Feng-Rong Chuang

QTc prolongation indicates a poor prognosis in patients with organophosphate poisoning

This study reviewed emergency department electrocardiograms of 223 patients with organophosphate poisoning from January 1982 to June 1994: 97 (43.5%) had QTc prolongation and were placed in group A; 126 patients without QTc prolongation were designated as group B. Compared with group B, group A patients had a higher mortality (19.6% v 4.8%, P < .001) and a higher incidence of respiratory failure (56.7% v 20.6%, P < .001). Serum cholinesterase levels were determined in the 223 patients: 92 (41.3%) were classified as severe poisoning. 32 (14.3%) as moderate, 41 (18.1%) as mild, and 58 (25.7%) as very mild. The severe group had a high incidence of QTc prolongation (P < .001), a high incidence of respiratory failure (P < 0.001), and a higher mortality rate (P < 0.001) than the other groups. Of the QTc prolongation patients, 59.8% (55/92) had a high incidence of respiratory failure (78.2% v 35.1%, P < .0001) and a higher mortality rate (29.1% v 8.1%, P < 0.05) compared with 40.2% (37/92) of the patients without QTc prolongation in the severe group. In conclusion, a complete electrocardiogram at the emergency department is important and of prognostic value.

Association between hypertensive disorders during pregnancy and end-stage renal disease: a population-based study

Background: Studies into the association between hypertensive disorders during pregnancy and end-stage renal disease are limited. We investigated the risk of end-stage renal disease after delivery among women with hypertensive disorders during pregnancy. Methods: We used insurance claims data from 1998 to 2009 to identify 26 651 women aged 19–40 years old who experienced hypertensive disorders during pregnancy; these women had no history of hypertension, diabetes, kidney disease or lupus. We also randomly selected 213 397 women without hypertensive disorders during pregnancy as a comparison cohort; the frequency was matched by age and index year of pregnancy. We compared the incidence of end-stage renal disease in the 2 cohorts. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) after controlling for demographic and clinical factors. Results: Women with hypertensive disorders during pregnancy had a greater risk of chronic kidney disease and end-stage renal disease, with adjusted HRs of 9.38 (95% CI 7.09–12.4) and 12.4 (95% CI 8.54–18.0), respectively, after controlling for urban status, coronary artery disease, congestive heart failure, hyperlipidemia and abruption. The HR for end-stage renal disease was 2.72 (95% CI 1.76–4.22) after we also controlled for hypertension and diabetes. Women with preeclampsia or eclampsia had a higher risk of end-stage renal disease (adjusted HR 14.0, 95% CI 9.43–20.7) than women who had gestational hypertension only (adjusted HR 9.03, 95% CI 5.20–15.7). Interpretation: Women with hypertensive disorders during pregnancy were at a high risk of end-stage renal disease. The risk was much greater for women who had preeclampsia or eclampsia than those who had gestational hypertension only.

Reduction of advanced glycation end product levels by on-line hemodiafiltration in long-term hemodialysis patients

BACKGROUND Advanced glycation end products (AGEs) are thought to be involved in many complications of end-stage renal disease. This study analyzed serum AGE level reduction rates and corresponding long-term changes in serum levels among different dialysis modes. METHODS Eighty-one patients with chronic uremia were divided into 3 groups receiving conventional hemodialysis (HD), high-flux HD, or on-line hemodiafiltration (HDF). Serum AGE levels were measured by competitive enzyme-linked immunosorbent assay predialysis and postdialysis and after 6 months. Additionally, AGE clearance was measured in 11 uremic patients treated with alternative high-flux HD and on-line HDF. RESULTS Although predialysis serum AGE levels were similar, postdialysis levels were significantly lower in patients treated with on-line HDF (35.4 +/- 4.2 microg/mL) compared with those treated with conventional HD (82.2 +/- 11.4 microg/mL; P = 0.003), but not high-flux HD (56.7 +/- 5.9 microg/mL; P = 0.15). The serum AGE level reduction rate in on-line HDF (61.5% +/- 4.2%) was significantly greater than that in conventional HD (20.5% +/- 2.4%; P < 0.001) and high-flux HD patients (40.4% +/- 2.7%; P = 0.049). AGE clearance was increased 50% with on-line HDF compared with high-flux HD, reaching borderline significance (P = 0.07). In a 6-month study, predialysis serum AGE levels were significantly lower in patients treated with on-line HDF compared with those treated with conventional and high-flux HD. CONCLUSION On-line HDF may provide an improved form of treatment that achieves significantly better AGE level reduction than high-flux HD and conventional HD. Uremic patients treated with on-line HDF for longer than 6 months achieved a significant reduction in predialysis serum AGE levels.

Extraintestinal manifestations of Edwardsiella tarda infection

Edwardsiella tarda, a member of the family Enterobacteriaceae, is a rare human pathogen. Gastroenteritis is the most frequently reported manifestation of E. tarda infection. In contrast, extraintestinal infection with E. tarda has rarely been reported. This study made a retrospective case and microbiological data review of patients with extraintestinal E. tarda infections to further understand this disease.

Real-Time PCR Analysis of the Intestinal Microbiotas in Peritoneal Dialysis Patients

ABSTRACT Bifidobacterium and Lactobacillus can beneficially affect the host by producing acetic acid and lactic acid, which lower pH and thereby inhibit the growth of pathogens or allow the probiotic bacteria to compete with pathogens for epithelial adhesion sites and nutrients. The transmural migration of enteric organisms into the peritoneal cavity can cause peritonitis in peritoneal dialysis (PD) patients. We hypothesized that the composition of the intestinal microbiota with regard to Lactobacillus species and Bifidobacterium species differed between PD patients and healthy controls. The aim of the study was to investigate these differences by real-time PCR analysis of fecal samples. From 1 August 2009 to 31 March 2010, a total of 29 nondiabetic PD patients and 41 healthy controls from China Medical University Hospital were recruited after giving their informed consent. Fecal samples were collected from the PD patients and their age-matched counterparts in the morning using a standardized procedure. DNA extracted from these samples was analyzed by real-time PCR. All bifidobacteria, Bifidobacterium catenulatum, B. longum, B. bifidum, Lactobacillus plantarum, L. paracasei, and Klebsiella pneumoniae were less frequently detected in the patient samples. Dysbiosis (microbial imbalance) may impair intestinal barrier function and increase host vulnerability to pathogen invasion. Further studies are necessary to confirm our findings before clinical trials with probiotic supplementation in PD patients.

Bilateral Moderate Hydroureteronephrosis Due to Uterine Prolapse: Two Case Reports and Review of the Literature

Uterine prolapse resulting in hydronephrosis was uncommon. We report two cases of complete uterine prolapse and bilateral moderate hydronephrosis. Case 1, she was admitted due to fever with pyuria. Uterine prolapse was noted by incidental finding. Urine culture showed Escherichia coli. She received total vaginal hysterectomy, which corrected the obstruction and bladder dysfunction. Case 2, she had a history of liver cirrhosis and was denied further operation due to bleeding tendency. Renal echo and intravenous pyelography showed bilateral moderate hydronephrosis with hydroureter in the two cases. Normal renal function was found in the two cases. We suggest early diagnosis and management are necessary in order to prevent renal failure and urinary tract infection.

Early Referral as an Independent Predictor of Clinical Outcome in End-Stage Renal Disease on Hemodialysis and Continuous Ambulatory Peritoneal Dialysis

Objectives. To evaluate the influence of early nephrology referral on clinical outcome in patients on maintenance hemodialysis (HD) and peritoneal dialysis (PD). Patients and Methods. This study retrospectively analyzed patients entering our HD and PD program from February 2000 to June 2003. Patients who presented to a nephrologist more than 6 months before starting dialysis were defined as early referral (ER). Meanwhile, patients transferred to the nephrology department less than 6 months before initial dialysis were considered late referral (LR). Results. HD Groups. Of 78 HD patients, 37 (47.1%) qualified for the ER group and 41 (52.6%) were designated to the LR group. The demographic data were analyzed for both the HD and PD groups. No significant differences in average age at dialysis, duration of hemodialysis, and gender were noted between these two groups. The same applied for the biochemical parameters in both groups. HD patients with early referral had significantly better survival (p < .05) as plotted with the Kaplan‐Meier method. In univariate analysis by cox proportional hazards mode, the early referral in HD patients [Exp (Coef) = 0.426, P < .01] significantly influenced survival. The various variables were further examined by multivariate analysis, and early referral, hemoglobin, and age still significantly impacted patient survival (P < .05). CAPD Groups. The survival curve related to early referral in continuous ambulatory peritoneal dialysis (CADP) patient survival rate was significantly higher for the early referral groups (P < .05). In addition, a multivariate analysis adjusting for several potential risk factors found that referral time remained significantly associated with patient survival. In additional, hemoglobin and age were significant and independent predictors of mortality. Conclusion. This study demonstrates that time between referral and starting dialysis is a predictor of survival for both HD and PD patients, with early referral being associated with longer survival time. These analytical results suggest that early referral before dialysis is important in determining long‐term prognosis in HD and PD patients.

Hypertensive Disorders in Pregnancy and Preterm Delivery and Subsequent Stroke in Asian Women A Retrospective Cohort Study

Background and Purpose— Few studies exist concerning the risk of stroke associated with hypertensive disorders in pregnancy (HDP) in Asian women. This study investigates whether preterm delivery further complicates this risk in women with HDP in Taiwan. Methods— Based on universal insurance claims data, 1092 pregnant women with newly diagnosed HDP from 2000 to 2004 and aged 15 to 40 years were identified as the HDP cohort. Then, 4715 randomly selected persons without HDP frequency matched with the index year were designated as the non-HDP controls. Both cohorts were followed-up until the end of 2008 to measure the incidence of stroke. Results— The HDP cohort had a higher incidence of stroke than the non-HDP cohort (30.1 vs 12.8 per 10 000 person-years), with an overall adjusted hazard ratio of 2.04 (95% CI, 1.18- 3.51) for stroke. Preterm delivery increased the risk of stroke to 3.22-fold (95% CI, 1.48–6.99; P for trend=0.002). The age-specific V-shape risk association showed that the highest risk of stroke was noted among subjects 15 to 18 years old in the HDP group (hazard ratio, 13.4; 95% CI, 1.54–116.7) and followed by women aged 35 years and older (hazard ratio, 5.56; 95% CI, 1.47–21.0). Conclusions— Pregnant women with HDP have an increased risk of subsequent stroke. Preterm delivery and older ages increase the risk of subsequent stroke. Adolescents with HDP also have an elevated risk of stroke. Early identification of women with HDP is needed for prevention.

Comparison of Iodixanol and Iohexol in Patients Undergoing Intravenous Pyelography: A Prospective Controlled Study

Background. Nephropathy associated with contrast medium exposure is a well-known complication of IVP. However, it is uncertain whether iso-osmolar non-iodinated contrast medium (iodixanol) is less nephrotoxic than low-osmolar contrast medium (iohexol). Materials and Methods. In this single-center, double-blind, prospective study, 50 patients undergoing IVP were randomized into two groups receiving different contrast medium: iodixanol and iohexol. Patients in high risk for contrast nephropathy were included, 28 with renal insufficiency and 19 with diabetes mellitus. We compared the nephrotoxic effect (contrast nephropathy), complement and cytokines profile between the iodixanol and iohexol groups. The mean volume of contrast medium in each IVP procedure was 0.8 mL/kg. Results. The incidence of contrast nephropathy was 4 percent among all patients (one iodixanol and one iohexol). We found no significant differences in contrast nephropathy and allergic reactions between the two groups. There was no significant difference in cytokine profiles in both groups (p > 0.05).The incidence of allergic reaction was 16 percent among all patients. Twelve percent (3/25) had late reaction after iohexol exposure compared to four percent (2/25) with iodixanol (p = 1.0). One patient had severe skin rash due to late adverse reaction after iodixanol. No mortality was found. Conclusions. New iodixanol and iohexol contrast medium for routine IVP examination are safe and have low nephrotoxicity profile, especially in elderly or high-risk patients. Iodixanol contrast medium has an increased risk to induce severe late adverse reaction compared to iohexol. Allergic reaction may be the main adverse effect after contrast medium infusion.

Outcome of living donor liver transplantation for glycogen storage disease.

GLYCOGEN storage diseases (GSD) are inherited disorders in which the amount and/or structure of glycogen in body tissues are abnormal. GSD I (von Gierke disease) is caused by a deficiency of glucose 6-phosphatase activity in the liver, kidney, and intestinal mucosa with glycogen overloading in these organs. The clinical manifestations are seizures, systemic acidosis, hyperlipidemia, hyperuricemia, and growth retardation. Without effective treatment, long-term complications occur, including gout, osteoporosis, short stature, and hepatic adenomas. GSD III (Cori disease) is caused by a deficiency of glycogen debranching enzyme activity and characterized with limit dextrin-like glycogen accumulated in both liver and muscle in most patients. Hepatomegaly, hypoglycemia, hyperlipidemia, and growth retardation are the main manifestations in children; while liver cirrhosis and /or hepatocellular carcinoma may occur later. Great progress in the management of GSD I and III has been made recently. For patients affected with GSD I, nocturnal nasogastric feeding of glucose or orally administered uncooked cornstarch is effective. With early diagnosis and initiation of treatment, normal growth and development may be expected. Some patients are free of long-term complications. Treatment of GSD III consists of highprotein diet, and frequent high carbohydrate meals for patients with hypoglycemia. Nocturnal gastric feeding or cornstarch supplements comprise effective therapy. However, some patients with GSD do not respond to diet therapy and may need frequent intravenous glucose infusions and even parenteral nutrition to maintain metabolic homeostasis. Liver transplantation (LT) is considered to correct the metabolic defects and the deleterious complications of GSD. LT for GSD I and III was first reported, respectively, by Malatack et al in 198 and by Superina et al in 1989. We present five cases of GSD (four GSD Ia; one GSD III), which were treated by living donor liver transplantation (LDLT) in our institution. These patients were unresponsive to medical therapy or developed serious complications of GSD. In this study we investigate the outcome of these children after LDLT for GSD. PATIENTS AND METHODS