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Abstract Background Loiasis is one of the significant filarial diseases for people living in West and Central Africa with wide endemic area but is not seen in China. As economy booms and international traveling increase, China faces more and more imported parasitic diseases that are not endemic locally. Loiasis is one of the parasitic diseases that enter China by travelers infected in Africa. The better understanding of the clinical and laboratory features of loa loa infection will facilitate the diagnosis and treatment of loiasis in China. Methods The study targeted travelers who were infected with L. loa in endemic Africa regions and returned to Beijing between 2014 and 2023. Epidemiological, clinical, and biological data as well as treatment of these patients were collected. Results Total 21 cases were identified as L. loa infection based on their typical clinical manifestations and parasite finding. All cases had a history of travel to Africa for more than 6 months, most of them are the construction workers dispatched to West Africa with outdoor activities. Calabar swelling (n = 19; 90.5%) and pruritus (n = 11; 52.4%) were among the most common clinical symptoms followed by muscle pain (n = 7; 33.3%) and skin rash (n = 2; 9.5%). The adult worms were observed in the eyelid or subconjunctiva (n = 2; 9.5%) and subcutaneous tissues (n = 2; 9.5%). Although all patients presented with a high eosinophil count (> 0.52 × 109/L), only two cases displayed microfilariae in fresh venous blood and positive for filarial antigen. A cut section of adult worm was observed through biopsy on a skin nodule surrounded by lymphocytes, plasma cells and eosinophils. All subjects were positive in PCR targeting L. loa ITS-1. The constructed phylogenetic tree based on the amplified ITS-1 sequences identified their genetical relation to the L. Loa from Africa. All patients treated with albendazole and diethylcarbamazine were recovered without relapse. Conclusion This study provides useful information and guideline for physicians and researchers in non-endemic countries to diagnose and treat loiasis and L. loa infections acquired from endemic regions.

BACKGROUND:Our previous studies showed that Trichinella spiralis paramyosin (TsPmy) is an immunomodulatory protein that inhibits complement C1q and C8/C9 to evade host complement attack. Vaccination with recombinant TsPmy protein induced protective immunity against T. spiralis larval challenge. Due to the difficulty in producing TsPmy as a soluble recombinant protein, we prepared a DNA vaccine as an alternative approach in order to elicit a robust immunity against Trichinella infection. METHODS AND FINDINGS:The full-length TsPmy coding DNA was cloned into the eukaryotic expression plasmid pVAX1, and the recombinant pVAX1/TsPmy was transformed into attenuated Salmonella typhimurium strain SL7207. Oral vaccination of mice with this attenuated Salmonella-delivered TsPmy DNA vaccine elicited a significant mucosal sIgA response in the intestine and a systemic IgG antibody response with IgG2a as the predominant subclass. Cytokine analysis also showed a significant increase in the Th1 (IFN-γ, IL-2) and Th2 (IL-4, 5, 6, 10) responses in lymphocytes from the spleen and MLNs of immunized mice upon stimulation with TsPmy protein. The expression of the homing receptors CCR9/CCR10 on antibody secreting B cells may be related to the translocation of IgA-secreted B cells to local intestinal mucosa. The mice immunized with Salmonella-delivered TsPmy DNA vaccine produced a significant 44.8% reduction in adult worm and a 46.6% reduction in muscle larvae after challenge with T. spiralis larvae. CONCLUSION:Our results demonstrated that oral vaccination with TsPmy DNA delivered by live attenuated S. typhimurium elicited a significant local IgA response and a mixed Th1/Th2 immune response that elicited a significant protection against T. spiralis infection in mice.

Trichinella spiralis infection induces protective immunity against re-infection in animal models. Identification of the antigens eliciting acquired immunity during infection is important for vaccine development against Trichinella infection and immunodiagnosis.The T. spiralis adult cDNA library was immunoscreened with sera from pigs experimentally infected with 20,000 infective T. spiralis larvae. Total 43 positive clones encoding for 28 proteins were identified; one of the immunodominant proteins was 20 kDa Ts-ES-1 secreted by Trichinella stichocytes and existing in the excretory/secretory (ES) products of T. spiralis adult and muscle larval worms. Ts-ES-1 contains 172 amino acids with a typical signal peptide in the first 20 amino acids. The expression of Ts-ES-1 was detected in both the adult and muscle larval stages at the mRNA and protein expression levels. Mice immunized with recombinant Ts-ES-1 (rTs-ES-1) formulated with ISA50v2 adjuvant exhibited a significant worm reduction in both the adult worm (27%) and muscle larvae burden (42.1%) after a challenge with T. spiralis compared to the adjuvant control group (p

Trichinellosis is a widespread zoonosis primarily caused by Trichinella spiralis. Mucosal immunity is crucial for preventing Trichinella spiralis infection. In our previous study, a DNA vaccine with the Trichinella antigen Ts87 delivered by an attenuated Salmonella typhimurium elicited partial protection against Trichinella spiralis infection in mice. In the current study, to elicit amore robust immune response and develop a potent vaccination strategy against trichinellosis, a heterologous prime-boost vaccination regimen for Ts87 was used in mice and the protective efficacy was evaluated compared to the homologous DNA prime-boost or protein prime-boost immunization alone. The results revealed that the DNA-prime/protein-boost vaccination with Ts87 induced higher levels of both humoral and cellular immune responses. The challenge results showed that mice with theDNA-prime/proteinboost vaccination displayed higher muscle larval reduction than those immunized with DNA prime-boost or protein prime-boost. The results demonstrated that mice vaccinated with Ts87 in a DNA-prime/protein-boost strategy effectively elicited a local IgA response and mixed Th1/Th2 immune response that might be responsible for improved protection against Trichinella spiralis infection. [ABSTRACT FROM AUTHOR]

Aim. To explore the efficacy of hospitals using case management with Directly Observed Treatment - Short course (DOTS) to monitor the adherence of patients with pulmonary tuberculosis in Taiwan. Background. Non-adherence to anti-tuberculosis chemotherapy is the major problem in treating patients with tuberculosis. Community-based case management coupled with DOTS has been applied to patients with tuberculosis and has resulted in good results in some countries. Taiwan has a high incidence of tuberculosis, and although it has implemented DOTS, the expected increased efficacy has not yet been realized. Design and methods. The study used a quasi-experimental design. Using age and gender as matching factors, 96 subjects were randomly assigned to one of three groups in 2002-2003. Experimental group I was to receive DOTS case management comprising in-hospital education, direct daily observation in the first two months and one home visit per week. Experimental group II received traditional case management comprising in-hospital education and one home visit per month. The control group did not receive any intervention. Results. The adherence, the rate of completion, the treatment success, sputum conversion and chest X-ray improvement of experimental group I were significantly improved compared with experimental group II and the control group. The completion rate in experimental group I was higher than the general rate for Taiwan during the past six years and the treatment success rate met the standards of the World Health Organization. Conclusion. Hospitals using case management with DOTS can improve the adherence of tuberculosis patients and the control of tuberculosis-epidemic situations. Relevance to clinical practice. In a rapidly changing healthcare environment, clinical nurses can make a significant contribution to healthcare delivery for tuberculosis patients. This study has provided further insight into the implementation of hospital-to-community level case management using DOTS by nurses. [ABSTRACT FROM AUTHOR]

The purpose of this cross-sectional study was to investigate the prevalence, interference with daily life, and risk factors of chronic pain among older people. A total of 219 older people were interviewed after being selected from communities of Taipei City, Taiwan, by a multiple-stage random-sampling technique. A face-to-face interview with a structured questionnaire was used to collect data. Our findings indicated that 42% (n=92) of older people experience chronic pain. Walking problems and moods were reported as the two leading causes of interference in daily life. There were statistically significant correlations between the presence of chronic pain and being a single female, having a low level of education, being influenced by religious beliefs, and being in poor health. We conclude that in Taipei City, approximately half of the older people have chronic pain and walking and mood problems. From our findings, we recommend paying attention to single females who have poor health and low education levels, as well as gaining a better understanding of the role that religious influences play in chronic pain, to better understand the prevalence of chronic pain in older people. Copyright © 2006 by Elsevier Science (USA). [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate the effect of a symptom management program on self-care of medication side effects among AIDS/HIV-positive patients. Sixty-seven patients from a sexually transmitted disease control center, a medical center, and a Catholic AIDS support group in Taipei were randomly assigned to three groups: one-on-one teaching, group teaching, and a control group. All subjects in each teaching group attended a 60- or 90- minute program on highly active antiretroviral therapy (HAART) side effect self-care education and skill training once per week for 3 weeks; subjects also underwent counseling by telephone. A medication side effect self-care knowledge questionnaire, Rosenberg's Self-Esteem Scale (RSES), and unscheduled hospital visits were used to evaluate the effectiveness of the symptom management program. The results revealed there were significant differences in mean difference of knowledge and unscheduled hospital visits between baseline and posttesting at 3 months for symptom management in the two groups. The mean difference of the selfesteem scale was not significant between the two groups. In summary, the symptom management program effectively increased the ability of AIDS/HIV-positive patients to self-care for medication side effects. We recommend that this program be applied in the clinical nursing practice. [ABSTRACT FROM AUTHOR]

The purpose of this study was to identify the variables related to quality of life in the population of individuals living with HIV/AIDS (PLWHA) in Taiwan. Purposive sampling was used to identify subjects from the outpatient departments (OPD) of three teaching hospitals and one sexually transmitted disease (STD) clinic in the Taipei area. For this study, the questionnaire included a demographic data sheet, physical-symptom distress and mood-disturbance scales, a personal-resource questionnaire (PRQ85-II) and a quality-of-life index (QLI). A total of 114 subjects completed the questionnaire. The results revealed that higher quality of life was associated with less mood disturbance (r = -.72; p <.001), reduced physical-symptom distress (r = -.47; r <.001), and higher levels of social support (r =.57; p <.001). PLWHA life quality was reflected accurately by mood disturbance, social support, physical-symptom distress, self-perceived mode of HIV transmission, and major source of financial support. These variables accounted for 60.9 % of QOL variance. As mood disturbance was the strongest predictor of quality of life, psychosocial intervention for mood disturbance should be emphasized and developed in future studies. [ABSTRACT FROM AUTHOR]

BACKGROUND: Post-operative nausea and vomiting is a common complication following general anaesthesia. Traditional Chinese medicine indicates that acupressure therapy may reduce nausea and vomiting in certain ailments. AIM(S) OF THE STUDY: The aim of this study was to examine the effect of stimulating two acupressure points on prevention of post-operative nausea and vomiting. DESIGN AND METHODS: A randomized block experimental design was used. The Rhodes Index of Nausea, Vomiting and Retching (INVR) questionnaire was used as a tool to measure incidence. To control the motion sickness variable, the subjects who underwent functional endoscopic sinus surgery (FESS) under general anaesthesia were randomly assigned to a finger-pressing group, a wrist-band group, and a control group. There were 150 subjects in total with each group consisting of 50 subjects. The acupoints and treatment times were similar in the finger-pressing group and wrist-band pressing group, whereas only conversation was employed in the control group. RESULTS: Significant differences in the incidence of the post-operative nausea and vomiting were found between the acupressure, wrist-band, and control groups, with a reduction in the incidence rate of nausea from 73.0% to 43.2% and vomiting incidence rate from 90.5% to 42.9% in the former. The amount of vomitus and the degree of discomfort were, respectively, less and lower in the former group. CONCLUSION: In view of the total absence of side-effects in acupressure, its application is worthy of use. This study confirmed the effectiveness of acupressure in preventing post-operative nausea and vomiting. [ABSTRACT FROM AUTHOR]

The triacetin and nitroglycerin barrier properties of layered-silicate reinforced ethylenepropylenediene monomer/chloroprene rubber (EPDM/CR) nanorubbers were investigated as rocket-propellant inhibitors. EPDM/CR nanorubbers with intercalated structures were formulated and prepared by the melt-compounding method. The triacetin permeability and nitroglycerin absorption were observed to decrease with increasing layered-silicate content. The layered silicates also improved the flame retardancies of the nanorubbers by forming silicate reinforced carbonaceous chars. Layered-silicate reinforced EPDM/CR nanorubbers are potentially effective rocket propellant-inhibiting materials.

To perform a meta-analysis to compare the efficacy and safety of diode laser transscleral cyclophotocoagulation (TSCPC) and cyclocryotherapy (CCT) in the treatment of intractable glaucoma. Systemic searches of the Ovid MEDLINE, EMBASE, and Cochrane Library databases yielded experimental and observational comparative studies. TSCPC and CCT efficacy and safety outcomes were compared. Subgroup analyses of participant ethnicity, preoperative intraocular pressure (IOP) level, and underlying causes of glaucoma were conducted. The pooled effects were computed using the random-effects model. The meta-analysis included nine studies totalling 668 eyes. There was no statistically significant difference between the TSCPC and CCT groups in the IOP reduction (IOPR%), decrease in antiglaucoma medications, the operative success rate with or without medications, or retreatment rate in the efficacy analysis. In the subgroup analysis, CCT had a better IOP-lowering effect among non-Asian participants and a non-inferior IOPR% to TSCPC among Asian participants. TSCPC and CCT were associated with similar rates of deterioration in visual acuity, postoperative visual analog scale, and other analysed postoperative complications in the safety analysis. In both groups, severe complications were uncommon. Diode laser TSCPC and CCT had nearly equivalent clinical efficacy in treating intractable glaucoma, while CCT demonstrated a better IOP-lowering effect in non-Asian. Both cyclodestructive procedures have a comparable safety profile., (© 2023 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To evaluate the intraocular pressure (IOP)-reducing efficacy and safety of Rho-kinase inhibitor (RKI)., Methods: Published studies in PubMed and EMBASE were searched on March 20, 2021. Study selection and data extraction were performed according to PRISMA. Meta-analysis of the IOP-lowering effect was performed with the bivariate random-effects model, with studies categorized into 2 classes: RKI versus placebo and RKI versus another medication. The main outcome was the difference in IOP reduction between RKI and non-RKI groups. Subgroup analysis of adjunctive RKI efficacy and additional review of its major ocular adverse events (AE) were also performed., Results: Ten (2.6%) out of 391 studies were retrieved. In the RKI versus placebo class, RKI showed greater IOP reduction after 4-8 weeks (mean difference =  - 1.69 mmHg [- 2.22, - 1.16], P < 0.001). In the RKI versus another medication class, IOP reduction by RKI was noninferior to timolol 0.5% twice-daily after 4-8 weeks (mean difference = 0.39 mmHg [0.01, 0.76], P = 0.043) and 12 weeks (mean difference = 0.48 mmHg [0.11, 0.85]; P = 0.011). In the subgroup analysis, the mean difference in IOP reduction by adjunctive RKI and placebo was - 1.42 mmHg (P < 0.001). The most common ocular AE of RKI was conjunctival hyperemia (19-65%), followed by conjunctival hemorrhage (6-20%) and cornea verticillata (13-26%)., Conclusions: With a treatment duration of 1-3 months, RKI showed effective IOP reduction noninferior to timolol as monotherapy and as adjunctive therapy. Our results suggested RKI be a reliable IOP control medication; however, its higher incidence of some ocular complications should be attended to., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Anti-glaucoma agents-induced corneal toxicity may be misdiagnosed as herpetic simplex keratitis (HSK). In our study, nineteen glaucoma patients were presumed to have HSK before referral. Corneal lesions were classified into (I) linear pseudodendritic lesions formed by elevated opacified cells, (II) linear pseudodendritic lesions formed by grouped superficial punctate keratitis (SPK), (III) satellite full-thickness epithelial defects, (IV) satellite lesions formed by elevated opacified cells, and (V) geographic lesions formed by grouped SPK. We observed thirty-one events, with 15 in the lower and 16 in the central corneas. There were 21 (67.7%) type II, five (16.1%) type V, two (6.5%) of each for types III and IV, and one (3.2%) type I events. Among linear lesions (types I and II), 17 (77.3%) had horizontal and 5 (22.7%) had curvilinear orientations. Exposure duration to the last-added anti-glaucoma agent was three days to 14.5 years. About half of the events (16/31, 51.6%) used prostaglandin analogues, and 30/31 (96.8%) applied benzalkonium chloride (BAK)-containing agents. All lesions resolved within two months after decreasing offending medications or enhancing protection of ocular surface. In conclusion, anti-glaucoma agents-induced pseudodendritic keratitis presents majorly in central-lower cornea as horizontally linear lesions, and BAK-containing agents are observed in the most events., (© 2021. The Author(s).)

Purpose: To describe the clinical features and surgical outcomes of diabetic retinopathy-associated lamellar macular hole and compare them with those of idiopathic lamellar macular hole., Methods: A total of 17 eyes with diabetic retinopathy-associated lamellar macular hole and 30 eyes with idiopathic lamellar macular hole undergoing surgery were retrospectively enrolled. Baseline best-corrected visual acuity, preoperative optical coherence tomography characteristics, and final best-corrected visual acuity were compared between two groups., Results: Both the baseline and the final best-corrected visual acuity in the diabetic retinopathy group were significantly worse than those in the idiopathic group (p = 0.029 for baseline, p = 0.002 for final). Lamellar macular hole in diabetic retinopathy tended to have a wider opening (p < 0.001) and a thinner residual base (p = 0.023). The width and height of parafoveal schisis in diabetic retinopathy-associated lamellar macular hole were both larger than those in idiopathic lamellar macular hole (p < 0.001 for both). After operation, both groups achieved significant improvement in best-corrected visual acuity (p < 0.01 for both)., Conclusion: Compared with idiopathic group, diabetic retinopathy-associated lamellar macular hole had worse baseline best-corrected visual acuity, wider defect, and more pronounced parafoveal schisis. However, significant visual improvement could be obtained after operation. All cases in both groups achieved good anatomical outcomes with normalization of foveal contour and reduction of parafoveal schisis.

Purpose: To develop and compare deep learning (DL) algorithms to detect keratoconus on the basis of corneal topography and validate with visualization methods., Methods: We retrospectively collected corneal topographies of the study group with clinically manifested keratoconus and the control group with regular astigmatism. All images were divided into training and test datasets. We adopted three convolutional neural network (CNN) models for learning. The test dataset was applied to analyze the performance of the three models. In addition, for better discrimination and understanding, we displayed the pixel-wise discriminative features and class-discriminative heat map of diopter images for visualization., Results: Overall, 170 keratoconus, 28 subclinical keratoconus and 156 normal topographic pictures were collected. The convergence of accuracy and loss for the training and test datasets after training revealed no overfitting in all three CNN models. The sensitivity and specificity of all CNN models were over 0.90, and the area under the receiver operating characteristic curve reached 0.995 in the ResNet152 model. The pixel-wise discriminative features and the heat map of the prediction layer in the VGG16 model both revealed it focused on the largest gradient difference of topographic maps, which was corresponding to the diagnostic clues of ophthalmologists. The subclinical keratoconus was positively predicted with our model and also correlated with topographic indexes., Conclusions: The DL models had fair accuracy for keratoconus screening based on corneal topographic images. The visualization mentioned in the current study revealed that the model focused on the appropriate region for diagnosis and rendered clinical explainability of deep learning more acceptable., Translational Relevance: These high accuracy CNN models can aid ophthalmologists in keratoconus screening with color-coded corneal topography maps., Competing Interests: Disclosure: B.-I. Kuo, None; W.-Y. Chang, None; T.-S. Liao, None; F.-Y. Liu, None; H.-Y. Liu, None; H.-S. Chu, None; W.-L. Chen, None; F.-R. Hu, None; J.-Y. Yen, None; I.-J. Wang, None, (Copyright 2020 The Authors.)

Purpose: To present recurrent corneal erosion (RCE) caused by late suture exposure after blepharoplasty., Methods: Four patients who have unilateral RCE were found to have previous blepharoplasty. The RCE was associated with late suture exposure. The clinical courses, characteristics, methods to identify the suture exposure and treatment were presented., Results: The clinical presentations including local erosion of upper bulbar conjunctiva, corneal abrasion lines, local corneal epithelial defects with rough border, and subepithelial opacity were noticed in all four patients. RCE symptoms exaggerated in eye blinking and did not respond to artificial tears treatment. Erosion recurred soon after the removal of therapeutic contact lenses. They underwent blepharoplasty 1-10 years before RCE emerged, and the RCE lasted 1-8 months before suture exposure was found. RCE healed within 1 week after suture removal., Conclusions: Suture exposure may occur several years after blepharoplasty and could cause RCE. Thorough exploration of the fornix by double eyelid eversion can identify the hidden sutures in such patients.

Background: Standing height (SH) is the most reliable parameter used to predict spirometric values in children, but measurement of this parameter may be difficult in children with thoracic or spinal abnormalities. This study was designed to establish reference equations to estimate SHs of children using their arm span length (ASL) or forearm ulnar length (UL) as an index., Methods: Children aged 1-17 years were enrolled to measure their SH, body weight, ASL, and UL. Sex and age were also recorded. The relationship between SH and children's weight, age, ASL, and UL were analyzed. Regression equations using different indexes for SH of enrolled cases were used, and adults aged 18-64 years were also enrolled for comparison., Results: A total of 512 children and 144 adults were enrolled. There was a strong linear relationship between SH and both ASL and UL in children and adults. Pearson's correlation coefficients of SH for ASL and UL were 0.989 and 0.968 (p < 0.001) in children and 0.933 and 0.845 (p < 0.001) in adults. The linear regression equations for estimating SH in children were calculated as SH = 9.363 + 0.943 ASL (r 2  = 0.978, p < 0.001) and SH = 14.542 + 5.570 UL (r 2  = 0.936, p < 0.001). In adults, age and sex were also added as indexes: SH = 59.849 + 0.642 ASL-0.047 Age +3.431 Sex (male = 1; female = 0) (r 2  = 0.887, p < 0.001) and SH = 102.824 + 2.317 UL -0.049 age + 6.739 sex (r 2  = 0.773, p < 0.001)., Conclusion: Both ASL and UL have a significant linear relationship with SHs of children and adults. True SH can be estimated using regression equations with ASL or UL as a single index for situations where direct measurement of SH is difficult., (Copyright © 2018. Published by Elsevier Taiwan LLC.)

Background: The prevalence of cognitive impairment is increasing due to the aging population, and early detection is essential clinically. The Ascertain Dementia 8 (AD8) questionnaire is a brief informant-based measure recently developed to assess early cognitive impairment, however, its overall diagnostic performance is controversial. The objective of this meta-analysis was to assess the diagnostic accuracy of the AD8 for cognitive impairment., Methods: All relevant studies were collected from databases including MEDLINE, EMBASE and the Cochrane Library up to April 2017. We used QUADAS-2 to assess the methodological quality after the systematic search. The accuracy data and potential confounding variables were extracted from the eligible studies which included those in English and non-English. All analyses were performed using the Midas module in Stata 14.0 and Meta-DiSc 1.4 software., Results: Seven relevant studies including 3728 subjects were collected, and classified into two subgroups according to the severity of cognitive impairment. The overall sensitivity (0.72, 0.91) was superior to specificity (0.67, 0.78). The pooled negative likelihood ratio (0.17, 0.13) was better than the positive likelihood ratio (2.52, 3.94). The areas under the summary receiver operating characteristic curve were 0.83 and 0.92, respectively. Meta-regression analysis showed that location (community versus non-community) may be the source of heterogeneity. The average administration time was less than 3 minutes., Conclusion: Our findings suggest that the AD8 is a competitive tool for clinically screening cognitive impairment and has an optimal administration time in the busy primary care setting. Subjects with an AD8 score ≧2 should be highly suspected to have cognitive impairment and a further definite diagnosis is needed.

Objectives: To evaluate the combined effects of surfactant lavage and intratracheally instillation of budesonide on meconium-injured piglet lungs., Design: A prospective, randomized, animal model study., Setting: An experimental laboratory., Subjects: Twenty-four anesthetized and mechanically ventilated newborn piglets., Interventions: Human meconium slurry was intratracheally instilled into piglet lungs to induce lung injury. The injured piglets were randomly assigned to either the sham treatment group (control) or one of the three therapeutic groups: the intratracheally instilled budesonide (Bud) group, the bronchoalveolar lavage with diluted surfactant (dsBAL) group, and the combination therapy of Bud and dsBAL (dsBAL + Bud) group., Measurements and Main Results: Cardiopulmonary profiles were measured hourly. Proinflammatory cytokine (interleukin-1β, interleukin-6, and interleukin-8) levels in bronchoalveolar lavage fluid were measured. Finally, the pulmonary histology of the experimental subjects was examined at the end of experiments. Both of the lavaged groups (dsBAL and dsBAL + Bud) showed significantly better oxygenation than those that had not undergone lavage (control and Bud) (p < 0.05). The dsBAL + Bud group showed a significantly higher lung compliance and required a significantly lower peak inspiratory pressure during the experimental periods than the other three groups (p < 0.05). All treatment groups had significantly lower concentrations of interleukin-1β concentration in the bronchoalveolar lavage fluid than the control group (p < 0.05). The dsBAL + Bud group also had a significantly lower interleukin-6 concentration in the bronchoalveolar lavage fluid (p< 0.05), as well as a significantly lower lung injury score based on pulmonary histology than the control group (p < 0.05)., Conclusions: Therapeutic bronchoalveolar lavage with diluted surfactant followed by intratracheal instillation of budesonide has a synergistic and beneficial effect when treating severe meconium-injured newborn piglet lungs.

Objective: Ankylosing spondylitis (AS) is a common inflammatory rheumatic disease. A higher prevalence of psychiatric comorbidities, including depressive disorder, has been proven in patients with AS. However, a clear temporal causal relationship between AS and psychiatric disorders has not been well established. We performed a nationwide population-based retrospective cohort study to analyze the relationship between AS and the subsequent development of psychiatric disorders, including schizophrenia, bipolar disorder, depressive disorders, anxiety disorders, and sleep disorders., Methods: We identified subjects who were newly diagnosed with AS between January 1, 2000, and December 31, 2008, in the Taiwan National Health Insurance (NHI) Research Database. A comparison cohort was constructed of patients without AS who were matched according to age and sex. All patients with AS and control patients were observed until diagnosed with psychiatric disorders, or until death or withdrawal from the NHI system, or until December 31, 2009., Results: The AS cohort consisted of 2331 patients and the comparison cohort consisted of 9324 matched control patients without AS. The adjusted HR for depressive disorders, anxiety disorders, and sleep disorders in subjects with AS were higher than those of the controls during followup (HR 1.718, 95% CI 1.303-2.265; HR 1.848, 95% CI 1.369-2.494; and HR 1.494, 95% CI 1.031-2.162, respectively)., Conclusion: AS might increase the risk of a subsequent newly diagnosed depressive disorder, anxiety disorder, or sleep disorder, but not schizophrenia or bipolar disorder. These observations highlight the need for psychiatric evaluation and intervention for patients with AS.

Objective: Primary Sjögren syndrome (pSS) is a chronic autoimmune disease. A clear temporal causal relationship between pSS and psychiatric disorders has not been well established. We used a nationwide population-based retrospective cohort study to explore the relationship between pSS and the subsequent development of psychiatric disorders., Methods: We identified subjects who were newly diagnosed with pSS between January 1, 2000, and December 31, 2008, in the Taiwan National Health Insurance (NHI) Research Database. A comparison cohort was constructed for patients without pSS. There were 2686 patients with pSS and 10,744 matched controls observed until diagnosed with psychiatric disorders or until death, withdrawal from the NHI system, or December 31, 2009. The Institutional Review Board of Taipei Veterans General Hospital approved this study (2012-12-013BC)., Results: The adjusted HR of depressive disorder, anxiety disorder, and sleep disorder in subjects with pSS were significantly higher at 1.829, 1.856, and 1.967 than those of the controls during the followup. We found that pSS might increase the risk of subsequent newly diagnosed depressive disorder, anxiety disorder, and sleep disorder that may impair life quality., Conclusion: Our findings highlight the need for psychiatric evaluation and intervention for patients with pSS.

Objectives: This study aims to contribute to the development of objective diagnostic standards in Traditional Chinese Medicine (TCM), in order to improve the training of physicians., Methods: We devised a questionnaire study to evaluate the accuracy of resident doctors' diagnostic skills by comparing their assessment of patients with those of their senior supervising physician and the patients themselves. We selected 39 patients with systemic lupus erythematosus (SLE) at Chang Gung Memorial Hospital, Taiwan, between November 1, 2008 and June 30, 2012, and had the resident doctors (R), their senior supervisor (S) and their patients (P) fill out questionnaires before treatment (V1), immediately after treatment (V5) and two months after treatment (V6), in order to record their assessments on the patients' condition. The R and S questionnaires covered subjective symptoms, tongue, and pulse, while the P questionnaires only included general symptoms. We then compared the assessment records to determine the level of agreement between them., Results: The agreements of inquiry during the study for P and S were 0.78 (V1) to 0.84 (V6) and 0.87 (V1) to 0.94 (V6) for R and S, respectively, the agreements between R and S for tongue diagnosis and pulse diagnosis were 0.87 (V1) to 0.90 (V6) and 0.91 (V1) to 0.95 (V6), respectively. All the above agreements improved with time from V1 to V6., Conclusions: The results show that the patient input was feasible and effective and that the questionnaire method provided an objective assessment standard to determine how successfully the resident doctor was trained. Furthermore, it facilitated a training process that could help resident doctors improve their skills., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the risk of Parkinson disease (PD) among patients with depression by using the Taiwan National Health Insurance Research Database (NHIRD)., Methods: We conducted a retrospective study of a matched cohort of 23,180 participants (4,634 patients with depression and 18,544 control patients) who were selected from the NHIRD. Patients were observed for a maximum of 10 years to determine the rates of new-onset PD, and Cox regression was used to identify the predictors of PD. We also examined the risk of PD after excluding patients who were diagnosed with PD within 2 or 5 years after their depression diagnosis. A logistic regression model was used to identify risk factors associated with PD onset in patients with depression., Results: During the 10-year follow-up period, 66 patients with depression (1.42%) and 97 control patients (0.52%) were diagnosed with PD. After adjusting for age and sex, patients with depression were 3.24 times more likely to develop PD (95% confidence interval 2.36-4.44, p < 0.001) compared with the control patients. After excluding patients who were diagnosed with PD within 2 or 5 years after their depression diagnosis, patients with depression had a higher hazard ratio for developing PD than the control patients. The odds ratios for age (1.09) and difficult-to-treat depression (2.18) showed that each is an independent risk factor for PD in patients with depression., Conclusion: The likelihood of developing PD is greater among patients with depression than patients without depression. Depression may be an independent risk factor for PD.

Pain is a common problem among the elderly. The entire scope of chronic pain relief strategies used by community elderly is still unclear. A limited number of studies have investigated this issue from diverse culture perspectives. In the present study, we investigated the use and perceived effectiveness of pain relief strategies adopted by the elderly; gender differences between frequently used relief strategies were also explored. Two hundred nineteen participants living in Taiwan City, Taiwan, were recruited by a random sampling method and interviewed face to face. The prevalence of chronic pain among the elderly was 42.0% (n = 92). The elderly tended to adopt multiple strategies (mean ± SD = 9.08 ± 3.56; range = 2-18) to relieve their chronic pain. In three domains of pain relief strategies, conventional medicine was used more frequently than complementary and alternative medicine and psychologic approaches. Most pain relief strategies were ineffective. Among the 22 strategies used, no strategy was reported as "much improved" by a majority of users. The top five pain relief strategies used by men and women were the same. Elderly women tended to adopt more psychologic approaches, such as acceptance and ignoring to relieve pain, than men. The findings suggest that nurses should pay more attention to the issue of chronic pain relief and provide the elderly with more effective pain relief strategies., (Copyright © 2011 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Background and Objective: ARDS is life-threatening acute respiratory failure, and pneumonia is one of the most common causes of direct ARDS. Procalcitonin (PCT) has been evaluated for its utility in determining the aetiology of community-acquired pneumonia (CAP), choice of antibiotics and prediction of outcome. This study evaluated the role of PCT in predicting the outcome of patients with ARDS caused by severe CAP., Methods: This was a prospective observational study conducted from September 2002 to December 2003. The plasma PCT was analysed at baseline, 24 and 72 h after enrolment and measured by ELISA., Results: Of the 22 patients with ARDS caused by CAP and enrolled in the study, 17 (77.3%) were alive 14 days after admission and five (22.7%) had died. The survivors had lower APACHE II scores (22.2 +/- 4.6 vs 30.6 +/- 9.6, P = 0.031), pneumonia severity index (141.9 +/- 2.2 vs 195.6 +/- 23.8, P = 0.005) and lower plasma PCT at baseline (9.83 +/- 3.54 vs 106.70 +/- 67.86, P = 0.004), at 24 h (10.51 +/- 5.39 vs 81.32 +/- 57.68, P = 0.014) and at 72 h (2.03 +/- 0.76 vs 19.57 +/- 6.67, P = 0.005)., Conclusion: PCT analysed within 72 h of the onset of ARDS predicted mortality of patients with ARDS caused by severe CAP.

Background/purpose: Acute respiratory distress syndrome (ARDS) is a serious disorder of intensive care unit patients. We evaluated the safety of continuous prone position ventilation (PRONE) and its effects on oxygenation and plasma cytokine concentrations in patients with ARDS caused by severe community-acquired pneumonia (CAP)., Methods: This was a prospective observational clinical study conducted in a respiratory intensive care unit of a 1200-bed medical center in central Taiwan. Twenty-two patients with severe CAP and ARDS were included. They were treated by traditional supine ventilation (SUPINE, n = 11) or PRONE (n = 11) if they met the criteria for ARDS. Patients in the PRONE group were ventilated in prone position continuously for at least 72 hours. Plasma cytokines were collected and analyzed at baseline, 24 hours and 72 hours after enrolment. Serial PaO2/FiO2 and complications were evaluated., Results: Complications associated with PRONE were minor and self-limited. PRONE had higher PaO2/FiO2 ratio than SUPINE did at 48 hours after enrolment. The levels of plasma IL-6 concentration declined significantly with time in the PRONE group (p = 0.011). The levels of plasma IL-6 concentration at enrolment, 24 hours and 72 hours after enrolment also predicted the 14th day mortality of all patients., Conclusion: PRONE was a safe and effective maneuver for improving oxygenation in patients with severe CAP and ARDS. PRONE also influenced IL-6 expression in patients with severe CAP.

Background and Objective: The triggering receptor expressed on myeloid cell-1 (TREM-1) is a newly discovered molecule that is associated with the inflammatory response to microorganisms. We investigated the role of surface and soluble TREM-1 in differentiating different disease entities in pleural effusion formation., Methods: Sixty-seven patients with pleural effusion due to transudate (14), malignancy (15), tuberculous pleuritis (16), para-pneumonic effusion (10) and empyaema (12) were included in this study. Surface TREM-1 was measured by flow cytometry and was expressed as mean fluorescence intensity and soluble TREM-1 was measured by ELISA and expressed as pg/mL. Results are given as mean levels +/- SEM., Results: Surface TREM-1 was measured in 24 patients and the levels were highest in para-pneumonic effusion (30.0 +/- 8.4) and lowest in malignant pleural effusion (5.2 +/- 1.1) and tuberculous pleuritis (5.2 +/- 2.4). Soluble TREM-1 was highest in effusions of infectious aetiology (para-pneumonic effusion (979.4 +/- 229.6) and empyaema (1712.6 +/- 299.5)) and lowest in non-infectious effusions (transudate (81.2 +/- 4.5 pg/mL) and malignancy (111.3 +/- 20.7). At a cut-off value of 114 pg/mL, soluble TREM-1 yielded a sensitivity of 87.5% and a specificity of 89.7% in differentiating non-infectious effusion from tuberculous pleuritis. At a cut-off value of 374 pg/mL, sTREM-1 yielded a sensitivity of 93.8% and a specificity of 90.9 in differentiating tuberculous pleuritis from bacterial pleural effusion., Conclusion: Soluble and surface TREM-1 are valuable markers in establishing the aetiology of pleural effusions.

Background: Thromboembolic disease is a major cause of morbidity and mortality in many countries. Our previous study found that Chinese subjects carried the same polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene as described in Western studies. The aim of the present study was to determine the influence of MTHFR polymorphism, B vitamins and other factors on plasma homocysteine (Hcy) levels and risk of thromboembolic disease in Chinese., Methods: One hundred and six subjects were enrolled into the study. They were categorized into 4 groups: healthy individuals (n = 42); those with diabetes mellitus (n = 20); those with deep vein thrombosis (DVT) (n = 11); and those with coronary artery disease (CAD) (n = 33). Plasma levels of folic acid, vitamins B6 and B12, Hcy, and fasting blood sugar were measured; total cholesterol, triglycerides, complete blood count, and 677 C-->T mutation in MTHFR were determined., Results: Plasma Hcy was lowest in the healthy subjects, higher in diabetics, followed by patients with DVT, and highest in patients with CAD (p < 0.001, ANOVA). MTHFR C677T polymorphism was the common factor affecting plasma logHcy levels in all 4 groups of subjects. Triglycerides affected plasma logHcy in the CAD patients. For the 4 groups as a whole, MTHFR polymorphism, triglycerides, and vitamin B12 were the most significant factors influencing plasma Hcy., Conclusion: We suggest that high plasma Hcy is an important risk factor for CAD. Other factors including MTHFR polymorphism, vitamin B12, triglycerides, total cholesterol, and gender might affect Hcy levels in different diseases and conditions.

Advanced non-small-cell lung cancer (NSCLC) patients with poor performance status (PS) are less likely to respond to chemotherapy, or to have an improvement in survival, but more likely to experience toxicity. We retrospectively evaluated the efficacy and tolerability of gefitinib in patients with advanced NSCLC and very poor PS in Taiwan. Patients with stage IIIB, IV NSCLC with an Eastern Cooperative Oncology Group (ECOG) PS of 3-4 received oral gefitinib 250 mg once daily. Totally, 52 patients were included (25 men, 27 women). Forty-three patients (82.7%) were in a PS of 3. Tumor response rate was 25.0% (13/52). Tumor response rate to gefitinib was highest in chemonaive patients 38.1% (8/21) vs. failed 1 chemotherapy regimen 13.3% (2/15) vs. failed 2 or more chemotherapy regimens 18.8% (3/16), p = 0.015. The median overall survival was 2.5 months (response group 9.1 months, stable disease 3.1 months, and progressive group 0.8 month, p < 0.001). Adverse events, mainly skin reactions and diarrhea, were generally mild (grade 1 or 2) except paronychia and acne. Thus, gefitinib has clinically antitumor activity and good tolerability in Taiwan patients with advanced NSCLC and very poor performance status, with a higher response rate than that seen Europe or in European heritage Americans. Chemonaive patients responded better than patients with prior chemotherapy. Formal clinical trials are warranted to evaluate the role of gefitinib in this situation.

Objective: The aim of this study was to evaluate the characteristics of asthma in patients with different ages of disease onset., Methodology: Five hundred and four asthmatic patients (303 males and 201 females) were divided into five groups based on age of onset (group I, age of onset < 15 years old; group II, 15-24 years old; group III, 25-44 years old; group IV, 45-64 years old; and group V, > 64 years old). The relationship between age of onset and the characteristics of asthma, including lung function, reversibility, atopic status and the incidence of coexistent allergic rhinitis was assessed. Multivariate analysis, adjusted for the duration of disease, gender, educational level, smoking status, and degree of previous inhaled corticosteroid treatment, was performed., Results: Thirty per cent of the patients developed asthma before they were 14 years old (group I), and the percentages of those developing asthma at other ages of onset were: group II, 12%; group III, 29%; group IV, 21% and group V, 8%. In all, 57.6% of the asthmatic patients had coexistent allergic rhinitis; younger patients tended to have this comorbidity. The pulmonary function of older onset asthma patients was worse than that of early onset patients. The multivariate analysis showed that there was a positive correlation between the reduction of pulmonary function and duration of the disease (P < 0.001), but there was no relationship between pulmonary function and gender (P = 0.502), educational level (P = 0.734), smoking pack-years (P = 0.902), or degree of use of inhaled corticosteroid treatment (P = 0.586)., Conclusion: Asthma is a heterogeneous disease with a wide variety of presentations. This study provides information about the disease characteristics and their relationship with age of onset. Further study is necessary to determine why these differences exist.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections are an emerging problem. Although most liver abscesses are caused by Escherichia coli and Klebsiella pneumoniae, S. aureus can occasionally be isolated as the pathogenic organism. Liver abscess caused by MRSA is rarely reported. Here, we report a case of liver abscess due to MRSA in a 34-year-old man with end-stage renal disease and a 13-year history of hemodialysis treatment.

Bacterial infection may adversely affect the hemostasis of patients with gastroesophageal variceal bleeding (GEVB). Antibiotic prophylaxis can prevent bacterial infection in such patients, but its role in preventing rebleeding is unclear. Over a 25-month period, patients with acute GEVB but without evidence of bacterial infection were randomized to receive prophylactic antibiotics (ofloxacin 200 mg i.v. q12h for 2 days followed by oral ofloxacin 200 mg q12h for 5 days) or receive antibiotics only when infection became evident (on-demand group). Endoscopic therapy for the GEVB was performed immediately after infection work-up and randomization. Fifty-nine patients in the prophylactic group and 61 patients in the on-demand group were analyzed. Clinical and endoscopic characteristics of the gastroesophageal varices, time to endoscopic treatment, and period of follow-up were not different between the two groups. Antibiotic prophylaxis decreased infections (2/59 vs. 16/61; P <.002). The actuarial probability of rebleeding was higher in patients without prophylactic antibiotics (P =.0029). The difference of rebleeding was mostly due to early rebleeding within 7 days (4/12 vs. 21/27, P =.0221). The relative hazard of rebleeding within 7 days was 5.078 (95% CI: 1.854-13.908, P <.0001). The multivariate Cox regression indicated bacterial infection (relative hazard: 3.85, 95% CI: 1.85-13.90) and association with hepatocellular carcinoma (relative hazard: 2.46, 95% CI: 1.30-4.63) as independent factors predictive of rebleeding. Blood transfusion for rebleeding was also reduced in the prophylactic group (1.40 +/- 0.89 vs. 2.81 +/- 2.29 units, P <.05). There was no difference in survival between the two groups. In conclusion, antibiotic prophylaxis can prevent infection and rebleeding as well as decrease the amount of blood transfused for patients with acute GEVB following endoscopic treatment.

Background: Infective endocarditis (IE) is a serious infectious condition, with high morbidity and mortality in hemodialysis (HD) patients. This study was undertaken to determine the IE risk factors in maintenance HD patients, and the mortality risk factors., Methods: We retrospectively reviewed all IE cases of maintenance HD patients at our center over the past 15 yrs (the study group). Regular HD patients without IE in the same period were used as the control group. The basic data of the two groups were analyzed to determine IE risk factors in HD patients. The in-hospital parameters of survival and mortality in the study group patients were used for mortality risk factors analysis., Results: There were 18 definite, and two possible, IE diagnoses in the study group and no cases in the 268 controls. There was no significant difference in age, sex, diabetes, hypertension, underlying malignancy, previous cerebral vascular accident (CVA) history, and calcium multiplied by phosphate product. There was a significant difference between the two groups (study group vs. controls) in pacemaker implant history (15 vs. 1.1%, p<0.01), previous heart surgery history (15 vs. 0.4%, p<0.01), congestive heart failure (CHF) (50 vs. 10.4%, p<0.05), duration on maintenance HD (12.9+/-19.1 vs. 57.9+/-42.3 months, p<0.001), serum albumin at the time of admission (2.91+/-0.40 vs. 3.96+/-0.52 g/dL, p<0.001). There were more patients dialyzed via non-cuffed dual-lumen catheters in the study group (55 vs. 0%, p<0.001), and fewer patients dialyzed via arteriovenous fistula (AVF) (25 vs. 87.7%, p<0.001). The mortality in HD patients with IE was high (60%), especially in patients with methicillin-resistant Staphylococcus aureus (MRSA) endocarditis (100%). The most common pathogen was S. aureus (n=12). MRSA was more common than methicillin-susceptible S. aureus (MSSA) (67 vs. 33%). Univariant analysis of in-hospital clinical parameters for mortality revealed no significant difference in age, diabetes, dual-lumen catheter implantation, serum albumin, time to diagnosis, and time to antibiotic use. Borderline statistical significance was noted in serum C-reactive protein (CRP) (p=0.051), and blood glucose level (p=0.056). There were more IE cases due to MRSA in the mortality group than in the survival group (8 vs. 0 cases, p=0.013), but fewer cases due to MSSA (0 vs. 4 cases, p=0.050)., Conclusions: IE should be considered in HD patients with the following risk factors, which include previous heart surgery or pacemaker implantation, shorter HD duration, and especially for patients dialyzed via dual-lumen catheters. The in-hospital clinical parameters including CRP and blood sugar level can offer information concerning prognosis. Since MRSA has increased in recent years and is associated with high mortality, strategies for prevention and treatment require development.

Objective: To investigate whether breathing pattern variability can serve as a potential weaning predictor for postoperative patients recovering from systemic inflammatory response syndrome (SIRS)., Design and Setting: A prospective measurement of retrospectively analyzed breathing pattern variability in a surgical intensive care unit., Patients: Seventy-eight mechanically ventilated SIRS patients who had undergone abdominal surgery were included when they were ready for weaning. They were divided into success (n=57) and failure (n=21) groups based upon their weaning outcome., Measurements and Results: Before weaning, tidal volume, total breath duration, inspiratory time, expiratory time, and peak inspiratory flow were continuously monitored for 30 min, while patients received 5 cmH2O pressure support weaning trial. After the patients successfully completed the trial, they were extubated. Successful weaning was defined as patients free from the ventilator for over 48 h, whereas a weaning failure was considered as reinstitution of mechanical ventilation within 48 h of extubation. The coefficient of variation and two values of standard deviation (SD1 and SD2; indicators of the dispersion of data points in the plot) obtained from the Poincaré plot of five respiratory parameters in the failure group were significantly lower than those in the success group. The area under the receiver operating characteristic curve of these variability indices was within the range of 0.73-0.80, indicating the accuracy of prediction., Conclusions: Small breathing pattern variability is associated with a high incidence of weaning failure in postoperative patients recovering from SIRS, and this variability may potentially serve as a weaning predictor.

Purpose: To examine the efficacy and safety of administration of calcium and magnesium orally and intraperitoneally to treat severe sodium fluoride intoxication., Materials and Methods: Mice were initially gavaged a lethal dose of sodium fluoride (NaF) or water. Then, mice were treated with water or varying concentrations of calcium chloride (CaCl2) or magnesium sulfate (MgSO4) via intraperitoneal (IP) route or via oral route. Mice were monitored for 24 h, and the time of death was recorded., Results: IP injections of large amounts of CaCl2 or MgSO4 were dangerous. All mice gavaged with water and then treated with oral CaCl2 or MgSO4 survived and displayed normal activity during the experiment. The survival rate of mice gavaged with a lethal dose of NaF and then treated with a high dose of oral CaCl2 or MgSO4 was significantly higher than those of using low dose., Conclusion: Oral administration of a high dose of CaCl2 or MgSO4 is a simple, safe, and effective adjunctive method for treating severe oral fluoride poisoning.

The purpose of this study was to identify the variables related to quality of life in the population of individuals living with HIV/AIDS (PLWHA) in Taiwan. Purposive sampling was used to identify subjects from the outpatient departments (OPD) of three teaching hospitals and one sexually transmitted disease (STD) clinic in the Taipei area. For this study, the questionnaire included a demographic data sheet, physical-symptom distress and mood-disturbance scales, a personal-resource questionnaire (PRQ85-II) and a quality-of-life index (QLI). A total of 114 subjects completed the questionnaire. The results revealed that higher quality of life was associated with less mood disturbance (r = -.72; p <.001), reduced physical-symptom distress (r = -.47; r <.001), and higher levels of social support (r =.57; p <.001). PLWHA life quality was reflected accurately by mood disturbance, social support, physical-symptom distress, self-perceived mode of HIV transmission, and major source of financial support. These variables accounted for 60.9 % of QOL variance. As mood disturbance was the strongest predictor of quality of life, psychosocial intervention for mood disturbance should be emphasized and developed in future studies.

Background: The clinical spectrum of severe acute respiratory syndrome (SARS) varies widely in the way that asymptomatic carriers are believed to exist in the community. Still there are severe forms of illness in which the patients deteriorate unexpectedly within hours. This study delineates clinical characteristics of such fatal cases of SARS for the purpose of identifying patients with poor outcome., Method: Patients with the diagnosis of probable or suspected SARS admitted to the Taipei Veterans General Hospital during the period from March 26, 2003 to May 25, 2003 were included. The medical records of fatal cases were retrospectively reviewed., Results: During the study period, thirty-six probable cases and 17 suspected cases of SARS were identified. Eight probable but none of the suspected cases died from acute respiratory distress syndrome (ARDS) with multiple organ dysfunction after a median of 6-day hospital stay (range, 1-30 days). All but 2 patients acquired the infection nosocomially. Of the fatal cases, four were males and 4 females, with the median age of 65 years (range, 29-76 yrs). All except 3 had co-morbid conditions, such as hypertension, diabetes mellitus, coronary artery disease or chronic obstructive pulmonary disease. The lactate dehydrogenase (LDH) values were abnormal (> 200 U/L) in all patients. The chest radiograph of these fatal cases consistently showed multifocal infiltration over the unilateral or bilateral lobe of the lung., Conclusions: Patients of SARS who had advanced age, co-morbid conditions, highly elevated LDH and multifocal infiltration over chest radiograph should be closely monitored and actively treated.