[Management and prognosis of extremely preterm infants with gestational age ≤25+6 weeks]

Objective: To investigate the outcomes including major complications and prognosis of extremely preterm infants with gestational age ≤25⁺⁶ weeks. Methods: The cross-sectional study enrolled 233 extremely preterm infants with gestational age ≤25⁺⁶ weeks who were admitted to the Department of Neonatology of Shenzhen Maternity and Child Healthcare Hospital from January 2015 to December 2021. The clinical data including perinatal factors, treatments, complications, and prognosis were extracted and analyzed. These extremely preterm infants were also grouped according to gestational age and year of admission to further analyze their survival rate, major complications, causes of death, and long-term outcomes. The comparisons between the groups were performed with Chi-square test and Kruskal-Wallis. Results: Among these 233 extremely preterm infants, 134 (57.5%) were males and 99 (42.5%) females. The gestational age was (24.6±0.9) weeks, the birth weight was 710.0 (605.0,784.5) g, and the overall survival rate was 61.8% (144/233). Among the surviving extremely preterm infants, the earliest gestational age was 22⁺² weeks and the lowest birth weight was 390 g. There were 17.6% (41/233) of extremely preterm infants had treatment withdrawn and were discharged in line with the will of guardians. Among the rest 192 extremely preterm infants managed with aggressive treatments, 14 (7.3%) died in hospital and 34 (17.7%) had treatment withdrawn later due to severe complications. Of the 192 extremely preterm infants, 144 (75.0%) survived, and the survival rate increased year by year (χ²=26.28, P<0.001) while the mortality decreased year by year (χ²=14.09, P=0.027). Among the survivors, 20.8%(30/144) had no major complications, and the incidence of complications was also negatively related with the gestational age (χ²=7.24, P=0.044), and the length of invasive ventilation was negatively related to the gestational age (χ²=29.14, P<0.001). In the group of less than 23⁺⁶ weeks, all extremely preterm infants had one or more major complications. The follow-up were completed in 122 infants and revealed that delayed motor development, language retardation, and hearing and vision impairment accounted for 17.2% (21/122), 8.2% (10/122) and 17.2% (21/122), respectively. Conclusions: Extremely preterm infants with gestational age ≤25⁺⁶ weeks are difficult to treat, but the survival rate of infants undergoing aggressive treatments increases year by year. Although the prevalence of major complications is still high, most extremely preterm infants have acceptable prognosis during follow-up.

[Post-discharge growth of extremely premature infants within corrected age of 24 months]

Objective: To demonstrate the post-discharge catch-up growth of extremely premature infants (EPI) within 24 months of corrected age. Methods: This study retrospectively collected the anthropomorphic measurements of 311 EPI who visited Shenzhen Maternity and Child Healthcare Hospital from August 2013 to April 2020. These infants were stratified according to gestational age at birth (GA): 23-24⁺⁶weeks, 25-26⁺⁶weeks, 27-27⁺⁶weeks; and birth weight:<750 g, 750-999 g, ≥1 000 g. The anthropomorphic measurements, including weight, length, and head circumference for age, were recorded timely from discharge to 24 months of corrected age. And the growth curve stratified by GA and birth weight were fitted in both chronological age and corrected age, which were then compared with the World Health Organization Child Growth Standards for term infant (2006 version), to investigate the catch-up growth pattern of EPI. And appropriate catch-up was defined as the measurements reached the 25^th percentile of WHO growth curve. Results: In these 311 EPI, 184 were males and 127 females, with gestational age of 23-27⁺⁶ weeks and birth weight of 480-1 430 g. Regardless of the GA and birth weight, the growth curves fitted in corrected age failed to overlap with that in chronological age by 24 months of corrected age. The growth velocity of weight, length and head circumference in both corrected and chronological age were all positively correlated with GA and birth weight: the 27-27⁺⁶weeks group showed a preferable growth pattern than the 25-26⁺⁶weeks group, and the curve of the 23-24⁺⁶weeks group was most unfavorable; and the same pattern was observed between the subgroups of different birth weight. Furthermore, the GA had more significant impact on the catch-up growth pattern than birth weight did. When assessed with corrected age curve, the weight and length of both male and female EPIs achieved appropriate catch-up by 24 months, as well as the head circumference of girls; whereas, boys' head circumference reached appropriate catch-up at the corrected age of 9 months, but fell behind the 25^th percentile after that. However, when assessed with chronological age curve, both boys and girls failed to achieve appropriate catch-up in weight, length and head circumference by age 24 months. And no matter in corrected or chronological age, all physical measurements of girls were lower than those of boys. Conclusions: The rapid catch-up growth of EPI happens within 6 months of corrected age. The lower the birth weight and gestational age, the lower the physical measurements at each corresponding month of age, and the longer it takes to achieve appropriate catch-up. Gestational age has a greater impact on the longitudinal catch-up growth than birth weight does. And girls generally grow slower than boys in either correct or actual age. Before 24 months of corrected age, the growth should be assessed with corrected age rather than chronological age.

[Risk factors and prognosis of bronchopulmonary dysplasia associated pulmonary hypertension in preterm infants]

Objective: To analyze clinical features, prognosis and risk factors of bronchopulmonary dysplasia (BPD) associated pulmonary hypertension (PH). Methods: Clinical data of 338 infants with BPD were collected from the neonatal intensive care unit (NICU) in Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University between January 2016 and December 2018. These infants were divided into PH group and non-PH group. The clinical features and prognosis were compared between these two groups by Chi-square test or nonparametric test. Risk factors for BPD-PH were analyzed with binary logistic regression model. Results: Among the 338 BPD infants, 314 had no PH (92.9%) and 24 had PH (7.1%), with an average gestational age of (27.1±1.8) weeks, and 206 were males and 132 females.PH infants had younger gestational age ((26.4±2.1) vs. (27.2±1.7) weeks, t=2.201, P=0.028) and lower birth weight ((798±255) vs. (1 003±240) g, t=4.030, P<0.01), compared to non-PH infants. Besides, duration of mechanical ventilation and non-invasive positive pressure ventilation were higher in PH group than that in non-PH group (14.3 (2.1, 43.7) vs. 0.5 (0, 4.7) d, Z=-4.553, P<0.01; 30.0 (22.5, 64.2) vs. 15.0 (7.0, 26.0) d, Z=-4.838, P<0.01). The proportions of maternal hypertension, small for gestational age (SGA), late onset sepsis, ventilator associated pneumonia, hemodynamically significant patent ductus arteriosus (hsPDA), patent ductus arteriosus (PDA) requiring ligation, severe BPD and severe extrauterine growth retardation (EUGR) were higher in PH group than those in non-PH group ((20.8% (5/24) vs. 6.4% (20/314), 33.3% (8/24) vs. 7.6% (24/314), 54.2% (13/24) vs. 7.3% (23/314), 25.0% (6/24) vs. 6.1% (19/314), 75.0% (18/24) vs. 39.2% (123/314), 45.8% (11/24) vs. 1.9% (6/314), 66.7% (16/24) vs. 7.3% (23/314), 75.0% (18/24) vs. 45.5% (143/314), all P<0.05). Multivariate logistic regression analysis showed that maternal hypertension (OR=12.950, 95%CI: 1.740-96.385), severe bronchopulmonary dysplasia (OR=10.160, 95%CI: 2.725-37.884), SGA (OR=4.992, 95%CI: 1.432-16.920), PDA requiring ligation (OR=19.802, 95%CI: 3.297-118.921), severe EUGR (OR=20.316, 95%CI: 2.221-185.853) were independent risk factors of BPD associated PH. In the 24 infants with PH, all 7 mild PH infants and 8 moderate PH infants survived, while 4 out of 9 severe PH infants died. Among the survivors, the longest duration of oxygen therapy was up to the corrected gestational age of 1 year and 2 months. Conclusions: PH is a severe complication of BPD, and associated with higher mortality and poor prognosis. Echocardiography screening and regular post-discharge follow up are recommended for BPD infants with risk factors of PH.

Correlation between miR-1207-5p expression with steroid-induced necrosis of femoral head and VEGF expression

OBJECTIVE

The aim of this study was to investigate the expression level of micro-ribonucleic acid-1207-5p (miR-1207-5p) in steroid-induced necrosis of femoral head (SNFH) and its correlation with SNFH. Meanwhile, we also aimed to analyze the relationship between miR-1207-5p expression and vascular endothelial growth factor (VEGF) in the femoral head.

PATIENTS AND METHODS

From May 2016 to December 2017, 60 patients aged (55.4±8.7) were selected in our hospital. All patients were diagnosed and confirmed as SNFH. Total RNA was extracted from the necrotic femoral head tissues and peripheral blood. Reverse Transcription-Polymerase Chain Reaction (RT-PCR) was used to detect the expression level of miR-1207-5p in tissues. At the same time, immunohistochemistry and Western blotting were adopted to detect VEGF expression in the bone tissue of patients with high or low expression of miR-1207-5p. 7 patients with femoral neck fracture aged (45.6±4.51) were enrolled in the control group. In the animal experiment, the rat SNFH model was established by intraperitoneal injection of lipopolysaccharide and methylprednisolone. Subsequently, the expression levels of miR-1207-5p and VEGF in necrotic femoral tissues were detected. Meanwhile, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining was applied to detect cell apoptosis in bone lacunae of miR-1207-5p high expression group and miR-1207-5p low expression group, respectively.

RESULTS

The expression level of miR-1207-5p in the necrotic bone tissue of the SNFH group was significantly higher than that of the control group. The expression level of miR-1207-5p was inversely proportional to Harris Hip score (p<0.05). A higher expression of miR-1207-5p indicated a lower expression level of VEGF (p<0.05). The animal experimental results revealed that miR-1207-5p expression in the necrotic femoral head tissue of SNFH group was significantly higher than that of the control group. Furthermore, the number of apoptotic cells in bone lacunae was remarkably higher in miR-1207-5p high expression group (p<0.05).

CONCLUSIONS

MiR-1207-5p is significantly up-regulated in necrotic femoral head tissue and serum of SNFH patients. Meanwhile, its expression level is inversely proportional to Harris Hip score of patients. The possible underlying mechanism may be related to the inhibitory effect of miR-1207-5p on VEGF.

P2556TXNDC5 is a novel therapeutic target of atrial fibrosis and fibrillation

Background

Atrial fibrillation (AF), one of the most common cardiac arrhythmias, increases the risk of stroke, systemic embolization and cardiovascular mortality. Atrial fibrosis, a hallmark of chronic AF, provides substrates to initiate/propagate fibrillation waves in the atria. There, however, lacks effective and specific therapeutics targeting atrial fibrosis. We have recently identified an endoplasmic reticulum (ER) protein thioredoxin domain containing 5 (TXNDC5) as a critical mediator of cardiac ventricular fibrosis. We hypothesized that TXNDC5 could also play an important role in the pathogenesis of atrial fibrosis and fibrillation.

Purpose

To determine the role of TXNDC5 in atrial fibrosis and fibrillation.

Methods and results

TXNDC5 transcript and protein levels were both significantly upregulated in the atrial tissue from patients with AF. In addition, TXNDC5 mRNA expression levels were positively correlated with those of transcripts encoding transforming growth factor β1 (TGFβ1) and extracellular matrix (ECM) proteins in human atrial tissue. Knockdown of TXNDC5 in human atrial fibroblasts (hAF) attenuated TGFβ1–induced hAF activation, proliferation and ECM protein upregulation, whereas overexpression of TXNDC5 was sufficient to trigger hAF activation, proliferation and ECM protein production. Further experiments revealed that the fibrogenic effects of TXNDC5 were dependent on c-Jun N-terminal kinase (JNK) signaling. Furthermore, using α-MHC-TGFβcys33ser mice, a transgenic mouse model with cardiac-specific overexpression of constitutively active TGFβ, which develop extensive atrial fibrosis and inducible AF, we showed that TXNDC5 was strongly upregulated in the fibrotic atria of α-MHC-TGFβcys33ser mice and specifically enriched in collagen-secreting atrial fibroblasts. Targeted deletion of TXNDC5 (Txndc5−/−) in α-MHC-TGFβcys33ser mice considerably mitigated the extent of atrial fibrosis. In addition, transesophageal atrial burst pacing induced AF in 75% (3 out of 4) α-MHC-TGFβcys33ser mice, whereas knockout of Txndc5 markedly reduced the inducibility of AF (25%, 3 out of 12) in α-MHC-TGFβcys33ser mice (Figure).

TXNDC5 KO Reduces AF Inducibility

Conclusion

The present study revealed that ER protein TXNDC5 augments atrial fibrosis by promoting cardiac fibroblast proliferation and ECM protein production via JNK signaling activation. Targeted deletion of Txndc5 protects against TGFβ induced atrial fibrosis and AF. Targeting TXNDC5, therefore, could be a promising new therapeutic approach to treat or prevent atrial fibrosis and AF.

Spleen-preserving versus spleen-sacrificing distal pancreatectomy in adults with blunt major pancreatic injury

Background

The aim of this study was to analyse outcomes of spleen‐preserving (SPDP) and spleen‐sacrificing (SSDP) distal pancreatectomy in adults with severe blunt pancreatic injuries.

Methods

This was an observational study of adult patients who underwent distal pancreatectomy for grade III or IV blunt pancreatic injury between 1991 and 2015. Outcomes of SPDP and SSDP were compared.

Results

Fifty‐one patients were included, of whom 23 underwent SPDP and 28 SSDP. The median Injury Severity Score (ISS) was 13·0 (i.q.r. 9·0–18·0). No significant differences were observed between the groups regarding sex, trauma mechanism, shock at triage, laboratory data, location, ISS, associated injury, length of stay, mortality or morbidity. Age (27·0 versus 36·5 years; P = 0·012) and time interval from injury to distal pancreatectomy (15·0 versus 44·0 h; P = 0·022) differed significantly between SPDP and SSDP groups respectively. The mortality rate was 4 per cent (1 of 23) versus 11 per cent (3 of 28) respectively (P = 0·617). Nine patients (39 per cent) developed abdominal morbidity after SPDP, compared with 17 (61 per cent) after SSPD (P = 0·125). In the SPDP group, eight patients had grade B postoperative pancreatic fistula (POPF), two of whom required further intervention. In the SSDP group, six of ten patients with grade B POPF required CT‐guided drainage, and a further five patients required reoperation for other causes. There were more reinterventions after SSDP: 11 of 28 (39 per cent) versus 3 of 23 (13 per cent) in the SPDP group (P = 0·037).

Conclusion

SPDP was performed more often in younger patients and at a shorter interval after severe blunt pancreatic injury. SPDP was associated with fewer reinterventions.

Improved carrier injection in GaN-based VCSEL via AlGaN/GaN multiple quantum barrier electron blocking layer

In this report, the improved lasing performance of the III-nitride based vertical-cavity surface-emitting laser (VCSEL) has been demonstrated by replacing the bulk AlGaN electron blocking layer (EBL) in the conventional VCSEL structure with an AlGaN/GaN multiple quantum barrier (MQB) EBL. The output power can be enhanced up to three times from 0.3 mW to 0.9 mW. In addition, the threshold current density of the fabricated device with the MQB-EBL was reduced from 12 kA/cm2 (9.5 mA) to 10.6 kA/cm2 (8.5 mA) compared with the use of the bulk AlGaN EBL. Theoretical calculation results suggest that the improved carrier injection efficiency can be mainly attributed to the partial release of the strain and the effect of quantum interference by using the MQB structure, hence increasing the effective barrier height of the conduction band.

Predictive factors for early failure of transarterial embolization in blunt hepatic injury patients

AIM

To evaluate the early success of transarterial embolization (TAE) in patients with traumatic liver haemorrhage and to determine independent factors for its failure.

MATERIALS AND METHODS

From January 2009 to December 2012, TAE was performed in 48 patients for traumatic liver haemorrhage. Their medical charts were reviewed for demographic information, pre-TAE vital signs and laboratory data, injury grade, type of contrast medium extravasation (CME) at CT, angiography findings, and early failure. "Early failure" was defined as the need for repeated TAE or a laparotomy for hepatic haemorrhage within 4 days after TAE. Variables were compared between the early success and early failure groups. Variables with univariate significance were also analysed using multivariate logistic regression for predictors of early failure.

RESULTS

Among 48 liver TAE cases, nine (18.8%) were early failures due to liver haemorrhage. Early failure was associated with injury grade (p = 0.039), major liver injury (grades 4 and 5; p = 0.007), multiple CMEs at angiography (p = 0.031), incomplete TAE (p = 0.002), and elevated heart rate (p = 0.026). Incomplete embolization (OR = 8; p = 0.042), and heart rate >110 beats/min (bpm; OR = 8; p = 0.05) were independent factors for early failure of TAE in the group with major liver injuries.

CONCLUSION

Major hepatic injury is an important factor in early failure. Patients with a heart rate >110 bpm and incomplete embolization in the major injury group have an increased rate of early failure. The success rate of proximal TAE was comparable to that of the more time-consuming, superselective, distal TAE.

Risk factors for liver abscess formation in patients with blunt hepatic injury after non-operative management

PURPOSE

To identify risk factors for liver abscess formation in patients with blunt hepatic injury who underwent non-operative management (NOM).

METHODS

From January 2004 to October 2008, retrospective data were collected from a single level I trauma center. Clinical data, hospital course, and outcome were all extracted from patient medical records for further analysis.

RESULTS

A total of 358 patients were enrolled for analysis. There were 13 patients with liver abscess after blunt hepatic injury. Patients with abscess had a significant increase in glutamic oxaloacetic transaminase (GOT, p = 0.006) and glutamic pyruvic transaminase (GPT, p < 0.0001), and a decrease in arterial blood pH (p = 0.023) compared to patients without abscess in the univariate analyses. In addition, high-grade hepatic injury and transarterial embolization (TAE, p < 0.001) were also risk factors for liver abscess formation. Five factors (GOT, GPT, pH level in the arterial blood sample, TAE, and high-grade hepatic injury) were included in the multivariate analysis. TAE, high-grade hepatic injury, and GPT level were statistically significant. The odds ratios of TAE and high-grade hepatic injury were 15.41 and 16.08, respectively. A receiver operating characteristic (ROC) analysis was used for GPT, and it suggested cutoff values of 372.5 U/L. A prediction model based on the ROC analysis had 100 % sensitivity and 86.7 % specificity to predict liver abscess formation in patients with two of the three independent risk factors.

CONCLUSIONS

TAE, high-grade hepatic injury, and a high GPT level are independent risk factors for liver abscess formation.

Serum lactic dehydrogenase strongly predicts survival in metastatic nasopharyngeal carcinoma treated with palliative chemotherapy

BACKGROUND AND OBJECTIVE

The survival outcomes of patients with metastatic nasopharyngeal carcinoma (NPC) differ significantly between individuals. This study aimed to evaluate whether serum lactic dehydrogenase (S-LDH) level had a clinical value in predicting clinical response and survival outcome for patients with metastatic NPC.

METHODS

S-LDH level was measured at baseline and then before every cycle of treatment in 689 NPC patients with distant metastases. Correlations of pre-treatment and post-treatment S-LDH levels to response of treatment and survival were analysed retrospectively.

RESULTS

Patients with elevated values of pre-treatment S-LDH (>245 IU/L) had significantly worse survival than those with normal values of pre-treatment S-LDH (≤245 IU/L) (P<0.001). Patients with elevated values of post-treatment S-LDH had worse survival compared with those with normal values of post-treatment S-LDH (P<0.001). Patients with normal values of pre-treatment and post-treatment S-LDH showed the highest response rate and the most favourable prognosis.

CONCLUSION

S-LDH appears to be a significant independent prognostic index in patients with disseminated NPC that should be considered in the comparison of the results achieved with different therapies and in planning new randomised clinical therapeutic trials.

Computed tomography in left-sided and right-sided blunt diaphragmatic rupture: experience with 43 patients

AIM

To investigate differences in the radiographic signs for left and right-sided blunt diaphragmatic rupture (BDR) in order to provide guidance to avoid missing these injuries.

MATERIALS AND METHODS

A retrospective review of the computed tomography (CT) examinations of 43 patients with BDR treated at our hospital between January 1995 and 2007 was undertaken. The presence of diaphragmatic discontinuity, diaphragmatic thickening, herniation of abdominal organs into the thoracic cavity, collar/hump sign, dependent viscera sign, abnormally elevated 4 cm or more above the dome of the other-sided hemi-diaphragm, and of associated injuries was recorded and their relationship to each other and to BDR diagnosis examined. A comparison between the use of axial and sagittal/coronal reconstruction images in diagnosis was also performed in 15 patients.

RESULTS

On axial imaging, left-sided diaphragmatic rupture occurred in 31 patients (72%) and right-sided in 12 (28%). Twenty-nine patients had associated injuries. More than 60% of the patients showed the "dependent viscera" sign, "abdominal organ herniation" sign, diaphragm thickening, or had a more than 4 cm elevation of one side of the diaphragm. "Diaphragmatic discontinuity" and "stomach herniation" were seen almost exclusively in left-sided rupture. Those with BDR and haemothorax had a significantly lower incidence of "diaphragm discontinuity" (p=0.034) than those without haemothorax. Sagittal/coronal reconstruction slightly increased the number of band signs, diaphragmatic discontinuities and diaphragmatic thickenings seen.

CONCLUSIONS

Of the CT signs examined in this study, when herniation of abdominal organs was used as a diagnostic marker, only a very small fraction of trauma patients identifiable by CT would be missed. Further, CT signs differ for left-sided and right-sided BDR, thus the possibility of BDR should be considered when any of the reported CT signs are present.

Lipid-lowering and LDL-oxidation inhibitory effects of aqueous extract of freshwater clam (Corbicula fluminea)--using tilapia as an animal model

A previous study has demonstrated that tilapia able to exhibit hyperlipidemia and hypercholesterolemia is a good model for the evaluation of beneficial effects of nutraceuticals. In this study, tilapia were used to evaluate the in vitro and in vivo effects of a hot water extract (FC-HW) of freshwater clam (Corbicula fluminea). FC-HW prolonged the lag phase of Cu(2+)-induced human and tilapia LDL oxidation. The prolongation of the lag phase was concentration-dependent in human (r(2)= 0.94) and tilapia LDL (r(2)= 0.98). The antioxidative potential of FC-HW was 0.33% (on a weight basis) of Trolox, a positive control. Male tilapia (n= 24) were randomly divided into 2 groups and separately fed for 60 d with an isocaloric also isoprotein diet containing 2% (w/w) FC-HW or a control diet. Body length and body mass were significantly higher in fish fed FC-HW than those of the control group (P < 0.05). Total triacylglycerol, cholesterol, and LDL-C in plasma of the FC-HW group were significantly lower (-89.9%, -61.8%, and -54.5%, respectively), while plasma total antioxidant capacity of the FC-HW group was higher and the lag phase in Cu(2+)-induced LDL oxidation was longer than those of the control group (P < 0.05). FC-HW demonstrated hypolipidemia and hypocholesterolemia effects and inhibited human LDL oxidation in vitro and tilapia LDL both in vitro and ex vivo, indicative that FC-HW can be a potential nutraceutical to reduce the risk factors of atherosclerosis.

Blunt pancreatic trauma and pseudocyst: management of major pancreatic duct injury

When there is no major pancreatic duct injury or the injury involves only the distal duct, percutaneous drainage should be considered the primary therapeutic procedure for traumatic pancreatic pseudocyst. If the pseudocyst does not then resolve, endoscopic retrograde pancreatography should be performed to prove proximal duct injury. When the major pancreatic duct is disrupted but not obstructed, pancreatic duct stenting may avert surgical resection. If the major duct is obstructed, surgical resection is required.

A new compound from Gentianopsis paludosa

A new compound, named gentianopfluorenone (1), along with three known compounds,1-O-beta-d-glucopyranosyl-5-hydroxy-3-methoxyxanthone (2), 1-O-[beta-d-xylopyranosyl-(1 --> 6)-beta-d-glucopyranosyl]-7,8-dihydroxy-3-methoxyxanthone (3), and apigenin (4), were isolated from the whole herb of Gentianopsis paludosa. On the basis of spectral and chemical evidence, the structure of 1 was elucidated as 4,4a,6-trihydroxy-5-methoxy-fluoren-2,9-dione. Compounds 2-4 were isolated from the plant for the first time.

Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury

BACKGROUND

Pancreatic stents can be used to treat a variety of acute and chronic pancreatic lesions. Sporadic successful trials in trauma patients have been reported. To our knowledge, however, a series with long-term follow-up has not previously been reported. We treated six patients in a 6-year period and report the long-term results.

METHODS

From February 1999 to February 2005, six blunt-trauma patients with major pancreatic duct disruption were treated with pancreatic duct stent at a single trauma center. Assessment of injury severity and diagnosis were based on abdominal computed tomography (CT) and proved by endoscopic retrograde pancreatography (ERP), with chart review used to establish mechanism of injury, timing of ERP, and stent placement, as well as the long-term outcome.

RESULTS

Three of the six injuries were classified AAST grade III and three were grade IV; the interval to ERP with stent placement ranged from 8 hours to 22 days after the injury. One patient developed sepsis and died. One patient's stent could be removed early (52 days post-stenting) with mild ductal stricture, whereas the other four were complicated by severe ductal stricture that required repeated and prolonged stenting treatment. Removal of the stents was only possible in three of these four cases (at 12, 19, and 39 months, respectively), with stent dislodgment in the pancreatic duct occurring in another.

CONCLUSIONS

Stent therapy may avoid surgery in the acute trauma stage, and may be preserved as another choice for acute grade IV pancreatic injury. However, variant outcome and long-term ductal stricture reveal that the role of pancreatic duct stent is uncertain and may not be suitable for acute grade III pancreatic injury. However, it needs more clinical data to define the value in the acute blunt pancreatic duct injury.

Autologous biologicals--science/regulations

There has been increased interest in Targeted Biologicals in the United States for several reasons. First, new technology is available to facilitate science-based isolate selection and manufacture. The science of Autologous/Targeted Biologicals will be discussed later in this presentation. A second reason for the increased interest in Targeted Biologicals is the fact that the livestock production methods have changed to favour herd/flock specific products controlled by a veterinarian. There have been changes in management methods such as segregated early weaning in swine, accelerated feeding and early weaning of dairy calves, and forced moulting in poultry. Herds and flocks have increased in stocking density and size. These factors stress animals and may facilitate mutation, strain variation and increased virulence of pathogens. Under these conditions, Traditional Biologicals may not be relevant to current field isolates. Many veterinarians favour vaccinating only for pathogens isolated from a herd/flock. A third reason for the increased interest in these products is that the licensing procedure for Targeted Biologicals is responsive to the needs of livestock producers. The process is abbreviated, requiring much less time and money. This allows for a more rapid response to emerging pathogens, strain variations and mutations, while facilitating the development of monovalent and multivalent products for limited markets or those for minor species.

[Epidemiological investigation on an outbreak of angiostrongyliasis cantonensis in Wenzhou]

OBJECTIVE

To find out the cause and transmission factors of an outbreak of eosinophilic meningoradiculitis in Wenzhou City during October to November in 1997.

METHODS

In addition to a retrospective cohort study on 182 persons who had dined at a same restaurant of the city, etiological and immunoserological investigations were conducted.

RESULTS

Among 105 cases who had eaten the undercooked Ampullaria gigas in that restaurant, 47 cases were infected, the incidence rate was 44.8%; whereas none of the persons who did not eat the under-cooked Ampullaria gigas in that restaurant got the infection, the difference between the two groups being significant(P < 0.001). The incidence rate of the cases who had eaten 4 and more pieces of the undercooked Ampullaria gigas was 86.2%(25/29), while that of those who had eaten less than 4 pieces was 28.9%(22/76), the difference between the two being very significant (chi 2 = 27.83, P < 0.001, RR = 2.98). The third stage larvae of the Angiostrongylus cantonensis were found out from Ampullaria gigas living in the same locality, and the adult worms of Angiostrongylus contonensis were found out from the rats living in the locality else. The positive rate of serum anti-Angiostrongylus cantonensis antibody in the patients was 84.0%.

CONCLUSION

On the basis of the clinical, epidemiological, immunoserological and etiological investigations, an outbreak of the angiostrongyliasis cantonensis caused by eating undercooked Ampullaria gigas was confirmed.

A collision model for DNA separation by capillary electrophoresis in dilute polymer solution

A theoretical description, based on chemical kinetics and electrochemistry, is given of DNA separation in dilute polymer solution by capillary electrophoresis. A self-consistent model was developed leading to predictions of the DNA electrophoretic velocity as a function of the experimental conditions--polymer concentration, temperature, and electric field strength. The effect of selected experimental variables is discussed. The phenomena discussed are illustrated for the example of 100 bp DNA ladder separation in dilute HPMC solution by capillary electrophoresis. This model is the first single model that can fully explain the dependence of DNA electrophoretic velocity on electrophoretic conditions.

[Capillary electrophoresis and chip capillary electrophoresis of carbohydrate]

Carbohydrate has many important functions in various biologic processes. Capillary electrophoresis (CE) is one of the key tools of carbohydrate analysis. Chip CE is a new but efficient technique in the study of life science. Carbohydrate analysis with CE and Chip CE are reviewed. Separation strategies and detection of CE for various carbohydrates, including monosaccharides, polysaccharides and glycoconjugates are described. The application and potential ability of Chip CE in carbohydrate research are reviewed as well.

Acute appendicitis during pregnancy: a clinical assessment

BACKGROUND

Acute appendicitis is the most common non-obstetric reason for laparotomy during pregnancy. The purpose of this study was to analyze the characteristics of the clinical presentations and postoperative outcomes of these patients and their fetuses.

METHODS

Patients who underwent appendectomies during pregnancy from July 1991 to June 1997 were retrospectively identified. Their ages, clinical presentations, the severity of the inflammatory change in the appendices, and the postoperative complications of these patients and fetuses were recorded and analyzed. Long-term outcomes were confirmed by telephone contact, when possible.

RESULTS

Forty-five pregnant women who underwent appendectomies for suspected acute appendicitis were retrospectively reviewed. The histopathological inflammatory change in the appendix was proven in 35 patients (78%). Sixty-three percent of the patients were multiparous, and 86% were in the first 2 trimesters. In the clinical settings, pain and tenderness in the right lower abdominal quadrant were the most common symptoms and signs in presentation. Perioperative administration of ritodrine had no obvious advantage in the prevention of fetal loss. Appendectomy was performed beyond 36 hours of onset of symptoms in 28% of the patients, among whom one-half had gangrenous or perforated appendices. Only one fetus was spontaneously lost in 32 patients with diseased appendices (3%), excluding 3 patients choosing artificial abortion. There was no maternal death in our series.

CONCLUSION

The rate of fetal loss due to surgery for acute appendicitis during pregnancy was low. Delay of operation was pertinent to the more-inflammatory changes of the appendix and to the higher maternal complication rate. Early surgical intervention is essential.

Gallbladder torsion: case report and review of the literature

Torsion of the gallbladder is a surgical emergency, occurring mainly in the elderly. Female is predominant to male with ratio 3 to 1. Despite its unknown etiology, the anatomical variations in the attachment of gallbladder which occur on the mobile mesentery to the inferior margin of the liver are usually found. When the gallbladder twists around the cystic duct and artery, torsion takes place with ensuing occlusion of the flow of bile and blood. Preoperative diagnosis is difficult to make; however, patients who receive prompt surgical treatment with cholecystectomy always get excellent outcomes. Mortality rate is low with 3% to 5%. Here, we report on elderly male patient with gallbladder torsion at our hospital and review the existing literature.

[Electrophoretic migration behavior of deoxyribonucleic acid fragments in three polymer solution concentration regions]

The theory of polymer coils shrinking in semi-dilute solution has recently been developed on polymer solution. The polymer solution from coils shrinking concentration Cs to uniform entangled concentt concentration C+ has been defined as semi-dilute solution. We experimentally investigated the electrophoretic migration behavior of 100 bp deoxyribonucleic acid (DNA) Ladder in hydroxypropyl methyl cellulose (HPMC) concentration ranging from 1.25 g/L to 16.06 g/L. The friction force mobility mu f is used to express the friction force that DNA will encounter in capillary electrophoresis. Our results indicate the division of polymer solution into three regions depending on the relationship of mu f and HPMC concentration and Ferguson plot. Resolutions of 200 bp/300 bp and 700 bp/800 bp show semi-dilute polymer solution suits large fragments and small fragments DNA separation respectively. the results confirm that the current polymer theory is valid under actual CE condition.

Combined endoscopic and surgical treatment for the polyposis of Peutz-Jeghers syndrome

Repeated laparotomy with extensive small bowel resectioning and eventual short-bowel syndrome is a major problem in Peutz-Jeghers syndrome (PJS) patients. This problem is caused by gastrointestinal polyposis with intussusception. A combined surgical and endoscopic approach can assess the extent of the polyposis, and small polyps can be removed by snare polypectomy. This can avert multiple enterotomies and decrease bowel resection segments. We applied an intraoperative colonscope via the enterotomy route in an 20-year-old PJS woman, and successfully removed the other 10 polyps distributed in the whole small bowel. As part of an aggressive approach to the management of polyposis in PJS, complete polypectomy can provide a longer symptom-free interval and remove potentially premaligment polyps.

Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma

BACKGROUND

Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management.

METHODS

During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material.

RESULTS

The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable.

CONCLUSION

With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.

Factors determining operative mortality of grade V blunt hepatic trauma

BACKGROUND

Despite recent advances in the management of severe hepatic injuries, the operative mortality rate of grade V hepatic injuries still ranges from 67% to 80%. Grade V hepatic injuries involving the retrohepatic cava or main hepatic veins are almost always lethal, especially those from blunt trauma. The purpose of this study is to understand the risk factors determining operative mortality in grade V blunt hepatic trauma, and to try to improve the surgical management of these injuries.

METHODS

A retrospective study was conducted at a medical center that offers services including primary, secondary, and tertiary care. Forty-four patients with grade V blunt hepatic injuries were treated during a 6-year period from January 1, 1991, to December 31, 1996. The operative mortality was compared by a multivariate analysis.

RESULTS

Forty-four patients with grade V blunt hepatic injuries were identified. Seven patients had only parenchymal injuries, and the others had vascular and associated parenchymal injuries. Venorrhaphy was used in 37 patients; 29 were treated using a nonshunting approach, and 8 with an atriocaval shunt. The overall mortality rate was 68% (30 of 44), and liver-related mortality was 50% (22 of 44). Univariate analysis revealed that the significant variables affecting operative mortality were initial systolic blood pressure, initial base deficit, the Glasgow Coma Scale, injury type, number of resected segments, and total intraoperative blood loss. Based on forward stepping logistic regression analysis, patients with an initial base deficit of -6 mmol/L or less (relative risk = 17.3), and a total intraoperative blood loss of 5,000 mL or more (relative risk = 23.5) would, significantly, encounter a worsening prognosis.

CONCLUSIONS

Initial base deficit and total intraoperative blood loss were the significant factors that determined operative mortality after grade V blunt hepatic trauma. We suggest that prompt resuscitation and expeditious and appropriate surgical management, to control operative blood loss, is the only way to reduce operative mortality in patients with grade V blunt hepatic trauma.

Blunt hepatic injury: minimal intervention is the policy of treatment

BACKGROUND

Many publications recommend nonoperative treatment for stable blunt hepatic injury patients. Unstable hemodynamic status is the only indication for surgery. When operation is indicated, controversies exist regarding which operative procedure will be more beneficial to the patients. The purposes of this study are to compare the results of operative and nonoperative management of patients with blunt hepatic injuries and to identify the optimal surgical approach when surgery is indicated.

METHODS

Different prospective protocols of treating adult blunt hepatic injuries were conducted. From 1992 to 1993 (group I), urgent surgery would be performed in the presence of hemoperitoneum. The policy shifted to aggressive nonoperative approach between 1996 and 1997 (group II). The patients from each period were divided into three subgroups. Group A included the patients who received nonoperative treatment in either period. Group B consisted of the patients who received surgery in the first period and nonoperative management in the second period. Group C included the patients who were operated on in either group. Comparisons were made between matched groups.

RESULTS

Groups IA and IIA patients had minor injuries and could be successfully treated nonoperatively. The results of groups IB and IIB were similar concerning hospital stay, morbidity, and mortality. Transfusion requirements of group IIB patients were significantly higher (2.2 vs. 1.1 units,p = 0.01) than those of group IB. However, 25 (58%) celiotomies of group IB patients were nontherapeutic. When surgery was indicated, group IC patients had significantly higher liver-related mortality (14 of 49 vs. 3 of 55, p = 0.002). Anatomic resection was performed more frequently in that period.

CONCLUSION

Nonoperative treatment significantly decreased the rate of nontherapeutic laparotomy but carried the risks of higher transfusion requirements and delaying operation. When surgery was indicated, the policy of minimal intervention positively affected the patients' outcomes. The goal of surgery should be hemorrhage control rather than resection of the injured liver tissues.

Laparoscopic decompression of abdominal compartment syndrome after blunt hepatic trauma

Abdominal compartment syndrome (ACS) can occur in a variety of surgical conditions, particularly those with major life-threatening hemorrhage, massive volume resuscitation, prolonged operation times, and coagulopathy. In severely traumatized patients, the incidence of ACS is reported to be as high as 14% to 15% after damage control laparotomies. Although favorable results have been achieved with nonsurgical management of adult blunt hepatic trauma, the failure rates still range from 0% to 19%. Exploratory laparotomy is considered the intervention of choice in patients with blunt hepatic trauma who fail nonsurgical treatment. Expedient abdominal decompression currently is the treatment of choice after ACS. Oliguria, tachypnea, and tachycardia developed in two blunt hepatic trauma patients with grade IV and V injuries while they were receiving nonsurgical treatment. The intra-abdominal pressures measured more than 35 and 25 cm H 2O, respectively. Two patients with grade II and III ACS received laparoscopic examination instead of laparotomy. Their ACS was decompressed effectively via laparoscopy without any adverse effects. Therefore, we suggest that laparoscopy can be used as a safe alternative for the decompression of ACS.

[Determination of sialic acids in serum of lung cancer with ultrafiltration-capillary electrophoresis]

A method for the determination of sialic acids in serum with ultrafiltration-capillary electrophoresis is described and the operation was optimized. Sialic acids were directly separated and analyzed with UV detection at 195 nm and without pre-or post-column derivatization. The recovery of N-acetylneuraminic acid (NANA) was 92.6%, the concentration and mass detection limit of NANA were 9.6 mumol/L and 39 fmol respectively. This method was used for the determination of NANA level in the serum of 11 lung cancer patients and 30 normal adults. The results showed that the average concentration of NANA in the serum of patients was much higher than that of normal adults with P < 0.001. The results were also compared with those obtained by the traditional colorimetric method, with good linear relationship of r = 0.983 at n = 10. It is concluded that the method described in this paper is simple and sensitive, and is suitable for basic research and clinical applications to malignant tumors.

[Influence of organic modifier on the retention behaviour in soil leaching column chromatography]

The relationship between capacity factors (k') of 55 nonionic compounds and broad methanol volume percentage (psi) of methanol-water eluent in soil leaching column chromatography (SLCC) was systematically investigated. The compounds consist of 11 chlorobenzenes, 14 alkylbenzenes, 22 polyphenyls and polycyclic aromatic hydrocarbons, and 8 pesticides. Reference soil was dry-packed into a stainless steel chromatographic column (10 mm i.d. x 100 mm) by a homemade pressurizing device, and isocratic methanolwater mixture with psi from 0.0 to 0.80 eluated through the column at a flow-rate of 1 mL.min-1. The column was thermostated at (25.0 +/- 0.1) degree C, and chromatographic peak was monitored by an online ultraviolet detector. The results show that both equations, log k' = log k'w + a psi + b psi 2(1) and log k' = log k'w - S psi (2), well fit the retention values. Equation (2) can be used practically due to few experimental data needed and simpler in formula. Explanation is also given for the existence of the carbon (or chlorine) number rule for two classes of homologous series (i.e. methylbenzenes, n-alkylbenzenes) and weak-polar chlorobenzenes in the SLCC process. The slope and intercept of the rule are also well correlated, and both decreases linearly with increasing eluent psi value.

[Chiral separation of naproxen and flurbiprofen by capillary electrophoresis]

The acidic chiral drugs naproxen and flurbiprofen were successfully separated into two enantiomers when beta-cyclodextrins (beta-CDs) were used as chiral selectors by capillary zone electrophoresis, under the conditions of 0.1 mol/L phosphate buffer with pH 4.92. The comparison of four CDs, namely beta-CD, DM-beta-CD, HP-beta-CD and TM-beta-CD for chiral separation was made. Naproxen can be separated by either beta-CD or its derivatives, while flurbiprofen can only be separated by TM-beta-CD among the CDs. The elution order of enantiomers of naproxen in different CDs was also studied, and the R form always eluted before S form when any of the four CDs was used as chiral selectors. The method of chiral separation for weak acidic compounds was also developed. It was proved that the optimum pH value for their chiral separation was about 5, close to its pKa value.

Postoperative myocardial infarction in a patient with perioperative ST-depression--a case report

Often we ignore electrocardiogram (EKG) evidence of ischemia and no adverse events occur. However, once in a while these ischemic episodes will turn into a full-blown myocardial infarction. Therefore, studying perioperative events which tilt the balance over to postoperative myocardial infarction (PMI) can enlighten our knowledge in postoperative myocardial infarction (MI) prevention. We present a case of ST depression in perioperative EKG evolving into postoperative MI. In this paper we attempt to explore various possibilities which could have altered this patient from her ischemic state into an infracted event.

Prognosis in presumptive hypoxic-ischemic coma in nonneurologic trauma

BACKGROUND

The neurologic outcome of comatose patients has a wide variation from complete reawakening to death. Methods of predicting the outcome of coma caused by either head injury or cardiac arrest have been the subject of much discussion in the literature. However, prediction of neurologic prognosis in comatose trauma patients without head injury has rarely been discussed. We reviewed our experience in treating patients with presumptive hypoxic-ischemic coma after trauma and tried to identify factors relating to their neurologic outcomes.

METHODS

Thirty-six patients with normal brain computed tomographic scans, who remained comatose 10 minutes after stabilization of their hemodynamic status, were studied. Serial motor response, verbal response, pupillary light reflex, presence of spontaneous breathing and seizure, and blood glucose level were recorded to evaluate their roles in predicting neurologic outcomes.

RESULTS

There were five deaths (mortality rate, 14%) and 11 patients (31%) with neurologic deficits. An absence of spontaneous breathing, a blood glucose level greater than 300 mg/dL during resuscitation, and a presence of seizure signified a poor prognosis. Initial neurologic evaluation at 10 minutes after stabilization of hemodynamic status was not accurate in predicting outcome. A motor response worse than withdrawal from painful stimuli at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome, with a 100% accuracy rate.

CONCLUSION

Hypoxic-ischemic coma in patients sustaining major trauma yielded a significantly better survival and neurologic outcome than that induced by cardiac arrest or head injury. Decision-making in the first 24 hours after injury should not be affected by the patient's neurologic status at that time. A motor response worse than withdrawal at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome.

Small bowel perforation: is urgent surgery necessary?

BACKGROUND

Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagnosis is also debatable. The purposes of this study were to evaluate the relationship between treatment delay and outcome of small bowel perforation after blunt abdominal trauma and to determine the best assessment plan for the diagnosis of this injury.

METHODS

One hundred eleven consecutive patients with small bowel perforations caused by blunt abdominal trauma were retrospectively reviewed. The patients were divided into four groups according to the time interval between injury and surgery. Hospital stay, time to resume oral intake, and mortality and morbidity rates were compared between groups. Physical signs, laboratory and computed tomographic findings, and the results of diagnostic peritoneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation.

RESULTS

Delay in surgery for more than 24 hours did not significantly increase the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increased significantly when surgery was delayed for more than 24 hours. Abdominal tenderness was a common finding, but it was not specific for bowel perforation. Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage. By using cell count ratio in diagnostic peritoneal lavage and/or increased lavage amylase activity, presence of particulate matter and/or bacteria in the lavage fluid, all patients with intraperitoneal bowel perforation were diagnosed accurately before operation.

CONCLUSION

Small bowel perforation has low mortality and complication rates if it is treated earlier than 24 hours after injury. The principle of "rushing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of treatment for the small bowel perforation should be lower than the limb-threatening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a specially designed positive criterion is applied.

Anesthesia for ankylosing spondylitis patients undergoing transpedicle vertebrectomy

BACKGROUND

Ankylosing Spondylitis (AS) patients present specific challenges to the anesthesiologists. Airway management, central venous access, positioning, neuraxial monitoring and protection as well as management of massive blood loss may prove to be difficult. We retrospectively reviewed the anesthetic management of consecutive AS patients who underwent transpedicle vertebrectomy (TPV).

METHODS

To secure airway and administer anesthesia, we used awake fiberoptic endotracheal intubation. The central venous access was attempted through the infraclavicular approach. The positioning was made possible with modification of the operation table and padding. The neuraxial monitoring was done with both somatosensory evoked potentials (SSEPs) and the modified transcranial magnetic evoked potential (tcMMEP). The spinal cord protection was attempted with deliberate hypothermia. To prevent massive blood loss we did controlled hypotension, and autotransfusion.

RESULTS

Fiberoptic endotracheal intubation was done smoothly in all cases except two. In one of these two cases, endotracheal intubation was successful only after cricothyroidectomy and retrograde intubation. In the other case antegrade stiff catheter guided intubation was attempted to overcome the acute angulation cause by fixed cervical flexion. Central venous access through infraclavicular approach was agreeable except one case of pneumothorax. Massive rapid blood loss during vertebral osteotomy, occurred in one patient with fall of the mean blood pressure to 20 mmHg and ventricular tachycardia for 10 min, during which all the SSEPs and tcMMEP activities disappeared. The patient recovered without sequelae.

CONCLUSIONS

Although it is extremely challenging, with proper planning, anticipation of difficulties and meticulous work in airway management, central venous catheterization and positioning as well as prevention of neurological injury and massive bleeding, we successfully accomplished fine job of anesthesia for the AS patients presented for correction of severe kyphosis.

Retroperitoneal laparostomy: an effective treatment of extensive intractable retroperitoneal abscess after blunt duodenal trauma

BACKGROUND

Delay in surgical treatment and duodenal wound dehiscence are two major causes of extensive retroperitoneal abscess formation after blunt duodenal injury. This complication is traditionally treated with primary repair of the duodenal wound and drainage of the abscess through anterior laparotomy. Pyloric exclusion is sometimes added as an adjunctive procedure. The anterior approach, however, may result in inadequate drainage, and repeat surgery is sometimes needed. We reviewed our experiences and evaluated the effectiveness of retroperitoneal laparostomy for the treatment of retroperitoneal abscess with continuous soiling.

METHODS

There were 52 blunt duodenal injuries during a 7-year period. Eleven patients developed extensive retroperitoneal abscesses.

RESULTS

All 11 patients were treated with anterior laparotomy initially. Five patients recovered after this procedure. Six patients continued to have retroperitoneal abscesses and were under septic status. Two patients received another anterior drainage, and had recurrent abscesses later. Retroperitoneal laparostomy was performed for these six patients. After retroperitoneal laparostomy, daily wound care, and antibiotic treatment, all six patients recovered. Only two patients developed incisional hernia.

CONCLUSION

Retroperitoneal laparostomy is effective in treating extensive intractable retroperitoneal abscess after blunt duodenal injury. Patients with the complications of duodenal leak and extensive retroperitoneal abscess should be treated with pyloric exclusion and drainage through anterior laparotomy first. If the duodenal wound does not heal after pyloric exclusion and retroperitoneal abscess persists, retroperitoneal laparostomy should be performed without further attempt to repair the wound.

Dynorphin A enhances mitogen-induced proliferative response and interleukin-2 production of rat splenocytes

It has been well known that immune function is modulated by endogenous opioid peptides: beta-endorphin and enkephalins. However, the effect of dynorphin A on the immune function has not been well documented. In this study, we investigated dynorphin A in the regulation of mitogen-induced proliferation and and interleukin-2 (IL-2) production of rat splenocytes. The results showed that dynorphin A 1-13 as well as dynorphin A 1-17 enhanced concanavalin A-stimulated [(3)H] thymidine uptake 46-112% and IL-2 production in a dose-dependent fashion. These effects were reversed by naloxone and norBNI, a selective kappa-receptor antagonist. Dynorphin A reduced cyclic AMP contents in spenocytes in naloxone and norBNI reversible fashion. The data suggest that dynorphin A enhanced mitogen-stumulated lymphocyte proliferation and IL-2 production via kappa-opioid receptor and cAMP pathway.

Surgical treatment and outcome after delayed diagnosis of blunt duodenal injury

OBJECTIVE

To review our experience of 18 patients with duodenal injuries after blunt trauma, the diagnosis of which had been delayed for more than 24 hours.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Taiwan, R.O.C.

SUBJECTS

18 patients who presented with duodenal injuries between January 1986 and December 1995.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

The reasons for the delay were: injuries not found during the first operation (n = 6), patients had not sought medical help (n = 6), and injuries treated conservatively at local hospitals (n = 5). There was one delay in our department because the patient lost consciousness. 12 patients were treated by pyloric exclusion with no deaths and four complications (one duodenal fistula and 3 retroperitoneal abscesses). The other 6 had various operations including pancreaticoduodenectomy, jejunostomy, and gastrostomy, with six complications and one death, giving an overall mortality of 6% and morbidity of 50%. Three patients developed delayed extensive retroperitoneal abscesses and all three were treated successfully by laparostomy. 16 of the 18 patients required enteral feeding through a jejunostomy.

CONCLUSIONS

Though the complication rate was high, the use of pyloric exclusion and a feeding jejunostomy kept the mortality low. Enteral nutrition should be started early. Laparostomy is a good way to manage retroperitoneal abscesses. To avoid delay, patients at risk of duodenal injuries should be evaluated early by experienced trauma surgeons and any central retroperitoneal haematoma should be explored during the initial laparotomy.

Modified transcranial electromagnetic motor evoked potential obtained with train-of-four monitor for scoliosis surgery

BACKGROUND

To monitor the spinal cord with somatosensory evoked potential (SSEP) is an accepted adjunct in the surgical correction of spinal deformities, but it does not directly assess the motor function. The use of motor evoked potential (MEP) has thus been introduced in an effort to meet this important need.

METHODS

This preliminary report concerned 30 cases of scoliosis who underwent surgical correction under the surveillance of modified transcranial electromagnetic motor evoked potential (tcMMEP). Train-of four (TOF) stimulator output was connected to an electromagnetic stimulator. The rate of repetition and interval of stimulation were controlled by TOF stimulator. Electromyographic (EMG) signals were obtained from the abductor hallucis muscle of both feet and interpreted as MEP activity. Anesthesia was made possible by propofol as a basic agent and isoflurane as supplement. Analgesia was obtained with sufentanil and fentanyl and amnesia enhanced by midazolam. Atracurium mixed with vecuronium in a ratio of 4:1 by weight in possible lowest dose was given to provide adequate muscle relaxation yet without the molestation of rapid reversal upon the request of wake-up test by the surgeon. Deliberate hypothermia and controlled hypotension were also applied since they did not interfere with the tcMMEP signals.

RESULTS

Although no attempt was made to control the level of muscle relaxation at T1 more than 30%, tcMMEP signals could be obtainable during induction, at the time of surgical correction and at the end of the operation. TcMMEP onset latency was 27.32 +/- 0.45 msec on the left side and 27.27 +/- 0.54 msec on the right side. The amplitude was 3.52 +/- 1.97 mV on the left side and 4.05 +/- 1.22 mV on the right side.

CONCLUSIONS

The modified tcMMEP is so stable and convincing that research for similar modification is now undergoing with the other brand of TOF monitor by our team.

Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury

BACKGROUND

Nonoperative management of blunt hepatic injury is currently a widely accepted treatment modality. Computed tomography (CT) is an important imaging study both for diagnosis and follow-up of these patients. There is, however, no reliable predictor of failure of nonoperative treatment other than the ultimate development of hemodynamic instability. Previous reports mostly were based on the data obtained from low-speed dynamic incremental scanners. The purpose of this study is to evaluate the value of a high-speed helical scanner in predicting the outcome of patients managed nonoperatively.

METHODS

During a 30-month period, 194 patients with blunt hepatic injury were treated, 150 of them were hemodynamically stable after initial resuscitation and underwent abdominal CT examination. All CT scans were performed with the High Speed Advantage Scanner. The CT scans and medical records were reviewed.

RESULTS

Nonoperative management was successfully applied to all patients with grade I and II, 93% of grade III, 87% of grade IV, and 67% of grade V liver injuries. Twelve patients required liver-related celiotomy. Pooling of contrast material was detected on the CT scans of 8 patients. Six (75%) of these patients developed hemodynamic instability and required liver-related celiotomy later. Pooling of contrast material can be detected in 50% of the patients receiving liver-related celiotomy.

CONCLUSION

The presence of pooling of contrast material within the hepatic parenchyma indicates free extravasation of blood as a result of active bleeding. In patients with blunt hepatic injury, if this sign is detected, nonoperative treatment should be terminated and angiography or celiotomy undertaken promptly. With the increasing use of high-speed spiral CT scanner and improvement in scanning technique, pooling of contrast material may become a sensitive sign for active bleeding and may be used as a guide for the selection of treatment modality.

Cell count ratio: new criterion of diagnostic peritoneal lavage for detection of hollow organ perforation

OBJECTIVES

Diagnostic peritoneal lavage (DPL) had been widely used in evaluating patients with suspected intraperitoneal injuries due to its high sensitivity. If the positive criteria are strictly followed, however, the incidence of nontherapeutic laparotomies will be unacceptably high. This realization has become more important recently with the popularization of nonoperative treatment for blunt solid organ injuries. For these patients, the early diagnosis of an associated hollow organ perforation is mandatory.

METHODS

Three hundred and twenty patients undergoing DPL over an 18-month period were retrospectively reviewed to evaluate the usefulness of "cell count ratio" in diagnosing hollow organ perforation. The cell count ratio was defined as the ratio between white blood cell count and red blood cell count in the lavage fluid divided by the ratio of the same parameters in the peripheral blood.

RESULTS

Two hundred twelve patients were diagnosed as having a positive DPL according to the classic criteria. Forty-four patients (21%) had a cell count ratio of greater than or equal to 1. The diagnosis at laparotomy was small bowel perforation in 31 patients, colon perforation in eight patients, diaphragmatic hernia in one patient, pancreatic transection in two patients, and liver laceration in two patients. None of the patients with a cell count ratio of less than I sustained hollow organ perforation. The average interval from injury to DPL was 5 hours, with the shortest being 1.5 hours.

CONCLUSION

A cell count ratio of greater than or equal to 1 predicted hollow organ perforation with a specificity of 97% and a sensitivity of 100%. The selective use of the cell count ratio has improved the probability of early diagnosis of bowel perforation without increasing the cost of care. Nonoperative management can be applied more confidently to those patients sustaining a blunt solid viscus injury of the abdomen if the cell count ratio is low. We conclude that the cell count ratio of DPL effluent is a very sensitive and specific indicator of hollow organ perforation. In the treatment of blunt abdominal injuries, if the cell count ratio is positive, nonoperative treatment should be abandoned and a laparotomy undertaken.

The maternal and fetal effects of the addition of sufentanil to 0.5% spinal bupivacaine for cesarean delivery

BACKGROUND

Opioid added to local anesthetic for spinal anesthesia was first introduced into clinical practice in 1979 with intrathecal morphine as a forerunner. As morphine is water soluble and has prolonged action, late respiratory depression following spinal anesthesia is not infrequent and is the most serious complication that causes our concern. Sufentanil which is more hydrophobic than morphine also with shorter duration of action and quicker onset when injected into the subarchnoid space could be more effective and a safer drug as an adjuvant to local anesthetic in spinal anesthesia.

METHODS

Forty-one parturients who had given consent to spinal anesthesia for Cesarean delivery, were anesthetized with 12.5 mg of 0.5% bupivacaine alone or in combination with 10 micrograms sufentanil in a randomized double blind manner. They were assigned either to C group (Control group) in which nothing is added to the local anesthetic and S group (Study group) in which sufentanil was added to the local anesthetic.

RESULTS

Perioperatively, hypotension occurred more in S group (17 against 11) but chest discomfort was less (3 against 7). Within 3 h after anesthesia 3 out of 19 parturients in S group requested analgesics but almost all parturients in C group did so.

CONCLUSIONS

The addition of intrathecal sufentanil to 0.5% bupivacaine for spinal anesthesia improved perioperative discomfort and significantly reduced the demand of post-operative analgesia but on the other hands, it tended to increase perioperative hypotension and cause mild pruritus.

Controlled reopen suture technique for pyloric exclusion

BACKGROUND

Pyloric exclusion had been widely used in the management of complicated duodenal injuries. The original concept of pyloric exclusion was that this technique would temporarily exclude the pylorus during the healing phase, but would subsequently allow resumption of normal gastrointestinal tract transit through the duodenum. The best method for pyloric exclusion has not been well established. Controversies exist regarding the need for a gastrojejunostomy and vagotomy as part of the procedure. None of these combinations can fulfill the original concept of pyloric exclusion and avoid late complications.

METHODS

We developed a controlled reopen suture technique for pyloric exclusion. This technique was applied to nine patients (group II) with a complicated blunt duodenal injury over the past 5 years. The clinical courses and outcomes of these patients were compared with an eight-patient comparison group treated by pyloric exclusion and gastrojejunostomy (group I) over the same time period.

RESULTS

All 17 patients survived. There were one early (duodenal wound leakage) and two late complications (marginal ulcers) in the group I patients. No delayed complications were found in the group II patients. The average hospital stay was about the same in both groups.

CONCLUSION

The controlled reopen suture technique is a quick and simple procedure. In the treatment of a complicated blunt duodenal injury, if repair of the duodenal wound will not compromise the lumen, gastrojejunostomy and vagotomy can be omitted when using this technique. This technique offers the best combination of limited surgery in the severely injured patient, effective exclusion of the duodenum until after the healing has occurred, and allowance for the resumption of normal gastrointestinal tract transit through the duodenum. The late complications of gastrojejunostomy can also be avoided.

Traumatic thoracic aortic injury caused by a sharp edge of left fractured rib on body position change: case report

Aortic injury caused by penetration of a fractured rib is very rare. We present a patient with aortic injury demonstrated using serial imaging studies. A 66-year-old woman fell from a ladder and sustained multiple left-side rib fractures. There was a small left hemothorax and widened mediastinum on the initial chest roentgenogram in the emergency department. Chest computed tomography (CT) revealed a posterior segmental fracture of the sixth rib on the left side with a sharp edge penetrating into the posterior aspect of the thoracic aorta. It was initially missed. More than 1000 cc of fresh blood suddenly gushed out of the chest tube 7 hours after the traumatic event. After resuscitation, an aortogram was performed which showed blood extravasation from the thoracic aorta at the rib fracture site. Unfortunately, surgical intervention was delayed and she died. Early detection and early surgical intervention are necessary in patients with a widened mediastinum and positive results on imaging studies.

Periaortic hematoma on helical CT of the chest: a criterion for predicting blunt traumatic aortic rupture

OBJECTIVE

The purpose of this study was to evaluate the accuracy of helical CT of the chest for predicting blunt traumatic aortic ruptures when periaortic hematoma is used as a positive criterion.

CONCLUSION

We recommend the use of periaortic hematoma as a criterion for predicting traumatic aortic ruptures on CT because this criterion is sensitive and can reduce the false-positive rate of CT interpretations.

Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma

BACKGROUND

Most blunt hepatic trauma patients can be managed nonoperatively. The current failure rate in adult blunt hepatic trauma is reportedly 0 to 19%. We wished to evaluate the applicability of laparoscopy and fibrin glue as a minimally invasive alternative to laparotomy in these unsuccessfully nonoperative cases.

METHODS

All adult patients with blunt hepatic trauma managed nonoperatively at Linkou, Chang Gung Memorial Hospital Medical Center, Taipei, Taiwan, over a 2-year period from July 1, 1994, to June 30, 1996, were eligible for the study. A laparoscopic examination was performed on those who failed conservative care before undertaking an exploratory laparotomy. Fibrin glue was sprayed over the wound surface if ongoing hemorrhage was evident from any liver laceration. The clinical data, operative and laparoscopic findings, operative methods, and outcomes of these patients were studied.

RESULTS

Of the 61 patients, 55 patients were successfully treated without operation. Of the six failures (10%) all were liver related. After the introduction of laparoscopy, the nontherapeutic laparotomy rate would have decreased from 100% (6 of 6) to 50% (3 of 6), and with the adjunctive use of fibrin glue, the laparotomy rate went down to 0% (0 of 6). There were no deaths among the six patients receiving laparoscopy and fibrin glues; and only one developed a liver abscess, for a morbidity rate of 17% (1 of 6).

CONCLUSIONS

The selective use of laparoscopy and fibrin glue can effectively reduce the nontherapeutic laparotomy rate among blunt hepatic trauma patients who fail nonoperative management.

Method for reduction of inhibition in a Mycobacterium tuberculosis-specific ligase chain reaction DNA amplification assay

The present study describes the identification of inhibitors of a Mycobacterium tuberculosis-specific gap ligase chain reaction (LCR) DNA amplification assay as well as a method for their removal. A major contributor to inhibition was deduced to be a calcium phosphate precipitate, CaHPO4. The precipitate forms during N-acetyl-L-cysteine-sodium hydroxide (NALC-NaOH) decontamination, digestion, and concentration of respiratory specimens. The solubility product of CaHPO4 precipitate at pH 7.8, the pH at which gap LCR is optimized, indicates that the precipitate releases an amount of phosphate ions sufficient to inhibit amplification. A method for removal of the precipitate was identified. The precipitate is dissociated by exposing it to a mildly acidic (pH 4.1) buffer during the first of two centrifugation steps; the inhibitory phosphate ions are removed by the centrifugation steps. When 100 NALC-NaOH respiratory sediments were tested by gap LCR, none of the sediments were inhibitory when the acidic buffer was used while 24 samples were inhibitory when TE buffer, pH 7.8, was used. In another study, when the acidic buffer wash was applied to 1,440 NALC-NaOH respiratory sediments, only 10 sediments were found to be inhibitory. None of the inhibited sediments were culture positive for M. tuberculosis. This work demonstrates that when inhibition mechanisms are identified, relatively simple protocols can be used to obtain low inhibition rates and to allow the use of larger volume equivalents in amplification reactions.

Malakoplakia of the mesocolon with gastric serosa invasion: a case report and review of the literature

Malakoplakia is a rare, granulomatous, inflammatory disease. The clinical presentation and radiological appearance of the malakoplakia mimics a malignant tumor. In this article we describe a case of the malakoplakia of the mesocolon with invasion into the serosa of the stomach. The frozen section report considered the lesion to be a malignancy. The definitive diagnosis depended on microscopic detection of Michaelis-Gutmann bodies by electronic microscope. We review the current literature about the malakoplakia of gastrointestinal tract, and focus on the pathogenesis, clinical manifestation, diagnosis and treatment.

A conformational switch in nuclear hormone receptors is involved in coupling hormone binding to corepressor release

Nuclear hormone receptors are ligand-regulated transcription factors that modulate gene expression in response to small, hydrophobic hormones, such as retinoic acid and thyroid hormone. The thyroid hormone and retinoic acid receptors typically repress transcription in the absence of hormone and activate it in the presence of hormone. Transcriptional repression is mediated, in part, through the ability of these receptors to physically associate with ancillary polypeptides called corepressors. We wished to understand the mechanism by which corepressors are recruited to unliganded nuclear hormone receptors and are released on the binding of hormone. We report here that an alpha-helical domain located at the thyroid hormone receptor C terminus appears to undergo a hormone-induced conformational change required for release of corepressor and that amino acid substitutions that abrogate this conformational change can impair or prevent corepressor release. In contrast, retinoid X receptors appear neither to undergo an equivalent conformational alteration in their C termini nor to release corepressor in response to cognate hormone, consistent with the distinct transcriptional regulatory properties displayed by this class of receptors.

Plasticity of tetramer formation by retinoid X receptors. An alternative paradigm for DNA recognition

Retinoid X receptors (RXRs) are transcription factors that traditionally have been thought to bind DNA as protein dimers. Recently, however, it has been recognized that RXRs can also bind to DNA as protein tetramers. Receptor tetramers form cooperatively on response elements containing suitably reiterated half-sites, and play an important role in determining the specificity of DNA recognition by different nuclear receptors. We report here that RXR tetramers exhibit significant functional plasticity, and form on response elements possessing diverse half-site orientations and spacings. This ability of RXRs to form tetramers and related oligomers appears to contribute to the synergistic transcriptional activation observed when multiple, spatially separated response elements are introduced into a single promoter. Oligomerization may therefore be a common paradigm for DNA recognition and combinatorial regulation by several different classes of transcription factors.