Interaction and joint effect of ALT and chronic liver disease on liver cancer in type 2 diabetes patients.

BACKGROUND: This study examined whether serum alanine transaminase (ALT) and chronic liver diseases were interactively, jointly, or independently associated with hepatocellular carcinoma (HCC) risk in type 2 diabetic patients. MATERIALS AND METHODS: A retrospective cohort study was conducted in 46,369 Chinese type 2 diabetic patients, aged 30 and older, in National Diabetes Care Management Program in 2002-2004. These data were analyzed by multivariate Cox proportional hazards models. RESULTS: Mean follow-up period was 8.20 years. Multivariate-adjusted hazard ratios of HCC were 2.85 (95% confidence interval, CI: 2.45-3.31), 3.80 (3.04-4.76), and 3.89 (3.08-4.91) for patients with a level of ALT 40-80, 80-120, and >120 U/L, respectively, compared with patients with a level of ALT < 40 U/L after multivariable adjustment. Significant hazard ratios of HCC for patients with a level of ALT ≥ 40 U/L and alcoholic liver damage, nonalcoholic fatty liver disease, liver cirrhosis, hepatitis B virus and hepatitis C virus infection, or any one of these chronic liver diseases compared with patients with ALT level < 40 U/L and no counterpart comorbidity were observed. Significant effect modifications were observed between ALT level with liver cirrhosis and HBV. CONCLUSIONS: Results suggest significant effect modification and joint associations of ALT ≥ 40 U/L and chronic liver diseases. Diabetes care should provide lifestyle or treatment interventions to manage ALT level, liver cirrhosis and hepatitis B virus infection for reducing burden of HCC.

Survival analysis of pediatric dialysis patients in Taiwan.

AIM: The long-term survival of Taiwanese children with end-stage renal disease (ESRD) has not been reported before. This study aimed to determine the long-term survival, mortality hazards and causes of death in paediatric patients receiving dialysis. METHODS: Paediatric patients (aged 19 years and younger) with incident ESRD who were reported to the Taiwan Renal Registry from 1995 to 2004 were included. A total of 319 haemodialysis (HD) and 156 peritoneal dialysis (PD) patients formed the database. After stratification by dialysis modality, multivariate Cox proportional-hazards model was constructed with age, sex and co-morbidity as predictive variables. RESULTS: The annual paediatric ESRD incidence rate was 8.12 per million of age-related populations. The overall 1-, 5-, and 10-year survival rates for PD patients were 98.1%, 88.0% and 68.4%, respectively, and were 96.9%, 87.3% and 78.5% for HD patients. The survival analysis showed no significant difference between HD and PD (P = 0.4878). Using '15-19 years' as a reference group, the relative risk (RR) of the youngest group (0-4 years) was 6.60 (95% CI: 2.50-17.38) for HD, and 5.03 (95% CI: 1.23-20.67) for PD. The death rate was 24.66 per 1000 dialysis patient-years. The three major causes of death were infection (23.4%), cardiovascular disease (13.0%) and cerebrovascular disease (10.4%). Hemorrhagic stroke (87.5%) was the main type of foetal cerebrovascular accident. CONCLUSION: We conclude that there was no significant difference of paediatric ESRD patient survival between HD and PD treatment in Taiwan. The older paediatric ESRD patients had better survival than younger patients.

The relationship of salivary and cord blood cortisol in preterm infants.

Recent studies reveal that salivary cortisol measurements accurately reflect blood cortisol levels in older children and adults; yet, the relationship between the two values in premature infants has not been established. This study explores the use of salivary cortisol as an accurate measure of adrenal steroid concentrations in premature infants to provide a reliable and less invasive tool for investigating hormonal stress response. Premature infants (n=51) were recruited, with saliva and blood collected immediately after birth, and cortisol levels measured by radioimmunoassay. A linear relationship emerged between cord plasma and salivary cortisol values in the 102 paired samples [(salivary cortisol) = 0.546 +/- 0.192 x (plasma cortisol), r = 0.481 and p = 0.0003]. Findings demonstrated that salivary and plasma cortisol levels were correlated in premature infants. This information will be useful in future studies that assess use of salivary cortisol to evaluate neonatal stress axis function.

A pilot study in acute subarachnoid haemorrhagic patients after aneurysm clipping with complementary therapies of Chinese medicine.

OBJECTIVES: Acute subarachnoid haemorrhage still has high mortality and morbidity despite the use of modern standard treatment. In Taiwan, complementary therapies of Chinese medicine are usually used to treat stroke patients. The aim of this study was to investigate the effect of complementary therapies of Chinese medicine on patients with acute subarachnoid haemorrhage after aneurysm clipping. DESIGN: This study was designed as a pilot study. A total of 32 patients with acute subarachnoid haemorrhage were randomly assigned to either a Chinese herbs extra group (CH) in which the patients were given complementary therapies of Chinese medicine and standard treatment, or a standard treatment only group (ST) in which patients were given standard treatment only. MAIN OUTCOME MEASURES: Glasgow Outcome Scale scores, which were assessed by an evaluator who was blinded to the groups, 3 months after admission, and total admission days including intensive care unit stay days. RESULTS: The average Glasgow Outcome Scale score 3 months after admission was 3.7±1.4 in the CH was greater than 3.0±1.7 in the ST (p=0.041). Average total admission days were 53.9±28.6 (median 61) in the ST longer than 28.1±19.1 (median 20.5) in the CH (p=0.004). CONCLUSION: Traditional Chinese medicine for the treatment of patients with acute subarachnoid haemorrhage is of value because they can increase Glasgow Outcome Scale scores 3 months after admission and also because they can reduce total admission days.

Applying cerebral hypothermia and brain oxygen monitoring in treating severe traumatic brain injury.

BACKGROUND: Severe traumatic brain injury (TBI) was to be one of the major health problems encountered in modern medicine and had an incalculable socioeconomic impact. The initial cerebral damage after acute brain injury is often exacerbated by postischemic hyperthermia and worsens the outcome. Hypothermia is one of the current therapies designed to combat this deleterious effect. The brain tissue oxygen (P(ti)o(2))-guided cerebral perfusion pressure (CPP) management was successfully reduced because of cerebral hypoxic episodes following TBI. MATERIALS AND METHODS: Forty-five patients with severe TBI whose Glasgow Coma Scale (GCS) score ranged between 4 and 8 during September 2006 and August 2007 were enrolled in China Medical University Hospital, Taichung, Taiwan. One patient with a GCS score of 3 was excluded for poor outcome. These patients were randomized into three groups. Group A (16 patients) was intracranial pressure/cerebral perfusion pressure (ICP/CPP)-guided management only, Group B (15 patients) was ICP/CPP guided with mild hypothermia, and Group C (14 patients) was combined mild hypothermia and P(ti)o(2) guided with CPP management on patients with severe TBI. All patients were treated with ICP/CPP management (ICP <20 mm Hg, CPP >60 mm Hg). However, the group with P(ti)o(2) monitoring was required to raise the P(ti)o(2) above 20 mm Hg. Length of intensive care unit stay, ICP, P(ti)o(2), Glasgow Outcome Scale (GOS) score, mortality, and complications were analyzed. RESULTS: The ICP values progressively increased in the first 3 days but showed smaller changes in hypothermia groups (Groups B and C) and were significantly lower than those of the normothermia group (Group A) at the same time point. We also found out that the averaged ICP were significantly related to days and the daily variations [measured as (daily observation - daily group mean)(2)] of ICP were shown to the significantly different among three treatment groups after the third posttraumatic day. The values of P(ti)o(2) in Group C tended to rise when the ICP decreased were also observed. A favorable outcome is divided by the result of GOS scores. The percentage of favorable neurologic outcome was 50% in the normothermia group, 60% in the hypothermia-only group, and 71.4% in the P(ti)o(2) group, with statistical significance. The percentage of mortality was 12.5% in the normothermia group, 6.7% in the hypothermia-only group, and 8.5% in the P(ti)o(2) group, without statistical significance in three groups. Complications included pulmonary infections, peptic ulcer, and leukocytopenia (43.8% in the normothermia group, 55.6% in the hypothermia-only group, and 50% in the P(ti)o(2) group). CONCLUSIONS: Therapeutic mild hypothermia combined with P(ti)o(2)-guided CPP/ICP management allows reducing elevated ICP before 24 hours after injury, and daily variations of ICP were shown to be significantly different among the three treatment groups after the third posttraumatic day. It means that the hypothermia groups may reduce the ICP earlier and inhibit the elicitation of acute inflammation after cerebral contusion. Our data also provided evidence that early treatment that lowers P(ti)o(2) may improve the outcome and seems the best medical treatment method in these three groups. We concluded that therapeutic mild hypothermia combined with P(ti)o(2)-guided CPP/ICP management provides beneficial effects when treating TBI, and a multicenter randomized trial needs to be undertaken.

Model-based prediction of length of stay for rehabilitating stroke patients.

BACKGROUND/PURPOSE: Accurate length-of-stay (LOS) estimates have an impact on medical costs for stroke patients. Most studies have reported only descriptive sample means or have provided linear-model-based estimates for LOS. This study calculated point and interval estimates by treating hospital discharge as an event, and utilizing the proportional hazards (PH) model to provide the estimation of hospital stay for first-ever stroke patients in a rehabilitation department of a clinical center. METHODS: Pairwise analysis for correlations between age, sex, comorbidity status, modified Barthel index (MBI) and functional independence measure (FIM) was performed. These explanatory variables are used in the K-sample comparisons, the Chi-squared test for association, the PH regression analysis, and log-transformed linear (LTL) regression. RESULTS: The PH model gave a prediction on estimated mean LOS, with an absolute bias of 0.85 days, by combining MBI and FIM into a single variable, or a bias of 1.15 days and 1.16 days with MBI and FIM variables, respectively. The LTL-based estimation generated a bias of 5.91 days. The PH model has relatively shorter confidence intervals than those obtained by sample-mean and LTL methods. CONCLUSION: We recommend using the PH model for predicting mean LOS when the PH assumption for patients with different clinical characteristics is satisfied. However, the proposed method only applies to rehabilitating stroke patients.

Prevalence of antimicrobial resistance in Helicobacter pylori isolates in Taiwan in relation to consumption of antimicrobial agents.

During 1998-2004, a total of 218 Helicobacter pylori isolates were obtained from patients who were randomised to receive one of the following regimens in a medical centre in Taiwan: lansoprazole, amoxicillin and clarithromycin (LAC) therapy; or lansoprazole, metronidazole and clarithromycin (LMC) therapy. In the LMC group, resistance rates for metronidazole and clarithromycin reduced from 48.6% (1998-2000) to 20.4% (2001-2004) (P<0.05) and from 13.5% to 6.3% (P<0.05), respectively. Analysis of annual antimicrobial consumption found that metronidazole use was slowly decreased both in the total population and in gastrointestinal disease patients. The per-protocol analysis revealed a higher eradication rate for patients using LMC therapy in 2001-2004 (82.6% vs. 75.0%), whilst there was similar efficacy for LAC therapy (84.8% vs. 84.2%). This observation suggests an effective programme to control H. pylori antibiotic resistance and hence elevate its cure rate.