Journal of the Chinese Medical Association

Pyogenic liver abscess in the elderly: What we have learned?

Yi-Tsung Lin, Chang-Phone Fung — 2012-03-26

Pyogenic liver abscess (PLA) remains a health problem in Taiwan. The annual incidence of PLA in Taiwan was 17.5 per 100,000 individuals in 2004, in contrast to only 2.3 and 3.6 per 100,000 individuals in Canada and the United States in 2003 and 2005, respectively. In Taiwan, Klebsiella pneumoniae is the leading pathogen, presenting in 78–80% of culture-confirmed cases, which is different from Western countries, where the most frequent etiological agents of PLA are Streptococcus, Escherichia coli, Staphylococcus, and anaerobic bacteria. The initial clinical symptoms and signs of PLA were not significantly different in both K. pneumoniae and non-K. pneumoniae patients. However, the K. pneumoniae patients were more likely to be younger and frequently associated with diabetes mellitus (DM) and had a high incidence of septic endophthalmitis (mostly due to serotypes K1 and K2 K. pneumoniae) and other metastatic infections, but with a lower mortality. The non-K. pneumoniae patients were more likely to be older and frequently associated with malignancy and had a higher mortality.

Predictive factors for operation and mortality following renal trauma

Shiou-Sheng Chen — 2012-03-26

The incidence of injury to the urologic system after trauma is about 10%. Blunt trauma followed by traffic accidents and during sports comprise 90% of the etiologies. In addition, the rate of penetrating injuries is increasing, especially in urban areas. The kidney is the most common urologic organ to be injured, followed by urinary bladder and the urethra. Isolated urologic trauma is rare; therefore, it is important to consider possible potential urological injury in the multiple trauma patients. Renal injury happens in 8%–10% of all blunt and penetrating abdominal injuries and is frequently managed conservatively. However, it is important to diagnose renal pedicle injury or laceration of ureteropelvic junction with potential retroperitoneal hemorrhage or urinoma. Therefore, the optimal management of major blunt and penetrating renal injuries remains controversial and deserves further evaluation. In this issue, Dr. Yang and colleagues have done a good job of finding the factors predictive of surgery and mortality in patients with renal injury.

Investigation on signal transduction pathways after H1 receptor activated by histamine in C6 glioma cells: Involvement of phosphatidylinositol and arachidonic acid metabolisms

Chin-Lu Tseng, Jiann-Wu Wei — 2012-04-02

Abstract: Background: Information related to histamine-induced cellular responses in C6 glioma cells through second messenger pathways has not been fully studied, especially the involvement of arachidonic acid (AA) metabolism. In addition, specific labeled ligand binding to histamine receptor sites still needs to be clarified.Methods: Labeled mepyramine ligand was used to study its binding sites; [3H] inositol was used to detect inositol 4-phosphate (IP1) formation, and fura-2/AM was used to detect intracellular free calcium ion ([Ca2+]i) level activated by the phosphatidylinositol-phospholipase C (PI-PLC) pathway. Also, labeled AA was used to detect the metabolism of AA and its metabolites release via the activation of phospholipase A2 in the presence of histamine.Results: C6 glioma cells incubated with histamine in the presence of 10 mM LiCl for 60 minutes induced an increase of IP1 and glycerophosphoric-inositol (GPI) accumulation. In addition, histamine caused an increase of extracellular AA with its metabolite release, eliciting a transient and sustained increase of free [Ca2+]i. The sustained increase of [Ca2+]i was almost or completely blocked by La3+ and excess ethylene diamine tetraacetic acid. The calcium ion influx associated with the sustained phase required the presence of histamine on the receptor sites, and could be blocked by a H1 antagonist, chlorpheniramine.Conclusion: C6 glioma cells possess histamine H1 receptors that have affinity towards [3H]mepyramine binding, and are coupled to PI-PLC to generate inositol phosphates and to increase [Ca2+]i, and they are coupled to phospholipase A2 (PLA2) to generate GPI and AA with its metabolite release. The transient increase in [Ca2+]i can be attributed to Ca2+ release from intracellular stores, whereas the sustained increase in [Ca2+]i is due to influx of extracellular calcium ions. The sustained increase in [Ca2+]i plays a role in the activation of histamine receptor-coupled PLA2.

Long-term follow-up of ulcerative colitis in Taiwan

2012-04-05

Abstract: Background: The incidence of ulcerative colitis (UC) has been increasing in Asia recently, but little long-term follow-up data is available. We aimed to understand the clinical characteristics of UC patients in the National Taiwan University Hospital (NTUH), a tertiary referral center in Taiwan.Methods: A retrospective study was conducted to review data from January 1, 1988 through December 31, 2008 compiled at NTUH. Patients' clinical information, demographic data, endoscopic pictures, treatment regimens, pathologic, and outcome details were reviewed, recorded, and analyzed.Results: A total of 406 patients were included (233 males and 173 females; median age at diagnosis was 36 years). The follow-up period ranged from 0.25 to 40.8 (mean, 7.3) years. The prevalence of UC in Taiwan was at least 7.4/100,000 in 2008. Bloody stool was the most common presentation (77.3%). Total colon was the most common (41.0%) disease involvement and proctitis the least common (21.1%). Six patients (1.5%) died during the follow up. Most of the UC patients (72.4%) could be controlled with 5-aminosalicylic acid alone, but about one third (30.9%) were admitted for treating the UC or UC-related complications. Twenty-three patients (5.5%) were treated surgically. Extra-gastrointestinal tract manifestations were noted in 4.5% of the UC patients, with primary sclerosing cholangitis (6 in 406, 1.5%) the most common. Colon cancer/severe dysplasia occurred in six (1.5%) of the patients.Conclusion: The incidence of UC has increased in Taiwan. Interestingly, CRC/dysplasia and PSC occur more frequently here than in other Asian nations.

Delayed primary closure versus primary closure for wound management in perforated appendicitis: A prospective randomized controlled trial

Ruey-An Chiang, Shan-Long Chen, Yao-Chung Tsai — 2012-04-05

Abstract: Background: It is still a matter of debate whether delayed primary closure (DPC) of contaminated abdominal incisions reduces surgical site infections compared with a primary closure (PC). The aim of this study was to determine the optimal method of wound closure for patients with perforated appendicitis.Methods: A total of 70 patients with perforated appendicitis were included. They were randomized to have their surgical incisions (skin and subcutaneous tissue) either PC or left open with Betadine-soaked gauze packing for DPC on the fifth postoperative day or later if the wound conditions were inappropriate for closure. A wound was considered infected if pus discharged from the incision site. The main outcome measures were the incidence of wound infection and the length of hospital stay (LOS).Results: In the entire series, wound infection developed after incision closure in 21.4% of the patients. The PC group had a higher incidence of wound infection (38.9% vs. 2.9%, p<0.001) and longer LOS (8.4 days vs. 6.3 days, p=0.038).Conclusion: Delayed primary closure is the optimal management strategy for perforated appendicitis wounds. It significantly reduces the wound infection rate and length of stay.

Magnetic resonance imaging guided biopsy of musculoskeletal lesions

2012-04-06

Abstract: Background: Minimally invasive interventional biopsy procedures have the advantages of accurate localization, small incisions, and rapid recovery. The purpose of this study was to clinically test and evaluate the efficacy of the magnetic resonance imaging (MRI)-guidance techniques for obtaining musculoskeletal biopsies using the appropriate imaging modalities and instruments.Methods: We used MRI-compatible biopsy needles from the Invivo Bone Biopsy Set (Daum, Germany), and a 1.5-T closed-magnet MRI scanner was used to perform the MRI-guided biopsy. The pulse sequences included fast spin echo T1- and T2-weighted imaging and gradient echo imaging. The inclusion criteria included the presence of bone or soft tissue masses, infectious disease, and other nonspecific lesions that required tissue confirmation. Lesions that could not be visualized by computed tomography (CT) or other imaging modalities were preferred.Results: From January 2005 through December 2009, 23 patients (12 males and 11 females, aged 11–82 years) underwent musculoskeletal MRI-guided biopsy. The biopsy locations were as follow: spine (n = 12), tibia (n = 3), pelvis (n = 1), femur (n = 2), scapula (n = 1), humerus (n = 1), ulna (n = 1), scapula (n = 1), and soft tissue mass of the shoulder (n = 1). The final diagnoses included bone metastasis (n = 7), spinal osteomyelitis and discitis (n = 5), osteonecrosis after chemotherapy (n = 4), bone marrow change or benign lesion without malignancy (n = 3), insufficiency fracture (n = 1), long bone osteomyelitis (n = 1), soft tissue metastasis (n = 1), and perineural ganglion cyst (n = 1). In 10 of the 23 cases, the lesions were barely visualized or invisible on CT guidance. Pathologic analysis and laboratory culturing revealed that the lesions were successfully accessed by MRI-guided biopsy in 100% (23/23) of cases. No obvious complications developed during or after the procedures.Conclusion: Biopsy under MRI guidance is especially valuable for the localization of bone marrow lesions, viable tumors (after chemotherapy or radiation), and lesions that cannot be visualized using CT. It is both accurate and safe, is a good alternative biopsy method, and may be a good adjunctive technique for the localization of bone lesions for radiofrequency ablation or other interventional procedures.

Cefuroxime-impregnated cement and systemic cefazolin for 1 week in primary total knee arthroplasty: An evaluation of 2700 knees

Chao-Ching Chiang, Fang-Yao Chiu — 2012-04-05

Abstract: Background: Infection is one of the most devastating complications after primary total knee arthroplasty (TKA). Antibiotics-impregnated cement has been used and proven effective in preventing deep infection. This study was to evaluate the long-term results of using cefuroxime-impregnated cement and systemic cefazolin for one week to assess their efficacy in preventing infection of primary TKA.Methods: From 1999 to 2007, 2700 cases of primary TKA were performed with cemented fixation of all patellar, tibial, and femoral components. Cefuroxime-impregnated cement for fixation and systemic cefazolin for one week were selected in all cases. The average follow-up period was 89 months (range, 40–140). The effects of this selected regime in the periprosthetic infection were evaluated.Results: A total of eight infections occurred after primary TKA, including five deep infections (0.19%) and three superficial infections (0.11%) in the 2700 knees. No loosening or osteolysis was noted.Conclusion: Comparable with other measurements, cefuroxime-impregnated cement, accompany by systemic cefazolin for 1 week was shown to control postoperative deep infection to 0.19% (after primary TKA was performed in an operative setting without lamina flow and body exhaust suit).

Ductus venosus Doppler velocimetry in normal pregnancies from 11 to 13 + 6 weeks' gestation—A Taiwanese study

2012-04-02

Abstract: Background: To investigate flow in the ductus venosus at 11–13 + 6 weeks of gestation in women with normal pregnancies in the Taiwanese population.Methods: Two hundred and fifty-two normal singleton pregnancies with gestational ages ranging from 11 to 13 + 6 weeks were examined in this study. The pulsatility index for veins (PIV), resistance index (RI), peak velocity during ventricular systole (S-wave), and peak velocity during ventricular diastole (D-wave) were recorded from the ductus venosus.Results: We analyzed 252 participants who all fulfilled the inclusion and exclusion criteria of our study. The mean maternal age was 31 (range 19–45 years), with a corresponding gestational age of 12 + 4 weeks (range 11–13 + 6). No significant change was found in the vascular indices as gestational age increased for the S-wave (S-wave = 1.4214 (GA) + 17.448, r = 0.09, P = 0.154), PIV (PIV = −0.0358 (GA) + 1.4143, r = −0.05, P = 0.378) and RI (RI = −0.035 (GA) + 1.1478, r = −0.064, P = 0.468). In contrast, the D-wave behaved differently from the other variables. There was a significant increase (r = 0.155, P = 0.013) in the D-wave with gestational age (D-wave = 1.4896 (GA) – 7.1547).Conclusion: D-wave velocity in the ductus venosus increased with gestational age. S-wave peak velocity showed an increasing trend and PIV showed a decreasing trend with gestational age, but they did not reach statistical significance.

Effect of oxidized regenerated cellulose on the healing of pharyngeal wound: An experimental animal study

2012-04-19

Abstract: Background: This study aimed to investigate the relationship between oxidized regenerated cellulose (ORC) and mucosa healing in an experimental animal model.Methods: Fifteen adult Sprague-Dawley rats were randomly divided into three groups that underwent different wound treatments. In Group 1, no pharyngeal wound was created. In Group 2, the pharyngeal wound was sutured with Prolene only. In Group 3, the pharyngeal wound was sutured with Prolene, and covered with one layer of ORC before closure of the skin wound. The animals were euthanized either 5 or 10 days after operation, and wound conditions were inspected and recorded. Specimens including sections of larynx and pharynx/upper esophagus were taken for microscopic and molecular biological examination.Results: The pharyngotomy/esophagotomy wounds achieved good healing outcomes 10 days after operation. Wounds treated with ORC had significantly diminished inflammatory cell infiltration in microscopic examination when compared with that of those without ORC 5 days after operation. The matrix metalloproteinases (MMP) expression level was higher in wounds of Group 2 and Group 3, when compared with that of group 1. In addition, the MMP expression level was lower in the ORC-treated wounds when compared with that of those without ORC. There was no significant difference in fibroblast proliferation, collagen deposition, endothelin-1, alpha-smooth muscle actin, and transforming growth factor beta 1 expression level between wounds treated with ORC and those without ORC.Conclusion: Reduced inflammatory response and decreased MMP expression level was observed in ORC-treated wounds. Whether ORC facilitates mucosa healing requires further investigation.

Foreign body in the ureter: A particle of glue after transarterial embolization of a renal pseudoaneurysm during percutaneous nephrostomy

Wen-Jung Chen, Shao-Chuan Wang, Sung-Lang Chen, Yu-Lin Kao — 2012-03-26

Abstract: Reports on foreign bodies within the ureter are extremely rare in the literature. Herein, we present a case of a foreign body in a ureter, specifically a particle of glue resulting from transarterial embolization of a renal pseudoaneurysm secondary to percutaneous nephrostomy. Emergent transarterial embolization was required due to life-threatening active bleeding of the pseudoaneurysm. However, the glue material subsequently fell into the ureter where it became a foreign body, resulting in obstructive uropathy. Several surgical interventions, including endoscopic and laparoscopic methods, were performed to retrieve the foreign body, but these attempts were unsuccessful. Finally, the glue material was spontaneously passed out by chance. To the best of our knowledge, this type of complication (a glue particle left over from an embolization procedure migrating into the urinary collecting system) has never been reported. We recommend close follow-up examinations after transarterial embolization for renal pseudoaneurysm in order to avoid possible obstructive uropathy caused by glue materials or coils.

Acute appendicitis with superior mesenteric vein septic thrombophlebitis

2012-03-26

Abstract: Septic thrombophlebitis of the superior mesenteric vein (SMV) is rarely caused by acute appendicitis. The clinical symptoms of SMV thrombophlebitis are varied and atypical, so the diagnosis is commonly delayed, resulting in a reported mortality rate of 30%–50%. We report a case of SMV septic thrombophlebitis caused by acute appendicitis in which the patient was successfully treated with surgical intervention, appropriate antibiotics, and anticoagulation therapy. A follow-up abdominal computed tomography scan after 3 months of treatment showed that the SMV thrombosis had been resolved.

Persistent cloaca presenting with a perineal cyst: Prenatal ultrasound and magnetic resonance imaging findings

2012-03-26

Abstract: A 40-year-old, primigravid woman presented at 23 weeks of gestation for evaluation of an extra-abdominal echogenic cystic mass of the fetus. Amniocentesis revealed a karyotype of 46,XX. Prenatal ultrasound showed a two-vessel umbilical cord, hydrocolpos, and distended bladder, urethra, and colon, and a perineal cystic mass. The kidneys and amniotic fluid amount were normal. Fetal magnetic resonance imaging revealed ascites, hydrocolpos, distended urinary bladder and colon, high rectum, and a perineal cyst. The fetus postnatally manifested persistent cloaca. The perineum was distended and smooth, without patent anal, vaginal, and urethral openings. The external genitalia were ambiguous with no labia majora, labia minora, or clitoris. The perineal cyst had a very small single orifice. We suggest that cloacal anomalies be considered in any female fetus with hydrocolpos, distended bladder and colon, ascites, and a perineal cyst.