Increased frequency of hospital admissions with active systemic lupus erythematosus disease activity defined by two different disease activity indices: A cohort study.

The objective of this cohort study was to evaluate the association between the frequency of hospital admissions and disease activity, as defined by two different disease activity measurements: the Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) and the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), in adult patients with systemic lupus erythematosus (SLEs). Patients with SLE were recruited from the rheumatology outpatient department of a regional hospital in southern Taiwan. SLE-DAS and SLEDAI-2K were used to define SLE disease activity and the cause of hospital admissions was identified by a rheumatologist based on medical records. A generalized linear model (GLM) with gamma distribution and log-linked function was used to analyze variables associated with the frequency of admission. The mean frequency of hospitalization was 0.34 times per year for all-cause and 0.21 times per year for SLE-related admission. Multivariate GLM analysis showed that moderate/severe SLE disease activity defined by SLE-DAS was associated with an increased frequency of all-cause and SLE-related hospital admissions while adjusting for other covariates. Moderate/severe SLE disease activity defined by SLEDAI-2K was only significantly associated with an increased frequency of all-cause hospitalization. When steroid dosage was included in the model, moderate/severe SLE disease activity defined by the SLE-DAS remained significantly associated with SLE-related hospital admissions (p = 0.032). In conclusion, disease activity defined by the SLE-DAS, but not SLEDAI-2K was associated with an increased frequency of SLE-related hospitalization. Steroid dosage, a lower educational level, and smoking were associated with an increased frequency of hospital admissions, whereas underweight and alcohol use were associated with a decreased frequency of hospital admissions. Rheumatologists should promptly control SLE disease activity of their patients, provide them with adequate health education, and maintain steroid doses to as low as possible to reduce the risk of hospital admissions.

Dependable algorithm for visualizing snoring duration through acoustic analysis: A pilot study.

Snoring is a nuisance for the bed partners of people who snore and is also associated with chronic diseases. Estimating the snoring duration from a whole-night sleep period is challenging. The authors present a dependable algorithm for visualizing snoring durations through acoustic analysis. Both instruments (Sony digital recorder and smartphone's SnoreClock app) were placed within 30 cm from the examinee's head during the sleep period. Subsequently, spectrograms were plotted based on audio files recorded from Sony recorders. The authors thereby developed an algorithm to validate snoring durations through visualization of typical snoring segments. In total, 37 snoring recordings obtained from 6 individuals were analyzed. The mean age of the participants was 44.6 ±â€…9.9 years. Every recorded file was tailored to a regular 600-second segment and plotted. Visualization revealed that the typical features of the clustered snores in the amplitude domains were near-isometric spikes (most had an ascending-descending trend). The recorded snores exhibited 1 or more visibly fixed frequency bands. Intervals were noted between the snoring clusters and were incorporated into the whole-night snoring calculation. The correlative coefficients of snoring rates from digitally recorded files examined between Examiners A and B were higher (0.865, P < .001) than those with SnoreClock app and Examiners (0.757, P < .001; 0.787, P < .001, respectively). A dependable algorithm with high reproducibility was developed for visualizing snoring durations.

Risk of dental malocclusion in children with upper respiratory tract disorders: A case-control study of a nationwide, population-based health claim database.

OBJECTIVES: The aim of this study was to evaluate the association between different upper respiratory tract disorders and severe dental malocclusion in pediatric patients. METHODS: Newly diagnosed patients (N = 773) with dental malocclusion aged 8-18 years and controls (N = 3865) were identified from the health claim records of the Longitudinal Health Insurance Database 2000 of Taiwan's National Health Insurance Research Database. Controls were frequency matched to the cases by sex, age group, and index year. Univariate and multiple logistic regression analyses were used to evaluate the association between severe dental malocclusion and six common upper respiratory tract disorders, including acute sinusitis, allergic rhinitis, chronic sinusitis, nasal septum deviation, nasal polyps, and hypertrophy of tonsil and adenoids. RESULTS: The risk of severe dental malocclusion was significantly elevated in pediatric patients with three upper respiratory tract disorders, including acute sinusitis (adjusted odds ratio [aOR] = 1.66, 95% confidence interval [95% CI] 1.39-1.99), allergic rhinitis (aOR = 1.64, 95% CI 1.34-2.02), and chronic sinusitis (aOR = 2.01, 95% CI 1.27-3.19). When all the six upper respiratory tract disorders were simultaneously included in the multiple logistic regression analysis, acute sinusitis (aOR = 1.48, p < 0.001) and allergic rhinitis (aOR = 1.34, p < 0.010) were significantly and independently associated with an increased risk of severe dental malocclusion. CONCLUSIONS: Findings from this nationwide, population-based case-control study indicated that acute sinusitis and allergic rhinitis were independently and significantly associated with an increased risk of severe dental malocclusion in pediatric patients. Pediatricians should remain vigilant for the risk of dental malocclusion in their patients with these disorders.

Respiratory pathogens - Some altered antibiotic susceptibility after implementation of pneumococcus vaccine and antibiotic control strategies.

BACKGROUND/PURPOSE: Antimicrobial resistance in Taiwan has been on the rise for two decades. The implementation of pneumococcal conjugate vaccination (PCV13) and enhanced antimicrobial control (2013-2015) by the government may have changed the antibiotic resistance. METHODS: Four respiratory pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, and Moraxella catarrhalis) isolated in a single medical center during 2008-2017 were studied. We defined three temporal stages: (a) the first era (2008-2012), prior to implementation of the national immunization program (PCV13 vaccination), (b) the second era (2013-2015), during which an enhanced antibiotic control strategy was implemented, and (c) the third era (2016-2017), after implementation. Antimicrobial drug sensitivities were collected from two other hospitals: one from east Taiwan, one from west-central Taiwan. RESULTS: S. pneumoniae was frequently isolated during the first era. It declined progressively during the second era of PCV13 vaccination. S. pyogenes and M. catarrhalis were not frequently isolated. The drug susceptibility of S. pneumoniae to ceftriaxone and vancomycin remained high. The antimicrobial susceptibility of H. influenzae to amoxillin/clavulante declined over the three temporal stages, from 91.9%-79.5%-58.5% (all p < 0.05). CONCLUSION: Antimicrobial resistance of H. influenzae increased during the latter part of the study period. The PCV13 vaccination program reduced the invasive pneumococcal disease and reduced the stress on the emergent drug resistance. This enhanced antibiotic control strategy was effective in terms of nosocomial drug resistance but not for community-associated pathogens.

Acute rhinosinusitis among pediatric patients with allergic rhinitis: A nationwide, population-based cohort study.

BACKGROUND: While chronic rhinosinusitis is a common complication of allergic rhinitis, the link between acute rhinosinusitis and allergic rhinitis is unclear. The aim of this study was to evaluate the risk of incident acute rhinosinusitis among pediatric patients with allergic rhinitis, using a nationwide, population-based health claims research database. METHODS: Newly diagnosed allergic rhinitis patients aged 5-18 years were identified from the health claim records of the Longitudinal Health Insurance Database 2000 of Taiwan's National Health Insurance Research Database. A comparison cohort was assembled by randomly selecting patients from the same database with frequency matching by sex, age group, and index year. All patients were followed until a diagnosis of acute rhinosinusitis or the end of the follow-up period. Cox proportional hazards model was used to assess the association between allergic rhinitis and acute rhinosinusitis. RESULTS: Of the 43,588 pediatric patients included in this study, 55.4% were male and 43.9% were between the ages of 5.0-7.9 years. The risk of acute rhinosinusitis was significantly higher in pediatric patients with allergic rhinitis compared to those without the condition (adjusted hazard ratio = 3.03, 95% confidence interval = 2.89-3.18). Similar hazard ratios were observed between male and female pediatric patients. CONCLUSIONS: This secondary cohort study using a nationwide, population-based health claim data of the Taiwan's NHIRD showed that allergic rhinitis was significantly associated with a higher risk of acute rhinosinusitis among pediatric patients.

Incident osteoarthritis and osteoarthritis-related joint replacement surgery in patients with ankylosing spondylitis: A secondary cohort analysis of a nationwide, population-based health claims database.

BACKGROUND: Ankylosing spondylitis (AS) might be associated with an increased risk of secondary osteoarthritis. However, there is a lack of studies assessing its impact on osteoarthritis-related surgery. The aim of this secondary cohort study was to investigate the risk of symptomatic osteoarthritis and osteoarthritis-related surgery, including total hip replacement surgery (THRS) and total knee replacement surgery (TKRS) in patients with AS. METHODS: Using the Taiwan's National Health Insurance Research Database, we identified 3,462 patients with AS between 2000 and 2012. A comparison cohort was assembled consisting of five patients without AS, based on frequency matching for sex, 10-year age interval, and index year, for each patient with AS. Both groups were followed until diagnosis of the study outcomes or the end of the follow-up period. RESULTS: Male patients with AS exhibited a significantly higher incidence of osteoarthritis (adjusted incidence rate ratio [IRR] 1.43; P < 0.001), THRS (adjusted IRR 12.59; P < 0.001), and TKRS (adjusted IRR 1.89; P = 0.036). Moreover, analyses stratified by age group (20-39 years versus 40-80 years) indicated a high IRR (adjusted IRR 27.66; P <0.001) for THRS among younger patients with AS. CONCLUSIONS: Male patients with AS had a significant higher risk of developing osteoarthritis, and receiving THRS and TKRS. Young patients with AS also showed a significant higher risk of receiving THRS.

Cardiovascular comorbidities of rheumatoid arthritis in Taiwanese adults: A retrospective single-center study.

OBJECTIVE: To evaluate the association between rheumatoid arthritis (RA) and cardiovascular comorbidities, including hyperlipidemia, hypertension, and diabetes, in Taiwanese patients based on the data from medical records. MATERIALS AND METHODS: A retrospective study was performed using the computerized medical records from a regional hospital located in southern Taiwan. A total of 2293 patients (age range 30-79 years) with a diagnosis of RA (International Classification of Diseases, Ninth Revision, Clinical Modification code 714.0) treated since the opening of the study hospital in July 2000 until February 2013 were included. The RA cases were frequency matched for age and sex with 9172 patients without RA. The associations of RA with hyperlipidemia, hypertension, and diabetes were evaluated using multiple logistic regression analysis. RESULTS: Significant associations between RA and hyperlipidemia (adjusted odds ratio [OR] = 2.05, 95% confidence interval [CI] = 1.77-2.38, P < 0.001) and hypertension (adjusted OR = 2.76, 95% CI = 2.43-3.14, P < 0.001) were observed. However, diabetes was not significantly associated with RA in either male or female patients. CONCLUSION: Findings from this retrospective medical record study indicated that hyperlipidemia and hypertension were significant cardiovascular comorbidities of RA.

Cancer studies based on secondary data analysis of the Taiwan's National Health Insurance Research Database: A computational text analysis and visualization study.

There has been a surge in the academic publication output based on secondary analyses of the data from the Taiwan's National Health Insurance claim records. It has become a challenge to comprehend such a rapid expansion of the literature. Therefore, this study aimed to explore the conceptual content of National Health Insurance Research Database-based cancer research, using the abstract of articles extracted from PubMed between 2002 and 2015. Search terms including "National Health Insurance Research Database (NHIRD) AND Taiwan," "Taiwan AND population-based," and "Taiwan AND nationwide" were used to search in PubMed with the publication date limited to between 1997 and 2015. The retrieved articles were manually screened to retain only those that were cancer-related and were based on secondary data analysis of the NHIRD. A total 589 articles were selected for subsequent text mining using the R software. Among the 589 articles, the top 5 most studied cancer types were breast (16.3%), lung (11.4%), colorectal (10.4%), liver (8.3%), and prostate (7.5%). The articles that received the highest number of citations by PubMed Central articles were cited 92 times. The top 3 most frequently occurred keywords in the abstracts of the 589 articles were cancer, patient, and risk, with 3670, 2535, and 1652 times, respectively. Analysis of key conception indicated that the most common conceptions were diabetes, survival, breast cancer, lung cancer, and colorectal cancer. In conclusion, in this study of 589 published articles on secondary data analysis of the NHIRD, indexed by PubMed between 2002 and 2015, we found that while the risk factors of cancer, treatment of cancer, and survival of cancer patients were popular research topics, end-of-life cancer care issues were less studied. Further studies should explore these areas since they are as important as treatment of the disease itself for many patients.

Characteristics of nontyphoidal Salmonella gastroenteritis in Taiwanese children: A 9-year period retrospective medical record review.

Nontyphoidal Salmonella is among the most common causes of acute pediatric gastroenteritis in Taiwan. It is important to study antibiotic resistance patterns in nontyphoidal Salmonella isolated from children. Therefore, the objective of this study was to investigate the prevalence of serogroups and susceptibility to antimicrobial nontyphoidal Salmonella isolated from Taiwanese children with gastroenteritis. A retrospective review of the medical records of patients aged under 18 years with a diagnosis of acute gastroenteritis at a regional hospital located in southern Taiwan from August 2000 to August 2009 was conducted. Patients whose records documented stool cultures positive for nontyphoidal Salmonella underwent serogrouping and antimicrobial susceptibility testing. Of the 1938 patients diagnosed with acute gastroenteritis, 100 (5.2%) had nontyphoidal Salmonella infections. Most of the cases of nontyphoidal Salmonella gastroenteritis occurred during the summer months of July and August. The most common Salmonella strains isolated were classified as belonging to serogroup B (51%). Three cases had blood cultures that tested positive for nontyphoidal Salmonella, all of which were classified as belonging to serogroup C2. Isolates from the stool cultures of 23 cases that occurred between 2007 and 2009 were further tested to determine their antimicrobial susceptibility profiles, and 87% of these isolates were sensitive to two common third-generation cephalosporins (cefotaxime and ceftriaxone). In conclusion, the results of this nine-year period medical record review study suggested that although extended-spectrum cephalosporins were more effective than ampicillin and ciprofloxacin in treating childhood nontyphoidal Salmonella gastroenteritis, only 87% of isolates were susceptible to these agents. Prevention through proper hygienic practices to minimize potential exposure to nontyphoidal Salmonella is clearly a better strategy than treating patients with antibiotics following the incidence of infection.

Risk factors for delayed diagnosis of scabies in hospitalized patients from long-term care facilities.

BACKGROUND: Delayed diagnosis of scabies can cause an institutional outbreak, which causes considerably economic burden to control. This study was to find the risk factors for delayed diagnosis of scabies in hospitalized patients from long-term care facilities. METHODS: We conducted a retrospective analysis of the hospitalized patients from long-term care facilities, diagnosed to have scabies between January 2006 and December 2008. A stepwise logistic regression analysis was performed to determine the risk factors for delayed diagnosis of scabies. RESULTS: A total of 706 episodes with scabies were identified retrospectively in 399 hospitalized patients from long-term care facilities. Of these, 44 episodes were considered as delayed diagnosis of scabies. These patients were more associated with chronic usage of steroid (73% vs. 10%, P < 0.001) and had longer duration of hospitalization than the others (30 vs. 13 days, P < 0.001). After logistic regression, steroid therapy was the risk factor of delayed diagnosis of scabies (odds ratio: 23.493). CONCLUSIONS: In the patients from long-term care facilities, clinical physicians should pay more attention to those with chronic usage of steroid to avoid delayed diagnosis of scabies. KEYWORDS: Scabies; Delayed diagnosis; Risk factor; Long-term care facility.

Prognostic factors of candidemia among nonneutropenic adults with total parenteral nutrition.

BACKGROUND: Immediate removal of central venous catheters (CVCs) is not possible in patients with candidemia requiring total parenteral nutrition (TPN). This study analyzed the possible prognostic factors for survival time after onset of candidemia among nonneutropenic adults requiring TPN. METHODS: We conducted a retrospective analysis from September 2003 to August 2005. RESULTS: A total of 59 nonneutropenic adults with candidemia and requiring TPN were identified retrospectively. All Candida isolates were susceptible to flucytosine and amphotericin B. With the exception of one C glabrata isolate, all other isolates were susceptible to fluconazole and itraconazole. The only predictor of 30-day survival rate after onset of candidemia identified in our analysis was an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 23 points or less. Adults with higher APACHE II scores, who did not have their CVCs changed, did not receive antifungal treatment, or who had thrombocytopenia had shorter survival times after the onset of candidemia. CONCLUSIONS: APACHE II scores, thrombocytopenia, antifungal agents, and CVCs changes are associated with survival time in nonneutropenic adults requiring TPN after the onset of candidemia.

Influence of breast-feeding on weight loss, jaundice, and waste elimination in neonates.

BACKGROUND: The Baby-Friendly Hospital Initiative began promoting exclusive breast-feeding in 2001 in Taiwan; however, few studies have investigated its impact. This study evaluated the influence of breast-feeding on Taiwanese neonates with regard to the frequency of jaundice, body weight loss (BWL), and elimination of both urine and stool. METHODS: The medical records of 313 healthy mother-neonate pairs admitted at our hospital were reviewed retrospectively and divided into three groups: exclusively breast-feeding (n=161), mixed (breast/formula) feeding (n=80), and exclusively formula feeding (n=72). RESULTS: Compared with the exclusively formula feeding group, in the exclusively breast-fed neonates, the average total serum bilirubin level at 3 days after birth (p < 0.001) and the rate of significant hyperbilirubinemia ≥ 15 mg/dL (p<0.05) were significantly higher; the average BWLs at 2 and 3 days after birth (p < 0.001, p < 0.001) and the rate of BWL ≥ 10% (p < 0.05) were significantly higher; the average frequency of stool passage at 2 and 3 days after birth (p < 0.001, p < 0.001) and urination at 1, 2, and 3 days after birth (p < 0.001, p < 0.001, p < 0.001) were significantly less. The factors associated with a mother's choice of infant feeding type include maternal age and delivery method. CONCLUSION: Breast-feeding during the initial days of life has a significant influence on the degree of jaundice, amount of BWL, and the frequency of stool passage and urination.

Neonatal tetanus after home delivery: report of one case.

Neonatal tetanus is a rare disease in developed countries, but remains common in developing countries. Pregnant women immigrating to Taiwan from developing countries may carry a risk of neonatal tetanus to the child, because of inadequate tetanus toxoid immunization and inappropriate postnatal cord care. Many young pediatricians in Taiwan are unfamiliar with this disease. Herein, we describe the clinical course of a newborn with neonatal tetanus, who was admitted with complaints of difficult feeding and muscle rigidity. After mechanical ventilation for 58 days and a prolonged hospital stay, the infant was discharged in good condition. It is important to maintain a high index of suspicion for neonatal sepsis when infants present with seizure-like symptoms, in order to allow its early diagnosis and appropriate treatment.

Levofloxacin versus tetracycline antibiotics for the treatment of scrub typhus.

BACKGROUND: Scrub typhus is an important febrile disease in Southeast Asia and is caused by Orientia tsutsugamushi. Fluoroquinolones have proved to be effective for scrub typhus in an animal model. However, it is unclear whether they are also effective clinically. METHODS: We retrospectively reviewed the hospital-based medical records of patients diagnosed to have scrub typhus by an indirect immunofluorescence antibody assay or PCR at a large referral hospital in Taiwan for a 6-year period (2001-2007). To determine the efficacy of levofloxacin for the treatment of scrub typhus, we divided the patients into a levofloxacin-treated group and a tetracycline antibiotics-treated group. RESULTS: Out of 132 patients with scrub typhus, 71 initially received levofloxacin and 61 initially received tetracycline antibiotics. There was no statistically significant difference in the effective rate between the two groups (91.5% and 95.1% cured, respectively; p=0.648). The time to defervescence in the levofloxacin-treated group was longer than in the other group (49+/-41.1 and 24+/-19.6hours, respectively; p=0.001). In the patients with higher APACHE II scores, higher mortality was found in the levofloxacin-treated group (44.4% and 0%; p=0.033). CONCLUSIONS: Levofloxacin is effective in patients with scrub typhus, but has a longer time to defervescence compared with tetracycline antibiotics. When levofloxacin is used for severe scrub typhus, higher mortality may be attributed to the longer time to defervescence.

Epidural abscess caused by Haemophilus aphrophilus misidentified as Pasteurella species.

Haemophilus aphrophilus is one of the normal oropharyngeal flora and rarely implicated as a pathogen of spinal infection. A case of H. aphrophilus bacteremia complicated with epidural abscess, psoas muscle abscess, and spondylodiscitis is described in this report. The pathogen was mis-identified as Pasteurella spp. at the very start, and was confirmed by the molecular method. He was successfully treated with adequate antibiotics and surgery. The clinical features of sixteen previously reported cases of spinal infection caused by H. aphrophilus are reviewed.

Combination carbapenem-sulbactam therapy for critically ill patients with multidrug-resistant Acinetobacter baumannii bacteremia: four case reports and an in vitro combination synergy study.

Infections caused by multidrug-resistant Acinetobacter baumannii have become a therapeutic challenge for clinicians worldwide. Although colistin and tigecycline have been successful in treating patients with these infections, these agents are not available on a worldwide basis. We describe four critically ill patients in Taiwan who were diagnosed with multidrug-resistant Acinetobacter baumannii bacteremia. All bacterial isolates from these patients were resistant to commonly available antibiotics, including carbapenems and sulbactam; however, combination therapy with a carbapenem and sulbactam led to favorable clinical outcomes in all four patients. We also conducted an in vitro study using isolates from these patients that showed that this drug combination had a synergistic effect with enhanced antibacterial activity against the isolates. Thus, a carbapenem-sulbactam combination may be a therapeutic alternative for multidrug-resistant Acinetobacter baumannii bacteremia in countries where colistin and tigecycline are not available for clinical use.

Septic arthritis in children: relationship of causative pathogens, complications, and outcome.

This retrospective study investigated the causative pathogens, complications, and outcome of 58 children who were hospitalized for septic arthritis at a tertiary care hospital in southern Taiwan from July 1988 to December 2000. The mean age was 3 years (range, 12 days-16 years). The males/females ratio was 1.2:1. Ninety percent of the cases involved lower extremities (knee, hip, and ankle) with the hip being the most common site of infection (54%). Joint pain (81%) was the most common clinical presentation, followed by fever (74%), local warmness and swelling (72%), and limitation of motion (64%). Erythrocyte sedimentation rate was elevated (> or = 20 mm/h) initially in 89% of the cases. The predominant causative organism was Staphylococcus aureus (43%, 25/58), 6 isolates of which were methicillin-resistant, followed by coagulase-negative Streptococcus (6), Streptococcus pneumoniae (3), Salmonella spp. (3), Haemophilus influenzae type b (2), and group B Streptococcus (2). The concomitant complications of septic arthritis were sepsis (9%, 5/58) and meningitis (2%, 1/58). Ten patients had sequelae, including limitation of motion (6), limping gait (2), limb-length discrepancy (1), and abnormalities of bone growth (1). This study found that S. aureus was the most common infecting microorganism in septic arthritis in children. Septic arthritis with concomitant osteomyelitis and infection due to methicillin-resistant S. aureus was associated with a significantly increased risk of sequelae (relative risk, 46.4, 95% CI, 2.9-748.8; relative risk, 16. 2, 95% CI, 1.3-204.9, respectively).