Chang Gung Children's Hospital Research Articles

Clinical and epidemiologic features of Coxsackievirus A6 infection in children in northern Taiwan between 2004 and 2009

Isolates of Coxsackievirus A6 (Cox A6) is increasing clinically in 2009 in Taiwan but detailed clinical features of Cox A6 infections in children have not been reported. This study is to define clinical manifestations and laboratory findings of Cox A6 infection in children. From January 2004 to December 2009, a total of 4,664 children with enterovirus infections, based on throat virus culture, were treated in Chang Gung Children's hospital. Two hundred and ninety-six (6.3%) patients positive for Cox A6 infection were included in this study. One hundred and forty-one (47.6%) inpatients were further analyzed for clinical presentations, laboratory findings, and clinical diagnoses. There were two peaks of Cox A6 infection in 2007 and 2009 during the study period, especially during the warm season. The proportion of Cox A6 among total enterovirus isolates was 15.5% in 2007 and up to 22.2% in 2009. The mean age of inpatients was 2.42 ± 0.14 years. The mean hospitalization duration was 4.21 ± 0.11 days. The most common symptoms were fever (100%), oral ulcers (90.8%), and decreased oral intake (89.4%). The mean duration of fever was 2.78 ± 1 days (range, 1-7 days). Seventy-seven (54.6%) patients had fever more than 3 days. The mean leukocyte count was 14,850/mm(3), and 63 (45%) patients had leukocytosis (>15,000/mm(3)). The mean serum C-reactive protein (CRP) level was 44.1 ± 3.3 mg/L (normal, <10 mg/L) and 62 (44%) had a CRP level >40 mg/L. One hundred and eight (76.6%) inpatients were diagnosed as herpangina and 18 (12.8%) hand-foot-mouth disease. Three patients had complications, including aseptic meningitis in one and encephalitis in two. All 141 inpatients recovered uneventfully. Cox A6 is among the major serotypes of enteroviruses in Taiwan and most cases presented as herpangina and hand-foot-mouth disease. Nearly half of the cases may have leukocytosis and elevated CRP levels. Outcomes are usually good.

Risk Factors and Outcomes of Guillain-Barré Syndrome with Acute Myelitis

Guillain-Barré syndrome and acute myelitis represent common and very rare etiologies of acute limb weakness in children, respectively. Typically, demyelination is most common, limited to either the central or peripheral nervous system. Concurrent acute myelitis and Guillain-Barré syndrome are seldom reported. We retrospectively reviewed cases of Guillain-Barré syndrome in Chang Gung Children's Hospital from 2000-2008. The risk factors of Guillain-Barré syndrome with or without acute myelitis were analyzed. Thirty-six children with Guillain-Barré syndrome were enrolled. Five children manifested coexisting acute myelitis. In the disease's earliest stage, differentiating concurrent acute myelitis and Guillain-Barré syndrome from Guillain-Barré syndrome only was difficult. Four of 5 children were aged more than 8 years. All patients developed a sharply defined sensory level, and manifested severe bladder dysfunction. Autonomic dysfunction was evident in three patients. All children with sufficient follow-up continued to demonstrate residual paresis, and two demonstrated significant long-term motor deficits. Detection of a sharply defined sensory level, severe bladder dysfunction, and autonomic dysfunction can be helpful in recognizing concurrent acute myelitis. Therefore, recognition of this combination of peripheral and central nervous inflammation early is important for determining prognoses and perhaps initial treatment.

Clinical Features of Newborns With Gastroschisis and Outcomes of Different Initial Interventions: Primary Closure Versus Staged Repair

Gastroschisis requires surgical management soon after birth. Few publications have reached conclusion regarding the differences of outcomes between primary closure (PC) and a staged repair with silo pouch reduction (SR); as the initial management of gastroschisis. A retrospective review was conducted in 44 newborns with gastroschisis between 1996 and 2007 at Chang Gung Children's Hospital. We recorded and analyzed basic demographic data, including birth body weight, gestational age, size of the wall defect, initial operative procedure, outcomes, and mortality. The male-to-female ratio was 21:23. Patients had a low birth body weight (2263 ± 539g, mean ± SD) and were borderline premature (gestational age = 36.3 ± 1.86 weeks). Thirty-two patients received PC and 12 received SR as the initial treatment. Seven of the newborn infants died because of delayed initial surgical intervention (n = 2), operation-related complications (n = 4), or underlying multiple congenital anomalies (n = 1). The mortality rate was 16%. When comparing PC and SR (excluding "complicated" gastroschisis), there were no significant differences in survival, days of ventilator use, days to reach full enteral feeding, and hospitalization. PC and SR are comparable as initial treatment modalities for gastroschisis. In addition to underlying gastrointestinal anomalies, the factors that led to significant morbidity in our study were bowel gangrene or perforation resulting from postponed surgical management and the development of abdominal compartment syndrome.

Cooperation of Gene Mutations Including Class I, Class II and Tumor Suppressor Genes In Childhood Acute Myeloid Leukemia and Their Impacts on Survivals

AbstractAbstract 2713 Background.The cooperation of gene mutations, especially their impacts on survivals of childhood acute myeloid leukemia (AML) has not been well known. Aims.Our aims were (1) to study the frequency of each gene mutation in childhood AML, (2) to study the impact of each gene mutation on the treatment outcome, and (3) to examine the cooperativity of gene mutations. Materials and Methods.From Feb. 1996 to Jan. 2010, bone marrow samples at diagnosis from 198 children with AML at Chang Gung Children's Hospital, Taoyuan and Mackay Memorial Hospital, Taipei, were analyzed for gene mutations including FLT3-ITD, FLT3-TKD (D835), c-KIT, cFMS, JAK 2V617F, NRAS, KRAS, PTPN11 (Class I mutations), RUNX1, CEBPα, NPM1 (Class II mutations), WT1 and P53 (tumor suppressor genes). The subtypes included: t(8;21) 19.9%, inv(16) 8.9%, t(15;17) 8.4%, t(9;11) 5.2%, t(10;11) 2.6%, trisomy 21 4.2%, intermediate-risk group 40.3% (including 13 patients with other MLL translocations), and poor-risk group 11.0% (including 7 patients with complex chromosomal abnormalities and 4 patients with MLL-PTD). Results.FLT3-ITD occurred in 15.0% of patients, FLT3-TKD 7.2%, c-KIT 11.5%, c-FMS 2.9%, JAK2V617F 3.3%, NRAS 9.1%, KRAS 7.7%, PTPN11 3.3%, RUNX1 2.7%, CEBPα 7.9%, NPM1 4.1%, WT1 3.9% and P53 1.7%. Taken together, 52.5% of patients had Class I gene mutations, 13.1% had Class II gene mutations, and 5.1% had WT1 or P53 mutations. In all, 59.1% of patients had Class I, Class II or tumor suppressor gene mutations. Only one patient (0.5 %) had gene mutations involving all Class I, Class II and tumor suppressor genes. Ninety-eight patients, who were treated with Taiwan Pediatric Oncology Group (TPOG) APL protocols (for acute promyelocytic leukemia) and TPOG 97A protocol (for other AML) (Liang et al, Leukemia 2006), were analyzed for survivals. In patients with t(8;21), the 5-year event-free survival (EFS) was 66±12%; 71±17% for patients with c-KIT mutations and 50±35% for the 2 patients with JAK2V617F. In patients with inv(16), the EFS of 70±15% seemed to be compromised (60±22%) for those with c-KIT mutations. In patients with t(15;17), the EFS of 78±11% was not compromised by FLT3-ITD or FLT3-TKD mutations. In patients with t(9;11), the EFS of 64% seemed to be compromised (50±35%) in the 2 patients with FLT3-TKD mutations. In 3 patients with t(10;11), no gene mutations were found. In trisomy 21, the EFS of 75±22% seemed to be compromised (50±35%) in the 2 patients with CEBPα mutations. Of the 5 patients with complex chromosomal abnormalities, the only one patient carrying RUNX1 survived. Of the 3 patients with MLL-PTD having an EFS of 33±27%, one each patient with c-FMS or WT1 mutation died. The only one patient who had all Class I, Class II and tumor suppressor gene mutations (FLT3-TKD+ CEBPα+ WT1) died in induction therapy. Two of the other 4 patients who had 3 mutations acrossing 2 classes had EFS of 6 and 10 months, respectively. Conclusions.Our study on a large cohort of pediatric AML patients revealed that 59.1% patients had at least one gene mutation. That 3 of 5 patients who had 3 gene mutations soon failed suggested that gene mutations, especially in 3 combinations, might compromise the survival. Further study on more patients is warranted to explore more of the prognostic significance of cooperating gene mutations in pediatric AML.(Supported by grants MMH-E-98009, NSC 96–2314-B-195-006-MY3, NHRI-EX-96-9434SI and DOH99-TD-C-111-006.) Disclosures:No relevant conflicts of interest to declare.

Cryptococcosis in Nonhuman Immunodeficiency Virus-Infected Children

Between 1991-2006, nine patients below age 18 years, with a microbiologic documentation of Cryptococcus neoformans infection and no evidence of human immunodeficiency virus infection, were identified and treated at Chang Gung Children's Hospital. All exhibited central nervous system involvement. Seven patients were female (age range, 9-16 years; mean age, 13.7 years). Five patients (56%) manifested underlying diseases and were receiving either steroid or immunosuppressant treatment at time of disease onset. Eight patients presented with meningitis. Headache, vomiting, and focal neurologic signs were the most common presentations. Protein and sugar levels in cerebrospinal fluid were within normal range in seven cases, whereas India ink smear and cryptococcal antigen testing were positive in 87% (7/8) and 78% (7/9) of patients, respectively. With prompt antifungal therapy, all survived, but one presented the sequel of blindness. Cryptococcosis is uncommon in the nonhuman immunodeficiency virus-infected pediatric population. Clinicians should take into account a diagnosis of central nervous system cryptococcosis when children present with prolonged headache, vomiting, and focal neurologic signs. Indian ink stain and cryptococcal antigen testing of cerebrospinal fluid should be performed.

Frequency of Ventilator-associated Pneumonia With 3-day Versus 7-day Ventilator Circuit Changes

Ventilator-associated pneumonia (VAP) is a common clinical problem. Previous studies involving adult patient cohorts have assessed various risk factors associated with VAP, including ventilator circuit changes. The objective of this study was to examine the incidence of and risk factors associated with VAP, particularly 3-day versus 7-day ventilator circuit changes, in a pediatric intensive care unit (PICU). This was a cohort observational study. Patients hospitalized in the PICU at Chang Gung Children's Hospital between November 2003 and September 2004 were enrolled. Investigators and critical-care specialists evaluated baseline characteristics, incidence of VAP, and related variables from PICU admission until discharge or death. Of 397 patients initially enrolled, 96 (aged 11-60 months) were available for statistical analysis and were assigned into two groups according to timing of ventilator circuit change: 3-day (n = 46) and 7-day circuit change (n = 50). No statistically significant differences were observed for VAP incidence (13% vs. 16%, p = 0.68) or hospital mortality (22% vs. 36%, p = 0.14) for 3-day versus 7-day circuit change. Incidence of VAP per 1000 ventilation days was 10.75 and 8.41 for 3-day and 7-day circuit change, respectively. Univariate analysis indicated statistical significance for the duration of mechanical ventilation (10.17 +/- 16.63 days vs. 18.20 +/- 14.99 days, p < 0.001), length of stay in PICU (22.30 +/- 20.48 days vs. 37.22 +/- 36.79 days, p = 0.0069) and presence of enteral nutrition [7 (15.22%) vs. 23 (46.0%), p = 0.0012]. Weekly circuit change does not contribute to increased rates of VAP in pediatric patients. Long-term studies evaluating risk factors in larger pediatric patient populations are warranted for further conclusive recommendations.

Analysis of Convulsive Status Epilepticus in Children of Taiwan

Convulsive status epilepticus is a medical emergency with significantly associated mortality and morbidity. The demographic data and outcomes of convulsive status epilepticus in children were collected for descriptive analysis. We retrospectively reviewed cases of convulsive status epilepticus in the Pediatric Intensive Care Unit of Chang Gung Children's Hospital between 1999 and 2006. We enrolled 141 patients with 198 episodes of convulsive status epilepticus, aged 2 months to 18 years: 24.8% of first episodes developed convulsive status epilepticus, with a duration of over 60 minutes. First episodes of convulsive status epilepticus were most often evidenced in febrile status during acute central nerve system infections (48.2%), and in nonfebrile status during acute noncentral nerve system illness in previously epileptic children (28.4%). Before their first episode, 63.8% of children were neurologically healthy, and 12.2% exhibited a prolonged febrile seizure. The most common etiology of mortality was acute central nervous system infection. The immediate mortality rate was 7.1%. Convulsive status epilepticus in childhood is more common, with a different range of causes and a lower risk of death, than convulsive status epilepticus in adults. Acute central nervous system infections appear to be markers for morbidity and mortality.

Norovirus Infection as a Cause of Diarrhea‐Associated Benign Infantile Seizures

Norovirus and rotavirus cause outbreaks of diarrheal disease worldwide. This prospective observational study was undertaken to investigate the clinical characteristics and complications, with a focus on convulsive disorders, of gastroenteritis caused by norovirus and rotavirus in hospitalized pediatric patients in northern Taiwan. Children hospitalized with acute gastroenteritis in Chang Gung Children's Hospital from August 2004 through January 2007 were enrolled in the study. Rotavirus and norovirus were detected by reverse-transcriptase polymerase chain reaction with fecal specimens and were genotyped by sequence analysis. The symptoms and complications, in particular convulsions, of acute gastroenteritis caused by rotavirus and norovirus were reviewed and compared. The occurrence of convulsions associated with norovirus infection was specifically analyzed and discussed. The neurological outcomes for all norovirus-infected patients with or without convulsions were followed up for 1 year. Results. Among the 353 patients with acute viral gastroenteritis without coinfection, rotavirus and norovirus isolates were detected in 101 patients (28.6%) and 64 patients (18.1%), respectively. We compared the symptoms between the 2 groups and found that rotavirus caused a higher frequency and longer duration of vomiting and a higher body temperature than did norovirus. Norovirus infection, on the other hand, caused significantly longer hospital stays (mean duration of stay [interquartile range], 6 [5-8] days vs. 5 [4-7] days; P <.001) and a significantly higher incidence of convulsions than did rotavirus infection (29.7% vs. 5%; P <.001). Three of the 19 patients with convulsions showed an abnormal record on electroencephalogram, but none had any neurological sequelae at the subsequent 1-year follow-up. The majority of norovirus strains (41 of the 56 genotypeable strains) belonged to genogroup GGII/4. Conclusions. Norovirus is a major cause of acute gastroenteritis in children. This study identified norovirus as an emerging agent causing convulsive disorder in children, particularly in young infants. Long-term neurological sequelae are uncommon.

Comparative molecular analysis of community-associated and healthcare-associated methicillin-resistant Staphylococcus aureus isolates from children in northern Taiwan

From August 2004 to July 2005, 210 clinical methicillin-resistant Staphylococcus aureus (MRSA) isolates were collected prospectively from 173 children admitted to Chang Gung Children's Hospital in Taiwan. A comparative molecular analysis of the 111 community-associated (CA) isolates from 102 children and the 99 healthcare-associated (HA) isolates from 71 children was conducted. In comparison to the HA isolates (31%), the CA isolates (90%) were more likely to have been isolated from pus (p <5 × 10–8). For each patient with MRSA infection, only the first isolate was selected for molecular analysis. The molecular characteristics differed significantly between the CA and the HA isolates (p <5 × 10–8). The clone characterized as sequence type (ST)59/pulsotype D (similar to USA1000)/staphylococcal chromosomal cassette (SCC)mec VT/Panton–Valentine leukocidin (PVL)-positive accounted for 69% of the CA isolates, and another clone, characterized as ST239/pulsotype A (Hungary clone)/SCCmec III/PVL-negative, accounted for 45% of the 71 HA isolates. The CA clone of ST59 also accounted for 20% of the HA isolates, including 47% of the 17 community-onset isolates. It was concluded that the molecular characteristics of clinical MRSA isolates from children differed significantly between the CA and the HA isolates in northern Taiwan. However, the CA clone of ST59 was also identified in a substantial proportion of HA isolates.

Rapidly progressive scoliosis after successful treatment for osteopenia in Costello syndrome

American Journal of Medical Genetics Part AVolume 146A, Issue 3 p. 393-396 Research Letter Rapidly progressive scoliosis after successful treatment for osteopenia in Costello syndrome† Jia-Woei Hou, Corresponding Author Jia-Woei Hou houjw741@cgmh.org.tw Division of Medical Genetics, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung Institute of Technology, Taoyuan, TaiwanDivision of Medical Genetics, Department of Pediatrics, Chang Gung Children's Hospital. 5, Fu-Shin St., Kwei-Shan, Taoyuan 333, Taiwan.Search for more papers by this author Jia-Woei Hou, Corresponding Author Jia-Woei Hou houjw741@cgmh.org.tw Division of Medical Genetics, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung Institute of Technology, Taoyuan, TaiwanDivision of Medical Genetics, Department of Pediatrics, Chang Gung Children's Hospital. 5, Fu-Shin St., Kwei-Shan, Taoyuan 333, Taiwan.Search for more papers by this author First published: 17 January 2008 https://doi.org/10.1002/ajmg.a.32121Citations: 7 † How to cite this article: Hou J-W. 2008. Rapidly progressive scoliosis after successful treatment for osteopenia in Costello syndrome. Am J Med Genet Part A 146A:393–396. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume146A, Issue31 February 2008Pages 393-396 RelatedInformation

Fatal Cytomegalovirus Gastrointestinal Disease in an Infant with Wiskott-Aldrich Syndrome

Although most cytomegalovirus (CMV) infections are asymptomatic or cause only mild disease, the virus can cause serious disease and even mortality in immunocompromised children. In patients with Wiskott-Aldrich syndrome (WAS), recurrent CMV infection is infrequently seen. A 3-month-old male infant was referred to Chang Gung Children's Hospital due to persistent thrombocytopenia and intermittent tachypnea. WAS complicated with CMV pneumonitis was diagnosed subsequently. He was discharged at the age of 7 months after a complete course of antiviral treatment. Unfortunately, refractory hemorrhagic gastritis developed later and recurred in spite of antiviral treatment and intravenous immunoglobulin. The patient died of recurrent gastrointestinal bleeding at the age of 23 months. This observation indicates that a case of WAS complicated with CMV gastrointestinal disease may need more vigorous treatment.

Nontyphoidal Salmonella Bacteremia in Previously Healthy Children: Analysis of 199 Episodes

Nontyphoidal Salmonella (NTS) bacteremia is not rare in otherwise healthy children in Taiwan. Few studies described the clinical manifestations and outcomes of NTS bacteremia in previously healthy children. Children with blood culture positive for NTS treated at Chang Gung Children's Hospital between May 1996 and June 2003 were identified from the microbiology logbook. Patients who had underlying events or concomitant diseases were excluded. We evaluated 199 patients. One hundred and eighteen (59.3%) were male children and 184 (92.5%) were between 3 months and 5 years of age. Fever (97.0%) and diarrhea (79.9%) were the most common initial presentations. Leukocytosis (leukocyte >15,000/mm) and elevated serum C-reactive protein concentration (> or =10 mg/L) were present in 14.6% and 79.4% of the patients, respectively. Eighty-three percent of 184 patients with antibiotic treatment received a third- or fourth-generation cephalosporin as definitive antibiotic therapy. Focal suppurative infections were present in 5 children (2.5%) on initial evaluation, and included meningitis in 2 and osteomyelitis in 3. Neither metastatic complications nor clinically recurrent diseases were found during a follow-up period of at least 12 months after treatment. No fatalities occurred in this series. In healthy children, NTS bacteremia was relatively benign and extraintestinal focal suppurative infections were infrequently seen. Less than 10 days of appropriate antibiotic treatment is probably adequate for those without a suppurative focus of infection.

Neurologic Sequelae of Enterovirus 17 Infection

The long-term neurologic sequelae, neurodevelopment, and cognitive function of 142 children with a history of enterovirus (EV) 17 infection with CNS involvement were determined in a study at the National Taiwan University Hospital, Taipei; and Chang Gung Children's Hospital, Taoyuan, Taiwan.

Congenital mesenteric hernia causing intestinal obstruction in children

A mesenteric hernia is one type of intraperitoneal hernia. There is no hernia sac in this situation but only a mesenteric defect, which is present at birth. Strangulated mesenteric hernia is a rare cause of intestinal obstruction especially in the pediatric population. Between January 1996 and January 2006, four patients with intestinal obstruction were determined to have congenital mesenteric hernia at Chang Gung Children's Hospital. Patients consisted of three boys and one girl, ranging in age from 2 years 5 months to 5 years 4 months. All patients presented with symptoms and signs indicative of intestinal obstruction. On physical examination, all patients appeared to be severely ill. A shock-like state was associated with necrosis of the strangulated bowel in two patients. A palpable abdominal mass was present in one patient with volvulus of small bowel. The plain abdominal radiography and the ultrasound scan also showed dilatation of the small bowel and excluded intussusception. All the patients underwent laparotomy after initial resuscitation. During laparotomy, three patients had incarceration of small bowel through the small mesenteric defect, and another one had volvulus with gangrenous bowel entrapped within a large mesenteric defect. The defects ranged in size are from 2 to 7 centimeters in diameter. Simple reduction of the incarcerated bowel with repair of the defect was performed in two patients, resection of gangrenous bowel and primary anastomosis was required in one patient, and resection with end ileostomy was needed in another one patient. There was no postoperative mortality in our patients. A mesenteric hernia is a rare cause of intestinal obstruction, especially in children. Open exploration is the only way to establish a clear anatomic diagnosis.

Prevention of unnecessary contralateral exploration using the silk glove sign (SGS) in pediatric patients with unilateral inguinal hernia

The issue of how to best detect an occult contralateral patent processus vaginalis (PPV) in a child who presents with a unilateral inguinal hernia has been debated for over 50 years. The ideal diagnostic tool would eliminate unnecessary contralateral exploration. The "silk glove sign" (SGS) or palpating the processus vaginalis over the pubic tubercle is the simplest preoperative diagnostic test for diagnosing contralateral PPV. In an attempt to determine whether it is possible with the SGS to evaluate the contralateral inguinal region to ascertain if a contralateral PPV is present, we prospectively reviewed our own experience at a single institution within a 5-year period. Between January 2001 and December 2005, 1,040 pediatric patients with inguinal hernias were treated by one surgeon at Chang Gung Children's Hospital. Of these, with the exception of 120 patients with clinical bilateral inguinal hernia, 920 patients (746 boys and 174 girls) with unilateral inguinal hernia underwent examination. A total of 180 (19.8%), of whom 154 were boys and 26 were girls, were SGS positive and underwent bilateral surgery. A PPV or true hernia sac was found in 164 (91.1%). The sensitivity of diagnosis by SGS was 93.1%. In the remaining 740 SGS-negative patients, a metachronous hernia developed in 20. The specificity of diagnosis by SGS was 97.3%. The SGS could detect a contralateral hernia in patients regardless of age, but the accuracy of detection in girls was lower than in boys. SGS is a simple, noninvasive method of preoperative evaluation of the groins. Accuracy through repeated and careful examination is about 91%. Our policy of contralateral exploration based on the SGS has been reliable in minimizing unnecessary surgical exploration.

Clinical observation of meningitis caused by penicillin-susceptible and -non-susceptibleStreptococcus pneumoniaein Taiwanese children

To compare differences between clinical features and outcome in bacterial meningitis caused by penicillin-susceptible Streptococcus pneumoniae (PSSP) with that caused by penicillin-non-susceptible Streptococcus pneumoniae (PNSP). All patients <18 yrs hospitalised with pneumococcal meningitis between January 1984 and December 2002 at Chang Gung Children's Hospital, Taipei were reviewed retrospectively. There were 28 PNSP (63.6%) and 16 PSSP cases of meningitis eligible for the study. The incidence of PNSP meningitis increased significantly over the 8-yr period (p = 0.007). Age <4 yrs (78.6% vs 50%), a lower initial white blood count (mean 11.7 vs 19.9 x10(9)/L), admission to the intensive care unit (70.4% vs 50%) and mortality (28.6% vs 6.3%) were more common in the PNSP group. However, the only significant finding was a lower proportion of polymorphic neutrophils in the CSF of the PNSP meningitis group (p = 0.04). There was an increase in PNSP isolates from patients with meningitis over the 8-yr study period. No major differences were observed in clinical or laboratory features or outcome between the PSSP and PNSP groups.

Clinical features of nosocomial infections by extended-spectrum β-lactamase-producing Enterobacteriaceae in neonatal intensive care units

To determine the risk factors for the acquisition of nosocomial extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae infection in infants hospitalized in neonatal intensive care units (NICUs) and to evaluate the therapeutic outcome of these infants. We retrospectively reviewed the medical records of infants with nosocomial ESBL-producing Enterobacteriaceae infection hospitalized in NICUs at Chang Gung Children's Hospital in 2001. The clinical features of these infants were compared with a cohort of non-ESBL-producing Enterobacteriaceae-infected infants during the same period. The therapeutic outcome of the infants in the ESBL group was analysed. Seventy infants were included in this study. Thirty-one infants with 34 isolates were identified in the ESBL group and 39 infants with 42 isolates in the non-ESBL group. Of the parameters analysed, including gestational age, birthweight, length of hospital stay before onset, the number of antibiotics used, the duration of third-generation cephalosporin usage and the number of patients receiving a third-generation cephalosporin prior to the onset of infection, no significant difference was found between the two groups. The infection-contributed case fatality rate was 3.0% (1 of 33) in the ESBL group, not significantly different from that in the non-ESBL group (1 of 41, 2.4%). Of the 31 patients in the ESBL group, 18 were treated with a carbapenem as definitive therapy while 13 were treated with a non-carbapenem antibiotic regimen. No significant difference was noted in terms of mortality rate between the two subgroups. The outcome of the infants hospitalized in the NICU with ESBL-producing enterobacterial infections was not indispensably grave, even when treated with a non-carbapenem antibiotic regimen. The risk factors for the acquisition of ESBL-producing enterobacterial infections in these infants were not identified in this series.

Fuzzy measure on vehicle routing problem of hospital materials

The traditional programming model is used to assume that each objective stands independently from one another; however, in reality, some interactions might exist between the criteria or attributes. In order to understand the problem of incomplete independence objectives, this study explores whether fuzzy measure is suitable for the vehicle routing problem or not. With the hospital operation scale expanding, the vehicle transmitting routing, which used to be planned by artificial and partly practical experience, has already insufficient. This study solves the vehicle routing problem by using the fuzzy measure method. It brings up a solving model to solve the immediate problem faced by the department of medical material transmitting in the hospital. Additionally, this study compares the fuzzy measure method with other programming methods, and takes Chang Gung Children's Hospital as the research objective. This study will demonstrate that it is unnecessary to consider the independence problem between objectives and the result of the programming is closer to the decision-maker's requirement when the fuzzy measure method is applied to objective programming. Besides, this study model can be regarded as a reference when the department of medical material transmitting in the hospital meditates its new transmitting routing in the future, or estimates present transmitting routing.

Predictors of Unfavorable Outcomes in Enterovirus 71-Related Cardiopulmonary Failure in Children

Enterovirus 71 (EV71) can sometimes cause fatal or disabling diseases in children; therefore EV71-infected children with cardiopulmonary failure were investigated at Chang Gung Children's Hospital to discover the prognostic predictors. We investigated 27 EV71-infected children with cardiopulmonary failure from May 2000 to September 2001 and analyzed their clinical data to find predictors associated with unfavorable outcomes of deaths or ventilator dependence. Of the 27 patients, 8 (30%) died and 10 (37%) were ventilator-dependent. Troponin I levels correlated most strongly with fatality, with 5 of the 6 children with troponin I levels >40 ng/ml dying (P = 0.001). Other factors correlated with fatality were cerebrospinal fluid white blood cell count > or =100/microL (P = 0.002) and initial systolic pressure < or =100 mm Hg (P = 0.05). Of the 19 survivors, 10 (53%) were left with central hypoventilation, dysphagia and/or limb weakness plus atrophy. The factors associated with ventilator dependence included higher inotrope equivalent (P < 0.001), duration of hypotension > or =40 hours, initial blood systolic pressure < or =100 mm Hg, positive EV71 isolation and age > or =12 months. Poor prognostic factors were related to cardiovascular and neurologic damage; therefore physicians may consider advanced cardiovascular support for EV71-infected children with cardiopulmonary failure.

Clinical Features and Genotyping Analysis of Community-Acquired Methicillin-Resistant Staphylococcus aureus Infections in Taiwanese Children

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection in children without health care-associated risk factors has emerged. To evaluate the clinical features and genotyping analysis of CA-MRSA in children in Taiwan, we conducted this study. Between July 2000 and June 2001, 198 episodes of S. aureus infection were identified in 191 children hospitalized at Chang-Gung Children's Hospital. The medical records of these children were retrospectively reviewed. The MRSA clinical isolates from each episode of infection, if available, were collected for pulsed-field gel electrophoresis (PFGE) typing and staphylococcal cassette chromosome mec (SCCmec) type determination. Among the 198 episodes of S. aureus infection, MRSA accounted for 47% of 114 CA infections and 62% of 84 hospital-acquired (HA) infections, respectively. Among 54 CA-MRSA infections, 32 episodes (59%) occurred in children without risk factors. Similar to HA-MRSA isolates, these CA-MRSA isolates were also multiresistant, with a high rate of resistance to clindamycin (93%) and erythromycin (94%), but 91% of them were susceptible to trimethoprim/sulfamethoxazole. Superficial soft tissue infection was the most common presentation, accounting for 65% of CA-MRSA infections. All 54 children with CA-MRSA infection recovered without sequelae, though 63% of 35 children with superficial soft tissue infection were treated with in vitro nonsusceptible antibiotics. Of the 83 clinical isolates (40 CA, 22 with no identified risk) available for analysis, 6 genotypes with 30 subtypes were identified. Three major PFGE patterns were identified, accounting for 94% of the isolates (92.5% for CA isolates, 95% for HA isolates). Type IV SCCmec was carried by 25 and 40% of CA and HA isolates, respectively. In Taiwan, MRSA was prevalent among pathogens of CA infections in children, and these CA isolates were multiresistant and genetically associated with HA isolates. In an area with a high prevalence of methicillin resistance, for children with putative S. aureus infection, even community-acquired, a glycopeptide-containing regimen should be considered for initial empirical therapy in the case of serious infection.