A comparison of effectiveness and cost between two models of care for individuals with schizophrenia living in Taiwan

Schizophrenia is a chronic disease that places tremendous costs and burden on patients, families, and communities. The purpose of this study was to compare the cost and effectiveness of a hospital-based home care model and a traditional community care model for schizophrenia in Taiwan using six principles of cost-effectiveness analysis. Based on the health care provider's analytic perspective, four effectiveness indicators and four service costs were identified and measured, and the ratio of average cost value to effectiveness score for each patient was calculated. According to that ratio, the hospital-based home care model was more cost-effective. The results suggest that the hospital-based outreach home care model is a cost-effective way to care for patients and their family in the community.

Ceramide inhibits the inwardly rectifying potassium current in GH(3) lactotrophs

The effects of ceramide on ion currents in rat pituitary GH(3) cells were investigated. Hyperpolarization-elicited K(+) currents present in GH(3) cells were studied to determine the effect of ceramide and other related compounds on the inwardly rectifying K(+) current (I(K(IR))). Ceramide (C(2)-ceramide) suppressed the amplitude of I(K(IR)) in a concentration-dependent manner, with an IC(50) value of 5 microM. Ceramide caused a rightward shift in the midpoint for the activation curve of I(K(IR)). Pretreatment with PD-98059 (30 microM) or U-0126 (30 microM) did not prevent ceramide-mediated inhibition of I(K(IR)). However, the magnitude of ceramide-induced inhibition of I(K(IR)) was attenuated in GH(3) cells preincubated with dithiothreitol (10 microM). TNF alpha (100 ng/g) also suppressed I(K(IR)). In the inside-out configuration, application of ceramide (30 microM) to the bath slightly suppressed the activity of large conductance Ca(2+)-activated K(+) channels. Under the current clamp mode, ceramide (10 microM) increased the firing of action potentials. Cells that exhibited an irregular firing pattern were converted to those displaying a regular firing pattern after application of ceramide (10 microM). Ceramide also suppressed I(K(IR)) in neuroblastoma IMR-32 cells. Therefore, ceramide can produce a depressant effect on I(K(IR)). The blockade of this current by ceramide may affect cell function.

Families of Chinese children with malignancy: the factors impact on mother's anxiety

This study examines the impact of the stress experienced by mothers during a child's cancer treatment. A descriptive correlation study has been designed to examine the relationships between uncertainty, sense of mastery, boundary ambiguity, and anxiety. The sample consists of 100 mothers recruited in two teaching hospitals in Taiwan. The sense of mastery was found to act as a mediator between uncertainty and anxiety, whereas uncertainty was a good predictor of boundary ambiguity. The first 2 months of treatment and the incidence of cancer recurrence represented a significant special experience for mothers. Nursing intervention to improve the mothers' sense of mastery and to assist families in establishing functional patterns of parent-child interaction is discussed.

Prolonged fractionation of paced right atrial electrograms in patients with atrial flutter and fibrillation

OBJECTIVES

This study investigated the extent of fractionation of paced right atrial electrograms in patients with and without paroxysmal atrial flutter (AFL) or atrial fibrillation (AF).

BACKGROUND

Slow conduction through nonuniform anisotropic atrial muscles, represented by fractionated electrograms, may favor the generation of atrial tachyarrhythmias.

METHODS

This study included 10 control patients (Group 1), 8 patients with documented paroxysmal AFL (Group 2) and 10 patients with documented paroxysmal AF (Group 3). Five electrode catheters were placed in the different sites of the right atrium and one catheter was positioned at the coronary sinus ostium. Atrial pacing from one site was done by a constant drive train with an extrastimulus inserted every fourth beat while recording at the other five sites was performed. The delay of each fractionated potential in the high-pass filtered atrial electrogram in response to extrastimulation was determined and used to construct conduction curves of delay versus the S1S2 interval.

RESULTS

The mean increase in electrogram duration between a coupling interval of 350 ms and 10 ms above atrial refractoriness was significantly greater in Groups 2 and 3 compared with that in Group 1 (8.5 +/- 2.5 vs. 11.0 +/- 2.7 vs. 5.9 +/- 2.3 ms, respectively, p < 0.001). The mean S1S2 interval at which delay increased suddenly was also longer in Groups 2 and 3 compared with Group 1 (326 +/- 9 vs. 343 +/- 12 vs. 307 +/- 17 ms, respectively, p < 0.001).

CONCLUSIONS

Increased delays in the individual potential of the fractionated atrial electrograms may be related to the development of AFL and AF.

Abnormal cardiovascular reflex tests are predictors of mortality in Type 2 diabetes mellitus

AIMS

To determine whether diabetic autonomic neuropathy is an important factor contributing to mortality in Type 2 diabetes mellitus.

METHODS

Between 1989 and 1993, 431 men and 181 women with Type 2 diabetes were given diabetic autonomic neuropathy cardiovascular reflex (CVR) tests. These subjects were followed for the subsequent 5--9 years to assess mortality rates.

RESULTS

The prevalence rate of abnormal CVR tests was 46.1% in patients with the history of diabetes less than 5 years and up to 69.4% when the history of diabetes exceeded 20 years. During the follow-up period from 1 January 1989 to 31 December 1997 (mean 7.7 years), a total of 135 participants died. The 8-year survival rate for patients with abnormal CVR tests was 63.6% in males and 76.4% in females, compared with 80.9 and 93.3% for patients with normal CVR tests. The results were grouped as: group 1, normal CVR tests without postural hypotension (PHT); group 2, normal CVR tests with PHT; group 3, abnormal CVR tests without PHT; and group 4, abnormal CVR tests with PHT. The 8-year survival rate was 85.4% in group 1, 80.9% in group 2, 74.5% in group 3 and 61.1% in group 4.

CONCLUSION

Type 2 diabetic patients with abnormal CVR tests may have increased mortality, and those combined with postural hypotension have higher mortality than those without. Abnormal CVR tests may be important predictors of mortality in Type 2 diabetes mellitus.

Ventilator-associated pneumonia with circuit changes every 2 days versus every week

BACKGROUND

Frequent ventilator circuit changes are expensive and sometimes unnecessary. Following the worldwide trend to lengthen the intervals for ventilator circuit change from 2 days to 1 week, this study aims to assure that low rate of ventilator-associated pneumonia (VAP) can be maintained with cost containment.

METHODS

Ventilator circuits were routinely changed every 7 days in the study period for 2 years and every 2 days during the historical control period of another 2 years. Pediatric patients (age less than 15 years) were not included. Nosocomial pneumonia was diagnosed by the criteria of the Centers of Disease Control and Prevention (CDC) of the United States (US). VAP was identified by combining and comparing 2 databases from the Respiratory Therapy Department and the Infection Control Unit of our hospital.

RESULTS

In the study group, 225 episodes of pneumonias were observed in 7,068 patients and 87,338 ventilator days. The rate of VAP was 2.58 per 1,000 ventilator days. There were 174 episodes of pneumonia in 6,213 patients and 65,467 ventilator days of the control group. The rate of VAP was 2.66 per 1,000 ventilator days. The difference between both groups was not significant (p = 0.803). Yet, the cost curbed was around 80,000 US dollars per year.

CONCLUSIONS

Extending ventilator circuit change interval from 2 days to 7 days do not increase the risk for VAP, but the cost savings for labor and supply are substantial.

Using buffy coat for reverse transcriptase-polymerase chain reaction in the diagnosis of dengue virus infection: preliminary study

Using reverse transcriptase-polymerase chain reaction (RT-PCR) to detect and type from viremic human serum samples for dengue virus infection is widely used today. However, a few false-negative results were reported due to very low titers of the virus particle in serum samples. As mononuclear cells, macrophages or monocytes are target cells for dengue virus infection, and the replication of virions can be observed in peripheral leukocytes frequently, the amount of virus particle in buffy coat should be higher than those in serum samples. Here, we describe a procedure in which RNA extraction from the buffy coat of a patient with a false-negative serum sample yielded specific viral RNA amplifiable by RT-PCR, thereby providing an alternative choice for the accurate diagnosis of dengue infection.

A 5-year study of the seroepidemiology of Klebsiella pneumoniae: high prevalence of capsular serotype K1 in Taiwan and implication for vaccine efficacy

Seroepidemiology of Klebsiella pneumoniae was determined for 1000 nonrepetitive K. pneumoniae isolates collected by a medical center in Taiwan during 1993-1997. Of these, 630 isolates (63%) were from community-acquired infections; the rest were from hospital-acquired infections. The isolates were serotyped according to capsular antigen by countercurrent immunoelectrophoresis. About 77% were typeable. Serotypes K1 and K2 accounted for 21.7% and 9.3% of the isolates, respectively, followed by K57 (5.1%), K54 (4.2%), K21 (3. 3%), and K16 (3%). The frequency of serotype K1 among bacteremic isolates (30.8%) far exceeded that reported by other investigators worldwide. Molecular typing of random K1 isolates by pulsed-field gel electrophoresis revealed several different pulsotypes, suggesting a nonclonal spread. This study indicates that a Klebsiella vaccine developed in Europe is not optimal for use in Taiwan because it does not contain the most predominant serotypes-K1, K54, and K57.

Meropenem versus imipenem/cilastatin in the treatment of sepsis in Chinese patients

BACKGROUND

Meropenem and imipenem are beta-lactam antibiotics of the carbapenem group. Carbapenems have bactericidal activity against a broad spectrum of bacteria, including most gram-positive cocci, gram-negative bacilli and anaerobes. Experience in using meropenem in Chinese patients has not been previously reported.

METHODS

Meropenem (2 g daily) and imipenem/cilastatin (2 g daily) were compared in an open, randomized, prospective study on the treatment of hospitalized Chinese septic patients. All participants (male or female) were hospitalized with a diagnosis of sepsis. All patients were randomly allocated to one of the two treatment groups: the meropenem group or the imipenem/cilastatin group. Clinical status was evaluated daily during treatment and at the end of therapy or when treatment was withdrawn. Patients were checked every day for potential side-effects, according to subjective and objective symptoms.

RESULTS

Fifty-three patients were enrolled in the study; 50 were evaluated for clinical efficacy and 27 patients were evaluated for bacteriologic efficacy. The most frequent clinical diagnoses were pneumonia and urinary tract infection. The predominant pathogens were Pseudomonas aeruginosa, Escherichia coli and Enterobacter cloacae. There were 31 pathogens isolated from 27 patients. A single pathogen was identified in 23 patients, and two pathogens were isolated from four patients. Satisfactory clinical outcome (excellent and good) was 84% in the meropenem group and 76% in the imipenem/cilastatin group. Satisfactory bacteriologic response was 80% in the meropenem group and 75% in the imipenem/cilastatin group. Transiently elevated liver enzymes were the most common side-effect. One patient treated with imipenem/cilastatin experienced a seizure during the study, while another patient treated with meropenem withdrew due to urticaria.

CONCLUSIONS

The efficacy and safety data presented in this report indicate that meropenem was well tolerated and appeared to be as effective as standard monotherapy with imipenem in bacteremic patients. Meropenem and imipenem/cilastatin were highly effective for the treatment of bacteremia in Chinese patients and only mild or negligible side-effects were noted.

Treatment of mastalgia with tamoxifen in male patients with liver cirrhosis: a randomized crossover study

OBJECTIVE

Mastalgia is occasionally found in patients with liver cirrhosis, especially in those receiving spironolactone for treatment of ascites. The pathogenesis is still unclear. Estrogen excess in cirrhotic patients and estrogenic effects of the spironolactone are possible leading causes. Treatment directed against the preponderance of estrogenic stimulation in these patients has never been investigated. This study was designed to investigate the efficacy and safety of tamoxifen, an estrogen antagonist, on mastalgia in patients with liver cirrhosis.

METHODS

A total of 16 male cirrhotic patients with mastalgia were randomly assigned to two groups. One group was treated with tamoxifen (20 mg p.o., b.i.d.) for 1 month, followed by placebo for the next month. The other group was treated in the reverse order. All patients received spironolactone for ascites and/or peripheral edema, and the drug was continued during the study period. The size of the breasts and the degree of breast pain and tenderness were recorded in all subjects before and after the treatment periods. Serum levels of estradiol and testosterone were measured using the radioimmunoassay method.

RESULTS

Of the 16 patients, 14 experienced a decrease or disappearance of the breast pain and/or tenderness during the tamoxifen treatment period, whereas only two of the 16 patients felt an improvement during the placebo period (p < 0.05). There were significant improvements in the breast pain and tenderness scores and decreases in the breast sizes during the tamoxifen treatment period (before vs after: 1.4+/-0.3 vs 0.4+/-0.2, p = 0.002; 1.9+/-0.2 vs 0.5+/-0.2, p < 0.001; and 6.8+/-0.6 vs 5.5+/-0.6 cm, p = 0.02, respectively), whereas no obvious change was seen during the placebo period. Serum levels of estradiol and testosterone did not change significantly after the tamoxifen or placebo treatments (p > 0.05). No major side effects were noted during the therapeutic periods.

CONCLUSIONS

Tamoxifen is effective and safe in the management of mastalgia in male cirrhotic patients taking spironolactone.

Antimicrobial resistance of Streptococcus pneumoniae isolated in Taiwan: an island-wide surveillance study between 1996 and 1997

Between August 1996 and July 1997, 550 clinically significant Streptococcus pneumoniae isolates were collected from 14 geographically separate laboratories in Taiwan. These isolates were serotyped and MICs were determined by agar dilution. Among serotypes covered by the 23-valent vaccine, types 19F, 19A, 23F, 23A and 6B dominated, comprising 255 isolates; among non-vaccine serotypes, types 35, 39, 34, 13 and 31 dominated, comprising 118 isolates. Of the 550 isolates, 310 (56.4%) were resistant to penicillin G (MIC 0. 12 mg/L), 238 (43.3%) with intermediate resistance (MIC 0.12-1 mg/L) and 72 (13.1%) with high-level resistance (MIC 2 mg/L). Most non-susceptible pneumococci were of serotypes 19F and 23F; non-susceptible isolates of these serotypes were distributed across all of Taiwan. Fourteen other antibiotics were tested; 83% of the isolates were resistant to tetracycline, 78% to azithromycin, 74% to erythromycin, 54% to clindamycin and 23% to chloramphenicol. Thus, macrolides can no longer be used as first line agents to treat pneumococcal infections in Taiwan. Multi-resistance (isolates resistant to three or more chemically unrelated antibiotics) was found in each serotype or group, but mostly in types 19F and 23F. The emergence of such strains complicates antibiotic selection, but both types are covered by the 23-valent vaccine, as were 82% of the isolates from blood and eight of the nine from cerebrospinal fluid. Good antibiotic control and appropriate use of this vaccine may improve the current problem in Taiwan, especially for the elderly.

The rebleeding course and long-term outcome of esophageal variceal hemorrhage after ligation: comparison with sclerotherapy

BACKGROUND

Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation and compare it with that after sclerotherapy.

METHODS

One hundred and eighty-five liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were randomized to undergo endoscopic variceal sclerotherapy or ligation. These patients received regular follow-up and detailed clinical assessment.

RESULTS

Two patients developed hepatoma within 6 months of entry in each group and were excluded. Another six patients in the sclerotherapy group and seven patients in the ligation group were excluded because of poor compliance or lost to follow-up. Therefore, 84 patients in each group were analyzed. In this long-term follow-up (55.3 +/- 12.5 months) the rebleeding rate for ligation was lower than that for sclerotherapy, regardless of whether the rebleeding was analyzed by patient number or Kaplan-Meier analysis. With regard to the rebleeding risk of various periods, the sclerotherapy risk was higher than that of ligation within 4 weeks of the initial endoscopic treatment or before variceal eradication. Multifactorial analysis showed hematemesis, poor hepatic function, and sclerotherapy were the risk factors determining rebleeding. The annual hepatocellular carcinoma incidence was 4.9%. There was no difference in survival between sclerotherapy and ligation. Multifactorial analysis showed that poor hepatic function was the only factor determining survival.

CONCLUSIONS

The rebleeding risk was higher in sclerotherapy than in ligation before variceal eradication, especially within 4 weeks of the initial endoscopic treatment. Long-term survival was dependent on hepatic reserve regardless of the treatment method.

Nosocomial gram-negative bacteremia in critically ill patients: epidemiologic characteristics and prognostic factors in 147 episodes

Although gram-positive organisms are the most common causes of nosocomial bloodstream infections, gram-negative bacteremia carries higher risks of severe sepsis, septic shock, and death among critically ill patients in intensive care units (ICUs). We performed a prospective epidemiologic analysis of nosocomial gram-negative bacteremia episodes among ICU patients and sought to identify risk factors for mortality among these patients. All episodes of nosocomial gram-negative bacteremia documented in five ICU wards of our hospital during a 2-year period were included. There were 147 episodes (124 patients) of gram-negative bacteremia documented during the study period. The overall mortality rate was 36.1%, and 77.4% of all deaths were directly related to the bloodstream infection. Gram-negative bacteremia was associated with prolonged ICU stay (45.7 d vs 6.1 d for all ICU patients). The most common isolate was Acinetobacter baumannii, followed by Burkholderia cepacia and Enterobacter cloacae. The most frequent source of infection was the lower respiratory tract (32.0%). Of the agents tested, ciprofloxacin, imipenem, and ceftazidime were the most active against the clinical isolates. Multivariate logistic regression analysis identified the presence of septic shock (odds ratio, OR = 17.66, p < 0.001) and rapidly fatal and ultimately fatal underlying conditions (OR = 3.47, p = 0.032) as being independent risk factors for mortality. Early appropriate antibiotic treatment did not result in significant improvement in survival. These findings suggest that prevention of lower respiratory tract colonization and nosocomial pneumonia are crucial for reducing the incidence of nosocomial gram-negative bacteremia in the ICU. Serious underlying illnesses and septic shock were the most important risk factors for death in these patients.

Intravenous ascorbic acid as an adjuvant therapy for recombinant erythropoietin in hemodialysis patients with hyperferritinemia

BACKGROUND

Inadequate iron mobilization and defective iron utilization may cause recombinant erythropoietin (rEPO) hyporesponsiveness in hemodialysis (HD) patients with iron overload. We have demonstrated that intravenous ascorbic acid (IVAA), but not intravenous iron medication, can effectively circumvent the functional iron-deficient erythropoiesis associated with iron overload in HD patients. However, it is uncertain whether all HD patients with hyperferritinemia will consistently respond to IVAA and which index may indicate functional iron deficiency in the special entity. Therefore, a prospective study was conducted to establish the guidelines for IVAA adjuvant therapy.

METHODS

Sixty-five HD patients with serum ferritin levels of more than 500 microgram/liter were recruited and divided into the control (N = 19) and IVAA (N = 46) groups. IVAA patients with a hematocrit (Hct) of less than 30% received 300 mg of ascorbic acid three times per week for eight weeks. Controls had a Hct of more than 30% and did not receive the adjuvant therapy. Red blood cell and reticulocyte counts, iron metabolism indices, erythrocyte zinc protoporphyrin (E-ZPP), and the concentrations of plasma ascorbate and oxalate were examined before and following the therapy.

RESULTS

Thirteen patients (four controls and nine IVAA patients) withdrew by the end of the study. Eighteen patients had a dramatic response to IVAA with a significant increase in their hemoglobin and reticulocyte index and a concomitant 24% reduction in rEPO dose after eight weeks. This paralleled a significant rise in serum iron and transferrin saturation (TS) and a fall in E-ZPP and serum ferritin (baselines vs. 8 weeks, serum iron 68 +/- 37 vs. 124 +/- 64 microgram/dl, TS 27 +/- 10 vs. 48 +/- 19%, E-ZPP 123 +/- 44 vs. 70 +/- 13 micromol/mol heme, and serum ferritin 816 +/- 435 vs. 587 +/- 323 microgram/liter, P < 0. 05). Compared with responders, mean values of hemoglobin, rEPO dose, iron metabolism parameters, and E-ZPP showed no significant changes in controls (N = 15) and in non-responders (N = 19). Thirty-seven patients (18 responders and 19 non-responders) were further analyzed by receiver operating characteristic curves to seek the criteria for prediction of a response to IVAA treatment. The results showed that E-ZPP at a cut-off level of more than 105 micromol/mol heme and TS at a level of less than 25% were more specific to confirm the status of functional iron deficiency in iron-overloaded patients. The two criterion values had the highest accuracy to predict a response to treatment.

CONCLUSIONS

Functional iron-deficient erythropoiesis plays a role in rEPO-hyporesponsive anemia in HD patients with hyperferritinemia. IVAA may be an adjuvant therapy for rEPO in these patients, and E-ZPP of more than 105 micromol/mol heme and TS of less than 25% should be used to guide the IVAA treatment.

Ossification of the posterior longitudinal ligament of the spine. A case-control risk factor study

STUDY DESIGN

A case-control study.

OBJECTIVES

To determine the risk factors for ossification of the posterior longitudinal ligament (OPLL) of the spine.

SUMMARY OF BACKGROUND DATA

Previous epidemiologic studies conducted in Japan showed consuming vegetable protein and salt was a risk factor for OPLL. Dietary habits of the Taiwanese and Japanese people are similar. Whether the similar dietary habits play an important role in the high prevalence of OPLL in Taiwan was of interest.

METHODS

A case-control study was conducted in a tertiary teaching hospital. The study included 98 consecutive cervical spine patients with OPLL, with 98 age-matched patients with cervical spondylosis serving as control subjects. Radiologic examinations, clinical interviews, physical examinations, and risk factor questionnaires were administered to all the participants.

RESULTS

Compared with incidence in the control patients, the frequency of the ossification of the anterior longitudinal ligaments was significantly higher in OPLL patients with OPLL (31% vs. 19%; P = 0.049), but there was no difference in incidence of ossification of the ligamentum flavum (13.3% vs. 16.3%; P = 0.546). More OPLL patients preferred a high-salt diet (OPLL/CS, no:somewhat:yes = 23/38:18/25:57/35;, X2 for trend = 6.3; P = 0.001) and pickled foods (OPLL/CS, no:somewhat:yes = 39/56:11/11:48/31; X2 for trend = 6.7; P = 0.0099). Fewer patients with OPLL consumed meat daily (63% vs. 79%; P = 0.018). High-salt diet (odds ratio = 2.62) and daily meat intake (odds ratio = 0.39) showed persistent association with OPLL in a multivariate logistic regression.

CONCLUSIONS

The similar dietary habits, particularly a high-salt and low meat intakes, may partially explain the high prevalence of OPLL in Taiwan and Japan. Modifying dietary habits may help prevent this disease, especially in those high-risk populations.

Helicobacter pylori clearance and serum gastrin and pepsinogen I concentrations in omeprazole treatment of duodenal ulcer patients

OBJECTIVE

To determine which demographic factors may influence serum gastrin and pepsinogen I (PGI) levels in duodenal ulcer patients undergoing omeprazole treatment.

METHODS

We conducted an outpatient-based prospective study in the Veterans General Hospital, Taipei, to investigate the pharmacological effects on patients with duodenal ulcers receiving omeprazole treatment for 4 weeks. Sixty-eight patients (61 males/7 females, aged 25 73 years) with endoscopically confirmed duodenal ulcer were included. Gastrin and pepsinogen I levels were measured before and after treatment. Demographic factors including age, sex, smoking, ulcer healing and antral Helicobacter pylori colonization/clearance were analyzed, in order to measure their probable influences on serum gastrin and pepsinogen I levels.

RESULTS

Ulcer healing was seen in 92.6% of patients while 48 (70.6%) antral clearances were seen in 66 H. pylori colonized patients at the end of trial. Omeprazole monotherapy led to a marked elevation of serum gastrin (85.8 pg x ml(-1), SD 32.0 pg x ml(-1) vs 133.9 pg x ml(-1), SD 71.6 pg x ml(-1), P < 0.01), and pepsinogen I (111.0 ng x ml(-1), SD 36.7 ng x ml(-1) vs 253.6 ng x ml(-1) , SD 64.8 ng x ml(-1), P < 0.01) levels when measured on day 29. Only patients showing antral H. pylori clearance exhibited an influence on the magnitude of pepsinogen I elevation following omeprazole monotherapy (143.9%, SD 67.3% vs 78.6%, SD 51.2%, P < 0.01). Moreover, the sensitivity and specificity of serum pepsinogen I variations were plotted on a receiving operating characteristic (ROC) curve. The 140% increased pepsinogen I level yielded a maximum accuracy of 80% specificity or 50% sensitivity to predict antral H. pylori clearance.

CONCLUSION

Antral H. pylori clearance is at least partially responsible for the omeprzaole-induced hyperpepsinogenemia I. The magnitude of hyperpepsinogenemia I probably provides a non-invasive alternative for predicting H. pylori clearance.

Presence of serum anti-p53 antibodies is associated with pleural effusion and poor prognosis in lung cancer patients

This study was designed prospectively to evaluate the development of anti-p53 antibodies (Abs) in lung cancer patients in relation to their clinical outcome. Sera, derived from 125 lung cancer patients, consisting of 14 small cell lung cancers (SCLC) and 111 non-SCLCs (NSCLC), were surveyed. The p53-null human NSCLC cell line, NCI-H1299, transfected with a human mutant p53 gene was prepared as the source of p53 antigen for immunoblotting analyses to detect the presence of serum anti-p53 Abs. The control group included sera from 10 healthy adults and 14 patients with benign pulmonary diseases. Clinical data including staging and survival were recorded for statistical analyses. The anti-p53 Abs were found in 8% (10 of 125) of the lung cancer patients studied (8.1% of NSCLC versus 7.1% of SCLC patients), whereas none of the control sera had detectable anti-p53 Abs. The presence of anti-p53 Abs was closely associated with malignant pleural effusions (P = 0.001). The p53 Ab-positive patients had a worse prognosis than the p53 Ab-negative patients (P < 0.02; median survival, 20 versus 41 weeks). In both univariate and multivariate analyses, the tumor extension and probably the presence of anti-p53 Abs were significant predictors for cancer death. The development of anti-p53 Abs (n = 9) was also a predictor for poor survival in patients with malignant effusions (n = 51). In conclusion, the presence of serum anti-p53 Abs is closely associated with malignant pleural effusions in lung cancer patients. It may serve as a negative prognostic factor for survival independent of malignant pleural effusions and tumor staging.

Sequential variceal pressure measurement by endoscopic needle puncture during maintenance sclerotherapy: the correlation between variceal pressure and variceal rebleeding

BACKGROUND/AIMS

The risk factors for esophageal variceal rebleeding are little known. Variceal pressure is one of the major determinants of variceal rupture, but the relationship between variceal pressure and variceal rebleeding during maintenance sclerotherapy has not been determined. This study was undertaken to evaluate the relationship between variceal pressure/gradient change and variceal rebleeding during maintenance sclerotherapy.

METHODS

Patients with liver cirrhosis and recent esophageal variceal hemorrhage underwent consecutive variceal pressure measurements by direct puncture of the varices before each elective sclerotherapy.

RESULTS

In 46 patients, the initial variceal pressure was no different regardless of age, sex, underlying etiology or hepatic reserve. Variceal pressure was higher in large varices, varices with more severe red wale markings, and varices with slower reduction in size during maintenance sclerotherapy. A larger volume of sclerosant was required to eradicate large varices, varices with more severe red wale markings, and varices with slower reduction in size during maintenance sclerotherapy. There was a positive correlation between initial variceal pressure and total amount of sclerosant (r=0.485, p=0.001). Initial variceal pressure was not related to rebleeding. Variceal pressure increased more in patients with rebleeding from varices per se (n=7) than in those without rebleeding (n= 24). There was no difference in pressure change between patients without rebleeding (n=24) and those with rebleeding from variceal ulcers (n=7).

CONCLUSIONS

Large varices, severe red color signs and slow reduction in variceal size were associated with higher initial variceal pressure, and more sclerosant was required to eradicate the varices. An increase in variceal pressure during maintenance sclerotherapy indicates a higher risk of variceal rebleeding, but not of variceal ulcer rebleeding.

Technical and clinical evaluation of an electrochemistry glucose meter: experience in a diabetes center

The Sensorex (Metertech, Taipei, Taiwan), an electrochemical blood glucose meter, is designed for self-monitoring of blood glucose (BG) concentrations in capillary blood through the use of an electrochemical test strip. The intra-assay coefficients of variation of Sensorex were 5.2, 5.4, and 4.7% at BG levels of 46, 154 and 302 mg/dl respectively. The BG concentrations tested by Sensorex were correlated well with those by YSI method (r approximately/= 0.85, P < 0.0001). The intraclass correlation coefficients (rI) between the results obtained by Sensorex and YSI were 0.84 in capillary blood and 0.69 in venous whole blood, which indicated good agreement between both methods. The Sensorex was evaluated by error grid analysis and revealed 'acceptance' results. In field test, the Sensorex results obtained by lay users were in concordance with those by trained technicians (rI = 0.87). Our data show that the Sensorex glucometer is reliable and easy to use. We also demonstrate a practical clinical approach for the evaluation of a novel SMBG system.

beta-Lactam resistance and beta-lactamase isoforms of Moraxella catarrhalis isolates in Taiwan

Moraxella catarrhalis is an important pathogen in both upper and lower respiratory tract infections. More than 90% of isolates worldwide produce beta-lactamase. The beta-lactamases produced by M. catarrhalis can be differentiated by isoelectric focusing (IEF) into BRO-1 and BRO-2 patterns. In this study, we investigated the prevalence of various beta-lactamase isoforms in clinical isolates of M. catarrhalis in Taiwan, as well as the relationships of these isoforms with antibiotic resistance. A total of 271 clinical isolates of M. catarrhalis were collected from 12 large medical laboratories in Taiwan from 1 August 1993 to 31 July 1995. The overall prevalence of beta-lactamase production was 98.2% (266 of 271 isolates). Analytical IEF revealed BRO-1 was the most common beta-lactamase pattern among the isolates (238 isolates, 88%); BRO-2 was the only other pattern found, with 32 (12%) isolates. The geometric mean minimum inhibitory concentration of ampicillin for BRO-1 producers was 63-fold higher than that for beta-lactamase-negative isolates, and 6.5-fold higher than that for BRO-2 producers. beta-Lactam antibiotics, such as amoxicillin + clavulanate and the cephalosporins, tested were very active against this species, regardless of whether the isolate produced beta-lactamase or not. In conclusion, beta-lactamase is common among clinical isolates of M. catarrhalis in Taiwan, with BRO-1 being the most common isoform. However, because most isolates tested were still sensitive to amoxicillin + clavulanate and cephalosporins, these agents appear to be reliable alternatives to first-line therapy when M. catarrhalis is contributing to a clinical infection.

Tachycardia-induced change of atrial refractory period in humans: rate dependency and effects of antiarrhythmic drugs

BACKGROUND

Atrial fibrillation (AF) has been shown to shorten the atrial effective refractory period (ERP) and make the atrium more vulnerable to AF. This study investigated the effect of atrial rate and antiarrhythmic drugs on ERP shortening induced by tachycardia.

METHODS AND RESULTS

Seventy adult patients without structural heart disease were included. For the first part of the study, right atrial ERP was measured with a drive cycle length of 500 ms before and after 10 minutes of rapid atrial pacing using five pacing cycle lengths (450, 400, 350, 300, and 250 ms) in 10 patients. For the second part of the study, the remaining 60 patients were included to study the effects of antiarrhythmic drugs on changes in atrial ERP induced by AF. Atrial ERP was measured with a drive cycle of 500 ms before and after an episode of pacing-induced AF. After the patients were randomized to receive one of six antiarrhythmic drugs (procainamide, propafenone, propranolol, dl-sotalol, amiodarone, and verapamil), atrial ERP was measured before and after another episode of pacing-induced AF. In the first part of the study, atrial ERP shortened significantly after 10 minutes of rapid atrial pacing, and the degree of shortening was correlated with pacing cycle length. The second part of the study showed that atrial ERP shortened after conversion of AF (172+/-15 versus 202+/-14 ms, P<0.0001) and that ERP shortening was attenuated after verapamil infusion (-4.6+/-1.2% versus -15.1+/-3.4%, P<0.001) but was unchanged after infusion of the other antiarrhythmic drugs. Furthermore, all of these antiarrhythmic drugs could decrease the incidence and duration of secondary AF.

CONCLUSIONS

The atrial ERP shortening induced by tachycardia was a rate-dependent response. Verapamil, but not other antiarrhythmic drugs, could markedly attenuate this effect. However, verapamil and the other drugs could decrease the incidence and duration of secondary AF.

Murine typhus presenting with multiple white dots in the retina

The retinal manifestations of murine typhus have rarely been reported. We report a case of murine typhus with multiple retinal white dots, which are similar to the presentation of multiple evanescent white dot syndrome.

Effect of sucralfate granules in suspension on endoscopic variceal sclerotherapy induced ulcer: analysis of the factors determining ulcer healing

Oesophageal ulcers commonly occur after endoscopic variceal sclerotherapy and usually cause complications and a delay in further sclerotherapy. The aims of this study are to investigate the effect of sucralfate granules in suspension on the treatment of endoscopic variceal sclerotherapy induced ulcer and analyse the factors determining the ulcer healing. Fifty-two patients with oesophageal variceal bleeding received elective endoscopic variceal sclerotherapy. After endoscopically proved oesophageal ulcers, they were randomized to receive either sucralfate granules in suspension (n = 22) or antacid (n = 23). Follow-up endoscopy was performed weekly. Ulcer healing rates were compared between the groups using the log-rank test. Forty-one ulcers receiving sucralfate and 48 ulcers receiving antacid treatment were evaluated. The clinical characteristics of the ulcers were similar in both groups. The ulcers in patients receiving sucralfate healed faster than those receiving antacid (P<0.02). On analysis of factors affecting ulcer healing, ulcers smaller than 1 cm2 (n = 59) appeared to heal faster than those larger than 1 cm2 (n = 30; P= 0.059) and shallow ulcers (n = 46) healed faster than deep ulcers (n = 43; P<0.001). On multifactorial analysis, ulcer depth was the only factor determining ulcer healing. The ulcer healing effects of sucralfate became more prominent when the ulcer was larger than 1.0cm2 (1.7+/-0.6 weeks vs 2.3+/-0.6 weeks, P= 0.011) and deep (1.7+/-0.7 weeks vs 2.5+/-1.0 weeks, P= 0.013) when compared with those receiving antacid. Sucralfate granules in suspension speed the healing of endoscopic variceal sclerotherapy induced ulcer, especially deep and large ulcers.

Differentiating syndrome X from coronary artery disease by treadmill exercise test in patients with chest pain and exercise-induced myocardial ischemia

Even though the underlying mechanisms of myocardial ischemia may be different, it is difficult to differentiate syndrome X from coronary artery disease (CAD) by means of the treadmill exercise test in elderly patients with chest pain and exercise-induced myocardial ischemia. One hundred sex- and age-matched patients-42 with syndrome X and 58 with CAD-were studied. Another 10 subjects with atypical chest pain, negative treadmill exercise test, and normal-appearing coronary angiograms served as controls. We evaluated the difference in exercise performance between patients with syndrome X and CAD, and the treadmill exercise test was undertaken with modified Bruce protocol within 2 weeks before coronary angiography. Parameters including time to 1 mm ST segment depression (STD), exercise duration (ED), heart rate (HR), systolic blood pressure, rate-pressure product (RPP), and percentage of age-predicted maximum HR (% HR) at different stages of the test were measured and then compared among the three groups of patients. Compared with CAD patients, syndrome X patients had significantly higher HR, % HR, and RPP at the time of 1 mm STD and at peak exercise. The time to 1 mm STD and ED were longer in syndrome X than in CAD patients. However, ED was shorter and HR, % HR, and RPP at peak exercise were similar in syndrome X patients as compared with control subjects. The new criterion of combined ED (> or =315 seconds) and RPP at peak exercise (> or =24,000 beats x mmHg/min) was found to be highly specific (86%) and moderately sensitive (64%) in differentiating syndrome X from CAD patients. The positive likelihood ratio for this criterion was 4.57 and negative likelihood ratio was 0.42. In conclusion, syndrome X patients had better exercise performance than CAD patients, but less ED and similar workload when compared with control subjects. The new criterion proposed in this study may provide a quick and simple way to differentiate syndrome X from CAD in a group of aged and predominantly male patients with chest pain and positive treadmill exercise test.

Sequential changes of esophageal motility after endoscopic injection sclerotherapy or variceal ligation for esophageal variceal bleeding: a scintigraphic study

OBJECTIVE

Endoscopic injection sclerotherapy and variceal ligation are two popular endoscopic methods used to treat esophageal variceal hemorrhage. These two methods have not been compared with regard to esophageal dysfunction after treatment. This is a prospective investigation of esophageal dysmotility after endoscopic injection sclerotherapy and variceal ligation.

METHODS

Sequential changes of esophageal motility after endoscopic injection sclerotherapy (n = 25) and variceal ligation (n = 25) were investigated in 50 cirrhotic patients with recent variceal bleeding. Another 22 cirrhotics without esophageal varices were included as controls. Radionuclide esophageal transit tests were performed before initial endoscopic treatment, and 1 and 3 months after variceal eradication.

RESULTS

The baseline esophageal transit time was longer in both the sclerotherapy (n = 25, 7.8 +/- 1.4 s) and ligation groups (n = 25, 8.2 +/- 1.8 s) than in controls (n = 22, 6.7 +/- 0.7 s, p < 0.005). The transit time was longer in patients with large varices than in those with small varices (8.3 +/- 1.7 vs. 7.2 +/- 0.7 s, p < 0.05). In the sclerotherapy group, the transit time was prolonged 1 month after variceal eradication, compared with its pretreatment state (n = 20, 7.6 +/- 1.5 vs. 10.0 +/- 2.2 s, p < 0.0001) but was shortened at 3 months compared with 1 month after variceal eradication (n = 12, 10.7 +/- 1.5 vs. 8.6 +/- 2.2 s, p < 0.05). Multiple regression analysis showed that the number of treatment sessions required to eradicate varices was the only significant factor associated with prolonged transit time (p < 0.05). In the ligation group, the transit time changed little at 1 month or 3 months after variceal eradication.

CONCLUSIONS

Impairment of esophageal motility can be significant with endoscopic injection sclerotherapy but is reversible. However, endoscopic variceal ligation exerts no significant impact on esophageal motility.

The health care needs of hospitalized patients with AIDS in Taiwan

The purpose of this study was to investigate and highlight health care needs as perceived by hospitalized patients with AIDS (PWA) in Taiwan. Convenience sampling was used for this study. Subjects were chosen from one of the medical centers in metropolitan Taipei, Taiwan. Criteria for sampling were that subjects be diagnosed with AIDS, hospitalized without complications of neuropathy, psychosis, or dementia, 12 years old or older, and able to speak Mandarin. Sample size was determined by the saturation principle. Eight subjects were interviewed in depth using a semistructured interview guide. These interviews were tape recorded and transcribed. Content analysis was applied to analyze interview data. The double coding percentage agreement was 0.81, and the intercoder percentage agreement was 0.89. Results revealed the most important health care needs associated with these patients included obtaining information about AIDS, protecting privacy, improving the quality and quantity of health care, securing family members' safety and financial security, and accepting the grief process. These findings suggest that the needs of the PWAs must be identified before nursing care is provided. Furthermore, developing a health care need scale is recommended for patients with AIDS to more effectively assess their health care needs.

Screening for acyclovir-resistant herpes simplex virus isolates from clinical samples

The ID90 or ID50 values of acyclovir for the herpes simplex virus strains isolated in VGH-Taipei were determined by plaque reduction method. Twenty HSV isolates of 1980's (1980-1985) and thirty of 1990's (1990-1995) were subjected to plaque reduction assay for susceptibility test to acyclovir. There were fifteen HSV isolates of 1990's whose ID90 were higher than those of 1980's, indicating a trend of more acyclovir resistant isolates in 1990's.

Clinical implications of the white nipple sign and its role in the diagnosis of esophageal variceal hemorrhage

OBJECTIVE

Differentiation of esophageal variceal hemorrhage from other sources of the GI tract is often difficult. This is a prospective investigation of the significance of the white nipple sign in patients with recent esophageal variceal hemorrhage.

METHODS

One hundred sixty-six patients with recent variceal hemorrhage were prospectively studied with respect to presence or absence of the white nipple sign and other stigmata of hemorrhage and compared with 100 patients with known varices but without a clinical history of bleeding.

RESULTS

The white nipple sign correlated positively with severity of bleeding (patients required more blood transfusion), hematemesis, and signs of shock. Patients with the white nipple sign also tended to undergo emergency endoscopy and have active bleeding at the time of endoscopy. There was no correlation between rebleeding rate after endoscopic therapy and presence of the white nipple sign. Appearance of the white nipple sign was closely related to the timing of endoscopy (p < 0.0001). The sensitivity and specificity of the white nipple sign in the diagnosis of esophageal variceal hemorrhage were 21 and 100%, respectively, compared with 100 and 54% for the red color sign. Furthermore, the sensitivity of the white nipple sign increased with shorter times between bleeding and endoscopy.

CONCLUSIONS

In patients with upper GI bleeding, the white nipple sign suggests that the varices bled recently and that the bleeding was severe. However, it has no predictive value for rebleeding after endoscopic therapy. Earlier endoscopy (i.e., within 24 h of bleeding) is suggested to improve the diagnostic rate of esophageal variceal hemorrhage.

Lack of NK cells and related cytokines in pleural effusion

BACKGROUND

Relatively low number and activity of natural-killer (NK) cells have been reported in malignant pleural effusions. However, there has been no report on NK cells related cytokines.

METHODS

Lymphocyte subpopulations were studied in 30 cases of pleural effusion with various etiologies, along with peripheral blood, by using flow cytometry. The related cytokine levels in peripheral blood and pleural fluid, including IL-1 alpha, IL-4 and IL-12, were also analyzed with ELISA assays.

RESULTS

The results showed significant increase of T-helper cell subpopulation in pleural effusion of various etiologies. No obvious change of B-lymphocyte subpopulation between peripheral blood and pleural effusion was found. IL-4 was undetectable in both peripheral blood and pleural fluid in most cases. IL-1 alpha was detectable in some cases and the level was highest in pleural fluid of empyema. Decreased NK cells were found in most cases of pleural effusion and accompanied by undetectable IL-12 both in pleural fluid and peripheral blood. The only one case with detectable IL-12 concentration in pleural fluid was the one with tuberculous pleurisy.

CONCLUSIONS

Increased T-helper cell subpopulation and decreased NK cell subpopulation were found in pleural effusion of various etiologies. In spite of the small series of our patients, the decrease of NK cell subpopulation and the undetectable IL-12 concentration in pleural effusion deserves further investigations.

The variation of cell type distribution in lung cancer: a study of 10,910 cases at a medical center in Taiwan between 1970 and 1993

The rise in the incidence of lung cancer has been associated with shifts in histologic distribution. A study was conducted to investigate changes in the cell type distribution in lung cancer in relation to age, sex, and smoking history, based on a retrospective analysis of 10,910 proven cases of lung cancer at the Veterans General Hospital-Taipei during the period from 1970 to 1993. The diagnosis in each case was substantiated by histologic samples from the original tumor site in the lung. Detailed smoking histories were obtained by personal interview at the time of the first admission. Adenocarcinoma (38.3%) was the most common type of lung cancer, followed by squamous cell carcinoma (37.1%) and small cell carcinoma (12.2%). Over the study period, the incidence of squamous cell carcinoma decreased from 46.4% to 36.2% in men (P < 0.005), adenocarcinoma increased from 30% to 36% in men (P = 0.001) and 50.7% to 64.8% in women (P = 0.008), and small cell carcinoma increased from 7% to 14% in men but showed no significant change in women. Adenocarcinoma exhibited a marked increase in both men and women, and surpassed squamous cell carcinoma as the most frequent type of lung cancer. Lung cancer among younger men, and among non-smoking older men and women, was more often adenocarcinoma. Small cell carcinoma showed a significant increase among males, differing from the trend for squamous cell carcinoma in men, though both are strongly associated with smoking. These findings suggest factors other then cigarette smoking could influence the development and distribution of lung cancer.

Elevation of interleukin-10 levels in malignant pleural effusion

STUDY OBJECTIVE

Human immunity has been found to have two major components, cellular and humoral immunity. T-helper type 1 (Th1) pathway favors cellular immunity and Th2 pathway favors humoral immunity. Early determination toward Th1 and Th2 cells in the immune response is dependent on the balance between interleukin-12 (IL-12), which favors Th1 responses, and IL-4, which favors Th2 responses. IL-2 and interferon-gamma (IFN-gamma) are produced in the Th1 pathway, and IL-4 and IL-10 are produced in the Th2 pathway. Lack of cellular immunity, IL-2, and IFN-gamma had been reported in malignant pleural effusions. However, to our knowledge, there are no previous reports on other cytokine components involving Th1 or Th2 pathway. The present study was designed to answer these questions.

DESIGN

Cytokine levels in peripheral blood and pleural fluid of 21 patients with malignant pleural effusion, including IL-4, IL-10, and IL-12, were analyzed with enzyme-linked immunosorbent assays. Lymphocyte subpopulations of peripheral blood and pleural effusion were also studied by using flow cytometry.

MEASUREMENTS AND RESULTS

The results showed a significant increase in IL-10 level as compared with blood samples. IL-4 and IL-12 were below minimal detectable concentrations both in the blood and the effusion. The ratio of pleural helper T cells was significantly higher than in the blood (p = 0.0002). The ratio of pleural natural killer (NK) cells was significantly lower than in the blood (p = 0.0001). The ratio of pleural suppressor T cells was lower than blood with borderline significance (p = 0.0522). No significant change in B-lymphocyte ratio between blood and pleural effusion was found (p = 0.2471). There was no correlation between difference in IL-10 level and lymphocyte subpopulation of pleural effusion and blood samples.

CONCLUSIONS

Helper T-cell subpopulations were increased while NK and suppressor T-cell subpopulations were decreased in malignant pleural effusions. The decrease in NK cell subpopulations with elevated IL-10 and minimal IL-12 concentration in neoplastic pleural effusion would suggest the usage of IL-12 or antibody of IL-10 to improve local cellular immunity. Further study is needed.

Serum cytokine level fluctuations in chemotherapy-induced myelosuppression

We have reported that serum granulocyte colony-stimulating factor (G-CSF) and interleukin-6 (IL-6) levels rise in patients with chemotherapy-induced myelosuppression. The aim of the present study was to determine whether other cytokines that function at different hematopoietic stages also fluctuate during chemotherapy-induced myelosuppression and whether the extent of cytokine level fluctuations correlate with myelosuppression severity. Fifteen patients participated in the study. Serum levels of stem cell factor (SCF), interleukin (IL)-1 alpha, IL-6, IL-3, granulocyte-macrophage CSF (GM-CSF) and G-CSF were analyzed before chemotherapy and during the myelosuppressive stage and correlations between cytokine levels and myelosuppression severity were examined. The results showed that both serum G-CSF and IL-6 levels rose in patients with chemotherapy-induced myelosuppression. The prechemotherapy serum G-CSF and IL-6 levels correlated well with their respective elevated levels during the myelosuppressive stage. The myelosuppression severity also correlated well with the extent of serum G-CSF level elevation. The serum IL-6 and G-CSF levels during the myelosuppressive stage correlated significantly. Serum SCF levels did not fluctuate significantly during myelosuppression, and IL-1, IL-3 and GM-CSF were rarely detected in serum even after chemotherapy. In the present study, the roles of IL-1 alpha, SCF, IL-3 and GM-CSF chemotherapy-induced myelosuppression were not clear.

Seasonal variation in the incidence of peptic ulcer and esophageal variceal bleeding in Taiwan

BACKGROUND

Seasonal variation of peptic ulcer and peptic ulcer bleeding has been reported in many western countries. To investigate the seasonal variation of peptic ulcer (PU) and esophageal variceal (EV) bleeding in Taiwan, this retrospective study was conducted.

METHODS

Seven hundred and forty-six cases of gastric ulcer (GU) bleeding, 777 cases of duodenal ulcer (DU) bleeding and 264 cases of EV bleeding were recruited from January 1, 1991 to December 31, 1992. Patients were sent to the Medical Emergency Room (MER) for hematemesis and/or melena. Upper gastrointestinal (UGI) endoscopic examinations were completed within 24 hours for all patients.

RESULTS

Significant seasonal variation was found in the incidence of PU and EV bleeding. PU bleeding was most often seen in March and EV bleeding was most often seen in February.

CONCLUSIONS

The possible mechanism for the cyclic change of PU and EV bleeding is unclear, but clearly more manpower is needed during the months of February and March for better management of the increasing number of cases of PU and EV bleeding.

Successful treatment of subcutaneous mycoses with fluconazole: a report of two cases

Lymphocutaneous sporotrichosis and chromoblastomycosis are subcutaneous mycoses caused by traumatic implantation of the fungus into the skin. Medical treatments for chromoblastomycosis has been disappointing, while lymphocutaneous sporotrichosis usually responds well to iodides. Here we present a case of chromomycosis and a case of lymphocutaneous sporotrichosis. Both patients were treated successfully with fluconazole.

The effects of accumulated experience on radiofrequency ablation of accessory pathways

Increasing experience in radiofrequency ablation for accessory pathways appears to reduce the procedure time, radiation time and radiofrequency pulse number, and results in a higher success rate. However, the effect of a learning curve on this procedure from the perspective of location and conduction direction of accessory pathways has not been reported before. The purpose of this study was to determine the effect of accumulated experience on the outcomes of radiofrequency ablation for accessory pathways and on the duration of the procedure parameters by analyzing the results of a dedicated ablation team. The first 512 patients with a single accessory pathway treated in this laboratory were included for analysis of the procedure parameters with respect to locations and conduction directions of accessory pathways. The results showed that the average procedure time, radiation time, and radiofrequency pulse number differed significantly among the different subgroups (left free wall, right free wall, posteroseptal and anteromidseptal location; manifest or concealed conduction). All subgroups except the anteromidseptal pathways showed a significant improvement of the procedure parameters with increased ablation experience. Although the initial rate of improvement was similar among the different subgroups, the rate of improvement in left free wall pathways nearly reached a plateau after 120 ablation procedures. Thus it was concluded that a certain number of ablation procedures was necessary before achievement of a high success rate with shorter procedure and radiation times and a lower radiofrequency pulse number.

Elevation of serum IL-6 levels in patients with acute bacterial infection

BACKGROUND

Serum cytokine levels have been reported to elevate in acute bacterial infection, but the relationship of differential elevation in cytokine levels to patients' clinical parameters and prognosis remains controversial. The present study was designed to evaluate whether serum interleukin-1 alpha (IL-1 alpha) and IL-6 levels were raised in patient with acute bacterial infection, and were correlated with patients clinical parameters.

METHODS

Thirty patients, aged from 20 to 91 years, calling our emergency room with clinical evidence of acute bacterial infection and marked leukocytosis, were enrolled in this study. Sera were collected immediately and analyzed for IL-1 alpha and IL-6 levels with Enzyme-Linked Immunosorbent Assay (ELISA) method.

RESULTS

All patients with acute bacterial infection had measurable higher levels of serum IL-6 than normal volunteers. Patients with higher serum IL-6 level were more likely to have fever, though without statistical significance (p = 0.09). Serum IL-6 levels did not correlate significantly with positive blood culture result, septic shock, or fatal outcome. Serum IL-1 alpha levels were below minimal detectable concentrations in all patients checked.

CONCLUSIONS

Serum IL-6 levels were elevated in patients with acute bacterial infection, and were possibly associated with the occurrence of fever. IL-1 alpha played no obvious role as systemic effector molecule in acute bacterial infection in our study.

The prognostic value of serum cytokine levels in patients with acute infections

BACKGROUND

Elevation of serum cytokine level, especially tumor necrosis factor-alpha (TNF-alpha) and granulocyte-colony stimulating factor (G-CSF), has been reported in acute bacterial infection. Elevation of serum TNF-alpha level upon patients' admission has also been reported to correlate with the fatal outcome.

METHODS

The present study is to evaluate, in addition to TNF-alpha and G-CSF, whether serum stem cell factor (SCF), interleukin-3 (IL-3) and granulocyte-macrophage-CSF (GM-CSF) levels to see if they were also elevated in patients with acute bacterial infection. It also tries to evaluate whether different degree of elevation of cytokine levels had any relationship to patients' clinical parameter, including fatality. Correlation between different kinds of cytokines was also studied.

RESULTS

Patients with bacterial growth in blood culture had higher level of serum G-CSF. Higher level of serum TNF-alpha was significantly associated with the occurrence of septic shock, but not of fatal outcome. Low serum G-CSF and high serum SCF level were significantly associated with fatal outcome; however, all the patients still had serum SCF levels within normal range. GM-CSF and IL-3 play no obvious role as systemic effector molecule in acute bacterial infection.

CONCLUSIONS

Higher levels of serum TNF-alpha are associated with the occurrence of septic shock. Low serum G-CSF levels are significantly associated with fatal outcome. Routine monitoring of serum G-CSF level in patients with severe infection in order to supplement recombinant G-CSF can possibly help patients to overcome the disaster.

Changes in portal hypertensive gastropathy after endoscopic variceal sclerotherapy or ligation: an endoscopic observation

To determine the effect of endoscopic variceal sclerotherapy or ligation on portal hypertensive gastropathy, 90 cirrhotic patients with esophageal variceal bleeding were randomized to receive sclerotherapy (n = 44) or ligation (n = 46). Follow-up endoscopic observations of the gastric mucosa were recorded at 3-month intervals after variceal eradication. Clinical characteristics in both groups were similar. Probability for a change in the severity of portal hypertensive gastropathy was not related to method of eradication. Most cases of portal hypertensive gastropathy that changed in severity returned to baseline status with time, but the return was faster after ligation than after sclerotherapy. According to the results of multivariate analyses, sclerosant volume was the only factor associated with a significant difference between the group with static gastropathy (n = 15) and that with dynamic change in gastropathy (n = 23) after sclerotherapy. No relevant factors were found in the patients receiving ligation. We conclude that changes in the severity of portal hypertensive gastropathy after endoscopic variceal sclerotherapy or ligation are reversible. Most cases of gastropathy return to baseline status sooner or later.

Clinical and radiological pictures of hepatocellular carcinoma with intracranial metastasis

Hepatocellular carcinoma (HCC) with extrahepatic spreading is not uncommon. In order to delineate the clinical and radiological pictures of HCC with intracranial metastasis, 33 documented cases were analysed. Eighteen had brain parenchymal metastasis without skull involvement; the other 15 cases disclosed skull metastasis with brain invasion. The underlying HCC are mainly of expanding (13/33, 39.4%) and multifocal (13/33, 39.4%) types. Eighteen cases (18/33, 54.5%) had mental changes not related to hypoglycaemia or hepatic encephalopathy. Eighteen cases (18/20, 90%) disclosed hyperdense mass lesions by non-contrast computed tomography (CT) scans and 17 cases showed homogeneous enhancement (17/22, 77.3%) by post-contrast CT images. In the non-skull involved group, five cases (5/12, 41.7%) disclosed ring-shape enhancement and 14 cases (14/16, 87.5%) had perifocal oedema, which were not seen in the skull involved group. Eight cases (8/33, 24.2%) presented as intracerebral haemorrhage. Twelve (12/33, 36.4%) died of brain herniation. Most (14/18, 77.8%) non-skull involved cases had simultaneous lung metastasis without bony metastasis, while the skull involved group often (10/15, 66.7%) disclosed extracranial bony metastasis without lung metastasis. The difference in extracranial metastasis was statistically significant (P < 0.05). The multivariate survival analysis disclosed that lower lactate dehydrogenase level (< or = 316 U/L, P = 0.029) and treatments (surgery or radiation, P = 0.001) were positively associated with longer survival. In conclusion, HCC with intracranial metastasis is symptomatic and life-threatening. Half the cases may come from pulmonary metastasis and the other half may be from bony metastasis. Brain irradiation or surgery can prolong their survival.

Comparison of endoscopic variceal injection sclerotherapy and ligation for the treatment of esophageal variceal hemorrhage: a prospective randomized trial

To determine the efficacy of endoscopic variceal sclerotherapy (EVS) and ligation (EVL) in the management of esophageal variceal bleeding, 134 cirrhotic patients were randomized to receive either treatment. The clinical and endoscopic characteristics were similar in both groups. Active bleeding was controlled with ligation (20 of 20) as efficiently as with sclerotherapy (14 of 16). Elective sclerotherapy consumed less time than ligation (7.9 +/- 1.8 minutes vs. 11.5 +/- 2.7 minutes, P < .001), but there was no difference between emergent sclerotherapy (14.5 +/- 5.8 minutes) and ligation (14.9 +/- 4.1 minutes). Ligation reduced one grade of variceal size more quickly than sclerotherapy (1.1 +/- 0.4 vs. 2.0 +/- 1.7 session, P < .001). The rebleeding rate was lower with ligation (13 of 67 vs. 28 of 67, P < .01). Esophageal ulcer was the most common source of rebleeding. Recurrence of varices appears more probable with ligation (P = .079). The complication rate was higher with sclerotherapy (15 of 67 vs. 3 of 67, P < .01), with esophageal stricture being the most common cause. Survival rate was the same in both groups even after stratifying patients into good and poor hepatic reserve groups. Hepatic failure was the major cause of death, followed by exsanguination. In summary, EVL was superior to EVS regarding rebleeding and complications but not in other aspects such as time consumption in elective treatment and recurrence of varices. Substantial results for long-term follow-up are required before conclusion of the treatment of choice.

Transcatheter arterial embolization for hepatocellular carcinoma with portal vein thrombosis

In order to evaluate the possible benefits of transcatheter arterial embolization (TAE) in hepatocellular carcinoma (HCC) patients with peripheral portal vein thrombosis, 96 consecutive HCC cases with peripheral portal vein thrombosis were analysed. Of them, 35 cases received TAE and 61 cases did not. Most (77.8%) of the TAE-treated cases showed decreased alpha-fetoprotein (AFP) levels after treatment, but 57.1% of them suffered another rise in AFP levels and subsequently died. One patient (2.8%) developed progressive jaundice after TAE and died within 1 month, while four of the non-TAE cases died within 1 month after diagnosis. In general, TAE is safe for HCC patients with peripheral portal vein thrombosis. In addition, using Cox's regression model for multivariate survival analysis, serum total bilirubin (< or =, > 2 mg/dL; P = 0.0254), AFP (< or = 3155 ng/mL, > 3155 ng/mL; P = 0.0002) and treatments (TAE, non-TAE; P = 0.0059) were found to affect their prognosis. There was significant difference in survival between TAE and non-TAE groups, the 6 month, 1 year and 2 year survival rates were 91.4 versus 62.3%, 51.4 versus 26.2% and 17.1 versus 4.9% (P = 0.0017). The median survival times of TAE and non-TAE groups were 10.3 versus 3.7 months, respectively. Though TAE only provided palliative treatment, it did prolong survival in HCC patients with peripheral portal vein thrombosis.

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening tool for dementia for a predominantly illiterate Chinese population

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) provides ratings of an individual's changes in everyday cognitive functions during the previous 10 years. Original studies conducted in Australia showed that its score was not influenced by the subjects' educational backgrounds and that it performed at least as well as the Mini-Mental State Examination (MMSE) as a screening instrument for dementia. The subjects of the present study were Chinese and included 399 community residents and 61 dementia patients. Their ages ranged from 50 to 92 years; their education levels ranged from 0 to 19 years, and 63% of them had never attended school. We administered the IQCODE to informants and the Cognitive Abilities Screening Instrument (CASI), from which a CASI-estimated score of the MMSE (MMSE-CE) can be obtained, to the subjects. The diagnosis of dementia was made independently by physicians according to the DSM-III-R criteria based on semistructured interview and testing, neurologic examination, and standardized assessments of cerebral vascular disease, Parkinson's disease, and depression. The Chinese IQCODE showed no association with the subjects' education level or gender, low association with their age, and moderately high association with their MMSE-CE score. The area under the receiver operating characteristic curve of the IQCODE was significantly larger than that of the MMSE-CE for the whole group and for the subgroup with 1 to 19 years of education but not for the subgroup with 0 years of education. Nine of the 26 items of the IQCODE could be deleted without appreciable reduction in sensitivity and specificity. The IQCODE (1) can be shortened to 17 items, (2) had good cross-cultural applicability, and (3) was better than the MMSE-CE as a screening tool for dementia in a population with large variation in educational backgrounds.

Do the reticulocyte maturation fractions and bone marrow reticulocyte count further help the classification of anemias?

BACKGROUND

Reticulocyte count plays a major role in anemic evaluation. The conventional method done by the manual supravital staining cannot subclassify the group of less than 2% of corrected reticulocyte count. The newly-developed flow cytometer provides different maturation fractions by measuring its fluorescent intensity. The reticulocytes are believed to shift to the circulation from the bone marrow earlier in more severe anemia. Therefore, the purpose of this study is to evaluate the role of reticulocyte maturation fractions and bone marrow reticulocyte in anemia classification.

METHODS

By using a fully automated counter, the roles of the reticulocyte with maturation and their shifting from bone marrow were evaluated in anemias. Different groups of subjects (243 in total) including aplastic, nutritional, and infiltrative anemias and anemia due to excess destruction and blood loss were studied. Each subject had bone marrow examination for morphologic diagnosis and reticulocyte evaluation.

RESULTS

Both the absolute count and the maturation fractions of reticulocytes showed significant difference among marrow infiltration, aplastic anemia, and hemolytic anemia. Both the absolute reticulocyte count and less mature fractions were lowest in aplastic group. The marrow reticulocyte counts and shift ratio to circulating blood added little benefit in the classification of anemias.

CONCLUSIONS

The automated reticulocyte count with maturation fractions helps classify anemias, particularly for those with low reticulocyte count by the manual method.

Plasma arginase concentration measured by an enzyme-linked immunosorbent assay (ELISA) in normal adult population

Human liver arginase has many biological effects on lymphocytes, macrophages, liver cells, and tumor cells, in addition to its major role in the liver urea cycle. We have developed a sandwich enzyme-linked immunosorbent assay (ELISA) method to quantitate arginase concentrations in plasma that can be applied to various body fluids. The sensitivity was 2.5 ng/mL. The coefficients of variation were good both in intra- and inter-assay. Using this method to study the stability of an arginase preparation, we found that plasma arginase was stable for only 1 or 2 days even at temperatures as low as 4 degrees C. The mean plasma level was 41.0 +/- 3.3 ng/mL (mean +/- SE) in 143 normal subjects. There was no age difference in the general population and in the male group. However, in the female group, the plasma arginase level increased with age (p = 0.05). Its biological significance was unclear. As a whole, the ELISA method for the measurement of arginase concentration in the body fluid is convenient and reliable.

HLA antigen and antibody association in platelet-alloimmunized patients

The frequencies of HLA antigens were compared between 55 patients with and 38 patients without lymphocytotoxic antibodies formation after long-term platelet transfusions. Only HLA-B60 and B75 were found to manifest significant difference between these two groups. Patients with HLA homozygosity had a higher incidence of alloimmunization. Although most of the platelet alloantibodies were against HLA antigens of high frequency, the HLA-antibodies were induced at a rate different from the frequency of their corresponding antigens. The antibodies against the first and second HLA loci are of similar frequencies. In conclusion, the patients with HLA homozygous alleles have a higher incidence of platelet alloimmunization, and the antibody of certain specificities has higher rate of occurrence. These findings may be helpful in platelet-donor selection.

Heterosexual transmission as the most common route of acute hepatitis B virus infection among adults in Taiwan--the importance of extending vaccination to susceptible adults

Sixty adult patients with acute viral hepatitis B (AVHB) and 93 controls were interviewed to assess potential risk factors of hepatitis B. Heterosexual contact was the only significant factor, and it was associated with 83% of cases. A history of having new sex partners or multiple sex partners within 6 months before the onset of AVHB or first sexual contact before 20 years of age were significantly associated with HBV infection (P < .005, respectively). There was a dose-response relationship between the number of sex partners and the risk of HBV infection. In multivariate analyses, a history of having new sex partners was the most important factor. Moreover, 18 of 24 sex partners of the patients were serum hepatitis B surface antigen- and HBV DNA-positive. Heterosexual contact is, therefore, the predominant route of HBV transmission among adults in Taiwan. Susceptible adults should receive vaccination.