Low-power laser therapy for gastrointestinal neoplasia.

The purpose of this study was to evaluate changes in the degree of neoplasia-induced stenosis and clinical symptoms before and after therapy with a contact low-power neodymium yttrium aluminum garnet (Nd:YAG) laser. Fifty patients with pathologically proven gastrointestinal (GI) neoplasia were studied; 21 with benign lesions and 29 with malignant tumors. The low-power contact Nd:YAG laser was applied toward the lesion, using an antegrade method as the scope was moved circumferentially and downward along the length of the lesions, step-by-step. The energy of the laser was 20W, with a duration of 1 to 2 min for each shot. Either the tumor was eradicated completely, or the neoplasia-induced stenosis was recanalized by laser via the endoscope. All benign lesions were completely remitted by laser therapy. The clinical symptoms in the 29 patients with malignant GI neoplasia showed a significant improvement (P < 0.001; Wilcoxon matched-pairs signed-rank test, one-tailed) after laser therapy in comparison with the symptoms before treatment. Malignant GI stenosis treated by laser resulted in recanalization in 93.1% of the 29 patients. Unfortunately, in 1 patient with gastric cancer, the disease progressively worsened after treatment. One of 3 patients with early cancer of the stomach who received laser therapy was found to have distant metastasis 2 years later. A patient with esophageal cancer developed an esophagobronchial fistula that was not a direct complication of the laser effect. Four patients with malignancies died of cancer progression during the 2 years of follow-up. We conclude that the low-power contact laser is a safe, convenient method for the treatment of both benign and malignant tumors. Patients with advanced obstructive lesions have a better quality of life after laser therapy.

Comparison of the sensitivity and specificity of an automatic ligase chain reaction assay system with a one-step polymerase chain reaction assay in the diagnosis of Mycobacterium tuberculosis complex.

BACKGROUND: Polymerase chain reaction (PCR) and ligase chain reaction (LCR) are two nucleic acid amplification-based molecular methods. The former has been used widely in the identification of Mycobacterium tuberculosis (M. tuberculosis). In contrast, the LCR assay which was recently introduced is not well known in our medical communities in Taiwan. To determine which method is more reliable and suitable for the identification of M. tuberculosis in our clinics, we compared the sensitivity and specificity of these two methods. METHODS: An automatic LCR assay system and a manual one-step PCR assay were studied in a side by side comparison of their performance in detection of M. tuberculosis. The automatic LCR system uses the single copy antigen protein b (Pab) gene and the manual one-step PCR assay uses the multi-copy IS6110 insertion element as the target DNA; both target DNA sequences are found specifically in M. tuberculosis complex. RESULTS: Both assays detected two of the M. tuberculosis complex strains, M. tuberculosis and M. bovis, but not other mycobacterial strains. In addition, both methods, which were based on different amplification principles, showed compatible sensitivity; as low as 10 and 100 copies of M. tuberculosis genomes were detected by the LCR and PCR assays, respectively. When the template DNA was less than 1000 copies, however, the automatic LCR assay system showed a lower reproducibility than that of the one-step PCR assay. CONCLUSION: Our results suggest that in addition to the PCR assay, the LCR assay is a useful method for the molecular identification of M. tuberculosis complex strains.

Application of chromosome 4q35-qter marker (pFR-1) for DNA rearrangement of facioscapulohumeral muscular dystrophy patients in Taiwan.

Facioscapulohumeral muscular dystrophy (FSHD) has been found to be linked to chromosome 4qter. A chromosome 4q35-ter marker, pFR-1 (subclone of the cosmid c51), has been recently isolated and used as a probe for mapping near, or within, the FSHD gene. To examine FSHD-associated DNA rearrangements in the Taiwan population, we used the pFR-1 probe to perform Southern blot analysis on 142 individuals, including 32 FSHD patients within 9 autosomal dominant families, five sporadic FSHD patients from 4 families (include one pair of twins), three sporadic scapuloperoneal syndrome (SPS) patients and two sporadic polymyositis patients with their unaffected parents, and 29 healthy controls. In 29 healthy individuals, 3 SPS and 2 polymyositis patients with their families, probe pFR-1 analysis revealed that all had polymorphic restriction fragments that were larger than 28 kb in length. All but 1 FSHD-affected individual had specific smaller EcoRI fragments (ranging in size from 10.5 to 27 kb). Two point linkage analysis between pFR-1 and the FSHD locus provided significant evidence for FSHD linkage (Z(max)=6.84). A similar smaller fragment was also present in 5 sporadic patients, while this smaller fragment could not be found in one of their parents. Identical EcoRI restriction fragment length polymorphism (RFLP) patterns linked to FSHD were shown in the monozygotic twins, even though they showed extreme variability in the expression of FSHD. We conclude that the pFR-1 probe is a tightly linked marker of FSHD and can be used to detect most DNA rearrangements associated with this disease in the Taiwan population. However, the same RFLP patterns may represent extreme variability in the expression of the FSHD gene.

Blood lactate threshold and type II fibre predominance in patients with exertional heatstroke.

OBJECTIVES: Severe damage to skeletal muscle is usually seen in patients with exertional heatstroke. Thirty seven young military recruits with exertional heatstroke in Taiwan from 1992 to 1995 were studied to evaluate changes in muscle pathology and blood lactate with exercise. METHODS: A biopsy sample of the vastus lateralis was taken from recruits within 10 days of the initial presentation. Results were compared with those from 15 controls matched for age and sex. During the recovery period, 90-150 days after exertional heatstroke, 29 patients participated in a constant work load test on the treadmill to assess their blood lactate threshold, and a second biopsy sample was taken. Each biopsy was examined histologically for pathology, distribution of fibre types, and fibre diameter. RESULTS: Twenty four of the 37 patients with exertional heatstroke developed rhabdomyolysis and 18 of these had type II fibre predominance in their muscle biopsy. The patients with type II fibre predominance had a higher tendency to develop rhabdomyolysis (chi 2 = 6.84, P < 0.01). The time required to reach a blood lactate threshold during a constant treadmill work load after recovery was significantly shorter in the patients with exertional heatstroke who had type II fibre predominance (P < 0.01). There was a positive correlation between the highest value of blood lactate and the percentage of type II fibres in all tested subjects (r = 0.82, P < 0.01). CONCLUSION: Patients with type II fibre predominance are more susceptible to exertional heatstroke and tend to have a higher blood lactate concentration and a shorter time to reach blood lactate threshold under a treadmill load test.

Panencephalitic Creutzfeldt-Jakob disease in a Chinese family. Unusual presentation with PrP codon 210 mutation and identification by PCR-SSCP.

A point mutation at codon 210 (GTT to ATT) of the prion protein gene on chromosome 20 was found in a 48-year-old CJD-affected woman of a Chinese family. This affected woman had an early onset and long-duration form of CJD. Serial magnetic resonance image (MRI) analysis of this woman showed severe brain atrophy, prominent diffuse white matter degeneration, and subsequent mineralization of basal ganglia and thalamus. MR spectroscopy (1H) analysis elucidated the absence of peaks of choline, creatine and N-acetylaspartate. Using polymerase chain reaction and single-strand conformational polymorphism (PCR-SSCP) techniques, presymptomatic diagnosis of the second son of this woman showed that he has a similar codon mutation of prion gene as his mother.

Vascular dementia of Binswanger's type: clinical, neuroradiological and 99mTc-HMPAO SPET study.

In 24 patients with vascular dementia of Binswanger's type (VDBT) and 14 age-matched neurologically normal volunteers, we investigated the relationship between clinical features, white matter lesions (leuco-araiosis) and cerebral atrophy on computed tomographic (CT) scan, and regional cerebral blood flow. All subjects underwent the Mini-Mental State Examination of Taiwan, version 1 (MMSE-T1), for assessing the severity of cognitive impairment. The patients were subdivided into two groups, one with mild to moderate (group I, MMSE-T1 scores: 11-24, n=11), and the other with severe dementia (group II, MMSE-T1 scores: below 10, n=13). White matter degeneration was evaluated with densitometric methods. Loss of brain parenchyma was estimated with seven linear measurements (Evan's ratio, third ventricle ratio, width of temporal horn tip, anterior-posterior length of temporal horn, anterior-posterior length of Sylvian fissure and width of frontal interhemispheric fissure) by CT scans. Regional cerebral blood flow was determined with technetium-99m hexamethylpropylene amine oxime (HMPAO) single-photon emission tomography (SPET). In neuroimaging studies, subcortical leuco-araiosis was localized at the frontal region in group I patients and scattered diffusely in group II patients. 99mTc-HMPAO SPET analysis revealed reduction of regional cerebral blood flow in the frontal lobe in group I patients and widespread reduction of regional cerebral blood flow in group II patients. A correlation between frontal leuco-araiosis and perfusion defect of the frontal pole was demonstrated in group I patients, showing findings typical of subcortical dementia. There was no difference in frontal atrophic measurements between group I patients and controls. Ratios of volumes of lost brain parenchyma and leuco-araiosis were significantly higher in group II patients than in the age-matched controls, corresponding to a diffuse cerebral perfusion defect. These results suggest that patients with VDBT have early frontal lobe involvement with posterior progression. Patients with mild VDBT are more likely to show reduction of frontal cerebral blood flow and leuco-araiosis, while those with severe VDBT are more likely to have diffuse leuco-araiosis, cerebral hypoperfusion and brain atrophy.

Panencephalitic Creutzfeldt-Jakob disease. Unusual presentation of magnetic resonance imaging and proton magnetic resonance spectroscopy.

We present serial magnetic resonance imaging (MRI) scans on a biopsy-verified case of Creutzfeldt-Jakob disease (CJD). The initial MRI scan demonstrated increased T2 signal-intensity within the basal ganglia and thalami. Subsequent MRI scans demonstrated a thin cortex, increased T2 signals diffusely within the white matter including U-fibers, and hypointense T2 signals within the basal ganglia, and thalami. Proton magnetic resonance spectroscopy (1H-MRS) study showed an absence of creatine, choline and N-acetylaspartate signals. By these characteristic findings, serial MRI and MRS studies may be helpful in differentiating CJD from other dementing illnesses.

Mitochondrial alterations of skeletal muscle in a heat stress rat model.

The morphological and ultrastructural alterations of skeletal muscle in experimental rats with heat stress were investigated. Fifteen male Sprague-Dawley rats were exposed in a 42 degrees C constant temperature oven, resulting in a heat stress state; ten rats were used as controls. All treated rats had weakness of the 4 limbs associated with increased serum creatine kinase levels (p < 0.01). Soleus muscles were submitted to histological, histochemical, ultrastructural and quantitative-morphometric analysis. The group receiving heat stress showed many ragged-red fibers in Gomori trichrome stain and appeared hyper-reactive in succinate dehydrogenase and cytochrome C oxidase stains. The ultrastructure of ragged-red fibers showed increased mitochondrial aggregation as multiple small nests, which were particularly located in the subsarcolemmal space. The mitochondrial area was significantly increased in heat stress rats (p < 0.001). The consistently increased mitochondrial area and histochemical alterations of mitochondria are early pathological abnormalities in muscles with heat stress and indicate fundamental impairment of energy metabolism.

A young adult with tuberculous meningitis diagnosed by polymerase chain reaction on serial CSF samples: a case report.

A polymerase chain reaction (PCR) assay was used to diagnose a young adult with tuberculous meningitis who presented with unusual clinical symptoms of an acute illness. He had repeated cerebrospinal fluid (CSF) samples taken, and the PCR assay for detecting mycobacterial deoxyribonucleic acid was negative for the first two CSF specimens, but was positive in the third. He was then treated with antituberculous drugs and had complete restoration three months later. A follow-up PCR of the CSF was still positive after one month of therapy using antituberculous drugs, but converted to a negative result one month later. It is concluded that it is valuable to repeatedly sample CSF specimens for PCR study in patients with clinically suspected tuberculous meningitis.

Vertebral artery dissection complicated by cervical manipulation: a case report.

A 32-year-old healthy man developed vomiting, blurred vision, and consciousness disturbance following cervical manipulation. Physical examination showed stuporous consciousness and spontaneous horizontal nystagmus. Computed tomography (CT) and magnetic resonance (MR) imaging of the brain revealed infarction in the territory of the basilar artery. Studies of MR angiography and vertebral angiography disclosed dissection of the right vertebral artery at the atlantoaxial segment. Antiedematous drugs were prescribed and the patient gradually improved. Neurologic examination six months later demonstrated mild cerebellar ataxia. Physicians and patients should be aware that vertebro-basilar dissection may follow cervical manipulation, and, more importantly, should attempt to prevent progressive infarction.

Hemiballism-hemichorea: clinical study in 23 Chinese patients.

BACKGROUND: Hemiballism-hemichorea, a well documented movement disorder, is not uncommon in the clinic. However, systematic analysis of the condition in ethnic Chinese on clinical grounds, is still inexplicably lacking. METHODS: This study focused on 23 Chinese patients with hemiballism-hemichorea in Taiwan. The general data, clinical pictures, blood biochemistries, past histories of systemic disease, neuroradiological imaging, methods of treatment, and prognoses of these patients were analyzed retrospectively. RESULTS: The study revealed that ischemic stroke (44%) is the leading cause of this movement disorder, and the metabolic disorder (22%) is also one of the common etiologies of dyskinesia in Chinese patients. In addition to those patients whose condition was caused by non-ketotic hyperglycemia, blood sugar had also obviously increased in patients where the cause was infarction. Pathological lesions contributed to hyperkinesia were found not only in the contralateral basal ganglion but also in the thalamus and subcortical areas. The characteristics of those patients where the cause was infarction and non-ketotic hyperglycemia were: age at onset greater than 60 years, and predominantly in women. Etiologies contributing to this movement disorder in younger patients differ from those in the older. Prognosis of the movement disorder in this study was favorable. CONCLUSIONS: Hemiballism-hemichorea is predisposed to occur in older Chinese women, and metabolic disorder is an important etiology of the movement disorder. When the dyskinesia is encountered in the clinic, the metabolic disorders must be first ruled out as the problem may be rapidly resolved by achieving metabolic control.

Rapid diagnosis of tuberculous meningitis by polymerase chain reaction assay of cerebrospinal fluid.

A polymerase chain reaction (PCR) method for the rapid diagnosis of tuberculous meningitis (TBM) was used to study prospectively 47 cerebrospinal fluid (CSF) samples from 45 patients. Twenty CSF samples were from patients with clinically suspected TBM and another 27 samples came from patients without clinically suspected TBM. Mycobacterial DNA was detected in 15 CSF samples (14 from patients with clinically suspected TBM and 1 from a patient not suspected of having TBM). Of the PCR-positive samples, 4 were also positive for mycobacterial culture. However, 32 PCR-negative samples were all culture-negative. All samples were negative for the acid-fast bacillus by direct smear. The single PCR-positive patient in the clinically unsuspected TBM group was initially diagnosed as suffering from aseptic meningitis on the basis of his clinical features. The mycobacterial culture of his CSF specimen was also positive and a revised diagnosis of an aseptic type of TBM was made. The estimations of specificity and sensitivity in this study were 100% and 70% respectively. The results showed that using a PCR to detect mycobacterial DNA in CSF for the early diagnosis of TBM is not only a rapid but also an accurate method.

Cardiovascular effects of NMDA in the RVLM of spontaneously hypertensive rats.

In this study we found that cardiovascular effects were differentially regulated by N-methyl-D-aspartate (NMDA) in the rostral ventral lateral medulla (RVLM) of spontaneously hypertensive rats (SHRs) compared to their normotensive controls (Wistar-Kyoto rats, WKYs). Adult SHRs and WKYs were anesthetized with urethane, cervically vagotomized, and placed in a sterotaxic frame. We found that electrical stimulation or local application of N-methyl-D-aspartate into the RVLM produced hypertension in both strains. Microinjection (3.5-4.0 nmol) of AP5 (2-amino-5-phosphono-valerate), an NMDA receptor antagonist, to the RVLM did not affect resting blood pressure; however, this agent antagonized hypertensive responses evoked by low-frequency electrical stimulation (5-20 Hz) in both strains. The elevation in blood pressure evoked by stimulation at a higher frequency (60 Hz) was not affected by AP5. These results suggest that NMDA receptors are involved in the low frequency, electrically evoked hypertension in both strains. We also found that SHRs had a larger pressor response to microinjection of NMDA and electrical stimulation than did WKYs. AP5 abolished the differences in evoked hypertension between WKYs and SHRs during low-frequency (5-10 Hz) electrical stimulation. These data suggest that the hypersensitivity of RVLM to low-frequency electrical stimulation in SHRs involve NMDA receptors. We previously reported that AP7 antagonizes NMDA and carotid clamping-induced hypertension. In this study, we found that when locally applied to RVLM, AP5 antagonized hypertension evoked by clamping the carotid arteries in SHRs and WKYs. Thus, carotid clamping-induced hypertension may also involve NMDA receptors in the RVLM.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholecystokinin facilitates methamphetamine-induced dopamine overflow in rat striatum and fetal ventral mesencephalic grafts.

The purpose of this study was to investigate the interactions of sulfated (S) and unsulfated (US) cholecystokinin (CCK) and methamphetamine (MA)-induced dopamine (DA) overflow in rat striatum. High-speed chronoamperometric recording techniques, using Nafion-coated carbon fiber electrodes, were used to evaluate extracellular DA concentration. CCK-8S, CCK-8US, MA, and DA were locally applied directly to the striatum of urethane-anesthetized Sprague-Dawley rats. We found that CCK potentiated MA-induced DA release in the anterior striatum. This response is probably mediated through CCK-A receptors because CCK-8S, but not CCK-8US, enhanced MA-induced responses. Replacement of Ca2+ with Mg2+ in the drug barrel antagonized this reaction, suggesting that the modulation of MA-induced DA release by CCK is Ca2+ dependent. Both MA-induced DA release and CCK modulatory effects disappeared in the striatum after unilaterally lesioning the medial forebrain boundle with 6-hydroxydopamine (6-OHDA). We had previously found that the zone of normalized dopamine clearance in 6-OHDA-lesioned rats was considerably larger than that of normalized release in the anterior striatum after fetal ventral mesencephalic (VM) transplantation, which may be a result of partial reinnervation from the transplant. In the present study, we found that the modulation of DA release by CCK was restored only in the zone of normalized release after fetal nigral transplantation; CCK did not increase MA-induced DA release throughout the larger partially innervated area. In conclusion, these findings suggest that not only DA release processes but also CCK modulatory mechanisms are restored in the anterior striatum after fetal VM transplantation.

[The effects of anticonvulsants on the epileptiform discharges--study by 24-hour ambulatory cassette EEG system].

Thirty-three epileptic children who had epileptiform discharges in conventional 16 channel EEG study were enrolled in this study. The patients have never been treated with medication at first visit. Then patient were put on ambulatory monitoring EEG with the Oxford Medilog 9-channel cassette EEG system, which included six symmetrical scalp leads, one EOG, one Chin EMG and one channel for time signal. The EEG record was processed under the rule of the international standard method in terms of 10-20 system. The 24 hours EEG cassettes which recorded before and after antiepileptic drugs therapy were reviewed by an experienced electroencephalographer on a video play back unit. The number and duration of spikes or spike wave discharges were calculated. Among those 22 cases who had studied completed, there are 11 cases with generalized spike waves (5 with irregular spike waves, 3 with regular 3 hz spike waves, 1 with multiple spike waves, 1 with slow sharp waves and 1 with abortive spike waves), and 11 cases with focal spike activities (5 with bilateral central or centrotemporal spikes, 4 with temporal spikes and 2 with occipital spike discharges). After anticonvulsants therapy, 9 cases (82%) out of those 11 cases with generalized spike waves, the spike waves were disappeared; 2 cases (18%) revealed no significant change in spike rate and duration.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrent ascending myelitis: an unusual presentation of herpes simplex virus type 1 infection.

We report on a healthy female with a unique relapsing transverse myelitis accompanied by herpes simplex virus type 1 (HSV-1) infection. Magnetic resonance imaging showed cord enlargement and increased signal intensity on T1-weighted image with gadolinium enhancement from T-4 to T-10 during the first attack and from C-1 to C-2 during the second episode. She was not diagnosed during the first attack. During the second episode, laboratory studies disclosed IgM and IgG antibodies to HSV at the outset with greater than fourfold increases in antibody levels in the serum and cerebrospinal fluid (CSF). Cells cultured from the CSF were positive for HSV-1 according to the immunofluorescence method. The presence of HVS-1 DNA in CSF was documented by polymerase chain reaction (PCR) technique. Acyclovir was given with a partial recovery. We anticipate that PCR assay of CSF will assist early diagnosis of herpetic central nervous system disorders.

Compressive radial nerve palsy induced by military shooting training: clinical and electrophysiological study.

Ten recruited soldiers developed acute left wrist drop and numbness on the back of the thumb after a three hour military shooting training. Neurological examination disclosed decreased muscle power (0-2/5) of left wrist dorsiflexion, hypalgesia and hypaesthesia on the radial side of the left hand, and diminished brachioradialis reflex. Electrophysiological studies showed prolonged distal latency, reduced amplitude and slowness of left radial nerve motor conduction velocity between the axilla and elbow. Electromyography (EMG) revealed fibrillation potentials at rest, polyphasic motor unit and an incomplete interference pattern at volition over the extensor digitorum communis and brachioradialis. Nine patients recovered completely clinically and electrophysiologically between nine and 12 weeks after the onset of the palsy. Sensation recovered faster than the weakness. One patient failed to recover after three months, possibly because of the longer duration of nerve compression. Longer nerve compression time and sustained, decreased muscle power with signs of active denervation in EMG are indicators of poor prognosis.

Dissociation of hypertension and enhanced clonidine-induced antinociception in spontaneously hypertensive rats.

In the present study, we evaluated the relationship between hypertension and the antinociceptive effect of clonidine in genetically hypertensive rats. Intraperitoneal (i.p.) administration of clonidine (0.69 mg/kg) produced hypoalgesia without lowering blood pressure in conscious spontaneously hypertensive (SH), spontaneously hypertensive-stroke prone (SH-SP) and Wistar-Kyoto (WKY) rats. The antinociceptive effect of clonidine, measured by the hot plate method, was greater in the hypertensive rats (SH-SP) than in their normotensive controls (WKY). The enhancement of clonidine-induced antinociception in these genetically hypertensive rats was not altered after acute lowering of blood pressure with guanethidine. Furthermore, the development of this hyper-antinociceptive effect of clonidine was earlier than that of hypertension in SH rats. In conclusion, our data suggest that the enhanced antinociceptive effect of clonidine in hypertensive animals is not directly related to blood pressure.

Primary carcinoma of the gallbladder: a review of 10 years of experience at Tri-Service General Hospital.

Thirty-two cases of primary carcinoma of the gallbladder proven by surgery and pathological biopsy between January 1982 and June 1991 at the Tri-Service General Hospital, Taipei, were analyzed retrospectively. There were 16 male and 16 female patients with a mean age of 66.1 years. The most common clinical manifestations were right upper quadrant abdominal pain and poor appetite. The most common laboratory finding was an elevation of alkaline phosphatase. The preoperative diagnostic rate of this series was 46.9% (15/32 cases), through use of abdominal sonography, computed tomography, endoscopic retrograde cholangiopancreatography and celiac angiography. The coexisting gallstone incidence was 65.6% and the resectability rate, 59.4%. The histological classifications were adenocarcinoma with variable differentiation in 31 cases, and undifferentiated adenocarcinoma in one. The liver was the most common site for metastasis (53.1%), followed by lymph nodes at porta hepatis (21.9%), omentum (12.5%), peritoneum (9.4%), lung (6.3%), colon (3.1%) and duodenum (3.1%). According to the Nevin's staging system, three patients were in stage I and all survived more than five years. Of the two patients in stage II, one survived longer than five years and the other survived longer than seven months. There were three cases in stage III: one patient died of metastasis eight months postoperatively, while the other two cases lived for seven and nine and a half months respectively. There were 24 cases in stage IV and stage V, all of them died less than six months after diagnosis. Poor prognosis for patients with primary carcinoma of the gallbladder makes early diagnosis and treatment important.