Update on uveomeningoencephalitides

PURPOSE OF REVIEW: Uveomeningoencephalitides, commonly known as Vogt-Koyanagi-Harada (VKH) disease, are characterized by chronic bilateral granulomatous panuveitis involving the central nervous, auditory and integumentary systems. Visual prognosis is generally favourable, but outcomes in patients with VKH disease may vary. Also, the treatment of choice differs in different parts of the world. This review addresses the literature on the possible pathogenesis, diagnosis and treatment of this disorder. RECENT FINDINGS: Atypical presentations of VKH disease, as well as those associated with interferon-alpha therapy, have been reported. Most reports suggest an association with autoimmunity. The diagnostic criteria were revised by the International Workshop on VKH in 1999, allowing for the presence of different ocular findings in the early and late stages of the disease. New techniques have also been developed to aid in the rapid diagnosis of VKH disease and evaluation of treatment. Different routes of administration of corticosteroid and adjuvant therapy were tried, with positive results. SUMMARY: Although the pathogenesis of VKH disease is uncertain and antigen-specific treatment strategies have not yet been developed, reports increasingly suggest an autoimmune nature for uveomeningoencephalitides. Currently, systemic corticosteroid therapy remains the standard initial treatment. Different routes of administration are used to reduce the frequency of side effects of systemic corticosteroids, and there are various adjuvant therapies. With the aid of modern equipment, early diagnosis and prompt and appropriate treatment, resulting in better visual outcomes, can be anticipated. A large-scale, multinational, prospective study is warranted to determine the optimal initial therapy.     

Pseudomembranous tracheobronchitis caused by Aspergillus in immunocompromised patients

We report 2 cases of Aspergillus pseudomembranous tracheobronchitis in patients with diabetes. The first patient succumbed to progressive obstructive respiratory failure despite mechanical ventilation and antifungal therapy. However, the second patient survived. Aspergillus tracheobronchitis should be considered in immuno-compromised patients presenting with cough, chest pain, fever, dyspnea and upper airway obstruction. Early bronchoscopy and histologic examination should be performed. Early, appropriate treatment may be life saving.     

Ruptured aneurysm of the sinus of valsalva into the right atrium without ventricular septal defect: a case report and literature review

Aneurysm of the sinus of Valsalva (ASV), frequently associated with ventricular septal defect (VSD), is a rare cardiac disease that may be acquired or congenital. Rupture of an ASV, rare in the noncoronary cusp, usually produces serious hemodynamic change and carries poor prognosis if not treated surgically. We present the case of a 55-year-old female who came to us complaining of exertional dyspnea. Transthoracic echocardiography and aortography showed a noncoronary cusp ASV with rupture into the right atrium but without VSD. Because of high left to right shunt flow, she underwent successful surgical intervention with aneurysm repair approached from both the aorta and right atrium with a knitted Dacron patch. This was a rare case of noncoronary cusp involvement in ASV that ruptured into the right atrium without VSD.     

Tolerability of ramipril 10 mg daily in high-risk cardiovascular patients in Taiwan: experience from Kaohsiung Medical University Chung-Ho Memorial Hospital

The Heart Outcomes Prevention Evaluation (HOPE) study demonstrated that the angiotensin-converting enzyme inhibitor, ramipril, significantly reduces mortality, myocardial infarction and stroke in high-risk cardiovascular patients, beyond the benefits from blood pressure lowering. The tolerability of ramipril 10 mg/day has been an important concern when applying these results. Following the same criteria as the HOPE study, we investigated the adverse effects profile and tolerability of 10 mg ramipril in high-risk patients at our institution. In total, 92 patients with high cardiovascular risk were eligible for this study. Initially, ramipril was prescribed 2.5 mg orally once daily, and then titrated up to 5.0, 7.5, and 10.0 mg/day at 1-month intervals. The target maintenance dose was 10 mg/day. All adverse events were recorded during at least 3 months of follow-up. After 4-6 months of the titration protocol, only 18 patients (25.3%) reached and remained on ramipril 10 mg/day; 11 (15.5%), 22 (30.9%), and 20 patients (28.2%) remained on 2.5, 5.0, and 7.5 mg/day, respectively. Twenty-one patients (22.6%) had at least one adverse event. Twelve patients (13.0%) stopped treatment because of adverse effects. A total of 23 episodes of adverse events were reported, including cough (15.1%), dizziness (6.0%), and hypotension (2.4%). Ramipril was relatively well tolerated in our study population. However, only one-quarter of our patients reached the target maintenance dose of 10 mg/day. Dry cough, dizziness, and hypotension were the major side effects. About 15% of our patients discontinued ramipril treatment, which is comparable with previous reports.     

Bowel preparation of outpatients for intravenous urography: efficacy of castor oil versus bisacodyl

The purpose of this study was to compare the efficacy of two laxatives, castor oil and bisacodyl, in the routine bowel preparation of outpatients for intravenous urography (IVU). We used castor oil in patients undergoing IVU for 1 month, and then used bisacodyl in patients undergoing IVU for another month. Two uroradiologists, unaware of the method of bowel preparation, reviewed the standard radiographs and graded the residue in the large bowel and the clearness of the opacified urinary collecting system. In total, 71 consecutive outpatients received castor oil, and 84 received bisacodyl. For the castor oil group, grades from the two uroradiologists did not differ in terms of fecal residue on plain abdominal images (p = 0.54), and visualization of the urinary system on the left (p = 0.36) and right sides (p = 0.63). Findings were similar for bisacodyl recipients (p = 0.11, 0.59, and 0.32, respectively). When the laxative effect of the two agents was compared, we found no difference in the grading of fecal residue on plain abdominal images (p = 0.14), or in visualization of the urinary system on the left (p = 0.31) and right sides (p = 0.98). In conclusion, we observed no difference in laxative efficacy between castor oil and bisacodyl; thus, bisacodyl may be a useful alternative for bowel preparation before IVU.     

Decline in titin content in rat skeletal muscle after denervation

Titin, an elastic and giant myofibrillar protein, is responsible for generating passive tension and maintaining sarcomere structure in striated muscles. Several studies have reported attenuation of passive tension and disorganization of sarcomere in atrophic muscles, but the changes of titin have not been investigated after denervation. For this purpose, we used sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunofluorescent staining to examine titin in innervated and denervated tibialis anterior (TA) muscles of the rat. With increasing denervation time, we found a greater loss of titin than myosin heavy chain (MHC) and actin contents in atrophic TA muscle. The ratios of titin/MHC and titin/actin gradually decreased following denervation. In contrast, ratios of MHC/actin in the denervated groups showed no significant differences with the controls even at 56 days postdenervation. The ultrastructure of myofibrils also showed disturbed arrangements of myofilaments and a disorganized contractile apparatus in denervated muscle. Immunofluorescent staining displayed translocation of the titin epitope from the Z-line to the I-band, suggesting that the apparent cleavage of titin occurred near the Z-line region during the atrophying process. Our study provides evidence that titin is more sensitive to degradation than MHC and actin after denervation. Moreover, the titin decline results in the loss of titin-based sarcomeric integrity in atrophic muscle.     

Unexpected mortality in pediatric patients with postoperative Hirschsprung’s disease

Hirschsprungs disease is characterized by lower intestinal obstruction. In this retrospective study, we investigated the postoperative complications and the causes of death in pediatric patients with Hirschsprungs disease. Between January 1981 and June 1998, 147 patients with Hirschsprungs disease underwent surgical intervention (129 with both colostomy and Soaves pull-through procedures) at Mackay Hospital. Of 147 total patients, 83.67% had aganglionosis in the rectosigmoid, 5.44% had colon involvement, and 4.08% had total colon aganglionosis, documented pathologically after a Soaves pull-through procedure. Any post-pull-through patient who showed symptoms of fever, leukocytosis, diarrhea, and clinical sepsis was diagnosed with Hirschsprungs enterocolitis. Four patients died within 4.5 months of surgery, and one patient died more than 4 years after surgery; these five patients were positive for Thomsen (T-) antigen. One patient died soon after rectal irrigation was performed in preparation for the surgery. All five of these patients had sepsis clinically, and anaerobic sepsis was attributed as the main cause of their deaths. Of interest in these cases is the presence of T-antigen, a potentially useful marker for anaerobic bacterial infection that may not be well known to most pediatricians. We recommend (1) determining the presence of T-antigen in patients with recurrent Hirschsprungs enterocolitis, (2) administering empirical antibiotics with anti-anaerobic activity as soon as possible, and (3) irrigating the colon in those patients who develop sepsis after a pull-through procedure.     

Unbearable weight: young adult women's experiences of being overweight

Being overweight is a hazard to health. Overweight people have a very negative image due to the marketing strategies for weight reduction and beauty products. Young women establishing self-image, seeking affirmation of social peers, and looking for potential mates are usually concerned about their weight and figure. To investigate the experience of young women who think they are overweight, how they come to think in this way, and the impact of this thinking, this qualitative pilot study conducted semi-structured interviews with five participants. On the basis of the qualitative method, data was subjected to constant comparison and content analysis. The phenomenon can thus be described in three major categories: (1) Social labeling of the overweight - a slim image is overwhelmingly preferred; (2) Pursuing attractiveness or health - a self-struggling process; (3) Weight reduction and self control - an endless struggle. The result of the study suggests there is a need for a competitive image to counter current obsessions with painfully slender figures in society. To protect the public's mental and physical health, nurses should play an active role in weight education based on a deeper and more dynamic understanding of being overweight.     

Sequential assessment of urodynamic findings before and after tension-free vaginal tape (TVT) operation for female genuine stress incontinence

OBJECTIVES: To sequentially compare the urodynamic findings in patients with genuine stress incontinence (GSI) before and after tension-free vaginal tape (TVT) operation. PATIENTS AND METHODS: Between January 2001 and January 2002, 24 consecutive patients with GSI who completed multi-channel urodynamic study and 20-minute pad test before operation and at 3, 6, and 12 months after operation were enrolled. The sequential urodynamic findings of each case were compared and analyzed. RESULTS: The mean age of the 24 patients was 60.6+/-10.7 years with the parity of 3.5+/-1.4. No statistical differences in voiding and storage functions before and after TVT operation were noted. In contrast, significant changes of stress urethral pressure profile (sUPP) including maximal urethral pressure, maximal urethral closure pressure, functional urethral length, urethral closure area and continence area were observed at 6 and 12 months postoperatively ( p<0.03 ). The median pad weight test decreased from 72g (range 10-220) to 0g 3 months after operation and remained unchanged at 6 and 12 months postoperatively. CONCLUSIONS: This prospective study demonstrates that TVT operation, if done properly, does not significantly impair voiding and storage functions. The significantly increased sUPP parameters may contribute, at least in part, to the high cure rate of TVT operation.     

Impact of radical hysterectomy for cervical cancer on urodynamic findings

To elucidate the impact of radical hysterectomy upon the urodynamic findings of patients with cervical cancer, 20 patients with cervical cancer at stage IB to IIA who underwent radical hysterectomy were recruited. Each patient underwent a 20-min pad test and urodynamic study prior to and 3 months after radical hysterectomy. ANOVA, Bonferroni test and paired t -test were utilized for analysis. The mean age of the 20 patients was 50.2±8.7 years with a mean parity of 3.5±1.5. Four (20%) of the 20 cases revealed normal urodynamic findings preoperatively, and the urodynamic findings became abnormal after surgery. Comparing the urodynamic parameters of both bladder voiding and storage functions pre- and post-surgery, we found significant impairments postoperatively in all 20 cases. Our data demonstrate that abnormal urodynamic findings may pre-exist for some patients with cervical cancer prior to surgical treatment. These findings may worsen, and/or additional abnormal states may arise subsequent to radical hysterectomy.Abbreviations GSI Genuine stress incontinence - MUCP Maximal urethral closure pressure - MUP Maximal urethral pressure Editorial Comment: This paper is interesting because of the attempt at getting longitudinal urodynamic data on patients undergoing radical hysterectomy. All diagnosis and data are based on urodynamic findings. The patients serve as their own controls and only 20% were normal before surgery. Urodynamic data are useless in the absence of clinical correlation, and only provide a photographic and not cinematic view of bladder function. I believe it to be critical to include such information to evaluate the value of the information presented if it were to add to our knowledge of bladder dysfunction following radical hysterectomy. Further studies with control groups with no surgery and with regular hysterectomy would add worthwhile information regarding the true impact of radical hysterectomy for cervical cancer on the lower urinary tract function.