Risk Factors of Carbapenem-resistant Enterobacteriaceae Acquisition at a Community-based Hospital

Objective@#The rising number of carbapenemase-resistant Enterobacteriaceae (CRE) cases has become a concern worldwidely. This study investigated patient characteristics with CRE and analyzed the risk factors associated with its acquisition. @*Methods@#A retrospective review of the electronic medical records of the Kangbuk Samsung Medical Center from May 2016 to April 2019 was performed. The inclusion criterion was hospitalized patients aged ≥18 years with confirmed CRE acquisition. Patients were divided by CRE acquired and non-required patients. CRE acquired patients were those with CRE confirmed by their active surveillance cultures, while non-acquired patients were those with carbapenemase-sensitive Enterobacteriaceae (CSE). If CRE was isolated more than once during hospitalization, only the first isolation was used for data analysis. Patient characteristics, antibiotic used, and the duration of use were compared between two groups using univariate analysis, and the risk factors associated with CRE were analyzed using multiple logistic regression analysis. @*Results@#Among the 73 CRE acquired patients, 44 (60.3%) were positive for carbapenemase-producing Enterobacteriaceae (CPE). Infection from Klebsiella pneumonia (42 cases, 57.5%), Escherichia coli (17 cases, 23.3%), and Enterobacter cloacae (5 cases, 6.8%). The risk of CRE acquisition was significantly increased by 4.99 times [confidence interval (CI), 1.40-17.78; p=0.013] with mechanical ventilation, 3.86 times (CI, 1.59-9.36; p=0.003) with penicillin administration, and 21.19 times (CI, 6.53-68.70; p<0.001) with carbapenem administration. @*Conclusions@#Proper antibiotic use including the selection, frequency, and duration, and patients on mechanical ventilators need close monitoring.

Symptomatic Choledochal Cyst in Association with Pregnancy Managed with EUS-guided Choledochoduodenostomy without Fluoroscopic Guidance / 대한췌담도학회지

Choledochal cyst has only rarely been encountered in association with pregnancy. The clinical manifestations are nonspecific and variable that makes it difficult to differentiate from physiologic changes in pregnancy. Consequently, diagnosis is often delayed until patients present with life-threatening complications. During pregnancy, symptoms of choledochal cyst may be developed by hormonal changes and the enlarged uterus. Because of the risk of fetal mortality and maternal morbidity, definitive surgical treatment should be delayed and step-by-step management should be carefully implemented to avoid complication until delivery. Herein, we report a case of enlarged, symptomatic choledochal cyst that developed in a 26-year-old pregnant woman. The temporal relationship between pregnancy and symptom development, as well as the biliary sludge formation in the enlarged cyst, suggest that the choledochal cyst was influenced by pregnancy. In order to buy time for fetal maturation, endoscopic ultrasonography-guided choledochoduodenostomy was performed for biliary decompression as a bridge to surgical excision.

Intranasal Insulin for Alzheimer's Disease and Amnestic Mild Cognitive Impairment: Systematic Review and Meta-analysis

OBJECTIVE: There is recent evidence that insulin resistance is responsible for increasing the risk of developing cognitive dysfunction. To systematically review the influence of intranasal insulin treatment on the cognitive function in Alzheimer's disease patients. METHODS: Randomized controlled trials comparing the cognitive effects of intranasal insulin therapy in Alzheimer's disease patients with controlled interventions were retrieved from Pubmed, Medline, Embase and Cochrane library. Meta-analysis was conducted on the cognitive measurements with a subgroup analysis by dose, gender and apolipoprotein E allele 4 (ApoE ε4) status. RESULTS: Seven randomized controlled trials were eligible for inclusion. Intranasal insulin had a positive influence on the cognitive function as compared to placebo without a statistical significance (standardized mean difference; SMD = 0.109; 95% confidence interval; CI −0.04 to 0.26; P=0.14). In subgroup analysis, a 20 IU dose of intranasal insulin induced a significant improvement in cognitive function (SMD = 0.14; 95% CI 0.05 to 0.24; P=0.004), but 40 IU did not show this effect (SMD = −0.01; 95% CI −0.11 to 0.09; P=0.82). ApoE ε4 positive patients showed a significant decline in cognitive function as compared to ApoE ε4 positive patients in the control group (SMD = −0.213; 95% CI −0.38 to −0.04; P=0.015). Such an effect was not apparent in ApoE ε4 negative patients. Gender had no influence on the cognitive outcomes. CONCLUSION: The results indicate that intranasal insulin may have beneficial effect in improving the cognitive function in Alzheimer's disease patients.

Practice Preferences on Dabigatran and Rivaroxaban for Stroke Prevention in Patients with Non-valvular Atrial Fibrillation

OBJECTIVE: Prescription rate of dabigatran and rivaroxaban, which are the direct oral anticoagulants (DOAC), has increased. We have analyzed the prescription trend and medication use of dabigatran and rivaroxaban in patients with non-valvular atrial fibrillation (NVAF). METHODS: It was retrospectively studied from September 2012 to April 2014 using the electronic medical records and the progress notes. Patients with NVAF (n=424) were evaluated on the medication use, prescribing preferences, adverse drug reactions (ADRs) and the availability of prescription reimbursement of dabigatran (n=210) and rivaroxaban (n=214). RESULTS: Dabigatran was prescribed higher than rivaroxaban (23.3% versus 7.5%, p<0.001) in the neurology department, but rivaroxaban was prescribed higher compared to dabigatran in the cardiology department (87.4% versus 74.3%, p<0.001). Dabigatran was prescribed more than rivaroxaban in high risk patients with CHADS2 score ≥ 3 (44.3% versus 31.3%, p=0.006). Dabigatran patients seemed to have more ADRs than patients with rivaroxaban (25.2% versus 11.2%, p<0.001), but no serious thrombotic events and bleeding were found. Only 35.6% (n=151) were eligible for prescription reimbursement by the National Health Insurance (NHI). Bridging therapy (86, 31.5%) and direct-current cardioversion (57, 20.2%) were main reasons of ineligibility for reimbursement. CONCLUSION: Prescription preferences were present in choosing either dabigatran or rivaroxaban for patients with NVAF. Inpatient protocols and procedures considering patient-factors in NVAF need to be developed.

Perception Gap between Preceptors and Pharmacy Students on Introductory Pharmacy Practice Education in Community Pharmacy Practice Setting

OBJECTIVE: This study was to investigate the perception gap between preceptors and pharmacy students on community pharmacy experiential education. METHODS: The online survey was performed for 55 preceptors and 215 pharmacy students separately from April 1 to April 30, 2014. The preceptors were who completed community pharmacy practice experience at least a session and the students were who involved in community pharmacy practice for more than 21 days. The questionnaires were prepared based on the lesson contents guideline of Introductory Pharmacy Practice Education of Community Pharmacy by Korea Association of Pharmacy Education. The survey questions were consisted with demographic characteristics, evaluation of student and preceptors, benefits and disadvantages of pharmacy practice for both groups. RESULTS: A total of 27 (49.1%) preceptors and 103 (47.9%) pharmacy students responded to the survey questionnaires. Preceptors indicated that students lacked face-to-face communication ability with patients, caregivers, and physicians. One of the Benefits of participating in pharmacy practice education as a preceptor included the improvement of self-esteem (70.37%). Disadvantages were identified as workload burden due to teaching and preceptor responsibilities at the same time. All students responded that benefits of experiencing pharmacy practice education were helping them determine their career, and they would consider working in community pharmacies (68.93%). However, handling over-the-counter drugs and communicating with doctors or nurses were identified as barriers. In addition, preceptors and pharmacy students expressed necessity of the standard text books and curriculums. CONCLUSION: This study identified the perception gap on community pharmacy experiential education between preceptors and pharmacy students. For the successful implementation of pharmacy practice experience, the effective and appropriate methods should be developed.

A Case of Reye Syndrome Following Treatment of Kawasaki Disease with Aspirin / 소아감염

Reye syndrome is a rapidly progressive encephalopathy with hepatic dysfunction, which often begins several days after apparent recovery from a viral illness, especially varicella or influenza A or B. Salicylate use was identified as a major precipitating factor for the development of Reye syndrome. With the recommendation to avoid use of salicylates in children, Reye syndrome has virtually disappeared in recent years. We report a case of Reye syndrome in a 5-month-old infant who had been treated with intravenous immunoglobulin and aspirin under the diagnosis of Kawasaki disease, and showed symptoms of sudden onset of irritability, rigidity, decreased activity, vomiting, poor appetite, lethargy, liver dysfunction without jaundice, coagulopathy, and hyperammonemia.

Etiology and Clinical Manifestations of Fever in Infants Younger than 3 Months Old: A Single Institution Study, 2008-2010 / 소아감염

PURPOSE: The purpose of this study is to investigate clinical features and causative organisms in febrile infants younger than three months, to help identification of high risk patients for serious bacterial infection (SBI). METHODS: A total of 313 febrile infants younger than three months, who had visited Seoul National University Children's Hospital from January 2008 to December 2010 were included. Clinical features, laboratory findings, causative organisms, and risk factors of SBI were analyzed by retrospective chart review. Causative bacterial or viral pathogens were identified by gram stain and cultures, rapid antigen tests, or the polymerase chain reaction from clinically reliable sources. RESULTS: Among 313 infants, etiologic organisms were identified in 127 cases (40.6%). Among 39 cases of bacterial infections, Escherichia coli (66.7%) and Streptococcus agalactiae (12.8%) were common. Enterovirus (33.7%), respiratory syncytial virus (19.8%), and rhinovirus (18.8%) were frequently detected in 88 cases of viral infection. Patients with SBI (39 cases) showed significantly higher values of the white blood cell count (14,473+/-6,824/mm3 vs. 11,254+/-5,775/mm3, P=0.002) and the C-reactive protein (6.32+/-8.51 mg/L vs. 1.28+/-2.35 mg/L, P<0.001) than those without SBI (274 cases). The clinical risk factors for SBI were the male (OR 3.7, 95% CI 1.5-8.9), the presence of neurologic symptoms (OR 4.8, 95% CI 1.4-16.8), and the absence of family members with respiratory symptoms (OR 3.6, 95% CI 1.2-11.3). CONCLUSION: This study identified common pathogens and risk factors for SBI in febrile infants younger than three months. These findings may be useful to guide management of febrile young infants.

Etiological Agents in Bacteremia of Children with Hemato-oncologic Diseases (2006-2010): A Single Center Study / 소아감염

PURPOSE: This study was performed to identify the etiologic agents and antimicrobial susceptibility patterns of organisms responsible for bloodstream infections in pediatric cancer patients for guidance in empiric antimicrobial therapy. METHODS: A 5-year retrospective study of pediatric hemato-oncologic patients with bacteremia in Seoul National University Children's Hospital, from 2006 to 2010 was conducted. RESULTS: A total of 246 pathogens were isolated, of which 63.4% (n=156) were gram-negative, bacteria 34.6% (n=85) were gram-positive bacteria, and 2.0% (n=5) were fungi. The most common pathogens were Klebsiella spp. (n=61, 24.8%) followed by Escherichia coli (n=31, 12.6%), coagulase-negative staphylococci (n=23, 9.3%), and Staphylococcus aureus (n=22, 8.9%). Resistance rates of gram-positive bacteria to penicillin, oxacillin, and vancomycin were 85.7%, 65.9%, and 9.5%, respectively. Resistance rates of gram-negative bacteria to cefotaxime, piperacillin/tazobactam, imipenem, gentamicin, and amikacin were 37.2%, 17.1%, 6.2%, 32.2%, and 13.7%, respectively. Overall fatality rate was 12.7%. Gram-negative bacteremia was more often associated with shock (48.4% vs. 11.9%, P<0.01) and had higher fatality rate than gram-positive bacteremia (12.1% vs. 3.0%, P=0.03). Neutropenic patients were more often associated with shock than non-neutropenic patients (39.6% vs. 22.0%, P=0.04). CONCLUSION: This study revealed that gram-negative bacteria were still dominant organisms of bloodstream infections in children with hemato-oncologic diseases, and patients with gram-negative bacteremia showed fatal course more frequently than those with gram-positive bacteremia.

Changes of Refractive Errors and Optometric Values in Fourth Graders at an Urban Elementary School in Korea

PURPOSE: To evaluate changes in refractive errors and quantify optometric values in 4th graders at an urban elementary school in Korea. METHODS: A total of 188 school children (376 eyes) were assessed in a population-based, cross-sectional and longitudinal follow-up study between March and December 2003. Uncorrected visual acuity, best corrected visual acuity, corneal refractive power measured with auto keratometer (KR-8100, Topcon(R) Inc., Japan), axial length measured with A-scan ultrasound biometry (A/B-scan system 835, Humphrey(R) Inc., Dublin, CA), and cycloplegic refraction were evaluated on March and December, respectively. RESULTS: Mean visual acuity decreased from -0.15+/-0.29 LogMAR to -0.20+/-0.35 LogMAR and mean spherical equivalent (SE) showed myopic progression from -0.65+/-1.57 diopter (D) to -0.88+/-1.75D. The prevalence rate of myopia ( or =+1.00D SE) was decreased from 8.0% to 5.8%. Mean corneal refractive power changed from 43.21+/-1.29D to 43.35+/-1.31D, and mean axial length changed from 23.38+/-0.88 mm to 23.60+/-0.92 mm, respectively. CONCLUSIONS: We assessed the changes of refractive errors and quantified the optometric values in a population-based, longitudinal follow-up study. The results showed that the prevalence of myopia and the mean axial length increased during our study in urban elementary 4th graders in Korea.

Surgical Management of Bilateral Exudative Retinal Detachment associated with Central Serous Chorioretinopathy

PURPOSE: To report a case of bilateral bullous exudative retinal detachment in central serous chorioretinopathy (CSC) which was attached by vitrectomy and internal drainage of the subretinal fluid. METHODS: A 47-year-old man affected by bilateral atypical CSC with a bullous retinal detachment with subretinal exudate. A fluorescein angiogram (FAG) showed multiple points of leakage and staining of subretinal fibrosis. A tentative diagnosis of Vogt-Koyanagi-Harada (VKH) syndrome was made and the patient was treated with systemic corticosteroids and immunosuppressive agents. However, the subretinal fluid was not absorbed. He was then treated with vitrectomy and internal drainage of subretinal fluid. RESULTS: The retina was attached successfully in both eyes. Visual acuity improved to 20/50 in his left eye but did not improve in the right eye due to subretinal fibrotic scarring and atropic changes on the macula. CONCLUSIONS: Our case suggests that the surgical management of bullous exudative retinal detachment is safe and necessary.

Ultrasound Biomicroscopic Assessment of the Changes in Angle Relationships after Laser Iridotomy in Primary Angle-Closure Glaucoma

PURPOSE: To identify the essential morphologic characteristics concerned with angle closure in chronic primary angle-closure glaucoma (PACG) and to assess the changes in quantified values for angle relationships after laser iridotomy (LI) in them using ultrasound biomicroscopy (UBM). METHODS: Anterior segment imaging and quantitative assessment of angle relationships were obtained in 25 eyes of 25 patients with chronic PACG using UBM (UBM plus2000 system, Paradigm(R) Inc., Utah, USA) before and 2 weeks after LI. RESULTS: The mean anterior chamber depth (ACD), anterior chamber angle (ACA), angle-opening distance (AOD500), and trabecular-iris distance (TID) were 2.16 mm, 12.73 degrees, 0.128 mm, and 0.101 mm, respectively. All our results were significantly smaller than previously reported quantified values in normal adult. In comparison between before and after LI, ACD and iris thickness (IT) did not change significantly, whereas ACA, AOD500, AOD250, and TID all significantly increased after LI. CONCLUSIONS: Using UBM, we identified the essential morphologic characteristics concerned with angle closure in chronic PACG and quantitatively demonstrated the result of treatment based on the changes of angle relationships after LI.

A Case Report of Acute Visual Acuity Decrease due to Choroidal Nonperfusion After Photodynamic Therapy

PURPOSE: We report a case of visual recovery in 11 weeks after acute, severe visual acuity decrease without significant fundus change following photodynamic therapy (PDT) for occult choroidal neovascularization (CNV) related to age-related macular degeneration. METHODS: A 79-year-old female patient visited our clinic because of decreased vision which had developed 1 week previously in her left eye. Best corrected visual acuity was 0.4 in the left eye. On fundus examination, there were multiple drusen around the fovea, hyperpigmentation and irregular elevation of retinal pigment epithelium, and serous pigment epithelium detachment on the macula. Fluorescein angiogram showed stippled hyperfluorescence with indistinct border in the early phase and hyperfluorescence due to the leakage from CNV of diffuse type ooze in the late phase. ICG angiogram showed focal hyperfluorescence in the mid and late phases. PDT with verteporfin was performed for regression of CNV. The day after PDT, visual acuity decreased to counting fingers at 20 cm and on fundus examination, there was no increase of serous pigment epithelium detachment or subretinal hemorrhage, but only mild retinal edema in the inferonasal area to the fovea. Fluorescein angiogram and ICG angiogram showed only round-shaped hypofluorescence due to choroidal nonperfusion localized to the PDT site. Eleven weeks after PDT, choroidal circulation returned to normal and visual acuity was 0.6. RESULTS: Acute, severe visual acuity decrease after PDT can be developed by choroidal nonperfusion and can be recovered with the improvement of choroidal perfusion.

Distribution of Refractive Errors and Quantified Optometric Values in Urban Elementary Fourth Graders in Korea

PURPOSE: To assess the distribution of ocular diseases, refractive errors, and quantified optometric values in urban elementary 4th graders in Korea. METHODS: A total of 234 schoolchildren were assessed in a population-based, cross-sectional study. The examination included uncorrected and corrected visual acuity measurements, corneal refractive power measurements using an autokeratometer (KR-8100, Topcon(R) Inc., Japan), ocular motility evaluation, slit-lamp biomicroscopy for the anterior segment and media, the measurements of anterior chamber depth, lens thickness, and axial length using an A-scan ultrasound biometry (A/B-scan system 835, Humphrey(R) Inc., Dublin, CA), retinoscopy under cycloplegia, and fundus examination. RESULTS: The prevalence rates of strabismus, epiblepharon, and amblyopia were 1.3%, 2.6%, and 1.7%, respectively. Mean visual acuity was -0.18 +/- 0.31 LogMAR. The prevalence rates of myopia (or=+1.00 D SE), and anisometropia (SE difference>or=1.00 D) were 46.2%, 7.3% and 5.9%, respectively. The means of corneal refractive power, axial length, and anterior chamber depth were 43.29 +/- 1.45 D, 23.42 +/- 1.26 mm, and 3.29 +/- 0.30 mm, respectively. CONCLUSIONS: We assessed the distribution of ocular diseases, refractive errors, and quantified optometric values in a population-based study. The results showed that increases in the prevalence of reduced vision and myopia are an important public health problem in urban elementary 4th graders in Korea.

Two cases of pancytopenia induced by ticlopidine / 대한내과학회지

Ticlopidine is an inhibitor of platelet aggregation used in the management and prevention of thromboembolic disorders. Hematological toxicity is one of the most important side effects of ticlopidine, including neutropenia, thrombocytopenia and more seriously aplastic anemia. We reported here two cases of very severe aplastic anemia developed after the use of ticlopidine. Both patients suffered from an acute cerebral infarction. Both patients developed pancytopenia 56 days and 51 days after treatment with 500 mg of ticlopidine daily. Both patients were hospitalized and received empiric antibiotic therapy and G-CSF. Twenty-three days and thirty days after the withdrawal of ticlopidine, the hematologic parameters of each patient improved.