Chang Gung Memorial Hospital-Kaohsiung Medical Research Articles

Characteristics and Outcome of Liver Transplantation in Children with Alagille Syndrome: A Single-center Experience

This study was carried out in Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan, with the aim of reviewing the characteristics and the outcome of liver transplantation (LT) in children with Alagille syndrome (AGS). We performed a retrospective analysis of transplant records of children diagnosed with AGS and undergoing LT between 1987 and 2010. Nine patients underwent living donor LT. Cholestasis and characteristic facies were seen in all patients. Posterior embryotoxon was seen in 4/9 (44.4%), butterfly vertebrae in 3/9 (33.3%), heart defect (pulmonary stenosis in 2) in 3/9 (33.3%), and renal disease in 2/9 (22.2%) patients. Five cases had cholestasis prior to the age of 60 days, whereas four cases had cholestasis after 60 days of age. Iminodiacetic acid scans showed no excretion of isotope into the bowel in four cases and suggested a false diagnosis of biliary atresia. All patients underwent diagnostic laparotomy and liver biopsy. Results of liver biopsy showed characteristic features of paucity of interlobular bile ducts in all patients. Kasai portoenterostomy was not performed in any patient prior to being referred for LT. The mean age at the time of LT was 4.6 years. The 5-year overall survival rate after living donor LT was 88.9%. Our conclusion is that the clinical features of AGS are informative. In addition, histological confirmation is important in the diagnosis. AGS children with severe liver disease had good prognoses with LT.

Magnetic Resonance Cholangiography in Living Donor Liver Transplantation

Exact knowledge of biliary anatomy is essential in living donor liver transplantation. The purpose of this study was to evaluate the accuracy of pretransplant magnetic resonance cholangiography (MRC) in depicting the biliary anatomy in comparison with intraoperative cholangiography (IOC). From May 2006 to July 2009, 451 potential living liver donors underwent pretransplant evaluation at the Chang Gung Memorial Hospital-Kaohsiung Medical Center. Two hundred thirty-three donors underwent donor hepatectomy. Of these, only 203 donors with both preoperative MRC and IOC were included in this study. Of the 451 potential donors, 218 (48.3%) were considered unsuitable for liver donation, hence was immediately disqualified after the initial evaluation for various reasons. Six of the 218 unsuitable donors (2.8%) were excluded due to complicated biliary anatomy. The overall accuracy rate of MRC for defining the biliary anatomy was 91.6%, with 84.9% sensitivity, 96% specificity, 88.2% positive predictive value, and 94.7% negative predictive value. There were 14 misidentified cases. The errors in MRC reading was largely attributed to the poor contrast between the biliary ducts and the surrounding tissues and organs. The concurrence between MRC and IOC were commendable (κ=0.9). No significant biliary complications were noted in the mismatch group. MRC is essential for all pretransplantation evaluation with 91.6% accuracy rate.

Do Cervical Degenerative Diseases Associate with Foreign Body Sensation of the Pharynx?

Foreign body sensation of the pharynx is a common complaint in otolaryngologic practice. The definite cause of this symptom is seldom precisely diagnosed, leading to chronic pharyngitis. The purpose of the present study was to evaluate the relationship between lump in throat and cervical degenerative disease by their clinical symptoms and the associated image characteristics. All patients with or without the complaint of lump in throat who attended the otolaryngologic clinics of Chang Gung Memorial Hospital-Kaohsiung Medical Center from January 2009 to May 2010 were prospectively eligible for this study. A total of 225 patients who met the inclusion criteria were assigned to either the study group (150 patients with symptoms of lump in the throat) or the control group (75 individuals without symptoms). All patients received plain views of the cervical lateral neck. The study group underwent further diagnostic examinations, including esophagography to exclude other diseases. Symptom scores (range, 0-3) and imaging characteristics such as the number (total spurs) and location (C level) of cervical osteophytes, interspace narrowing, spondylolisthesis, and retrolisthesis were compared between the two groups. It was found that the study group had a significantly greater number of total spurs (P<0.001), and C45, C56, and C67 were the predominant sites, with significant odds ratios of more than 2 at all these levels. Only C67 revealed a difference in interspace narrowing, and only C45 showed a difference in spondylolisthesis between groups. Hence, a high correlation was found between the lump-in-throat sensation and total number of spurs, especially at the levels of C45, C56, and C67. This result implied that cervical osteophytes might be associated with foreign body sensations of the pharynx.

61 An Association of Oxidative Stress Biomarkers and Mitochondrial DNA Copy Number in Chronic Dialysis Patients

AN ASSOCIATION OF OXIDATIVE STRESS BIOMARKERS AND MITOCHONDRIAL DNA COPY NUMBER IN CHRONIC DIALYSIS PATIENTS Jin-Bor Chen, Wen-Chin Lee, Chien-Chun Kuo, Ben-Chung Cheng, Shang-Chih Liao Division of Nephrology, Chang Gung Memorial HospitalKaohsiung Medical Center, Taiwan The purpose of study is to investigate the association of mitochondrial biogenesis and oxidative stress in chronic dialysis patients. A total of 199 chronic dialysis patients (hemodialysis: 111, peritoneal dialysis: 88) (mean age 48.9 year-old, male/female, 80/119) and 213 healthy control (mean age 49.4 year-old, male/female, 83/130) were enrolled as investigated subjects. Demographic, hematological, biochemical data, oxidative stress biomarkers, mitochondrial (mt) DNA copy number were compared between two groups. Plasma thiobarbituric acid-reactive substances (TBARS) and plasma free thiols were measured as indicators of oxidative damage to plasma lipids and antioxidant defense, respectively. mt DNA copy number in peripheral blood leukocytes was determined by calculating the relative mtDNA amount to the nuclear DNA by quantitative polymerase chain reaction. The mt DNA copy number were expressed by transforming to log values. The results showed dialysis patients had higher serum BUN, Cr, P, K, triglyceride levels, and lower Hb, albumin, cholesterol levels than control. TBARS levels (1.09 vs 0.77 uM/L, p=0.00) and mt DNA copy number (2.92 vs 2.54, p=0.00) were higher in dialysis patients than control. Free thiols levels were lower in dialysis patients (1.5 vs 2.12 uM/L, p=0.00) compared to control. The mt DNA copy number in dialysis patients were correlated with age, free thiols levels, body height (Pearson correlation). However, diabetes, cardiac disease, hypertension, stroke did not show positive impact on mt DNA copy number. In conclusion, chronic dialysis patients showed an increased oxidative stress status and thus leading to compensatory increased mt DNA copy number.

Hypersensitive Joint Reaction After Etanercept Treatment in a Patient with Juvenile Rheumatoid Arthritis

To the Editor: Etanercept is a soluble tumor necrosis factor (TNF) antagonist used worldwide for autoimmune diseases, including rheumatoid arthritis (RA), juvenile RA (JRA)1, psoriatic arthritis, and ankylosing spondylitis2. The optimal dose of etanercept that is both effective and safe may depend on individual patient factors, and it remains a topic that would benefit from further studies. We report the first case of hypersensitive joint reaction in a patient with JRA under etanercept treatment. A 19-year-old woman was diagnosed with polyarticular JRA at the age of 15 years. Presentation at the time of diagnosis included swelling and arthralgia in the knees, ankles, and elbows for more than 6 weeks. She also complained of a painful sensation in both hip joints and morning stiffness in her hands during that period. The laboratory data showed antinuclear antibody (ANA) of 1:40 (speckled), rheumatoid factor 28.8 IU/ml (normal < 15 IU/ml), and C3/C4 levels 150/35 mg/dl at diagnosis. Because of a poor response to disease-modifying antirheumatic drugs (DMARD), including methotrexate (10 mg/m2/week) and prednisolone (0.25 mg/day/kg), which were administered for more than 3 months, she took etanercept at a dose of 25 mg (0.6 mg/kg/week) subcutaneously once a week. However, she complained of swelling in multiple joints, which was most notable over the right knees and ankles and lasted for 2–3 days after each etanercept injection. Because of the adverse joint reaction … Address correspondence to Dr. H-C. Kuo, Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center, 123 Ta-Pei Road, Niaosung Hsiang, Kaohsiung, Taiwan. E-mail: erickuo48{at}yahoo.com.tw.

Pilot Scheme of Health Policy in Stroke Adjuvant Acupuncture Therapy for Acute and Subacute Ischemic Stroke in Taiwan

To reduce the health care burden of strokes, the Taiwan Department of Health launched the Pilot Scheme of the Health Policy in Stroke Adjuvant Acupuncture Therapy (HPSAAT) in 2006. This cross-sectional, hospital-based, match-controlled study at Chang Gung Memorial Hospital-Kaohsiung Medical Center during 2006∼2008 retrospectively evaluated the clinical characteristics of acute and subacute ischemic stroke patients who electively joined the HPSAAT. The study also evaluated the safety and clinical benefits of adjuvant acupuncture in treating acute and subacute ischemic stroke patients. Twenty-six HPSAAT participants and 52 age-sex matched random controls were enrolled. The stroke baseline of the HPSAAT participants was more severe than the non-HPSAAT controls. Although the stroke severity closely correlates to mortality and comorbidity, this study noted no significant complications in the HPSAAT participants during the acupuncture treatment course. Adjuvant acupuncture was considered safe at the acute and subacute stages of ischemic stroke. Due to uneven baseline severity, the clinical benefits in reducing neurological deficits and functional recovery were not concluded in this study.

Myelitis in Patients with Systemic Lupus Erythematosus

Objective: Myelitis is a rare but severe neurologic presentation of patients with systemic lupus erythematosus (SLE). Few large-scale retrospective cohort studies have been conducted, especially in Taiwan; therefore, we designed a retrospective study to investigate the disease parameters, treatment, and prognosis of myelitis in southern Taiwan. Methods: We reviewed medical records of patients with SLE who were evaluated at the Chang Gung Memorial Hospital-Kaohsiung Medical Center between January 1998 and January 2009. A total of 10 patients with myelopathy were included in the study. Neurologic variables and serologic features of SLE were assessed. Magnetic resonance images (MRI) of the spine and cerebrospinal fluid profiles were collected. We also analyzed the treatment and outcome of myelitis. Results: The cohort of 10 patients included 8 females (80%) and 2 males (20%). Three patients (30%) were initially admitted under the tentative impression of urinary tract infection (UTI). In 8 patients diagnosed with myelitis using MRI, 7 patients (88%) had increased T2 MRI signal intensity over the cervical and upper thoracic spinal area. Treatment regimens included conventional high-dose glucocorticoid, pulse methylprednisolone, cyclophosphamide, and plasma exchange. Six patients (60%) had a poor outcome. Additional cyclophosphamide was used in 5 patients and 3 of them (60%) had a good outcome. Conclusion: SLE patients, who contracted myelitis, presented with possible urinary difficulty and were admitted under the tentative impression of UTI. Besides, the most frequent site of lupus myelitis is the cervical to upper thoracic spinal area. Treatment with high-dose glucocorticoid and cyclophosphamide may be related to a better outcome compared to those without using cyclophosphamide.

Hepatic steatosis with hepatitis B virus/hepatitis C virus dual infection

We read with great interest the article by Bini et al.,1 who reported a study of hepatitis B virus (HBV) infection among 1257 patients with chronic hepatitis C virus (HCV) infection in the United States. They concluded that younger age, Asian race, injection drug use, and a greater number of lifetime sexual partners are risk factors for HBV-HCV dual infection. An interesting and clinically important finding is the marked difference in the severity of liver disease. Compared with patients monoinfected with HCV, patients dually infected with HBV and HCV have higher alanine aminotransferase levels and necroinflammatory scores, more advanced fibrosis, and faster fibrosis progression rates. In particular, patients with dual infection have a greater severity of hepatic steatosis, which has never been evaluated in this population before. To further elucidate the association between HBV-HCV dual infection and hepatic steatosis, we conducted a study enrolling 100 consecutive dually infected patients [59 males and 41 females, 52.5 ± 11.3 years old, with 31% positive for HBV DNA by the COBAS Amplicor HBV monitor (Roche Diagnostics, Branchburg, NJ) and 100% positive for HCV RNA by Amplicor (Roche Diagnostics)] and 100 age-matched, sex-matched, and body mass index (BMI)–matched individuals with chronic hepatitis C in Taiwan, in which both viruses are endemic.2-4 Patients with HBV-HCV dual infection and patients with HCV monoinfection were similar with respect to the ratio of diabetes mellitus, HCV genotype, alanine aminotransferase levels, and necroinflammatory scores, although patients with dual infection had more advanced fibrosis scores (F3 and F4; P = 0.041) and lower platelet counts (P = 0.045) than those with HCV monoinfection. Based on the Metavir classification system,5 the prevalence of hepatic steatosis was comparable between the two groups; however, dually infected patients had a higher severity of steatosis (grade 2 or 3) than those infected with HCV alone (P = 0.025; Fig. 1). Among dually infected patients, factors associated with the presence of steatosis by multivariate analysis were advanced fibrosis [odds ratio (OR) = 3.703, 95% confidence interval (CI) = 1.527-9.009, P = 0.004] and BMI (OR = 1.191, 95% CI = 1.037-1.368, P = 0.014). Likewise, independent variables associated with advanced fibrosis were the platelet count (104/μL; OR = 0.818, 95% CI = 0.725-0.923, P = 0.001), grade 2 or 3 steatosis (OR = 6.695, 95% CI = 1.911-23.45, P = 0.003), and higher necroinflammatory scores (OR = 2.880, 95% CI = 1.084-7.647, P = 0.034). Steatosis grade in the 100 patients dually infected with HBV and HCV and in the 100 age-matched, sex-matched, and BMI-matched patients monoinfected with HCV. Grade 2 or 3 steatosis was more frequently found in dually infected patients versus those infected with HCV alone (P = 0.025). Hepatic steatosis, a frequent histological feature of chronic HCV infection, has been recognized as a cofactor influencing the presence and progression of fibrosis.6, 7 In contrast, the association between HBV infection and hepatic steatosis is controversial.8, 9 In this case-control study, our data, in keeping with the findings of Bini et al.,1 confirm that patients dually infected with HBV and HCV have more severe steatosis than those with HCV monoinfection. Furthermore, multivariate analysis has shown that steatosis in HBV-HCV dual infection correlates independently with advanced fibrosis and BMI; however, the latter association was not found by Bini et al. The reasons for this difference are likely the small number of dually infected subjects in their study and differences in the patient characteristics. In our study, most of the dually infected patients had lower serum HBV loads because HBV is usually acquired perinatally or in early infancy and is inhibited by a subsequent HCV superinfection.2-4 Further investigation will be required to elucidate the contribution of steatosis to fibrogenesis in patients with HBV-HCV dual infection. Chao-Hung Hung M.D.*, Chuan-Mo Lee M.D.*, Sheng-Nan Lu M.D., M.P.H., Ph.D.*, Jing-Houng Wang M.D.*, Chien-Hung Chen M.D., Ph.D.*, Tsung-Hui Hu M.D., Ph.D.*, * Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital–Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

Reply: Ethical perspectives on living donor organ transplantation in Asia

We thank Omar et al. for their interest in our article entitled “Ethical Perspectives on Living Donor Organ Transplantation in Asia.”1 We are aware that there is no legal compensated living donation in Sweden. With respect to their article “Compensated Living Kidney Donation: A Plea for Pragmatism,”2 to which we referred in our article, we agree that they discussed a proposed scheme of compensated kidney donation as a way of addressing the current kidney shortage because true altruism in living organ donation is usually unsuccessful. As such, we stated that some believe that a regulated market is an ethical vehicle for shortening waiting lists and decreasing illegal organ sales. However, when we added “this concept forms the basis for compensated living donation in Sweden,” we did not mean to imply that compensated living donation is actually happening in Sweden. What we wished to convey is the possibility of implementing compensated living donation in Sweden because altruism only in living kidney donation is generally an unsuccessful doctrine in increasing organ donation2 and just compensation may gain public support and increase living donation. Some European countries share this view, and this position has been voiced by other authors.3 Again, just compensation is an ethical question. Allan M. Concejero M.D.*, Chao-Long Chen M.D.*, * Chang Gung Memorial Hospital–Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

P3.52. Coordinated expression of iNOS–VEGF/VEGF-receptors in epithelial white lesions provoked by Qat chewing: Immunohistochemical study

P3.51. Expression of FLJ10540 is correlated with aggressiveness of oral cavity squamous cell carcinoma by stimulating cell migration and invasion via increased FOXM1 and MMP-2 activity C.-H. Chen *, C.-Y. Chien , F.-M. Fang b Department of Otolaryngology, Chang Gung Memorial HospitalKaohsiung Medical Center, Taiwan Department of Radiation Oncology, Chang Gung Memorial HospitalKaohsiung Medical Center, Taiwan

Liver Graft Regeneration in Right Lobe Adult Living Donor Liver Transplantation

Optimal portal flow is one of the essentials in adequate liver function, graft regeneration and outcome of the graft after right lobe adult living donor liver transplantation (ALDLT). The relations among factors that cause sufficient liver graft regeneration are still unclear. The aim of this study is to evaluate the potential predisposing factors that encourage liver graft regeneration after ALDLT. The study population consisted of right lobe ALDLT recipients from Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan. The records, preoperative images, postoperative Doppler ultrasound evaluation and computed tomography studies performed 6 months after transplant were reviewed. The volume of the graft 6 months after transplant divided by the standard liver volume was calculated as the regeneration ratio. The predisposing risk factors were compiled from statistical analyses and included age, recipient body weight, native liver disease, spleen size before transplant, patency of the hepatic venous graft, graft weight-to-recipient weight ratio (GRWR), posttransplant portal flow, vascular and biliary complications and rejection. One hundred forty-five recipients were enrolled in this study. The liver graft regeneration ratio was 91.2 +/- 12.6% (range, 58-151). The size of the spleen (p = 0.00015), total portal flow and GRWR (p = 0.005) were linearly correlated with the regeneration rate. Patency of the hepatic venous tributary reconstructed was positively correlated to graft regeneration and was statistically significant (p = 0.017). Splenic artery ligation was advantageous to promote liver regeneration in specific cases but splenectomy did not show any positive advantage. Spleen size is a major factor contributing to portal flow and may directly trigger regeneration after transplant. Control of sufficient portal flow and adequate hepatic outflow are important factors in graft regeneration.

Patient characteristics and intravenous immunoglobulin product may affect eosinophils in Kawasaki disease

Pediatric Allergy and ImmunologyVolume 19, Issue 2 p. 184-185 Patient characteristics and intravenous immunoglobulin product may affect eosinophils in Kawasaki disease Ho-Chang Kuo, Ho-Chang Kuo Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorChih-Lu Wang, Chih-Lu Wang Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorLin Wang, Lin Wang Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorHong-Ren Yu, Hong-Ren Yu Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorKuender D. Yang, Kuender D. Yang Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this author Ho-Chang Kuo, Ho-Chang Kuo Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorChih-Lu Wang, Chih-Lu Wang Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorLin Wang, Lin Wang Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorHong-Ren Yu, Hong-Ren Yu Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this authorKuender D. Yang, Kuender D. Yang Division of Pediatric Allergy and Immunology, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Kaohsiung, Taiwan. 123 Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung County, Taiwan 833. E-mail: erickuo48@yahoo.com.twSearch for more papers by this author First published: 01 February 2008 https://doi.org/10.1111/j.1399-3038.2007.00657.xCitations: 15Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume19, Issue2March 2008Pages 184-185 RelatedInformation

A Quality and Cost-Benefit Analysis of Dialyzer Reuse in Hemodialysis Patients

Background. To evaluate the benefits of dialyzer reuse for hemodialysis (HD) patients, including the cost of HD treatment and patient's survival, a comparison was made regarding the standard practice of single-use dialysis. Methods. From January 1, 2005, to December 31, 2005, a total of 128,232 successive HD treatments in 822 patients in Chang Gung Memorial Hospital-Kaohsiung Medical Center were included in this study. Results. Approximately 54.25% (446/822) of patients reused dialyzers. The average times of dialyzer reuse was 2.54. The annual hollow fiber cost is reduced by $241,054.08 U.S. dollars (NT $7,834,257.60). The annual cost of hollow fiber was reduced by $540.48 U.S. dollars (NT $17,565.60) in one patient with dialyzer reuse. The mortality rates in dialyzer reuse and single use groups were 3.1% and 10.9% within one year (p < 0.0001). Multiple logistic regressions showed that single use compared with reuse was associated with higher mortality after adjusting co-morbid conditions including age, diabetes mellitus, etc. Conclusions. We concluded that the benefits of dialyzer reuse included safety in our center and reduction in cost during a 12-month period. Dialyzer reuse may be a safe alternative.

Spinal cord tumor mimicking obstetric brachial plexus palsy

a Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan b Department of Diagnostic Radiology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan c Department of Neurosurgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan

Ischemia heart disease and greater waist circumference are risk factors of renal function deterioration in male gout patients

We examined the incidence of renal function deterioration (RFD) in a population of male gout patients and to identify associated risk factors. Subjects who had been regularly followed up for more than 2 years and had visited Chang Gung Memorial Hospital-Kaohsiung Medical Center Rheumatology Clinic between June 1, 2006 and January 31, 2007 were enrolled. Four subjects were excluded as secondary gout was suspected. Group I (Gr I) comprised subjects without RFD and group II (Gr II) comprised subjects with RFD during the follow-up period. RFD was defined as absolute increment in creatinine (Cr) levels over 0.4 mg/dl for subjects with baseline Cr levels <or=1.4 mg/dl or as more than 50% increment of baseline Cr level per 12-month interval in average for subjects with baseline Cr levels >1.4 mg/dl. Clinical parameters were analyzed to study the potential risk factors of RFD. Of 318 male gout patients, 296 (93.1%) were categorized as Gr I, and 22 (6.9%) were categorized as Gr II. The observation periods for Gr I and Gr II were 81.20+/-53.29 and 92.41+/-46.72 months, respectively (p=0.338). Initial Cr levels are similar between the two groups (1.25+/-0.51 vs 1.25+/-0.61, p=0.963). Multiple logistic regression analysis revealed that current age, age at disease onset, disease duration, treatment duration, body weight, height, family history of gout, tophi, urolithiasis, tobacco use, alcohol consumption, history of cerebral vascular accident, hypertension, diabetes mellitus, dyslipidemia, base-line and final Cr, blood urea nitrogen level, serum uric acid level, and body-mass index were not independent risk factors. However, history of ischemic heart disease [IHD; odds ratio (OR) 7.68, 95% confidence interval (CI) 1.99-29.70] and greater waist circumference (WC; OR 1.06, 95% CI 1.01-1.11) were two independent risk factors of RFD. Additionally, the Cox multivariable analysis disclosed that IHD (p<0.001) and greater WC (p=0.011) deteriorated kidney function in these patients. The incidence of RFD in male gout patients is 6.9%. History of IHD and greater WC are two independent risk factors for developing RFD.

Unenhanced CT in the Diagnosis of Small Bowel Intussusception

Departments of *Pediatrics, †Pathology, ‡Radiology, and §Pediatric Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan Reprint Address: Mao-Meng Tiao, MD, Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, 123 Ta-Pei Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan

Chronic Myeloid Leukemia After Living Donor Liver Transplantation

ArticlePlus Click on the links below to access all the ArticlePlus for this article. Please note that ArticlePlus files may launch a viewer application outside of your web browser. https://links.lww.com/TP/A33 A 51-year-old Taiwanese man was a known hepatitis B virus carrier with cirrhosis and bilobar hepatocellular carcinoma (HCC). He underwent four episodes of transarterial embolization for the HCC. On follow-up, he had HCC recurrences and was advised liver transplantation. He underwent routine pretransplant workup and subsequently underwent right lobe living donor liver transplantation. The perioperative course was uneventful. The immunosuppression used tacrolimus, mycophenolate mofetil, and prednisone. Posttransplant, he underwent 10 cycles of doxorubicin-based chemotherapy due to tumor invasion to the hilar soft tissue and microscopic portal vein tumor thrombosis. He did well postchemotherapy and had no episodes of graft rejection or HCC recurrence. At 6 months posttransplant, he developed nonspecific leukocytosis. At 13 months posttransplant, his white blood cell count (WBC) was 46.2×103. At 14 months posttransplant, the leukocytosis increased to 63×103 (segmenters 49, bands 17, lymphocytes 7.5, monocytes 3.5, eosinophils 1.5, basophils 4, blasts 1, promyeloblast 1, myeloblast 2.5) with no apparent focus of infection (Supplemental Table 1). The C-reactive protein was <3.14. He was advised chromosomal studies and bone marrow biopsy. Leukemia was entertained. Cytogenetic analyses done on Geimsa banded chromosomes from cultured bone marrow cells showed 46, XY, t(9;22)(q34;q11), 100% (Supplemental Fig. 1). A genetic study from peripheral blood sample in the nested polymerase chain reaction assay showed b2a2 BCR-ABL. Bone marrow biopsy revealed hypercellular marrow with myeloid and megakaryocytic hyperplasia, eosinophilia, and basophilia consistent with myeloid leukemia, chronic phase (Supplemental Table 2; Supplemental Fig. 2). Cytoreduction with hydroxyurea was started. Complete hematologic remission (CHR) was reached in 2 months, and continuous CHR thereafter. The WBC count decreased from 95.1×103 to 4.3×103 within 7 months treatment with hydroxyurea. Imatinib was started after 9 months of hydroxyurea treatment. Continuous CHR was also noted with imatinib; and genetic study done from peripheral blood samples at 3 months and 6 months after imatinib treatment showed continuous major molecular remission (Supplemental Table 3). At 40 months posttransplant to present date, the patient is alive with no HCC recurrence, and no episode of graft rejection. He remains on CHR 25 months after the diagnosis of leukemia. His current medications include low-dose tacrolimus, mycophenolate, and imatinib. Myeloproliferative disorder is a life-threatening condition that can present after the use of immunosuppression in order to prevent rejection in transplantation. However, acute leukemias are rare after solid organ transplantation with an incidence of 0.2–2.5% in reported series (1). There are approximately 13 cases of acute leukemia after solid organ transplant reported in the English medical literature (1–6). Chronic myeloid leukemia (CML) has not been reported after liver transplantation. There were no molecular data of the BCR-ABL at the time of transplantation. However, serial pretransplant hematologic data showed that all hematologic parameters were within acceptable limits. In the early chronic phase of CML, the most common presentation is leukocytosis or thrombocytosis only. Leukocytosis, which was noted for about 6 months before the diagnosis of CML was made, may have been suppressed by doxorubicin (Table 1). Doxorubicin may have suppressed hematopoiesis whereby the patient presented with leukopenia at that time delaying the diagnosis of CML.TABLE 1: Pretransplant and posttransplant hematologic dataIn summary, although rare, leukemia should be considered in any posttransplantation recipient presenting with hematological abnormalities and history of posttransplant chemotherapy. Allan Concejero Chao-Long Chen Chih-Chi Wang Shih-Ho Wang Chih-Che Lin Yueh-Wei Liu Chin-Hsiang Yang Chee-Chien Yong Liver Transplantation Program Department of Surgery Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine Taiwan Ming-Chung Wang Division of Hematology Department of Medicine Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine, Taiwan Hock-Liu Eng Liver Transplantation Program Department of Pathology Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine Taiwan