Hsiao-Yu Yang

Stress, Insomnia, and Chronic Idiopathic Urticaria-A Case-Control Study

BACKGROUND AND PURPOSE There is growing evidence that stress might play a crucial role in the pathogenesis of urticaria. This study examined the association between chronic idiopathic urticaria and stress from major life events and explored the validity of the biopsychosocial model of stress as it relates to urticaria. METHODS A total of 75 consecutive cases with chronic idiopathic urticaria and 133 controls with tinea pedis who visited a dermatologic clinic for treatment were recruited for participation in this study. Subjects in both groups were assessed with a semi-structured questionnaire to determine the number and subjective weighting of major life events, somatic symptoms, insomnia, irregularity of daily life, perceived family support, ego-function, positive coping, and negative coping. Structural equation modeling was used to examine the influence of biologic, psychologic, and social factors on the development of urticaria. Cluster analysis was used to classify subjects according to risk of developing urticaria. RESULTS In the 6 months preceding disease onset, patients with chronic idiopathic urticaria had significantly more life events, higher subjective weighting of impacts from life events, more somatic symptoms, more severe insomnia, less family support, more negative coping tendencies, and were younger in age. Good ego-function, coping strategies and family support were associated with decreased frequency of urticaria. CONCLUSIONS Stress is an important risk factor for the development of chronic idiopathic urticaria while positive coping tendencies and good family support appear to have preventative effects. Insomnia might be the most important psychosomatic symptom that is a predisposing factor for chronic urticaria.

Increased Mortality Risk for Cancers of the Kidney and Other Urinary Organs among Chinese Herbalists

Background A national survey in Taiwan has shown that Chinese herbal therapy increases the risk of chronic kidney disease. However, it is unknown whether herbal therapy will increase the risk of urological cancers. The purpose of this study was to determine whether Chinese herbalists are at higher risk for urological cancers. Methods We studied all Chinese herbalists in Taiwan that were registered in the Chinese Herbalist Labor Union between 1985 and 2000. We retrospectively followed their survival status and causes of death using the National Mortality Registry Database from 1985 to 2004. Standardized mortality ratios (SMRs) for urological cancers in herbalists were calculated and compared with those of the general population of Taiwan. Results A total of 6548 Chinese herbalists were enrolled and 88,289 person-years were accrued during the observation period. After adjustment for age and sex, the SMR for urological cancers was significantly higher for Chinese herbalists than for the general population (SMR = 3.10; 95% CI: 1.41–5.87). When further stratified by location, the SMR for kidney cancer and other urinary organ cancers (SMR = 3.81; 95% CI: 1.39–8.28) except bladder cancer (SMR = 2.26; 95% CI: 0.47–6.59) were significantly higher for the Chinese herbalists. The SMR for chronic and unspecified nephritis, renal failure, and renal sclerosis were also significantly higher for herbalists (SMR = 2.40; 95% CI: 1.40–3.84). Conclusions Chinese herbalists have a significantly higher risk for urological cancers. This increased risk among herbalists highlights the urgent need for safety assessments of Chinese herbs.

Occupational kidney disease among Chinese herbalists exposed to herbs containing aristolochic acids.

Objective Many Chinese herbs contain aristolochic acids (ALAs) which are nephrotoxic and carcinogenic. The objective of this study was to identify whether exposure to herbs containing ALAs increased the risk of kidney disease among Chinese herbalists. Methods A nested case–control study was carried out on 6538 Chinese herbalists registered between 1985 and 1998. All incident cases of chronic renal failure reported to the Database of Catastrophic Illness of the National Health Insurance Bureau between 1995 and 2000 were defined as the case group. Up to four controls without renal failure were randomly matched to each case by sex and year of birth. A structured questionnaire survey was administered between November and December 2002. The Mantel–Haenszel method and conditional logistic regression were used to estimate the risks. Results 40 cases and 98 matched controls were included in the final analysis. After adjusting for age, frequent analgesic use, and habitual consumption of alcohol, fermented or smoked food, we found manufacturing and selling Chinese herbal medicine (OR 3.43, 95% CI 1.16 to 10.19), processing, selling or dispensing herbal medicines containing Fangji (OR 4.17, 95% CI 1.36 to 12.81), living in the workplace (OR 3.14, 95% CI 1.11 to 8.84) and a history of taking of herbal medicines containing Fangji (frequently or occasionally) (OR 5.42, 95% CI 1.18 to 24.96) were significantly associated with renal failure. Conclusion Occupational exposure to and consumption of herbs containing ALAs increases the risk of renal failure in Chinese herbalists.

Increased Risks of Upper Tract Urothelial Carcinoma in Male and Female Chinese Herbalists

BACKGROUND/PURPOSE It has been shown that herbs that contain aristolochic acid induce urological cancer. Chinese herbalists have easy access to such herbs. Our previous mortality study has shown a significantly increased risk of urological cancer in female but not male herbalists. To re-examine this risk in male herbalists, the incidence of urological cancer was analyzed. METHODS We enrolled all 6550 Chinese herbalists in Taiwan registered during 1985-2000, and we retrospectively followed the development of cancer until 2001 by analysis of data collected from the Taiwan Cancer Registry. Standardized incidence ratios (SIRs) were calculated for urological cancers in herbalists and compared with those for the general population in Taiwan. RESULTS There were 30 newly diagnosed cases of urological cancer and most of them were transitional cell carcinoma (93.1%). The mean age at diagnosis for urothelial carcinoma was 51.6 years, and 51.9% were in the upper urinary tract. After adjustment for age and sex, the SIR for all urological cancers was 3.51 [(95% confidence interval (CI): 2.37-5.01]. When stratified by location, the SIRs for kidney and upper urinary tract cancers and bladder cancer were 4.24 (95% CI: 2.47-6.80) and 2.86 (95% CI: 1.52-4.89), respectively. When analyzed by sex, the SIRs for all urological cancers, kidney and upper urinary tract cancers, and bladder cancer were also significantly increased in male herbalists. CONCLUSION The significant risk of urothelial carcinoma noted in male herbalists increases our suspicion that this is an occupational disease that renders regular health assessment of herbalists an urgent necessity.

Chinese herbs containing aristolochic acid associated with renal failure and urothelial carcinoma: a review from epidemiologic observations to causal inference.

Herbal remedies containing aristolochic acid (AA) have been designated to be a strong carcinogen. This review summarizes major epidemiologic evidence to argue for the causal association between AA exposure and urothelial carcinoma as well as nephropathy. The exposure scenarios include the following: Belgian women taking slimming pills containing single material Guang Fang Ji, consumptions of mixtures of Chinese herbal products in the general population and patients with chronic renal failure in Taiwan, occupational exposure in Chinese herbalists, and food contamination in farming villages in valleys of the Danube River. Such an association is corroborated by detecting specific DNA adducts in the tumor tissue removed from affected patients. Preventive actions of banning such use and education to the healthcare professionals and public are necessary for the safety of herbal remedies.

Occupational Exposure to Herbs Containing Aristolochic Acids Increases the Risk of Urothelial Carcinoma in Chinese Herbalists

PURPOSE Aristolochic acid can cause urothelial carcinoma. Herbal remedies containing aristolochic acids were previously categorized as proven group 1 human carcinogens by the WHO cancer agency, the International Agency for Research on Cancer. However, the health effect on workers exposed to aristolochic acid is unclear. Fangchi, a representative herb containing aristolochic acid, is commonly used in the Chinese herbal medicine industry. We determined whether workers exposed to fangchi are at increased risk for urothelial carcinoma. MATERIALS AND METHODS We designed a case-control study based in a national representative cohort of Chinese herbalists. This study analyzed 6,564 Chinese herbalists employed between 1985 and 1998. All incident cases of urothelial carcinoma that occurred between 1988 and 2001 were defined as the case group. Controls were selected from the baseline cohort in a randomized manner. A total of 24 cases and 140 controls were included in analysis. Information about fangchi exposure was obtained in a questionnaire survey administered in 2002. RESULTS Processing, selling or dispensing herbs containing fangchi significantly increased the risk of urothelial carcinoma (HR 2.4, 95% CI 1.1-5.3, p = 0.03). This relationship was independent of cigarette smoking or potential arsenic exposure from drinking water from deep wells. CONCLUSIONS Exposure to the Chinese herbal drug fangchi increases the risk of urothelial carcinoma in herbalists. Appropriate medical monitoring is warranted for workers who have similar exposure.

Pulmonary fibrosis in workers exposed to non-asbestiform tremolite asbestos minerals.

Background: Studies of the health effects of non-asbestiform asbestos minerals remain inconclusive. Nephrite is a type of non-asbestiform tremolite mineral. We assessed the risk for pulmonary fibrosis in workers who process nephrite. Methods: A cross-sectional study that included 344 stone workers and their families was undertaken in Taiwan in 2010. The diagnostic criteria for pulmonary fibrosis included (1) radiographic fibrosis profusion of 1/1 or greater and (2) audible lung crackles confirmed by physician. The nephrite samples were analyzed using polarized light and transmission electron microscopy combined with selected-area electron diffraction and energy-dispersive x-ray spectroscopy. Results: After excluding 16 subjects with histories of tuberculosis or previous employment in metal casting and welding, as well as 23 family members who had not worked in the stone industry, we analyzed 305 subjects. Processing nephrite increased the risk for pulmonary fibrosis (odds ratio = 2.8 [95% confidence interval = 1.0–9.9] and unchanged after adjustment for age and smoking). Bulk sample analyses showed that the nephrite is a tremolite mineral composed of both asbestiform and non-asbestiform components. The cat’s-eye nephrite had the highest asbestiform fibrous content, and the average length and aspect ratio of elongated mineral particles were the highest of all the nephrite types. Compared with workers processing other types of nephrite, workers processing cat’s-eye nephrite had the highest risk for pulmonary fibrosis. Conclusion: Processing non-asbestiform tremolite mineral may increase the risk for pulmonary fibrosis. Medical monitoring is warranted for workers with such exposure.

Pleural Plaque Related to Asbestos Mining in Taiwan

A 78-year-old woman complained of twisting-like pain in her left lower chest. During physical examination, friction rubbing was noted in both lungs. Chest radiography showed extensive bilateral pleural calcification. High-resolution computed tomography confirmed the presence of bilateral calcified pleural plaques. The patient had worked at a Japanese asbestos factory in Taiwan for 1 year when she was 16 years old. Her job involved picking out asbestos fibers from crushed asbestos minerals, but no protective equipment was used at that time. This is believed to be the first reported case of asbestos-related disease in Taiwan that resulted from asbestos mining. We also summarize the history of domestic asbestos mining, importation of asbestos, and trends in asbestos use in Taiwan.

Association of blood lead and mercury with estimated GFR in herbalists after the ban of herbs containing aristolochic acids in Taiwan

Objective This study was undertaken to explore the association of estimated glomerular filtration rate (GFR) with exposure to aristolochic acids (ALAs) and nephrotoxic metals in herbalists after the ban of herbs containing ALAs in Taiwan. Methods This cross-sectional study recruited a total of 138 herbalists without end-stage renal disease or urothelial carcinoma from the Occupational Union of Chinese Herbalists in Taiwan in 2007. Aristolochic acid I (ALA-I) was measured by ultra-high-pressure liquid chromatography/ tandem mass spectrometry (UHPLC-MS/MS) and heavy metals in blood samples were analysed by Agilent 7500C inductively coupled plasma-mass spectrometry. Renal function was assessed by using a simplified Modification of Diet in Renal Disease Study equation to estimate GFR. Results Blood lead was higher in herbal dispensing procedures (p=0.053) and in subjects who self-prescribe herbal medicine (p=0.057); mercury was also higher in subjects living in the workplace (p=0.03). Lower estimated GFR was significantly associated with lead (β=−10.66, 95% CI −18.7 to −2.6) and mercury (β=−12.52, 95% CI −24.3 to −0.8) with a significant interaction (p=0.01) between mercury and lead; however, estimated GFR was not significantly associated with high ALA-I level groups, arsenic and cadmium after adjusting for other confounding factors. Conclusions We found that lower estimated GFR was associated with blood lead and mercury in herbalists after the ban of herbs containing ALAs in Taiwan. The ALA-I exposure did not show a significant negative association of estimated GFR, which might due to herbalists having known how to distinguish ALA herbs after the banning policy. Rigorous monitoring is still needed to protect herbalists and the general population who take herbs.

Carving of non-asbestiform tremolite and the risk of lung cancer: a follow-up mortality study in a historical nephrite processing cohort

Objectives The health risks associated with exposure to non-asbestiform asbestos minerals, including nephrite, are unclear. In 1965 nephrite processing began in the town of Fengtian in Taiwan, and the majority of inhabitants were involved in the industry from 1970 until 1980. The objectives of this study were to examine lung cancer deaths and assess the carcinogenic effects of nephrite carving. Methods We studied mortality due to lung cancer (ICD-9 code 162 for cancers of the trachea, bronchus and lung) from 1979 to 2011. We calculated the standardised mortality ratio (SMR) for lung cancer using the age- and sex-specific cancer mortality rates in eastern Taiwan as the standard rates. Air samples, bulk samples and a surface sample were analysed. Results Nephrite is a non-asbestiform asbestos mineral composed of microcrystalline tremolite. During nephrite processing, in personal air samples the average concentration of elongated mineral particles with the morphological characteristics of asbestos fibres was 1.4 f/cm3, with rough grinding generating the highest concentrations (4.7 f/cm3). Transmission electron microscopy (TEM) confirmed that the air samples contained intact asbestiform tremolite fibres. The ambient air samples and the wipe sample indicated paraoccupational contamination. The crude mortality rates for lung cancer were higher in Fengtian than in Taiwan for all age groups and both genders. The SMR for lung cancer was 1.28 (95% CI 1.12 to 1.45). Conclusions Nephrite carving may increase the risk of lung cancer. Appropriate medical monitoring is warranted for workers who are exposed to similar materials.