Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli sequence type ST131 has emerged as the leading cause of community-acquired urinary tract infections and bacteremia worldwide. Whether environmental water is a potential reservoir of these strains remains unclear. River water samples were collected from 40 stations in southern Taiwan from February to August 2014. PCR assay and multilocus sequence typing (MLST) analysis were conducted to determine the CTX-M group and sequence type, respectively. In addition, we identified the seasonal frequency of ESBL-producing E. coli strains and their geographical relationship with runoffs from livestock and poultry farms between February and August 2014. ESBL-producing E. coli accounted for 30% of the 621 E. coli strains isolated from river water in southern Taiwan. ESBL-producing E. coli ST131 was not detected among the isolates. The most commonly detected strain was E. coli CTX-M group 9. Among the 92 isolates selected for MLST analysis, the most common ESBL-producing clonal complexes were ST10 and ST58. The proportion of ESBL-producing E. coli was significantly higher in areas with a lower river pollution index (P = 0.025) and regions with a large number of chickens being raised (P = 0.013). ESBL-producing E. coli strains were commonly isolated from river waters in southern Taiwan. The most commonly isolated ESBL-producing clonal complexes were ST10 and ST58, which were geographically related to chicken farms. ESBL-producing E. coli ST131, the major clone causing community-acquired infections in Taiwan and worldwide, was not detected in river waters.
Children with febrile urinary tract infections (UTIs) are prone to kidney scarring if they are not treated promptly; however, ambiguous symptoms before fever onset makes the early detection of UTIs difficult. Our study aimed to identify urethral discharge as an early manifestation in children with UTI.This study enrolled 678 children younger than 24 months with paired urinalysis and culture performed between 2015 and 2021; 544 children were diagnosed with UTIs. Clinical symptoms, urinalysis, and paired urine culture results were compared.Urethral discharge was observed in 5.1% of children with UTI and yielded a specificity of 92.5% for diagnosing UTI. Children with urethral discharge had a less severe UTI course, furthermore, nine of them received antibiotics before fever occurred and seven of them were free of fever during UTI course. Urethral discharge was associated with alkalotic urine and Klebsiella pneumonia infection.Urethral discharge is an early symptom in children with UTI; it may present before fever onset and help ensure prompt antibiotic intervention.
Purpose: We report three cases illustrating an alternative treatment option for premacular haemorrhage. Methods: This retrospective interventional case study included three eyes in three patients with premacular haemorrhage caused by idiopathic thrombocytopenic purpura in the first case, trauma in the second case and retinal arterial macroaneurysm in the third case. All patients underwent non-vitrectomizing vitreous surgery. Visual acuity as well as slit-lamp and indirect ophthalmoscopic examinations were performed pre- and postoperatively to evaluate the resolution of premacular haemorrhage and changes in lenticular opacity. Results: At postoperative day 1, visual acuity had improved from counting fingers (CF) to 6/12 in case 1, from CF to 6/20 in case 2 and from CF to 3/60 in case 3. Examination of the fundus showed resolution of the premacular haemorrhage with mild vitreous haemorrhage in all cases. Final best corrected visual acuities were 6/6, 6/7.5 and 6/15, respectively. The lens remained clear in two of two phakic eyes at the last follow-up visit. Conclusions: In these selected cases, non-vitrectomizing vitreous surgery was a useful and safe alternative for the treatment of premacular haemorrhage. Premacular haemorrhage causes sudden and severe visual loss. Different causes of premacular haemorrhage have been reported, the most common being Valsalva retinopathy and Terson's syndrome. In addition, such haemorrhages may occur in association with vascular disorders (e.g. proliferative diabetic retinopathy, retinal macroaneurysm, arteriosclerosis, hypertension, and retinal artery or vein occlusion), chorioretinitis, haematological disorders, shaken baby syndrome and age-related macular degeneration. The haemorrhage may occur spontaneously or as a result of trauma (Russell & Hageman 1992; Iijima et al. 1998; Ulbig et al. 1998; Meier et al. 2005). A variety of approaches to treating premacular haemorrhage have been attempted, with varying degrees of success. These approaches have included: observation to allow retinal and vitreous haemorrhage to clear spontaneously; membranotomy by pulsed neodymium:yttrium aluminium garnet (Nd:YAG) laser, argon laser or frequency-doubled Nd:YAG, and vitrectomy (Gabel et al. 1989; Brent et al. 1993; Ulbig et al. 1998; Moorthy 2000; Puthalath et al. 2003). Herein, we report three patients with premacular haemorrhage who were treated by non-vitrectomizing vitreous surgery. Excellent visual recovery was achieved in all cases. Three eyes of three consecutive patients with acute visual loss as a result of premacular haemorrhage without vitreous haemorrhage were included in the study. Two of these patients were not candidates for laser membranotomy; the other chose to undergo non-vitrectomizing vitreous surgery. Pre- and postoperative detailed ophthalmological examinations were performed and recorded, including visual acuity (VA), intraocular pressure (IOP), slit-lamp biomicroscopy, and dilation of the pupil with 10% phenylephrine and 1% tropicamide for indirect ophthalmoscopy. Informed consent was obtained from all patients after the procedure had been discussed. The procedure was performed in the operating room with the patient in supine position. General or retrobulbar anaesthesia was administered and the bulbar conjunctiva was prepared with 5% betadine. The eyelids were opened by lid speculum. Non-vitrectomizing vitreous surgery was performed using a modified 20-gauge (cases 1 and 2) or 25-gauge (case 3) standard pars plana vitrectomy technique without the creation of an infusion port. Two sclerotomy sites were made at a distance of 4 mm from the surgical limbus in the superotemporal and superonasal quadrants. A fibre-optic light source and bent 21-gauge (cases 1 and 2) or 26-gauge (case 3) needle were introduced through the sclerotomy sites with the help of a hand-held vitrectomy lens (Fig. 1A). Membranotomy was initiated immediately, without first cutting the vitreous or performing any other intraocular manoeuvre (Fig. 1B), which resulted in the immediate drainage of the haemorrhage into the vitreous cavity. No solution or gas were injected into the eye. The sclerotomy was closed with 8–0 nylon, except in the sutureless 25-gauge case. All patients were followed up at 24 hours and at 1, 3 and 5 weeks postoperatively, and then every 3 months. The efficacy of the treatment was judged by the clearing of the premacular haemorrhage, VA and the status of the lens. Case 1. (A) In non-vitrectomizing vitreous surgery, a hand-held lens system, a fibre-optic light source and bent 21-gauge needle are introduced through the sclerotomy sites. (B) Membranotomy is performed by bent needle. (C) Fundus photograph 1 day after surgery showing resolution of the premacular haemorrhage with mild vitreous haemorrhage (visual acuity [VA] = 6/12). (D) Fundus photograph 3 weeks after surgery showing complete resolution of the premacular haemorrhage (VA = 6/6). A 13-year-old girl, suffering from idiopathic thrombocytopenic purpura, consulted our department because of sudden visual loss in her left eye after trauma that had occurred about 5 days previously. On examination, VA was 6/5 in the right eye and counting fingers (CF) in the left eye. Examination of the fundus of the left eye showed a well-circumscribed premacular haemorrhage of three disc diameters in size beneath a transparent membrane. Because the patient was too nervous to undergo laser membranotomy, non-vitrectomizing vitreous surgery was performed under general anaesthesia. At 24 hours postoperatively, the subject's vision had improved to 6/12 and examination of the fundus showed resolution of the premacular haemorrhage with mild residual vitreous haemorrhage (Fig. 1C). At 3 weeks postoperatively, VA had improved to 6/6 (Fig. 1D). At 46 months postoperatively, the subject's VA was 6/6 and the lens remained clear in her left eye. A 38-year-old man who had sustained a head injury resulting in a subdural haemorrhage underwent a craniotomy. He consulted our department because of blurred vision in his left eye 8 days after the head injury. On examination, VA was 6/7.5 in the right eye and CF in the left. Anterior segments were quiet and IOP normal in both eyes. Fundus examination revealed a well-circumscribed premacular haemorrhage of 12 disc diameters in size beneath a transparent membrane in the left eye (Fig. 2A) and a normal right eye. After some discussion, the patient chose to undergo non-vitrectomizing vitreous surgery. Case 2. (A) Preoperative fundus photograph shows well-circumscribed premacular haemorrhage of 12 disc diameters in size beneath a transparent membrane; visual acuity (VA) is counting fingers. (B) One day later, fundus examination shows resolution of the premacular haemorrhage with mild vitreous haemorrhage; VA has improved to 6/20. At postoperative day 1, the patient's vision had improved to 6/20 and fundus examination showed resolution of the premacular haemorrhage with mild vitreous haemorrhage (Fig. 2B). One month postoperatively, the subject's vision had improved to 6/7.5. At 30 months, VA was 6/7.5 and the lens remained clear in the left eye. An 85-year-old man was referred to our hospital because of sudden loss of vision in his left eye of 14 days' duration. Visual acuity in the left eye was CF. Slit-lamp biomicroscopic examination was unremarkable except for the presence of a posterior chamber intraocular lens in both eyes. Funduscopic examination of the left eye revealed a retinal arterial macroaneurysm at the temporal upper arcade with premacular haemorrhage of four disc diameters in size beneath a transparent membrane (Fig. 3A). Because the subject had Parkinson's disease, he was unable to hold his head still on the slit-lamp for laser membranotomy. After some discussion, the patient chose to undergo non-vitrectomizing vitreous surgery under general anaesthesia. Case 3. (A) Preoperative fundus photograph showing a retinal arterial macroaneurysm at the temporal upper arcade with premacular haemorrhage of four disc diameters in size beneath a transparent membrane; visual acuity is counting fingers. (B) One day later, fundus examination shows resolution of the premacular haemorrhage with residual subretinal haemorrhage surrounding the retinal arterial macroaneurysm and mild vitreous haemorrhage; VA has improved to 3/60. One day after surgery, the subject's vision improved to 3/60 and fundus examination showed resolution of the premacular haemorrhage with residual subretinal haemorrhage surrounding the retinal arterial macroaneurysm and mild vitreous haemorrhage. At 2 months postoperatively, residual submacular haemorrhage was observed and VA had improved to 6/30 (Fig. 3B). At 6 months, the subject's VA had improved to 6/15. Spontaneous clearing of premacular haemorrhage may occur, but it usually takes several months. Formation of an epiretinal membrane may be induced (O'Hanley & Canny 1985) and the longstanding contact of the retina with dissolving haemoglobin and its catabolites may cause toxic retinal damage, which may be irreversible (Ulbig et al. 1998). Some studies have suggested that 3 months represents a reasonable period of observation for spontaneous clearing of haemorrhage (Kuhn et al. 1998; Meier et al. 2005), but others advocate early intervention to prevent irreversible retinal damage (Garcia-Arumi et al. 1994). Some authors recommend treatment of premacular haemorrhage with a pulsed Nd:YAG laser. This creates a focal opening and gives the entrapped blood a pathway into the vitreous cavity to accelerate clearing and visual improvement. In the largest, longterm series reported to date, Ulbig et al. (1998) described the treatment effect of pulsed Nd:YAG laser in 16 eyes and cited a macular hole and a retinal detachment as complications. Other potential complications of using the Q-switched Nd:YAG laser for the treatment of premacular haemorrhage and experimental vitreous membranes include choroidal and retinal haemorrhage, retinal hole, rupture of the blood vessel, macular hole, retinal detachment and formation of an epimacular membrane (Bonner et al. 1983; Jampol et al. 1983; Puliafito et al. 1984; Ulbig et al. 1998; Kwok et al. 2003). The formation of an epimacular membrane is more common in patients undergoing laser membranotomy than vitrectomy. It also occurs more often in sub-internal limiting membrane (ILM) haemorrhage than in subhyaloidal haemorrhage (Mennel 2007). The success of the laser treatment depends on the focusing and localization of the membrane and the co-operation of the patient. Therefore, this treatment cannot be performed in babies, preschool children or patients who cannot immobilize their head on the slit-lamp, or in eyes with vitreous haemorrhage; thus laser treatment was a poor option for cases 1 and 3 in our series. Early vitrectomy has been reported to be predictive of a better outcome in patients with Terson's syndrome (Garweg & Koerner 2009) and is also beneficial in clearing premacular haemorrhage and improving VA. It allows for the immediate removal of the haemorrhage and analysis of the surgically removed anterior wall of the haemorrhage cavity, and defines the location of the haemorrhage (Mennel 2007). However, possible complications of vitrectomy include active bleeding, anterior and posterior retinal breaks, macular contusion injury and nuclear sclerotic cataract (Brent et al. 1993; Meier et al. 2005). The incidence of post-vitrectomy nuclear sclerotic cataract is relatively low in young patients but increases over time, as observed during longterm follow-up. Thompson (2004) reported that nuclear sclerosis was about six to seven times more common in eyes that had been surgically treated with vitrectomy to correct macular holes and epiretinal membranes than in untreated eyes among patients of all ages. Saito et al. (1999) reported on non-vitrectomizing vitrectomy for macular pucker to prevent postoperative nuclear sclerosis. We saw similar benefits in our cases. No complications occurred during surgery or in the postoperative follow-up period. Final best corrected VAs in our three cases improved from CF to 6/6, 6/7.5 and 6/15, respectively. The lens remained clear in two of two phakic eyes postoperatively at 46 and 30 months, respectively. Compared with standard vitrectomy, non-vitrectomizing vitreous surgery is advantageous in that it requires less surgical time, causes less surgical trauma, and circumvents the formation of postoperative nuclear sclerosis, but it is not suitable for cases associated with vitreous haemorrhage. However, it takes some time to clear the drained vitreous blood in eyes treated with non-vitrectomizing vitreous surgery. Although no complications associated with non-vitrectomizing vitreous surgery occurred in our cases, a longterm, large-scale case study is necessary to evaluate the risk of secondary membrane formation as it occurs in laser membranotomy, and to establish whether this technique is more suitable for subhyaloidal haemorrhages than sub-ILM haemorrhages. This technique may be a useful alternative for treating selected cases of acute premacular haemorrhage when the patient is too young to undergo laser membranotomy, such as in case 1, in patients with phakic lenses who do not want to undergo laser membranotomy, such as in case 2, or in patients with Parkinson's disease who cannot immobilize their head on the slit-lamp for laser membranotomy, such as in case 3. To the best of our knowledge, the treatment of premacular haemorrhage by non-vitrectomizing vitreous surgery has not been reported previously. Non-vitrectomizing vitreous surgery for the treatment of selective acute premacular haemorrhage is a safe and effective alternative to standard vitrectomy when a patient is not a suitable candidate for laser membranotomy. Further longterm study, preferably in a prospective, randomized study of all available modalities of treatment, is necessary to define the benefits and disadvantages of this procedure. This study was supported by the Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (grant VGHKS-92-65).
ABSTRACT The existence of specific immunoglobulin E (IgE) allows us to determine the allergens that cause the allergic disease. For the purposes of allergen avoidance and immunotherapy, the measurement of specific IgE is widely applied in clinical laboratories. However, if IgE from the serum of an allergic patient exhibits reactivity to multiple allergens, it would cause a problem. The present study analyzes whether the serum IgE with multiple reactivity is due to the presence of unique IgE against the common epitope shared by different allergens or the presence of multiple IgEs against different epitopes on different allergens. The quantitative-competitive inhibition tests and the immunoblotting were applied to analyze the immunosimilarity among examined allergens. The result shows that the competitive inhibition of IgE binding between shrimp and crab allergens is higher than those between either shrimp and cockroach or between crab and cockroach. Furthermore, the results of immunoblotting are consistent with those of quantitative-competitive inhibition tests. These results allow us to detect the cross-reactivity for atopic IgE against multiple allergens.
Mycoplasma pneumoniae infection is usually self-limited without severe sequelae. We report 5 pediatric patients with necrotizing pneumonitis caused by Mycoplasma pneumoniae and reviewed the reported cases in the English language. Protracted course of fever and respiratory distress were noted in all 5 patients. Macrolides and adequate chest tube drainage for pleural effusion were the mainstay of treatment.
There is little information available on the association between primary renal disease (PRD) and long-term mortality in the pediatric dialysis population. The objective of this study was to explore mortality risks in children and adolescents on chronic dialysis, specifically focused on the risk of various PRDs. The study cohort included children and adolescents with end-stage renal disease (ESRD) (aged < 20 years) who had received dialysis for at least 90 days between 2000 and 2014 and were identified from Taiwan's National Health Insurance medical claims. A total of 530 children and adolescents were included in the study. The median age of the included patients was 13.6 years and 305 (57.5%) patients were males. One hundred and seven patients died during the follow-up period and the median survival time was 6.0 years. Mortality was highest in the youngest patients. For patients with the following PRDs, mortality was significantly higher than that in patients with primary glomerulonephritis: secondary glomerulonephritis (adjusted hazard ratio (aHR): 2.50; 95% confidence interval (CI): 1.03⁻6.08), urologic disorder (aHR: 4.77; 95% CI: 1.69⁻13.46), and metabolic diseases (aHR: 5.57; 95% CI: 1.84⁻16.85). Several kinds of PRDs appear to have high mortality risks in the pediatric dialysis population. These differences in mortality risk highlight the importance of the focused clinical management of these high-risk subgroups.
Human herpesvirus 8 (HHV8) is the etiologic agent for primary effusion lymphoma (PEL). The aim of this study is to investigate the effects of cisplatin on the PEL cells. Cisplatin treatment induced apoptosis and inhibited the growth of PEL cells, and the effect was more profound in the HHV8-positive lymphoma cells compared with the EBV-positive lymphoma cells. Cisplatin treatment decreased the expression of HHV8 latent genes and activated p53 at serine 15 in PEL cells. Our results indicate that cisplatin can disrupt HHV8 latency and induce reactivation of p53 and highly selective treatment modality for this virally induced lymphoma.
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