Background Tranexamic acid is commonly used to treat various kinds of bleeding disorders. It has been shown to cause severe convulsions in animal experiments. Aims We report a patient who experienced a single convulsive seizure that resulted in transient hyperammonemia during treatment with tranexamic acid. Case report A 68-year-old man was admitted and received tranexamic acid for persistent hemoptysis. After 5 days of admission, clonic convulsions that progressed to generalized seizures were noted following the intravenous administration of the tranexamic acid. Elevated ammonia level (233 μmol/l) was found. No further seizures occurred after immediate discontinuation of the drug. No other cause of seizures was found. The ammonia level on the following day normalized even without any treatment for the hyperammonemia. Conclusions This case highlights that generalized convulsion is a very rare, but serious adverse effect of tranexamic acid. Generalized convulsion should be considered as a potential cause of transient hyperammonemia.

Non-typeable Haemophilus influenzae (NTHi) is an important community bacterial pathogen in lower respiratory tract infections worldwide. 1 Bandi V. Apicella M.A. Mason E. et al. Nontypeable Haemophilus influenzae in the lower respiratory tract of patients with chronic bronchitis. Am J Respir Crit Care Med. 2001; 164: 2114-21192 Crossref PubMed Scopus (185) Google Scholar , 2 Foxwell A.R. Kyd J.M. Cripps A.W. Nontypeable Haemophilus influenzae: pathogenesis and prevention. Microbiol Mol Biol Rev. 1998; 62: 294-308 Crossref PubMed Google Scholar , 3 Erwin A.L. Smith A.L. Nontypeable Haemophilus influenzae: understanding virulence and commensal behavior. Trends Microbiol. 2007; 15: 355-362 Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar Nosocomial transmission of biotypes II and III NTHi has been described previously. 4 Hekker T.A. van der Schee A.C. Kempers J. Namavar F. van A.L. A nosocomial outbreak of amoxycillin-resistant non-typeable Haemophilus influenzae in a respiratory ward. J Hosp Infect. 1991; 19: 25-31 Abstract Full Text PDF PubMed Scopus (8) Google Scholar , 5 Goetz M.B. O'Brien H. Musser J.M. Ward J.I. Nosocomial transmission of disease caused by nontypeable strains of Haemophilus influenzae. Am J Med. 1994; 96: 342-347 Abstract Full Text PDF PubMed Scopus (15) Google Scholar , 6 Van D.M. Walden C. Walker E.S. Reynolds S.A. Levy F. Sarubbi F.A. An outbreak of infections caused by non-typeable Haemophilus influenzae in an extended care facility. J Hosp Infect. 2007; 66: 59-64 Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar , 7 Mehtar S. Law C.A. An outbreak of beta-lactamase producing Haemophilus influenzae (biotype III) on a geriatric ward. J Hosp Infect. 1980; 1: 357-358 Abstract Full Text PDF PubMed Scopus (11) Google Scholar Here we report a biotype I, multidrug-resistant (MDR) nosocomial NTHi outbreak in a respiratory care ward (RCW).

Intraperitoneal bladder rupture is a rare cause of acute abdomen with bloody ascites. We report herein the case of a patient who had alcoholic liver cirrhosis and multiple liver nodules, and experienced acute bloody ascites and oliguric acute renal failure in association with intraperitoneal bladder rupture. A 33-year-old male suffered from acute abdominal pain and oliguria following consumption of a large amount of alcohol and after blunt abdominal trauma. He was also found to have acute renal failure and newly onset bloody ascites that rapidly subsided following transurethral catheter drainage. Computed tomography cystography revealed intraperitoneal extravasation of contrast from the dome of the bladder, suggestive of intraperitoneal bladder rupture. The patient received surgical repair and was discharged with full recovery. This case shows that it is important for physicians to be aware of the possibility of intraperitoneal bladder rupture after alcohol consumption accompanied with abdominal blunt trauma. In particular, it has diagnostic complications for underlying liver tumors.

Totally implantable venous access ports (TIVAPs) are frequently used in oncology patients who require long-term courses of chemotherapy. We report a silent, but potentially hazardous complication of catheter fracture and hepatic migration in a 64-year-old male. The patient presented with a painful, rapid swelling of subcutaneous tissue around the port area during a saline flush. A chest radiograph showed that the disconnected catheter had separated from the port and was no longer in its original location. A chest CT scan revealed that the disconnected catheter was found to be embolized to the right atrium, inferior vena cava and right hepatic vein. The patient was treated successfully with percutaneous transfemoral retrieval of the catheter under fluoroscopic guidance. To our knowledge, there have been no previous reports of migration of the fractured catheter of a TIVAP into the right hepatic vein. This case highlights that the integrity of TIVAPs should be ascertained before chemotherapeutic drugs are administered.

The characteristics of pulmonary tuberculosis (TB) in the elderly are different from young patients. This leads to delay in diagnosis and higher mortality from TB in the aged population. The aim of this study was to investigate the impact of age on the demographic, clinical, radiographic characteristics, and treatment outcomes of pulmonary TB patients in Taiwan.

Diabetes mellitus (DM) is a known risk factor for pulmonary tuberculosis (PTB). This study aimed to determine if type 2 DM alters manifestations and treatment outcome of PTB. Records of 217 consecutive culture-proven PTB patients were analysed retrospectively. The manifestations and treatment outcomes of 74 patients with type 2 DM (PTB-DM group) were compared to 143 patients without DM (PTB group). PTB-DM patients showed higher frequencies of fever, haemoptysis, positive acid-fast bacilli sputum smears, and consolidation, cavity, and lower lung field lesions on chest radiographs, and higher mortality rate. Furthermore, type 2 DM, age 65 years, and extensive radiographic disease were factors independently associated with an unfavorable outcome. This study confirmed that clinical manifestations and chest radiographs of PTB patients associated with type 2 DM significantly depart from the typical presentation. Type 2 DM seems to have a negative effect on treatment outcome of PTB.

Burkholderia cepacia is increasingly reported as a nosocomial pathogen as well as causing severe pulmonary infection in patients with cystic fibrosis and fatal bacteraemia in patients with chronic granulomatous disease, newborn infants, and patients with haematological malignancies or solid tumours.1 Nosocomial spread of B. cepacia is frequently caused by contamination of disinfectant solutions or hospital equipment.2 We experienced an outbreak of B. cepacia that lasted for three months and report the findings of our investigation.

Tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) is over-expressed in many human malignancies, including gastric cancer, and is associated with poor outcome. The purpose of this study was to evaluate the clinical and prognostic significance of preoperative serum TIMP-1 levels in gastric cancer patients. One hundred and seventy gastric cancer patients who underwent gastrectomy between 1996 and 2001 were enrolled in this study. The serum concentration of TIMP-1 protein in these patients and in 116 healthy controls was determined using an enzyme-linked immunoassay (ELISA). When a serum TIMP-1 level >95 percentile of healthy controls was set as the upper cut-off value (348.8 ng/ml), abnormally high serum TIMP-1 were observed in 29 (17.1%) of the gastric cancer patients vs 4.3% of healthy controls (p<0.001). The sensitivity and specificity of serum TIMP-1 as a diagnostic tumor marker were 17.1% and 97.7%, respectively. Serum TIMP-1 was positively associated with morphologic appearance (Borrmann type), tumor size, depth of wall invasion, lymph node metastasis, liver metastasis, and peritoneal seeding. It was also positively associated with lymphatic invasion, perineural invasion, and pathological stage. It was not significantly associated with age, gender, tumor location, or histological type. A higher serum TIMP-1 group was significantly associated with lower survival rates than the lower serum TIMP-1 group (cut-off value at the median; 5-yr survival rate: 32.3% vs 55.6%, log-rank p = 0.0011). When the patients were divided into 2 groups using the 95 percentile TIMP-1 level of controls as the cut-off value, 5-yr survival rates were 24.6% and 47.5% respectively for the higher and lower TIMP-1 groups (log rank p = 0.0147). An elevated preoperative level of serum TIMP-1 was significantly associated with progressive disease, advanced stage, and worse survival in gastric cancer patients. Although it is not a good marker for diagnosis, elevated serum TIMP-1 level shows promise as a marker for prognosis in patients with gastric cancer.

PURPOSE: To determine the role of ultrasound (US)-guided core needle biopsy as an initial diagnostic test for palpable breast masses.MATERIALS AND METHODS: Ninety-eight consecutive patients, each with a palpable breast mass, were referred for US-guided core biopsy by a multidisciplinary team of physicians who specialize in the care of breast diseases. All palpable breast masses were clearly visible on high-resolution US. Ninety-nine core needle biopsies were performed under local anesthesia with use of freehand technique, mostly in an outpatient setting. Core needle path through each mass was documented in two orthogonal sections. A mean of 3.4 tissue core samples (range, 1-7) were obtained in each patient.RESULTS: Core needle biopsy resulted in the diagnosis of 66 malignancies, two cases of atypical ductal hyperplasia (ADH), and 30 benign diseases of the breast. Surgery with curative intent was performed in 63 breast malignancies and excisional biopsies were performed for 10 benign diseases (two cases of ADH and eight benign lesions). Twenty-five breast masses were managed nonoperatively: chemotherapy, was performed in three locally advanced breast cancers and 3-year follow-up was conducted for 22 benign lesions. Malignancies were correctly diagnosed in all cases. No malignancy was discovered at surgery or during clinical follow-up of ADH and no benign breast lesions were diagnosed by core needle biopsy. US-guided core needle biopsy is 100% sensitive and specific for palpable breast malignancies, with no false-positive results. A puncture site ecchymosis was the only morbidity! or complication noted.CONCLUSION: US-guided core needle biopsy is a safe and accurate first diagnostic test for palpable breast masses that require tissue proof.

The prognostic significance of DNA ploidy on gastric cancer patients is still controversial. This study is intended to examine the DNA contents of freshly resected cancer tissue and to investigate its clinicopathologic and prognostic correlation in gastric cancer patients. 159 gastric cancer patients who underwent gastric resection between Nov.1995 to Oct.1998 were included in this study. The pathologic stage was I in 26, II in 21, III in 77 and IV in 35. The DNA index (DI) and cell cycles were measured with DNA flow cytometry using normal human lymphocytes as controls. The median DI of gastric cancer tissue was 1.3 (range 0.9 -3.3). Aneuploidy (DI was greater than or equal to 1.2 or less than or equal to 0.9) was noted in 92 patients (57.8%). The median synthetic phase fraction (SPF) was 9% (range, 0 - 51.5). The male gender, histologically differentiated type, positive LN, and more advanced stage was significantly associated with a higher level of DI (p = 0.0073, p = 0.0040, p = 0.031 and p = 0.0055, respectively). No significant correlation was noted between SPF and clinicopathologic parameters. The 3-year disease-free survival rate of diploid patients was significantly better than that of aneuploidy (48.6% vs 18.9%, log-rank p = 0.0073). The SPF had no prognostic significance on disease-free survival (log rank p = 0.348). Multivariate analysis revealed DNA ploidy and distant metastasis was the two independent prognostic factors influencing disease-free survival of the patients studied.

BACKGROUND/AIMS:Patients with advanced or metastatic cancer have compromised nutritional, metabolic, and immune conditions. Little is known about gastroduodenal perforation in cancer patients.METHODOLOGY:Data of 11 cancer patients with gastroduodenal perforation were retrospectively reviewed.RESULTS:There were 2 females and 9 males with a mean (+/- s.e.) age of 56.7+/-4.7 years and a median of 55. The primary malignancies included lung cancers (3 cases), hepatocellular carcinomas (2 cases), squamous cell carcinomas of the tongue (2 cases), malignant lymphoma of the small bowel (1 case), adenocarcinoma of the pancreas (1 case), adenocarcinoma of the stomach (1 case), and acute lymphoblastic leukemia (1 case). The average duration of symptoms was 36.5+/-10.1 hours (median: 24 hours). Methods of surgical treatment included simple closure of the perforation (6 cases), truncal vagotomy and pyloroplasty (3 cases), pyloroplasty (1 case), and subtotal gastrectomy (1 case). Four patients (36.4%) had post-operative complications. The post-operative hospital mortality rate was 18.2%. One patient died of sepsis with gastrointestinal hemorrhage and 1 died of hepatic failure and respiratory failure. Pre-operative shock is the only significant factor in predicting operative mortality.CONCLUSIONS:Gastroduodenal perforation occurring in cancer patients without chemotherapy had favorable short-term operative results.

BACKGROUND AND OBJECTIVES:Many series describing the management of major bile duct injuries after laparoscopic cholecystectomy have been reported with satisfactory short-term results. However, the information of their prognosis with sufficient time-period follow-up is sparse.METHODS:Sixteen consecutive patients with major bile duct injury following laparoscopic cholecystectomy were retrospectively reviewed, including six common bile duct transections, four bile duct perforations, and six hilar strictures but without perforation. With respect to the level of bile duct injuries, there were the following based on Bismuth's classification: type 1 in six patients, type 2 in five patients, type 3 in three patients, type 4 in one patient, and type 5 in one patient. All patients received surgical management, interventional radiology and endoscopic treatment. The time periods of follow-up ranged from 37 to 72 months (mean, 52 months). The final results were rated as being excellent, good, fair, or poor, based on the criteria of symptoms, biochemical data, and radiology.RESULTS:There was no procedure-related mortality. Ten of the 16 patients had either excellent or good results, two had fair results, and four had poor results. Of the latter four, the patients had been classified as Bismuth type 1, 3, 4, and 5, respectively, and all sustained a failed initial surgical repair.CONCLUSIONS:Using a multidisciplinary approach, 12 (75%) of the 16 patients attained a promising result through a long-term follow-up, while those with the higher biliary stricture and with an unsuccessful initial surgical repair had a disappointing outcome.

BACKGROUND/AIMS Primary carcinoma of the gallbladder is rare and associated with a late diagnosis and poor prognosis. Concurrent acute cholecystitis frequently obscures the presence of carcinoma. The information regarding gallbladder carcinoma with acute cholecystitis is limited. In order to better understand the presentation of gallbladder carcinoma with acute cholecystitis, we retrospectively reviewed the data of patients with primary carcinoma of the gallbladder. METHODOLOGY The data of 86 patients with primary carcinoma of the gallbladder treated between 1979 and 1994 were compiled and reviewed. The patients were divided into 2 groups: Group 1 (with acute cholecystitis, 21 patients) and Group 2 (without cholecystitis, 65 patients). Clinicopathological comparisons were made and evaluated between these two groups RESULTS The average age of Group 1 patients was older than that of Group 2 patients (75+/-2 years vs. 63+/-2 years; p<0.05). Three Group 1 patients presented with sepsis. The interval between the onset of symptoms and hospital admission in Group 2 patients was significantly (p<0.05) longer than that in Group 1 patients (243+/-95 days vs. 20+/-11 days). Leukocytosis (>11,000/mm3) was more common in Group 1 patients than in Group 2 patients (47.6% vs. 15.4%). Jaundice was more common in Group 2, and fever was common in Group 1. The majority of Group 2 gallbladder cancers were stage V (75.4%). In contrast, 52.4% of Group 1 gallbladder cancers were stage III and 38.1% were stage V. The 30-day postoperative mortality rate in Group 1 and Group 2 patients was 9.5% and 7.7%, respectively. The cumulative survival of Group 1 patients was not different from that of Group 2 patients (log-rank test, p>0.05). CONCLUSIONS Age, the interval of symptoms prior to admission, the location of abdominal pain, fever, leukocytosis, and the absence of jaundice suggested the presence of acute cholecystitis in gallbladder carcinoma. A high index of suspicion of the disease, intraoperative examination of gallbladder specimens, and more aggressive surgical treatment may improve patient survival.

BACKGROUND/AIMS:Spontaneous gastroduodenal perforation is a rare and lethal complication in cancer patients receiving chemotherapy.METHODOLOGY:Data of 9 patients with spontaneous gastroduodenal perforation occurring during chemotherapy were reviewed.RESULTS:All 9 patients were male with an average age of 54.4+/-2.5 years. The primary malignancies included 5 head and neck cancers, 2 esophageal cancers, 1 malignant lymphoma, and 1 hepatocellular carcinoma. Abdominal pain was the most common symptom. The average interval between the onset of symptoms and surgery was 2.9+/-0.7 days (range: 16 hours to 7 days). Perforation was located on the duodenum (6 patients) and on the lower part of the body of the stomach (3 patients). Simple closure of the perforation was performed on 8 patients, and subtotal gastrectomy on 1 patient. Culture of the ascitic fluid of 8 patients revealed E. coli, Klebsiella pneumoniae, streptococcus viridans, and enterococcus. Four patients (44.4%) had post-operative complications. The 30-day post-operative mortality was 44.4% (4/9). Three patients died of sepsis with multiple organ failure, and 1 died of hepatic failure. Age, anaemia, leukopenia, serum albumin levels, impaired renal or liver functions are not significant operative risk factors. Pre-operative shock is a significant factor in predicting operative mortality and complications.CONCLUSIONS:High index with suspicion of the disease with early treatment may improve survival of cancer patients with spontaneous gastroduodenal perforation.

BACKGROUND:Adjuvant chemotherapy has improved the length of disease-free survival and overall survival in node-negative breast cancer patients. It has been a common practice to select only the patients with higher rates of recurrence for adjuvant therapy. Therefore, it is essential to define the risk factors in node-negative breast cancer patients.MATERIALS AND METHODS:Two hundred fifty-five patients with axillary node-negative breast cancers without adjuvant chemotherapy or hormonal therapy at Chang Gung Memorial Hospital between 1981 and 1986 were included in this study. Tissue blocks for DNA flow cytometry study was available in the tumors of 145 patients.RESULTS:The median follow-up period was 121 months and the percentages of patients with 10 years of disease-free survival (DFS) and overall survival (OS) were 75.1% and 82.2%, respectively. The significant poor prognostic factors for 10 years of OS were a tumor size larger than 3 cm, negative estrogen and progesterone receptor status, and having a non-diploid tumor (p value = 0.0176, 0.048 and 0.016, respectively). The patients with frozen section, high mitotic rate, and Scarff-Blood-Richardson (SBR) grade II and III tumors had a worse prognosis than the others, but this trend did not reach statistical significance. The patients with positive estrogen receptor status had a 10-year disease-free rate (DFR) of 94%, and these with tumors less than 2 cm plus SBR grade I had a 10-year DFR of 92%.CONCLUSION:The node-negative breast cancer patients with a low risk of recurrence were those who had estrogen receptor positive, tumor less than 2 cm with SBR grade I, and intraductal carcinomas. Adjuvant chemotherapy would be no benefit for these patients.

BackgroundHepatic resection is the treatment of choice for unilateral intrahepatic stones. The availability of the flexible choledochoscope has greatly changed the management of intrahepatic stones. Little has been reported regarding hepatic resection for bilateral intrahepatic stones.

BACKGROUND/AIMS Gastrointestinal hemorrhages of obscure origin are often difficult to diagnose and manage. Of these, splanchnic artery aneurysms have emerged as an important disorder because of the increasing prevalence and formidable mortality rate associated with their rupture. We herein evaluated extra-enteric gastrointestinal bleeding related to these ruptured aneurysms. METHODOLOGY The medical records of 17 patients with splanchnic artery aneurysms known to be exclusively manifested as gastrointestinal bleeding were reviewed. The pathogenesis, clinical picture, diagnostic tests, management, complications, and outcomes were compiled and analyzed. RESULTS Of the seventeen patients, 12 patients had true aneurysms; 5 patients had false aneurysms. Pancreatitis, trauma, iatrogenic hepatobiliary injury, and atherosclerosis were the four major etiologies. The sensitivity rates measured by endoscopy, ultrasonography, computed tomography and visceral angiography were 20%, 50%, 67%, and 100%, respectively. An exact diagnosis was attained in 94% of the patients at the time of management. Transcatheter embolization was employed in 7 patients, complicated with hepatic and splenic infarcts, and pyogenic liver abscesses in 2 instances. Two patients had recurrent bleeding aneurysms post embolotherapy. Ten patients underwent surgical intervention which resulted in 2 cases of hepatic failure. One out of 5 patients with a true aneurysm died, while 4 out of 12 patients with false aneurysms eventually died. Overall, the mortality rate was 29%. CONCLUSION Even though the exact diagnosis can be made in most of the patients by modern imaging studies, the mortality rate was still formidable, especially in patients with false aneurysms, in whom the underlying causal diseases substantially influenced the major outcome.

BACKGROUND/AIMS:Results of the surgical management of 60 adults with choledochal cysts at Chang Gung Memorial Hospital Taipei are presented.PATIENTS AND METHODS:All patients were diagnosed and surgically managed during the period between March 1979 and December 1992. There were 47 females and 13 males, with ages ranging from 16 to 81 years (mean age = 31.9 years). Of the total, there were 41 Type I, one Type II, 14 Type IV, and four Type V choledochal cysts classified according to Todani's classification system. The definite surgical procedures were cyst excision and hepatico-jejunostomy in 43 cases in type I and IV diseases, one cyst excision in type II disease, two hepatectomy for type V disease, cyst enterostomy in seven cases, and T-tube choledochocystostomy in seven cases.RESULTS:The operative mortality rate was 3.3% and the complication rate related to the surgical procedure was 20%. Early postoperative complications include wound infection, leakage of anastomosis, acute pancreatitis, septic shock, left pleural effusion, and intra-abdominal abscessing. Reoperations were needed in the early postoperative days in two cases due to hepatico-jejunostomy leakage and intraabdominal abscess formation. Long-term surgical outcome, concerning recurrence of symptoms, was related to the following factors, excluding the factors of surgery: presence of bile duct lithiasis, common channel less than 22 mm, presence of preoperative pancreatitis and acute angle type pancreaticobiliary unions. Only common channel less than 22 mm is statistically significant. The percentage of recurrence of the symptoms after resectional surgery was 32.5% in the long term follow-up period. Most of the cases responded well to an antibiotics treatment. Three of the cases required a second operation or PTCD as well as dilatation to treat the recurrent cholangitis.CONCLUSION:Although the recurrence of symptoms is not uncommon and satisfactory explanation of the analysed factors is still the treatment of choice for adult patients with choledochal cysts.