-resistant mice during endotoxemia

Platelet-activating factor (PAF) is a phosphoglyceride secreted by a variety of cells and has been implicated in endotoxin toxicities. To further confirm its role in endotoxin-induced tissue injuries and death, we conducted an experiment on endotoxin-resistant (C3H/HeJ strain) and endotoxin-sensitive (C3H/HeN strain) mice. The experiment consisted of three parts: 1) the LD50 of endotoxin from E. coli 0127:B8 cells was quantitated in C3H/HeN mice; 2) the lethality of PAF in C3H/HeJ mice at a dose lethal to C3H/HeN mice was determined; and 3) the blood levels of PAF in C3H/HeJ and C3H/HeN mice were measured after a dose of endotoxin lethal to the C3H/HeN strain was injected. PAF contained in the blood samples was extracted by a solid phase procedure and assayed by a radioimmunoassay method. The results showed that endotoxin-resistant and endotoxin-sensitive mice were equally susceptible to death induced by the same lethal dose of PAF. After injection with endotoxin, the blood PAF levels in C3H/HeN mice increased significantly (p < 0.01) at 60 minutes and 90 minutes, with a peak level three times that of the control group. The blood PAF levels in C3H/HeJ mice, however, remained unelevated throughout the experiment. The timing of the occurrence of the peak blood PAF level in the C3H/HeN mice corresponded with the emergence of their illness from the endotoxin injection. These findings shed new light on our understanding of the resistant mechanisms of C3H/HeJ mice to bacterial endotoxin and affirm the possible role of PAF in mediating endotoxin toxicities.

Vertebrobasilar insufficiency related to cervical spondylosis. A case report and review of the literature

A 64-year-old man suffered from symptoms of vertebrobasilar insufficiency (VBI) while turning his head to the left. Roentgenograms of the cervical spines showed severe spondylosis. Cerebral angiography demonstrated compression of the left vertebral artery by osteophytes of the cervical spine when the patient turned his head to the left. He was treated surgically by fixation of the vertebral bodies with good relief of symptoms during one year of follow-up. VBI induced by spondylotic compression of the vertebral artery is uncommon. We therefore reviewed the literature and suggested a more simple method of operation.