Zhonghua yi xue za zhi = Chinese medical journal; Free China ed最新文献

Diabetic ketoacidosis (DKA) and pancreatic pseudocysts are rare complications following treatment of hematological malignancies with L-asparaginase (L-asp). Persistent hyperglycemia with recurrent DKA presenting as a long-term complication of L-asp-induced pancreatitis is even rarer. A 21-year-old man with pre-B-type acute lymphoblastic leukemia (ALL) developed pancreatic pseudocysts, DKA and persistent hyperglycemia after L-asp therapy. The patient was treated with oral hypoglycemic agents (OHA) for sugar control thereafter. Ten months later, another episode of DKA developed during relapsed ALL without having obvious precipitating factors. Insulin was then instituted for control of his blood sugar until death. The leukemic process may play some role in glucose homeostasis and may be considered as a precipitating factor for DKA. The patient finally died of disease progression of ALL and sepsis 2 years after the initial diagnosis of ALL.

Gonadal dysgenesis and Mullerian agenesis both are common causes of primary amenorrhea. Coexistence of gonadal dysgenesis and Mullerian agenesis has been previously described as a rare event. The karyotypes, 45,XO,45,X/46,XX,45,X/46,X,dic(X),46,XX, and 46,XY, have been reported in the literature. A 22-year-old woman presented with primary amenorrhea and normal intelligence. Her physical examination confirmed the absence of breast development and axillary hair. The woman weighed 43 kg and was 150 cm tall. Scoliosis of the thoracic spine was noted on a chest X-ray film. Also, her pelvic examination revealed a vaginal introitus with a vaginal depth of 7 cm, measured by sounding. Her external genitalia were female but lacked pubic hair. The rectal examination failed to reveal a uterus. Pelvic ultrasound disclosed the absence of uterus and ovaries, and her serum gonadotropin levels were in the menopausal range (FSH, 118.59 IU/L; LH, 38.94 IU/L). Estradiol was less than 10 pg/ml. Two mosaic cell lines, 45,X (50%) and 46,X,del(X)(p22.2X50%), were found in the chromosomal study. Laparoscopic evaluation confirmed the absence of uterus and ovaries with normal fallopian tubes. Coexistence of gonadal dysgenesis and Mullerian agenesis is a rare event. The two mosaic cell lines 45,X/46,X,del(X)(p22.2) in this combination have not been reported before. In patients with this condition, estrogen will initiate and sustain maturation and function of secondary sexual characteristics, and lifelong hormone therapy will protect against osteoporosis and cardiovascular disease.

Background: Cervical cancer is the most common malignancy in women in Taiwan. In order to improve the detection of cervical lesions using the Papanicolaou (Pap) smear in screening, a number of adjunctive tests have been developed. The purpose of this study is to evaluate the utility of a magnified chemiluminescent screening examination (speculoscopy) combined with the Pap smear (PapSure) in detecting cervical cancer.

Methods: A total number of 572 women underwent routine cervical cancer screening by receiving a Pap smear and speculoscopy examination. When either the Pap smear or speculoscopy result was positive, colposcopy was performed. Targeted biopsies were taken from any suspicious lesions that were found by positive colposcopies and the data analyzed using McNemar's test.

Results: Eighty-two women had a positive on either screening test. Of the 62 biopsy specimens obtained, 3 women showed high-grade squamous intraepithelial lesions (HGSIL), and 13 women showed low-grade squamous intraepithelial lesions (LGSIL). The histopathological findings were correlated at different levels with the results of the Pap smear alone and speculoscopy alone and both combined. The Pap smear alone detected 1.0% (6 of 572) of significant pathology, while speculoscopy alone detected 2.3% (13 of 572) of significant pathology. The use of the PapSure showed enhanced detection (16 of 572) compared with either the Pap smear alone or speculoscopy alone.

Conclusions: Speculoscopy can be combined with the Pap smear (PapSure) as a cervical cancer screening test to yield a higher detection rate of biopsy-confirmed cervical pathology in women than the use of the Pap smear or speculoscopy alone.

Background: Infections are a frequent complication in cirrhotics, and gastrointestinal bleeding may increase the infection rate. Nonabsorbable antibiotics or quinolone have been employed to decrease the incidence of infection. Since most of these studies were performed in western countries, it is still unclear whether this holds true in our Taiwan cirrhotic patients. Thus we conducted this study using a different formula of antibiotics to evaluate the efficacy of reducing infection rates in cirrhotics with upper gastrointestinal bleeding.

Methods: From July 1999 to August 2000, all cirrhotic in-patients presenting with upper gastrointestinal bleeding but without infection were enrolled. The patients should not have received antibiotics within 2 weeks before admission and should have expected life expectance more than 7 days. Eligible patients who had received endoscopy within 12 hours of hospitalization were randomly allocated into 2 groups. Group A received intravenous cefazolin 1 gm every 8 hours started before endoscopy. After 3 days of prophylactic parenteral antibiotics, antibiotics were shifted to oral cephalexin of 500 mg every 6 hours for 4 days. Group B served as control subjects. All patients received chest X-ray, blood and urine cultures, and ascites culture and sputum culture if ascites and sputum were found. Patients were excluded when initial blood, urine or ascites culture was positive for bacterial growth.

Results: Ninety-seven patients were included. Group A was comprised of 47 patients and Group B comprised of 50 patients. There was no significant difference in age, sex, Child-Pugh's score or initial hemoglobin between the 2 groups. Proved infection developed in 6 patients of Group B. By contrast, no proved infection was found in Group A. Three organisms belonged to gram-negative bacilli and 3 organisms were gram-positive cocci. The incidence of proved infection during hospitalization was 0% in Group A and 12.0% in Group B (p = 0.027). If possible infection cases (patient's body temperature more than 38 degrees C for more than 2 days) were included, the infection rate was 6.4% in Group A and 26% in Group B (p = 0.013). Infection-related mortality occurred in 2 patients in Group B, but none in Group A.

Conclusions: Our prophylactic antibiotic treatment proved safe and effective in reducing the infection rate in cirrhotics with upper gastrointestinal bleeding.

The presence of a persistent left superior vena cava (PLSVC) is the most common congenital disorder of thoracic venous anomaly. Failure of the left anterior cardinal vein to degenerate results in persistent left superior vena cava. It is usually discovered during central venous catheterization or surgical repair of congenital heart disorder. Although most patients with isolated PLSVC or double SVC are asymptomatic, there are some important clinical implications in certain situations, such as central venous catheterization or cardioplegia, which may result in serious complications. In this article, we present a case with PLSVC revealed by chest roentgenogram after pulmonary artery catheterization via left internal jugular vein. We also discuss the role of computed tomography in the diagnosis of PLSVC.

Background: Development of pharmacological treatment in mental disorders has risen drastically over the past decade in Taiwan. We performed a survey of the National Health Insurance claims for outpatient psychiatric services to study the utilization of psychotropic drugs. The analysis followed the drug classification and standardized measurements proposed by the World Health Organization.

Methods: The sampling datasets from the National Health Insurance Research Database served as data sources. They represented 0.2% of the entire claims for outpatient medical services in 2000. The measurement units used for psychotropic drugs were either prescription volumes (drug items) or the number of defined daily doses (DDDs). To estimate the proportion of the population treated daily with psychotropic drugs, numbers of DDDs per 1000 inhabitants per day were also calculated. Beside overall description, the data of psychotropic substance prescriptions were analyzed by stratifying patient's age, physician's specialty, accreditation status of hospital, and chemical subgroup of psychotropic drugs.

Results: Prescription of psychotropic drug items (n = 63,539) was 3.24% of the total drug items (n = 1,958,820) claimed. The psychotropic drugs were prescribed to 9.2% of the total patients and in 9% of the total visits. Major consumers of psychotropic drugs were between 35-74 years of age and there were more women than men. The psychiatrist was the largest group of physicians who had prescribed psychotropic drugs and contributed 18.5% of all drug items and 38.3% of total DDDs of psychotropic drugs. The number of DDDs per 1000 inhabitants per day for all kinds of psychotropic drugs was estimated to be 32.94 in Taiwan, where anxiolytics accounted 14.30, hypnotics and sedatives 10.64, antipsychotics 3.41, antidepressants 3.06 and mood stabilizers 1.43. Ordered by total DDDs, the top 10 most frequently used chemical substances were flunitrazepam, alprazolam, fludiazepam, oxazolam, lorazepam, diazepam, zolpidem, estazolam, zopiclone, and haloperidol.

Conclusions: The usage level of psychotropic drugs in Taiwan was lower than in most industrialized countries, especially for antidepressants. The future goals are to focus on the longitudinal analysis of general trend for each psychotropic substance and to associate the pharmacoepidemiological data in parallel with the upcoming epidemiological study of mental disorders in Taiwan.

Pre-Descemet's dystrophy is a symmetrical bilateral comeal dystrophy consisting of multiple small discrete opacities of lipid-like material in the deep stroma just anterior to the pre-Descemet's membrane. We presented a case of a 46-year-old male who visited our hospital on account of acute conjunctivitis. On routine examination, we found multiple fine gray dots in the pre-Descemet's area and large, dark, scaly skin lesions over extensor surfaces of the extremities. After consultation with a dermatologist, X-linked recessive ichthyosis was diagnosed.

Background: Neonatal Duhamel's pull-through was compared with 2 other approaches to Hirschsprung's disease (HD) diagnosed in the neonatal period.

Methods: Fifty HD patients, undergoing Duhamel's pull-through, were divided into 3 groups. Group I had 14 patients with neonatal pull-through; group II had 9 patients with delayed one-stage pull-through; and group III had 27 patients with two-stage pull-through. Operative bleeding and time, complications, and functional results were analyzed.

Results: The operative bleeding and operative time were significantly more and longer in group III (p < 0.001). Post-operative enterocolitis and fecaloma occurred in 9 (18%) and 16 (32%) patients respectively, and neither of the complications were different among 3 groups (p = 0.826 and 0.868). The common wall of the rectal pouch in group I was eliminated by endo-GIA stapler in 11 patients, and clamp placement in 3. Of 4 patients of group I with fecaloma, only I used endo-GIA stapler. The functional results were good in 35 patients, with mild constipation in 15 and were not statistically different among 3 groups (p = 0.184).

Conclusions: HD on neonates can be successfully treated by Duhamel's pull-through in neonatal period using endo-GIA stapler. The functional results are as good as those with the delayed one-stage or two-stage Duhamel's procedure, with the child usually benefitting by not having home enema or stoma.

Over the past 20 years, new methods have been developed that have allowed scientists to visualize the human brain in action. Initially positron emission tomography (PET) and now functional magnetic resonance imaging (fMRI) are causing a paradigm shift in psychiatry and the neurosciences. Psychiatry is abandoning the pharmacological model of 'brain as soup', used for much of the past 20 years. Instead, there is new realization that both normal and abnormal behavior arise from chemical processes that occur within parallel distributed networks in specific brain regions. Many of these pathological circuits are becoming well characterized, in disorders ranging from Parkinson's disease, to obsessive-compulsive disorder, to depression. Most recently, there has been an explosion of new techniques that allow for direct stimulation of these brain circuits, without the need for open craniotomy and neurosurgical ablation. The techniques include transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), vagus nerve stimulation (VNS), and deep brain stimulation (DBS). This review will describe these new tools, and overview their current and future potential for research and clinical neuropsychiatric use. The psychiatry of the future will be better grounded in a firm understanding of neuroanatomy and neurophysiology (as well as pharmacology). These brain stimulation tools, or their next iterations, will play an ever-larger role in clinical neuropsychiatric practice.