懷孕是一種有致糖尿病前期(pro-diabetogenic)的狀態，這種生理變化有利提升循環中血糖來滿足胎兒的需求。妊娠期糖尿病(gestational diabetes mellitus, GDM)在懷孕期間的發生率2 ~ 14%，或許會增加母親子癲前症、高血壓、剖腹產及日後糖尿病的發生率，GDM也可能提高胎兒動脈粥樣硬化、巨嬰及成長限制的機率。此外，由於正值生育年齡女性體重過重(overweight)及肥胖(obesity)人數愈來愈多，以致GDM確診病患數有上升趨勢。儘管藥物治療被視為改善婦女GDM的好方法，但在疾病的初期僅少數婦女有典型高血糖症狀。因此，適當飲食及監控良好的運動成為胎兒與母親健康並且預防GDM惡化的不錯選項。

BACKGROUND Interleukin (IL)-1beta may effectively decrease introcular pressure (IOP) when administered by subconjunctival injection in normal rabbit. However, IL-1beta is a large molecular agent and an inflammation factor. The aim of this study was to evaluate the penetrability of IL-1beta, and the concentrations of both tumor necrosis factor (TNF)-alpha and IL-6 in the aqueous humor of normal rabbits treated with IL-1beta. METHODS A total of 170 rabbits were used in the study and were assigned to several different treatment groups as follows: 125 of the rabbits were assigned to two groups. In one group, 33 rabbits were injected subconjunctivally with IL-1beta and 39 were injected with saline alone. In the other group, 27 rabbits were given eye drops containing IL-1beta (400 ng/ml) and 26 were given saline alone. Aqueous humor (AH) was drawn and the concentration of IL-1beta within the fluid measured. The IOP was measured in another six rabbits after administration of eye drops containing IL-1beta (400 ng/ml). A further 20 rabbits were assigned to 3 groups as follows: eight untreated normal controls; six injected subconjunctivally with IL-1beta; and six injected subconjunctivally with saline alone. AH was drawn and the concentration of TNF-alpha in the fluid was measured. Another 19 rabbits were assigned to 3 groups as follows: seven untreated normal controls; and six injected subconjunctivally with IL-1beta; and six injected subconjunctivally with saline alone. AH was drawn and the concentration of IL-6 in the fluid measured. Measurement of cytokine concentration was by radio-immunoassay in all cases. RESULTS The IL-1beta concentration in the AH was higher in those animals in which it had been administered subconjunctivally (P < 0.01). The IL-1beta concentration in the AH of the animals given eye drops was almost the same as that in the controls (P > 0.05). The administration of IL-1beta in the form of eye drops had little effect upon IOP reduction. Lower TNF-alpha concentrations were seen in the AH after the subconjunctival administration of IL-1beta, but the concentration of IL-6 was the same as in the normal controls. CONCLUSIONS IL-1beta shows good corneal penetrability after subconjunctival injection into normal rabbit eyes. The IOP reduction induced by IL-1beta is unlikely be associated with an inflammatory response.

A 27-year-old male presented with progressive dyspnea and productive cough with whitish sputum for several months. Severe central and peripheral cyanosis and leg edema were also noted. Right heart failure was diagnosed based on echocardiograph findings, and pulmonary thromboembolism was suspected due to elevated D-dimer level. Anti-phospholipid syndrome was diagnosed based on the elevation of anti-cardiolipin immunoglobulin G, and nifedipine, enoxaparin, furosemide, and continuous oxygen were given as initial treatment. Bilateral pulmonary fibrothorax was noted on Chest X-ray, and pulmonary tuberculosis was confirmed by positive sputum acid fast stain. The patient was discharged with improvement in dyspnea and cyanosis after isolation for anti-tuberculosis medication. Finally, his condition improved significantly during the year following hospitalization, and pulmonary artery pressure returned to normal after the complete anti-tuberculosis treatment course and long-term oral anticoagulant treatment. Consequently, prompt diagnosis and appropriate medication, including anti-TB medication, anticoagulant drug, and continuous oxygen, are essential to improve clinical prognosis of cor pulmonale due to reversible etiologies such as pulmonary tuberculosis and chronic pulmonary thromboembolism.

PURPOSE:To determine the effects of misakinolide (MISA) A, which leads to the disassembly of actin filaments, on the actin cytoskeleton of cultured human trabecular meshwork (HTM) cells and on intraocular pressure (IOP) in living rats and monkeys. METHODS:Cultured HTM cells were treated with MISA A, and the changes in the actin cytoskeleton were determined by immunofluorescence microscopy. Elevated IOP was induced in cynomolgus monkeys by unilateral laser photocoagulation of the trabecular meshwork (TM). The IOP response after topical administration of MISA A was determined in normotensive rats (Tonopen) and glaucomatous monkeys (pneumotonometer and Tonopen) at 0.5, 1, 2, 3, 4, 5, and 6 hr. RESULTS:MISA A caused dose- and time-dependent disruption of actin stress fibers in cultured HTM cells. Actin microfilaments and vinculin containing focal contacts deteriorated after 2 hr, 30 and 10 min of incubation with 5 nM, 10 nM, and 25 nM MISA A, respectively. Recovery was also dose- and time-dependent. The actin-disrupting effects were not reversible when the cells were incubated with MISA A at a low dose (10 nM) for 24 hr or a high dose (25 nM) for 30 min. Topical administration of MISA A significantly decreased IOP in rats by 5.8 +/- 0.5 (mean +/- SEM) (p < 0.05) Tonopen rat units. In monkeys, IOP was decreased by 3.8 +/- 0.5 mmHg (p < 0.001) in the normotensive eye and by 9.2 +/- 1.2 mmHg (p < 0.001) in the glaucomatous eye. CONCLUSIONS:MISA A greatly altered the actin cytoskeleton and cellular adhesions and reduced IOP, suggesting that MISA A may be a useful antiglaucoma strategy.

Objectives: To report and discuss a case of pneumonia with tibia osteomyelitis in a 79-y-o woman, and how UTI complicated the disease process and influenced the recovery.Methods: This patient had been diagnosed to have tibia osteomyelitis by diagnosed to have tibia osteomyelitis by changes. Diagnosis of pneumonia was made several weeks after chronic osteomyelitis had been treated. Significant improvement of clinical symptoms from pneumonia was achieved with appropriate antimicrobial therapy. However, UTIs complicated the treatment process and lengthened her hospital stay.Results: This patient's complaints and clinical symptoms were resolved gradually.Conclusion: UTI is an ordeal for a critically ill patient. Prevention of UTI is essential for the sake of patient health and medical costs.

An 84‐year‐old Asian woman with hypertension and chronic renal failure was evaluated for incoherent speech, followed by intermittent interruptions of consciousness, and then status epilepticus after ingesting one star fruit ( Averrhoa carambola ) each day for 3 days. Conventional first‐line anticonvulsants and hemodialysis were administered without significant control of the patient's seizures. Treatment was started with propofol, an intravenous agent that induces anesthesia with rapid onset and elimination from the central nervous system; this resulted in complete control of the seizures. Propofol may be an effective alternative when dialysis and conventional first‐line anticonvulsants are unsuccessful in treating the symptoms of neurotoxicity.

Topical administration of prostaglandin F2a (PGF2a) produced a reduction in intraocular pressure in eyes of rabbits, cats, and cynomolgus monkeys. In rabbit eyes at 5 or 6 hr, 50 ng, 100 ng, or 250 ng of PGF2a caused a significant intraocular pressure reduction with a small miotic effect. Treatment with 500 ng, 750 fig, or 1000 ng of PGF2a lowered intraocular pressure significantly in cat eyes for at least 24 hr with the development of profound pupillary constriction. Administration of 500 ng, 750 ng, or 1000 ng of PGF2a produced a significant reduction of intraocular pressure in monkey eyes lasting at least 24 hr, with an initial hypertensive phase and a small decrease in pupillary diameter in the treated eyes. Tonography revealed an increased facility of outflow simultaneous with the reduction of intraocular pressure in the eyes of cats and monkeys. These increases of outflow facility could not explain completely the reductions in intraocular pressure. The aqueous humor flow measured by fluorophotometry was unaltered in both species, and possible reasons for this finding are discussed. Anterior chamber aqueous humor protein was significantly higher in cat eyes topically treated with 750 ng of PGF2o than in the diluent-treated fellow eyes. Invest Ophthalmol Vis Sci 25:1087-1093, 1984

Between January 1999 and December 2003, 81 cases of single pathogen-related culture-proven Gram-negative adult bacterial meningitis were identified at Chang Gung Memorial Hospital-Kaohsiung. Of these 81 cases, Acinetobacter infection was found in 13 cases. Clinical and laboratory data of these Acinetobacter meningitis patients were studied and were compared with those of other 68 non-Acinetobacter Gram-negative bacterial meningitis (GNBM) patients. Of the 13 implicated Acinetobacter strains, A. baumannii was the most common (12), and the other was A. lwoffii (1). Eleven of these 13 cases were due to a post-neurosurgical infection. The results of the antibiotic susceptibility test of the 13 Acinetobacter strains from cerebrospinal fluid included ceftriaxone, (1/13, 8%), ciprofloaxin (6/13, 46%), ceftazidime (6/13, 46%), cefepime (7/13, 54%), ampicillin-subtactam (7/13, 54%), imipenem (12/13, 92%) and meropenem (12/13, 92%). One strain with pan-drug resistant A. baumannii (PDRAB) emerged in 2003. A statistically significant difference between Acinetobacter meningitis and non-Acinetobacter GNBM included hydrocephalus and ceftazidime-resistance. A mortality rate was 30% (4/13), and 7 of the other 9 survivals had severe neurologic deficits. The emergence of Acinetobacter infections in adult post-neurosurgical infections, multiple antibiotic resistant characteristics, and the emergence of PDRAB strain remained a challenge of the initial management of this specific meningitis. Use of carbapenem, especially meropenem, could be considered as one of the initial empiric antibiotics chosen for the management of adult post-neurosurgical meningitis.

This 16-year (1986-2001) retrospective study enrolled 80 infantile patients (aged, 30-365 days old) with culture-proven bacterial meningitis. The most prevalent pathogens were Salmonellaspecies, Streptococcus (S.) agalactiae, Escherichia (E.) coli, and Haemophilus (H.) influenzae, accounting for about 59% of the episodes. Meningitis caused by Salmonella species, E. coli and H. influenzae occurs more often in the older infants, while that caused by S. agalactiae occurs more often in young infants. Our study revealed a decrease in the proportion of Salmonella meningitis from 27% in the first 8 years to 9% in the second 8 years with E. coli replacing Salmonella species as the leading pathogen of this disease during the second period. Overall mortality rate for both periods of time was 11%. However, if we take those with undesirable poor outcomes into account, 43% of patients could be considered treatment failures. The study also reveals a high prevalence of neurological complications when this disease is caused by H. influenzae, S. pneumoniae, and Salmonella species. Stepwise logistic regression analysis revealed that only initial changing levels of consciousness (P = 0.006) were independently associated with treatment failure. The most frequent neurological complications associated with this disease included subdural empyema, hydrocephalus, cerebral infarctions, and seizures. Because therapeutic regimens may require attention to the eradication of bacterial pathogen but also the neurological complications, early diagnosis and choice of appropriate antibiotics are essential to increasing the possibility of survival.

In this study, 34 clinical cerebrospinal fluid isolates of Cryptococcus neoformans were serotyped, and their in vitro susceptibilities to amphotericin B, fluconazole, and voriconazole were analyzed. Of these 34 isolates, serotype A was found in 29 isolates and serotype B in the other five. The voriconazole geometric mean MIC was significantly lower than the amphotericin B/antibiotic medium 3 geometric mean MIC (P < 0.0001 at both 48 and 72 h), as well as the fluconazole geometric mean MIC (P < 0.0001 at both 48 and 72 h). Of the three antifungal agents, only fluconazole, with geometric mean MICs at both 48 and 72 h, showed significant difference between the serotypes A and B of C. neoformans.

Chryseobacterium meningosepticum is an uncommon pathogen causing adult bacterial meningitis. Herein, we report the case history of one 21-year-old woman with this uncommon central nervous system infection. A diagnosis of adult C. meningosepticum meningitis can only be confirmed by a positive cerebrospinal fluid (CSF) culture. The patient had insulin-dependent diabetes mellitus as the underlying condition associated with this infection. The clinical presentations were fever, headache, consciousness disturbance, and seizure. CSF analysis revealed a purulent inflammatory reaction. After a 21-day course of intravenous cefepime (6 g/day) treatment, this patient was discharged in a state of complete recovery.

Sixty patients with Guillain-Barré syndrome (GBS), aged 16-83 years, have been identified over a period of 7 years. Of 60 patients, 30 received the double filtration plasmapheresis (DFP), 4 received intravenous immunoglobulin, and the other 26 received supportive care only. Therapeutic outcomes at 1 year were determined using a modified Barthel index. At a follow-up of 1 year or longer, 31 patients (52%) had recovered, 24 (40%) had residua, and 5 (8%) had died. According to the statistical analysis, disability at the nadir and electrophysiological signs significantly influenced the long-term outcomes. Complications associated with DFP procedures included physiologic change, technique-related complications, and vascular access-related complications. None of our patients had fatal complications related to DFP treatment. Contrary to the established belief that the disease has a favorable outcome, several hospital-treated patients may still die or present residua even several months after the onset of symptoms. Because disability at the nadir influences the outcomes, early diagnosis and choice of appropriate treatment, which might include DFP, to prevent further neurological deficits, are essential to maximize the potential for survival.

To determine the epidemiologic trends, prognostic factors, and therapeutic results of neonatal bacterial meningitis, 60 neonatal patients with culture-proven neonatal bacterial meningitis were enrolled in this study. To compare changes over time, the appearance of disease among the patients was divided into two equal periods (1986-1993 and 1994-2001). Group B streptococci were the most common causative pathogens, accounting for approximately 32% of the episodes. Escherichia coli, the next most common pathogen, was more frequently observed in the second period. Seventy-seven percent of gram-negative bacilli isolates were resistant to ampicillin. Moreover, oxacillin-resistant Staphylococcus and ampicillin-resistant group B streptococci strains occurred in the second periods as late-onset neonatal bacterial meningitis. The overall mortality rates for the first and second study period were 17% and 8%, respectively. However, if individuals with poor outcomes were taken into account, 38% of patients were considered treatment failures. Significant prognostic factors included the presence of seizures, thrombocytopenia, and high cerebrospinal fluid protein and low cerebrospinal fluid glucose concentration. Although the mortality rate was significantly reduced in the second period, there has been increasing incidence of the emergence of resistant strains presenting a therapeutic challenge. The presentation in neonatal bacterial meningitis might be nonspecific, and blood culture results were negative in 45% of the episodes. Early diagnosis, choice of appropriate antibiotics, and correction of metabolic derangement are essential to improving outcomes. Chang C-J, Chang W-N, Huang L-T, Huang S-C, Chang Y-C, Hung P-L, Tasi C-Y, Lu C-H, Cheng B-C, Lee P-Y, Chang H-W. Neonatal bacterial meningitis in southern Taiwan.

Twenty-seven adult patients were identified as having community-acquired Klebsiella pneumoniae meningitis. The K. pneumoniae isolates, collected from cerebrospinal fluid samples, were tested for in vitro antimicrobial susceptibilities. The prognostic factors of these 27 patients were also analysed. All of the third- and fourth-generation cephalosporins tested, as well as monobactam, carbapenem and ciprofloxacin, had good activities against the isolated K. pneumoniae strains. None of the clinical isolates was detected as being an extended-spectrum beta-lactamase-producing pathogen. Among the third- and fourth-generation cephalosporins, ceftizoxime, cefepime, ceftriaxone and cefotaxime had superior activities, with MIC90s about four- to eight-fold lower than those of ceftazidime and moxalactam. Mortality rates of patients classified by different antimicrobial agents were as follows: ceftazidime 38% (8/21) and cefepime 16.7% (1/6). The presence of septic shock and the initial level of consciousness at the start of appropriate antimicrobial therapy were the major determinants of survival and neurological outcomes in these 27 patients. Early diagnosis and choice of appropriate antibiotics according to antimicrobial susceptibilities may improve therapeutic outcomes.

OBJECTIVE:To report the safety and efficacy of long-term, low-dose cyclophosphamide therapy in a child with idiopathic pulmonary hemosiderosis (IPH). CASE SUMMARY:A 7-year-old boy diagnosed with IPH 4 years previously was initially prescribed prednisolone. Because he only had a transient response to prednisolone, oral cyclophosphamide 2 mg/kg/d was later added. A dramatic improvement was noted during the subsequent follow-up. One year after cyclophosphamide therapy, the patient suddenly developed thrombocytopenia (platelet count 75 x 10(3)/mm(3)), with the platelet count decreasing to 10 x 10(3)/mm(3) over the following 10 months. Cyclophosphamide was tapered to an alternating daily dosage of 1 mg/kg. The tapering resulted in a subsequent increase in the platelet count, which was maintained between 20 and 50 x 10(3)/mm(3) without occurrence of petechiae or spontaneous bleeding. Under this reduced dosing regimen, the disease has remained in remission for >1 year. DISCUSSION:Due to the low prevalence of IPH, only limited data document the safety and efficacy of immunosuppressive therapy in treating this disease. Although our patient showed a good response to low-dose cyclophosphamide, he developed thrombocytopenia with its use. The mechanism is unclear, but it may be similar to that of high-dose cyclophosphamide-induced myelosuppression. Due to the development of thrombocytopenia, the use of cyclophosphamide was maintained under a reduced dosing regimen. The benefit of long-term immunosuppressive therapy is controversial, and more clinical evidence is required to support its continued usage. CONCLUSIONS:Long-term, low-dose cyclophosphamide is effective in treating childhood IPH, but caution should be exercised due to the possible development of thrombocytopenia. Periodic monitoring of the platelet count in long-term treatment is recommended.

BACKGROUND Despite the advent of modern neurosurgical techniques, new antibiotics, and powerful imaging technologies, brain abscess remains a potentially fatal central nervous system infection. AIM To determine the epidemiological trends, prognostic factors, and outcomes of bacterial brain abscess, to improve the therapeutic strategy for this disease. DESIGN Retrospective hospital-based epidemiology study. METHODS Over a period of 15 years (1986-2000), 123 patients were retrospectively identified as having brain abscesses at Kaohsiung Chang Gung Memorial Hospital. To compare changes over time, the appearance of disease among our patients was divided into two time periods: 1986-1993 and 1994-2000. RESULTS The prevalence rate of brain abscesses caused by Gram-negative organisms significantly increased in the second study period. Viridans streptococci and Klebsiella pneumoniae were the two prevalent pathogens associated with haematogenous spread. Metastatic septic abscess, a devastating complication of K. pneumoniae septicaemia, frequently occurs in diabetic patients, with a high mortality rate. Viridans streptococci were the most prevalent pathogens from infection in paranasal sinusitis, but no fatality occurred. In recent years, head trauma and/or post-neurosurgical states have become important predisposing factors, and nosocomial infections also play an important role. DISCUSSION Despite the availability of new antibiotics and the development of better neurosurgical techniques, therapeutic outcomes of brain abscess showed no significant change when comparing the two study periods, and only the presence of septic shock influenced outcome.

Between January 1986 and December 1999, 109 adult patients with culture-proven community-acquired bacterial meningitis were identified at Kaohsiung Chang Gung Memorial Hospital. To compare changes over time, the appearance of disease among our patients was divided into two equal time periods: an earlier time period (1986-1992) and a later time period (1993-1999). In this study, there was a decreasing proportion of community-acquired bacterial meningitis compared with nosocomial bacterial meningitis in adult patients in recent years. Its proportion declined dramatically from 81% in the earlier 7 years to 37% in the later 7 years. Of the pathogens, Klebsiella (K.) pneumoniae was the most frequently implicated pathogen, followed by Viridans (V.) streptococci, Streptococcus pneumoniae, and Staphylococcus aureus. Other rare organisms including Acinetobacter baumannii, Salmonella Group B and D, Proteus mirabilis, Group B, D, and non-A, non-B and non-D streptococci, and coagulase-negative staphylococci emerged during the second period. There was a decrease in the mortality rate from 44% in the first to 34% in the second time period, but the overall mortality rate remained high. Of the implicated pathogens, patients infected with V. streptococci had a consistently favorable prognosis, while a dramatic decrease in the mortality rate of those infected with K. pneumoniae was seen in recent years. In the multiple logistic regression analysis, only the presence of septic shock and seizures was independently associated with mortality. The timing of appropriate antimicrobial therapy, as defined by consciousness level, was a major determinant of survival and neurological outcomes for patients with community-acquired bacterial meningitis, and the first dose of an appropriate antibiotic should be administrated before a patient's consciousness deteriorates to a Glasgow coma scale score lower than 10.