The role of autonomic nervous system function in hypothermia-mediated sepsis protection.

OBJECTIVE: The objective of this study is to determine whether hypothermia will lessen decreases in heart rate variability and improve outcome in a rat model of sepsis. METHODS: Thirty-six male Sprague-Dawley rats were randomized into 3 groups: control, low sepsis, and high sepsis groups. These groups were each subdivided into a normothermia (37°C) (n = 6) and a hypothermia group (34°C) (n = 6). Cyclophosphamide (100 mg/kg) was administered 5 days before Staphylococcus aureus injection to produce conditions in which sepsis could be induced reliably. Hypothermic rats received temperature reduction for 1 hour post injection. Electrocardiogram was recorded before, after, and 1 day after staphylococcal injection, and the low frequency, high frequency (HF), and LF/HF ratio measurements of heart rate variability and the frequencies of arrhythmia were recorded. The effects of time, sepsis severity, and hypothermia on these variables were analyzed using a multivariate generalized estimation equation mode. RESULTS: Four deaths occurred in the normothermic group, and none, in the hypothermic group. Sepsis of both low and high severity increased low frequency and HF 1 day after sepsis induction. Hypothermia significantly decreased HF in low, but not high sepsis severity. CONCLUSIONS: Hypothermia decreased mortality in septic rats. The influence of hypothermia on HF depended on the severity of the sepsis.

Arsenic, vinyl chloride, viral hepatitis, and hepatic angiosarcoma: a hospital-based study and review of literature in Taiwan.

BACKGROUND: Hepatic angiosarcoma (HAS) is a rare type of liver cancer that is often fatal, and arsenic and vinyl chloride monomer (VCM) are two major causal agents. Whereas Taiwan is an endemic area of liver cancer, epidemiologic data on HAS are limited. We reviewed the cases observed at a teaching hospital to evaluate the roles of VCM, arsenic, and viral hepatitis in the occurrence of HAS. METHODS: We reviewed the medical records of patients with pathological proof of HAS from January 2000 to August 2010 at a teaching hospital which is adjacent to the major VCM processing area in Taiwan and nearby an endemic area of arsenic exposure from drinking water. We also conducted a literature review and included all patients of HAS reported in Taiwan. RESULTS: Six male and three female cases aged from 56 to 83 years (64.6 ± 8.2 years) were identified at the hospital. The differences in clinical features between men and women were not statistically significant. None of them had exposure to VCM or arsenic in drinking water. Two had evidence of hepatitis C infection, but none had evidence of hepatitis B infection. Five male and four female cases aged 30 to 82 years (58.6 ± 15.5 years) were identified in the literature, including two with arsenic exposure and one with chronic hepatitis B infection. CONCLUSIONS: HAS is rare in Taiwan, and we found no evidence supporting a major role of VCM, arsenic in drinking water, or viral hepatitis in its occurrence.

Effects of epinephrine on heart rate variability and cytokines in a rat sepsis model.

Catecholamines have both anti-inflammatory and vasoactive properties. A decreased cardiac response to catecholamines has been associated with a high risk of death in sepsis and septic shock. The aim of this study was to investigate the effects of epinephrine (EPI) on heart rate variability (HRV) and autonomic balance, as well as cytokine levels, in a rat sepsis model. Thirty-six male Sprague-Dawley rats were assigned to 4 experimental groups and 2 control groups of 6 rats each. The rats in the experimental groups were inoculated with a lipopolysaccharide (LPS, endotoxin) to establish a sepsis model. Group A received only LPS; group B received LPS, antecedent EPI and the nonselective ß-blocker propranolol; group C received LPS and antecedent EPI; and group D received LPS, antecedent EPI and the selective ß1-blocker esmolol. One control group received EPI and the other received saline placebo. Heart rate variability (HRV) was analyzed and tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and interleukin-1ß (IL-1ß) levels were measured. Measurements were carried out at baseline, at 0 hour after EPI infusion, and at 0.5, 2, and 4 hours after LPS inoculation. There were significant differences in HRV and cytokine levels between the groups, indicating that LPS infusion caused autonomic imbalance. Antecedent EPI significantly decreased the level of TNF-α in group C compared with group A in which TNF-α level peaked at 2 hours and then declined. Propranolol (group B) but not esmolol (group D) administration resulted in elevated TNF-α levels, comparable to those observed in group A. In conclusion, antecedent administration of EPI in a rat sepsis model inhibits the production of TNF-α possibly via the ß2-adrenoceptor.

Associations between arsenic in drinking water and the progression of chronic kidney disease: A nationwide study in Taiwan.

To evaluate the associations between exposure to arsenic in drinking water and the progression of chronic kidney disease (CKD), we conducted a study in Taiwan. We recruited 8854 participants from a nationwide health screening program from 2000 to 2009 who were at least 20 years old and had two checkups in a 24-month period with at least 12 months apart. We defined CKD as having an estimated glomerular filtration rate (eGFR)<90ml/min/1.73m2 or renal dysfunction demonstrated by proteinuria and a rapid progression of CKD as a decline in eGFR>5ml/min/1.73m2/year. Arsenic levels were assessed on the basis of a governmental nationwide survey. Of the 8854 participants, 1341 exhibited rapid progression. Participants who lived in areas with arsenic levels≥50µg/L had a higher risk of rapid progression, with an odds ratio of 1.22 (95% confidence interval: 1.05-1.42, p<0.01) after adjusting for hypertension, diabetes mellitus, proteinuria, and anemia. The results showed that a high arsenic level in drinking water was a risk factor for rapid progression of CKD, independent of most of the documented risk factors. Screening and intervention programs should be implemented in endemic areas of exposure to reduce the risk.

Further evidence of the usefulness of Acute Physiology and Chronic Health Evaluation II scoring system in acute paraquat poisoning.

OBJECTIVE AND METHOD: We have previously successfully applied the Acute Physiology and Chronic Health Evaluation (APACHE) II system to assess the severity of patients with acute paraquat poisoning, and this article investigates further evidence of the usefulness of APACHE II system in predicting the in-hospital mortality of 64 patients with acute paraquat poisoning over a period of 12 years. The predictive factors including APACHE II score, plasma paraquat concentration, severity index of paraquat poisoning (SIPP), and estimated ingestion dosage of paraquat for evaluating the outcome in paraquat-poisoned patients were assessed. RESULTS: Overall mortality was 71.9%: 46 out of 64 patients died. Non-survivors (n = 46) had a higher APACHE II score (23.3 +/- 12.7) than survivors (n = 18) (6.1 +/- 4.2) (p < 0.001). The plasma paraquat concentration, SIPP, and estimated ingestion dosage of paraquat were significantly higher in non-survivors than in survivors (p < 0.05, in all comparisons). By multiple logistic regression analysis, only the APACHE II score and peak data of blood sugar in 24 h after admission were capable of predicting in-hospital mortality. By using the area under receiver operating characteristic curves (AURC), the APACHE II system yielded better discriminative power (AURC = 0.893) than SIPP (AURC = 0.674), plasma paraquat concentration (AURC = 0.676), and estimated ingestion dosage of paraquat (AURC = 0.673). An APACHE II score greater than 13 predicted in-hospital mortality with 67% sensitivity and 94% specificity. CONCLUSIONS: The APACHE II score is a simple, reproducible, and practical tool for evaluating the severity of acute paraquat poisoning.

Short report: persistent bradycardia caused by ciguatoxin poisoning after barracuda fish eggs ingestion in southern Taiwan.

We report an outbreak of ciguatoxin poisoning after barracuda fish ingestion in southern Taiwan. Three members of a family developed nausea, vomiting, watery diarrhea, and myalgias about 1 hour after eating three to ten eggs of a barracuda fish. Numbness of the lips and extremities followed the gastrointestinal symptoms about 2 hours after ingestion. Other manifestations included hyperthermia, hypotension, bradycardia, and hyperreflexia. Bradycardia persisted for several days, and one patient required a continuous infusion of intravenous atropine totaling 40 mg over 2 days. Further follow-up of the patients disclosed improvement of neurologic sequelae and bradycardia, but sensory abnormalities resolved several months later. In conclusion, ciguatoxin poisoning causes mainly gastrointestinal and neurologic effects of variable severity. In two patients with ciguatoxin poisoning after barracuda fish egg ingestion, persistent bradycardia required prolonged atropine infusion.

Isolated hepatic tuberculosis mimicking liver tumors in a dialysis patient.

Cases of isolated hepatic tuberculosis (TB) are rare. The diagnosis is often delayed or missed because of nonspecific symptoms and laboratory findings. Besides, the disease is extremely rare even in a country where TB is an alarming public health problem. This report demonstrates the difficulty in correctly diagnosing local hepatic TB. We report the case of a 62-year-old male patient with end-stage renal disease treated with hemodialysis, who developed 2 months of abdominal distension and general anorexia, with hyperechoic hepatic lesions on ultrasound. Computed tomography suspected multiple liver tumors. The liver biopsy finally led to the diagnosis of TB of the liver without other involvements. We conclude that isolated hepatic TB is one of the rare forms of extrapulmonary TB in dialysis patients. A greater awareness of this rare clinical entity may prevent needless surgical interventions.

Recurrent Hypokalemic Periodic Paralysis Unmasks Sjogren Syndrome without Sicca Symptoms.

Hypokalemic Periodic Paralysis (HPP) may occur as a rare complication of Sjogren Syndrome (SS) and Renal Tubular Acidosis (RTA). A 64-year male patient came with HPP, and was later diagnosed with distal RTA. The patient, who had no xerostomia and xerophthalmia, was diagnosed with primary SS from serologic and histologic findings of minor salivary gland biopsy. The patient recovered after potassium replacement therapy. Renal biopsy was also performed and revealed evidence of tubulointerstitial nephritis. Corticosteroids were administered and there was no recurrence of HPP during a 4-year follow-up period. The case highlights the significance of acute hypokalemia management in emergency department as it can unmask SS even if the SS is not associated with sicca symptoms. Hypokalemic paralysis associated with normal anion gap metabolic acidosis should prompt toward the diagnosis of SS.

Hepatic angiosarcoma may have fair survival nowadays.

Hepatic angiosarcoma (HAS) is rare but often fatal. A review of literature in 1979 found that only 3% of the 70 patients lived for more than 2 years, but the survival might have been improved over the years. We conducted a retrospective study and reviewed the medical records of patients who visited a teaching hospital in Taiwan from January 2000 to August 2010 and had pathological proof of HAS. In addition, we conducted a review of literature and compared those who survived for 2 years or more to those who did not. Of the 3503 patients with primary liver cancer we identified, 9 had HAS, of whom 3 (33.3%) survived for 2 years or more. One survived for 24 months without surgical resection, and the other two received surgery with postoperative chemotherapy and were still alive 32 and 37 months later, respectively. Through reviewing literature, we identified 3 more patients in Taiwan who had survived for 2 years or more. One survived for 42 months without surgical resection, the other two received segmentectomy with postoperative chemotherapy or radiotherapy. We also identified 8 such cases outside Taiwan, including 1 who received chemotherapy without surgery and survived for 53 months. None of the differences in the clinical characteristics between those who had and had not survived for 2 years or more reached statistical significance. In conclusion, we believe the combination of surgery and adjuvant chemotherapy may be able to achieve long-term survival in some HAS patients nowadays, and it is even possible to achieve fair survival using chemotherapy alone.

Severity assessment in acute paraquat poisoning by analysis of APACHE II score.

BACKGROUND AND PURPOSE: Several methods have been proposed to predict prognosis in patients with paraquat poisoning, but all have their limitations. This retrospective study evaluated the usefulness of Acute Physiology and Chronic Health Evaluation (APACHE) II scores in risk stratification for patients with paraquat poisoning. METHODS: Data from 58 adults with a diagnosis of paraquat poisoning presenting to a general hospital over a 10-year period were analyzed. APACHE II scores were calculated at 24 hours after admission and data on related parameters during the first 24 hours were collected for study. RESULTS: The overall in-hospital mortality was 72.4% and mortality in the intensive care unit was 82.2%. APACHE II scores were higher in non-survivors (n = 42, 23.3 +/- 12.4) than in survivors (n = 16, 6.7 +/- 4.1; p < 0.001). All 26 patients (44.8%) who received mechanical ventilation died. Of the 32 patients who received hemoperfusion, 25 (78.1%) died. Plasma paraquat concentration, estimated ingested amount of paraquat, and APACHE II score were significantly higher in non-survivors than in survivors (p < 0.05 for all comparisons). There were significant correlations between APACHE II score and the following variables: plasma paraquat concentration, estimated ingested amount of paraquat, and the peak values during the first 24 hours after admission for fraction of inspired oxygen, alveolar-arterial oxygen gradient, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and serum creatinine (p < 0.05 for all comparisons). Higher APACHE II score was associated with greater mortality. All patients who had an APACHE II score greater than 20 died before discharge. CONCLUSIONS: This study has demonstrated that the APACHE II score is positively correlated with plasma paraquat concentration and ingested amount of paraquat. An APACHE II score of 20 or higher is a good predictor of in-hospital mortality.