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Objective Over the last decade, charcoal burning has become a common method of suicide in Taiwan; however, the underlying psychiatric diagnoses and gender differences have yet to be examined. Methods We conducted a retrospective chart review on inpatients after suicide attempt by charcoal burning during 2000-2010. The patients were referred to the psychiatric consultation team and diagnoses were made according to DSM-IV. We chose those who were admitted to the nephrology ward in the same period due to accidental carbon monoxide intoxication as controls. Demographic and laboratory data, psychiatric diagnoses and reasons for suicide were obtained and analyzed. Results Among seventy-three patients, major depressive disorder (49.3%) and adjustment disorder (41.1%) were most frequently diagnosed. Breaking-up, financial debt and physical/mental illnesses were the top three reasons for suicide (17.8% each). The male-to-female gender ratio was 1.5:1. Female patients had higher rates of major depressive disorders, while male patients presented more adjustment disorders comorbid with alcohol use disorders. Conclusion There were gender differences in patients of suicide attempt by charcoal burning, in terms of demographic profiles and psychiatric diagnoses. Suicide risk assessment and prevention should be tailored by gender.

Introduction This retrospective observational study examined the clinical features, the degrees of toxic hepatitis, physiological markers and clinical outcomes after intentional paraquat poisoning and sought to determine what association, if any, might exist between these findings. Methods A total of 187 patients were referred for management of intentional paraquat ingestion between 2000 and 2010. Patients were categorized into two groups according to their hepatic complication, i.e. with (N = 87) or without (N = 100) toxic hepatitis. Demographic, clinical and laboratory data were obtained for analysis. Mortality rates were also analysed. Results It was found that patients with toxic hepatitis were younger (39.7 ± 13.7 vs 44.2 ± 16.6 year old, P = 0.046), and suffered from greater incidences of acute respiratory failure (63.2 vs 48.0%, P = 0.037) and acute renal failure (75.9 vs 56.0%, P = 0.004) than patients without hepatitis. The hospitalization period was longer in patients with hepatitis than without hepatitis (16.2 ± 14.6 vs 11.2 ± 12.1 days, P = 0.012), even though there was no difference in mortality rate between both groups (56.3 vs 53.0%, P = 0.649). Notably, the symptoms of toxic hepatitis developed within 6.7 ± 6.3 days of exposure to paraquat with aspartate aminotransferase (AST) 138 ± 156 U/L, alanine aminotransferase (ALT) 127 ± 114 U/L and total bilirubin 2.7 ± 2.6 mg/dL. The hepatitis peaked at 9.5 ± 8.8 days with AST 125 ± 139 U/L, ALT 183 ± 181 U/L and total bilirubin 3.2 ± 3.6 mg/dL. Nevertheless, the symptoms resolved within 17.3 ± 9.8 days of paraquat exposure, and none of the patients died of hepatic complication. Conclusions A substantial proportion of paraquat patients suffered from hepatic complication (46.52%), but the spectrum of hepatitis in these patients seemed mild and transient.

Background: Proteinuria in patients with diabetes mellitus (DM) is sometimes caused by glomerular diseases other than diabetic nephropathy. In patients with type 2 DM (T2DM), specific predictors for non-diabetic renal disease (NDRD) are needed in addition to the traditional indicators for renal biopsy. Methods: From 1 January 2000 to 31 March 2011, we retrospectively enrolled 54 T2DM patients with proteinuria who had undergone renal biopsies into the present study. Associations between NDRD and 20 potential biomarkers, including serum levels of Igs and proteins associated with kidney function, and urinary protein and red blood cell levels, and hepatitis virus carrier status, were analyzed by multivariate logistic regression. Results: Multivariate logistic regression showed that reduced serum IgG (odds ratio [OR] 0.997; P = 0.006; 95% confidence interval [CI] 0.94–0.998) and creatinine (Cr; OR 0.587; P = 0.014; 95% CI 0.348–0.897) were predictors of NDRD. The area under the receiver operating characteristic curve (AUCROC) confirmed the good discriminatory power of IgG (AUCROC 0.857 ± 0.058; 95% CI 0.744–0.970; P

In May 2011, the illegal use of the phthalate plasticizer di(2-ethylhexyl) phthalate in clouding agents for use in foods and beverages was reported in Taiwan. This food scandal has caused shock and panic among the majority of Taiwanese people and has attracted international attention. Phthalate exposure is assessed by ambient monitoring or human biomonitoring. Ambient monitoring relies on measuring chemicals in environmental media, foodstuff and consumer products. Human biomonitoring determines body burden by measuring the chemicals, their metabolites or specific reaction products in human specimens. In mammalian development, the fetus is set to develop into a female. Because the female phenotype is the default, impairment of testosterone production or action before the late phase may lead to feminizing characteristics. Phthalates disrupt the development of androgen-dependent structures by inhibiting fetal testicular testosterone biosynthesis. The spectrum of effects obtained following perinatal exposure of male rats to phthalates has remarkable similarities with the human testicular dysgenesis syndrome. Epidemiological studies have suggested associations between phthalate exposure and shorter gestational age, shorter anogenital distance, shorter penis, incomplete testicular descent, sex hormone alteration, precocious puberty, pubertal gynecomastia, premature thelarche, rhinitis, eczema, asthma, low birth weight, attention deficit hyperactivity disorder, low intelligence quotient, thyroid hormone alteration, and hypospadias in infants and children. Furthermore, many studies have suggested associations between phthalate exposure and increased sperm DNA damage, decreased proportion of sperm with normal morphology, decreased sperm concentration, decreased sperm morphology, sex hormone alteration, decreased pulmonary function, endometriosis, uterine leiomyomas, breast cancer, obesity, hyperprolactinemia, and thyroid hormone alteration in adults. Finally, the number of phthalate-related scientific publications from Taiwan has increased greatly over the past 5 years, which may reflect the health effects from the illegal addition of phthalate plasticizer to clouding agent in foodstuff over the past two decades.

Aim: This study examines the epidemiology of transitional cell carcinoma (TCC) in end-stage renal disease (ESRD) population from Taiwan, the area with the highest incidence and prevalence of ESRD. Methods: A total of 98 out of 10 890 ESRD patients were referred for management of TCC between 2000 and 2008. Demographic, clinical and laboratory data were collected and patient mortality and tumour recurrence rates were analyzed. Results: TCC patients were aged 61.4 ± 10.2 years and 66.3% were female. The average time from initiation of dialysis to tumour detection was 51.2 ± 36.4 months. Hypertensive nephrosclerosis, diabetes mellitus, chronic glomerulonephritis and unknown aetiology accounted for 25.5%, 20.4%, 22.4% and 31.6% of the causes of renal failure, respectively. The aetiology of renal failure for the 31.6% of patients was unclear, but chronic tubulointerstitial nephritis following long-term consumption of Chinese herbs (19.4%) or analgesic compounds (3.1%) was considered in some patients. Almost all (98.0%) patients presented with gross haematuria. Most TCC were in early stage (stage 0, 3.1%; stage I, 56.1%) during diagnosis. At the end of this study, 17 of 98 (17.3%) patients died. Multivariate Cox regression analysis found that age (odds ratio = 1.140, 95% confidence interval = 1.049–1.239, P = 0.002) and tumour pain (odds ratio = 0.234, 95% confidence interval = 0.057–0.961, P = 0.044) were significant risk factors for all-cause mortality. Furthermore, 35.7% of TCC recurred during follow up. The 5 year patient and tumour-free survival rates were 72.4% and 14.4%, respectively. Conclusion: The data shows that Taiwanese patients with ESRD had high incidence (0.9%) and recurrence (35.7%) of TCC.

Elevated white blood cell (WBC) counts predict coronary heart disease and all-cause mortality in the general population. Chronic inflammation and malnutrition are associated with increased risk of cardiovascular death in individuals with chronic kidney disease. In this study, we investigated the association between WBC count with inflammation, malnutrition, and mortality in maintenance hemodialysis (MHD) patients. A total of 959 MHD patients were stratified into four equal sized groups based on WBC count. Demographic, hematological, nutritional and inflammatory markers, and biochemical and dialysis-related data were obtained for cross-sectional analysis. All patients were followed for one year to investigate the risks for mortality. The mean WBC count was 6.4 ± 1.8 × 10(3)/µL (range: 2.3-16.3 × 10(3)/µL). Stepwise multiple linear regression analysis indicated a positive correlation between WBC count and inflammation (high-sensitivity C-reactive protein > 3 mg/L). Forty-five patients (4.7%) died within the 1-year study period. Cox multivariate regression analysis demonstrated that total WBC count significantly predicts 1-year mortality due to all-cause (hazard ratio (HR): 1.228, 95% confidence interval (CI): 1.095-1.378; P < 0.001), due to cardiovascular disease (HR: 1.242, 95% CI: 1.046-1.475; P = 0.013) and due to infection (HR: 1.252, 95% CI: 1.066-1.470; P = 0.006). These findings suggest that total WBC count should be measured in future studies that evaluate the clinical outcome of MHD patients and that dialysis patients with elevated WBC counts require further medical attention to reduce risks of mortality.

Although the incidence of septic pericarditis in hemodialysis populations is less frequent in the modern antibiotic era, it is still a cause of death partly because diagnosis is sometimes difficult and uncertain.From 2002 to 2006, 12 out of a total of 12,213 maintenance hemodialysis patients were referred for management of septic pericarditis. Patients were diagnosed as either definite or probable septic pericarditis. A definite diagnosis of septic pericarditis is based on the discovery of pathogenic bacteria in pericardial effusion, whereas a probable diagnosis is based on the proof of bacterial infection elsewhere in a patient with otherwise unexplained pericarditis, or appropriate response to a trial of systemic antibiotics.Four (33.3%) patients were diagnosed as definite pericarditis, whereas eight (66.7%) patients as probable pericarditis. It was found that although oxacillin-resistant Staphylococcus aureus (ORSA) (4/12 or 33.3%) and tuberculous (4/12 or 33.3%) pericarditis were common, salmonella pericarditis (2/12 or 16.7%) was also not uncommon. Pericardiocentesis, or pericardial window with pericardiectomy, was performed in three (25%) and two (16%) of patients with cardiac tamponade, respectively. Two patients died because of severe ORSA (1/12 or 8%) and salmonella (1/12 or 8%) sepsis. Finally, there were four (33%) patients who developed constrictive pericarditis after follow-up.These data are important because the spectrum of septic pericarditis was clearly different between Taiwan and other developed countries. Furthermore, it is the only report in which patients were diagnosed as either definite or probable septic pericarditis, therefore improving the sensitivity of diagnosis as in the case of tuberculous pericarditis.

The cardiothoracic ratio (CTR) indicates the left ventricular size; however, the significance of the CTR in patients on maintenance peritoneal dialysis (PD) remains unclear. In this study, 335 PD patients were enrolled and demographic, biochemical, co-morbidity, and dialysis-related data were obtained. The factors determining CTR were further analyzed. All patients were followed up for two years to investigate the mortality risks. We defined a normal CTR as less than the mean CTR value, mild cardiomegaly as a CTR between the mean and mean + 1 SD, and moderate-to-severe cardiomegaly as more than the mean CTR + 1 SD. Among the 335 patients, 163 patients were classified as having a normal CTR ( 55.7%). χ2-analysis showed that the incidences of malnutrition and anemia were significantly higher in patients with severe cardiomegaly than in patients of the other groups. The CTR was positively correlated with age, but negatively correlated with albumin and hemoglobin levels. Twenty-six patients (7.7%) had died by the end of the study. Cox multivariate analysis revealed that the CTR significantly predicts all-cause two-year mortality in PD patients on maintenance PD; therefore, the CTR correlates with the nutritional and anemic status of PD patients and is a reliable predictor for all-cause two-year mortality. The analytical results of this study support continued efforts to reduce the CTR and treat underlying causes in patients with cardiomegaly.

Background. Cadmium exposure is related to severity of diabetes and diabetes-related organ damage in diabetic patients. Elevated blood cadmium levels (BCLs) are well known in maintenance haemodialysis (MHD) patients but the clinical significance in diabetic MHD patients remains unknown. Methods. A total of 212 diabetic MHD patients were enrolled in this 18-month prospective study and were categorized into three equal groups according to the basal BCL: high (>0.889 μg/L; n = 71), middle (0.373― 0.889 μg/L; n = 70) and low (

Objectives: Myofibroblasts are a vital component of stroma of many malignant neoplasms, but it is not yet established whether stromal myofibroblasts also exist in benign tumours such as oncocytoma of the kidney. Materials and methods: Histomorphological and immunohistochemical analysis of 16 renal oncocytomas diagnosed at Chang Gung Memorial Hospital, Taiwan, has been performed. Results: Renal oncocytomas were composed of oncocytes, large cells with granular eosinophilic cytoplasm, arranged mostly in sheets, in tubulocystic or combined pattern. Few oncocytes appeared to be undergoing proliferation or apoptosis. MIB-1 and active caspase 3 indices were low, but higher in tumour than in surrounding non-tumour parenchyma (MIB-1: 0.93 ± 0.09 versus 0.46 ± 0.07, P

Aim: Chronic inflammation, which is common in dialysis patients, often causes malnutrition and even protein-energy wasting. However, the association of high-calcium dialysate with malnutrition and/or inflammation in non-diabetic maintenance haemodialysis patients remains unclear. This study investigated the possible adverse effects of high-calcium dialysate and mortality in this population. Methods: A total of 717 non-diabetic haemodialysis patients participated in this 2 year prospective study. The subjects were categorized into three subgroups based on whether dialysate calcium concentrations were high (3.5 mEq/L), standard (3.0 mEq/L) or low (2.5 mEq/L). Demographic, haematological, nutritional and inflammatory markers, biochemical and dialysis-related data were obtained for cross-sectional analysis. Causes of death and mortality rates were also analyzed for each subgroup. Results: Patients with high-calcium dialysate (n = 82) had a higher incidence of malnutrition and inflammation (61.0% vs 44.1% and 43.9%, respectively) than those with standard- and low-calcium dialysate (n = 528 and 107). Backward stepwise multiple regression analysis revealed that high-calcium dialysate was negatively correlated with nutritional index, serum albumin levels, but positively associated with the inflammatory marker of serum ferritin levels. At the end of the 2 year follow up, 45 patients had died. Cox multivariate analysis demonstrated that high-calcium dialysate was a significant associated factor (relative risk 2.765; 95% confidence interval 1.429–5.352) for 2 year all-cause mortality in these patients. Conclusion: The analytical results indicate that high-calcium dialysate is associated with malnutrition and inflammation as well as 2 year mortality in non-diabetic maintenance haemodialysis patients and the findings suggest that this population, even those with optimal mineral balance, should avoid high-calcium dialysate.

A total of 959 Taiwanese patients undergoing maintenance hemodialysis-102 underweight (BMI or= 25 kg/m(2)) were recruited into this three-year, multicenter longitudinal study. It was found initially that the underweight group had more females, longer hemodialysis durations, less use of a biocompatible membrane (BCM) dialyzer, higher erythropoietin doses and Kt/V(urea), and lower white blood cell counts, hemoglobin, serum creatinine and phosphate, and high sensitivity C-reactive protein (hsCRP) than other groups (P < 0.001). Furthermore, a chi(2)-test demonstrated that underweight patients had poorer nutrition (P = 0.023), but less systemic inflammation (P < 0.001) than other groups. A stepwise multiple linear regression analysis established that age, sex, diabetes mellitus, hemodialysis duration, use of BCM dialyzer, Kt/V(urea), creatinine, high-density lipoprotein cholesterol, and hsCRP were significant risk factors associated with BMI (P < 0.001-0.002). After three years, 149 (15.5%) patients had died, including 22 of 102 (21.6%) underweight patients, 64 of 492 (13.0%) normal weight patients, 38 of 187 (20.3%) overweight patients, and 25 of 178 (15.5%) obese patients. The primary causes of mortality were cardiovascular (52.3%) and infection (39.6%). A multivariate Cox regression analysis revealed that age, diabetes mellitus, BMI, albumin, hsCRP, and cardiothoracic ratio were significant risk factors associated with all-cause mortality over three years (P < 0.001-0.022). Finally, Kaplan-Meier analysis confirmed that underweight patients suffer higher mortality than other groups (Log rank, P = 0.0392); therefore, the data have demonstrated a survival disadvantage of low BMI in Taiwanese patients undergoing maintenance hemodialysis.

Background: Patients with chronic peritoneal dialysis (CPD) use glucose-based dialysate to maintain their life; however, whether the glycemic status influences outcome of these patients without diabetes remains unknown. Methods: We conducted a cross-sectional and 18-month prospective study, and 269 nondiabetic patients with CPD were enrolled in a medical center. Glycated hemoglobin (HbA1c) levels were measured at baseline and categorized in tertiles of HbA1c: high (>5.4%), middle (5.1–5.4%) and low normal (Results: The study results showed high HbA1c group patients had a trend of being older and having higher body mass index (BMI) than other group patients. Stepwise multiple linear regression analysis showed HbA1c was positively related to age, BMI and the peritoneal solute transport rate. After 18 months of follow-up, Cox multivariate analysis showed that HbA1c (HR: 4.114; 95% CI: 1.426–11.872; p = 0.009) was the significant risk factor for all-cause mortality after relating variables were adjusted. Moreover, high HbA1c (HR: 3.892; 95% CI: 1.273–11.959; p = 0.026) and low HbA1c (HR: 1.179; 95% CI: 1.160–1.198; p = 0.039), with middle HbA1c group as the reference, also significantly predicted for mortality in these patients. Conclusions: HbA1c levels, or presence of low or high HbA1c, are associated with 18-month all-cause mortality in nondiabetic patients with CPD.

BACKGROUND: The clinical significance of blood lead levels (BLLs) in chronic peritoneal dialysis (CPD) patients was undetermined prior to this study. METHODS: A total of 315 patients on CPD were included in this 18-month prospective study. BLLs measured at baseline were categorized according to a BLL tertile of high (>8.66 microg/dL), middle (5.62-8.66 microg/dL) and low (

Lead is involved in the pathogenesis of atherosclerosis and hypertensive disease and may be related to cerebrovascular disease. We studied the association of body lead level with stroke subtypes and severity of cerebral atherosclerosis in order to identify the significance of lead exposure to cerebrovascular disease.From April, 2002 to March, 2005, we studied the lead level in all patients receiving digital subtraction angiography. Diameter stenosis at extracranial carotid, intracranial carotid and vertebrobasilar system was calculated according to the NASCET criteria. A blood sample and a mobilization test of 72-h urine sample were collected for lead measurement.In a total of 213 subjects, 19 were free of stroke (blood lead level=4.62+/-2.41 microg/dL, body lead store=39.04+/-20.91 microg) and 194 were stroke patients (4.89+/-2.75 microg/dL, 45.13+/-29.8 microg; all stroke vs. non-stroke, P0.05). In the 153 subjects with atherosclerotic origin, body lead store but not blood lead level in the intracranial carotid system was significantly higher inor =50% group than50% group (blood lead: 5.61+/-3.02 microg/dL vs. 4.80+/-2.50 microg/dL, Student's t-test, P=0.129; body lead store: 51.7+/-27.0 microg vs. 41.9+/-23.5 microg, Student's t-test, P=0.038, multivariate logistic regression, odds ratio=1.02, 95% CI: 1.00-1.03, P=0.043). However, there was no significant association between lead level and stenotic severity in extracranial and vertebrobasilar systems (P0.05).Our study demonstrated that long-term lead exposure as measured by body lead store might carry a potential risk of intracranial carotid atherosclerosis.

The aim of this study was to assess the relationship between the serum ferritin level and the 1-year outcome in diabetic maintenance hemodialysis (MHD) patients.The prospective clinical study enrolled 187 diabetic MHD patients from a university hospital in Taiwan. All the patients were divided into 3 groups according to their serum ferritin levels: group I (200 ng/mL; n = 71), group II (200-700 ng/mL; n = 97), and group III (700 ng/mL; n = 19). A total of 26 demographic, clinical, and laboratory variables were analyzed as predictors of the 1-year mortality.There were no significant differences between these 3 groups except in their erythropoietin usage, hemoglobin, transferrin saturation, and high-sensitive C-reactive protein levels. The 1-year mortality rates were 9.2%, 11.4%, and 46.2% in groups I, II, and III, respectively. Group I and group II patients had a lower 1-year mortality rate than group III patients (log-rank test; chi = 8.807; P = 0.0112).The study suggested that serum ferritin levels predict both all-cause and infection-cause 1-year mortality in diabetic patients on MHD. In such patients, the serum ferritin levels are associated with both iron stores and the inflammation status.

To determine the prognostic value of day 1 urine excretion of cadmium (1st DUE-Cd) for predicting outcomes in intensive care unit (ICU) patients.Prospective study.ICUs in Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taiwan, ROC.Two hundred one ICU patients.Urine and blood samples were taken within 24 hours after admission.Disease severity, hospital mortality, and number of organ failures were evaluated in each medical ICU patient. Stepwise multiple linear regression analysis indicated that a history of chronic hepatitis, serum albumin, and glutamic-pyruvic transaminase were significantly related to 1st DUE-Cd after adjusting for other related variables. Cox multivariate analysis revealed that serum blood urea nitrogen level and ICU 1st DUE-Cd were significantly related to hospital mortality after other risk factors and scoring systems were adjusted. Each 1-microg increase in ICU 1st DUE-Cd was associated with a 7% increase in hospital mortality rate. All patients with poisoning magnitude of cadmium excretion (10 microg/day) died, except one and those with normal cadmium excretion survived. Chi-square values of the Hosmer-Lemeshow goodness-of-fit test were 6.936 (p = 0.544), and area under the receiver operating characteristic curve was 0.868 (95% confidence intervals: 0.82-0.92) for ICU 1st DUE-Cd.The ICU 1st DUE-Cd may predict hospital mortality in critically ill medical patients. Because of excess mortality and relatively small sample size, the predictive role of DUE-Cd needs further external validation.

This study determines the clinical significance of residual renal function (RRF), defined as residual daily urine volume (RDUV), in maintenance hemodialysis (MHD) patients.This multi-center study enrolled 704 MHD patients. Geographic, hematological, biochemical, and dialysis-related data were obtained. Values for nutritional and inflammatory markers were analyzed together with RDUV.In total, 670 of 704 patients (95.2%) with HD duration greater than 1 year had abnormal RDUV (500 ml). Patients with higher RRF were younger, had shorter HD duration, higher prevalence of hypertension and levels of serum albumin, high density lipoprotein (HDL), and lower mid-week inter-dialysis body weight increase (MIBWI), cardio-thoracic ratio, levels of intact parathyroid hormone, high sensitivity C-reactive protein (Hs CRP), and KT/V (Daugirdes) values than those with low RRF. Stepwise multiple regression analysis demonstrated that RRF was positively correlated with serum albumin, HDL levels, and presence of hypertension, and negatively correlated with age, HD duration, and MIBWI in MHD patients. Moreover, after adjusting factors that were significantly related to serum albumin or Hs CRP, RRF was still positively correlated with serum albumin (0.000137 +/- 0.000585, p = 0.0197) and negatively correlated with log Hs CRP (-0.000184 +/- 0.000952, p = 0.0533). A one-liter increase in RDUV was associated with a 1.4 g/L increase in serum albumin level in MHD patients.This clinical study first demonstrated that RRF affects nutritional and inflammatory status in MHD patients. Because malnutrition and inflammation can cause high mortality in MHD patients, preserving RRF is important for these patients.

This study evaluated the relationship between pregnancy rate and semen cadmium concentration. This prospective and nonrandomized clinical study analyzed 341 male partners of infertile couples undergoing infertility evaluation and management. Semen samples were collected to analyze semen quality and cadmium concentrations. The main outcome was pregnancy during 60-day infertility treatment. Simple linear regression analysis revealed an association between semen cadmium concentration NS sperm count (r = −0.150, P = 0.0416) in nonsmoking subjects (n = 184). In both smokers and nonsmokers, semen cadmium concentrations were significantly higher in non-pregnant patients than in pregnant patients. In nonsmokers, Cox multi-variable fertility ratio analysis demonstrated an association between semen cadmium concentration and fertility (fertility ratio of log semen cadmium = 0.24; 95% confidence intervals (CI) = 0.12–0.47, P

Background: Arterial stiffness as determined by brachial-ankle pulse wave velocity (baPWV) has been demonstrated to predict cardiovascular events or mortality in patients with end-stage renal disease. Peritoneal function and residual renal function (RRF) both are important for patients undergoing peritoneal dialysis (PD). No association has yet been established between arterial stiffness, and RRF and peritoneal function in patients undergoing PD. Methods: 146 PD patients received PD lasting over 4 months. baPWV was determined using an automated, non-invasive, waveform analysis device. Results: This retrospective study revealed independent correlations between baPWV and mean arterial pressure, age, status of diabetes mellitus and RRF as well as an inverse correlation with body mass index. Conclusion: This retrospective study showed that arterial stiffness is independently correlated with RRF. Interestingly, peritoneal function test is not associated with baPWV value.

Atherosclerotic vascular change affecting the lower extremities is the most common peripheral vascular disease. Ankle-brachial index (ABI) and toe-brachial index (TBI) are common, non-invasive diagnostic tests for atherosclerosis in the lower extremities. Peritoneum is a vascular-based structure. The use of glucose-based hyperosmolar solutions for PD patients results in a significant increase in blood glucose load and can be considered atherogenic. The association between ABI or TBI values and peritoneal function in patients undergoing peritoneal dialysis remains unclear. We presumed that the risk factors for atherosclerosis in large and small vessels may differ.A total of 146 peritoneal dialysis patients, 41 males and 105 females (119 without diabetes and 27 with diabetes), received peritoneal dialysis for more than four months. Patients who had dialysis-related peritonitis within six months prior to this study were excluded. The ABI or TBI was determined using an automated, non-invasive, waveform analysis device.The ABI value correlated positively with mean arterial pressure and TBI value. The TBI value correlated positively with ABI value and inversely with fasting serum glucose and serum total cholesterol concentrations. Peritoneal function was not correlated with ABI or TBI.This cross-sectional study demonstrated that risk factors in peritoneal dialysis patients for atherosclerosis in large vessels and small vessels differed. Interestingly, peritoneal function test is not associated with ABI or TBI value. However, further investigation of the association between ABI or TBI value and cardiovascular events is required for this patient group.

This report describes 2 cases of star fruit intoxication successfully treated with charcoal hemoperfusion (CHP). Common clinical characteristics of the reported cases included persistent hiccup, consciousness disturbance, coma, need for ventilator support, and admission to an intensive care unit. The optimum treatment for star fruit intoxication has been controversial, with modality, dose, and appropriate timing of extracorporeal therapy debated. Analysis of the 2 reported cases shows several advantages of CHP, including increased extraction efficiency, rapid recovery of consciousness, decreased time of intensive care unit admission, and good clinical tolerance. CHP may provide an alternative treatment modality in cases with life-threatening star fruit intoxication with poor response to intensified hemodialysis.

Previous studies of general populations indicated environmental exposure to low-level cadmium increases mortality. However, the effect of cadmium exposure on maintenance hemodialysis (MHD) patients is unclear. A total of 937 MHD patients from 3 centers in Taiwan were enrolled in this 36-month observational study. Patients were stratified by baseline blood cadmium level (BCL) into 3 groups: high BCL (>0.521 μg/L; n = 312), intermediate BCL (0.286−0.521 μg/L; n = 313), and low BCL (

Studies indicate that environmental exposure to lead is associated with reduced renal function. Whether lead affects progressive diabetic nephropathy is unclear. Eighty-seven patients with type II diabetes and diabetic nephropathy (serum creatinine of 1.5-3.9 mg/dl) with normal body lead burden and no lead exposure history were observed over a 12-month period. Thirty subjects with high normal body lead burdens (80-600 microg) were randomly assigned to a chelation and control group. For 3 months, the 15 chelation-group patients underwent lead-chelation therapy with calcium disodium ethylenediaminetetraacetic acid weekly until body lead burden fell60 microg, and the 15 control group subjects received a weekly placebo. During the following 12 months, renal function was regularly assessed at 3-month intervals. The primary outcome was an elevation of serum creatinine to 1.5 times baseline value during the observation period. A secondary outcome was temporal changes in renal function following chelation therapy. Twenty-six patients achieved the primary outcome. Basal blood lead levels and body lead burden were the most important risk factors in predicting progressive diabetic nephropathy. Following chelation, the rates of decline in glomerular filtration rates in the chelation group and the control group, respectively, were 5.0+/-5.7 ml and 11.8+/-7.0 ml/min/year/1.73 m(2) of body surface area (P=0.0084) during follow-up, although both groups had similar rates of progression of renal function during the 12-month observation period. We concluded that low-level environmental lead exposure accelerates progressive diabetic nephropathy and lead-chelation therapy can decrease its rate of progression.

A 42-year-old woman with a 24-year history of systemic lupus erythematous and lupus nephritis for 8 years who had been receiving regular hemodialysis for 4 years for nonoligoric end-stage renal disease (ESRD) ingested about 100 mL of 40.8% chlorpyrifos in a suicide attempt. On admission to our emergency department, she was drowsy. Gastric lavage, activated charcoal, pralidoxime (PAM), and atropine were administered 4 h later. Her consciousness level improved gradually with treatment, which included hemodialysis. However, on the second hospital day, intermittent fever to 38.4 degrees C, sore throat, and trismus were noted. About 45 h after chlorpyrifos ingestion, the patient developed profound motor paralysis followed by respiratory arrest, consistent with the diagnosis of intermediate syndrome (IMS), even with adequate atropine and PAM. Chorealike involuntary movements of her upper limbs were noticed on the fifth day. Intermittent tonic-clonic seizures, each attack lasting for 3 to 5 min, appeared on the 13th day, which responded well to intravenous diazepam and phenytoin. She was discharged on the 18th day. This case suggests that patients with ESRD suffering chlorpyrifos intoxication are at risk of IMS. Prompt endotracheal intubation, intensive care, and hemodialysis are necessary for life support.

Renal oncocytoma has been repeatedly reported in Western countries, but only a few cases have been reported in Eastern countries. This study aims to review the clinical course of renal oncocytoma in an Eastern country such as Taiwan.Sixteen cases of renal oncocytoma seen between 1987 and 2002 at Chang Gung Memorial Hospital, Taipei, Taiwan, were studied.Preoperatively, all patients were diagnosed to have renal cell carcinoma, following various radiologic studies. Perioperatively, frozen sections of three patients indicated renal oncocytoma in two and renal cell carcinoma in one. Renal oncocytoma has marked similarities to renal cell carcinoma, according to various radiologic, cytologic, and pathological investigations, so an accurate diagnosis is difficult to achieve, either preoperatively or perioperatively. Therefore, rather than being treated with partial nephrectomy, all patients were treated aggressively with unilateral radical nephrectomy. Postoperatively, all 16 patients were followed up, from 12 to 189 months, with a mean of 58.7 months. Notably, all patients survived with no evidence of tumor recurrence.The experience in Taiwan is generally that renal oncocytoma behaves benignly, as reported in other areas. The excellent prognosis associated with this tumor appears to indicate that partial nephrectomy may suffice for removing the tumor, while sparing other unaffected renal parenchyma.

Paraquat, 1,1'-dimethyl-4,4'-bipyridylium dichloride, is a commonly applied bipyridyl contact herbicide. Paraquat poisoning from suicidal ingestion causes high mortality rates, and severe poisoning has been uniformly fatal in pregnant females (nine of nine cases). We presented a case of severe paraquat poisoning from suicidal ingestion in a woman in the third trimester of pregnancy (G5P4A1). Urine dithionate test was strongly positive (showed dark blue color). She was managed with charcoal hemoperfusion x 2, megadose of cyclophosphamide, and methylprednisolone pulse therapy. Despite initial deterioration of renal and liver function, she had a normal spontaneous delivery of a healthy girl baby 14 weeks after the exposure. The child reached developmental milestones normally and appeared healthy and well nourished at age 5. This may be the first documentation of a pregnant woman with moderate to severe paraquat poisoning successfully delivering a healthy baby.

patients with acute myocardial infarction☆ Ja-Liang Lin ⁎, Pao-Hsien Chu , Dan-Tzu Lin-Tan , Ching-Wei Hsu , Wen-Hung Huang , Kuan-Hsing Chen , Tzung-Hai Yen a,1 a Division of Nephrology and Clinical Toxicology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Chang Gung University and School of Medicine, Taipei, Taiwan, ROC b Division of Cardiology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Chang Gung University and School of Medicine, Taipei, Taiwan, ROC

Emamectin benzoate is the 4'-deoxy-4'-epi-methyl-amino benzoate salt of avermectin B1 (abamectin), which is similar structurally to natural fermentation products of Streptomyces avermitilis. Emamectin benzoate is being developed as a newer broad-spectrum insecticide for vegetables and has a very low application rate. The mechanism of action involves stimulation of high-affinity GABA receptors and a consequent increase in membrane chloride ion permeability. Animal studies indicate a wide margin of safety because mammalian species are much less sensitive due to lower GABA receptor affinities and relative impermeability of the blood-brain barrier. Notably, the literature has not reported human exposure resulting in toxicity.This paper describes a case of acute poisoning with Proclaim insecticide (Syngenta, Taiwan), consisting of 2.15% w/w emamectin benzoate in 2, 6-bis (1, 1-dimethylethyl)-4-methyl-phenol and 1-hexanol. The clinical manifestation was transient gastrointestinal upset with endoscopy-proven gastric erosion and superficial gastritis, mild central nervous system depression, and aspiration pneumonia. No specific antidote exists for emamectin benzoate intoxication; this patient was treated successfully with gastric lavage, administration of activated charcoal, and empiric antibiotics. Drugs that enhance GABA activity such as barbiturates and benzodiazepines were avoided.

Acute renal failure associated with scrub typhus infection is not rare as previously thought. The possibility of scrub typhus should be borne in mind when patients present with fever and varying degrees of acute renal failure, particularly if an eschar exists, along with a history of environmental exposure in an area like Taiwan, where scrub typhus is endemic. Prompt diagnosis and the use of appropriate antibiotics can rapidly alter the clinical course of the disease and prevent the development of serious or fatal complications. To illustrate the above point, this study reports 3 cases of scrub typhus associated with acute renal failure. They were seen at Chang Gung Memorial Hospital in a 2-year interval. Case 1 was referred from district hospital with clinical features of multiple organ dysfunctions, including shock, fever, acute respiratory failure, acute renal failure, and acute hepatitis. Case 2 was admitted with the chief problems of shock, fever, acute renal failure, and DIC. Case 3 visited our outpatient clinic due to fever, maculopapular rash and acute renal failure. In all these patients, the diagnosis was confirmed using immunofluorescence techniques, which showed that Orientia tsutsugamushi had an IgM titer of 1:80 or greater. Notably, despite having varying degrees of acute renal deterioration, the patients responded very well to doxycycline therapy and recovered completely. Additionally, a total of 4 similar cases of scrub typhus associated with acute renal failure were reviewed from the past literature.

Introduction:Acute inhalation of mercury fumes or vapors is a rare but frequently fatal cause of acute lung injury. This report describes a rare cause of mercury inhalation from Chinese red. Case Report: An 87-year-old male inhaled the vapors from heating Chinese red (Cinnabar, mercury sulphide) intended to treat his foot ulceration. He subsequently developed acute lung injury (progressive dyspnea and acute respiratory failure) that was treated with mechanical ventilation. DMPS (2,3-Dimercapto-1-propanesulfonic acid) and penicillamine were used as chelating agents, and methylprednisolone pulse therapy was used to treat his pulmonary disease. Despite being extubated once, the patient eventually died from profound hypoxemia. Conclusion:A rare case of mercury intoxication was due to inappropriate use of an alternative medicine, Chinese red. This case serves as a reminder of the toxicity of the noxious gas from this substance and the importance of being familiar with alternative medicines.

Paraquat poisoning is the most common cause of fatal herbicide intoxication, mostly through oral ingestion. This work reports two cases of death following intravenous paraquat injection. The clinical courses of the two cases were fulminated and fatal. Toxic symptoms and severe organ function impairment developed soon after paraquat injection. Timely treatment with activated charcoal hemoperfusion with pulse steroid and cyclophosphamide was attempted in both cases; however, both cases died within five days owing to multiple organ failure. In cases of intravenous paraquat intoxication, toxic signs develop more quicker than with oral ingestion. The prognosis of intravenous paraquat intoxication is extremely poor.

Chronic occupational exposure to lead is related to low urate excretion and a high incidence of gout in lead workers. However, whether chronic low-level environmental lead exposure influences urate excretion in the general population remains unknown.We studied 111 healthy subjects with normal renal function (serum creatinine levelor =1.4 mg/dL) and no previous lead exposure or systemic diseases. All subjects had their blood lead levels measured, received ethylenediaminetetraacetic acid mobilization tests to assess their body lead burdens, and were investigated for renal function and urate excretion to assess the relation between lead and urate excretion. We studied urate excretion before and after lead chelation therapy in 24 subjects with high-normal body lead burden (78 mg and600 mg).Healthy subjects with gout (n = 27) manifested a higher body lead burden (84 +/- 42 mg vs. 45 +/- 30 mg, P0.0001) and lower urate clearance (3.7 +/- 1.2 mL/min/1.73 m(2) vs. 6.0 +/- 2.8 mL/min/1.73 m(2), P0.0001) than did those without gout (n = 84). Blood lead levels and body lead burden of all subjects were within the safe range. In analyses that adjusted for age, sex, body mass index, protein intake, and creatinine clearance, blood lead level was significantly related to serum urate level (beta coefficient [+/- SE] = 0.23 +/- 0.11, P = 0.03), and body lead burdens were related to all indices of urate excretion (serum urate: beta coefficient = 0.023 +/- 0.005, P0.0001; daily urate excretion: beta coefficient = -1.55 +/- 0.40, P = 0.0002; urate clearance: beta coefficient = -0.030 +/- 0.006, P0.0001; fractional urate excretion: beta coefficient= -0.034 +/- 0.006, P0.0001). Following lead chelation therapy, urate clearance increased after body lead burden was reduced (3.4 +/- 1.2 mL/min/1.73 m(2) vs. 4.9 +/- 1.4 mL/min/1.73 m(2), P0.005).Chronic low-level environmental lead exposure may inhibit urate excretion in the general population, and lead chelation therapy reduces this inhibition. These findings support efforts to reduce sources of environmental lead exposure and suggest alternative approaches to hyperuricemia and gout in the general population.

Objective To report a severe case of paraquat poisoning successfully treated with repeated-pulse therapy of methylprednisolone. Design Case study. Setting University Hospital, Lin-Kou Medical Center, Taipei, Taiwan, Republic of China. Patients A 60-yr-old man with paraquat poisoning with severe acute renal failure (serum creatinine level of 11.8 mg/dL and serum paraquat level of 3.66 microg/mL at 10 hrs after ingestion) and severe hypoxemia (Pao2, 66.6 mm Hg). Intervention Repeated 3-day pulse therapy with methylprednisolone, one course of 2-day cyclophosphamide, and a high dose of dexamethasone for 33 days. MEASUREMENTS AND MAIN OUTCOME: Arterial blood gas analysis was obtained regularly. A chest radiography was obtained every week. The arterial blood oxygen concentrations dramatically elevated from 66 mm Hg to 97 mm Hg, and the chest radiographs markedly improved after repeated-pulse therapy with anti-inflammatory agents and cyclophosphamide. Conclusions We successfully treated a severe paraquat poisoned patient with repeated methylprednisolone pulse therapy and prolonged dexamethasone treatment. This case demonstrates that the severe inflammation, not the fibrosis, of the lungs plays a major role in the lethal hypoxemia of patients with paraquat poisoning during the subacute period and confirms our previous hypotheses. Clearly, the use of anti-inflammatory therapy to treat paraquat-poisoned patients needs further evaluation; however, anti-inflammatory therapy may be an effective treatment after failure of standard therapies.

This report describes a 56-year-old man with a ruptured infected abdominal aortic aneurysm secondary to Salmonella bacteremia, initially presenting as acute pyelonephritis. Spike fever with severe back pain continued despite empiric antibiotic treatment at a local hospital. Hypotension with a sudden hemoglobin drop was observed on the second hospitalization day. Abdominal computed tomography to further examine the bleeding focus confirmed a rupture of the mycotic abdominal aortic aneurysm. This case was successfully treated through prompt surgical intervention and aggressive protracted antibiotic therapy. The case presented herein raises concerns about the uncommon but life-threatening mycotic aneurysm presented initially as acute pyelonephritis. Early diagnosis and appropriate surgical and antibiotic treatment of the Salmonella mycotic aortic aneurysm is crucial for a satisfactory outcome.

Salmonella enteritidis infection occurs primarily in animals and often results in self-limited gastroenteritis in accidental cross contamination in human. However, the acute renal failure could be a rare but serious complication of the S. enteritidis infection. We report one case of acute renal failure from severe dehydration caused by S. enteritidis food poisoning. The acute renal failure completely recovered after hydration and antibiotic treatment.