Drug Prescribing in the Elderly Receiving Home Care.

BACKGROUND: To compare the prevalence of potentially inappropriate medications (PIMs) using the 2012 and 2003 Beers Criteria in frail older patients receiving home health care services (HHS), and to explore the correlates of PIMs based on the 2012 Beers criteria. MATERIALS AND METHODS: A total of 145 older patients (mean age, 80.9 ± 7.6 years) with Barthel scale ≤ 60 receiving regular HHS from a university hospital between January 2013 and June 2013 were retrospectively enrolled. The 2003 and 2012 Beers criteria were used separately to detect PIMs. Logistic regressions, receiver-operating-characteristic curve analyses and number needed to harm were used, where appropriate. RESULTS: The 2012 Beers Criteria identified more PIM cases than did the 2003 Beers Criteria (66.9% versus 55.9%, P < 0.05). Multivariate analysis revealed that PIM identified by the 2012 Beers Criteria was associated with an increased number of medications prescribed (P = 0.019) and the presence of psychiatric diseases (P = 0.001). Moreover, the area under the receiver-operating-characteristic curve for the number of drugs to predict the risk of PIM was 0.674 (P < 0.001) with the optimal cutoff value of 6 medications. After adjusting for age, sex, Charlson comorbidity index and psychiatric disorders, patients taking ≥6 drugs (adjusted odds ratio, 2.33; adjusted number needed to harm, 3.93; P < 0.05) had a significantly higher risk for PIM than those taking <6 drugs. CONCLUSIONS: Our data showed that the 2012 Beers Criteria was more sensitive in detecting PIMs than the 2003 Beers Criteria. Furthermore, frail older patients receiving HHS with polymedication and with psychiatric illnesses had higher risk of PIM when using the 2012 criteria. The number of medications prescribed could be a useful index for risk stratification, and at the same time help physicians to be aware of the high risk for PIM when prescribing 6 or more drugs to frail older adults during in-home visits.

Freestyle groin flaps: the real axial flap design and clinical application.

BACKGROUND: The groin flap represents a milestone in the history of flap development, since it was the first successful free cutaneous flap. Once widely used, it is currently less popular owing to the variations in vascular anatomy and the small, short pedicle. To enhance the clinical applications of the groin flap, its merits need to be promoted and its faults improved, including making some useful innovations. METHODS: From February 2010 to February 2014, we successfully treated 35 patients with soft tissue defects in the extremities (28 patients), buttock (1 patient), and head (6 patients) using new designs in groin flaps: axial free (34 patients) or pedicle (1 patient) groin flaps. RESULTS: All types of axial groin flaps survived successfully in the 2 to 38 months' (mean, 15.6 months) follow-up. The branches of the superficial circumflex iliac artery used for the axial flap design were 2 to 4 (mean, 3.09). The flap size ranged from 1×1.5 cm to 11×30 cm. No significant complications developed in any of the patients, with the exception of 2 mildly bulky flaps. CONCLUSIONS: This axial design of freestyle groin flaps not only preserves the earlier merits of the groin flap but also creates many new advantages: (1) reliability is greater, (2) ability to tailor the dimensions and flap paddles to the lesions, (3) options available to "lengthen" flap pedicles, and (4) local anesthesia usable with free flaps for reconstruction.

Seasonality, clinical types and prognostic factors of Vibrio vulnificus infection.

INTRODUCTION: Vibrio vulnificus infection, an uncommon but life-threatening illness, manifests as two main types, primary septicemia and primary wound infections.  Little information regarding the seasonality of V. vulnificus infections in tropical areas and prognostic factors of primary V. vulnificus wound infections is available. METHODOLOGY: This retrospective study was conducted to include 159 V. vulnificus-infected admissions at our institution in southern Taiwan, 63 with primary septicemia (Group 1) and 96 with primary wound infections (Group 2), from 1999 to 2008, for analysis. RESULTS: The case-fatality rate was 24%. Eighty-eight percent of these cases occurred during April to November. During December to March, patients in Group 2 were less likely to have acquired the infection compared with those in Group 1. Group 1 was more likely to have comorbidities and a higher case-fatality rate compared to Group 2. In multivariate analysis, hemorrhagic bullous skin lesions/necrotizing fasciitis (P=0.024), lesions involving two or more limbs (P=0.043), and shock on admission (P=0.015) were related to an increased mortality risk, while surgery < 24 hours after admission (P=0.001) was related to a decreased mortality risk in Group 1; however, hemorrhagic bullous skin lesions/necrotizing fasciitis (P=0.045) was the only prognostic factor in Group 2. CONCLUSION: The presence of hemorrhagic bullous lesion/necrotizing fasciitis is the main prognostic factor for primary septicemia or primary wound infections caused by V. vulnificus. Persons with an underlying immunocompromised status should avoid consuming raw/undercooked seafood or exposing wounds to seawater and should wear clothing during handling of seafood/fishing, especially in warmer months.

The Laboratory Risk Indicator for Necrotizing Fasciitis score for discernment of necrotizing fasciitis originated from Vibrio vulnificus infections.

BACKGROUND: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis (NF). Its application, however, is mainly for NF types I and II. The practical relevance of the LRINEC score for Vibro vulnificus-related skin and soft tissue infection (SSTI) was hardly ever investigated. The aim of this study was to assess the applicability of the LRINEC scoring system and to identify NF-predicting factors in patients with V. vulnificus-caused SSTI. METHODS: A retrospective study was conducted, enrolling 125 consecutive patients diagnosed with V. vulnificus-related SSTI who were admitted to a teaching hospital between January 2003 and December 2011. Demographics, laboratory data, comorbidities, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed. RESULTS: The mean (SD) age of the 125 patients was 63.0 (10.9) years; 58% of the patients were male. The mean (SD) LRINEC score at admission was 2.4 (1.9) points. Of the 125 patents, 72 (58%) had NF. Multivariate analysis revealed that the presence of hemorrhagic bullous lesions (p = 0.002) and higher LRINEC scores at admission (p < 0.0001) were significantly associated with the presence of NF. In addition, the area under the receiver operating characteristic curve for the LRINEC scoring model for detecting NF was 0.783 (p < 0.0001). An optimal cutoff LRINEC score of 2 or greater had a sensitivity of 71%, a specificity of 83%, and a positive predictive value of 85%, with an 11.9-fold increased risk for the presence of NF (p < 0.0001). CONCLUSION: We have demonstrated that the LRINEC score and hemorrhagic bullous/blistering lesions are significant predictors of NF in patients with V. vulnificus-related SSTI. V. vulnificus-infected patients having hemorrhagic bullous/blistering lesions or with an LRINEC score of 2 or greater should be thoughtfully evaluated for the presence of NF. LEVEL OF EVIDENCE: Diagnostic test study, level II.

Antibiotic therapy for necrotizing fasciitis caused by Vibrio vulnificus: retrospective analysis of an 8 year period.

OBJECTIVES: To compare the effectiveness of a third-generation cephalosporin alone, a third-generation cephalosporin plus minocycline, and a fluoroquinolone in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus. METHODS: A retrospective review of case notes was performed for 89 patients who presented with NF caused by V. vulnificus and underwent surgical intervention within 24 h of admission between 2003 and 2010. Data on comorbidities, clinical manifestations, laboratory studies, treatments and outcomes were extracted for analysis. These patients were grouped according to the antimicrobials prescribed: those who received only a third-generation cephalosporin (Group 1; n = 18); a third-generation cephalosporin plus minocycline (Group 2; n = 49); or a fluoroquinolone with/without minocycline (Group 3; n = 22). RESULTS: The mean age of the 89 patients included in the study was 64.0 ± 12.0 years (range 33-89 years); 55% of the patients were male. There were no differences in age, sex or clinical characteristics among the three groups except that patients in Group 3 had a higher frequency of underlying chronic renal insufficiency than those in Groups 1 and 2 (P = 0.009). Groups 2 and 3 each had a significantly lower case fatality rate than Group 1 (61% in Group 1 versus 14% in Group 2, P = 0.0003; 61% in Group 1 versus 14% in Group 3, P = 0.0027), while no difference in case fatality rate was noted between Groups 2 and 3. CONCLUSIONS: Our data suggested that, in addition to primary surgery, fluoroquinolones or third-generation cephalosporins plus minocycline are the best option for antibiotic treatment of NF caused by V. vulnificus.

Significant elevation of plasma pentraxin 3 in patients with pelvic inflammatory disease.

BACKGROUND: Pentraxin 3 (PTX3) plays an important role in innate immune responses and in inflammation disease. The aim of this study was to investigate the diagnostic and prognostic potential of PTX3 in pelvic inflammatory disease (PID) and correlate it with the severity and outcome of PID. METHODS: Blood specimens were collected from 64 patients with PID before and after treatment and 70 healthy controls and the plasma levels of PTX3 were measured using enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: It was found that the plasma level of PTX3 expression was elevated in PID patients compared with healthy controls and decreased significantly after they received treatment. When the cut-off level of plasma PTX3 was set at 2.87 ng/mL, PTX3 had higher sensitivity (84.38%) and lower false-negative rate (15.63%) than CRP (79.69% and 20.31%, respectively) in predicting PID. The level of PTX3 also exhibited a significant correlation with length of hospital stay (r=0.581, p<0.001). CONCLUSIONS: Plasma PTX3 concentration not only predicts the presence of PID with lower false-negative rate than CRP, but plasma PTX3 concentration is also affiliated with the presence of tubo-ovarian abscess (TOA) and the length of hospital stay.

First identification of methicillin-resistant Staphylococcus aureus MLST types ST5 and ST45 and SCCmec types IV and Vt by multiplex PCR during an outbreak in a respiratory care ward in central Taiwan.

We used molecular typing methods to investigate an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infections in a respiratory care ward in Taiwan. From March to June 2006, the incidence of MRSA infection increased 3.75-fold. The overall carrier rates among the health care workers (HCWs) were 31.3% (total S. aureus), 16.4% (MRSA), and 14.9% (methicillin-sensitive SA, MSSA). Pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), antibiograms derived from susceptibility testing of MRSA isolates, and multiplex polymerase chain reaction (PCR) provided strong epidemiologic and microbiologic evidence that the outbreak of MRSA infections at our hospital was linked to the same PFGE pulsotype A SCCmec type II, pvl-negative, MLST ST5 strain of MRSA isolated from seven HCWs and five patients. The outbreak was controlled by application of topical fucidin ointment to the anterior nares in all colonized HCWs. Multiplex PCR combined with PFGE and MLST is a feasible method for outbreak investigations in routine clinical laboratories.

Trends of mycobacterial clinical isolates in Taiwan.

Non-tuberculous mycobacteria (NTM) can cause chronic pulmonary infection, however, NTM infection is generally overlooked. This retrospective study analyzed the frequencies of Mycobacterium tuberculosis complex (MTBC) and NTM clinical isolates from 99 200 specimens of patients suspected with pulmonary mycobacterial infection in Taiwan from 2002-2007. A total of 8024 mycobacterial isolates, including 5349 MTBC and 2675 NTM, were obtained from the 99 200 specimens in the study period. The overall mycobacterial isolation rate was 8.09% (8024/99 200), and the overall MTBC and NTM isolation rate was 5.39% (5349/99 200) and 2.7% (2675/99 200), respectively. Notably, the prevalence of NTM isolates among the identified mycobacteria strains was increased 2.6 fold from 2002 (17.54%, 147/838) to 2007 (45.80%, 659/1439). The frequencies of MTBC and NTM isolates showed a reciprocal trend: the NTM isolation rates were steadily increasing while the overall mycobacterial isolation rates remained stable over the study period. Our results suggest that the diagnosis, identification and susceptibility tests for NTM should be standardized and integrated in clinical routines, for providing the information of NTM infection and prescribing clinical treatment in a more precise and efficient way to reduce the increasing NTM in the studied area.

Seroepidemiology of hepatitis A virus infection among schoolchildren in Taiwan.

Taiwan was a hyperendemic area for hepatitis A virus (HAV) infection before 1980. The aim of this study was to examine the association between seropositivity of antibodies against HAV (anti-HAV) by a community-based survey. School children from 10 elementary and 3 junior high schools, as well as staff members who worked at the above schools in central Taiwan were selected at random in this study. Anti-HAV was tested in sera of 1,954 healthy schoolchildren (aged 7-15 years old) and 254 teachers by enzyme-linked immunosorbent assay. Schoolchildren had a low prevalence of anti-HAV (2.3%) in contrast to the high seroprevalence in their teachers (52%). The seropositive rates of HAV antibody among the study subjects were increasing with age. No significant differences of anti-HAV seroprevalence among the study subjects were observed when they were stratified by gender, geographical area, household members, and parental education. Whereas, the anti-HAV seroprevalence was significantly higher in schoolchildren who were either aboriginal or living in areas without a supply of drinking tap-water. The seroprevalence of HAV data among the healthy pediatric population would be helpful to evaluate the need for mass vaccination policies.

Clinical outcomes and prognostic factors for patients with Vibrio vulnificus infections requiring intensive care: a 10-yr retrospective study.

OBJECTIVE: Vibrio vulnificus infection is uncommon but potentially life-threatening. The aim of this study was to evaluate clinical outcomes and prognostic factors for patients with V. vulnificus infections admitted to an intensive care unit. DESIGN: Retrospective study. SETTING: Multidisciplinary intensive care unit in a 2300-bed teaching hospital. PATIENTS: Eighty-five adult patients (≥ 18 yrs) with V. vulnificus infections who required intensive care were enrolled and reviewed during a 10-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-four of the 85 patients died, giving an intensive care unit mortality rate of 40%. The mean Acute Physiology and Chronic Health Evaluation II score on intensive care unit admission was 18.4 (95% confidence interval, 17.1-19.8). The most common underlying disease was hepatic disease (48%) followed by diabetes mellitus (22%). Multivariate analysis showed that risk factors for intensive care unit mortality were the presence of hemorrhagic bullous skin lesions/necrotizing fasciitis (relative risk, 2.4; 95% confidence interval, 1.3-4.5; p = .006), skin/soft tissue infections involving two or more limbs (relative risk, 2.5; 95% confidence interval, 1.1-5.7; p = .025), and higher Acute Physiology and Chronic Health Evaluation II scores on intensive care unit admission (relative risk, 1.2; 95% confidence interval, 1.1-1.3; p = .0001). In contrast, surgical treatment < 24 hrs after arrival was inversely associated with intensive care unit mortality (relative risk, 0.35; 95% confidence interval, 0.15-0.79; p = .012). In addition, the area under the receiver operating characteristic curve for Acute Physiology and Chronic Health Evaluation II for predicting intensive care unit mortality was 0.945 (95% confidence interval, 0.873-0.983; p = .0001). An optimal cutoff Acute Physiology and Chronic Health Evaluation II score of ≥ 20 had a sensitivity of 97% and a specificity of 86% with a 41.4-fold increased risk of fatality (p = .0003). CONCLUSIONS: This study found that V. vulnificus-infected patients with hemorrhagic bullous skin lesions/necrotizing fasciitis, skin/soft tissue infections involving two or more limbs, or higher Acute Physiology and Chronic Health Evaluation II scores have high risks of intensive care unit mortality. However, patients receiving prompt surgical treatments within 24 hrs after admission have better prognoses.

Prognostic factors for primary septicemia and wound infection caused by Vibrio vulnificus.

OBJECTIVES: The purpose of this study was to explore the predictive factors for mortality in primary septicemia or wound infections caused by Vibrio vulnificus. METHODS: A retrospective review of 90 patients 18 years and older who were hospitalized due to V vulnificus infection between January 2000 and December 2006 was performed. Clinical characteristics, laboratory studies, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and receiver operating characteristic curve analyses were performed. RESULTS: Of 90 patients identified as V vulnificus infections, 39 had primary septicemia and 51 had wound infection. The mean age was 63.0 +/- 11.9 years. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) and Mortality in Emergency Department Sepsis (MEDS) scores on admission were 11.1 +/- 4.9 and 5.5 +/- 3.8, respectively. Fifteen patients died, yielding an in-hospital mortality rate of 17%. Multivariate analysis revealed that higher APACHE II (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.8; P< .0001) and MEDS (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .0201) scores on admission were significantly associated with mortality. The area under the receiver operating characteristic curves values for APACHE II and MEDS in predicting in-hospital mortality were 0.928 (95% CI, 0.854-0.972) and 0.830 (95% CI, 0.736-0.901), respectively. CONCLUSIONS: The APACHE II and MEDS scores on admission are significant prognostic indicators in primary septicemia or wound infections caused by V vulnificus. A further prospective study to strengthen this point is required.

Metal concentrations in sediments of the Tamsui River, flows through central metropolitan Taipei.

This work analyzed metal concentrations and potential sources of sediment pollutants in the Tamsui River, Taiwan, by instrumental neutron activation analysis. The Tamsui River, the second longest of Taiwan's three major rivers, flows through metropolitan Taipei City in northern Taiwan and is renowned for its preserved mangrove wetlands. In total 11 elements Al, As, Br, Cs, Fe, La, Mg. Mn, Na, Sc, and Ti were identified in 24 samples taken from three sites upriver, the mangrove area and estuary during the spring of 2004. Specifically, the most abundant Al metal concentration was 15.6-0.92 mg/g adopted as standard reference in this study. Only few sites had As at the statistical meaning (>DL). Furthermore, arsenic concentrations fluctuated at roughly 0.67 +/- 0.09 mg/kg based on variations in background counts in various gamma-ray spectra. Elemental concentrations of these elements were compared with those in other nations, and discussed in the context of enrichment factors calculated for elements using the earth crust of various sediments as references, based on elemental values of Al.

Pediatric reference intervals for several biochemical analytes in school children in Central Taiwan.

BACKGROUND/PURPOSE: Reference intervals of biochemical tests for screening for diabetes mellitus and liver and renal function among school children in Central Taiwan have never been documented. Therefore, this study aimed to establish the reference intervals for the above mentioned biochemical tests for pediatric populations. METHODS: A total of 4326 subjects, including 2029 kindergarten children, 1624 elementary-school children, 325 junior-high-school children, and 348 teachers were selected randomly in Central Taiwan. All serum alanine aminotransferase (ALT), blood urea nitrogen (BUN), creatinine (Cr) and glucose levels were determined using a Beckman Synchron CX5 analyzer. The reference intervals reflected estimates of the 2.5th-97.5th percentiles of non-parametric distributions. RESULTS: Adults had significantly higher biochemical analyte values [except for BUN/creatinine (B/C) ratio] than children had. Multiple logistic regression analysis showed that biochemical analyte values were significantly higher in male than in female subjects. The concentrations of glucose and Cr increased with age. On the contrary, the B/C ratio decreased with age. CONCLUSION: Our study provides new pediatric reference intervals (2.5th-97.5th percentiles) of 60-99 mg/dL for serum glucose concentrations, 8-38 IU/L for ALT, 0.4-1.1 mg/L for Cr, 8.7-18.0 mg/L for BUN, and 10-34 for B/C ratio. The B/C ratio in children was higher than those of adults, possibly due to that children had a higher intake of protein.

Severity of disease as main predictor for mortality in patients with pyogenic liver abscess.

BACKGROUND: The purpose of this study was to explore the relationship between severity of illness at admission and mortality of patients with pyogenic liver abscess (PLA). METHODS: Medical records from 298 PLA patients > or =18 years old were reviewed. Severity of illness at admission was evaluated with the Acute Physiology and Chronic Health Evaluation (APACHE) II and the simplified acute physiology score (SAPS) II scoring systems. Stepwise logistic regression and receiver-operating-characteristic curve analyses were performed. RESULTS: The case-fatality rate was 10%. Multivariate analysis showed that APACHE II (P = .0004), SAPS II (P = .0008), the presence of gas-forming abscess (P <.0001), and the presence of anaerobic infection (P <.0001) all were associated with mortality. The area under the receiver-operating-characteristic curve was .884 (95% confidence interval .842 to .918) for APACHE II and .857 (95% confidence interval .812 to .895) for SAPS II, which were not significantly different (P = .490). The optimal cutoff APACHE II value of > or =15 had a sensitivity of 77% and a specificity of 92%, with a 20.3-fold risk of mortality (P <.0001). The SAPS II cutoff value of > or =28 had a sensitivity of 74% and a specificity of 82%, with a 7.2-fold risk of mortality (P = .008). CONCLUSIONS: Both the APACHE II and the SAPS II scoring methods are appropriate for assessing mortality of PLA patients.

Pyogenic liver abscess in the elderly: clinical features, outcomes and prognostic factors.

BACKGROUND: pyogenic liver abscess (PLA) is a potentially life-threatening disease in middle-to-old aged persons. OBJECTIVE: to compare the differences in clinical features and outcomes between older and younger PLA patients, and to identify predictors of outcomes in older patients. DESIGN: retrospective chart review of all PLA patients between July 1999 and June 2007. SETTING: a 1,600-bed primary and tertiary care centre. SUBJECTS: in total, 339 patients were enrolled and included 118 > or =65 years of age (the elderly group) and 221 patients <65 years of age (the non-elderly group). METHODS: clinical features, laboratory, imaging and microbiologic findings, treatment and outcomes for each of the included patients were collected. The predictor of outcome was determined using logistic regression and purposeful selection of covariates. RESULTS: the elderly group had a higher APACHE II score on admission, a biliary abnormality, a malignancy, a pleural effusion, polymicrobial, anaerobic or multi-drug-resistant isolates, inappropriate initial antibiotics, a longer hospitalisation and a longer parenteral antibiotic treatment period than the non-elderly group, whereas the non-elderly group was more likely to be alcoholic men with cryptogenic origin of abscess and Klebsiella pneumoniae infection. There was no difference in case fatality between the elderly (13.6%) and non-elderly (8.6%) groups despite the elderly group having a poorer host status on admission. In multivariate analysis, age (P = 0.028) and APACHE II score at admission > or =15 (P = 0.001) were risk factors, but K. pneumoniae infection (P = 0.012) was a protective factor for fatality in older PLA patients. CONCLUSIONS: these data suggest that older PLA patients would have a fair outcome compared to younger patients, but require longer hospitalisations.

Significant elevation of a Th2 cytokine, interleukin-10, in pelvic inflammatory disease.

BACKGROUND: We investigated the expressions and ratios of type 1 T helper cell (Th1) cytokines interferon-gamma (IFN-gamma) and interleukin-2 (IL-2), as well as type 2 T helper cell (Th2) cytokines interleukin-4 (IL-4), interleukin-5 (IL-5), interleukin-13 (IL-13) and interleukin-10 (IL-10) in pelvic inflammatory disease (PID) patients. METHODS: The human cytokine LINCOplex multiplex bead array was used to measure the plasma levels of Th1 and Th2 cytokines in 50 healthy controls, as well as in 41 PID patients before and after routine protocol treatment. RESULTS: Significantly increased expressions of Th1 cytokine IFN-gamma (p=0.004), as well as Th2 cytokine IL-5 (p=0.001), and dramatically increased IL-10 (p=0.0001), but significantly decreased expression of Th1 cytokine IL-2 (p=0.029) in PID patients were found after comparison to the control group. The ratio of IFN-gamma to IL-13 showed a significant increase, but the ratios of IFN-gamma to IL-10 and IL-2 to IL-10 was significantly decreased in PID patients before treatment compared to after treatment and controls. CONCLUSIONS: The results indicate that the imbalance and cross-regulation between Th1 and Th2 cytokines pathways is probably contributed to the mechanism of PID.

Comparison of Escherichia coli and Klebsiella pneumoniae liver abscesses.

BACKGROUND: Escherichia coli and Klebsiella pneumoniae are the most common causative pathogens of pyogenic liver abscesses. The objective of this study was to compare outcome between patients with liver abscesses due to E coli and those with liver abscesses caused by K pneumoniae; we also aimed to identify separately the predictors of mortality in the 2 groups. METHODS: We conducted a retrospective study of 202 patients who presented with pyogenic liver abscesses caused by either E coli or K pneumoniae from July 2000 to June 2005. Outcome of the patients was analyzed by exact logistic regression with adjustment for baseline and clinical covariates. Significant predictors of mortality in the E coli and the K pneumoniae groups were investigated by multivariate analysis of demographic and clinical variables in each group. RESULTS: Of the 202 patients (128 men and 74 women; age range, 19 to 89 years), pyogenic liver abscess was due to E coli infection in 55 patients and K pneumoniae in 147 patients. In contrast to patients with K pneumoniae, patients with E coli liver abscess were more likely to be older and female, have a biliary abnormality or malignancy, pleural effusion, polymicrobial infection with anaerobic or multi-drug-resistant organisms, a higher APACHE II score, and to have been treated initially with ineffective antibiotics; they were also less likely to have diabetes mellitus. The cause of K pneumoniae liver abscess was often cryptogenic. The sensitivity, specificity, positive predictive value, and likelihood ratio of the presence of biliary disorders and coexisting malignancy as a predictive parameter of E coli liver abscess were 25%, 96%, 67%, and 5.45/1, respectively. The sensitivity, specificity, positive predictive value, and likelihood ratio of the presence of diabetes mellitus with an abscess of cryptogenic origin as a predictive parameter of K pneumoniae liver abscess were 39%, 84%, 81%, and 2.36/1, respectively. There was no significant difference in mortality between patients with E coli and those with K pneumoniae infections (26% vs 4%; adjusted OR, 4.2; 95% CI, 0.63 to 27; P = 0.105). However, for patients with liver abscess caused by E coli, the APACHE II score at admission (OR, 1.7; 95% CI, 1.1 to 2.6; P = 0.021), malignancy (OR, 26; 95% CI, 1.8 to 370; P = 0.016), and right-lobe abscess (OR, 0.0029; 95% CI, 0.00010 to 0.15; P = 0.004) were significant predictors of death, whereas uremia (OR, 52; 95% CI, 3.5 to 750; P = 0.004) and multi-drug-resistant isolates (OR, 26; 95% CI, 2.3 to 290; P = 0.009) were significant predictors of death in the K pneumoniae group. CONCLUSIONS: A higher APACHE II score at admission and a higher frequency of coexisting malignancy may have contributed to the higher, although not significant, mortality rate in patients with liver abscess caused by E coli infection. Clinicians should begin with broad antibiotic coverage such as a second-generation cephalosporin and an aminoglycoside with metronidazole when treating liver abscesses with E coli as the likely pathogen due to the high frequency of multi-drug-resistant isolates among E coli isolates.

Seroprevalence of Helicobacter pylori infection among schoolchildren and teachers in Taiwan.

BACKGROUND: Helicobacter pylori are associated with chronic antral gastritis that is related to duodenal ulcer, gastric ulcer, and probably gastric adenocarcinoma. Infection of H. pylori during childhood is considered an important risk factor for gastric carcinoma in adult life. MATERIALS AND METHODS: To examine the epidemiologic characteristics of H. pylori infection among schoolchildren in central Taiwan, a community-based survey was carried out using stratified sampling in 10 elementary schools and three junior high schools including students and theirs teachers. Serum specimens of 1950 healthy schoolchildren (aged 9-15 years old) and 253 teachers who were randomly sampled were screened for the H. pylori antibodies by enzyme-linked immunosorbent assay. Statistical analysis was performed by using the SPSS for Windows statistical software system. RESULTS: A total of 332 subjects were H. pylori antibodies positive, giving an overall prevalence of 15.1%. The age-specific seropositive rates were 11.0% in 9-12 years age group, 12.3% in 13-15 years age group, and 45.1% in the teacher group. The older the age, the higher the seroprevalence (OR = 11.53; 95% CI = 6.73-19.74; p < .001 for children vs. teachers). There was no difference in the seroprevalence of H. pylori infection by gender, ethnicity, geographical area, socioeconomic level, parental education, sibship size, family members, and source of drinking water. CONCLUSION: The teachers had a much higher prevalence of H. pylori antibodies. The finding suggests that these teachers (adults) might be infected in their early childhood and implies that the poor environmental and hygienic conditions might be responsible for it. It seemed that poor water supply system, sewage disposal, and other environmental hygiene in adult might play some roles in H. pylori infection in Taiwan (before early 1980s).

Utilizing self-prepared ELISA plates for a cross-population study of different anti-HBe IgG subclass profiles.

Fourteen serum samples obtained from hepatitis B virus (HBV) chronic carriers and patients recovered from hepatitis B infection were used with four sodium dodecyl sulfate-treated enzyme-linked immunosorbent assay (ELISA) plates available commercially, and one self-prepared HBcAg analog for evaluation of anti-HBe subclass pattern absorbance. The self-prepared plates had the best performance and were thus used for samples obtained from 104 (60 male and 44 female) HBV chronic carriers and 439 (247 male and 192 female) recovered individuals. Tests for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were also carried out in 21 of the subjects (>25 IU/ml). Statistical comparison of these patients with elevated ALT/AST levels with other ALT/AST-normal chronic carriers revealed no significant differences in the anti-HBe OD, although the mean optical density (OD) of patients with elevated ALT/AST levels was higher. The results suggest that the anti-HBe IgG subclass profiles in the chronic carriers did not change with inflammation of the liver, and were independent of sex and age. In contrast to previous anti-HBc findings, the distribution pattern of anti-HBe subclasses in HBV chronic carriers was IgG1 > IgG4 > IgG3 while in the recovered individuals it was IgG1 > IgG3 > IgG4, for both males and females. Subclasses IgG1 and IgG2 were the most and least prevalent isotypes, respectively, in both study groups. The results of the study suggest that induction of IgG1 and/or IgG3 antibodies is important for effective virus neutralization, while IgG2 antibodies are of limited importance. Significantly higher OD values for anti-HBe IgG4 were observed when comparing samples from the chronic carriers and recovered individuals, which may reflect the effects of persistence. Further, in contrast to previous anti-HBs results, the concentrations of total IgG and IgG1 were higher in the samples from chronic carriers relative to those from recovered individuals.

Seroepidemiology of hepatitis A, B, C, and E viruses infection among preschool children in Taiwan.

Taiwan was a hyperendemic area for hepatitis A and B viruses (HAV and HBV) infection before late 1980s. To study the seroprevalence of hepatitis A, B, C, and E viruses (HCV and HEV) infection among preschool children in Taiwan, a community-based survey was carried out in 54 kindergartens in 10 urban areas, 10 rural areas, and 2 aboriginal areas randomly selected through stratified sampling. Serum specimens of 2,538 preschool children were screened for the hepatitis A, C, and E antibodies by a commercially available enzyme immunoassay and for HBV markers by radioimmunoassay methods. The multivariate-adjusted odd ratios (OR) with their 95% confidence intervals (CI) were estimated through the multiple logistic regression analysis. Females had a statistically significantly higher HAV seroprevalence than males. The seroprevalence of HCV infection increased significantly with age. The larger the sibship size, the higher the seroprevalence of HBV infection. Aboriginal children had a significantly higher seroprevalence of HBV and HEV infection and lower seroprevalence of HCV infection than non-aboriginal children. A significantly higher seroprevalence of HBV infection was found in rural children than urban children. There was no significant association between serostatus of HAV and HEV infection and between serostatus of HBV and HCV infection among preschool children in Taiwan. The poor environmental and hygienic conditions in the aboriginal areas might play a role in infection with HBV and HEV.