Recombinant human leukemia inhibitory factor enhances the development of preimplantation mouse embryo in vitro

OBJECTIVE

To assess the effect of recombinant human leukemia inhibitory factor (rhLIF) on mouse embryos in vitro.

DESIGN

Controlled prospective study.

SETTING

Academic research environment.

ANIMAL(S)

Female CB6F1 mice between 6 and 8 weeks old.

INTERVENTION(S)

Mice were divided randomly into three groups, which included a control group in an in vivo study (group I) and two groups in an in vitro study (groups II and III). Mice were killed at 116-120 hours (group I) and 44-48 hours (groups II and III) after hCG injection. Two-cell embryos (groups II and III) and blastocysts (group I) were obtained. Embryos in group II were cocultured with human tubal fluid (HTF) + 0.5% human serum albumin and in group III with HTF + rhLIF (1,000 U/mL) under paraffin oil.

MAIN OUTCOME MEASURE(S)

The embryonic numbers in different stages were recorded and compared.

RESULT(S)

Similar early embryo development to the four- to eight-cell and morula stages was noted between groups II and III (87.3% versus 91.0% and 74.6% versus 87.1%, respectively). However, further embryo development to the blastocyst, expanded blastocyst, and hatching blastocyst in group II (48.1%, 31.7%, and 18.5%, respectively) was lower than that in group III (83.6%, 53.7%, and 37.8%).

CONCLUSION(S)

RhLIF does not provide obvious stimulation in the early mouse embryo. However, rhLIF has positive effects on preimplantation blastocyst growth, differentiation, and hatching.

In vitro activity of quinupristin/dalfopristin against clinical isolates of common gram-positive bacteria in Taiwan

The MICs of quinupristin/dalfopristin against common Gram-positive bacteria isolated from various clinical specimens at a university hospital in Taiwan were determined by the agar dilution method. The tested bacteria included methicillin-resistant Staphylococcus aureus (MRSA), methicillin-susceptible S. aureus (MSSA), methicillin-resistant Staphylococcus epidermidis (MRSE), methicillin-susceptible S. epidermidis (MSSE), Streptococcus pyogenes, Streptococcus pneumoniae, and Enterococcus faecalis. With the exception of E. faecalis all bacteria were susceptible to quinupristin/dalfopristin. The MIC50 and MIC90 were, respectively, 0.25 microgram/mL and 0.5 microgram/mL for both MRSA and MSSA; 0.25 microgram/mL and 0.5 microgram/mL for MRSE; 0.25 microgram/mL and 0.25 microgram/mL for MSSE; 0.125 microgram/mL and 0.125 microgram/mL for S. pyogenes; and < or = 0.03 microgram/mL and 0.25 microgram/mL for S. pneumoniae. Eighty-two percent of the tested E. faecalis isolates were intermediately resistant or resistant to quinupristin/dalfopristin, with an MIC50 of 2 micrograms/mL and an MIC90 of 4 micrograms/mL. Quinupristin/dalfopristin seems to be a promising antimicrobial agent against common Gram-positive bacteria other than E. faecalis in Taiwan.

Body position, membrane diffusing capacity and pulmonary capillary blood volume in chronic bronchitis and pulmonary emphysema

BACKGROUND

The effect of body position on diffusing capacity and its components, membrane diffusing capacity (Dm) and pulmonary capillary blood volume (Vc), in patients with chronic obstructive pulmonary disease (COPD) has remained elusive. This study was designed to evaluate the effect of body position on diffusing capacity for carbon monoxide (DLco), Dm and Vc in male patients with chronic bronchitis and pulmonary emphysema.

METHODS

Pulmonary function tests including spirometry and lung volume were assessed in the erect position, and DLco, Dm and Vc were measured in the erect and supine positions in a random order in 17 men with chronic bronchitis and 19 men with pulmonary emphysema.

RESULTS

Spirometry results and lung volumes were comparable between both groups of patients; however, significantly lower values of DLco and Kco (DLco corrected by alveolar volume, VA) were observed in the emphysema than in the bronchitis group. In the bronchitis group, Kco and Vc were significantly higher in the supine than in the erect position, but Dm was significantly lower in the supine position. Alternation of body position did not significantly affect DLco and its components in the emphysema group. DLco, Kco and Vc in both the erect and supine positions were significantly higher in the bronchitis than in the emphysema group. Vc-SE (SE, the data in the supine minus those in the erect position) was also significantly higher in the bronchitis group. In the bronchitis group, DLco-SE was significantly correlated with Dm-SE and Vc-SE. However, Kco-SE was highly correlated with Dm-SE. In the emphysema group, DLco-SE and Kco-SE were highly correlated with Vc-SE only.

CONCLUSIONS

An increase in Vc in the supine position may account for the postural effect on Kco in bronchitis patients. In patients with pulmonary emphysema, decreased DLco and an absence of postural effect on DLco and its components may be due to a widespread abnormality of the pulmonary capillary bed. These findings may be of value in elucidating the difference in mechanisms of impaired gas exchange between patients with chronic bronchitis and pulmonary emphysema.

Different dietary fats influence serum and tissue lipids and anti-cardiolipin antibody levels in autoimmune-prone NZB/W F1 mice

To investigate the influence of different dietary fats on lipids and anti-cardiolipin antibody levels, autoimmune NZB/W F1 mice were fed on diets containing 200 g dietary fat as palm oil, lard-soyabean oil (1:1, w/w), soyabean oil, rapeseed oil or fish oil/kg. In addition, each dietary fat group was divided into an early-feeding group with feeding from 2 months of age, and a late-feeding group with feeding from 5 months of age. Serum levels of triacylglycerol, phospholipid, cholesterol and anti-cardiolipin antibody were measured at regular intervals, and mice were killed at the age of 7 months for analysis of hepatic lipid and fatty acids. The results showed that hepatic triacylglycerol and cholesterol contents were lower in mice fed on fish oil than in those fed on palm oil. In contrast, hepatic phospholipid content was higher in mice of the fish oil group than in those of the other four dietary fat groups. Composition profiles for both hepatic and renal oleic acid (18: 1n-9), linoleic acid (18: 2n-6) and eicosapentaenoic acid (20: 5n-3) were similar to those of the dietary fats in mice of both early-feeding and late-feeding groups. Fish oil intake decreased arachidonic acid (20: 4n-6) concentration in kidney tissue but not in liver tissue. Serum triacylglycerol, cholesterol and phospholipid levels were lower in mice fed on fish oil than in those fed on palm oil. Immunoglobulin (Ig) M anti-cardiolipin antibody was lower for the fish oil group than for the other groups. The IgG anti-cardiolipin antibody level was significantly lower in mice fed on fish oil compared with that of the palm oil group only in the early-feeding group. There was a positive correlation between serum IgM anti-cardiolipin antibody and phospholipid levels (early-feeding group r 0.902, P < 0.05; late-feeding group r 0.894, P < 0.05). These findings suggest dietary fish oil may affect both lipid levels and anti-cardiolipin antibody, contributing to alleviation of the autoimmune process in autoimmune-prone NZB x NZW F1 mice.

[Vancomycin-resistant enterococci in north-eastern Taiwan]

Vancomycin-resistant enterococci (VRE) is a world-wide emerging pathogen. The first confirmed VRE isolate in Taiwan was detected in 1995. After that, more and more isolates of VRE were found in western part of Taiwan. However, before this report, there was no any isolate of VRE found in eastern part of Taiwan. In December 1997 and January 1998, two cases of VRE urinary tract infection were found in two regional hospitals in north-eastern Taiwan. They had received prolonged treatment with multiple antibiotics for other infections before they got VRE infection. The isolates showed susceptibility to other antimicrobial agents by routine disk diffusion susceptibility test and these two patients were successfully treated. The VRE did not spread in those two hospitals. After further study, the 3 isolates from these two patients all had minimum inhibitory concentration of vancomycin >256 microg/mL. They all carried van A gene and the pulsed-field gel electrophoresis demonstrated they belonged to different DNA types. It was concluded that VRE appeared in north-eastern Taiwan but the strains were not from a common source.

Isolation of a chinese hamster ovary (CHO) cDNA encoding phosphatidylglycerophosphate (PGP) synthase, expression of which corrects the mitochondrial abnormalities of a PGP synthase-defective mutant of CHO-K1 cells

Phosphatidylglycerophosphate (PGP) synthase catalyzes the first step in the cardiolipin (CL) branch of phospholipid biosynthesis in mammalian cells. In this study, we isolated a Chinese hamster ovary (CHO) cDNA encoding a putative protein similar in sequence to the yeast PGS1 gene product, PGP synthase. The gene for the isolated CHO cDNA was named PGS1. Expression of the CHO PGS1 cDNA in CHO-K1 cells and production of a recombinant CHO PGS1 protein with a N-terminal extension in Escherichia coli resulted in 15-fold and 90-fold increases of PGP synthase specific activity, respectively, establishing that CHO PGS1 encodes PGP synthase. A PGP synthase-defective CHO mutant, PGS-S, isolated previously (Ohtsuka, T., Nishijima, M., and Akamatsu, Y. (1993) J. Biol. Chem. 268, 22908-22913) exhibits striking reductions in biosynthetic rate and cellular content of phosphatidylglycerol (PG) and CL and shows mitochondrial morphological and functional abnormalities. The CHO PGS-S mutant transfected with the CHO PGS1 cDNA exhibited 620-fold and 7-fold higher PGP synthase activity than mutant PGS-S and wild type CHO-K1 cells, respectively, and had a normal cellular content and rate of biosynthesis of PG and CL. In contrast to mutant PGS-S, the transfectant had morphologically normal mitochondria. When the transfectant and mutant PGS-S cells were cultivated in a glucose-depleted medium, in which cellular energy production mainly depends on mitochondrial function, the transformant but not mutant PGS-S was capable of growth. These results demonstrated that the morphological and functional defects displayed by the PGS-S mutant are due directly to the reduced ability to make normal levels of PG and/or CL.

Antibiotic usage in primary care units in Taiwan

To understand the situation of antibiotic usage in primary care units in Taiwan, we collected all prescriptions over a 1 week period during March 2 to March 7, 1992, December 2 to December 7, 1992, and January 14 to January 19, 1994 from out-patient clinics of public health stations located in various parts of Taiwan. In the first time period 60 health stations were sampled, 18,350 patient-visits made and 23,674 diagnoses recorded. In the second time period 168 health stations were sampled, 84,143 patient-visits made and 96,528 diagnoses recorded. In the third time period 173 health stations were sampled with 85,623 patient-visits and 105,132 diagnoses recorded. The percentages of total patient-visits that resulted in antibiotic treatment were 16.7, 13.5 and 12.4% in the three time periods, respectively. The patient group under the age of 11 received the highest percentage of antibiotic treatment. The percentage of patient-visits that resulted in treatment with two or more types of antibiotics decreased from 25.4% in March, 1992 to 13.2% in January, 1994. Common cold was the most frequent diagnosis in patients receiving antibiotic therapy during the three time periods and accounted for 36.9% of total antibiotic prescriptions. Of the patients with the diagnosis of common cold, 29.7% received antibiotic treatment, of whom the largest group were paediatric patients (< 16 years). Penicillins, macrolides and cephalosporins were the most commonly prescribed antibiotics and accounted for 34.0, 21.8 and 21.3% of all prescribed antibiotics in the three study periods.

Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases

From March of 1995 to November of 1997, 95 free radial forearm flaps for orofacial reconstructions were performed and included in this prospective study of donor site morbidity. All flaps were elevated using the suprafascial dissection technique. Donor site closure was performed with either split-thickness skin grafts (64 cases) or full-thickness skin grafts (31 cases). Among the 95 flaps, there were two complete flap losses and one partial flap loss because of arterial thrombosis. One orocutaneus fistula was successfully treated with a pedicled pectoralis major flap. At the donor site, the rate of complete take of skin graft was 94 percent in 95 patients. Functional and aesthetic results evaluated at least 6 months postoperatively in 50 patients revealed no significant change in grip power, pulp-to-pulp pinch power, or wrist movement in the complete skin graft take group (45 cases), whereas in the partial skin graft failure group (5 cases), both grip power and movement were significantly decreased. There was no remarkable cold intolerance in any of the 50 patients. Critical evaluations of sensory change revealed numbness distal to the donor site in 54 percent of the patients. However, dysesthesia was usually mild and improved spontaneously as time passed. Aesthetic outcome was rated as good or fair in 98 percent of the cases. The results of this prospective study show that suprafascial elevation of the radial forearm flap is superior to the classic elevation technique, particularly with regard to a higher rate of immediate complete take of skin grafts, thus avoiding impairment of range of motion and strength of the donor hand.

[Supra-fascial elevated free forearm flap--indications, surgical technique and follow-up examination of the donor site defect]

From March 1995 to May 1997, 66 free radial forearm flaps were used for orofacial reconstructions. All flaps were elevated following the suprafascial technique. Donor-site closure was performed with split-thickness skin grafts in 54 cases, and with full-thickness skin grafts in 12 patients. Investigations after six months included grip strength, pulp-to-pulp pinch strength, range of motion as compared to preoperative values, aesthetical self-assessment, cold intolerance, and dysesthesias. The latter evaluation could be performed in 42 patients, whereas the complete follow-up protocol included 36 patients. Primary wound healing with immediate complete take of skin grafts was achieved in 93.9%. Grip strength and pulp-to-pulp pinch strength showed no decrease postoperatively. An impairment of range of motion of the wrist was observed in 2.8%. There was no cold intolerance. Aesthetical outcome was rated as good or fair in 97.3%. Slight numbness distally to the donor-site was found in 59.5%. The results of this prospective study show a superiority of suprafascial elevation of the radial foream flap as compared to the classic elevation technique, particularly in a higher rate of primary wound healing, thus avoiding impairment of range of motion and strength of the donor hand.

A novel spliced transcript of influenza A/WSN/33 virus

It has been shown that influenza A virus M1 mRNA has two alternative 5" splice sites: a distal 5" splice site producing M3 mRNA that has the coding potential for 9 amino acids and a proximal 5" splice site producing M2 mRNA that encodes the essential M2 ion-channel protein. In this study, we demonstrated that the laboratory widely used strain A/WSN/33, but not A/Udorn/72 possessed another novel 5" splice site producing a transcript with the coding potential for 54 amino acids. We nominated this novel transcript as M4 mRNA. M4 mRNA was detected in A/WSN/33-infected cells derived from different species. Sequence comparison of M1 mRNA in both A/WSN/33 and Udorn/72 at position 143 to 151 reveals that this novel 5" splice site generated in WSN was due to one nucleotide difference at position 147. Several strains of influenza A viruses other than WSN also possess the potential M4 5" splice site by sequence analysis from the files of GenBank.

Dietary fiber content and composition of fruits in Taiwan

Forty-one fresh fruits frequently consumed in the Taiwan area were analysed for their dietary fiber content by an enzymatic-gravimetric method. Total dietary fiber (TDF) of these fruits ranged from 0.2 g (per 100 g edible weight) in grapes to 8.6 g in eggfruit. In citrus fruit, the proportion of soluble fiber in TDF was more than 50%. However, in some fruits like guavas and waxapple, soluble fiber took less than 30% of TDF. Soluble fiber in almost all fruit was comprised of a large amount of uronic acids, while the composition of insoluble non-cellulose polysaccharides (INCP) varied a great deal. Mangos and pummelos of different varieties were different in their sugar composition of INCP. Insoluble non-cellulose polysaccharides of a crisp type of persimmon had more arabinose and galactose, but those of soft persimmon contained mainly xylose. These results show that different types of fruit are distinct in their composition and hence, the properties of their dietary fiber. These data are useful for dietary assessments in Taiwan and South-East Asia.

In vitro activity of meropenem against common pathogenic bacteria isolated in Taiwan

The in vitro antimicrobial activity of meropenem, in comparison with nine other antimicrobial agents, against 12 different common pathogenic bacteria were evaluated to know the susceptibility of common bacteria to meropenem in Taiwan. Meropenem was active against most Gram-positive, Gram-negative, and anaerobic bacteria, including methicillin-sensitive Staphylococcus aureus, Streptococcus pyogenes, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Pseudomonas aeruginosa, Burkholderia cepacia, Acinetobacter baumannii, Haemophilus influenzae, and Bacteroides fragilis. For many of them, meropenem was the most active one in comparison with other broad-spectrum cephalosporins, aztreonam, imipenem, and ciprofloxacin. It is concluded that meropenem is a very active agent against most common pathogenic bacteria. It is uncommon for these common bacteria, except MRSA and Stenotrophomonas maltophilia, to be resistant to meropenem in Taiwan, where a high prevalence of resistance to other antimicrobial agents was found in many of the common bacteria.

Site-directed mutagenesis of large plasmids

A protocol combining recombination PCR and long-distance PCR is demonstrated to be highly accurate and rapid for site-directed mutagenesis of large (> 10 kb) plasmids. Application of this protocol to the generation of mutant rabies virus glycoproteins expressed by the baculovirus/insect cell system illustrates the usefulness of this approach in facilitating structure-function relationships in this important eukaryotic expression system.

Smoking-associated mitochondrial DNA mutations and lipid peroxidation in human lung tissues

To investigate the effect of cigarette smoking on mitochondrial DNA (mtDNA) mutation and lipid peroxidation in lung tissues, 152 samples from lung resections were collected. A novel deletion of 4,839 bp of mtDNA was found in 80 (52.6%) of the 152 lung samples. The breakpoints of the 4,839-bp mtDNA deletion were flanked by a nine-nucleotide direct repeat (5'-CATACACAA-3'). The frequency of occurrence and the proportion of the 4,839-bp mtDNA deletion in the lung increased significantly with the smoking index in terms of pack-years (P < 0.05). The incidence and proportion of the 4,839-bp mtDNA deletion in the lung tissues of current smokers were significantly higher than in those of nonsmokers (P < 0.05). In addition, we found that the content of lipid peroxides in the lung tissues of the smokers was significantly higher than in that of nonsmokers, and increased with the smoking index. The average malondialdehyde level in the lung tissues was 12.81 +/- 4.99 micromol/g for subjects with a smoking index of more than 50 pack-yr, and was 5.39 +/- 0.48 micromol/g for nonsmokers (P < 0.05). Multiple regression analysis showed that the smoking index, tissue lipid-peroxide content, and FEV1/FVC ratio were correlated with the proportion of the 4,839-bp mtDNA deletion in the lung. These results suggest that cigarette smoke plays an important role in the increase in mtDNA mutation and lipid peroxidation in the lung tissues of smokers.

Efficacy and adverse effects of higher dose amphotericin B monotherapy for cryptococcal meningitis in patients with advanced HIV infection

Treatment with a low daily dose of amphotericin B (0.4 mg/kg) in AIDS patients with cryptococcal meningitis has been associated with low efficacy and high mortality. We report our successful clinical experiences on a higher daily dose of amphotericin B (0.8-1.0 mg/kg) monotherapy in treating cryptococcal meningitis from June 1994 to August 1997 in 13 cases of advanced HIV infection. Most of them (12/13) had at least one of several poor prognostic factors. The mean duration of amphotericin B administration was 26 days (range, 3 to 58 days). Both microbiologically and clinically successful rates of treatment at the end of amphotericin B therapy were high (85%, 11/13). The median duration of negative CSF culture post therapy was 17 days (range, 8 to 33 days). Bone marrow toxicities were; thrombocytopenia (46%) and significant anemia (92%) after a mean of 9 days of treatment. Both, impaired renal function and hypokalemia, were seen in 10 cases (77%), while elevation of amylase and lipase values were present in 6 cases (46%). Our report reveals that a higher daily dose of amphotericin B can achieve a high efficacy in treatment of cryptococcal meningitis in AIDS patients, even though most cases had poor prognostic factors and were in severe immunocompromised states. However, clinicians should monitor higher dose-related adverse effects carefully.

Transzygomatic coronoidectomy through an extended coronal incision for treatment of trismus due to an osteochondroma of the coronoid process of the mandible

Osteochondroma is the most common benign tumor of the skeletal system. In the craniofacial skeleton, however, osteochondroma is uncommon. Even more rare is osteochondroma of the coronoid process. A review of the literature reveals only 31 reported cases of osteochondroma of the coronoid process of the mandible. The preponderance of patients were young men (67.7%) and most presented with a facial deformity. As a benign tumor, the problems with surgical treatment have dealt with the inaccessibility of the lesion and hence the surgical approach of choice. The previous surgical approaches have either been intraoral, external, or a combination of both. We present a transzygomatic approach via a coronal incision that gives excellent access and a good cosmetic result, and protects the facial nerve from damage.

The inhibitory effect of common traditional anti-rheumatic herb formulas on prostaglandin E and interleukin 2 in vitro: a comparative study with Tripterygium wilfordii

To understand the clinical efficacy of traditional anti-rheumatic herbal medicines on acute and severe arthritis or immune diseases, four herbal formulas and one herb were tested in vitro to determine their effects on prostaglandin E2 (PGE2) and interleukin 2 (IL2). Peripheral blood mononuclear cells from healthy subjects were incubated with different concentrations of four herbal formulas including Shaur Yau Gan Tsao Tang (SYGTT), Shang Jong Shiah Tong Yong Tong Feng Wan (SJSTY), Shu Jin Lih An Saan (SJLAS), Ma Shing Yih Gan Tang (MSYGT) and one herb, Tripterygium wilfordii (T2) with and without mitogen stimulation. PGE2 and IL2 from culture supernatant were measured by enzyme immunoassay. The results showed that SYGTT, SJSTY, SJLAS at concentration of 100 microg and MSYGT at 500 microg/ml can significantly inhibit PGE2 release (P < 0.05) from mononuclear cells. However, T2 at 2 microg/ml expressed the same response. For the inhibition of IL2, the concentration of SYGTT, SJSTY and SJLAS must exceed 100 symbol microg/ml. MSYGT failed to inhibit IL2 at even concentrations of 500 microg/ml but T2 at a very low concentration (0.6 microg/ml) could strongly inhibit it. The findings suggest that the majority of traditional anti-rheumatic herbal formulas or herbs, except for T2, should not be used to treat acute and critical arthritis or immune diseases.

Emphysematous prostatic abscess due to Klebsiella pneumoniae

Prostatic abscess is an unusual occurrence in the era of modern antibiotics. We report a rare case of emphysematous prostatic abscess owing to Klebsiella pneumoniae in a 45-year-old man with a 10-year history of alcoholism and a 6-year history of diabetes mellitus. Prostatic abscess is a difficult clinical diagnosis without specific symptoms and signs. Computerized tomography can assist in making the diagnosis of emphysematous prostatic abscess. Definitive treatment is complete surgical drainage and the use of effective antibiotics.

Efficacy and safety of cefepime treatment in Chinese patients with severe bacterial infections: in comparison with ceftazidime treatment

An open label, randomized comparative study was conducted to evaluate the safety and efficacy of cefepime, in comparison with ceftazidime, in the treatment of adult hospitalized Chinese patients with severe bacterial infections. Forty patients with severe infections including septicemia, urinary tract infection and bacterial pneumonia were randomly assigned to receive treatment with cefepime (2 g intravenously every 12 h) or ceftazidime (2 g intravenously every 8 h). The cefepime group (20 evaluable patients) and ceftazidime group (16 evaluable patients) were comparable with respect to age, sex, underlying diseases and distribution of infection type. In both groups urinary tract infection was the most common type of infection and Escherichia coli was the most common etiologic microorganism. The rates of satisfactory clinical response were similar in the cefepime and ceftazidime groups (95 versus 93.7%; 95% confidence interval: -0.14 - 0.17, P = 0.87). The bacteriological response rates of the cefepime and ceftazidime groups did not differ significantly (88.9 versus 85.7%; 95% confidence interval: -0.30 - 0.36, P = 0.85). Both cefepime and ceftazidime were well tolerated, with similar incidence of side effects. The results of this study suggest that cefepime is as safe and effective as ceftazidime for the treatment of serious infections in adult hospitalized Chinese patients.

Clinical features and outcome in disseminated mycobacterial diseases in AIDS patients in Taiwan

OBJECTIVE

To describe and compare the clinical features and outcome of disseminated tuberculosis (TB) and Mycobacterium avium complex (MAC) disease in AIDS patients.

DESIGN

Prospective cohort study.

SETTING

A 1800-bed university teaching hospital, the largest centre for HIV/AIDS patients in Taiwan.

METHODS

From July 1994 through June 1997, a standardized protocol was used to record the demographic and clinical features in all hospitalized HIV-infected patients, and to perform routine studies and invasive procedures for diagnosis of disseminated mycobacterial diseases. To compare the survival, control patients were selected from the HIV-infected patients hospitalized in the same hospital during the same study period, and had similar age, sex, CD4+ cell counts and antiretroviral therapy regimens.

RESULTS

A total of 22 cases of disseminated TB and 15 cases of disseminated MAC were identified. Disseminated TB and MAC occurred in patients with similarly low CD4+ cell counts (median, 23 versus 5 x 10(6)/l; P = 0.08). The clinical features favouring disseminated TB included night sweats, peripheral lymphadenopathy, acid-fast bacilli in sputum smears, chest radiographic findings of hilar enlargement, and lack of prior AIDS-defining illnesses. Hepatosplenomegaly, elevated serum alkaline phosphatase (more than twice the upper limit of normal), elevated serum gamma-glutamyl transpeptidase (more than three times the upper limit of normal), and leukopenia favoured disseminated MAC. The patients with disseminated TB survived much longer than patients with disseminated MAC (mean survival, 96 versus 22 weeks, P = 0.008) but had a similar outcome to control patients (P = 0.60).

CONCLUSION

Disseminated TB and MAC are distinguishable by clinical features in AIDS patients with similar immunocompromised states. Those features may facilitate diagnosis and selection of specific therapeutic regimens. Disseminated TB was not associated with a shortened survival period in AIDS patients when they completed anti-TB treatment. In contrast, disseminated DMAC was associated with shortened survival despite treatment with potent regimens. These results may emphasize the importance of prophylaxis for MAC in this population.

An effective analytical psychotherapy in crosscultural context. An East Asian student in the United States

An effective analytical psychotherapy of a severe anxiety disorder with panic, in a crosscultural context of East Asia and the United States, specifically a Japanese student studying English, is presented. What was crucial in facilitating the therapeutic process was an introduction of analytical way of looking at life born of Western culture into an integrative orientation of Asian culture and mentality.

Cerebral air embolism complicating bilevel positive airway pressure therapy

A 13 yr old male with acute lymphoblastic leukaemia who received bilevel positive airway pressure ventilation via a face mask for post-transplant pneumonitis developed subcutaneous emphysema, radiographic evidence of pulmonary interstitial emphysema, pneumomediastinum and 6 h later, right hemiparesis and focal livedo reticularis. This case illustrates that severe barotrauma may complicate noninvasive bilevel positive airway pressure ventilation.

Isolation and characterization of the gene (CLS1) encoding cardiolipin synthase in Saccharomyces cerevisiae

In eukaryotic cells, cardiolipin (CL) synthase catalyzes the final step in the synthesis of CL from phosphatidylglycerol and CDP-diacylglycerol. CL and its synthesis are localized predominantly to the mitochondrial inner membrane, and CL is generally thought to be an essential component of many mitochondrial processes. By using homology searches for genes potentially encoding phospholipid biosynthetic enzymes, we have cloned the gene (CLS1) encoding CL synthase in Saccharomyces cerevisiae. Overexpression of the CLS1 gene under its endogenous promoter or the inducible GAL1 promoter in yeast and expression of CLS1 in baculovirus-infected insect cells resulted in elevated CL synthase activity. Disruption of the CLS1 gene in a haploid yeast strain resulted in the loss of CL synthase activity, no detectable CL, a 5-fold elevation in phosphatidylglycerol levels, and lack of staining of mitochondria by a dye with high affinity for CL. The cls1::TRP1 null mutant grew on both fermentable and non-fermentable carbon sources but more poorly on the latter. The level and activity of cytochrome c oxidase was normal, and a dye whose accumulation is dependent on membrane proton electrochemical potential effectively stained the mitochondria. These results definitively identify the gene encoding the CL synthase of yeast.

Tuberculous peritonitis: analysis of 35 cases

Thirty five patients with tuberculous peritonitis were studied retrospectively. Tuberculous peritonitis was defined as the isolation of Mycobacterium tuberculosis from ascites or dialysate, and/or caseating granuloma/acid-fast bacilli from peritoneal biopsy specimens from patients with pulmonary tuberculosis or a response to treatment for tuberculosis. Among the patients studied, nine with cirrhosis of the liver; seven with diabetes mellitus and six with end-stage renal disease, of whom four had undergone continuous ambulatory peritoneal dialysis. The most frequent signs of tuberculous peritonitis included ascites, fever and anemia. Ascites was found in 31 patients (89%). Abnormal findings on chest radiographs were found in 26 patients (74%), of whom 22 patients (63%) had pleural effusion and five had miliary lung lesions. Seven out of 35 patients were found to have positive culture of sputum or pleural effusion for M. tuberculosis. Two patients were found to have concomitant tuberculous peritonitis and enteritis. Multiple organ involvement was found in eight patients. Eleven patients (31%) died: eight were older than 60 years; six had cirrhosis of the liver and nine were diagnosed post-mortemly. In Taiwan, tuberculous peritonitis should be considered in patients with abnormality of chest radiography and nonresolving peritonitis.

The PEL1 gene (renamed PGS1) encodes the phosphatidylglycero-phosphate synthase of Saccharomyces cerevisiae

Phosphatidylglycerophosphate (PG-P) synthase catalyzes the synthesis of PG-P from CDP-diacylglycerol and sn-glycerol 3-phosphate and functions as the committed and rate-limiting step in the biosynthesis of cardiolipin (CL). In eukaryotic cells, CL is found predominantly in the inner mitochondrial membrane and is generally thought to be an essential component of many mitochondrial functions. We have determined that the PEL1 gene (now renamed PGS1), previously proposed to encode a second phosphatidylserine synthase of yeast (Janitor, M., Jarosch, E., Schweyen, R. J., and Subik, J. (1995) Yeast 13, 1223-1231), in fact encodes a PG-P synthase of Saccharomyces cerevisiae. Overexpression of the PGS1 gene product under the inducible GAL1 promoter resulted in a 14-fold increase in in vitro PG-P synthase activity. Disruption of the PGS1 gene in a haploid strain of yeast did not lead to a loss of viability but did result in a dependence on a fermentable carbon source for growth, a temperature sensitivity for growth, and a petite lethal phenotype. The pgs1 null mutant exhibited no detectable in vitro PG-P synthase activity and no detectable CL or phosphatidylglycerol (PG); significant CL synthase activity was still present. The growth arrest phenotype and lack of PG-P synthase activity of a pgsA null allele of Escherichia coli was corrected by an N-terminal truncated derivative of the yeast PG-P synthase. These results unequivocally demonstrate that the PGS1 gene encodes the major PG-P synthase of yeast and that neither PG nor CL are absolutely essential for cell viability but may be important for normal mitochondrial function.

The nucleolin binding activity of hepatitis delta antigen is associated with nucleolus targeting

Hepatitis delta antigens (HDAgs) are important for the replication and assembly of hepatitis delta virus (HDV). To understand the association between HDAgs and cellular proteins and the mechanism of viral multiplication, we have studied the interaction between HDAgs and nucleolin, a major nucleolar phosphoprotein. The interaction between HDAgs and nucleolin was first demonstrated by immunofluorescence staining studies. HDAgs and endogenous nucleolin were colocalized in the nucleoli of cultured cells transfected with plasmids encoding the small and large HDAg. Coimmunoprecipitation results indicated that the NH2-terminal domain of HDAg was essential for its binding to nucleolin. In vitro ligand binding assays revealed two nucleolin binding sites, NBS1 and NBS2. Each spanned amino acid residues 35-50 and 51-65, respectively, with a conserved core sequence K(K/R)XK. HDV replication was modulated by exogenous human nucleolin. In addition, a small HDAg mutant S-d65/75, which possesses both NBS1 and NBS2, was capable of transactivating HDV replication, whereas the small HDAg mutant S-d50/75, which retained NBS1 but not NBS2, was unable to support the replication of HDV. Thus, the nucleolin binding activity of HDAg is critical for its nucleolar targeting and is involved in the modulation of HDV replication.

Capnocytophaga bacteremia: clinical features of patients and antimicrobial susceptibility of isolates

Capnocytophaga has been recognized as an opportunistic pathogen causing systemic infections in immunocompromised individuals with granulocytopenia and oral ulceration. Treatment of Capnocytophaga infection is often empiric. We retrospectively analyzed the clinical features of all patients with Capnocytophaga bacteremia seen at the National Taiwan University Hospital between January 1981 and December 1996 and the antimicrobial susceptibility of the isolates recovered from these patients. All the patients had underlying diseases, namely neoplastic disease (9 patients), hyperthyroidism (1), and bronchiectasis and tetralogy of Fallot (1). The clinical features of these patients were primary bacteremia (10) and pneumonia (1). Nine patients had nosocomial bacteremia and 10 patients had monomicrobial bacteremia. None had septic shock. All the patients responded well to appropriate antimicrobial therapy and survived. All isolates were susceptible to amoxicillin-clavulanate, imipenem, ciprofloxacin, erythromycin, clindamycin, tetracycline, and chloramphenicol but resistant to aminoglycosides and sulfamethoxazole-trimethoprim. The susceptibilities to penicillin, ampicillin, piperacillin, cephalosporins, and aztreonam were variable. Capnocytophaga bacteremia should be included in the differential diagnosis of febrile neutropenia in immunocompromised patients, especially in the presence of oral mucositis and ulceration.

Further characterization of the binding properties of a GalNAc specific lectin from Codium fragile subspecies tomentosoides

Previous study on the binding properties of a lectin isolated from Codium fragile subspecies tomentosoides (CFT) indicates that this lectin recognizes the GalNAc alpha1--> sequence at both reducing and nonreducing ends. In this study, the carbohydrate specificity of CFT was further characterized by quantitative precipitin (QPA) and inhibition of lectin-enzyme binding assays. Of the glycoforms tested for QPA, all asialo-GalNAc alpha1--> containing glycoproteins reacted well with the lectin. Asialo hamster and ovine submandibular glycoproteins, which contain almost exclusively Tn (GalNAc alpha1-->Ser/Thr) residues as carbohydrate side chains, and Streptococcus type C polysaccharide completely precipitated the lectin added, while the GalNAc beta1-->containing Tamm-Horsfall Sd(a+) glycoprotein and its asialo product were inactive. Among the oligosaccharides tested for inhibiting lectin-glycoprotein interaction, GalNAc alpha1-->3GalNAc beta1-->3Gal alpha1-->4Gal beta1--> 4Glc(Fp) and Gal beta1-->3GalNAc alpha1-->benzyl (T alpha) were the best, and about 125-fold more active than GalNAc. They were about 3.3, 6.6, and 43 times more active than Tn containing glycopeptides, GalNAc alpha1-->3(LFuc alpha1--> 2)Gal(Ah) and Gal beta1-->3GalNAc(T), respectively. From the present and previous results, it is concluded that the combining site of CFT is probably of a groove type that recognizes from GalNAc alpha1--> to pentasaccharide(Fp). The carbohydrate specificity of this lectin can be constructed and summarized in decreasing order by lectin determinants as follows: Fp and T alpha > Tn cluster > Ah >> I/II.

Burkholderia cepacia bacteremia: a retrospective analysis of 70 episodes

Burkholderia cepacia, a widespread gram-negative environmental bacillus associated with nosocomial infections, is considered to be of relatively low virulence and rarely to cause invasive disease. We retrospectively analyzed the risk factors, clinical manifestations, antimicrobial susceptibilities, and prognostic factors of B. cepacia bacteremia cases. From 1982 through 1995, 70 episodes of bacteremia due to B. cepacia occurred in 52 patients at the National Taiwan University Hospital. The overall case fatality rate was 11%. Sixty-four episodes were nosocomial infections. The common predisposing conditions were stay in an intensive care unit (61%) and invasive procedures, including urinary catheter (54%), intravenous catheter (70%), and intubation (57%). Three episodes involved polymicrobial bacteremia. In 41 episodes in which the infectious focus was identified, the respiratory tract was the most common portal of entry (17/41) followed by intravascular catheters (11/41). Most strains tested were susceptible to ceftazidime (95%), piperacillin (93%), minocycline (85%), and cefotaxime (82%); but most were resistant to aminoglycosides, tetracycline, carbenicillin, and ticarcillin. For empirical therapy of B. cepacia bacteremia, ceftazidime or piperacillin should be the drug of choice.

Signal transduction in the carnivorous plant Sarracenia purpurea. Regulation of secretory hydrolase expression during development and in response to resources

Carnivory in plants has developed as an evolutionary adaptation to nutrient-poor environments. A significant investment of the resources of a carnivorous plant is committed to producing the traps, attractants, and digestive enzymes needed for the carnivory. The cost:benefit ratio of carnivory can be improved by either maximizing the prey capture rate or by reducing the metabolic commitment toward carnivory. Using the pitcher plant Sarracenia purpurea, we have investigated whether the expression of the hydrolytic enzymes needed for digestion is regulated in response to the presence of prey. Expression of protease, RNase, nuclease, and phosphatase activities could be induced in the fluid of nonactive traps by the addition of nucleic acids, protein, or reduced nitrogen, suggesting that hydrolase expression is induced upon perception of the appropriate chemical signal. Hydrolase expression was also developmentally controlled since expression commenced upon opening of a trap, increased for several days, and in the absence of prey largely ceased within 2 weeks. Nevertheless, the traps remained competent to induce expression in response to the appropriate signals. These data suggest that in young traps hydrolase expression is developmentally regulated, which is later replaced by a signal transduction mechanism, and they demonstrate the ability of a carnivorous species to respond to the availability of resources.

Photodynamic therapy: applications in bladder cancer and other malignancies

Photodynamic therapy (PDT) has gained popularity in the past 10 years because of advances in laser and pharmacokinetic technologies and the development of new photosensitizers. Early studies on PDT with focal illumination for papillary bladder cancer obtained reasonable response rates for small tumors but recurrence was common. Whole bladder irradiation, once a suitable light-delivery system had been developed, gave promising outcomes with acceptable rates of complications. PDT for prostate cancer is still at the experimental stage but initial results have been promising. Clinical trials of PDT for brain tumors have shown no significant complications but no improvement in survival rate compared with other treatment modalities. PDT is particularly useful for early superficial lung cancers that are localized to one or a few discrete sites; it is also safe to use in patients who are too sick to be treated with conventional therapies. Preoperative PDT has reduced the extent of surgery necessary in some patients. Clinical experience with PDT for gynecological cancer is limited and prospective studies are needed. In head and neck oncology, PDT should prove a useful option, but methodological problems need to be overcome. Good responses of esophageal cancer to PDT have led to governmental approval of Photofrin, a photosensitizer, in several countries for either palliative use or treatment of inoperable or recurrent cancer. The use of PDT for early gastric cancer has great potential but several technical problems remain. PDT has proven generally effective for skin cancer when hematoporphyrin derivative or Photofrin is used but more long-term follow-up data are required for PDT with 5-aminolevulinic acid. Overall, PDT is changing from a scientific curiousity into an accepted modality for the treatment of cancer, with an improved likelihood of finding further clinical applications.

Haemophilus aphrophilus bacteraemia complicated with vertebral osteomyelitis and spinal epidural abscess in a patient with liver cirrhosis

Haemophilus aphrophilus is rarely implicated as an aetiology of spinal epidural abscess. A 73-year-old woman with liver cirrhosis who developed H. aphrophilus bacteraemia complicated with vertebral osteomyelitis and spinal epidural abscess is presented. Without surgical decompression, she was successfully treated with cefotaxime for 3 weeks, followed by maintenance with ciprofloxacin for another 10 weeks. The clinical features of eight previously reported cases of vertebral osteomyelitis without epidural abscess due to H. aphrophilus are reviewed.

Tumor necrosis factor-alpha gene polymorphism in chronic bronchitis

Airway inflammation is an important pathologic feature in chronic bronchitis, and we hypothesized that individuals with greater inflammatory responses may be more likely to acquire the disease. A polymorphism at -308 position of the tumor necrosis factor-alpha (TNF-alpha) gene has been described, with the rarer allele, TNF2, demonstrated to have higher inducibility in vitro. We investigated the distribution of this polymorphism in a case-control study. The genotype was determined in 42 male patients with chronic bronchitis, 42 sex-, age-, and smoking index-matched control subjects, and 99 random-sampled schoolchildren. We report here that the TNF2 allele is overrepresented in the patient group. The allele frequency of TNF2 is 5.1% in the schoolchildren, 2.4% in the control group, and 19% in the bronchitis group (p < 0.01). Carriage of the TNF2 allele confers a higher risk to the development of chronic bronchitis (odds ratio = 11.1, 95% CI = 2.89-42.57). The results demonstrate the important pathologic role of TNF-alpha in chronic bronchitis and suggest that greater inflammatory response may predispose an individual to this disease.

The antimicrobial susceptibility of Mycobacterium chelonae isolated from corneal ulcer

PURPOSE

To determine the in vitro susceptibility of Mycobacterium chelonae isolates from corneal ulcers to various traditional and newly-developed antimicrobial agents, alone or in combination.

METHODS

Fifteen strains of M. chelonae isolated from corneal ulcers were collected at the National Taiwan University Hospital from 1989 to 1993. Susceptibility to antimicrobial agents was tested by the broth microdilution method to determine the minimum inhibitory concentration (MIC). The antimicrobial effects of combinations of antimicrobial agents were assessed by the checkerboard titration method to determine the fractional inhibitory concentration (FIC) index.

RESULTS

The MIC results showed that traditional antituberculous drugs had poor activity against M. chelonae. In the aminoglycoside group, tobramycin and amikacin had better activity than gentamicin. Among macrolides, clarithromycin was especially effective, with an MIC ranging from 0.125 to 1 microgram/ml. Among various beta-lactam antibiotics, imipenem was the only one to demonstrate good anti-mycobacterial activity. Of the quinolone group, ciprofloxacin was the most effective, with an MIC ranging from 0.5 to 16 micrograms/ml. Combination of an aminoglycoside with imipenem, ciprofloxacin or clarithromycin all showed antagonistic effect.

CONCLUSIONS

The results suggested that amikacin, clarithromyicn, imipenem and ciprofloxacin had good in vitro antimicrobial activity against M. chelonae. However, no synergistic effect could be demonstrated for combinations of an aminoglycoside with other effective drugs.

In vitro activities of antimicrobial agents, alone and in combinations, against Burkholderia cepacia isolated from blood

Burkholderia cepacia is a widespread, environmental gram-negative bacillus that is associated with nosocomial infections. This bacterium is considered to be an important pathogen in immunocompromised patients and is inherently resistant to multiple antimicrobial agents. To compare the activity of different antimicrobial agents and the potential of combinations against invasive strains of B. cepacia, we collected 36 isolates of B. cepacia from blood cultures and checked their susceptibilities to 13 antimicrobials by broth microdilution method. Most strains tested were susceptible to minocycline (94.4%), ceftazidime (86.1%), ciprofloxacin (83.3%), and trimethoprim-sulfamethoxazole (83.3%). All strains were resistant to aminoglycosides, and only some strains were susceptible to imipenem (16.7%), aztreonam (19.4%), moxalactam (25.0%), piperacillin (25.0%), and carbenicillin (47.2%). The effects of combinations of ceftazidime with amikacin, ceftazidime with ciprofloxacin, and ciprofloxacin with amikacin were assayed by checkerboard titration method. Synergistic effect was found in 28 out of 36 tested strains (77.8%), when ceftazidime was combined with amikacin, in 25 out of 36 strains (69.4%) when ceftazidime was combined with ciprofloxacin, and in only 8 out of 36 strains (22.2%) when ciprofloxacin was combined with amikacin.

Interstitial photodynamic therapy in the canine prostate with disulfonated aluminum phthalocyanine and 5-aminolevulinic acid-induced protoporphyrin IX

BACKGROUND

Photodynamic therapy (PDT) is an experimental approach for treating prostate cancer localized to the gland that does not involve surgery or irradiation. Second-generation photosensitizers 5-aminolevulinic acid (ALA) and aluminum disulfonated phthalocyanine (AlS2Pc) were studied in the normal canine prostate.

METHODS

Tissue biodistribution of photosensitizers on serial biopsies was examined using fluorescence microscopy. Photodynamic therapy was done by delivering red light interstitially at 100 mW through fibers placed under transrectal ultrasound guidance.

RESULTS

Peak levels of AlS2Pc appeared at 5-24 hr and at 3 hr for ALA. Macroscopic PDT lesions were up to 12 mm in diameter using AlS2Pc, but only 1-2 mm with ALA. Light at 300 mW caused thermal lesions. At 28 days, damaged glands remained atrophic, but the interlobular supporting stroma was well-preserved. Urethral lesions healed by 28 days without functional impairment.

CONCLUSIONS

Although the results with ALA were disappointing, PDT using AlS2Pc looks like a promising modality for treatment of localized prostate cancer.

Transrectal ultrasound guided manipulation of the canine prostate with minimum intervention

The canine prostate is a widely used and well established animal model for the assessment of therapeutic effects of laser technology in the search for better options for the treatment of benign prostatic hyperplasia. Conventionally for such experiments, the canine prostate is approached by laparotomy or transperineal urethrotomy. We have demonstrated a technique involving the use of ultrasound guided biopsy of the liver and prostate, and percutaneous laser treatment of the prostate, which has proved to be effective in reducing adverse effects on the experimental animals but without compromising scientific requirements for the experiments. We conclude that state-of-the-art percutaneous procedures not only refine animal intervention significantly but are also technically feasible for most laser studies using the canine prostate as an experimental model in the live animal.

Outbreak of scarlet fever at a hospital day care centre: analysis of strain relatedness with phenotypic and genotypic characteristics

An outbreak of scarlet fever involving 12 children occurred at a hospital day care centre from February to March 1996. Twenty-five throat isolates of Streptococcus pyogenes (GAS, group A streptococcus) available from 24 children, including 10 children with scarlet fever and 14 asymptomatic carriers, and one asymptomatic staff member were studied for the presence of genes encoding streptococcal pyrogenic exotoxin types A (speA), B (speB), and C (speC) and for protease activity. Antimicrobial susceptibilities using the E-test, cluster analysis by cellular fatty acid composition and random amplified polymorphic DNA (RAPD) patterns by means of arbitrarily-primed polymerase chain reaction (APPCR) of the isolates were performed to investigate the outbreak. Only one isolate from an asymptomatic child possessed the speA gene. All isolates possessed the speB gene and 24 (96%) isolates were positive for the speC gene. There was no difference in protease activity between isolates from children with scarlet fever and from asymptomatic carriers. Thirteen isolates (10 recovered from children with scarlet fever, two from asymptomatic children, and one from the staff member) were considered to be the same strain according to the identical antimicrobial susceptibility profile and RAPD patterns and were also considered to be similar by cluster analysis of fatty acid composition. These findings suggest that the outbreak was caused by a unique clone of GAS. We conclude that RAPD typing and cluster analysis by cellular fatty acids composition both provide a powerful tool for epidemiological investigation of GAS infections.

Usefulness of argyrophilic nucleolar organizer regions score to differentiate suspicious malignancy in pulmonary cytology

OBJECTIVE

Pulmonary cytologic specimens reported as "suspicious for malignancy" pose problems in clinical management. Silver staining for argyrophilic nucleolar organizer regions (AgNOR) has proved useful in making a cytopathologically differential diagnosis between benign and malignant cells. This study aimed to evaluate the usefulness of AgNOR score in the diagnosis of pulmonary cytologic specimens deemed inconclusive by conventional staining methods.

METHODS

Pulmonary cytologic specimens initially reported as suspicious for malignancy with Papanicolaou or May-Grünwald-Giemsa (MGG) staining obtained from 35 proved cases were destained then restained using the AgNOR technique. Another 35 cases with clear cytologic diagnosis were also examined for comparison. The median number of dots, defined as the AgNOR score, was used to differentiate malignant from benign specimens.

RESULTS

Malignant cases had significantly higher AgNOR scores than benign ones (p<0.001). There were no significant differences among smears previously stained with Papanicolaou or MGG method, among specimens obtained via bronchoscopic brushing, fine-needle aspiration of lung or pleural effusion, or among subgroups of malignant diseases. Based on the results of our previous study, the cutoff value of the AgNOR score to differentiate benignancy from malignancy was set at 6. At this setting, the sensitivity and specificity of AgNOR score were 88% and 80%, respectively, in aiding a differential diagnosis of pulmonary cytologic specimens initially classified as suspicious for malignancy. For those cases with a clear cytologic diagnosis, the sensitivity and specificity of AgNOR score were 92% and 100%, respectively. For all cases, the sensitivity of AgNOR score was 90% and the specificity was also 90%.

CONCLUSIONS

The AgNOR score is of value in aiding a differential diagnosis between benign and malignant lesions in pulmonary specimens with equivocal cytologic features.

Bacteremia due to Klebsiella oxytoca: clinical features of patients and antimicrobial susceptibilities of the isolates

Forty-three patients with Klebsiella oxytoca bacteremia were seen between July 1980 and June 1996 at National Taiwan University Hospital (Taipei, Taiwan). We retrospectively analyzed the clinical features of these patients and the antimicrobial susceptibilities of the 43 isolates recovered from them. Twenty-seven patients (63%) had community-acquired bacteremia, and 16 patients (37%) had polymicrobial bacteremia. The clinical syndromes included hepatobiliary infections (58% of patients), primary bacteremia (23%), intravascular device-associated infections (7%), urinary tract infections (5%), skin and soft-tissue infections (5%), and peritonitis (2%). Most of these patients (93%) had underlying diseases including hepatobiliary diseases (53%), neoplastic diseases (42%), and diabetes mellitus (16%). Eight patients (19%) had septic shock, and two (5%) had disseminated intravascular coagulation. Four patients (9%) died of K. oxytoca bacteremia. All isolates were susceptible to ampicillin/sulbactam, cefmetazole, imipenem, aminoglycosides, and quinolones, and 86% of the isolates were susceptible to cefazolin.

Secular trends in the epidemiology of nosocomial fungal infections at a teaching hospital in Taiwan, 1981 to 1993

OBJECTIVE

To describe the incidence and patterns of nosocomial fungal infection in a large teaching hospital in Taiwan.

DESIGN

Prospective, hospitalwide nosocomial surveillance data from 1981 through 1993 were analyzed to show the secular trend in nosocomial fungal infection rates and to identify the most common pathogens and sites of infection (other than skin) in this hospital.

SETTING AND PATIENTS

The National Taiwan University Hospital is a medical school-affiliated hospital in the city of Taipei, Taiwan, with a 1200-bed capacity before 1991 and 1500 beds since 1992. It provides both primary and tertiary medical care.

RESULTS

The overall nosocomial fungal infection rate rose from 0.9 infections per 1000 discharges in 1981 to 6.6 per 1000 discharges in 1993, with the highest rate at the medical intensive-care unit (26.5/1000 discharges in 1993). This increase in infection rate was found at four major anatomic sites of infection, particularly including the bloodstream (0.08-2.19/1000 discharges) and the urinary tract (0.36-2.95/1000 discharges). Of 256 pathogens causing nosocomial fungemia from 1981 through 1993, Candida albicans was the most commonly isolated (50.8%), followed by Candida tropicalis (17.6%). Candida parapsilosis (11.7%), and Candida glabrata (8.2%). As compared to isolates from 1981 through 1988, the proportion of C parapsilosis and C glabrata isolated between 1989 and 1993 increased more than sixfold and fourfold, respectively. The increasing importance of fungal infections was confirmed further by the increased use of amphotericin B and azoles in this hospital.

CONCLUSIONS

Candida species and other yeasts have become a prominent cause of nosocomial infections in this hospital. These fungal pathogens accounted for a higher proportion of nosocomial bloodstream and urinary infections than any single bacterial species. Therefore, it is important to conduct a prospective epidemiological study and to establish in vitro antifungal susceptibility testing to enhance efforts to control nosocomial fungal infections and to minimize the risk of emergence of antifungal resistance.

Flavimonas oryzihabitans bacteremia: clinical features and microbiological characteristics of isolates

Flavimonas oryzihabitans is rarely reported as a pathogen in humans. Twelve cases of F. oryzihabitans bacteremia were diagnosed at National Taiwan University Hospital over a 3-year period. The clinical features of these patients were analyzed, and antimicrobial susceptibilities and random amplified polymorphic DNA (RAPD) patterns of the 12 isolates were studied. Among these 12 patients, eight (67%) had underlying neoplastic diseases and all acquired F. oryzihabitans bacteremia while hospitalized. The clinical syndromes included primary bacteremia in 5 patients (42%), biliary tract infection in 3 (25%), and peritonitis, subdural empyema, infusion-related bacteremia, and pneumonia in 1 each. Polymicrobial bacteremia or concomitant fungemia was seen in three patients (25%). All the patients survived after antibiotic treatment. All isolates were susceptible to piperacillin, third-generation cephalosporins, aminoglycosides, and quinolones but resistant to cephalothin, cefuroxime, and trimethoprim. Susceptibility to aztreonam was variable (25%). The RAPD patterns differed among the isolates, indicating the epidemiological unrelatedness of these infections. F. oryzihabitans should be included as an etiology of severe nosocomial infection in patients with underlying debilitating diseases.

Treatment of frontal sinus osteoma using a craniofacial approach

Osteoma is one of most common benign tumors of the nose and paranasal sinuses, with the frontal sinus being its most frequent location. It may be locally destructive and aggressive with possible intracranial complications. Osteoma of the frontal sinus comprises 57% of all osteomas in the paranasal sinuses. In 1939, Childrey reviewed 3,510 consecutive sinus radiographs taken for any reason and found an incidence of 0.43% of paranasal sinus osteomas. There are many operative approaches for frontal sinus osteomas, such as external frontoethmoidal approach and osteoplastic frontal sinusectomy, both with high recurrence rates. Those traditional operative methods cannot radically eradiate the osteoma grown in the posterior table of the frontal sinus. From July 1991 to June 1992, three patients with symptomatic frontal sinus osteomas were operated by a craniofacial approach. One patient is presented here in detail. A coronal incision is used and is found to be beneficial both in surgical exposure and in reconstruction with a calvarial bone graft. The patient has been followed for 3.5 years without osteoma recurrence.

The efficacy of an iron chelator (CP94) in increasing cellular protoporphyrin IX following intravesical 5-aminolaevulinic acid administration: an in vivo study

5-Aminolaevulinic acid (ALA)-induced protoporphyrin IX (PpIX) is proving to be a useful photosensitizer for photodynamic therapy (PDT). Conversion of PpIX to haem requires catalysed chelation with iron, and thus the presence of an iron chelator should, in theory, lead to an increase in cellular PpIX accumulation. This paper assesses the in vivo effect of a new iron chelator, 1,2-diethyl-3-hydroxypyridin-4-one (CP94), on the kinetics of PpIX in different layers of the bladder wall. Wistar rats were given 1% or 10% ALA intravesically with or without intraperitoneal CP94. The biodistribution of ALA-induced PpIX in the bladder was evaluated using fluorescence microscopy. Photodynamic effects on the bladder were compared in rats receiving various drug dosimetries. In CP94-treated rats, 5-7 h after administration of 10% ALA solution, the fluorescence intensity of PpIX in the urothelium was doubled compared with animals given ALA alone, whereas in the muscle layer PpIX remained at a low level similar to that found without the iron chelator. At an ALA concentration of 1%, although the PpIX concentration was not increased with CP94, the urothelial selectivity of PDT compared with the muscle layer was enhanced. In conclusion, by using CP94, a further reduction in skin photosensitization may be possible as similar photodynamic effects can be achieved with a lower dose of ALA. The addition of CP94 seems to be an effective and convenient way to potentiate ALA-induced PpIX tissue selectivity between the urothelium and the underlying layers of the bladder wall.

Therapeutic effects of diuretics and paracentesis on lung function in patients with non-alcoholic cirrhosis and tense ascites

BACKGROUND/AIMS

Ascites may cause or aggravate pulmonary dysfunction in patients with liver cirrhosis. Diuretics and paracentesis are the main therapies for ascites. The aim of the present study was to evaluate and compare the therapeutic effects of diuretics and large-volume paracentesis on lung function in 26 male patients with non-alcoholic cirrhosis and tense ascites.

METHODS

The patients were divided into two groups. Group A was composed of 13 subjects who were treated with diuretics including spironolactone (100-400 mg/day) and furosemide (80-320 mg/day). In group B, 13 subjects received large-volume paracentesis plus intravenous albumin (6-8 g/l ascites removed). Pulmonary function tests including spirometry, plethysmography, single-breath carbon-monoxide diffusing capacity (DLco) and arterial blood gases, were done 1 day before diuretic treatment and 1 day after termination of the study in group A patients, and 1 day before and after large-volume paracentesis in group B subjects.

RESULTS

Before treatment, the clinical and laboratory data were comparable between the two groups. After treatment, ventilatory function as evidenced by forced expiratory volume in 1 s, forced vital capacity, total lung capacity, functional residual capacity and expiratory reserve volume, and DLco increased significantly in both groups. Arterial PO2 and PCO2 increased significantly and AaPO2 (alveolar-arterial PO2 difference) decreased significantly in the subjects treated with diuretics. Nevertheless, paracentesis did not improve arterial blood gases. The changes in lung volumes, DLco and PaO2 after treatment (the data after minus those before treatment) were comparable, except that a significant decrease in AaPO2 was observed in the diuretic group.

CONCLUSIONS

Both diuretic therapy and large-volume paracentesis significantly improved the ventilatory function in patients with tense cirrhotic ascites. In terms of oxygenation improvement as evaluated by AaPO2, diuretic treatment may be superior to large-volume paracentesis.

Usefulness of AgNOR score in differentiating benign from malignant pulmonary aspiration cytology

OBJECTIVE

Malignant cells are known to display greater argyrophil staining for nucleolar organizer regions (AgNORs) than for benign cells due to their active proliferation. In this study we assessed the diagnostic value of AgNOR staining on 47 fine needle aspiration cytologic specimens of lung previously stained with the May-Grünwald-Giemsa (MGG) method.

METHODS

Cytologic specimens obtained from fine needle aspiration of the lung in 47 proven cases prestained with the MGG technique were destained and restained with the AgNOR method. Seventeen of them were benign and 30 malignant. To differentiate malignant from benign entities, the highest median value for AgNOR number (AgNOR score) obtained from the benign cases was chosen as a cutoff point (test specificity, 100%).

RESULTS

AgNOR scores of malignant cases were significantly higher than those of benign cases (P < .001). There was no significant difference between two subgroups of benign diseases or among four subgroups of malignant diseases. The sensitivity of the AgNOR score was 93% (28/30) in providing a diagnosis of malignancy when the cutoff value was set at 6.

CONCLUSION

The AgNOR technique may be of considerable value in aiding a diagnosis of malignancy, especially when the score is > 6.

Life-threatening scrub typhus with meningoencephalitis and acute respiratory distress syndrome

A 21-year-old man presented with fever, rash, seizure, stiff neck and rapidly progressive bilateral pulmonary infiltrates. Cerebrospinal fluid (CSF) study revealed pleocytosis with predominant polymorphonuclear cells, and hypo-glycorrhachia. Status epilepticus occurred, followed by acute respiratory distress syndrome with respiratory failure. Blood and CSF cultures for bacteria were negative, but an indirect immunofluorescence assay revealed a fourfold rise in antibody to Rickettsia tsutsugamushi in paired serum and a 1:2560 (+) IgM antibody titer. Severe scrub typhus with meningoencephalitis and extensive pneumonitis was diagnosed. The patient survived after intravenous minocycline therapy and intensive care, including aggressive seizure control, supportive mechanical ventilation and avoidance of fluid overloading. He had a nearly complete recovery. Practicing physicians in Taiwan should be aware of this reportable disease and its potentially serious complications if not promptly diagnosed and treated.