Sonographic evaluation of cellulitis in children

Within a 3 year period from July 1996 to July 1999, a total of 105 children with clinical diagnosis of cellulitis were evaluated by ultrasonography. Eighty-six children (age range, 17 days to 15 years) fulfilling the sonographic criteria for diagnosis of cellulitis were enrolled into the study. The sonographic features were used to correlate with clinical symptoms and their duration, the peripheral leukocyte count, and the serum C-reactive protein level. Pus aspiration for immediate microscopic and later bacteriologic studies was carried out under sonographic guidance. Ultrasonographic features of cellulitis included subcutaneous tissue thickening without distortion and pus (25 cases, 29%), distortion of subcutaneous tissue without pus accumulation (26 cases, 30%), distortion of subcutaneous tissue with pus accumulation (19 cases, 23%), and distortion of tissue with abscess formation (16 cases, 18%). The presence of sonographic features of tissue distortion with or without pus accumulation, including abscess formation in children with cellulitis, correlated with a longer duration of symptoms (greater than 4 days), the presence of high-grade fever, higher peripheral leukocyte count, and higher serum C-reactive protein levels. Those patients who underwent sonographically guided aspiration or surgical intervention showed a shorter hospital stay and fever duration than those without such aspiration. Our results indicated that ultrasonography is of great value in managing cellulitis by providing information regarding the progression of inflammation. Sonographically guided aspiration of pus may be a treatment of choice, as it may decrease the need for operation.

Transarterial embolisation of complex cavernous sinus dural arteriovenous fistulae with low-concentration cyanoacrylate

We report the effectiveness of low-concentration n-butyl-2-cyanoacrylate (NBCA)-Lipiodol-tungsten mixture (10-15 %) in the management of patients with aggressive or recurrent complex cavernous dural arteriovenous fistulae (CSDAVF). We treated five patients with complex CSDAVF with a low concentration of an NBCA-Lipiodol-tungsten mixture after catheterisation of the feeding arteries arising from the external carotid artery. Three had a recurrent CSDAVF after transarterial particulate embolisation. Three refused transvenous treatment or could not be treated in this way; two patients had also feeding dural branches of the internal carotid artery. All patients had complete resolution of symptoms and signs within a month of the procedure. No definite neurological complication was found during follow-up ranging from 12 to 36 months. Transarterial embolisation with low-concentration cyanoacrylate appears to be an effective alternative management of aggressive or recurrent CSDAVF.

Graft failure caused by pulmonary venous obstruction diagnosed by intraoperative transesophageal echocardiography during lung transplantation

IMPLICATIONS

Intraoperative transesophageal echocardiography can be useful to diagnose pulmonary venous anastomotic stenoses during lung transplantation.

Necrotising pneumonitis in children

We retrospectively analysed the clinical features and outcome of children under 17 years of age with necrotising pneumonitis (NP). The radiographs and CT scans of the chest of children under 17 years of age between July 1995 and March 1999 who had complicating community-acquired pneumonia were reviewed. CT scans were obtained for persistent fever, respiratory distress and sepsis despite empiric antibiotic therapy and closed tube drainage. A total of 21 children had the radiographic features of NP of whom 11 (52%) patients were successfully managed using antibiotic therapy with or without closed tube drainage. Ten patients required thoracoscopic decortications and/or lysis of pleural adhesions or debridement of empyema due to refractory pleural sepsis, failure of pulmonary re-expansion and persistent air-leaks. The most common pathogens identified were Streptococcus pneumoniae (n = 3), Staphylococcus aureus (n = 2), and Haemophilus influenzae type b (n = 2). The days of hospital stay, duration of fever and days of C-reactive protein return to normal were significantly less for the medically versus the surgically treated children (P < 0.05).

CONCLUSION

The clinical course of necrotising pneumonitis in children following complicated pneumonia is often prolonged despite adequate antibiotic therapy. Necrotising pneumonitis with co-existing multiple loculations, pneumothorax/ bronchopleural fistula in the empyema and extensive pleural peel are poor prognostic factors for medical therapy. Thoracoscopic removal of loculated empyema, lysis of adhesions and/or decortication are effective in relieving tachypnoea, chest pain, and controlling fever and improve the outcome, especially in children with empyema.

Infected cephalohematoma associated with sepsis and skull osteomyelitis: report of one case

Osteomyelitis is rarely complicated by an infected cephalohematoma. We report a case of an infected cephalohematoma associated with Escherichia coli sepsis and osteomyelitis of the skull. This 37-day-old boy had E. coli sepsis, which had a poor response to antibiotic treatment. An infected cephalohematoma was found when he was 43 days old. Cranial computed tomography (CT) scanning showed cephalohematoma with abscess formation and underlying bony destruction over the left parietal region. Antibiotics alone could not eradicate the infection. Extensive incision, drainage, and debridement of the necrotic bone resulted in prompt improvement. Three weeks of ceftizoxime administered intravenously, followed by 3 weeks of cefixime given orally completed the treatment course.

Expression of capsid [correction of caspid] protein VP1 for use as antigen for the diagnosis of enterovirus 71 infection

To produce enterovirus 71 antigen for diagnostic purposes, the gene encoding the entire capsid protein VP1 was amplified by reverse transcription-polymerase chain reaction (RT-PCR), cloned and expressed in Escherichia coli as a poly-histidine fusion protein. Western blotting experiments with sera from patients with enterovirus 71 infection indicated that immunoglobulin G (IgG) and IgM antibodies bound to a single polypeptide VP1. According to these results, IgM anti-VP1 appeared in sera of patients with a symptomatic enterovirus 71 acute infection, whereas IgG anti-VP1 was present in sera of past infection. This finding suggests that detecting IgG and IgM immune responses against linear epitopes of recombinant VP1 is an effective means of determining the different phases of enterovirus 71 infection. In addition, sera containing coxsackie virus 16 (CA16) antibodies did not cross-react with the recombinant VP1 of enterovirus 71, despite the homology between VP1 proteins of both viruses. Comparison with reference PCR and neutralization assays showed these antibody tests to be appropriate for the serodiagnosis of enterovirus 71 infection.

Influenza A virus infection in infants

Influenza A virus causes a variety of respiratory and nonrespiratory illness in children. The symptomatology varies with different age groups. The purpose of this retrospective study was to define the clinical characteristics of influenza A infection in Taiwanese infants. During the period from December 1997 to February 1998, 37 febrile patients younger than 1 year of age, including five newborns, were admitted to our hospital due to suspicion of sepsis or meningitis. The medical records of these patients were retrospectively evaluated. Influenza A virus was isolated from the specimens of the throat swabs in all patients, whereas no bacterial pathogen was detected. The most common clinical manifestations of these infants were lower respiratory tract infections, including pneumonia, bronchiolitis, and croup. There was no significant difference between the clinical characteristics of infants younger than 3 months and those aged from 3 months to 1 year. The mean duration of fever, peak of body temperature, and duration of hospitalization were 3.41 (+/-1.86) versus 4.4 (+/-2.02) days, 39.0 (+/-0.57) versus 39.9 (+/-0.63) oC, 4.9(+/-1.49) versus 6.3 (+/-3.7) days in infants younger than 3 months and infants aged from 3 months to 1 year, respectively. The older infants aged from 3 months to 1 year had a significantly higher peak body temperature than the infants younger than 3 months (p < 0.05). Two patients with croup had a more severe clinical course, however, the outcomes were good in all patients. During an influenza A virus outbreak, influenza A infection should be included in the differential diagnosis of infants with lower respiratory tract infection.

Effects of glucose-free maintenance solution on plasma glucose during anesthesia in patients undergoing long neurologic surgery

BACKGROUND

Using glucose-free solution as fluid maintenance is widely advocated during neurosurgery because of concerns about hyperglycemia aggravating cerebral ischemia. This study evaluated the alterations in plasma glucose concentrations in both adult and pediatric patients undergoing lengthy neurologic surgery, during which they were given glucose-free solutions.

METHODS

This study included 154 patients (ASA class II, aged 3 months-75 years) undergoing elective neurosurgical procedures. They were divided into two groups: group A (15-75 years-of-age) and group P (3 months-14 years-of-age). Groups A (n = 126) and P (n = 28) were further divided into five subgroups, respectively, based on the duration of surgery: 5, 6, 7, 8 and 9 hours. Anesthesia was maintained with isoflurane, fentanyl and vecuronium. Blood sampling was undertaken every hour throughout surgery.

RESULTS

Adult patients differed significantly in body weight (61.5 +/- 10.9 vs 25.6 +/- 14.9 kg), age (58.9 +/- 15.7 vs 7.5 +/- 4.3 years), use of preoperative beta-blocking agents (33/126 vs 1/28) and the need for blood transfusion (58/126 vs 24/28). Neither group had elevated glucose levels. Compared with pediatric patients, the incidence of intraoperative hypoglycemia was statistically higher in adult patients, with a rate that peaked in the eighth (25.9%, group A vs 0% group P) and ninth hours (27.3%, group A vs 0% group P) of surgery. There were no differences in glucose concentrations at other points in time.

CONCLUSIONS

In contrast to pediatric patients, intraoperative hypoglycemia occurred more often in adult patients during prolonged neurosurgical procedures when glucose-free solution was used for fluid maintenance. Therefore, frequent determination of plasma glucose concentrations is mandatory, especially in patients undergoing long-lasting neurosurgical anesthesia.

Proinflammatory cytokines increase in sepsis after anti-adhesion molecule therapy

Cytokine mediators and leukocyte-endothelial cell adhesion molecules are critical and interdependent components of the acute inflammatory response in sepsis. We hypothesized that the administration of monoclonal antibodies to intercellular adhesion molecule-1 (CD54) or E- and L-selectin (CD62E/L) would decrease serum levels of the proinflammatory cytokines interleukin-1beta (IL-1), IL-6, and IL-8 and tumor necrosis factor receptor (TNFR-1) in baboons during sepsis. Adult male baboons received infusions of 1 x 10(9) colony forming units (CFU)/kg heat-killed Escherichia coli (E. coli) followed 12 h later by live E. coli (1 x 10(10) CFU/kg). At the time of live bacterial infusion, six septic animals were treated with a monoclonal antibody to CD54 and six with an antibody to CD62E and L (1 mg/kg). Eight untreated septic animals served as controls. Sequentially drawn serum samples were assayed for IL-1, IL-6, IL-8, and TNFR-1 using enzyme-linked immunoassay (ELISA). Data were compared using Mann-Whitney U tests and Chi-square analyses. Median survival was decreased in both treatment groups compared to controls (P < 0.05). Peak IL-1 level was higher than controls in septic animals treated with anti-CD54 but not anti-CD62E/L (P < 0.05, P = NS, respectively). Elevations in IL-6, IL-8, and TNFR-1 were increased and prolonged in both antibody treated groups compared to controls (P < 0.05). These results provide the first in vivo evidence that leukocyte-endothelial adhesion molecules CD54 and CD62E/L regulate cytokine production in sepsis.

Nutritional status of mechanically ventilated critically ill patients: comparison of different types of nutritional support

Malnutrition is a common problem in hospitalized patients. Early assessment of nutritional status may help in identifying patients for whom nutritional interventions are needed. The purpose of this study was to assess and compare the nutritional status of mechanically ventilated critically ill patients who were receiving nutritional support. Forty-nine patients were divided into either enteral nutrition, total parenteral nutrition or combined (enteral plus total parenteral nutrition) groups. Anthropometric and biochemical measurements, and medical status (APACHE II score) were assessed at the 1st day and 14th day of admission in the intensive care unit (ICU) of Taichung Veteran General Hospital. The length of ventilator dependency was significantly positively correlated with calorie and carbohydrate intake in the pooled group. Patients receiving enteral and combined nutrition showed significantly lower anthropometric measurements at the 14th day after admission. Patients in all groups had abnormal mean biochemical values at the 1st day of admission. Subjects in the combined group showed a significant increase in prealbumin and the Maastricht Index levels after 14 days. Patients in all three groups were malnourished when admitted to the ICU. Patients showed a slightly improvement of nutritional status after receiving nutritional support for 14 days.

Candidaemia in special care nurseries: comparison of albicans and parapsilosis infection

OBJECTIVES

Candidaemia caused by Candida parapsilosis (CP) is being increasingly reported among infants in neonatal intensive care units (NICU). To assess relative severity, clinical manifestations of candidaemia caused by C. albicans (CA) and CP in a NICU were compared.

METHODS

Between January 1994 and July 1997, episodes of candidaemia occurring among infants hospitalized in the NICU were identified in a children's hospital. The demographic characteristics, associated risk factors, clinical manifestations and outcome of the infants with CP fungaemia were collected and compared with those of the infants with CA fungaemia.

RESULTS

Twenty-four episodes caused by CA and 22 episodes caused by CP were included in this study. No significant differences were found between the two groups for gestational age, birth weight, male gender, post-natal age at onset of candidaemia, frequency of antecedent neonatal events, prior duration of antibiotic therapy and hyperalimentation, as well as presence of central venous catheter (CVC). Infants with CA fungaemia were significantly more likely than those with CP fungaemia to present with hypoxaemia, bradycardia and respiratory distress requiring intubation, and have a longer prior duration of indwelling CVC and a higher dissemination rate. The eradication rate of candidaemia and overall case fatality rate were comparable in both groups. but CP fungaemia did not appear to cause acute lethal events.

CONCLUSION

The presenting signs of CP fungaemia are relatively not so severe, but CP fungaemia, which is relatively difficult to eradicate, increases the morbidity and mortality of the infants.

The interference of uptake of thallium-201 in cultured rat myocardial cells with existence of potassium related pharmaceuticals--a preliminary report

Thallium-201 myocardial perfusion imaging is wildly used to detect and assess the extent of jeopardized myocardial ischemia in the coronary artery disease and the viability of myocardium post infarction. In recent years, there has been a great deal of pharmacological development of blockers and openers of potassium channel. In this study, we will discuss the interference of uptake of thallium-201 ion in cultured neonatal rat myocytes with existence of a variety of pharmacological agents. The cultures of neonatal rat myocardial cells were incubated with different agents such as potassium chloride, sodium-potassium ATPase pump inhibitor (ouabain), cesium compound, variable potassium channel blockers (4 AP, TEA and glibenclamide) and their openers (minoxidil, and cromakalim). The radioactivity of intracellular thallium-201 that could enter rat myocardial cells was detected by gamma counter sixty minutes after thallium-201 was added. In this study we found that thallium and potassium ions behave in an analogous manner in cultured rat myocardial cells. Both 2.5 mM and 5 mM concentration of extracellular potassium ion significantly result in reduction of thallium-201 ion influx in rat myocardial cells. 0.5 mM ouabain, an inhibitor of sodium-potassium ATPase pump, reduced about 40% of influx of thallium-201 ion in cultured rat myocardial cells via active transport. Combination of both potassium ion and ouabain inhibit most of thallium-201 ions influx in myocardial cells, but it is not completely inhibited. Cesium, a potassium antagonist, also interferes with the uptake of thallium-201 in cultured rat myocytes in our study. The most interesting finding in our investigation is that potassium channel blockers such as TEA and glibenclamide, inhibit the influx of thallium-201 in myocytes. However, potassium channel openers have no overt effect on influx of thallium-201 in cultured rat myocytes. We indirectly observe about 60% of influx of thallium-201 ion into cultured rat myocardial cells via active sodium-potassium ATPase pump. Potassium, cesium and potassium channel blockers, such as TEA and glibenclamide, inhibited the different percentage of influx of thallium-201 in cultured rat myocardial cells in this study.

[Clinical analysis on 238 cases of longitudinal fracture of posterior teeth]

OBJECTIVE:To investigate the characteristics and clinical features of the longitudinal fractures of posterior teeth and evaluate the therapeutic methods.METHODS:The records of 238 cases with the longitudinal fractures of posterior teeth were analyzed retrospectively. The clinical features were sum med up. Eextractions of teeth were performed in 108 patients, and the conservative therapies in 130.RESULTS:The incidence of longitudinal fractures of posterior teeth was highest in the 30-59 years. The rate between male and female was 4:3. The longitudinal fractures of posterior teeth most occurred in the first molar of the maxilla with endodontic treatment. The follow up peroid was more than 2 years in 83 cases. The success rate was 75/83. CONCLUSION:The longitudinal fractures of posterior teeth can be cured by early fixation, and prevented by avoiding dysfunctional bite, treating subclinical fracture, and using proper methods of treatment of endodontics.

Vanidipinedilol: a vanilloid-based beta-adrenoceptor blocker displaying calcium entry blocking and vasorelaxant activities

Calcium channel and beta-adrenoceptor blockade have proved highly useful in antihypertensive therapy. Studies of the mechanisms of action of vanidipinedilol that combine these effects within a single molecule are described here. Intravenous injection of vanidipinedilol (0.1, 0.25, 0.5, 1.0, and 2.0 mg/kg) produced dose-dependent hypotensive and bradycardic responses, significantly different from nifedipine-induced (0.5 mg/kg, i.v.) hypotensive and reflex tachycardic effects in pentobarbital-anesthetized Wistar rats. A single oral administration of vanidipinedilol at doses of 10, 25, and 50 mg/kg dose-dependently reduced blood pressure with a decrease in heart rate in conscious spontaneously hypertensive rats (SHRs). In the isolated Wistar rat atrium, vanidipinedilol (10(-7), 10(-6), and 10(-5) M) competitively antagonized the (-)isoproterenol-induced positive chronotropic and inotropic effects and inhibited the increase in heart rate induced by Ca2+ (3.0-9.0 mM) in a concentration-dependent manner. The parallel shift to the right of the concentration-response curve of (-)isoproterenol and CaCl2 suggested that vanidipinedilol possessed beta-adrenoceptor-blocking and calcium entry-blocking activities. On tracheal strips of reserpinized guinea pig, cumulative doses of vanidipinedilol (10(-10) to 3x10(-6) M) produced dose-dependent relaxant responses. Preincubating the preparation with ICI 118,551 (10(-10), 10(-9), 10(-8) M), a beta2-adrenoceptor antagonist, shifted the vanidipinedilol concentration-relaxation curve significantly to a region of higher concentrations. These results implied that vanidipinedilol had a partial beta2-agonist activity. In the isolated thoracic aorta of rat, vanidipinedilol had a potent effect inhibiting high-K+-induced contractions. KCI-induced intracellular calcium changes of blood vessel smooth muscle cell (A7r5 cell lines) determined by laser cytometry also was decreased after administration of vanidipinedilol (10(-8), 10(-7), 10(-6) M). Furthermore, the binding characteristics of vanidipinedilol and various antagonists were evaluated in [3H]CGP-12177 binding to ventricle and lung and [3H]nitrendipine binding to cerebral cortex membranes in rats. The order of potency of beta1- and beta2-adrenoceptor antagonist activity against [3H]CGP-12177 binding was (-)propranolol (pKi, 8.59 for beta1 and 8.09 for beta2) > vanidipinedilol (pKi, 7.09 for beta1 and 6.64 for beta2) > atenolol (pKi, 6.58 for beta1 and 5.12 for beta2). The order of potency of calcium channel antagonist activity against [3H]nitrendipine binding was nifedipine (pKi, 9.36) > vanidipinedilol (pKi, 8.07). The ratio of beta1-adrenergic-blocking/calcium entry-blocking selectivity is 0.1 and indicated that vanidipinedilol revealed more in calcium entry-blocking than in beta-adrenergic-blocking activities. It has been suggested that vanidipinedilol-induced smooth muscle relaxation may involve decreased entry of Ca2+ and partial beta2-agonist activities. In conclusion, vanidipinedilol is a nonselective beta-adrenoceptor antagonist with calcium channel blocking and partial beta2-agonist associated vasorelaxant and tracheal relaxant activities. Particularly, the vasodilator effects of vanidipinedilol are attributed to a synergism of its calcium entry blocking and partial beta2-agonist activities in the blood vessel. A sustained bradycardic effect results from beta-adrenoceptor blocking and calcium entry blocking, which blunts the sympathetic activation-associated reflex tachycardia in the heart.

Relationship between serotypes and genotypes based on the hypervariable region of the S1 gene of infectious bronchitis virus

To group infectious bronchitis virus (IBV) isolates, a genetic grouping method based on hypervariable region 1 (HVR 1, nucleotides 168 to 197) was compared with that based on the whole S1 gene. Both methods resulted in the same grouping data. So the grouping method based on HVR 1 could represent the grouping method based on the whole S1 gene. Taiwan isolates could not be placed within the existing groups. In order to test the correlation between genotype and serotype, a one-way neutralization test was used to compare 9 Taiwan isolates selected from different genotypes with Massachusetts (Mass) (H120) and Connecticut (Conn) standard strains. In addition, a two-way cross-neutralization test was performed in embryonated eggs with the beta method (constant-virus, diluted-serum) and the reciprocal neutralization titers were calculated to give the relatedness (r) values. The results of two kinds of neutralizing tests showed that the serotypes of 9 isolates were different from Mass or Conn. Based on the r-values, 9 isolates were divided into two serotypes which were correlated with their genotypes. From pathogenicity tests, IBV Taiwan isolates could be divided into high, intermediate, and low pathogenicity according to their pathogenicity indexes. However, no relationship exists between pathotype and genotype. In conclusion, the genetic typing method based on HVR 1 can be used for typing IBV isolates.

Foot complications in people with diabetes: a community-based study in Taiwan

BACKGROUND AND PURPOSE

This comparative cross-sectional and community-based study was aimed at defining foot complications in diabetic patients. These data have not yet been reported for Asian societies.

METHODS

Of a population of 3,602 subjects aged 35 years or more in Chin-Shan, Taipei, 309 diabetic patients were identified. Two hundred and nineteen (71%) of those patients were compared to 100 individuals randomly selected for the nondiabetic control group in the same community.

RESULTS

Three diabetic patients underwent lower extremity amputation and four had skin ulcerations. Diabetic patients had a significantly higher prevalence of peripheral neuropathy (32.4% vs 16%), arterial insufficiency (12.6% vs 3.0%), and medial arterial calcification (13.6% vs 5.0%), when compared to the nondiabetic controls. The age and sex-adjusted rates of hallux valgus, loss of skin hair on the dorsum of the foot, tinea unguium, arterial insufficiency, medial artery calcification, and peripheral neuropathy were significantly higher in diabetic than nondiabetic subjects. Aging and hyperglycemia (> 140 mg/dL) increased the prevalence of foot complications in both groups. Foot complications were also remarkably associated with the duration of diabetes (p = 0.003).

CONCLUSIONS

This study shows that diabetes mellitus is associated with an increased likelihood of foot complications in this geographically defined Taiwanese population. Patient age and diabetic duration are associated with the significantly higher prevalence of foot complications.

Affinity cleavage at the divalent metal site of porcine NAD-specific isocitrate dehydrogenase

A divalent metal ion, such as Mn2+, is required for the catalytic reaction and allosteric regulation of pig heart NAD-dependent isocitrate dehydrogenase. The enzyme is irreversibly inactivated and cleaved by Fe2+ in the presence of O2 and ascorbate at pH 7.0. Mn2+ prevents both inactivation and cleavage. Nucleotide ligands, such as NAD, NADPH, and ADP, neither prevent nor promote inactivation or cleavage of the enzyme by Fe2+. The NAD-specific isocitrate dehydrogenase is composed of three distinct subunits in the ratio 2alpha:1beta:1gamma. The results indicate that the oxidative inactivation and cleavage are specific and involve the 40 kDa alpha subunit of the enzyme. A pair of major peptides is generated during Fe2+ inactivation: 29.5 + 10.5 kDa, as determined by SDS-PAGE. Amino-terminal sequencing reveals that these peptides arise by cleavage of the Val262-His263 bond of the alpha subunit. No fragments are produced when enzyme is incubated with Fe2+ and ascorbate under denaturing conditions in the presence of 6 M urea, indicating that the native structure is required for the specific cleavage. These results suggest that His263 of the alpha subunit may be a ligand of the divalent metal ion needed for the reaction catalyzed by isocitrate dehydrogenase. Isocitrate enhances the inactivation of enzyme caused by Fe2+ in the presence of oxygen, but prevents the cleavage, suggesting that inactivation occurs by a different mechanism when metal ion is bound to the enzyme in the presence of isocitrate: oxidation of cysteine may be responsible for the rapid inactivation in this case. Affinity cleavage caused by Fe2+ implicates alpha as the catalytic subunit of the multisubunit porcine NAD-dependent isocitrate dehydrogenase.

Pharmacokinetics, tissue distribution and photodynamic therapy efficacy of liposomal-delivered hypocrellin A, a potential photosensitizer for tumor therapy

Hypocrellin A, from Hypocrella bambusae, is a novel photosensitizer of high singlet oxygen quantum yield for photodynamic therapy (PDT). Tissue distributions were studied in tumor-bearing mice as a function of time following administration. The tumor model was S-180 sarcoma transplanted into one hind leg of male Kunming mice; hypocrellin A (HA) was delivered to the mice by intravenous injection of 5 mg/kg of body weight as a suspension either as a unilamellar liposome or in dimethyl sulfoxide (DMSO)-solubilized saline. The HA was isolated from several tissues and organs, as well as tumors and peritumoral muscles and skin. Quantitation was performed by a high-performance liquid chromatographic technique with detection that utilizes the native fluorescence of HA. Independent of the delivery system, the dye was retained in tumors at higher concentrations than in normal tissues, except for kidney, liver, lung and spleen. The dye retention in tumors was high and was vehicle dependent. For the liposomal system, the maximal accumulation in tumor and maximal ratios of dye in tumor versus peritumoral muscle and skin occurred 12 h postinjection; for the DMSO saline system, the maximal ratio occurred earlier, 6 h postadministration. Liposomal delivery improved the selective accumulation of the dye in tumor with higher maximal levels in tumor and higher ratios of tumor-to-muscle and tumor-to-skin. Levels of dye were very low or not detectable in the brain. The PDT efficacy of HA in the liposome and DMSO saline systems was determined by evaluating the tumor volume regression percent. The PDT efficacy of HA in liposomes was highest when light treatment was performed at 12 h postinjection, consistent with the highest retention of HA in tumors. Similarly, the maximal PDT efficacy in DMSO saline was attained at 6 h postinjection, the highest HA retention point in tumor. Moreover, the peak PDT efficacy of HA in liposomes was much higher than that of HA in DMSO saline and even hematoporphyrin monomethylether.

Non-typhoid Salmonella subdural empyema in children: report of two cases

Subdural empyema caused by Salmonella in childhood is an uncommon condition. The predisposing factors for this condition are not clearly established, especially in young children. Here we present two cases of subdural empyema caused by non-typhoidal Salmonella. Both of the patients suffered prolonged fever without local signs of infection on admission. Subdural empyema was subsequently detected by brain echo and brain computerized tomography (CT) scan in both cases. Cerebrospinal fluid (CSF) study was not done in case one due to prominent mass effect on brain CT; in case two the CSF analysis showed pleocytosis, but CSF bacterial culture was negative. Neither enteritis nor obvious meningeal sign was noted. Both cases responded well to surgical drainage and systemic antibiotics treatment.

Comparison of enterovirus 71 and coxsackie-virus A16 clinical illnesses during the Taiwan enterovirus epidemic, 1998

OBJECTIVES

To compare enterovirus 71 (EV 71) with coxsackievirus A16 (Cox A16) clinical illness in patients at Chang Gung Children's Hospital during Taiwan's enterovirus epidemic of 1998.

METHODS

With the use of the immunofluorescence assay and neutralization test, 177 cases of EV 71 and 64 cases of Cox A16 illness were confirmed from April to September, 1998. The clinical signs and symptoms, complications and case fatality rates were compared.

RESULTS

Three-fourths of the cases were younger than 3 years of age, and the ratio of males to females was 1.3 in the EV 71 group and 1.2 in the Cox A16 group. In the EV 71 group 120 (68%) cases were uncomplicated, including 94 cases of hand, foot and mouth disease and 15 cases of herpangina, and 57 (32%) cases had complications, including 13 (7.3%) cases of aseptic meningitis, 18 (10%) cases of encephalitis, 4 (2.3%) cases of polio-like syndrome, 8 (4.5%) cases of encephalomyelitis and 12 (6.8%) cases of fatal pulmonary edema. Fourteen (7.9%) patients died, including 12 cases of pulmonary edema and 2 cases of encephalitis; seven (4%) patients had sequelae. By contrast, 60 (94%) of the 64 cases of Cox A16 infection were uncomplicated and only 4 (6.3%) cases were complicated by aseptic meningitis; no fatalities or sequelae were observed. By multivariate analysis vomiting (P = 0.01) and fever higher than 39 degrees C plus lasting longer than 3 days (P = 0.02) were significantly more frequent in the EV 71 group.

CONCLUSION

EV 71 illness is more severe with significantly greater frequency of serious complications and fatality than is illness caused by Cox A16.

Clinical features and risk factors of pulmonary oedema after enterovirus-71-related hand, foot, and mouth disease

BACKGROUND

In Taiwan, from April to July, 1998, an epidemic of hand, foot, and mouth disease associated with enterovirus 71 (EV71) occurred with fatal complications. We did a clinical study of EV71-related diseases in Taiwan.

METHODS

We studied 154 children with virus-culture confirmed EV71 infection. Children were divided into three groups: 11 patients with pulmonary oedema; 38 patients with central nervous system (CNS) involvement and no pulmonary oedema; and 105 children without complications. We compared the clinical features, laboratory findings, risk factors, and outcome among these three groups.

FINDINGS

Nine children with pulmonary oedema had hand, foot, and mouth disease, one had herpangina, and one had febrile illness with eight children with limb weakness and one with limb hypesthesia. All children had had sudden onset of tachycardia, tachypnoea, and cyanosis 1-3 days after onset of the disease. Nine of 11 children died within 12 h of intubation; one child was braindead within 15 h and died 17 days after intubation; one child was in deep coma and died 3 months later. In children with CNS complication and no pulmonary oedema, one child died of pneumonia after 4 months of ventilator support and four children had sequelae. All 105 children without complications recovered. There was a significant association between CNS involvement and pulmonary oedema (odds ratio 12.4 [95% CI 2.6-60.1], p=0.001). Risk factors for pulmonary oedema after CNS involvement were hyperglycaemia, leucocytosis, and limb weakness. Hyperglycaemia was the most significant prognostic factor for pulmonary oedema (odds ratio 21.5 [3-159], p=0.003).

INTERPRETATION

EV71 can cause hand, foot, and mouth disease, CNS involvement with severe sequelae, and fatal pulmonary oedema. Hyperglycaemia is the most important prognostic factor.

Color Doppler ultrasonographic evaluation of osteomyelitis in children

We investigated the capability of color Doppler sonography in evaluating acute osteomyelitis in children. Twelve children suspected of having osteomyelitis were evaluated with color Doppler ultrasonography at admission and at regular intervals to observe the inflammatory process of osteomyelitis, determine the response of antibiotic therapy, and predict the need of surgery in these patients. At admission, color Doppler flow within or around the infected periosteum was found in patients with symptoms for 4 days or longer, whereas those with symptoms for less than 4 days showed no color Doppler flow within and around the periosteum. During sonographic follow-up, six cases were found to have increased color Doppler vascular flow within and around the affected periosteum, and two of them had periosteal abscess. They eventually required surgical treatment. Persistent or increased color Doppler flow during follow-up examination correlated with elevated serum levels of C-reactive protein as well. Our study indicated that color Doppler vascular flow within or around the infected periosteum correlated with advanced acute osteomyelitis, and surgery usually was required in these patients. Those with early stage acute osteomyelitis usually showed no vascular flow within or around the infected periosteum. Thus, color Doppler sonography allowed detection of advanced osteomyelitis and revealed the progression of inflammation during antibiotic therapy. Color Doppler ultrasonography might be valuable in determining the efficacy of antibiotic therapy and justifying the need for operation.

Stability of blood pressure: is a sequential blood pressure reading protocol efficient for a large-scale community screening programme

The purpose of this study is to assess the relative stability of the systolic and diastolic blood pressure (BP) measures obtained in a state-wide screening programme. A state-wide hypertension survey was conducted in California in 1983 in which a total of 6381 adults were interviewed in their homes. Three BP measurements were taken, with a 5-min interval between each measure. The BP screening protocol used by The Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure recommended a total of three measures, in which the second and the third measures are averaged. Results of the household survey indicated significant differences between the three subsequent BP measurements (P < 0.001), with much smaller differences between the second and third measure. This result implies that BP of an individual is approaching stability after the second measure and, consequently, two subsequent BP measurements may be sufficient to identify subjects with elevated BP. We compare the three-measure screening protocol with a two-measure screening protocol in which only the first two BP readings are taken and the second reading is used to indicate BP levels of subjects. The percentage of agreement between the three-measure and the two-measure screening protocols is 97.57%. Using the three-measure screening protocol as a standard, the sensitivity and false-negative rate are 98.73% and 0.43%, respectively. The two-measurement screening protocol is recommended as an equally sensitive and a more efficient procedure for a large-scale community-screening programme.