Initial experience on rifampin and pyrazinamide vs isoniazid in the treatment of latent tuberculosis infection among patients with silicosis in Hong Kong

OBJECTIVE: To compare the adverse effects and treatment adherence between 2 months of rifampin plus pyrazinamide (2RZ) and 6 months of isoniazid (6H). BACKGROUND: Patients with silicosis in Hong Kong are at high risk of acquiring tuberculosis. A previous study showed that treatment with 6H reduced the risk of silico-tuberculosis by one half. METHOD: Patients with silicosis and a Mantoux skin test reaction > or =10 mm were randomized to receive either 2RZ or 6H daily. Liver function testing was done monthly during the initial 2 months. The adverse effects and treatment adherence were compared between the two regimens. RESULTS: Forty patients (mean age, 61.6 +/- 9.1 years) and 36 patients (mean age, 57.6 +/- 9.7 years) were randomized to the 2RZ and 6H arms, respectively (p > 0.05) [+/- SD]. Baseline characteristics were comparable. Nineteen patients in the 2RZ arm had peak alanine transaminase (ALT) levels > 1.5 times the upper limit of normal (ULN) in comparison with only five study subjects of the 6H arm (47.5% vs 13.9%, p < 0.01). Fourteen patients (35%) in the 2RZ arm and 1 patient (2.8%) in the 6H arm had peak ALT levels more than five times the ULN (p < 0.001). Only seven patients had symptoms suggestive of hepatitis; none of the patients had jaundice. All recovered after withholding treatment. In the 2RZ study arm, none of the baseline characteristics predicted hepatotoxicity. Other adverse effects were generally mild and comparable between both study arms. Treatment was stopped prematurely in 45% and 36.1% of patients in the 2RZ and 6H arms, respectively (p = 0.43). The main reasons were hepatotoxicity for the 2RZ arm and voluntary withdrawal after experiencing other minor adverse effects for the 6H arm. CONCLUSION: A higher incidence of hepatotoxicity was associated with rifampin plus pyrazinamide than isoniazid in the treatment of latent tuberculosis infection among patients with silicosis in Hong Kong.     

Ultrasonographic diagnosis of inflammatory pseudotumor of the ileum complicating with intussusception: a case report

Inflammatory pseudotumor is one of the etiologies that may cause small bowel intussusception. Because of its emergency, early diagnosis plays a pivotal role in successful management. Ultrasonography is a safe and handy diagnostic tool without invasiveness and it is advantageous for early preoperative diagnosis. We present a case of ileal intussusception caused by inflammatory pseudotumor, which was diagnosed preoperatively with ultrasonography and was proven by operation. The ultrasonographic feature of the inflammatory pseudotumor was heterogeneously hyperechoic and it should be included in the differential diagnosis of hyperechoic leading lesions of small bowel intussusception in adults.     

Surgical validation and implications for transcatheter closure of quantitative echocardiographic evaluation of atrial septal defect

Accurate evaluation of secundum atrial septal defect (ASD) is important for the success of transcatheter closure. The purpose of this study was (1) to describe a quantitative evaluation by transthoracic (TTE) and transesophageal (TEE) echocardiography of the various morphologic features of ASD that might be important for patient selection for transcatheter closure, and (2) to assess the reliability of these 2 methods by surgical findings. Preoperative TTE and TEE were used to evaluate the ASD of 27 children undergoing surgical closure. Measurements included the diameters of ASD and the atrial septal lengths in the transverse and longitudinal axis, and the width of the superior, inferior, anteroinferior, and posterior septal margins. The shape and location of the ASD and the adequacy of the septal margins for anchoring occluding devices were determined. Echocardiographic data were compared with corresponding surgical measurements. No significant difference occurred in the means of all the parameters measured with the 3 methods, except for the transverse ASD diameter (p <0.05). Good agreement occurred between TTE and TEE and surgical data, except for the transverse ASD diameter, transverse atrial septal length, and the posterior septal margin on TTE. Intraclass correlations between TTE and TEE and surgical measurements of all parameters were good, except for the transverse ASD diameter. The accuracy in determining shape and location of the ASD by TTE and TEE were 100%, whereas that for determining the adequacy of septal margins was 98% and 97%, respectively. In conclusion, TTE and TEE are reliable methods for quantitative evaluation of ASD.     

Imaging characteristics of anomalous left coronary artery from the pulmonary artery

SUMMARY: The authors report the imaging characteristics of the anomalous origin of the left coronary artery from the pulmonary artery in a 6 1/2-month-old male infant using electrocardiography, echocardiography, angiography, and electron-beam computed tomography. The patient presented with tachycardia, prolonged and interrupted feeding, failure to thrive, and myocardial infarction, and after diagnosis of the anomalous origin of the left coronary artery, survived the reimplantation of the left coronary artery directly to the ascending aorta. When reviewed 7 months after surgery, echocardiography showed improved left ventricular function and surface electrocardiography showed regression of pathologic Q waves in leads I, V 4, V 5, and V 6.     

AngioJet thrombectomy and stenting for reperfusion in acute MI complicated with cardiogenic shock.

AngioJet thrombectomy (AJ) has been shown to be safe and effective in treatment of acute myocardial infarction (AMI). However, use of AJ has not been studied extensively in AMI with cardiogenic shock (CS). Clinical outcomes in 19 patients with CS and treated with AJ were retrospectively analyzed. Immediate stenting was also performed. Procedure success (final diameter stenosis < 50% and TIMI flow > or = 2) was achieved in 95%, with final TIMI 3 flow in 89%. Clinical success (procedure success without major in-hospital cardiac events) was achieved in 68%. There were five in-hospital deaths and no patients experienced stroke or required emergent bypass surgery. At 30-day follow-up, there were no additional deaths or stroke, and two patients had undergone target vessel revascularization. AJ is relatively safe and effective in the setting of AMI complicated with CS, allowing for immediate definitive treatment. This strategy may offer improved mortality in these high-risk patients.     

Predictive factors for lymph node metastasis in early gastric cancer

AIM: To analyze the predictive factors for lymph node metastasis (LNM) in early gastric cancer (EGC). METHODS: Data from patients surgically treated for gastric cancers between January 1994 and December 2007 were retrospectively collected. Clinicopathological factors were analyzed to identify predictive factors for LNM. RESULTS: Of the 2936 patients who underwent gas-trectomy and lymph node dissection, 556 were diag-nosed with EGC and included in this study. Among these, 4.1% of patients had mucosal tumors ...     

Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers

AIM: To identify the predictors of rebleeding after initial hemostasis with epinephrine injection (EI) in patients with high-risk ulcers. METHODS: Recent studies have revealed that endoscopic thermocoagulation, or clips alone or combined with EI are superior to EI alone to arrest ulcer bleeding. However, the reality is that EI monotherapy is still common in clinical practice. From October 2006 to April 2008, high-risk ulcer patients in whom hemorrhage was stopped after EI monotherapy were studied using clinical, laboratory and endoscopic variables. The patients were divided into 2 groups: sustained hemostasis and rebleeding. RESULTS: A total of 175 patients (144, sustainedhemostasis; 31, rebleeding) were enrolled. Univariate analysis revealed that older age (≥ 60 years), advanced American Society of Anesthesiology (ASA) status (category Ⅲ , Ⅳ and Ⅴ ), shock, severe anemia (hemoglobin < 80 g/L), EI dose ≥ 12 mL and severe bleeding signs (SBS) including hematemesis or hematochezia were the factors which predicted rebleeding. However, only older age, severe anemia, high EI dose and SBS were independent predictors. Among 31 rebleeding patients, 10 (32.2%) underwent surgical hemostasis, 15 (48.4%) suffered from delayed hemostasis causing major complications and 13 (41.9%) died of these complications. CONCLUSION: Endoscopic EI monotherapy in patients with high-risk ulcers should be avoided. Initial hemostasis with thermocoagulation, clips or additional hemostasis after EI is mandatory for such patients to ensure better hemostatic status and to prevent subsequent rebleeding, surgery, morbidity and mortality.     

Gastric metastasis of hepatocellular carcinoma via a possible existing retrograde hematogenous pathway

Background and Aim: Hepatocellular carcinoma (HCC) tends to metastasize to extrahepatic organs. Stomach involvement has been seldom reported and has always been considered as direct invasion. This study aims to propose a possible existing pathway for the hematogenous metastasis of HCC to the stomach. Methods: Only seven cases with stomach involvement were found from 8267 HCC patients registered at our hospital between 2000 and 2007. Their laboratory data, the findings of computed tomography and upper endoscopy, therapeutic procedures, such as esophageal variceal banding ligation (EVL), and transhepatic arterial embolization (TAE) were further studied. Results: All seven patients were male. Liver cirrhosis was found in six patients (6/7 = 85.7%), HCC with portal vein thrombosis (PVT) in six patients (6/7 = 85.7%), splenomegaly in five patients (5/7 = 71.4%) and esophageal varices in five patients (5/7 = 71.4%). Six patients underwent TAE and one patient underwent EVL before the development of HCC in the stomach. Four patients had HCC at the cardia, one patient at the anterior wall of the high body and two patients at the greater curvature of the high body, far away from the original HCC. Six patients eventually developed distant metastasis. HCC with gastric metastasis developed 53–126 days after TAE in five patients and 74 days after EVL in one patient. Conclusions: When cirrhotic patients with portal hypertension have HCC with PVT, a hematogenous pathway can exist for gastric metastasis of tumor thrombi involving hepatofugal flow to the stomach after TAE or EVL apart from the major pathway of direct invasion.     

Venous thromboembolism in southern Chinese patients with systemic lupus erythematosus

The objective is to study the annual incidence and standardized incidence ratio (SIR) of venous thromboembolism (VTE) in a cohort of Chinese patients with systemic lupus erythematosus (SLE). VTE events of SLE patients occurring between 1999 and 2008 were identified from our database, and the annual incidence of VTE was calculated according to the cohort size. SIRs were estimated by the ratios of the incidence of VTE in SLE to the general population. In 2008, 516 SLE patients were in our cohort. The mean age of SLE onset was 32.2 ± 14 years and the duration of SLE was 9.3 ± 8.8 years. Fifty-seven percent of the patients had disease duration of ≥5 years. Between 1999 and 2008, 18 episodes of VTE occurred in 14 patients. The incidence of VTE did not show significant fluctuation and the mean annual incidence was 4.2/1,000 patient–year. The reported VTE events were: popliteal vein thrombosis (56%), pulmonary embolism (22%), renal vein, retinal vein, subclavian vein and dural sinus thrombosis (5.6% each). The cumulative risks of VTE since SLE diagnosis were 2.8% and 3.7% at 5 and 10 years, respectively. Compared to the general population, the mean SIR of VTE in SLE patients within this period was 11.9 (7.31–19.6; p < 0.001). The SIR of VTE was highest in patients under the age of 30 years. The presence of the antiphospholipid antibody was independently associated with VTE (HR 4.36 [1.67–11.4]; p = 0.003). Although venous thrombosis is uncommon in Chinese, Chinese patients with SLE are 12 times more prone to VTE than the general population.     

The rule of bigeminy revisited: analysis in sudden cardiac death syndrome

Background

The rule of bigeminy is commonly explained by a reentrant mechanism. We hypothesize that in patients with prolonged ventricular repolarization, the rule of bigeminy may be caused by premature ventricular complexes (PVCs) due to early afterdepolarizations. We evaluated these ventricular arrhythmias over extended periods in patients with sudden cardiac death syndrome.

Methods

The electrocardiographic (ECG) characteristics of 15 recordings from the PhysioNet Sudden Cardiac Death Holter Database were analyzed for the persistence of bigeminy, interaction between the underlying cardiac rhythm and the coupling interval, and influence of a prolonged initiating RR cycle on the self-perpetuation of the arrhythmias.

Results

Eight (53%) patients had classic torsade de pointes (TdP), 5 (33%) had other polymorphic ventricular tachycardia (VT), and 2 (13%) had monomorphic VT. Group A, which comprised 6 of the patients with TdP, had the following ECG tetrad: (1) frequent ventricular bigeminy (>5% of total ventricular arrhythmias), (2) long corrected QT interval (>0.5 second), (3) relatively fixed coupling interval, and (4) onset of bigeminy (n = 4) and TdP (n = 6) after a short-long RR sequence. Patients in group A had slower heart rates (mean RR = 1.12 ± 0.26 vs 0.77 ± 0.13 seconds, P < .01), longer QT intervals (corrected QT = 0.57 ± 0.06 vs 0.45 ± 0.06 second; P < .01) and more cases with prominent U waves (83% vs 33%, P < .05) than patients in group B (n = 9), composed of patients who had other types of VT, or TdP without frequent bigeminy.

Conclusions

We identified a set of ECG characteristics that supports the notion that premature ventricular complexes during self-perpetuating ventricular bigeminy (“rule of bigeminy”) in long QT syndromes may be due to early afterdepolarizations.