Drug resistance pattern of Mycobacterium tuberculosis in a university hospital in Taiwan, 1998-2002.

BACKGROUND AND PURPOSE: During 1998-2002, most specialized tuberculosis (TB) hospitals in Taiwan were closed; as a result, more TB patients are being managed in general hospital settings. This study investigated the prevalence, patterns and risk factors of drug-resistant Mycobacterium tuberculosis at a university hospital in the 5 years after decentralization of the TB administrative and clinical control infrastructure which occurred during the implementation of the national health insurance system in Taiwan. METHODS: A total of 1411 initial isolates of M. tuberculosis from specimens collected during January 1998 through December 2002 were tested for drug susceptibility of first-line anti-TB drugs using the agar proportional method. RESULTS: The numbers of newly diagnosed culture-positive TB patients increased from 139 in 1998 to 380 in 2002. The drug resistance pattern of M. tuberculosis among these isolates was as follows: 268 (19.0%) strains were resistant to isoniazid, 86 (6.1%) to rifampin, 221 (15.7%) to ethambutol, 141 (10.0%) to streptomycin, and 430 (30.5%) to 1 of these 4 drugs. Multidrug resistance (MDR), i.e., resistance to at least rifampin and isoniazid, was observed in 72 isolates (5.1%). Of the 1411 patients, isolates from patients with age < 65 years had a higher multiple drug resistance rate than those from patients with age > or = 65 years (57/781, 7.3% vs 15/630, 2.4%; p < 0.001). In the analysis of risk factors for MDR, patients with MDR isolates had a significantly higher incidence of previous TB history, anti-TB therapy, longer duration of symptoms, cavitary lesions in chest X-ray, and mortality. CONCLUSION: A dramatic increase in cases of TB among patients treated at this university hospital was seen after the decentralization of the TB control infrastructure in Taiwan. The prevalence of drug resistance in isolates from culture-positive TB patients was 30.5% and the prevalence of MDR was 5.1%.     

Allo-immunization during pregnancy. Clinical results from 1983 to 1989 in a Scandinavian university hospital.

From 1983 to 1989, 147,068 pregnancies were analyzed for allo-immunization against erythrocyte antigens. Approximately half of the cases were due to immunization against factor D and the others were due to allo-immunization against other antigens (K, c, E, etc.). In 61 cases exchange transfusion of the newborn was needed and in 115 cases diagnostic amniocentesis was done during pregnancy. Intrauterine transfusions were performed in 10 cases. Fetal and neonatal mortality was 4% in these moderate to severe cases, all due to immunization against D. Immunization against D was due to failure to give immunoglobulin anti-D in about 2/3 of the cases. Systematic prophylactic treatment with anti-D during pregnancy would probably not be cost-effective in this population.     

Gender differences in the patterns of coronary angiography and PTCA use in a university hospital in Taiwan.

BACKGROUND AND PURPOSE: Coronary artery angiography (CAG) and percutaneous transluminal coronary angioplasty (PTCA) are important procedures for the diagnosis and treatment of patients with coronary artery disease. However, long-term trends in the frequency of CAG and PTCA use and their relation to gender have not been clearly determined in the Asian population. The purpose of this study was to investigate gender differences in the patterns of CAG and PTCA use in a university hospital in Taiwan during the period of 1983 through 1996. METHODS: We studied the monthly data of all patients who underwent CAG or PTCA in a university hospital in Taipei from 1983 through 1996. A time series analysis was used to estimate gender differences in the patterns of CAG and PTCA use. RESULTS: The frequency of CAG and PTCA increased significantly during this period. Before 1990, only a small number of patients underwent PTCA. However, this number increased steadily after 1990. Men were more likely to undergo CAG and PTCA than women. A time series analysis with fitted models was used to create an integrated moving average model. For CAG, the value of the estimated intercept for men was 2.5 times greater than that for women. In the PTCA series, the value of the intercept in men was 4.4 times greater than that in women. The patterns of trend change showed greater increases in men than in women, and a greater increase in the PTCA than in the CAG series. By transfer function modeling and intervention analysis, we found that the effect of CAG on the frequency of PTCA in men was 1.8 times greater than its effect in women. The estimated influence of the use of a new catheterization room (added in 1993) was 2.8 times greater in men than in women. The fitted model correlated well with the observed values in the next 12 months for both genders. CONCLUSIONS: We concluded that women had fewer CAG and PTCA procedures than men, and the influence of CAG on the PTCA series was significantly higher in men than in women.     

Impulsive behaviors in female patients with eating disorders in a university hospital in northern Taiwan

Eating disorders (EDs) are often associated with various impulsive behaviors. This study investigated the prevalence of impulsive behaviors in ED patients in Taiwan. Three hundred sixteen female outpatients with ED and 142 psychiatric controls were recruited. All participants completed self-administered questionnaires assessing lifetime presence of impulsive behaviors, including suicide, self-injury, stealing, alcohol use, illicit drug use, excessive spending, sexual promiscuity, and general psychopathology. More than 60% of the ED patients had at least one impulsive behavior. The most common impulsive behaviors among ED patients were excessive spending (34.9%), deliberate self-harm (32.7%), and stealing (26.3%). However, there were no significant differences in prevalences of any impulsive behaviors between ED patients and psychiatric controls. Clinicians should routinely assess and treat impulsive behaviors in female psychiatric patients with negative affectivity, regardless of the presence of ED, to help prevent potential adverse outcomes related to impulsive behaviors.     

Disease patterns and socioeconomic status associated with utilization of computed tomography in Taiwan, 1997-2003.

BACKGROUND/PURPOSE: The utilization of computed tomography (CT) has rapidly grown year after year. Yet, literature that explores the factors related to CT utilization is limited. We attempted to determine the profiles of populations with high rates of CT usage, and to understand the association of disease patterns and socioeconomic status with CT-involved treatments. METHODS: National Health Insurance medical claim data from the cohort of 200,000 samples representing 23 million insured people during 1997-2003 were used for analysis. Multiple logistic regression analysis was performed to identify factors associated with CT usage. RESULTS: Annual growth rate in CT usage during 1997-2003 was 7.35% and average use of CT was 28.69 per 1000 people. The diseases associated with the highest CT usage rates were neoplasm (169 per 1000 people), diseases of the circulatory system (33 per 1000 people), and congenital malformations (20 per 1000 people). Disease patterns with high annual growth rate of CT usage were morbidities originating in the perinatal period (29.85%), mental disorders (15.47%), and other disease patterns without clear symptoms and diagnosis (13.33%). Individuals with lower salary used CT more frequently than those with higher salary. Multiple logistic regression analysis showed that cancer patients had significantly higher likelihood (odds ratio [OR], 7.71) of CT use than those with other diseases. Males (OR, 1.64) and elderly (OR, 1.96-7.05) had higher likelihoods of CT use and those with higher salaries had lower likelihood (OR, 0.50-0.89) of CT use. CONCLUSION: Neoplasm, diseases of the circulatory system, congenital malformations, and poor socioeconomic status were significantly associated with a higher rate of CT utilization. The distribution of disease patterns varied with gender, age groups, salary levels, and health care regions household income levels. Further study is needed to better understand the nature of the findings.     

Performance of a commercial polymerase chain reaction test for endocervical Chlamydia trachomatis infection in a university hospital population.

OBJECTIVES: To examine the accuracy of a commercial polymerase chain reaction (PCR) test (Amplicor CTR, Roche Diagnostic Systems, Branchburg NJ) for identification of endocervical chlamydial infections through both laboratory evaluation and among a diverse teaching hospital patient population. METHODS: Testing of reliable threshold inocula and reproducibility were carried out using laboratory stock organisms. Paired endocervical samples from patients with a wide range of indications were tested by PCR and an established culture procedure, and discrepant pairs were further analyzed to determine true results. RESULTS: Laboratory evaluation suggested that one copy of target DNA from a viable organism consistently yielded a positive result, and test reproducibility was very good, with an overall coefficient of variation of 15%. Compared to true results in 1,588 paired clinical samples from 1,489 women with a 10% prevalence of infection, the PCR test and culture yielded respective sensitivities of 87.4% and 78.0%, and negative predictive values of 98.6% and 97.6%. Specificity and positive predictive value for both tests were 100%. Cost per specimen was nearly identical at $18.84 and $18.88 respectively. Polymerase inhibitors and organisms lacking target DNA were not found in false-negative PCR samples. CONCLUSION: This commercial PCR test is accurate, cost-competitive, and much faster than culture for diagnosis of endocervical chlamydia infections in our population of intermediate prevalence of chlamydial infection.     

Factors associated with tocolytic hospitalizations in Taiwan: evidence from a population-based and longitudinal study from 1997 to 2004

Background

The primary objective of this study was to determine if elevated antiphospholipid antibody titers were correlated with the presence of preeclampsia/eclampsia, systemic lupus erythematosus (SLE), placental insufficiency, and a prolonged length of stay (PLOS), in women who delivered throughout Florida, USA.

Methods

Cross-sectional analyses were conducted using a statewide hospital database. Prevalence odds ratios (OR) were calculated to quantify the association between elevated antiphospholipid antibody titers and four outcomes in 141,286 women who delivered in Florida in 2001. The possibility that the relationship between elevated antiphospholipid antibody titers and the outcomes of preeclampsia/eclampsia, placental insufficiency, and PLOS, may have been modified by the presence of SLE was evaluated in a multiple logistic regression model by creating a composite interaction term.

Results

Women with elevated antiphospholipid antibody titers (n = 88) were older, more likely to be of white race and not on Medicaid than women who did not have elevated antiphospholipid antibody titers. Women who had elevated antiphospholipid antibody titers had an increased adjusted odds ratio for preeclampsia and eclampsia, (OR = 2.93 p = 0.0015), SLE (OR = 61.24 p < 0.0001), placental insufficiency (OR = 4.58 p = 0.0003), and PLOS (OR = 3.93 p < 0.0001). Patients who had both an elevated antiphospholipid antibody titer and SLE were significantly more likely than the comparison group (women without an elevated titer who did not have SLE) to have the outcomes of preeclampsia, placental insufficiency and PLOS.

Conclusion

This exploratory epidemiologic investigation found moderate to very strong associations between elevated antiphospholipid antibody titers and four important outcomes in a large sample of women.     

Emergency peripartum hysterectomy in a teaching hospital in Eastern Taiwan.

This study aims to review the incidence, indications, risk factors and complications associated with emergency peripartum hysterectomy in a teaching hospital. We reviewed records of patients undertaking emergency peripartum hysterectomy performed at our institution from 1998 to 2004. Emergency peripartum hysterectomy was defined as one performed for haemorrhage unresponsive to other treatments <24 h after delivery. Eight cases of emergency peripartum hysterectomy were performed. The rate of peripartum hysterectomy was 0.25%. The main indications for hysterectomy were uterine atony and abnormal placentation. No maternal death occurred. Use of peripartum hysterectomy may become necessary in managing obstetrical haemorrhage refractory to other measures.     

Characterization of a 411-bp fragment of the rpoB gene in clinical isolates of Mycobacterium tuberculosis in a university hospital in northern Taiwan.

BACKGROUND AND PURPOSE: This study analyzed rpoB gene mutation and its correlation with demographic and clinical data, and the drug resistance profile in 41 consecutive patients with rifampin (RIF)-resistant Mycobacterium tuberculosis isolated at National Taiwan University Hospital from 2000 to 2002. METHODS: The 411-bp fragment of the rpoB gene from 94 M. tuberculosis isolates (including 41 RIF-resistant and 53 RIF-susceptible isolates) was amplified and sequenced. RESULTS: Of the 41 RIF-resistant isolates, 87.8% (36/41) showed mutations in rpoB. The following mutations were identified: Ser531 (68.3%), His526 (9.8%), Ser522 (4.9%) and Gln513 (4.9%). No silent substitutions were observed. No mutation within the entire 411-bp fragment was found in 12.2% (5/41) of the RIF-resistant isolates and 100% (53/53) of the RIF-susceptible isolates. Patients whose RIF-resistant isolates did not have rpoB mutation had higher frequencies of the following characteristics: elderly, no previous history of tuberculosis, human immunodeficiency virus-negative, no extrapulmonary tuberculosis involvement and favorable prognosis. Drug resistance patterns in RIF-resistant M. tuberculosis strains were significantly correlated with isoniazid resistance, i.e., multidrug-resistant strains (90.2%). CONCLUSIONS: RIF-resistant M. tuberculosis isolates with rpoB mutation were clustered in the 69-bp core region in this study. Rapid detection of RIF resistance could be achieved by testing for rpoB mutation in Taiwan.     

Deliveries at a district hospital in Rwanda, 1997-2000.

OBJECTIVES: To obtain data on pregnancy outcomes and maternal mortality at a district hospital in Rwanda. METHODS: All delivery records from January 1997 to December 2000 were reviewed. RESULTS: Over the 4-year period, 3408 women delivered a total of 3497 neonates, and 349 stillbirths (10%) occurred. The mean birthweight (twins excluded) was 3097 g and decreased significantly from 3160 g in 1997 to 3043 g in 2000. The prevalence of low birthweight was 12.5%. The mean age of women was 26.2 years. Cesarean section was done in 26% of deliveries at the hospital, equaling a cesarean section rate of 1.1% in the population. Nineteen maternal deaths occurred, yielding a (hospital) maternal mortality rate of 600 per 100000 live births. Uterine rupture occurred in 52 women, of whom six died (11.5%). CONCLUSIONS: Efforts to educate women at risk to deliver at a health center, and early referral of women to the hospital should be reinforced. The reduction of mean birthweight is of concern and reasons for this need to be analyzed.     

Lymphadenitis caused by non-tuberculous mycobacteria in a university hospital in Taiwan: predominance of rapidly growing mycobacteria and high recurrence rate.

BACKGROUND AND PURPOSE: Lymphadenitis is the most common manifestation of infection due to non-tuberculous mycobacteria (NTM) in otherwise healthy children. This disease is rare in adults and its geographic variations in etiology and clinical manifestations remain unclear. The aim of this study was to describe the etiology, clinical presentation, treatment, and outcome of NTM lymphadenitis. METHODS: Medical records of patients with culture-proven NTM lymphadenitis treated at a university hospital in Taiwan from January 1997 through December 2004 were retrospectively reviewed. RESULTS: In total, 12 patients with NTM lymphadenitis were identified, including 6 males and 7 adults (> or = 16 years). The majority (83%) of patients presented with an enlarged palpable mass and 9 (75%) had preceding constitutional symptoms. The most common site of lymphadenitis was the cervical area (83%) and 8 patients (75%) had multiple lymph node involvement. Rapidly growing mycobacteria (RGM) accounted for 75% of the etiology of NTM lymphadenitis, followed by Mycobacterium avium complex (MAC) [2 patients]. A high recurrence rate (42%) after primary treatment was noted among those patients who received clarithromycin-containing regimens for a median of 6 months. CONCLUSIONS: This study found that both previously healthy children and adults were susceptible to NTM lymphadenitis. RGM was the most common etiology rather than MAC among NTM species causing lymphadenitis. Inadequate surgical excision of the diseased lymph nodes and insufficient coverage of antimycobacterial therapy both contributed to the high recurrence rate.     

Observations from a maternal and infant hospital in Kabul, Afghanistan--2003

Afghanistan is believed to have one of the highest infant and maternal mortality rates in the world. As a result of decades of war and civil unrest, Afghan women and children suffer from poor access to health services, harsh living conditions, and insufficient food and micronutrient security. To address the disproportionately high infant and maternal mortality rates in Afghanistan, the US Department of Health and Human Services pledged support to establish a maternal health facility and training center. Rabia Balkhi Hospital in Kabul, Afghanistan, was selected because this hospital admits approximately 36,000 patients and delivers more than 14,000 babies annually. This article reports the initial observations at Rabia Balkhi Hospital and describes factors that influenced women's access, the quality of care, and the evaluation health care services. This observational investigation examined areas of obstetric, laboratory and pharmacy, and ancillary services. The investigators concluded that profound changes were needed in the hospital's health care delivery system to make the hospital a safe and effective health care facility for Afghan women and children and an appropriate facility in which to establish an Afghan provider training program for updating obstetric skills and knowledge.     

Appendectomy in pregnancy: the experience of a university hospital.

The files of pregnant patients who underwent appendectomy at our hospital over the period 1977-96 were studied retrospectively. Forty-six patients were operated upon amongst 52 108 deliveries over this period. Of those 27 had uncomplicated acute appendicitis and six had one of the complications of acute appendicitis (a prevalence of 0.063%). Thirteen had normal appendices (71.7% accuracy). Obstetric complications occurred in four patients, with three fetal losses (6.5%). Those with complicated appendicitis had significantly delayed presentation, in-hospital delay and prolonged postoperative stay. Recently we used diagnostic laparoscopy in two patients for diagnosis and to perform appendectomy in one. In conclusion, the incidence of acute appendicitis in pregnancy seems to be the same over the period of gestation and the diagnostic accuracy seems to be related both to the late presentation by the patient and to physician delay. Maternal morbidity and fetal loss are mostly limited to those with complicated appendicitis.     

Recombinant activated factor VII as a promising adjuvant therapy for postpartum hemorrhage in the practice of obstetric anesthesia: experience from a university hospital in Taiwan

Massive postpartum hemorrhage is one of the major complications in the peripartum period. In some critical cases, hemostasis is hard to achieve even after a hysterectomy has been performed. Recombinant activated factor VII has been reported as a promising adjuvant therapy for obstetric hemorrhage, although it remains unlicensed for this indication. Eight cases receiving recombinant activated factor VII in postpartum hemorrhage refractory to the conventional therapy in a Taiwanese hospital were analyzed retrospectively. A good response, defined as bleeding control in 15 min, was achieved in six patients (75%) with a single dose ranging from 55 to 105 μg/kg. The two patients with a poor response were later discovered to have had unsolved birth canal injuries. No drug-related adverse effects were noted. We recommend that any surgical bleeding should first be controlled, as well as the correction of metabolic and hematological abnormalities; however, in the situation of intractable postpartum hemorrhage, recombinant activated factor VII offers a salvage therapy and should be considered early, even before hysterectomy.     

Early postpartum discharge at a university hospital. Outcome analysis

OBJECTIVE: To determine whether implementation of an early hospital discharge policy was effective in safely reducing hospital stay and acceptable to patients. STUDY DESIGN: The study was a prospective, observational trial. Early discharge was defined as discharge from the hospital either on the first day after vaginal delivery or on the second day after delivery by cesarean section. A "stayover mom" policy was subsequently implemented to allow a mother the option to remain in the hospital overnight after discharge. This prospective study was divided into three consecutive three-month periods: (1) routine care (n = 576), (2) early discharge (n = 622), and (3) early discharge with stay-over mom (n = 574). Primary outcome measurements were length of hospital stay and patient willingness. RESULTS: With proper review of written instructions, all eligible patients were willing to be discharged early. As compared with the routine care group, the length of hospital stay was shorter by 0.8 days (95% CI, 0.4-1.2 days) in the early discharge group (P < .01) and by 1.1 days (95% CI, 0.5-1.7 days) in the early discharge with stayover mom group (P < .005). The stayover mom policy was more desirable because of limitations in obtaining timely transportation and concern about the infant warranting continued observation. The need for maternal readmission was rare (15 cases, 0.8% of total), with endometritis equally common (n = 3 in each group). CONCLUSION: Early postpartum discharge, especially including a stayover mom policy, was acceptable to our predominantly Medicaid population. The reduced hospital stay was not associated with increased maternal morbidity.     

Perinatal outcome in adolescent pregnancies: a case-control study from a Turkish university hospital

OBJECTIVE: To determine whether adolescent pregnancy is associated with increased risk for adverse pregnancy outcome. STUDY DESIGN: Retrospective case-control study which enrolled 1460 singleton adolescent pregnancies and 2980 controls, delivered at Hacettepe University Hospital between January 1990 and January 1998. RESULTS: Significantly higher rate of perinatal and severe perinatal complications were noted in adolescents. The presence of historical risks, multiparity, young age and lack of prenatal care were significant predictors of these complications. Exclusion of them except for age, revealed comparable perinatal and severe perinatal complications in both groups. CONCLUSION: Adolescent women who receive adequate prenatal care are at no greater risk of an adverse obstetric outcome than adult women of a similar sociodemographic background.