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Objective: This study attempted to identify any differences between the outcomes of patients with severe traumatic brain injury (TBI) who were directly transported to Chang Gung Memorial Hospital and those who were stabilised initially at other hospitals in south-central Taiwan., Methods: A retrospective review of the records of 254 patients with isolated severe TBI who visited this hospital's emergency department from July 2003 to June 2008, of whom 167 were referred from other hospitals. Logistic regression was used to assess the effects of transfer and its components on mortality., Results: Transfer from another hospital was not significantly correlated with mortality in this study (OR 0.513, 95% CI 0.240 to 1.097). Moreover, neither intubation (OR 1.356, 95% CI 0.445 to 4.133) nor transfer time over 4 h (OR 0.549, 95% CI 0.119 to 1.744) had a significant effect on mortality., Conclusion: No differences in outcome were found between patients with isolated severe TBI who were directly transported and those transferred to this hospital's emergency room.

The stability of thick shell encapsulated bubbles is studied analytically. 3-D small perturbations are introduced to the spherical oscillations of a contrast agent bubble in response to a sinusoidal acoustic field with different amplitudes of excitation. The equations of the perturbation amplitudes are derived using asymptotic expansions and linear stability analysis is then applied to the resulting differential equations. The stability of the encapsulated microbubbles to nonspherical small perturbations is examined by solving an eigenvalue problem. The approach then identifies the fastest growing perturbations which could lead to the breakup of the encapsulated microbubble or contrast agent., (© 2012 Acoustical Society of America.)

Pulsed Q collision induced dissociation (PQD) was developed to facilitate detection of low-mass reporter ions from labeling reagents (e.g., iTRΑQ) in peptide quantification using an LTQ mass spectrometer (MS). Despite the large number of linear ion traps worldwide, the use and optimization of PQD for protein identification have been limited, in part due to less effective ion fragmentation relative to the collision induced dissociation (CID). PQD expands the m/z coverage of fragment ions to the lower m/z range by circumventing the typical low mass cut-off of an ion trap MS. Since database searching relies on the matching between theoretical and observed spectra, it is not clear how ion intensity and peak number might affect the outcomes of a database search. In this report, we systematically evaluated the attributes of PQD mass spectra, performed intensity optimization, and assessed the benefits of using PQD on the identification of peptides and phosphopeptides from an LTQ. Based on head-to-head comparisons between CID (higher intensity) and PQD (better m/z coverage), peptides identified using PQD generally have Xcorr scores lower than those using CID. Such score differences were considerably diminished by the use of 0.1% m-nitrobenzyl alcohol (m-NBA) in mobile phases. The ion intensities of both CID and PQD were adversely affected by increasing m/z of the precursor, with PQD more sensitive than CID. In addition to negating the 1/3 rule, PQD enhances direct bond cleavage and generates patterns of fragment ions different from those of CID, particularly for peptides with a labile functional group (e.g., phosphopeptides). The higher energy fragmentation pathway of PQD on peptide fragmentation was further compared to those of CID and the quadrupole-type activation in parallel experiments., (© American Society for Mass Spectrometry (outside the USA), 2011)

The measurements for predicting early deterioration of stroke patients is controversial. We studied laboratory measurements and previously identified risk factors to identify factors or predictors of early deterioration after stroke. A prospective observational study of 196 patients with first-time acute ischemic stroke was performed. Demographic data, patient histories, laboratory measurements, and initial stroke severity assessments were recorded. Patients with early deterioration in National Institutes of Health Stroke Scale scores (increase ≥3 points within 3 days) were defined as having stroke-in-evolution (SIE). Thirty patients were diagnosed with SIE. An initial National Institutes of Health Stroke Scale score of 12 or higher, a Glasgow Coma Scale score of 12 or lower, d-dimers more than 1000, or blood urea nitrogen/creatinine (BUN/Cr) ratio higher than 15 were more frequent in SIE patients. After multivariate analysis, only a BUN/Cr higher than 15 was independent predictor of SIE. These patients were 3.41-fold more likely to have SIE (P = .008). These findings suggest that BUN/Cr may be a novel predictor of SIE, potentially useful in emergency departments., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: Necrotizing fasciitis (NF) is a life threatening infectious disease with a high mortality rate. We carried out a microbiological characterization of the causative pathogens. We investigated the correlation of mortality in NF with bloodstream infection and with the presence of co-morbidities., Methods: In this retrospective study, we analyzed 323 patients who presented with necrotizing fasciitis at two different institutions. Bloodstream infection (BSI) was defined as a positive blood culture result. The patients were categorized as survivors and non-survivors. Eleven clinically important variables which were statistically significant by univariate analysis were selected for multivariate regression analysis and a stepwise logistic regression model was developed to determine the association between BSI and mortality., Results: Univariate logistic regression analysis showed that patients with hypotension, heart disease, liver disease, presence of Vibrio spp. in wound cultures, presence of fungus in wound cultures, and presence of Streptococcus group A, Aeromonas spp. or Vibrio spp. in blood cultures, had a significantly higher risk of in-hospital mortality. Our multivariate logistic regression analysis showed a higher risk of mortality in patients with pre-existing conditions like hypotension, heart disease, and liver disease. Multivariate logistic regression analysis also showed that presence of Vibrio spp in wound cultures, and presence of Streptococcus Group A in blood cultures were associated with a high risk of mortality while debridement > = 3 was associated with improved survival., Conclusions: Mortality in patients with necrotizing fasciitis was significantly associated with the presence of Vibrio in wound cultures and Streptococcus group A in blood cultures.

We report the first three-dimensional photonic metamaterial, an array of erected U-shape plasmonic gold meta-molecules, that exhibits a profound response to the magnetic field of light incident normal to the array. The metamaterial was fabricated using a double exposure e-beam lithographic process. It was investigated by optical measurements and finite-element simulations, and showed that the magnetic field solely depends on the plasmonic resonance mode showing either enhanced in the centre of the erected U-shape meta-molecule (16 times enhancement) or enhanced around two prongs of erected U-shape meta-molecule (4 times enhancement).

Focal adhesions undergo myosin-II-mediated maturation wherein they grow and change composition to modulate integrin signalling for cell migration, growth and differentiation. To determine how focal adhesion composition is affected by myosin II activity, we performed proteomic analysis of isolated focal adhesions and compared protein abundance in focal adhesions from cells with and without myosin II inhibition. We identified 905 focal adhesion proteins, 459 of which changed in abundance with myosin II inhibition, defining the myosin-II-responsive focal adhesion proteome. The abundance of 73% of the proteins in the myosin-II-responsive focal adhesion proteome was enhanced by contractility, including proteins involved in Rho-mediated focal adhesion maturation and endocytosis- and calpain-dependent focal adhesion disassembly. During myosin II inhibition, 27% of proteins in the myosin-II-responsive focal adhesion proteome, including proteins involved in Rac-mediated lamellipodial protrusion, were enriched in focal adhesions, establishing that focal adhesion protein recruitment is also negatively regulated by contractility. We focused on the Rac guanine nucleotide exchange factor β-Pix, documenting its role in the negative regulation of focal adhesion maturation and the promotion of lamellipodial protrusion and focal adhesion turnover to drive cell migration., (© 2011 Macmillan Publishers Limited. All rights reserved)

Pyrolytic carbon thin films were deposited on quartz plates through a chemical vapor deposition process, by using a biphenyl precursor, 4,4'-bis(chloromethyl-1,1'-biphenyl). The pyrolytic carbons were microporous and catalytic toward reduction of tri-iodide, and the films thus obtained possessed a metallic appearance with good mirror reflections, hydrophilic surfaces, and low sheet resistances. The pyrolytic carbon-coated quartz plates were used, in place of the commonly used Pt-coated fluorine-doped tin oxide glass, as the counter electrode for dye-sensitized solar cells (DSSCs). The light to electricity conversion efficiency of the cell thus obtained was reasonably high, achieving 78% of that obtained by using the conventional but much more expensive Pt counter electrode. From the electrochemical impedance spectroscopic analysis, one found that the minor reduction in the conversion efficiency came from the relatively higher resistance and lower catalytic activity of the pyrolytic carbon. This work demonstrates that the newly developed pyrolytic carbon films may be a promising alternative to Pt as the counter electrode material for DSSCs., (Copyright © 2011 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

This study looked at spectral analysis of heart rate variability (HRV) between patients with type 2 diabetes mellitus (DM) and healthy controls. The association between diabetic autonomic neuropathy (DAN) with HRV parameter changes and DM risk factors (including nephropathy) was investigated. HRV parameters were compared between 271 patients with DM and 160 controls. A statistically significant difference was found between the two groups for each parameter. Patients with DM were then divided into three groups by the levels of individual risk factors: body mass index, total cholesterol, 2-h postprandial plasma glucose concentration, glycosylated haemoglobin, duration of DM and the albumin-creatinine ratio. HRV parameters decreased significantly in patients with DM as the risk factor level progressed. This study identified previously known and new potential risk factors for the development of DAN, which may be important for the development of risk reduction strategies.

Glycomic analysis is an increasingly important field in biological and biomedical research as glycosylation is one of the most important protein post-translational modifications. We have developed a new technique to detect carbohydrates using surface enhanced Raman spectroscopy (SERS) by designing and applying a Rhodamine B derivative as the SERS tag. Using a reductive amination reaction, the Rhodamine-based tag (RT) was successfully conjugated to three model carbohydrates (glucose, lactose, and glucuronic acid). SERS detection limits obtained with a 633 nm HeNe laser were ∼1 nM in concentration for all the RT-carbohydrate conjugates and ∼10 fmol in total sample consumption. The dynamic range of the SERS method is about 4 orders of magnitude, spanning from 1 nM to 5 μM. Ratiometric SERS quantification using isotope-substituted SERS internal references allows comparative quantifications of carbohydrates labeled with RT and deuterium/hydrogen substituted RT tags, respectively. In addition to enhancing the SERS detection of the tagged carbohydrates, the Rhodamine tagging facilitates fluorescence and mass spectrometric detection of carbohydrates. Current fluorescence sensitivity of RT-carbohydrates is ∼3 nM in concentration while the mass spectrometry (MS) sensitivity is about 1 fmol, achieved with a linear ion trap electrospray ionization (ESI)-MS instrument. Potential applications that take advantage of the high SERS, fluorescence, and MS sensitivity of this SERS tagging strategy are discussed for practical glycomic analysis where carbohydrates may be quantified with a fluorescence and SERS technique and then identified with ESI-MS techniques.

A 3-D thick-shell contrast agent dynamics model was developed by coupling a finite volume Navier-Stokes solver and a potential boundary element method flow solver to simulate the dynamics of thick-shelled contrast agents subjected to pressure waves. The 3-D model was validated using a spherical thick-shell model validated by experimental observations. We then used this model to study shell break-up during nonspherical deformations resulting from multiple contrast agent interaction or the presence of a nearby solid wall. Our simulations indicate that the thick viscous shell resists the contrast agent from forming a re-entrant jet, as normally observed for an air bubble oscillating near a solid wall. Instead, the shell thickness varies significantly from location to location during the dynamics, and this could lead to shell break-up caused by local shell thinning and stretching., (Copyright © 2010 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Poly(p-phenylene) (PPP), an important blue emitter, is difficult to be fabricated in thin film form with a wet process because of its insoluble and infusible characteristics resulting from its rigid backbone structure. Therefore, various indirect and multistep synthetic approaches have been proposed for fabrication of PPP films. In this article, a chemical vapor deposition polymerization process was developed to fabricate successfully PPP films in one-step directly without the often required postreaction thermal treatment. We further demonstrated that the polymer chain conformation of the film can be effectively adjusted through a simple surface treatment of the substrate, and the variations in film morphology induced by the substrate characteristics led to significant changes in the optoelectronic properties of the film.

Background: The aim of this study was to assess the outsourcing situation in Taiwanese hospitals and compares the differences in hospital ownership and in accreditation levels., Methods: This research combined two kinds of methods: a questionnaire survey and the in-depth interview to two CEOs of the sample hospitals. One hospital is not-for-profit, while the other is a public hospital and the research samples are from the hospital data from Taiwan's 2005 to 2007 Department of Health qualifying lists of hospital accreditation. The returned questionnaires were analyzed with STATISTICA 7.1 version software., Results: The results for non-medical items showed medical waste and common trash both have the highest rate (94.6 percent) of being outsourced. The gift store (75 percent) and linen (73 percent) follow close behind, while the lowest rate of outsourcing is in utility maintenance (13.5 percent). For medical items, the highest rate of outsourcing is in the ambulance units (51.4 percent), while the hemodialysis center follows close behind with a rate of 50 percent. For departments of nutrition, pharmacy, and nursing however, the outsourcing rate is lower than 3 percent. This shows that Taiwan's hospitals are still conservative in their willingness to outsource for medical items. The results of the satisfaction paired t-test show that the non-medical items have a higher score than the medical items. The factor analysis showed the three significant factors in of non medical items' outsourcing are "performance", "finance", and "human resource". For medical items, the two factors are "operation" and satisfaction". To further exam the factor validity and reliability of the satisfaction model, a confirmative factor analysis (CFA) was conducted using structure equation modeling (SEM) method and found the model fitting well., Conclusion: Hospitals, especially for public hospitals, can get benefits from outsourcing to revive the full-time-equivalent and human resource limitation.

Objective: Overcrowding in hospitals, especially in EDs, is a serious problem in the United States, Europe, and Taiwan. However, the association between prolonged ED boarding stay and mortality in patients with necrotizing fasciitis remains underinvestigated., Methods: This was a retrospective study. A total of 195 patients were enrolled and analyzed. The sample was divided into 2 groups: nonmortality and mortality. A stepwise logistic regression model was developed to investigate 3 factors of clinical relevance predicting patient mortality., Result: The results of the stepwise logistic regression analysis revealed that hypotension (odds ratio [OR], 32.9; 95% confidence interval [CI], 6.9-156.0) and prolonged ED boarding stay (OR, 3.4; 95% CI 1.3-8.6) were both associated with higher mortality. Early operation (OR: 0.16; 95% CI: 0.06-0.45) was associated with lower mortality., Conclusion: Prolonged ED boarding stay was associated with increased mortality in patients with necrotizing fasciitis. Early operation (within 24 hours of ED arrival) was associated with decreased mortality.

Background: Laboratory risk indicator for necrotizing fasciitis (LRINEC score) is a simple laboratory tool used to distinguish between necrotizing soft-tissue infections (NSTI) and other soft-tissue infections. A LRINEC score of > or =6 is considered as denoting a high risk of necrotizing fasciitis. A certain LRINEC score might also be associated with mortality and other outcomes of patients with NSTI., Methods: A review of the medical charts of patients was carried out. The study sites were one tertiary academic centre and one community, university-affiliated hospital. All adult patients with necrotizing soft-tissue infections from 2002 to 2005 were selected then LRINEC scores were calculated for each patient. We enrolled patients where there was sufficient information to determine that the LRINEC score was either <6 or > or =6., Results: A total of two hundred and nine patients were enrolled and analysed. The overall mortality rate was 33 of 209 (15.8%) and amputation rate was 55 of 209 (26.3%). The amputation rates were defined as numbers of patients who received amputation divided by numbers of total patients. Enrolled patients were divided into two groups. Group I was those whose LRINEC score was <6 and group II was those whose LRINEC score was > or =6. Significant differences in mortality rate (P = 0.04) and amputation rate (P = 0.002) were noted between two groups., Conclusion: The LRINEC score is associated with the outcomes of patients with NSTI. Patients with a LRINEC score of > or =6 have a higher rate of both mortality and amputation.

Objective: Graves' disease (GD) is known to be associated with thyroglobulin (TG) and CD40 genes. Therefore, we decided to investigate the relationship of age at onset of GD with CD40 and TG gene susceptibilities in a Taiwanese population., Design and Method: We analyzed the association of TG and CD40 polymorphisms with age at onset of GD in Taiwanese patients. We stratified patients into those with early onset (<40 years; 30.3+/-4.8 years; n=135) and later onset (>or=40 years; 52.3+/-6.3 years; n=80) and compared the results with those of 141 normal controls., Results: We found a significant statistical difference in the T/T genotype frequency of E33 single nucleotide polymorphism (SNP) and G/G genotype frequency of E12 SNP when compared with the control group (P<0.001). In addition, the frequencies of the T allele and TT genotype of the CD40 SNP were found to be significantly increased in GD patients who developed GD aged over 40 years than those below 40 years (allele: chi(2)=5.299, P=0.021, OR=1.597; genotype: chi(2)=6.168, P=0.046). By contrast, the frequencies of genotypes in the TG gene E10, E12, and E33 SNPs were not found to be significantly different in GD patients who developed GD when aged over 40 years when compared with those aged below 40 years., Conclusions: These data suggest that the T/T genotype and T allele in the CD40 gene are more likely to be associated with late-onset GD in Taiwanese patients.

Objective: The aim of the study was to identify risk factors for mortality in patients brought to the emergency department (ED) after blunt traumatic brain injury (TBI)., Methods: The medical records of such patients who visited the ED from June 2004 to May 2005 were retrospectively reviewed. Data (age, gender, initial Glasgow coma scale (GCS) scores, initial vital signs, brain computed tomography scan findings and cause of trauma) were collected from the records of 204 TBI patients, who were treated at the ED and needed intensive care. Among these patients, 48 died in the intensive care unit (ICU) of the hospital. Logistic regression was used to assess factors affecting mortality after trauma., Results: Age (odds ratio (OR) 1.04; 95% CI 1.01 to approximately 1.07), GCS score less than 9 (OR 19.29; 95% CI 5.04 to approximately 73.82) and skull bone fracture (OR 10.44; 95% CI 3.59 to approximately 30.38) were identified as possible risk factors of mortality in TBI patients., Conclusion: These predictors appear to be clinically relevant and may help improve ED triage of TBI patients in need of ICU care.

Acquired hemophilia A is defined as the development of factor VIII inhibitors in a nonhemophilic patient. The inhibitors can develop in association with autoimmune disease, allergic drug reactions [1,2], malignancies [2], and pregnancy [3]. It is rare, but frequently complicated by severe bleeding and compartment syndrome [1,4]. Therapeutic cupping is a traditional remedy done by applying heated cup over the back and limbs to cause congestion. This procedure is mostly used by South Asian and Middle Eastern countries. We report a 58-year-old woman who presented with extensive and compressive bruising which led to pending compartment syndrome of her left thigh in 2 days after cupping. The coagulopathy was first considered owing to new-onset severe deep tissue bleeding. Acquired hemophilia A was diagnosed with prolonged activated partial thromboplastin time (83 seconds) and incorrectable mixing plasma test. Quantitative assays revealed reduced level of factor VIII (b0.1%) and the presence of factor VIII inhibitors (20 BU) in the serum. Fresh frozen plasma transfusion, coagulation factor supply, and immunosuppressive therapy with steroid began immediately after diagnosis was made. Her activated partial thromboplastin time was gradually normalized. She was discharged home with improving symptoms and minimized bruises 1 week later. To our knowledge, acquired hemophilia A associated with therapeutic cupping has never been mentioned before in the literature.

A single nucleotide polymorphism (SNP) located at position-1 in the Kozak sequence of the CD40 gene has been associated with the development of GD in Caucasian and Koreans. This study investigated possible associated between CD40 SNP and the development of GD in a Taiwanese population. To do this, we enrolled 215 Taiwanese patients with GD and 141 controls from the Endocrine Clinic of Kaohsiung Medical University Hospital. This study investigated the association between gene polymorphism and relapse of hyperthyroidism after the discontinuation of medication in three GD patient groups based on time to relapse and a control group, and compared clinical and laboratory data of patients regrouped in three CD40 SNP genotypes. No significant difference in allele or CD40 SNP genotype frequency was observed between patients with GD and control subjects (P = 0.859 and P = 0.959, respectively). Furthermore, we analyzed the distribution of CD40 genotypes and three groups based on time to relapse after drug withdrawal. The cutoff points were 9 months, 9 months to 3 years, and more than 3 yr in subgroups of patients with GD divided by clinical and laboratory variables. Although no significant genotype-phenotype associations were found, the T allele and TT genotype frequency was significantly smaller in GD patients who had developed the disease before 35 years old than those who developed it after 35 years old (x (2) = 6.272, P = 0.043) (TT + CT v.s. CC, x (2) = 4.951, P = 0.030). These findings suggest that this CD40 gene polymorphism is not associated with GD in Taiwan and is, therefore, not contributing to susceptibility to the disease there.

Magnesium hydroxide extracted from magnesium-bearing minerals is considered a promising agent for binding CO2 as a carbonate mineral in a gas-solid reaction. An efficient extraction route consisting of hydrothermal treatment on serpentine in HCl followed by NaOH titration for Mg(OH)2 precipitation was demonstrated. The extracted Mg(OH)2 powder had a mean crystal domain size as small as 12 nm and an apparent surface area of 54 m2/g. Under one atmosphere of 10 vol% CO2/N2, carbonation of the serpentine-derived Mg(OH)2 to 26% of the stoichiometric limit was achieved at 325 degrees C in 2 h; while carbonation of a commercially available Mg(OH)2, with a mean crystal domain size of 33 nm and an apparent surface area of 3.5 m2/g, reached only 9% of the stoichiometric limit. The amount of CO2 fixation was found to be inversely proportional to the crystal domain size of the Mg(OH)2 specimens. The experimental data strongly suggested that only a monolayer of carbonates was formed on the crystal domain boundary in the gas-solid reaction, with little penetration of the carbonates into the crystal domain.

Hemorrhagic bullae are a clinical manifestation of many underlying diseases, especially soft-tissue infection. The aim of this study was to evaluate the characteristics and prognosis of cirrhotic patients with hemorrhagic bullae. Fifteen patients with liver cirrhosis and hemorrhagic bullae had been admitted to Chang Gung Memorial Hospital, Kaohsiung, from January to December 2003. Their clinical courses were retrospectively reviewed in detail and all of the collected data were analyzed. This study puts emphasis on the clinical presentation and outcome of these cases. The mean age of patients was 55.0 +/- 12.1 years, and 12 patients were male. Prostration and unusual extremity pain were the two leading reasons to visit our Emergency Department. The hemorrhagic bullae were located on the upper or lower extremities and in one patient, on the whole body. In this series all hemorrhagic bullae were infection-related. Although aggressive treatment was started immediately upon arrival, 14 patients died of overwhelming sepsis and 12 patients died within 48 h from the emergence of hemorrhagic bullae. Hemorrhagic bullae in cirrhotic patients usually imply a fatal infection and Gram-negative bacteria are the most common pathogen. Appropriate antimicrobial therapy and early surgical intervention are necessary to achieve survival in these patients.

Transient ischemic attack is one of the most common causes of transient neurologic deficit. Anemic hypoxia results from reduced hemoglobin content with normal arterial oxygen tension and saturation. Anemic hypoxia caused by blood loss or hemolysis has not been considered as an independent factor leading to significant neurologic problems because cerebral homeostasis adjusted by the physiologic regulation in cerebral hemodynamics and oxygenation would meet the brain oxygen requirement in most circumstances even with profound anemia. We report a case of severe anemia associated with transient ischemic attack involving vertebrobasilar circulation.

Glyphosate-surfactant is used extensively as a nonselective herbicide. Suicidal attempts with glyphosate-surfactant herbicide (GlySH) has been encountered with increasing frequency. The effect of GlySH intoxication often involves multiple systems. We report a case of a severely intoxicated man who developed chemical pneumonitis and respiratory failure after suicidal ingestion of GlySH. Acute pancreatitis, which was never covered by any previous case reports, developed in the first day, and the symptom persisted for 10 days during hospitalization.

Background: Dermatologic complaints are common presentations in the ED. Hemorrhagic bullae are an example of dermatologic manifestation caused by variable etiologies. The life-threatening skin lesion usually is an external sign of a systemic or immune response stimulated by an infection, toxin, medication, or disease process. Although most patient with life-threatening skin lesion, such as hemorrhagic bullae, may appear ill, patients who present in the early course of illness may appear well but deteriorate rapidly. For greater comprehension of hemorrhagic bullae, we prospectively followed 42 patients who presented with hemorrhagic bullae at the ED and analyzed their clinical characteristics and their confirmative diagnoses., Methods: This is a prospective, observational cohort study conducted at a university-affiliated community hospital. Data were collected from January 2002 to January 2007. Patients presenting to the ED with hemorrhagic bullae were enrolled prospectively., Results: All of our patients with hemorrhagic bullae had evidence of a serious disease: necrotizing fasciitis (42 case, 100%). The most common comorbidity was diabetes mellitus (18 cases; 42.9%). Vibrio species was the most common organism from blood culture (8/16 cases) and wound culture (17/27 cases). Streptococcal species was found in only 1 patient via blood culture and 4 patients via wound culture. The yield of positive wound culture with Vibrio species was significantly greater than with streptococcal species (P < .05). Fourteen (33.3%) patients came to the ED for help 48 hours later after the onset of hemorrhagic bullae. None of these 14 patients died. In our total of 42 patients, 8 (19%) died., Conclusion: In our study, the most common causative disease of hemorrhagic bullae was necrotizing fasciitis. Hemorrhagic bullae are a more common clinical feature in Vibrio infection than in streptococcal infection. Hemorrhagic bullae may occur in the early stage of necrotizing fasciitis. Necrotizing fasciitis may be the first sign that emergency physicians come across in patients with hemorrhagic bullae that are not in the oral, genital, anal, ocular area, and high index of suspicion of Vibrio infection should be considered. More aggressive treatment may be needed as hemorrhagic bullae may occur in the early stage of a serious disease. Further multi-institution study may be required to support these findings.

Background: Necrotizing fasciitis is an uncommon and life-threatening soft tissue infection with high mortality. Though early aggressive surgical intervention is important for improving survival, the impact of mortality from different microorganisms remains uncertain. Our study aims to identify the association of mortality and different microorganisms, and the positive and negative predictors of mortality in patients with necrotizing fasciitis., Methods: This retrospective cohort study enrolled patients admitted via the emergency department (ED) with discharged diagnosis of necrotizing fasciitis (International Classification of Diseases, Ninth Revision, code 72886). Multivariate logistic regression analysis was used to identify microbiological, clinical, and biochemical variables independently associated with the mortality of necrotizing fasciitis., Results: Multivariate logistic regression analysis showed that Vibrio infection, Aeromonas infection, hypotension, malignancy, and band form 10% or greater were significantly associated with increase of mortality (P < .05). They were considered as positive predictors of mortality. The presence of hemorrhagic bullae, however, was significantly associated with decrease of mortality (P < .05). It was considered as negative predictor of mortality., Conclusion: Aeromonas infection, Vibrio infection, cancer, hypotension, and band form white blood cell count greater than 10% are independent positive predictors of mortality in patients with necrotizing fasciitis. Streptococcal and staphylococcal infections, in contrast, are not predictors of mortality. The presence of hemorrhagic bullae is an independent negative predictor of mortality. Further study should focus on the accuracy of these factors.

Metformin-associated lactic acidosis is a rare but serious condition and potentially even more hazardous during pregnancy. We reported a case of lactic acidosis in a 28-year-old pregnant woman (gravida 3, para 0, abortion 2, ante-partum 22 weeks) after ingestion of 39.50 g (approximately 80 tablets) metformin in a suicide attempt. She had no pre-existing systemic illness. Analysis of arterial blood gases revealed a high anion gap (28.1 mEq/l) and a normal osmol gap (8 mEq/l) metabolic acidosis. Other etiologies of high anion gap and normal osmol gap metabolic acidosis were excluded by laboratory investigation. The patient was treated on an emergency basis and received aggressive fluid management, intravenous sodium bicarbonate (1 mEq/kg) and activated charcoal, orally. The fetal condition was monitored intensively. The fetus was delivered smoothly via vaginal delivery in a healthy state at the 38th gestational week. Clinical follow-up over the next 2 years confirmed no congenital abnormality. We present a case of successful management of metformin-associated lactic acidosis during pregnancy, treated simply, with intravenous sodium bicarbonate and intensive fetal monitoring. This relatively noninvasive method is an effective treatment option. However, hemodialysis still has a valuable role in the management of acidosis which proves refractory to conservative treatment, such as that described., ((c) 2008 S. Karger AG, Basel.)

Acute cardiac tamponade requires urgent diagnosis and treatment. We report a case involving a 70-year-old man who was receiving warfarin treatment for 12 years following mitral valve replacement. The international normalised ratio (INR) was checked and echocardiography performed regularly in the clinic. The last INR was 2.1, checked 2 weeks before admission to the emergency department. The last echocardiography performed 3 months previously revealed no pericardial effusion. The patient suffered from progressive dyspnoea and orthopnoea for several days. Cardiac tamponade was diagnosed, and the INR at that time was 7.52. Urgent pericardiocentesis and pericardiotomy were undertaken and 1300 ml of pericardial blood was drained. Following surgery the patient's recovery was uneventful. An intravenous vitamin K injection and fresh frozen plasma transfusion were administered to reverse the patient's over-anticoagulated state. The final pathology revealed chronic inflammation and there was no malignancy, and no bacteria or mycobacterium were seen. Emergency physicians should remember that over-anticoagulation with warfarin may contribute to certain complications, including haemopericardium, and that strict control of target INR should be the goal for patients who require continuous warfarin treatment.

Background: Several risk score systems are designed for triage patients with acute nonvariceal upper gastrointestinal bleeding (UGIB). Blatchford score, which relies on only clinical and laboratory data, is used to identify patients with acute UGIB who need clinical intervention (before endoscopy). Clinical Rockall score, which relies on only clinical variables, is used to identify patients with acute UGIB who have adverse outcome, such as death or recurrent bleeding. Complete Rockall score, which relies on clinical and endoscopic variables, is also used to identify patients with acute UGIB who died or have recurrent bleeding. In our study, we define patients who need clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control) as high-risk patients. Our study aims to compare Blatchford score with clinical Rockall score and complete Rockall score in their utilities in identifying high-risk cases in patients with acute nonvariceal UGIB., Methods: International Classification of Diseases, Ninth Revision, Clinical Modification codes for admission diagnosis were used to recognize a cohort of patients (N = 354) with acute UGIB admitted to a tertiary care, university-affiliated hospital. Medical record data were abstracted by 1 research assistant blinded to the study purpose. Blatchford and Rockall scores were calculated for each enrolled patient. High risk was defined as a Blatchford score of greater than 0, a clinical Rockall score of greater than 0, and a complete Rockall score of greater than 2. Patients were defined as needing clinical intervention if they had a blood transfusion or any operative or endoscopic intervention to control their bleeding. Such patients were defined as high-risk patients., Results: The Blatchford score identified 326 (92.1%) of the 354 patients as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control). The clinical Rockall score identified 289 (81.6%) of the 354 patients as high-risk, and the complete Rockall score identified 248 (70.1%) of the 354 patients as high-risk. The yield of identifying high-risk cases with the Blatchford score was significantly greater than with the clinical Rockall score (P < .0001) or with the complete Rockall score (P < .0001). In our total 354 patients, 246 (69.5%) patients were categorized as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control, as aforementioned) in our study. The Blatchford score identified 245 (99.6%) of 246 patients as high-risk. Only 1 patient who met the study definition of needing clinical intervention was not identified via Blatchford score. This patient did not have recurrent bleeding nor die and did not receive blood transfusion. The clinical Rockall score identified 222 (90.2%) of 246 patients as high-risk. Twenty-four patients who met the study definition of needing clinical intervention were not recognized via clinical Rockall score. Of these patients, 0 died, 7 developed recurrent bleeding, and 6 needed blood transfusion. The complete Rockall score identified 224 (91.1%) of 246 patients as high-risk. Twenty-two patients who met the study definition of needing clinical intervention were not recognized via complete Rockall score. Of these patients, 2 died, 3 developed recurrent bleeding, and 20 needed blood transfusion., Conclusions: The Blatchford score, which is based on clinical and laboratory variables, may be a useful risk stratification tool in detecting which patients need clinical intervention in patients with acute nonvariceal UGIB. It does not need urgent endoscopy for scoring and has higher sensitivity than the clinical Rockall score and the complete Rockall score in identifying high-risk patients.

A DNA technique has been established for the identification to species level of tortoises. The test on the shell of the animal was used to identify samples from the species Kachuga tecta. A total of 100 tortoise shell specimens collected from the National Council of Agriculture (COA), Taiwan, were used in this study. Primer pairs were designed to amplify partial DNA fragments of cytochrome b within the mitochondrial genome. The DNA data showed that among the 100 samples, there were four distinct haplotype DNA sequences, within which there were a total of 90 variable sites. Between haplotypes I and II, there was only 1 nucleotide difference at position 228. Between haplotypes I and III, 65 nucleotide differences were observed; haplotypes I and IV, 62 nucleotide differences; and haplotypes III and IV, 56 nucleotide differences were observed. There were 66 and 63 nucleotide differences between haplotypes II and III and haplotypes II and IV respectively. All four haplotypes were compared with the DNA sequences held at the GenBank and EMBL databases. The most similar species were K. tecta (haplotype I and II), Morenia ocellata (haplotype III) and Geoclemys hamiltonii (haplotype IV), and their respective mtDNA similarities were 99.5%, 99.3%, 89.9% and 99.5%. However, as haplotype III was only 89.9% homologous with M. ocellata, it would seem that this haplotype shows only a limited relationship with a similar species registered currently in these databases. The method established by this study is an additional method for the identification of samples protected under Convention International Trade in Endangered Species (CITES) and will improve the work for the preservation of the endangered species.

We present a novel hybrid algorithm, integrating a genetic algorithm (GA) and constrained differential dynamic programming (CDDP), to achieve remediation planning for an unconfined aquifer. The objective function includes both fixed and dynamic operation costs. GA determines the primary structure of the proposed algorithm, and a chromosome therein implemented by a series of binary digits represents a potential network design. The time-varying optimal operation cost associated with the network design is computed by the CDDP, in which is embedded a numerical transport model. Several computational approaches, including a chromosome bookkeeping procedure, are implemented to alleviate computational loading. Additionally, case studies that involve fixed and time-varying operating costs for confined and unconfined aquifers, respectively, are discussed to elucidate the effectiveness of the proposed algorithm. Simulation results indicate that the fixed costs markedly affect the optimal design, including the number and locations of the wells. Furthermore, the solution obtained using the confined approximation for an unconfined aquifer may be infeasible, as determined by an unconfined simulation.

In time-varying ground water remediation, the lack of an optimal control algorithm to simultaneously consider fixed costs and time-varying operating costs makes it nearly impossible to obtain an optimal solution. This study presents a novel algorithm that integrates a genetic algorithm (GA) and constrained differential dynamic programming (CDDP) to solve this time-varying ground water remediation problem. A GA can easily incorporate the fixed costs associated with the installation of wells. However, using a GA to solve for time-varying policies would dramatically increase the computational resources required. Therefore, the CDDP is used to handle the subproblems associated with time-varying operating costs. A hypothetical case study that incorporates fixed and time-varying operating costs is presented to demonstrate the effectiveness of the proposed algorithm. Simulation results indicate that the fixed costs can significantly influence the number and locations of wells, and a notable total cost savings can be realized by applying the novel algorithm herein.

Leptospirosis, a zoonotic disease with worldwide distribution, is often overlooked in Taiwan. Clinicians at our medical center in southern Taiwan became alert to the potential for leptospirosis after the first documented case of severe leptospirosis--Weil's syndrome was diagnosed at our emergency department in early September 2000. Four additional cases of leptospirosis were subsequently diagnosed within a 2-month period. All of the patients were hospitalized, and presented with high fever, severe myalgia, jaundice, and acute renal failure. Two of these patients who rapidly received doxycycline therapy survived, while the remaining three patients who received delayed penicillin therapy died. These cases suggest that the incidence of leptospirosis may have been underestimated in Taiwan, and underscore the urgent need for increased clinician awareness of this infectious disease.

Background: Transgenic animals have become valuable tools for both research and applied purposes. The current method of gene transfer, microinjection, which is widely used in transgenic mouse production, has only had limited success in producing transgenic animals of larger or higher species. Here, we report a linker based sperm-mediated gene transfer method (LB-SMGT) that greatly improves the production efficiency of large transgenic animals., Results: The linker protein, a monoclonal antibody (mAb C), is reactive to a surface antigen on sperm of all tested species including pig, mouse, chicken, cow, goat, sheep, and human. mAb C is a basic protein that binds to DNA through ionic interaction allowing exogenous DNA to be linked specifically to sperm. After fertilization of the egg, the DNA is shown to be successfully integrated into the genome of viable pig and mouse offspring with germ-line transfer to the F1 generation at a highly efficient rate: 37.5% of pigs and 33% of mice. The integration is demonstrated again by FISH analysis and F2 transmission in pigs. Furthermore, expression of the transgene is demonstrated in 61% (35/57) of transgenic pigs (F0 generation)., Conclusions: Our data suggests that LB-SMGT could be used to generate transgenic animals efficiently in many different species.

Background: Gingival enlargement induced by nifedipine (NIF), a calcium antagonist, has been reported in human and animal studies. However, three-dimensional morphologic measurements of gingivae have never been used to describe this type of enlargement. We previously established an animal model of cyclosporin-induced gingival enlargement. The present study used morphologic measurements to examine whether or not NIF-induced gingival enlargement occurs in the animal model., Methods: Eighty male Sprague-Dawley rats were divided into four groups. Rats in each group received daily NIF, at a dosage of 0, 10, 30 or 50 mg/kg body weight, by gastric feeding for nine weeks. Gingival dimensions (including buccolingual and mesiodistal widths, and vertical height) were assessed from stone models obtained from the mandibular incisor regions every three weeks., Results: Over the course of the nine-week experiments, significant dimensional changes of the gingivae were observed according to two main factors: 1) the dose or, 2) the treatment duration. Gingival dimensions (including buccolingual and mesiodistal widths, and vertical height) significantly increased with the duration of NIF treatment. Dimensional alterations of gingivae were noted among the different dosage groups, but significant differences were mainly observed in those groups compared to the 50 mg/kg group., Conclusions: The finding of increased gingival morphology in NIF-treated rats in this study shows that gingival enlargement can be induced by NIF in rats.

The first case report of gingival overgrowth induced by nifedipine (NIF), a calcium-beta blocker, was in 1984. However, the association between gingival alterations and the drug therapy of sodium diphenyl hydantoinate was initially described in 1939. The purpose of the experimental study was to examine the effect of NIF on gingival morphology in an animal model. Forty-five male Sprague-Dawley rats were randomly divided into 3 groups. Animals in each group daily received NIF in dimethyl sulfoxide by gastric feeding at a dosage of 0 (control), 30, or 50 mg/kg body weight for 9 weeks. Gingival gross morphology was assessed tri-weekly from stone models obtained from the mandibular incisal region. Animals were sacrificed at the end of study and tissue blocks were processed for histopathologic and histometric evaluation. Histometric analysis was performed at 5 selected tissue levels. Macro- and microscopic significantly increased gingival dimensions were demonstrated in NIF-treated animals compared to control. Although a fibrovascular tissue was observed in the tooth-gingiva interface for both NIF-treated and control animals, it was thicker and appeared earlier in NIF-treated animals. The results of the present study suggest that gingival overgrowth can be induced by NIF in rats and that the gingival overgrowth appears dose dependent.

An 18-year-old schizophrenic female was recently treated after overdosing on trihexyphenidyl, thioridazine and an unknown antidepressant. On presentation to a local hospital, she was cyanotic with dilatated pupils and in acute respiratory failure. She was intubated prior to transfer. While in our Emergency Department, she exhibited occasional premature ventricular contractions which later became intermittent torsade de pointes. As this was an anticholinergic overdose we infused sodium bicarbonate in an attempt to increase protein binding, hoping to decrease the concentration of toxic metabolites. We also tried to suppress the dysrhythmia by infusing magnesium. The potassium level was borderline low so a supplemental infusion was initiated. Defibrillation was attempted. To try to shorten the action potential duration by activating the K+ channel, an isuprel infusion was also attempted. All methods failed. The patient fluctuated between an irregular sinus rhythm with prolonged QT interval and pulseless torsade de pointes for almost 24 hours. At all times, she responded appropriately to pain. Finally we attempted blockade of the calcium channel using verapamil with dramatic results. Each single bolus (0.1 mg/kg) successfully converted the patient back to sinus rhythm for some 15-20 minutes before the torsade recurred. After the initiation of a continuous verapamil infusion (0.005 mg/kg/hr), the patient remained in stable sinus rhythm. Verapamil proved highly effective in this patient with an anticholinergic overdose induced dysrhythmia.

Background: Acute pancreatitis as a complication of organophosphate intoxication has been infrequently addressed. Previous reports have suggested that acute pancreatitis may follow the oral ingestion of several organophosphates, including parathion, malathion, difonate, coumaphos, and diazinon, or after cutaneous exposure to dimethoate. No cases of acute pancreatitis following mevinphos (CAS 7786-34-71) poisoning have been reported to date. The possible pathogeneses of the pancreatic insult in organophosphate intoxication are excessive cholinergic stimulation of the pancreas and ductular hypertension., Case Report: We describe a patient presenting with painless acute pancreatitis following an intentional ingestion of large amounts of mevinphos. Serum amylase and lipase values were increased and determination of amylase isoenzymes confirmed a pancreatic origin. A computerized tomograph of the abdomen showed diffuse swelling of the pancreas. The patient was discharged after a seven week clinical course, complicated by a delayed neuropathy., Conclusions: As acute pancreatitis in organophosphate intoxication may be more common than reported, serum pancreatic enzymes and appropriate imaging studies should be more liberally utilized. Early recognition and appropriate therapy for acute pancreatitis may lead to an improved prognosis.