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RationaleAcute respiratory distress syndrome (ARDS) is a lethal complication of severe bacterial pneumonia due to the inability to dampen overexuberant immune responses without compromising pathogen clearance. Both of these processes involve tissue-resident and bone marrow (BM)–recruited macrophage (MΦ) populations which can be polarised to have divergent functions. Surprisingly, despite the known immunomodulatory properties of mesenchymal stem cells (MSCs), simultaneous interactions with tissue-resident and recruited BMMΦ populations are largely unexplored.ObjectivesWe assessed the therapeutic use of human placental MSCs (PMSCs) in severe bacterial pneumonia with elucidation of the roles of resident alveolar MΦs (AMΦs) and BMMΦs.MethodsWe developed a lethal, murine pneumonia model using intratracheal infection of a clinically relevant Klebsiella pneumoniae(KP) strain with subsequent intravenous human PMSC treatment. Pulmonary AMΦ and recruited BMMΦ analyses, histological evaluation, bacterial clearance and mice survival were assessed. To elucidate the role of resident AMΦs in improving outcome, we performed AMΦ depletion in the KP-pneumonia model with intratracheal clodronate pretreatment.Measurements and main resultsHuman PMSC treatment decreased tissue injury and improved survival of severe KP-pneumonia mice by decreasing the presence and function of recruited M1 BMMΦ while preserving M2 AMΦs and enhancing their antibacterial functions. Interestingly, PMSC therapy failed to rescue AMΦ-depleted mice with KP pneumonia, and PMSC-secreted IL-1β was identified as critical in increasing AMΦ antibacterial activities to significantly improve pathogen clearance—especially bacteraemia—and survival.ConclusionsHuman PMSC treatment preferentially rescued resident M2 AMΦs over recruited M1 BMMΦs with overall M2 polarisation to improve KP-related ARDS survival.

We describe the molecular epidemiology and resistance patterns of blaOXA-48Klebsiella pneumoniaeand Escherichia coliin Taiwan.

ABSTRACTBackground: Rapid response teams (RRTs) improve mortality by intervening in the hours preceding arrest. Implementation of these teams varies across institutions.Setting and Design: Our health-care system has two different RRT models at two hospitals: Hospital A does not utilize a proactive rounder while Hospital B does. We studied the patterns of RRT calls at each hospital focusing on the differences between night and day and during nursing shift transitions.Results: The presence of proactive surveillance appeared to be associated with an increased total number of RRT calls with more than twice as many calls made at the smaller Hospital B than Hospital A. Hospital B had more calls in the daytime compared to the nighttime. Both hospitals showed a surge in the night-to-day shift transition (7–8am) compared to the preceding nighttime. Hospital A additionally showed a surge in calls during the day-to-night shift transition (7–8pm) compared to the preceding daytime.Conclusions: Differences in the diurnal patterns of RRT activation exist between hospitals even within the same system. As a continuously learning system, each hospital should consider tracking these patterns to identify their unique vulnerabilities. More calls are noted between 7–8am compared to the overnight hours. This may represent the reestablishment of the ‘afferent’ arm of the RRT as the hospital returns to daytime staffing and activity. Factors that influence the impact of proactive rounding on RRT performance may deserve further study.

Epidemiology of fosfomycin susceptibility and the plasmid-mediated fosfomycinase genes of carbapenem-resistant Klebsiella pneumoniae(CRKP) isolates in Taiwan remain unclear.

ABSTRACTThe capsular polysaccharides in different serotypes of Klebsiella pneumoniae(KP) coded by the (CPS) gene cluster are characterized by a conserved and a hyper-variable region. We performed a virulence study by switching genes in the highly conserved region of the CPS cluster between strains. Six genes in the CPS conserved region in serotype K20, including galF, acidPPc, wzi, wza, wzband wzc, were knocked out and replaced by the homologous genes from serotype K1. Compared to the parental K20 strain, the mutants showed a decline in lethality (LD50) in mice from 10-fold to > 105-fold and were categorized in terms of the effect on virulence as low (L) for galFand acidPPC, moderate (M) for wzi, and high (H) for wza, wzband wzc. Although substituting the acidPPCgene from K1 for acidPPCin the K20 strain fully restored virulence, substitution with the wzi, wza, wzbor wzchomologs from K1 did not. The restoration with wzifrom K1 led to a partial restoration of virulence, with the LD50in mice changing from 104to 103CFU.For the wza, wzband wzcgenes, Complementation of K20 wza, wzband wzcfrom K1 resulted in varied degrees of lethality in mice. Variable improvement in serum killing and phagocytosis was observed when the knockout mutants were compared with the gene-switched strains. In conclusion, homologous genes for capsule synthesis failed to exhibit the same functionality when switched between serotypes and virulence was decreased in different degree in according to the genes' homology.

ABSTRACTIn this study, a novel colloidal gold-based immunochromatographic strip (ICS) containing anti-Klebsiella pneumoniaecapsular polysaccharide polyclonal antibodies was developed to specifically detect K. pneumoniaeserotypes K1 and K2. Capsular polysaccharide K1 and K2 antigens were first used to produce polyclonal anti-K1 and anti-K2 antibodies. Reference strains with different serotypes, nontypeable K. pneumoniaestrains, and other bacterial species were then used to assess the sensitivity and specificity of these test strips. The detection limit was found to be 105CFU, and the ICSs were stable for 6 months when stored at room temperature. No false-positive or false-negative results were observed, and equivalent results were obtained compared to those of more conventional test methods, such as PCR or serum agglutination. In conclusion, the ICS developed here requires no technical expertise and allows for the specific, rapid, and simultaneous detection of K. pneumoniaeserotypes K1 and K2.

The study was to assess the relationship between antibiotic therapy and the outcome in intensive care unit (ICU) patients with Stenotrophomonas maltophiliabloodstream infection (BSI).

Patients in intensive care units (ICUs) are especially prone to colonization and infection by carbapenem-resistant Enterobacteriaceae. We conducted a multicenter investigation to study the clinical and microbiological characteristics of patients with carbapenem nonsusceptible Klebsiella pneumoniaeand Escherichia coliin ICUs of Taiwanese hospitals.

The paper compares two elastoplastic models for incorporating the effects of material nonlinearity into a finite element procedure in the large deflection analyses of angle beam columns and trusses. These are the fiber and the lumped plasticity models. In the fiber model, the element cross section is divided into a finite number of elementary areas, from which the sectional rigidities, resisting forces, and moments, allowing for material yielding and strainunloading, are calculated. In the lumped plasticity model, the inelastic behavior is defined for the whole cross section. The stress resultants in the cross section interact to produce yielding for the section. Yielding in the element is treated in a lumped manner, in which the plasticity effects are assumed to occur only at generalized locations plastic hinges, while the element between the hinges remains elastic. Numerical studies of the large deflection behavior of restrained imperfect angle columns, Kbraced angle frames, and of singleangle web member trusses using the two elastoplastic models are presented. Tests on two pairs of angle trusses with web members on either the same side or opposite sides of the chord are described.

IMPORTANCE Hospitalized older adults often lack decisional capacity, but outside of the intensive care unit and end-of-life care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care. OBJECTIVE To describe the scope of surrogate decision making, the hospital course, and outcomes for older adults. DESIGN, SETTING, AND PARTICIPANTS Prospective, observational study conducted in medicine and medical intensive care unit services of 2 hospitals in 1 Midwestern city in 1083 hospitalized older adults identified by their physicians as requiring major medical decisions. MAIN OUTCOMES AND MEASURES Clinical characteristics, hospital outcomes, nature of major medical decisions, and surrogate involvement. RESULTS According to physician reports, at 48 hours of hospitalization, 47.4% (95% CI, 44.4%-50.4%) of older adults required at least some surrogate involvement, including 23.0% (20.6%-25.6%) with all decisions made by a surrogate. Among patients who required a surrogate for at least 1 decision within 48 hours, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning. Patients who needed a surrogate experienced a more complex hospital course with greater use of ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P < .001), artificial nutrition (1.7% of patients and 14.4% of surrogates; P < .001), and length of stay (median, 6 days for patients and 7 days for surrogates; P < .001). They were more likely to be discharged to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P < .001) and had higher hospital mortality (0.0% patients and 5.9% surrogates; P < .001). Most surrogates were daughters (58.9%), sons (25.0%), or spouses (20.6%). Overall, only 7.4% had a living will and 25.0% had a health care representative document in the medical record. CONCLUSIONS AND RELEVANCE Surrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Surrogates commonly face a broad range of decisions in the intensive care unit and the hospital ward setting. Hospital functions should be redesigned to account for the large and growing role of surrogates, supporting them as they make health care decisions.

Among physicians who perform endoscopic retrograde cholangiopancreatography (ERCP), the relationship between procedure volume and outcome is unknown.

ABSTRACTRace, age, sex, and environmental conditions have significant impacts on lymphocyte subset values. It is important to establish the local reference ranges from healthy and non-HIV-positive adults in the local population for clinical decision making. In this study, the reference ranges for lymphocyte subsets among Chinese adults were established by analysis by single-platform flow cytometry of the lymphocyte compositions of 273 healthy adult blood donors between 17 and 59 years of age. The 95% reference ranges for CD3+T cells, CD3+CD4+T helper cells, and CD3+CD8+T suppressor cells are 723 to 2,271 cells/µl, 396 to 1,309 cells/µl, and 224 to 1,014 cells/µl, respectively. The 95% reference ranges for CD19+B cells and CD56+NK cells are 118 to 645 cells/µl and 61 to 607 cells/µl, respectively. Significant gender and age differences in the lymphocyte subsets have been demonstrated. Our results have also shown that the T-lymphocyte compositions in Hong Kong Chinese were comparable to those of other Asian populations but were different from those of Caucasians.

Hetero-resistant vancomycin intermediate Staphylococcus aureus(hVISA) emerges worldwide in recent decade. The purpose of this study was to investigate the glycopeptide usage trend, the prevalence of methicillin-resistant Staphylococcus aureus(MRSA) with reduced vancomycin susceptibility, the susceptible rates to newer antimicrobials, molecular epidemiology, clinical characteristics, as well as patient outcome among S. aureusbacteremia cases in a Taiwanese medical center.

Toll‐like receptors (TLRs) activate biochemical pathways that evoke activation of innate immunity, which leads to dendritic cell (DC) maturation and initiation of adaptive immune responses that provoke allograft rejection. We aimed to prolong allograft survival by selectively inhibiting expression of the common adaptors of TLR signaling, namely MyD88 and TRIF, using siRNA. In vitro we demonstrated that blocking expression of MyD88 and TRIF led to reduced DC maturation. In vivotreatment of recipients with MyD88 and TRIF siRNA significantly prolonged allograft survival in the BALB/c > C57BL6 cardiac transplant model. Moreover, the combination of MyD88 and TRIF siRNA along with a low dose of rapamycin further extended the allograft survival (88.8 ± 7.1 days). Tissue histopathology demonstrated an overall reduction in lymphocyte interstitium infiltration, vascular obstruction and hemorrhage in mice treated with MyD88 and TRIF siRNA vector plus rapamycin. Furthermore, treatment was associated with an increase in the numbers of CD4+CD25+FoxP3+regulatory T cells and Th2 deviation. To our knowledge, this study is the first demonstration of prolonging the survival of allogeneic heart grafts through gene silencing of TLR signaling adaptors, highlighting the therapeutic potential of siRNA in clinical transplantation.

Delirium evaluation in patients in the ICU requires the use of an arousal/sedation assessment tool prior to assessing consciousness. The Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) are well-validated arousal/sedation tools. We sought to assess the concordance of RASS and SAS assessments in determining eligibility of patients in the ICU for delirium screening using the confusion assessment method for the ICU (CAM-ICU).

Klebsiella pneumoniaeis the major cause of liver abscesses in several Asian countries. Differences in the type of circulating Klebsiellastrains and/or the genetic make up of the host seem to be plausible explanations for this.

Serotype K1 Klebsiella pneumoniae with multilocus sequence type 23 (ST23) has been strongly associated with liver abscess in Taiwan. Few data regarding the strain types and virulence of this serotype from other Asian countries are available. Serotype K1 K. pneumoniae strains isolated from liver abscess and stool samples from subjects hospitalized in Hong Kong, Singapore, and Taiwan hospitals were examined. Forty-seven serotype K1 isolates were identified: 26 from liver abscess samples and 21 from stool samples. MLST revealed 7 sequence types: 85.1% (40 of 47 isolates) belonged to ST23, 1 isolate belonged to ST163 (a single-locus variant of ST23), and 2 isolates were ST249 (a 3-locus variant of ST23). New STs, namely, ST367, ST425, and ST426, were allocated to 3 of 4 isolates from stool samples. The virulence of these strains was determined by neutrophil phagocytosis and mouse infection models. Except for two ST23 isolates, all Klebsiella pneumoniae isolates were resistant to phagocytosis. Resistance to serum killing varied in isolates of ST23, while all non-ST23 strains were susceptible to serum killing except one with ST249 from a liver abscess. All hypervirulent isolates with a 50% lethal dose of <102CFU were from ST23, were resistant to phagocytosis and serum killing, and also carried both virulence-associated genes, rmpA and aerobactin. Multilocus sequence typing genotype 23 was the most prevalent sequence type among serotype K1 K. pneumoniae isolates from both liver abscess and stool samples in the Asia Pacific region. Serotype K1 K. pneumoniae isolates with capsule expression leading to phagocytic resistance and with the aerobactin gene were associated with hypervirulence.

Operating room efficiency is an important concern in hospitals today both in the public and private sectors. Currently, a paucity of literature exists to evaluate the impact of anaesthetic training on operating room efficiency in the Australian health system. At Monash Medical Centre, Clayton, private consultant operating sessions and public teaching operating sessions use the same operating theatres, nursing and technical staff. Consultant anaesthetists and obstetricians perform all tasks during private sessions, whereas anaesthetic and obstetric trainees perform many tasks during public sessions. In this prospective observational study, total case time, anaesthesia controlled time and the surgical time were measured for elective caesarean section under spinal anaesthesia in 59 patients (private consultantn=29, public teaching n=30). Increases in total case time (24 minutes, P <0.001), anaesthesia controlled time (5.2 minutes, P <0.015) and surgical time (19.25 minutes, P <0.001) were observed in the public teaching group compared with the private consultant group. The participation of anesthetic trainees in caesarean sections results in a modest increase in anaesthetic controlled time of approximately five minutes per case or 16 minutes in an operative session with three cases scheduled. Elimination of anaesthetic ‘training’ time does not allow scheduling of an extra elective caesarean section. Reduced operating theatre throughput is unlikely to be a consequence of training specialist anaesthetists in this clinical setting.

RNAi‐based therapy is a promising strategy for the prevention of ischemia‐reperfusion injury (IRI). However, systemic administration of small interfering RNA (siRNA) may cause globally nonspecific targeting of all tissues, which impedes clinical use. Here we report a hepatocyte‐specific delivery system for the treatment of liver IRI, using galactose‐conjugated liposome nanoparticles (Gal‐LipoNP). Heptocyte‐specific targeting was validated by selective in vivodelivery as observed by increased Gal‐LipoNP accumulation and gene silencing in the liver. Gal‐LipoNP TLR4 siRNA treatment resulted in a significant decrease of serum alanine transferase (ALT) and aspartate transaminase (AST) in a hepatic IRI model. Histopathology displayed an overall reduction of the injury area in the Gal‐LipoNP TLR4 siRNA treated mice. Additionally, neutrophil accumulation and lipid peroxidase‐mediated tissue injury, detected by MPO, MDA and ROS respectively, were attenuated after Gal‐LipoNP TLR4 siRNA treatment. Moreover, therapeutic effects of Gal‐LipoNP TLR4 siRNA were associated with suppression of the inflammatory cytokines IL‐1 and TNF‐α. Taken together, this study is the first demonstration of liver IRI treatment using liver‐specific siRNA delivery.

ABSTRACTOmpK35 and OmpK36 are the major outer membrane porins of Klebsiella pneumoniae. In this study, a virulent clinical isolate was selected to study the role of these two porins in antimicrobial resistance and virulence. The single deletion of ompK36(ΔompK36) resulted in MIC shifts of cefazolin, cephalothin, and cefoxitin from susceptible to resistant, while the single deletion of ompK35(ΔompK35) had no significant effect. A double deletion of ompK35and ompK36(ΔompK35/36) further increased these MICs to high-level resistance and led to 8- and 16-fold increases in the MICs of meropenem and cefepime, respectively. In contrast to the routine testing medium, which is of high osmolarity, susceptibility tests using low-osmolarity medium showed that the ΔompK35mutation resulted in a significant (≥4-fold) increase in the MICs of cefazolin and ceftazidime, whereas a ΔompK36deletion conferred a significantly (4-fold) lower increase in the MIC of cefazolin. In the virulence assays, a significant (P< 0.05) defect in the growth rate was found only in the ΔompK35/36mutant, indicating the effect on metabolic fitness. A significant (P< 0.05) increase in susceptibility to neutrophil phagocytosis was observed in both ΔompK36and ΔompK35/36mutants. In a mouse peritonitis model, the ΔompK35mutant showed no change in virulence, and the ΔompK36mutant exhibited significantly (P< 0.01) lower virulence, whereas the ΔompK35/36mutant presented the highest 50% lethal dose of these strains. In conclusion, porin deficiency in K. pneumoniaecould increase antimicrobial resistance but decrease virulence at the same time.

OmpK35 and OmpK36 are the major outer membrane porins of Klebsiella pneumoniae. In this study, a virulent clinical isolate was selected to study the role of these two porins in antimicrobial resistance and virulence. The single deletion of ompK36 (ompK36) resulted in MIC shifts of cefazolin, cephalothin, and cefoxitin from susceptible to resistant, while the single deletion of ompK35 (ompK35) had no significant effect. A double deletion of ompK35 and ompK36 (ompK35/36) further increased these MICs to high-level resistance and led to 8- and 16-fold increases in the MICs of meropenem and cefepime, respectively. In contrast to the routine testing medium, which is of high osmolarity, susceptibility tests using low-osmolarity medium showed that the ompK35 mutation resulted in a significant (≥4-fold) increase in the MICs of cefazolin and ceftazidime, whereas a ompK36 deletion conferred a significantly (4-fold) lower increase in the MIC of cefazolin. In the virulence assays, a significant (P < 0.05) defect in the growth rate was found only in the ompK35/36 mutant, indicating the effect on metabolic fitness. A significant (P < 0.05) increase in susceptibility to neutrophil phagocytosis was observed in both ompK36 and ompK35/36 mutants. In a mouse peritonitis model, the ompK35 mutant showed no change in virulence, and the ompK36 mutant exhibited significantly (P < 0.01) lower virulence, whereas the ompK35/36 mutant presented the highest 50% lethal dose of these strains. In conclusion, porin deficiency in K. pneumoniae could increase antimicrobial resistance but decrease virulence at the same time.

ABSTRACTThe genetic structure of β-lactamases in Acinetobactergenospecies 3 (AG3) isolates in Taiwan was studied to analyze their high rates of resistance to β-lactams, including carbapenems (57.9%). blaIMP-1and blaIMP-8were located in a class 1 integron. blaOXA-58was bracketed by ISAba3. A novel TnpF-like integrase gene was identified upstream of blaVEB-3. Adjacent to the 5′ sequence of the blaADCgene, folEwas identified. Four new Acinetobacter-derived cephalosporinase (ADC) enzymes were found, which clustered phylogenetically with published AG3 ADC proteins.

The Glidescope® Video Laryngoscope (Glidescope, Verathon Medical, Bothell, WA, USA) is a relatively new intubating device. It has been proposed to be useful for securing both routine airways and those where direct laryngoscopy may be difficult. In this prospective observational study, data for 742 intubations using the Glidescope were collected to investigate whether four factors are associated with successful tracheal intubation at first attempt using the Glidescope: previous Glidescope experience, previous direct laryngoscopy experience, level of anaesthesia training and clinical airway assessment.The likelihood of successful tracheal intubation at first attempt using the Glidescope increased with increasing previous Glidescope experience. Similarly, success was more likely in airways that were assessed as normal compared with those where direct laryngoscopies were either predicted or known to be difficult. Subgroup analysis indicated 83% first attempt success by ‘experienced’ Glidescope users in patients with documented difficult direct laryngoscopies. This supports its use as an adjunct device for management of airways where direct laryngoscopies prove difficult. With regard to the level of anaesthesia training, only medical students were more likely to fail with the Glidescope. Success was not associated with previous experience in direct laryngoscopy. The lack of association with direct laryngoscopy experience and level of anaesthesia training (beyond student level) suggests that expertise with traditional airway tools is not necessary to become proficient with the Glidescope.

ABSTRACTRecurrent Klebsiella pneumoniaeliver abscesses (KLAs) are rarely reported. Six cases of recurrent KLAs are characterized. Most of the patients had diabetes and K1 serotype KLAs. All of the isolates were uniformly susceptible to cefazolin. Distinct molecular fingerprints were found for the strains isolated from both primary and recurrent KLAs.

ABSTRACTAmong 235 extended-spectrum β-lactamase-producing Klebsiella pneumoniae(ESBL) isolates collected from a nationwide surveillance performed in Taiwan, 102 (43.4%) were resistant to amikacin. Ninety-two of these 102 (90.2%) isolates were carrying CTX-M-type β-lactamases individually or concomitantly with SHV-type or CMY-2 β-lactamases. The armAand rmtBalleles were individually detected in 44 and 37 of these 92 isolates, respectively. One isolate contained both armAand rmtB. The coexistence of the aac(6′)-Iland rmtBgenes was detected in three isolates. CTX-M-type β-lactamase genes belonging to either group 1 (CTX-M-3 and CTX-M-15) or group 9 (CTX-M-14) were found in all armA-or rmtB-bearing ESBL-producing K. pneumoniaeisolates, and all were conjugatively transferable. All except one of the isolates bearing armAproduced CTX-M enzymes of group 1, and the remaining isolate bearing armAproduced a group 9 CTX-M-type β-lactamase. On the contrary, in the majority of rmtBcarriers, the CTX-M-type β-lactamase belonged to group 9 (62.2%). Molecular typing revealed that the amikacin-resistant ESBL-producing K. pneumoniaeisolates were epidemiologically unrelated, indicating that the acquisition of resistance was not through the spread of a resistant clone or a resistance plasmid. A tandem repeat or multiple copies of blaCTX-M-3were found in some armA-bearing isolates. An ISEcp1insert was found in all CTX-M ESBL-producing K. pneumoniaeisolates carrying armAor rmtB. In conclusion, the concomitant presence of a 16S rRNA methylase gene (armAor rmtB) and blaCTX-Mamong amikacin-resistant ESBL-producing K. pneumoniaeisolates is widespread in Taiwan.

ABSTRACTCapsular serotypes, magA, and rmpAhave been documented in high prevalence for Klebsiella pneumoniaeliver abscess. To investigate the regional difference and the correlation of capsular serotype, magA, and rmpAwith virulence, 73 isolates were collected in Singapore and Taiwan. Capsular serotypes were determined by countercurrent immunoelectrophoresis, the presence of magAand rmpAwas determined by PCR, and virulence was determined by phagocytosis and mouse inoculation. Isolates from Singapore were similar to those from Taiwan in genomic heterogeneity, prevalence of serotype, and the presence of magAand rmpA.The most common serotype was K1 (34/73; 46.6%), followed by K2 (15/73; 20.5%). magAwas restricted to serotype K1. All K1 or K2 isolates and 66.7% (16/24) of isolates that were neither serotype K1 nor serotype K2 (non-K1/K2) carried rmpA. Serotype K1 or K2 isolates demonstrated significantly more phagocytic resistance and virulence than did rmpA-positive and -negative groups of non-K1/K2 isolates. In the non-K1/K2 group, the virulence profiles of rmpA-positive strains from Taiwan and Singapore were different by phagocytosis assay and in the mouse model, indicating that factors other than rmpAcontributed to virulence. The characteristics of K. pneumoniaeliver abscess in Singapore and Taiwan are similar. Capsular serotype K1 or K2 plays a more important role than magAand rmpAin determining virulence in K. pneumoniaeliver abscess.

ABSTRACTA nosocomial pyogenic liver abscess caused by an extended-spectrum beta-lactamase-producing Klebsiella pneumoniaeisolate presented in a man with adenocarcinoma of the stomach. The K. pneumoniaestrain isolated from blood and liver aspirate cultures after antibiotic therapy for recurrent bacteremia was resistant to all extended-spectrum beta-lactams except imipenem and differed from K. pneumoniaestrains causing community-acquired liver abscesses.

Femoral neck area expands and BMD decreases in premenopausal women. We used longitudinal DXA measurements on 388 premenopausal white sisters to show significant heritability of the rates of change in femoral neck area, BMC, and BMD.

Femoral neck area expands and BMD decreases in premenopausal women. We used longitudinal DXA measurements on 388 premenopausal white sisters to show significant heritability of the rates of change in femoral neck area, BMC, and BMD.Introduction:Bone mass and structure are highly heritable. However, genetic effects on age‐related changes in bone mass and structure in adults have been much less studied.Materials and Methods:DXA measurements were made on 388 healthy white premenopausal sisters from 178 families. Rates of change in femoral neck area, BMC, and BMD, as well as body weight, were calculated from two measurements made an average of 5.7 years apart. Mixed models were used to test whether bone changes were related to age or weight change. Variance components models were used to estimate the heritability of the rates of change. A method was proposed to correct for the underestimation of heritabilities caused by measurement errors of the rates of change.Results:Femoral neck area increased with age, whereas BMD decreased. All of the rates of change at the femoral neck were positively correlated with weight change, but the rates of femoral neck changes did not vary with age. Adjusted for weight change, change in femoral neck BMC became negative. Significant heritabilities (0.29–0.36) were detected for changes in femoral neck BMC, BMD, and area adjusted for weight changes. Correction for DXA measurement error in the rate estimates increased the heritability estimates (from 0.29–0.36 range to 0.37–0.64 range).Conclusions:Rates of change are heritable for femoral neck area, BMC, and BMD in premenopausal white women.

The Alox15gene was recently identified as a negative regulator of peak BMD in mice. Polymorphisms in human ALOX12, but not ALOX15, were significantly associated with spine BMD in white men and women, suggesting that ALOX12may contribute to normal variation in BMD.Introduction:Osteoporosis is a complex disease with both genetic and environmental risk factors. A major determinant of osteoporosis is peak BMD, which is a highly heritable trait. Recently, the arachidonate 15‐lipoxygenase(Alox15) gene was identified as a negative regulator of peak BMD in mice.Materials and Methods:To assess the contribution of lipoxygenase genes to normal BMD variation in healthy white men and women, we performed population‐ and family‐based association studies of two arachidonate lipoxygenase genes: ALOX15, which is the human homolog of mouse Alox15, and ALOX12, which is functionally similar to Alox15. Single nucleotide polymorphisms (SNPs) distributed across the two genes were genotyped. BMD was measured at the femoral neck and lumbar spine in 411 men 18–61 years of age and 1291 premenopausal women 20–50 years of age.Results:Moderate evidence of association was found between spine BMD and six SNPs in the ALOX12gene in both men and women (p= 0.0052–0.050). Furthermore, the most common SNP haplotype in ALOX12showed evidence of significant association with high spine BMD in men (p= 0.0083), whereas the second most common haplotype was associated with high spine BMD in women (p= 0.0081).Conclusions:Polymorphisms in the ALOX12gene may contribute to normal variation in spine BMD.

The Alox15gene was recently identified as a negative regulator of peak BMD in mice. Polymorphisms in human ALOX12, but not ALOX15, were significantly associated with spine BMD in white men and women, suggesting that ALOX12may contribute to normal variation in BMD.

In recent years, the ever-rising construction cost of heavy rail underground metros has slowed down their development in many countries. In most major cosmopolitan cities, a backbone network of heavy rail underground metro had been highly developed. Under such circumstances, using a lighter scale system, which meets the increasing traffic demands and supplements the existing backbone network, will certainly exalt the financial viability of a new rail transit extension. Also, it is an effective measure to enhance the urban transport functionality. This paper reviews a number of emerging alternative and innovative rail transit technologies, and serves as a reference to practitioners who are involved in the planning and design of rail transit systems.

To describe the patterns and predictors of hospital resource utilization in a cohort of children with newly diagnosed cancer, a retrospective cohort study of 195 consecutively diagnosed children with cancer at a single large Midwestern children's hospital was conducted. Patients were diagnosed between November 1995 and March 1997. All hospital encounters for these patients starting from the time of diagnosis to 3 years from diagnosis were identified using hospital administrative data. The patients were categorized into four diagnostic groups: lymphoid malignancies (acute lymphoblastic leukemia and lymphoma), myeloid leukemias (acute myeloid leukemia and chronic myeloid leukemia), central nervous system tumors, and solid tumors. Hospital charges and length of stay for patients in each diagnostic category were described. Predictive models for total resource consumption (total hospital charges) and intensive care use were derived. One hundred sixty-five of the 195 were admitted to Riley Hospital for Children at least once during the 3-year period following diagnosis. Among these 165, mean age at diagnosis was 6.9 years (minimum newborn, maximum 18.7 years). The ratio of boys to girls was 99:66 (1.5:1). The distribution of 165 diagnoses was as follows: 65 (39%) with lymphoid malignancy, 13 (8%) with myeloid leukemia, 36 (22%) with central nervous system tumors, and 51 (31%) with solid tumors. Sixty-two patients (38%) used the pediatric intensive care unit (PICU) at least once; 22 patients (13%) underwent stem cell transplantation. Sixty-five patients (39%) entered clinical trials. One hundred thirty-nine patients (84%) were alive at the end of 3 years. Three-year cumulative hospital charges were $16 million-almost $100,000/child hospitalized. Half of these charges were incurred in the first 4.5 months after diagnosis. Half of all hospital charges accrued to only 12.7% of patients; these patients were more likely to have a diagnosis of myeloid leukemia, to have undergone stem cell transplantation, and to have used the PICU. There were three independent predictors of hospital charges (log transformed): stem cell transplantation, PICU utilization, and death within 3 years of diagnosis. PICU utilization was predicted by tumor type (myeloid leukemia and central nervous system tumors were positive predictors of PICU utilization; lymphoid malignancy and solid tumors were negative predictors), stem cell transplantation, and death within 3 years of diagnosis. The authors conclude that hospitalization for childhood cancer is common, costly in the short term, and to some extent predictable. These data suggest that failures of current treatment not only lead to death but also add significantly to hospital resource utilization.

ABSTRACTA new SHV-derived extended-spectrum β-lactamase, SHV-57, that confers high-level resistance to ceftazidime but not cefotaxime or cefazolin was identified from a national surveillance study conducted in Taiwan in 1998. An Escherichia coliisolate resistant to ampicillin, cephalothin, and ceftazidime but sensitive to cefoxitin, ceftriaxone, cefotaxime, imipenem, and a narrow-spectrum cephem (cefazolin) was isolated from the urine of a patient treated with β-lactam antibiotics. Resistance to β-lactams was conjugatively transferred with a plasmid of about 50 kbp. The pI of this enzyme was 8.3. The sequence of the gene was determined, and the open reading frame of the gene was found to consist of 861 bases (GenBank accession number AY223863). Kinetic parameters showed that SHV-57 had a poor affinity to cefazolin. The Kmvalue toward cefazolin (5.57 × 103μM) was extremely high in comparison to those toward ceftazidime (30.9 μM) and penicillin G (67 μM), indicating its low affinity to cefazolin. Although the Kmvalue of the β-lactamase inhibitor was too high for the study of catalytic activity (kcat), indicating the low kcatof SHV-57, the SHV-57 carrier was highly susceptible to a β-lactam-β-lactamase inhibitor combination. Comparison of the three-dimensional molecular model of SHV-57 with that of the SHV-1 β-lactamase suggests that the substitution of arginine for leucine-169 in the Ω loop is important for the substrate specificity.

The role of the LRP5gene in rare BMD‐related traits has recently been shown. We tested whether variation in this gene might play a role in normal variation in peak BMD. Association between SNPs in LRP5and hip and spine BMD was measured in 1301 premenopausal women. Only a small proportion of the BMD variation was attributable to LRP5in our sample.

The role of the LRP5gene in rare BMD‐related traits has recently been shown. We tested whether variation in this gene might play a role in normal variation in peak BMD. Association between SNPs in LRP5and hip and spine BMD was measured in 1301 premenopausal women. Only a small proportion of the BMD variation was attributable to LRP5in our sample.Introduction:Mutations in the low‐density lipoprotein receptor‐related protein 5(LRP5) gene have been implicated as the cause of multiple distinct BMD‐related rare Mendelian phenotypes. We sought to examine whether the LRP5gene contributes to the observed variation in peak BMD in the normal population.Materials and Methods:We genotyped 12 single nucleotide polymorphisms (SNPs) in LRP5using allele‐specific PCR and mass spectrometry methods. Linkage disequilibrium between the genotyped LRP5SNPs was measured. We tested for association between these SNPs and both hip and spine BMD (adjusted for age and body weight) in 1301 healthy premenopausal women who took part in a sibling pair study aimed at identifying the genes underlying peak bone mass. Our study used both population‐based (ANOVA) and family‐based (quantitative transmission disequilibrium test) association methodology.Results and Conclusions:The linkage disequilibrium pattern and haplotype block structure within the LRP5gene were consistent with that observed in other studies. Although significant evidence of association was found between LRP5SNPs and both hip and spine BMD, only a small proportion of the total variation in these phenotypes was accounted for. The genotyped SNPs accounted for ∼0.8% of the variation in femoral neck BMD and 1.1% of the variation in spine BMD. Results from our sample suggest that natural variation in and around LRP5is not a major contributor to the observed variability in peak BMD at either the femoral neck or lumbar spine in white women.

ABSTRACTA total of 1,838 subjects from the community and 393 subjects from health care-related facilities in Taiwan were evaluated for the prevalence of nasal Staphylococcus aureuscolonization and to identify risk factors associated with S. aureusand methicillin-resistant S. aureus(MRSA) colonization. Among the community subjects, 3.5% had nasal MRSA colonization. Subjects from health care-related facilities had a lower S. aureuscolonization rate (19.1%) than community subjects (25.2%) but had a significantly higher rate of colonization with MRSA (7.63%). Age (P< 0.001) was a significant risk factor for S. aureuscolonization, with subjects under age 20 years or between 71 and 80 years showing higher rates of colonization. Recent gastrointestinal disease (P= 0.011) and hospital admission (P= 0.026) were risk factors for nasal MRSA colonization. Comparison of hospital MRSA isolates with the colonization strains by staphylococcal cassette chromosome mec(SCCmec) gene typing and pulsed-field gel electrophoresis (PFGE) typing revealed that most MRSA strains carried in the community were SCCmectype IV and that most clinical hospital isolates were type III, while health care facility-related carriage isolates were mainly SCCmectype III and type IV. Two new variant SCCmectypes were identified. Six clusters of PFGE patterns were distinguished: two mainly comprised health care facility-related MRSA strains, three mainly comprised community MRSA strains, and one comprised mixed community and health care facility-related MRSA strains. In conclusion, a high prevalence of MRSA colonization was observed among people with no relationship to the hospital setting. The high level of multiple-drug resistance among community MRSA strains in association with the previously reported excessive use of antibiotics in Taiwan highlights the importance of the problem of antibiotic selective pressure. Our results indicate that both the clonal spread of MRSA and the transmission of hospital isolates contribute to the high MRSA burden in the community.

AbstractObjectives:To rapidly establish a temporary isolation ward to handle an unexpected sudden outbreak of severe acute respiratory syndrome (SARS) and to evaluate the implementation of exposure control measures by healthcare workers (HCWs) for SARS patients.Design:Rapid creation of 60 relatively negative pressure isolation rooms for 196 suspected SARS patients transferred from 19 hospitals and daily temperature recordings of 180 volunteer HCWs from 6 medical centers.Setting:A military hospital.Results:Of the 196 patients, 34 (17.3%) met the World Health Organization criteria for probable SARS with positive results of serologic testing for SARS-associated coronavirus (SARS-CoV), reverse transcriptase polymerase chain reaction (RT-PCR) from nasopharyngeal or throat swabs for SARS-CoV, or both. Seventy-four patients had suspected SARS based on unprotected exposure to SARS patients; three of them had positive results on RT-PCR but negative serologic results. The remaining 88 patients did not meet the criteria for a probable or suspected SARS diagnosis. Of the 34 patients with probable SARS, 13 were transferred to medical centers to receive mechanical ventilation due to rapid deterioration of chest x-ray results, and three patients died of SARS despite intensive therapy in medical centers. During the study period, one nurse developed probable SARS due to violation of infection control measures, but there was no evidence of cross-transmission to other HCWs.Conclusions:Despite the use of full personal protection equipment, the facility failed to totally prevent exposures of HCWs to SARS but minimized the risk of nosocomial transmission. Better training and improvements in infection control infrastructure may limit the impact of SARS.

Salivary gland cancers are a rare malignancy accounting for less than 1% of all cancers and 3-6% of cancers of the head and neck region. The classification of salivary gland tumors is traditionally based on morphology and the different subtypes exhibit various clinical behaviors. The low grade and biologically indolent cell types include the adenoid cystic, acinic cell and adenocarcinoma while the salivary duct, squamous and mucoepidermoid are more active and high grade. The initial management of salivary gland malignancies is to assess resectability and possible adjuvant radiation therapy. Those with locoregional recurrence or metastatic disease are treated with systemic therapy. Numerous studies with small sample sizes have assessed the activity of different cytotoxic agents. Both single agent and combination chemotherapy have been used for the treatment of this disease. For these agents, the response rates are generally modest with objective response rates ranging from 15-50%. Duration of response is typically cited in the range of 6-9 months. Clinicopathological data have demonstrated correlations between poor clinical outcomes and the expression of molecular markers such as mutated p53 protein and vascular endothelial growth factor (VEGF) in salivary gland cancers. Recent studies have also evaluated the epidermal growth factor receptor family including erbB1 / EGFR and erbB2 / HER2 as potential therapeutic targets. While the prognostic significance of EGFR overexpression has not been well defined, overexpression of the HER2 oncoprotein has been associated with biological aggressiveness and poor prognosis in most series. Given the suboptimal response rates, duration of response, and toxicity of conventional chemotherapy, a better understanding of the biology of salivary gland malignancies will lead to improved prognostication and treatment. With the emergence of molecular targeted therapy, these tumors become an optimal candidate for trials of investigational drugs and established drugs for new indications.

It has not been demonstrated that the implementation of computerized quality improvement strategies can improve client-centered outcomes in public community based, long-term care (CBLTC) programs.

ABSTRACTTwo Escherichia coliisolates were recovered from the blood of two cancer patients and were demonstrated to produce high levels of the AmpC β-lactamase with isoelectric points of >9.0. The hypertranscription of ampCRNA was observed by Northern blot hybridization in both isolates. One isolate (isolate EC44) had a point mutation (G→A at position −28) and insertion of thymidine between positions −20 and −19 of the ampCpromoter gene (GenBank accession no. AE000487). The single nucleotide insertion of T between positions −19 and −20 created an optimal distance (17 bp) in the Pribnow box for ampChyperproduction. The other isolate (isolate EC38) had two point mutations (G→A at position −28 and C→T at position +58) and a 2-base (GT) insertion between positions −14 and −15. Although the insertion of GT between positions −14 and −15 may create a new promoter next to the original promoter, cloning of the ampCregion with truncated nucleotides of the original −35 region of EC38 failed to verify the hypothesis that a new promoter would be created by such a nucleotide insertion. Instead, multiple start sites for ampCtranscription at −1, +1, +2, and +3 were observed in an S1 nuclease protection assay. These results suggest that the RNA polymerase is flexible in the selection of a start site in ampChypertranscription. In conclusion, nucleotide insertions between the −35 and −10 ampCpromoter sequences was the mechanism for the hyperproduction of AmpC β-lactamase and resistance to oxyimino-cephalosporins. The failure of the two patients to respond to treatment with oxyimino-cephalosporins highlights the important role of such a resistance mechanism in the clinical setting.

ABSTRACTFrom January 1995 to May 2000, a total of 107 adults with liver abscess due to Klebsiella pneumoniaeadmitted at a large medical center in northern Taiwan were reviewed. Patients were considered to have received cefazolin or an extended-spectrum cephalosporin if they received at least 3 days of that antibiotic within the first 5 days of hospitalization. Fifty-nine (55.1%) patients received cefazolin, and 48 (44.9%) patients received an extended-spectrum cephalosporin. The demographic data, clinical features, severities of illness, and rates of early drainage for the two groups were comparable. However, the rates of developing complications for the two groups were significantly different (37.3 versus 6.3%, respectively; P< 0.001). Furthermore, six independent factors preventing severe complications following liver abscess due to K. pneumoniaewere identified: normal platelet count, alkaline phosphatase less than 300 U/liter, no gas formation in the abscess, APACHE III score less than 40, use of an extended-spectrum cephalosporin, and early drainage. In conclusion, cefazolin therapy may be suboptimal for patients with liver abscess due to K. pneumoniaedespite active in vitro susceptibility. Use of an extended-spectrum cephalosporin and early drainage for patients with liver abscess due to K. pneumoniaeare suggested.

The objective of this study was to determine if vasorelaxant responses to calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP), and acetylcholine are altered in aortic rings of mice lacking genetic expression of endothelial nitric oxide synthase (eNOS) or inducible nitric oxide synthase (iNOS) genes (i.e., eNOS- and iNOS-knockout mice) as compared with control (wild-type) mice. Aortic rings from eNOS-knockout (eNOS (−/−)) mice did not relax in response to acetylcholine, thereby confirming previous reports. Aortic rings from iNOS-knockout (iNOS (−/−)) mice relaxed in response to acetylcholine in an endothelium-dependent manner. However, maximum relaxations in endothelium-intact rings were significantly (p < 0.05) larger than in control mice (85.3 ± 3.1 in iNOS (−/−) mice vs. 67.9 ± 5.6 in controls). CGRP caused concentration-dependent relaxations in aortas of all three types of mice control mice, iNOS (−/−) mice, and eNOS (−/−) mice. Vasorelaxant responses to CGRP in control and iNOS (−/−) mice had identical relationships; both were partially dependent on endothelium. In eNOS (−/−) mice, dose-response curves of CGRP in endothelium-intact and endothelium-denuded rings were not significantly different, indicating loss of the partial dependence on endothelium. The vasorelaxant responses to VIP were completely dependent on endothelium in control and iNOS (−/−) mice. Maximum relaxations to VIP in iNOS (−/−) mice (77.4 ± 2.7) were significantly greater than in control mice (64.0 ± 5.5). Vasorelaxant responses to VIP in eNOS (−/−) aortic rings were also endothelium-dependent, but responses were greatly attenuated compared with wild-type mice. Relaxations induced by VIP (1 × 10−7M) in endothelium-intact aortic rings of eNOS (−/−) mice and control mice were 18.3 ± 5.4 and 64.0 ± 5.5, respectively. These findings demonstrated that, in eNOS (−/−) mice, aortic vasorelaxant responses to CGRP were fully present but no longer dependent on the endothelium, and responses to VIP were greatly attenuated compared with control and responses to acetylcholine were abolished. In iNOS (−/−) mice, aortic vasorelaxant responses to VIP and acetylcholine were significantly greater than wild-type control, suggesting that induction of iNOS may have attenuated vascular responses to VIP and acetylcholine in wild-type controls.

To design a brief cognitive screener with acceptable sensitivity and specificity for identifying subjects with cognitive impairment