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This prospective study assessed the effectiveness of screening older long-term care residents (LTCRs) for fracture risk and osteoporosis in Taiwan. Fracture risk screening was done using the Fracture Risk Assessment Tool (FRAX), and those with high or moderate risk were offered osteoporosis workup and treatment at the hospital. Among 785 LTCRs screened, 338 men (mean age 75.6) and 447 women (mean age 81.2) were included. Only 5.2% of women and no men were using anti-osteoporosis medication. Based on the Bone Health and Osteoporosis Foundation (BHOF) recommendations, 69.2% of men and 92.6% of women were classified as high fracture risk. In 110 participants willing to receive bone mineral density examination, osteoporosis was diagnosed in 86.2% of women and half of men. FRAX could effectively differentiate fracture risk in 648 LTCRs who completed 2-year follow-ups; no fracture occurred in the low-risk group. The study emphasizes the importance of fracture risk screening to enhance osteoporosis diagnosis and treatment among LTCRs. [ABSTRACT FROM AUTHOR]

Ritonavir-boosted tipranavir (TPV/r) and darunavir (DRV/r) have been approved in patients with virological resistance to multiple protease inhibitors (PIs). Whether the HIV-1 from these patients with virological failure to first-generation PIs remains susceptible to TPV/r or DRV/r is questionable. The susceptibilities of HIV-1 isolates to second-generation PIs in patients who experienced virological failure in three time periods were analysed: 9-2006 to 4-2007 (period 1), 5-2007 to 12-2007 (period 2) and 1-2008 to 8-2008 (period 3). A total of 53 subjects were enrolled, and 51 subject isolates (96.2%) were resistant to ≤1 PIs. The mutation scores for TPV and DRy, and the percentage of isolates with resistance to TPV or DRy, increased significantly from period 1 to period 3. Our data revealed a significant increase in the levels of genotypic resistance to TPV and DRV over the past two years in patients with virological failure to first-generation Pls. [ABSTRACT FROM AUTHOR]

In regions that are hyperendemic for chronic hepatitis B virus (HBV) infection, prevalence of and risk factors associated with isolated anti-hepatitis B core antibody (anti-HBc) in HIV-positive patients are less well described. HIV-positive patients who were tested for hepatitis B surface antigen (HBsAg), anti-hepatitis B surface antibody (anti-HBs) and anti-HBc at designated hospitals for HIV care in Taiwan were included for analysis. HBV DNA was detected by real-time polymerase chain reaction in patients with and without isolated anti-HBc. Of 2351 HIV-positive patients, 450 (19.1%) were HBsAg positive, 411 (17.5%) were anti-HBc positive alone and 963 (41.0%) for both anti-HBs and anti-HBc. Compared with patients who were positive for both anti-HBs and anti-HBc, patients with isolated anti-HBc were older, less likely to have anti-hepatitis C virus antibody (anti-HCV), had lower CD4 lymphocyte counts and higher plasma HIV RNA loads. Older age (adjusted odds ratio, 1.029; 95% confidence interval, 1.015–1.043) and CD4 <100 cells/μL (adjusted odds ratio, 1.524; 95% confidence interval, 1.025–2.265) were independently associated with isolated anti-HBc by logistic regression, while presence of anti-HCV and injecting drug use were not. HBV DNA was detectable in 8.3% of 277 patients with isolated anti-HBc and 14.3% of 56 patients with both anti-HBs and anti-HBc ( P = 0.160). In a country hyperendemic for HBV infection, HIV-positive patients at older age and with CD4 <100 cells/μL were more likely to have isolated anti-HBc, suggesting that compromised immunity plays a role in the presence of this marker. [ABSTRACT FROM AUTHOR]

Objectives Recent studies suggest that patients with HIV infection are at increased risk for incident diabetes mellitus (DM). We investigated the incidence and risk factors of DM among HIV-infected patients receiving combination antiretroviral therapy (CART) in Taiwan. Methods Incident cases of DM were identified among HIV-infected patients at the National Taiwan University Hospital between 1993 and 2006. A retrospective case–control study was conducted after matching cases with controls for sex, age at HIV diagnosis, year of HIV diagnosis, mode of HIV transmission and baseline CD4 lymphocyte count. A multivariate analysis was performed to identify risk factors for incident DM among HIV-infected patients. Results In 824 HIV-infected patients eligible for analysis, 50 cases of incident DM were diagnosed, resulting in an incidence of 13.1 cases per 1000 person-years of follow-up. In total, 100 matched controls were identified. Risk factors for incident DM were a family history of DM [odds ratio (OR) 2.656; 95% confidence interval (CI) 1.209–5.834], exposure to zidovudine (OR 3.168; 95% CI 1.159–8.661) and current use of protease inhibitors (OR 2.528; 95% CI 1.186–5.389). Conclusions Incident DM was associated with a family history of DM, exposure to zidovudine and current use of protease inhibitors in HIV-infected patients receiving CART in Taiwan. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to analyse the trends of mortality and causes of death among HIV-infected patients in Taiwan from 1984 to 2005. Methods Registered data and death certificates for HIV-infected patients from Taiwan Centers for Disease Control were reviewed. Mortality rate and causes of deaths were compared among patients whose HIV diagnosis was made in three different study periods: before the introduction of highly active antiretroviral therapy (HAART) (pre-HAART: from 1 January 1984 to 31 March 1997), in the early HAART period (from 1 April 1997 to 31 December 2001), and in the late HAART period (from 1 January 2002 to 31 December 2005). A subgroup of 1161 HIV-infected patients (11.4%) followed at a university hospital were analysed to investigate the trends of and risk factors for mortality. Results For 10 162 HIV-infected patients with a mean follow-up of 1.97 years, the mortality rate of HIV-infected patients declined from 10.2 deaths per 100 person-years (PY) in the pre-HAART period to 6.5 deaths and 3.7 deaths per 100 PY in the early and late HAART periods, respectively ( P<0.0001). For the 1161 patients followed at a university hospital (66.8% with CD4 count <200 cells/μL), HAART reduced mortality by 89% in multivariate analysis, and the adjusted hazard ratio for death was 0.28 (95% confidence interval 0.24, 0.33) in patients enrolled in the late HAART period compared with those in the pre-HAART period. Seventy-six per cent of the deaths in the pre-HAART period were attributable to AIDS-defining conditions, compared with 36% in the late HAART period ( P<0.0001). The leading causes of non-AIDS-related deaths were sepsis (14.7%) and accidental death (8.3%), both of which increased significantly throughout the three study periods. Compared with patients acquiring HIV infection through sexual contact, injecting drug users were more likely to die from non-AIDS-related causes. Conclusions The mortality of HIV-infected patients declined significantly after the introduction of HAART in Taiwan. In the HAART era, AIDS-related deaths decreased significantly while deaths from non-AIDS-related conditions increased. [ABSTRACT FROM AUTHOR]

To ascertain whether hepatitis C (HCV) co-infection affects the progression of HIV infection, we initiated an eight-year prospective observational study at a university hospital in Taiwan where seroprevalences of HCV antibody and HIV antibody were low. Fifty-three (12.0%) consecutive non-haemophiliac HIV1-infected patients with HCV co-infection and 387 (88.0%) patients without HCV and hepatitis B co-infection were enrolled between June 1994 and June 2002 and observed until December 2002. Outcomes evaluated included the risk for acute hepatitis, hepatic decompensation, HIV disease progression and mortality, and changes of CD4+ count and plasma viral load (PVL) after initiation of highly active antiretroviral therapy (HAART) at the end of the study. The baseline CD4+ count, PVL and proportion of patients with AIDS-defining opportunistic illnesses (OI) at study entry were similar between patients with HCV co-infection and those without co-infection, but HCV-co-infected patients were older (39 versus 35 years, P = 0.01) and had a higher proportion of intravenous drug use (17.0% versus 0.8%, P < 0.001). After a total observation duration of 1137 patient-years (PY) (median, 791 days; range, 3–3053 days), the incidence of acute hepatitis in HCV-co-infected patients was 13.89 per 100 PY (95% confidence interval [CI], 13.31–14.49) and that in patients without co-infection was 6.39 per 100 PY (95% CI, 6.24–6.55 per 100 PY), with an adjusted odds ratio (OR) of 2.769 (95% CI, 1.652–4.640). At the end of the study, CD4+ count increased by 137 × 106 and 157 × 106/L in patients with and without HCV co-infection, respectively, (P = 0.47). The proportions of achieving undetectable PVL (<400 copies/mL) after HAART was similar (76.7% versus 74.9%, P = 0.79). The adjusted OR for development of new AIDS-defining OI was 1.826 (95% CI, 0.738–4.522) in HCV-co-infected patients as compared with HCV- uninfected patients. The adjusted hazards ratio for death of HCV-co-infected patients when compared with those without co-infection was 0.781 (95% CI, 0.426–1.432). Our findings suggested that HCV co-infection was associated with a significantly higher risk for acute hepatitis in HIV-infected patients receiving antiretroviral therapy, but it had no adverse impact on virological, immunological and clinical responses to HAART and survival when compared with patients without HCV and HBV co-infection. [ABSTRACT FROM AUTHOR]

Lactic acidosis (LA), a rare but life-threatening adverse effect associated with antiretroviral therapy, has been reported with an increasing frequency since the mid1990s. From June 1994 to June 2002, a total of six patients, four males and two females with a median age of 43 years (range, 30 to 74 years), had been diagnosed with LA. The estimated incidence of LA was 5.1 per 1000 patient-years (PYs) on highly active antiretroviral therapy (HAART) (95% confidence interval [95% CI], 4.5-5.5 per 1000 PYs) and 4.4 per 1000 PY on nucleoside analogues (NAs) (95% CI, 3.9-4.7 per 1000 PYs). Their median body mass index at diagnosis of LA was 17.6 kg/m2 (range 16.3 to 22.6 kg/m2). The median CD4+ lymphocyte count at the initial diagnosis of HIV infection and at the onset of LA was 38 cells/µL (range, 4 to 103 cells/µL) and 108 cells/µL (range, 79 to 224 cells/µL), respectively. The most common symptoms were nausea, vomiting, and dyspnoea. All of the patients had findings suggestive of NA-related mitochondrial toxicity, such as myositis, pancreatitis, fatty hepatitis, peripheral neuropathy or lipodystrophy. The prescribed NA related to LA were stavudine in six patients, lamivudine, five, and didanosine, one. Despite treatment, all patients died of persistent circulatory collapse following LA. The median duration from diagnosis to death was eight days (range, 4-17 days). Our report highlights that clinicians caring for patients with AIDS should be alerted to the potentially fatal LA associated with antiretroviral therapy when patients present with low body mass index, lipodystrophy, unexplained abdominal symptoms, dyspnoea, or elevated aminotransferases. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate internal medicine residents' HIV-related knowledge and their attitudes towards caring for HIV-infected patients, and determine the extent to which these variables influence their care-providing intention. A cross-sectional survey was conducted in 56 internal medicine residents at a university hospital in Taiwan. Results showed residents' lack of sufficient knowledge was reflected by their inaccurate assessment of HIV-associated risk and their tendency to overuse protective gear in unnecessary situations. In general, residents expressed slightly positive attitudes with a neutral intention to care for HIV-infected patients. Knowledge and attitudes were significantly correlated with intention. The use of stepwise regression analysis revealed attitudes accounted for 59% of the variance in intention. Future efforts should focus on designing, implementing, and evaluating educational programmes that address residents' needs to ensure a solid HIV-related knowledge base, support their positive attitudes, address their ambivalent feelings toward providing HIV care, and enhance their intention to care for HIV-infected patients. [ABSTRACT FROM AUTHOR]

Aims This study aimed to assess the prevalence of amoebiasis among patrons visiting gay saunas in Taiwan. Methods A cross-sectional survey was conducted using questionnaire interview and indirect hemagglutination assays and specific Entamoeba histolytica antigen assays of blood and rectal swab specimens, respectively, among patrons visiting 10 gay saunas between September 2006 and December 2006. Results During the three-month study period, 208 blood and 120 rectal swab specimens were tested for E. histolytica infection. Amoebiasis was detected among 3.8% and 3.3% of the patrons by serologies and antigen assays, respectively. During the latest sexual encounter, more than 70% of the patrons had oral-anogenital sex, and only 20% used condoms during oral-anogenital contact. Conclusion Our findings suggest that there is a potential risk of E. histolytica transmission among the patrons visiting gay saunas who do not practise safe sex consistently in Taiwan. [ABSTRACT FROM AUTHOR]

Resistance mutations A2058G and A2059G, within the 23S rRNA gene of Treponema pallidum, have been reported to cause treatment failures in patients receiving azithromycin for syphilis. Genotyping of T. pallidum strains sequentially isolated from patients with recurrent syphilis is rarely performed. From September 2009 to August 2013, we collected 658 clinical specimens from 375 patients who presented with syphilis for genotyping to examine the number of 60-bp repeats in the acidic repeat protein ( arp) gene, T. pallidum repeat ( tpr) polymorphism, and tp0548 gene, and to detect A2058G and A2059G point mutations by restriction fragment length polymorphism. Treponemal DNA was identified in 45.2% ( n = 298) of the specimens that were collected from 216 (57.6%) patients; 268 (40.7%) specimens tested positive for the 23S rRNA gene, and were examined for macrolide resistance. Two isolates (0.7%) harboured the A2058G mutation, and no A2059G mutation was identified. A total of 14 strains of T. pallidum were identified, with 14f/f (57.5%) and 14b/c (10.0%) being the two predominant strains. Forty patients who presented with recurrent episodes of syphilis had T. pallidum DNA identified from the initial and subsequent episodes, with five cases showing strain discrepancies. One patient had two strains identified from different clinical specimens collected in the same episode. Our findings show that 14f/f is the most common T. pallidum strain in Taiwan, where the prevalence of T. pallidum strains that show A2058G or A2059G mutation remains low. Different genotypes of T. pallidum can be identified in patients with recurrent episodes of syphilis. [ABSTRACT FROM AUTHOR]

Background: Data are limited regarding the effectiveness and safety of generic velpatasvir plus sofosbuvir (VEL/SOF) for hepatitis C virus (HCV) in patients with or without human immunodeficiency virus (HIV) coinfection., Aim: To evaluate the effectiveness and safety of generic VEL/SOF-based therapy for HCV infection in patients with or without HIV coinfection in Taiwan., Methods: Sixty-nine HIV/HCV-coinfected and 159 HCV-monoinfected patients receiving 12 weeks of generic VEL/SOF with or without ribavirin (RBV) for HCV were prospectively enrolled. The anti-viral responses and the adverse events (AEs) were compared between the two groups. The characteristics potentially related to sustained virological response 12 weeks off therapy (SVR 12 ) were analysed., Results: The SVR 12 was achieved in 67 HIV/HCV-coinfected patients (97.1%; 95% CI: 90.0%-99.2%) and in 156 HCV-monoinfected patients (98.1%; 95% CI: 94.6%-99.4%) receiving VEL/SOF-based therapy, respectively. The SVR 12 rates were comparable between HIV/HCV-coinfected and HCV-monoinfected patients, regardless of pre-specified baseline characteristics. One hundred twenty-two (53.5%) and seven (3.1%) patients had baseline resistance-associated substitutions (RASs) in HCV NS5A and NS5B regions, but the SVR 12 rates were not affected by the presence or absence of RASs. One (1.4%) and five (3.1%) patients in the HIV/HCV-coinfected and HCV-monoinfected groups had serious AEs. No patient died or discontinued treatment due to AEs. The eGFR remained stable throughout the course of treatment in HIV/HCV-coinfected patients receiving anti-retroviral therapy containing tenofovir disoproxil fumarate (TDF)., Conclusions: Generic VEL/SOF-based therapy is well-tolerated and provides comparably high SVR 12 rates for HCV infection in patients with and without HIV coinfection., (© 2018 John Wiley & Sons Ltd.)

Mycobacterial bone marrow (BM) infection is the most common diagnosis established by BM examinations for fever of unknown origin. In this study, clinical features and outcomes of patients who fulfilled the criteria for BM infection due to Mycobacterium tuberculosis (MTB) and non-tuberculous mycobacteria (NTM) at a medical centre in Taiwan from 2001 to 2009 were investigated. The BM histopathological findings were also analysed. A total of 24 patients (16 men, eight women) with mycobacterial BM infections were found. Of these, nine (38%) were positive for human immunodeficiency virus (HIV) and six (25%) had no pre-existing immunocompromised conditions. MTB isolates were obtained from 11 (46%) patients and NTM species were isolated from 10 (42%) patients, including M. avium complex (MAC, n = 7) and M. kansasii (n = 3). Patients with MTB infections were significantly older than those with NTM infections (60·5 vs. 47·7 years, P = 0·043) and were less likely to have a positive BM culture (45% vs. 100%, P = 0·012). The 90-day survival rates for MTB and NTM BM infections were 68% and 60%, respectively (P = 0·61). In addition, the presence of BM granulomas was significantly more common in patients with MTB BM infections than in those with NTM infections (82% vs. 30%, P = 0·030). In Taiwan, the importance of NTM was not inferior to MTB and besides MAC, M. kansasii might be an important pathogen in non-HIV-infected patients. The presence of BM granulomas and caseation provides valuable information regarding early treatment pending culture results.

A single strain of Mycobacterium massiliense (BRA 100), a subspecies of the Mycobacterium abscessus complex, has been responsible for an epidemic of post-surgical infections in Brazil. Outside Brazil, this is the first report to describe a single emerging strain of M. massiliense (TPE 101) associated with extrapulmonary infections. This phenomenon may be underestimated because sophisticated molecular typing of M. abscessus is not routinely performed. Our molecular epidemiology study was triggered by an outbreak investigation. Nine case isolates were grown from the surgical sites of nine mostly paediatric patients receiving operations from 2010 to 2011. All available non-duplicated isolates of M. abscessus during this period were obtained for comparison. Mycobacteria were characterized by multilocus sequence analysis (MLSA), repetitive sequence PCR (rep-PCR) and pulsed-field gel electrophoresis (PFGE). Of 58 isolates of M. abscessus overall, 56 were clinical isolates. MLSA identified 36 of the isolates as M. massiliense. All case isolates were indistinguishable by PFGE and named the TPE 101 pulsotype. Of the stored strains of M. abscessus, TPE 101 strains were over-represented among the control surgical wound (7/7, 100%) and subcutaneous tissue isolates (4/5, 80%) but rare among the respiratory isolates (1/16, 6%) and absent from external skin, ocular and environmental samples. In conclusion, a unique strain of M. massiliense has emerged as a distinctive pathogen causing soft tissue infections in Taiwan. Further study to identify whether this is due to an occult common source or to specific virulence factors dictating tissue tropism is warranted., (© 2013 The Authors Clinical Microbiology and Infection © 2013 European Society of Clinical Microbiology and Infectious Diseases.)

The population of elderly patients entering chronic dialysis programmes is increasing. Elderly patients are susceptible to malnutrition and have multiple complicating disorders in addition to uraemia. Selecting appropriate dialysis modality is particularly critical in elderly patients. Continuous ambulatory peritoneal dialysis (CAPD) has many advantages to elderly patients; however, the clinical outcome varies for elderly CAPD patients. In comparison with Westerners, Southeast Asians have a small body mass index and may be more suited to CAPD therapy. To identify the prognostic predictors in elderly Southeast Asian patients, this historical cohort study analysed 144 patients aged > or = 65 years at initiation of CAPD. A group of haemodialysis (HD) patients aged > or = 65 years was utilised as the control group. Survival curves for patient and technique were derived from Kaplan-Meier analysis and were further analysed by Cox-Mantel log-rank test. To elucidate the impact of individual factors on patient survival, various significant univariables were further subjected to multivariate analysis. No significant increase existed for relative risk of technique failure in elderly patients compared with younger patients. This analytical data indicates that CAPD was as good as HD for elderly uraemic patients regarding to the patient survival. Diabetes, dependent patients, low albumin levels and previous HD history were significant poor prognostic factors for survival of elderly CAPD patients. In conclusion, CAPD is an effective modality of renal replacement therapy for Southeast Asian elderly patients. The technique survival was not affected by patient age.

Because of the rapid industrial and economic growth, Taiwan and other developing countries have faced an enormous increase in the number of motorcycles, which has subsequently caused a rapid increase of the motorcycle-related traumatic brain injuries (TBI). In order to tackle this serious problem, stepwise approaches for TBI were implemented in Taiwan from 1991 to 2007. Step 1 was to do a nationwide TBI registry in order to identify the risk factors and determinants. We found that the major cause of TBI in Taiwan was motorcycle-related injury, and very few motorcyclists wore a helmet. Step 2 was to launch the implementation of the helmet use law on June 1, 1997. A rapid decline of TBI hospitalizations and deaths was demonstrated soon thereafter. Step 3 was to enroll into international collaborations with the Global Spine and Head Injury Prevention Project (Global SHIP Project) groups for TBI. The comparative results thus obtained could be used to develop prevention strategies for developing countries. Step 4 was to implement clinical researches for TBI, which included a Propofol study, hyperbaric oxygen therapy (HBOT), brain parenchymal oxygen (PbtO2) monitoring, etc. Step 5 was to develop guidelines for the management of severe TBI in Taiwan. Through a 2-year period of review, discussion, and integration, a 9-chapter guideline was published in June 2007. In summary, our experience and process for management of TBI in Taiwan can be used as a reference for other developing countries.

The planes which serve as references for cranium and face in dental clinical application included the occlusal plane, Frankfort plane, Camper's plane and hamular-incisive-papilla (HIP) plane. The HIP occlusal plane is a horizontal plane passing through the bilateral hamular notches and the incisive papilla (Dent Surv. 1975;51:60). The aim of this study was to estimate the relationship between the various occlusal planes and the HIP plane in Taiwanese young adults with approximately optimal occlusion. Study casts of 100 young adults (50 men and 50 women) were selected in this study. All market points on the maxillary casts were measured by a three-dimensional precise measuring device. The angular relationship between the four various occlusal planes and the HIP plane were investigated. The vertical distances between the cusp tips and incisal edges of maxillary teeth to the HIP plane were measured. Data were performed by the Statistic analysis software programme (JMP 4.02). The Student's t-test and Pearson's correlation test were used to test the statistical significance (P < 0.05). The results showed that the occlusal plane defined as the incisal edge of maxillary central incisor to mesiobuccal cusp tips of maxillary second molars had the smallest included angle with the HIP plane (2.61 +/- 0.81 degrees). The incisal edge of maxillary right central incisal to mesiopalatal cusp tips of maxillary first molars had the largest included angle with the HIP plane (7.72 +/- 1.60 degrees). The curve is drawn through the buccal cusp tips of maxillary teeth had better parallelism with the HIP plane.

Having contact and interacting with HIV/AIDS patients has long been recognized as a means for improving AIDS-related knowledge and attitudes among physicians and hence for increasing their intention to provide AIDS care. To investigate the impact of one-month residency training in an AIDS inpatient unit on internal medicine residents, this quasi-experimental, pre-post, two-group study, conducted from April 2000 to April 2001, used questionnaires. At follow-up, residents who received training in the AIDS unit (experimental group) were significantly more knowledgeable about HIV/AIDS, had more positive attitudes and greater intention to care for HIV-infected patients than residents who did not receive this training (control group). Results suggest that a one-month AIDS residency training intervention can effectively enhance residents' HIV-related knowledge, attitudes and intention to care for patients infected with HIV.

We assessed the seroprevalence of Toxoplasma gondii infection and incidence of toxoplasma encephalitis (TE) in 844 non-haemophiliac HIV-infected patients in Taiwan between June 1994 and April 2003. Approximately 70% (69.3%) of them had a baseline CD4+ lymphocyte count of 200 x 10(6)/L or less, and more than 70% (73.9%) having initiated highly active antiretroviral therapy. The seroprevalence of T. gondii infection was 10.2%, which did not differ with sex,age,route of transmission, birth inside or outside of Taiwan, or CD4+ lymphocyte stratifications. After a median observation duration of 603 days (range, 1-3264 days), 10 (1.2%) patients developed 11 episodes of TE after a median interval of 30 days (range, 1-941 days) between enrolment and diagnosis of TE, with an incidence of 0.59 per 100 person-years (PY) (95% confidence interval, 0.56-0.63 per 100 PY). We concluded that the incidence of TE of HIV-infected patients in Taiwan was lower than that reported in western countries because of a lower seroprevalence of T. gondii infection and use of antimicrobial prophylaxis and antiretroviral therapy, although most of the patients were at the late stage of HIV infection.

Background: Limited data are available on the clinical significance of cryptococcaemia, which occurs in 10-30% of patients with cryptococcal diseases., Aim: To describe the clinical features of cryptococcaemia and identify its prognostic factors., Study Design: Retrospective cohort study., Methods: All adult patients with Cryptococcus neoformans isolated from blood culture at the National Taiwan University Hospital, Taipei, 1981-2001, were included. Demographic and clinical information was obtained from medical records., Results: Fifty-two patients were diagnosed and treated for cryptococcaemia. Acquired immunodeficiency syndrome (24/52, 46%), immunosuppressive therapy (12/52, 23%) and decompensated liver cirrhosis (11/52, 21%) were the three major predisposing conditions. Forty-two patients (81%, n=52) had sepsis, including four patients with septic shock, when blood cultures were obtained. Of the 38 patients in whom lumbar puncture was done, cerebrospinal fluid culture showed meningeal involvement in 32 (84%). The 30-day fatality rate was 37%. Liver cirrhosis, septic shock at presentation, an initial APACHE II score >/=20, age >/=60 years and female gender were associated with mortality under univariate analysis. Starting antifungal therapy within 48 h after blood culture was associated with improved survival. Under multivariate analysis, liver cirrhosis remained a strong independent predictor of mortality at 30 days after blood culture (HR 16.3, 95%CI 2.6-101.7, p=0.003)., Discussion: Patients with cryptococcaemia have a high risk of mortality within 30 days. Sepsis and meningeal involvement are common. Those with liver cirrhosis have a particularly poor prognosis.

Setting: National Taiwan University Hospital, Taipei, Taiwan., Objective: To study the variations in the NRAMP1 gene using five genotypes (274C/T, 577-18G/A, A318V, D543N and 3' untranslated region [UTR]), and the susceptibility of tuberculosis and HIV infection in Taiwanese., Design: The study sample included 49 patients with tuberculosis, 48 healthy control subjects and 60 HIV-infected patients. The polymerase chain reaction (PCR) products amplified from their genomic DNA were subjected to restriction enzyme digestion and were analysed using agarose gel electrophoresis., Results: A318V was not polymorphic in the studied population. Only D543N and 3'UTR were more heterozygous. In 274 C/T and 577-18G/A, the allele frequencies showed the predominant type to be the homozygous patterns C/C (94%) and G/G (94%), respectively. There were no statistically significant differences between the tuberculosis patients and the healthy control subjects. Despite the high susceptibility to Mycobacterium tuberculosis in HIV-infected patients, genotypic frequencies in the HIV-positive patients were not significantly different between tuberculous (n = 29) and non-tuberculous patients (n = 31). In comparison with previous studies, there were significant differences between different ethnic groups in allele frequencies for 274C/T, D543N and 3'UTR., Conclusion: The allele and genotype of NRAMPI polymorphism among Taiwanese differed from those of Caucasians, Africans and Hispanics. No allelic associations were identified between the NRAMP1 alleles and tuberculosis susceptibility.

Objective: To determine factors that correlate with increased antibiotic use among adult inpatients in Taiwan., Design: Retrospective survey of medical records., Setting: 14 acute-care hospitals (8 regional hospitals, 6 medical centers) in Taiwan., Participants: A systematic probability sample from each hospital, totaling 663 adult inpatients who were discharged or had died in early 1999., Measurements: Infectious disease physicians at the 14 hospitals collected data from medical records regarding patient demographics, hospitalization, discharge diagnosis, and antibiotics received., Results: A total of 447 (67%) patients received antibiotics for an overall rate of 813 antibiotic-days (number of days patients received each antibiotic)/1,000 patient-days. Both the proportion of beds in intensive care units ([ICUs] Pearson correlation coefficient [r], 0.67; 95% confidence interval [CI 95], 0.36-0.89; P<.01) and the proportion of patients admitted to surgical services (r, 0.66; CI 95, 0.20-0.88; P=.01) correlated with the mean patient rate of antibiotic-days/hospital-day (MPAUD). In contrast, we found no correlation between the proportion of patients who received antibiotics and the MPAUD. Using multiple linear regression, medical center status was the only independent predictor for increased MPAUD (regression coefficient [b], 0.15; CI 95, 0.05-0.24; P<.01). There was no correlation between pooled rates of antibiotic-days/hospital-day and any hospital demographic factors. First-generation cephalosporin (39%) and aminoglycoside (24%) use accounted for the majority of antibiotic-days., Conclusions: Antibiotic use is greater in medical centers than in regional hospitals and appears to be independent of surgical case mix or the proportion of ICU beds. Determination of multiple, independent measures of antibiotic use may be necessary to understand the relation between antibiotic use and resistance in hospital.

Debrisoquine 4-hydroxylase (CYP2D6) is one of the cytochrome P450 enzyme families that metabolize many compounds. Polymorphic activities of debrisoquine 4-hydroxylase were suggested to be associated with some complex diseases, such as cancer and Parkinson's disease. Schizophrenia is also a complex disorder, and hence we are interested in understanding if the CYP2D6 gene is a susceptibility gene for schizophrenia in Chinese. We determined the genotype and allele frequencies of four molecular variants of CYP2D6 gene (i.e. 188C/T, 1934G/A, 2938C/T and 4268C/G) in 162 Chinese schizophrenic patients and 94 non-psychotic control subjects from Taiwan. No significant differences of allele or genotype frequencies of three polymorphisms (i.e. 188T/C, 2938C/T and 4268C/G) were detected between patients and control subjects. The 1934A allele, which accounts for the majority of poor metabolizers in Caucasians, was not detected in either patients or control subjects, indicating that the 1934A allele is very rare in Chinese. Our data suggest that the CYP2D6 gene may not be a susceptibility gene for schizophrenia in Chinese schizophrenic patients.

Several linkage studies have suggested that chromosome 22q12-q13 is a putative region for schizophrenic genes. In this study, the human tissue inhibitor of metalloproteinase-3 (TIMP-3) gene was investigated as positional candidate gene for schizophrenia because of its regulatory function on extracellular matrix proteins, cell adhesion molecules, and neural cell adhesion molecules in the brain. We systematically searched for the nucleotide variants by sequencing all the exons and their flanking intronic sequences in a sample of Chinese schizophrenic patients from Taiwan. Two silent mutations in the exon 3 were identified: c.249T-->C at codon 83 (His) and c.261C-->T at codon 87 (Ser). However, no mutations causing amino acid alteration or aberrant splicing of transcripts were observed. Hence, it is unlikely that the TIMP-3 gene itself may play an important role in the genetic susceptibility to schizophrenia. Further case control association study revealed a significant difference of genotype distribution of the c.249T-->C between schizophrenic patients and control. This finding supports that 22q12 is a schizophrenia susceptible region, and it is likely that there might be other genetic mutations in the neighborhood of the TIMP-3 gene locus that may contribute to the susceptibility of schizophrenia., (Copyright 2001 Wiley-Liss, Inc.)

The clinical spectrum of AIDS and changes of morbidity and mortality associated with HIV infection following initiation of highly active antiretroviral therapy (HAART) are rarely described in the less developed countries in the Asia-Pacific region. We prospectively observed on a follow-up basis 309 HIV-infected patients (82.8% with AIDS) at National Taiwan University Hospital in Taiwan, where highly active antiretroviral therapy (HAART) has been provided to all patients at no charge at any stage of HIV infection since April 1, 1997, to describe the spectrum of HIV-associated opportunistic diseases and evaluate changes of morbidity and mortality from June 24, 1994 through June 23, 1999. Of the patients, 59.3% at study entry had a CD4+ lymphocyte count of <50 cells/microliter. The five leading HIV-associated opportunistic infections included oroesophageal candidiasis (195 patients), Pneumocystis carinii pneumonia (93), tuberculosis (77), mucocutaneous herpes simplex infection (74), and cytomegalovirus diseases (73). The incidence rates of seven major AIDS-defining opportunistic diseases were declining though the changes of the relative proportions varied. The median duration of hospitalization decreased from 36 days in 1995 to 12 days in 1999 (p =.0001). Overestimated mortality rate declined from 148.4 per 100 patient-years in 1995 to 7.4 per 100 patient-years in 1999 (p =.0001) whereas the underestimated mortality rate declined from 110.5 to 5.39 per 100 patient-years (p =.0001). Risk ratio (RR) for mortality in patients who received HAART compared with those who did not was 0.410 (95% confidence interval [CI], 0.249-0.674; p =.0004) and the RR was 0.250 (95% CI, 0.127-0.492; p =.0001) when the analysis was limited to patients with an initial CD4+ lymphocyte count <100 cells/microliter and follow-up duration >30 days after adjusting for their age, gender, type of risk behavior, and CD4+ lymphocyte count. Morbidity and mortality were declining with each study year even in a population consisting mainly of patients at the advanced stage of HIV infection in Taiwan. Earlier diagnosis, accumulation of clinical experience, and use of HAART were associated with lower mortality rates.

From January 1987 through December 1998, Penicillium marneffei infection (23 patients) or colonization (1 patient) was diagnosed in a total of 24 patients in Taiwan. Of these 24 patients, 16 (67%) had AIDS and 20 (83%) had disseminated P. marneffei infection. The majority (63%) of the infections were considered indigenous. The number of cases has increased markedly in recent years, with 17 of the 24 cases diagnosed from 1996 through 1998. Twenty preserved isolates of P. marneffei, recovered from 11 patients treated at National Taiwan University Hospital during the period of January 1996 through December 1998, were studied to determine the epidemiology of P. marneffei infections. Among the 20 isolates, a total of 8 strains (highly related isolates) were identified on the basis of tests for susceptibility to 5 antifungal agents, for chromosomal DNA restriction fragment-length polymorphism types, and for randomly amplified polymorphic DNA patterns. One of the strains (6 isolates) was isolated from 4 patients treated in 1997 and 1998. Strain spreading of P. marneffei may partially contribute to the increased number of infections caused by this organism in immunosuppressed patients in Taiwan.

We describe a 66-year-old woman with infective endocarditis due to Cardiobacterium hominis whose condition, complicated by severe aortic regurgitation and congestive heart failure, necessitated aortic valve replacement despite treatment with ceftriaxone followed by ciprofloxacin. The blood isolate of C. hominis produced beta-lactamase and exhibited high-level resistance to penicillin (MIC, >==256 microgram/ml) and reduced susceptibility to vancomycin (MIC, 8 microgram/ml).

Background: Diarrhea is a frequent gastrointestinal symptom in patients with acquired immuno-deficiency syndrome (AIDS) and is a major source of morbidity and mortality. A stepwise diagnostic approach is often recommended to search for treatable causes. However, whether the stepwise diagnostic approach is adequate for planning treatment and whether specific treatment for infectious etiologies will affect the survival of patients with AIDS remain unknown., Methods: From March 1996 to September 1997, endoscopy was performed in AIDS patients with diarrhea, the etiology of which was not identified by noninvasive methods. Specific treatment was given according to the identified etiologies and symptomatic treatment was given for those without definite diagnosis. The clinical symptoms, signs, and duration of follow-up were recorded and survival patterns were analyzed., Results: Etiologic diagnoses were made in 26 of 40 patients (65%) who underwent endoscopic studies. Amebic colitis and cytomegalovirus colitis were the 2 leading causes of prolonged diarrhea in patients with AIDS. Thirty-five patients (87.5%) recovered after treatment. The difference in survival time after diarrhea between patients whose symptoms resolved after treatment and those who continued to have diarrhea was statistically significant (p < 0.001)., Conclusions: Endoscopic studies were helpful for the diagnosis of prolonged diarrhea in AIDS patients who had negative stool studies and did not respond to 2 weeks of empiric treatment. Specific treatment according to the results of endoscopy may improve survival in these patients.

One hundred years after introduction of the Eucalyptus tree to Taiwan, a predominantly subtropical island, we analyzed clinical and microbiological data of 59 patients with Cryptococcus neoformans infection hospitalized at National Taiwan University Hospital during 1982 to 1997. There were 38 (64.4%) cases of cryptococcosis caused by the var. neoformans and 21 (35.6%) caused by the var. gattii. Thirty-three patients (55.9%) had impaired T cell function, which included 12 patients with acquired immunodeficiency syndrome (AIDS). Eleven of the 12 patients with AIDS were diagnosed after 1995, and 11 cases were caused by var. neoformans. Minimum inhibitory concentrations (MICs) determined by the NCCLS broth microdilution method using antibiotic medium 3 improved the discrimination of in vitro susceptibility against amphotericin B and demonstrated that var. gattii isolates were less susceptible (geometric means 0.25 microg/ml versus 0.64 microg/ml, P < 0.001). In addition, a higher proportion of var. gattii were less susceptible to flucytosine as compared with var. neoformans (35.0% versus 64.9%, P = 0.030). There was no seasonal clustering for isolation of var. neoformans, though infections caused by var. gattii peaked in July and August. Compared with the first study of cryptococcosis (1957-1972) at NTUH, this study demonstrated the increase in immunocompromised and elderly patients, as well as a higher proportion of Cryptococcus isolated from blood or bone marrow. Facing the increasing adaptive plantation of Eucalyptus in Taiwan, the importance of field study regarding the role of Eucalyptus plantations in Taiwan and occurrence of cryptococcosis in human beings cannot be over-emphasized.

Objectives: To describe the incidence and presentations of invasive amoebiasis (IA) in patients with HIV infection in an area endemic for amoebic infection and to assess the role of the indirect haemagglutination (IHA) assay in the diagnosis of IA in HIV-infected patients., Design: Retrospective study of 18 cases of IA and HIV infection., Setting: A university hospital, the largest centre for management of HIV-associated complications in Taiwan., Methods: Medical, microbiological and histopathological records of 296 HIV-infected patients and serological data of IHA assay of 126 HIV-infected patients were reviewed to identify cases of IA from 23 June 1994 to 31 March 1999. An IHA titre > or = 1 : 128 was considered positive. Clinical characteristics of HIV-infected patients with IA and without IA were compared., Results: Eighteen of the 296 patients (6.1%) with HIV infection were diagnosed with IA: 12 patients were diagnosed with definite IA and six with probable IA. The clinical manifestations included amoebic colitis (13 patients), amoebic liver abscess (nine), both colitis and abscess (four), and pleural effusion (two). IA was the initial presentation of HIV infection in nine patients. Co-infection with other enteric pathogens was diagnosed in six patients with IA. Compared with the 161 patients without IA who were newly diagnosed with HIV infection, the nine patients with IA had a higher median CD4+ lymphocyte count (202 x 10(6)/l versus 33 x 10(6)/l; P = 0.0017), were less likely to be diagnosed with AIDS (55.6% versus 85.4%; P = 0.039), and had fewer concurrent AIDS-defining illnesses (median number 0 versus 2; P = 0.003). Estimated mean survival duration was not significantly different between the two groups (597 days versus 611 days). Fourteen out of 126 patients (11.1%) had an IHA titre > or = 1 : 128. Of the 18 patients diagnosed with IA, 13 had a titre > or = 1 : 128. The sensitivity of IHA assay in the diagnosis of IA was 72.2% (13 out of 18) and the specificity was 99.1% (107 out of 108). The positive predictive value of IHA test for IA of this patient population was 92.9% (13 out of 14) whereas the negative predictive value was 95.5% (107 out of 112)., Conclusion: IA is an increasingly important parasitic disease among patients with HIV infection in Taiwan. IHA assay has a good specificity and high negative predictive value in diagnosis of IA.

The objective of this study was to empirically estimate the expected utility gained from the implementation of the 1997 helmet law in Taiwan by using quality-adjusted survival time (QAST). We randomly selected 400 out of 8221 registered cases of head injury and successfully interviewed 99 cases with the index of health-related quality of life (IHRQ). The function of IHRQ was then multiplied with the corresponding survival function to obtain the QAST for head injury. The total utility gained from the helmet law in Taipei within 1 year was estimated by multiplying the expected loss of utility per patient with the number of prevented cases. The results showed that after 80 months of follow-up, the QAST of the injured population was 66.3 quality-adjusted life-months (QALMs), while that of the reference population was 78.7 QALMs. We extrapolated the QAST for total life expectancy by simulating the survival of head injury cases using the life table data from the general population. The life-long utility loss of a head injury case was found to be 4.8 quality-adjusted life-years (QALY). The number of prevented cases during the first year of enforcement of the helmet law was estimated to be 1300 cases in Taipei, which amounted to 6240 QALYs gained. For lack of data, we were unable to calculate the possible gain from helmet on reduction of severity among nonfatal cases with head injury, and the estimation was only a lower bound. We concluded that the QAST approach is a feasible approach applicable to health policy decision-making, especially in cost-utility analysis.

To understand the etiology and clinical outcome of bacterial and fungal sepsis in patients with advanced human immunodeficiency virus (HIV) infection in Taiwan, we conducted a prospective study of nonmycobacterial bacteremia and fungemia in HIV-infected patients with fever who were admitted to a university hospital in Taiwan during a 42-month period. Of 210 patients, 41 (19.5%) had a total of 52 episodes of sepsis due to nonmycobacterial bacteria or fungi, or both (15.5% of 336 episodes of fever). All but one patient had acquired immunodeficiency syndrome (AIDS), and the mean CD4 lymphocyte count was 29/microL (range, 0-321/microL). A total of 57 pathogens (39 bacteria and 18 fungi) were isolated from blood; polymicrobial sepsis due to both bacteria and fungi occurred in four episodes. Nontyphoid Salmonella (NTS) was the most common cause of community-acquired bacteremia (24/30, 80%). Staphylococcus aureus bacteremia was diagnosed in three episodes while Streptococcus pneumoniae bacteremia was found in only one. Cryptococcus neoformans was the most common cause of fungemia and was responsible for 12 episodes, while fungemia due to Penicillium marneffei and Histoplasma capsulatum, two emerging fungi in Taiwan, were diagnosed in four cases and one case, respectively. Nine episodes, eight of bacteremia and one of candidemia, were nosocomial. The overall in-hospital mortality was 29%, and nosocomial sepsis was associated with a higher mortality rate (56%, p = 0.02). The mean duration of survival after recovery from initial sepsis was 426 days. We conclude that NTS bacteremia was the most common cause of sepsis in patients with advanced HIV infection in Taiwan and clinicians caring for such patients should watch for emerging fungal infections. Nosocomial sepsis was associated with a high mortality rate. The mean survival duration after recovery from sepsis of our patients was short.

An open label, randomized comparative study was conducted to evaluate the safety and efficacy of cefepime, in comparison with ceftazidime, in the treatment of adult hospitalized Chinese patients with severe bacterial infections. Forty patients with severe infections including septicemia, urinary tract infection and bacterial pneumonia were randomly assigned to receive treatment with cefepime (2 g intravenously every 12 h) or ceftazidime (2 g intravenously every 8 h). The cefepime group (20 evaluable patients) and ceftazidime group (16 evaluable patients) were comparable with respect to age, sex, underlying diseases and distribution of infection type. In both groups urinary tract infection was the most common type of infection and Escherichia coli was the most common etiologic microorganism. The rates of satisfactory clinical response were similar in the cefepime and ceftazidime groups (95 versus 93.7%; 95% confidence interval: -0.14 - 0.17, P = 0.87). The bacteriological response rates of the cefepime and ceftazidime groups did not differ significantly (88.9 versus 85.7%; 95% confidence interval: -0.30 - 0.36, P = 0.85). Both cefepime and ceftazidime were well tolerated, with similar incidence of side effects. The results of this study suggest that cefepime is as safe and effective as ceftazidime for the treatment of serious infections in adult hospitalized Chinese patients.

From November 1995 to October 1997, seven patients with invasive infections due to Rhodococcus equi were treated in Taiwan. Four patients had pulmonary lesions, and one each of the remaining three patients had a recurrent Port-A-Cath (Kabi-Pharmacia, North Ryde, New South Wales, Australia)-related bacteremia, a primary bacteremia, and a brain abscess. Three patients had underlying hematologic malignancies, and one each of the remaining four patients had diabetes mellitus, Waldenström's macroglobulinemia, long-term use of steroids, and AIDS. The 13 isolates of R. equi recovered from these patients were identified by using API Coryne System (bioMérieux, Marcy l'Etoile, France), VITEK GPI card (bioMérieux Vitek, Hazelwood, MO), supplemental biochemical tests, and cellular fatty acid chromatograms. Susceptibilities of these isolates to 16 antimicrobial agents, with use of the agar dilution method, varied; among them, amikacin and trimethoprim-sulfamethoxazole were the most active agents. Different random amplified polymorphic DNA (RAPD) patterns of isolates from different patients documented the lack of epidemiological relatedness of the causative organisms of these infections. This study confirms the emergence of multidrug-resistant R. equi infection in Taiwan and documents the relapsing or reactivating nature of this infection.

Objective: To describe and compare the clinical features and outcome of disseminated tuberculosis (TB) and Mycobacterium avium complex (MAC) disease in AIDS patients., Design: Prospective cohort study., Setting: A 1800-bed university teaching hospital, the largest centre for HIV/AIDS patients in Taiwan., Methods: From July 1994 through June 1997, a standardized protocol was used to record the demographic and clinical features in all hospitalized HIV-infected patients, and to perform routine studies and invasive procedures for diagnosis of disseminated mycobacterial diseases. To compare the survival, control patients were selected from the HIV-infected patients hospitalized in the same hospital during the same study period, and had similar age, sex, CD4+ cell counts and antiretroviral therapy regimens., Results: A total of 22 cases of disseminated TB and 15 cases of disseminated MAC were identified. Disseminated TB and MAC occurred in patients with similarly low CD4+ cell counts (median, 23 versus 5 x 10(6)/l; P = 0.08). The clinical features favouring disseminated TB included night sweats, peripheral lymphadenopathy, acid-fast bacilli in sputum smears, chest radiographic findings of hilar enlargement, and lack of prior AIDS-defining illnesses. Hepatosplenomegaly, elevated serum alkaline phosphatase (more than twice the upper limit of normal), elevated serum gamma-glutamyl transpeptidase (more than three times the upper limit of normal), and leukopenia favoured disseminated MAC. The patients with disseminated TB survived much longer than patients with disseminated MAC (mean survival, 96 versus 22 weeks, P = 0.008) but had a similar outcome to control patients (P = 0.60)., Conclusion: Disseminated TB and MAC are distinguishable by clinical features in AIDS patients with similar immunocompromised states. Those features may facilitate diagnosis and selection of specific therapeutic regimens. Disseminated TB was not associated with a shortened survival period in AIDS patients when they completed anti-TB treatment. In contrast, disseminated DMAC was associated with shortened survival despite treatment with potent regimens. These results may emphasize the importance of prophylaxis for MAC in this population.

From July 1984 to December 1996, we tested and studied 303 haemophilic patients for the infection of the human immunodeficiency virus (HIV). Among the 261 haemophilia A patients 44 were HIV positive (16.9%), while none of the haemophilia B patients was HIV positive. The mean age of the 44 HIV-seropositive patients in 1984 was 20.6 years (2-37 years). Seven who had known seroconversion dates and 29 whose first seropositive dates were known seroconverted before 1986. Acquired immunodeficiency syndrome (AIDS) has developed in 16 patients, nine of whom presented with Pneumocystis carinii pneumonia, three with tuberculosis infection, and 13 had died. The Kaplan-Meier estimate of the progression rate to AIDS after the date of first seropositive test is about 30% at the 10th year. The median survival time after development of AIDS obtained from the Kaplan-Meier estimate of the survival curve was 11.7 months. Statistical analysis for the covariate effects on the risk of developing AIDS by the Cox proportional hazards model revealed that there was a statistically significant negative association of the risk for progression to AIDS with the logarithm of initial CD4 cell counts (P = 0.027) and the rate of decline of CD4 cell counts (P = 0.040), but not with age (P = 0.650). In conclusion, the clinical characteristics of AIDS haemophiliacs in Taiwan were not different from that observed in western countries. Low initial CD4 cell count and sharp decline in CD4 cell counts, but not age, increased the risk of progression to AIDS.

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out by recruiting patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. A total of 6,410 cases of traumatic spinal fracture were registered among which were 1,586 new cases of SCI. The results represented 70% of the scope of SCI in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million population. The mean age was 46.1 years-old with a plateau distribution for over 20 years and older. Geriatric victims are a major group of SCI in Taiwan. The male to female ratio was 3 to 1. The leading causes of SCI were traffic accidents and accidental falls. Motorcycle collisions accounted for 62% of the traffic accidents, and as most of the motorcycle riders were not helmet users, head injury became the major associated injury of SCI in Taiwan. The effectiveness of the comprehensive care system for SCI patients in Taiwan is relatively good, as reflected by the low rates of complications of SCI, the low mortality rate (6.6%) and the high percentage (67.4%) of SCI patients achieving self-care ultimately at home after rehabilitation. The analysis of person days healthy life loss and quality adjusted survival time revealed that SCI patients in Taiwan required 4 years to cope with the morbidity, and on average, could return to the main stream of life for another 30 years.

From January 1978 to December 1995, 92 cases of Moyamoya disease were collected from seven major medical centers in Taiwan. The data gave an annual incidence rate of 0.048 per 100,000 population. There were 40 males and 52 females and the ages ranged from 2 to 62 years with the peak incidence in the 31-40 year age group (23 cases). Cerebral infarction occurred in 20 out of 24 juvenile patients (83%), and in 24 out of 68 adult patients (35%). The difference was statistically significant. Haemorrhagic stroke was more frequent in adult patients. Computed tomographic scans following stroke showed cerebral infarction in 44 cases, ventricular haemorrhage in 26 cases, intracerebral haemorrhage in 14 cases and pure subarachnoid haemorrhage in eight. The most frequent initial symptom was motor disturbance (59%), followed by headache (49%) and impaired consciousness (35%). This survey showed an incidence rate much lower than that in Japan, but comparable with those in other Oriental countries and higher than those in Western countries. The male-to-female ratio once differed considerably from that of the Japanese series, but from the present study is now quite similar.

This project was designed to examine the epidemiology of traumatic brain injury (TBI) in Taiwan. A total of 58,563 cases of TBI was collected from 114 hospitals in Taiwan during the period July 1, 1988-June 30, 1994. Traffic accident was the major cause of TBI (69.4%), followed by falls and assaults. Motorcyclists accounted for the vast majority of TBI cases among traffic accident victims (64.5%). The Glasgow Coma Scale was used in assessing the severity. 41,646 cases (79.5%) were considered mild, 4,637 cases (8.9%) moderate, and 6,078 cases (11.6%) severe. Skull x-ray showed fracture in 7,663 cases (14.6%). Intracranial hemorrhage was identified in 28.6% of patients receiving CT scanning. Craniotomy was performed in 5,226 cases (9%). The outcome of TBI was determined by the Glasgow Outcome Scale. Death occurred in 2,621 cases (5.4%), vegetative state in 429 cases (0.9%), severe disability in 1,293 cases (2.6%), moderate disability in 1,890 cases (3.9%), and good recovery in 42,596 cases (87.2%). The severity and outcome were worse than those of Western reports. In order to alleviate this problem, a helmet use persuasion program was conducted by the Police Department in Taipei City from January to June, 1994. Results of this program showed a significant reduction of TBI-related hospitalization, severity and fatality during this period of intervention. This study points out the seriousness of TBI in Taiwan and suggests some approaches and priorities for prevention.

Histoplasmosis is one of the most common opportunistic fungal infections in immunocompromised patients in endemic areas. We report the first two microbiologically documented cases of histoplasmosis in Taiwan. The first patient, with acquired immunodeficiency syndrome and a depleted CD4+ lymphocyte count, presented with a history of prolonged fever, papular skin rashes, pancytopenia and elevation of liver enzymes. He was diagnosed and treated initially for systemic toxoplasmosis, but the microbiologic and pathologic findings of the autopsied specimens disclosed disseminated infection caused by Histoplasma capsulatum. The second patient, an elderly man receiving corticosteroids for adrenal insufficiency, manifested with laryngeal histoplasmosis and was successfully treated with ketoconazole.

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out among patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. In all, 1,586 new cases of SCI were registered, representing about 70% of all possible SCI cases in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million people, whereas it was 47.5 for the geriatric section. The mean age was 46.1 years with a plateau distribution after 20 years and older. Geriatric victims (297 cases, 18.7%, group II) formed a major section of SCI cases in Taiwan. Another group of younger SCI patients (15-64 years old, 1,232 cases, group I) was selected for comparison. The results showed that the male-to-female ratio, pattern of neurological deficits, and causes of injury and death of geriatric SCI patients differed significantly from those of the younger SCI group. Elderly women were exposed to a higher risk of SCI than younger women (M/F ratio 1.7:1). Falls were the leading cause of geriatric SCI, and two thirds of them occurred on level ground. Traffic accidents accounted for a third of SCI cases, half of which involved motorcycle accidents, a fifth of them pedestrians. Quadriplegia and quadriparesis occurred more frequently among elderly cases of SCI than in the younger group and a higher proportion of them died of SCI complications. Two thirds of elderly SCI patients recovered well enough after comprehensive treatment to be able to take care of themselves at home. The government should initiate programs of prevention to reduce the prevalence of geriatric SCI in Taiwan.

To understand the clinical characteristics and outcome of tuberculosis (TB) in patients with acquired immunodeficiency syndrome (AIDS) in Taiwan, we reviewed the medical records of 118 adult AIDS patients who were hospitalized at National Taiwan University Hospital between January 1988 and September 1995. Among them, 29 (24.6%) had TB. The mean age of the AIDS patients with TB was 37 years (range, 25-66 yr). Most patients were in the advanced stages of AIDS when human immunodeficiency virus (HIV) infection and/or TB were first diagnosed. The mean CD4+ lymphocyte count was 0.037 x 10(9)/L (range, 0-0.152 x 10(9)/L) at the time TB was diagnosed. There was no statistically significant difference in the mean CD4+ lymphocyte count between patients with isolated pulmonary TB and those with extrapulmonary involvement. Twenty-two patients (75.8%) had extrapulmonary TB with the most common site being the lymph nodes (72.7%). Clinical symptoms were nonspecific, and the chest physical examination was not helpful in the diagnosis. Acid-fast bacilli were detected in sputum smears from eight patients (36.4%). A primary tuberculosis pattern (hilar adenopathy, pleural effusion, middle or lower lobe infiltrates) in the chest radiographs was the most common radiologic finding (36.4%) in patients with pulmonary TB. The reactivation pattern (predominant upper-lobe infiltrates with or without cavitation) could only be found in cases of pulmonary TB without extrapulmonary involvement. Atypical patterns (diffuse interstitial infiltrates mimicking Pneumocystis carinii pneumonia or other patterns) and normal chest radiographs were noted in nearly one-third of the patients with pulmonary TB. A good response to antituberculosis drugs and a favorable outcome were demonstrated in the patients, except for two with drug-resistant Mycobacterium tuberculosis infection. Early identification of TB in HIV-infected patients requires clinical awareness of the unusual clinical presentations, especially among patients in the advanced stages of AIDS.

The incidence of nosocomial candidemia increased 27-fold over the past 13 years at National Taiwan University Hospital. In order to investigate its predisposing factors, clinical manifestations and prognostic determinants, a prospective observational study of nosocomial candidemia was undertaken at the hospital. From 1 May 1994 to 30 April 1995, 118 consecutive adult patients with 120 Candida spp blood isolates were analyzed. Clinical presentations included fever (100%) with a median duration of 3 days, diarrhea within 7 days of candidemia (27.9%) and macronodular skin emboli (7.6%). Laboratory studies showed worsening azotemia (35.6%), elevation of aminotransferase (28.3%), leukocytosis (27.1%) and thrombocytopenia (23.3%). Use of multiple antibiotics, retained vascular catheters and parenteral nutritional support were the three most common predisposing factors for candidemia. C. albicans was the most common isolate (50%), followed by C. tropicalis (20%), C. glabrata (14%), C. parapsilosis (9.2%). C. guilliermondii (2.5%), and C. Krusei (1.7%). C. tropicalis was more frequently the cause of candidemia in patients with leukemia and neutropenia, while C. glabrata was more commonly seen in patients receiving fluconazole prophylaxis. A severity scoring system adopted from prospective bacteremia studies proved to be highly predictive of mortality in candidemic patients. The overall case fatality rate was 70/118 (59.3%), and 51/70 (72.9%) were attributable to candidemia. In a multivariate analysis, the prognostic factors adversely influencing outcome were: higher severity scores, no removal of the catheter, persistent candidemia and lack of antifungal therapy.

Six cardiotoxins and one neurotoxin isolated and purified from the Taiwan cobra venom (Naja naja atra) possess distinct pharmacological and biochemical properties despite the existence of a grossly similar tertiary structure among these toxins, i. e., a core consisting of a series of short loops and four disulfide bridges. A systematic structure comparison of these major toxin isoforms was made by the secondary-structure predictions together with computer model-building based on the primary sequences and the established X-ray and NMR structures of one published cardiotoxin isoform and cobrotoxin. It is of interest to find that some defined and subtle differences can be detected upon the superposition of these three-dimensional polypeptide chains, which may reflect the intrinsic differences in the surface hydrophobicity of cardiotoxins and cobrotoxin as revealed by hydropathy profiles of these toxins in one of three major loops. The differences seem to correlate with different inhibitory activities exhibited by cardiotoxins in contrast to the lack of activity by cobrotoxin on protein kinase C (PKC).

This study was to follow-up the screening positives of hypertension and diabetes screened in 1989 by the Yang-Ming Crusade. The purposes were to understand the control situation of hypertensive and diabetic positives, to understand the continuing situation of diagnosis and treatment by local health center, and to understand the medical attitude and behavior of the screening positives. A total of 768 positives were screened in 1989 and 462 (60.2%) were interviewed. Among them, 44.4% were male and 55.6% were female; 27.7% were aged 50-59 and 28.4% were aged 60-69; 337 positives were hypertensive, 97 were diabetic and 28 had both conditions. The results of follow-up in 1990 showed that, 34.2% of 462 interviewees had gone to the local health center for testing, 37.7% had regular treatment and 19.7% (91 persons) had become normal. The leading methods of treatment were western doctor (35%), local health center (27.2%) and pharmacies (18.7%). Most patients pursued a regular treatment. The reasons not to have a regular treatment were that it was unnecessary because of lack of symptoms (37.2%), lack of time (18.1%), and that it was unnecessary because of cure (3.5%). The results showed that patients lacked knowledge of chronic diseases. Health education is important to let patients have proper information about regular treatment. Logistic regression analysis showed that two factors, "age" and "geographic area", were significantly related to submitting to testing in the local health center. The results of logistic regression also indicated that three factors, "whether having submitting to testing in the local health center or not", "age", and "geographic area", were significantly related to regular treatment.

This study was designed to examine the descriptive epidemiology of head injuries in an urban population in the Taiwan area, Taipei City, during the period from July 1, 1987 to June 30, 1988. Clinical records reviewed included emergency room (ER) charts, inpatient charts of 19 major hospitals, death registration forms and medical examiners' reports in this city. A formulated definition was used to identify patients with head injuries. A total of 4,692 cases were collected, which included 4,319 hospital inpatients and 373 non-hospital deaths. The average incidence rate for head injury was 180/100,000 per year, 246/100,000 for males and 111/100,000 for females. The highest incidence rate was observed in the elderly group followed by the age group of 20-29 years. Sixty eight percent of the head injuries were caused by traffic accidents, 59.7 percent of which were involved in motorcycle rides. This rate was higher than those in any western reports. Among the 10-39 age group, the head injuries caused by traffic accidents were mainly due to motorcycle accidents. However, most of the children and the elderly who were injured were either pedestrians or bicycle riders. The average mortality rate was 23/100,000 per year, 34/100,000 for males and 12/100,000 for females. Initially the Glasgow Coma Scale was used in assessing the severity of head injuries. Seventy-two percent of the cases were considered mild, and 28 percent moderate to severe in degree, including 609 deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

An epidemiological study of head injuries in Hualien County, Taiwan, was undertaken from July 1, 1987 to June 30, 1988. Clinical records, including emergency room (ER) charts, inpatient charts from the four major hospitals and coroner or medical examiner reports in this county, were reviewed. A formulated definition was used in identifying patients with head injury. A total of 1,183 cases were identified. They included 975 hospital inpatients and 208 nonhospital deaths. The age-adjusted incidence rate for head injuries was 333/100,000 for all, 450/100,000 for males and 194/100,000 for females, with a male-to-female ratio of 2.32. The cumulative incidence rate from 0 to 69 years of age was 27.6% for males and 13.7% for females. The highest incidence rate was observed in the elderly group, whereas in other published reports the highest occurrence has been noted in the young adult group. An extraordinary 82% of the head injuries were associated with traffic accidents, 71% of which directly involved motorcycle riders. The age-adjusted mortality rate was 89/100,000 per year, 127/100,000 for males and 44/100,000 for females. The cumulative mortality rate was 8.7% for males and 3.2% for females. These are the highest rates ever reported. Sixty percent of the 1,183 patients had a moderate to severe injury or were dead. In the remaining 40%, the injury was considered mild. The elderly group presented with the highest percentage of moderate to severe degrees of injury, as well as mortality. Among traffic accident victims, those from motorcycle accidents and pedestrians had the highest percentage of severe head injuries.(ABSTRACT TRUNCATED AT 250 WORDS)