Yen Chung Lin

RISK STRATIFICATION AND CLINICAL OUTCOMES IN PATIENTS WITH ACUTE PULMONARY EMBOLISM

OBJECTIVES Pulmonary embolism is a common disease associated with a high mortality rate. The risk assessment and appropriate treatment selection of patients with acute pulmonary embolism remains a challenge. DESIGN AND METHODS This single center cohort study included a total of 150 patients (96 male, age = 71 ± 15 years) with acute pulmonary embolism confirmed by spiral-computed tomography or magnetic resonance image. The prognostic performance of the clinical characteristics and laboratory values were investigated to predict the in-hospital hemodynamically instable events and 30-day all-cause mortality. RESULTS The rate of in-hospital hemodynamic instability and 30-day all-cause mortality was 21% and 12%, respectively. A multivariate Cox regression analysis demonstrated that a heart rate ≥ 110 bpm (odd ratio 4.26 [95% CI 1.42-12.77]), chronic pulmonary disease (6.47 [1.99-21.04]), WBC ≥ 11,000 mm(3) (3.78 [1.32-10.82]), and D-dimer level ≥ 4.0 μg/mL (3.68 [1.01-13.43]) independently predicted the 30-day fatal outcome. A Kaplan-Meier survival analysis showed that the categorization based on the number of risk factors was significantly associated with the likelihood of 30-day all-cause mortality (P<0.0001). CONCLUSIONS The initial presentation of tachycardia, presence of chronic pulmonary disease, elevated WBC and D-dimer on admission can be used to identify the risk for a short-term fatal outcome within 30 days in patients with acute pulmonary embolism.

Measurement Error as Alternative Explanation for the Observation that CrCl/GFR Ratio is Higher at Lower GFR

BACKGROUND AND OBJECTIVES Overestimation of GFR by urinary creatinine clearance (CrCl) at lower levels of GFR has long been attributed to enhanced creatinine secretion. However, this does not take into consideration the contribution of errors in measured GFR (and CrCl) due to short-term biologic variability or test imprecision. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We analyzed cross-sectional data among 1342 participants from the Chronic Renal Insufficiency Cohort study with baseline measurement of GFR by iothalamate clearance (iGFR) and CrCl by 24-hour urine collection. We examined the CrCl/iGFR ratio classified by categories of iGFR and also by categories of CrCl. RESULTS Overall, mean CrCl/iGFR ratio was 1.13. CrCl/iGFR ratio was higher at lower iGFR categories. In contrast, this ratio was lower at lower CrCl levels. We hypothesize these relationships could be due to measurement error, which is bolstered by replicating these trends in a simulation and modeling exercise in which there was no variation in the ratio of CrCl/iGFR with true kidney function but taking into account the effect of measurement error in both CrCl and iGFR (of magnitudes previously described in the literature). In our simulated data, the observed CrCl/iGFR ratio was higher at lower observed iGFR levels when patients were classified by categories of observed iGFR. When the same patients were classified by categories of observed CrCl, the observed CrCl/iGFR ratio was lower at lower observed CrCl levels. CONCLUSIONS The combined empirical and modeling results suggest that measurement errors (in both CrCl and iGFR) should be considered as an alternative explanation for the longstanding observation that the ratio of CrCl to iGFR gets larger as iGFR decreases.

Kidney Cancer Linked to Chronic Hepatitis in the Asia-Pacific: A Population-Based Analysis.

Background: The association of renal cancer with viral hepatitis infection remains unclear. Using an insurance data set, this population-based case-control study evaluated the association of renal cancer with chronic hepatitis virus infection in an endemic area of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. Methods: We enrolled 17,747 patients with renal cancer during the period from 2000 to 2011 from the National Health Insurance Research Database of Taiwan. The control group comprised 35,494 randomly selected people without renal cancer matched by age and gender to the patients in the study group. ORs were calculated to assess the association of chronic hepatitis virus infection with renal cancer by using logistic regression analysis. Results: Renal cancer was associated with HBV and HCV infection (OR 1.38, 95% CI 1.24-1.54; OR 1.24, 95% CI 1.07-1.44, respectively). An analysis stratified by gender and age revealed that young male HBV carriers had a higher risk of renal cancer compared with men without viral hepatitis (age <55 years: OR 1.94, 95% CI 1.57-2.39; 55≤ age <64 years: OR 1.40, 95% CI 1.05-1.86). Male HCV-infected patients aged <55 years (OR 1.90, 95% CI 1.11-3.26) and female HCV carriers aged between 55 and 64 years (OR 1.59, 95% CI 1.00-2.53) had a significantly higher risk of renal cancer compared with their counterparts. Conclusions: Renal cancer is significantly associated with chronic hepatitis infection, particularly in younger HBV-infected men.

Emerging hyperkalemia following valproic acid use in an elderly patient with late-onset mania

medications quetiapine and olanzapine, may be associated with sleepwalking and sleep-related eating in some individuals. This occurs possibly via 5-HT-2A/2C antagonismmediated mechanisms, and may be dose dependent. The sleepwalking in this vignette did not emerge until the dose of night time ziprasidone was increased from 40 mg to 60 mg. Clinicians should be aware of this type of sleep dysfunction as a rare but possible adverse effect of atypical antipsychotic drug therapy.

Errtuam: Determinants of the creatinine clearance to glomerular filtration rate ratio in patients with chronic kidney disease: A cross-sectional study (BMC Nephrology (2013) 14 (268))

After the publication of our paper Lin et al. “Determinants of the creatinine clearance to glomerular filtration rate ratio in patients with chronic kidney disease: a cross-sectional study” BMC Nephrology 2013, 14:268, we became aware of errors in the manuscript arising from to a misunderstanding of serum creatinine calibration in the released Chronic Renal Insufficiency Cohort (CRIC) study data obtained from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Data Repository. Specifically further multiplication by 0.95 was actually not necessary to arrive at the standardized creatinine values.Here we present the revised results of the re-analyses along with revisions of the relevant tables. Mean CrCl/iGFR ratio should be 1.13 ± 0.46 instead of 1.19 ± 0.48. The main conclusion of the paper remain unchanged: “Contrary to what had been suggested by prior smaller studies, CrCl/GFR ratio does not vary with degree of proteinuria or race/ethnicity. The ratio is also closer to 1.0 than reported by several frequently cited reports in the literature.”

Prolonged hemiballism after the remission of non-ketotic hyperosmolar syndrome.

A 78-year-old Taiwanese woman presented with polyuria. She denied history of type 2 diabetes mellitus, or cerebral vascular disease. In examinations, the skin turgors were dry. The laboratory data revealed that serum glucose level was 45.34 mmol per litre, sodium level was 133 mmol per litre, haemoglobin A1c was 13.5% and serum osmolarity was 308 mmol per litre. The serum ketone body was negative. However, …

Myelomatous Orbital and Intracranial Involvement

CLINICAL PRESENTATION A 41-year-old Taiwanese man presented to the emergency room with sudden proptosis of the left eye (Figure 1). He had a history of end-stage renal disease and had undergone continuous ambulatory peritoneal dialysis for 1 year before admission. On examination, there was exophthalmos and chemosis of the left eye with impaired vision. A urinary test for Bence-Jones proteins was positive, and serum electrophoresis showed monoclonal gammopathy. Magnetic resonance imaging revealed soft tissue involvement of the left orbital cavity and left frontal area (Figure 2). A bone marrow biopsy revealed plasma cell myeloma, lambda light chain. The patient was admitted for chemotherapy and palliative radiotherapy for brain and orbital lesions. The proptosis improved, but the vision in the left eye remained poor. Despite treatment, neutropenic fever and new involvement of plasma cells in the pleural space occurred, and he died 3 months later. Secondary myelomatous orbital involvement is extremely rare and accounts for less than 1% of all orbital tumors. It was first introduced by Rodman and Font1 in 1972 and usually shows gradual-onset proptosis after the diagnosis of multiple myeloma, especially in those refractory to chemotherapy. Intracranial lesions in multiple myeloma are also rare and an ominous signs, just the same as orbital involvement. If the dura or subdura space is involved, it may mimic meningioma.2 Unilateral proptosis of the eye ball is usually a sign of an orbital tumor or infection, but hematological malignancies such as myeloma should be taken into account. REFERENCES