Plasma nuclear and mitochondrial DNA levels as predictors of outcome in severe sepsis patients in the emergency room

BACKGROUND AND AIM

The sensitivity and specificity of biomarkers and scoring systems used for predicting fatality of severe sepsis patients remain unsatisfactory. This study aimed to determine the prognostic value of circulating plasma DNA levels in severe septic patients presenting at the Emergency Department (ED).

METHODS

Sixty-seven consecutive patients with severe sepsis and 33 controls were evaluated. Plasma DNA levels were estimated by real-time quantitative polymerase chain reaction assay using primers for the human β-hemoglobin and ND2 gene. The patients' clinical and laboratory data on admission were analyzed.

RESULTS

The median plasma nuclear and mitochondria DNA levels for severe septic patients on admission were significantly higher than those of the controls. The mean plasma nuclear DNA level on admission correlated with lactate concentration (γ = 0.36, p = 0.003) and plasma mitochondrial DNA on admission (γ = 0.708, p < 0.001). Significant prognostic factors for fatality included mechanical ventilation within the first 24 hours (p = 0.013), mean sequential organ failure assessment (SOFA) score on admission (p = 0.04), serum lactate (p < 0.001), and both plasma nuclear and mitochondrial DNA on admission (p < 0.001). Plasma mitochondrial DNA was an independent predictor of fatality by stepwise logistic regression such that an increase by one ng/mL in level would increase fatality rate by 0.7%.

CONCLUSION

Plasma DNA has potential use for predicting outcome in septic patients arriving at the emergency room. Plasma mitochondrial DNA level on admission is a more powerful predictor than lactate concentration or SOFA scores on admission.

Prevalence, awareness, treatment and control of hypertension in Taiwan: results of Nutrition and Health Survey in Taiwan (NAHSIT) 1993-1996

The objective of this paper is to describe hypertension status in Taiwan using data from the Nutrition and Health Survey in Taiwan (NAHSIT) 1993-1996, which adopted a clustered stratified multistage sampling scheme. A total of 4838 males and 4876 females aged 4 years and above were interviewed and examined corresponding to a response rate of 74%. Almost all of them (97.5%) had blood pressures measured. The results show that the mean blood pressure of adult males was higher than that of adult females below 45 years of age. After that, the pattern was reversed. When defined by JNC IV criteria (SBP/DBP > or = 160/95 mm Hg or taking antihypertensive drugs), the prevalence was 13% in adult males (> or = 19 years) and 12% in adult females. When defined by JNC VI criteria (SBP/DBP > or = 140/90 mm Hg or taking antihypertensive drugs), the prevalence was 26% in adult males and 19% in adult females. The prevalence in the mountainous area, was the highest among the seven survey strata. Under the JNC IV definition, 43% males and 53% females with hypertension knew their disease status, 31% of males and 45% of females took medicine for it, and 15% of males and 22% of females had their blood pressure under control. Percentages of awareness, treatment, and control were much lower with the JNC V definition, which was introduced toward the end of survey period. People in metropolitan areas had the highest rates of awareness, treatment, control, and compliance to medication.

HbA1C Variability Is Strongly Associated With the Severity of Peripheral Neuropathy in Patients With Type 2 Diabetes

Variability in HbA1c is associated with a higher risk of cardiovascular disease and microvascular complications in patients with type 2 diabetes. The present study evaluated the severity of somatic nerve dysfunction at different stages of chronic glycemic impairment, and its correlation with different cardio-metabolic parameters. The study was conducted on 223 patients with type 2 diabetes. We calculated the intrapersonal mean, standard deviation (SD), and coefficient of variation of HbA1c for each patient using all measurements obtained for 3 years prior to the study. Patients were divided into quartiles according to the SD of HbA1c, and we constructed composite scores of nerve conduction as the severity of peripheral neuropathy. Linear regression analysis was performed to evaluate the influence of independent variables on mean composite scores. Those with higher SD-HbA1c had a higher body mass index, mean and index HbA1c, triglyceride and uric acid level, urinary albumin excretion and albumin-creatinine ratio, proportion of insulin therapy, and prevalence of hypertension as the underlying diseases, but lower estimate glomerular filtration rate (eGFR). In addition, those with higher SD-HbA1c showed lower amplitudes and reduced motor nerve conduction velocity in tested nerves, and lower sensory nerve conduction velocity in the sural nerve. Furthermore, those with higher SD-HbA1c had higher composite scores of low extremities. Multiple linear regression analysis revealed that diabetes duration, SD-HbA1c, and eGFR were independently associated with mean composite scores. Based on our results, HbA1c variability plus chronic glycemic impairment is strongly associated with the severity of peripheral neuropathy in patients with type 2 diabetes. Aggressively control blood glucose to an acceptable range and avoid blood glucose fluctuations by individualized treatment to prevent further nerve damage.

HbA1C Variability Is Strongly Associated With the Severity of Cardiovascular Autonomic Neuropathy in Patients With Type 2 Diabetes After Longer Diabetes Duration

Background

Variability in the glycated hemoglobin (HbA1c) level is associated with a higher risk of microvascular complications in patients with type 2 diabetes. We tested the hypothesis that HbA1c variability is not only strongly associated with the presence but also the degree of severity of cardiovascular autonomic neuropathy (CAN) in patients with long diabetes durations (more than 10 years).

Methods

For each patient, the intrapersonal mean, standard deviation (SD), and coefficient of variation (CV) for HbA1c were calculated using all measurements obtained 3 years before the study. We constructed the composite autonomic scoring scale (CASS) as a measure of the severity of cardiovascular autonomic functions. Stepwise logistic regression and linear regression analyses were performed to evaluate the presence of CAN and the influence of independent variables on the mean CASS, respectively.

Results

Those with CAN had a higher mean age, a higher low-density lipoprotein cholesterol (LDL-C), HbA1c-SD, HbA1c-CV, mean HbA1c, and index HbA1c, higher prevalence of retinopathy as the underlying disease, and lower high-density lipoprotein (HDL) levels. Stepwise logistic regression showed that HbA1c-SD and retinopathy were risk factors that were independently associated with the presence of CAN. Mean HbA1c, HbA1c-CV, HbA1c-SD, and index HbA1c were positively correlated with mean CASS, and a multiple linear regression analysis revealed that HbA1c-SD was independently associated with the mean CASS.

Conclusion

HbA1c variability is strongly associated with not only the presence but also the degree of severity of CAN. A longitudinal study is required to confirm whether controlling blood glucose level is effective in reducing CAN progression.

Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department

Elderly people are more susceptible to sepsis and experience more comorbidities and complications than young adults. Serum lactate is a useful biomarker to predict mortality in patients with sepsis. Lactate production is affected by the severity of sepsis, organ dysfunction, and adrenergic stimulation. Whether the predictive ability of serum lactate will be different between non-elderly and elderly patients is unknown.A retrospective cohort study was conducted to compare the prognostic value of hyperlactatemia in predicting the mortality between elderly (≥65 years) and non-elderly (<65 years) patients with sepsis.This is a single-center retrospective observational cohort study conducted from January 2007 to December 2013 in southern Taiwan. All patients with sepsis, who used antibiotics, with blood culture collected, and with available serum lactate levels in the emergency department, were included in the analysis. We evaluated the difference in serum lactate level between the elderly and non-elderly septic patients by using multiple regression models.A total of 7087 patients were enrolled in the study. Elderly and non-elderly patients accounted for 62.3% (4414) and 40.2% (2673) of all patients, respectively. Statistically significant difference of serum lactate levels was not observed between elderly and non-elderly survivors (2.9 vs 3.0 mmol/L; P = .57); however, elderly patients had lower lactate levels than those within the 28-day in-hospital mortality (5.5 vs 6.6 mmol/L, P < .01). Multiple logistic regression revealed higher adjusted mortality risk in elderly and non-elderly patients with lactate levels of ≥4.0 mmol/L (odds ratio [OR], 4.98 and 5.82; P < .01, respectively), and lactate level between 2 and 4 mmol/L (OR, 1.57 and 1.99; P < .01, respectively) compared to that in the reference group with lactate levels of <2.0 mmol/L in each group. In receiver operating characteristic curve analysis, sensitivity rates for predicting mortality were 0.80 and 0.77 for non-elderly and elderly patients, respectively, by using serum lactate levels higher than 2.0 mmol/L.Septic elderly non-survivors had 1 mmol/L lower serum lactate level than those of the non-elderly non-survivors. Lactate >2 mmol/L still could provide enough sensitivity in predicting sepsis mortality in elder patients.

Manifestations and Outcomes of Patients with Parkinson's Disease and Serious Infection in the Emergency Department

BACKGROUND

Several comorbidities contribute to an increased risk of infections in Parkinson's disease (PD) as the disease progresses. However, few studies have examined the correlation between sepsis and PD.

AIM

The aim of this study is to disclose the presentation and outcome of serious infection in patients with PD in the emergency department.

METHODS

This retrospective cohort study enrolled patients with PD who had serious infection and were admitted to the emergency department between January 2007 and December 2013. For clinical comparison, we compared the clinical features, laboratory data, and outcomes with those of age- and sex-matched patients who had serious infection but not PD.

RESULTS

There were a total of 1,200 episodes of infected PD patients and 2,400 age- and sex-matched infected patients without PD as disease controls. PD patients had fewer comorbidities and lower severity of infectious disease but longer hospital stays than control group patients. The incidences of respiratory tract and urinary tract infections were higher in PD patients. The levels of inflammatory and organ dysfunction biomarkers in PD were lower and compatible with the severity of infectious disease. A total of 86 (7.2%) infected PD patients died during the 28-day admission compared to 339 (14.1%) in non-PD patients. Serum C-reactive protein, bandemia, and lactate could be used to predict mortality in infected PD patients.

CONCLUSIONS

In infected patients with PD, respiratory and urinary tract infections were the two most common infectious sources. Empiric therapy based on experience could treat both respiratory and urinary tract infections. Early diagnosis and treatment are essential for survival.

Impact of oxidative stress on treatment outcomes in adult patients with sepsis: A prospective study

PURPOSE

Oxidative stress has been shown to reflect on the development of sepsis and disease severity. In the present study, we evaluated the effects of increased levels of oxidative stress and decreased antioxidant coactivity in patients with sepsis, and the importance of oxidative stress on treatment outcomes.

METHODS

Biomarkers of oxidative stress (thiobarbituric acid-reactive substances [TBARS]) and antioxidant capacity (glutathione peroxidase [GPx] and glutathione content [thiol]) were prospectively evaluated along with biochemical and clinical data in 100 patients with sepsis on days 1, 4, and 7 after admission.

RESULTS

The TBARS level of the non-survivor group was significantly higher than that of the survivor group on day 1 and day 4 and negatively correlated with thiol upon admission. However, thiol was positively correlated with lactate concentration. The TBARS and lactate levels upon admission were independent predictors of fatality.

CONCLUSIONS

We conclude that a TBARS cut-off value of 18.30 μM can be used to predict fatality, and an increase in the TBARS concentration by 1 μM will increase the fatality rate by 0.94%. In the panel of biomarkers, the TBARS assay can be considered as a prognostic biomarker for the treatment of patients with sepsis.

Increased circulating endothelial progenitor cells and improved short-term outcomes in acute non-cardioembolic stroke after hyperbaric oxygen therapy

Background

Acute ischemic stroke is a leading cause of mortality and long-term disability, and profiles of endothelial progenitor cells (EPCs) reflect the degree of endothelial impairment. This study tested the hypothesis that hyperbaric oxygen therapy (HBOT) both improves the clinical short-term outcomes and increases the number of circulating EPCs and antioxidant capacity.

Methods

The numbers of circulating EPCs [CD133⁺/CD34⁺ (%), KDR⁺/CD34⁺ (%)], biomarkers for oxidative stress (thiols and thiobarbituric acid-reactive substances), and clinical scores (National Institutes of Health Stroke Scale [NIHSS], Barthel index [BI], and modified Rankin Scale [MRS]) were prospectively evaluated in 25 patients with acute non-cardioembolic stroke under HBOT at two time points (pre- and post-HBOT). The biomarkers and clinical scores were compared with those of 25 age- and sex-matched disease controls.

Results

The numbers of KDR⁺/CD34⁺ (%) in the HBOT group following HBOT increased significantly, whereas the numbers of CD133⁺/CD34⁺ (%) also showed a tendency to increase without statistical significance. The mean high-sensitivity C-reactive protein levels showed significant decrease post-HBOT follow-up in the HBOT group. The changes in KDR⁺/CD34⁺EPC (%) numbers were positively correlated with changes in clinical outcomes scores (BI, NIHSS, and MRS) in the HBOT group.

Conclusions

Based on the results of our study, HBOT can both improve short-term clinical outcomes and increase the number of circulating EPCs in patients with acute non-cardioembolic stroke.

The role of blink reflex R1 latency as an electrophysiological marker in diabetic distal symmetrical polyneuropathy

OBJECTIVE

Studies showed a relatively prolonged blink R1 latency in patients with diabetic distal symmetrical polyneuropathy (DSPN) compared to that without DSPN. We tested the hypothesis that blink R1 latency would provide a diagnostic alternative to nerve conduction studies (NCS) in DSPN and act as a marker of the severity of NCS abnormalities in DSPN.

METHOD

A total of 109 patients with type 2 diabetes underwent blink reflex studies and NCS. We used the composite amplitude scores of nerve conductions (CAS), which consisted of motor (tibial, peroneal and ulnar) and sensory (sural and ulnar) amplitudes for estimating the severity of NCS.

RESULTS

Patients with DSPN had longer blink R1, R2, and contralateral R2 latencies (P < 0.0001, P = 0.001, and P = 0.031, respectively) and higher CAS (P < 0.0001). Area under curve on receiver operating characteristic curve analysis in diagnosing occurrence of DSPN in blink R1 latency was 0.772 (P < 0.0001). Multiple linear regression analysis showed that blink R1 latency was independently associated with CAS.

CONCLUSION

Blink R1 latency may be valuable in auxiliary diagnosis and in determining the severity of NCS abnormalities in DSPN.

SIGNIFICANCE

Blink R1 latency can be added as a supplemental marker of severity of NCS in DSPN, especially if the patient's sural amplitudes has a floor effect.

Additional chromosomal abnormalities in core-binding factor acute myeloid leukemia

Despite sharing a similar genetic abnormality, patients with core binding factor acute myeloid leukemia (CBF-AML), which is characterized by the presence of t(8;21) or inv(16)/t(16;16), show heterogeneous survival. Other molecular or cytogenetic factors are supposed to have an impact on the prognosis. We enrolled 24 CBF-AML patients to determine the impact of cytogenetic abnormality, and c-KIT, FLT3, NPM1, and CEBPA mutations on the prognosis. Only three patients had the c-KIT mutation (3/24, 12.5%) and one had the FLT3 mutation. However, over half of the patients (14/24) harbored additional cytogenetic changes, including ten with loss of sexual chromosomes (LOS) [all in the t(8;21) group], and six had additional abnormalities (two cases had both LOS and additional abnormalities). From this small-number study, no association was found between c-KIT mutation and survival and relapse rate. However, additional chromosome abnormalities had a significant association with relapse of the disease (P = 0.027). Stem cell transplant had a trend of benefitting patients after relapse (P = 0.065). This implies that chromosome abnormalities occur in CBF-AML and might take part in the heterogeneous nature of CBF-AML.

Central nervous system involvement in hepatocellular carcinoma: clinical characteristics and comparison of intracranial and spinal metastatic groups

From January 1993 to December 2006 we analyzed the clinical characteristics of patients with hepatocellular carcinoma (HCC) with central nervous system (CNS) metastasis at the Kaohsiung Chang Gung Memorial Hospital, Taiwan. Forty-six patients with HCC and CNS metastasis were identified, of whom 36 had intracranial metastasis and 10 had spinal metastasis. The clinical presentations, laboratory data and imaging studies were collected and analyzed. The age at the time of HCC diagnosis ranged from 34 to 78 years; CNS metastasis occurred between 0 and 85 months after diagnosis and death followed between 0 and 93 months later. The Glasgow Coma Scale (GCS) score at the time of CNS metastasis ranged from 7 to 15 and the Child-Pugh score at diagnosis of HCC ranged from 5 to 15. Patients with spinal metastasis had a higher GCS score and lower Child-Pugh score at diagnosis. None of the serum biochemical studies showed unique abnormalities. From the data currently available, intracranial metastasis is the most common site of CNS metastasis of HCC. Advances in treating and diagnosing HCC have improved patient outcomes remarkably; however, CNS metastasis continues to have a grave prognosis. Without a specific biomarker for predicting CNS involvement in HCC, a high index of suspicion for the diagnosis should be maintained, particularly in HCC hyperendemic areas such as Taiwan.

Neuropsychiatric symptoms in Parkinson's disease: association with caregiver distress and disease severity

OBJECTIVES

The condition of caregivers is important to the quality of care received by people with Parkinson's disease (PD), especially at the late disease stages. This study addresses the distress placed on caregivers by participants' neuropsychiatric symptoms at different stages of PD in Taiwan.

METHODS

This prospective study enrolled 108 people with PD. All participants were examined with the Unified Parkinson's Disease Rating Scale (UPDRS), Neuropsychiatric Inventory (NPI), Mini-Mental State Examination (MMSE), Cognitive Abilities Screening Instrument (CASI), and Clinical Dementia Rating (CDR) scale. Caregiver distress was measured using the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D). Statistical analysis was used to explore the PD-related factors that contribute to caregiver distress.

RESULTS

The mean follow-up interval in the 108 PD participants were 24.0 ± 10.2 months with no participant lost to follow-up due to death. NPI-distress (the sum of NPI caregiver distress scale across the 12 domains of the NPI) was positively correlated with NPI-sum (the total score across the 12 domains of the NPI) (r = 0.787, p < 0.001), CDR (r = 0.403, p < 0.001), UPRDS (r = 0.276, p = 0.004), and disease duration (r = 0.246, p = 0.002), but negatively correlated with CASI (r = -0.237, p = 0.043) and MMSE (r = -0.281, p < 0.001). Multiple linear regression analysis showed that only NPI-sum and disease duration were independently correlated with NPI-distress.

CONCLUSION

The disease duration and NPI-sum are independent predictors of caregiver distress in Taiwanese populations with PD. Early detection and reduction of neuropsychiatric symptoms in people with PD can help decrease caregiver distress.

Serum adhesion molecules as outcome predictors in adult severe sepsis patients requiring mechanical ventilation in the emergency department

BACKGROUND AND AIM

Serum adhesion molecules play a pivotal role in the pathogenesis of sepsis syndrome. This study aimed to evaluate the prognostic value of serum adhesion molecules in patients with severe sepsis and mechanical ventilation (MV) at the emergency department.

METHODS

Eighty-seven consecutive patients with severe sepsis, including 35 with MV, were evaluated. Serum samples were collected for analysis of serum adhesion molecules. The patients' clinical and laboratory data on admission were also recorded.

RESULTS

The maximum 24-h APACHE II and 24-h SOFA scores were significantly higher in the severe sepsis patients requiring MV than in patients without MV (p=0.02 and p<0.001). Mortality rate was significantly higher in severe sepsis patients requiring MV than in patients without MV (40% [14/35] vs. 9.6% [5/52], p=0.001). Both VCAM-1 level (p=0.03) and lactate concentration (p=0.04) on admission had significant differences between survivors and non-survivors in patients requiring MV. In the logistic regression model, only VCAM-1 level (p=0.049) was independently predictive of mortality. By correlation analysis, lactate concentration significantly correlated with the mean VCAM-1 level on admission (γ=0.484, p=0.004). The area under the ROC curve for VCAM-1 level was 0.747 (p=0.02, 95% CI: 0.576-0.918). The cut-off value of VCAM-1 level for predicting hospital mortality in severe sepsis patients receiving MV was 1870ng/mL, with 77% sensitivity and 71% specificity; then the likelihood ratio equals 2.7.

CONCLUSIONS

In this study, VCAM-1 level is a more powerful outcome predictor of hospital mortality in severe sepsis patients requiring MV than lactate concentration and other conventional parameters on admission. This suggests that increased plasma VCAM-1 concentration may be useful in identifying who are at risk of hospital mortality among severely septic patients requiring MV.

The Role of Monocyte Percentage in Osteoporosis in Male Rheumatic Diseases

Osteoporosis is easily overlooked in male patients, especially in the field of rheumatic diseases mostly prevalent with female patients, and its link to pathogenesis is still lacking. Attenuated monocyte apoptosis from a transcriptome-wide expression study illustrates the role of monocytes in osteoporosis. This study tested the hypothesis that the monocyte percentage among leukocytes could be a biomarker of osteoporosis in rheumatic diseases. Eighty-seven males with rheumatic diseases were evaluated in rheumatology outpatient clinics for bone mineral density (BMD) and surrogate markers, such as routine peripheral blood parameters and autoantibodies. From the total number of 87 patients included in this study, only 15 met the criteria for diagnosis of osteoporosis. Both age and monocyte percentage remained independently associated with the presence of osteoporosis. Steroid dose (equivalent prednisolone dose) was negatively associated with BMD of the hip area and platelet counts were negatively associated with BMD and T score of the spine area. Besides age, monocyte percentage meets the major requirements for osteoporosis in male rheumatic diseases. A higher monocyte percentage in male rheumatic disease patients, aged over 50 years in this study, and BMD study should be considered in order to reduce the risk of osteoporosis-related fractures.

The Prognostic Value of Serum Soluble TREM-1 on Outcome in Adult Patients with Sepsis

Increased soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) levels have been reported in patients with sepsis. We tested the hypotheses that serum sTREM-1 levels increase in the early phase of sepsis and decrease after sepsis under appropriate treatment and that sTREM-1 levels can predict therapeutic outcomes. One hundred and fifty-five patients prospectively underwent blood samples including biochemical data, sTREM-1, and biomarkers on endothelial dysfunction as well as clinical severity index examinations. Blood samples from Days 1, 4, and 7 after admission were checked. For comparison, 50 healthy subjects were selected as healthy control. Those patients who had sepsis had significantly higher sTREM-1 levels than those of healthy control. sTREM-1 levels positively correlated with biomarkers for endothelial dysfunction (ICAM-1, VCAM-1, and E-selectin) and lactate level as well as clinical severity index (maximum 24 h APACHE score and Sequential Organ Failure Assessment (SOFA) score) upon admission. sTREM-1 concentrations were significantly higher from Day 1 to Day 7 in the non-survivors than in the survivors. A stepwise logistic regression analysis showed only sTREM-1 level and maximum 24 h SOFA score upon admission were significantly associated with fatality. Area under the receiver operating characteristic curve analysis for the diagnostic accuracy of sTREM-1 in sepsis-related fatality gave a value of 0.726, with a cutoff value of 384.6 pg/mL (sensitivity = 80.8% and specificity = 61.5%). sTREM-1 level may be valuable in auxiliary diagnosis, and it can serve as a useful biomarker as a screening service and follow-up therapeutic outcomes in sepsis.

Impact of prior statin use on mortality in patients with type 2 diabetes mellitus and bloodstream infection

Objective

This study assessed the effect of prior statin use on the 28-day mortality of patients with type 2 diabetes mellitus (DM) who develop bloodstream infections.

Methods

This retrospective cohort study included all adult type 2 DM patients with bacteremia and verified prior medication history who visited the emergency department of a single tertiary hospital between January 2007 and December 2013. All major adverse consequences including septic shock events, use of mechanical ventilation, intensive care unit admission, and 28-day mortality were assessed.

Results

A total of 1,979 patients were enrolled in the study, of whom 507 were taking statins. Statin users had less severe disease presentation and lower levels of sepsis biomarkers such as bandemia (1.3 ± 3.1 vs 1.8 ± 4.2). After adjustment for confounding variables using a Cox regression model, only older age (adjusted hazard ratio [HR]: 1.04, 95% confidence interval [CI], 1.01–1.04), urinary tract infection (adjusted HR: 0.56, 95% CI, 0.43–0.75), and prior statin use (adjusted HR: 0.58, 95% CI: 0.42–0.85) were significantly associated with 28-day in-hospital mortality.

Conclusion

Prior statin treatment in patients with type 2 DM and bacteremia was associated with a lower 28-day in-hospital mortality rate.

Outcomes of adjunctive steroid therapy in adult patients with bacterial meningitis in Taiwan: A nationwide population-based epidemiologic study

BACKGROUND

Although corticosteroids are an effective anti-inflammatory adjuvant therapy, the role of adjunctive steroid therapy in treating adult bacterial meningitis in Taiwan remains controversial.

METHODS

Cases of acute bacterial meningitis were identified from the annual hospitalization discharge claims of the National Health Insurance Research Database using International Classification of Diseases, Ninth Revision codes from January 2000 to December 2013. Patients were classified into two groups: (1) steroid group (adjunctive steroids and empirical antibiotics) and (2) placebo group (empirical antibiotics only).

RESULTS

There were 15,037 patients enrolled in this study; of these, 57% (7175/15,037) and 52% (7862/15,037) were placed in the placebo and steroid groups, respectively. The case-fatality rates were 11.5% (826/7175) in the placebo group and 19.9% (1562/7862) in the steroid groups during hospitalization (P = 0.77). Further, the hazard ratio (relative to placebo group) of in-hospital and one-year case fatality rate were 0.923 (95% confidence interval [CI]: 0.846-1.007, P = 0.073) and 1.514 (95% CI: 1.425-1.608, P < 0.0001) according to the multivariate Cox model after adjustment for age and sex.

CONCLUSION

On the basis of these results, steroid group had a more fulminant clinical course (e.g., acute respiratory failure and pneumonia, etc.), and unfavorable outcomes than placebo group. Therefore, more prospective, randomized, double-blind trials are warranted to evaluate the efficacy of adjunctive steroid therapy in treating adult bacterial meningitis in Taiwan.

Close relationship between cardiovagal function and sural sensory nerve action potential in type 2 diabetes

OBJECTIVE

Both diabetic distal symmetrical polyneuropathy (DSPN) and cardiac autonomic neuropathy (CAN) indicate the length-dependent pattern of disease. Decreased parasympathetic activity has been found in the early phase of CAN and sural sensory nerve action potential (SNAP) imply axonal loss in DSPN.

METHOD

All patients with type 2 diabetes underwent cardiovascular autonomic function and nerve conduction studies (NCS). We constructed modified composite autonomic scoring scale (CASS) and composite score of NCS to measure the severity of CAN and DSPN, respectively.

RESULTS

Patients with a longer duration of diabetes had a lower heart rate response to deep breathing (HR_DB), Valsalva ratio (VR), and baroreflex sensitivity (BRS), higher CASS, a higher percentage of CAN, lower sural SNAP, higher composite score of NCS, and a higher percentage of DSPN. Multiple linear regression analysis showed that only sural SNAPs were independently associated with mean HR_DB.

CONCLUSION

Sural SNAP was closely correlated with parameters of cardiovagal functions in patients with different durations of diabetes. The percentage and severity of CAN and DSPN increase with longer duration of diabetes.

SIGNIFICANCE

The independent association of sural sensory nerve action potential amplitude and heart rate response to deep breathing with type 2 diabetes is important because combined testing increases diagnostic sensitivity and specificity.

Prenatal bupropion exposure enhances the cocaine reward and stress susceptibility in adult mice

Although a growing body of evidence supports the notion that certain antidepressant treatments in pregnancy produce earlier delivery and minor behavioral teratogenesis in infants, the long-term effects of such treatments in adulthood remain ill-defined. Recently, postnatal exposure to psychotropic drugs was found to affect the emotional development and susceptibility to abused drugs. Thus, this study aimed to examine whether prenatal exposure of four frequently-used antidepressants, bupropion, fluvoxamine, citalopram, and trazodone, altered the responsiveness to stress and cocaine in the adulthood. Dams received daily injection of bupropion (25 or 12.5 mg/kg), citalopram (5 mg/kg), fluvoxamine (10 mg/kg), trazodone (20 mg/kg) or saline throughout their third trimester of gestation, and several birth outcome indices were then examined. Locomotor activity, naive anxiety levels, and the sensitivity to the cocaine reinforcing effects were observed in pups at their day 56-60 post partum. We found that trazodone treatment produced a high mortality rate in pups after weaning. Mice, prenatally treated with bupropion at 25 mg/kg, exhibited lower rearing numbers and ambulatory activity as compared to the saline-treated mice. More importantly, such treatment enhanced the mouse sensitivity to the reinforcing effects of cocaine. Taken together, these results suggest that use of bupropion in the late pregnancy may run a risk of enhancing the offspring's susceptibility to stress and cocaine reward in adulthood.

Pregnancy following in vitro fertilization and embryo transfer by microsurgical epididymal sperm aspiration from a patient with congenital absence of the vas deferens: a case report

Congenital absence of the vas deferens (CAVD) has been considered a virtually untreatable cause of male infertility. Men with this condition have been shown on testicular biopsy to have adequate spermatogenesis, and are theoretically producing sperm capable of fertilizing an oocyte. Yet epididymal transit was thought to be essential for the maturation of spermatozoa and development of their fertilizing ability since the characteristics of sperm motility improve as the sperm passes through the cauda. However recent studies in man have shown that spermatozoa aspirated from the obstructed caput epididymis and ductuli efferentia are, in fact, capable of fertilization in vitro. Microsurgical epididymal sperm aspiration (MESA) from the proximal region (caput) of the epididymis, obtained 0.5 x 10(6) sperm per ml, following washing and direct swim-up. Twelve oocytes were inseminated and three embryos were generated for transfer. The patient conceived and delivered a healthy female baby weighting 2838 gm, on March 3, 1994. This is the first documentation in Taiwan of live birth resulting from MESA from a patient with CAVD combined with in vitro fertilization and embryo transfer.

Methamphetamine-induced conditioned place preference is facilitated by estradiol pretreatment in female mice

Ovarian hormones were well documented to modulate the dopamine release in the central dopaminergic systems. The dopamine-releasing effects in the nucleus accumbens, a major target of the mesolimbicortical dopaminergic system, were closely associated with the reinforcing effects of two psychomotor stimulants, cocaine and methamphetamine. This study aimed to examine the sex differences in the cocaine- and methamphetamine-reinforcing behavior, conditioned place preference. In addition, the modulating effects of estradiol and progesterone on methamphetamine-induced conditioned place preference were investigated in both sexes of adult gonadectomized mice. There was no sex difference in the sensitivity to the cocaine (5 mg/kg)-induced conditioned place preference. However, female mice exhibited a more potent methamphetamine (1 mg/kg)-induced conditioned place preference than did male mice. Moreover, pretreatment with estradiol for two consecutive days before the beginning of the conditioning and throughout the four daily conditionings (0.47 microg/day for totally six days) effectively facilitated methamphetamine-induced conditioned place preference in gonadectomized female mice, but not in gonadectomized male mice. Progesterone, under a similar treatment regimen (0.47 microg/day for six consecutive days), did not alter the methamphetamine-induced conditioned place preference in either sex of gonadectomized mice. Taken together, we conclude that the facilitating effects of estradiol on methamphetamine-induced conditioned place preference could be sex-dependent with an eminent sensitivity associated with the adult female mice.