Journal of the Chinese Medical Association

Portal-systemic collaterals and hepatic encephalopathy

Che-Chang Chan — 2011-12-14

Chronic liver diseases or liver injuries commonly result in portal hypertension and the formation of portal-to-systemic collaterals (PSCs). PSCs form through the appearance of large or small vascular communications between the portal and systemic circulatory routes. These collateral vasculatures will shunt part of the portal blood flow, bypassing the liver, to the systemic circulation. Shunting the portal blood flow through collateral vessels is an attempt to decompress a highly pressurized portal system. However, the shunting of portal blood flow through PSCs may interfere with the detoxification processes of the liver. The uncleared toxic substances in the bloodstream may then reach the brain to cause neuropsychological dysfunction, known as hepatic encephalopathy.

Portosystemic collaterals are not prerequisites for the development of hepatic encephalopathy in cirrhotic rats

2011-11-24

Abstract: Background: Liver functions and portosystemic collaterals influence the development and severity of hepatic encephalopathy (HE) in cirrhosis. However, it has not been examined which factor has a greater influence or if shunts can be used to determine the presence and severity of HE. The expression of tumor necrosis factor-α (TNF-α) is increased in cirrhosis, and its role in HE deserves further evaluation.Methods: Portal hypertension was induced by portal vein ligation (PVL; a model of high-degree portosystemic shunting without significant liver damage) and liver cirrhosis was induced by bile duct ligation (BDL; a model of low-degree shunting with liver cirrhosis) in male Spraque-Dawley rats. Sham-operated rats were used as controls. Motor activity counts, hemodynamic parameters, plasma levels, liver biochemistry parameters, TNF-α, and a flow-pressure curve study of portosystemic collaterals (where a higher slope indicates fewer portosystemic collaterals) were performed on Day 7 after PVL and Week 5 after BDL.Results: Portal pressure was significantly higher in the PVL and BDL groups than in controls. The liver biochemistry parameters, TNF-α, and motor activities were not significantly different between the PVL and PVL-control groups. In the BDL group, TNF-α, AST, and total bilirubin levels were significantly higher and the motor activity counts were lower than in the BDL-control group. Moreover, in the BDL rats, TNF-α (p=0.037, R=-0.490), AST (p=0.007, R=-0.595) and total bilirubin (P=0.001, R=−0.692) levels, but not the slopes of the flow-pressure curves, were significantly and negatively correlated with the motor activity counts.Conclusion: The presence of a high degree of portosystemic shunting without significant liver damage may not be adequate for the development of HE.

Frequency and risk factors associated with atherosclerotic plaques in patients with a zero coronary artery calcium score

2011-12-26

Abstract: Background: Analysis of the coronary artery calcium levels usually provides important information that can be used in patient prognosis and stratification of treatment when coronary artery disease is suspected. However, plaques, with or without significant stenosis, have been reported in patients without coronary artery calcium. The aim of this study was to determine the frequency and risk factors of the development of coronary artery plaques in individuals with a zero calcium score.Methods: Analysis of coronary artery calcium levels and coronary computed tomography angiography (CTA) were performed using 64-slice computed tomography (CT). The demographic data, clinical risk factors, and imaging features of 519 consecutive patients (54 ± 10 years, male:female ratio of 56:44) were retrospectively analyzed. The presence of plaques and the degree of the resulting stenosis were recorded. Descriptive, univariate, and multivariate analyses were carried out to identify the frequency and risk factors associated with the presence of coronary artery plaques.Results: Among 66 patients, 82 coronary arteries were found to have plaques, and six coronary arteries showed significant stenosis. Univariate analysis showed that an age greater than 55 years, male gender, a body mass index (BMI) of more than 27, hypertension, and diabetes mellitus are significant factors associated with the development of coronary artery plaques. Multivariate logistic regression analysis showed that an age over 55 years (p = 0.012, OR = 2.13, 95% C.I. = 1.18–3.84) and BMI greater than 27 (p = 0.026, OR = 2.01, 95% C.I. = 1.09–3.72) are independent factors associated with the presence of plaques in patients with a zero calcium score.Conclusion: The results of this study show that plaques are present in a significant proportion of individuals with a zero coronary artery calcium score. In addition, advanced age and obesity are risk factors associated with the development of plaques.

Clinical outcomes and prognostic factors of Ewing sarcoma: A clinical analysis of 12 patients in Taiwan

2011-12-02

Abstract: Background: Ewing sarcoma is extremely rare in people from East and Southeast Asia.Methods: The records of 12 patients diagnosed with primary Ewing sarcoma and treated at our institution from 1997 to 2009 were retrospectively reviewed.Results: There were seven male and five female patients and their mean age at diagnosis was 22 years (range, 12–48 years). Two patients (16.7%) had distant metastasis at diagnosis. The primary tumor sites were the trunk in seven patients (58.3%) and the extremities in five patients (41.7%). Eleven patients received neoadjuvant chemotherapy followed by wide excision surgery, and then adjuvant chemotherapy. One patient received only chemotherapy without surgical intervention due to poor cardiac and pulmonary function. At a mean follow-up of 33 months, the 2-year overall survival rate (OS) was 45.5%. Distant metastasis was the only statistically significant prognostic factor of OS in our study. The 2-year OS rates of patients with lung metastasis and without lung metastasis were 0% and 42.9%, respectively (p = 0.021). The t(11;22)(q24:q12) translocation was present in all patients in our series.Conclusion: We confirmed that distant metastases is highly predictive of a poor outcome, and that the t(11;22)(q24:q12) translocation was present in all patients in our series.

Predictive indications of operation and mortality following renal trauma

2011-12-26

Abstract: Background: This study is a review of our experiences related to managing patients with renal injuries and identifying the predictive indicators of surgery and mortality.Methods: A retrospective review study was performed in our university hospital. Patients with renal injuries were enrolled. Data comparisons were performed between four patient groups (operation vs. nonoperation groups and mortality vs. survival groups, respectively).Results: Seventy-three patients were enrolled in this study, 55 of whom (75.34%) were male. Nine patients (12.33%) were severely injured (Injury severity score (ISS) ≥ 16), and nine (12.33%) had high renal injury scores (Renal injury scale (RIS) ≥ 4). Seven patients (9.59%) had received operations, and four (5.48%) died of hemorrhagic shock and multiple organ failure. After performing multivariate analysis, patients who received operations had significantly higher ISS (≥16) and RIS (≥4) scores compared with patients who did not undergo operations. ISS ≥ 16 and Glasgow coma scale (GCS) < 8 were significantly correlated with mortality.Conclusion: In conclusion, ISS ≥ 16 and RIS ≥ 4 are predictive factors for necessitating an operation, and higher injury severity (ISS ≥ 16) and lower consciousness level (GCS < 8) scores are significantly associated with mortality after renal trauma.

Prevalence of maternal group B streptococcus colonization and vertical transmission in low-risk women in a single institute

2011-12-07

Abstract: Background: Intrapartum administration of antibiotics lowers the risk of neonatal group B streptococcus (GBS) infection based on recommended guidelines (a risk-based approach and a culture-based screening approach). However, many pregnant women do not undergo culture-based screening, nor treatment with prophylactic antibiotics after a GBS risk-based approach. Therefore, the value of GBS detection in asymptomatic low-risk pregnant women is controversial.Methods: A cohort study of 354 asymptomatic pregnant women at more than 37 weeks’ gestation who were planning to undergo vaginal delivery, and 118 neonates (107 paired samples of both mother and newborn), was conducted to evaluate the GBS colonization rate of these pregnant women and the subsequent vertical transmission rate, using a culture method.Results: The positive rate for GBS culture was 6.2% (22/354). Among 107 paired samples, six maternal samples and one neonatal sample were positive for GBS culture, with an estimated vertical transmission rate of 16.7% (1/6).Conclusion: Although the positive rate of GBS culture was lower in asymptomatic low-risk pregnant women, the possibility of vertical transmission might be high. This finding is worthy of further investigation.

Differences between children and adults with otitis media with effusion treated with CO2 laser myringotomy

Chan-Wei Chang, Ya-Wen Yang, Chong Yau Fu, An-Suey Shiao — 2011-11-28

Abstract: Background: The safety and advantages of CO2 laser myringotomy for otitis media with effusion (OME) are well described. The goal of such treatment is to avoid unnecessary ventilation tube insertion. Comparisons between different age groups treated with this modality are lacking, and prognostic factors for treatment outcomes are not available.Methods: We conducted a retrospective cohort study that included 130 children (160 ears) and 96 adults (108 ears) with OME persisting after conservative antibiotic treatment. In eligible patients, we performed laser myringotomy in the affected ear. Follow-up was scheduled every week for 1 month and then every month for 6 months. Results for 233 ears were available for analysis; 24 ears were excluded (19 due to cancer, four due to a cleft palate, and one due to Down syndrome) and 10 patients (11 ears) were lost during follow-up. A logistic regression model was used for analysis, with success of therapy as the binary outcome.Results: Adult patients had more unilateral lesions (p < 0.001) and serous fluid effusions (p < 0.001) than did the pediatric patients. However, there was no significant difference in the cure rate (children: 58.1%; adults: 64.7%) and positive culture rate (children: 15.1%; adults: 14.3%) between patient groups. Three factors were found to be associated with a poor prognosis: multiple occurrences in children (p < 0.001), mucoid effusion (p = 0.04), and a history of ventilation tube use in adults (p < 0.001). No other variables predicted treatment outcome.Conclusion: Our findings suggest that CO2 laser myringotomy is a useful treatment modality for OME in children and adults, except for children with multiple occurrences and in adults with mucoid effusions and a history of ventilation tube use.

A predictive model of the association between gene polymorphism and the risk of noise-induced hearing loss caused by gunfire noise

Ben-Chih Yuan, Feng-Ming Su, Wen-Tung Wu, Wen-Sheng Liu, Kuo-Hsun Chiu — 2011-10-26

Abstract: Background: Noise-induced hearing loss (NIHL) is one of the common diseases in otology. In general, we assume that most people who are exposed to loud noise constantly, e.g., soldiers, will suffer from hearing loss. Hearing loss is related to the gene polymorphisms, with the Wolfram syndrome type 1 gene (T2500C), interleukin-4 receptor α chain (Q576R) and chloride channel-Kb (T481S) polymorphisms being most related to NIHL.Methods: We analyzed the association between the polymorphisms and the risk of NIHL in 119 subjects who were exposed to the same loud gunfire. In the current study, 39 persons with hearing loss and 80 with normal hearing were recruited from military officers and soldiers that were exposed to gunfire.Results: The results showed that the genetic variation of Wolfram syndrome type 1 gene was a more crucial factor than other genes in causing hearing loss. There was a significant difference (p=0.027) in WFS1 (T2500C) polymorphism between NIHL subjects and controls.Conclusion: In this study, we found that although loud noise could usually result in hearing damage, the clinical characteristics of hearing loss were irrelevant to gunfire noise. The gene polymorphisms provide predictors for us to evaluate the risk of NIHL prior to gunshot training.

Bladder outlet obstruction due to labial agglutination

Ching-Hsin Chang, Yu-Hua Fan, Alex Tong-Long Lin, Kuang-Kuo Chen — 2011-12-02

Abstract: Here, we report the case of a 63-year-old female patient who presented with emptying symptoms and was subsequently diagnosed with delayed labial agglutination. The adhered labia minora were divided by blunt dissection, and a topical estrogen ointment was applied after surgery. The patient’s voiding symptoms were completely resolved and no recurrence of labial agglutination was noted 3 months after surgery. Labial agglutination is rare but often manifests with nonspecific emptying symptoms. Nevertheless, it can be easily diagnosed on physical examination and successfully treated by surgical intervention and the application of a local estrogen ointment. We present this rare case in order to emphasize the importance of physical examination.

Dural sinus malformation with arteriovenous fistulae in a newborn: Positive outcome following endovascular management

2011-11-28

Abstract: Dural sinus malformation (DSM) is an extremely rare and congenital cerebrovascular malformation that is associated with dural arteriovenous fistula and a large dural lake, which may mimic the clinical malformations of an infantile dural arteriovenous shunt or the vein of Galen. Early diagnosis and treatment of DSM is crucial in order to avoid irreversible brain injuries or heart failure. Here, we report an unusual case of extensive DSM that showed good clinical and angiographic results after endovascular embolization.