Pulmonary Mycoses in Immunocompromised Hosts (면역기능저하 환자에서 폐진균증에 대한 임상적 고찰)
-
- Tuberculosis and Respiratory Diseases
- /
- v.45 no.6
- /
- pp.1199-1213
- /
- 1998
Background : The number of immunocompromised hosts has been increasing steadily and a new pulmonary infiltrate in these patients is a potentially lethal condition which needs rapid diagnosis and treatment. In this study we sought to examine the clinical manifestations, radiologic findings, and therapeutic outcomes of pulmonary mycoses presenting as a new pulmonary infiltrate in immunocompromised hosts. Method : All cases presenting as a new pulmonary infiltrate in immunocompromised hosts and confirmed to be pulmonary mycoses by pathologic examination or by positive culture from a sterile site between October of 1996 and April of 1998 were included in the study and their chart and radiologic findings were retrospectively reviewed. Results : In all, 14 cases of pulmonary mycoses from 13 patients(male : female ratio = 8 : 5, median age 47 yr) were found. Twelve cases were diagnosed as aspergillosis while two were diagnosed as mucormycosis. Major risk factors for fungal infections were chemotherapy for hematologic malignancy(10 cases) and organ transplant recipients(4 cases). Three cases were receiving empirical amphotericin B at the time of appearance of new lung infiltrates. Cases in the hematologic malignancy group had more prominent symptoms : fever(9/10), cough(6/10), sputum(5/10), dyspnea(4/10), chest pain(5/10). Patients in the organ transplant group had minimal symptoms(p<0.05). On simple chest films, all of the cases presented as single or multiple nodules(6/14) or consolidations(8/14). High resolution computed tomograph showed peri-lesional ground glass opacities(14/14), pleural effusions(5/14), and cavitary changes(7/14). Definitive diagnostic methods were as follows : 10 cases underwent minithoracotomy, 2 underwent video-assisted thoracoscopic surgery, 1 underwent percutaneous needle aspiration and 1 case was diagnosed by culture of abscess fluid. All cases received treatment with amphotericin B with 1 case each being treated with liposomal amphotericin B and itraconazole due to renal toxicity. Lung lesion improved in 12 of 14 patient but 4 patients died before completing therapy. Conclusion : When a new lung infiltrate develops presenting either as a nodule or consolidation in a neutropenic patient with hematologic malignancy or in a transplant recipient, you should always consider pulmonary mycoses as one of the differential diagnosis. By performing aggressive work up and early treatment, we may improve prognosis of these patients.
Kimura's Disease is a chronic inflammatory and proliferative condition producing subcutaneous masses especially in the head and neck area. This report of our experience with 5 patients with this disease is the first in the Korean surgical literature. Kimura's Disease is thought to be part of the larger spectrum of the entity known as angiolymphoid hyperplasia with eosinophilia (ALHE). It is characterized pathologically by hyperplastic lymphoid follicles, eosinophilic infiltration, and vase 비 ar proliferation. It produces masses which are most common in the area of the parotid, submandibular gland and upper neck. These masses occupy the subcutaneous tissues but also extend into salivary tissue and into upper neck nodes. One of our patients had masses in the groin. The tumors are extremely vascular due to the presence of new proliferative vessels and sinusoids. The average age of our 5 patients was 35, but all but one case were younger than 38 years of age. The male: female ratio was 3 : 2, and the average duration of symptoms was 5,2years. All patients had peripheral blood eosinophilia. All had multiple masses, sometimes symmetrical. The management was surgery alone in one case, surgery and steroids in one case, surgery and radiotherapy in two cases, and all three modalities in one case. The relationship of this entity to ALHE and our experience in the management of this disease are presented. A clinicopathological discrepancy alerted us to the existence of Kimura's Disease. A nineteen-year old male presented with subcutaneous masses over both mastoid areas present for 3 years (Case III). When biopsy on each side was reported as 'eosinophilic granuloma' we submitted the slides to an internationally expert pathologist. Symmetrically occurring tumors in the peri-parotid subcutaneous areas did not fit any category of neoplasm or granuloma known to us. The diagnosis, made by Dr. Gist Fan at the Ochsner Clinic, was Kimura's Disease. We found two additional cases in a review of soft tissue eosinophilic granuloma previously reported at Presbyterian Medical Center, and since then have diagnosed two new cases. These five cases constitute the basis for this, the largest series to be reported in Korea. These vascular, tumor-like lesions of the skin, subcutaneous areas and subjacent structures of the head and neck have been a variety of names, such as angiolymphoid hyperplasia with eosinophilia, eosinophilic hyperplastic lymphogranuloma, angioblastic lymphoid hyperplasia with eosinophilia, histioid hemangioma, and epithelioid hemangioma. The history of this disease spectrum dates back to 1937 when Kimm and Szeto (1) reported 7 cases of 'eosinophilic hyperplastic lymphogranuloma' in the Proceedings of the Chinese Medical Journal. In 1948 Kimura and his associates(2) reported additional cases in Japan under the title 'On the unusual granulation combined with hyperplastic changes of lymphatic tissue.' From then until 1966 several hundred cases were reported in China and Japan. The first report from the West was by Wells and Whimster(3) in the British Journal of Dermatology, in 1969. These authors coined the term, angiolymphoid hyperplasia with eosinophilia (ALHE). Since that time a debate has ensued as to whether Kimura's Disease and ALHE are distinct entities, or whether Kimura's is part of the larger spectrum of ALHE, perhaps a later or advanced phase. From the clinical perspective, surgeons should be aware of the diagnosis of Kimura's Disease not only as part of the differential diagnosis of head and neck tumors but also because these lesions are indolent, and generally require conservative surgical removal as part of the management program. CASE I. A 37-year-old female company employee presented in August 1982 with submental swelling of 12 years' duration and with inguinal swelling of 7 years' duration. The submental mass measured 5x5cm. and the inguinal mass was 8x4cm. in size. Peripheral eosinophilia varying from 14% to 40% was found. On August 20, 1982, the submental mass was removed and a superficial groin dissection was done. In May 1983 an intraoral lesion of the palate was removed. The patient is free of disease. CASE II. A 23-year-old unemployed man visited this hospital for the first time in July, 1984, with swelling of the right cheek present for 6 years. The mass was soft and ill-defined but measured 10x20cm. and extended from the submandibular upper neck to the zygomatic arch, and from the mastoid to the cheek, over the parotid gland. Eosinophilia varying from 27% to 29% was noted in the peripheral blood. On March 21, 1986, the lesion was resected. The procedure comprised an extended superficial parotidectomy from the temporalis fascia to the upper neck. Post-operatively radiotherapy 3000 rad tissue dose was administered using the 6 MeV linear accelerator. The patient remains free of disease. CASE III. A 19-year-old student came to the clinic with masses over both mastoid areas, present 3 years. On the right there were two adjacent lesions, one over the mastoid, the other in the upper jugular level of the neck. On the left it was a single mass over the mastoid. Eosinophilia varied from 13 to 32% in the peripheral blood, and 11.6% in the bone marrow. Incisional biopsy revealed 'eosinophilic granuloma' and a trial of predisolone was employed. The mass increased in size so a small dose of radiation (600 rads) was used, with substantial regression,. The lesion on the left was excised and follwed by 1000 rads radiotherapy. Finally recurrent tumor on the right side was removed on November 5, 1985. The patient remains free of disease. CASE N. A 29-year-old local merchant had had swelling of both upper necks since childhood. At the time of his first visit on March 17, 1986, the right submandibular mass measured 5x3.5cm. and the ,right upper neck and parotid tail mass measured 2.5cm. On the left there were masses in the upper neck, the largest of which measured 2.5cm, and of the parotid tail, 2.0cm. in size.(See Fig. 1) Peripheral eosinophilia of 39% was recorded. Left side partial parotidectomy and resection of the upper neck and subdigstric mases was done on May 2, 1986. The mass involving the right parotid tail and upper neck nodes was removed on Angust 7,1986. Postoperatively the patient was placed on prednisolone 30 mg. per day. No definite masses are palpable. CASE V. A 66-year-old housewife informed us, at the time of her first visit in May, 1986, that she had had multiple neck masses since 10 years ago. On the right side there was a 2.5cm. subcutaneous mass of the upper neck, over the upper jugular chain. On the left there was a 9x4.5cm. mass involving the entire parotid, the post-auricular area and the upper neck. A third mass presented in the submental area and measured 3.5cm. (See Fig. 2) Eosinophilia of 51% was noted in the peripheral blood. partial excision of the left upper neck lesion and complete excision of the submental mass were performed on june 6, 1986. post-operatively she was placed on 20 mg. of prednisolone daily, but when the mass re-grew after two months she was referred to Radiation Therapy for a 2500 rad course of treatment. A barely palpable thickening remains.
As business incubation centers (BICs) have been operating for more than 10 years in Korea, many early stage startups tend to use the services provided by the incubating centers. BICs in Korea have accumulated the knowledge and experience in the past ten years and their services have been considerably improved. The business incubating service has three facets : (1) business infrastructure service, (2) direct service, and (3) indirect service. The mission of BICs is to provide the early stage entrepreneurs with the incubating service in a limited period time to help them grow strong enough to survive the fierce competition after graduating from the incubation. However, the incubating services sometimes fail to foster the independence of new startup companies, and raise the dependence of many companies on BICs. Thus, the dependence on BICs is a very important factor to understand the survival of the incubated startup companies after graduation from BICs. The purpose of this study is to identify the main factors that influence the firm's dependence on BICs and to characterize the relationships among the identified factors. The business incubating service is a core construct of this study. It includes various activities and resources, such as offering the physical facilities, legal service, and connecting them with outside organizations. These services are extensive and take various forms. They are provided by BICs directly or indirectly. Past studies have identified various incubating services and classify them in different ways. Based on the past studies, we classify the business incubating service into three categories as mentioned above : (1) business infrastructure support, (2) direct support, and (3) networking support. The business infrastructure support is to provide the essential resources to start the business, such as physical facilities. The direct support is to offer the business resources available in the BICs, such as human, technical, and administrational resources. Finally, the indirect service was to support the resource in the outside of business incubation center. Dependence is generally defined as the degree to which a client firm needs the resources provided by the service provider in order to achieve its goals. Dependence is generated when a firm recognizes the benefits of interacting with its counterpart. Hence, the more positive outcomes a firm derives from its relationship with the partner, the more dependent on the partner the firm must inevitably become. In business incubating, as a resident firm is incubated in longer period, we can predict that her dependence on BICs would be stronger. In order to foster the independence of the incubated firms, BICs have to be able to manipulate the provision of their services to control the firms' dependence on BICs. Based on the above discussion, the research model for relationships between dependence and its affecting factors was developed. We surveyed the companies residing in BICs to test our research model. The instrument of our study was modified, in part, on the basis of previous relevant studies. For the purposes of testing reliability and validity, preliminary testing was conducted with firms that were residing in BICs and incubated by the BICs in the region of Gwangju and Jeonnam. The questionnaire was modified in accordance with the pre-test feedback. We mailed to all of the firms that had been incubated by the BICs with the help of business incubating managers of each BIC. The survey was conducted over a three week period. Gifts (of approximately ₩10,000 value) were offered to all actively participating respondents. The incubating period was reported by the business incubating managers, and it was transformed using natural logarithms. A total of 180 firms participated in the survey. However, we excluded 4 cases due to a lack of consistency using reversed items in the answers of the companies, and 176 cases were used for the analysis. We acknowledge that 176 samples may not be sufficient to conduct regression analyses with 5 research variables in our study. Each variable was measured through multiple items. We conducted an exploratory factor analysis to assess their unidimensionality. In an effort to test the construct validity of the instruments, a principal component factor analysis was conducted with Varimax rotation. The items correspond well to each singular factor, demonstrating a high degree of convergent validity. As the factor loadings for a variable (or factor) are higher than the factor loadings for the other variables, the instrument's discriminant validity is shown to be clear. Each factor was extracted as expected, which explained 70.97, 66.321, and 52.97 percent, respectively, of the total variance each with eigen values greater than 1.000. The internal consistency reliability of the variables was evaluated by computing Cronbach's alphas. The Cronbach's alpha values of the variables, which ranged from 0.717 to 0.950, were all securely over 0.700, which is satisfactory. The reliability and validity of the research variables are all, therefore, considered acceptable. The effects of dependence were assessed using a regression analysis. The Pearson correlations were calculated for the variables, measured by interval or ratio scales. Potential multicollinearity among the antecedents was evaluated prior to the multiple regression analysis, as some of the variables were significantly correlated with others (e.g., direct service and indirect service). Although several variables show the evidence of significant correlations, their tolerance values range between 0.334 and 0.613, thereby demonstrating that multicollinearity is not a likely threat to the parameter estimates. Checking some basic assumptions for the regression analyses, we decided to conduct multiple regression analyses and moderated regression analyses to test the given hypotheses. The results of the regression analyses indicate that the regression model is significant at p < 0.001 (F = 44.260), and that the predictors of the research model explain 42.6 percent of the total variance. Hypotheses 1, 2, and 3 address the relationships between the dependence of the incubated firms and the business incubating services. Business infrastructure service, direct service, and indirect service are all significantly related with dependence (β = 0.300, p < 0.001; β = 0.230, p < 0.001; β = 0.226, p < 0.001), thus supporting Hypotheses 1, 2, and 3. When the incubating period is the moderator and dependence is the dependent variable, the addition of the interaction terms with the antecedents to the regression equation yielded a significant increase in R2 (F change = 2.789, p < 0.05). In particular, direct service and indirect service exert different effects on dependence. Hence, the results support Hypotheses 5 and 6. This study provides several strategies and specific calls to action for BICs, based on our empirical findings. Business infrastructure service has more effect on the firm's dependence than the other two services. The introduction of an additional high charge rate for a graduated but allowed to stay in the BIC is a basic and legitimate condition for the BIC to control the firm's dependence. We detected the differential effects of direct and indirect services on the firm's dependence. The firms with long incubating period are more sensitive to indirect service positively, and more sensitive to direct service negatively, when assessing their levels of dependence. This implies that BICs must develop a strategy on the basis of a firm's incubating period. Last but not least, it would be valuable to discover other important variables that influence the firm's dependence in the future studies. Moreover, future studies to explain the independence of startup companies in BICs would also be valuable.
The wall shear stress in the vicinity of end-to end anastomoses under steady flow conditions was measured using a flush-mounted hot-film anemometer(FMHFA) probe. The experimental measurements were in good agreement with numerical results except in flow with low Reynolds numbers. The wall shear stress increased proximal to the anastomosis in flow from the Penrose tubing (simulating an artery) to the PTFE: graft. In flow from the PTFE graft to the Penrose tubing, low wall shear stress was observed distal to the anastomosis. Abnormal distributions of wall shear stress in the vicinity of the anastomosis, resulting from the compliance mismatch between the graft and the host artery, might be an important factor of ANFH formation and the graft failure. The present study suggests a correlation between regions of the low wall shear stress and the development of anastomotic neointimal fibrous hyperplasia(ANPH) in end-to-end anastomoses. 30523 T00401030523 ^x Air pressure decay(APD) rate and ultrafiltration rate(UFR) tests were performed on new and saline rinsed dialyzers as well as those roused in patients several times. C-DAK 4000 (Cordis Dow) and CF IS-11 (Baxter Travenol) reused dialyzers obtained from the dialysis clinic were used in the present study. The new dialyzers exhibited a relatively flat APD, whereas saline rinsed and reused dialyzers showed considerable amount of decay. C-DAH dialyzers had a larger APD(11.70
The wall shear stress in the vicinity of end-to end anastomoses under steady flow conditions was measured using a flush-mounted hot-film anemometer(FMHFA) probe. The experimental measurements were in good agreement with numerical results except in flow with low Reynolds numbers. The wall shear stress increased proximal to the anastomosis in flow from the Penrose tubing (simulating an artery) to the PTFE: graft. In flow from the PTFE graft to the Penrose tubing, low wall shear stress was observed distal to the anastomosis. Abnormal distributions of wall shear stress in the vicinity of the anastomosis, resulting from the compliance mismatch between the graft and the host artery, might be an important factor of ANFH formation and the graft failure. The present study suggests a correlation between regions of the low wall shear stress and the development of anastomotic neointimal fibrous hyperplasia(ANPH) in end-to-end anastomoses. 30523 T00401030523 ^x Air pressure decay(APD) rate and ultrafiltration rate(UFR) tests were performed on new and saline rinsed dialyzers as well as those roused in patients several times. C-DAK 4000 (Cordis Dow) and CF IS-11 (Baxter Travenol) reused dialyzers obtained from the dialysis clinic were used in the present study. The new dialyzers exhibited a relatively flat APD, whereas saline rinsed and reused dialyzers showed considerable amount of decay. C-DAH dialyzers had a larger APD(11.70