Tissue eosinophilia and computed tomography features in paediatric chronic rhinosinusitis with nasal polyps requiring revision surgery.

BACKGROUND: Endoscopic sinus surgery (ESS) is an effective and safe treatment modality for medically recalcitrant chronic rhinosinusitis (CRS) in the paediatric population, especially in older children or those with nasal polyposis (CRSwNP). We aimed to elucidate the inflammatory pattern and clinical characteristics of CRSwNP related to revision surgery after ESS in a paediatric population. METHODS: We retrospectively enrolled 146 patients with bilateral CRSwNP. Twenty-two patients had recurrent nasal polyps that required revision surgery. The clinical characteristics, computed tomography (CT) features, tissue eosinophil count, and immunoactivity of signature cytokines in the two groups were analysed. RESULTS: Tissue eosinophil infiltration and immunoreactivity of eosinophilic cationic protein and IL-5 in the sinus mucosa were higher in patients that required revision surgery. The revision surgery group was significantly younger and had positive aeroallergen test results, higher total Lund-Mackay scores, and ethmoid/maxillary sinus ratio on CT images than those without revision surgery. A nomogram was developed to predict the probability of the requirement of revision surgery according to the logistic regression analysis results. CONCLUSIONS: We developed a nomogram model using clinical characteristics, tissue eosinophilia, and CT features for the preoperative identification of patients vulnerable to revision surgery in paediatric CRSwNP. This could help clinicians predict the probability of recurrence and perform intensive postoperative adjunct therapy and follow-up.

Molecular signalling involved in upper airway remodelling is enhanced in patients with obstructive sleep apnoea.

OBJECTIVE: This study aimed to elucidate whether molecular signalling involved in upper airway remodelling is enhanced in patients with obstructive sleep apnoea. METHOD: Twenty patients with mild obstructive sleep apnoea (control group) and 40 patients with moderate to severe obstructive sleep apnoea (obstructive sleep apnoea group) who desired uvulopalatopharyngoplasty were recruited for the study. After uvulopalatopharyngoplasty, surgical specimens of the uvula were subjected to haematoxylin and eosin, Masson's trichrome and immunohistochemical staining. Western blot and reverse transcriptase-polymerase chain reaction were used to evaluate the protein and messenger RNA expressions. RESULTS: The obstructive sleep apnoea group showed more severe inflammation, increased collagen deposition and higher immunohistochemical staining intensity for TGF-ß and MMP-9 as well as higher protein and messenger RNA expression of MMP-9, VEGF, TGF-ß, p38 MAPK, SMAD 2/3, AKT and JNK in the uvula than control group. CONCLUSION: Patients with obstructive sleep apnoea demonstrated more severe inflammation, increased airway remodelling, and increased protein and messenger RNA expression of pro-inflammatory and pro-fibrotic cytokines in the uvula than control participants.

Risk prediction models for delirium in the intensive care unit after cardiac surgery: a systematic review and independent external validation.

Numerous risk prediction models are available for predicting delirium after cardiac surgery, but few have been directly compared with one another or been validated in an independent data set. We conducted a systematic review to identify validated risk prediction models of delirium (using the Confusion Assessment Method-Intensive Care Unit tool) after cardiac surgery and assessed the transportability of the risk prediction models on a prospective cohort of 600 consecutive patients undergoing cardiac surgery at a university hospital in Hong Kong from July 2013 to July 2015. The discrimination (c-statistic), calibration (GiViTI calibration belt), and clinical usefulness (decision curve analysis) of the risk prediction models were examined in a stepwise manner. Three published high-quality intensive care unit delirium risk prediction models (n=5939) were identified: Katznelson, the original PRE-DELIRIC, and the international recalibrated PRE-DELIRIC model. Delirium occurred in 83 patients (13.8%, 95% CI: 11.2-16.9%). After updating the intercept and regression coefficients in the Katznelson model, there was fair discrimination (0.62, 95% CI: 0.58-0.66) and good calibration. As the original PRE-DELIRIC model was already validated externally and recalibrated in six countries, we performed a logistic calibration on the recalibrated model and found acceptable discrimination (0.75, 95% CI: 0.72-0.79) and good calibration. Decision curve analysis demonstrated that the recalibrated PRE-DELIRIC risk model was marginally more clinically useful than the Katznelson model. Current models predict delirium risk in the intensive care unit after cardiac surgery with only fair to moderate accuracy and are insufficient for routine clinical use.

Clinical and molecular features of adenovirus type 2, 3, and 7 infections in children in an outbreak in Taiwan, 2011.

OBJECTIVES: We studied paediatric patients with human adenovirus (HAdV) infection during the 2011 outbreak in northern Taiwan to define the clinical features of different HAdV genotypes in children. METHODS: Between January and December 2011, 637 patients <19 years of age exhibited culture-confirmed adenoviral infection in Chang Gung Memorial Hospital, and provided specimens available for genotyping by multiplex real-time PCR. Clinical data were collected retrospectively. RESULTS: Excluding five cases with multiple genotypes, 632 cases were included for analysis. Three genotypes were identified, including HAdV-3 (429/632; 67.6%), HAdV-7 (144/632; 22.6%) and HAdV-2 (59/632; 9.8%). Median age was 4.58 years (range 2 months to 18 years), with children infected with HAdV-3 significantly older (82.9% >3 years; p <0.001). Of the 621 inpatients, 98.2% had fevers and all exhibited respiratory symptoms, 75 patients (12.1%) had lower respiratory tract infections, 20 (3.2%) required intensive care (HAdV-2: 1; HAdV-3: 8; and HAdV-7: 11), and three died (all HAdV-7-infected). HAdV-3-infected patients were significantly more likely to have upper respiratory symptoms and a high serum C-reactive protein level >100 mg/L, whereas leucocytosis (white blood cell count >15 000/mm3) was more common in HAdV-2-infected patients (p 0.007). HAdV-7 infections were significantly associated with a longer duration of fever, leucopenia (white blood cell count <5000/mm3), thrombocytopenia (platelet count <150 000/mm3), lower respiratory tract infections, a longer length of hospital stay, and requiring intensive care (all p <0.001). CONCLUSION: Childhood HAdV-2, HAdV-3 and HAdV-7 infections may exhibit different clinical manifestations. Although HAdV-3 was the most prevalent genotype observed during the 2011 Taiwan outbreak, HAdV-7 caused more severe disease characteristics and outcomes.

Pain following double-bundle anterior cruciate ligament reconstruction: correlation with morphological graft findings and dynamic contrast-enhanced MRI.

AIM: To determine the relationship between knee pain following anterior cruciate ligament (ACL) graft placement with morphological graft findings and dynamic contrast enhancement as assessed at MRI. MATERIAL AND METHODS: Following institutional review board approval, 37 consecutive patients with double-bundle ACL reconstruction were enrolled. Thirteen patients had pain and 24 were asymptomatic. Imaging was performed using a 1.5 T MRI machine an average of 7.6 months after surgery. Graft-related (increase signal intensity, abnormal orientation, discontinuity, cystic degeneration, anterior translation of lateral tibia, arthrofibrosis), and non-graft related causes of knee pain (meniscal tear, cartilage injury, loose bodies, and synovitis) were evaluated. During dynamic contrast enhancement analysis, peak enhancement (ePeak) was calculated by placing a region of interest at the osteoligamentous interface of each bundle. Student's t-test was used for continuous variables analysis and chi-square or Fisher's exact test was used for categorical variables analysis. RESULTS: There was no difference between symptomatic and asymptomatic patients regarding morphological graft-related or non-graft-related causes of knee pain. For dynamic contrast enhancement analysis, symptomatic patients had significantly lower ePeak values than asymptomatic patients in the anteromedial (p = 0.008) and posterolateral (p = 0.001) bundles or when using the higher ePeak value in either bundle (p = 0.003). CONCLUSION: Morphological ACL graft findings as assessed at MRI could not be used to distinguish between symptomatic and asymptomatic patients. However, lower ePeak values had a significant association with knee pain. This may indicate poor neovascularization of the graft, potentially leading to graft failure.

Necrotizing pneumonia caused by nanC-carrying serotypes is associated with pneumococcal haemolytic uraemic syndrome in children.

Streptococcus pneumoniae infection is a leading cause of morbidity and mortality worldwide. One of the most severe complications of invasive pneumococcal disease (IPD) is haemolytic uraemic syndrome (HUS). This study was undertaken to determine the risk factors and role of pneumococcal neuraminidases in HUS in children with IPD. Eighteen cases of HUS and 54 patients with IPD without HUS were identified. The controls were patients with culture-confirmed IPD without HUS. Clinical and laboratory characteristics of the two groups of patients were compared. Bacterial isolates from both groups were serotyped, sequence typed and examined for their carriage of three neuraminidase genes. Necrotizing pneumonia and serotype 3 infection were significantly associated with HUS in children with IPD, suggesting that a severe pulmonary suppurating disease increase the risk of HUS. Serotype 14 was associated with necrotizing pneumonia but not HUS. Children with HUS were more likely to require surgery and had a longer duration of hospitalization. The study identified a significantly higher carriage of a neuraminidase gene, nanC, in the causative pneumococcal isolates from patients with HUS (89% versus 41%, p 0.001). The sensitivity and specificity of nanC to predict HUS were 89% and 59%, respectively. In conclusion, necrotizing pneumonia, serotype 3 infection and neuraminidase gene nanC were associated with HUS in children with IPD. The result suggests that NanC could provide an additive effect to NanA and NanB in the overall activity of pneumococcal neuraminidases to expose Thomsen-Friedenreich antigen on various cells in patients with HUS.

Cancellation of elective operations on the day of intended surgery in a Hong Kong hospital: point prevalence and reasons.

OBJECTIVE: To determine the point prevalence of elective surgical case cancellations and the reasons. DESIGN: Cross-sectional study. SETTING: Teaching hospital, Hong Kong. PATIENTS; Operating theatre records of elective surgery cancellations from 1 January 2009 to 31 December 2009 were retrospectively reviewed. MAIN OUTCOME MEASURES. Cancellation of scheduled elective surgery on the day of surgery and the corresponding reasons. RESULTS: Of 6234 cases scheduled, 476 were cancelled, which yielded a point prevalence of 7.6%, with a 95% confidence interval of 7.0-8.3%. The highest number of cancellations occurred in patients scheduled for major general surgical procedures (n=94, 20%), major urological procedures (n=64, 13%), major orthopaedic surgery (n=38, 8%), and ultra-major cardiothoracic surgery (n=29, 6%). The most common category for cancellation was facility (73%), followed by work-up (17%), patient (10%), and surgeon (1%). No available operating room time due to overrun of the previous surgery was the most common reason for case cancellation (n=310). Compared to general surgery, the odds of no available operating time was significantly less in orthopaedics (odds ratio=0.26; 95% confidence interval, 0.17-0.39), otolaryngology (0.25; 0.13-0.46), neurosurgery (0.36; 0.16-0.70), paediatrics (0.53; 0.31-0.87), gynaecology (0.18; 0.11-0.29), ophthalmology (0.19; 0.07-0.41), and dentistry (0.10; 0.00-0.60). CONCLUSIONS. Case cancellations were mainly due to facility factors, such as no operating room time being available. The odds of having no operating room time available varied between surgical specialties.

Complicated features in a young child with influenza B virus pneumonia and co-infection with Stenotrophomonas maltophilia.

A 3.5-year-old child with influenza B virus pneumonia developed pneumomediastinum and subcutaneous emphysema on the 3rd day of illness. Bronchoscopy demonstrated obstruction of the left main bronchus by mucopurulent sputum. Culture of the broncho-alveolar lavage yielded Stenotrophomonas maltophilia. After the respiratory complications resolved (11 days), the patient developed neurological symptoms and was diagnosed as acute disseminated encephalomyelitis (ADEM). Stenotrophomonas maltophilia was probably a factor in the development of pneumomediastinum. To our knowledge, this is the first case report of influenza virus infection with Stenotrophomonas maltophilia co-infection associated with spontaneous pneumomediastinum.

Inhibitory effects of epidermal growth factor on progesterone production of ovarian granulosa cells in Tsaiya duck (Anas platyrhynchos var. domestica).

1. The purpose of this study was to investigate the effects of epidermal growth factor (EGF) on progesterone (P(4)) secretion from ovarian granulosa cells in Tsaiya ducks (Anas platyrhynchos var. domestica). 2. We obtained the largest (F1) follicle from Tsaiya duck, the granulosa layer was separated and the cells were isolated according to their proximity to the germinal disc. 3. The granulosa cells were cultured in vitro, the culture media and the cells were used to determine P(4) and steroidogenic enzyme concentrations, respectively. 4. P(4) concentrations were decreased in cultured granulosa cells taken proximal to the germinal disc (GD) compared to those distal to the germinal disc (NGD). 5. EGF inhibited both basal and ovine luteinising hormone (oLH)-induced P(4) concentrations. It also inhibited the P(4) secretion via protein kinase A (PKA) pathway when cultured with GD and NGD granulose cells (mixed together) in vitro. 6. Western blot results showed decreased concentrations of cytochrome P450 side-chain cleavage (P450scc) enzyme, 3ß-hydroxysteroid dehydrogenase (3ß-HSD) enzyme and steroid acute regulatory (StAR) protein expression, when the cells were co-treated with EGF and oLH. 7. The inhibitory effect of oLH-induced P(4) production was attenuated by EGF by the addition of MAP-erk kinase (MEK) inhibitor (PD98059) suggests EGF may inhibit P(4) production by affecting via the mitogen-activated protein kinase (MAPK) pathway.

MR spectroscopy and MR perfusion character of cerebral sparganosis: a case report.

The authors report the case of a 46-year-old woman with cerebral sparganosis resulting from infection with a larva of Spirometra. Computed tomography and magnetic resonance imaging revealed a mass lesion with prominent perifocal oedema in the left parietal lobe. Advanced imaging pulse sequences, including MR spectroscopy and MR perfusion, were performed. During surgery for the removal of a granuloma, the parasite was discovered and excised. Following treatment, the patient's neurological deficits markedly improved.

Characterisation of plasmids encoding CTX-M-3 extended-spectrum beta-lactamase from Enterobacteriaceae isolated at a university hospital in Taiwan.

CTX-M-3 is the most common extended-spectrum beta-lactamase produced by Enterobacteriaceae in Taiwan. The present study was conducted to characterise the genetic environment surrounding bla(CTX-M-3). A total of 11 ceftriaxone-resistant isolates were studied: Escherichia coli (n=4), Klebsiella pneumoniae (n=5) and Salmonella enterica serotypes Anatum (SA831R) and Potsdam (SC72). Molecular methods used included polymerase chain reaction, sequencing, DNA-DNA hybridisation, conjugation, physical mapping and restriction fragment length polymorphism (RFLP) analysis. All isolates examined carried bla(CTX-M-3) on large plasmids (>70kb). The resistance plasmids of the two Salmonella and two K. pneumoniae strains (KP104 and KP116) were confirmed to be conjugative in vitro. RFLP analysis indicated that the plasmids were different. Physical mapping also revealed the difference between the two Salmonella plasmids, pSA831R (82kb) and pSC72 (74kb). An insertion sequence, ISEcp1, was found upstream of each bla(CTX-M-3) gene. However, sequencing of downstream regions of the bla genes showed two different patterns: the presence of orf477 in pSA831R and of orf1-mucA in pSC72, pKP104 and pKP116. IncI1-type oriT and nikA sequences were present in the plasmids of all the clinical isolates tested, except S. Anatum. Different bla(CTX-M-3)-carrying plasmids were identified among the enterobacteria studied. The presence of ISEcp1 in all isolates may be associated with the widespread resistance among Enterobacteriaceae. Although the plasmids were not identical, they appeared to belong to the same incompatibility group (IncI1-like plasmids), suggesting that they are genetically related but may have evolved divergently over time.

Synchronous ipsilateral renal cell and transitional cell carcinoma.

The coexistence of multiple and synchronous primary neoplasms in the genitourinary system has only rarely been described in the literature. We present the case of a 78-year-old man with haematuria as the initial presentation, finally proven to be transitional cell carcinoma (TCC) combined with renal cell carcinoma (RCC). Intravenous urography (IVU), CT and arterial angiography studies revealed a space-occupying nodule at the right upper renal pelvicalyces showing mild enhancement with contrast medium. Another strong contrast medium enhancing exophytic tumour was found at the lower pole of kidney; there were hypodense foci and calcified components in this lesion. A right nephroureterectomy was performed. Pathological diagnosis was a papillary TCC and a clear cell type RCC. This is a rare case of combined renal malignancies diagnosed by imaging.

Intussusception and intestinal malrotation in an infant: a case report.

An abnormal cecum position is usually found in patients with intestinal malrotation. We report one case with intussusception and intestinal malrotation in a 10-month-old infant. An unusual radiologic imaging feature and also abnormal intussusception mass location are discussed.

Use of parenteral testosterone prior to hypospadias surgery.

Surgical correction of genital defects was formerly proposed when the size of the penis was sufficient to permit easy surgical repair. To enlarge penile size, temporary stimulation with testosterone or dihydrotestosterone cream has been used; however, the results were not only inconsistent, but absorption was also variable. We report our experience with parenteral testosterone as an adjunct to reconstructive genital surgery in 25 patients aged 6-18 months from July 1999 to December 2000, including 8 with penile hypospadias, 15 with penoscrotal hypospadias, and 2 with perineal hypospadias. Each had a penis that was significantly smaller than usual. Testosterone enanthate 25 mg was given i.m. once per month for a total of three doses before surgical repair. Penile length and glans circumference were measured before therapy and at operation. Side effects such as the development of pubic hair and acne were monitored. Bone age was checked 1 year later. An increase in penile length (from 19.8 +/- 2.4 mm to 23.8 +/- 2.0 mm) and glans circumference (from 27.4 +/- 1.4 mm to 37.84 +/- 2.6 mm) was apparent in all except 2 patients (P < 0.001 for both, paired t-test). Four patients had a significant increase in either penile length or glans circumference after the initial dose so that no further injections were required. No definite secondary effects were found. Preoperative parenteral testosterone therapy thus causes a significant increase in penile length and glans circumference without apparent side effects. We suggest that this therapy prior to microphallic hypospadias repair is appropriate.

Perforation of toxic megacolon in non-typhoid Salmonella enterocolitis spares young infants and is immune-mediated.

Intestinal perforation, a life-threatening complication of toxic megacolon (TM) following non-typhoid Salmonella infection, is relatively uncommon in infants less than 1 year of age. The situation, also found in typhoid fever, appears to be cytokine-mediated. This finding may justify immunotherapy for older children with TM associated with non-typhoid Salmonella infection in order to prevent this complication.

Different proinflammatory reactions in fatal and non-fatal enterovirus 71 infections: implications for early recognition and therapy.

AIM: The mechanism of pulmonary oedema, a life-threatening manifestation of enterovirus 71 (EV71) encephalitis, is unclear. Our aim was to assess the relationship of proinflammatory cytokines to EV71-related pulmonary oedema. METHODS: Proinflammatory responses in 33 EV71 patients with various complications and 21 normal healthy children were measured using an enzyme-linked immunosorbent assay. RESULTS: EV71 patients with both encephalitis and pulmonary oedema were found to have much higher levels of blood interleukin-6 (IL-6) (947 +/- 1239 vs 4.9 +/- 3.1 pg/ml, p = 0.0003), tumour necrosis factor-alpha (TNF-alpha) (22.4 +/- 29.5 vs 5.3 +/- 1.0 pg/ml, p = 0.0035), interleukin Ibeta (IL-1beta) (48.4 +/- 85.2 vs 4.9 +/- 10.1 pg/ml, p = 0.01), white blood cell count (28.3 +/- 7.6 vs 15.5 +/- 6.8 10(9)/L, p > or = 0.0001) and blood glucose (501 +/- 186 vs 165 +/- 117 mg/dL, p = 0.0009) than patients with EV71 encephalitis alone. In fact, the cytokine levels in patients with encephalitis only or in those without complications were not significantly different from the levels found in normal children. The sensitivity, specificity, positive and negative predictive values of IL-6 > 70 pg/ml for EV71 encephalitis with pulmonary oedema were all 100%. CONCLUSION: Patients with EV71-related encephalitis combined with pulmonary oedema were found to have significantly elevated levels of proinflammatory cytokines and the best predictor for this complicated condition was found to be the level of serum IL-6.

Isocupressic acid blocks progesterone production from bovine luteal cells.

The needles of ponderosa pine (Pinus ponderosa Laws.) were reported to induce abortions when fed to late-term pregnant beef cows in North America. An in vivo study of pregnant cows suggested that isocupressic acid (IA) was the main abortifacient isolated from needles and bark of the pine. However, the mechanism of abortifacient activity of IA is not clear yet. In a pregnant cow, the corpus luteum of the ovary helps the maintenance of pregnancy by its progesterone production. This study involved the IA extracted from the root of the Taiwan cypress (Juniperus formosana) and used a frozen-thawed bovine luteal cell culture system to investigate the action of IA on progesterone production. Thawed bovine luteal cells (1 x 10(5) cells/ml/well) in M199 medium were cultured in 24-well culture plates at 37 degrees C in a 5% CO2 incubator. Ten ml of tested drugs, IA at 1 to 1000 ng/ml and/or ovine luteinizing hormone (oLH) at 1 to 100 ng/microl or 8-bromo-cyclic adenosine monophosphate (8-Br-cAMP) with 0.1-10 mM, were added into each well. After 4 hours of incubation, the media were harvested and assayed for progesterone by an enzyme immunoassay. Progesterone production from cells was the indicator used to evaluate the action of IA. All tested doses of IA significantly inhibited progesterone production in both basal and oLH stimulating conditions. Also those dosages inhibited cyclic adenosine-3',5'- monophosphate (cAMP) stimulation, suggesting a post-cAMP mechanism is involved in the IA action. We concluded that IA can induce pregnant cows to abort partly through blocking luteal function and may be identified as a new abortifacient chemical.

Characteristics of group A streptococcal bacteremia with comparison between children and adults.

This retrospective study aimed to compare the characteristics of group A streptococcal bacteremia in children and adults. A total of 76 (12 children and 64 adults) patients with group A streptococcal bacteremia treated from October 1995 through September 2000 at the Linko Chang Gung Memorial Hospital were included. The mean age was 47.6 years (range, 12 days-90 years). Forty-four (57.9%) patients had predisposing medical conditions. Malignant cancer (23.7%) and diabetes (22.4%) were the 2 most common conditions, which occurred only in adults. Two (16.7%) children had chickenpox associated with secondary group A streptococcal bacteremia. Skin and soft tissue infection (60.5%) was the most common clinical manifestation. The mortality rate related to group A streptococcal bacteremia was 25%. Twelve patients met the criteria of streptococcal toxic shock syndrome and 6 (50%) were children (p<0.05). Despite immediate and aggressive treatment, mortality due to streptococcal toxic shock syndrome was 66.7%. The incidence of streptococcal toxic shock syndrome was much higher in children (50%) than in adults (9.4%). Early diagnosis of invasive group A streptococcal infections and streptococcal toxic shock syndrome requires awareness of the presentations and a high level of suspicion. For fulminant group A streptococcal infection, a combination of a beta-lactam antibiotic plus clindamycin and/or adjuvant therapy with intravenous immunoglobulin is recommended.

Childhood and adolescent tuberculosis in northern Taiwan: an institutional experience during 1994-1999.

UNLABELLED: This study evaluated the clinical characteristics of childhood and adolescent tuberculosis (TB) at the end of the twentieth century in a referral children's hospital in northern Taiwan. The hospital charts were reviewed retrospectively of children/adolescents aged less than 18 y who were seen in a children's hospital in northern Taiwan between 1994 and 1999 and diagnosed with TB. A total of 62 individuals was diagnosed during this period. The patients' demographic data, presenting symptoms, clinical features, bacteriological results, drug susceptibility and tuberculin skin-test results were analysed. Most diagnosed cases lay in one of two main age ranges, younger than 5 y and adolescents. The presenting symptoms of study subjects were typically non-specific. Bone involvement occurred for 21 patients (33.9%) and was the most common extrapulmonary manifestation. Mycobacterium tuberculosis was isolated from 47 patients (75.8%). Five isolates were resistant to pyrazinamide, three to streptomycin and one to isoniazid, but no multidrug resistant isolates of TB were detected from culture-proven cases. Seventeen of 47 (36.2%) culture-proven patients revealed negative acid-fast staining initially but, subsequently, M. tuberculosis was isolated from various clinical specimens using a standard method at a later date. The tuberculin skin test was positive for 24 of 32 patients (75%) who received such an examination. CONCLUSION: Extrathoracic TB was more common in children below 5 y of age than their adolescent counterparts, and chiefly involved the peripheral long bones. The potential drug resistance of M. tuberculosis in childhood and adolescent TB did not appear to have been a major problem in northern Taiwan before the year 2000.