Search

Summary Background Septic acute kidney injury (AKI) is a common complication in intensive care units (ICU), it and portends a higher risk of morbidity and death than nonseptic AKI. However, its outcome and prognostic factors among elderly postoperative patients remain unknown. We aimed to determine the risk factors and predictors of mortality among postoperative elderly patients (≥ 65 years) with septic AKI requiring acute dialysis. Methods The study protocol was based on that of a clinical cohort study of renal failure patients in the database of the National Taiwan University Surgical ICU Acute Renal Failure (NSARF) Study Group. From January 2002 to July 2009, patients (aged > 18 years) with postoperative AKI requiring renal replacement therapy (RRT) were recruited for this study. Each case of septic AKI before operation was identified and patients with end-stage renal disease were excluded. Results A total of 292 postoperative patients with septic AKI requiring dialysis were identified during the study period. The mean (SD) age was 65.9 (11.9) years and 68.2% were men. Abdominal surgery was the most common type of surgery (42.8%), followed by cardiovascular (28.8%) and chest surgery (15.4%). The most common indications for RRT in this study cohort were azotemia in 223 patients (76.4%) and fluid overload in 62 patients (21.2%); 92 (31.5%) patients had one indication, 170 (58.2%) had two indications, and 30 (10.3%) had more than three indications. The elderly patients (those ≥ 65 years) had anemia, underwent abdominal surgery, and received dialysis for fluid overload more frequently than the young adults. By contrast, the young adults were more likely to present with shock requiring vasopressor use and have abnormal liver functions. In the elderly subgroup, the outcome was found to be associated with mechanical ventilator use, but not with disease severity, comorbidities, types of surgery and the indication for dialysis. Conclusions The hospital mortality of postoperative elderly patients with septic AKI was more than 60% and was not affected by age. Mechanical ventilator use was the major risk factor and prognostic factor for elderly patients in this clinical setting.

The emergence of a second primary cancer is usually one of the leading causes of therapeutic failure in patients with known malignancies. Detection of a second primary cancer may reduce the corresponding morbidity and mortality, especially in patients without the symptoms that are illustrative of a second primary malignancy. Here, we report a rare coincidence of an asymptomatically synchronous esophageal cancer incidentally detected by F-18 fluorodeoxyglucose positron emission tomography/computed tomography in a 65-year-old prostate cancer patient. The treatment strategy was accordingly changed to esophagectomy with colon interposition and jejunostomy after neoadjuvant chemotherapy and radiotherapy.

Kidney impairment is noted in primary aldosteronism (PA), and probably initiated by glomerular hyperfiltration.A prospectively defined survey was conducted on 602 patients who were suspected of PA in the multiple-center Taiwan Primary Aldosteronism Investigation (TAIPAI) database. Estimated glomerular filtration rate (eGFR) was calculated and followed up at 1 yr after treatment.The diagnosis of PA was confirmed in 330 patients. Among them 17% of these patients had kidney impairment (eGFR60 ml/min/1.73 m²). Patients with PA had a higher prevalence of estimated hyperfiltration than those with essential hypertension (EH) (14.5% vs. 7.0%, p=0.005). The eGFR independently predicted PA (OR, 1.017) in the propensity-adjusted multivariate logistic model. In PA, plasma renin activity and lower serum potassium (p=0.018) was correlated with kidney impairment (p=0.001), while this relationship was not significant in patients with EH. Either unilateral adrenalectomy or treatment of spironolactone for PA patients caused a decrease of eGFR (p0.001). Pre-operative hypokalemia (p=0.013) and the long latency of hypertension (p=0.016) could enhance the significant decrease of eGFR after adrenalectomy.Patients with aldosteronism had relative estimated hyperfiltration than patients with EH. Calculation of eGFR may increase the specificity in identifying patients with PA. Our findings demonstrate the correlation of serum potassium and renin with estimated hyperfiltration in PA and their relationship to kidney damage. These results provide a high priority for future renal protective strategies and methods for the early diagnosis and prompt treatment of PA.

To compare the diagnostic accuracy of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) in the detection of colon lesions with that of delayed PET/computed tomography (CT) performed after the administration of a laxative-augmented contrast medium.All patients gave written informed consent according to the guidelines issued by the institutional review board. In a prospective study performed from November 2005 to December 2006, images obtained in 847 patients were reviewed by two physicians in consensus. Colorectal FDG uptake on initial PET images that exceeded background FDG accumulation was graded as minimal, equivocal, or positive. When the initial PET scan revealed a colorectal region of increased uptake, either oral or anal laxative-augmented contrast medium was administered on the basis of the site of colorectal FDG focus and delayed PET/CT was performed. Initial PET findings were reevaluated and revised when necessary. Comparison was performed on a per-patient basis. Findings at histopathologic analysis and clinical follow-up served as the reference standard. The accuracy of PET was compared with that of PET/CT by using the McNemar test.Colorectal FDG foci were seen on initial images in 137 patients. Uptake on the initial images was reported as minimal in 14 patients, equivocal in 68, and positive in 55. With use of a laxative-augmented contrast medium and delayed PET/CT, the proportions of equivocal and positive results decreased by 84% (57 of 68 patients) and 58% (18 of 31 patients), respectively. The accuracy of delayed PET/CT in the depiction of colorectal cancer was greater than that of initial PET (93.4% [128 of 137 patients] vs 71.5% [98 of 137 patients], respectively; P.01).Delayed PET/CT with laxative-augmented contrast medium is more accurate than initial PET alone in the detection of colorectal cancer. This approach has promise as a tool for guiding decisions about how to treat patients with colorectal FDG foci.http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101193/-/DC1.

Angioma serpiginosum is an uncommon, acquired vascular nevoid disorder with capillary dilation and proliferation in the papillary dermis. The eruptions are asymptomatic and characterized by grouped, erythematous to violaceous, serpiginous and punctate macules. The condition usually appears in females during adolescence on unilateral lower extremities and the buttocks. We report a rare case with a late onset and atypical distribution of lesions in a 48-year-old female patient who had groups of punctate lesions on her left foot for four to five years. Histopathological examination showed hyperkeratosis and multiple dilated and proliferated capillaries in the papillary dermis. Inflammation and extravasation of red blood cells were not found. According to the clinical and pathological findings, we established a diagnosis of angioma serpiginosum. She was treated with a pulsed dye laser, and the angiomatous lesions subsequently improved.

Technetium-99m labeled human serum albumin (Tc-99m HSA) is an important radiopharmaceutical for clinical applications, such as cardiac function tests or protein-losing gastroenteropathy assessment. However, because of transfusion-induced infectious diseases, the safety of serum products is a serious concern. In this context, serum products acquired from patients themselves are the most ideal tracer. However, the development of rapid separation and easy clinical labeling methods is not yet well established. Under such situation, products from the same ethnic group or country are now recommended by the World Health Organization as an alternative preparation. This article describes the on-site preparation of Tc-99m HSA from locally supplied serum products. Different formulations were prepared and the labeling efficiency and stability were examined. Radio-labeling efficiencies were more than 90% in all preparation protocols, except for one that omitted the stannous solution. The most cost-effective protocol contained HSA 0.1 mg, treated with stannous fluoride 0.2 mg, and mixed with Tc-99m pertechnetate 30 mCi. A biodistribution study was performed in rats using a gamma camera immediately after intravenous administration of radiolabeled HSA. Tissue/organ uptake was obtained by measuring the radioactivity in organs after sacrificing the rats at timed intervals. The biologic half-life was about 32 min, determined from sequential venous blood collections. These data indicate that our preparation of Tc-99m HSA is useful and potentially applicable clinically. In addition, this on-site preparation provides the possibility of labeling a patient's own serum for subsequent clinical application.

Hyponatremia can be classified as acute or chronic depending on its duration, and treatment options are tailored to this classification. However, it is sometimes difficult to differentiate acute from chronic hyponatremia in the Emergency Department (ED). The objective of this study was to identify characteristics to help diagnose and manage acute hyponatremia in the ED. Patients with acute hyponatremia in the ED were enrolled from a retrospective 2-year chart review. Eleven patients (0.8%) were identified with acute hyponatremia out of a total of 1321 hyponatremic patients. There were nine women and two men. The mean age was 48.9 years. The mean sodium (Na(+)) level was 115+/-4 mmol/L. Accompanying biochemical abnormalities included hypouricemia and hypouremia with increased fractional excretions of uric acid (UA) and urea. The estimated amount of water intake ranged from 2.5 to 10 liters (mean, 5.1+/-2.3 liters) during the day before ED presentation. All patients were treated with hypertonic saline and furosemide at a correction rate of 1.6+/-0.5 mmol/L/h. No patients had neurological sequelae after treatment. The causes of acute hyponatremia included induction of abortion with oxytocin (n=1), primary polydipsia on neuroleptic agents (n=2), polyethylene glycol (PEG) preparation for colonoscopy (n=1), diuretic therapy for hypertension (n=4), ecstasy use (n=1), and weight-reducing herbal teas (n=2). We conclude that in the right clinical setting, high free water intake and low serum urea and UA favor acute hyponatremia. A detailed drug history may be helpful in the differential diagnosis of acute hyponatremia.

Potassium supplements have been recommended to hasten recovery and prevent cardiopulmonary complications in patients with thyrotoxic periodic paralysis (TPP). However, this recommendation has not yet been proven efficacious. Thirty-two patients with acute attacks of TPP over a 3-year-period were divided into 2 groups. Group A (n = 12) was a control group treated with normal saline infusion 125 mL/hr only. Group B (n = 20) received intravenous KCl administration at a rate of 10 mmol/hr in normal saline 125 mL/hr. During the attack and for 6 hours after muscle recovery, hemodynamics were continuously recorded and muscle strength and plasma K(+) concentration were measured hourly. The sex, age, muscle strength, thyroid function, biochemical values including plasma K(+) levels, as well as the time from attack to therapy (3.6 +/- 1.6 v 3.3 +/- 1.0 hr) were not significant between the 2 groups. However, recovery time was significantly shorter in the KCl group than the control (6.3 +/- 3.8 v 13.5 +/- 7.5 hr, P.01). Rebound hyperkalemia greater than 5.5 mmol/L occurred in 40% patients receiving KCl. The dose of KCl administered and peak K(+) concentration were positively correlated (r = 0.85, P.001). In conclusion, KCl therapy proves to help the recovery of paralysis in TPP associated with rebound hyperkalemia. KCl supplementation should be given as small as possible (10 mmol/hr) to avoid rebound hyperkalemia unless there are cardiopulmonary complications.

Hypokalemia with paralysis (HP) is a potentially reversible medical emergency. It is primarily the result of either hypokalemic periodic paralysis (HPP) caused by an enhanced shift of potassium (K(+)) into cells or non-HPP resulting from excessive K(+) loss. Failure to make a distinction between HPP and non-HPP could lead to improper management. The use of spot urine for K(+) excretion rate and evaluation of blood acid-base status could be clinically beneficial in the diagnosis and management. A very low rate of K(+) excretion coupled with the absence of a metabolic acid-base disorder suggests HPP, whereas a high rate of K(+) excretion accompanied by either metabolic alkalosis or metabolic acidosis favors non-HPP. The therapy of HPP requires only small doses of potassium chloride (KCl) to avoid rebound hyperkalemia. In contrast, higher doses of KCl should be administered to replete the large K(+) deficiency in non-HPP.

We report the case of a 57-year-old woman with the history of stage IB cervical cancer. She was found to have a metastatic squamous cell carcinoma in sigmoid colon. FDG PET/CT was then performed for whole-body cancer work-up. Intense FDG activity accumulated in the sigmoid tumor, with an unusually high SUVmax of 72.42, and was seen downwardly connected with the activity of urinary bladder on PET images. On the coregistered CT images, irregular wall thickening was noted for both sigmoid colon and urinary bladder with a hypodensity tract communicating with each other. It was concluded that recurrent cervical cancer involving urinary bladder and sigmoid colon resulted in colovesical fistula.

Objective.We retrospectively analyzed all primary aldosteronism (PA) patients undergoing NP-59 SPECT/CT imaging with regard to their clinicolaboratory and imaging features, investigation, and outcomes.Material and Methods.11 PA patients who presented to our hospital for NP-59 SPECT/CT imaging between April 2007 and March 2012 and managed here were analyzed.Results.Among 11 PA patients, eight (73%) had stage 1 hypertension, three (27%) stage 2 hypertension, four (36%) normal plasma aldosterone concentration, nine (82%) nonsuppressed plasma renin activity (PRA), six (55%) normal aldosterone-renin-ratio (ARR), eight (73%) serum potassium ≧3 mEq/L, seven (64%) subclinical presentation, seven (64%) negative confirmatory testing, and four (36%) inconclusive results on CT scan and seven (64%) on planar NP-59 scan. All 11 (100%) patients had positive results on NP-59 SPECT/CT scan. Two (18%) met typical triad and nine (82%) atypical triad. Among nine atypical PA patients, three (33%) had clinical presentation, six (67%) subclinical presentation, six (67%) negative confirmatory testing, and four (44%) inconclusive results on CT scan and six (67%) on planar NP-59 scan. All patients had improved outcomes. Significant differences between typical and atypical PA existed in PRA and ARR.Conclusions.NP-59 SPECT/CT may provide diagnostic potential in stage 1 hypertensive and atypical PA.

A 73-year-old man with a 10-year history of hypertension exhibited poorly controlled systolic blood pressure (BP), which remained at 190 mm Hg, despite treatment with six different classes of antihypertensives in the past 2 years. Laboratory analysis revealed potassium levels of 3.9 mmol/l, plasma aldosterone concentration (PAC) of 8.42 ng/dl (3.7–24.0 ng/dl), plasma renin activity (PRA) of 0.21 ng/ml/h (0.15–2.33 ng/ml/h), aldosterone-to-renin ratio (ARR) of 40.1 (>30), 24-h urinary vanillylmandelic acid levels of 1.67 mg (

Metastasis of colorectal adenocarcinoma to the larynx is a very rare condition. Here, we report a 72-year-old woman with a history of rectal adenocarcinoma. She was referred for whole-body FDG PET/CT scanning because of an elevating serum level of carcinoembryonic antigen. PET images showed focally increased FDG accumulation in the larynx (SUVmax=12.9). Coregistered CT images showed mild wall thickening at the left subglottic area. The findings of after excisional biopsy confirmed that this FDG-avid lesion was metastatic adenocarcinoma of the colorectal origin.

Primary aldosteronism (PA) may be missed in patients with chronic kidney disease (CKD), because CKD may disturb the renin-angiotensin-aldosterone system. Adrenal vein sampling has increased risks in patients with CKD. We report the case of a 58-year-old man with CKD and suspected PA. Left adrenal aldosteronism was diagnosed by NP-59 SPECT/CT. Left adrenalectomy demonstrated adrenocortical nodular hyperplasia. Plasma aldosterone normalized and blood pressure stabilized after surgery. NP-59 SPECT/CT may be a helpful diagnostic tool for detecting and lateralizing PA in CKD patients.

TO THE EDITOR: Roy et al. recently published a study adopting a standardized protocol of intravenous insulin administration to reduce glycemia in diabetic cancer patients undergoing 18F-FDG PET ( [1][1] ). The authors claimed that the pretest intravenous insulin injection in diabetic patients is a

The application of an artificial neural network (ANN) in prediction of outcomes using clinical data is being increasingly used. The aim of this study was to assess whether an ANN model is a useful tool for predicting skeletal metastasis in patients with prostate cancer. Consecutive patients with prostate cancer who underwent the technetium-99m methylene diphosphate (Tc-99m MDP) whole body bone scintigraphies were retrospectively analyzed between 2001 and 2005. The predictors were the patient's age and radioimmunometric serum PSA concentration. The outcome variable was dichotomous, either skeletal metastasis or non-skeletal metastasis, based on the results of Tc-99m MDP whole body bone scintigraphy. To assess the performance for classification model in clinical study, the discrimination and calibration of an ANN model was calculated. The enrolled subjects consisted of 111 consecutive male patients aged 72.41 +/- 7.69 years with prostate cancer. Sixty-seven patients (60.4%) had skeletal metastasis based on the scintigraphic diagnosis. The final best architecture of neural network model was four-layered perceptrons. The area under the receiver-operating characteristics curve (0.88 +/- 0.07) revealed excellent discriminatory power (p0.001) with the best simultaneous sensitivity (87.5%) and specificity (83.3%). The Hosmer-Lemeshow statistic was 6.74 (p = 0.080.05), which represented a good-fit calibration. These results suggest that an ANN, which is based on limited clinical parameters, appears to be a promising method in forecasting of the skeletal metastasis in patients with prostate cancer.

A 61-year-old woman, in receipt of haemodialysis for 11 years, was diagnosed with a high-grade papillary urothelial carcinoma of the urinary bladder. Thallium-201 single photon emission computed tomography/computed tomography (SPECT/CT) was performed during the cancer work-up (Figure ​(Figure1).1). Unenhanced CT images of the SPECT/CT demonstrated a left adrenal mass (31.7 mm in size) with a homogeneous density of 62 HU. Scintigraphic SPECT images of the SPECT/CT showed an abnormal focus of increased radiotracer activity in the left upper quadrant of abdomen. The corresponding SPECT/CT fusion images confirmed the focus in the left adrenal medulla. The patient underwent a left adrenalectomy and the pathological findings indicated the histological characteristics of pheochromocytoma (Figure ​(Figure22). Fig. 1 New advance of image-rendering display: thallium-201 SPECT/CT. The coronal (left column), sagittal (middle column) and transaxial (right column) views of the CT images (top row) and corresponding SPECT images (middle row) fused to the SPECT/CT images ... Fig. 2 A pathological section of the left adrenal gland revealed a uniform proliferation of medullary cells, showing a nesting (Zellballen) pattern composed of well-defined cell clusters with amphophilic cytoplasm surrounded by fibrovascular stroma (haematoxylin ... Pheochromocytoma is a rare catecholamine-secreting tumour with a potential for cardiovascular devastation if the diagnosis is overlooked. The tumour may present with a diversity of imaging features that result from various histological degenerations including fibrosis, calcification, congestion, haemorrhage, necrosis and cystic change. Therefore, pheochromocytoma is often referred to as an epithet ‘imaging chameleon’ [1]. An adrenal mass with attenuation value >10 HU on CT usually suggests a radiological diagnosis of pheochromocytoma. Thallium-201, a widely used radiotracer for myocardial perfusion scintigraphy, has been proved effective in the diagnosis of various tumours through the mechanisms of increased vascularity and higher mitotic rate in tumour cells. Its uptake into tumour cells also reflects the cell membrane functions of the Na+/K+ ATPase pump, Tl+-Na+-2Cl− cotransport system and calcium-dependent ion channel. We firstly report a long-term haemodialysis patient whose pheochromocytoma is visualized through thallium-201 uptake within the left adrenal medulla by means of real-time functional SPECT and anatomical CT fusion images in tracing the site of pheochromocytoma. Diagnosis of pheochromocytoma in long-term haemodialysis patients is quite difficult since symptoms and signs implying pheochromocytoma are easily attributed to haemodialysis effects or complications of chronic renal disease. Measurement of urinary catecholamines and their metabolites is not feasible in anuric patients. Plasma catecholamines are also unreliable due to the impact of haemodialysis. With the help of advanced imaging fusion science, integrated thallium-201 SPECT/CT could be a promising paradigm for the diagnosis of pheochromocytoma in haemodialysis patients [2]. Conflict of interest statement. None declared.

Diet is thought to be one of the leading causes of bone mineral loss in aging people. In this study, we explored the potential impact of a vegetarian diet on bone mineral density (BMD) in adult Taiwanese men and women. This was a cross-sectional study of the relationship between diet (vegetarian versus non-vegetarian) and BMD and the incidence of osteoporosis. Bone mineral density was determined in a cohort of 1865 adult male and female patients who underwent routine examination in a regional teaching hospital in Taiwan between February 2003 and February 2004. Subjects with definite vertebral problems, known osteopathy, or poor posture were excluded. Dual-energy X-ray absorptiometry (DEXA) was used to determine BMD, on the right hip in men and on lumbar vertebrae L2 to L4 in women. The subjects were grouped according to sex and diet, and were then stratified by age within each of the four groups. The outcome measures were the BMD value and the incidence of osteopenia or osteoporosis according to defined criteria. Bone mineral density gradually declined with increasing age in Taiwanese men, while Taiwanese women showed a precipitous decrease in BMD after the 5th decade. However, no statistical differences in BMD were observed between vegetarians and non-vegetarians of either sex. The proportion of subjects with osteopenia or osteoporosis also appeared comparable between vegetarians and non-vegetarians of either sex. BMD shows an age-related decline in Taiwanese men and women, and eating a vegetarian diet does not appear to affect this decline.

Hypotension is one of the most frequent adverse effects of spinal anesthesia. Several factors might be related to the occurrence of hypotension. Predictions of the hypotensive event, however, had been addressed by only a few authors using logistic regression (LR) models. Artificial neural networks (ANN) are pattern-recognition tools that can be used to detect complex patterns within data sets. The purpose of this study was to develop the ANN-based predictive model to identify patients with high risk of hypotension during spinal anesthesia. From September 2004 to December 2006, the anesthesia records of 1501 patients receiving surgery under spinal anesthesia were used to develop the ANN and LR models. By random selection 75% of data were used for training and the remaining 25% of data were used as test set for validating the predictive performance. Five senior anesthesiologists were asked to review the data of test set and to make predictions of hypotensive event during spinal anesthesia by clinical experience. The ANN model had a sensitivity of 75.9% and specificity of 76.0%. The LR model had a sensitivity of 68.1% and specificity of 73.5%. The area under receiver operating characteristic curves were 0.796 and 0.748. The ANN model performed significantly better than the LR model. The prediction of clinicians had the lowest sensitivity of 28.7%, 22.2%, 21.3%, 16.1%, and 36.1%, and specificity of 76.8%, 84.3%, 83.1%, 87.0%, and 64.0%. The computer-based predictive model should be useful in increasing vigilance in those patients most at risk for hypotension during spinal anesthesia, in allowing for patient-specific therapeutic intervention, or even in suggesting the use of alternative methods of anesthesia.

Measuring the plasma parathyroid hormone (PTH) concentration is crucial to evaluate renal bone disease in patients with renal failure. Although frequent measurement is needed to avoid inadequate prescription of phosphate binders and vitamin D preparations, artificial intelligence can repeatedly perform the forecasting tasks and may be a satisfactory substitute for laboratory tests. Neuro-fuzzy technology represents a promising forecasting application in clinical medicine. We therefore constructed a coactive neuro-fuzzy inference system (CANFIS) to predict plasma PTH concentrations in hemodialysis patients. The CANFIS was constructed with clinical parameters (patient age, plasma albumin, calcium, phosphorus, alkaline phosphatase, and calcium-phosphorus product) from a cohort of hemodialysis patients, and plasma PTH concentration measured by radioimmunoassay (RIA) was the supervised outcome. The accuracy of the CANFIS was prospectively compared with RIA in another hospital. Plasma PTH concentrations measured by RIA and predicted by CANFIS were 179.04 +/- 38.18 ng/l and 179.34 +/- 37.76 ng/l, respectively (p = 0.15). The CANFIS was able to precisely estimate plasma PTH concentrations in hemodialysis patients. These results suggest that the neuro-fuzzy technology, based on limited clinical parameters, is an excellent alternative to RIA for accurately predicting plasma PTH concentration in hemodialysis patients.

Osteoporosis is an essential index of health and economics in every country. Recognizing asymptomatic elderly population with high risks of osteoporosis remains a difficult challenge. For this purpose, we developed and validated an artificial neural network (ANN) to identify the osteoporotic subjects in the elderly. The study population consisted of 1403 elderly adults (mean age 63.50 +/- 0.24 years ranged from 50 to 91 years old, 157 male and 1246 female) randomly selected into 3 sets, 703 participants in training set, 350 participants in selection set, and the remaining 350 participants in test set. The input variables included demographic characteristics, anthropometric measurements, and clinical data. The outcome variable was dichotomous, either non-osteoporotic (T-score of greater than -2.5) or osteoporotic (T-score of -2.5 or less) groups classified by the measurement from dual energy X-ray absorptiometry. ANN was constructed with data from training and selection sets and validated in test set whose outcome variable was unknown to the network. The performance of ANN was evaluated by discrimination and calibration simultaneously. After training processes, the final best ANN was a multilayer perceptron network which determined seven input variables (gender, age, weight, height, body mass index, postmenopausal status, and coffee consumption) as significant features. The discriminatory power of ANN for test set was excellent (area under receiver operating characteristics curve = 0.82 +/- 0.03). ANN also had statistically good fit represented by statistically insignificant Hosmer-Lemeshow statistic (p = 0.24). These results suggested that our final ANN concurrently had good discriminatory power and good-fit calibration. ANN can be used as a promising tool for the elderly to stratify high risk subjects into osteoporotic group.

To the Editor: Researchers increasingly investigate artificial neural networks as a tool for individualized prediction in clinical medicine. A recent article by Oates et al.1 in Kidney International, concluded that an artificial neural network could identify significant urinary protein spots for predicting class and chronicity in patients with lupus nephritis. However, only the discrimination statistic was used. Measurement of the calibration statistic, a key step to evaluate the goodness-of-fit reliability for neural networks was ignored. Without both statistics, readers cannot recognize whether the model is truly applicable.

Hypokalemic paralysis is a less recognized but reversible disorder in elderly patients. This report describes two elderly Chinese males (age 74 and 78 years) who had progressive muscle weakness and eventually paralysis. Physical examination showed symmetrical flaccid paralysis of extremities. Both had the major biochemical abnormality of profound hypokalemia (1.4 and 1.8 mmol/L) accompanied by high urine K+ excretion and hyperchloremic metabolic acidosis. A positive urine anion gap and alkaline urine pointed to the diagnosis of distal renal tubular acidosis. Large doses of potassium chloride supplementation were required to restore muscle strength. Pertinent investigations, including elevated titers of antinuclear antibody and rheumatoid factor, positive anti-Ro antibody, low serum C3 and C4 levels, and delayed saliva excretion on salivary scintigraphy suggested Sjogren syndrome. Despite the lack of sicca syndrome at the initial presentation, both had development of typical sicca syndrome and positive Schirmer test at the 5-month and 1-year follow-up, respectively. Potassium citrate supplement and prednisolone therapy completely corrected the hypokalemia and metabolic acidosis. Extraglandular involvement with distal renal tubular acidosis preceding the typical sicca syndrome may induce hypokalemic paralysis and unveil Sjogren syndrome in elderly males.

Hyperkalemia is a less-recognized life-threatening cause of paralysis. We describe a 38-year-old uremic man on regular hemodialysis (HD) without interruption who suffered from muscle weakness progressing to ascending symmetric paralysis, and inability to masticate. Physical examination revealed flaccid paralysis with areflexia of the four limbs. Computed tomography of the brain and cervical spine did not demonstrate any organic lesions. Laboratory investigations revealed serum K+ 8.1 mmol/L, urea nitrogen 32 mmol/L, creatinine 919 micromol/L. Of note, electrocardiography (ECG) did not show typical features of hyperkalemia. Emergent HD with low K+ dialysate (1.0 mmol/L) rapidly normalized serum K+ (4.7 mmol/L) and reversed all neuromuscular symptoms within one hour. Upon reviewing his food and medication history, he admitted drinking 750 ml of raw coconut juice per day (K+ concentration 44.3 mmol/L) to quench his thirst for three consecutive days. Hyperkalemia should be born in mind in the differential diagnosis of acute paralysis despite no ECG changes. Hidden sources of K+ intake, such as coconut juice, should not be overlooked, especially in patients with impaired renal function.

We read with interest the research article by Bigi et al. [1], and praise their achievement to build two machine learning models, artificial neural network and Bayesian measure of how well a model to recognize subjects correctly as two different classes. From the perspective of goodnessof-fit, calibration evaluates the degree of correspondence between the estimated probabilities produced by a model and the actual observation. classifier, and compare their performance for classifying Common assessments used in discrimination for predicpredischarge risks in patients with uncomplicated myocardial infarction on the basis of exercise electrocardiography and pharmacological stress echocardiography. In the field of machine learning, artificial neural network tive classification include sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios for positive and negative tests, and area under the receiver– operating characteristics curve [3]. In contrast, although model is an artificial intelligence composed of individual nonlinear processing elements arranged in highly intercon

Background: Estimating total body water (TBW) is crucial in determining dry weight and dialytic dose for hemodialysis patients. Several anthropometric equations have been used to predict TBW, but a more accurate method is needed. We developed an artificial neural network (ANN) to predict TBW in hemodialysis patients. Methods: Demographic data, anthropometric measurements, and multifrequency bioelectrical impedance analysis (MF-BIA) were investigated in 54 patients. TBW measured by MF-BIA (TBW-BIA) was the reference. The predictive value of TBW based on ANN and five anthropometric equations (58% of actual body weight, Watson formula, Hume formula, Chertow formula, and Lee formula) was evaluated. Results: Predictive TBW values derived from anthropometric equations were significantly higher than TBW-BIA (31.341 ± 6.033 liters). The only non-significant difference was between TBW-ANN (31.468 ± 5.301 liters) and TBW-BIA (p = 0.639). ANN had the strongest Pearson’s correlation coefficient (0.911) and smallest root mean square error (2.480); its peak centered most closely to zero with the shortest tails in an empirical cumulative distribution plot when compared with the other five equations. Conclusion: ANN could surpass traditional anthropometric equations and serve as a feasible alternative method of TBW estimation for chronic hemodialysis patients.

Superparamagnetic nanoparticles have been widely utilized for in vivo or in vitro biomedical applications. Knowledge on the distribution of injected particles in organs is necessary to gain access to diagnosis or therapeutics. Thus, an in vivo study on the bio-distribution of the directly Tc-99m-labeled ferrite nanoparticles which were intravenously injected into tail vein of Wistar rats is performed. The dynamic bio-distribution was monitored by gamma camera. The scintigrams show that the injected dose are taken up by liver and lung. From dynamic scintigraphic image, it is observed that the uptake of particles by the organ is very fast and completed within first few minutes after intravenous injection. To investigate to what extent the Tc-99m labeled ferrite beads can be further conjugated with therapeutic drug, poly(ethylene glycol) (PEG) and two types of herb medicines, i.e. the Gentiana comnination and Trionyx sinensis with a function for chronic hepatitis, were sequentially conjugated with the ferrite adio-beads. It is demonstrated that the relative radioactivity of liver compared to that by lung and heart is lowered by the PEG modification. We also have performed in vivo study by applying the commercially available Nd-Fe-B magnet onto the site before intravenous injection into rat. The result implies that the directly Tc-99m labeled ferrite nanoparticles, conjugated with biocompatible medicals, may implicate for diagnostic and therapeutic applications.

Y-C Chen, Y-C Su, J-E Tzeng, C-K Wei, J-S Chiu, C-W Lin and Y-F Wang Division of Nephrology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan; Division of Hematology-Oncology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan; Department of Medicine, Tzu Chi University, Hualien, Taiwan; Department of Pathology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan; Department of General Surgery, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan; Department of Nuclear Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan and Department of Medical Imaging, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan

A 31-year-old man underwent a whole-body F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) scan for cancer screening. There was no history of diabetes, thyroid disease, or noticeable exercise before imaging. The results demonstrated diffusely increased uptake of F-18 FDG in the thyroid and thymus. In addition, there was symmetrically increased uptake of F-18 FDG in skeletal muscles, especially in the psoas and limb muscles. The concurrent appearance of these characteristics led to a diagnosis of Graves' disease.

Pier Giuseppe Agostoni, Milano Marina Aiello, Parma Nicolino Ambrosino, Gussago Eleftherios Anevlavis, Nea Ionia Veena B. Antony, Indianapolis, Ind. Lorenzo Appendini, Veruno Hormoz Ashtyani, Hackensack, N.J. I. Azziz, Edmunds Philip Bardin, Clayton, Melbourne Harry Bassaris, Patra Eric Bateman, Groote Schuur, Cape Town Robert P. Baughman, Cincinnati, Ohio Egmont Baumgartner, Hall, Tirol F. Xaver Baur, Hamburg Robert Berent, Wels Sten Erik Bergstrom, Huddinge Andrea Bianco, Napoli Sebastiano Bianco, Milano Roland Bittner, Berlin Francesco Blasi, Milano Annette Boehler, Zurich Thomas Boehm, Zurich Josef R.M. Bolitschek, Linz T. Bombeli, Zurich Louis-Philippe Boulet, Sainte-Foy Henri Bounameaux, Geneve Demosthenes E. Bouros, Athens Homer A. Boushey, San Francisco, Calif. Lennart Braback, Sundsvall Thomas Brack, Zurich Aidan Bradford, Dublin Christian Brambilla, Grenoble Antonio Braschi, Pavia Otto M. Braun, Horn O. Brandli, Faltigberg Vita Brusasco, Genova Martin H. Brutsche, Basel Jean-Luc Burgaud, Sophia Antipolis Andrew Bush, London Cecilia Calabrese, Napoli Philippe Camus, Dijon Pier Aldo Canessa, Sarzana, La Spezia Laura Carrozzi, Pisa Antonio Castagnaro, Mantova Sergio Cavaliere, Brescia M. Cazzola, Napoli I. Cerveri, Pavia Pascal Chanez, Montpellier Neil S. Cherniack, Newark, N.J. Alfredo Chetta, Parma Gianfranco Chiari, Parma Luke Clancy, Dublin Enrico Clini, Gaiato dei Pavullo Henri Colt, La Jolla, Calif. J.H. Coote, Birmingham Giuseppe M. Corbo, Roma Antonio Corrado, Firenze Paolo Coruzzi, Parma U. Costabel, Essen J. Costello, London Nunzio Crimi, Catania Isidor Dab, Bruxelles Roberto Dal Negro, Bussolengo Filiberto Dalmasso, Torino Peter Dalquen, Basel Peter Davies, Liverpool Fernando De Benedetto, Chieti Francesco de Blasio, Arco Felice Marc Decramer, Leuven P.N. Richard Dekhuijzen, Nijmegen Jose Pablo Diaz Jimenez, Barcelona Robert Dinwiddie, London Peter Dorow, Berlin Keith Dorrington, Oxford Roberto Duranti, Firenze Michael Dusmet, London J. Eckmayr, Wels B. Emmerich, Munchen Armin Ernst, Boston, Mass. Santiago Ewig, Bonn H. Fabel, Hannover A. Fairfax, Stafford Franco Falcone, Bologna Rudolf Ferlinz, Bad Gastein Jean-William Fitting, Lausanne Pierre Fournel, St. Etienne Lutz Freitag, Hemer Dimitris Georgopoulos, Heraklion Vassilis Georgoulias, Heraklion Helen Giamarelou, Marousi, Athens Simon Godfrey, Jerusalem A. Greening, Edinburgh Paul Haber, Wien Dean Handley, Marlborough, Mass. Patricia L. Haslam, London W. Heindl, Wien Arthur Helbling, Bern Bill Hesselmar, West Perth Richard Hodder, Ottawa J.C. Hogg, Vancouver Rudolf Maria Huber, Munchen Gerard Huchon, Paris David W. Hudgel, Detroit, Mich. Stasia Jastrzembski, Newark, N.J. Amal Jubran, Maywood, Ill. Frank Kanniess, Grosshansdorf Jack Kastelik, Cottingham, East Yorkshire Philipp Kaufmann, Zurich Roland Keller, Aarau Frank Kelly, London Paul Kemp, Leeds Ok Hwa Kim, Kyonggi-do Carl M. Kirsch, San Jose, Calif. Nikolaus Konietzko, Essen D. Kohler, Schmallenberg-Grafschaft Richard Kraemer, Bern Claus Kroegel, Jena Friedrich Kummer, Wien Boris Lams, London Irene Lang, Wien Didier Lardinois, Zurich R. Lazor, Geneve Ph. Leuenberger, Lausanne Brian Lipworth, Dundee H. Lode, Berlin Stelios Loukides, Athens Maurizio Luisetti, Pavia Piero Maestrelli, Padova H. Magnussen, Grosshansdorf Katerina Malagari, Papagou, Athens Carlo Manca, Parma Milan Marel, Praha Charles-Hugo Marquette, Lille C. Marriott, London Praveen N. Mathur, Indianapolis, Ind. Heinrich Matthys, Freiburg/Br. Harald Mauch, Berlin Thomas Meisl, Wien Giovanni Migliori, Tradale M. Miniati, Pisa Anna Maria Moretti, Bari A.H. Morice, Cottingham Gianna Moscato, Pavia Michael Rolf Mueller, Wien