Low Level Viremia Is Associated With Serious non-AIDS Events in People With HIV

Background

The consequences of low-level viremia in people with HIV are unclear. We used data from the US Military HIV Natural History Study to examine the association of low-level viremia (LLV) and serious non-AIDS events (SNAEs).

Methods

Included participants initiated antiretroviral therapy after 1996 and had ≥3 viral loads (VLs) measured, using an assay with a lower limit of detection of <50 copies/mL, ≥6 months after antiretroviral therapy initiation. VLs were categorized as lower levels of LLV (51-199 copies/mL), higher level of low-level viremia (HLLV; 200-999 copies/mL), and (VF; ≥200 copies/mL on 2 or more successive determinations or a single VL ≥1000 copies/mL), and virologic suppression (VS; ie, VL <50 copies/mL). Viral blips (ie, VLs between 50 and 999 copies/mL that are preceded and succeeded by VL <50 copies/mL) were analyzed in the VS category. Cox proportional hazards models were used to examine the association of LLV and SNAEs, adjusted hazard ratios and 95% confidence intervals are presented.

Results

A total of 439 (17.4%) SNAEs were recorded among the 2528 participants (93% male, 40% Caucasian, 43% African American) followed for a median of 11 years. In 8.5% and 4.6% of the participants, respectively, LLV and HLLV were the highest recorded viremia strata. Compared with VS, SNAEs were associated with LLV (1.3 [1.2-1.4]), HLLV (1.6 [1.5-1.7]), and virologic failure (1.7 [1.7-1.8]).

Conclusions

The results of this study suggest that LLV is associated with the occurrence of SNAEs and needs further study.

Neurocognitive Dysfunction With Neuronal Injury in People With HIV on Long-Duration Antiretroviral Therapy

BackgroundNeurologic outcomes in people with HIV (PWH) on long-duration antiretroviral therapy (ART) are not fully understood and the underlying pathophysiology is unclear. To address this, we established a cohort of such individuals and compared them to HIV-negative controls using a novel matching technique. Both groups underwent extensive cognitive testing, evaluation for psychiatric measures, and MRI and cerebrospinal fluid (CSF) analyses.MethodsParticipants underwent comprehensive neuropsychological (NP) testing and completed standardized questionnaires measuring depressive symptoms, perceptions of own functioning, and activities of daily living as part of an observational study. Brain MRI and lumbar puncture were optional. Coarsened Exact Matching (CEM) was used to reduce between-group differences in age and sex, and weighted linear/logistic regression models were used to assess the effect of HIV on outcomes.ResultsData were analyzed from 155 PWH on ART for at least 15 years and 100 HIV-negative controls. Compared to controls, PWH scored lower in the domains of attention/working memory (PWH Least Square Mean [LSM]=50.4 vs. controls LSM=53.1, p=0.008) and motor function (44.6 vs. 47.7, p=0.009), and a test of information processing speed (symbol search 30.3 vs. 32.2, p=0.003). They were more likely to self-report a higher number of cognitive difficulties in everyday life (p=0.011). PWH also reported more depressive symptoms, general anxiety, and use of psychiatric medications (all with p<0.05). PWH had reduced proportions of subcortical gray matter on MRI (β=-0.001, p<0.001) and CSF showed elevated levels of neurofilament-light chain (664 vs. 529 pg/mL, p=0.01) and TNF-α (0.229 vs. 0.156 ng/mL, p=0.0008).ConclusionsPWH, despite effective ART for over a decade, displayed neurocognitive deficits and mood abnormalities. MRI and CSF analyses revealed reduced brain volume and signs of ongoing neuronal injury and neuroinflammation. As the already large proportion of virologically controlled PWH continues to grow, longitudinal studies should be conducted to elucidate the implications of cognitive, psychiatric, MRI, and CSF abnormalities in this group.

1392. Associations between Stigma and Physical and Mental Health in the U.S. Military HIV Natural History Study

Background

Despite increasing attention to HIV-related stigma within the DoD, to date, the majority of research has focused on civilians, up to half of whom report perceived or experienced stigma. However, military service members and retirees with HIV may be particularly vulnerable to stigma and its adverse correlates.

Methods

The current study utilized cross-sectional data collected within the U.S. Military HIV Natural History Study. Participants completed questionnaires, including the Center for Epidemiologic Studies Depression scale, the Short Form Health Survey, the Internalization Subscale of the HIV Stigma Scale, and a measure of stigma experienced in the past year. Experiences of stigma were dichotomized to indicate presence or absence. Linear and logistic regressions were used to examine associations between internalized stigma and psychosocial functioning. All analyses were adjusted for age, race, sex, marital status, military rank, and duty status (i.e., active duty or retired).

Results

The sample comprised 399 participants (93.5% male; 46.0% Black/African American; Mage: 50.8 ± 13.2 years; Mage at HIV diagnosis: 31.9 ± 8.2 years; 32.4% on active duty). The majority (94.4%) had an undetectable viral load at the time of the visit. Fourteen percent reported being teased, treated unfairly, or discriminated against in the past year due to their HIV status, and 8% reported discrimination specifically within healthcare. Adjusting for covariates, internalized stigma was associated with poor physical (p &lt; .001) and overall mental (p &lt; .001) health. Internalized stigma was also associated with greater odds of reporting elevated depression (p &lt; .001).

Conclusion

In this sample of service members and retirees with HIV, a small but significant minority of participants reported experiencing stigma. Rates of stigma were lower than those observed in some civilian samples, though heterogeneity in sampling and methodology preclude direct comparisons. Internalized stigma was associated with poor physical and mental health, signaling a need for continued efforts to assess both experienced and internalized stigma. Future research should explore associations between stigma, ART adherence, and other metrics of health, such as CD4 count, substance use, and cardiometabolic risk.

Disclosures

All Authors: No reported disclosures.

Coccidioidomycosis Seroincidence and Risk among Military Personnel, Naval Air Station Lemoore, San Joaquin Valley, California, USA1

We conducted a retrospective cohort study that tested 2,000 US military personnel for Coccidioides antibodies in a disease-endemic region. The overall incidence of seroconversion was 0.5 cases/100 person-years; 12.5% of persons who seroconverted had illnesses requiring medical care. No significant association was found between demographic characteristics and seroconversion or disease.

Prospective Evaluation of an Abbreviated Test Battery to Screen for Neurocognitive Impairment in HIV-Positive Military Members

Human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND) affects around 20-50% of people living with HIV (PLWH). Although batteries of tests are used to identify neurocognitive impairment (NCI), they are long and difficult to perform during a routine clinic visit, thus impairing the ability to diagnose HAND. Therefore, a brief yet sensitive screening tool to identify NCI is necessary. This study prospectively evaluated an abbreviated screening battery with reported 86.5%/87.1% sensitivity/specificity, identified from a planned post-hoc analysis in a prior neurocognitive study among military PLWH. Adult HIV-positive military beneficiaries in the U.S. Military HIV Natural History Study, who agreed to undergo a comprehensive seven-domain neuropsychological battery (16 tests), and who completed an additional 20-min abbreviated battery (AB), comprised of four tests, prior to the full battery (FB) were included in this analysis. A group of 169 individuals completed both tests, of which 25.4% had a positive AB and 17.8% had NCI on FB (global deficit score ≥ 0.5). With the FB as the reference standard, the specificity for the AB was 79.9% (73.2-86.5), however the sensitivity was 50.0% (32.1-67.9). In those with NCI by FB but not AB, the most common impaired domains were executive function (73.3%) and memory (73.3%), both being domains not fully tested by the AB. An abbreviated HAND screening battery of four tests requiring approximately 20 min provided a relatively high level of specificity but lacked sensitivity for detection of NCI. Inclusion of additional domains or alternative scoring approaches may improve sensitivity but require further study. Continued efforts are needed to develop an effective brief screening test for HAND.

Association of White Matter Hyperintensities With HIV Status and Vascular Risk Factors

OBJECTIVE

To test the hypothesis that brain white matter hyperintensities (WMH) are more common in people living with HIV (PLWH), even in the setting of well-controlled infection, and to identify clinical measures that correlate with these abnormalities.

METHODS

Research brain MRI scans, acquired within longitudinal studies evaluating neurocognitive outcomes, were reviewed to determine WMH load using the Fazekas visual rating scale in PLWH with well-controlled infection (antiretroviral therapy for at least 1 year and plasma viral load <200 copies/mL) and in sociodemographically matched controls without HIV (CWOH). The primary outcome measure of this cross-sectional analysis was increased WMH load, determined by total Fazekas score ≥2. Multiple logistic regression analysis was performed to evaluate the effect of HIV serostatus on WMH load and to identify MRI, CSF, and clinical variables that associate with WMH in the PLWH group.

RESULTS

The study included 203 PLWH and 58 CWOH who completed a brain MRI scan between April 2014 and March 2019. The multiple logistic regression analysis, with age and history of tobacco use as covariates, showed that the adjusted odds ratio of the PLWH group for increased WMH load is 3.7 (95% confidence interval 1.8-7.5; p = 0.0004). For the PLWH group, increased WMH load was associated with older age, male sex, tobacco use, hypertension, and hepatitis C virus coinfection, and also with the presence of measurable tumor necrosis factor α in CSF.

CONCLUSION

Our results suggest that HIV serostatus affects the extent of brain WMH. This effect is mainly associated with aging and modifiable comorbidities.

Risk Factors Associated With Chronic Liver Enzyme Elevation in Persons With HIV Without Hepatitis B or C Coinfection in the Combination Antiretroviral Therapy Era

Background

As morbidity due to viral coinfections declines among HIV-infected persons, changes in liver-related morbidity are anticipated. We examined data from the US Military HIV Natural History Study (NHS), a cohort of military beneficiaries, to evaluate incidence and risk factors associated with chronic liver enzyme elevation (cLEE) in HIV-monoinfected patients in the combination antiretroviral therapy (cART) era.

Methods

Participants who were hepatitis B virus and hepatitis C virus seronegative with follow-up after 1996 were included. We defined chronic liver enzyme elevation (cLEE) as alanine aminotransferase elevations ≥1.25 times the upper limit of normal on at least 2 visits, for a duration of ≥6 months within 2 years. We used multivariate Cox proportional hazards models to examine risk factors for cLEE.

Results

Of 2779 participants, 309 (11%) met criteria for cLEE for an incidence of 1.28/100 PYFU (1.28–1.29/100 PYFU). In an adjusted model, cLEE was associated with Hispanic/other ethnicity (reference Caucasian: hazard ratio [HR], 1.744; 95% CI, 1.270–2.395), non–nucleoside reverse transcriptase inhibitor–based cART (reference boosted protease inhibitors: HR, 2.232; 95% CI, 1.378–3.616), being cART naïve (HR, 6.046; 95% CI, 3.686–9.915), or having cART interruptions (HR, 8.671; 95% CI, 4.651–16.164). African American race (HR, 0.669; 95% CI, 0.510–0.877) and integrase strand transfer inhibitor (INSTI)–based cART (HR, 0.222; 95% CI, 0.104–0.474) were protective.

Conclusions

Our findings demonstrate that initiation and continued use of cART are protective against cLEE and support the hypothesis that HIV infection directly impacts the liver. INSTI-based regimens were protective and could be considered in persons with cLEE.

1539. Pilot Study of Sexual Networks and Sexually Transmitted Infection Risk in a Military Population

Background

In the U.S., military members experience a higher incidence of sexually transmitted infections (STIs) than the age and gender-adjusted general population, placing a costly and preventable burden on the military health system (MHS). These increased rates are likely due to differences in both individual and network level risk factors. To assess the feasibility of a survey examining the impact of sexual network risk factors on risk, a survey assessing STI individual and network level risk factors to include a 90-day sexual partnership inventory was piloted at a single military medical center.

Methods

A sample of 50 military beneficiaries completed a computer-assisted self-interview (CASI) cross-sectional egocentric survey administered on a tablet. Demographical and clinical data were captured from the electronic medical record. Non-parametric statistics were used to analyze the data.

Results

45 of 50 subjects (90%) completed the survey. 40 (88%) subjects completed at least one partnership survey and reported 1 to 20 partners per subject. Respondents were mostly active duty (91.8%) and had been active duty for less than five years (68.2%). Common risk behaviors were explored and included meeting partners online (68.75%) and having partners who use drugs (48.94%) or are heavy drinkers (44.68%). Partnership inventories suggest sexual concurrency and disassortative mixing on age, racial and ethnic groups, and military service.

Conclusion

While previous studies demonstrate that service members will complete sexual risk behavior surveys, this pilot egocentric partnership study demonstrates their willingness to provide detailed information on risk behaviors as well as detailed information on sexual partnerships. While we report on statistically significant associations, these may be subject to bias due to the underlying characteristics of the source population. As a result, these data will not likely be reflected in the full study population. 80% of pilot subjects completed the questionnaire and submitted at least one partnership survey, indicating the possibility of gathering more diverse individual sexual risk questionnaires from active duty service members. Based on these data, a multisite study of sexual networks was implemented in the MHS and is currently under analysis.

Disclosures

All Authors: No reported disclosures

1180. Seroincidence and Risk of Coccidioidomycosis Infection Among Active Duty Personnel Stationed at Naval Air Station Lemoore in the San Joaquin Valley of California

Background

Coccidioidomycosis ranges clinically from a self-limited respiratory illness to multi-organ dissemination. Based largely on skin testing from the 1940s, 60% of infections are thought to be asymptomatic. Limited Coccidioides seroincidence data support our understanding of the epidemiology and pathogenicity of this disease.

Methods

This retrospective cohort study tested 2000 U.S. military personnel for Coccidioides exposure after transfer to an endemic region of California between 2011 and 2017. The presence of IgG and IgM anti-Coccidioides antibodies were tested on pre- and post-transfer serum samples from the DoD Serum Repository to establish rates of seroconversion. Medical histories and participant demographics including race/ethnicity and military occupational specialty codes were collected from the electronic medical record and participants were stratified by a history of Coccidioides-specific or general respiratory illness based on ICD9/ICD10 coding.

Results

Thirty of 2000 participants tested newly positive for anti-Coccidioides antibodies after 12 months on station. Seroconversion incidence varied from 0.0-1.32 annually and overall 0.5 per 100 person years. Seroconverters were more frequently diagnosed with coccidioidomycosis or pneumonia than non-converters (p=0.027). No statistically significant association between demographic characteristics and seroconversion or disease was observed. Clinical disease was detected in only three seroconverters (10%).

Incidence Rate of Coccidioidomycosis Infection among Active Duty Stationed at NAS Lemoore, 2011-2017

Conclusion

In this study Coccidioides seroincidence was similar to that observed by others, adding longitudinal evidence to epidemiologic assumptions about coccidioidomycosis. A trend toward increasing incidence over the course of the study is consistent with the classification of coccidioidomycosis as an emerging infectious disease. While transmission is typically related to exposure, we did not detect a difference based on military occupational specialty codes. Overall, rates of diagnosed disease in our cohort were lower than the historically-assumed 40% symptomatic rate, although this conclusion is limited by the retrospective nature of the study. Further clinical and epidemiologic coccidioidomycosis research, particularly in broader endemic regions, is warranted.

Disclosures

All Authors: No reported disclosures

367. Use of a Brief Task-Based Measure to Assess the Functional Consequences of Cognitive Impairment in HIV

Background

In spite of viral suppression with antiretroviral therapy (ART), neurocognitive impairment (NCI) affects ~20% of those infected with HIV; most are asymptomatic or only mildly impaired based on instrumental activity of daily living (IADL) self-reported questionnaires. Previous studies have shown a strong association between depression, common among HIV+, and self-reported IADL impairment, potentially confounding evaluation of the functional impact of NCI. We studied a brief (15–20 minutes) task-based measure of function, the Texas Functional Living Scale (TFLS), in the context of HIV, NCI, and depression.

Methods

Baseline data were analyzed from parallel, longitudinal cohort studies of neurocognitive function among HIV+ and demographically matched HIV-subjects enrolled at NIH and DoD sites. Subjects recruited at NIH were on ART with viral suppression (VS) ≥1 year and nearly all in the DoD also had long-term VS. All participants underwent a standardized, comprehensive neurocognitive battery (7 domains), as well as the TFLS. Global deficit score (GDS) ≥0.5 defined neurocognitive impairment (NCI) and TFLS impairment was defined as T-score >1 standard deviation below mean (i.e., < 40).

Results

420 subjects were evaluated with demographics in Table 1. Eighty-five subjects (20%) had NCI by GDS and 57 (13%) subjects had TFLS impairment. 17% had a Beck Depression Inventory II (BDI) score ≥13 indicating significant depressive symptoms. In univariate analysis of Table 1 variables, only HIV status was not significantly different between those with or without TFLS impairment, however after adjustment using multivariable logistic regression, only education level, race, and NCI were associated with TFLS impairment; depressive symptoms (BDI ≥13) were not associated with functional impairment measured by TFLS.

Conclusion

In parallel DoD and NIH cohorts of well-treated HIV+ and matched HIV- subjects, task-based functional impairment measured by TFLS was strongly associated with NCI, but not with depressive symptoms, suggesting the potential utility of this measure to better understand the functional consequences of HIV associated neurocognitive disorders. While the association of TFLS with education was expected, that with race was not and requires further study.

Disclosures

All authors: No reported disclosures.

Evaluating the Training of Chinese-Speaking Community Health Workers to Implement a Small-Group Intervention Promoting Mammography

This study evaluated the training of Chinese American Community Health Workers (CHWs) to implement a small-group mammography video and discussion program as part of a randomized controlled trial that had the goal to increase adherence to mammography screening guidelines among Chinese American women. A total of 26 Chinese American CHWs in the metropolitan Washington DC area, Southern California, and New York City participated in a 4-h training workshop and completed surveys before and after the workshop to assess their knowledge regarding mammography screening guidelines and human subjects protection rules. The results showed significantly increased knowledge of mammography screening guidelines and human subjects protection rules (both p < 0.01) after the training. CHWs were also trained to lead a discussion of the video, including screening benefits and misconceptions. Forty-three audio recordings of discussions led by 13 active CHWs were transcribed and qualitatively analyzed to assess implementation fidelity. Ten out of 13 active CHWs fully addressed about 3 of the 5 benefit items, and 11 out of 13 CHWs fully addressed more than 5 of the 9 misconception items. Chinese CHWs can be trained to implement research-based intervention programs. However, a one-time training resulted in moderate adherence to the discussion protocol. Ongoing or repeat trainings throughout the intervention period may be needed to enhance implementation fidelity.

Aortic valve endocarditis presents as pseudoaneurysm of the superior mesenteric artery

Mycotic aneurysms are an important cause of morbidity and mortality in endocarditis despite advanced antibiotic therapy. Visceral artery aneurysms are uncommon and usually remain clinically silent until rupture. We now report a case of successful surgical treatment of a superior mesenteric mycotic aneurysm of the superior mesenteric artery, followed by a review of pertinent clinical information.

Toward an understanding of mothering: the care giving process of mothers with autistic children

The purpose of this study was to explore the care-giving experience of mothers with autistic children. In this qualitative study, a focus group and in-depth interviews were conducted with mothers with an autistic child to uncover the nature of their mothering experience. Data were analyzed for themes with the constant comparison approach of grounded theory. Three themes emerged: (a) the perception about their disabled child; (b) their special concerns for caring for this child and (c) reclaiming and discovering self through understanding the meaning of mothering. The results can help health workers to gain a deeper understanding of the care-giving process for mothers with an autistic child and facilitate mothers to find the meaning of care and their well-being.

Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer

BACKGROUND

Recurrent vulvar cancer involving the femoral artery after groin radiation is usually considered inoperable. A patient with such recurrent vulvar cancer successfully treated by femoral vascular graft and rectus abdominis myocutaneous flap reconstruction with limb salvage is described.

CASE

A 51-year-old woman had recurrent vulvar cancer involving the right femoral vessels 6 months after a radical vulvectomy plus inguinal lymphadenectomy and postoperative pelvic and groin radiation. Radical en bloc excision of tumor along with the involved femoral artery and vein followed by Gore-Tex vascular graft and rectus abdominis myocutaneous flap reconstruction led to a complete remission. However, occlusion of the grafted vessels occurred 21 months following bypass surgery. Since the compensatory collaterals were established, debridement and removal of the occluded graft were carried out. The patient has been clinically free of disease for more than 48 months since graft reconstruction surgery.

CONCLUSION

It is highlighted that aggressive tumor resection with limb salvage is feasible even for patients with vulvar cancer of the groin recurrence involving the femoral artery after primary surgery and groin radiation.

Thoracic outlet syndrome caused by first rib hemangioma

We report a case of first rib hemangioma that caused thoracic outlet syndrome. A 50-year-ole woman who was admitted to our hospital with a clinical diagnosis of thoracic outlet syndrome presented with fullness and easy fatigue of her right arm. Her right arm discomfort was associated with intermittent engorgement of superficial veins over the shoulder girdle. A chest radiograph revealed an enlargement of the anterior aspect of the first rib with fine bony trabeculations. Computed tomography scan showed contrast enhancement over the enlarged rib. Our tentative preoperative diagnosis was a benign first rib hypertrophic change, such as an old fracture with exuberant callus formation. A right-arm venogram revealed a patent subclavian vein with an extrinsic compression, which occluded on arm abduction. The findings of neural conduction studies of both upper extremities were symmetric and normal. The patient agreed to surgery because of the occlusive condition of the subclavian vein on arm abduction and progressive arm weakness in recent months. Segmental transection of the offending portion of the enlarged first rib was complicated by difficulty in isolating the whole length of the compressed but normal-appearing subclavian vein by our initial transaxillary and infraclavicular approaches because the medial aspect of the subclavian vein was obstructed by the enlarged first rib, which extended medially to the junction of the right jugular and subclavian veins. Successful segmental transection of the enlarged first rib was finally accomplished by combined transaxillary, infraclavicular, and supraclavicular approaches. A moderate amount of rib bleeding from resection ends was noted during segmental resection of the enlarged first rib, resulting in local hematoma formation. A 470-mL bloody discharge was collected from the vacuum ball inserted via the transaxillary route during her 12-day hospitalization. Pathologic examination revealed an intraosseous hemangioma. The patient had a prolonged course to partial recovery of her arm numbness, but signs of venous compression were much improved at 6 months' follow-up. Although hemangioma is benign, its hypervascular nature may cause catastrophic intraoperative bleeding.

The possible role of magnesium in protection of premature infants from neurological syndromes and visual impairments and a review of survival of magnesium-exposed premature infants

The survival rate of very preterm, low birth weight infants (weighing less than 1500 g) is 85 per cent in the USA and is ever increasing, while 42 to 75 per cent of extremely premature infants (weighing 751-1000 g) survive. Of great concern is the lack of consistent decrease in neurological syndromes and associated visual impairments. Because of short gestations, these infants have not had time to accrue up to 80 per cent of magnesium normally present at term. These very preterm infants are at highest risk for cerebral hypoxia/ischemia (H/I), intracranial hemorrhage (ICH), periventricular leukomalacia (PVL) or cystic PVL (CPVL), and possible sequelae, cerebral palsy (CP) and mental retardation (MR). These syndromes are associated with damage to optic structures and the visual pathways which traverse the brain. Visual defects are common in surviving preterm infants. Increased levels of harmful neurochemical mediators that have been reported in these conditions include oxygen free radicals, excitatory amino acids, tumor necrosis factor-alpha (TNF-a), and thromboxane A2 (TXA2) which are aggravated in magnesium deficiency and may be ameliorated by magnesium. We review the published data concerning the effects of prenatal magnesium supplementation on ICH, CPVL, CP and MR and available reports concerning survival. Further considerations on the safety and efficacy of magnesium sulphate administration given prenatally to the preterm neonate await the outcome of three trials that are continuing for more than a year on three continents.

Extrasplenic pseudoaneurysm. The role of color flow Doppler ultrasound in diagnosis

Pseudoaneurysm of the splenic artery has been rarely reported and the Doppler echocardiographic finding seldom described. Herein we report a rare case of huge extrasplenic pseudoaneurysm, which was detected by color flow Doppler ultrasonography and successfully treated by ligation of the splenic artery and resection of the pseudoaneurysm.

Adrenal cancer with hypertension but low plasma renin and aldosterone

Patients with malignant lesions of the adrenal gland may present with a syndrome of excess mineralocorticoids. Both primary hyperaldosteronism and excess mineralocorticoids other than aldosterone resulting from adrenal carcinoma have rarely been reported. In most patients with adrenal tumors secreting mineralocorticoids other than aldosterone, distant metastasis had already occurred at the time of diagnosis and the prognosis was poor. We present a rare case of adrenal cancer with hypertension in a patient with low plasma renin activity and a low plasma aldosterone concentration. The patient's blood pressure returned to normal after removal of the tumor. The patient is still alive and without recurrence 6 years after surgery. This case illustrates the value of thorough evaluation of hypertension and prompt surgical treatment for patients with adrenal cancer.

Minimally invasive cardiac surgery for intracardiac congenital lesions

OBJECTIVE

Minimally invasive cardiac surgery has recently been applied to the correction of intracardiac lesions. This report reviews our experience of minimally invasive cardiac surgery in 119 patients with intracardiac congenital lesions.

METHODS

From October 1995 to April 1997, 119 patients (48 male and 71 female, aged 0.9-65 years old, 18.5+/-17.8) received elective minimally invasive cardiac surgery at Chang Gung Memorial Hospital, Taipei, Taiwan for repair of atrial septal defect (96 patients) or ventricular septal defect (23 patients). The operations were performed through right submammary incision (ASD) or left parasternal minithoracotomy (VSD), under femoro-femoral or femoro-atrial cardiopulmonary bypass with fibrillatory arrest.

RESULTS

All of the defects were repaired successfully. The bypass time was 25-125 min (46+/-18). The operation time was 1.5-5.2 h (2.8+/-0.8). The postoperative course was uneventful in all patients. Follow-up (1.0-18.2 months, mean 7.3) was complete, with no late deaths or residual shunt. All patients were found to be in NYHA functional class I or II.

CONCLUSION

Our experience demonstrate that minimally invasive cardiac surgery is a technically feasible, safe, and effective procedure in surgical correction of selective simple intracardiac congenital lesions, yielding good short-term results.

Video-assisted cardiac surgery for intracardiac tumors

OBJECTIVE

To present our experience in surgical excision of intracardiac tumors in three patients using video-assisted cardiac surgical techniques.

METHODS

Three patients received emergency video-assisted cardiac surgery for excision of right atrial or left atrial tumors. These surgeries were performed through right anterior submammary minithoracotomies and guided by video-assisted endoscopic techniques by projected images on a video monitor while under femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest. Conventional instruments were used.

RESULTS

All but one of the tumors were excised completely. The bypass time was 88-148 min. The operation time was 3.5-4.4 h. There were no operative deaths. Pathological examination of the tumors showed left atrial myxoma, metastatic left atrial choriocarcinoma, and right atrial lymphoma. One patient died from non-cardiac origin 5 weeks after discharge. Follow-up was completed with the two survivors. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. They were both in New York Heart Association functional class I or II. They were satisfied with the cosmetic healing of their incisions.

CONCLUSION

Video-assisted cardiac surgery is technically feasible and can be performed in surgical excision of intracardiac tumors.

Internal iliac artery aneurysmo-rectal fistula associated with multiple aortoiliac aneurysms

Fistular communication between an internal iliac artery aneurysm and rectum presenting as massive lower gastrointestinal tract bleeding is a rare entity in clinical practice. Prompt diagnosis and experienced therapeutic application determine the outcome. Herein we report the successful management of such a complication. A 68-year-old male had multiple aneurysms over the abdominal aorta and bilateral iliac arteries. It was the largest aneurysm arising from the right internal iliac artery which ruptured into the rectum and resulted in massive hematochezia. After extraanatomical bypass with right axillo-femoral and femoro-femoral crossover grafts to restore the circulation to the bilateral lower limbs, the infrarenal abdominal aorta just immediately above the proximal aneurysm was transected and closed as a blind stump. All the aneurysms were included in this resection and as much of the infected aneurysm tissue was debrided as possible. The rectum was exteriorized using Hartmann's procedure. The patient survived the operation and was discharged in good condition.

Continuous antegrade warm blood cardioplegia attenuates augmented coronary endothelium-dependent contraction after cardiac global ischemia and reperfusion

BACKGROUND

Experiments were designed to evaluate the effect of warm blood cardioplegia on endothelium-dependent contraction of the coronary endothelium after cardiac global ischemia and reperfusion.

METHOD

Dogs (n = 12 in each group) were exposed to extracorporeal circulation with the body temperature at 37 degrees C (group 1) or 28 degrees C (groups 2 and 3). The ascending aorta was crossclamped for 120 minutes while continuous infusion of warm blood cardioplegec solution (group 1) or intermittent infusion of cold (4 degrees C) crystalloid cardioplegic solution (group 2) was performed via the coronary arteries through the aortic root. Cardioplegic solution was not used in group 3 animals. The heart was then allowed to function for 60 minutes of reperfusion. Reperfused (groups 1, 2, and 3) and control (group 4) coronary arteries were then harvested for study.

RESULTS

Perfusate hypoxia caused endothelium-dependent contraction in the arteries of all four groups that could be attenuated by NG-monomethyl-L-arginine (L-NMMA) or L-NMMA plus D-arginine, but not by L-NMMA plus L-arginine or endothelin receptor A and B antagonist PD 145065. The endothelium-dependent contraction results in groups 2 and 3 (75% +/- 4% and 80% +/- 5%, respectively) were significantly greater than those in groups 1 and 4 (15% +/- 3% and 18% +/- 5%, respectively). Scanning electron microscope studies showed that platelet adhesion and aggregation, areas of microthrombi, disruption of endothelial cells, and separation of the intercellular junction could be found in coronary segments from groups 2 and 3, but not in vessels from groups 1 and 4.

CONCLUSION

These experiments suggest that global ischemia and reperfusion enhances hypoxia-mediated endothelium-dependent contraction of the coronary endothelium and damages the ultrastructure. These kinds of changes can be prevented by continuous antegrade infusion of warm blood cardioplegic solution during global ischemia.

Isolated common iliac artery occlusion secondary to atherosclerotic plaque rupture from blunt abdominal trauma: case report and review of the literature

Traumatic isolated common iliac artery occlusion is unusual. Only rare cases of common iliac arterial injuries resulting from blunt abdominal trauma have been reported, and most of them were attributed to the seat-belt syndrome and associated with visceral organ perforation or pelvic fracture. We reported an unusual isolated common iliac artery occlusion secondary to atherosclerotic plaque rupture from blunt abdominal compressive trauma without other visceral injury. This case presented with acute limb ischemia and paralysis that was successfully treated by thromboendarterectomy. The symptoms and signs, surgical modalities, and associated injuries were reported and the literature was also reviewed.

[Investigation on the parasites of alien laborers in Kaohsiung]

In the past year, stool specimens of 1,732 alien laborers were examined for intestinal parasites. There was no significant difference in the positive rate between males and females. All alien laborers were examined in 3 hospitals and the positive rates were 24.8% (191/769), 13.6% (109/804) and 12.6% (20/159). Broken down by nationality, the positive rates in laborers from Thailand, Indonesia, the Philippines and Malaysia were 23.9% (192/803), 20.3% (62/305), 12.1% (60/498) and 4.8% (6/126) respectively. Of all alien laborers, 17.2% (297/1,732) had single infections of parasites and 1.3% (23/1,732) had multiple infections. Opisthorchis viverrinii was the most prevalent parasite found in infected alien laborers. 91.5% of alien laborers were aged from 21 to 40-years-old and had positive rates of parasites reaching 91.0%. The time of arrival in Taiwan had an effect in all alien laborers examined for parasites. The positive rate in laborers arriving during April to June was 22.7% which was significantly higher than the 16.3% for laborers arriving in other months.

Value of immunoperoxidase staining of thyroglobulin in fine needle aspiration cytology of thyroid diseases

To elucidate the value of thyroglobulin staining by the immunoperoxidase method in fine needle aspiration cytology of thyroid diseases, it was performed on fine needle aspiration smears of 57 cases of various thyroid diseases. Thirteen of 22 cases (59%) with benign nodular goiter were positive. Eight of 14 cases (57%) with papillary thyroid carcinoma were positive. Among these eight cases with positive staining, seven were at clinical stage II or less. Among the other six cases with negative staining, five cases were in clinical stage III or more. There was a significant relationship between clinical stage and thyroglobulin staining (P < .05). One of 10 cases with thyroid cysts was positive. One of four cases with anaplastic carcinoma was positive. One of two cases with follicular thyroid carcinoma was positive. Two cases of subacute thyroiditis were positive. One case of Hashimoto's thyroiditis was positive. Two cases of metastatic thyroid cancer from the ovary were negative. These results reveal that positive thyroglobulin staining was helpful in defining the source of tissue from the thyroid. However, negative staining could not definitively exclude a thyroid origin. Positive thyroglobulin staining in papillary thyroid carcinoma correlated with less advanced clinical stages.

A novel antibiofilm technology for contact lens solutions

PURPOSE

Nonsteroidal anti-inflammatory drugs, including sodium salicylate, inhibit extracellular bacterial biofilm production. The authors studied the effect of the addition of sodium salicylate on bacterial adherence and biofilm formation on contact lenses and cases and commonly used medical polymers.

METHODS

The study was done in vitro with bacterial adherence and biofilm measured on lenses and cases that were exposed to saline contaminated with Staphylococcus epidermidis and Pseudomonas aeruginosa with and without 1 and 3 mm sodium salicylate. Bacterial adherence to contact lenses was quantitated by a vortex assay and by scanning electron microscopy. Biofilm formation on contact lens cases and other polymers was measured by an optical density assay and a radiolabeling assay.

RESULTS

Inhibition of biofilm formation was demonstrated on plastic contact lens cases in a dose-related manner with 1 and 3 mm sodium salicylate. A dose-related decrease in bacterial adherence also was noted. Assays with contact lenses also demonstrated less adherence in the presence of sodium salicylate. Electron micrographs of the contact lens showed less biofilm, most noticeable with 3 mm salicylate. Other studies demonstrated decreased adherence of S. epidermidis to polyethylene and polystyrene. Sodium salicylate also decreased biofilm on plastic tissue culture wells, but sorbic acid paradoxically increased deposition.

CONCLUSION

The authors found that the addition of low-dose sodium salicylate to saline decreased the adherence of S. epidermidis and P. aeruginosa to contact lenses and lens cases. Biofilm production also was decreased on the lens cases and on medical polymers used to make plastic cases. These studies suggest that sodium salicylate deserves additional study to determine its use in contact lens solutions.

Endothelium-dependent contraction of canine coronary artery is enhanced by crystalloid cardioplegic solution

Experiments were designed to determine whether hyperkalemic crystalloid cardioplegic solution enhances endothelium-dependent contraction of coronary arteries. Segments of canine coronary arteries (n = 8 in each group) were preserved in cold (4 degrees C) crystalloid cardioplegic solution (group 1) and physiologic solution (group 2) for 60 minutes. Segments of preserved and control (group 3) coronary arteries with or without endothelium were suspended in organ chambers to measure isometric force. Perfusate hypoxia (oxygen tension 35 +/- 5 mm Hg) caused endothelium-dependent contraction in the arteries of all three groups. However, vascular segments with endothelium of group 1 exhibited hypoxic contraction (68.5% +/- 15.3% of the initial tension contracted by prostaglandin F2 alpha 2 x 10(-6) mol/L, p < 0.05) that was significantly greater than contraction of the group 2 and group 3 segments with endothelium (26.6% +/- 5.6% and 20.6 +/- 4.4%). The hypoxic contraction in arteries of group 1 could be attenuated by NG-monomethyl-L-arginine, the blocker of endothelial cell synthesis of the nitric oxide from L-arginine. The action of NG-monomethyl-L-arginine could be reversed by L-arginine but not D-arginine. Thus after preservation with cardioplegic solution, augmented endothelium-dependent contraction, occurs by L-arginine-dependent pathway, would favor coronary vasospasm after cardiac operation.

Enhancement of endothelium-dependent contraction of the canine coronary artery by UW solution

University of Wisconsin (UW) solution has been used almost routinely in the preservation of the hepatic, pancreatic, renal, and cardiac allografts. However, its effect on vascular endothelium is unknown. Experiments were designed to evaluate its effect on canine coronary endothelium. Canine coronary arteries (n = 8 in each group) were preserved in cold (4 degrees C) UW solution (group 1) and physiological solution (group 2) for 6 hr immediately after harvesting. Segments of preserved and control (group 3) coronary arteries with or without endothelium were then suspended in organ chambers to measure isometric force. Perfusate hypoxia (pO2 30 +/- 5 mmHg) caused endothelium-dependent contraction in the arteries of all 3 groups. However, vascular segments with endothelium of group 1 exhibited hypoxic contractions (107 +/- 26% of the initial tension contracted by prostaglandin F2 alpha 2 x 10(-6) mol/L, P < 0.05) that were significantly greater than those of the group 2 and group 3 segments with endothelium (25 +/- 5% and 20 +/- 4%). The hypoxic contraction in arteries of group 1 could be attenuated by NG-monomethyl-L-arginine (L-NMMA), the blocker of endothelial cell synthesis of the nitric oxide from L-arginine. The action of L-NMMA could be reversed by L-arginine but not D-arginine. Endothelium-dependent relaxation of coronary endothelium to acetylcholine and adenosine diphosphate and endothelium-independent relaxation and contraction of coronary smooth muscle were not altered by the UW solution. After preservation with the UW solution, endothelium-dependent contraction of the canine coronary arteries, occurs by L-arginine-dependent pathway, is enhanced. This augmentation by the UW solution would favor vasospasm after transplantation.

Thoracoscopic management of effusive pericardial disease: indications and technique

Video-assisted thoracoscopic technique was evaluated in 28 patients who underwent operation for massive pericardial effusion. Excellent results were obtained using this newly developed approach for inspection of all pericardial surfaces as well as pleural and pulmonary disorders. No perioperative or postoperative complications ensued. Videothoracoscopy revealed positive lung malignancies in 11 patients, and these would not have been promptly diagnosed without thoracoscopy. Thoracoscopy also confirmed metastatic deposits on the pleura and diaphragm in 4 other patients. The visible nodules were proved to be metastatic adenocarcinoma. In 13 patients, thoracoscopy did not reveal malignancy, although 2 of these patients had a clinically suspected malignant lung tumor. Other indications for thoracoscopic drainage included 2 patients with impending pericardial tamponade after heart procedures and 6 patients with recurrent/loculated pericardial effusion. All of the patients showed promising and favorable postoperative courses after thoracoscopy. From our experience, video-assisted thoracoscopy was a safe and effective procedure, especially for those patients with combined pericardial effusion and abnormal pulmonary or pleural pathology in whom subxiphoid pericardial window was not clearly diagnostic at the time of operation. It was effective also in the situation with recurrent or loculated pericardial effusion which allowed localization and drainage of it. We believe that the use of videothoracoscopy to visualize the whole pericardial and pleural cavity will continue to be of great benefit to patients with combined pericardial and pleural/lung diseases.

Imaged thoracic resection of a huge mediastinal tumor--role of extended incision and the use of conventional instruments

Intrathoracic lesions are usually removed through conventional thoracotomy. The long incision and the spreading of the rib usually results in much pain and interference of chest wall mechanics. Today, with the development of imaged thoracic surgery (combination of thoracoscope and video optics), major procedures can be performed through small incisions. However, indications are greatly limited due to lack of suitable instrumentation and restricted space of the trocar channel especially when a huge intrathoracic tumor is encountered. In this selected report, we demonstrate a successful procedure using extended incision and conventional instruments in imaged resection of a huge cystic intrathoracic tumor. The procedure offers the benefit of safe, easy and fast manipulation. The patient had an uneventful postoperative course and was discharged on the fourth postoperative day.

Video-assisted thoracic surgery. The Chang Gung experience

Thoracoscopy has assumed a major role in the management of a variety of surgical diseases of the chest. This technique, which was primarily devised for diagnostic purposes, has subsequently come to be used for therapeutic applications in most centers today. In this report we review 300 cases of therapeutic thoracic procedures in which a video-assisted technique was used. We describe mainly our own experience and the basic approach strategies we found helpful in the video-assisted procedures. No complications or deaths were attributable to these procedures. Our conclusions were as follows: (1) Video-assisted thoracic surgery can be as effective therapeutically as many formal thoracotomy. (2) Excellent exposure can be obtained by the use of double-lumen endotracheal tubes. (3) Video-assisted thoracic surgery is an excellent alternative treatment for pneumothorax, blebs, and bullous disease. (4) Video-assisted thoracic surgery allows safe, complete, visually guided wedge resection of lung lesions, lobectomy, pericardiectomy, removal of mediastinal tumor, esophagectomy, and reconstruction of the thoracic esophagus. (5) Video-assisted thoracic surgery also allows management of a broad scope of other general thoracic diseases such as empyema, pleural effusion, and chest trauma (hemothorax), as well as cancer staging. (6) Video-assisted thoracic surgery will not compromise the primary diagnostic and therapeutic goals set forth for the patient. (7) Because conventional instruments and extended manipulation incisions can be used, video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened stays in the hospital, and therefore savings in cost. Accordingly, we are now using video-assisted thoracic surgery to treat the majority of patients with surgical diseases of the chest.

Severe isolated acute hepatic graft-versus-host disease with vanishing bile duct syndrome

A 28-year-old man with chronic myelogenous leukaemia in blastic transformation underwent allogeneic bone marrow transplantation from his HLA-identical brother. Severe, progressive cholestatic jaundice developed from day 25 and did not respond to repeated therapy with high-dose methylprednisolone. In addition to marked cholestasis, both liver biopsy (day 69) and autopsy (day 134) findings revealed total disappearance of interlobular bile ducts in all of the portal areas, although extrahepatic manifestations of GVHD were minimal. Isolated acute vanishing bile duct syndrome can occur as the most severe form of acute hepatic GVHD.

Somatostatin-containing carcinoid tumor of the duodenum in neurofibromatosis: report of a case

We report a case of von-Recklinghausen's disease presenting with obstructive jaundice and found to have a somatostatin-containing carcinoid tumor in the papilla of Vater and a small neurofibroma in the duodenum. A 42-year-old woman with von-Recklinghausen's disease presented with intermittent jaundice, pruritus, and mild steatorrhea of a two-year duration. Abdominal ultrasonography and computed tomography showed dilated intrahepatic ducts, common bile duct and pancreatic ducts. Duodenoscopy showed a tumor at the papilla of Vater, but a preoperative biopsy failed to provide a definite diagnosis. Laparotomy revealed a yellowish tumor at the papilla of Vater and another nodule on the mesenteric side of the second section of the duodenum. Microscopically, the tumor at the papilla of Vater was found to be a somatostatin-containing carcinoid tumor. The small nodule on the mesenteric side was a neurofibroma. The jaundice, pruritus and steatorrhea disappeared after surgery.

Epstein-Barr virus (EBV) gene expression in EBV-positive peripheral T-cell lymphomas

Epstein-Barr virus (EBV) DNA has been detected in peripheral T-cell lymphomas. In this study, analysis of the EBV termini indicated that the infection was clonal and nonpermissive. Analysis of viral expression detected the processed, spliced mRNAs representing EBNA1, LMP1, LMP2, and BamHI A transcripts in all EBV-positive peripheral T-cell lymphomas. The LMP1 protein was detected by immunofluorescence in a single specimen. In contrast, neither the EBNA2 protein nor the spliced EBNA2 mRNA were detected. These data indicate that EBV-infected T-cell lymphomas are clonal expansions of a single EBV-infected cell with a pattern of gene expression which is distinct from that detected in Burkitt's lymphomas or posttransplant lymphomas but similar to viral expression in nasopharyngeal carcinomas.

[Insulinoma in childhood--report of a case]

A 14-year-old boy was having recurrent hypoglycemia over the past 6 months, so he was brought to our hospital for further evaluation. During the episodes of hypoglycemia, his serum insulin level was inappropriately high and the symptoms of hypoglycemia were dramatically ameliorated by intravenously administering glucose bolus. Computed tomography of the abdomen revealed a 1 x 1 cm mass located at the tail of the pancreas. Under the impression of an insulinoma, enucleation of the tumor was performed smoothly, and the pathological finding confirmed the diagnosis. The postoperative course was smooth and no episodes of hypoglycemia were noted after treatment. In children with hypoglycemic attacks, adequate blood sampling before correction to determine plasma insulin levels is essential.

Gastro-pleural fistula related with penetrating stab injuries of the chest and abdomen: laparotomy or thoracotomy

A 30-year-old male presented with left side empyema due to gastro-pleural fistula following repair of penetrating stab injuries of left lower chest and abdomen. Exploratory thoracotomy was done due to persistent moderate amount of purulent discharge. However, fistula tract was not detected through this approach. The small fistula tract was repaired finally through laparotomy. We recommended the abdominal approach if the disease is not combined with diaphragmatic hernia. Transabdominal approach showed superiority in this rare entity.

Pulmonary artery perforation after Kirschner wire migration: case report and review of the literature

Utilization of Kirschner wires for bone and joint fixation is potentially complicated by migration of the wire from the fixation site over time. However, a review of the literature disclosed few reports of this complication. We describe such a case in order to emphasize the potential danger of the migration of such metallic devices used near thoracic cavity.

Pancreatitis related to antiphospholipid antibody syndrome in a patient with systemic lupus erythematosus

A 39-year-old woman was admitted with abdominal pain and dyspnea, and a diagnosis of systemic lupus erythematosus with renal involvement was established. Laboratory tests revealed highly elevated anticardiolipin antibody, thrombocytopenia and false positive VDRL. Generalized thrombus formation and Libman-Sacks endocarditis were found at postmortem examination. The pancreas showed chronic inflammation with thrombi in pancreatic arteries, but no vasculitic change was observed. Lowering of pancreatic blood flow because of arterial thrombi was a possible cause of pancreatitis in this patient. The spectrum of antiphospholipid antibody associated diseases may be extended to include pancreatitis as a thrombotic complication.

Clinicopathological spectrum of Epstein-Barr virus-associated T cell malignancies

It has been recently demonstrated that the Epstein-Barr virus (EBV) can infect human thymocytes and may be involved in the T cell neoplasms, in addition to African Burkitt's lymphoma, nasopharyngeal carcinoma and Hodgkin's disease. Four distinct clinicopathologic categories of EBV-associated T cell malignancies have been recognized. The angiocentric T cell lymphoma or lymphomatoid granulomatosis involving the nose (or midline lethal granuloma) and skin is frequently EBV-associated. The other 3 groups include angioimmunoblastic lymphadenopathy-like lymphoma, node-based T immunoblastic lymphoma which may contain Reed-Sternberg-like giant cells (Hodgkin's-like lymphoma), and T cell lymphoma resembling malignant histiocytosis. Both the CD4 and CD8 T cell subsets, and a hitherto undefined T lineage lacking CD4/CD8 expression have been involved. The common clinical features are prolonged fever, skin lesions, lymphadenopathy, hepatosplenomegaly, and pancytopenia. Serologic assays suggest that a chronic active EBV infection may exist in most of these patients. The EBV genomes appear to proliferate in clonal and episomal form in the neoplastic cells which show expression of latent membrane proteins. Although an indolent local phase may exist, the clinical course is aggressive for most patients with frequent development of drug resistance to conventional chemotherapy. EBV-associated T cell lymphoma constitutes a separate entity of virus-associated human diseases and opens a potential field to investigate the pathogenesis of EBV-associated human malignancies.

Hodgkin's disease and non-Hodgkin's lymphoma containing Reed-Sternberg-like giant cells in Taiwan. A clinicopathologic analysis of 50 cases

Hodgkin's disease (HD) is uncommon in Taiwan. In reviewing the clinicopathologic features of 50 cases, the authors found that the diagnosis of HD was complicated with non-Hodgkin's lymphoma (NHL). Fourteen cases were reclassified as NHL containing Reed-Sternberg (RS) giant cells, mostly peripheral T-cell lymphoma (PTL), and 34 cases as classic HD, which included 8 cases of lymphocyte predominance, 10 of nodular sclerosis, 12 of mixed cellularity, and 4 of lymphocyte depletion. For cases of HD, there was a bimodal age-incidence distribution with peaks at the third and fifth decades; 61.8% manifested Stage B symptoms and 80.6% had Stage III/IV disease. The group of patients with NHL, compared with those with classic HD, was found to be older (mean age, 41.4 years versus 33.1 years; P less than 0.05), to have more extranodal disease (35.7% versus 8.8%, P less than 0.05), less complete remission rate (25% versus 67.9%, P less than 0.05), and shorter median survival (29 months versus 90 months). Most of the NHL patients originally were diagnosed as having atypical or unclassified HD. Thus, the authors conclude that the previous observation of a predominance of mixed cellularity HD in Asian regions may be attributable to the inclusion of PTL, which may mimic HD in histology. Because there is a marked difference in clinical behavior and prognosis, it is important to distinguish between HD and NHL containing RS giant cells in an area with a high incidence of PTL.

[Migration of Kirschner wire from the right sternoclavicular joint into the main pulmonary artery. A case report]

The use of Kirschner wires (K-wires) for bone and joint fixation carries the risk of migration of the wire from the fixation site over time. However, review of the literatures disclosed rather few reports on this issue. We describe such a case in order to emphasize the potential complication and serious hazard that migration of such metallic devices can result in, especially when the fixation site is close to the thoracic cavity.

Cutaneous angiocentric T-cell lymphoma associated with Epstein-Barr virus

BACKGROUND

Two unusual cases of cutaneous angiocentric T-cell lymphoma were found to be associated with Epstein-Barr virus infection.

OBJECTIVE

The objective was to study the clinical course and the response of the disease to conventional chemotherapy.

METHODS

Histologic specimens from both patients were studied. Clonal proliferation was assessed by Southern blot hybridization.

RESULTS

The disease in both patients was rapidly progressive and responded poorly to aggressive treatment. Biopsy specimens showed infiltration of atypical lymphoid cells with angiocentricity and angiodestruction, which probably resulted in the observed tissue necrosis. Clonal proliferation of Epstein-Barr virus DNA was detected in tissue from primary skin lesions and disseminated nasal lesions.

CONCLUSION

Epstein-Barr virus-associated angiocentric T-cell lymphoma in our patients was characterized by an aggressive course and resistance to conventional chemotherapy. A search for Epstein-Barr virus and the human T-lymphotropic virus should be performed in patients with atypical features of cutaneous T-cell lymphoma.

Endothelium-dependent production of prostacyclin in human internal mammary artery

The internal mammary artery (IMA) has become the conduit of choice in coronary artery bypass surgery because of superior long-term patency. It had been shown that IMA graft could release prostacyclin. Prostacyclin is a potent vasodilator and also can inhibit platelet aggregation. To determine the role of human IMA endothelium in production of prostacyclin, we tested the reactivity of segments of human IMA to hypoxia in vitro. Human IMAs were harvested during coronary artery bypass surgery. Prostacyclin was measured from fluid in the organ baths by radioimmunoassay of its major hydrolytic product 6-keto-prostaglandin F1 alpha. Rings (4 mm in length) of IMA, with and without endothelium, were suspended in organ baths containing physiologic salt solution. Rings were contracted with norepinephrine, and exposed to hypoxia (pO2 35 +/- 5 mmHg) for 15 minutes then reoxygenated. In segments with endothelium, hypoxia induced a transient relaxation followed by contraction. The transient relaxation was associated with a significantly increased production of 6-keto-prostaglandin-F1 alpha (from 34.1 +/- 2.7 pg/ml prehypoxia to 51.6 +/- 6.7 pg/ml during hypoxia, mean +/- SEM, p less than 0.05). This transient relaxation was blocked by indomethacin but not by NG-monomethyl-L-arginine (L-NMMA) and free radical scavengers (superoxide dismutase, catalase and deferoxamine). However, in segments without endothelium, the prehypoxia (14.7 +/- 0.9) and during hypoxia (15.5 +/- 1.4) level of 6-keto-prostaglandin F1 alpha were not increased and were significantly lower than those with endothelium. This study demonstrated that endothelium of IMA grafts could release prostacyclin either in a basal condition or upon stimulation of hypoxia. This ability possibly contributes to its long-term patency.

Aggressive peripheral T-cell lymphomas containing Epstein-Barr viral DNA: a clinicopathologic and molecular analysis

The Epstein-Barr virus (EBV) has been shown to be associated with posttransplant lymphoma, Hodgkin's disease, and T-cell lymphoma, in addition to African Burkitt's lymphoma. In a retrospective study of 56 consecutive cases of T-cell lymphoma, EBV DNA was found by Southern blot and in situ DNA hybridization in 10 (20%) of 50 peripheral T-cell lymphomas, but in none of six cases of T-lymphoblastic lymphoma. Peripheral T-cell lymphomas containing EBV DNA could be subclassified into three categories according to histology and immunophenotypic studies: (1) T-cell lymphoma of the helper phenotype, five cases. Two cases had histologic features resembling angioimmunoblastic lymphadenopathy (AILD). (2) T-cell lymphoma of the cytotoxic/suppressor phenotype, four cases. AILD-like features could also be recognized in two cases. Reed-Sternberg-like giant cells were identified in three cases designated Hodgkin-like T-cell lymphoma. (3) Angiocentric T-cell lymphoma or lymphomatoid granulomatosis in one case, initially affecting the skin and nose; no T-cell subset could be defined. Six of the eight EBV DNA-positive patients tested for serum EBV antibodies had elevated titers of IgG antiviral capsid antigen (greater than 640) and/or early antigen (greater than 10). From combined studies of Southern blot hybridization by using EBV termini fragment probe and in situ DNA hybridization, the EBV genomes appeared to be clonotypically proliferated in the neoplastic T cells. The patients in all three groups usually had prolonged fever preceding the diagnosis, hepatosplenomegaly, an aggressive clinical course, and poor response to chemotherapy; nine died with a median survival of only 8 months. We propose that these EBV-associated aggressive T-cell lymphomas, like human T-cell leukemia/lymphoma virus-positive T-cell lymphoma, have characteristic clinicopathologic features and should be treated as a separate disease entity.

Epstein-Barr virus-associated peripheral T-cell lymphoma of activated CD8 phenotype

Two childhood cases are reported of peripheral T-cell lymphoma; the neoplastic cells expressed activated CD8 (T8) phenotype and contained Epstein-Barr viral (EBV) DNA. Both patients had an aggressive and rapid clinical course despite chemotherapy. Elevated titers of antibodies to EBV-viral capsid antigen (greater than 640) and early antigen (greater than 10) were found in both patients. Histology revealed pleomorphic immunoblastic lymphoma with extensive necrosis in one case and an angioimmunoblastic lymphadenopathy-like pattern containing Reed-Sternberg-like giant cells in the other. Southern blot hybridization studies showed clonal rearrangement of the T-cell-receptor beta gene in both cases, and a cytogenetic study on one case revealed clonal structure abnormality involving chromosomes 1, 6, 7, 10, and 19. Analysis of the tumor DNA showed a high copy number of EBV genome per cell compared with that of Raji and Marmoset B 95.8 lines; the study for human T-cell leukemia virus type I was negative. The EBV genome was found by in situ hybridization in the tumor nuclei in both cases. In addition to Burkitt's lymphoma, T-cell lymphoma of the helper phenotype, and Hodgkin's disease, EBV can contribute to the development of CD8-positive aggressive T-cell lymphoma.

Cutaneous manifestations of postthymic T cell malignancies: description of five clinicopathologic subtypes

This study was undertaken to identify the cutaneous manifestations among different prognostic subgroups of postthymic T cell malignancies. Cutaneous involvement was demonstrated in 43 of 88 cases. We recognized five clinicopathologic subtypes: type I, classical cutaneous T cell lymphoma (CTCL) or mycosis fungoides, six cases; type II, primary large cell type CTCL, Ki-1 antigen (Ki-1+ or Ki-1-), seven cases; type III, primary angioinvasive T cell lymphoma, three cases; type IV, human T-lymphotropic virus type I (HTLV-I+) adult T cell leukemia/lymphoma (ATL), eight cases; type V, secondary cutaneous involvement by peripheral T cell lymphoma (PTL), 19 cases. Primary CTCL and ATL tend to involve papillary dermis with or without epidermotropism, whereas PTL and angioinvasive T cell lymphoma predominantly affect skin adnexae, vessels, and subcutis. Cutaneous lesions in type V PTL are heterogeneous and may be confused with panniculitis, vasculitis, or an eczematous eruption. Classic CTCL, Ki-1+ lymphoma, and angioinvasive T cell lymphoma have a chronic course, whereas ATL, Ki-1- large cell lymphoma, and PTL are clinically aggressive.

Correlation between sonography and pathology in thyroid diseases

Ultrasonography was performed on the thyroid glands of 47 patients with various thyroid diseases, in a fresh state, immediately following operation. The thyroid glands were then sectioned along the plane of the most significant sonographic changes. The pathologic changes of the sectioned plane were observed and compared with the sonographic changes. In nodular goiter, the sonographic changes were usually heterogeneous. The margin was either well-defined or ill-defined, and cystic changes might play a minor or major part in the thyroid nodules. In follicular adenoma, the changes were isoechoic in adenoma with embryonal type follicles and hyperechoic in adenoma with colloid type follicles. In adenoma of the oxyphilic cells, the echogenicity was somewhat greater in the hemorrhagic part compared to the area with oncocytic change only. In papillary carcinoma, the lesions usually manifested as well-limited, heterogeneous, hypoechoic nodules. Cystic degenerations were frequently noted. There were discrete particles corresponding to microcalcification in 4 out of 6 cases. In follicular carcinoma, the sonographic changes also showed well-limited nodules. However, the echogenicity was not decreased as much as in papillary carcinoma, and it could be either homogeneous and isoechoic, or hypoechoic. Relatively large particles with an acoustic sign, which corresponded to calcification, were noted in 2 out of 4 cases. In medullary carcinoma, the lesion was well-limited and hypoechoic. The particles present in sonography corresponded to calcification in the amyloid. In Graves' disease, the main sonographic change was a diffusely homogeneous, isoechoic or hypoechoic lesion. Cystic change was rarely present. Dispersed particles were rarely present and corresponded to fibrosis in the thyroid tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Albright's syndrome with acromegaly and Hashimoto's thyroiditis: report of a case

The case of a 35-year-old woman with Albright's syndrome, acromegaly and Hashimoto's thyroiditis is presented. She had noted deformity of the left mandible and chest from childhood. She developed persistent galactorrhea and amenorrhea after the delivery of her second child. X ray of the skull, and a head CT, revealed a pituitary tumor and fibrous dysplasia of the left mandible, sphenoid, zygomatic bone and pteryoid plate. Serum GH and PRL levels were markedly elevated. She received recontouring surgery of the left mandible, and a pathological examination confirmed the diagnosis of fibrous dysplasia. Chest X ray also showed fibrous dysplastic change of the left 4th, 5th, 6th and 7th ribs and left clavicle. Because of poor response to bromocriptine, she received a craniotomy to remove the pituitary macroadenoma. Pathological examination of the tumor revealed an acidophilic tumor. Postoperative radiotherapy was given for residual active tumor. She developed adrenal crisis two months after radiotherapy when she discontinued replacement therapy. The diagnosis of Hashimoto's thyroiditis was arrived at by palpation of the goiter, elevated thyroid antibodies, ultrasound pictures of the thyroid, fine needle aspiration cytology and hypothyroidism. To our knowledge, this is the first report of Albright's syndrome with Hashimoto's thyroiditis. The hypothesis of autoimmune disease is proposed to explain the hypofunction of the endocrine glands associated with Albright's syndrome.

Primary myelofibrosis in children: report of 4 cases

From 1982 to 1985, four cases of primary myelofibrosis were diagnosed in our department. Three were boys and one was a girl. Their ages ranged from 7 months to 15 years. The diagnosis was made based on anemia, leukoerythroblastic change and presence of giant platelets in the peripheral blood, and a bone marrow biopsy showing myelofibrosis. Most of them had anemia, fever, and hepatosplenomegaly on admission. The anemia was severe and refractory to repeated transfusions and steroid therapy in 3 out of the 4 cases. Splenectomy was performed in 1 case, but without satisfactory results. The clinical course and blood pictures in one case resembled leukemia of megakaryocyte lineage (M7), but results of marker studies of the blast cells ruled out the possibility of M7. Three of them underwent leukemic transformation within 2 years and died soon after. The other one died of sepsis 2 weeks after diagnosis. Myelofibrosis in childhood occurs rarely, however, when it does, it always runs a rapid and fatal course.