Bilateral laparoscopic gonadectomy for testicular feminization syndrome

Defects of androgen receptor gene lead to testicular feminization syndrome, which is one of the most common etiology of male pseudohermaphroditism. A 22-year-old phenotypic female with primary amenorrhea and insomnia is presented. Gross appearance revealed sparse axillary and pubic hair, poor breast development, clitoromegaly and absence of vagina. Ultrasound demonstrated no evidence of the uterus or adnexal structures, but the prostate gland was found. The laboratory data showed elevated follicle-stimulating hormone and a male 46, XY karyotype. Computed tomography localized the position of bilateral undescending testes, which were removed by operative laparoscopy procedures later. The patient was discharged without complication postoperatively.

Congenital bilateral agenesis of diaphragm: report of a case

Bilateral agenesis of the diaphragm is a rare, life-threatening malformation. Infants with this defect rarely survive to have surgical intervention. We report a 32-week premature female infant who was born to a 36-year-old mother via vaginal delivery. The pregnancy course was complicated by hypertension and polyhydramnios. Cytogenetic study showed a normal 46 XX female karyotype. She had cyanosis, respiratory distress and scaphoid abdomen at birth. A roentgenograph confirmed the diagnosis of diaphragmatic hernia. Surgery was performed at 21 h of age. Bilateral agenesis of diaphragm, herniation of abdominal organs and oesophagus and pulmonary hypoplasia were noted. Furthermore, stomach and spleen were adherent to the mediastinum and vertebrae. The patient developed hypotension and persistent hypoxaemia and expired at age of 26 h. Autopsy revealed bilateral agenesis of diaphragm, hypoplasia of lungs, and pancreas fibrosis with mild hypoplasia of islets of Langerhans.

CONCLUSION

Bilateral agenesis of diaphragm associated with pancreas fibrosis is a rare entity, and its clinical significance needs further investigation.

Different viral aetiology of hepatocellular carcinoma between two hepatitis B and C endemic townships in Taiwan

In Taiwan, we found two hepatitis B virus (HBV)- and hepatitis C virus (HCV)-endemic townships, Paisha and Tzukuan, with an anti-HCV prevalence of 19 and 37% in men, and 26 and 38% in women, respectively. The hepatitis B surface antigen (HBsAg)-positive rates were 25 and 18%, for men and women in Paisha, and 25 and 22% in Tzukuan, respectively. According to the national death certification database (1982 to 1991), the annual age-adjusted mortality rates per 100,000 population for liver cancer among men and women were 83.0 and 13.8, respectively, in Paisha, and 55.9 and 17.0 in Tzukuan compared with 30.9 and 9.1 in Taiwan as a whole. The male-to-female ratios were 6.0 in Paisha and 3.3 in Tzukuan. Aetiology of 11 cases of hepatocellular carcinoma (HCC) from Paisha and 14 cases from Tzukuan were analysed. All HCC cases from Paisha were HBsAg positive, while 13/14 HCC cases from Tzukuan were anti-HCV positive. The endemic duration of HCV in Tzukuan seemed long enough to induce HCC, but the HCV appeared to be a newly introduced infection in Paisha.

Comparative direct electrophysiological effects of propofol on the conduction system and ionic channels of rabbit hearts

1. Propofol, an intravenous anaesthetic agent, can affect cardiac conduction but the ionic mechanisms have not been well defined. 2. This study measured the direct effects of propofol on the cardiac conduction system by using intracardiac recording/stimulation in Langendorff-perfused rabbit hearts. The underlying ionic mechanism was elucidated by using the whole-cell voltage clamp on rabbit isolated atrial and ventricular myocytes. 3. Propofol prolonged significantly the AV conduction (AH) interval at a clinically relevant concentration (3 microM). This AH interval prolongation was dose-dependent (3 to 100 microM). At higher concentrations, the AV nodal Wenckebach cycle length and its refractory period were also prolonged (10 to 100 microM). In addition, the conduction through the His-Purkinje system (HV interval) and the atrial tissue (SA interval), as well as the spontaneous cycle length, were lengthened dose-dependently (30 to 100 microM). 4. In isolated ventricular myocytes, Na current was decreased dose-dependently by propofol. In part this was due to a negative-shift of the steady-state voltage-dependent inactivation and a slowed rate of recovery from inactivation. The INa suppression by propofol was frequency-dependent. Propofol also blocked the ICa. The ED50 for peak current inhibition was 6.9 +/- 0.9 (n = 6) and 8.3 +/- 1.5 microM (n = 7) for INa and ICa, respectively. 5. The transient outward potassium current (Ito) of atrial myocytes was suppressed with an ED50 of 5.7 +/- 0.8 microM (n = 11), which was only partly caused by a left-shift of the steady-state inactivation. The inward rectifier K current (IK1) of the ventricular cells was reduced somewhat by propofol. 6. In summary, propofol can cause direct dromotropic and chronotropic effects on the cardiac conduction system, especially the atrioventricular node. These changes can be attributed, at least in part, to its direct dose-dependent suppression of the cardiac ICa, INa and Ito. Special concerns in the use of propofol anaesthesia for cardiac patients and the therapeutic antiarrythmic potential of propofol-like compounds are addressed.

Enhanced interleukin-4 expression in patients with endometriosis

OBJECTIVE

To investigate the expression of cytokines by T-helper cells type 1 (interleukin [IL]-2 and interferon-gamma [IFN-gamma]) and type 2 (IL-4 and IL-10) in peripheral blood monocytes and peritoneal fluid (PF) cells from patients with endometriosis.

DESIGN

Peripheral blood (PB) monocytes and PF cells from patients with endometriosis were isolated and the expression of cytokines investigated.

SETTING

Institute for the treatment of endometriosis and research institute in university-based medical center.

PATIENT(S)

The study included 7 women with normal pelvic structure, 36 patients with endometriosis, and 7 women with pelvic adhesion but without apparent endometriotic lesion. The existence and severity of endometriosis was determined by laparoscopic examination.

INTERVENTION(S)

All patients received laparoscopic operation to identify the existence and stages of endometriosis. Danazol (200 mg, twice daily) was prescribed for those with endometriosis.

MAIN OUTCOME MEASURE(S)

Transcription of cytokines were directly analyzed using the reverse transcriptase-polymerase chain reaction method. The concentrations of cytokines in peritoneal fluids and sera were analyzed by the ELISA.

RESULT(S)

Levels of IL-4 messenger RNA (mRNA) and protein in the PB and peritoneal cells of patients with endometriosis were higher than those of normal patients, whereas levels of IFN-gamma mRNA and protein were suppressed. There were no significant changes in the mRNA or protein levels of IL-2 or IL-10 in both peritoneal fluids and sera. The level of IL-4 was reduced to normal after combined treatment with laparoscopic surgery and danazol. The secretion of IFN-gamma was elevated after treatment.

CONCLUSION(S)

Cytokine secretion by T-helper cells type 1 and type 2 is altered in women with endometriosis, suggesting that these T-helper subsets play a role in the immunologic responses to endometriosis.

Surgical results of 23 patients with tracheobronchial injuries

The objective of this study was to evaluate the surgical results of tracheobronchial injuries. Between July 1988 and March 1996, tracheobronchial surgery was performed on 23 injured patients. According to the aetiology, the injuries were categorized as blunt injury (n = 13), cutting or penetrating injury (n = 5), and corrosive injury (n = 5). Blunt injuries included three complete laryngotracheal disruptions, one tracheal laceration, and eight bronchial ruptures. Cutting or penetration injuries included four laryngotracheal ruptures and one tracheal cutting wound. Corrosive injuries included one tracheal necrosis, one tracheal stenosis and three esophagorespiratory fistulae. Operative procedures that were performed on the tracheobronchus included tracheoplasty (n = 12), bronchoplasty (n = 7), sleeve resection of the trachea (n = 2) and bronchus (n = 2). Two hospital deaths were encountered, with a mortality rate of 8.7%. One patient with caustic injury died of bronchopleural fistula and empyema. The other patient died with multiple injuries from multiple organ failure which was unrelated to the bronchoplasty. One postoperative complication was restenosis of the trachea in a caustic injured patient, which was treated by a T-tube insertion. In conclusion, tracheobronchoplasty is an effective life-saving emergency procedure for the patients with tracheobronchial injuries.

Long QT syndrome in children

Long QT syndrome is a disease that can cause syncope, seizures and sudden death. From June 1990 to June 1996, 11 children (male/female: 714; ages: 1 day-13 years with a median of 5.4 years) from different families were found to have long QT syndrome. Their corrected QT intervals (QTc) were 0.46-0.59 sec (median: 0.53 sec). All patients had normal hearing. One patient had Marfan syndrome with mitral valve prolapse. The presentation symptoms were: sudden death (2), seizures (6) and syncope (3). Their electrocardiogram abnormalities included: torsades de pointes (7), sinus bradycardia (4), T wave abnormalities (4), monomorphic ventricular tachycardia (2) and congenital complete atrioventricular block (1). All patients were treated with beta-blockers and one had pacemaker implantation. In a follow-up period of 0.5-6 years, 6 were symptom free, 1 died of ventricular tachycardia and 2 had recurrent syncope.

Bronchial stenosis mimicking the scimitar syndrome: report of one case

The scimitar syndrome, also known as hypogenetic lung syndrome, has the classic radiological appearance of hypoplasia of the right lung, dextroposition of the heart, and a curvilinear density in the right lower lung that courses to the right cardiophrenic angle known as a scimitar sign. We report a case with stenosis of the main stem of the left bronchus and an emphysematous change of the left lung which shifted the heart to the right side and compressed the right lung. A curvilinear density was also noted in the right lower lung field. All these radiological findings together mimic the chest radiographic appearance of the scimitar syndrome.

Evaluation of the number of laser-Doppler measurements in assessing regional diaphragmatic microcirculation

As regional diaphragmatic microvascular blood flow varies widely, the aim in this study was to estimate the number of repeated measurements, obtained by Laser-Doppler flowmetry (LDF), required to achieve a standard level of precision. In 40 urethane-anesthetized Sprague-Dawley rats, computer-aided LDF scanning coupled with a microscope generated diaphragmatic blood flow (Qdi) ranging between 94 and 944 mV with the frequency histogram displaying non-Gaussian distributions. A sampling technique was used to assess the number of measuring sites required for valid estimates of the regional diaphragmatic microvascular flow. From a total of 1,000 Qdi values, random samples of sizes between 5 and 100 were repeatedly drawn to estimate the variability of median flow. Our data shows that the 95th percentile decreased gradually, from a +30% error at n = 5 down to +20% at n = 15-20, remained between +20 and +15% up to n = 35, and reached +10% at n = 50. Moreover, by expressing the precision level of measurements as the length of a 95% confidence interval (beta), a linear relationship between beta values obtained either by the sampling method or repeated measures analysis of variance can be shown (r = 0.902, p < 0.001); beta values by either method were within +/-20% error of the mean values at sample sizes above n = 15. It is therefore recommended that for microscope-guided LDF scanning in the assessment of the distribution of diaphragmatic microvascular blood flow, at least 15 repeated measurements should be done to reach an acceptable standard level of precision. However, facing with clinical situations where 'blind' LDF scanning inevitably includes measurements over large vessels, the minimal sample sizes required to represent tissue perfusion demand further exploration.

Age-related propofol effects on electrophysiological properties of isolated hearts

We compared the direct effects of propofol on the conduction system of neonatal (< 7 days) and adult (> 3 mo) rabbit hearts using intracardiac recording/ stimulation in Langendorff-perfusion and autonomic blockade. At a low concentration (3 microM), propofol caused a slight but significant lengthening of the atrio-ventricular (AV) conduction interval of the adult hearts, but not of neonatal hearts. At a higher concentration (10 microM and above), propofol significantly prolonged the AV conduction interval in a frequency-dependent manner in both neonates and adults. The AV Wenckebach cycle length was also lengthened, with the change more significant in the adults. However, with concentrations of propofol up to 100 microM, the neonatal hearts frequently (9 of 13 experiments) progressed to complete AV block, which was not observed in the adults. Conduction through the atrial tissue (SA interval) and the His-Purkinje system (HV interval), as well as the spontaneous heart rate, were all slowed by propofol at 30 microM or above. However, the lengthening of SA interval was more pronounced in the neonates, and only in the neonate was the atrial refractory period prolonged by propofol at 10 microM and above. We conclude that 3 microM propofol produces no significant direct effects on the neonatal cardiac electrophysiological properties, although AV conduction of the adult heart may be suppressed at this concentration of propofol. At higher concentrations, age-related propofol effects were demonstrated in the AV node and the atrial tissue.

Surgical treatment of pediatric lung abscess

Eight pediatric patients with lung abscesses underwent surgical intervention in our hospital during a 7-year period. All the abscesses were associated with severe sepsis or complicated by a bronchopleural fistula that did not respond to medical treatment and tube thoracostomy. Seven patients required unilateral thoracotomies, and one patient with bilateral lesions required simultaneous bilateral thoracotomies. One tension pneumatocele required a preceding pneumonostomy. All patients underwent decortication and at least one additional surgical procedure consisting of: lung debridement plus bronchial closure (n = 4); lobectomy (n = 2); bisegmentectomy (n = 3); and/or segmentectomy (n = 1). There were no operative deaths, but two patients had persistent air leakage that was treated by bronchial closure. The average hospital stay was 22 days (postoperative 10.1 days). All the patients recovered completely. For many pediatric lung abscesses that do not respond to medical treatment and simple drainage procedures, surgical intervention is indicated and can shorten the hospital stay.

Endothelium on the flow surface of human aortic Dacron vascular grafts

PURPOSE

We have previously observed endothelium on two human vascular prostheses explanted under optimal conditions for flow surface preservation. In this study we sought to further verify the hypothesis that endothelialization can occur on clinical grafts and that it can be detected in specimens that have been promptly removed and properly preserved in a timely manner.

METHODS

We studied 29 aortic grafts. Of these, 11 Dacron bypass grafts were in a condition suitable for analysis with light microscopy and immunocytochemistry staining, and scanning and transmission electron microscopy.

RESULTS

Three grafts had endothelium beyond the pannus, identified by factor VIII/ vWF, Ulex europaeus agglutinin, and collagen IV positivity. Specimen A, a knitted 6-year implant, was preserved by embalming 3 hours after the patient's death and had a firmly attached outer capsule with fibroblasts, collagen, giant cells, and microvessels in the interstices. Specimen B, a woven 18-year implant, was retrieved at reoperation and immediately fixed in 10% formalin; it had no outer capsule and no tissue ingrowth. Specimen C, a woven 7-year implant, was removed and fixed 5 hours after the patient's death; it had a firmly attached outer capsule but no tissue ingrowth beyond the outer portion of the wall.

CONCLUSIONS

The rapidity with which the specimens were fixed probably enabled identification of endothelium. These findings suggest that endothelialization of synthetic arterial grafts may occur more frequently in human beings than previously recognized.

Accelerated endothelialization model for the study of Dacron graft healing

Accelerated endothelialization was studied by creating a vascular tissue environment around porous Dacron grafts. Three study groups, each containing 10 dogs, were divided equally into 2- and 4-week implant periods, with 8 mm x 6 cm knitted Dacron grafts implanted in the abdominal aorta. Grafts in group 1, the control group, were implanted conventionally. In group 2 each implanted graft was completely wrapped in a resected segment of the autogenous inferior vena cava, with its intima against the wall. In group 3 the adventitial side of the vein was wrapped against the wall. The vein wrap produced accelerated endothelialization as follows: endothelial-like cell coverage scores at 2 and 4 weeks were, respectively, 78% and 98% for group 2 and 80% and 95% for group 3, compared to only 14% and 50% for group 1 (p < 0.05). The neointima, which contained smooth muscle cells, was formed as early as 2 weeks in the vein-wrapped grafts. There were no differences in the speed of healing or in healing patterns according to whether the intimal or the adventitial side of the inferior vena cava was placed against the graft. Histologic findings did not support the hypothesis that accelerated flow surface endothelialization results in direct migration of endothelial cells from the intima of the vein wrap, and there was no clear correlation between the surface endothelial-like cell coverage and microostia. To gain further insight into why accelerated healing occurs in this model, earlier observations accompanied by molecular biology analysis are needed, and vein wrap studies provide a method of comparison for this work.

Implant site influence on arterial prosthesis healing: a comparative study with a triple implantation model in the same dog

PURPOSE

The purpose of this study was to develop a cost-effective canine graft healing model that gives information on various implant sites and controls for variable factors between graft locations and between animals and to compare the influence of implant site (retropleural, retroperitoneal, and subcutaneous areas) on arterial graft healing in the same subject under such controlled study conditions.

METHODS

Five mongrel dogs were studied for 8 weeks, and one was studied for 3 years. Each received three porous Dacron grafts during the same surgery: a carotid-femoral bypass (C-FB) and interposition grafts in the descending thoracic aorta and abdominal aorta. To produce comparable shear stress calibers of the C-FB and abdominal aorta grafts were 2 mm less than those of the descending thoracic aorta, and a distal arterio-venous fistula was created to further increase the C-FB flow. For comparable blood aggregation status platelet aggregation was preevaluated and adjusted with antiplatelet agents. Graft flow surfaces were assessed for thrombus-free surface and endothelial-like cell coverage scores. Tissue samples were studied with hematoxylin-eosin, factor VIII/ von Willebrand factor, smooth muscle alpha-actin staining, and scanning electron microscopy and transmission electron microscopy.

RESULTS

All grafts were patent. Shear stress for the three grafts and platelet aggregation among the study subjects were comparable. Healing of descending thoracic aorta and abdominal aorta grafts was similar, but C-FB healing was slow, incomplete, and uneven, with a high incidence of seroma. Eight-week and 3-year results were comparable.

CONCLUSIONS

This model gives broad healing information about the areas where grafts are often implanted in humans. Eight weeks appears to be a sufficient period to reflect basic and general healing characteristics. Grafts heal better in the retropleural and retroperitoneal areas than in the subcutaneous tissues.

Clinical application of transorotracheal tube tracheal insufflation of oxygen in patients undergoing simple video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery (VATS) has been performed during ganglionectomy and bullectomy and usually requires a collapsed or immobilized lung. Transtracheal insufflation of oxygen (TRIO) maintains an immobilized lung, adequate oxygenation, and partial CO2 elimination but has never been used for VATS. We have simplified the TRIO design with a catheter inserted through the lumen of the orotracheal tube in what we call "transorotracheal tube TRIO" (TRIO-TOTT) and investigated its clinical use on simple VATS. Eleven patients undergoing bullectomy for primary simple pneumothorax (PSP) were studied. During the performance of VATS, a 12-gauge suction catheter was inserted as our modification and connected to the gas outlet of an anesthetic machine. The flow rate of oxygen was maintained at 10 L/min. Blood gas was collected prior to TRIO-TOTT, during TRIO-TOTT at 5, 10, 15, and 20 min, and 5 min after TRIO-TOTT. The blood gas data showed excellent oxygenation while the PaCO2 increased at a rate of 1.2 mm Hg/min compared to 3-4 mm Hg/min for apnea oxygenation. After 20 min, the mean +/- SEM PaO2 and PaCO2 were 428 +/- 27 and 65.0 +/- 2.6 mm Hg, respectively. We conclude that TRIO-TOTT is a simple, safe, and effective ventilation method for simple VATS.

Effect of altered blood flow on the caliber and morphology of the internal thoracic artery in the dog

OBJECTIVE

The purpose of this study was to evaluate in dogs the effect of blood flow alteration on caliber and morphology of in situ internal thoracic arteries.

METHODS

Six dogs underwent creation of a unilateral distal arteriovenous fistula between the internal thoracic artery and vein at the sixth rib to create high flow, and in six others the internal thoracic artery was unilaterally skeletonized and dissected. For both groups the contralateral internal thoracic artery served as the control; sides were alternated among cases. Blood flow was measured for shear stress calculation before and after surgical alteration. After 2 months, internal thoracic arteries were harvested with the entire anterior chest plate, which was dynamically inflated and fixed with 10% formalin at a controlled pressure of 120 mm Hg after angiography had been done at the same pressure. The luminal diameters were then measured at eight levels on the angiograms. Arterial tissue samples were taken at three levels and embedded, sectioned, and treated with hematoxylin-eosin and Verhoeff-van Gieson stains. Digital imaging analysis was used for quantitative morphometric studies.

RESULTS

All fistulas remained patent. In comparison with control arteries, high-flow internal thoracic arteries dilated and low-flow internal thoracic arteries narrowed, which was associated with significant change in shear stress for both groups. There were no substantial structural changes in the walls of either group.

CONCLUSION

In the dog, the luminal diameter of the internal thoracic artery responds to altered blood flow without intimal thickening or other undesirable wall changes.

Prognosis of coronary arterial lesions in Kawasaki disease treated without intravenous immunoglobulin

From 1981 to 1989, a total of 86 consecutive patients with definite Kawasaki disease who received aspirin but not intravenous immunoglobulin (IVIG) therapy during the acute stage were studied. Thirty-eight of them (44%) had coronary arterial lesion (CAL) on initial two dimensional echocardiograms. Of them, 21 (56%) had ectatic coronary changes, 13 (34%) had small to large coronary aneurysms (diameter < or = 8 mm) and 4 (10%), giant coronary aneurysms (diameter > 8 mm). Patients with CAL had, in the acute stage, a longer duration of fever (p < 0.01), higher maximum platelet counts (p < 0.05) and a higher one-hour erythrocyte sedimentation rate (< 0.01) than those without. Males were associated with a higher incidence of aneurysmal dilatation of the CAL. By actuarial event-free analysis, more than half of the ectatic coronary lesions regressed within two months of onset, and 86% became normal on echocardiograms within a two-year follow-up period. Ectatic lesions had a significantly higher chance of regression than aneurysmal lesions (p < 0.01). Furthermore, none of the giant aneurysms regressed (p < 0.05, as compared with those coronary aneurysms smaller than 8 mm in diameter). It was concluded that coronary arterial lesions occurred in a substantial number of Chinese children with Kawasaki disease who received only aspirin therapy. Regression of the lesions was related to their size and morphology.

Clinical implications of short-axis aortopulmonary rotation on juxtacommissural origin of the coronary artery in transposition of the great arteries and surgical strategy

BACKGROUND

The relationship of short-axis aortopulmonary rotation (APR) with juxtacommissural origin of the coronary arteries (JOCA) in transposition of the great arteries (TGA) has never been elucidated. The surgical outcome of arterial switch operation (ASO) is influenced by the presence of JOCA.

METHODS

Fifteen patients with TGA who presented to our institution between 1988 and 1995, and 23 cases from the literature, all with documented JOCA and APR, were analyzed. Each coronary arterial type was assigned to one of five patterns, according to similarities of epicardial configuration. All our patients underwent an ASO with various techniques to deal with JOCA.

RESULTS

JOCA near the facing commissure (FC, 35 cases), were more frequent with anterior TGA (29/31, 94%) except types 5cj and 9j that were seen with posterior and right lateral TGA (4/4, 100%); whereas JOCA near the right-hand nonfacing commissure (RNC, 3 cases) were related with posterior TGA. Eta-square analysis showed significant correlation between various JOCA and short axis APR. Thirteen of our cases had JOCA near FC, two near RNC. Five of the former in whom the coronary artery was excised as a single button had a superior trapdoor; using a two-button technique three of the former had a lateral funnel and one of the latter had a medial trapdoor for the JOCA; all survived although on late noncoronary death was noted. In the remaining six cases without augmentation, only one survived (8/1 vs 1/5, p < 0.02).

CONCLUSION

JOCA in TGA was related to short axis APR, generally near FC in anterior TGA (except types 5cj and 9j), and near the RNC in posterior TGA. A superior (lateral) or medial flap, to augment the coronary button for JOCA near FC or RNC is helpful for a successful ASO.

Results of surgical treatment of 107 patients with complications of pulmonary tuberculosis

The objective of this study was to evaluate the results of surgical intervention performed on 107 patients with pulmonary tuberculosis complications. Between September 1988 and December 1995, 107 patients underwent a total of 126 operations for major complications of pulmonary tuberculosis. One hundred and twenty-six operations consisted of lobectomies only or plus other lung resections performed in 55 cases, pneumonectomies in 20 cases, segmentectomies in 18 cases, wedge resections in two cases, tracheobronchoplasties in four cases, decortications in two cases, cavernostomies with concomitant muscle transpositions in seven cases, thoracoplasties reserved for the previously failed operations or to be a supplement for pulmonary resections in 18 cases. The operative mortality rate was of 1.8%, and the major complication rate was of 16.8%. Twenty-eight (26.1%) patients with tuberculosis bacilli in sputum before operation have converted except one diabetic patient. In conclusion, surgery is indicated in pulmonary tuberculosis complications that are life-threatening or unresponsive to chemotherapy. Pulmonary resection is the procedure of choice for most cases that require surgery.

[119 emergency medical transport of the elderly]

A retrospective analysis of emergency ambulance transports in the EMS-Tainan was made to evaluate the utilization of emergency medical system by the elderly and to determine the factors that may influence these transports. The study group consisted of 4,090 emergency ambulance transports from 1/1/1195 to 30/4/1995. 1,017 patients (24%) were aged over 65. The main characteristics of these elderly patients were as follows: more non-trauma cases, higher severity of triage, and longer total transport time (23.0 +/- 0.5 vs. 18.9 +/- 0.2 minutes) were noted. In addition, 136 (13.4%) of the elderly patients were not received by the EMS network hospital. The most important factors that affect the total transport time in the elderly group were triage classification and trauma, which determined that speed of transport. In the elderly group, female patients tend to be older, of more severe triage classification, more nontrauma-related, have longer total transport time, and have less access to the EMS than male patient. Based on these results, we recommended make efficient transport in order to provide better emergency care for the elderly. A network linking the elder users with EMS dispatch center should improve the efficiency in fulfilling the EMS calls, and further investigation about the value of such a network is warranted. It is also important to establish a competent and countrywide database for EMS users and to pursue ongoing planning in order to evaluate and investigate the needs of EMS for elderly patients in the future.

Anomalous pulmonary venous pathway traversing pulmonary parenchyma. Diagnosis and implication

STUDY OBJECTIVES

To describe four patients having total anomalous pulmonary venous connection with an intrapulmonary vertical vein, rendering difficulty in diagnosis and surgery.

SETTING

a tertiary referral center.

PATIENTS AND METHODS

By reviewing medical records, 4 of 25 patients with right atrial isomerism and total anomalous pulmonary venous connection were identified to have an intrapulmonary vertical vein. All four patients underwent echocardiography, catheterization, and angiography. One underwent MRI. Two underwent open-heart surgery and one received a modified Blalock-Taussig shunt.

RESULTS

Right atrial isomerism was present in all four patients. On chest x-ray films, an abnormal shadow resembling scimitar syndrome was seen in two patients. Imaging the vertical vein was unsuccessful with an echocardiogram in all four patients. The intrapulmonary course of the vertical vein was depicted with a pulmonary venogram in two patients and with magnetic resonance in one patient. The intrapulmonary segment remained undetected until autopsy in one patient. All four patients died. At autopsy, the pulmonary venous confluence was hypoplastic in all four hearts. The vertical vein was buried in pulmonary parenchyma and drained to superior vena cava with significant obstruction.

CONCLUSION

In the presence of right atrial isomerism and total anomalous pulmonary venous connection, there may be an intrapulmonary pulmonary venous connection that may be obstructed. Anastomosing the pulmonary venous confluence to the atrium may be difficult because of hypoplasia of the pulmonary venous confluence.

Immunohistochemical analysis of nm23-H1 in stage I non-small cell lung cancer: a useful marker in prediction of metastases

BACKGROUND

About 30% to 40% of patients with pathologic stage I non-small cell lung cancer die within 5 years after complete resection. The identification of subgroups with high risk of recurrence is important. The level of nm23-H1/nucleoside diphosphate kinase expression has been reported to correlate inversely with the metastatic potential of some tumors.

METHODS

We examined immunohistochemically the expression of nm23-H1 in 32 stage I non-small cell lung cancers to determine its value in predicting the outcome of the operation.

RESULTS

Twelve (37.5%) recurrences and ten deaths occurred in this series. There were eight (25%) distant and four (12.5%) locoregional recurrences. Of the 32 pathologic stage I non-small cell lung cancers, 10 (31.3%) were positive for nm23-H1 gene product. None of the patients with a higher nm23-H1 protein level had detectable distant metastases at the end of this study (chi 2 test, p < 0.05). The median follow-up time to date is only 35 months (range, 18 to 83 months), and so far no significant difference in overall survival rate has been observed between the groups with high and low nm23-H1 protein levels.

CONCLUSIONS

The level of nm23-H1 protein is more useful than the T status or histologic type for the prediction of distant metastases, whereby cases may be selected for postoperative adjuvant chemotherapy.

Catheter ablation of junctional ectopic tachycardia by guarded low dose radiofrequency energy application

The prognosis of junctional ectopic tachycardia has been poor. A 9-year-old boy with dilated cardiomyopathy and this incessant form of tachycardia underwent RF ablation. Without retrograde atrial depolarization during tachycardia, serials of low dose RF energy were applied near the His-bundle area to find out the arrhythmogenic foci. The optimal site for ablation showed rate acceleration at low dose application and rate slowing down followed by conversion upon increasing the energy. By using this guarded low dose ablation technique, the tachycardia was eliminated without AV block. The LV function also improved.