Shen-Yang Lee

Tumor characteristics of urothelial carcinoma on multidetector computerized tomography urography.

PURPOSE We investigated the relationship between tumor characteristics of urothelial carcinoma and detectability on multidetector computerized tomography urography. MATERIALS AND METHODS We retrospectively reviewed all adult consecutive patients with hematuria who underwent multidetector computerized tomography urography during a 23-month period at our hospital. Patients with a final diagnosis of urothelial carcinoma verified by histological examination of surgical specimens were included in the study. The presence and location of urothelial carcinomas on multidetector computerized tomography urography without knowledge of final diagnosis were recorded. Tumor characteristics (location, size, histological classification and stage) were recorded based mainly on histological findings. The association between tumor characteristics and urothelial carcinoma detectability on multidetector computerized tomography urography was analyzed. RESULTS A total of 70 patients who underwent multidetector computerized tomography urography had 87 verified urothelial carcinomas. Of these carcinomas 6 (6.9%) were undetectable by multidetector computerized tomography urography, including 5 ureteral and 1 bladder urothelial carcinoma. Size of detectable and nondetectable tumors on multidetector computerized tomography urography differed significantly (3.05 +/- 1.79 vs 0.65 +/- 0.99 cm, respectively, p = 0.001). Tumor location (p = 0.009), tumor size 1 cm or larger (p = 0.003) and noncarcinoma in situ tumors (p = 0.001) were significantly associated with multidetector computerized tomography urography detectability. Conversely organ confined disease had no association with multidetector computerized tomography urography detectability. Multivariate analyses showed that noncarcinoma in situ tumor was a significant predictor of multidetector computerized tomography urography detectability (p = 0.001). CONCLUSIONS Multidetector computerized tomography urography is useful for detecting nearly all urothelial carcinomas in adults with hematuria. Careful assessment by multidetector computerized tomography urography is needed to detect small (less than 1 cm) or ureteral urothelial carcinomas. It remains a challenge to detect carcinoma in situ tumors by multidetector computerized tomography urography. Thus, negative results of urothelial carcinomas on multidetector computerized tomography urography do not exclude the presence of carcinoma in situ tumors.

Paraquat poisoning in pediatric patients.

Objective This observational study examined the outcome of Taiwanese pediatric patients with paraquat poisoning and compared these data with the published data on paraquat poisonings from other international poisoning centers. Methods We performed a retrospective study on children with acute paraquat poisoning that were admitted to the Chang Gung Memorial Hospital during a period of 10 years (2000–2010). Of the 193 paraquat poisoning patients, only 6 were children. Results The mean age was 8.85 ± 5.55 (1–15.6) years. Younger patients had accidentally swallowed paraquat, whereas older patients had intentionally ingested paraquat. Most patients were referred within a relatively short period (0.5–2.0 hours). Paraquat poisoning was associated with high morbidity and often resulted in severe complications, including acute respiratory distress syndrome and multiple-organ failure. The complications included shock (50.0%), hypoxemia (33.3%), respiratory failure (33.3%), nausea/vomiting (16.7%), abdominal pain (33.3%), hepatitis (66.7%), gastrointestinal tract bleeding (33.3%), acute renal failure (33.3%), and seizures (16.7%). Patients were treated aggressively with a standard detoxification protocol consisting of gastric lavage, active charcoal, charcoal hemoperfusion, and cyclophosphamide and steroid pulse therapies. Secondary bacterial infections were common after hospitalization and included sepsis (33.3%), pneumonia (33.3%), and urinary tract infection (50.0%). In the end, 2 patients (33.3%) died from multiple-organ failure, despite intensive resuscitation. Conclusions Our data (mortality rate, 33.3%) are comparable to the data of other published reports from other international poison centers. Evidently, a prompt diagnosis of paraquat poisoning and an immediate institution of a detoxification protocol is a prerequisite for a favorable outcome.

Evaluation of renal function of angiomyolipoma patients after selective transcatheter arterial embolization.

Background:Angiomyolipoma patients may have renal insufficiency before selective transcatheter arterial embolization (TAE) or may undergo subsequent surgery after TAE. Therefore, this retrospective study examined our experience with TAE or TAE and subsequent surgery on renal function of angiomyolipoma patients with and without preexisting renal insufficiency. Methods:25 patients who had undergone TAE for renal angiomyolipoma over a 7-year period were reviewed. The 25 patients were grouped according to whether or not they had undergone further surgery. Preexisting renal insufficiency was compared between the 2 groups. The TAE and surgery group was further subdivided into 2 subgroups according to total nephrectomy or not. The TAE-alone group was further subdivided into 2 subgroups by presence of preexisting renal insufficiency or not. In each group and subgroup, pre-TAE and post-TAE renal function, including serum creatinine and creatinine clearance were compared. Results:TAE rather than TAE and surgery was more likely chosen in the presence of preexisting renal insufficiency (6/13 versus 1/12, P = 0.035). In TAE-alone patients, no statistical differences were noted between serum creatinine and creatinine clearance before and after TAE. Conversely, TAE and surgery patients who had undergone total nephrectomy rather than nephron-sparing surgery differed significantly in preand post-TAE serum creatinine (0.77 versus 1.07, P = 0.014) and creatinine clearance (98.1 versus 70.7, P = 0.032). Conclusions:This study demonstrated that TAE alone for treating renal angiomyolipomas was able to preserve renal function, despite the presence of mild preexisting renal insufficiency. Conversely, surgery after TAE, particularly total nephrectomy, should be avoided whenever possible.

Role of serum sodium in assessing hospital mortality in cancer patients with spontaneous tumour lysis syndrome inducing acute uric acid nephropathy

Spontaneous tumour lysis syndrome (STLS) inducing acute uric acid nephropathy, a rare and neglected disease, presents more insidiously than conventional post‐treatment tumour lysis syndrome. Although STLS is a serious and potentially fatal complication in patients with neoplastic disorders, few investigations have addressed the relevance of clinical and laboratory features in assessing prognosis. A retrospective study was conducted, reviewing the records of all patients who developed acute renal failure (ARF) at Chang Gung memorial hospital between 1 July 1999 and 30 June 2003. STLS‐induced acute uric acid nephropathy was identified in 12 of 1072 ARF patients (1.1%) during the study period. All patients had advanced stage tumours with large tumour burden, and 66.7% of cases had abdominal organ involvement. All 12 hyperuricemic patients became oliguric despite conservative therapy, and remained hyperuricemic (21.6 ± 5.2 mg/dl) before dialysis therapy. Diuresis developed in eight patients (66.7%), with associated resolution of hyperuricemia, azotemia and metabolic derangements following dialysis initiation. Overall hospital mortality was 58.3%. Death in most patients was related to hyponatremia and hypoalbuminemia on admission. The serum sodium was found to have the best Youden index (0.86) and highest overall prediction accuracy (93%). Moreover, serum sodium and serum albumin for individual patients were significantly and positively correlated (r = 0.617, p = 0.032). This investigation confirms a grave prognosis for cancer patients with STLS inducing acute uric acid nephropathy. Hyponatremia and hypoalbuminemia on the first day of admission indicate poor prognosis in such patients.

Risk factors for mortality in Asian Taiwanese patients with methanol poisoning

Introduction Methanol poisoning continues to be a serious public health issue in Taiwan, but very little work has been done to study the outcomes of methanol toxicity in the Asian population. In this study, we examined the value of multiple clinical variables in predicting mortality after methanol exposure. Methods We performed a retrospective observational study on patients with acute poisoning who were admitted to the Chang Gung Memorial Hospital over a period of 9 years (2000–2008). Out of the 6,347 patients, only 32 suffered methanol intoxication. The demographic, clinical, laboratory, and mortality data were obtained for analysis. Results Most patients were middle aged (46.1±13.8 years), male (87.5%), and habitual alcohol consumers (75.0%). All the poisonings were from an oral exposure (96.9%), except for one case of intentionally injected methanol (3.1%). After a latent period of 9.3±10.1 hours, many patients began to experience hypothermia (50.0%), hypotension (15.6%), renal failure (59.4%), respiratory failure (50.0%), and consciousness disturbance (Glasgow coma scale [GCS] score 10.5±5.4). Notably, the majority of patients were treated with ethanol antidote (59.4%) and hemodialysis (58.1%). The remaining 41.6% of patients did not meet the indications for ethanol therapy. At the end of analysis, there were six (18.8%), 15 (46.9%), and eleven (34.4%) patients alive, alive with chronic complications, and dead, respectively. In a multivariate Cox regression model, it was revealed that the GCS score (odds ratio [OR] 0.816, 95% confidence interval [CI] 0.682–0.976) (P=0.026), hypothermia (OR 168.686, 95% CI 2.685–10,595.977) (P=0.015), and serum creatinine level (OR 4.799, 95% CI 1.321–17.440) (P=0.017) were significant risk factors associated with mortality. Conclusion The outcomes (mortality rate 34.4%) of the Taiwanese patients subjected to intensive detoxification protocols were comparable with published data from other international poison centers. Furthermore, the analytical results indicate that GCS score, hypothermia, and serum creatinine level help predict mortality after methanol poisoning.

Upper tract urothelial carcinomas in patients with chronic kidney disease: relationship with diagnostic challenge.

Chronic kidney disease and upper tract urothelial carcinomas display a bidirectional relationship. Review of the literature indicates that early diagnosis and correct localization of upper tract urothelial carcinomas in dialysis patients and kidney transplant recipients are important but problematic. Urine cytology and cystoscopy have limited sensitivity for the diagnosis of upper tract urothelial carcinomas in dialysis patients. Enhanced computed tomography and magnetic resonance imaging could prove useful for the detection and staging of upper tract urothelial carcinomas in dialysis patients. Renal ultrasound can detect hydronephrosis caused by upper tract urothelial carcinomas in kidney transplant recipients but cannot visualize the carcinomas themselves. High detection rates for upper tract urothelial carcinomas in kidney transplant recipients have recently been demonstrated using computed tomography urography, which appears to be a promising tool. To detect carcinomas in dialysis patients and kidney transplant recipients as early as possible, regular screening in asymptomatic patients and diagnostic work-up in symptomatic patients should be performed using a combination of urological and imaging methods. Careful assessment of subsequent recurrence within the contralateral upper urinary tract and the urinary bladder is necessary for dialysis patients and kidney transplant recipients with upper tract urothelial carcinomas.

Spectrum of corrosive esophageal injury after intentional paraquat or glyphosate-surfactant herbicide ingestion

Background Data on the spectrum of corrosive injury to the esophagus after paraquat or glyphosate-surfactant ingestion are sparse in the literature and confined to case studies and brief reports. Therefore, this study aimed to examine the clinical features, degrees of esophageal injury, and clinical outcomes after paraquat or glyphosate herbicide ingestion, and sought to determine what association, if any, may exist between these findings. Methods We performed an observational study on 47 patients with paraquat or glyphosate ingestion who underwent endoscopic evaluation over a period of 11 years (2000–2011). Results Corrosive esophageal injuries were classified as grade 1 in 14 (glyphosate-surfactant) and three (paraquat), grade 2a in nine (glyphosate-surfactant) and 18 (paraquat), and grade 2b in one (glyphosate-surfactant) and two (paraquat) patients. No patients had grade 0, 3a, or 3b esophageal injuries. Therefore, the severity of corrosive injury was more severe in the paraquat group (P = 0.005). After toxin ingestion, systemic toxicity occurred, with rapid development of systemic complications in many cases. Neurologic complications occurred more frequently in the glyphosate-surfactant group (29.2% versus 0%, P = 0.005), although respiratory failure (4.2% versus 34.8%, P = 0.008), hepatitis (12.5% versus 52.2%, P = 0.004), and renal failure (20.8% versus 52.2%, P = 0.025) developed more frequently in the paraquat group. Patients with glyphosate poisoning had shorter hospital stays than patients with paraquat poisoning (13.3 ± 15.1 days versus 26.8 ± 10.2 days, P = 0.001). Nevertheless, there was no significant difference in mortality rate between the glyphosate-surfactant and paraquat groups (8.3% versus 13.0%, P = 0.601). We ultimately found that patients with grade 2b esophageal injury suffered from a greater incidence of respiratory (100.0% versus 5.9%, P = 0.001) and gastrointestinal (66.7% versus 11.8%, P = 0.034) complications than patients with grade 1 injury, regardless of herbicide type. Conclusion Paraquat and glyphosate are mild caustic agents that produce esophageal injuries of grades 1, 2a, and 2b only. Our data also suggest a potential relationship between the degree of esophageal injury and systemic complications.

Successful treatment of autoimmune thrombocytopenic purpura with rituximab in a dialysis patient with systemic lupus erythematosus

Autoimmune thrombocytopenic purpura (ATP) in systemic lupus erythematosus involves autoantibody mediated destruction of platelets. In dialysis patients with refractory ATP which is unresponsive to corticosteroid and immunosuppressive agents, the management is difficult. B cell targeted therapy with rituximab has emerged as a promising agent by reducing the levels of pathogenic autoantibodies. However, its safety and efficacy in dialysis patients are uncertain. In this report, we described a dialysis patient with refractory lupus-related ATP, whose platelet counts responded only to rituximab. Furthermore, no severe side effects were noted during the treatment period, suggesting that rituximab can be administered safely in dialysis patients.

Application of the Age, Creatinine, and Left Ventricular Ejection Fraction Score for Patients on Extracorporeal Membrane Oxygenation.

Patients on extracorporeal membrane oxygenation (ECMO) usually have high mortality rate and poor outcome. Age, Creatinine, and Left Ventricular Ejection Fraction (ACEF) score is an easy-calculating score and provides good performance on mortality prediction in patients undergoing cardiac operations or percutaneous coronary intervention, but it has not been applied to patients on ECMO before. In this study, we aimed to use ACEF score obtained within 1 week of ECMO support for in-hospital mortality prediction in patients on ECMO due to severe myocardial failure. This study reviewed the medical records of 306 patients on ECMO at a specialized intensive care unit (CVSICU) in a tertiary-care university hospital between March 2002 and December 2011, and 105 patients on veno-arterial ECMO due to severe myocardial failure were enrolled. Demographic, clinical, and laboratory variables were retrospectively collected as survival predictors. The overall mortality rate was 47.6%. The most frequent condition requiring ICU admission was postcardiotomy cardiogenic shock. Multiple logistic regression analysis indicated that post-ECMO ACEF score, Sequential Organ Failure Assessment score, and troponin I on day 1 of ECMO support were independent risk factors for in-hospital mortality. Using the area under the receiver operating characteristic curve (AUROC), the post-ECMO ACEF score indicated a good discriminative power (AUROC 0.801 ± 0.042). Finally, cumulative survival rates at 6-month follow-up differed significantly (P < 0.001) for an ACEF score ≤ 2.22 versus those with an ACEF score > 2.22. After ECMO treatment due to severe myocardial failure, post-ECMO ACEF score provides an easy-calculating method with a reproducible evaluation tool with excellent prognostic abilities in these patients.

Outcomes of patients with acetaminophen-associated toxic hepatitis at a far east poison center

BackgroundThere is an overall paucity of data regarding the outcomes of patients with acetaminophen-associated toxic hepatitis in Taiwan. Therefore, the purpose of this study was to recruit a larger number of patients and to examine the clinical features, the degrees of toxic hepatitis, the physiological markers, and the clinical outcomes after intentional acetaminophen poisoning, and to determine what association, if any, might exist between these findings.MethodsWe examined the medical records of 187 patients with intentional acetaminophen poisoning who were examined at Chang Gung Memorial Hospital between 2000 and 2011. Patients were categorized into 2 groups according to hepatic complications, i.e. with (n = 15) or without (n = 172) toxic hepatitis. Demographic, clinical, and laboratory data were collected, and the mortality rate was analyzed.ResultsIt was found that patients with toxic hepatitis had higher serum acetaminophen level (P = 0.007), but they also arrived to the hospital later (P < 0.001) than patients without toxic hepatitis. Furthermore, patients with toxic hepatitis showed higher incidences of acute respiratory failure (P = 0.012) than those shown by patients who did not have hepatitis. The laboratory examinations also revealed greater degrees of granulocytosis (P < 0.001) and poorer liver function tests (P < 0.001) in patients with hepatitis than in patients without hepatitis. Nevertheless, a univariate logistic regression model failed to identify any significant risk factors for toxic hepatitis complication after ingestion (P > 0.05). At the end of the analysis, 1 patient with toxic hepatitis died of liver failure. Finally, there was no significant difference in mortality between patients with and without hepatitis (P = 0.080).ConclusionThe analytical data revealed that toxic hepatitis was not uncommon (15/187 or 8.0%) after acetaminophen overdose. Further studies are warranted.