The Respiratory Impacts of Air Pollution in Children: Global and Domestic (Taiwan) Situation

Air pollution is a global issue that threatens the health of human beings. Epidemiologic reports have shown air pollution exposures to result in millions of deaths annually. Infancy and childhood, the period of organ and lung development, is most susceptible to these environmental hazards; as a result, the risks of respiratory diseases are increased after air pollution exposure. These pollutants can originate from indoor and ambient environment, presenting as vapor or particles, and differ in chemical compositions. This review will give brief introduction to various major pollutants and their origin, as well the correlation with respiratory diseases after exposure. We will also present several current facts in domestic area (Taiwan), regarding the status of local air-pollution, and discuss its impacts on pediatric respiratory health. This report will provide useful information for clinicians and offer advice for policy makers to develop public health guidelines of pollution control and prevention.

Pulmonary function evaluation in pediatric patients with primary immunodeficiency complicated by bronchiectasis

BACKGROUND

Primary immunodeficiency (PID) accompanying with recurrent respiratory infections is thought to have a devastating effect on lung function. However, the associations between the airway structural abnormalities on chest computed tomography (CT), severity of dyspnea, and deterioration of pulmonary function test (PFT) have not been fully addressed.

METHODS

Children diagnosed with PID in a tertiary referred center in northern Taiwan were enrolled. Demographic and clinical data including age, sex, age at diagnosis of PID, and follow-up period were collected. Chest CT images (modified Reiff scores), parameters of PFT, and life quality questionnaires (mMRC dyspnea scale) were analyzed and correlated using Spearman's rank correlation test.

RESULTS

A total of nineteen children with PID were enrolled and thirteen patients were diagnosed as having bronchiectasis based on chest CT scans. Modified Reiff scores of chest CT scan were negatively correlated with FEV₁ (% predicted) and FEV₁/FVC ratio (P < 0.05). A strongly negative correlation was found between the mMRC dyspnea scale and FEV₁ (% predicted) and FVC (% predicted), but positively correlated with RV (% predicted) and RV/TLC ratio (P < 0.05). Furthermore, there was a negative correlation between FVC (% predicted) with increasing follow-up period (P < 0.05).

CONCLUSIONS

In pediatric patients with PID, chest CT scan appears to be a good tool for not only the diagnosis of bronchiectasis, but also the degree of pulmonary function impairment. Further quality of life impairments could be particularly due to the airflow obstruction and air trapping related to bronchiectasis.

Diagnostic pitfalls of acute eosinophilic pneumonia in an adolescent boy following cigarette smoking: A case report

RATIONALE

Acute eosinophilic pneumonia (AEP) is characterized by acute febrile respiratory symptoms, bilateral lung infiltrates, and pulmonary eosinophilia. AEP is closely related to cigarette smoking but is rarely suspected in pediatric cases despite the fact that there is a relatively high incidence of cigarette smoking among adolescents in Taiwan.

PATIENT CONCERNS

We report a case of a previously healthy 15-year-old boy who presented with fever and acute progressive dyspnea. Due to lack of awareness of cigarette smoking history in adolescents and the nonspecific signs and symptoms of AEP at early stages, the patient was initially treated as community-acquired pneumonia (CAP) but was unresponsive to antibiotics treatment.

DIAGNOSES

A combination of a recent onset smoking history and pulmonary eosinophilia on bronchoalveolar lavage confirmed the diagnosis of cigarette-induced AEP.

INTERVENTIONS

Corticosteroid treatment was prescribed.

OUTCOMES

The condition improved within 24 hours, with resolution of alveolar infiltrates on chest radiographs.

LESSONS

With the increasing incidence of smoking amongst adolescents in Taiwan, careful history questioning regarding cigarette smoking is necessary. Due to similarities in initial clinical and radiographic features of AEP and CAP, adolescents with suspected CAP who are unresponsive to antibiotic treatment but have a subsequent rise in peripheral eosinophils should raise the clinician's suspicion of AEP related to cigarette smoking.

Metabolomics Reveals Anaerobic Bacterial Fermentation and Hypoxanthine Accumulation for Fibrinous Pleural Effusions in Children with Pneumonia

Fibrin formation in infectious parapneumonic effusion (IPE) characterizes complicated parapneumonic effusion and is important for providing guidelines for the management of IPEs that require aggressive interventions. We aim to identify metabolic mechanisms associated with bacterial invasion, inflammatory cytokines, and biochemical markers in cases of fibrinous infectious pleural effusions in children with pneumonia. Pleural fluid metabolites were determined by ¹H nuclear magnetic resonance spectroscopy. Metabolites that contributed to the separation between fibrinous and nonfibrinous IPEs were identified using supervised partial least squares discriminant analysis ( Q²/ R² = 0.84; P_permutation < 0.01). IL-1β in the inflammatory cytokines and glucose in the biochemical markers were significantly correlated with 11 and 9 pleural fluid metabolites, respectively, and exhibited significant overlaps. Four metabolites, including glucose, lactic acid, 3-hydroxybutyric acid, and hypoxanthine, were significantly correlated with plasminogen activator inhibitor type 1 in the fibrinolytic system enzymes. Metabolic pathway analysis revealed that anaerobic bacterial fermentation with increased lactic acid and butyric acid via glucose consumption and adenosine triphosphate hydrolysis with increased hypoxanthine appeared to be associated with fibrinous IPE. Our results demonstrate that an increase in lactic acid anaerobic fermentation and hypoxanthine accumulation under hypoxic conditions are associated with fibrin formation in IPE, representing advanced pleural inflammatory progress in children with pneumonia.

Congenital tuberculosis: case report and review of the literature

Congenital tuberculosis is rare, even where tuberculosis (TB) is endemic. A 14-day-old girl presented with a 3-day history of fever and respiratory distress. Her mother was diagnosed with a disseminated TB infection immediately after the delivery which was confirmed by a positive TB-polymerase chain reaction (TB-PCR) and subsequent culture from ascites and sputum. The infant was separated from her mother at birth. Her chest radiograph showed bilateral miliary nodules. Congenital TB was strongly suspected because of the symptoms, signs and maternal TB history, and was confirmed by TB-PCR and culture from the gastric lavage. Timely administration of standard anti-TB therapy resulted in a good outcome. The case highlights the importance of maternal TB history and typical miliary pattern on chest radiography for early diagnosis of congenital or neonatal TB which in turn facilitates prompt treatment and the prognosis.

Overexpression of matrix metalloproteinase-9 in adolescents with primary spontaneous pneumothorax for surgical intervention

OBJECTIVE

To determine gene expression profiles associated with bullae formation in patients with primary spontaneous pneumothorax and to identify candidate genes associated with surgical intervention.

METHODS

Twenty-four adolescents with primary spontaneous pneumothorax were enrolled prospectively. A global gene expression analysis of 9 paired lung biopsies (lesion and normal adjacent sites) was performed to identify differentially expressed genes associated with spontaneous pneumothorax. Pathway and network analysis was performed using the Database for Annotation, Visualization and Integrated Discovery web tool. Candidate genes and encoding proteins were assessed in blood samples and compared between patients with pneumothorax and healthy control patients.

RESULTS

A total of 1519 differentially expressed transcripts corresponding to known genes were identified comparing the lesion lung with paired adjacent normal lung. The altered genes were mainly associated with focal adhesion and extracellular matrix-receptor interaction pathways. Genes involved in proteolysis and peptidase activity were up-regulated predominantly, especially matrix metalloproteinase-1 and -9 genes. Compared with the recovery stage, blood levels of matrix metalloproteinase-9/tissue inhibitor of metalloproteinase-1 were increased at the acute stage in patients with pneumothorax and, when compared between patients treated operatively with those treated nonoperatively, were also significantly greater. In addition, ratios of their serum levels were significantly greater in patients with pneumothorax compared with healthy control patients. Furthermore, matrix metalloproteinase-9 was predominantly overexpressed in neutrophils, alveolar macrophages, and mesothelial cells of lung biopsies.

CONCLUSIONS

An imbalance of cell-extracellular matrix interactions appears to be associated with primary spontaneous pneumothorax. Matrix metalloproteinase-9 overexpression may particularly play a role in contributing to pleural porosity for surgical intervention.

Effect of a financial incentive on the acceptance of a smoking cessation programme with service charge: a cluster-controlled trial

INTRODUCTION

Frontline health care professionals in Hong Kong may encounter high refusal rates for the Hospital Authority's Smoking Counselling and Cessation Programme (SCCP) when smokers know it is subject to a service charge. We compared SCCP booking and attendance rates among smokers with or without a financial incentive.

METHODS

In this multicentre non-randomised cluster-controlled trial, adult smokers who attended one of six general out-patient clinics between November 2015 and April 2016 were invited to join an SCCP. Attendees in the three intervention-group centres but not the three control-group centres received a supermarket coupon to offset the service charge.

RESULTS

A total of 173 smokers aged 18 years or older (92 in the intervention group and 81 in the control group) were recruited into the study. In the intervention group, 47 smokers (51%) agreed via a questionnaire that they would join the SCCP, compared with only 23 smokers in the control group (28%). The booking rates were 83% (n=39) in the intervention group and 83% (n=19) in the control group. Among those who had booked a place, 19 (49%) intervention-group participants and 11 (58%) control-group participants attended an SCCP session. Multivariable logistic regression revealed that offering a coupon was associated with agreeing to join an SCCP (odds ratio=4.963, 95% confidence interval=2.173-11.334; P<0.001) and booking an SCCP place (odds ratio=4.244, 95% confidence interval=1.838-9.799; P<0.001).

CONCLUSION

Provision of a financial incentive was positively associated with agreement to join an SCCP and booking an SCCP place. Budget holders should consider providing the SCCP free of charge to increase smokers' access to the service.

Translesional pressure gradient and leptomeningeal collateral status in symptomatic middle cerebral artery stenosis

BACKGROUND AND PURPOSE

Leptomeningeal collateral (LMC) status governs the prognosis of large artery occlusive stroke, although factors determining LMC status are not fully elucidated. The aim was to investigate metrics affecting LMC status in such patients by using computational fluid dynamics (CFD) models based on computed tomography angiography (CTA).

METHODS

In this cross-sectional study, patients with recent ischaemic stroke or transient ischaemic attack attributed to atherosclerotic M1 middle cerebral artery (MCA) stenosis (50%-99%) were recruited. Demographic, clinical and imaging data of these patients were collected. Ipsilesional LMC status was graded as good or poor by assessing the laterality of anterior and posterior cerebral arteries in CTA. A CFD model based on CTA was constructed to reflect focal hemodynamics in the distal internal carotid artery, M1 MCA and A1 anterior cerebral artery. Pressure gradients were calculated across culprit MCA stenotic lesions in CFD models. Predictors for good LMC status were sought in univariate and multivariate analyses.

RESULTS

Amongst the 85 patients enrolled (mean age 61.5 ± 10.9 years), 38 (44.7%) had good ipsilesional LMC status. The mean pressure gradient across MCA lesions was 14.8 ± 18.1 mmHg. Advanced age (P = 0.030) and a larger translesional pressure gradient (P = 0.029) independently predicted good LMCs. A lower fasting blood glucose level also showed a trend for good LMCs (P = 0.058).

CONCLUSIONS

Our study suggested a correlation between translesional pressure gradient and maturation of LMCs in intracranial atherosclerotic disease. Further studies with more exquisite and dynamic monitoring of cerebral hemodynamics and LMC evolution are needed to verify the current findings.

Diagnostic value of bronchoalveolar lavage in children with nonresponding community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in hospitalized children. In CAP, causative agents are seldom identified using noninvasive diagnostic procedures. For those children not responding to empiric antibiotic therapy, it is vital to identify the causative pathogens for further management.

METHODS

We aimed to determine the usefulness of identifying the causative agents by bronchoalveolar lavage (BAL) in hospitalized children with nonresponding CAP. Ninety children hospitalized for CAP and treated with empiric antibiotics but having persistent fever ≥48 hours were enrolled, and their BAL data were retrospectively reviewed.

RESULTS

Aerobic bacteria were isolated from 38 (42%) of 90 cultures, and anaerobic bacteria were isolated from eight (24%) of 33 cultures. The bacteria isolated most frequently were Streptococcus viridians (26.3%), Pseudomonas aeruginosa (23.7%), and Staphylococcus aureus (15.8%). Streptococcus pneumoniae was isolated from the BALs of only two children, and Haemophilus influenzae from none. For positive aerobic culture results, BAL results guided modifications of antibiotic regimens in 21 episodes (21 of 38, 55.3%).

CONCLUSION

BAL results guided a change of antimicrobials in 55% of children with positive aerobic cultures (29% of all children in the study) and contributed to a high rate of successful therapy.

Whole-Genome Sequencing of a Family with Hereditary Pulmonary Alveolar Proteinosis Identifies a Rare Structural Variant Involving CSF2RA/CRLF2/IL3RA Gene Disruption

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease in which the abnormalities in alveolar surfactant accumulation are caused by impairments of GM-CSF pathway attributing to defects in a variety of genes. However, hereditary PAP is extremely uncommon and a detailed understanding in the genetic inheritance of PAP in a family may provide timely diagnosis, treatment and proper intervention including genetic consultation. Here, we described a comprehensive analysis of genome and gene expression for a family containing one affected child with a diagnosis of PAP and two other healthy siblings. Family-based whole-genome analysis revealed a homozygous deletion that disrupts CSF2RA, CRLF2, and IL3RA gene in the pseudoautosomal region of the X chromosome in the affected child and one of asymptomatic siblings. Further functional pathway analysis of differentially expressed genes in IL-1β-treated peripheral blood mononuclear cells highlighted the insufficiency of immune response in the child with PAP, especially the protection against bacterial infection. Collectively, our results reveal a novel allele as the genetic determinant of a family with PAP and provide insights into variable expressivity and incomplete penetrance of this rare disease, which will be helpful for proper genetic consultation and prompt treatment to avoid mortality and morbidity.

The prognosis of acute symptomatic seizures after ischaemic stroke

OBJECTIVE

Acute symptomatic seizure (AS) after ischaemic stroke is defined as a seizure occurring ≤7 days of the stroke. There remains a lack of information on the prognosis of AS after ischaemic stroke and how it should be treated.

METHODS

We prospectively recruited patients after their incidents of ischaemic stroke from a population-based stroke registry. Stroke aetiology was defined according to Trial-of-ORG-10172 in acute-stroke treatment (TOAST). Patients were examined for any transient complete-occlusion with recanalisation (TCOR) and haemorrhagic transformation. The seizure outcomes were (1) acute clustering of seizures ≤7 days, (2) seizure recurrence associated with stroke recurrence beyond the 7-day period and (3) unprovoked seizure (US) >7 days.

RESULTS

104 patients (mean age 65 years/55% female) with AS after ischaemic stroke were identified (mean follow-up 6.17 years). Comparison of the group of patients with AS and those without seizures showed that patients with AS had significantly less large-vessel and small-vessel disease but more cardioembolisms (p<0.05) and a higher proportion of TCOR (p<0.01), multiple territory infarcts (p=0.007) and haemorrhagic transformations (p<0.01). Using Kaplan-Meier statistics, the risk of acute clustering of seizures ≤7 days was 22%, with a statistical trend for TCOR as a predictive factor (p=0.06). The risk of seizure recurrence associated with worsening/recurrence of stroke beyond 7 days was 13.5% at 2 years, 16.4% at 4 years and 18% at 8 years. Presence of >2 cardiovascular risk factors (p<0.05) and status epilepticus (P<0.05) are predictive risk factors on Cox regression model. The risk of US was 19% at 2 years, 25% at 4 years and 28% at 8 years with epileptiform EEG as a predictive factor (p<0.05).

CONCLUSIONS

Seizure recurrence following AS after ischaemic stroke may appear as acute clustering. Afterwards, seizures may occur as often with a recurrent stroke as without one within 4.2 years. We recommend the use of antiepileptic agents for up to 4 years if the underlying stroke aetiology cannot be fully treated.

Good collateral circulation predicts favorable outcomes in intravenous thrombolysis: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Baseline collateral status has been correlated with outcomes of acute ischaemic stroke patients receiving intravenous thrombolysis (IVT) in previous studies. We carried out the current systematic review and meta-analysis to synthesize currently available evidence regarding such correlations.

METHODS

Full-text articles published since 2000 were retrieved and screened. The overall effect sizes of good versus poor collateral status over a series of outcomes and certain baseline features were estimated by random-effects models and presented in risk ratios (RRs) or mean differences.

RESULTS

Overall, 28 (3057 patients) and 14 (1584 patients) studies were included in qualitative and quantitative synthesis, respectively. Compared with poor pre-treatment collateral status, good collaterals showed a beneficial effect over the primary outcome of a favorable functional outcome at 3 or 6 months [RR, 2.45; 95% confidence interval, 1.94-3.09; P < 0.001] in acute ischaemic stroke patients receiving IVT treatment. However, such an effect tended to be different between studies with prescribed time windows of 3, 4.5 and > 4.5 h (up to 7 h), with the RRs being 2.21, 2.48 and 5.00, respectively (I²  = 53%). Good pre-treatment collaterals were also associated with a smaller infarct size at baseline, and a lower rate of symptomatic intracranial hemorrhage and a higher rate of neurological improvement early after IVT treatment.

CONCLUSIONS

The present study has demonstrated the prognostic value of baseline collateral circulation for outcomes of acute ischaemic stroke patients receiving intravenous reperfusion therapies, studied with different time windows of up to 7 h after ictus for IVT therapy.

Metabolomic Profiling of Infectious Parapneumonic Effusions Reveals Biomarkers for Guiding Management of Children with Streptococcus pneumoniae Pneumonia

Metabolic markers in biofluids represent an attractive tool for guiding clinical management. The aim of this study was to identify metabolic mechanisms during the progress of pleural infection in children with Streptococcus pneumoniae pneumonia. Forty children diagnosed with pneumococcal pneumonia were enrolled and analysis of pleural fluid metabolites categorized by complicated parapneumonic effusions (CPE) and non-CPE was assessed by using ¹H-NMR spectroscopy. Multivariate statistical analysis including principal components analysis (PCA) and partial least-squares discriminant analysis (PLS-DA) were performed. Metabolites identified were studied in relation to subsequent intervention procedures by receiver operating characteristic (ROC) curve analysis. Ten metabolites significantly different between CPE and non-CPE were identified. A significantly lower level of glucose for glycolysis was found in CPE compared to non-CPE. Six metabolites involving bacterial biosynthesis and three metabolites involving bacterial fermentation were significantly higher in CPE compared to non-CPE. Glucose and 3-hydroxybutyric acid were the metabolites found to be useful in discriminating from receiving intervention procedures. Metabolic profiling of pleural fluid using ¹H-NMR spectroscopy provides direct observation of bacterial metabolism in the progress of pneumococcal pneumonia. An increase in the metabolism of butyric acid fermentation of glucose could potentially lead to the need of aggressive pleural drainage.

Diagnostic utility of QuantiFERON-TB Gold In-Tube test in pediatric tuberculosis disease in Taiwanese children

PURPOSE

To compare the performance of a commercial interferon-gamma release assay, QuantiFERON TB Gold-in-Tube (QFG-IT) with the tuberculin skin test (TST) in Taiwanese children for the diagnosis of active tuberculosis (TB).

METHODS

A retrospective chart analysis of pediatric patients (<18 years of age) who underwent QFG-IT tests and TST for the confirmation of active TB between January 2008 and June 2014.

RESULTS

The sensitivity of QFG-IT was 100% [95% confidence interval (CI): 63.1-100], versus sensitivity of 62.5% for TST (95% CI 24.5-91.5). The positive predictive value of QFG-IT was 100 (95% CI: 89.7-100), while the negative predictive value for TST was 86.9% (95% CI: 67-96.3). Among three patients with Bacillus Calmette-Guérin (BCG) osteitis, two patients with TST were positive, but all tested samples for QFG-IT were negative.

CONCLUSION

QFG-IT assay was more sensitive for the diagnosis of TB disease than TST in an intermediate burden population with universal neonatal BCG vaccination. The increased recognition of BCG induced osteitis in recent years has alerted physicians that BCG induced lesions should be suspected when TST is positive but QFG-IT is negative. Despite higher costs for QFG-IT than TST, they have additional value for the diagnosis of active TB and should be performed when a diagnosis of TB remains in doubt.

Chest Wall Constriction after the Nuss Procedure Identified from Chest Radiograph and Multislice Computed Tomography Shortly after Removal of the Bar

BACKGROUND

This study radiographically examined the changes in the chest walls of patients with pectus excavatum (PE) after Nuss bar removal, to define the deformation caused by the bar and stabilizer. In the first part of the study, we compared the changes in chest radiographs of patients with PE to a preoperation PE control group. In the second part, we used multislice computed tomography (CT) scans to provide three-dimensional reconstructions with which to evaluate the changes to the thoracic wall.

METHODS

Part 1 From June 2006 to August 2011, 1,125 patients with PE who had posteroanterior chest radiographs taken before undergoing the Nuss procedure at four hospitals were enrolled as a preoperative control group. At the same time, 203 patients who had the bar removed were enrolled as the study group. The maximum dimensions of the outer boundary of the first to ninth rib pairs (R1-R9, rib pair width), chest height, and chest width were measured. Part 2 Thirty-one consecutive patients with PE (20 males and 11 females) who underwent Nuss bar removal were evaluated 7 to 30 days after operation. During this period, a further 34 patients with PE who had undergone CT imaging before bar insertion were evaluated and compared with the postoperative group.

RESULTS

Part 1 The width of the lower ribs (R4-R9) after bar removal was significantly less than in the age-matched controls. The ribs adjacent to the bar (R5-R7) showed the greatest restriction. The width of the upper ribs (R1-R3) 2 to 3 years after bar placement did not differ significantly from the controls. Patients who were operated on after 10 years of age had less of a restrictive effect. Three years of bar placement resulted in more restriction than a 2-year period, particularly in patients younger than 10 years old. Part 2: A significant constriction of the chest wall was observed in 13 patients after removal of the Nuss bar. Constriction at ribs 5 to 8 was found to be present adjacent to the site of bar insertion. However, constriction of the chest wall was found in only 3 of the 34 patients in the preoperative group. The severity of constriction (as graded by the spline model) also increased in the postoperative group.

CONCLUSION

The growth of the chest wall was restricted after placement of the Nuss bar for PE correction. Long-term follow-up of chest wall growth is needed to clarify whether such constriction resolves with time.

Rapid increase in the height and width of the upper chest in adolescents with primary spontaneous pneumothorax

BACKGROUND

We determined the chest height in a cohort of patients with primary spontaneous pneumothorax (PSP) who had received chest radiographic examinations prior to the attack. The aim of this study was to determine when their chest height began to change and how this was related to the PSP.

METHODS

From June 2009 to February 2012, the chest posteroanterior radiographs of 156 patients with PSP (Group 1) were reviewed. Among another 3134 patients with PSP, we identified 52 patients who had a chest posteroanterior radiograph prior to the attack (Group 2). We also recruited 196 controls for comparison (Group 3). The chest height and chest width at different levels were measured and analyzed.

RESULTS

Before 14 years of age, the chest height of patients in Group 2 was no different from that of patients in Group 3. By the age of 14 years, however, the chest height and upper chest width of patients with PSP was significantly higher than that of the normal controls. The difference from normal chest height did not increase at adulthood.

CONCLUSION

The rapid increase in chest height and upper chest width is a unique finding in patients with PSP. It might be attributable to the occurrence of PSP. This finding may also help to identify patients who are at risk of PSP.

Defective innate immune responses to respiratory syncytial virus infection in ovalbumin-sensitized mice

BACKGROUND/PURPOSE

Respiratory viral infections have frequently been reported to closely correlate with asthma exacerbations. Distinctive expression of cytokine/chemokine and anomalous responses of innate immunity induced by respiratory viral infections were suggested to play a key role. This study further evaluates the effects of airway sensitization on innate immunity in response to different viruses.

METHODS

Murine sensitization was established using an ovalbumin (OVA) sensitization model. Mice were subsequently infected with either respiratory syncytial virus (RSV) or human metapneumovirus (hMPV). Type I interferon (IFN), cytokines, and chemokines were measured in bronchoalveolar lavage (BAL) fluid. Pulmonary tissue samples were collected for the analysis of viral titers and type I IFN signal transcriptors.

RESULTS

Distinct expressions of cytokine/chemokine responses after viral infection were also found in mice with OVA sensitization. A significant increase of virus replication was found in lungs of RSV-infected sensitized mice. The increment of RSV titer was associated with the decreased levels of type I IFN. Although Toll-like receptor 3 (TLR3) expression was significantly increased in the lungs, the key signal transcriptor, IFN regulatory factor 3, was significantly suppressed in the RSV-infected sensitized mice.

CONCLUSION

A defective antiviral innate response was observed in the murine respiratory allergy model. Suppressed expression of IFN signal transcriptor contributes to decreased production of type I IFN. The defective innate immune response might result in acute viral exacerbations of allergic airway diseases.

Factors associated with proceeding to surgical intervention and recurrence of primary spontaneous pneumothorax in adolescent patients

Primary spontaneous pneumothorax (PSP) is not uncommon, and its recurrence is often a challenging clinical problem. Surgical management and predisposing factors for the recurrence of PSP, however, have not yet been well elucidated in adolescent patients. The major aim of this study was to investigate factors associated with proceeding to surgical intervention and recurrence of PSP in adolescents. Two hundred and nineteen episodes of PSP in 171 adolescent patients were retrospectively reviewed. The clinical and radiological spectrum of PSP and factors for proceeding to surgical intervention were assessed in these 171 patients. Risk factors for the recurrence of PSP were further analyzed in 128 patients with first attack of PSP. The male-to-female ratio of the 171 PSP patients was 9:1, and the mean age was 17.6 ± 1.5 years. The median body mass index (BMI) percentile was 11 (range 2-31), and 45 (34 %) patients had underweight BMI. The incidence of recurrent PSP was high with a total recurrence rate of 21 %. Ipsilateral recurrence rate of PSP after video-assisted thoracoscopic surgery (VATS) was much less than that of the conservative treatment (4 vs. 18 %). A large-size pneumothorax with a persistent air leak was the most significant factor for proceeding to VATS surgery (P = 0.001). In addition, it was a significant factor influencing the recurrence of PSP (P = 0.014). Other factors that did not significantly affect the recurrence rate were BMI, smoking status, and the number of bullae.

CONCLUSION

Adolescent PSP has a high recurrence rate of 21 % after a 2-year follow-up. A large-size pneumothorax with a persistent air leak may not only lead to surgical intervention but also the risk of a recurrence of PSP. The initial size of pneumothorax may not only guide the management process but also predict the risk of a recurrence in adolescent patients with PSP.

Pontine microbleeds and depression in stroke

OBJECTIVES

Depression is the most common affective disorder following stroke yet the neuroanatomical model of poststroke depression (PSD) remains unclear. This study examined the association between PSD and cerebral microbleeds (CMBs) and hypothesized that CMBs in specific regions would be associated with PSD.

METHODS

Of the 4766 patients with first ever or recurrent acute ischemic stroke admitted to the Acute Stroke Unit of the Prince of Wales Hospital between June 2004 and October 2010, 229 met the entry criteria and formed the study sample. Patients with a Geriatric Depression Scale score of 7 or above were classified as having PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging.

RESULTS

Compared to the non-PSD group, patients with PSD were more likely to have pontine CMBs (32.0% vs 18.2%; P = .019). The presence of pontine CMBs remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.2 (P = .016).

CONCLUSION

The results suggest that pontine CMBs are associated with a higher risk of developing PSD.

A possible familial lymphoproliferative disorder in two male siblings of children with recurrent wheezing and lung infections since infancy

Malignancies that result in wheezing in infants are very uncommon. Given its rarity in children, the diagnosis is challenging, and in the absence of a high index of suspicion, delayed diagnosis is not uncommon. Here we report two male siblings of children who presented with recurrent wheezing and recurrent lung infections since infancy. Both children showed no laboratory evidence of immunodeficiency. Lymphocytic interstitial pneumonia or hypersensitivity pneumonitis was histologically suspected in lung biopsy specimens from the older brother. He subsequently developed Epstein-Barr virus (EBV)-associated hemophagocytic lymphohistiocytosis and died. Based on the family history, we screened mutations among PRF1, Munc13-4, STX11, SH2D1A, and XIAP genes for the younger brother, but did not identify any mutations. He also underwent lung biopsy, which showed interstitial infiltration of lymphoid cells. In situ hybridization for EBV-encoded RNA showed a positive nuclear signal in the lymphoid cells. The presence of clonal B-cell proliferations was detected by clonally rearranged immunoglobulin studies. Lymphomatoid granulomatosis grade 3 was finally diagnosed. The progression of disease was rapid, and the patient died, despite rituximab therapy. The similar clinical manifestations in two male siblings suggest the possibility that a previously undescribed genetic defect contributed to these familial lymphoproliferative malignancies.

Preceding human metapneumovirus infection increases adherence of Streptococcus pneumoniae and severity of murine pneumococcal pneumonia

BACKGROUND

Coinfection with respiratory virus and Streptococcus pneumoniae has been frequently reported in several epidemiologic studies. The aim of this study was to explore the effect of preceding human metapneumovirus (hMPV) inoculation on subsequent pneumococcal infection.

METHODS

Hep-2 and A549 cells were infected with hMPV then inoculated with S. pneumoniae. Bacterial adhesion was measured using colony forming unit and cytometric-fluorescence assays. In vivo bacterial adhesion was examined in hMPV-infected mice after inoculation of fluorescence-conjugated S. pneumoniae. Pulmonary inflammation (bacterial titers, cytokine levels, and histopathology) of hMPV-infected mice was investigated after inoculation with S. pneumoniae.

RESULTS

In vitro results of bacterial infection with S. pneumoniae on A549 and Hep-2 monolayer cells showed that even though cellular adherence was variable among different serotypes, there was significantly enhanced bacterial adherence in A549 cells with preceding hMPV infection. In addition, in vivo study of hMPV-infected mice showed increased adhesion of S. pneumoniae on the bronchial epithelium with delayed bacterial clearance and exacerbated histopathology. Furthermore, mice with preceding hMPV infection showed repressed recruitment of airway neutrophils with decreased expression of neutrophil chemoattractants during pneumococcal infection.

CONCLUSION

These results suggest that hMPV-infected airway cells, especially the lower airway epithelium, express increased adherence with S. pneumoniae. Furthermore, hMPV-infected mice showed impaired recruitment of airway neutrophils, possibly leading to delayed bacterial clearance and exacerbated pulmonary inflammation, after secondary infection with pneumococcal isolates.

The value of total protein in guiding management of infectious parapneumonic effusion by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

BACKGROUND/PURPOSE

Infectious parapneumonic effusion (PE) contains proteins originating from circulation as well as proteins locally released by inflammatory pulmonary cells. The purpose of this study was to investigate the value of total protein analysis in guiding management of infectious PE by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

METHODS

Fifty-seven children with pneumonia followed by PE were consecutively enrolled into our study. Protein profiles generated by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry after fractionating samples with functionalized magnetic beads (C8) were used for differentiating complicated PE (CPE) from non-CPE. A training set was used to generate classification models and the clinical efficacy of these models in detecting CPE and the need for intervention was then evaluated in an independent set.

RESULTS

The MS spectra derived from PE were analyzed, and classification models were constructed in the training set. A total of 123 mass/charge (m/z) values were identified and 23 m/z values which were significant with p < 0.05 were used as classifiers. An optimized genetic algorithm model containing enforced selection of three significant downregulated m/z values (2127, 2232, and 2427) was able to classify CPE with 100% positive predictive value and predict the need of aggressive therapeutic intervention with 77% positive predictive value.

CONCLUSION

A diagnostic model construction comprising three potential biomarkers can predict CPE and need for surgical intervention rapidly and precisely. Pleural fluid proteins downregulated during the progression of pneumonia could potentially guide the management of infectious PE.

Location of infarcts and apathy in ischemic stroke

BACKGROUND

Apathy is common in stroke survivors. Unlike poststroke depression, apathy after stroke has not been extensively investigated and the significance of the location of infarcts in the development of apathy following a stroke is unknown. This study examined the association between poststroke apathy (PSA) and the location of infarcts.

METHODS

A cohort of 185 patients with acute ischemic stroke admitted to the Stroke Unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the index stroke, a psychiatrist administered the Apathy Evaluation Scale (AES). PSA was defined as an AES score of 37 or above. The presence and location of infarcts were evaluated with magnetic resonance imaging.

RESULTS

Altogether 185 patients met the entry criteria and formed the study sample; 20 (10.8%) had PSA. PSA patients were older and had higher stroke severity and more depressive symptoms. The PSA group also had lower levels of physical and cognitive functioning. Compared with the non-PSA group, PSA patients were more likely to have acute pontine infarcts (35.0% vs. 11.5%; p = 0.011). They had a higher mean number (0.5 ± 0.7 vs. 0.1 ± 0.3; p = 0.003) and larger volume (0.6 ± 1.4 vs. 0.1 ± 0.3 ml; p = 0.002) of acute pontine infarcts. Six variables were entered into the predictive regression model: age, the presence, number and volume of acute pontine infarcts, the number of old infarcts and periventricular white matter hyperintensities scores. The volume of infarcts remained an independent predictor of PSA in the multivariate analysis, with an odds ratio of 3.9 (p = 0.007). The Geriatric Depression Scale, National Institutes of Health Stroke Scale, Barthel Index and Mini-Mental State Examination scores were also entered into the subsequent associative regression model; the volume of acute pontine infarcts remained a significant predictor (odds ratio = 3.8).

CONCLUSIONS

This is the first report of an association between pontine infarcts and the risk of PSA. The results suggest that pontine infarcts may play a role in the development of PSA. The importance of acute pontine infarcts in the pathogenesis of PSA warrants further investigation.

Serotonin receptor 2C gene polymorphism associated with post-stroke depression in Chinese patients

The serotonin receptor 2C (HTR2C) gene has been shown to play a pivotal role in major depression. We examined the association between post-stroke depression (PSD) and polymorphism in HTR2C. A cohort of 223 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a geriatric depression scale score of 7 or above. Possible confounding factors, including previous history of stroke, severity of stroke, level of social support, and recent life events, were investigated. All patients were genotyped for polymorphisms of HTR2C. Separate analyses were performed for males and females. Sixty-one patients were found to have PSD. There were significant associations between the HTR2C gene and PSD status in the male patients, but not in the female ones. After adjusting for possible confounders, the rs12837651 T allele (odds ratio = 4.020) and the rs2192371 G allele (odds ratio = 2.866) were found to be significantly associated with PSD in males. Genetic variation in HTR2C receptors appears to be involved in the pathogenesis of PSD in Chinese males.

Macrolide-resistant Mycoplasma pneumoniae in children in Taiwan

The aim of this study was to estimate the prevalence of macrolide-resistant Mycoplasma pneumoniae in Taiwan and to compare the clinical courses of pediatric patients with macrolide-resistant (MR) M. pneumoniae and macrolide-susceptible (MS) M. pneumoniae infection. Patients were among the children admitted to Chang Gung Children's Hospital with mycoplasmal pneumonia between February and December 2011. Detection for macrolide resistance was performed after informed consent was obtained. We retrospectively reviewed medical records and compared the clinical courses of two groups of patients of 73 children enrolled into our study. The rate of macrolide resistance in M. pneumoniae was 12.3 %. Longer hospital stay was observed in the MR patients than MS patients [median, 7 days vs. 5 days (P = 0.019)]. Clinical features or radiographic or laboratory findings are not helpful to differentiate MR from MS mycoplasmal pneumonia. Early diagnosis of MR mycoplasmal pneumonia is crucial for the best management of these patients and obviates the need for extensive etiological searches of these nonresponding cases.

Poststroke fatigue is associated with caudate infarcts

OBJECTIVE

The caudate nucleus may be involved in the pathogenesis of the fatigue observed in neurological disorders. However, the significance of caudate lesions in poststroke fatigue (PSF) is unknown. This study examined the association between caudate infarcts and PSF.

METHODS

Five hundred Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. All participants were assessed for PSF with the Fatigue Severity Scale (FSS) three months after their index stroke. PSF was defined as a mean FSS score of 4.0 or more. Physical functioning and depressive symptoms were measured by the Barthel Index (BI) and the Geriatric Depression Scale (GDS).

RESULTS

One hundred and twenty-five (25.0%) of the patients had PSF. Compared to the non-fatigue group, the PSF patients were more likely to be women and had hyperlipidemia, lower BI and higher GDS scores. Caudate (8.0% versus 1.3%, p=0.001) and putamen (19.2% versus 12.0%, p=0.043) acute infarcts were more common in the PSF group, whereas pons infarcts (13.6% versus 22.2%, p=0.038) were less common. Acute caudate infarcts remained an independent predictor of PSF in the multivariate analysis, with an odds ratio of 6.4.

CONCLUSIONS

The results suggest that patients with PSF are more likely to have caudate infarcts.

Diaphragmatic paralysis among very low birth weight infants following ligation for patent ductus arteriosus

Management of diaphragmatic paralysis (DP) among newborn infants remains controversial, especially for very low birth weight (VLBW) infants following ligation for patent ductus arteriosus (PDA). This study aimed to characterize the impact of DP after PDA ligation among VLBW infants. Clinical characteristics of DP cases treated with either diaphragmatic plication or conservative methods were described as well. The medical records of VLBW infants who underwent PDA ligation in Chang Gung Memorial Hospital between January 2000 and December 2011 were retrospectively reviewed, and DP was suspected if postligation chest X-rays showed an elevation of the left diaphragm as confirmed by a chest ultrasonograph. For each DP case, three other infants that received PDA ligation with proximate birth dates and who were closely matched in terms of gestational age (±1 week) and birth weight (±10 %) were selected as the control group. A total of eight preterm infants were diagnosed as having DP and 24 infants were selected as the control group. The affected infants usually presented with respiratory distress and extubation failure. The study demonstrated that, among our patient population, DP was associated with a significantly longer duration of ventilator dependency (56.1 ± 16.0 vs. 29.8 ± 17.7 days, p = 0.001) and a higher incidence of severe bronchopulmonary dysplasia (87.5 vs. 23 %, p = 0.002). For selective infants with DP-related ventilatory failure after PDA ligation, surgical plication may facilitate extubation. Diaphragmatic paralysis should be evaluated carefully among VLBW infants receiving PDA ligation because of its adverse impact on ventilator dependency and correlation to a higher incidence of severe bronchopulmonary dysplasia.

Clinical features of radiologically confirmed pneumonia due to adenovirus in children

BACKGROUND

Clinical features of radiologically confirmed pneumonia due to adenovirus in children have not been comprehensively evaluated.

OBJECTIVE

To describe the detailed clinical features of radiologically confirmed adenovirus-associated pneumonia in children.

STUDY DESIGN

Of 3298 children with a throat virus culture positive for adenovirus treated at a university-affiliated hospital, from January 2000 to June 2008, in northern Taiwan, 80 hospitalized children (2.4%) with radiologically confirmed pneumonia were identified. From four children with incomplete medical records, only demographics were included for analysis.

RESULTS

The median age was 2.97 years, ranging from 25 days to 14 years. Seventy-three patients (96%) had fever, with a median duration of 7 days. The three most common respiratory symptoms were cough (99%), rhinorrhea (82%) and dyspnea (42%). Gastrointestinal symptoms were recorded in 80% of the patients, and neurologic symptoms in four children. Leukocytosis (WBC≥15,000/μL) was noted in 19 (25%) patients. Only six patients (8%) had a normal serum C-reactive protein (CRP) value (<5 mg/L), while 48 patients (63%) had a CRP level >40 mg/L. Seventeen (21%) children required intensive care. Seventy-three patients (96%) recovered uneventfully. Sequelae were seen in two patients and death in 1. Of the 69 isolates with serotyping determination, seven serotypes were identified, with a predominant serotype (type 3 for 73%).

CONCLUSION

Less than 5% of the children with adenoviral infection had radiologically confirmed patch pneumonia. The manifestation of pneumonia caused by adenovirus was similar to that of bacterial pneumonia.

Autonomic dysfunction in ischemic stroke with carotid stenosis

OBJECTIVES

Impaired autonomic function is common in acute ischemic stroke. Previous limited studies have suggested that atherosclerosis may affect the distensibility of the carotid sinus and then impair the cardiovascular autonomic function. This study sought to investigate cardiovascular autonomic function in patients with ischemic stroke with carotid stenosis.

METHODS

Eighty-five patients with ischemic stroke (58 ones without carotid stenosis and 27 ones with carotid stenosis, average 6 months after stroke onset) and 37 elderly controls were recruited. All performed Ewing's battery autonomic function tests.

RESULTS

From Ewing's battery of autonomic function tests, atypical, definite, or severe autonomic dysfunction was identified in 69.0% patients without carotid stenosis and 88.9% with carotid stenosis, with significant difference between the two groups, and the prevalence of autonomic dysfunction in both groups was higher than that in controls (21.6%). Patients with carotid stenosis showed impairment of all parasympathetic tests (all P < 0.05) and one of the sympathetic tests [Mean fall in systolic blood pressure (BP) on standing: P = 0.051], and those without carotid stenosis only showed impairment in two parasympathetic tests (Valsalva ratio: P = 0.014; heart rate response to deep breathing: P < 0.001) in comparison with controls. Patients with carotid stenosis had significantly more impairment than those without carotid stenosis in some autonomic parameters (Valsalva ratio: P < 0.05; mean fall in systolic BP on standing: P < 0.05).

CONCLUSIONS

Cardiovascular autonomic function is impaired in patients with ischemic stroke, but patients with carotid stenosis show more severely impaired parasympathetic and sympathetic functions.

Predictors of the depressive symptomatology of the family caregivers of Chinese stroke patients in Hong Kong

The aim of this cross-sectional study was to determine the socio-demographic and clinical factors associated with depressive symptoms in the family caregivers of Hong Kong Chinese stroke patients. One hundred and twenty-three patients at a stroke clinic and their family caregivers formed the study sample. The depressive symptoms of both the patients and their family caregivers were rated with the Chinese version of the 15-item Geriatric Depression Scale (GDS). Participants' socio-demographic data and clinical characteristics served as the independent variables in relation to the caregivers' GDS scores. Patients' and caregivers' somatic and psychological conditions were measured with 10 scales. In univariate analysis, caregivers' GDS scores were significantly correlated with certain of their characteristics [Modified Life Event Scale (MLES), Cumulative Illness Rating Scale (CIRS) and Lubben Social Network Scale (LSNS) scores, sex and being a housewife] and those of the patients (GDS score and being a housewife). Multiple regression analysis showed caregivers' MLES and CIRS scores and patients' GDS scores to be independent correlates of caregivers' GDS scores. Adverse events encountered by caregivers in the past 6 months, their current health problems and patients' depressive symptoms were found to be the principal factors associated with caregivers' depressive symptoms.

Intracranial electroencephalogram to evaluate refractory temporal and frontal lobe epilepsy

OBJECTIVE

We undertook a collaborative study in a multidisciplinary team to channel refractory epilepsy patients to test a hypothesis about placement of intracranial electroencephalography arrays.

DESIGN

This was a descriptive case series. Prospective non-invasive presurgical evaluations were based on clinical semiology, magnetic resonance imaging, video-electroencephalography findings and neuropsychological assessments. If the results were discordant, a hypothesis was generated using individualised combinations of positron emission tomography, single-photon emission computed tomography, functional magnetic resonance imaging and Wada tests. The indications for intracranial electroencephalography were: (a) focal magnetic resonance imaging, ictal/interictal scalp electroencephalography with variable results (group A); (b) multi-focal magnetic resonance imaging, focal/multi-focal ictal scalp electroencephalography (group B); (c) non-lesional magnetic resonance imaging, focal/multi-focal ictal scalp electroencephalography (group C). We evaluated whether the seizure-onset zones and eloquent areas were delineated, surgical outcomes (if operated on), and pathology results.

SETTING

A tertiary referral centre for neurology in Hong Kong.

PATIENTS

A total of 105 refractory epilepsy patients completed non-invasive presurgical evaluations over the period 2007 to 2009. Thirty-two patients were eligible for direct resective surgery, and another 25 patients had a testing hypothesis formulated. Of these 25 patients, 10 were eligible for intracranial electroencephalography based on technical/financial considerations.

RESULTS

All 10 patients (group A=2, group B=4, group C=4) had their epileptogenic zones defined. Six patients underwent functional mapping, all of whom had their eloquent areas defined. Seven of the 10 patients underwent resective surgery; four of them achieved Engel class I/II outcomes. The dichotomised outcomes were 100% (group A), 50% (group B), and 33% (group C) achieving Engel class I/II. Two patients had asymptomatic subdural haematoma. There was no intracranial infection or operative mortality. In five (71%) of seven of the patients, a histological diagnosis was established.

CONCLUSION

Proper deployment of intracranial electroencephalography is useful in the presurgical evaluation of patients with refractory epilepsy. This modality of management is potentially of benefit for patients with refractory epilepsy, but is underutilised locally.

ACE gene sequence and nucleotide variants in IgA nephropathy

INTRODUCTION

Association studies with single nucleotide polymorphisms (SNPs) have been contradictory. Haplotypes may be more helpful. With gene sequencing, all SNPs can be found for construction of haplotypes.

METHODS

The ACE gene was sequenced in four healthy Chinese subjects and 20 patients with IgA nephropathy (IgAN) to observe if differences exist among SNPs and haplotypes. 20 patients on angiotensin 1-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ATRA) therapy were then compared with another 20 patients not treated with ACEI /ATRA to determine their renal outcome in response to ACEI/ATRA therapy and whether their genetic profile of ACE gene could play a role in determining their outcome to ACEI /ATRA therapy and progression to end-stage renal failure (ESRF).

RESULTS

IgAN patients had 53 variants, of which 17 were unique, whereas normal subjects had 38 variants, of which two were unique (p less than 0.005). No unique variant was a significant risk factor for IgAN. Significant genotype and allele frequency differences in five variants were observed between IgAN patients with renal impairment and those with ESRF (p less than 0.02).

CONCLUSION

Our data suggests that at least in the ACE gene, haplotyping SNPs within a single gene seems to have no added advantage over genotyping the individual component SNPs. The D allele and haplotype 3 confer an adverse prognosis, while the I allele and haplotype 5 appear to be renoprotective. The data suggests that genotypes of the ACE gene are linked to certain haplotypes, which could influence IgAN patients' response to ACEI/ATRA therapy.

Cerebral microbleeds and depression in lacunar stroke

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMB) are common in stroke survivors and the community-dwelling elderly. The clinical significance of CMB in the development of depression after a stroke is unknown. This study examined the association between poststroke depression (PSD) and CMB.

METHODS

A cohort of 235 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a Genetic Depression Scale score of ≥7. The presence and location of CMB were evaluated with MRI.

RESULTS

In comparison with the non-PSD group, PSD patients were more likely to have lobar CMB (33.3% versus 19.9%; P=0.022). Lobar CMB remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.08 (P=0.032).

CONCLUSIONS

The results suggest that lobar CMB may play a role in the development of PSD. The importance of CMB in the pathogenesis of depression in stroke survivors and the general elderly population warrants further investigation.

Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) of urinary protein in acute kidney injury

Recent experimental and clinical studies have shown the importance of urinary proteomics in acute kidney injury (AKI). We analyzed the protein in urine of patients with clinical AKI using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) for its diagnostic value, and followed them up for 40 months to evaluate prognosis. Urine from 31 consecutive cases of AKI was analyzed with SDS-PAGE to determine the low, middle and high molecular weight proteins. Fractional excretion of sodium (FENa) was estimated from serum and urine creatinine and sodium (Na). The cases were followed-up for 40 months from the end of the recruitment of study cases. Glomerular protein was higher in the hematuria group when compared with the non-hematuria group (P <0.04) and in the AKI group than in the acute on chronic renal failure (AKI-on-CRF) group (P <0.002). Tubular protein was higher in the AKI-on-CRF group (P <0.003) than in the AKI group. Tubular protein correlated with FENa in groups with diabetes mellitus (DM), AKI-on-CRF, and without hematuria (P <0.03, P <0.02 and P <0.004, respectively). Pattern of protein did not differ between groups with and without DM and clinical acute tubular necrosis (ATN). At the end of 40 months follow-up, category with predominantly glomerular protein progressed to chronic renal failure (CRF) or end-stage renal failure in higher proportion (P <0.05). In clinical AKI, we observed that glomerular protein dominated in cases with glomerular insult, as indicated by hematuria. Tubular protein was common in the study cases with CRF, DM and cases without hematuria. This indicates tubulo-interstitial injury for AKI in these cases. Patients with predominantly glomerular protein had an adverse outcome.

Cerebral microbleeds and symptom severity of post-stroke depression: a magnetic resonance imaging study

BACKGROUND

Cerebral microbleeds (CMBs) are common in stroke survivors, although their clinical significance in the development of psychiatric conditions following stroke remains unknown. This study examines the association between post-stroke depression (PSD) symptom severity and CMBs.

METHODS

Amongst the 4088 patients with acute ischemic stroke who had been admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong, between December 2004 and May 2009, 994 patients were recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all 994 patients and made a diagnosis of PSD three months after the index stroke. PSD symptom severity was assessed with the 15-item Geriatric Depression Scale (GDS). Seventy-eight patients were found to have PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging (MRI).

RESULTS

Seventy-eight patients (7.8%) had PSD. CMBs were identified in 20 PSD patients. Relative to the no-CMB group, the mean GDS score of patients with lobar CMBs was significantly higher (12.6±2.6 versus 10.4±2.5, p=0.01 after adjusting for age, sex, global cognitive functions, neurological deficits and white matter hyperintensities).

LIMITATIONS

Patients with more severe stroke, those who died before the three-month follow-up and those who became depressed later were excluded, as were those unable to give their consent due to dementia or aphasia. These selection biases may limit the generalizability of the findings.

CONCLUSIONS

The results suggest that lobar CMBs may contribute to PSD symptom severity. The importance of CMBs in the pathogenesis of other psychiatric disorders in stroke survivors and other patient populations warrants further investigation.

Impact of patterns of proteinuria on renal allograft function and survival: a prospective cohort study

BACKGROUND

Proteinuria is an important complication in renal transplant recipients. The aim of this prospective study was to evaluate the long-term impact of transplant proteinuria patterns on allograft function and survival.

METHODS

We analyzed urinary protein of a cohort of 83 renal transplants with proteinuria ≥0.5 g/d by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and radial immunogel diffusion assay. After initial stratification and analysis, the cohort was followed up for 16 yr. The graft outcome and survival were analyzed using Cox regression model to determine their association with different patterns of initial transplant proteinuria.

RESULTS

Group with predominantly glomerular (middle- and high-molecular-weight with or without low-molecular-weight) proteinuria (61%) had higher serum creatinine (p < 0.001) than the group with predominantly tubular (low-molecular-weight) proteinuria (39%). The incidences of chronic graft dysfunction and graft loss had increased in the glomerular proteinuria group (p < 0.001, hazard ratio 3.6, 95% confidence interval 1.7-7.5 and p < 0.001, hazard ratio 4.9, 95% confidence interval 1.9-12.1, respectively). Patient death did not differ (p = 0.434, hazard ratio 1.5, 95% confidence interval 0.5-4.5).

CONCLUSION

  Proteinuria in renal transplants can be differentiated into glomerular and tubular types based on molecular weight. Glomerular proteinuria is associated with significant increase in graft dysfunction and graft loss.

Operational definitions improve reliability of the age-related white matter changes scale

BACKGROUND AND PURPOSE

Although the age-related white matter changes (ARWMC) scale has been advocated to be applicable to both MRI and CT for assessing the severity of WMC, its inter-rater reliability on CT is only fair. We aimed to operationalize the ARWMC scale and investigate the effect of this operationalization on the reliability and validity on MRI and CT.

METHODS

Operational definitions of the ARWMC scale were derived from Erkinjuntti research criteria for subcortical vascular dementia and Scheltens scale. Using original and operationalized ARWMC scale, eight observers recorded the time for rating per MRI and per CT. We investigated the inter-rater and intrarater reliability as well as validity against volume using data from 97 stroke patients.

RESULTS

Inter-rater reliability of the operationalized scale on CT (0.874, 95% confidence interval [0.780-0.934]) was better than the original scale (0.569, 95% confidence interval [0.247-0.775]). Its intrarater reliability on CT (0.869) and reliability on MRI (inter-rater: 0.860; intrarater: 0.838) was comparable with the original scale (CT intrarater: 0.750 and on MRI inter-rater: 0.845; intrarater: 0.853). The time required to administer the operationalized scale (4'2″ for MRI and 1'18″ for CT) was similar to that of the original scale (3'56″ for MRI and 1'16″ for CT). The original scale and operationalized scale also significantly correlated with WMC volume (operationalized scale ρ = 0.613, P < 0.001, original scale ρ = 0.638, P < 0.001).

CONCLUSION

Operational definitions improve the inter-rater reliability of ARWMC scale on CT, and it correlates with volumetric measurement.

White matter hyperintensities in post-stroke depression: a case control study

OBJECTIVE

Despite extensive research on post-stroke depression (PSD), the role of white matter hyperintensities (WMHs) in its pathogenesis remains uncertain. The aim of this study was to evaluate the relationship between WMHs and PSD in Chinese patients with first or recurrent stroke.

METHODS

A cohort of 994 patients with acute ischaemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all patients and made a diagnosis of PSD 3 months after the index stroke. 78 (7.8%) patients had PSD; 78 stroke patients matched according to age and sex but without PSD served as a control group. The severity and location of WMHs were evaluated with MRI.

RESULTS

In comparison with the non-PSD group, patients in the PSD group were more likely to have severe deep WMHs (12.8% vs 1.3%; p=0.009). Severe deep WMHs remained an independent predictor of PSD in the multivariate analysis with an OR of 13.8 (p=0.016).

CONCLUSION

The results suggest that WMHs may play a role in the development of PSD. The importance of WMHs in the treatment and outcome of PSD warrants further investigation.

Genetic polymorphisms of Chinese patients with ischemic stroke and concurrent stenoses of extracranial and intracranial vessels

The etiology of concurrent stenoses of extracranial and intracranial vessels in patients with ischemic stroke is poorly understood, but hereditary factors are believed to be important. We aimed to determine whether genetic polymorphisms affecting homocysteine and lipid metabolism are associated with concurrent stenoses. The genotypes of 191 Han Chinese patients with acute ischemic stroke, of whom 47 (25%) had concurrent stenoses, and 167 healthy control patients in Hong Kong were examined for the following polymorphisms: paraoxonase 1 (PON1) Q192R, methylenetetrahydrofolate reductase (MTHFR) A222V, glutamate-cysteine ligase catalytic-subunit (GCLC)-129C>T, and oxidized low-density lipoprotein receptor (OLR) 3' untranslated region C>T (rs1050283). The genotype distributions of PON1 Q192R and MTHFR A222V, which affect lipid and homocysteine metabolism, differed significantly between patients with stroke and healthy controls. The presence of at least one R allele in PON1 Q192R and a TT allele in OLR rs1050283 were associated with concurrent stenoses. We also identified a possible association between the presence of at least one V allele in MTHFR A222V and concurrent stenoses. This study shows that genetic polymorphisms affecting homocysteine and lipid metabolism are possible risk factors for stroke and concurrent stenoses.

Frequency of ventilator-associated pneumonia with 3-day versus 7-day ventilator circuit changes

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common clinical problem. Previous studies involving adult patient cohorts have assessed various risk factors associated with VAP, including ventilator circuit changes. The objective of this study was to examine the incidence of and risk factors associated with VAP, particularly 3-day versus 7-day ventilator circuit changes, in a pediatric intensive care unit (PICU).

METHODS

This was a cohort observational study. Patients hospitalized in the PICU at Chang Gung Children's Hospital between November 2003 and September 2004 were enrolled. Investigators and critical-care specialists evaluated baseline characteristics, incidence of VAP, and related variables from PICU admission until discharge or death.

RESULTS

Of 397 patients initially enrolled, 96 (aged 11-60 months) were available for statistical analysis and were assigned into two groups according to timing of ventilator circuit change: 3-day (n = 46) and 7-day circuit change (n = 50). No statistically significant differences were observed for VAP incidence (13% vs. 16%, p = 0.68) or hospital mortality (22% vs. 36%, p = 0.14) for 3-day versus 7-day circuit change. Incidence of VAP per 1000 ventilation days was 10.75 and 8.41 for 3-day and 7-day circuit change, respectively. Univariate analysis indicated statistical significance for the duration of mechanical ventilation (10.17 +/- 16.63 days vs. 18.20 +/- 14.99 days, p < 0.001), length of stay in PICU (22.30 +/- 20.48 days vs. 37.22 +/- 36.79 days, p = 0.0069) and presence of enteral nutrition [7 (15.22%) vs. 23 (46.0%), p = 0.0012].

CONCLUSION

Weekly circuit change does not contribute to increased rates of VAP in pediatric patients. Long-term studies evaluating risk factors in larger pediatric patient populations are warranted for further conclusive recommendations.

Comparing late-onset and neonatally-diagnosed congenital cystic adenomatoid malformation of the lung

BACKGROUND

Most congenital cystic adenomatoid malformations (CCAM) are found in utero or during the immediate neonatal period. Some malformations regress in utero, while others persist and remain unnoticed until later in childhood. The optimal clinical management of patients with CCAM is controversial. The aim of this study is to suggest a safe strategy for treatment of CCAM based upon the age of the patient at diagnosis, by analyzing the clinical features of CCAM and considering the possibility of regression in early infancy.

METHOD

This is an observational retrospective study of 19 patients with CCAM. The clinical features, histopathological classification, status of lesion regression, diagnostic method, treatment, and outcome were collected. Patient data were analyzed highlighting age at disease presentation.

RESULTS

Five out of the seven neonates with neonatally-diagnosed CCAM presented with respiratory distress. Eight of the twelve patients in the late-onset group had respiratory tract infections. Regression of the lesion during the early postnatal period was documented in 4 neonatally-diagnosed CCAMs, while none of the patients in the late-onset group showed signs of radiographic changes after a mean follow up of 4 years. Skeletal malformation was the most common associated anomaly in our series.

CONCLUSION

Conservative treatment is suggested for neonatally-diagnosed CCAM because of possible postnatal remission. Surgery may be required in older patients because of possible recurrent infections, infrequent mass regression, radiation exposure, and inconveniencies during follow-up visits. A thorough survey of possible associated skeletal anomalies in patients with CCAM is also recommended as early correction can improve life quality.

Microbleeds and post-stroke emotional lability

OBJECTIVE

The clinical significance of microbleeds (MBs) in the development of psychiatric conditions following a stroke is unknown. Lesions located in various cortical and subcortical areas are thought to be involved in the pathophysiology of post-stroke emotional lability (PSEL). This study examined the association between PSEL and MBs.

METHODS

A total of 519 Chinese patients with acute ischaemic stroke consecutively admitted to the acute stroke unit of a university affiliated regional hospital in Hong Kong were screened for PSEL 3 months after their index stroke. The number and location of MBs were evaluated with MRI.

RESULTS

According to Kim's criteria, 74 (14.3%) patients had PSEL. In comparison with the non-PSEL group, patients in the PSEL group were more likely to have MBs in the thalamus as a whole (16.2% vs 6.5%; p = 0.004), its anterior (6.9% vs 2.0%, p = 0.02) and paramedian territories (8.1% vs 3.1%; p = 0.04), and a higher number of MBs in the entire brain (1.7+3.4 vs 1.3+5.0; p = 0.031). MBs in the thalamus remained an independent predictor of PSEL in the multivariate analysis, with an odds ratio of 4.7 (p = 0.002).

CONCLUSION

Our results suggest that MBs in the thalamus may play a role in the development of PSEL. The importance of MBs in PSEL and other psychiatric conditions in stroke survivors warrants further investigation.

Use of magnetic resonance angiography to predict long-term outcomes of ischemic stroke patients with concurrent stenoses in Hong Kong

PURPOSE

To determine the long-term outcome of ischemic stroke patients with concurrent intracranial and extracranial atherosclerosis using magnetic resonance angiography.

METHODS

A prospective cohort of patients in Hong Kong with acute ischemic stroke was studied with magnetic resonance angiography of the brain and carotid duplex. All patients were followed up regularly for the development of recurrent stroke, cardiac events, or death.

RESULTS

Totally 343 patients with acute ischemic stroke were included, of whom 104 (30%) had concurrent intracranial and extracranial lesions. The follow-up period was up to 76 months (mean 44.5 months). Overall, 55 patients (15.5%) died of any cause and 91 patients (26.5%) suffered a further nonfatal vascular event. The overall 5-year cumulative rates of mortality, restroke and poor outcomes (combined death and further vascular events) were 18, 27 and 37%, respectively. In patients with concurrent lesions, these rates were 31, 41 and 51%, respectively. The corresponding rates were 13, 22 and 31% in patients without concurrent lesions. The risks were highest in the first year after stroke. More deaths (log rank, 16.3; p = 0.0001), restrokes (log rank, 9.71; p = 0.002) and poor outcomes (log rank, 13.87; p = 0.0001) were found among patients with concurrent lesions. The presence of concurrent vascular lesions, advanced age, smoking, hyperlipidemia and previous history of stroke were independent predictors of poor outcomes.

CONCLUSIONS

The long-term prognosis of ischemic stroke patients with concurrent atherosclerosis of intracranial and extracranial vessels is poor. They are at high risk of further vascular events or death.

Hand-assisted laparoscopic colectomy versus standard laparoscopic colectomy: a cost analysis

OBJECTIVE

There is a relative dearth of literature comparing hand-assisted (HALC) to standard (SLC) laparoscopic colectomies. HALC seems beneficial in terms of shorter operative times and lower conversion rates, but this is counterbalanced by a greater inflammatory response, larger incisions and higher direct costs. Nevertheless, these results are not consistent throughout existing studies and there are to date no detailed cost comparisons. Our hypothesis was that HALC would not incur significantly higher institutional costs compared with standard laparoscopic techniques.

METHOD

Patients undergoing either SLC or HALC between August 2004 and September 2006 were retrospectively reviewed. All patients were managed using a standard protocol. Outcomes assessed included operative times, conversion rates, pain scores, time to resolution of ileus, length of stay and complications. Total costs were calculated from the day of surgery. Statistical analyses included chi(2), Fisher's exact test, the Mann-Whitney U-test or nonparametric bootstrapping method.

RESULTS

Seventy-three patients underwent SLC while 101 had HALC. Demographics and indications for surgery in both groups were similar; the majority were performed for colorectal cancers. Operative times were shorter (147.5 vs 172.5 min, P < 0.05) and complication rates lower (28.7%vs 45.2%, P < 0.025) for HALC. There was no significant difference in the other clinical outcomes. Operative costs and cost of consumables were higher for HALC (US$4024.2 vs US$3568.1, P = 0.01 and US$1724.7 vs US$1302.7, P < 0.001, respectively). However, total costs were not significantly different (HALC US$8999.8, SLC US$7910.7, P = 0.11).

CONCLUSION

Institutional costs are not significantly higher for HALC compared with SLC.