Screw-in atrial lead in a sick sinus syndrome patient with anomalous inferior vena cava

Anomalous inferior vena cava without intracardiac anomaly is an unusual condition. Herein, we report a 48-year-old female with left-sided inferior vena cava and azygous continuation. accompanied by sick sinus syndrome. This anomaly resulted in difficulty in implanting a traditional hook-on atrial lead. Atrial lead dislodgment occurred repeatedly soon after implanting the pacemaker because of an anomalous zygous vein draining into the superior vena cava, making a giant connection with the right atrium, thus eliminating the space of the atrial appendage for lead lodgment. Finally, we attempted to utilize a screw-in atrial lead in this patient and she is currently doing well. We therefore suggest that a screw-in atrial lead should be taken into account for such patients in order to obtain a stable fixation.

Genetic analysis of recent Taiwanese isolates of a variant of coxsackievirus A24

Epidemics of acute hemorrhagic conjunctivitis (AHC) caused by a variant of coxsackievirus A24 (CA24v) reappeared in Taiwan in 1990 and 1994, following the first two epidemics of 1985--86 and 1988--89. To analyze the genetic diversity of recent CA24v in Taiwan, 7 Taiwanese strains isolated during the 1990--94 period were studied together with one Japanese and two Thai strains isolated in 1993. A fragment of 674 nucleotides between the carboxy terminal 3A and the amino terminal 3D polymerase, including the entire 3C protease (3C(pro)), was amplified by a reverse transcription-polymerase chain reaction (RT-PCR) and the nucleotide sequences were determined. In the 549 nucleotides (183 amino acids) of the entire 3C(pro), we found nucleotide differences at 80 positions between 10 strains and the prototype strain, EH24/70, one of the earliest strains of CA24v. Most of the nucleotide changes were synonymous substitutions and only nine amino acid changes were found. The nucleotide sequence homologies among 71 strains worldwide were 88-100%. These 71 nucleotide sequences were then analyzed by Neighbor-joining method and phylogenetically separated into three distinct genotypes. Genotype I consisted of early strains isolated in 1970--71 from Singapore and Hong Kong. Genotype II included isolates from Singapore and Thailand obtained in 1975. Genotype III comprised strains from the eastern hemisphere isolated in 1985--94 from Japan, Taiwan, China, Hong Kong, Thailand, Singapore, Pakistan and Ghana. They were further divided chronologically into six clusters. The recent isolates from Taiwan obtained in 1985/1986, 1988/1989 and 1990--94 were classified into genotype III Clusters 1, 5, and 6 respectively. The evolutionary rate was re-estimated to be 3 x 10(- 3) 30 years after the emergence of the virus.

Molecular epidemiology of enterovirus 71 in Taiwan

Taiwan suffered a severe and widespread outbreak of enterovirus infection in 1998. More than 400 children were hospitalized, with seventy-eight fatalities due to central nerve system (CNS) involvement and cardiopulmonary collapse. Enterovirus 71 (EV71) was incriminated as the causative agent for the fatal cases. To understand the viral molecular epidemiology in this outbreak, fragments of 207-bp length of the VP4 region in 23 Taiwanese EV 71 isolates were sequenced. Pair-wise comparison revealed a 17.5-24.4% difference between the isolates and the prototype BrCr. However, all the changes in the VP4 region of the isolated strains were synonymous substitutions. Phylogenetic analysis was performed on these 23 isolates and 21 others deposited in GenBank. In this study, forty-four EV71 isolates from the world were separated into three distinct genotypes: A, B and C. The EV71 prototype strain, BrCr/70, is the only strain of genotype A. Group B included strains from the United States, Japan and Taiwan. Most strains in genotype B were isolated prior to 1990. Group C consisted of strains from Japan and Taiwan. Most strains of genotype C were isolated after 1990, they were further divided into 3 clusters: i.e. C-1, C-2 and C-3. In Taiwan, two genotypes, B and C-3, were co-circulating during the outbreak in 1998, although a minor group of genotype B may have appeared in Taiwan before 1986. The majority of the isolates clustered in genotype C-3. Genotype C showed a higher evolutionary rate than genotype B (3.9 x 10(-3) vs. 1.4 x 10(-3)) in the VP4 region. There seems to be a worldwide trend with strains of genotype B appearing earlier than strains of genotype C which took over later in the dominance.

Abnormal glucose tolerance in transfusion-dependent beta-thalassemic patients

OBJECTIVE

To study the prevalence of and risk factors for abnormal glucose tolerance in transfusion-dependent beta-thalassemic patients.

RESEARCH DESIGN AND METHODS

A total of 89 transfusion-dependent beta-thalassemic patients were interviewed. Diabetes was previously diagnosed in 14 of them. In the remaining 75 patients, 68 participated in an oral glucose tolerance test. Potential risk factors were identified using the independent t test, chi2 test, and Fisher's exact test. Logistic regression analysis was used to select the independent risk factors that best predicted abnormal glucose tolerance A two-tailed P value of <0.05 was considered to be statistically significant.

RESULTS

The prevalence of impaired glucose tolerance was 8.5% (7 of 82) and that of diabetes was 19.5% (16 of 82). Presentation with diabetic ketoacidosis was 31.1% (5 of 16). The risk factors for abnormal glucose tolerance found in transfusion-dependent beta-thalassemic patients were serum ferritin concentration and hepatitis C infection.

CONCLUSIONS

The interaction of iron overload and hepatitis C infection worsened the prognosis of thalassemic patients. Aggressive iron-chelation therapy as well as prevention and treatment of hepatitis C infection should be mandatory in managing glucose homeostasis in transfusion-dependent beta-thalassemic patients in Taiwan.

Hemorrhagic viral keratoconjunctivitis in Taiwan caused by adenovirus types 19 and 37: applicability of polymerase chain reaction-restriction fragment length polymorphism in detecting adenovirus genotypes

PURPOSE

Acute keratoconjunctivitis with prominent subconjunctival hemorrhage (SCH) is usually perceived by a clinician as acute hemorrhagic conjunctivitis (AHC) associated with enteroviruses; however, SCH can also be an adenoviruses infection. A rapid and sensitive laboratory diagnosis is helpful for differential diagnosis. Therefore, the sensitivity and applicability of polymerase chain reaction (PCR) and reverse transcription (RT)-PCR diagnoses were evaluated for keratoconjunctivitis associated with viral infection.

METHODS

Conjunctival swabs from patients with acute conjunctivitis were tested using a PCR-restriction fragment length polymorphism (PCR-RFLP) for adenovirus detection and RT-PCR for enterovirus detection. The results were compared with those using the culture isolation and neutralization test; also, the clinical findings of the patients were analyzed with special attention to SCH patterns.

RESULTS

Neither coxsackievirus A type 24 variant (CA24v) nor enterovirus type 70 (EV70) was detected in 113 patients with acute conjunctivitis. The positive results of adenovirus (Ad) were 39.9% by the PCR method and 37.1% by culture isolation. For the patients with adenoviral conjunctivitis, 68.1% was owing to Ad37 and 19.2% was owing to Ad19. SCH was present in 51.5% of the positive cases, and 44.7% of the Ad-positive patients had secondary illnesses.

CONCLUSIONS

SCH can be a predominant presentation of Ad19 and Ad37 keratoconjunctivitis and may herald a new stage in the evolution of adenoviruses. PCR and PCR-RFLP are rapid and reliable methods for Ad detection and typing; however, if the amplified genes and restriction enzymes are not properly selected, they may not be able to detect new genotypes of adenoviruses or the evolution of these viruses.

[Illness knowledge, social support and self care behavior in adolescents with beta-thalassemia major]

The purpose of this study was to explore the relationships among illness knowledge, social support and self-care behavior in adolescents with beta-thalassemia major. The subjects were 58 beta-thalassemia major adolescents recruited from the pediatric hematology outpatient departments of three hospitals in North Taiwan. All data were analyzed by descriptive statistics, one-way ANOVA, t-test, Pearson correlation, and stepwise multiple regression. The results showed that: (1) Scoring in illness knowledge, the best was treatment knowledge, and the worst was the knowledge of complications and symptoms. (2) The result for social support indicated that the family was the major source of support, and that classmates/friends provided the least support for thalassemic adolescents. (3) Scoring in self care behavior, the best was the medical and chelate therapy, and the worst was the management of problems and coping. (4) Individual characteristic differences, including sex, level of education, length of illness, complications of thalassemia, hospitalization due to thalassemic complications and receiving other treatments were correlated with their illness knowledge, social support or self-care behavior. (5) Illness knowledge, social support which were positively correlated with self-care behavior. (6) 50.0% of the variance in self-care behavior can be explained by emotional support from family, general knowledge of thalassemia, treatment knowledge and appraisal support from family. These findings could provide referential material for nursing research and nursing practice.

Emerging new frontiers in cardiac pacing: cardiac pacing in heart failure

Indications for pacing have leapt beyond sinus node dysfunction and atrioventricular (AV) block. Pacing for the purpose of improving hemodynamics has become the prime subject of exploration. Several studies have reported hemodynamic and clinical improvement with bi-ventricular pacing and AV sequential pacing. Data is still pouring in from the various ongoing trials regarding the beneficial effects of these methods of pacing. This is especially true in a subset of patients with intractable heart failure. There are several indicators to identify these patients. Those who have intra-ventricular conduction defects and those who demonstrate hemodynamic improvement after temporary pacing are certainly the candidates who will benefit most from this new form of pacing. Prolonged PR interval or left bundle branch block with intractable heart failure also falls into this category. The rationale of pacing in heart failure is to correct the cardiac dysynchrony that occurs frequently in these patients. Cardiac dysynchrony can occur due to ineffective synchronization between atria and ventricles (AV dysynchrony) or due to lack of synchronization within the two ventricles (ventricular dysynchrony). This is overcome by AV sequential pacing or by multi chamber pacing using the coronary sinus as portal of entry of the electrode into the cardiac vein to pace the left ventricle. Pacing leads and generators have been designed to suit the new found methods of pacing. Clinical trials are in full swing to establish the efficacy of these methods.

Efficient diagnosis of dengue infections using patients' peripheral blood leukocytes and serum/plasma

OBJECTIVE

Dengue fever has been one of the most important health problems in Taiwan since a large outbreak during 1987 and 1988. It is critically necessary to have a diagnostic approach that can detect early infections in an outbreak or even find infections existing in silent transmission of the disease.

METHODS

To develop an efficient diagnostic protocol, 105 plasma/serum and 35 peripheral blood leukocyte (PBL) specimens from the 1994 outbreak in southern Taiwan were collected for assessment by various diagnostic techniques in this study.

RESULTS

In acute blood samples, dengue viruses were isolated from 19.4% (14/72) and 33.3% (14/42) of reported and confirmed cases, respectively. Viral RNA in serum/plasma was detected from 20.0% (12/60) of acute samples, which was significantly higher than that from convalescent samples (3/44; 6.8%). However, viral RNA in PBLs, detected by reverse transcription polymerase chain reaction (PBL-RT-PCR), could be observed in 73.2% (19/26) and 66.7% (6/9) of acute and convalescent samples, respectively. The persistence of dengue viruses in PBLs was also evidenced by the presence of viral antigens in 42.9% (4/7) of confirmed convalescent samples by the immunofluorescence antibody test. In addition, IgM antibodies were detected in 43.8% (46/105) of reported cases and 85.2% (46/54) of confirmed cases by the IgM antibody capture enzyme-linked immunosorbent assay (MAC-ELISA).

CONCLUSIONS

Although IgM antibody detection achieved the highest detection rate among techniques assessed in this study, no individual test can actually reach full efficiency for early diagnosis of dengue infections. Here, we propose a protocol which applies MAC-ELISA and PBL-RT-PCR in sequence, by which 22 confirmed cases were definitely proved as dengue positive. High levels of both sensitivity and specificity were shown in this protocol.

Isolation of rat mitochondrial transcription factor A (r-Tfam) cDNA

We have isolated rat mitochondrial transcription factor A (Tfam; formerly known as mtTFA) cDNA clones from a rat cerebellum cDNA library using human Tfam cDNA as a probe. The deduced amino acid sequence of r-Tfam shows 62% and 89% overall identity to human and mouse Tfam, respectively. We also show the presence of two r-Tfam isoforms in testis as for mouse. Our findings suggest that the mechanisms underlying transcription of mitochondrial genes are conserved among rat, mouse, and human.

Micronized ethylcellulose used for designing a directly compressed time-controlled disintegration tablet

Ethylcellulose (EC) of varying particle sizes has been used as an outer coating layer to design a novel dry-coated tablet with time-controlled drug release. This dry-coated tablet, containing a core tablet of sodium diclofenac and an outer coating layer of EC, was prepared by direct compression. The drug release from dry-coated tablet exhibited an initial lag period that was dependent on the particle size of the EC powder, followed by a stage of rapid drug release. The smaller the EC particle size used the longer the lag time obtained, suggesting the particle size of EC powder could modulate the timing of drug release from such a dry-coated tablet. The period of the lag time for sodium diclofenac released from dry-coated tablets was correlated with the penetration distance of the solvent into dry-coated tablet by an in vitro dye penetration study. The densest packing of EC powders appeared on the upper and lower surfaces of dry-coated tablet after compression, resulting in a tight structure yielding a slower penetration of the solvent. Whereas loose packing of EC powders occurred in the middle of the lateral surface of dry-coated tablet, this loosely packed surface readily allowed solvent penetration and that finally caused the splitting of tablet shell into two halves in the dissolution medium. The results suggest that these dry-coated tablets prepared with different particle sizes of EC powder as an outer coating layer might offer a desirable release profile for drug delivery at the predetermined times and/or sites.

The effects of aging on AV nodal recovery properties

The purpose of this study was to assess the changes of AV nodal recovery properties with aging. Although in children and young adults it was found that there were age dependent changes in their AV nodal recovery properties, in the older population this information was not available. In 92 subjects (aged 16-92 years) without AV nodal disease or dual AV nodal pathway physiology, their AV nodal recovery curves were studied by delivering premature atrial extrastimuli coupled to basic atrial beats during cardiac electrophysiological study. Data were analyzed using linear regression and curve-fitting techniques. Patients were grouped by age, group I < 40 years (n = 33), group II 40-59 years (n = 26), and group III > 60 years (n = 33). The results showed that the AV nodal recovery curve did not change significantly in the aging process except that the AV nodal effective refractory period had a positive correlation with increasing age. The latter was significantly increased in group III when compared to group I or group II. For this parameter, when patients whose AV nodal refractory period was limited by the atrial refractory period were excluded, there was still a statistically significant increase in group III compared to group II (P < 0.05): group I (n = 27): 202+/-42 ms; group II (n = 17): 197+/-26 ms; and group III (n = 17): 224+/-46 ms. The results suggest that the AV nodal recovery curve remains unchanged once it reaches adulthood, with the exception that the nodal effective refractory period becomes slightly longer after age 60.

Low prevalence of coronary arterial disease in Chinese adults with mitral stenosis

BACKGROUND

We attempted to evaluate the prevalence of coronary artery disease in Chinese adults with severe rheumatic mitral stenosis.

METHODS

We prospectively performed coronary angiography in 119 consecutive Chinese patients older than 40 years old (mitral valve area less than 1.5 cm2) who were about to undergo balloon mitral commissurotomy for significant rheumatic mitral stenosis. The exclusion criteria were the presence of left atrial cavitary thrombi or mitral regurgitation greater than grade 3.

RESULTS

There were 32 men (26%) and 87 women (74%) with a mean age of 55 +/- 9.7 years (ranging from 40 to 78). Ninety-two patients (77%) were in atrial fibrillation. The prevalence of risk factors for atherosclerotic cardiovascular disease were hypertension (22%), diabetes mellitus (4%), hypercholesterolemia > or = 240 mg/dL (5%), hypertriglyceridemia > or = 150 mg/dL (13%), and cigarette use (7%). Coronary artery disease on angiography was defined as stenosis of more than 50% of the luminal diameter. We found that only 2 patients (1.7%) had coronary artery disease.

CONCLUSION

The prevalence of coronary artery disease was much lower than in previous reports, some of which, however, had already pointed out the relatively low prevalence of coronary artery disease in rheumatic mitral disease. The definite mechanisms require further study.

The characteristics of phosphorus removal in an anaerobic/aerobic sequential batch biofilter reactor

Previous research has shown that alternated anaerobic/aerobic conditions are effective in removing phosphorus from wastewater using a biofilter system. However, few studies have been conducted on the features of polyphosphate (poly-P) accumulating organisms (PAOs) in biofilm on phosphorus removal. This study investigated the characteristics of the phosphorus removal mechanism in various hydraulic loads and anaerobic/aerobic time ratios using a sequential batch biofilter reactor. The storage and release of intracellular inclusions, especially polyhydroxyalkanoates (PHAs) and poly-P, would be an important factor for phosphorus removal. Under different operating conditions, total phosphorus removal was always determined by accumulation of PHAs and phosphorus release under the anaerobic phase. The PHA accumulation under the anaerobic phase was always in proportion to the biofilm phosphorus content under aerobic conditions. The result shows PAOs activity was closely related to PHA accumulation. However, the PHA accumulation under the anaerobic phase would be dependent on the hydrolysis of the complex carbon source into short chain fatty acids (SCFA). The result would be demonstrated by the simple carbon source effect. The effect of the An/Ox time ratio on TP removal was significant. Shorter anaerobic time would result in insufficient phosphorus release and greater time would result in inactive PAOs. The appropriate An/Ox time ratio was suggested as 1/2. Comparisons of the phosphorus removal characteristics between biofilm and suspended growth under the same growth conditions are discussed in detail.

Localizing ventricular tachycardia through entrainment

Area(s) of slow conduction are thought to be present within the reentry circuit of most clinically important ventricular tachycardia (VT). To prevent recurrence after ablation of VT late after myocardial infarction, it is desirable to localize and destroy area(s) of slow conduction "critical link" within the reentry circuit. Conventionally, they may be identified by endocardial catheter mapping, continuous electrical activity, mid-diastolic potentials, earliest endocardial activation, pace-mapping etc. However, none of these methods are very specific. Entrainment method may be used to localize the slow conduction zone of reentrant VT. Concealed entrainment is consistent with pacing at a site in the reentry circuit but may also occur at some "bystander" sites that are close to the reentry circuit but are not participating in the circuit itself. During pacing at the slow conduction area of the reentry circuit, the stimulus to QRS (S-QRS) interval should equal the electrogram to QRS (EG-QRS) interval during VT. Similarly the post-pacing interval (PPI) approximates the tachycardia cycle length. During pacing at bystander sites, the S-QRS interval may be greater, less than or equal to the EG-QRS interval, depending on the conduction time from the bystander site to the circuit. The PPI, however, always exceed the tachycardia cycle length. In conjunction with concealed entrainment, the use of diastolic potential, double potentials and continuous electrical activity enhances the prediction of radiofrequency termination of post-infarction VT.

Brugada syndrome without mutation of the cardiac sodium channel gene in a Taiwanese patient

We describe a 45-year-old Taiwanese man with specific features of Brugada syndrome but no clinical features of structural heart disease. He was successfully treated with an implantable cardioverter-defibrillator. His electrocardiogram (ECG) patterns changed intermittently. Alpha-adrenoceptor stimulation and beta-adrenoceptor blockade augmented the characteristic ST-segment elevation, whereas alpha-adrenoceptor blockade and beta-adrenoceptor stimulation mitigated the ST-segment elevation. Intravenous procainamide administration did not aggravate ST-segment elevation when ECG had shown coved ST elevation in the right precordial leads. Molecular study did not reveal the same mutations in the cardiac sodium channel gene (SCN5A) as previously reported in Brugada syndrome. This case demonstrates the genetic heterogeneity of SCN5A in Brugada syndrome.

T cell lymphoproliferative disorder following bone marrow transplantation for severe aplastic anemia

Post-transplant lymphoproliferative disorder (PTLD) is uncommonly of T cell origin, especially following BMT. We describe a 13-year-old boy with severe aplastic anemia (SAA) and no evidence of Fanconi's anemia who underwent BMT at 11 years of age using CY 10 mg/kg once daily i.v. on days -5, -4, antilymphocyte globulin (ALG) 30 mg/kg once daily i.v. on days -5 approximately -3 and CsA from day -1 as conditioning. The BMT failed and he received a further peripheral blood stem cell transplant (PBSCT) 240 days after BMT. Conditioning was with CY 50 mg/kg once daily i.v. on days -5 approximately -2, and ALG 15 mg/kg once daily i.v. on days -4 approximately -2. GVHD prophylaxis included CsA and MTX. Engraftment was later confirmed by cytogenetic studies. Desquamation and ulcers of the oral mucosa and mouth angle developed in the 13th month post PBSCT. A buccal mucosa biopsy on day +524 revealed only plasmacytosis. Immunosuppressants were discontinued at that point. Generalized lymphadenopathy, prolonged fever (waxing and waning) and facial swelling developed in the 18th month post PBSCT. A neck lymph node biopsy on day +601 showed T cell lymphoma of diffuse large cell type with monoclonal TCR gamma-chain gene rearrangement. A FISH study showed that the malignant T cells were of recipient origin. EBV in situ hybridization was negative. He did not receive further treatment apart from discontinuation of immunosuppressants. He was followed up in our out-patient clinic and showed good performance 1170 days post PBSCT. We speculate that a different mechanism was operating in the pathogenesis of T cell lymphoma in this case. Risk factors include SAA and two transplants, conditioned with CY and ALG, long term use of CsA and treatment with azathioprine.

Staurosporine promotion of formation of continuous monolayers of primary rat hepatocytes by improving attachment and spreading

Primary rat hepatocytes form discontinuous monolayers even at their maximum density. Here, we show that staurosporine promotes attachment and spreading of hepatocytes onto culture substrates, so that hepatocytes form a close, continuous monolayer. This treatment did not attenuate major hepatic functions. Therefore, this technique is promising for making seamless cell-sheet structures, which will be applicable for cell-polarity experiments or artificial liver construction.

An outbreak of enterovirus 71 infection in Taiwan, 1998. II. Laboratory diagnosis and genetic analysis

BACKGROUND

An epidemic of enterovirus 71 (EV71) occurred in Taiwan from April to December of 1998, with two peaks, one in June and the other in October. Many enteroviruses were isolated in our laboratory from 258 cases during this outbreak. Approximately half of the enteroviruses isolated were EV71 and one fifth were coxsackievirus A16.

OBJECTIVES

To analyze laboratory findings in the EV71 epidemic of 1998 in Taiwan, various EV71 specimens in different cell lines were examined. In addition, genetic analysis of 5' non-coding region (NCR) was performed to analyze the strain variation in this outbreak.

RESULTS

The cytopathic effect induced by EV71 was observed 2-13 (mean of 4.5) days post-inoculation in Vero cells and 4-15 (mean of 6.6) days in green monkey kidney (GMK) cells inoculated with throat swabs. Of the total positive EV71 cases, virus was most frequently obtained from throat swabs (91.7%), less from stools (64.8%), and none from cerebral spinal fluid (CSF). Molecular analyses of EV71 by sequencing the 5' NCR of 34 strains obtained from different clinical categories and various geographic areas showed that their sequences differed (0-13 bp in 681 bp sequenced) by approximately 0-2%. The sequences of these isolates differed from EV71 prototype BrCr or MS strain by 17.5-19%, with the exception of two samples which exhibited nucleotide variation by only 8.9 and 8.2%, when compared to the MS strain.

CONCLUSION

EV71 was most frequently isolated from throat swab specimens in Vero cells. The molecular analyses of the 5' NCR of EV71 revealed that most isolates from this epidemic belonged to a group of closely related clones and only two were in a different group which was clustered with the EV71 MS strain.

Genetic analysis of enterovirus 71 isolated from fatal and non-fatal cases of hand, foot and mouth disease during an epidemic in Taiwan, 1998

A large scale outbreak of hand-foot-and-mouth disease (HFMD) occurred in Taiwan in 1998, in which more than 80 children died of shock syndrome with pulmonary edema/hemorrhage. Enterovirus 71 was implicated as the cause of this outbreak. In order to understand the virological basis responsible for mortality on this scale, nucleotide sequences of VP1 that is important for serotypic specificity, and the 5'-non-coding region (5'-NCR) that is important for replication efficiency, were analyzed comparatively. Phylogenetic analysis of both VP1 and 5'-NCR of nine EV71 isolates derived from specimens of fatal patients and seven isolates derived from uncomplicated HFMD patients showed that all but one isolate fell into genotype B. The one distinct isolate from a case of uncomplicated HFMD belonged to genotype C that was clustered along with one isolate from Taiwan in 1986. Complete sequence analysis of two selected isolates, one from the spinal cord of a fatal case and one from the vesicle fluid of a patient with mild HFMD, confirmed a high degree (97-100%) of identity in nucleotide sequence throughout the entire genome, except focal regions of 3C and 3'-NCR where the nucleotide homology was 90-91%. The identity of the deduced amino acid sequence in the 3C region that encodes viral proteinase dropped further to 86%, a result of missense mutations at the first nucleotide position of many codons.

Treatment results of the TPOG-NHL92 protocols for childhood non-Hodgkin's lymphomas in Taiwan: a report from the Taiwan Pediatric Oncology Group (TPOG)

A nation-wide chemotherapeutic trial for childhood non-Hodgkin's lymphoma (NHL) was conducted by the Taiwan Pediatric Oncology Group (TPOG). Four TPOG-NHL92 protocols based on stage and histology were activated in 1992: TPOG-92LD (treatment duration: 8 months) was used for localized (stages I/II) NHL with any histology, 92LB (2 years), 92SNC (5 months), and 92LC (1 year) for advanced (stages III/IV) lymphoblastic (LB), small non-cleaved cell (SNC), and large cell (LC) lymphoma, respectively. From January 1992 through June 1998, 200 children with newly diagnosed NHL from 13 member hospitals of TPOG were enrolled. There were 140 boys and 60 girls. Their ages at diagnosis ranged from 2.4 months to 18.3 years with a median of 8.2 years. There were 54 (27.3%) patients with LB, 94 (47.5%) with SNC including B-cell acute lymphoblastic leukemia (B-ALL), and 50 (25.2%) with LC. Stages I, II, III, and IV (including B-ALL) of the disease comprised 5%, 10%, 43%, and 42% of cases, respectively. There were 176 patients eligible for evaluation of treatment results. The remission rate of induction was 82.4%, induction failed in 22 (12.5%) patients, and nine patients died during induction. As of August 31, 1999, 26 patients relapsed, six died during remission, one patient developed secondary acute myelomonocytic leukemia, and 105 patients remained in continuous remission with a median remission duration of 49 months. The event-free survival (EFS) at 7 years was 63.5%, 61.5% and 65% for LB, SNC, and LC groups (P = 0.8298). The 7-year EFS for stages I/II, III, and IV of the disease was 73%, 68.9%, and 50.3% (P = 0.0212), respectively. We concluded that following the strategy of stratification of therapy, only disease stages had prognostic significance in this study. More efforts are needed to improve our treatment results.

Negative regulation of the antimetastatic gene Nm23-H1 by thyroid hormone receptors

Metastasis of various malignant cells is inversely related to the abundance of the Nm23-H1 protein. The possible role of thyroid hormones in tumor metastasis has now been investigated by examining the effect of T3 on the expression of the Nm23-H1 gene. Human hepatoma HepG2 cells, in which endogenous thyroid hormone receptor subtype alpha1 (TRalpha1) is expressed at a low level, were stably transfected, either with expression plasmids encoding wild-type TRalpha1 or a dominant negative mutant of TRalpha1, or with the empty vector (yielding HepG2-Wt, HepG2-Mt, and HepG2-Neo cells, respectively). Immunoblot analysis revealed that exposure of HepG2-Wt and HepG2-Neo cells, but not HepG2-Mt cells, to T3-induced time-dependent decreases in the abundance of Nm23-H1 messenger RNA and protein, with the extent of these effects correlating with the level of expression of TRalpha1. An in vitro assay also revealed that T3 induced a marked increase in the invasive activity of HepG2-Wt cells; it induced a smaller increase in that of HepG2-Neo cells but had no effect on that of HepG2-Mt cells. Finally, the promoter region of Nm23-H1 spanning nucleotides -471 to -437 (relative to the transcriptional initiation site) inhibited the expression of a downstream reporter gene, in a T3-dependent manner, in COS-1 cells also transfected with an expression plasmid encoding TRalpha1 or TRbeta1. The DNA binding domain of TRbeta1 was required for this inhibitory effect. These results indicate that T3, acting through TRs, inhibits transcription of Nm23-H1, and that this effect is mediated by a negative regulatory element in the promoter region of the gene. Thus, it is possible that T3 promotes tumor metastasis by inducing down-regulation of Nm23-H1 expression.

Characterization of acute myeloid leukemia with MLL rearrangements--no increase in the incidence of coexpression of lymphoid-associated antigens on leukemic blasts

MLL gene rearrangements are associated with coexpression of myeloid- and lymphoid-associated antigens on leukemic blasts and a dismal outcome in acute lymphoblastic leukemia (ALL). Whether the same conditions can apply to acute myeloid leukemia (AML) is not quite clear. Rearrangements of the MLL gene were analyzed on 113 patients with newly diagnosed de novo AML in a single institution. Sixteen (14%) of them showed rearranged bands by Southern blot analysis, including three (50%) of six infants, three (14%) of 21 children between 1 and 15 years and 10 (12%) of 86 adults. MLL rearrangements were not only detected in M5 (four of 12 patients, 33%) and M4 (six of 31, 19%) subtypes but also in other non-M4-M5 AML (six of 70, 9%), including M1, M2 and M7, but not M3 subtype. Seven patients had chromosomal abnormalities involving 11q23, but nine did not. The latter comprised three (6%) of 48 patients with normal karyotype, one with t(8;21), none with t(15;17), inv(16) or t(9;22), and four (15%) of 27 with cytogenetic aberrations other than those specific structural abnormalities. In contrast to ALL, AML patients with MLL rearrangements did not tend to coexpress lymphoid- and myeloid-associated antigens simultaneously on leukemic blasts and have similar outcome as those without the gene rearrangements.

Bone marrow transplantation from an HLA-matched unrelated donor for treatment of Chediak-Higashi syndrome

Chediak-Higashi syndrome (CHS) is a rare autosomal recessive disease characterized by partial albinism and large granules in all granule-containing cells. It is also associated with recurrent pyogenic infections secondary to impaired leukocyte function. Most patients with CHS enter an accelerated phase that leads to repeated infections and bleeding complications, often resulting in death. The first accelerated phase may occur shortly after birth or several years later. There are no curative treatments, and bone marrow transplantation (BMT) is the treatment of choice. Here, we report the case of a boy with CHS. The diagnosis was made at the age of 1 month, on the basis of the characteristic clinical findings and family history. He received BMT from an HLA-matched unrelated donor. After BMT, fluorescent cytometric analysis of polymorphonuclear leukocytes showed normalized cellular granularity and a normal increase in CD11b expression on N-formylmethionyl-leucyl-phenylalanine stimulation. The accelerated phase did not develop during 27 months of follow-up. Without BMT, CHS is usually fatal before the age of 10 years. BMT from an unrelated donor may be an effective treatment option for those who lack sibling donors. In addition to the characteristic leukocytic dysfunctions, fluorescent cytometric analysis of cellular granularity and surface molecules offer useful diagnostic information.

Nephrotic syndrome in a bone marrow transplant recipient without chronic graft-versus-host disease

A 5-year-old girl developed severe proteinuria and microscopic hematuria 17 months after allogeneic bone marrow transplantation (BMT) for chronic myeloid leukemia. These nephrotic symptoms occurred during cyclosporin tapering, in the absence of other signs of chronic graft-versus-host disease (GVHD). A renal biopsy revealed focal segmental glomerulosclerosis. After methylprednisolone therapy, the proteinuria gradually decreased. The altered or disordered immune regulation that occurred after BMT may have resulted in the development of nephrotic syndrome.

Overexpression of thyroid hormone receptor beta1 is associated with thyrotropin receptor gene expression and proliferation in a human thyroid carcinoma cell line

To correlate the differentiation phenotype of two human thyroid cancer cell lines with their expression of various molecular markers, we analyzed the mRNA levels of four thyroid-specific genes, including thyrotropin receptor (TSHR), thyroglobulin (Tg), thyroid transcription factor-1 (TTF-1), and paired-box containing transcription factor-8 (PAX-8) genes. The results showed a differentiation-status-related pattern in which a well-differentiated cell line (WRO) expressed all the four genes, in contrast to an anaplastic cell line (ARO) that expressed TTF-1 and reduced levels of TSHR, but no Tg or PAX-8 genes. Furthermore, to verify the finding of concomitant loss of beta subtype thyroid hormone receptor (TRbeta) and TSHR gene expression in neoplastic thyroid tumors (Bronnegard et al. 1994), we examined the expression levels of TRbeta1 gene in these cell lines. Whereas the WRO cells produced an abundant amount of TRbeta1 protein detectable by immunoprecipitation, the ARO cells produced none. This new observation prompted us to investigate whether overexpression of TRbeta1 protein in ARO cells might produce changes in the differentiation phenotypes. We found that the level of expression of the TSHR gene and the proliferative index of ARO cells were significantly upregulated in the cells stably transfected with wild-type TRbeta1. These findings suggest that TRbeta1 protein overexpression can affect the differentiation phenotypes and induce more efficient cell proliferation of the anaplastic ARO cells.

Molecular characterization of myocardial fibrosis during hypothyroidism: evidence for negative regulation of the pro-alpha1(I) collagen gene expression by thyroid hormone receptor

The purpose of this study was to gain insights into the underlying mechanism of myocardial fibrosis during hypothyroidism. Treatment of cardiac fibroblasts with a medium lacking thyroid hormone led to a 47% increase in [3H]thymidine incorporation into the cell nuclei compared with that in untreated cells. Northern blot analysis of RNA from cardiac fibroblasts grown in a thyroid hormone depleted medium resulted in a 38% increase in the abundance of mRNA for pro-alpha1(I) collagen. At the protein level, the amount of type I collagen, as determined by immunoprecipitation, was increased either in the cell lysate (46%) of cardiac fibroblasts grown in a thyroid hormone depleted medium or in the medium (44%). The chimeric plasmid, ColCAT 3.6, contains the 5'-flanking region of the rat pro-alphal(I) collagen gene (from bases -3520 to +115) fused to the chloramphenicol acetyltransferase (CAT) gene. The plasmid was cotransfected with thyroid hormone receptor (TR) expression plasmid into rat cardiac fibroblasts and COS-l cells (monkey mesangial cells). Cells transfected with the ColCAT plasmid in the presence of thyroid hormone (100 nM T(3)) had a significant decrease (39% in fibroblasts, P<0.01; 52% in COS-1 cells, P<0.001) in CAT activity when compared to cells not exposed to thyroid hormone. Transient co-transfection of TR with various pro-alphal(I) collagen/CAT deletion constructs showed that T(3)-dependent repression was preserved with the deletion from 3520 bp of the flanking sequence to a 5' end point at position -224, indicating that a thyroid hormone-response element (TRE) was localized at the region -224 to +115. The TR-DNA binding assays demonstrated binding of the human TRbeta1 to a fragment containing a proposed TRE located between position -35 and +115 in the 5'-flanking region of the rat pro-alphal(I) collagen gene.

Potential of the insecticides acephate and methamidophos to contaminate groundwater

The possible contamination of groundwater by the insecticides acephate and methamidophos was assessed using the behavior assessment model (BAM) and the groundwater pollution-potential model (GWP). The dissipation coefficients of the two insecticides in two soils (Annei silt loam and Pingchen silt clay loam) at different moisture contents (50 and 100% field capacity) and soil temperatures (20 and 30 degrees C) were studied by determining the degradation and adsorption of each insecticide in the soil. The movement of acephate and methamidophos was studied by leaching each insecticide in a soil column in the laboratory. The absorption coefficient of methamidophos was much higher than that of acephate in both types of soil. In the leaching test, methamidophos more easily leached out from the Pingchen soil column than from the Annei soil column. Methamidophos was rapidly degraded, with a half-life of 1.11 to 1.61 days in the Annei soil and 7.50 to 13.20 days in the Pingchen soil at different temperatures and soil water contents. Acephate was found to have a longer half-life than methamidophos in soil; however, the mobility of methamidophos in both soils was slower than that of acephate. The mobility of acephate in soil is somewhat faster than that of methamidophos, and thus acephate may lead to the contamination of groundwater much more easily than methamidophos under normal conditions.

rDLG6: a novel homolog of Drosophila DLG expressed in rat brain

Drosophila DLG (Discs Large Tumor Suppresser Protein) is a component of septate junctions, and disruption of its gene leads to over growth of imaginal discs. Homologs of Drosophila DLG recently isolated from mammalian tissue have been classified as members of the MAGUK (Membrane Associated GUanylate Kinase) superfamily of proteins. Using a modified RT-PCR method applied to rat tissues, we have isolated cDNA clones encoding a novel MAGUK family member that we have named rDLG6. Immunoblot and immunohistochemical analyses revealed that rDLG6 protein is predominantly expressed in brain. GST pull-down assays showed that the PDZ domain of rDLG6 protein binds to the C-terminus of the AMPA (alpha-Amino-3-hydroxy-5-Methyl-isoxazole-4-Propionic Acid) receptor GluR2 subunit.

Cough threshold in people with spinal cord injuries

BACKGROUND AND PURPOSE

The purpose of this study was to compare the cough threshold between people with and without spinal cord injury (SCI). The effect of smoking on cough threshold was also investigated.

SUBJECTS

The participants were 26 people with SCI (15 smokers, 11 nonsmokers) and 18 people without SCI (9 smokers, 9 nonsmokers).

METHODS

Aerosols of citric acid were delivered with incremental doubling concentration from 62.5 mmol to 2 mol. Cough threshold was defined as the first concentration of citric acid that induced at least 2 coughs, which is associated with large chest excursion and concurrently acoustic response.

RESULTS

The mean cough thresholds of smokers and nonsmokers with SCI (209 and 417 mmol, respectively) were lower than those of smokers and nonsmokers without SCI (467 and 1,072 mmol, respectively). The mean citric acid cough thresholds decreased in smokers with and without SCI when compared with nonsmokers with and without SCI.

CONCLUSION AND DISCUSSION

The cough sensitivity increased in subjects with SCI, and smoking could also increase the cough sensitivity. Training about the frequency and technique of cough in patients with SCI should be carefully monitored.

Development of acute lymphoblastic leukemia in a child after treatment of Langerhans cell histiocytosis: report of one case

Langerhans cell histiocytosis (LCH) is a group of poorly understood disorders. To our knowledge, LCH is a non-malignant disorder. The association of LCH with a secondary neoplasm has not been well assessed, however, a few cases have been reported. We report a case of LCH, a localized osteolytic lesion over metaphysis of left femur, who was treated with local curettage and chemotherapy with vincristine, prednisone and 6-mercaptopurine (6-MP) for eight months from end of 1991 to August, 1992. Six years later, she had acute lymphoblastic leukemia (ALL) in 1998. In review of current literature, only 5 cases of LCH, including our case, have preceded ALL. The possible association, a reactive process or a therapy-related process, between LCH and acute leukemia is still unclear at present and needs to be explored by more studies in the future.

Acute respiratory distress syndrome due to tuberculosis in a child after allogeneic bone marrow transplantation for acute lymphoblastic leukemia

We report the occurrence of tuberculosis in a 10-year-old Taiwanese boy, approximately 4 months after he received a matched-related bone marrow transplantation from his sister for acute T-cell lymphoblastic leukemia. After transplantation, grade III acute graft-versus-host disease developed and the patient was treated with prednisolone and cyclosporine. Marrow failure was noted on day 77 post-transplantation, however, after an episode of herpes zoster infection. Interstitial pneumonia, diagnosed on the basis of chest x-ray and computed tomography findings, occurred on day 120. Histologic examination of an open-lung biopsy specimen showed caseating granulomas and a few acid-fast bacilli. The patient died of acute respiratory distress syndrome, despite immediate implementation of antituberculosis therapy. Sputum cultures grew Mycobacterium tuberculosis 5 weeks later. This report demonstrates that the possibility of tuberculosis needs to be considered in immunocompromised patients, and that appropriate prophylaxis should be instituted in areas where tuberculosis is endemic.

Right pneumothorax resulting from an endocardial screw-in atrial lead

Right pneumothorax complicated by an endocardial atrial lead has never been reported. Herein, we report on a small-build 79-year-old Taiwanese woman who suffered from complete AV block and underwent dual-chamber permanent pacemaker implantation. An active fixation screw-in atrial lead was chosen. The procedure was complicated by right pneumothorax associated with atrial perforation. Since simple measurements of the implantation parameters could not be used to predict the occurrence of perforation, great caution should be taken in to avoid overscrewing the atrial lead, and in scrutinizing the penetration depth of the helix of the lead under fluoroscopy.

Expression of mutant thyroid hormone nuclear receptors in human hepatocellular carcinoma cells

To understand the expression and role of thyroid hormone nuclear receptors (TRs) in hepatocarcinogenesis, we characterized the TRs in 16 human hepatocellular carcinoma (HCC) specimens. The full-length cDNAs for the two TR subtypes, alpha1 and beta1, were cloned from several tumors by reverse transcription-polymerase chain reaction. Southern blot analysis indicated that, in addition to the full-length cDNA, truncated TRalpha1 and TRbeta1 cDNAs were present in nine tumors (53%). In addition, point mutations detected by the mismatch RNase cleavage assay in TRalpha1 and TRbeta1 were found in 65% and 76% of the tumors, respectively. The mutations were confirmed by DNA sequencing. Interestingly, most of the TRalpha1 mutations were in amino acid codons 209-228 and 245-256, two hot-spots in HCC patients. However, no hot-spot was detected in TRbeta1. The expression of TRalpha1 and TRbeta1 proteins was determined in the tissue extracts by western blotting. TRbeta1 protein was expressed or elevated in 10 tumors but not in normal livers, whereas the expression of TRalpha1 was variable among tumors. The mutant TR proteins were translated in vitro, and their hormone- and DNA-binding activities were evaluated. Abnormal binding to the thyroid hormone response elements was observed. The proteins' DNA binding activity was either partially impaired or completely lost. The high prevalence of TR mutations found in the tumors of patients with hepatocellular carcinoma suggests that mutant TRs could play an important role in liver carcinogenesis.

Typhoid fever presenting as infection-associated hemophagocytic syndrome: report of one case

This report describes a 13-year-old boy who had high fever with severe pancytopenia and acute psychosis as initial presentation. Bone marrow examination was compatible with infection-associated hemophagocytic syndrome (IAHS). Blood culture showed no growth of bacteria while the culture of bone marrow yielded Salmonella typhi. The clinical condition stabilized shortly after the use of ceftriaxone. This case illustrates that typhoid fever must be included in the differential diagnosis of IAHS. In cases with IAHS, bacterial culture as well as morphological study of bone marrow is necessary for the evaluation of etiological agent and to avoid injudicious use of chemotherapy.

Abdominal weight and inspiratory resistance: their immediate effects on inspiratory muscle functions during maximal voluntary breathing in chronic tetraplegic patients

OBJECTIVE

To study the immediate effects of maximal voluntary (MV) breathing, with and without abdominal weight (AW) or inspiratory resistance (IR), on inspiratory muscle functions in chronic tetraplegic patients.

DESIGN

A crossover trial design.

SETTING

Rehabilitation department of a university hospital.

PARTICIPANTS

Nine tetraplegic men injured at the C4 to T1 levels, with a mean duration of injury of 72.8 months.

INTERVENTIONS

Each subject performed MV breathing without and with AW load (AWMV breathing) and IR load (IRMV breathing) separately.

MAIN OUTCOME MEASURES

Electromyographic (EMG) activity of the inspiratory muscles, mouth pressure, inspiratory flow, and inspiratory volume.

RESULTS

AWMV breathing evoked greater diaphragmatic EMG activity, inspiratory flow, and inspiratory volume than did IRMV breathing, although the increase of diaphragmatic EMG activity was not statistically significant. Conversely, IRMV breathing produced greater sternocleidomastoid EMG activity and negative mouth pressure than did AWMV breathing. Both AWMV and IRMV breathing evoked greater inspiratory muscle EMG activity than did MV breathing.

CONCLUSION

AW and IR loads have differential immediate effects on the inspiratory muscle functions during MV breathing in patients with chronic tetraplegia, suggesting that these two breathing maneuvers may have dissimilar mechanisms of training in such patients. The muscle EMG activity evoked during MV breathing with AW or IR is greater than that without a mechanical load, implying that mechanically loaded training in tetraplegic patients results in load compensatory adjustments via their respiratory motor output to improve respiratory function.

Superior vena cava syndrome as a complication of transvenous permanent pacemaker implantation

Venous thrombosis induced by a transvenous permanent pacemaker is a common complication. However, superior vena cava (SVC) syndrome caused by pacemaker leads is only occasionally seen and its prevalence has been estimated to be less than 1 in 1000 pacemaker patients. Herein, we report a Taiwanese patient of high grade AV block, who presented with SVC syndrome 2 years after transvenous permanent pacemaker implantation. This case features fibrotic stenosis of the junction of right brachiocephalic trunk and SVC, and an extensive thrombus formation resulting in complete obliteration of the left brachiocephalic vein. The collateral circulation was so delicate that he still could lead a rather normal life, even if anticoagulant therapy proved to be ineffective from an angiographic point of view.

Cystic neuroblastoma with hepatic metastasis: report of one case

Neuroblastoma is the most common infant malignancy, but cystic neuroblastoma is a rare presentation of this disease. There were only thirty-one reported cases in literature. Here we report another case. A 4-month-old female baby presented with a huge abdominal mass which was histologically proved to be a cystic neuroblastoma. Her urinary vanillylmandelic acid (VMA) was elevated. The image studies, including abdominal sonography, computed tomography, and magnetic resonance image, revealed a huge main mass with calcification and septa in the abdominal cavity, and multiple metastatic nodules with septation in the liver. A three-layer fluid-fluid level was found in the main mass and also in the metastatic nodules. No previous report showed a three-layer fluid-fluid level in the cystic component of neuroblastoma like the case presented here. It may be evidence of easy hemorrhagic character of this tumor.

Niemann-Pick disease type C (a cellular cholesterol lipidosis) treated by bone marrow transplantation

Bone marrow transplantation (BMT) has been used for a wide variety of lysosomal storage diseases with encouraging results. We report a 3-year 5-month-old girl with Niemann-Pick type C disease (NPC) who received an allogeneic BMT. The patient presented with repeated lower respiratory tract infections, hepatosplenomegaly, failure to thrive, and developmental delay. Chest computed tomography (CT) revealed diffuse interstitial lung infiltration. Bone marrow and liver biopsies revealed abundant lipid-filled foamy macrophages. Skin fibroblast sphingomyelinase assay revealed partial deficiency. The ability of her skin fibroblasts to esterify cholesterol was very low, and the cells stained brightly for free cholesterol. She received BMT from a healthy HLA-identical male sibling donor at the age of 2 year 6 months. Full engraftment was evidenced by repeated bone marrow sex chromosome studies. Regression of the hepatosplenomegaly, markedly reduced foamy macrophage infiltration in bone marrow, and decreased interstitial lung infiltration was noted 6 months after BMT. Her neurological status, however, deteriorated. Follow-up magnetic resonance image (MRI) revealed progressive, diffuse brain atrophy. We conclude that resolution occurred in the liver, spleen, bone marrow and lung following successful engraftment. Such a response is remarkable since the underlying problem involves a membrane receptor for cholesterol. This positive response might be due to replacement of the monocyte-phagocytic system or it may imply the existence of cross-correction in the NPC membrane receptor defect by BMT approach. Since BMT did not halt the neurological deterioration, it is unlikely to be an adequate treatment for NPC.

Decreased diversity of hepatitis C virus quasispecies during bone marrow transplantation

To elucidate the role of host immune status in the evolution and complexity of hepatitis C virus (HCV) quasispecies, three chronic HCV-infected patients who underwent bone marrow transplantation (BMT) were studied. The three transplanted patients' sera were sampled at pre-BMT, 3 months after BMT, and 12 months after BMT and the nucleotide diversity and substitution of the hypervariable region (HVR) of HCV quasispecies were analyzed. The nucleotide diversity was high at the pre-BMT period (28.2-43.4 x 10(-2) nucleotide difference/site). HVR of HCV quasispecies then became homogeneous in the first 3 months after BMT (0.11-6.40 x 10(-2) nucleotide difference/site). The nucleotide diversity of HVR at 12 months after BMT of all three patients was higher than that of 3 months after BMT but still lower than that of pre-BMT (2.09-6.40 x 10(-2) nucleotide difference/site). The analysis on nucleotide substitution rate showed a higher value between pre-BMT and 3 months after BMT (0.624-0.708 nucleotide difference/site per year) than that between 3 months and 12 months after BMT (0.072-0.127 nucleotide difference/site per year). HCV RNA titer decreased when the host had a low white cell count and increased accordingly. It was concluded that the evolution of HVR of HCV quasispecies related to the immune status of the host during BMT: after immunosuppression, an initial increase of viral populations was followed by the emergence of a dominant strain while the quasispecies gradually recovered as the immunity of the host gained its competence.

Nonfunctioning pancreatic tumor manifestated as abdominal mass in a child

This report concerns a 9-year-old girl with a nonfunctioning pancreatic tumor presented as an abdominal mass. An encapsulated tumor, measuring approximately 8 x 7 cm, was found during operation, and debulking surgery was done. Histopathologic studies proved that it was a pancreatic tumor, compatible with non-functioning islet cell tumors. She displayed neither clinical picture of jaundice, nor excessive hormonal manifestations such as diarrhea or flushing. No evidence would suggest its association with multiple endocrine neoplasia type I. To our knowledge, it has never been reported in children in Taiwan.

Comparison of immunogenicity of simultaneous and nonsimultaneous vaccination with MMR and JE vaccine among 15-month-old children

To evaluate the immunogenicity of measles- mumps- rubella (MMR) vaccination with Japanese encephalitis (JE) vaccine nonsimultaneously and simultaneously, 145 babies, aged 15 months were enrolled into two groups. Group A received MMR and JE vaccines nonsimultaneously at an interval of 6 weeks; group B received the vaccinations simultaneously. Antibody titers of MMR and JE were detected before and 8 weeks after vaccination. A total of 118 babies (61 in group A; 57 in group B) completed the study. In group A, mean increments of logarithmic geometric mean titers (GMTs) of MMR and JE were 4.51, 5.93, 4.07 and 1.99; seroresponse rates were 100% (61/61), 77.05% (47/61), 96.72% (59/61) and 59.02% (36/61) respectively. In group B, mean increments of logarithmic GMTs of MMR and JE were 4.35, 5.37, 4.44 and 1.93; seroresponse rates were 98.25% (56/57), 77.19% (44/57), 98.25% (56/57) and 57.89% (33/57) respectively. There were no significant differences between these two groups. These results suggest that simultaneous and nonsimultaneous vaccination with MMR and JE vaccines were similar in immunogenicity.

Detection of human papilloma virus and Epstein-Barr virus DNA in nasopharyngeal carcinoma by polymerase chain reaction

Nasopharyngeal carcinoma (NPC) is an unique epithelial malignancy which occurs at a high frequency in certain regions of Southeast Asia. Human papilloma virus (HPV) and Epstein-Barr virus (EBV) have both been identified in tissue specimens from NPC. Nevertheless, the association between viral infection and NPC remains unclear. The purpose of this study was to demonstrate that simultaneous infection with EBV and HPV can occur in NPC. Eighty-eight fresh tissue samples which contained sufficient and adequate DNA from patients with histologically confirmed NPC were examined for the existence of HPV and EBV DNA by polymerase chain reaction (PCR). The results showed that HPV and EBV DNA were detected in 51% and in 83% of the specimens, respectively. Coexistence of EBV and HPV in NPC was found in 42% of the samples. The "high risk" types including HPV-16 and HPV-18 accounted for 67% of 45 HPV positive samples. Furthermore, 80% of HPV-16 or HPV-18 positive samples also contained EBV DNA. Our findings suggest that coexistence of EBV and "high risk" HPV-16 or HPV-18 infection may be an important factor in the pathogenesis of NPC.

Characterization of atrioventricular nodal reentry with continuous atrioventricular node conduction curve by double atrial extrastimulation

BACKGROUND

Characterization of typical atrioventricular nodal reentrant tachycardia (AVNRT) with continuous AVN conduction (A1A2/A2H2) curves by double atrial extrastimulation (A1A2A3) has never been systematically studied.

METHODS AND RESULTS

This study was composed of 33 patients with typical AVNRT and continuous AVN conduction curves (group 1) and 103 patients with AVNRT and discontinuous AVN conduction curves (group 2). Using A1A2A3 with predefined fast pathway-conducted A2, we examined the effects of slow pathway ablation on the A2A3/A3H3 curves in both groups. In group 1, anterograde AVN effective refractory period (272+/-33 versus 277+/-47 ms, P>0.05) and AVN Wenckebach block cycle length (320+/-45 versus 343+/-59 ms, P>0.05) remained unchanged after ablation. A2H2max was shorter in group 1 than group 2 (237+/-89 versus 395+/-72 ms, P<0.05) at baseline. It shortened in group 2 (395+/-72 versus 221+/-78 ms, P<0.001) but remained unchanged in group 1 (237+/-89 versus 214+/-59 ms, P>0.05) after ablation. A1A2A3 could further disclose discontinuous A2A3/A3H3 curves in 29 patients of group 1. A3H3max shortened in both groups (375+/-81 versus 238+/-82 ms, P<0.001, and 419+/-104 versus 220+/-78 ms, P<0.001, respectively) in a similar fashion. Successful ablation resulted in loss of the left portion of the A2A3/A3H3 curves in the 4 patients of group 1 with continuous A2A3/A3H3 curves.

CONCLUSIONS

Use of A1A2A3 could expose discontinuous A2A3/A3H3 curves in most patients with continuous A1A2/A2H2 curves. Significant shortening of A3H3max after ablation may be indicative of successful elimination of AVNRT.

Unexpected mortality from the use of E. coli L-asparaginase during remission induction therapy for childhood acute lymphoblastic leukemia: a report from the Taiwan Pediatric Oncology Group

The relative efficacy and toxicity of E. coli L-asparaginase and epidoxorubicin used in remission induction therapy for childhood acute lymphoblastic leukemia (ALL) were assessed in a randomized trial conducted in Taiwan. All patients had standard-risk ALL, defined as a leukocyte count <10 x 10(9)/l and were aged between 1 and 2 or 7 and 10 years, or a leukocyte count <50 x 10(9)/l and were aged between 2 and 7 years, without evidence of a T cell or mature B cell immunophenotype, central nervous system leukemia or expression of two or more myeloid-associated antigens. Ninety-three patients were randomized to receive E. coli L-asparaginase at 10,000 IU/m2 thrice weekly for nine doses and 108 to receive epidoxorubicin at 20 mg/m2 weekly for two doses during remission induction with daily prednisolone, weekly vincristine and, on day 22, a dose of etoposide plus cytarabine. Patients treated with L-asparaginase had a significantly higher rate of fatal infection with or without hemorrhage than did those who received epidoxorubicin during remission induction (six of 93 vs none of 108, P = 0.009), resulting in a lower rate of complete remission in the former group (93.6 vs 99.1%, P = 0.05). In addition, patients treated with L-asparaginase had a higher frequency of hyperglycemia and hypoalbuminemia. The overall rate of event-free survival was lower in patients treated with L-asparaginase than in other patients (P = 0.06); estimated 3-year rates were 72% (95% confidence interval, 55-89%) and 87.2% (78-96%), respectively. We conclude that L-asparaginase (Leunase) given at 10,000 IU/m2 for nine doses was poorly tolerated and resulted in excessive toxicity, both through its effects as a single agent and possibly through potentiation of etoposide.

Seroepidemiology of human parvovirus B19 in Taiwan

In order to determine the prevalence and risk factors of human parvovirus B19 (B19) infection in Taiwan, a seroepidemiological study was carried out in 19 townships. Serum samples were collected from 862 healthy residents, who were selected by stratified random sampling from various study areas. They were chosen from four different ethnic groups including aborigines, Fukien Taiwanese, Hakka Taiwanese, and mainland Chinese. Serum samples were screened for B19 IgG antibody by indirect antibody capture enzyme-linked immunosorbent assay (ELISA) and B19 IgM by IgM antibody capture (MAC)-ELISA, respectively. The overall prevalence of anti-B19 IgG and anti-B19 IgM was 32.8% and 0.35%, respectively. The anti-B19 seropositive rate in females was significantly higher than that of males (36.4% vs. 29.4%, P < .001). The age-sex-adjusted seropositive rate in urban townships (39.9%) was higher than that in aboriginal townships (30.5%, P < .001). The seropositive rate increased significantly with age showing a dose-response relationship (P=0.0001 based on a trend test). Blood transfusion was found to be associated with an increased seropositive rate showing a multivariate-adjusted odds ratios of 1.6.

Longitudinal observation and outcome of nonfamilial childhood haemophagocytic syndrome receiving etoposide-containing regimens

The long-term outcome of 22 children treated with etoposide-containing regimens for haemophagocytic syndrome (HS) were longitudinally studied; none of them had a family history of the disease. All patients received etoposide-containing (150 mg/m2/d) regimens, combined, in 16 cases, with intravenous immunoglobulin (IVIG) and prednisolone. Complete remission (CR) was achieved in 12 patients, partial remission in seven, and early mortality occurred in three. Of the 12 CR patients, only four remain alive and disease-free, with a median follow-up of 47.4 months; one CR patient died due to infection and the remaining seven had relapsed diseases. Three patients with a partial response or with relapsed disease progressed to T-cell lymphoma, characterized, in the two cases tested, by clonal chromosomal abnormalities. Epstein-Barr virus (EBV) infection was implicated in disease pathogenesis in 15/22 patients. The overall survival was 45.5%, 40.9% and 40.9% at 1, 3 and 5 years, respectively, and disease-free survival for CR patients at these same times was 45.5%, 36.4% and 36.4%. The etoposide-containing regimen would appear to be an effective initial therapeutic option for childhood HS. However, in view of the frequency of partial remissions and relapsed disease, a more intensive chemotherapy or bone marrow transplantation should be applied. The progression to EBV-containing T-cell lymphoma in three patients is consistent with the previous observation that EBV-associated HS is a potentially malignant disease.

Simultaneous multiple viral infections in childhood acute lower respiratory tract infections in southern Taiwan

Thirty paediatric patients with acute lower respiratory tract infections (ALRI) caused by simultaneous multiple viral infections (SMV) in a 3-year interval were reviewed. Twenty patients were infected with two viruses simultaneously; nine patients with three viruses; and one patient with four viruses. The frequency of individual viruses were: adenovirus, 18 (60 per cent); respiratory syncytial virus, 7 (23 per cent); influenza virus type A, 6 (20 per cent); influenza virus type B, 15 (50 per cent); parainfluenza virus type 1, 11 (37 per cent); parainfluenza virus type 3, 13 (43 per cent). There was no difference between the clinical presentations of ALRI with SMV and those of ALRI with a single virus. In conclusion, SMV was not uncommon in children with ALRI; the clinical presentations of multiple viral infection were similar to those of single viral infection.