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Objective The combined effects of individual and neighborhood socioeconomic status (SES) on survival rates of patients with Alzheimer's disease (AD) remain unclear. Design Retrospective cohort study. Setting National Health Insurance Bureau of Taiwan data (2003–2012). Participants Patients with AD. Measurements The authors aimed to analyze the effects of neighborhood and individual SES on the 5-year survival rates of patients with AD. The author defined individual and neighborhood SES based on income-related insurance payment amounts and residence in advantaged versus disadvantaged areas and compared survival rates using the Cox proportional hazards model after adjusting for risk factors. Results A total of 1,754 patients with AD were identified. Each patient was followed for 5 years or censored. The 5-year overall survival rates were worst for those with a low individual SES in a disadvantaged area. After adjustment for sex, age, and comorbidities, patients with a low individual SES living in disadvantaged areas had the worse survival rate than those with a high SES (hazard ratio: 2.19; 95% confidence interval [CI]: 1.53–3.13). In contrast, after the adjustment for characteristics, patients with a high individual SES in disadvantaged areas had a similar mortality rate to those with a high individual SES in advantaged areas (hazard ratio: 0.93; 95% CI: 0.64–1.35). Conclusion Despite universal health coverage, patients with AD and a low individual SES in disadvantaged areas exhibited the worst survival rate. The socioeconomic survival gradient among patients with AD in Taiwan may result from differences in major attributes of individual and neighborhood SES.

Background Type 2 diabetes mellitus is common in patients undergoing dialysis. However, the association between anti-diabetic drug use and survival outcomes is rarely discussed. We aimed to investigate whether continued anti-diabetic medication use affects the survival of diabetic dialysis patients and whether different hypoglycemic drug use influences prognosis. Methods Using a nationwide database, we enrolled patients with incident end-stage renal disease under maintenance dialysis during 2011–2015 into the pre-existing diabetes dialysis (PDD), incident diabetes after dialysis (IDD), and non-diabetic dialysis (NDD) groups. The PDD group was further subclassified into patients who continued (PDD-M) and discontinued (PDD-NM) anti-diabetic drug use after dialysis. Results A total of 5249 dialysis patients were examined. The PDD-NM group displayed a significantly higher mortality rate than the IDD, PDD-M, and NDD groups (log-rank test P Conclusions For dialysis patients with diabetes, continuous administration of anti-diabetic drugs after dialysis and choice of medication may affect outcomes.

We investigated the preventive and risk factors of rapid cognitive decline in patients with Alzheimer’s disease (AD). Using the Chang Gung Research Database (CGRD), we enrolled patients with AD aged over 65 years between 1 January 2001 and 30 May 2019, and followed up for at least two years. Rapid cognitive decline was defined by a Mini-Mental State Examination (MMSE) score decline of ≥4 in 2 years. A longer prescription of acetylcholinesterase inhibitors (AChEIs) was defined as 22 months based on the median treatment duration of the cohorts. The Cox proportional hazards regression model adjusted for age, sex, medication, and physical comorbidities was used to examine the candidate risk and protective factors. We analyzed data from 3846 patients with AD (1503 men, 2343 women) with a mean age and percentage of females of 77.8 ± 6.2 years and 60.9%, respectively. The mean duration of patients with AD receiving AChEIs was 658.7 ± 21.9 days. In general, 310 patients with AD showed a rapid cognitive decline, accounting for 8.1%. Treatment of a consecutive AChEI prescription for &gt, 22 months in patients with AD was a protective factor against rapid cognitive decline (adjusted hazard ratio (aHR) = 0.41, 95% confidence interval (CI) = 0.33–0.52, p &lt, 0.001). Patients with AD aged &gt, 85 years (aHR = 0.53, 95% CI = 0.36–0.79, p &lt, 0.01) and aged 75–85 years (aHR = 0.73, 95% CI = 0.57–0.93, p &lt, 0.05) had a significantly lower risk of rapid cognitive decline than those aged 65–75 years. Additionally, patients with mild and moderate AD (clinical dementia rating (CDR = 1, aHR = 1.61, 95% CI = 1.26–2.07, p &lt, 0.001, CDR = 2, aHR = 2.64, 95% CI = 1.90–3.65, p &lt, 0.001) were more likely to have rapid cognitive decline than those with early AD (CDR = 0.5). Sex, medication with different types of AChEIs, and physical comorbidities were not associated with rapid cognitive decline. These findings indicate that it is important to maintain longer consecutive AChEI prescriptions in patients with AD to prevent cognitive decline.

Family caregivers play an increasingly critical role in cancer patients' symptom management as the number of cancer patients receiving home care grows. However, there is a lack of research measuring the impact of the family caregivers' hesitancy to use analgesics on analgesic adherence and the resulting influence on patient pain intensity.To examine whether family caregivers' hesitancy to use analgesics is a mediator that influences patient adherence and investigate how analgesic regimen adherence affects pain intensity.This study used a cross-sectional and descriptive design. One hundred seventy-six patient-family caregiver dyads (N = 352) were recruited from one local hospital in southern Taiwan. Instruments included the Short Version of the Barriers Questionnaire-Taiwan, the Morisky Medication Adherence Measure-Taiwan, the Brief Pain Inventory-Chinese, and demographic and illness questionnaires. A one-way analysis of variance and post hoc comparisons were performed to assess the influence of analgesic regimen adherence on pain intensity. Sobel tests were used to examine mediating effects.Family caregivers' hesitancy to use analgesics was a significant mediator between patient barriers to use analgesics and patient analgesic regimen adherence (P0.0001). Patients with low and moderate adherence levels reported significantly higher levels of pain severity (F = 3.83, P0.05).This study showed that family caregivers' hesitancy to use analgesics was a significant mediator associated with their hesitancy to use analgesics and the patients' analgesic adherence. It is important for health care providers to consider family caregivers' hesitancy to use analgesics when attempting to improve adherence to pain management regimens in clinical practice.

Constipation is one of the most frequent non-motor problems in older adults. As constipation is commonly ignored by dementia patients, it is not usually reported on time. Constipation has a serious impact on the activity of daily living and quality of life in dementia patients. The relationships between constipation, demographic variables, and the nutritional status of patients with dementia remain unknown. This study aimed to assess the possible factors associated with constipation. This cross-sectional study was conducted at the Kaohsiung Chang Gung Memorial Hospital from January to November 2019. This hospital is a medical center and the main referral hospital of southern Taiwan, serving 3 million inhabitants. In total, 119 patients with dementia were evaluated using the Rome III diagnostic criteria for functional constipation. There were 30 patients with dementia included in the constipation group and 89 patients with dementia included in the no constipation group. Mini-Nutritional Assessment and 3-day diet diary records were employed. The clinical dementia rating score was used to evaluate the severity of dementia in patients of the outpatient clinic. Approximately 25.2% of dementia patients had constipation. Patients in the dementia with constipation group were older, had severer dementia, and displayed a lower water intake. After multivariable adjustment, low liquid consumption was the predictor of constipation among patients with dementia. The findings support the clinical recommendations to treat constipation with an increased liquid intake, but not exercise, in dementia patients.

Background The 2019 novel coronavirus disease pandemic (COVID-19) is one of the most serious health risks facing the global population. Teachers’ responses are important in the management of the outbreak in schools. The purpose of this study is to examine teachers’ risk perception, self-efficacy, response efficacy, and approach to disease prevention during the COVID-19 outbreak in Taiwan. Methods A descriptive, cross-sectional online survey was completed by 344 teachers across four levels of education. Pearson correlations between major variables were calculated. General linear model with a posthoc test was used to estimate the least squares means for each level of the independent variables and test the mean differences between the response scores. Results The teachers with a higher risk perception showed a stronger adoption of disease prevention measures, but they also showed lower self-efficacy. In addition, teachers with higher self-efficacy had higher response efficiency. Female teachers had relatively stronger adoption of disease prevention measures than their male colleagues, and age was associated with a 0.040 point increase in adoption scores. Elementary school teachers were significantly stronger in this regard than teachers at junior high schools, high schools and universities in terms of behavior scores. Conclusions High implementation rate of Taiwanese teachers’ disease prevention measures came from their higher risk perceptions. Among them, older female teachers, especially those who teach at elementary schools, are key to implementing disease prevention measures.

Ketamine-associated diseases have been increasing with the rise in ketamine abuse. Ketamine-associated uropathy is one of the most common complications. We investigated the effects of ketamine-associated uropathy on renal health and determined predictors of renal function decline in chronic ketamine abusers. This retrospective cohort study analyzed 51 patients (22 with ketamine-associated hydronephrosis and 29 with ketamine cystitis) from Kaohsiung Veterans General Hospital in Taiwan. Primary renal outcome was end-stage renal disease or estimated glomerular filtration rate decline &gt, 30% from baseline. Compared with the ketamine cystitis group, the hydronephrosis group had lower initial and final estimated glomerular filtration rates and higher alkaline phosphatase and gamma-glutamyl transferase levels (p &lt, 0.05). Elevated cholestatic liver enzyme levels correlated with renal dysfunction in ketamine-associated uropathy. The hydronephrosis group had a higher proportion of patients reaching endpoints than the ketamine cystitis group (50% and 7%, respectively, p &lt, 0.001). After adjusting for age, sex, and initial serum creatinine level, hydronephrosis remained an independent risk factor for renal function deterioration. Ketamine-associated hydronephrosis was a poor renal outcome and strong predictor of renal function decline in chronic ketamine abusers. Elevated cholestatic liver enzyme levels correlated with the severity of ketamine-associated uropathy. Ultrasonography screening of these high-risk groups and regular renal function follow-ups are necessary.

Medial vascular calcification has emerged as a key factor contributing to cardiovascular mortality in patients with chronic kidney disease (CKD). Vascular smooth muscle cells (VSMCs) with osteogenic transdifferentiation play a role in vascular calcification. Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase inhibitors reduce reactive oxygen species (ROS) production and calcified-medium–induced calcification of VSMCs. This study investigates the effects of dextromethorphan (DXM), an NADPH oxidase inhibitor, on vascular calcification. We used in vitro and in vivo studies to evaluate the effect of DXM on artery changes in the presence of hyperphosphatemia. The anti-vascular calcification effect of DXM was tested in adenine-fed Wistar rats. High-phosphate medium induced ROS production and calcification of VSMCs. DXM significantly attenuated the increase in ROS production, the decrease in ATP, and mitochondria membrane potential during the calcified-medium–induced VSMC calcification process (p &lt, 0.05). The protective effect of DXM in calcified-medium–induced VSMC calcification was not further increased by NADPH oxidase inhibitors, indicating that NADPH oxidase mediates the effect of DXM. Furthermore, DXM decreased aortic calcification in Wistar rats with CKD. Our results suggest that treatment with DXM can attenuate vascular oxidative stress and ameliorate vascular calcification.

Summary Purpose The purpose of this study was to understand the situation of diabetes patients receiving examinations for diabetes complications and to explore the factors influencing their intention to receive examinations for diabetes complications. Methods A cross-sectional study was performed that included 251 diabetes patients who visited outpatient clinics in Southern Taiwan. A survey using a self-administered questionnaire was conducted from October 2015 to January 2016. The questionnaire included items on demographic characteristics, perceived susceptibility to diabetes complications, perceived seriousness of diabetes complications, perceived benefits of taking action to receive diabetes complication examinations, perceived barriers to taking action to receive diabetes complication examinations, and the intention to receive diabetes complication examinations. The data were analyzed using regression analysis. Results The percentage of participants who received fundus, foot, and kidney examinations was 67.7%, 61.4%, and 73.3%, respectively. Every point increase on the perceived barriers to taking action to receive diabetes complication examinations scale increased the intention to receive a foot examination in the following year by 0.91 times ( p =.002), and every point increase on the perceived susceptibility to diabetes complications scale increased the intention to receive a kidney examination in the following year by 1.19 times ( p =.045). Conclusions Nurses should shoulder the responsibility to increase patients' intention to receive examination of diabetes complications. The results of this study can be used to promote nurses' care efficacy in preventing diabetes complications. They can also provide medical institutions with information to establish prevention and control policies for diabetes complications.

Background Patients with end-stage renal disease have a higher risk of death from cardiovascular events, which can be mainly attributed to coronary artery calcification (CAC). Wnt signaling is involved in vascular development and may play a role in vascular calcification. This study aimed to evaluate CAC prevalence in patients on dialysis with severe secondary hyperparathyroidism (SHPT) and identify CAC risk factors. Methods The study is a retrospective analysis of the severe hyperparathyroidism registration study that prospectively recruited patients on dialysis with severe SHPT who were candidates for parathyroidectomy, from October 2013 to May 2015. CAC and bone mineral density (BMD) were measured. Demographic and clinical data including calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone, Dickkopf-related protein 1 (DKK1), and sclerostin levels were analyzed. CAC scores were reported in Agatston units (AU). Results A total of 61 patients were included in this study. No CAC, mild CAC (100 AU), and severe CAC (>400 AU) were observed in 4.9%, 11.4%, 14.8%, and 68.9% of patients, respectively. DKK1 and sclerostin were not associated with CAC. In univariate analysis, CAC was significantly correlated with age, sex (male), total cholesterol, and intravenous pulse calcitriol (p0.05). In multivariate analysis, the stepwise forward multiple linear regression revealed that CAC was associated with age, male sex and intravenous pulse calcitriol (p

Purpose This study aimed to develop a quantitative dry cupping system that can monitor negative pressure attenuation and soft tissue pull-up during cupping to quantify soft tissue compliance. Methods Baseball players with myofascial pain syndrome were recruited to validate the benefits of cupping therapy. Nine of 40 baseball players on the same team were diagnosed with trapezius myofascial pain syndrome; another nine players from the same team were recruited as controls. All participants received cupping with a negative pressure of 400 mmHg for 15 minutes each time, twice a week, for 4 weeks. Subjective perception was investigated using upper extremity function questionnaires, and soft tissue compliance was quantified objectively by the system. Results During the 15-minute cupping procedure, pressure attenuation in the normal group was significantly greater than that in the myofascial group (p = 0.017). The soft tissue compliance in the normal group was significantly higher than that in the myofascial group (p = 0.050). Moreover, a 4-week cupping intervention resulted in an obvious increase in soft tissue lift in the myofascial pain group (p = 0.027), although there was no statistical difference in the improvement of soft tissue compliance. Shoulder (p = 0.023) and upper extremity function (p = 0.008) were significantly improved in both groups, but there was no significant difference between the two groups. Conclusion This quantitative cupping monitoring system could immediately assess tissue compliance and facilitate the improvement of soft tissues after cupping therapy. Hence, it can be used in athletes to improve their functional recovery and maintain soft tissues health during the off-season period.

The current absence of a disease-modifying treatment for Alzheimer disease highlights the necessity for the benefits of nonpharmacological approaches. We aimed to investigate the effect of exercise in older patients with Alzheimer dementia. This is an observational, prospective cohort study in medical center. Eighty older patients with Alzheimer dementia, including 54 with mild dementia and 26 with moderate dementia, were followed up over 2 years. Patients were divided into exercise and no-exercise groups according to their weekly exercise habit. Mini-Mental State Examination (MMSE), clinical dementia rating (CDR), and senior fitness test were checked initially. We defined death and unexpected hospitalization as the outcomes. Age, sex, education years, and MMSE showed no significant differences between the groups (P > .05) in all patients. All the patients of the exercise group had significantly better left upper body strength, higher aerobic endurance, and left and right balance maintenance time than those of the no-exercise group (P .05). The exercise group had significantly better lower body strength, left upper body strength, aerobic endurance, right upper body flexibility, lower body flexibility, balance maintenance, and agility than the no-exercise group in patients with mild dementia (P

Background Patients with renal infarction are vulnerable to thromboembolic complications with poor outcomes. There is limited report concerning the effect of anti-coagulant therapy in this population. Aim To assess the impact of anti-coagulant therapy on outcomes in patients with renal infarction. Design A retrospective cohort study of 101 renal infarction patients was conducted. Methods The association between anti-coagulant therapy, all-cause mortality, thromboembolic complications and renal outcome was evaluated. Demographic data and comorbidities were collected for analysis. Anti-coagulant therapy was treated as a time-dependent variable. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multi-variate Cox proportional hazards models. Results Fifty-seven (56.4%) patients with renal infarction received anti-coagulant therapy during the study period. The all-cause mortality rate was 7.56 per 100 patient-years. Age (HR 1.05, 95% CI 1.02-1.08) was a risk factor for all-cause mortality and anti-coagulant therapy was associated with a 92% improved survival (HR 0.08, 95% CI 0.02-0.34). Twelve (11.9%) thromboembolic events occurred following renal infarction. Current smoking (HR 10.37, 95% CI 1.60-67.43) had an adverse effect and anti-coagulant therapy (HR 0.14, 95% CI 0.03-0.73) had a significant protective impact on thromboembolic complications. There was no significant association between anti-coagulant therapy and long-term renal outcome in renal infarction patients including the monthly change in the estimated glomerular filtration rate (eGFR), the incidence of eGFR reduction of more than 50% and end-stage renal disease. Conclusion Anti-coagulant therapy in patients with renal infarction was associated with better survival and reduced thromboembolic complications.

Denosumab, a novel agent that inhibits osteoclasts, reduces the risk of fracture in patients with osteoporosis. However, worsening of hypophosphatemia and other symptoms may be induced by denosumab in patients with pre-existing hypophosphatemic osteomalacia. A 58-year-old man with hepatitis B presented with diffuse bone pain and muscle weakness. Denosumab was prescribed by the orthopedist according to documented low bone mass and spine compression fracture. After administering denosumab, the patient's bone pain worsened, and he later developed a right tibia stress fracture. His condition was diagnosed as adult-onset hypophosphatemic osteomalacia complicated by multiple bone fractures, which resulted from Fanconi syndrome with proximal tubulopathy due to tenofovir disoproxil fumarate (TDF) treatment for his hepatitis B. Denosumab use leads to aggressive hypophosphatemic osteomalacia and the complication of stress fractures, because of its effects on bone resorption. Physicians should be aware that in patients with chronic hepatitis B monoinfection who are administered TDF therapy, bone pain or fracture is possible but preventable by timely monitoring of serum phosphate levels. Denosumab should not be used in patients with untreated osteomalacia or vitamin D deficiency, as it may lead not only to hypocalcemia but also to hypophosphatemia in these patients.

Since wrist-joint position affects finger muscle length and grip strength, we studied its biomechanical relevance in prolonged handwriting. We recruited participants from young adults, aged 18–24, and separated them into control ( n = 22) and in-pain ( n = 18) groups, based whether or not they experience pain while handwriting. The participants then performed a writing task for 30 min on a computerized system which measured their wrist-joint angle and documented their handwriting kinematics. The in-pain group perceived more soreness and had a less-extended wrist joint, longer on-paper time, and slower stroke velocity compared to control group. There was no significant difference in handwriting speed and quality between the two groups. The wrist extension angle significantly correlated with perceived soreness. Ergonomic and biomechanical analyses provide important information about the handwriting process. Knowledge of pen tip movement kinematics and wrist-joint position can help occupational therapists plan treatment for individuals with handwriting induced pain.

Secondary hyperparathyroidism (SHPT) may worsen with administration of denosumab in chronic renal failure patients with low bone mass.This study aimed to evaluate the short-term effect of coadministration of calcitriol and denosumab on PTH secretion and parathyroid structure and the incidence of adverse effects in patients with SHPT and low bone mass.This was a 24-week, open-label study at Kaohsiung Veterans General Hospital in Kaohsiung, Taiwan.Dialysis patients with SHPT (intact parathyroid hormone [iPTH]800 pg/mL) and low bone mass (T score-2.5) were enrolled.Patients received denosumab (60 mg) and doses of calcitriol adjusted to achieve iPTH300 pg/mL.Parathyroid gland volume was assessed upon study initiation and completion. Serum calcium, phosphate, alkaline phosphatase, iPTH, and adverse effects were assessed at each visit (Day 7, 14, and 21, and every month thereafter).iPTH significantly decreased (mean decrease, 58.28 ± 6.12%) with denosumab/calcitriol administration (P.01) but not in the controls (patients not receiving denosumab). Parathyroid gland volume decreased (mean decrease, 21.98 ± 5.54%) with denosumab/calcitriol administration (P.01) and progressively increased (20.58 ± 4.48%) in the controls (P.05). Serum alkaline phosphatase and iPTH levels were significantly correlated to decreased iPTH and regression of parathyroid hyperplasia (P.05). The most common adverse events were hypocalcemia (33.33%) and respiratory tract infection (4.17%). Hypocalcemia rapidly resolved with calcium and calcitriol supplements.Denosumab allows for supra-physiologic doses of calcitriol resulting in decreased parathyroid secretion and parathyroid hyperplasia. Supervised administration and weekly laboratory and clinical monitoring of serum calcium are recommended during the first month to prevent hypocalcemia.

In this study, we aimed to provide a large-scale set of psycholinguistic norms for 3,314 traditional Chinese characters, along with their naming reaction times (RTs), collected from 140 Chinese speakers. The lexical and semantic variables in the database include frequency, regularity, familiarity, consistency, number of strokes, homophone density, semantic ambiguity rating, phonetic combinability, semantic combinability, and the number of disyllabic compound words formed by a character. Multiple regression analyses were conducted to examine the predictive powers of these variables for the naming RTs. The results demonstrated that these variables could account for a significant portion of variance (55.8 %) in the naming RTs. An additional multiple regression analysis was conducted to demonstrate the effects of consistency and character frequency. Overall, the regression results were consistent with the findings of previous studies on Chinese character naming. This database should be useful for research into Chinese language processing, Chinese education, or cross-linguistic comparisons. The database can be accessed via an online inquiry system (http://ball.ling.sinica.edu.tw/namingdatabase/index.html).

In Taiwan, the current status of family-witnessed resuscitation (FWR) and the factors associated with behavioural intentions to implement FWR have not been systematically examined using representative medical staff.We explored predictive factors for behavioural intentions to implement FWR among medical staff using constructs from the theory of planned behaviour.A survey of 1605 medical staff from five hospitals in southern Taiwan was conducted. Data were collected using a researcher-made questionnaire containing theory of planned behaviour constructs and demographic items. The dependent variable was intention to implement FWR, and the independent variables were three theory of planned behaviour constructs (attitudes, subjective norms, and perceived behavioural control) and the demographic characteristics. A generalized estimating equation was used to identify factors associated with the behavioural intentions.In total, 1122 valid questionnaires revealed that only 3.7% of participants advocated FWR policies. The construct scores for intention to implement FWR were 2.96 (on a five-point Likert scale), and the theory of planned behaviour constructs that significantly predicted intention to implement FWR were positive attitudes and subjective norms ( p0.001). Classification of hospitals ( p=0.018) and restrictive provisions for FWR ( p=0.004) were additional significant predictors of intention to implement FWR. Moreover, medical staff employed at regional hospitals demonstrated higher intentions, positive attitudes and subjective norms than did those employed at the medical centre.According to the findings of this study, it may be desirable for administrators to prioritize the implementation of the FWR policy in regional hospitals. We recommend affording the factors of positive attitudes and subjective norms high priority to improve the medical staff's behavioural intentions of FWR practice.

Summary Objective Suppressors of cytokine signalling (SOCS) proteins regulate cytokine responses and control immune balance. The objective of our study was to determine whether the expression of SOCS1 and its potential regulatory microRNAs (miRNAs) in leukocytes is correlated to the development of dengue haemorrhagic fever (DHF). Methods We performed a case–control study to investigate the SOCS1 and miRNA expression in leukocytes for patients with DF and DHF in a DENV-2 outbreak that occurred in Taiwan between 2002 and 2003. We performed reverse transcription polymerase chain reaction to evaluate the expression of SOCS1 and its regulatory miRNAs in mononuclear leukocytes obtained from patients with or without DHF. The reciprocal relationship between SOCS1 and miR-150 expression was validated in DENV-2-infected peripheral mononuclear cells (PBMCs). Results SOCS1 expression and lower IFN-γ level were significantly reduced in DHF patients, but not in patients with DF. Elevated SOCS1 and reduced miR-150 levels were detected 24 h after DENV-2 infection in PBMCs. Transfection of a miR-150 mimic into CD14 + cells infected with DENV-2 suppressed the induction of SOCS1 expression in a dose-dependent manner. Conclusion We demonstrate for the first time that augmented miR-150 expression with depressed SOCS1 expression in CD14 + cells are associated with the pathogenesis of DHF.

INTRODUCTION The purpose of this study was to investigate the feasibility of patient-centered teleconsultation for various cutaneous wounds by using store-and-forward technology. MATERIALS AND METHODS From July 2011 to November 2011, 53 patients with various wound conditions were enrolled in this study. The patients took their own wound images shortly before face-to-face consultations with a plastic surgeon, and the images were sent via e-mail to another 3 remote plastic surgeons along with brief medical information. All 4 surgeons completed a standard questionnaire individually, which addressed questions regarding the presence of wound conditions (gangrene, necrosis, erythema, and cellulitis/infection), as well as suggested clinical treatment with antibiotics and debridement. The evaluations were compared among the 3 remote surgeons as well as the remote and onsite surgeons. RESULTS The 53 wounds included in our study exhibited different causative mechanisms and locations on the body. The concordances between the remote and onsite surgeons were 92%, 79%, 83%, and 85% regarding the presence of gangrene, necrosis, erythema, and cellulitis/infection, respectively. The agreement rates regarding the treatment suggestion with antibiotic use and debridement between the remote surgeons and the onsite surgeon were both 83%. The remote surgeons reported high specificity, at least 84%, in all parameters of wound descriptions or treatment suggestions. CONCLUSIONS The patient-centered teleconsultation system based on store-and-forward technology is a feasible tool for wound management, and it shows promises in future clinical applications by decreasing clinic visits.

Introduction: Right-sided native endocarditis is a difficult case with fewer cardiac symptoms and fewer classic signs of cutaneous vascular lesions compared with left-sided endocarditis. Patient concerns: A 68-year-old Taiwanese man with a history of gouty arthritis, hyperlipidemia, and adrenal insufficiency presented to our ED and complained dyspnea and low back pain for 1 month. Diagnosis assessment: The PE showed bilateral crackles on chest auscultation and a palpable fluctuant mass over the anterior chest wall. The chest and abdominal CT scan showed multiple abscess formations involving pulmonary, sternal, and paraspinal areas. The TEE being performed and an oscillating mass over the anterior and septal leaflets of the tricuspid valve and moderate tricuspid regurgitation. Interventions: Only pharmacologic treatment without surgical interventions. Outcomes: Deceased, patient expired on day 4 after ED visit. Conclusion: This case arose as a sequela of staphylococcal endocarditis associated with persistent bacteremia and immunological dysregulation. The diagnosis of right-sided endocarditis is easily missing, multidisciplinary approach should be triggered as soon as possible, which might lead to a better outcome. Right-sided IE is still an important public health issue in southern Taiwan.

SummaryObjective Secondary hyperparathyroidism and its associated abnormalities in mineral metabolism and haemodynamic changes increase the cardiovascular risk in patients with end-stage renal disease (ESRD). Our objective was to determine the association of parathyroidectomy (PTX) with major cardiovascular events in nondiabetic dialysis patients with severe secondary hyperparathyroidism (SHPTH). Design and Patients We performed a cohort study with fifty-three nondiabetic ESRD patients who were treated with maintenance haemodialysis and who had intact parathyroid hormone (PTH) levels > 800 pg/ml. Participants received either only medical therapy or medical therapy and total PTX with autotransplantation for SHPTH. Measurements We evaluated the associations between PTX and major cardiovascular events including death, cerebrovascular accident and myocardial infarction. The biochemical and haemodynamic changes associated with PTX were measured. Results During the mean follow-up of 72 months, twenty-three patients received only medical treatment (medical group) while thirty patients underwent PTX in addition to medical treatment (PTX group). The two groups were comparable in respect of baseline characteristics. PTX group was found to be associated with a reduced incidence of major cardiovascular events (P = 0·021). A multiple Cox regression analysis showed that the variable significantly associated with major cardiovascular events was treatment modality (medical therapy vs medical therapy and parathyroidectomy, hazard ratio = 26·12, 95% CI = 1·30–526·27, P = 0·033). Blood pressure, haemoglobin, alkaline phosphatase, calcium, phosphate and calcium × phosphate product significantly improved after PTX. Conclusions PTX was associated with better cardiovascular outcome in nondiabetic dialysis patients with severe SHPTH.

Background & Objectives Cardiovascular disease remains the most common cause of death for patients on chronic dialysis. End stage renal disease patients undergoing dialysis imposed to reduce phosphorus intake, which likely contributes to development of vegetarian diet behaviors. Vegetarian diets are often lower in protein content, in contradiction to the recommendation that a high protein diet is followed by patients undergoing dialysis. The purpose of the study was to investigate the effects of a vegetarian diet on the nutritional and cardiovascular status of dialysis patients. Design, Setting, Participants, Measurements A study of 21 vegetarian dialysis patients and 42 age- and sex-matched non-vegetarian dialysis patients selected as controls was conducted in the Kaohsiung Veterans General Hospital. Brachial-ankle pulse wave velocity and biochemistry data including total homocysteine levels, serum lipid profiles, high-sensitivity C-reactive protein, vitamin D levels, albumin, and normalized protein catabolic rate were measured. Results Compared with the non-vegetarian control group, vegetarian subjects had lower body weight, body mass index, serum phosphate, blood urea nitrogen, serum creatinine, vitamin D, uric acid, albumin, and normalized protein catabolic rate (p < 0.05). The vegetarian group showed higher brachial-ankle pulse wave velocity than the non-vegetarian group (1926.95 ± 456.45 and 1684.82 ± 309.55 cm/sec, respectively, p < 0.05). After adjustment for age, albumin, pre-dialysis systolic blood pressure, and duration of dialysis, vegetarian diet remained an independent risk factor for brachial-ankle pulse wave velocity. Conclusions The present study revealed that patients on dialysis who follow vegetarian diets may experience subclinical protein malnutrition and vitamin D deficiency that could offset the beneficial cardiovascular effects of vegetarianism.

We have previously discovered that star fruit can induce oliguric acute renal failure. To investigate the mechanisms of star fruit-associated acute oxalate nephropathy, the nephrotoxic effect of star fruit was examined in both cellular experiments and animal models. We evaluated renal function, pathological changes in kidney tissues and apoptotic effects using terminal deoxynucleotidyl transferase nick-end labeling (TUNEL) assay in four groups of rats – a control group (CG), fed with tap water (1); a star fruit group (SG), fed with star fruit juice naturally containing 0.2 M oxalate (2); and oxalate groups (OxG), fed with 0.2 M (3) or 0.4 M (4) oxalate solution. The effects of both star fruit juice and oxalate on MDCK cells were also analyzed by flow cytometry. We found that the mean creatinine clearance was significantly lower in the SG, 0.2 M OxG and 0.4 M OxG. Dose-dependent apoptotic effects were evident from the TUNEL assay, and flow cytometry analysis of treated MDCK cells showed dose- and time-dependent effects. Our findings suggest that star fruit juice produces acute renal injury, not only through the obstructive effect of calcium oxalate crystals, but also by inducing apoptosis of renal epithelial cells, which may be caused by the levels of oxalate in the fruit.

To investigate the role of oxalate in star fruit neurotoxicity, rats were given star fruit or oxalate after a sham operation or modified five-sixths nephrectomy; namely, star fruit (SC) or oxalate (OxC) for sham-operated rats and star fruit (SNx), calcium gluconate treated star fruit juice (SCaNx), or oxalate (OxNx) for nephrectomized rats. After feedings, none of the rats in SC, OxC, and SCaNx groups developed movement disorders or died, while all rats in SNx group and OxNx group presented movement disorders and two rats in SNx group and four rats in OxNx group died within minute to hour after development of myoclonic jerk and/or tonic-clonic convulsion. The plasma oxalate levels rose significantly only in the SNx group and OxNx group that also presented clusters of generalized spike-waves in the electroencephalographic recordings. In conclusion, oxalate may play a key role in star fruit neurotoxicity in nephrectomized rats and probably in uremic patients.

Some patients with refractory peritoneal dialysis-related peritonitis continue to develop intra-abdominal complications despite removal of the peritoneal catheter. Repeated percutaneous drainage or open laparotomy is often required, and mortality is not uncommon. The benefits of pelvic drainage placement during catheter removal in decreasing these complications and interventions remain unproven.Forty-six patients with refractory peritonitis who underwent removal of a Tenckhoff catheter between 1991 and 2013 were reviewed retrospectively. Twelve patients had pelvic drainage using closed active suction devices during catheter removal (drainage group). The remaining 34 patients underwent catheter removal without drainage (non-drainage group). The outcomes measured were the development of intra-abdominal complications and the requirement for repeated percutaneous drainage or open laparotomy within 90 days after the catheter removal.Baseline characteristics were similar with the exception of a higher median number of previous peritonitis episodes in the drainage group compared with the non-drainage group (2 vs 0, P = 0.02). During the follow-up period, intra-abdominal complications occurred in 15 (44%) of 34 patients in the non-drainage group, compared with one (8%) of 12 patients in the drainage group (P = 0.03). Twelve (35%) patients in the non-drainage group required repeated percutaneous drainage or open laparotomy for management, compared with zero (0%) patients in the drainage group (P = 0.02). Drain tubes were removed at a median of 6 days (inter-quartile range: 5-10) without complications.In the management of refractory peritonitis, pelvic drainage during removal of dialysis catheter decreases the risk of subsequent intra-abdominal complications and invasive interventions.

Training that focuses on strength, balance, and endurance, the so-called combined exercise, can enhance physical function, including gait, according to a literature review. However, the effects of combined exercise on improving gait variability are limited. The objective of this study is to investigate the effects of 12 weeks of combined exercise comprised of resistance, endurance, and balance training on gait performance in older adults. Twenty-nine community-dwelling older adults were recruited and assigned to either the experimental group (n = 17) or the control group (n = 12). The 12-week intervention was a combined exercise program at 1 h per day and 3 days per week. The participants received an assessment for both a 6-min walk and gait during both habitual walking and fast walking conditions at pre-intervention and after 8 and 12 weeks of exercise. The 6-min walk was used to assess gait endurance. GAITRite was used to evaluate gait. An analysis of covariance with the pretest score as the covariate was used to determine the difference in each dependent variable between groups. The level of significance was set as p less than 0.05. Our results showed significant between-group effects in the 6-min walk and velocity, stride time, and stride length in both conditions after 8 weeks of exercise and significant between-group effects in the 6-min walk test and all selected gait parameters in both conditions after 12 weeks of exercise. Our findings demonstrate that a 12-week combined exercise program may positively affect gait endurance and gait performance including gait variability in habitual walking and fast walking conditions among older adults. The current study provides important evidence of short-term combined exercise effects on improvements in gait performance.

Aim Hyperkalemia increases the risk of sudden cardiac death (SCD) in hemodialysis patients. Our objective was to determine the association between administering low potassium dialysate to hyperkalemic hemodialysis patients and SCD. Methods We conducted a retrospective cohort study with patients undergoing maintenance hemodialysis from May 1, 2006, through December 31, 2013. The dialysate composition was adjusted over time according to monthly laboratory results. A 1.0 mEq/L potassium dialysate was applied in patients with predialysis hyperkalemia (>5.5 mEq/L) and was included as a time-dependent confounding factor. The clinical characteristics of enrolled patients, the incidence and timing of SCD and risk factors for all-cause mortality and SCD were analyzed. Results There were 312 patients on maintenance hemodialysis during the study period. One hundred and fifty-seven patients had been dialyzed against a 1.0 mEq/L potassium dialysate at least once. The rates of all-cause mortality and SCD were 48.17 and 20.74 per 1000 patient-years, respectively. A 1.12-fold increase in the risk of SCD in the 24-hour period starting with the hemodialysis procedure and a 1.36-fold increase in the 24 hours preceding a weekly cycle were found (p = 0.017). Multivariate Cox proportional hazards models showed that age, diabetes mellitus and predialysis hyperkalemia (>5.0 mEq/L) were significant predictors of all-cause mortality and SCD. Exposure to 1.0 mEq/L potassium dialysate, Kt/V, and serum albumin were independent protective factors against all-cause mortality. Only exposure to 1.0 mEq/L potassium dialysate significantly prevented SCD (hazard ratio = 0.33, 95% CI = 0.13–0.85). Conclusions Using low potassium dialysate in hyperkalemic hemodialysis patients may prevent SCD.

Lymphocytic hypophysitis may involve the pituitary gland and various hormonal abnormalities. A 72-year-old man presented with euvolemic hyponatremia caused by glucocorticoid deficiency. After glucocorticoid replacement, hypernatremia in the presence of dilute urine was found. Central diabetes insipidus (DI) was confirmed later by a significant increase in urine osmolality after vasopressin administration. Brain magnetic resonance imaging showed a pituitary mass and loss of hyperintense signal in the posterior pituitary gland on T1-weighted imaging. The patient underwent a transsphenoidal adenectomy, and pathological examination of dissected tissues showed a typical finding of lymphocytic hypophysitis. Two months after surgery, the patient's central DI had resolved sufficiently that 1-desamino-8- d -arginine vasopressin therapy was discontinued without polyuria. However, he was kept on glucocorticoid and levothyroxine therapy. In conclusion, lymphocytic hypophysitis may feature a concealed central DI caused by glucocorticoid deficiency-associated hyponatremia.

SummaryIt is known that thrombosis is a leading cause of vascular access failure and that the formation of thrombus requires platelets. The activation of platelets induces the increase in intracellular Ca2+ levels ([Ca2+]i) leading to aggregation and thrombosis. We compared the platelet [Ca2+]i before and after stimulation between the patients with and without easily occluded vascular access. Our study included two groups of hemodialysis patients. Group 1 consisted of 21 patients who had received chronic hemodialysis therapy for more than 6 months. They had had more than three events (including three) of vascular access failures during the past year. Group 2 consisted of 21 hemodialysis patients with age, sex, and diabetes mellitus matched who had never suffered from any event of vascular access failure. We measured the basal and stimulated platelet [Ca2+]i after stimulation with 1 U/ml thrombin, 1 µM arachidonic acid, 1 µM platelet activation factor (PAF), and 10 µM adenosine diphosphate (ADP), respectively. Our results showed that in Ca2+-containing media, there was no significant differences in the basal [Ca2+]i , but the maximal increases of [Ca2+]i of platelets were higher (p

Microscopic polyangiitis (MPA), Wegener's granulomatosis and Churg-Strauss syndrome are known as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Cerebrovascular diseases have been rarely reported to be associated with MPA. In this study, we reported a 72-year-old man with MPA showing an initial presentation of pontine infarction, mononeuropathy multiplex and progressively deteriorating renal function. He was diagnosed with MPA on the basis of increased myeloperoxidase-specific ANCA activity, mononeuritis multiplex and the findings of renal biopsy. After receiving an aggressive treatment consisting of plasma exchange, his neurological deficit dramatically improved. For stroke patients with acute nephritis, the possibility of ANCA vasculitis should be considered. Early diagnosis may improve the prognosis.

Background/Aim: Uremic patients are at an increased risk of being affected by tuberculosis (TB). Periodical tuberculin skin tests were suggested to detect TB-infected patients. These were replaced by chest radiographs in endemic areas like Taiwan. However, almost 50% of the TB incidence in dialysis patients was extrapulmonary. In this study, we tried to investigate the value of tuberculin tests in dialysis patients in endemic areas. Methods: The patients were recruited from our dialysis unit. Purified protein derivative (PPD) and control tests with antigens for Candida and toxoid were performed using the Mantoux method. PPD with >10-mm induration will be considered positive. Skin anergy meant that the indurations of all antigens were less than 5 mm. A follow-up was done 12 months after the tests. Results: A total of 177 patients were evaluated. Anergy was found in 40 patients (22.6%). A positive predictor of anergy was age >45 years (p = 0.03), while a negative predictor was prealbumin >20 mg/dl (p = 0.04). Fifty-three patients (30%) had positive PPD tests. Seven of the positive PPD patients (13.2%) developed active TB during the following years. Among the 40 patients with skin anergy, 6 (15%) were found to have active TB. Of the 48 patients (21.1%) with indurations of the PPD tests between 5 and 10 mm, none was found to have active TB. Conclusion: Although anergy will influence the sensitivity of PPD tests, these tests in combination with anergy tests could help to establish the diagnosis of TB in uremic patients, even in TB-endemic areas.

Arteriovenous fistula (AVF) is an uncommon but well-known complication of percutaneous renal biopsy. Most postbiopsy AVFs are asymptomatic and regress spontaneously; however, some AVFs result in hypertension, hematuria and renal insufficiency. Transplant renal artery stenosis (TRAS) is a potentially curable cause of posttransplant arterial hypertension, allograft dysfunction and graft loss. Whether postbiopsy AVF superimposed on TRAS also regresses spontaneously is unknown. The authors present a case of acute renal failure in a 56-year-old male renal allograft recipient with the combination of postbiopsy AVF and TRAS. At first, the authors performed percutaneous angioplasty with stent implantation for the TRAS, but the AVF gradually enlarged. Eighteen months later, the patient began to experience hypertension, and his serum creatinine level increased; he received transcatheter arterial embolization therapy for enlarged AVF, and his renal function returned to baseline level.

Denosumab is widely used for bone diseases with increased bone resorption. Its effectiveness in patients with severe secondary hyperparathyroidism on dialysis is unclear.This study aimed to evaluate the efficacy and safety of denosumab in patients with severe secondary hyperparathyroidism who are on dialysis.This 6-month prospective, open-labeled study evaluated 12 patients (five women, seven men; mean age 53.5 ± 3.8 y). All had intact PTH (iPTH;1000 pg/mL), low bone mass (T-score-1.0 SD), and bone pain and were poor surgical candidates. Serum calcium, phosphorus, alkaline phosphatase (AP), and iPTH levels were assessed at baseline and every month thereafter. Vertebral spine x-rays and bone mineral densities (BMDs) (lumbar spine and femoral neck) were assessed at the start and end of the study. All patients received denosumab (60 mg), calcitriol, phosphate binders, and dialysate calcium that were adjusted according to the biochemistry data.The BMD increased in both the femoral neck (mean increase 23.7% ± 4.0%) and lumbar spine (17.1% ± 2.6%) after 6 months. In the first month, most patients had increased iPTH levels, which dramatically decreased from 1702.1 ± 181.9 to 518.8 ± 126.8 pg/mL by the end of the study after increasing the calcitriol dose. All patients had significant decreases in AP, calcium × phosphorus, and bone pain. Changes in femoral neck BMD correlated only with AP and iPTH levels.Denosumab is effective in restoring bone mass and reducing bone pain in patients on dialysis with secondary hyperparathyroidism. It also allows for a more aggressive use of calcitriol to control hyperparathyroidism.

Intracellular recording was used to study the effects of eight opioid tetrapeptides with similar amino acid sequences, namely endomorphin-1 (Tyr-Pro-Trp-Phe-NH2), endomorphin-2 (Tyr-Pro-Phe-Phe-NH2), morphiceptin (Tyr-Pro-Phe-Pro-NH2), hemorphin-4 (Tyr-Pro-Trp-Thr), Tyr-MIF-1 (Tyr-Pro-Leu-Gly-NH2), Tyr-W-MIF-1 (Tyr-Pro-Trp-Gly-NH2), TAPS (Tyr-D-Arg-Phe-Sar) and DALDA (Tyr-D-Arg-Phe-Lys-NH2), on neurons of the rat locus coeruleus, using a submerged brain slice preparation. All the tetrapeptides inhibited the spontaneous firing of all neurons of the locus coeruleus tested. Higher concentrations also caused hyperpolarization of the neurons and a reduction in input resistance. These inhibitory effects were rapidly and completely reversed by CTAP (D-Phe-Cys-Tyr-D-Trp-Arg-Thr-Pen-Thr-NH2, a selective micro-opioid receptor antagonist). The IC50 of the opioid tetrapeptides, in terms of inhibition of spontaneous firing of locus coeruleus neurons, as compared to the concentrations which produced a 5-mV hyperpolarization (HC5 mV) were calculated, giving the same rank order of potency: TAPS (IC50 = 1.9 nM, HC5 mV = 3.4 nM) > endomorphin-1 (IC50 = 8.8 nM, HC5 mV = 22.1 nM) and endomorphin-2 (IC50 = 5.3 nM, HC5 mV = 16.1 nM)> DALDA (IC50 = 20 nM, HC5 mV = 143 nM) > morphiceptin (IC50 = 65 nM, HC5 mV = 335 nM) > Tyr-W-MIF-I (IC50 = 3.8 microM, HC5 mV = 6.7 microM) > hemorphin-4 (IC50 = 6.7 microM, HC5 mV = 36.9 microM) > Tyr-MIF-1 (IC50 = 37.5 microM, HC5 mV = 76.2 microM). Comparison of the ability of endomorphin-1 and endomorphin-2 to inhibit spontaneous firing based on single-cell recordings (n = 5) showed these two peptides to be equipotent. Based on these results, the structure-activity relationships of these opioid tetrapeptides are discussed herein.

Background: The objective of this study was to assess the impact of heparin concentration retained in temporary double-lumen catheters on bleeding risk. Methods: Activated partial thromboplastin time (aPTT) was measured in patients hemodialyzed via double-lumen catheters. Heparin solutions of 5,000 U/ml (group 1, n = 95) and 1,000 U/ml (group 2, n = 89) were randomly retained in catheters after placement and each hemodialysis (HD) session. Blood transfusion, bleeding episodes, and changes of hematocrit were recorded. Results: The aPTT at the beginning of HD or 10 min after heparin lock was significantly prolonged, which was more prominent in the 5,000 U/ml group, whereas the aPTT declined to baseline values at the end of HD or before the next dialysis session in both groups. Infection and occlusion rates were similar in both groups. More patients suffered from major bleeding and prominent decline of hematocrit in the 5,000 U/ml group. Conclusions: Low-dose heparin (1,000 U/ml) retention in double-lumen catheters for temporary HD maintains comparable catheter patency and might reduce the bleeding risk.

BACKGROUND/PURPOSE: Nurses in emergency departments are high-risk groups who are most likely to experience the offense of violent behaviors. In a comparison on the occurrence of verbal and physical abuses in emergency departments, this study aimed to analyze the correlation of staff properties and occupational conditions in an attempt to provide a reference on violence prevention. METHODS: Eleven hospitals in southern Taiwan were selected and a survey of 267 nurses was conducted. The results were analyzed by percentage, Pearsons chi2 test and logistic regression. RESULTS: The 236 valid questionnaires showed that nurses experienced significantly more verbal abuse (92%) than physical abuse (30%). The highest occurrence of verbal abuse was 49% in night shift, and the physical abuse was 44% in overnight shift. Long waiting (89%), difference in cognition (87%), and lack of communication (82%) were the common causes. The occurrences of verbal abuse and physical abuse were significantly correlated to less-informed (odds ratio [OR], 1.67 and 1.22, respectively) and basic-level nurses (OR, 2.30 and 1.34, respectively). In addition, younger age (OR, 2.80; p < 0.01) and single status (OR, 9.09; p

We performed a study to determine whether prophylactic hemodialysis reduces contrast nephropathy (CN) after coronary angiography in advanced renal failure patients.Pre-existing renal failure is the greatest risk factor for CN. Hemodialysis can effectively remove contrast media, but its effect upon preventing CN is still uncertain.Eighty-two patients with chronic renal failure, referred for coronary angiography, were assigned randomly to receive either normal saline intravenously and prophylactic hemodialysis (dialysis group; n = 42) or fluid supplement only (control group; n = 40).Prophylactic hemodialysis lessened the decrease in creatinine clearance within 72 h in the dialysis group (0.4 +/- 0.9 ml/min/1.73 m(2) vs. 2.2 +/- 2.8 ml/min/1.73 m(2); p0.001). Compared with the dialysis group, the serum creatinine concentrations in the control group were significantly higher at day 4 (6.3 +/- 2.3 mg/dl vs. 5.1 +/- 1.3 mg/dl; p = 0.010) and at peak level (6.7 +/- 2.7 mg/dl vs. 5.3 +/- 1.5 mg/dl; p = 0.005). Temporary renal replacement therapy was required in 35% of the control patients and in 2% of the dialysis group (p0.001). Thirteen percent of the control patients, but none of the dialysis patients, required long-term dialysis after discharge (p = 0.018). For the patients not requiring chronic dialysis, 13 patients in the control group (37%) and 2 in the dialysis group (5%) had an increase in serum creatinine concentration at discharge of more than 1 mg/dl from baseline (p0.001).Prophylactic hemodialysis is effective in improving renal outcome in chronic renal failure patients undergoing coronary angiography.

Bacteremia has been considered as a surrogate marker of severe infection in several infectious diseases. However, it remains uncertain whether the presence of bacteremia correlates with severe infection in patients with complicated acute pyelonephritis (APN).We performed a retrospective study to investigate the relationship between the presence of bacteremia and disease severity in complicated APN. To do this, we reviewed medical records from 128 patients diagnosed with complicated APN admitted to Kaohsiung Veterans General Hospital, Taiwan between January, 2003 and December, 2003. In our analysis, we compared clinical presentation, treatment response, and outcome in patients with and without bacteremia.Fifty-four of 128 patients (42%) were bacteremic. This group of patients presented more frequently with severe sepsis or septic shock (P0.001), compared with nonbacteremic patients. Other factors that correlated with the presence of bacteremia were older age, diabetes mellitus, more band forms in neutrophil cell counts, impaired renal function, and a lower level of serum albumin. Using a multivariate logistic regression analysis, we show that lower levels of serum albumin (odds ratio, 0.18; 95% CI, 0.05-0.65; P = 0.008) and presence of severe sepsis (odds ratio, 4.76; 95% CI, 1.43-15.84; P = 0.011) were independent factors associated with bacteremia. Following treatment, the bacteremic group took a longer time to become defervescent than the nonbacteremic group (5.1 +/- 2.3 vs. 4.2 +/- 1.6 days, P = 0.023). Also, the bacteremic group had a greater mean duration of intravenous antibiotics administration and longer hospital stays (P0.001). Multiple logistic regression analysis shows that non-Escherichia coli bacteremia, presence of urolithiasis or hydronephrosis, shorter duration of antibiotics administration, and being male were significantly associated with recurrence of urinary tract infection within 6 months.Bacteremia in cases of complicated APN indicates a severe disease, which is more likely to recur in patients with non-E coli bacteremia. Our study showed that bacteremia is indeed a useful clinical indicator of severe disease and, if found, should influence patient management. Therefore, we recommend that blood culture samples should be taken in all patients with complicated APN.

Intradialysis hypertension is a frustrating complication among hemodialysis (HD) patients. This study was conducted to investigate the physiological changes during intradialytic hypertension. The beat-to-beat continuous heart rate, hematocrit (Hct) changes during HD, serum levels of nitric oxide, plasma levels of catecholamine, renin, endothelin (ET-1), cardiac output (CO), and peripheral vascular resistance (PVR) were measured before and after HD in patients prone to develop intradialysis hypertension (n = 30) and from age, sex-matched control HD subjects (n = 30). It was found that the baseline values of Hct, serum levels of nitric oxide, plasma levels of catecholamine, renin, and ET-1, CO, PVR, and power index (low frequency/high frequency ratios) of heart rate variability were not significantly different between the patients and control subjects. In the hypertension-prone group, the plasma levels of catecholamine, renin, and the serial measurements of power index, did not show significant changes. However, the patients showed a significant elevation of systemic vascular resistance (56.8 +/- 9.2% vs 17.7 +/- 9.5; P0.05), ET-1 (510.9 +/- 43.3 vs 276.7 +/- 30.1 pg/ml; P0.05) and a significant decrease of nitric oxide (NO)/ET-1 balance (0.018 +/- 0.003 vs 0.034 +/- 0.005; P0.05) at the end of HD compared with the control patients. It was found that the physiological changes in intradialysis hypertension patients were characterized by inappropriately increased PVR through mechanisms that did not involve sympathetic stimulation or renin activation but might be related with altered NO/ET-1 balance.

We studied the clinical course of 26 systemic lupus erythematosus(SLE) patients who started regular dialysis at our hospital and whose stay exceeded a three-month duration in order to investigate the long-term prognosis in a Chinese cohort. Clinical and serological activities of lupus before and after dialysis were analysed. To compare the long-term survival rate, controls were set using 78 age-matched end-stage renal disease (ESRD) patients who did not have SLE or diabetes mellitus and entered the chronic dialysis program at a similar period with SLE dialysis patients. There was a significant decrease in clinical lupus activity after starting regular dialysis (P < 0.05); however, the serologicalactivity remained the same. The five-and ten-yearsurvivalrates were significantly lower in the SLE patients (73 and 38% in the SLE group versus 95 and 88% in the non-SLE group, P < 0.05). SLE patients had a 4.3-times higher risk of death than non-SLE patients (P < 0.05, 95% confidence interval,1.2-15.2). Also, the deceased SLE patients had persistent lower serum levels of complement 3. SLE patients with ESRD remain clinically quiescent despite persistent serological abnormalities and have a worse prognosis than other uremia patients in the Chinese population.

High vibration perception threshold and autonomic dysfunc- tion in hemodialysis patients with intradialysis hypotension. Background. Intradialysis hypotension is a common prob- lem among hemodialysis patients. Some studies have shown that autonomic neuropathy could be a major cause of intradialysis hypotension, whereas others have not. Furthermore, whether there are parallel changes in the autonomic nervous system and somatic nerves remains unclear. Methods. We investigated the autonomic and peripheral nervous functions of 12 chronic hemodialysis patients who suf- fered from intradialysis hypotension, and of 12 age- and sex- matched hemodialysis patients who had stable blood pressure during hemodialysis. We used spectral analysis of their heart rate variability and systemic vascular resistance to evaluate auto- nomic functions. Vibrameter and nerve conduction studies to assess peripheral nervous function were also performed. Low- frequency/high-frequency ratio power index was used as a sur- rogate of sympathovagal balance. Results. The power index rose progressively in the control group and reached significantly high levels at hour 4 compared to the basal values (3.7 0.5 vs. 2.1 0.3; P 0.05). However in the group prone to hypotension, the power index remained almost unchanged. In addition, their systemic vascular resis- tance was lower than that in the control group (13.7 1.8 vs. 22.3 2.6 Wood units; P 0.05). The vibration perception thresholds of the index finger and great toe were significantly higher in the group prone to hypotension (4.7 0.7 vs. 2.2 0.3 vibration units and 3.1 0.4 vs. 1.5 0.2 vibration units, respectively; both P 0.05). Conclusion. We found that more severe damage to auto- nomic and peripheral nervous system occurred in patients prone to hypotension.

Carambola (star fruit) has been reported to contain neurotoxins that cause convulsions, hiccups, or death in uremic patients, and prolong barbiturate-induced sleeping time in rats. The constituent responsible for these effects remains uncertain. Carambola contains a large quantity of oxalate, which can induce depression of cerebral function and seizures. This study was conducted to investigate the role of oxalate in carambola toxicity in rats.The effects on barbiturate-induced sleeping time and death caused by intraperitoneal administration of carambola juice were observed in Sprague-Dawley rats. To obtain a dose-dependent response curve and evaluate the lethal dose, rats were treated with serial amounts of pure carambola juice diluted with normal saline in a volume of 1:1. To test the role of oxalate in the neurotoxic effect of carambola, either 5.33 g/kg carambola after oxalate removal or 5.33 g/kg of pure carambola juice diluted with normal saline were administered intraperitoneally, while the control group was given normal saline before pentobarbital injection. The effects of carambola and oxalate-removed carambola on barbiturate-induced sleeping time were compared with those of saline. To assess the lethal effect of oxalate in carambola, we gave rats chemical oxalate at comparable concentrations to the oxalate content of carambola.Carambola juice administration prolonged barbiturate-induced sleeping time in a dose-dependent manner. The sleeping time of rats that received normal saline and 1.33 g/kg, 2.67 g/kg, 5.33 g/kg, and 10.67 g/kg of carambola juice were 66 +/- 16.6, 93.7 +/- 13.4, 113.3 +/- 11.4, 117.5 +/- 29.0, and 172.5 +/- 38.8 minutes, respectively. The three higher-dose groups had longer sleeping times than controls (p0.05 or 0.005). This effect was eliminated after the removal of oxalate from carambola juice. Four of eight rats in the 10.67-g/kg group and all rats in the 21.33 g/kg and chemical oxalate groups died after seizure. Lethal doses of carambola juice were rendered harmless by the oxalate removal procedure.Oxalate is a main constituent of carambola neurotoxicity. This finding suggests that patients with carambola intoxication should be treated for oxalate toxicosis.

In this study, we intend to establish a connection between star fruit and acute oxalate nephropathy and also investigate predisposing factors for its development. Male Sprague-Dawley rats of 180 to 200 g were assigned to four groups; namely, control, experimental, fasting, and water-deprivation groups. The former two groups were subjected to both fasting and water deprivation, whereas the latter two groups were subjected to either fasting or water deprivation, respectively. Except for tap water for controls, the remaining groups were administered 4 mL/100 g of body weight of sour star fruit juice with an oxalate concentration of 2.46 g/dL. After these procedures, serial measurement of serum creatinine levels and kidney pathological examination were performed. Peak serum creatinine levels in the control, experimental, fasting, and water-deprivation groups were 0.50 +/- 0.04, 1.46 +/- 0.26, 0.68 +/- 0.20, and 0.52 +/- 0.08 mg/dL, respectively. The experimental group had a greater peak serum creatinine level (P0.05). Mean serum creatinine levels of the experimental group days 0, 1, 2, 3, 4, and 5 were 0.43 +/- 0.03, 1.11 +/- 0.18, 1.31 +/- 0.27, 1.16 +/- 0.28, 0.8 +/- 0.26, and 0.82 +/- 0.28 mg/dL, respectively. Mean serum creatinine levels days 1 to 3 were greater than that day 0 (P0.05). Pearson's correlation analysis of peak serum creatinine level and kidney weight for the experimental group showed a significant correlation (R = 0.75; P0.05; n = 9). In addition to typical changes of oxalate nephropathy, kidney pathological examination showed many refractile oxalate crystals with all rainbow colors under polarized light microscopy in the experimental group. In conclusion, sour star fruit with abundant oxalate contents could cause acute oxalate nephropathy in rats under the conditions of fasting and water deprivation.

The action of propofol on the rat locus coeruleus was examined using intracellular recording from in vitro brain slice preparations. Concentrations of propofol between 3 and 300 microM were tested. At 100 microM, propofol completely inhibited the firing of all neurons tested (n=34); this was associated with a 5.7-mV hyperpolarization (range 0-16 mV, n=33) and a 35.6% reduction in input resistance (range 7.3-66.1%, n=33). The propofol-induced responses were not affected by 2-hydroxysaclofen (50 microM) or BaCl(2) (300 microM), but were completely blocked by bicuculline methiodide (100 microM) or picrotoxin (100 microM), indicating that propofol acts on GABA(A) receptors. As assessed by inhibition of the spontaneous firing rate, propofol was 5.6-fold more potent than GABA (gamma-aminobutyric acid). Potentiation of the propofol effect by other general anesthetics or other drugs was also investigated. When pentobarbital (100 microM) was tested alone on locus coeruleus cells, no change in membrane potential or input resistance was seen and there was only a 20.3+/-7.2% (n=8) inhibition of firing rate; however, in combination with 30 microM propofol, it caused a 6.1-fold greater increase in membrane hyperpolarization and a 9.7-fold greater reduction in input resistance than 30 microM propofol alone. A relatively low concentration of alphaxalone (10 microM), when tested alone, had little effect on the membrane potential or input resistance and only produced a 46.0+/-8.9% (n=8) inhibition of firing rate; however, in combination with 30 microM propofol, it caused a 9.3-fold greater hyperpolarization and an 8.6-fold greater reduction in input resistance compared with 30 microM propofol alone. In contrast, diazepam caused no potentiation of either propofol- or GABA-induced responses. Our data also indicate that locus coeruleus neuron GABA(A) receptors possess distinctive pharmacologic characteristics, such as blocking of the propofol effects by zinc and insensitivity to diazepam and the direct action of pentobarbital. On the basis of these pharmacologic properties, we suggest that locus coeruleus neuron GABA(A) receptors do not contain the gamma subunit.

Safrole is a weak hepatocarcinogen, and its carcinogenic effect has been linked to the formation of stable safrole DNA adducts. In this study, we tested whether safrole also induces oxidative damages in Sprague-Dawley rats. By single i.p. injection, safrole dose-dependently induced the formation of hepatic lipid hydroperoxides (LHP) and 8-hydroxy-2'-deoxyguanosine (8-OH-dG). The safrole-induced LHP reached peak level on day 3 and gradually returned to the basal level on day 15. On the other hand, 8-OH-dG levels from the similarly treated rats peaked on day 5 and returned to basal level on day 15. Safrole also dose-dependently induced serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities. We also examined the protective effect of vitamin E, deferoxamine and N-acetylcysteine against the safrole-induced oxidative damage. N-Acetylcysteine, the precursor of glutathione, exerted the greatest protective effect among the three antioxidants tested. In contrast, buthionine sulfoximine, the glutathione synthesis inhibitor, enhanced the safrole-induced oxidative damage, as evidenced by the elevation of LHP and 8-OH-dG levels on day 3 (P

Malaria, a major public health problem worldwide, is a predominant infectious disease in most tropical and subtropical countries. Before 1965, Taiwan was a hyperendemic area, but most cases are now imported. We present our experience of dealing with various malaria infections. Charts of malaria patients visiting university hospitals in southern Taiwan between January 1991 and June 2002 were available for review. All diagnoses were made by positive blood smear and detailed history that included countries visited, paroxysm of symptoms, and medical treatment. Seventeen patients, 6 women and 11 men (mean age, 32.3 ± 11.8 years), were enrolled. Six were infected with Plasmodium falciparum , eight with Plasmodium vivax , two with a combination of P. falciparum and P. vivax , and one with an unidentified infection. All Taiwanese patients infected with P. falciparum ( n = 5) contracted the disease in Africa or Indonesia. All Taiwanese patients infected with P. vivax ( n = 4) contracted the disease in Southeast Asia or Oceania. Fever and chills were the leading symptoms of malaria. P. falciparum infection was treated with quinine and doxycycline/tetracycline, with the addition of artesunate for cerebral malaria. P. vivax infection was treated with chloroquine and primaquine. Maintaining a high degree of suspicion in patients with a history of travel to malaria-endemic areas is the major cornerstone of malaria diagnosis. Erroneous diagnosis and improper treatment leads to greater morbidity and even mortality.