Risk prediction models for delirium in the intensive care unit after cardiac surgery: a systematic review and independent external validation

Numerous risk prediction models are available for predicting delirium after cardiac surgery, but few have been directly compared with one another or been validated in an independent data set. We conducted a systematic review to identify validated risk prediction models of delirium (using the Confusion Assessment Method-Intensive Care Unit tool) after cardiac surgery and assessed the transportability of the risk prediction models on a prospective cohort of 600 consecutive patients undergoing cardiac surgery at a university hospital in Hong Kong from July 2013 to July 2015. The discrimination (c-statistic), calibration (GiViTI calibration belt), and clinical usefulness (decision curve analysis) of the risk prediction models were examined in a stepwise manner. Three published high-quality intensive care unit delirium risk prediction models (n=5939) were identified: Katznelson, the original PRE-DELIRIC, and the international recalibrated PRE-DELIRIC model. Delirium occurred in 83 patients (13.8%, 95% CI: 11.2-16.9%). After updating the intercept and regression coefficients in the Katznelson model, there was fair discrimination (0.62, 95% CI: 0.58-0.66) and good calibration. As the original PRE-DELIRIC model was already validated externally and recalibrated in six countries, we performed a logistic calibration on the recalibrated model and found acceptable discrimination (0.75, 95% CI: 0.72-0.79) and good calibration. Decision curve analysis demonstrated that the recalibrated PRE-DELIRIC risk model was marginally more clinically useful than the Katznelson model. Current models predict delirium risk in the intensive care unit after cardiac surgery with only fair to moderate accuracy and are insufficient for routine clinical use.

A NOVEL OLEAGINOUS YEAST STRAIN WITH HIGH LIPID PRODUCTIVITY AND ITS APPLICATION TO ALTERNATIVE BIODIESEL PRODUCTION

Five lipid-producing yeast strains, CHC08, CHC11, CHC28, CHC34, and CHC35, were revealed by Sudan Black B staining to contain lipid droplets within cells. Molecular analysis demonstrated that they were 2 strains of Candida parapsilosis, Pseudozyma parantarctica, Pichia manshurica, and Pichia occidentalis. Following batch fermentation, P. parantarctica CHC28 was found to have the highest biomass concentration, total lipids and lipid content levels. The major fatty acids in the lipids of this yeast strain were C16 and C18. Predictions of the properties of yeast biodiesel using linear equations resulted in values similar to biodiesel made from plant oils. Preliminary production of yeast biodiesel from P. parantarctica CHC28 was accomplished through esterification and transesterification reactions. It was found that yeast lipids with high acid value are easily converted to biodiesel at an approximately 90% yield. Therefore, it is possible to use crude lipids as alternative raw materials for biodiesel production.

Distance dependence of energy transfer from InGaN quantum wells to graphene oxide

We report the distance-dependent energy transfer from an InGaN quantum well to graphene oxide (GO) by time-resolved photoluminescence (PL). A pronounced shortening of the PL decay time in the InGaN quantum well was observed when interacting with GO. The nature of the energy-transfer process has been analyzed, and we find the energy-transfer efficiency depends on the 1/d² separation distance, which is dominated by the layer-to-layer dipole coupling.

Optical coupling from InGaAs subcell to InGaP subcell in InGaP/InGaAs/Ge multi-junction solar cells

Spatially-resolved electroluminescence (EL) images in the triple-junction InGaP/InGaAs/Ge solar cell have been investigated to demonstrate the subcell coupling effect. Upon irradiating the infrared light with an energy below bandgap of the active layer in the top subcell, but above that in the middle subcell, the EL of the top subcell quenches. By analysis of EL intensity as a function of irradiation level, it is found that the coupled p-n junction structure and the photovoltaic effect are responsible for the observed EL quenching. With optical coupling and photoswitching effects in the multi-junction diode, a concept of infrared image sensors is proposed.

Cancellation of elective operations on the day of intended surgery in a Hong Kong hospital: point prevalence and reasons

OBJECTIVE

To determine the point prevalence of elective surgical case cancellations and the reasons.

DESIGN

Cross-sectional study.

SETTING

Teaching hospital, Hong Kong. PATIENTS; Operating theatre records of elective surgery cancellations from 1 January 2009 to 31 December 2009 were retrospectively reviewed. MAIN OUTCOME MEASURES. Cancellation of scheduled elective surgery on the day of surgery and the corresponding reasons.

RESULTS

Of 6234 cases scheduled, 476 were cancelled, which yielded a point prevalence of 7.6%, with a 95% confidence interval of 7.0-8.3%. The highest number of cancellations occurred in patients scheduled for major general surgical procedures (n=94, 20%), major urological procedures (n=64, 13%), major orthopaedic surgery (n=38, 8%), and ultra-major cardiothoracic surgery (n=29, 6%). The most common category for cancellation was facility (73%), followed by work-up (17%), patient (10%), and surgeon (1%). No available operating room time due to overrun of the previous surgery was the most common reason for case cancellation (n=310). Compared to general surgery, the odds of no available operating time was significantly less in orthopaedics (odds ratio=0.26; 95% confidence interval, 0.17-0.39), otolaryngology (0.25; 0.13-0.46), neurosurgery (0.36; 0.16-0.70), paediatrics (0.53; 0.31-0.87), gynaecology (0.18; 0.11-0.29), ophthalmology (0.19; 0.07-0.41), and dentistry (0.10; 0.00-0.60). CONCLUSIONS. Case cancellations were mainly due to facility factors, such as no operating room time being available. The odds of having no operating room time available varied between surgical specialties.

Energy transfer from InGaN quantum wells to Au nanoclusters via optical waveguiding

We present the first observation of resonance energy transfer from InGaN quantum wells to Au nanoclusters via optical waveguiding. Steady-state and time-resolved photoluminescence measurements provide conclusive evidence of resonance energy transfer and obtain an optimum transfer efficiency of ~72%. A set of rate equations is successfully used to model the kinetics of resonance energy transfer.

Oblique electron-beam evaporation of distinctive indium-tin-oxide nanorods for enhanced light extraction from InGaN/GaN light emitting diodes

This paper presents a novel and mass-producible technique to fabricate indium-tin-oxide (ITO) nanorods which serve as an omnidirectional transparent conductive layer (TCL) for InGaN/GaN light emitting diodes (LEDs). The characteristic nanorods, prepared by oblique electron-beam evaporation in a nitrogen ambient, demonstrate high optical transmittance (T>90%) for the wavelength range of 450nm to 900nm. The light output power of a packaged InGaN/GaN LED with the incorporated nanorod layer is increased by 35.1% at an injection current of 350mA, compared to that of a conventional LED. Calculations based on a finite difference time domain (FDTD) method suggest that the extraction enhancement factor can be further improved by increasing the thickness of the nanorod layer, indicating great potential to enhance the luminous intensity of solid-state lighting devices using ITO nanorod structures.

Broadband and omnidirectional antireflection employing disordered GaN nanopillars

Disordered GaN nanopillars of three different heights: 300, 550, and 720 nm are fabricated, and demonstrate broad angular and spectral antireflective characteristics, up to an incident angle of 60? and for the wavelength range of lambda=300-1800 nm. An algorithm based on a rigorous coupled-wave analysis (RCWA) method is developed to investigate the correlations between the reflective characteristics and the structural properties of the nanopillars. The broadband and omnidirectional antireflection arises mainly from the refractive-index gradient provided by nanopillars. Calculations show excellent agreement with the measured reflectivities for both s- and p- polarizations.

Enhanced light output from a nitride-based power chip of green light-emitting diodes with nano-rough surface using nanoimprint lithography

Enhanced light extraction from a GaN-based power chip (PC) of green light-emitting diodes (LEDs) with a rough p-GaN surface using nanoimprint lithography is presented. At a driving current of 350 mA and with a chip size of 1 mm × 1 mm packaged on transistor outline (TO)-cans, the light output power of the green PC LEDs with nano-rough p-GaN surface is enhanced by 48% when compared with the same device without a rough p-GaN surface. In addition, by examining the radiation patterns, the green PC LED with nano-rough p-GaN surface shows stronger light extraction with a wider view angle. These results offer promising potential to enhance the light output powers of commercial light-emitting devices by using the technique of nanoimprint lithography under suitable nanopattern design.

Characterisation of plasmids encoding CTX-M-3 extended-spectrum β-lactamase from Enterobacteriaceae isolated at a university hospital in Taiwan

CTX-M-3 is the most common extended-spectrum beta-lactamase produced by Enterobacteriaceae in Taiwan. The present study was conducted to characterise the genetic environment surrounding bla(CTX-M-3). A total of 11 ceftriaxone-resistant isolates were studied: Escherichia coli (n=4), Klebsiella pneumoniae (n=5) and Salmonella enterica serotypes Anatum (SA831R) and Potsdam (SC72). Molecular methods used included polymerase chain reaction, sequencing, DNA-DNA hybridisation, conjugation, physical mapping and restriction fragment length polymorphism (RFLP) analysis. All isolates examined carried bla(CTX-M-3) on large plasmids (>70kb). The resistance plasmids of the two Salmonella and two K. pneumoniae strains (KP104 and KP116) were confirmed to be conjugative in vitro. RFLP analysis indicated that the plasmids were different. Physical mapping also revealed the difference between the two Salmonella plasmids, pSA831R (82kb) and pSC72 (74kb). An insertion sequence, ISEcp1, was found upstream of each bla(CTX-M-3) gene. However, sequencing of downstream regions of the bla genes showed two different patterns: the presence of orf477 in pSA831R and of orf1-mucA in pSC72, pKP104 and pKP116. IncI1-type oriT and nikA sequences were present in the plasmids of all the clinical isolates tested, except S. Anatum. Different bla(CTX-M-3)-carrying plasmids were identified among the enterobacteria studied. The presence of ISEcp1 in all isolates may be associated with the widespread resistance among Enterobacteriaceae. Although the plasmids were not identical, they appeared to belong to the same incompatibility group (IncI1-like plasmids), suggesting that they are genetically related but may have evolved divergently over time.

Integron-associated imipenem resistance in Acinetobacter baumannii isolated from a regional hospital in Taiwan

We investigated the genetic properties of imipenem-resistant Acinetobacter baumannii collected from a regional hospital in Taiwan. Pulsed-field gel electrophoresis demonstrated that the isolates were genetically diverse. Polymerase chain reaction, DNA sequencing, and DNA-DNA hybridisation showed that the bla(IMP-1) gene resided as a cassette in a plasmid-borne class 1 integron in two isolates. The majority of the resistant isolates were plasmid-less and carried no bla(IMP), bla(VIM) or bla(CFI) genes, indicating that other uncharacterised metallo-beta-lactamases or mechanisms other than enzyme production are involved in carbapenem resistance in this group of A. baumannii. We conclude that multidrug resistance of A. baumannii was a combined effect of lateral gene transfer and clonal spread of multiple resistant clones. Strict measures should be implemented to control the further spread of resistance.

Isolation of Salmonella enterica serotype choleraesuis resistant to ceftriaxone and ciprofloxacin

Salmonella enterica serotype choleraesuis (S choleraesuis) usually causes systemic infections in man that need antimicrobial treatment. We isolated a strain of S choleraesuis that was resistant to ceftriaxone and ciprofloxacin from a patient with sepsis. Ciprofloxacin resistance was associated with mutations in gyrA and parC, whereas the ampC gene (bla(CMY-2)), responsible for ceftriaxone resistance, was carried by a transposon-like mobile element. This element was found inserted into finQ of a potentially transmissible 140 kb plasmid, with an 8 bp direct repeat flanking the junction regions. The appearance of this resistant S choleraesuis is a serious threat to public health, and thus constant surveillance is warranted.

Efficacy of Helicobacter pylori eradication on platelet recovery in children with chronic idiopathic thrombocytopenic purpura

AIM

Little is known about the influence of environmental factors on the epidemiology of idiopathic thrombocytopenic purpura (ITP). The role of Helicobacter pylori infection in relation to the development and/or persistence of ITP in infected patients remains controversial. Therapy used for eradicating H. pylori has led to a rise in platelet counts in a significant number of adult patients. but few paediatric studies have been undertaken to evaluate such treatment. The aim of this prospective study was to determine the prevalence of H. pylori and to evaluate whether H. pylori eradication can induce chronic ITP regression in children.

METHODS

To investigate new, noninvasive techniques for diagnosis of H. pylori infection, an enzyme immunoassay for H. pylori antigens in faeces (HpSA) was evaluated. Patient eligibility criteria included isolated thrombocytopenia (< or = 50 x 10(9) L-(-1)) for more than 6 months without any identifiable cause and either normal or increased marrow megakaryocytes. H. pylori status was monitored before eradication and 4, 12, and 24 mo, after the end of treatment using Premier Platinum HpSA.

RESULTS

In this study we evaluated 22 chronic ITP patients, 9 of whom were infected with H. pylori. Using repeated HpSA testing, we demonstrated for eradication of H. pylori after treatment in all infected patients. Five of the nine patients had increased platelet counts that persisted throughout the follow-up period.

CONCLUSION

These results should stimulate additional research into the involvement of H. pylori infection in chronic ITP in childhood. This approach may offer an accepted algorithm at least for some of these patients.

Efficacy of Helicobacter pylori eradication on platelet recovery in children with chronic idiopathic thrombocytopenic purpura

AIM

Little is known about the influence of environmental factors on the epidemiology of idiopathic thrombocytopenic purpura (ITP). The role of Helicobacter pylori infection in relation to the development and/or persistence of ITP in infected patients remains controversial. Therapy used for eradicating H. pylori has led to a rise in platelet counts in a significant number of adult patients. but few paediatric studies have been undertaken to evaluate such treatment. The aim of this prospective study was to determine the prevalence of H. pylori and to evaluate whether H. pylori eradication can induce chronic ITP regression in children.

METHODS

To investigate new, noninvasive techniques for diagnosis of H. pylori infection, an enzyme immunoassay for H. pylori antigens in faeces (HpSA) was evaluated. Patient eligibility criteria included isolated thrombocytopenia (< or = 50 x 10(9) L-(-1)) for more than 6 months without any identifiable cause and either normal or increased marrow megakaryocytes. H. pylori status was monitored before eradication and 4, 12, and 24 mo, after the end of treatment using Premier Platinum HpSA.

RESULTS

In this study we evaluated 22 chronic ITP patients, 9 of whom were infected with H. pylori. Using repeated HpSA testing, we demonstrated for eradication of H. pylori after treatment in all infected patients. Five of the nine patients had increased platelet counts that persisted throughout the follow-up period.

CONCLUSION

These results should stimulate additional research into the involvement of H. pylori infection in chronic ITP in childhood. This approach may offer an accepted algorithm at least for some of these patients.

Isocupressic acid blocks progesterone production from bovine luteal cells

The needles of ponderosa pine (Pinus ponderosa Laws.) were reported to induce abortions when fed to late-term pregnant beef cows in North America. An in vivo study of pregnant cows suggested that isocupressic acid (IA) was the main abortifacient isolated from needles and bark of the pine. However, the mechanism of abortifacient activity of IA is not clear yet. In a pregnant cow, the corpus luteum of the ovary helps the maintenance of pregnancy by its progesterone production. This study involved the IA extracted from the root of the Taiwan cypress (Juniperus formosana) and used a frozen-thawed bovine luteal cell culture system to investigate the action of IA on progesterone production. Thawed bovine luteal cells (1 x 10(5) cells/ml/well) in M199 medium were cultured in 24-well culture plates at 37 degrees C in a 5% CO2 incubator. Ten ml of tested drugs, IA at 1 to 1000 ng/ml and/or ovine luteinizing hormone (oLH) at 1 to 100 ng/microl or 8-bromo-cyclic adenosine monophosphate (8-Br-cAMP) with 0.1-10 mM, were added into each well. After 4 hours of incubation, the media were harvested and assayed for progesterone by an enzyme immunoassay. Progesterone production from cells was the indicator used to evaluate the action of IA. All tested doses of IA significantly inhibited progesterone production in both basal and oLH stimulating conditions. Also those dosages inhibited cyclic adenosine-3',5'- monophosphate (cAMP) stimulation, suggesting a post-cAMP mechanism is involved in the IA action. We concluded that IA can induce pregnant cows to abort partly through blocking luteal function and may be identified as a new abortifacient chemical.

Short-term ceftriaxone therapy for treatment of severe non-typhoidal Salmonella enterocolitis

AIM

To evaluate the clinical efficacy of a short-course ceftriaxone therapy in the treatment of paediatric patients with severe non-typhoidal Salmonella enterocolitis.

METHODS

During a 1 y period, all paediatric patients who were suspected having Salmonella enterocolitis by the presentation of bloody and/or mucoid diarrhoea with or without fever were eligible for the study. Patients with either negative stool cultures or bacteraemia were excluded. Severe enterocolitis was defined as a bloody and/or mucoid diarrhoea associated with high fever persisting for longer than 48 h and signs of moderate or severe dehydration. The patients with severe enterocolitis were assigned to treatment with ceftriaxone (50 mg kg(-1) d(-1)) for 3-5 d, while the rest were given supportive treatment only. Before treatment all study patients received blood testing for white blood cell (WBC) count, C-reactive protein (CRP) level and blood culture. The duration of the fevers was recorded. Patients were followed up after clinical recovery for the possibility of relapse.

RESULTS

Seventy-three patients with culture-confirmed Salmonella enterocolitis without bacteraemia were analysed. The duration of fever was longer in severe cases who were treated with ceftriaxone than those who were not. However, rapid defervescene was found after short-course ceftriaxone therapy in those patients with severe enterocolitis. CRP was significantly higher in severe cases. There was no significant difference in the WBC count between the two groups of patients. No relapse was found in these patients.

CONCLUSION

High CRP, prolonged high fever and signs of moderate or severe dehydration appear appropriate to define severe cases of Salmonella enterocolitis. Short-course ceftriaxone therapy is clinically beneficial to these patients. Neither clinical nor microbiological relapse was seen after therapy.

Splenic abscess caused by group A beta-haemolytic streptococcus

A case of a pyoderma complicated with splenic abscess and bacteraemia caused by group A streptococcus was treated successfully with antibiotics alone for 4 weeks. To our knowledge, this is the first reported case of splenic abscess associated with group A streptococcal bacteraemia. Advances in antibiotic therapy and imaging techniques have improved the management and outcomes of splenic abscesses. Clinicians should be aware of the possibility of splenic abscess after a pyoderma or a sepsis-like episode.

CONCLUSION

Splenic abscesses can be diagnosed by serial ultrasound or CT scan examinations and should be treated with antibiotics for 4-6 weeks.

Use of parenteral testosterone prior to hypospadias surgery

Surgical correction of genital defects was formerly proposed when the size of the penis was sufficient to permit easy surgical repair. To enlarge penile size, temporary stimulation with testosterone or dihydrotestosterone cream has been used; however, the results were not only inconsistent, but absorption was also variable. We report our experience with parenteral testosterone as an adjunct to reconstructive genital surgery in 25 patients aged 6-18 months from July 1999 to December 2000, including 8 with penile hypospadias, 15 with penoscrotal hypospadias, and 2 with perineal hypospadias. Each had a penis that was significantly smaller than usual. Testosterone enanthate 25 mg was given i.m. once per month for a total of three doses before surgical repair. Penile length and glans circumference were measured before therapy and at operation. Side effects such as the development of pubic hair and acne were monitored. Bone age was checked 1 year later. An increase in penile length (from 19.8 +/- 2.4 mm to 23.8 +/- 2.0 mm) and glans circumference (from 27.4 +/- 1.4 mm to 37.84 +/- 2.6 mm) was apparent in all except 2 patients (P < 0.001 for both, paired t-test). Four patients had a significant increase in either penile length or glans circumference after the initial dose so that no further injections were required. No definite secondary effects were found. Preoperative parenteral testosterone therapy thus causes a significant increase in penile length and glans circumference without apparent side effects. We suggest that this therapy prior to microphallic hypospadias repair is appropriate.

Different proinflammatory reactions in fatal and non-fatal enterovirus 71 infections: implications for early recognition and therapy

AIM

The mechanism of pulmonary oedema, a life-threatening manifestation of enterovirus 71 (EV71) encephalitis, is unclear. Our aim was to assess the relationship of proinflammatory cytokines to EV71-related pulmonary oedema.

METHODS

Proinflammatory responses in 33 EV71 patients with various complications and 21 normal healthy children were measured using an enzyme-linked immunosorbent assay.

RESULTS

EV71 patients with both encephalitis and pulmonary oedema were found to have much higher levels of blood interleukin-6 (IL-6) (947 +/- 1239 vs 4.9 +/- 3.1 pg/ml, p = 0.0003), tumour necrosis factor-alpha (TNF-alpha) (22.4 +/- 29.5 vs 5.3 +/- 1.0 pg/ml, p = 0.0035), interleukin Ibeta (IL-1beta) (48.4 +/- 85.2 vs 4.9 +/- 10.1 pg/ml, p = 0.01), white blood cell count (28.3 +/- 7.6 vs 15.5 +/- 6.8 10(9)/L, p > or = 0.0001) and blood glucose (501 +/- 186 vs 165 +/- 117 mg/dL, p = 0.0009) than patients with EV71 encephalitis alone. In fact, the cytokine levels in patients with encephalitis only or in those without complications were not significantly different from the levels found in normal children. The sensitivity, specificity, positive and negative predictive values of IL-6 > 70 pg/ml for EV71 encephalitis with pulmonary oedema were all 100%.

CONCLUSION

Patients with EV71-related encephalitis combined with pulmonary oedema were found to have significantly elevated levels of proinflammatory cytokines and the best predictor for this complicated condition was found to be the level of serum IL-6.

School-aged children with Kawasaki disease: high incidence of cervical lymphadenopathy and coronary artery involvement

OBJECTIVE

We describe 10 school-aged children with Kawasaki disease (KD) with a high incidence of cervical lymphadenopathy and coronary abnormality.

METHODS

Based on a database of 1002 children with KD in Chang Gung Children's Hospital from January 1983 to March 2001, 10 (1%) school-aged patients (five boys, five girls) who met the diagnostic criteria of KD were included for analysis.

RESULTS

Cervical lymphadenopathy was noted in all (100%) of these patients. Unilateral neck mass mimicking acute suppurative infections not responding to antibiotic therapy was the initial presentation in nine (90%) of the 10 patients. The mean interval between disease onset and diagnosis was 9.9 +/- 3.3 days (range, 6-15 days). Seven (70%) of these patients responded to one course of high-dose intravenous immunoglobulin (IVIG) therapy (2 g/kg) and oral aspirin (80-100 mg/kg per day), two (20%) required a second course of IVIG, and one (10%) responded to high-dose aspirin treatment only. Coronary artery abnormality (dilatation or aneurysm) was documented by echocardiography in seven (70%) patients (four boys, three girls). In six patients, the coronary artery abnormalities resolved in 1 year, while one patient had persistent right coronary artery aneurysm, which necessitated continued anticoagulant and low-dose aspirin therapy.

CONCLUSION

The incidence of school-aged children among patients with KD is about 1% in our hospital. These patients are notable for the high incidence of initial manifestations of unilateral neck mass and coronary artery involvement. This disease should be listed as the differential diagnosis in school-aged children presenting with fever and neck mass that do not respond to antibiotic therapy.

Molecular epidemiology of nalidixic acid-resistant campylobacter isolates from humans and poultry by pulsed-field gel electrophoresis and flagellin gene analysis

To investigate the potential of poultry products as the source of human infections associated with quinolone-resistant campylobacters, 140 human and 75 poultry isolates of nalidixic acid-resistant campylobacters were collected between 1996 and 1998, and analysed by two molecular typing methods. By the analysis of restriction fragment length polymorphism of the flagellin gene, 33 distinct patterns were obtained, with 18 of which shared by both human (89%) and poultry (93%) isolates. By the pulsed-field gel electrophoresis of SmaI-restricted macrofragments, 105 different profiles were obtained, and 11 were found in both human (40%) and poultry (23%) isolates. When the two typing methods were combined, 112 unique genotypes were obtained, 11 of which were shared by both populations, including 53 (38%) human isolates and 14 (19%) poultry isolates. Although domestic poultry products are still important sources of the quinolone-resistant campylobacter infections in humans, there are other factors that might contribute to these increasing infections simultaneously. A more stringent policy in the use of antimicrobial agents in food animals can no longer be ignored.

Deep neck infections in children

From December 1989 through 1998, a total of 68 children with deep neck infection were enrolled into this study. The mean age was 5.9 years (range, 1 month-15.8 years). Infections in the retropharyngeal space (36.7%) were most common, followed by parapharyngeal space (30.8%), peritonsillar space (20.6%), and submandibular space (11.9%). Fever, neck pain, and swelling were the most frequent symptoms. The most common pathogens were viridans streptococci (41%, 16/39) and Staphylococcus aureus (26%, 10/39). Other isolates included Prevotella spp., Veillonella spp., Klebsiella pneumoniae, Escherichia coli, Morganella spp., and Enterobacter spp. Mixed infection was found in 46% (18/39) of patients. The mean duration of hospitalization was 12.4 days (range, 2-45 days). Complete resolution was achieved in 61 (89.7%) children. Complications occurred in 7 patients, including recurrence, mediastinal spread, bacteremia, and suppurative thyroiditis; the patient with mediastinal spread plus bacteremia died. Five patients had congenital cyst and 4 of them had complications or recurrence/relapse. In conclusion, infections in the retropharyngeal space and polymicrobial infections were most common in deep neck infection of Taiwan children.

The tetrapod limb: a hypothesis on its origin

A wrist joint and structures typical of the hand, such as digits, however, are absent in [Eustenopteron] (Andrews and Westoll, '68, p 240). Great changes must have been undergone during evolution of the ankle joint; the small number of large bones in the fin must somehow have developed into a large number of small bones, and it is very difficult to draw homologies in this region, or even be certain of what is being compared (Andrews and Westoll, '68, p 268). The tetrapod limb is one of the major morphological adaptations that facilitated the transition from an aquatic to a terrestrial lifestyle in vertebrate evolution. We review the paleontological evidence for the fin-limb transition and conclude that the innovation associated with evolution of the tetrapod limb is the zeugopodial-mesopodial transition, i.e., the evolution of the developmental mechanism that differentiates the distal parts of the limb (the autopodium, i.e., hand or foot) from the proximal parts. Based on a review of tetrapod limb and fish fin development, we propose a genetic hypothesis for the origin of the autopodium. In tetrapods the genes Hoxa-11 and Hoxa-13 have locally exclusive expression domains along the proximal-distal axis of the limb bud. The junction between the distal limit of Hoxa-11 expression and of the proximal limit of Hoxa-13 expression is involved in establishing the border between the zeugopodial and autopodial anlagen. In zebrafish, the expression domains of these genes are overlapping and there is no evidence for an autopodial equivalent in the fin skeleton. We propose that the evolution of the derived expression patterns of Hoxa-11 and Hoxa-13 may be causally involved in the origin of the tetrapod limb.

Secular trends in incidence and antimicrobial resistance among clinical isolates of Salmonella at a university hospital in Taiwan, 1983-1999

The incidence and antimicrobial resistance among clinical isolates of salmonella at a university hospital in Taiwan between 1983 and 1999 are summarized in this report. A total of 7986 isolates were analysed. Serogroup B has been the most prevalent over the years, with an apparently continuous decline after 1995. Concordant decrease was also found among S. choleraesuis and S. typhi isolates in recent years. In contrast, the proportion of serogroup D strains increased significantly after 1996. S. typhi remained relatively susceptible to most of the antimicrobial agents examined. For non-typhoidal isolates, antimicrobial resistance to ampicillin (62%), chloramphenicol (67%), and sulfamethoxazole-trimethoprim (37%) was relatively higher than that reported elsewhere. Newer generation cephalosporins and fluoroquinolones remained effective over the years, although emerging resistance to these drugs has been noticed since 1992. A more prudent selection and use of antimicrobial agents, in both humans and animals, and a continuous surveillance of resistance are essential in the future.

Role of calcium-independent phospholipases (iPLA(2)) in phosphatidylcholine metabolism

The proposed role of calcium-independent phospholipase A(2) (iPLA(2)) in membrane phospholipid homeostasis was tested by examining the perturbation of phosphatidylcholine metabolism by enzyme overexpression. There are alternatively spliced forms of murine iPLA(2) that were widely expressed in mouse tissues: a long form containing exon-9 that is membrane-associated and a short form lacking exon-9 that is distributed between the membrane and cytosolic fractions. Enforced expression of either iPLA(2) isoform led to a significant increase in intracellular free fatty acid, lysophosphatidylcholine, and GPC without a concomitant increase in the incorporation of either exogenous arachidonic acid or choline. The accumulation of lysophosphatidylcholine in iPLA(2)-expressing cells illustrates the limited capacity of cells for reacylation and degradation of lysophospholipids. Since iPLA(2) overexpression did not accelerate either phospholipid remodeling or phosphatidylcholine synthesis, this enzyme does play a determinant (rate-controlling?) role in either of these cellular processes.

Characteristics of group A streptococcal bacteremia with comparison between children and adults

This retrospective study aimed to compare the characteristics of group A streptococcal bacteremia in children and adults. A total of 76 (12 children and 64 adults) patients with group A streptococcal bacteremia treated from October 1995 through September 2000 at the Linko Chang Gung Memorial Hospital were included. The mean age was 47.6 years (range, 12 days-90 years). Forty-four (57.9%) patients had predisposing medical conditions. Malignant cancer (23.7%) and diabetes (22.4%) were the 2 most common conditions, which occurred only in adults. Two (16.7%) children had chickenpox associated with secondary group A streptococcal bacteremia. Skin and soft tissue infection (60.5%) was the most common clinical manifestation. The mortality rate related to group A streptococcal bacteremia was 25%. Twelve patients met the criteria of streptococcal toxic shock syndrome and 6 (50%) were children (p<0.05). Despite immediate and aggressive treatment, mortality due to streptococcal toxic shock syndrome was 66.7%. The incidence of streptococcal toxic shock syndrome was much higher in children (50%) than in adults (9.4%). Early diagnosis of invasive group A streptococcal infections and streptococcal toxic shock syndrome requires awareness of the presentations and a high level of suspicion. For fulminant group A streptococcal infection, a combination of a beta-lactam antibiotic plus clindamycin and/or adjuvant therapy with intravenous immunoglobulin is recommended.

Liver abscess caused by Klebsiella pneumoniae in siblings

Klebsiella pneumoniae has been emerging as the leading cause of liver abscess in diabetic patients. Results of molecular typing of K. pneumoniae isolates from two siblings with liver abscess, their family members, and the environment suggest a possibility of cross infection of liver abscess by the fecal-oral route within diabetic patients.

Large drug resistance virulence plasmids of clinical isolates of Salmonella enterica serovar Choleraesuis

Salmonella enterica serovar Choleraesuis generally causes systemic human salmonellosis without diarrhea, and therefore, antimicrobial treatment is essential for such patients. The drug resistance information on this organism is thus of high value. Serovar Choleraesuis usually harbors a virulence plasmid (pSCV) of 50 kb in size. Of the 16 clinical isolates identified to be serovar Choleraesuis, all except one harbored a pSCV and seven of them carried a pSCV of more than 125 kb in size. A pSCV was defined as a plasmid carrying spvC and characteristic deletions detected by PCR and by DNA-DNA hybridization (for the former criterion). The results of PCR, restriction fragment profiles, and Southern DNA-DNA hybridizations of the profiles all indicated that such larger pSCVs were derived from the 50-kb plasmid recombined with non-pSCVs found in some clinical isolates. Fifteen of the 17 strains, including a laboratory strain, were then tested for drug resistance against 16 antibiotics with E-test and the dilution method. The laboratory strain, which harbored a 50-kb pSCV and a 6-kb non-pSCV, was resistant only to sulfonamides (SUL), and its resistance gene, sulII, checked with PCR and DNA-DNA hybridization, was located on the 6-kb non-pSCV. All 14 clinical strains were resistant to multiple drugs. Of the 14, 7 were resistant to SUL, and the resistance gene was located on a plasmid. The sulII gene, but not bla(TEM-1), was carried only on the 6-kb non-pSCV. Of the remaining six large plasmids, three of 90 kb, two of 136 kb, and one of 140 kb, the last three were pSCVs and carried the other SUL gene (sulI) and the bla(TEM-1) gene. The six strains were also resistant to trimethoprim-sulfamethoxazole. None of the 50-kb pSCVs carried resistance genes. These drug resistance genes on the large pSCVs were apparently also acquired through recombination.

Childhood and adolescent tuberculosis in northern Taiwan: an institutional experience during 1994-1999

This study evaluated the clinical characteristics of childhood and adolescent tuberculosis (TB) at the end of the twentieth century in a referral children's hospital in northern Taiwan. The hospital charts were reviewed retrospectively of children/adolescents aged less than 18 y who were seen in a children's hospital in northern Taiwan between 1994 and 1999 and diagnosed with TB. A total of 62 individuals was diagnosed during this period. The patients' demographic data, presenting symptoms, clinical features, bacteriological results, drug susceptibility and tuberculin skin-test results were analysed. Most diagnosed cases lay in one of two main age ranges, younger than 5 y and adolescents. The presenting symptoms of study subjects were typically non-specific. Bone involvement occurred for 21 patients (33.9%) and was the most common extrapulmonary manifestation. Mycobacterium tuberculosis was isolated from 47 patients (75.8%). Five isolates were resistant to pyrazinamide, three to streptomycin and one to isoniazid, but no multidrug resistant isolates of TB were detected from culture-proven cases. Seventeen of 47 (36.2%) culture-proven patients revealed negative acid-fast staining initially but, subsequently, M. tuberculosis was isolated from various clinical specimens using a standard method at a later date. The tuberculin skin test was positive for 24 of 32 patients (75%) who received such an examination.

CONCLUSION

Extrathoracic TB was more common in children below 5 y of age than their adolescent counterparts, and chiefly involved the peripheral long bones. The potential drug resistance of M. tuberculosis in childhood and adolescent TB did not appear to have been a major problem in northern Taiwan before the year 2000.

Endogenous endophthalmitis and necrotising pneumonia caused by Klebsiella pneumoniae in a child with beta-thalassaemia major

A case beta-thalassaemia major complicated with Klebsiella pneumoniae endogenous endophthalmitis is presented to increase physician awareness of the association of the two clinical conditions. Severe morbidity including subretinal abscess and retinal detachment may develop despite aggressive intravenous and intravitreal ceftriaxone therapy, along with vitrectomy and external drainage.

Effect of N(G)-nitro-L-arginine methyl ester on intestinal permeability following intestinal ischemia-reperfusion injury in a rat model

Subclinical intestinal ischemia-reperfusion injury (IRI) causes an increase in mucosal permeability and may represent an early event in the pathogenesis of necrotizing enterocolitis in premature infants. Previous studies suggested that continuous, endogenous formation of nitric oxide (NO) maintains the mucosal integrity of the intestine, thus protecting the gut from injuries from blood-borne toxins and tissue-destructive mediators. This study was undertaken to assess whether the inhibition of NO production causes an increase in intestinal permeability in rats following IRI. Sprague-Dawley rats weighing 200-300 g were divided into 4 groups: (1) untreated group (normal control); (2) ischemia-reperfusion group; (3) early N(G)-nitro-L-arginine methyl ester (L-NAME), a specific inhibitor of NO production, treatment group, and (4) late L-NAME treatment group. Transient IRI was induced by 30-min occlusion, followed by reperfusion of the isolated ileal loop. The L-NAME was administered 15 min before and after mesenteric ischemia as a 25-mg/kg bolus. Fluorescein isothiocyanate-dextran (FITC-D) was used to quantitatively assess the alteration in mucosal permeability of the intestine. There was no significant increase in the portal vein FITC-D level among normal controls, ischemia-reperfusion group and late L-NAME-treated group, but there was an approximately 6-fold increase in the early L-NAME treatment group. The pathological features of the intestine following IRI include denudation of the villus epithelium and reduction of villus height, associated with marked inflammatory cell infiltration over the lamina propria. These results suggest that endogenous NO may play a role in the protecting intestinal integrity after IRI.

Epstein-Barr virus-associated hemophagocytic syndrome masquerading as lymphoma: a case report

Virus-associated hemophagocytic syndrome (VAHS) is a non-neoplastic, generalized histiocytic proliferation with prominent hemophagocytosis associated with a systemic viral infection. Although Epstein-Barr virus (EBV) is one candidate virus for this association, thorough serologic and molecular biologic studies to determine the presence of the viral infection have been lacking in many reports. Whereas elevated liver function tests are common findings in patients with VAHS, exudative ascites and abdominal lymphadenopathy are rare. We describe a case of EBV-AHS masquerading as lymphoma in which treatment with intravenous immunoglobulins was associated with complete clinical remission at 2 years and 6 months after the onset. Regardless of the exact mechanism responsible for ascites formation in VAHS, this case adds support to the possible involvement of EBV in patients with abdominal lymphadenopathy and ascites.

Surgical implications of pseudomonas aeruginosa necrotizing fasciitis in a child with acute lymphoblastic leukemia

Necrotizing fasciitis caused by Pseudomonas aeruginosa is extremely rare. Only 4 cases were reported in the literature. The authors report the occurrence of P aeruginosa necrotizing fasciitis starting out as a vulval abscess in a girl before induction chemotherapy for acute lymphoblastic leukemia. To our knowledge, this is the second case described in association with leukemia. In this case, the outcome was favorable because of early surgical intervention, confirming the diagnosis. J Pediatr Surg 36:948-950.

Ginseng flowers stimulate progesterone production from bovine luteal cells

Our previous report first showed evidence that polysaccharides isolated from ginseng leaves obtained from Jilin, China possess luteotropic activities. In this study, we made further investigations on the root and flowers of Korean ginseng by means of the same bioassay system described briefly as follows. Frozen-thawed bovine luteal cells (1 x 10(5) cells/ml/well) in M199 were incubated in 24-well culture plates at 37 degrees C in a 5 % CO2 incubator. Ten microl of tested drugs with 1, 10 and 100 microg/ml were added into each well. After 4- and 24-hr incubation, the media were harvested and assayed for progesterone by an enzyme immunoassay. The production of progesterone from cells is the indicator for evaluating the action of tested drugs. Results showed that hot water extracts ofginseng flowers (GF-1) with 10 to 100 microg/ml significantly increased progesterone production, whereas those from ginseng root (GR-1) could not. Crude polysaccharides (GF-2) isolated from GF-1 is the active component and the small molecules (mw < 10,000 dalton) are excluded, indicating that the ginseng root has no luteotropic activities, but the polysaccharides of ginseng flowers have.

Carriage of antibiotic-resistant pneumococci among Asian children: a multinational surveillance by the Asian Network for Surveillance of Resistant Pathogens (ANSORP)

To investigate the nasal carriage of antibiotic-resistant pneumococci by children, anterior nasal swabs were done for 4963 children <5 years old in 11 countries in Asia and the Middle East. In total, 1105 pneumococci isolates (carriage rate, 22.3%) were collected, 35.8% of which were found to be nonsusceptible to penicillin. Prevalence of penicillin nonsusceptibility was highest in Taiwan (91.3%), followed by Korea (85.8%), Sri Lanka (76.5%), and Vietnam (70.4%). Penicillin resistance was related to residence in urban areas, enrollment in day care, and a history of otitis media. The most common serogroups were 6 (21.5%), 23 (16.5%), and 19 (15.7%). The most common clone, as assessed by pulsed-field gel electrophoresis, was identical to the Spanish 23F clone and to strains of invasive isolates from adult patients. Data in this study documented the high rate of penicillin or multidrug resistance among isolates of pneumococci carried nasally in children in Asia and the Middle East and showed that this is due to the spread of a few predominant clones in the region.

Acute disseminated encephalomyelitis in autoimmune hemolytic anemia

A 16-year-old female with chronic autoimmune hemolytic anemia is presented. She was diagnosed with acute disseminated encephalomyelitis by clinical findings and magnetic resonance imaging (MRI), and the condition occurred after a systemic infection with Cryptococcus neoformans. Intravenous immunoglobulin therapy remarkably improved the patient's neurologic deficit and resolved abnormalities evidenced on MRI. To our knowledge, this report is the first of a pediatric patient with autoimmune hemolytic anemia complicated by acute disseminated encephalomyelitis that developed after an apparently successful treatment of cryptococcal meningitis.

Lack of evidence of an association between the carriage of virulence plasmid and the bacteremia of Salmonella typhimurium in humans

The involvement of the virulence plasmid (pSTV) of Salmonella typhimurium in human salmonellosis was examined. Most of the 224 clinical strains isolated from the blood (53) and nonblood samples (171) contained a 90 kb or larger plasmid, most of which were pSTV. The rates of pSTV carriage in the isolates showed no statistically significant difference between those derived from the blood and those from other sources (87% vs. 83%; chi2=0.49, 0.1<P<0.9), suggesting that pSTV may not play a critical role in promoting S. typhimurium bacteremia in humans. Nine strains with representative plasmid profiles were tested for the mouse virulence. The result revealed that these clinical isolates contained all three virulent types known: the avirulent, the highly virulent when a pSTV was present, and the moderately virulent regardless of the presence or absence of pSTV. This indicated that mouse virulence of S. typhimurium did not correlate their virulence in humans. Clinical data showed that most patients with primary bacteremia had underlying immunosuppressive diseases, whereas only a few patients with secondary bacteremia had preexisting diseases (87% vs. 13%; chi2=22.73, P<0.005). It is suggested that the contribution of pSTV to S. typhimurium bacteremia in humans is likely to be limited, and both the host factor and the microbial virulence determinants on the chromosome are more important than virulence plasmid in predisposing patients to bacteremia.

Septic arthritis of the hip caused by Salmonella typhi

We describe septic arthritis of the hip in a child with typhoid fever. The aetiological diagnosis was confirmed by a positive Widal test as well as by isolation of Salmonella typhi from joint aspirate. Treatment with ceftriaxone along with surgical drainage was successful.

MDM2 and MDMX can interact differently with ARF and members of the p53 family

Members of the p53 family of transcription factors have essential roles in tumor suppression and in development. MDM2 is an essential regulator of p53 that can inhibit the transcriptional activity of p53, shuttle p53 out of the nucleus, and target p53 for ubiquitination-mediated degradation. Little is known about the interaction and selectivity of different members of the p53 family (p53, p63, and p73) and the MDM2 family (MDM2 and MDMX). Here we show that the transcriptional activities of p53 and p73, but not that of p63, were inhibited by both MDM2 and MDMX. Consistent with these, we found that MDMX can physically interact with p53 and p73, but not with p63. Moreover, ectopically expressed MDM2 and MDMX could induce alterations in the subcellular localization of p73, but did not affect the subcellular localization of p53 and p63. Finally, we demonstrate that while ARF can interact with MDM2 and inhibit the regulation of p53 by MDM2, no interaction was found between ARF and MDMX. These data reveal that significant differences and selectivity exist between the regulation of different members of the p53 family by MDM2 and MDMX.

Determination of polychlorinated dibenzo-p-dioxin and dibenzofuran congeners in air particulate and marine sediment standard reference materials (SRMs)

Due to the limited number of environmental matrix certified reference materials (CRMs) with assigned values for natural levels of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs), an interlaboratory study was undertaken by the National Institute of Standards and Technology (NIST) and Environment Canada to establish reference concentration values for selected PCDD/Fs in two well-characterized NIST Standard Reference Materials (SRMs): SRM 1649a (Urban Dust) and SRM 1944 (New York/New Jersey Waterway Sediment). Results from 14 laboratories were used to provide reference values for the seventeen 2, 3, 7, 8-substituted PCDD/F congeners, the totals for individual tetra- through hepta-substituted PCDD/F homologues, and the total amount of tetra- through hepta-substituted PCDD/Fs. The mass fractions for the individual 2, 3, 7, 8-substituted congeners range from approximately 0.01 microg/kg to 7 microg/kg dry mass.

Gene conversion may aid adaptive peak shifts

Gene conversion is often viewed as a homogenizing force that opposes adaptive evolution. The objective of this study is to suggest a potential role for gene conversion in adaptive evolution of proteins through aiding the transfer of a population from one adaptive peak to another. Our hypothesis starts with the observation that a tandem gene duplication may result in an extra gene copy that is released from selective constraints. In such cases, individually deleterious mutations may accumulate on the extra copy of the gene, and through gene conversion these mutations may subsequently be presented to the functioning gene for selection en masse. Thus, groups of mutations that jointly confer a selective advantage may regularly be made available for selection. We present a mathematical model of this process and identify the range of rates of gene conversion, gene duplication and mutation under which it may operate. The results indicate that the process may be biologically feasible if the rate of appearance of the potentially beneficial mutations is not too small in relation to the rates of null mutation and of gene conversion. This process appears to be a possible mechanism for effecting adaptive peak shifts in large populations. We show that all the evolutionary steps in the proposed model may have occurred in the evolution of primate gamma -globin genes. We suggest that hide-and-release mechanisms for genetic variation may constitute a more general principal of evolvability.

Humans and old world monkeys have similar patterns of fetal globin expression

The expression of epsilon- and gamma-globin mRNA and protein has been determined in three Old World monkey species (Macaca mulatta, Macaca nemestrina, and Cercopithecus aethiops). Using RT-PCR with primers for epsilon- and gamma-globin, both mRNAs were detected in early fetal stages, whereas at 128 days (85% of full term), only gamma was expressed. High-performance liquid chromatography was used for separation and quantitation, and matrix-assisted laser desorption/ionization mass spectrometry was used for identification of globin polypeptides. An alpha-globin polymorphism was observed in all of the species examined. During fetal life, gamma-globin was the predominant expressed beta-type globin. The red blood cells of infants still contained substantial amounts of gamma-globin, which declined to negligible levels in 14 weeks as beta-globin expression reached adult values. The ratio of gamma1- to gamma2-globins (equivalent to Ggamma/Agamma in humans) was approximately 2.5, similar to the Ggamma/Agamma ratio observed in humans. Thus, gamma-globin gene expression in these Old World monkeys species has three features in common with human expression: expression of both duplicated gamma genes, the relative preponderance of gamma1 over gamma2 expression, and the delay of the switch from gamma- to beta-globin until the perinatal period. Thus, the catarrhines seem to share a common pattern of developmental switching in the beta-globin gene cluster, which is distinct from the timing of expression in either prosimians or the New World monkeys. Our results indicate that an Old World monkey, such as Rhesus, could serve as a model organism (resembling humans) for experimentally investigating globin gene expression patterns during the embryonic, fetal, and postnatal stages.