Mechanism of Lipid Accumulation through PAR2 Signaling in Diabetic Male Mice

Background@#Protease-activated protein-2 (PAR2) has been reported to regulate hepatic insulin resistance condition in type 2 diabetes mice. However, the mechanism of lipid metabolism through PAR2 in obesity mice have not yet been examined. In liver, Forkhead box O1 (FoxO1) activity induces peroxisome proliferator-activated receptor γ (PPARγ), leading to accumulation of lipids and hyperlipidemia. Hyperlipidemia significantly influence hepatic steatoses, but the mechanisms underlying PAR2 signaling are complex and have not yet been elucidated. @*Methods@#To examine the modulatory action of FoxO1 and its altered interaction with PPARγ, we utilized db/db mice and PAR2-knockout (KO) mice administered with high-fat diet (HFD). @*Results@#Here, we demonstrated that PAR2 was overexpressed and regulated downstream gene expressions in db/db but not in db+ mice. The interaction between PAR2/β-arrestin and Akt was also greater in db/db mice. The Akt inhibition increased FoxO1 activity and subsequently PPARγ gene in the livers that led to hepatic lipid accumulation. Our data showed that FoxO1 was negatively controlled by Akt signaling and consequently, the activity of a major lipogenesis-associated transcription factors such as PPARγ increased, leading to hepatic lipid accumulation through the PAR2 pathway under hyperglycemic conditions in mice. Furthermore, the association between PPARγ and FoxO1 was increased in hepatic steatosis condition in db/db mice. However, HFD-fed PAR2-KO mice showed suppressed FoxO1-induced hepatic lipid accumulation compared with HFD-fed control groups. @*Conclusion@#Collectively, our results provide evidence that the interaction of FoxO1 with PPARγ promotes hepatic steatosis in mice. This might be due to defects in PAR2/β-arrestin-mediated Akt signaling in diabetic and HFD-fed mice.

Analysis of Physiological Indicators Related to Dietary Regimen during the First Year in Patients on Hemodialysis / 임상간호연구

PURPOSE: The purpose of this study was to determine the time and content of dietary education by analyzing the physiological indicators of hemodialysis patients during their first year and to present baseline data related to dietary education for patients on hemodialysis. METHODS: For this retrospective study physiological indicators for 73 patients on hemodialysis were analyzed. Data included levels of potassium, phosphorus, albumin and the IDWG rate, and Kt/V during the first year after starting hemodialysis. Repeated-measure ANOVA was used for statistical analysis. RESULTS: Serum levels of phosphorus (p < .006), albumin (p < .001) and the IDWG rate (p < .001) increased significantly in the 7 months fromthe start of hemodialysis. CONCLUSION: The results indicate that the period in which diet related educational intervention is necessary is before physiological changes, that is, after 6 months of dialysis. The contents for effective education should include phosphorus-limited and weight control dietary restrictions at 6 months.

Sesquiterpenoids from the heartwood of Juniperu s chinensis

A new sesquiterpenoid, 11-hydroxy-valenc-1(10),3(4)-dien-2-one (3), two chemically synthesized but first isolate from nature, 3-oxocedran-8β-ol (1) and valenc-1(10),3(4),11(12)-trien-2-one (2) along with four known compounds, sugiol (4), (+)-nootkatone (5), 11-hydroxy-valenc-1(10)-en-2-one (6), and clovandiol (7), were isolated from the heartwood of Juniperus chinensis. All chemical structures were elucidated using extensive spectroscopic analysis including 1D and 2D NMR spectroscopy. Valenc-1(10),3(4),11(12)-trien-2-one (2) exhibited significant inhibitory activity against butyrylcholinesterase with an IC₅₀ value of 68.45 µM.

Inhibition of advanced glycation endproducts formation by Korean thistle, Cirsium maackii

Objective: To evaluate inhibitory potential of seven Korean thistles against the advanced glycation endproducts (AGE) formation as well as to identify responsible compounds from the most active species. Methods: We used an in vitro AGE inhibition assay to evaluate the anti-diabetic complication potential of the methanol extracts of the selected Korean thistles. Results: Among the seven Korean thistles, the leaves of Cirsium maackii (C. maackii) exhibited the most significant inhibitory activity against AGE formation. By means of bioassay-directed fractionation, a lignan, chlorogenic acid and 14 flavonoids were isolated from the active ethyl acetate soluble fraction of a methanol extract from C. maackii leaves. Luteolin and its 5-O-glucoside have been previously isolated; however, a lignan and 13 known compounds were isolated for the first time from C. maackii leaves in this study. Most of the isolated compounds exhibited inhibitory activities against potential AGE formation. Among them, cernuoside was shown to be the most potent AGE inhibitor with an IC50 value of 21.21 μ mol/L. Most importantly, two major flavonoids, luteolin and its 5-O-glucoside, also significantly inhibited AGE formation, with IC50 values of 36.33 and 37.47 μ mol/L, respectively. Structure activity relationship revealed that the presence of free 3' and 4' dihydroxyl group in flavonoids skeleton played an important role in AGE inhibition. Conclusions: These results indicate that C. maackii and C. maackii-derived flavonoids might be explored further to develop therapeutic agents for the prevention of diabetic complications due to their significant inhibitory activity against AGE formation.

Inhibition of advanced glycation endproducts formation by Korean thistle, Cirsium maackii

OBJECTIVE@#To evaluate inhibitory potential of seven Korean thistles against the advanced glycation endproducts (AGE) formation as well as to identify responsible compounds from the most active species.@*METHODS@#We used an in vitro AGE inhibition assay to evaluate the anti-diabetic complication potential of the methanol extracts of the selected Korean thistles.@*RESULTS@#Among the seven Korean thistles, the leaves of Cirsium maackii (C. maackii) exhibited the most significant inhibitory activity against AGE formation. By means of bioassay-directed fractionation, a lignan, chlorogenic acid and 14 flavonoids were isolated from the active ethyl acetate soluble fraction of a methanol extract from C. maackii leaves. Luteolin and its 5-O-glucoside have been previously isolated; however, a lignan and 13 known compounds were isolated for the first time from C. maackii leaves in this study. Most of the isolated compounds exhibited inhibitory activities against potential AGE formation. Among them, cernuoside was shown to be the most potent AGE inhibitor with an IC50 value of 21.21 μ mol/L. Most importantly, two major flavonoids, luteolin and its 5-O-glucoside, also significantly inhibited AGE formation, with IC50 values of 36.33 and 37.47 μ mol/L, respectively. Structure activity relationship revealed that the presence of free 3' and 4' dihydroxyl group in flavonoids skeleton played an important role in AGE inhibition.@*CONCLUSIONS@#These results indicate that C. maackii and C. maackii-derived flavonoids might be explored further to develop therapeutic agents for the prevention of diabetic complications due to their significant inhibitory activity against AGE formation.

Kambin's Triangle Approach of Lumbar Transforaminal Epidural Injection with Spinal Stenosis

OBJECTIVE: To compare the short-term effect and advantage of transforaminal epidural steroid injection (TFESI) performed using the Kambin's triangle and subpedicular approaches. METHOD: Forty-two patients with radicular pain from lumbar spinal stenosis were enrolled. Subjects were randomly assigned to one of two groups. All procedures were performed using C-arm KMC 950. The frequency of complications during the procedure and the effect of TFESI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual numeric scale (VNS) and a five-grade scale. Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors (Kambin's triangle or subpedicular approach, age, duration of symptoms and sex) and the therapeutic effect. RESULTS: VNS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups. There were no statistical differences in changes of VNS, effectiveness and contrast spread pattern between these two groups. No correlation was found between the other variables tested and therapeutic effect. Spinal nerve pricking occurred in five cases of the subpedicular and in none of the cases of the Kambin's triangle approach (p<0.05). CONCLUSION: The Kambin's triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages (i.e., less spinal nerve pricking during procedure). The Kambin's triangle approach maybe an alternative method for transforaminal epidural steroid injection in cases where needle tip positioning in the anterior epidural space is difficult.

The Analysis of Epithelial Ingrowth after LASIK Using a Femtosecond Laser

PURPOSE: To analyze the incidence and clinical course of epithelial ingrowth after laser in situ keratomileusis (LASIK) using a femtosecond laser. METHODS: We retrospectively evaluated the results of 1158 eyes of 581 patients who received LASIK with the flap created by a femtosecond laser from February 2006 to March 2009 at our institute. We investigated the incidence and clinical course of LASIK in which the flap was created by a femtosecond laser. RESULTS: Epithelial ingrowth was first detected one week after surgery in 12 (57%) of 21 eyes and within one month in 19 eyes (90%). Epithelial ingrowth was localized most commonly near the temporal and nasal flap edge in 12 eyes (57%). In two eyes (9.5%), an isolated ingrowth mass was located in the pupillary area. The development of more than 2.0 mm of epithelial ingrowth was observed in three eyes (0.25%). Among 28 eyes with loose epithelium or epithelial detachment during surgery, epithelial ingrowth was observed in six eyes (21.4%) compared with 15 (1.32%) of 1130 eyes without loose epithelium or epithelial detachment. Therefore, epithelial detachment during surgery was significantly associated with epithelial ingrowth (p = 0.00). CONCLUSIONS: In LASIK in which the flap is created by a femtosecond laser, damage to the epithelial layer increases the chances of epithelial ingrowth. Therefore, avoiding epithelial defects with a gentle maneuver is needed to reduce the chance of epithelial ingrowth during surgery.

Factors influencing birth weight premature infants / 소아과

PURPOSE: The purpose of this study was to identify factors influencing premature infants who are small for their gestational ago. METHODS: The medical records of 1,010 premature infants of 26 to 35 weeks of gestational age born at Il-Sin Christian Hospital, Busan from January 2000 to August 2006 were reviewed. We collected data on gestational age, birth weight, infant gender, birth order, maternal age and previous abortion history and analyzed the factors influencing premature infants who were small for their gestational ago at birth. RESULTS: In our study more female than male (P=0.042) in premature infants who were small for their gestational ago were born from mothers aged younger than 20 or older than 35 (P=0.041). But association between smallness for gestational age and birth order or maternal previous abortion history was statistically insignificant (P=0.228, P=0.129). CONCLUSION: Considering the association of birth weight and the survival rate of premature infants, it is thought that maternal age had an influence on the survival rate of premature infants. Social and political support to lower the teenager pregnancy and older pregnancy is expected to increase the survival rate of premature infants and the birth of healthy normal neonates.

Different characteristic between Escherichea coli and non-Escherichea coli urinary tract infection / 소아과

PURPOSE: Urinary tract infection (UTI) is a common bacterial infectious disease in childhood. Especially UTI in infant and young children is associated with urinary tract anomalies such as hydronephrosis, vesicoureteral reflux. The aim of this study was to compare the clinical and laboratory characteristics, and uroradiologic findings of UTI caused by pathogens other than E. coli with UTI caused by E. coli in infant and young children. METHODS: We retrospectively reviewed medical records of 170 infants and children, who had been admitted for UTI to Il Sin Christian Hospital from January 2003 to December 2005. All patients were divided into two groups; E. coli and non-E. coli UTI, and they were compared for demographic data, clinical data (degree and duration of fever, time to defervescence, and length of hospital stay), underlying urinary tract anomalies (by history and ultrasonography), recurrent infection (by history and past medical records), and laboratory data [urinalysis, white blood cells (WBC) count in peripheral blood, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum creatinine level]. RESULTS: Of the 170 UTI patients, the number of non-E. coli UTI was 114 (67.1%) and E. coli UTI was 56 (32.9%). As compared to E. coli group, non-E. coli group was younger in age (0.52+/-0.59 years vs 0.84+/-1.39years, P<0.05), had higher rates of urinary tract anomalies [n=46 (82.1%) vs n=53 (46.5%), P<0.001], higher recurrence rate, shorter time to defervescence, less peripheral blood WBC count, lower level of CRP, lower level of ESR. CONCLUSION: The characteristics of non-E. coli UTI compared to E. coli UTI was younger age, milder clinical symptoms and signs, higher rates of urinary tract anomalies and higher recurrence rate.

Comparison of Clinical Result of LASIK using between Femtosecond Laser and Microkeratome for Correction of Myopia

PURPOSE: To compare results between in femtosecond laser and microkeratome LASIK correction of myopia METHODS: We retrospectively analyzed the result of 94 eyes of 47 patients in the femtosecond group (F) and 103 eyes of 52 patients in the microkeratome group (M). All patients had undergone LASIK using either a femtosecond laser or a microkeratome for making of flap. Patients were divided into groups I (6D or =6D) according to preoperative myopia. Each patient was followed up for over 6 months with measurements of uncorrected visual acuity and manifest refraction at 1 week and 1, 3, and 6 months after operation. Complications during and after the operation were reviewed retrospectively in two groups 6month after the operation. RESULTS: In groups F-I, F-II, M-I, and M-II, postoperative 6-month uncorrected visual acuity was 0.98+/-0.08, 0.96+/-0.09, 0.97+/-0.03, 0.98+/-0.09. At the 6-month follow-up, there were no significant differences between the two groups in uncorrected visual acuity and mean spherical equivalent. Corneal opacity was found in 3 eyes in group M and complication related with flap was found 1 eye in group F and 4 eyes in group M. CONCLUSIONS: During a 6-month follow up, LASIK using either a femtosecond laser or a microkeratome has an similar effect in uncorrected visual acuity and mean spherical equivalent. Thus LASIK for using femtosecond laser can be used as an alternative procedure to correct myopia.

Analysis of anthropometric data for premature infants of 26 to 35 weeks of gestation; comparison with the data of 1960's / 소아과

PURPOSE: The anthropometric data of newborns published by Lubchenco et al in the 1960's have been most commonly used in Korea as a standard of newborn growth. We hypothesized that Lubchenco's data have limitations for Korean premature infants born in the 2000's. We analyzed and compared the data of birth weight, length, and head circumference. METHODS: The medical records of 1,159 premature infants of 26 to 35 weeks of gestational age born at Il-Sin Christian Hospital of Busan from January 2,000 to August 2,006 were reviewed. The anthropometric data from total 1,010 premature infants were analyzed after excluding the data from infants whose gestational age were estimated by other than ultrasonogram, and infants with major congenital anomalies or chromosomal anomaly, born from foreign parent, and extreme outliers. RESULTS: In the birth weights by gestational age, our 90 percentile values were lower than Lubchenco's 90 percentile values for all gestational age studied, particularly for less than 30 weeks the 90 percentile curve was drawn at the area as that of Lubchenco' 75 percentile. And our 10 percentile values were higher than Lubchenco's 10 percentile values for all gestational age studied. In the birth length and head circumference by gestational age, our 90 percentile values were lower than Lubchenco's 90 percentile values for all gestational age studied, and the 90 percentile curve was drawn at the area as that of Lubchenco's 75 percentile. And our 10 percentile values were higher than Lubchenco's 10 percentile values for all gestational age studied. CONCLUSION: It is unreasonable to apply Lubchenco's data published before 4th decades to present Korean premature infants and have a risk to underestimate intrauterine growth retardation or small for gestational age and large for gestational age. Considering for the possibility of increasing the mortality and morbidity of premature infants due to delayed diagnosis and treatment by these underestimating, our anthropometric data of premature infant is expected to contribute to lower the mortality and morbidity of premature infants.

Normal Macular Thickness Measured Macular Mapping of OCT3

PURPOSE: The authors used the instrument, OCT3, to evaluate the reproducibility and map the macular thickness rapidly in normal subjects METHODS: Macular thickness was measured in 120 eyes of 62 normal subjects, aged 18 to 79 years, with the macular OCT3 map. There was no history of ocular disease in any of the subjects, and routine ophthalmoscopic examination results were normal. RESULTS: The coefficient value for macular thickness was lower than 2%, indicating that OCT3 provides reliable measurements. Macular thickness of normal subjects was 193.4 +/- 14.6 micro meter in the central ring, 273.0 +/- 14.8 micro meter in the inner ring and 238.2 +/- 15.6 micro meter in the outer ring. The nasal and superior quadrants of the inner ring and the nasal quadrant of the outer ring had higher thickness measurements than another. A decrease of retinal thickness was observed in the old group. However, gender did not have a significant effect on the values. CONCLUSIONS: Macular thickness analysis with OCT3 provided a detailed map of the macular thickness. This indicates that the method may provide a sensitive detection of pathologic thickening or thinning of the retina and suggests that the macular thickness decreases with age.

Binocular Retinal Detachment after Incomplete Diving

PURPOSE: To report a case of traumatic retinal detachment associated with ocular injury in incomplete diving. METHODS: A 15-year-old female complaining of floaters before the eyes was referred to our hospital. In both fundus, we found retinal holes in inferonasal quadrant. We investigated physical properties of retinal detachment associated with diving. RESULTS: When the human body falls down from 10 m height, the impact power is the same as the pressure exerted by 595 kg weight to the body for one second. And this power may cause retinal detachment. CONCLUSIONS: Today there are many sport activities and retinal injuries can occur by various mechanism. We report our clinical experience with retinal detachment associated with diving.

A Longitudinal Molecular Epidemiologic Study of Methicillin-resistant Staphylococcus aureus (MRSA) Isolates from a University Hospital / 감염

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the important nosocomial pathogens and establishs the endemicity within many large hospitals in Korea. The identification and eradication of infection source is essential to prevent and control the spread of MRSA infection. So it is necessary to know how many MRSA clones have existed and how these clones have changed. The aim of this study is to determine the molecular epidemiology of MRSA over a 8-years period from 1991 to 1998 by using pulsed-field gel electrophoresis (PFGE) typing method in a university hospital. METHODS: MRSA isolates from various clinical specimens were collected during 8 years from 1991 to 1998 in Korea University Guro Hospital. The identification of S. aureus was done by catalase and coagulase test. Methicillin resistance was tested by oxacillin disk diffusion method. Pulsed field gel electrophoresis (PFGE) using SmaI was performed for molecular typing. We determined the clonality of MRSA strains by dendrogam analysis. RESULTS: One hundred four MRSA isolates were collected from clinical specimens. PFGE typing showed 8 types and 13 subtypes totally. Type A and type B were the major clonal strains, which comprized of 41.3% (43 strains) and 37.5% (39 strains), respectively, and other types were isolated in small numbers. In 1991, type A and type B were encountered in 36.8% (7/19) each, respectively. In 1994, type A was 65.2% (15/23) and type B was 21.7% (5/23). In 1998, type A was 75.0%(18/24) and type B was 4.2%(1/24). Total types and subtypes according to years were 4 types and 6 subtypes in 1991, 5 types and 6 subtypes in 1992, 4 types and 4 subtypes in 1993, 4 types and 6 subtypes in 1994 and 4 types and 7 subtypes in 1998, respectively. CONCLUSION: The diversity of MRSA strains were observed over 8 years. Type A and type B have been isolated as dominant clones in a university hospital during 8 years. It is presumed that they have isolated from clinical specimens continuously and established the endemicity in this hospital. So it is necessary to prevent the spread of dominant clones intensively, to study the difference of virulence between the dominant and minor clones, and to determine the introduction and spread of MRSA from the community and other hospitals. The PFGE technique was a useful epidemiologic tool for tracking and typing the MRSA isolates.

A Case of Eosinphilia-Myalgia Syndrome / 대한류마티스학회지

Eosinophilia-myalgia syndrome (EMS) is a multisystemic disorder characterized by severe myalgia and peripheral eosinophilia, and frequently accompanied by fasciitis, neuropathy and various cutaneous manifestations associated with consumption of L-tryptophan. Although EMS has not been uncommon in the United States, it has not been reported in Korea. We experienced a 28-year-old man who presented with severe myalgia, peripheral eosinophilia, right upper extremity motor weakness developed during ingestion of L-tryptophan containing food. He was diagnosed as EMS based on the diagnostic criteria by the Centers for Disease Control. His symptoms and laboratory findings including severe myalgia and eosinophilia rapidly improved after steroid treatment. To our knowledge, this is the first case report of EMS developed in L-tryprophan users in Korea. We report a case of EMS with a review of literature.

A Surveillance on Nosocomial Acquisition of Clostridium difficile and Comparative Analysis of 3 Molecular Typing Methods including Pulsed-Field Gel Electrophoresis, Arbitrarily Primed Polymerase Chain Reaction, and Ribotyping / 감염

BACKGROUND: Clostridium difficile is a major cause of nosocomial infectious diarrhea. Nosocomial clusters of C. difficile disease have been ascribed to the transfer of the organism form patient to patient. The aim of this study was to survey the nosocomial acquisition of C. difficile infection and to evaluate the efficacy and efficiency of epidemiologic typing systems by molecular analysis of the isolates. METHODS: A surveillance study for C. difficile acquisition was performed in patients admitted to neurology ward (NW) and medical intensive care unit (MICU) in an 800-bed tertiary-care hospital from August 1998 to October 1998. Stool specimens were taken weekly for culture of C. difficile. All isolates were examined for toxin B gene by PCR assay. Three molecular typing methods, including pulsed-field gel electrophoresis (PFGE), ribotyping, and arbitrarily primed polymerase chain reaction (AP-PCR) were used to differentiate individual strains of C. difficile isolates. Their performance characteristics were compared according to the consensus guidelines by the European Society for Clinical Microbiology and Infectious Disease. RESULTS: A total of 38 C. difficile strains were isolated from 308 stool cultures. The period prevalence was 7.4/1000 patient-days and 21.2/1000 patient-days in the NW and MICU, respectively (P=0.034). The acquisition incidence of C. difficile infection was 1.85/ 1,000 patient-days and 5.33/1,000 patient-days in NW and MICU, respectively. The toxin B gene was detected in 38% (8/21) of C. difficile isolates; 62.5% from diarrheal patients and 23% from asymptomatic patients. In a comparison of the three typing systems, the typeability was 0.444 by PFGE, 0.972 by AP-PCR and 1 by ribotyping, and the discrimination index was 0.975 by PFGE, 0.810 by AP-PCR and 0.777 by ribotyping. All three typing systems were highly reproducible. AP-PCR was the least costly and most rapid method. CONCLUSION: The relatively high prevalence of C. difficile infection in the hospital might indicate a potential nosocomial spread, even though the acquisition incidence was low. AP-PCR appears to be an efficacious and efficient method for the epidemiologic study of C. difficile infection, and its suboptimal discriminative power may be enhanced by complementary PFGE.

A Surveillance on Nosocomial Acquisition of Clostridium difficile and Comparative Analysis of 3 Molecular Typing Methods including Pulsed-Field Gel Electrophoresis, Arbitrarily Primed Polymerase Chain Reaction, and Ribotyping / 감염

BACKGROUND: Clostridium difficile is a major cause of nosocomial infectious diarrhea. Nosocomial clusters of C. difficile disease have been ascribed to the transfer of the organism form patient to patient. The aim of this study was to survey the nosocomial acquisition of C. difficile infection and to evaluate the efficacy and efficiency of epidemiologic typing systems by molecular analysis of the isolates. METHODS: A surveillance study for C. difficile acquisition was performed in patients admitted to neurology ward (NW) and medical intensive care unit (MICU) in an 800-bed tertiary-care hospital from August 1998 to October 1998. Stool specimens were taken weekly for culture of C. difficile. All isolates were examined for toxin B gene by PCR assay. Three molecular typing methods, including pulsed-field gel electrophoresis (PFGE), ribotyping, and arbitrarily primed polymerase chain reaction (AP-PCR) were used to differentiate individual strains of C. difficile isolates. Their performance characteristics were compared according to the consensus guidelines by the European Society for Clinical Microbiology and Infectious Disease. RESULTS: A total of 38 C. difficile strains were isolated from 308 stool cultures. The period prevalence was 7.4/1000 patient-days and 21.2/1000 patient-days in the NW and MICU, respectively (P=0.034). The acquisition incidence of C. difficile infection was 1.85/ 1,000 patient-days and 5.33/1,000 patient-days in NW and MICU, respectively. The toxin B gene was detected in 38% (8/21) of C. difficile isolates; 62.5% from diarrheal patients and 23% from asymptomatic patients. In a comparison of the three typing systems, the typeability was 0.444 by PFGE, 0.972 by AP-PCR and 1 by ribotyping, and the discrimination index was 0.975 by PFGE, 0.810 by AP-PCR and 0.777 by ribotyping. All three typing systems were highly reproducible. AP-PCR was the least costly and most rapid method. CONCLUSION: The relatively high prevalence of C. difficile infection in the hospital might indicate a potential nosocomial spread, even though the acquisition incidence was low. AP-PCR appears to be an efficacious and efficient method for the epidemiologic study of C. difficile infection, and its suboptimal discriminative power may be enhanced by complementary PFGE.

Etiology of Community-Acquired Pneumonia Surveyed by 7 University Hospitals / 감염

BACKGROUND: Community-acquired pneumonia (CAP) is one of the leading causes of mortality and morbidity, but its management is still challenging. The limitations of diagnostic methods to identify etiologic agents rapidly make it necessary to use empiric antibiotics in almost all patients, and furthermore the discovery of new respiratory pathogens and the emergence of antibiotic-resistant organisms pose difficulties to the selection of an empiric antibiotic regimen. To clarify the factors necessary for the optimal choice of empirical antibiotics, such as the frequency of etiologic agents, the attributable rates to death and antimicrobial resistance rates in the community, six university hospitals in Seoul and one university hospital in Cheonan were participating in this study. METHODS: Medical records of adults (> 15 years of age) hospitalized for CAP or pulmonary tuberculosis between March 1995 and February 1996, were reviewed. Patients who satisfied all of the following criteria were included in the study: (1) fever or hypothermia; (2) respiratory symptoms; and (3) pulmonary infiltrates on chest roentgenogram. To exclude cases of pulmonary tuberculosis whose roentgenographic features were so typical that it could be easily differentiated from conventional pneumonia, two additional criteria were required for inclusion: antibiotic treatment during the first week of hospital admission and initiation of anti-tuberculosis medications thereafter. Organisms isolated from sterile body sites, acid-fast bacilli or Mycobacterium tuberculosis isolated from sputum, pathogens diagnosed by a 4-fold rising titer to "atypical" pathogens, or pathogens revealed by histopathology were defined as definitive cause of pneumonia; isolates from sputum with compatible Gram stain, pathogens diagnosed by a single diagnostic titer plus use of a specific antimicrobial agent, or tuberculosis diagnosed by clinical response to anti-tuberculosis medications were considered probable cause of pneumonia. The records of the clinical microbiology were reviewed for isolates of S. pneumoniae, H. influenzae, M. catarrhalis, Mycobacterium or acid-fast bacilli, and mycoplasma. Then the frequency of these agents, antimicrobial resistance rates of respiratory pathogens from all body sites, and their clinical significance were evaluated. RESULTS: After excluding 365 patients (230 with pulmonary tuberculosis and 135 with CAP) who were screened for inclusion but did not meet the inclusion criteria, 246 persons were enrolled in this study. Their mean age was 58.2 years old with slight male predominance (58.2%), and 171 (71%) patients had underlying illnesses. Blood cultures were performed on 191 (77.6%) patients and serologic tests on 44 (18.3%) patients. The etiologic agents were identified in 31.3%, and the list of individual agents, in decreasing order, was pulmonary tuberculosis (17 definite and 3 probable: data of six hospitals), S. pneumoniae (8 definite and 10 probable), non-pneumococcal streptococci (3 definite), aerobic gram-negative bacilli (7 definite and 4 probable), Haemophilus spp. (11 probable), mycoplasma (1 definite and 4 probable), polymicrobial infections (2 definite and 2 probable : E. coli and S. agalactiae, M. tuberculosis and S. aureus, S. pneumoniae and H. influenzae, and A. baumannii and K. pneumoniae), S. aureus (2 definite and 2 probable), and mucormycosis (1 definite). Among gram-negative bacilli, K. pneumoniae was the most common agent (8 isolates). The rates of admission to the intensive care unit and of using assisted ventilation were 18% and 9.3% respectively. The mortality was 13.8% and logistic regression analysis showed that hypothermia and tachypnea were associated with death. Hospital stay averaged 19 days. Susceptible rates of S. pneumoniae isolated from all body sites to penicillin ranged from 8% to 28% but all seven isolates from blood of patients with pneumonia were susceptible to penicillin. Also all 8 isolates of K. pneumoniae from patients with pneumonia were susceptible to cefotaxime and gentamicin. CONCLUSION: In Korea, in addition to S. pneumoniae, M. tuberculosis is an important agent causing community-acquired pneumonia. The low incidence of etiologic diagnosis is probably related to infrequent requesting of test to "atypical" pathogens and does not represent the true incidence of infections by "atypical" pathogens, which will be answered by a prospective study. The antimicrobial resistance rates of major respiratory pathogens from sterile body sites are low, however, because of a small number of the isolates this result needs confirmation by a nationwide surveillance of antimicrobial resistance.

A Case of Campylobacter jejuni Enterocolitis with Acute Pancreatitis and Hemolytic Uremic Syndrome / 감염

Campylobacter jejuni enterocolitis is one of the common causes of acute infectious diarrhea, but most of them remain unrecognized by routine microbiologic examination. Its clinical manifestations are watery diarrhea, malaise, fever and abdominal pain. The clinical course is self-limited in majority of cases. However cases of Campylobacter jejuni infections as cholecystitis, pancreatitis, peritonitis or cystitis have been infrequently reported. Moreover, reactive arthritis, hepatitis, interstitial nephritis or hemolytic uremic syndrome rarely develops in Campylobacter jejuni enterocolitis. We experienced a patient with Campylobacter jejuni enterocolitis, who had shown complex clinical features manifested by pancreatitis and hemolytic uremic syndrome. We reported the case with literature reviews.

Retinal Hemorrhage in an Adult with P. vivax Malaria / 감염

Malaria is a worldwide febrile illness with high morbidity and mortality. High fever, jaundice, hemolysis, and hepatosplenomegaly are usual symptoms and signs of malaria, whereas retinal hemorrhage is an unusual finding. Retinal hemorrhage has been known to be one of the clinical manifestations in severe Plasmodium falciparum infection, especially in children developing cerebral malaria. However, retinal hemorrhage can occur in adult patients with severe parasitemia, shizontemia, anemia and may occur in malaria infections caused by other Plasmodium species, because it is due to dense parasitemia in deep vascular beds. A case of Plasmodium vivax malaria with retinal hemorrhage has not been reported as yet. We report a Plasmodium vivax malaria patient with retinal hemorrhage, who presented with severe schizontemia and anemia.