Disseminated Cryptococcus neoformans infection involving multiple bones and lung in an immunocompetent patient: a case report.

BACKGROUND: Cryptococcal osteomyelitis is a rare and potentially serious condition, typically encountered in individuals with compromised immune systems. This case underscores the unusual occurrence of disseminated Cryptococcosis in an immunocompetent person, involving multiple bones and lungs, with Cryptococcus neoformans identified as the causative agent. CASE PRESENTATION: An Indonesian man, previously in good health, presented with a chief complaint of successive multiple bone pain lasting for more one month, without any prior history of trauma. Additionally, he reported a recent onset of fever. On physical examination, tenderness was observed in the left lateral chest wall and right iliac crest. Laboratory findings indicated mildly elevated inflammatory markers. A computed tomography (CT) scan of the chest revealed an ovoid solid nodule in the right lower lung and multifocal osteolytic lesions in the sternum, ribs, and humeral head. A magnetic resonance imaging (MRI) study of the sacrum showed multiple lesions in the bilateral iliac bone and the lower L4 vertebral body. Confirmation of Cryptococcal osteomyelitis involved a fine-needle biopsy and culture, identifying Cryptococcus neoformans in the aspirate. The patient responded positively to targeted antifungal treatments, leading to a gradual improvement in his condition. CONCLUSIONS: This case emphasizes the need to consider Cryptococcus neoformans osteomyelitis in immunocompetent patients with bone pain. A definitive diagnosis involves a fine-needle biopsy for pathology and culture, and prompt initiation of appropriate antifungal treatment has proven effective in preventing mortality.

Use of trimethoprim-sulfamethoxazole in a patient with G6PD deficiency for treating Pneumocystis jirovecii pneumonia without haemolysis: Case report and literature review.

WHAT IS KNOWN AND OBJECTIVE: A fixed dose of trimethoprim-sulphamethoxazole (TMP/SMZ) is the first-line therapy for Pneumocystis jirovecii pneumonia (PJP). Other alternative regiments have shown a suboptimal cure rate. However, TMP/SMZ has been reported to cause haemolyses when administered to patients with G6DP deficiency. PJP might be fatal without treatment. To date, there is still insufficient evidence to manage PJP with TMP/SMZ in G6DP deficiency population. CASE DESCRIPTION: We report a G6PD-deficient patient with human immunodeficiency virus (HIV) and PJP infection treated successfully with 21 days of high dose TMP/SMZ without any signs and symptoms of haemolysis. WHAT IS NEW AND CONCLUSION: Based on our experience, it is worth to note that despite TMP/SMZ is consider unsafe in patient with pre-existing G6PD-deficiency, it could still be suggested as the initial drug of choice in Taiwanese or southeast Asian population for treating PJP infected HIV patient.

Cutaneous tuberculosis simultaneously presenting as a subcutaneous nodule and mass: A case report.

Although the incidence of tuberculosis (TB) is decreasing globally, it remains an endemic disease in Taiwan. The etiology of cutaneous TB can be endogenous or exogenous. The mechanism of infection could be direct inoculation, contiguity, or hematogenous dissemination. The clinical manifestations are diverse, ranging from scrofuloderma, acute miliary TB, tuberculous chancre, tuberculosis verrucosa cutis, and lupus vulgaris to tuberculid. Basis the bacterial load, cutaneous TB is classified as multibacillary or paucibacillary. We present a case of cutaneous TB that initially presented as a subcutaneous nodule and a mass. The cutaneous TB likely originated from underlying TB lymphadenitis and TB spine and presented as scrofuloderma.

Analysis of Micro-Machining Process for External Thread of Micro Round Tube.

This study aims to analyze the stainless steel micro round tube external threading process for the influence of different outer threading pitches (0.25 mm, 0.4 mm) and outer diameters (Ø1.9, Ø1.94, Ø2). This study also analyzes the effects of different friction factors (0.1, 0.3, 0.5, 0.7, and 0.9) and different tube thicknesses (0.4, 0.45, 0.5, 0.55, and 0.6 mm) on the threading process. This study considers size effect to use corrected material parameters for the microtube to conduct the finite element analysis by DEFORM-3D software. The goal is to understand stainless steel (SUS304) micro round tube threading and the difference by using macro material parameter analysis. The historic forming data from the simulation and experiment of threading processing are presented, and the corresponding stress/strain distribution and thread shape are also calculated. The experiment results are compared to the simulation results to verify the reliability of this analysis method. The result shows that the torque/stress/strain obtained by the modified model is always lower than by Swift's model. It means that the size effect can be considered to apply on the forming process and provided proper torque to form the external thread of the micro round tube, e.g., the maximum torque of the round die for M2 × 0.25 occurs over the fourth stroke. For the influence of the outer diameter of the micro round tube, the larger diameter induces the larger maximum torque on the round die for M2 × 0.4, but for the smaller pitch of M2 × 0.25, the larger maximum torque is not influenced by the diameter of the tube. When the pitch of the round die is increased, the torque, stress and strain are also increased relatively. As the friction factor and torque between the round die and tube increase, the stress and strain become lower. Changing the tube thickness will not significantly change the torque, the stress, and the strain. These results guide the simulation and experiment of optimized micro round tube threading development and design to reduce cost and increase product quality.

Trend and Predictors of Short-term Mortality of Adult Bacteremia at Emergency Departments: A 14-Year Cohort Study of 14 625 Patients.

BACKGROUND: Bacteremia is a life-threatening condition with a high mortality rate in critical care and emergency settings. The current study investigated the trend of mortality and developed predictive models of mortality for adults with bacteremia at emergency departments (EDs). METHODS: We conducted a retrospective cohort study of adults with bacteremia at the ED of China Medical University Hospital. Patient data were obtained from the Clinical Research Data Repository, and mortality information was obtained from the National Death Registry. We developed a new model to predict 7-day mortality in the derivation population and compared the model performance of the new model with Pitt Bacteremia Score (PBS) and Bloodstream Infection Mortality Risk Score (BSIMRS) in the validation population. RESULTS: We identified 14625 adult patients with first-time bacteremia at the ED, of whom 8.4% died within 7 days. From 2003 to 2016, both the cumulative incidence and 7-day mortality rate of bacteremia decreased significantly. The ED bacteremia mortality (ED-BM) model included PBS parameters, age, infection source, baseline steroid use, and biochemical profiles (estimated glomerular filtration rate, platelet, blood urea nitrogen, potassium, and hemoglobin) for predicting 7-day mortality. The discrimination performance of the ED-BM model (area under curve [AUC], 0.903) was significantly better than that of PBS (AUC, 0.848) or BSIMRS (AUC, 0.885). CONCLUSIONS: Although the cumulative incidence and mortality of ED bacteremia decreased, its mortality burden remains critical. The proposed ED-BM model had significantly better model performance than other scoring systems in predicting short-term mortality for adult patients with bacteremia at EDs.

Younger adults with mild-to-moderate COVID-19 exhibited more prevalent olfactory dysfunction in Taiwan.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) is rapidly transmitted from person to person, causing global pandemic since December 2019. Instantly detecting COVID-19 is crucial for epidemic prevention. In this study, olfactory dysfunction is a significant symptom in mild to moderate COVID-19 patients but relatively rare in other respiratory viral infections. The Taiwan smell identification test (TWSIT) is a speedy and inexpensive option for accurately distinguishing anosmia that also quantifies the degree of anosmia. Using TWSIT in the outpatient clinic for early identifying the patients with mild to moderate COVID-19 can be promising. METHODS: Nineteen patients confirmed COVID-19 in central Taiwan were collected and divided into two groups: olfactory dysfunction and non-olfactory dysfunction. Demographic characteristics, laboratory findings, and the results of the olfactory test were compared between these two groups. FINDINGS: Thirteen (68.4%) of the 19 patients had olfactory dysfunction. The patients with olfactory dysfunction were younger than those without this symptom. The statistical difference in age distribution was significant between these two groups (IQR: 25.5-35.5 vs. IQR: 32.5-60.3; p-value: 0.012). There was no significant difference in gender, smoking history, comorbidities, travel history, respiratory tract infection symptoms, and laboratory findings between these two groups. CONCLUSION: This study demonstrated that young adults were prone to develop olfactory dysfunctions. In the flu season, olfactory dysfunction is considered a specific screening criterion for early detecting COVID-19 in the community. TWSIT can serve as a decent test for quantifying and qualifying olfactory dysfunction.

Mortality outcomes with hydroxychloroquine and chloroquine in COVID-19 from an international collaborative meta-analysis of randomized trials.

Substantial COVID-19 research investment has been allocated to randomized clinical trials (RCTs) on hydroxychloroquine/chloroquine, which currently face recruitment challenges or early discontinuation. We aim to estimate the effects of hydroxychloroquine and chloroquine on survival in COVID-19 from all currently available RCT evidence, published and unpublished. We present a rapid meta-analysis of ongoing, completed, or discontinued RCTs on hydroxychloroquine or chloroquine treatment for any COVID-19 patients (protocol: https://osf.io/QESV4/ ). We systematically identified unpublished RCTs (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Cochrane COVID-registry up to June 11, 2020), and published RCTs (PubMed, medRxiv and bioRxiv up to October 16, 2020). All-cause mortality has been extracted (publications/preprints) or requested from investigators and combined in random-effects meta-analyses, calculating odds ratios (ORs) with 95% confidence intervals (CIs), separately for hydroxychloroquine and chloroquine. Prespecified subgroup analyses include patient setting, diagnostic confirmation, control type, and publication status. Sixty-three trials were potentially eligible. We included 14 unpublished trials (1308 patients) and 14 publications/preprints (9011 patients). Results for hydroxychloroquine are dominated by RECOVERY and WHO SOLIDARITY, two highly pragmatic trials, which employed relatively high doses and included 4716 and 1853 patients, respectively (67% of the total sample size). The combined OR on all-cause mortality for hydroxychloroquine is 1.11 (95% CI: 1.02, 1.20; I² = 0%; 26 trials; 10,012 patients) and for chloroquine 1.77 (95%CI: 0.15, 21.13, I² = 0%; 4 trials; 307 patients). We identified no subgroup effects. We found that treatment with hydroxychloroquine is associated with increased mortality in COVID-19 patients, and there is no benefit of chloroquine. Findings have unclear generalizability to outpatients, children, pregnant women, and people with comorbidities.

A multicenter, randomized, open-label, controlled trial to evaluate the efficacy and tolerability of hydroxychloroquine and a retrospective study in adult patients with mild to moderate coronavirus disease 2019 (COVID-19).

OBJECTIVE: In this study, we evaluated the efficacy of hydroxychloroquine (HCQ) against coronavirus disease 2019 (COVID-19) via a randomized controlled trial (RCT) and a retrospective study. METHODS: Subjects admitted to 11 designated public hospitals in Taiwan between April 1 and May 31, 2020, with COVID-19 diagnosis confirmed by pharyngeal real-time RT-PCR for SARS-CoV-2, were randomized at a 2:1 ratio and stratified by mild or moderate illness. HCQ (400 mg twice for 1 d or HCQ 200 mg twice daily for 6 days) was administered. Both the study and control group received standard of care (SOC). Pharyngeal swabs and sputum were collected every other day. The proportion and time to negative viral PCR were assessed on day 14. In the retrospective study, medical records were reviewed for patients admitted before March 31, 2020. RESULTS: There were 33 and 37 cases in the RCT and retrospective study, respectively. In the RCT, the median times to negative rRT-PCR from randomization to hospital day 14 were 5 days (95% CI; 1, 9 days) and 10 days (95% CI; 2, 12 days) for the HCQ and SOC groups, respectively (p = 0.40). On day 14, 81.0% (17/21) and 75.0% (9/12) of the subjects in the HCQ and SOC groups, respectively, had undetected virus (p = 0.36). In the retrospective study, 12 (42.9%) in the HCQ group and 5 (55.6%) in the control group had negative rRT-PCR results on hospital day 14 (p = 0.70). CONCLUSIONS: Neither study demonstrated that HCQ shortened viral shedding in mild to moderate COVID-19 subjects.

Clinical features, antifungal susceptibility, and outcome of Candida guilliermondii fungemia: An experience in a tertiary hospital in mid-Taiwan.

BACKGROUNDS: Candida guilliermondii is rarely isolated from clinical specimen. C. guilliermondii fungemia is seldom reported in the literature. The aims of this study were to report the clinical features, antifungal susceptibility, and outcomes of patients with C. guilliermondii fungemia. METHODS: From 2003 to 2015, we retrospectively analyzed the clinical and laboratory data of patients with C. guilliermondii fungemia in a tertiary hospital in mid-Taiwan. We performed a multivariable logistic regression analysis to identify the risk factors of mortality. The Sensititre YeastOne microtiter panel assessed the susceptibility of antifungal agents. RESULTS: In this study, we identified 36 patients with C. guilliermondii fungemia. The median age of patients was 50.5 years (range, 17 days to 96 year) and 20 cases (56%) were male. The incidence of C. guilliermondii fungemia was 0.05 per 1000 admissions. Malignancy was the most common co-morbidity, and 25 (69%) patients had central venous catheter in place. Thirty-day overall mortality was 16.7%. In multivariate logistical regression analysis, catheter retention was an independent risk factor of mortality. According to epidemiological cutoff values, most clinical isolates (21/22, 95.5%) belonged to the wild-type MIC distributions for amphotericin B and flucytosine; however, the isolates were less susceptible to fluconazole (68%) and echinocandins (77-91%). CONCLUSION: Despite the lower mortality rate associated with C. guilliermondii fungemia, the removal of a central venous catheter remained an independent factor influencing the outcome of patients. The clinical significance of less susceptibility of C. guilliermondii to triazoles and echinocandins remains to be elucidated.

Analysis of Deep Drawing Process for Stainless Steel Micro-Channel Array.

The stainless steel bipolar plate has received much attention due to the cost of graphite bipolar plates. Since the micro-channel of bipolar plates plays the role of fuel flow field, electric connector and fuel sealing, an investigation of the deep drawing process for stainless steel micro-channel arrays is reported in this work. The updated Lagrangian formulation, degenerated shell finite element analysis, and the r-minimum rule have been employed to study the relationship between punch load and stroke, distributions of stress and strain, thickness variations and depth variations of individual micro-channel sections. A micro-channel array is practically formed, with a width and depth of a single micro-channel of 0.75 mm and 0.5 mm, respectively. Fractures were usually observed in the fillet corner of the micro-channel bottom. According to the experimental results, more attention should be devoted to the fillet dimension design of punch and die. A larger die fillet can lead to better formability and a reduction of the punch load. In addition, the micro-channel thickness and the fillet radius have to be taken into consideration at the same time. Finally, the punch load estimated by the unmodified metal forming equation is higher than that of experiments.

Isolated tuberculous liver abscess in an immunocompetent adult patient: A case report and literature review.

Tuberculous liver abscess is a rare disease entity even in endemic areas of Mycobacterium tuberculosis. It is usually accompanied by pulmonary tuberculosis or enteric tuberculosis. Further, an isolated tuberculous liver abscess is extremely rare. The disease is diagnosed by laparotomy or postmortem autopsy in most cases, and some authors adopted a 9-month antituberculosis regimen. We herein report a case of an isolated tuberculous liver abscess that initially manifested as persistent fever and general malaise, which was diagnosed by liver biopsy and treated successfully with a 6-month antituberculosis regimen and percutaneous abscess drainage.

Mortality outcomes with hydroxychloroquine and chloroquine in COVID-19 from an international collaborative meta-analysis of randomized trials

Investimento substancial em pesquisa COVID-19 foi alocado para ensaios clínicos randomizados (ECRs) sobre hidroxicloroquina/cloroquina, que atualmente enfrentam desafios de recrutamento ou descontinuação precoce. Nosso objetivo é estimar os efeitos da hidroxicloroquina e da cloroquina sobre a sobrevivência em COVID-19 de todas as evidências de RCT atualmente disponíveis, publicadas e não publicadas. Apresentamos uma rápida meta-análise de ECRs em andamento, concluídos ou descontinuados em tratamento com hidroxicloroquina ou cloroquina para qualquer paciente com COVID-19 (protocolo: : https://osf.io/QESV4/). Identificamos sistematicamente ECRs não publicados (ClinicalTrials.gov, WHO Plataforma Internacional de Registro de Ensaios Clínicos, registro Cochrane COVID até 11 de junho de 2020), e ECRs publicados (PubMed, medRxiv e bioRxiv até 16 de outubro de 2020). Todas as causas mortalidade foi extraída (publicações/pré-impressões) ou solicitada aos investigadores e combinados em meta-análises de efeitos aleatórios, calculando odds ratio (ORs) com intervalos de confiança de 95% (ICs), separadamente para hidroxicloroquina e cloroquina. Pré-especificado as análises de subgrupo incluem configuração do paciente, confirmação de diagnóstico, tipo de controle e status de publicação. Sessenta e três estudos eram potencialmente elegíveis. Incluímos 14 ensaios não publicados (1308 pacientes) e 14 publicações/preprints (9011 pacientes). Resultados para hidroxicloroquina são dominados por RECOVERY e WHO SOLIDARITY, dois ensaios altamente pragmáticos, que empregaram doses relativamente altas e incluíram 4.716 e 1.853 pacientes, respectivamente (67% dos o tamanho total da amostra). O OR combinado na mortalidade por todas as causas para hidroxicloroquina é 1,11 (IC 95%: 1,02, 1,20; I² = 0%; 26 ensaios; 10.012 pacientes) e para cloroquina 1,77 (IC 95%: 0,15, 21,13, I² = 0%; 4 ensaios; 307 pacientes). Não identificamos efeitos de subgrupo. Nós achamos isso tratamento com hidroxicloroquina está associado ao aumento da mortalidade na COVID-19 pacientes, e não há benefício da cloroquina. Os achados não têm generalização clara para ambulatorial, crianças, gestantes e pessoas com comorbidades.