ABSTRACT: Leptospirosis is the most common zoonosis in the world but remains underreported, owing to protean manifestations and ignorance about the disease among healthcare providers in Taiwan. From September 2000 to March 2006, surveillance of 455 multiple organ dysfunction syndrome patients with unclear cause or clinical suspicion of leptospirosis was performed. Diagnosis was further confirmed by microscopic agglutination test or isolation of leptospira. Cases were classified as excluded based on confirmed etiology other than leptospirosis or negative paired serologic test. Forty-two patients were confirmed as leptospirosis, which accounted for 9.2% of total patients with multiple organ dysfunction syndrome. Forty-nine excluded cases were identified for a case-control analysis for clinical distinction. The most common presentations of leptospirosis were fever (97.6%), acute kidney injury (85.7%), and jaundice (61.9%). The leptospirosis group showed lower urine specific gravity (cutoff value: 1.0145) and enlarged kidney size (cutoff value: 11.05 cm) as compared with the excluded cases by multivariate logistics regression. Delayed antibiotics administration prolongs the duration of hospitalization (R Square:.486, P<.01). No mortality has been found in the leptospirosis group after initiation in 2003 of rapid IgM serology assay that showed considerably high sensitivity and specificity. Leptospirosis accounts for a salient cause of multiple organ dysfunctions in Taiwan. Early awareness of leptospirosis by distinct presentations, followed by prompt antibiotics therapy can dramatically save the patients. The easy-performed rapid IgM serology assay is suitable as a rapid screening test for the diagnosis of leptospirosis.

ABSTRACT: Leptospirosis is the most common zoonosis in the world but remains underreported, owing to protean manifestations and ignorance about the disease among healthcare providers in Taiwan. From September 2000 to March 2006, surveillance of 455 multiple organ dysfunction syndrome patients with unclear cause or clinical suspicion of leptospirosis was performed. Diagnosis was further confirmed by microscopic agglutination test or isolation of leptospira. Cases were classified as excluded based on confirmed etiology other than leptospirosis or negative paired serologic test. Forty-two patients were confirmed as leptospirosis, which accounted for 9.2% of total patients with multiple organ dysfunction syndrome. Forty-nine excluded cases were identified for a case-control analysis for clinical distinction. The most common presentations of leptospirosis were fever (97.6%), acute kidney injury (85.7%), and jaundice (61.9%). The leptospirosis group showed lower urine specific gravity (cutoff value: 1.0145) and enlarged kidney size (cutoff value: 11.05 cm) as compared with the excluded cases by multivariate logistics regression. Delayed antibiotics administration prolongs the duration of hospitalization (R Square:.486, P<.01). No mortality has been found in the leptospirosis group after initiation in 2003 of rapid IgM serology assay that showed considerably high sensitivity and specificity. Leptospirosis accounts for a salient cause of multiple organ dysfunctions in Taiwan. Early awareness of leptospirosis by distinct presentations, followed by prompt antibiotics therapy can dramatically save the patients. The easy-performed rapid IgM serology assay is suitable as a rapid screening test for the diagnosis of leptospirosis.

BACKGROUND: Depression is related to morbidity and mortality in patients with kidney failure treated by dialysis, but its influence on patients with earlier stages of chronic kidney disease (CKD) is uncertain. This study investigates the association of depressive symptoms with clinical outcomes in patients with CKD not requiring dialysis. STUDY DESIGN: Prospective observational cohort study. SETTING & PARTICIPANTS: 568 participants with CKD not requiring maintenance dialysis were recruited consecutively at a tertiary hospital in Southern Taiwan and followed up for 4 years. PREDICTORS: Baseline status of depressive symptoms. OUTCOMES: The primary outcome is a composite of progression to end-stage renal disease (ESRD), defined as requiring maintenance dialysis treatment, or all-cause mortality; and secondary outcome was first hospitalization. MEASUREMENTS: Depressive symptoms were assessed by Beck Depression Inventory. Estimated glomerular filtration rate (eGFR) was computed using the 4-variable MDRD (Modification of Diet in Renal Disease) Study equation. RESULTS: 428 participants completed the questionnaires and 160 (37%) had depressive symptoms. During a mean follow-up of 25.2 ± 11.9 months, 136 participants (32%) reached the primary outcome (119 reached ESRD and 17 died) and 110 participants (26%) were hospitalized. High depressive symptoms increased the risk of progression to ESRD or death (HR, 1.66; 95% CI, 1.14-2.44) and first hospitalization (HR, 1.59; 95% CI, 1.03-2.47). Participants with high depressive symptoms had more rapid GFR decrease (eGFR slopes of -2.3 [25th-75th percentile,-5.3 to -0.4] vs -1.2 [25th-75th percentile,-3.5 to 0.3] mL/min/1.73 m(2) per year; P = 0.001) and initial dialysis treatment at a higher eGFR (OR for initiation of dialysis at eGFR >5 mL/min/1.73 m(2), 4.45; 95% CI, 1.44-13.78). LIMITATIONS: A single-center study of Taiwanese, Beck Depression Inventory evaluates only depressive symptom burden. CONCLUSIONS: Depressive symptoms in CKD are independent predictors of adverse clinical outcomes, including faster eGFR decrease, dialysis therapy initiation, death, or hospitalization. Depression should be evaluated early and treated in patients with CKD.

Background: Hemoglobin variability in hemodialysis patients treated with erythropoiesisstimulating agents has been used to evaluate mortality and comorbidity. Different outcomes have been reported in American and European hemodialysis patients. There are, however, few studies of the effects of hemoglobin variability in peritoneal dialysis patients. Methods: We investigated hemoglobin variability in 363 peritoneal dialysis patients over 2 years to evaluate mortality and the association with comorbidity, peritonitis, and hospitalization. The hemoglobin of all patients selected for the study had been monitored for at least 6 months (April 2008 to September 2008). We assessed hemoglobin variability as fluctuations from the target hemoglobin level (11-12.5 g/dL). We defined the following 6 patient groups on the basis of hemoglobin patterns: consistently low (< 11 g/dL), consistently target range (11-12.5 g/dL), consistently high (> 12.5 g/dL), low-amplitude fluctuation with low hemoglobin levels, low-amplitude fluctuation with high hemoglobin levels, and high amplitude fluctuation. Results: Only 2% of patients maintained a stable hemoglobin level within the target range and 46.8% of patients exhibited consistently low hemoglobin levels. After 2 years of observation, there was no difference in mortality as assessed by Kaplan-Meier analysis. There were also no differences in peritonitis and hospitalization between the 6 groups. However, the length of hospital stay was longer in the high amplitude fluctuation group (p = 0.008). Conclusion: Hemoglobin variability does not predict mortality in peritoneal dialysis patients.

ABSTRACT:: Acute kidney injury (AKI) is a significant complication after hematopoietic stem cell transplantation (HSCT) and frequently limits treatment success. Patients suffering complications with AKI often have high mortality. This investigation analyzed the outcomes of patients receiving allogeneic HSCT and identified the association between prognosis and RIFLE (risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function and end-stage renal disease) classification. This study reviewed the medical records of 101 patients receiving allogeneic HSCT during an 8-year period at a specialized hematology ward in a university hospital in Taiwan. Demographic, clinical and laboratory variables were retrospectively gathered as predicators. Overall 6-month mortality was 36.6%(37/101). Mortality progressively and significantly increased (χ for trend, P < 0.001) based on RIFLE classification severity. Multiple variable Cox regression analysis identified maximum RIFLE score on day 7 to 14 post-HSCT, occurrence of hepatic veno-occlusive disease and respiratory failure during admission as independent risk factors for 6-month mortality. Using the area under the receiver operating characteristic curve, the RIFLE classification on day 7 to 14 post-HSCT has the best discriminative power (area under the receiver operating characteristic curve: 0.696 ± 0.057, P < 0.001) compared with day 0 to 7, 14 to 30 and 30 to 60 post-HSCT. Cumulative survival rates at 6-month follow-up differed significantly (P < 0.05) among non-AKI, RIFLE-R versus RIFLE-I and RIFLE-F. Hepatic veno-occlusive disease, respiratory failure and severity of maximum RIFLE score on day 7 to 14 post-HSCT were independent predictors for 6-month mortality. RIFLE classification on day 7 to 14 post-HSCT can improve the accuracy of 6-month mortality in patients who received allogeneic HSCT.

Preimplantation genetic diagnosis (PGD) is gradually widely used in prevention of gene diseases and chromosomal abnormalities. Much improvement has been achieved in biopsy technique and molecular diagnosis. Blastocyst biopsy can increase diagnostic accuracy and reduce allele dropout. It is cost-effective and currently plays an important role. Whole genome amplification permits subsequent individual detection of multiple gene loci and screening all 23 pairs of chromosomes. For PGD of chromosomal translocation, fluorescence in-situ hybridization (FISH) is traditionally used, but with technical difficulty. Array comparative genomic hybridization (CGH) can detect translocation and 23 pairs of chromosomes that may replace FISH. Single nucleotide polymorphisms array with haplotyping can further distinguish between normal chromosomes and balanced translocation. PGD may shorten time to conceive and reduce miscarriage for patients with chromosomal translocation. PGD has a potential value for mitochondrial diseases. Preimplantation genetic haplotyping has been applied for unknown mutation sites of single gene disease. Preimplantation genetic screening (PGS) using limited FISH probes in the cleavage-stage embryo did not increase live birth rates for patients with advanced maternal age, unexplained recurrent abortions, and repeated implantation failure. Polar body and blastocyst biopsy may circumvent the problem of mosaicism. PGS using blastocyst biopsy and array CGH is encouraging and merit further studies. Cryopreservation of biopsied blastocysts instead of fresh transfer permits sufficient time for transportation and genetic analysis. Cryopreservation of embryos may avoid ovarian hyperstimulation syndrome and possible suboptimal endometrium.

BACKGROUND Renal dysfunction is an established predictor of all-cause mortality in intensive care units. This study analyzed the outcomes of coronary care unit (CCU) patients and evaluated several biomarkers of acute kidney injury (AKI), including neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18) and cystatin C (CysC) on the first day of CCU admission. METHODOLOGY/PRINCIPAL FINDINGS Serum and urinary samples collected from 150 patients in the coronary care unit of a tertiary care university hospital between September 2009 and August 2010 were tested for NGAL, IL-18 and CysC. Prospective demographic, clinical and laboratory data were evaluated as predictors of survival in this patient group. The most common cause of CCU admission was acute myocardial infarction (80%). According to Acute Kidney Injury Network criteria, 28.7%(43/150) of CCU patients had AKI of varying severity. Cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.05) between patients with AKI versus those without AKI. For predicting AKI, serum CysC displayed an excellent areas under the receiver operating characteristic curve (AUROC)(0.895±0.031, p<0.001). The overall 180-day survival rate was 88.7%(133/150). Multiple Cox logistic regression hazard analysis revealed that urinary NGAL, serum IL-18, Acute Physiology, Age and Chronic Health Evaluation II (APACHE II) and sodium on CCU admission day one were independent risk factors for 6-month mortality. In terms of 6-month mortality, urinary NGAL had the best discriminatory power, the best Youden index, and the highest overall correctness of prediction. CONCLUSIONS Our data showed that serum CysC has the best discriminative power for predicting AKI in CCU patients. However, urinary NGAL and serum IL-18 are associated with short-term mortality in these critically ill patients.

Background and objectives Hyperuricemia is an independent risk factor for mortality, cardiovascular disease, and renal disease in general population. However, the relationship between hyperuricemia with clinical outcomes in CKD remains controversial. Design, setting, participants,& measurements The study investigated the association between uric acid with all-cause mortality, cardiovascular events, renal replacement therapy, and rapid renal progression (the slope of estimated GFR was less than -6 ml/min per 1.73 m(2)/y) in 3303 stages 3-5 CKD patients that were in the integrated CKD care system in one medical center and one regional hospital in southern Taiwan. Results In all subjects, the mean uric acid level was 7.9±2.0 mg/dl. During a median 2.8-year follow-up, there were 471 (14.3%) deaths, 545 (16.5%) cardiovascular events, 1080 (32.3%) participants commencing renal replacement therapy, and 841 (25.5%) participants with rapid renal progression. Hyperuricemia increased risks for all-cause mortality and cardiovascular events (the adjusted hazard ratios for quartile four versus quartile one of uric acid [95% confidence interval] were 1.85 [1.40-2.44] and 1.42 [1.08-1.86], respectively) but not risks for renal replacement therapy (0.96 [0.79-1.16]) and rapid renal progression (1.30 [0.98-1.73]). Conclusions In stages 3-5 CKD, hyperuricemia is a risk factor for all-cause mortality and cardiovascular events but not renal replacement therapy and rapid renal progression.

Trisomy 12p syndrome is a rare chromosomal abnormality, which presents with facial dysmorphism, moderate to severe psychomotor retardation and generalized hypotonia. Here we present the prenatal sonographic findings investigated of a fetus in prenatal diagnosis with a de novo trisomy of 12p identified by array-comparative genomic hybridization (aCGH).

Background: Extracorporeal membrane oxygenation (ECMO) has been utilized for critically ill patients such as those with life-threatening respiratory failure or post-cardiotomy cardiogenic shock. Patients on ECMO with acute renal failure have high mortality rates. This study identifies specific predictors of hospital mortality for patients receiving ECMO and continuous arteriovenous hemofiltration (CAVH). Methods: This study reviewed the medical records of 123 critically ill patients on ECMO plus CAVH at a cardiovascular surgical intensive care unit (CVSICU) at a tertiary care university hospital between March 2003 and August 2010. Patient baseline, clinical, and laboratory data were collected retrospectively as survival predicators. Results: The overall mortality rate was 85.4%. The most common conditions requiring ECMO plus CAVH were cardiogenic shock and oliguria. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and organ system failure (OSF) score both indicated good discriminative power (area under the receiver operating characteristic curve [AUROC] 0.812 ± 0.048 and 0.758 ± 0.057, respectively). Multiple logistic regression analysis indicated that age, mean arterial pressure, and OSF score on day 1 of ECMO plus CAVH were independent risk factors for hospital mortality. Cumulative survival rates at the 6-month follow-up differed significantly (p < 0.001) between those with an OSF score 4 vs. those with an OSF score > 4. Conclusions: During ECMO plus CAVH support, both the OSF and APACHE II scores showed good discriminative power in predicting hospital mortality for these patients.