Multidrug Resistant Acinetobacter baumannii: Risk Factors for Appearance of Imipenem Resistant Strains on Patients Formerly with Susceptible Strains

BACKGROUND: Multidrug resistant Acinetobacter baumannii (MDRAB) is an important nosocomial pathogen usually susceptible to carbapenems; however, growing number of imipenem resistant MDRAB (IR-MDRAB) poses further clinical challenge. The study was designed to identify the risk factors for appearance of IR-MDRAB on patients formerly with imipenem susceptible MDRAB (IS-MDRAB) and the impact on clinical outcomes. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective case control study was carried out for 209 consecutive episodes of IS-MDRAB infection or colonization from August 2001 to March 2005. Forty-nine (23.4%) episodes with succeeding clinical isolates of IR-MDRAB were defined as the cases and 160 (76.6%) with all subsequent clinical isolates of IS-MDRAB were defined as the controls. Quantified antimicrobial selective pressure, "time at risk", severity of illness, comorbidity, and demographic data were incorporated for multivariate analysis, which revealed imipenem or meropenem as the only significant independent risk factor for the appearance of IR-MDRAB (adjusted OR, 1.18; 95% CI, 1.09 to 1.27). With selected cases and controls matched to exclude exogenous source of IR-MDRAB, multivariate analysis still identified carbapenem as the only independent risk factor (adjusted OR, 1.48; 95% CI, 1.14 to 1.92). Case patients had a higher crude mortality rate compared to control patients (57.1% vs. 31.3%, p = 0.001), and the mortality of case patients was associated with shorter duration of "time at risk", i.e., faster appearance of IR-MDRAB (adjusted OR, 0.9; 95% CI, 0.83 to 0.98). CONCLUSIONS/SIGNIFICANCE: Judicious use of carbapenem with deployment of antibiotics stewardship measures is critical for reducing IR-MDRAB and the associated unfavorable outcome

Syndromic Recognition of Influenza A Infection in a Low Prevalence Community Setting

BACKGROUND: With epidemics of influenza A virus infection, people and medical professionals are all concerned about symptoms or syndromes that may indicate the infection with influenza A virus. METHODOLOGY/PRINCIPAL FINDINGS: A prospective study was performed at a community clinic of a metropolitan area. Throat swab was sampled for 3-6 consecutive adult patients with new episode (<3 days) of respiratory tract infection every weekday from Dec. 8, 2005 to Mar. 31, 2006. Demographic data, relevant history, symptoms and signs were recorded. Samples were processed with multiplex real time PCR for 9 common respiratory tract pathogens and by virus culture. Throat swab samples were positive for Influenza A virus with multiplex real time PCR system in 12 of 240 patients. The 12 influenza A positive cases were with more clusters and chills than the other 228. Certain symptoms and syndromes increased the likelihood of influenza A virus infection. The syndrome of high fever plus chills plus cough, better with clustering of cases in household or workplace, is with the highest likelihood (positive likelihood ratio 95; 95% CI 12-750). Absence of both cluster and chills provides moderate evidence against the infection (negative likelihood ratio 0.51; 95% CI 0.29-0.90). CONCLUSIONS/SIGNIFICANCE: Syndromic recognition is not diagnostic but is useful for discriminating between influenza A infection and common cold. In addition to relevant travel history, confirmatory molecular test can be applied to subjects with high likelihood when the disease prevalence is low

Molecular signature of clinical severity in recovering patients with severe acute respiratory syndrome coronavirus (SARS-CoV)

BACKGROUND: Severe acute respiratory syndrome (SARS), a recent epidemic human disease, is caused by a novel coronavirus (SARS-CoV). First reported in Asia, SARS quickly spread worldwide through international travelling. As of July 2003, the World Health Organization reported a total of 8,437 people afflicted with SARS with a 9.6% mortality rate. Although immunopathological damages may account for the severity of respiratory distress, little is known about how the genome-wide gene expression of the host changes under the attack of SARS-CoV. RESULTS: Based on changes in gene expression of peripheral blood, we identified 52 signature genes that accurately discriminated acute SARS patients from non-SARS controls. While a general suppression of gene expression predominated in SARS-infected blood, several genes including those involved in innate immunity, such as defensins and eosinophil-derived neurotoxin, were upregulated. Instead of employing clustering methods, we ranked the severity of recovering SARS patients by generalized associate plots (GAP) according to the expression profiles of 52 signature genes. Through this method, we discovered a smooth transition pattern of severity from normal controls to acute SARS patients. The rank of SARS severity was significantly correlated with the recovery period (in days) and with the clinical pulmonary infection score. CONCLUSION: The use of the GAP approach has proved useful in analyzing the complexity and continuity of biological systems. The severity rank derived from the global expression profile of significantly regulated genes in patients may be useful for further elucidating the pathophysiology of their disease

4C Strategic Marketing Framework to Improve the Joint Clinics Operation

　全民健保的醫療制度下實現了公平正義，大家都享有相同的醫療資源。但因健保收費過於低廉，民眾又不知珍惜，處處浪費，造成財務不足現象，而健保局给醫院给付偏低，醫院往往是處於虧損狀態。全民健保因財務困難，只得實施總額制。另外健保局引用論病計酬，也就是診斷關聯群（Diagnosis Related Group, DRG）支付制度，由於同一種疾病的治療難度因人而異，於是醫院拒收較難治療的患者（如高齡者、病情複雜者）。台灣醫療產業在國際上，因為保費低廉、全民納保、就醫方便、保障範圍廣等成果被譽為「健康烏托邦」，各國專家紛紛前來學習,但財務發生困難，醫療產業M型化，只有大醫院及診所才能生存，中、小型醫院則因要投入設備、開刀房、加護病房、急診及大量人力、物力，負擔沈重而無以為繼，纷纷结束營業。全台各醫院主治醫師也出來闖天下，設立診所。在診所林立的競爭紅海內，要如何脱穎而出求得存活？本文即探討台灣醫療產業的市場狀況，並藉由聯合診所的競爭比較來探討經營策略及管理。本研究以邱志聖(2011)之4C行銷策略架構為分析之理論基礎，從聯合診所經營的方向、策略，如何透過外顯單位效益成本、資訊搜尋成本、道德危機成本，以及專屬陷入成本中來計算總成本；而由4C架構與競爭分析，A聯合診所初期於資訊搜尋成本、道德危機成本、專屬陷入成本（C2 ~C4 ） 均居於劣勢，故要好好強化居於優勢的外顯單位效益成本（ C1）,病人期能早期診斷、治療，恢復健康。此外，藉由分析來引導開業醫師如何創造經營的環境，使病人恢復健康,必要時調整策略方向，使聯合診所更具競爭力。Under national health insurance system, we are entitled to the same health care resources and then achieve fairness and justice. Because health insurance fees are too low and people do not cherish welfare policy, the system results in financial deficit. The hospital is often at a loss due to low payment from the government. The National Health Insurance Agency has to implement the global budget system and DRG system (Diagnosis Related Group) to rescue the finances. Under DRG system, the same disease means the same payment and the hospital may reject some patients (such as the elderly, the complicated patients). Taiwan's medical industry in the world, because of low insurance premiums, convenient medical care, all people included in the health insurance system, is known as the "Health Utopia". The experts from different countries come to learn this system. But in M-type of the medical industry, only large hospitals and clinics can survive, medium and small hospitals due to heavy burden, such as much investment in equipment, operating rooms, intensive care units, emergency and manpower, come to the close of business. How to stand out alive when physicians set up their clinics in the Red Sea of competition? This article is to explore Taiwan's medical industry market status and by comparison to investigate joint clinic business strategy and management. In this study, we use Chiou’s (2011) “the 4C Strategic marketing framework” for the theoretical basis of analysis to improve the joint clinics operation and strategy. The “4C Strategic Marketing Framework” methodology means the stage of “the Cost of Utility”, “the Cost of Information Searching”, “the Cost of Moral Hazard”, and “the Cost of Asset Specifity”. And by the 4C structure and competition analysis, the initial joint clinic A in the information search costs, moral hazard costs, the asset specificity costs (C2 ~ C4) are living in disadvantage, so to take advantage of the utility costs (C1) and to achieve early diagnosis, treatment and recovery of the patients are important . Further more, by analyzing how to guide practitioners to create an environment that make the patient healthy, to adjust the strategic direction when necessary to enable the joint clinic more competitive

Cordyceps Sobolifera Extract Ameliorates Lipopolysaccharide-Induced Renal Dysfunction in the Rat

Abstract: Cordyceps Sobolifera (CS), an economic traditional Chinese herb, may ameliorate nephrotoxicity-induced renal dysfunction in the rat via antioxidant, anti-apoptosis, and antiautophagy mechanisms. We investigated the water extract of fermented whole broth of CS on lipopolysaccharide (LPS)-induced renal cell injury in vitro and in vivo. CS effect on LPSinduced epithelial Lilly pork kidney (PK1) and Madin-Darby canine kidney epithelial (MDCK) cell death was detected with MTT assay. Two-month treatment of CS effects on renal blood flow (RBF), glomerular filtration rate (GFR), plasma blood urea nitrogen, creatinine level and leukocytes (WBC) count were determined in the LPS-treated rats. We further examined the effects of CS supplement on renal tubular oxidative stress, endoplasmic reticulum stress, apoptosis and autophagy by Western blot analysis. LPS dose-dependently induced PK1 and MDCK cell death, which can be ameliorated by CS treatment. LPS significantly decreased RBF and GFR and increased blood leukocyte counts, plasma blood urea nitrogen and creatinine level in the rat after 24 hours of injury. LPS enhanced renal tubular ER stress, autophagy and apoptosis via by increase protein expressions of GRP78, caspase 12, Beclin-1 and Bax/Bcl-2 ratio. These findings are associated with the significant 523 staining in renal proximal and distal tubular ED-1, GRP78, Beclin-1 autophagy, and TUNEL apoptosis in the LPS-treated kidneys. Two months of CS supplement significantly improved RBF, GFR and WBC values and reduced ED-1, GRP78, Beclin-1 autophagy and TUNEL apoptosis in the LPS-treated kidneys. Long-term CS treatment reduced LPS-induced stress responses and tissue damage possibly via blocking LPS-triggered signaling pathways

Folliculotropic mycosis fungoides: A case after one-year follow-up

Mycosis fungoides is the most common form of cutaneous T-cell lymphoma (CTCL); it rarely exhibits a predilection for hair follicle infiltration. We describe a patient with preferential localization of skin lesions in the head and neck region with eyelid involvement, grouped follicular papules and acneiform lesions, severe pruritus and secondary bacterial infections. The histological presentation showed folliculotropic neoplastic lymphoid cells instead of epidermotropic infiltrates. The final diagnosis was folliculotropic mycosis fungoides (FMF), a rare, more aggressive variant of CTCL. Clinical manifestations of FMF may be challenging; thus, multiple, deep biopsy containing adnexal structures, are required to make this crucial diagnosis