Risk factors of mortality for nosocomial pneumonia: importance of initial anti-microbial therapy

Nosocomial pneumonia is a common nosocomial infection and has high mortality rate. Risk factors of mortality of nosocomial pneumonia were studied in 132 hospitalised patients who developed nosocomial pneumonia. The overall mortality rate was 64/132, 48.5%. Of the 11 risk factors univariately associated with mortality due to nosocomial pneumonia, only the inappropriate initial anti-microbial therapy, high simplified acute physiology score and multiple organ failures remained significant after stepwise logistic regression. Gram-negative bacilli were still the most pre-dominant causative microbiologic agents of nosocomial pneumonia with Pseudomonas aeruginosa (20.3%), Acinetobacter baumannii (18.6%) and Escherichia coli (5.9%) being the three most predominant pathogens. A. baumannii were significantly more predominant among non-survivors than survivors (13.56 vs. 5.08%, p=0.0418). The incidence rate of methicillin-resistant Staphylococcus aureus was 19.5% higher than previous reports. We conclude that inappropriate initial anti-microbial therapy for nosocomial pneumonia is associated with the mortality rate of nosocomial pneumonia, and appropriate anti-microbial therapy improves outcome of nosocomial pneumonia.

Fluconazole disk diffusion test with methylene blue- and glucose-enriched Mueller-Hinton agar for determining susceptibility of Candida species

A 25-microg fluconazole disk diffusion test using a Mueller-Hinton agar plate containing 2% glucose and 5 microg of methylene blue/ml (GM-MH) was compared to the macrodilution reference method for 210 Candida species. The GM-MH agar plate was read at 24 h. The predictive values of disks with susceptible, intermediate, and resistant results on the GM-MH agar plate at 24 h were 97.1, 56.3, and 76.5%, respectively.

Clinical correlates of antifungal macrodilution susceptibility test results for non-AIDS patients with severe Candida infections treated with fluconazole

Although the clinical correlates of the reference antifungal susceptibility test results in hematogenous and deep-seated Candida infection are still controversial, we evaluated the clinical correlates of this test in deep-seated Candida infections in non-AIDS patients. Thirty-two non-AIDS patients with hematogenous or deep-seated Candida infections were treated with intravenous fluconazole (400 mg a day), and the clinical outcomes were evaluated. Coexisting bacterial infections were treated with appropriate antibiotics, superinfection or reinfection was excluded, inadequate fluconazole therapy was avoided, and essential surgical intervention was performed. The MICs of fluconazole for these 32 Candida isolates were determined according to the M27-A procedure approved by the National Committee on Clinical Laboratory Standards. MICs were interpreted as susceptible (< or =8 microg/ml), dose-dependent susceptible (16 to 32 microg/ml), and resistant (> or =64 microg/ml) according to the criteria of the M27-A standard. The success rates were 79% (19 of 24; 95% confidence interval [CI], 59 to 93%) in the susceptible category, 66% (4 of 6; 95% CI, 19 to 95%) in the dose-dependent susceptible category, and 0% (0 of 2; 95% CI, 0 to 84%) in the resistant category. We conclude that the clinical correlation of the reference antifungal susceptibility test results is high in hematogenous and deep-seated Candida infections.

Nosocomial infections with ceftazidime-resistant Pseudomonas aeruginosa: risk factors and outcome

Prospective studies were conducted for nosocomial Pseudomonas aeruginosa infections from February 1, 1994, to October 30, 1995. Of 97 P. aeruginosa isolates from 97 patients, 35 were resistant to ceftazidime. Logistic regression revealed previous cephalosporin or piperacillin use as independent risk factors for nosocomial ceftazidime-resistant P. aeruginosa infection. Pulsed-field gel electrophoresis revealed that four nosocomial ceftazidime-resistant P. aeruginosa infections were caused by cross-infection, probably through medical personnel.

Cat-scratch disease caused by Bartonella henselae: the first case report in Taiwan

We report a typical case of cat-scratch disease caused by Bartonella henselae, in Taiwan. A 20-year-old man developed right axillary lymphadenopathy 2 weeks after being scratched on his right hand by a kitten. The axillary lymphadenopathy resolved gradually and spontaneously after 10 weeks without specific treatment. Serologic tests were not done during the acute stage of the event. However, an immunofluorescent antibody test performed during the convalescent stage was positive for B. henselae antibodies, and the concentration dropped by fourfold 2 months later. Histopathologic examination of a biopsy specimen from the right axillary lymph node revealed findings characteristic of cat-scratch disease including multiple foci of microabscesses surrounded by histiocytes and infiltration by plasma cells and lymphocytes. This is the first reported case of cat-scratch disease in Taiwan, with a history of contact with a cat, a positive serologic test for B. henselae infection and characteristic histopathologic findings of cat-scratch disease which met the criteria for diagnosis.

Discovery of encysted Paragonimus westermani eggs in the omentum of an asymptomatic elderly woman

We report a case of asymptomatic chronic infiltrate of the omentum by eggs of Paragonimus westermani in an elderly woman who had immigrated to Taiwan from mainland China 46 years ago. The patient had a habit of eating raw freshwater crabs from the lakes of eastern China during her period of residence in that country. She stopped eating raw crabs after coming to Taiwan 20 years ago. During surgery for a peptic ulcer complicated by severe bleeding in 1995, her omentum was found to contain many small nodules approximately 2 x 2 x 1.5 cm in size. Biopsy of the nodules revealed eggs of P. westermani embedded in necrotic debris surrounded by capsules. A sputum examination result was negative and a chest radiograph was normal. The majority of the nodules in the omentum were removed during the surgery and praziquantel was given. At the present time, the patient remains asymptomatic.

Double-blind placebo-controlled study of oxatomide in the treatment of childhood asthma

Oxatomide is an orally active H1-histamine receptor antagonist. It has been demonstrated to have therapeutic efficacy in the treatment of allergic diseases in adults. The aim of this study was to evaluate the efficacy and safety of oxatomide in the treatment of asthma in children. Sixty-four asthmatic children of both sexes, aged between 5 and 16 years, were enrolled in this double-blind, placebo-controlled trial with a duration of 4 months. Patients were randomized chosen to receive either oxatomide with a daily dose of 1 to 2 mg/kg body weight or a placebo twice daily. Clinical evaluations including pulmonary function tests and immunological studies. The patients' impression on the effect of treatment also were recorded during the study. The effects of bronchodilatation and normalizing pulmonary function were observed 2 months after oxatomide treatment. The levels of eosinophil cationic protein and total asthma symptom scores were significantly reduced during treatment with oxatomide. There was no significant change in total IgE or IgG4 before or after treatment in either the treatment or control groups. During the study, two (5.8%) oxatomide treated patients reported slight drowsiness and one (2.9%) reported body weight gain. Routine laboratory tests showed no significant alterations. In conclusion, oxatomide was generally well tolerated in this study and may have the potential of being an effective treatment for childhood asthma.

Neglect of childhood strabismus: Keelung Ann-Lo Community ocular survey 1993-1995

Strabismus is a major cause of amblyopia. Parents not aware of the adverse outcome of untreated strabismus is thought to be a major reason of their affected child not being discovered earlier. An ocular survey was therefore conducted to examine the relative neglect of strabismus by the public, using myopia as a reference eye disorder. Specific objectives included estimating the prevalence of these ocular diseases, comparing the self-reported rate to the test-based rate, and investigating how much parents knew about these ocular diseases. Between 1993 and 1995, 862 elementary students in the first, third, and sixth grade at Keelung Ann-Lo Community were screened. The prevalence of manifest strabismus was 1.62% (95% CI = 1.19% approximately 2.05%). Of those with strabismus, three (21.4%) knew that they had strabismus. Neither the prevalence nor the self-known proportion of strabismus changed substantially with school grade, suggesting that the majority of strabismus afflicted children remain unrecognized during their elementary school years. The amblyopia proportion in those with tropia was 42.9% and reduced to 21.5% after abnormal refractive error was excluded. Of six knowledge statements about each ocular disorder, parents answered 2.13 (SD = 1.40) strabismus statements correctly, which was significantly less than their response on myopia statements (4.32 with SD = 1.24) (p < .0001). Onset age of strabismus was the question answered least correctly, implying that parents are not aware of the timing of treating strabismus. Our findings suggest that childhood strabismus was neglected by the public before the implementation of National Health Insurance (NHI). Should a similar study continued to be conducted in the future, the efficacy of NHI in the early recognition and treatment on childhood strabismus can be evaluated.

Antituberculosis drug resistance in Keelung area-1993 to 1994

Patterns of drug resistance of 176 isolates of Mycobacterium tuberculosis collected from 1993 to 1994 were reviewed retrospectively. The rates of resistance to isoniazid, rifampicin, ethambutol and streptomycin were 84.1%, 17.6%, 23.3% and 11.9% respectively and the incidence of multidrug-resistant M. tuberculosis was 17.0%. Comparisons between 1993 and 1994 showed decrease in rates of resistance to rifampicin (25% vs. 7.5%) and ethambutol (36.5% vs. 7.5%) and the incidence of multidrug-resistant tuberculosis (25% vs. 7.5%). In contrast, the rate of resistance to isoniazid increased from 79.2% to 84.1%. Due to the high frequency of resistance to multiple drugs in tuberculosis isolates at Chang Gung Memorial Hospital, Keelung, three-combined (isoniazid+rifampicin+ethambutol) regimen of antituberculosis drugs may be ineffective as initial therapy for one-fourth of patients in our hospital. Of epidemiological factors, previous treatment was found to influence the rates of drug resistance. Of roentgenographic features, stage of chest roentgenography was found to be a positive predictor of infection with multidrug-resistant tuberculosis. The information provided in this study may help us understanding the epidemiology of M. tuberculosis in Keelung and refining antituberculosis treatment for our patients.

Pulmonary actinomycosis appearing as a "ball-in-hole" on chest radiography and bronchoscopy

A 40 year old diabetic man with pulmonary actinomycosis was admitted to hospital with recurrent haemoptysis. The chest radiograph showed an air meniscus in the left upper lobe, a rare presentation of pulmonary actinomycosis. Bronchoscopic examination revealed a mass in a cavity which has never been reported previously. He underwent lobectomy and the surgical specimen revealed sulphur granules, the typical pathological finding of actinomycosis, without evidence of fungal or mycobacterial infection.

Effect of nasal continuous positive airway pressure on methacholine-induced bronchoconstriction

Bronchial hyper-responsiveness is a cardinal feature of asthma. To determine whether nasal continuous positive airway pressure (NCPAP) influences airway smooth muscle in response to exogenous stimuli, we examined the effect of NCPAP on aerosolized methacholine-induced bronchoconstriction in 16 stable asthmatic patients. The dose-response curve for each subject was measured by a log transformation and linear regression analysis as well as a formula fitted to the data points to obtain values for a (slope) and b (position). The PD20FEV1 significantly increased in patients receiving 8 cmH2O of NCPAP by one doubling dose compared with that in patients using sham pressure. NCPAP shifted the dose-response curves to be flatter, deviated upwards and to the right. The coefficient a, indicating bronchial reactivity, was significantly lower in patients receiving NCPAP. The coefficient b, indicating the bronchial sensitive threshold, was higher after applying NCPAP. In contrast, coefficients a and b did not change in subjects with sham pressure. NCPAP also significantly enhanced the bronchodilator effect of inhaled salbutamol in response to methacholine-induced bronchoconstriction. In summary, we have shown that NCPAP therapy improves bronchial smooth reactivity with an increase in PD20FEV1 and a reduction in the bronchial reactivity and bronchial sensitivity. Therefore, NCPAP may provide an adjuvant therapy in patients with acute bronchial asthma.

Bacteremia due to non-typhi Salmonella: analysis of 64 cases and review

Within a 5-year period, 64 patients were hospitalized at the Chang Gung Memorial Hospital of Keelung (Taiwan) with bacteremia due to non-typhi Salmonella. Fifteen were < 24 weeks of age, 17 were between 6 months and 5 years of age, and 32 were > 18 years of age. An analysis of these patients revealed several significant differences between pediatric and adult patients. For instance, 87.5% of the adults but none of the children were debilitated because of severe underlying disease. Mortality was high (40.6%) among adults, but no deaths were observed among the children. Diarrhea occurred significantly more frequently among children (68.7%) than among adults (15.6%), while the contrary was observed in regard to chills, which occurred in 31% of adults and none of the children. It is concluded that bacteremia due to non-typhi Salmonella presents with different clinical features in adults than it does in children; furthermore, in adults the disease can be considered life-threatening, but in children it is associated with a favorable prognosis.

Preference for the Diskhaler rather than the metered dose inhaler in patients with airway obstruction

A powder system, the Diskhaler inhaler (DI) has been developed to overcome the limitations of the metered dose inhaler (MDI) in the treatment of obstructive airway diseases. Seventy-three patients were enrolled in this prospective study to compare these 2 modes of treatment. The first 2 weeks involved using the DI and the second 2 weeks the MDI. We found that the Diskhaler was easy to learn to use with a success rate of 68.0% on the first attempt, and 100% by the third. Only 4.8% patients could not perform the whole procedure perfectly two weeks later, compared with a 9.5% failure rate with the MDI. The use of the DI did not result in hand-breathing coordination problems as found in 25% of MDI users. After two weeks of use, 65.6% preferred the Diskhaler (P < 0.001), 89.1% felt it was more convenient to use (P < 0.001), and 85.1% felt it was easier to carry around (P < 0.01) compared with previous devices used. Among the 52 patients who completed the study using both inhalers, more patients (92.3%) using the DI were able to use the device correctly than those using the MDI (65.4%). After 2 weeks of use, 100% of the Diskhalers were still working, and 85.0% were kept clean. The only problem encountered was that 0.2% of the blisters had not been punctured appropriately. This should be emphasized when teaching the patients. In conclusion, the Diskhaler is easier to learn, simpler to manipulate and more convenient to use resulting in an increased patient compliance. It is also environmentally a better choice for inhalation therapy.

Intrathoracic tracheal dimensions and shape changes in chronic obstructive pulmonary disease

Changes in intrathoracic tracheal dimensions and shape in patients with chronic obstructive pulmonary disease (COPD) are commonly noted, but the cause is not clear. This study reveals a significantly larger lateral tracheal diameter (LTD) in patients with COPD. The larger LTD has a significant positive linear correlation with a larger lateral chest diameter. This finding supports the hypothesis that in patients with COPD the increase in volume of both lungs pressing on the mediastinum will exert a lateral pressure on the trachea, resulting in a decrease in frontal and an increase in the lateral trachea diameter. Patients with COPD have a smaller tracheal index: FTD/LTD (FTD: frontal tracheal diameter). Saber-sheath trachea (tracheal index < 2/3) is a specific radiographic diagnostic parameter for the diagnosis of COPD (specificity, 92.9%), although the sensitivity (39.1%) is low.

[Long-term mechanical ventilation survey]

Although home mechanical ventilation is common in western countries, it is still extremely rare in Taiwan. The objectives of this study are (1) to review retrospectively the types of disorders and outcomes of these patients requiring prolonged mechanical ventilation (MV), and (2) to survey the home status of twelve patients on home mechanical ventilation. From January 1990 to April 1992, one hundred fifteen patients receiving prolonged MV ( > or = 30 days & > or = 8-10 hrs/day) were studied in the medical intensive care unit at Chang Gung Memorial Hospital. Eighty-two patients (71.3%) for whom long-term MV were thought to be beneficial were divided into three groups by disorder: (1)primary pulmonary disorder (N = 55, 67.07%) (2) neuromuscular disorder (N = 18, 21.95%), (3) brain stem disorder (N = 9, 10.98%). The outcomes of these eighty-two patients were as follows: expired, 37 (45.12%), completely weaned, 21 (25.61%), unweanable 24, including 12 (14.63%) hospitalized and 12 (14.63%) discharged home. The three outcomes of prolonged MV were significantly associated with the three types of disorder (P = 0.0035). Among these three disorders, duration of MV were longest in the neuromuscular group, whatever the outcome. There was significant difference in the duration of MV for the different outcomes of group I & group III. The mean duration at home for the twelve home MV patients (5 male and 7 female, mean age +/- SD = 46.08 +/- 20.83 years old) was 9.93 +/- 8.11 month, with the longest being 21.5 months. Four expired within two months of discharge to home, two patients had to be readmitted once (one C2-C5 spinal cord injury patient for pneumonia, and the other for brain stem deterioration). When comparing hospital stay, four patients improved in the maximal free time (the mean improvement, 5.75 +/- 3.11 hours/day), seven remained unchanged, while one regressed.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetes mellitus and hypertension based on the family history and 2-h postprandial blood sugar in the Ann-Lo district (northern Taiwan)

From July 1988 to June 1990, we performed an epidemiological study on the prevalence of hypertension and diabetes mellitus (DM) in the Ann-Lo district, a suburban area of Northern Taiwan. One third of the population in the district was randomly sampled. A total of 9087 persons were screened with 67.4% participating. Following completion of the questionnaire blood pressure, 2 h postprandial blood sugar were determined. DM was defined when the blood sugar was over 200 mg/dl or the subject had a diabetic history. Hypertension was defined if the systolic blood pressure was over 160 mmHg or the diastolic blood pressure over 95 mmHg. Statistical comparisons were performed with a chi-square test, analysis of covariance, stepwise multiple regression and Pearson correlation matrix. In this study, the prevalence rate of DM was 2.6% and of hypertension was 6.4%. For those patients 40 years or older, the prevalence rate for DM was 8.0% and for hypertension was 19.7%. The prevalence of hypertension was 24.8% in overt diabetes and 5.2% in the normal subjects. Analysis of the data between risk factors of DM revealed that DM correlated with age, body mass index, hypertension, smoking, family history of DM and correlated negatively with education. Hypertension correlated with gender, alcohol intake and smoking, sugar level, age and body mass index. The prevalence rate of diabetes and hypertension were quite high in the district and this study pointed out the important risk factors for hypertension and DM in Taiwan.

Respiratory changes and pulmonary complications following orthotopic liver transplantation

In conclusion, we observed a worsening of LIS post-OLT, especially on the fourth postoperative day. The drop in this score implies a complicated course accompanied by a high mortality rate and increased medical expenses. Among the four components, oxygenation index and chest roentgenography score play an important and practical role. Measuring the AaD(O2) has its clinical merit, while the PEEP score and compliance of the respiratory system are of limited usefulness in this setting. The pleural effusions developed after OLT showed a trend towards increasing in amount until the sixth day and then gradually decreasing, except those cases with complications.

[Pulmonary nocardiosis with skin and subcutaneous dissemination. An imitator mimicking tuberculosis]

Nocardiosis is a localized or disseminated infection caused by an aerobic bacteria, usually introduced through the respiratory tract. The pulmonary event may provoke an acute or chronic process mimicking tuberculosis. We herein report a case of pulmonary nocardiosis with skin and subcutaneous dissemination, presenting with the clinical manifestations similar to pulmonary tuberculosis. A 60-year-old male was admitted to the hospital because of a left upper cavitary lung lesion in combination with old treated pulmonary tuberculosis, chronic obstructive pulmonary disease, diabetes mellitus, and drug-induced adrenal insufficiency. Clinical presentations manifested as pulmonary tuberculosis in the beginning, but the left cavitary lung lesion progressed to both lungs and disseminated to produce skin and subcutaneous abscesses in spite of antituberculous therapy. Eventually, Nocardia spp. was found by the Gram's stain, the modified acid-fast stain, and cultures of sputum and subcutaneous abscesses. Thereafter, he received treatment for nocardiosis with trimethoprim/sulfamethoxazole for 30 weeks. Twenty-six months later after discontinuing trimethoprim/sulfamethoxazole, the recurrence of Nocardia was noted from sputum. Therefore, if there is no improvement after antituberculous therapy for patient with the cavitary lung lesion due to possible pulmonary tuberculosis, then the possibility of nocardiosis should be considered, especially when progressive lung lesion or extrapulmonary dissemination develops.

Broncholithiasis: a neglected bronchial disease in this country. Illustration of three cases

A broncholith is a calcified lymph node which partially or completely erodes into the bronchial lumen. Its manifestations are non-specific and may result in life-threatening complications. In Taiwan, pulmonary tuberculosis, one of the most common etiologies of broncholithiasis, is common. To our knowledge, no report on broncholithiasis can be found in literature in this country. We herein present three cases of broncholithiasis experienced in the past 11 years in Chang Gung Memorial Hospital. The presenting manifestations are obstructive pneumonia in two cases, and hemoptysis in the other one. In two of them, the broncholiths were located in the right side. Fiberoptic bronchoscopy was performed, and the stones were visible in all of them. Bronchoscopic removal of stone was successful in two cases, and the other coughed up stones spontaneously after bronchoscopies. In the absence of significant symptoms or complications, only observation is necessary. For the symptomatic borncholiths, we advocate that bronchoscopic removal is worth trying to eliminate the necessity of thoracotomy unless complications are present, which indicate surgical intervention such as massive hemoptysis, fistula formation between tracheobronchial trees and esophagus or vessels, recurrent pulmonary infection or suspicion of malignancy.

Pulmonary manifestations of Staphylococcus aureus septicemia

This study includes 140 episodes (138 cases) of Staphylococcus aureus septicemia, made up mostly of community-acquired, nonintravenous drug abuse (nonIVDA) cases. Unlike other series, injury wounds and skin or soft tissue infections were the most common sites of primary infection. In spite of a different patient population and lack of cases with tricuspid valvular endocarditis, the lungs were still the most common site of secondary infectious foci and most developed within two weeks of onset of the septicemia.

Liver transplantation in Taiwan: the Chang Gung experience

Between March 1984 and February 1991, six orthotopic liver transplantations were performed at the Chang Gung Memorial Hospital in Taiwan. The indications for transplantation were Wilson's disease (5 patients) and biliary atresia (1 patient). Donors and recipients were matched only for size and ABO blood group compatibility, and the recipient operations were performed without the use of a venovenous bypass. Arterial reconstruction was carried out by end-to-end hepatic artery anastomosis (4), thoracic aortic conduit (1), or interposition of an iliac artery graft (1), whereas biliary reconstruction was accomplished by a choledochocholedochostomy using a T-tube stent (4) or a choledochocholedochostomy using an external cholecystostomy without stenting (2). Biliary complications occurred in three patients, and all required additional surgery. The average duration of donor-liver cold ischemia, operating time, and blood loss during surgery were 7 h and 50 min (range, 4.5-9 h), 13.5 h (range, 11.8-17 h), and 4,385 ml (range, 750-12,000 ml), respectively. The immunosuppressive regimens included a cyclosporin-steroid combination (n = 2) and a triple-drug combination (n = 4). All except one of the surviving patients experienced at least one rejection episode that was reversed by a methyl-prednisolone bolus and/or recycle. One patient developed a primary cytomegalovirus (CMV) infection that responded well to Ganciclovir treatment. Two of the patients died, one of injuries sustained in a traffic accident 3 years after transplantation, and the other of massive upper gastrointestinal bleeding. The overall survival value at 3 months was 83%, and the follow-up period ranged from 3 months to 7 years. All of the survivors have achieved complete rehabilitation and currently enjoy an excellent quality of life with normal liver function. Although the present study involved a small number of cases, our results indicate that liver transplantation can be successfully achieved in a high proportion of patients with acceptable morbidity, mortality, and cost in an Asian setting. The extreme shortage of donor organs is currently the most important obstacle limiting the application of liver transplantation in Taiwan.

[Significant risk factors of attempted suicide in Chang Gung Memorial Hospital Keelung]

From September 1988 to December 1989, 50 patients who had attempted suicide were admitted to the Division of General Internal Medicine in Keelung Chang Gung Memorial Hospital. Thirty-seven of the patients were female; the average age was 39.6 years. Thirty-three were married. Thirty-six had children, the average educational level was 7.1 years. The mean monthly income per family member was close to that of the corresponding population. Nine patients had pre-existing chronic medical diseases. Five patients had pre-existing confirmed diagnosis of psychosis. Thirty-nine patients had abnormal personality disorders or certain personality traits. Statistically, age between 30-39, female, low educational level, pre-existing psychosis, and abnormal personality disorders or personality traits are probable significant risk factors of attempted suicide.

Respiratory failure of acute organophosphate and carbamate poisoning

Respiratory failure (RF) developed in 43 (40.2 percent) of 107 patients with acute organophosphate or carbamate poisoning; 22 (51.2 percent) died. The 64 patients who did not develop RF survived. All cases of RF developed within 96 hours after poisoning: within 24 hours in 35 patients (acute onset) and between 24 and 96 hours in eight patients (subacute onset). Severity of poisoning was the primary determinating factor for RF. Cardiovascular collapse and pneumonia were also associated with RF. In 19 patients with cardiovascular collapse, 17 had acute onset of RF and two had subacute onset. In 28 patients with pneumonia, 17 developed acute onset of RF and eight developed subacute onset. No organophosphorus compound caused RF more frequently than another. The duration of ventilator support for subacute RF was significantly longer than for acute RF (287 +/- 186 vs 115 +/- 103 hours, p = 0.02). The use of pralidoxime did not reduce the incidence of RF. We found that severity of poisoning, cardiovascular collapse, and pneumonia were the predisposing factors to RF. The golden time for treatment of acute organophosphate or carbamate poisoning was the initial 96 hours. No RF occurred after this time. Aggressive treatment and prevention of the above three factors will reduce the incidence of RF, or in other words, reduce the mortality.

Treatment for collapsed lung in critically ill patients. Selective intrabronchial air insufflation using the fiberoptic bronchoscope

A new, simpler method to re-expand collapsed lungs was introduced in 14 procedures in 12 critically ill patients. To close the bronchus, we wedge the fiberoptic bronchoscope into each segment or subsegment of the collapsed lung instead of using a balloon cuff. Room air was then insufflated into the atelectatic alveoli after repetitive sputum suctioning and bronchial washing with normal saline solution. Complete re-expansion was achieved in 12 of the 14 procedures and partial in two. The average alveolar-arterial oxygen pressure difference (P[A-a]O2) declined from 217.5 before the procedure to 200.3, 150.0 and 152.2, respectively at 30 minutes, 12 hours and 24 hours after. There were no complications.

The clinical manifestations of the tuberculous pleural effusion in adult patients

The clinical data of 52 patients with tuberculous pleural effusion were analyzed. Their average age was 48 years old. Thirty two (62%) of them were sick for less than one week. Fever, chest pain and cough were the predominant pictures. Six of the 52 patients had coexisting disease. Intermediate strength protein purified derivative (PPD) test was found to be positive in 14 out of 31 (45%) patients. Their pleural effusions were usually unilateral, right-sided, and nearly half of them occupied more than half of the hemithorax. One third of these patients and concomitant pulmonary tuberculosis and pleural effusion. None of the patients had grossly bloody effusion. All of the effusions were exudative, and the glucose levels in the pleural fluid were invariably above 60 mg/dl. Presence of mesothelial cells in the pleural fluid was found in 28% of them, but none of the patients presented with significant eosinophils in the pleural fluid. Pleural fluid and sputum cultures for Mycobacterium tuberculosis usually reveal a negative study unless a concomitant pulmonary lesion was present. Combined antituberculosis and prednisolone treatment decreased the duration of constitutional symptoms and hastened the resolution of pleural effusion. In conclusion, tuberculous pleural effusion should be considered in elderly patients presenting with massive exudative pleural effusion even with a negative PPD study. Cultures of sputum and pleural fluid are less helpful in patients without parenchymal disease. Prednisolone is recommended in extremely ill patients.

Fever characteristics in tuberculosis--clinical observation in 597 cases

Fever characteristics were analyzed in 597 cases of tuberculosis diagnosed by positive culture for mycobacteria tuberculosis admitted to Chang Gung Memorial Hospital between March 1984 and February 1986. Among them, fever was noted in 356 cases (60.0%). Several factors were predisposing to the absence of fever: having a past history of tuberculosis (p less than or equal to 0.01), having a limited lung lesion (p less than 0.05), having an infection with isoniazide (INH) resistant strain (p less than 0.05). Fever typically developed in the late afternoon or evening in 66% of the cases, and this typical fever was significantly more common in patients less 60 years of age (p less than 0.05). The fever was low grade (less than 38.5 degrees C) in 59% of the cases. Among the 137 cases whose fever courses were completely monitored in the hospital, there were 30 cases (22%) whose fever subsided within 3 days after the start of antituberculous chemotherapy, 102 cases (74%) within 1 week and 128 cases (93%) within 2 weeks. Fever resolved within 4 weeks in all but one patient. There was no clinical factor predisposing to the delay of time for the fever to resolve including sex, age, immunocompromised condition, having a past history of tuberculosis, the infectious site(s) of tuberculosis, the extent of pulmonary involvement, the presence of cavitation in pulmonary involvement, and infection with resistant strains.

Pleural mesothelioma--analysis of 12 cases in Chang-Gung Memorial Hospital

Twelve cases of pathologically proved pleural mesothelioma collected from 1983 to 1987 were analyzed retrospectively. There were 9 males, and 3 females, aged 14-76 year-old (mean 54 year-old). Eight cases were malignant mesothelioma. Four cases were benign mesothelioma. The male to female ratio in malignant tumor was 1 to 7; in benign tumor it was 1 to 1. The mean age in malignant mesothelioma was 45 year-old, and in benign mesothelioma it was 58. Of the 8 cases with malignant mesothelioma, there were 2 cases (25%) of fibrous type, 1 case (12.5%) of epithelial type, and 5 cases (62.5%) of mixed type. Asbestos exposure history was not evident in our series. Definitive diagnosis was obtained in 10 cases by thoracotomy (83%). Two cases of malignant mesothelioma were verified by pleural biopsy. The diagnostic yield is 40% for pleural biopsy, and 100% for thoracotomy. Bronchoscopic examination, percutaneous biopsy, and pleural effusion analysis were useless in making a definitive diagnosis and distinguishing from metastatic adenocarcinoma in our opinions.

Pleural effusion in pancreatitis with pancreatico-pleural fistula: report of a case

Pancreatic pleural effusion due to an internal fistula is an uncommon and often unrecognized clinical syndrome which complicates chronic pancreatitis. It frequently presents with chest and respiratory symptoms of pleural effusion with little abdominal complaints, and history of previous pancreatic disease is often absent, making the diagnosis easily missed. A case of pancreatic pleural effusion due to an internal fistula is presented. To the best of our knowledge, this is the only case report in English journals on a pancreatico-pleural fistula resulting in pleural effusion that was not massive and the effusion amylase level was below 1,000 IU/L while being diagnosed. The potential of computed tomography in the diagnosis of this disease is illustrated.

Effects of quinidine on atrioventricular nodal reentrant paroxysmal tachycardia

Electrophysiologic studies were performed in 14 patients with atrioventricular nodal reentrant paroxysmal tachycardia (PSVT) before and after oral administration of 1.2-1.6 g quinidine sulfate over a 24-hour period (0.3-0.4 g every 6 hours). Studies were performed after 0.5-1 mg i.v. atropine before and after quinidine. All 14 patients had induction of sustained PSVT before quinidine, with or without atropine. After quinidine, 11 patients lost the ability to induce echoes or sustain PSVT, reflecting depression of the retrograde pathway with either absence of atrial echoes (six patients) or induction of nonsustained PSVT, with termination of echoes or PSVT occurring after QRS (block in retrograde pathway) (five patients). In only one of these 11 patients was sustained PSVT inducible after addition of atropine. All 11 were discharged on the same dose of quinidine. In three patients, quinidine was discontinued because of side effects. Follow-up in the remaining eight patients for 8 +/- 2 months showed no recurrence of sustained PSVT. Three of the 14 patients had induction of sustained PSVT after quinidine. Ventricular paced cycle length producing ventriculoatrial block was 314 +/- 7 msec (mean +/- SEM) before and 392 +/- 13 msec after quinidine (p less than 0.01) in the 14 patients, suggesting depression of the retrograde pathway with quinidine. In summary, quinidine inhibited induction of sustained atrioventricular nodal reentrant tachycardia with depression of the retrograde pathway. It is very effective in preventing recurrence of PSVT in most patients.

Left ventricular performance in various heart diseases with or without heart failure:--an appraisal by quantitative one-plane cineangiocardiography

Quantitative one-plane cineangiocardiography in right anterior oblique position for evaluation of LV performance was carried out in 62 patients with various heart diseases and in 13 subjects with normal LV. Parameters for evaluating both pump and muscle performances were derived from volume and pressure measurements. Of 31 patients with either systolic hypertension or LV myocardial diseases (coronary artery disease or idiopathic cardiomyopathy), 14 had clinical evidence of LV failure before the study. It was found that mean VCF and EF were most sensitive indicators of impaired LV performance among the various parameters. There was a close correlation between mean VCF and EF, yet discordant changes of both parameters were noted in some patients. Furthermore, wall motion abnormalities were not infrequently observed in patients with coronary artery disease or primary cardiomyopathy. Therefore, assessment of at least three ejection properties (EF, mean VCF and wall motion abnormalities) are considered to be essential for full understanding of derangement of LV function in heart disease. This is especially true of patients with coronary artery disease. LV behavior in relation to different pathological stresses or lesions, such as chronic pressure or volume load, myocardial disease and mitral stenosis, was also studied and possible cause of impaired LV myocardial function in mitral stenosis was discussed.