Well-differentiated papillary mesothelioma of tunica vaginalis testis of unknown malignant potential: Sonographic appearance.

Paratesticular mesothelioma is a rare differential diagnosis in the presence of scrotal hydrocele. A 17-year-old boy presented with a 3-year history of progressive hydrocele. Sonography revealed a large left paratesticular mass within the hydrocele. Serum tumor markers were negative. Left hydrocelectomy was performed and pathological analysis of the epididymal mass revealed a well-differentiated papillary mesothelioma. We discuss the sonographic and pathological findings of this rare neoplasm.

Angiographic factors associated with haemorrhagic presentation of brain arteriovenous malformation in a Chinese paediatric population.

OBJECTIVE: To identify specific angiographic factors associated with haemorrhagic presentation of brain arteriovenous malformation in Chinese paediatric patients. DESIGN: Retrospective cross-sectional observational study. SETTING: Four locoregional tertiary neurosurgical centres in Hong Kong: Queen Elizabeth Hospital, Tuen Mun Hospital, Kwong Wah Hospital, and Pamela Youde Nethersole Eastern Hospital. PATIENTS: Patients aged 18 years or younger who underwent pretreatment digital subtraction angiography for brain arteriovenous malformation between 1 January 2005 and 31 July 2013 were included. Patients were divided into haemorrhagic and non-haemorrhagic groups based on the initial presentation. Pretreatment digital subtraction angiographies were independently reviewed by two experienced neuroradiologists. MAIN OUTCOME MEASURES: The following parameters were evaluated for their association with haemorrhagic presentation by univariate and multivariate analyses: nidus location, nidus size, nidus morphology (diffuse or compact); origin and number of arterial feeders; venous drainage; number of draining veins; presence of aneurysms, venous varices, and venous stenosis. RESULTS: A total of 67 children and adolescents (28 male, 39 female) with a mean age of 12 years were included. Of them, 52 (78%) presented with haemorrhage. Arteriovenous malformation size (P=0.004) and morphology (P=0.05) were found to be associated with haemorrhagic presentation by univariate analysis. Small arteriovenous malformation nidus size and diffuse nidal morphology were identified as independent risk factors for haemorrhage by multivariate analysis. CONCLUSION: Smaller arteriovenous malformation size and diffuse nidal morphology are angiographic factors independently associated with haemorrhagic presentation. Bleeding risk is important in determining the therapeutic approach (aggressive vs conservative) and timeframe, particularly in paediatric patients.

Voiding urosonography with second-generation ultrasound contrast versus micturating cystourethrography in the diagnosis of vesicoureteric reflux.

Vesicoureteric reflux has been associated with paediatric urinary tract infection. Fluoroscopic micturating cystourethrography (MCU) has been the gold standard of diagnostic test for decades; however, it has been criticized owing to its lower detection rate and radiation dose to children. Therefore, new radiation-free reflux imaging modalities have been developed, in which ultrasound-based contrast-enhanced voiding urosonography (ceVUS) is a good example. However, ultrasonography has been considered as an operator-dependent examination. Therefore, our study aimed to examine the inter-observer agreement of this sonographic technique, which has not been evaluated before. Moreover, the second-generation ultrasound contrast SonoVue has been recently marketed, and the data on its efficacy on intravesical use in ceVUS is relatively scarce. Thus, we also aimed to investigate the diagnostic performance and safety profile of SonoVue-enhanced VUS in the diagnosis of vesicoureteric reflux. Our prospective comparative study compared the diagnostic performance of ceVUS with MCU in young children presenting with first episode of urinary tract infection. We performed sequential ceVUS and MCU examinations in 31 patients (62 pelvi-ureter units). Perfect inter-observer agreement (Cohen's kappa statistics = 1.0, p < 0.001) was achieved in ceVUS, suggesting its good reliability in reflux detection and grading. Using MCU as reference, ceVUS had 100 % sensitivity and 84 % specificity and carried higher reflux detection rate than MCU (p < 0.001). There was no complication encountered. Conclusion: Voiding urosonography is a reliable, sensitive, safe and radiation-free modality in the investigation of vesicoureteric reflux in children. It should be incorporated in the diagnostic algorithm in paediatric urinary tract infection.

Paediatric vesicoureteric reflux imaging: where are we? Novel ultrasound-based voiding urosonography.

Vesicoureteric reflux is an important association of paediatric urinary tract infection. Fluoroscopic micturating cystourethrography and radionuclide cystography have been employed for detecting and grading vesicoureteric reflux. However, both modalities involve ionising radiation, which can pose significant radiation risk to growing children. They also have a lower detection rate due to intermittent fluoroscopic technique in micturating cystourethrography, and lower spatial resolution in radionuclide cystography. Therefore, newer radiation-free ultrasound-based contrast-enhanced voiding urosonography has been developed in Europe for 15 years. This article aimed to summarise the current literature and discuss the first local pilot study in our institution on detection of vesicoureteric reflux by contrast-enhanced voiding urosonography. Contrast-enhanced voiding urosonography is a valid alternative to micturating cystourethrography in assessing vesicoureteric reflux, based on its superior diagnostic performance, reliability, safety, feasibility, and radiation safety for children. Therefore, it should be incorporated in the guideline for investigating paediatric urinary tract infection.

Insidious rifampin-associated renal failure with light-chain proteinuria.

A patient who was receiving rifampin treatment for tuberculosis developed heterogenous light-chain proteinuria and insidious renal failure after a period of fluid restriction. The renal damage was characterized pathologically by an interstitial nephritis with invasive tubular casts and an associated renal vein thrombosis. The possible role of the light-chain proteinuria in the pathogenesis of the renal failure is discussed.

A method for the preparation of protein-protein conjugates of predetermined composition.

A novel procedure for the synthesis of well-defined protein-protein conjugates is described using ovalbumin (OA) and IgG as test proteins. This procedure involves the highly selective and rapid reaction of alkyl halide and sulfhydryl groups, which have been grafted, respectively, onto the proteins to be conjugated. Accordingly, iodoacetylated IgG, (ICH2CO)nIgG, was prepared by the reaction of the epsilon-amino groups of IgG with the N-hydroxysuccinimide ester of iodoacetic acid (NHIA), the degree of iodoacetylation (n) being proportional to the concentration of NHIA. OA was reacted with S-acetylmercaptosuccinic anhydride (SAMSA) under conditions yielding, on the average, a monosubstituted derivative. Following removal of the protective S-acetyl group, the resulting -SH derivative of OA was reacted with (ICH2CO)nIgG. The OAx-IgG conjugates so produced were characterized by gel filtration, specific radioactivity (using tritiated OA) and immunodiffusion. It was found that the average number of OA molecules coupled per IgG molecule could be controlled by varying the degree of iodoacetylation of IgG.

Use of developmental language scales in Chinese children.

The Reynell Developmental Language Scale (RDLS) and Symbolic Play Test (SPT) have been useful language tests for assessing the language age of children. Both tests have been validated in English-speaking children. However, there have been no studies conducted for Chinese children, whether Mandarin (Northerners) or Cantonese (Southerners) is used as the main dialect. As the Chinese population is the largest ethnic group in the world, and Chinese emigration occurred to nearly all parts of the world, it is essential to test whether these language tools can be applied for this ethnic group. The objective of this research was to study whether RDLS and SPT are useful in assessing the language age of Chinese children. Both RDLS (Chinese version) and SPT are conducted for 116 Chinese (Cantonese-speaking) children, aged 13-59 months, in Hong Kong. There is a significant positive correlation of the language age using RDLS and SPT with the chronological age of Chinese children. Both RDLS and SPT can be adopted in determining the language/mental age of Chinese (Cantonese-speaking) children.

Knowledge of cardiopulmonary resuscitation among the public in Hong Kong: telephone questionnaire survey.

OBJECTIVES: To evaluate the knowledge of basic life-support and training experience in cardiopulmonary resuscitation among the public in Hong Kong and to identify areas for improvement in public education. DESIGN: Telephone interview using a structured multiple-choice questionnaire. SETTING: Random cross-section of the Hong Kong public, from mid-March to May 2002. PARTICIPANTS: Men and women aged 16 years and older selected using random telephone dialling. MAIN OUTCOME MEASURE: Overall score in the cardiopulmonary resuscitation knowledge questionnaire. RESULTS: Of the 357 participants, approximately 12% had received cardiopulmonary resuscitation training. Cardiopulmonary resuscitation knowledge in Hong Kong was poor, even among the previously trained and especially with regard to circulatory maintenance. The most common reason for not taking cardiopulmonary resuscitation training was lack of time. CONCLUSION: The degree of citizen preparedness in initiating cardiopulmonary resuscitation is very poor in Hong Kong. Intensified educational efforts and exploration of new approaches to improve this first stage in the chain of survival are warranted.

Symptoms and pulmonary function in western red cedar workers related to duration of employment and dust exposure.

Measurements of total dust concentration were made in a western red cedar sawmill that employed 701 workers. Both area sampling and personal sampling of total dust were done over an 8-hr shift corresponding to job descriptions and locations to assign each worker an exposure level. A total of 652 (93%) of the workers completed a respiratory-occupational questionnaire and performed spirometry, of whom 334 were assigned an exposure level. Dust exposure ranged from undetectable to 6.0 mg/m3 with a median exposure level of 0.2 mg/m3. Only 10% of the workers with an assigned exposure level were exposed to more than 1.0 mg/m3. Work-related asthma, defined as symptoms of asthma which improved on days off work, was reported by 52 workers (8.0%) and was more prevalent after 10 or more yr of employment. Chronic cough, dyspnea, persistent wheeze, and physician-diagnosed asthma were unrelated to either work duration or exposure. Levels of forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1.0) were lower with dust concentrations greater than 2.0 mg/m3, controlling for age and smoking; maximum mid-expiratory flow rate (FEF25-75%) and FEV1.0/FVC were unrelated to dust exposure concentration. Work-related symptoms of eye irritation were seen more commonly with exposure to dust concentrations of 3.0 mg/m3 or more. It is concluded that symptoms of work-related asthma in red cedar workers are more common after 10 yr of exposure, and that levels of pulmonary function are lower with higher wood dust exposures.

Lymphocyte transformation studies in drug hypersensitivity.

In a group of patients with clinically diagnosed drug hypersensitivity the in vitro lymphocyte response to the suspected drug was assessed by the lymphocyte transformation test. The test gave positive results in all 15 patients with penicillin-induced immediate or accelerated allergic reactions and positive immediate skin-test reactivity to the major or the minor antigenic determinant of penicillin, or both, but in only 3 of the 12 patients with delayed-onset maculopapular rashes induced by penicillin, despite positive immediate reactivity to the skin-test reagents.Lymphocyte stimulation greater than five times the control level was demonstrated for five patients with penicillin-induced erythroderma, Stevens-Johnson syndrome or a serum-sickness-like illness, or with methicillin-induced interstitial nephritis, all of whom had negative reactions to the appropriate skin-test reagents. A low level of stimulation was seen in eight other skin-test-negative patients with possible allergic reactions induced by penicillins. However, in all subjects tested the stimulation was significantly greater than the mean for control subjects.For 9 of 11 patients with isoniazid-induced hepatitis or maculopapular rashes, but for only 8 of 31 patients with eruptions induced by a variety of drugs other than penicillins and isoniazid, significant stimulation occurred in the lymphocyte transformation test.It is concluded that the lymphocyte transformation test is useful in the detection of hypersensitivity to the penicillins (although in IgE-mediated reactions skin testing is clearly preferable) and isoniazid but is of limited value in the demonstration of hypersensitivity to other drugs.

Symposium on allergic lung diseases. 3. Serum and sputum immunoglobulin E levels in respiratory diseases in adults.

Using a solid-phase radioimmunoassay, serum IgE level was determined in 46 normal subjects, 53 patients with bronchial asthma, 44 patients with chronic bronchitis and / or emphysema, and 19 patients with restrictive lung disease. Sputum IgE was measured simultaneously in 51 of the subjects. The range of serum IgE concentration in the normal subjects was wide. It varied between 15 and 750 ng/ml with a mean of 135 ng. Asthmatic patients had significantly higher levels of serum IgE with a mean of 579 ng/ml, but only 30% fell outside the normal 95% confidence limits. Patients with chronic bronchitis, emphysema and restrictive lung diseases had normal IgE levels. There was a significant correlation between serum and sputum IgE levels.

Effects of tolerogenic conjugates in a canine model for reaginic hypersensitivity. I. suppression of hapten-specific IgE antibody response.

Intraperitoneal administration to dogs of conjugates consisting of the 2,4-dinitrophenyl (DNP) groups coupled to nonimmunogenic macromolecules such as the copolymer of D-glutamic acid and D-lysine (DNP16-DGL) prior to sensitization with DNP2-ovalbumin led to the development of hapten-specific tolerance with respect to the IgE antibody response. Administration of these same conjugates to sensitized dogs resulted in complete abrogation of the ongoing anti-DNP IgE antibody production. A similar hapten-specific suppression of the ongoing anti-DNP response was also observed using the conjugates of DNP9-canine gamma globulins, and the tolerogenic effect was dose-dependent. The state of hapten-specific immunosuppression induced by these two types of tolerogenic conjugates was maintained despite repeated booster injections of the sensitizing antigens at biweekly inervals.

Mechanical properties of the lung in extrinsic allergic alveolitis.

The lung function of 14 patients with extrinsic allergic alveolitis caused by exposure to mouldy hay (farmer's lung) or to birds (bird fancier's lung) was studied one week and four to six weeks after the last exposure to antigen. These data, together with lung mechanics measured four weeks after antigen exposure, were compared with measurements in 34 healthy non-smoking control subjects. Shortly after exposure to antigen there were reduction in lung volumes, increased elastic recoil (reduced compliance), and varied effects on expiratory flow and reduced gas transfer. With time, lung volumes and gas transfer improved, but expiratory flow often remained decreased. The data on lung mechanics showed that reduced compliance was often found, but this increased recoil did not always produce high airflow indicating increased upstream airways resistance. Patients with a longer duration of the illness tended to have increased compliance (reduced recoil) and low airflow. These results show that the described pathological changes of airway involvement, fibrosis, and emphysema in allergic alveolitis are manifest in the lung function of patients with the disease.

Specific IgE antibodies in workers with occupational asthma due to western red cedar.

The presence of specific IgE antibodies in the serum of patients with occupational asthma resulting from exposure to western red cedar (RCA) was studied by a radioallergosorbent test (RAST). The antigen matrix used in the RAST was either a conjugate of Sepharose particles with antigens in a crude cedar extract or with plicatic acid, the major haptenic component of cedar antigens. Of eighteen patients with clinical RCA and positive reaction to antigenic bronchoprovocation, eight were found to have abnormal RAST values. By appropriate absorption experiments, the serum RAST activity was shown to represent cedar antigen-specific IgE antibodies. No significant RAST activity was detected in the serum specimens from sixteen control subjects or from ten patients with negative bronchoprovocation-reaction to antigenic challenge. These results suggest that IgE antibody-mediated allergic reaction may be an important pathogenetic factor in RCA.

Extrinsic allergic alveolitis from bird exposure. Studies on the immediate hypersensitivity reaction.

Six patients with extrinsic allergic alveolitis had weak immediate and strong late reactions of intracutaneous injection of bird serum. Biopsy of the late reaction revealed vasculitis and immunoglobulin and complement deposition in one. The antibody responsible for the immediate hypersensitivity could be transferred in serum. It was short lasting (4 hr) and resistant to heat and 2-mercaptoethanol. No evidence of an immediate reaction in the lungs could be detected following inhalation challenge as judged by examination of spirometry, flow volume loops and single breath nitrogen washout curves.

Plasma histamine after methacholine, allergen, and aspirin challenges.

Plasma histamine levels were measured by radio-enzymatic technique in seven patients following 10 challenges: five methacholine challenge tests, four antigen inhalation challenge tests, and one oral aspirin challenge test. Baseline plasma histamine was the same in all patients except in the aspirin-challenged patient, who had a higher baseline histamine level. There was no statistical change in the level of histamine throughout the test in either the methacholine-challenged or the antigen-challenged patients, whereas there was a marked increase in histamine levels in the aspirin challenged patient. A possible explanation is that methacholine and antigen are inhaled and therefore have primarily local effects on the lung, whereas oral aspirin has a systemic effect with consequently systemic changes in histamine which are detectable as changes in plasma level.

Grain-dust extract induced direct release of mediators from human lung tissue.

To explore the mechanisms of grain dust-induced acute bronchoconstriction, extracts of grain dust were incubated with chopped human lung fragments. The supernatants of the incubation media were examined for the presence of leukotrienes and histamine with high-performance liquid chromatographic techniques. Human lung fragments responded to the extract of grain dust by releasing histamine in a dose-dependent manner. Moreover, leukotrienes (B4, D4, and E4 were also found to be released. The action of grain dust appeared to be independent of the complement pathway or cell cytotoxicity since the lung tissue released the chemical mediators in the absence of plasma and responded to further reaction with compound 48/80 after interaction with grain dust. These data demonstrate that grain-dust extract may induce the release of mediators of anaphylaxis by a nonimmunologic process. This may explain the occurrence of acute bronchoconstriction in some of the grain workers.

Histamine and leukotrienes release in bronchoalveolar fluid during plicatic acid-induced bronchoconstriction.

Bronchoalveolar lavage (BAL) was performed before and 10 minutes after inhalation challenge with plicatic acid in five patients with red cedar asthma. There was a significant release of histamine and leukotriene E4 into the BAL fluid in all the patients after challenge. Inhalation challenge with methacholine in six patients with nonoccupational asthma and inhalation challenge with plicatic acid in two subjects without asthma did not result in the release of mediators in the BAL fluid. These studies provide direct evidence that plicatic acid-induced bronchoconstriction was accompanied by increased levels of histamine and leukotriene E4 release, whereas a nonimmunologic induction of bronchoconstriction did not induce such local mediator release. BAL may provide a useful means of studying the pathogenesis of occupational asthma caused by exposure to low-molecular-weight compounds.

Symptoms, pulmonary function, and bronchial hyperreactivity in western red cedar workers compared with those in office workers.

An epidemiologic health study was carried out on 652 cedar mill workers and a control group of 440 male office workers not exposed to air contaminants. Participants completed a medical-occupational questionnaire with trained interviewers, had allergy skin tests, performed spirometry, and had bronchial reactivity assessed by methacholine inhalation testing. After adjusting for differences in age, race, and smoking, cedar workers were found to have significantly higher prevalences of cough, phlegm, and dyspnea than did office workers. Symptoms of asthma and work-related asthma, but not persistent wheeze or doctor-diagnosed asthma, were reported in a significantly higher proportion of cedar workers than of office workers. Cedar workers also had significantly lower lung function test results than did office workers after controlling for height, age, race, and smoking. Bronchial hyperreactivity, defined by a methacholine PC20 less than 8 mg/ml, was more prevalent among cedar workers than among office workers, with the increase being limited to the nonatopic subgroup of workers. The prevalence of bronchial hyperreactivity increased with duration of employment among cedar workers but not among office workers. We conclude that exposure to western red cedar dust is harmful to the respiratory health of the workers, causing asthma and other respiratory symptoms, bronchial hyperreactivity, and lower levels of lung function.