Journal of the Chinese Medical Association

Community-acquired Methicillin Resistant Staphylococcus aureus and Endocarditis: An Emerging Pathogen?

Yu-Jiun Chan — 2010-02-01

The Global Spread of 2009 H1N1 Influenza: A False Pandemic?

Teh-Ia Huo — 2010-02-01

Seroprevalence of Antibodies to Pandemic (H1N1) 2009 Influenza Virus Among Hospital Staff in a Medical Center in Taiwan

2010-02-01

Background: The pandemic (H1N1) 2009 influenza emerged in April 2009 and spread rapidly and broadly all over the world. In addition to specific antiviral agents, massive vaccination is thought to be the most effective way of controlling the transmission. To understand the prevaccination status of certain risk groups, this study compared the baseline sero-prevalence of antibodies to the pandemic (H1N1) 2009 influenza virus among hospital staff with different contact risks and that of the general population. Methods: A total of 295 serum samples from hospital staff and 244 control serum samples from people who came for physical check-up (control group) were collected between October 2009 and November 2009 before the massive vaccination campaign. The hospital staff was divided into first-line risk personnel (group 1) and second-line risk personnel (group 2) according to their potential contact risks. Hemagglutination-inhibition (HI) tests were conducted to determine the individual serological status. The seropositive rate (SPR, defined as the proportion with HI titer ≥ 1:40) of antibodies to H1N1 influenza virus and its geometric mean titer (GMT) were calculated and compared among the different groups. Results: The mean ages and sex ratio (% male) of the hospital staff and control groups were 36.9 ± 10.6 years and 52.0 ± 12.6 years, and 24.4% and 57.6%, respectively. The SPR of the antibodies to H1N1 influenza virus of the hospital staff was significantly higher than that of the control group (20.0% vs. 2.9%, p < 0.001). Furthermore, the SPR antibodies to H1N1 influenza virus of group 1 were significantly higher than that of group 2 (30.8% vs. 12.6%, p < 0.001). However, the GMT of antibodies to H1N1 influenza virus of the hospital staff was not significantly different from that of the control group (p = 0.925). Conclusion: The SPR of antibodies against the pandemic (H1N1) 2009 virus in the hospital staff was higher than that in the general population, reflecting a higher contact risk. Prevaccination surveillance of the immune status of different risk groups may help to prioritize which groups should be vaccinated first.

Serum Interleukin-12 Levels in Alcoholic Liver Disease

2010-02-01

Background: Interleukin (IL)-12 is a proinflammatory cytokine produced by antigen-presenting cells upon stimulation by diverse stimuli. This study aimed to explore the relationship between IL-12 serum levels and different stages of alcoholic liver disease, alcoholic intake status and abstinence from alcohol. Methods: A total of 35 healthy controls without alcohol consumption and 94 patients with alcoholic liver disease (17 with alcoholic steatosis, 37 with alcoholic hepatitis, 40 with alcoholic cirrhosis) were included. Their serum IL-12 levels were measured and followed-up at the 3rd, 6th and 9th months. Data were further analyzed according to abstinence from alcohol or not. Results: Mean serum IL-12 levels were higher in the alcoholic hepatitis group (163.1 ± 57.8 pg/mL) than in the alcoholic liver cirrhosis group (110.5 ± 41.6 pg/mL) and alcoholic steatosis group (74.4 ± 26.2 pg/mL). All of these 3 alcoholic groups had higher serum IL-12 levels than the control group (39.3 ± 8.3 pg/mL; p < 0.02). Among the patients who abstained from alcohol, there was no difference in serum IL-12 levels between control and steatosis patients at the 9th month, but the serum IL-12 levels of the hepatitis and cirrhosis groups were still higher than in the control group (p < 0.001 and p = 0.001, respectively). In addition, the patients who continued to drink alcohol had higher serum IL-12 levels than those who abstained from alcohol in the steatosis, hepatitis and cirrhosis groups. At the cut-off value of 54 pg/mL, IL-12 had good sensitivity and specificity in the diagnosis of alcoholic liver disease. Conclusion: Serum IL-12 levels reflected the different stages of alcoholic liver disease and can represent the status of continuous alcohol consumption. It has the potential to be a biomarker of alcoholic liver disease.

Prophylactic Antibiotic Administration Induced Bronchospasm as Increased Airway Pressure During General Anesthesia

2010-02-01

Background: Anaphylactic reaction induced bronchospasm as wheezing and severe elevation of airway pressure was observed in a succession of patients during general anesthesia at our institute in November 2007. The aim of this survey was to investigate the suspected causes and risk factors of these anaphylactic reactions and the degree of correlation. Methods: All patients who received general anesthesia between November 1 and November 10, 2007 were enrolled. Underlying diseases, substances including intravenous and inhalational anesthetics, antibiotics, and the degree of increase in airway pressure were recorded. Enrolled patients were divided into a significant-airway-pressure-elevation group (Group P) and a no-airway-pressure-elevation group (Group N). Results: A new brand of cephalexin (Roles®) used as a prophylactic antibiotic was identified as the most likely causative substance of this succession of suspected anaphylactic reactions (28 in 185 patients, 15.14%), and rapid administration was a contributor to these anaphylactic reactions. Conclusion: In this study, we found that rapid administration of Roles® was the main cause of suspected anaphylactic reaction presenting as bronchospasm with severe elevated airway pressure. Using Roles® as the prophylactic antibiotic is not recommended in patients receiving general anesthesia.

Features and Prognostic Factors for Elderly With Acute Poisoning in the Emergency Department

2010-02-01

Background: Elderly persons with acute poisoning in the emergency department (ED) and prognostic factors of outcomes have not been well addressed in previous research. This study aimed to investigate the characteristics of elderly patients with acute poisoning visiting the ED, and to identify the possible predictive factors of mortality. Methods: Patients aged ≥ 65 years with acute poisoning who visited the ED in Taipei Veterans General Hospital from January 1, 2006 through to September 30, 2008 were enrolled in the study. We collected demographic information on underlying diseases, initial presentations, causes and toxic substances, complications, dispositions, and outcomes. Analyses were conducted among different groups categorized according to age, suicide attempt, and outcome. Multiple logistic regression was applied to identify possible predictive clinical factors influencing mortality in the elderly with acute poisoning. Results: A total of 250 patients were enrolled in the study, with a mean age of 77 years and male predominance. The most common cause of intoxication was unintentional poisoning. Medication accounted for 57.6% of poisonous substances, of which benzodiazepine was the most common drug, followed by warfarin. The overall mortality rate was 9.6%. The average length of stay in the ED increased significantly in the old (65–74 years), very old (75–84 years) and extremely old (≥ 85 years) groups. Suicide attempt patients experienced more complications including respiratory failure, aspiration pneumonia, hypotension and mortality. Three clinical predictive factors of mortality were identified: herbicide poisoning, hypotension and respiratory failure upon presentation. Conclusion: Our results demonstrated that elderly patients with acute poisoning had a mortality rate of 9.6%. Suicide attempts resulted in more serious complications. The risk factors for mortality were herbicide intoxication, hypotension and respiratory failure.

The Unusual Presentation of Gastric Adenocarcinoma as a Testicular Mass: A Favorable Response to Docetaxel and Cisplatin Plus Oral Tegafur/Uracil and Leucovorin

2010-02-01

Gastric cancer is one of the most common malignancies in the world. The routes of metastasis include direct extension, lymphatics, and peritoneal or hematogenous spread. Testicular metastasis is rare. We present here a 23-year-old gastric cancer patient who first presented with right-side testis swelling and pain. Diagnosis of metastatic adenocarcinoma was made after right-side orchiectomy. Gastric adenocarcinoma with ascites and peritoneal seeding was found after esophagogastroscopy and abdominal computed tomography. The patient received chemotherapy consisting of docetaxel 36 mg/m2 and cisplatin 30 mg/m2 on day 1 and day 8, plus oral tegafur/uracil 300 mg/m2/day and leucovorin 90 mg/day on day 1 to day 14 in a 21-day cycle, and he had a partial response to the chemotherapy. Metastatic tumors, especially gastric adenocarcinoma, should be considered in the differential diagnosis of patients presenting with testicular mass and they may respond well to chemotherapy.

Hepatocellular Carcinoma With Presentation of Budd-Chiari Syndrome

2010-02-01

Budd-Chiari syndrome is defined as hepatic venous outflow obstruction at any level from the small hepatic veins to the junction of the inferior vena cava and the right atrium independent of the underlying disease. We report here a 40-year-old male patient who complained of abdominal fullness and bilateral lower leg edema for 1 month. A physical examination disclosed bilateral lower leg edema. Abdominal sonography revealed a small amount of ascites with thrombosis of the inferior vena cava and right hepatic vein. Viral hepatitis marker tests showed positive hepatitis B surface antigen. Tumor markers showed elevated serum a-fetoprotein levels. Computed tomography and magnetic resonance imaging confirmed hepatocellular carcinoma with inferior vena cava and right hepatic vein thrombosis. Therefore, hepatocellular carcinoma with Budd-Chiari syndrome was diagnosed. The patient was treated with intravenous heparin, which was then changed to oral warfarin. Although it is relatively rare, clinicians should be aware of hepatocellular carcinoma with Budd-Chiari syndrome when leg edema occurs without hypoalbuminemia in patients with chronic hepatitis B, because these patients are in the high-risk group for developing hepatocellular carcinoma. Regular follow-up of chronic hepatitis B, including biochemical and sonography surveillance, should be performed.

An Outbreak of Foxglove Leaf Poisoning

Chun-Chi Lin, Chen-Chang Yang, Dong-Haur Phua, Jou-Fang Deng, Li-Hua Lu — 2010-02-01

Comfrey (Symphytum officinale) leaves resemble those of foxglove (Digitalis purpurea) when the plant is not in bloom and, therefore, cardiac glycoside poisoning may occur when people confuse foxglove with comfrey. We report an outbreak of foxglove leaf poisoning following the use of alleged “comfrey” herbal tea. Nine patients were involved and initially presented with nausea, vomiting, diarrhea and dizziness. Significant cardiotoxicity developed later among the 3 patients who also had mild hyperkalemia. Peak serum digoxin concentration measured by immunoassay was elevated in all patients and ranged from 4.4 ng/mL to 139.5 ng/mL. Patients with severe cardiotoxicity were treated with temporary cardiac pacing. Moreover, 40–80 mg of digoxin-specific antibody therapy was given without any effect. All patients recovered uneventfully. Our report highlights the potential risk of misidentification of herbs; in this case, D. purpurea was mistaken for S. officinale. Physicians should be aware that cardiac glycoside poisoning could arise from such misidentification. Public education about the toxicity of D. purpurea poisoning may reduce the risk of misidentification and subsequent poisoning.

Invasive Adenocarcinoma of the Prostate With Urethral Tumor

2010-02-01

Metastases of prostate cancer to the penis and urethra are rare and often represent advanced disease. We describe a case of newly diagnosed prostatic adenocarcinoma with metastases to the corpus spongiosum, cavernosum, and the anterior urethra. A male patient, 77 years of age, initially had lower urinary tract obstruction symptoms. His prostate-specific antigen level was 5.02 ng/mL. Digital rectal examination disclosed stony hard tumors at both lobes of the prostate. Transrectal ultrasound-guided biopsy of the prostate revealed adenocarcinoma over both lobes; the Gleason score was 4 + 4 = 8. Cystoscopy showed a penile urethral tumor and biopsy disclosed metastatic adenocarcinoma of the prostate; the Gleason score was 4 + 4 = 8. The patient initially received hormone therapy. Biochemical failure developed after 15 months and rapidly progressed to a hormone-refractory stage. Docetaxel was then prescribed. The patient died in the 25th month after the diagnosis.

Congenital Rubella Syndrome With Autistic Disorder

Shyh-Jou Hwang, Ying-Sheue Chen — 2010-02-01

Congenital rubella syndrome (CRS) consists of a group of abnormalities that develop in children as a result of maternal infection with rubella virus. CRS may lead to new physical symptoms during adolescence or adulthood, referred to as “late manifestations”. Psychiatric disorders are often seen among CRS patients, with an incidence of 4.12–7.3% for autism. We report a case of adolescent CRS with autism. A 20-year-old man had received treatment with antipsychotics and antidepressants since the age of 12 years because of unstable moods, violence, and stereotypic behavior. During follow-up, he developed some insidious-onset physical problems, including hyperlipidemia, dyspnea, constipation, torticollis and a tilted trunk. Under careful survey and evaluation, some physical problems were recognized as side effects of psychotropics, which gradually subsided after adjustment of the medications, and some of the problems were considered partially as manifestations of CRS, such as progressive pulmonary artery stenosis-related dyspnea. We managed some of the patient's physical problems and then he received catheterization for pulmonary artery stenosis. His general physical condition improved and some further improvement in psychiatric status was noted thereafter. Because of a high comorbidity rate for patients with autistic disorder, the clinician should be aware of the possibility of CRS if the patient has multiple congenital physical abnormalities with a history of maternal rubella infection. If patients develop physical symptoms in adolescence, awareness of late manifestations of CRS and differentiation from the adverse effects of psychotropic medications are essential. In addition to psychiatric treatment, management of physical problems associated with CRS would be beneficial for the patients' psychiatric condition.

Novel Application of Artificial Dermis Plus Autologous Vital Epithelial Cells: Improved Wound Epithelialization

Li-Tzu Lee, Po-Cheung Kwan, Yong-Kie Wong — 2010-02-01

The purpose of this study was to evaluate artificial dermis with the simultaneous addition of autologous epithelial cells for oral lesion defect reconstruction. Surgical wounds reconstructed with artificial dermis plus scraped epithelial cells were evaluated in 5 patients with oral benign lesions or squamous cell carcinoma. Clinical follow-up indices included scar formation and tissue surface texture observation. The neomucosal layers were analyzed histologically to establish the degree of epithelialization. Clinical observation showed that the oral mucosal texture was smoother in artificial dermis with added epithelial cells at 4 weeks postoperation compared with artificial dermis alone. The wound contraction and scar formation processes were slow. Viable epithelial cells with flat rete ridges remained in the artificial dermis, and a neoepithelial layer was present in the histological findings. We showed that healthy granulation tissue and neoepithelial formation in artificial dermis with epithelial cells was beneficial for the repair of oral defects. Scraping oral epithelial cells and applying them to artificial dermis assisted in the early preparation of composite grafts and minimized requirement for donor sites. This technique may improve the treatment of patients with oral benign tumors and early-stage squamous cell carcinoma.