Submucous cleft palate

Submucous cleft palate (SMCP) is a subgroup of cleft palate which is often unawared by general practitioners. The diagnostic triad of (1) bifid uvula, (2) translucent zone in soft palate and (3) bony notch in the posterior edge of the hard palate can be variable in their severity among each patient. Some patients with SMCP will have speech problems with velopharyngeal insufficiency (VPI) and/or articulation errors. Patients will also have middle ear effusion as in an overt cleft palate. Surgical treatment is indicated in the presence of VPI or recurrent otitis media. There are controversies on the timing and type of surgical intervention. This study was the first part of an ongoing study on SMCP. It was a retrospective review of the SMCP patients treated before June 1988 to compare the results among different age groups and surgical procedures. It was found that neither age nor type of surgery was a determinant for a satisfactory correction of VPI. Unless the patient had recurrent otitis media, surgery should not be performed before having a thorough speech evaluation including perceptual assessment and instrumental assessment. The type of surgery should be decided according to the findings from the instrumental assessment.

[Epidemiologic analysis of 845 cases of pedestrian traffic injuries]

BACKGROUND

Pedestrian-vehicle collision is a serious public health problem today in Taiwan, but this issue of pedestrian safety has received relatively little attention. The purpose of this study was to evaluate the characteristics of pedestrian injury after involvement in a collision.

METHODS

An epidemiologic study on 845 traffic accident consecutive victims, managed at Tri-Service General Hospital in 1990, was performed. They were interviewed with a brief questionnaire about demographic data and types of accident including injured site, Injury Severity Score (ISS) and outcome; the latter was obtained by review of medical records and by a telephone survey performed four months after discharge.

RESULTS

Results showed a common distribution of injuries for all age groups. Of the 845 patients, 487 were male and 358 were female (sex ratio = 1.4:1). The majority of injuries (84.8%) occurred for pedestrians who were walking on the side of, or crossing, the road. Four hundred and ninety-six victims (58.7%) were treated in the Emergency Department only, while 342 patients (40.5%) were further admitted as inpatients; the remaining 34 patients (4.0%) died in the Emergency Department (0.8%), or as inpatients (3.2%). The study showed fatality rates according to age as follows: 0.5% age 1 to 19, 1.8% age 20 to 39, 4.6% age 40 to 59, 7.5% age 60 or older, with the elderly having the highest pedestrian death rate. Elder pedestrians who were struck by motor vehicles also had the highest fatality rate of all pedestrian injury victims. The percentage of pedestrian injuries is fairly constant from month to month. For time of day, 12 noon and 3 to 5 pm were associated with the most injuries for age 0-19 youths; 4 pm and 10 pm for age 20-59 adults; 8 am and 7 pm for age 60 or older. There was a significant difference of mean ISS between the nonsurvivors (27.8) and the survivors (4.6) (p < 0.01). When nonsurvivors were compared with survivors, among the aged (> 60), high Abbreviated Injury Scale (AIS) of head, and high ISS were most common among nonsurvivors (p < 0.01).

CONCLUSIONS

That pedestrians are the least protected participants in traffic. Situations is reflected by a considerable fatality rate among pedestrians. Data from this study should be useful for designing, implementing, and evaluating a targeted pedestrian safety program in Taiwan.

Psammocarcinoma of the peritoneum

The cytologic and histologic features of two cases of psammocarcinoma of the peritoneum are reported. The previously proposed histologic diagnostic criteria for this tumor are expanded in order to accommodate the present two cases. The cytologic features of this tumor have not previously been reported.

Merkel's cell (neuroendocrine) carcinoma of the vulva

BACKGROUND

Merkel's cell carcinoma rarely arises in the vulva. It is unclear whether those cases arising in the vulva behave differently from the usual Merkel's cell carcinomas.

METHODS

A Merkel's cell carcinoma of the vulva was studied by light microscopy, immunohistochemistry, and electron microscopy. The clinical data of this case and of other reported cases are summarized and compared with those of Merkel's cell carcinoma in general.

RESULTS

This tumor showed the characteristic trabecular pattern of Merkel's cell carcinoma. The tumor cells were immunoreactive to low-molecular-weight cytokeratin and neuron-specific enolase. This patient was treated initially with local excision. She died 17 months later with progressive metastatic disease unresponsive to chemotherapy. This case study and the review of six other cases indicate that Merkel's cell carcinoma of the vulva is universally metastatic, both to the regional lymph nodes and distant sites, and that it invariably follows a rapidly fatal course.

CONCLUSION

Merkel's cell carcinoma of the vulva appears to have a biologic behavior more aggressive than that of Merkel's cell carcinoma in general. An initial modality combining chemotherapy, with or without irradiation, with aggressive surgery should be tried in future cases.

The effect of heated humidifier in the prevention of intra-operative hypothermia

Unintentional hypothermia is common in patients undergoing "routine anesthesia in surgery". The aims of the study were to estimate the difference of changes of body temperature during abdominal and limb operations and to evaluate the effectiveness of the heated humidifier for reducing intraoperative heat loss. Forty-three patients were randomly being allocated into 3 groups. Group I consisted of 14 patients undergoing abdominal operation without the use of heated humidifier. Another 22 patients were being assigned as group II to have a heated humidifier on the inspiratory limb of the breathing circuit. The inspired gas was warmed to 39 degrees C and the relative humidity was 90%. 7 patients undergoing limb operation were attributed to group III without using heated humidifier to humidify and warm up the inspired gas. For body temperature monitoring, the probe was placed on the patient's nasopharynx and the temperature was measured immediately before induction of anesthesia, post-intubation, and then once again every 15 minutes up to 3 hours after induction. All patients in the 3 groups showed a rapid decrease of body temperature in the first hour and then the hypothermic change was slow down. The lowest level of body temperature was reached at about 2 hours after induction. Patients undergoing abdominal operation decreased body temperature greater than those undergoing limb operation for about 2 degrees C after 3 hours of anesthesia and surgery. Warming and humidifying the inspired gas effectively reduced the heat loss. We concluded that abdominal operation induce hypothermia more than limb operation. The use of heated humidifier was effective in maintaining body temperature.

[Head injuries in traffic accidents with emphasis on the comparisons between motorcycle-helmet users and non-users]

Motor-vehicle incidents in Taiwan are a major cause of head injuries. Our objective was to analyze the characteristics of head injuries caused by motor vehicle accidents in terms of the injured person's demographic characteristics, time and types of crash, injury severity on the abbreviated injury scale (AIS), medical cost and benefits of helmet protection. For this purpose we conducted an epidemiologic survey of 2451 consecutive victims of traffic accidents, coming to, or managed at, the emergency care department of a large Taipei metropolitan hospital in 1990. The results showed that the most common cause of head injury in traffic accidents was a motorcycle incident. Motorcycle accident injured patients were generally young males, laborers or students. Most head injuries occurred between 16:00 and 23:00, and peaking at 21:00 in a day. Forty-three points four percent of patients were admitted, major head injury fatalities occurred within one week of the collision. The elderly or patients with high AIS comprised most nonsurvivors. According to our data, helmet usage was about 14% overall. Helmetless young riders were numerous among the total victims. A significant difference was noted in the severity of injury of helmeted users of motorcycles, compared with those who wore no helmet. As expected, patients who did not wear a helmet had a greater AIS average and higher rate of fatality. Forty-one of the 42 fatalities were patients who had been riding on motorcycles without helmets. Helmets provide adequate protection and reduce severity of injury, and medical cost for motorcycle collisions.

Combined effects of chuling (Polyporus umbellatus) extract and mitomycin C on experimental liver cancer

Chuling (Polyporus umbellatus), one of the commonly used Chinese medical herbs, was combined with mitomycin C and then studied against intrahepatic implantation of sarcoma 180 tumor cells in mice. Oral administration of chuling extract, intraperitoneal injection of mitomycin C and the combination of both increased the life span of tumor-bearing mice 71.6%, 70.1% and 119.9%, respectively. The same treatments were found to be cytotoxic to Sarcoma-180-induced liver tumor cells. The synthetic rates of DNA, RNA and protein were all inhibited measurably by the combined treatment. Histopathological studies showed that lymphocytes infiltrated and surrounded the cancer cells, and there was some fibrosis found in normal cells and cancer cells. These results indicate the potential use of chuling as an anticancer agent.

Proximal deletion of the long arm of chromosome 1: [del(1)(q23-q25)]

A patient with bilateral complete cleft of the lip and palate (CLP) had a proximal deletion of the long arm of chromosome 1 (1q). This rare chromosomal abnormality was characterized by pre- and postnatal growth retardation, psychomotor retardation, and specific craniofacial and other systemic anomalies. There is a high incidence of CLP in proximal 1q deletion syndrome, especially bilateral CLP. Twelve other cases reported in the literature having this deletion and associated anomalies were reviewed.

Risk factors of lung cancer by histological category in Taiwan

The relationship between various risk factors and lung cancer by different histological types was evaluated in a case-control study. A total of 72 adenocarcinoma patients and 59 squamous/small cell lung cancer patients, 262 hospital controls and 262 neighborhood controls were interviewed. Multiple conditional logistic regression analyses revealed that occupational exposures to asbestos and working as a cook were significant risk factors associated with adenocarcinoma of the lung. An inverse association between incense burning and the adenocarcinoma was noted. The squamous and small cell carcinomas of the lung were significantly associated with cigarette smoking, passive smoking exposure from friends at entertainment activities, the use of coal as cooking fuel, history of prior tuberculosis and chronic bronchitis, and occupational exposures to asbestos.

Osteoblastoma of the nasal cavity

The clinicopathological features of a rare case of osteoblastoma of the nasal cavity arising from the nasal turbinate are reported and compared with four reported cases of osteoblastoma with nasal cavity involvement. Two of the five tumours involved the nasal cavity and paranasal sinuses. The remaining three tumours were confined in the nasal cavity; one arose from nasal bone and two from nasal turbinate periosteum. Four tumours were successfully treated with local excision. One tumour recurred locally after excision; the recurrence was apparently controlled by further local excision.

[Estimation of case fatality rate and incidence rate of traffic injury in Taiwan--analysis of 4,329 victims at a medical center]

Accidents remain the third leading cause of mortality in Taiwan, of which traffic injuries constitute the major part. In order to characterize traffic injuries and to estimate the annual traffic injury rate in Taiwan, we conducted an epidemiologic study of 4,329 consecutive traffic accident victims, managed at the Tri-Service General Hospital from January to December of 1990. Victims were interviewed for demographic data and types of accident using a brief questionnaire. The questions included injury site and Injury Severity Score (ISS); final diagnosis and outcome were obtained by review of medical records and by a telephone survey performed 4 months after discharge. The sex- and age-specific case fatality rates calculated from the data obtained in this study were used to divide the annual incidence of traffic mortality abstracted from the vital statistics of Taiwan (1990) and, thus, to obtain an annual frequency of traffic injury cases under certain assumptions. The results showed that more men than women were injured in all age groups. The highest frequency of traffic injuries was noted in patients ranging in age from 20 to 39 years. Up to 58.9% of the victims were motorcycle users, followed by pedestrians (19.5%) and automobile-users (16.0%). The case fatality rate was 2.5% for males and 1.7% for females. The estimated annual traffic incidence was about 330,000, and the total annual rate of traffic injuries in Taiwan was 1,627/100,000 (2,188/100,000 for men and 1,114/100,000 for women).(ABSTRACT TRUNCATED AT 250 WORDS)

Cytology of thyroglossal cyst papillary carcinoma

The cytologic and histologic features of two cases of carcinoma arising in thyroglossal cyst are reported. The carcinoma in both cases was papillary thyroid carcinoma. The aspirated cyst fluid in one case revealed only macrophages and benign squamous epithelial cells, while in the other case the cyst fluid showed cytologic features of papillary carcinoma including psammoma bodies and epithelial cells with papillary clustering, intranuclear cytoplasmic inclusions, and positive immunohistochemical reaction to thyroglobulin.

Cytology of allergic bronchopulmonary aspergillosis

The cytologic features of a case of allergic bronchopulmonary aspergillosis (ABPA) are reported and the literature reviewed. The bronchial brushing smears in this case showed mucus that contained laminated aggregates of eosinophils with scattered Charcot-Leyden crystals and fungal hyphae. These cytologic findings, overlooked by the initial examining pathologist, reflected the "mucoid impaction of bronchi" component of ABPA and are therefore diagnostic of ABPA. A cytologic diagnosis of a clinically unsuspected ABPA would lead to the correct treatment and prevent unnecessary surgery.

Prevalence of goiters in school children residing in villages where underground water is used

A representative of Fuder village in Taichung County complained that many residents had a goiter problem, which he felt might be related to pollution from the nearby Youshi industrial area. The purpose of this study was to determine whether school children in the Fuder area have a high prevalence of goiters. We chose children of the Schichi elementary school in the Fuder area as the study population, and children of the Goumei elementary school, far from the Youshi industrial area, as controls. Both groups were from a similar geographic location (near the sea), had similar socioeconomic status, and both drank underground water. Thyroid enlargement was examined by palpation as recommended by the World Health Organization. Thyroid antibodies and hormones were determined in school children with a goiter and age-sex-matched normal control children using the particle agglutination method and radioimmunoassay, respectively. In total, 1,692 school children were examined, including 875 males and 817 females. Of these, 126 school children (7.4%) had a goiter of Grade I or above. The prevalence of goiters in Shichi and Goumei were 8.8% (59/671) and 6.6% (67/1,021), respectively. There was no significant difference between these two areas. We compared the prevalence of goiters in these two schools where underground water is drunk with another previous study in Peimen and Putai where tap water is used. There was a statistically significant difference (7.4% vs 2.6%, p < 0.0001). This suggests that the higher prevalence rate of goiters in Shichi and Goumei is related to the drinking of underground water. We recommend that the use of tap water and continued salt iodization is the way to prevent endemic goiter in these areas. A further comprehensive study is needed to determine the nature of the goitrogen in the underground drinking water of the Fuder area.

[Risk factors of lung cancer]

The relationship between various risk factors and lung cancer was evaluated in a case-control study. One hundred and forty-one cancer patients newly cytologically or pathologically diagnosed from May 1990 to July 1991 at Tri-Service General Hospital (TSGH) were recruited as cases. Two control groups were also studied: 282 hospital controls two-to-one matched with cases on sex, age, hospital of admission and insurance status were selected from the TSGH Ophthalmologic Department, and 282 neighborhood controls two-to-one matched on sex, age, and residence were randomly selected from eligible neighbors. A comparison of interview data between cases and hospital controls based on multiple conditional logistic regression revealed that cigarette smoking, keeping doves as pet, occupational exposure to cotton dust and working as a cook were risk factors for lung cancer. An inverse association between incense burning and lung cancer was noted. The comparison between cases and neighborhood controls showed lung cancer was significantly associated with cigarette smoking, keeping doves, prior chronic bronchitis, occupational exposure to cotton dust, asbestos and radiation, low frequency of burning incense, and low intake of vitamin A derived from vegetables and fruits. There was no association between lung cancer and working as a cook when cases were compared with neighborhood controls.

Mycobacterial spindle cell pseudotumor of lymph nodes

Two cases of spindle cell pseudotumor in the lymph nodes of patients with acquired immunodeficiency syndrome caused by mycobacterial infection are reported and the literature reviewed. The lesions mimicked neoplasms because they were composed predominantly of spindle cells arranged in a storiform pattern. Most of the spindle cells were phagocytic cells that contained large amounts of mycobacteria. It is important for the pathologist to recognize the lesion so that a prompt tissue diagnosis can be provided because specific therapy is available.

Open tip rhinoplasty

An open tip rhinoplasty was used to correct moderate to severe secondary cleft lip nasal deformities in 122 patients from January 1986 to January 1988. The results of the surgery on 92 patients who were followed for 1 year or more were evaluated. When the surgery was performed after the age of 3 years, 60% of the patients had a satisfactory result. The pathology of the deformity included 32% with deficiencies of the nasal lining, 35% needed framework support such as a columellar strut, and 45% required correction of columellar deficiencies. Patients using a postoperative nasal stent had a 71% satisfactory result compared with a 37% satisfactory result when the stent was not used. The pathology and techniques to correct the nasal deformity are described.

Hyperamylasemia following cardiopulmonary bypass

In order to study the occurrence of postbypass hyperamylasemia, 75 patients undergoing cardiopulmonary bypass (CPB) were studied from March 1989 to January 1990. There were 49 males and 26 females. Among them, 27 had congenital heart disease, 30 had valvular disease, and 18 had coronary artery disease. There were 27 patients with at least one elevated serum amylase sample after operation. Thus, the overall incidence of hyperamylasemia was 36%. As compared with the preoperative data (1.3%), there was a statistically significant difference in the occurrence of hyperamylasemia (p less than 0.05). Three patients had overt clinical pancreatitis postoperatively. There was no positive correlation between the serum amylase level and the occurrence of pancreatitis (p greater than 0.05). Forty-two cases had a significant elevation of the amylase creatinine clearance ratio (ACCR) after CPB. However, there was no significant difference between the groups with pulsatile and nonpulsatile CPB (p greater than 0.05). Three patients (4%) died in our series. The causes of death were heart failure in two and fulminant pancreatitis associated with low cardiac output in one. Although our experience in dealing with pancreatitis improved survival, mortality was still high (33.3%) in our series. Nevertheless, there was no apparent correlation between mortality and postbypass hyperamylasemia (p greater than 0.05). Logistic regression analysis was used to analyze the risk factors of the occurrence of hyperamylasemia, and the analysis revealed that patients with coronary artery disease were susceptible to postbypass hyperamylasemia. Our studies indicate that the use of total serum amylase or ACCR to monitor for the occurrence of pancreatitis in postbypass patients is inadequate.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting local or regional recurrence in breast cancer

Between 1975 and 1989, 535 patients with infiltrating ductal carcinoma of the breast in various clinical stages were treated by modified radical mastectomy and axillary node clearance, followed by chemotherapy, endocrine therapy or radiotherapy. Median follow-up was 3 years (5 months to 15 years). Fifty-eight local or regional recurrences occurred. The 5-year and 10-year actuarial risks of breast recurrences were 14% +/- 2% and 23% +/- 4%, respectively. Using multivariate analysis with the Cox regression model, the most important multivariate-adjusted independent contributing factors to local or regional breast recurrences were age less than or equal to 40 (p less than 10(-4), relative risk = 2.94), positive lymph nodes greater than 3 (p less than 10(-3), relative risk = 2.57), and multicentricity (p = 0.044, relative risk = 2.73). The overall 5-year survival rate of recurrent patients was 64 +/- 7%, and was significantly worse when breast recurrence occurred in the first 18 months after operation. The multivariate-adjusted relative risk of death for early recurrence was 4.35 (p = 0.04). The unadjusted 5-year survival rate for early recurrence was 58% +/- 1%, and 85% +/- 8% for late recurrence. This study confirms the relationship between young age and low breast control rates. It emphasizes the adverse prognosis of early breast recurrences as compared to the relatively favorable outcome of late recurrences.

Angiosarcoma in postsurgical lymphedema. An unusual occurrence in a man

A 63-year-old man underwent partial left axillary node dissection for metastatic melanoma of unknown primary. Lymphedema of his left upper extremity developed after surgery. Eight years later, extensive cutaneous angiosarcoma developed in the edematous limb. The occurrence of cutaneous angiosarcoma in postsurgical lymphedema is extremely rare in men; to our knowledge, our case is the fifth such case thus far reported.

An analysis of traffic injuries in Taiwan in relation to alcohol use and economic loss

Breath alcohol analysis of 449 patients with motor vehicle injuries attending the emergency department of a Taiwan urban general hospital during a 10-week period showed that 19.2 per cent had breath alcohol concentration (BAC greater than 0.002 per cent and 8.5 per cent greater than or equal to 0.05 per cent). Injured males were more likely to have BAC greater than or equal to 0.05 per cent than women (11 per cent vs 0 per cent). Injuries resulting from alcohol-associated collisions were about 6.7 times more likely to occur between 1800 and 0600 than at other time periods. A telephone survey after hospital discharge showed that the risk factors of alcohol use, speed at time of collision and type and site of collision were significantly associated with degree of economic loss resulting from the accidents. Logistic regression analysis showed that the odds of high economic loss associated with BAC greater than 0.002 per cent were three times greater than for persons in whom no alcohol was detected. This is the first study in Taiwan to use breath alcohol analysis in assessing the effect of alcohol consumption on motor vehicle injuries. The results show that alcohol use is an important cause of motor vehicle injuries. Preventive measures such as strict legal control of drunk driving and limitation of the hours that drinking places can stay open at night are recommended to reduce the damage caused by this severe public health problem.

Studies on the photochemical and photocytotoxic properties of the new PDT photosensitizer aluminum sulfonated phthalocyanine

The properties of photosensitization of sulfonated aluminum phthalocyanine (ALSPC), a new photosensitizer of potential use in cancer photodynamic therapy (PDT) was studied on both the molecular and cellular levels. The mechanism of ALSPC photosensitization on the molecular level was investigated by testing its efficiency of singlet oxygen (1O2) production, using the method of tryptophan degradation and that of ESR spectroscopy and observing the enhancing effect of D2O and the quenching effect of NaN3. Results of all these experiments confirmed the important role of the Type II or 1O2 mechanism in ALSPC photosensitization. In our in-vitro experiments, ALSPC's incorporation into cells and its photocytotoxic effect were investigated on a human liver cancer cell line. The cell incorporation was illustrated by the laser-excited fluorescence spectra emitted both from cell homogenate and cell monolayers incubated with ALSPC aqueous solution. The position of fluorescence peak observed, implied that ALSPC exists in the cells mainly as monomers. The efficiency of cell killing of ALSPC photosensitization was estimated by counting surviving cells with the method of trypan blue staining and by the method of radioisotope labelling. Experiments using the latter method also showed DNA damage caused by ALSPC photosensitization.