[Development of Markov models for economics evaluation of strategies on hepatitis B vaccination and population-based antiviral treatment in China]

Objective: To construct the Markov models to reflect the reality of prevention and treatment interventions against hepatitis B virus (HBV) infection, simulate the natural history of HBV infection in different age groups and provide evidence for the economics evaluations of hepatitis B vaccination and population-based antiviral treatment in China. Methods: According to the theory and techniques of Markov chain, the Markov models of Chinese HBV epidemic were developed based on the national data and related literature both at home and abroad, including the settings of Markov model states, allowable transitions and initial and transition probabilities. The model construction, operation and verification were conducted by using software TreeAge Pro 2015. Results: Several types of Markov models were constructed to describe the disease progression of HBV infection in neonatal period, perinatal period or adulthood, the progression of chronic hepatitis B after antiviral therapy, hepatitis B prevention and control in adults, chronic hepatitis B antiviral treatment and the natural progression of chronic hepatitis B in general population. The model for the newborn was fundamental which included ten states, i.e. susceptiblity to HBV, HBsAg clearance, immune tolerance, immune clearance, low replication, HBeAg negative CHB, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma (HCC) and death. The susceptible state to HBV was excluded in the perinatal period model, and the immune tolerance state was excluded in the adulthood model. The model for general population only included two states, survive and death. Among the 5 types of models, there were 9 initial states assigned with initial probabilities, and 27 states for transition probabilities. The results of model verifications showed that the probability curves were basically consistent with the situation of HBV epidemic in China. Conclusion: The Markov models developed can be used in economics evaluation of hepatitis B vaccination and treatment for the elimination of HBV infection in China though the structures and parameters in the model have uncertainty with dynamic natures.

[Cost-effectiveness of community-based treatment of chronic hepatitis B in China]

Objective: Since eliminating hepatitis B in China would need considerable public health resources, the economics problem of the strategy of community-based antiviral treatment for chronic hepatitis B (CHB) has become an important issue. The cost-effectiveness and affordability of the strategy were evaluated in this study. Methods: According to the advocacy on eliminating hepatitis B by WHO and the comprehensive protocol of community based prevention of major infectious diseases and the guideline for CHB prevention and treatment in China, the decision analytic Markov model was constructed with the parameters from national surveys or Meta-analysis. A cohort population aged 20-59 years was used as study subjects. The strategy of CHB antiviral treatment was compared with the strategies of hepatitis B vaccination and non-intervention, respectively. The costs and disability-adjusted life years (QALYs) of the strategies were calculated from the societal and payer perspectives. The incremental cost-effectiveness ratio (ICER) and the cost-effectiveness ratio (CER) were calculated for the comparison of the strategies. One-way and probability sensitivity analysis were performed for uncertainty of the results. And the cost-effectiveness and affordability curves were introduced to estimate the budget impact on the strategies. Results: In the Chinese aged 20-59 years, the ICER of CHB antiviral treatment was 37 598.6 yuan (RMB) per QALYs and the ICERs were smaller in the low age groups, indicating that the antiviral treatment strategy is cost-effective and low age groups should be the priority population. The ICER of hepatitis B vaccination was -64 000.0 yuan (RMB) per QALYs, indicating that hepatitis B vaccination is cost saving. The CER of CHB antiviral treatment ranged from 731.8 to 1 813.3 yuan (RMB) per QALYs compared with hepatitis B vaccination, and the CER of CHB antiviral treatment was higher than that of hepatitis B vaccination in all age groups, indicating that hepatitis B vaccination would be more cost-effective than CHB antiviral treatment. The price of antiviral drug, entercavir, can influence the cost effectiveness of CHB antiviral treatment. If the price of entercavir declined half, CHB antiviral treatment would be cost-saving. The probability sensitivity analysis showed that people's willing to pay for CHB antiviral treatment should not be ignored, although the results of economics evaluation of CHB antiviral treatment were reliable. The results of affordability analysis indicated that the antiviral treatment strategy could not be implemented with the budget lower than 30 million yuan (RMB), the probability of implementing the strategy was 42.6% if the budget reaches 127 million yuan (RMB), and only when the budget reaches 269 million yuan (RMB), the goal of CHB antiviral treatment strategy can be fully realized. Conclusions: Although the strategy of CHB antiviral treatment as prevention in Chinese aged 20-59 years is cost-effective, it is not an appropriate public health measure due to the high cost. The cost effectiveness would be higher by conducting hepatitis B vaccination and then antiviral treatment in susceptible population.

[Cost-effectiveness and affordability of strategy for preventing mother-to-child transmission of hepatitis B in China]

Objective: To evaluate the cost effectiveness of nationwide prevention of mother to child transmission (PMTCT) strategy for hepatitis B, and estimate the willing to pay and budget impacts on the PMTCT. Methods: The decision analytic Markov model for the PMTCT was constructed and a birth cohort of Chinese infants born in 2013 was used to calculate the cost-effectiveness of the PMTCT among them compared with those receiving no intervention. The parameters in the model were obtained from literatures of national surveys or Meta-analysis. The costs, cases of HBV-related diseases and quality-adjusted life-years (QALYs) were obtained from the societal and payer perspectives, respectively. The incremental cost-effectiveness ratio (ICER) was used as measures of strategy optimization. One-way and probability sensitivity analysis were performed to explore the uncertainty of the primary results. In addition, cost-effectiveness acceptability curve and cost-effectiveness affordability curves were drawn to illustrate the cost effectiveness threshold and financial budget of the PMTCT strategy. Results: The lifetime cost for PMTCT strategy was 4 063.5 yuan (RMB) per carrier, which was 37 829.7 yuan (RMB) lower compared with those receiving no intervention. Due to the strategy, a total of 24.516 1 QALYs per person would be gained, which was higher than that in those receiving no intervention. From societal perspective, the ICER was -59 136.6 yuan (RMB) per additional QALYs gained, indicating that the PMTCT is cost effective. The results were reliable indicated by one-way, multi-way and probability sensitivity analyses. By the CEAC, the willing to pay was much lower than the cost-effectiveness threshold. From the affordability curve of the PMTCT strategy, the annual budget ranged from 590.4 million yuan (RMB) to 688.8 million yuan (RMB), which was lower than the financial ability. Based on the results of cost-effectiveness affordability curves, the higher annual budget was determined, the higher probability of affordability for the PMTCT would be obtained under the same willing to pay state. Only when the annual budget reaches 688.8 million yuan (RMB), the goal of PMTCT would be fully realized. Conclusions: The PMTCT strategy in China was cost effective, and the cost is not beyond the financial budget needed and the willing to pay. The strategy, which is consistent with the global hepatitis B elimination efforts, should be conducted widely in China.

Manganese-Enhanced T1 Mapping in the Myocardium of Normal and Infarcted Hearts

Background

Manganese-enhanced MRI (MEMRI) has the potential to identify viable myocardium and quantify calcium influx and handling. Two distinct manganese contrast media have been developed for clinical application, mangafodipir and EVP1001-1, employing different strategies to mitigate against adverse effects resulting from calcium-channel agonism. Mangafodipir delivers manganese ions as a chelate, and EVP1001-1 coadministers calcium gluconate. Using myocardial T1 mapping, we aimed to explore chelated and nonchelated manganese contrast agents, their mechanism of myocardial uptake, and their application to infarcted hearts.

Methods

T1 mapping was performed in healthy adult male Sprague-Dawley rats using a 7T MRI scanner before and after nonchelated (EVP1001-1 or MnCl2 (22 μmol/kg)) or chelated (mangafodipir (22-44 μmol/kg)) manganese-based contrast media in the presence of calcium channel blockade (diltiazem (100-200 μmol/kg/min)) or sodium chloride (0.9%). A second cohort of rats underwent surgery to induce anterior myocardial infarction by permanent coronary artery ligation or sham surgery. Infarcted rats were imaged with standard gadolinium delayed enhancement MRI (DEMRI) with inversion recovery techniques (DEMRI inversion recovery) as well as DEMRI T1 mapping. A subsequent MEMRI scan was performed 48 h later using either nonchelated or chelated manganese and T1 mapping. Finally, animals were culled at 12 weeks, and infarct size was quantified histologically with Masson's trichrome (MTC).

Results

Both manganese agents induced concentration-dependent shortening of myocardial T1 values. This was greatest with nonchelated manganese, and could be inhibited by 30-43% with calcium-channel blockade. Manganese imaging successfully delineated the area of myocardial infarction. Indeed, irrespective of the manganese agent, there was good agreement between infarct size on MEMRI T1 mapping and histology (bias 1.4%, 95% CI -14.8 to 17.1 P>0.05). In contrast, DEMRI inversion recovery overestimated infarct size (bias 11.4%, 95% CI -9.1 to 31.8 P=0.002), as did DEMRI T1 mapping (bias 8.2%, 95% CI -10.7 to 27.2 P=0.008). Increased manganese uptake was also observed in the remote myocardium, with remote myocardial ∆T1 inversely correlating with left ventricular ejection fraction after myocardial infarction (r=-0.61, P=0.022).

Conclusions

MEMRI causes concentration and calcium channel-dependent myocardial T1 shortening. MEMRI with T1 mapping provides an accurate assessment of infarct size and can also identify changes in calcium handling in the remote myocardium. This technique has potential applications for the assessment of myocardial viability, remodelling, and regeneration.

[Cost-effectiveness and cost-benefit analysis on strategy for preventing mother-to-child transmission of hepatitis B virus]

OBJECTIVE

Through cost-benefit analysis (CBA), cost-effectiveness analysis (CEA) and quantitative optimization analysis to understand the economic benefit and outcomes of strategy regarding preventing mother-to-child transmission (PMTCT) on hepatitis B virus.

METHODS

Based on the principle of Hepatitis B immunization decision analytic-Markov model, strategies on PMTCT and universal vaccination were compared. Related parameters of Shenzhen were introduced to the model, a birth cohort was set up as the study population in 2013. The net present value (NPV), benefit-cost ratio (BCR), incremental cost-effectiveness ratio (ICER) were calculated and the differences between CBA and CEA were compared.

RESULTS

A decision tree was built as the decision analysis model for hepatitis B immunization. Three kinds of Markov models were used to simulate the outcomes after the implementation of vaccination program. The PMTCT strategy of Shenzhen showed a net-gain as 38 097.51 Yuan/per person in 2013, with BCR as 14.37. The universal vaccination strategy showed a net-gain as 37 083.03 Yuan/per person, with BCR as 12.07. Data showed that the PMTCT strategy was better than the universal vaccination one and would end with gaining more economic benefit. When comparing with the universal vaccination program, the PMTCT strategy would save 85 100.00 Yuan more on QALY gains for every person. The PMTCT strategy seemed more cost-effective compared with the one under universal vaccination program. In the CBA and CEA hepatitis B immunization programs, the immunization coverage rate and costs of hepatitis B related diseases were the most important influencing factors. Outcomes of joint-changes of all the parameters in CEA showed that PMTCT strategy was a more cost-effective.

CONCLUSIONS

The PMTCT strategy gained more economic benefit and effects on health. However, the cost of PMTCT strategy was more than the universal vaccination program, thus it is important to pay attention to the process of PMTCT strategy and the universal vaccination program. CBA seemed suitable for strategy optimization while CEA was better for strategy evaluation. Hopefully, programs as combination of the above said two methods would facilitate the process of economic evaluation.

Development of Ohmic nanocontacts via surface modification for nanowire-based electronic and optoelectronic devices: ZnO nanowires as an example

We demonstrated a nanocontacting scheme using a focus ion beam (FIB) system without further heat treatment for ZnO nanowires. This scheme includes Ga ion surface modification and direct-write Pt deposition induced by Ga ion, leading to an Ohmic nanocontact with a specific contact resistance as low as 2.5 × 10(-6)Ω cm(2). Temperature-dependent measurements show that the transport of the FIB-Pt contact on the ZnO nanowire with local surface modification is governed by field emission tunneling. Taking advantage of area-selected and room-temperature processes, Ga ion surface modification and direct-write Pt deposition using a FIB system demonstrates a feasible Ohmic scheme.

Contrast echocardiography: finding its place in stem cell therapy

To date, the underlying mechanism responsible for the restoration of the injured myocardium following transplantation of stem cells has not been clearly identified. Molecular imaging is essential to the continued progress of stem cell therapy by elucidating the biology of transplanted stem cells in vivo. Currently, several imaging modalities are in development in the rapidly evolving field of molecular imaging. Contrast echocardiography has the potential to define its role in shaping the future development of stem cell therapy. We describe the current state of contrast echocardiography and its future direction herein.

Molecular cloning and temporal-spatial expression of I element in gregarious and solitary locusts

It has been reported that many genes and small RNAs are associated with density-dependent polyphenism in locusts. However, the regulatory mechanism underlying gene transcription is still unknown. Here, by analysis of transcriptome database of the migratory locust, we identified abundant transcripts of transposable elements, which are mediators of genetic variation and gene transcriptional regulation, mainly including CR1, I, L2 and RTE-BovB. We cloned one I element, which represents the most abundant transcripts in all transposable elements, and investigated its developmental and tissue-specific expression in gregarious and solitary locusts. Although there are no significant differences of I element expression in whole bodies between gregarious and solitary locusts at various developmental stages, this I element exhibits high expression level and differential expression pattern between gregarious and solitary locusts in central and peripheral nervous tissues, such as brain, antenna and labial palps. These results suggest that I element is potentially involved in the response of neural systems to social environmental changes in locusts.

Primary mediastinal large B-cell lymphoma mimicking liposarcoma

A 78-year-old man consulted for acute exacerbation of chronic obstructive pulmonary disease (COPD) and an incidental finding of an anterior mediastinal tumor on chest radiograph was noted on admission. Chest computed tomography (CT) revealed a fat-containing mediastinal mass with solid component. Mediastinal liposarcoma was the initial diagnosis based on image characteristics but histopathologic examination of the excised tumor revealed lymphoma infiltration of the mediastinal adipose tissue. To our knowledge, this is the first case report of lymphomatous growth in mediastinal lipomatosis.

Immune responses to foot-and-mouth disease virus in pig farms after the 1997 outbreak in Taiwan

This paper reports on a retrospective study of the antibody responses to structural and non-structural proteins of FMD virus O Taiwan 97 in six pig herds in Taiwan in the year after the 1997 Taiwanese FMD outbreak. All herds were vaccinated against FMD after the outbreak as part of the countrywide control program. Three of the herds had confirmed FMD infections (herds N, O and P) and three herds remained non-infected (herds K, L and M). The serum neutralizing antibody titers and the non-structural protein ELISA (NSP) antibody responses in sows and 1-month-old pigs in the infected herds were higher than in the non-infected herds, but over time a number of positive NSP reactors were detected. From the serological studies and the herd monitoring and investigations it was considered that the FMD NSP positive reactors may not have constituted a true reservoir of FMD virus infection especially in herds where susceptible pigs were no longer present post-exposure or post-vaccination. Pigs vaccinated with an unpurified FMD type O vaccines being used at that time also showed false positive responses for NSP antibodies.

Immune responses of pigs to commercialized emulsion FMD vaccines and live virus challenge

The immune response to structural and non-structural proteins (NSPs) was studied on sequential serum samples in swine from O/Taiwan/97 FMDV challenge studies, outbreaks and after vaccination. The results showed that pigs vaccinated with a commercial vaccine prior to or after infection maintained high neutralizing antibody titers with gradual decline from peak titers over the duration of this study. However, neutralizing antibody titers in non-vaccinated pigs only reached moderate levels 2-4 weeks post infection and remained low thereafter. For the 3B and 3ABC NSP antibody ELISA responses, there were gradually decreasing levels of NSP antibody over time. In multiple vaccinations, all pigs showed significant increases in neutralizing antibodies after booster vaccination. For the 3B NSP antibody ELISA after vaccination, the mean S/P ratios for pigs vaccinated with all three FMD vaccines were all below the 0.23 cut-off value set by the manufacture, but some sera from individual vaccinated pigs gave results above this cut-off after primary or secondary vaccination. However, with the 3ABC NSP antibody ELISA, all sera from vaccinated pigs had negative results for NSP antibody for all time points.

The effect of smoking on tuberculosis: different patterns and poorer outcomes

SETTING

It has been well documented that smoking increases the risk of tuberculosis (TB). However, few studies have evaluated the impact of smoking on TB. We conducted this retrospective study to evaluate the influences of smoking on the manifestation and outcome of TB.

DESIGN

All culture-confirmed TB patients from July 2002 to December 2003 were identified and their medical records reviewed.

RESULTS

A total of 523 TB patients, including 207 (39.6%) who had ever smoked, were studied. The ever-smokers were significantly older, more likely to have underlying diseases and a duration of symptoms > 60 days, and less likely to have extra-pulmonary involvement and have completed treatment (64.7% vs. 78.5%). Radiographically, more ever-smokers with pulmonary tuberculosis (PTB) presented with miliary lesions, multiple nodules or masses, upper lung predominance and cavitation than never-smokers. Although smoking was associated with poor prognosis on univariate survival analysis, multivariate analysis revealed that independent poor prognostic factors included age, underlying disease, symptom duration < or = 60 days, extra-pulmonary involvement, serum albumin level < 3.5 g/dl and delayed treatment.

CONCLUSIONS

Our results demonstrate that smoking is significantly associated with radiographic manifestations of PTB, but not with death among PTB patients.

Comparison of sensitivity and specificity in three commercial foot-and-mouth disease virus non-structural protein ELISA kits with swine sera in Taiwan

Three commercialized ELISA kits for the detection of antibodies to the non-structural proteins (NSPs) of FMD virus were compared, using sera from uninfected, vaccinated, challenged and naturally infected pigs. The kinetics of the antibody response to NSPs was compared on sequential serum samples in swine from challenge studies and outbreaks. The results showed that ELISA A (UBI) and ELISA B (CEDI) had better sensitivity than that of the 3ABC recombinant protein-based ELISA C (Chekit). The peak for detection of antibodies to NSPs in ELISA C was significantly delayed in sera from natural infection and challenged swine as compared to the ELISA A and B. The sensitivity of the three ELISAs gradually declined during the 6-month post-infection as antibodies to NSP decline. ELISA kits A and B detected NSP antibody in 50% of challenged pigs by the 9-10th-day and 7-8th-day post-challenge, respectively. ELISA B and C had better specificity than ELISA A on sequential serum samples obtained from swine immunized with a type O FMD vaccine commercially available in Taiwan. Antibody to NSPs before vaccination was not detected in swine not exposed to FMD virus, however, antibody to NSPs was found in sera of some pigs after vaccination. All assays had significantly lower specificity when testing sera from repeatedly vaccinated sows and finishers in 1997 that were tested after the 1997 FMD outbreak. However, when testing sera from repeatedly vaccinated sows or finishers in 2003-2004, the specificity for ELISAs A, B and C were significantly better than those in 1997. This effect was less marked for ELISA A. The ELISA B was the best test in terms of the highest sensitivity and specificity and the lowest reactivity with residual NSP in vaccinates.

Predictors for toxicity profiles of weekly docetaxel in non-small cell lung cancers

17153

Background: Weekly docetaxel has been proved recently to be safer and equivalently effective compared with traditional tri-weekly docetaxel as second-line treatment for NSCLC. However, the risk factors for toxicity of weekly docetaxel in this group of patients are still unknown. Methods: We reviewed advanced NSCLC patients receiving 2nd line or 3rd line weekly docetaxel from 1999 to 2003 from cancer registry and pharmacy records in our hospital. Clinical characteristics, previous chemotherapy regimens, laboratory data, docetaxel administration schedules/dosage, and treatment efficacy were retrospectively collected. Logistic regression was performed to identify risk factors for adverse outcomes. Cox’s proportional hazards model was used to analyze cumulative-dose related adverse events. Results: A total 155 patients were analyzed for treatment effect and toxicity. The overall response rate of weekly docetaxel (36–40 mg/m2) was 5.16% and median survival of all patients was 8.1 months. The incidence of treatment withdrawal due to adverse events was 43.23 % and significantly related to previous anthracycline use (odds ratio 4.582; P = 0.0144) and chronic hepatitis B or C virus (HBV/HCV) infection(odds ratio 3.928; P=0.0058). The incidence of grade 3 or 4 neutropenia was 23.2% and was significantly associated with old age (odds ratio 7.232; P < 0.001), lower baseline white count(odds ratio 5.57; P < 0.05), and chronic HBV/HCV infection(odds ratio 3.25; P < 0.05). The incidence of fluid retention was 41.29% and the median cumulative dose of docetaxel at onset was 327 mg/m2. Abnormal liver function significantly increased the risk for fluid retention(odds ratio 2.368; P < 0.05); steroid premedication (odds ratio 0.184; P < 0.01), higher albumin(odds ratio 0.237; P < 0.01), and previous surgical resection(odds ratio 0.341; P < 0.05) decreased the risk. Conclusions: Salvage weekly docetaxel for NSCLC patients in Taiwan remains toxic. Part of the reasons for the significant toxicities is that chronic HBV/HCV infection, which occurs in around 20% of general populations in Taiwan, represents a significant risk factor for neutropenia, fluid retention, and treatment withdrawal. The role of prophylactic anti-viral agents in these patients should be explored in the future.

[Table: see text]

Recognising tuberculosis in the lower lung field: an age- and sex-matched controlled study

OBJECTIVE

Tuberculosis (TB) can sometimes present with consolidation in the lower lung field. This study was conducted to compare the manifestations of lower-lung-field TB (LLFTB) and other pulmonary TB.

DESIGN

All new culture-proven TB patients with lower-lung-field consolidation from July 2001 through December 2002 were included. Age- and sex-matched TB patients with upper lung involvement were selected as controls.

RESULTS

A total of 79 patients with LLFTB were included. Their mean age was 58.8 years; 46 were male. The clinical, radiographic and laboratory findings were similar in the LLFTB and the control groups, except that the LLFTB patients had less cavitation (P = 0.005). Patients with LLFTB were diagnosed (P = 0.051) and treated (P = 0.001) later than the control patients. The calibres of the trachea and both main bronchi were significantly smaller in the LLFTB group (P < 0.001). More patients with LLFTB developed segmental or lobar atelectasis during follow-up (P = 0.028).

CONCLUSIONS

The manifestations of LLFTB are non-specific. The lower-lung involvement, the lower incidence of cavitation and the higher probability of segmental or lobar atelectasis implied that LLFTB was primary TB. A small bronchial calibre probably contributed to its development.

Pandrug-resistant Pseudomonas aeruginosa among hospitalised patients: clinical features, risk-factors and outcomes

Between 1 January 2003 and 31 December 2003, 37 patients had positive cultures of pandrug-resistant Pseudomonas aeruginosa (PDRPA) resistant to all commercially available anti-pseudomonal antimicrobial agents in Taiwan, including anti-pseudomonal penicillins, ceftazidime, fourth-generation cephalosporins, aztreonam, carbapenems, aminoglycosides and ciprofloxacin. Nineteen (51.4%) patients had PDRPA infections, including pneumonia (17 patients), catheter-related bacteraemia (one patient) and anal abscess (one patient). Eighteen patients were classified as having PDRPA colonisation, based on absence of clinical signs or symptoms of infection. In total, 92 isolates were recovered from various specimens, with the majority (85.9%) recovered from respiratory tract secretions (sputa, bronchial washings and pleural effusions), followed by urine (4.3%) and catheter tips (3.3%). Twenty-eight (75.7%) patients yielded cultures of non-PDR P. aeruginosa isolates before isolation of PDRPA, with a mean period between the first isolation of non-PDR P. aeruginosa and the isolation of PDRPA of 128.3 days. Most patients had received beta-lactam antibiotics, fluoroquinolones or carbapenems for prolonged periods. Univariate analysis showed that PDRPA infection, male gender and the presence of fever at the time of PDRPA isolation were associated with increased mortality.

Genetic polymorphism of epoxide hydrolase and glutathione S-transferase in COPD

Genetic susceptibility to the development of chronic obstructive pulmonary disease (COPD) might depend on variation in the activities of enzymes that detoxify cigarette smoke products, such as microsomal epoxide hydrolase (mEPHX) and glutathione S-transferase (GST). It was investigated whether polymorphisms in these genes had any association with susceptibility to COPD and COPD severity. The genotypes of 184 patients with COPD and 212 control subjects were determined by polymerase chain reaction followed by restriction fragment length polymorphism analysis of the mEPHX, GSTM1, GSTT1 and GSTP1 genes. All subjects were smokers or exsmokers. The proportion of GSTM1-null genotypes was significantly higher in patients with COPD than in control subjects (61.4 versus 42.5%). No differences were observed in the frequency of polymorphic genotypes for mEPHX, GSTT1 and GSTP1. During combined analysis of genetic polymorphisms for mEPHX, GSTM1 and GSTP1, it was found that there are strong indicators for susceptibility to COPD (genotype combination with at least one mutant mEPHX exon-3 allele (histidine 113), GSTM1 null and homozygous for the GSTPI isoleucine 105 allele). The frequencies of homozygous mutant alleles of mEPHX exon 3 and the GSTMI-null genotype were significantly higher in patients with severe COPD (forced expiratory volume in one second of <35% of the predicted value). It is proposed that the combination of genetic variants including at least one mutant microsomal epoxide hydrolase exon-3 allele and glutathione S-transferase M1-null and homozygous isoleucine 105 glutathione S-transferase P1 genotypes are significant indicators of susceptibility to chronic obstructive pulmonary disease in the Taiwanese population. In addition, the homozygous variant of microsomal epoxide hydrolase exon 3 and the glutathione S-transferase M1-null genotype are independent risk factors for developing severe chronic obstructive pulmonary disease.

Patient mortality of active pulmonary tuberculosis requiring mechanical ventilation

Mortality remains high among patients with pulmonary tuberculosis requiring mechanical ventilation (TBMV). This study was carried out to establish the mortality rates of TBMV and to identify factors that contribute to in-hospital mortality. From January 1996-April 2001, there were 825 patients with active pulmonary tuberculosis at the National Taiwan University Hospital, Taipei, Taiwan. Of these, 41 suffered acute respiratory failure and required mechanical ventilation in the intensive care unit (ICU). Of these 41 patients, 38 were followed up for 180 days. In-hospital deaths were documented in the medical records and all possible parameters contributing to mortality were collected. Of the 41 patients, 27 died in the hospital and 14 were discharged alive (in-hospital mortality rate 65.9%), with (mean +/- SD) 40.7 +/- 35.4 admission days before death. Of the 27 that died, 25 died during ICU admission and two died after being transferred to the ward. The mortality rate for the 180-day monitoring period was 79%. Factors contributing to in-hospital mortality included consolidations on chest radiographs and multiple organ failure. The mortality rate in the patients with pulmonary tuberculosis requiring mechanical ventilation is very high, with two factors affecting in-hospital mortality. These factors were multiple organ failure and consolidation on chest radiographs.

Tuberculous myositis: a rare but existing clinical entity

OBJECTIVES

To investigate the clinical characteristics of patients with tuberculous myositis.

METHODS

From January 1996 to March 2001, patients with positive cultures of Mycobacterium tuberculosis or histology-proven caseous granulomatous inflammation from muscular specimens were identified and their medical records were reviewed.

RESULTS

Thirty-five patients were identified. Infection-related myositis was initially suspected in 20 patients (57.1%). The routes of infection were contiguous spread in 22 patients (62.8%), haematogenous spread in 10 (28.6%) and traumatic inoculation in three (8.6%). Five patients (14.3%), including the three who had received corticosteroids, died of uncontrolled sepsis. The computed tomography or the magnetic resonance imaging of the involved muscles showed findings suggestive of tuberculous myositis in 15 patients (42.9%).

CONCLUSIONS

Tuberculosis should be considered as one of the possible aetiologies of myositis, especially among patients with suggestive radiographic findings or in endemic areas of tuberculosis. Patients who develop tuberculous myositis after using corticosteroids have poor prognoses.

Optimization of foot-and-mouth disease vaccination protocols by surveillance of neutralization antibodies

An appropriate immunization program for pigs in a foot-and-mouth disease (FMD) endemic area was proposed based on data analysis obtained from serological surveillance in Taiwan, after an intensive vaccination program. To provide an adequate passive immunity for piglets, gilts that have completed two basic vaccinations must be boosted once before breeding. To achieve an efficient response to the FMD vaccine for piglets born to well vaccinated sows, vaccination need to be delayed until 10-12 weeks of ages for the first immunization, followed by a boost 4 weeks later.

Variations in the NRAMP1 gene and susceptibility of tuberculosis in Taiwanese

SETTING

National Taiwan University Hospital, Taipei, Taiwan.

OBJECTIVE

To study the variations in the NRAMP1 gene using five genotypes (274C/T, 577-18G/A, A318V, D543N and 3' untranslated region [UTR]), and the susceptibility of tuberculosis and HIV infection in Taiwanese.

DESIGN

The study sample included 49 patients with tuberculosis, 48 healthy control subjects and 60 HIV-infected patients. The polymerase chain reaction (PCR) products amplified from their genomic DNA were subjected to restriction enzyme digestion and were analysed using agarose gel electrophoresis.

RESULTS

A318V was not polymorphic in the studied population. Only D543N and 3'UTR were more heterozygous. In 274 C/T and 577-18G/A, the allele frequencies showed the predominant type to be the homozygous patterns C/C (94%) and G/G (94%), respectively. There were no statistically significant differences between the tuberculosis patients and the healthy control subjects. Despite the high susceptibility to Mycobacterium tuberculosis in HIV-infected patients, genotypic frequencies in the HIV-positive patients were not significantly different between tuberculous (n = 29) and non-tuberculous patients (n = 31). In comparison with previous studies, there were significant differences between different ethnic groups in allele frequencies for 274C/T, D543N and 3'UTR.

CONCLUSION

The allele and genotype of NRAMPI polymorphism among Taiwanese differed from those of Caucasians, Africans and Hispanics. No allelic associations were identified between the NRAMP1 alleles and tuberculosis susceptibility.

Cyclooxygenase-2 inducing Mcl-1-dependent survival mechanism in human lung adenocarcinoma CL1.0 cells. Involvement of phosphatidylinositol 3-kinase/Akt pathway

Cyclooxygenase 2 (COX-2) has been reported to be commonly expressed in advanced stages of human lung adenocarcinoma. In this study, the COX-2 constitutive expression vector was transfected into a human lung adenocarcinoma cell line CL1.0 and several clones were obtained which stably expressed COX-2. These COX-2-overexpressed clones demonstrated remarkable resistance to apoptosis induced by Ultraviolet B (UVB) irradiation, vinblastine B (VBL) cell lymphoma-2 (Bcl-2), or other anti-cancer drugs. To understand how COX-2 prevents apoptosis, the investigators examined the expression level of Bcl-2 family members. Mcl-1, but not other Bcl-2 members, was significantly up-regulated by COX-2 transfection or prostaglandin E(2) (PGE(2)) treatment. Treatment of COX-2-overexpressed cells (cox-2/cl.4) with two specific COX-2 inhibitors, NS-398 and celecoxib, caused an effective reduction of the increased level of Mcl-1. These data suggest that the expression level of Mcl-1 is tightly regulated by COX-2. Moreover, transfection of cox-2/cl.4 cells with antisense Mcl-1 enhanced apoptosis induced by UVB irradiation, revealing that Mcl-1 plays a crucial role in cell survival activity mediated by COX-2. Furthermore, COX-2 transfection or PGE(2) treatment evidently activated the phosphatidylinositol 3-kinase (PI3K)/Akt pathway. Inhibition of the PI3K pathway by LY294002 or wortmannin effectively attenuated the increased level of Mcl-1 induced by COX-2 or PGE(2). Blocking the PI3K activity with a dominant-negative vector, DN-p85, also greatly diminished the level of Mcl-1 and enhanced UVB-elicited cell death in cells transfected by COX-2. In a similar way, LY294002 inhibited cell survival and Mcl-1 level in PGE(2)-treated CL1.0 cells. These findings suggest that COX-2 promotes cell survival by up-regulating the level of Mcl-1 by activating the PI3K/Akt-dependent pathway.

Stimulation of smooth muscle cell proliferation by ox-LDL- and acetyl LDL-induced macrophage-derived foam cells

To test the hypothesis that LDL lacking of initial oxidation may also anticipate an essential role in the progression for atherosclerotic lesions, we studied the in vitro effect of foam cells induced by low density lipoprotein (LDL), oxidized (ox)-LDL or acetyl-LDL on smooth muscle cell (SMC) proliferation. Intraperitoneal macrophages collected from ICR mice were incubated with buffered saline LDL, ox-LDL or acetyl-LDL to induce foam cell formation. Porcine aortas with atherosclerotic lesions were collected from 5 pigs fed high cholesterol diets. The results indicate that foam cells induced by ox-LDL and acetyl-LDL, but not by LDL, promoted SMC proliferation. SMC proliferation was also increased by ruptured, ox-LDL- and acetyl-LDL- induced foam cells. Immunohistochemically, epitopes of the LDL, ox-LDL, and malondialdelyde (MDA)-LDL were present in atherosclerotic lesions, but the acetyl epitope was not. We suggest that foam cells, whether induced by the oxidized or acetyl or acetyl (unoxidized) form, play an essential role in the pathogenesis of atherosclerosis by stimulating SMC proliferation.

Effects of birth season, breed, sex, and sire family on cardiac morphology determined in pigs (Sus scrofa domestica) by use of echocardiography

PURPOSE

Echocardiography played an important role in the screening and diagnosis of hypertrophic cardiomyopathy. In the study reported here, we attempted to evaluate the effects of birth season, breed, sex, and sire family on cardiac morphology determined in pigs by use of echocardiography.

METHODS

A total of 411 pigs (mean body weight and age of 105.7 +/- 10.6 kg and 214.4 +/- 25.5 days, respectively) with different genetic backgrounds (Landrace, Yorkshire, and their two-way crossbred) were studied. Cardiac morphologic measurements included thickness of left ventricle and interventricular septum at end-systolic and end-diastolic phases. Meanwhile, the statistical model included the following effects: birth season, breed, sex, interaction between breed and sex, sire family, body weight, and age.

RESULTS

Mean cardiac morphologic measurements were as follows: thickness of the interventricular septum at end-systolic and end-diastolic phases was 1.74 and 1.14 cm, respectively; and thickness of the left ventricular free wall at end-systolic and end-diastolic phases was 1.81 and 0.98 cm, respectively. Medium positive correlations existed among the cardiac morphologic measurements r = 0.31 to 0.53; P < 0.001). Pigs born in spring had significantly (P < 0.05) lower cardiac thickness at the end systolic phase than did pigs born in other seasons, and Landrace pigs had higher cardiac morphologic measurements than did Yorkshire and two-way crossbred pigs. Additionally, thickness of interventricular septum at the end-diastolic phase in male pigs was significantly higher than that in female pigs (P < 0.05). Cardiac morphologic measurements for the sire family were significantly (P < 0.05) different, and contributed 77.2 to 87.9% of the total variation, suggesting that genetic variation in cardiac morphology might exist in pigs.

CONCLUSIONS

Cardiac morphology of pigs might be influenced by genetic background. The effects of birth season, breed, sire family, and sex should be adjusted when using pigs as an animal model for comparative cardiovascular studies.

Development of high-density DNA microarray membrane for profiling smoke- and hydrogen peroxide-induced genes in a human bronchial epithelial cell line

Development of the high-density DNA microarray technique permits the analysis of thousands of genes simultaneously for their differential expression patterns in various biological processes. Through clustering analysis and pattern recognition, the significance of differentially expressed genes can be recognized and correlated with biological events that may take place inside the cell and tissue. With this notion in mind, high-density DNA microarray nylon membrane with colorimetry detection was used to profile the expression of smoke- and hydrogen peroxide-inducible genes in a human bronchial epithelial cell line, HBE1. On the basis of the time course of expression, at least three phases of change in gene expression could be recognized. The first phase is an immediate event in response to oxidant injury. This phase includes induction of the bcl-2 and mdm-2 genes, which are involved in the regulation of apoptosis, and the mitogen-activated protein (MAP) kinase phosphatase 1 (MKP-1) gene, that functions as a regulator of various mitogen-activated protein kinase activities. The second phase, usually 5 h later, includes the induction of various stress proteins and ubiquitin, which are important in providing the chaperone mechanism and the turnover of damaged macromolecules. The third phase, which is 5-10 h later, includes the induction of genes that are apparently involved in reducing oxidative stress by metabolizing reactive oxygen species. In this phase, enzymes associated with tissue and cell remodeling are also elevated. These results demonstrate a complex gene expression array by bronchial epithelial cells in response to the insult of oxidants that are relevant to environmental pollutants.

High incidence of erythromycin resistance among clinical isolates of Streptococcus agalactiae in Taiwan

The in vitro susceptibilities of 266 isolates of Streptococcus agalactiae determined by the agar dilution method showed that 6% of isolates were nonsusceptible to penicillin and 46% was resistant to erythromycin. Of the erythromycin-resistant isolates, 86.3% had the macrolide-lincosamide-streptogramin (MLS) resistance phenotype (constitutive MLS, 85.5%; inducible MLS, 0.8%) and 13.7% had the M phenotype.

Risk factors for ICU mortality in critically ill patients

BACKGROUND AND PURPOSE

Advances in critical care medicine have increased the chances of survival for patients with severe illness or trauma. However, such patients consume a large proportion of medical resources. This study sought risk factors for mortality that have potential to be modified among patients treated in medical or surgical intensive care units (ICUs).

METHODS

This 6-month prospective observational study was conducted in the medical and surgical ICUs of an 1,800-bed university hospital. All adult patients with an expected ICU stay of 48 hours or more were followed up regularly until discharge from the ICUs, or for 10 weeks during their stay in ICUs.

RESULTS

Of 342 patients enrolled, 77 (22.5%) died during a median follow-up period of 5 days (range, 2-70 days). Among a range of variables at the time of ICU entry or developing during stay in ICUs, 17 were associated with higher mortality rate. Multivariate analysis using a logistic regression model demonstrated that the presence of systemic inflammatory response syndrome (SIRS) at the time of ICU entry (adjusted relative risk, ARR, 2.85; 95% confidence interval, CI, 1.16-7.05), Acute Physiological and Chronic Health Evaluation (APACHE) II score on ICU Day 4 (ARR 1.12 with increment of one score; 95% CI 1.01-1.24), Therapeutic Intervention Scoring System (TISS) score on Day 4 (ARR 1.13 with increment of one score; 95% CI 1.05-1.23), parenteral nutrition (ARR 4.97, 95% CI 1.73-14.26), and nosocomial Candida infection (ARR 3.39, 95% CI 1.12-10.23) were independently associated with ICU mortality.

CONCLUSIONS

In addition to SIRS and the APACHE II and TISS scores, this study found that nosocomial Candida infection and parenteral nutrition were independently associated with mortality after control for admission conditions, severity of illness scores, and interventions.

Application of mucin quantitative competitive reverse transcription polymerase chain reaction in assisting the diagnosis of malignant pleural effusion

Aberrant expression of mucin genes occurs frequently in advanced cancer. Using quantitative competitive reverse transcriptase/polymerase chain reaction (QC RT-PCR), the expression of three mucin genes--MUC1 (widely expressed in epithelial cells), MUC2 (mainly expressed in intestinal epithelial cells), and MUC5AC (mainly from airway and gastric epithelial cells)--was evaluated in 112 patients with pleural effusions (including 54 cytologically positive malignant pleural effusions, 35 benign exudative pleural fluids, and 23 cytologically negative pleural effusions from cancer patients). The expression ratios of MUC1 and MUC5AC, but not MUC2 gene, were significantly higher in malignant than benign pleural fluids (p < 0.000). The cutoff value, sensitivity, and specificity of MUC1 expression ratio were: 0.126, 64.6%, and 95.7%; and were 0.028, 72.3%, and 95.7%, respectively, for MUC5AC. In combined evaluation with both MUC1 and MUC5AC, the sensitivity was 86.1% and specificity was 91.5%. The positive and negative predictive values were 93.3%, and 82.7%, respectively. We considered mucin QC RT-PCR to be a useful tool in assisting the diagnosis of malignant pleural effusion.

Hospital-based management of acute asthmatic exacerbation: an assessment of physicians' behavior in Taiwan

This retrospective study was conducted to assess Taiwanese emergency physicians for their preference in management and adherence to guidelines in treating patients with acute exacerbation of asthma. One hundred twenty patients from hospitals of three different levels were evaluated by reviewing their medical records. Our study revealed that physicians from medical centers and regional hospitals assessed patients more often with arterial blood gas or pulse oximetry; prescribed more doses of beta2-agonist nebulizers; administered more doses of beta2-agonist nebulizers before administering parenteral aminophylline; and prescribed ipratropium nebulizers more often as adjunctive therapy. On the other hand, physicians from district hospitals more frequently prescribed parenteral aminophylline as the first-line medication and more often prescribed only a single dose of beta2-agonist nebulizer. Most emergency physicians in Taiwan did not adhere to guidelines. Specifically, these included omission of peak expiratory flow as the means to assess the severity of asthma exacerbation and response to treatment; suboptimal use of inhaled bronchodilators, such as beta2-agonists and ipratropium; and inappropriate use of parenteral aminophylline as the first-line medication.

Severe community-acquired pneumonia due to Acinetobacter baumannii

STUDY OBJECTIVES

To investigate the clinical, epidemiologic, and microbiological characteristics of community-acquired pneumonia (CAP) due to Acinetobacter baumannii.

METHODS

Retrospective chart and radiographic reviews of all patients who were admitted to National Taiwan University Hospital from January 1993 to August 1999, fulfilled the criteria for CAP, and had an isolate of A. baumannii from blood or pleural fluid at hospital admission.

RESULTS

Thirteen patients (9 men and 4 women; age range, 37 to 85 years) met the criteria. Conditions associated with the infection included male gender, old age, alcoholism, malignancy, cerebrovascular disease, diabetes mellitus, renal disease, and liver cirrhosis. Eleven patients (85%) acquired the infection during the warmer months of April to October. Twelve patients (92%) had a fulminant course presenting with septic shock and respiratory failure, and 11 patients (85%) needed ventilator support and were treated in an ICU. Six patients (46%) had leukopenia. Lobar consolidations were found in 12 patients (92%), and pleural effusions were present in 4 patients (31%). All patients had positive blood culture results, two patients (15%) had positive pleural effusion culture findings, and nine patients (69%) positive sputum culture results. All the isolates were susceptible to imipenem, and most were susceptible to aminoglycosides, ceftazidime, ciprofloxacin, and extended-spectrum penicillins. Eight patients (62%) died. Four of the five survivors were initially treated with combination of a third-generation cephalosporin and an aminoglycoside.

CONCLUSION

A. baumannii should be considered as a possible etiologic agent in community-acquired lobar pneumonia when (1) patients with a fulminant course present during the warmer and more humid months of the year, and (2) patients are younger alcoholics. A good sputum smear, defined as a Gram stain smear of an adequate sputum specimen that comes from the lower respiratory tract and contains > 25 leukocytes per high-power (100x) field on microscopic examination, can help early diagnosis and treatment. A combination of a third-generation cephalosporin and an aminoglycoside may be appropriate empirical therapy.

Collapsin response mediator protein-1 and the invasion and metastasis of cancer cells

BACKGROUND

Numerous genetic changes are associated with metastasis and invasion of cancer cells. To identify differentially expressed invasion-associated genes, we screened a panel of lung cancer cell lines (CL(1-0), CL(1-1), CL(1-5), and CL(1-5)-F(4) in order of increasing invasive activity) for such genes and selected one gene, collapsin response mediator protein-1 (CRMP-1), to characterize.

METHODS

We used a microarray containing 9600 gene sequences to assess gene expression in the cell panel and selected the differentially expressed CRMP-1 gene for further study. We confirmed the differential expression of CRMP-1 with northern and western blot analyses. After transfecting and overexpressing CRMP-1 in highly invasive CL(1-5) cells, the cells were assessed morphologically and with an in vitro invasion assay. We used enhanced green fluorescent protein-tagged CRMP-1 and fluorescence microscopy to localize CRMP-1 intracellularly. CRMP-1 expression in 80 lung cancer specimens was determined by real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR). All statistical tests were two-sided.

RESULTS

Expression of CRMP-1 was inversely associated with invasive activity in the cell panel, an observation confirmed by northern and western blot analyses. CRMP-1-transfected CL(1-5) cells became rounded and had fewer filopodia and statistically significantly lower in vitro invasive activity than untransfected cells (all P< .001). During interphase, CRMP-1 protein was present uniformly throughout the cytoplasm and sometimes in the nucleus; during mitosis, CRMP-1 was associated with mitotic spindles, centrosomes, and the midbody (in late telophase). Real-time RT-PCR of lung cancer specimens showed that reduced expression of CRMP-1 was statistically significantly associated with advanced disease (stage III or IV; P = .010), lymph node metastasis (N1, N2, and N3; P =.043), early postoperative relapse (P = .030), and shorter survival (P = .016).

CONCLUSIONS

CRMP-1 appears to be involved in cancer invasion and metastasis and may be an invasion-suppressor gene.

Induction of cytochromes P450 1A1 and 1B1 by emodin in human lung adenocarcinoma cell line CL5

Emodin (3-methyl-1,6,8-trihydroxyanthraquinone) is an active compound of many laxative herbal drugs. The present study aimed to determine the effects of emodin on cytochrome P450 (P450)-dependent monooxygenases of human lung adenocarcinoma CL5 cells. Treatment of CL5 cells with 100 microM emodin for 24 h induced benzo[a]pyrene hydroxylation, 7-ethoxyresorufin O-deethylation, and 7-ethoxycoumarin O-deethylation activities of S9 fractions. Immunoblot analysis of CL5 S9 proteins revealed that emodin induced proteins immunorelated to P450s 1A1 and 1B1. Northern blot analysis of total cellular RNA showed that emodin induced P450s 1A1 and 1B1 mRNA levels in CL5 cells. These inductive effects on P450 monooxygenase activity, protein, and mRNA were concentration- and time-dependent. Addition of emodin to CL5 cell microM S9 inhibited its 7-ethoxycoumarin O-deethylation activity. Treatment of CL5 cells with 10 microM 3-methylcholanthrene for 24 h induced monooxygenase activity and P450s 1A1 and 1B1 proteins and mRNA levels. Treatment of the lung cells with 100 microM emodin or purpurin (1,2,4-trihydroxyanthraquinone) for 24 h produced greater induction of P450s 1A1 and 1B1 mRNA than did anthraflavic acid (2,6-dihydroxyanthraquinone) or anthraquinone. The emodin treatment induced P450s 1A1 and 1B1 mRNA in human lung carcinoma NCI-H322 and breast cancer MCF-7 cells. Emodin induced P450 1A1, but not 1B1, mRNA in human hepatoma HepG2 cells. The present study demonstrates that emodin is an inducer of P450s 1A1 and 1B1 protein and mRNA in human lung adenocarcinoma CL5 cells. Modulation of P450 by emodin may be an important factor affecting metabolism and toxicity of the hydroxyanthraquinone in humans.

Real-time interactive coronary MRA

An interactive real-time imaging system capable of rapid coronary artery imaging is described. High-resolution spiral and circular echo planar trajectories were used to achieve 0.8 x 1.6 mm2 resolution in 135 ms (CEPI) or 1.13 x 1.13 mm2 resolution in 189 ms (spirals), over a 20-cm FOV. Using a sliding window reconstruction, display rates of up to 37 images/sec were achieved. Initial results indicate this technique can perform as a high-quality 2D coronary localizer and with SNR improvement may enable rapid screening of the coronary tree.

Nosocomial Exophiala jeanselmei pseudoinfection after sonography-guided aspiration of thoracic lesions

BACKGROUND AND PURPOSE

During the period from August 1994 to October 1998, a total of 19 isolates of Exophiala jeanselmei were recovered from 17 patients with various underlying thoracic diseases treated at National Taiwan University Hospital. The purpose of this study was to describe the clinical characteristics of these patients and to determine the microbiologic relatedness of the E. jeanselmei.

METHODS

Of the 19 isolates, 11 from nine patients were preserved and were identified based on their biotypes as determined by the API ID32C System, their cellular fatty acid profiles by gas-liquid chromatography, their antibiotypes to five antifungal agents by the E-test, and their random amplified polymorphic DNA (RAPD) patterns by arbitrarily primed PCR. Extensive environmental surveillance cultures and cultures from the skin of eight patients and hands of one physician were also performed.

RESULTS

One of the 17 patients had E. jeanselmei isolated from cutaneous phaeohyphomycosis (3 isolates), and the other 16 patients had isolations from pleural effusion specimens (15 isolates) or lung mass (1 isolate) following sonography-guided aspiration. The latter 16 patients had no clinical or pathologic evidence of fungal infection. Isolates (clone 1) from aspirated specimens had identical biotypes, antibiotypes, and RAPD patterns, which were different from those of the three isolates (clone 2) from the patient with a cutaneous lesion. All specimens from environmental sources, patients' skin, and the hands of the physician were negative for E. jeanselmei.

CONCLUSION

This series of patients demonstrates the difficulty in identifying the sources of a nosocomial pseudoinfection due to this slow-growing microorganism when isolated from pleural effusion specimens.

Synthetic peptide-based vaccine and diagnostic system for effective control of FMD

We have designed synthetic peptides corresponding to two different regions of the genome of foot-and-mouth disease virus (FMDV) that are effective as (a) a vaccine or (b) a diagnostic reagent which differentiates convalescent from vaccinated animals, respectively. The peptide vaccine is based on a sequence from the prominent G-H loop of VP1, one of the four capsid proteins. The sequence was optimized by the inclusion of a cyclic constraint and adjoining sequences, and broader immunogenicity was obtained by the incorporation of consensus residues at hypervariable positions. The peptide also included a promiscuous T-helper epitope for effective immunogenicity in outbred populations of large animals.The diagnostic reagent, a peptide based on non-structural (NS) protein 3B, is used in immuno-assays for the detection of antibodies. Antibodies to this NS protein are present in the sera of infected animals but not in the sera of vaccinated animals. The VP1 peptide can be used in complementary immuno-assays for confirmation of NS test results and to monitor for vaccination. This system for differential diagnosis is important to establish the disease-free status of a country.

Serial analysis of fat-containing macrophages in bronchoalveolar lavage fluid in a patient with fat embolism syndrome

Recent studies suggest that an increase in fat-containing macrophages in bronchoalveolar lavage (BAL) fluid may be helpful in the diagnosis of fat embolism syndrome (FES). Nevertheless, none of these studies have explored the sequential findings of BAL fluid. We report the case of a 19-year-old man admitted to our intensive care unit because of dyspnea with radiographic evidence of bilateral alveolar infiltrate after traumatic fracture. Analysis of BAL fluid on the third hospital day revealed 8.3% fat-containing macrophages and a lipid-laden macrophages (LLM) index of 23. Pathologic examination of lung biopsy showed numerous fat globules within arterioles. For comparison, the BAL fluid from four other patients with acute respiratory distress syndrome (ARDS) but without FES was also analyzed. The underlying diseases leading to ARDS included Wegener's granulomatosis in one case, pneumonia in two cases, and alveolar proteinosis in one case. The percentages of fat-containing macrophages in these specimens were 1.3%, 52%, 2.3%, and 74%, respectively. The LLM indexes were 1, 133, 3, and 243, respectively. As the patient's condition improved, the percentage of fat-containing macrophages in the BAL fluid decreased to 4.7% on the eighth hospital day and the LLM index also decreased to 6. These findings suggest that the presence of fat-containing macrophages in BAL fluid is not specific for the diagnosis of FES, but serial changes in the percentage of these cells and the LLM index may be helpful in the follow-up of disease severity.

Enhanced transepithelial antigen transport in intestine of allergic mice is mediated by IgE/CD23 and regulated by interleukin-4

BACKGROUND & AIMS

We previously described a system for enhanced transepithelial transport of antigen in which both the amount of specific antigen and its rate of transport were dramatically increased in intestine of sensitized rats compared with controls. This study investigated the essential components mediating antigen uptake in mice genetically deficient for interleukin (IL)-4 or CD23.

METHODS

Mice were actively or passively sensitized to horseradish peroxidase (HRP). Jejunal segments from control or sensitized mice were mounted in Ussing chambers and challenged with HRP from the luminal side. Tissues were processed for electron microscopy, and photomicrographs were analyzed for antigen uptake (location and area of HRP-containing endosomes). Immunohistochemistry and reverse-transcription polymerase chain reaction were used to detect epithelial CD23 expression.

RESULTS

Actively sensitized IL-4(+/+), but not IL-4(-/-) mice, displayed increased transepithelial antigen transport and CD23 expression on enterocytes. Passively sensitized IL-4(+/+) and IL-4(-/-) mice displayed elevated antigen transport after transfer of immune serum but not if the serum was depleted of immunoglobulin (Ig) E or IL-4. IL-4 added to cultured IEC-4 cells up-regulated expression of CD23 messenger RNA. The augmented antigen uptake was inhibited by anti-CD23 and was absent in sensitized CD23(-/-) mice.

CONCLUSIONS

Our studies indicate that IL-4 regulates IgE/CD23-mediated enhanced transepithelial antigen transport in sensitized mouse intestine.

Rapid evaluation of left ventricular volume and mass without breath-holding using real-time interactive cardiac magnetic resonance imaging system

OBJECTIVES

The purpose of this study was to validate cardiac measurements derived from real-time cardiac magnetic resonance imaging (MRI) as compared with well-validated conventional cine MRI.

BACKGROUND

Although cardiac MRI provides accurate assessment of left ventricular (LV) volume and mass, most techniques have been relatively slow and required electrocardiogram (ECG) gating over many heart beats. A newly developed real-time MRI system allows continuous real-time dynamic acquisition and display without cardiac gating or breath-holding.

METHODS

Fourteen healthy volunteers and nine patients with heart failure underwent real-time and cine MRI in the standard short-axis orientation with a 1.5T MRI scanner. Nonbreath-holding cine MRI was performed with ECG gating and respiratory compensation. Left ventricular end-diastolic volume (LVEDV), left ventricular endsystolic volume (LVESV), ejection fraction (EF) and LV mass calculated from the images obtained by real-time MRI were compared to those obtained by cine MRI.

RESULTS

The total study time including localization for real-time MRI was significantly shorter than cine MRI (8.6 +/- 2.3 vs. 24.7 +/- 3.5 min, p < 0.001). Both imaging techniques yielded good quality images allowing cardiac measurements. The measurements of LVEDV, LVESV, EF and LV mass obtained with real-time MRI showed close correlation with those obtained with cine MRI (LVEDV: r = 0.985, p < 0.001; LVESV: r = 0.994, p < 0.001; EF: r = 0.975, p < 0.001; LV mass: r = 0.977, p < 0.001).

CONCLUSIONS

Real-time MRI provides accurate measurements of LV volume and mass in a time-efficient manner with respect to image acquisition.

Acute respiratory distress syndrome in a woman with heroin and methamphetamine misuse

Methamphetamine, heroin, and cannabis are three of the most commonly misused drugs in Asia. In Taiwan, cases of misuse of methamphetamine have been increasing. In this paper, we report the case of a 23-year-old woman who had a 10-year history of smoking methamphetamine and intermittent use of heroin for 3 to 4 years. She developed pulmonary toxic effects associated with misuse of heroin and methamphetamine. She was brought to the emergency room because of consciousness disturbance and acute respiratory failure. Her symptoms of rapid progression of refractory hypoxemia, ill-defined densities over both lung fields, and normal pulmonary artery wedge pressure were consistent with acute respiratory distress syndrome. Rapid resolution of infiltrations and improvement of oxygenation were observed after mechanical ventilation with positive end-expiratory pressure support and oxygen therapy. She was discharged on the fifteenth hospital day without any sequela except for mild exertional dyspnea.

Pulmonary fungal infection: emphasis on microbiological spectra, patient outcome, and prognostic factors

STUDY OBJECTIVES

To investigate the microbiological spectra, patient outcome, and prognostic factors of pulmonary fungal infection.

DESIGN

The medical and microbiological records of patients with pulmonary fungal infection were retrospectively analyzed.

SETTING

A university-affiliated tertiary medical center.

PATIENTS AND METHODS

From January 1988 to December 1997, all cases of pulmonary fungal infection were reviewed. The criteria for inclusion were obvious lung lesion shown on chest radiographs and one of the following: (1) the presence of fungi in or isolation of fungi from the biopsy specimen of open thoracotomy, thoracoscopy, transbronchial lung biopsy, or ultrasound-guided percutaneous needle aspiration/biopsy; or (2) isolation of fungi from pleural effusion or blood, with no evidence of extrapulmonary infection.

RESULTS

A total of 140 patients were included. Ninety-four cases of pulmonary fungal infection (67%) were community acquired. The most frequently encountered fungi were Aspergillus species (57%), followed by Cryptococcus species (21%) and Candida species (14%). There were 72 patients with acute invasive fungal infection, with a mortality rate of 67%. Multivariate logistic regression analysis showed that nosocomial infection (p = 0.014) and respiratory failure (p = 0.001) were significantly and independently associated with death of acute invasive fungal infection.

CONCLUSIONS

Pulmonary fungal infection of community-acquired origins is becoming a serious problem. It should be taken into consideration for differential diagnosis of community-acquired pneumonia. Furthermore, acute invasive fungal infection is associated with a much higher mortality rate for patients with nosocomial infection or complicating respiratory failure. Early diagnosis with prompt antifungal therapy, or even with surgical intervention, might be warranted to save patients' lives.

The effects of sensitization and hypersensitivity reaction on transepithelial antigen transport of rat nasal mucosa

METHODS

The prevalence of airway allergy is very high. The ways that antigen passes across the airway tract epithelial barrier are not well understood. This study uses a model antigen, horseradish peroxidase (HRP), to sensitize and challenge the respiratory tract in the rat model.

RESULTS

The results showed increases in HRP endosomes in nasal epithelial cells 5 minutes after HRP challenge in the sensitized rats compared with controls, which were further increased 30 minutes after HRP challenge, as well as with the paracellular region filled with HRP products. Meanwhile, mast cells were activated as shown by degranulation. Analysis of cell type showed that there were many more HRP endosomes in the nonciliated cells and there were many more nonciliated cells in the nasal mucosa of the sensitized rats.

CONCLUSION

The results demonstrate that sensitization promotes airway mucosal epithelial cells' uptake and transport of specific antigen and that mast cells may play certain roles in this process.