The Effects of Urokinase Instillation Therapy via Percutaneous Transthoracic Catheter in Loculated Tuberculous Pleural Effusion: A Randomized Prospective Study

The purpose of this study was to propose that intrapleural urokinase (UK) instillation could reduce pleural thickening in the treatment of loculated tuberculous pleural effusion. Forty- three patients who were initially diagnosed as having loculated tuberculous pleural effusion were assigned at random to receive either the combined treatment of UK instillation including anti-tuberculosis agents (UK group, 21 patients) or strictly the unaccompanied anti-tuberculous agents (control group, 22 patients). The UK group received 100, 000 IU of UK dissolved in 150 ml of normal saline daily, introduced into the pleural cavity via a pig-tail catheter. The control group was treated with anti-tuberculous agents, excepting diagnostic thoracentesis. After the cessation of treatment, residual pleural thickening (RPT) was compared between the two groups. Clinical characteristics and pleural fluid biochemistry were also evaluated. The RPT (4.59 +/-5.93 mm) of the UK group was significantly lower than that (18.6 +/-26.37 mm) of the control group (p or = 10 mm (6.0 +/- 3.4 wks) was detected to be significantly longer than in those with RPT or = 10 mm, as compared to patients with RPT< 10 mm in the UK group. These results indicate that the treatment of loculated tuberculous pleural effusion with UK instillation via percutaneous transthoracic catheter can cause a successful reduction in pleural thickening.

Randomized Trial of Early Versus Late Alternating Radiotherapy/ Chemotherapy in Limited-Disease Patients with Small Cell Lung Cancer / 대한방사선종양학회지

PURPOSE: A randomized prospective study was conducted to compare the efficacy of early or late alternating schedules of radiotherapy, and carboplatin and ifosfamide chemotherapy in patients with limited-disease small cell lung cancer. MATERIALS AND METHODS: From August 1993 to August 1996, a total of 44 patients with newly diagnosed, limited-disease small cell lung cancer, PS H0~2, wt loss<10% were enrolled in a randomized trial which compared early alternating radiotherapy (RT)/chemotherapy (CT) and late alternating RT/CT. The CT regimen included ifosfamide 1.5 g/m(2) IV, d1-5 and carboplatin AUC 5/d IV, d2 performed at 4 week intervals for a total of 6 cycles. RT (54 Gy/30 fr) was started after the first cycle of CT (early arm, N=22) or after the third cycle of CT (late arm, N=22) with a split course of treatment. RESULTS: The pretreatment characteristics between the two arms were well balanced. The response rates in the early (86%) and late (85%) arm were similar. The median survival durations and 2-year survival rates were 15 months and 22.7% in the early arm, and 17 months and 14.9% in the late arm ( p=0.47 by the log-rank test). The two-year progression free survival rates were 19.1% in the early arm and 19.6% in the late arm ( p=0.52 by the log-rank test). Acute grade 3 or 4 hematologic and nonhematologic toxicities were similar between the two arms. Eighteen patients (82%) completed 6 cycles of CT in the early arm and 17 (77%) in the late arm. Four patients received less than 45 Gy of RT in the early arm and two in the late arm. There was no significant difference in the failure patterns. The local failure rate was 43% in the early arm and 45% in the late arm. The first site of failure was the brain in 24% of the early arm patients compared to 35% in the late arm (p=0.51). CONCLUSION: There were no statistical differences in the overall survival rate and the pattern of failure between the early and late alternating RT/CT in patients with limited-disease small cell lung cancer.

Mycobacterial Infection after Kidney Transplantation: Single Center Experience / 대한이식학회지

PURPOSE: Transplant recipients under maintenance immunosuppression are likely to be exposed to mycobacterial infection that is associated with increased morbidity and mortality. METHODS: This review is based on the clinical data of 103 post-transplant tuberculosis recipients from the 1863 renal allograft recipients database between 1984 and 1999. Kinds of immunosuppression, history of acute rejection, use of anti-lymphocyte antibody, age and sex of recipient, presence of diabetes, presence of hepatitis B antigen pre- transplant, and history of pre-transplant tuberculosis were considered as potential risk factors for the development of post-transplant method and Cox proportional hazard model were used for the analyses. RESULTS: During 80 months of mean follow-up period, a total of 103 recipients were found to have tuberculosis (80 males and 23 females, mean age was 39.95+/-11.85 years old). Mean time interval from transplant to diagnosis of tuberculosis was 46+/-34.3 months. Cumulative incidence of tuberculosis post-transplant 5 and 10 year was 4.73 and nd culture for AFB, AFB-PCR, adenosine deaminase test, bronchoalveolar 7.76%, respectively, which were higher than that of the overall Korean population (0.8% in 1995). We a lavage and tissue biopsy (closed or bron-choscopic), and pleural tapping with biopsy. The treatment protocol was not different with regimens for general population. Duration of treatment differed from the clinical improvement (mean duration was 10.5 months). The pulmonary infection (including pleural effusion) was most common form of infection (n=71, 68.9%). Extra-pulmonary infection (including miliary tuberculosis) was 31.1% (n=32), which was higher than that of tuberculosis in Korean population (25% in 1998). In Cox regression analysis, previous history of tuberculosis was the strongest risk factor affecting the development of tuberculosis. Use of azathioprine-steroids or use of anti-lymphocyte antibody was also found to be a significant risk factor, respectively. Ten-year patient/graft survival rate in recipients with extra- pulmonary infection was 60.4/48.9, which was significantly inferior compared with those among the tuberculosis-free recipients (84.7/69.4%), or patients with tuberculosis limited to lung and pleura (81.1% and 56.6%). These differences were statistically significant (P<0.05, respectively). CONCLUSION: Taking considering that the pre-transplant tuberculosis history was strongest risk factor of post-transplant tuberculosis, strategy on the prophylaxis for tuberculosis should be planned.

Intrathecal Synthesis of Immunoglobulin G (IgG) and Anti-Tbc Humoral Immune Response in the Tuberculous Meningitis

The Immunological diagnosis of tuberculous meningitis (TBM) requires the presence of de novo synthesis of immunoglobulin in the central nervous system. We investigated the CNS IgG synthetic rate and IgG antibody titers against lipoarabinomanan (LAM) and PPD antigens in the serum and CSF by using ELISA in patients with TBM and patients with only pulmonary tuberculosis (PTB). The CNS IgG synthetic rate was markedly increased in all 11 patients with TB with PTB (56.42+l886 mg/day vs 7.47+435 mg/day). On the other hand, abnormally elevated IgG titers in the CSF against either LAM or PPD antigen were present in all 7 patients with TBM and in 4 of 11 patients with PTB tested. The 4 patients with the false positivity showed markedly elevated IgG antibody titers in the sera suggesting the passive diffusion of IgG antibodies through the intact blood brain barrier from the sera to the CSF. It is likely that the simultaneous measurement of CNS IgG sythesis is an useful addition to the ELISA of IgG antibody titration against the antigens of M. tuberculare in the CSF for the accurate diagnosis of TBM, especially in the endemic area of tuberculosis.