[IgG4-related diseases of retroperitoneum in urinary and male reproductive system: a clinicopathological analysis of eleven cases]

Objective: To analyze the clinicopathological features of IgG4-related diseases (RD) of retroperitoneum and the urinary and male reproductive system (IgG4-RUMR). Methods: A total of 11 IgG4-RUMR cases from January 2013 to March 2021 were retrospectively collected at Peking University Third Hospital and Shandong Provincial Hospital affiliated to Shandong First Medical University. The clinicopathologic features, laboratory and imaging findings were analyzed and scored according to the 2019 ACR/EULAR classification criteria for IgG4-RD. Results: The 11 patients (male:female is 9∶2; mean age 59 years, range from 44 to 83 years) were initially admitted to the Deparment of Urology/Kidney Transplantation (10 cases) and the Department of Oncology (1 case). All patients had urogenital disorders or imaging abnormalities. Three of the 11 patients had a history of IgG4-RD such as lacrimal gland engorgement, salivary gland engorgement and IgG4-associated pancreatitis. Abnormal retroperitoneal soft tissue and hydronephrosis were found in eight cases, while epididymal and spermatic cord masses were found in one case, simple renal mass in one case, and"benign prostatic hyperplasia"in one case. In the 10 patients tested for serum IgG4, the serum IgG4 level was 0.8-14.4 g/L. Histologically, all cases showed significant lymphoplasmacytic infiltration and storiform fibrosis, and some were accompanied by obliterative phlebitis. The number of IgG4 positive plasma cells was 12-155 per high-power field, and the IgG4/IgG ratio was 15%-77%. According to the 2019 ACR/EULAR IgG4-RD classification standard 11 cases scored 20-48 points, all of which met the diagnostic criteria of IgG4-RUMR. Therapeutically, the patient with a simple renal mass underwent partial nephrectomy. The patient with prostate lesion underwent transurethral resection of prostate and was initially diagnosed as nonspecific chronic prostatitis. Later, the patient was admitted again because of salivary gland swelling, and the pathologic diagnosis was amended. The patient with epididymal and spermatic cord masses participated in a clinical trial about retroperitoneal fibrosis. The remaining eight patients received symptomatic treatment such as adhesiolysis and stent placement. All the patients were subsequently treated with glucocorticoid/immunosuppressant and symptoms relieved. Conclusions: IgG4-RUMR is uncommon. In clinical practice, information from clinical, serologic, radiologic and pathologic evaluations must be integrated. IgG4-RUMR should be considered in the differential diagnosis of urinary and male reproductive diseases. The 2019 ACR/EULAR classification criteria for IgG4-RD, while relatively complex, are objective and practical in the diagnosis of IgG4-RUMR.

[Clinical effect of fractional carbon dioxide laser in the treatment of contracture scars]

Objective: To explore the clinical effect of the fractional carbon dioxide laser in the treatment of contracture scars. Methods: A retrospective before-after self-control study was conducted. From December 2016 to April 2021, 16 patients (7 males and 9 females, aged 3-49 years) with contracture scars causing impaired function of the adjacent joint were admitted to Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Eighteen joint scars of 16 patients were treated with fractional carbon dioxide laser every 2-3 months until the joint retained its normal range of motion or the effect plateaued. The treatment times of each patient were recorded. Before the first treatment and 6 months after the last treatment, the ranges of motion of the affected joint were measured in each patient, and the difference was calculated, meanwhile, the Vancouver Scar Scale (VSS) was used to evaluate the scar of each patient. In the treatment of 1 joint scar in each of 6 patients (totally 6 times of treatments), the ranges of motion of the affected joint before the current treatment, immediately after the treatment, and at the first follow-up after the treatment were documented, and the differences between the ranges before and immediately after the treatment as well as between the ranges before and at the first follow-up after the treatment were calculated. Adverse effects after the treatment in the treatment area were documented. At the last follow-up, a self-made questionnaire was used to collect the implementation status of the physical therapy and other scar management modalities during the treatment interval and follow-up period. Data were statistically analyzed with Wilcoxon rank sum test. Results: Eighteen joint scars in 16 patients received 2 (1, 3) times of fractional carbon dioxide laser treatment. The range of motion of the affected joint of 16 patients 6 months after the last treatment was 56.5 (39.0, 128.8)°, notably higher than 38.4 (22.9, 116.3)° before the first treatment (Z=-3.724, P<0.01), showing a remarkable improvement by 17.4 (8.0, 24.1)°. The vascular distribution, softness, and thickness scores, and total score in VSS scoring of scars of 16 patients 6 months after the last treatment were significantly lower than those before the first treatment (Z=-2.989, -3.762, -2.814, -3.739, P<0.01), with the most obvious improvement in softness. In 6 times of treatments, the range of motion of the affected joint immediately after treatment and at the first follow-up of (2.5±0.6) months after treatment were 156.2 (148.0, 164.2)° and 160.2 (156.7, 166.4)°, both notably higher than 151.4 (145.7, 155.3)° before treatment (Z=-2.201, -2.201, P<0.05), showing a remarkable improvement by 9.1 (4.4, 13.0)° and 13.1 (8.0, 15.7)°, respectively. No adverse effects such as blisters, infection, or hypertrophic scar formation were observed in the treatment area of 16 patients after treatment. Most patients adopted physical therapy, compression, silicone gel or sheets, and braces during the treatment interval and follow-up period. Conclusions: The fractional carbon dioxide laser can soften the scar and increase the range of motion of the affected joint, which is suitable for the clinical treatment of mild contracture scars.

Outcome of antenatally diagnosed cardiac rhabdomyoma: case series and a meta-analysis

OBJECTIVES

Rhabdomyoma, the most common primary fetal cardiac tumor, is often associated with tuberous sclerosis (TS). We aimed to evaluate outcome in cases diagnosed with fetal cardiac rhabdomyoma.

METHODS

This study presents 11 cases with fetal cardiac rhabdomyoma. In addition, all relevant published cases of antenatally diagnosed cardiac rhabdomyoma since 1982 were identified from MEDLINE. We evaluated the following risk factors associated with clinical impact and perinatal outcome: family history of TS, gestational age at diagnosis, tumor size, site and number of tumors, tumor progression, and associated intracardiac and extracardiac anomalies.

RESULTS

In this meta-analysis, 138 cases, including nine newly added by us, were categorized into Group A (107 live babies) and Group B (16 neonatal deaths and 15 intrauterine fetal deaths). Univariate analysis showed that large cardiac tumors (P < 0.0001), fetal dysrhythmia (P < 0.0001) and hydrops (P < 0.0001) were strong predictors of neonatal outcome. Tumor size >or= 20 mm (relative risk (RR), 20.6; 95% CI, 2.2-195.9; P = 0.009) and fetal dysrhythmia (RR, 13.6; 95% CI, 2.9-62.3; P = 0.001) were significantly associated with neonatal morbidity. TS, present in 85/133 (63.9%) cases, was significantly associated with multiple cardiac tumors (P < 0.0001) and family history of TS (P = 0.02).

CONCLUSIONS

Large tumor size and hydrops are significantly associated with poor neonatal outcome, whereas family history of TS and multiple fetal cardiac tumors are associated with TS. Any sonographic detection of a fetal cardiac tumor should warrant further investigation for the possible presence of associated disorders.

Iatrogenic cardiovocal syndrome caused by transcatheter coil closure of patent ductus arteriosus

Two infants developed hoarseness unexpectedly the day after transcatheter coil closure of a slender patent ductus arteriosus (PDA). The pathogenesis of this complication appears to be similar to that of the classic cardiovocal syndrome. During the intervention, the inappropriately implanted coil might have distorted the slender PDA, thereby causing angulation of the pliable PDA itself and precipitating impingement on the left recurrent laryngeal nerve. Fortunately, both infants recovered spontaneously from the hoarseness within several weeks. At present, the definite underlying neuropathology of this complication is unknown as we have not yet confirmed recovery of the left vocal cord movement by follow-up fibreoptic bronchoscopy.

CONCLUSION

Iatrogenic cardiovocal syndrome could occur in infants after transcatheter coil closure of a slender PDA, using the currently popular 0.038-inch coil. A coil with a smaller diameter might prevent the occurrence of this syndrome.

Fixed-dose combination chemotherapy (Rifater/Rifinah) for active pulmonary tuberculosis in Taiwan: a two-year follow-up

SETTING

Veterans General Hospital-Taipei, Taiwan.

OBJECTIVE

To assess the efficacy and safety of a fixed-dose combination (FDC) of Rifater (RFT)/Rifinah (RFN) in the treatment of newly diagnosed smear-positive pulmonary tuberculosis.

DESIGN

Patients were randomly assigned to two 6-month short-course chemotherapy regimens. One group of patients was treated with FDCs and another was given the four component drugs (INH, RMP, EMB and PZA) as separate formulations.

RESULTS

The 105 patients enrolled in the study were divided into two treatment groups. Fifty-one patients who had completed treatment without interruption, 26 in the FDC group and 25 in the separate regimen, were eligible for analysis at the end of 2 years. Among the patients with a drug susceptibility test result available, four in the FDC group had bacilli resistant to pyrazinamide. In the separate regimen group, two patients had bacilli resistant to ethambutol and six had bacilli resistant to pyrazinamide. The two regimens were of similar effectiveness with regard to sputum conversion, compliance and radiological improvement. No patient with FDC treatment developed gastointestinal symptoms, visual disturbance or peripheral neuropathy (P < 0.05). However, FDC treatment resulted in drug-induced fever in one patient. One patient (3.8%) in the FDC group relapsed 5 months after completing treatment.

CONCLUSION

This study suggests that the two regimens had similar effectiveness in the treatment of smear-positive pulmonary tuberculosis. However, the fewer adverse drug events among those patients treated with the FDC regimen suggests that it has a better safety profile.

Childhood tuberculosis presenting as an anterior chest wall abscess

Chest wall abscess is a rare manifestation of childhood tuberculosis. We report a case of a tuberculous chest wall abscess in a 4-year-old healthy girl who had received Bacillus Calmette-Guerin (BCG) vaccination at birth. She developed a localized anterior chest wall mass, which was initially mistaken for enchondroma on the chest radiograph. Pathologic examination of the biopsy specimen revealed chronic granulomatous inflammation and positive acid-fast staining, which confirmed the diagnosis of chest wall tuberculosis infection. She received a 12-month course of anti-tuberculous treatment and was perfectly well 1 year later. The chest wall lesion resolved without the need for surgery. In conclusion, tuberculosis should be excluded in children with undiagnosed chest wall lesions, especially in endemic areas, even if they have been vaccinated with BCG. Adequate anti-tuberculosis treatment can result in a complete recovery.

The effect pathway of retinoic acid through regulation of retinoic acid receptor alpha in gastric cancer cells

AIM

To evaluate the role of RARalpha gene in mediating the growth inhibitory effect of all-trans retinoic acid (ATRA) on gastric cancer cells.

METHODS

The expression levels of retinoic acid receptors (RARs) in gastric cancer cells were detected by Northern blot. Transient transfection and chlorophenicol acetyl transferase (CAT) assay were used to show the transcriptional activity of beta retinoic acid response element (betaRARE) and AP-1 activity. Cell growth inhibition was determined by MTT assay and anchorage-independent growth assay, respectively. Stable transfection was performed by the method of Lipofectamine, and the cells were screened by G418.

RESULTS

ATRA could induce expression level of RARalpha in MGC80-3, BGC-823 and SGC-7901 cells obviously, resulting in growth inhibition of these cell lines. After sense RARalpha gene was transfected into MKN-45 cells that expressed rather low level of RARalpha and could not be induced by ATRA, the cell growth was inhibited by ATRA markedly. In contrast, when antisense RARalpha gene was transfected into BGC-823 cells, a little inhibitory effect by ATRA was seen, compared with the parallel BGC-823 cells. In transient transfection assay, ATRA effectively induced transcriptional activity of betaRARE in MGC80-3, BGC-823, SGC-7902 and MKN/RARalpha cell lines, but not in MKN-45 and BGC/aRARalpha cell lines. Similar results were observed in measuring-antiAP-1 activity by ATRA in these cancer cell lines.

CONCLUSION

ATRA inhibits the growth of gastric cancer cells by up-regulating the level of RARalpha RARalpha is the major mediator of ATRA action in gastric cancer cells; and adequate level of RARalpha is required for ATRA effect on gastric cancer cells.

Attenuation of morphine dependence and withdrawal in rats by venlafaxine, a serotonin and noradrenaline reuptake inhibitor

The effects of venlafaxine, a novel serotonin and adrenaline reuptake inhibitor, on the morphine withdrawal and activation of morphine conditioned place preference (CPP), were investigated in rats. Our results showed that the most morphine withdrawal signs, including jumping, writhing, shakes, exploring, lacrimation, piloerection, irritability, and diarrhea, were attenuated by pretreatment with 10 or 20 mg/kg venlafaxine. To investigate the effects of venlafaxine on relapse to opiate dependence, the morphine CPP was used and a dopamine D2 antagonist sulpiride was selected as a control drug. The morphine CPP disappeared following a 28-day drug-free period and appeared again after given a single injection of 1 mg/kg morphine. Acute treatment with sulpiride (25 or 50 mg/kg, i.p.) 30 min prior to 1 mg/kg morphine injection significantly blocked the reacquisition of CPP, while venlafaxine (10 or 20 mg/kg, i.p.) did not show significant effect. However, chronic treatment with venlafaxine (5 or 10 mg/kg, i.p. twice, daily, for seven consecutive days) significantly attenuated the reacquisition of morphine CPP, whereas chronic treatment with sulpiride (10 or 20 mg/kg, i.p.) have no significant effect. Our results demonstrated for the first time that venlafaxine strongly attenuates morphine withdrawal and morphine-induced reaquisition of

Utility of PCR assays for rapid diagnosis of BCG infection in children

We report Mycobacterium bovis BCG infection in two children vaccinated with BCG (Tokyo strain) on the first day of life. Their diagnoses were made by biopsy of skin lesions and pus from an anterior chest wall abscess, respectively, yielding a positive culture of mycobacteria fully susceptible to rifampicin, isoniazid and ethambutol, but resistant to pyrazinamide. M. bovis BCG was identified by a negative niacin test, absence of nitrate reductase and resistance to pyrazinamide and cycloserine. The diagnoses were further confirmed by a combination of an allele-specific polymerase chain reaction ated strain of Mycobacterium bovis, is the only available vaccine for the prevention of tuberculosis. Although complications are rare after BCG vaccination and the outcome is usually favourable, serious BCG infections can occur. We report two cases of M. bovis BCG infection in children, a 4-year-old immunocompetent girl and an 8-month-old immunodeficient boy. To our knowledge, this is the first report of BCG complications in children in which two recently developed polymerase chain reaction (PCR) based methods were used for rapid identification of M. bovis BCG infection. (PCR) and a multiplex PCR method. Based on the drug susceptibility results, treatment with rifampicin, isoniazid and ethambutol was instituted. One patient (Case 1) improved clinically and is well after treatment. However, the other patient with severe combined immunodeficiency died of disseminated BCG infection in spite of intensive anti-tuberculosis therapy. Although BCG is considered to be a safe vaccine, it should be kept in mind that complications related to BCG do occur.

Hepatocellular carcinoma with Pancoast's syndrome as an initial symptom: a case report

Pancoast's syndrome refers to a condition consisting of Horner's syndrome and arm pain that is most commonly found in patients with a lung tumor of the superior sulcus invading the upper ribs or spine, lower brachial plexus and sympathetic chain. We report a 76-year-old female who had a thoracic inlet mass that presented as Pancoast's syndrome, showing profound pain, numbness and weakness of the left upper limb. Further evaluation revealed an increased level of serum alpha-fetoprotein (24278 ng/ml), cryptogenic liver cirrhosis and primary hepatocellular carcinoma with protruding T3 vertebra metastasis that resulted in Pancoast's syndrome. To our knowledge, it is a rare case and only one case has been reported previously.

Clinical experience in using polymerase chain reaction for rapid diagnosis of pulmonary tuberculosis

BACKGROUND

Polymerase chain reaction (PCR) techniques have revolutionized the diagnosis of tuberculosis (TB). PCR has significantly improved the sensitivity and specificity of existing diagnostic methods. In this study, we report our experience using a modified IS6110-based nested PCR assay for rapid diagnosis of pulmonary TB.

METHODS

A total of 327 respiratory specimens from 275 patients suspected of having pulmonary TB at Taipei Veterans General Hospital were tested using the nested PCR assay, acid-fast smear and culture for the presence of Mycobacterium tuberculosis complex (MTB). Nested PCR was performed with IS6110-based primers specific for MTB. We reviewed the medical records of patients and analyzed the clinical features. The PCR results were compared with the final clinical diagnosis.

RESULTS

We identified MTB in 167 of 327 samples by the nested PCR assay. No non-tuberculous Mycobacterium (NTM) was identified among the clinical samples. Diagnosis by PCR took about 6 hours in this study. The sensitivity and specificity compared with culture were 94.7% and 100%, respectively for the smear-positive, culture-positive samples, and 76.7% and 98.6% for the smear-negative, culture-positive samples. The overall sensitivity, specificity, positive and negative predictive values, compared with culture results, were 91.7%, 98.6%, 98.8% and 90.6%, respectively. Two specimens positive by PCR and negative by culture were taken from patients on anti-TB drug therapy. These specimens were culture-positive before anti-TB drug therapy. After resolution of the discrepancies by studying the patients' clinical data, both specificity and positive predictive value reached 100%.

CONCLUSIONS

The results indicated that this in-house nested PCR assay is a rapid and sensitive method for diagnosing pulmonary TB. It is also good for excluding infections caused by NTM.

[Regulation of cell cycle by retinoic acid in gastric cancer cells]

Retinoic acid can induce growth inhibition and apoptosis, and regulate cell cycle in many types of cancer cell lines. In this study, we investigated the role of all-trans retinoic acid (ATRA) and its mechanism of action in human gastric cancer cell lines. Our results demonstrated that ATRA effectively inhibited growth in three of four gastric cancer cell lines by induction of G0/G1 arrest, and did not induce apoptosis in four gastric cancer cell lines. In RA-sensitive cell lines, ATRA-induced G0/G1 arrest is associated with down regulaton of c-myc and hyperphosphorylated Rb expression, and up regulation of p21WAF1/CIP1 and p53 expression. There were no significant changes in cyclin D1 or CDK4 expression induced by ATRA. Futhermore, expression of these genes were not regulated by ATRA in ATRA-resistant gastric cancer cell line. These results indicate that growth inhibition, rather than apoptosis, is correlated with G0/G1 arrest of these cell lines, more important molecules related cell cycle, including c-myc, p21WAF1/CIP1, p53 and Rb, are involveed in regulation of cell cycle in gastric cancer cells.

Transcatheter closure of atrial septal defect guided by on-line transesophageal echocardiography

Transcatheter occlusion of secundum atrial septal defect has been tried since 1976. Some investigators have incorporated on-line transesophageal echocardiography so as to better monitor the procedure. Most, however, have used endotracheal intubation and general anesthesia. The aim of this study was to evaluate the feasibility of adjunct guidance using on-line transesophageal echocardiography without intubation and general anesthesia in adolescent or adult patients undergoing transcatheter occlusion of secundum atrial septal defects. Ten consecutive cases (age 15-68 years) of secundum atrial septal defects with a pulmonary to systemic flow ratio of > 1.5 and a balloon-stretched diameter of < or = 25 mm were enrolled in the study. The Sideris' buttoned devices were used. The procedure was guided by on-line transesophageal echocardiography and fluoroscopy. Endotracheal intubation and general anesthesia were not employed. The diameters of the atrial septal defects ranged from 6 to 19 mm as determined by transesophageal echocardiography, from 7 to 20 mm as determined by atrial angiography and from 11 to 25 mm as determined by balloon sizing. The Sideris' buttoned devices were successfully deployed in all the patients. On-line transesophageal echocardiography greatly facilitated balloon sizing, device development and immediate assessment. One device unbuttoned 24 hours after the procedure and was retrieved smoothly. The remaining 9 patients were followed-up for 12 months. Two patients had no shunt, 3 had a trivial (average diameter by transesophageal echocardiography = 1-3 mm) and 4 had a small (average diameter = 4-6 mm) residual shunt at the latest follow-up. The cardiothoracic ratios decreased from 0.52 +/- 0.06 to 0.48 +/- 0.06 (p = 0.0131). There was no mortality, stroke or device fracture during the follow-up period. Thus, transcatheter occlusion of secundum atrial septal defect under adjunct guidance using on-line transesophageal echocardiography without endotracheal intubation and general anesthesia is promising for selected patients.

The changing pattern of intestinal tuberculosis: 30 years' experience

SETTING

Although the incidence of tuberculosis had been decreasing for many years, it has recently risen.

OBJECTIVES

To investigate the changes in the pattern and distribution of intestinal tuberculosis and to alert surgeons to the importance of maintaining a high index of suspicion for this disease entity.

DESIGN

Retrospective analysis of 134 patients with intestinal tuberculosis discharged from the Veterans General Hospital in Taipei from 1965 to 1995. All records, bacteriological examinations and pathological specimens were reviewed and extracted onto a standard questionnaire.

RESULTS

A decline in the case numbers of intestinal tuberculosis was noted after 1975. However, there seems to be a slight rise in case numbers since 1990. The average age of those patients after 1990 (64.8 years) is higher than those before 1990 (44.4 years). None of our patients had clinical signs of human immunodeficiency virus (HIV) infection. Most patients (81.3%, 109/134) had not received a definite diagnosis until surgery. Active pulmonary tuberculosis was found in 37 patients (29.1%).

CONCLUSION

The possible reasons for the rise in cases of intestinal tuberculosis in our patients may be linked to an increased life expectancy, the reappearance of some formerly 'silent' tuberculosis cases, and relapse in patients having received incomplete antituberculosis chemotherapy. Its insidious and non-specific clinical presentation makes the diagnosis of intestinal tuberculosis difficult. An increased index of suspicion and greater familiarity with the disease may shorten the time of diagnosis and may also prevent some unnecessary operations.

Surgical closure of atrial septal defect. Minimally invasive cardiac surgery or median sternotomy?

BACKGROUND

Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions.

METHODS

We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure.

RESULTS

The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 +/- 12) and 14 to 158 min (27 +/- 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt.

CONCLUSION

Our results suggest that MICS is a good option for surgical closure of ASD.

PCR diagnosis on formalin-fixed, paraffin-embedded tissues with acid-fast stain and culture negativity in chronic dialysis patients of cervico-mediastinal tuberculous lymphadenitis

BACKGROUND

Bacteriologic studies often provide negative results in tuberculous infection, and do not favour early diagnosis. Polymerase chain reaction (PCR) is known to diagnose tuberculosis quickly. With this in mind, we used PCR to detect mycobacterial DNA on formalin-fixed, paraffin-embedded tissues with acid-fast stain and culture negativity in two dialysis patients with cervico-mediastinal lymphadenopathy.

METHODS

Sections of neck lymph nodes were cut at two different levels. At each level, two semi-adjacent sections with a thickness of 5 microm each were cut using standard microtomes with disposable blades. The first section mounted on a glass slide was stained by Ziehl-Neelsen, and the second section was examined by PCR based on a 123 bp fragment of IS6110 that is specific for the Mycobacterium tuberculosis complex.

RESULTS

The histology of lymph nodes disclosed inflammatory necrotizing granulomas, but acid-fast stain for M. tuberculosis was negative in the two patients. DNA of M. tuberculosis was detected in lymph node samples from each patient by PCR on the IS6110 element and by dot-blot hybridization.

CONCLUSIONS

PCR assay is a potentially useful approach for early and rapid diagnosis of tuberculous lymphadenitis in chronic dialysis patients, since mycobacterial staining and culture often provide negative results.

Video-assisted cardiac surgery: preliminary results in Chang Gung Memorial Hospital

OBJECTIVE

To summarize the experience of utilization of video-assisted endoscopy in 91 patients operated on at Chang Gung Memorial Hospital, Taipei, China.

METHODS

From October 1995, through August 1996, 91 patients (44 male and 47 female) received video-assisted cardiac surgery (VACS). Their ages ranged from 1 year to 79.5 years (25.7 +/- 21.7). Indications for surgery were atrial septal defect (59 patients), ventricular septal defect (15), coronary artery disease (4), severe mitral regurgitation (4), severe tricuspid regurgitation (3), thrombosis of mitral mechanical prosthesis (3), left atrial tumor (2), and left ventricular thrombus with dilated cardiomyopathy (1). The VACS was performed through right or left anterior minithoracotomy and guided by video-assisted endoscopic techniques by means of projected images on the video monitor under extracorporeal circulation. The aorta was not cross-clamped and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest (rectal temperature 22.6 +/- 4.0 degrees C). Conventional instruments were used.

RESULTS

All lesions were corrected successfully. The bypass time was 27 to 335 minutes (72.8 +/- 52.7). The operative time was 1.3 to 8.5 hours (3.0 +/- 1.7). There were no operative deaths and 3 late deaths. Follow-up was complete in all survivors (6 to 16 months, mean 8.7). Most of them were found to be in NYHA functional I or II.

CONCLUSION

Our preliminary experiences demonstrate that VACS is simple and effective in surgical correction of selected cardiac lesions. Short-term results show good outcomes.

Nonspecific and immune-specific up-regulation of cytokines in rabbit dermal tuberculous (BCG) lesions

To our knowledge, this is the first sequential study of cytokines in tissue sections of developing and healing tuberculous (BCG) lesions. In situ hybridization, immunohistochemical, and RT-PCR techniques were used. Cytokine mRNAs showed a biphasic pattern. The percentage of mononuclear cells (MN) containing IL-1beta, TNF-alpha, MCP-1, and IL-8 mRNAs was highest in 1- to 3-day lesions, apparently because of the nonspecific inflammatory response caused by the tubercle bacilli in the BCG vaccine. At 5 days, this percentage was significantly reduced. With IFN-gamma, the peak and trough were delayed by 2 days. By 9 days, the percentage of MN containing the mRNAs of all five cytokines had again increased and the rabbits had become tuberculin-positive. In general, MCP-1 and TNF-alpha proteins and the vascular adhesion molecules, ICAM, VCAM, and perhaps ELAM, peaked at about 3 days. Many mononuclear cells surrounding the central areas of solid and liquefied caseous necrosis contained chemokine IL-8 mRNA. IL-8 is known to attract PMN, and PMN were present nearby. In contrast, MN containing chemokine MCP-1 mRNA were present more peripherally in areas rich in macrophages and lymphocytes. The early nonspecific cytokine response seems to be an adjuvant effect of the mycobacteria in BCG vaccine in that it causes a rapid entry of macrophages, lymphocytes, granulocytes, and probably dendritic cells into local sites of antigen deposition. This effect should be considered in developing improved vaccines for the prevention of tuberculosis, because BCG vaccines producing a strong early cytokine response should be more immunogenic than BCG vaccines with similar antigens producing a weak response.

One-stage sternal stenting with homograft bone after cardiac operation in pediatric patients

Low cardiac output after open heart operations in neonates and infants carries a high mortality. Delayed sternal closure may be life-saving but may prolong hospital stay and increase costs. To circumvent these issues, we shaped homograft bone and interposed it between the sternal edges to allow primary wound closure in 2 pediatric patients. Midterm results are satisfactory.

Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach

BACKGROUND

Minimally invasive cardiac surgical techniques recently have been applied in the management of a variety of intracardiac lesions.

METHODS

Fourteen patients (6 boys and 8 girls; age, 8.9 +/- 5.5 years; body weight, 29.0 +/- 13.5 kg) were operated on using minimally invasive cardiac surgical techniques for the closure of a ventricular septal defect (subarterial in 11 patients and perimembranous in 3 patients). The operations were performed through a left anterior minithoracotomy and were guided by video-assisted endoscopic techniques under femorofemoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The right ventricular outflow tract was entered after pericardiotomy was performed.

RESULTS

Closure of the defect (directly in 4 patients and by patch in 10 patients) was performed successfully in all patients. A right ventricular outflow tract obstruction and ruptured sinus of Valsalva aneurysm also were repaired in 1 patient each. The duration of cardiopulmonary bypass was 41 +/- 10 minutes (range, 28 to 100 minutes) and the total operative time was 2.2 +/- 0.8 hours (range, 1.3 to 3.5 hours). All the patients recovered rapidly from their operation and had an uneventful postoperative course. Follow-up (mean, 6.2 months; range, 6 to 9 months) was complete in all patients. There were no late deaths. Transthoracic echocardiographic examination showed no residual shunt and no aortic regurgitation in all patients.

CONCLUSIONS

Our experience demonstrates that minimally invasive cardiac surgical techniques are technically feasible and an alternative option for the repair of a ventricular septal defect.

Drug resistance of Mycobacterium tuberculosis isolated from patients at a medical center in Taiwan

BACKGROUND

The advent of bactericidal drugs has had a major impact on the treatment of pulmonary tuberculosis. However, the main reasons for continuing tuberculosis prevalence are the resistance of mycobacteria and patients' lack of endurance to undergo the long-term therapy. In Taiwan, the prevalence of tuberculosis among the population of over 20-year olds has fallen from about 5.15% in 1957, to 0.88% in 1982, but then increased to 1.29% in 1987. Although it continued decreasing to 0.65% in 1994, tuberculosis remains a potential public health problem.

METHODS

To determine the temporal status of drug resistance pattern among the Mycobacterium tuberculosis (M. tuberculosis) isolated at Veterans General Hospital (VGH)-Taipei, analysis was undertaken of the drug susceptibility data reported by the central Mycobacterial Laboratory, using conventional indirect methods, between 1990 to 1992.

RESULTS

The susceptibility pattern of 651 M. tuberculosis isolates obtained from patients admitted to VGH-Taipei during 1990 to 1992 were analyzed; 504/651 (77.4%) were sensitive to all drugs tested. Among veterans, 23.7% (95/401) had organisms resistant to one or more antituberculosis medications: 11.5% (46/401) to a single drug; 6.2% (25/401) to two drugs; 3.2% (13/401) to three drugs, and 2.7% (11/401) to four drugs. The overall resistance rates in isolates from 250 non-veterans (142 males and 108 females) were 22.5% (32/142) in male patients and 18.5% (20/108) in female patients. Among the 142 male patients, 6.3% were resistant to a single drug; 3.5% to two; 7.7% to three and 4.9% to four drugs. Among 108 female patients, 8.3% to a single drug; 1.9% to two drugs; 2.8% to three drugs, and 5.6% to four drugs. The proportion of drug-resistance was higher in the isolates from patients with a history of previous therapy (p < 0.05). Overall, of the 401 veterans with positive cultures, 4.0% had isolates resistant to only isoniazid (INH), 14.7% had isolates resistant to at least INH, and 7.5% had isolates resistant to both INH and rifampin (RIF). Of the 142 non-veteran males, 1.4% had isolates resistant to only INH, 16.9% had isolates resistant to at least INH, and 10.6% had isolates resistant to both INH and RIF. Of the 108 non-veteran females, 3.7% had isolates resistant to only INH, 12.0% had isolates resistant to at least INH, and 8.3% had isolates resistant to both INH and RIF. Among the 401 veterans, all the drug resistant isolates were found in patients older than 45 years, and of these, 66.3% (63/95) were over 65 years, whereas age was not a significant factor for predicting resistance rates among the non-veteran patients.

CONCLUSIONS

There has been a marked increase in drug-resistant tuberculosis in old aged veterans. In contrast, age was not found to be a significant factor to predict resistance rates among the non-veterans. Previously treated patients are at increased risk for drug resistance. In view of these data, it is important to identify drug susceptibility patterns accurately from all tubercle bacilli isolated from patients as this has implications for control programs as well as for patient therapy. Surveillance of drug resistance is again being considered for patients admitted to this hospital, and all physicians are urged to remain alert to drug-resistance rates and patterns in the areas where they practice.

Unusual manifestations in children with Kawasaki disease

Between January 1983 and December 1992, the medical records of 187 patients (116 boys and 71 girls) with Kawasaki disease (KD) who were admitted to the hospital in the acute phase were retrospectively reviewed. Of these, 175 patients (93.6%) were under 4 years of age. Among the six principal symptoms of KD, the incidence of cervical lymphadenopathy (41.2%) was relatively low. Additionally, we found some unusual features including intussusception in a 4-month-old female, transient thrombocytopenia in seven children (3.7%) and isolated azotemia in five. KD is a systemic disease of unknown etiology. The diverse associated features make KD puzzling and difficult to diagnose. In caring for children with KD, physicians should be alert to the principal symptoms as well as the unusual associated manifestations.

Large bowel tuberculosis and possible influencing factors for surgical prognosis: 30 years' experience

The incidence of tuberculosis is rising in the United States. Similarly, the incidence of pulmonary tuberculosis in Taiwan is increasing, but that of large bowel tuberculosis in this region has not been reported. The purpose of this study was to investigate the changing disease pattern and to determine some possible surgical prognostic factors for large bowel tuberculosis. Seventy cases of large bowel tuberculosis treated at our institute during the period 1965-1995 were reviewed and analyzed. A steady decline in the case number of large bowel tuberculosis were noted from 1975, but there seems to be a slight increase in cases since 1990. The average age of these patients was 65.1 years, and none had human immunodeficiency virus infection. The ileocecum is the most common region of involvement. Of these 70 patients, 59 had not been definitively diagnosed until surgery. Active pulmonary tuberculosis was found in 18 patients (25.7%). The incidence of postoperative pulmonary complications was higher in patients with active pulmonary tuberculosis or disseminating large bowel tuberculosis. Postoperative abdominal complications, including intestinal obstruction, abdominal cutaneous fistula, and wound infection, were seen in 13 patients, none of whom had active pulmonary tuberculosis. Although the incidence of tuberculosis has been reduced for years, it is now rising. Physicians should bear in mind the possibility of large bowel tuberculosis in patients with intestinal obstruction without specific origin. Postoperative respiratory care is important for patients with pulmonary tuberculosis, with either active or disseminating lesions.

Endocarditis due to Neisseria sicca: report of one case

Many species of the Neisseria, which are respiratory commensals in humans, have been regarded as being nonpathogenic or as causing disease in only immunocompromised hosts. We report a case in which Neisseria sicca was the cause of infective endocarditis in a child with a ventricular septal defect and review the literature on endocarditis due to N. sicca infection. Most of these patients had an underlying heart disease. Dental caries and poor oral hygiene may be two factors that predispose patients to the infection. N. sicca endocarditis usually results in a subacute onset of symptoms and, if not diagnosed early and treated, is associated with a high rate of embolic complications.

Pulmonary vascular obstructive disease and hemoptysis in a child with tetralogy of Fallot and patent ductus arteriosus

Tetralogy of Fallot (TOF) and patent ductus arteriosus complicated by pulmonary vascular obstructive disease (PVOD) and hemoptysis in a 5-year-old girl are described. The echocardiogram was typical of TOF, as well as ductus arteriosus and right aortic arch. Cardiac catheterization revealed a pulmonary vascular resistance of 44 hybrid resistance units, and the pulmonary-to-systemic resistance ratio was 1.4. Diagnosis of PVOD was made by cardiac catheterization. Angiography revealed a bronchial artery arising from the left subclavian artery. PVOD itself, rupture of a bronchial artery or both, were considered the contributory causes of hemoptysis in this patient.

Video-assisted cardiac surgery in closure of atrial septal defect

BACKGROUND

Video-assisted endoscopy has been applied in the management of a variety of intrathoracic vascular lesions. Here we report its use in the correction of intracardiac congenital defects.

METHODS

Eight patients (3 male and 5 female) underwent operation for closure of an atrial septal defect. The patients ranged in age from 2.0 to 60.9 years (mean, 19.2 +/- 19.0 years). The patients weighed 11 to 66 kg (mean, 41.3 +/- 23.5 kg). The ratio of pulmonary blood flow to systemic blood flow ranged from 2.0 to 6.0 (mean, 3.4 +/- 1.3). The mean pulmonary artery pressure was 19.7 +/- 4.0 mm Hg (range, 13 to 24 mm Hg). The operations were performed through a right anterior minithoracotomy and guided by video-assisted endoscopic techniques under femorofemoral or femoral-right atrial extracorporeal circulation. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest (rectal temperature, 22.0 degrees +/- 2.0 degrees C). Transesophageal echocardiographic monitoring was maintained during the operations. The right atrium was entered after pericardiotomy. Primary closure of the defect was performed successfully in all patients. Conventional nondisposable instruments were used for dissection, grasping, suturing, and hemostasis.

RESULTS

The durations of extracorporeal circulation and operation ranged from 47 to 126 minutes (mean, 80 +/- 31 minutes) and from 2.2 to 4.5 hours (mean, 3.1 +/- 0.8), respectively. All patients recovered from the operation rapidly with an uneventful postoperative course.

CONCLUSIONS

Our experience demonstrates that video-assisted cardiac surgery is technically feasible and can be used with excellent results for the repair of congenital heart defects in general.

Successful intravenous streptokinase treatment of a child with Kawasaki disease complicated by acute myocardial infarction

A 9-year-old boy developed ischemic cardiac symptoms 1 year after he presented with Kawasaki disease. The myocardial infarction was confirmed by the typical changes of electrocardiograms, echocardiograms, cardiac enzymes, thallium myocardial scintigrams, and angiograms. With successful intravenous streptokinase therapy, he remained well during the following 4 months.

Aneurysm of the aortic sinus of Valsalva with reversed shunt of ductus arteriosus

A rare case of aneurysm of aortic sinus of Valsalva associated with patent ductus arteriosus and Eisenmenger's syndrome in a 7-yr-old boy is described. The diagnosis was made by echocardiography and cardiac angiography.

Non-hyperventilation respiratory therapy of persistent pulmonary hypertension of the newborn

Persistent pulmonary hypertension of the newborn (PPHN) is one of the most challenging situations in the neonatal intensive care nursery and it is associated with a high mortality rate. Hyperventilation therapy has been recommended as the primary ventilator management during recent decades. The associations of pulmonary barotrauma, chronic lung disease and hearing impairment raised the questions of significant pulmonary and neurological complications with this therapeutic modality. From July 1990 to April 1993, 14 cases of neonatal persistent pulmonary hypertension were treated with nonhyperventilation respiratory therapy at the Chang Gung Memorial Hospital. The goals of this therapy were to attain a pH level between 7.40 and 7.50, a PaO2 level between 60 and 90 mmHg and a PaCO2 level between 30 and 50 mmHg. High peak inflating pressure (> 35 cmH2O) and high ventilator rates (> 60/min) were avoided. The average duration on a ventilator was 6.8 +/- 2.9 days. Four patients had pulmonary barotrauma (29%); three of which were pulmonary interstitial emphysema and one pneumothorax. Three patients died (21%). Only one patient had neurological sequelae. No one had developed chronic lung disease. The non-hyperventilation approach for PPHN may be considered as an alternative ventilator management before starting a more aggressive hyperventilation therapy.

Serological evaluation for tuberculosis by antigen 60 IgG ELISA test

BACKGROUND

Tuberculosis remains a significant global health problem, especially among developing countries. It unfortunately results in high morbidity and mortality rates. This disease is also prevalent to a large extent in Taiwan. The traditional tuberculous tests, including the acid-fast smear and culture, have a limited activity in regard to extrapulmonary or smear-negative tuberculosis. A new testing is necessary to improve diagnosis of this disease.

METHODS

An enzyme-linked immunosorbent assay (ELISA) test for detection of serum IgG antibodies, based on Antigen 60, was applied to 146 subjects including 68 non-tuberculous cases and 78 tuberculous cases. A titer of less than 200 serounits was considered negative, and one of 200 or more serounits was thought positive.

RESULTS

In the healthy group, which included 5 newborns, 5 children and 20 healthy adults, 6.1% (2/30) showed positive results. Of the 15 hospital attendants, 60% (9/15) also displayed positive results. Nine of 17 cases (52.9%) with non-tuberculous pulmonary diseases had positive results. Among 6 cases with other diseases, the results were all negative. The false positive rate in non-tuberculous group was 29.4% (20/68). In 10 cases with inactive pulmonary tuberculosis, 30% (3/10) showed positive results. In 50 with active pulmonary tuberculosis, 88% (44/50) generated positive results. Effectual results were obtained in 66.7% (8/12) of the cases with extrapulmonary tuberculosis. Including 6 cases with mixed pulmonary and extrapulmonary tuberculosis, 83.3% (5/6) proved positive results. The positive rate in active tuberculous group was 83.8% (57/68).

CONCLUSIONS

The ELISA test, for detection of IgG antibody with Antigen 60, is helpful in improving the diagnosis of tuberculosis, especially in extrapulmonary tuberculosis.

Extralobar pulmonary sequestration presenting as an anterior mediastinal tumor in an adult

Extralobar pulmonary sequestration (EPS) is a rather uncommon congenital anomaly. Most patients are diagnosed in their early life or during the first decade because of the early appearance of symptoms, including feeding difficulty, cyanosis, and dyspnea, or because of symptoms arising from the associated congenital abnormalities. Extralobar pulmonary sequestration is more often found between the lower lobe and the diaphragm and is usually associated with other congenital abnormalities, but the case reported herein differs in these respects. In this report, an incidental finding of EPS is described in a 30-year-old Chinese man, where EPS presents as an anterior mediastinal mass roentgenographically. The mass was attached to the right suprahilar region by a fibrovascular pedicle which contained a small elastic artery, veins, and nerve bundles.

First alveolar-arterial oxygen gradient (AADO2) in mechanical ventilation as a predictor for duration of intubation in respiratory distress syndrome

From January 1988 to May 1992, 33 premature infants (inborn, gestational age less than 35 weeks), put on respirator therapy (before six hours of age) due to severe respiratory distress syndrome (RDS), were studied to examine if the first alveolar-arterial oxygen gradient (AaDO2) after initiating mechanical ventilation could be used as a predictor of intubation duration. They were divided into three groups: nine cases without associated diseases or severe complications who were successfully extubated (group I), 10 cases with associated diseases or severe complications who were successfully extubated (group II), and 14 cases where death occurred before extubation (group III). After intubation, the relationship between the first AaDO2 and the intubation duration thereafter was examined. A significant correlation between AaDO2 and the number of days of intubation was demonstrated only in group I (r = 0.93, p < 0.001). Among the groups, the means of the gestational ages, Apgar scores, data of the first arterial blood gas sample and ventilator settings after intubation, and AaDO2 were not statistically different. The results suggest that the first AaDO2 cannot be used to predict mortality and morbidity, but it can be used as a predictor of the number of days of intubation in surviving RDS infants without associated diseases or severe complications. If a surviving patient with RDS is not extubated by the expected date, one should search for possible associated diseases or severe complications.

Primary chylopericardium: report of a case

A 14-year-old girl was admitted due to exertional dyspnea of one month's duration. A grade 3/6 holosystolic murmur with distant heart sounds was heard at the left sternal border. Chest roentgenograms and echocardiograms showed a large amount of pericardial and left pleural effusion and a small perimembranous ventricular septal defect. Subxyphoid pericardial drainage and left pleural intubation were performed. The fluid from both sites was defined as chyle by the milky white appearance, presence of microscopic fat droplets and the lymphocyte predominance in the white cell count. Lymphangiograms and a chest computed tomographic scan demonstrated thoracic duct obstruction and leakage of contrast to pericardial and pleural spaces. The patient was treated with a medium chain triglyceride diet. Unfortunately, massive reaccumulation of the effusion was later noted. Therefore, a median sternotomy with ligation of the thoracic duct, creation of a posterior pericardio-pleural window and implantation of a left pleuro-peritoneal shunt with a Denver peritoneo-venous shunt were performed. Follow-up for one year with two-dimensional echocardiograms showed no more accumulation of the pericardial effusion.

Modified Fontan procedure for complex congenital heart disease

The Fontan procedure is frequently used for correction of complex congenital heart disease, but the postoperative morbidity and mortality rates are still high. The results in 35 consecutive patients who underwent the Fontan procedure from January 1980 to June 1991 are reviewed. The patients comprised 26 boys and nine girls aged from 1.7 to 14.8 (mean 6.8) years. The underlying diseases were univentricular heart (19 patients), tricuspid atresia (eight), complete atrioventricular canal (three patients, two of whom had straddling atrioventricular valve) and other conditions (five). Valved conduits were implanted in four patients and non-valved in 15. Direct right atrium-pulmonary artery anastomosis was performed in 16 patients. The overall hospital mortality rate was 23% (eight patients); in the final year of the review it was 11%. Follow-up of the survivors ranged from 1 to 120 (mean 25) months. All except two patients attained New York Heart Association functional class I or II. Three patients underwent reoperation for atrioventricular valve regurgitation and conduit stenosis with good results. It is concluded that the Fontan procedure is a good palliative operation for complex congenital heart disease.

Chest roentgenographic guidelines in the selection of patients for fiberoptic bronchoscopy

We conducted this study to define the value of fiberoptic bronchoscopy (FOB) in the evaluation of chest radiographic abnormalities and to provide guidelines for fiberoptic bronchoscopy on the basis of chest radiographic appearances. Fiberoptic bronchoscopy without fluoroscopy was carried out in 530 patients, 455 male and 75 female, aged 19 to 85 years, during a 1-year period at Chest Department, Veterans General Hospital, Taipei. Of 530 patients, 19 (3.6 percent) had normal chest radiographs, and the remaining 511 (96.4 percent) patients had abnormal chest radiographs. Overall diagnostic yield of FOB was 55.4 percent in patients with abnormal chest radiographs and 52.6 percent in patients with normal chest radiographs. On the basis of radiographic findings, patients with lobar collapse (87.0 percent), hilar abnormalities (81.8 percent), pericardial effusions (66.7 percent), mass lesions (> 4 cm) (65.7 percent), and pleural effusions (64.9 percent) were most frequent to obtain a positive diagnosis via bronchoscopy (p < 0.001). Of 530 patients; mass lesion was the most frequent abnormality on bronchoscopy and had the highest incidence of providing a positive diagnosis (36.2 percent) (p < 0.001). A predilection of mass lesion on bronchoscopy was seen for chest radiographic features of lobar collapse (64.8 percent) and mass (> 4 cm) (47.0 percent) (p < 0.001). Of 19 patients with normal chest radiographs, a correct diagnosis was made in 4 (21.1 percent) with bronchoscopic findings of mass lesions, 3 (15.8 percent) with endobronchial abnormalities, and 3 (15.8 percent) patients with abnormal bronchial mucosa. Indeed, the decision to perform bronchoscopy should be guided by many factors other than chest radiograph. In this study, however, emphasis has been placed on the incidence of positive diagnosis via bronchoscopy on the basis of chest radiographic patterns. In this respect, we believe that in patient with lobar collapse, hilar abnormality, pericardial effusion, mass lesion (> 4 cm), and pleural effusion on the chest radiograph bronchoscopy should be considered.

Arterial switch operation in a neonate with simple transposition of great arteries

Transposition of the great arteries (TGA) is characterized by severe and life-threatening hypoxemia during a newborn period. Without treatment, most of the patients die during early infancy. We reported a 20-day-old male newborn who was referred to our hospital due to severe cyanosis and respiratory distress. Echocardiograms revealed D-TGA with an intact ventricular septum. There was no pulmonary stenosis or other major cardiac anomalies. The cardiac catheterization and angiographic findings which were performed 4 days later were consistent with the diagnosis of echocardiography. The systolic left and right ventricular pressures were 65 and 69 mmHg respectively. Arterial switch operation was performed at the age of 28 days. Postoperative course was uneventful. The cardiac recatheterization and angiographic study performed 6 months after operation, and the latest non-invasive examination including chest X-ray, electrocardiogram and echocardiographic assessment revealed good ventricular performance and normal semilunar valve function. There was no obstruction at the anastomotic site. The patient has been doing well with regular follow-up at our clinic for 2 years and 6 months without medication.

Lymph node tuberculosis: 7-year experience in Veterans General Hospital, Taipei, Taiwan

We retrospectively studied 71 cases of lymph node tuberculosis confirmed by culture or pathology from 1983 to 1989. Young adults were most frequently involved and the female to male ratio was 3:2. of 71 patients, three-quarters presented with palpable masses and two-thirds were asymptomatic. The cervical nodes were most frequently involved. Roentgenographic evidence of pulmonary tuberculosis was detected in 42% of patients and sputum culture-positive tuberculosis occurred in 7%. Tuberculin skin testing is less useful in our country due to routine BCG vaccination during infancy and early childhood. Selective excisional biopsy in addition to clinical information was necessary for differential diagnosis. 48 patients received regular treatment and were followed up for at least 1 year. Fresh nodes or enlargement of existing nodes developed in 10% of patients during treatment. Residual nodes were present in 10% of patients at the end of 9-month treatment with rifampicin, isoniazid and ethambutol, including prolonged or modified regimens in some individuals. In conclusion, in areas with a high frequency of tuberculous strains presenting a primary resistance to isoniazid, a 9-month regimen of rifampicin, isoniazid and ethambutol is recommended for lymph node tuberculosis.

[Anaphylactic shock after readministration of rifampicin: a case report]

Many reports have shown that rifampicin could induce a variety of adverse effects. However, anaphylactic shock occurring after readministration of rifampicin, to our knowledge, has not been reported thoughtfully. Herein we present a case with anaphylactic shock after readministration of rifampicin. The possible mechanism may be the interaction between IgE antibody and mast cell or basophils. Compared with continuous regimen, intermittent rifampicin regimen has longer interval to accumulate more rifampicin-induced antibodies, and more immunogenic side effects are the sequelae when re-encountered with rifampicin.

Takayasu's arteritis with aortoaortic bypass graft and renal autotransplantation: report of one case

Takayasu's arteritis is a rare inflammatory disease of the aorta and its major branches which occurs predominantly in young women. The clinical course has been described as two stages: 1) initial phase, with inflammatory process and systemic manifestations; and later 2) pulseless phase, with multiple arterial occlusions. A 20-year-old female came to visit this hospital for the first time at 10 years of age with occlusion of the left subclavian artery and of the thoracoabdominal aorta. Aortoaortic bypass surgery was performed using a 14 mm woven graft from the ascending aorta to the descending aorta on the infrarenal portion. The postoperative course was uneventful. Exertional dyspnea and hypertension progressively developed. However, in the past year, angiograms have shown a marked stenosis on the proximal portion of the left renal artery. Autotransplantation for the left-sided kidney was performed. The patient did well, and remained free of symptoms until this time of writing, 12 months after the operation.

Multiple cerebral aneurysms in a child with cardiac myxoma

Neurologic involvement is not uncommon in cardiac myxoma, yet its association with multiple cerebral aneurysms is rare, especially in children. We describe a patient with left atrial and ventricular myxoma, who otherwise lacked cardiac symptomatology and did not exhibit auscultatory, roentgenologic, or electro-cardiographic evidence of heart disease. The clinical presentation was a sudden attack of a cerebrovascular occlusive disorder. Multiple fusiform aneurysms at the frontal and parietal branches of the left anterior and middle cerebral arteries were demonstrated on cerebral angiograms. The myxomas were surgically removed and the patient improved.

Effects of antibiotics and other drugs on toxin production in Clostridium difficile in vitro and in vivo

In an attempt to understand more completely why patients treated with phenothiazines (chlorpromazine and cyamemazine), methotrexate, and certain antibiotics such as clindamycin have an increased risk of developing pseudomembranous colitis, the production of toxins A and B by Clostridium difficile in the presence of these drugs was measured in vitro as well as in vivo by using axenic mice. None of the drugs tested increased the production of toxins either in vitro or in vivo.

Effects of granulocyte-macrophage colony-stimulating factor and interleukin 6 on the growth of leukemic blasts in suspension culture

We examined the stimulatory effects of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin 6 (IL)-6 on the in vitro proliferation of leukemic blast cells from patients with acute leukemia. Bone marrow or peripheral blood leukemic blast cells were obtained from 21 patients, including 14 cases of acute myeloblastic leukemia (AML), four cases of acute lymphoblastic leukemia (ALL), two cases of acute undifferentiated leukemia, and one case of acute mixed-lineage leukemia. The proliferation of leukemic blast cells was evaluated by measuring the incorporation of 3H-thymidine into cells incubated with various concentrations of cytokines for 3 days. GM-CSF stimulated the DNA synthesis (with greater than 2.0 stimulation index) of blast cells in 9 of 14 (64%) AML cases, two cases of acute undifferentiated leukemia and one case of acute mixed-lineage leukemia. Only two cases of AML blasts responded to IL-6 to grow in the short-term suspension cultures. GM-CSF and IL-6 did not display a synergistic effect on the growth of leukemic cells. Moreover, GM-CSF and IL-6 did not stimulate the proliferation of ALL blast cells. Binding study also revealed the specific binding of GM-CSF on the blast cells of acute undifferentiated leukemia and acute mixed-lineage leukemia. Our results indicated that leukemic blast cells of acute undifferentiated leukemia and acute mixed-lineage leukemia possessed functional GM-CSF receptors.

Genetic and molecular analysis of pIP417 and pIP419: Bacteroides plasmids encoding 5-nitroimidazole resistance

This report describes a genetic and molecular analysis of two transferable Bacteroides plasmids, pIP417 and pIP419, which carry genetic determinants conferring low-level resistance to 5-nitroimidazoles. The restriction endonuclease cleavage sites for each plasmid were localized. The NiR genetic determinants of pIP417 and pIP419 plasmids have been cloned into the Bacteroides cloning vector pBI191 (C.J. Smith, J. Bacteriol. 164, 294-301, 1985) as PvuII and Sau3A fragments, respectively. Both inserts had different restriction sites and did not cross-hybridize by Southern blot analysis. Genetic data obtained by cloning into pBI191 clearly show that the PvuII-generated fragments A (Rep) and B (Mob) of pIP417 are involved in plasmid replication and transfer, respectively. Although encoding resistance to the same antibiotic, both plasmids appeared different with regard to the 5-nitroimidazole resistance and replication genetic determinants. However, they share a homology in a region involved, at least in one case, in plasmid transfer. Considering the spontaneous high level of resistance to 5-nitroimidazole in Escherichia coli, this work, based on direct gene cloning into Bacteroides, demonstrates the value of such an approach.

Results of Senning operation for transposition of great arteries

We report our results with 10 infants and children who underwent atrial repair using the Senning operation between 1985 and 1990. All cases had abdominal situs solitus, levocardia and atrio-ventricular concordance (D-bulboventricular loop). Nine patients had simple D-transposition of the great arteries without ventricular septal defects (VSD) or left ventricular outflow tract obstruction. The other patient had a double outlet right ventricle with subpulmonic VSD and pulmonary hypertension (PHT) and underwent a palliative Senning procedure. All patients had a balloon atrial septostomy (BAS) before surgery, except for one with Taussig-Bing syndrome. One patient had a Blalock-Hanlon operation after BAS. The age at the time of surgery ranged from two months to four years seven months (mean: 22 months) and weight ranged from 4.3-12 kg. There were two hospital mortalities including the patient with VSD and PHT. All of the patients had echocardiographic examinations and six of the eight survivors received cardiac recatheterization four to 19 months (mean: 7.4 months) postoperatively. No baffle leaks were noted in the survivors. Two patients had both mild tricuspid regurgitation and slightly decreased right ventricular contractility, and one patient had a pressure gradient of 6 mmHg between the superior vena cava and neo-right atrium. The clinical follow-up interval was eight to 64 months (mean: 31.4 months). All survivors showed a sinus rhythm on their latest electrocardiogram and were participating in normal daily activities without medication.

Clinical and hemodynamic results after Fontan operation

Twenty-six patients, ranging in age from 2 to 14 years (mean, 6 years and 8 months), with tricuspid atresia or other complex cyanotic cardiac diseases underwent a modified Fontan operation between 1980 and 1990. In 13 patients, palliative operations had been previously performed. There were 7 mortalities within 1 month after the operation. Seventeen of the 19 survivors were followed up for 5-122 months (mean, 27) with no late deaths. Fifteen patients were in the New York Heart Association functional class 1. Two patients required reoperations at 2 and 57 months postoperatively: the former for atrio-ventricular valvular regurgitation, and the latter for late-developing conduit obstruction and residual atrial right to left shunting. Fourteen patients underwent cardiac catheterization after 1-57 months (mean, 9.8) postoperatively. Two patients had a residual right to left shunt at the atrial level, while the oxygen saturation in the remaining 12 patients was above 90%. Thus, the modified Fontan operation offers an alternate surgical approach for patients with complex congenital heart disease for whom no other palliative procedure can be expected to obtain significant improvement. It can be performed with good clinical and hemodynamic results in selected patients.