Kuo-Yang Huang

Inaccuracy of lung adenocarcinoma subtyping using preoperative biopsy specimens

Background: The prognostic significance of the new classification of lung adenocarcinoma proposed in the 2015 World Health Organization guideline has been validated. This study aimed to compare the preoperative classification of the adenocarcinoma subtype based on computed tomography–guided 18‐gauge core needle biopsy (CTNB) or radial probe endobronchial ultrasound (R‐EBUS) specimens, with the postoperative classification based on the resected specimens. Methods: We retrospectively analyzed a consecutive series of 128 patients (60 CTNB and 68 R‐EBUS) who underwent surgery for preoperatively confirmed lung adenocarcinoma between 2010 and 2014. Comprehensive histological subtyping was performed according to the 2015 World Health Organization classification system. Diagnostic concordance of subtypes between small biopsy and resection specimens was assessed. Results: Concordant subtyping of adenocarcinomas between the predominant pattern on resections and biopsy sections was observed in 58.6% of cases (75 of 128; 95% confidence interval [CI], 49.9%‐66.8%). Preoperative subtyping was accurate in only 30% of samples (3 of 10) with a predominance of solid patterns. None of the 5 micropapillary predominant cases was detected by CTNB or R‐EBUS. For the concordance of the presence or absence of micropapillary/solid component, the sensitivity was as low as 16.5% (95% CI, 9.1%‐26.5%). The detection rate by CTNB/R‐EBUS increased with the increase in the percentage of micropapillary/solid component; however, even in the ≥40% micropapillary/solid group, only 24% of cases were detected by CTNB/R‐EBUS. Conclusions: The accuracy of the estimation of adenocarcinoma histological subtype based on preoperative biopsy sections was unsatisfactory.

The Risk of Chronic Kidney Disease in Tuberculosis: A Population-based Cohort Study

BACKGROUND The relationship between tuberculosis (TB) and subsequent chronic kidney disease (CKD) remains unclear. Therefore, we examined the risk of CKD among patients with TB in a nationwide study. METHODS We conducted a retrospective cohort study using data from the National Health Insurance system of Taiwan. The cohort included 8735 patients who were newly diagnosed with TB. Patients were recruited between 1998 and 2002, and the date of diagnosis was defined as the index date. Each patient was randomly matched with four people from the general population without TB, according to age, gender and the index year. The occurrence of CKD was followed up until the end of 2011. The relative risks of CKD were estimated using the Cox proportional hazard model after adjusting for age, gender, index year and comorbidities. RESULTS The overall incidence of CKD was 1.27-fold greater in the TB cohort than in the non-TB cohort. The adjusted hazard ratio (HR) of CKD associated with TB was higher in women (1.72; 95% confidence interval [CI]: 1.33-2.22), those aged <50 years (1.67; 95% CI: 1.15-2.41) and those without comorbidities (1.39; 95% CI: 1.06-1.83). In addition, patients with more comorbidities among hypertension, diabetes and hyperlipidemia have a greater risk of developing CKD in both cohorts, and the adjusted HRs were higher in the TB cohort than in the non-TB cohort. CONCLUSION TB patients had a significantly higher risk of developing CKD than the general population. The detailed mechanisms need further investigation.

Pleural Empyema and Aortic Aneurysm: A Retrospective National Population-Based Cohort Study.

AbstractPleural empyema (PE) may evolve into necrosis, fistula in the thorax, and sepsis; thus, it is also associated with high mortality.We investigated and analyzed the risk of aortic aneurysm (AA) in a cohort study of patients with PE.A total of 34,250 patients diagnosed with PE were identified as the PE cohort, and 137,000 patients without PE were selected randomly as the control group and matched by sex, age, and index year of PE diagnosis. Patients ages 20 years and younger with a history of AA were excluded. The risk of AA was analyzed using a Cox proportional hazards regression model.Excess risk of AA development was 1.69-fold higher in PE patients (adjusted hazard ratio [aHR] = 1.69; 95% confidence interval [CI] = 1.39–2.05) compared with non-PE patients. The patients with PE exhibited a greater adjusted risk of AA (aHR = 2.01; CI = 1.44–2.81) even if they did not have any of the 9 comorbidities included in our analysis (diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, heart failure, cardiac artery disease, stroke, bacterial endocarditis, and rheumatic endocarditis). Compared with the patients without any of the 9 comorbidities or PE, the patients with only PE had a greater risk of developing AA (aHR = 2.00; CI = 1.43–2.79). The PE cohort had a significantly higher cumulative incidence of AA than the non-PE cohort did during 12 years of follow-up.In a large-scale cohort, patients with PE are linked with an increased risk of AA.

Adenosine deaminase activity in pleural effusions of lymphoma patients

BACKGROUND AND AIM The purpose of this study was to assess the relationship of pleural adenosine deaminase (P-ADA) and non-Hodgkins lymphoma (NHL). DESIGN AND METHODS We retrospectively analysed 63 NHL patients with pleural effusions who accepted a diagnostic thoracentesis and who had P-ADA available at the China Medical University Hospital (Taichung, Taiwan) between January 2003 and April 2012. RESULTS There were 46 exudates [40 malignant pleural effusions (MPE), 5 complicated para-pneumonic effusions and 1 undiagnosed effusion] and 17 transudates. The P-ADA activity was significantly different between the two groups (P < 0.005). Among 40 MPE cases, 29 were due to B-cell and 11 due to T-cell NHL. There was no pleural transudative effusion with P-ADA value higher than 26 U/l in our study, but simultaneously 48% (22/46) of exudative pleural effusions showed a P-ADA value under that cut-off point. The P-ADA level reached the diagnostic cut-off for tuberculosis (40 IU/l) in 11 cases of MPE (11/40 = 27.5%): 9 B-cell NHL (9/29 = 31%) and 2 T-cell NHL (2/11 = 18%). The median levels (25th, 75th percentiles) of P-ADA were 28 IU/l (14-50) in the MPE of B-cell NHL and 26 IU/l (14-28) in the T-cell NHL (P = 0.693). CONCLUSIONS The use of P-ADA in NHL effusion could aid the separation of transudates from exudates. Around one-quarter MPE of NHL had abnormal P-ADA ( > 40 IU/l). There was no difference in the P-ADA activity in T-cell and B-cell NHL.

Diagnostic pitfalls of discriminating lymphoma-associated effusions

AbstractHigh serum lactate dehydrogenase (LDH) level, immunologic defects, enlarged mediastinal lymph nodes, and frequent hydration and diuresis in lymphoma patients may affect the development of pleural effusion (PE). The study was to assess the clinical utility of “Light criteria” and the “recommended algorithm for investigating PEs” in patients with lymphoma.The characteristics of 126 PEs of lymphoma patients who underwent diagnostic thoracentesis between January 1, 2003, and April 30, 2012, were reviewed. Using Light criteria, 29 (23%) PEs were incorrectly classified. The sensitivity for exudates in Light criteria was 88% and the specificity was only 44%. In 32 transudates, PE LDH correlated with blood LDH concentration (P < 0.001, r = 0.66). Nine transudates were misclassified as exudates (50%; 9/18) just due to PE LDH more than two-thirds the upper limits. Among the 56 bilateral PEs, 33 (59%) were exudates. Ten (63%) polymorphonuclear (PMN)-predominant exudative PEs were malignant. Infective PEs were often mononuclear (67%) rather than PMN predominant.When a patient has lymphoma with either unilateral or bilateral PE, thoracentesis for microbiological testing and cytology is imperative. Carefully clinical correlation in addition to the result from Light criteria and differential cell count is essential for prompt management.

Risk of cataract for people with tuberculosis: results from a population-based cohort study.

BACKGROUND Tuberculosis (TB) is an infectious disease involving multiple organs, including the eyes. We examined the risk of cataract among patients with TB using population data. METHOD Using data from the National Health Insurance (NHI) system of Taiwan, we established a TB cohort with 6994 patients newly diagnosed between 2000 and 2010. For each TB patient, four subjects without TB were randomly selected for the non-TB cohort, frequency matched by age, sex and diagnosis years. The incidence of cataract was measured by the end of 2011. The hazard ratio (HR) of cataract was estimated using Cox proportional hazards regression analysis. RESULTS The overall incidence rate of cataract was 21% greater in the TB cohort than in the non-TB cohort (22.9 vs. 18.8/1000 person-years, P < 0.001), with an adjusted HR (aHR) of 1.26 (95%CI 1.16-1.37). Cataract incidence increased with age, and was higher in men than women and much higher for those with comorbidity. The hazard of cataract was higher in the first 6 months after TB diagnosis. CONCLUSION TB patients are at elevated risk of developing cataract. Although the incidence decreased with time, the aHR remains statistically significant through the follow-up years.

Sleep disorders in individuals without sleep apnea increase the risk of peripheral arterial disorder: A nationwide population-based retrospective cohort study

STUDY OBJECTIVES Previous literature lacks the analysis of non-apnea sleep disorder (NASD) and peripheral arterial disease (PAD). The aim of this study was to evaluate the association between NASD and risk of developing PAD using retrospective data from a national database in Taiwan. DESIGN, SETTING, AND PARTICIPANTS We identified 46,064 patients with NASD using the catastrophic illness registry of the Taiwan National Health Insurance Research Database (NHIRD) from 1996 to 2010. We also selected a comparison cohort of 92,128 subjects who were randomly frequency-matched by age, sex, and entry year of the NASD cohort from the same database. INTERVENTIONS non-apnea sleep disorders. MAIN OUTCOME AND MEASUREMENTS The study followed up all subjects from their entry date to the occurrence of PAD. We evaluated the risks of PAD using Cox proportional hazards regression models. The survival function for PAD was assessed using the Kaplan-Meier method. RESULTS The risk of PAD was 1.49-fold in patients with NASD compared with patients without NASD after adjusting for age, sex, and comorbidities. Patients with NASD and diabetes or with NASD and hyperlipidemia had an increased risk of PAD compared to those without NASD and diabetes or hyperlipidemia. CONCLUSIONS We demonstrated the significantly increased risk of PAD in NASD patients through a nationwide population-based retrospective cohort study.

Chronic Obstructive Pulmonary Disease is Associated with an Increased Risk of Peripheral Arterial Disease

Chronic obstructive pulmonary disease (COPD), peripheral arterial disease (PAD) and ischemic heart disease are considered to be a smoking-related triad. However, only a few studies investigated the relationship between COPD and PAD using limited study sample. We aimed to examine the risk of PAD among patients with COPD using a nationwide cohort database in Taiwan. We conducted a retrospective cohort study using data from the National Health Insurance system of Taiwan. The COPD cohort included 361,023 patients who were newly diagnosed and recruited between 1998 and 2008. Each patient with COPD was randomly frequency-matched with two participants without COPD on age, sex, and the year of index date. The newly diagnosis of PAD was followed up until the end of 2010. The relative risks of PAD were estimated using Cox proportional hazard models after adjusting for age, sex, index year and comorbidities. The overall incidence rate of PAD was 2.34–fold greater in the COPD cohort than in the non-COPD cohort (3.71 vs. 1.58 per 1000 person-years). Further analyses indicated that the risk of PAD was higher in males, individuals younger than 50 years, and without comorbidity among the subgroups. This nationwide population-based study indicates that the incidence of PAD is significantly higher in patients with COPD than in those without COPD and the hazard ratio was especially high in younger patients. Therefore, regular examination for PAD in patients with COPD may be considered.

A Rare Complication of Pig-Tail Catheter Insertion

A 79-year-old man had loculated pleural effusion with presentation of progressive shortness of breath for a few months. A 14F pig-tail catheter was inserted under echo guidance. The tube drainedmoderate quantities of straw-colored fluid without any obstructions, and laboratory analysis confirmed the fluid to be transudative. Chest radiograph (Figure 1) after the procedure revealed that the entry of the catheter was too low. Computed tomography (Figure 2) manifested that the catheter was inserted into the liver. However, the nature of the draining fluid was unexplainable. After tracing previous chest images (Figure 3), a huge liver cyst was detected very close to the effusion. The patient made an uneventful recovery with a definitive diagnosis of tuberculosis. Tube thoracostomy is an invasive procedure, and complications can result due to inadequate knowledge of thoracic anatomy or inadequate training and experience. Tubemalposition can be intraparenchymal, fissural, chest wall, mediastinal, or abdominal. Incidence of abdominal tube placement is about 1 to 7% (1–3). When a huge liver cyst and massive pleural effusion exist, it is hard to distinguish the true position of the diaphragm under echography. The operator should confirm the inserted site in relation to the patient’s external anatomy rather than relying exclusively on the ultrasound demonstration of fluid collection. Conservative treatment is reasonable because echo-guided percutaneous drainage of simple liver cysts is a well-recognized procedure with low complication rates. n

Incomplete border sign.

A chest radiograph of a 42-year-old woman for employee health check-up showed a near normal appearance. However, there is a rounded radiopacity in left upper quarter which overlapping with the clavicle and the first rib by an incomplete border (Figure 1a, incomplete border sign). Computed tomography (CT) revealed a well-defined nodule protruding from the posterior chest wall (Figure 1b). CT-guided biopsy …