Effects of short-term oral anticoagulation following surgical bioprosthetic aortic valve replacement.

BACKGROUND: Short-term oral anticoagulation (OAC) is recommended for patients after surgical bioprosthetic aortic valve replacement (bAVR); however, the potential benefits remain controversial. This study evaluated the effects of short-term OAC following bAVR. METHODS: From 2010 to 2017, total 450 patients who underwent bAVR were enrolled. The outcomes of patients who did (OAC group) and who did not receive OAC (without-OAC group) after bAVR were compared. Propensity-score matching (PSM) was used to adjust for potential confounders, and a 1:1 matched cohort was formed. The main outcomes were all-cause mortality and bioprosthetic valve dysfunction (BVD). RESULTS: A total of 175 (39%) patients received OAC after bAVR. The median follow-up period was 2.9 years, the median duration of OAC use was 4 months; 162 pairs of patients were identified after the PSM. There was no significant difference in the prevalence of 1-year embolism/ischemic stroke between the OAC and without-OAC group in PSM cohort (0.62% vs. 1.89% for embolism, p = 0.623; 0 vs. 1.23% for ischemic stroke, p = 0.499). The prevalence of 1-year intracranial hemorrhage (ICH) between OAC and without-OAC group was also comparable (0.62% vs. 0.62%, p = 1). The OAC group had a lower all-cause mortality (adjusted hazard ratio (aHR):0.488, 95% confidence interval (CI): 0.259-0.919). There was also a trend for reduced BVD in the OAC group (aHR: 0.661, 95% CI: 0.339-1.290). CONCLUSION: Our study demonstrated that short-term OAC use after bAVR was associated with lower all-cause mortality. The prevalence of 1-year embolism/ischemic stroke/ICH were comparable despite of OAC use.

Targeting nanoparticle-conjugated microbubbles combined with ultrasound-mediated microbubble destruction for enhanced tumor therapy.

The stress of the abnormal stromal matrix of solid tumors is a major limiting factor that prevents drug penetration. Controlled, accurate, and efficient delivery of theranostic agents into tumor cells is crucial. Combining ultrasound with nanocarrierbased drug delivery systems have become a promising approach for targeted drug delivery in preclinical cancer therapy. In this study, to ensure effective tumor barrier penetration, access to the tumor microenvironment, and local drug release, we designed targeted nanoparticle (NP)-conjugated microbubbles (MBs); ultrasound could then help deliver acoustic energy to release the NPs from the MBs. The ultrasound-targeted MB destruction (UTMD) system of negatively charged NPs was conjugated with positively charged MBs using an ionic gelation method. We demonstrated the transfer of targeted NPs and their entry into gastric cancer cells through ligand-specific recognition, followed by enhanced cell growth inhibition owing to drug delivery-induced apoptosis. Moreover, the UTMD system combining therapeutic and ultrasound image properties can effectively target gastric cancer, thus significantly enhancing antitumor activity, as evident by tumor localization in an orthotopic mouse model of gastric cancer. The combination of ultrasound and NP-based drug delivery systems has become a promising approach for targeted drug delivery in preclinical cancer therapy.

Stochastic approach for mechanistic interaction under longitudinal studies with noninformative right censoring.

Characterizing the mechanistic interactions between exposures and diseases is one of the most critical issues in epidemiologic studies. Previous studies have proposed a stochastic sufficient component cause framework, under which each sufficient cause is treated as a stochastic process instead of a time-invariant random variable. However, different types of mechanistic interactions such as synergism and agonism cannot be further identified. In this study, we proposed a stochastic marginal sufficient component cause model to conceptualize and identify agonism and synergism by exploiting the additional information. We further provided six approaches to identify and estimate agonism and synergism based on an additive hazard model and a complementary log model. Researchers can easily adjust confounding factors by including appropriate covariates into a regression model. Simulations have proven that approaches under three models are all valid tests. The power of an additive hazard model increases as the total follow-up time increases and is higher than that of the other two models. We applied this method to a Taiwanese cohort data set to investigate the mechanistic interaction among hepatitis B and C viruses on the incidence of hepatocellular carcinoma. The hazard of people with agonistic interaction is 1.28×10-5 (95% CI: 6.97×10-6 , 1.87×10-5 ), and the cumulative hazard of those people is 7.41×10-2 (95% CI: 4.09×10-2 , 1.07×10-1 ), which is approximately 3.5 times stronger than that of synergistic interaction. The proposed method makes it possible to quantify different types of mechanistic interactions in longitudinal studies with censored data.

Cumulative experience of preoperative real-time augmented fluoroscopy-guided endobronchial dye marking for small pulmonary nodules: An analysis of 30 initial patients.

BACKGROUND/PURPOSE: Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) for use in guiding endobronchial dye marking of small pulmonary nodules prior to thoracoscopic surgery is still under development. We sought to evaluate the effect of the cumulative experience on procedural parameters of CBCT-AF-guided endobronchial dye marking for preoperative localization of small pulmonary nodules. METHODS: Clinical variables and treatment outcomes of the 30 initial patients with small pulmonary nodules who were managed with CBCT-AF-guided endobronchial dye marking followed by thoracoscopic resection in our institution were analyzed. Two sequential groups of patients (group I and group II, n = 15 each) were compared with regard to localization time and radiation doses. The Mann-Whitney U test and chi-square test or Fisher exact test were used in the statistical analyses. RESULTS: In the entire cohort, the median size of solitary pulmonary nodules on preoperative computed tomography (CT) images was 9.3 mm (interquartile range, 7.4-13.6 mm), and their median distance from the pleural surface was 15.2 mm (interquartile range, 10.3-27.1 mm). The median tumor depth-to-size ratio was 1.6 (interquartile range, 1.1-2.3). A significant reduction in single DynaCT radiation (3690.4 versus [vs.] 1132.3 µGym2; P < 0.001) and total radiation exposure (median, 4878.8 vs. 1673.8 µGym2; P < 0.001) was noted in group II (late patients) compared with group I. CONCLUSION: Our initial results of CBCT-AF-guided lung marking demonstrate that the cumulative experience with several technical modifications can achieve the same purpose of endobronchial localization with less procedure-related radiation exposure.

[Exploring Sleep Quality, Spiritual Health, and Related Factors in Nurses in the Intensive Care Unit].

BACKGROUND: Nurses in intensive care units (ICUs) care for critically ill and dying patients. The stressful nature of the work performed by these nurses may affect their spiritual health and sleep quality. PURPOSE: The purpose of this correlational study was to explore the sleep quality, spiritual health, and related factors in a sample of ICU nurses. METHODS: A cross-sectional correlational design with stratified random sampling was applied. A total of 170 clinical nurses were recruited from the ICUs of a medical center in northern Taiwan. A demographic characteristics questionnaire, the spiritual health scale-short form, and the Pittsburgh Sleep Quality Index (PSQI) were used for data collection. RESULTS: The average PSQI score was 7.07, with 62.9% of the participants reporting poor sleep quality. A significantly negative correlation was identified between the spiritual-health-scale item "connections to others" and the PSQI. "Connections to others", "chronic diseases", and "menstrual cycle discomfort" were the important predictive factors of sleep quality in the ICU nurses in this study. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The findings of this study support nurses engaging in regular exercise that is both low-intensity and not subject to time or space restrictions in order to help prevent chronic diseases and relieve dysmenorrhea. Furthermore, education and training related to spiritual health should be incorporated into the whole-person education curriculum in order to enhance spiritual status and improve sleep quality.

[Quality of Life of Primary Caregivers of Liver Cirrhosis Patients and Related Factors].

BACKGROUND: The prognosis of patients with liver cirrhosis often involves multiple complications and repeated admissions, which may significantly burden and reduce the quality of life of the primary caregivers of these patients. PURPOSE: The purpose of this correlational study was to explore the relationship between the burden of caregivers of liver cirrhosis patients and their quality of life. METHODS: A structured questionnaire, which included the Primary Caregiver Burden Scale, Coping Behaviors Scale, the WHOQOL-BREF, and a caregiver demographic datasheet, was used to collect data. Descriptive and inferential statistics (independent t-test, one-way ANOVA, Pearson's product-moment correlation, and stepwise regression analysis) were used to analyze data. RESULTS: A total of 113 participants were recruited from a medical center in northern Taiwan. The results revealed: (1) The highest average scores for caregiver burden were in the financial domain, while the lowest average scores were in the physical domain. The highest average scores for quality of life were observed in the environment domain, while the lowest average scores were in the physical health domain. (2) Most of the caregivers adopted a problem-solving oriented strategy to care for their patient. (3) Overall care burden correlated negatively with overall quality of life (r = -.223, p < .05). The caregivers' "self-assessed health", "financial load", and "daily care hours" were significant factors affecting overall quality of life (F = 52.78, p < .05), accounting for 58% of the total variance in the results. CONCLUSIONS: The results of this study may help nurses better understand and work to reduce the burden of caregivers in order to enhance their quality of life. Nurses should assess caregiver burden, especially in cases where caregivers themselves are in a poor financial situation or have poor self-assessed health, in order to provide necessary support and assistance.

Microstructural changes of brain in patients with aromatic L-amino acid decarboxylase deficiency.

Aromatic L-amino acid decarboxylase (AADC) deficiency is an uncommon inherited neurometabolic disease. The clinical presentations and MR findings in children with AADC deficiency were investigated. Total 12 children (6 boys, 6 girls), aged from 9 to 50 months (mean, 23 ±13 months), with AADC deficiency, were enrolled for analysis. Of 12 patients enrolled, clinical presentations included global developmental delay with generalized hypotonia in 12 (100%), dystonia in 12 (100%), oculogyric crisis in 12 (100%), and excessive sweating in 8 (67%). Sleep problem was also found in 4 (33%). Of 15 MR examinations, the major changes included 6 (40%) with diffusely prominent bilateral frontal sulci, 10 (67%) with prominent frontal horns, and 12 (80%) with hypomyelination. In AADC patients, the frontal horn was significantly widened (P < 0.01), and the volume of caudate nucleus was also significantly smaller than that of controls (P = 0.02). The ratios of thickness of the splenium to that of the genu of corpus callosum were also significantly increased (P < 0.01). There was also significant decrease of fiber density indices in major white matter fiber tracts. Using Tract-Based Spatial Statistics approach, we also revealed significant change in major fiber tracts related to language function and motor function. In conclusion, the present study indicated that AADC deficiency may have significant impact on brain development, especially the frontal lobe and fiber tracts related to language function and motor function. Long-term follow-up of brain MRI in patients with AADC deficiency may clarify the possible effect of AADC deficiency on brain development. Hum Brain Mapp 38:1532-1540, 2017. © 2016 Wiley Periodicals, Inc.

Laparoscopic percutaneous jejunostomy with intracorporeal V-Loc jejunopexy in esophageal cancer.

BACKGROUND: Barbed sutures are widely used in various laparoscopic digestive surgeries. The purpose of this paper is to present our initial experience of laparoscopic percutaneous jejunostomy with unidirectional barbed sutures in esophageal cancer patients and compare it with our early cases using traditional transabdominal sutures. METHODS: A total of 118 esophageal cancer patients who underwent laparoscopic percutaneous jejunostomy were identified in a single institution in Taiwan from June 2014 to May 2016. The authors' traditional technique consisted of using transabdominal sutures with bolsters to fix a jejunum loop onto the anterior abdominal wall. A novel technique was introduced using intracorporeal suturing with knotless unidirectional barbed monofilament absorbable sutures (V-Loc) to attain a seal around the feeding catheter. A comparison between these two techniques was performed. RESULTS: Twenty cases with barbed V-Loc sutures and 98 cases with transabdominal sutures were identified. The V-Loc sutures appeared to reduce peristomal skin ulcers (19.4 vs. 0 %, p = 0.040), postoperative pain scores during the first 24 h (1.8 ± 1.4 vs. 0.9 ± 1.1, p = 0.007) and on postoperative day 2 (1.7 ± 1.4 vs. 1.0 ± 0.8, p = 0.026) when compared to patients receiving transabdominal sutures. The mean suturing time using V-Loc sutures was 22 min (14-60 min). The mean onset to resumption of enteral feeding was 1.8 ± 0.8 days and the mean duration of postoperative hospital stay was 8 ± 5.1 days, both of which were comparable in the two groups. There was no surgical mortality in our series. CONCLUSIONS: In the study cohort, the use of knotless unidirectional barbed sutures instead of traditional transabdominal sutures had similar outcomes and appears to be a feasible option for intracorporeal jejunopexy when performing laparoscopic jejunostomy in patients with esophageal cancer.

Twenty-years of lung transplantation in Taiwan: Effects of cumulative institutional experience on early outcomes.

BACKGROUND/PURPOSE: Lung transplantation in Taiwan began in 1991, but the experience was limited and diverse in the early years. We examined the cumulative institutional experience of the largest lung transplant cohort in Taiwan. METHODS: A retrospective review of lung transplantations performed at a single institution from December 1995 through August 2016 was conducted. For comparative purposes, the cohort was divided into halves, with an early group (undergoing lung transplantation in the first decade) vs a late group (undergoing lung transplantation in the second decade). Standardized donor selection, organ procurement, and preservation protocols for brain-dead donors were applied. The outcomes measured were 30-day mortality and actuarial survival using the Kaplan-Meier method. RESULTS: The cohort included 50 recipients in the early group and 42 recipients in the late group. Compared with the early group, recipients in the late group were significantly older (38.8 ± 11.6 vs 44.8 ± 13.4 years, p = 0.024) and more of them required mechanical ventilation before transplant (26.0% vs 66.7%, p < 0.001). There were more female donors (12.0% vs 33.3%, p = 0.021) and gender-matched donors (34.0% vs 61.9%, p = 0.012) in the late group. A total of 87 recipients (94.6%) had cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) support during transplant, and CPB was used significantly less in the late group. Graft procedures (14.0% vs 47.6%, p < 0.001), delayed chest closure (0% vs 21.4%, p < 0.001), and early tracheostomy (24.0% vs 52.4%, p = 0.005) were performed more in the late group. The durations of hospital and ICU stays were comparable in both groups, but the 30-day mortality was significantly lower in the late group (30.0% vs 2.4%, p = 0.001). CONCLUSION: Although the results were undesirable in the first decade of the transplant program, the cumulative institutional experience led to significantly improved outcomes in the second decade of the transplant program.

Case detection and diagnosis of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism.

BACKGROUND/PURPOSE: Even though the increasing clinical recognition of primary aldosteronism (PA) as a public health issue, its heightened risk profiles and the availability of targeted surgical/medical treatment being more understood, consensus in its diagnosis and management based on medical evidence, while recognizing the constraints of our real-world clinical practice in Taiwan, has not been reached. METHODS: The Taiwan Society of Aldosteronism (TSA) Task Force acknowledges the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics into the management of PA. RESULTS: When there is suspicion of PA, a plasma aldosterone to renin ratio (ARR) should be obtained initially. Patients with abnormal ARR will undergo confirmatory laboratory and image tests. Subtype classification with adrenal venous sampling (AVS) or NP-59 nuclear imaging, if AVS not available, to lateralize PA is recommended when patients are considered for adrenalectomy. The strengths and weaknesses of the currently available identification methods are discussed, focusing especially on result interpretation. CONCLUSION: With this consensus we hope to raise more awareness of PA among medical professionals and hypertensive patients in Taiwan, and to facilitate reconciliation of better detection, identification and treatment of patients with PA.

[Decreasing the Output of Biomedical Waste in the Intensive Care Unit].

BACKGROUND & PROBLEMS: Advancing healthcare technologies have increased the use of disposable supplies that are made with PVC (polyvinyl chloride). Furthermore, biomedical effluents are steadily increasing due to severe patient treatment requirements in intensive care units. If these biomedical wastes are not properly managed and disposed, they will cause great harm to the environment and to public health. The statistics from an intensive care unit at one medical center in northern Taiwan show that the per-person biomedical effluents produced in 2014 increased 8.51% over 2013 levels. The main reasons for this increase included the low accuracy of classification of the contents of biomedical effluent collection buckets and of personnel effluents in the intensive care unit and the generally poor selection and designation of appropriate containers. PURPOSE: Improvement measures were implemented in order to decrease the per-day weight of biomedical effluents by 10% per person (-0.22 kg/person/day). METHODS: The project team developed various strategies, including creating classification-related slogans and posting promotional posters, holding education and training using actual case studies, establishing an "environmental protection pioneer" team, and promoting the use of appropriate containers. RESULTS: The implementation of the project decreased the per-day weight of biomedical effluents by 13.2% per person. CONCLUSIONS: Implementation of the project effectively reduced the per-person daily output of biological wastes and improved the waste separation behavior of healthcare personnel in the unit, giving patients and their families a better healthcare environment and helping advance the cause of environmental protection worldwide.

Dressing with epigallocatechin gallate nanoparticles for wound regeneration.

Several reagents have been studied to overcome the problems encountered with antiseptic use, such as moderate cutaneous wound cytotoxicity and skin thinning. We successfully prepared a gelatin/chitosan/epigallocatechin gallate nanoparticle incorporated in a poly(γ-glutamic acid)/gelatin hydrogel, which comprised activated carbon fibers with gentamicin, to fabricate a sandwiched dressing to enhance wound regeneration. The inner layer of activated carbon fibers with gentamicin was designed to prevent bacterial infection, and the outer layer of gelatin/chitosan/epigallocatechin gallate nanoparticles incorporated in a poly(γ-glutamic acid)/gelatin hydrogel was designed to prevent inflammation and facilitate reepithelialization. An in vitro study demonstrated that the dressing effectively inhibited target microorganisms, and scanning electron microscope and confocal laser scanning microscope indicated that the nanoparticles were homogeneously dispersed and migrated into the hydrogel. The in vivo study reported that the sandwiched dressing, comprising the poly(γ-glutamic acid)/gelatin hydrogel, was easy to remove from the wound and facilitated wound tissue regeneration and accelerated healing process.

Nationwide epidemiology and prognosis of dialysis-requiring acute kidney injury (NEP-AKI-D) study: Design and methods.

AIM: Acute kidney injury (AKI) carries an increasing incidence rate worldwide and increases the risk of developing end-stage renal disease (ESRD) as well as the medical expenses during the post-AKI course. The Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs) has thus launched a nationwide epidemiology and prognosis of dialysis-requiring acute kidney injury (NEP-AKI-D) study, which prospectively enrols critically ill patients with AKI. Through thoroughly evaluating the risk and prognostic factors of AKI, we hope to lower the incidence of AKI and ESRD from the perspective of AKI-ESRD interaction. METHODS: The CAKs includes 30 hospitals which distribute widely through the four geographical regions (north, middle, south, and east) of Taiwan, and have a 1:1 ratio of medical centres to regional hospitals in each region. The NEP-AKI-D study enrols intensive care unit-based AKI patients who receive dialysis in the four seasonal sampled months (October 2014, along with January, April, and July 2015) in the included hospitals. The collected data include demographic information, pertaining laboratory results, dialysis settings and patient outcomes. The data are uploaded in a centre website and will be audited by on-site principal investigators, computer logic gates, and the CAKs staffs. The outcomes of interest are in-hospital mortality, dialysis-dependency and readmission rate within 90 days after discharge. CONCLUSION: The NEP-AKI-D study enrols a large number of representative AKI patients throughout Taiwan. The results of the current study are expected to provide more insight into the risk and prognostic factors of AKI and further attenuated further chronic kidney disease transition.

Silver-based wound dressings reduce bacterial burden and promote wound healing.

Various types of wound dressings have been designed for different purposes and functions. Controlling bacterial burden in a wound during the early phase is important for successful wound repair. Once bacterial burden is under control, the active promotion of wound healing is another important factor for efficient wound healing. This study investigated the potential of three silver-containing dressings, namely KoCarbonAg(®) , Aquacel(®) Ag and Acticoat 7, in reducing bacterial survival and promoting wound healing. The ability of these dressings to block the entry of bacteria from external environment and retain intrinsic bacteria was studied in vitro. In addition, the study used a rat model to compare the healing efficiencies of the three dressings and investigate the quantity of collagen synthesis in vivo. In vitro results indicated that the silver-containing dressings prevented bacterial growth in wounds by blocking the entry of external bacteria and by retaining the bacteria in the dressing. In vivo study indicated that reduction in bacterial burden accelerated wound healing. Wounds treated by the silver-containing dressings showed better healing than those treated with gauze. Moreover, KoCarbonAg(®) further accelerated wound healing by promoting collagen synthesis and arrangement.

Prognostic factors and complication rates for double-filtration plasmapheresis in patients with Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is an acute immune-mediated demyelinating polyradiculoneuropathy that could lead to disabilities if not properly treated. There are only limited data on the prognostic factors and complications when using double-filtration plasmapheresis in these patients. We reviewed the medical records of 60 GBS patients who underwent double-filtration plasmapheresis as the first-line therapy at a tertiary care teaching hospital. The severity of disease was evaluated at different time points using disability scores. Functional outcome was defined as good (GBS disability score 0 to 2) or poor (GBS disability score 3 to 6) at 28 days after admission. The cohort included 22 women and 38 men with a mean age of 50 ± 18 years. In univariate logistic regression analysis, potential factors associated with poor outcome include an older age (P = 0.101), the absence of preceding respiratory tract infection (P = 0.043), mechanical ventilation (P = 0.016), a lower hematocrit (p = 0.072), a lower serum sodium level (P = 0.153) and a higher disability score on admission (P < 0.001). In multivariate analysis, a higher disability score on admission was associated with a poorer outcome (OR, 5.61; 95% CI, 2.34 to 13.43; P < 0.001), whereas the presence of prodromal upper respiratory tract infection correlated with a better outcome (OR, 0.13; 95% CI, 0.03-0.59; P = 0.009). Among 60 patients, eleven (18.3%) have various complications attributed to plasmapheresis treatment. Six patients (10.0%) developed deep vein thrombosis and two experienced catheter-related infection (3.3%). Hypotension, allergy and hemolysis occurred in one patient each (1.7%). In conclusion, we describe our experiences of using DFPP in the treatment of GBS. The pretreatment severity score was the most significant predictor of treatment outcome, suggesting that early referral and timely treatment are important. Potential complications such as catheter-related infection and deep vein thrombosis should be monitored carefully.

Association between management of metabolic syndrome and progression of early-stage chronic kidney disease: an observational cohort study.

OBJECTIVES: To analyze the effect of treating metabolic syndrome (MetS) on further kidney function decline in patients with early-stage chronic kidney disease (CKD). METHODS: In a study period of 24 months, 162 patients with early stage CKD were enrolled. Baseline and follow-up data related to the occurrence of MetS and glomerular filtration rate (GFR) were assessed. Subjects were classified into controlled MetS (group 1) and uncontrolled MetS (group 2). Furthermore, they were subdivided into four subgroups: (A) controlled MetS at baseline and at follow-up, (B) uncontrolled MetS at baseline but controlled MetS at follow-up visits, (C) controlled MetS at baseline but uncontrolled MetS at follow-up visits, and (D) uncontrolled MetS at baseline and follow-up visits. RESULTS: Final GFR was lower in group 2 versus group 1 (69.21 ± 20.20 vs. 82.86 ± 22.33 mL/min/1.73 m(2), p <0.001). The presence of MetS had high risk to develop late-stage CKD (HR = 3.279, 95% CI: 1.545-6.958, p = 0.002). Moreover, subgroup D (HR = 2.982, 95% CI: 1.287-6.908, p = 0.011) and the presence of three (p = 0.026) or four (p = 0.049) metabolic components had high risk to develop late-stage CKD. CONCLUSION: Treating MetS slows CKD progression in patients with early-stage of CKD.

Evaluation of various silver-containing dressing on infected excision wound healing study.

Silver-containing dressings have been widely used for controlling wound infection. However, the relationship between different concentrations of silver in dressings and their antimicrobial activities and wound-healing efficacies remains unclear. In the present study, we (in cooperation with Bio-medical Carbon Technology) investigated various silver-containing activated carbon fibers to understand the effects of different silver concentrations on the efficacies of a silver containing dressing. Our results indicated that various silver-containing activated carbon fibers exhibited good antibacterial effects and biocompatibility in terms of cell viability and that silver concentration showed a minor influence on cell growth. The infected excision wound model indicated that compared to silver-containing activated carbon fiber and other commercial silver-containing dressings assisted wound healing by promoting granulation and collagen deposition. Meanwhile, the silver ion can only be restrained in epidermis by intact skin. During application on the wound area, a temporary increase of serum silver can be detected, but this elevated serum silver level decreased to a subtle level after the removal of silver-containing activated carbon fiber.

Non-tuberculous and tuberculous mycobacterial peritonitis in peritoneal dialysis patients.

INTRODUCTION: Peritoneal dialysis (pd)-associated mycobacterium peritonitis is an important clinical entity in patients with end stage renal disease. They present a significant diagnostic and therapeutic challenge for clinicians because clinical findings and laboratory investigations can not be differentiated from symptoms caused by non-tuberculous mycobacterium (ntm), Mycobacterium tuberculosis (tb) or other bacteria. The aim of the present article is to know the differences between the clinical manifestations and laboratory investigations, the appropriate diagnosis, treatment strategies and prognosis for tb and ntm disease in patients with pd-associated mycobacterial infections. METHODS: This was a retrospective observational study conducted over a period of 25 years. Out of 1737 patients, only 7 were diagnosed with mycobacterial peritonitis. RESULT: Evaluable data showed that there were three patients diagnosed with ntm peritonitis and four patients with tuberculous peritonitis. The mean age of the patients was 53.9 ± 11.8 years. Although all patients developed abdominal pain and cloudy dialysate, only four patients (57.1%) had fever. Two patients (28.6%) suffered severe sepsis and septic shock. Therefore, the patient survival rates for ntm and tuberculous peritonitis were 100.0% and 75.0%, respectively. Two patients were shifted to long-term hemodialysis; therefore, the technical survival rates for ntm and tuberculous peritonitis were 66.7% and 50.0%, respectively. Notably, recurrence of mycobacterial infection was found in one patient with both pulmonary tuberculosis and tuberculous peritonitis. CONCLUSION: The diagnosis of mycobacterial peritonitis remains a challenge to medical staffs because of its insidious nature, the variability of its presentation and the limitations of available diagnostic test.