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Background: The aged people seeking otological consultation tend to increase for the purpose of applying for hearing disability certificate. When the subjective pure-tone thresholds (PTTs) are unreliable due to patient incooporation, the objective click auditory brainstem response (ABR) is used to confirm the hearing thresholds. In this study, we assess the accuracy of ABR thresholds in the aged and determine the "ABR confirmation criteria" for normal hearing and hearing handicap., Methods: This is a prospective study. ABR thresholds were compared with pure-tone thresholds (PTTs) in 100 ears of 50 subjects over 60 years of age using kappa measure of agreement. Based on receiver operating characteristic (ROC) curve and positive likelihood ratio (LR), the most appropriate "ABR confirmation criteria" for normal hearing and hearing handicap were determined., Results: According to kappa statistics, the agreement between ABR thresholds and PTTs is better in the 2- to 4-kHz region. For normal hearing, the agreement is best when confirming the average PTTs of 2, 3 and 4 kHz by the ABR threshold of 25 dB nHL (K = 0.53, p < 0.001). For hearing handicap, the agreement is best when confirming the PTTs of 3 kHz by the ABR threshold of 55 dB nHL (K = 0.60, p < 0.001). Based on ROC curve and positive LR, the ABR accuracy, for normal hearing, is excellent at a cutoff of 30 dB nHL compared with the average PTT of 2, 3 and 4 kHz. For hearing handicap, the ABR accuracy is best in excess of 55 dB nHL compared with the PTT at 3 kHz., Conclusions: We conclude that ABR is a useful diagnostic tool to confirm the validity of pure-tone audiogram for presbycusis.

Background: Frequent ventilator circuit changes are expensive and sometimes unnecessary. Following the worldwide trend to lengthen the intervals for ventilator circuit change from 2 days to 1 week, this study aims to assure that low rate of ventilator-associated pneumonia (VAP) can be maintained with cost containment., Methods: Ventilator circuits were routinely changed every 7 days in the study period for 2 years and every 2 days during the historical control period of another 2 years. Pediatric patients (age less than 15 years) were not included. Nosocomial pneumonia was diagnosed by the criteria of the Centers of Disease Control and Prevention (CDC) of the United States (US). VAP was identified by combining and comparing 2 databases from the Respiratory Therapy Department and the Infection Control Unit of our hospital., Results: In the study group, 225 episodes of pneumonias were observed in 7,068 patients and 87,338 ventilator days. The rate of VAP was 2.58 per 1,000 ventilator days. There were 174 episodes of pneumonia in 6,213 patients and 65,467 ventilator days of the control group. The rate of VAP was 2.66 per 1,000 ventilator days. The difference between both groups was not significant (p = 0.803). Yet, the cost curbed was around 80,000 US dollars per year., Conclusions: Extending ventilator circuit change interval from 2 days to 7 days do not increase the risk for VAP, but the cost savings for labor and supply are substantial.

Background: Meropenem and imipenem are beta-lactam antibiotics of the carbapenem group. Carbapenems have bactericidal activity against a broad spectrum of bacteria, including most gram-positive cocci, gram-negative bacilli and anaerobes. Experience in using meropenem in Chinese patients has not been previously reported., Methods: Meropenem (2 g daily) and imipenem/cilastatin (2 g daily) were compared in an open, randomized, prospective study on the treatment of hospitalized Chinese septic patients. All participants (male or female) were hospitalized with a diagnosis of sepsis. All patients were randomly allocated to one of the two treatment groups: the meropenem group or the imipenem/cilastatin group. Clinical status was evaluated daily during treatment and at the end of therapy or when treatment was withdrawn. Patients were checked every day for potential side-effects, according to subjective and objective symptoms., Results: Fifty-three patients were enrolled in the study; 50 were evaluated for clinical efficacy and 27 patients were evaluated for bacteriologic efficacy. The most frequent clinical diagnoses were pneumonia and urinary tract infection. The predominant pathogens were Pseudomonas aeruginosa, Escherichia coli and Enterobacter cloacae. There were 31 pathogens isolated from 27 patients. A single pathogen was identified in 23 patients, and two pathogens were isolated from four patients. Satisfactory clinical outcome (excellent and good) was 84% in the meropenem group and 76% in the imipenem/cilastatin group. Satisfactory bacteriologic response was 80% in the meropenem group and 75% in the imipenem/cilastatin group. Transiently elevated liver enzymes were the most common side-effect. One patient treated with imipenem/cilastatin experienced a seizure during the study, while another patient treated with meropenem withdrew due to urticaria., Conclusions: The efficacy and safety data presented in this report indicate that meropenem was well tolerated and appeared to be as effective as standard monotherapy with imipenem in bacteremic patients. Meropenem and imipenem/cilastatin were highly effective for the treatment of bacteremia in Chinese patients and only mild or negligible side-effects were noted.

Background: Relatively low number and activity of natural-killer (NK) cells have been reported in malignant pleural effusions. However, there has been no report on NK cells related cytokines., Methods: Lymphocyte subpopulations were studied in 30 cases of pleural effusion with various etiologies, along with peripheral blood, by using flow cytometry. The related cytokine levels in peripheral blood and pleural fluid, including IL-1 alpha, IL-4 and IL-12, were also analyzed with ELISA assays., Results: The results showed significant increase of T-helper cell subpopulation in pleural effusion of various etiologies. No obvious change of B-lymphocyte subpopulation between peripheral blood and pleural effusion was found. IL-4 was undetectable in both peripheral blood and pleural fluid in most cases. IL-1 alpha was detectable in some cases and the level was highest in pleural fluid of empyema. Decreased NK cells were found in most cases of pleural effusion and accompanied by undetectable IL-12 both in pleural fluid and peripheral blood. The only one case with detectable IL-12 concentration in pleural fluid was the one with tuberculous pleurisy., Conclusions: Increased T-helper cell subpopulation and decreased NK cell subpopulation were found in pleural effusion of various etiologies. In spite of the small series of our patients, the decrease of NK cell subpopulation and the undetectable IL-12 concentration in pleural effusion deserves further investigations.

Background: Seasonal variation of peptic ulcer and peptic ulcer bleeding has been reported in many western countries. To investigate the seasonal variation of peptic ulcer (PU) and esophageal variceal (EV) bleeding in Taiwan, this retrospective study was conducted., Methods: Seven hundred and forty-six cases of gastric ulcer (GU) bleeding, 777 cases of duodenal ulcer (DU) bleeding and 264 cases of EV bleeding were recruited from January 1, 1991 to December 31, 1992. Patients were sent to the Medical Emergency Room (MER) for hematemesis and/or melena. Upper gastrointestinal (UGI) endoscopic examinations were completed within 24 hours for all patients., Results: Significant seasonal variation was found in the incidence of PU and EV bleeding. PU bleeding was most often seen in March and EV bleeding was most often seen in February., Conclusions: The possible mechanism for the cyclic change of PU and EV bleeding is unclear, but clearly more manpower is needed during the months of February and March for better management of the increasing number of cases of PU and EV bleeding.

Lymphocutaneous sporotrichosis and chromoblastomycosis are subcutaneous mycoses caused by traumatic implantation of the fungus into the skin. Medical treatments for chromoblastomycosis has been disappointing, while lymphocutaneous sporotrichosis usually responds well to iodides. Here we present a case of chromomycosis and a case of lymphocutaneous sporotrichosis. Both patients were treated successfully with fluconazole.

Background: Serum cytokine levels have been reported to elevate in acute bacterial infection, but the relationship of differential elevation in cytokine levels to patients' clinical parameters and prognosis remains controversial. The present study was designed to evaluate whether serum interleukin-1 alpha (IL-1 alpha) and IL-6 levels were raised in patient with acute bacterial infection, and were correlated with patients clinical parameters., Methods: Thirty patients, aged from 20 to 91 years, calling our emergency room with clinical evidence of acute bacterial infection and marked leukocytosis, were enrolled in this study. Sera were collected immediately and analyzed for IL-1 alpha and IL-6 levels with Enzyme-Linked Immunosorbent Assay (ELISA) method., Results: All patients with acute bacterial infection had measurable higher levels of serum IL-6 than normal volunteers. Patients with higher serum IL-6 level were more likely to have fever, though without statistical significance (p = 0.09). Serum IL-6 levels did not correlate significantly with positive blood culture result, septic shock, or fatal outcome. Serum IL-1 alpha levels were below minimal detectable concentrations in all patients checked., Conclusions: Serum IL-6 levels were elevated in patients with acute bacterial infection, and were possibly associated with the occurrence of fever. IL-1 alpha played no obvious role as systemic effector molecule in acute bacterial infection in our study.

Background: Elevation of serum cytokine level, especially tumor necrosis factor-alpha (TNF-alpha) and granulocyte-colony stimulating factor (G-CSF), has been reported in acute bacterial infection. Elevation of serum TNF-alpha level upon patients' admission has also been reported to correlate with the fatal outcome., Methods: The present study is to evaluate, in addition to TNF-alpha and G-CSF, whether serum stem cell factor (SCF), interleukin-3 (IL-3) and granulocyte-macrophage-CSF (GM-CSF) levels to see if they were also elevated in patients with acute bacterial infection. It also tries to evaluate whether different degree of elevation of cytokine levels had any relationship to patients' clinical parameter, including fatality. Correlation between different kinds of cytokines was also studied., Results: Patients with bacterial growth in blood culture had higher level of serum G-CSF. Higher level of serum TNF-alpha was significantly associated with the occurrence of septic shock, but not of fatal outcome. Low serum G-CSF and high serum SCF level were significantly associated with fatal outcome; however, all the patients still had serum SCF levels within normal range. GM-CSF and IL-3 play no obvious role as systemic effector molecule in acute bacterial infection., Conclusions: Higher levels of serum TNF-alpha are associated with the occurrence of septic shock. Low serum G-CSF levels are significantly associated with fatal outcome. Routine monitoring of serum G-CSF level in patients with severe infection in order to supplement recombinant G-CSF can possibly help patients to overcome the disaster.

Background: Reticulocyte count plays a major role in anemic evaluation. The conventional method done by the manual supravital staining cannot subclassify the group of less than 2% of corrected reticulocyte count. The newly-developed flow cytometer provides different maturation fractions by measuring its fluorescent intensity. The reticulocytes are believed to shift to the circulation from the bone marrow earlier in more severe anemia. Therefore, the purpose of this study is to evaluate the role of reticulocyte maturation fractions and bone marrow reticulocyte in anemia classification., Methods: By using a fully automated counter, the roles of the reticulocyte with maturation and their shifting from bone marrow were evaluated in anemias. Different groups of subjects (243 in total) including aplastic, nutritional, and infiltrative anemias and anemia due to excess destruction and blood loss were studied. Each subject had bone marrow examination for morphologic diagnosis and reticulocyte evaluation., Results: Both the absolute count and the maturation fractions of reticulocytes showed significant difference among marrow infiltration, aplastic anemia, and hemolytic anemia. Both the absolute reticulocyte count and less mature fractions were lowest in aplastic group. The marrow reticulocyte counts and shift ratio to circulating blood added little benefit in the classification of anemias., Conclusions: The automated reticulocyte count with maturation fractions helps classify anemias, particularly for those with low reticulocyte count by the manual method.

The frequencies of HLA antigens were compared between 55 patients with and 38 patients without lymphocytotoxic antibodies formation after long-term platelet transfusions. Only HLA-B60 and B75 were found to manifest significant difference between these two groups. Patients with HLA homozygosity had a higher incidence of alloimmunization. Although most of the platelet alloantibodies were against HLA antigens of high frequency, the HLA-antibodies were induced at a rate different from the frequency of their corresponding antigens. The antibodies against the first and second HLA loci are of similar frequencies. In conclusion, the patients with HLA homozygous alleles have a higher incidence of platelet alloimmunization, and the antibody of certain specificities has higher rate of occurrence. These findings may be helpful in platelet-donor selection.