Laparoscopic fenestration of a simple hepatic cyst

Hepatic cysts are usually asymptomatic, most being detected incidentally during imaging. Distinction has to be made between a simple hepatic cyst from more sinister types such as a parasitic cyst and a cyst occurring as part of a neoplastic process. Intervention in a simple hepatic cyst is only indicated when they become symptomatic or when they grow at a rapid rate. Surgery is the mainstay of treatment, with laparoscopic intervention becoming more and more widely accepted. We present here the first case of laparoscopic fenestration of liver cyst performed in our hospital and also review the literature on this modality of treatment.

An unusual cutaneous metastasis from hepatocellular carcinoma

Cutaneous metastases from hepatocellular carcinoma are rare. In this report we detail a case of hepatocellular carcinoma with the unusual manifestations of multiple skin metastases. A 49-year-old male, who had received surgical resection of hepatocellular carcinoma one year prior, presented with multiple reddish-blue, firm, painless and nonulcerative cutaneous papules and nodules over the fingers, palms, toes, soles and back. Pathology of the cutaneous nodules showed characteristic hepatocellular carcinoma with trabecular gland formation. These lesions grew very rapidly and developed to cauliflower appearances which had not been described previously in the literature. The patient died of respiratory failure secondary to lung metastasis two months after the first appearance of the skin lesions.

A minimal transverse incision with low median sternotomy for pediatric congenital heart surgery

OBJECTIVES

Median sternotomy is the incision of choice for most cardiac surgical procedures, but the full-length vertical skin incision generally leaves an unsightly scar. In certain patients undergoing short, low-risk procedures, cosmetic considerations are of relatively greater importance.

METHODS

A minimal transverse curvilinear skin incision with low median sternotomy is described which gives adequate exposure for selected open-heart procedures. Since September 1997, this approach has been used in 22 pediatric patients undergoing open-heart surgery including five cases of Fallot's tetralogy. We also compared the operation time and result with other approaches.

RESULTS

Using this modified method, the exposure of the heart was good enough, and there were no difficulties in cannulating the ascending aorta for cardiopulmonary bypass. Although it took a longer time to close the wound, the operation time was similar to the standard approach. The small transverse wound was not visible under conventional clothes.

CONCLUSIONS

A minimal transverse incision with low median sternotomy provides an alternative approach for small wound open-heart surgery in patients with a simple congenital cardiac defect. It is technically feasible and has a good cosmetic result.

Ruptured abdominal aortic aneurysms: a personal experience

Despite advances in surgical technique and peri-operative care, mortality from ruptured abdominal aortic aneurysm presenting to a hospital remains around 50%. This is in contrast to the mortality rate of < 5% for elective repair. In a two and a half year period,the principal surgeon operated on 10 patients with ruptured AAA, with a peri-operative and overall mortality of 30%. One of the ten patients had a ruptured mycotic aneurysm. We present our experience with these patients and also correlate this with recent publications.

Rapid identification of mycobacterium tuberculosis complex from Bactec 12B broth cultures originating from non-respiratory secretion specimens: comparison between Accuprobe and in-house polymerase chain reaction

The rapid identification of Mycobacterium tuberculosis complex from 161 consecutive positive Bactec 12B cultures originated from non-respiratory secretion specimens was evaluated by comparing Accuprobe and an in-house polymerase chain reaction method. Using conventional biochemical method as the gold standard, 85.7% of the isolates (n = 138) were identified as Mycobacterium tuberculosis. The sensitivities of Accuprobe and the in-house-polymerase chain reaction method in identifying Mycobacterium tuberculosis complex were 92.0% (127/138) and 93.5% (129/138), respectively. Specificities of both methods being 87.0% (20/23 for both tests). Using a batch system of performing identification once weekly, the average turnaround time for Accuprobe, from the time of primary inoculation, was 27 days, which was comparable with that of in-house polymerase chain reaction, which was 29 days. The average time required for a confirmatory result based on conventional biochemical identification method was 84 days. The estimated reagent cost of in-house polymerase chain reaction was only one-fifth of that of Accuprobe. Therefore, the choice of methodology will depend on the individual laboratory's availability of resources and clinical demand. In the event of discrepant results between rapid identification methods and conventional methods, histological examination and clinical assessment can provide guidance as to the nature of the infection.

The prognostic significance of p16(INK4a)/p14(ARF) locus deletion and MDM-2 protein expression in adult acute myelogenous leukemia

BACKGROUND

The p16(INK4a) locus encodes two distinct proteins, p16(INK4a) and p14(ARF). Although p16(INK4a) and p15(INK4b) are involved in the phosphorylation of the retinoblastoma (Rb) protein, p14(ARF) interacts with the MDM-2 oncoprotein antagonizing its function as a suppressor of p53. The role of deletions of p16(INK4a)/p14(ARF) and p15(INK4b) and expressions of MDM-2 in myeloid leukemias and its influence on prognosis remain unclear.

METHODS

The authors analyzed deletions of p16(INK4)/p14(ARF) and p15(INK4b) in 74 adults with acute myeloid leukemia (AML) by Southern blotting. Western blotting was used to determine Rb protein phosphorylation in patients with deletions of p16(INK4)/p14(ARF) and p15(INK4b). Then, they analyzed the levels of MDM-2 protein expression and correlated it with prognosis in an expanded population of 79 adults with AML by immunoblot analysis and solid-phase radioimmunoassay.

RESULTS

Deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b) occurred in 4 of 74 patients (5%) (hemizygous in 3, homozygous in 1 patient). Although the complete remission (CR) rate was similar (79% vs. 50%; P = 0.187), CR duration (10 vs. 46 weeks; P < 0.001), event free survival rate (EFS; 6 vs. 85 weeks; P < 0.004) and overall survival rate (11 vs. 86 weeks; P = 0.001) were significantly shorter in patients with deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b). Thirty-seven (47%) of 79 patients studied for MDM-2 showed increased MDM-2 expression. These patients had a significantly shorter EFS rate (50 vs. 64 weeks; P = 0.023) and a trend for shorter CR duration (24 vs. 53 weeks; P = 0.07). Overall survival rate was not significantly different (50 vs. 84 weeks; P = 0.136).

CONCLUSIONS

The authors concluded that 1) deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b) occur with low incidence in patients with AML; 2) patients with deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b) have a significantly shorter CR duration, EFS rate, and overall survival rate than do patients without deletions; (3) overexpression of MDM-2 is common in AML and is associated with shorter CR duration and EFS rate. Mechanisms other than p14(ARF) deletion are responsible for MDM-2 overexpression, and this overexpression may play a role in the biology of the disease.

Need for vaccination of susceptible food handlers against hepatitis A in Taiwan

BACKGROUND

With the improvement in the socioeconomic situation and general hygiene standards in Taiwan, the prevalence of antibodies to the hepatitis A virus (anti-HAV) in the general population has declined markedly in recent years. To avoid food-borne outbreaks of HAV infection caused by susceptible food handlers in Taiwan, we investigated the seroprevalence of anti-HAV among the target population and also evaluated the immunogenicity and reactogenicity of the inactivated hepatitis A vaccine in this study group.

METHODS

Two hundred and forty-four food handlers employed in four restaurants at Taipei Veterans General Hospital participated in the anti-HAV serologic screening program in July 1997. Of them, 48 susceptible food handlers received three doses of 720 enzyme-linked immunosorbent units of inactivated hepatitis A vaccine at 0, 1 and 6 months.

RESULTS

Of the 244 food handlers who underwent anti-HAV serologic screening, 169 (69.3%) were anti-HAV positive. The seroprevalence of anti-HAV was related to age: 91.5% of food handlers over 30 years of age were positive for anti-HAV but only 22.8% of food handlers younger than 30 were anti-HAV positive. Anti-HAV response was observed in all vaccinees after a booster vaccination at month 6. The response persisted to 1 year. The side-effects of the vaccinations were minimal.

CONCLUSIONS

Susceptible food handlers should receive hepatitis A vaccination. Hepatitis A vaccine is safe and immunogenic in this target population.

The prognostic significance of p16(INK4a)/p14(ARF) locus deletion and MDM-2 protein expression in adult acute myelogenous leukemia

BACKGROUND

The p16(INK4a) locus encodes two distinct proteins, p16(INK4a) and p14(ARF). Although p16(INK4a) and p15(INK4b) are involved in the phosphorylation of the retinoblastoma (Rb) protein, p14(ARF) interacts with the MDM-2 oncoprotein antagonizing its function as a suppressor of p53. The role of deletions of p16(INK4a)/p14(ARF) and p15(INK4b) and expressions of MDM-2 in myeloid leukemias and its influence on prognosis remain unclear.

METHODS

The authors analyzed deletions of p16(INK4)/p14(ARF) and p15(INK4b) in 74 adults with acute myeloid leukemia (AML) by Southern blotting. Western blotting was used to determine Rb protein phosphorylation in patients with deletions of p16(INK4)/p14(ARF) and p15(INK4b). Then, they analyzed the levels of MDM-2 protein expression and correlated it with prognosis in an expanded population of 79 adults with AML by immunoblot analysis and solid-phase radioimmunoassay.

RESULTS

Deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b) occurred in 4 of 74 patients (5%) (hemizygous in 3, homozygous in 1 patient). Although the complete remission (CR) rate was similar (79% vs. 50%; P = 0.187), CR duration (10 vs. 46 weeks; P < 0.001), event free survival rate (EFS; 6 vs. 85 weeks; P < 0.004) and overall survival rate (11 vs. 86 weeks; P = 0.001) were significantly shorter in patients with deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b). Thirty-seven (47%) of 79 patients studied for MDM-2 showed increased MDM-2 expression. These patients had a significantly shorter EFS rate (50 vs. 64 weeks; P = 0.023) and a trend for shorter CR duration (24 vs. 53 weeks; P = 0.07). Overall survival rate was not significantly different (50 vs. 84 weeks; P = 0.136).

CONCLUSIONS

The authors concluded that 1) deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b) occur with low incidence in patients with AML; 2) patients with deletions of p16(INK4a)/p14(ARF) and/or p15(INK4b) have a significantly shorter CR duration, EFS rate, and overall survival rate than do patients without deletions; (3) overexpression of MDM-2 is common in AML and is associated with shorter CR duration and EFS rate. Mechanisms other than p14(ARF) deletion are responsible for MDM-2 overexpression, and this overexpression may play a role in the biology of the disease.

Human exposure to respirable suspended particulate and airborne lead in different roadside microenvironments

The aim of this study is to evaluate the particulate air pollution in selected roadside microenvironments of Hong Kong through an intensive field study dated from January 1997 to February 1997. The study employed the microenvironment monitoring technique to access the exposure of pedestrians to respirable suspended particulate and airborne lead (Pb) at heavily trafficked roadsides. A total of 62 roadside sites in 14 districts covering the most urbanized and densely populated areas were selected. It was found that pedestrians were exposed to a 24 h average of respirable suspended particulate, PM10, and airborne Pb (APb), typically ranged from 25.56 to 337.40 microg/m3 and 70.71 to 285.71 ng/m3, respectively. The average PM10 concentrations at different roadside microenvironments corresponding to urban residential, urban commercial, urban industrial and new town areas were 91.84, 129.08, 83.83, and 118.89 microg/m3 respectively. The corresponding values for APb were 130.01, 143.40, 127.40 and 173.17 ng/m3, respectively. It was found that measurement at EPD nearby rooftop monitoring stations might not reflect the actual roadside PM10 exposure. Most APb field study data was significantly higher than the nearby fixed station data.

Serum pharmacokinetics of antimycobacterial drugs in patients with multidrug-resistant tuberculosis during therapy

Serum samples of 13 patients with multidrug-resistant tuberculosis were taken 0, 1, 2, 4, 8 h after administration of antimycobacterial drugs for assay of levels in order to gain further insight into their basic pharmacokinetics. The drugs assessed were amikacin, kanamycin, ofloxacin, levofloxacin, para-aminosalicylic acid, prothionamide, cycloserine, pyrazinamide and ethambutol. Techniques used for assay were reversephase high-performance liquid chromatography, gas liquid chromatography and fluorescent polarization immunoassay. The results from 12 patients were evaluated. These provided new pharmacokinetic data on high-dose levofloxacin, cycloserine and prothionamide given once daily, and could be useful in guiding the scheduling of drugs. The data obtained might also lead to insights into the development of therapeutic drug monitoring in multidrug-resistant tuberculosis.

Stereotactic brain biopsies in AIDS patients--early local experience

AIM

To assess the usefulness of stereotactic brain biopsies in AIDS patients with cerebral lesions in Singapore.

METHODS

A total of 10 patients with AIDS and cerebral lesions underwent stereotactic brain biopsies in the Department of Neurosurgery, Tan Tock Seng Hospital (TTSH) between September 1997 and September 1998. The patients were referred from the Communicable Diseases Centre (CDC), TTSH. These patients either failed a trial of therapy for toxoplasmosis encephalitis (TE) or had CT/MRI scans which did not suggest TE. Four were CT-guided and six were MRI-guided stereotactic biopsies. The Radionics Cosman-Robert-Wells (CRW) stereotactic apparatus was used for all cases.

RESULTS

The male to female ratio was 9:1. Histological diagnosis from biopsy was lymphoma (5), metastatic adenocarcinoma (1), TE (1), abscess (1), encephalitis (1) and granulomatous tissue (1-presumed tuberculosis).

CONCLUSION

The early experience is that stereotactic brain biopsy is useful in patients with AIDS and cerebral lesions. The etiology is confirmed in the majority of cases and impacts on management decisions and prognostication.

Hepatitis B vaccination in patients with chronic hepatitis C

The aim of the study was to evaluate the safety, immunogenicity, and possible therapeutic effect of hepatitis B vaccine in patients with chronic hepatitis C. The subjects studied included three groups: group I, 26 patients with chronic hepatitis C who were susceptible to hepatitis B virus infection; group II, 35 healthy subjects who were susceptible to both hepatitis B and hepatitis C virus infection; and group III, 30 patients with chronic hepatitis C receiving no hepatitis B vaccination as controls. Three 20 microg/dose of recombinant hepatitis B vaccines were given to subjects of groups I and II in months 0, 1, and 6. Blood samples from the subjects were collected before and 1 month after each dose of vaccination for serological testing. The subjects of groups I and II had similar antibody to hepatitis B surface antigen (anti-HBs) response rates after the first (30.8% vs. 17.1%), second (61.5% vs. 60.0%), and third (88.5% vs. 91.4%) doses of vaccination. Also, their geometric mean titers of anti-HBs did not differ much when vaccination completed in 7 months (360 vs. 581 mIU/ml). During vaccination period, patients with chronic hepatitis C demonstrated no significant change of serum cytokines and HCV RNA levels, but significantly lowered ALT levels after three doses of vaccination. Hepatitis B vaccination is safe and immunogenic in patients with chronic hepatitis C. It did not significantly affect their levels of HCV RNA, but tended to lower ALT levels.

Clinics in diagnostic imaging (45). Osmotic myelinolysis ( central potine myelinolysis)

A 65-year-old woman developed progressive neurological deterioration following rapid correction of hyponatremia. Magnetic resonance imaging showed T2 hyperintense areas in the central pons, basal ganglia and deep white matter, typical of osmotic myelinolysis (OM). Previously thought to be uniformly fatal, there are increasing reports of non-fatal cases of OM. The recognition and understanding of this entity is important to prevent or reduce the incidence of its occurrence, as there is no specific treatment once it develops. The clinical and radiological features of OM are reviewed.

Aminoglycoside resistance in Mycobacterium kansasii, Mycobacterium avium-M. intracellulare, and Mycobacterium fortuitum: are aminoglycoside-modifying enzymes responsible?

Aminoglycoside acetyltransferase was detected in Mycobacterium kansasii and M. fortuitum but not in M. avium-M. intracellulare when they were screened by a radioassay. Aminoglycoside phosphotransferase and nucleotidyltransferase activities were absent from all three species tested. Acetyltransferases from both M. kansasii and M. fortuitum displayed relatively high K(m)s, all at the millimolar level, for substrates including tobramycin, neomycin, and kanamycin A. The K(m) of each substrate was well above the corresponding maximum achievable level in serum. The low affinities of these enzymes for their substrates suggested that drug modification in vivo was very unlikely. Among the various substrates tested, no apparent positive correlation was found between substrate affinity and resistance level. The presence of aminoglycoside-modifying enzymes in these mycobacterial species was therefore not shown to confer resistance to aminoglycosides.

Improved recovery of Mycobacterium tuberculosis from pleural aspirates: bedside inoculation, heparinized containers and liquid culture media

The effects of bedside inoculation, heparinized containers and liquid culture media on the recovery of Mycobacterium tuberculosis from pleural aspirates were evaluated in this study. Of 155 patients, 63 were diagnosed to have pleural effusion tuberculous in origin. The overall recovery of M. tuberculosis was 57.1%. Bedside inoculation of the specimens produced a significantly higher yield than laboratory inoculation using non-heparinized specimens. When the pleural aspirates were transported in heparinized containers, the recovery rate was comparable to that from bedside inoculation, but lower when non-heparinized containers were used. No significant difference was found in recovery rate between the two liquid media, but the rate was significantly higher with the use of liquid media than conventional solid media. Thus, bedside inoculation of pleural aspirates, use of heparinized containers for transport for delayed inoculation in the laboratory and use of liquid culture media are recommended.

Radiation dose reduction in paediatric cranial CT

BACKGROUND

There is no consensus about the optimal milliamperage-second (mAs) settings for computed tomography (CT). Most operators follow the recommended settings of the manufacturers, but these may not be the most appropriate settings.

OBJECTIVE

To determine whether a lower radiation dose technique could be used in CT of the paediatric brain without jeopardising the diagnostic accuracy of the images.

MATERIALS AND METHODS

A randomised prospective trial. A group of 53 children underwent CT using manufacturer's default levels of 200 or 250 mAs; 47 underwent scanning at 125 or 150 mAs. Anatomical details and the confidence level in reaching a diagnosis were evaluated by two radiologists in a double-blinded manner using a 4-point scoring system.

RESULTS

For both readers there was no statistically significant difference in the confidence level for reaching a diagnosis between the two groups. The 95 % confidence intervals and P values were -0.9-1.1 and 0.13 (reader 1) and -1.29-1.37 and 0.70 (reader 2), respectively. Reliability tests showed the results were consistent.

CONCLUSIONS

The recommended level may not be the optimum setting. Dose reduction of 40 % is possible on our system in paediatric brain CT without affecting the diagnostic quality of the images.

A two dose combined hepatitis A and B vaccine in Chinese youngsters

This open, randomized study was conducted in healthy Chinese youngsters, aged between 10 and 19 years to compare the reactogenicity and immunogenicity of two vaccines: the combined vaccine against hepatitis A and B was administered in a two-dose schedule with the profile of the corresponding monovalent vaccines, while the concomitant vaccine was administered also on a two-dose schedule but simultaneously in opposite arms. All vaccinees had antibodies against hepatitis A (anti-HAV) after the 2-dose administration, whereas all but four in the first and two in the second group had protective titres against hepatitis B (anti-HBs). At month 7, the geometric mean titres for both antibodies were more than double for the group of subjects receiving the combined vaccine: 3,701 vs. 1,705 mIU/ml for the anti-HAV, and 1,524 vs. 720 mIU/ ml for the anti-HBs response. Injection site pain was the most commonly reported local symptom and headache was the most reported general symptom. It is concluded that this combined vaccine against hepatitis A and B, administered according to a two-dose schedule, is well-tolerated and highly immunogenic.

A randomized, double-blind, controlled trial of consensus interferon in the treatment of Chinese patients with chronic hepatitis C

OBJECTIVE

Patients with chronic hepatitis C virus (HCV) infection have an increased risk of developing cirrhosis or hepatocellular carcinoma. Consensus interferon (CIFN) offers sustained clinical efficacy to patients studied in the Western countries. This randomized, double-blind, controlled trial in 75 Chinese patients with chronic hepatitis C compared treatment with CIFN or placebo to determine whether CIFN had efficacy and safety in Chinese patients similar to that in Western patients.

METHODS

Patients were randomized to receive CIFN (3 microg or 9 microg) or placebo given subcutaneously 3 times/wk for 24 wk, followed by 24 wk of observation. Efficacy was assessed by normalization of serum alanine transaminase (ALT) and clearance of serum HCV RNA concentrations to undetectable levels by reverse-transcription polymerase chain reaction.

RESULTS

There was a greater benefit with CIFN 9 microg than with CIFN 3 microg or placebo. At the end of 24 wk of treatment, the ALT response was 64%, 38.5%, and 8.4% for the 9-microg, 3-microg, and placebo-treated groups, respectively. After an additional 24 wk of observation, sustained ALT responses were 44%, 23.1%, and 12.5% for the 9-microg, 3-microg, and placebo-treated groups, respectively. HCV RNA clearance at the end of treatment was 56%, 42.3%, and 4.2%; and after 24 wk of additional observation, 40%, 11.5%, and 0% for the 9-microg, 3-microg, and placebo-treated groups, respectively. There were no unexpected adverse reactions to CIFN.

CONCLUSIONS

The results show that administration of CIFN subcutaneously at 9 microg 3 times a week is safe and can effectively reduce serum ALT and HCV RNA concentrations in Chinese patients with chronic hepatitis C.

Circulating intercellular adhesion molecule-1 in chronic liver disease and hepatocellular carcinoma

BACKGROUND

Intercellular adhesion molecule-1 (ICAM-1) is important in the migration and adhesion of immune cells from the circulation to their targets. A circulating form of ICAM-1 (cICAM-1) is elevated in the serum of patients with hepatitis and various cancers. Our aim was to determine the clinical significance of cICAM-1 in chronic liver diseases and hepatocellular carcinoma (HCC).

METHODS

We measured the serum cICAM-1 levels in 91 patients with HCC, 47 with liver cirrhosis, 41 with chronic viral hepatitis and 32 healthy controls using an enzyme-linked immunosorbent assay. Ninety-eight patients had serial follow-up.

RESULTS

The cICAM-1 levels in patients with HCC (737 +/- 212 ng/ml) and liver cirrhosis (593 +/- 145 ng/ml) were significantly higher than those in patients with chronic viral hepatitis (488 +/- 127 ng/ml) and controls (318 +/- 64 ng/ml). HCC patients had higher cICAM-1 levels than all the other groups. cICAM-1 levels in patients with chronic viral hepatitis correlated with serum alanine aminotransferase, prothrombin time and indocyanine green retention ratio. In HCC patients, alpha-fetoprotein levels and tumor size paralleled cICAM-1 concentrations. Furthermore, HCC patients with distant metastases had higher cICAM-1 levels than those without distant metastases, and levels of cICAM-1 in patients with stage IV HCC were higher than those in HCC patients with stages I, II or III disease. During a seven-year follow-up, 14 patients with chronic hepatitis developed liver cirrhosis when their cICAM-1 levels increased significantly. In 47 HCC patients, cICAM-1 levels decreased after tumor resection or transcatheter arterial embolization, and increased when the tumor recurred. cICAM-1 levels increased gradually in 14 patients with advanced HCC without specific therapy.

CONCLUSIONS

CICAM-1 levels are increased in patients with chronic hepatitis, liver cirrhosis and HCC. This reflects the severity and progression of chronic liver disease and HCC. Sequential measurements of cICAM-1 seem more valuable than a single-point assessment in evaluating the progress of liver disease.

The prognostic significance of p16INK4a/p14ARF and p15INK4b deletions in adult acute lymphoblastic leukemia

Cytogenetic/molecular abnormalities significantly influence the prognosis of patients with acute leukemia. Recently, two genes, p16INK4a and p15INK4b, encoding two cyclin-dependent kinase inhibitor proteins of the INK4 family of Mr 15,000 and 16,000, respectively, have been localized to 9p21. Remarkably, the p16INK4a locus has been found to encode a second protein, p14ARF, known as p19ARF in mice, with a distinct reading frame. Like p16INK4a, p14ARF is involved in cell cycle regulation, blocking cells at the G1 restriction point through the activity of MDM-2 and p53. We studied bone marrow samples of 42 newly diagnosed and untreated patients with acute lymphoblastic leukemia for the incidence of deletions of p16INK4a/p14ARF and p15INK4b using Southern blot analysis and determined the clinical outcome with regard to complete remission (CR) duration, event-free survival, and overall survival. We found deletions of p16INK4a/p14ARF in 17 of 42 patients (40%), with homozygous deletions in 11 of 42 patients (26%) and hemizygous deletions in 6 of 42 patients (14%). The gene for p15INK4b was codeleted in most, but not all, cases and was never deleted without deletion of p16INK4a/ p14ARF. No correlation was observed between molecular studies and karyotype abnormalities as determined by conventional cytogenetics. Furthermore, no difference was found in the CR rate, CR duration, event-free survival, and overall survival in patients with homozygous gene deletions compared to patients with no deletions or loss of only one allele.

Serum levels of cytokines in hepatitis C-related liver disease: a longitudinal study

BACKGROUND

Elevated serum cytokine levels are found in patients with acute and chronic hepatitis B. However, little is known about the development and progression of cytokines in hepatitis C infection. We conducted this study to evaluate the change and clinical significance of cytokines in the different stages of hepatitis C infection.

METHODS

Circulating interleukin-1 beta (IL-1 beta), interleukin-2 receptor (IL-2r), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) were measured by enzyme-linked immunosorbent assay in 29 patients with acute hepatitis C (AHC), 43 patients with chronic hepatitis C (CHC), 40 patients with liver cirrhosis (LC) and positive serum anti-hepatitis C antibody (anti-HCV), 36 patients with hepatocellular carcinoma (HCC) and positive anti-HCV and 30 normal controls. A cohort of patients with chronic hepatitis C was monitored for a median of seven years.

RESULTS

Serum IL-1 beta, IL-2r, IL-6 and TNF-alpha levels were significantly elevated in all patient groups compared with controls (p < 0.05). The serum IL-1 beta, IL-2r and TNF-alpha levels in patients with LC or HCC were higher than that in patients with AHC or CHC (p < 0.05). In the longitudinal follow-up, 12 patients with chronic hepatitis at enrollment in the study developed liver cirrhosis. For these patients, serum levels of IL-1 alpha, IL-2r and TNF-alpha were higher in liver cirrhosis than in chronic hepatitis (p < 0.05). In addition, the serum concentrations of these cytokines correlated better with indices of hepatic dysfunction (prothrombin time and indocyanine green retention ratio) than with parameters of hepatic inflammation (alanine aminotransferase and aspartate aminotransferase).

CONCLUSIONS

Serum IL-1 beta, IL-2r, IL-6 and TNF-alpha levels are elevated in patients with hepatitis C-related liver diseases, especially in LC and HCC patients. These levels reflect hepatic dysfunction better than liver inflammation parameters, which might explain the higher serum concentrations of cytokines in LC patients.

Report of eight cases of pulmonary actinomycosis and their treatment with imipenem-cilastatin

Studies on the efficacy of antimicrobial agents against actinomycosis in vivo have been limited apart from those involving penicillin. A prospective ministudy on the efficacy of imipenem-cilastatin in the treatment of pulmonary actinomycosis was performed based on preliminary encouraging in vitro and in vivo data. Eight patients were diagnosed as having pulmonary actinomycosis using fibreoptic bronchoscopy (7) and percutaneous transthoracic needle biopsy (1) in the authors' unit between 1994 and 1996. Each patient received a 4-week course of imipenem-cilastatin that comprised 2 weeks of intravenously administered drug (500 mg at 8-hourly intervals) and 2 weeks of intramuscularly administered drug (500 mg at 12-hourly intervals). Seven patients showed a very good clinical and radiographic response as well as bronchoscopically-documented treatment success. Treatment failed in one patient. Amongst the former group, one patient was lost to follow-up, another relapsed 3 months after treatment cessation and the rest remained relapse-free when followed-up for 18-44 months (mean 30.2 months). Furthermore, all patients showed good clinical tolerance and no abnormal treatment-related laboratory findings. The favourable outcome for most patients in this mini-study suggest that a 4-week parenteral course of imipenem-cilastatin is an efficacious treatment for pulmonary actinomycosis. This antimicrobial regimen might be a promising alternative to the time-honoured long-course treatment with intravenous and oral penicillin.

Long-term follow-up of hepatitis A vaccination in children

We conducted this follow-up study to evaluate the long-term immunogenicity of an inactivated hepatitis A vaccine in children. Ninety-six children who had seroconversion to antibody to HAV (anti-HAV) after receiving a three-dose schedule of inactivated hepatitis A vaccine were enrolled into this study. Sixty months after the initial vaccination, all vaccinees who received annual follow-up still had protective levels of anti-HAV. The geometric mean titer (GMT) of anti-HAV, peaking at month 7 (4133 mIU/mL), kept declining throughout the follow-up period. The GMTs in months 12, 24, 36, 48 and 60 were 1722, 896, 896, 645 and 403 mIU/mL, respectively. Nine of the vaccinees were hepatitis B virus carriers. Their anti-HAV titers tended to be lower than those of the remaining vaccinees at all time-points, but the difference was not significant (p > 0.05). Natural booster was noted in one vaccinee during the follow-up period. In conclusion, inactivated hepatitis A vaccine is safe and immunogenic in children, the duration of protection against HAV infection is longer than five years.