[Clinical comparative study on resection and non-resection of the fifth metatarsal to rheumatoid forefoot deformity].

OBJECTIVE: To explore clinical effect of the fifth metatarsal head excision and non-excision in rheumatoid arthritis (RA) forefoot deformity reconstruction. METHODS: Retrospective analysis was performed on 50 patients (76 feet) with moderate to severe forefoot deformity caused by RA treated from May 2015 to January 2019. According to degeneration of the fifth metatarsophalangeal joint,the fifth metatarsal head was retained or excised by wind-like forefoot reconstruction,and divided into the fifth metatarsal head preservation group (preservation group) and the fifth metatarsal head resection group (resection group). Twenty-four female patients in preservation group,aged from 47 to 81 years old with an average of (60.37±8.60) years old;the course of disease ranged from 13 to 22 years with an average of (19.00±3.06) years;body mass index (BMI) ranged from 21 to 28 kg·m-2 with an average of (23.53±2.47) kg·m-2;six patients (6 feet) with moderate hallux valgus deformity and 18 patients (30 feet) with severe hallux valgus deformity;treated with the first metatarsophalangeal joint fusion combined with the second th the fourth metatarsophalangeal joint arthroplasty and the fifth metatarsophalangeal joint cleanup. Twenty-six female patients in resection group were female,aged from 30 to 80 years old with an average of (58.53±13.70) years old;the course of disease ranged from 8 to 25 years with an average of (17.94±3.92) years;BMI raged from 20 to 28 kg·m-2 with an average of (24.60±2.03) kg·m-2;4 patients (4 feet) with moderate bunion valgus deformity and 22 patients (36 feet) with severe bunion valgus deformity;treated by the first metatarsophalangeal joint fusion combined with the second th the fifth metatarsophalangeal joint resection of the metatarsophalangeal head. Operation time and postoperative complications between two groups were observed,hallux valgus angle (HVA),intermetatarsal angles between the first and the second metatarsals (IMAFS),intermetatarsal angles between the first and fifth metatarsals (IMAFF),Japanese Society for Surgery of Foot (JSSF) score before surgery and at the latest follow-up were compared. RESULTS: Fifty patients were followed-up from 14 to 46(25.30±8.83) months in resection group and 12 to 48 with an average of (24.30±11.12) months in preservation group,while no significant difference between two groups (P>0.05). There were no significant difference in operation time and postoperative complications between two groups (P>0.05). JSSF scores,HVA,IMAFS and IMAFF in fesection group were improved from (45.09±3.35) points,(38.90±13.67) °,(12.88±1.72) °,(32.50±2.99) ° before operation to (81.60±3.27) points,(15.40±0.90),(9.06±2.27) °,(22.20±1.98) ° at the latest follow-up (P<0.05);preservation group were improved from (47.09±3.96) points,(43.30±12.65) °,(13.99±3.13) °,(33.20±6.14) ° to (83.10±3.66) points,(15.20±1.54) °,(8.99±1.02) °,(24.70±1.88) °,respectively. There were no significant difference in JSSF score,HVA,IMAFS and IMAFF between two groups before operation and the latest follow-up (P>0.05). At the latest follow-up,there were statistically significant differences in pain and deformity in JSSF scores between two groups (P<0.05). CONCLUSION: Both rheumatoid anterior foot reconstruction and anterior foot reconstruction fifth metatarsophalangeal joint debridement showed significant improvement in clinical efficacy and imaging results. Compared with rheumatoid prefoot reconstruction,the fifth metatarsophalangeal joint reconstruction for the treatment of moderate and severe deformity of rheumatoid prefoot showed better improvement in pain,but worse improvement in deformity. For the moderate to severe deformity of the forefoot caused by rheumatoid disease,patients with mild to moderate degenerative deformity of the articular surface of the fifth metatarsal phalanges may be considered for use.

Identification of three elevenin receptors and roles of elevenin disulfide bond and residues in receptor activation in Aplysia californica.

Neuropeptides are ubiquitous intercellular signaling molecules in the CNS and play diverse roles in modulating physiological functions by acting on specific G-protein coupled receptors (GPCRs). Among them, the elevenin signaling system is now believed to be present primarily in protostomes. Although elevenin was first identified from the L11 neuron of the abdominal ganglion in mollusc Aplysia californica, no receptors have been described in Aplysia, nor in any other molluscs. Here, using two elevenin receptors in annelid Platynereis dumerilii, we found three putative elevenin GPCRs in Aplysia. We cloned the three receptors and tentatively named them apElevR1, apElevR2, and apElevR3. Using an inositol monophosphate (IP1) accumulation assay, we demonstrated that Aplysia elevenin with the disulfide bond activated the three putative receptors with low EC50 values (ranging from 1.2 to 25 nM), supporting that they are true receptors for elevenin. In contrast, elevenin without the disulfide bond could not activate the receptors, indicating that the disulfide bond is required for receptor activity. Using alanine substitution of individual conserved residues other than the two cysteines, we showed that these residues appear to be critical to receptor activity, and the three different receptors had different sensitivities to the single residue substitution. Finally, we examined the roles of those residues outside the disulfide bond ring by removing these residues and found that they also appeared to be important to receptor activity. Thus, our study provides an important basis for further study of the functions of elevenin and its receptors in Aplysia and other molluscs.

Phlebopus roseus, a new edible bolete from China, is associated with insects and plants.

Phlebopus roseus is described as new based on collections from southwest China. Phylogenetic analyses of nuclear rDNA internal transcribed spacer region ITS1-5.8S-ITS2 (ITS) and portions of nuclear 28S rDNA (28S), translation elongation factor 1-alpha (tef1), and the largest and second largest subunits of RNA polymerase II (rpb1, rpb2) support P. roseus as a novel species in the genus Phlebopus (Boletinellaceae, Boletales). The new species resembles P. portentosus but differs from it in that mature basidiomata have a bright rose-red-colored stipe and a radiate tubular hymenophore with nested pores. Despite extensive searching, P. roseus has only been found at four sites within a 24-hectare orchard dominated by Eriobotrya japonica, which is agriculturally important given its fruit production (loquats). Therefore, this species appears to be endemic and geographically restricted. The ecology of this bolete is also unique. In line with the trophic behavior of other species in the Boletinellaceae, our observations indicate that P. roseus forms a symbiotic association with the scale insect Coccus hesperidum, identified through sequence analysis of its mitochondrial cytochrome c oxidase subunit I (COI) region, to form fungus-insect galls that develop on roots of E. japonica trees. Phlebopus roseus is an edible mushroom species and is collected from the type location by farmers and sold commercially in limited quantities at local markets alongside P. portentosus and other fungi.

Malignant ureteral obstruction: experience and comparative analysis of metallic versus ordinary polymer ureteral stents.

BACKGROUND: To study the outcome and experience of using metallic stents in treating patients with malignant ureteral obstruction (MUO). METHODS: Seventy-six patients with MUO were assigned to the metallic stent group (MSG) or the ordinary polymer stent group (OPSG) according to the different materials. The success rate of the operation, duration of operation, patency rate serum creatinine values ,postoperative complications and QOL scores were compared between the two groups. RESULTS: In the OPSG and MSG, the success rates of the operation were 95.5% and 96.9%, respectively, and the durations of the operation were 20.6 ± 2.2 min and 50.9 ± 10.3 min (P < 0.01), respectively. There was no significant difference between the groups in serum creatinine values at 3 days after the operation (P > 0.05); however, the creatinine values at 3 days after the operation decreased significantly compared with those before the operation (P < 0.01). In the OPSG, there was no significant difference in creatinine values between 3 days and 6 months after operation, while the creatinine values 1 year after operation were increased significantly compared to those at 3 days after the operation (P < 0.05). In the MSG, there was no significant difference among creatinine values at different intervals (P > 0.05). The total rate of post-procedural complication was lower in the MSG than that in the OPSG(P < 0.05). There was no significant difference in the QOL score between the two groups before the operation (P > 0.05); however, the QOL scores at 6 months and 1 year after the operation were higher in the MSG than that in the OPSG(P < 0.05). In the MSG, there was no significant difference in the QOL score between preoperation and 6 months after surgery. Similarly, there was also no difference in the QOL score between 6 months after surgery and 1 year after surgery(P > 0.05). On the contrary, the differences of QOL score in the OPSG group were much significant between disparate time intervals (P < 0.05). CONCLUSIONS: For patients with MUO who require long-term retention of the stent, metallic stents with longer indwelling time are superior to ordinary polymeric stents.

Combined single-level subtotal corpectomy and decompression for cervical spondylotic myelopathy treatment.

BACKGROUND: The purpose of this study was to summarize outcomes of patients with refractory multisegmental cervical spondylotic myelopathy (CSM) who were treated by combined single-level subtotal corpectomy and decompression of the intervertebral space using the anterior approach. METHODS: Forty-five consecutive patients with multisegmental CSM were included; their ages ranged from 37 to 72 years. Seventeen (37.8%) patients had noncontiguous or 'jumping' multisegmental CSM and 28 (62.2%) had contiguous multisegmental CSM. The mean preoperative Japanese Orthopedic Association (JOA) score was 8.1 points. All patients underwent combined single-level decompression of the involved intervertebral space and subtotal corpectomy together with subsequent fusion and internal fixation. An anterior approach was used for all patients. A cage filled with bone graft was inserted and internal fixation was performed after single-level intervertebral space decompression. Mesh filled with bone graft was inserted and plate internal fixation was performed after subtotal corpectomy. RESULTS: Follow-up data (average follow-up, 14 months) were available for all 45 patients; the mean postoperative JOA score was 13.2 points, which was significantly different from the preoperative JOA score. Bony fusion was achieved in all patients based on postoperative radiography, and no pseudoarthrosis was observed during follow-up. CONCLUSIONS: An excellent outcome can be achieved with the combination of single-level subtotal corpectomy and decompression of the intervertebral space using the anterior approach to treat multisegmental CSM.

Dihydroarteminsin-induced apoptosis is not dependent on the translocation of Bim to the endoplasmic reticulum in human lung adenocarcinoma cells.

Bim, a proapoptotic BH3-only member of Bcl-2 family, has been considered to play an important role in initiating mitochondrial apoptotic pathway. Our previous studies have shown the ability of dihydroarteminsin (DHA) to induce apoptosis in human lung adenocarcinoma (ASTC-a-1) cells. In this study, we investigated the function of Bim during DHA-induced apoptosis in ASTC-a-1 and another human lung adenocarcinoma (A549) cell lines. Confocal imaging of single living cell expressing GFP-BimL showed the translocation of Bim to endoplasmic reticulum (ER) rather than mitochondria during DHA-induced apoptosis. Moreover, we also found that DHA induced ER stress and an increase of Bim protein levels. However, silencing Bim by short hairpin RNA did not inhibit DHA-induced caspase-9 activation and cell apoptosis. Taken together, our results demonstrate for the first time that DHA induces Bim translocation to ER, but DHA-induced apoptosis is not dependent on Bim in ASTC-a-1 and A549 cell lines.

[Effect of siRNA-Cox-2 on the growth inhibition and apoptosis of cartilage endplate chondrocytes].

OBJECTIVE: To investigate the influence of siRNA-COX-2 gene upon the growth inhibition and apoptosis of cartilage endplate chondrocytes and provide new methods and evidence for siRNA in gene therapy of cartilage endplate chondrocytes. METHODS: According to the sequence of COX-2 mRNA, COX-2 siRNA was designed, synthesized, cloned into the GFP reporter pcDNA6.2GW/EmGFPmiR vector and transfected into Hep cell line. The integrity of inset fragment was detected by colony PCR (polymerase chain reaction) and sequencing analysis. The cultured cartilage endplate chondrocytes were divided into 4 groups: control group (untreated), negative siRNA group (treatment with 30 nmol/L negative control siRNA), siRNA1 group (treatment with 15 nmol/L COX-2 siRNA) and siRNA2 group (treatment with 30 nmol/L COX-2 siRNA). The biological activity of recombinants was identified with the interference efficiency of COX-2 siRNA recombinant by real-time PCR and Western blot. And the effects of COX-2 inhibitor on the growth of chondrocytes were detected by WST-8 and the mRNA expressions of survivin, bcl-2 and bax genes measured by real-time PCR. RESULTS: The sequences of inset fragment in 4 siRNA expressing recombinants were correct. After COX-2 transfection, the expression of COX-2 mRNA in chondrocytes was 51.3% ± 7.2% in the siRNA1 group and 35.4% ± 3.6% in the siRNA2 group. Western blot showed that the expression of COX-2 protein decreased, especially in siRNA2 group (P < 0.05). And the cell survival rate was 100.0% ± 8.3% in the control group, 84.9% ± 4.2% in the negative control siRNA group, 52.5% ± 6.7% in the siRNA1 group and 48.9% ± 5.4% in the siRNA2 group (P < 0.05). Meanwhile, the expressions of mRNA of survivin and bcl-2 decreased while the expression of bax mRNA increased in degenerative cartilage endplate chondrocytes transfected with COX-2 siRNA (P < 0.05). CONCLUSION: COX-2-targeting siRNA inhibits the expression of COX-2, suppresses the proliferation of chondrocytes and induces the cell apoptosis. These effects may be attributable to the up-regulation of survivin and bcl-2 and the down-regulation of bax.

Occurrence of human cytomegalovirus glycoprotein B genotypes in immunocompetent and immunosuppressed Taiwanese patients.

OBJECTIVES: To investigate the differences of genotypic distributions among isolates between immunosuppressed and immunocompetent patients in a Taiwanese population. METHODS: Human cytomegalovirus (HCMV) isolates from 76 patients with adequate chart data were analyzed. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to define gB genotypes which include gB1 to gB4. The clinical data of the 76 patients were retrospectively collected by chart review and classified into an immunosuppressed (n = 32) or immunocompetent (n = 44) group. RESULTS: Among the 32 immunosuppressed patients, the most commonly identified HCMV genotypes were gB1 (27/32, 84.3%) and gB3 (4/32, 12.5%). 59.1% (26/44) of the immunocompetent patients were infected by gB1 while 38.6% (17/44) of them were infected by gB3. The frequency of gB1 infection in the immunosuppressed group was significantly higher than that in the immunocompetent group (p = 0.025). However, there was no statistically significant difference between gB1 and gB3 distributions by clinical diagnosis within each group. CONCLUSIONS: Only gB1 and gB3 genotypes were identified in this Taiwanese population. Although there is no significant difference between clinical diagnosis and gB genotyping, gB1 infection is significantly more predominant in immunosuppressed patients.

Artemisinin induces caspase-8/9-mediated and Bax/Bak-independent apoptosis in human lung adenocarcinoma (ASTC-a-1) cells.

Artemisinin (ARTE), an antimalarial phytochemical component from the sweet wormwood plant, has been shown a potential anticancer activity by inducing cell apoptosis. The aim of this report is to explore the mechanism of ARTE-induced human lung adenocarcinoma (ASTC-a-1) cell apoptosis. Cell counting kit (CCK-8) assay showed that ARTE induced cytotoxcity in a dose- and time-dependent manner. Confocal microscopy fluorescence imaging of cells stained with Hoechst 33258 and flow cytometry (FCM) analysis of cells stained with Annexin V-FITC/propidium iodide (PI) showed that ARTE induced reactive oxygen species (ROS)-dependent apoptosis. Confocal fluorescence resonance energy transfer (FRET) imaging of single living cells expressing SCAT3, SCAT9 or CFP-Bid-YFP and fluorometic substrate assay showed that ARTE induced the activation of caspase-3, -8 and -9. Moreover, inhibition of caspase-8 or -9 completely blocked ARTE-induced apoptosis which was only partially attenuated by caspase-3 inhibitor. Interestingly, silencing Bax and Bak by RNA interference (RNAi) did not attenuate ARTE-induced apoptosis. Collectively, ARTE induces caspase-dependent but Bax/Bak-independent apoptosis in ASTC-a-1 cells.

New progress in adjacent segment degeneration/disease.

Adjacent segment degeneration/disease (ASD) has been generally accepted as a long-term complication after spinal surgery. Although the incidence of ASD is not very high, it is gradually recognized to be a very important factor in evaluation of the long-term effect of spinal fusion. There are many views concerning pathogenic factors and ways of prevention and treatment. The authors review and discuss the current research and this article will describe recent advances in ASD.

Clinical characteristics of patients with Acinetobacter junii infection.

BACKGROUND AND PURPOSE: Acinetobacter junii is a human pathogen but A. junii infection is rarely reported. This study aimed to delineate the characteristics of A. junii infection. METHODS: The medical records of 34 patients who were treated at Taipei Veterans General Hospital, Taipei, Taiwan, from May 1999 to May 2007 and had A. junii isolated from sterile sites were reviewed. Isolates of A. junii were identified by using API ID 32 GN and were confirmed by analysis of the 16S-23S rRNA intergenic spacer region. RESULTS: Thirty five infections with A. junii were identified. The most common underlying conditions included prior antibiotic use (56%), central venous catheterization (50%), and malignancy (38%). Systemic inflammatory response syndrome and shock developing within 1 week were observed in 27 (77%) and 8 (23%) episodes, respectively. Eighty percent of the infectious episodes were hospital acquired. The infections were primary bacteremia (n = 32), empyema (n = 1), peritonitis (n = 1), and keratitis (n = 1). Polymicrobial infection was present in 9 episodes (26%). A. junii isolates remained susceptible to most of the tested antimicrobial agents, but the hospital-acquired isolates had higher resistance rates than the community-acquired isolates. Four patients (11.4%) died of A. junii infection despite appropriate antimicrobial therapy for 3 patients. Shock that developed within 1 week of bacteremia was associated with a poor outcome (p = 0.01). CONCLUSIONS: A. junii is an opportunistic pathogen that mainly affects patients who have had prior antimicrobial therapy, invasive procedures, or malignancy. Newly emerging infections caused by A. junii and the increasing antimicrobial resistance among hospital-acquired A. junii isolates should be monitored.

Clinical and bacteriological characteristics of pyogenic liver abscess in non-diabetic patients.

BACKGROUND AND PURPOSE: Diabetes mellitus is an important risk factor for Klebsiella pneumoniae liver abscess, but many patients with pyogenic liver abscess (PLA) do not have diabetes. This study was conducted to compare the clinical characteristics and prognostic factors of K. pneumoniae PLA with that caused by other organisms in non-diabetic patients. METHODS: The medical charts of patients with a diagnosis of PLA were retrospectively reviewed from January 2005 to December 2007. The clinical symptoms and signs, laboratory data, and risk factors were analyzed. RESULTS: There were 50 patients in the K. pneumoniae group and 34 patients in the non-K. pneumoniae group. The clinical presentations did not differ between the 2 groups. The patients in the non-K. pneumoniae group had a higher prevalence of malignant disease than those in the K. pneumoniae group (58.8% vs 6.0%; p < 0.001). Non-K. pneumoniae PLA was strongly associated with hepatobiliary tumor (p = 0.015). Among the non-K. pneumoniae isolates, Escherichia coli was the most common pathogen (n = 20; 58.8%). Forty seven K. pneumoniae isolates (94%) were susceptible to all tested antimicrobial agents except ampicillin, while the non-K. pneumoniae Gram-negative pathogens had greater resistance to first-generation cephalosporins. Poor prognostic factors included chronic renal failure (p = 0.005), abscess rupture (p = 0.036), and right lower lung infiltration (p = 0.049). CONCLUSIONS: Hepatobiliary malignancy and newly diagnosed malignancy were risk factors for non-K. pneumoniae liver abscess in non-diabetic patients. Physicians should ascertain the presence of underlying malignancy in patients with non-K. pneumoniae PLA.

Clinical significance of Blastocystis hominis: experience from a medical center in northern Taiwan.

BACKGROUND AND PURPOSE: Blastocystis hominis is an intestinal protozoan. The pathogenic role of this organism in human beings is still controversial and has varied among reports from different geographic areas. The purpose of this study was to determine the clinical significance of B. hominis in northern Taiwan. METHODS: A total of 100 patients who had a positive B. hominis stool examination during the period April to December of 2001 were retrospectively identified from Taipei Veterans General Hospital. The demographic and clinical characteristics of these patients were reviewed from the medical records. RESULTS: All of the patients were adults. Fifty nine patients had more than one underlying diseases, including malignancies. Twenty one patients presented with fever and 10 patients had gastrointestinal symptoms, including diarrhea and/or abdominal pain. However, all of the patients had other conditions that might have contributed to the clinical presentation, and they improved without specific treatment for B. hominis. Furthermore, there were no significant differences in clinical symptoms and white blood cell count between patients with malignancy or diabetes mellitus and those without. Six patients had hypereosinophilia that could not be attributed to other causes. Among 34 patients who had a further stool examination within one year, B. hominis was undetectable in 31 patients (91.2%), despite their having no specific antiprotozoal treatment. CONCLUSIONS: The association of clinical symptoms and B. hominis could not be delineated from our study, even in immunocompromised patients. All of the patients improved without receiving any specific therapy. More studies from different areas are needed in order to delineate the clinical significance B. hominis.

The type-2 variant of human cytomegalovirus glycoprotein N (gN-2) is not the rarest in the Chinese population of Taiwan: influence of primer design.

Studies of the human cytomegalovirus (HCMV) glycoprotein N (gpUL73-gN) showed that genotypic variations exist in different geographic areas, with gN-2 unidentified in Chinese population. The purpose of this study was to determine the HCMV gN variants in the Chinese population of Taiwan. Primers were designed and a polymerase chain reaction (PCR) was carried out on the UL73 gene. The PCR products were subjected to restriction fragment length polymorphism (RFLP) analysis. The same PCR-RFLP assay was repeated using primers published previously to demonstrate the influence of primer design. Of the 48 clinical HCMV isolates, 33 were positive for PCR products by both primer sets. Fifteen were positive only by the "in-house" PCR. The distribution of gN-1, gN-2, gN-3, and gN-4 by RFLP analysis was 14:11:7:17, with one isolate positive for both gN-1 and gN-2. The published primers detected the four genotypes with the number of 14:0:2:17. The under-representation of gN-2 and gN-3 by the method published previously may be due to inappropriate primer design when re-examining the sequences. On the basis of the results of this study, gN-2 is not the rarest gN genotype in the Chinese population of Taiwan. The design of primers used for PCR-RFLP genotyping may have a great influence on the frequency distribution of HCMV genomic variants.

Risk factors and mortality in patients with nosocomial Staphylococcus aureus bacteremia.

BACKGROUND: Infections due to methicillin-resistant Staphylococcus aureus have become increasingly common in hospitals worldwide. S aureus continues to be a cause of nosocomial bacteremia. METHODS: We analyzed the clinical significance (mortality) of MRSA and methicillin-susceptible S aureus bacteremia in a retrospective cohort study in a 2900-bed tertiary referral medical center. Survival and logistic regression analyses were used to determine the risk factors and prognostic factors of mortality. RESULTS: During the 15-year period, 1148 patients were diagnosed with nosocomial S aureus bacteremia. After controlling potential risk factors for MRSA bacteremia on logistic regression analysis, service, admission days prior to bacteremia, age, mechanical ventilator, and central venous catheter (CVC) were independent risk factors for MRSA. The crude mortality rate of S aureus bacteremia was 44.1%. The difference between the mortality rates of MRSA (49.8%) and MSSA bacteremia (27.6%) was 22.2% (P < .001). Upon logistic regression analysis, the mortality with MRSA bacteremia was revealed to be 1.78 times higher than MSSA (P < .001). The other predicted prognostic factors included age, neoplasms, duration of hospital stay after bacteremia, presence of mechanical ventilator, and use of CVC. CONCLUSIONS: Resistance to methicillin was an important independent prognostic factor for patients with S aureus bacteremia.

Risk factors for mortality in patients with Acinetobacter baumannii bloodstream infection with genotypic species identification.

BACKGROUND AND PURPOSE: Acinetobacter baumannii is an increasingly common nosocomial infection with a high mortality rate. Identification of predictor factors of mortality from A. baumannii infection is important for the implementation of therapeutic management for patients with higher risk. However, many studies have reported data for Acinetobacter calcoaceticus-A. baumannii complex, which might lead to an uncertainty of results. In this study, we aimed to identify the predictive factors for mortality of patients infected with true A. baumannii that had been precisely identified by genotypic methodology. METHODS: Sixty seven patients with documented A. baumannii bacteremia were identified from a medical center in northern Taiwan during the period between February 1998 and February 2001. The patients' medical records were retrospectively reviewed. RESULTS: The risk factors associated with mortality in patients with A. baumannii bacteremia were underlying disease with malignancy, end-stage renal disease, and inappropriate antibiotic therapy. Laboratory variables, such as creatinine level, were also associated with poor prognosis by multivariate analysis. CONCLUSIONS: Increased serum creatinine level, malignancy and inappropriate therapy within 3 days were related to increased mortality in patients with A. baumannii bloodstream infection. Physicians should be aware of patients with poor prognostic factors and initiate prompt strategies, including appropriate antimicrobial therapy, in order to reduce mortality.

Predictive value of two commercial human immunodeficiency virus serological tests in cases with indeterminate Western blot results.

BACKGROUND AND PURPOSE: Serodiagnosis of human immunodeficiency virus (HIV) infection typically requires repeatedly reactive positive screening test followed by Western blot (WB) assay. When WB assay result is indeterminate, the results of follow-up WB assay may remain inconclusive. This study evaluated use of enzyme-linked immunosorbent assay (ELISA) and particle agglutination test (PAT) as sequential screening tests with WB assay for the diagnosis of HIV infection. METHODS: From January 1, 2000 to December 31, 2003, a total of 565 serum samples collected from individuals with a previous positive or borderline positive ELISA test for HIV at regular check-up (281 samples) and a second group of individuals with known risk of HIV exposure or suspected infection based on clinical presentation (284 samples) were tested for HIV infection by ELISA, PAT and WB assay. RESULTS: The result was positive for HIV infection and confirmed by WB assay in 197 samples (22.5%), indeterminate in 127 samples (22.5%) and negative in 241 samples (42.6%). The sensitivity and specificity of ELISA were 100% and 21.6% and of PAT were 99.5% and 95%, respectively. Among the 197 HIV-infected cases, all ELISA and PAT results were concordant with WB assay except 1 (1/197) with negative PAT. Positive ELISA, positive PAT and indeterminate WB assay results were found in 9 of the 284 samples (7 individuals) from at-risk patients. Among these 7 individuals, 5 were later proved to have HIV infection. WB assay in 1 of the 7 individuals remained indeterminate 1 year later, and the remaining case was lost to follow-up. CONCLUSION: We suggest initial ELISA followed by PAT as sequential screening for HIV infection. When both screening tests are concordant but subsequent WB assay is indeterminate, further evaluation (such as nucleic acid amplification test) should be arranged as soon as possible.

Impact of the 1997 revised Centers for Disease Control criteria on case rates of legionellosis in Taiwan: review of 38 cases at a teaching hospital, 1998-2002.

In 1997, the United States Centers for Disease Control and Prevention (CDC) published revised case definitions for legionellosis which eliminated the previously used category of "probable case" based on a single indirect fluorescence antibody (IFA) titer. This study evaluated the influence of revision on the case rates of legionellosis in Taiwan. From 1988 to 2002, 4615 patients with pneumonia were tested for legionellosis in our hospital. The testing methods included IFA assay for serum specimens and direct fluorescence antibody (DFA) assay for sputum specimens. Using the revised criteria, Legionnaires' disease (LD) was diagnosed by DFA in 27 cases and by IFA in 11 cases. The most common underlying conditions were cigarette smoking (44.7%), chronic obstructive pulmonary disease (28.9%) and corticosteroid use (26.3%). The clinical features were nonspecific, including fever (73.7%), dyspnea (63.2%), cough (63.2%) and leukocytosis (63.2%). The overall mortality rate was 18.4%, and the directly LD-attributable mortality rate was 10.5%. Nasogastric tube insertion, endotracheal intubation, congestive heart failure before the onset of LD, inappropriate antimicrobial therapy, respiratory failure and absence of fever during the LD course were significantly associated with LD-attributable mortality. Older age (>70 years) was not associated with higher mortality (p=0.053). Using the revised diagnostic criteria in our series, the positive rate of case identification by IFA was 0.26%, while use of the previous case definitions resulted in a positive rate of 7.6% (including probable and definitive cases). Recognition that the original CDC criteria of IFA titer >1:256 or elevation of IFA titer <4-fold in paired sera could not adequately define an LD etiology has led to a dramatic lowering of case rates among studies after the criteria revision in Taiwan and elsewhere. Assays that are faster, more sensitive and less technician dependent are needed to diagnosis this disease.

Bacteremia in patients with hematological malignancies.

BACKGROUND: An appropriate regimen in the empirical therapy of neutropenic fever episodes must be individualized at each institution. Hospitals have different patterns of microbial isolates and antibiotic resistance that must be taken into account. The aim of this study was to investigate isolates of bacteremia and their antibiotic susceptibility in patients with hematological malignancies. METHODS: All positive blood cultures at a medical center in Taiwan between 1999 and 2002 from patients with hematological malignancies were evaluated. Eleven kinds of antibiotics were tested for antimicrobial activities. The risk factors for mortality were evaluated. RESULTS: Three hundred seventy-one episodes of bacteremia in 266 patients with hematological malignancies were recorded. Gram-negative bacilli (GNB) were still predominant and accounted for 78.2% of isolates, followed by gram-positive cocci for 20.8% of isolates, and anaerobes for 1% of isolates. Escherichia coli was the most common isolated organism accounting for 27.5% of GNB isolates. Other isolates included Klebsiella pneumoniae (19.3%), Pseudomonas aeruginosa (11%), and Enterobacter cloacae (10.1%). The most isolated microorganisms were susceptible to cefoperazone/sulbactam, piperacillin/tazobactam, cefepime or imipenem. Age, GNB microorganism and inadequate empirical antibiotics were risk factors. CONCLUSIONS: We suggest that cefoperazone/sulbactam, piperacillin/tazobactam, cefepime or imipenem is an ideal empirical therapy.