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

Background: Potential risks for a surviving twin after fetal death of a co-twin in twin-to-twin transfusion syndrome (TTTS) has been documented. Although some studies suggest ending a twin pregnancy after a single fetal death as soon as possible in order to minimize the risks of thromboembolic complications in the surviving twin, we are more concerned about the risks of a premature birth. In this study, we searched for a potential marker to predict thromboembolic complications in the surviving twin.

Methods: From 1993 to 1998, nine women in two teaching hospitals had pregnancies complicated by TTTS and the death of one fetus. In addition to routine ultrasound examinations and obstetric monitoring, all patients had disseminated intravascular coagulation tests. The outcome of the surviving fetus was recorded.

Results: Three patients had silent and minimal coagulopathy (33%) that revealed only the presence of D-dimer. Among these three patients, two had a disappearance of serum D-dimer, but the other one had persistent D-dimer levels for more than 5 weeks and delivered a fetus with a cerebral infarction. Except for the above-mentioned fetus, all surviving fetuses were normal and healthy and were delivered at the median gestational age of 33 (range, 31-36) weeks. Of the nine surviving children, the mean interval between fetal death of one twin and delivery of the healthy twin was 22.7 days, ranging from 3 days to 47 days.

Conclusions: All patients having TTTS associated with one fetal death should be carefully monitored for coagulopathy; the appropriate time for delivery might depend on the duration of persistent D-dimer in the maternal blood. The long-term presence of D-dimer in the maternal serum may indicate a severe underlying thromboembolic complication in the surviving twin after intrauterine death of a monochorionic twin. Due to the increased risks of morbidity in premature births, the benefit of early termination of pregnancy in order to protect against subsequent sequelae in the surviving twin is minor and remains an area for future research.

Background: Diagnosis of premature rupture of membranes (PROM) is difficult in equivocal cases. The concentrations of human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP) and creatinine are high in amniotic fluid. The purpose of this study was to determine the usefulness of vaginal fluid hCG, AFP and creatinine measurements in the detection of PROM.

Methods: About 3 ml of normal saline was used to irrigate the posterior vaginal fornix and was collected for the measurement of hCG, AFP and creatinine. The control group included 10 normal pregnant women in the third trimester (> 28 weeks of gestational age). Levels of hCG, AFP and creatinine were compared with those of 10 women with confirmed PROM.

Results: The median levels of vaginal fluid hCG of normal pregnant women and pregnant women with confirmed PROM were 35.0 mIU/ml and 478.0 mIU/ml (p = 0.0046), respectively. For AFP, the corresponding values were 0.80 ng/ml and 54.24 ng/ml (p < 0.0001), respectively, and for creatinine, the values were 0.05 mg/dl and 0.95 mg/dl (p < 0.0001), respectively. All three markers were significantly higher in the experimental group than in the control group. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for hCG were 80%, 70%, 72.7%, 77.8% and 75%, respectively. For AFP, these values were 90%, 100%, 100%, 90.9%, and 95.0%, respectively, and for creatinine, they were 90%, 100%, 100%, 90.9%, and 95%, respectively. The diagnostic value of AFP or creatinine level in vaginal washing may be better than that of hCG, though the difference was not statistically significant, probably due to the limited case number.

Conclusions: Creatinine in vaginal fluid washings is a useful marker for PROM. It was less expensive and easier to measure than hCG and AFP, and appears to be more accurate than hCG.

Background: The perinatal management of congenital complete heart block (CCHB) remains controversial. The purpose of this study was to present a therapeutic modality for CCHB.

Methods: We collected retrospective cases of all pregnant women admitted to our hospital between January 1992 and June 1999 whose babies developed CCHB antenatally. After a series of examinations, maternal, fetal and neonatal data were analyzed.

Results: Nine fetuses from six mothers (cases 1-6) in nine different pregnancies were studied. In case 1, both consecutive fetuses had CCHB and in case 2, all three consecutive fetuses had CCHB. The other mothers (cases 3-6) had only one fetus each with CCHB. Of the seven fetuses with isolated CCHB, four underwent observation only due to late-onset, or nonimmunologic CCHB, two received dexamethasone and/or intravenous immunoglobulin therapy because of the presence of hydropic signs, and one received dexamethasone at 23 weeks' gestation due to early-onset CCHB. Shortening fractions of the right ventricle had good compensation in four fetuses, without any treatment, and improving compensation in two of three fetuses receiving dexamethasone therapy. All seven fetuses were delivered smoothly and pacemakers were implanted shortly after birth. Two other fetuses had a poor outcome due to associated ventricular septal defect or hemoglobin Bart's disease. Furthermore, we gave dexamethasone (2 mg/day) instead of prednisolone (10 mg/day) for the next pregnancies of patients 3 to 5, beginning at 12 weeks of gestation. No fetal CCHB developed again.

Conclusions: For pregnant women with previous fetal immunologic CCHB, early initiation of dexamethasone instead of prednisolone might be effective to cross the placenta and avoid recurrences. Dexamethasone is also effective for fetal CCHB of early onset, fetal hydrops or heart failure. Observation only is suggested for nonimmunologic CCHB and remote or late-onset immunologic CCHB. Other modalities were tried for very sick fetuses, but their effectiveness was not predictable.

Aberrant cervical carotid artery is an uncommon anomaly. Because this anomaly can lie in close proximity to the midline of the posterior part of the pharynx, it poses a significant risk during both major pharyngeal tumor resection and less extensive procedures such as tonsillectomy, adenoidectomy and palatopharyngoplasty. Five cases of aberrant cervical carotid artery were encountered and diagnosed using computerized tomography. In all five cases, the anomalous finding did not correlate with the presenting symptoms. Computerized tomographic images of these cases are provided. A review of the literature and the embryology of the aberrant carotid artery are presented. Awareness of the anomaly by radiologists and surgeons is essential to avoid accidental injury to the vessel during surgery.

We report a case study of an 86-year-old female patient with severe cholestatic hepatitis who was undergoing treatment with oral ticlopidine 250 mg daily for coronary artery disease. The patient had nausea and vomiting and was jaundiced after taking ticlopidine for 6 weeks. She was admitted to the hospital for further evaluation. Ultrasound and endoscopic retrograde cholangiopancreatography eliminated the presence of biliary obstruction. Results from a liver biopsy showed a histopathologic picture consistent with cholestatic hepatitis. Ticlopidine-induced cholestatic hepatitis has been reported 32 times in the foreign literature. This is the first reported severe cholestatic hepatitis (total bilirubin up to 43 mg/dl) case in Taiwan. Ticlopidine-related blood dyscrasia is a renowned adverse drug effect; liver function should be monitored in patients receiving ticlopidine therapy.

Background: Age-related cataracts are the main cause of blindness throughout the world. Nonetheless, population-based data on the epidemiology of age-related cataracts among Taiwanese populations are not readily available. This study was conducted to estimate the prevalence of age-related cataracts and to determine the relationships of age, gender, blood pressure, diabetes and smoking to the risks of age-related cataracts in an urban Taiwanese population.

Methods: The study was part of a population-based survey of eye diseases among residents aged 50 years or older in Peitou Precinct, Taipei, Taiwan. Of the 2,700 eligible persons, 2,038 (75.5%) underwent a standard evaluation protocol including dilated slit-lamp examination, a questionnaire of medical and ophthalmic histories and blood pressure measurement.

Results: Among the participants, 1,040 were diagnosed with age-related cataracts. The prevalence was 51.0% (95% confidence interval, 48.9%-53.2%). Nuclear opacity was the most prevalent type (718/1,040; 35.2%) of cataracts, followed by posterior subcapsular opacity (311/1,040; 15.3%) and cortical opacity (163/1,040; 7.8%). An increased risk of age-related cataracts was associated with female gender (p = 0.002). When a single type of lens opacity was considered, diabetes was significantly associated with a posterior subcapsular cataract (p = 0.022). Overall, older women with diabetes and relatively lower diastolic blood pressure were more likely to have age-related cataracts.

Conclusions: The study provided the first prevalence data on age-related cataracts in an urban Taiwanese population and highlighted the relationships of age, gender, blood pressure and diabetes to the frequency and type of age-related cataracts. The results can assist in the design and implementation of intervention programs to reduce the prevalence of age-related cataracts.

Background: Problem-based learning (PBL) in small-group tutorials has been a trend in medical education. Chinese students are known to be reserved and passive; thus, they may not be adaptable to PBL. Neuroanatomy, important to clinical neurology, is difficult to learn. We incorporated clinical neurology with PBL, complementary to the traditional neuroanatomy curriculum, to evaluate the feasibility of PBL for Chinese students in Taiwan.

Methods: Forty-two second-year medical students and seven tutors participated in the clinical neurology PBL small-group tutorials. Twelve case reports were discussed weekly beginning in February, 1999. Each case was designed to meet the progressive curriculum of the neuroanatomy course. The tutors evaluated the students by the degree of their preparation, participation, key-point comprehension and interaction. All tutors and students filled out questionnaires at the end of each session.

Results: The majority of the students and tutors agreed that the case materials were clearly written. Ninety percent of the students agreed that the case materials matched the traditional content of neuroanatomy. Eighty-five percent of students and 71% of tutors were satisfied and found the class rewarding. Ninety-one percent of students and 74% of tutors were in favor of PBL being continued.

Conclusions: This preliminary PBL, small-group tutorial learning in clinical neurology showed satisfactory results and was, indeed, complementary to a traditional neuroanatomy course. The students, as early as during the second year of their medical school education, were able to learn through the PBL. More integration of basic and clinical sciences by PBL may be considered in future curricula designs.

Background: Salmon calcitonin, a polypeptide hormone, is used in the treatment of osteoporosis, hypercalcemia and Paget's disease. The purpose of this study was to evaluate the pharmacokinetics and relative bioavailability of two salmon calcitonin products, Miacalcic (Novartis Pharmaceuticals, Basle, Switzerland) and Calcinin (Purzer Pharmaceuticals, Taipei, Taiwan).

Methods: This was a randomized, single-dose, crossover study conducted under fasting conditions with a washout period of 1 week between doses. Ten healthy male subjects were enrolled in this study. Each subject received a 100 IU dose (20 micrograms; 50 IU/ampule x 2) of salmon calcitonin intramuscularly (i.m.) followed by collection of blood samples at specified time intervals. Serum salmon calcitonin concentrations were measured using a validated radioimmunoassay method with a detection limit of 15.0 pg/ml. Values for the area under the serum concentration from time zero to last time and infinity curve (AUC0-t and AUC0-infinity), peak concentration (Cmax), time to peak concentration, terminal first order rate constant, terminal half-life, mean residence time, total clearance divided by absolute bioavailability, onset time, maximal effect and duration were compared for each product.

Results: The 90% confidence intervals for AUC0-t, AUC0-infinity and Cmax after logarithmic transformation were 93.2% to 113.1%, 97.2% to 114.9% and 84.9% to 108.0%, respectively.

Conclusions: Based on the two one-sided tests procedure, we conclude that Miacalcic and Calcinin are bioequivalent.

Background: A study of tamoxifen, ifosfamide, epirubicin and cisplatin (TIEP) chemotherapy was conducted in patients with extensive-disease, small-cell lung cancer (SCLC) to assess response and toxicity.

Methods: From November, 1997, to February, 1999, 11 patients were treated, including six chemo-naïve patients and five patients previously treated with cisplatin plus etoposide (EP). The treatment regimen included tamoxifen 60 mg twice daily orally on days 1 to 3, ifosfamide 3 g/m2 intravenous (i.v.) infusion for 60 minutes with mesna on day 2, epirubicin 50 mg/m2 i.v. bolus on day 2 and cisplatin 60 mg/m2 i.v. for 60 minutes on day 2, every 4 weeks for up to six cycles.

Results: All patients were evaluated for toxicity and response rate. As expected, the major toxicity was myelosuppression. Grade 3 or 4 leukopenia or neutropenia occurred in all patients during treatment. Two patients (18.2%) experienced fever in association with the neutropenia, one of whom died of sepsis. Grade 3 anemia occurred in two patients (18.2%) during treatment. Toxicities other than neutropenia and anemia were limited. After two cycles of treatment, five of six chemo-naïve patients (83%), and one of five previously treated patients (20%) attained a partial response (overall 54.5%, 95% confidence interval 25%-83.9%). Median survival time was 8.5 and 6 months in chemo-naïve and previously EP-treated patients, respectively. The response rate and median survival time in chemo-naïve patients did not improve compared with a previous study of ifosfamide plus etoposide undertaken 4 years earlier.

Conclusions: Although TIEP is an active combination regimen with an acceptable toxicity profile in Chinese patients with extensive-disease SCLC, it showed no remarkable benefit compared with other regimens used in chemo-naïve patients. The 20% response rate and median survival of 6 months in EP-treated patients deserve further study.

Parkinsonism secondary to neoplasm is uncommon. We report two patients with bilaterally symmetric parkinsonism as the initial presentation of their brain tumors. The first patient was a 71-year-old woman who presented with a gradual onset of bilateral resting tremor, bradykinesia and rigidity. Computerized tomography (CT) of the brain revealed a large parasagittal tumor in the left frontal lobe. The patient completely recovered from the parkinsonian symptoms after removal of the brain tumor. The second patient, a 74-year-old man with a history of renal cell carcinoma of the right kidney suffered from an insidious onset of bilateral bradykinesia, rigidity and gait difficulty. Cerebral metastasis was noted on the brain CT scan. Early recognition of intracranial tumor as the cause of parkinsonism is important for the management of this type of movement disorder. Moreover, brain CT scanning plays an important role in the differential diagnosis of patients with parkinsonian symptoms.