ALK-positive anaplastic large cell lymphoma with a monomorphic small-cell pattern masquerading as inflammatory gastric lesions

INTRODUCTION

Anaplastic lymphoma kinase-positive (ALK+) anaplastic large cell lymphoma (ALCL) with a non-common pattern can be diagnostic challenging. Pathologists can be unavoidably and unintentionally blind to non-descript tumor cells in a lymphohistiocytic- (LH) or small-cell (SC)-pattern. We report a case of primary systemic ALK+ ALCL with a SC pattern that presented as secondary gastric lesions with a mixed LH and SC pattern that was masqueraded as inflammatory lesions.

CASE REPORT

A 34-year-old woman with intractable epigastric pain was referred to have repeated endoscopy with biopsy. She was found to multiple gastric erosions and nodules that were diagnosed as inflammatory lesions both endoscopically and histologically. Meanwhile, she developed an acute onset of severe back pain associated with a pathologic compression fracture in the T3 thoracic vertebral body. Imaging studies disclosed a disseminated systemic disease involving abdominopelvic lymph nodes and cervical and thoracic vertebral bodies. The needle biopsy of the pelvic lymph node disclosed diffuse proliferation of monomorphic small round cells that were diffusely positive for CD30 and ALK. A diagnosis of ALK+ ALCL with a monomorphic SC pattern was rendered.

DISCUSSION

A retrospective review of the gastric biopsies with the aid of immunohistochemistry enabled us to recognise the presence of lymphomatous infiltrates with a mixed LH and SC pattern in every piece of gastric biopsies that were repeatedly misdiagnosed as inflammatory lesions. This case illustrates a significant diagnostic pitfall of the LH- and SC-patterns in ALK+ ALCL, in which the tumour cells featuring lymphoid, plasmacytoid or histiocytoid appearance can be masqueraded as inflammatory cells.

Could Hong Kong Primary Schoolchildren be Taught to Perform Compression-Only CPR: A Pilot Study

Objective

To evaluate whether Hong Kong primary schoolchildren could be taught to perform compression-only CPR.

Design

Prospective experimental trial

Subjects

Primary schoolchildren of age 9-12 years old from different Cub Scout packs attended a 2 hour voluntary compression-only CPR training session between late 2014 and mid-2015.

Main outcome measures

Cardiopulmonary resuscitation (CPR) knowledge in the format of pre- and post-test multiple choices questions (MCQ). Psychomotor skills assessment including correct hand position, compression depth, compression rate and chest wall recoil between each compression.

Results

A total of 112 primary schoolchildren attended the training session, in them 72% were boys. Pretest score and post-test score was 2.81/5 and 4.82/5, respectively. The difference was statistically significant (p<0.05). About 96% of subjects had correct hand position at all time during CPR. Mean compression rate was 119/minute. Mean compression depth was 3 cm. About 47% of subjects had 100% complete recoil of chest wall following compression.

Conclusion

Primary schoolchildren above 9 years old are able to acquire essential knowledge and skills in compression-only CPR. Their physical strength may limit their ability to perform effective chest compression; it is still worthwhile to advocate CO-CPR education in primary schoolchildren in Hong Kong in order to raise their interest in this life saving skills and to equip them with essential cognitive skills in emergency situations. To achieve optimal cost-effectiveness and a compression depth of at least 4 cm, body weight of 53 kg or above should be considered as a selection criterion.

High-quality cell block preparation from scraping of conventional cytology slide: a technical report on a modified cytoscrape cell block technique

BACKGROUND

Immunocytochemistry (ICC) on formalin-fixed paraffin embedded cell blocks is an ancillary tool commonly recruited for differential diagnoses of fine needle aspiration cytology (FNAC) samples. However, the quality of conventional cell blocks in terms of adequate cellularity and evenness of distribution of cytologic material is not always satisfactory for ICC. We introduce a modified agarose-based cytoscrape cell block (CCB) technique that can be effectively used for the preparation of cell blocks from scrapings of conventional FNAC slides.

METHODS

A decoverslipped FNAC slide was mounted with a small amount of water. The cytological material was scraped off the slide into a tissue mold by scraping with a cell scraper. The cytoscrape material was pelleted by centrifugation and pre-embedded in ultra-low gelling temperature agarose and then re-embedded in conventional agarose. The final agarose gel disk was processed and embedded in paraffin.

RESULTS

The quality of the ICC on the CCB sections was identical to that of the immunohistochemical stains on histological sections. By scrapping and harvesting the entirety of the cytological material off the cytology slide into a compact agarose cell button, we could avoid the risk of losing diagnostic material during the CCB preparation.

CONCLUSION

This modified CCB technique enables concentration and focusing of minute material while maintaining the entire amount of the cytoscrape material on the viewing spot of the CCB sections. We believe this technique can be effectively used to improve the level of confidence in diagnosis of FNAC especially when the FNAC slides are the only sample available.

Is ultrasonography-guided modified coaxial core biopsy of the breast a better technique?

OBJECTIVE

To compare the diagnostic rate, patient comfort, and complications of ultrasonography-guided breast biopsy using a modified coaxial technique with ultrasonography-guided fine needle aspiration and traditional core biopsy. A secondary objective was to describe the use of the coaxial technique for the biopsy of breast lesions and our initial experience.

DESIGN

Retrospective study.

SETTING

A regional hospital in Hong Kong.

PATIENTS

Patients, who were referred for ultrasonography-guided fine needle aspiration or biopsy from 23 November 2007 to 19 March 2008, were divided into three groups. For breast lesions of 8 mm or smaller, fine needle aspirations were performed. For breast lesions larger than 8 mm, the patients were randomly divided into groups receiving traditional core biopsies and coaxial biopsies. The pathological reports were reviewed.

MAIN OUTCOME MEASURES

Diagnostic rate, patient comfort assessed in terms of pain, and any procedural complications.

RESULTS

A total of 45 ultrasonography-guided fine needle aspirations or biopsies of breast lesions were performed. All core biopsies using the traditional core technique (n=15) and coaxial technique (n=16) were diagnostic. While for fine needle aspirations, three (21%) of 14 were not diagnostic and repeat biopsies were undertaken for the corresponding patients. Except for one breast lesion biopsied with the coaxial technique that revealed invasive ductal carcinoma, all others yielded benign lesions. The average pain score for coaxial biopsies was 2.2, while for traditional core biopsies and fine needle aspirations, average scores were 3.7 and 3.8, respectively (P=0.022). No procedure-related complication was documented with either of the three techniques.

CONCLUSION

Modified coaxial core biopsy of the breast has an optimal diagnostic rate and hence avoids the need for repeat biopsies. It is associated with better patient comfort and no increase in the risk of complications.

Oesophageal gastro-intestinal stromal tumour presenting with rupture into pleural cavity

Gastro-intestinal stromal tumours are rarely found in the oesophagus and it is uncommon for these tumours to present with rupture. In this paper, we report a case where the tumour ruptured through the distal oesophagus. As a result, the patient underwent surgical tumour dissection. A histopathological examination of the tumour mass confirmed that it was a gastro-intestinal stromal tumour. In this report, we review the diagnosis, pathology, and treatment of a patient presenting with a ruptured oesophageal gastro-intestinal stromal tumour.

Synergistic effects of dopamine and Zn2+ on the induction of PC12 cell death and dopamine depletion in the striatum: possible implication in the pathogenesis of Parkinson's disease

The mechanism that underlies the progressive degeneration of the dopaminergic neurons in Parkinson's disease (PD) is not clear. The Zn(2+) level in the substantia nigra of Parkinson's patients is increased. However, it is unknown whether Zn(2+) has a role in the degeneration of dopaminergic neurons. This study identifies an interaction between dopamine and Zn(2+) that induces cell death. When PC12 cells were pretreated with Zn(2+) before dopamine treatment, dopamine and Zn(2+) synergistically increased cell death, while Zn(2+) and H(2)O(2) had only additive effects on cell death. The synergistic effect appeared to be caused by increased apoptosis rather than necrosis. The synergistic effect was specific for Zn(2+). The synergistic effect was inhibited by thiol antioxidants but was not significantly affected by calcium channel blockers. There is a similar synergistic effect when dopamine and Zn(2+) were coinfused into the striatum, resulting in striatal dopamine content depletion in vivo. Thus, both dopamine oxidation and Zn(2+) are possibly linked to the degeneration of dopaminergic neurons.

Idiopathic myelofibrosis with extramedullary haemopoiesis involving the urinary bladder in a Chinese lady

Extramedullary haemopoiesis (EMH) associated with idiopathic myelofibrosis most commonly involves the reticuloendothelial organs, such as the spleen and liver, although ectopic haemopoietic tissue has also been described rarely in the lymph nodes, skin, gastrointestinal tract, pleura, peritoneum, central nervous system, and genital and urinary tracts. We report on a 54-year-old Chinese lady with a long history of idiopathic myelofibrosis who presented with gross haematuria and left hydronephrosis due to EMH in the bladder trigone. Cystoscopic examination revealed a sessile necrotic papillary growth at the trigone, obstructing the left ureteric orifice. Transurethral resection of the bladder tumour was performed, and microscopic examination of the tumour chips demonstrated atypical megakaryocytes, immature granulocytes and normoblasts, confirming the presence of EMH. The residual bladder tumour responded well to low dose radiotherapy, with subsequent disappearance of haematuria and normalization of ultrasonogram findings.

Reversal of mivacurium chloride: edrophonium of spontaneous recovery in microscopic laryngeal surgery

BACKGROUND

A double-blind, randomized study was designed to compare the recovery manner of mivacurium infusion with or without edrophonium reversal in microscopic laryngeal surgery. Neuromuscular blockade was quantified using the train-of-four stimuli to the ulnar nerve and quantification of the ratio of the fourth twitch to the first twitch.

METHODS

With the approval of the Human Studies Committee of the Taipei Veterans General Hospital and patient informed consent, 40 healthy (ASA I or II) patients with age from 24 to 54 years, undergoing microscopic laryngeal surgery were randomly selected for study. Mivacurium chloride 0.2 mg/kg was given intravenously, and then it was given in continuous infusion to maintain muscle relaxation at 90% twitch block during the procedure. At the end of operation, mivacurium infusion was terminated. In a double-blind manner, group I patients (n = 20) received intravenous edrophonium 1 mg/kg and atropine 0.01 mg/kg for reversal when T1 was at 10% recovery whereas patients in Group II (n = 20) received placebo in the same manner. Mean infusion rate, recovery index (RI50, time from T1 25% to T1 50%; RI75, time from T1 25% to T1 75%), extubation time, and discharge time between groups were compared. Nausea, vomiting, and dysrhythmias were also documented until the patient was discharged from hospital.

RESULTS

The demographic data between two groups were similar. The recovery index (RI75) for group I was shorter than that of placebo group (5.3 +/- 2.19 min vs. 7.3 +/- 0.9 min) and the difference was statistically significant (P = 0.017). There were no statistically significant differences in mean infusion rate, incidence of nausea and vomiting, and discharge time from the POR. The incidence of tachycardia or arrhythmia in group I was significantly greater than that in group placebo.

CONCLUSIONS

Mivacurium, a short-acting nondepolarizing agent, is a suitable muscle relaxant for patients receiving microscopic laryngeal surgery. Recovery time with the use of edrophonium as reversal agent was shorter than with placebo, but extubation and discharge time did not differ in two groups. The time which could be saved by the use of edrophonium for reversal of mivacurium to hasten the maximal recovery appears to be less than a few minutes. Therefore, clinically, the value of routine use of edrophonium to obtain a faster recovery does not outweigh its demerits of cost and risk and is not worthy of recommendation.

Activities of monomeric insulin analogs at position A8 are uncorrelated with their thermodynamic stabilities

Previous studies have demonstrated that the potency and thermodynamic stability of human insulin are enhanced in concert by substitution of Thr(A8) by arginine or histidine. These surface substitutions stabilize the N-terminal alpha-helix of the A chain, a key element of hormone-receptor recognition. Does enhanced stability necessarily imply enhanced activity? Here, we test by structure-based mutagenesis the relationship between the stability and activity of the hormone. To circumvent confounding effects of insulin self-association, A chain analogs were combined with a variant B chain (Asp(B10), Lys(B28), and Pro(B29) (DKP)) to create a monomeric template. Five analogs were obtained by chain combination; disulfide pairing proceeded in each case with native yield. CD and (1)H NMR spectra of the DKP analogs are essentially identical to those of DKP-insulin, indicating a correspondence of structures. Receptor binding affinities were determined by competitive displacement of (125)I-insulin from human placental membranes. Thermodynamic stabilities were measured by CD titration; unfolding was monitored as a function of guanidine concentration. In this broader collection of analogs receptor binding affinities are uncorrelated with stability. We suggest that receptor binding affinities of A8 analogs reflect local features of the hormone-receptor interface rather than the stability of the free hormone or the intrinsic C-capping propensity of the A8 side chain.

Hierarchical protein folding: asymmetric unfolding of an insulin analogue lacking the A7-B7 interchain disulfide bridge

The landscape paradigm of protein folding can enable preferred pathways on a funnel-like energy surface. Hierarchical preferences may be manifest as a nonrandom pathway of disulfide pairing. Stepwise stabilization of structural subdomains among on-pathway intermediates is proposed to underlie the disulfide pathway of proinsulin and related molecules. Here, effects of pairwise serine substitution of insulin's exposed interchain disulfide bridge (Cys(A7)-Cys(B7)) are characterized as a model of a late intermediate. Untethering cystine A7-B7 in an engineered monomer causes significantly more marked decreases in the thermodynamic stability and extent of folding than occur on pairwise substitution of internal cystine A6-A11 [Weiss, M. A., Hua, Q. X., Jia, W., Chu, Y. C., Wang, R. Y., and Katsoyannis, P. G. (2000) Biochemistry 39, 15429-15440]. Although substantially disordered and without significant biological activity, the untethered analogue contains a molten subdomain comprising cystine A20-B19 and a native-like cluster of hydrophobic side chains. Remarkably, A and B chains make unequal contributions to this folded moiety; the B chain retains native-like supersecondary structure, whereas the A chain is largely disordered. These observations suggest that the B subdomain provides a template to guide folding of the A chain. Stepwise organization of insulin-like molecules supports a hierarchic view of protein folding.

Anesthetic management of parturients with Eisenmenger's syndrome--report of two cases

Pregnancy is badly tolerated in patients with Eisenmenger's syndrome; maternal mortality with coherent fetal morbidity is high. Even with the advancement of both obstetric and anesthetic managements, the maternal mortality still exceeds 25%. Once conception occurs in patients of Eisenmenger's syndrome with severe pulmonary hypertension, interruption of pregnancy is still the best manipulation to be recommended. We report two cases of parturients with Eisenmenger's syndrome, who underwent termination of pregnancy. In this report, the obstetric and anesthetic management of this kind of parturients with Eisenmenger's syndrome has been thoroughly discussed.

Prostaglandins may participate in opioidergic and cholinergic control of the diurnal changes of tuberoinfundibular dopaminergic neuronal activity and serum prolactin level in ovariectomized, estrogen-treated rats

The roles of prostaglandins (PGs) involved in opioidergic, cholinergic, and serotonergic regulation of the diurnal changes of tuberoinfundibular dopaminergic (TIDA) neuronal activities were investigated in ovariectomized, estrogen-treated rats. Treatment with naloxone [10 mg/kg, intraperitoneal (i.p.)], atropine (5 mg/kg, i.p.), or ketanserin (10 mg/kg, i.p.) at either 1200 or 1400 h prevented the afternoon decrease of TIDA neuronal activity and the prolactin (PRL) surge. Intracerebroventricular (i.c.v.) injection of PGE(1) (5 microg/3 microl/rat) at 1500 h significantly reversed the effects of naloxone and atropine, but not that of ketanserin. In ovariectomized, estrogen-primed rats pretreated with indomethacin, i.c.v. injection of either nicotine (10 ng/rat) or fentanyl (10 ng/rat) failed to suppress the TIDA neuronal activity and to stimulate the PRL secretion. These data suggest that PG may be involved in opioidergic and cholinergic control of the diurnal changes of TIDA neuronal activity and the PRL secretion in ovariectomized (OVX) + E(2) rats.

Chinese writing function in patients with left versus right putaminal hemorrhage

This study was designed to explore the Chinese writing function of patients with subcortical stroke. Two cohorts of patient subjects with either the left or the right subcortical strokes, mainly putaminal hemorrhagic strokes, and one group of normal controls participated in the study. All participants received a writing test battery including the three aspects of writing function, that is, Spontaneous Writing, Writing to Dictation, and Writing from Copy, as well as a battery of non-writing linguistic tests. Comparing with normal controls revealed that writing function change occurred in both patient groups. The deficits in the patients with the left subcortical stroke essentially included Spontaneous Writing, and Writing to Dictation. These impairments were most likely secondary to aphasic disorders. The writing problem, mainly Writing from Copy, was noted in the patients with the right subcortical stroke. This deficit, however, was independent of the core linguistic impairment. On the basis of the results, we suggest that the lesion involving white matter in the left hemisphere probably interrupts left perisylvian cortical language organization in a manner that produces problems with spontaneous writing and writing to dictation, which are language-related, associated with lesion in the dominant hemisphere. This further suggests that left or right subcortical lesions in the putamen and surrounding white matter are associated with differential effects (language vs. non-language based effects) which are similar to such differences observed with left vs. right cortical lesions.

Prostaglandins play an important role in diurnal changes of tuberoinfundibular dopaminergic neuronal activity and prolactin secretion in ovariectomized, estrogen-treated rats

Intracerebroventricular injection of prostaglandins (PGs) has long been shown to stimulate the secretion of prolactin (PRL). The action of specific PG and the underlying mechanism, however, remain inconclusive. In this study, we evaluated the involvement of PGs in the diurnal changes of the tuberoinfundibular dopaminergic (TIDA) neurons and PRL secretion in ovariectomized (OVX) rats treated with estrogen (E2). Prior treatment of indomethacin (50 mg/kg, subcutaneous) for 24 h significantly prevented the afternoon decrease of TIDA neuronal activity and blocked the PRL surge. Intracerebroventricular injection of PGE(1) (5 microg/3 microl/rat) at 1000 h significantly lowered the activity of TIDA neurons, while similar treatment of PGE2 was without effect. In OVX + E(2) rats pretreated with indomethacin, PGE(1) given at 15, but not 30 or 180 min before decapitation at 1500 h significantly reversed the effects of indomethacin on TIDA neuronal activity, while the blocked PRL surge was not reversed. The PGs also exhibited a stimulatory effect on nigrostriatal dopamine (DA) neurons with PGE2 being the most effective agent. These results indicate that endogenous PGs play a significant role in the control of central DA neurons, especially the diurnal changes of TIDA neuronal activity and PRL secretion in OVX + E2 rats.

Hierarchical protein "un-design": insulin's intrachain disulfide bridge tethers a recognition alpha-helix

A hierarchical pathway of protein folding can enable segmental unfolding by design. A monomeric insulin analogue containing pairwise substitution of internal A6-A11 cystine with serine [[Ser(A6),Ser(A11),Asp(B10),Lys(B28),Pro(B29)]insulin (DKP[A6-A11](Ser))] was previously investigated as a model of an oxidative protein-folding intermediate [Hua, Q. X., et al. (1996) J. Mol. Biol. 264, 390-403]. Its structure exhibits local unfolding of an adjoining amphipathic alpha-helix (residues A1-A8), leading to a 2000-fold reduction in activity. Such severe loss of function, unusual among mutant insulins, is proposed to reflect the cost of induced fit: receptor-directed restoration of the alpha-helix and its engagement in the hormone's hydrophobic core. To test this hypothesis, we have synthesized and characterized the corresponding alanine analogue [[Ala(A6),Ala(A11),Asp(B10),Lys(B28), Pro(B29)]insulin (DKP[A6-A11](Ala))]. Untethering the A6-A11 disulfide bridge by either amino acid causes similar perturbations in structure and dynamics as probed by circular dichroism and (1)H NMR spectroscopy. The analogues also exhibit similar decrements in thermodynamic stability relative to that of the parent monomer as probed by equilibrium denaturation studies (Delta Delta G(u) = 3.0 +/- 0.5 kcal/mol). Despite such similarities, the alanine analogue is 50 times more active than the serine analogue. Enhanced receptor binding (Delta Delta G = 2.2 kcal/mol) is in accord with alanine's greater helical propensity and more favorable hydrophobic-transfer free energy. The success of an induced-fit model highlights the applicability of general folding principles to a complex binding process. Comparison of DKP[A6-A11](Ser) and DKP[A6-A11](Ala) supports the hypothesis that the native A1-A8 alpha-helix functions as a preformed recognition element tethered by insulin's intrachain disulfide bridge. Segmental unfolding by design provides a novel approach to dissecting structure-activity relationships.

The management of isolated thrombocytopenia in Chinese adults: does bone marrow examination have a role at presentation?

We performed a retrospective analysis of bone marrow examination (BME) in the management of Chinese adult patients less than 60 years of age with isolated thrombocytopenia at presentation. Eighty-three patients with a median age of 39 years presenting with isolated thrombocytopenia (median platelet count: 38 x 10(9)/l) had routinely undergone BME as part of the laboratory investigations during the period from January 1996 to December 1999. All 83 patients had bone marrow findings of active marrow suggesting causes due to peripheral destruction. All of these patients responded to steroid or intravenous immunoglobulin (IVIg) therapy at presentation if their platelet counts were significantly low or if they had mucosal bleeding. Eighty-one of the 83 patients, after a median of 20 months follow-up, were finally diagnosed as having idiopathic thrombocytopenic purpura (ITP). The remaining two patients were finally confirmed as cases of systemic lupus erythematosus (SLE). Our results suggest that BME is not helpful in the diagnosis of isolated thrombocytopenia or suspected ITP in adult patients at presentation, provided that a thorough clinical history and physical examination are undertaken and that the blood count and peripheral blood smear show no abnormalities apart from the thrombocytopenia.

Overexpression of c-H-ras p21 is correlated with vascular endothelial growth factor expression and neovascularization in advanced gastric carcinoma

BACKGROUND AND AIMS

ras Gene and its product (p21) have been reported to be associated with vascular endothelial growth factor (VEGF), which is one of the most important angiogenic factors, and tumor-associated angiogenesis. We tried to evaluate the correlation between the expression of c-H-ras gene product p21 and angiogenesis in advanced gastric carcinoma.

METHODS

Immunohistochemical expression of c-H-ras p21 and VEGF was examined in 49 advanced gastric adenocarcinomas. In addition, double immunohistochemical staining was performed using anti-CD34 and anti-Ki-67 antibodies, and the intratumoral microvessel densities and their endothelial proliferative labeling indices were then counted to evaluate the degree of angiogenesis.

RESULTS

The expression of c-H-ras p21 was demonstrated in 43 out of 49 gastric adenocarcinomas (87.8%). It did not correlate with histologic type, depth of invasion or metastasis. However, the degree of c-H-ras p21 expression was correlated with VEGF. In addition, the degree of c-H-ras p21 expression was correlated with increased intratumoral microvascular density and endothelial proliferative activity.

CONCLUSIONS

We suggest that c-H-ras oncogene product p21 contributes to the upregulation of tumor-associated angiogenesis by the increased production of VEGF in advanced gastric carcinomas. Therefore, treatment involving the targeting of ras oncogene could inhibit solid tumor growth by suppressing tumor-associated angiogenesis.

Myositis ossificans of the chest wall simulating malignant neoplasm

Myositis ossificans originating from the chest wall is extremely rare. We report a case of myositis ossificans occurring in a young woman with progressive painful swelling in the chest wall. Preoperative examination suggested a malignant neoplasm originating from soft tissue. Although rare, myositis ossificans is one of the potential causes of painful swelling in the chest wall, and can be mistaken for a malignant neoplasm.

Metastatic renal cell carcinoma in a meningioma: a case report

Tumor-to-tumor metastasis is rare. We report a case of metastatic renal cell carcinoma in meningioma. A 67-year-old woman presented a two-week history of motor dysphagia and decreased short-term memory. She had undergone a left radical nephrectomy for a renal cell carcinoma 7 years ago, and had not received any adjuvant therapy. MRI disclosed a 3.0 x 3.0 x 3.0-cm sized round tentorial-based extraaxial mass with peritumoral edema in the left posterior temporal lobe. During operation, the tumor was found to be an encapsulated mass firmly attached to the tentorium. Histologically, the tumor was a meningotheliomatous meningioma extensively infiltrated by metastatic renal cell carcinoma, accompanying widespread coagulative necrosis. Immunohistochemical staining for cytokeratin revealed strong positivity only in the renal cell carcinoma component. The patient's postoperative course was uneventful. Post-operative radiation therapy was applied to the whole brain. Three months after operation, the patient developed right hemiparesis and dysphagia. Brain MRI at that time did not reveal recurrence or any other causative lesions, although the whole body scan disclosed uptake at the second lumbar vertebra and rib. The patient refused further treatment.

Churg-Strauss syndrome with perforating ulcers of the colon

We report a case of a 72-year-old woman with Churg-Strauss syndrome, who presented with intestinal perforation. She has had bronchial asthma with peripheral blood eosinophilia for 30 years. Gross findings of a resected colon showed multiple ulcers with perforation. Histologic findings demonstrated transmural inflammation infiltrated with large numbers of eosionophils, neutrophils and lymphoplasma cells, and characteristic extravascular granuloma in the subserosa. There were multifocally-distributed transmural vasculitis showing all stages of activity in medium and small-sized arteries and veins located in the submucosa, and proper muscle and subserosal layers of the colon, some of which revealed granulomatous inflammation. Histologic finding of liver showed chronic viral hepatitis B with mild inflammatory activity and macronodular cirrhosis. Immunohistochemical findings, acid fuschin orange G staining and electromicroscope found no evidence of hepatitis B virus infection contributing to the pathogenesis of this lesion.

Specific induction of glutathione S-transferase GSTM2 subunit expression by epigallocatechin gallate in rat liver

The antitumor effect of green tea polyphenols has been well characterized in numerous papers. However, the mechanism of their action is still poorly defined. In this study, epigallocatechin gallate (EGCG), the main ingredient of green tea extract, was studied for its effect on the expression of glutathione S-transferases (GSTs) in rat liver to examine the mechanism of action. Liver samples were collected from Sprague-Dawley rats treated with EGCG in H(2)O by portal vein perfusion and examined for total GST activity and GST expression. The results showed that the induction of GST activity by EGCG was dose- and time-dependent. GST activity was increased about 28-fold at 12 hr after treatment. Three GST subunits (GSTA1/2, GSTM1, and GSTM2) were examined by Western blot for changes in protein level affected by EGCG (1 mg/kg weight). Only GSTM2 revealed a significant time-dependent increase, with a maximal induction of approximately 2.0-fold. The differential effect of EGCG on GST subunit expression was also verified by immunocytochemical examination and showed strong induction of the GSTM2 (but not the GSTA1/2 and GSTM1) level in liver section. This induction occurred as early as 3 hr after treatment and extended gradually outward from the hepatic veins as treatment time increased. The change in the GSTM2 protein level was accompanied by a corresponding alteration in mRNA quantity ( approximately 2.0-fold of control). Our report is the first to demonstrate a specific induction of the GSTM2 subunit by a chemopreventor and suggests a primary influence of EGCG on GSTM2 gene expression.

Cloning and expression of ZAK, a mixed lineage kinase-like protein containing a leucine-zipper and a sterile-alpha motif

A novel mixed lineage kinase-like protein ZAK, containing a leucine-zipper (LZ) and a sterile-alpha motif (SAM), was cloned. This cDNA has 2456 bp and encodes a protein of 800 amino acids that contains a kinase catalytic domain, a leucine-zipper and a SAM. The molecular weight of this protein is 91kDa. Northern blot analysis revealed that the expression of this ZAK gene is found in various parts of human tissues. We also found that ZAK proteins might form homodimers or oligomers in mammalian cells. MLKs have been proposed to function as mitogen-activated protein kinase kinase kinase in pathways leading to MAPK cascade. The expression of ZAK in mammalian cells specifically leads to the activation of the JNK/SAPK pathway as well as the activation of transcription factor, NF-kappaB. Overexpression of the ZAK gene induces the apoptosis of a hepatoma cell line.

[Effect of jiaweiyiguanjian decoction on hypothalamus-pituitary-thyroid gland (HPT) in rat model with Yin-deficiency of liver and kidney induced by slow irritation]

OBJECTIVE

To explore the mechanism of Jiaweiyiguanjian decoction in nourishing the liver and kidney.

METHOD

A rat model with Yin-deficiency of liver and kidney was made by way of slow irritation. Thyrotropin-releasing-hormone(TRH) of thyron and blood, TSH of pituitary and blood, thyroxine, 3,5,3',5-tetraiodothyronine(FT4) and 3,3',5-traiodothyronine(FT4), 3,3',5-traiodothyronine(rT3) were used as indexes to study the effect of the decoction on HPT.

RESULT

The TRH Secretion from hypothalamus increased (P < 0.05), TSH of pituitary and blood reduced(P < 0.05), FT3 and FT4 of blood decreased at the same time and rT3 of blood, increased. The indexes of the treatment group were found almost the same as the those of the normal control group.

CONCLUSION

Jiaweiyiguanjian Decoction could adjust HPT.

Autologous bone marrow transplantation for patients with acute myeloid leukaemia: prospective follow-up study

OBJECTIVE

To study the use of autologous bone marrow transplantation to treat acute myeloid leukaemia when complete remission had been achieved and when no human leukocyte antigen matched related donor was available.

DESIGN

Prospective follow-up study.

SETTING

Government hospital, Hong Kong.

PATIENTS

Eight patients (median age, 34 years [range, 16-45 years]) with acute myeloid leukaemia in whom complete remission had been achieved.

INTERVENTION

Conditioning regimen of carmustine, amsacrine, etoposide VP-16, cytarabine, and infusion of unpurged marrow.

MAIN OUTCOME MEASURES

Median time taken to reach neutrophil and platelet counts of > or =0.5 x 10(9) /L and > or = x 10(9) /L, respectively; mortality and relapse rates; and follow-up regimens used.

RESULTS

Engraftment was successfully achieved in all patients and there were no early procedure-related mortalities. The median times required to reach a neutrophil count of > or =0.5 x 10(9) /L and a platelet count of > or =20 x 10(9) /L were 30 days (range, 18-36 days) and 38 days (range, 15-53 days), respectively. The median duration of hospital stay was 37 days (range, 25-43 days). Two patients died of a relapse of leukaemia at 6 and 9 months post-transplantation. Two patients experienced relapses: one at 8 months post-transplantation, for which conventional chemotherapy was restarted, and one at 18 months; treatment with all-trans-retinoic acid and conventional chemotherapy achieved a third complete remission in the latter patient, who had acute promyelocytic leukaemia. Continuous remission has been achieved in four of the eight patients after a median follow-up duration of 26 months (range, 6-43 months).

CONCLUSION

Autologous bone marrow transplantation is an acceptable treatment for patients with acute myeloid leukaemia who lack a human leukocyte antigen-matched related donor.

Comparison of recovery characteristics of sevoflurane and halothane for outpatient surgery in infants

BACKGROUND

Sevoflurane, a newly approved potent inhaled anesthetic in Taiwan, provides rapid emergence from anesthesia in adults and children. Clinically, it is difficult to accurately assess the rate of recovery from anesthesia in infants. This study was designed to compare the emergence characteristics of halothane with those of sevoflurane having recourse to a respiratory agent monitor in infants undergoing outpatient surgery.

METHODS

Forty infants of ASA class I, scheduled for day-case urologic surgery were studied. Patients were randomly allocated to two groups of 20. Sevoflurane or halothane was used as the inhaled anesthetic. Toward the end of surgery, sevoflurane or halothane was turned off. The concentrations of exhaled sevoflurane or halothane were read every minute after its discontinuation until extubation. The decay curve of the exhaled concentration of either agent was recorded minute by minute for 10 minutes. The time intervals from discontinuation of the inhalation agent to spontaneous movement and tracheal extubation were recorded. Untoward side-effects during emergence were also compared.

RESULTS

Sevoflurane was eliminated faster than halothane. Based on the decay curves of the exhaled concentrations of the two agents, the time constant for halothane was 2.59 minutes and that for sevoflurane was only 1.43 minutes. The time from discontinuation of agent to extubation was also shorter for sevoflurane. Postoperative restlessness or agitation occurred more frequently in infants who received sevoflurane, although the difference was of no statistical significance.

CONCLUSIONS

Sevoflurane is superior to halothane for rapid elimination in infant outpatient surgery as gauged by observation of end-tidal concentration elimination curves recorded with a respiratory agent monitor. No other postoperative side-effect was evident in sevoflurane anesthesia.

Gastric malignant stromal tumor with long stalk impacted into duodenum

Most GIST have traditionally been classified as submucosal origin by upper gastrointestinal series (UGIS) or endoscopy. However, we experienced a gastrointestinal mesenchymal origin tumor expressed by polypoid mass with a long stalk. The gastric outlet was obstructed by the polypoid mass on the duodenum. The microscopic findings of the resected mass showed a stromal cell component by immunohistochemical stain. We experienced gastric stromal tumor found as a polypoid mass with long stalk which was easily detected by endoscopy. It would not have been suspected as a stromal tumor as a result of endoscopic findings only.

A neural-network method for the nonlinear servomechanism problem

The solution of the nonlinear servomechanism problem relies on the solvability of a set of mixed nonlinear partial differential and algebraic equations known as the regulator equations. Due to the nonlinear nature, it is difficult to obtain the exact solution of the regulator equations. This paper proposes to solve the regulator equations based on a class of recurrent neural network, which has the features of a cellular neural network. This research not only represents a novel application of the neural networks to numerical mathematics, but also leads to an effective approach to approximately solving the nonlinear servomechanism problem. The resulting design method is illustrated by application to the well-known ball and beam system.

Abnormal erythropoiesis in erythroleukemia: a fluorescence in situ hybridization study

Erythroleukemia is an uncommon leukemia with heterogeneous morphologic and karyotypic features. Some cases might actually represent acute myeloid leukemia with a reactive erythroid hyperplasia. In this report, we described a 68-year-old woman with erythroleukemia and monosomy 7 and showed by fluorescence in situ hybridization that both myeloid and erythroid lineage were clonally involved and that both normal and abnormal erythroid populations coexisted, albeit indistinguishable by morphological examination. These findings may account for the variation in the erythropoietic activity observed in the clinical course of erythroleukemia.

The neuromuscular effects of mivacurium in adults with priming technique during nitrous oxide-fentanyl anesthesia: a randomized comparative study with succinylcholine

BACKGROUND

We investigated the neuromuscular effects of equipotent dose (3 x ED90) of mivacurium either given as a single bolus or under the influence of priming technique, comparing with that of succinylcholine in adults undergoing elective surgery during nitrous oxide-narcotic anesthesia.

METHODS

Sixty ASA class I patients of either sex with age between 16 to 49 years were randomly assigned to 3 groups for a trial of mivacurium under nitrous oxide-narcotic anesthesia. Group I (non-priming group, n = 20) received mivacurium 0.25 mg/kg straight as a single intubating dose; Group II (priming group, n = 20) received an intubating dose of 0.225 mg/kg mivacurium which was preceded by 0.025 mg/kg 3 min earlier; and Group III received an intubating bolus of succinylcholine 1 mg/kg. Thenar electromyogram response to supramaximal train-of-four stimulation of the ulnar nerve at 12-s intervals was used to determine neuromuscular blockade. Blood pressure and heart rate were recorded before and at 1-min interval for 3 min after injection of drugs. Data were presented as mean +/- standard deviation. P value < 0.05 was considered statistically significant.

RESULTS

The onset time of mivacurium was accelerated by priming procedure in comparison with the nonpriming technique (2.0 min vs. 2.7 min), but it was much slower than that of succinylcholine (0.8 min). The priming procedure did not influence the duration of action or recovery. Side effects of mivacurium, such as cutaneous flushing and hypotension, were minimal at this dose in our patients.

CONCLUSIONS

Priming technique (with 10% of the total dose as the priming dose, and 3 min as the priming interval) can hasten the onset of mivacurium in adults during nitrous oxide-narcotic anesthesia without influencing the duration of action and recovery time.

Acute myeloid leukemia with a novel (7;11)(q36;q13) translocation

A 79-year-old female presented with acute myeloblastic leukemia without maturation. Cytogenetic studies showed a previously undescribed abnormality of t(7;11)(q36;q13). The significance of the involvement of 11q13 in the pathogenesis of myeloid leukemia is discussed.

Splenic lymphoma with villous lymphocytes showing del(7) and inv(10)

A 49-year-old woman presented with splenic lymphoma with villous lymphocytes (SLVL) that showed a clonal abnormality of del(7)(q22q32) in addition to inv(10)(p13q23), the latter being a previously undescribed abnormality in chronic lymphoproliferative disorders. A review of the literature on cytogenetic abnormalities of SLVL indicates that del(7q) is strongly associated with SLVL and may be important in the pathogenesis of this disorder.

Mini-proinsulin and mini-IGF-I: homologous protein sequences encoding non-homologous structures

Protein minimization highlights essential determinants of structure and function. Minimal models of proinsulin and insulin-like growth factor I contain homologous A and B domains as single-chain analogues. Such models (designated mini-proinsulin and mini-IGF-I) have attracted wide interest due to their native foldability but complete absence of biological activity. The crystal structure of mini-proinsulin, determined as a T3R3 hexamer, is similar to that of the native insulin hexamer. Here, we describe the solution structure of a monomeric mini-proinsulin under physiologic conditions and compare this structure to that of the corresponding two-chain analogue. The two proteins each contain substitutions in the B-chain (HisB10-->Asp and ProB28-->Asp) designed to destabilize self-association by electrostatic repulsion; the proteins differ by the presence or absence of a peptide bond between LysB29 and GlyA1. The structures are essentially identical, resembling in each case the T-state crystallographic protomer. Differences are observed near the site of cross-linking: the adjoining A1-A8 alpha-helix (variable among crystal structures) is less well-ordered in mini-proinsulin than in the two-chain variant. The single-chain analogue is not completely inactive: its affinity for the insulin receptor is 1500-fold lower than that of the two-chain analogue. Moreover, at saturating concentrations mini-proinsulin retains the ability to stimulate lipogenesis in adipocytes (native biological potency). These results suggest that a change in the conformation of insulin, as tethered by the B29-A1 peptide bond, optimizes affinity but is not integral to the mechanism of transmembrane signaling. Surprisingly, the tertiary structure of mini-proinsulin differs from that of mini-IGF-I (main-chain rms deviation 4.5 A) despite strict conservation of non-polar residues in their respective hydrophobic cores (side-chain rms deviation 4.9 A). Three-dimensional profile scores suggest that the two structures each provide acceptable templates for threading of insulin-like sequences. Mini-proinsulin and mini-IGF-I thus provide examples of homologous protein sequences encoding non-homologous structures.

Effect of BL-10 (tianzhu), BL-11 (dazhu) and GB-34 (yanglinquan) acuplaster for prevention of vomiting after strabismus surgery in children

BACKGROUND

Stimulation of P6 (Neiguan) acupoint can prevent nausea and vomiting in adults. However, there is no antiemetic effect in children undergoing strabismus surgery. The effect of P6 may act only on hollow organs; in contrast, BL-10 (Tianzhu), BL-11 (Dazhu) and GB-34 (Yanglinquan) are more related to the meridians of the eye. Therefore these three more relevant acupoints, BL-10, BL-11 and GB-34 were stimulated to evaluate the antiemetic effect in children undergoing strabismus surgery.

METHODS

Sixty-five children, ASA physical status I, between 3 and 14 years of age, were randomly divided into two groups as follows: placebo group (n = 31) and acuplaster group (n = 34). Bilateral acupressure using the Vital Point Needleless Acuplaster (Koa, Japan) was applied to BL-10, BL-11 and GB-34 points the night before surgery. Anesthesia was induced and maintained with halothane and nitrous oxide in oxygen. Postoperative emesis was assessed at early (at PACU) and late (at ward) phases, and was recorded by an investigator blind to the treatment characteristics.

RESULTS

In the early emesis phase, the incidence of vomiting was 35.5% for placebo group, compared with 14.7% for acuplaster group. In the late emesis phase, acuplaster patients had a significantly lower incidence of vomiting (23.5% vs. 58.1% in placebo patients, p < 0.05). The overall postoperative vomiting incidence in the acuplaster patients in a 24 h period which was significantly decreased was 29.4% as opposed 64.5% in the placebo group (p < 0.05).

CONCLUSIONS

The results demonstrated that prophylactic use of bilateral noninvasive acuplaster on the BL-10, BL-11, and GB-34 acupoints significantly reduces vomiting after strabismus correction. The mechanism may be dispersal of these three acupoints, thus diminishing the parasympathetic stimulation resulting from surgical traction of eye muscles.

Dedifferentiated liposarcoma: a clinicopathological analysis of 155 cases with a proposal for an expanded definition of dedifferentiation

We studied 155 cases of dedifferentiated liposarcoma to define its clinicopathologic features and behavior, in particular how the extent and grade of dedifferentiation affected outcome. Tumors occurred in late adult life (median, 61.5 years: range, 21-92 years), most commonly in the retroperitoneum (106 cases), extremities and trunk (32 cases), and scrotum/spermatic cord (13 cases). The majority of dedifferentiated liposarcomas presented as de novo lesions, whereas the remainder developed as a late complication of a preexisting well-differentiated liposarcoma after an average interval of 7.7 years. At the time of presentation, most of the dedifferentiated liposarcomas displayed extensive areas of high-grade dedifferentiation resembling malignant fibrous histiocytoma or high-grade fibrosarcoma, whereas a minority contained only areas of low-grade dedifferentiation resembling fibromatosis or well-differentiated fibrosarcoma. Divergent myosarcomatous or osteosarcomatous differentiation was observed focally in six cases. The behavior of dedifferentiated liposarcomas was that of a high-grade sarcoma with a local recurrence rate of 41%, a metastatic rate of 17%, and disease-related mortality of 28%. The most important prognostic factor was location in that retroperitoneal tumors had significantly worse survival than those in other sites. Tumors were divided into those having less than or those with more than 25% dedifferentiation, and dedifferentiated zones were classified into low grade or high grade. Neither low-grade dedifferentiation nor a low percentage of dedifferentiation was associated with an improved outcome for the tumors examined in this study; however, in no cases was the absolute size of the dedifferentiated focus <2 cm. Therefore, this study did not determine a minimum, or threshold, amount of dedifferentiation below which outcome was more favorable. The behavior of liposarcomas in which the dedifferentiated component was entirely low grade was more similar to that of traditional dedifferentiated liposarcoma than to that of well-dedifferentiated liposarcoma. Our study supports the expansion of the definition of dedifferentiated liposarcoma to include tumors with low-grade dedifferentiation and also suggests that low-grade dedifferentiation represents a precursor lesion of high-grade dedifferentiation.

Priming technique accelerates the onset time of mivacurium in children during halothane anesthesia

BACKGROUND

Mivacurium is considered a relaxant suitable for tracheal intubation in children due to its rapid onset. We compared the neuromuscular effects of mivacurium, with and without priming, in children undergoing elective surgery during halothane anesthesia.

METHODS

Forty pediatric patients (2-10 yr, ASA class I) were randomly into 2 groups and studied under halothane anesthesia. The non-priming group (n = 20) received mivacurium 0.25 mg/kg, and the priming group (n = 20) received a priming dose of mivacurium 0.025 mg/kg, followed by an intubating dose of 0.225 mg/kg 3 min later. Thenar Electromyogram responsive to supramaximal train-of-four stimulation of the ulnar nerve at 12 s intervals was used as neuromuscular monitoring.

RESULTS

The onset time in the priming group was significantly faster than in the non-priming group (1.04 min vs. 1.7 min). The mean time from injection of intubating dose to spontaneous recovery to 25%, 50% and 75% twitch were not influenced by priming technique. Side effects, such as cutaneous flushing and hypotension, were unremarkable at this dose in children.

CONCLUSIONS

Priming technique can significantly accelerates the onset of mivacurium in the pediatric patients under halothane anesthesia.

Improved treatment outcome in adult acute lymphoblastic leukemia using the intensive German protocol, a preliminary report

Thirty-nine consecutive patients with acute lymphoblastic leukemia were treated with an intensive chemotherapy protocol. There were 23 males and 16 females with a median age of 37 years (range: 15-65). Eighteen patients had common ALL, seven had pre-B ALL, three early-precursor B ALL, seven T-ALL and four had aberrant expression of myeloid antigens (c-ALL in three and pre-B ALL in one). The median initial leukocyte count was 11.8 x 10(9)/l (range: 0.65-295). Cytogenetic result of the marrow was available in 16 of 39 patients (41 per cent) and showed Philadelphia positivity in six, a normal result in six and one each of t(4,11), t(1,19), hyperdiploidy and del 12p. Hepatosplenomegaly was present in about 20 per cent of the patients. L-Asparaginase-related hepatic toxicity was the commonest toxicity (48.7 per cent) during phase I of induction. Prolonged pancytopenia and hypoplastic death were common during phase II. With the use of growth factors during the neutropenic period of phase II induction, the rate of hypoplastic death was reduced from 40 per cent to 3 per cent. Common causes of treatment failure included early hypoplastic death (27.8 per cent) and leukemia relapses (50 per cent) while primary refractory leukemia, hepatic failure and perforated peptic ulcer contributed to 11.1, 5.5 and 5.5 per cent of the other deaths. A high complete remission (CR) rate (87.4 per cent) was achieved after phase I induction. The median event-free survival (EFS) was 8 months and the 3-year event-free survival was 43 per cent. This result compared favourably to the other regimens previously employed in our institution. In conclusion, satisfactory survival can be achieved with this intensive regimen. Good supportive care was however, essential to minimize toxicities.

Terbutaline inhalation suppresses fentanyl-induced coughing

PURPOSE

To study the suppressive effect of inhalation of a selective beta 2-adrenergic bronchodilator terbutaline, and the effect of an intravenous anticholinergic, atropine, on fentanyl-induced coughing.

METHODS

We studied 131 ASA class I patients, aged 16-45 yr, scheduled for elective surgery, randomized into four groups. Fifteen minutes before bolus fentanyl (5 micrograms.kg-1, iv), patients inhaled either normal saline (4 ml; Group I, n = 30) or terbutaline (5 mg in 2 ml normal saline; Group 2, n = 34) via a jet nebulizer. After inhalation of normal saline, patients in Group 3 (n = 32) received sterile water iv instead of fentanyl. Patients in Group 4 (n = 35) were pretreated with atropine (0.01 mg.kg-1, iv) 10 min before iv fentanyl bolus. The onset, frequency and intensity of cough were observed immediately by an anaesthetist blinded to the study.

RESULTS

The cough frequency was higher in Groups I (43%) and 4 (46%) than in Groups 2 (3%) and 3 (0%) (P < 0.05). The onset time and intensity of cough showed no difference among groups. No truncal rigidity was observed in patients receiving fentanyl bolus iv. The blood pressure, heart rate, and peripheral oxygen saturation did not change in Groups 1, 2, and 3, while patients in Group 4 showed an increase in heart rate (25.5 +/- 15.2%).

CONCLUSIONS

The inhalation of a selective beta 2-adrenergic bronchodilator, terbutaline, effectively inhibited fentanyl-induced cough, whereas atropine, an antimuscarinic vagolytic, had no efficacy. Our results suggest that bronchoconstriction may underlie the mechanism on fentanyl-induced cough.

Mapping the functional surface of insulin by design: structure and function of a novel A-chain analogue

Functional surfaces of a protein are often mapped by combination of X-ray crystallography and mutagenesis. Such studies of insulin have yielded paradoxical results, suggesting that the native state is inactive and reorganizes on receptor binding. Of particular interest is the N-terminal alpha-helix of the A-chain. Does this segment function as an alpha-helix or reorganize as recently proposed in a prohormone-convertase complex? To correlate structure and function, we describe a mapping strategy based on protein design. The solution structure of an engineered monomer ([AspB10, LysB28, ProB29]-human insulin) is determined at neutral pH as a template for synthesis of a novel A-chain analogue. Designed by analogy to a protein-folding intermediate, the analogue lacks the A6-A11 disulphide bridge; the cysteine residues are replaced by serine. Its solution structure is remarkable for segmental unfolding of the N-terminal A-chain alpha-helix (A1 to A8) in an otherwise native subdomain. The structure demonstrates that the overall orientation of the A and B chains is consistent with reorganization of the A-chain's N-terminal segment. Nevertheless, the analogue's low biological activity suggests that this segment, a site of clinical mutation causing diabetes mellitus, functions as a preformed recognition alpha-helix.

All-trans retinoic acid (ATRA) in the treatment of acute promyelocytic leukemia (APL)

Acute promyelocytic leukemia is characterized by the reciprocal translocation of chromosomes 15 and 17. All-trans retinoic acid (ATRA) efficiently induces differentiation of the abnormal promyelocytes. In this study, we had used ATRA as the primary induction therapy for 17 newly diagnosed patients, and as the salvage therapy for 11 patients who relapsed from or were resistant to chemotherapy. All patients received subsequent consolidation chemotherapy. Complete remission (CR) rate, early death rate (within 28 days of diagnosis) were then compared to an historical control of 50 APL patients treated with combination chemotherapy; and event-free survival of the 17 newly diagnosed patients was compared to the historical control. In the ATRA group, 26 of the 28 patients (93 per cent) attained complete remission. Two of 28 (7 per cent) died within 28 days of ATRA therapy. There was no case of primary resistance to ATRA. Combination chemotherapy was added to ATRA in five patients due to rapidly increasing leucocyte count. There was one case of retinoic acid syndrome which resolved with steroid. When compared to the 50 cases of historical control, there is significant improvement in the overall CR rate (92 per cent versus 59 per cent, p = 0.001) and a significant reduction in the early mortality rate (7 per cent versus 41 per cent, p = 0.001). Moreover, when the survival result of the 17 newly diagnosed patients were compared with the control, there is a significant improvement in the projected EFS at 3 years (64 per cent versus 25 per cent, p = 0.007). In conclusion, ATRA was shown to improve the CR rate, reduce induction mortality and significantly prolong the event-free survival.

Incidence and risk factors of guidewire-induced arrhythmia during internal jugular venous catheterization: comparison of marked and plain J-wires

STUDY OBJECTIVES

To compare the incidence and risk factors of guidewire-induced arrhythmia (GIA) during internal jugular venous catheterization (IJV).

DESIGN

Prospective study.

SETTING

Operating rooms at a medical center.

PATIENTS

303 ASA physical status I, II, III, and IV patients undergoing elective surgery.

INTERVENTIONS

All patients were cannulated with the central venous catheters placed via the right internal jugular vein after induction of anesthesia. They were randomly divided into two groups. In one group, we used a marked J-wire and inverted up to, but not beyond 20 cm (Group M, n = 127). In the other group, a plain unmarked J-wire was used and inserted at will (Group UM, n = 176). All IJV catheterizations were performed by residents, and the length of J-wire inserted was then measured.

MEASUREMENTS AND MAIN RESULTS

Types of arrhythmia [eg, premature atrial contraction (PAC) or premature ventricular contraction (PVC)] were interpreted by attending anesthesiologists on lead II ECG. Patients in Group UM had a significantly greater incidence of GIA than those in Group M (28.4% vs. 3.9%; p < .005). However, in both groups, PAC occurred more frequently than PVC. Factors such as the inserted length of guidewire longer than 20 cm, body height less than 170 cm, and female gender were significantly associated with GIA (p < 0.005).

CONCLUSIONS

Limiting the length of the guidewire insertion to less than or equal to 20 cm for right IJV catheterization by using a marked J-wire will reduce the incidence of GIA. We recommend the use of a marked J-wire for IJV catheterization.

Pure red cell aplasia: clinical features and treatment results in 16 cases

Pure red cell aplasia (PRCA) is a rare hematological disease characterized by selective marrow erythroid aplasia. We report the clinical features and treatment results of 16 Chinese patients with PRCA. Nine (56%) cases were not associated with any underlying disorders and were considered idiopathic, while seven patients (44%) had associated diseases, three involving the thymus, two with T large granular lymphocyte leukemia (T-LGLL), and one each with Stevens-Johnson syndrome and acute hepatitis A. Conventional-dose corticosteroid therapy resulted in complete remission in three of 13 patients. Cyclosporin A was used in six patients. There were three complete and one partial remissions. High-dose methylprednisolone was ineffective in four patients who failed conventional-dose corticosteroids but achieved complete remission in one patient with thymoma who did not respond to thymectomy. Antithymocyte globulin was used in four patients, resulting in partial remission in only one patient with concomitant T-LGLL. Intravenous gamma globulin and danazol were ineffective in three patients. Thymectomy was performed in two patients, with one patient remitting. This is the largest series of PRCA reported in an oriental population. Our results indicate that treatment of PRCA may still be problematic and better therapeutic strategy will have to be defined.

5-Hydroxytryptophan: an absorption and fluorescence probe which is a conservative replacement for [A14 tyrosine] in insulin

Use of insulin's intrinsic tyrosine absorption and fluorescence to monitor its interaction with the insulin receptor is limited because the spectral properties of the receptor tryptophan residues mask the spectral properties of the hormone tyrosine residues. We describe the synthesis of an insulin analog where A14 tyrosine is replaced by a tryptophan analog, 5-hydroxytryptophan. This insulin is spectrally enhanced since 5-hydroxytryptophan has an absorption band above 300 nm which is at lower energies than the absorption of tryptophan. Steady-state and time-resolved fluorescence parameters indicate that 5-hydroxytryptophan reports the same information about the environment of the A14 side chain as does the corresponding tryptophan-containing insulin. The synthetic hormone is a full agonist compared to porcine insulin, but has slightly reduced specific activity. Consequently, this spectrally enhanced insulin analog will be useful for hormone-receptor interaction studies since it can be observed by both absorption and fluorescence even in the presence of the tryptophan-containing receptor.

Intensive consolidation chemotherapy for newly diagnosed acute myeloid leukemia using a regime containing moderate dose cytosine arabinoside and mitoxantrone

Fifty patients with previously untreated acute myeloid leukemia were treated with an induction regimen consisting of cytosine arabinoside 100 mg/m2 per day by 18 h i.v. infusion for 7 days, daunorubicin 50 mg/m2 per day by i.v. bolus injection for 3 days and etoposide 75 mg/m2 per day by 1 h i.v. infusion for 7 days. Thirty seven of them (74%) went into complete remission (CR) and they all then received two consecutive courses of consolidation chemotherapy consisting of cytosine arabinoside 500 mg/m2 per day by 1 h i.v. infusion every 12 h for 4 days (total eight doses) and mitoxantrone 12 mg/m2 daily by 30 min i.v. infusion for 3 days. They were followed by maintenance chemotherapy with cytosine arabinoside and thioguanine 2 monthly. With a median follow up time of 24 months, 20 of the 37 complete responders had relapsed (54%). The disease-free survival (DFS) of 37 CR patients and the overall survival of all patients at 24 months were 37 and 44%, respectively. Age of patients and number of courses of induction chemotherapy to achieve CR were significant factors predicting DFS. Myelosuppression was the major toxic side effects. Ten patients had prolonged marrow suppression following consolidation chemotherapy. In conclusion, despite the significant myelosuppression observed, overall improvement in treatment outcome was not demonstrable with the use of this intensive consolidation therapy.