Search

In recent years, reinforcement learning (RL) has achieved a remarkable achievement and it has attracted researchers' attention in modeling real-life scenarios by expanding its research beyond conventional complex games. Prediction of optimal treatment regimens from observational real clinical data is being popularized, and more advanced versions of RL algorithms are being implemented in the literature. However, RL-generated medications still need careful supervision of expertise parties or doctors in healthcare. Hence, in this paper, a Supervised Optimal Chemotherapy Regimen (SOCR) approach to investigate optimal chemotherapy-dosing schedule for cancer patients was presented by using Offline Reinforcement Learning. The optimal policy suggested by the RL approach was supervised by incorporating previous treatment decisions of oncologists, which could add clinical expertise knowledge on algorithmic results. Presented SOCR approach followed a model-based architecture using conservative Q-Learning (CQL) algorithm. The developed model was tested using a manually constructed database of forty Stage-IV colon cancer patients, receiving line-1 chemotherapy treatments, who were clinically classified as 'Bevacizumab based patient' and 'Cetuximab based patient'. Experimental results revealed that the supervision from the oncologists has considered the effect to stabilize chemotherapy regimen and it was suggested that the proposed framework could be successfully used as a supportive model for oncologists in deciding their treatment decisions.

Purpose To compare clinical characteristics and treatment outcomes of intra-arterial thrombectomy (IAT) in acute basilar artery occlusion (BAO) with and without underlying intracranial atherosclerotic stenosis (ICAS) and to investigate the usefulness of preprocedural CT angiography findings in the diagnosis of ICAS. Materials and Methods Twenty patients who received IAT for acute BAO between September 2014 and March 2019 were included. Additional therapies such as angioplasty, stent placement, and tirofiban infusion were provided while treating ICAS. Clinical and angiographic results of treatment were recorded. Preprocedural CT angiography findings in ICAS and non-ICAS groups were compared to assess (i) basilar tip opacification, (ii) partial occlusion, (iii) presence of convex border, (iv) occlusion segment longer than two thirds of the basilar artery or 20 mm, (v) dense basilar artery, and (vi) wall calcification in the occluded segment. Results Among the 20 patients (mean age, 71.3 y; mean stroke score, 24.8), optimal recanalization was achieved in 19 (95%). Three patients had good clinical outcomes. There were 6 patients with underlying ICAS. No difference was observed between ICAS and non-ICAS groups in terms of optimal angiographic recanalization and good outcome. On CT angiography, basilar tip occlusion (100% vs 29%), partial occlusion (100% vs 83%), and long occlusion length (100% vs 14%) significantly differed between the groups (P ≤ .01). Conclusions In acute BAO, underlying ICAS does not affect optimal recanalization rate or clinical outcome. Preprocedural CT angiography is a potentially useful tool to detect it.

We evaluated the analytical and clinical performance of a novel circulating tumor cell (CTC)-based blood test for determination of programmed death ligand 1 (PD-L1) protein expression status in real time in treatment-naïve non-small cell lung cancer (NSCLC) patients. CTCs were detected in 86% of patients with NSCLC (I-IV) at the time of diagnosis, with a 67% PD-L1 positivity rate (≥ 1 PDL + CTC). Among 33 NSCLC patients with PD-L1 results available via both tissue immunohistochemistry (IHC) and CTC assays, 78.9% were positive according to both methods. The CTC test identified an additional ten cases that were positive for PD-L1 expression but that tested negative via IHC analysis. Detection of higher PD-L1 expression on CTCs compared to that in the corresponding tissue was concordant with data obtained using other platforms in previously treated patients. The concordance in PD-L1 expression between tissue and CTCs was approximately 57%, which is higher than that reported by others. In summary, evaluation of PD-L1 protein expression status on CTCs isolated from NSCLC patients is feasible. PD-L1 expression status on CTCs can be determined serially during the disease course, thus overcoming the myriad challenges associated with tissue analysis.

Background/Aim: Casticin, one of the active components of Vitex rotundifolia L., presents biological and pharmacological activities including inhibition of migration, invasion and induction of apoptosis in numerous human cancer cells in vitro. This study aimed to assess the effects of casticin on tumor growth in a human oral cancer SCC-4 cell xenograft mouse model in vivo. Materials and Methods: Twenty-four nude mice were injected subcutaneously with SCC-4 cells and when palpable tumors reached a volume of 100-120 mm(3) the mice were randomly divided into three groups. The control (0.1% dimethyl sulfoxide), casticin (0.2 mg/kg), and casticin (0.4 mg/kg) groups were intraperitoneally injected every two days for 18 days. Tumor volume and body weights were measured every two days. Results: Casticin significantly decreased tumor volume and weight in SCC-4 cell xenograft mice but there was no statistically significant difference between the body weights of control mice and mice treated with 0.2 mg/kg or 0.4 mg/kg casticin. Therefore, the growth of SCC-4 cells in athymic nude mice can be inhibited by casticin in vivo. Conclusion: These findings support further investigations in the potential use of casticin as an oral anti-cancer drug in the future.

Periodontal diagnosis requires discovery of the relations among teeth, gingiva (i.e., gums), and alveolar bones, but alveolar bones are inside gingiva and not visible for inspection. Traditional probe examination causes pain, and X-ray based examination is not suited for frequent inspection. This work develops an automatic non-invasive periodontal inspection framework based on gum penetrative Optical Coherence Tomography (OCT), which can be frequently applied without high radiation. We sum up interference responses of all penetration depths for all shooting directions respectively to form the shooting amplitude projection. Because the reaching interference strength decays exponentially with tissues&rsquo, penetration depth, this projection mainly reveals the responses of the top most gingiva or teeth. Since gingiva and teeth have different air-tissue responses, the gumline, revealing itself as an obvious boundary between teeth and gingiva, is the basis line for periodontal inspection. Our system can also automatically identify regions of gingiva, teeth, and alveolar bones from slices of the cross-sectional volume. Although deep networks can successfully and possibly segment noisy maps, reducing the number of manually labeled maps for training is critical for our framework. In order to enhance the effectiveness and efficiency of training and classification, we adjust Snake segmentation to consider neighboring slices in order to locate those regions possibly containing gingiva-teeth and gingiva&ndash, alveolar boundaries. Additionally, we also adapt a truncated direct logarithm based on the Snake-segmented region for intensity quantization to emphasize these boundaries for easier identification. Later, the alveolar-gingiva boundary point directly under the gumline is the desired alveolar sample, and we can measure the distance between the gumline and alveolar line for visualization and direct periodontal inspection. At the end, we experimentally verify our choice in intensity quantization and boundary identification against several other algorithms while applying the framework to locate gumline and alveolar line in vivo data successfully.

Digital dental reconstruction can be a more efficient and effective mechanism for artificial crown construction and period inspection. However, optical methods cannot reconstruct those portions under gums, and X-ray-based methods have high radiation to limit their applied frequency. Optical coherence tomography (OCT) can harmlessly penetrate gums using low-coherence infrared rays, and thus, this work designs an OCT-based framework for dental reconstruction using optical rectification, fast Fourier transform, volumetric boundary detection, and Poisson surface reconstruction to overcome noisy imaging. Additionally, in order to operate in a patient&rsquo, s mouth, the caliber of the injector is small along with its short penetration depth and effective operation range, and thus, reconstruction requires multiple scans from various directions along with proper alignment. However, flat regions, such as the mesial side of front teeth, may not have enough features for alignment. As a result, we design a scanning order for different types of teeth starting from an area of abundant features for easier alignment while using gyros to track scanned postures for better initial orientations. It is important to provide immediate feedback for each scan, and thus, we accelerate the entire signal processing, boundary detection, and point-cloud alignment using Graphics Processing Units (GPUs) while streamlining the data transfer and GPU computations. Finally, our framework can successfully reconstruct three isolated teeth and a side of one living tooth with comparable precisions against the state-of-art method. Moreover, a user study also verifies the effectiveness of our interactive feedback for efficient and fast clinic scanning.

Ouabain, a cardiotonic steroid and specific Na+ /K+ -ATPase inhibitor, has a potential to induce cancer cell apoptosis but the mechanisms of apoptosis induced by ouabain are not fully understand. The aim of this study was to investigate the cytotoxic effects of ouabain on human prostate cancer DU 145 cells in vitro. Cell morphological changes were examined by phase contrast microscopy. Cell viability, cell cycle distribution, cell apoptosis, DNA damage, the production of ROS and Ca2+ , and mitochondrial membrane potential (ΔΨm ) were measured by flow cytometry assay. Results indicated that ouabain induced cell morphological changes, decreased total cell viability, induced G0/G1 phase arrest, DNA damage, and cell apoptosis, increased ROS and Ca2+ production, but decreased the levels of ΔΨm in DU 145 cells. Ouabain also increased the activities of caspase-3, -8, and -9. Western blotting was used for measuring the alterations of apoptosis-associated protein expressions in DU 145 cells and results indicated that ouabain increased the expression of DNA damage associated proteins (pATMSer1981 , p-H2A.XSer139 , and p-p53Ser15 ) and ER-stress-associated proteins (Grp78, ATF6β, p-PERKThr981 , PERK, eIF2A, GADD153, CaMKIIβ, and caspase-4) in time-dependently. Furthermore, ouabain increased apoptosis-associated proteins (DR4, DR5, Fas, Fas Ligand, and FADD), TRAIL pathway, which related to extrinsic pathway, promoted the pro-apoptotic protein Bax, increased apoptotic-associated proteins, such as cytochrome c, AIF, Endo G, caspase-3, -8, and -9, but reduced anti-apoptotic protein Bcl-2 and Bcl-x in DU 145 cells. In conclusion, we may suggest that ouabain decreased cell viability and induced apoptotic cell death may via caspase-dependent and mitochondria-dependent pathways in human prostate cancer DU 145 cells.

Tumors with epicenter in the thalamus occur in about 4 % of pediatric brain tumors. The histological diagnosis is mainly gliomas. Among them, low-grade glioma (LGG) constituted of a significant entity of the tumors (Cuccia et al., Childs Nerv Syst 13:514–521, 1997; Puget et al., J Neurosurg 106:354–362, 2007; Bernstein et al., J Neurosurg 61:649–656, 1984; Bilginer et al., Childs Nerv Syst 30:1493–1498, 2014). Since Kelly’s report in 1989, >90 % resection of thalamic tumors were achieved in reported series (Ozek and Ture, Childs Nerv Syst 18:450–6, 2002; Villarejo et al., Childs Nerv Syst 10:111–114, 1994; Moshel et al., Neurosurgery 61:66–75, 2007; Albright, J Neurosurg 100(5 Suppl Pediatrics): 468–472, 2004; Kelly, Neurosurgery 25:185–195, 1989; Drake et al., Neurosurgery 29: 27–33, 1991). Sixty-nine cases of thalamic tumors in children were retrospectively reviewed. There were 25 cases of LGGs. We analyzed our experience and correlated it with reported series. Summing up of 4 reported series and the present series, there were 267 cases of thalamic tumors in children. Among these tumors, 107 (40.1 %) were LGGs and 91 (34.1 %) were low-grade astrocytomas (LGAs). In the present series, all of the 25 LGGs were LGAs that consisted of 11 pilocytic astrocytomas (PAs) and 14 diffuse astrocytomas (DAs). Six cases received biopsy sampling only. The remaining 19 cases received different degrees of surgical resection via several approaches. Radical (>90 %) resection was achieved better in PAs comparing with DAs. There was no operative mortality. Two patients had increased neurological deficits. In a mean follow-up period of 11.9 years, three patients died of tumor progression and one patient died of anaplastic change. The 5- and 10-year overall survival (OS) was 87.1 and 87.1 %, respectively. Thalamic LGGs are mainly LGAs and are indolent. The rate of >90 % resection was relatively low in the present series. By applying contemporary diagnostic MRI studies, surgical facilities, and appropriate approaches in selective cases, we may try maximum neuroprotective radical (>90 %) resection.

Studies have identified frailty as an effective predictor of fracture; however, the correlation between frailty and fracture differs between various stages of frailty.The main aim is to determine the correlation between various stages of frailty and fracture risk; a secondary purpose is to determine the correlation between subgroups (e.g., females, females with a hip fracture, or aged 65 years or older) within the stages of frailty and fracture risk. Finally, effect of frailty criteria on the association between stages of frailty and fracture risk was tested.We conducted a systematic review and meta-analysis. The inclusion criteria were as follows: (a) a prospective study design; (b) subjects aged 55 years or older; (c) a division into robust, prefrail, and frail groups; and (d) reported confidence intervals of hazard ratio. Two investigators independently assessed quality and discussed their findings to reach consensus. The quality of the literature was assessed and the level of evidence was also determined.In total, five studies included 103,783 older people and recorded 2,960 fractures. The results identified that the risk of fracture in the frail people was higher than that in both the robust people (summary HR: 1.67; 95% CI [1.46-1.91]) and prefrail people (summary HR: 1.28; 95% CI [1.16-1.40], and that the risk of fracture in the prefrail people was higher than that in the robust people (summary HR: 1.30; 95% CI [1.20-1.41]). A subgroup analysis revealed that among female adults, older females with hip fracture, or those aged 65 years or more, those who were categorized as frail showed the highest fracture risk, followed by those who were categorized as prefrail.Professional nurses caring for frail or prefrail people should actively develop fracture prevention measures to reduce the risk of death caused by fractures.

Purpose: Carcinoma of unknown origin has a poor outcome and usually occurs in elderly patients. In this article, we analyzed the prognostic factors in elderly patients with cancer of unknown primary site (CUP) for treatment considerations. Patients and Methods: Patients >70 years old with histologically proven carcinoma were retrospectively reviewed. The prognostic factors were analyzed with univariate and multivariate Cox regression. Results: We included 63 patients aged 70–79 years and 51 patients ≥80 years old. The results of multivariate Cox regression in the 70–79 years age group revealed white blood cell count ≤104/ml [p = 0.033; hazard ratio (HR) 2.51, range 1.079–5.840] and albumin ≥3.5 g/dl (p = 0.007; HR 3.38, range 1.398–8.177) as independent factors. In the group of patients ≥80 years old, Eastern Cooperative Oncology Group performance status 4/ml (p = 0.001), albumin ≥3.5 g/dl (p = 0.006), lactate dehydrogenase (LDH) ≤250 U/l (p = 0.002) and non-chest metastasis (p = 0.043) were significantly better with univariate analysis. Multivariate Cox regression revealed albumin ≥3.5 g/dl (p = 0.007; HR 3.28, range 1.389–7.745) and LDH ≤250 U/l (p = 0.045; HR 3.18, range 1.026–9.848) as independent factors. Conclusions: For elderly patients with CUP, the serum albumin level seems to be a consistently independent prognostic factor. In patients >80 years old, serum LDH plays an important role in prognosis. This study is helpful in predicting the outcome and management for this group of patients.

Candida parapsilosis was recently reclassified into 3 closely related species, C. parapsilosis sensu stricto, Candida orthopsilosis, and Candida metapsilosis. Variation in susceptibility characteristics and prevalence of the 3 genomic species could have therapeutic and epidemiologic implications. The aim of this study is to characterize the genetic and antifungal susceptibility profiles of 97 C. parapsilosis isolates from 71 patients. Among the 71 nonduplicate isolates, 85.9% (61/71) were identified as C. parapsilosis sensu stricto, 5.6% (4/71) as C. metapsilosis, and 8.5% (6/71) as C. orthopsilosis species based on sequences of the internal transcribed spacer (ITS) region. The delineation of these 3 species is concordant with that achieved by pulsed-field gel electrophoresis of BssHII restriction fragments at 75% similarity. Antifungal susceptibility tests showed that most isolates were susceptible to flucytosine, azoles, amphotericin B, and echinocandins, whereas 3 C. metapsilosis isolates from 1 patient showed resistance and susceptible-dose dependence to fluconazole. The C. metapsilosis isolates exhibited significantly higher MIC values to both fluconazole and voriconazole than those of C. parapsilosis sensu stricto and C. orthopsilosis. On the other hand, the C. metapsilosis isolates showed significantly lower MIC values on 24 h to caspofungin than those of C. parapsilosis sensu stricto and C. orthopsilosis. For micafungin, the isolates of C. parapsilosis sensu stricto had significantly higher MIC values on 24 h than those of C. orthopsilosis and C. metapsilosis. Compared to Candida albicans, mutations from proline to alanine were identified on the hot spot 1 of Fks1 in all these C. parapsilosis sensu lato isolates regardless of their MIC levels. Some of the C. orthopsilosis and C. metapsilosis isolates expressed the isoleucine to valine substitution on the hot spot 2 region. However, the amino acid variations in these isolates did not correlate to their MIC values of echinocandin.

Recently, we reported that diploid sequence type (DST) 140 was a predominant type of Candida tropicalis among isolates with fluconazole minimum inhibitory concentrations (MICs)or=64 microg/ml collected in the Taiwan Surveillance of Antimicrobial Resistance of Yeasts (TSARY) in 1999. To determine if DST140 persists in Taiwan, we have used multilocus sequence typing to characterize the genetic profiles of 31 resistant isolates (MICsor=64 microg/ml), together with 19 susceptible isolates (MICsor=16 microg/ml) collected in TSARY 2006. Among the 50 isolates, 33 distinct DSTs were detected. Of the 31 resistant isolates, 11 (35.5%) belonged to two closely related DSTs (140 and 98), whereas none of the 19 susceptible isolates did (p = 0.004). The isolates belonging to DST140 and 98 were from different geographic regions instead of a restricted area. Thus, our data show temporal and spatial transmission of C. tropicalis clones with high fluconazole MICs in Taiwan from 1999 to 2006.

Multilocus sequence typing (MLST) was used to characterize the genetic profiles of 52 Candida tropicalis isolates collected from 10 hospitals in Taiwan. A total of 33 diploid sequence types (DSTs) were differentiated among the 52 isolates and all were novel to the Internet C. tropicalis DST database (http://pubmlst.org/ctropicalis/). Eleven (33.3%) of the 33 DSTs could be assigned to 3 major clonal clusters (1-3) based on eBURST calculation. Only clonal cluster 1 co-clustered isolates from UK and the United States. Clonal cluster 2 was enriched with isolates with resistance or trailing growth of fluconazole (14/20, 70%). Furthermore, there are a number of pulsed-field gel electrophoresis subtypes associated with the isolates in this cluster, demonstrating that possibly more than one clone with resistant or trailing property have emerged and spread in Taiwan in 1999.

This study was designed to pursue the identification of optimal restriction enzyme for pulsed-field gel electrophoresis (PFGE) analysis of Candida tropicalis. Twelve restriction enzymes were tested on C. tropicalis strains. Our results indicate that BssHII, NaeI, and RsrII were useful enzymes for PFGE analysis, and NaeI was the best for PFGE analysis of C. tropicalis isolates.

Medulloblastoma (MB) is a type of malignant tumor arising only in the cerebellum that was first defined by Cushing and Bailey in 1920s. In this review paper, we trace the evolution of risk stratification and the correlated changing concept of management in the past years. Outcome analysis of the hospital series of the Taipei Veterans General Hospital, Cheng Hsin General Hospital, and Taipei Medical University Hospital was performed to correlate prognostic indicators with reported studies. The purpose is to provide clues for age-specific and risk-adjusted optimal, effective, but beneficial and protective treatment strategies of these tumors in children.

Multilocus sequence typing (MLST) was used to characterize the genetic profiles of 51 Candida albicans isolates collected from 12 hospitals in Taiwan. Among the 51 isolates, 16 were epidemiologically unrelated, 28 were isolates from 11 critically ill, human immunodeficiency virus (HIV)-negative patients, and 7 were long-term serial isolates from 3 HIV-positive patients. Internal regions of seven housekeeping genes were sequenced. A total of 83 polymorphic nucleotide sites were identified. Ten to 20 different genotypes were observed at the different loci, resulting, when combined, in 45 unique genotype combinations or diploid sequence types (DSTs). Thirty (36.1%) of the 83 individual changes were synonymous and 53 (63.9%) were nonsynonymous. Due to the diploid nature of C. albicans , MLST was more discriminatory than the pulsed-field gel electrophoresis-BssHII-restricted fragment method in discriminating epidemiologically related strains. MLST is able to trace the microevolution over time of C. albicans isolates in the same patient. All but one of the DSTs of our Taiwanese strain collections were novel to the internet C. albicans DST database ( http://test1.mlst.net/ ). The DSTs of C. albicans in Taiwan were analyzed together with those of the reference strains and of the strains from the United Kingdom and United States by unweighted-pair group method using average linkages and minimum spanning tree. Our result showed that the DNA type of each isolate was patient specific and associated with ABC type and decade of isolation but not associated with mating type, anatomical source of isolation, hospital origin, or fluconazole resistance patterns.

A case of acquired Chiari malformation type I with frontal fistulous arteriovenous malformation (AVM) is presented, and the pathophysiology is discussed. The tonsillar herniation and hydrocephalus both resolved after AVM was excised. This case provides some insight into the complex hemodynamic change exerted by the fistulous AVM and the mechanism of the development of acquired Chiari malformation type I.

Objective: Carotid blowout syndrome is a severe complication of head and neck cancer. High mortality and major neurologic morbidity are associated with carotid blowout syndrome with massive bleeding. Prediction of outcomes for carotid blowout syndrome patients is important for clinicians, especially for patients with the risk of massive bleeding. Methods: Between 1 January 2001 and 31 December 2011, 103 patients with carotid blowout syndrome were enrolled in this study. The patients were divided into groups with and without massive bleeding. Prognostic factors were analysed with proportional hazard (Cox) regressions for carotid blowout syndrome-related prognoses. Survival analyses were based on the time from diagnosis of carotid blowout syndrome to massive bleeding and death. Results: Patients with massive bleeding were more likely to have hypoalbuminemia (albumin ,3.5 g/dl; P ¼ 0.023). Univariate analysis of carotid blowout syndrome-related massive bleeding showed that treatment for carotid blowout syndrome (best supportive care, P ¼ 0.000; embolization, P ¼ 0.000), monocytosis (monocytes .1000 cells/ml, P ¼ 0.041) and hypoalbuminemia (P ¼ 0.010) were important to prognosis. Concurrent chemoradiotherapy (P ¼ 0.007), elevated lactate dehydrogenase (.250 U/l; P ¼ 0.050), local recurrence (P ¼ 0.022) and hypoalbuminemia (P ¼ 0.038) were related to poor prognosis in carotid blowout syndrome-related death. In multivariate analysis, best supportive care and hypoalbuminemia were independent factors for both carotid blowout syndrome-related massive bleeding (P ¼ 0.000) and carotid blowout syndrome-related death (P ¼ 0.013), respectively. Conclusion: Best supportive care and serum albumin are important prognostic factors in carotid blowout syndrome. It helps clinicians to evaluate and provide better supportive care for these patients.

Objectives Successful clones of Neisseria gonorrhoeae multiantigen sequence typing sequence type (ST) 1407 and ST1407-related genotypes have been reported to cause cefixime and ceftriaxone treatment failure in many countries. We characterized the 47 isolates of a strain cluster of ST4378, a genotype that differs in the porB sequence by only one nucleotide from ST1407, in Taiwan during April 2006 to June 2012. Methods We identified 47 ST4378 isolates among our 2357 total isolates from the Gonococci-National Isolate Collection for Epidemiology. The corresponding patients' medical records were collected. The 47 isolates were further typed by multilocus sequence typing. Genes involved in β-lactam (ponA), quinolone (gyrA and parC) and multidrug (mtrR, porB1b and pilQ) resistance were sequenced. Antimicrobial susceptibility was determined by the disc diffusion test and Etest. Results Cefixime MICs for the 47 isolates ranged from 0.016 to 0.19 mg/L and ceftriaxone MICs ranged from 0.012 to 0.094 mg/L. Forty-six of the 47 isolates had a mosaic penA allele type XXXIV and one had a new allele type XL, which appeared to be a recombinant of mosaic penA type XXXIV and non-mosaic penA type II. All of the isolates harboured nearly identical polymorphism in the ponA, gyrA, parC, mtrR, porB1b and pilQ genes. Among the 33 patients with known medical records, 25 (76%) were men who have sex with men (MSM), 3 (9%) were bisexual and 5 (15%) were heterosexual. Fourteen (42%) of the 33 patients had HIV, 8 (24%) had syphilis and 7 (21%) had both infections. Conclusions This is the first report of a cluster of ST1407-related strains in Taiwan. ST4378 is a genotype that may develop to cause third-generation cephalosporin treatment failures. Our results showed that ST4378 strains primarily transmitted in a high-risk MSM/bisexual network. The potential of these strains to become untreatable and spread to other low-risk sexual networks should be closely monitored.

To observe the clinicopathologic and resistance profiles of the Nocardia brasiliensis causing cutaneous nocardiosis in Taiwan, 12 N. brasiliensis isolates were prospectively collected from patients with cutaneous nocardiosis in a hospital during 2002-2012. Clinicopathologic data were obtained, and isolates were identified by biochemical methods and 16S rRNA sequencing. Susceptibilities to 14 antimicrobial compounds were tested. Isolates were further genotyped by sequencing of 16S rRNA, secA1, hsp65, and gyrB genes. The nodulopustular pyoderma associated with sporotrichoid spreading was the most common skin presentations caused by N. brasiliensis. All of the isolates were susceptible to amikacin, gentamicin, tobramycin, piperacillin/tazobactam, and trimethoprim/sulfamethoxazole and resistant to kanamycin, erythromycin, and oxacillin, while susceptibilities to imipenem, vancomycin, penicillin-G, tetracycline, clindamycin, and ciprofloxacin varied among the 12 isolates. GyrB genotyping delineated the 12 isolates into 2 major groups, which was coincident with different single nucleotide substitutions at position 160 (G versus T) of 16S rRNA, different levels of imipenem minimum inhibition concentration (4-32 versus 0.25-0.75 mg/L), and prevalence of lymphadenitis (66.7 versus 16.7%). We have noted that tiny pustular lesions can be the first sign of cutaneous nocardiosis, which we believe has not been previously emphasized. No resistance to trimethoprim and sulfamethoxazole was found; therefore, sulphonamide drugs remain effective for treatment of cutaneous nocardiosis in Taiwan.

Background Carcinoma of unknown primary site (CUP) has a poor prognosis and the prognostic factors in these patients are not well established. Furthermore, there are no selection criteria for patients who should benefit from chemotherapy. Methods The medical records of 179 CUP patients who were treated at Taipei Veterans General Hospital from 2000 to 2009 were reviewed. Factors associated with survival were determined by Kaplan-Meier analysis. Differences between the groups with and without palliative chemotherapy were analyzed. Results Univariate analysis revealed multiple prognostic factors, including performance status, lung metastasis, number of metastatic organs, serum albumin, corrected serum calcium, lactate dehydrogenase (LDH), sodium, and cholesterol levels, palliative chemotherapy, and white blood cell and lymphocyte counts. Multivariate analysis showed that performance status < 2, serum albumin level ≥ 3.5 g/dl, corrected serum calcium level < 10.7 mg/dl, single metastatic organ, and palliative chemotherapy were independent factors of better prognosis. Patients with better performance status, higher serum albumin, and lower serum LDH levels had significantly greater benefit from palliative chemotherapy. Conclusions Certain patients with unfavorable CUP will have better survival. Identification of patients with unfavorable CUP who could benefit from palliative chemotherapy warrants future prospective studies.

Tissue expansion has become invaluable for burn-scar reconstruction. However, its use is hindered by the complications that often result in expansion failure. This study attempts to identify the risk factors of expansion failure in burn patients, as such factors have not been clearly defined.This study included 62 tissue expansions in 37 burn patients from January 2001 to June 2009. Factors including patient's age, sex, co-morbidities, expander size, implantation site, volume injected at implantation, preinflation volume ratio (PVR=volume injected at implantation/expander size), final inflation volume ratio (FIVR=cumulative volume injected at completion of expansion/expander size) and expansion duration were analysed. Cases were allocated into success (n=53) and failure (n=9) groups. Logistic regression was used in multivariate analysis for identifying predictors of expansion failure.The mean age of the patients was 29.6 years. The male to female ratio was 1:1.4. Expansion complication and failure rates were 53% (n=33) and 14.5% (n=9), respectively. The risk factors statistically correlated to expansion failure (p0.05) were age, expander size, PVR and implantation at lower limb. Expansion of lower limbs carried a risk of failure 43 times greater than other sites.We conclude that tissue expansion should be avoided in older patients and in lower limbs. The largest possible expander size and inflation at time of implantation should be used to lower the risk of expansion failure.

Neisseria gonorrhoeae infection is the second major cause of sexually transmitted diseases worldwide. Development of resistance to multiple classes of antimicrobials in N. gonorrhoeae has compromised treatment and disease control. Herein, we report the availability of the draft genome sequence of a multidrug-resistant N. gonorrhoeae isolate, TCDC-NG08107, which spread in groups of men who have sex with men (MSM) in Taiwan.

In this study, 80 Candida glabrata isolates from intensive care unit and human immunodeficiency virus (HIV)-infected patients were typed by multilocus sequence typing (MLST), pulsed-field gel electrophoresis (PFGE), and mating type class determination. Among the 25 patients with multiple isolates, 19 patients (76%) contained multiple isolates exhibiting identical or highly related PFGE and MLST genotypes, which may indicate the maintenance or microvariation of one C. glabrata strain in each patient. However, isolates from six patients (24%) displayed different sequence types, PFGE genotypes, or mating type classes, which may indicate colonization with more than one clone over time or strain replacement. High correlations among PFGE genotypes, sequence types, and mating types were found ( P < 0.01). MLST exhibited less discriminatory power than PFGE with BssHII. The genotypes, sequence types, and mating type classes were independent of anatomic sources, drug susceptibility, and HIV infection status.

This report describes the investigation of the genetic profiles of 53 Candida albicans isolates collected from 18 hospitals in Taiwan using three PFGE-based typing methods (PFGE karyotyping, and PFGE of SfiI and BssHII restriction fragments) and one repetitive-sequence-PCR (rep-PCR) method. All four methods were able to identify clonal related isolates from the same patients. PFGE-BssHII exhibited the highest discriminatory power by discriminating 40 genotypes, followed by PFGE-SfiI (35 genotypes) and then by rep-PCR (31 genotypes), while PFGE karyotyping exhibited the lowest discriminatory power (19 genotypes). High discriminatory power can also be achieved by combining typing methods with different typing mechanisms, such as rep-PCR and PFGE-based typing methods. The results also showed that the genotype of each isolate was patient-specific and not associated with the source of the isolation, geographic origin or antifungal resistance.

Invasive fungal infection has become a major cause of morbidity and mortality in immunocompromised patients. Rapid identification of pathogenic fungi to species level is critical for disease treatment. A real-time LightCycler assay aiming at rapid detection and species identification of pathogenic fungi from clinical isolates was developed. Template DNAs of different species were amplified and detected in real time by employing SYBR Green fluorescent dye. The target sequences for species-level detection were located between the 18S and 28S rDNA. Seven fungal species encountered frequently in the clinical setting, Candida albicans, Candida glabrata, Candida krusei, Candida parapsilosis, Candida tropicalis, Candida guilliermondii and Cryptococcus neoformans, could be discriminated by species-specific primers and confirmed by melting-curve analyses. The range of linearity was from 1 ng to 1 pg (microl(-1) water) and the sensitivity was 1 pg fungal DNA microl(-1). Identification by this real-time PCR method matched biochemical identification for all 58 clinical strains. Therefore, the method is simple, rapid and sensitive enough for detection and identification of several fungal species.

BackgroundMassive hemorrhages occur in 6%-10% of patients with advanced cancer. Acute carotid blowout syndrome is the most severe massive hemorrhagic complication in head and neck cancer patients.MethodsThis was a single institute, retrospective, case control study. A total of 45 patients were enrolled in this study. The predisposing factors, management, and prognosis of acute carotid blowout syndrome were evaluated.ResultsAmong the baseline characteristics, the site of the primary tumor (P = .003), origin of bleeding (P = .048), method of intervention (P = .005), and time to intervention (P = .006) were significantly different factors between survivor and nonsurvivor patients. After 24 hours of onset, a Glasgow Coma Scale score (P = .000), the use of inotropic agents (P = .007), and neutrophil-to-lymphocyte ratio (P = .019) were significantly predicting factors for outcome. Multivariate logistic regression analyses revealed bleeding from common carotid artery was an independent factor for long-term survival (odds ratio, 25.951; 95% confidence interval [CI], 1.373-490.441; P < .030). The median overall survival of survivors and nonsurvivors were 12.1 (range, 3.7-118.7; 95% CI, 4.33-54.87) and 11.9 (range, 0.7-53.5; 95% CI, 5.78-25.69) months, respectively (P = .092).ConclusionsEarly and aggressive intervention is important for the successful management of acute carotid blowout syndrome. The Glasgow Coma Scale score, the use of inotropic agents, and neutrophil-to-lymphocyte ratio 24 hours after the onset were predictive factors for patients' outcomes. Bleeding from common carotid artery is an independent prognostic factor in multivariate analysis. Long-term survival can be achieved after successful management.