Objective Adiponectin (ADPN) has been shown to protect against cardiovascular disease for the general population with problematic metabolic syndrome. However, it remains unclear whether ADPN is associated with mortality in patients on maintenance hemodialysis (HD). Methods, Patients or Materials We selected 85 HD patients [51 men/34 women; mean age, 64±2 years; underlying kidney diseases, diabetic nephropathy in 36 patients (42.3%), chronic glomerulonephritis in 29 (34.1%), hypertensive nephrosclerosis in 10 (11.8%), and others in 10 (11.8%)] who survived for more than 3 months after the start of HD. We first measured serum ADPN levels and prospectively followed patients for the next 3 years. Results We were able to follow 74 of 85 patients; 59 survived, and 15 died. Serum log-transformed ADPN levels were negatively correlated with BMI (r=-0.43, p<0.01). Despite a similar BMI (20.7±0.8 vs. 20.3±0.4 kg/m2), the expired patients had significantly higher ADPN compared with the surviving patients (20.5 μg/ml [14.0-23.5] vs. 14.2 μg/ml [9.7-21.3], p<0.05). Cox-hazards multivariate regression analysis adjusted for conventional case-mix features (age, sex, and underlying kidney disease) revealed that serum ADPN became a significant determinant of all-cause mortality. There was a 10.3% risk increment for each 1-μg/ml increase in ADPN during the follow-up. Kaplan-Meier analysis revealed that patients with higher ADPN levels (≥15 μg/ml) had a significantly lower survival rate compared with those with lower ADPN levels (<15 μg/ml) (76 vs. 92%, p<0.05). Conclusion These results indicated that high rather than low ADPN independently predict total mortality in HD patients.
Objective We hypothesized that non-invasive positive pressure ventilation (NPPV) would improve an acute asthma attack in mild to moderate cases without bronchodilator therapy. Methodology A total of 44 eligible patients with acute asthma of mild to moderate severity who had acute attacks were randomly allocated to a NPPV (n=30) or control group (n=14). Both groups received intravenous infusion of hydrocortisone prior to the study. Patients in the NPPV group were divided into two subgroups at random: a high- (n=16) and a low-pressure group (n=14). The former had a fixed expiratory positive airway pressure and inspiratory positive airway pressure of 6 cmH2O and 8 cmH2O, respectively, while the latter had levels of 4 cmH2O and 6 cmH2O, respectively. Effects on the following variables were assessed: FEV1, oxygen saturation, heart rate, respiratory rate, scores of accessory muscle use and wheezing by auscultation, modified Borg scale score, and mean intra-airway pressure on the monitor. Results A total of 26 patients completed the study in the NPPV group. The mean percent change in FEV1 significantly improved after 40 minutes in the high-pressure group compared with that in the control group (p<0.0001). Similar significant improvements in modified Borg scale score and physical examination findings were observed in the high- and low-pressure groups. None of the patients required re-hospitalization or return to the emergency room in either the NPPV or control group. Conclusion We conclude that higher inflation pressure on NPPV led to clinical improvement in patients with acute asthma attacks of mild to moderate severity.
Background There is insufficient evidence for the efficacy of a transdermal tulobuterol patch (TP), although combination therapy with bronchodilators is recommended for chronic obstructive pulmonary disease (COPD). Objective A randomized, controlled crossover study was conducted to evaluate the clinical efficacy and safety of the TP in 16 patients with COPD. Slow-release theophylline was used as a control drug. Methods Following a 2-week run-in period, patients were randomly allocated to two groups by the envelope method; they then received the TP and theophylline for 4 weeks each by the crossover method. Pulmonary function tests, peripheral blood examination, and electrocardiography were performed before and after each treatment period. Patients recorded in diaries their symptom scores, numbers of administrations of inhaled β2 agonists, and presence/absence of adverse reactions. Results Patients receiving TP exhibited significant improvement in the number and ease of sputum expectorations and in cough frequency score and wheezing severity score compared with baseline (p<0.05); the corresponding improvement in patients receiving theophylline was non-significant. Assessment of quality of life by the St. George's Hospital Respiratory Questionnaire revealed that treatment with TP was associated with significant improvement in symptoms, impact, and total scores compared with baseline (p<0.05); theophylline gave only a non-significant improvement in total score. Neither drug caused significant changes in the results of physiological examinations or in pulse or blood pressure. There was no difference in safety between the treatments. Conclusion Treatment of COPD patients with TP is more effective than with theophylline.
We present a case of scleroderma complicated by severe pulmonary hypertension. The use of a three-drug (bosentan, iloprost, and sildenafil) approach contributed to significant improvement of both the clinical conditions and the pulmonary hemodynamics. Combining three pulmonary vasodilators with different mechanisms of action could benefit patients with severe pulmonary hypertension resistant to conventional therapy.
A 30-year-old normocalcemic man with hypopituitarism, hypogonadism, diabetes mellitus, and secondary hemochromatosis due to multiple blood transfusions was admitted because of adrenal crisis. After intravenous administration of saline and cortisol, the corrected serum level of calcium decreased to 7.3 mg/dl. This osteoporotic patient had been prescribed alendronate for radial bone fracture. Since the increase in intact PTH (68 pg/ml) was impaired compared to that seen in hypocalcemic patients with secondary hyperparathyroidism, we presume that the patient has had latent hypoparathyroidism, which was unmasked by the administration of glucocorticoid and bisphosphonate. With a supplemented dose of 1α-OHD3, the patient has been eucalcemic.
We present the case of a 55-year-old man with ruptured arterial aneurysm accompanied by microscopic polyangiitis in the kidney. He was admitted to our hospital because of general fatigue, fever and serious numbness of his extremities. Microscopic polyangiitis (MPA) was diagnosed on the basis of cardinal symptoms, including rapidly progressive glomerular nephritis, peripheral nerve disorder and the lung abnormality, as well as positive MPO-ANCA findings. Hemodialysis had to be started on admission because of renal failure. Renal biopsy demonstrated necrotizing glomeruli, crescent formation with interstitial infiltrates. There were no immune deposits on immunofluorescence study or electron micrographs. The pathological diagnosis was necrotizing glomerulonephritis involving small and medium-sized arteries. He was treated with intravenous semi-pulse methylprednisolone therapy because of the intensely pathological renal activation and the abnormal shadow on chest X-ray. The inflammatory reaction subsequently improved, MPO-ANCA decreased and the lung lesions diminished. He complained of sharp pain of sudden onset on his left side. His hemoglobin dropped from 9.8 g/dl to 6.0 g/dl developed in the subsequent hours, but there were no sign of hemorrhage. Abdominal CT scan showed a large left-sided perinephric, intracapsular hematoma. Selective arterial angiography showed multiple aneurysms in renal and hepatic arteries. No active bleeding was present and he recovered with transfusion, supportive therapy and monitoring alone. Multiple aneurysms detected by angiography in the renal and hepatic arteries showed improvement. He is currently stable on regular hemodialysis treatment with a low dose of oral prednisolone.
A 72 year-old man. He was diagnosed with rheumatoid arthritis in 2002. In January 2005 he noted productive cough and fever; he was diagnosed as eosinophilic pneumonia (EP). We discontinued administration of bucillamine and methotrexate and started to treat with oral prednisolone 30 mg daily. To rule out drug-induced EP, prednisolone was tapered by 10 mg per week. Consolidation occurred in the right lower lobe when prednisolone was decreased to 5 mg daily. After increasing the dose of prednisolone to 30 mg daily again, consolidation was promptly resolved. It was considered to be important to rule out drug-induced EP.
Gefitinib, the epidermal growth factor receptor tyrosine kinase inhibitor, is effective for patients with non-small cell lung cancer. However, a serious adverse effect, interstitial lung disease (ILD), has been reported. The re-administration of gefitinib might be considered when there is no other choice of treatment and a therapeutic effect can be expected; however, there is no published data on the safety of restarting gefitinib after its discontinuation in cases suspected of having gefitinib-induced ILD. We report a case with recurrent gefitinib-induced ILD, which suggests that re-administration of gefitinib should be considered cautiously in patients who have previously developed gefitinib-induced ILD.
It has long been suggested that infectious agents may trigger sarcoidosis through their infectious or antigenic properties. A patient with airway colonization from P. aeruginosa in the setting of idiopathic bronchiolitis (IB) mimicking diffuse panbronchiolitis (DPB) developed sarcoidosis. Impressive clinical and radiological improvement of both bronchiolitis and sarcoidosis features was achieved with a one-year treatment with low-dose erythromycin, thus suggesting a possible link between the two conditions in this specific case. Pathogenic hypotheses and therapeutic implications are specifically discussed.
We report 3 patients with nephrotic syndrome ascribed to primary systemic AL amyloidosis that were successfully treated with VAD (vincristine, doxorubicin and dexamethasone) alone. M-protein in serum disappeared soon after VAD, and nephrotic syndrome gradually improved in parallel with a decrease in daily protein excretion in urine. Long-term follow-up of these patients showed neither relapse of nephrotic syndrome nor reappearance of M-protein. High-dose melphalan followed by autologous stem cell support is a standard therapy for primary systemic AL amyloidosis, but in high-risk cases for this treatment, such as elderly patients and those with multiple organ involvement, VAD might be a therapeutic option.
We present a 21-year-old woman with an oculogyric crisis following the administration of clebopride. Based on the temporal relationship of the administration of clebopride to the occurrence of the event and the absence of other possible etiologies, clebopride is implicated as the cause of this acute oculogyric crisis, despite the fact that a cause-and-effect relationship cannot be confirmed.
An 85-year-old man patient was admitted to the hospital complaining of fever and bilateral leg pain with swelling and erythema. A laboratory investigation revealed leukocytopenia, thus suggesting sepsis. Gram negative rods were detected in the specimen from the affected skin and empiric antibacterial therapy was initiated. The following day, his symptoms worsened and Pseudomonas aeruginosa was isolated from the blood culture and the skin specimen. Magnetic resonance imaging (MRI) did not show the typical characteristics of necrotizing fasciitis. In spite of intensive medical treatment, the patient's condition became critical, and on day 10 after admission, he died of multiple organ failure. An autopsy revealed necrotizing fasciitis due to P. aeruginosa. This is a rare case and its clinical presentation was atypical. The clinical diagnosis of this infection may be difficult, and therefore such cases warrant the careful attention of physicians.