C. elegans CED-12 acts in the conserved crkII/DOCK180/Rac pathway to control cell migration and cell corpse engulfment

We have identified and characterized a novel C. elegans gene, ced-12, that functions in the conserved GTPase signaling pathway mediated by CED-2/Crkll, CED-5/DOCK180, and CED-10/Rac to control cell migration and phagocytosis of apoptotic cells. We provide evidence that ced-12 likely acts upstream of ced-10 during cell migration and phagocytosis and that CED-12 physically interacts with CED-5 and forms a ternary complex with CED-2 in vitro. We propose that the formation and localization of a CED-2-CED-5-CED-12 ternary complex to the plasma membrane activates CED-10, leading to the cytoskeletal reorganization that occurs in the polarized extension of cell surfaces in engulfing cells and migrating cells. We suggest that CED-12 counterparts in higher organisms regulate cytoskeleton dynamics, as CED-12 does in C. elegans.

The alkaloids of Artabotrys uncinatus

A novel type of alpha,beta-butenolide alkaloid, uncinine (1), two novel oxoaporphines, artabonatine C (2) and artabonatine D (3), a new oxazoloaporphine, artabonatine E (4), and a new 7,7'-bisdehydroaporphine, artabonatine F (5), along with 25 known alkaloids, were isolated from Artabotrys uncinatus. The structures of 1-5 were determined using NMR and mass spectral data. Atherospermidine and squamolone exhibited cytotoxicity against hepatocarcinoma cancer cell lines (Hep G(2) and 2,2,15), and the activity of some of the alkaloids in an antithrombin assay is also discussed.

Bullatacin, a potent antitumor annonaceous acetogenin, inhibits proliferation of human hepatocarcinoma cell line 2.2.15 by apoptosis induction

Bullatacin, isolated from the fruit of Annona atemoya, is one of the most potentially effective antitumor annonaceous acetogenins. Bullatacin was studied here for its ability to inhibit the proliferation of 2.2.15 cells, hepatitis B virus (HBV) DNA transfected human hepatocarcinoma cell line. It was found that bullatacin induced cytotoxicity of 2.2.15 cells in a time- and dose-dependent manner. Fifty percent effective dose (ED50) on day 1 of exposure to bullatacin were 7.8 +/- 2.5 nM for 2.2.15 cells. [3H]-Thymidine incorporation assays showed almost the same results. Bullatacin-treatment also reduced concentrations of hepatitis B surface antigen (HBsAg) in the cultured medium released from 2.2.15 cells, coincident with the decrease in the cell proliferation. Analysis of mophological changes of bullatacin-treated 2.2.15 by inverted phase-contrast microscope and eletron microscopy revealed a possible model of action for bullatacin to inhibit proliferation of 2.2.15 cells by inducing apoptosis. Most of the bullatacin-induced cell death was found to be due to apoptosis, as determined by double staining with fluorescein-isothiocyanate (FITC)-labeled annexin V and propidium iodide (PI).

Hydrachine A, a novel alkaloid from the roots of Hydrangea chinensis

A novel alkaloid, hydrachine A (3), has been isolated, along with 15 known compounds, from the roots of Hydrangea chinensis. The structure and stereochemistry of the new alkaloid 3 was determined using extensive 2D NMR data.

Novel cytotoxic annonaceous acetogenins from Annona muricata

Seven new annonaceous acetogenins, muricins A-G (1-7), as well as five known compounds, a mixture of muricatetrocin A (8) and muricatetrocin B (9), longifolicin (10), corossolin (11), and corossolone (12), were isolated from the seeds of Annona muricata. The structures of all isolates were elucidated and characterized by spectral and chemical methods. These acetogenins showed significantly selective in vitro cytotoxicities toward the human hepatoma cell lines Hep G(2) and 2,2,15.

Antiplatelet activity of N-methoxycarbonyl aporphines from Rollinia mucosa

Bioassay-directed fractionation of the stems of Rollinia mucosa led to the isolation of new N-methoxycarbonyl aporphine alkaloids, romucosine A (1), romucosine B (2), romucosine C (3), and romucosine D (4), along with the known alkaloid, N-methoxylcarbonyl-nornuciferine (5). Alkaloids 1 and 4 exhibited significant inhibition of collagen, arachidonic acid, and platelet activating factor-induced platelet aggregation, and alkaloid 3 also showed an inhibitory effect on arachidonic acid induced platelet aggregation.

Cytotoxic constituents of the fruits of Cananga odorata

A new guaipyridine sesquiterpene alkaloid, cananodine (1), and two new eudesmane sesquiterpenes, cryptomeridiol 11-alpha-L-rhamnoside (2) and gamma-eudesmol 11-alpha-L-rhamnoside (3), along with gamma-eudesmol (4), were isolated from the fruits of Cananga odorata. The structures of compounds 1-3 were established on the basis of NMR and MS methods. In addition, compounds 1-4 and four previously reported alkaloids, cleistopholine (5), N-trans-feruloyltyramine (6), (+)-ushinsunine-beta-N-oxide (7), and lyscamine (8), were evaluated for cytotoxicity against two human hepatocarcinoma cell lines.

Vaginal expulsion of submucous myomas after laparoscopic-assisted uterine depletion of the myomas

STUDY OBJECTIVE

To determine the safety and side effects that may be caused by laparoscopic-assisted uterine depletion (LAUD) of submucous myomas.

DESIGN

Retrospective chart review and follow-up (Canadian Task Force classification II-2).

SETTING

University-affiliated tertiary referral center.

PATIENTS

Five hundred twenty women with symptomatic myomas warranting surgical treatment, who wished to retain their uteri.

INTERVENTION

Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries.

MEASUREMENTS AND MAIN RESULTS

Postoperative sonographs showed submucous myomas in 53 (10.2%) women. During follow-up for a mean of 8.6 months very few complications occurred; however, nine women (1.7%) experienced vaginal expulsion of myomas from 2 weeks to 5 months postoperatively. Four of them were readmitted within 43 days with high fever and fetid discharge, and cervical cultures revealed heavy growth of Escherichia coli in three. Vaginal myomectomy was performed in six patients, and one woman passed the myoma spontaneously. Histopathologic studies of these nine specimens showed that two had infarction, three had coagulative necrosis, and four had degeneration. After treatment, all nine women had normal menstruation and their symptoms resolved during follow-up of at least 3 months.

CONCLUSION

In our experience LAUD led to satisfactory symptomatic improvement and reduction in myoma volume and few complications. If vaginal expulsion of submucous fibroids can be viewed as a side effect, we should pay close attention to women with submucous myomas, especially within 2 months of LAUD. Otherwise, more dangerous complications could occur.

Mechanical effects of liriodenine on the left ventricular-arterial coupling in Wistar rats: pressure-stroke volume analysis

1. In a recent in vivo study, liriodenine, an aporphine alkaloid, has been identified as a prominent anti-arrhythmic agent that can prevent rats' sudden deaths, even at the dose as low as 10(-7) g kg(-1). The aim of this study was to determine whether liriodenine at its effective anti-arrhythmic dose of 10(-7) g kg(-1) had effects on the left ventricular (LV)-arterial coupling in Wistar rats. 2. LV pressure and ascending aortic flow signals were recorded to construct the ventricular and arterial end-systolic pressure-stroke volume relationships to calculate LV end-systolic elastance (E(es)) and effective arterial volume elastance (E(a)), respectively. The optimal afterload (Q(load)) determined by the ratio of E(a) to E(es) was used to measure the optimality of energy transmission from the left ventricle to the arterial system. 3. Liriodenine at the dose of 10(-7) g kg(-1) showed no significant changes in basal heart rate (HR), cardiac output (CO), LV end-systolic pressure (P(es)), E(a), E(es), and Q(load). 4. By contrast, liriodenine at the dose of 10(-6) g kg(-1) produced a significant fall of 2.0% in HR and a significant rise of 5.8% in CO, but no significant change in P(es). Moreover, liriodenine administration of 10(-6) g kg(-1) to rats significantly decreased E(es) by 8.5% and E(a) by 10.6%, but did not change Q(load). 5. We conclude that liriodenine at the dose of 10(-7) g kg(-1) has no effects on the mechanical properties of the heart and the vasculature and the matching condition for the left ventricle coupled to its vasculature in rats. Even at 10 times the effective anti-arrhythmic dose, liriodenine shows no effects on the efficiency of energy transferred from the left ventricle to the arterial system.

Four alkaloids from Annona cherimola

Four alkaloids, annocherine A, annocherine B, cherianoine, and romucosine H, along with one known alkaloid, artabonatine B, were isolated from the MeOH extract of the stems of Annona cherimola. Their structures were identified on the basis of both analysis of their spectral data and from chemical evidence.

UCN-01 suppresses E2F-1 mediated by ubiquitin-proteasome-dependent degradation

E2F-1 regulates the transcription of genes required for DNA synthesis. Previously, we have reported that UCN-01 suppresses E2F-1 protein expression without any noticeable effect on its mRNA level in gastric cancer cell line SK-GT5 (Clin. Cancer Res., 4: 2201-2206, 1998). In this study, we investigated the mechanism responsible for the suppression of E2F-1 expression by UCN-01 in SK-GT5 cells. After 24-h exposure to 1 microM UCN-01, E2F-1 protein expression was decreased by >99%. The suppressive effect of UCN-01 could be reversed by ubiquitin-dependent proteasome inhibitors such as calpain inhibitor I and lactacystin. Transfection experiments using expression plasmids encoding full-length E2F-1 or truncated E2F-1 with deletion of the COOH-terminal region (which is required for eliciting ubiquitination and protein degradation) revealed that the expression of truncated E2F-1 was not affected by UCN-01. Other cell-cycle-related and ubiquitin-proteasome-regulated proteins such as p21, p27, and cyclin B1 were not repressed by UCN-01 in E2F-1-overexpressing cells. In vitro-translated, full-length E2F-1 degraded more rapidly upon incubation with extracts from UCN-01-treated cells when compared with truncated E2F-1. Taken together, these data indicate that UCN-01 suppresses E2F-1 protein expression mediated by the ubiquitin-proteasome pathway in a specific manner.

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.

Analysis of programmed cell death in the nematode Caenorhabditis elegans

The nematode Caenorhabditis elegans has been shown to be an excellent model organism with which to study the mechanisms of programmed cell death because of its powerful genetics and the ability to study cell death with single-cell resolution. In this chapter, we describe methods that are commonly used to examine various aspects of programmed cell death in C. elegans. These methods, in combination with genetic analyses, have helped identify and characterize many components of the C. elegans cell death pathway, illuminating the mechanisms by which these components affect programmed cell death.

Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids

OBJECTIVE

To evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids.

DESIGN

Prospective clinical study.

SETTING

University-affiliated tertiary referral center.

PATIENT(S)

Eighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri.

INTERVENTION(S)

Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries.

MAIN OUTCOME MEASURE(S)

Percentage reduction in the dominant fibroid size and clinical response evaluation.

RESULT(S)

Eighty-five (97.7%) of 87 patients underwent technically successful laparoscopic coagulation of uterine vessels without intraoperative complications. The mean follow-up time was 10.2 months. Symptomatic improvement was reported in 76 (89.4%) of 85 patients, including 18 (21.2%) with complete resolution of symptoms. Significant reductions in the dominant fibroid size (average, 76%) and the uterine volume (average, 46%) were sonographically demonstrated. Two patients conceived 4 and 9 months, respectively, after treatment. Three (3.5%) premenopausal women became postmenopausal postoperatively.

CONCLUSION(S)

Laparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.

A novel mutation in the calcium-sensing receptor gene in a Chinese subject with persistent hypercalcemia and hypocalciuria

Familial hypocalciuric hypercalcemia (FHH) is an autosomal dominant disorder characterized by high penetrance of relatively benign, lifelong persistent hypercalcemia and hypocalciuria. By contrast, neonatal severe hyperparathyroidism represents a life-threatening form of hypercalcemia that can cause the early newborn mortality if immediate intervention is not undertaken. Both disorders are due to inactivation mutation of the human calcium-sensing receptor (CaSR) gene on chromosome 3q21-24. Up to now, more than 30 mutations in the CaSR gene associated with FHH have been described. In this study, we analyzed one 79-yr-old male with hypocalciuric hypercalcemia without siblings or children to compare with an additional group of 50 normal Chinese subjects in Taiwan. DNA sequence analysis of the CaSR gene was performed. The result showed that the proband had a heterozygous nonsense mutation in exon 7 of the CaSR gene at codon 648 (CGA-->TGA/Arg-->Ter). This mutation, located in the COOH-terminal of the first intracellular loop of the CaSR, predicts a markedly truncated protein. We have identified a novel R648X mutation in the CaSR gene in one patient with FHH in Taiwan

Thoracoscopic retrieval of metal rods after penetrating chest injury: case report

Thoracoscopy has been used for both diagnostic and therapeutic purposes. Its use in the trauma field is rapidly increasing. Here, we present a case of chest trauma that was successfully treated using the thoracoscopic approach. A 43-year-old male patient was brought to our emergency room with a severe right chest wall-penetrating metal-rod injury, which had occurred after falling from a height. The chest X-ray showed an upper right lung lobe injury. Video-assisted thoracoscopic surgery (VATS) was performed for diagnosis of any other associated injury and for management of the penetrating injury. The prognosis was good. We believe that minimal thoracoscopic surgery is an alternative way that provides a more rapid diagnosis, and a less-invasive and safe operation for acute chest trauma patients.

Cytotoxic constituents of Polyalthia longifolia var. pendula

A new halimane diterpene, 3beta,5beta, 16alpha-trihydroxyhalima-13(14)-en-15,16-olide (1), and a new oxoprotoberberine alkaloid, (-)-8-oxopolyalthiaine (2), along with 20 known compounds, were isolated from a methanolic extract of Polyalthia longifolia var. pendula. The structures of compounds 1 and 2 were established by spectroscopic analysis. Several of these compounds were evaluated for cytotoxicity toward a small panel of human cell lines.

Paradoxical cerebral air embolism after removal of a central venous catheter: case report

Paradoxical cerebral air embolization through a residual tract after the removal of a central venous catheter is a serious complication of central venous cannulation. Air embolisms resulting from residual catheter tracts in general patients and in single lung transplant patients have been reported. The generally accepted mechanism of this complication is failure of a spontaneous collapse or thrombotic obliteration of a well-formed catheter tract. It may be related to the duration of catheter insertion, the patient's nutritional status, the diameter of the indwelling catheter, the upright position of the patient, deep inspiration or coughing, and improper wound dressing and catheter removal. Cardiovascular collapse, pulmonary or neurologic sequelae, and even death, are commonly noted in patients with air embolism. In this article, we report on cerebral air embolization as a complication with the removal with a central venous catheter in a patient with bullous emphysema. A high degree of suspicion and a prompt diagnosis are required for successful application of established therapy. Simple prophylactic procedures and constant awareness of the unusual mechanism of air embolism remain the best treatment.

Power Doppler angiographic appearance and blood flow velocity waveforms in invasive cervical carcinoma

OBJECTIVES

The aim of this study was to investigate the effectiveness of transvaginal power Doppler angiography in predicting cervical malignancy by detecting intratumoral blood flow and to understand the relationship between squamous cell carcinoma (SCC) serum levels and intratumoral blood flow analysis of invasive cervical carcinoma before treatment.

METHODS

Thirty-eight patients with cervical carcinoma (35 with stages Ia to IVb invasive carcinoma, 3 with cervical carcinoma in situ) were enrolled for the evaluation of tumor flow using transvaginal ultrasound accompanied with power Doppler angiography before surgery. The pulsatility, resistance index, and vascular index of tumor flow were measured. Thirty patients with proven healthy cervices were used as the control group. Pretreatment SCC serum levels were obtained in 34 women with cervical carcinoma.

RESULTS

The pulsatility index and resistance index were significantly lower in the study group than in the control group (P < 0.0001). The vascular index was also significantly lower in the study group than in the control group (P < 0.0001). There were no significant differences among patients with SCC type and non-SCC type cervical carcinoma (P > 0.05) among the six parameters. There was no significant correlation between the pretreatment SCC serum levels with any of the six parameters obtained from the intratumoral blood flow analysis in the SCC group.

CONCLUSIONS

Transvaginal ultrasound with power Doppler angiography is a valuable diagnostic tool for differentiating benign tumors of the cervix from malignant ones. Intratumoral blood flow of the cervix supplied us with practical diagnostic information before surgery and may aid in early prediction and management of cervical carcinoma. The use of transvaginal ultrasound with power Doppler angiography in the grading of vascularity ratio within cervical masses provided more sonographic characteristics among the different subclassifications of cervical cancer and is more useful than color Doppler imaging in the visualization of sonographic morphology.

Spirostanol sapogenins from the underground parts of Tupistra chinensis

Chemical examination of the underground parts of Tupistra chinensis led to the isolation of two new 5beta-spirostane type steroidal sapogenins, tupichigenin B (1) and C (2), together with two known steroidal sapogenins, ranmogenin A (3) and delta25(27)-pentrogenin (4). The structures of 1 and 2 were established as spirost-25(27)-ene-1beta,3beta,4beta,5beta,6b eta-pentaol and 1beta,2beta,3beta,4beta,5beta-pentahydroxyspi rost-25(27)-en-6-one, respectively, on the basis of detailed analysis of their physical and spectral data.

Combining radiation therapy with interleukin-3 gene immunotherapy

The goal of this study was to explore immunological strategies to increase local and systemic tumor control in patients receiving radiation therapy. In previous studies, interleukin-3 (IL-3) gene expression within murine tumors was shown to increase their response to irradiation through immune mechanisms. In this study, the efficacy of systemically administered IL-3 gene-transduced irradiated tumor cell vaccines was tested for their ability to augment radiation responses against established immunogenic (FSAR) and nonimmunogenic (FSAN) tumors. Vaccines of irradiated FSAR/FSAN or FSAN-JmIL-3/FSAR-JmIL-3 cells were given intraperitoneally just before and after local irradiation of parental tumors with diameters of 8 mm, as well as in two booster doses. The IL-3 gene-transduced tumor cell vaccines were more effective than the parental vaccines at delaying tumor growth after irradiation, although no complete cures resulted. Responses were largely specific to the tumor type, indicating that tumor-specific immunity was enhanced by IL-3 vaccine administration. When the experiment was repeated in the C3H/HeJ mice, which are deficient in tumor necrosis factor-alpha production, the vaccines were still effective, but less so than in C3H/HeN mice. Systemic IL-3 vaccine treatment increased intratumoral levels of intercellular adhesion molecule-1, Mac-1, EB22/5.3, tumor necrosis factor-alpha, and IL-1 mRNA in irradiated tumors, indicating that cellular infiltration was part of the response. The study demonstrates that local radiation therapy can enhance the efficacy of genetically altered vaccine-based immunotherapy for cancer by decreasing tumor burden. At the same time, tumor cell vaccines may improve the cure rate of local radiation therapy by eliminating residual cancer cells. Although less effective than intratumoral gene expression, administration of IL-3 gene-transduced tumor cell vaccines is clinically a more feasible strategy that may be useful in situations in which the tumor load is small.

Aristolactams and dioxoaporphines from Fissistigma balansae and Fissistigma oldhamii

Investigation of extracts of Fissistigma balansae and Fissistigma oldhamii resulted in the isolation of 11 aristolactams-stigmalactam (1), piperolactam A (2), piperolactam C (3), aristolactam AII (4), aristolactam AIIIa (5), aristolactam BII (6), aristolactam BIII (7), aristolactam FII (8), goniothalactam (9), enterocarpam I (10), and velutinam (11)-as well as two dioxoaporphines, noraristolodione (12) and norcepharadione B (13). The new compound 1 was identified by spectral data interpretation. Compounds 1-13 were subjected to antiplatelet aggregation testing.

Thoracoscopic removal of intrathoracic neurogenic tumors: a combined Chinese experience

OBJECTIVE

To review the surgical and clinical results of minimally invasive resection of intrathoracic neurogenic tumors using a video-assisted thoracoscopic technique.

SUMMARY BACKGROUND DATA

Thoracoscopy has emerged as a possible means for diagnosing and managing various intrathoracic disorders. Benign intrathoracic tumors often are ideal lesions for resection using a video-assisted technique. The authors report on their combined experience with the thoracoscopic resection of 143 intrathoracic neurogenic tumors.

METHODS

Between March 1992 and February 1999, 143 patients with intrathoracic neurogenic tumors were diagnosed and underwent resection using video-assisted thoracoscopic techniques in three teaching centers. Case selection, surgical technique, and clinical results were reviewed.

RESULTS

The average age of the patients was 40.8 years; 57.3% were male. Thirty-eight patients (27%) had symptoms attributable to the masses. Seventy-two masses were neurofibromas, 33 were neurilemmomas, 7 were paragangliomas, and 31 were ganglioneuromas. All but seven tumors were located in the posterior mediastinum. The masses were on average 3.5 cm in greatest diameter. The mean surgical time was 40 minutes, and the average hospital stay was 4.1 days. There were no major postoperative complications or recurrences to date. Nine patients reported paresthesias over the chest wall during a mean follow-up of 29 months.

CONCLUSIONS

Resection of intrathoracic neurogenic tumors using a thoracoscopic technique based on standard surgical indications would seem to be appropriate. Most of these masses are benign and readily removed. For dumbbell tumors, a combined thoracic and neurosurgical approach is mandatory.

Cost-effective approach of video-assisted thoracic surgery: 7 years experience

BACKGROUND

Cost containment is the driving force behind current health care reform. While video-assisted thoracic surgery (VATS) permits a less invasive approach to surgical diseases of the chest, cost is one aspect that is seldom discussed. In Asia, cost-effectiveness essential for the survival of this approach. We present our cost-effective experience with VATS in 2300 patients over a 7-year period.

METHOD

Between 1992 and 1999, 2300 patients underwent video-assisted thoracic surgery at Chang Gung Memorial Hospital. The mean age was 53.2 years (range, 22 days to 102 years); 67% (1541 patients) were men. The VATS technique was mainly performed based on traditional surgical principles. Conventional instruments and the fundamental surgical techniques of dissection, suturing, hemostasis, and tissue approximation that are familiar in the open setting were modified and used to enhance cost savings during VATS.

RESULTS

Surgery was performed on 41 patients on an emergency basis (24 with impending cardiac tamponade and 17 with hemothorax). The mean hospital stay of the patients treated by VATS was 4.5 days. The majority of the patients were operated on successfully using conventional instruments under video vision. The overall operative cost was decreased as compared to common VATS techniques. No delayed morbidity was noted in our patients after a mean follow-up period of 39 months (range, 1 to 68 months).

CONCLUSION

It is our experience that VATS procedures should be performed with the same expertise as open surgery. Conventional instruments similar to those used in open thoracotomy can be incorporated in VATS, and with a more natural hand manipulation. Only through stringent use of expensive endoscopic consumables and application of modified techniques based on traditional surgical principles can VATS be performed efficaciously and economically for a wide range of thoracic conditions.

Catamenial hemoptysis: report of a case treated with thoracoscopic wedge resection

Catamenial hemoptysis is a rare form of hemoptysis. It is a term for the condition of hemoptysis associated with menses. Few cases have been reported in the literature. Only one case, treated by video-assisted thoracoscopic wedge resection, has been described. We report the case of a 26-year-old woman who suffered from catamenial hemoptysis for 7 months and was treated successfully with a video-assisted thoracoscopic (VATS) wedge resection of the lesion. No evidence of recurrence was noted in the postoperative follow-up period of 48 months. We suggest that VATS is the good choice for single focus catamenial hemoptysis.

Prenatal diagnosis and management of congenital cystic adenomatoid malformation

Congenital cystic adenomatoid malformation (CCAM) is a rare pulmonary malformation resulting from excessive overgrowth of the terminal bronchioles. We present two CCAM case studies: type I (macrocystic) and type III (microcystic), diagnosed by antenatal ultrasonography at 31 and 21 weeks' gestation, respectively. In the former, multiple dilated cystic masses in the fetal left lung, with polyhydramnios, were identified during the antepartum examination. A postnatal thoracotomy with lobectomy was performed due to persistent cyanosis and resulted in a good outcome. In the latter case, an echogenic mass with multiple cysts in the fetal right lung was detected by prenatal sonography. The parents decided to terminate the pregnancy after prenatal counseling.

A novel agarofuran sesquiterpene, celahin D from Celastrus hindsii Benth

A novel agarofuran sesquiterpene polyol ester, 1beta,2beta,6alpha,15beta-tetracetoxy-8 beta,9alpha-dibenzoyloxy-beta- dihydroagarofuran (celahin D) (1), two known analogues of 1,1beta-acetoxy-8beta,9alpha-dibenzoyloxy-4al pha6alpha-dihydroxy-2beta(alphamethylbutanoyloxy)-beta-++ +dihydroagarofuran (2) and beta-acetoxy-8beta,9alpha-dibenzoyloxy-6alpha-hy droxy-2beta(alpha -methylbutanoyloxy)-beta-dihydroagarofuran (3), and a known cytotoxic sesquiterpene pyridine alkaloid, emarginatine E (4) were isolated from the stems of Celastrus hindsii Benth. Three known triterpenes, loranthol (5), lupenone (6) and friedelinol (7) were also obtained from the titled plant. Structural elucidation of compound 1 was established by 2D NMR spectra.

ent-kaurane diterpenoids from Annona glabra

Three new kaurane diterpenoids, annoglabasin C (16alpha-acetoxy-ent-kauran-19-oic acid-17-methyl ester) (1), annoglabasin D (16alpha-acetoxy-ent-kauran-19-al-17-methyl ester) (2), and annoglabasin E (16alpha-hydro-19-ol-ent-kauran-17-oic acid) (3), and a new norkaurane diterpenoid, annoglabasin F (16alpha-acetoxy-19-nor-ent-kauran-4alpha-ol-17-methyl ester) (4), along with 13 known kaurane derivatives were isolated from the stems of Annona glabra. 16alpha-Methoxy-ent-kauran-19-oic acid (5) and 16alpha-hydro-ent-kauran-17,19-dimethyl ester (6) were obtained for the first time as natural products. The structures of compounds 1-6 were characterized by spectral analysis.

New alkaloids from Annona purpurea

Three new alkaloids, promucosine (1), romucosine F (2), and romucosine G (3), along with 28 known compounds, were isolated from the MeOH extract of stems of Annona purpurea. The structures of 1-3 were determined on the basis of spectral data and chemical evidence.

Tupichigenin A, a new steroidal sapogenin from Tupistra chinensis

From the underground parts of Tupistra chinensis, a novel polyhydroxylated spirostanol sapogenin, tupichigenin A [(20S, 22R)-spirost-25(27)-ene-1beta,2beta,3beta,5beta- tetraol] (1), was isolated and determined structurally on the basis of spectroscopic methods. Also isolated was the known steroidal sapogenin (20S, 22R)-spirost-25(27)-ene-1beta,2beta,3beta,4beta, 5beta, 7alpha-hexaol-6-one (2).

Mechanisms for the formation of glycoxidation products in end-stage renal disease

BACKGROUND

Advanced glycation end products (AGEs) accumulate on tissue and plasma proteins in patients with renal failure far in excess of normal aging or diabetes. The aim of these studies was to elucidate the nature of the precursors and the pathways that lead to an accelerated formation of two structurally identified AGEs [pentosidine and Nepsilon(carboxymethyl)lysine (CML)] in the uremic milieu.

METHODS

Serum levels of the glycoxidation products, pentosidine and CML, were quantitated by high-performance liquid chromatography in uremic patients treated by dialysis. The formation of early glycation products (as furosine) and late glycoxidation products was modeled in uremic serum and in spent peritoneal dialysate.

RESULTS

Clinical factors that affect circulating levels of AGEs included dialysis clearance and dialyzer membrane pore size, but not the presence or absence of diabetes. Both pentosidine and CML form at an accelerated rate in serum from uremic patients. Chelating agents most effectively slow the formation in vitro. In uremic fluids, the primary mechanism of formation of pentosidine is through the Amadori pathway. The primary mechanism of formation of CML is through metal-chelated autoxidation of reducing sugars generating reactive carbonyl precursors. In uremic serum, the presence of an unidentified reactive low molecular weight precursor accelerates the formation of pentosidine.

CONCLUSIONS

The formation of the two glycoxidation products, pentosidine and CML, proceeds by different pathways and is enhanced by different precursors in the uremic milieu. The formation of both AGEs is markedly enhanced by metal-catalyzed reactions, evidence for the presence of increased metal-ion mediated oxidant stress in uremia.

Spuriously high CK-MB isoenzyme activity mimicking acute myocardial infarction in a patient with adenocarcinoma of the rectum

A 58-year-old Chinese male presented with precordial distress and was found to have elevated creatine kinase (CK)-myocardial bound (MB) (determined by the Kodak Ektachem Clinical Chemistry Slide method) activity and an abnormal electrocardiogram. Eventually, the patient was diagnosed with an annular ulcerative tumor 10 cm above the anal orifice. The tumor was an adenocarcinoma of the rectum and was immunoreactive for CK-BB (brain type). CK isoenzyme electrophoresis disclosed both BB and MM (muscle type) bands. We concluded that the level of CK-MB determined using the Kodak Ektachem Clinical Chemistry Slide method was spuriously elevated in our patient with adenocarcinoma of the rectum, without evidence of myocardial injury. Institutions using the Kodak Ektachem Clinical Chemistry Slide system for CK should be aware of this possibility.

A novel mutation in the hepatocyte nuclear factor-1alpha/MODY3 gene in Chinese subjects with early-onset Type 2 diabetes mellitus in Taiwan

AIMS

The goal of this study was to determine the frequency of mutation in hepatic nuclear factor (HNF)-1alpha, a gene recently implicated as causing maturity-onset diabetes of the young (MODY) and to analyse the respective clinical presentations in an ethnically Chinese population.

METHODS

Fifteen unrelated subjects (nine females and six males) aged less than 35 years who had early-onset diabetes were analysed to test the possibility that mutation of the HNF-1alpha gene was responsible for this disorder. Genomic DNA extraction, polymerase chain reaction and DNA sequence analysis were performed accordingly.

RESULTS

One patient with MODY had a novel missense mutation in exon 3 of the HNF-1alpha gene (Y218C) in a region of the protein that corresponds to a predicted DNA binding domain.

CONCLUSIONS

A Y218C mutation in HNF-1alpha gene was identified in one family in Taiwan.

Clinical significance of serum soluble interleukin 2 receptor-alpha in esophageal squamous cell carcinoma

Although the serum level of soluble interleukin-2 receptor alpha (sIL-2Ralpha) has been shown to correlate with progression and prognosis of several cancers, data to support its clinical significance to esophageal squamous cell carcinoma (ESCC) are limited. This study was conducted to assess the prognostic value and source of sIL-2Ralpha in patients with ESCC. From January 1986 to June 1997, 125 patients with histopathologically confirmed ESCC were enrolled for study. Ninety-three patients underwent en bloc esophagectomy, and 32 patients with unresectable tumor underwent palliative surgery. Four (4.3%; 4 of 93) patients died of surgical complications. Serum levels of sIL-2Ralpha were measured by ELISA. Expression of IL-2Ralpha, IL-2Rbeta, and IL-2Rgamma in the pathological section was determined, respectively, by immunohistochemistry (IHC) and in situ hybridization (ISH). Compared with the healthy control group (1020 +/-476 pg/ml, n = 103), ESCC patients tended to have significantly higher serum sIL-2Ralpha concentrations (1424 +/- 798 pg/ml, n = 121). The sIL-2Ralpha level was correlated with age, Tumor-Node-Metastasis classification, tumor stage, reading score of the IHC staining, and survival but not with the pathological grade or lymphovascular invasion. Prognosis was worse for patients with high sIL-2Ralpha levels (> or =1500 pg/ml) than for those with low serum sIL-2Ralpha levels (< 1500 pg/ml; P = 0.0209). It can be used as an independent prognostic factor of ESCC. In the pathological sections, expression of IL-2Ralpha, IL-2Rbeta, and IL-2Rgamma was detected in 17 (18.1%), 83 (89.2%), and 83 (89.2%) cases, respectively, by IHC, and the message of IL-2Ralpha was identified in tumor cells by ISH in 30.1% (28 of 93) of the cases. Serum concentrations of sIL-2Ralpha are frequently elevated in ESCC patients and are correlated with disease progression and survival. These data indicate that, in addition to activated T cells, cancer cells could be an important source of sIL-2Ralpha in ESCC patients.

Strong association of antiepithelial cell antibodies with HLA-DR3 or DR7 phenotype in patients with recurrent oral ulcers

BACKGROUND

Previous studies showed that antiepithelial cell antibodies (anti-ECA) were present in 71% (15/21) of patients with recurrent oral ulcers (ROU) and that there was a strong association of human leukocyte antigen (HLA)-DRw9 with ROU in Chinese patients. In this study, we assessed anti-ECA in a larger group of Chinese patients with ROU (n = 88) in order to further investigate the association of anti-ECA with HLA-DR and -DQ antigens.

METHODS

The anti-ECA in the sera of ROU patients were detected by an indirect immunofluorescence technique with rat esophagus as the substrate, and the HLA-DR and -DQ antigens in ROU patients were typed by a standard microcytotoxicity assay using Terasaki's oriental tray.

RESULTS

The rate of anti-ECA positivity was significantly higher (p < 0.0001) in ROU patients (68%) than in healthy control subjects (0%). Furthermore, the rate of anti-ECA positivity in patients with major or minor oral ulcers (72%) was significantly higher (29%) than that in patients with herpetiform ulcers (p < 0.05). There was a significant increase in the frequency of DR3 or DR7 antigen expression (p < 0.0001, pc [p corrected] < 0.001, relative risk [RR] = 4.3, etiologic fraction = 0.41) in anti-ECA-positive ROU patients compared with the corresponding frequencies in healthy control subjects. There was also a significant increase in the frequency of DR7 or DRw9 antigen expression (p < 0.005, pc < 0.05, RR = 4.7, etiologic fraction = 0.45) compared to healthy controls.

CONCLUSIONS

Because only DR3 or DR7 antigen occurred more frequently in anti-ECA-positive than in anti-ECA-negative ROU patients (p < 0.0007, pc < 0.05, RR = 19.6, etiologic fraction = 0.51), we concluded that the gene coding for DR3 or DR7 antigen may contribute to the presence of anti-ECA in Chinese patients with ROU.

Association of HLA-te22 antigen with anti-nuclear antibodies in Chinese patients with erosive oral lichen planus

The purpose of this study was to determine the frequencies of the presence of serum anti-nuclear antibodies (ANA) and smooth muscle antibodies (SMA) in 76 patients with oral lichen planus (OLP), in 77 patients with other oral mucosal diseases, and in 41 healthy control subjects. HLA phenotypes in some of the patients with OLP and recurrent aphthous ulcers (RAU) were determined to show whether there was an association of HLA antigens with the presence of autoantibodies. Indirect immunofluorescence techniques with mouse liver or stomach as the substrate were used to detect the serum ANA or SMA, respectively. The B lymphocytes isolated from peripheral blood were used for HLA typing by means of a standard microcytotoxicity assay. We found that the positive rate of serum ANA in patients with OLP (29%, p < 0.01), especially in patients with erosive OLP (34%, p < 0.001), was significantly higher than that in the normal control subjects (5%). The frequency of serum SMA in patients with OLP (20%, p < 0.01), in patients with RAU (17%, p < 0.01), or in patients with oral squamous cell carcinomas (41%, p < 0.001) was also significantly higher than that in normal control individuals (0%). In the erosive OLP group, the HLA-Te22 antigen occurred more frequently in patients with positive ANA (75%, p < 0.05) than in those with negative ANA (25%). We conclude that there is an association of HLA-Te22 antigen with ANA in Chinese patients with erosive OLP.

Genetic variation of Japanese encephalitis virus in Taiwan

A 280-nucleotide sequence from the capsid-premembrane (C/preM) gene region of 44 Japanese encephalitis (JE) virus strains isolated in Taiwan from mosquitoes from 1983 to 1994, and 3 strains, (Ling [1965], Chang [1965], and HV1 [1958]) isolated from human brain were analyzed by direct sequencing of reverse transcription-polymerase chain reaction (RT-PCR) amplified products and compared with the corresponding sequences of reference strains. The overall sequence homology of the 47 isolates was > or = 93.3%. Taking 12% nucleotide divergence as a cut-off value, all isolates fell into genotype 3, which included strains from Japan, China, the Philippines, Sri Lanka, India, and Nepal. High nucleotide homology was observed among isolates from different regions of Taiwan and different time periods; on the other hand, high variation existed among isolates from the same region and time period. Phylogenetic analysis showed that the 47 Taiwan isolates fell into three clusters. Twenty-five isolates formed cluster 1, 18 isolates cluster 2, and four isolates cluster 3. Isolates in cluster 1 showed greater (< or = 2.9%) intragroup divergence compared to those in cluster 2 (< or = 1.1%) or cluster 3 (< or = 0.7%). The majority of isolates from northern (73.3%) and central (60%) Taiwan belonged to cluster 1, whereas most isolates (66.7%) from southern Taiwan belonged to cluster 2. Comparison with other Asian JE virus strains showed that isolates of cluster 1 were more specific to Taiwan than isolates of cluster 2 and cluster 3.

NUC-1, a caenorhabditis elegans DNase II homolog, functions in an intermediate step of DNA degradation during apoptosis

One hallmark of apoptosis is the degradation of chromosomal DNA. We cloned the Caenorhabditis elegans gene nuc-1, which is involved in the degradation of the DNA of apoptotic cells, and found that nuc-1 encodes a homolog of mammalian DNase II. We used the TUNEL technique to assay DNA degradation in nuc-1 and other mutants defective in programmed cell death and discovered that TUNEL labels apoptotic cells only during a transient intermediate stage. Mutations in nuc-1 allowed the generation of TUNEL-reactive DNA but blocked the conversion of TUNEL-reactive DNA to a subsequent TUNEL-unreactive state. Completion of DNA degradation did not occur in the absence of cell-corpse engulfment. Our data suggest that the process of degradation of the DNA of a cell corpse occurs in at least three distinct steps and requires activities provided by both the dying and the engulfing cell.

Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage : a randomized controlled trial

BACKGROUND AND PURPOSE

Cerebral blood flow (CBF) is reduced after subarachnoid hemorrhage (SAH), and symptomatic vasospasm is a major cause of morbidity and mortality. Volume expansion has been reported to increase CBF after SAH, but CBF values in hypervolemic (HV) and normovolemic (NV) subjects have never been directly compared.

METHODS

On the day after aneurysm clipping, we randomly assigned 82 patients to receive HV or NV fluid management until SAH day 14. In addition to 80 mL/h of isotonic crystalloid, 250 mL of 5% albumin solution was given every 2 hours to maintain normal (NV group, n=41) or elevated (HV group, n=41) cardiac filling pressures. CBF ((133)xenon clearance) was measured before randomization and approximately every 3 days thereafter (mean, 4.5 studies per patient).

RESULTS

HV patients received significantly more fluid and had higher pulmonary artery diastolic and central venous pressures than NV patients, but there was no effect on net fluid balance or on blood volume measured on the third postoperative day. There was no difference in mean global CBF during the treatment period between HV and NV patients (P=0.55, random-effects model). Symptomatic vasospasm occurred in 20% of patients in each group and was associated with reduced minimum regional CBF values (P=0.04). However, there was also no difference in minimum regional CBF between the 2 treatment groups.

CONCLUSIONS

HV therapy resulted in increased cardiac filling pressures and fluid intake but did not increase CBF or blood volume compared with NV therapy. Although careful fluid management to avoid hypovolemia may reduce the risk of delayed cerebral ischemia after SAH, prophylactic HV therapy is unlikely to confer an additional benefit.

Furoquinolines with antiplatelet aggregation activity from leaves of Melicope confusa

Using antiplatelet aggregation as a guide for fractionation, four furoquinoline-type alkaloids, confusameline (1), skimmianine (2), kokusaginine (3), and O-methylconfusameline (4), were isolated from the leaves of Melicope confusa. All compounds showed significant antiplatelet aggregation activity.

Vertical alignment axis for transtibial prostheses: a simplified alignment method

BACKGROUND AND PURPOSE

To evaluate a simplified method of alignment for fitting a transtibial prosthesis known as the vertical alignment axis method.

METHODS

We measured the relationship between the vertical projection of the prosthetic socket center (geometric center of the cross section of the transtibial prosthetic socket at the level of the patella tendon bar) and the alignment reference center (junction of the middle and posterior thirds of the longitudinal axis of the shoe) in 36 dynamically aligned transtibial prostheses. The prostheses were fabricated by students, and the fit (proper vs improper) was assessed by the faculty.

RESULTS

The faculty members found 26 of the 36 prostheses to be properly fitted. The vertical projections of the socket centers of the properly-fitted prostheses were concentrated within a small area of the shoe tracing (a mean value of 1.3 mm medially and 6.4 mm anteriorly from the alignment reference center). Conversely, in the improperly-fitted prostheses, the vertical projections of the socket center were scattered well away from the alignment reference center; the mediolateral deviation was significantly greater for improperly-fitted prostheses than for those that were properly fitted (p < 0.001).

CONCLUSIONS

These results demonstrate the usefulness of the vertical alignment axis procedure. This procedure may help clinicians to better understand the alignment of transtibial prostheses and gait deviations associated with improper prosthesis fit.

Antiplatelet actions of aporphinoids from Formosan plants

Seventeen aporphines were tested for antiplatelet activity. L-(+)-hemovine HCl and 7-hydroxydehydrothalicsimidine strongly inhibited platelet aggregation induced by adenosine 5'-diphosphate (ADP), arachidonic acid (AA), collagen, and platelet-activating factor (PAF). The latter showed the strongest antiplatelet activity with an IC50 of 70.4 microM against AA-induced platelet aggregation.

New annonaceous acetogenins from Rollinia mucosa

Four new compounds, a mixture of 20,23-cis-2,4-trans-bullatalicinone (1) and 20,23-cis-2,4-cis-bullatalicinone (2), rollimusin (3), and rolliacocin (4), along with eight known acetogenins, were isolated from an ethyl acetate extract of the unripe fruits of Rollinia mucosa. The structures and stereochemistry of 1-4 were determined on the basis of spectral data and chemical evidence.

Two components of transducer adaptation in auditory hair cells

Mechanoelectrical transducer currents in turtle auditory hair cells adapted to maintained stimuli via a Ca(2+)-dependent mechanism characterized by two time constants of approximately 1 and 15 ms. The time course of adaptation slowed as the stimulus intensity was raised because of an increased prominence of the second component. The fast component of adaptation had a similar time constant for both positive and negative displacements and was unaffected by the myosin ATPase inhibitors, vanadate and butanedione monoxime. Adaptation was modeled by a scheme in which Ca(2+) ions, entering through open transducer channels, bind at two intracellular sites to trigger independent processes leading to channel closure. It was assumed that the second site activates a modulator with 10-fold slower kinetics than the first site. The model was implemented by computing Ca(2+) diffusion within a single stereocilium, incorporating intracellular calcium buffers and extrusion via a plasma membrane CaATPase. The theoretical results reproduced several features of the experimental responses, including sensitivity to the concentration of external Ca(2+) and intracellular calcium buffer and a dependence on the onset speed of the stimulus. The model also generated damped oscillatory transducer responses at a frequency dependent on the rate constant for the fast adaptive process. The properties of fast adaptation make it unlikely to be mediated by a myosin motor, and we suggest that it may result from Ca(2+) binding to the transducer channel or a nearby cytoskeletal element.

Aggregation inhibitory activity of minor acetophenones from Paeonia species

Two minor acetophenones, 2,5-dihydroxy-4-methoxy-acetophenone (2) and 2,5-dihydroxy-4-methylacetophenone (7) from Paeonia species were found to selectively inhibit the aggregation of rabbit platelets induced by arachidonic acid. They were more potent than the major compound, paeonol (1), and 7 also inhibited the formation of TXA2 and PGD2 from arachidonic acid.

Detection of Epstein-Barr virus in esophageal squamous cell carcinoma in Taiwan

OBJECTIVE

Recently, an association between viral infection and the development of esophageal carcinoma has been reported, particularly the human papilloma virus (HPV) and Esptein-Bar virus (EBV). However, geographic variation in carcinogenesis is realized. In this study, we investigate the viral carcinogenesis and the biologic effect of viral infection on esophageal squamous cell carcinoma (ESCC) in Taiwan.

METHODS

To determine the association of viral infection (EBV and HPV) with ESCC, we applied polymerase chain reaction (PCR), immunohistochemistry, and in situ hybridization (ISH) to examine 119 surgical specimens from different sites of esophagus in 31 ESCC patients. Additionally, an immunoperoxidase method was used to detect EBV latent membrane protein-1 (LMP-1), p53, CD45RO (UCHL-1), Fas ligand (Fas L), and RNA ISH with oligonucleotide sequences was used to detected interleukin-6 (IL-6) mRNA.

RESULTS

By PCR, EBV DNA was detected in 11 cases (35.5%). Expression of EBERs in ESCC was further confirmed with ISH. Nonetheless, no LMP-1 expression was detected. On the other hand, human papillomavirus (HPV) was identified in only one case (3.2%) of ESCC. Furthermore, HPV was located by ISH in the distant normal region rather than in tumor cells. In EBV-positive cases, accumulation of p53 protein was detected in 10 lesions (91%); CD45RO+ lymphocytes together with expressions of FasL and IL-6 were respectively identified in 100%, 63.6%, and 54.5% of 11 EBV-positive lesions. Interestingly, in the EBV-negative cases (n = 20), p53 protein was detected in 40% of lesions; CD45RO 30%; FasL 50%, and IL-6 10%.

CONCLUSIONS

In this study, no correlation was found between the presence of EBV in ESCC and the patients' age, sex, as well as survival. Although our results indicate that EBV could be associated with ESCC, the clinical role of EBV in ESCC remains to be determined.

[Immunity against diphtheria in Taiwan]

The vaccination of combined diphtheria, pertussis, and tetanus (DPT) vaccine provides good immunity against childhood diphtheria in Taiwan. However, a waning protective antibody level has been observed with an increase in age. Therefore, we assessed diphtheria immunoglobulin (DIG) level in Taipei City as representatives of urban dwellers and in King-Shan County as representatives of rural dwellers to evaluate the status of immunity against diphtheria in the population of Taiwan. In total, 1239 serum samples collected from the resident population, age 0-91 years, were detected by toxin neutralization test with VERO cells. The DIG level > or = 0.01 IU/mL was considered to be seropositive and > or = 0.1 IU/mL was considered to be fully protective. The positive rate and fully protective rate for all persons were 79.9% and 36.6%, respectively. The age specific positive rate and fully protective rate for children under 14 years of age were 97.0% and 78.0%, for 20-29 years of age group, were 38.0% and 8.3%, respectively, to be the lowest record among tested age groups. Then, both rates increased proportionately with age. Among those birth cohorts born in the diphtheria immunization era (since 1955), the antibody levels were inversely correlated with age, suggesting a decreased opportunity for exposure to natural diphtheria infection in the recent years and the duration of the vaccine inoculation. This finding indicates the need of a booster vaccination for young adults to ensure a full term protection and a long lasting diphtheria control.

Emphysema surgery--loop ligation approach

OBJECTIVES

To demonstrate the efficacy of using thoracoscopic endoloop ligation of bullae in patients with bullous emphysema.

METHODS

From 1992 to 1997, 93 advanced age (mean age, 66 years) and oxygen dependency patients underwent thoracoscopic procedure using endoloop ligation for treatment of bullous emphysema. Clinical data were collected from chart review. Thoracoscopic loop ligation of bulla was carried out under general anesthesia with double lumen endotracheal tube and single lung ventilation.

RESULTS

Eighty-two patients (88%) exhibited subjective improvement in their symptom status at 3-month follow-up (from grade 2 or 3 to grade 1 or 2) according to the modified Medical Research Council dyspnea scale. The mean duration of chest drainage was 7.5 days (range, 4-19 days). Average hospital stay was 9.5 (range, 5-26) days. There was no post-operative death. A comparison of pre-operative and post-operative functional evaluation was available in 27 patients who showed an average increase in FEV1 (from 0.89 to 1.12 l) and declined in residual volume after operation. Complications include persistent airleak over 10 days in nine patients (9.7%), wound infection in three patients and localized empyema in five patients. There was no recurrent after a mean follow-up of 37 months.

CONCLUSION

Thoracoscopic loop ligation of bulla has proven to be a safe, reliable and cost effective means of technique for bullous emphysema.