The Kaohsiung Journal of Medical Sciences

Extensively drug‐resistant Acinetobacter baumannii (XDRAb) emerges as an important pathogen of health care–associated infections and outbreaks worldwide. During January and February 2006, there was a hospital‐wide outbreak of XDRAb at a medical center in Taiwan. Without limiting the usage of carbapenems or the closure of any ward, this outbreak was effectively controlled. We investigated the molecular epidemiology and reported the infection control experiences. XDRAb is defined as A baumannii that is resistant to multiple antibiotics but susceptible to tigecycline and polymyxin B. During the outbreak, the clinical and environmental XDRAb isolates were collected and studied by antimicrobial susceptibility testing, pulsed‐field gel electrophoresis, and polymerase chain reaction for Verona integron‐encoded metallo‐beta‐lactamases, imipenemases, and oxacillinases (OXA). Our measures to control the outbreak included private room isolation of patients until there were three successive negative cultures, reinforcement of contact precautions, daily environmental cleansing with room‐dedicated cleaning tools and sodium hypochlorite, and careful auditing of adherence. During the outbreak, 32 clinical XDRAb isolates came from 13 patients who were hospitalized in four intensive care units and three wards. Most (7 of 13, 53.8%) cases were associated with a surgical intensive care unit. The results from pulsed‐field gel electrophoresis study indicated that all isolates were of one genotype. All 32 isolates harbored ISAba1‐bla_{OxA‐51‐like} and bla_OxA‐72 genes. After this outbreak till August 2010, further incidences of XDRAb were sporadic cases of XDRAb with different clones and did not reach the level of outbreak. To our knowledge, this is the first reported hospital‐wide outbreak caused by OXA‐72 carbapenemase–producing A baumannii in the Asia‐Pacific region, with successful and sustained control. Although the source or vehicle of the outbreak was not identified, our results suggest that a hospital‐wide outbreak can be successfully managed with strict infection control measures, and that the limitation of the use of carbapenems and closure of wards may not be necessary.

A medium‐sized general hospital using a fee‐for‐service model implemented a hospital‐wide picture archiving and communication system (PACS) in two stages. This study evaluated the reporting time with filmless operation and the effect of filmless imaging on referring physicians' use of the radiologic service before and after completion of the second stage of PACS implementation. The relationship between the total number of hospital patients and the number of radiologic department patients was also evaluated. All sample images were retrieved from the PACS. All corresponding reports except for one for a computerized tomography study were available. The median reporting time for different studies performed during working hours was less than 2 hours. There was a significantly positive and linear relationship (p < 0.01) between the total number of hospital patients and the number of radiologic department patients after hospital‐wide implementation of PACS. We conclude that the fee‐for‐service model had no negative impact on referring physicians' use of radiologic services in a filmless hospital.

Fournier's disease, a form of necrotizing fasciitis, is a rapidly progressing subcutaneous infection of the male genitalia. We report a case of Fournier's disease with the unusual etiology of a perforated duodenum. This patient suffered from progressive right scrotal swelling after percutaneous transhepatic cholangeal drainage. Scrotal exploration revealed a large abscess with muscle necrosis that had spread up to the right retroperitoneal space. Radiologic studies and second abdominal exploration documented the origin as a perforated duodenum. The pus distribution in this case suggested that the infection process differed from that in previous reports. In future cases of Fournier's disease involving previous abdominal events, we recommend that abdominal origins be carefully surveyed before scrotal exploration.

Lectures are of great value to students. However, with the introduction of hybrid problem‐based learning (PBL) curricula into most medical schools, the emphasis on lectures has decreased. This paper discusses how lectures can be used in a PBL curriculum, what makes a great lecture, and how to deliver a lecture that fits with these changes.

Since its introduction in 1985 by Ciaglia et al, percutaneous dilational tracheostomy (PDT) has gradually become the procedure of choice in establishing a long‐term airway in many intensive care units (ICU). However, the safety of performing PDT in patients with barotrauma is still unknown and has never been reported. We present the case of a 35‐year‐old man with AIDS, who was admitted to our medical ICU for pneumonia and acute respiratory distress syndrome. He developed subcutaneous emphysema and pneumomediastinum as complications of mechanical ventilation. After stabilization of the barotrauma, he underwent PDT with the standard Ciaglia Blue Rhino technique. However, rapid and extensive progression of preexisting barotrauma occurred shortly after PDT. This severe complication was nearly fatal. The prolonged procedure during which the susceptible lung was exposed to longer duration of high airway pressure was thought to be the mechanism of rapid deterioration of the preexisting barotrauma. With aggressive supportive care, the patient survived. To prevent further deterioration of preexisting barotrauma during and after PDT in future cases, we propose some principles that should be strictly followed. Under administration of these principles, we safely performed PDT in another case with preexisting barotrauma 1 month later.

Vitiligo is a refractory skin disease. To investigate the risk factors and treatment responses of patients with vitiligo in Japan, we recorded and analyzed the details of 713 vitiligo patients (comorbidity, treatment responses, family history, age, and sex) who visited the dermatology clinic of the Nagoya City University Hospital, Nagoya, Japan between January 2004 and August 2010 (mean age, 35.2 years; 302 men, 411 women) using logistic regression analysis. The results are expressed as odds ratios (OR) with 95% confidence interval (CI). Patients were diagnosed with vitiligo [n = 644; 338 generalized type (47.4%), 170 segmental type (23.8%), and 136 localized type (19.1%)], nevus depigmentosus (n = 53, 7.4%), halo nevus (n = 14, 2.0%), and hypomelanosis of Ito (n = 2, 0.3%). For generalized and localized types, none of the analyzed factors were statistically significant. For the segmental type, antinuclear antibody (OR = 1.005; 95% CI, 1.00–1.01; p < 0.05) and onset age < 14 years were the significant factors in patients between 15 years and 29 years (OR = 0.246; 95% CI, 0.113–0.538; p < 0.001), 30–54 years (OR = 0.0419; 95% CI, 0.0133–0.132; p < 0.001), and >55 years (OR = 0.0171; 95% CI, 0.00333–0.0879; p < 0.001). The treatment response rates for narrow‐band UV‐B, topical vitamin D₃, and punch graft (1 mm minigraft) were, respectively, as follows: (1) generalized type: 46.3%, 21.1%, and 38.9%; (2) segmental type: 20.3%, 29.0%, and 77.3%; and (3) localized type: 29.2%, 54.8%, and 73.3%. We report the comorbidities and efficacy rates of these treatments. The response data for these treatments, in particular, would be of assistance to the previous explanations, because there were only a few reports on the response data for these treatments. The appropriate treatment should be selected depending on the type of vitiligo.

The aim of this study was to evaluate the effect of an electromagnetic field (EMF), generated close to the ovaries, on primordial follicles. A total of 16 rats were used in this study. The study group consisted of rats exposed to an EMF in the abdominal region for 15 min/d for 15 days. Both the study and control group were composed of eight rats. After the treatment period of 15 days, the ovaries of the rats were extracted, and sections of ovarian tissue were taken for histological evaluation. The independent samples t test was used to compare the two groups. In the study group, the means of the right and left ovarian follicle numbers were 34.00 ± 10.20 and 36.00 ± 10.53, respectively. The average total ovarian follicle number was 70.00 ± 19.03. In the control group, the means of the right and left ovarian follicle numbers were 78.50 ± 25.98 and 71.75 ± 29.66, respectively, and the average total ovarian follicle number was 150.25 ± 49.53. The comparisons of the means of the right and left ovarian follicle numbers and the means of the total ovarian follicle numbers between the study and control groups indicated that the study group had significantly fewer follicles (p < 0.001, p = 0.011, and p = 0.002, respectively). This study found a significant decrease in the number of ovarian follicles in rats exposed to an EMF. Further clinical studies are needed to reveal the effects of EMFs on ovarian reserve and infertility.

Problem‐based learning (PBL) is an excellent opportunity for students to take responsibility for their learning and to develop a number of cognitive skills. These include identifying problems in the trigger, generating hypotheses, constructing mechanisms, developing an enquiry plan, ranking their hypotheses on the basis of available evidence, interpreting clinical and laboratory findings, identifying their learning needs, and dealing with uncertainty. Students also need to work collaboratively in their group, communicate effectively, and take active roles in the tutorials. Therefore, interaction in the group between students and their tutor is vital to ensure deep learning and successful outcomes. The aims of this paper are to discuss the key principles for successful interaction in PBL tutorials and to highlight the major symptoms of superficial learning and poor interactions. This comprises a wide range of symptoms for different group problems, including superficial learning. By early detection of such problems, tutors will be able to explore actions with the group and negotiate changes that can foster group dynamics and enforce deep learning.

Nervous system manifestations are present in up to 70% of patients with systemic lupus erythematosus (SLE). The spectrum of clinical symptoms varies widely, from severe, life‐threatening symptoms at presentation, such as transverse myelitis, to symptoms of more subtle and subclinical abnormalities of neurocognitive function. We report the case of a 14‐year‐old patient with SLE and lupus nephritis under regular steroid therapy, who had a sudden onset of consciousness change. Brain magnetic resonance imaging showed a huge mass lesion. After surgical decompression and corticosteroid pulse therapy, the patient's neurologic symptoms improved dramatically. Brain biopsy revealed perivasculitis of the brain with marked perivascular infiltration of eosinophils, macrophages, and neutrophils. Microhemorrhage was also evident. The patient recovered without obvious neurologic sequelae.