Multiresidue Gas Chromatographic Method for Determining Synthetic Pyrethroid Pesticides in Agricultural Products: Collaborative Study

Fourteen laboratories from 6 countries and regions participated in an international collaborative study to evaluate a multiresidue gas chromatographic (GC) method for determining 8 synthetic pyrethroid pesticides in grains, fruits, and vegetables. The study design was based on Youden’s matched-pairs principle for collaborative tests of analytical methods. Each laboratory analyzed 12 collaborative samples of wheat, oranges, and tomatoes as blind samples. Wheat samples were extracted with acetonitrile–water (2 + 1), while orange and tomato samples were extracted with acetone. Residues were partitioned into hexane, evaporated to dryness with a rotary evaporator, and then dissolved in hexane. The hexane extract was partitioned with acetonitrile and cleaned up on a 5% water-deactivated Florisil column with 6% ethyl ether in hexane as eluant. Residue concentrations were determined by GC with electron capture detection with split-less injection by comparison with single-point calibration standards. The appropriate standard concentration was determined by screening sample extracts before analysis. The multiresidue method was tested over the concentration range of 0.0951.909 mg/kg depending on the 8 different of pesticides and agricultural products analyzed in the collaborative study. Statistical analysis of data from 13 laboratories showed weighted average recoveries for 8 pyrethroids in wheat, oranges, and tomatoes at 0.105–1.909,0.095–1.909, and 0.105–0.954 mg/kg, respectively, ranging from 91.8 to 100.2%, from 88.1 to 100.6%, and from 88.2 to 101.5%, respectively. Reproducibility relative standard deviation values ranged from 6.46 to 17.74%, from 5.94 to 18.13%, and from 5.59 to 10.48%, respectively. Repeatability relative standard deviation values ranged from 6.34 to 10.84%, from 5.19 to 11.72%, and from 3.20 to 8.09%, respectively. The multiresidue GC method for determining synthetic pyrethroid pesticides in agricultural products has been adopted first action by AOAC INTERNATIONAL.

Retinol binding protein and vitamin D associations with serum antibody isotypes, serum influenza virus-specific neutralizing activities and airway cytokine profiles

Vitamin A supports the induction of immunoglobulin (Ig)A responses at mucosal surfaces in mice, but much less is known about the influence of vitamins on antibody isotype expression in humans. To address this knowledge gap, we examined 46 residual blood samples from adults and children, some of whom were experiencing influenza virus infections of the respiratory tract. Assays were performed for retinol binding protein (RBP, a surrogate for vitamin A), vitamin D (a related vitamin) and antibody isotypes. Results showed that all but two tested samples exhibited RBP and/or vitamin D insufficiencies or deficiencies. Vitamin D correlated with blood IgM and IgG3, while RBP correlated with IgG4 and IgA. RBP also correlated positively with age and with influenza virus-specific antibody neutralization titres. Individuals with low blood RBP levels exhibited the highest frequencies of over-expressed cytokines and growth factors in nasal wash samples, an indication of inflamed mucosal tissues. While cause-effect relationships were not discerned, results support a hypothesis that vitamins directly influence B cell isotype expression in humans, and by so doing may help protect mucosal surfaces from respiratory viral disease.

Accelerated BEP for metastatic germ cell tumours: a multicenter phase II trial by the Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP)

BACKGROUND

This Australian single-arm, multicenter, phase II trial evaluated feasibility, tolerability and activity of accelerated bleomycin, etoposide and cisplatin (BEP) as first-line chemotherapy for metastatic germ cell tumours.

PATIENTS AND METHODS

Patients were planned to receive cisplatin 20 mg/m(2) and etoposide 100 mg/m(2) days 1-5, and pegfilgrastim 6 mg day 6, all repeated every 2 weeks for four cycles (three cycles for good prognosis). Bleomycin was given at 30 000 IU weekly to a total of 12 doses (9 doses for good prognosis). Primary end point was feasibility, defined as the proportion of patients able to complete the etoposide and cisplatin components of BEP and be eligible to receive a fourth cycle of BEP by day 50.

RESULTS

Twelve poor, 16 intermediate and 15 good prognosis (n = 43) eligible patients were enrolled. Two patients aged >40 years were ineligible and excluded from analyses. The regimen was feasible in 86%, not feasible in 7% and not assessable in 7% of patients. Most common grade 3/4 adverse events were non-neutropenic infection (16%) and febrile neutropenia (12%). Complete response (CR) to chemotherapy and surgery was achieved in 33% poor-prognosis, 81% intermediate-prognosis and 100% good-prognosis patients. At median follow-up of 27 months (range 6-42), the 2-year progression-free survival was 50% for poor-prognosis, 94% for intermediate-prognosis and 92% for good-prognosis patients.

CONCLUSION

Accelerated BEP is feasible and tolerable. Efficacy data appear to be promising. This trial and a similar UK study provide the rationale for a randomised trial comparing accelerated versus standard BEP. Australian New Zealand Clinical Trials Registry Registration number. ACTRN 12607000294459.

Molecular diagnosis in clinical parasitology: When and why?

Microscopic detection and morphological identification of parasites from clinical specimens are the gold standards for the laboratory diagnosis of parasitic infections. The limitations of such diagnostic assays include insufficient sensitivity and operator dependence. Immunoassays for parasitic antigens are not available for most parasitic infections and have not significantly improved the sensitivity of laboratory detection. Advances in molecular detection by nucleic acid amplification may improve the detection in asymptomatic infections with low parasitic burden. Rapidly accumulating genomic data on parasites allow the design of polymerase chain reaction (PCR) primers directed towards multi-copy gene targets, such as the ribosomal and mitochondrial genes, which further improve the sensitivity. Parasitic cell or its free circulating parasitic DNA can be shed from parasites into blood and excreta which may allow its detection without the whole parasite being present within the portion of clinical sample used for DNA extraction. Multiplex nucleic acid amplification technology allows the simultaneous detection of many parasitic species within a single clinical specimen. In addition to improved sensitivity, nucleic acid amplification with sequencing can help to differentiate different parasitic species at different stages with similar morphology, detect and speciate parasites from fixed histopathological sections and identify anti-parasitic drug resistance. The use of consensus primer and PCR sequencing may even help to identify novel parasitic species. The key limitation of molecular detection is the technological expertise and expense which are usually lacking in the field setting at highly endemic areas. However, such tests can be useful for screening important parasitic infections in asymptomatic patients, donors or recipients coming from endemic areas in the settings of transfusion service or tertiary institutions with transplantation service. Such tests can also be used for monitoring these recipients or highly immunosuppressed patients, so that early preemptive treatment can be given for reactivated parasitic infections while the parasitic burden is still low.

Structure of plasma and tissue kallikreins

The kallikrein kinin system (KKS) consists of serine proteases involved in the production of peptides called kinins, principally bradykinin and Lys-bradykinin (kallidin). The KKS contributes to a variety of physiological processes including inflammation, blood pressure control and coagulation. Here we review the protein structural data available for these serine proteases and examine the molecular mechanisms of zymogen activation and substrate recognition focusing on plasma kallikrein (PK) and tissue kallikrein (KLK1) cleavage of kininogens. PK circulates as a zymogen bound to high-molecular-weight kininogen (HK). PK is activated by coagulation factor XIIa and then cleaves HK to generate bradykinin and factor XII to generate further XIIa.A structure has been described for the activated PK protease domain in complex with the inhibitor benzamidine. Kallikrein-related peptidases (KLKs) have a distinct domain structure and exist as a family of 15 genes which are differentially expressed in many tissues and the central nervous system.They cleave a wide variety of substrates including low-molecular-weight kininogen (LK) and matrix proteins. Crystal structures are available for KLK1, 3, 4, 5, 6 and 7 activated protease domains typically in complex with S1 pocket inhibitors. A substrate mimetic complex is described for KLK3 which provides insight into substrate recognition. A zymogen crystal structure determined for KLK6 reveals a closed S1 pocket and a novel mechanism of zymogen activation. Overall these structures have proved highly informative in understanding the molecular mechanisms of the KKS and provide templates to design inhibitors for treatment of a variety of diseases.

Characterizing hepatitis B stigma in Chinese immigrants

Health-related stigma is a cause of stress, alienation and discrimination that can serve as a barrier to prevention and care for infectious diseases such as HIV. Hepatitis B virus (HBV)-related stigma is common in Asian immigrants, but has not been formally evaluated. The aim of this study was to develop and validate the first HBV stigma instrument and to begin to evaluate HBV stigma in Chinese immigrants. The HBV stigma instrument was developed based on constructs from validated HIV stigma scales and organized into five domains. A written survey was compiled to include demographic data, HBV knowledge questions and stigma items. The survey was pilot tested in English and Chinese and then finalized. Data were obtained from 201 patients seen in an urban Chinatown Internal Medicine practice. The stigma items showed a high degree of reliability when assessed in aggregate (α = 0.85) as well as within individual domains. Stigma was greatest in the Fear of Contagion domain. Knowledge questions showed a corresponding deficit in understanding of modes of HBV transmission. An inverse relationship between stigma scores and familiarity with HBV provided evidence of construct validity. In multivariable analysis, having a family member with HBV and higher HBV knowledge subset scores were associated with lower degrees of stigma. In conclusion, the hepatitis B stigma instrument showed reliability and construct validity. The relationship identified between familiarity and knowledge regarding HBV with lower stigma scores provides the basis for the development of interventions to reduce HBV stigma.

The prevalence and clinical correlates of elevated ALT levels in an urban Chinatown community

Alanine aminotransferase (ALT) levels are a primary consideration in treatment decisions regarding hepatitis B virus (HBV) infection. Levels can be elevated as a result of HBV-related liver injury or to other causes. The aim of this study was to assess the background prevalence and clinical correlates of elevated ALT levels in Chinese immigrants who were HBsAg negative. Subjects consisted of adults seen in an urban Chinatown Internal Medicine practice between 1, 2006 and 12, 2007. Clinical information was collected retrospectively. An elevated ALT level was defined as >19 U/L for women and >30 U/L for men. The primary analysis focused on 2457 persons who were HBsAg negative. Their mean age was 55 +/- 18 years, 64% were female and 36% were obese. All subjects were ethnically Chinese and 96% were born in Asia. Thirty percent had an elevated ALT level. In univariate analysis, factors associated with elevated ALT included older age (P < 0.001), female gender (P = 0.001), obesity (P < 0.001), diabetes (P < 0.001), hypercholesterolemia (P < 0.001) and hypertension (P < 0.001). In multivariate analysis BMI, diabetes, female gender and hypercholesterolemia were significantly associated with elevated ALT level. An additional analysis focused on a group of patients who were HBsAg positive, HBeAg negative and had HBV-DNA levels <1000 copies/mL. Fifty percent had elevated ALT levels. In conclusion, elevated ALT levels are common among Chinese immigrants without HBV (30%) and are associated with features of the metabolic syndrome. Liver biopsy should be performed in selected patients with HBV to distinguish the cause of ALT elevation before initiating antiviral therapy.

Optimization of coagulation-flocculation process for pulp and paper mill effluent by response surface methodological analysis

Coagulation-flocculation is a proven technique for the treatment of high suspended solids wastewater. In this study, the central composite face-centered design (CCFD) and response surface methodology (RSM) have been applied to optimize two most important operating variables: coagulant dosage and pH, in the coagulation-flocculation process of pulp and paper mill wastewater treatment. The treated wastewater with high total suspended solids (TSS) removal, low SVI (sludge volume index) and high water recovery are the main objectives to be achieved through the coagulation-flocculation process. The effect of interactions between coagulant dosage and pH on the TSS removal and SVI are significant, whereas there is no interaction between coagulant dosage and water recovery. Quadratic models have been developed for the response variables, i.e. TSS removal, SVI and water recovery based on the high coefficient of determination (R(2)) value of >0.99 obtained from the analysis of variances (ANOVA). The optimum conditions for coagulant dosage and pH are 1045mgL(-1) and 6.75, respectively, where 99% of TSS removal, SVI of 37mLg(-1) and 82% of water recovery can be obtained.

Treatment of pulp and paper mill wastewater by polyacrylamide (PAM) in polymer induced flocculation

The flocculation performances of nine cationic and anionic polyacrylamides with different molecular weights and different charge densities in the treatment of pulp and paper mill wastewater have been studied. The experiments were carried out in jar tests with the polyacrylamide dosages range of 0.5-15 mg l(-1), rapid mixing at 200 rpm for 2 min, followed by slow mixing at 40 rpm for 15 min and settling time of 30 min. The effectiveness of the polyacrylamides was measured based on the reduction of turbidity, the removal of total suspended solids (TSS) and the reduction of chemical oxygen demand (COD). Cationic polyacrlyamide Organopol 5415 with very high molecular weight and low charge density is found to give the highest flocculation efficiency in the treatment of the paper mill wastewater. It can achieve 95% of turbidity reduction, 98% of TSS removal, 93% of COD reduction and sludge volume index (SVI) of 14 ml g(-1) at the optimum dosage of 5 mg l(-1). SVI values of less than 70 m lg(-1) are found for all polyacrylamide at their respective optimum dosage. Based on the cost evaluation, the use of the polyacrylamides is economically feasible to treat the pulp and paper mill wastewaters. This result suggests that single-polymer system can be used alone in the coagulation-flocculation process due to the efficiency of the polyacrylamide. Sedimentation of the sludge by gravity thickening with settling time of 30 min is possible based on the settling characteristics of the sludge produced by Organopol 5415 that can achieve 91% water recovery and 99% TSS removal after 30 min settling.

A preliminary assessment of consumer's exposure to pesticide residues in fisheries products

The fisheries products in this study comprise fish, bivalve, crustacean and cephalopod collected from different types of markets in Taiwan between the years 2001 and 2003. A total of 91 pesticide residues belonging to four major pesticide groups were tested and analyzed. The test results show that 65.40% of fish, 93.55% of shellfish, 84.92% of crustacean and 98.33% of cephalopod samples contain no detectable residues. There are only two kinds (organochlorine and organophosphate) of totally six pesticides (DDTs, dieldrin, chlorpyrifos, fenitrotion, fenthion and prothion) that have been detected from the fisheries products in this study. For there were pesticides present in the fish products, consumption of fisheries product there was no zero risk. But the exposure of consumer did not exceed the acceptable daily intakes (ADI). For male, there was the highest risk in exposure to dieldrin, which the percentage of ADI was 93.56%. This study also suggests that a yearly monitoring program for organophosphate pesticide residues in fish is necessity.

Drotrecogin alfa (activated) prevents smoke-induced increases in pulmonary microvascular permeability and proinflammatory cytokine IL-1beta in rats

In an established rat model of smoke inhalation injury, we conducted a dose-response study to examine the protective effects of Xigris [drotrecogin alfa (activated) (DrotAA)], a recombinant form of human activated protein C (APC). DrotAA is a serine protease (approximately 55 kD molecular weight) with the same amino acid sequence and the glycosylation site as human plasma-derived APC. A total of 120 F344/NH rats (half each gender, approximately 175 g body weight) were randomly divided into five groups and exposed nose-only to air or diesel fuel smoke for 20 min. These rats were then i.v. administered with DrotAA in 0, 5, 10, and 20 mg/kg body weight, respectively, immediately following smoke exposure. Treatment with DrotAA significantly attenuated smoke inhalation injury in a dose-dependent manner at 2 hours after insult, as indicated by preserving microvascular permeability and proinflammatory cytokine IL-1beta (but not TNF-alpha and neuropeptide substance P) in bronchoalveolar lavage fluid (BALF). Moreover, the rats treated with 20 mg/ kg of DrotAA had an improvement of the expiration phase of pulmonary dynamic compliance. At all dosages, however, DrotAA also significantly increased all phases of pulmonary resistance compared with either the controls or to smoke inhalation alone. Generally, these data suggest that DrotAA may exert an anti-inflammatory effect by inhibiting cytokine-mediated inflammatory amplification. However, additional studies following a clinical course are needed to confirm the maximum efficiency and possible side effects of this recombined human activated protein C.

Relative rates of non-pneumonic SARS coronavirus infection and SARS coronavirus pneumonia

BACKGROUND

Although the genome of severe acute respiratory syndrome coronavirus (SARS-CoV) has been sequenced and a possible animal reservoir identified, seroprevalence studies and mass screening for detection of subclinical and non-pneumonic infections are still lacking.

METHODS

We cloned and purified the nucleocapsid protein and spike polypeptide of SARS-CoV and examined their immunogenicity with serum from patients with SARS-CoV pneumonia. An ELISA based on recombinant nucleocapsid protein for IgG detection was tested with serum from 149 healthy blood donors who donated 3 years previously and with serum positive for antibodies against SARS-CoV (by indirect immunofluorescence assay) from 106 patients with SARS-CoV pneumonia. The seroprevalence of SARS-CoV was studied with the ELISA in healthy blood donors who donated during the SARS outbreak in Hong Kong, non-pneumonic hospital inpatients, and symptom-free health-care workers. All positive samples were confirmed by two separate western-blot assays (with recombinant nucleocapsid protein and recombinant spike polypeptide).

FINDINGS

Western-blot analysis showed that the nucleocapsid protein and spike polypeptide of SARS-CoV are highly immunogenic. The specificity of the IgG antibody test (ELISA with positive samples confirmed by the two western-blot assays) was 100%, and the sensitivity was 94.3%. Three of 400 healthy blood donors who donated during the SARS outbreak and one of 131 non-pneumonic paediatric inpatients were positive for IgG antibodies, confirmed by the two western-blot assays (total, 0.48% of our study population).

INTERPRETATION

Our findings support the existence of subclinical or non-pneumonic SARS-CoV infections. Such infections are more common than SARS-CoV pneumonia in our locality.

A study of admission criteria and early management of adult patients with acute asthma

We studied the admission criteria and first 24-hour management of 62 asthmatic patients admitted from Accident and Emergency (A&E) department of a state hospital. Data was collected prospectively over a 6-month period from the doctors' medical records with reference to recommendations of the Malaysian Thoracic Society (MTS) on management of acute asthma. Peak Expiratory Flow Rate (PEFR) records were present in only 14.5% of the A&E notes and 54.8% of the ward notes. Most of these readings were below 75% of predicted normal values. Over half of the patients had records on ability to speak full sentences, and respiratory and pulse rates. Based on other records on criteria for life-threatening features (including arterial blood gases), 42% of patients studied had life threatening asthma exacerbations. Most received appropriate treatment as recommended by the MTS. We conclude that while most patients were admitted and treated appropriately, medical documentation regarding acute asthma assessment were inadequate in some.

A case of disseminated Mycobacterium marinum infection following systemic steroid therapy

We describe the dissemination of Mycobacterium marinum infection from the right middle finger to the whole extremity and two legs, with the involvement of tendons and joints, in a patient who was treated with a steroid when Mycobacterium marinum infection was not suspected. The patient was successfully treated with a combined surgical and medical approach.

Differences in clinical and laboratory diagnostic characteristics of penicilliosis marneffei in human immunodeficiency virus (HIV)- and non-HIV-infected patients

We compared the clinical and laboratory features of human immunodeficiency virus (HIV)- and non-HIV-infected patients with penicilliosis marneffei. HIV-infected patients had a higher incidence of fungemia. A total of 85.7% of the HIV-negative patients had underlying diseases including hematologic malignancies or had received therapy with corticosteroids or cytotoxic agents. By a Penicillium marneffei-specific mannoprotein Mp1p enzyme-linked immunosorbent assay, serum antigen titers were found to be higher in HIV-positive patients, whereas serum antibody levels were found to be higher in HIV-negative patients.

Comparison of a picture-sort food-frequency questionnaire with 24-hour dietary recalls in an elderly Utah population

OBJECTIVE

To evaluate the 137-item Utah Picture-sort Food-frequency Questionnaire (FFQ) in the measurement of usual dietary intake in older adults.

DESIGN

The picture-sort FFQ was administered at baseline and again one year later. Three seasonal 24-hour dietary recall interviews were collected during the year between the two FFQs. Mean nutrient intakes were compared between methods and between administrations of the FFQ.

SETTING

The FFQ interviews were administered in respondents' homes or care-centres. The 24-hour diet recalls were conducted by telephone interview on random days of the week.

SUBJECTS

Two-hundred-and-eight men and women aged 55-84 years were recruited by random sample of controls from a case-control study of nutrition and bone health in Utah.

RESULTS

After adjustment for total energy intake, median Spearman rank correlation coefficients between the two picture-sort FFQs were 0.69 for men aged < or = 69 years, 0.66 for men aged > 69 years; and 0.68 for women aged < or = 69 years, 0.67 for women aged > 69 years. Median correlation coefficients between methods were 0.50 for men < or = 69 years old, 0.52 for men > 69 years old; 0.55 for women < or = 69 years old, 0.46 for women > 69 years old.

CONCLUSIONS

We report intake correlations between methods and administrations comparable to those reported in the literature for traditional paper-and-pencil FFQs and one other picture-sort method of FFQ. This dietary assessment method may improve ease and accuracy of response in this and other populations with low literacy levels, poor memory skill, impaired hearing, or poor vision.

Food poisoning due to methamidophos-contaminated vegetables

BACKGROUND

Organophosphate poisoning is well known for its characteristic symptoms and signs, but food poisoning caused by pesticide-contaminated food is seldom reported.

CASE REPORT

We report three incidents of food poisoning that resulted from exposure to the organophosphate insecticide methamidophos in vegetables. These outbreaks caused a cholinergic syndrome in 4 patients. The cholinergic overactivity led as to suspect organophosphate food poisoning. All patients recovered well following appropriate therapy. The clinical diagnosis of organophosphate poisoning was confirmed by reduced levels of erythrocytes and plasma cholinesterase and the presence of methamidophos in the vegetable leftovers. The implicated vegetables and levels of methamidophos were: Ipomoea batatas 255 ppm, Gynura bicolor 110 ppm, and red cabbage 26.3 ppm. Since methamidophos is normally applied to vegetables during planting, improper selection and/or overuse of pesticide or improper harvest times may explain the occurrence of these high residue levels of methamidophos.

Long-term colchicine for recalcitrant palmoplantar pustulosis: treatment outcome in 3 patients

Palmoplantar pustulosis (PPP) is a chronic, relapsing, pustular eruption affecting the palms and soles for which treatment is often difficult and frustrating. Short-term colchicine has been used to treat PPP with variable response. We report on the successful treatment of 3 patients with severe, therapy-resistant, chronic PPP. We observed significant reduction in the frequency of pustular eruptions and the number of pustules with maximum tolerable doses of colchicine treatment for up to 12 months.

Group G beta-hemolytic streptococcal bacteremia characterized by 16S ribosomal RNA gene sequencing

Little is known about the relative importance of the four species of Lancefield group G beta-hemolytic streptococci in causing bacteremia and the factors that determine the outcome for patients with group G beta-hemolytic streptococcal bacteremia. From 1997 to 2000, 75 group G beta-hemolytic streptococcal strains were isolated from the blood cultures of 66 patients. Sequencing of the 16S rRNA genes of the group G beta-hemolytic streptococci showed that all 75 isolates were Streptococcus dysgalactiae subspecies equisimilis. The API system (20 STREP) and Vitek system (GPI) successfully identified 65 (98.5%) and 62 (93.9%) isolates, respectively, as S. dysgalactiae subspecies equisimilis with >95% confidence, whereas the ATB Expression system (ID32 STREP) only successfully identified 49 isolates (74.2%) as S. dysgalactiae subspecies equisimilis with >95% confidence. The median age of the patients was 76 years (range, 33 to 99 years). Fifty-six patients (85%) were over 60 years old. All patients had underlying diseases. No source of the bacteremia was identified (primary bacteremia) in 34 patients (52%), whereas 17 (26%) had cellulitis and 8 (12%) had bed sore or wound infections. Fifty-eight patients (88%) had community-acquired group G streptococcal bacteremia. Sixty-two patients (94%) had group G Streptococcus recovered in one blood culture, whereas 4 patients (6%) had it recovered in multiple blood cultures. Fifty-nine patients (89%) had group G Streptococcus as the only bacterium recovered in their blood cultures, whereas in 7 patients other bacteria were recovered concomitantly with the group G Streptococcus in the blood cultures (Staphylococcus aureus in 3, Clostridium perfringens in 2, Citrobacter freundii in 1, and Bacteroides fragilis in 1). Overall, 10 patients (15%) died. Male sex, diagnosis other than cellulitis, hospital-acquired bacteremia, and multiple positive blood cultures were associated with mortality [P < 0.005 (relative risk [RR] = 7.6), P < 0.05 (RR = 3.7), P < 0.005 (RR = 5.6), and P < 0.05 (RR = 5.6), respectively]. Unlike group C beta-hemolytic streptococcal bacteremia, group G beta-hemolytic streptococcal bacteremia is not a zoonotic infection in Hong Kong.

Two cases of pyomyositis caused by Klebsiella pneumoniae and review of the literature

Two patients with diabetes mellitus developed Klebsiella pneumoniae pyomyositis involving multiple muscles and other metastatic foci associated with bacteraemia. The cases are presented here, and the 22 cases of gram-negative pyomyositis reported previously in the literature are reviewed. As gram-positive cocci cause 99% of pyomyositis, it is postulated that the pathogenesis of pyomyositis may be associated with the ability of the bacteria to adhere to muscles by various cell surface adhesins that are not present in gram-negative bacilli. It is also postulated that a high serum glucose concentration may facilitate the growth and formation of the Klebsiella pneumoniae capsule, hence increasing its virulence and causing serious disseminated Klebsiella infections in diabetic patients.

Fatal poisoning by butachlor and chlornitrofen ingested from a bottle marked as nitrofen

Nitrofen has been banned in Taiwan since January 1, 1983 due to its tetrogenicity. A 78-y-o female consumed about 500 ml of herbicide, labeled as nitrofen, in a suicide attempt. Consciousness disturbance occurred immediately. After 9 h, bloody-tarry stool was noted. Hematemesis occurred 19 h later. Hepatotoxicity and nephrotoxicity also developed. Twitching of head and both upper extremities lasting 20-30 sec and up to 5 min developed on day 3. Sometimes an upward gaze with the face turned to the right or a convulsion of the right upper extremity was observed. EEG showed alpha coma, generalized slow spike-and-wave complexes, and isolated generalized sharp waves mainly in the left occipital area. On day 7, endotracheal intubation was performed due to apnea; she expired on day 9. The pesticide was found to contain butachlor and chlornitrofen. The Agricultural Committee prohibited the marketing of chlornitrofen due to its generation of tumors in animals. The combination of butachlor and chlornitrofen can result in consciousness disturbance, leucocytosis, gastrointestinal hemorrhage, rhabdomyolysis, hypocalcemia, hypoalbuminemia, elevated amylase, nephrotoxicity, hepatotoxicity, seizures and death. The cytotoxicity of butachlor may be related to the patient's death. Active components of pesticides should be checked if the clinical course of a poisoned patient is unusual to allow appropriate interventions.

Dissipation of epoxiconazole in the paddy field under subtropical conditions of Taiwan

The environmental fate and distribution of fungicide epoxiconazole were studied by a rice paddy field model ecosystem. One week before the head-sprouting stage, rice plant was treated separately once with OPUS (tradename of epoxiconazole) 12% SC 2.1 kg ha(-1) and 1.4 kg ha(-1), respectively. Soil, water and rice plant were sampled seven days intervals nine times after application. The bioconcentration factor of epoxiconazole on mosquito fish in the ecosystem was also determined, based on the amounts of epoxiconazole content both in fish and water. This was initiated one day after the fungicide treatment, and continued for four days. In addition, the residue of epoxiconazole in rice grains was analyzed after harvest. After harvest, both planted water spinach (Ipomoea aquatica Forsk) and edible amaranth (Amaranthus mangostanüs L.) were analyzed. The results showed that epoxiconazole degraded in the local environment under the experimental conditions described. The degradation equations were in accordance with the first order kinetics. The DT50 of soil, field water and rice plant were 20-69 days, 11-20 days and 14-39 days, respectively. The bioconcentration factors of epoxiconazole on mosquito fish were 12.9 and 10.6 from 2.1 kg ha(-1) and 1.4 kg ha(-1) treatment, respectively. Residues of epoxiconazole in both rice and harvest vegetables were non-detectable. This indicates that epoxiconazole applied to rice at the recommended rates and application frequencies will not accumulate on rice grain and successive cropping vegetables.

groEL encodes a highly antigenic protein in Burkholderia pseudomallei

No recombinant protein is available for serodiagnosis of melioidosis. In this study, we report the cloning of the groEL gene, which encodes an immunogenic protein of Burkholderia pseudomallei. Bidirectional DNA sequencing of groEL revealed that the gene contained a single open reading frame encoding 546 amino acid residues with a predicted molecular mass of 57.1 kDa. Basic Local Alignment Search Tool analysis showed that the putative protein encoded by groEL is homologous to the chaperonins encoded by the groEL genes of other bacteria. It has 98% amino acid identity with the GroEL of Burkholderia cepacia, 98% amino acid identity with the GroEL of Burkholderia vietnamiensis, and 82% amino acid identity with the GroEL of Bordetella pertussis. Furthermore, it was observed that patients with melioidosis develop a strong antibody response against GroEL, suggesting that the recombinant protein and its monoclonal antibody may be useful for serodiagnosis in patients with melioidosis and that the protein may represent a good cell surface target for host humoral immunity. Further studies in these directions would be warranted.

Overabundance of CD45RA(+) (quiescent-phenotype) cells within the involuted CD4(+) T-cell population follows initiation of immune depression in energy-deficient weanling mice and reflects involution exclusive to the CD45RA(-) subset

Previous studies have identified an overabundance of quiescent-phenotype (CD45RA(+)) CD4(+) T cells throughout the lymphoid system of weanling mice at an advanced stage of food intake restriction mimicking marasmus. The objective of this investigation was to determine the timing of this phenomenon relative to the development of depression in cell-mediated immune competence. Two experiments were conducted in which male and female weanling C57BL/6J mice, initially 19 d of age, either were permitted free access to a complete purified diet or were subjected to restricted intake of this diet, producing loss of 1.5-2% of initial body weight daily. In the first experiment, feeding periods of 3, 6, 9, 12 and 14 d were examined, and a zero-time control group (19 d old) was also included. Expression of CD45RA was assessed by flow cytometry in CD4(+) T cells from the blood, spleen and mesenteric lymph nodes. Despite reduction in CD4(+) T-cell numbers, evident in all three lymphoid compartments of the malnourished mice by d 6, energy-restricted mice maintained the numbers of CD4(+)CD45RA(+) T cells at the level found in the zero-time control group. Consequently, the malnourished group exhibited a high percentage of CD4(+) T cells expressing CD45RA by d 9 in the blood and mesenteric nodes and by d 12 in the spleen. In the second study, malnourished and age-matched control groups were sensitized to sheep red blood cells on d 3 and energy-restricted mice exhibited depression in the delayed hypersensitivity response to this antigen when assessed on d 9 after challenge 24 h previously. Energy deficiency pathology includes a shift toward CD4(+) T cell quiescence that may contribute to ongoing immunodepression without being involved in its initiation. Remarkably, this imbalance develops because involution of the CD4(+) subset in the energy-deficient mice is confined to the CD45RA(-) population.

Immunorestitution diseases in patients not infected with HIV

The aim of this study was to assess the clinical spectrum of immunorestitution disease (IRD) in hospitalized patients over a 12-month period. In nine of 18 patients who presented with clinical deterioration during reduction or cessation of immunosuppressants (n = 6) or bone marrow engraftment (n = 3), IRD cases included the following infections: scabies infestation (n = 1); gastric strongyloidiasis (n = 1); hepatosplenic candidiasis (n = 1); methicillin-resistant Staphylococcus aureus abscess formation (n = 2); polyomavirus-related hemorrhagic cystitis (n = 3); and influenza A pneumonitis (n = 1). Immunopathological damage during withdrawal of immunosuppression is an incidental way to uncover an asymptomatic infectious disease. Serial monitoring of hematological and clinical profiles is essential in making a diagnosis of IRD.

Biotyping of Penicillium marneffei reveals concentration-dependent growth inhibition by galactose

Thirty-two isolates of the dimorphic fungus Penicillium marneffei were studied for their biochemical properties. All isolates possessed the enzyme urease and were inhibited by 500 mg of cycloheximide per liter. No strain fermented glucose, and thus no strain fermented any of the other five sugars tested. All assimilated glucose, maltose, and cellobiose; only one of the isolates did not assimilate salicin. Totals of 65.6, 84.4, and 71.9% of the isolates assimilated trehalose, xylose, and nitrate, respectively. Twelve strains possessed the enzyme beta-galactosidase. Overall, 17 different biotypes were recognized, but no association was found between the human immunodeficiency virus status of the patients and the biotype. A novel finding of concentration-dependent growth inhibition of P. marneffei by galactose is described. Inhibition of growth occurred at a low concentration of galactose (0.015 to 0.25%) when galactose was the sole carbon source in the medium. Morphological changes of the fungal cells were observed in the presence of galactose.

Cell-wall-deficient bacteria and culture-negative febrile episodes in bone-marrow-transplant recipients

BACKGROUND

Although about 75-80% of neutropenic fevers are thought to be caused by infections, a causal organism can be confirmed microbiologically or suspected clinically in only 30-50%, and even fewer of these cases (16%) have a documented bacteraemia. The cause of neutropenic fever in the remaining cases remains elusive. We investigate the role of cell-wall-deficient bacteria in bone-marrow transplantation (BMT).

METHODS

Blood cultures were obtained from bone-marrow-transplant recipients and were inoculated into an aerobic bottle with resin, an anaerobic bottle, and a bottle to isolate cell-wall deficient bacteria. When growth was detected in the blood-culture bottle for cell-wall-deficient bacteria, 20 microL of the broth was subcultured and the isolate identified by standard biochemical methods. The microbiological findings were correlated with the clinical characteristics of the patients.

FINDINGS

From the 86 BMT recipients enrolled into the study, 798 sets of blood cultures were sent for laboratory analysis. 55 blood cultures were positive in the aerobic bottle, and the same isolates were also detected in 52 blood-culture bottles for cell-wall-deficient forms. For 20 sets of blood cultures, the isolates were detected only in the bottle for cell-wall-deficient forms. Blood for 13 (65%) of these 20 sets were sampled in the pre-engraftment neutropenic period, three (15%) during conditioning when the absolute neutrophil count was above 0.5 x 10(3)/L, and four (20%) in the post-engraftment period. 17 (85%) of the isolates were gram positive: four (20%) were Staphylococcus spp and ten (50%) were Bacillus spp. Antibiotic treatment was successful in 19 (95%) of 20 episodes.

INTERPRETATION

Bacteraemia due to cell-wall-deficient forms causes a significant proportion of so-called culture-negative febrile episodes in BMT recipients.

Isolation and characterization of a Salmonella enterica serotype Typhi variant and its clinical and public health implications

We report the isolation and characterization of a member of the family Enterobacteriaceae isolated from the gallbladder pus of a food handler. Conventional biochemical tests suggested Salmonella enterica serotype Typhi, but the isolate agglutinated with poly(O), 2O, 9O, and Vi Salmonella antisera but not with poly(H) or any individual H Salmonella antisera. 16S rRNA gene sequencing showed that there were two base differences between the isolate and Salmonella enterica serotype Montevideo, four base differences between the isolate and serotype Typhi, five base differences between the isolate and Salmonella enterica serotype Typhimurium, and six base differences between the isolate and Salmonella enterica serotype Dublin, indicating that the isolate was a strain of S. enterica. Electron microscopy confirmed that the isolate was aflagellated. The flagellin gene sequence of the isolate was 100% identical to that of the H1-d flagellin gene of serotype Typhi. Sequencing of the rfbE gene, which encoded the CDP-tyvelose epimerase of the isolate, showed that there was a point mutation at position +694 (G-->T), leading to an amino acid substitution (Gly-->Cys). This may have resulted in a protein of reduced catalytic activity and hence the presence of both 2O and 9O antigens. We therefore concluded that the isolate was a variant of serotype Typhi. Besides antibiotic therapy and cholecystectomy, removal of all stones in the biliary tree was performed for eradication of the carrier state.

Candida tropicalis and Penicillium marneffei mixed fungaemia in a patient with Waldenström's macroglobulinaemia

A patient with Waldenstrom's macroglobulinaemia who had previously been treated with cladribine presented with septic arthritis caused by Escherichia coli. The patient's condition subsequently deteriorated, and he succumbed to pneumonia and mixed fungaemia due to Candida tropicalis and Penicillium marneffei. Profound lymphopenia coexisted with fungaemia. This is the first reported case of mixed Penicillium marneffei and Candida fungaemia and penicilliosis marneffei in a patient with Waldenstrom's macroglobulinaemia. Penicilliosis marneffei should be considered as a potential complication in patients with markedly impaired cell-mediated immunity who have travelled to or resided in endemic areas. Patients who have undergone therapy with purine nucleoside analogues such as fludarabine and cladribine are also at risk.

Rhodococcus equi infections in immunocompetent hosts: case report and review

Rhodococcus equi is an unusual cause of infection in humans. Infection in immunocompetent patients is extremely rare-only 19 cases in immunocompetent hosts have been reported. Localized infections represent nearly 50% of reported cases. Pulmonary infections account for only 42% of infections in immunocompetent hosts, compared with 84% of infections in immunocompromised hosts. The mortality rate among immunocompetent patients is approximately 11%, compared with rates of 50%-55% among human immunodeficiency virus (HIV)-infected patients and 20%-25% among non-HIV-infected immunocompromised patients. Treatment of infections in immunocompetent hosts depends on the site of infection. Serious infections need to be treated with combinations of parenteral antibiotics, followed by combinations of oral antibiotics. Surgical treatment is necessary for certain types of local infections. We report a pulmonary infection due to R. equi in an immunocompetent patient, and we review all reported cases of R. equi infection in immunocompetent hosts.

Vogt-Koyanagi-Harada disease: extensive vitiligo with prodromal generalized erythroderma

The occurrence of vitiligo with prodromal erythema in Vogt-Koyanagi-Harada (VKH) disease is rarely observed. We describe a 68-year-old Chinese woman who developed extensive vitiligo 6 months after the onset of a generalized erythroderma and 12 months after the onset of acute bilateral uveitis. She also had a 4-year history of psoriatic plaques on the trunk which resolved completely without recurrence 15 months after the onset of erythroderma. The extensive cutaneous inflammation prior to the onset of vitiligo in our patient with VKH disease has not been reported before and strongly suggests an immunologic etiology for VKH disease.

Leukocytoclastic vasculitis complicating Klebsiella pneumoniae bacteremia

A 79-year old woman, with a history of hypertension, presented with clinical features of congestive heart failure, fever, a purpuric rash, and left lower quadrant abdominal tenderness. Contrast computed tomography scan of the abdomen showed features of acute diverticulitis, and blood culture was subsequently positive for Klebsiella pneumoniae. Histological examination of a biopsy of the rash confirmed a diagnosis of leukocytoclastic vasculitis (LCV). The bacteremia responded to intravenous amoxycillin/clavulanic acid and gentamicin and the rash subsided. This case represents the first case of LCV complicating K. pneumoniae bacteremia in the English literature. The English literature on bacteria-associated LCV is reviewed. Taking aside organisms such as Rickettsia that cause endothelial invasion, the associated bacterial species tends to be subacute or chronic pathogens e.g. Mycoplasma pneumoniae, Mycobacterium tuberculosis, and Yersinia enterocolitica; or the disease process is of a subacute or chronic nature e.g. endocarditis, bronchiectesis, and cystic fibrosis, leading to prolonged exposure to pathogens that apparently cause acute pyogenic infections, such as K. pneumoniae.

A case of recurrent disseminated granuloma annulare

We present an 11-year-old boy who developed multiple pruritic, skin-coloured papules on his forehead, which subsequently spread to his trunk and limbs over a period of 6 months. Histology revealed granuloma annulare. The lesions underwent spontaneous regression over the next five years. He presented again when he was 18 years old, with a spontaneous eruption of multiple lesions on the trunk and the limbs 2 years after complete clinical remission from the first attack. A punch biopsy performed at this presentation revealed granuloma annulare again. No treatment was given and he is still being followed up. The tendency for spontaneous resolution of granuloma annulare is well recognised. Recurrent localized lesions often disappeared more rapidly than the original ones. Recurrence of disseminated GA, to our knowledge, has not been reported before.

Enhancement by ampicillin of antibody responses induced by a protein antigen and a DNA vaccine carried by live-attenuated Salmonella enterica serovar Typhi

Live-attenuated Salmonella species are effective carriers of microbial antigens and DNA vaccines. In a mouse model, the immunoglobulin M (IgM) and total antibody levels directed toward the lipopolysaccharide of Salmonella enterica serovar Typhi were significantly enhanced at day 21 after oral immunization with live-attenuated serovar Typhi (strain Ty21a) when ampicillin was concomitantly administered (P < 0.05 and P < 0.005, respectively). The heat-killed Ty21a-stimulated lymphocyte proliferation indices for the ampicillin group at day 21 were significantly higher than those for the normal saline (NS) group (P < 0.005, P < 0.001, and P < 0.01) for all three doses of antigen (10(4), 10(5), and 10(6) heat-killed Ty21a per well, respectively). The 50% lethal doses for mice from the ampicillin and NS groups immunized with Ty21a with pBR322 after wild-type serovar Typhi challenge on day 24 were 3.4 x 10(7) and 5.0 x 10(6) CFU, respectively. The fecal bacterial counts for the ampicillin group at days 1, 3, and 5 were significantly lower than those for the NS group (P < 0.01, P < 0.01, and P < 0.05, respectively), and there was a trend toward recovery of Ty21a in a larger number of mice from the ampicillin group than from the NS group. Furthermore, the IgG2a levels directed toward tetanus toxoid were significantly enhanced at days 7 and 21 after oral immunization with Ty21a that carried the fragment c of tetanus toxoid when ampicillin was concomitantly administered (P < 0.05 and P < 0.005, respectively), and the IgM and total hepatitis B surface antibody levels were significantly enhanced at days 7 (P < 0.005 and P < 0.05, respectively) and 21 (P < 0.01 and P < 0.05, respectively) after oral immunization with Ty21a that carried the DNA vaccine that encodes hepatitis B surface antigen when ampicillin was concomitantly administered. The present observation may improve the efficacy of the protein antigens and DNA vaccines carried in live-attenuated bacteria, and further experiments should be carried out to determine the best antibiotics and dosage regimen to be used, as well as the best carrier system for individual protein antigens and DNA vaccines.

Interlaboratory study of identification and quantitation of multiresidue pyrethroids in agricultural products by gas chromatography-mass spectrometry

This paper deals with the different GC-MS analytical conditions adopted by four laboratories in an attempt to confirm the accuracy of the GC-electron-capture detection (ECD) analytical results during the international collaborative study for the establishment of the AOAC Official Method 998. 01. What is especially noted is that two laboratories have conducted comparative analysis of the respective 12 blind samples with both methods of GC-ECD and GC-MS, and the analytical results of the two methods turn out to be basically identical. This fully demonstrates that GC-MS is not only an effective confirmation tool in the analysis of the pyrethroid residues but also of sufficient sensitivity regarding the maximum residue limit of determination prescribed by FAO/WHO. Moreover, its selectivity is better than GC-ECD.

Immunorestitution disease involving the innate and adaptive response

Immunorestitution disease (IRD) is defined as an acute symptomatic or paradoxical deterioration of a (presumably) preexisting infection that is temporally related to the recovery of the immune system. We report the temporal sequence of events that led to IRD caused by Pneumocystis carinii and Aspergillus terreus in 2 human immunodeficiency virus (HIV)-negative patients soon after the recovery of adaptive and innate immunity, respectively, and we review episodes noted in the English-language literature that fit the definition of IRD (109 episodes in 107 patients). The median time from the recovery of neutrophil counts or termination of steroid therapy to the development of IRD was 8 days in cases of pulmonary aspergillosis (23 episodes) and hepatosplenic candidiasis (8) and 21 days for viral diseases such as hepatitis B (24) and viral pneumonitis (6). For IRD due to mycobacteriosis (27 episodes) and cryptococcosis (4) in HIV-positive patients, the median interval between the initiation of highly active antiretroviral therapy (HAART) and the onset of IRD was 11 days; for viral infections, including those due to cytomegalovirus (14), hepatitis B virus (1), and hepatitis C virus (2), the median interval was 42 days. As an emerging clinical entity, IRD merits further study to optimize treatment of immunosuppressed patients.

Cutaneous leishmaniasis: a report of two cases seen at a tertiary dermatological centre in Singapore

Cutaneous leishmaniasis (CL) is not common in South-East Asia and often presents as a granulomatous plaque on the exposed areas, with a high index of suspicion required for diagnosis. Two such cases were seen at the National Skin Centre recently, and both were Gurkha men with a history of travel to Belize. They were treated with intravenous sodium stibogluconate with success. A discussion on CL and its management follows.

Bacteremia due to Staphylococcus aureus with reduced susceptibility to vancomycin

Four cases of bacteremia caused by Staphylococcus aureus with heteroresistance to vancomycin (hetero-VRSA) were described. In at least two of these four mortalities, the cause of death was temporally related to the hetero-VRSA bacteremia. The vancomycin and teicoplanin MICs of the resistant subpopulations of these four hetero-VRSA were 8 and 24 microg/ml, respectively. All isolates were producers of beta-lactamase, produced penicillin-binding protein PBP2a, and possessed the mecA gene accounting for methicillin resistance. Thickening of the peptidoglycan cell wall was observed by electron microscopy. When ampicillin was combined with vancomycin, in vitro synergism was detected using the checkerboard titration method (epsilonFIC = 0.13). The use of vancomycin plus ampicillin-sulbactam could be a viable option in treating severe hetero-VRSA infection in view of the higher affinity of ampicillin toward PBP2a.

Cellulitis complicating lymphoedema

In ten hospitalised patients with cellulitis complicating lymphoedema encountered over a 3-year period (1996-1998), the underlying diseases were carcinoma of the cervix (n = 4), uterus (n = 1), vagina (n = 1), breast (n=2) and nasopharynx (n= 1), and retroperitoneal squamous cell carcinoma (n = 1). Three of the ten patients had positive blood cultures, compared to none of the 20 age-matched, sex-matched controls hospitalised for cellulitis without lymphoedema. The mean duration of fever, tachycardia and cellulitis was significantly longer in patients with lymphoedema than in those without (P<0.05, P<0.05, and P<0.005 respectively). Early treatment initiated by patients themselves may help stop bacterial replication in the initial stages and minimise further damage to the lymphatic system.

Bacteremia caused by staphylococci with inducible vancomycin heteroresistance

The clinical significance of bacteremia due to vancomycin-heteroresistant staphylococci and a rapid laboratory screening method were examined; 203 strains of staphylococci isolated from patients with clinically significant bacteremia were screened by the disk-agar method with use of vancomycin-salt agar to demonstrate satellitism around an aztreonam disk as well as by conventional population screening. Eighteen isolates (three Staphylococcus aureus and 15 coagulase-negative staphylococci) were shown to be heteroresistant to vancomycin. A case-control clinical study showed that the interval between admission and bacteremia, admission to the intensive care unit, prior use of vancomycin and/or beta-lactams, and isolation of methicillin-resistant staphylococci were significantly more common among patients with bacteremia due to staphylococci with heteroresistance to vancomycin; these patients had an overall mortality of 44.4%. The use of vancomycin and admission to the intensive care unit were independently significant risk factors on multivariate analysis. Vancomycin heteroresistance is inducible by salt and beta-lactams. Indiscriminate sequential use of beta-lactams and glycopeptides may facilitate the emergence of glycopeptide resistance.

A preliminary communication of an insight scale in the assessment of lithium non-adherence among Chinese patients in Hong Kong

BACKGROUND

Studies on the relation between insight and medication adherence are limited in Chinese populations.

METHOD

Eighty Chinese outpatients with mood disorder and on lithium for at least one year were asked to complete an 11-item insight scale. Lithium adherence was determined by: (a) subjective report; (b) doctor's clinical impression; or (c) serum lithium level.

RESULTS

The overall insight score (median = 9, range 1-11) exhibited no significant difference between adherent (N = 58, 72.5%) and non-adherent (N = 22, 27.5%) patients. A two-factor model emerged on factor analysis. Lithium adherent (median = 7, range 1-7) patients had a significantly higher score than non-adherent (median = 6, range 0-7) patients on the 'medical help seeking' factor (Mann-Whitney U-test Z = 2.00, P < 0.05) but not the 'perception of illness' factor.

CONCLUSION

The overall conceptual structure of insight in Chinese and Western patients appears similar, but further study is required to explore the complexity of Chinese patients' explanatory models of their illness and to enhance the validity of the insight scale.

Free medialis pedis flap as a coverage and flow-through flap in hand and digit reconstruction

BACKGROUND

Skin and soft-tissue defects of the hand and digit present a challenge for the hand surgeon especially in meeting the reconstructive needs of thickness, texture, color matching, and sensation. It becomes an even bigger challenge to reconstruct the defect in a devascularized finger with segmental loss of the neurovascular bundle. We use the relatively new flap, the medialis pedis flap, to solve the above conditions and compare it with traditional flaps.

METHODS

From May of 1994 to March of 1997, the free medialis pedis flap was used to reconstruct 19 digit and hand defects; the flap sizes ranging from 1.5 x 3.0 cm to 3.0 x 9.0 cm. Sixteen flaps were used for simple coverage of digit defects, including 12 for single-digit and 4 for multiple-digit reconstruction. The remaining three flaps were used as coverage and a flow-through flap for devascularized fingers.

RESULTS

All 19 flaps survived and achieved a good protective sensation. The appearance was very satisfactory, and the donor-site scars were without sensory problems.

CONCLUSION

Compared with traditional flaps, the free medialis pedis has the following advantages: it provides good thickness, texture, and color matching for hand and digit resurfacing; it can be used as a flow-through flap and as coverage for a devascularized finger in a one-stage procedure; the size of the feeding vessels of the flap matches those of the digital vessels well; and it consists of glabrous skin rich in nerve endings, so it has good potential for sensory recovery. Because of all of these characteristics, the free medialis flap may become a better consideration for hand surgeons.