A 5-year study of the seroepidemiology of Klebsiella pneumoniae: high prevalence of capsular serotype K1 in Taiwan and implication for vaccine efficacy

Seroepidemiology of Klebsiella pneumoniae was determined for 1000 nonrepetitive K. pneumoniae isolates collected by a medical center in Taiwan during 1993-1997. Of these, 630 isolates (63%) were from community-acquired infections; the rest were from hospital-acquired infections. The isolates were serotyped according to capsular antigen by countercurrent immunoelectrophoresis. About 77% were typeable. Serotypes K1 and K2 accounted for 21.7% and 9.3% of the isolates, respectively, followed by K57 (5.1%), K54 (4.2%), K21 (3. 3%), and K16 (3%). The frequency of serotype K1 among bacteremic isolates (30.8%) far exceeded that reported by other investigators worldwide. Molecular typing of random K1 isolates by pulsed-field gel electrophoresis revealed several different pulsotypes, suggesting a nonclonal spread. This study indicates that a Klebsiella vaccine developed in Europe is not optimal for use in Taiwan because it does not contain the most predominant serotypes-K1, K54, and K57.     

Serial antinuclear antibodies titre in pleural and pericardial fluid.

The antinuclear antibodies (ANA) test has been a cornerstone of the evaluation of connective tissue disease. The aim of this study was to investigate the diagnostic value of the ANA test in pleural or pericardial effusions of unknown causes. Over a 3-yr period, a total of 126 pleural fluid and 30 pericardial fluid samples were analysed. ANA tests were performed using a commercially available kit. The ANA kit used an indirect immunofluorescent antibody method with a human epithelial (HEP-2) cell line as substrate. Patients with high fluid ANA titre (>1:160) received a second aspiration 2 weeks after the initial aspiration if diagnosis was not confirmed. ANA results were positive in 39 pleural and 10 pericardial fluid samples. All but one of the effusions with positive ANA testing were exudative. Eleven pleural or pericardial effusions due to active systematic lupus erythematosus were identified and all had high ANA titres (1:160) with various staining patterns. Thirty-eight of 145 patients (26%) with effusions of nonlupus aetiologies had positive ANA testing in pleural or pericardial fluid. Thirteen of these 38 patients had high ANA titre. Malignant or paramalignant effusions constituted 11 of the 13 samples. In conclusion, although a negative antinuclear antibodies test makes a diagnosis of lupus serositis unlikely, high antinuclear antibodies titres in pleural or pericardial fluid are not diagnostic of lupus serositis even when as high as 1:5,120. An unexplained high antinuclear antibodies titre in pleural or pericardial effusion warrants search for malignancy.     

Changes of heart rate variability during ventilator weaning

STUDY OBJECTIVES: Despite the recognition that ventilator weaning is associated with a change in autonomic nervous system activity, there has not been any report concerning the change of heart rate variability (HRV), a reliable method to detect autonomic nervous system activity, in patients during weaning. The aim of this study was to investigate the change of autonomic nervous system activity during ventilator weaning by HRV analysis. DESIGN: Prospective study. SETTING: A 16-bed medical ICU of a tertiary university hospital. PATIENTS: Twenty-four patients receiving mechanical ventilation were included. Twelve patients with successful extubation after a spontaneous breathing trial (SBT) [T-piece trial] were classified as the success group; otherwise, the patients were placed in the failure group. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Variables, including the total power (TP), and the high-frequency (HF) and low-frequency (LF) components of HRV, were measured in three phases: assist/control mandatory ventilation, pressure support ventilation (PSV), and SBT. While shifting from PSV to SBT, the HRV components decreased significantly in the failure group (TP, p = 0.025; LF, p = 0.007; HF, p = 0.031), but not in the success group. CONCLUSIONS: By HRV analysis, reduced HRV and vagal withdrawal of the autonomic nervous system activity are the main changes in patients with weaning failure.     

Correlation between bone mineral density and plasma lipids in Taiwan

Many studies showed that depression is correlated with osteoporosis, while others showed that low cholesterol level is also related to depression. However, these relationships still remain controversial. Since the bone mineral density (BMD) is related to depression and depression is related to hypocholesterolemia, there might exist a correlation between BMD and plasma cholesterol levels. To prove this, we enrolled 5000 individuals, 2170 males, and 2830 females, who had health check-ups at a private clinic between 1998 and 1999. They were divided into three groups. Group 1 was composed of male subjects; Group 2, female subjects; and Group 3, females aged over 50 to exclude pre-menopausal females. Each subject had a routine physical examination, fasting blood drawing, BMD measured by dual energy x-ray absorptiometry (DEXA) over the wrist, and was given a questionnaire to answer. Between Groups 1 and 2, the females were significantly younger, had higher body mass index (BMI), total cholesterol (TC), high density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDLC), and platelet, but lower BMD, fasting plasma glucose (FPG), triglycerides (TG), hemoglobin (Hgb), and white blood cell (WBC) count. As for Groups 1 and 3, all the aforementioned findings still remained the same except that the systolic blood pressure (SBP) was higher and diastolic blood pressure (DBP) was lower in Group 3. Our results showed that BMD is negatively related to age in males. In females, it is negatively correlated with age, FPG, PPG, SBP, DBP, TC, LDLC, TG, and Hgb, but positively related to BMI and platelet. However, for females in Group 3, BMD is only negatively related to age, FPG, SBP, and TG but positively related to BMI. Stepwise multiple regression analysis showed that the BMD is negatively related to age but positively related to BMI in both males and females. In Group 3, BMD is negatively related to age and FPG but positively related BMI. In conclusion, no correlation exists between BMD and cholesterol. This implies that the depression is not significantly related to cholesterol and/or BMD. This might be due to various confounding factors, which could affect their relationships. The negative correlation between BMD and FPG is only observed in females older than 50 years. Further studies are needed to clarify these relationships.     

Dengue fever with acute acalculous cholecystitis

Dengue fever (DF) with acute acalculous cholecystitis is rarely reported. To investigate the incidence, treatment, and prognosis of acute acalculous cholecystitis in DF patients, we retrospectively studied 10 patients with DF and acute acalculous cholecystitis. From October 2001 to July 2002, 131 patients were diagnosed with DF. Ten of 131 DF patients (7.63%) had complications of acute acalculous cholecystitis. Two patients underwent cholecystectomy and one underwent percutaneous transhepatic gallbladder drainage due to poor resolution of acute acalculous cholecystitis. We found acute acalculous cholecystitis in a small proportion of patients with DF. In our experience, closely monitoring vital signs to avoid shock and correct thrombocytopenia to avoid bleeding could be adequate for most patients. In some cases, surgical treatment may be needed for DF fever patients with complications of diffuse peritonitis.     

Characteristics of Chinese patients with symptomatic Brugada syndrome in Taiwan

Since 1992, the Brugada syndrome has been increasingly recognized worldwide, although its incidence and distribution remain unclear. In Asia, several cases have been reported in Japan, Thailand, Singapore, and Vietnam. However, little information is available from the Chinese population. Since June 1997, we have identified 10 patients with the diagnosis of the Brugada syndrome from six hospitals in Taiwan. All patients were male with the mean age of 46 +/- 7 years (range 36-61). They all had a normal chemistry profile, coronary angiography and echocardiography. Clinical presentations varied from seizure and syncope to sudden cardiac death. MRI and ultrafast CT of the heart did not show any abnormalities. Sustained ventricular tachycardia/ventricular fibrillation (VF) was induced in 7 of 8 patients who underwent an electrophysiologic study. The pharmacological provocation test was positive in 4 of 5 patients. One of the 4 patients who had a genetic study showed SCN5A gene mutation. An implantable cardioverter defibrillator (ICD) was implanted in 8 patients. During a mean follow-up of 29 +/- 17 months (range 2-54), 3 of 8 patients who had an ICD received appropriate ICD discharges after implantation. These 3 patients who were subsequently treated with antiarrhythmic agents have had no further recurrent ICD discharges. Two patients who refused ICD implantation are alive and well without taking antiarrhythmic agents. Our study showed that the clinical characteristics of our patients are similar to those described in the literature and that ICD is an effective treatment modality for patients with recurrent VF. However, antiarrhythmic agents may be beneficial for suppressing arrhythmia recurrences in selected patients.     

Acute and long‐term clinical and angiographic outcomes of coronary stenting using Palmaz‐Schatz stent and ACS Multi‐Link stent

Acute and long‐term (≥ 3 years) outcomes of coronary artery stenting using Palmaz‐Schatz and Multi‐Link stent implantations between November 1995 and October 1999 were analyzed. There were 655 Palmaz‐Schatz stent implantations in 577 lesions on 477 patients (group A) and 428 Multi‐Link stent implantations in 381 lesions on 326 patients (group B). The baseline characteristics were similar in the two groups. Group B had more complex lesions, longer stenotic lesions, and larger reference vessel sizes than group A. However, both groups had a similar in‐hospital cardiac events. Four hundred and two patients with 488 lesions in group A and 260 patients with 307 lesions in group B underwent a 6‐month follow‐up coronary angiography. The restenotic rate per lesion was 16% in both groups (P = 0.872). A 3‐year angiographic follow‐up was performed in 262 patients of group A (301 lesions) and 139 patients of group B (162 lesions), and restenosis was noted in only 3 patients (1.36%) in group A and 5 patients (4%) in group B, in which the lesion was patent at the 6‐month angiographic follow‐up. Significant increase in minimal luminal diameter was noted from 2.23 ± 0.66 mm at 6 months to 2.33 ± 0.64 mm in group A (P < 0.01), and insignificant increase from 2.23 ± 0.77 to 2.28 ± 0.82 mm was noted in group B (P = 0.27). No differences were noted between the two groups in mortality, reinfarction, recurrent angina, target lesion angioplasty, or elective coronary artery bypass surgery during a follow‐up period of 60 ± 3 months. Forty‐five patients (9.4%) in group A and 18 patients (5.5%) in group B received additional stenting procedures for newly developed lesions. The overall cardiac event‐free survival was 66% in group A and 72% in group B (P = 0.844). In conclusion, the procedural success rate, in‐hospital morbidity, 6‐month angiographic results, and long‐term (≥ 3 years) clinical and angiographic outcomes were similar with coronary stenting using either Palmaz‐Schatz or Multi‐Link stent. The stented lesions were stable; however, late regression of minimal luminal diameter was noted in both groups, and progression of atherosclerotic change in the nonstented site was noted during long‐term follow‐up. Catheter Cardiovasc Interv 2004;62:453–460. © 2004 Wiley‐Liss, Inc.     

Relative impact of low-density lipoprotein-cholesterol concentration and insulin resistance on carotid wall thickening in nondiabetic, normotensive volunteers

The relative effect of an increase in low-density lipoprotein-cholesterol (LDL-C) concentration, as compared with insulin resistance and its manifestations, on intimal medial thickening (IMT) of the common carotid artery was defined in 72 healthy men and women. Insulin-mediated glucose disposal was quantified by the insulin suppression tests, in which the height of the steady-state plasma glucose (SSPG) concentration during the last 30 minutes of a 180-minute infusion of octreotide, insulin, and glucose provides an estimate of insulin resistance. IMT was determined by high-resolution B-mode ultrasonography. Univariate analyses defined statistically significant correlation coefficients between IMT and LDL-C concentration (r =.25, P <.05), SSPG concentration (r =.32, P <.01), triglycerides (TG) (r =.25, P <.05), and high-density lipoprotein-cholesterol (HDL-C) (r = -.28, P <.05) concentrations (changes associated with insulin resistance) and ratio of waist-to-hip girth (r =.29, P <.05). When forward step-wise linear regression analysis was used, concentrations of SSPG, LDL-C and HDL-C all emerged as independent predictors of IMT (P <.05). Furthermore, the magnitude of their relationship to IMT values was comparable. These results provide evidence that insulin resistance is as significant a predictor of degree of atherogenesis (estimated by IMT) of the common carotid artery as a high LDL-C concentration.     

Systemic Chlamydia trachomatis infection in mice: a comparison of lymphogranuloma venereum and trachoma biovars.

We developed a murine model of systemic infection with Chlamydia trachomatis biovar lymphogranuloma venereum (LGV). The pathological features of this infection resemble those of human LGV infection since both are characterized by granuloma formation. Mice developed resistance to reinfection with LGV, and this resistance was based on cellular immune mechanisms since it was transferable with immune spleen cells but not with immune serum. Resistance required viable organisms for induction. We compared LGV biovar infection with trachoma biovar infection. Trachoma biovar produced similar but less marked microbiological and pathological features. Cross-immunity was less apparent between serovars from trachoma and LGV biovars than it was between serovars within the same biovar. This model of systemic C. trachomatis infection will be useful in exploring virulence features of LGV.     

The association of marital status and hospice use in the USA

BACKGROUND: Married individuals are more likely to use hospice than unmarried individuals. We examine this association and how it is influenced by gender. METHODS: Medicare beneficiaries dying of cancer were studied. RESULTS: Currently married (OR 1.36 95% C.I. 1.28-1.45) or ever married (OR 1.23 95% C.I. 1.16-1.31) subjects were more likely to use hospice than never married subjects. A significant interaction between marital status and gender (P < .001) was observed. CONCLUSIONS: Subjects likely to enroll in hospice are subjects likely to have greater supportive relationships.