Diffuse Abdominal Uptake Mimicking Peritonitis in Gallium Inflammatory Scan: An Unusual Feature of Acute Q Fever

The clinical features in patients with acute Q fever are variable. We present a patient with fever, abdominal distension, pericardial effusion, and diffuse gallium uptake in the abdominal cavity, mimicking peritonitis or peritoneum carcinomatosis. Serologic surveys revealed acute infection by Coxiella burnetii. The patient responded poorly to doxycycline and improved with oral levofloxacin. During the afebrile period, gallium inflammatory scan showed resolution of previous diffuse uptake in the abdomen, and cardiac echo resolution of pericardial effusion, which was suggestive of peritoneal inflammation related to acute C. burnetii infection. Therefore, clinicians in Taiwan should be alert to the possibility of acute Q fever in patients with fever of unknown cause, especially with clinical evidence of peritoneal and/or pericardial inflammation.

Treatment of volatile organic compounds from polyurethane and epoxy manufacture by a trickle-bed air biofilter

The objective of this study was to evaluate the performance of a trickle-bed air biofilter (TBAB) for the removal of volatile organic compound (VOC) produced during polyurethane (PU) and epoxy manufacture. The major VOCs emitted are ethyl acetate (EA) for PU and EA and xylene for epoxy production. For the treatment of VOCs emitted during PU production, the employed coal carbon appears to be efficient as a VOC concentration buffer in the biofiltration of waste gases. Based on the results of EA and total hydrocarbon (THC) removal, it was concluded that the TBAB is suitable for controlling VOC emission during PU manufacture. For the treatment of VOCs emitted during epoxy production, it was found that the performance of the TBAB is relatively poor due to the lack of VOC sources. However, this problem could be easily solved by mixing the VOCs emitted during PU and epoxy manufacture.

Laparoscopic esophagectomy

Minimally invasive esophagectomy is emerging as an alternative option to open esophagectomy for benign and malignant esophageal diseases. This article provides a detailed review of the history of minimally invasive esophagectomy and an update on the currently accepted techniques for minimally invasive esophagectomy and its outcomes.

Epidemiologic analysis and antifungal susceptibility of Candida blood isolates in southern Taiwan

Candidemia is a clinically important disease which has increased in incidence worldwide in recent decades. In order to identify the risk factors for mortality in candidemic patients and to elucidate the role of antifungal susceptibility testing, a retrospective cohort study was performed of 56 episodes of candidemia in 1998 at a medical center in southern Taiwan. The minimal inhibitory concentration (MIC) of these isolates was determined by E-test. Malignancy and alimentary diseases (42.9%) were the most common underlying conditions of these patients. There was no difference of Candida spp. distribution among patients treated in medical or surgical departments, except that all 5 isolates of C. intermedia were found in patients treated in medical departments (p=0.02) and 50% of candidemic infants had C. parapsilosis isolates (p=0.046). Among all Candida isolates, 3 (5.4%) were fluconazole non-susceptible. C. tropicalis had a significantly higher rate of amphotericin B resistance than the other species (p=0.007). Thirty four patients died and 70.6% of these deaths were attributable to candidemia. Thrombocytopenia, septic shock at the date of candidemia onset, C-reactive protein > 100 mg/L, blood urea nitrogen > 20 mg/dL, length of stay < 60 days, and Acute Physiology and Chronic Health Evaluation II score > or = 10 points were significantly associated with the death attributable to candidemia. Thrombocytopenia was the only independent predictor for mortality in the multivariate analysis. When the breakpoint of fluconazole was set at 2 microg/mL, as opposed to 8 microg/mL as in the National Committee for Clinical Laboratory Standards (NCCLS) criteria, the clinical outcome of death was significantly correlated to the MICs of the blood isolates. The correlation between MIC of fluconazole determined by E-test data, which is more easily obtainable than with NCCLS methods, and outcome requires larger scale investigation.

The present and future organisation of Veterinary Services in Asia: the examples of the Republic of Korea and Japan

The Veterinary Services of the Republic of Korea and Japan are reviewed and summarised. To cope with ever-increasing demands on Veterinary Services, both countries have made continued efforts to expand the services, which currently only have a limited number of government personnel. To overcome some of the problems associated with international trade, e.g. outbreaks of foot and mouth disease and classical swine fever (hog cholera), the authorities of the Republic of Korea are considering strengthening quarantine services by combining the National Veterinary Research and Quarantine Service and the National Plant Quarantine Service of the Ministry of Agriculture and Forestry (MAF). In the field of veterinary public health services, the Republic of Korea and Japan have different organisational structures. All Veterinary Services, including veterinary public health, are kept within the MAF in the Republic of Korea, whereas in Japan, the Ministry of Agriculture, Forestry and Fisheries (MAFF) deals with general animal production and health services and the Ministry of Health, Labour and Welfare (MHLW) deals with the safety of animal products, food poisoning and the prevention/control of zoonoses, such as rabies and Q fever. In Japan, after the occurrence of bovine spongiform encephalopathy in 2001, the authorities undertook a thorough review of the Veterinary Services, focusing particularly on food safety. A reorganisation of the administrative structure was proposed, and will be completed by the end of 2003. Subject to the approval of the Diet (House of Councillors), an independent 'Food Safety Commission' will be created within the cabinet office which will undertake risk analyses related to foods, and risk management will be carried out by the relevant ministry, i.e. the MAFF or the MHLW. The Animal Health Division of the MAFF will also be moved from the Livestock Industry Department to a new 'Consumer Safety Department' of the MAFF, where additional responsibilities in fish health control and feed safety control will be assumed.

Current status of minimally invasive esophagectomy

Minimally invasive esophagectomy is emerging as an option in the management of benign and malignant esophageal diseases. With minimally invasive esophagectomy, the conventional laparotomy is substituted with laparoscopy and the open thoracotomy with thoracoscopy. This article discusses the surgical techniques and outcomes for a variety of minimally invasive esophagectomy options.

Features predicting adverse outcomes of status epilepticus in childhood

OBJECTIVE

To examine variables that might predict abnormal outcome of status epilepticus among children.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All children younger than 15 years who were admitted to the paediatric intensive care unit with status epilepticus between 1997 and 2002.

MAIN OUTCOME MEASURES

Neurodevelopmental outcomes.

RESULTS

Two of the 25 patients died, resulting in a mortality rate of 8%. No deaths were due to status epilepticus itself. No patient with febrile or idiopathic status epilepticus developed epilepsy. Neurological deterioration was observed in a quarter (six of 23) of the survivors. Symptomatic aetiology (acute or remote) and refractory status epilepticus were associated with adverse outcomes (P<0.05). Young age at status epilepticus (<12 months) and duration of status epilepticus (>60 minutes) tended to be more frequent among those who developed adverse outcome. Rectal diazepam was given before hospital arrival in only four patients.

CONCLUSIONS

Paediatric patients with status epilepticus who had normal neurodevelopmental status before the onset of an attack and who did not sustain an acute insult to the central nervous system or have progressive encephalopathy, had favourable outcomes. Prompt use of rectal diazepam or buccal midazolam administered by caretakers or paramedics should be encouraged.

Antibody responses to human rotavirus (HRV) in gnotobiotic pigs following a new prime/boost vaccine strategy using oral attenuated HRV priming and intranasal VP2/6 rotavirus-like particle (VLP) boosting with ISCOM

Safer and more effective human rotavirus (HRV) vaccines are needed. We evaluated oral priming with attenuated WaHRV (AttHRV) followed by boosting with two intranasal (IN) doses of VP2/6 virus-like particles (2/6 VLP) with immunostimulating complexes (ISCOM) to determine if this regimen induces protection against diarrhoea and viral shedding in the gnotobiotic pig model. IgM, IgA and IgG antibody titres in serum and intestinal contents were quantified by enzyme-linked immunosorbent assay (ELISA) and serum neutralizing antibody titres were measured by a virus neutralization (VN) test. Seven groups of neonatal gnotobiotic pigs were vaccinated at post-inoculation days (PID) 0, 10 and 21 and challenged with virulent WaHRV at PID 28. The vaccine groups included: (1, 2) oral priming with AttHRV and boosting with two IN immunizations with 2/6 VLP-ISCOM (Att + 2/6 VLP-ISCOM) at VLP concentrations of 250 micro g or 25 micro g; (3, 4) three IN immunizations with 2/6 VLP-ISCOM at VLP concentrations of 250 micro g or 25 micro g (2/6 VLP-ISCOM); (5) three oral immunizations with AttHRV (3xAttHRV); (6) one oral immunization with AttHRV (1xAttHRV); (7) controls (ISCOM matrix and/or diluent). The pigs that received 3xAttHRV or Att + 2/6 VLP250-ISCOM had the highest protection rates against diarrhoea upon challenge at PID 28 with virulent WaHRV. The IgA antibody titres to HRV in intestinal contents were significantly higher in the Att + 2/6 VLP250-ISCOM group than in all other groups prechallenge (PID 28). Serum VN antibody titres were statistically similar after the first inoculation among the groups given AttHRV, but at PID 28 VN antibody titres were significantly higher for the 3xAttHRV and Att + 2/6 VLP250-ISCOM groups than for the 1xAttHRV group suggesting that boosting with 2/6 VLP also boosted VN antibody responses. In humans, intestinal IgA antibodies have been correlated with protection against symptomatic reinfection. Thus the vaccine regimen of one oral dose of AttHRV and two IN immunizations with 2/6 VLP250-ISCOM may be an alternative to multiple-dose live oral vaccines in humans.

Acute hepatitis with or without jaundice: a predominant presentation of acute Q fever in southern Taiwan

Acute Q fever was previously regarded as an uncommon infectious disease in Taiwan but has been increasingly recognized recently. Acute febrile illness, hepatitis, and pneumonia are the 3 most common manifestations of this condition, whereas jaundice is rarely reported among patients with acute Q fever. We report 2 cases of acute Q fever with jaundice and multi-organ involvement. The first patient presented with fever, severe headache, and acute abdomen necessitating laparotomy and was complicated with acute cholestatic hepatitis, acute non-oliguric renal failure and disseminated intravascular coagulation. The second patient had acute cholestatic hepatitis and thrombocytopenia, and the latter was likely related to the infection of bone marrow by Coxiella burnetii, as evidenced by the presence of C. burnetii DNA detected by nested polymerase chain reaction. The incidence and clinical significance of hyperbilirubinemia was also determined by review of medical records of 35 cases of acute Q fever cases diagnosed serologically at National Cheng Kung University Hospital from 1994 to 2001. All had biochemical hepatitis and 23% had hyperbilirubinemia (serum bilirubin > or =2 mg/dL). The febrile course before admission and the period between the initiation of effective medication to defervescence were longer in patients with hyperbilirubinemia than in patients without hyperbilirubinemia, although this difference was not significant. Our results suggest that the predominant presentation of acute Q fever in southern Taiwan is acute febrile illness with hepatitis and that jaundice is not uncommon. Due to the clinical polymorphism of acute Q fever, the threshold of surveys for C. burnetii infections should be low for febrile patients with elevated transaminases or hyperbilirubinemia of unknown cause.

Prostatic abscess in southern Taiwan: another invasive infection caused predominantly by Klebsiella pneumoniae

Prostatic abscess, though rarely encountered since the introduction of broad-spectrum antibiotics, can cause significant morbidity and mortality. We retrospectively reviewed 17 cases of prostatic abscess treated during an 11-year period at 2 medical centers in southern Taiwan. Most of these patients were elderly (mean age, 59 years) with diabetes mellitus (10 cases, 59%) or hepatic cirrhosis (5 cases, 29%). Fourteen (82%) of the 17 patients were febrile, with chills occurring in about a half of these. Of the symptoms and signs referable to the lower urinary tract, dysuria (71%) was the most common complaint. Pain was usually localized in the suprapubic (35%) or perineal (18%) area. The common findings of digital rectal examination were prostatic enlargement (77%) and fluctuation (23%). Prostatic abscess was impressed from the findings of hypoechoic area with thick walls on transrectal ultrasound or an enlarged gland with fluid-density collections on computed tomography. All causative pathogens were gram-negative bacilli, including Klebsiella pneumoniae (10 cases), Escherichia coli (2), and Pseudomonas aeruginosa (1). Various measures were undertaken to allow drainage, including transurethral incision or resection of the prostate, open perineal incision, laparotomy, and transrectal ultrasound- or computed tomography-guided needle aspiration. In conclusion, K. pneumoniae was the predominant pathogen of prostatic abscess, and was frequently identified as the causative pathogen in patients with diabetes mellitus. Diagnosis of prostatic abscess based merely on symptomatology is implausible, and image studies, such as transrectal ultrasound or computed tomography scan, are warranted. Optimal management includes adequate drainage of abscess and antimicrobial therapy.

Pretargeting for cancer radioimmunotherapy with bispecific antibodies: role of the bispecific antibody's valency for the tumor target antigen

The use of a divalent effector molecule improves bispecific antibody (bsMAb) pretargeting by enabling the cross-linking of monovalently bound bsMAb on the cell surface, thereby increasing the functional affinity of a bsMAb. In this work, it was determined if a bsMAb with divalency for the primary target antigen would improve bsMAb pretargeting of a divalent hapten. The pretargeting of a (99m)Tc-labeled divalent DTPA-peptide, IMP-192, using a bsMAb prepared by chemically coupling two Fab' fragments, one with monovalent specificity to the primary target antigen, carcinoembryonic antigen (CEA), and to indium-loaded DTPA [DTPA(In)], was compared to two other bsMAbs, both with divalency to CEA. One conjugate used the whole anti-CEA IgG, while the other used the anti-CEA F(ab')(2) fragment to make bsMAbs that had divalency to CEA, but with different molecular weights to affect their pharmacokinetic behavior. The rate of bsMAb blood clearance was a function of molecular weight (IgG x Fab' < F(ab')(2) x Fab' < Fab' x Fab' conjugate). The IgG x Fab' bsMAb conjugate had the highest uptake and longest retention in the tumor. However, when used for pretargeting, the F(ab')(2) x Fab' conjugate allowed for superior tumor accretion of the (99m)Tc-IMP-192 peptide, because its more rapid clearance from the blood enabled early intervention with the radiolabeled peptide when tumor uptake of the bsMAb was at its peak. Excellent peptide targeting was also seen with the Fab' x Fab' conjugate, albeit tumor uptake was lower than with the F(ab')(2) x Fab' conjugate. Because the IgG x Fab' bsMAb cleared from the blood so slowly, when the peptide was given at the time of its maximum tumor accretion, the peptide was captured predominantly by the bsMAb in the blood. Several strategies were explored to reduce the IgG x Fab' bsMAb remaining in the blood to take advantage of its 3-4-fold higher tumor accretion than the other bsMAb conjugates. A number of agents were tested, including those that could clear the bsMAb from the blood (e.g., galactosylated or nongalactosylated anti-id antibody) and those that could block the anti-DTPA(In) binding arm [e.g., DTPA(In), divalent-DTPA(In) peptide, and DTPA coupled to bovine serum albumin (BSA) or IgG]. When clearing agents were given 65 h after the IgG x Fab' conjugate (time of maximum tumor accretion for this bsMAb), (99m)Tc-IMP-192 levels in the blood were significantly reduced, but a majority of the peptide localized in the liver. Increasing the interval between the clearing agent and the time the peptide was given to allow for further processing of the bsMAb-clearing agent complex did not improve targeting. At the dose and level of substitution tested, galacosylated BSA-DTPA(In) was cleared too quickly to be an effective blocking agent, but BSA- and IgG-DTPA(In) conjugates were able to reduce the uptake of the (99m)Tc-IMP-192 in the blood and liver. Tumor/nontumor ratios compared favorably for the radiolabeled peptide using the IgG x Fab'/blocking agent combination and the F(ab')(2) x Fab' (no clearing/blocking agent), and peptide uptake 3 h after the blocking agent even exceeded that of the F(ab')(2) x Fab'. However, this higher level of peptide in the tumor was not sustained over 24 h, and actually decreased to levels lower than that seen with the F(ab')(2) x Fab' by this time. These results demonstrate that divalency of a bsMAb to its primary target antigen can lead to higher tumor accretion by a pretargeted divalent peptide, but that the pharmacokinetic behavior of the bsMAb also needs to be optimized to allow for its clearance from the blood. Otherwise, blocking agents will need to be developed to reduce unwanted peptide uptake in normal tissues.

Design of a retroviral-mediated ecdysone-inducible system and its application to the expression profiling of the PTEN tumor suppressor

We have engineered the ecdysone-inducible mammalian expression system for general retroviral delivery to cultured mammalian cells. We inducibly expressed PTEN in the glioblastoma cell line, U87MG, lacking this gene. Because nearly all cells are recruited on induction, we find both up- and down-regulated genes by cDNA microarray analysis. The changes we see are similar to those observed after treatment with LY294002, an inhibitor of phosphatidylinositol 3-OH kinase, fully consistent with the model that PTEN antagonizes phosphatidylinositol 3-OH kinase. Both treatments result in suppressed expression of the transforming growth factor (TGF)-beta gene and the genes of the cholesterol biosynthesis pathway. Our results illustrate the power of using a fully inducible expression system in conjunction with cDNA microarray analysis for exploring gene function.

Recent advances in brain injury research: a new human head model development and validation

Many finite element models have been developed by several research groups in order to achieve a better understanding of brain injury. Due to the lack of experimental data, validation of these models has generally been limited. Consequently, applying these models to investigate brain responses has also been limited. Over the last several years, several versions of the Wayne State University brain injury model (WSUBIM) were developed. However, none of these models is capable of simulating indirect impacts with an angular acceleration higher than 8,000 rad/s(2). Additionally, the density and quality of the mesh in the regions of interest are not detailed and sensitive enough to accurately predict the stress/strain level associated with a wide range of impact severities. In this study, WSUBIM version 2001, capable of simulating direct and indirect impacts with a combined translational and rotational acceleration of the head up to 200 g and 12,000 rad/s(2) has been developed. This new finely meshed model, consisting of more than 314,500 elements and 281,800 nodes, also simulates an anatomically detailed facial bone model. An additional new feature of the model is the damageable material property representation of the facial bone and the skull, allowing it to simulate bony fractures. The model was subjected to extensive validation using published cadaveric test data. These data include the intracranial and ventricular pressure data reported by Nahum et al. (1977) and Trosseille et al. (1992), the relative displacement data between the brain and the skull reported by King et al. (1999) and Hardy et al. (2001), and the facial impact data reported by Nyquist et al. (1986) and Allsop et al. (1988). With the enhanced accuracy of model predictions offered by this new model, along with new experimental data, it is hoped that it will become a powerful tool to further our understanding of the mechanisms of injury and the tolerance of the brain to blunt impact.