Synergism between two amphenicol of antibiotics, florfenicol and thiamphenicol, against Staphylococcus aureus.

Synergistic effects between the same class of antibiotics are rarely reported. In the current study, two amphenicols, namely florfenicol and thiamphenicol, exhibited both in vitro and in vivo synergism against clinical isolates ofStaphylococcus aureusfrom chickens, cattle and pigs. Checkerboard assays on 21S. aureusisolates showed that in 80 per cent of methicillin-susceptibleS. aureus(MSSA) and 82 per cent of methicillin-resistantS. aureus(MRSA) isolates tested, the minimal inhibitory concentration (MIC) of florfenicol could be reduced by 75 per cent (1/4 MIC) or more (up to 1/16 MIC) when combined with 1/2 MIC of thiamphenicol to exhibit antimicrobial activity comparable to the respective drugs at original strength (1×MIC). A synergistic effect (fractional inhibitory concentration index ≤0.5 or ≥2-log10decrease in colony-forming unit/ml in time-kill study) was evident against 30 per cent of MSSA and 45 per cent of MRSA strains tested. A study in mice revealed that the florfenicol/thiamphenicol combination at reduced dosages provided sufficient protection againstS. aureuschallenge. The possible mechanism warrants further study but likely includes the facilitated uptake of thiamphenicol via florfenicol action, and this facilitation was not limited to amphenicol class. The present study may offer new strategy for combination therapy and provide potential alternatives for effective treatment againstS. aureusinfections.

Hypospadias repair using a double onlay preputial flap.

From an anatomical view, a more reasonable blood supply can be achieved in hypospadias repair using a double-faced onlay flap. A urethroplasty was performed in 15 patients with middle or posterior hypospadias using a double-faced onlay preputial flap (DOPF). In this method, the urethral plate is preserved and a double-faced preputial flap is developed. The inner face of the flap is sutured to the urethral plate to create the neourethra and the outer face together with the rest of the dorsal prepuce is used for ventral skin coverage. Postoperative complications occurred in 2 patients: 1 developed a fistula in the subcoronal region and 1 had dorsal skin necrosis and suture disruption of the glanular wings. The overall complication rate was 13%. The DOPF provides a well-vascularized ventral skin cover and reduces the area of avascular dorsal skin. The viability of the neourethra can be evaluated by simply looking at the outer face of the flap. However, the complication rate is similar to that of other techniques.

Malignant mixed müllerian tumors of the ovary.

Malignant mixed Müllerian tumor (MMMT) of the ovary is very rare, and to the best of our knowledge, only a few cases have been reported in the literature from Taiwan. We report two recent cases of ovarian MMMT at our hospital. Case 1 was a 59-year-old female with stage IIIC MMMT of the ovary, with a tumor having carcinomatous and sarcomatous elements. The carcinomatous component was composed of a high-grade epithelial malignancy including serous, endometrioid, clear cell and undifferentiated carcinoma elements. The sarcomatous component was composed of a homologous malignant mesenchymal element with conspicuous hyaline globules. The patient died of the disease six months after debulking surgery. Case 2 was a 42-year-old female with ovarian stage IIC MMMT. The carcinomatous component was composed of grade II-III clear cell carcinoma and the sarcomatous component was composed of high-grade non-specific spindle cell sarcoma, which was positive for vimentin, but negative for cytokeratin, desmin and S-100 protein on immunostaining. The patient died of the disease four months after debulking surgery. These two patients both underwent hysterectomy, bilateral salpingo-oophorectomy and omentectomy and both received platinum-based chemotherapy after debulking surgery.

Toxic megacolon secondary to infective colitis in children.

BACKGROUND AND PURPOSE: Toxic megacolon is a fulminating and potentially lethal complication of severe colitis. Toxic megacolon secondary to infective colitis in children is rare. We analyzed the clinical course, pathology, treatment, and outcome of toxic megacolon secondary to infective colitis in children. METHODS: The medical records of all 20 children treated for infective colitis complicated with toxic megacolon during a 12-month (October 1997-October 1998) period were retrospectively reviewed. RESULTS: There were 10 boys and 10 girls, with a mean (+/- standard deviation, SD) age of 26.2 +/- 12.9 months (range, 6-57 mo). With an initial presentation of nonspecific gastroenteritis syndrome lasting several days, the disease progressed rapidly. In the acute stage, most patients developed toxic signs such as mental change, ranging from irritability to stupor (20, 100%), fever (19, 95%), tachycardia (20, 100%), abdominal distension (20, 100%), and abnormal stool pattern (19, 95%). Initial investigations revealed anemia (11, 55%), leukocytosis (11, 55%), and elevated levels of C-reactive protein ranging from 25.0 mg/L to 483.0 mg/L with a mean +/- SD of 185.7 +/- 129.1 mg/L (normal range, < 8 mg/L) (20, 100%). Salmonella enteritidis (12 patients, 60%) and Clostridium difficile (1, 5%) were isolated from stool samples in some cases. Plain abdominal x-rays revealed severe colonic dilatation. Prolonged hospitalization (mean, 33.6 d) and intensive therapy including a combination of broad-spectrum antibiotics, physical decompression, and total parenteral nutrition were necessary. Three patients (15%) underwent surgical management; the pathologic findings in these patients demonstrated severe transmural inflammation. We believe that bacterial and/or endotoxin translocation played an important role in gut failure. Three patients (15%) in the study died. CONCLUSION: Toxic megacolon in infective colitis is a fulminating illness that has a high mortality rate. The disease course can be divided into three stages: the acute toxic stage, the gut failure stage, and the convalescence or deterioration stage. Early diagnosis and aggressive management are important.

[Intravenous infection of C. albicans induces apoptosis of cortical thymocytes in mice].

In this study, we aimed to understand the location of apoptotic cells in murine thymus and phenotype of murine thymocytes involved in C. albicans induced apoptosis. Results showed that significant increase of apoptotic cells in thymus began at 6 h after intravenous injection of C. albicans and kept increased at 12 h, 18 h and 24 h. Quantitative changes of thymocytes with different phenotype measured by flow cytometry revealed that percentage of CD3+ and CD8+ cells were significantly reduced compared to the controls. Moreover in situ cell death detection of thymic tissue revealed that apoptotic cells induced by C. albicans mainly located in the thymic cortex, while in the thymic medulla a very small number of thymocytes was involved. Taken together our study indicates that C. albicans induces apoptosis of murine thymocytes, moreover the apoptosis possibly involves the major immature CD3+ CD4+ CD8+ cells in the thymic cortex and minor mature CD3+ CD4- CD8+ cells in the thymic medulla.

Testicular yolk sac tumors in children.

BACKGROUND: Testicular tumors in children are uncommon, comprising about 1% of pediatric malignancies. Yolk sac tumor is the most common malignant testicular tumor in children. Because yolk sac tumor in children is rarely seen, its treatment has been controversial. We reviewed the records of 15 children with testicular yolk sac tumor treated at our hospital in order to evaluate optimal management and treatment outcome. METHODS: From February, 1981, to August, 1996, 15 children with testicular yolk sac tumor were treated. Mean patient age at diagnosis was 15.8 months (range, 7-22 months). Fourteen patients presented with stage I disease and one presented with stage III disease. Mean follow-up was 88 months (range, 2-156 months). RESULTS: All 15 patients received radical inguinal orchiectomy as initial treatment. Serum alpha-fetoprotein (AFP) concentrations were measured in 14 stage I patients preoperatively and were elevated in all of them. During follow-up, the one stage III patient died of the disease. Of the remaining 14 patients, two (14.3%) had recurrence with elevated AFP at three months and 10 months postorchiectomy, respectively. These patients were managed with cisplatin-based combination chemotherapy. To date, they are both alive with no further recurrence, and AFP concentrations returned to normal after chemotherapy. Overall, of the 15 patients with testicular yolk sac tumor, 14 (93.3%) survived without disease. CONCLUSIONS: Our results suggest that testicular yolk sac tumor in children is a tumor with a favorable prognosis. Serum AFP concentration is extremely useful in diagnosis and monitoring of treatment response. Radical inguinal orchiectomy alone seems adequate for patients with stage I disease if serum AFP concentrations return to normal postoperatively. Cisplatin-based combination chemotherapy should be administered in patients with tumor recurrence or metastasis.

Pelvic abscess after ultrasound-guided aspiration of endometrioma: a case report.

A 31-year-old female with four years of infertility due to endometriosis and severe pelvic adhesions underwent transvaginal ultrasound-guided aspiration of an ovarian endometrioma before ovulation induction for in vitro fertilization (IVF) and embryo transfer. Seven days following the aspiration, the patient developed acute abdominal pain; diagnostic laparoscopy was performed at a local medical center, revealing a right tubo-ovarian abscess. Exploratory laparotomy ensued and right salpingo-oophorectomy was performed. A combination regimen of three antibiotics was administered and the patient was transferred to the intensive care unit of the Cathay General Hospital two days after surgery for further care. Her postoperative condition was uneventful and she recovered quickly. The patient then continued with further IVF treatment.

Germ cell tumor in infancy and childhood: experience at one institute compared to other studies.

To understand the difference in incidence and distribution of germ cell tumor (GCT) between cases seen in this institute and Western studies, 98 cases of GCTs collected from 1979 to 1996 were included 50 with gonadal GCTs, 9 with mediastinal GCTs; 9 with retroperitoneal GCTs, 10 with sacrococcygeal GCTs and 20 with intracranial GCTs; all were analyzed retrospectively by chart review. The incidences of testicular and intracranial GCT in all GCTs were higher in this study, i.e. 26.5%(26/98) and 20.4%(20/98) compared to 7% and 6% of American reports. But the incidence of sacrococcygeal GCT in all GCTs was lower in this study, i.e. 10.2%(10/98) compared to 41% of American reports. The incidences of testicular and ovarian GCT in all GCTs were about the same in this study, i.e. 26.5%(26/98) and 24.5%(24/98) compared to 7% and 29% of American reports; 51%(50/98) of all GCTs were gonadal in this study compared to 36% in the American reports.

Intraoperative non-puncture laparoscopic examination of contralateral internal inguinal rings is feasible in children with unilateral hydrocele.

BACKGROUND: Intraoperative non-puncture laparoscopic examination using the hernia sac as the scope entrance has been successfully conducted in children with unilateral inguinal hernia. This technique selects patients for contralateral inguinal exploration. In spite of the thin and narrow processus vaginalis, children with unilateral hydrocele encounter the same problem of subsequent contralateral inguinal hernia or hydrocele. In this study, we discuss the feasibility of this technique in children with unilateral hydrocele. METHODS: From July 1993 to September 1995, 91 children with unilateral hydrocele were examined during surgery at our institution. The results, including success rate, complications, patent rate of contralateral internal ring and contralateral subsequent hernia or hydrocele, at at least one year follow-up, were compared with those of 329 children with unilateral hernia undergoing the same examination during this period. RESULTS: A patent contralateral processus vaginalis was recognized in 31 children and all were confirmed by surgical exploration. The examination failed in three patients, of whom two had a tear in the processus vaginalis and one had retroperitoneal air dissection as a result of false insertion of the laparoscopic sheath. One patient had a postoperative wound infection. No patient with contralateral obliterated processus vaginalis developed inguinal hernia or hydrocele during follow-up of at least one year. The results were similar to those of the 329 children with hernia who underwent the same procedure in the same period. CONCLUSIONS: Intraoperative non-puncture laparoscopic examination is feasible in children with unilateral hydrocele.

Value of gamma-glutamyl transpeptidase for early diagnosis of biliary atresia.

BACKGROUND: Early diagnosis of congenital biliary atresia (BA) is important because the prognosis is closely related to timing of a hepaticoportoenterostomy. In this study, we discuss whether the elevation of serum gamma-glutamyl transpeptidase (GGT) is accurate for the early differentiation of BA from neonatal hepatitis (NH). METHODS: The effectiveness of using GGT before the age of 10 weeks and other tools in the differential diagnosis of BA and NH were analyzed retrospectively by reviewing the charts of 29 BA and 12 NH patients. The results of serial liver enzyme studies, abdominal sonography, hepatobiliary scintigraphy and transcutaneous liver biopsy were compared between both groups. RESULTS: The peak GGT value in BA before 10 weeks of age was significantly higher than that in NH (622.5 +/- 211.9 U/l vs 168.8 +/- 100.3 U/l, respectively, p < 0.001). When a serum GGT concentration greater than 300 U/l was used as a diagnostic criterion for BA in patients younger than 10 weeks of age, the diagnostic accuracy was 85%. When an increase in GGT value (in serial measurements) of greater than 6 U/l/day was used as a criterion, the accuracy was 88%. The diagnostic accuracy of abdominal sonography, hepatobiliary scintigraphy and liver biopsy was 68%, 67% and 79%, respectively. CONCLUSIONS: GGT concentration is diagnostically valuable when the results of other diagnostic methods are not available, or are controversial, in differentiating between BA and NH.

Malignant epithelial neoplasm consistent with primitive cystic hepatic neoplasm with mesothelial differentiation: a case report.

Mesothelioma are primary tumors of the celiomic cavity and are seen more often in adults than in children: only an estimated 2-5% of all cases present within the first two decades of life. To best knowledge of the reviewing world literature reported to date, no more than 80 proved cases of this tumor have occurred in children. One-third of mesothelioma originate in the peritoneum and two-thirds arise in the pleural cavity. Mesothelioma of the liver are extremely rare; a review of the English literature shows only three adult cases that have been reported as fibrous mesothelioma of the liver; experience with these cases suggests a high potential for recurrence, but no progression to malignancy. Cystic mesothelioma occur mainly in adults and are considered to be benign and curable. We describe a case of malignant epithelial neoplasm consistent with primitive cystic hepatic neoplasm with mesothelial differentiation arising in a 3-year-old boy, a condition which has never before been reported in childhood. Malignant primitive cystic mesothelioma is possible that some cases of intraabdominal mesenchymoma or hamartoma with malignant differentiation may have been misdiagnosed in the past; future cases should be fully evaluated, to establish the true incidence of mesothelioma disease in children.

Successful surgical treatment of bilateral congenital chylothorax: a case report.

A male infant was diagnosed at 19 days old to have a right chylothorax. Conservative management, including median-chain triglyceride (MCT) diet, total parenteral nutrition (TPN) and chyle drainage, were unsuccessful. The boy received a right thoracotomy with ligation of the thoracic duct and sutures of leaking lymphatic ducts at the age of 65 days. The result of the operation was satisfactory but left chylothorax developed six days later. Left thoracotomy was performed eight days later to suture the leaking lymphatic chains and finally the patient recovered well. Followed for one year, the patient's physical development was satisfactory. Prompt surgical intervention for congenital chylothorax is strongly recommended, if medical treatment fails.

Stomach rupture associated with physical struggle in a child.

A 5-year-old girl with spontaneous rupture of the stomach was treated successfully with excision of the ischemic edges of the perforation with primary repair. In this case, vigorous resistance against medical measurement resulted in rupture of the stomach, which was already distended with a large amount of fluid and air. The child survived following immediate surgical intervention and intensive postoperative care.

Protection against Fas/APO-1- and tumor necrosis factor-mediated cell death by a novel protein, sentrin.

Fas/APO-1 and TNF receptor 1 share a common signaling motif in their cytoplasmic tail called the "death domain." Using the death domain as bait in the yeast two-hybrid system, several death domain-containing proteins that participate in cell death signaling have been identified. Here we report the isolation of a novel protein, sentrin, which interacts with Fas/APO-1 and TNF receptor 1 but not with FADD/MORT1 or CD40. Two-hybrid interaction assays reveal that sentrin associates only with the signal-competent forms of Fas/APO-1 or TNF receptor 1 death domains. Sentrin is a novel protein of 101 amino acids with homology to ubiquitin, Nedd8, and a Saccharomyces cerevisiae protein, Smt3. When overexpressed, sentrin provides protection against both anti-Fas/APO-1 and TNF-induced cell death.

The physiological effect of CO2 pneumoperitoneum in pediatric laparoscopy.

BACKGROUND: The physiological effect of CO2 pneumoperitoneum during laparoscopy is a great concern of the anesthesiologists. Its effect in pediatric laparoscopy has not been previously reported. The purpose of this study was to examine the physiological alteration of pediatric patients during CO2 pneumoperitoneum. METHODS: One hundred and twenty six children aged from 11 mon to 13 yr undergoing laparoscopic inguinal exploration were divided into three groups based on age orientation: group I comprising 40 children with age from 11 mon to 2 yr; group II 46 children with age between 2 to 5 yr; and group III 40 children aged from 5 to 13 yr. All patients received endotracheal anesthesia with halothane-N2O in 50% O2 and atracurium for muscle relaxation. Respiration was controlled by an Ohmeda 7000 ventilator with constant minute ventilation to maintain baseline end-tidal CO2 tension (PETCO2) between 32-33 mmHg. After anesthesia, CO2 was insufflated into the peritoneal cavity via the opened hernia sac. The intraabdominal pressure exerted by CO2 was 10 mmHg and the duration of pneumoperitoneum and laparoscopy was 15 min. We recorded airway pressure, PETCO2, body temperature, blood pressure, heart rate, heart rhythm, and oxygen saturation simultaneously at 1 min interval before, during, and after laparoscopy. RESULTS: The airway pressure and PETCO2 showed significant increases during laparoscopy (15-18% and 18-20% respectively) in all cases, but the percentage of increases were not significantly different among groups. However, the PETCO2 change in terms of time lag were different between groups: (1) the time lag from CO2 insufflation to the emergence of PETCO2 change (latent period) was respectively 0.7 +/- 0.1 (mean +/- SD) min in group I, 0.9 +/- 0.2 min in group II and 1.5 +/- 0.2 min in group III (p < 0.05); (2) the PETCO2 change from baseline to a plateau (ascending period) was respectively 4.2 +/- 0.6 min in group I, 6.3 +/- 1.0 min in group II and 9.1 +/- 1.1 min in group III (p < 0.05); (3) the PETCO2 decline from plateau to baseline after CO2 deflation (descending period) was respectively 6.2 +/- 0.5 min in group I, 8.3 +/- 0.8 min in group II and 12.0 +/- 1.3 min in group III (p < 0.05). The body temperature and hemodynamics including blood pressure, heart rate, heart rhythm, oxygen saturation were not significantly changed during laparoscopy in all groups. CONCLUSIONS: The changes of PETCO2 during laparoscopy did not influence the hemodynamic stability in our study. The younger children give a faster reaction time of PETCO2 change after CO2 insufflation than do the older children which may be related to the variation of physiological exhibition at different state of development.

Thyroid cancer in children and adolescents.

BACKGROUND: Thyroid cancer in children and adolescents has rarely been reported in Taiwan. The purpose of this study is to realize the characteristics of thyroid cancer of children and adolescents. METHODS: From 1971 to 1992, a total of 726 patients with cancer of thyroid were treated at Veterans General Hospital-Taipei. Of these, 37 were below the age of 21, and were followed 1 to 21 years with an average of 7.4 years. RESULTS: Only one patient with thyroid cancer had the history of previous radiation therapy for head and neck tumor. Neck mass was the most common mode of presentation and 36% had associated cervical adenopathy. Histologically, papillary cancer was found in 29 patients, follicular cancer in 7 and medullary cancer in 1. There was no undifferentiated cancer. Twenty-three patients had lymph node metastases. Eight patients developed distant metastases, especially to the lung, and most of them were male. Recurrence after initial surgical treatment was found in 12 patients, without significant association with the surgical procedure. The major operative complication was hypoparathyroidism. Disease-related mortality occurred in only one case (2.8%). CONCLUSIONS: Well-differentiated carcinomas of the thyroid in children and young adults are rare in Taiwan and are mostly papillary carcinomas not related to previous neck irradiation. Before the age of puberty, boys were predominant in this series. The rate of distant metastasis was higher in males. The prognosis after surgical treatment is excellent.

Histiocytosis X involving thyroid gland: a case report.

Diffuse histiocytosis X involving thyroid gland is rare. A 10-year-old boy with progressively enlarged neck mass, skin rash over scalp and face, splinter hemorrhage, otitis externa, episodes of pneumothorax and abnormal liver function was hospitalized. Thyroid scan showed a nonfunctioning mass in the right lobe of the thyroid and needle aspiration biopsy suspected histiocytosis X. Right thyroid lobectomy was performed and revealed histiocytosis X in light and electron microscopic examinations.

Pancreatoblastoma: a case report.

Primary neoplasms of the pancreas are rare in children. One variant of these tumors is pancreatoblastoma, comprising 0.5% of epithelial tumors of the pancreas. It usually affects children at 1-8 years of age, with quite equal sex ratio. The tumor can be found at any site of pancreas, but it most commonly arises in the head of pancreas. Histopathologically, pancreatoblastoma is an encapsulated tumor with distinct organoid structures and sometimes squamoid corpuscles. Acinar cells with zymogen granules are occasionally found. The tumor has favorable prognosis. We present a 14-year-old female who was admitted due to prolonged jaundice for about 2 months. Physical examination revealed pale conjunctiva, yellowish skin color and hepatosplenomegaly. Abdominal sonography and CT scan showed dilated common bile duct and a tumor mass about 2 x 2 cm in dimension located a pancreatic head. She received surgical operation to relieve obstructive jaundice and later Whipple's operation for radical resection. Six months after operation, the patient received the examination of abdominal sonography, CT scan and gallium tumor scan but there was no evidence of local recurrence or distant metastasis. Now the patient is living well for more than one year. Because of its rare occurrence, we demonstrate this case and review the literature.