Keh-Gong Wu

Bacterial infection in association with snakebite: A 10-year experience in a northern Taiwan medical center

BACKGROUND Microbiological data of secondary wound infections following snakebites is rarely reported in Taiwan. The objective of this study was to assess the secondary wound infection after venomous snakebites. METHODS We conducted a 10-year retrospective survey on patients admitted for venomous snakebites and microbiological data of wound cultures at a medical center in northern Taiwan. RESULTS Between April 2001 and April 2010, 231 patients who experienced snakebites were included. Male predominated, accounting for 62.3% (144). The age range of patients was 4-95 years. Ninety-five (41.1%) people were bitten by Trimeresurus mucrosquamatus, followed by Tstejnegeri, and cobra. A total of 61 pathogens were obtained from 21 patients. Thirty-nine (63.9%) isolates were gram-negative bacteria, 14 (23%) gram-positive pathogens, and 8 (13.1%) anaerobic pathogens. There were 17 patients bitten by cobra in these 21 patients. Morganella morganii and Enterococcus species were the most common pathogens identified in the wound cultures. CONCLUSION Cobra bite causes more severe bacterial infection than other kinds of snakebites. Oral amoxicillin/clavulanate plus ciprofloxacin or parenteral piperacillin/tazobactam alone can be the choices for empirical or definitive treatment, and surgical intervention should be considered for established invasive soft tissue infections.

Correlations of serum Interleukin-16, total IgE, eosinophil cationic protein and total eosinophil counts with disease activity in children with atopic dermatitis.

Several laboratory parameters have been investigated for assessing disease activity in children with atopic dermatitis (AD). Analyses of the correlation between these parameters and clinical severity can help to choose a convincing tool. This study compared the significance of serum interleukin-16 (IL-16), serum total immunoglobulin E (IgE), serum eosinophil cationic protein (ECP), and total eosinophil count (TEC) in reflecting AD severity to order to identify the most relevant objective tool for assessing AD activity and to assess the correlation between these laboratory parameters. The Severity Scoring of Atopic Dermatitis (SCORAD index) was used for the assessment of disease activity in 48 pediatric patients in the acute exacerbation phase and in the maintenance phase after improvement of clinical findings with conventional treatment for 8 weeks. Serum levels of total IgE, ECP, and IL-16 as well as TEC were measured on the same time points and compared with healthy non-atopic controls. The correlation between SCORAD and each laboratory parameter was tested for significance and compared. Serum levels of ECP and IL-16 of AD patients were significantly higher than those of controls. These serum parameters, except TEC, declined significantly after conventional treatment with clinical improvement. There was positive correlation with SCORAD for serum IgE (r=0.317, p=0.028), TEC(r=0.434, p=0.002), IL-16 (r = 0.321, p=0.026) in the acute exacerbation phase and with SCORAD for serum IgE (r=0.510, p<0.001), TEC(r=0.489, p<0.001), serum ECP (r=0.468, p=0.001) in the maintenance phase. Serum levels of total IgE, IL-16, ECP, and TEC correlated with the SCORAD index in pediatric patients with atopic dermatitis. Thus, they can serve as serum markers for monitoring disease activity in childhood atopic dermatitis.Several laboratory parameters have been investigated for assessing disease activity in children with atopic dermatitis (AD). Analyses of the correlation between these parameters and clinical severity can help to choose a convincing tool. This study compared the significance of serum interleukin-16 (IL-16), serum total immunoglobulin E (IgE), serum eosinophil cationic protein (ECP), and total eosinophil count (TEC) in reflecting AD severity to order to identify the most relevant objective tool for assessing AD activity and to assess the correlation between these laboratory parameters. The Severity Scoring of Atopic Dermatitis (SCORAD index) was used for the assessment of disease activity in 48 pediatric patients in the acute exacerbation phase and in the maintenance phase after improvement of clinical findings with conventional treatment for 8 weeks. Serum levels of total IgE, ECP, and IL-16 as well as TEC were measured on the same time points and compared with healthy non-atopic controls. The correlation between SCORAD and each laboratory parameter was tested for significance and compared. Serum levels of ECP and IL-16 of AD patients were significantly higher than those of controls. These serum parameters, except TEC, declined significantly after conventional treatment with clinical improvement. There was positive correlation with SCORAD for serum IgE (r=0.317, p=0.028), TEC(r=0.434, p=0.002), IL-16 (r = 0.321, p=0.026) in the acute exacerbation phase and with SCORAD for serum IgE (r=0.510, p<0.001), TEC(r=0.489, p<0.001), serum ECP (r=0.468, p=0.001) in the maintenance phase. Serum levels of total IgE, IL-16, ECP, and TEC correlated with the SCORAD index in pediatric patients with atopic dermatitis. Thus, they can serve as serum markers for monitoring disease activity in childhood atopic dermatitis.

Application of a Molecular Method for the Classification of Human Enteroviruses and its Correlation with Clinical Manifestations

BACKGROUND/PURPOSE A new molecular classification scheme has recently been adopted that groups all enteroviruses into four species, designated human enterovirus A (HEV-A) through D. In this study, we tried to demonstrate the correlation between this molecular classification scheme and clinical manifestations in patients. METHODS We retrospectively reclassified the clinical isolates of enteroviruses from the preceding 4.5 years in our virology laboratory using reverse transcription-polymerase chain reaction, and reviewed the clinical manifestations of 138 pediatric patients. RESULTS We reclassified 23 isolates of the five serotypes into the HEV-A group, 110 isolates of 16 sero-types into the HEV-B group, five isolates into the HEV-C group, and no isolate of the HEV-D group. HEV-A species caused significantly more hand-foot-and-mouth disease (p < 0.001), herpangina (p = 0.029), and myoclonic jerks (p < 0.001) compared with HEV-B species. However, HEV-B species caused significantly more pharyngitis (p = 0.043), respiratory tract infections (p = 0.046), nausea and vomiting (p = 0.007), and aseptic meningitis (p = 0.001). The only death in our report was caused by coxsackievirus A16, which belonged to the HEV-A group. CONCLUSION The association between the molecular classification of enteroviruses and related disease patterns is an important finding. We suggest that this molecular classification could be applied in a clinical laboratory as an alternative method under certain circumstances, such as limited availability of antisera or questionable serotyping results, to identify the untypeable isolates.

The epidemiology and prognostic factors of mortality in critically ill children with acute kidney injury in Taiwan

The incidence of acute kidney injury (AKI) in critically ill children varies among countries. Here we used claims data from the Taiwanese National Health Insurance program from 2006 to 2010 to investigate the epidemiological features and identify factors that predispose individuals to developing AKI and mortality in critically ill children with AKI. Of 60,338 children in this nationwide cohort, AKI was identified in 850, yielding an average incidence rate of 1.4%. Significant independent risk factors for AKI were the use of extracorporeal membrane oxygenation, mechanical ventilation or vasopressors, intrinsic renal diseases, sepsis, and age more than 1 year. Overall, of the AKI cases, 46.5% were due to sepsis, 36.1% underwent renal replacement therapy, and the mortality rate was 44.2%. Multivariate analysis showed that the use of vasopressors, mechanical ventilation, and hemato-oncological disorders were independent predictors of mortality in AKI patients. Thirty-two of the 474 patients who survived had progression to chronic kidney disease or end-stage renal disease. Thus, although not common, AKI in critically ill children still has a high mortality rate associated with a variety of factors. Long-term close follow-up to prevent progressive chronic kidney disease in survivors of critical illnesses with AKI is mandatory.

Infectious Endocarditis in Pediatric Patients: Analysis of 19 Cases Presenting at a Medical Center

BACKGROUND/PURPOSE Infectious endocarditis (IE) is a rare, but potentially fatal disease in pediatric patients. In this study, we reviewed the symptoms and signs, etiology, laboratory findings and outcomes of IE patients over the past 10 years. METHODS Patients (< 18 years old) with definite IE according to the modified Duke criteria, or patients with positive pathological findings, between September 1998 and September 2008 were included in the study. The etiology, symptoms and signs, laboratory findings and outcomes were collected via chart review. RESULTS Nineteen cases (13 boys and 6 girls) ranging in age from 2.5 months to 18 years (mean = 7.98 years; median = 5 years) were included. Nine out of 17 cases (52.9%) had microscopic hematuria and two out of three (66.7%) cases showed elevated rheumatoid factor levels. Seventeen (89.5%) had fever and seven (36.8%) had major vessel embolic events. Blood cultures yielded Staphylococcus aureus in seven cases, and viridans Streptococci in two cases. The other three cases had Pneumococcus, Pseudomonas aeruginosa and Candida albicans. Two patients died and one was discharged in a critical condition. Two of the seven (28.6%) patients with a positive blood culture for S. aureus died, three (42.9%) had an embolic event and one (14.3%) had central nervous system complications (intracranial hemorrhage). The initial C-reactive protein levels in the blood culture-positive group were significantly higher than those in the blood culture-negative group (p = 0.035). CONCLUSION S. aureus is one of the most common etiologies in IE patients, while viridans Streptococcus accounts for fewer cases than suggested by previous studies. IE caused by S. aureus seems to carry a higher risk of mortality, and embolic events are associated with increased mortality.

A pilot study evaluating the clinical and immunomodulatory effects of an orally administered extract of Dendrobium huoshanense in children with moderate to severe recalcitrant atopic dermatitis.

Atopic dermatitis (AD) is a common inflammatory skin disorder for which few safe and effective systemic treatments are available. To test the clinical and immunomodulatory effects of a crude polysaccharide fraction isolated from Dendrobium huoshanense for the treatment of AD, we conducted a pilot, uncontrolled case series study. Twenty-seven patients aged 4–18 years (mean±SD, 10.82±4.4) with AD that had not responded to topical therapy were treated with polysaccharide derived from D. huoshanense for 4 weeks and followed-up for another 4 weeks. Progression of AD was determined with the Lund-Browder chart for children, the Investigators Global Atopic Dermatitis Assessment (IGADA), and the Scoring Atopic Dermatitis (SCORAD) at weeks 0, 2, 4, and 8. Serum levels of cytokines were evaluated. Safety was determined with laboratory and clinical tests. The lesion area, IGADA score, total SCORAD result, and score for sleeplessness decreased significantly from weeks 0 to 4, but did not change significantly between weeks 4 and 8. The scores for subjective symptoms and pruritus decreased significantly from week 0 to week 4 and increased significantly from week 4 to week 8. Serum levels of IL-5, IL-13, IFN-γ, and TGF-β1 decreased significantly between weeks 0 and 4 and between weeks 0 and 8. No significant difference in the levels of IL-10 was found. The polysaccharide from D. huoshanense reduced the levels of some cytokines associated with AD and had beneficial effects on symptoms. No serious adverse effects occurred when it was administered orally for 4 weeks.Atopic dermatitis (AD) is a common inflammatory skin disorder for which few safe and effective systemic treatments are available. To test the clinical and immunomodulatory effects of a crude polysaccharide fraction isolated from Dendrobium huoshanense for the treatment of AD, we conducted a pilot, uncontrolled case series study. Twenty-seven patients aged 4–18 years (mean±SD, 10.82±4.4) with AD that had not responded to topical therapy were treated with polysaccharide derived from D. huoshanense for 4 weeks and followed-up for another 4 weeks. Progression of AD was determined with the Lund-Browder chart for children, the Investigators Global Atopic Dermatitis Assessment (IGADA), and the Scoring Atopic Dermatitis (SCORAD) at weeks 0, 2, 4, and 8. Serum levels of cytokines were evaluated. Safety was determined with laboratory and clinical tests. The lesion area, IGADA score, total SCORAD result, and score for sleeplessness decreased significantly from weeks 0 to 4, but did not change significantly between ...

A comparative study of loratadine syrup and cyproheptadine HCL solution for treating perennial allergic rhinitis in Taiwanese children aged 2-12 years.

We assessed the efficacy of loratadine syrup compared with cyproheptadine HCl solution for treating children aged from 2 to 12 years with perennial allergic rhinitis (PAR) in Taiwan. Sixty children with mite-induced PAR were enrolled and randomly placed into two treatment groups: loratadine syrup or cyproheptadine HCl solution. Treatment efficacy and symptom changes from baseline to post-treatment were evaluated by total symptom scores and visual analogue scales (VAS) during a 2-week period. There were no differences in age, gender, height, or weight between the two groups. After 2 weeks of treatment, there was a significantly greater reduction in symptom scores in the loratadine group than in the cyproheptadine group (p<0.001). Clinical and subjective VAS showed significant differences in percentage changes from baseline between the loratadine and cyproheptadine groups at all time points (allp<0.001, in favor of loratadine). Clinical VAS change at week 1: 95.1 vs 11.3; subjective VAS change at week 1: 88.6 vs 13.6; clinical VAS change at week 2: 125.5 vs 18.3; subjective VAS change at week 2: 101.4 vs 7.1. Thus, loratadine was superior to cyproheptadine for alleviating both nasal and non-nasal symptoms of perennial allergic rhinitis in Taiwanese children aged 2–12 years.

Clinical analysis of Enterobacter bacteremia in pediatric patients: A 10-year study

BACKGROUND Enterobacter species has emerged as an important pathogen of nosocomial bacteremia. The purpose of this study is to review the clinical characteristics of bacteremia in pediatric patients. MATERIALS AND METHODS We reviewed retrospectively the medical records of patients (under the age of 18 years) having Enterobacter bacteremia who were treated at Taipei the Veterans General Hospital from January 2001 to June 2011. RESULTS In total, 853 positive blood cultures were obtained from 620 patients during the study period. Among them, 96 episodes of Enterobacter bacteremia were found in 83 patients, accounting for 11.3% of all bacteremia. Eighty-two cases (98.8%) were nosocomial infections. Most of the cases were neonates (62 cases, 74.7%) and premature infants (51 cases, 61.5%). The common sources of bacteremia were the respiratory tract (53.0%), followed by intravascular catheter (10.8%), multiple sources (10.8%), and the gastrointestinal tract (8.4%). The overall case fatality rate was 18.1%, with the highest rate being reported among premature infants. The factors responsible for the deaths were leukocytosis and a higher median number of underlying diseases. CONCLUSION Based on the findings of the present study, it can be concluded that Enterobacter species are probably an important pathogen of nosocomial bacteremia in premature neonates. The number of underlying diseases should be considered a major factor influencing the prognosis.

Epidemiology of respiratory syncytial virus in children with lower respiratory tract infection.

Respiratory syncytial virus (RSV) is the most frequent pathogen found in hospitalized young children with lower respiratory tract infection, and the virus is distributed worldwide. Respiratory distress and respiratory failure are caused by RSV in some severe cases. Its appearance always varies every year and depends on differences of latitudes, altitudes and climates. The purpose of this study was to investigate the epidemiology of hospitalized children from a hospital located in northern Taiwan with RSV induced lower respiratory tract infection. This study was conducted from January 2001 to December 2003, and the selected patients were children aged under five and diagnosed with lower respiratory tract infection. The means adopted in this study were analyses of clinical presentations and laboratory tests (including viral identification with either virus culture or RSV antigen rapid test from the nasopharyngeal aspirate). The results showed that 153 children were positive with RSV identification. These cases were diagnosed in clinical practice all year round, and its peak was in spring, especially in March and April. Thirteen percent of all RSV-infected children in this study presented as severe form with respiratory distress and a need of respiratory support. However, none of these cases died from this disease, and all cases recovered without long-term respiratory complication. We concluded that RSV infection was still a common pathogen for young children in northern Taiwan; in addition, March and April were regarded as peak months of epidemic. Patients aged under 12 months or suffered from underlying cardiopulmonary disease were at high risk of getting severe forms of RSV infection.

A population-based analysis of children with pneumonia among intensive care units in Taiwan

BACKGROUND Pneumonia is a major diagnosis in children that requires intensive care and is a major cause of mortality in critically ill children. A survey on current epidemiology and case fatality-associated conditions is crucial for the care of critically ill children with pneumonia in an intensive care unit (ICU). METHODS The sex, age, seasonality of admission, area of distribution, and case fatality rate of children younger than 18 years who had pneumonia and were admitted to an ICU during the period 2006-2010 were obtained from the National Health Insurance Research Database (NHIRD) of Taiwan. The enrolled children were grouped by age (0-2 years, 3-5 years, 6-11 years, and 12-17 years). The need for invasive procedures such as endotracheal tube (ET) insertion, mechanical ventilation (MV), tracheostomy, central venous catheter (CVC) insertion, chest tube insertion/drainage, chest surgery, and extracorporeal membranous oxygenation (ECMO) were analyzed to clarify their association with case fatality in critically ill children with pneumonia. RESULTS Of the 12,577 children enrolled, 7131 (56.7%) were boys and 5446 (43.3%) were girls. The younger age groups had more cases of pneumonia, but less often required invasive procedures. Children 0-2 years old (n = 6083) accounted for approximately one-half (48.4%) of all enrolled children. This group had the lowest case fatality rate (3.1%; 187/6083 children) and lowest need for invasive procedures (31.1%; 1892/6083 children), whereas children in the 12-17 year-old group had the highest case fatality rate (9.9%; 140/1417 children) and the highest need for invasive procedures (59.8%; 847/1417 children) (p < 0.001). The percentage of pneumonia cases was highest in the spring (30.1%) and lowest in the summer (21.7%). The invasive procedures associated with case fatality were ET/MV (OR, 14.31; p < 0.001), CVC insertion (OR, 7.46; p < 0.001), ECMO intervention (OR, 4.59; p < 0.001), and chest tube insertion/drainage (OR, 1.87; p < 0.001). CONCLUSION The number of cases of pneumonia that required ICU admission was greater among younger children than among older children. Factors associated with the higher case fatality rate included older age at presentation, the need for invasive procedures (e.g., ET/MV, CVC insertion, chest tube insertion/drainage, and ECMO), underlying comorbidities and complications.