Infection control for SARS in a tertiary neonatal centre

The Severe Acute Respiratory Syndrome (SARS) is a newly discovered infectious disease caused by a novel coronavirus, which can readily spread in the healthcare setting. A recent community outbreak in Hong Kong infected a significant number of pregnant women who subsequently required emergency caesarean section for deteriorating maternal condition and respiratory failure. As no neonatal clinician has any experience in looking after these high risk infants, stringent infection control measures for prevention of cross infection between patients and staff are important to safeguard the wellbeing of the work force and to avoid nosocomial spread of SARS within the neonatal unit. This article describes the infection control and patient triage policy of the neonatal unit at the Prince of Wales Hospital, Hong Kong. We hope this information is useful in helping other units to formulate their own infection control plans according to their own unit configuration and clinical needs.

Treatment of neuroendocrine tumours in adults with 131I-MIBG therapy

This is a retrospective review of 131I-MIBG therapy for metastatic neuroendocrine tumours in 25 adult patients. The tumours comprised 17 carcinoids, six paragangliomas, one somatostatinoma and one intestinal smooth muscle sarcoma. All patients (age range 28-84 years) had stage IV disease and a positive diagnostic 123I-MIBG scan. Patients received 11.1 GBq (300 mCi) of 131I-MIBG given in three cycles at 3-monthly intervals. The mean cumulative dose was 27.7 GBq (751 mCi). Symptomatic response was observed in 80%, hormonal response in 55% and tumour response in 48% (WHO criteria). Of the 25 patients, 40% are still under follow-up. Death was due to disease progression in all except one. The median survival time was 48 months from diagnosis of metastatic disease, and 17 months from the last 131I-MIBG therapy. The 5-year survival rate was 59% (95% confidence interval, 34%-78%). There was no statistical difference in survival between previously treated (chemo/radiotherapy) and treatment-naive patients. Side-effects were minimal and commonly include nausea (in the first 24 h) and a transient fall in platelet count. 131I-MIBG provides a good therapeutic response in patients with metastatic neuro-endocrine tumours.

Novel search for heavy nu mixing from the beta+ decay of 38mK confined in an atom trap

A new technique, full neutrino momentum reconstruction, is used to set limits on the admixture of heavy neutrinos into the electron neutrino. We measure coincidences between nuclear recoils and positrons from the beta decay of trapped radioactive atoms and deduce the neutrino momentum. A search for peaks in the reconstructed recoil time-of-flight spectrum as a function of positron energy is performed. The admixture upper limits range from 4 x 10(-3) to 2 x 10(-2) and are the best direct limits for neutrinos (as opposed to antineutrinos) for the mass region of 0.7 to 3.5 MeV.

Determination of Cr3+, CrO42-, and Cr2O72- in environmental matrixes by high-performance liquid chromatography with diode-array detection (HPLC-DAD)

A high-performance liquid chromatographic method with diode array detection (HPLC-DAD), based on chelation with ammonium pyrrolidinedithiocarbamate (APDC), has been developed for the determination of chromium species. Determination of Cr3+, CrO42-, and Cr2O72- was performed for standards and synthetic environmental matrixes. This method is robust, rugged, and can be used for rapid routine determination of chromium species with high precision and reliability. Sample pretreatment is simple. The method is capable of discriminating not only between Cr(III) and Cr(VI) but also between the chemical forms of Cr(VI) - CrO42- and Cr2O72-. By analysis of numerous samples the method has been shown to be selective, sensitive, and free from matrix interference, which is crucial for the determination of chromium species in difficult-to-analyze environmental matrixes. This method has been validated by means of an interlaboratory study. Although different speciation techniques were used during this study, there was good agreement between results from the two laboratories. The method detection limits were 7 and 4 mg L(-1) for Cr3+ and Cr2O72-, respectively. Recoveries of the analytes from spiked samples were 98% and 100% for Cr3+ and Cr2O72-, respectively. Both were based on a 10-mL sample volume spiked with 0.4 mg L(-1) chromium.

Cerebral vasculitis in a child following post-streptococcal glomerulonephritis

Cerebral vasculitis following acute post-streptococcal glomerulonephritis (APSGN) is a rare neurological complication. An 11-year-old girl with biopsy proven APSGN developed an acute seizure disorder. Clinical and computed tomography findings were consistent with vasculitis.

Caspase-10 is an initiator caspase in death receptor signaling

A role for caspase-10, previously implicated in the autoimmune lymphoproliferative syndrome, in death receptor signaling has not been directly shown. Here we show that caspase-10 can function independently of caspase-8 in initiating Fas- and tumor necrosis factor-related apoptosis-inducing ligand-receptor-mediated apoptosis. Moreover, Fas crosslinking in primary human T cells leads to the recruitment and activation of caspase-10. Fluorescent resonance energy transfer analysis indicates that the death-effector domains of caspase-8 and -10 both interact with the death-effector domain of FADD. Nonetheless, we find that caspase-8 and -10 may have different apoptosis substrates and therefore potentially distinct roles in death receptor signaling or other cellular processes.

Classification of human lung carcinomas by mRNA expression profiling reveals distinct adenocarcinoma subclasses

We have generated a molecular taxonomy of lung carcinoma, the leading cause of cancer death in the United States and worldwide. Using oligonucleotide microarrays, we analyzed mRNA expression levels corresponding to 12,600 transcript sequences in 186 lung tumor samples, including 139 adenocarcinomas resected from the lung. Hierarchical and probabilistic clustering of expression data defined distinct subclasses of lung adenocarcinoma. Among these were tumors with high relative expression of neuroendocrine genes and of type II pneumocyte genes, respectively. Retrospective analysis revealed a less favorable outcome for the adenocarcinomas with neuroendocrine gene expression. The diagnostic potential of expression profiling is emphasized by its ability to discriminate primary lung adenocarcinomas from metastases of extra-pulmonary origin. These results suggest that integration of expression profile data with clinical parameters could aid in diagnosis of lung cancer patients.

The treatment of gastroesophageal reflux disease with proton-pump inhibitors and its implications on managed care--clinical overview of gastroesophageal reflux disease. Roundtable discussion

The importance of gastroesophageal reflux disease (GERD) to managed health care systems cannot be overestimated. It contributes significantly to the use of health care resources, including doctor's services, medication consumption, and diagnostic testing. A roundtable meeting of 13 managed care experts was convened January 23, 2001 in Dallas, to discuss the implications of GERD on the managed care system. The following proceedings are published in five sections. In the first part, Jeffrey Danzig, MD, a gastroenterologist, provides the clinical foundation for the discussion, based on the existing literature and his personal practice.

Urinary cytokines: clinically useful markers of chronic renal disease progression?

Many factors that drive glomerular and tubulointerstitial fibrogenesis have been identified. These include hemodynamic factors, chemokines, inflammatory mediators, cytokines, and lipids. These strides in knowledge are important in identifying those patients at increased risk of progressive renal disease as well as in developing targets for therapeutic interventions. Identifying 'progressors' is crucial since the distribution of the slope of the glomerular filtration rate of patients with chronic kidney disease is not normal. Some patients appear to progress very rapidly, such as those with diabetes, whereas other patients fail to progress at all. Developing strategies targeted at identifying the fast from the slow progressors is therefore of paramount importance if we are to deploy resources rationally in the management of patients with chronic kidney disease. The use of urinary cytokine markers as predictors of progression of renal disease is reviewed in this paper.

Primary anconeal fracture in a boxer

A 14-month-old speyed female Boxer was presented with acute non-weight-bearing lameness in the right forelimb. Radiography revealed separation of the anconeal process, which was thence surgically removed. Histological examination of the anconeal process confirmed a primary fracture. Isolated unilateral anconeal process fracture in the dog is rare and this report includes histopathological findings of a primary anconeal fracture.

Ocular complications of paediatric patients with nephrotic syndrome

PURPOSE

To investigate ocular complications arising from nephrotic syndrome and/or its treatments in children.

METHODS

A cross-sectional study was conducted in a teaching hospital. A total of 31 paediatric patients with nephrotic syndrome were studied. Comprehensive ophthalmic assessments on best-corrected visual acuity, intraocular pressure, slit-lamp and fundus examination were taken. Information regarding histological diagnosis of nephrotic syndrome and its treatment regimen in each patient was reviewed and analysed.

RESULTS

Bilateral posterior subcapsular cataracts were detected in three of 29 patients (10.3%) who received steroid therapy. Two had normal vision while one had visual acuity reduced to 6/15 in both eyes. The age of onset of the nephrotic syndrome in these three patients was 2 years, which was significantly younger than those without cataract (5.4 +/- 3.2 years, P < 0.001). Three patients (9.7%) had isolated asymptomatic fundal findings of tortuous and dilated retinal vessels. Hypertensive retinopathy was found in one patient (3.2%). No steroid-induced glaucoma, uveitis, ocular infection, or other eye complications related to the use of steroids or other immunosuppressive agents were noted.

CONCLUSIONS

Children who have nephrotic syndrome often require prolonged, intermittent high dose of systemic corticosteroid therapy. Paediatricians should be aware of the potential risk of developing steroid-related complications, especially posterior subcapsular cataract. It appears to have a higher risk when steroid therapy is used in very young patients. Early detection would help to prevent amblyopia development, particularly in the group of immature eyes.

Traditional Chinese medicine (tongue acupuncture) in children with drooling problems

Tongue acupuncture is an innovative technique in traditional Chinese medicine. We have demonstrated that specific tongue acupoints are related to various functional domains. This study aimed to assess the efficacy of tongue acupuncture in children with neurologic disability who had severe drooling problems. We conducted an intent-to-treat study in a cohort of 10 children. A continuous course of tongue acupuncture was performed daily to five acupoints in the tongue for a total of 30 sessions. Standardized outcome measures of drooling were evaluated by a blinded assessor to study the efficacy at baseline and after a course of treatment. Statistically significant improvement was noted in the following outcome measures: (1) mean visual analog scale (VAS) decreased from 6.6 (pre-TAC) to 4.67 (post-TAC) (P = 0.002); (2) mean drooling quotient (DQ) decreased from 14.016% (pre-TAC) to 8.335% (post-TAC) (P = 0.0078); and (3) mean drooling score (DS) decreased from 7.4 (pre-TAC) to 4.4 (post-TAC) (P = 0.002). This study demonstrated the efficacy of tongue acupuncture as an adjunctive or alternative treatment for patients with drooling problems and can be integrated as part of the oromotor stimulation program, drooling program, and behavioral modification program before subjecting the patient to invasive surgical procedures on the salivary glands.

Outcome of liver resection and transplantation for fibrolamellar hepatocellular carcinoma

Fibrolamellar hepatocellular carcinoma (FL HCC) is an uncommon variant of hepatocellular carcinoma occurring usually in non-cirrhotic livers. Hepatic resection or transplantation offers the only chance of cure. We reviewed our experience of surgery for FL HCC from 1985-1998. Twenty patients with FL HCC (13 females and 7 males) median age 27 years (range 12-69) were treated either by hepatic resection [n = 11; extended right hepatectomy (5), extended left hepatectomy (1), right hemihepatectomy (2), left hemihepatectomy (2), left lateral segmentectomy (1)] or, if the disease was non-resectable, by transplantation (n = 9). The median follow up was 25 months (1-63). The prognostic factors analysed included size [less than 5 cm (3 patients), more than 5 cm (17 patients)], number [solitary (16 patients), multiple (4 patients)], capsular invasion (6 patients), vascular invasion (11 patients) and lymph node invasion (6 patients). The overall survival at 1, 3 and 5 years was 89.5, 75 and 50%, respectively. The liver resection survival was better than liver transplantation survival at 3 years 100 vs 76%, respectively (P < 0.025). Although all prognostic factors analysed did not show a significant difference, there is tendency that tumour stage was the most significant for prognosis. Most of the patients in this study are young and presented without specific symptoms, with normal liver function range and had no tumour marker to help in diagnosis. As a result most of our patients were diagnosed late. However the outcome of surgical intervention was favourable.

Randomised controlled study of oral erythromycin for treatment of gastrointestinal dysmotility in preterm infants

AIM

To evaluate the effectiveness of oral erythromycin as a prokinetic agent for the treatment of moderately severe gastrointestinal dysmotility in preterm very low birthweight infants.

METHODS

A prospective, double blind, randomised, placebo controlled study in a tertiary referral centre of a university teaching hospital was conducted on 56 preterm infants (< 1500 g) consecutively admitted to the neonatal unit. The infants were randomly allocated by minimisation to receive oral erythromycin (12.5 mg/kg, every six hours for 14 days) or an equivalent volume of placebo solution (normal saline) if they received less than half the total daily fluid intake or less than 75 ml/kg/day of milk feeds by the enteral route on day 14 of life. The times taken to establish half, three quarters, and full enteral feeding after the drug treatment were compared between the two groups. Potential adverse effects of oral erythromycin and complications associated with parenteral nutrition were assessed as secondary outcomes.

RESULTS

Twenty seven and 29 infants received oral erythromycin and placebo solution respectively. The times taken to establish half, three quarters, and full enteral feeding after the drug treatment were significantly shorter in the group receiving oral erythromycin than in those receiving the placebo (p < 0.05, p < 0.05 and p < 0.0001 respectively). There was also a trend suggesting that more infants with prolonged feed intolerance developed cholestatic jaundice in the placebo than in the oral erythromycin group (10 v 5 infants). None of the infants receiving oral erythromycin developed cardiac dysrhythmia, pyloric stenosis, or septicaemia caused by multiresistant organisms.

CONCLUSIONS

Oral erythromycin is effective in facilitating enteral feeding in preterm very low birthweight infants with moderately severe gastrointestinal dysmotility. Treated infants can achieve full enteral feeding 10 days earlier, and this may result in a substantial saving on hyperalimentation. However, until the safety of erythromycin has been confirmed in preterm infants, this treatment modality should remain experimental. Prophylactic or routine use of this medication for treatment of mild cases of gastrointestinal dysmotility is probably not warranted at this stage.

A clinical comparison of the safety and efficacy of MultiHance (gadobenate dimeglumine) and Omniscan (Gadodiamide) in magnetic resonance imaging in patients with central nervous system pathology

RATIONALE AND OBJECTIVES

The safety and diagnostic efficacy of MultiHance (gadobenate dimeglumine) in the central nervous system (CNS) were evaluated in a double-blind, multicenter, phase III clinical trial.

METHODS

Two hundred five patients highly suspected of having a CNS lesion (by previous imaging exam) were enrolled at 16 sites in the United States. Patients were randomized to one of three incremental dosing regimens. Magnetic resonance imaging with Omniscan (gadodiamide) at doses of 0.1 and 0.3 mmol/kg was compared with MultiHance (gadobenate dimeglumine) at doses of 0.05 and 0.15 mmol/kg and at 0.1 and 0.2 mmol/kg.

RESULTS

Compared with predose images alone, efficacy was demonstrated in each of the gadobenate dimeglumine and gadodiamide groups (single and cumulative doses) as indicated by the level of diagnostic information, number of lesions detected, and contrast-to-noise ratio measurements. The level of diagnostic information from gadobenate dimeglumine at 0.1 mmol/kg was equivalent to that with gadodiamide at the same dose. One of the two blinded reviewers found equivalence between the gadobenate dimeglumine 0.05 mmol/kg dose and gadodiamide at 0.1 mmol/kg. Both reviewers found the level of diagnostic information to be equivalent after the second dose of contrast for all three dosing regimens. The cumulative doses of gadobenate dimeglumine were well tolerated and as safe as gadodiamide.

CONCLUSIONS

Gadobenate dimeglumine is comparable to gadodiamide in terms of safety and efficacy for imaging of CNS lesions, with a possible advantage in imaging applications owing to enhanced T1 relaxivity.

Normal pulse oximeter reading in a cyanotic infant

A newborn infant who presented with central cyanosis was found to have hereditary methaemoglobinaemia. The pulse oximeter readings and physical findings were incompatible. Clinical assessment remains an important part in the management of such cases.

Airway difficulties caused by improperly applied cricoid pressure

Cricoid pressure, when properly applied, may prevent gastric regurgitation and may improve the view of laryngoscopy. When improperly applied, however, it can impede laryngoscopy and mask-ventilation. When faced with a "cannot intubate" or "cannot mask-ventilate" situation, clinicians should reevaluate the manner with which the assistant is applying cricoid pressure and must be prepared to adjust or even to release it.

The tissue distribution of tumor necrosis factor-alpha in rats: a compartmental model

Tumor necrosis factor (TNF) is widely accepted to be the mediator of the cascade of metabolic abnormalities associated with both critical and chronic illness. TNF binding to cell surface receptors mediates its physiologic actions, although the exact mechanism of TNF action is unknown. Therefore, this study was designed to investigate the in vivo metabolism of TNF using a mathematical model to examine tissue uptake and loss of TNF over time. Two distinct patterns of TNF uptake were observed. Muscle tissues were found to accumulate TNF over the entire experimental period, whereas the visceral organs were found to have a rapid initial accumulation of TNF followed by a rapid loss of TNF back to the plasma or out into the bile or the urine. These patterns of TNF binding and retention may reflect the number of TNF receptors or their affinity for TNF, as well as the balance between cell surface and soluble TNF receptors. Furthermore, TNF binding patterns provide insight into the biologic action of TNF at these sites.