A Point-based Mortality Prediction System for Older Adults with Diabetes.

The mortality prediction models for the general diabetic population have been well established, but the corresponding elderly-specific model is still lacking. This study aims to develop a mortality prediction model for the elderly with diabetes. The data used for model establishment were derived from the nationwide adult health screening program in Taiwan in 2007-2010, from which we applied a 10-fold cross-validation method for model construction and internal validation. The external validation was tested on the MJ health screening database collected in 2004-2007. Multivariable Cox proportional hazards models were used to predict five-year mortality for diabetic patients ≥65 years. A total of 220,832 older subjects with diabetes were selected for model construction, of whom 23,241 (10.5%) died by the end of follow-up (December 31, 2011). The significant predictors retained in the final model included age, gender, smoking status, body mass index (BMI), fasting glucose, systolic and diastolic blood pressure, leukocyte count, liver and renal function, total cholesterol, hemoglobin, albumin, and uric acid. The Harrell's C in the development, internal-, and external-validation datasets were 0.737, 0.746, and 0.685, respectively. We established an easy-to-use point-based model that could accurately predict five-year mortality risk in older adults with diabetes.

A prospective clinical study of isoniazid-rifampicin-pyrazinamide-induced liver injury in an area endemic for hepatitis B.

In order to evaluate the incidence, predisposing factors and clinical course of antituberculous drug-induced liver injury in hepatitis B surface antigen (HBsAg)-positive carriers and non-carriers, in an area endemic for hepatitis B, we prospectively followed 240 patients (154 male, 86 female; mean age 40 years) who had received daily isoniazid, rifampicin, ethambutol and pyrazinamide for the treatment of pulmonary tuberculosis. Patients with heavy alcohol consumption, with pretreatment serum alanine aminotransferase (ALT) elevation and who had less than 3 months post-treatment follow-up were excluded from the study. Thirty-one (13%) patients were positive for serum HBsAg before treatment. Sixty-three (26%; 95% CI: 21-32%) patients developed antituberculous drug-induced liver injury. The incidence of drug-induced liver injury was significantly more frequent in patients > 35 years of age than in patients < or = 35 years of age (33 vs 17%; P < 0.05), but was not different between HBsAg carriers and non-carriers (29 vs 26%; P > 0.05). Using step-wise logistic regression analysis, patient age > 35 years was the only independent variable for predicting antituberculous drug-induced liver injury, while sex, acetylator phenotype, HBsAg carrier status and severity of tuberculosis were not. The peak serum ALT levels in antituberculous drug-induced liver injury were not significantly different between HBsAg carriers and non-carriers. Only one 61-year-old HBsAg carrier developed severe jaundice after 6 months antituberculous therapy; he subsequently died of hepatic failure. In conclusion, the incidence of antituberculous drug-induced liver injury was significantly higher in patients > 35 years of age than in patients < or = 35 years of age, but was not different between HBsAg carriers and non-carriers. Mortality occurred in an aged HBsAg carrier superimposed with antituberculous drug-induced liver injury.

Polymerase chain reaction analysis for viral nucleic acids in acute sporadic hepatitis patients negative for serum hepatitis B surface antigen and antibodies to hepatitis C virus.

BACKGROUND: Polymerase chain reaction (PCR) is both very sensitive and very valuable in the clarification of the pathogenesis of viral hepatitis from type A to E (HAV to HEV). METHODS: This study was aimed to detect viral nucleic acids with PCR in 33 consecutive, acute sporadic hepatitis patients who were seronegative for hepatitis B surface antigen and antibody to hepatitis C virus by conventional radioimmununoassay or enzyme-linked immunoassay. RESULTS: Of the totals, 10 (30.3%) had detectable viral genomes. HBV DNA and HCV RNA were each detected in 2 (7.4%) of 27 patients with a self-limiting course. By contrast, HBV DNA was detected in the two (33.3%, p = 0.14) and HCV RNA in the three (50%, p = 0.03) of the six patents who became chronic; another one who had subsequent multiple exacerbations of hepatitis was positive for both HBV DNA and HCV RNA. HDV RNA was not detectable in all subjects. Although four (12.1%) were positive for antibody against HEV, none had detectable HEV RNA. Spontaneous disease resolution predominantly occurred in patients without detectable hepatitis B and hepatitis C genomes (100% of 23 patients vs 40% of 10 patients, p < 0.01). CONCLUSIONS: These results demonstrate that a combination of serological and molecular tests is mandatory for the appraisal of acute sporadic non-B non-C hepatitis and its clinical prognosis, they also raise the possibility of a hepatotrophic agent other than HAV to HEV. Recent documentation of the new GBV-C (hepatitis G virus) suggests the necessity of studying the unidentified pathogenesis in patients with non-A to E hepatitis.

Ruptured hepatocellular carcinoma: treatment strategy and prognostic factor analysis.

BACKGROUND: The prognosis of ruptured hepatocellular carcinoma (HCC) is generally poor, but few studies have focused on the analysis of prognostic factors of this catastrophic event. METHODS: Eighty-four consecutive patients with ruptured HCC were included. Twenty-nine clinical and laboratory variables were correlated to prognosis by using uni- and multivariate analyses. RESULTS: Epigastralgia and/or right upper quadrant abdominal pain was the most common initial presentation (70%), followed by shock (42%), abdominal distension (27%) and others (17%). Of these 84 patients, 50 patients were treated by supportive measure, 21 by operation and 13 by transcatheter arterial embolization (TAE). The median survival was 13, 30 and 202 days in each group, respectively, and 24 days overall. TAE showed the lowest hemostatic failure rate (20%). Univariate analysis showed that active treatment (operation or TAE), group I tumor with a solitary nodule or single nodule with proliferation into surrounding area, serum creatinine (< or = 1.2 mg/ml), alkaline phosphatase (< or = 95 U/L), alanine aminotransferase (ALT, < or = 40 U/L), total bilirubin (< or = 1.6 mg/ml), initial systolic blood pressure (> or = 90 mmHg), and absence of main portal vein thrombosis were correlated with a survival longer than 90 days (p < 0.05) in univariate analysis. Active treatment, ALT level and initial systolic blood pressure were still significant in multivariate analysis (p < 0.05). CONCLUSIONS: TAE may help stop the tumor bleeding. Treatment regimen, ALT levels and initial blood pressure are correlated with the prognosis of ruptured HCC.

Prevalence and type of precore hepatitis B virus mutants in hepatitis D virus superinfection and its clinical implications.

To study the prevalence and type of the hepatitis B e antigen (HBeAg)-negative mutant in hepatitis D virus (HDV) superinfection, the precore region of hepatitis B virus (HBV) was analyzed by cycle sequencing. Of the 58 samples sequenced, 24 were wild type and 34 carried mutants. The precore stop mutation (TAG) at the 28th codon was found in 32 cases, other mutations were found in 7, and double mutations were found in 5. The absence of HBeAg showed a substantial agreement with the presence of mutants (kappa value, 0.74). Of the acute hepatitis patients, HDV replication and clinical manifestations were not significantly different between those with mutant and wild type virus, except that those with mutant virus were older (mean age, 48 vs. 28 years; P < .002). The absence of HBeAg in these patients is mainly due to HDV superinfection in older HBV carriers who already had precore mutant.

Seasonal variation in the incidence of peptic ulcer and esophageal variceal bleeding in Taiwan.

BACKGROUND: Seasonal variation of peptic ulcer and peptic ulcer bleeding has been reported in many western countries. To investigate the seasonal variation of peptic ulcer (PU) and esophageal variceal (EV) bleeding in Taiwan, this retrospective study was conducted. METHODS: Seven hundred and forty-six cases of gastric ulcer (GU) bleeding, 777 cases of duodenal ulcer (DU) bleeding and 264 cases of EV bleeding were recruited from January 1, 1991 to December 31, 1992. Patients were sent to the Medical Emergency Room (MER) for hematemesis and/or melena. Upper gastrointestinal (UGI) endoscopic examinations were completed within 24 hours for all patients. RESULTS: Significant seasonal variation was found in the incidence of PU and EV bleeding. PU bleeding was most often seen in March and EV bleeding was most often seen in February. CONCLUSIONS: The possible mechanism for the cyclic change of PU and EV bleeding is unclear, but clearly more manpower is needed during the months of February and March for better management of the increasing number of cases of PU and EV bleeding.

Acute relapsing hepatitis A in Taiwan--a rare event not related to multiple viral infection: a report of two cases.

From 1981 to 1993, 40 cases of acute type A viral hepatitis were reviewed and 2 cases (5%) of relapsing hepatitis were reported here. One case relapsed two weeks after remission and the other relapsed three weeks after remission, both had benign courses and recovered within four months. They were negative for serum hepatitis B surface antigen and hepatitis B core IgM antibodies. The serum autoantibodies, hepatitis C antibodies and hepatitis E antibodies were all negative during relapse. In summary, relapsing hepatitis A is rare in Taiwan and it is not related to multiple viral infections.

Clinical and radiological pictures of hepatocellular carcinoma with intracranial metastasis.

Hepatocellular carcinoma (HCC) with extrahepatic spreading is not uncommon. In order to delineate the clinical and radiological pictures of HCC with intracranial metastasis, 33 documented cases were analysed. Eighteen had brain parenchymal metastasis without skull involvement; the other 15 cases disclosed skull metastasis with brain invasion. The underlying HCC are mainly of expanding (13/33, 39.4%) and multifocal (13/33, 39.4%) types. Eighteen cases (18/33, 54.5%) had mental changes not related to hypoglycaemia or hepatic encephalopathy. Eighteen cases (18/20, 90%) disclosed hyperdense mass lesions by non-contrast computed tomography (CT) scans and 17 cases showed homogeneous enhancement (17/22, 77.3%) by post-contrast CT images. In the non-skull involved group, five cases (5/12, 41.7%) disclosed ring-shape enhancement and 14 cases (14/16, 87.5%) had perifocal oedema, which were not seen in the skull involved group. Eight cases (8/33, 24.2%) presented as intracerebral haemorrhage. Twelve (12/33, 36.4%) died of brain herniation. Most (14/18, 77.8%) non-skull involved cases had simultaneous lung metastasis without bony metastasis, while the skull involved group often (10/15, 66.7%) disclosed extracranial bony metastasis without lung metastasis. The difference in extracranial metastasis was statistically significant (P < 0.05). The multivariate survival analysis disclosed that lower lactate dehydrogenase level (< or = 316 U/L, P = 0.029) and treatments (surgery or radiation, P = 0.001) were positively associated with longer survival. In conclusion, HCC with intracranial metastasis is symptomatic and life-threatening. Half the cases may come from pulmonary metastasis and the other half may be from bony metastasis. Brain irradiation or surgery can prolong their survival.

Injection with nondisposable needles as an important route for transmission of acute community-acquired hepatitis C virus infection in Taiwan.

A prospective case-controlled study was conducted in order to determine the transmission route of community-acquired hepatitis C virus (HCV) infection in Taiwan. Thirty-eight consecutive patients (25 men and 13 women) with acute community-acquired HCV infection and 76 age (within 3 years)- and sex-matched healthy control subjects without HCV infection were enrolled. Serum anti-HCV was tested by second generation immunoassay. The sera of 26 family members from 12 families of index patients were also tested for anti-HCV. A questionnaire covering the history of blood transfusion, surgery, intravenous drug abuse, prostitute contact, dental procedures, injection, acupuncture, tattooing, and ear-piercing was conducted among patients and control subjects. Univariate analysis revealed injection with nondisposable needles was an independent risk factor (P = 0.02, odds ratio = 4.17, 95% confidence interval = 1.24-14.47) associated with HCV infection. Other risk factors were not significant. Only 2 (7.7%) family members of index patients had an anti-HCV. In conclusion, more vigorous effort to prohibit the use of nondisposable needles should be promoted to interrupt the spread of community-acquired HCV infection in Taiwan. Of note, a significant number of patients (34.2%) contracted HCV infection without identifiable risk factors. Unidentified routes need to be investigated.

Transcatheter arterial embolization for hepatocellular carcinoma with portal vein thrombosis.

In order to evaluate the possible benefits of transcatheter arterial embolization (TAE) in hepatocellular carcinoma (HCC) patients with peripheral portal vein thrombosis, 96 consecutive HCC cases with peripheral portal vein thrombosis were analysed. Of them, 35 cases received TAE and 61 cases did not. Most (77.8%) of the TAE-treated cases showed decreased alpha-fetoprotein (AFP) levels after treatment, but 57.1% of them suffered another rise in AFP levels and subsequently died. One patient (2.8%) developed progressive jaundice after TAE and died within 1 month, while four of the non-TAE cases died within 1 month after diagnosis. In general, TAE is safe for HCC patients with peripheral portal vein thrombosis. In addition, using Cox's regression model for multivariate survival analysis, serum total bilirubin (< or =, > 2 mg/dL; P = 0.0254), AFP (< or = 3155 ng/mL, > 3155 ng/mL; P = 0.0002) and treatments (TAE, non-TAE; P = 0.0059) were found to affect their prognosis. There was significant difference in survival between TAE and non-TAE groups, the 6 month, 1 year and 2 year survival rates were 91.4 versus 62.3%, 51.4 versus 26.2% and 17.1 versus 4.9% (P = 0.0017). The median survival times of TAE and non-TAE groups were 10.3 versus 3.7 months, respectively. Though TAE only provided palliative treatment, it did prolong survival in HCC patients with peripheral portal vein thrombosis.

Natural history of hepatitis D viral superinfection: significance of viremia detected by polymerase chain reaction.

BACKGROUND/AIMS: Polymerase chain reaction (PCR) is very sensitive. The aim of the study was to reevaluate viral replication in hepatitis D virus (HDV) superinfection by PCR. METHODS: HDV and hepatitis B virus (HBV) were detected by PCR in 185 patients. RESULTS: The acute hepatitis group had the highest detection rate of HDV RNA compared with chronic hepatitis, cirrhosis, hepatocellular carcinoma, and remission groups (63 of 64 vs. 35 of 47, 17 of 23, 19 of 30, and 7 of 21) and the highest alanine aminotransferase (ALT) levels (mean, 1741 U/L vs. 266 to 27 U/L; P < 0.05). The detection rate of HBV DNA was the lowest in the acute group (41%) compared with 66%, 70%, 80%, and 57% in the remaining groups (P < 0.02). At the chronic stage, 13%-25% of cases had HDV RNA, and 30%-48% of cases had HBV DNA detected by PCR but not by traditional method. HDV RNA was associated with ALT levels in horizontal and longitudinal analyses. CONCLUSIONS: HDV superinfection may be divided into the following three phases: acute phase, active HDV replication and suppression of HBV with high ALT levels; chronic phase, decreasing HDV and reactivating HBV with moderate ALT levels; and late phase, development of cirrhosis and hepatocellular carcinoma caused by replication of either virus or remission resulting from marked reduction of both viruses.

A terminal deletion (14)(q31.1) in a child with microcephaly, narrow palate, gingival hypertrophy, protuberant ears, and mild mental retardation.

A female child with a terminal deletion on the long arm of chromosome 14, 46,XX,del(14)(q31.1), presented with microcephaly, narrow palate, gingival hypertrophy, protuberant ears, and a small haemangioma on the back. She was mildly mentally retarded. Only a few patients with a partial deletion of 14q (14q-) have been reported without consistent clinical findings. Although a clinical syndrome associated with ring chromosome 14, r(14), has been established, no distinct pattern has been so far reported in 14q-.

Epidemiology and early diagnosis of primary liver cancer in China.

Epidemiological studies in different areas in China have revealed several outstanding risk factors of PLC, i.e., HBV infection, pollution of drinking water, contamination of food by AFB1 and/or nitrosamines, and family predisposition. Accordingly, a program of HBV vaccination, improved supply of drinking water, better preservation and storage of food, and possibly chemoprevention for high-risk populations should be effective preventive measures. Studies have shown that frequent AFP screening in high-risk populations is highly recommended to detect early cases of PLC. According to research in Qidong, careful follow-up of the dynamic changes of AFP in individuals with persistent low levels of positive AFP is important for distinguishing other conditions from true PLC. Newer means for the localization of small-size PLC (under 5 cm), such as type B ultrasonography, nuclide scanning, computerized tomography, and hepatoangiography, represent remarkable progress in improving markedly the success of surgery and hence the survival rate of PLC patients. The advances in knowledge of PLC have been encouraging. Although much work remains to be done on the etiological agents and the mechanism of oncogenesis, it is time that larger scale control measures be put into effect in high-incidence areas to discover if one of the most common cancers in the world can be controlled.

Yq- in a child with livedo reticularis, snub nose, microcephaly, and profound mental retardation.

A child with terminal deletion of the long arm of the Y chromosome (Yq--) presented with marked livedo reticularis, snub nose, microcephaly, short stature, and other dysmorphic features. He was profoundly mentally retarded. Most of the patients with Yq- have been reported as having varying dysmorphic features, mental retardation, and short stature. This child, in addition to the above, has livedo reticularis and microcephaly. He was of normal birthweight and, therefore, does not come into the syndrome of microcephaly, snub nose, livedo reticularis, and low birthweight dwarfism. Further information on Yq- should be obtained to ascertain if consistent patterns of abnormalities exist.

Chromosomes in patients receiving methadone and methadyl acetate.

Chromosomes of peripheral leukocytes were examined in 28 addicts participating in a Veterans Administration-Special Action Office for Drug Abuse Prevention (SAODAP) cooperative study of methadyl acetate vs methadone. Blood samples for 72-hour leukocyte cultures were drawn after nearly 40 weeks of maintenance therapy while subjects were receiving active medication. For comparison, ten nondrug users were also studied. The frequency of chromosome damage was not greater in subjects maintained on methadyl acetate or methadone than in nondrug users.

In vitro effects of imipramine on proliferation of human leukocytes.

The effects of imipramine hydrochloride on cell proliferation were investigated in leukocyte cultures derived from normal volunteers. Nine different doses of imipramine were added in vitro at random for 4, 24, 48, and 68 hours, the three lowest concentrations being within the range of plasma levels reported in psychiatric patients receiving the drug therapeutically. Cell proliferations, as measured by mitotic index, was affected by both the concentration and the duration of drug exposure; the higher the dose and/or the longer the drug in culture, the lower the mitotic index. Imipramine concentrations corresponding to therapeutic plasma levels had no effect on mitotic index regardless of the length of exposure.

Marijuana exposure in vivo and human lymphocyte chromosomes.

Sequential chromosome examinations of peripheral lymphocte cultures were carried out on 21 adult male volunteers who smoked natural blend marijuana cigarettes containing about 1%, 2%, or no delta9-THC. For a limited number of subjects, blood samples from a single venipuncture were cultured independently in two cytogenetic laboratories, and later the slides were exchaged for re-analysis. There were significant differences between laboratories in the absolute break frequencies recorded. These inter-laboratory differences were demonstrated for both techniques of cell culture and metaphase analysis. Neither laboratory found a statistically significant increase in break frequencies asssociated with marijuana smoking. The present study, therefore, failed to detect a measurable effect of marijuana smoking on chromosomal aberrations in subjects experienced in the use of the drug.

Chromosomes in old age: a six year longitudinal study.

This first longitudinal study on aged subjects confirms previous cross-sectional observations of increasing aneuploidy with advancing age in women but not in men. In this study of 17 aged twins (mean age 89.7 years), 11 women and 6 men, spanning an interval of approximately 6 years between examinations, only women showed a significant increase in hypodiploidy (also hyperdiploidy and monosomy C). This increase in hypodiploidy was not due to a high frequency of chromosome loss in a few subjects but rather was exhibited by most of the subjects. While men showed a loss in G-group chromosomes during this 6-year interval, that loss was not statistically significant. These findings confirm for the first time by means of longitudinal follow-up that women and not men, even in the ninth decade of life, show a significant increase in hypodiploidy.

Survival of octogenarians: six years after initial chromosome examination.

The frequencies of hypodiploidy, hyperdiploidy, monosomy C, monosomy G, and breaks were lower in the 19 female octogenarians who survived chromosome examination by six years than in the 19 who died, although none of the differences were statistically significant. In men, if anything, the trend was in the opposite direction with the nine survivors having higher frequencies than the 14 decedents. Again the differences were small and none were statistically significant. In neither sex, was there a relationship between length of survival and any of the parameters examined. Repeat chromosome examinations (two each, average interval 2.4 years) were available for seven women (one survivor and six decedents). There were no statistically significant differences between the two chromosome examinations except for an increase in monosomy C. Seven individuals, however, including but a single survivor, form too small a group to permit definitive conclusions about the lack of a relationship between chromosomal changes and survival.