Prevalence of deep venous thrombosis in the lower limbs and the pelvis and pulmonary embolism in patients with positive antiphospholipid antibodies

BACKGROUND

Antiphospholipid antibodies (AA) are immunoglobulins that cross-react with phospholipid on cell membrane, and are therefore associated with a hypercoagulable state manifested by arterial/venous thromboses. We aimed to determine the prevalence of deep venous thrombosis in the lower limbs and the pelvic region (DVT) and pulmonary embolism (PE) in patients with positive AA.

METHODS

Sixty-six patients (48 female, 18 male) with positive lupus anticoagulant (LA) and/or positive anticardiolipin antibody (aCL) underwent radionuclide (RN) venography with 370 MBq of 99mTc-MAA. Pulmonary perfusion scintigraphy was performed in 58 patients. Fifteen patients had positive LA and positive aCL (LA+/aCL+), 33 patients had positive LA only (LA+/ aCL-) and 18 patients had positive aCL only (LA-/aCL+). 43 patients were diagnosed with primary antiphospholipid syndrome (APS) and 19 were diagnosed with APS associated with SLE.

RESULTS

DVT was detected in 21 of 66 patients (32%). Patients with LA+/aCL+ showed higher prevalence of DVT (53%) as compared to LA+/aCL- (27%) and LA-/aCL+ (22%). PE was found in 13 of 58 patients (22%). The prevalence of PE was higher in patients with positive aCL (33% in LA+/aCL+; 36% in LA-/aCL+) than in patients with negative aCL (10%).

CONCLUSION

Because of the high prevalence of DVT and PE in patients with AA, RN scintigraphy must be recommended in screening for these clinical troubles. These results indicate that the prevalence of DVT and PE may vary in subgroups of AA.

Acute hepatitis C among Japanese hemodialysis patients: a prospective 9-year study

OBJECTIVES

The aims of this prospective survey were to determine the incidence and clinical characteristics of newly acquired hepatitis C virus (HCV) infection in hemodialysis patients after the start of antibody to HCV (anti-HCV) screening for blood products in Japan in 1989.

METHODS

In serial serum samples from 269 hemodialysis patients who were followed over a mean period of 6.6 yr (+/- 2.1 yr) from 1990 to 1998, HCV RNA and anti-HCV were detected by reverse transcription-polymerase chain reaction and second generation ELISA, respectively.

RESULTS

During the observation period, newly acquired HCV infection was found in 26 (15.4%) of the 169 hemodialysis patients without anti-HCV or HCV RNA at entry, an annual incidence rate of 2.59%. Of these 26, only four had a history of blood transfusion, one of whom had received the blood transfusion after 1992, the year in which screening of blood products for anti-HCV by second-generation ELISA was introduced in Japan. Persistent HCV viremia was found in 17 (65.4%) of the 26 patients; the other nine (34.6%) had transient HCV infection. The mean period of continuous ALT abnormality was significantly longer in the former (12.4+/-13.6 months) than in the latter (1.9+/-3.5 months) (p = 0.0067). However, only three (17.6%) of 17 patients with chronic HCV viremia had continuous ALT abnormality for more than 24 months; in all of them, ALT eventually normalized.

CONCLUSIONS

These findings indicate that newly acquired HCV infection has continued to occur in hemodialysis patients after the initiation of anti-HCV screening of blood products and that the abnormal ALT found in these patients is related to HCV chronicity.

Influenza in three patients with human immunodeficiency virus infection

Three Japanese outpatients with human immunodeficiency virus (HIV) infection on anti-retroviral therapy showed evidence of influenza in January 1999. CD4+ T cell counts of these patients prior to the diagnosis of influenza were 72, 248, and 152/mm3, and HIV RNA levels were 19,953, 1,259, and 1,585 copies/ml, respectively. Fever continued 4 to 5 days with no severe complications. One patient showed post-influenzal bronchitis which was effectively treated by antibiotics. None of these patients showed increased serum HIV RNA levels during and after influenza, however, in one patient, a transient reduction of CD4+ and CD8+ cells was seen during the active phase of influenza. Although symptoms of influenza in HIV carriers are generally mild and similar to those in healthy adults, careful follow-up is needed as symptoms of influenza in some HIV-infected patients can be prolonged and serious.

Hepatitis C virus infection in institutionalized psychiatric patients: possible role of transmission by razor sharing

The objective of this study was to determine if HCV can be transmitted from patient to patient in psychiatric institutions and to determine possible routes of infection. We did a cross-sectional survey of 196 Japanese psychiatric patients tested for HCV and HBV markers and 400 age- and sex-matched controls. Anti-HCV was detected in 10.2% and antibody to hepatitis B core antigen was detected in 44.4% of the patients, a significantly higher prevalence than found among matched controls. A multiple regression logistic analysis was used to identify risk factors that could indicate the route of infection by HCV. Duration of hospitalization, age, razor sharing, and history of surgery proved to be statistically significant independent risk factors associated with positive anti-HCV results [odds ratio (OR), 4.00; 95% confidence interval (CI), CI, 1.74-9.19; OR, 2.19; 95% CI, 1.27-1.3.77; OR, 4.90; 95% CI, 1.29-18.86; OR, 3.35; 95% CI, 0.997-11.3, respectively]. These observations suggest that razor sharing played an important role in the spread of the HCV infection in the institutionalized psychiatric patients we studied.

[Evaluation of a rapid enzyme immunoassay for detection of influenza A virus among adult and elderly patients]

Directigen Flu A, an enzyme immunoassay membrane test for the detection of influenza A virus, was compared with serum hemagglutinine inhibition assay in adult and elderly patients. Throat specimens were collected by vigorous swabbing from febrile patients who were suspect for influenza by clinical symptoms and tested with Directigen Flu A. Serum samples were collected from the patients at onset of illness and two to eleven weeks later and tested for antibody titer to influenza A/H1N1, A/H3N2, and B. A total of 57 patients were involved in this study; 32 under 59 years of age and 25 over 60 years of age. Influenza was diagnosed in 42 patients by HI titer elevation (73.7%). Directigen Flu A was positive in 25 patients. Results of Directigen Flu A and HI test agreed in 40 patients. Sensitivity and specificity of Directigen Flu A were 59.5% (25/42) and 100% (15/15), respectively. There was no significant difference in sensitivity between the two age groups. These results indicate the potential usefulness of Directigen Flu A in the surveillance of influenza A infection in the geriatric population. Directigen Flu A gives results within 15 minutes without expensive equipment. Use of Directigen Flu permits the timely administration of antiviral therapy and infection control among hospitalized and institutionalized geriatric patients.

Markedly high seroprevalence of hepatitis B virus infection in comparison to hepatitis C virus and human T lymphotropic virus type-1 infections in selected Solomon Islands populations

To determine the prevalences of hepatitis B virus (HBV), hepatitis C virus (HCV), and human T lymphotropic virus type-1 (HTLV-1) infections in residents of the Solomon Islands, we surveyed 1,610 serum samples from 1,113 outpatients and 497 healthy volunteer blood donors at the Central Hospital in Honiara, the Solomon Islands. The prevalence of hepatitis B surface antigen (HBsAg) by radioimmunoassay (RIA) (n = 315, 19.6%) was significantly different from that of antibody to HCV (anti-HCV) by a second-generation enzyme immunoassay (EIA) (n = 4, 0.2%) and antibody to HTLV-1 (anti-HTLV-1) by an ELISA with Western blot analysis to verify the positivity (n = 49, 3.0%) (P < 0.0001, respectively). There were no significant differences in the prevalences of these markers between outpatients and blood donors. Hepatitis B e antigen (HBeAg) was detected by RIA in 130 (41.3%) of 315 HBsAg-positive samples. The distribution of HBsAg subtypes by EIA was 190 adr (60.3%), 111 ayw (35.2%), and 14 (0.4%) other subtypes. The HBeAg prevalence decreased with age in all groups for each subtype. There were no significant differences in the prevalence of HBeAg among HBsAg subtypes. We conclude that HBV infection is highly endemic in selected Solomon Islands populations, and that the high prevalence of HBeAg may be associated with the spread of HBV infection there.

201Tl SPET in the differential diagnosis of brain tumours

The aims of this study were to assess the utility of 201Tl single photon emission tomography (SPET) in the differential diagnosis of brain tumours and to elucidate the relationship between 201Tl tumour uptake and degree of contrast-enhancement on magnetic resonance imaging (MRI). Early (15 min) and delayed (3 h) 201Tl SPET imaging and T1-weighted MRI were performed before and after Gd-DTPA enhancement in 101 (41 malignant and 60 benign) untreated brain tumours. The 201Tl uptake ratio (tumour-to-normal brain count ratio) for both the early and delayed SPET studies and the retention index (the ratio of delayed to early 201Tl uptake) were calculated. Malignant tumours were separated from benign tumours with 87% accuracy based on the assumption that tumours with a 201Tl retention index < 0.7 or no abnormal uptake are benign. Meningiomas and pituitary adenomas were differentiated from other benign tumours by their characteristic pattern on SPET. The degree of contrast-enhancement of the tumour on MRI was concordant with the early 201Tl uptake ratio for most histological types. However, schwannomas and cavernous haemangiomas showed a low 201Tl uptake ratio in spite of a high degree of contrast-enhancement on MRI. In conclusion, 201Tl SPET provides additional information that helps in the differential diagnosis of brain tumours.

[Antibody response to a single injection of influenza vaccine among geriatric inpatients vaccinated annually]

To determine the efficacy of a single influenza vaccine administration in the elderly receiving annual influenza vaccination, antibody response to influenza vaccine was compared between once and twice injections in a geriatric cohort. Influenza vaccination had been done for 69 inpatients in the year prior to the study, and was administered twice for 34 of them and once for the other 35 during the study period. Influenza vaccine was injected twice to 77 inpatients who had not received influenza vaccine in the year prior to the study. Hemoagglutination inhibition (HI) antibody titer for influenza A/H1N1, A/H3N2, and B was measured before vaccination, after the first vaccination, after the second vaccination, and after the epidemic period, September 1995 to April 1996. HI antibody titer prior to vaccination was significantly higher in the patients who had received influenza vaccination the previous year. The influenza vaccine induced an increase in HI titer in almost all subjects, and the geometric mean of the HI titer after vaccination in the patients who received vaccine once was comparable to that of the patients injected vaccine twice. The number of patients with HI titers of over 128x increased, and the frequency ranged from 60.0% to 97.1% for the influenza viruses of the three subtypes. The frequency of HI titers over 128x was not significantly different among the three groups. The second vaccination did not increase the number of patients with HI titers over 128x when compared with the number after the first injection in the patients who had received influenza vaccine the previous year. These results suggest that prior vaccination does not diminish the antibody response to influenza vaccine in the elderly. The efficacy of a single influenza vaccination is comparable to that achieved by twice injections in the elderly receiving annual influenza vaccination.

[Impact of influenza epidemics and efficacy of vaccination among geriatric inpatients]

To determine the impact of influenza epidemics among geriatric inpatients and to monitor the clinical efficacy of influenza vaccination, the influenza infection rate in non-vaccinated inpatients was determined serologically and the incidence of febrile episodes and death were compared between the vaccinees and non-vaccinees hospitalized in the referred hospital from January through September, 1995. Three influenza subtypes, influenza A/H1N1, A/H3N2, and B, were endemic simultaneously from January to March in 1995. The pattern of incidence of febrile episodes varied for each ward. A total of 123 non-vaccinated inpatients were tested for elevation of serum hemagglutination inhibition titer to the three subtypes of influenza virus. Of these, 58 (47.2%) patients were infected with at least one of the influenza viruses during the epidemic of 1995. No patient with pre-existing HI titer over 128X was infected with any of three types of influenza, indicating that HI titer over 128X is the protective level. The febrile episode frequency was significantly higher in the non-vaccinees than in the vaccinees (49.6% vs. 32.6%), but it was quite comparable in the two groups after the influenza epidemic (34.9% vs. 35.8%). The number of observed deaths from January to September of 1995 was 4 (4.9%) in the vaccinee group and 12 (9.8%) in the non-vaccinee group. These results suggest that influenza epidemics have a striking impact on geriatric inpatients and that influenza vaccination has significant efficacy for the reduction of harmful events associated with influenza infection.

[Effect of the prior influenza vaccination on serum antibody titer induction by subsequent inactivated influenza vaccine in the elderly]

In order to investigate the effects of prior influenza vaccination on subaequent annual influenza vaccination in the geriatric population, we analyzed serum hemagglutinine inhibition antibody tirers (HI titer) before and after vaccination with inactivated influenza vaccine in elderly inpatients. A total of 163 inpatients of 60 years or older were enrolled with informed consent. They were classified by vaccination status in the previous year, 53 patients had inactivated vaccine (inactivated). 52 patients had genetically assorted cold-adapted influenza live attenuated vaccine (cold-adapted), and 53 had no influenza vaccine history during the past year. The HI titer was higher in the inactivated group than in the cold-adapted and non-vaccinated groups, suggesting residual immunological effects of inactivated influenza vaccine from the previous year vaccination. The HI titer after the inactivated vaccine in 1993 was higher in both the inactivated and cold-adapted groups than in the non-vaccinated group. The number of patients with HI titers of 2(7) or higher, which is the putative protective HI titer level for influenza infection, was significantly higher in both the inactivated and cold-adapted groups than the non-vaccinated group. These results suggest that continuous annual influenza vaccination does not impair the effects of vaccination, and may actively promote elevated HI titers.

[Clinical significance of peak body temperature, white blood cell count, and C-reactive protein level in febrile episodes among geriatric inpatients]

To investigate the clinical implication of peak body temperature, peripheral blood white blood cell (WBC) count, and serum C-reactive protein (CRP) level in febrile symptoms among geriatric hospitalized patients, they were analyzed in 968 febrile episodes obtained from 433 hospitalized patients in the referred hospital. Episodes of one day duration were most frequent (41.6%). WBC count was elevated over 8000/microliters in 475 episodes (49.1%) and CRP exceeded 1.0 mg/dl in 770 episodes (79.5%). Frequency of WBC elevation decreased and frequency of CRP elevation increased according to the time course. The mean value of CRP increased significantly according to the time course. The frequency of WBC count increase and CRP elevation and their averages correlated to the peak body temperature. The peak body temperature displayed the most striking correlation to the length of febrile episodes among three clinical indicators, peak body temperature, WBC count, and CRP level. These results indicate that the elevation of WBC count and/or CRP level is frequent in geriatric patients with febrile symptoms. Peak body temperature may serve as a clinical indicator of the severy of the febrile disease occurring in geriatric patients.

Thyroid nodules: evaluation with US-guided core biopsy with an automated biopsy gun

To evaluate the efficacy of ultrasound (US)-guided automated core biopsy of thyroid nodules, 74 biopsies were performed in 61 consecutive patients with an 18-gauge short-throw (1.1-cm excursion) biopsy gun. Results were correlated with diagnoses made at surgery (n = 38) or at sonographic follow-up of at least 6 months (n = 36). Sensitivity, specificity, and accuracy of diagnoses made with automated core biopsy were 84%, 95%, and 91%, respectively. US-guided biopsy with an automated biopsy gun allowed accurate assessment of thyroid nodules.

[US-guided core biopsy of the breast with an automated biopsy gun: comparison with an aspiration core needle device]

To evaluate the efficacy of an automated Tru-cut type of biopsy gun in US-guided breast biopsy, we performed 162 breast biopsies in 148 patients using an 18 gauge short-throw (1.1cm excursion) Tru-cut-type biopsy gun (Ace-cut needle). The results of the series were compared with another series of aspiration core biopsies, which were performed on 113 breast lesions in 112 patients using an 18 gauge Sure-cut needle. The results of the two series were correlated with the diagnoses made at surgery or clinical follow-up. Sensitivity, specificity, and accuracy for the automated biopsy gun were 89.2%, 94.9%, and 92.7%, and for the Sure-cut needle, 75.0%, 78.6%, and 77.5%, respectively (p < 0.01 for specificity and accuracy, by chi 2 test). There were no serious complications. The diagnostic surgical biopsy to operated cancer ratios in 1991 (without core biopsy), 1993 (with aspiration core biopsy), and 1995 (with automated core biopsy) were 2.9 (46/10), 2.0 (30/17), and 0.5 (12/24), respectively. We concluded that US-guided breast biopsy with an automated biopsy gun is a safe and highly accurate method, and could replace the diagnostic surgical biopsy.

[Serum albumin level as a predictor of incidence of febrile episodes and mortality in hospitalized geriatric patients]

To investigate the relationship between serum albumin level and incidence of febrile episodes and mortality in the elderly, we studied 748 patients hospitalized for over one year. The subjects included 123 males and 355 females with a mean age 81.2 years. The average serum albumin level was 3.79 g/dl and levels of serum albumin decreased with advancing age. The incidence of febrile episodes was 1.8 per year in patients with serum albumin levels over 4.1 g/dl, increasing with decline of serum albumin levels. The incidence of febrile episodes was 5.3 per year in patients with serum albumin levels under 3.0 g/dl. Patients with serum albumin levels under 3.0 g/dl displayed a high incidence of febrile episodes irrespective of age. Age adjusted in-hospital mortality was 40.4% during the observed period in patients with serum albumin levels under 3.0 g/dl, significantly higher than that of the patients with serum albumin levels over 3.1 g/dl. Relative risk of febrile episode and mortality calculated using the patients with serum albumin levels over 4.1 g/dl as a control was 2.9 and 2.1, respectively, in the patients with serum albumin levels under 3.0 g/dl. These results indicate that serum albumin level is a simple, but strong, predictor of susceptibility of febrile episode and death. Patients with serum albumin levels under 3.0 g/dl may constitute a high risk group for febrile episode and death.

[Incidence and duration of febrile episodes in a hospitalized geriatric cohort]

Fever is a common and important clinical symptom observed among hospitalized geriatric patients. To investigate the frequency and duration of fever episodes, we surveyed fever episodes in a hospital where the frequency of patients over 60 years of age exceeds 90 per cent of the patients. Fever episodes with body temperature of over 37.5 degrees C were registered from May in 1991 to December in 1994, and 6809 episodes were subjected to analysis. The average incidences per month were 157.1, 165.3, 158.0, and 139.3 in 1991, 1992, 1993, and 1994, respectively. The numbers of episodes per month did not show any significant correlation with temperature or humidity. Average duration of the episodes were 8.0, 6.5, 7.6, and 6.7 days for 1991, 1992, 1993, and 1994, respectively. Episodes of one day duration were the most frequent in all months, and the frequencies of that ranged from 37.1% to 58.6% with a mean of 47.8%. The average duration of episodes and the frequency of one day episodes did not change significantly irrespective of a notable decrease in the total incidence. The high frequency of one day episodes and their consistency through the observed period suggest that fevers with one day duration are one of the characteristic features of the febrile symptoms in geriatric patients. Causality and prevention methods for these one day fever episodes should be investigated.

[Evaluation of immunochromatography assay technique for detection of antibody to hepatitis B surface antigen (HBsAg)]

A new immunochromatography assay (Dainascreen Ausab Dainabot) has been recently introduced for the detection of the presence of antibody to HBsAg. To evaluate the feasibility of using the Dainascreen Ausab, we carried out comparison tests with this method and PHA. In the test of 439 sera from HB vaccinees, inhabitants in Iki Island, Nagasaki Pref., patients with autoimmune diseases and with acute hepatitis B, 154 (31.2%) were positive by Dainascreen Ausab, 145 (29.4%) were positive by PHA and 145 (29.4%) were positive by both Dainascreen Ausab and PHA. Nine (1.8%) were positive by only Dainascreen and there were none positive by only PHA. A good correlation was observed between the titer of the antibody by this method and IMx. The anti-HBs assay by this method was able to be completed within 15 minutes and the procedure was very simple. The results indicate that the sensitivity of Dainascreen is superior to PHA and that it is easy to use.

Hypoperfusion and vasoreactivity in the thalamus and cerebellum after stroke

BACKGROUND AND PURPOSE

Cerebellar hypoperfusion in the contralateral hemisphere after stroke is well studied and termed crossed cerebellar diaschisis. However, studies of hypoperfusion in the ipsilateral thalamus have been few. The purpose of this study was to investigate the prevalence of hypoperfusion and vasoreactivity to acetazolamide in the thalamus and cerebellum after stroke.

METHODS

We studied cerebral blood perfusion in the thalamus and cerebellum of 14 patients with unilateral cerebral infarction using [123I]isopropyliodoamphetamine single-photon emission computed tomography (123I-IMP SPECT). We also administered acetazolamide-stressed 123I-IMP SPECT to determine vasodilator capacity in these two areas. Regions of interest were drawn over the bilateral thalami and bilateral cerebellar cortices, and asymmetry indexes were obtained.

RESULTS

We found ipsilateral thalamic hypoperfusion in 12 (85.7%) and contralateral cerebellar hypoperfusion in 11 (78.6%) of 14 patients. Hypoperfusion was improved (p < 0.01 by the Wilcoxon signed rank test) in 11 (91.7%) of the 12 patients with ipsilateral thalamic hypoperfusion and in seven (63.6%) of the 11 patients with contralateral cerebellar hypoperfusion.

CONCLUSIONS

Hypoperfusion in the ipsilateral thalamus and contralateral cerebellum is common, and vasoreactivity to acetazolamide is preserved in both the thalamus and the cerebellum with hypoperfusion.

Fatty metamorphosis in hepatocellular carcinoma: radiologic features in 10 cases

We describe the sonographic, CT and angiographic findings in 10 cases of hepatocellular carcinoma in which extensive fatty metamorphosis occurred within the tumors. Fatty change was diffuse in smaller tumors (less than 3.5 cm) and focal in larger tumors (greater than 3.5 cm). Fatty metamorphosis characteristically caused a low-attenuation area on CT (less than -10 H) and a highly echogenic area on sonography. The sonographic appearance of small hepatocellular carcinomas with fatty metamorphosis was identical to the findings in cavernous hemangioma or focal fatty change of the liver. CT correctly revealed the presence of fat in these hepatocellular carcinomas. In these cases, hepatic arteriography showed no tumor stain; however, CT arteriography (dynamic CT during injection of contrast medium into the hepatic artery) was useful in showing the tumor, its capsule, and its internal septa. In the diagnosis of large hepatocellular carcinoma, the presence of intratumoral fat is not likely to be problematic, but small tumors that are diffusely infiltrated by fat must be distinguished from such benign conditions as focal fatty change, lipoma, and angiomyolipoma.