Characteristics of community-acquired methicillin-resistant Staphylococcus aureus in infants and children without known risk factors

This retrospective study sought to determine the characteristics of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in patients younger than 18 years without known risk factors who were treated at a teaching hospital in central Taiwan. Epidemiological and clinical data were collected from medical charts. Possible risk factors included hospitalization within the past 6 months, transfer from other hospitals or nursing homes, and having underlying illness. A total of 173 isolates of community-acquired S. aureus were analyzed. Seventeen (9.8%) of these 173 isolates were methicillin-resistant S. aureus collected from patients without risk factors, 31 (17.9%) were methicillin-resistant S. aureus from patients with risk factors, and the other 125 (72.3%) were methicillin-susceptible S. aureus. Most isolates of community-acquired methicillin-resistant S. aureus collected from patients without risk factors (14/17, 82.4%) were obtained from the infected wounds of skin or soft tissues. Only 4 (23.5%) in 17 patients with isolates resistant to methicillin were prescribed antimicrobial therapy with glycopeptides. Nevertheless, all patients recovered without any long-term sequelae. These results highlight the fact that community-acquired methicillin-resistant S. aureus infections occur frequently in Taiwan among patients who have no established risk factors for this infection.

Surgical treatment for rectal prolapse

BACKGROUND

The problem of full-thickness rectal prolapse is formidable, with no clear predominant treatment of choice. Several operations have been proposed to correct rectal prolapse which can be divided into transabdominal and perineal procedures.

METHODS

From September 1982 to October 1999, 32 patients with rectal prolapse were treated with surgical procedures. There were 16 males and 16 females with a mean age of 58.3 years (Range 17-89). Forteen patients received rectopexy procedure, 6 patients received sigmoidectomy, 6 patients received perineal rectosigmoidectomy, 1 patient received Delorme procedure, 1 patient received Thiersch procedure and 4 patients received laparoscopic-assisted sigmoidectomy. The median follow up times were 7.5 years.

RESULTS

In the rectopexy group, complication occurred in one patient (7.1%) and one patient recurred (7.1%). In the sigmoidectomy group, there were no complication but one patient recurred (10%). In the perineal rectosigmoidectomy group, there were no complication, but one patient recurred (16.7%). The total complication rate were 3.1% and total recurrence rate were 9.3%.

CONCLUSIONS

Although, the best operation for rectal prolapse remains a controversial subject, we believe that laparoscopic-assisted sigmoidectomy offers a promising new option for the treatment of rectal prolapse.

Epidemiologic features of rotavirus infection in Taiwan: a review

Group A rotaviruses are a major cause of severe gastroenteritis in children under 4 years of age worldwide. Group A rotaviruses have been identified in many animal and bird species; they are antigenically complex, and multiple serotypes infect humans. Reassortant rotavirus vaccines are now available that confer protection against severe illness due to rotavirus serotypes G1-4. Before vaccines are introduced, it is necessary to establish their efficacy and to establish a baseline for future surveillance strategies. The purpose of the present review is to describe current knowledge of the diversity of rotavirus in Taiwan. The present review is based on the available published studies and data from China Medical College Hospital (Taiwan). In Taiwan, rotavirus has been detected year-round, with the epidemic peak swinging from November-December in 1984 to January-March in 1988-95 and then back to December-March in 1996-99. Most affected patients are under 2 years of age. Only group A rotavirus has been found. Neither group B nor group C rotavirus have been identified. G1 strains have been the predominant strains except for the year 1992-93, when G2 strains were prevalent. There has been no G4 strain detected in published studies. The electropherotype 'baba' has been observed every year. Five other electropherotypes have been sporadically found. Half of the strains that have been studied were genotype P[8] and their VP7 serotype was G1 or G3. All genotype P[4] strains have shown serotype G2. It is expected that the reassortant rotavirus vaccine will be effective in prevention of severe illness caused by rotavirus in Taiwan.

Transfer of a protein binding epitope to a minimal designed peptide

Results from protein mutagenesis and x-ray crystallographic studies of the multidomain protein Vascular Cell Adhesion Molecule (VCAM) were used to design cyclic octapeptides that retain the critical structural and binding elements of the epitope of VCAM in the interaction with the integrin alpha 4 beta 1 (VLA-4). Changes in the activities of peptide analogues correlated with the relative activities of protein mutants of VCAM, and predicted the properties of two new mutants that bound alpha 4 beta 1 with improved affinity vs wild type protein. The nmr structures of two peptides revealed a high degree of similarity to the structure of the VCAM binding epitope. These results demonstrate that a compact binding epitope identified via protein structure-function studies may be transferred to a synthetically accessible small peptide with the key structure-activity relationships intact.

Immunogenicity and safety of an inactivated hepatitis A vaccine in Taiwanese adults and children

The safety and immunogenicity of an inactivated hepatitis A vaccine (AVAXIM, 160 antigen units) was evaluated in 190 subjects: 50 children aged from 2 to 5 years, 70 children aged from 6 to 17 years and 70 adults aged from 18 to 30 years in a monocentric, open, non-controlled, phase III trial conducted in Taipei, Taiwan from December 1996 to October 1997. The vaccine was administered intramuscularly, with a two-dose schedule 6 months apart. Clinical adverse events were monitored during the seven days following each injection. Hepatitis A virus (HAV) antibody titers were measured by modified radioimmunoassay on the day of inclusion and four weeks after both the first dose and booster injection. Among the 190 subjects who received the first dose, 174 (91.6%) were initially HAV seronegative and 16 (8.4%) were HAV seropositive at inclusion. One hundred and seventy-four subjects (91.6%) received the booster dose and completed the study. One month after the first dose, all the subjects, whatever the age, presented HAV antibody titers over 20 mIU/ml. In children (2 to 17 years), the GMT was 136 mIU/ml at week 4 and 7,906 mIU/ml four weeks after the booster dose. In adults (> or = 18 years), GMT values were 93 mIU/ml at week 4 and 3,655 mIU/ml four weeks after the booster. These results show a strong anamnestic response to the second dose of vaccine and are compatible with long-term antibody persistence in each age group. The vaccine was safe and well tolerated. No vaccine-related serious adverse event occurred. No immediate reaction occurred. The majority of the reactions were reported by adults after the primary injection. Local reactions (pain and redness) were reported by 9.0% and 4.0% of the subjects after the primary and the booster doses, respectively. Systemic reactions (mainly myalgia/arthralgia or asthenia) affected less than 10% of the subjects after the first dose and less than 3% after the booster. Results from this study in a Taiwanese population are consistent with those obtained with the same vaccine in previous European studies in children and adults, and suggest that AVAXIM (160 AU) is suitable for use in all subjects aged over 2 years.

Vibrio aerogenes sp. nov., a facultatively anaerobic marine bacterium that ferments glucose with gas production

A mesophilic, facultatively anaerobic, marine bacterium, designated strain FG1T, was isolated from a seagrass bed sediment sample collected from Nanwan Bay, Kenting National Park, Taiwan. Cells grown in broth cultures were motile, Gram-negative rods; motility was normally achieved by two sheathed flagella at one pole of the cell. Strain FG1T required Na+ for growth, and exhibited optimal growth at 30-35 degrees C, pH 6-7 and about 4% NaCl. It grew anaerobically by fermenting glucose and other carbohydrates with production of various organic acids, including acetate, lactate, formate, malate, oxaloacetate, propionate, pyruvate and succinate, and the gases CO2 and H2. The strain did not require either vitamins or other organic growth factors for growth. Its DNA G+C content was 45.9 mol%. It contained C12:0 as the most abundant cellular fatty acid. Characterization data, together with the results of a 16S rDNA-based phylogenetic analysis, indicate that strain FG1T represents a new species of the genus Vibrio. Thus, the name Vibrio aerogenes sp. nov. is proposed for this new bacterium. The type strain is FG1T (= ATCC 700797T = CCRC 17041T).

Expression of the mucosal vascular addressin, MAdCAM-1, in inflammatory liver disease

AIMS/BACKGROUND

The integrin alpha4beta7 and mucosal addressin cell adhesion molecule-1 (MAdCAM-1) are involved in normal recirculation of lymphocytes between the blood and the tissues of the gastrointestinal tract. In this study we have examined the expression of MAdCAM-1 in human liver.

METHODS

MAdCAM-1 expression was determined in archival human liver tissues by immunohistochemistry.

RESULTS

While MAdCAM-1 was not detected in normal fetal or adult human liver, expression was observed in association with portal tract inflammation in a variety of liver diseases. Detailed analysis of liver biopsies from patients with hepatitis C showed a positive correlation between the portal/periportal component of the histological activity index (HAI) grade and the presence or absence of MAdCAM-1 expression.

CONCLUSION

MAdCAM-1 expression may be important in the recruitment of lymphocytes to the liver during inflammation.

MR imaging findings of enteroviral encephaloymelitis: an outbreak in Taiwan

BACKGROUND AND PURPOSE

An outbreak of enterovirus infection occurred in Taiwan from late spring to early fall of 1998. Most of the pediatric infections presented as hand-foot-mouth disease (HFMD) and herpangina. A small portion of patients had symptoms of polio-like encephalitis and paralysis. The purpose of this study was to review the MR imaging findings in CNS involvement of enterovirus infection.

METHODS

Twenty patients who had HFMD and clinical encephalitis were examined with MR imaging. T1-weighted and T2-weighted MR images were obtained. From the rectum, throat, CSF, and peripheral blood, the presence of enterovirus 71 (EV 71) was determined by virus culture, immunofluorescent microscopy, immunologic dot blotting, and reverse-transcription polymerase chain reaction.

RESULTS

MR imaging studies of 20 patients showed hyperintensity in the brain stem and spinal cord in 15 patients, as seen on T2-weighted images. The major CNS lesions were in the medulla oblongata, pons, midbrain, and the dentate nuclei of the cerebellum. In some cases, the lesions involved the spinal cord (three cases) as well as the thalamus (two cases) and putamina (one case). Five patients had normal MR imaging results. After the appropriate management for tachycardia and tachypnea, 18 patients recovered within 1 to 2 weeks. In the follow-up MR imaging examination of five patients, the lesions completely disappeared within 2 weeks to 2 months. In two patients who were still respirator-dependent, MR imaging showed the tissue destruction in the posterior portions of the medulla, pons, and the ventral horns of cervical spinal cord. In one patient, most of midbrain was damaged. The presence of EV 71 was detected in specimens from 18 patients.

CONCLUSION

Because EV 71 was identified in 18 patients, and no other virus was detected, EV 71 was determined to be the major causative agent of this encephalomyelitis. Brain stem and cervical spinal cord involvement are characteristic findings of enteroviral encephalomyelitis.

Community-acquired Pseudomonas aeruginosa bacteremia and sepsis in previously healthy infants

Pseudomonas aeruginosa bacteremia, or sepsis, often occurs in hospitals, affecting mainly children with underlying problems. However, it can also appear in communities, and affects infants and children without underlying diseases. We report eight cases of Pseudomonas aeruginosa bacteremia, or sepsis, in previously healthy infants over a three-year period. All patients were less than twelve months old and the majority presented with sepsis, diarrhea, ecthyma gangrenosum, and neutropenia. The infection route may have been the gastrointestinal tract. Concomitant gastrointestinal infections may have played a role in pathogenesis.

An evaluation of the safety and immunogenicity of a five-component acellular pertussis, diphtheria, and tetanus toxoid vaccine (DTaP) when combined with a Haemophilus influenzae type b-tetanus toxoid conjugate vaccine (PRP-T) in Taiwanese infants

OBJECTIVE

Immunologic interference particular to the Haemophilus influenzae type b (Hib) response has been observed with previous acellular pertussis-Hib combination vaccines. To test this hypothesis a clinical trial to assess the safety and immunogenicity of a five-component (pertussis toxoid [PT], filamentous hemagglutinin [FHA], pertactin [PRN], and fimbriae 2 and 3 [FIM]), pertussis vaccine combined with diphtheria and tetanus toxoids (DTaP) when given simultaneously with a lyophilized Hib-tetanus toxoid conjugate vaccine (PRP-T) in infants at 2, 4, 6, and 18 months of age was conducted. The study compared two methods of administration: both vaccines combined in a single syringe and administered as a single injection, or both vaccines administered concurrently but at separate sites of injection.

METHODS

Healthy 2-month-old infants were enrolled at the National Taiwan University Hospital. DTaP, PRP-T, and oral poliomyelitis vaccine (OPV) were given at 2, 4, 6, and 18 months. Reaction information was collected by telephone 2 days after each vaccination. Serum was collected at 2, 6, 7, 18, and 19 months of age.

RESULTS

One hundred thirty-five healthy infants were enrolled in Taiwan, of which 127 (94%) completed the 18-month booster: 68 received the combined vaccine and 67 the separate vaccines. All vaccines were well tolerated. No differences in rates of local and systemic reactions were seen between the two methods of administration. No serious adverse events were reported. Serologic responses were comparable between the groups. Pertussis responses (enzyme-liked immunoabsorbant assay units [EU]/mL) at 7 months were, for combined versus separate, PT (131 vs 105), FHA (116 vs 116), PRN (100 vs 77), and FIM (922 vs 702). At 19 months, pertussis results were, for combined versus separate, PT (216 vs 182), FHA (203 vs 200), PRN (263 vs 197), and FIM (892 vs 732). Only the 7-month PT response in the combined group was significantly higher (combined 131 EU/mL vs separate 105 EU/mL). After the third dose (age 6 months), all subjects achieved serologic serum antibody levels indicative of protection against Hib, diphtheria, tetanus, and poliovirus types 1, 2, and 3. In fact, 96% of children had anti-PRP levels indicative of protection (>/=0.15 microgram/mL) against Hib after only two doses. At 7 months, anti-PRP geometric mean titer values were 11.8 micrograms/mL in the combined group compared with 13.0 micrograms/mL in the separate group. The anti-PRP geometric mean titers after the 18-month booster were 58.5 micrograms/mL in the combined group versus 55.3 micrograms/mL in the separate group.

CONCLUSION

The five-component DTaP vaccine may be combined with PRP-T vaccine without clinically significant immunologic interaction when given in a 2-, 4-, 6-, and 18-month schedule.

Comparison of once daily cefpodoxime proxetil suspension and thrice daily cefaclor suspension in the treatment of acute otitis media in children

An open-labeled and randomized trial was conducted to compare the efficacy and safety of once daily cefpodoxime proxetil suspension (10mg/kg/day) and thrice daily cefaclor (45mg/kg/day) in the treatment of acute otitis media in children. A total of 57 children aged from 6 months to 9 years were enrolled; 23 were treated with cefpodoxime and 34 with cefaclor. Satisfactory clinical outcome, either cure or improvement, was achieved at the end of treatment in 90% of patients in the cefaclor group and 95% of patients in the cefpodoxime group (p > 0.05). Clinical recurrence was identified at the follow-up visits in one case of the cefaclor group (3%), and none in the cefpodoxime group (p > 0.05). These drugs were well tolerated by 14/21 (67%) in the cefpodoxime-treated group and 27/32 (84%) in the cefaclor-treated group. The incidence of adverse events was slightly higher in the cefpodoxime group than in the cefaclor group, however the difference did not reach statistical significance (p > 0.05). The daily cost of once-daily cefpodoxime was lower than that of thrice-daily cefaclor. We conclude that cefpodoxime administered once daily is as effective and safe as cefaclor administered thrice daily in the treatment of acute otitis media in children. The less dosing frequency and lower daily price of cefpodoxime provide additional benefits.

Immunogenicity and safety of Haemophilus influenzae type b conjugate vaccine (HibTITER) and a combination vaccine of diphtheria, tetanus, pertussis and HibTITER (TETRAMUNE) in two-month-old infants

A study was undertaken to evaluate the safety and immunogenicity of a combination vaccine (TETRAMUNE) of conjugate Haemophilus influenzae type b (Hib) vaccine (HibTITER) and DTP (Diphtheria, Tetanus and Pertussis) vaccine. A total of 93 healthy children were randomized to receive either TETRAMUNE (combined group), or DTP and HibTITER administered concurrently (separate group) in separate syringes at approximately 2, 4 and 6 months of age in Taiwan. Serologic responses were largely comparable between the two vaccine groups; almost all subjects were seropositive to Hib PRP (polyribosylribitol phosphate) and were protected against diphtheria and tetanus after 2 doses of vaccine and mounted prominent responses to the components of Bordetella pertussis. Subjects in the combined group did not experience more adverse reactions compared with those in the separate group. We concluded that HibTITER was highly immunogenic and safe when administered concurrently with DTP vaccine to Taiwanese children. TETRAMUNE was also safe and immunogenic and might reduce the number of injections to achieve the same protection.

Bacteremia and fungemia in hematological and oncological children with neutropenic fever: two-year study in a medical center

A retrospective study of bacteremia in children with neutropenic fever admitted to a medical center in Taiwan from Jan. 1994 to Dec. 1995 was performed. There were in total 273 episodes of neutropenic fever during this period, but only 79 pathogens were isolated from blood specimens in 70 episodes. Klebsiella pneumoniae (27.8%), E. coli (10.1%), Staphylococcus aureus (10.1%) and Pseudomonas aeruginosa (7.6%) were the most common pathogens. All the isolates of S. aureus were methicillin sensitive. About half of K. pneumoniae (10/22) was multiple-drug resistant. There were seven infection-related mortality cases, three due to multiple-drug resistant K. pneumoniae, one due to S. aureus, one alpha-hemolytic streptococcus and two fungemia (Cryptococcus neoformans and Fusarium sp.). Vancomycin is not necessary in initial empiric therapy of neutropenic fever, while cefazolin or oxacillin may be included in cases with central venous access device. Antibiotics to cover intestinal flora, especially K. pneumoniae, are paramount in our hospital.

Mononucleosis syndrome and coincidental human herpesvirus-7 and Epstein-Barr virus infection

Two girls (a 5 year old and a 21 month old) experiencing mononucleosis syndrome with coincidental human herpesvirus (HHV)-7 and Epstein-Barr virus (EBV) infections are described. One patient had primary HHV-7 infection and reactivated EBV infection. The other had primary HHV-7 and EBV infections. These cases indicated that HHV-7 is capable of inducing infectious mononucleosis-like illness. Multiple herpesvirus infection in one of the patients also suggests that interaction among herpesviruses can occur in vivo. The consequence of this interaction may have clinical implications.

Diphtheria, tetanus and whole cell pertussis vaccine combined with hepatitis B vaccines: a comparison of two doses (10 microg and 5 microg)

BACKGROUND

A combined diphtheria-tetanus-whole cell pertussis-hepatitis B (DTPwHB) vaccine might facilitate the achievement of universal vaccination of infants against hepatitis B.

METHODS

A double blind, randomized, two-armed, single center study was undertaken to evaluate the immunogenicity and reactogenicity of combined tetravalent DTPwHB vaccine, with two dosages of hepatitis B component (10 microg and 5 microg). The combined vaccine was tested in the context of a simplified vaccination schedule at 1.5, 3.5 and 6 months of age, to 120 healthy infants born to hepatitis B surface antigen-negative mothers after priming with one dose of hepatitis B vaccine (10 microg) at birth. Antibodies to each antigenic component were measured from blood samples collected immediately after birth, pre- and postvaccination blood samples.

RESULTS

The reactogenicity profiles were similar in the two groups. No serious adverse events were reported. One month after completion of the four-dose vaccination schedule, all subjects except one in Group 1 (10 microg) had protective titers of anti-HBs (10 mIU/ml). At this time the geometric mean titer in Group 1 (10 microg) was higher than that observed in Group 2 (5 microg), 696 vs. 488 mIU/ml (P = 0.19). One month after three doses all subjects in both groups had protective antidiphtheria titers and antitetanus titers. The vaccine response rate to the Bordetella pertussis component of the vaccine was 88.0% in Group 1 and 96.2% in Group 2 (P = 0.86).

CONCLUSION

Both combined tetravalent vaccines are safe and immunogenic when administered to infants born to a hepatitis B surface antigen-negative mother, with a 10-microg dose of priming hepatitis B vaccine at birth. This combined tetravalent DTPwHB vaccine may play an important role to promote integration of HB vaccine into the Expanded Program of Immunization in hepatitis B-endemic areas.

Fuzzy homogeneity approach to multilevel thresholding

The spatial ambiguity among pixels has inherent vagueness rather than randomness, therefore, the conventional methods might not work well. We propose fuzzy homogeneity vectors to handle the greyness and spatial uncertainties among pixels, and to perform multilevel thresholding. The experimental results prove that the proposed approach works better than the histogram-based algorithms.

Evaluation of a live attenuated varicella vaccine in 15- to 18-month-old healthy children

A clinical trial was conducted in Taiwan in 15- to 18- month-old healthy children to study the reactogenicity and immunogenicity of live varicella vaccine combined with standard measles-mumps-rubella vaccine. A total of 118 varicella antibody-negative children were enrolled. They received one dose of varicella vaccine and one dose of measles-mumps-rubella vaccine at the same time. The vaccines were well tolerated; adverse reactions were mild and infrequent, with 2% of vaccines developed skin rash. No vesicular rash was seen. Concomitant varicella vaccination did not significantly increase the incidences of reactions associated with MMR vaccine. The seroconversion rates to varicella, measles, mumps and rubella all approached 100%. This study confirmed that simultaneous administration of live attenuated varicella vaccine and MMR vaccine was safe and immunogenic in healthy young children in Taiwan.

Mucosal addressin cell adhesion molecule-1 (MAdCAM-1). Its binding motif for alpha 4 beta 7 and role in experimental colitis

The integrin alpha 4 beta 7 and mucosal addressin cell adhesion molecule-1 (MAdCAM-1) are molecules involved in the normal recirculation of lymphocytes between the blood and the gastrointestinal tract. These molecules may play a complementary and significant role in animal models of colitis. We have investigated the structural interaction between alpha 4 beta 7 and MAdCAM-1. Site-directed mutagenesis studies of the MAdCAM-1 molecule has led to the identification of the amino acid residue (LDT) in the loop between beta strands C and D of the Ig-superfamily-like folds being involved in the adhesive and cell activation functions of MAdCAM-1 with alpha 4 beta 7.

Immunogenicity of Haemophilus influenzae b conjugate vaccine (HibTITER) and safety of HibTITER and a combination vaccine of diphtheria, tetanus, pertussis and HibTITER in infants two months of age: a preliminary report

A study was undertaken to evaluate the safety and immunongenicity of a conjugate Haemophilus influenzae type b (Hib) vaccine (HibTITER) when administered concurrently with DTP (diphteria, tetanus and pertussis) vaccine in separate syringes. A total of 90 healthy children (45 per group) were randomized to receive either TETRAMUNE, a vaccine combining HibTITER with whole-cell DTP (group A), or DTP and HibTITER administered concurrently (group B) in separate syringes at approximately 2, 4 and 6 months of age in Taiwan. All children in group B achieved anti-Hib PRP (polyribosylribitol phosphate) antibody titers above 0.15 microgram/ml and 91% developed antibody titers above 1.0 microgram/ml following the third immunization. Incidences of adverse reactions were comparable between groups A and B. Besides, the incidences of adverse reactions were not significantly more frequent compared with DTP vaccination alone. We concluded that HibTITER was highly immunogenic and safe when administered concurrently with DTP vaccine to Taiwanese children. TETRAMUNE was also safe and the number of injections may be reduced in the future.

Safety and immunogenicity of a conjugated Haemophilus influenzae type B polysaccharide-Neisseria meningitidis outer membrane protein vaccine

This study was performed to determine the immunogenicity and safety of a conjugate Haemophilus influenzae type b (Hib) vaccine (PedvaxHIB:Merck Sharp & Dohme Inc, West Point, PA, USA) in Taiwanese children. There were two groups in this study. Group A included 56 infants at 2 months of age, who received an initial dose of Hib conjugate vaccine at age 2 months and 4 months. Another booster dose was given between 12 and 15 months of age. Group B included 58 children, aged 11 to 14 months, who were vaccinated at the time of enrollment and 2 months after the first vaccination. The results showed that this Hib conjugate vaccine was highly immunogenic with 100% and 86% of vaccinees in group A developing anti-Hib polyribosylribitol phosphate (PRP) antibody titers above 0.15 microgram/mL and 1 microgram/mL, respectively, after two vaccinations. A slightly better response rate was observed in group B, with 100% and 97% of vaccinees developing antibody titers above 0.15 microgram/mL and 1 microgram/ml, respectively, after two vaccinations. A significant booster effect was seen in group A; the proportion of subjects with antibody titers above 1 microgram/mL increased from 38% to 95%, and the geometric mean titer increased from 0.68 microgram/mL to 11.92 micrograms/mL. Adverse reactions were uncommon. Mild reactions consisted of low-grade fever and local discomfort. We conclude that the Hib conjugate vaccine is highly immunogenic and safe when given to Taiwanese children as young as 2 months of age.

Seroepidemiological study of measles after the 1992 nationwide MMR revaccination program in Taiwan

The incidence of measles declined rapidly in Taiwan after the introduction of the measles vaccine into the routine immunization schedule in 1978. However, an epidemic still occurred every 3-5 years until recently. A nationwide measles-mumps-rubella (MMR) revaccination program for school and preschool children has been in place since 1992 to control the indigenous transmission of measles. In order to understand the current immune status after this recent nationwide revaccination program, we determined the presence of measles IgG antibodies by enzyme-linked immunosorbent assay (ELISA) in 1,281 blood samples from healthy persons aged from 2 months to above 30 years collected between 1993 and 1995, and also in another batch of 90 sera samples from children aged 2 years collected before 1992. The results showed that 1) the measles antibody seropositive rate (36.4%) was lowest in children aged 5-7 months and rose to an unexpectedly high level of 85.8% at the age of 12-14 months, 2) the seropositive rate rose further to between 85.9% and 95.1% after 2 years of age and remained high in adults and pregnant women, and 3) the seropositive rate of the 2-year-old children collected before 1992 was 61.4%, which was significantly lower than the rate of the same age group collected after the nationwide MMR revaccination program. We conclude that the national revaccination program has promoted effectively measles immunity in Taiwan. This immunity explains the rarity of reported measles cases since the last epidemic in 1989. This revaccination program should continue and be extended to all preschool children and young adults so that indigenous measles can be eliminated by the year 2000.

Mucosal addressin cell adhesion molecule-1: a structural and functional analysis demarcates the integrin binding motif

The leukocyte integrin receptor, alpha 4 beta 7, and the mucosal addressin cell adhesion molecule-1 (MAdCAM-1) are postulated to be important in regulating lymphocyte trafficking to normal intestine. Here we provide the first description of MAdCAM-1 expression in inflamed intestine. Using mouse models of experimentally induced colitis, we show a concordant increase in MAdCAM-1 expression associated with increased cellular infiltrates in areas of intestinal inflammation. To understand more of the molecular nature of the interactions between MAdCAM-1 and its leukocyte ligand, the alpha 4 beta 7 integrin receptor, we have analyzed the structural and functional properties of chimeric recombinant MAdCAM-1 proteins in vitro. Using site-directed mutagenesis and molecular modeling, we demarcate the alpha 4 beta 7 binding motif as three linear residues within the C-D loop in the first domain of MAdCAM-1. Mutation of residue L40, D41, or T42 in the first domain completely abrogates alpha 4 beta 7+ cell binding and cellular activation. Mutagenesis of other residues in the first domain do not impact these functions. We have modeled peptides based on the predicted structure of the alpha 4 beta 7 integrin binding motif on MAdCAM-1 and are able to show specific and selective blocking of cell binding. These observations suggest that the amino acid residues LDT on MAdCAM-1 play a role in the interaction with alpha 4 beta 7 in cell adherence and cell activation.

Mucosal addressin cell adhesion molecule-1: a structural and functional analysis demarcates the integrin binding motif

The leukocyte integrin receptor, alpha 4 beta 7, and the mucosal addressin cell adhesion molecule-1 (MAdCAM-1) are postulated to be important in regulating lymphocyte trafficking to normal intestine. Here we provide the first description of MAdCAM-1 expression in inflamed intestine. Using mouse models of experimentally induced colitis, we show a concordant increase in MAdCAM-1 expression associated with increased cellular infiltrates in areas of intestinal inflammation. To understand more of the molecular nature of the interactions between MAdCAM-1 and its leukocyte ligand, the alpha 4 beta 7 integrin receptor, we have analyzed the structural and functional properties of chimeric recombinant MAdCAM-1 proteins in vitro. Using site-directed mutagenesis and molecular modeling, we demarcate the alpha 4 beta 7 binding motif as three linear residues within the C-D loop in the first domain of MAdCAM-1. Mutation of residue L40, D41, or T42 in the first domain completely abrogates alpha 4 beta 7+ cell binding and cellular activation. Mutagenesis of other residues in the first domain do not impact these functions. We have modeled peptides based on the predicted structure of the alpha 4 beta 7 integrin binding motif on MAdCAM-1 and are able to show specific and selective blocking of cell binding. These observations suggest that the amino acid residues LDT on MAdCAM-1 play a role in the interaction with alpha 4 beta 7 in cell adherence and cell activation.

Influenza B virus infection associated with shock in a two-month-old infant

Influenza B virus usually causes a mild and self-limiting illness. A 2-month-old infant presented with acute symptoms suggestive of septic shock but recovered after vigorous resuscitation 1 day later. Influenza B was isolated from a throat swab taken from the infant. Bacterial cultures of blood, urine and spinal fluid had no growth. This case illustrates that the clinical signs and symptoms of influenza in infants may be indistinguishable from bacterial sepsis.

Homocystinuria presenting as fatal common carotid artery occlusion

A patient with homocystinuria presenting with fatal cerebral infarction that resulted from left common carotid artery occlusion is reported. This 13-year-old, healthy and intelligent girl presented with progressive cerebral infarction. Angiography revealed total occlusion of the left common carotid artery and stenosis of the right common carotid artery. Distal stenosis of bilateral vertebral arteries was also observed. Initially Takayasu arteritis with unusual manifestation was considered. However, later investigations revealed homocystinuria was the underlying cause. The sudden onset of fatal stroke as the initial clinical presentation of homocystinuria, as observed in this previous healthy teenager, is noteworthy. We suggest metabolic screening for homocystinuria when treating a patient with unusual vascular lesions.

Prevalence of Legionella pneumophila infection in children and its role in pediatric community-acquired atypical pneumonia

The infection status of Legionella pneumophila in children and its role in pediatric community-acquired pneumonia were investigated. Because exposure to Legionella pneumophila may be highly variable and there has been no unanimously agreed-upon cut-off values in previous seroprevalence studies, 60 serum samples collected from infants aged 12 to 18 months were examined using immunofluorescence antibody test to determine the cut-off titer which represents past Legionella pneumophila infection. An IFA titer of greater than or equal to 32 was found to be suitable to represent past L. pneumophila infection. A seroepidemiological study of the prevalence of L. pneumophila in 180 children showed the prevalences in children aged 7 to 18 years to be between 28.4 and 35%. Fifty-three paired sera were tested to determine the role of Legionella pneumophila in pediatric, community-acquired, atypical pneumonia. The frequency of confirmed disease was 0% and of presumptive cases was 5.7%. Legionella pneumophila was not a common etiologic agent of pediatric pneumonia in Taiwan.

Case report: paucity of interlobular bile ducts in Chinese children

Sixteen Chinese children with cholestasis since early infancy were diagnosed to have paucity of interlobular bile ducts (PILBD) or its equivalent. Twelve children belonged to the syndromic group of PILBD and four children belonged to the non-syndromic group. A definite histological diagnosis of bile duct paucity was established in only two children (aged 4 and 9 months) during the first percutaneous needle biopsy. In the remaining 14 children a varying degree of bile duct destruction was evident in the follow up percutaneous or wedge liver biopsies. The evolving changes were characterized by inflammatory infiltration near or at the ductal wall, the presence of dysmorphic ductules, the degeneration of ductal epithelia and a progressive decrease of interlobular bile ducts. Of 10 children who underwent laparotomy for definite diagnosis, kasai operation was performed in two of them. In the syndromic PILBD group, all children, including two paired siblings, had at least three of five major clinical features. Hypoplasia of the extrahepatic biliary tree was found in five children and atresia of the extrahepatic bile duct was found in one. Three of six children studied were shown, by polymerase chain reaction, to have cytomegalovirus infection in the liver. This study demonstrates that bile duct paucity is a result of progressive bile duct destruction. A definitive diagnosis is difficult to make in early infancy. Thus, the careful evaluation of extrahepatic features in cholestatic children and follow-up liver biopsies are indicated. Although the pathogenetic mechanism of PILBD is unknown, bile duct destruction is the common pathway leading to paucity of bile ducts irrespective of syndromic or non-syndromic types.

Similar but nonidentical amino acid residues on vascular cell adhesion molecule-1 are involved in the interaction with alpha 4 beta 1 and alpha 4 beta 7 under different activity states

The integrin receptors alpha 4 beta 1 and alpha 4 beta 7 both bind to vascular cell adhesion molecule-1 (VCAM-1). Here, we report that the amino acid residue requirements for murine VCAM-1 adhesion to murine alpha 4 beta 1 (WEHI 231) and alpha 4 beta 7 (38C13/beta 7-transfectant) positive cells are strikingly similar but nonidentical under multiple adhesion activity states. By site-directed mutagenesis of domain 1 of VCAM-1, the amino acid residues on the loop between beta strands C and D (R36, Q38, I39, D40, P42) and on the adjacent antiparallel beta strand F (L70 and T72) were required for basal level adhesion to both alpha 4 beta 1-positive and alpha 4 beta 7-positive cells. Mutation at two other sites, N44 (loop between beta strands C and D) and E66 (loop between beta strands E and F), specifically reduced alpha 4 beta 7-positive cell adhesion, but not alpha 4 beta 1-positive cell adhesion. Mutation H85A augmented alpha 4 beta 7 binding but not alpha 4 beta 1 binding. These apparent differences relate to the higher intrinsic activity state of alpha 4 beta 1 on WEHI 231 than on alpha 4 beta 7 (38C13/beta 7-transfectant). In contrast, under higher adhesion activity states induced by either MnCl2 or truncation of the beta 7 cytoplasmic tail, mutation of either amino acid residue D40 or L70 completely blocked cell adhesion without evidence of structural perturbation of VCAM-1. These results suggested that the two structurally discontinuous amino acid residues, the negatively charged D40 and the hydrophobic L70 adjacently located on domain 1 of VCAM-1, are essential for interaction under multiple activity states with both alpha 4 beta 1 and alpha 4 beta 7 integrin receptors.

Similar but nonidentical amino acid residues on vascular cell adhesion molecule-1 are involved in the interaction with alpha 4 beta 1 and alpha 4 beta 7 under different activity states

The integrin receptors alpha 4 beta 1 and alpha 4 beta 7 both bind to vascular cell adhesion molecule-1 (VCAM-1). Here, we report that the amino acid residue requirements for murine VCAM-1 adhesion to murine alpha 4 beta 1 (WEHI 231) and alpha 4 beta 7 (38C13/beta 7-transfectant) positive cells are strikingly similar but nonidentical under multiple adhesion activity states. By site-directed mutagenesis of domain 1 of VCAM-1, the amino acid residues on the loop between beta strands C and D (R36, Q38, I39, D40, P42) and on the adjacent antiparallel beta strand F (L70 and T72) were required for basal level adhesion to both alpha 4 beta 1-positive and alpha 4 beta 7-positive cells. Mutation at two other sites, N44 (loop between beta strands C and D) and E66 (loop between beta strands E and F), specifically reduced alpha 4 beta 7-positive cell adhesion, but not alpha 4 beta 1-positive cell adhesion. Mutation H85A augmented alpha 4 beta 7 binding but not alpha 4 beta 1 binding. These apparent differences relate to the higher intrinsic activity state of alpha 4 beta 1 on WEHI 231 than on alpha 4 beta 7 (38C13/beta 7-transfectant). In contrast, under higher adhesion activity states induced by either MnCl2 or truncation of the beta 7 cytoplasmic tail, mutation of either amino acid residue D40 or L70 completely blocked cell adhesion without evidence of structural perturbation of VCAM-1. These results suggested that the two structurally discontinuous amino acid residues, the negatively charged D40 and the hydrophobic L70 adjacently located on domain 1 of VCAM-1, are essential for interaction under multiple activity states with both alpha 4 beta 1 and alpha 4 beta 7 integrin receptors.

The association of syndromic paucity of the interlobular bile ducts and congenital mechanical obstruction of the small intestine

Three patients with congenital mechanical intestinal obstruction and features of syndromic paucity of the interlobular bile ducts (SPILBD) are presented. Two of them have siblings with syndromic paucity of the interlobular bile ducts. Two patients had jejunoileal atresia, while the other had a meconium plug with intestinal perforation. All subjects underwent surgery for intestinal obstruction within the first 24 h of life. Progressive disappearance of the bile ductules was observed in one case. We believe that an insult such as vascular insufficiency to both bile ductal epithelium and the small intestine may be the cause of this congenital disorder.

Recombinant alpha-interferon treatment of intracranial hemangioma and Kasabach-Merritt syndrome in an infant with cytomegalovirus

A 2-month-old girl presented with enlarged head girth, generalized petechiae, anemia, coagulopathy and hepatosplenomegaly. Imaging studies showed a huge, dumbbell-shaped intracranial hemangioma located between the falx, and involving the supra- and infra-tentorium, extending through the posterior fontanel to involve the subgaleal area. A urine culture grew cytomegalovirus. Severe thrombocytopenia was refractory to a massive platelet transfusion, intravenous immunoglobulin and corticosteroid therapy. Hypertension, pulmonary hemorrhage and sepsis complicated the course. After establishing a diagnosis of Kasabach-Merritt syndrome, subcutaneous injections of alpha-interferon were given with an initial dose of 1 x 10(6) IU/m2 followed by 3 x 10(6) IU/m2 per day for 12.5 mo. Her platelet count rose gradually and became stable after 1.5 mo of interferon treatment. The intracranial hemangioma regressed remarkably and the hepatosplenomegaly was also resolved. The infant showed good growth and development, without obvious side-effects during the 23-month follow-up period. The treatment with recombinant alpha-interferon appeared to be effective in reversing thrombocytopenia associated with the patient's massive intracranial hemangioma.

Structural requirements for adhesion of soluble recombinant murine vascular cell adhesion molecule-1 to alpha 4 beta 1

This study describes the identification of seven amino acid residues of the vascular cell adhesion molecule (VCAM-1) that influence binding to the alpha 4 beta 1 receptor. Using recombinant murine VCAM-1-IgG, which is bound by both mouse (WEHI 231) and human (Ramos) lymphoid cells, two approaches demonstrated the crucial role of the first two NH2-terminal Ig-like domains in binding: (a) blocking monoclonal anti-mouse VCAM-1 antibodies bound to only truncation variants that included the first two domains; (b) site-direct mutagenesis of the first NH2-terminal domain showed that alanine substitution of the amino acid residues R36, D40, K46, S54, N65, T72, and E81 partially or completely reduced adherence by human and/or mouse cells. Of these D40, when mutated to A, N, or K (but not E), showed complete abrogation of adherence by mouse and human cells, as well as inability to bind blocking anti-murine VCAM-1 antibody MVCAM.A429, while not inducing gross structural perturbations in VCAM-1. By molecular modeling, the D40 residue was located on a beta turn connecting two beta strands defined as C and D. The residues R36, K46, S54, N65, T72, and E81, which perturb cell adherence and caused small changes to gross structure, are conformationally near or adjacent to D40. Although these residues, identified as crucial for cell adhesion, are all located in domain 1, it is evident that there is a structural requirement for domains 1 and 2 to be intact so that cell adhesive function can occur.

Interferon-gamma increases alveolar macrophage Ia antigen expression despite oral administration of dexamethasone to rats

Corticosteroids have multiple effects on immune and inflammatory responses and decrease host resistance to a broad range of microorganisms. Resident tissue macrophages have been proposed as a target for the immunosuppressive effects of corticosteroids and are important in host defense against infections. During infection-induced immune responses, macrophages are activated after exposure to interferon-gamma (IFN-gamma), and class II major histocompatibility (Ia) antigens on their surface are increased. We investigated the effect of orally administered corticosteroids on alveolar macrophages, the resident macrophages of the lung parenchyma. We hypothesized that corticosteroids would inhibit the activation of alveolar macrophages and measured induction by IFN-gamma of Ia antigens as a marker of cell activation. Alveolar macrophages from normal and corticosteroid-treated rats were exposed to recombinant murine IFN-gamma (rMuIFN-gamma) in vitro and assayed for Ia transcription and surface Ia expression. Ia mRNA accumulation was induced in alveolar macrophages from normal and corticosteroid-treated rats after exposure in vitro to rMuIFN-gamma. Furthermore, rMuIFN-gamma increased surface expression of Ia proteins on alveolar macrophages from corticosteroid-treated rats, although to a lesser extent than on cells from control rats. Finally, surface Ia expression could also be increased in vivo by exposure of corticosteroid-treated rats to an aerosol containing rMuIFN-gamma. These results demonstrate that administration of oral corticosteroids, while establishing a state of immunosuppression in rats, does not abolish responsiveness of rat alveolar macrophages to rMuIFN-gamma. We speculate that IFN-gamma-induced augmentation of phagocytic cell function may constitute an important therapeutic modality to treat complications of immunodeficiency.

In vivo immune responses to Candida albicans modified by treatment with recombinant murine gamma interferon

The immunologic effects of in vivo administration of recombinant murine gamma interferon (rMuIFN-gamma) were determined in a murine model of candidiasis. Naive mice were given graded doses of rMuIFN-gamma and then challenged intravenously with Candida albicans. Increased morbidity and mortality were noted in four different strains of mice, viz., BALB/c, A/J, Swiss Webster, and CBA/J, providing the mice had not been immunized with C. albicans before challenge. Quantitative culture of selected organs of Swiss Webster and CBA/J mice surviving treatment with rMuIFN-gamma revealed elevated numbers of C. albicans cells, particularly in the kidneys, but also in the liver, lungs, and spleen. The lungs, livers, and spleen of female CBA/J mice were more protected from increased multiplication of the fungus than were those of males of the same species or female Swiss Webster mice. On the basis of these initial findings, the effect of treatment with 5,000 U of rMuIFN-gamma on immune responses in a gastrointestinal model of candidiasis was determined. CBA/J mice that had been colonized with C. albicans as infants were boosted with a cutaneous inoculation of the fungus when 6 to 10 weeks old; development of delayed hypersensitivity (DH), antibodies, and protective responses was assayed at intervals thereafter. Daily treatment with rMuIFN-gamma (beginning 1 day before cutaneous inoculation) suppressed weak immune responses but had little effect on responses which were strong. For example, DH and anti-C. albicans antibody production were suppressed in animals colonized with C. albicans but not boosted by cutaneous inoculation, and DH was suppressed in uncolonized animals that had been inoculated once cutaneously with the fungus as well. There was no rMuIFN-gamma-induced suppressive effect of DH in mice which had been stimulated maximally with C. albicans, i.e., colonized animals that had been boosted cutaneously with the organisms. Collectively, these data indicate that naive mice or mice with minimal levels of anti-C. albicans sensitivity, females somewhat more so than males, were sensitive to suppressive effects of in vivo treatment with rMuIFN-gamma when challenged with C. albicans. In contrast, under conditions similar to those of humans, in whom underlying immunity to C. albicans is usually present, suppression of host responses to C. albicans was not observed in immunized mice in response to treatment with rMuIFN-gamma.

Transforming growth factor-beta 1 modulates the expression of class II histocompatibility antigens on human cells

We have examined the effects of transforming growth factor-beta (TGF-beta 1) on the expression of the class II histocompatibility Ag, HLA-DR: 1) induced by human rIFN-gamma (rHuIFN-gamma) in human melanoma, Hs294T cells and 2) constitutively expressed in a subclone Hs294T cell line. The expression of HLA-DR Ag on Hs294T cells was induced by rHuIFN-gamma in a dose- and time-dependent manner with maximal levels obtained with 10 ng/ml rHuIFN-gamma after 48 h exposure. Treatment of Hs294T cells with natural porcine platelet-derived or human rTGF-beta 1 (1 to 100 ng/ml) in the presence of rHuIFN-gamma (0.1 to 10 ng/ml) reduced the percentage of cells positive for this Ag by approximately 40 to 50%, as determined by flow cytometry. This suppressive effect of TGF-beta 1 was not restricted to Hs294T cells inasmuch as rHuIFN-gamma induced HLA-DR surface Ag expression on PBMC-derived adherent cells was also significantly inhibited by TGF-beta 1. Northern blot analysis of cytoplasmic RNA extracted from Hs294T cells indicated that the decreased levels of HLA-DR cell-surface Ag correlated with decreased levels of mRNA transcripts encoding this Ag. TGF-beta 1 also effectively reduced the levels of HLA-DR mRNA in 1) cells that had been pretreated with rHuIFN-gamma and were expressing maximal levels of HLA-DR surface antigen and 2) cells that constitutively expressed HLA-DR surface Ag without exogenous rHuIFN-gamma treatment.

Transforming growth factor-beta 1 modulates the expression of class II histocompatibility antigens on human cells

We have examined the effects of transforming growth factor-beta (TGF-beta 1) on the expression of the class II histocompatibility Ag, HLA-DR: 1) induced by human rIFN-gamma (rHuIFN-gamma) in human melanoma, Hs294T cells and 2) constitutively expressed in a subclone Hs294T cell line. The expression of HLA-DR Ag on Hs294T cells was induced by rHuIFN-gamma in a dose- and time-dependent manner with maximal levels obtained with 10 ng/ml rHuIFN-gamma after 48 h exposure. Treatment of Hs294T cells with natural porcine platelet-derived or human rTGF-beta 1 (1 to 100 ng/ml) in the presence of rHuIFN-gamma (0.1 to 10 ng/ml) reduced the percentage of cells positive for this Ag by approximately 40 to 50%, as determined by flow cytometry. This suppressive effect of TGF-beta 1 was not restricted to Hs294T cells inasmuch as rHuIFN-gamma induced HLA-DR surface Ag expression on PBMC-derived adherent cells was also significantly inhibited by TGF-beta 1. Northern blot analysis of cytoplasmic RNA extracted from Hs294T cells indicated that the decreased levels of HLA-DR cell-surface Ag correlated with decreased levels of mRNA transcripts encoding this Ag. TGF-beta 1 also effectively reduced the levels of HLA-DR mRNA in 1) cells that had been pretreated with rHuIFN-gamma and were expressing maximal levels of HLA-DR surface antigen and 2) cells that constitutively expressed HLA-DR surface Ag without exogenous rHuIFN-gamma treatment.

Irreversible thermodynamics of an isometric twitch, time-dependent general formulation

We used the phenomenological laws of irreversible thermodynamics, to derive a system of coupled differential equations describing the time course of the mechanochemical coupling underlying an isometric twitch. Our general description is concerned only with the fundamental process of energy transduction taking place within an idealized unit element of muscle and does not include the description of associated processes such as the excitation-contraction coupling and the mechanical or external coupling that, in bulk muscle, lead to or mediate the fundamental process. The values of the initial conditions and of four parameters are required to solve for the time course of the process. Two of the parameters have a clear physical interpretation and, for the specific case of muscular contraction involving hydrolysis of ATP, their values can be readily estimated from available experimental data. The interpretation of the two other parameters is more speculative, but, from their strong interdependence with the other parameters, their values can be also approximated. Solution of the coupled differential equations yields results consistent with the typical experimental time course of an isometric twitch.

Effects of etomidate given in repeated doses

Fifty fit, female patients were given four consecutive intravenous doses of etomidate 10 mg, so as to maintain sleep, after establishment of epidural block for postpartum sterilization. A matched group was given four doses of thiopentone 125 mg. Cumulative hypnotic effect, as judged by increasing sleep duration with second and subsequent doses, was much less with etomidate than with thiopentone. Etomidate did not depress blood pressure, whereas it fell progressively with successive doses of thiopentone. Injection pain was reported in 68% of patients receiving etomidate, and this tended to increase with successive doses; 12% also showed local inflammation at the injection site. Tremor, due to etomidate, was common, but did not increase with successive doses. Feelings of sleepiness, lasting several hours after waking, were more common after thiopentone than after etomidate.

Acid aspiration during laparoscopy

The prophylactic efficacy of pre-operative antacid administration was shown by comparing the pH and volumes of gastric contents in 50 female patients treated with 10 ml of Mist. Magnesium Trisilicate B.P.C. with that of 50 controls. Routine antacid prophylaxis was advocated for all patients undergoing pelvic laparoscopy as intra-operative conditions increase the risk of pulmonary acid aspiration.

Clinical evaluation of etomidate as an induction agent

A comparative study between Etomidate and Thiopentone was carried out on 100 healthy female patients scheduled for post-partum abdominal sterilization under epidural analgesia. Our results show Etomidate to be a safe and effective induction agent, comparable to Thiopentone in having a rapid onset of action and rapid recovery time. The pulse rates and blood pressures remained relatively stable during the use of Etomidate. However, there was a high incidence of transient respiratory upsets while causing less respiratory depression than Thiopentone. The objectionable features of Etomidate are high incidence of pain on injection and involuntary muscular activity, which account for the low anaesthetist acceptance rate.

Complication of laparoscopy under general anaesthesia

Two cases are presented in which injury to the stomach occurred in association with laparoscopy under general anaesthesia. The common aetiological factor was gastric inflation resulting from I.P.P.V. via mask. Precautionary measures in the anaesthetic induction technique are described.

Intravenous flunitrazepam as an anesthetic induction agent

The effects of the fluorinated benzodiazepine compound flunitrazepam were studied in eighty patients. The drug was administered intravenously in a standard dose of 2 mg, 3 mg, or 4 mg to supplement lumbar epidural analgesia. Induction was smooth and pleasant. The sleep onset time was dose related and exceeded one minute in the majority of patients. Sleep was invariably produced in patients receiving 4 mg but at lower dosage some patients failed to become unconscious. Pain in the arm during injection was a common feature. The respiratory rate was slightly increased, but in two patients apnoea occurred at induction. The cardiovascular system was minimally depressed with a small decrease in systolic blood pressure and pulse rate. Recovery from sleep was slow but sequelae were minimal. The sedative and amnesic properties contributed significantly to the high rate of patient acceptance.

Clinical evaluation of etidocaine in continuous caudal analgesia for pelvic floor repair and post-operative pain relief

A randomized double-blind trial compared 1-0% etidocaine and 1-5% lignocaine (both with 1/200,000 adrenaline), for caudal anaesthesia for pelvic floor repair. Etidocaine was highly effective for the surgical procedure, with rapid onset of action, adequate muscle relaxation and longer duration of action. Its use for post-operative analgesia may be hindered by the concomitant immobilization of the legs. The problem of tachyphylaxis with etidocaine needs further investigation.