Development of a real-time recombinase-aided amplification (RT-RAA) molecular diagnosis assay for sensitive and rapid detection of Toxoplasma gondii

Toxoplasma gondii, a protozoan intracellular parasite, is present in a wide range of hosts, including virtually all species of warm-blooded vertebrates. Toxoplasmosis spreads to humans through a variety of pathways, including contaminated food or water, and close contact with various types of domestic animals. It poses a severe threat to human health, and contributes to important economic losses, not only in cost-of-illness but also in surveillance programs. It is thus necessary to develop a rapid point-of-care field diagnostic technology to control or prevent pathogen transmission to economically important livestock animals, domestic animals, and human beings. In this study, we develop a real-time isothermal amplification method capable of detecting the T. gondii genome in swine and feline blood samples. This method can detect toxoplasma genome with a lowest detection limit of 10² copies of per reaction under optimal reaction conditions of 36 °C for 25 min. The assay displayed advantages in sensitivity and specificity in comparison to traditional real-time PCR, and can be performed in a portable instrument.

Latent pseudorabies virus infection in medulla oblongata from quarantined pigs

Pseudorabies virus (PRV) is a major pathogen in pig husbandry and is also a risk to human well-being. Pigs with latent PRV infection carry the virus lifelong, and it can be activated under conducive conditions. This poses a very important challenge to the control of the virus and may even prevent its elimination. To investigate latent infection with wild-type (wt) PRV, and also infection due to the use of live attenuated vaccines on farms, 80 pigs from two large-scale swine operations were traced. At 6 months old, the quarantined pigs were slaughtered and brain samples were collected. A PCR assay targeting the gB and gE genes was developed to detect PRV DNA fragments in medulla oblongata. Five of the samples (6.3%) were gB and gE gene fragment double-positive, 60 of the samples (75%) were gB single-positive, and 15 samples (18.7%) showed double-negative. A portion of latency-associated transcripts (LATs), EP0 mRNA, were found to be present in the gB gene fragment positive samples. Furthermore, the five double-positive samples were transmitted blindly, and apparent cytopathic effects were found in three of the five samples in the fourth generation. By means of Western blotting, PCR and sequencing, two of the isolated viruses were found to be related to vaccine strain Bartha-K61. Another was closely related to domestic epidemic strains HN1201 and LA and relatively unrelated to other Asian isolates. These results suggest that the live vaccines are latently present in brains, in a manner similar to wt PRV, and this poses potential safety issues in the pig husbandry industry. Wt PRV and live vaccine viruses were found to co-exist in pigs, demonstrating that the live vaccines were unable to confer complete sterilizing immunity, which may explain outbreaks of pseudorabies on vaccinated farms.

Isolation and sequence analysis of the complete VP2 gene of canine parvovirus from Chinese domestic pets and determination of the pathogenesis of these circulating strains in beagles

Canine parvovirus (CPV) causes acute gastroenteritis in domestic dogs, cats, and several wild carnivore species. In this study, the full-length VP2 gene of 36 CPV isolates from dogs and cats infected between 2016 and 2017 in Beijing was sequenced and analyzed. The results showed that, in dogs, the new CPV-2a strain was the predominant variant (n = 18; 50%), followed by the new CPV-2b (n = 6; 16.7%) and CPV-2c (n = 3; 8.3%) strains, whereas, among cats, the predominant strain was still CPV-2 (n = 9; 25%). One new CPV-2a strain, 20170320-BJ-11, and two CPV-2c strains, 20160810-BJ-81 and 20170322-BJ-26, were isolated and used to perform experimental infections. Multiple organs of beagles that died tested PCR positive for CPV, and characteristic histopathological lesions were observed in organs, including the liver, spleen, lungs, kidneys, small intestines, and lymph nodes. Experimental infections showed that the isolates from the epidemic caused high morbidity in beagles, indicating their virulence in animals and suggesting the need to further monitor evolution of CPV in China.

pUC18-CpG stimulates RAW 264.7 via TBK1-mediated pathway and presents adjuvanticity in mice

Phosphorothioate CpG oligodeoxynucleotides (ODN) are reported to be recognized by the membrane-bound TLR9 and trigger the MyD88-dependent up-regulation of Type I interferons and pro-inflammatory cytokines. Whether plasmids containing multiple CpG motifs stimulate the same signaling pathway is yet to be determined. The present results show that the CpG motifs enrich plasmid pUC18-CpG stimulates RAW 264.7 in vitro, mainly through the TBK1-mediated signaling pathway, causing the up-regulation of IFN-β, and pro-inflammatory cytokines TNF-α and IL-6. When pUC18-CpG is co-administered with the recombinant Echinococcus granulosus antigen, the antigen-specific antibody titers are markedly increased compared to the Quil-A adju- vanted group. Antigen specific cytokine quantification shows that cytokine profiles from the pUC18-CpG adjuvanted-group are switched to a Th1-biased immune response.

Phospholipase C signaling is involved in porcine reproductive and respiratory syndrome virus infection in cell cultures

The phospholipase C (PLC) is a family of kinases that hydrolyze phosphatidylinositol 4,5-bisphosphate [PI(4,5)P2] to generate two second messengers, inositol 1,4,5-trisphosphate (IP3) and diacylglycerol (DAG), which stimulate distinct downstream signaling. Recently, it has been reported that PLC signaling is activated by multiple viruses for efficient replication and the virus-induced inflammatory response. In this study, we demonstrated that PLC-specific inhibitor U73122 strongly suppressed porcine reproductive and respiratory syndrome virus (PRRSV) productive infection in cell cultures. The inhibitor affected both viral post-binding cell entry and post-entry processes. The virus infection led to an early transient activation of PLCγ-1 at 0.5 h post-infection (hpi), and sustained event at a stage from 4 to 16 hpi in MARC-145 cells. In addition, U73122 inhibited the activation of p38 MAPK signaling stimulated by PRRSV infection, suggesting that PLC signaling may be associated with the virus infection-induced inflammatory response. Taken together, these studies suggested that PLC signaling played an important role in PRRSV infection or pathogenesis. Keywords: PRRSV; U73122; phospholipase C; PLCγ-1.

Development of a recombinase polymerase amplification assay with lateral flow dipstick for rapid detection of feline parvovirus

Feline panleukopenia caused by feline parvovirus (FPV), a single-stranded DNA virus, is typically highly contagious and often presents with lethal syndrome. The broad spectrum of possible hosts suggests its potential for transmission from animal to person through close contact with pets. FPV thus serves as an example of the importance of new rapid point-of-care field diagnostic tools for the control and prevention of transmission, especially among rare wild animals and pet cats. Recombinase polymerase amplification (RPA), as a real-time and isothermal method, could be a more affordable alternative to PCR when combined with a lateral flow dipstick (LFD) indicator. In this study, we report a novel FPV lateral flow dipstick RPA (LFD-RPA) instant detection method capable of detecting a range of different FPV strains. The LFD-RPA assay consists of specific primers, probe, and nucleic acid strip. It is capable of detecting 10² copies of target nucleic acid per reaction, which is one order of magnitude higher than the sensitivity of traditional PCR. The most suitable reaction conditions for this assay are at 38 ℃ for 15 min. This paper develops an efficient visual detection system that can eliminate the need for professional staff and expensive and sophisticated equipment for field detection.

[RET pro-oncogene and medullary thyroid carcinoma]

Medullary thyroid carcinoma (MTC) originats from the parafollicular C cells of the thyroid, which is one of the most aggressive forms of thyroid malignancy with the poor prognosis. Hereditary MTC has multiple endocrine neoplasia types 1, 2A and 2B. The mutation of RET proto-oncogene has been identified as the main cause of MTC, and all mutations locate among the exons 5, 8, 10, 11, 13, 14, 15, and 16. Mutation analysis of the RET may provide a theoretical basis for the prevention, diagnosis and treatment of MTC.

Molecular epidemiological and phylogenetic analyses of canine parvovirus in domestic dogs and cats in Beijing, 2010-2013

Fifty-five samples (15.62%) collected from dogs and cats were identified as canine parvovirus (CPV) infection in Beijing during 2010-2013. The nucleotide identities and aa similarities were 98.2-100% and 97.7-100%, respectively, when compared with the reference isolates. Also, several synonymous and non-synonymous mutations were also recorded for the first time. New CPV-2a was dominant, accounting for 90.90% of the samples. Two of the 16 samples collected from cats were identified as new CPV-2a (12.5%), showing nucleotide identities of 100% with those from dogs. Twelve samples (15.78%) collected from completely immunized dogs were found to be new CPV-2a, which means CPV-2 vaccines may not provide sufficient protection for the epidemic strains.

Long terminal repeat sequences from virulent and attenuated equine infectious anemia virus demonstrate distinct promoter activities

In the early 1970s, the Chinese Equine Infectious Anemia Virus (EIAV) vaccine, EIAV(DLA), was developed through successive passages of a wild-type virulent virus (EIAV(L)) in donkeys in vivo and then in donkey macrophages in vitro. EIAV attenuation and cell tropism adaptation are associated with changes in both envelope and long terminal repeat (LTR). However, specific LTR changes during Chinese EIAV attenuation have not been demonstrated. In this study, we compared LTR sequences from both virulent and attenuated EIAV strains and documented the diversities of LTR sequence from in vivo and in vitro infections. We found that EIAV LTRs of virulent strains were homologous, while EIAV vaccine have variable LTRs. Interestingly, experimental inoculation of EIAV(DLA) into a horse resulted in a restriction of the LTR variation. Furthermore, LTRs from EIAV(DLA) showed higher Tat transactivated activity than LTRs from virulent strains. By using chimeric clones of wild-type LTR and vaccine LTR, the main difference of activity was mapped to the changes of R region, rather than U3 region.

Evaluation of proteinuria in healthy living kidney donor candidates

BACKGROUND

Evaluation of living kidney donor candidates includes careful assessment for the presence or absence of kidney disease. Kidney donation has been considered to be at least relatively contraindicated if urinary total protein excretion is above the normal range. However, at the present time, there is no uniformly accepted level of urine total protein excretion that would exclude donation. Albumin excretion instead of total protein excretion as a criterion has not previously been evaluated.

MATERIALS AND METHODS

This was a prospective observational study over a 3-year period in a single tertiary care center designed to assess current selection criteria for kidney donation with respect to urine total protein and albumin excretion.

RESULTS

Twenty four percent (25 of 105) of healthy adult kidney donor candidates had elevated urinary total protein excretion rates (150 to 292 mg/24 h). Of these 105 candidates, 39 had simultaneous measurements of both urinary total protein and albumin. Although one-third (13/39) had elevated 24-hour urine total protein values, none had elevated urine albumin excretion.

CONCLUSION

Measurement of albumin, the most common single protein found in urine, appears to be helpful in the evaluation of proteinuria in donor candidates. Many healthy adult kidney donor candidates have mildly elevated total protein excretion but normal albumin excretion. We believe that such patients should not be excluded from donation.

Midterm outcome of mitral valve regurgitation after repair of atrioventricular septal defect

The purpose of this retrospective study was to evaluate the outcome of mitral regurgitation (MR) following repair of atrioventricular septal defects (AVSDs). Echocardiograms of all survivors after AVSD surgery between 1991 and 1996 were reviewed. This study enrolled 16 patients who had had more than two postoperative color Doppler studies. On each echocardiogram, MR severity was graded on a 1+ to 4+ scale, based on the size of the MR jet. Mean age at surgery was 31.1 months (range 2.5 to 83) and mean postoperative follow-up duration was 23.6 months (range 1 to 59). Mild deterioration of mitral valve function was common. MR severity increased by one or more grades in 5 patients (31%) between the initial and final examinations. However, the deterioration in mitral valve function occurred primarily on the immediate postoperative stage. On mid-term follow-up, the MR improved, or at least became stationary, in all patients. Mitral valvuloplasty was not necessary in surviving patients. We conclude that postoperative MR remains fairly stable following AVSD repair. Serious deterioration is rare.

Surgery for achalasia: long-term results in operated achalasic patients

Achalasia is a functional disorder of the alimentary tract due to decreased or absent peristalsis of the esophageal body and obstructive outlet of the esophagus. Surgical treatment, eg. esophagomyotomy of the lower esophageal sphincter (LES), was one choice for resolving the problem and its effect was affirmative from reviews of many internationally authorized articles. However, few reports have ever questioned the long-term effects of it. From January 1968 to May 1996, 159 esophageal achalasic patients, 90 males and 69 females, were admitted due to dysphagia or food regurgitation. One hundred and forty-five patients had received 158 operations related to this benign motor disorder. The majority of patients received either modified Heller esophagomyotomy (M) or M plus modified Belsy Mark IV antireflux procedure (M+W) for primary treatment of their esophageal disorder, while conditional selection with addition of esophageal resection as advanced procedures for failure of primary surgery. We retrospectively studied these patients, collected their preoperative and postoperative clinical results, analyzed the causes of recurrent symptoms, compared the long-term results in different surgical procedures and searched for the pathogenesis of their failure. The results disclosed that the overall success rate for both methods was 73.1% with 85.7% for patients receiving M+W (56) and 64.9% of M (77) only. Through long-term follow-up, we had an improvement rate of 97.4% at an early stage and 53.3% for M at a late stage and 98.4% and 55.6% for M+W, respectively. The postoperative natural course of achalasic patients could be seen and progressive deterioration of the operated patients with time was noted. Several factors might contribute to the causes of unsuccessful surgery. We summarized them as incomplete myotomy, fused or healed myotomy, gastroesophageal reflux (GER), mucosal hernia and co-combined antireflux procedure by hypercalibrated or floppy wrapping. Esophagomyotomy or myotomy plus antireflux procedure for the esophagus could be concluded to rather effective in the long-term but palliative treatments for achalasia chronic deterioration of the results could be found for both of them. Defective myotomy and GER may be the major causes for their failure. The choice of types of surgery between M and M+W was not the cause of the unsuccessful results whereas the operative strategy and procedures would have a certain significance on the long-term effect.

Neonatal tuberous sclerosis with cardiac rhabdomyomas presenting as fetal supraventricular tachycardia

A case of fetal tuberous sclerosis with multiple intracardiac rhabdomyomas exhibited persistent supraventricular tachycardia. The tachycardia was terminated by the use of cardiac version. The largest tumor almost occluded the right ventricular inlet portion. The obstruction was relieved after surgical removal of the largest tumor. No arrhythmia was noted after 3 months of follow-up.

Case report: agenesis of the right lung diagnosed by three-dimensional reconstruction of helical chest CT

Unilateral pulmonary agenesis is extremely rare and the diagnosis can be made by a number of conventional methods. We report two cases: a 16-day-old girl and a 14-year-old girl presenting with tachypnoea in whom three-dimensional reconstruction of helical chest computed tomography was used to demonstrate the complete absence of the carina, right main bronchus and right lung. To our knowledge, these are the first cases of right lung agenesis diagnosed by this method.

Effect of pregnancy on renal function in patients with moderate-to-severe diabetic renal insufficiency

OBJECTIVE

Previous studies of patients with diabetic nephropathy and mild renal impairment have suggested no determination in renal function as a result of pregnancy. The objective of this study was to determine whether pregnancy may permanently worsen renal function in women with diabetic nephropathy and moderate-to-severe renal insufficiency.

RESEARCH DESIGN AND METHODS

Eleven patients were identified with diabetic nephropathy and moderate-to-severe renal dysfunction (creatinine [Cr] > or = 124 mumol/l [1.4 mg/dl]) at pregnancy onset by retrospective chart review. Alterations in glomerular filtration rate were estimated by using linear regression of the reciprocal of Cr over time. An equal number of nonpregnant premenopausal type 1 diabetic women with similar degrees of renal dysfunction served as a comparison group for nonpregnant rate of decline of renal function and potential contributing factors.

RESULTS

Mean serum Cr rose from 159 mumol/l (1.8 mg/dl) prepregnancy to 221 mumol/l (2.5 mg/dl) in the third trimester. Renal function was stable in 27%, showed transient worsening in pregnancy in 27%, and demonstrated a permanent decline in 45%. Proteinuria increased in pregnancy in 79%. Exacerbation of hypertension or preeclampsia occurred in 73%. Seven patients progressed to dialysis 6-57 months postpartum, with 71% (five of seven) of these cases attributed to acceleration of disease during the pregnancy. Student's tests and repeated-measures analysis of variance support a pregnancy-induced acceleration in the rate of decline of renal function.

CONCLUSIONS

In this series, patients with diabetic nephropathy and moderate-to-severe renal insufficiency were found to have a > 40% chance of accelerated progression of their disease as a result of pregnancy.

Separation of thoracopagus conjoined twins. A case report

A pair of thoracopagus conjoined twins with a connection at the atrioventricular groove of both hearts and a huge conjoined liver were surgically separated. An aortopulmonary shunt was created for Twin B, a victim of complex congenital heart disease with hypoplastic right heart syndrome, who died 5 hours later. However, Twin A survived after prolonged endotracheal intubation and parenteral nutrition. He survived for 7 months, and went home, but finally died of sepsis. In reviewing 47 pairs of surgically separated thoracopagus conjoined twins, in 30 pairs of type A (Leachman's classification, completely separate hearts), 42 patients survived (70%); in 5 pairs of type B (atrial connection only), one patient survived (10%); in 9 pairs of type C (both atrial and ventricular interconnections), none survived; in 3 pairs of unknown type, 2 survived. Total survival rate of surgically separated thoracopagus conjoined twins was 47.9%. The survival rate was 38.2% in those operated in the neonatal period (n = 34) and 63.6% in those operated over 1 month of age (n = 44) (p = 0.016). In conclusion, thoracopagus conjoined twins are rare. Although its separation carries a high risk, especially in those with cardiac connection, this report confirmed that separation is still feasible under proper preparation and planning.

Unilateral pulmonary vein stenosis with atrial septal defect: report of one case

A male infant with stenosis of the left pulmonary veins and atrial septal defect is reported. He began to have repeated pulmonary infections, with poor response to medical treatment, when he was 6 months old. Localized stenosis of the left upper and lower pulmonary veins were diagnosed with cardiac catheterization at the age of 7 months. Transvenous balloon dilation was attempted, but failed. Surgical treatment with pericardial patch venoplasty of the left pulmonary veins and closure of the atrial septal defect successfully released the pulmonary venous obstruction. There has been a follow-up for more than one year, and no cardiopulmonary symptoms were reported.

Pregnancy in women on haemodialysis and peritoneal dialysis

Pregnancy in women with renal insufficiency and end-stage renal disease, while uncommon, is definitely possible, and such women should not assume they are infertile. Contraception should be prescribed for those who do not want to conceive. For the woman who is dialysed during pregnancy, the risks can be minimized by aggressive blood pressure control and prompt diagnosis and treatment of bleeding episodes; however, no degree of vigilance can guarantee that a woman will not suffer any of the severe complications that have been described in pregnant dialysis patients. Intensive dialysis should be undertaken to maintain chemistries that are as nearly normal as possible, and premature labour should be treated with indomethacin. Our current state of knowledge suggests that the success rate of pregnancy in dialysis patients is no better than 52%. It remains to be seen whether CAPD and erythropoietin improve the currently poor outcome. While transplantation offers the best chance of child bearing for women with end-stage renal disease, transplantation is not always possible. Thus we no longer discourage women on dialysis from becoming pregnant as long as they understand that the likelihood of success is small and that serious risks are involved, and as long as they are willing to follow the time-consuming regimen we think it is necessary for their safety. We hope that, in time, increased experience with pregnant dialysis patients will lead to more successful outcomes and that the possibility of parenthood will be added to the improved quality of life in these women.

Comparison of conventional and simultaneous compression-ventilation cardiopulmonary resuscitation in piglets

To determine the mechanism of cardiac output and hemodynamic changes during cardiopulmonary resuscitation (CPR), we performed 60 min of CPR using a mechanical resuscitator ("Thumper", MII, USA) in 20 piglets (13.7 +/- 1.2 kg) following cardiac arrest induced by intravenous injection of KCl. Conventional CPR (C-CPR), i.e., 60 external chest compressions (60 psi force, 3 cm deep, and 50% duration) and 12 ventilations (following every 5th compression, with peak airway pressure of 30 cmH2O) per minute, was performed in 10 piglets; and simultaneous compression and ventilation CPR (SCV-CPR), i.e., 60 external chest compressions of the same magnitude, simultaneously with 60 ventilations (with peak airway pressure of 60 cmH2O) per minute, was performed in the 10 other piglets. Cardiac output in C-CPR and SCV-CPR was maintained near 70% or more of baseline throughout the CPR. Systemic vascular resistance dropped to below 50% of baseline. Systolic, mean and diastolic arterial pressures were maintained above 70, 40, and around 20 mmHg, respectively, during the first 30 min of CPR. Central venous pressure rose after arrest and subsequent CPR to above 25 mmHg, and remained high in SCV-CPR, but declined thereafter in C-CPR. Aortic diastolic minus right atrial diastolic pressure was around 15 mmHg early in CPR and dropped to almost zero thereafter. Serial arterial blood gas analyses showed a significant deterioration after 20 min of SCV-CPR. All but one piglet in the SCV-CPR group died after 60 min of CPR. Postmortem examination revealed that pulmonary barotrauma was more extensive and severe in SCV-CPR than in C-CPR.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency and outcome of pregnancy in women on dialysis

Two hundred six dialysis units were surveyed to determine the frequency and outcome of pregnancy in dialysis patients. Ninety-four percent of the units responded. Of the 1,281 women of childbearing age cared for in these units, 1.5% became pregnant during the 2-year study period. Thirty-seven percent of pregnancies resulted in surviving infants. Pregnancies that took place from 1990 on had a 52% success rate. There was no significant difference in outcome as a result of dialysis modality or erythropoietin use. All but one of the infants were premature. Pregnancy entailed substantial risks for the mother.

Open heart surgery in geriatric patients

With the progress of medical science, the scope of open heart surgery has expanded. From 1975 through 1987, we operated on 114 consecutive patients aged 65 years and over with the aid of a cardiopulmonary bypass in the Department of Surgery, National Taiwan University Hospital. The annual number of these elderly patients has increased gradually, reaching 6.4% of the annual open heart cases in 1987. Eighty-six of our 114 patients were males and 28 were females. Their ages ranged from 65 to 88 years with an average of 68.5 years. Overall, 65 patients (57%) were operated on for coronary artery disease and/or its associated lesions; 41 (36%), for valvular heart disease; six, for aortic dissection; two, for cardiac tumor; and one, for congenital pulmonary stenosis. One patient had combined coronary artery disease and aortic dissection. The mortality for isolated coronary artery bypass surgery was 12%; for single valvular surgery it was 11%. The complexity of the surgical procedure increased the operative mortality. The overall mortality was 23.6% (27/114), with subsequent death in 5.7% during an average of 25 months of follow-up. Because of the degeneration of organ-systems in elderly patients, and its frequent association with poor cardiac reserve and other medical problems, these elderly cardiac patients should be checked thoroughly before they are considered for open heart surgery. Our experience suggests that open heart surgery can be done in selected patients aged 65 years or older with acceptable risks. Age alone should not be an absolute contraindication to surgery, and clinical improvement is to be expected after surgery.

Rupture of chordae tendineae in acute rheumatic carditis: report of one case

Acute rheumatic carditis is a rare cause of ruptured chordae tendineae of the mitral valve. Such rupture could result in severe mitral regurgitation and in fatality. Surgical valvuloplasty or valve replacement is usually necessary. A 12-year old boy presented with acute rheumatic carditis, complicated with rupture of the chordae tendineae of the mitral valve leading to intractable congestive heart failure and cardiogenic shock. He was successfully treated by a simple repair of the chordae and by mitral valvuloplasty.

Fate of the autologous tri-cusp-valved pericardial conduit in the right ventricular outflow tract of growing pigs

No perfect valve or valved conduit is currently available to reconstruct the right ventricular outflow tract (RVOT) in pediatric patients. To investigate the fate of autologous pericardial valved conduit, twenty piglets weighing 12.2 +/- 1.4 kg were divided into two groups. In 10 of them, the pericardium was immersed in 0.6% glutaraldehyde for 5 minutes (Gr PG) and then washed with normal saline. In the other 10 pigs, the pericardium was immersed in normal saline only (Gr PN) after procurement. Afterwards the autologous pericardium was tailored as designed to build a tri-cusp-valve inside the pericardial conduit with reconstruction of the sinus of Valsalva. This conduit was connected to the pulmonary trunk (PT) distally and RVOT proximally without a pump. The PT was then doubly ligated just above the annulus. The pigs survived 114 +/- 92 days in Gr PG and 82 +/- 50 days in Gr PN. The body weight increased to 42 +/- 29 kg in Gr PG and 30 +/- 9 kg in Gr PN. No cusps adhered to the conduit wall in either group. In Gr PN, the valve became retracted; in 7 of them an aneurysm developed proximal to the stenotic pulmonary valve, while only one pig in Gr PG developed an aneurysm. In Gr PG, the leaflet and conduit showed evidence of growth. In contrast, no evidence of valve growth was found in Gr PN. Calcification was evident more in Gr PG than in Gr PN either on the leaflet (9/10 vs. 5/10) or in the wall of conduit (8/10 vs. 6/10), but the differences were not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcium and phosphorus fluxes during hemodialysis with low calcium dialysate

We evaluated the acute effects of varying dialysate calcium concentration on plasma concentrations and dialyzer fluxes of calcium and phosphorus in adult hemodialysis patients. Seven individuals with stable end-stage renal failure were dialyzed 4 hours, three times weekly. The effects of dialysates containing 1.75, 1.25, or 0.75 mmol/L (70.1, 50.1, or 30.1 mg/L) of calcium were compared. Each patient was studied once at each bath calcium concentration. Compared with the predialysis mean value of 2.27 mmol/L (9.1 mg/dL), plasma total calcium concentration increased, remained constant, or decreased with the 1.75-, 1.25-, or 0.75-mmol/L calcium dialysates, respectively. The 0.75-mmol/L calcium dialysate did not cause signs or symptoms of hypocalcemia (and the plasma calcium concentration did not fall below 1.80 mmol/L [7.2 mg/dL]). Plasma phosphorus concentrations decreased equally from a predialysis mean value of 2.16 mmol/L (6.7 mg/dL), regardless of the dialysate calcium concentration. After 4 hours of treatment with the three different dialysates, the cumulative calcium fluxes were significantly different. With 1.75 mmol/L calcium, mean bodily calcium accumulation was 21.9 mmol (879 mg). With 1.25 mmol/L, there was no net calcium flux. With 0.75 mmol/L, mean patient calcium loss was 5.8 mmol (231 mg). Mean phosphorus removal after 4 hours was 32.5 mmol (1,006 mg) and was unaffected by dialysate calcium concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Exfoliative dermatitis secondary to tobramycin sulfate

We report a case of exfoliative dermatitis clearly linked to intravenous and intraperitoneal administration of tobramycin. Despite the complicated drug regimen with which the patient was treated, tobramycin was implicated by rechallenge with the drug once before its role was understood and again at an outside hospital.

Temporary loss of limb function secondary to soft tissue calcification in a patient with rhabdomyolysis-induced acute renal failure

A case of unusually severe soft tissue calcification with temporary loss of limb function in a patient with rhabdomyolysis-induced acute renal failure (ARF) is described. A large dose of intravenous (IV) calcium was administered early in the hospital course to treat hypocalcemia, and hemodialysis, when initiated, was with a 1.75-mmol/L calcium dialysate. This case illustrates the danger of administering calcium supplementation and raises questions about the use of normal to high dialysate calcium concentration in the early stages of rhabdomyolysis-induced oliguric ARF. Calcium supplementation should be reserved for patients with clear clinical signs of hypocalcemia and dialysate calcium should be adjusted to prevent excessive positive calcium balance.

Downward displacement of aortic anulus leading to aortic and mitral regurgitation

A rare case of combined aortic and mitral regurgitation resulting from downward displacement of the aortic anulus is reported. The patient was treated successfully with an aortic valve replacement with a Björk-Shiley valve prosthesis, which was anchored at the normal site of the aortic anulus. No procedures were performed on the mitral valve, but mitral regurgitation was not evident postoperatively.

Ventricular septal defect in Chinese with aortic valve prolapse and aortic regurgitation

The incidence of aortic valve prolapse and aortic regurgitation (AR) among Chinese with ventricular septal defect (VSD) has not been studied, and controversies still exist regarding optimal surgical treatment and timing of operation for this condition. A prospective study of 332 consecutive patients with VSD showed that aortic valve prolapse and AR occurred in 43 (11.9%) patients. Valve lesions occurred more commonly among patients with subpulmonic VSD (28.0%) than with subaortic VSD (8.8%) (P less than 0.005). A retrospective study of another 306 patients revealed that 37 (12.1%) had valve complications. Of the 80 patients with valve lesions, 60 were males and 20 were females. The youngest ages of prolapse and AR in subpulmonic VSD were 7 months and 3 years 8 months, respectively; those in subaortic VSD were 2 years and 3 years 6 months, respectively. Valve prolapse occurred mostly before the age of 6-10 years, leading progressively to AR. The coronary cusps prolapsed in subpulmonic VSD were limited to the right cusp; and those in subaortic VSD were the right cusp, noncoronary cusp, or both. The magnitude of left-to-right shunts was small and the pulmonary artery pressure was normal in the majority of patients. Seventy-two patients underwent open-heart closure of the VSD, with additional valvuloplasty in 15 and valve replacement in three patients. It is concluded that Chinese with VSD are prone to develop aortic valve complications. Surgical closure of the subpulmonic VSD may restore the prolapsed valve to normal. Closure of the subaortic VSD has little effect. Valvuloplasty in subaortic VSD may palliate AR, but in all probability cannot restore valve competency.

Hyperprolactinemia in patients with renal insufficiency and chronic renal failure requiring hemodialysis or chronic ambulatory peritoneal dialysis

Hyperprolactinemia is common in patients with renal failure. Because radiographic contrast material given during a computed tomographic (CT) scan of the sella as part of the evaluation for prolactinoma worsens renal insufficiency, we attempted to define the point at which hyperprolactinemia becomes an expected finding in patients with renal insufficiency in this study. Of 59 patients with serum creatinine levels of 1.5 to 12 mg/dL, 16 (27.1%) were hyperprolactinemic. Of these 16, nine were not taking medications known to raise prolactin levels and their prolactin levels were less than 100 ng/mL. In the eight patients taking medications prolactin levels were much higher. In one patient the prolactin level fell from 2,210 to 100 ng/mL when methyldopa was discontinued. In patients with chronic renal failure prolactin levels were similar regardless of the method of dialysis. We conclude that in the absence of medications known to affect prolactin secretion, hyperprolactinemia occurs infrequently (18.3%) and, when it occurs, is mild (less than 100 ng/mL). Marked hyperprolactinemia may occur in patients taking such medications. These should be stopped and the prolactin level rechecked before a CT scan is performed.

Pregnancy in women with renal disease and moderate renal insufficiency

Data were gathered on 25 pregnancies in 23 women with moderate renal insufficiency as defined by a serum creatinine level of 1.4 mg/dl or greater prior to or at the onset of pregnancy. Twelve of the women had primary glomerular diseases, five (accounting for seven pregnancies) had interstitial diseases, and six had other renal diseases. In seven women with baseline serum creatinine levels ranging from 1.7 to 2.7 mg/dl, pregnancy was accompanied by a decline in renal function that was believed to be greater than expected from the natural history of the disease. The change ranged from a rise in serum creatinine level of 1.2 mg/dl to a functional decline that required dialysis. In 14 women (16 pregnancies), renal function either remained stable or declined to a degree consistent with the natural history of the disease. In two, the follow-up period was not long enough to judge the effect on the natural history of the disease. In 14 pregnancies, development or worsening of hypertension occurred. In nine, the diastolic blood pressure rose to 110 mm Hg or greater, and delivery was required because of hypertension. Twenty-three of 25 pregnancies ended in live births (92 percent) and 21 babies survived (84 percent). Fourteen of the 23 live births were premature. It is concluded that, in a substantial fraction of women with moderate renal insufficiency, pregnancy is accompanied by a decline in renal function; however, the fetal survival is much better than previously reported.

Two-dimensional echocardiographic detection of pericardiocentesis-induced intrapericardial thrombus

Heart puncture-induced hemopericardium is a serious complication of the pericardiocentesis. Two-dimensional echocardiographic examination performed in two patients just before and after the development of hemopericardium revealed a unique image in which pericardial bleeding manifested itself by an echodensity thrombus appearance adjacent to the cardiac chambers. With appropriate differentiation to some other intrapericardial echodensity masses, such distinctive images can be highly specific for active bleeding into the pericardial sac.

Acute fatty liver of pregnancy. Survival with early cesarean section

We have cared for two women with acute fatty liver of pregnancy in the past two years. Both patients survived as did three of babies. This compares with published mortality rates of up to 85% with this condition. Both patients presented with symptoms and signs of impending liver failure during the third trimester of pregnancy. Both patients were jaundiced, had elevated aminotransferases, leukocytosis, hepatic encephalopathy, and disseminated intravascular coagulation. The diagnosis was confirmed by liver biopsy in both. We attribute the unusually good outcome of these women and their children to early recognition of their disorder and prompt delivery once the diagnosis was considered.

Neuroendocrine alterations in systemic disease

Systemic disorders clearly may exert a significant influence on neuroendocrine function. Disorders that cause significant stress to the body, either physical or psychological, may cause a resetting upward of the HPA axis to provide sufficient cortisol to counteract the stress and to help sustain energy substrate levels. GH levels also increase in many of these situations, again promoting sufficient energy substrate levels. In some circumstances the concomitantly low somatomedin activity may be speculated to be adaptative to prevent the insulin-like agonist activity of these substances as well as to prevent energy expenditure in body growth. However, in other situations such as chronic renal failure and cirrhosis, the decreased somatomedin activity may be primary, causing decreased feedback at the hypothalamic-pituitary level and increased GH levels. The stress-induced rise in PRL may also play a minor role in preserving energy substrate since high levels may promote insulin resistance. In most illnesses the 'euthyroid sick syndrome' develops. Whether such patients are 'euthyroid' or mildly hypothyroid is a matter of controversy. The fact that protein losses are increased during fasting when the lowered T3 levels are returned to normal with exogenous T3 supplementation suggests that these patients are indeed hypothyroid and this hypothyroidism serves to conserve energy substrate by decreasing the metabolic rate. The reproductive axis is often impaired with systemic illness. Again, teleologically this may be viewed as an inactivation of non-essential functions in times of stress. It would appear that the changes that occur with systemic illness, in general, are favourable to the organism in that they promote survival. The detailed neurotransmitter and hypophyseotrophic hormone changes resulting in the alteration in pituitary function remain to be elucidated for the most part.

Hospital-acquired renal insufficiency: a prospective study

Twenty-two hundred sixty-two consecutive medical and surgical admissions were evaluated prospectively to determine the contribution of iatrogenic factors to the development of renal insufficiency in hospital. Of 2,216 patients at risk, some degree of renal insufficiency developed in 4.9 percent. Decreased renal perfusion, postoperative renal insufficiency, radiographic contrast media, and aminoglycosides accounted for 79 percent of the episodes. Iatrogenic factors, broadly defined, accounted for 55 percent of all episodes. Poor prognostic indicators included oliguria, urine sediment abnormalities and, most importantly, severity of renal insufficiency; with an increase in serum creatinine of 3 mg/dl or greater, the mortality rate was 64 percent. Age, admission serum creatinine levels, and the number of episodes of renal insufficiency did not significantly affect outcome. We conclude that there is a substantial risk of the development of renal failure in hospital and that the mortality rate due to hospital-acquired renal insufficiency remains high.