Kuo-Wei Wang

Bacterial meningitis in infants: the epidemiology, clinical features, and prognostic factors.

This 16-year (1986-2001) retrospective study enrolled 80 infantile patients (aged, 30-365 days old) with culture-proven bacterial meningitis. The most prevalent pathogens were Salmonellaspecies, Streptococcus (S.) agalactiae, Escherichia (E.) coli, and Haemophilus (H.) influenzae, accounting for about 59% of the episodes. Meningitis caused by Salmonella species, E. coli and H. influenzae occurs more often in the older infants, while that caused by S. agalactiae occurs more often in young infants. Our study revealed a decrease in the proportion of Salmonella meningitis from 27% in the first 8 years to 9% in the second 8 years with E. coli replacing Salmonella species as the leading pathogen of this disease during the second period. Overall mortality rate for both periods of time was 11%. However, if we take those with undesirable poor outcomes into account, 43% of patients could be considered treatment failures. The study also reveals a high prevalence of neurological complications when this disease is caused by H. influenzae, S. pneumoniae, and Salmonella species. Stepwise logistic regression analysis revealed that only initial changing levels of consciousness (P = 0.006) were independently associated with treatment failure. The most frequent neurological complications associated with this disease included subdural empyema, hydrocephalus, cerebral infarctions, and seizures. Because therapeutic regimens may require attention to the eradication of bacterial pathogen but also the neurological complications, early diagnosis and choice of appropriate antibiotics are essential to increasing the possibility of survival.

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy.

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.

The significance of seizures and other predictive factors during the acute illness for the long-term outcome after bacterial meningitis

BACKGROUNDnSeizures are important neurological complications of bacterial meningitis, but no information about its epidemiology and the outcomes of seizures after community-acquired bacterial meningitis (CABM) in an adult population have been reported.nnnAIMSnTo determine the frequency, clinical relevance, subtypes of seizures during the acute phase of bacterial meningitis, and the long-term outcomes of seizure complicating adult CABM.nnnMETHODSnIn this 12-year retrospective study, 117 adult patients were identified with culture-proven CABM. A comparison was made between the clinical data of the patients with and without seizures during hospitalization.nnnRESULTSnThirty-one patients had seizures during CABM, accounting for 27% (31/117) of the episodes. The time interval between the onset of bacterial meningitis and the seizures was 1-21 days (mean, 4 days). Furthermore, 80% (25/31) of the episodes occurred within 24 h of presentation. Ten patients who had seizures progressed to status epilepticus. At follow-up after completing treatment, 10 patients completely recovered and were seizure-free, 19 died of meningitis during the acute stage and the other two progressed to chronic epilepsy.nnnCONCLUSIONnA log-rank test demonstrated that the long-term outcome of adult CABM with acute seizures produced worse outcomes than for those who had no seizures, though no difference was noted between focal and generalized seizures. None of our patients without seizures in the acute phase of bacterial meningitis developed late seizures during the follow-up periods. Poor outcome in this study may attribute to neurological complications such as seizure, hydrocephalus, infection itself, or a combination of complications.

A clinical and electrophysiologic survey of childhood Guillain-Barré syndrome

In this 16-year (1986-2001) retrospective study, 23 childhood patients were identified with Guillain-Barré syndrome. According to clinical and electrophysiologic findings, 18 patients manifested acute inflammatory demyelinating polyradiculoneuropathy, 2 had Miller Fisher syndrome, 1 had axonal forms, and 2 were unclassified. Seasonal preponderance was evident in 39% of patients with Guillain-Barré syndrome, developing the disease in the winter (November to January) with upper respiratory infection the most frequent preceding event. The most common manifestation was limb weakness, with various degrees of motor weakness in 22 patients. Bulbar involvement was the most common cranial palsy, and it was evident in 30% of the episodes. Only one of these progressed to mechanical ventilation during hospitalization. Altogether, approximately 61% of the episodes exhibited sensory symptoms. At a follow-up of 1 year or more, 20 patients recovered and 3 had residua. Furthermore, no fatality occurred in our study. Our study also demonstrates that the clinical course of childhood Guillain-Barré syndrome has a shorter recovery time as compared with an adult patient group. Therapeutic outcome is favorable for patients who receive prompt treatment.

Guillain–Barré syndrome in southern Taiwan: clinical features, prognostic factors and therapeutic outcomes

To determine the clinical features, prognostic factors, and therapeutic results of Guillain–Barré syndrome (GBS) in order to improve the therapeutic strategy for this disease. We retrospectively reviewed the electrodiagnostic study and medical records of patients with GBS admitted to Chang Gung Memorial Hospital, Kaohsiung, between January 1986 and December 2000. Outcomes and prognosis were followed‐up after 1u2003year. Ninety‐six patients were enrolled in this study. According to the clinical and electrophysiological findings, 77 patients were acute inflammatory demyelinating polyradiculoneuropathy, seven were Miller Fisher syndrome, and six were axonal forms, and six were unclassified. At a follow‐up of 1u2003year, 61 patients (64%) recovered, 30 (31%) had residua and five (5%) died. Amongst these 30 had residua, including unassisted gait in 19, assisted gait in four, and wheel/bed bound in seven. According to the statistical analysis, disabilities at the nadir (Pu2003<u20030.0001) and at admission (Pu2003=u20030.014) were significant prognostic factors. Variables used for the stepwise logistic regression, and the results revealed that after analysis for all the above variables, only disability at the nadir (Pu2003<u20030.0001) was independently associated with the treatment failure rate. Our study revealed 27% of cases in need of respiratory support during hospitalization, and 5% of hospital‐treated patients die from the complications. Furthermore, 31% had residua at a follow‐up of 1u2003year or more. If prognostic factors are considered, disability at the nadir during hospitalization demonstrates consistently poor therapeutic outcomes. Therefore, early diagnosis, choice of appropriate treatment, and preventing complications during acute stages are essential to maximize the potential for survival.

Predictive Factors and Long-Term Outcome of Respiratory Failure after Guillain-Barré Syndrome

Objective:To analyze predictive factors and long-term recovery in patients with Guillain-Barré syndrome (GBS) who are in need of mechanical ventilation. Methods:In this 15-year retrospective study, 77 adult patients were identified with GBS. A comparison was made between the clinical data from patients who required mechanical ventilation and those who did not. Furthermore, the therapeutic outcomes of those 25 patients in need of mechanical ventilation during hospitalization at 1 year were determined using a modified Barthel index. A score below 12 was defined as a poor outcome, whereas a score of 12 or more was good. Results:The study revealed 32% of patients (25/77) in need of respiratory support during hospitalization. At a follow-up of 1 year among the 25 ventilated patients, 7 patients (28%) had normal or minor signs and symptoms, 6 had unassisted gait, 3 had assisted gait, 6 were wheelchair- or bed-bound, and 3 died. The cause of death was septicemia with septic shock in all 3 cases. Factors that predict respiratory failure in the study GBS patients were disability grade on admission and areflexia. Those ventilated patients who had low maximal inspiratory pressure (PImax) (<14.5 cmH2O) and maximal expiratory pressure (PEmax) (<13.5 cmH2O) values at the time of intubation and the presence of complications after mechanical ventilation inevitably had worse outcomes than those who had not. Conclusion:If low values of PImax and PEmax at intubation were detected, aggressive respiratory management, which might include tracheostomy to allow more efficient bronchial clearing, and prevention of complications caused by prolonged course of mechanical ventilation are essential to maximize the potential for survival.

Adult Streptococcus pneumoniae meningitis in Southern Taiwan: epidemiologic trends and prognostic factors

The clinical features of 22 adult patients with Streptococcus pneumoniae meningitis, retrospectively collected over a 16-year period, were reviewed. Otopharyngeal infection, haematogenous spread and cranial neurosurgery continue to be the predominant routes of infection. Most patients acquired the infection in the community, and predisposing underlying conditions are common. The proportion of S. pneumoniae meningitis compared to all microorganisms causing meningitis in adults declined dramatically from 17% in the first 8 study years to 4% in the last 8 study years. However, all penicillin-resistant S. pneumoniae strains were found in the second half of the study period, accounting for 25% of these episodes. The overall mortality rates for the first and second halves of the study period were 43% and 63%, respectively. Third-generation cephalosporins were the antibiotics of choice for the treatment of S. pneumoniae meningitis in this study, however, the emergence of resistant strains may create a therapeutic challenge in the future. To avoid treatment failure, early diagnosis, careful monitoring of the clinical course and the choice of appropriate antibiotics according to the in vitro antimicrobial susceptibilities, are necessary.

Prognostic factors and therapeutic outcome of isolated symptomatic middle cerebral artery stenosis.

To analyze the prognostic factors and therapeutic outcome of adult patients with isolated symptomatic stenosis of the middle cerebral artery (MCA). Forty‐nine patients were retrospectively verified with isolated symptomatic stenosis of the MCA through both magnetic resonance angiogram and transcranial color‐coded duplex sonography. Therapeutic outcome at 1u2003year or more was determined using a modified Barthel index (BI). For the purpose of analysis, the patients were divided into two groups: a good outcome group (BIu2003≥u200312) and a poor outcome group (BIu2003<u200312 or recurrent stroke). The association between different therapeutic regimens and the percent free of recurrent stroke after the first event of cerebral infarction was assessed with Kaplan–Meier plots compared by a log‐rank test. These patients accounted for 2.8% of all patients with the first event of cerebral infarction during the same period. At follow‐up of 1u2003year or more, 63% had good outcomes whilst the other 37% had poor outcomes. Overall, 26.5% suffered from recurrent strokes during the follow‐up period. According to the statistical analysis, the stepwise logistic regression revealed that only the National Institutes of Health Stroke Scale (NIHSS) at the time of admission was independently associated with a poor outcome. Furthermore, Kaplan–Meier analysis showed a significantly higher percentage of patients free of recurrent stroke events amongst those who were treated with warfarin. The NIHSS at the time of admission was a predictor of outcome amongst our patients, and stenosis of the MCA implies the danger of recurrent cerebral events. Our study also demonstrates the efficacy of oral anticoagulants in the secondary prevention in this specific group of patients. Therefore, we look forward to more prospective multicenter investigations in evaluating the efficiency of therapy in the future.